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Case 1.4 Oxygenation

By Mikki Meadows‐Oliver, PhD, RN, FAA

SUBJECTIVE

Matthew, a 27‐day‐old infant, arrives at the office with complaints of “breathing fast” and congestion since yesterday. He is accompanied by both parents. He has had no fever. At home, his rectal temperature was 37.2 degrees this morning. The parents tried using a humidifier to alleviate the symptoms, but they do not feel that this helped. They also used a bulb syringe with nasal saline to help relieve nasal congestion. Matthew has had several visitors at his home during the first few weeks of his life, including small children who attend day‐care centers. His mother thinks that some of those visitors may have had cold symptoms, although she tried to keep anyone who seemed sick away from Matthew.

Diet: Normally breastfeeding every 2–3 hours; occasionally supplementing with a milk‐based formula. Since yesterday, intake has decreased.

Elimination: 4–6 wet diapers since yesterday, which is decreased from his normal urine output. 2–3 bowel movements.

Sleep: Normally sleeps approximately 5 hours at night with several naps throughout the day. However, since yesterday, Matthew’s sleep has been interrupted.

Medications: Currently taking no prescription, herbal, or over‐the‐counter medications.

Allergies: No known allergies to food, medications, or environment.

Birth history: Matthew was the product of a 39‐week gestation. He was delivered via planned cesarean section. Matthew’s mother had no falls or known exposures to environmental hazards. She has a history of chlamydia during the pregnancy at 36 weeks’ gestation. She was treated with antibiotics. The only other prescription medications taken during the pregnancy were prenatal vitamins. She did not use tobacco products or use illicit drugs. She stated that she drank an occasional glass of wine during the third trimester. Matthew’s birth weight was 3250 g, and his Apgar scores were 9 at 1 minute and 9 at 5 minutes.

Social history: Matthew was born to a 32‐year‐old mother. He lives at home with both parents. Neither parent has any other children. The mother works as a secretary, and the father works in construction. Matthew’s father is a smoker. The family has 2 cats.

Family medical history: PGF (age 65): Type 2 diabetes mellitus; PGM (age 64): breast cancer at age 55; MGF (age 60): asthma; MGM (age 64): healthy; mother (age 32): asthma; father (age 32): seasonal allergies.

OBJECTIVE

Vital signs: Weight: 4050 grams; length: 48 cm; temperature: 37.2°C (rectal); pulse oximeter reading: 91% on room air.

General: Alert, well‐hydrated, well‐nourished baby in mild respiratory distress.

Skin: Clear with no lesions noted; no cyanosis of skin, lips, or nails; no diaphoresis noted; good skin turgor.

Head: Normocephalic; anterior fontanelle open and flat (2 cm × 2 cm); posterior fontanelle open and flat (0.5 cm × 0.5 cm).

Eyes: Red reflex present bilaterally; pupils equal, round, and reactive to light; no discharge noted.

Ears: Pinnae normal; tympanic membranes gray bilaterally with positive light reflex.

Nose: Both nostrils congested; cloudy discharge present in nares; mild nasal flaring.

Oropharynx: Mucous membranes moist; no teeth present; no lesions.

Neck: Supple; no nodes.

Respiratory: RR = 42; expiratory wheezing present in all lobes; intercostal retractions present; no grunting; no deformities of the thoracic cage noted.

Cardiac/Peripheral vascular: HR = 120; regular rhythm; no murmur noted; brachial and femoral pulses present and 2+ bilaterally.

Abdomen/Gastrointestinal: Soft, nontender, nondistended, no evidence of hepatosplenomegaly.

Genitourinary: Normal male genitalia; testes descended bilaterally.

Back: Spine straight.

Extremities: Full range of motion of all extremities; warm and well‐perfused; capillary refill <2 seconds; negative hip click.

Neurologic: Good suck and cry; good tone in all extremities; positive Moro, rooting, plantar, palmar, and Babinski reflexes.

CRITICAL THINKING

1 Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___Chest radiograph (anterior‐posterior [AP] and lateral views)___Nasopharyngeal swab to detect respiratory syncytial virus (RSV)___Complete blood count

2 What is the most likely differential diagnosis and why?___Bronchiolitis___Upper respiratory infection (URI)___Chlamydial pneumonia

3 What is the plan of treatment, referral, and follow‐up care?

4 What demographic characteristics might affect this case?

5 Does the patient’s psychosocial history impact how you might treat him?

6 What if the patient lived in a rural, isolated setting?