Blake Photo Time-Line

ONLC PEDIATRICS OCHSNER, BATON ROUGE REGION LA

Grondin, Blake John MRN: 12051461, DOB: 2/14/2020, Sex: M

Acct #: 72015194439 Enc. Date 12/20/2021

12/20/2021 - Office Visit in O'Neal - Pediatrics

Reason for Visit Follow-up

Diagnoses

Codes

Comments

Bronchiolitis - Primary

ICD-10-CM: J21.9 ICD-9-CM: 466.19

Problem List as of 12/20/2021

Date Reviewed: 12/20/2021

Codes

Priority

Class

Noted - Resolved

Newborn affected by maternal use of other drugs of addiction

ICD-10-CM: P04.49 ICD-9-CM: 760.79

2/14/2020 - Present

Overview Addendum 2/14/2020 2:04 PM by Myriam Ortiz-de Jesus, MD

Polysubstance drug exposure during pregnancy. Infant UDS + for opioids. Buprenorphine screen and meconium screen pending. Infant at high risk for withdrawal and this was explained to mom as well as the need for observation for a minimum of 72 hrs. Mother verbalized understanding. Mom may breast feed infant. Plans: NAS every 3 hrs, SS consult.

Mother's group B Streptococcus colonization status unknown

ICD-10-CM: IMO0002 ICD-9-CM: IMO0002

2/14/2020 - Present

Overview Signed 2/14/2020 2:03 PM by Myriam Ortiz-de Jesus, MD

S/P adequate intrapartum prophylaxis.

Routine or ritual circumcision

ICD-10-CM: Z41.2 ICD-9-CM: V50.2 ICD-10-CM: Z38.00 ICD-9-CM: V30.00

Unknown - Present

RESOLVED: Single liveborn infant delivered vaginally

2/14/2020 - 5/18/2020

Overview Addendum 2/14/2020 2:06 PM by Myriam Ortiz-de Jesus, MD AGA male infant , Ballard at 37 weeks. Will need car seat test.

Patient as-of Visit

Allergies as of 12/20/2021

Allergies last reviewed by James A. Wayne Jr., MD on 12/20/2021 0933 No Known Allergies

Immunizations as of 12/20/2021 Immunization

Administered On

DTaP / HiB / IPV

02/14/2020, 04/27/2020, 09/03/2020 04/27/2020, 07/09/2020, 09/03/2020 04/27/2020, 07/09/2020, 09/03/2020 04/27/2020, 07/09/2020, 09/03/2020

Hepatitis B, Pediatric/Adolescent Pneumococcal Conjugate - 13 Valent

Rotavirus Pentavalent

Outpatient Medications at Start of Encounter as of 12/20/2021 Disp

Refills

Start

End

albuterol (PROVENTIL/VENTOLIN HFA) 90 mcg/actuation inhaler (Taking)

6.7 g

0

12/16/2021

Generated on 7/19/22 2:38 PM

Page 1

ONLC PEDIATRICS OCHSNER, BATON ROUGE REGION LA

Grondin, Blake John MRN: 12051461, DOB: 2/14/2020, Sex: M

Acct #: 72015194439 Enc. Date 12/20/2021 12/20/2021 - Office Visit in O'Neal - Pediatrics (continued)

Outpatient Medications at Start of Encounter as of 12/20/2021 (continued) Disp

Refills End Sig: Give 2 puffs every 6hrs for 3 days, then give 2 puffs every 6hrs as needed for shortness of breath or cough cefdinir (OMNICEF) 250 mg/5 mL suspension (Taking) 35 mL 0 12/16/2021 12/26/2021 Sig - Route: Take 1.7 mLs (85 mg total) by mouth 2 (two) times daily. for 10 days - Oral dextromethorphan 15 mg/5 mL syrup (Taking) Sig - Route: Take 10 mLs by mouth 4 (four) times daily as needed for Cough. - Oral Class: Historical Med inhalation spacing device (RITEFLO AEROCHAMBER) (Taking) 1 each 0 12/16/2021 Sig: Use as directed for inhalation. Notes to Pharmacy: Please give mask appropriate for 22mo old Start

Medications the Patient Reported Taking

Disp 6.7 g

Refills

Start

End

albuterol (PROVENTIL/VENTOLIN HFA) 90 mcg/actuation inhaler (Taking)

0

12/16/2021

Sig: Give 2 puffs every 6hrs for 3 days, then give 2 puffs every 6hrs as needed for shortness of breath or cough cefdinir (OMNICEF) 250 mg/5 mL suspension (Taking/Expired) 35 mL 0 12/16/2021

12/26/2021

Sig: Take 1.7 mLs (85 mg total) by mouth 2 (two) times daily. for 10 days Route: Oral dextromethorphan 15 mg/5 mL syrup (Taking) Sig: Take 10 mLs by mouth 4 (four) times daily as needed for Cough. Class: Historical Med Route: Oral inhalation spacing device (RITEFLO AEROCHAMBER) (Taking) 1 each 0

12/16/2021

Sig: Use as directed for inhalation. Notes to Pharmacy: Please give mask appropriate for 22mo old

Progress Notes

Progress Notes by James A. Wayne Jr., MD at 12/20/2021 9:00 AM Author: James A. Wayne Jr., MD Service: —

Author Type: Physician

Filed: 12/21/2021 8:16 AM

Encounter Date: 12/20/2021

Creation Time: 12/20/2021 9:29 AM

Status: Signed

Editor: James A. Wayne Jr., MD (Physician)

Assessment/Plan: Bronchiolitis

Pts wheezing has resolved. No steroids indicated. Right TM still bulging and red so need to continue an abx to complete tx course for OM. Change albuterol to as needed use. Tylenol (acetaminophen) or Motrin/Advil (ibuprofen) may be given for fever or discomfort and supportive care. Offer fluids to promote adequate hydration. Humidifier may help with nasal congestion. RTC/ER prn increased WOB, fever > 5 days, signs of dehydration or for parental questions or concerns.

