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.
