Gender: Male

Age: 4 years old

Date: 3/15/21

Chief Complaint: “barking cough” x 3 days

History of Present Illness:

EG is a 4 year old boy with no past medical history presenting with his mother, complaining of barking cough, rhinorrhea, and nasal congestion x 3 days. Mother states coughing began 3 days ago, and was nonproductive and “sounded like a seal,” so she took him to the emergency room, where they diagnosed him with Croup, stated he had left-sided stridor, and gave him one dose of prednisone. She presents to the office today for follow up evaluation, stating that the cough improved yesterday but returned and worsened again last night, and was accompanied by fever of 101 degrees Fahrenheit. Mother states cough has been worse at night than it is during the day. Mother denies administering any medications to the patient, other than the prednisone he got at the hospital. Additionally, mother states child has been more irritable over the past few days. Denies loss of appetite, nausea, vomiting, diarrhea, SOB, wheezing, voice changes, abdominal pain, dizziness, recent travel, or sick contacts.

Past Medical History: No significant PMHX.

Immunizations: All vaccinations up to date.

Past Surgical History: Denies previous surgeries or blood transfusions

Medications: None

Allergies: none

Family History:

Mother –25, alive and well

Father –26, alive and well

Sister -2, alive and well

Social History:

EG attends preschool. Mother works as a teacher, father is a contractor.

Habits – Mother denies any smoking in the household.

Travel – Mother denies any recent travel.

Diet – Mother states that for the past few days he eats a balanced diet.

Review of Systems:

General –Admits to fever beginning last night. Denies recent loss of appetite, weight loss, generalized weakness/fatigue, or night sweats.

Skin, hair, nails – Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.

Head – Denies head trauma.

Eyes – Denies itching, other visual disturbances, does not go to eye Dr.

Ears – Denies any changes in hearing.

Nose/sinuses –Mother admits to clear nasal discharge x 3 days. Denies obstruction, or nose bleeds.

Mouth/throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers.

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion

Pulmonary system – Admits to barking nonproductive cough x 3 days. Denies wheezing, difficulty breathing, coughing up blood, blue coloration.

Cardiovascular system – Denies loss of consciousness.

Gastrointestinal system –Denies intolerance to specific foods, nausea, vomiting, diarrhea, constipation, difficulty swallowing, heartburn, unusual abdominal pain, diarrhea, jaundice, constipation, or blood in stool.

Genitourinary system – Denies urinary frequency or urgency, decreased or increased urination.

Nervous – Denies seizures, headache, loss of consciousness, sensory disturbances, imbalance, loss of strength change in cognition / mental status / memory, or weakness.

Musculoskeletal system – Denies muscle/joint pain, deformity or swelling, redness or arthritis.

Peripheral vascular system – Denies swelling of lower legs or hands, or color changes.

Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions.

Endocrine system – Denies increased drinking, eating, or urination, heat or cold intolerance, excessive sweating.

Physical Exam

General: Well-appearing, well-nourished, alert and oriented x 3.

Vital Signs:

R: 22 breaths/minute, unlabored P: 116 beats/minute, regular

T: 100.5 degrees F (tympanic)   O2 Sat: 100% on room air

Height: 40 inches Weight: 38 lbs. BMI 16.7

Skin: Warm and moist, normal turgor.

Hair: Average quantity, even distribution, smooth texture. No signs of seborrhea, lice, or nits.

Nails: No clubbing, capillary refill < 2 seconds throughout.

Head: Normocephalic, atraumatic, nontender to palpation.

Eyes: Symmetrical OU, No evidence of strabismus, exophthalmos, or ptosis. Sclera is white, conjunctiva pink, and clear. Full visual fields, PERRLA

Ears: Symmetrical and normal size. No evidence of lesions, masses, or trauma to external ears. No discharge or foreign bodies in external auditory canals AU. Tympanic membranes pearly gray with cone of light well seen. Auditory acuity intact.

Nose: Nasal mucosa moist with clear discharge from bilateral nares. Symmetrical, no obvious masses, lesions, deformities, trauma. Septum midline without lesions, deformities, injection, or perforation. No evidence of foreign bodies.

Mouth and Pharynx: Pharynx is slightly red, uvula pink, no erythema/lesions, tonsils present. Lips pink and moist without cyanosis or lesions. Non-tender to palpation. Palate pink and well-hydrated, without lesions, masses, scars. Non-tender to palpations, continuity intact. Palate rises symmetrically. Postnasal drip noted in posterior pharynx. Gingivae pink and moist. Tongue pink, well-papillated

Neck: Thyroid nontender to palpation, no thyromegaly or bruits noted. No palpable lymph nodes.

Lungs: Clear to auscultation bilaterally, no audible wheezing, rhonchi, or stridor. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus intact throughout.

Heart: Normal heart rate. S1 and S2 noted. No murmurs, S3, S4, splitting of heart sounds, friction rubs or extra sounds.

Abdomen: Symmetrical; soft, non-tender, no palpable masses

Extremities: No evidence of clubbing, cyanosis or edema. DP and TP pulses 2+ B/L and equal.

Assessment:

EG is a 4 y/o male with no significant pmhx who presented to the office today with his mother c/o barking cough, nasal congestion, rhinorrhea x 3 days, and fever since last night.

Differential Diagnosis:

1)  Croup (laryngotracheobronchitis)- has barking cough that is worse at night, fever, had stridor in hospital

2) Viral URI- has fever, cough, rhinorrhea, and  nasal congestion

3) Influenza- has fever, cough, rhinnorhea, congestion, cranky

4) Bronchitis- has fever, nonproductive cough, rhinnorhea, congestion, irritable

5) Covid-19- has fever, cough

6) Bacterial Pharyngitis- fever, throat redness. Less likely to be strep. Bacterial due to cough, rhinnorhea, nasal congestion

Plan:

1) Cough, nasal congestion, rhinnorhea- Orapred 1 tsp at bedtime for 5 days. Use cool mist humidifier as needed, or shower vapors. Return if symptoms do not resolve or worsen in 2-3 days.

2) Fever, irritability- Motrin/Tylenol PRN.