Age: 6.0
Sex: F
Vaccine: FLU4
Symptoms: Fluid intake reduced, Gastrointestinal sounds abnormal, Glucose urine absent, Haematemesis, Haematuria
Clinical narrative: 01/09/23 Reason for Appointment  1. Vomiting, right side pain since thursday.starts in the front and wraps around to theback. has had discomfort on the left side some. vomiting has increased. 50 cent peiceamount that looked like blood, clumped. not eating. constant pain. will moan in painafter walking. here with mom  Assessments  1. Generalized abdominal pain - R10.84 (Primary)  2. Nausea and vomiting, unspecified vomiting type - R11.2  3. Other constipation - K59.09  Treatment  1. Generalized abdominal pain   Notes: use simethicone drops to help wtih gas pain Due to patient age input from and independent historian (caregiver) was needed to complete this visit.     2. Nausea and vomiting, unspecified vomiting type   Start Ondansetron HCl Solution, 4 MG/5ML, 2.5 ml as needed nausea, Orally, every 4hours, 2 days, 30 ml, Refills 0  3. Other constipation   Notes: use chocolate exlax or rectal suppository if no BM by this evening. symptoms secondary to constipation but with hyperactive BS I would not be surprised if she is starting with a stomache virus as well.     Follow Up  call with update later today  History of Present Illness  HPI:          thursday evening started with abd pain that was localized to the right side of her abd. then she complained that it started to go to her back. she started vomiting friday evening. she did go to school on friday. she continued to vomit on sunday and seemed to worsen. she was up a lot last night with abd pain. no dysuria. no diarrhea. normal BM this morning but patient said it was only a "little bit". BM did not help the pain. no fevers. patient was here last week and with noted firmness to LLQ. mom reports that she had bought some juice to help with stooling. last BM prior to this morning was thursday last week. patient very tearful with notable discomfort during questioning. she is not eating well. mom did note what appeared to be blood in one of her emesis. but it was not noted again after that.   Vital Signs  BP: 104/62 mm Hg, Pulse sitting: 110, RR: 20 /min, Temp: 98.8 F, Wt: 45.2 lbs, Oxygen sat %: 97.  ________________________________________________________________________________ 1/9/2023 3:24:11 PM > mom called stated that she has given gas drops  2-3 and nausuea meds 2x. pt is still crying in pain. mom ask pt where pain is and pt points to middle of stomach. pt is saying she isn't feeling any but pt did fall asleep for a little bit earlier.  pt is not eating and has only had a few sips of water. mom is wondering if she should give pt allergy med tonight? . i mentioned trying popcicles to help with fluid intake? 1/9/2023 5:00:48 PM > have her give the exlax or suppositories   1/9/2023 5:03:34 PM > advised mom, she will call back in the morning with an update.   1/10/2023 9:01:24 AM > mom gave nausea med at about 2 then mom gave popcicle at about 4 and pt threw it up. at 6:25pm mom gave nausea med. then at 6:40pm mom gave 1/2 dose of exlax  and pt threw up within 15 min. then at 7:30pm mom gave another 1/2 dose and pt didn't throw up until about bed time then pt woke up throwing up at 11. mom was wondering about giving pt a full piece of exlax and if she did do the full piece does she need to wait to give supos? pt still hasn't pooped.  1/10/2023 10:18:28 AM > give her the full exlax and a suppository at this point. give exlax 30 min after a dose of zofran   1/10/2023 10:27:22 AM > gave mom info.   1/11/2023 9:55:56 AM > mom stated pt did poop. few small brown solid poop, pt is still having alot pain but hasn't thrown up. pt is drinking more but still not eating as much. mom stated pt is having skin discoloration/ splotchy purplish, red on ankle and feet. mom hasn't noticed them being any colder to the touch.  1/11/2023 10:01:11 AM > I am going to order an abd xray. have her give her another enema today as well.  1/11/2023 1:17:13 PM > i added labs to the xray. please have mom get them done today  1/11/2023 1:19:09 PM > mom has already done xray but will be taking pt back to do lab work today.  1/12/2023 7:50:37 AM > attempted call with no answer. left vm for return call  1/12/2023 8:23:58 AM > mom states labwork was done yesterday at 430p. called lab, lab states it was put under the wrong patient? she is faxing results now. 1/12/2023 10:35:34 AM > based on labs/UA will empirically treat for HUS. need stools specimen collected before starting ATB but start ATB today. advised to go to ED with uncontrolled pain or worsening rash to legs. mom aware and voices understanding 1/12/2023 4:31:41 PM > spoke with mother. they gave patient an enema and she had a decent BM but has not had another one since then. pain slightly improved with BM. advised to give chocolate exlax to try and get her to have another BM and collect that stool for culture  1/13/2023 12:21:22 PM > mom called back and patient is in severe pain after starting ATB. she is taking her to  ED. report called to ED physician  01/17/2023  Reason for Appointment  1. dx with HSP aka IGA. mom and pt report that pt is doing better. still has intermittentdiscomfort and the rash has increased again. pt is able to eat now. here with mom Assessments  1. HSP (Henoch Schonlein purpura) - D69.0 (Primary)  2. Asymptomatic microscopic hematuria - R31.21  3. Other proteinuria - R80.8  Treatment  1. HSP (Henoch Schonlein purpura)        LAB: URINALYSIS W/REFLEX TO MICROSCOPIC       Notes : 1/18/2023 8:16:00 AM > trace blood and protein which is less than last week. will repeat UA next week along with VS during a nurse visit. please schedule NV after school 1/18/2023 8:26:08 AM > nv scheduled for monday the 23rd. 1/18/2023 8:27:20 AM > notified dad of result and reminded of apt on monday.  Notes: improving. continue to monitor.     Follow Up  1 week for UA and BP check  History of Present Illness  HPI:          Hospital follow up. admitted inpatient for pain control. BP was elevated and had blood in urine so kept for observation. she is feeling better overall but rash is not resolving. no fevers. no gross hematuria. no headaches. abd pain mostly resolved. she is now having BM's and constipation is improving as well. she is starting to eat more again as well. discharged on oral steroids.  Vital Signs  BP: 108/64 mm Hg, Pulse sitting: 99, RR: 20 /min, Temp: 97.6 F, Wt: 47.4 lbs, Oxygen sat %: 99.   Since this, patient has been seen in office weekly for urine analysis and vitals. Patient has had persistent protein in her urine and has had to follow with Nephrology and Gastroenterology as it has persisted and she has had flare ups since. She has presented to ER additionally for her flareups.  3/13/2023 ? patient was seen by nephrology and weekly urines and vitals were discontinued. We plan to follow-up with her in 2 months for a urinalysis and vitals.