DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: H1N1 contact, acute illness.
HISTORY OF PRESENT ILLNESS: This is a (XX)-month-old little girl who three days ago, father reports, saw her PCP, who diagnosed the child with bronchitis and reactive airway. She was prescribed medications to include bronchodilators. The child has been doing well otherwise, taking p.o., has a dry cough, no distress, no reported fever. However, her sister was diagnosed with H1N1. This is an intermittent contact. The child was a full-term delivery without any complications and does not have any chronic pulmonary or lung conditions. There has been no nasal flaring or respiratory distress. No otic discharge, had some clear nasal discharge, and some recent eye discharge and drainage, but to injection to the eye. No abdominal pain or distention. No sputum production. No vomiting or persistent diarrhea. Her eyes have been watery. No listlessness or loss of consciousness. No seizure activity. No rashes.
PAST MEDICAL HISTORY: Negative.
PAST SURGICAL HISTORY: Negative.
SOCIAL HISTORY: She has two siblings that are here with her today. No second-hand smoke exposure.
ALLERGIES: No known drug allergies.
MEDICATIONS: Albuterol SVN treatments.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: This is a (XX)-month-old little girl, who is mildly ill appearing, but nontoxic, consoled.
VITAL SIGNS: Pulse 156, respiratory rate 28, temperature 98.2, and pulse oximetry 97% on room air.
HEENT: Head: Normocephalic and atraumatic. Eyes: Slightly watery. Noninjected. Ears: External canals are clear. TMs are gray and translucent. Nose is clear. Nasal discharge. Mouth is pink and moist. Throat: Slightly injected. No exudate or retropharyngeal prominence. No oropharyngeal lesions.
NECK: Supple. Trachea is midline, mobile. No cervical adenopathy.
LUNGS: Coarse breath sounds, but no wheezes, crackles, or rhonchi.
CARDIOVASCULAR: Regular rhythm. S1, S2.
ABDOMEN: Bowel sounds are positive in all four quadrants. Soft and nontender. No hepatosplenomegaly, mass, rebound, rigidity, or guarding.
EXTREMITIES: No clubbing or cyanosis.
NEUROLOGIC: Awake and alert.
SKIN: Clear. Petechiae, rashes.
EMERGENCY DEPARTMENT COURSE: Education was given regarding the presentation. Of the three family members here today, she is the only one who meets criteria for treatment with Tamiflu. This was discussed with the father and he did verbalize understanding.
CLINICAL IMPRESSION:
1. Bronchitis with reactive airway.
2. H1N1 influenza contact.
PLAN:
1. We encouraged her to continue taking the medications as prescribed by her primary physician from three days ago. We will add Tamiflu 25 mg p.o. b.i.d.
2. An influenza A and B nasal swab was obtained here in the department and will be sent for H1N1 testing should it turn positive.
3. She is to follow up with this result with her pediatrician.
4. We are encouraging her to follow up with the pediatrician tomorrow or return to the department sooner should the child worsen in any way.
Fever has been treated by father with Tylenol and verbalized understanding this.
DISPOSITION: Discharged.
