Angkor Hospital for Children Faculty Development Course

Patient Presentations II

The Problem List

Progress notes and Presentations are different except for the problem list.

Progress Note CHIEF COMPLAINT: Irritable with fever for 2 days. HISTORY OF PRESENT ILLNESS: 2-week-old boy who was eating/growing well until about 48 hours prior to admission, developed irritability, fussiness, vomiting, and then up to 39.5C. No ill contacts. PAST MEDICAL HISTORY: Normal pregnancy, spontaneous vaginal delivery (NSVD) at term without complications, mother healthy throughout pregnancy. Bottle-fed and lives in a home where there are smokers. No previous illnesses. PAST SURGICAL HISTORY: None. MEDICATION(S): None. REVIEW OF SYSTEMS: Positive as above. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Lives with his mother (single) and maternal grandparents. Grandfather is a heavy smoker. PHYSICAL EXAMINATION: VITAL SIGNS: 38.4- 165 - 60 - 3.1kg (BW 3.0kg) GENERAL: Irritable and fussy HEENT: Anterior fontanelle flat. Bilateral TMs clear. NP moist. Neck is supple, no nuchal rigidity. No adenopathy. HEART: Rapid without murmur. Cap refill <2s. LUNGS: clear bilateral ABDOMEN: No masses, distention, or visceromegaly GENITOURINARY/RECTAL: bilateral testes down, normal EXTREMITIES: No cyanosis, edema NEUROLOGIC: No focal deficits SKIN: No rashes

Presentation The patient is a 2 week old male with a 2 day history of fever up to 39.5C associated with irritability and vomiting. The child had an unremarkable birth history with no maternal illnesses. He is bottle-fed and has been otherwise healthy since birth. No one else in the family is sick. On physical exam, temp 38.4, pulse 165, respirations 60, weight 3.1 kg. In general, the child was irritable and fussy, but without focal signs of infection or significant dehydration on exam.

A/P: 2 week old male with febrile illness r/o sepsis 1. Sepsis Workup CBC, UA, CXR, LP, blood/urine cultures Amp/Gent until labs back 2. FEN (fluid, electrolytes, nutrition) Check electrolytes Fluid bolus Normal feeding as tolerated

Angkor Hospital for Children Faculty Development Course

Patient Presentations II

Writing a Problem List

or Why do we write progress notes? Who is it for? You On-call doctor Outpatient/follow-up doctor Nurses, lab personnel, therapists, pharmacists, nutritionists, case managers

What is it for? Guide your thoughts and other peoples thoughts regarding the management of the patient Helps to organize your thoughts better Why should I do it? Saves time no need keep explaining the same thing to different people (other doctors, therapists, nurses, etc.) Reminds us of important things to do Helps guide therapy if something happens when youre not there Makes presenting the patient easier How do I make one? Start with the patients identification (age, gender, # days in the hospital) List the patients problems should include issues of nutrition, physical therapy, patient education, disposition (planning for discharge) when appropriate as well Contains an assessment of patients current status Some Common Abbreviations Should be in order of seriousness in Problem Lists Describe the patients management plan You can add your main differential diagnosis if HD# = hospital day # it will help explain your plan to others. ABD# = antibiotic day # D# = day # How often do I need to make one? D#2/4 = day number 2 of 4 days Depends on how much the patient is changing. s/p = status post, in a condition Of there is a change in plan, you can note that following eg s/p surgery, s/p change. accident If the patients management isnt changing, you fx = fracture can write management/plan unchanged cx = culture
A/P: 8yo HD#3 s/p motorcycle accident with mult rib fx s/p L chest tube, traction for a R mid-femur fx with resp distress after 3u PRBC. 1. Resp distress probably due to fluid overload from blood/IVFs - Diff dx: fat embolism, splinting/inadequate pain control, pneumothorax, PE. - pain management, CXR pending. - Furosemide if CXR rules out pneumothorax. 2. Mult rib fx and femur fx - Surgeon following. Pain control, DVT prophylaxis and physical therapy. 3. Post-traumatic anemia s/p 3u PRBC - Monitor signs/symptoms internal bleeding. Serial Hgb every 8hrs until stable. 4. Nutrition - Hold diet until resp status stabilizes.

Angkor Hospital for Children Faculty Development Course

Patient Presentations II

Case 1 New Patient 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 any perinatal 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 <2s Abd: Soft and apparently nontender. BS+. No masses or organomegaly. umbilicus - no discharge/erythema. GU: Nl circumcised male without signs of infection. Extremities: Full range of motion/no swelling. Neuro: Normal reflexes/non-focal LAB: WBC 22; UA, blood/urine cultures pending. Case 3 OPD Patient HPI: 5 year old previously healthy female awoke this morning with a twisted face. Food falls from the left side of her mouth and she has difficulty with left eye closure. She denies excessive eye tearing, fever, cough, nausea/vomiting, diarrhea, colds or recent travel. No headaches, difficulty walking or poor coordination, weakness, numbness/tingling, vision or hearing changes, incontinence, seizures, or taste disturbances. PMH: Right otitis media 6 months prior. No history of varicella or parotitis. Immunizations are up to date. Birth history is non-contributory. Normal development. No medications or known allergies. FMH: Parents healthy. 4 year old sister with resolved case of Bells palsy and a healthy 1 year old brother. SH: Shares room with siblings. Attends school & church. ROS: Unremarkable PE: 37.2C rectally; HR 100; RR 20; BP 90/50; ht 114cm; wt 20.4kg (95%-ile). Gen: Alert and oriented HEENT: (See neuro). TMs normal bilaterally. NP - no erythema/exudate. Neck supple, no adenopathy Lungs: CTAB CV: RRR without murmur or extra sounds. Abd: Soft and non-tender. No organomegly. Ext: Full range of motion of all extremities. Strength 5+/5+ in all extremities. Neuro: PERRL, cranial nerves II-XII grossly intact except for 7th L cranial nerve palsy. No atrophy, fasciculations, tremors. Cerebellar testing normal. Romberg . Sensation/reflexes normal bilaterally.

