The patient has respiratory symptoms, physical exam, and CXR consistent with bacterial pneumonia. The patient does not show signs of respiratory distress, hypoxia, or dehydration and is taking adequate oral intake. There is no history of asthma or chronic pulmonary disease and I do not feel the need to prescribe steroids or albuterol. Clinical exam is not concerning for bacteremia or sepsis, and there is no radiologic evidence of effusion or empyema. I am comfortable with home management and oral antibiotics. The patient was discharged home with appropriate antibiotics and PCP follow-up. Return precautions were given to include increased work of breathing, persistent fevers >101 for >2-3 days, severe vomiting, inability to tolerate antibiotics, lethargy, worsening chest pain, or other new concerns. [Patient,Parent,Caregiver] verbalized understanding, feels comfortable with proposed plan, and all questions were answered prior to discharge.
There are 0 form elements.
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 0, 141 boilerplate words
Send Feedback for this SOAPnote
You must be logged in to post a comment.