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Pediatrics Ben A. Kapinsky Jr Case Study
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Pediatrics Ben A. Kapinsky Jr Case Study
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Ben A. Kapinsky Jr.– Pediatrics1cc//1pmh
CC – Fatiuge, shortness of breath, and cough
Diagnosis – Staph Aureus CAP superinfection postinfluenza.
- Influenza, pneumonia-community aquired, pulmonary embolism, asthma
Tests- Chest x-ray pa and lat, ABG, CBC, influenza PCR, sputum culture, blood culture,
Problem Statement:
( Demographic description – chief complaint – Hx and PE key findings – risk factors )
Ben A. Kapinsky Jr. is a 18yo man presenting with complaint of fatigue, shortness of breath, and cough.
He states his symptoms started 4 days ago, he is coughing yellow-green sputum and has SOB on minimal
exertion as well as chest pain near the chest wall @ R-lung 6-8 th-intercoastal-space @ midaxillary-line.,
fever of 104 and hypoxemia (91%). PE shows dehydration, enlarged tonsils and tender-enlarged ant-
cervical lymph nodes. He’s had asthma as a child and reports getting over flu-symptoms 2 weeks ago.
CC: Ben A. Kapinsky Jr. is a 18yo man presenting with complaint of fatigue, shortness of breath, and
cough.
HPI: He states his symptoms started 4 days ago, he is coughing yellow-green sputum and has SOB on
minimal exertion as well as chest pain near the chest wall @ R-lung 6-8 th-intercoastal-space @
midaxillary-line., fever of 104 and hypoxemia (91%).
Meds: Ibuprofen for pain
PMH: Had flu like symptoms 2 weeks ago that resolved. Childhood asthma that has resolved
ROS: Only positive findings are seen in HPI
Physical Exam:
VS: Pulse – 120; BP – 120/80 RR – 24; T – 103.2F; SpO2 – 91%
Skin: Signs of dehydration
Mouth: Dry oral mucous membranes, Tonsils enlarged and erythematous w/o airway compromise
Neck: Tender 1cm -1.5cm anterior cervical lymph nodes, no posterior nodes palpable
Lung: auscultation shows coarse crackles in RLL and RML fi
ASSESSMENT/PLAN
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