Febrile Infant - H&P

HPI:

[ Patient first name ] is a [ Age ] old M with PMHx significant for potential HSV exposure, deferred postnatal vitamin K supplementation, unvaccinated infant status, prematurity, intrauterine substance exposure presenting with fever x1d and dehydration. Presents alongside parents who aid history taking given patient age. Parents first noticed symptoms develop -- days ago, such as rhinorrhea, cough,

PE:
General: Febrile per vitals, ill-appearing child
Growth: Normal interval growth
HEENT: Fontanelle sunken, red reflex present, no discharge from eyes, nares patent, + discharge from nostrils, palate intact, no thrush observed
Respiratory: BS clear/R=L, no increased work of breathing, good air exchange
Cardiovascular: Tachycardic, brachial=femoral pulses, peripheral and central capillary refill prolonged >3s
Abdomen: Soft, nontender, no HSM, no mass, no hernia
Neuro: Ill-appearing but responds to stimuli

Assessment and Plan:

[ Peds Cache ST ]
[ Patient first name ] is a [ Age ] old M with PMHx significant for potential HSV exposure, deferred postnatal vitamin K supplementation, unvaccinated infant status, prematurity, intrauterine substance exposure presenting with fever x1d and dehydration, admitted for sepsis rule-out and parenteral rehydration.

MDM: [ Patient first name ] presents after --days of fever with TMax --F. At presentation, temperature >38°C with physical exam significant for tired-appearing infant and vital signs suggestive of dehydration. .dehydrationMDM s/p --boluses while in Peds ED. Per AAP guidelines and hospital protocol, will begin appropriate workup per patient's age: UA w reflex UC, BCx, inflammatory marker surveillance, and inflammatory marker surveillance given altered mental status. Will continue to monitor for changes to clinical picture, and in meantime provide supportive treatment such as mIVF and Tylenol PRN. .custodyMDM .nutritionMDM

Febrile infant
8do to 21do OR 22do to 28do OR 29do to 60do
c/f UTI, sepsis, meningitis/meningoencephalopathy
- febrile x --- d
- s/p LP?
Plan:
- f/u UA, BCx, CSF studies
- Begin empiric abx: IV ampicillin 150mg/kg q8h + IV gentamicin 4mg/kg q24h
- IV Tylenol PRN made available
- qAM procal
- consider ID consult

Dehydration, mild (< 5% weight loss in infants, 3% in children)
- s/p x-- NS boluses in Peds ED OR Peds Urgent Care
- Clinical signs of decreased UOP ( cc/kg/h) present at admission
- Initial chemistry significant for normal sodium levels, started on isotonic fluids
Plan:
- d/t initial electrolytic abnormalities observed at presentation, serial chemistries q
-

Nutrition
-
Plan:
- Regular diet as tolerated

Vaccine Counseling
- Per my chart review, [State Vaccine Portal] review, as well initial discussion with caregivers,[ Patient first name ] at elevated risk for infections preventable with routine vaccination
Plan
- Counsel at discharge on matters related to health maintenance

Dispo considerations
- Pending infectious workup, outpt abx regimen, and clinical picture, will discharge home with parents
- Consider discussing gentamicin ototoxicity closer to dc

Caregiver lives at distance
- Patient from [ * Pt Address ], anticipate hardship with

Family disruption due to custody issue
- Social work following
- CYFD case #
- NOT ALLOWED AT BEDSIDE: