Identifying Data:

Full Name: D.T

Address: Queens, NY

Age: 5 months old

Race/Nationality: Hispanic 

Date and Time: 9/7/2021 7:00 AM 

Location: QHC Pediatric Emergency Department 

Source of Information: Mother 

Source of Referral: Mother 

Reliability: Unable to assess reliability of patient due to age 

Mode of Transport: Private vehicle 

Chief Complaint: cough x four days 

History of Present Illness: 

5-month-old full-term male, with no PMHx, who presents to the ED with mother for cough x four days. Per mother, the patient was congested last week, and she brought him to the pediatrician, who prescribed cough syrup, mother is unsure of the name of the medication, and recommended using a humidifier. Mother states that since then, the patient’s congestion and cough have been worsening. She reports she brought him in today because he started to have shortness of breath last night, which worsened this morning. Mother reports a subjective fever, rhinorrhea, and decreased appetite, stating the patient is not finishing his bottle. Mother denies giving the patient any medication for the fever. She denies that the patient has weight loss, vomiting, change in bowel habits, change in wet diaper amounts or any other symptoms at this time. Mother denies any sick contacts at home or recent travel. Mother states the household is not vaccinated for COVID-19. 

Past Medical History:

• Denies.
• Denies any hospitalizations, transfusions, or injuries. 

Past Surgical History:

• Denies 

Family History: 

• Mother: alive and well
• Father: alive and well 

Medications:

• Denies 

Allergies:

• No known drug, food, or seasonal allergies.  

Immunizations:

• Up to date.

Social history:

• Patient lives at home with mother and father in a nonsmoking household. 
• No recent travel

Nutrition:

• Patient currently has a decreased appetite but is tolerating his formula. 

Sleep:

•  Denies difficulties 

Review of Systems: 

General: Admits to fever and decreased appetite. Denies fatigue, weight loss/gain. 

Skin: Denies dry skin, rash or pruritus. 

Head: Denies head trauma. 

Eyes: Denies change in vision.  

Ears: Denies discharge, tinnitus, ear tugging. 

Nose/Sinuses: Admits to nasal congestion and rhinorrhea.

Mouth/throat: Denies bleeding gums, mouth ulcers. 

Neck: Denies neck stiffness, localized swelling/lumps or decreased range of motion. 

Respiratory: Admits to cough and shortness of breath. Denies wheezing, sputum production. 

Cardiovascular: Denies leg edema, hypertension, syncope. 

GI: Denies abdominal pain, vomiting, hematemesis, diarrhea or constipation. 

GU: Denies hematuria or change in wet diapers. 

MSK: Denies redness or decreased range of motion. 

Physical Exam: 

VS: T 99 F, HR 156 bpm, RR 44, O2 sat 92%, Wt 9.072 kg 

Gen: Alert and oriented. Well-developed and well-nourished. Strong cry.

Skin: Warm and dry. No rashes, lesions or pigmentations.

Head: Normocephalic, atraumatic. 

Ears: Ear canals with no swelling bilaterally. Tympanic membranes normal bilaterally. 

Eyes: Pupils equal and reactive. Sclera non-icteric. Red reflex normal bilaterally. 

Mouth/Throat: uvula midline, no erythema, or exudates. 

Neck: Trachea midline, supple. 

CV: Regular rate and rhythm. S1 and S2 with no murmurs. Pulses within normal limits. 

Resp: Lungs with wheezing in all lung fields. Retractions present.

Abd: Soft, non-tender, no masses. No organomegaly. 

Neuro: Alert 

Ext: 2+ capillary refill to all digits. 

Differentials: Bronchiolitis, pneumonia, COVID-19, reactive airway disease

Assessment: 

5-month-old male, with no PMHx, who presents for a cough and congestion x four days with associated fever and shortness of breath. On physical exam patient has retractions with wheezing in all lung fields. 

Plan: 

• Order GenMark respiratory panel 
• Order DuoNeb 3 mL once 
• Monitor the patient

Addendum: 

• Patient’s respiratory panel positive for RSV and rhinovirus 
• Patient received two additional albuterol 2.5 mg each with improvement.
• Patient is currently in no acute distress and currently is not tachypneic
• Patient will be discharged home with return precautions given. Discussed that the mother should return with the patient if the patient has worsening difficulty breathing, fever or any other concerning symptoms. Discussed mother can switch between Ibuprofen and Tylenol as needed. Mother was agreeable with the plan. All questions answered.