Med/Anc

Note Type  : Generic Progress Notes  : Emergency

Service
Date/Tim  : Tan Yin Ying,
 : 16/04/2011 14:16 Performed By
e Dr
Note Title  : ED clerking

Generic Progress Notes

Subjective / Current Problems :    - Green zone -

Informant: mother

6y7m, malay girl

No known medical illness

C/o diarrhea and vomiting since 2am this morning

HOPI:
Vomiting and diarrhea
- more than 10x
- no blood
- loose stool

A/w abdo pain

- unable to describe the nature

No fever
No URTI symptoms
No chest pain / shortness of breath
No UTI symptoms

Able to tolerate orally minimally

No other family members had similar complaint

No h/o taking outside food

Objective / Examination  :    alert

conscious
pink
not tachypnoec

lethargy
moist tongue
skin turgor normal
skin dry
warm peripheries
CRT <2sec

T: 37
HR: 120, good vol
RR: 26
spo2: 99% on air

CVS:DRNM
 Lungs: clear
PA: soft, non tender, no guarding/ rigidity, no mass
palpable

tonsil: enlarge bilaterally, no exudate

throat: not inflammed
Diagnosis  :    AGE with no degydration
Current Medical Conditions :   
Plan  :    SW Dr Nantha

- admit observation
- RP, FBC, VBG
- wt: 16kg
- start 1x maintainance = 54ml/hr
- ORS per purge
- encourage orally
- sy PCM 240mg stat
 

Note Type  : Generic Progress Notes Med/Anc Service : Emergency

Date/Time : 16/04/2011 14:16 Performed By : Tan Yin Ying, Dr
Note Title  : ED clerking
Generic Progress Notes
Subjective / Current Problems :    - Green zone -

Informant: mother

6y7m, malay girl

No known medical illness

C/o diarrhea and vomiting since 2am this morning

HOPI:
Vomiting and diarrhea
- more than 10x
- no blood
- loose stool

A/w abdo pain

- unable to describe the nature

No fever
No URTI symptoms
No chest pain / shortness of breath
No UTI symptoms

Able to tolerate orally minimally

No other family members had similar complaint

No h/o taking outside food

Objective / Examination  :    alert

conscious
pink
not tachypnoec
 lethargy
moist tongue
skin turgor normal
skin dry
warm peripheries
CRT <2sec

T: 37
HR: 120, good vol
RR: 26
spo2: 99% on air

CVS:DRNM
Lungs: clear
PA: soft, non tender, no guarding/ rigidity, no mass
palpable

tonsil: enlarge bilaterally, no exudate

throat: not inflammed
Diagnosis  :    AGE with no degydration
Current Medical Conditions :   
Plan  :    SW Dr Nantha

- admit observation
- RP, FBC, VBG
- wt: 16kg
- start 1x maintainance = 54ml/hr
- ORS per purge
- encourage orally
- sy PCM 240mg stat

Laboratory
Chem Path
(Renal Profiles)- Urea

16/04/2011 14:48
7.6 mmol/L 
(Renal Profiles)- Sodium
138
16/04/2011 14:48 mmol/L 

(Renal Profiles)- Potassium

16/04/2011 14:48 3.30 mmol/L 
(Renal Profiles)- Chloride

16/04/2011 14:48
106.0 mmol/L 
(Renal Profiles)- Creatinine
16/04/2011 14:48 47.4 umol/L 

Laboratory
Chem Path
(Renal Profiles)- Urea
16/04/2011 14:48
16/04/2011 14:48 7.6 mmol/L
(Renal Profiles)- Sodium
16/04/2011 14:48
16/04/2011 14:48 138 mmol/L
(Renal Profiles)- Potassium
16/04/2011 14:48
16/04/2011 14:48 3.30 mmol/L
(Renal Profiles)- Chloride
16/04/2011 14:48
16/04/2011 14:48 106.0 mmol/L
(Renal Profiles)- Creatinine
16/04/2011 14:48
16/04/2011 14:48 47.4 umol/L