Case 2 IPD Patient HPI: 12 year old previously healthy male who went to a wedding two days ago. Everyone in the wedding apparently had problems afterwards with abdominal cramps. He awoke yesterday morning with pain in his abdomen - sharp and localized in the right lower quadrant. Yesterday, he was admitted and underwent appendectomy. On surgery, appendix inflamed but not ruptured. Today, still no BM or passing gas. Patient states uncomfortable. He received one dose of antibiotics before his surgery yesterday afternoon. PE: 38.0C; HR 100; RR 20; BP 100/60; ht 142cm; wt 32kg. Gen: Alert and responsive in mild distress HEENT: No scleral icterus. Mucous membranes moist. Neck: Supple. Lungs: Faint bibasilar crackles CV: RRR without murmurs or abnl sounds. Abd: Right lower quadrant tenderness without rigidity. Wound dressing clean/dry/intact. No masses. Rectal: Deferred. Ext: Unremarkable. LAB/STUDIES: None ordered this am.

Case 4 ICU Patient HPI: 3 year old previously healthy male developed congestion and fever 3 days ago. He admitted due to temp 39.5 degrees C and because he was lethargic, weak with decreased muscle tone. Mother states that he has not eaten or drank much since admission with no urine output since yesterday evening. Receiving Ceftriaxone 1gm daily and D51/4NS @50cc/hr PMH: Two ear infections but no other infections or illnesses. Normal prenatal course and NSVD without complications. Normal growth and development. No regular meds or known allergies. PE: 39.6C oral, last paracetamol dose 4 hours ago. HR 100-120; RR: 24-32; SBP: 70-85; O2 Sat: 98% on RA. I/O 1450/200 Wt 16.5 kg (90%-ile) Ht 96 cm (65%-ile) Gen: Lethargic and ill, difficult to arouse. Skin: No rashes/jaundice. HEENT: Normocephalic. No conjunctival injection. PERRL. No papilledema. TMs erythematous and bulging bilaterally. NP dry and mildly erythematous, no exudate. Neck: Posterior cervical lymphadenopathy. Rigidity present with positive Brudzinskis sign. Lungs: CTA bilaterally. No assessory muscle use. CV: Tachy, no murmurs or extra sounds. Abd: +BS, Nontender, nondistended. No organomegaly. Ext: Positive Kernigs sign. No edema or digital clubbing. LAB: This am WBC 14.2. No differential. CRP 40. CXR clear.

Angkor Hospital for Children Faculty Development Course

Patient Presentations II

Your Problem List

Patient Presentation Templates The patient is a _________ age _______________________. who presented with

chief complaint

ID & Present Illness New patient

Pertinent past medical history, social history, family history.

Physical Exam Investigations

On physical exam vitals, pertinent physical findings Labs showed pertinent lab and test results The patient is a _________ age admitted for _______________________.
primary diagnosis

Problem List & Plan

1. 2. 3. etc

Angkor Hospital for Children Faculty Development Course

Patient Presentations II

ID IPD Objective

This is a _________ age ___________________.

hospital day # _____ admitted for primary diagnosis

Today vitals, pertinent physical findings, pertinent lab and test results The patient is better/worse/stable. 1. 2. 3. etc This is a _________ age ___________________. hospital day # _____ admitted for

Assessment & Plan

ID ICU patient 24 hour summary

primary diagnosis

Over the last day vitals, pertinent physical findings, pertinent lab and test results Overall, this patient is better/worse/stable.

Problem List & Plan

1. 2. 3. etc The patient is a _________ age _______________________. who presented with

chief complaint

OPD patient

ID & Present Illness

Pertinent past medical history, social history, family history.

Objective Assessment & Plan

On physical exam vitals, pertinent physical findings, pertinent investigations 1. 2. 3. etc The patient is a _________ age _______________________.
Pertinent past medical history

Consultation

ID & reason for consultation Physical Exam Investigations Problem & Questions

who presented with condition requiring consultation

On physical exam vitals, pertinent physical findings Labs showed pertinent lab and test results
Problem requiring consultation, summary of current therapies

what, why, when, how?

Angkor Hospital for Children Faculty Development Course

Patient Presentations II

ID Hand-Over

This is a _________ age ___________________.

hospital day # _____ admitted for

primary diagnosis

Over the last 24 hrs vitals, pertinent physical findings, pertinent lab and test results 24 hour summary or Things to be aware of for tonight are Plan Diagnosis & Prognosis Simple Problem List & Management Plan Open Discussion
What needs follow-up

In simple, understandable terms. What can they expect? What is the problem & what are you (or the parents) going to do about it? Do you have any questions?

Family