CHIEF COMPLAINT: Nasal congestion and cough.
SUBJECTIVE: The patient is a 3-year-4-month-old previously healthy male who presents with a 3-day history of nasal congestion and cough. According to him and mom, he began having nasal congestion initially and the snot became more green on the day of presentation. He has also been fussy today and has had decreased appetite only today.
Mother reports that he has been drinking well. He has had good urine output. No change in stool. He has had no vomiting; although, he did complain of mild abdominal pain today, earlier in the day, that has since resolved. He has also had cough, which mother says that although he has had no mucus production with the cough, it has sounded “wet.” He has been afebrile through this course and has no known sick contacts; although, he is in preschool 3 days per week.
The patient has a history of viral-induced wheezing and has been given an albuterol inhaler in the past. They have not been using the inhaler with his cough because mother says that it does not sound the same as when he was originally prescribed the inhaler. His last use of the inhaler was about 2-3 weeks ago. He does take Flonase and Zyrtec every evening for allergies and is continued on these medications. Mother has given him no other medicines with the current illness.
PAST MEDICAL HISTORY:
1. Viral-induced wheezing.
2. Allergic rhinitis.
ALLERGIES: No known drug allergies.
OBJECTIVE:
VITAL SIGNS: Temperature 97.6, heart rate 106, respiratory rate 30, blood pressure 88/60, weight 15.6 kg, which is 57th percentile for age; height 96.5 cm, which is 24th percentile for age, for a BMI of 16.8, which is 81st percentile for age.
GENERAL: Awake, alert, sitting in a chair in the exam room next to mother, pleasant and interactive throughout the exam.
HEENT: Normocephalic, atraumatic. Pupils are equal, round, reactive to light. Conjunctivae are clear without injection or exudate. Nares patent with some erythema and swelling of the turbinates and some obvious nasal crusting. Oropharynx with mild erythema of the posterior oropharynx. No exudate. TMs clear on the right without signs of effusion. Left is slightly more dull but no obvious effusion.
NECK: Supple with shotty cervical lymphadenopathy.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. Good breath sounds bilaterally, not tachypneic. No flaring. No respiratory distress, no retractions.
HEART: Normal rate, regular rhythm. No murmurs.
ABDOMEN: Soft, nontender, nondistended. No hepatosplenomegaly or mass.
SKIN: No rashes.
EXTREMITIES: Moves all extremities well. DP pulses 2+ bilaterally. Capillary refill less than 2 seconds peripherally.
ASSESSMENT: The patient is a 3-year-4-month-old male with 3 days of rhinorrhea and cough without fever consistent with a viral upper respiratory infection.
PLAN:
1. Continue supportive care including good oral hydration and Tylenol or Motrin for fever or pain.
2. Described to mother that symptoms are currently consistent with a viral upper respiratory infection; however, a bacterial infection could develop. She was given signs to look for further progression of symptoms, including prolonged fever, respiratory distress and inability to tolerate p.o.
3. Recommended followup as needed for worsening symptoms or next scheduled well-child check. Recommended continuation of Flonase and Zyrtec as previously prescribed.