Subjective:

HISTORY OF PRESENT ILLNESS: 22mo male here for F/U of wheezing and ear infection dx last week. Has been getting albuterol Q6 x 3 days. No further fever. Albuterol does seem to help. Activity level is back to normal Generated on 7/19/22 2:38 PM Page 2

ONLC PEDIATRICS OCHSNER, BATON ROUGE REGION LA

Grondin, Blake John MRN: 12051461, DOB: 2/14/2020, Sex: M

Acct #: 72015194439 Enc. Date 12/20/2021

Progress Notes (continued) Progress Notes by James A. Wayne Jr., MD at 12/20/2021 9:00 AM (continued)

Current Outpatient Medications: • albuterol (PROVENTIL/VENTOLIN HFA) 90 mcg/actuation inhaler, Give 2 puffs every 6hrs for 3 days, then give 2 puffs every 6hrs as needed for shortness of breath or cough, Disp: 6.7 g, Rfl: 0 • cefdinir (OMNICEF) 250 mg/5 mL suspension, Take 1.7 mLs (85 mg total) by mouth 2 (two) times daily. for 10 days, Disp: 35 mL, Rfl: 0 • dextromethorphan 15 mg/5 mL syrup, Take 10 mLs by mouth 4 (four) times daily as needed for Cough., Disp: , Rfl: • inhalation spacing device (RITEFLO AEROCHAMBER), Use as directed for inhalation., Disp: 1 each, Rfl: 0

Review of patient's allergies indicates: No Known Allergies

History reviewed. No pertinent past medical history.

Review of Systems Constitutional: Negative for activity change, appetite change and fever. HENT: Positive for nasal congestion, rhinorrhea and sneezing. Eyes: Negative for discharge. Respiratory: Positive for cough. Negative for wheezing. Cardiovascular: Negative for chest pain. Gastrointestinal: Negative for abdominal pain, constipation, diarrhea and vomiting. Musculoskeletal: Negative for myalgias.

Objective:

PHYSICAL EXAM: Vitals:

12/20/21 0910

Temp:

(!) 95.3 °F (35.2 °C)

TempSrc:

Tympanic

Weight: Height:

5.579 kg (12 lb 4.8 oz)

2' 10.5" (0.876 m)

General: Alert and vigorous. Good color. No distress. Skin: No rashes or cyanosis. Eyes: No redness or injection. Discharge: None

ENT: Ears: Normal pinna/lobes. Left TM clear. Right TM bulging and slightly erythematous with purulent effusion Nasopharynx: Clear rhinorrhea and audible nasal congestion. Mouth/Throat: No oral lesions. Throat: no redness or tonsil enlargement. Neck: Supple, with no masses. Full range of motion present. Lymphatic: No adenopathy in anterior cervical or posterior cervical lymph node regions. Lungs/Chest: Clear to auscultation bilaterally. No wheezes or crackles. Good air flow, and no retractions. Heart: Normal sinus rhythm and regular rate. No murmurs.

Generated on 7/19/22 2:38 PM

Page 3

ONLC PEDIATRICS OCHSNER, BATON ROUGE REGION LA

Grondin, Blake John MRN: 12051461, DOB: 2/14/2020, Sex: M

Acct #: 72015194439 Enc. Date 12/20/2021

Progress Notes (continued) Progress Notes by James A. Wayne Jr., MD at 12/20/2021 9:00 AM (continued) Electronically signed by James A. Wayne Jr., MD on 12/21/2021 8:16 AM

Follow-up and Disposition History

12/20/2021 0933 - James A. Wayne Jr., MD Dispositions:

Follow up if symptoms worsen or fail to improve. ·

Follow-up Information None

Follow Up Call No data filed

Generated on 7/19/22 2:38 PM

Page 4

ONLC PEDIATRICS OCHSNER, BATON ROUGE REGION LA

Grondin, Blake John MRN: 12051461, DOB: 2/14/2020, Sex: M

Acct #: 72015178898 Enc. Date 12/16/2021

12/16/2021 - Office Visit in O'Neal - Pediatrics

Reason for Visit Cough Fever

Nasal Congestion

Sick since Monday with CCC. Started with fever yesterday. Playful and active. Will drink well, not eating as much. Ear drainage also.

