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 #: 72011877124 Adm: 12/5/2020

12/05/2020 - ED in O'Neal - Emergency Dept. (continued)

ED Provider Note (continued) Cardiovascular: Negative for cyanosis.

Gastrointestinal: Negative for diarrhea and vomiting. Genitourinary: Negative for decreased urine volume. Musculoskeletal: Negative for extremity weakness. 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 [12/05/20 1735] BP

Pulse Resp Temp SpO2

--

(!) 177 (!) 56 99.8 °F (37.7 °C)

97 %

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: R TM is unremarkable. L TM is erythematous. Nose and Throat: 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: Tachypneic. Audible inspiratory and expiratory wheezing noted. No retraction, nasal flaring, or grunting. No stridor, 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:

12/05/20 1735

12/05/20 1759

12/05/20 1924

Pulse: Resp: Temp:

(!) 177

(!) 187

(!) 170

(!) 56

35

36

99.8 °F (37.7 °C)

TempSrc:

Rectal

SpO2: Weight:

97%

95%

95%

9.117 kg (20 lb 1.6 oz)

Generated on 7/19/22 2:38 PM

Page 44