Pediatric Discharge Summary Transcription Sample Report

DATE OF ADMISSION:  MM/DD/YYYY

DATE OF DISCHARGE:  MM/DD/YYYY

PRIMARY DIAGNOSIS:  Community-acquired pneumonia.

SECONDARY DIAGNOSIS:  Bronchiolitis.

DISCHARGE MEDICATIONS:
1.  Ceftin 125 mg/5 mL at 6 mL p.o. b.i.d. for 7 days.
2.  Orapred 15 mg/5 mL, 1/2 teaspoon p.o. b.i.d. for 2 days.
3.  Albuterol premix nebs 0.083% via nebulizer q. 4-6 hours p.r.n. shortness of breath or wheezing.

DISCHARGE INSTRUCTIONS:  The patient was told to return to the emergency department if symptoms return or worsen prior to followup visit.

LABORATORY AND DIAGNOSTIC DATA:  CBC on admission showed a white count of 21,300, hemoglobin 12.8, hematocrit 37.2, and platelets 480,000. Basic metabolic panel on admission showed sodium 140, potassium 4.2, chloride 106, CO2 of 20, BUN 11, creatinine 0.2, and glucose 106. CBC prior to discharge; WBC 9500, hemoglobin 12.2, hematocrit 36.2, and platelets 456,000. UA was negative. Viral cultures for parainfluenza, adenovirus, and influenza virus were negative. RSV culture was negative. Chest x-ray revealed findings consistent with perihilar pneumonia, both sides, with infiltrate in the right middle lobe as well. Blood cultures were negative x2 days. Urine culture was negative x2 days.

HOSPITAL COURSE:  The patient is a (XX)-year-old Caucasian male with a history of reactive airway disease, who was brought to the ER with shortness of breath, wheezing, and retractions. The patient’s initial blood work showed elevated white count, and chest x-ray showed perihilar pneumonia. The patient was started on Rocephin IV at 50 mg/kg/day divided q. 12 hours and started also on Solu-Medrol IV and given albuterol and Atrovent breathing treatments. The patient’s condition continued to improve. O2 saturations improved. The patient was weaned from the Atrovent nebs to only albuterol nebs q. 4 hours and then weaned to q. 6 hours. The patient remained afebrile throughout the hospital course. The patient was hospitalized for a total of 3 days and was stable for discharge with the above medicines and followup instructions given.

Pediatric Discharge Summary Sample #2

DATE OF ADMISSION:  MM/DD/YYYY

DATE OF DISCHARGE:  MM/DD/YYYY

ADMISSION DIAGNOSIS:  Bronchiolitis.

DISCHARGE DIAGNOSES:
1.  Bronchiolitis.
2.  Dehydration.
3.  Hypoxia, resolved.

CONSULTANTS:  None.

PROCEDURES:  None.

HISTORY OF PRESENT ILLNESS:  Please see detailed history and physical. In brief, this is an approximately (XX)-month-old female, who was well until the day prior to admission, when she developed upper respiratory infection symptoms. These progressed to tachypnea, wheezing, and vomiting. She was evaluated in the office where she was found to be tachypneic and wheezing on physical exam. She vomited in the office and had vomited at home. She received a nebulizer treatment, which improved her somewhat, but she continued to retract and wheeze; therefore, it was felt that she would benefit from admission for further evaluation and management. Her history is significant in that she has an egg allergy by allergy testing, and her mother has a history of hay fever and asthma.

HOSPITAL COURSE (BY PROBLEM):
1.  Regular care and nutrition: The patient was placed on IV fluids D5 quarter-normal saline plus 20 mEq KCl per liter after the first void. This was to provide rehydration. The patient’s initial electrolytes revealed a sodium of 136, potassium 4.5, chloride 98, bicarb 18, BUN 17, creatinine 0.5, and glucose 106. After rehydration, electrolytes revealed a sodium of 139, potassium 4.7, chloride 102, bicarb 26, and therefore an improvement in metabolic acidosis. After a few hours without vomiting, she was placed on a clear liquid diet, and this was advanced as tolerated. The patient had no further emesis during the hospitalization and was tolerating a general diet at the time of discharge.
2.  Bronchiolitis/hypoxia: The patient was placed on pulse oximeter to monitor her oxygen levels. She was placed on as much as 1 liter of oxygen for decreased 02 saturation of 88%. The oxygen was discontinued on the second morning of hospitalization, and she was on and off of it periodically during the day. By the second morning of hospitalization, she had been off 02 completely for approximately 12 hours. During hospitalization, she was treated with Xopenex nebulizer treatments 1.25 mg per respiratory protocol. These were weaned to q. 4 hours, and the patient tolerated this well. The patient was also placed on Solu-Medrol 2 mg per kg IV bolus, then 2 mg per kg divided q. 6 hours. A trial of an anti-inflammatory medication and bronchodilator medication was given because of the parental history of asthma, and the child history of atopy, because of the potential for a good response. Indeed, the child responded nicely with resolution of retractions and wheezing by the second morning of hospitalization. The patient had initially been febrile on admission. The patient had no further fever after admission.

An influenza swab was negative. A chest x-ray was obtained, which revealed prominence of the perihilar bronchovascular markings and hyperinflation of the lungs suggestive of bronchiolitis. There were no consolidations or effusion seen. On the second morning of hospitalization, the patient’s IV came out. Because the patient had markedly improved, it was felt that the patient could be changed over to oral medication. The patient, therefore, received 1-1/2 teaspoon of Orapred, which she tolerated fine.

On the second day of hospitalization, by physical exam, the patient was mostly clear to auscultation. She was alert and happy and was eating well. She was very much improved. The mother was very happy. Because of her tolerance of a normal diet, her rehydration, and her resolution of hypoxia and wheezing, it was felt that she could be discharged to home in good condition.

Home nebulizer setup was ordered. The potential need for maintenance therapy with some inhaled steroid was discussed with the mother at the bedside. We felt that it might be the option for this patient because she clearly responded to medications, she had a family history of atopy, as well as food allergy, and she is unable to get the flu shot because of her egg allergy, and would therefore be subject to illness from influenza. The mother will give consideration to this.

In the meantime, she will be treated with Orapred approximately 2 mg/kg/day for 4 more days with 1/2 teaspoon to be given this evening and 1/2 teaspoon p.o. b.i.d. for 4 days more. The patient will also be placed on Xopenex 0.63 mg q. 4 to 6 hours p.r.n. cough or wheeze with the minimum of t.i.d. to q.i.d. and told to recheck on Friday in 2 days. Xopenex will be used since the patient was tachycardic during hospitalization, up to 160 to 170. The purposes of the medication as well as the pathophysiology of wheezing were discussed with the parent at the bedside. She voiced her understanding and agreement with the plan of therapy.

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