Subjective
Danny Rivera is an 8 years old boy presenting with a wet cough. He reports that the cough has lasted three days. He describes the cough as wet and gurly.
Objective
The cough is temporarily treated by the children’s cough medicine his mother gave him. He reports that the cough is not aggravated by activity. He reports the cough gets worse at night, which keep him up at night. He reports tenderness of his throat. He reports a history of frequent rhinorrhea and cough. Risk factor includes second-hand smoke from father, history of pneumonia in the past year, and being overwiegt for his age.
Assessment
He has no acute respiratory distress, his lungs are clear to auscultation and is afebrile, He has current rhinorrhea, examination of the nose reveals boggy turbinate. His throat appears red with visible cobblestoning in the back. His respiratory rate is inscreased, and he present mild tachycardia.
Plan
I recomende calling his grandmother to pick him up from school. He should see his primary care provider within the next few days for an evaluation and tests to rule out asthma and allergies. In the meantime, he should be allowed to rest and should be given cough medicine as needed.
