The patient is a 3-1/2-year-old male with a 5-day history of nausea, vomiting, temperature elevation, increasing lethargy.He was seen and evaluated in the office on the day of admission and brought to the emergency room for lumbar puncture.This revealed cloudy fluid.Also, a CBC was consistent with a bacterial process.
PHYSICAL EXAMINATION
Blood pressure 92/64, pulse 100, respirations 24, temperature 100.8.HEENT revealed marked stiffness of the neck with nuchal rigidity.Positive Brudzinski, Kernig signs.Chest was clear.Heart regular in rhythm.Abdomen was soft.Neurologic:The patient was fairly lethargic and did not respond appropriately to painful stimuli.
LABORATORY DATA
Lumbar puncture revealed normal pressure.CSF protein 67.WBC 7040 with 98% polys, 2% lymphs, 210 rbc’s.Gram stain positive for gram-negative cocci.CSF glucose 26, serum glucose 96.CBC revealed WBC of 21.9 with 70 segs, 13 bands, 14 lymphs.Hemoglobin 11.6, hematocrit 35.1.
PLAN
Patient to be admitted emergently with probable meningitis.
FOOTNOTE
Line 21.Sign was changed to signs for plural agreement (Brudzinski, Kernig signs).
Line 22.Neuro was expanded to Neurologic for clarity.
Line 31.The 2 different laboratory test results (hemoglobin and hematocrit) were separated for clarity.
This 67-year-old female was evaluated by me in the emergency department at approximately 0630 hours for complaints of repeated episodes of vomiting, numbering at least 5 during the preceding 8 or so hours. She stated that she is a known diabetic and has taken fingerstick readings of 423 and 241 at home. She is on multiple medications including regular insulin 10 units in the a.m., along with Ultralente 16 units at h.s., along with Trental, Pamelor, and niacin. She is a known diabetic for 54 years. She also admits to some chest pain, somewhat burning in nature, without radiation into her face, neck, or arms. There is no history of diarrhea. She has a previous history of coronary artery bypass surgery some 4 years earlier.
PHYSICAL ASSESSMENT
Physical assessment reveals her temperature to be 98.2, pulse 60, respirations 20, and a blood pressure of 102/50. Initially her color was pale. Her mucous membranes did appear dry. Heart rate was regular without murmurs. There was a well-healed cicatrix to the anterior midsternal region. Lungs were clear to auscultation. The abdomen was soft with generalized tenderness. No unusual pulsating masses. Lower extremities were free of any pretibial edema.
IMPRESSION
1. Diabetes mellitus, out of control.
2. Dehydration.
3. Electrolyte imbalance.
PLAN
While in the emergency department, multiple diagnostic studies were performed, including CBC, glucose, BUN, potassium, sodium, UA, Panel A, ABG, PT, PTT, electrocardiogram, CPK-MB via electrophoresis. Her serum glucose was noted to be 511, serum sodium of 129, and a BUN of approximately 30.
During her ER stay she was given normal saline with some subjective improvement. She was also given Compazine 10 mg IM for repeated vomiting. Her condition at the time of admission was slightly improved.
FOOTNOTE
Line 9 (Page 1). In duration was deleted. (Duration indicates time span. Five episodes of vomiting is the amount, not the duration.)
Line 11 (Page 1). Alternative: Finger stick.
Line 36-40 (Page 1). The abbreviations used were expanded for clarity.
Line 42 (Page 1). Plan was deleted since it had already been dictated in
Elevated blood sugars uncontrolled by high-dose outpatient insulin.
HISTORY AND PHYSICAL FINDINGS
The patient is an 80-year-old white male with history of type 2 diabetes, intermittently requiring insulin, with recent flare-up of his chronic congestive heart failure and bronchitis, which resulted in an elevation of blood sugars. He has been on Glucotrol 15 mg b.i.d., but blood sugars were going over 400 on his Glucometer at home for the last week and a half. He was started on insulin and this dose increased to 90 units per day, given concomitantly with the Glucotrol. He was also given some Zaroxolyn for the flare-up of congestive heart failure he had last week. As a result, his blood sugars have not come down significantly, still running frequently off the scale on the Glucometer at home and running as high as 557 two days ago at a laboratory. His sodium has dropped from the mid to high 120s down to low 120s, and BUN and creatinine have risen secondary to Zaroxolyn as in the past. He has been treated with ampicillin for his bronchitis. The patient also has a history of permanent left nephrostomy tube for ureteropelvic junction dysfunction.
