DISCHARGE SUMMARY

ADMITTING DIAGNOSIS

1. Pneumonia

2. Strep pharyngitis.

3. Bilateral otitis media.

4. Dehydration.

DISCHARGE DIAGNOSIS: Same.

HOSPITAL COURSE: After admission, ___ [NAME] was placed on IV Ampicillin. Her admitting chest x-

ray showed a bilateral pneumonia involving the perihilar, lingual, middle lob, anterior segment of the right upper

lobe. She was initially started on sips of clear liquids the night of admission and was advanced with a diet for

her age on her first hospital day. The child was also placed on Aminophyllin and received Bronkosol as needed

for wheezing. Her clinical condition improved markedly over the next 24 hours. Upon examination on the ___

[DATE], it was felt that ___ [NAME] was ready to be discharged to home in the care of her parents.

DISCHARGE PHYSICAL EXAMINATION: General: The patient is a well nourished, well developed 10-

year-old white female who appears to be in acute distress. Skin: Excellent profusion. HEENT: Ears: TM’s are

red. Nose: Clear. Throat: Injected. Neck: Supple. Chest: Bilateral rales. Minimal wheezing bilaterally. Heart:

Regular rhythm without murmurs. Abdomen: Soft without organomegaly. Genitalia: Female. Neurological:

Intact.

DISCHARGE PLANS: The patient is to be discharged to home and care of her parents.

DISCHARGE MEDICATIONS: Ceclor 250 mg p.o. t.i.d.

The patient is to return to the office for reexamination.