Diagnoses

Codes

Comments

Bronchiolitis - Primary

ICD-10-CM: J21.9 ICD-9-CM: 466.19 ICD-10-CM: H66.006 ICD-9-CM: 382.00

Recurrent acute suppurative otitis media without spontaneous rupture of tympanic membrane of both sides

Problem List as of 12/16/2021

Date Reviewed: 12/16/2021

Codes

Priority

Class

Noted - Resolved

Newborn affected by maternal use of other drugs of addiction

ICD-10-CM: P04.49 ICD-9-CM: 760.79

2/14/2020 - Present

Overview Addendum 2/14/2020 2:04 PM by Myriam Ortiz-de Jesus, MD

Polysubstance drug exposure during pregnancy. Infant UDS + for opioids. Buprenorphine screen and meconium screen pending. Infant at high risk for withdrawal and this was explained to mom as well as the need for observation for a minimum of 72 hrs. Mother verbalized understanding. Mom may breast feed infant. Plans: NAS every 3 hrs, SS consult.

Mother's group B Streptococcus colonization status unknown

ICD-10-CM: IMO0002 ICD-9-CM: IMO0002

2/14/2020 - Present

Overview Signed 2/14/2020 2:03 PM by Myriam Ortiz-de Jesus, MD

S/P adequate intrapartum prophylaxis.

Routine or ritual circumcision

ICD-10-CM: Z41.2 ICD-9-CM: V50.2 ICD-10-CM: Z38.00 ICD-9-CM: V30.00

Unknown - Present

RESOLVED: Single liveborn infant delivered vaginally

2/14/2020 - 5/18/2020

Overview Addendum 2/14/2020 2:06 PM by Myriam Ortiz-de Jesus, MD AGA male infant , Ballard at 37 weeks. Will need car seat test.

Patient as-of Visit

Allergies as of 12/16/2021

Allergies last reviewed by James A. Wayne Jr., MD on 12/16/2021 1021 No Known Allergies

Immunizations as of 12/16/2021 Immunization

Administered On

DTaP / HiB / IPV

04/27/2020, 07/09/2020, 09/03/2020 02/14/2020, 04/27/2020, 09/03/2020 04/27/2020, 07/09/2020, 09/03/2020 04/27/2020, 07/09/2020, 09/03/2020

Hepatitis B, Pediatric/Adolescent Pneumococcal Conjugate - 13 Valent

Rotavirus Pentavalent

Generated on 7/19/22 2:38 PM

Page 5

ONLC PEDIATRICS OCHSNER, BATON ROUGE REGION LA

Grondin, Blake John MRN: 12051461, DOB: 2/14/2020, Sex: M

Acct #: 72015178898 Enc. Date 12/16/2021 12/16/2021 - Office Visit in O'Neal - Pediatrics (continued)

Outpatient Medications at Start of Encounter as of 12/16/2021 Disp

Refills

Start

End

dextromethorphan 15 mg/5 mL syrup Sig - Route: Take 10 mLs by mouth 4 (four) times daily as needed for Cough. - Oral Class: Historical Med erythromycin (ROMYCIN) ophthalmic ointment 1 Tube 0

4/10/2021

12/16/2021

Sig: Place a 1/2 inch ribbon of ointment into the left lower eyelid TID erythromycin (ROMYCIN) ophthalmic ointment 1 Tube

0

6/17/2021

12/16/2021

Sig: Place a 1/2 inch ribbon of ointment into the lower eyelid of bil eye four times daily for 5 days Class: Print

Ordered Medications

Disp 6.7 g

Refills

Start

End

albuterol (PROVENTIL/VENTOLIN HFA) 90 mcg/actuation inhaler

0

12/16/2021

Sig: Give 2 puffs every 6hrs for 3 days, then give 2 puffs every 6hrs as needed for shortness of breath or cough cefdinir (OMNICEF) 250 mg/5 mL suspension 35 mL 0 12/16/2021

12/26/2021

Sig - Route: Take 1.7 mLs (85 mg total) by mouth 2 (two) times daily. for 10 days - Oral inhalation spacing device (RITEFLO AEROCHAMBER) 1 each 0

12/16/2021

Sig: Use as directed for inhalation. Notes to Pharmacy: Please give mask appropriate for 22mo old

Ordered Facility-Administered Medications

Dose

Freq

Start

End

albuterol nebulizer solution 2.5 mg

2.5 mg

Clinic/HOD 1 time

12/16/2021

12/16/2021

Route: Nebulization

All Meds and Administrations

albuterol nebulizer solution 2.5 mg [583171810] Ordering Provider: James A. Wayne Jr., MD

Status: Completed (Past End Date/Time) Starts/Ends: 12/16/21 1000 - 12/16/21 0950

Ordered On: 12/16/21 0947

Ordered Dose (Remaining/Total): 2.5 mg (0/1)

Route: Nebulization

Frequency: Clinic/HOD 1 time

Ordered Rate/Order Duration: — / —

12/16/21 0950 Timestamps

Action

Dose

Route

Other Information

Given

2.5 mg

Nebulization

Performed by: Amanda Altazan, RN Scanned Package: 0487-9501-01

Outpatient Medication Detail

Disp

Refills

Start

End

DAW

inhalation spacing device (RITEFLO AEROCHAMBER)

