2 5 All Other
Resume:
Name: Hayden Lynn Griffin DOB: */**/**** MRN: *****849 PCP: Andrea F Logan, MD Legal Name: Hayden Lynn Griffin
CHIEF COMPLAINT
HPI
Hayden Lynn Griffin is a 9 m.o. female who presents with shortness breath wheezing diagnosed with RSV recently. The severity of the symptoms is moderate. The symptoms have been present for about a week. Relieving factors include rest breathing treatments. Exacerbating factors include activity. The mother reports malaise and fever associated with the chief complaint.
HISTORIAN
Mother
EXTERNAL NON-ED NOTES REVIEWED
None
CURRENT MEDICATIONS
ED Provider Notes (Hayden)
Signed Dec 11, 2024
Chief Complaint
Patient presents with
• Respiratory Distress
• Fever
Previous Medications
ALBUTEROL
(PROVENTIL) 2.5 MG /3
ML (0.083 %) NEBULIZER
SOLUTION
Take 3 mLs (2.5 mg total)
by nebulization every 6
(six) hours as needed
FAMOTIDINE (PEPCID) 40
MG/5 ML (8 MG/ML)
SUSPENSION
Take 1 mL (8 mg total) by
mouth in the morning.
ED Provider Notes by Stephen Bell at 12/11/2024 3:47 PM https://mychart.mysrhs.com/MyChart/app/visits/note?csn=WP-244Gd-2FxzHZXiExrusCOx7b-2BFm0ekzwaHY-3D&fromPvdPage=1 1/9/25, 6:34 AM Page 1 of 11
ALLERGIES
No Known Allergies
PAST MEDICAL HISTORY
CHRONIC CONDITIONS REVIEWED THAT COULD IMPACT CARE None
SURGICAL HISTORY
History reviewed. No pertinent surgical history.
SOCIAL HISTORY
Past Medical History:
Diagnosis Date
• Acid reflux
Social History
Socioeconomic History
• Marital status: Single
Spouse name: None
• Number of children: None
• Years of education: None
• Highest education level: None
Occupational History
• None
Other Topics Concern
• None
Social History Narrative
3/20/2024 - Lives with mom, dad and 2 older sisters. Takes Sensitive Premium 4-6 oz every 4 hours.
Social Drivers of Health
Financial Resource Strain: Not on file
Food Insecurity: Not on file
Transportation Needs: Not on file
Physical Activity: Not on file
Stress: Not on file
Social Connections: Not on file
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FAMILY HISTORY
REVIEW OF SYSTEMS
Twelve point review of systems performed.
All Systems otherwise negative except as noted in the History of Present Illness. PHYSICAL EXAM
VITAL SIGNS: Pulse 168 Temp 101.7 F (38.7 C) (Rectal) Wt 9.492 kg (20 lb 14.8 oz) SpO2 93%
Constitutional: Well developed, Well nourished, moderate distress, Non-toxic appearance.
HENT: Normocephalic, Atraumatic, Bilateral external ears normal, Oropharynx moist, No oral exudates, Nose nares/turbinates-Normal. Neck- Normal range of motion, No tenderness, Supple, No stridor.
Eyes: PERRL, EOMI, Conjunctiva normal, No discharge. Respiratory: Breath sounds tachypnea
cardiovascular: Cardiac normal rhythm, No murmurs, No rubs, No gallops. GI: Bowel sounds normal, Soft, No tenderness, No masses, No pulsatile masses. Musculoskeletal: Intact distal pulses, No edema, No tenderness, No cyanosis, No clubbing. Good range of motion in all major joints. No tenderness to palpation or major deformities noted. Back- No tenderness.
Integument: Warm, Dry, No erythema, No rash.
Lymphatic: No lymphadenopathy noted.
Neurologic: Alert & oriented Normal motor function, Normal sensory function, No focal deficits noted.
