Chapter 9: The Respiratory System | Azaria Taylor's Chart Note

CHART NOTE

Patient Name: Taylor, Azaria
ID Number: GLW0331
Examination Date: April 22, 20xx

SUBJECTIVE
This is a 9-year-old female who returns with about 10 days of nasal congestion, cough, and running a fever of 101–103°.

OBJECTIVE
Patient is cooperative but subdued with mild, audible nasal congestion. Throat is clear and neck supple without adenopathy. Coarse rales heard in the left lung bases, both posteriorly and laterally. No wheezes or grunting. CXR results show consolidation (density) in the left middle lobe and infiltrate (fluid accumulation) in the left lower lobe.

ASSESSMENT
Left middle and lower lobe pneumonia.

PLAN
Augmentin® (antibiotic drug), 250 mg chewable, one t.i.d. (3 times a day) x 10 days. Patient should drink fluids for fever control. Recheck in 10 days. Repeat chest X-ray in 4 weeks to verify clearing.