- 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