S :( Subjective)
18 month old male presents with fussy than usual, tugging his ears. Last week patient had cold, initial temperature of 102 deg.F, runny nose and slight cough. Afebrile until last night, this was 104deg.F. Decrease appetite, eating fairly okay. Left nostril with thick mucus discharge, mucus yellow at time. Denies any sore throat, producing tears. Patient continues to cough, productive. No wheezing, hemoptysis, orthopnea or PND (paroxysmal nocturnal dyspnea), denies any SOB (shortness of breath), Tolerated PO (oral intake) well. Takes bottle of milk to bed every night.Parent denies no n/v (nausea, vomiting), no d/c (diarrhea, constipation).last BM 2 days ago, wetting diapers okay. No complaints of dysuria or abdominal pain.
Allergy: No known drug allergy. No food, environmental or latex allergies.
Past surgeries: none
Medications: No current medications, herbs or OTC medications.
Medical History: No known medical history, denies any family member with current illness.
Immunization: up to date – appropriate to age.
O: (Objective):
PE: (physical examination)
VS: (vital signs) T:102 deg F. BP 88/56 RR: 22, HR: 110, regular, Pulse Ox 99%RA. General: Awake alert, Fussy, mucous membranes moist, fair skin turgor; WD/WN (well-developed/well-nourished)
HEENT:
Head: NC/AT (norm cephalic/atraumatic)
Eyes:
PERRLA (pupils’ equal, round, and reactive to light and accommodation). Ears:
External ears without any redness, No erythema, no discharge. No pain to pinna, no pre/post LAD, canals clear bilateral, tympanic membrane intact. Right ear, pearly gray TM. Left ear- bulging Redness to TM, discharge behind TM.
Throat:
Posterior pharynx without erythema or exudates. Tongue protrudes straight. Uvula is midline.2+ bilateral edema with erythema and exudate, No LAD. Neck: No nuchal rigidity, good ROM (range of motion); No masses/LAD (lymphadenopathy) CV:
RRR (regular
