Michael Martinez – Pediatrics

CC – Cough

Diagnosis – Bronchiolitis by RSV

- Upper respiratory infection, influenza, pneumonia, pharyngitis, group A streptococcus, reactive

airway disease, bronchiolitis

Tests- Rapid Influenza diagnostic test (RIDT), Rapid strep antigen detection test (RST/RADT), Chest x-ray

AP, Respiratory Syncytial Virus (RSV) antigen

Problem Statement:

( Demographic description – chief complaint – Hx and PE key findings – risk factors )

Michael Martinez is a 2 year old boy brought in by his mother with complaint of cough. The mother

states that the cough had started 2 days prior and is productive of yellow sputum, during this same time

the mother reports him having a 102F fever which is ongoing with nasal congestion that has progressed

to difficulty breathing and decreased appetite for the past 5 days. Physical exam shows boggy gray nasal

turbinates, nasal flaring, intercoastal retractions on inspiration and an expiratory wheeze heard in lower

lung fields bilaterally as well as Left submandibular adenopathy. Risk factors include Michael’s father

who is a current smoker. (reduce to 70 words)