SUBJECTIVE FINDINGS:

Patient ID: J.T., 7-year-old white male, single, student, seen on 4/4/18. Pt is in the clinic with
mother who is a reliable historian.

Chief Complaint: Cough that is worse at night and limiting activity and congestion.

HIP: Mother states pt has had a cough for 2-3 weeks that worsens at night time and limiting pt
activity. The patient has been congested starting within the last week. Mother states the pt felt
warm last night but did not have his temperature measured. Patient does not complain of
abdominal pain, diarrhea, or constipation. Mother notes the patient’s appetite is slightly
decreased. Patient has been using rescue inhaler 3 times in the last week and taking daily allergy
medications.

PMH: Pt has a history of Reactive airway disease that was diagnosed with RSV at 12 months
old. Pt was diagnosed with allergic rhinitis at three years of age. Pt had PE tubes placed at age
four with no other surgeries or hospitalizations noted. NKDA. No history of blood transfusions
or psychiatric history.

Personal History: pt is an elementary school student, single. Lives with mom, dad, and 2
younger siblings in a single-family home.

Social History: Pt does not have tobacco use but father smokes in home sometimes. No alcohol
use, no illicit drug use. Unknown economic status or health insurance statue. Pt has shelter but
unknown if he has access to food, clean water, or electricity. Exercise and dietary habits
unknown.

Health Maintenance: Last PE and labs unknown. Up to date on vaccines. Pt had flu vaccine last
fall.

Allergies: NKA

Family History: Mother is living and healthy, Father is living with asthma, brother is living with
asthma and allergies, sister is living and healthy, Grandparents are living and healthy. No history
of HTN, Cancer, DM, heart disease, or stroke.

Current Medications & Treatments: Pt is taking Pro Air albuterol MDI HFA with spacer 2
puffs every 4-6 hours as needed for SOB/Chest tightness and use 2 puffs 15-30 minutes before
exercise or strenuous activity. Singulair 5mg daily. Claritin 10mg daily.

Review of Systems

General: Pt felt warm last night with no temperature measured. denies chills, malaise, fatigue,
night sweats. 


Diet: Slight decrease in appetite. Denies restriction in diet, taking vitamins or supplements
Skin, hair, nails: Denies rash, lesions, eruptions, itching, pigment changes

Head and Neck: denies headache, dizziness, head injuries, loss of consciousness

Eyes: Denies Blurring, double vision, visual changes, wearing glasses, trauma, and eye disease.

Ears: Denies hearing loss, pain, discharge, dizziness, ringing in ears

Nose: Congestion noted for about one week. Pt takes daily medications for seasonal allergies
during spring. Denies nosebleeds, postnasal drip.

Throat and mouth: Denies hoarseness, sore throat, bleeding gums, ulcers, tooth problems

Gastrointestinal: Denies indigestion, heartburn, vomiting, constipation, stool changes

Lymph: Denies tenderness and enlargement

Endocrine: Denies intolerance to heat or cold, changes in weight, excessive thirst or urination,
hair changes, or a change in hat, glove or shoe size.

Cardiovascular: Denies chest pains, palpitations, swelling, exercise intolerance. Sleeps with one
pillow

Chest and Lungs: Intermittent Productive Cough present with clear/white sputum, pt has
shortness of breath and needing to use rescue inhaler, dyspnea on exertion. Denies night sweats
and exposure to TB

Hematology: Denies anemia and easy bruising

Genitourinary: denies pain with urination, flank pain, urgency, frequency, nocturia, hematuria,
and dribbling

Male: Denies puberty onset and testicular pain

Musculoskeletal: Denies joint pain, warmth in joints, or swelling in joints

Neurologisc Denies fainting, weakness, loss of coordination

Mental status: Denies trouble concentrating, sleeping, eating, socializing, changes in mood, or
suicidal thoughts

OBJECTIVE FINDINGS:

Physical Exam:
VS: Ht 47 inches, Wt: 58 lbs, BP: 98/64, HR: 105, RR: 18, Temp: 100.4, Peak Flow: 150, O2: 96%

General Appearance: A&Ox3, 7 year old white male mildly ill appearing, gait and posture
intact, appropriately dressed for weather.

Head, Neck, Throat: Head normocephalic, oval without deformities. Hair is evenly distributed
throughout without infestation. Temporal arteries without bruits. Trachea midline without
tugging. Cervical range of motion intact. Carotid arteries symmetrical, pulse waveform with
distinct beginning and end without bruit. Thyroid symmetrical, no enlargement, no tenderness,
no lumps. No jugular venous distension. No lymphadenopathy.

Eyes symmetrical, irises brown, pupils equal and reactive to light bilaterally. Conjunctiva pink,
Sclera white, no drainage or discharge bilaterally. No strabismus. No nystagmus. Normal eye
movement bilaterally. Visual fields intact bilaterally.

Ears rounded, even with outer eye canthus, helix firm bilaterally. Ear lobes symmetrical. No
deformities, no lesions, no drainage externally. Internal auditory canal without drainage, redness,
edema, pain, and tenderness bilaterally. Left tympanic membrane visible, grey, translucent
without inflammation, Landmarks visible, cone of light at 8 o clock. Right tympanic membrane
red and bulging, no landmarks visible.

Nose and Mouth appropriate size for face, color confluent with entire face. Nasal mucosa pink
and moist no turbinates visible. No discharge, no sinus swelling or tenderness. Septum midline.
Lips pink, moist, symmetrical. Buccal mucosa pink and moist without lesions. Teeth clean,
without braces, no dental carries. Gums pink and moist without bleeding and tenderness. Tongue
soft, pink, midline with full range of motion intact. Tonsils +1 without swelling, exudate, or
drainage. Posterior pharynx erythematic with petechia present. Uvula midline. Hard and soft
palates intact. Palatine arch rounded.

