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**Start of Template**
Pt is a [<2 years old] who presents with [_].
[nasal congestion, rhinorrhea, cough, wheezing, low-grade fever, difficulty feeding, increased work of breathing with tachypnea, accessory muscle use (intercostal retractions), nasal flaring, and grunting
Mental Status: fussy, lethargic
Feeding/hydration status: oral intake
Hx of eczema]
ROS:
as per hpi, otherwise neg
PMH:
[Pt does not have any significant prenatal, birth, or PMH]
[Hx <12 weeks old, history of prematurity (<35 weeks gestation), hx of intubation, underlying cardiopulmonary disease, immunodeficiency, in utero smoke exposure, congenital abnormalities, severe neuromuscular disease]
Vitals: [Stable]
[Concern for pneumonia if fever >39°, tachycardia, tachypnea, O2 94% on RA, birth weight less than 5 lb, 1 oz]
Bronchiolitis score: [<3]
[<1 year old
0: RR <40, wheezing none, retractions none
1: RR 41-54, expiratory wheeze, retractions in one location
2: RR 55-65, inspiratory and expiratory wheeze, retractions in 2 locations
3: RR >65, diminished breath sounds, retractions in 3 or more locations
> 1 year
0: RR <30, wheezing none, retractions none
1: RR 31-38, expiratory wheeze, retractions in one location
2: RR 39-45, inspiratory and expiratory wheeze, retractions in 2 locations
3: RR >45, diminished breath sounds, retractions in 3 or more locations
Normal 0 to 1; Mild 2 to 3; Moderate 4 to 6; Severe 7 to 9]
PE
General: [Awake in bed, alert, no distress] [No evidence of grunting, nasal flaring, head bobbing]
Head: [Normocephalic, anterior fontanelle flat, normal conjunctivae, clear tympanic membranes bilaterally, nasal congestion, supple/non tender neck, with no lymphadenopathy]
Heart: [Normal, regular rhythm, no murmur.]
Abdomen: [Non-distended, soft, non-tender, no masses palpated]
Extremities: [Warm, well perfused, no edema.]
Neurologic: [Alert, moving all extremities equally.]
Skin: [No rashes or bruising. No cyanosis present]
Lungs: [Regular rate, clear/course breaths sounds to auscultation bilaterally, no wheezes or crackles, non-labored respiration without costal/subcostal retractions or stridor.]
[Labs: Consider CBC, blood cultures, urinalysis and urine culture, chest x-ray, rapid viral testing
Imaging: XR]
A/P:
1. Viral bronchiolitis:
Likely secondary to RSV
-Pt parent as educated that viral testing, chest imaging, the use of bronchodilators, systemic or inhaled corticosteroids, epinephrine, or antibiotics are not indicated at this time.
-Pt parents were reassured that based off of pt vital signs and physical exam they should continue with supportive treatment including maintaining adequate hydration, nutrition, etc
-Ibuprofen/Tylenol PRN
-Pt parent was educated on red flag signs including continued high fever despite treatment with ibuprofen and Tylenol. Decreased fluid intake or urine output, increased WOB including nasal flaring, grunting, retractions.
-Pt was given a prescription to the ROC to be evaluated if symptoms worsen.
-Pt parent was educated on prevention of RSV. Including strict hand hygiene. Avoidance of large crowds and day care settings. Breast feeding for at least six months and prevention of exposure to second hand smoke.
[Patient education: RSV is highly contagious and is transmitted through direct contact with respiratory droplets. Secretions can remain infectious for more than six hours on hard surfaces such as tabletops, cribs, and toys. Strict hand hygiene must be adhered to, including washing hands before and after contact with a patient infected with RSV, after contact with surfaces near the patient, and after removal of gloves. Alcohol-based hand solutions are recommended for health care professionals; soap and water should be used if these are not available. In addition to frequent hand washing by caregivers, avoidance of large crowds and day care settings can also decrease the risk of infection. The morbidity of respiratory infections can be lowered by encouraging exclusive breastfeeding for at least six months and preventing exposure to secondhand smoke.]
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