Age: 3 Months
MRN: 987573
| Time | Provider | Notes |
|---|---|---|
| 0800 | Mary Rolland, RN | Patient brought to urgent care by mother with complaints of inconsolable crying and skin feeling warm to touch. No medications given prior to arrival. Infant screaming at triage. |
| Status | Time | Ordering Physician | Order |
|---|---|---|---|
| Active | 0800 | Johhanna Bach PA | acetaminophen 15mg/kg (Tylenol 160mg/5ml) liquid suspension PO now |
| Active | 0800 | Johhanna Bach PA | 0.9% Normal Saline Solution IV bolus 20ml/kg over 1 hour now |
| Time | 0800 |
|---|---|
| Weight | 6.3kg (14lb) |
| Length | 24 inches/61 cm |
| Heart Rate | 150 |
| Blood Pressure | 80/54 |
| Respiratory Rate | 30 |
| Pulse Ox | 92% on Room Air |
| Temperature | 102F/38.8C Axillary |
| Pain | NOT MEASURED |
| Assessment | ||
|---|---|---|
| Client Pain Score using FLACC | ||
| Client observed to have quivering chin, kicking and squirming. Client crying steadily but is distractible. |