Inpatient Sample Chart 2 DS, H&P

  Inpatient sample charts / Sample Inpatient cases / Inpatient DRG coding / DRG coding sample charts

DISCHARGE SUMMARY

Primary Diagnosis

Acute Hypoxemic resp failure- background of asthma

 

Secondary Diagnosis

 h/o MS

 Depression

 Chronic pain

 Asthma

 Migraine HA

 

Pertinent Labs, Imaging and Procedures

 no invasive procedures done

 

 CTA chest 3/15/22

IMPRESSION:

1. No evidence of pulmonary emboli to the segmental pulmonary arteries.

2. Patchy and groundglass opacities throughout the lungs, suggestive of

COVID pneumonia.

3. Hepatic steatosis.

 

Hospital Course

Acute Hypoxemic resp failure- background of asthma, RESOLVED NOW

   covid was negative x 2

   cont br tx, o2 support, wean as able- now on on ra

   on abx - levofloxacin, on  steroids

   Consult ID- rec repeat serology, BC and other labs

   Afebrile

 

 h/o MS

   last steroids were 1 mo ago 

 Depression

   cont home meds

  Hypothyroidism

   cont levothyroxine

  Chronic pain

   resume home meds, avoid opioids if able

  Migraine

   restart Fioricet prn

  PPX - dvt-heparin, gi-none needed

 Condition on Discharge

 Stable

 

Physical Exam on Discharge  

General: conscious, coherent, nad

Eye: anicteric sclerae, pink palpebral conjunctivae

Neck: supple, non-tender

Respiratory: symmetrical chest expansion, ctab

Chest: rrr, no mrg

Gastrointestinal: nabs, Soft, Non-tender

Integumentary: warm, dry, good capillary refill

Extremities: 2+ pulses distally, no c/c/e

Lymphatics: no lymphadenopathy appreciated, neck normal

Neurologic: oriented x 3, no fd's noted, mmt 5/5

Psychiatric: not homicidal, not suicidal

 

Diet

Advance diet as tolerated

 

Activity

 Advance as tolerated

 

Disposition

 Home

 

Pending Labs

 None

 

H&P

 

 

Chief Complaint

Pt arrives from PCP office, reporting worsening cough she has had since Sunday. Pts reports O2 of 85% at PCPs office. Pt reports chest tightness, denies fever. Pt reports diff breathing, denies all other complaints.

 

History of Present Illness

Pt is a 42 y/o female with a h/o ms, chronic pain, and anxiety who came for dyspnea, Symptoms were present for the last 3 days. Other symptoms have been cough, fatigue and chest pain. Workup showed severe pna and resp failure. She was admitted for further care.

 

Review of Systems

All other systems were reviewed and are negative except for what is mentioned in the hpi.

 

Physical Exam

Vitals & Measurements

T: 36.8  °C (Tympanic)  TMIN: 36.2  °C (Tympanic)  TMAX: 36.8  °C (Tympanic)  HR: 92(Peripheral)  HR: 92(Peripheral)  RR: 20  RR: 20  BP: 141/81  SpO2: 92%  SpO2: 92%  HT: 170.000 cm  WT: 113.000 kg  Pain Score: 9  O2 Flow Rate: 6  O2 Therapy: Nasal cannula   

General: conscious, coherent, nad

Eye: anicteric sclerae, pink palpebral conjunctivae

Neck: supple, non-tender

Nose: nc in place

Respiratory: symmetrical chest expansion, bilat crackling noted

Chest: rrr, no mrg

Gastrointestinal: nabs, Soft, Non-tender

Integumentary: warm, dry, good capillary refill

Extremities: 2+ pulses distally, no c/c/e

Lymphatics: no lymphadenopathy appreciated, neck normal

Neurologic: oriented x 3, no fd's noted, mmt 5/5

Psychiatric: not homicidal, not suicidal

 

Assessment/Plan

Acute Hypoxemic resp failure- background of asthma

   covid was negative x 2

   cont br tx, o2 support, wean as able

   on abx - levofloxacin, on iv steroids

  h/o MS

   on fetzima

 Depression

   cont home meds

 Hypothyroidism

   cont levothyroxine

  Chronic pain

   resume home meds, avoid opioids if able

 other chronic conditions to be monitored and tx to be adjusted as needed

 PPX - dvt-heparin, gi-none needed

 

Pt will be admitted to full inpatient status. Given their current diagnosis and medical condition it is reasonable to assume that they will need a minimum of a 2-night hospitalization for further evaluation and treatment of their current medical conditions.

