Assesment pedi

The patient, a child, was brought to the ER with a chief complaint of an allergic reaction to a spider bite. The assessment revealed some symptoms such as irritability, crying, and a red rash on the left leg. The patient had a fever, but it decreased after medication. An x-ray was ordered to rule out a foreign body in the left foot. The patient was given medication for pain and inflammation. Sepsis was ruled out. Initially, the doctor considered transferring the patient to another facility but decided to discharge the patient as they seemed stable. The mother was given discharge instructions and medication for the wound and rash. The patient's condition improved upon discharge. I'm Alexis Bikes, I'll be completing my pediatric assessment review on patient WM that was present to JMH ER on 2-16-24. Before my assessment was started, I did receive verbal consent from the patient's mother to continue. This patient was transported by private car to the ER by his mother. The chief complaint at admission was an allergic reaction to a spider bite. The patient is alert with some irritability and crying noted. Vital signs and triage were 102.6 for the temp, 197 pulse, 26 respiration, 92% O2 on room air, blood pressure was 103 over 64. Patient's current weight is 10.89 kilograms. Mother denies any nausea or vomiting. Patient also stated she had not given the patient any medication in the past 24 hours nor had the babysitter. Perla with no drainage or abnormalities noted to the eyes bilaterally. Patient was able to move all extremities and they were all equal and present. Patient currently taking no routine home medications. No history of any surgeries or illnesses. No family history of any respiratory issues. Lungs are clear in all four quadrants. No accessory muscles present while breathing. No respiratory distress. Normal breathing patterns noted. Skin color is pink. However, the patient did have a red rash on the left side, on the left leg that started from his foot and moved upward to his knee. Level of consciousness is appropriate for age. Some anxiety was noted while not being held by the mother when the nurse was present in the room. The chest is symmetrical in size. There is no cough noted. There is some nasal drainage that was present while the patient is crying with no nasal flaring. The drainage from the nasal cavity is clear and thin in small amounts. Capillary refill is one second. There is a family history of cardiac issues. The maternal grandmother has hypertension. There was no growth delays reported and there's also no difficulty breathing noted at this time. There was no murmurs, thrills, or rubs noted upon auscultation. Peripheral pulses are palpable and equal in strength. There is some edema, some swelling noted to the left foot. Patient nor family has any type of history with any type of GI issues. No nausea or vomiting noted. Patient is fatigued primarily from crying. No difficulty swallowing. Abdomen is non-extended, equal in size, is palpable, bowel sounds heard in all four quadrants. The patient is hydrated, no signs and symptoms of any type of dehydration noted. Necus membranes are moist and pink. Mother states that the patient has a good appetite with no weight loss noted from the last physician visit. His food preferences are preferably junk food. She does state that she does get him to eat green leafy vegetables at least three times a week. Fluid intake for the past 24 hours was 2400 mLs of fluid. Last bowel movement noted was this morning, which was solid and brown in color. The mother states that he did have some issues with constipation a week ago, however they have subsided. There is no history of any endocrine issues in neither the patient nor the family. There is no history of any type of urinary issues in neither the patient or the family. The patient has not had any type of weight loss or weight gain significantly within the last primary visit. There's no bruising noted. The patient does have some edema noted to the left foot that may be stemming from the infection. The mother does not state that she has started to potty train the child. The child is still wearing diapers and incontinent of bowel and bladder. Urine output, the child did have one wet diaper while in the waiting room. The pee color was yellow, there was no odor that was noted. All male urinary characteristics are present and no abnormalities are noted. There are no history of any muscular skeletal issues in the patient nor in the family. All extremities are present and equal in strength. All extremities are also symmetrical. There's no webbing of the digits or noted. There's no limb discrepancies. There's no limitations on any ADLs within the range, the child's age range. There's currently no family history or history of patient having any type of integumentary issues. The patient does have a current integumentary issue to the left foot. There's a two by two puncture wound noted to the left foot. There's also some two plus edema noted to that left foot. And there's also a rash to the left leg that starts at the ankle of the foot and moves upward to the lower part of the knee in that leg. The left foot is warm to touch. The nail beds are pink. The patient does not verbally