Syncope and collapse Chronic lymphoid leukemia without mention of having achieved remission Other secondary thrombocytopenia Anemia in neoplastic disease Conjunctivitis unspecified Unspecified essential hypertension Peripheral vascular disease unspecified Other and unspecified hyperlipidemia Gout unspecified Esophageal reflux
 
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
Sulfa (Sulfonamide Antibiotics)
 
Attending: ___.
 
Chief Complaint:
Syncope
 
Major Surgical or Invasive Procedure:
None

 
History of Present Illness:
Mrs. ___ is a ___ w/ h/o CLL and systolic murmur who presents 
s/p syncope and fall from standing. She had a mechanical fall 
approximately one week ago due to loss of balance, but did not 
black out. Today, she was in the kitchen cooking when she felt a 
bit weak, went and sat down for a brief period. Later, she felt 
better and resumed cooking. She felt weak again, blacked out and 
awoke on the floor. She pushed her med alert button, and EMS 
transported to ___. She does not believe that she hit her 
head, but was unconscious at the time of impact with the ground. 
 
The patient denies any chest pain, dizziness or dyspnea, and no 
history of these. She denies dysuria, cough, fevers, chills, 
diarrhea, pain or changes in vision.  
She does have intermittent constipation.  
In the ED, initial VS were:97 72 122/57 18 100%  
Chem 7 unremarkable. CBC remarkable for Hct of 27.7 and plt 19.  

 
On arrival to the floor, patient has no complaints and has no 
areas of pain from the fall.  
 
REVIEW OF SYSTEMS:  
(+) occasional constipation  
(-) fever, chills, night sweats, headache, vision changes, 
rhinorrhea, congestion, sore throat, cough, shortness of breath, 
chest pain, abdominal pain, nausea, vomiting, diarrhea, 
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
 
Past Medical History:
CHRONIC LYMPHOCYTIC LEUKEMIA (cycle 1 of rituxin in ___, 
previously attempted one cycle of bendamustine; recent bone 
marrow biopsy approx a week ago)  
MDS
GOUT  
HYPERLIPIDEMIA  
HYPERTENSION  
PERIPHERAL VASCULAR DISEASE  
VERTIGO  

 
Social History:
___
Family History:
She thinks her father might have had prostate cancer.  There are 
no other known cancers in the family.  No blood disorders.

 
Physical Exam:
ADMISSION PHYSICAL EXAM:  
VS - 98.4 150/54 64 18 100%RA  
GENERAL - well-appearing, in NAD, comfortable, appropriate, 
quite pleasant  
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear  
NECK - supple, JVP 9cm H2O  
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp 
unlabored, no accessory muscle use  
HEART - PMI non-displaced, RRR, III/VI systolic murmur heard 
best in RUSB with radiation to carotids  
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no 
rebound/guarding  
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) 
 
SKIN - no rashes or lesions; no traumatic injuries appreciated 
on exam  
LYMPH - no cervical, or supraclavicular LAD  
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength 
___ throughout, sensation grossly intact throughout  

Discharge Exam
VS - 98.4 127/42 66 18 98%RA
lying: 128/60  standing: 118/58
Tele: ___ few PVCs 
GENERAL - well-appearing female, in NAD, comfortable, 
appropriate, quite pleasant  
HEENT - NCAT, PERRL, EOMI, crusting around left eye with 
erythema and purulence in nasal portion of left conjunctiva, 
MMM, OP clear  
NECK - supple,   
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no 
accessory muscle use  
HEART - PMI non-displaced, RRR, III/VI systolic murmur heard 
best in RUSB & radiates to carotids  
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no 
rebound/guarding  
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) 
 
SKIN - no rashes or lesions  
LYMPH - no cervical, or supraclavicular LAD  
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength 
___ throughout, sensation grossly intact throughout 
 
Pertinent Results:
Admission Labs:

