[##-month/year-old male/female] with history and exam consistent
with likely croup.
Initial consideration in this patient included croup, pneumonia, allergic
reaction, bacterial tracheitis, pharyngitis, pneumonia, bronchitis, epiglottitis,
retropharyngeal abscess (RPA), peritonsillar abscess (PTA), diphtheria, foreign
body obstruction, and esophageal pathology among others.
Patient presented with [mother/father/parents] with report of [dry/barking]
cough consistent with croup in patient within the expected age (3 months to
approximately 5 years old). Patient [with/without
measured/reported] fever and associated [upper respiratory symptoms]. Patient noted to have a Westley Croup Score
of [0-17] consistent with [mild/moderate/severe] illness. Doubt pneumonia given absence of productive
cough or abnormal lung sounds. Chest
x-ray [felt to not be indicated at this time/obtained and noted to be
unremarkable]. No evidence of acute
otitis media noted on exam. No evidence
of significant pharyngeal erythema, exudate, or other findings suggestive of significant
pharyngitis on ED evaluation.
Doubt bacterial tracheitis in otherwise well-appearing child
without findings suggestive of purulent sputum, respiratory distress, or other
suggestive findings. Improvement noted
with treatment with [Decadron/racemic epinephrine/Acetaminophen/Ibuprofen] in
the ED prior to discharge. Patient noted
to be tolerating fluids by mouth prior to discharge with no evidence of
stridor, cyanosis or respiratory distress at time of discharge.
Prior to discharge, we discussed return precautions, specifically
for evidence of worsening infection or bacterial tracheitis, treatment [with
Decadron/Acetaminophen/Ibuprofen], and follow up with primary care doctor
within [2-3 days/1 week] for further evaluation, and the patient's
[mother/father/parents] demonstrated understanding and agreement.
https://www.mdcalc.com/westley-croup-score
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