Blake Photo Time-Line

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

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