please critque my PN below? thank you very much

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Posted by yag from IP 174.109.98.28 on October 06, 2016 at 13:30:12:

HISTORY
HPI;INFORMANT MOTHER OF 1YR F, CC 102F FEVER X2DY. MEASURED AT FOREHEAD,
TREATED W ACETAMINOPHEN, REACHING 99F. ASSOCIATED W DRY COUGH, R EAR TUGGING
& DECREASED FEEDING. W VOMITING TWICE X1DY, NONBILIOUS, UNRELATED TO
FEEDING. W SEIZURE & INCONTINENCE & POST ICTAL DROWSINESS. PARTIAL RELIEF W
SPONGE BATH. W DYSURIA. NO IRRITABILITY. NO DIARRHEA. 4-5 WET DIAPERS W
REGULAR FLUID INTAKE. NO ILL CONTACTS, RECENT TRAVEL OR DAY CARE ATTENDANCE.
NO RASH.

ROS;AS ABOVE
ALL;NKDA MED;ACETAMINOPHEN PMH/PSH;NONE FH;N/C DIET;REASTFED TIIL 2MO, THEN
GIVEN FORMULA PNH;FULL TERM, NSVD, W NO PERINATAL COMPLICATIONS.
IMMUNIZATIONS
UTD & MILESTONES N AT LAST CHECKUP X9MO SH;HAS 3YO SIBLING, LIVING W BOTH
PARENTS. SAFE HOME ENVIRONMENT, MOTHER DENIES STRESS/SADNESS


PHYSICAL EXAMINATION
(none)


Diagnosis #1: MENINGITIS
History Finding(s)
102F FEVER X2DY
ASSOCIATED W DRY COUGH, R EAR TUGGING
& DECREASED FEEDING.
W VOMITING TWICE X1DY, NONBILIOUS,
UNRELATED TO FEEDING.
W SEIZURE & INCONTINENCE & POST ICTAL
DROWSINESS.

Diagnosis #2: FEBRILE CONVULSION
History Finding(s)
102F FEVER X2DY, PARTIALLY RESPONDING
TO TREATMENT
W SEIZURE & INCONTINENCE & POST ICTAL
DROWSINESS.
ASSOCIATED W DRY COUGH, R EAR TUGGING
& DECREASED FEEDING.

Diagnosis #3: URINARY TRACT INFECTION
History Finding(s)
102F FEVER X2DY
W DYSURIA.
W VOMITING TWICE X1DY, NONBILIOUS,
UNRELATED TO FEEDING.

Diagnostic Study/Studies
PHYSICAL EXAM
LP-CSF
ANALYSIS, BLOOD CULTURE, CBC, LYTES
THROAT SWAB, PNEUMATIC OTOSCOPY, U/A


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