Forrest 9-14

ex9_ch14
LOD = 2:12

HISTORY AND PHYSICAL EXAMINATION

PATIENT NAME: Baby Taylor

HOSPITAL NO.: 4465578

DATE OF ADMISSION: January 5, _____

HOSPITAL COURSE
The patient was a 1.3-year-old 5 1.305-kg [minus 1.5 for INCORRECT ENGLISH WORD] product of a 27 weeks 27-week gestation to a G1, 15-year-old black female. Pregnancy complicated by preeclampsia and gonorrhea, treated on August 5, 1996. The mother is Rh positive, serology negative, rubella titer reactive, hepatitis surface antigen negative,. HIV negative. The patient was delivered secondary to pre-term labor and increased blood pressure. C-section was performed the. The [minus 0.5 for OMITTED CRITICAL PUNCTUATIONS] patient delivered without spontaneous respiration. The patient was intubated with 3.0 ET tube, and Survanta 5.2 cc were given forper [minus 0.5 for WRONG CONJUNCTION / PREPOSITION / ARTICLE] protocol. The patient was transferred to NICU, and UAC and UVC were placed without difficulty. Apgar Apgars were 11 and 9 at one and five minutes, respectively.

PHYSICAL EXAMINATION
WEIGHT: 1.305 kg.
LENGTH: 38 cm.
HEAD CIRCUMFERENCE: 27.5 cm.
Weight 1.305 kg, length 38 cm, head circumference 27.5 cm.
VITAL SIGNS: Temperature 97.4, pulse 144, respiratory respiration [minus 0.5 for MINOR ERROR] 40.
GENERAL: Well -developed black male, proximately approximately [minus 1.5 for INCORRECT ENGLISH WORD] 27 weeks weeks’ gestation.
HEENT: Normocephalic. [minus 0.5 for PUNCTUATION ERROR] Anterior fontanel Normocephalic, anterior fontanelle is flat and soft. Eyes are open, ears open. Ears are normal. Oral pharynx Oropharynx [minus 1.5 for MISSPELLED MEDTERM] benign.
NECK: Supple without masses.
HEART: Regular rate and rhythm without murmurs, murmur, rub, or galloped. gallop. [minus 1.5 for INCORRECT ENGLISH WORD/s]
LUNGS: Mild subcostal retractions, mild intercostals retraction, rales intercostal retractions. Rales [minus 0.5 for MINOR ERROR] bilaterally, breath sound bilaterally. Breath sounds equal bilaterally.
ABDOMEN: Soft and non tender, positive nontender. Positive bowel sound, GU normal sounds.
GENITOURINARY: Normal male genitalia, no cc or pee. [minus 1.5 for INCORRECT ENGLISH WORD]

EXTREMITIES: No clubbing, cyanosis, or edema.

IMPRESSIONS
IMPRESSION
1. Pre-term birth, living child approximately 29 weeks weeks’ gestation.
2. Hyaline membrane disease.
3. Ruled- Rule out sepsis.
4. Mother pre-treated with steroids and antibiotics.

PLAN
1. Admit to an NICU, [minus 0.5 for MINOR ERROR] IV fluids and antibiotics.
2. Enzai MV SIMV [minus 1.5 for INCORRECT MEDICAL / ENGLISH ABBREVIATIONS] and survanta Survanta. [minus 1.5 for CASING OF MEDICATIONS]
3. Indomethacin.

line count = 26.30
negative pts. = 13.50 (51%)
ACCURACY = 49%