Peds URI

I have reviewed the above documentation.  ROS reviewed with patient.  Past {AHLTA} records reviewed during this visit.



  { } {year/month} old child presents with { } days of {cough, }{congestion, }{rhinorrhea, }{throat pain, }{ear pain, }{pulling at ears}.  Parents report child is overall {well}.  Child is {eating normally}.  {Drinking normally}.  Urinated { } times in the last 24 hours.  {}No emesis.  {}No diarrhea.  {}No changes in bowel habits.


  Child {is} up to date on immunizations.  {No} sick contacts.


--- Allergies ---


--- Medications ---




    { }



  Vitals reviewed and {}WNL.  Manual count of respiratory rate was { }.

GEN: Child appears {appropriate} for age.  {No} acute distress.

EYE:  {}Normal conjunctiva, normal lids. {No }Scleral icterus.  PERRL, normal iris.

ENT: {}Moist mucous membranes.  Normal external appearance of ears, nose. TM's normal {without erythema, }{without effusion }bilaterally.

NECK: {}Normal appearance.  {No }Tonsillar enlargement.  {No }Tonsillar exudate. 

LYMPH: {No }cervical lymphadenopathy.

CARD: {}S1, S2 RRR no M/R/G.  

LUNG: {}CTAB no W/R/R. {}Normal resp effort.  {}No grunting.  {}No retractions.  {}No accessory muscle use.  Child positions themselves {}normally, with {}NO tripod or sniffing position.

ABD: {}Soft, NT, ND, NABS.  No HSM.

SKIN: {}Skin warm and dry without rash or lesions.  

EXT:  {}No CCE. 

{GU:     {Normal male genitalia.  Testicles bilaterally descended and palpable.}{Normal external female genitalia.}}

{GI:     {}Normal anus.}


{Rapid strep: { }; Throat culture performed;}




# { }

{Overall well appearing child.  No evidence of serious bacterial illness at this time.  Reasonable to treat conservatively with close return precautions.  Parents agree.}


-- { }

-- Discussed return precautions at length, to include increased work of breathing, accessory muscle use, retractions, grunting, a preference for tripod or sniffing position.  Return immediately if unable to tolerate PO, less than 3 wet diapers in 24 hours, bilious, bloody, or frequent emesis, bloody stools. Also discussed appropriate use of acetaminophen (15mg/kg/dose, no more than 5 doses/24 hours) or motrin (10mg/kg/dose, no more than 4 doses/24 hours) for symptomatic relief of discomfort from fever >= 100.4F.  Encouraged parents to call for any other concern we did not specifically address.