DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
ADMISSION DIAGNOSES:
1. Altered mental status.
2. History of fever, rule out sepsis.
3. Hypothyroidism.
4. History of ethanol abuse.
5. Hypokalemia.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Status post acute myocardial infarction.
3. Hypothyroidism.
4. History of ethanol abuse.
5. Ruled out sepsis.
6. Resolved hypokalemia.
HOSPITAL COURSE: Please see the detailed H&P for more information. This is a pleasant (XX)-year-old female who has been admitted through the emergency department for evaluation of fever associated with altered mental state with decreased level of consciousness. The patient had been admitted to the progressive care unit and recommended serial cardiac enzymes to rule out any cardiac event and also started on Rocephin 1 gram IV once a day. Recommended blood cultures and also requested a neurology consult, infectious disease consult, as well as cardiac evaluation.
The patient was noted to have positive cardiac enzymes with elevated troponin of 3.2, for which she has been recommended cardiac catheterization by the cardiologist. The patient was also evaluated with MRI of the brain, which did not reveal any acute abnormality. The patient has been evaluated with CT scan of the brain, which revealed evidence of old lacunar infarct in the region of the left internal capsule. The patient has been followed with blood cultures, which have been negative.
The patient underwent cardiac catheterization, which revealed moderate coronary artery disease, 50%, in the mid LAD, for which no interventional cardiac consultation was recommended. The patient was also noted to have ostial OM1 lesion of 50%. She has not been recommended any PTCA/angioplasty by the interventional cardiologist. Once the patient was cleared from the cardiac standpoint as well as neurology standpoint, she was discharged with the below discharge instructions to be followed up on an outpatient basis.
DISCHARGE MEDICATIONS: Avelox 400 mg once a day, Plavix 75 mg once a day, aspirin 325 mg once a day, Lopressor 25 mg twice a day, Lipitor 10 mg once a day, levothyroxine 50 mcg once a day, and Premarin 0.9 mg once a day.
DISCHARGE INSTRUCTIONS: The patient was recommended to follow up with her primary care doctor in 1 to 2 weeks’ time.
