Encounter Note
LEO JENKINS
Subjective
AUTO-FILL FROM TRIAGE
History of Present Illness (HPI)
Mother reports 3-day history of rhinorrhea and 12-hour history of fever (102.4°F). Leo is lethargic and refusing oral fluids. Tylenol given at 06:00 with minimal effect.
Objective
Temp
HR
RR
O2 Sat
Physical Exam Findings
Assessment
Diagnosis / ICD-10
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J00: Acute Nasopharyngitis
R50.9: Fever, Unspecified
Plan
Instructions & Medications
1. Continue supportive care (Hydration). 2. Alternate Tylenol/Motrin every 4 hours. 3. Follow up in 48 hours if fever persists.
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