RFoster1
Guru
Can anyone see a comprehensive HPI in this dictation?
"The patient is a 8 week old M former 32 weeker and Group B Strep meningitis with parenchymal involvement, UTI, bacteremia s/p 28 day course of penicillin. At the time seizures were demonstrated on EEG. Patient has been experiencing difficulty with oral feeds, specifically signs of oromotor dysfunction. His neurologic prognosis per the primary team is poor. He was evaluated by OT and had been observed choking with swallowing. A modified barium swallow study showed tracheal aspiration, deep largyngeal penetration, and nasophargyngeal reflux. After discussion between the primary team and the family, the option of stable feeding access via G-tube was decided upon versus NGT feeding trials. Currently the patient has been NPO since noon per the mother, yet she states she fed him 30 cc of PO feeds. He is resting comfortably with a recently replaced NGT."
TPA "I have seen and examined the patient with the resident team on 02/06/2014 and confirmed the resident's findings as documented above. I have reviewed the laboratory and radiologic studies. I agree with the resident's plan as outlined above. In brief, the patient is a 2 month old infant w/ h/o prematurity, meningitis who presents with feeding intolerance and aspiration. MBSS + aspiration of thin liquids. UGI pending. Will review UGI and plan lap gtube if UGI shows normal anatomy."
TIA for any help! I'm having trouble finding more than 3 elements.
"The patient is a 8 week old M former 32 weeker and Group B Strep meningitis with parenchymal involvement, UTI, bacteremia s/p 28 day course of penicillin. At the time seizures were demonstrated on EEG. Patient has been experiencing difficulty with oral feeds, specifically signs of oromotor dysfunction. His neurologic prognosis per the primary team is poor. He was evaluated by OT and had been observed choking with swallowing. A modified barium swallow study showed tracheal aspiration, deep largyngeal penetration, and nasophargyngeal reflux. After discussion between the primary team and the family, the option of stable feeding access via G-tube was decided upon versus NGT feeding trials. Currently the patient has been NPO since noon per the mother, yet she states she fed him 30 cc of PO feeds. He is resting comfortably with a recently replaced NGT."
TPA "I have seen and examined the patient with the resident team on 02/06/2014 and confirmed the resident's findings as documented above. I have reviewed the laboratory and radiologic studies. I agree with the resident's plan as outlined above. In brief, the patient is a 2 month old infant w/ h/o prematurity, meningitis who presents with feeding intolerance and aspiration. MBSS + aspiration of thin liquids. UGI pending. Will review UGI and plan lap gtube if UGI shows normal anatomy."
TIA for any help! I'm having trouble finding more than 3 elements.
