INPATIENT FACE SHEET

WEST, KEITHIPCase010Dr. BLACKAdmission:02/09/YYYYDOB: 05/23/YYYYROOM: 331 CHIEF COMPLAINT: Difficulty breathing and hyperpyrexiaHISTORY OF PRESENT ILLNESS: This is an 8-month-old white male seen by Dr. White at theLofty Pines Health Center for a viral-type syndrome. The mother states that the baby hada temperature over the weekend with it being 104 on Saturday night and 103 last night.The baby has progressively gotten more worked up, more short of breath and has had moreproblems with congestion. The baby was admitted for observation and evaluation of hisupper respiratory and lower respiratory disease. This is the first hospitalization forthis child.PAST MEDICAL HISTORY: This baby only has one other hospitalization besides that of birthand that was for admission to the hospital for respiratory distress syndrome and wastaken care of by Dr. Smith in the neonatal intensive care unit. He only stayed less thana week and did quite well and there was no need for follow up. The mother states that thepatient was born three weeks early and the doctors felt that this was secondary to herhaving a kidney stone. The child had a normal, spontaneous, vaginal birth. He was 19inches at birth and weighed 6 pounds 15 ounces.FAMILY HISTORY: There is a family history of diabetes, paternal great grandmother; heartdisease, grandfather. One brother has congenital heart disease, and an uncle hascongenital heart disease. There are 2 maternal aunts who died of myocardial infarction.There is no tuberculosis, hypertension, or cancer in the family. There also is a familyhistory of paternal grandfather with allergies and desensitizations. Mother and father donot have allergies.SOCIAL HISTORY: This is an only child.REVIEW OF SYSTEMS: Growth and development is within normal limits. Patient is a goodeater, nonfussy. Still takes occasional Prosobee but is not on a strict formula diet atthis time.GENERAL: This is an 8-month-old looking his stated age with respiratory problems with arapid rate and rather annoyed with a stuffed-up nose.TEMPERATURE: 101.3 PULSE: 158 RESPIRATIONS: 62DD: 02/09/YYYYDT: 02/10/YYYYContinued on next pagePhysician AuthenticationGLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234