1 each

0

12/16/2021

--

Sig: Use as directed for inhalation. Sent to pharmacy as: inhalation spacing device (RITEFLO AEROCHAMBER) Class: Normal Notes to Pharmacy: Please give mask appropriate for 22mo old Order: 583171814 Date/Time Signed: 12/16/2021 12:52 E-Prescribing Status: Receipt confirmed by pharmacy (12/16/2021 12:52 PM CST)

Outpatient Medication Detail

Disp

Refills

Start

End

DAW

cefdinir (OMNICEF) 250 mg/5 mL suspension

35 mL

0

12/16/2021 12/26/2021 --

Sig - Route: Take 1.7 mLs (85 mg total) by mouth 2 (two) times daily. for 10 days - Oral Generated on 7/19/22 2:38 PM

Page 6

ONLC PEDIATRICS OCHSNER, BATON ROUGE REGION LA

Grondin, Blake John MRN: 12051461, DOB: 2/14/2020, Sex: M

Acct #: 72015178898 Enc. Date 12/16/2021 12/16/2021 - Office Visit in O'Neal - Pediatrics (continued)

Outpatient Medication Detail (continued)

Disp

Refills

Start

End

DAW

Sent to pharmacy as: cefdinir (OMNICEF) 250 mg/5 mL suspension Class: Normal Order: 583171813 Date/Time Signed: 12/16/2021 10:15 E-Prescribing Status: Receipt confirmed by pharmacy (12/16/2021 10:15 AM CST)

Outpatient Medication Detail

Disp 6.7 g

Refills

Start

End

DAW

albuterol (PROVENTIL/VENTOLIN HFA) 90 mcg/actuation inhaler

0

12/16/2021

--

Sig: Give 2 puffs every 6hrs for 3 days, then give 2 puffs every 6hrs as needed for shortness of breath or cough Sent to pharmacy as: albuterol (PROVENTIL/VENTOLIN HFA) 90 mcg/actuation inhaler Class: Normal Order: 583171811 Date/Time Signed: 12/16/2021 10:12 E-Prescribing Status: Receipt confirmed by pharmacy (12/16/2021 10:12 AM CST)

Outpatient Medication Detail

Disp

Refills

Start

End

DAW

inhalation spacing device (Discontinued)

1 each

0

12/16/2021 12/16/2021 --

Sig: Use as directed for inhalation. Sent to pharmacy as: inhalation spacing device Class: Normal Notes to Pharmacy: Please give with a mask appropriately sized for a 22month old Order: 583171812 Date/Time Signed: 12/16/2021 10:12 E-Prescribing Status: Receipt confirmed by pharmacy (12/16/2021 10:12 AM CST)

Clinic-Administered Medication Detail

Dose

Frequency Start

End

DAW

albuterol nebulizer solution 2.5 mg

2.5 mg

Clinic/HOD 1 time

12/16/2021 12/16/2021 --

Class: Normal Route: Nebulization Order: 583171810 Date/Time Signed: 12/16/2021 09:47

Progress Notes

Progress Notes by James A. Wayne Jr., MD at 12/16/2021 9:30 AM Author: James A. Wayne Jr., MD Service: —

Author Type: Physician

Filed: 12/16/2021 12:55 PM

Encounter Date: 12/16/2021

Creation Time: 12/16/2021 9:48 AM

Status: Signed

Editor: James A. Wayne Jr., MD (Physician)

Assessment/Plan: Bronchiolitis - albuterol nebulizer solution 2.5 mg - albuterol (PROVENTIL/VENTOLIN HFA) 90 mcg/actuation inhaler; Give 2 puffs every 6hrs for 3 days, then

give 2 puffs every 6hrs as needed for shortness of breath or cough Dispense: 6.7 g; Refill: 0 - inhalation spacing device; Use as directed for inhalation. Dispense: 1 each; Refill: 0

Recurrent acute suppurative otitis media without spontaneous rupture of tympanic membrane of both sides - cefdinir (OMNICEF) 250 mg/5 mL suspension; Take 1.7 mLs (85 mg total) by mouth 2 (two) times daily. for 10 Generated on 7/19/22 2:38 PM Page 7

ONLC PEDIATRICS OCHSNER, BATON ROUGE REGION LA

Grondin, Blake John MRN: 12051461, DOB: 2/14/2020, Sex: M

Acct #: 72015178898 Enc. Date 12/16/2021

Progress Notes (continued) Progress Notes by James A. Wayne Jr., MD at 12/16/2021 9:30 AM (continued) days Dispense: 35 mL; Refill: 0

Pt with wheezing due to viral infection, Also with bilateral otitis media. Will treat OM with abx, however antibiotics will no affect congestion and cough. Albuterol 2.5mg neb given with excellent response. Improved air mvt, esepcially at right lung base and mild wheezing heard there. Pt fell asleep after the treatment. Tylenol (acetaminophen) or Motrin/Advil (ibuprofen) may be given for fever or discomfort and supportive care. Offer fluids to promote adequate hydration. Humidifier may help with nasal congestion. RTC/ER prn increased WOB, fever > 5 days, signs of dehydration or for parental questions or concerns.

Subjective:

HISTORY OF PRESENT ILLNESS: 22mo male with 4 day h/o congestion and cough. +post tussive emesis. + fever to 102 yesterday. + suprasternal retractions noted in addition to noisy breathing.