Skin, Hair, Nails: skin uniformly warm and dry, resilient, turgor < 2, no edema. Tan in color,
olive overtonesHair has male distribution pattern. Nails are nontender, medium length, clean,
without deformities. Nail bed pink, nail base 160 degrees, no redness, exudate, or swelling
around folds.

Chest/Lungs: Skin pink and warm. No pallor. No cyanosis. AP/Lateral Ratio 1:2, no barrel
chest, no pectus excavatum, no pectus carinatum. Chest movement symmetrical, Respirations
equal and regular, non-labored, no accessory muscle use. Chest expansion symmetrical.
Resonance on percussion over all lung fields. Wheezing auscultated in all fields.

Heart/blood vessels: PMI nondisplaced at 5th intercostal space at the midclavicular line.
Regular heart rate and rhythm. S1 and S2 equal. No splitting, no murmurs, no bruits, no lifts, no
heaves, no thrills. Carotid pulses equal bilaterally with crescendo and decrescendo, rate regular.
No JVD. Pulses 2+ bilaterally on upper and lower extremities. No edema.

Abdomen: Skin pink, no venous pattern visible. Abdomen rounded and symmetric. No
distension. Umbilicus midline, no herniations, no masses. Bowel sounds active in all four
quadrants. No hepatomegaly, no splenomegaly. Tympany predominant in all four quadrants. No
tenderness on palpation.

MS: Gait is even, equal stride and appropriate base support. Curvature of cervical, thoracic, and
lumbar spine is appropriate. No kyphosis, no lordosis. Joints appropriate size and contour with
no swelling or crepitus. All joints have full range of motion. Muscle strength 5/5 in all
extremities. No edema, spasms, masses, atrophy, hypertrophy in any muscle groups bilaterally.

Neuro: Awake, alert3. Coordination and fine motor skills intact. All reflexes 2+ bilaterally.

ASSESSMENT

Differentials:

1) Influenza (J10.1) is typically seen with an acute onset, high fever, headache, dry cough,
and achy muscles and joints. This patient had all symptoms usually associated with
diagnosis
2) URI (J06): signs and symptoms include congestion, runny nose, cough that may affect
sleep, fever may be present, increase pressure in middle ear. Complications include
AOM, asthma exacerbation, sinusitis.
3) Allergic Rhinitis (J30.1): presents with nasal congestion, sneezing, clear rhinorrhea,
puffiness of eyes, post nasal drip, cough, sore throat.
4) Acute Bacterial Sinusitis (J01.80): presents with symptoms lasting more than 10 days
without any improvement, high fever, purulent nasal discharge, headache, facial pain,
cough, ear pain, sore throat
5) Strep Throat (J02.0): present with sudden onset of fever, headaches, sore throat, cold type
symptoms like nasal congestion
6) Acute Otitis Media (H66.001): presence of moderate to severe bulging of the TM,
erythema of TM, seen following a viral upper respiratory infection
7) Otitis Externa (H60.8X): tenderness of the tragus, pinna, diffuse ear canal edema, ear
canal erythema, otorrhea.

Problem List: Mildly intermittent productive cough with clear/white sputum for 2-3 weeks,
SOB and use of rescue inhaler, wheezing in lungs, congestion for one week, 100.4 temperature,
petechial in posterior pharynx, red/bulging tympanic membrane.

ICD10 and CPT codes:

- Cough- R05
- Fever- R50.9
 - URI- J06
- AOM- H66.001
- Nasal congestion- R09.81
- Rapid flu- 87804
- Rapid strep- 87800
- Exam: 99214
- CBC- 85025

PLAN

Diagnostics: Flu test negative, Rapid strep test Negative, CBC with normal limits, CXR clear

I suspect that this child started out with some type of allergic rhinitis that progressed into
a URI. URIs can cause some of his other symptoms like and exacerbation of undiagnosed asthma
which would lead him to need to use his rescue inhaler. This child also has acute otitis media
which is often seen following a URI. URIs are typically treated symptomatically. The patient
should continue to take antipyretic medications like Tylenol and Motrin to reduce fever. It is
important for the patient to stay hydrated during this time as well. The patient can take a cough
suppressant and decongestant if necessary. I would think about giving this patient an antibiotic
because the symptoms have lasted for a long period of time and is also dealing with AOM. When
treating AOM for a patient older than 24 months you can prescribe antibiotics for severe AOM
or do watchful waiting based on a joint decision-making with parent. Amoxicillin is the first line
antibiotic is the pt has not received it in the last 30 days. Dosage for amoxicillin would be 80-90
mg/kg/day in two divided doses.

I would consider giving this child an in-office Albuterol nebulizer treatment to help with
the exacerbation of the asthma type symptoms he is having. He is experiencing some wheezing
in the office. This child has no officially been diagnosed with asthma but the symptoms he is
experiencing along with the need to use the inhaler before exercise would lead to believe he has
untreated asthma and is having an asthma exacerbation. If after this child has been treated for the
current illness and is still using his rescue inhaler more than 2 times a week he will need to step
up in treatment. He may eventually need referral for an asthma specialist and future allergy
testing

It is important to educate the patient on the importance of taking all of the prescribed
medication even when they begin to feel better they should finish the medication. The patient
should also be reeducated on the correct use of an inhaler and be able to correctly demonstrate
the correct usage back to provider. The patient should follow up or call if the symptoms worsen
or if they do not get better within a week. Make sure to remind patient to cover mouth and nose
when coughing or sneezing to prevent the spread of germs. Washing hands is also key in the
prevention of spreading disease. No referral to be made at this time.
Resources: Clinical Guidelines to Family Practice, Up to date