Upper Respiratory Symptoms in child

Age: ‍ ‍monthsyears old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍hourday history of upper respiratory symptoms

Symptoms include:

‍cough, ‍non-productiveproductive of ‍clearcolored phlegm

‍runny nose, ‍clearcolored

‍nasal congestion

‍sneezing

‍sore throat

‍fever, up to ‍°, over ‍ ‍hoursdays

‍difficulty breathing

‍headache, ‍diffuse, ‍persistentintermittent, ‍pressurethrobbing, ‍mild

‍lethargy

‍irritability

‍decrease in fluids intake

‍decrease in urine ouput

‍decrease in appetite

‍rash

‍vomiting, ‍ episodes ‍per day, ‍, ‍hematemesis

‍abdominal pain, ‍diffuse, ‍dull, ‍mild



Alleviating factors: ‍none, ‍effectiveineffective



Contributing factors:

‍similar symptoms in close contacts

‍attendance at daycare or school

‍secondhand smoke exposure

‍recent travel

no history of: ‍recurrent upper respiratory infections, ‍respiratory allergies, ‍asthma, ‍prematurity

no use of: ‍recent antibiotics



Vaccination status: ‍up-to-datedelayedincompleteunknown





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Head: fontanelles ‍soft, ‍normocephalic

Eyes: conjunctiva/sclera ‍normalinjection, lids/lashes ‍normalerythema, ‍PERRL, extraocular movements ‍intact, red reflex ‍present, corneal light reflex ‍symmetrical, fix and follow test ‍intact

Ears: tympanic membranes ‍normal ‍, auditory canal ‍ on ‍rightleft, hearing ‍intact

Nose: ‍clear, ‍nasal flaring, discharge ‍clear, ‍

Throat: ‍normal, ‍palate intact, ‍redness

Neck: ‍normal, ‍lymphadenopathy, ‍nuchal rigidity, ‍torticollis, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍

Genitourinary: external genitalia ‍normal, testes ‍descended, penis ‍normal, Tanner stage ‍

Extremities: ‍normal inspection, ‍joints ‍normal, ‍limited ROM, ‍normal spine, Barlow ‍negative, Ortolani ‍negative, ‍normal pulses, cap refill ‍< 3> 3 sec

Skin: ‍rashlesions on ‍

Musculoskeletal: joints ‍ ‍normal, ‍limited ROM

Neurologic: cranial nerves ‍grossly intact, overall motricity ‍normal for agelimb weakness, muscle tone ‍normal for age, gait ‍appropriate for age, reflexes ‍intact 2+

Mental status: ‍alert, ‍, reactive to ‍





ASSESSMENT:

‍Viral URI ‍likelysuspectedpossible

DDx: URI, bacterial pharyngitis, sinusitis, influenza, allergic rhinitis, postnasal drip, bronchiolitis, asthma exacerbation, acute bronchitis, pneumonia, COVID-19, croup, epiglottitis, tonsillitis, adenoiditis, laryngitis, laryngopharyngeal reflux, herpangina, hand, foot, and mouth disease, foreign body aspiration





PLAN:

Investigations:

- Chest X-ray

- ‍Influenza test, ‍Covid test, ‍Strep test

- Blood work: ‍CBC, ‍lytes, ‍creatinine, ‍CRP

Treatments:

- Nasal saline irrigation

- Hydration maintenance

- ‍Acetaminophen

- ‍Ibuprofen

- ‍Antibiotics

Further care:

- Follow-up in ‍ ‍daysweeks

- Return if symptoms worsen or if new symptoms develop

- Referral to ER if severe shortness of breath, signs of dehydration, or high fever occur