General Pediatric Intake

Subjective:
Chief Complaint:
Persistent cough and fever

History of Present Illness:
The patient is a three-year and ten-month-old boy who was previously well but is unvaccinated. He fell ill on Thursday, the 16th, presenting with generalized malaise, poor appetite, and fever. His symptoms were initially managed with Tylenol and Advil, which provided temporary relief. Three days later, he developed a dry, persistent cough, and experienced post-tussive and post-prandial emesis. He also complained of feeling excessively hot, had chills, and rigors at home, but did not experience any seizures. There were no symptoms of diarrhea, but he did have abdominal pain. He was treated with Combantrin, a medication suggested by a pharmacist for possible pinworms. His siblings also experienced symptoms of a viral cold and dry cough but have mostly recovered. There is no history of travel or visitors from outside Canada. The family lives in xxx in government-subsidized housing. The patient has extensive dental caries and primarily consumes a diet of fish, cassava, pumpkin, mushroom, and raw red meat. He is not yet in school but attends a strong start program. The family does not have a family doctor, and the patient has not received vaccinations due to being born during the COVID-19 pandemic. There are no developmental concerns reported by the mother.

Past Medical History:
Unvaccinated due to being born during the COVID-19 pandemic. Extensive dental caries. No other significant medical conditions reported.

Past Surgical History:
The patient has no surgical history.

Family History:
No significant medical conditions reported in first-degree relatives.

Social History:
Lives in xxx with parents and three siblings in government-subsidized housing. Father works in construction, mother is a caregiver. No tobacco exposure reported.

Pregnancy History:
Born at Regional Medical Center without complications. Normal newborn screening. No pregnancy or birth complications reported.

Development:
The patient is not yet in school but attends a strong start program. No developmental concerns reported by the mother. Immunizations are not up-to-date as the patient is unvaccinated due to being born during the COVID-19 pandemic.

The Review of Systems:
Constitutional – Fever, chills, no weight loss, no night sweats, fatigue, weakness
Eyes – No double vision, no blurry vision
ENT – No hearing impairment, dizziness, runny nose, nose bleeds, nasal septum deviation, sore throat
Integumentary – No rashes, dry skin, eczema
Cardiovascular – No chest pain, heart palpitations, dizziness
Respiratory – Persistent cough, no wheezing
Endocrine – No known thyroid issues, no changes to appetite, no weight change, no tiredness/lethargy
Gastrointestinal – Abdominal pain, no nausea, vomiting, diarrhea, or constipation
Genito Urinary – No dysuria, hematuria, frequency, urgency, bedwetting
Musculoskeletal – No joint tenderness, redness or swelling
Neurological – No headaches, no weakness, no history of seizures
Psychology – No changes in mood, no anxiety
Hematology – Denies easy bruising

Current Medications:
Tylenol and Advil for fever and pain, Combantrin for possible pinworms.

Allergies:
No known drug, food, or environmental allergies reported.

Nutritional History:
Diet primarily consists of fish, cassava, pumpkin, mushroom, and raw red meat. No excessive milk intake.

Immunizations:
Unvaccinated due to being born during the COVID-19 pandemic.

Objective:
Vital Signs:
Blood pressure: 101/55 mmHg, Heart rate: 115 bpm, Respiratory rate: 34-44 breaths/min, Temperature: Not mentioned, PO2: 99-100% on room air.

Physical Examination:
General – Ill-looking but not toxic
Head – Normocephalic, atraumatic
Eyes – PERRLA, no discharge, sclera white, conjunctiva pink
ENT – Throat inflamed, no exudates, ears normal
Cardiovascular – Heart rate regular, S1S2 normal, strong peripheral pulses
Respiratory – Tachypnea, decreased entry on right lung, coarse crackles, bronchial breathing
Skin – No rashes
Abdomen – Mildly distended, soft, 4-5 cm hepatomegaly
Musculoskeletal – No tender, swollen, warm, or erythematous joints
Neurological – Alert, GCS 15/15, no meninges, no lateralizing signs

Test Results:
Chest X-ray: Right-sided necrotizing pneumonia, possible pleural effusion. Blood work: WBC 15.7, Neutrophils 11.3, Lymphocytes 2.5, Monocytes 1.4, Hemoglobin 57, MCV 70, RDW 16.7, Platelets 567, Sodium 130, Potassium 4.1, Chlorine 95, Bicarb 24, BUN 2.8, Creatinine 4.7, Glucose 6.3, GGT 18, AST 63, ALT 45, ALP 84, Albumin 23, Total protein 75, CRP 186. Nasopharyngeal swab sent for extended trial, including mycoplasma.

Assessment and Plan:
- Necrotizing Pneumonia (486): Right-sided necrotizing pneumonia with possible pleural effusion.
Plan:
• Initiated IV antibiotics at 50 mg/kg dose
• D5NS at maintenance rate of 50 mg/hr
• Nasopharyngeal swab sent for extended trial, including mycoplasma
• Discussed with Regional Medical Center, CTU, and accepted by Dr. Morgan for admission

- Anemia (285.9): Hemoglobin is 57, indicating anemia.
Plan:
• Monitor hemoglobin levels
• Consider iron supplementation if indicated

- Dehydration (276.51): Signs of dehydration with dry mucosal membranes.
Plan:
• Maintain hydration with IV fluids

- Fever (780.6): Persistent fever managed with Tylenol and Advil.
Plan:
• Continue Tylenol and Advil for fever management

- Abdominal Pain (789.06): Mild abdominal pain reported.
Plan:
• Monitor symptoms
• Consider further evaluation if pain persists

Problem:

1. Right-sided necrotizing pneumonia (486), possible pleural effusion, extensive dental caries, dehydration.

Differential Diagnosis:
Viral pneumonia, bacterial pneumonia, atypical pneumonia.

Plan:

• Discuss with Regional Medical Center, CTU. Patient accepted by Dr. Morgan for admission.  
• Administer antibiotics 50 mg/kg IV.  
• Administer D5NS at maintenance 50 mg/hr.  
• Provide Acetaminophen and Ibuprofen for analgesia and antipyresis.  
• Discuss the importance of adequate fluid intake and monitoring clinical manifestations with the patient.  
• Monitor clinical status.  
• Follow up with pediatrician post-discharge.