Pedatric Evaluation for Gabriel

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Thank you for referring Gabriel to the Pediatric Department for evaluation of his cough, fever, and possible right middle lobe infiltrate. I had the pleasure of seeing him with his mother and grandfather with Dr. Govan today in the Emergency Department. He was discharged home with a prescription for amoxicillin 90 mg/kg divided into 3 doses per day for 10 days, as well as Ventolin 2 puffs q.4h. for 2 weeks. We asked that he please follow up with his GP this Friday.

PAST MEDICAL HISTORY AND MEDICATIONS:

Gabriel is a previously healthy 20-month-old male with no significant past medical history and no medications. It should be noted that he did have one episode of otitis media in November, which was treated with amoxicillin. In terms of his birth history, he was delivered at 39 weeks gestation via spontaneous vaginal delivery. There were no issues with the pregnancy or with the delivery. Birth weight was 7 pounds, 11 ounces. His immunizations are up-to-date.

FAMILY HISTORY:

Family history is relevant for eczema, asthma, and hay fever allergies.

HISTORY OF PRESENTING ILLNES...

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