Thank you for referring Gabriel to the Pediatric Department for evaluation of his cough, fever, and possible right middle lobe infiltrate. I had the pleasure of seeing him with his mother and grandfather with Dr. Govan today in the Emergency Department. He was discharged home with a prescription for amoxicillin 90 mg/kg divided into 3 doses per day for 10 days, as well as Ventolin 2 puffs q.4h. for 2 weeks. We asked that he please follow up with his GP this Friday.
PAST MEDICAL HISTORY AND MEDICATIONS:
Gabriel is a previously healthy 20-month-old male with no significant past medical history and no medications. It should be noted that he did have one episode of otitis media in November, which was treated with amoxicillin. In terms of …show more content…
When I saw in the Emergency Department he looked well and was comfortable sleeping in his mom’s arms, and when awakened he was talking, active, but was a bit cranky. He is mucous membranes appeared moist. His vitals were as follows: Temperature 37.2, heart rate 110, respiratory rate anywhere from 28-30 and he was saturating 98% on room air at triage. His cardiovascular exam revealed normal S1, S2 with no murmurs. I should note that his tympanic membranes were normal bilaterally. Respiratory exam revealed some crackles in the right mid-posterior region but with no wheezes. He had good air entry bilaterally. He did have some slight bilateral costal indrawing, as well as some nasal flaring. His abdomen was soft with no masses.
No blood work was performed on him at this time. Chest x-ray performed in the community does appear to show a small right middle lobe infiltrate.
IMPRESSION AND PLAN:
Gabriel Marshall is a 20-month-old who presented with persistent fevers for 3 days as well as shortness of breath and some signs of respiratory difficulty including slight costal and dry and nasal flaring. However, at this time he appears very stable as well as his family is very reliable. Thus, our management is as follows:
1. He will be discharged home and asked to please follow up with his family physician this Friday, which is in 2 days.
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PHYSICAL EXAMINATION: Vital signs are WNL. Apparently he has had no chills, night sweats, or favors. Generalized malaise and a lack of energy have been the main concerns. HEART: Regular rate and rhythm with S1 and S2. No S3 or S4 is heard at this time. LUNGS: Bilateral rhonchi. No significant amphoric sounds are noted. ABDOMON: Soft nontender. No hepatosplenomegaly or masses are detected. RECTAL EXAM: Prostate smooth and firm. No stool is present for hemoccult test.
A 68 year old male presented to the emergency department at 0800 hours via ambulance after experiencing chest discomfort and intermittent palpitations since 0500 hours. Prior to presentation, the patient stated he
Physical Examination: General: The patient is an alert, oriented male appearing his stated age. He appears to be in moderate distress. Vital signs: blood pressure 132/78 and pulse 68 and regular. Temperature is 38.56 oC (101.4 oF). HEENT:Normocephalic, atraumatic. Pupils were equal, round, and reactive to light. Ears are clear. Throat is normal. Neck: The neck is supple with no carotid bruits. Lungs: The lungs are clear to auscultation and percussion. Heart: Regular rate and rhythm. Abdomen:Bowel sounds are normal. There is rebound tenderness with maximal discomfort on palpation in the right lower quadrant. Extremities: No clubbing, cyanosis, or edema.
As such, the diagnosis and management of AOM has a significant impact on the health of children, cost of providing care, and overall use of antibacterial agents (AAFP, 2004). Watchful waiting can have many benefits for the children and the provider if used properly. Diagnosing AOM can be tricky. The signs and symptoms can also be related to other illnesses such as an upper respiratory virus. Throwing antibiotics at any illness use to be the course of action. However, now that there is evidence that bacteria have become resistant to some antibiotics, clinicians are testing out other means of treating illnesses. If the child presenting with symptoms of AOM has no underlying conditions and has means to follow up with the doctor if the symptoms progress, watchful waiting is an appropriate approach for treating the child. According to the research, placebo controlled trials have shown that children have responded well without antibacterial intervention. Giving the opportunity for the illness to resolve without antibacterial intervention not only benefits the child but, the caregivers and the clinician. It benefits the child by not being exposed to antibiotics that are not needed, therefore creating a potential resistance to that antibiotic. It benefits the caregiver by not spending money on a medication their child does not need. Last, it benefits the clinician by preventing resistance to an antibiotic that may be useful in the near future.