Psychiatric: Affect normal, Judgment normal, Mood normal. LABS (INDEPENDENTLY EVALUATED FOR CLINICAL DECISION MAKING) Intimate Partner Violence: Not on file
Housing Stability: Not on file
Family History
Problem Relation Age of Onset
• Anemia Mother
Copied from mother's history at birth
Labs Reviewed
COMPREHENSIVE METABOLIC PANEL -
Abnormal; Notable for the following
components:
Result Value
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CO2 18 BUN 8 Creatinine 0.29 Glucose 110 AST 45 Alkaline Phosphatase 223 Albumin 5.2 Total Bilirubin <0.2 Anion Gap 15.1 All other components within normal limits
LACTIC ACID - Abnormal; Notable for the
following components:
Lactate 2.1 All other components within normal limits
CBC WITH DIFFERENTIAL - Abnormal; Notable
for the following components:
Hemoglobin 10.1 Hematocrit 31.0 MCV 77.9 MCH 25.4 MPV 9.1 All other components within normal limits
MANUAL DIFFERENTIAL - Abnormal; Notable
for the following components:
Neutrophils % 62 Lymphocytes % 31 Monocytes Absolute 0.61 All other components within normal limits
PROCALCITONIN - Normal
CBC AND DIFFERENTIAL
Narrative:
The following orders were created for panel
order CBC and Differential.
Procedure Abnormality
Status
CBC With Differential[132196309]
Abnormal Final result
Manual Differential[132197292] Abnormal
Final result
Please view results for these tests on the
individual orders.
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LABS (CONSIDERED BUT NOT PERFORMED)
CRP
RADIOLOGY
Imaging Results
XR CHEST, PORTABLE (1 V) (Final result) Result time 12/11/24 15:59:00 Final result
Impression:
IMPRESSION:
1. NO ACUTE CARDIOPULMONARY PROCESS IS IDENTIFIED
RADIOGRAPHICALLY.
Narrative:
EXAMINATION:
XR CHEST, PORTABLE (1 V), 12/11/2024 3:42 pm
CLINICAL HISTORY:
10 m/o Female, SOB. SOB
COMPARISON:
July 16, 2024
FINDINGS:
The cardiomediastinal silhouette is within normal limits of size. No pneumothorax, pleural effusion or acute infiltrate is identified. No acute osseous abnormality.
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RADIOLOGY (CONSIDERED BUT NOT PERFORMED)
None
RADIOLOGICAL STUDIES INDEPENDENTLY INTERPRETED FOR INITIATING CLINICAL CARE BEFORE THE OFFICIAL RADIOLOGICAL READ WAS AVAILABLE Chest x-ray
PREVIOUS RADIOLOGY RESULTS REVIEWED
Results for orders placed during the hospital encounter of 07/16/24 XR CHEST, PORTABLE (1 V)
Narrative
EXAMINATION:
XR CHEST, PORTABLE (1 V). IMG1259. 7/16/2024 10:24 pm. 5 m/o . CLINICAL HISTORY:
Cough. Cough. .
COMPARISON:
June 24, 2024.
FINDINGS:
Normal study.
Impression
IMPRESSION:
No evidence of acute abnormality.
No results found for this or any previous visit.
