# data[].attributes.body
Initials: M.Z.

Age: 4 months old

Sex: Male

Weight: 7.749 kg

NKA

ER chief complaint: hematuria

Admitting diagnosis: fever & probable pyelonephritis

Pt. ill for 3 days leading to admission, fever up to 38 degrees with some associated rigors that decreased with Tylenol

Pt. had previous bouts of pyelonephritis secondary to Enterococcus faecalis and Klebsiella

# data[].attributes.body
Pain typically not reported by caregivers

FLACC scale - 0/10

When observed, pain managed with Tylenol & Advil and holding

Anti-pyretic meds helped reduce fever

# data[].attributes.body
CWMS satisfactory

Capillary refill: 1-2 seconds

Pulse oximetry within range (100% O2 sats on RA)

BP: 93/52

HR: 124 (apical pulse regular)

Elevated rectal temperature initially up to 39.9 degrees in ER. Temperature within range (36.6 degrees axillary) upon writer's assessment

# data[].attributes.body
Abdomen rounded, soft upon palpation

Bowel sounds active in all 4 quadrants

No nausea/vomiting/diarrhea

Decreased oral intake leading to admission, but has since been feeding by breast and bottle

# data[].attributes.body
Decreased urine output

Some dysuria

Urine darker/orange coloured & stronger smelling at beginning of admission but has since became clear and colourless/yellow

# data[].attributes.body
Some cough leading to admission, no congestion

Lung sounds clear bilaterally

RR increased with fever at beginning of admission, but no other signs of distress

No apnea

# data[].attributes.body
Braden Scale (lowest risk): no limitations with mobility, skin rarely moist (routine diaper changes), no apparent problem with friction-shear, tissue perfusion & oxygenation excellent, nutrition adequate

# data[].attributes.body
D5NS at left foot, initially infusing @ 10 ml/hr, then 5 ml/hr, then decreased to 3 ml/hr

# data[].attributes.body
Family members are actively involved in care

Mom and sister present at bedside at all times. While mom cannot speak English, sister is able to help translate and effectively communicate needs and concerns to healthcare team

Dad also present at bedside and conveyed concerns to writer and nurses as they arose

Family very appreciative of nurses

# data[].attributes.body
Lives in Abbotsford with parents, 18-year-old brother, and sisters ages 16, 12, 10 and 6

Family recently emigrated from Afghanistan

Mom only speaks Farsi, but sister at bedside can communicate in English

# data[].attributes.body
Pt.'s father is the sole breadwinner for the family

Family has some relatives and close friends within the Afghan community who offer support

# data[].attributes.body
Piaget: Sensorimotor (birth to 18-24 months)

Erikson: Trust vs. Mistrust (birth to 1 year)

M.Z. was born at 37 weeks gestation via healthy, spontaneous vaginal delivery with no pregnancy complications. Immunizations are up to date. At 4 months old, this patient cries but quiets when fed and comforted. He makes eye contact and will recognize familiar faces, including those of his mother and sibling who are always present at the bedside. He remained pleasant during the majority of assessments. He is able to reach for objects, and was shown to increase activity when his sister showed him a toy.

# data[].attributes.body
CRP (ref <7.5): initial (207.9), trending downwards (97.3, 49.3, 24.3)

Sodium (ref: 135-145): slightly low at 134

Urine leukocyte esterase (ref: neg): 25

Estimated GFR not performed

Urine glucose/ketones/blood/nitrite: neg

Urine pH (ref: 5-7): 6.5

# data[].attributes.body
IV D5NS for decreased oral intake

Tylenol and Advil for pain and fever

IV Ceftriaxone to treat infection