Clinical note · #45
Consultation
Chief complaint: a 5-month-old boy with cough.
History of present illness: a 5-month-old boy brought by his parents because of 2 days of cough. Mother took him when cough started 2 days ago to clinic where they told the mother he has viral infection and gave him Tylenol, but yesterday at night cough got worse and he also started having fever. Mother did not measure it.
Review of systems: no vomiting. No diarrhea. He had runny nose started with the cough two days ago. No skin rash. No cyanosis. Pulling on his right ear. Feeding: he is bottle-fed 2 ounces every 2 hours. Mother states he urinates 5 to 6 times a day, stools 1 time a day. He is still feeding well.
Immunizations: he received the first set of shots and is due for the second set on 01/17/2025.
Birth history: he was premature at 33 weeks, born at hospital, kept in NICU for a week for feeding problems as the mother said. Mother had good prenatal care from 4 weeks with more than 12 visits. No complications during pregnancy. Rupture of membranes happened two days before labor. Mother received antibiotics, but she is not sure if she also received steroids.
Family history: no history of asthma or lung disease.
Social history: lives with parents and two siblings (18 and 14 years old). They have animals, but outside the house, and father smokes outside the house. No sick contacts as the mother said.
Past medical history: no hospitalizations. History of 2 previous ear infections, the last one in November treated with ear drops, because there was pus coming from the right ear as the mother said.
Allergies: no known drug allergies. Medications: none.
Physical examination
- Vital signs: temperature 100.1, heart rate 184, respiratory rate 48. Weight 7 kg.
- General: in no acute distress.
- Head: normocephalic and atraumatic. Open, soft, and flat anterior fontanelle.
- Neck: supple. Nose: dry secretions.
- Ear: right ear full of yellowish material, most probably pus and necrotic tissue. Tympanic membrane bilaterally visualized.
- Mouth: no pharyngitis. No ulcers. Moist mucous membranes.
- Chest: bilateral audible breath sounds. No wheezes.
- Heart: regular rate and rhythm with no murmur.
- Abdomen: soft, nontender, and nondistended.
- Genitourinary: Tanner I male with descended testes.
- Extremities: capillary refill less than 2 seconds.
Labs: white blood cell 8.1, hemoglobin 10.5, hematocrit 30.9, and platelets 380,000. CRP 6, segments 41, and bands 41. RSV positive.
Chest X-ray was ordered and interpreted by me: bronchiolitis with hyperinflation and bronchial wall thickening in the central hilar region. Subsegmental atelectasis in the right upper lobe and left lung base.
Assessment: atelectasis, and RSV antigen is positive.
Diagnoses: respiratory syncytial virus bronchiolitis with right otitis externa.
Plan: ciprofloxacin eardrops twice daily for right otitis externa.
Disposition: admit to telemetry for further work-up for bronchiolitis.