Patient Care
General Services
(Vital Signs)- Temperature
16/04/2011 21:54 38.0 degC 
16/04/2011 20:43 37.2 degC 
16/04/2011 18:50 37.4 degC 
16/04/2011 17:46 37.0 degC 
16/04/2011 16:39 37.5 degC 
16/04/2011 15:06 37.0 degC 
(Vital Signs)- Pulse Rate
16/04/2011 21:54 120 bpm 
16/04/2011 20:43 132 bpm 
16/04/2011 18:50 118 bpm 
16/04/2011 17:46 150 bpm 
16/04/2011 16:39 130 bpm 
16/04/2011 15:06 121 bpm 
(Vital Signs)- Respiration
16/04/2011 21:54 23 bpm 
16/04/2011 20:43 24 bpm 
16/04/2011 18:50 25 bpm 
16/04/2011 17:46 25 bpm 
16/04/2011 16:39 25 bpm 
16/04/2011 15:06 23 bpm 
(Vital Signs)- Systolic Blood Pressure
16/04/2011 21:54 96 mmHg 
16/04/2011 20:43 93 mmHg 
16/04/2011 18:50 91 mmHg 
16/04/2011 17:46 98 mmHg 
16/04/2011 16:39 87 mmHg 
16/04/2011 15:06 90 mmHg 
(Vital Signs)- Diastolic Blood Pressure
16/04/2011 21:54 60 mmHg 
16/04/2011 20:43 40 mmHg 
16/04/2011 18:50 51 mmHg 
16/04/2011 16:39 48 mmHg 
16/04/2011 15:06 55 mmHg 
(Vital Signs)- MAP
71
mmHg 
16/04/2011 21:54

16/04/2011 20:43 58 mmHg 

16/04/2011 18:50 65 mmHg 
16/04/2011 17:46 71 mmHg 

16/04/2011 16:39

60 mmHg 
16/04/2011 15:06 68 mmHg 
(Vital Signs)- SPO2
16/04/2011 21:54 99 % 
16/04/2011 20:43 100 % 
16/04/2011 18:50 100 % 
16/04/2011 17:46 100 % 
16/04/2011 16:39 98 % 
16/04/2011 15:06 98 % 

