PEDIATRICIAN: Dr. Jane Doe

OBSTETRICIAN: Dr. Jeff Doe

CHIEF COMPLAINT: Prematurity, 35-week twin gestation, RDS.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old gravida 2, para 1, full term 1, living 1, mother who presented with contractions and leg swelling. Her EDC was MM/DD/YYYY. She received prenatal care with Dr. (XX) for monochorionic diamniotic twin gestation. A primary C-section was done for maternal ITP. Twin B was footling breech and velamentous cord. The mother received spinal anesthesia. AROM was clear at delivery. Maternal blood type is O positive. The antibody screen is negative. HIV negative. Hep B negative. RPR nonreactive. She denies HSV. She is rubella immune. GBS unknown. Positive PPD with negative chest x-ray. Baby girl (XX) twin B was received by the ALS team, noted to have cyanosis with grunting and retracting. Please see ALS note. The infant was admitted to the NICU, placed on nasal CPAP of plus 5 and weaned to 25% FiO2. UAC and UVC catheter were placed by the ALS RN. Birth weight 2635 g, head circumference 39.5 cm, length 47.5 cm. Glucose was 42 and the followup was 51.

ADMISSION VITAL SIGNS: Axillary temp 36.1, heart rate 170, respiratory rate 60, BP was 46/40 with a mean of 44.

PHYSICAL EXAMINATION:
HEAD, EYES, EARS, NOSE, AND THROAT: Anterior fontanelle is soft and flat. Bilateral red reflex is seen. Palate is intact. Nares appear patent. Ears are grossly normal.
CARDIOVASCULAR: Heart rate is regular rate and rhythm with no murmur audible. Pulses are 2+ and equal in 4 extremities. Cap refill is 2 to 3 seconds. The infant is noted to be plethoric.
RESPIRATORY: Bilateral breath sounds are equal and coarse. Substernal retractions on nasal CPAP are noted.
GASTROINTESTINAL: Abdomen is soft, nondistended, with positive bowel sounds. There is a 3-vessel cord. No hepatosplenomegaly or masses are felt.
GENITOURINARY: Female genitalia. The anus is patent.
MUSCULOSKELETAL: The spine is intact. There are no hip clicks.

IMPRESSION:
1. A 35-week twin B female.
2. Respiratory distress syndrome (RDS).
3. Suspected sepsis.

PLAN:
1. Wean CPAP as tolerated. Obtain chest x-ray and follow up ABG.
2. CBC, blood culture on admission, AMP and CEF. Follow up CBC and CRP in a.m.
3. UAC half normal saline, 1 unit of heparin per mL at 1 mL an hour.
4. UVC 200 D10W with 200 mg of calcium gluconate per 100 and 0.5 units of heparin per mL at 8 mL an hour for total fluids of 80 mL per kilo per day.
5. BMP and bili in a.m.
6. The father of the baby was updated at the bedside on infant’s condition and plan of care.

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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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OBJECTIVE:  The patient is a healthy-looking young woman. Blood pressure is 112/72. Temperature is 97.8. HEENT: Both tympanic membranes are clear. Both conjunctivae are clear. Nose: Clear. There is no tonsillopharyngeal redness. There is no neck gland enlargement and neck is supple. Chest and Lungs: Clear. No rales. No rhonchi. No wheezing. Heart: Normal. Regular rhythm and no murmurs. Abdomen: Flat and soft, no hepatosplenomegaly.

ASSESSMENT:
1.  Costochondritis.
2.  Most probable dehydration, explains the dizziness and nausea and headache yesterday and the day before when the temperature was very hot outside.

PLAN:  The patient was advised to make sure that she gets enough water. She will take Motrin or any ibuprofen preparation for the chest pain. She will observe whether the pins and needles in both fingers recur. We asked her to take a multivitamin.

SUBJECTIVE:  The patient has been coughing intermittently for a week now. When he coughs, it is continuous. He sounds very croupy. He did not have any fever. Otherwise, he feels fine. Last night, started with stuffy nose. The patient takes albuterol p.r.n. and Flovent. For the past few days, mom has been administering both the Flovent and albuterol. He was never diagnosed as severely asthmatic.

