Case description for C-Takes documenting:
Setting: Inpatient.
Specialty: Pediatrics. 
Note detail level (1-5): 5.
Level of abbreviation (Low/Medium/High): Low.

CC/HPI:  
X was in her regular state of good health when, at 0200 2 Feb, she awoke crying. Her mother thought she felt hot. She performed an axillary temperature at that time. She reported the temperature to be 104F. She then administered a "children's dose" of Tylenol. The patient reached a temperature of around 101 to 102F. Her mother then took her to the ER. This was around 0900. At the time of assessment in the ER her temperature was 104F. The patient was then taken to the staff pediatrician in the clinic. After a full physical exam revealed no other likely source of infection a urine specimen was collected by catheter. Lab results of this specimen showed >100WBCs and moderate leukocyte esterase. X was ordered at that time for Septra 5mL PO BID and Tylenol 4mL PO q4-6. She was then sent home with these prescriptions. However, the patient vomited the medications. Her mother and she returned to the pediatric clinic for refractory fevers and inability to tolerate PO antibiotics. At this time X had a seizure as described by her mother: her eyes rolled up in her head and she went rigid and kind of vibrated. This was in the waiting room of the pediatric clinic. The pediatrician was called but the episode was over. The patient was then admitted to 5w due to seizure, failure of outpatient medical management, and inability to tolerate PO medication. 

ROS: 
Her mother reports decreased feeding. She also reports decreased wet diapers, with only a few "barely wet" ones. Further, she denies lethargy, SOB, pulling at ears, rhinorrhea, or cough. She also denies diarrhea and does not feel there is anything else out of the ordinary.

Past Medical History:  
The patient was delivered via c-section at 39+5. No infectious risk factors were identified at birth. She showed no signs or symptoms of congenital syndromes or diseases; In other words, the perinatal period was uncomplicated. Since her birth there was one instance of lacrimal duct stenosis that has been resolved and a case of roseola two months ago that has also resolved.

Past Surgical History:  
No reported past surgical history.

Allergies:
No known drug or food allergies.

Medications:
Tylenol 4mL, last dose at 1540 - vomited.
Septra 4mL, last dose at 1540 - vomited.

Vaccinations:
Reviewed and current as of 2Feb2013.

Diet:  
She is currently taking formula, mushed rice and cereal.

Social History: 
X lives at home with her two brothers, four and seven, two cats, and her mom and dad. She is not enrolled in day-care. Mother and father are happily married. Mother works at a middle school. Father is in the Navy.

Family History: 
No history of persistent UTI or VUR. No family history of seizure. 

PE:
Weight on admission: 6.8kg
Vit: T 104, HR 141, RR 28, SPo2 97% on RA.
Gen: X is a sick appearing infant female in mild distress. She is clinging to her mother and crying.
Neuro: There is not any ptosis or facial asymmetry. There are not signs of focal neurologic deficit. Her pupils are equal in size and reactive to light.
HEENT: Mucous membranes are dry. There is not deformity, swelling, nor hematoma; No venous distention or gaping sutures. Her tympanic membranes are clear bilaterally. There is not erythema or exudate in the pharynx, nor cough. The patient's nares are patent bilaterally. There is not rhinorrhea. Her red reflexes are intact bilaterally. There is not any periauricular, occipital, cervical, or submandibular lymphadenopathy. 
CV: No murmurs rubs or gallops. Her heart has a regular rate and rhythm. 
Pulm: Her chest is clear to auscultation bilaterally. There are not any wheezes, rales, nor rhonchi. 
GI: Her abdomen shows no distention and there are normal bowel sounds in all four quadrants. On palpation there are no signs of hepatosplenomegaly. 
GU: There is not any vaginal discharge. She has normal appearing female genitalia without erythema. 
MSK: She moves all extremities without impairment. 
Integumentary: There are not any rashes nor lesions.

Labs/Ancillary:

Urinalysis Site/Specimen

WBC URINE >100 (H) 
RBC URINE 28 (H) 
Bacteria URINE OCCASIONAL (H) 
Mucus URINE RARE 
Color URINE YELLOW 
Clarity URINE SLIGHTY CLOUDY 
pH URINE 6.0 
Specific Gravity URINE 1.016 
Protein URINE 50 mg/dL (1+) (H) 
Glucose URINE NEGATIVE 
Ketones URINE TRACE (H) 
Bilirubin URINE NEGATIVE 
Blood URINE SMALL (1+) (H) 
Nitrite URINE NEGATIVE 
Urobilinogen URINE NORMAL 
Leukocyte Esterase URINE MODERATE (H) 

Problem list:
Inability to feed. 
Low diaper count. 
Labs concerning for UTI. 
Fever.
Vomiting. 
Seizure. 

A/P:  
X is an 8 month old female in mild distress who appears ill. She has had a two day history of high fever and a likely episode of febrile seizure. She also has a UA concerning for UTI and is very volume-down. There is not any lethargy at this time nor focal neurologic deficits/signs nor continued seizure. However, she is unable to tolerate anything PO. Her vital signs are otherwise stable. 

1. UTI w/ fevers and seizures:
- IV access, CBC, blood cultures x1
- Rocephin 50mg/kg IV daily. Adjust as needed by culture.
- Tylenol 120mg PR q6.
- Motrin 85mg PO q8 as tolerated and PRN.

   * Renal Ultrasound to r/o renal scarring and hydronephrosis. 
   * EEG to r/o seizure disorder. 

2. Dehydration:
- IVF:  mIVF D51/4NS @35cc/h.
- I/O:  daily weights and record In/out/diapers.
- Diet:  Formula and clears Po ad lib.

3. Seizure:
- With further seizure, spinal tap and culture CSF. 

4. Further workup:

   * If recurrent UTI, w/u for VUR with VCUG.