MEDICATIONS
Allopurinol 100 mg b.i.d.; Lasix 160 mg a.m., 120 mg p.m.; Feldene 20 mg q.a.m.; Metamucil 2 tablespoons h.s.; Darvocet-N 100, 1 every 4 to 6 hours p.r.n. pain; Dalmane 15 mg h.s.; nitroglycerin 0.4 mg sublingually p.r.n. chest pain; Micro-K 10 mEq 1 to 3 times per day; Cardizem 60 mg q.i.d.; Isordil 30 mg q.i.d. He had 95 units of insulin the day prior to admission and, I believe, 80 units of combined NPH and regular insulin the day of admission.
PHYSICAL EXAMINATION
Vital signs include temperature 97.7, pulse 72, respirations 28, blood pressure 120/70. General examination reveals an obese white male. HEENT reveals PERRL. Normal fundi. TMs normal. Pharynx clear. Neck without JVD. Coronary examination reveals a regular rate and rhythm. Lungs are clear. A few coarse bibasilar rales. Abdomen is obese without masses. Back with left nephrostomy tube. Genital examination indicates an uncircumcised male. Testicular edema that was noted last week in the office prior to Zaroxolyn therapy is now resolved. Extremities show 1+ edema extending all the way to the thighs and presacral area. Is wearing TED hose. Right leg is worse than left per usual.
LABORATORY
CBC reveals white blood count is 7000 with 66 polys, no bands, 23 lymphs, 8 monos, 3 eosinophils. Hematocrit 45.0. Blood sugar on admission 445. Electrolytes reveal sodium 115, potassium 3.2, chloride 72, CO2 32. BUN 73, creatinine 2.6.
IMPRESSION
1. Type 2 diabetes — flare-up secondary to congestive heart failure and bronchitis.
2. Recent exacerbation of congestive heart failure — resolved.
3. Hyponatremia, probably secondary to hyperglycemia (artificial) and Zaroxolyn.
4. Acute exacerbation of chronic renal failure secondary to Zaroxolyn.
5. Recent history of decreased auditory acuity — probably secondary to Lasix and Zaroxolyn, although Lasix dose has been chronically the same.
PLAN
The patient will be given subcutaneous and IM insulin as required to bring his blood sugars down to a more acceptable range, and then NPH and regular insulin will be given on a split-dose b.i.d. dosing regimen.
FOOTNOTE
Line 33 (Page 1). Alternative: 4-6.
Line 35 (Page 1). Alternative: 1-3.
Line 40 (Page 1). Exam was expanded in the heading.
Line 42 (Page 1). BP was expanded to blood pressure for clarity.
Line 1 (Page 2). The dictation error was corrected; TED’s was changed to TED.
Line 18 (Page 2). In the Impression, the dictated number 4 was corrected to be numeral 5.
Line 23 (Page 2). The slang term subcu was expanded to subcutaneous.
A 34-year-old lady who comes to clinic today with longstanding history of hypothyroidism, for which she has taken Cytomel in the past. Comes in today for a refill of medication and further evaluation.
Examination shows her to be in no acute distress. Blood pressure 120/88. HEENT normal. Chest is clear. Cardiac examination reveals regular rate and rhythm without murmur.
ASSESSMENT
A 34-year-old lady with longstanding hypothyroidism. I would prefer to switch her to Synthroid 0.1 mg as I think the packaging is more uniform in this product. Then test thyroid-stimulating hormone in 1 month.
FOOTNOTE
Line 7. The article A was added to avoid beginning the sentence with a numeral.
Line 13. The blood pressure value 120 by 88 is written 120/88.
Line 18. A zero was inserted before the decimal point for clarity.
Lines 19, 20. TSH is expanded in the assessment for clarity.
One grain of thyroid did not work as well as 1-1/2 in terms of reducing facial and neck edema. When she sleeps away from home, however, the edema does not occur. It is almost certainly an allergy to some component of her house. I suggested, since she is going to college, that she try to taper and discontinue the thyroid over a 3-month period. Will return in 6 months if still on 1-1/2 grains, otherwise 1 year if on a lower dose of thyroid. Pulse 75, blood pressure normal. Heart and lungs okay. Has a small mole which does not appear to be a problem.
