BR is a 6 y/o male who presents to the clinic with his mother c/o fever, cough and congestion x3 days. Symptoms started 3 days ago, mainly as a runny, stuffy nose and slight cough, but patient is presenting now as the symptoms, particularly the fever and cough, appear to be worsening. Patient’s cough is productive and his breathing appears slightly labored. The cough is worse at night. Patient’s temperature was low-grade, 102 F orally, yesterday but mother hasn’t checked again today. Patient isn’t eating or sleeping well and is less active than usual. Patient looks ill and lethargic. Patient admits to difficulty breathing and sick contacts, his older brother who has similar symptoms but not as severe. Patient denies history of asthma.
Differential diagnoses:
bronchiolitis
influenza – parainfluenza
common cold – adenovirus, rhinovirus
Past medical history:
No significant pmh
Immunizations – all up to date
Past surgical history:
None
Medications:
None
Allergies:
None
Family history:
Father, 28 – alive and well
Mother, 27 – alive and well
Brother, 2 – also sick with congestion and cold
Social history:
BR lives at home with his parents and brother. Mother is primary caregiver, father works as a religious community figure.
Home environment – safe, has working smoke alarm and carbon monoxide detector.
BR has a babysitter with his brother.
Denies recent travel.
Usually sleeps well, around 11 hours a night, but cough has been waking him up.
Usually has a well-balanced diet but has decreased appetite since symptoms began.
ROS:
General – Admits to decrease in appetite, recent fever, fatigue. Denies chills, night sweats, weakness, or recent weight gain or loss.
Skin, Hair, Nails – Denies changes in texture, excessive dryness or sweating, itchiness, discoloration in skin or moles/rashes.
Head – Denies headache, dizziness or head trauma.
Eyes – Denies contacts or glasses, visual disturbances, itchiness or increased sensitivity to light.
Ears – Denies pain, discharge or ringing in ears.
Nose/Sinuses – Admits to clear nasal discharge x3 days. Denies bleeding or obstruction.
Mouth and Throat – Denies bleeding gums, sore throat, sore tongue or mouth ulcers.
Neck – Denies lumps, swelling or stiffness/decreased ROM.
Pulmonary System – Admits to cough, difficulty breathing, wheezing. Denies SOB, coughing up blood or blue discoloration.
Cardiovascular System – Denies chest pain, high blood pressure or fainting.
Gastrointestinal System – Admits to decrease in regular appetite. Denies intolerance to foods, N/V/D, difficulty swallowing, excessive burping or passing gas, abdominal pain or change in bowel habits.
Genitourinary –Denies change in amount or frequency of urination, change in color of urine or painful urination.
Musculoskeletal System – Denies muscle/joint pain, redness or swelling.
Peripheral Vascular System – Denies color or temperature change to extremities.
Hematologic System – Denies anemia, easy bruising or bleeding.
Endocrine System – Denies excessive thirst or hunger, heat or cold intolerance.
Nervous System – Denies loss of consciousness, numbness, change in mental status or memory.
Physical Exam:
Vital signs:
Temp: 106.1 F oral
HR: 125 bpm, regular
RR: 24 breaths/min, labored
Ht: 42”
Wt: 45 lbs
General: Patient appears ill, difficulty breathing. Is well-developed, well-nourished.
Eye: red reflex is present bilaterally, conjunctiva is normal, no discharge or erythema, PERRLA
Ear: symmetrical and size is unremarkable. No evidence of external lesions, masses or trauma to the ear. No discharge or foreign bodies in auditory canals AU. Tympanic membranes are pearly gray with present cone of light. Auditory acuity intact.
Nose: no evidence of external lesions, masses or trauma to the nose. Clear nasal discharge is noted.
Mouth: throat is slightly erythematous, otherwise unremarkable.
Neck and thyroid: trachea is midline, no scars, thyromegaly or bruits noted. No palpable lymph nodes.
Respiratory: breathing is labored, presence of wheezing and accessory muscle use.
Cardiovascular: regular rate and rhythm, no murmurs present
Gastrointestinal: belly is soft, non-distended, non-tender and no palpable masses
Skin: cheeks appear flushed and warm, rest of skin color and temperature is unremarkable. No rashes or lesions present.
Assessment:
6 y/o male presents with fever, cough and congestion x3 days. Symptoms are progressively worsening. Cough is productive and is worse at night and fever is rising. Patient appears ill, lethargic, is having labored breathing, is wheezing and using accessory muscles.
Problem list:
- Fever 106 F oral
- Respiratory complications – cough, labored breathing, wheezing, accessory muscle use
- Congestion
Plan:
- Fever – send to ER for temperature of 106 F. Tylenol prn, fluids, cool compresses, rest
- Respiratory complications – send to ER for oxygen supplementation
- Congestion – saline nasal drops and aspirations
Admitted to the PICU – given CPAP, supplementary oxygen. Respiratory panel done to confirm RSV along with 1 other viruses, adenovirus.