 

Images

 

CTA chest 3/15/22

IMPRESSION:

1. No evidence of pulmonary emboli to the segmental pulmonary arteries.

2. Patchy and groundglass opacities throughout the lungs, suggestive of

COVID pneumonia.

3. Hepatic steatosis.

 

 

Problem List/Past Medical History

Ongoing

Anxiety and depression

Chronic back pain

Colitis

Hyperlipidemia

Hypertension

Migraine

Multiple sclerosis

Osteoarthritis

Historical

No qualifying data

 

Procedure/Surgical History

•Arthroscopy of knee

•Cesarean section

•FESS - Functional endoscopic sinus surgery

•Hysterectomy

 

Medications

Inpatient

albuterol 2.5mg/3mL inhalation solution, 2.5 mg= 3 mL, NEB, q2hr, PRN

clonazePAM, 0.5 mg= 1 tab(s), Oral, BID, PRN

DuoNeb, 3 mL, NEB, BID

levoFLOXacin, 750 mg= 150 mL, IV Piggyback, Q24hr

magnesium oxide, 400 mg= 1 tab(s), Oral, As Directed, PRN

Magnesium Sulfate 50% additive + D5W 200 mL

methylPREDNISolone IV, 80 mg= 2 vial(s), IV Push, q6hr

Normal Saline 1,000 mL, 1000 mL, IV

Normal Saline Flush, 10 mL, IV Push, As Directed, PRN

ondansetron, 4 mg= 2 mL, IV Push, q6hr, PRN

oxyCODONE immediate release, 5 mg, Oral, q6hr, PRN

potassium chloride, 20 mEq= 1 tab(s), Oral, As Directed, PRN

Tylenol, 650 mg= 2 tab(s), Oral, q6hr, PRN

 

Home

amitriptyline 100 mg oral tablet, 200 mg= 2 tab(s), Oral, Once a day (at bedtime)

baclofen 20 mg oral tablet, 20 mg= 1 tab(s), Oral, TID

benzonatate 100 mg oral capsule, 100 mg= 1 cap(s), Oral, BID

busPIRone 15 mg oral tablet, 15 mg= 1 tab(s), Oral, BID

diazePAM, 5 mg, Oral, TID

divalproex sodium 250 mg oral tablet, extended release, 750 mg= 3 tab(s), Oral, Once a day (at bedtime)

Fetzima 120 mg oral capsule, extended release, 120 mg= 1 cap(s), Oral, HS

gabapentin 600 mg oral tablet, 600 mg= 1 tab(s), Oral, QID

hydroCHLOROthiazide 25 mg oral tablet, 25 mg= 1 tab(s), Oral, HS

hydrOXYzine hydrochloride 50 mg oral tablet, 50 mg= 1 tab(s), Oral, TID, PRN

levothyroxine, 175 mcg, Oral, Daily

meloxicam 15 mg oral tablet, 15 mg= 1 tab(s), Oral, HS

pravastatin 20 mg oral tablet, 20 mg= 1 tab(s), Oral, Once a day (at bedtime)

ProAir HFA 90 mcg/inh inhalation aerosol, 2 puff(s), INH, q4hr, PRN

ramelteon 8 mg oral tablet, 8 mg= 1 tab(s), Oral, Once a day (at bedtime)

Singulair 10 mg oral tablet, 10 mg= 1 tab(s), Oral, qPM

tiZANidine 4 mg oral capsule, 4 mg= 1 cap(s), Oral, TID

 

Allergies

Keflex (Hives)

azithromycin (Hives)

penicillins (Hives)

Social History

Alcohol - Denies Alcohol Use

Electronic Cigarette/Vaping - Denies Electronic Cigarette Use

Electronic Cigarette Use: Never.

Substance Abuse - Denies Substance Abuse Never

Tobacco - High Risk

10 or more cigarettes (1/2 pack or more)/day in last 30 days Tobacco Use:. 3/4 pack per day. 15 year(s).

 

Family History

Deceased Family Member(s):