Note: Make sure the attending you are dictating
Date of Admission: 10/30/10 under is the attending who is discharging the patient.
This may not necessarily be the attending on the
Date of Discharge to Home: 10/31/10 patient sticker
Admitting Diagnosis: 1. Acute gastroenteritis
Discharge Diagnosis: 1. Acute viral gastroenteritis secondary to rotavirus
2. Dehydration – resolved
3. Metabolic acidosis – improved Must state where patient is being
4. Hypokalemia – resolved discharged to.
5. Clinical GER
Discharge Condition: Good
Brief History of Present Illness: This is a two month old male who had a one week history of
watery, foul smelling diarrhea and associated vomiting. Patient had been afebrile. No URI
symptoms, no sick contacts, no recent travel, no day care, no antibiotic use Patient was exposed to a
Hospital Course: Patient was initially started on IV fluids at a rate equal to 1 ½ maintenance.
Patient tolerated Isomil DF formula well and gained weight. There was no further emesis. Number
of stools decreased significantly after admission and became formed prior to day of discharge. Stool
was positive for rotavirus. Stool Wright stain was negative. Patient was afebrile throughout hospital
stay. Parents were educated regarding overfeeding. No spit ups were observed in the hospital.
Parents were instructed on reflux precautions due to history. Initial BMP within normal limits except
bicarbonate of 14 and potassium of 3.2 which improved to 19 and 4.1, respectively on repeat.
Physical Examination at Discharge:
T: 99.3F BP 85/42 HR 130 RR 36 Weight 5.3kg
General: Awake, alert, no apparent distress
HEENT: Normocephalic, atraumatic. Anterior fontanelle open, soft and flat. Bilateral red reflex
present. Mucus membranes moist.
CVS: Regular rate and rhythm. No murmurs appreciated. Note: Discharge summaries
Respiratory: Clear to auscultation bilaterally. should be BRIEF. Try to limit to
Abdomen: Normoactive bowel sounds. Soft. Non-tender, non-distended. one typed page. Think of it as if
GU: Uncircumcised. Testis descended. you were the primary physician.
Extremities: Full range of motion. Ortlani and Barlow negative What information would you want
Skin: No rashes. Capillary refill brisk. to have. Also, remember, time is
Neuro: No focal deficits. money. Most pediatricians have
Medications: None only a brief amount of time to
review this document.
Activity: As tolerated
Diet: Isomil DF limiting to no more than 3 ounces every 3 hours. Reflux precautions.
Follow Up: Pediatrician-Dr Smith at Lied Clinic on Nov 3rd at 10:30 am. (555-5555).
Instructions: Return to the ER or call Pediatrician if patient is
appearing more tired than usual, has had no wet diapers in six Instructions should be in layman’s terms
hours, worsening diarrhea or vomiting or any other concerns. not medical terms.
PMD needs to be identified on all DC
summaries. Rev 04/10
D. Eakin, MD