Daniel DeMarco Focused H&P#5 Pediatrics

Chief Complaint: Decreased intake of food and drink, decreased urination and stooling

 

History of Present Illness:

 

MG is a 5yo female, otherwise healthy, with 3d history of blister-like lesions in mouth, hands, and feet that began on Saturday. She also had a fever on Saturday with TMax 101F which resolved with Motrin and APAP. Patient went to PMD who diagnosed her with HFM disease. Mother brought patient to ED because she hasn’t been eating or drinking. MG had 3 episodes of nbnb vomiting yesterday and today. She voided 1x yesterday and has not voided today. Last BM was Wednesday. Endorses abdominal pain. + Sick contact at school where other child was diagnosed with HFM disease a week earlier. No recent travel, antibiotic use.

 

ED course included 1x NS bolus and Ondansetron 2mg IV one time.

 

Immunizations: UTD

Allergies: NKDA

Medications: None

PMH: Denies

PSH: Denies

Home: Lives with mother and father at home. Mother and father are nonsmokers.

Family History: None

 

Review of Systems:

General: Admits weakness. Denies fever, anorexia, weight loss, weight gain, change in activity level 

Neuro: Denies HA, trauma, LOC, seizure activity, developmental delays 

HEENT: Admits blisters in mouth. Denies change in vision, hearing, pruritus, photo/phonophobia, neck pain, runny nose, ear pain, sore throat, dysphagia, odynophagia.

CV: Denies shortness of breath, sweating, color changes with feeding, chest pain, palpitations, recent history of murmur, fainting, or dizziness with activity 

Respiratory: Denies cough, wheezing, shortness of breath

GI: Admits nausea, nbnb vomiting, constipation. Denies diarrhea, hematemesis, hematochezia, or melena

GU: Admits oliguria. Denies dysuria, frequency, urgency, hematuria

Endo: Denies polyuria/polydipsia, heat/cold intolerance, growth pattern abnormalities

MS: Denies myalgias, arthralgias, trauma, limp, weakness

Skin: Admits blister-like lesions on hands, feet. Denies rashes, bruising, petechiae

 

Laboratory Findings/Diagnostic Imaging:

BUN: 20.9

Cr: 0.46

Bicarb: 13

Glucose: 62

CRP: 2.37

CBC: Normal

Urine Ketones: >160

Abdominal XR: Normal

AUS: RLQ with reactive lymph nodes

RVP: Negative

 

Physical Exam:

Vital Signs:

BP: 100/59

Pulse: 83bpm

RR: 22 breaths/min

Temp: 36.6C (Oral)

SpO2: 96%RA

Ht: 40.0 inches

Wt: 18.2kg

 

General Survey: Alert, NAD.

Skin: Bilateral fingertips and big toes with blister-like lesions. Some skin tenting noted. No petechiae, purpura. No jaundice, cyanosis, mottling. No rashes. 

Hair: Average quantity and distribution.

Nails: Capillary refill <2s throughout.

Head: NC/AT. Non-tender to palpation throughout.

Eyes: PERRLA. EOM intact and nonpainful. Red reflex present bilaterally. No crusting on lashes. No discharge.

Ears: External ear with no masses, lesions. Nontender to palpation. Auditory canal with no injection. B/L TMs pearly gray with cone of light in appropriate position.

Nose: Nares patent. Mucosa pink. Septum midline. Turbinates non-boggy, non-hyperemic.

Throat: Dry mucosa. Ulcerated lesions on tongue and bilaterally on mucosa. Good dentition. Gingiva without lesions, masses. Uvula midline. No tonsillar swelling. 

Neck: Supple. No thyromegaly. No lymphadenopathy.

Cardiovascular: Regular rate and rhythm. S1 and S2. No murmurs, gallops, rubs.

Chest and Pulmonary: Symmetrical rise and fall of chest wall. No labored breathing, accessory muscle use. Clear to auscultation bilaterally.

Abdomen: Nondistended. BS +. Soft, non-tender. No guarding, rebound tenderness. No hepatosplenomegaly.

 

Assessment/Plan:

MG is a 5yo female that is hemodynamically stable and being admitted for severe dehydration in the setting of hand, foot, and mouth disease.

 

#Dehydration 2/2 HFM Disease

– Start D5NS with 10mEq/L KCl @1.5x MIVF (85cc/hr), wean as tolerated

– Repeat BMP in AM

 

#FEN/GI

– Regular Diet

– Encourage PO fluids

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student