At the Family Doctor's surgery
You are the family Doctor in a city based practise. Your next patient is Rory Gallagher, a four month old boy. His mother has brought him to you to check him over to make sure nothing is wrong. She tells you the following:
You collect a little more information; you find he was born normally at term, that he is the mother and her boyfriend’s first child, that he is smiling, fixing and following with his eyes, and is beginning to control his head better. He is up to date with his immunisations too.
You decide to examine him:
HR 145/min, RR 35/min, capillary refill 2 sec, temp 37.3 C
Slightly pale, but not clinically anaemic.
Pink in air.
Unhappy and intermittently crying.
Runny nose, some large airway crackles in the chest on both sides, no recession.
Heart sounds and pulses normal
Abdomen soft and not distended. Bowel sounds heard. Liver 1 cm below costal margin.
You note some marks on the skin, in the right axilla, the right side of the abdomen and at the top of the natal cleft.
Anterior fontanelle full. Moving all limbs. Responding to being moved by further crying. Not interested in surroundings.
His mother is keen to take him home again as she has some shopping and cooking to do, but could bring him back or even take him to the hospital tomorrow if tests are needed.
What is the most appropriate plan at this stage?
Map: TAME case 5 - Rory Gallagher (Branched Tutor version) (279)
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