Current Outpatient Medications: • albuterol (PROVENTIL/VENTOLIN HFA) 90 mcg/actuation inhaler, Give 2 puffs every 6hrs for 3 days, then give 2 puffs every 6hrs as needed for shortness of breath or cough, Disp: 6.7 g, Rfl: 0 • cefdinir (OMNICEF) 250 mg/5 mL suspension, Take 1.7 mLs (85 mg total) by mouth 2 (two) times daily. for 10 days, Disp: 35 mL, Rfl: 0 • dextromethorphan 15 mg/5 mL syrup, Take 10 mLs by mouth 4 (four) times daily as needed for Cough., Disp: , Rfl: • inhalation spacing device, Use as directed for inhalation., Disp: 1 each, Rfl: 0 No current facility-administered medications for this visit.

Review of patient's allergies indicates: No Known Allergies

No past medical history on file.

Review of Systems Constitutional: Positive for appetite change and fever. Negative for activity change. HENT: Positive for nasal congestion, rhinorrhea and sneezing. Eyes: Negative for discharge. Respiratory: Positive for cough. Negative for wheezing. Cardiovascular: Negative for chest pain. Gastrointestinal: Positive for vomiting. Negative for abdominal pain, constipation and diarrhea. Musculoskeletal: Negative for myalgias.

Objective:

PHYSICAL EXAM: Vitals: Generated on 7/19/22 2:38 PM

Page 8

ONLC PEDIATRICS OCHSNER, BATON ROUGE REGION LA

Grondin, Blake John MRN: 12051461, DOB: 2/14/2020, Sex: M

Acct #: 72015178898 Enc. Date 12/16/2021

Progress Notes (continued) Progress Notes by James A. Wayne Jr., MD at 12/16/2021 9:30 AM (continued) 12/16/21 0935 Pulse: (!) 130 Temp: 100.1 °F (37.8 °C) TempSrc: Tympanic SpO2: 96% Weight: 12 kg (26 lb 7.3 oz)

General: Alert and vigorous. Good color. No distress. Skin: No rashes or cyanosis. Eyes: No redness or injection. Discharge: None

ENT: Ears: Normal pinna/lobes. Bilateral TMs bulging and erythematous with purulent effusion. Nasopharynx: Clear rhinorrhea and audible nasal congestion. Mouth/Throat: No oral lesions. Throat: no redness or tonsil enlargement. Neck: Supple, with no masses. Full range of motion present. Lymphatic: No adenopathy in anterior cervical or posterior cervical lymph node regions. Lungs/Chest: Diffuse inspiratory rhonchii throughout lung fields, slightly decreased air mvt at bases bilaterally; coarse wheezes c/w mucus plugging, but no fine wheezes or crackles noted. Heart: Normal sinus rhythm and regular rate. No murmurs.

Electronically signed by James A. Wayne Jr., MD on 12/16/2021 12:55 PM

Progress Notes by James A. Wayne Jr., MD at 12/16/2021 9:30 AM Author: James A. Wayne Jr., MD Service: —

Author Type: Physician

Filed: 12/16/2021 12:55 PM

Encounter Date: 12/16/2021

Creation Time: 12/16/2021 10:17 AM

Status: Signed

Editor: James A. Wayne Jr., MD (Physician)

Albuterol 2.5mg nebulizer treatment given. Pt had significant improvement in air movt after the treatment. Rhonchii resolved and now mild wheezing heard at right lung base after air mvt in that area improved. Pt fell asleep after the treatment.

Electronically signed by James A. Wayne Jr., MD on 12/16/2021 12:55 PM

Follow-up and Disposition History

12/16/2021 1020 - James A. Wayne Jr., MD Dispositions:

Follow up in about 5 days (around 12/21/2021) for for follow upof wheezing. ·

Follow-up Information None

Follow Up Call No data filed

Generated on 7/19/22 2:38 PM

Page 9

BRMH EMERGENCY DEPARTMENT 17000 Medical Center Dr Baton Rouge LA 70816

Grondin, Blake John MRN: 12051461, DOB: 2/14/2020, Sex: M Acct #: 72014918667 Adm: 11/22/2021

11/22/2021 - ED in O'Neal - Emergency Dept.

ED Arrival Information

Expected

Arrival

Acuity Less Urgent

Means of arrival Personal Transportation

-

11/22/2021 17:30

Escorted by

Service Emergency Medicine

Admission type Emergency

Chief Complaint Facial Laceration

Self

Arrival complaint Fell, Cut on forehead

Patient as-of Visit

Allergies as of 11/22/2021

Allergies last reviewed by Amanda Carmon, RN on 11/22/2021 1743 No Known Allergies

Immunizations as of 11/22/2021 Immunization

Administered On

DTaP / HiB / IPV

04/27/2020, 07/09/2020, 09/03/2020 02/14/2020, 04/27/2020, 09/03/2020 04/27/2020, 07/09/2020, 09/03/2020 04/27/2020, 07/09/2020, 09/03/2020

Hepatitis B, Pediatric/Adolescent Pneumococcal Conjugate - 13 Valent

Rotavirus Pentavalent

ED Provider Note

11/22/2021

ED Provider Notes by Nicholas S. Boies, NP at 11/22/2021 2042 Author: Nicholas S. Boies, NP

Service: Emergency Medicine

Author Type: Nurse Practitioner

Filed: 11/23/2021 9:21 AM

Date of Service: 11/22/2021 8:42 PM Status: Addendum

Editor: Nicholas S. Boies, NP (Nurse Practitioner)

1. Lac Repair [583171809] ordered by Nicholas S. Boies, NP Procedure Orders

Encounter Date: 11/22/2021

History

Chief Complaint Patient presents with • Facial Laceration Fell while running indoors, struck head on refrigerator, laceration to left side of forehead

Mother State pt. His his head on a door at home, no loc. Pt. Playing and acting normal.

