Pediatric Clinical Case Presentation

Chief Complaint (CC):

• Cough and wheezing; follow-up from ER visit

History of Present Illness (HPI):

• The patient is a 6-month-old Caucasian male who presents today for a follow-up after an emergency room visit last night. The mother reports that the patient had a fever of 102°F, accompanied by wheezing and an increasing cough, which prompted the ER visit. While in the emergency room, the patient received a Rocephin shot, one dose of an oral steroid, and a breathing treatment before being discharged. The mother reports that the patient did not sleep through the night; although the fever has resolved, the patient remains occasionally irritable with a wet cough and audible wheezing.

Review of Systems (ROS) - Pertinent Positives:

• General: History of fever yesterday and irritability, as reported by the mother.
• HEENT: Nasal congestion, according to the mother.
• Respiratory: Reported wheezing and intermittent cough, as per the mother’s observations.

Physical Examination (PE) - Pertinent Positives:

• Vital Signs:
  • Temperature: 98.4°F
  • Heart Rate: 143 bpm
  • Oxygen Saturation: 96% on room air
• Height: 26 inches