Download Care Transitions: Mr Scott Discharge Summary

Discharge Summary
Principal Diagnosis
Acute on chronic systolic congestive heart failure
Last ECHO February 2011 - EF 15%
Secondary Diagnosis
Nausea and Vomiting
Urinary Tract Infection
Delirium
Dementia – Last MMSE - 22/30
Acute MI - January 2011
CAD s/p BMS to L CFX January 2011
HTN
Hyperlipidemia
Type II Diabetes – Last HBA1C 7.5
CC: “I can’t keep anything down”
Brief HPI
Mr. Scott is an 78 year old AA male, who was admitted to this hospital with complaints of early
satiety, abdominal fullness, nausea and vomiting. He had been unable to keep any solids or
fluids down without vomiting over the last 2 days. There was no associated chest or abdominal
pain. No constipation or diarrhea. No fever or chills or associated urinary symptoms.
One week prior to the onset of the above symptoms, he had also noticed increasing shortness
of breath, orthopnea and paroxysmal nocturnal dyspnea with significant lower extremity edema.
He has a history of an acute MI in January 2011. Since his MI, he has had worsening
symptoms of biventricular heart failure.
Meds on Admission
Furosemide 20mg qday
Clopidogrel 75mg qday
ASA 325mg qday
Simvastatin 20mg qHS
Metoprolol 25mg BID
Lisinopril 20mg qday
Donepezil 10mg qday
Glipizide XL 10mg qday
Pertinent Admission PE
Temp: 37.3 °C, Heart Rate : 108. Resp: 28, BP: 136/78 mmHg, O2 sat: 80%, Weight: 117.9
kg (260 lb)
CV: Regular, borderline tachycardia, +JVD to jaw line, sustained apical impulse, 2+ pitting
edema in both lower extremities
PULM: Light basilar crackles
ABD: Soft, minimally tender to palpation at epigastrium, non-distended, no masses or
hepatosplenomegaly
Pertinent Admission Labs:
WBC: 13.0, Neut 67%, Hgb 8.8, Hct 28.4, MCV 77, Na 139, Cl 110, K 3.5, BUN 9, Cr 1.1, Glu
114
Trop 0.06, BNP: 1026
CXR: enlarged cardiac silhouette with pulmonary edema
EKG: IVCD, sinus tachycardia
Hospital Course
Acute Decompensated Heart Failure: He was started on IV furosemide on the medical floor
with little success, He was therefore transferred to the ICU for aquapheresis and inotrope
administration. With cardiology assistance, the patient was started on dobutamine drip and
ultrafiltration was done. Over the next 24 hours, the patient’s UOP was 6.5L. His abdominal
fullness resolved and he was able to eat 3 full meals without nausea or vomiting. Over the next
2 days, he diuresed ~ 20L of fluid. He was visited by the CHF team, who provided further
education about how to manage heart failure at home. Over the course of his hospitalization, he
diuresed ~ 24L of fluid. At discharge, the patient was sleeping supine with no PND. He was also
able to eat three full meals/day without symptoms of early satiety.
Nausea and Vomiting:Thought to be due to the CHF exacerbation. Symptoms improved with
treatment of CHF. Was started on nexium, which helped his symptoms. He was seen by GI who
recommended an outpatient EGD.
Mild dementia with superimposed delirium: On the second day of Mr. Scott’s admission, he
became quite confused and was disoriented to time and place. O2 sat ranged from 85 – 92%.
He was also noted to have leukocytosis. Pancultures done revealed that he had a UTI for which
Levaquin was started based on the culture and sensitivity. With continued treatment of his CHF,
his oxygen saturations improved. His mental status also began to improve. At the time of
discharge, he was oriented to person and place but not to time.
Type 2 diabetes: Accu-Cheks were done every 4 hours. He came in on glipizide but was
switched to lantus and aspart insulin for ease of inpatient management, which he tolerated well
during his hospital stay.
Microcytic Anemia:On admission, he had been noted to have a microcytic anemia (MCV 75)
with an iron deficiency iron panel, which remained stable at a Hgb of ~10 until day 5 of his
hospitalization, when it dropped to 7.9. He received 1 unit pRBCs to prevent exacerbation of his
heart failure from anemia. He tolerated this well, and his Hgb stabilized at 9.5. He was
evaluated by GI who recommended an outpatient EGD when he was more hemodynamically
stable.
Hypokalemia:At the peak of his diuresis in the MICU, the patient had one episode of leg
cramps attributed to hypokalemia likely 2/2 to aggressive diuresis, which resolved following
repletion with oral Potassium.
Code Status: FULL
PCP Communication
The PCP was contacted and informed about the patient’s admission, medications changed and
tests to be completed and followed up on in the outpatient setting.
Disposition
The patient was discharged to home, where he lives alone, His niece would check in on him 3
times a week. He will follow up with the CHF clinic in one week, and with his PCP in two
weeks.
At discharge, the patient’s niece stated that his functional and cognitive status had improved..
He was able to sleep supine, though could walk only 50 feet without shortness of breath. He
was also able to eat full meals without early satiety.
Pertinent Labs at Discharge
Wt at discharge was 225lbs, which is obese, but at goal for fluid balance.
BP was 106/77, goal 90s/60s - 100s/70s.
BUN 9, Cr 1.0, Na 136, K 4.2
EF not reevaluated during this visit; last documented at 15%
Discharge Instructions
Not discharged on beta blocker because pt acutely decompensated with diuresis requiring
inotropic support. May restart beta blocker at later follow-up appointment.
Pt was instructed to limit fluids to 1L per day, and salt restricted to 2gm per day. Emphasis was
placed on the importance of avoiding pre-packaged / canned / pre-made / fast foods. He was
instructed to weigh himself every day, to call HF clinic if he gained >3 lbs or go to HF clinic if he
gained >5lbs, and return to the ED if he gained >10lbs, had shortness of breath or chest pain.
Meds at Discharge
Stopped:
Metoprolol for reasons above
Continued:
Clopidogrel 25mg qday
ASA 325mg qday
Simvastatin 20mg qHS
Donepezil 10mg qday
Lantus Insulin 10units QHS
Changed:
Lisinopril 5mg qday
Furosemide 40mg qd
New:
Ferrous Sulfate 325 TID
Esomeprazole 40mg BID