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… PHYSICAL EXAMINATION:
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.