maine4me
Guru
I work for a group of hospitalists and am having an issue with the following note. To me it looks as if there is a minimal exam at best. I see the notation for Heart: RSR, however I do not see much more than that. I would appreciate someone looking at this a letting me know what level you get, and how you reached that decision.
Impression:
-
r/o UTI - mixed culture
Hypokalemia - repleted
Adrenal Insufficiancy on chronic steroids
PUD
Fibromyalgia
Depression/Anxiety/panic attacks
Celiac Sprue
Embolic CVA - anticoagulated on Coumadin 1999
Supratheraputic INR - improving
Hx of recurrent vertigo
Plan:
-
place TEDS
consult ATC
hold coumadin until INR < 3
Note:
-
Chart reviewed
Pt feels weakness has improved
Orthostatic this AM - has been followed by ATC for the same
Appetite is returning
Afebrile since admission
Vital Signs
Date Time Temp Pulse Resp B/P O2 Delivery
12/29/10 10:28 Room Air
12/29/10 07:30 96.9 103 20 94/51
12/29/10 02:30
12/29/10 0723
Blood Pressure Assessment 94/51 Left Upper Arm Standing
Blood Pressure Assessment 113/62 Left Upper Arm Sitting
Blood Pressure Assessment 159/77 Left Upper Arm Supine
Blood Pressure Assessment 136/83 Left Upper Arm Supine
Percent Meal Consumed 25% - 75% House
Lungs: clear
Heart: RSR
Probable viral syndrome - no evidence of UTI. No elevated WBCs or fever. Neg nitrate and Neg esterase
Unable to recuture urine - on antibiotics x 3 days
C/o post nasal drip and nasal congestion on admission - resolving.
Postural hypotension noted - will consult ATC who has been managing as an out pt
Ceftriaxone 50mls @100 mls/hr
Sodium 1 gm/ Q24H/IV
Dextrose
Anyhydrous DAY # 3
Pre-admission Medications:
-
Cortef 10 Mg PO DAILY
Midodrine Hcl 10 Mg PO DAILY
Coumadin 4 Mg PO TAKE AS DIRECTED
Coumadin 6 Mg PO TAKE mon and thurs
Klor-Con 20 Meq PO DAILY
Clonidine 0.1 Mg PO DAILY
Omega 3-6-9 1200 Mg PO DAILY
Niacin 500 Mg Capsule PO DAILY
Tramadol Hcl 1 Tab PO Q4-6H PRN severe back pain
Ultram 100 Mg PO Q4-6H
Gabapentin 100 Mg PO TID
Prilosec Otc 20 Mg PO BID
Amitriptyline 100 mg PO HS
Sertraline Hcl 75 Mg PO DAILY
Fexofenadine Hcl (Allegra) 60 Mg Tablet PO BID
Flonase 0.05% Nasal Spray 2 Spray NASAL DAILY
Probiotic Formula Capsule 2 Each PO BID
Garlic 400 Mg PO DAILY
Multivitamin Tablet 1 Tab PO DAILY
Vitamin C 1000 Mg PO DAILY
Calcium + D 2 Udtab PO DAILY
Clinical Data:
-
Hemoglobin 12.0 gm/dL 12/29/10 0700
Hematocrit 37.3 % 12/29/10 0700
White Blood Count 5.8 K/mm3 12/29/10 0700
Platelet Count 204 K/mm3 12/29/10 0700
Sodium Level 138 mmol/L 12/29/10 0700
Potassium Level 3.6 mmol/L 12/29/10 0700
Chloride Level 106 mmol/L 12/29/10 0700
Carbon Dioxide Level 24.7 mmol/L 12/29/10 0700
Blood Urea Nitrogen 10 mg/dL 12/29/10 0700
Creatinine 0.81 mg/dL 12/29/10 0700
Estimat Glomerular Filtration Rate > 60 12/29/10 0700
Fasting Glucose 91 mg/dL 12/29/10 0700
Calcium Level 8.5 mg/dL L 12/29/10 0700
Total Bilirubin 0.7 mg/dL 12/29/10 0700
Aspartate Amino Transf (AST/SGOT) 28 IU/L 12/29/10 0700
Alanine Aminotransferase (ALT/SGPT) 20 IU/L 12/29/10 0700
Total Protein 5.9 g/dL L 12/29/10 0700
