CHIEF COMPLAINT: D i f fi c u l t y breathing. HISTORY PRESENT ILLNESS M s a 5 vear old white male who has a long history of asthma. He had been seen by me in the office this morning because he had developed a cough and was running a low grade fever. At that time I diagnosed tonsillitis and placed him on P e nVee K 250 mgs. q.i.d. He was also on Robitussin cough syrup p.r.n. On the evening of admission ._began having a coughing spell and it was unrelieved by the Robitussin. He became short of breath and was there- fore brought to the Emergency Room for evaluation. On arrival in the Emergency Room he was not wheezing however following a treatment with a hand held nebulizer with normal saline he did have some mild wheezes in the right lung as noted by the cardiopulmonary tech. When I listened to him, I didn't hear any wheezing however his lungs were definitely tighter than they had been in the morning. Therefore Timmy was admitted and placed in a croup tent for observation. REVIEW OF SYSTEMS: He has some mild nausea and vomited several times on the day prior to admission. No vomiting on the day of admission. He also complains of some mid epigastric discom fort. It is possible these symptoms are related to the Zarontin which he takes for his seizure disorder but the possibility also exists that these are emotionally related. PAST MEDICAL HISTORY, FAMILY HISTORY AND SOCIAL HISTORY: VITAL SIGNS: Temperature normal. See old records. HEENT: Head normocephalic. Eyes: PERL, EOM intact. Ears: Tympanic membranes normal bila- terally. Nose no congestion. Throat: Severely injected, tonsils are enlarged with white exuda- tes. NECK: Supple, there is bilateral anterior cervical adenopathy. LUNGS: Clear but breath sounds are decreased symmetrically. HEART: S-1 and S-2 were normal, no murmurs or gallops are heard, rhythm was regular. ABDOMEN: Soft, tender in the mid epigastric area without rebound, rigidity or guarding, bowel sounds normal. GENITALIA: Circumcised p e n i s , t e s t e s both descended. EXTREMITIES: Within normal l i m i t s . NEUROLOGICAL: Appropriate f o r age. ASSESSMENT: Tonsillitis; asthma and seizure disorder. PLAN: Timmy is being admitted and he will be placed in a croup tent. His Zarontin, Slo-Phyllin and Pen Vee K will be continued and he will receive treatments with a hand held nebulizer. •Dictation Date: 6/27/83 Transcribed: 6/28/83 by: ?? Signed M C 78611 Peds HISTORY & PHYSICAL