Medical Record For
Rowan Sanchez
Patient Information
Rowan Sanchez
DOB:
2/14/2018
Sex:
Male
Gender Idenity:
Male
MRN:
843203
Weight:
35 lbs or 15.88 kg
Admitting Diagnosis:
Bacterial Sinusitis
Admitting Physician:
Michael Stark, M.D.
Past Medical History
Allergies
Penicillin allergy ( Reactions: hives and cough)
Medical Problems
Seasonal Allergies
Surgical History
none
Social History
Lives with mom and dad. Has an older brother named Robbie.
Provider Notes
| Time | Provider | Notes |
|---|---|---|
| 0800 | Michael Stark, M.D. | 6-year-old, AAO x3, developmentally appropriate male, brought to the Emergency Department by both mother. Presented with rhinorrhea, cough, and fever x 2 days. Tmax at home: 102.5 degrees. Admitted for bacterial sinusitis. Plan: Nasopharyngeal cultures, antibiotics and monitor the patient. |
Vital Signs
| Time | 0830 |
|---|---|
| Heart Rate | 110 |
| Blood Pressure | 122/86 |
| Respiratory Rate | 20 |
| Pulse Ox | 96% on Room Air |
| Temperature | 101.8 F Oral |
| Pain | 4/10 |