Pulse rate is at 72. The blood pressure was 140 / 95,which is suggestive of high blood pressure and related to his medical history. No heart murmur was noted, and no other abnormalities were noted.
The prescribing of antibiotics for AOM can have an impact on the health of the treated children and increases the cost of providing care. Watchful waiting is the recommendation from the AAFP & AAP in cases of uncomplicated AOM that are a result of other illnesses such as an upper respiratory virus. In the past doctors would immediately prescribe antibiotics for the signs and symptoms of an ear infection, however new evidence shows that over time bacteria have become resistant to certain antibiotics and so other means of treatment must be explored. If a child presents with symptoms of AOM and has no other underlying illness or condition, then watchful waiting is an appropriate avenue of treatment for the child. The research showed placebo trials had favorable outcomes and children responded without antibiotic interventions. If watchful waiting is used the child is not exposed to unneeded antibiotics and this reduces the chances of antibiotic resistance in the future. In addition, it also reduces the amount of money spent on health care needs in the form of purchasing medications. It should be noted that watchful waiting should only be considered in cases of uncomplicated AOM and that education should be given to care givers on when to follow up if symptoms do not improve within 48-72 hours. In the even that symptoms do not resolve then antibiotics may become necessary.
According to the provider, the claimant's cough has been improved. His review of systems was positive for fatigue, malaise, sleep difficulty, shortness of breath, wheezes, and a cough. His blood pressure was 115/71 mmHg and his BMI was 30.35 kg/m2. The physical examination revealed wheezes. Clonazepam was prescribed for agitation. Atorvastatin, Nystatin, Citalopram, and a probiotic were prescribed. Continued use of Aspirin and a regular inhaler were suggested. Further, a follow-up visit with Endocrinology, Cardiology, and Pulmonology. As it relates to a spot in his lung, a repeat CT scan was recommended. The bronchial washes were negative for
States that it started 3 days back and uses oxygen at home. States that he is a former smoker and laying on his back feels better. Also says he has a list of medication, more than 20. Pt has a history of COPD, CHF, DM,morbid obesity, HTN, HLM, hypothyroid, and sleep apnea. Has no accessory muscle use. CC is shortness of breath. Assessment is that there is no deformities or trauma of the head or neck area. Chest shows no signs of deformities or trauma. The abdominal area is tender and warm to the touch. Pelvis and back was not assessed. The upper and lower extremities show signs of low circulation and swelling. PMS=4. I helped with placing the BP cuff on the left arm and attaching it to the monitor. First vitals were recorded. O2 was given by the Nurse and then Albuterol by nebulizer. After 30 minutes, I assisted the Nurse and other hospital workers in moving the PT to a bigger bed. Second set of vitals were recorded. After becoming stable the Pt was moved up to the floor.
My initial belief was that the child might be exhibiting signs of strep throat. However after the physician was able to perform a rapid Strep test, which produced negative results, I felt it was best to further investigate the symptoms occurring
G.M. was then immediately transferred to Rady Children’s hospital Emergency Room by her parents. Upon nursing assessment she presented with vital signs within the same range from her clinic visit. These were repeated every fifteen minutes until stable. Her skin was flushed and diaphoretic. Mucous membranes appeared dry with significant skin cracking around the mouth. Patient was alert and oriented times three and pupils were equal, round, and reactive to light and accommodation. Her breath sounds were clear and equal bilaterally, with no adventitious sounds noted. However, patient G.M. appeared to have
In February 2000, a 19 year old patient presented to a family practice physician and nurse practitioner with problems associated with her nose and sinuses. Upon on the initial evaluation, the nurse practitioner determined that the patient’s symptoms were consistent with allergies and prescribed the patient Amoxicillin. Ten days later the patient was prescribed a second course of antibiotics. The patient returned six months later, in August 2000, for complaints of epistaxis and was diagnosed with sinusitis by unknown mentioned provider in this case study. In August 2000, it was noted that the patient also complained of multiple other symptoms which included anosmia, regular nosebleeds, diurnal pain located in the frontal region of the