Reporte zur Charge N032748

Symptomtext

Patient was seen at PCP office the morning of 5/3/2019 for cough, lungs CTA, b/l, no wheezes, rales, or rhonchi. Tonsils difficult to visualize, rapid flu and strep negative. Patient is lethargic, clinging to mother. Patient is drooling and breathing loudly. No chest retractions. Due to drooling and harsh breathing, epiglottitis is a concern. Possible diagnosis: Epiglottitis, croup, URI. Once xray results were reviewed, mother advised to take patient to hospital for evaluation and patient was admitted for IV antibiotics. Hospital report noted 18month old that presents for concerns for RPA, several days of history of cough, congestion, and there is a change in cough and voice character yesterday through today, mother described as more muffled. Patient drooling this morning. No rash or medication history. Patient presents well appearing, NAD, awake and interactive during exam, no stridor. Patient was seen in the hospital for concern of RPA. While hospitalized he was seen by ENT doctors who recommended starting IV antibiotics. He continued on antibiotics until he started looking better, then was transitioned to Augmentin by mouth. When patient improved , his breathing less noisy and he was eating and drinking normally, he was ready for discharge.