Patient Presentation:
C.L., a 14 year old female presents to the health center with initial
complaints of headache, nausea/vomiting/diarrhea and abdominal pain for
the past 3 days. Patient is unable to tolerate any oral fluids. Caregiver
states general malaise and vertigo with position changes. Upon interview,
patient complains of an intermittent cough. No sputum is present. Upon
examination oral temperature is 104.2, all other vital signs stable.
Crackles noted bibasilar upon auscultation of lungs. Pt complains of
tenderness in right upper abdominal quadrant in addition to minimal
abdominal cramping. No other complaints. Pt has been unable to take
antipyretics related to nausea. Attempted Pedialyte at home for hydration
but was unsuccessful.
Differential Diagnoses:
Acute appendicitis, Gastritis, Pneumonia
Diagnosis:
Patient was sent for chest x-ray. Results showed bilateral lower lobe
infiltrates. Complete blood count (CBC) drawn. White count elevated at
14,000 white blood cells per microliter. Diagnosis: Pneumonia
Treatment:
Admit to hospital for treatment. Intravenous (IV) fluids for hydration.
Push oral fluids as tolerated. Monitor vital signs every 4 hours for
changes with particular focus on temperature. Give antibiotic Rocephin® 50
mg/kg IV piggy back once daily.
Outcome:
Patient spent two days in hospital receiving IV antibiotics and IV fluids.
Oral temperature was down to 98.8 upon discharge on the morning of day 3.
WBC within normal limits. Tolerating oral diet without difficulty.
Ambulating per self. Mild cough continues, although improved. Oxygen
saturation maintained within normal limits on room air. Discharged to home
on Biaxin® 500 mg one tab twice daily for 10 days. Activity as tolerated.
Case created by Carrie Loberg, 2010.