OBJECTIVE:  The patient is ambulatory. He appears well. He is not in any acute distress. Temperature is 98.4. He weighs 64 pounds. He is up and about. His cough is dry. HEENT: Both tympanic membranes are clear. Both conjunctivae are clear. Nose is clear. Mouth is clear. There is no neck mass. Chest and Lungs: Symmetric. Good air entry and clear breath sounds. Heart: Normal. Abdomen: Benign.

ASSESSMENT:  Cough for about a week, most likely viral, could be allergic in nature.

PLAN:  We have reassured mom that his examination is normal. We would wait about several days. He has an appointment on Tuesday, and we think that would just be right to evaluate him. Otherwise, if he develops a fever, mom will call.

SUBJECTIVE:  The patient has had sore throat, dysphagia, and halitosis for about one day. He has had congestion and coryza without cough for about one week. There has been no fever, headache, earache, chest pain, dyspnea, wheezing, stomach ache, nausea, vomiting, or diarrhea.

OBJECTIVE:  Temperature is 97.4 orally. Weight is 90 pounds. In general, he looks well without significant distress. Tympanic membranes are clear bilaterally without any redness or pus. He had a slight nasal congestion with red mucosa. Oropharynx reveals red tonsils and palate without any exudate. Bilateral tender anterior cervical nodes. Lungs are clear to auscultation with good breath sounds. No rales, rhonchi, or wheezes. Cardiovascular: Regular rate and rhythm. No murmur. Abdominal exam was normal.

LABORATORY DATA: Rapid strep test was positive.

ASSESSMENT:
1.  Strep pharyngitis.
2.  Allergic rhinitis.

PLAN:
1.  Penicillin 250 mg p.o. t.i.d. for 10 days.
2.  Change his toothbrush in three days.
3.  He will be contagious for 24 hours, though can go back to school in two days if he is feeling well.
4.  Anyone he has been in contact with that has a sore throat should see their physician.

SUBJECTIVE:  The patient was seen a few weeks ago for pneumonia, thought to be mycoplasma, and treated with azithromycin. At that time, we were not sure if the wheezing was related to the infection or perhaps early asthma, but he got better. He had a cold for a few days and started wheezing two days ago. That night, he was taken to the emergency room where he had significant wheezing but responded to a nebulizer. They sent him home with a Ventolin HFA and AeroChamber, but he was unable to do it effectively and mom switched to his cousin’s nebulizer, an albuterol solution, which was much better than that. He seems to be doing a lot better now and only has some significant congestion and occasional cough. He is otherwise well.

OBJECTIVE:  Temperature is 97.4. Weight is 40 pounds. In general, he is well, happy, and active. There is no respiratory distress worsened with coughing. Tympanic membranes are normal bilaterally. He had a clear nasal discharge with red mucosa. There was no neck adenopathy. Lungs were clear to auscultation. Good breath sounds. There were no rales, rhonchi, or wheezing. Cardiovascular: Regular rate and rhythm, no murmur. Abdominal exam was normal.

ASSESSMENT:
1.  Reactive airways disease, responding well to nebulized albuterol.
2.  Upper respiratory tract infection.

PLAN:
1.  We gave him a prescription for albuterol solution, and he is to use one ampule every four hours until we see him again.
2.  We also gave them a nebulizer with tubing so that he would have his own rather than using his cousin’s.
3.  Follow up in five days, at which point we will begin to taper his nebulizer if he is doing well.

SUBJECTIVE:  Dad has noted a rash on the patient since Friday. She did not have any fever and no upper respiratory symptoms. Rash is raised, small and itchy. Dad has been giving her Benadryl.

OBJECTIVE:  The patient is alert, awake, and not in any distress. HEENT: Both tympanic membranes are clear. Both conjunctivae are clear. Nose: Clear. Mouth is clear, and there is no redness of the pharynx. There is no neck gland enlargement. Chest and Lungs: Clear. Heart: Normal. Abdomen: Benign. There is a rash on the trunk. These are raised, slightly erythematous papules, very fine and almost have a sandpaper feel to it. The upper extremities are also a little bit involved, but none on the lower extremities.

