Pediatrics_Ben_Kaplinski.docx

Ben A. Kapinsky Jr.– Pediatrics 1cc//1pmh CC – Fatiuge, shortness of breath, and cough Diagnosis – Staph Aureus CAP superinfection postinfluenza. - Influenza, pneumonia-community aquired, pulmonary embolism, asthma Tests- Chest x-ray pa and lat, ABG, CBC, influenza PCR, sputum culture, blood culture, Problem Statement: ( Demographic description – chief complaint – Hx and PE key findings – risk factors ) Ben A. Kapinsky Jr. is a 18yo man presenting with complaint of fatigue, shortness of breath, and cough. He states his symptoms started 4 days ago, he is coughing yellow-green sputum and has SOB on minimal exertion as well as chest pain near the chest wall @ R-lung 6-8th-intercoastal-space @ midaxillary-line., fever of 104 and hypoxemia (91%). PE shows dehydration, enlarged tonsils and tender-enlarged antcervical lymph nodes. He’s had asthma as a child and reports getting over flu-symptoms 2 weeks ago. CC: Ben A. Kapinsky Jr. is a 18yo man presenting with complaint of fatigue, shortness of breath, and cough. HPI: He states his symptoms started 4 days ago, he is coughing yellow-green sputum and has SOB on minimal exertion as well as chest pain near the chest wall @ R-lung 6-8th-intercoastal-space @ midaxillary-line., fever of 104 and hypoxemia (91%). Meds: Ibuprofen for pain PMH: Had flu like symptoms 2 weeks ago that resolved. Childhood asthma that has resolved ROS: Only positive findings are seen in HPI Physical Exam: VS: Pulse – 120; BP – 120/80 RR – 24; T – 103.2F; SpO2 – 91% Skin: Signs of dehydration Mouth: Dry oral mucous membranes, Tonsils enlarged and erythematous w/o airway compromise Neck: Tender 1cm -1.5cm anterior cervical lymph nodes, no posterior nodes palpable Lung: auscultation shows coarse crackles in RLL and RML fi ASSESSMENT/PLAN This study source was downloaded by from CourseH on :10:43 GMT -06:00 Test Results:  Chest X-ray PA and Lateral: Right upper and middle lobe infiltrates, no hyperexpansion – consistent with lobular pneumonia  Arterial Blood Gas (ABG): Hypoxia with normal pCO2 and normal pH.  CBC: Leukocytosis with left shift and increase in neutrophils  Influenza PCR nasal: Negative for influenza virus  Sputum gram stain: Negative  Blood culture and sensitivity: Positive for Gram+, Group A Strep Pneumoniae, sensitivity pending. Management Plan  ADMIT  O2 for hypoxemia  Establish IV  Empirical antibiotics for CAP Exercises: 1. Trachea, pharynx, bronchi 2. skip This study source was downloaded by from CourseH on :10:43 GMT -06:00 This study source was downloaded by from CourseH on :10:43 GMT -06:00 Powered by TCPDF ()