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Medical Transcription Pediatric Discharge Summary Transcribed Sample Report

DATE OF ADMISSION:  MM/DD/YYYY

DATE OF DISCHARGE:  MM/DD/YYYY

HISTORY OF PRESENT ILLNESS:  The infant is (XX) weeks' gestation appropriate for gestational age baby boy. Birth weight was 5 pounds 8 ounces.  Dr. John Doe is the OB.  Pediatrician is Dr. Jane Doe.  Mother is (XX) years old, gravida 4, para 3-0-0-3, O positive, serology negative.  Other prenatal labs negative.  Mother is group B strep unknown.  There was a history of previous C-section, but this time, it was a VBAC and delivered vaginally.  Apgars were 8 and 9.  Rupture of membrane was 5 hours prior to delivery.  No antibiotics were given during labor.  Infant was born with Apgar scores of 8 and 9 and then infant developed decreased perfusion, pale color, grunting, retractions, tachypnea.  The infant was brought to NICU and was placed on pulse oximeter.  Although the O2 saturations were okay on room air, the infant had increased work of breathing, grunting, retractions, respiratory rate was 70-80 breaths per minute, which increased to 90 breaths per minute.  The infant was admitted to NICU for further management.

PHYSICAL EXAMINATION:  On admission, respiratory rate of 70-80 per minute, grunting and retracting, increased work of breathing.  Lungs had occasional rales bilaterally, good air exchange.  Heart with regular rate and rhythm.  No murmur.  Pulses were normal.  Abdomen was soft.  No hepatosplenomegaly.  Mean arterial pressure was low in 20s.  Neurological exam was grossly normal.  Genitourinary exam was normal.  Preterm male, testes descended bilaterally.

LABORATORY DATA ON ADMISSION:  Chest x-ray had bilateral streaky infiltrates along with granularity consistent with moderate RDS.

DIAGNOSIS ON ADMISSION:
1.  A 35 weeks' gestation appropriate for gestational age male.
2.  Respiratory distress syndrome.
3.  Rule out sepsis.
4.  Rule out hypoglycemia.
5.  Hypovolemia secondary to low mean arterial pressure and metabolic acidosis.

The initial blood gas which was done, because of O2 saturations staying stable on room air, had base deficit of –6.  The parents were told regarding the sick status of the infant and management in NICU.

HOSPITAL COURSE:
1.  RDS.  The infant had significant respiratory distress.  Although initially O2 saturations remained stable on room air, saturations started to drift down and the infant had significant metabolic acidosis, which did not correct with a bolus of normal saline x2, so the infant had to be started on about 30% FiO2, which was weaned gradually.  The infant was given sodium bicarbonate bolus to fix the metabolic acidosis.  The infant continued on chest PT and suctioning, the respiratory distress gradually improved.  The infant was weaned to room air, and the pulse oximetry was discontinued and the problem was resolved after the respiratory rate had decreased to normal, O2 saturations were stable, and metabolic acidosis was resolved.
2.  Metabolic acidosis.  As above.  Base deficit started at –6, remained at –5 and –6 until after two boluses of normal saline and sodium bicarbonate was given and until the infant was started on FiO2, after which it resolved gradually.
3.  Rule out sepsis.  Workup was done secondary to respiratory distress.  Workup remained negative.  The infant was on ampicillin and gentamicin until 72-hour negative cultures, after which the antibiotics were stopped and the problem was resolved.
4.  Fluid, electrolytes, and nutrition.  Initially, the infant was NPO, on IV fluids.  TPN was started.  The infant was started on feeds slowly and was advanced to full feeds.  Currently, the infant is nippling all his feeds and nippling it well, voiding and stooling.
5.  Hyperbilirubinemia.  Bilirubin increased to 6.5 on day #1.  The infant was started on phototherapy.  Bilirubin further increased later on and then remained stable subsequently.  The phototherapy was discontinued.  Bilirubin stayed stable, so the infant was observed clinically.

The infant was in stable condition.  Vital signs were stable.  Heart, regular rate and rhythm.  No murmur.  Pulses were normal.  Abdomen was soft.  No hepatosplenomegaly.  Neurological exam, grossly good tone.  Genitourinary exam was normal male.  No circumcision was done.  Testes were descended bilaterally.

DIAGNOSIS ON DISCHARGE:
1.  A 35-week gestation appropriate for gestational age male.
2.  Respiratory distress syndrome, resolved.
3.  Sepsis, ruled out.
4.  Hypovolemia, resolved.
5.  Metabolic acidosis, resolved.
6.  Hypoglycemia was ruled out.
7.  Hyperbilirubinemia, resolved.

CONDITION ON DISCHARGE:  Stable.

PLAN ON DISCHARGE:  Follow up with Dr. Jane Doe in 1 week.

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