Cough in a 2-yr-old Boy

Physical Examination

  • General appearance: Well-developed male child, awake and alert, who has obvious dry cough and mild respiratory distress. No cyanosis. He is able to speak with a normal-sounding voice.

  • Vital signs:
  • Temperature: 37° C
  • Pulse: 115 beats/min
  • BP: 100/75 mm Hg
  • Respirations: 30/min

  • Skin: Pink, warm, dry; no cyanosis or rash. Capillary refill normal.

  • HEENT: Tympanic membranes normal bilaterally. Nasal passages clear, no discharge. No drooling. No erythema or exudate in pharynx. Nontender, supple neck; no adenopathy.

  • Pulmonary: Significant wheezing in the left lung that appears to be transmitted to the right lung. No rhonchi, rales, or stridor; no retractions or use of accessory muscles.

  • Cardiovascular: Mild tachycardia. S1 and S2 normal; no murmurs rubs or gallops.

  • Gastrointestinal: Abdomen soft and not tender or distended. Bowel sounds normal.

  • Genitourinary: Unremarkable

  • Musculoskeletal: Normal appearance and movement of extremities.

  • Neurologic: Awake and alert. Cranial nerves grossly intact. Normal motor and sensory exam.

  • Mental status: Responds appropriately for his age.