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Inpаtient Cаse - Pаtient 2 Use the chart dоcumentatiоn belоw for questions 104-106. __________________________________________________________________________________________________________________________ Discharge Summary DATE OF ADMISSION: 9/8 DATE OF DISCHARGE: 9/10 DISCHARGE DIAGNOSIS: Acute pyelonephritis E. coli sepsis, resistant to ampicillin and penicillin secondary to pyelonephritis. ADMISSION HISTORY: This 21-year-old female was admitted to the hospital with discomfort in the right side. Other than this she has been healthy. On the day of admission, she developed severe discomfort in the lower back. She was having fever and chills for which she took an aspirin and then she came to the emergency department. COURSE IN HOSPITAL: The patient was treated with intravenous antibiotics in the form of gentamicin and cefoxitin. She continued to improve on this regimen and became afebrile after about three days of treatment. Her physical examination remained essentially unchanged; however, there was marked improvement in the patient’s general condition. The patient also had an onset of herpes simplex infection on her upper lip, for which she was given acyclovir ointment. INSTRUCTIONS ON DISCHARGE: The patient was discharged home on ciprofloxacin 500 mg p.o. b.i.d. × 12 days. A repeat blood culture done just prior to discharge showed no growth at the end of 7 days. She is to be followed up in my office in about a week after discharge to have a repeat urine culture done. The patient was also given a prescription for bupropion to assist smoking cessation. ___________________________________________________________________________________________________________________________ History and Physical Exam ADMITTED: 9/8 REASON FOR ADMISSION: This was the first hospital admission for this 21-year-old white female, who experienced discomfort on the right side of her lower back with some dysuria about 3 days prior to admission. On the evening of admission, she started experiencing fever and chills and took some aspirin. This did not help her symptoms so she came to the emergency department. HISTORY OF PRESENT ILLNESS: PAST MEDICAL HISTORY: Remarkable only for “walking pneumonia” treated with erythromycin 3 months ago. She also suffered contusion of her right kidney after a fall from a horse about 4 years prior to admission. ALLERGIES: None known CHRONIC MEDICATIONS: None FAMILY HISTORY: Remarkable for multiple members of the family having seasonal allergies SOCIAL HISTORY: The patient lives with two friends and is employed by a saddle shop. She drinks about one drink a week and smokes a pack of cigarettes a day. REVIEW OF SYSTEMS: The patient relates that there has been no weight gain or loss and that she was well functioning until three days ago when she developed lower back pain, primarily on the right side. She also relates that she has had dysuria for this same time period. PHYSICAL EXAMINATION: VITAL SIGNS: P 120/min, regular; BP 120/70; Temp 103 degrees; R 16/min, regular GENERAL: The patient is a well-developed female of her stated age. She appears lethargic but responsive. The patient appears septic. SKIN: Warm to touch HEENT: Pupils equal, react briskly to light. Mucous membranes of the eyes, nose, mouth, and oropharynx are normal. NECK: Supple, trachea is central, the carotid pulses are symmetrical. There is no goiter. LUNGS: Clear to auscultation and percussion BACK: Positive pain to palpation and percussion right costovertebral angle HEART: Peripheral pulses are symmetrical. The cardiac apex is not displaced. The heart sounds are normal and there are no added sounds or murmurs. ABDOMEN: Soft, nontender, with no masses palpable. The bowel sounds are normal. GENITALIA: Normal female RECTAL: Deferred EXTREMITIES: Femoral pulses normal, no edema NEUROLOGIC: Grossly intact LABORATORY DATA: WBC 15.9 with differential of 57 Segs; 33 Bands; 6 Lymphs; 4 Monos. Electrolytes were normal. BUN 11. Urine culture grew out E. coli, more than 100,000 colonies per mL. Blood culture was also positive for E. coli. This was sensitive to gentamicin and cefoxitin, as well as many other antibiotics. Urinalysis on admission revealed many WBCs and marked bacteriuria. Chest x-ray was unremarkable. IMPRESSION: Admit for clinical features of acute pyelonephritis and septicemia. PLAN: Hydrate and start IV antibiotics. ___________________________________________________________________________________________________________________________ Progress Notes Progress Notes ___________________________________________________________________________________________________________________________ Physician's Orders
Sаme-Dаy Surgery - Pаtient 3 Use the chart dоcumentatiоn belоw for questions 107-109. __________________________________________________________________________________________________________________________ Discharge Summary DATE OF ADMISSION: 08/03 DATE OF DISCHARGE: 08/03 DISCHARGE DIAGNOSIS: Sinus infection Chronic serous otitis media, bilateral ears Adenoid hypertrophy Obstruction of Eustachian tubes PROCEDURES: Adenoidectomy Bilateral myringotomy INSTRUCTIONS ON DISCHARGE: Contact my office for follow-up in 1 week Take Augmentin 500 mg by mouth BID per day for 10 days Hydrocodone 7.5/100 mg q 4–6 hours, 1–2 tabs PRN for pain ~ contains acetaminophen. Limit as directed. ___________________________________________________________________________________________________________________________ History and Physical Exam ADMITTED: 08/03 REASON FOR ADMISSION: This is a 35-year-old patient who has recurrent sinusitis and chronic otitis media, bilateral ears. The patient also suffers from adenoidal obstruction of the eustachian tubes and nasopharynx. Treatment has consisted of antihistamines and decongestants as well as antibiotic therapy. This has been ineffective to control the inflammation. The patient has requested surgery for definitive treatment of the condition. PAST MEDICAL HISTORY: Negative ALLERGIES: None known CHRONIC MEDICATIONS: None FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: The patient has had repeated office visits over the past 3 years for sinusitis and otitis media. The patient has no other health problems. PHYSICAL EXAMINATION: This is a Hispanic female in no acute distress. BP is 120/70. Temp. is 99.0 degrees. Pulse is 72. Respirations 12. HEENT: Tympanic membranes are red otherwise normal. NECK: Supple CHEST: Clear to percussion and auscultation HEART: Regular force, rate, and rhythm ABDOMINAL: Normal, no masses EXTREMITIES: No edema, normal IMPRESSION: Sinus infection and chronic otitis media ___________________________________________________________________________________________________________________________ Progress Notes Progress Notes ___________________________________________________________________________________________________________________________ Physician's Orders