I got Jonathan's medical records from the hospital and took a few days and summarized them. Below is the one page medical history summary that I print out and take with me (or give to Linda if she's taking him in) to give the doctor. Since then the doctors have been amazed and exhuberant that it was provided to them. They thanked us profusely and read it thoroughly. It helped thing quite a bit. Feel free to use this as an example of how to do a medical summary for your child or for yourself.
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| žAdmit: 7/25/96 6:11, emergency outpatient | Diag: CAH, Vomiting |
| žAdmit: 7/19/96 14:46 | Discharged: 7/20/96 |
comments: "...admitted to emergency room with a history of lethargy since this morning, runny nose and cough one week, 'cold sweats', but no fever. Mom states that she gave the patient Cortef 25 mg intramuscularly in addition to his usual six o'clock dose, but she did not notice any improvement in his activity level. ..."
Medications: Florinef 0.05 mg twice a day, Cortef 10 mg per 5 ml: 1ml-6am, 1ml-2pm, 1.2ml-10pm |
| žAdmit: 4/22/96 18:05, emergency outpatient | Diag: vomiting onset today |
| žAdmit: 3/30/96 9:46, emergency outpatient | Diag: vomiting, coughing |
| žAdmit: 1/14/96 15:20, emergency outpatient | Diag: vomiting, tugging at ears, croupy cough |
| žAdmit: 12/26/95 14:45 | Discharged: 12/28/95 |
comments:"..on the morning of admission, he had recurrent vomiting. Mother brought him to the emergency room...Doctor Bryant saw the patient, and he was determined to be in a mild adrenal crisis, and agreed with the increase in steroid use as well as monitoring Accu-Checks and blood pressure closely. ...it was also noted that he had increased cervical and inguinal adenopathy as well as pharyngitis with an exudate. His blood sugars improved during this hospital stay to normal, approximately 101 to 158 on the date of discharge." |
| žAdmit: 12/21/95 18:34, emergency outpatient | Diag: coughing, retracting rib cage |
| žAdmit: 12/20/95, emergency outpatient | Diag: wheezing, coughing, vomiting |
| žAdmit: 11/30/95 19:36, emergency outpatient | Diag: wheezing, coughing, subcostal retractions |
| žAdmit: 8/24/95 19:09, emergency outpatient | Diag: difficulty breathing |
| žAdmit 5/5/95 18:53, emergency outpatient | Diag: high fever |
Throat culture: Abundant Haemophilus influenzae (5/5/95 19:56) |
| žAdmit: 1/13/95 21:54 | Discharged: 1/14/95 |
Diag: pneumonia
comments: "Mom reports that this patient had a temperature of 101 at 12:30, noon, and Mom gave him some liquid and some medication, and his temperature gradually raised up to 103 degrees Fahrenheit. According to Mom. she gave the patient a double dose of Cortef...About four o'clock in the afternoon, the patient got up from his nap and he was arced up and his eyes were glazed up. Mom reports it was a seizure-like episode. X-Ray...shows some developing infrahilar infiltrate. Blood gasses showed co2 of 54 and a percent saturation of 87.8. Chem-20 shows phosphorus of 5.1, uric acid 2.6, total bilirubin 0.2. On complete blood count his white blood cell count was 13.6, mean corpuscular hemoglobin concentration 32.6, and differential: polys 80, lymphocytes 12."
Assessment: 1. Possible pneumonia, 2. Febrile seizure, 3. Congenital adrenal hyperplasia. |
| žAdmit: 6/11/94 2:00 | Dismissed: 6/12/94 |
Diag: bronchitis (bronchiolitis) |
| žAdmit 1/26/94 13:40 | Dismissed: 3/15/94 |
Diag: r/o sepsis c-phase
Principal Diagnosis: 1. Congenital Adrenal Hyperplasia, V21 alpha hydroxylase deficiency type.
2. Group B Strep sepsis and pneumonitis.
3. Hyperkalemia and hyponatremia, secondary to CAH.
4. Respiratory distress secondary to Group B Streptococcus sepsis and pneumonitis.
5. Thrombocytopenia, renal insufficiency, seizure activity secondary to Group B Strep.
6. Hyperbilirubinemia and cholestatic jaundice.
7. Small ventricular septal defect and patent ductus arteriosus. |