Georgia College and State University

School of Nursing
Episodic Document
Patient Information:
Initials: BA_______Age: 3 y 3 months____
of visit: 9/28/15_

Sex: M______

Date

Chief Complaint(s) or Reason for Visit: Deep cough which started

today, fever, and runny nose
o

HPI:
Onset _Today________
___________________________________
Location of problem _Respiratory
______________________________
Duration of problem _Today
_
_________________________________
Character of problem Unable to describe character of
pain_____________
Intensity rating: /10 or other:
N/A_________________________
Aggravating Factors Worse at
night_________________________________
Relieving Factors _None
tried_____________________________________
Treatments Tried
__None_______________________________________
Smoking: _Never
smoked_________________________________________
Additional information Mother stated the patient
started with cough this morning and it just got worse.
She stated he has never had a cough like this before.
She stated he has had a runny nose for about 3 days
prior to this, temperature high of 99.0F axillary and
she gave him Childrens Tylenol about 3 hours ago.
The mother reported that he still plays, but the cough
is what has her concerned. The mother denies any
recent trauma, ingestion of any foreign body, food
allergies, history of asthma, and any recent surgeries
on head/neck. She reported he had his annual checkup this year and lab work, which were fine. In
addition, the mother reported that the patient has no
medical conditions, only took a multivitamin, just
started attending daycare, and was a full term infant

delivered vaginally. The mother reported no

complications during pregnancy and she nor the
father have a significant medical history._

Current Medications and how patient takes the medications:

Flintstone Chewable Multivitamin

One tablet day

Additional Information:
Allergies:
_N.K.D.A_______________________________________________________________________
Current Immunizations: Up-to-date on all immunizations required for his
age, including influenza vaccine; no special immunizations required due to
lack of co-morbidities_____________ _
PMH, Chronic Problems, Significant birth history: Vaginal birth at 38 weeks
gestational age. APGAR score of 9; No significant medical
history___________________________________________________
Past Surgical Hx:_None
_
Substance use/amount: Alcohol Y/N amount N/A
__
Tobacco (smoke any form, smokeless any form) Y/N Type/amount/how long:
N/A_No one smokes in the home
____________________
Illicit drugs Y/N amount N/A No one uses illicit drugs in the home
Family Hx:
o Mother:30s alive and
well_________________________________________________________
o Father:30s alive and
well__________________________________________________________
o Maternal Grandmother: Deceased
unknown__________________________________________
o Maternal Grandfather: Deceased
unknown___________________________________________
o Paternal Grandmother: Deceased 70s
MI_____________________________________________
o Paternal Grandfather: Deceased 60s
MI______________________________________________
o Siblings: (1) brother (10 y/o) alive and
well____________________________________________

INTERVAL HISTORY: Have they been to the ER, seen other providers, any
procedures (mammograms, etc.) since their last visit to the practice? Mother
denies the patient has been seen by any other providers, no recent ER visits,
and no recent procedures.____________________________

Review of Systems:
Neg.

Constitutional
Pos.

Chills

Neg.

HEENT
Pos.

Dysphagia

Decreased activity
Weight Gain

Ear Discharge
Esotropia

Weight Loss
Fussiness

Exotropia

Irritability at night
Lethargy

Eye Discharge
Eye Redness

Headache
Hearing loss

Fever: duration 1 day

Tmax:99.0F Ax
Other:

Neg.

Metabolic
Pos.

Polydipsia

Pharyngitis
Rhinorrhea

Polyuria
Polyphagia

Brittle Nails
Cold intolerance

Heat intolerance
Hirsute
Thinning Hair

Other:_________

Neg.

Gastrointestinal
Pos.

Abdominal Pain

Constipation
Diarrhea

Nausea
Reflux

Vomiting
Other: __________

Nasal Congestion
Otalgia

Respiratory
Neg.
Pos.

