History of Present Illness:
19-month old patient presenting with unexplained, intermittent consolable crying and subfebrile temperatures (max 38.0°) since the previous day, as well as a single episode of non-bilious vomiting after breakfast. No further abnormalities in the review of symptoms.
Past Medical History:
Viral pharyngitis 10 days prior, symptom free interval of 1 week. Atypical Kawasaki 6 months prior. Vaccinations according to guidelines.
Patient in fair general condition, afebrile, vitals stable, mild pharyngitis, further examination without pathological findings.
We decided on symptomatic treatment and follow-up the following day.
The Patient returns the same evening due to progressing symptoms (persistent crying) and febrile temperatures.
Physical Examination 2:
Decreased general condition wihle febrile with tachycardia and tachypnea (normal vitals after antipyretics), mild pharyngitis and possible abdominal tenderness. Further examination without pathological findings, notably no nuchal rigidity.