Paeds ED Admission

Introduction: Introduced myself as the Physician Associate on duty. Chief Complaint - Presenting Issue: 3-year-old male presenting with a fever and cough. - The patient has had a fever for two days, a productive cough, and reports of decreased appetite. No recent travel history. No known allergies. No known chronic medical conditions. No previous surgeries or hospitalizations. Past Medical History - No known chronic medical conditions - No previous surgeries or hospitalizations Pregnancy and labour: - Born at term, vaginal delivery, no complications. Drug History - Medications: None. - Allergies: No known allergies. Family History - Father has a history of asthma. Social History - Non-smoker. - No alcohol consumption. - No illicit drug use. - No recent travel information. - No social worker involvement. Physical Examination - Vital Signs: Blood pressure 100/60 mmHg, heart rate 120 bpm, respiratory rate 30 breaths/min, temperature 38.5°C, oxygen saturation 98% on room air. - General examination: Appears unwell, but alert and responsive. - Airway: Patent, no stridor. - Breathing: Mildly increased work of breathing, scattered wheezes heard on auscultation. - Cardiovascular: Regular rhythm, no murmurs, good perfusion, capillary refill <2 seconds. - Disability: GCS 15, blood glucose 5.2 mmol/L, appropriate behaviour for age. - ENT: Mildly inflamed tympanic membranes bilaterally. - Abdo: Soft, non-tender, normal bowel sounds. - MSK: No deformities, full range of motion. - Neuro: Alert and oriented, cranial nerves intact, normal reflexes. Investigations - Pathology: CBC, CRP, and blood cultures sent. - Imaging: Chest X-ray ordered. - Other Investigations: None. Assessment - Presumed diagnosis: Bronchiolitis. - Differential diagnosis: Pneumonia. Plan/Treatment - Immediate Management: Administered paracetamol for fever. Nebulised salbutamol given. - Investigations: Chest X-ray to be reviewed. Blood test results pending. - Referrals: Discussed with senior doctor. - Discharge & Follow-up Instructions: Advised on home care, including rest, fluids, and paracetamol for fever. Return to ED if symptoms worsen. Follow-up with GP in 2 days. Date: 1 November 2024.