A nurse in a pediatric provider's office is caring for a child. Exhibits Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again. Nurses' Notes 6 weeks ago, 0755: Child is 18.2 kg (40 lb) and 102 cm (40 in) tall 0800: Parent reports child is listless, refusing to eat or drink due to a sore throat, and has been febrile for the past 24 hr. Parent is also concerned that for the past month the child has been snoring when they sleep. Child has large amount of clear nasal drainage. Mucous membranes are pink and slightly dry. Mouth breathing is noted, and breath is foul smelling. No retractions or nasal flaring noted. Breath sounds are clear bilaterally with an occasional dry hacking nonproductive cough. Child reports throat pain as 6 on the Wong-Baker FACES pain scale of 0 to 10. Child also reports their left ear is hurting. No ear canal drainage noted. Cervical nodes are swollen and tender to touch bilaterally. Skin is warm and dry to touch. Has dry, scaly patches of hyperpigmented skin in bilateral antecubital space. Parent reports seeing child scratching there recently. Parent states, "They still wear pull-on diapers at night because they usually wet the bed."

Rationale for Correct Choices: Refusing to eat or drink due to sore throat: Poor oral intake during febrile illness increases the risk of dehydration and suggests the throat pain is interfering with nutrition and hydration, which needs to be addressed promptly. Snoring when sleeping for the past month: Chronic snoring in children can indicate obstructive sleep apnea due to enlarged tonsils or adenoids, often related to recurrent ENT infections. This should be evaluated for possible ENT referral. Mouth breathing and foul-smelling breath: These findings are commonly associated with chronic tonsillitis or adenoid hypertrophy. Halitosis in the context of throat symptoms suggests chronic infection or obstruction. Left ear pain: Ear pain without visible drainage may suggest otitis media. In the context of a recent upper respiratory infection and sore throat, middle ear involvement is highly likely and requires provider assessment. Swollen, tender cervical lymph nodes: These are signs of immune response, possibly from a bacterial infection like strep throat or viral illnesses. Tender lymphadenopathy, along with sore throat and fever, should be evaluated. Dry, scaly patches of hyperpigmented skin in antecubital space: These are characteristic of eczema. When eczema becomes itchy or visibly irritated, it increases the risk of secondary skin infections and may need topical treatment adjustment. Rationale for Incorrect Findings: Skin is warm and dry: This is expected during fever and indicates the child is not currently experiencing chills or sweating. It is a benign finding and does not require intervention on its own. No retractions or nasal flaring; breath sounds clear bilaterally: These normal respiratory findings indicate the child is not experiencing respiratory distress or lower airway involvement, making this a reassuring sign.