The history is provided by the mother. General Injury The incident occurred just prior to arrival. The incident occurred at home. The injury mechanism was a direct blow. The wounds were not self-inflicted. Pertinent negatives include no nausea, no seizures and no cough.

Review of patient's allergies indicates: No Known Allergies

No past medical history on file. Generated on 7/19/22 2:38 PM

Page 10

BRMH EMERGENCY DEPARTMENT 17000 Medical Center Dr Baton Rouge LA 70816

Grondin, Blake John MRN: 12051461, DOB: 2/14/2020, Sex: M Acct #: 72014918667 Adm: 11/22/2021

11/22/2021 - ED in O'Neal - Emergency Dept. (continued)

ED Provider Note (continued) Past Surgical History: Procedure

Laterality

Date

• CIRCUMCISION

Family History Problem

Relation Mother

Age of Onset

• Rheum arthritis

Copied from mother's history at birth • Mental illness Copied from mother's history at birth • No Known Problems

Mother

Father

• Heart disease

Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather

• No Known Problems • No Known Problems • No Known Problems

Social History

Tobacco Use • Smoking status:

Never Smoker

• Smokeless tobacco:

Never Used

Substance Use Topics • Alcohol use:

Never Never

• Drug use:

Review of Systems Constitutional: Negative for fever. HENT: Negative for sore throat. Respiratory: Negative for cough.

Cardiovascular: Negative for palpitations. Gastrointestinal: Negative for nausea. Genitourinary: Negative for difficulty urinating. Musculoskeletal: Negative for joint swelling. Skin: Positive for wound. Negative for rash. Neurological: Negative for seizures. Hematological: Does not bruise/bleed easily.

Physical Exam

Initial Vitals [11/22/21 1739] BP

Pulse Resp Temp SpO2

--

117

24

97 °F (36.1 °C)

100 %

MAP --

Physical Exam

Nursing note and vitals reviewed. Constitutional: He appears well-developed and well-nourished. HENT: Right Ear: Tympanic membrane normal. Generated on 7/19/22 2:38 PM

Page 11

BRMH EMERGENCY DEPARTMENT 17000 Medical Center Dr Baton Rouge LA 70816

Grondin, Blake John MRN: 12051461, DOB: 2/14/2020, Sex: M Acct #: 72014918667 Adm: 11/22/2021

11/22/2021 - ED in O'Neal - Emergency Dept. (continued)

ED Provider Note (continued) Left Ear: Tympanic membrane normal. Nose: Nose normal. Mouth/Throat: Mucous membranes are moist. Oropharynx is clear. Eyes: Conjunctivae are normal. Neck: Neck supple. Cardiovascular: Normal rate and regular rhythm. Pulmonary/Chest: Breath sounds normal. Abdominal: Abdomen is soft. There is no abdominal tenderness. There is no rebound and no guarding. Musculoskeletal: General: Normal range of motion. Cervical back: Neck supple.

Neurological: He is alert. Skin: Skin is warm. Capillary refill takes less than 3 seconds. Middle forehead laceration, 1cm, bleeding stopped.

ED Course Lac Repair

Date/Time: 11/23/2021 8:43 AM Performed by: Nicholas S. Boies, NP Authorized by: Christopher P. Ferguson, MD

Consent: Consent obtained: Verbal Consent given by: Parent

Risks, benefits, and alternatives were discussed: yes Risks discussed: Infection and poor cosmetic result Anesthesia: Anesthesia method: Topical application Topical anesthetic: LET Laceration details: Location: Face Face location: Forehead

Length (cm): 1 Depth (mm): 5 Pre-procedure details: Preparation: Patient was prepped and draped in usual sterile fashion Exploration: Wound exploration: entire depth of wound visualized Wound extent: fascia violated

Wound extent: no areolar tissue violation noted , no foreign bodies/material noted , no muscle damage noted , no nerve damage noted , no tendon damage noted , no underlying fracture noted and no vascular damage noted Contaminated: no Treatment: Wound cleansed with: initially cleaned with peroxide, then cleaned with chlorhexidine . Amount of cleaning: Standard Debridement: None Skin repair: Generated on 7/19/22 2:38 PM Page 12

BRMH EMERGENCY DEPARTMENT 17000 Medical Center Dr Baton Rouge LA 70816

Grondin, Blake John MRN: 12051461, DOB: 2/14/2020, Sex: M Acct #: 72014918667 Adm: 11/22/2021

11/22/2021 - ED in O'Neal - Emergency Dept. (continued)

