DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
DISCHARGE DIAGNOSES:
1. Congestive heart failure.
2. Acute bronchitis.
3. Prerenal azotemia.
4. Elevated liver function tests secondary to medications.
5. History of uncontrolled hypertension with hyperkalemia secondary to prerenal azotemia.
6. Non-insulin-dependent diabetes, legally blind secondary to macular degeneration, and normochromic normocytic anemia.
CONSULTANTS: None.
PROCEDURES PERFORMED: None.
BRIEF HISTORY AND HOSPITAL COURSE: The patient is a (XX)-year-old Hispanic female. She has a past medical history significant for normochromic normocytic anemia, osteoarthritis, and non-insulin-dependent diabetes. The patient is legally blind secondary to macular degeneration, hypertension, and moderate to severe aortic stenosis. The patient was admitted after she presented with severe cough, dyspnea on exertion with no significant chest pains. The patient on admission was noted to have prior sodium of 133, potassium 5.8, and chloride 102. BUN of 25 with creatinine of 1.3. LFTs noted alkaline phosphatase 174, SGPT 61, and SGOT 92. Total CPK 104 with MB within normal limits. Troponin within normal limits. B-natriuretic peptide was 660. The patient had hepatitis screenings done, which were negative for A, B, and C. Also, she has a history of chronic anemia with WBC 9.2, hemoglobin 9.8, hematocrit 29.8, MCV 102.0, and platelets 157,000.
Cardiologist was consulted at that time and basically impression and recommendations are that patient’s medications may be causing the prerenal azotemia and also elevated LFTs. She had a chest x-ray done that showed mild central pulmonary congestion with minimal left pleural effusion. A 12-lead EKG done this admission revealed normal sinus rhythm with first degree AV block and bifascicular block. Echocardiogram showed normal left ventricular size and function, mitral annular calcification, mild aortic valve stenosis, calculated aortic valve area of 1.2 meters squared, trace aortic regurgitation, mild mitral regurgitation, trace tricuspid regurgitation, with pulmonary systolic pressure of 42. The patient was advised to stop all oral medications. Her insulin was continued. Also, the patient was put on Accu-Chek with a sliding scale. She was also put on Lasix 40 mg IV daily, and electrolytes were monitored. Hepatitis screening done, which was negative. Repeat LFTs done within 36 hours revealed almost normalization of the LFTs, that is alkaline phosphatase, SGPT, and SGOT. Alkaline phosphatase was 130, SGPT 43, and SGOT of 35, sodium 131, potassium 5.0, chloride 98, CO2 of 22, glucose 118, BUN 19, and creatinine 0.8.
The patient is therefore being discharged today. She has also been put on Norvasc, which has controlled her blood pressure, and Catapres 0.1 mg b.i.d.
DISCHARGE MEDICATIONS: Norvasc 5 mg p.o. daily; Catapres 0.1 mg p.o. b.i.d.; and Lasix 20 mg p.o. daily. The patient will also stay on Avelox 400 mg p.o. daily. She has been instructed to stop Diovan; HCTZ; Prandin; metformin; and just continue on her NPH insulin 7 units in the morning and 7 units in the p.m.
DISCHARGE INSTRUCTIONS: The patient was advised to return within one week.
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DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
DISCHARGE DIAGNOSES:
1. Acute coronary syndrome has been ruled out.
2. Myopathy. The patient is feeling better.
3. Dyslipidemia.
4. Hypertension.
5. Thoracic aortic aneurysm repair.
6. Status post coronary artery bypass graft.
7. Sleep apnea.
8. Implantable cardioverter-defibrillator.
9. Right arm paresthesias.
ADMISSION DIAGNOSES:
1. Chest pain, rule out acute coronary syndrome.
2. Myopathy secondary to Vytorin.
3. Dyslipidemia.
4. Hypertension.
5. Thoracic aortic aneurysm repair.
6. Status post coronary artery bypass graft.
7. Sleep apnea.
8. Implantable cardioverter-defibrillator.
9. Right arm paresthesias.
CONSULTANTS: Cardiology.
LABORATORY DATA: There are 3 sets of cardiac enzymes that are negative. Complete metabolic panel shows sodium 141, potassium 4.1, chloride 104, CO2 of 26, glucose 96, BUN 19, creatinine 1.2, calcium 9.8, total protein 7.4, albumin 4.1, globulin 3.1, A/G ratio 1.3, bilirubin total 0.3, alkaline phosphatase 61, ALT 14 and AST 19. Sedimentation rate is 17. Hemogram: WBCs of 6, hemoglobin of 14.2, hematocrit of 43, and platelet count of 204. Lipid profile: Triglycerides 136, cholesterol 158, HDL 37, LDL 94 and TSH 2.88.
DIAGNOSTIC STUDIES: Negative stress test, negative for ischemia. EKG, normal sinus rhythm with nonspecific ST-T wave changes.
DISCHARGE MEDICATIONS: Home medications as is minus Vytorin.
HOSPITAL COURSE: This is a (XX)-year-old male who underwent stress test to rule out ischemia because of chest discomfort. Stress test is not positive for ischemia. The patient is completely asymptomatic, hemodynamically stable, and wants to go home. The patient was advised to stop Vytorin, to see his primary care physician for hypercholesterolemia therapy, and to continue home medications as is. The patient’s cardiac workup unofficially is negative. Stress test is negative and 2D echo is within normal limits.
DISPOSITION: Discharged home.
FOLLOWUP: Follow up with Cardiology in two to three days and primary care physician within one week.
