Patient Summery Report

1. BIODATA:
• Name: Peter Kirui
• Age: 5 years
• Gender: Male
• Contact Details: (Mother's Phone) +254 712 3456782. PRESENTING COMPLAINT:
• Complaint: Cough, difficulty breathing, and fever.
• Duration: 4 days.3. HISTORY OF PRESENT ILLNESS:
• Peter started with a mild cough and low-grade fever four days ago. Over the next two days, the
cough worsened, becoming productive, with yellow-green sputum. His mother reports Peter has
been experiencing difficulty breathing, especially at night, and he is breathing faster than usual.
He also complains of chest pain when coughing. The fever has persisted, with the highest
recorded temperature being 38.5°C (101.3°F). He is less active than normal and has a reduced
appetite. There has been no vomiting, diarrhea, or exposure to known sick contacts.4. PAST MEDICAL HISTORY:
• No history of previous hospitalizations or significant illnesses. No known allergies. His growth
and development have been normal for age. He has had occasional colds but no history of
chronic respiratory issues or recurrent infections.5. IMMUNIZATION HISTORY:
• Up-to-date with the Kenyan Expanded Programme on Immunization (KEPI). Received all routine
childhood vaccinations, including measles and pneumococcal vaccines.6. FAMILY HISTORY:
• No family history of asthma, tuberculosis, or other chronic respiratory conditions. His siblings
are healthy. No recent travel history outside the locality.7. SOCIAL HISTORY:
• Peter lives with his parents and two siblings in a semi-urban area. The family uses firewood for
cooking, and there is often smoke exposure in the home. No pets. Peter attends a local
kindergarten.8. SYSTEMIC EXAMINATION RESULTS:
• General Appearance: Ill-looking, febrile, and appears mildly dehydrated. Lethargic but
responsive to stimuli.(i) VITAL SIGNS:
o Temperature: 38.3°C (100.9°F)
o Respiratory Rate: 38 breaths per minute (tachypnea)
o Heart Rate: 120 beats per minute (tachycardia)
o Oxygen Saturation: 94% on room air(ii) RESPIRATORY EXAMINATION:
o Chest wall movement asymmetrical, with reduced expansion on the left side.
o Dullness on percussion over the left lower lung zone.
o Auscultation: Decreased breath sounds on the left side with coarse crackles and
occasional wheeze.(iii)CARDIOVASCULAR EXAMINATION:
• Normal heart sounds, no murmurs.
• Abdominal Examination: Soft, non-tender, no organomegaly.
• Neurological Examination: Alert and oriented, normal tone and reflexes.9. SUGGESTED PROVISIONAL DIAGNOSIS:
Left lower lobe pneumonia.10. SUGGESTED DIFFERENTIAL DIAGNOSES:
• Acute bronchitis
• Tuberculosis
• Asthma exacerbation with superimposed infection
• Foreign body aspiration (less likely given history)SUGGESTED DIAGNOSTIC TESTS:
• Full Blood Count
• Chest X-ray
• Pulse OximetrySUGGESTED TREATMENT PLAN:
o Antibiotics: Amoxicillin 500 mg, taken orally three times daily for 7 days.
o Antipyretic: Paracetamol 250 mg, taken orally every 6 hours as needed for fever.
o Oral rehydration solution to prevent dehydration.SUGGESTED SUPPORTIVE CARE:
o Encourage fluids and small frequent meals.
o Monitor respiratory status and temperature.
o Advise rest and limited physical activity.SUGGESTED FOLLOW-UP PLAN:
• Review in the outpatient clinic after 2 days.
• Immediate return to the hospital if symptoms worsen, such as increased difficulty breathing,
persistent high fever, or signs of dehydration.

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