De Paul Medical Center



Mock Inpatient Medical Record

Facility Name:

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|Patient Name: PACKARD, Baby Boy |DOB 9 September 2008 |

|Medical Record #: 1234567-8 | |Sex: M |

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|Diagnosis: 28-wk Preemie; Respiratory Distress Syndrome; Sepsis w/u |

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|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: |

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|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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