Accessory
muscles use

activity

Dyspnea
Stridor with

Production

Sputum

Wheezing
Cough:
Quality Harsh,

Deep
Freq: Often

Exposure to TB

Sneezing
Tearing

Other: _________

Vision changes
Vision loss

Cardiovascular and
Vascular
Neg.
Pos.

Chest Pain

Other: ____________

Beat

Irreg. Heart

Palpitations

Syncope

Cool extremities
Cyanosis

Edema

Other: _________

Urinary
Neg.
Pos.

Decreased Urine
Output

Immunological
Neg.

Dysuria
Enuresis

Allergy

Environmental

Flank Pain
Foul urine odor

Food allergy
Seasonal allergy

Hematuria
Other: ____________

Urticaria

Pos.

Allergic Rhinitis

__________
Neg.

Other:

Hematologic
Pos.

Easy bleeding

Easy bruising

Lymphadenopathy

Neg.

Female Reproductive
Pos.

Dysmenorrhea

Dyspareunia

Menorrhagia
Vaginal Discharge

Vaginal itching
Foul vaginal odor

Other:_____________

Menarche age:
Last Menses:
Regular

Frequency:

Irregular
Flow:

Neg.

Skin
Pos.

Acne

Eczema

Pruritus
Psoriasis

Skin lesion

Other:____________

Neg.

Male Reproductive
Pos.

Straining to urinate

Urinary hesitancy

Urinary Retention

Erectile
dysfunction

Hematospermia

Penile discharge

Premature
ejaculation

Scrotal mass

Neg.

Petechiae
Other:_________

Musculoskeletal
Pos.

Back pain

Bone pain

Joint pain

weakness

Joint swelling
Muscle

Myalgia

Other: _________

Scrotal pain

Other:
_______________

Neurological
Neg.
Pos.

Aphasia or
dysarthria

Psychiatric
Neg. Pos.

Appropriate
interaction

Agnosia

Balance
disturbance

Behavioral
changes

Difficulty
concentrating

Confusion
Paraesthesia

Seizure

Tremor

Memory loss

Other:
_______________

Distorted body
image

Obsessive
behaviors

Self-conscious

Other: ________

Objective Findings:
Vital Signs:
o Blood Pressure: _92/54________ Pulse: _98_________ Respirations:
_24_____________
o Temperature: 99.2F (Axillary) __ Pulse Ox: _99%____ Weight (%): 34lbs
(63%) _____
o Height (%): 39 inches (68%) ____
BMI (%): 15.7 (43%) _____
Physical Exam:
Physical Exam
Constitutional: Show
Head/Skull: Show
Appearance

Normocephalic

Closed anterior and posterior which is appropriate for

Normal stucture alignment
Facial features

Fontanels

age
Hair Distribution

Normal Distribution

Eyes: Show
Surrounding Structures OS

Normal Structures

Other:___________

Surrounding Structures OD

Normal Structures

Other:___________

External Eye OS

Normal

Other:___________

External Eye OD

Normal

Other:___________

Eye Lids OS

Normal

Other:___________

Eye Lids OD

Normal

Other:___________

Pupil OS

PERRLA

Pupils OD

PERRLA

Other:___________
Other:___________

Conjunctiva OS

Clear

Other:___________

Conjunctiva

Clear

Other:___________

OD

Sclera

OS

Normal

Sclera

OD

Normal

Other:___________
Other:___________

Iris OS

Normal

Other:___________

Iris OD

Normal

Other:___________

Cornea OS

Normal

Cornea OD

Normal

Fundoscopy OS

Other:___________

Choose an item.

Other:___________
Fundoscopy

OD

Other:___________

Choose item

Lens OS

Clear

Other:___________

Lens OD

Clear

Other:___________

Ocular Muscles

Normal cardinal gaze

Red Reflex

Present Bilaterally

Ears: Show

Nose and Sinus: Show

Mouth/Teeth:
Lips

Normal fullness and symmetry

Teeth

Normal dentation

Other:__________________

Other:__________________
Buccal

pink and moist

Other:__________________
Tongue

Normal

Palate

Choose an item.

