Influenza with other respiratory manifestations Anemia unspecified Leukocytopenia unspecified Legal blindness as defined in U.S.A. Diabetes mellitus without mention of complication type II or unspecified type not stated as uncontrolled Hypertensive chronic kidney disease benign with chronic kidney disease stage I through stage IV or unspecified Chronic kidney disease Stage II (mild) Peripheral vascular disease unspecified Other persistent mental disorders due to conditions classified elsewhere Nonspecific abnormal results of function study of liver Abdominal pain epigastric
 
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
Cough, fatigue  
 
Major Surgical or Invasive Procedure:
None

 
History of Present Illness:
The patient is ___ year old man with history of hypertension, 
DM2, blindness, and dementia presenting with ___ days of fatigue 
associated with dry cough, low grade fevers, and diffuse body 
aches. The patient defers much of the history to his wife who 
intermittently answers questions for him. He states that ~3 days 
he slipped outside of his home and hit his back. He has had no 
anginal chest pain nor shortness of breath. He has sinus 
congestion without runny nose or sore throat. He has no abd 
pain, no dysuria, no change in bowels. His AM blood sugars at 
home have been 95 and 135 the past 2 days. He has been eating 
and drinking poorly. He has diffuse sweats. The fatigue is 
notable enough to keep him from walking without assistance from 
his wife.  

Upon arrival to the ED, the initial vital signs were 100.3 
156/79 110 14 99%RA. A chest xray was normal. He received 1L of 
saline and tylenol. A nasal aspirate was done for influenza.  

Upon review of systems, patient confirms pertinent positives as 
above.  Denies) Denies recent weight loss or gain. Denies 
headache, sinus tenderness. Denied shortness of breath. Denied 
chest pain or tightness, palpitations. Denied nausea, vomiting, 
diarrhea, constipation. No recent change in bowel habits.  

 
Past Medical History:
Type 2 Diabetes mellitu
Hypertension
Hyperlipedmia  
Legal blindness (can see shapes but blurry)  
History of atypical chest pain  
Dementia  
PVD see ABI from ___ for details  

 
Social History:
___
Family History:
Non-contributory 
 
Physical Exam:
Vitals: 98.3 142/100 79 20 97%RA wt 198pounds  
Gen: thin, eldery ___ male in NAD, sweaty  
HEENT: EOMI, no pallor. mild sinus tenderness. dry MM. no oral 
lesions  
Neck: supple. flat JVP  
Chest: CTAB w/o wheeze  
CV: RRR no m/r/g  
Abd: soft minimal tender to RUQ  
Ext: no c/c/e  
Skin: right thigh with skin graft harvest  
Neuro:  
-MS: a,ox2 ("hospital, ___, President Obama"). 
coherent response to interview. unable to alternate A-1,B-2, 
etc.  
-CN: II-XII intact except for vision pupils reactive, face 
symmetric, palate and tongue midline.  
-Motor: nl tone and bulk. ___ hand grip/bicep/tricep hip-flex 
plantar/dorsiflex bilat.  
-DTR: 1+ throughout  
-___: light touch intact to face/hands/feet  
 
Pertinent Results:
___ 07:00PM BLOOD WBC-5.9 RBC-4.25* Hgb-13.1* Hct-37.8* 
MCV-89 MCH-30.9 MCHC-34.7 RDW-12.7 Plt ___

___ 06:30AM BLOOD WBC-2.1* RBC-4.00* Hgb-12.5* Hct-35.3* 
MCV-88 MCH-31.2 MCHC-35.4* RDW-12.7 Plt ___

___ 07:00PM BLOOD Neuts-84.0* Lymphs-9.7* Monos-5.3 Eos-0.5 
Baso-0.5
___ 06:30AM BLOOD Neuts-46.5* ___ Monos-10.9 
Eos-2.9 Baso-1.1

___ 07:00PM BLOOD ___ PTT-26.5 ___

___ 07:00PM BLOOD Glucose-187* UreaN-18 Creat-1.5* Na-138 
K-3.9 Cl-102 HCO3-24 AnGap-16

___ 06:30AM BLOOD Glucose-127* UreaN-14 Creat-1.2 Na-141 
K-4.3 Cl-106 HCO3-26 AnGap-13

___ 07:45AM BLOOD ALT-49* AST-197* AlkPhos-47 Amylase-84 
TotBili-0.4
___ 06:30AM BLOOD ALT-55* AST-165* AlkPhos-43 TotBili-0.3

___ 07:05PM BLOOD Lactate-1.3

___ 9:55 pm Influenza A/B by ___
      Source: Nasopharyngeal aspirate. 
                            **FINAL REPORT ___
   DIRECT INFLUENZA A ANTIGEN TEST (Final ___: 
      Positive for Influenza A viral antigen. 
      REPORTED BY PHONE TO ___. ___ (___) ON ___ AT 
12;25PM. 
   DIRECT INFLUENZA B ANTIGEN TEST (Final ___: 
      NEGATIVE FOR INFLUENZA B VIRAL ANTIGEN. 