complain of pain, however, he does grimace when that foot is touched. There's no bruising noted anywhere, no surgical incisions, no pressure ulcers, no lesions. There is no vision or auditory impairment noted, nor was reported by the mother previously that was noted. There is current pain noted to the left foot. Patient has a FLAX score of eight. Also, patient is holding the left foot, pain seems to intensify with any type of touching or movement of the foot. The mother indicated that she had not given the child anything for pain, and that the mother also stated that the patient did not get any rest, average about two hours from the previous night due to pain in that left foot and had been holding that foot all night. Mother states that patient does not have any routine issues with any type of sleep. The mother does report that the patient does have a plush Spider-Man toy that he does sleep with at night, and he did not have it present at the babysitter last night, so that could be a factor as well. Upon triage, fever was noted at 102.6. The mother stated that in the past 24 hours, the babysitter noted that the highest temp obtained from the child was 104.2. That was axillary. English is the child and the family's primary language. The child is able to verbalize simple words within his age. Mother states that patient has not had any detectable disabilities or abnormalities when it comes to learning. The patient's mother states that he has hit all milestones up until when at years old from his checkups with his primary care for doctor. The mother did disclose that the family structure is a bit out of whack. She did state that they are going through some financial issues in which the child is staying at the babysitter's primarily while they are working one day, one night. The family consists of the mother, the father, and two siblings, one older and one younger. The mother voices fear of child being hospitalized and them not being able to afford it due to not having any health insurance. The patient's mother denies any type of religious beliefs, however, she did request that we do not send any type of spiritual intervention into the room. After assessment, the patient was completed and the doctor did go in and assess the patient. There were some orders that were written. We did obtain a 24 gauge to the left arm. He did order some lab work. We did a CBC, which in detail, the white blood cell count was 7.8, red blood cell 4.25, hemoglobin 11.4, the platelets is 335,000, NPV was 8.9 indicative of infection, sodium 136, potassium 4.3, chloride 104, carbon dioxide 20, the BUN is 10, creatinine is 0.5, and glucose is 96, just to touch on the high points. He also ordered an x-ray of the left foot. While speaking to the mother, the mother did disclose that the patient may have stepped on a nail and not actually a spider bite, so the x-ray was ordered to rule out any type of foreign body inside of the left foot. He also ordered a culture of the left foot as it has some purulent drainage noted. Medications that were ordered were rosepin, 816.45 milligrams IV, one time stat dose. We also gave acetaminophen, it's going to be 163.29 milligrams PO. This was to alleviate the initial temp of 102.6 for the fever. However, 45 minutes later, temp was obtained again, and the temp was 101.9, so the temp was going down. However, the child was still in pain, so he ordered another dose of ibuprofen at 108.86 milligrams PO, one time dose. Also, he ordered some solumedrol, 22 milligrams IV for one time dose for the inflammation. Lactic acid was obtained on this patient and came back at 1.3, so sepsis was ruled out at this time. Initially, the MD was moving toward sending the patient to a higher level of care. However, after the initial dose of the antibiotic, the steroid, and also the ibuprofen that subsided the fever, the MD said at that time he felt that the patient was stable enough to discharge home. The mother also agreed and stated that she understood the reasoning for the doctor's decision. Discharge instructions that were given to the mother was to keep the child hydrated, return to the ER if the patient had a recurrent rash on that left foot, or had any type of fever continuing that did not subside with Tylenol ibuprofen. The mother was also informed to return to the ER the next day for a follow-up around 1 p.m. should be when the cultures had been obtained to rule out any type of staph or MRSA. The mother was instructed to observe and monitor that left foot for any type of increased drainage or a color change in the drainage. The child was discharged home with some VACTRBAN ointment for the wound on the left foot, some Omniceft liquid, 125 milligrams per 5 ml, 75 milligrams PO, Q12 hours for 10 days, and then also some Benadryl, 12.5 milligrams, Q6 PRN PO for the rash that's on the left leg. The mother did also verbalize acceptance and understanding of the doctor's discharge instructions and then also agreed to follow up with the child's primary care physician on Monday. On discharge, the patient's temp was 99.0, pulse was 152, respirations 24, O2 was 98% on room air, blood pressure was 92 over 57, there was no distress noted, no irritability noted, child seemed to be in greater spirits with no pain.