ASSESSMENT:  Fine papular, slightly erythematous rash on the trunk. Cannot rule out the possibility of strep. Could be viral. Could be allergic in nature.

PLAN:  Rapid strep test and throat culture will be done to rule out the possibility of strep. If it is negative, management will be only the use of Benadryl or Zyrtec since this is only once a day. We also gave dad a sample of Eucerin anti-itch cream.

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DATE OF DISCHARGE:  MM/DD/YYYY

DISCHARGE DIAGNOSES:
1.  Asperger syndrome.
2.  Bipolar disorder.
3.  Syncopal episode, now resolved.

CONSULTANTS:
1.  Jane Doe, MD, Psychiatry
2.  John Doe, MD, Neurology

PROCEDURES PERFORMED:
1.  Electroencephalogram.
2.  MRI of the head.
3.  Echocardiogram of the heart.

BRIEF HISTORY OF PRESENT ILLNESS:  This is the second admission in the last several days for this (XX)-year-old Hispanic male with a history of Asperger syndrome and some behavioral problems, including bipolar disorder, for which he has been on psychotropic medications. He was recently hospitalized with lethargy and elevated valproic acid level, in the 250 range. During his hospital stay at that time, his valproic level had dropped to 82, he was tolerating feeds, and therefore was discharged home. When he got home later that evening, he received his usual dose of 600 mg of Seroquel in the evening but was later found by his father to be lethargic, diaphoretic, and complaining of excessive tiredness. Therefore, the patient was brought back into the emergency department.

The patient was tachycardic on arrival to the ED, but his vital signs were otherwise stable. He was given 1 liter of normal saline bolus at the time, and an EKG was done, which revealed a normal sinus rhythm with a QTc of 396 milliseconds and QRS duration was 84 milliseconds.

LABORATORY DATA:  Initial laboratory data showed a white count of 3200, which is up from his prior admission, hemoglobin of 12.2, hematocrit of 36.2, and platelets of 194,000 with 36 segs, 6 bands, 35 lymphocytes, 16 monocytes, and 4 lymphocytes. Basic metabolic panel was unremarkable. CPK was 110. The valproic level was 26. Urine toxicology screen was positive for tricyclics, but this is not unexpected since the patient is on Seroquel.

HOSPITAL COURSE:  The patient was admitted to the pediatric progressive care unit for neurologic and cardiac monitoring. An echocardiogram done of the heart revealed normal cardiac anatomy and function with trace tricuspid, pulmonary, and mitral regurgitation. Neurology was consulted, and an EEG and MRI of the brain were done, with the EEG being normal for age and MRI negative for any pathology. Further lab tests were also done, which included an ESR level. TSH was normal. ANA was negative and anti-RNP antibody was also negative. B12 level was slightly elevated at 1268.

IV fluids were given to the patient on his arrival to the floor. The patient continued to do well and was later able to be transferred to a regular medical bed on the peds floor. Psychiatry was consulted, and adjustments were made to his psychotropic medication. The Depakote was initially held at the time of admission but later restarted. The Seroquel evening dose was decreased from 600 mg to 300 mg, per Psychiatry recommendations. Trileptal was also discontinued during his hospital stay.

The patient continued to do well without further complaints of weakness, dizziness, near syncopal episodes or lethargy. The patient tolerated p.o. well and ambulated without difficulty.

DISCHARGE MEDICATIONS:  The patient is to be discharged home on the following medications:
1. Seroquel 25 mg p.o. q.a.m., Seroquel 50 mg p.o. q.p.m. at 1700 hours, Seroquel 300 mg p.o. nightly.
2. Depakote ER 500 mg SR tablets p.o. daily.
3. Prozac 10 mg p.o. daily.
4. Clonidine 0.1 mg p.o. q.a.m., clonidine 0.05 mg p.o. daily at 1300 hours.

DISCHARGE INSTRUCTIONS:  The patient is to follow up with the psychiatrist in one week.

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