Follow up DFASM2 4 – Irritability in An Infant

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Irritability in An Infant

 

Where?:

 Primary care physician’s office

Doctor’s name and Position

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Patient’s name:

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Age:

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Presenting complaint:

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- Irritability + fussiness

Past medical history:

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O/E:

- No sign of teething
- Normal throat
- Temperature 37.8°C
- Fontanelles + lymph nodes + abdominal exam = normal
- 28.7 inches
- 20.3 lbs
- Bulging + discolored eardrums

Diagnosis:

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Treatment:

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- Tylenol

Risk factors for amoxicillin resistance:

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Prognosis:

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Second visit : O/E - Treatment - What treatment is not recommended? - Prognosis:

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O/E: Fluid in Anthony’s ears

 Treatment: à Wait and see

 What treatment is not recommended? ATB, decongestants and antihistamines

 Prognosis: Anthony will probably be fine but observation for hearing loss. Check up in 3 months.

 

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