DATE OF ADMISSION: MM/DD/YYYY

DATE OF DISCHARGE: MM/DD/YYYY

DIAGNOSES:

1. Malignancy of the bronchial lung.
2. Pleural effusion.
3. Metastatic malignancy to the liver.
4. Ascites.
5. Chronic airway obstruction.
6. Anemia.
7. Diabetes.
8. History of tobacco use.

PROCEDURES DURING THIS ADMISSION: Percutaneous abdominal drainage and injection of chemotherapy.

HISTORY OF PRESENT ILLNESS: The patient is a pleasant (XX)-year-old gentleman with history of a small cell lung cancer treated with both chemotherapy and radiation. He had been in stable condition as of late until about one month ago when he started to develop symptoms of increasing shortness of breath. This has been associated with swelling in his lower extremities as well as development of jaundice.

He presented to the emergency department where he was noted to have a right upper lobe infiltrate and a new right pleural effusion. For that, he was admitted for further evaluation and treatment. Also, complains upon admission of decreased appetite and constipation.

HOSPITAL COURSE: After assessment in the emergency department, the patient was admitted and placed on IV fluids. Labs were obtained, and consult was made to the pulmonary specialist regarding the patient’s diagnoses of lung CA and pneumonia. The patient was placed on the community-acquired pneumonia protocol and treated with IV antibiotics. For management of his diabetes, a consult was made to the endocrine specialist, and he was maintained on nutritional therapy, Accu-Chek monitoring, insulin therapy with evaluation of TSH and hemoglobin A1c. A consult was made to the pulmonary specialist regarding his pleural effusion and shortness of breath. After assessment and evaluation, recommendation was for ultrasound-guided thoracentesis, evaluation of the abdomen for ascites, and oxygen to keep saturation greater than 93%.

On MM/DD/YYYY, the patient also underwent evaluation by bilateral venous Doppler of the lower extremities with no evidence of deep vein thrombosis of the right or left leg noted. He also underwent evaluation for dyspnea with a 2-dimensional echocardiogram. This revealed concentric left ventricular hypertrophy present with normal left ventricular systolic function noted. Abnormal diastolic compliance was seen. No pericardial effusion was noted.

The patient underwent ultrasound-guided paracentesis for his diagnosis of ascites and successful paracentesis was done with removal of about 250 mL of bloody ascitic fluid. CT scan of the brain obtained on MM/DD/YYYY revealed no acute intracranial pathology identified. Current scan appears similar to that of previous done almost 10 months ago. Ultrasound of the chest was ordered with regard to pleural effusion. Ultrasound revealed a small right pleural effusion present. Despite removal of fluid, the patient continued to have dyspnea and shortness of breath.

Discussion was made with the patient and his family with regard to his current condition and overall poor prognosis. He was treated in the past with both chemotherapy and radiation and now presents with pleural effusion and ascites with associated jaundice. The patient was made a DNR with full active treatment and was in agreement to single-agent chemotherapy for salvage chemotherapy. The patient was then treated with single-agent irinotecan (CPT-11), but despite treatment, he continued to have jaundice, elevated bilirubin, and progressive metastatic disease to the liver.

Discussion was made with both the patient and his wife with regard to discharge planning and hospice care. It was the wish of the patient that he return to home to be cared for by family and for hospice consult to be obtained. Social work was consulted with regard to arranging hospice care at home. Once these arrangements were completed and necessary equipment obtained, the patient was then discharged to home under the care of hospice. We will continue to monitor him closely while under the care of hospice at home.

DATE OF ADMISSION: MM/DD/YYYY

DATE OF DISCHARGE: MM/DD/YYYY

CHIEF COMPLAINT: Dizziness.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female with complaint of dizziness and diaphoresis episodes for one day. The patient stated that she awoke on the morning of admission feeling nauseous, and she had taken her blood pressure medication after she felt extremely weak and lightheaded. She had a left-sided headache, and she said that she had left facial numbness and left arm numbness. She had no loss of consciousness. She had no visual problems. She denied any chest pain, palpitation or shortness of breath. On her way to the hospital, her symptoms did improve.

PAST MEDICAL HISTORY: TIA and hyponatremia.

PAST SURGICAL HISTORY: Hernia.

ALLERGIES: No known drug allergies.

HOME MEDICATIONS: Diovan, Toprol, and aspirin.

SOCIAL HISTORY: Negative smoker, negative alcohol.

PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.4 degrees, pulse 82, respiratory rate 20, and blood pressure 132/82. GENERAL: The patient appeared comfortable in no acute distress. HEENT: Normocephalic and atraumatic. Pupils were round and reactive to light. Extraocular muscles were intact, anicteric. TMs were clear and without erythema. NECK: Supple and nontender. Negative lymphadenopathy, negative masses, negative JVD. CARDIAC: Regular rate and rhythm, S1 and S2. Negative murmurs. RESPIRATORY: Clear to auscultation. Negative rales, negative rhonchi, negative wheezes. ABDOMEN: Soft, nontender, and nondistended. Positive bowel sounds. EXTREMITIES: Negative cyanosis, negative edema. NEUROLOGIC: There were no focal neurologic deficits.

LABORATORY DATA: Initial labs showed an ESR of 30 with serum sodium of 124, BUN of 11, and creatinine of 1.3. Hemoglobin 9.6 and hematocrit 29.

ASSESSMENT: The patient was admitted with what appeared to be an episode of transient ischemic attack with unilateral facial numbness as well as arm numbness and weakness with headache and weakness. Symptoms did resolve. The patient was admitted to telemetry to monitor for arrhythmias. Serial cardiac enzymes and EKGs were requested, as well as an echocardiogram and carotid Doppler. Due to the finding of hyponatremia upon admission, sodium was 124 and this was also evaluated with renal ultrasound, a nephrology consultation was requested. Serial stool hemoccults were requested due to the finding of anemia as well as abdominal ultrasound.

HOSPITAL COURSE: The patient’s hospital course was relatively uncomplicated. The patient did have nephrology consultation due to the finding of hyponatremia. The patient also had a cardiology consultation and a neurology consultation. Due to the finding of anemia, the patient also had a gastrointestinal consultation. Not only did the patient have anemia, but the patient also had elevation in liver enzymes and a CAT scan finding, which was reported to show fatty liver changes.

Laboratory tests during this hospitalization showed the patient to have, as stated before, low sodium with sodium of 124. This low sodium was noted to resolve and the number did improve throughout the hospitalization. The patient had normal BUN with creatinine between 1.1 and 1.2. The patient had total cholesterol of 240 with HDL of 136 and an LDL of 86. Cardiac enzymes were negative for myocardial infarction. B-type natriuretic peptide was slightly elevated at 120 with normal being between 0 and 100. CK-MB fractions were negative. Amylase as well as lipase were both within normal limits. Iron was 60. Urine sodium was low at 22. CA-125 was normal at 21.2. Alpha-fetoprotein was normal at 7.5. TSH was normal at 3.7. CEA was normal at 0.6. Folic acid was normal at 7.4. Vitamin B12 level was normal at 526. Hepatitis viral profile was negative for hepatitis B, hepatitis A, and hepatitis C. Urine osmolality was low at 148 with blood osmolality normal at 262. Urinalysis was negative for finding of urinary tract infection. Hemoglobin was ranging between 9.6 and 8.7, with the lowest being 8.7. This number did improve throughout the hospitalization. Hemoglobin electrophoresis was normal with no hemoglobin variation.

The patient had an MRI of the brain performed, which showed no acute ischemia identified. There was mild age-related chronic small vessel ischemic disease. Noncontrast CAT scan of the head showed no evidence of acute infarct. There was no mass effect or midline shift. Chest x-ray showed eventration of the right hemidiaphragm, otherwise unremarkable. Abdominal ultrasound showed fatty liver changes and normal gallbladder. CAT scan of the abdomen performed showed liver, gallbladder, biliary tree, and pancreas was unremarkable. The spleen was normal in size. There were no adrenal lesions. The kidneys were normal in size. There was no renal calcification seen. There was no hydronephrosis. There was no evidence of any retroperitoneal bleeding. The CAT scan of the pelvis performed showed what appeared to be routine IUD in place. There was right colonic diverticulum. Echocardiogram performed showed preserved left ventricular systolic function with evidence of possible diastolic compliance changes. There was trivial valvular flow abnormality. There were no gross mural thrombi or vegetations.

This patient did slowly improve throughout the hospitalization and sodium did correct itself. She had no further episodes of transient ischemic attack, and it was felt that the patient’s low sodium was due to excess fluid oral hydration, and the patient had been drinking excessive amount of water, and as a result, this had resulted in the low sodium. The patient’s sodium did improve. The patient was also made aware that she needed to follow up for further workup and followup of the low hemoglobin, and she also needed further followup and workup for fatty liver changes. With the patient feeling improved, the patient was discharged to home. The patient was discharged with instructions to follow up as an outpatient.

PRINCIPAL DIAGNOSIS: Transient cerebral ischemia.

SECONDARY DIAGNOSES:
1. Hyponatremia.
2. Acute renal failure.
3. Hypertensive heart disease.
4. Iron-deficiency anemia.
5. Chronic nonalcoholic liver disease.

DATE OF DISCHARGE: MM/DD/YYYY

ADMISSION DIAGNOSES:
1. Chronic renal failure secondary to lupus, status post renal transplantation in the past.
2. Hypertension.
3. Hyperlipidemia.
4. History of deep venous thrombosis.

