History
Identifying Data:
Full Name: ML3
Address: N/A
Date of Birth: N/A
Date & Time: 05/5/23, 10:00 am
Location: QHC
Religion: N/A
Source of Information: Mother
Reliability: Reliable
Source of Referral: Self
Mode of Transport: N/A
Chief Complaint: “My son has been coughing and having trouble breathing” x 1 day.
4 y/o with known history of asthma, up to date on all immunizations, brought in by EMS accompanied by mother for worsening cough and trouble breathing since yesterday. Mom notes cough is “barking” in quality and pt has been less reluctant to talk since it seems to trigger cough. She also notes pt endorses intermittent, generalized abdominal pain, but no pain today. Multiple treatments of albuterol have been given since yesterday and 4 mL of prednisone (prescribed by PMD) was given to the patient today with minimal improvement. Denies headaches, fever, chills, nausea, vomiting, diarrhea, dysuria, nasal congestion, ear pain, sore throat, recent sick contacts, or recent travel.
Initial DDx:
Croup
Asthma Exacerbation
Bacterial Tracheitis
Epiglottitis
URI
Past Medical History:
Childhood Illnesses- Asthma
Immunizations – Up to date; flu vaccine yearly
Screening test and results – N/A
Past Surgical History:
No past surgical history.
Denies any blood transfusions.
Medications:
Albuterol, prn for asthma exacerbations
Allergies:
NKDA
Family History:
Mother – 32 y/o, alive and well
Dad – 33 y/o, alive and well
Maternal grandparents – alive and well
Paternal grandparents – alive and well
Denies family h/o cancer, asthma, kidney disease, or diabetes.
Social History:
Patient lives with mother and father.
Habits –No history of smoking, alcohol abuse, or history of illicit substances. Denies drinking coffee.
Travel – No recent travel.
Diet – Has a well-balanced diet.
Exercise – Mom states he is pretty active.
Safety measures – Admits to wearing a seatbelt.
Sexual Hx – N/A
Review of Systems:
General –Denies recent weight loss or gain, fever or chills, night sweats, loss of appetite or generalized weakness/fatigue.
Skin, hair, nails – Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.
Head – Denies headache or head trauma.
Eyes – Denies lacrimation, pruritus, visual disturbances. Does not wear glasses.
Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids.
Nose/sinuses –Positive for rhinorrhea. Denies epistaxis, or nasal polyps.
Neck – Denies localized swelling/lumps or stiffness/decreased range of motion
Breast – Denies lumps, nipple discharge, or pain.
Mouth/throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes or use dentures.
Pulmonary system –Positive for cough. Denies dyspnea on exertion. Denies wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).
Cardiovascular system –Denies irregular heartbeat, chest pain, edema/swelling of ankles or feet, syncope or known heart murmur.
Gastrointestinal system – Positive for abdominal pain. Usually has regular bowel movements daily. Denies nausea and diarrhea. Denies vomiting, intolerance to specific foods, dysphagia, pyrosis, unusual flatulence or eructations, jaundice, hemorrhoids, or constipation.
Genitourinary system – Denies dysuria and blood in urine. Denies nocturia, urinary frequency, urgency, oliguria, polyuria, incontinence, or flank pain.
Menstrual/Obstetrical – N/A
Musculoskeletal system – Denies muscle/joint pain from arthritis. Denies deformity or swelling, or redness.
Nervous – Denies loss of strength or weakness. Denies seizures, headache, ataxia, change in cognition.
Peripheral vascular system – Denies peripheral edema, intermittent claudication, coldness or trophic changes, varicose veins, or color changes.
Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, or history of DVT/PE. Denies blood transfusion.
Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter
Psychiatric – Denies depression/sadness, anxiety, OCD or ever seeing a mental health professional.
Physical
General: Male appears clean & casually-groomed, alert & active. Also has good posture and well-developed. Does not appear to be acute distress.
Vital Signs: P: 112 beats/min, regular
R: 24 breaths/min, unlabored
O2 Sat: 98 % on room air
T: 37.1 degrees C (oral)
Weight: 19.8 kg
Head, Skin, & Nails
Hair: Average quantity and distribution. Black color. Curly texture. No evidence of lice or seborrheic dermatitis.
Skin: Warm and moist, smooth texture, good turgor.
Nails: No clubbing, capillary refill <2 seconds in upper and lower extremities
Head: Normocephalic, atraumatic, non-tender to palpation throughout.
Eye Exam
Eyes – No strabismus, exophthalmos, or ptosis. Sclera white, cornea clear, conjunctiva pink. Visual acuity uncorrected – 20/0 OS, 20/20 OD, 20/20 OU. Visual fields full OU. PERRLA, EOMs intact with no nystagmus.
Fundoscopy – Red reflex intact OU. Cup to disk ratio< 0.5 OU. No AV nicking, hemorrhages, exudates or neovascularization OU.
