PSReport 0801
PATIENT NAME:
MR #:
ADMISSION DATE:
DISCHARGE DATE:
Jaheem Arnold
7013920
02/13/2014
02/20/2014
ADMITTING DIAGNOSIS
Reactive airway disease.
DISCHARGE DIAGNOSIS
Reactive airway disease.
HISTORY OF PRESENT ILLNESS
The patient is a 19-month-old African American male who had been well until 2 days prior to admission, when
he developed a loose cough. Mother gave him an over-the-counter children’s cough remedy several times each
day. He was afebrile during this time. During the day, the child had increased difficulty breathing, and
wheezing was noted in the late p.m. when the child was brought to the emergency room. In the ER, the child
was found to have a fever of 102 degrees Fahrenheit rectally. He was found to be in respiratory distress and
was given Ventolin nebulization and admitted.
PHYSICAL EXAMINATION
Physical examination showed a patient sitting in bed with mild respiratory distress. He was alert. Respiratory
rate was 40, heart rate was 115, temperature was 102.3 degrees. Right tympanic membrane was slightly
erythematous. There was slight nasal flaring. Throat was slightly injected. On auscultation, the lungs were
found to have diffuse inspiratory and expiratory wheezes. The heart showed the presence of normal heart
sounds with mild tachycardia.
HOSPITAL COURSE
Reactive airway disease. The patient was admitted, started on theophylline, given a bolus of theophylline 1
mg/kg, and subsequently put on a maintenance dose of theophylline. High-flow nebulization was also given
p.o. every 2 hours. With this management, the patient showed rapid improvement and his respiratory
treatments were gradually spaced out so that, subsequently, the patient was changed to oral medication of
theophylline. Theophylline levels were monitored during the hospital course.
CONDITION ON DISCHARGE
The child was discharged after 1-week hospitalization on theophylline. Condition at time of discharge was
improved.
DISCHARGE INSTRUCTIONS
Mother was instructed to bring him to our office in 1 week.
______________________________
Mencer Alcott, MD
MA/ps
D: 02/20/2014
T: 02/20/2014