Age: 16.0
Sex: M
Vaccine: COVID19
Symptoms: International normalised ratio increased, Mean cell haemoglobin concentration normal, Mean cell haemoglobin normal, Mean cell volume normal, Mean platelet volume increased
Clinical narrative: HPI:  Patient is a 16-year-old male who was upgraded to our emergency department after blood work showed a significant thrombocytopenia.  Please see walk-in clinic provider NP for presenting history and physical exam.  Patient reports to me development of sore throat as well as blood from the throat last Thursday.  Patient also began to notice development of bruising to his legs without any injury approximately a week ago.  Denies any pain.  Denies any blood in the urine or stool.  No other medical complaints at this time.  Chief Complaint Patient presents with ? Sore Throat     was seen a few weeks ago for ear infection, also had sore throat at that time that never went away.  School nurse wanted him swabbed for strep and covid PCR ? Bleeding/Bruising     has large bruising to right leg for about a week, no injury.  also states bruise to upper left thigh and right shoulder and scattered small bruises.  School nurse wants his platelets checked.  Denies pain.  States mild bleeding in gums and states notices blood in back of throat       ROS:  See HPI above.  All other 12 review systems negative otherwise specified in HPI above. ROS   PMH:  Past Medical History Past Medical History: Diagnosis Date ? Asthma   ? GI symptoms 10/2018   with pharyngitis ? Headache   ? Strep throat   ? Tonsillar and adenoid hypertrophy     nasal scope     Past Surgical History Past Surgical History: Procedure Laterality Date ? COLONOSCOPY   12/07/2018   with biopsies ? ESOPHAGOGASTRODUODENOSCOPY   12/07/2018   with biopsies ? TONSILLECTOMY & ADENOIDECTOMY   2011     Family History Family History Problem Relation Age of Onset ? Hypertension Father   ? Diabetes Mellitus Father       Social History    Tobacco Use ? Smoking status: Never Smoker ? Smokeless tobacco: Never Used ? Tobacco comment: no second hand smoke exposure Substance Use Topics ? Alcohol use: No     Allergies: No Known Allergies   Meds:   No current facility-administered medications on file prior to encounter.    Current Outpatient Medications on File Prior to Encounter Medication Sig Dispense Refill ? albuterol HFA 108 (90 Base) MCG/ACT inhaler Inhale 2 puffs every 4 hours as needed. 1 inhaler 1 ? Aspirin-Acetaminophen-Caffeine (EXCEDRIN PO)       ? acetaminophen (TYLENOL) 325 MG tablet Take 975 mg by mouth every 6 hours as needed for Pain.     ? naproxen (NAPROSYN) 220 MG tablet Take 440 mg by mouth twice daily - with breakfast and supper.         Physical Exam:  Blood pressure (!) 148/93, pulse 107, temperature 98.6 °F (37 °C), resp. rate 20, height 6' 5" (1.956 m), weight (!) 348 lb 8 oz (158.1 kg), SpO2 96 %.   O2 flow:            Physical Exam  Constitutional: He is well-developed, well-nourished, and in no distress. No distress.  HENT:  Head: Normocephalic.  Right Ear: External ear normal.  Nose: Nose normal.  Mouth/Throat: Oropharynx is clear and moist. No oropharyngeal exudate.  Mild erythema in the posterior pharynx with some bleeding.  No posterior pharynx edema.  Eyes: Conjunctivae are normal. Right eye exhibits no discharge. Left eye exhibits no discharge. No scleral icterus.  Cardiovascular: Exam reveals no gallop and no friction rub.  No murmur heard. Pulmonary/Chest: Effort normal. No stridor. No respiratory distress. He has no wheezes. He has no rales.  Abdominal: Soft.  Left upper quadrant tenderness.  Musculoskeletal:        General: No tenderness, deformity or edema.     Cervical back: Normal range of motion.  Neurological: He is alert. Gait normal. GCS score is 15.  