INPATIENT FACE SHEET

WEST, KEITHIPCase010Dr. BLACKAdmission:02/09/YYYYDOB: 05/23/YYYYROOM: 331 ADMISSION DATE:02/09/YYYYDISCHARGE DATE: 02/11/YYYYADMISSION DIAGNOSIS: Bronchiolitis with hyperpyrexia; history of premature delivery withone hospitalization for lung immaturity at time of birth.DISCHARGE DIAGNOSIS: Bronchiolitis with fever and poor fluid intake.SUMMARY: This is an 8-month-old white male seen by Dr. White at the Lofty Pines HealthCenter for a viral-type syndrome. The mother states that the baby had a temperature overthe weekend, going up to 104 and 103 the night prior to admission. The baby hasprogressively gotten more worked up, more short of breath and has had respiratory disease.The patient was hospitalized for his respiratory distress and lower respiratory disease.Positive physical exam on admission included both lung fields filled with rhonchi andoccasional rales. There were no signs of consolidation. The patient was put in a crouptent during his hospital stay and was placed on Ampicillin four times a day for his twodaycourse. He tolerated the croup tent well and the antibiotics. His lungs progressivelycleared, and the patient was discharged on 02-11-YYYY. He was discharged on theinstructions to force fluids, saline nose drops and bulb suction as needed, Amoxicillin125 milligrams three times a day, and to return to the clinic in one week to see Dr.Swisher.Lab data – white count was 10.7, hemoglobin was 12.2, hematocrit was 37.7, 13 segmentedcells, 77 lymphocytes, 10 monocytes. Chest x-ray was within normal limits.DD: 02/11/YYYYDT: 02/20/YYYYReviewed and Approved: Fred Moore MDATP-B-S:02:1001261385: Fred Moore MD(Signed: 02/11/YYYY 04:14:44 PM EST)Physician AuthenticationGLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234