Other:__________________

Uvula

Normal configuration

Oropharynx

pink and moist

Tonsils

+2

Other: Normal____________
Other:__________________
Other:__________________
Other:__________________

Neck:
Palpation of Thyroid: Normal
Abn:___________________________________

Lymphatic: Show

Describe

Respiratory: Show
Cardiac: Show

Abdomen: Show

Male Exam Deferred

Musculoskeletal Show

Neurological Show

Skin Show
Results of labs done today: _No labs collected today, prior labs drawn a
three months ago within normal limits

Assessment/Plan:

First Diagnosis: Larynotracheobronchitis (Croup)

9:464.4_________________

ICD-

Additional teaching or comments: The patients mother was notified that he has
laryngotracheobronchitis also known as the croup that is commonly caused by viruses,
therefore handwashing is important. She was instructed to encourage fluids (water, water
and 100% juice, popsicles) to maintain hydration and keep secretions loose, smoke
exposure should be avoided, keep the childs head elevated, and sleeping in the same room
with the child during this time so she can be immediately available if the child begins to
have difficulty breathing. The croup can be worsened by agitation and crying so the mother
was encouraged to keep the child as comfortable as possible. The mother was informed that
other treatments, such as antibiotics (ineffective for viral infections), cough medicines,
decongestants, and sedatives are also not recommended for croup. Furthermore,
humidification has not been proven beneficial for croup. She was informed that symptoms
generally improve with one dose of the steroid medication and symptoms resolve without
significant complications. She can give OTC Childrens Tylenol for the temperature as
needed. The mother was educated on when to seek immediate medical attention for:
worsening respiratory signs/symptoms (stridor at rest, inability to swallow or drooling, pale
or blue-tinged skin, inability to speak or cry due to difficulty taking a breath, sucking in of
the skin around the ribs and the top of the sternum with breathing). If these symptoms
should occur the mother was instructed not to attempt to drive the child to the hospital but
call emergency medical services by dialing 911. The mother was informed if no
improvement was seen after 24 hours to contact the office, as well as if signs/symptoms

persist or worsen. A follow-up appointment was scheduled for 2 days. She verbalized
understanding and has no questions or concerns at this time.

Medications Added This Visit

Medication Name
Dexamethasone
1mg/ml

Quantity
6 mL

Dose
6 mL

Sig
Take 6 mL by
mouth once

Childrens Tylenol
OTC

1 bottle (120 mL)

5 mL (160 mg/5mL)

Take 5 mL by mouth
every 4-6 hours as
needed for
pain/temperature. Do
not exceed 25 mL/24
hours. Do not give
more than 5 doses in
24 hours.

Office Code for Visit:

Est. Pt.
Office

New Pt.
Office

Est. Pt.
Health Check

New Pt.
Health Check

99211
99212
99213
99214
99215

------99201
99202
99203
99204
99205

99391 (<
1yr)
99392 (1-4yr)
99393 (511yr)
99394 (1217yr)
99395
(18yr>)

99381 (<
1yr)
99382 (14yr)
99383 (511yr)
99384 (1217yr)
99385
(18yr>)

Additional Procedure Codes,

Immunization, Lab, etc.

Reference
Bjornson, C. L., & Johnson, D. W. (2013). Croup in children. CMAJ: Canadian Medical
Association Journal
Journal De L'association Medicale Canadienne, 185(15),
1317-1323. doi:10.1503/cmaj.121645
Burns, C., Dunn, A., Brady, M. Starr, N., & Blosser, C. (2012). Pediatric Primary Care.
(5th ed.) Saunders.
Zoorob, R., Sidani, M., & Murray, J. (2011). Croup: an overview. American Family
Physician, 83(9), 10671073 7p.