DISCHARGE DIAGNOSES:
1. Chronic renal failure secondary to lupus, status post renal transplantation in the past.
2. Hypertension.
3. Hyperlipidemia.
4. History of deep venous thrombosis.

PROCEDURES: Deceased donor renal transplantation on date of admission.

CONSULTANTS:
1. Urology.
2. Nephrology.

BRIEF HISTORY AND HOSPITAL COURSE: This is a (XX)-year-old female with a history of end-stage renal disease secondary to chronic lupus nephritis, who had previously had a transplant six years ago that failed two years later. She was placed back on the waiting list and had a deceased donor organ offered. The final crossmatch was compatible. After checking a CT of the abdomen to be sure that a retroperitoneal hematoma found two months ago was resolved, the patient was taken to the operating room for transplantation.

On the day of admission, the patient was noted to have a transplant that was relatively uneventful. It was a right kidney with an IVC extension graft. It was placed on the left side, which was the same side as a left AV graft. In the OR, the patient was noted to have venous hypertension in the external iliac vein. The kidney was relatively dark. Therefore, a ligation of the AV graft was performed.

At this point, there was good venous outflow for the kidney and the kidney became pink. Total cold ischemic time was 12 hours. The kidney was initially slow to recover function. She remained in the ICU postoperatively until postoperative day #2, at which time she was transferred to the floor with increasing urine output. She had mild ATN but never required dialysis during this hospital stay.

Her creatinine on admission was 7.7 and postoperatively it peaked to 8 and this was on postoperative day #4. Thereafter, it began to decrease as the kidney recovered and it was 5.3 on the date of discharge, which was 7 days postoperative. Again, the patient did not require dialysis during this admission.

Immunosuppression consisted of daily Thymoglobulin for a total of 5 days. As urine output picked up on the 6th day, the patient was started on Prograf and Myfortic. She was given a standard 5-day prednisone taper. She was tapered down to 10 mg daily. Since the patient was on prednisone preoperatively, she was maintained on prednisone on discharge as part of her maintenance drugs.

Foley catheter was removed on day 5 postoperatively. Her JP drain remained in place when she was discharged since it was putting out 100 mL per day. Urology was consulted for outpatient stent removal. She was given dietary counseling by nutritional services. She was given teaching by the transplant nurse practitioner as well as transplant pharmacist. Followup appointment was given.

ACTIVITY RESTRICTIONS: To avoid lifting greater than 10 pounds for 2 months and she was given diet order of 2-gram sodium diet.

DISCHARGE MEDICATIONS: Myfortic 720 b.i.d., Prograf 1 mg b.i.d., aspirin daily, Septra 1 daily, Valcyte 450 daily, Mycelex Troches 2 times a day, prednisone 10 mg daily, Senokot 1 b.i.d., Pepcid 20 b.i.d., Norvasc 10 daily, labetalol 400 mg b.i.d., Lasix 40 mg daily, and Darvocet as needed for pain.

DATE OF DISCHARGE: MM/DD/YYYY

ADMISSION DIAGNOSIS: Pancreatitis.

DISCHARGE DIAGNOSES:
1. Pancreatitis, resolving.
2. Allergic rhinitis.
3. Headache.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female with no significant past medical history other than some mild nonspecific headache for the last six months, who was transferred for evaluation of pancreatitis and possible appendicitis. As per the family, the patient was in her usual state of health until approximately 7 in the evening, one day prior to admission, when she developed epigastric chest-like pain.

At that time, she felt like she could not breathe and turned pale and after throwing up in the emergency department had some relief. During her initial workup in the emergency department, she had elevated amylase at 750 and elevated lipase at 520. Alkaline phosphatase was also noted to be elevated at 198, and AST and ALT were normal. On report from parents, a CT was performed where there was a question of appendicitis, but after being reviewed by the pediatric radiologist, it was felt that the CT looked normal.

The patient did undergo an ultrasound upon arrival to this facility, right upper quadrant ultrasound, which was read as normal. There was also some question of debris in her bladder based on the review of the CT, so urinalysis was performed, which also appeared negative without any signs of infection. The patient had her amylase and lipase followed throughout her hospitalization with her amylase at the time of her arrival here being 210 and on the day of discharge down to 146. Her lipase had remained normal throughout her hospitalization in addition to her alkaline phosphatase, AST and ALT.

The patient did report some frontal-like headache during her hospitalization that was treated with some Tylenol and Toradol. Parents reported strong family history of allergic rhinitis, and the patient does have what appears to be allergic rhinitis symptoms. We recommended to the mother that we treat this appropriately and see if her headaches do resolve.

