4 year old with pneumonia sent home from hospital

Case Overview

• Location: FL
• Age/Gender: 4 years old, Male
• Past Medical History:
• Past Surgical History:

The patient was a four-year-old male, up-to-date with vaccinations and with no prior medical history; he did attend daycare.

- 5/31/2023: to ED (at St. Lucie)
o Mom said nausea/vomiting, cough, fever, not eating normal amount, drinking “some.” Evaluated elsewhere 5/30/2023 and given Zofran; worse today w/ 101 fever at home, worsening cough and c/o abdominal pain.
o ED vitals @ 2027: T 103.1, HR 184, RR 22, O2 89% on RA  started on O2 mask
 2259: T 98.5, HR 144, RR 30, O2 100% on mask
o PE:
 General “NAD, cooperative, well appearing, playful”
 Lungs: “Bilateral wheezes, decreased breath sounds on the right, no retractions, oxygenating in the low 90s on 3 L nasal cannula”
 Abd: “Periumbilical, RLQ tendernesss, soft, no rebound, guarding, no CVA tenderness”
o Labs:
 WBCs 14.9 H
 Hgb 10.6 L
 HCt 31.1 L
 Sodium 132 L
 BUN 20 H
 Glucose 143 H
 Negative for COVID-19, Influenza A and B, Group A Strep Screen, RSV Antigen
 Blood cultures pending
o CXR Impression: “Consolidated infiltrate in the mid to upper right lung and mild mid left lung infiltrate.”
o CT Abdomen & Pelvis w/ Impression: “1. Constipation. 2. Incidentally noted is a consolidated infiltrate and atelectasis the right lung base, mild to moderate right pleural effusion, left lung densities likely infiltrates only partially included on this study. Chest imaging recommended with consideration for CT scan.”
o Dx pneumonia, hypoxemia, periumbilical pain, RLQ pain (per coding summary)
 ED Primary impression at 2201: Right middle lobe pneumonia
• Secondary: Hypoxia, right upper lobe pneumonia
o “Sepsis bundle” initiated; transferred to Lawnwood to pediatric ER MD
 Ceftriaxone, DuoNeb, 20 mL/kg fluid bolus
 Also given acetaminophen at 2057
 “Blood cultures pending” at discharge
 Transfer accepted at 2208
o At some point, blood cx + for penicillin resistant Strep pneumo
 Resistant to ceftriaxone, penicillin, erythromycin
 Susceptible to vancomycin, levofloxacin
 Notification from lab to hospital of gram positive cocci on 6/1/2023 at 2201
 Notification from lab to hospital of final results on 6/3/2023 at 1331
 No indication Lawnwood or patient ever told

- 5/31/2023: transferred to Lawnwood ED for pediatric ED doctor
o ED provider report @ 2334:
 “… Went to St. Lucie today where patient was diagnosed with right-sided pneumonia meeting sepsis criteria and having hypoxia. Was given ceftriaxone but no azithro. Sent here for peds admit. On 2L face mask here….”
 ED Vitals @ 2346: T 36.8, HR 147, RR 24, BP 117/66, O2 100% on mask
 PE:
• Gen: “Well appearing/NAD”
• Abd: “Soft/non-tender”
• Resp: “No resp distress”
• Etc.
 Azithromycin IV 181 mg given in ED
 MDM Notes: “Patient meet sepsis criteria secondary to right-sided pneumonia. Titrated down to 2 liters nasal cannula. Will add azithromycin to cover for atypical pneumonia. Pediatric hospitalist called for admission. Patient admitted in stable condition.”
• Primary impression: Pneumonia involving right lung
• Secondary impression: Hypoxia, sepsis


