DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
DISCHARGE DIAGNOSIS: Congestive heart failure.
SECONDARY DIAGNOSES:
1. Myelodysplasia.
2. Fever.
3. Chronic atrial fibrillation.
4. Benign prostatic hypertrophy.
5. Hyperlipidemia.
6. Hypertension.
7. Non-insulin-dependent diabetes mellitus.
OPERATIONS PERFORMED: No operations, except for bone marrow aspiration and biopsy.
HISTORY OF PRESENT ILLNESS: This (XX)-year-old Hispanic male with a history of chronic atrial fibrillation, hypertension, hyperlipidemia, non-insulin-dependent diabetes mellitus, and BPH was admitted for a chief complaint of increasing shortness of breath, on and off, for the past week prior to admission. The patient had mild chest discomfort but otherwise was doing fairly well. However, recently, he developed severe shaking chills associated with more recent fever but no coughing, rhinitis, sore throat, nor any nausea, vomiting or diarrhea.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.4, pulse 96, respiration 26, BP 136/66.
GENERAL: The patient is a well-nourished, well-developed male in no acute distress.
HEENT: Within normal limits.
LUNGS: Clear to auscultation.
HEART: Irregular rhythm without murmurs.
ABDOMEN: Benign.
MUSCULOSKELETAL: With 2+ edema.
CNS: Grossly intact.
DIAGNOSTIC DATA: Chem-7: Sugar was 134, BUN 20, creatinine 1.2. Electrolytes were normal. Liver enzymes were within normal limits, except for elevated SGOT of 298, SGPT of 140, total bilirubin of 2.0. LDH was 584. BNP 680, troponin 1 was 0.06. Total iron 30, iron binding capacity 268. CBC: Hemoglobin 7.8, hematocrit 22.8 with normal indices. WBC 23.2 with 57 segs, 14 bands, 13 metamyelocytes, 13 nucleated RBCs, platelets 128. Pro-time/INR 2.8. Folate and B12 were within normal limits. Urinalysis unremarkable.
Chest x-ray showed CHF with bilateral pleural effusion, small. CAT scan of the abdomen showed evidence of asbestosis with moderate sized right pleural effusion, atelectasis, and a possible 3.6 cm mass in the area of the left lower base of the lung, otherwise, the abdomen was unremarkable. CT of the chest revealed moderate right pleural effusion, slight decrease when compared to previous CT scans, bilateral calcified and noncalcified pleural plaques, mild dependent atelectasis both lower lobes, rounded atelectasis of the left base that is prominent on a previous CT. Echocardiogram was within normal limits, except for diastolic dysfunction as well as pulmonary hypertension.
HOSPITAL COURSE: The patient was admitted for a chief complaint of fever as well as CHF. After appropriate blood cultures were obtained, the patient was started on Rocephin at 2 grams IV q.24 h. as well as on vancomycin 0.75 grams q.12 h. The patient subsequently became afebrile and remained fairly stable thereafter. Blood counts revealed no evidence of bacterial infection. An echocardiogram revealed no evidence of valvular lesions. The antibiotics were continued through the hospitalization, and just a couple of days before discharge, he was switched over to Avelox but he remained afebrile throughout and no further fever occurred during the hospitalization. His congestive heart failure was treated initially with Lasix and he tolerated diuresis very well. Overall, the patient did remarkably well with less shortness of breath and with stable vital signs. The blood transfusions corrected his anemia, and hemoglobin and hematocrit increased to 11.4 and 34.6 respectively. No evidence of acute MI occurred during the hospitalization. He remained in atrial fibrillation and vital signs again remained stable. The patient’s leukocytosis continued to be remarkably elevated with subsequent white counts ranging from 15.4 all the way up to 18 with still significant bands, approximately 10-14, as well as metamyelocytes from 5 to 10 throughout the hospitalization. Dr. Jane Doe was consulted who performed a bone marrow biopsy and aspiration. The patient tolerated the procedure well. The findings suggested significant myelodysplasia. The patient’s electrolytes remained normal throughout the hospitalization. His blood sugars remained fairly stable at approximately 110 to 130 throughout the hospitalization. He was placed on a sliding scale of insulin and was also restarted on his glyburide, and again during the hospitalization, he had no evidence of any significant hypo or significant hyperglycemia. The patient was also continued on his usual medications of Cozaar as well as metoprolol, Protonix, and Pravachol without any problems.
DISPOSITION: The patient was discharged in fairly good condition.
DISCHARGE INSTRUCTIONS: He is to recheck with myself as well as with Dr. Jane Doe in one week. He is to remain on a cardiac/diabetic diet.
DISCHARGE MEDICATIONS:
1. Warfarin 3 mg daily.
2. Pravastatin 40 mg daily.
3. Metoprolol 50 mg b.i.d.
4. Cozaar 50 mg daily.
5. Glyburide 2.5 mg b.i.d.
6. Avelox 400 mg daily.
7. Lasix 40 mg daily.
8. KCl 20 mEq.
