5-1 Disscussion

image1.jpg

Global Care Medical Center

100 Main St, Alfred NY 14802

(607) 555-1234

Hospital No. 999

Inpatient Face Sheet

Patient Name and Address

Gender

Race

Marital Status

Patient No.

WEST, KEITH

417 RUSH ROAD

ALMOND, NY 14804

M

W

S

IPCase010

Date of Birth

Age

Maiden Name

Occupation

05/23/YYYY

8 mo

N/A

N/A

Admission Date

Time

Discharge Date

Time

Length of Stay

Telephone Number

02-09-YYYY

15:55

02-11-YYYY

1300

02 DAYS

(607)000-8107

Guarantor Name and Address

Next Of Kin Name and Address

WEST, KEN

417 RUSH ROAD

ALMOND, NY 14804

WEST, KELLY

417 RUSH ROAD

ALMOND, NY 14804

Guarantor Telephone No.

Relationship to Patient

Next of Kin Telephone Number

Relationship to Patient

(607)000-8107

Father

(607)000-8107

Mother

Admitting Physician

Service

Admit Type

Room Number/Bed

Fred Moore, MD

N/A

N/A

331

Attending Physician

Admitting Diagnosis

John Black, MD

BRONCHIOLITIS / CROUP

Primary Insurer

Policy and Group Number

Secondary Insurer

Policy and Group Number

Blue Cross of WNY

76894567-900

N/A

N/A

Diagnoses and Procedures

ICD Code

Principal Diagnosis

Bronchiolitis with fever

Secondary Diagnoses

Principal Procedure

Croup tent with nebulizer

Secondary Procedures

Discharge Instructions

Activity: ( Bed rest ( Light ( Usual ( Unlimited ( Other:

Diet: ( Regular ( Low Cholesterol ( Low Salt ADA ( Soft

Follow-Up: (Call for appointment ( Office appointment on Recheck in one week.

Special Instructions:

Attending Physician Authentication:

Reviewed and Approved: John Black MD

ATP-B-S:02:1001261385: John Black MD

(Signed: 02/09/YYYY 04:20:44 PM EST)

WEST, KEITH

IPCase010

Dr. BLACK

Admission:02/09/YYYY

DOB: 05/23/YYYY

ROOM: 331

History & Physical Exam

CHIEF COMPLAINT: Difficulty breathing

HISTORY OF PRESENT ILLNESS: This is an 8-month-old white male seen by Dr. White at the Lofty Pines Health Center for a viral-type syndrome. The mother states that the baby had a temperature over the weekend with it being 134 on Saturday night and 103 last night. The baby has progressively gotten more worked up, more short of breath and has had more problems with congestion. The baby was admitted for observation and evaluation of his upper resporitory and lower respiratory disease. This is the first hospitalization for this child.

PAST MEDICAL HISTORY: This baby only has one other hospitalization besides that of birth and that was for admission to the hospital for respiratory distress syndrome and was taken care of by Dr. Smith in the neonatal intensive care unit. He only stayed less than a week and did quite well and there was no need for follow up. The mother states that the patient was born three weeks early and the doctors felt that this was secondary to her having a kidney stone. The child had a normal, spontaneous, vaginal birth. He was 19 inches at birth and weighed 6 pounds 15 ounces.

GENERAL: This is an 8-month-old looking his stated age with respiratory problems with a rapid rate and rather annoyed with a stuffed-up nose.

TEMPERATURE: 101.3 PULSE: 158 RESPIRATIONS: 62

EENT: Extraocular movements are full. Pupils are equal, round, and reactive to light and accommodation – red reflexes within normal limits. Nose – stuffed up with clear rhanirea. Mouth – within normal limits.

CHEST: No inflammation of the bronchioles.

HEART: Regular rhythm. Without murmur, rub, or gallop that I can detect, but the patient indeed had a tachycardia at the time of examination. The patient has low blood pressure.

ABDOMEN: Within normal limits.

LAB DATA: Complete Blood Count revealed: White count was 10.7, hemeglabon was 12.2, hematocrit was 37.7, 13 segmented cells, 77 lymphocytes, 10 monocytes. Uranalisis was within normal limits except for trace blood on dipstick; doubt whether that is significant. Chest x-ray was within normal limits.

IMPRESSION: 1. Bronchiolitis 2. History of premature delivery with one hospitalization for lung immaturity at time of birth. 3. Anisocoria

Plan: Patient will need forced fluids and close observation. Provide patient decongestant. Provide patient with COX-2 inhibitor.

DD: 02/09/YYYY

Reviewed and Approved: Fred Moore MD

ATP-B-S:02:1001261385: Fred Moore MD

(Signed: 02/09/YYYY 04:14:44 PM EST)

DT: 02/10/YYYY

Physician Authentication

Global Care Medical Center ( 100 Main St, Alfred NY 14802 ( (607) 555-1234