General Paediatrics Clinical Note

PATIENT'S NAME: Sarah Jenkins Date of Service: 01/11/2024 Date of Birth: 15/03/2022 Age: 2 years, 7 months, 17 days Sex: Female Accompanied By: Emily Jenkins (Mother) Subjective: - Reason for Visit: Persistent cough and low-grade fever for 3 days. - History of Present Illness: Sarah developed a non-productive cough 3 days ago, which has since become productive with clear mucus. Her mother reports intermittent low-grade fever (max 38.2°C) managed with paracetamol. No difficulty breathing or wheezing noted by mother. Appetite slightly reduced, but remains hydrated. Attends nursery. - Review of Systems: - Respiratory: Productive cough, no shortness of breath, no stridor. - Constitutional: Low-grade fever, mild fatigue. - HEENT: No ear pain, no sore throat, no nasal discharge initially, now clear rhinorrhoea. - Gastrointestinal: Normal bowel movements, no vomiting or diarrhoea. - Skin: No rashes. - Past Medical History: Full-term healthy baby. No significant past medical history. No hospitalisations. - Medication History: Paracetamol 120mg as needed for fever (last dose 6 hours ago). - Allergies: No known drug allergies (NKDA). No food or environmental allergies. - Immunisations: Up-to-date according to EPI-SA schedule (all recommended doses for age received). - Growth and Development: Meeting all developmental milestones. Walks independently, uses several words, feeds self with spoon. No recent concerns from mother. - Diet and Nutrition: Breastfed until 12 months, now on solids and cow's milk. Eats a varied diet, no specific food preferences or aversions. Good hydration with water. No food security concerns. - Family History: Mother has seasonal allergies. Maternal grandfather had hypertension. No family history of TB or diabetes. Objective: - Growth Parameters: Wt: 13.5 kg, Ht: 92 cm - Vital Signs: Temp: 37.8°C, Pulse: 110 bpm, Respiratory Rate: 28 bpm, Blood Pressure: 90/55 mmHg, Oxygen Saturation: 98% on room air Physical Examination: - General Appearance: Alert, interactive and playful, in no acute distress. Mild nasal congestion. - Eyes: Clear conjunctivae, pupils equal and reactive to light. No discharge. - Nose: Clear rhinorrhoea, mild mucosal oedema. - Ears: Tympanic membranes clear, intact, and pearly grey bilaterally. No discharge. Responds to soft voice. - Throat: Oropharynx mildly erythematous. Tonsils 1+. No exudates. - Chest/Lungs: Symmetrical chest expansion. Good air entry bilaterally. Occasional scattered coarse crepitations, no wheeze or rhonchi. No increased work of breathing. - Cardiovascular: S1 S2 heard, regular rhythm. No murmurs. Peripheral pulses strong and equal. Capillary refill time <2 seconds. - Abdomen: Soft, non-tender, non-distended. No organomegaly detected. Bowel sounds present and active. - Skin: Warm and dry. No rashes, lesions, or petechiae. Good skin turgor. - Musculoskeletal: Full range of motion in all extremities. No joint effusions or tenderness. Normal gait for age. No deformities. - Central Nervous System: Alert and oriented to surroundings. Appropriate tone and reflexes for age. Good head control. Demonstrates age-appropriate social interaction and play. Investigations: - Rapid Strep Test: Negative - Urinalysis: Negative Assessment and Plan: - Viral Upper Respiratory Tract Infection (URTI) - Investigations planned for this issue: None at this time, symptoms are consistent with viral aetiology. - Treatment planned for this issue: Supportive care including adequate hydration, nasal saline drops for congestion, and paracetamol for fever/discomfort as needed. Advised mother on signs of worsening condition (e.g., increased work of breathing, persistent high fever, lethargy) and to return if concerns arise. - Relevant referrals for this issue: None. Clinician Signature: Dr. Aisha Khan