DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
BRIEF HISTORY AND HOSPITAL COURSE: This is a (XX)-year-old female with known sickle cell anemia and history of asthma. The patient presents, on the day of admission, with cough for one week and fever to 101.8. Her cough is dry and nonproductive. She has a known history of asthma. Prior to admission, father started her nebulization. Father also noticed increased jaundice over the past 24 hours. She had no rhinorrhea, shortness of breath or wheezing at home. She did have mild chest pain in the upper chest wall.
Her initial workup included laboratory studies, blood culture, chest x-ray, CBC, and CMP. Chest x-ray was negative for any infiltrates. She was empirically started on IV antibiotics, Rocephin, and Zithromax was added to her regimen. She was given supplemental oxygen and maintained her saturation above 95%. Her folic acid and hydroxyurea were continued, and respiratory treatments with albuterol were given q. 3 hours. Over the next few days, she continued with high spiking fever, continued with chest pain, and IV Toradol was started for her pain. Because of her symptoms, an influenza swab was obtained and was found to be positive for influenza B. She was started on Tamiflu.
Her hemoglobin was noticed to drop with hemoglobin of 8.2, but her reticulocyte count stayed elevated at 18.8%. The repeat chest x-ray showed no significant change, no infiltrate. Her temperature curve began to improve, and she remained afebrile for 24 hours, and on MM/DD/YYYY, she was ready for discharge.
SIGNIFICANT FINDINGS: As noted above.
PROCEDURES AND TREATMENTS DONE: IV hydration, IV antibiotics, and respiratory treatments with albuterol.
DISCHARGE CONDITION: The patient was stable.
FINAL DIAGNOSES:
1. Sickle cell crisis.
2. Acute exacerbation of asthma.
3. Influenza B with respiratory manifestations.
DISCHARGE DIET: Regular.
PHYSICAL ACTIVITY: As tolerated.
DISCHARGE MEDICATIONS: Albuterol one amp via neb q. 4 hours. New nebulizer dispensed to the home by home care agency. Tamiflu 75 mg p.o. b.i.d. x3 additional days, penicillin V potassium 250 mg p.o. b.i.d., hydroxyurea 400 mg p.o. daily, and folic acid 5 mg p.o. daily.
DISCHARGE INSTRUCTIONS: Follow up in the pediatric hematology-oncology clinic in one week.
