Heart is in a regular rhythm and no murmurs are heard. Rhonchi and occasional wheezes are heard on auscultation, but there are no retractions. His chest has an increased AP diameter and it is tympanitic (hyperresonant) to percussion. He has multiple small lymph nodes palpable in his upper neck. His eyes are clear, nasal mucosa is boggy with clear discharge, and his pharynx has moderate lymphoid hypertrophy. He is alert and cooperative in minimal distress if any. In his home environment, there are no smokers or pets.Įxam: VS T 38.1, P 100, RR 24, BP 85/65, oxygen saturation 99% in room air. His family history is notable for a brother who has asthma. He is otherwise healthy and he is fully immunized. His past history is notable for eczema and dry skin since infancy. He has no known allergies to foods or medications. He has had similar episodes in the past, but this episode is worse. There are colds going around the pre-school. He is noted to have morning sneezing and nasal congestion. Initially the cough improved but it worsened over the next 2 days. His parents have been using a decongestant/antihistamine syrup and albuterol syrup which were left over from a sibling. He has also had a mild fever, but his temperature has not been measured at home. Burns School of MedicineĪ three year old comes in with a complaint of coughing for 2 weeks. Case Based Pediatrics Chapter Case Based Pediatrics For Medical Students and Residentsĭepartment of Pediatrics, University of Hawaii John A.
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