T3 – Respiratory Case 3

Triage note:  

2yr old boy  

Whole family have had fluey colds this week  

Pt temperature fluctuating and chesty cough  

Summer holiday in Scotland this year ended up admitted with bilateral pneumonia  

Doesn’t appear as unwell as he did then but obviously parents concerned  

Examining clinician note:  

Whole family been unwell, all improving except for him  

Has had cough for 1w, fevers for last 4d  

Wet sounding cough, has been more clingy, appetite reduced  

Drinking well and wet nappies  

Temp 39.3  

HR 160  

RR 48  

O2 sat 94%  

No tracheal tug or recession  

Crackles and wheeze heard left base  

CRT 2 sec  

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