Skin: Skin is warm. He is not diaphoretic.  Multiple baseball to softball size bruises to the bilateral lower extremities worse on the right than left.  Mild petechiae.  Psychiatric: Mood, memory, affect and judgment normal.      Diagnostics:  Results for orders placed or performed during the hospital encounter of 05/10/21 CBC WITH DIFFERENTIAL Result Value Ref Range   White Blood Cells 7.72 4.0 - 13.0 K/uL   Red Blood Cells 3.48 (L) 4.15 - 5.30 M/uL   Hemoglobin 10.8 (L) 11.8 - 15.4 g/dL   Hematocrit 30.5 (L) 35.5 - 46.5 %   MCV 87.7 77 - 94 fL   MCH 31.0 25.0 - 32.3 pg   MCHC 35.4 31.9 - 35.9 g/dL   RDW 16.2 (H) 11.5 - 14.8 %   Platelet Count 9 (LL) 160 - 424 K/uL   MPV 11.4 (H) 6.8 - 10.5 fL   Neutrophil % Pending %   Lymphocyte % Pending %   Monocyte % Pending %   Eosinophil % Pending %   Basophil % Pending %   Absolute Neutrophils Pending 1.6 - 7.5 K/uL   Absolute Lymphocytes Pending 1.2 - 4.9 K/uL   Absolute Monocytes Pending 0.1 - 0.9 K/uL   Absolute Eosinophils Pending 0.0 - 0.6 K/uL   Absolute Basophils Pending 0.0 - 0.2 K/uL COMPREHENSIVE METABOLIC PANEL Result Value Ref Range   Sodium 138 133 - 144 mEq/L   Potassium 4.4 3.5 - 5.0 mEq/L   Chloride 101 95 - 107 mEq/L   Carbon Dioxide 22 22 - 32 mEq/L   Anion Gap 15 6 - 15 mEq/L   BUN 14 8 - 24 mg/dL   Creatinine 0.81 0.69 - 1.20 mg/dL   Glomerular Filt Rate NOT CALCULATED due to age less than 18 years. mL/min   Glucose 110 (H) 70 - 100 mg/dL   Albumin 4.9 3.5 - 5.2 g/dL   Calcium 10.0 8.6 - 10.4 mg/dL   AST 23 11 - 41 IU/L   ALT 28 (H) 0 - 19 IU/L   Alkaline Phosphatase 142 90 - 366 IU/L   Bilirubin, Total 0.4 <1.5 mg/dL   Total Protein 7.7 5.9 - 7.8 g/dL   Globulin 2.8 1.8 - 3.7 g/dL   A:G Ratio 1.8 1.2 - 2.7 PROTHROMBIN TIME Result Value Ref Range   Prothrombin Time 18.4 (H) 12.0 - 14.6 sec   INR 1.5 (H) 0.9 - 1.1 PTT, PARTIAL THROMBOPLASTIN Result Value Ref Range   PTT 32 23 - 36 sec CRITICAL VALUE HEME Result Value Ref Range   Critical Value              ED Course:   Patient was upgraded to the emergency department after he was noted to have significant thrombocytopenia.   Patient is pleasant he has no active complaints other than some throat irritation bleeding in the throat and bruising that was nontraumatic to the legs.  My physical examination reveals multiple rather large bruises to the bilateral lower extremities up to softball size worse on the right than left.  Patient had some mild left upper quadrant discomfort.  Very minimal bleeding in the posterior pharynx.   I personally reviewed the labs and CBC revealed an anemia at 10.830.5 hemoglobin hematocrit respectively.  Most notably a 9000 thrombocytopenia.  CMP essentially unremarkable.  INR 1.5 PTT normal.  I added on Lyme disease and tick-borne illness as well as a Monospot type and screen.   Patient did receive his 1st visor vaccine for COVID-19 on April 29, 2021.   IV was established in the emergency department in consultation made to Pediatric Oncology.     I spoke with pediatric oncology in regards to patient's history and present illness.  He does agree that the patient should in fact be transferred under the pediatric care but recommended under the general hospitalist service.  He did not advise to proceed with any active treatment in our emergency department such as gamma globulin, platelets or steroids.   Awaited call back from pediatric hospitalist and spoke with Dr.  She has agreed to accept the patient in transfer.   Patient and family are comfortable disposition plan no further questions at this time.   Impression: 1. ITP    Disposition: Transfer      ED on 5/10/2021   Revision History   Detailed Report  Note shared with patient Note filed date Mon May 10, 2021 12:24 PM