Respiratory Hospitalizations H&P

HPI:

[ Name ] is a [ * Pt Age-DOB-Gender-Sex ] with medical history significant for -- presenting for SOB. -- is present at bedside and aids history taking. [ Name ]'s began on and has worsened since. Patient has tried -- for their symptoms but has not seen adequate control of their SOB so presented for further evaluation.

PE:
General:
Respiratory:
Cardiovascular: RRR, no murmurs rubs or gallops, capillary refill
Integumentary: skin not mottled, grossly no lesions or rashes of exposed skin
Psychiatric: appropriate for situation, 

Assessment and Plan:

[ Peds Cache ST ]
[ Patient first name ] is a [ Age ] old M previously healthy and presenting for increased WOB, admitted for respiratory support, now at LFNC.

MDM: [ Patient first name ] currently on day of illness --. At presentation, afebrile, will CTM status. Vital signs suggestive of dehydration. .dehydrationMDM s/p --boluses while in Peds ED. Will continue to monitor for changes to peripheral clinical picture, such as by providing supportive treatment as appropriate. .custodyMDM .nutritionMDM

Acute Hypoxic Respiratory Distress
Bronchiolitis Asthma, mild intermittent
- First day of illness:
- FABRC negative, RAPRPP positive for
- max O2 requirement thus far:
- s/p duonebs x
Plan:
- Alb/HTS/CPT q4h
- Tylenol PRN made available
- qAM inflammatory markers (
- Asthma action plan at discharge, Per GINA guidelines, escalation of asthma plan recommended

https://ginasthma.org/wp-content/uploads/2026/05/GINA-2026-Strategy-Report-WMS.pdf

Dehydration, mild (< 5% weight loss in infants, 3% in children)
- s/p x-- NS boluses in Peds ED OR Peds Urgent Care
- Clinical signs of decreased UOP ( cc/kg/h) present at admission
- Initial chemistry significant for normal sodium levels, started on isotonic fluids
Plan:
- d/t initial electrolytic abnormalities observed at presentation, serial chemistries q
-

Nutrition
-
Plan:
- Regular diet as tolerated

Vaccine Counseling
- Per my chart review, NMSIIS review, as well initial discussion with caregivers,[ Patient first name ] at elevated risk for infections preventable with routine vaccination
Plan
- Counsel at discharge on matters related to health maintenance

Caregiver lives at distance
- Patient from [ * Pt Address ], anticipate hardship with

Family disruption due to custody issue
- Social work following
- CYFD case #
- NOT ALLOWED AT BEDSIDE:

Interim Summary
This interim summary covers from - through -

Admit Date: [ Admit Date/Time ]
Interim Date: [ Current Date and Time ]
Attending Physician at the time of Discharge: N/A

Hospital Course by system:
Brief HPI: The patient is a previously healthy month old who presented to the hospital with symptoms consistent with bronchiolitis: cough, congestion, rhinorrhea, respiratory distress, and hypoxemia of %. He was placed on oxygen and admitted for further management

A/B: The patient required a maximum support of via high flow nasal cannula. By the time of discharge the patient was drinking well, saturating >90% on room air and went home without supplemental oxygen.

CV: Hemodynamically stable throughout admission

CNS: He got Tylenol and ibuprofen as needed

FEN/GI: He required IVF for mild dehydration and because of high oxygen requirements..

HEME/ID: He was afebrile throughout admission. _ positive.