___ 08:20PM URINE  COLOR-Straw APPEAR-Clear SP ___
___ 08:20PM URINE  RBC-1 WBC-9* BACTERIA-FEW YEAST-NONE 
EPI-0
___ 05:48PM   GLUCOSE-110* UREA N-22* CREAT-0.8 SODIUM-139 
POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-28 ANION GAP-15
___ 05:48PM   estGFR-Using this
___ 05:48PM   CK(CPK)-121
___ 05:48PM   CK-MB-4 cTropnT-<0.01
___ 05:48PM   WBC-4.3 RBC-2.56* HGB-9.6* HCT-27.7* MCV-108* 
MCH-37.6* MCHC-34.8 RDW-25.1*
___ 05:48PM   NEUTS-64.4 ___ MONOS-5.5 EOS-2.7 
BASOS-0.3
___ 05:48PM   PLT COUNT-19*#

Imaging:
CT HEAD W/O CONTRAST (___): No acute intracranial process

CXR (___): IMPRESSION: 
1.  No focal consolidation.  Slight blunting of the posterior 
right 
costophrenic angle may be artifactual, although trace pleural 
effusion not
excluded.  
2.  Hiatal hernia.  
3.  Persistent cardiomegaly without overt pulmonary edema. 

TTE (___): The left atrium is elongated. Left ventricular 
wall thickness, cavity size and regional/global systolic 
function are normal (LVEF >55%). The right ventricular cavity is 
mildly dilated with normal free wall contractility. The aortic 
valve leaflets (3) are mildly thickened but aortic stenosis is 
not present. Trace aortic regurgitation is seen. The mitral 
valve leaflets are mildly thickened. There is no mitral valve 
prolapse. Mild (1+) mitral regurgitation is seen. Moderate to 
severe [3+] tricuspid regurgitation is seen. There is moderate 
pulmonary artery systolic hypertension. Significant pulmonic 
regurgitation is seen. There is a trivial/physiologic 
pericardial effusion. 

IMPRESSION: Preserved biventricular systolic function. 
Moderate-severe tricuspid regurgitation with moderate pulmonary 
artery systolic hypertension.  

Discharge Labs:
___ 06:30AM BLOOD WBC-5.4 RBC-2.55* Hgb-9.7* Hct-27.8* 
MCV-109* MCH-37.9* MCHC-34.7 RDW-25.1* Plt Ct-21*
___ 06:30AM BLOOD Glucose-100 UreaN-23* Creat-1.1 Na-139 
K-4.0 Cl-102 HCO3-29 AnGap-12
___ 06:30AM BLOOD Calcium-8.6 Phos-4.5 Mg-1.8
 
Brief Hospital Course:
Ms. ___ is a ___ with a history of chronic lymphocytic 
leukemia, anemia, and thrombocytopenia who presents s/p syncopal 
episode today and was found to have a systolic murmur.
 
Active Issues:

# Syncope: Pt with single syncopal episode. No traumatic 
injuries on exam. CT head was unremarkable. The patient's 
infectious work up has been unrevealing. Patient has not had any 
chest pain or dyspnea, but considering pt's murmur and age, may 
have significant AS lesion. Syncope work up was negative 
revealing negative cardiac enzymes x2, no significant 
arrhythmias on telemetry, echo showed TR and PR but not AS, and 
orthostatic vitals were within normal limits. It is unlikely 
that patient had a stroke given no focal neurologic deficits or 
seizure since there was no reports of tongue biting, urinary 
incontinence, or shaking. Pt symptoms could be from her anemia, 
although her H/H were at her baseline. On discharge pt no longer 
was dizzy or lightheaded.

# Anemia: Patient's anemia likely secondary to CLL and treatment 
effects. Her H/H is consistent with prior recent values, if not 
a bit higher. We trended her lab values and they were stable.  

# Thrombocytopenia: pt with profound thrombocytopenia with plts 
19K. Again, consistent w/ recent priors, and likely secondary to 
known CLL and treatment effects. Pt did not have any signs of 
significant hematoma from her fall.  

# CLL: Pt is s/p 1 cycle of Rituxan and a BM biopsy 1 week ago 
with results of this pending. I notified pt oncologist Dr. 
___ her admission as well as the hematology-oncology 
felllow. Pt will follow up with Dr. ___ as an outpatient for 
results of BM biopsy and next step in treatment plan.  

