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Master Medical Report for Mira Sahin

Patient Information:

• Name: Mira Sahin

• Date of Birth: October 21, 2022

• Age: 18 months

• NHS Number: 7296238925

Medical Summary:
Mira was admitted to Addenbrooke's Hospital due to symptoms of a high fever and respiratory issues. Following evaluation, it was determined she is suffering from a viral infection. Recommendations for care include symptom management at home unless further complications arise.

Timeline of Events and Medical Interventions:

• May 2, 2024: Onset of symptoms; high fever begins.

• May 5, 2024:

• 3:30 PM: Ece calls 111 after Mira's condition does not improve.

• 4:15 PM: Mira is transported to Addenbrooke's Hospital.

• 5:45 PM: Mira is weighed for accurate medication dosing.

• 6:00 PM: Mira is officially admitted and given a bed.

• 6:30 PM: Urine sample collected.

• 7:25 PM: Mira experiences diarrhea.

• 8:00 PM: First blood sample is taken; doctor prescribes no antibiotics, citing no mucus buildup and a need to allow Mira's immune system to combat the viral infection.

• 8:40 PM: Temperature recorded at 39.6°C.

• Subsequent Days: Mira's fever management includes administering Calpol up to four times a day. Ibuprofen is added to the regimen to help control the fever.

• Dietary Notes: Mira manages to eat half an oat bar, half a banana, three bread sticks, and four mini strawberry apple paws.

Consultations and Medical Observations:

• Dr. Ehab: Assessed Mira, confirming no ear infection or significant mucus buildup. Advised against antibiotics to encourage natural immune response.

• Follow-up Instructions:

• Monitor for persistent vomiting, breathing difficulties, lethargy, or poor mobility.

• Return to hospital if temperature exceeds 40°C, or if other severe symptoms develop.

• Continue with nutritional support at home and monitor hydration.

Medication and Treatment Plan:

• Calpol (Paracetamol): Administered as needed for fever, not to exceed four doses per day.

• Ibuprofen: Added for additional fever control, to be taken as per doctor’s instructions ensuring hydration.

• Home Care: Focus on hydration, rest, and monitoring temperature.

Emergency Instructions:

• In case of severe symptoms such as high fever persisting above 40°C, difficulty breathing, or if Mira is unusually lethargic and not moving well, it is advised to return to Addenbrooke's Hospital without delay.

General Advice:

• Maintain a quiet, comfortable environment for Mira at home.

• Keep a detailed log of her temperature, symptoms, medication times, and doses to ensure comprehensive monitoring and to provide accurate updates to healthcare providers.

Conclusion:
This report compiles all key events, medical advice, and treatment plans related to Mira Sahin's recent health issues. Continuous monitoring and adherence to the prescribed treatment plan are crucial for her recovery. The healthcare team at Addenbrooke's remains available for consultation and further assistance as needed.

This master report provides a thorough overview of Mira's current medical situation and can be used for future reference or consultations with healthcare professionals. If any additional details or corrections are needed, please advise.

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