H&P
History
Identifying Data:
Full Name: SS
Address: N/A
Date of Birth: N/A
Date & Time: 04/28/23, 7:30am
Location: QHC
Religion: N/A
Source of Information: Self
Reliability: Reliable
Source of Referral: Self
Mode of Transport: N/A
Chief Complaint: “My daughter has had a fever and cough” x 3 days.
4 y/o female with a PMH of febrile seizures, up to date on all immunizations, accompanied by mother presents to the ED with intermittent fever and cough for 3 days. Mother states pt began with an oral temperature of 101.2 degrees F, with last temperature of 102 F last night. Tylenol was given for fever with mild improvement, last given at 8pm. Mother endorses pt has been less active and has decreased appetite and rhinorrhea. Also admits to decreased urine output. Denies nausea, vomiting, diarrhea, dysuria, hematuria, ear pain, sore throat, no recent sick contacts, no recent travel, no recent antibiotic use.
Initial DDx:
Pneumonia
Influenza
COVID
Rhinovirus
Past Medical History:
Febrile Seizures
Childhood Illnesses- N/A
Immunizations – Up to date; flu vaccine yearly
Screening test and results – N/A
Past Surgical History:
No past surgical history.
Denies any blood transfusions.
Medications:
Not on any medications at this time.
Allergies:
NKDA
Family History:
Mother – 35 y/o, alive and well
Dad – 36 y/o, alive and well
Maternal/paternal grandparents – Alive and well
Denies family h/o diabetes and cancer.
Social History:
Patient lives with mother and father.
Habits –No history of smoking, alcohol abuse, or history of illicit substances. Denies drinking coffee.
Travel – No recent travel.
Diet – Has a well-balanced diet.
Exercise – Mom states she is pretty active.
Safety measures – Admits to wearing a seatbelt.
Sexual Hx – N/A
Review of Systems:
General – Positive for loss of appetite and fever. Denies recent weight loss or gain, chills, night sweats, or generalized weakness/fatigue.
Skin, hair, nails – Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.
Head – Denies headache or head trauma.
Eyes – Denies lacrimation, pruritus, visual disturbances. Does not wear glasses.
Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids.
Nose/sinuses – Positive for rhinorrhea. Denies epistaxis, or nasal polyps.
Neck – Denies localized swelling/lumps or stiffness/decreased range of motion
Breast – Denies lumps, nipple discharge, or pain.
Mouth/throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes or use dentures.
Pulmonary system – Positive for cough. Denies dyspnea on exertion. Denies wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).
Cardiovascular system –Denies irregular heartbeat, chest pain, edema/swelling of ankles or feet, syncope or known heart murmur.
Gastrointestinal system – Usually has regular bowel movements daily. Denies nausea, diarrhea and abdominal pain. Denies vomiting, intolerance to specific foods, dysphagia, pyrosis, unusual flatulence or eructations, jaundice, hemorrhoids, or constipation.
Genitourinary system – Denies dysuria and blood in urine. Denies nocturia, urinary frequency, urgency, oliguria, polyuria, incontinence, or flank pain.
Menstrual/Obstetrical – N/A
Musculoskeletal system – Denies muscle/joint pain from arthritis. Denies deformity or swelling, or redness.
Nervous –Hx of febrile seizures. Denies loss of strength or weakness. Denies headache, ataxia, change in cognition.
Peripheral vascular system – Denies peripheral edema, intermittent claudication, coldness or trophic changes, varicose veins, or color changes.
Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, or history of DVT/PE. Denies blood transfusion.
Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter
Psychiatric – Denies depression/sadness, anxiety, OCD or ever seeing a mental health professional.
Physical
General: Female appears clean & casually-groomed, alert & active. Also has good posture and well-developed. Does not appear to be in acute distress.
Vital Signs: P: 155 beats/min, regular
R: 26 breaths/min, unlabored
O2 Sat: 96% on room air
T: 36.9 degrees C (oral)
Weight: 17.6 kg
Head, Skin, & Nails
Hair: Average quantity and distribution. Brown color. Straight texture. No evidence of lice or seborrheic dermatitis.
Skin: Warm and moist, smooth texture, good turgor.
Nails: No clubbing, capillary refill <2 seconds in upper and lower extremities
Head: Normocephalic, atraumatic, non-tender to palpation throughout.
Eye Exam
Eyes – No strabismus, exophthalmos, or ptosis. Sclera white, cornea clear, conjunctiva pink. Visual acuity uncorrected – 20/0 OS, 20/20 OD, 20/20 OU. Visual fields full OU. PERRLA, EOMs intact with no nystagmus.
Fundoscopy – Red reflex intact OU. Cup to disk ratio< 0.5 OU. No AV nicking, hemorrhages, exudates or neovascularization OU.
Ear Exam
Symmetrical and appropriate in size. No lesions/masses/trauma on external ears. No discharge/foreign bodies in external auditory canals AU. TM’s pearly white/infarct with light reflex in good position AU. Auditory acuity intact to whispered voice AU. Weber midlines/Rhinne reveals AC>BC AU.
Nose & Sinuses Exam
Nose – Symmetrical/no masses/lesions/deformities/trauma/discharge. Nares patent bilaterally/nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions/deformities/injection/perforation. No foreign bodies.
Sinuses – Non-tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.
Mouth & Pharynx
Lips – Pink, moist; no cyanosis or lesions. Non-tender to palpation.
Mucosa – Pink ; well hydrated. No masses; lesions noted. Non-tender to palpation. No leukoplakia.
Palate – Pink; well hydrated. Palate intact with no lesions; masses; scars. Non-tender to
Palpation; continuity intact.