In addition to this, the patient did not continue with antibiotics during her hospitalization here; although, she did receive her first dose at the outside facility. She remained afebrile without any abdominal pain and tolerated starting of her low-fat diet well without any emesis or abdominal pain.

PHYSICAL EXAMINATION: On the day of discharge, the patient’s temperature is afebrile with stable vital signs. General: The patient is sitting up in bed, playing on her computer, in no acute distress. HEENT: Normocephalic and atraumatic. Moist mucous membranes. No sinus tenderness. Nasal mucosa slightly erythematous. Conjunctivae and sclerae clear. Lungs: Clear to auscultation bilaterally. Good air exchange. Cardiovascular: Regular rate and rhythm without murmur, 2+ pulses. Capillary refill less than 2 seconds. Abdomen: The patient does have some right lower quadrant mild tenderness with deep palpation but no rebound tenderness. No guarding. She does have some mild left upper quadrant tenderness. No hepatosplenomegaly.

ASSESSMENT AND PLAN: The patient is a (XX)-year-old female with acute episode of pancreatitis, which appears to be resolving. In addition to this, she appears to have allergic rhinitis that is untreated and could be contributing to her frequent headaches. We will discharge her home today on Flonase, loratadine and have her follow up with her labs in approximately a week and have her discuss these results with her primary care physician. We will also have her continue with low-fat diet until she is cleared by her primary care physician.

DATE OF DISCHARGE: MM/DD/YYYY

ADMISSION DIAGNOSES: Impairment of mobility and activities of daily living requiring inpatient rehabilitation; peripheral vascular disease, status post left below-the-knee amputation; history of right below-the-knee amputation; bacteremia; pneumonia; Clostridium difficile enterocolitis; end-stage renal disease, on hemodialysis; diabetes mellitus; diabetic peripheral neuropathy; blindness with retinal detachment; atrial fibrillation, status post pacemaker insertion; coronary artery disease; hypertension; anemia with chronic renal disease.

DISCHARGE DIAGNOSES: Impairment of mobility and activities of daily living requiring inpatient rehabilitation; peripheral vascular disease, status post left below-the-knee amputation; history of right below-the-knee amputation; bacteremia; pneumonia; Clostridium difficile enterocolitis; end-stage renal disease, on hemodialysis; diabetes mellitus; diabetic peripheral neuropathy; blindness with retinal detachment; atrial fibrillation, status post pacemaker insertion; coronary artery disease; hypertension; anemia with chronic renal disease; left shoulder pain, likely bursitis.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic male who was readmitted here. The patient was admitted initially after the left below-the-knee amputation. The patient was in need of rehabilitation at the time and the patient was admitted. The patient was also being treated for pneumonia during that hospitalization with hemodialysis for end-stage renal disease. The patient was doing well and progressing well until MM/DD/YYYY when he became lethargic and became hypoxemic.

The patient was readmitted back with a diagnosis of new pneumonia. The patient was treated with antibiotics. The patient was getting better but the patient still has significant amount of bacteremia as well as Clostridium difficile enterocolitis. Appropriate medical treatments were initiated. Obviously, the patient became quite a bit more deconditioned and was having significant difficulty with self-care activities and mobility due to the recent BKA with a history of right below-the-knee amputation in the past. The patient required moderate to maximal assistance for mobility and was not ambulatory at all. The patient required similar assistance for self-care activities and the patient was quite deconditioned.

The patient obviously was in need of comprehensive inpatient rehabilitation care. The patient’s case was reviewed at the preadmission meeting here. It was determined that the patient would benefit from comprehensive inpatient rehabilitation and was an excellent candidate. Therefore, the patient was admitted. This hospitalization was reasonable and medically necessary. The patient will continue to require close monitoring of his medical condition as well as his functional condition.

HOSPITAL COURSE: The patient received comprehensive inpatient rehabilitation care. The patient received physiatric care for rehabilitation and medical intervention. The patient was also followed for nephrology management. Overall, the patient remained medically stable. The patient was continued on oral vancomycin due to persistently positive Clostridium difficile toxin. The patient had intermittent diarrhea as well. The patient continued to receive hemodialysis three times a week. The latest BUN was 42 and creatinine was 4.2. Potassium was 4 and sodium was 134.

Anemia was stable with hemoglobin of 9.6 and hematocrit of 29.4. The patient was continued on insulin and also Aranesp for his anemia. The left stump was healing well. There were some scabs, but there was no evidence of infection. Gentle wrapping was done but stump shrinker was not used in view of incomplete healing at the time of discharge. The patient has evidence of pleural effusion. The chest x-ray showed some pleural effusion and possible right basilar infiltrate. Nephrology followed the patient very closely. The patient was able to participate in the rehabilitation program as fully as he possibly could do. Discharge planning was done.

