Progress Notes

Name: Shielalene Baruwan

Age: 9
Chief Complaint: Fever and chills for 2 hours duration
D1

Time Focus Nurses Notes

2:00 Fever and -Patient came in at 2 am with fever (39.4) and chills and was decked on D1
am chills for 2 -Around 2:05 a.m patient was attended to by junior intern assigned and later
hours on, the senior ER physician on duty
duration
2:30 Fever and -Dr. Espalda came in around 2:30 a.m and extracted blood from patients R
a.m chills for 2 antecubital fossa
hours -Patients SO was instructed to buy Hydrite.
duration
3:00 Fever -Patient was given paracetamol at 3 a.m for the fever.
am -Patient was advised to sleep.
6:00 -Patient woke up around 6 a.m and was free of fever and chills.
a.m. -Patients temperature was at 36.8
-RR 23, BP 100/90, PR 119
6:45 CBC -At 6:45, patient and SO was met again by Dr. Espalda to discuss the results
a.m of CBC and revealed that platelets have gone done since last extraction
(yesterday) although the results are within normal limits
7:00 -At 7:00, patient was advised for admission which the patients SO accepted
a.m -Initial diagnosis: AVI

7:20 -At 7:20 a.m, patient had an IV insertion done by a pediatric doctor at the R
a.m metacarpal, and was hooked on to a D5LR bottle containing 1 L to run for 6
hour
7:30 Focused -Junior intern with student nurse performed focused assessment to the
a.m. assessment patient focusing on respiratory and HEENT
8:25 Admission At 8:25, patient was transferred to 4North Pediatric Unit in room 426 C
a.m and was then admitted.

Name: Nastor Cuaresma

Age: 25
Chief Complaint: Wound at right hand
Minor Room

Time Focus Nurses Notes

9:45 Wound -Patient came in with SO to seek consult, treatment and advice on wound
a.m that patient came to have at around 7 a.m.
 -Patient had wound wrapped in a semi-soiled bandage with blood stains
-Patient advised to have wound cleaned and have 2 shots of anti - tetanus
toxoid injections
9:55 Wound -Assigned JI began cleaning wound after the patient washed his hands in the
a.m. Minor room
-Wound care was initiated with the use of hydrogen peroxide
10:05 Wound -ER Doctor on duty came to see the patient and continued wound care
a.m. -Initially prepared steristrip to seal wound
-Upon further assessment, skin evaluated to be wrinkled and would not
produce a good recovery
10:10 Wound care -Decided to peel skin off and proceed with suturing the wound instead
a.m.
10:20 Tetanus -Patient received (2) shots of anti-tetanus toxoid intramuscularly (R and L)
a.m. Toxoid
Injections
10:35 Discharge -Patient educated on wound care
a.m. -Patient advised for discharge