Chapter 9: The Respiratory System | Emma LaCross's Chart Note

CHART NOTE

Patient Name: LaCross, Emma
ID Number: YPU2975
Examination Date: June 10, 20xx

SUBJECTIVE
This 2-year-old female presents with a sore throat and cough that started last night and, according to the mother, "sounded quite croupy." The patient's temperature was not taken.

OBJECTIVE
Patient is alert, well hydrated, afebrile (without fever), and in no acute distress. Both tympanic (pertaining to the eardrum) membranes are clear. Throat is mildly injected (filled with fluid). No exudate or enlarged tonsils. Neck is supple without adenopathy. Lungs are clear with no wheezing or rales. Heart is without murmur (abnormal or extra sound heard during a heartbeat).

ASSESSMENT
Croup

PLAN
Mother will use a vaporizer, elevate the child's head when resting, and push fluids. Prescribed Robitussin® DM at bedtime only. Patient should return in 2–4 days if no improvement. Discussed with the mother the normal course of croup and suggested she return or visit an urgent care facility if the condition worsens.