FUNCTIONAL STATUS: The patient required minimal assistance for bed mobility and minimal to moderate assistance for functional transfers using right prosthesis. The patient was obviously nonweightbearing at the left lower extremity due to recent BKA. The patient was not ambulatory. The patient also required assistance for wheelchair mobility due to blindness. The patient required supervision for eating and grooming and upper body dressing, minimal assistance for lower body dressing, maximal to total assistance for bathing and toileting. Extensive family training was done.

DISCHARGE MEDICATIONS: Betoptic S one drop each eye at bedtime; Lasix 40 mg p.o. daily; Lantus insulin 20 units subcutaneously at bedtime, one month’s supply; Xalatan ophthalmic solution one drop to each eye at bedtime; Protonix 40 mg p.o. daily; Zoloft 50 mg p.o. at bedtime; Nephro-Vite one p.o. daily; vancomycin orally 250 mg q. 6 hours x1 month; and Vicodin one p.o. t.i.d. p.r.n., #60.

FOLLOWUP: The patient will have followup with Nephrology on next hemodialysis day. The patient will also have followup with Dr. John Doe. The patient will be followed here in about four weeks. The patient was referred to outpatient physical therapy here two times a week for four weeks and these are to be done on nonhemodialysis days. The patient will continue with preprosthetic training and stump wrapping.

DISCHARGE DIET: A 2000-calorie ADA with renal diet.

DISCHARGE EQUIPMENT: The patient already has a front-wheel walker, wheelchair, bedside commode, and shower chair. Sliding board was ordered.

DISCHARGE CONDITION: Medically stable.

DISPOSITION: The patient is being discharged home with wife and family assistance.

DATE OF DISCHARGE:  MM/DD/YYYY

ADMITTING DIAGNOSIS: Hematuria.

DISCHARGE DIAGNOSES:
1. Hematuria, resolved.
2. Atrial flutter and atrial fibrillation, ablation on MM/DD/YYYY.
3. History of myocardial infarction, anterior coronary stenting on MM/DD/YYYY.
4. History of dyspnea.
5. Ischemic heart disease, left ventricular ejection fraction of 25%.
6. Possible passage of renal calculi.

HISTORY OF PRESENT ILLNESS: The patient is a very pleasant (XX)-year-old gentleman who was just discharged from the hospital the day before admission here after undergoing an ablation for his atrial fibrillation and atrial flutter. He was discharged on outpatient Lovenox and Coumadin in stable condition. He states that he has noticed a red color to his urine and also had some shortness of breath, and he was admitted for further evaluation.

HOSPITAL COURSE: The patient was admitted and placed on routine cardiac telemetry orders, and urology was consulted and Dr. John Doe saw him in this regard. He also underwent a V/Q scan, which was low probability for pulmonary embolism. He had a chest x-ray that was unremarkable other than a small left pleural effusion and Lasix was begun.

He stated that he had some right inguinal site discomfort, and he passed some blood in urine and then the discomfort was relieved and afterwards that hematuria also cleared out. He subsequently had clear urine from that point on. He had an IVP and showed possible prostatic enlargement and no real opaque calculi formation or obstructive uropathy.

He did well with increased activity, and he was discharged home in stable condition.

DISCHARGE INSTRUCTIONS: The patient is to follow with Dr. Jane Doe in one to two weeks. He is to follow a heart-healthy diet with light and easy gradual return to normal activity over the next day or two. He is to obtain PT, INR, and to avoid all smoking or tobacco product exposure.

MEDICATIONS ON DISCHARGE: Coumadin 5 mg on Monday, Wednesday, and Friday, 7.5 mg on Tuesday, Thursday, Saturday, and Sunday; Zocor 10 mg at bedtime; Pepcid 20 mg daily; Cordarone 200 mg daily; Coreg 3.125 mg b.i.d. ; Lasix 20 mg daily; and K-Dur 20 mEq daily.

CONDITION: The patient was discharged stable.

DISCHARGE DIAGNOSES:
1.  Status post foreign body removal of left thigh.
2.  Fasciotomy of left thigh.
3.  Status post repair of left sciatic nerve.

PROCEDURES:
1.  Removal of foreign body, left thigh.
2.  Fasciotomy, left thigh.
3.  Evacuation of hematoma.
4.  Repair of sciatic nerve.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male who was transferred from an outside hospital after a blast wound to his left thigh. An x-ray showed a foreign body in the posterior left thigh. He complained of pain in this area as well as some numbness down to the foot, which propagated upward. No other complaints.

PAST MEDICAL HISTORY: Significant for murmur since birth.

PAST SURGICAL HISTORY: None.

CURRENT MEDICATIONS: Zyrtec, amoxicillin, and Flonase.

ALLERGIES: None.

FAMILY HISTORY: Significant for father with blood clots.

SOCIAL HISTORY: The patient denies smoking and drug use. He does use occasional alcohol.