EKG (INDEPENDENTLY INTERPRETED)
PROCEDURE
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ED COURSE & MEDICAL DECISION MAKING
Conditions considered based on the patient's current presentation and available information:
1: RSV bronchiolitis
2: Pneumonia
3: Metabolic abnormalities
4. Secondary infection
Treatments initiated to mitigate the need for escalation of care and to treat immediate clinical condition:
The medications that were given during this visit includes: ED Medication Orders (From admission, onward)
Start Ordered Status
Ordering
Provider
12/11/24
1900
12/11/24
1742
Discontinued BELL,
STEPHEN W
12/11/24
1800
12/11/24
1756
Last MAR
action: Given
BELL,
STEPHEN W
12/11/24
1745
12/11/24
1733
Last MAR
action: Given
BELL,
STEPHEN W
12/11/24
1700
12/11/24
1541
Discontinued BELL,
STEPHEN W
acetaminophen
(TYLENOL) oral liquid
142.4 mg 6 times daily
Route: Oral Ordered
Dose: 15 mg/kg
acetaminophen
(TYLENOL) oral liquid
142.4 mg Once
Route: Oral Ordered
Dose: 15 mg/kg
ipratropium-albuteroL
(DUONEB) 0.5 mg-3
mg(2.5 mg base)/3 mL
nebulizer solution 3
mL Once (RT)
Route: Nebulization
Ordered Dose: 3 mL
Placed in "And" Linked
Group
ibuprofen (MOTRIN)
100 mg/5 mL
suspension 95 mg 4
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Patient presents with respiratory failure. Reviewed the medical record noted above differential diagnoses above noted that the chest x-ray is without infiltrate. I suspect this is all RSV bronchiolitis the CBC is without evidence of any bacteremia electrolyte status and renal function mild metabolic acidosis liver functions normal discussion with pediatrics patient was admitted
12/11/24
1600
12/11/24
1546
Last MAR
action: Given
BELL,
STEPHEN W
12/11/24
1600
12/11/24
1547
Last MAR
action: Given
BELL,
STEPHEN W
12/11/24
1600
12/11/24
1551
Last MAR
action: Given
BELL,
STEPHEN W
times daily
Route: Oral Ordered
Dose: 10 mg/kg
prednisoLONE
(ORAPRED) 15 mg/5
mL (3 mg/mL) oral
solution 10 mg Once
Route: Oral Ordered
Dose: 10 mg
ipratropium-albuteroL
(DUONEB) 0.5 mg-3
mg(2.5 mg base)/3 mL
nebulizer solution 3
mL Once (RT)
Route: Nebulization
Ordered Dose: 3 mL
Placed in "And" Linked
Group
ibuprofen (MOTRIN)
100 mg/5 mL
suspension 95 mg
Once
Route: Oral Ordered
Dose: 10 mg/kg
ED Vitals
Date and
Time Temp Pulse Resp BP SpO2 RN/Tech
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Treatment considered but not performed: Antibiotics Discussed the management of the patient with: Mother and pediatrics DISPOSITION
Hospitalization considered and based on the patient's current presentation and available information patient was admitted.
FINAL IMPRESSION
.
12/11/24
1740
-- -- -- -- 93 % SLH
12/11/24
1740
101.7 F (38.7
C)
-- -- -- -- JS
12/11/24
1710
-- 168 -- -- 99 % FM
12/11/24
1537
-- -- -- -- 96 % FM
12/11/24
1535
101.3 F (38.5
C)
176 -- -- 96 % FM
Diagnoses
Diagnosis Comment Added By
Time
Added
Team
Role
Provider
Specialty
RSV
bronchiolitis
Stephen W
Bell, MD
12/11/20
24 6:39
PM
Attendin
g
Provider
Emergency
Medicine
Acute
respiratory
failure,
unspecified
whether with
hypoxia or
hypercapnia
Stephen W
Bell, MD
12/11/20
24 6:40
PM
Attendin
g
Provider
Emergency
Medicine
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The discharge medications included (please note that some discharge medications may be mentioned above, and may not be listed below): None
ED Prescriptions
ED Events
Date/Time Event User Comments
12/11/24
1553
Time of first ED
Physician/APN/
PA contact
BELL, STEPHEN
WADE
--
12/11/24
1835
Disposition
Selected
BELL, STEPHEN
WADE
--
ED Disposition
ED
Dispositio
n
Admit
Condition
Stable
User
Stephen
W Bell,
MD
Comment
--
Diagnoses
Diagnosis Comment Added By
Time
Added
Team
Role
Provider
Specialty
RSV
bronchiolitis
Stephen W
Bell, MD
12/11/20
24 6:39
PM
Attendin
g
Provider
Emergency
Medicine
Acute
respiratory
failure,
unspecified
Stephen W
Bell, MD
12/11/20
24 6:40
PM
Attendin
g
Provider
Emergency
Medicine
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Parts of this note were created using Dragon Voice Recognition software program. While efforts were made to correct any mistakes made by this voice recognition software program, nonsensical phrases may remain in this note. Stephen W Bell, MD
12/11/24 1840
whether with
hypoxia or
hypercapnia
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