Level 3: Cough – Contrasting Case #1: Patient Information

Given these changes from the original case, what is your diagnosis?

What is your diagnostic explanation?

As compared to the long case, this patient is a 4 year old boy brought to the clinic by his mother due to a cough.

HPI: The boy’s mother states that for the past few weeks her son has been coughing frequently at night. She says it is a dry hacking cough. She states he has otherwise been healthy lately, and he has not had a problem with coughing in the past. She denies any fevers, vomiting, rhinorrhea, nasal congestion, wheezing, stridor, fatigue, or cyanosis. He has not had any sick contacts.

SH: The patient lives at home with parents and sister. Mom stays at home with children. Father smokes. No pets.

FMH: Maternal grandmother- 55 years old, healthy; Maternal grandfather- 56 years old, HTN, asthma; Paternal grandmother- 60 years old, hyperlipidemia; Paternal grandfather- 60 years old, type 1 diabetes, HTN; Mom- 28 years old, asthma; Dad- 30 years old, healthy; Sister- 2 years old, healthy

ROS: Noncontributory

PE –
VS: Temp 98.6, HR 106, BP 100/60, RR 22, Height 101cm (50th percentile), Weight 16kg (50th percentile)
General: Alert. No acute distress.
HEENT: Normocephalic, PERRLA, normal tympanic membranes, nose and oropharynx normal
Neck: No masses/lumps
Cardiac: RRR. Normal S1 and S2. No murmurs.
Lungs: Normal breath sounds on auscultation.
Abdomen: Bowel sounds present. No abdominal tenderness. No hepatomegaly. No abdominal distension.
Neuro: Good tone in all four extremities.
Skin: Normal