Reference no: EM133695495
Assignment:
A 22-month-old male is brought in by mother to your primary care office with c/o "sounding like he is wheezing and has a bark-like cough". Started with nasal congestion a few days ago which was clear, but now looks a little yellow. Attends daycare. Fever of 101.5 last night which was reduced with Tylenol, tactile fever again this a.m. Has been irritable and very clingy. Gave an albuterol treatment last night (has a nebulizer at home for her older child) but it did not seem to help.
"Gets a lot of colds." Concerned because he is "always sick; has not had a cough like this before" asking if you will do a chest X-ray. Has not eaten any solid food for two days, drinking most of his bottles and his diapers are less full than usual.
PMH: F/T NSVD, no complications during/after birth, denies hospitalizations, has had a few ear infections, most recent one a few weeks ago, treated with Cefdinir.
Immun: UTD with 15-month vaccines, except for MMR (does not want to give until he is 3 years of age because of concerns with Autism). Received Flu vaccine in November. Has not received any COVID vaccines. Is overdue for the 18 mo. Vaccines has not had his 18 mo. WCV, because he kept getting sick.
Meds: Multivitamin with Fluoride 0.25 mg daily
Allergies: NKA, NKDA
PE:
Vitals: T 38.1 C, HR 122, RR 34, 02 Sat 96%, Wt. 11.5 kg
General: Anxious, crying upon approach, consoled by mother.
Skin: Warm, facial flushing, normal turgor, no rashes.
HEENT: NC, No conjunctival injection, no discharge, TMs pearly gray, sharp LR bilat, nares with watery yellow d/c, pharynx mildly injected,
MMMs, lips pink
Neck: Supple, no LAD
Lungs: CTA, no retractions, Inspiratory stridor with crying
CV: RRR, no Murmur
GI: abd. Soft, NTND
- What is the differential diagnosis? (include at least 3)
- What is your assessment diagnosis? Why have you decided on this?
- Demonstrate your understanding of the pathophysiology regarding this diagnosis.
- What testing should be done now if any? Why/Why not? Should any imaging be done? Why/Why not?
- How will you manage this child? Can he be sent home or does he need further evaluation/referral to the emergency room?
- Does he need IV fluids?
- Does he need an antibiotic or any other medication?
- What is the appropriate education for this parent?
- If not managed appropriately, what is/are the medical/legal concern(s) that may arise?
- What is the follow-up for this patient?