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 the cough started a few days ago. She states her son will cough severely for several minutes intermittently followed by a whooping sound. He has occasionally coughed so hard that he has vomited following an episode. She also states that he had rhinorrhea, nasal congestion, and sneezing a couple of weeks ago.
PMH: No significant illnesses since birth. Born full-term at 38 weeks gestation via vaginal delivery. Mom denies any complications during pregnancy or at birth. She tested negative for HepB, HIV, and GBS. He has been growing well and meeting developmental milestones. Parents do not believe in vaccinations.
SH: Lives at home with parents and sister. Mom stays at home with children. Father smokes. No pets.
FMH: All alive and well.
ROS –
General: No lethargy, no change in appetite
HEENT: See HPI
Cardiovascular: Doesn’t complain of chest hurting or feeling his heart beat fast
Respiratory: See HPI
GI: No diarrhea/constipation
GU: No problems with urination
Derm: No rashes
Neurology: No lethargy, listlessness
Heme: No bruising
PE –
VS: Temp 98.6, HR 106, BP 100/60, RR 30, Height 101cm (50th percentile), Weight 16kg (50th percentile)
General: Alert. No acute distress.
HEENT: Normocephalic, PERRLA, Conjunctival hemorrhages, 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
