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Patient Name: Sophie Fadel
Date of Birth: January 15, 2050
MRN: 12345678
Date of Visit: October 8, 2054
Referring Physician: Dr. Smith
Attending Physician: Dr. [Your Name]

Chief Complaint:

Sophie is a 4-year-old girl presenting with a high fever and persistent cough for the past three days.

History of Present Illness:

Sophie's mother reports that Emily started with a low-grade fever three days ago, which has progressively increased to 102°F. She has had a non-productive cough that worsens at night and has been experiencing mild nasal congestion. There are no associated symptoms of vomiting, diarrhea, or rash. Sophie has been lethargic and irritable but is still able to eat and drink fluids. No recent travel or known sick contacts.

Past Medical History:

• Asthma (managed with albuterol as needed)

• No previous hospitalizations or surgeries

• Up to date on vaccinations

Medications:

• Albuterol inhaler as needed

• No other medications

Allergies:

• No known drug allergies

Family History:

• Non-contributory. The mother has a history of asthma.

Social History:

• Lives with their parents and a 6-year-old brother. Attends preschool. No tobacco or alcohol exposure was reported.

Review of Systems:

• General: Fever, fatigue

• Respiratory: Cough, no wheezing or stridor noted

• Cardiovascular: No palpitations, normal heart rate

• Gastrointestinal: No vomiting or diarrhea

• Neurological: No seizures or changes in consciousness

Physical Examination:

• Vital Signs: Temp 102.5°F, HR 110 bpm, RR 24, BP 100/60, SpO2 98% on room air

• General: Alert but fussy, appears mildly dehydrated

• HEENT: Mild nasal congestion, no conjunctival injection, throat erythematous without exudate

• Lungs: Clear to auscultation bilaterally, no wheezes or crackles

• Heart: Regular rhythm, no murmurs

• Abdomen: Soft, non-tender, no organomegaly

• Extremities: No cyanosis or edema

Assessment:

1. Viral upper respiratory infection (likely viral bronchitis)

2. Mild dehydration due to fever and decreased oral intake

Plan:

1. Encourage fluid intake; offer clear liquids

2. Antipyretics (acetaminophen) for fever management

3. Monitor respiratory status; continue albuterol as needed for wheezing

4. Follow up in 3-5 days or sooner if symptoms worsen (e.g., difficulty breathing, high fever, or new symptoms)

5. Educate parents on warning signs that require immediate attention

Signature:

Dr. [Your Name], MD
Pediatrician

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