Daniel DeMarco SOAP Note #3 Pediatrics

 

S

 

AR is a 7mo14d female with no PMH admitted with atypical Kawasaki Disease. She is s/p IVIG yesterday. Tolerated well. No ADRs. Afebrile overnight. Mother states she is feeding well, 4oz. Similac q4h. Mother believes redness of eyes has decreased slightly. No vomiting, no diarrhea.

 

O

 

V/S

T 36.2C (36-37.1)

HR 103bpm (94-148)

RR 25bpm (22-42)

SpO2 99%RA (97-100)

BP 86/54 (80/49-102/69)

Wt: 8.363kg

 

I/Os

Ins: 0.75x MIVF

Outs: 1.58 cc/kg/hr

 

Diagnostic Imaging

Echo: Normal

 

PE

General: AOx3. NAD.

Skin: Warm, moist. Some residual macules and papules on bilateral proximal thighs.

Eyes: PERRL. EOMI. Mild erythema of bilateral conjunctiva L>R.

Heart: RRR. Normal S1, S2. No m/g/r.

Chest: CTAB. No rhonchi, crackles, wheezes.

Abdomen: Nondistended. BS+. Soft. NTTP. No organomegaly. No masses.

Extremities: No cyanosis. Capillary refill <2s throughout. Full range of motion.

 

A

 

AR is a hemodynamically stable 7mo14d female with atypical Kawasaki Disease.

 

P

 

#Kawasaki Disease

– s/p IVIG (6/18/19)

– Cont. ASA 162mg PO q6h

– CRP, LFTs, CBC in AM

 

#Fever

– APAP Rectal 120mg q4h prn for fever >38C

– Ibuprofen PO liquid 85mg q6h prn for fever >38C unresponsive to APAP

 

#FEN/GI

– Regular Diet

– Ranitidine HCl Oral Liq 8mg PO q12h

 

Disposition: Will observe x48h s/p IVIG to assess for recurrent fevers. If afebrile, hemodynamically stable, and clinically improving, will discharge with f/u with Pediatrician in 1-2d and f/u with Cardiology in 2-3wks. Will require low dose ASA until Cardiology f/u.

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student