Patient Care
General Services
(Vital Signs)- Temperature
16/04/2011 21:54
16/04/2011 21:54 38.0 degC
16/04/2011 20:43
16/04/2011 20:43 37.2 degC
16/04/2011 18:50
16/04/2011 18:50 37.4 degC
16/04/2011 17:46
16/04/2011 17:46 37.0 degC
16/04/2011 16:39
16/04/2011 16:39 37.5 degC
16/04/2011 15:06
16/04/2011 15:06 37.0 degC
(Vital Signs)- Pulse Rate
16/04/2011 21:54
16/04/2011 21:54 120 bpm
16/04/2011 20:43
16/04/2011 20:43 132 bpm
16/04/2011 18:50
16/04/2011 18:50 118 bpm
16/04/2011 17:46
16/04/2011 17:46 150 bpm
16/04/2011 16:39
16/04/2011 16:39 130 bpm
16/04/2011 15:06
16/04/2011 15:06 121 bpm
(Vital Signs)- Respiration
16/04/2011 21:54
16/04/2011 21:54 23 bpm
16/04/2011 20:43
16/04/2011 20:43 24 bpm
16/04/2011 18:50
16/04/2011 18:50 25 bpm
16/04/2011 17:46
16/04/2011 17:46 25 bpm
16/04/2011 16:39
16/04/2011 16:39 25 bpm
16/04/2011 15:06
16/04/2011 15:06 23 bpm
(Vital Signs)- Systolic Blood Pressure
16/04/2011 21:54
16/04/2011 21:54 96 mmHg
16/04/2011 20:43
16/04/2011 20:43 93 mmHg
16/04/2011 18:50
16/04/2011 18:50 91 mmHg
16/04/2011 17:46
16/04/2011 17:46 98 mmHg
16/04/2011 16:39
16/04/2011 16:39 87 mmHg
16/04/2011 15:06
16/04/2011 15:06 90 mmHg
(Vital Signs)- Diastolic Blood Pressure
16/04/2011 21:54
16/04/2011 21:54 60 mmHg
16/04/2011 20:43
16/04/2011 20:43 40 mmHg
16/04/2011 18:50
16/04/2011 18:50 51 mmHg
16/04/2011 17:46
16/04/2011 17:46 55 mmHg
16/04/2011 16:39
16/04/2011 16:39 48 mmHg
16/04/2011 15:06
16/04/2011 15:06 55 mmHg
(Vital Signs)- MAP
16/04/2011 21:54
16/04/2011 21:54 71 mmHg
16/04/2011 20:43
16/04/2011 20:43 58 mmHg
16/04/2011 18:50
16/04/2011 18:50 65 mmHg
16/04/2011 17:46
16/04/2011 17:46 71 mmHg
16/04/2011 16:39
16/04/2011 16:39 60 mmHg
16/04/2011 15:06
16/04/2011 15:06 68 mmHg
(Vital Signs)- SPO2
16/04/2011 21:54
16/04/2011 21:54 99 %
16/04/2011 20:43
16/04/2011 20:43 100 %
16/04/2011 18:50
16/04/2011 18:50 100 %
16/04/2011 17:46
16/04/2011 17:46 100 %
16/04/2011 16:39
16/04/2011 16:39 98 %
16/04/2011 15:06
16/04/2011 15:06 98 %

Med/Anc
Note Type  : Visit Summary  : Paediatrics
Service
Date/Tim  : Hazwani Effendy Bt Ashraff,
 : 17/04/2011 11:23 Performed By
e Dr

History
am round
SW Dr Maryam
 
6y7m / Girl
No known medical illness
 
Problem : AGE with no dehydration
 
Progress :
on full maintanance
comfortable
oral intake improving
diarrhoea x 1 ,more solid
vomit x 1
urine output good
fever settling
 
o/e :
alert
pink
hydration good
no sunken eyes
 
BP 101/66(80)
HR 132
RR 32
spo2 100% on RA
temp 37.3
 
lungs clear
CVS DRNM
abd soft,nontender
 
Plan :
Fluid
reduce to 1/2 maintanance IVD HSD5% 27mls / hr
 
Ix
trace stool for ova cyst , FEME , C+s
tarce urine C+S
 
Medications
ORS / vomit
Syp PCM 240 mg QID

 
Others
strict I/O chart
vital signs monitoring
review pm ,KIV discharge pm if well
 

Note Type  : Visit Summary Med/Anc Service : Paediatrics

Date/Time : 17/04/2011 11:23 Performed By : Hazwani Effendy Bt Ashraff, Dr
History
am round
SW Dr Maryam
 
6y7m / Girl
No known medical illness
 
Problem : AGE with no dehydration
 
Progress :
on full maintanance
comfortable
oral intake improving
diarrhoea x 1 ,more solid
vomit x 1
urine output good
fever settling
 
o/e :
alert
pink
hydration good
no sunken eyes
 
BP 101/66(80)
HR 132
RR 32
spo2 100% on RA
temp 37.3
 
lungs clear
CVS DRNM
abd soft,nontender
 
Plan :
Fluid
reduce to 1/2 maintanance IVD HSD5% 27mls / hr
 
Ix
trace stool for ova cyst , FEME , C+s
tarce urine C+S
 
Medications
ORS / vomit
Syp PCM 240 mg QID

 
Others
strict I/O chart
vital signs monitoring
review pm ,KIV discharge pm if well