Discharge Summary Admitted Question & Answer Guide (With Explanation)
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Original Question
Discharge Summary Admitted: 1/5/ 20YY Discharged: 1/9/20YY ADMITTING DIAGNOSES: 1. Induction of labor Severe pre-eclampsia TUGR DISCHARGE DIAGNOSES: Severe pre-eclampsia 2. Accelerated hypertension 13. JUGR Patient is a 35-year-old, gravida 3, para 2, admitted for induction due to severe pre-eclampsia and late decelerations. She was admitted for induction and began on Pitocin. However, due to persistent late decelerations, patient underwent a primary low flap transverse cesarean section with delivery of a 4-pound, 12-ounce liveborn male with 6, 9 Apgars. There were no postoperative problems other than accelerated hypertension, for which the patient was started on Apresoline and Aldomet. Last blood pressure reading was 180/90. Discharge hemoglobin and hematocrit were 11.3 and 32.4, and platelet count was 122. The platelet count had been as low as 94,000. The patient’s magnesium levels when she was on magnesium ranged between 4.5 and 4, her electrolytes were normal, alkaline phosphatase 262 and 304. The hemoglobin and hematocrit on admission were 13 and 37, platelet count was 158,000. The PT and PTT were normal. The urinalysis was negative The patient was discharged in satisfactory condition with diet and activity as tolerated. Patient will continue to take Aldomet and Apresoline. I will see the patient in my office in 1 week for staple removal
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