Sample IP chart 1 H&P and DS

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

DISCHARGE SUMMARY

 

Final Diagnoses:

Active Hospital Problems

                Diagnosis              

•             (Principal) NONRUPTURED CEREBRAL ANEURYSM              

•             ALCOHOLIC CIRRHOSIS   

•             METABOLIC ACIDOSIS     

•             HYPONATREMIA               

•             LEUKOCYTOSIS   

 

Resolved Hospital Problems

No resolved problems to display. 

 

Discharge Disposition:

Home 

Medications, instructions, follow up information: See patient Discharge Instructions/AVS. 

Hospital Course and Significant Findings:

As per admitting history "32 y/o female with a history of cirrhosis, smoker says she has been having headache, N,V for about 4 days. Per ED MD's note "Note mild diffuse abdominal pain.  She got up today to get into the shower when she felt lightheaded/dizzy and passed out. Unknown length of time of LOC but sister who saw her in the bathroom did 12 chest compressions when patient became conscious. Patient admits to hearing her sister as soon as she passed out screaming and felt her chest compressions. She reports some mild chest pain in anterior mid chest, non radiating".  Denies any chest pain, palpitations, SOB, cough, dysuria, fevers or chills.

LP was neg for SAH and patient was transferred to RWC for angio in am. "

Patient admitted to the neuroscience service

Hospital course by Events

Events:

3/6 - txf for active but unruptured aneurysm - DSA done

3/7 - NAEO. Remains neurologically intact and on Decadron taper per NSGY.

3/8 - s/p Stent assisted coiling

3/9 - remains stable overnight, NAEO

Events;

3/10- stable

Hospital course by System

Neuro: Symptomatic unruptured L MCA M1 aneurysm (3 cm wide) without SAH

 ASA + Plavix for 6 months and than probably ASA for life ( NIR will follow )

Patient will be on Decadron taper per NIR Dr  recommendation for 1 week.  

ID; mild leuckocytosis due to steroids

Hyponatremia; on salt tablets , will taper off

Tobacco consumption, counseled, nicotine patch

Ambulating well prior to discharge

 Neuro exam non focal at discharge

  

Primary Procedures:

Procedure(s):

EMBOLIZATION

 

Secondary Procedures:

None

 

Reason for Hospital Admission (Admitting Diagnosis):

Aneurysm

 

Complications: none

 

Consults:

Smoker: Yes - An outpatient referral was made for smoking cessation counseling. 

Condition on Discharge: stable

 

Code Status at Time of Discharge: Full Code

 

H&P

 

Chief Complaint:

Intracranial aneurysm

 

History of Present Illness:

Ms. XXX is a 32 yo female who presented to the MMMYYY ED after what she described as fainting. In ED, Imaging with giant left MCA aneurysm with some adjacent parenchymal edema.  LP with clearing of RWC. Transferred to NNN for angiogram/treatment planning. Pt reports long standing HA but no acute worsening or HA to history to suggest prior/recent SAH.

 

Medications Prior to Admission:

Current Facility-Administered Medications for the 3/6/22 encounter (Hospital Encounter)

Medication         Dose      Route

•             Naltrexone Microspheres IM ER Suspension 380 mg (VIVITROL)  380 mg intraMUSCULAR

 

Outpatient Medications Marked as Taking for the 3/6/22 encounter (Hospital Encounter)

Medication         Sig

•             Nicotine Polacrilex (NICORETTE) 2 mg Bucl Gum Chew 1 piece of gum in mouth every hour for 6 weeks when urge to smoke, then 1 gum every 3 hours for 3 weeks, then 1 gum every 6 hours for 3 weeks. Do not exceed 24 pieces of gum in 24 hours.

•             Gabapentin (NEURONTIN) 300 mg Oral Cap          Take 1 capsule by mouth daily at bedtime

•             Multivitamin (Daily-Vite) Oral Tab             Take 1 tablet by mouth daily

 

 

Current Hospital Medications:

 

Current Facility-Administered Medications

Medication         Dose      Route    Frequency          Last Admin

•             Gabapentin Cap 300 mg (NEURONTIN)   300 mg Oral        QHS      

•             THERA-M 9 mg iron-400 mcg 1 tablet (Multivitamin-Iron-FA-Calcium-Minerals)   1 tablet               Oral        Daily                1 tablet at 03/06/22 0811

•             Chlorhexidine Gluconate Oral Soln 15 mL (PERIDEX)         15 mL   Oral        Q12H     15 mL at 03/06/22 0811

