Infant Colic Intake

Subjective:
Chief Complaint:
Fever and loose motions.

History of Present Illness:
Pt, a [age not specified]-month-old female, presents with hx of fever since Monday and loose stools since Sunday. Caregivers report intermittent pyrexia responsive to acetaminophen and ibuprofen, with recurrence q few hours. Loose stools occurred 3-4 times on Sunday, increased to 5-6 times on Monday and Tuesday, now decreased in frequency but still loose in consistency, not completely watery. No hematochezia or mucus noted. Associated sx include rhinorrhea, cough, and anorexia. No emesis. Mild weight loss reported (0.2-0.2 kg). No dysuria or pain with micturition. No skin rash. Brief episode of conjunctival injection on Monday, resolved spontaneously. Caregivers note change in voice and reduced ability to cry loudly, suspecting pharyngitis. No recent travel except attendance at xxx Fair on Monday, where pt had direct contact with animals and consumed food without hand hygiene. No known sick contacts at home, but twin brother had recent URI sx and attends daycare. No hx of similar prior episodes. Immunizations up to date. No current or recent use of antiretroviral or other chronic medications except acetaminophen and ibuprofen as needed for fever.

Past Medical History:
- Preterm twin pregnancy
- No previous hospitalizations reported
- No chronic health issues reported
- No previous illnesses or conditions reported

Pregnancy History:
- Twin gestation
- No maternal health complications reported
- No maternal medications or supplements reported
- No prenatal complications reported
- No mode of delivery specified

Birth and Development History:
- No birth weight or length provided
- No Apgar scores provided
- No neonatal complications reported
- No developmental milestones discussed

Past Surgical History:
- No information available

Allergies:
- No allergies reported

Current Medications:
- Acetaminophen (Tylenol) as needed for fever
- Ibuprofen (Advil) as needed for fever
- No antiretroviral medicine
- Not taking any other medicine except Advil and Tylenol

Immunizations:
- Up-to-date per caregiver report

Family History:
- Twin brother with recent upper respiratory infection, attends daycare
- No one sick at home currently
- No relevant familial diseases or genetic conditions reported
- No history of infantile colic in siblings reported

Social History:
- Primary caregivers: parents
- Daycare attendance planned for February 1
- Twin brother currently attends daycare
- No feeding patterns, sleep environment, or routines specified

Environmental History:
- Recent exposure to animals at xxx Fair
- No pets at home reported
- No smoking or other environmental exposures reported
- No housing conditions specified

The Review of Systems:
Constitutional:
- Intermittent fever since Monday, responsive to antipyretics, recurs every few hours
- Mild weight loss (0.2-0.2 kg)
Eyes:
- Brief conjunctival injection on Monday, resolved
- No red eye currently
ENT:
- Rhinorrhea
- Cough
- Change in voice, reduced ability to cry loudly
- No nasal congestion or discharge
Cardiovascular:
- No murmur or cyanosis
Respiratory:
- Cough present
- No wheezing
Gastrointestinal:
- Loose stools since Sunday, frequency decreased, not completely watery
- No vomiting
- No blood in loose motions
- No mucus in loose motions
Genitourinary:
- No crying during urination
- Normal urination
Musculoskeletal:
- No abnormal movements reported
Skin:
- No skin rash
Neurological:
- No seizures reported
Psychiatric:
- Not applicable

Development:
Caregivers report mild weight loss of 0.2 kg. Immunizations are up to date. No concerns regarding gross or fine motor skills, language, or social-emotional development were raised. Brief episode of conjunctival injection resolved spontaneously. No parental concerns regarding vision or hearing. Twin brother attends daycare and had recent upper respiratory infection symptoms.

Nutritional History:
Caregivers report decreased appetite. No vomiting or feeding difficulties. No mention of food allergies, intolerances, or special dietary restrictions. No use of nutritional supplements. No issues with chewing or swallowing. No concerns regarding access to food or feeding environment.

Objective:
Vital Signs:
- Weight: Not documented
- Length: Not documented
- Head circumference: Not documented
- Temperature: 37°C (current, per caregiver)
- Respiratory rate: Not documented
- Heart rate: Not documented

Physical Examination:
General:
- Active, well-nourished child, no apparent distress
Head:
- Normocephalic, fontanelles not specifically assessed
Eyes:
- No discharge, no current conjunctival injection
ENT:
- Tympanic membranes clear, no significant erythema
- Throat: unable to fully visualize, voice change noted
Neck:
- Not specifically assessed
Cardiovascular:
- Regular rate and rhythm, no murmur
Respiratory:
- Normal breath sounds, no wheezing or crackles
Abdomen:
- Not specifically assessed
Genitourinary:
- Not specifically assessed
Musculoskeletal:
- Not specifically assessed
Skin:
- No rash
Neurological:
- Not specifically assessed

Evaluation:
- No evidence of infant colic
- Clinical picture consistent with acute viral gastroenteritis and upper respiratory tract infection
- No signs of underlying serious illness on examination

Assessment:
Problem:
- Acute fever (780.60)
- Loose stools (787.91)
- Upper respiratory symptoms (460) (rhinorrhea, cough)
- Anorexia (783.0)
- Mild weight loss (783.21)

Diagnosis Rational Discussion:
- Diagnosis based on acute onset of fever, loose stools, and upper respiratory symptoms following animal exposure, with physical findings and history supporting viral etiology; bacterial infection considered due to duration of fever and cough, pending further workup

Differential Diagnosis:
- Viral gastroenteritis
- Viral upper respiratory tract infection
- Bacterial pharyngitis
- Pneumonia
- Post-infectious diarrhea

Plan:
- Chest x-ray ordered to evaluate for pneumonia
- Throat swab for bacterial infection
- Hold antibiotics; prescription provided to initiate only if bacterial infection or pneumonia confirmed
- Continue supportive care with antipyretics (acetaminophen, ibuprofen) as needed
- Monitor for worsening symptoms; follow-up as soon as results available or if clinical status deteriorates

Treatments:
- Supportive care: acetaminophen and ibuprofen for fever
- No antibiotics initiated at this time
- No other medications or therapies recommended