TEMPLATE
Respiratory
X y male/female admitted with a diagnosis of respiratory distress secondary to viral
infection/bronchiolitis/asthma exacerbation/pneumonia. Seen in ER with VS RR x HR x
O2 sat x % in room air. PE in the ER was + for Xxxxxxxxx. Received 3 treatments of
Albuterol/Atrovent with minimal improvement. Admitted for further management.
ROS fever vomiting diarrhea history of travel or sick contacts
PMH
Birth history
Allergies
Hospitalizations
Surgeries
Lives with
Family history + for
Attends grade
Developmental history
PE
HR RR O2 sat % in room air T
BP Weight
Alert active in mild to moderate distress
Speaks well, feeding well
Normocephalic, anterior fontanel open and flat
Nasal discharge minimal abundant
Neck no masses, supple
Chest symmetric, + for suprasternal, intercostal and subcostal retractions, air entry fair,
decrease or good, wheezing, crackles, expiratory phase is normal or prolonged
Heart S1/S2+ no murmurs
Abdomen soft no masses, no organomegaly, umbilical hernia
Pulses present bilaterally, well perfused
Genitals
Skin no rash
Labs reviewed
Chest x ray
A/P
X y male/female with
Fever
X y male/female seen in ER for fever, VS in ER T HR RR , PE in the ER was + for
Xxxxxxxxx, a full sepsis work up was done and baby was started on xxxx cultures sent to
fu results and continue management
ROS fever vomiting diarrhea history of travel sick contacts
PMH
Birth history
Allergies
Hospitalizations
Surgeries
Lives with
Family history + for
Attends grade
Developmental history
PE
HR RR O2 sat % in room air T
BP Weight
Alert active in mild to moderate distress
Speaks well, feeding well
Normocephalic, anterior fontanel open and flat
Nasal discharge minimal abundant
Neck no masses, supple
Chest symmetric, + for suprasternal, intercostal and subcostal retractions, air entry fair,
decrease or good, wheezing, crackles, expiratory phase is normal or prolonged
Heart S1/S2+ no murmurs
Abdomen soft no masses, no organomegaly, umbilical hernia
Pulses present bilaterally, well perfused
Genitals
Skin no rash
Labs reviewed
Chest x ray
A/P
X y male/female with
Progress note
5 y female /male with a diagnosis of xxxxxxxxxxxxxxxxxx, managed with
xxxxxxxxxxxx.
Mom says he /she spent the night well, eating without problems, no vomiting no diarrhea
PE
HR RR O2 sat % in room air T
BP Weight
Alert active in mild to moderate distress
Speaks well, feeding well
Normocephalic, anterior fontanel open and flat
Nasal discharge minimal abundant
Neck no masses, supple
Chest symmetric, + for suprasternal, intercostal and subcostal retractions, air entry fair,
decrease or good, wheezing, crackles, expiratory phase is normal or prolonged
Heart s1/s2+ no murmurs
Abdomen soft no masses, no organomegaly, umbilical hernia
Pulses present bilaterally, well perfused
Genitals
Skin no rash
A/P