Admission Note

Clinical Note: Patient: Emily Smith Age: 4 years old (DOB: 15/03/2020) cc: Mother, Sarah Smith Date seen: 01/11/2024 – 03/11/2024 (inpatient admission) Clinician: Dr. Anya Sharma, Paediatrician Chief Complaint: - High fever and sore throat for 2 days, refusing to eat or drink. History of Presenting Complaint: Emily Smith, a 4-year-old female, presented with a sudden onset of high-grade fever (up to 39.8°C) two days prior to admission. Her mother reports Emily has been lethargic, irritable, and has complained of a very sore throat, making it difficult for her to swallow even liquids. She has had no cough, rhinorrhoea, or rash. No known sick contacts, but attends nursery. Over-the-counter paracetamol provided minimal relief. Physical Examination: General appearance on admission: - Emily appeared flushed, lethargic, and irritable, reluctant to make eye contact. She was alert but subdued, lying quietly on her mother's lap. Throat examination: - Oropharynx was hyperaemic with significant tonsillar erythema and exudates. Uvula appeared swollen. No peritonsillar bulging noted. Neck examination: - Mild anterior cervical lymphadenopathy, bilateral, tender to palpation, approximately 1-1.5 cm in size. Supple neck with full range of motion. Special Investigations: - Full blood count results: WBC 18.5 x 10^9/L (elevated), Neutrophils 85% (elevated), Lymphocytes 12% (decreased), Hb 12.8 g/dL (normal), Platelets 350 x 10^9/L (normal). - C-reactive protein (CRP) level: 75 mg/L (elevated). - EEG investigation status or results: Not indicated, not performed. Diagnosis: - Primary diagnosis: Bacterial Tonsillitis - Secondary or co-occurring diagnosis: Dehydration (mild) Management Plan: - Medical interventions performed: IV access secured in right antecubital fossa for fluid rehydration and antibiotic administration. Started on 0.9% Normal Saline at 50ml/hour. - Results of blood tests during admission: Repeat CRP on day 2 showed decrease to 40 mg/L. Blood cultures pending. - Medications initiated with dosage and indication: IV Cefotaxime 50mg/kg every 8 hours for bacterial tonsillitis. Oral Paracetamol 15mg/kg every 6 hours PRN for fever/pain. - Symptomatic treatments provided: Oral rehydration therapy attempted, but poor intake necessitated IV fluids. Cool compresses for fever. - Details of further investigations planned or performed: Throat swab taken for culture and sensitivity. Pending results to guide antibiotic therapy if needed. 02/11/2024 Examination: - General appearance: Emily appeared brighter and more interactive. Fever had subsided with regular paracetamol. Tolerating sips of water. - HEENT: Tonsillar erythema and exudates slightly reduced. Uvula less swollen. No new findings. - Other systems: Cardiovascular and respiratory systems normal. Abdomen soft, non-tender. Skin turgor improved. Management: - Discharge instructions, medications, dosages, and duration: Discharge initiated. Oral Amoxicillin 25mg/kg three times a day for 7 days. Continue Paracetamol PRN for pain/fever. Advise mother to ensure good oral fluid intake. - Instructions for managing future symptoms such as fever: Advised to continue fever management with Paracetamol and return if fever persists beyond 24 hours post-discharge or if breathing difficulties or rash develop. Follow-up: - Follow-up with GP in 3-5 days for review. If no improvement or worsening of symptoms, return to paediatric emergency department.