Forrest 10-14

ex10_ch14 (ethnic voice)
LOD = 2:14

DISCHARGE SUMMARY

PATIENT NAME: Jennifer Bakutis

HOSPITAL NO.: 9682967

DATE: December 19, _____

ADMISSION DIAGNOSIS
Pneumonia.

HISTORY OF PRESENT ILLNESS
A 7-year-old white female with partial trisomy 13 followed at the University medical center for chronic rewind [minus 1.5 for INCORRECT ENGLISH WORD] pneumonia.

ETIOLOGY
Unknown.

She was seen by Dr. Scott Miller for this [minus 1.5 for INCORRECT ENGLISH WORD/s] prior to admission and began on augmentin. [minus 1.5 for CASING OF MEDICATIONS] She had fever then and continued to have fever and was seen at the emergency room at the hospital on the night of admission showing a right middle and lower lobe infiltrate. She was admitted for further IV treatment.

HISTORY OF PRESENT ILLNESS
A 7-year-old white female with partial trisomy 13, followed at University Medical Center for chronic recurrent pneumonia, etiology unknown. She was seen by Dr. Scott Miller 4 days prior to admission and begun on Augmentin. She had fever then and continued to have fever, and was seen in the emergency room at the hospital on the night of admission, showing a right middle and lower lobe infiltrate. She was admitted for further IV treatment.

PHYSICAL EXAMINATION
Within a [minus 0.5 for ADDING WORDS NOT DICTATED] normal limits, except for ronchi andrhonchi in [minus 3.0 for INCORRECT SPELLING MEDICAL TERM] the chest. The child has no verbal communication and forpoor [minus 1.5 for INCORRECT ENGLISH WORD] socialization.

ADMISSION LABORATORY
On admission hemoglobin was 12.3, hematocrit 36.0, white count 12300, [minus 0.5 for STYLES ERROR] with 54 segs, 37 lymphs, 3 monos, 5 eos, and 1 basos. [minus 0.5 for GRAMMAR ERROR] Chem 6 was within normal limits except for a blood sugar of 141.

URINALYSIS
Within normal limits. Mycoplasma and RSV were negative. Throat culture shows normal flora.

ADMISSION LABORATORY
On admission hemoglobin was 12.3, hematocrit 36.0, white count 12,300, with 54 segs, 37 lymphs, 3 monos, 5 eos, and 1 baso. Chem 6 was within normal limits except for a blood sugar of 141. Routine urinalysis, within normal limits. Mycoplasma and RSV were negative. Throat culture shows normal flora.

HOSPITAL COURSE
She was started on a claforan 300Claforan 300 [minus 1.5 for CASING OF MEDICATIONS] mg IV q.6h q.6 h. and nebulized albuterol q.4h. q.4 h. Temperature was normal during the entire stay. While being treated, the child chests child’s chest [minus 0.5 for GRAMMAR ERROR] finding slowly improved, and the lungs were clear to auscultation on the night of October 16. October 16, _____.

At that time, she was placed on sip cell.Cefzil. [minus 3.0 for INCORRECT MEDICINE NAME] The claforanClaforan was stopped on. On [minus 0.5 for OMITTED CRITICAL PUNCTUATIONS] the morning of discharge, chest x-ray showed the right middle lobe clear and the right lower lobe showing minimal residual infiltrate. Lung was cleared Lungs were clear [minus 0.5 for GRAMMAR ERROR] to auscultation.

DISPOSITION
Discharged. Discharge.

DISCHARGED MEDICATION
Sip cell 250

DISCHARGE MEDICATIONS
Cefzil 250 mg b.i.d.., Ventolin by aerosol 2 to 3 times a day.

FOLLOW UP
Appointment in one 1 week.

line count = 25.76
negative pts. = 16.50 (64%)
ACCURACY = 36%