John is a 13 yr old male who presents to your clinic accompanied by his mother with complaint of productive cough, chest and nasal congestion and intermittent chills x 7 days. He reports symptoms initially started with mild nasal congestion, clear runny nose and sorethroat, but got worse the past few days. He now has chest congestion, productive cough with greenish-yellow sputum, chills, and mild headache x 2 days. OTC meds for cold have not helped. He denies any known sick contact.
Mother further reports she noticed John has been wheezing more the past 2 months. He used to use his albuterol inhaler about once a month but now uses it 3-4 times a week. Both John and his mom reported nighttime dry cough and wheezing which occurs about 1-2 times a week
Past Medical History: Asthma, Allergic rhinitis, Atopic dermatitis
Medication History: Albuterol HFA prn, Zyrtec 10mg QD, Tylenol 500mg -1tab prn for headache and chills.
Family Medical History: Father: HTN; Mom: healthy. 3 siblings-all healthy
Drug Allergy: NKDA
Social History: Denies alcohol or cigarette use. Denies illicit drug use. Occupation: Student.
Vaccination: Up to date
Physical Exam
Gen: Slightly lethargic, otherwise in no acute distress
V/S: BP: 124/72, HR: 110, T: 101.3(oral), RR: 22, wt: 132lbs, Ht: 66inches
HEENT: Nasal mucosa erythematous, mild nasal congestion, tonsils and pharynx normal, slight postnasal drainage, light green nasal discharge.
CV: Normal S1& S2, rhythm regular
Resp: regular. Mild expiratory wheezing bilaterally to auscultation. No use of accessory muscles. 02 saturation: 95%
Abd: Soft, non-distended, non-tender, bowel sounds + and normal x 4 quadrants, no masses palpated.

John is a 13 yr old male who presents to your clinic accompanied by his mother with complaint of productive cough, chest and nasal congestion and intermittent chills x 7 days. He reports symptoms initially started with mild nasal congestion, clear runny nose and sorethroat, but got worse the past few days. He now has chest congestion, productive cough with greenish-yellow sputum, chills, and mild headache x 2 days. OTC meds for cold have not helped. He denies any known sick contact.
Mother further reports she noticed John has been wheezing more the past 2 months. He used to use his albuterol inhaler about once a month but now uses it 3-4 times a week. Both John and his mom reported nighttime dry cough and wheezing which occurs about 1-2 times a week
Past Medical History: Asthma, Allergic rhinitis, Atopic dermatitis
Medication History: Albuterol HFA prn, Zyrtec 10mg QD, Tylenol 500mg -1tab prn for headache and chills.
Family Medical History: Father: HTN; Mom: healthy. 3 siblings-all healthy
Drug Allergy: NKDA
Social History: Denies alcohol or cigarette use. Denies illicit drug use. Occupation: Student.
Vaccination: Up to date
Physical Exam
Gen: Slightly lethargic, otherwise in no acute distress
V/S: BP: 124/72, HR: 110, T: 101.3(oral), RR: 22, wt: 132lbs, Ht: 66inches
HEENT: Nasal mucosa erythematous, mild nasal congestion, tonsils and pharynx normal, slight postnasal drainage, light green nasal discharge.
CV: Normal S1& S2, rhythm regular
Resp: regular. Mild expiratory wheezing bilaterally to auscultation. No use of accessory muscles. 02 saturation: 95%
Abd: Soft, non-distended, non-tender, bowel sounds + and normal x 4 quadrants, no masses palpated.