History

Identifying Data:

Full Name: Mr. B

Address: Not Disclosed

Age: 16 years

Date & time: 4/13/2021 7:00 AM

Location: QHC Peds ED

Religion: Not disclosed

Source of Information: Mother & aide

Reliability: Reliable

Source of Referral: Self

Mode of Transport: Self

Chief Complaint: “SOB, wheeze” x 4 days

History of Present Illness:

16 year old M with history of Down’s Syndrome, asthma, obesity presents to Peds ED for SOB, wheezing x4 days. Mother reports symptoms began at night after patient received 1^st dose of Pfizer COVID-19 vaccine earlier in the day. Gave albuterol inhaler and nebulizer with improvement of symptoms. The following 2 days patient had no symptoms during the day, but symptoms returned at nighttime. Gave same treatment with improvement. Last night episode occurred with symptoms worsening, more difficulty breathing and wheezing. Nebulizer treatment had less improvement.

Denies sick contacts, cyanosis, cough, fever, chills, change in appetite, nasal congestion, chest pain, abdominal pain, nausea, vomiting, diarrhea.

Past Medical History:

Down’s Syndrome

Obesity

PDA

Mild intermittent asthma

Immunizations – UTD  

Past Surgical History:

PDA device closure

Medications:

Albuterol 108 mcg/act inhaler 2 puffs q6 hrs prn wheeze

Albuterol 0.083% solution 3 mL via nebulizer TID prn wheeze

Loratadine 5 mg/5mL syrup PO daily

No vitamins, herbal teas or supplements

Allergies:

NKDA

Dust mites – itch

No known food allergies, no shellfish or seafood allergies

Family History:

No pertinent family history

Social History:

Mr. B is an 16 month old male living with mother and father in a house, attends school virtually

Travel-No recent travel

Sleep-Sleeps 7 hours per night

Review of Systems:

General-See HPI

Skin, hair, nails – Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.

Head – Denies headache, head trauma, LOC, fracture

Eyes – Denies lacrimation, erythema, visual changes, photophobia

Ears – Denies pain, deafness, discharge. No hearing aids.

Nose/sinuses – See HPI

Mouth/throat – Denies bleeding gums, mouth ulcers, voice changes. Last dental visit 6 months ago

Neck – Denies swelling, lumps, decreased ROM

Pulmonary system – See HPI

Cardiovascular system –See HPI

Gastrointestinal system-  See HPI

Nervous –Denies seizures, loss of consciousness

Musculoskeletal– Denies deformity, swelling, redness

Hematological system –Denies bleeding, easy bruising, lymph node enlargement, blood transfusions

Vital Signs

BP: 132/80

HR: 112 BPM, regular

RR: 38 breaths/minute, unlabored

Temp: 98.4 degrees F oral

O2 Sat: 97% on room air

Physical Exam:

General: Obese male, well groomed, non-toxic appearing. Appears stated age.

Skin:   warm & moist, good turgor. capillary refill <2 seconds throughout. No jaundice or pallor. No petechiae or rash.

Head: atraumatic, no signs of injury

Ears – external ears symmetrical. No lesions/masses/trauma on external ears. No discharge/foreign bodies in external auditory canals. TMs pearly white, intact with light reflex in position bilaterally.

Eyes – symmetrical; sclera white; conjunctiva pink and moist, no discharge. PERRLA

Nose – Congestion. Nasal mucosa moist. No masses, trauma, or deformities

Lips –  Pink, moist; no cyanosis or lesions.  

Oropharynx – Well hydrated; no injection; exudate; masses; lesions; foreign bodies. Tonsils present with no injection or exudate.  Uvula pink, no edema, lesions

Neck – FROM, supple, no rigidity, nontender. Trachea midline.   No masses; lesions; scars; pulsations noted. no stridor noted. no palpable adenopathy noted.

Chest – Symmetrical, no deformities, no evidence trauma. No paradoxic respirations or use of accessory muscles noted.

Lungs – Tachypnea, wheezes in middle and lower lung fields

Heart:  Regular regular rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No friction rubs appreciated.

Abdomen: Bowel sounds normoactive in all four quadrants. Abdomen soft and nontender throughout, nondistended, no masses or hernias. Tympanic throughout.

Neuro: Alert, no focal deficit noted.

Assessment:

16 year old M with history of Down’s Syndrome, asthma, obesity presents to Peds ED for SOB, wheezing x4 days.

Plan:

• Shortness of breath
  • Asthma exacerbation vs pneumonia vs viral illness vs vaccine reaction
  • Duoneb & Prednisone (Prelone 60 mg elixir)
    1. Reassessment after duoneb – no wheezes or adventitious sounds auscultated, tachypnea persists
  • Cepheid negative for COVID, influenza A&B, RSV
  • CXR showed bilateral perihilar infiltrates consistent with pneumonia
  • Transfer to Cohen’s for admission