This 36-year-old man was doing well until 3 years ago, when he developed progressively severe fatigue. At that time he had been in a stressful job situation. However, these symptoms have persisted and gotten worse, although the stress has improved. There is no relation to meals or time of day, although he is somewhat more tired in the afternoons. He sleeps 7 to 8 hours during the week and 12 hours on weekends. Chemistry-2, CBC, Epstein-Barr studies, and thyroid function tests have been normal. Was tried on Thyrolar one-half grain because of low normal T4, but there was no benefit. Has received Parnate, Nardil, and other antidepressants, including vitamin B12 injections, without any benefit. He has a 3-year history of constant burning in the eyes. An ophthalmologist did not find anything wrong.
REVIEW OF SYSTEMS
Has periodic dizziness particularly when standing up rapidly, occasional tinnitus, frequent constipation and occasional diarrhea, nocturia x2 or 3, cold extremities, and dry skin of relatively recent onset. Has some anxiety and insomnia and is depressed, apparently in relation to his condition.
FAMILY HISTORY
Father has heart disease. Brother has retinitis pigmentosa.
GROSS NEUROLOGIC: Gross neurologic examination is normal.
SKIN: Skin is normal.
RECTAL: Rectal examination not done.
ASSESSMENT
1. Chronic fatigue.
2. Burning eyes.
3. Depression.
4. Signs of possible hypothyroidism.
5. Constipation and diarrhea.
PLAN
We will check basal temperatures and begin thyroid prescription if low. Gave therapeutic trial of 6-cc vitamin C, 4-cc calcium/magnesium, 1 cc of B6, B12, B5, and B complex IV. Will repeat if helpful. Other recommendations as noted and return in 4 weeks.
FOOTNOTE
Line 13 (Page 1). Chem was expanded to Chemistry. Exam was expanded to Examination.
Line 35 (Page 1). Exam was expanded to Physical Examination. Line 36 (Page 1). Height and weight was added for clarity.
Lines 36-47 (Page 1). The subheadings were added in Physical Examination to follow proper format.
Line 9 (Page 2). Alternative: I.V. (intravenous). The slang term cal/mag was expanded to calcium/magnesium for clarity.
First seen in my office on referral. Enclosed is a copy of his referral notice.
Examination on the 19th did reveal bilateral serous otitis, decreased nasal airway secondary to adenoid hypertrophy, and bilateral tonsillar hypertrophy.
It is my recommendation that he undergo an adenotonsillectomy with the insertion of ventilating tubes.
4. Urinary frequency. Rule out urinary tract infection.
5. Hypertrophy of gums.
6. Right popliteal mass.
7. Possible psoriasis.
DISCHARGEDIAGNOSES
1. Left lower leg cellulitis.
2. Left lower leg ulceration.
3. Diabetes mellitus.
4. Urinary frequency. Rule out urinary tract infection.
5. Hypertrophy of gums.
6. Right popliteal mass.
7. Possible psoriasis.
ADMIT INFORMATION
Full history and physical have been dictated. Briefly, this is a 48-year-old white female with obesity and diabetes who has had a smoldering left lower extremity cellulitis for the past 2 to 3 months. It is possibly related to her pruritus and psoriasis. She has been treated in the past with Coumadin and IV antibiotics. On the day of admission she presented to my office with worsening of the cellulitis and a new 2-cm ulceration and was admitted for IV antibiotics and further evaluation.
ALLERGIES
ALLERGY TO PENICILLIN AND SULFA AND POSSIBLY TO COUMADIN.
Medications on admission were Procardia, Mellaril, Aldactone, Glucotrol, and hydrochlorothiazide. The extremities revealed bilateral edema 1 to 2+ to the knees, with erythema and diffuse excoriations with erythema from the ankle to the midshin area on the left lower extremity. She had a 2 x 2-cm superficial ulcer on the lateral aspect of the ankle. Of note on the right popliteal fossa, she had a mobile, firm mass, 2 x 2 cm.
