Paediatric Discharge Summary

Paediatric Discharge Summary Emily Smith DOB: 15/03/2022 MRN: PSM20220315ES Date of Review: 1 November 2024, 14:30 Dr. Thomas Kelly, Consultant Paediatrician, thomas.kelly@childrenshospital.co.uk Admission and Discharge - Admission Date: 28/10/2024 - Discharge Date: 1 November 2024 - Responsible Consultant: Dr. Thomas Kelly, Consultant Paediatrician Background - Emily has a known history of recurrent viral-induced wheeze, with her last hospital admission for similar symptoms in May 2024. No other significant past medical history. Summary of Admission Emily Smith, a 2-year-old female, was admitted on 28/10/2024 with a 2-day history of increasing cough, fever, and respiratory distress, consistent with a viral-induced wheeze exacerbation. On admission, she presented with tachypnoea (RR 45), mild intercostal recession, and widespread expiratory wheeze. Oxygen saturation was 92% on air. Investigations included a chest X-ray which showed hyperinflation but no consolidation, and a nasopharyngeal aspirate which was positive for Rhinovirus. She was commenced on salbutamol nebulisers every 4 hours, oral prednisolone 2mg/kg once daily for 3 days, and supplemental oxygen to maintain saturations above 94%. Her clinical condition improved steadily over 72 hours, with reduced work of breathing, decreased wheeze, and maintenance of oxygen saturations on room air. She tolerated oral fluids and food well throughout her admission. Condition on Discharge - Emily is clinically stable, afebrile, and maintaining oxygen saturations at 97% on room air. Her respiratory rate is 28 breaths per minute, and mild residual scattered wheeze is noted on auscultation. She is alert, interactive, and eating well. Discharge Medications - Salbutamol inhaler 100mcg: 2 puffs via spacer as needed for wheeze, up to every 4 hours. This is a continuation of her home medication. - Prednisolone oral solution 5mg/ml: 4ml (20mg) once daily for 1 further day (total 3 days course completed). This is a new prescription for a short course. Information and Advice Provided to Parents - Parents were advised to continue salbutamol as needed and to complete the prednisolone course. Detailed instructions on spacer technique were reviewed. They were counselled on recognising signs of worsening respiratory distress (increased breathing rate, deeper indrawing, blueness around lips, poor feeding/fluid intake, reduced alertness) and instructed to return to the emergency department immediately if these occur. Advice on maintaining good hand hygiene and avoiding exposure to sick contacts was also given. A follow-up phone call will be made by the ward nurse in 48 hours to check on Emily's progress. Follow-up Plan - Routine follow-up with the GP within 5-7 days for a general check-up. No specific paediatric outpatient follow-up is planned at this time unless symptoms recur or worsen.