Albumin 3.1 gm/dL L 12/29/10 0700
Globulin 2.8 gm/dL 12/29/10 0700
Alkaline Phosphatase 69 U/L 12/29/10 0700
Prothromb Time International Ratio 3.16 INR 12/29/10 0700
Impression:
-
r/o UTI - mixed culture
Hypokalemia - repleted
Adrenal Insufficiancy on chronic steroids
PUD
Fibromyalgia
Depression/Anxiety/panic attacks
Celiac Sprue
Embolic CVA - anticoagulated on Coumadin 1999
Supratheraputic INR - improving
Hx of recurrent vertigo
Plan:
-
place TEDS
consult ATC
hold coumadin until INR < 3
Note:
-
Chart reviewed
Pt feels weakness has improved
Orthostatic this AM - has been followed by ATC for the same
Appetite is returning
Afebrile since admission
Vital Signs
Date Time Temp Pulse Resp B/P O2 Delivery
12/29/10 10:28 Room Air
12/29/10 07:30 96.9 103 20 94/51
12/29/10 02:30
12/29/10 0723
Blood Pressure Assessment 94/51 Left Upper Arm Standing
Blood Pressure Assessment 113/62 Left Upper Arm Sitting
Blood Pressure Assessment 159/77 Left Upper Arm Supine
Blood Pressure Assessment 136/83 Left Upper Arm Supine
Percent Meal Consumed 25% - 75% House
Lungs: clear
Heart: RSR
Probable viral syndrome - no evidence of UTI. No elevated WBCs or fever. Neg nitrate and Neg esterase
Unable to recuture urine - on antibiotics x 3 days
C/o post nasal drip and nasal congestion on admission - resolving.
Postural hypotension noted - will consult ATC who has been managing as an out pt
Ceftriaxone 50mls @100 mls/hr
Sodium 1 gm/ Q24H/IV
Dextrose
Anyhydrous DAY # 3
Pre-admission Medications:
-
Cortef 10 Mg PO DAILY
Midodrine Hcl 10 Mg PO DAILY
Coumadin 4 Mg PO TAKE AS DIRECTED
Coumadin 6 Mg PO TAKE mon and thurs
Klor-Con 20 Meq PO DAILY
Clonidine 0.1 Mg PO DAILY
Omega 3-6-9 1200 Mg PO DAILY
Niacin 500 Mg Capsule PO DAILY
Tramadol Hcl 1 Tab PO Q4-6H PRN severe back pain
Ultram 100 Mg PO Q4-6H
Gabapentin 100 Mg PO TID
Prilosec Otc 20 Mg PO BID
Amitriptyline 100 mg PO HS
Sertraline Hcl 75 Mg PO DAILY
Fexofenadine Hcl (Allegra) 60 Mg Tablet PO BID
Flonase 0.05% Nasal Spray 2 Spray NASAL DAILY
Probiotic Formula Capsule 2 Each PO BID
Garlic 400 Mg PO DAILY
Multivitamin Tablet 1 Tab PO DAILY
Vitamin C 1000 Mg PO DAILY
Calcium + D 2 Udtab PO DAILY
Clinical Data:
-
Hemoglobin 12.0 gm/dL 12/29/10 0700
Hematocrit 37.3 % 12/29/10 0700
White Blood Count 5.8 K/mm3 12/29/10 0700
Platelet Count 204 K/mm3 12/29/10 0700
Sodium Level 138 mmol/L 12/29/10 0700
Potassium Level 3.6 mmol/L 12/29/10 0700
Chloride Level 106 mmol/L 12/29/10 0700
Carbon Dioxide Level 24.7 mmol/L 12/29/10 0700
Blood Urea Nitrogen 10 mg/dL 12/29/10 0700
Creatinine 0.81 mg/dL 12/29/10 0700
Estimat Glomerular Filtration Rate > 60 12/29/10 0700
Fasting Glucose 91 mg/dL 12/29/10 0700
Calcium Level 8.5 mg/dL L 12/29/10 0700
Total Bilirubin 0.7 mg/dL 12/29/10 0700
Aspartate Amino Transf (AST/SGOT) 28 IU/L 12/29/10 0700
Alanine Aminotransferase (ALT/SGPT) 20 IU/L 12/29/10 0700
Total Protein 5.9 g/dL L 12/29/10 0700
Albumin 3.1 gm/dL L 12/29/10 0700
Globulin 2.8 gm/dL 12/29/10 0700
Alkaline Phosphatase 69 U/L 12/29/10 0700
Prothromb Time International Ratio 3.16 INR 12/29/10 0700