Version 2024/2025
, Nurse note - ANS✔✔--Nurse Notes
Jake Mason is an 18-month-old male with a two-day history of congested coughing with
a thick yellow sputum expectorated. Cough is worse at night. His father has brought him
to the urgent care clinic for treatment.
Vitals @9:30 - ANS✔✔--Pulse: 105
BP: 107/64
RR: 38
temp: 101.8 °F / 38.8 °C
spo2: 92%
Case findings - ANS✔✔--- Exposure to second hand smoke
- Coughing x 2 days
- Expectorating sputum
- Cough worse at night
- Fever
Hx Findings Feedback - ANS✔✔--- Expectorating yellow sputum
- Rhinorrhea
- Exposure to sick children
- Febrile
- Decreased appetite
Doorway information - ANS✔✔--Name: Jake Mason.
DOB: August 14th.
Age: 18-months-old.
Gender: Male.
Primary language: English.
Admitting care provider: Emily Michaels, MD.
MRN: 7821478.
Your patient today is Jake Mason, an 18-month-old male. Jake presents with a two-day
history of congested coughing with a thick yellow sputum expectorated. His cough is
worse at night. His father has brought him to the urgent care clinic for treatment.
Orders (Health Care Provider) - ANS✔✔--Admission Orders
Physician/Unit: Dr. Michels/Urgent Care.
Diagnosis: Cough
Condition: Stable.
Vitals: Once.
Allergies: No known.
Medications: Dr. Micahels will be in shortly to see the patient.
Admitting Notes (Health Care