Patient: Becky Smith DOB: 01/26/XXXX Age: 5 y/o Attending: Dr. D. Miles Allergies: NKA MR#: 203. Patient Chart #203 Becky Smith
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1 Patient Chart #203 Becky Smith 1 Property of CSCLV CSCLV Rev: 06/04/2018
2 Chief Complaint: Abdominal pain. Informant: Parents. HISTORY & PHYSICAL HPI: Ill looking patient, healthy until 2 days ago when began complaining of (c/o) a stomachache and refused solid food. Patient developed fever of 101.6F on day two and woke up vomiting this morning. Patient was brought to emergency department (ED) by parents. VS in ED: BP- 106/68, P- 110, RR- 24, T (oral) 101.4F, pain score 10 on FACES scale with pain in the right lower quadrant (RLQ). PMX: Placement of tympanostomy tubes (serous otitis media) at 19 months. Regular well child checkups. IMMUNIZATIONS: Up-to-date per parents ALLERGIES: No known allergies (NKDA). Review of Systems Patient is a healthy, well-developed 5-year-old female with c/o abdominal pain in right lower quadrant (RLQ). Normal growth and development per age. Immunizations up-to-date including flu vaccine this year. No prior hospitalizations. No routine home medications. Cardiac, pulmonary, GU, integumentary, musculoskeletal are within defined parameters (WDP). CURRENT MEDICATIONS: None Plan: Laparoscopic appendectomy (suspect ruptured appendix) and transfer to pediatric unit. Dictated: Dr. D. Miles 2 Property of CSCLV CSCLV Rev: 06/04/2018
3 PHYSICIAN ORDERS Day Time PHYSICIAN ORDER AND SIGNATURE Yesterday 1800 Admit to pediatrics Diagnosis Status post (S/P) appendectomy Code Status Full Code Vital Signs Every 4 hours (Q4H) and as needed (PRN). Continuous pulse oximetry. Oxygen By nasal cannula (N/C) as needed, titrate to keep SpO2 >92%. Allergies NKDA Diet NPO Activity Incentive spirometer every hour (Q1H) when awake (or blow bubbles). Ambulate in hallway four times a day. Nursing Communication Nasal gastric (NG) tube to low intermittent wall suction (LIWS). Check NG tube placement as needed. Measure NG output Q4H. Replace NG output ml for ml: D5/½ Normal Saline (NS) + 20 meq potassium chloride (KCL) per liter (L); replace/infuse via IV Q 4H. Call HCP for NG output < 5 ml/hr., T > 102, HR > 110, BP <80/50 or > 120/80 IV Fluids D5 ½ NS + 20 meq KCL/L 60 ml/hr. Daily Medications ceftazidime 1 gm intravenous (IV) every 8 hours (Q8H) infuse over 30 minutes PRN Medications ondansetron 2 mg IV every 6 hours (Q6H) PRN for nausea acetaminophen 325 mg rectal (PR) Q4H PRN for fever > 101.0F or pain scale of 1-2 morphine 1 mg IV every 2 hours (Q2H) PRN pain scale 3-6 morphine 2 mg IV every 2 hours PRN pain scale > 6 PROVIDER SIGNATURE Dr. D. Miles 3 Property of CSCLV CSCLV Rev: 06/04/2018
4 NURSING FLOW SHEET DATE: Yesterday TIME VITAL SIGNS BLOOD PRESSURE PULSE RESP RATE TEMP SCORE PAIN LOCATION CHARACTER OXYGEN RESP OXIMETER DIET / % EATEN NUTR SUPP FEEDING PO NPO NPO NPO INTAKE IV NGT Replacement URINE OUTPUT DRAINS PROBLEM / EVENT DOCUMENTATION DATE / TIME. SIGNATURE 4 Property of CSCLV CSCLV Rev: 06/04/2018
5 MEDICATION ADMINISTRATION RECORD Pg. 1 SCHEDULED MEDICATIONS Intravenous Fluids D5 ½ NS + 20 KCL/L at 60 ml/hr. MEDICATION ceftazidime 1 gm IV Q8H SIGNATURE INTLS SIGNATURE INTLS 5 Property of CSCLV CSCLV Rev: 06/04/2018
6 MEDICATION ADMINISTRATION RECORD Pg. 2 NON SCHEDULED MEDICATIONS MEDICATION ondansetron 2 mg IV Q6H PRN for nausea acetaminophen 325 mg PR Q4H PRN for fever > 101.0F or pain scale 1-2 morphine 1mg IV Q2H PRN pain scale 3-6 morphine 2 mg IV Q2H PRN pain scale>6 Fluid replacement for NG output ml per ml: D5/½ NS + 20 KCL meq/l, Replace/infuse via IV Q 4H. SIGNATURE INTLS SIGNATURE INTLS 6 Property of CSCLV CSCLV Rev: 06/04/2018
7 LAB STUDIES & DIAGNOSTICS HEMATOLOGY LAB TEST NORMAL RANGE PATIENT VALUE Red Blood Cells (RBC) Males: million /mm3 4.1 Females: million/mm3 Hematocrit (HCT) Males: 37-49% Females: 36-46% 38% Hemoglobin (Hgb) Males: g/100 ml Females: g/100 ml 14 White Blood Cells (WBC) 4,500-11,000/mm3 12,000 (H) Platelets (Plt) X 103 mm3 400 MCV CHEMISTRIES LAB TEST NORMAL RANGE PATIENT VALUE Sodium (NA+) meq/l 137 Potassium (K+) meq/l 4.2 Chloride (CL-) meq/l 99 Carbon Dioxide (C02) meq/l 26 Glucose mg/dl 86 Blood Urea Nitrogen (BUN) 8-25 mg/dl 11 Creatinine Male: mg/dl Female: mg/dl C-Reactive Protein mg/dl (H) Property of CSCLV CSCLV Rev: 06/04/2018
8 IMAGING CAT SCAN of Abdomen CAT SCAN Right pelvic inflammatory lesion that could represent acute appendicitis with localized perforation and adenopathy. Thickening noted around appendix. Impression: Ruptured appendix M. Bowler MD Dictated by: Dr. Michelle Bowler 8 Property of CSCLV CSCLV Rev: 06/04/2018
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