Identifying Data:
Full Name: XX
Address: XX
Date of Birth: XX
Date & Time: 02/09/24 at 4PM
Location: Queens Hospital Center, NY
Religion: Christian
Source of Information: Mother
Reliability: Reliable
Source of Referral: Mother
Mode of Transportation: In car with mother

Chief Complaint: Trouble breathing x 1 day

History of Present Illness:
A 2 month old preterm infant with no PMHx brought in by his mother presents to the ER with increased work of breathing since this morning. Mother reports that the baby was febrile at 102F, tired, and has not been feeding since this morning. Mother also noted that the baby was pulling to breathe, so she decided to bring him to the ER. She reports cough, nasal congestion, and normal urine output. Mother states that she gave 2 doses of OTC Tylenol, the last dose 1 hour ago. Patient’s older brother has similar symptoms and tested positive for RSV. Denies recent travel. Denies diarrhea, constipation, vomiting, rash, drooling, cyanosis.

Past Medical History:
Present Illnesses – N/A
Immunizations: Fully up to date for 2 months

Past Hospitalizations:
None

Past Surgical History:
None

Medications:
Vitamin D supplementation
Tylenol 15 mg/kg, last dose 1 hour ago

Allergies:
No known drug, food, or environmental allergies

Family History:
Mother – alive with DM2
Father – alive and well
Maternal Grandmother – alive with DM2, breast cancer
Maternal Grandfather – deceased
Paternal Grandmother – deceased
Paternal Grandfather – deceased

Social History:
Mr. KV lives with his mother, father, and older brother in Jamaica, Queens.
No smokers in the home, no pets
Safety: is properly restrained with a seatbelt and rear facing car seat; home equipped with smoke and carbon monoxide detectors
Travel: Denies recent travel
Diet: Feeds 4 fl oz of milk every 4 hours, alternating between Enfamil and breast milk

Birth History:
Gestational Age: preterm at 36 weeks and 4 days
Hospital: Queens Hospital Center
Birth weight: 6 lb 1 oz
NSVD, no complications during pregnancy or delivery

Review of Systems:
General – Endorses fever. Denies weight loss, night sweats.
Skin, hair, nails – Denies pruritus. Denies discoloration, excessive sweating, skin changes, and hair changes.
Head – Denies headache, dizziness, trauma, fainting.
Eyes – Denies discharge.
Ears – Denies discharge.
Nose/Sinuses – Endorses nasal congestion. Denies epistaxis, swelling.
Mouth/Throat – Denies dysphagia, sore throat, hoarseness, cough. Last dental exam: N/A.
Neck – Denies swollen glands.
Breasts – Denies skin changes, lumps, nipple discharge.
Pulmonary System – Endorses cough, SOB, wheezing. Denies DOE, hemoptysis or cyanosis.
Cardiovascular System – Denies palpitations.
Gastrointestinal System – Endorses loss of appetite. Denies changes in stool, hemorrhoids, constipation, rectal bleeding or diarrhea.
Genitourinary System – Denies urinary frequency, oliguria, nocturia, incontinence.
Sexual History – Denies history of STIs.
Nervous – Denies changes in mental status.
Musculoskeletal system – Denies reduced mobility. Denies tenderness to palpation and erythema.
Peripheral vascular system – Denies edema, varicosities.
Hematological System – Denies lymph node enlargement, blood transfusions, anemia, clotting.
Endocrine system – Denies diabetes, heat or cold intolerance, excessive hunger/thirst.
Psychiatric – Denies irritability, and changes in eating habits.

Physical
General: Well groomed male, appearing as his stated age of 2 months. He appears tired and alert. He is fussy when awakened and appears to be in acute distress with subcostal retractions.
Vital Signs:
BP: Seated – (R) 74/52
R: 28 breaths/min, labored
P: 197 beats/min, regular rhythm
T: 102.3 F (Rectal)
O2 Sat: 83%, room air
Height: 20 inches Weight: 13 lbs BMI: 22.8

Skin, Hair, Nails, Head:
Skin: Warm and moist. No discoloration. No jaundice, skin mottling, cyanosis.
Hair: Regular quantity, even distribution. Color is dark brown, and the texture is normal. No visible dandruff or lice.
Nails: No clubbing, pitting, signs of infection. Capillary refill < 2 seconds in upper extremities.
Head: Normocephalic, atraumatic, anterior fontanelle flat.

Eyes:
Eyes appear symmetrical. Eye lashes are well distributed. No strabismus or ptosis noted. Sclera white with no jaundice, cornea clear with no signs of abrasion or nodules. Conjunctiva is clear with no foreign bodies.

Ears:
External ears with no masses or discharge. TMs pearly gray, no effusions or pus noted.

Thorax/Lungs
+Right lung field with crackles, left lung field with wheezing. +Respirations were labored, subcostal retractions noted. Chest was symmetrical. No tenderness to palpation.

Heart
+Tachycardia with normal rhythm. Distinct S1/S2 with no murmurs, splitting, friction rubs, or S3/S4 appreciated.

Mouth/Neck/Pharynx
Lips: Pink, no cyanosis or edema.
Buccal Mucosa: Pink, poorly hydrated.
Palate: Pink.
Teeth: N/A
Gingivae: Moist, with no bleeding, ulcerations, or discoloration.
Tongue: Symmetrical.
Oropharynx: Poorly hydrated, no exudates, masses, or foreign bodies. Uvula pink, midline elevation, no ulcerations.
Neck: Trachea midline. No masses, scars or pulsations noted. Non-tender to palpation. No lymphadenopathy.

Neuro Exam
Mental Status: tired in appearance and fussy when awakened

Differential Diagnosis
Pneumonia
RSV
COVID-19
Influenza A/B

Labs/Imaging
COVID 19, Flu, RSV swab
POC Glucose
CBC with differential
CMP
Procalcitonin
VBG
Portable CXR
EKG
Urine and blood culture

Assessment
2 month old preterm male presenting to the ED for respiratory distress with increased work of breathing. Patient was tachycardic, febrile at 102 F, O2 saturation at 83%, demonstrating subcostal retractions on PE. Crackles appreciated in the right lung field and wheezing appreciated in the left lung field. The patient was placed on 8L nasal cannula and saturation improved to 95%. Labs significant for leukocytosis and elevated procalcitonin. RSV positive. CXR suggestive of RUL consolidation indicating possible PNA. Rest of labs/imaging unremarkable.

Diagnosis: Right upper lobe pneumonia and acute bronchiolitis s/t RSV

Plan
IV Ceftriaxone 75 mg/kg x 5.897 kg for PNA
Dose administered: 442.3 mg in 50 mL
Transfer to Cohen’s Children’s Hospital for further evaluation and monitoring.

Patient Education:
RSV is the most common cause of bronchiolitis (inflammation of the small airways in the lungs) in children younger than one year old. It infects the lungs and breathing passages. It can be spread through contact with droplets from the nose and throat of infected people when they cough and sneeze. Treatment includes managing fever and pain, and maintaining hydration.
Parents were advised to avoid sick contacts with infant to avoid transmission of viruses.
Follow up with primary care provider to remain up to date on vaccinations and regular follow up visits.