Pulmonary Case Study

HISTORY OF PRESENT ILLNESS

Patient is a 1-year-old female who has been congested for several days.  The child has sounded hoarse, has had a croupy cough, and was seen 2 days ago.  Since that time she has been on Alupent breathing treatments via machine, amoxicillin, Ventolin cough syrup, and Slo-bid 100 mg b.i.d., but is not improving.  Today the child is not taking food or fluids, has been unable to rest, and has been struggling in her respirations.

PHYSICAL EXAMINATION

Physical examination in the ER showed an alert child in moderate respiratory distress.  Respiratory rate was 40, pulse 120, temperature 99.6.  HEENT was within normal limits.  Neck was positive for mild-to-moderate stridor.  Chest showed a diffuse inspiratory and expiratory wheezing.  No rales were noted.  Heart showed regular rhythm without murmur, gallop, or rub.  Abdomen was soft, nontender; bowel sounds normal.  Extremities are within normal limits.  Viewing the chest wall, patient had subcostal-intercostal retractions.

The child was sent for a PA and lateral chest x-ray to rule out pneumonia.  No pneumonia was seen on the films.

It was agreed to admit the patient to the pediatric unit for placement in a croup tent with respiratory therapy treatments q.3h.  The child was also placed on Decadron besides the amoxicillin and continuation of the Slo-bid.

EMERGENCY ROOM DIAGNOSES

1. Acute laryngeal-tracheal bronchitis.

2. Bronchial asthma.

FOOTNOTE

Line 8.  That was changed to who.

Line 10.  He was changed to she.

Line 16.  Exam was expanded to Examination in the report.

Line 30.  The slang term peds was changed to pediatric.

Line 36.  Alternative:  Laryngotracheal.