Blake Photo Time-Line

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

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