Ear Exam
Symmetrical and appropriate in size. No lesions/masses/trauma on external ears. No discharge/foreign bodies in external auditory canals AU. TM’s pearly white/infarct with light reflex in good position AU. Auditory acuity intact to whispered voice AU. Weber midlines/Rhinne reveals AC>BC AU.
Nose & Sinuses Exam
Nose – Rhinorrhea noted on anterior rhinoscopy. Symmetrical/no masses/lesions/deformities/trauma/discharge. Nares patent bilaterally/nasal mucosa pink & well hydrated. Septum midline without lesions/deformities/injection/perforation. No foreign bodies.
Sinuses – Non-tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.
Mouth & Pharynx
Lips – Pink, moist; no cyanosis or lesions. Non-tender to palpation.
Mucosa – Pink ; well hydrated. No masses; lesions noted. Non-tender to palpation. No leukoplakia.
Palate – Pink; well hydrated. Palate intact with no lesions; masses; scars. Non-tender to
Palpation; continuity intact.
Teeth – Good dentition / no obvious dental caries noted.
Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge. Non-tender to palpation.
Tongue – Pink; well papillated; no masses, lesions or deviation. Non-tender to palpation.
Oropharynx – Well hydrated; no injection; exudate; masses; lesions; foreign bodies.
Tonsils present with no injection or exudate. Uvula pink, no edema, lesions
Neck Exam
Neck– Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to
palpation. FROM; no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no cervical adenopathy noted.
Thyroid – Non-tender; no palpable masses; no thyromegaly; no bruits noted.
Thorax & Lungs:
Chest – Symmetrical, no deformities, no trauma, Respirations unlabored andno use of accessory muscles noted. Lat to Ap diameter 2:1. Non-tender to palpation throughout.
Lungs – Croupy cough. No wheezing, rales, stridor, or rhonchi. No nasal flaring or retractions. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout.
Cardiac Exam
Heart: PMI in 5th ICS in midclavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate & rhythm. S1 & S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.
Abdominal Exam: Abdomen flat and symmetric, and no scars, striae, or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/iliac or femoral bruits. Pt is non-tender to palpation in all four quadrants. (-) guarding. (-) obturators sign, (-) psoas signs, (-) rebound tenderness. No hepatosplenomegaly to palpation, no CVA tenderness appreciated.
Neurologic:
Mental status: Patient is alert. Cranial nerves II-XII intact. Recent and remote memory is intact, attention, abstract thinking, and new learning ability are intact. Pt has good muscle bulk and tone with strength 5/5, no fasciculations. Cerebellar: Rapid alternative movements, finger to nose intact. Gait including normal stride, on toes, on heels, and tandem walking intact. Negative Romberg and Pronator Drift. Sensory: Pinprick, light touch, graphesthesia, stereognosis, position and vibration intact bilaterally.
Reflexes:
| Biceps | Triceps | Brachioradialis | Patellar | Ankle/Achilles | Babinski | |
| Right | 2+ | 2+ | 2+ | 2+ | 2+ | absent |
| Left | 2+ | 2+ | 2+ | 2+ | 2+ | absent |
Peripheral Vascular: Extremities are normal in color and temperature, no edema. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing or cyanosis. No stasis changes or ulcerations noted.
Musculoskeletal (Upper Extremity): No soft tissue swelling / erythema /
ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM of all upper and lower extremities bilaterally. No evidence of spinal deformities.
Assessment:
4 y/o male with a history of asthma presents with rhinorrhea and mild barking cough most consistent with croup and abdominal pain most likely due to constipation. Will order respiratory viral panel to rule out any respiratory viral infection and abdominal x-ray for suspected constipation. Start Albuterol nebulizer treatment and Decadron, then reassess.
Labs:
Respiratory Viral Panel (Cepheid): negative
Imaging:
Abdominal X-ray: Copious amounts of stool visualized throughout the colon and non-obstructive bowel gas pattern. No abnormal calcifications.
Differential Diagnosis After:
Croup – Patient has the classic “barking/seal-like” cough on exam.
Reassessment:
On reassessment patient is not having any respiratory difficulty but continues to present with “barking” cough. Respiratory viral panel negative. Abdominal x-ray shows signs of constipation.
Plan:
Start Miralax 0.5 packets (8.6g in total) by mouth daily for 14 days for constipation. Continue Albuterol treatments as needed for asthma exacerbations. Discussed Croup diagnosis with mother and explained that cough will resolve on its own within a few days. Also explained that supportive care is the mainstay of treatment. Supportive care instructions were given including fluid intake and antipyretics for any spike in temperature. Strict follow up precautions for which to return were given if signs and symptoms of respiratory distress are noted. Mother also instructed to follow up with PMD within 3-4 days.
