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 #: 72013267927 Adm: 5/16/2021

05/16/2021 - ED in O'Neal - Emergency Dept. (continued)

ED Provider Note (continued) Respiratory: Positive for cough. Cardiovascular: Negative for palpitations. Gastrointestinal: Negative for nausea and vomiting. Genitourinary: Negative for difficulty urinating. Musculoskeletal: Negative for joint swelling. Skin: Negative for rash. Neurological: Negative for seizures. Hematological: Does not bruise/bleed easily. All other systems reviewed and are negative.

Physical Exam

Initial Vitals [05/16/21 0926] BP

Pulse Resp Temp SpO2

--

120

24

97.1 °F (36.2 °C)

--

MAP --

Physical Exam Vital signs and nursing notes reviewed. Constitutional: Patient is in no acute distress. Patient is active. Non-toxic. Well-hydrated. Well-appearing. Patient is attentive and interactive. Patient is appropriate for age. No evidence of lethargy or irritability. Head: Normocephalic and atraumatic. Ears: Right TM erythema and left TM bulging. Nose and Throat: Nasal congestion. Moist mucous membranes. Symmetric palate. Posterior pharynx is clear without exudates. No palatal petechiae. Eyes: PERRL. Conjunctivae are normal. No scleral icterus. Neck: Supple. No cervical lymphadenopathy. No meningismus. Cardiovascular: Regular rate and rhythm. No murmurs. Well perfused. Pulmonary/Chest: No respiratory distress. No retraction, nasal flaring, or grunting. Breath sounds are clear bilaterally. No stridor, wheezes, rales, or rhonchi. Abdominal: Soft. Non-distended. No crying or grimacing with deep abd palpation. Bowel sounds are normal. Musculoskeletal: Moves all extremities. Brisk cap refill.

Skin: Warm and dry. No bruising, petechiae, or purpura. No rash Neurological: Alert and interactive. Age appropriate behavior.

ED Course Procedures

ED Vital Signs: Vitals:

05/16/21 0926

Pulse: Resp: Temp:

120

24

97.1 °F (36.2 °C)

TempSrc:

Axillary

Weight:

10.5 kg (23 lb 1.9 oz)

Abnormal Lab Results: Generated on 7/19/22 2:38 PM

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