Teeth – Good dentition / no obvious dental caries noted.
Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge. Non-tender to palpation.
Tongue – Pink; well papillated; no masses, lesions or deviation. Non-tender to palpation.
Oropharynx – Well hydrated; no injection; exudate; masses; lesions; foreign bodies.
Tonsils present with no injection or exudate. Uvula pink, no edema, lesions
Neck Exam
Neck– Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to
palpation. FROM; no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no cervical adenopathy noted.
Thyroid – Non-tender; no palpable masses; no thyromegaly; no bruits noted.
Thorax & Lungs:
Chest – Symmetrical, no deformities, no trauma, Respirations unlabored and use of accessory muscles noted. Lat to Ap diameter 2:1. Non-tender to palpation throughout.
Lungs – Bilateral wheezing and RLL rales noted, but no stridor. Prolonged expiration present. Decreased air entry bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout.
Cardiac Exam
Heart: PMI in 5th ICS in midclavicular line. Carotid pulses are 2+ bilaterally without bruits. Tachycardic with regular rate & rhythm. S1 & S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.
Abdominal Exam: Abdomen flat and symmetric, and no scars, striae, or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/iliac or femoral bruits. Pt is non-tender to palpation in all four quadrants. (-) guarding. (-) obturators sign, (-) psoas signs, (-) rebound tenderness. No hepatosplenomegaly to palpation, no CVA tenderness appreciated.
Breast Exam: Breast symmetric and smooth without masses. Nipples without discharge.
Pelvic Exam: N/A
Rectal: N/A
Neurologic:
Mental status: Patient is alert. Cranial nerves II-XII intact. Recent and remote memory is intact, attention, abstract thinking, and new learning ability are intact. Pt has good muscle bulk and tone with strength 5/5, no fasciculations. Cerebellar: Rapid alternative movements, finger to nose intact. Gait including normal stride, on toes, on heels, and tandem walking intact. Negative Romberg and Pronator Drift. Sensory: Pinprick, light touch, graphesthesia, stereognosis, position and vibration intact bilaterally.
Reflexes:
| Biceps | Triceps | Brachioradialis | Patellar | Ankle/Achilles | Babinski | |
| Right | 2+ | 2+ | 2+ | 2+ | 2+ | absent |
| Left | 2+ | 2+ | 2+ | 2+ | 2+ | absent |
Peripheral Vascular: Extremities are normal in color and temperature, no edema. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing or cyanosis. No stasis changes or ulcerations noted.
Musculoskeletal (Upper Extremity): No soft tissue swelling / erythema /
ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM of all upper and lower extremities bilaterally. No evidence of spinal deformities.
Assessment:
4 y/o female with PMH of febrile seizures, immunized, afebrile with wheezing and rales RLL with suspicion for pneumonia vs viral URI. Will order respiratory viral panel and CXR. Start DuoNeb and Decadron and reassess.
Labs:
Respiratory Viral Panel
Negative
SARS-CoV-2 PCR
Negative
Imaging:
CXR – negative for pleural effusion or pneumothorax. No definite consolidation or free intraperitoneal air.
Reassessment: Upon reassessment, patient with RLL rales, no wheezing, SpO2 99% on room air. CXR negative, but with rales, tachypnea, and retractions with suspicion for pneumonia. Will order CBC w/ diff, BMP, hepatic panel, and UA.
CBC
WBC 6.89
RBC 4.51
HGB 11.7
CRIT 36.2
MCV 80.3
MCH 25.9
MCHC 32.3
MPV 8.0
RDW 15.7
PLT 349
NEUTP% 86.3
LYMPHP% 10.3
MONOC% 2.6
EOS% 0.4
BASO% 0.1
Imm Gran 0.3
NEUT Abs 5.94
LYMPH Abs 0.71
MONO Abs 0.18
EOS Abs 0.03
BASO Abs 0.01
Imm Gran Abs 0.02
NRBC Abs 0.00
NRBC% 0.00
Urinalysis
Yellow
Clear
SGUR >= 1.030
PHUR 6.0
PROTUR 30
GLUUR >=1000
UKETONE trace
UBILI negative
UBLOOD negative
BACTUR negative
RBCUR 0-3
WBCUR 0-4
SQUAMOUSEC 0-4
HYALCAST 0-4
NIUR negative
LEUKU negative
Hepatic Panel
TP 7.7
ALB 4.8
TBILI <0.15
DBILI <0.2
SGOT 26
SGPT 10
ALK Phos 175
BMP
NA 138
K 3.9
CL 100
CO2 17
BUN 9
CREATININE 0.47
GLU 276
CA 9.9
ANOINGAP 21
Reassessment: Upon reassessment, pt with intercostal and supraclavicular retractions. Labs show elevated Glucose at 276 most likely due to Decadron and stress, and CO2 at 17 with anion gap of 21. Will order a VBG to look for source of respiratory distress.
VBG
pH 7.35
PCO2 33
PO2 70
NA 138
K 3.7
Cl 106
Ca 1.23
Hct 32
Glucose 232
Lactate 4.6
Total Hgb 10.7
OxyHgb 94.4
Carboxyhgb 2.0
Methemoglobin <0.7
Deoxyhgb 3.1
O2Sat 96.8
TCO2 19
Base Excess -7
HCO3 18
Differential Diagnosis After:
Pneumonia: The clinical picture presented most like pneumonia, although labs and imaging didn’t show evidence of infection.
Plan:
Will start patient on IV fluids (1 L NS) for rehydration and elevated glucose levels. Start 3rd DuoNeb treatment. Recheck vital signs. Will transfer patient for in-patient treatment. Will continue close observation and reassessment while awaiting transfer.
