Dates of Service:
Admission Diagnosis:
Jaundice
Discharge Diagnosis:
Indirect hyperbilirubinemia
Hospital Course
Describe hospital course…
[The Hospital course is like the History part and the physical examination below is the PE part of the H & P.]
PHYSICAL EXAMINATION
Vital Signs:
General: Awake and alert, comfortable, in NAD.
Skin: Scleral icterus greatly improved from yesterday. Skin less jaundiced.
Head – NC/AT; AF open and is flat. No cephalohematoma or caput.
Eyes – Red reflex present b/l.
Ears – TMs normal
Nose – Normal mucous membranes, no rhinorhea
Throat & Mouth – Sucking and rooting reflex present, palate normal.
Neck – Supple
Lungs – CTAB
Heart – RRR, no murmurs, 2+ brachial and femoral pulses, CR <3 sec
Abdomen: Normal BS, soft, non-distended, no massess, umbilicus clean.
Genitourinary: Normal female external genitalia
Extremities: Negative Galeazzi Sign, Negative Ortolani and Barlow, FROM
Back: No tuft or hair, no dimple
Neurologic: Normal Moro, rooting, Babinski reflexes
Diagnostic Findings:
Dietary Instructions: Breast or bottle ad lib
Medications: Cholecalciferol 400 units; Sig: Take 1ml daily; Disp: 50ml
Disposition and Follow-Up: Discharged home. Follow up with PCP in 2-3 days.
Condition of Patient at Discharge: Stable