T2 – Respiratory Case 2

Triage note:  

6 month old baby  

Seen by GP yesterday, diagnosed bronchiolitis  

Still unwell today and now fever 39.4C which has worried mum as GP told her would not get a temp with bronchiolitis  

Examining clinician note:  

As above  

Not obviously more unwell, actually better than was a few days ago, mum just worried about the temp  

Wet nappies+, bowels and, taking at least 50% of feeds  

Has vomited a couple of times  

Has had calpol 1hr ago  

Quiet but alert/responsive/interested  

Temp 39.5  

No rash  

CRT 2s  

RR 40  

O2 sat 95%  

Chest moderate recession  

Widespread transmitted sounds, normal air entry, nil focal  

HR 178 reg HS 1+2+0  

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