chapter 7.docx - CHAPTER 7 PART 1 7.1 DISCHARGE SUMMARY 87 year old female who was admitted from a nursing home History of present illness Admitted with

chapter 7.docx - CHAPTER 7 PART 1 7.1 DISCHARGE SUMMARY 87...

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CHAPTER 7, PART 1 7.1 DISCHARGE SUMMARY 87 year old female who was admitted from a nursing home. History of present illness: Admitted with dehydration and pleural effusion Taking aspirin on a regular basis Past medical history: Significant for chronic diastolic heart failure and Type 2 diabetes mellitus The patient was discharged back to the nursing home on day six Final Diagnoses: pleural effusion from acute on chronic diastolic congestive heart failure dehydration primary thrombocytopenia with petechial hemorrhage and hematoma of the eylids and arms and hands urinary tract infection type 2 diabetes mellitus 7.2 34 year old African American male Admission diagnosis: Sickle cell pain crisis
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Discharge Diagnosis: Sickle cell pain crisis/Staph (staphylococcus) aureus bacteremia Secondary diagnosis: Sickle cell disease, priapism, chronic lower back pain secondary to sickle cell diagnosis , mild persistent asthma, gastroesophageal reflux disease (GERD), and grade 2 hemorrhoids Procedures: PICC line placement, and transesophageal echocardiogram (heart and aorta Hospital Course : PICC line was placed percutaneously into the superior vena cava Disposition is to home with home care 7.3 DISCHARGE SUMMARY Date of Admission : 11/19/xx Date of Discharge : 11/21/xx Discharge Diagnoses : 1. Anemia in chronic kidney disease 2. Chronic kidney disease, stage 3 3. Diabetes mellitus, Type 2 4. Hypertension 5. Coronary artery disease
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6. Congestive heart failure 7. Hypokalemia Attending Physician for Service
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  • Fall '11
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  • Human Anatomy, Atherosclerosis, Chronic kidney disease, acute myocardial infarction

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