Patient Name: SB

Date: 11/13/2021

Location: QHC Pediatric ED

 

CC: cough

HPI: 12 y/o male with no PMH presented to pediatric clinic at QHC and was referred to pediatric ER by PCP for chest x-ray and nebulizer treatment. Patient presented with a complaint of cough x 1 month. Patient stated that the cough had a gradual onset, has been happening intermittently throughout the day for about a month, is non-productive, and happens more commonly after eating or laying down. Sitting upright or standing improves the cough and cough medicine administered by the patient’s mom has not had any effect on cough. Patient was seen at NSLIJ Pediatric ED two weeks ago for the same complaint, was prescribed Zantac and Azithromycin but has not had much improvement since. Patient denied any associated URI symptoms, sick contacts, or recent travel. Patient denied congestion, itchy/watery eyes, rhinorrhea, headache, fever, chills, diaphoresis, neck pain, arthralgia/myalgia, ear pain, body aches, SOB, chest pain, dysphagia, abdominal pain, nausea, vomiting, diarrhea, weight loss/gain.

 

PMH

• Denies

 

Medications

• Denies any standing medications
• Finished course of Azithromycin on 11/09

 

Allergies

• NKDA, denies environmental/food allergies

 

Past Surgical History

• Denies

 

Family History

• Non-contributory

 

Social History

• 12 y/o male living with mother, father, and 2 older sisters aged 14 and 17. Patient attends public school and has a diet consisting of mostly meat, rice, vegetables, sandwiches and fast food. Patient does not smoke, drink alcohol, use illegal substances.

 

ROS

General: Denies fever, night sweats, fatigue, weakness, loss of appetite, recent weight loss/gain.

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

Head: Denies head trauma, unconsciousness, fractures.

Ears: denies pain, discharge.

Nose/sinuses: denies discharge, epistaxis.

Neck: denies localized swelling/bumps, decreased range of motion.

Pulmonary System: admits to cough. Denies SOB, wheezing, hemoptysis, cyanosis.

Cardiovascular System: denies chest pain, palpitations, known heart murmur.

Gastrointestinal System: Denies nausea, vomiting, diarrhea, constipation, abdominal pain, change in appetite, jaundice, change in bowel habits.

Genitourinary System: denies dysuria, frequency, urgency, hesitancy.

Musculoskeletal System: denies deformity, swelling, redness.

Hematologic System: denies easy bruising/bleeding, lymph node enlargement.

Nervous system: denies seizures, loss of consciousness, weakness

 

Physical Exam

BP: 118/77     HR: 98     RR: 20      SpO2: 97%      T: 97.8 F

Height: 5’3      Weight: 178 lbs.     BMI: 31.53

 

General: Well-developed, in no acute distress.

Skin: warm, good turgor, not jaundiced/mottled/pale. No petechiae or rash.

Head: no cranial deformity or facial anomaly.

Eyes: pupils equal, reactive to light with no nystagmus.

Nose: symmetrical, no masses, lesions, deformities. Nasal mucosa pink and well-hydrated. No foreign bodies, polyps, or congestion.

Ears: symmetrical and normal size. No masses, lesions, trauma on external ears. No discharge or foreign bodies in external auditory canals AU. TM’s non-erythematous with light reflex in normal position AU.

Lips: pink, moist, no cyanosis or lesions.

Oral mucosa: pink, well-hydrated.

Pharynx: mild erythema, no exudates, masses, lesions, foreign bodies.

Thorax and lungs: chest symmetrical, no deformities, no evidence of trauma. Respirations unlabored, no paradoxic respirations, no use of accessory muscles. Mild wheezing present bilaterally. No rales or rhonchi. No nasal flaring.

Cardiovascular: normal rate and rhythm. Pulses 2+ throughout. S1 and S2 normal, no murmurs heard.

Abdomen: bowel sounds normal, abdomen soft, non-distended, mildly tender to palpation in epigastric area.

Neurologic: patient alert and oriented, sensory and motor intact, no ataxia.

Musculoskeletal: normal range of motion and 5/5 strength in all extremities.

 

Assessment:

            12 y/o male with no PMH presenting with intermittent non-productive cough for one month, worsened with laying down and after meals. Patient was prescribed Azithromax and Zantac in NSLIJ ED two weeks ago. Patient finished course of Azithromax and stopped taking Zantac since he has not had any symptom improvement. Patient was seen today in clinic by PCP and was referred to ED for chest x-ray and nebulizer treatment for suspected asthma. Bilateral wheezing and mild tenderness to palpation in epigastric area of abdomen.

 

Differential Diagnosis:

• Asthma: most likely due to wheezing and cough present for extended period of time, likely aggravated by acid reflux.
• GERD: Possible with only symptom being cough which occurs more commonly with meals and laying down but trial of Zantac did not improve cough.
• URI: less likely as only symptom of cough is ongoing for one month, no other URI symptoms.
• Pneumonia: least likely with no flu-like symptoms, lungs with moderate wheezing but no other adventitious sound, cough affected more by food and positioning.

 

Plan:

• Chest x-ray AP and Lateral
• CBC with differential
• Comprehensive metabolic panel
• Lipase
• Viral URI panel
• Throat culture
• Ipratropium-albuterol (Duoneb) 0.5-2.5 mg/3 mL nebulizer
• Prednisone 60 mg PO

 

Results:

• Chest x-ray: normal chest radiograph study. No focal consolidation, pleural effusion, pneumothorax, pulmonary edema, free air.
• Viral URI panel: negative for Covid-19, Influenza A and B, RSV.
• CBC and CMP: mildly increased lymphocytes (3.4), eosinophils (0.26)
• Lipase WNL
• Wheezing improved after two treatments of Duoneb

Disposition:

• Patient discharged with diagnosis of reactive airway disease and cough variant asthma
• Prescribed Albuterol Sulfate 108 (90 base) mcg/act

• • 2 puffs inhalation every 6 hours as needed
• Prescribed Prednisone 40 mg daily for 4 days
• Prescribed trial of Pantoprazole 1 mg/kg/day once daily for 4 weeks
  • If no relief, follow-up with gastroenterologist in one month
• Follow-up with Asthma Clinic in 3 days
• Follow-up with PCP in 7 days