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Teaching through Progress NotesAngkor Hospital for Children

Faculty Development Course

Progress notes should follow our thought processes and guide our students.

7 July 11 24hr Summary: Tm 37.3, HR 115-135, RR 20-40, SBP 100-114. Now 37.1-132-30-110/60.8:20am Wt 30.1kg (admit 27.3kg), O2 sat 100% on NR, I/O 3450/2145, tolerating nl diet.

resp distress after 3u PRBC yesterday/this am. O2 now by NR mask. CXR pending.CT is sealed/no leaks.

R A&R in no acute distress (NAD)Worsening respiratory distress withbibasilar crackles up, breathsounds throughout lung fields.

I WBC 8.7C Tachy, no abnormal heart sounds.

H Hgb 124 (yest am 70/admit 11.5)M ABG 7.47/30/70/23/92% on RAA Nl urine. Tolerating normal diet.N RLE: distal pulses 2/2, cap refill

8/2/2019 Teaching Thru PNs HO

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Teaching through Progress NotesAngkor Hospital for Children

Faculty Development Course

Case 1

HPI: 5 day old previously healthy male infant who refused

his feeding six hours before admission. Rectal temp was

39.8C. Mother denies runny nose, cough, vomiting,

diarrhea or decreased voiding (usually 8-10 wet diapers a

day). He is exclusively breastfed and nurses every 2 hours

until today.

NSVD at term, no complications. Discharged home at 2

days of age. Birth wt 3.2kg, length 49cm. Mom denies anyperinatal infections, fever, vaginal discharge, or herpes in

herself. No one at home is ill and he does not attend

daycare.

PMH: Surgeries: circumcision. Nl development.

SOCIAL: No pets, smokers or ill contacts.

PE: 39.2C rectally; HR 142; RR 30; BP 69/42 R leg;

ht 49cm; HC 36 cm; wt 3.1kg.

Gen: Fussy but non-toxic.

Skin: Pink, warm and dry. No rashes.

HEENT: Normocephalic. Fontanelles soft/flat. TMs nl.Mucous membranes moist. NP without erythema.

Neck: Supple without lymphadenopathy or rigidity.Lungs: CTAB, no grunting/flaring/retractions.

CV: RRR w/o murmurs/abnl sounds, cap refill

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Teaching through Progress NotesAngkor Hospital for Children

Faculty Development Course

Case #____

A

P

Even if we havent seen yourpatient, we should be able to look atyour A/P and understand theircondition and important pointsregarding their care.

Develop a problem list.

Make it easy to follow your thoughtsCeftri (6/14)if... thencan when