PHYSICAL EXAMINATION: Vital Signs: The patient’s vital signs were stable. General: The patient is alert and oriented x3. He is cooperative and pleasant. HEENT: Head is atraumatic and normocephalic. Ears: Pneumotympanum. Eyes: Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Nose: No rhinorrhea. Mouth reveals mucous membranes to be pink and moist throughout. Trachea is midline. No tracheal deviation. Lungs: Clear to auscultation bilaterally. Heart: Regular rate and rhythm. S1 and S2. There is a grade 3/6 systolic murmur noted. Abdomen: Soft, flat, and nontender. Bowel sounds are positive in all four quadrants. Extremities: Pulses are +2. No ankle edema. He has no swelling to the left thigh. He did have a jagged entrance wound in the left lateral thigh. He has normal strength in the left foot but decreased sensation.

HOSPITAL COURSE: The patient was taken to surgery next day for evacuation of foreign body throughout the sciatic nerve. The patient’s pain was well controlled. Due to this, his diet was advanced, and he did continue to work with physical therapy. He did progress well. He received daily dressing changes, which were uneventful. The patient was discharged home in stable condition. He will follow up with Dr. John Doe in approximately two weeks and with Dr. Jane Doe in one week. He will continue on a regular diet and was instructed to continue using a walker and not to bear full weight on his left foot. He and his wife were taught how to perform dressing changes for the left thigh. He was instructed to perform daily dressing changes, to wash surgery wound with soap and water, pad it dry, and then cover with dry dressings. He was sent home on Keflex and Darvocet. He was instructed to look for any redness, swelling, drainage or fever greater than 101 degrees. He was advised to give the doctors a call and/or present to the emergency department immediately without hesitation. He did verbalize understanding of all instructions given.

CONDITION ON DISCHARGE: Stable.

DATE OF DISCHARGE: MM/DD/YYYY

DISCHARGE DIAGNOSES:
1. Fever.
2. Drenching sweats.
3. Possible typhoid.
4. Travel-related illness.
5. Abnormal antistreptolysin-O titers.
6. Dry bronchitic cough.
7. Right axillary induration.

DISCHARGE MEDICATIONS:
1. Rocephin 2 grams IV push q. 24 h. x7 more days or total of 10.
2. Vibramycin 100 mg p.o. b.i.d. x7 days or total of 10.

PROCEDURES: None.

CONSULTANTS: None.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old normally healthy Hispanic male who had gone to Central America. He had flown in from Central America, and at that time, his mother noted that he was probably more tired and had less appetite. They came home on Saturday. He thought he was developing allergy symptoms and vague headache. By Sunday, he began developing drenching sweats, chills, and a temperature of 103 as well as lower back pain. His father started him on antibiotics at this time. On Monday, he was unable to go to work, was constipated, followed by some stools. He continued to have drenching night sweats, and by Tuesday, his father brought him to the emergency room where his white count was 6000, hemoglobin 15.4, and platelets normal. There was mild abnormality of the ALT. Monospot was negative. Malaria smear was negative. Chest x-ray was negative. He was admitted. Blood cultures were obtained. He ate nowhere except at the resort, except for one night. He did no snorkeling. He went into the rainforest. He ate no shellfish, just salmon and marlin.

PAST MEDICAL HISTORY: Right ACL repair and closed reduction, left arm, both 10 years ago.

ALLERGIES: NONE KNOWN.

HABITS: Tobacco: Denied. Alcohol: Occasionally on weekends. Street Drugs: Denied. Transfusions: Denied.

SOCIAL HISTORY: The patient is single and employed. His parents are in good health. He has an older brother.

FAMILY HISTORY: Noncontributory.

REVIEW OF SYSTEMS: Otherwise negative, except for some past diarrhea but is basically healthy.

PHYSICAL EXAMINATION: GENERAL: It is confirmed that he has significant sweats and drenches his clothes. VITAL SIGNS: He is 5 feet 7 inches, was not weighed. Temperature is 97.8, pulse 88, respirations 20, and blood pressure 146/88. HEENT: There is no scleral injection. Pupils are equal. Oropharynx is benign. There are areas of a few shotty nodes, particularly on the right. NECK: Perfectly supple. LUNGS: He was observed to be having a dry, hacking, nonproductive cough that improved as he was hospitalized. CARDIAC: Regular rhythm. No murmurs. ABDOMEN: Soft. No organomegaly. LYMPHATICS: He has some shotty nodes. EXTREMITIES: No calf pain. No rash. NEUROLOGIC: Grossly intact. MUSCULOSKELETAL: He has right axillary area induration without actual appreciable masses or nodes.

