DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
DISCHARGE DIAGNOSES:
1. Acute gastroenteritis.
2. Dehydration.
3. Urosepsis.
4. Abdominal pain.
5. Gallbladder stone.
6. Coronary artery disease.
7. Hypertension.
8. Diabetes mellitus.
9. Abdominal aortic aneurysm.
10. Polymyalgia rheumatica.
BRIEF HISTORY AND HOSPITAL COURSE: This is a (XX)-year-old female who was admitted to the hospital following diarrhea, vomiting, abdominal pain, and dehydration. The patient was admitted for IV hydration and evaluation of symptoms and management. The patient recently had been in the hospital with abdominal pain, nausea, and vomiting. She was diagnosed to have diverticulosis and gallbladder stones, however was negative for cholecystitis. The patient had conservative management with IV antibiotics and was discharged back to the nursing home almost a month ago.
The patient had the present symptoms for the past one to two days and was not taking any oral feedings and was having severe nausea, vomiting, and dehydration along with diarrhea and hence was brought in to rule out acute cholecystitis or an infectious colitis or diverticulitis. The patient initially was admitted with IV fluids. The patient was started on IV antibiotics, namely Rocephin. The patient was also found to have UTI and was treated with Rocephin. The patient was also continued on all other medications and was put on IV fluids and clear liquid diet as tolerated.
Pancultures were done and a gastroenterology evaluation was obtained. Initial amylase and lipase were within normal limits. Troponin T was negative. X-ray of the abdomen showed nonspecific bowel gas pattern, no signs of any obstruction or ileus. The patient continued to get better with the present treatment. Abdominal pain symptoms resolved. No new evidence of cholecystitis or diverticulitis. Diarrhea and vomiting resolved, and the patient was much hydrated. Urine culture in the meantime showed Klebsiella pneumoniae, which were ESBL positive and was sensitive only to Primaxin.
The patient had an ID evaluation done, and they recommended IV Primaxin for seven-day duration. The patient was started on IV Primaxin 500 mg q. 8 hours, and a PICC line had been ordered for IV antibiotics to be given at the nursing home. The patient is much comfortable now. The patient was also found to have right lower extremity edema, and a Doppler study was done, which was negative for any DVT. Rocephin antibiotic was discontinued, and the patient is on Primaxin with ESBL precautions. The plan is for the patient to get a PICC line today and would be later discharged back to the nursing home.
DISPOSITION: The patient was discharged to the nursing home today.
