SEEN AT KIDS OPD
AGE- __
WEIGHT- __ KG
TEMPERATURE- __ *C
PULSE– __ BPM
SPO2- __ %
RDT- __
HISTORY TAKEN FROM __
PC-FEVER 1/7
HPC- CHILD WITH __NO CHRONIC ILLNESS HAS BEEN IN __HIS USUAL STATE OF HEALTH ___
ODQ- CHILLS-, RHINORRHEA-, NASAL CONGESTION-, COUGH-, POOR FEEDING-, DIFFICULTY BREATHING-, FAST BREATHING-, NOISY BREATHING-, CHEST PAIN-, IRRITABLE-, VOMITING-, ,DIARRHOEA-, LETHAGY-, CRYING ON MICTURITION-, FREQUENCY-, COLA-LIKE URINE-, SEIZURES-, EAR DISCHARGE-, EAR TUGGING-
PMSHx
DRUG HISTORY- __
FAMILY HISTORY- SCD-, G6PD-, ASTHMA-, HYPERTENSION-, DIABETES-, EPILEPSY-
SOCIAL HISTORY- CHILD LIVES WITH __ AT __, CHILD IS __ CHILD OUT OF __ CHILDREN , FATHER IS BARBER , MOTHER IS A MOMO VENDOR. _SLEEPS UNDER ITN
ON EXAMINATION- A __GENDER CHILD IN _NO OBVIOUS RESPIRATORY DISTRESS, AFEBRILE, ANICTERIC, NOT PALE, _WELL HYDRATION.
CNS- CONSCIOUS AND ALERT, GCS 15/15
CVS- S1 AND S2 PRESENT, NO MURMUR
RES- AIR ENTRY IS ADEQUATE, BREATH SOUNDS VESICULAR, NO ADDED SOUND
ABD- FULL, MOVES WITH RESPIRATION, NO TENDERNESS, NO ORGANOMEGALY, BOTH KIDNEYS NOT BALLOTABLE
ENT- TONSILS ARE _
IMPRESSION ___
PLAN
COUNSEL MOTHER ON DISEASE CONDITION AND DANGER SIGNS
REVIEW ON __
