EXAMPLE
Nimisha Shah, M.D.
DISCHARGE SUMMARY
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FINAL DIAGNOSES:
1.
Acute viral meningitis, more likely secondary to HSV.
Questionable superimposed bacterial meningitis.
2.
Gastritis, resolved.
3.
Dehydration, improved.
4.
Intractable headache, resolved.
5.
Oral candidiasis.
HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old middleage female with no significant past medical history presented to
ER with headache, nausea and vomiting and noted to have
lymphocytic leukocytosis suggestive of viral meningitis, hence
admitted to med/surg floor.
HOSPITAL COURSE: Initially she received IV hydration, IV Demerol
p.r.n. for pain control, along IV Phenergan for nausea, vomiting,
oral proton pump inhibitors and Tylenol p.r.n. Headache
intensity was controlled with Demerol and Vicodin but she
continued to remain febrile, hence infectious disease
consultation with Dr. Charney obtained and initially advised
continuing the same supportive treatment. But since she continued
to have the persistent symptoms headache and fever, IV antibiotic
Rocephin was advised in view of partially treated bacterial
meningitis and she received oral antibiotic as an outpatient.
However, cerebrospinal fluid serology was not suggestive of any
bacterial meningitis and the culture remained normal. Her CSF was
serology revealed HSV positive for IgG and IgM. Hence, IV
acyclovir was added on 1/09/06 and advised to continue until more
specific cerebrospinal fluid PCR study results were available.
All blood cultures remained normal. She was noted to have oral
candidiasis and p.o. Diflucan and nystatin swish-and-swallow was
given and responded well to the above treatment.
PHYSICAL EXAMINATION ON TRANSFER: On the day of transfer, he was
afebrile, vital were stable. LUNGS: Clear to auscultation. NECK:
Rigidity had markedly cleared. LUNGS: Clear to auscultation.
CARDIOVASCULAR: S1, S2 regular. ABDOMEN: Bowel sounds regular,
soft and nontender. CNS: Alert and oriented x3, no focal neuro
deficits noted.
CONDITION AT DISCHARGE: Discharged in fair condition.
time of transfer the patient was stable.
DISCHARGE INSTRUCTIONS:
1.
Diflucan 150 mg p.o. daily.
2.
Rocephin 2 gm IV daily.
3.
Acyclovir 750 mg IV every 8 hours.
At the
4.
5.
6.
7.
8.
9.
10.
Tylenol p.r.n.
Phenergan 12.5 mg IV every 6 as needed.
Protonix 50 mg one p.o. daily.
Vicodin 7.5 SR 100 p.o. every 4 as needed for headache.
CBC, Chem-7 twice a week.
Will follow up with cerebrospinal fluid PCR study and
inform Dr. Charney.
Will request continued followup.