ED Provider Note (continued) Repair method: Sutures Suture size: 5-0 Suture material: Nylon Suture technique: Simple interrupted Number of sutures: 1 Approximation: Approximation: Close (wound margin irregular) Repair type: Repair type: Simple Post-procedure details: Dressing: Non-adherent dressing and bulky dressing Procedure completion: Tolerated with difficulty

Labs Reviewed - No data to display

Imaging Results None

Medications LETS (LIDOcaine-TETRAcaine-EPINEPHrine) gel solution ( Topical (Top) Given 11/22/21 1856)

Clinical Impression: Final diagnoses: [S01.81XA] Facial laceration, initial encounter (Primary)

ED Disposition

Condition

Discharge

Stable

ED Prescriptions None

Follow-up Information Follow up With

Specialties

Details

Why

Contact Info

Lois H. Gesn, MD Pediatrics

Schedule an appointment as soon as possible for a visit

For suture removal

16777 MEDICAL CENTER DR Baton Rouge LA 70816 225-754-3278

Generated on 7/19/22 2:38 PM

Page 13

BRMH EMERGENCY DEPARTMENT 17000 Medical Center Dr Baton Rouge LA 70816

Grondin, Blake John MRN: 12051461, DOB: 2/14/2020, Sex: M Acct #: 72014918667 Adm: 11/22/2021

11/22/2021 - ED in O'Neal - Emergency Dept. (continued)

ED Provider Note (continued)

Nicholas S. Boies, NP 11/23/21 0847

Nicholas S. Boies, NP 11/23/21 0921

Electronically signed by Nicholas S. Boies, NP at 11/23/2021 9:21 AM

Procedures

Lac Repair [583171809] (Final result) Electronically signed by: Nicholas S. Boies, NP on 11/23/21 0843 Ordering user: Nicholas S. Boies, NP 11/23/21 0843 Authorized by: Christopher P. Ferguson, MD Frequency: Routine Once 11/23/21 0844 - 1 occurrence

Status: Completed

Ordering provider: Nicholas S. Boies, NP

Ordering mode: Standard Class: Point Of Care Lab status: Final result

Quantity: 1

Instance released by: Nicholas S. Boies, NP 11/23/2021 8:43 AM Order comments: This order was created via procedure documentation

Lac Repair [583171809]

Resulted: 11/23/21 0843, Result status: Final result

Ordering provider: Nicholas S. Boies, NP 11/23/21 0843

Order status: Completed

Filed by: Nicholas S. Boies, NP 11/23/21 0847 Narrative: Nicholas S. Boies, NP 11/23/2021 8:47 AM Lac Repair Date/Time: 11/23/2021 8:43 AM Performed by: Nicholas S. Boies, NP Authorized by: Christopher P. Ferguson, MD

Resulting lab: BRMH EMERGENCY DEPARTMENT

Consent: Consent obtained: Verbal Consent given by: Parent

Risks, benefits, and alternatives were discussed: yes Risks discussed: Infection and poor cosmetic result Anesthesia: Anesthesia method: Topical application Topical anesthetic: LET Laceration details: Location: Face Face location: Forehead

Length (cm): 1 Depth (mm): 5 Pre-procedure details: Preparation: Patient was prepped and draped in usual sterile fashion Exploration: Wound exploration: entire depth of wound visualized Wound extent: fascia violated Wound extent: no areolar tissue violation noted, no foreign bodies/material noted, no muscle damage noted, no nerve damage noted, no tendon damage noted, no underlying fracture noted and no vascular damage noted Contaminated: no Treatment: Wound cleansed with: initially cleaned with peroxide, then cleaned with

Generated on 7/19/22 2:38 PM

Page 14

BRMH EMERGENCY DEPARTMENT 17000 Medical Center Dr Baton Rouge LA 70816

Grondin, Blake John MRN: 12051461, DOB: 2/14/2020, Sex: M Acct #: 72014918667 Adm: 11/22/2021

11/22/2021 - ED in O'Neal - Emergency Dept. (continued)

Procedures (continued)

chlorhexidine. Amount of cleaning: Standard Debridement: None Skin repair: Repair method: Sutures Suture size: 5-0 Suture material: Nylon Suture technique: Simple interrupted Number of sutures: 1 Approximation: Approximation: Close (wound margin irregular) Repair type: Repair type: Simple Post-procedure details: Dressing: Non-adherent dressing and bulky dressing Procedure completion: Tolerated with difficulty

Testing Performed By

Lab - Abbreviation Name

Director

Address

Valid Date Range

507 - BRMHP

BRMH EMERGENCY DEPARTMENT

Aimee Goodier, M.D.

17000 Medical Center Dr. Baton Rouge LA 70816

12/28/20 1443 - Present

Generated on 7/19/22 2:38 PM

Page 15

BRMH EMERGENCY DEPARTMENT 17000 Medical Center Dr Baton Rouge LA 70816

Grondin, Blake John MRN: 12051461, DOB: 2/14/2020, Sex: M Acct #: 72014491025 Adm: 10/16/2021

10/16/2021 - ED in O'Neal - Emergency Dept.

