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Discharge Summary Medical Transcription Transcribed Dictation Sample Report

DATE OF ADMISSION:  MM/DD/YYYY

DATE OF DISCHARGE:  MM/DD/YYYY

CHIEF COMPLAINT:  Malaise, sore throat, joint pain x2 weeks.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female with a history of degenerative joint disease presenting with a two-week history of malaise followed by sore throat two days after the onset of her malaise, in addition to diffuse joint pain.  The patient states that all of her symptoms have been getting progressively worse over the past several weeks, and the patient was taken to an outside hospital the week prior to admission for these symptoms and was discharged with penicillin from which she had no relief of her symptoms.  The patient also indicated that she had loose stools, approximately two per day for the last two weeks, as well as several episodes of epistaxis in the last one week prior to admission.  The patient does report episodic fevers over the past several weeks ranging from 99 to 103, although her fevers had resolved two days prior to admission.  The patient did indicate that she had two episodes of nausea and vomiting last week.  She denies cough, although she has a mild headache and dyspnea with exertion.  She denies abdominal pain.  She denies recent sick contacts.  She denies nasal congestion, drainage or recent travel.  No history of IV drug use.  The patient indicates that her husband, whom she has not had contact with for the last several years, was diagnosed with hepatitis C.

PAST MEDICAL HISTORY:  Degenerative joint disease, mainly affecting the neck and the back.

FAMILY HISTORY:  Significant for CHF, diabetes, cancer.

SOCIAL HISTORY:  The patient is a former smoker.  The patient denies illicit drug use.

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

MEDICATIONS:  Outpatient medications include fluticasone, lactulose, Neurontin, and cefotetan.

REVIEW OF SYSTEMS:  Significant for fever; fatigue; sore throat x2 weeks; epistaxis x1 week, several episodes; occasional mild dyspnea for 2 weeks; difficulty swallowing for 2 weeks; sore throat for 2 weeks; nausea and vomiting for 1 week; and diarrhea for 2 weeks, approximately 2 episodes per day; arthralgias; arthritis, as per history of present illness; and an arm and leg rash, which occurred 1 week ago and has since resolved.  In addition, the patient indicates that she has both upper and lower extremity weakness but has no focal weakness.  She indicates she has global weakness.

PHYSICAL EXAMINATION:
GENERAL APPEARANCE:  Well-nourished, well-developed, alert and oriented x3.
VITAL SIGNS:  Temperature 101, respiratory rate 20, blood pressure 126/81, and pulse 110.  The patient was saturating at 98% on room air.
HEENT:  Eyes:  Conjunctivae are clear bilaterally.  PERRLA.  EOMI.  ENT:  Hearing normal.  Tympanic membranes were normal bilaterally.  The patient did have some erythema bilaterally, on the nasal mucosa.  Oral:  The patient did have erythema of the oropharynx, in the posterior aspect, without exudates or lesions.
NECK:  The patient did have tenderness to palpation in the mid neck region.  She indicates that this was from her sore throat.  No tracheal deviation.  No neck adenopathy or masses.  Thyroid was not enlarged and not nodular.
LUNGS:  Clear to auscultation bilaterally.  No wheezes, rhonchi or rales were appreciated.
HEART:  The patient had a regularly irregular rhythm.  Normal S1, S2.  No S3, S4, murmurs, rubs or clicks were appreciated.  No JVD, 2+ pedal pulses.  No pedal edema was appreciated.  No carotid bruits.
BREASTS:  No masses were appreciated.  No axillary adenopathy was appreciated.
ABDOMEN:  Soft, nontender, nondistended.  Decreased bowel sounds throughout.  No masses.  No organomegaly was appreciated.
GENITOURINARY:  Exam was deferred.
LYMPHATICS:  No neck or axillary adenopathy was appreciated.
MUSCULOSKELETAL:  The patient had 3/5 strength in both the upper and lower extremities bilaterally, which was questionably due to poor effort.  The patient had normal muscle tone.
SKIN:  No rashes, lesions or ulcers were appreciated.  Pressure wounds were not appreciated.
NEUROLOGIC:  Cranial nerves II through XII were grossly intact bilaterally.  The patient had decreased upper and lower extremity strength as described above.  No focal motor or sensory deficits were appreciated.
PSYCHIATRIC:  Normal judgment and insight.  The patient was alert and oriented x3.  Recent and remote memory intact and normal mood and affect.

LABORATORY DATA:  On admission, white blood cell count 14.6, hemoglobin 11.8, platelets 354, hematocrit 34.6, neutrophils 84.8%, lymphocytes 8.8%.  Sodium 134, potassium 4.2, chloride 96, bicarbonate 24, BUN 17, creatinine 1, glucose 86, calcium 8.6.  AST 192, ALT 112, alkaline phosphatase 114, amylase 69, lipase 46, albumin 3.2, total protein 7.6, total bilirubin 0.7, direct bilirubin 0.3.  Chest x-ray showed mild bilateral congestion.  EKG showed sinus tachycardia at 110.  No ST or T wave changes were appreciated.

