Pediatric Discharge Summary Medical Transcription Sample Report for MTs

DATE OF ADMISSION:  MM/DD/YYYY

DATE OF DISCHARGE:  MM/DD/YYYY

ADMITTING DIAGNOSES:

1.  A 28-week gestational male, twin A.
2.  Discoordinate twin.
3.  Intrauterine growth restriction.
4.  Prolonged premature rupture of membranes.
5.  Respiratory depression.
6.  Hypotonia secondary to magnesium therapy.

DISCHARGE DIAGNOSES:  Per discharging physician.

REASON FOR ADMISSION:  Respiratory depression requiring intubation.

HISTORY OF PRESENT ILLNESS:

This patient is the twin A of a 28-week gestation twin pregnancy of a (XX)-year-old prima gravida with an estimated date of confinement of MM/DD/YYYY, which gives an estimated gestational age of 28 weeks. Mother is blood type O positive, hepatitis B, gonorrhea, Chlamydia, HIV and VDRL negative. Pregnancy was complicated with twin gestation with one discoordinate twin; this is the undergrown baby. The mother had rupture of membranes on MM/DD/YYYY, approximately 20:30 in the evening. Estimated fetal weight was approximately 910 grams. Mother was admitted to the hospital and treated with tocolysis with magnesium sulfate and terbutaline as well as antibiotic prophylaxis on ampicillin and erythromycin. She did complete a full course of betamethasone on MM/DD/YYYY. She continued to progress in labor despite tocolytics, and it was elected to allow her to continue to delivery. Cesarean section was done secondary to a breech presentation. Apgar scores were 4 at one minute and 7 at five minutes. In the delivery room, the baby was noted to be very slim with poor tone and poor respiratory effort. The color did not improve with oxygen and stimulation. There was a short course of mask CPAP followed quickly by elective intubation with a 2.5 endotracheal tube. Following intubation, the color and activity did improve and the infant was transported to the neonatal intensive care unit.

PHYSICAL EXAMINATION:  On admission revealed a grossly normal-appearing, undergrown, preterm male with respiratory failure. Birth weight was 790 grams. Birth length was 34 cm.  Birth head circumference was 23.4 cm, which is AGA for gestational age. Vital Signs:  Pulse 120, respirations 60, blood pressure 61/33 and temperature 35.1. Skin was pink with acrocyanosis. HEENT is normocephalic. Anterior fontanelle is open and soft, features normal. Eyes, ears, nose and mouth appear grossly normal. Red reflex bilaterally. Neck appears normal with no visible masses. Chest symmetrical with diminished breath sounds bilaterally. Few rales noted. Cardiovascular:  Regular rate and rhythm. No murmurs. Peripheral pulse is palpated. Abdomen had three-vessel cord. Positive bowel sounds. No palpable organomegaly or mass. GU is normal male with testes present but not descended to the scrotum, which is appropriate for gestational age. Anus appeared patent. Musculoskeletal:  No obvious deformation or abnormalities noted. Neurologic:  The patient is responsive with symmetrical movements and moderate tone.

HOSPITAL COURSE BY SYSTEMS:
1. NEUROLOGIC:  Cranial ultrasound performed on MM/DD/YYYY showed a small left subependymal hemorrhage with no intraventricular hemorrhage. This was repeated on MM/DD/YYYY, which showed a small left subependymal hemorrhage that was resolving. Eye examination performed on MM/DD/YYYY showed some immature vessels into zone II. This was repeated on MM/DD/YYYY by Dr. Doe, which showed the immature vessels into zone II and no retinopathy of prematurity noted. This will be followed up in approximately two weeks to reevaluate. Hearing screen is pending. Clinically, the child has remained neurologically stable with good tone, good activity, moving all extremities, and no abnormalities have been noted to date.

