HPI: 16moF otherwise healthy, presents with fever and fussiness. Has had 4 days of upper respiratory symptoms with decreasing PO over this same time. Yesterday she had vomiting, though the parents deny and blood or bile. Today has taken only minimal formula and has gone 12 hours without a wet diaper. Presents for further evaluation.

ROS:

Gen: Fever. Decreased energy, fatigue, fussiness

HEENT: +congestion, rhinorrhea,

Pulm: No cough, no breathing difficulty

CV: no color change, no sweating with feeds

Ab: +Vomit, no diarrhea

Extremities: no rashes, no bruising

Neuro: fussy, no seizure like activities

PHMx: FT, SVD; no surgeries

Vax: received 2mo and 4mo shots; family has not been able to get her into PCP since 4mo visit

SH: Lives at home with Dad

Exam:

Vitals: T-39.5, HR- 181, RR-45, BP: 96/52, SaO2: 99% @RA

GEN: Very fussy, difficult to console

HEENT: anterior fontanelle is full, scant nasal secretions

Pulm: CTAB

CV: Tachycardic; No murmurs

Ab: soft, NTND

Extremities: 2-3s CR, no bruising

Neuro: difficult to console at time, CN2-12 intact, good strength and tone throughout

Following the course of action you took in question 1, lumbar puncture is attempted. After 2 attempts, you get the following:

Nuc Cells: 1800 (80% Neutrophils 18% Lymphs)

RBCs: 200

Protein: 150

Glucose: 70

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