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
...
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
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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 100000831988016 from CourseHero.com on 05-01-2022 11:27:52 GMT -05:00
https://www.coursehero.com/file/62247365/Pediatrics-Ben-Kaplinskidocx/
This study source was downloaded by 100000831988016 from CourseHero.com on 05-01-2022 11:27:52 GMT -05:00
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