Medical Record For
Jimmy Davis
Patient Information
Jimmy Davis
DOB:
11/28/2019
Sex:
Male
Gender Identity:
Male
MRN:
861399
Weight:
48.5 lbs or 21.99 kg
Admitting Diagnosis:
Shortness of breath, RSV
Admitting Physician:
Derrick Stone, M.D.
Past Medical History
Allergies
No Known Drug Allergies
Medical Problems
Asthma, history of frequent asthma exacerbation with associated hospitalization
Surgical History
N/A
Social History
Lives with mom, dad, and grandfather. Both parents work full-time jobs. 1st grader at the local elementary school. Attends after-school program. Grandfather picks him up from school. Grandfather smokes 1PPD, outside of the home.
Provider Notes
| Time | Provider | Notes |
|---|---|---|
| 0830 | Derrick Stone M.D. | Patient Jimmy Davis admitted from the emergency department with complaints of shortness of breath, and they tested positive for RSV. Patient responded well to the albuterol nebulizing treatments in the emergency department and is being admitted for further monitoring. |
Vital Signs
| Time | 0800 | |
|---|---|---|
| Heart Rate | 105 bpm | |
| Blood Pressure | 100/70 mmHg | |
| Respiratory Rate | 25 breaths/min | |
| Temperature | 98.6 F | |
| Pulse Oximetry | 98% | |
| Oxygen in Liters | On Room Air | |
| Pain |  |