SUBJECTIVE: The patient is a (XX)-month-old female who presents for a chief complaint of cough and congestion. A couple of days ago, the patient presented to the clinic for the same complaint and was told she had a viral infection and was sent home with no medication on this visit.
Dad stated that the patient has had worsening of cough and congestion, especially during nighttime, that has caused her to have trouble taking bottle and going to sleep. These have lasted for a total of 3-4 days.
Parents have been trying to use a humidifier at home but have seen no improvement. Besides the above symptoms, the patient also had a fever of 101 four days ago but recently has had no fever.
She has had no nausea or vomiting. No diarrhea or constipation. Dad states that there are possible sick contacts at his workplace. Dad denies recent travel. The cough, he describes, as dry cough that comes on and off. It does not occur in a cluster.
Mom is not here at the clinic but called in and said that she is concerned for an enlarged lymph node behind the right ear.
OBJECTIVE:
VITAL SIGNS: Temperature 97.8; pulse 104, respiratory rate 21, weight 9.8 kg, height 76.2 cm.
GENERAL: Awake, alert, in no acute distress.
HEENT: Tympanic membranes are clear bilaterally. Normocephalic. Clear conjunctivae. Congested nose. Oropharynx is moist with no lesions, no exudate.
HEART: Regular rate and rhythm.
LUNGS: CTAB.
ABDOMEN: Soft. Positive bowel sounds, nontender, nondistended.
GENITOURINARY: Female, Tanner stage I.
EXTREMITIES: Warm and well perfused.
SKIN: No rash or lesion.
ASSESSMENT AND PLAN: This is a (XX)-month-old girl with cough and congestion, likely secondary to viral upper respiratory infection.
PLAN: The patient’s dad was reassured this is just a viral infection that will run its course, so it will take a little bit for the cough and congestion to improve. The patient’s dad was encouraged to keep using the humidifier, use nasal saline spray and to have the patient have small frequent feeds to help her with the decreased feeding. The patient was given a prescription for normal saline spray and Afrin to help her with the congestion.