HOSPITAL COURSE: The patient was asked to give a stool sample, which took several days to accomplish. He was started on Rocephin to cover the possibility of typhoid fever as the symptoms of dry cough, constipation, high fever, normal white count, and a travel history were considered compatible. An ASO titer proved positive at 488, though certainly this does not fit with the cough symptom or the other symptoms.

An ultrasound was done to evaluate liver and spleen size, which were normal. An ultrasound was done to look in the axilla for nodes and no nodes were found. The patient denied any exposure to pets or animals. Because there was a question of adenopathy, lymphadenopathy workup was done. The toxoplasma titers are nondiagnostic and HIV was negative. A mono screen was negative. Herpes simplex PCR in the blood was negative. Lyme serology was negative. CMV IgG was negative. His CMV IgM was negative. Epstein-Barr virus shows an IgG of 7540, compatible with previous mono, with negative IgM. Malaria smears were negative. In addition to this, the patient also had Ehrlichia PCR and Bartonella PCR performed as well as pasteurella serology and tularemia serology.

The patient, by 48 hours, was 80% to 85% better. The sweating seemed to have resolved. His appetite was starting to return. It was elected to send him home and empirically treat him as if he has typhoid. He did note that when he gave stool, it was mucusy and it was our impression that the patient did respond to empiric Rocephin and Vibramycin. It was elected to continue this for another four weeks awaiting labs and cultures. He was told to return in two weeks to follow up. He did have also a normal chest x-ray.

DATE OF DISCHARGE: MM/DD/YYYY

DISCHARGE DIAGNOSES:
1. Decompensated congestive heart failure secondary to dilated cardiomyopathy, ejection fraction of 15%.
2. Fecal impaction.
3. Urinary tract infection.
4. Hypertension.
5. Type 2 diabetes, uncontrolled.
6. Hypothyroidism.
7. Hyperlipidemia.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old lady with dilated cardiomyopathy, ejection fraction of 15% , who presented to the emergency room with shortness of breath, difficulty voiding, and severe constipation. This patient has been followed by home physicians and is managed on a diuretic and low dose of angiotensin receptor blocker at home. Over the last few days, prior to admission, she has had weight gain, increased shortness of breath, and leg swelling. She had difficulty voiding as well as constipation. She denied any fevers, chills or dysuria.

PHYSICAL EXAMINATION: GENERAL: The patient was found to be alert, in mild respiratory distress. VITAL SIGNS: Blood pressure 102/66, pulse rate 74, respiratory rate 22 to 24, afebrile. HEENT: Unremarkable. NECK: Supple. Mild jugular venous distention at 6 cm of water. LUNGS: Bilateral scattered wheezing and crackles at both bases. HEART: S1, S2 soft. Regular rate and rhythm. No murmur or gallop. ABDOMEN: Soft, distended with positive bowel sounds but diminished. No organomegaly or masses. EXTREMITIES: There is 2+ bilateral pitting edema, pulses preserved.

LABORATORY DATA: Upon admission, CBC revealed WBC 8.6, hemoglobin 13.4, hematocrit 41.4, platelets 208, and normal differential. Chemistry showed sodium 139, potassium 4.6, chloride 100, bicarbonate 30, BUN 30, creatinine 1.1, glucose 134. Liver function tests normal. Albumin 3.5, troponin less than 0.4, calcium 8.1, magnesium 2.1. BNP upon admission 1014, upon discharge BNP of 484. TSH high at 13, free T4 normal, free T3 low. Hemoglobin A1c is 7.5%.

DIAGNOSTIC DATA: Echo Doppler showed dilated cardiomyopathy, ejection fraction of 15%. Acute abdominal series showed fecal impaction but no obstruction. Chest x-ray showed pleural effusion, especially on the right, and congestive heart failure. Urinalysis: Positive nitrites, large leukocytes. Upon discharge, urine culture negative. EKG: Sinus rhythm, premature ventricular complexes, left bundle branch block, which is chronic.

HOSPITAL COURSE: The patient was seen in the emergency room when she was found to have stool impaction. It was manually disimpacted, and the patient received a bowel regimen with MiraLax and Colace around the clock. She achieved good bowel evacuation throughout hospitalization.

For congestive heart failure, she was diuresed with intravenous Bumex, and upon discharge, the Bumex dose was increased from 1 to 2 mg daily. Potassium supplementation was also added to the patient’s regimen. Due to the patient’s relative hypertension, she is not able to tolerate any bigger dose of angiotensin receptor blocker or beta blocker. The patient achieved excellent diuresis throughout hospitalization and with resolution of leg edema and shortness of breath. Oxygen was weaned off.

In regards to other issues, she was diagnosed with a urinary tract infection, treated with five full days of intravenous Levaquin. Upon discharge, urine culture was already normal. Also, she was found to be mildly hypothyroid and a low dose of thyroid supplementation, levothyroxine at 25 mcg, was started during hospitalization.

