Qualitative Analysis Chart
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Walter State Community College *
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Feb 20, 2024
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Qualitative Analysis Chart
Intro to Health Information Management Technology
Professor: Eva Davis WHARTON GENERAL HOSPITAL
CLINICAL RESUME
The clinical resume should recapitulate concisely:
1. Date of Admission
2. Date of Discharge
3. Final Diagnosis (es)
4. Date and name
of procedures performed
5. Reasons for
ATTENDING PHYSICIAN:
DATE OF ADMISSION: December 13, 2006
DATE OF DISCHARGE: December 16, 2006
DISCHARGE DIAGNOSES: Acute asthmatic bronchitis
Right middle lobe pneumonia
HISTORY: An 8-year old black make, admitted with chief complaints of shortness of breath, cough and wheezing, which began at 1:00 A.M. on the night prior to admission. On examination, patient's temperature
hospitalization
6. Complications
7. Significant findings
8. Treatment
9. Condition of the patient on discharge
10. Pertinent instructions given to the patient and/or family including:
a. Physical activity
b. Medication
c. Diet
d. Follow-up care
was 101.0, oral, pulse of 108, respiration rate of 132, blood pressure 120/60, weight 60 pounds. He is a well-developed and nourished Caucasian boy, alert and in moderate respiratory distress.
POSITIVE PHYSICAL FINDINGS: Head, eyes, ears, nose, and throat were unremarkable. Chest with increased breath sounds, all fields have scattered inspiratory and expiratory rhonchi, left and right lung bases, with the right side being greater than the left. No appreciable wheezes or
rales at the time of examination. Abdomen, genitalia, extremities and neurological were unremarkable.
HOSPITAL COURSE: Patient was started on intravenous fluids of D5 and one-third normal Saline, intravenous Aminophylline and Ampicillin intravenously.
On admission, his white blood cell count was 19.4, with 71 segs, 1 band,
26 lymphs, and 2 monocytes. Chest x-ray done at Waterford Clinic indicated a right middle lobe pneumonia. A repeat chest x-ray done later in the admission, indicated a clearing of this left middle lobe pneumonitis. Urinalysis was performed on admission, which indicated a 3+ glucose, positive blood in urine, but on repeat urinalysis, these abnormalities were cleared. Patient temperature throughout the hospitalization was low grade 99 to 100 degrees oral. Patient was taken off intravenous fluids two days after admission and begun on Amoxil 250 mgs p.o. q.i.d. and Theophyl-SR capsules 125 mgs b.i.d.
He was discharged in good condition on the 16
th
of December 2005 on
Amoxil and Theophyl same dosages as he had in the hospital.
WHARTON GENERAL HOSPITAL
HISTORY
DATE ADMITTED: 12-13-06
ATTENDING PHYSICIAN:
CHIEF COMPLAINT: Shortness of breath, cough, and wheezing.
HISTORY OF PRESENT ILLNESS: Eight (8) year old Caucasian male admitted via PGH Waterford Clinic. Mother states that at approximately 1:00 a.m. on the night prior to admission
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the patient began to develop wheezing and shortness of breath quite suddenly. He had experienced dry, nonproductive cough for approximately one day prior to that time. Mother checked the patient at that time and found him "warm to touch." Soon after onset of symptoms the patient was given Vicks Vaporub on the chest and a warm wash cloth was applied to his chest also. He seemed to respond well to this treatment. Mother also put vaporizer near the bed of the child with good results. The child slept intermittently through the rest of the evening with less labored breathing. At 7:30 a.m. on the morning of admission the mother turned the vaporizer
off and by 9:00 a.m. the boy was once again experiencing shortness of breath and labored breathing. Soon after this the mother took the child to the emergency at Waterford where he was given Epinephrine with good results. Chest x-ray was performed at that time. IV was started and Aminophyllin was begun also. There was no complaint of chest pains or nausea and vomiting.
PAST MEDICAL HISTORY: Hospitalizations-none. Surgeries- none. Trauma- laceration to lip at age twelve (2). Medications-Vaporub for two days prior to admission. The patient was also given one teaspoon of liquid Penicillin on the night of admission. Allergies-none know. Eating habits good. Illness-chickenpox three years prior to admission. No history of asthma, pneumonia,
or bronchitis.
FAMILY HISTORY: Mother age 29 alive and well. (Grandmother with positive history of asthma.) Father age 33 alive and well. Brother age 10 alive and well with history of asthmatic bronchitis as a baby. Sister age 6 with a history of pneumonia multiple times and frequent upper respiratory infections and dehydration. Brother age 3 alive and well.
SOCIAL HISTORY: The patient is in the third grade doing well in school according to the mother.
REVIEW OF SYSTEMS: Weak, tired and run down. Weight steady and gaining well. Hematopoietic-noncontributory. CNS-non contributory. Ears-noncontributory. Sinuses- non contributory. Throat-noncontributory. Thyroid-noncontributory. Respiratory-shortness of breath
and wheezing. See HPI. Cough is dry and nonproductive. Cardiac -noncontributory. Gastrointestinal - no nausea, vomiting, diarrhea, or constipation. Genitourinary - noncontributory. Musculoskeletal-noncontributory.
WHARTON GENERAL HOSPITAL
PHYSICAL EXAMINATION RECORD
PHYSICAL EXAMINATION: Temperature 111.0, pulse 108, respiratory rate 32, blood pressure
120/60, weight 60 pounds.
GENERAL-this well-developed and nourished Caucasian female boy, alert and in moderate respiratory distress. NVGK (not very good kid.)
HEENT: Normocephalic. PERRLA. EOM intact. Sclerae nonicteric. Canals with yellow, thick cerumen. Tympanic membranes therefore not able to be visualized at the time of exam. Mucosa moist, septum midline. Gag reflex intact. Tonsils without hyperemia.
ADENOPATHY: No palpable cervical adenopathy.
CHEST: Symmetric. Intercostal retractions, moderate.
LUNGS: With increased breath sounds all fields. Scattered inspiratory and expiratory rhonchi left and right lung bases. Right side greater than left. No appreciable wheezes or rales at this time.
HEART: S1 and S2 at a rate of 108 per minute. No murmurs or gallop rhythm appreciated.
ABDOMEN: Flat. Bowel sounds present. No discernible organomegaly or tenderness.
GENITALIA: Normal genitalia for sex and age. No abnormalities.
EXTREMITIES: No swelling or edema.
NEUROLOGICAL: Alert and oriented. Motor: normal power and tone. Deep tendon reflexes: 2+
upper extremities, 2+ lower extremities. Cranial nerves II through XII intact.
ASSESSMENT: Acute asthmatic attack. Possible pneumonia (questionable infiltrate lower lobe).
PLAN: Hydration with intravenous fluids. D5 in one-third Normal saline. Aminophylline 5 mg/kg. q6h, Ampicillin 200 mg/kg/24h (divided q6h).
CBC on admission - white blood cell count 19.4, RBC's 4.69, hemoglobin 13.3, hematocrit 38.3, MCV 82, segs 71, bands 1, lymphs 26, monos 2.
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