The Mystery Infection

A worried mom runs her six-year-old son into a crowded ER. She carries him in her arms, because his fever has left him weak and too tired to walk. After he’s checked in, the nurse takes his vital signs. The young boy answers some questions about how he’s feeling, but he leaves most of the details to his mother to answer. She fills in details about what her son has experienced over the past few days. The information provided is organized into medical files that the medical team will review.

Review the patient’s medical file and highlight information you feel is important in helping the little boy.

Think about what symptoms he experienced as well as other clues that may help you figure out why he is so sick (highlight)

Medical File

Patient's Name Patient 1

Age 6 Temperature 103.5°F

Date Jan. 17 Blood Pressure 90/72

Height 48 in. Pulse 90 bpm

Weight 55 lbs. Respiratory Rate 23 bpm

Case Notes

Patient is a previously healthy six-year-old boy. He says he is hot and tired and points to his chest when asked what hurts. His mother reports that he came home from school five days ago with what she thought was a cold, but the symptoms have only gotten worse. He has had a constant fever over the past few days and complained of being cold. He has a dry cough that seems to get worse at night. His mother reports episodes where it feels like he is really struggling to breathe.

The patient is extremely weak and his mom says that he is sleeping 12–14 hours a day. She has been giving him over-the-counter medications, but they don’t seem to have helped his fever or his pain and discomfort. He is drinking plenty of water and eating small meals.

Other than school and soccer practice, the patient has not been around other large groups and has not traveled. The mother said she had not heard of anything going around school, but she did note that two of his teammates were coughing at the practice they had a week ago.

Physical Exam

Patient has a mild ear infection in both ears.

There are no spots or lesions in the mouth or throat. There is no rash on the body.

Patient does not appear to be congested and does not have a runny nose.

Patient has wheezing and rapid breathing.

Patient’s speech and vision appear normal. The infection in the ears does seem to be causing slight hearing loss.
What does he have?