•             Magnesium Sulfate 2 gram/50 mL (4 %) IV Premix             2 g         intraVENOUS     see instruction 

•             Docusate Sodium Cap 100 mg (COLACE) 100 mg Oral        BID        

                Or

•             Docusate Sodium Oral Liquid 100 mg (COLACE)  100 mg Nasogastric         BID        

•             Flu Vaccine QS 2021-22 (6 mos up) PF IM Syg 0.5 mL (FLULAVAL QUAD)  1 Each  intraMUSCULAR               Prior to Discharge      

•             Pneumococcal 23-Val PS Vaccine Inj Syg 0.5 mL (PNEUMOVAX-23)            0.5 mL  intraMUSCULAR               Prior to Discharge      

•             Nicotine 7 mg/24 hr 1 Patch (NICODERM CQ)      1 Patch Transdermal       QAM     1 Patch at 03/06/22 0811

Allergies:

No Known Allergies

 

Past Medical History:

Active Ambulatory Problems

                Diagnosis             Date Noted

•             ALCOHOL INTOXICATION              09/28/2021

•             LEUKOCYTOSIS  09/28/2021

•             MODERATE ALCOHOL USE DISORDER      09/28/2021

•             CERVICAL HIGH RISK HPV TEST POSITIVE 02/07/2022

 

No Additional Past Medical History

 

 

Past Surgical History:

Past Surgical History:

Procedure           Laterality             Date

•             NEGATIVE PAST SURGICAL HX       

 

Social History: 

Social History

 

Socioeconomic History

•             Marital status:   Single/Never Married

                                Spouse name:   None

•             Number of children:        None

•             Years of education:         None

•             Highest education level: None

Tobacco Use

•             Smoking status: Current Every Day Smoker

                                Packs/day:          0.50

•             Smokeless tobacco:        Never Used

Vaping Use

•             Vaping Use:        Never used

Substance and Sexual Activity

•             Alcohol use:       Yes

                                Alcohol/week:  4.0 standard drinks

                                Types:   4 Standard drinks or equivalent per week

•             Drug use:             Yes

                                Comment: marijuana

•             Sexual activity:  Yes

                                Partners:             Male

                                Birth control/protection:              Natural Family Planning

 

 

E-Cigarettes/Vaping

                Questions           Responses

                E-Cigarette/Vaping Use Never User

                Passive Exposure             No

                Counseling Given             No

 

 

E-Cigarette/Vaping Substances

                Questions           Responses

                Nicotine               No

                THC        No

                CBD        No 

 

 

Family History:

Family History

Problem               Relation               Age of Onset

•             Breast Cancer    Mother  

•             Ovarian Cancer None      

•             Uterine Cancer  None      

•             Colon Cancer     None      

 

 

Review of Systems:

Negative except as per HPI

 

Objective:

BP 117/71  | Pulse 87  | Temp 98.3 °F (36.8 °C)  | Resp 13  | SpO2 100%  | Breastfeeding No

No intake or output data in the 24 hours ending 03/06/22 0921

 

Physical Exam:

General appearance - alert, well appearing, and in no distress

Chest - clear to auscultation, no wheezes, rales or rhonchi

Heart - regular rate and rhythm

Neurological - motor and sensory grossly normal bilaterally, mild decrease grip strength on right.

CT HEAD WITHOUT CONTRAST

 

** HISTORY **:

32 years old,  Head trauma, mod-severe Headache, new or worsening, post exertion or sex (Age 19-49y)

 

** TECHNIQUE **:

CT images of the head acquired without intravenous contrast.

Impression

 

Giant 3 cm left M1 MCA aneurysm with mild surrounding vasogenic edema as described. Recommend neurointerventional/neurosurgical consultation for further management.

 

Impression

 

Motion degraded exam limiting evaluation.

 

Giant left MCA aneurysm, measuring 3 cm on same-day CTA, with mild to moderate surrounding vasogenic edema and mass effect on the left lateral ventricle. 

 

Assessment and Plan:

32 yo female with giant left MCA aneurysm here for diagnostic cerebral angiogram to more accurately define anatomy. Procedure including rationale, risks, benefits and alternatives dicussed with pt. Questions answered. Consent obtained.

·               RISKS DISCUSSED INCLUDE, BUT ARE NOT LIMITED TO: DEATH, STROKE, BLEEDING, VESSEL INJURY INCLUDING DISSECTION OR PERFORATION, INFECTION, ALLERGIC REACTION, DAMAGE TO KIDNEYS, OTHER UNFORESEEABLE COMPLICATIONS