Pediatric Discharge Summary Transcribed MT Sample Report
DISCHARGE DIAGNOSES:
1. Term female infant, newborn.
2. Transient tachypnea of the newborn, resolved.
3. Jaundice.
HISTORY OF PRESENT ILLNESS: This is a (XX) and (XX) weeks' gestation female infant born on MM/DD/YYYY at (XX) hours. Mother is (XX) years old, gravida 2, para 1, AB 1, blood type B positive, GBS negative, hepatitis B surface antigen negative, rubella immune, VDRL nonreactive. Mother had a history of abnormal quad screen during this pregnancy. Amniocentesis was normal. Membranes ruptured artificially 10 hours prior to delivery with clear fluid. Infant delivered by C-section for failure to descend. Mother did receive ampicillin, gentamicin, and clindamycin prior to delivery for elevated maternal temperature. Apgar scores were 8 and 8 at one and five minutes respectively. The infant was given mask CPAP with oxygen for positive pressure ventilation due to respiratory distress with subcostal retractions and persistent cyanosis. The infant was admitted to special care nursery due to persistent retractions and mild hypoxia.
PHYSICAL EXAMINATION: VITAL SIGNS: On admission, weight 3660 grams, length 53 cm, head circumference 33.2 cm. Temperature 99.5, pulse 144, respiratory rate 48, blood pressure 68/42. GENERAL: Nutrition status good. Term infant. HEENT: Anterior fontanelle soft. Mucosa moist and pink. Caput noted. NECK: No masses. LUNGS: Normal AP chest diameter and expansion. No asymmetry. Clear auscultation. Subcostal retractions. HEART: Normal S1 and S2. No murmur. ABDOMEN: No masses. No hepatosplenomegaly. Normal bowel sounds. Normal umbilical cord. GENITOURINARY: Normal female external genitalia. MUSCULOSKELETAL: Normal strength and tone for age. EXTREMITIES: Warm, no edema. NEUROLOGIC: Normal behavior for age and condition. No abnormal movements. SKIN: No lesions.
HOSPITAL COURSE AND TREATMENT:
1. Term female infant. Hepatitis B vaccine deferred. Hearing screen OAE passed bilaterally. Newborn screen drawn after 24 hours of age. Infant breast and bottle feeding with adequate output.
2. Transient tachypnea of the newborn, resolved. The infant presented with persistent retractions and mild hypoxia after C-section delivery. Chest x-ray consistent with retained fluid. The infant was placed on nasal cannula oxygen. Oxygen weaned to room air within 24 hours. Respiratory status also normalized within 24 hours. CBC was done on initial presentation. White count of 41,000, normal differential, H and H of 19.5 and 56.8, platelet count 354,000. Blood culture drawn, negative for 48 hours.
3. Jaundice. The infant was noted to be mildly jaundiced on the day of discharge. Bilirubin level was 6.6 at approximately 60 hours of life, which is in the low risk zone.
PHYSICAL EXAMINATION AT DISCHARGE: VITAL SIGNS: Discharge weight of 3540 grams. GENERAL: Nutrition status good. HEENT: Anterior fontanelle soft. Mucous membranes moist and pink. Mild molding, gradually resolving. Still with mild facial edema, gradually resolving. Red reflex present bilaterally. NECK: No masses. LUNGS: Breath sounds are clear. Good aeration. No retractions. CARDIOVASCULAR: Regular rate and rhythm. No murmur. ABDOMEN: No masses. No hepatosplenomegaly. Normal bowel sounds. Umbilical cord drying. GENITOURINARY: Normal female external genitalia. EXTREMITIES: Warm without edema. No hip clicks. SKIN: No lesions. Mild jaundice of the face and chest. A few Mongolian spots over the buttock areas. NEUROLOGIC: Normal behavior for age and condition. No abnormal movements. Normal tone and strength for age.
DISCHARGE INSTRUCTIONS:
1. Follow up with Dr. Doe within 48 hours.
2. Ad lib feeding by breast and bottle. Monitor output, supplement as needed.
3. Monitor jaundice, mother counseled.
4. Consider hepatitis B vaccine series.
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