- 6/1/2023:
o Nursing records:
 0110: “transported via stretcher with mom at bedside and ED nurse, pt asleep with O2 via mask, no acute distress noted at this time, on RA O2 at 100%. IV on left AC patient, intact with Zithromax infusing….”
 0115 Sepsis Screening:
• Temp: no
• HR: yes
• RR: yes
• WBC results / band results: “No results past 48 hrs”
• Pediatric glucose results: “No results past 48 hrs”
• Etc. -- (criteria met)
 0115: Pain Assessment:
• Face: occasional grimace 1
• Activity: Lying quietly 0
• Cry: Moans or whimpers 1
• Total score: 2
• Pain location: Abdomen
• Pt on RA 100%, “pulse ox continue”
 0122 Vitals: T 37.3, HR 148, RR 24, O2 100%; LOC alert
 0400 Vitals: T 98.2 axillary, HR 134, RR 24, O2 100% on RA
 0411: Pain assessment 0
 0730 Vitals: T 38.0 oral, HR 177, RR 28, O2 100% on RA
 0800 shift assessment:
• Respiratory:
o Respirations even and unlabored: No
o Respiratory effort and pattern: Accessory muscles use, shallow
o Bilateral lung sounds clear, equal and undiminished: No
o All lobes: “Snoring”
• Cough/sputum: Intermittent non productive cough
• Mouth/throat: dry, cracked lips
• Abdomen: Firm, w/ generalized/diffuse tenderness to palpation; bowel sounds active x4, passing flatus
• Everything else WNL
• Sepsis assessment same as above; positive for severe sepsis: 1 – “Dr. Freeland notified”
• Pain assessment score 2
o Admitted for observation – Peds H&P:
 Time 6/1/23 @ 1055 – accurate?
 CC: Fever
 HPI: “This is a 4 y/o male who presented to the ER with fever and vomiting. Mother reports that patient started with vomiting on 5/28/23. No diarrhea, but mother reports constipation. The following day, he started with fever. No cough, nasal congestion, or difficulty breathing. [WTF?] Pt does attend daycare.”
 Vitals @ 0730:
• T 100.4
• HR 177
• RR 28
• O2 100% on RA
 PE:
• General: “appropriate, no apparent distress, not toxic appearing”
• Respiratory: “normal breath sounds, no distress”
• Abdomen: “normal bowel sounds, non-tender, soft”
 Labs noted: Mycoplasma pneumoniae IgM non-reactive
 Diagnosis, Assessment & Plan:
• “This is a 4 y/o male with pneumonia.”
• Plan:
o Admit to peds for obs
o Vitals Q4
o Continuous pulse ox
o Peds diet
o Tylenol/motrin PRN
o Rocephin IV
• “Pt with no respiratory distress or hypoxia since admission. Stable for d/c home on oral antibiotics. Return to ER if any concerning symptoms.”
• Signed at 1101 – so it appears this H&P was done at the same time as the discharge summary.
Further nursing notes:
1120 Vitals: T 36.9, HR 145, RR 26, O2 100%
 1241: PIV discontinued
 1243: time of discharge
• Discharge vitals: T 36.9, HR 145, RR 26, BP 117/66, O2 100% (these are all old)
o Discharged
 Rx Cefdinir 250 mg/5 mL suspension, 5 mL PO daily x 10 days
• At some point this was apparently changed to Augmentin because Cefdinir was unavailable
 To f/u w/ PCP in 2 days

- 6/3/2023: to ED at Lawnwood – initial greet time 2219:
o “Pt was brought to the ED 4 days ago for resp distress and admitted for pneumonia, sent home next day on Augmentin. Fever, cough, and congestion have persisted, and today pt developed diarrhea x3 and vomiting x1. Still seems to have trouble breathing.”
o ROS: Mom reports decreased appetite and activity, nasal congestion, cough, shortness of breath, diarrhea, vomiting, decreased urination
o Vitals @ 2216: O2 95% on RA, BP 109/68, T 38.1, HR 177, RR 22
o PE:
 General: “Awake, alert, tired appearing”
 Respiratory/Chest: “Atraumatic, tachypnea (RR 60s), Wheezing mild, Retractions moderate”
 All else WNL
 Clinical impression: Pneumonia.
• Secondary: Loculated pleural effusions.
o Labs:
 Sodium 132 L
 CO2 16 L
 BUN 47 H
 Calcium 8.0 L
 Total Bili 4.3 H
 AST 192 H (ALT 23 WNL)
 WBCs 13.7 (WNL)
 Hgb 8.1 L (Hct TNP)
 Plt 124 L
 RSV antigen, COVID-19, Influenza A negative
 Influenza B positive
o CXR impression:
 1. Opacification of the right upper and lower pleural spaces concerning for loculated pleural effusions. Cannot exclude loculated empyemas as the patient has a diagnosis of pneumonia.
 2. Diffuse opacification of the right lung corresponds with pneumonia.
o CT chest w/ contrast impression:
 1. Right upper lobe consolidative pneumonia is visualized, extending from the anterior right upper lobe towards the apex.
 2. Parapneumonic effusion, which is loculated is visualized mostly within the lower pleural space, with the loculated portion extending anterolaterally.
 3. Irregular appearing cystic spaces within the aerated left lower lobe adjacent to the pneumonia and pleural effusion.
o 0021: on FiO2 24, flow rate 20 (?)
o 0103: Pt accepted for transfer to Palms West for PICU
o 0225 Vitals: T 37.2, HR 156, RR 22, BP 106/57, O2 100% on HFNC, Flow rate 2

- 6/4/2023: Admitted Palms West
o Admitted to PICU
 Seizures a few hours later --> intubated
 Hgb 2.2, plt 51k
 Coombs + IgG --> multiple transfusions, IVIG
o Septic shock w/ multi-organ dysfunction, acute respiratory failure, DIC, seizures 2/2 necrotizing pneumococcal pneumonia w/ right-sided parapneumonia empyema
o Stormy course

- 7/6/2023: discharged home on enalapril, amlodipine, clonidine

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