CHIEF COMPLAINT: Nasal congestion.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-month old with nasal congestion and difficulty breathing that has been going on for about a day now. Nothing seems to have precipitated it. There are sick contacts at home. The child has had no cough. No stridorous sounds. The child has been otherwise acting okay, able to tolerate p.o. in smaller doses and making good urine output. He has been acting himself other than the congestion.
PAST MEDICAL HISTORY: None.
ALLERGIES: None.
MEDICATIONS: None.
SOCIAL HISTORY: No tobacco, alcohol or drugs.
REVIEW OF SYSTEMS: CONSTITUTIONAL: No fevers or chills. CARDIOVASCULAR: No chest pain. PULMONARY: No cough. GASTROINTESTINAL: No abdominal pain or vomiting. NEUROLOGIC: No headaches. All other systems per HPI and otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure not obtained, pulse 140, respiratory rate 60, O2 sat 98%.
GENERAL: The child appeared well. Had no signs of trauma. Eyes: Pupils are 4-2. TMs are clear. Nasal cavity showed some discharge. Oropharynx clear.
NECK: No adenopathy.
PULMONARY: Lungs were clear to auscultation with the exception of some upper airway noises but no stridor.
CARDIOVASCULAR: S1, S2, regular rate and rhythm.
ABDOMEN: Soft, nontender, positive bowel sounds.
VASCULAR: Brisk cap refill.
EMERGENCY DEPARTMENT COURSE: The patient had bulb suctioning with decrease in respiratory rate to 45, decrease in pulse to 125 and sats remained good at 99%.
MEDICAL DECISION MAKING: The patient is a (XX)-month-old here with what appears to be a URI. We believe the child’s difficulty breathing is related to congestion. Extensive counseling was done with the family with regards to bulb suctioning. The child will be put on amoxicillin, as the child has no followup, but we do not think that this represents a bacterial infection at this time or serious bacterial illness. The patient appeared well at discharge and vitals have normalized.
CLINICAL IMPRESSION: Upper respiratory tract infection.
DISPOSITION: Discharged to home.
PLAN:
1. Follow up with primary care doctor.
2. Return for worsening or bleeding.
3. Take antibiotics.
*******************************************************************
CHIEF COMPLAINT: Sore throat.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female with sore throat that has been going on for 3 days. It is about 8/10 at this time. It does not radiate, associated with ear congestion. The patient reports no fevers or chills. No difficulty swallowing or handling secretions.
PAST MEDICAL HISTORY: None.
ALLERGIES: None.
MEDICATIONS: None.
SOCIAL HISTORY: No alcohol, drugs or smoking.
REVIEW OF SYSTEMS: CARDIOVASCULAR: No chest pain. PULMONARY: No shortness of breath. GASTROINTESTINAL: No abdominal pain. NEUROLOGIC: No headaches or weakness. All other systems per HPI, otherwise, negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: See nurse’s note.
GENERAL: The patient appeared well and in no distress.
HEENT: Head: No signs of trauma. Eyes: Pupils 4-2. Ears, nose and throat: TMs clear. Oropharynx had bilateral tonsillar exudates but well-appearing patent airway.
PULMONARY: Lungs are clear to auscultation bilaterally.
CARDIOVASCULAR: S1, S2, regular rate and rhythm.
ABDOMEN: Soft, nontender, nondistended. Positive bowel sounds.
SKIN: No rashes.
VASCULAR: Brisk cap refill.
NEUROLOGIC: Nonfocal, gait normal.
PSYCHIATRIC: Normal mood and affect.
MEDICAL DECISION MAKING: This is a (XX)-year-old here with what appears to be pharyngitis, likely strep pharyngitis given her recent sick contacts. The patient has no signs or RPA or PTA on exam. Appears nontoxic. The patient will be discharged to home, put on penicillin V potassium and told to follow up with primary care doctor and given precautions to come back for difficulty swallowing.
CLINICAL IMPRESSION: Streptococcal pharyngitis.
DISPOSITION: Discharged to home.
PLAN:
1. To take antibiotics.
2. Follow up with doctor.
3. Return for any concerns.
