Medical Case Summary

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Descriptor: Addilyn Reese is a 7 month old Caucasian female with a past medical history of Gastro-esophageal reflux disease (GERD), who has been brought to the pharmacy by her father who is seeking treatment for a fever.
SUBJECTIVE
CC: “She woke up with a fever today.”
HPI:
Addilyn Reese is a 7 month old Caucasian female with a past medical history of GERD. Her father has brought her into the pharmacy with the chief complain regarding a fever that she has been experiencing, since she woke up in the morning. Her temperature was taken with an ear thermometer with a reading of 101.3°F. She is eating food and drinking fluids normally, but her father states how she appears uncomfortable and not herself. She is experiencing a runny nose and she does not have any rashes. No medications have been used to treat her. Addilyn has a history with GERD and is taking ranitidine …show more content…
Fever Non-drug therapy: The patient should wear light weight clothing and be in rooms with a comfortable temperature at about 68°F. The patient should receive sufficient fluid intake, and the fluid intake should be increased by about 30-60 mL/hour. Drug therapy: Take Acetaminophen (Little Remedies for Fevers) 160 mg / 5 mL, at a dose of 2.5 mL every 4-6 hours, as needed. The patient should not exceed 5 doses in one day. Efficacy Monitoring: Monitor the patient’s temperature and see if it is decreasing after taking the medication. The patient’s temperature should decrease by 1-2 degrees within 30 minutes to one hour. Safety Monitoring: Do not take more than 5 doses of the medication. Also, monitor for any adverse side effects. Patient Education: Educate the patient’s caregiver to provide the correct dose to the patient and not to overdose. Also, teach the caregiver on how to dose the medication properly with the instrument provided with the medication. Collaboration: If the fever has not decreased or been resolved in 3 days, then refer to the patient’s pediatrician.
2. Immunization
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