HOSPITAL COURSE AND TREATMENT:
1. Malaise, sore throat, arthralgias:  Based on the patient's signs and symptoms, it was felt that she had a viral upper respiratory infection.  Rapid strep was sent as well as a throat culture, which were both negative.  The patient was started on normal saline at 150 mL per hour for dehydration.  On admission, blood cultures were taken and were found to be negative.  In addition, a urine culture was taken, which grew Proteus mirabilis in the suspicious range.  All other cultures were negative for the duration of her admission.  The patient did receive one dose of ceftriaxone IV in the emergency room.  During the initial portion of her admission, the patient continued to have symptoms as outlined above.  Her antibiotic regimen was switched from ceftriaxone to moxifloxacin IV.  Another reason why antibiotics were used in this patient is because although we felt a viral etiology was most likely responsible for the symptoms, we felt that the patient should be covered until further workup was obtained.  During the course of her admission, the patient did have cyclic fevers ranging from low-grade 100 to 100.5 during her admission.  Most of these fevers were observed to have been between the hours of 6 p.m. and early morning hours.  Despite having antibiotic therapy, the patient did spike fevers to 103.5, at which point blood cultures were drawn and subsequently found to be negative.  In addition, the patient was empirically started on vancomycin and Zosyn for a short course until her fever resolved.  In addition, the patient did have leukocytosis during the initial portion of her admission, which gradually decreased to a white blood cell count in the normal range.  Following a short course of vancomycin and Zosyn, an ID consult was obtained and it was recommended that the patient be started on doxycycline instead of vancomycin and Zosyn.  In addition, they suggested obtaining several labs.  The patient received one dose of doxycycline and on the following day was noted to have acute renal failure.  It was not known whether this acute renal failure occurred as a result of the patient undergoing CT scan with contrast, contrast nephropathy, versus recent administration of doxycycline.  A renal consult was called and it was suggested that IV hydration be maintained with normal saline in addition to a course of Mucomyst.  This recommendation was followed and the patient's creatinine did decrease to the normal range prior to discharge.  Regarding the patient's fever, it was also believed that the patient could have a possible autoimmune/rheumatologic disorder causing her cyclic fevers.  A rheumatology consult was obtained and Dr. Doe did follow the patient.  Regarding her laboratory values, the patient did have a positive CMV IgG, negative CMV IgM, positive EBV IgG, negative EBV IgM.  HIV 1 and 2 were negative.  Parvovirus B19 IgG was 2.8, which is elevated, and Parvovirus B19 IgM was negative.  In addition, antistreptolysin O antibody was negative, was at 72.7.  The patient did have hepatitis serologies drawn and these were all negative.  In terms of viral hepatitis, the patient did have c-ANCA and p-ANCA antibodies negative and a titer was negative.  It was felt by Rheumatology that this patient possibly had adult onset Still's disease.  A CT scan was performed on the chest and the patient was noted to have bilateral pleural effusions of moderate size on the left and small on the right, as well as bilateral axillary adenopathy.  An ultrasound-guided thoracentesis was ordered; however, by the time this procedure took place, there was minimal fluid in the pleural space and a CT-guided aspiration was recommended.  The patient refused the CT-guided thoracentesis, so therefore tissue was not obtained.  In addition, the patient ruled out for TB by a negative PPD placed during her admission (0 mm induration).  During the course of her admission, the patient did have cyclic fevers in the first portion; however, after approximately 5 to 6 days, the patient had resolution of her fevers, although she did still experience arthralgias.  The patient's sore throat did resolve during admission and the patient did not have any additional episodes of epistaxis.  Due to the fact that this patient had a fever of unknown origin, a hematology consult was obtained in order to perform a bone marrow biopsy in light of the imaging and laboratory data obtained thus far.  However, the patient declined the bone marrow biopsy; although, she indicated that she would have this done as an outpatient.  Hematology consult was also called due to the fact that the patient had anemia from 11.8 on admission to 7.2, which subsequently rebounded to 8.6 without the need for transfusions.  Iron studies were obtained, which did show anemia, likely anemia of chronic disease.  The patient was suspected of having endocarditis due to these cyclic fevers.  An echocardiogram was obtained, which was negative for endocarditis.
2.  Acute renal failure:  As indicated above, the patient did receive IV contrast as well, which was likely the cause of her acute renal failure (creatinine from 0.8 to 2.6 on MM/DD/YYYY).  A renal consult was called.  This patient was felt to have contrast nephropathy and was put on IV fluids with Mucomyst as well.  The patient's creatinine did decrease to the 1.5 range upon discharge.  Although the patient was felt to have contrast nephropathy, as indicated above, the patient was recently started on doxycycline immediately prior to her acute renal failure, and this was also a possibility.  As soon as the acute renal failure was found, the patient was taken off doxycycline.
3.  Anemia:  The patient's anemia was felt to be secondary to phagocytosis from a rheumatologic process such as Still's disease, although bone marrow failure could not be completely ruled out, from a viral or other common infectious etiologies such as a fungal infection.  The patient was seen by Dr. Doe from Hematology, who suggested bone marrow biopsy, but the patient refused.  She indicated that she would have this done as an outpatient.  The patient's hemoglobin did increase from a nadir of 7.2 to 8.6 upon discharge and she did not require transfusions during her admission.

PROCEDURES PERFORMED:  None.

CONSULTS OBTAINED:  Rheumatology, Nephrology, Infectious Diseases, and Hematology.

CONDITION AT DISCHARGE:  Stable.

DISCHARGE INSTRUCTIONS:
1.  The patient was told to follow up with her primary medical doctor, Dr. John Doe, within one to two weeks following discharge.  In addition, the patient was told to follow up with Dr. Jane Doe at her rheumatology clinic on MM/DD/YYYY at 10 a.m. and appointment was made for this patient.
2.  The patient was told to return if she had any additional or increasing symptoms.  The patient was discharged on Ultram 100 mg p.o. q.6h. p.r.n. for pain and was told to take this for a total of three to four days after discharge.  In addition, the patient was instructed to continue on her outpatient medications as previously described.  The patient was referred to Dr. Jeff Doe for followup regarding a bone marrow biopsy.

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