SOAP note A two-year-old is admitted to

SOAP note A two-year-old is admitted to the pediatric unit at 0600 via the ED with c/o a productive cough x 3 days, fever, wheezing and poor solid food intake, but is drinking clear liquids well. There is no family history of asthma. The child attends daycare 5 days a week and all immunizations are up to date. The child’s eight-year-old sibling has had cold symptoms x 7 days. Someone in the household does smoke cigarettes inside the home on a regular basis. Admission (ED) and current VS: HR:138-152 bpm BP: 85/93 mmHg and 47/61 mmHg Temperature: 99.2 degrees F and 98.8 degrees F RR= 28 and 24 O2 sats: 94% and 96% on room air Treatment and Orders: Nebulizer (Xopenex) treatment given in ED and ordered q 4 hours. O2 sats to stay above 94%. Last nebulizer treatment was at 5:30am. Routine VS ordered. Output: Voided x 1 since admission (pale yellow urine, 50mL output). Last stool was yesterday (soft, brown). Physical examination: the patient is lying in bed, responsive, interactive if prompted, but slightly irritable. Lungs with 2+ wheeze and slight intercostal retractions bilaterally. Nares patent without flaring. Capillary refill is two seconds. HRR without murmur. Skin warm/dry/pink/without rash. Abdomen soft, +BS in all quadrants, non-tender. Labs: CBC pending. RSV swab is positive.

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