Laboratory on admission revealed urine with 80 to 150 wbc’s, 3 to 6 rbc’s, 10 to 15 epithelials, but only a few bacteria. Sodium was 138. Electrolytes were normal. BUN and creatinine were normal. The creatinine was 1.4, which is probably acceptable for this obese woman. PT was slightly elevated at 15.6. PTT was normal. Subsequent chemistry panel was essentially normal. CBC revealed a white blood cell count of 6, hemoglobin of 12, hematocrit of 35, with 345,000 platelets and a normal smear.
HOSPITAL COURSE BY PROBLEMS
1. Cellulitis and ulceration as well as chronic skin problems. The patient was seen in consultation by a dermatologist who confirmed my diagnosis of cellulitis. She was placed on IV Kefzol for 48 hours with marked improvement in her cellulitis. Her skin condition was consistent with lichen simplex chronicus, and she was begun on Topicort cream b.i.d. Her Coumadin was not continued as she had no venogram or Doppler evidence of deep venous thrombosis in the past. As well, she seems to feel that the Coumadin made her rash worse.
2. Gum hypertrophy. I felt that this was most likely periodontal disease but checked a CBC to make sure she had no evidence of leukemia with leukemic infiltrates. The CBC was normal, and she will see her private dentist on discharge.
3. History of urinary tract infection. The admission UA was abnormal. I have obtained a catheterized specimen for urinary culture. As she will be on Keflex antibiotics for the cellulitis on discharge, I will give no other antibiotics until the results of the urine culture are back.
DISCHARGE MEDICATIONS
Glyburide 2.5 mg q.d., Keflex 500 mg p.o. q.i.d., Lasix 20 mg q.d., Mellaril 50 mg q.h.s., Topicort cream to affected areas b.i.d., and normal saline dressing changes for wound care.
FOOTNOTE
Line 16 (Page 1). Although the dictator said “as above” for the Discharge Diagnoses, it is preferable to type the diagnosis in full.
Lines 28, 29 (Page 1). Alternative: 2-3 months.
Line 26 (Page 1). Allergies were classified under a separate heading for clarity.
Lines 46, 47 (Page 1). Alternative: 80-150 wbc’s, 3-6 rbc’s, 10-15 epithelials. The slang term epis was translated as epithelials. Alternative: epithelial cells.
Line 1 (Page 2). Chem panel was expanded to chemistry panel.
Line 8 (Page 2). Alternative: I.V.
Line 22 (Page 2). The slang term cath was translated as catheterized.
The patient is an elderly, pleasant female who is quite cooperative.She was admitted to the hospital because of cellulitis of the right lower extremity.There has been blistering of the area on the dorsum of the foot as well as higher up towards the ankle.She has redness extending all the way up to the mid-pretibial area.There is no history of lymphadenopathy, and judging from the chart, she has been afebrile.She was started, after finding out that her white count was abnormal, on Cefobid and tobramycin and infectious disease consultation sought.
PHYSICAL EXAMINATION
Exam today shows a temperature of 37 degrees Centigrade, a blood pressure of 130/70, a respiratory rate of 20, and pulse rate of 80. General appearance:An elderly female in no acute distress.
Head and ENT:Grossly negative. Neck:Supple. Lungs:Clear and resonant. Heart:Grade 1 systolic murmur; otherwise negative.
Abdomen:Scars of surgery.The abdomen is not obese but protruding.She has some left lower quadrant discomfort that is mild. Vaginal and rectal:Not done. Lymph nodes:No enlargement. Exam of the extremities reveals blistering cellulitis over the dorsum of the foot with swelling and extension of the abnormal coloration to the mid-pretibial area.The foot appears warmer than the other.
After sterile preparation the 2 blisters were aspirated, 0.2 cc of fluid was taken out, and this was sent for Gram stain and culture.
IMPRESSION
Probable streptococcus cellulitis.
DISCUSSION
The patient has had a Gram stain done yesterday, and it does show gram-positive cocci.This may well be staph, but I think we should give her penicillin till the culture reports are out.The blistering is typical of strep.I would go ahead and give her 2 million q.6h. of the penicillin and modify therapy according to culture report.
I thank you for allowing me to participate in the care of this pleasant, elderly female and will reassess p.r.n.
FOOTNOTE
Line 42.The brief form strep was expanded to streptococcus in the Impression.