2. CARDIOVASCULAR:  Echocardiogram on MM/DD/YYYY revealed a patent ductus arteriosus. This was followed with indomethacin x3 doses. Repeat echocardiogram on MM/DD/YYYY showed no patent ductus arteriosus and resolution. The child did have some initial hypotension, which required dopamine, which was initiated on MM/DD/YYYY and continued through MM/DD/YYYY; the last several days being very low dose dopamine to increase renal perfusion. The pressure has stabilized with good perfusion and cardiovascularly stable. However, on MM/DD/YYYY, murmur was again auscultated on the left upper and lower sternal borders. Repeat echocardiogram revealed a very large patent ductus arteriosus with enlargement of the left atrium. Please see that dictation. Due to the previous Indocin therapy failure, it was elected to have PDA ligation. This was performed on MM/DD/YYYY by Dr. Doe. Please see his dictation. Following that procedure, the infant had some hypotension requiring dopamine, low dose. This was slowly increased over the next following two or three days. By MM/DD/YYYY, dobutamine was added secondary to decreasing pressures. Epinephrine was kept at the bedside; however, it was never used. Dopamine and dobutamine were continued until MM/DD/YYYY at which time they were weaned off, and the child has maintained pressure since that time with good clinical examination and blood pressure remaining 36-48.

3. RESPIRATORY:  The infant was intubated in the delivery room secondary to respiratory depression. The infant has remained ventilated to this date. Originally, on SIMV conventional, was switched to a jet ventilator on MM/DD/YYYY and back to conventional SIMV on MM/DD/YYYY. Has remained on this mode since that time. Initial venous blood gas obtained on the day of admission was pH of 7.32, pCO2 50, pO2 of 52, bicarbonate 28.1 and base excess of 2.1. Blood gas prior to changing to the jet ventilator was pH 7.21, pCO2 of 74, pO2 65, bicarbonate 27.1, and base excess -0.3. Following the jet ventilator, switching back to conventional, pH was 7.24, pCO2 of 44, pO2 of 51, bicarbonate 19.9, and base excess -6.6. The infant has continued to require significant ventilatory support and has been somewhat problematic with elevated pCO2; however, has been maintained on adequate oxygenation over that time. This is thought to be secondary to the BPD this child would obviously be developing secondary to its premature age of birth and the prolonged exposure to the ventilator and oxygen. Following admission to the NICU, there were two doses of Curosurf that were administered shortly after admitted to the NICU. Several episodes of apnea and bradycardia were noted. Early on the course, there had been no apnea or bradycardia noted, in the last approximately 25 days. At the time of this dictation, the infant is currently on SIMV pressure support. Peak inspiratory pressure of 25. Post end expiratory pressure of 6, pressure support of 14, rate of 38. Latest capillary blood gas shows a pH of 7.30, pCO2 64, pO2 34, bicarbonate 31.5, and a base excess of 5.6 and a FiO2 of 50%. The remainder of the ventilatory course will be addressed by the discharging physician.

4. INFECTIOUS DISEASE:  Blood culture was obtained on the date of admission; shows no growth. Ampicillin and gentamicin were initiated on the admission as well and discontinued at 48 hours secondary to negative cultures. On MM/DD/YYYY, endotracheal aspirate was obtained, which showed heavy growth of Enterobacter cloacae. Cefotaxime antibiotic was initiated. A repeat of the endotracheal aspirate on MM/DD/YYYY revealed heavy growth of Enterobacter cloacae that was resistant to cefotaxime, and at that time, gentamicin was added for synergism. A repeat endotracheal aspirate on MM/DD/YYYY continued to show the persistence of Enterobacter cloacae with sensitivity to cefotaxime, gentamicin and cefepime. It was elected to treat with monotherapy cefepime, and this is most likely due to colonization of the endotracheal tube. Dr. Doe of Infectious Disease was consulted and has been following the patient. Blood culture on MM/DD/YYYY with no growth. Blood culture from MM/DD/YYYY revealed Candida parapsilosis. Amphotericin B was initiated. The infant tolerated the trial dose, and treatment dose was initiated the following day, on MM/DD/YYYY. The amphotericin was continued until MM/DD/YYYY at which time it was discontinued. Repeat blood culture on MM/DD/YYYY revealed Candida parapsilosis. Blood culture from MM/DD/YYYY with no growth. It was of this blood culture that the time frame for discontinuing the amphotericin B was established. On identification of the candidemia, a spinal tap was performed with cerebrospinal fluid for culture, which was plated on MM/DD/YYYY. There was no growth and no fungus isolated. Cefepime therapy was continued for the Enterobacter until MM/DD/YYYY at which time it was discontinued. At the time of this dictation, the patient is currently on no antibiotics.

