De Paul Medical Center
Mock Inpatient Medical Record
Facility Name:
| | |
|Patient Name: PACKARD, Baby Boy |DOB 9 September 2008 |
|Medical Record #: 1234567-8 | |Sex: M |
| | | | | |
|Diagnosis: 28-wk Preemie; Respiratory Distress Syndrome; Sepsis w/u |
| | | | | |
| |
|History and Physical: Birth Weight 1120 gm; RDS – endotracheal intubation, assisted ventilation,, and surfactant; Sepsis w/u – Amp & Gen;|
|NPO – UA/UV/HAL.. |
|Treatment: |Ventilatory settings 18/6 x 40, Fi02: 75%; |
| |UAC ½ NS & CaGluc 200 mg/100 mL @ 1.5 mL/hr; |
| |UVC D12.5W HAL @ 5 mL/hr; |
| |pIV lock |
|Medications: |
|Ampicillin 55 mg IV q 6h; |
|Gentamicin 2.8 mg IV q 24h; |
|Vitamin A 5000 Units IM q M-W-F x 12 doses; |
|Sweat-Ease 0.5 mL PO PRN |
|Progress Notes: |Stable on vent with hi Fi02; |
| |Soft murmur, consider PDA, order Echo, hold at 140 mL/kg daily |
| |Culture pending – continue Abx |
| |Head U-S ordered |
|Last Physician’s Orders: |
| |
|EchoCardioGram “possible PDA”; |
|ABG q 4h; Fi02 PRN to keep SpO2 88-92% (Alarms 85-95%); |
|Gent levels pre/post next dose; |
|Chem10, CBC-S q AM |
|Head Sonogram |
|Discharge Plan: Patient is a poor candidate for imminent discharge. |
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