A 6 YEAR OLD GIRL WITH FEVER AND ABDOMINAL PAIN

DATE & TIME FOCUS PROGRESS NOTE

10/2715 PAIN D: The patient woke up
7:00 screaming in pain and holding
her left side, saying it was
hurting.
In addition, the mother
reported that the child had a
fever of 102.6º F 2 days ago,
but denied any vomiting,
diarrhea, or dysuria. She
stated that the patient also
had a mild cough and that her
last bowel movement was
about 2 days ago.
A: The patient was made NPO
in the emergency room and
was treated with 300 mg of
Ibuprofen by mouth for pain.
Once the diagnosis of left
lower lobe pneumonia was
established, the patient was
discharged home on
Augmentin ES 600 mg every 12
hours for 10 days and asked to
follow up with her primary
care provider in 1 week. Blood
and urine cultures showed no
growth at 5 days
R: Patient rate pain zone 1-10
scale and states “ I feel much
better”