5. HEMATOLOGY:  The patient’s blood type is O positive, Coombs negative. The infant was noted early on in the admission to be jaundiced. Phototherapy was initiated on MM/DD/YYYY and discontinued on MM/DD/YYYY. Peak bilirubin was 7.1 mg/dL. The last bilirubin obtained, MM/DD/YYYY, showed a total bilirubin of 3.8, conjugated 2.3, and unconjugated 1.4. The infant has been anemic on several occasions and has received four transfusions of packed red blood cells on MM/DD/YYYY, MM/DD/YYYY, MM/DD/YYYY and MM/DD/YYYY. Initial CBC on MM/DD/YYYY showed a white blood cell count of 4.5, hemoglobin of 17.4, hematocrit of 51.1, and platelets of 202,0000. Following identification of the candidemia, the infant had a marked thrombocytopenia. On MM/DD/YYYY, the CBC showed a white count of 3800, hemoglobin 12.1, hematocrit 34.7, and platelets 27,000. This decreased to the low on MM/DD/YYYY, which showed 12,000 platelets. The child received three transfusions of platelets during this time, which slowly increased the platelets. The final CBC obtained MM/DD/YYYY to date showed a white count of 7700, hemoglobin 13.2, hematocrit 37.4 and platelets at 49,500. Differential; polymorphonuclear cells 50%, bands 2%, lymphocytes 42%, and monocytes 6%. The anemia this child has developed is most likely secondary to prematurity and iatrogenic blood draws. No other hematologic source had been identified to date.

6. HEALTHCARE MAINTENANCE:  Birth weight was 790 grams, birth head circumference was 23.4 cm, and birth length was 35 cm. The patient was initially NPO with IV fluids and D10W. TPN was initiated on MM/DD/YYYY and has been continued to date. Enteral feeds of premature infant male via NG tube were started on MM/DD/YYYY. They have been slowly increased until the PDA ligation at which time the infant was NPO for several days. Enteral feeds were again reinitiated on MM/DD/YYYY and it has slowly been increased. At the date of this dictation, the infant is currently on 13 mL q.3 h. and tolerating well. Nippling has not been attempted to date secondary to endotracheal tube.

IMMUNIZATIONS:  Per discharging physician.

PROCEDURES:  Umbilical artery catheter and umbilical venous catheter were inserted on MM/DD/YYYY and discontinued on MM/DD/YYYY. PDA ligation was performed on MM/DD/YYYY.

DISCHARGE PLAN WITH DISPOSITION:  Per discharging physician.


DATE OF ADMISSION:  MM/DD/YYYY

DATE OF DISCHARGE:  MM/DD/YYYY

ADMITTING DIAGNOSES:

1.  Intrauterine pregnancy at 36 weeks.
2.  Twin gestation.
3.  Breech presentation of twin A.

DISCHARGE DIAGNOSES:
1.  Intrauterine pregnancy at 36 weeks.
2.  Twin gestation.
3.  Breech presentation of twin A.
4.  Status post primary low transverse cesarean section for malpresentation of twins.

CHIEF COMPLAINT:  At the time of admission, contractions.

HISTORY:  The patient is a (XX)-year-old gravida 1 at 36 weeks with known twins with contractions and good fetal movement, no bleeding, no loss of fluids.

