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5013 Samples in 40 Types as on 07/07/2023

Medical Specialty:
Discharge Summary

Sample Name: Neonatal Discharge Summary


Description:  The patient is an 1812 g baby boy born by vaginal delivery to a 32-year-old gravida 3, para 2 at 34 weeks of gestation. Mother had two previous C-sections.
(Medical Transcription Sample Report)

HOSPITAL COURSE: The patient is an 1812 g baby boy born by vaginal delivery to a 32-year-old gravida 3, para 2 at 34 weeks of gestation. Mother had two previous C-sections. Baby was born at 5:57 on 07/30/2006. Mother received ampicillin 2 g 4 hours prior to delivery. Mother came with preterm contractions, with progressive active labor in spite of the terbutaline and magnesium sulfate. Baby was born with Apgar scores of 8 and 9 at delivery. Fluid was cleared. Nuchal cord x1. Prenatal was at ABC Valley. Prenatal labs were O positive, antibody negative, rubella immune, RPR nonreactive. Baby was suctioned on perineum with good support. The baby was admitted to the NICU for prematurity and to rule out sepsis. Baby's cry was good. Color, tone, and __________ mild retractions. CBC, CRP, blood cultures were done. IV fluids of D10 at a rate of 6 mL an hour. Ampicillin and gentamicin were started via protocol. At the time of admission, the patient was stable on room air and has feeding issues. Baby was fed EBM 22 and NeoSure per os. Ampicillin and gentamicin were started per protocol but were discontinue when blood cultures came out negative after 48 hours. The patient continues on feeding issues, will not suck properly, was kept in the NICU, and put on OG tube for a couple of days after which p.o. feeds were advanced. Also, the baby was able to suck properly and was tolerating feeds. The baby was fed EBM 22 and NeoSure was added a day before discharge. At the time of discharge, baby was stable on room air, baby was tolerated p.o. foods and was sucking properly, was taking ad lib feeds and gaining weight.

ADMISSION DIAGNOSES: Respiratory distress, rule out sepsis and prematurity.

DISCHARGE DIAGNOSES: Stable, ex-34-week preemie.

Pediatrician after discharge will be Dr. X.

DISCHARGE INSTRUCTIONS: To follow up with Dr. X in 2 to 3 days, an appointment was made for 08/14/2006. CPR teaching was completed on 08/11/2006 to parents. Formula feeding schedule with breast and NeoSure 2 to 3 ounces per feed. Ad lib feeding on demand.

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Abscess with Cellulitis - Discharge Summary Anterior Cervical Discectomy & Fusion - Discharge Summary Back & Leg Pain - Discharge Summary Back Pain - Discharge Summary BRCA-2 mutation Bronchiolitis - Discharge Summary Cardiac Transfer Summary Cardio/Pulmo Discharge Summary Cellulitis - Discharge Summary Chest Pain & Respiratory Insufficiency CHF & Pleural Effusion - Discharge Summary Cholecystitis - Discharge Summary Cholestasis Of Pregnancy Chronic Abscesses - Discharge Summary Cognitive Linguistic Impairment - Discharge COPD - Discharge Summary COPD & Bronchitis - Discharge Summary CVA - Discharge Summary D&C - Discharge Summary Death Summary Death Summary - 1 Death Summary - 2 Discharge Summary Discharge Summary - 1 Discharge Summary - 10 Discharge Summary - 11 Discharge Summary - 12 Discharge Summary - 13 Discharge Summary - 14 Discharge Summary - 15 Discharge Summary - 16 Discharge Summary - 17 Discharge Summary - 18 Discharge Summary - 19 Discharge Summary - 2 Discharge Summary - 3 Discharge Summary - 4 Discharge Summary - 5 Discharge Summary - 6 Discharge Summary - 7 Discharge Summary - 8 Discharge Summary - 9 Discharge Summary - ATV Accident Discharge Summary - Cerebral Palsy Discharge Summary - Cholelithiasis Discharge Summary - COPD Discharge Summary - Gastric Bypass Discharge Summary - Hemodialysis Discharge Summary - Hip Surgery Discharge Summary - Lymphoma Discharge Summary - Mesothelioma Discharge Summary - Mesothelioma - 1 Discharge Summary - Migraine Discharge Summary - Multiple Trauma Discharge Summary - Nephrology Discharge Summary - Peripheral vascular disease Discharge Summary - Respiratory Distress Discharge Summary - Respiratory Failure Discharge Summary - Urology Discharge Summary - Urology & Nephrology Ectopic Pregnancy - Discharge Summary ER Report - Chest Pain & Fever ESRD - Discharge Summary Falls - Discharge Summary Gastric Bypass Summary Gastroenteritis - Discharge Summary Gastrointestinal Bleed - Discharge Summary GI Bleed - Discharge Summary Goldenhar Syndrome - Discharge Summary Hemiarthroplasty - Discharge Summary Hip Surgery - Discharge Summar Hypothermia - Discharge Summary Hysterectomy - Discharge Summary Hysterectomy - Discharge Summary - 1 Hysterectomy - Discharge Summary - 2 Intrauterine Pregnancy - Discharge Summary Kawasaki Disease - Discharge Summary Knee Arthroplasty - Discharge Summary Knee Osteoarthrosis - Discharge Summary Knee Surgery - Discharge Summary Lap Chole - Discharge Summary Laryngitis - Discharge Leiomyosarcoma Mastoiditis - Discharge Summary Mullerian Adenosarcoma Multiple Medical Problems - Discharge Summary Neck Pain - Discharge Summary Neonatal Discharge Summary Neonatal Discharge Summary - 1 Neurology - Discharge Summary Occupational Therapy Discharge Summary ORIF - Discharge Summary Otitis Media - Discharge Summary Pancreatic Mass - Discharge Summary Pneumonia - Discharge Summary Pneumonia & COPD - Discharge Summary Post Thyroidectomy - Discharge Summary Prematurity - Discharge Summary Psychiatric Discharge Summary Psychiatric Discharge Summary - 1 Psychiatric Discharge Summary - 2 Pyelonephritis - Discharge Summary Renal Disease - Discharge Summary Speech Therapy - Discharge Summary Speech Therapy - Discharge Summary - 1 Speech Therapy - Discharge Summary - 2 TAH - Discharge Summary Urology Discharge Summary
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Keywords: discharge summary, gestation, preemie, prematurity, sepsis, neosure, feeds, born, delivery, perineum, discharge,