Reflex sympathetic dystrophy involving the left upper extremity. Neurogenic bowel and bladder, resolved.
The baby was delivered at 39 weeks gestational age with a three-vessel cord and Apgars of 7 and 8. DeLee suction was used as well as blow-by O2. Mother did get Nubain during labor. Birth weight was grams. The child began, shortly after birth, having some grunting, retractions, and was admitted to Special Care Nursery.
While in Special Care Nursery, the following issues were addressed. The child was originally n.
The child was again made n. The hyperalimentation was continued at this point in time. Feeds resumed on the next day at 10 mL q.
Feeds were resumed later in the day after the procedure by p. The child had poor toleration of feedings, and the NG bolus feeds were needed a substantial amount of the time. The patient was having multiple episodes of spitting up of food and not tolerating p.
Reglan was started, and later, by recommendation of the ENT, Prevacid was begun. Bronchoscopy performed by Dr. John Doe showed some subglottic stenosis, likely due to acid reflux. He recommended Prevacid, and the Reglan was continued. The child was intubated on the day of admission and was given Narcan.
The patient was extubated the next day and placed on nasal cannula. The CPAP was removed in the morning and tolerated well. The patient received ampicillin and gentamicin for 5 days worth of 10 doses of ampicillin, and blood cultures remained negative. Poor tolerating of feeds and low tone of the child.
Pediatric Neurology was involved because of both poor tolerating of feeds and low tone of the child. PT and Orthopedics were consulted concerning this issue. There were multiple episodes of ankle stretching, and they recommended further treatment as an outpatient.
Need for auditory evoked response test. The patient passed the AER. Anterior fontanelle was soft and flat. There was no murmur. The patient was discharged to home with parents. Discharged to home with apnea monitor. Feeds, 45 to 60 mL q. Continue the Prevacid and Reglan as prescribed.
Visiting nurse will be coming twice a week for two months. Follow up with Dr. Jane Doe in one week. Follow up with Neonatal High-Risk Clinic.Background. Glycogen synthase kinase 3-beta (GSK3B) is a serine/threonine kinase which is directly inhibited by lithium.
A −50T/C single nucleotide polymorphism (SNP) localized within the promoter region of the GSK3B gene has previously been shown to be associated with response to lithium prophylaxis in .
The sample reports have been checked for accuracy in spelling, but please keep in mind nobody's perfect, and we do appreciate any notification of errors. These sample medical reports may also include some styles or report formats that are unusual, and if so, this would be due to the preference of the dictating physician.
Transcribed medical transcription neonatal discharge summary example report for reference by medical transcriptionists and allied health professionals. Discharge summary transcription helps in converting all these disparate documents and notes into an accurately transcribed text format which can be further used by the patient or the healthcare provider.
We report a series of 5 case-patients who had Israeli spotted fever, of whom 2 had purpura fulminans and died.
Four case-patients were given a diagnosis on the basis of PCR of skin biopsy specimens 3–4 days after treatment with doxycycline; 1 case-patient was given a .
A Discharge Summary provides an overview of a patient’s hospitalization from admission through discharge.
It can be a few brief paragraphs or a multipage report, depending on the complexity of the patient’s condition and treatment.