OB HISTORY:  Present pregnancy with previous receipt of a steroid window.

GYN HISTORY:  Significant for chlamydia, which was treated.

MEDICAL HISTORY:  Unremarkable.

MEDICATIONS:  Prenatal vitamins.

ALLERGIES:  None.

SURGICAL HISTORY:  None.

SOCIAL HISTORY:  No drinking, smoking or drug use. No domestic violence. The father of the baby is currently involved, and the patient is living with a friend.

PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature is 36.2, pulse 88, respirations 18 and blood pressure 121/58.
HEART:  Regular rate and rhythm.
LUNGS:  Clear.
ABDOMEN:  Soft and gravid.
VAGINAL:  Exam 4, 100 and bulging bag of water.
Baby A had tones in the 130s plus accels, no decels. Baby B had tones in the 150s with accels and no decels. Tocometer showing every 5-minute contractions. The plan was to admit the patient and proceed with cesarean section.

HOSPITAL COURSE:  Postoperatively, the patient did well. She was eating, ambulating and voiding, passing gas by postoperative day #2, and on postoperative day #3, she continued to do well. She had been seen by Social Work and options made aware to the patient. She was ready for discharge. She remained afebrile throughout her hospital course.

DISCHARGE INSTRUCTIONS:  She will be discharged to home to follow up in two weeks for a wound check.

MEDICATIONS AT THE TIME OF DISCHARGE:  Percocet, Motrin and Colace.

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DATE OF ADMISSION:  MM/DD/YYYY

DATE OF DISCHARGE:  MM/DD/YYYY

BRIEF HISTORY:
The infant was born approximately 11:00 a.m. on MM/DD/YYYY to her (XX)-year-old gravida 4, para 4, abortion 0, O positive mother. EDC was MM/DD/YYYY. There was no premature rupture of membranes. Amniotic fluid was clear. Delivery was by C-section because of repeat C-section. Spinal anesthesia was used. Apgars were 9 and 9. Upon arrival at the nursery, gestational age was 39 weeks by dates, 39 weeks by exam. Birth weight was 6 pounds 2 ounces or 2780 grams. Length was 18.5 inches or 47 cm. OFC 32 cm. 

PHYSICAL EXAMINATION:  On admission revealed a term appropriate for gestational age infant with milia, salmon patches over the eyes and speckles over the glabella and the philtrum, 1.4 cm breast buds bilaterally. No Epstein pearls. Hips within normal limits.

HOSPITAL COURSE:  Throughout hospitalization, the infant did well. The infant was bottle fed and was taking about 2 ounces per feed upon discharge. The infant was not gaining weight with a discharge weight of 5 pounds 16 ounces. There was jaundice noticed during hospitalization. Mother's blood type was O positive. The infant's blood type was A positive with weakly positive direct Coombs. Bilirubin level on MM/DD/YYYY came back 7.6. Bilirubin level on MM/DD/YYYY came back 8.3. The infant did not appear to be becoming any more jaundiced and no further bilirubin level levels were done. Mother did have a car seat available upon release. The infant had passed her hearing screen. The infant had received the hepatitis B vaccine on MM/DD/YYYY. Mother was released on MM/DD/YYYY. Discharge physical exam of the infant was unremarkable and it was felt that the infant could be released to her mother. 

DISCHARGE DIAGNOSES: 

1.  Term newborn female. 

2.  ABO incompatibility with positive direct Coombs. 

3.  Hyperbilirubinemia. 

4.  Salmon patch. 

5.  Milia. 

6.  Not gaining weight. 

7.  Hearing screen passed. 

8.  Hepatitis B vaccine given. 

DISPOSITION:  The infant was released to her mother. Mother is to call me if she had any problems or appeared to be becoming any more jaundiced. Mother was to bring her back in two days for the nursery nurses to recheck her and bring her back to my office in about a week for me to check. If there are any problems before that time, she is to get in touch with me by phone.





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