ED Arrival Information

Expected

Arrival

Acuity Non-Urgent

Means of arrival Personal Transportation

-

10/16/2021 07:41

Escorted by

Service Emergency Medicine

Admission type Emergency

Chief Complaint Nasal Congestion

FAMILY MEMBER

Arrival complaint poss ear infection,congestion,coughing,fever yesterday

Patient as-of Visit

Allergies as of 10/16/2021

Allergies last reviewed by Leslie Verdin, RN on 10/16/2021 0749 No Known Allergies

Immunizations as of 10/16/2021 Immunization

Administered On

DTaP / HiB / IPV

04/27/2020, 07/09/2020, 09/03/2020 02/14/2020, 04/27/2020, 09/03/2020 04/27/2020, 07/09/2020, 09/03/2020 04/27/2020, 07/09/2020, 09/03/2020

Hepatitis B, Pediatric/Adolescent Pneumococcal Conjugate - 13 Valent

Rotavirus Pentavalent

ED Provider Note

10/16/2021

ED Provider Notes by Nathan P. Freeman, MD at 10/16/2021 0750 Author: Nathan P. Freeman, MD

Service: Emergency Medicine

Author Type: Physician

Filed: 10/16/2021 7:51 AM

Date of Service: 10/16/2021 7:50 AM Status: Signed

Editor: Nathan P. Freeman, MD (Physician)

Encounter Date: 10/16/2021

History

Chief Complaint Patient presents with • Nasal Congestion woke up yesterday with nasal congestion, runny nose, drainage from his eyes.

The history is provided by the mother. Otalgia

The current episode started yesterday. The problem occurs rarely. The problem has been unchanged. There is pain in both ears. There is no abnormality behind the ear. He has been pulling at the affected ear. Nothing relieves the symptoms. Nothing aggravates the symptoms. Associated symptoms include congestion, ear pain and rhinorrhea. Pertinent negatives include no fever, no nausea, no sore throat, no cough and no rash.

Review of patient's allergies indicates: No Known Allergies No past medical history on file. Past Surgical History: Procedure

Laterality

Date

• CIRCUMCISION Generated on 7/19/22 2:38 PM

Page 16

BRMH EMERGENCY DEPARTMENT 17000 Medical Center Dr Baton Rouge LA 70816

Grondin, Blake John MRN: 12051461, DOB: 2/14/2020, Sex: M Acct #: 72014491025 Adm: 10/16/2021

10/16/2021 - ED in O'Neal - Emergency Dept. (continued)

ED Provider Note (continued)

Family History Problem

Relation Mother

Age of Onset

• Rheum arthritis

Copied from mother's history at birth • Mental illness Copied from mother's history at birth • No Known Problems

Mother

Father

• Heart disease

Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather

• No Known Problems • No Known Problems • No Known Problems

Social History

Tobacco Use • Smoking status:

Never Smoker

• Smokeless tobacco:

Never Used

Substance Use Topics • Alcohol use:

Never Never

• Drug use:

Review of Systems Constitutional: Negative for fever. HENT: Positive for congestion, ear pain and rhinorrhea. Negative for sore throat. Respiratory: Negative for cough.

Cardiovascular: Negative for palpitations. Gastrointestinal: Negative for nausea. Genitourinary: Negative for difficulty urinating. Musculoskeletal: Negative for joint swelling. Skin: Negative for rash. Neurological: Negative for seizures. Hematological: Does not bruise/bleed easily.

Physical Exam

Initial Vitals [10/16/21 0746] BP

Pulse Resp Temp SpO2

--

(!) 148 26

97 °F (36.1 °C)

97 %

MAP --

Physical Exam

Constitutional: He appears well-developed and well-nourished. HENT: Head: No signs of injury.

Right Ear: No drainage. Tympanic membrane is abnormal. A middle ear effusion is present. Left Ear: No drainage. Tympanic membrane is abnormal. A middle ear effusion is present. Nose: No nasal discharge.

Generated on 7/19/22 2:38 PM

Page 17

BRMH EMERGENCY DEPARTMENT 17000 Medical Center Dr Baton Rouge LA 70816

Grondin, Blake John MRN: 12051461, DOB: 2/14/2020, Sex: M Acct #: 72014491025 Adm: 10/16/2021

10/16/2021 - ED in O'Neal - Emergency Dept. (continued)

ED Provider Note (continued) Mouth/Throat: Mucous membranes are moist. Oropharynx is clear. Eyes: Conjunctivae and EOM are normal. Pupils are equal, round, and reactive to light. Neck: Neck supple. No neck adenopathy. Normal range of motion. Cardiovascular: Normal rate and regular rhythm. Pulmonary/Chest: Effort normal and breath sounds normal. No nasal flaring. No respiratory distress. He has no wheezes. He exhibits no retraction. Abdominal: Abdomen is soft. Bowel sounds are normal. He exhibits no distension. There is no abdominal tenderness. There is no guarding. Musculoskeletal:

General: No tenderness or deformity. Normal range of motion. Cervical back: Normal range of motion and neck supple. No rigidity.

Neurological: He is alert. Skin: Skin is warm and dry.

ED Course Procedures Labs Reviewed - No data to display

Imaging Results None

Medications - No data to display

Clinical Impression: Final diagnoses: [H65.113] Acute mucoid otitis media of both ears (Primary) [R05.9] Cough [R09.81] Nasal congestion [B34.9] Viral syndrome

ED Disposition

Condition

Discharge

Stable

Generated on 7/19/22 2:38 PM

Page 18