C10019168 / invoice 10000

Reason: Coughing, Breathing Difficulties?Started last night - dry hacking, some loud resp heard when breathing. Has been lethargicAte a bit this am - then V+ up the food 20min later, now bringing up frothHistory:Chronic conditions: BehaviourChronic medications: fluoxetine, intermittent claratyne Examination:Behaviour/Demeanour: BAR/ sweetNo skin tentingHeart: sounds normal, no murmur, synchronous pulsesChest clearMM: pinkCRT: <2 secsEyes: NAD distance exam Periph LN: NADAbdo palpation: WNLSkin/ coat: goodProblem list:CoughingV+Assessment:Likely upper resp tract infection - KCAdvised could be something else - V+ - intoxication vs fb ingestionCoughing - other lung pathology Treatment:Codiene 30mg - 1/4 - 1/2 SID - TID as neededDiscussed can cause sedation Plan:For Os to ensure drinking, eatingVan check hydration at home - skin tent/ gums - pinkDiscussed RRRTo let us know if deterioration / worried Call back set    Vital Signs    MMColour: Pink;       BodyScore: 7;       CRT: < 2 sec;