DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-and-(XX)-month-old African-American female child who was admitted through the emergency room on the day of admission with a history of coughing and being sick for two to three days. Mother was treating her at home with the nebulizer machine, giving her treatments every four to six hours and noticed that the child was breathing hard and breathing heavy, so she decided to bring her to the emergency room. There is no history of fever, vomiting, diarrhea, and no other health condition, except for the breathing problem.
PAST MEDICAL HISTORY: Significant for this being a term child. Had no problems initially and no problems needing oxygen, but when she was 2 or 3 months old, we think she had episodes of bronchiolitis, and since then, has developed wheezing and asthma for which she received nebulizer treatment. She was hospitalized once for a few days.
SOCIAL HISTORY: The child stays with mother and father and siblings, and there is a family history of asthma. The parents smoke and have been counseled about the importance of smoke-free environment for the child since she definitely gets into trouble with cigarette smoke. The child is up-to-date on immunizations, and growth and development have been appropriate. She is a climber. She climbs on everything. She copies whatever you say, and she is a busy child with some good temper tantrums.
HOSPITAL COURSE: In the emergency room, initially, she had a low-grade fever and her respirations were 34 to 38. Her pulse oximetry in the emergency room was in the 80s, so at this point, she was placed on O2 by nasal cannula, which the child was having problems keeping the nasal cannula in, and she continued to receive some oxygen supplement. The nasal cannula was discontinued the next day, and instead, we put her in a mist tent, which was more tolerable to her. Her pulse oximetry was better and it remained in the high 90s; although, it was difficult to keep the child in the mist tent for long. WBC count was 11,600 initially with a normal differential. Her electrolytes were also within normal limits. Her RSV, which was sent from the emergency room, is still pending. Her chest x-ray was read as having some lingular pneumonia. She was placed on oral Zithromax and Orapred. She is receiving nebulizer treatments, which consisted of Xopenex, initially more frequently and subsequently every four hours and p.r.n. Since yesterday, the child has been afebrile, eating good, and busy. We have discontinued her mist tent, and she seemed to be doing good with pulse oximetry, and her respirations are in 20s, 24 today. It was decided to send her home.
PHYSICAL EXAMINATION: General: The patient is sitting on the bed playing. There is no nasal flaring or retractions. She has got a good color. Vital Signs: Her respiratory rate is 22 to 24. HEENT: Her pupils are equal, round, and reacting to light. Her oral mucosa is pink and moist. Tympanic membranes are healthy. Lungs: Good air entry bilaterally with end-expiratory wheezes still. Heart: Regular sinus rhythm. No tachycardia. Abdomen: Soft. No tenderness. No masses. Bowel sounds are present. Extremities: Full range of movement. Genitalia: External female. Skin: Good turgor, and there are no rashes.
ASSESSMENT AND PLAN: The patient is an approximately (XX)-year-old little girl with a known history of asthma who had a flare-up, which is probably due to the lingular pneumonia, which seemed to be resolving, so I am sending her home today. She does not need any Zithromax anymore, she has received it for four days, but she will be taking some Orapred, tapering doses, for the next two days and then also receiving nebulizer treatments every four hours. Mother has been advised to minimize exposure to cigarette smoke again and she understands. She will be seen in our office tomorrow for a followup and also for a flu shot.