 CHEST (PA & LAT) Study Date of ___ 8:34 ___ 
Study is somewhat compromised secondary to body habitus. The 
lungs 
are clear without consolidation or edema. The mediastinum is 
unremarkable.  The cardiac silhouette is within normal limits 
for size. No effusion or pneumothorax is noted. The visualized 
osseous structures are unremarkable.   IMPRESSION: No acute 
pulmonary process. 
 
Brief Hospital Course:
The patient is a ___ year old man with diabetes, hypertension, 
hyperlipidemia, legal blindness presenting with URI symptoms, 
cough, and significant fatigue.  

# Influenza A, causing fever / Fatigue:  Patient presented with 
fever, diffuse body aches, cough and sweats, all which would be 
quite consistent with influenza.  Negative CXR is reassuring for 
no secondary bacterial pneumonia.  No significant metabolic 
derangement other than mild pre-renal state. As patient 
presented nearly 5 days into symptoms would be outside of window 
for directed antivirals. Nasal aspirate was positive for 
influenza, type A.  Given IV fluids.  Once symptomatically 
improved, he was discharged home.

# Anemia: Noted on admission. Additionally, patient was 
clinically dry.  During his stay, he had some dropping in Hct, 
likely secondary to dilution combined with some bone marrow 
suppression given acute illness.  Upon discharge, was 
recommended to follow-up with primary care physician ___ ___ 
days to have repeat lab draw.  

# Leukopenia: Worsening since admission. As above, may be 
secondary to marrow suppression, along with some dilution 
secondary to IV fluid.  Although low, he was never neutrapenic.  
Upon discharge, was recommended to follow-up with primary care 
physician ___ ___ days to have repeat lab draw. 

# Transaminitis: Stable, some improvement in AST. ___ be 
secondary to viral illness. Also could be med effect given 
recently started Aricept. Wife denies alcohol consumption.  
Holding statin inpatient and post-discharge with plan to have 
lab rechecked as a outpatient.

# Diabetes mellitus: Appears well controlled per OMR.  Patient 
was continued on sulfonylurea and insulin sliding scale 
inpatient.  Upon discharge, she was retarted on Metformin.  

# Hypertension: Normotensive, with improved volume status.  
Continued on Lisinopril.  HCTZ was held initially but restarted 
prior to discharge.
  
# Epigastric pain: Unclear etiology. ___ simply be heartburn in 
the setting of nausea and decreased po intake. Also with 
transaminitis as above, but pain not truly in in left upper 
quadrant.  Improving by discharge and treated with Maalox 
inpatient.

# Recent fall: Likely mechanical due to physical decline and 
poor vision. ___ evaluated and recommended home ___ services which 
were arranged on discharge.
 
Medications on Admission:
Aricept 10 mg daily  
Glipizide 10 mg bid  
Metformin 1000 mg bid  
Lisinopril/hydrochlorothiazide ___ mg daily  
Aspirin 81 mg daily  

 
Discharge Medications:
1. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).  
2. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a 
day).  
3. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 
 
4. Lisinopril-Hydrochlorothiazide ___ mg Tablet One Tablet 
PO once a day.  
5. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.  

 
Discharge Disposition:
Home With Service
 
Facility:
___
 
___:
Primary: Influenza, type A

Secondary: Diabetes mellitus, hypertension, hyperlipedmia, legal 
blindness, dementia, peripheral vascular disease

 
Discharge Condition:
Hemodynamically stable and afebrile.

 
Discharge Instructions:
You were admitted with muscle aches and fever.   You were found 
to have Influenza, type A.  You were treated with IV fluids and 
nursing support.  Once improved, you were dishcarged home for 
further recovery.

Please take all medications as prescribed.  While inpatient the 
following medication was held due to some elevated liver tests. 
- Simvastatin 40 mg daily

Please do not restart this medication unless instructed to do so 
by your primary care physician.

Keep all outpatient appointments.

You need to get your influenza vaccine every year given your 
other illnesses put you at increased risk for severe 
complications.

Seek medical advice if you notice fevers, chills, difficulty 
breathing, chest pain, recurrent falls or any other symptom 
which is concerning you.
 
Followup Instructions:
___

{'cough': ['Influenza with other respiratory manifestations'], 'fatigue': ['Influenza with other respiratory manifestations'], 'fevers': ['Influenza with other respiratory manifestations'], 'body aches': ['Influenza with other respiratory manifestations'], 'sweats': ['Influenza with other respiratory manifestations'], 'low grade fevers': ['Influenza with other respiratory manifestations'], 'diffuse body aches': ['Influenza with other respiratory manifestations'], 'sinus congestion': ['Influenza with other respiratory manifestations'], 'diffuse sweats': ['Influenza with other respiratory manifestations'], 'anginal chest pain': [], 'shortness of breath': [], 'abd pain': [], 'dysuria': [], 'change in bowels': [], 'headache': [], 'sinus tenderness': [], 'weight loss or gain': [], 'chest pain or tightness': [], 'palpitations': [], 'nausea': [], 'vomiting': [], 'diarrhea': [], 'constipation': [], 'change in bowel habits': [], 'recent weight loss or gain': [], 'headache, sinus tenderness': [], 'shortness of breath, denied': [], 'chest pain or tightness, denied': [], 'palpitations, denied': [], 'nausea, vomiting, diarrhea, constipation, change in bowel habits, denied': []}