Report 2: Discharge Summary
1. Chronic pelvic pain secondary to pelvic metastatic clear cell carcinoma of unknown primary location.
2. Vena Cava syndrome post placement of Hickman catheter.
3. Anemia due to chronic disease.
The patient is a 78 year old female whom we have been following in our clinic for hypertension and also chronic pudendal nerve pain. She had been recently diagnosed with pelvic metastatic clear cell carcinoma, which her primary location is unknown at this time. She will be discussing this further after the pathology reports are read. During her hospital stay a Hickman catheter was placed in order to have IV access for pain medication or future cancer therapy. She was also admitted for chronic pain. She did develop swelling of her arms and neck. She was brought to interventional radiology and she did have venography and the Hickman catheter was removed. Her swelling to her arms and neck have decreased greatly. She denies any shortness of breath. No choking sensation as previously noted. Her pain has been managed well with fentanyl patch at 175mcg. She has also been on IV heparin therapy for anticoagulation following the vena cava syndrome. Today, the patient has been having complaints of nausea. She did get some dexamethasone IV for her nausea, which did improve later this morning. Her blood pressure has been under good control. Her labs today include a WBC of 5.18, hemoglobin 7.8, hematocrit 23.7, protime 14.4, INR 1.5, PTT 39.6, BUN 6, sodium 139, potassium 4.2, and CO2 27.2.
1. Will continue home medications.
2. Phenergan 12.5 1-2 tabs p.o. p.r.n. every 6 hours for nausea.
3. Lovenox 1 mg/kg subcutaneously every 24 hours.
4. Fentanyl patch 175 mcg to be changed every 3 days.
5. Epogen 40,000 units subcutaneously weekly at the Cancer Center.
REPORT 3. CLINIC CHART NOTE
HISTORY: This 16 year old female is seen today after falling off a curb and twisting her right ankle. She is normally a patient of Dr. Anderson, who is out of town this week. She states that she has pain surrounding the entire foot and ankle. Seems unable or unwilling to bear weight.(Problem focused history)
PHYSICAL EXAM: Ankle and foot examined. Foot is warm to the touch. Some swelling and bruising noted around the lateral aspect of the ankle. X-ray is negative for fracture. (problem focused examination)
IMPRESSION: Sprained right ankle. (MDM complexity straightforward)
PLAN: Elevation; ice to affected area. Weight bearing only as tolerated. Return for follow-up p.r.n.
REPORT 4: ADMIT INPATIENT
This is a 19 year old with a living-related donor kidney transplant as of last month and admitted to hospital for possible sepsis.
HISTORY: This patient has Type 1 diabetes and had been on dialysis for a number of years before transplantation. She received her mother’s kidney on the 14th of last month from the Medical Center Transplant Program in Dallas. She was there this Tuesday for a transplant visit and apparently did not feel well, but they were not certain whether this was a problem or not; but they did go ahead and do blood cultures and called the public health nurse, who was visiting the patient today, and said that one of the cultures was positive for group B strep. The home health nurse called me and stated that the patient has really gone downhill the past few days and was quite fatigued with generalized malaise. Denied cough, fever, or shaking chills but looked poor overall, and the nurse was quite concerned. We recommended she be brought here for evaluation and treatment as an emergency. After arrival here, she was in no acute distress. Initially, she had bibasilar crackles on deep breathing; however, most of these cleared. I cannot hear any significant pulmonary abnormality on auscultation or percussion. Her heart is normal regular rhythm. No significant murmurs, rubs, S3, or S4. Her abdomen is negative. Her left lower-quadrant kidney is nontender. She has no lateralizing neural sounds. She is a little lethargic. She does not feel warm. Apparently she is afebrile. Her blood pressure is normal, and she is not tachycardic, but she simply does not look well. Past history, social history, and system review are per our recent old chart and noncontributory at present.
CLINICAL IMPRESSION: One positive group B strep blood culture, significance, and/or etiology to be determined. My impression at this time is probably a significant finding, and I suspect that this will become a progressive syndrome of not treated.
1. Living-related donor kidney transplant
2. Diabetes mellitus type 1
REPORT 5: NEPHROLOGY HOSPITAL PROGRESS NOTE
This patient continues to be stable with no new problems. Her cultures remain negative, and she remains afebrile. Her clearance is pending, but she certainly has settled down nicely. The main problem we are having is with her diabetic management. It simply is not working with the former twice a day of 70/30 insulin plus a nighttime Lantus. I think we should go one way or the other, and we will go to Humalog before each meal, starting with an estimated dose of 15 per meal and 40 of Lantus in the evening, and we will titrate from there. We will get Accu-Cheks before each meal to reflect the previous meal’s dose of Humalog and adjust it accordingly. Other than that, tomorrow we will review her case with infectious disease with regard to the duration of her antibiotic therapy. Thus far, our cultures have remained negative; however, the positive group B strep is not the type of typical contaminant you get in a blood culture, and we must take it at face value.
You are to complete the homework template. Below is an example:
It should be a chart with each report, a code and explanation of code.