On MM/DD/YYYY, the patient was hemodynamically stable, afebrile, and ready for discharge home. Diet and activity as tolerated.

MEDICATIONS AT HOME: Novolin insulin 70/30, 25 units subcu q.a.m., 15 units subcu q.p.m.; Zocor 20 mg daily; Bumex 2 mg daily; potassium chloride 20 mEq daily; Diovan 80 mg half tablet daily; FiberCon one tablet daily; levothyroxine 0.025 mg daily; glycerin suppository daily p.r.n.; Fleet enema daily p.r.n.; and Dulcolax tablet 10 mg daily p.r.n.

BNP to be done in about one to two weeks and TSH in two months.

FOLLOWUP:  The patient is to follow up with home doctor.

DATE OF DISCHARGE: MM/DD/YYYY

HISTORY OF PRESENT ILLNESS: The patient was born by a normal spontaneous vaginal delivery to a (XX)-year-old female, G1, P0, blood type AB+, GBS negative, hepatitis B negative, HIV negative, rubella immune, VDRL nonreactive mother who denied any tobacco, alcohol or drug use during pregnancy.

HOSPITAL COURSE: The baby was delivered at 39 weeks gestational age with a three-vessel cord and Apgars of 7 and 8. DeLee suction was used as well as blow-by O2. Mother did get Nubain during labor. Birth weight was 2825 grams.

The child began, shortly after birth, having some grunting, retractions, and was admitted to Special Care Nursery. While in Special Care Nursery, the following issues were addressed.

1. Nutrition. The child was originally n.p.o. with IV fluids of D10W running at 10 mL per hour. Hyperalimentation was begun on MM/DD/YYYY. NG bolus feeds were started on MM/DD/YYYY at 15 mL q. 3 hours. The child was again made n.p.o. on MM/DD/YYYY with having some desaturations. The hyperalimentation was continued at this point in time. Feeds resumed on the next day at 10 mL q. 3 hours, and as feeds were able to be advanced, the IV fluids and hyperalimentation were decreased. The child underwent an ENT procedure on MM/DD/YYYY and was made n.p.o. on that date. Feeds were resumed later in the day after the procedure by p.o. and NG bolus. The child had poor toleration of feedings, and the NG bolus feeds were needed a substantial amount of the time.

2. Gastroesophageal reflux disease. The patient was having multiple episodes of spitting up of food and not tolerating p.o. feeds very well. Reglan was started, and later, by recommendation of the ENT, Prevacid was begun.

3. Subglottic stenosis. ENT procedure on MM/DD/YYYY. Bronchoscopy performed by Dr. John Doe showed some subglottic stenosis, likely due to acid reflux. He recommended Prevacid, and the Reglan was continued.

4. Respiratory distress. The child was intubated on the day of admission and was given Narcan. The patient was extubated the next day and placed on nasal cannula. There were some low saturations, which followed in the nasal CPAP at +5. FiO2 50% was started and saturation improved. The CPAP was removed in the morning and tolerated well. On MM/DD/YYYY, the child began having some desaturations, and oxygen by nasal cannula was started at 1/16th of a liter.

5. Increased bilirubin. Bilirubin levels seemed to be elevated on MM/DD/YYYY and single phototherapy was begun on that day.

6. Sepsis. The patient received ampicillin and gentamicin for 5 days worth of 10 doses of ampicillin, and blood cultures remained negative.

7. Poor tolerating of feeds and low tone of the child. Pediatric Neurology was involved because of both poor tolerating of feeds and low tone of the child. MRI was performed without sedation on MM/DD/YYYY with results showing no evidence of brain parenchymal or structural abnormalities.

8. Talipes equinovarus. PT and Orthopedics were consulted concerning this issue. There were multiple episodes of ankle stretching, and they recommended further treatment as an outpatient.

9. Factor for anemia. H&H levels are 15 and 43.

10. Need for auditory evoked response test. The patient passed the AER.

PHYSICAL EXAMINATION ON DISCHARGE:
VITAL SIGNS: Stable.
HEAD: Anterior fontanelle was soft and flat.
LUNGS: Clear.
HEART: There was no murmur.
ABDOMEN: Soft and nondistended.

DISCHARGE DISPOSITION:  The patient was discharged to home with parents.

DISCHARGE INSTRUCTIONS:
1.  Discharged to home with apnea monitor.
2.  Feeds, 45 to 60 mL q. 3-4 hours, either p.o. or NG bolus.
3.  Continue the Prevacid and Reglan as prescribed.
4.  Visiting nurse will be coming twice a week for two months.
5.  Follow up with Dr. Jane Doe in one week.
6.  Follow up with Neonatal High-Risk Clinic.
7.  Also, get OT/PT as an outpatient.