# Conjunctivitis: Pt developed redness and crusting of her left 
eye while in hospital. This appeared to be a conjunctivitis 
which was treated initially with erythromycin ointment. On 
discharge pt was given prescription for trimethoprim-polymixin 
eye drops for the remainder of 7 days of treatment. Pt eye 
should be re-evaluated at her post hospitalization PCP 
___.

Chronic Issues:

# HTN: mildly hypertensive 150/54 on arrival. We initially held 
pt hypertension medications given her syncopal episode. We then 
continue enalapril, amlodipine, and atenolol and pt remained 
normotensive. 

# GERD: Pt was asymptomatic so we continued omeprazole.

Transitional Issues:
1. Pt will need left eye re-evaluated s/p 7 days of antibiotic 
eye drops for conjunctivitis.
 
Medications on Admission:
Preadmission medications listed are correct and complete.  
Information was obtained from PatientwebOMR.
1. Polyethylene Glycol 17 g PO DAILY 
2. Docusate Sodium 100 mg PO BID 
3. Atorvastatin 10 mg PO DAILY 
4. Amlodipine 5 mg PO DAILY 
5. Moexipril 15 mg PO DAILY 
6. Allopurinol ___ mg PO DAILY 
7. Atenolol 25 mg PO DAILY 
8. Levothyroxine Sodium 50 mcg PO DAILY 
9. Magnesium Oxide 400 mg PO TID 
10. Omeprazole 10 mg PO DAILY 
11. Ondansetron 8 mg PO Q8H:PRN nausea 
12. Prochlorperazine 5 mg PO Q6H:PRN nausea 
13. Senna 1 TAB PO DAILY 

 
Discharge Medications:
1. Allopurinol ___ mg PO DAILY 
2. Amlodipine 5 mg PO DAILY 
3. Atenolol 25 mg PO DAILY 
4. Atorvastatin 10 mg PO DAILY 
5. Docusate Sodium 100 mg PO BID 
6. Levothyroxine Sodium 50 mcg PO DAILY 
7. Moexipril 15 mg PO DAILY 
8. Polyethylene Glycol 17 g PO DAILY 
9. Senna 1 TAB PO DAILY 
10. Magnesium Oxide 400 mg PO TID 
11. Ondansetron 8 mg PO Q8H:PRN nausea 
12. Prochlorperazine 5 mg PO Q6H:PRN nausea 
13. Omeprazole 10 mg PO DAILY 
14. Artificial Tears ___ DROP LEFT EYE Q4H:PRN dry eye 
RX *peg 400-hypromellose-glycerin [Artificial Tears] 1 %-0.2 
%-0.2 % ___ drops in each eye Q4H:PRN dry eye Disp #*1 Bottle 
Refills:*0
15. Polymyxin B Sul-Trimethoprim *NF* (trimethoprim-polymyxin B) 
0.1-10,000 %-unit/mL OS QID Duration: 7 Days 
RX *trimethoprim-polymyxin B 10,000 unit/mL-0.1 % 2 drops(s) OS 
four times a day Disp #*1 Bottle Refills:*0

 
Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Syncope

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker 
or cane).

 
Followup Instructions:
___

{'Syncope': ['Syncope and collapse'], 'Fall': ['Syncope and collapse'], 'Weakness': ['Syncope and collapse', 'Chronic lymphoid leukemia', 'without mention of having achieved remission'], 'Constipation': ['Other and unspecified hyperlipidemia'], 'Systolic murmur': ['Peripheral vascular disease', 'unspecified'], 'Anemia': ['Anemia in neoplastic disease'], 'Thrombocytopenia': ['Other secondary thrombocytopenia'], 'Conjunctivitis': ['Conjunctivitis', 'unspecified'], 'Hypertension': ['Unspecified essential hypertension'], 'Hyperlipidemia': ['Other and unspecified hyperlipidemia'], 'Gout': ['Gout', 'unspecified'], 'Esophageal reflux': ['Esophageal reflux']}