INPATIENT FACE SHEET

WEST, KEITHIPCase010Dr. BLACKPage 2 continuedAdmission:02/09/YYYYDOB: 05/23/YYYYROOM: 331 EENT: Extraocular movements are full. Pupils are equal, round, and reactive to light andaccommodation – red reflexes within normal limits. Nose – stuffed up with clearrhinorrhea. Mouth – within normal limits.CHEST: Both lung fields are filled with rhonchi and occasional rales. There were no signsof consolidation.HEART: Regular rhythm. Without murmur, rub, or gallop that I can detect, but the patientindeed had a tachycardia at the time of examination.ABDOMEN: Within normal limits.GENITALIA: Circumcised male with testes descended. Good femoral pulses bilaterally. No hipclicks.RECTUM: Anus patent.EXTREMITIES: Within normal limits.LAB DATA: Complete Blood Count revealed: White count was 10.7, hemoglobin was 12.2,hematocrit was 37.7, 13 segmented cells, 77 lymphocytes, 10 monocytes. Urinalysis waswithin normal limits except for trace blood on dipstick; doubt whether that issignificant. Chest x-ray was within normal limits.IMPRESSION: 1. Bronchiolitis with hyperpyrexia. 2. History of premature delivery with onehospitalization for lung immaturity at time of birth.Patient will need forced fluids and close observation.DD: 02/09/YYYYDT: 02/10/YYYYReviewed and Approved: Fred Moore MDATP-B-S:02:1001261385: Fred Moore MD(Signed: 02/09/YYYY 04:14:44 PM EST)Physician AuthenticationGLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234