Physician Associate-Vorlage
Paeds ED Admission
Eine professionelle Physician Associate-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
Need a clear and concise way to document paediatric emergency admissions? This Paeds ED Admission template is perfect for Physician Associates. It provides a structured format to record essential information, from the chief complaint and medical history to physical examination findings, investigations, and treatment plans. This template ensures all critical details are captured, helping you create comprehensive and accurate medical records. With Heidi, this template can be quickly populated from your visit transcript, saving you time and improving documentation efficiency.
Vorlagenvorschau
Introduction: Introduced myself as the Physician Associate on duty.
Chief Complaint
- Presenting Issue: 3-year-old male presenting with a fever and cough.
- The patient has had a fever for two days, a productive cough, and reports of decreased appetite. No recent travel history. No known allergies. No known chronic medical conditions. No previous surgeries or hospitalizations.
Past Medical History
- No known chronic medical conditions
- No previous surgeries or hospitalizations
Pregnancy and labour:
- Born at term, vaginal delivery, no complications.
Drug History
- Medications: None.
- Allergies: No known allergies.
Family History
- Father has a history of asthma.
Social History
- Non-smoker.
- No alcohol consumption.
- No illicit drug use.
- No recent travel information.
- No social worker involvement.
Physical Examination
- Vital Signs: Blood pressure 100/60 mmHg, heart rate 120 bpm, respiratory rate 30 breaths/min, temperature 38.5°C, oxygen saturation 98% on room air.
- General examination: Appears unwell, but alert and responsive.
- Airway: Patent, no stridor.
- Breathing: Mildly increased work of breathing, scattered wheezes heard on auscultation.
- Cardiovascular: Regular rhythm, no murmurs, good perfusion, capillary refill <2 seconds.
- Disability: GCS 15, blood glucose 5.2 mmol/L, appropriate behaviour for age.
- ENT: Mildly inflamed tympanic membranes bilaterally.
- Abdo: Soft, non-tender, normal bowel sounds.
- MSK: No deformities, full range of motion.
- Neuro: Alert and oriented, cranial nerves intact, normal reflexes.
Investigations
- Pathology: CBC, CRP, and blood cultures sent.
- Imaging: Chest X-ray ordered.
- Other Investigations: None.
Assessment
- Presumed diagnosis: Bronchiolitis.
- Differential diagnosis: Pneumonia.
Plan/Treatment
- Immediate Management: Administered paracetamol for fever. Nebulised salbutamol given.
- Investigations: Chest X-ray to be reviewed. Blood test results pending.
- Referrals: Discussed with senior doctor.
- Discharge & Follow-up Instructions: Advised on home care, including rest, fluids, and paracetamol for fever. Return to ED if symptoms worsen. Follow-up with GP in 2 days. Date: 1 November 2024.
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