Herpesviral meningitis Malignant neoplasm of rectum Ulcer of anus and rectum Other gastritis without bleeding Duodenitis without bleeding Essential (primary) hypertension Major depressive disorder single episode unspecified Other iron deficiency anemias
 
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Major Surgical or Invasive Procedure:
EGD
Colonoscopy
Biopsy during colonoscopy
Lumbar puncture

attach
 
Pertinent Results:
ADMISSION LABS:
___ 11:00AM   WBC-10.0 RBC-4.66 HGB-8.4* HCT-30.9* MCV-66* 
MCH-18.0* MCHC-27.2* RDW-20.1* RDWSD-45.3
___ 11:00AM   NEUTS-85.1* LYMPHS-6.6* MONOS-7.7 EOS-0.0* 
BASOS-0.2 IM ___ AbsNeut-8.47* AbsLymp-0.66* AbsMono-0.77 
AbsEos-0.00* AbsBaso-0.02
___ 11:00AM   PLT COUNT-225
___ 11:00AM   GLUCOSE-111* UREA N-15 CREAT-1.0 SODIUM-128* 
POTASSIUM-4.6 CHLORIDE-95* TOTAL CO2-18* ANION GAP-15
___ 11:00AM   ALT(SGPT)-13 AST(SGOT)-20 ALK PHOS-80 TOT 
BILI-1.0
___ 11:00AM   ALBUMIN-4.9
___ 07:20AM BLOOD Hypochr-1+* Anisocy-1+* Macrocy-1+* 
Microcy-1+* Polychr-1+* Tear Dr-1+* RBC Mor-SLIDE REVI

___ 11:42AM BLOOD Ret Aut-3.1* Abs Ret-0.13*
___ 07:20AM BLOOD calTIBC-371 VitB12-293 Folate-8 
Ferritn-5.6* TRF-285
___ 11:42AM BLOOD Hapto-208*
___ 07:20AM BLOOD TSH-1.1
___ 07:20AM BLOOD 25VitD-17*
___ 03:30AM BLOOD IgA-162

___ 03:40PM CEREBROSPINAL FLUID (CSF)  TNC-146* RBC-7* 
POLYS-1 ___ MONOS-12 BASOS-1 OTHER-0
___ 03:40PM CEREBROSPINAL FLUID (CSF)  TNC-141* RBC-2 
POLYS-1 ___ MONOS-3 OTHER-0
___ 03:40PM CEREBROSPINAL FLUID (CSF)  PROTEIN-100* 
GLUCOSE-57
___ 11:00AM   Lyme Ab-NEG
___ 04:45PM BLOOD Trep Ab-NEG
___ 07:20AM BLOOD HIV Ab-NEG
___ 03:05PM BLOOD Parst S-NEGATIVE
 
MICRO:
___ 3:40 pm CSF;SPINAL FLUID     
Site: LUMBAR PUNCTURE
      TUBE #3. 
   GRAM STAIN (Final ___: 
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 
      NO MICROORGANISMS SEEN.  

   FLUID CULTURE (Final ___:    NO GROWTH. 

HSV CSF HSV2 + low positive

IMAGING:
CT head w/o acute intracranial process

Discharge Labs:

___ 06:00AM BLOOD WBC-5.6 RBC-3.79* Hgb-7.2* Hct-27.1* 
MCV-72* MCH-19.0* MCHC-26.6* RDW-22.1* RDWSD-56.4* Plt ___
___ 06:00AM BLOOD Glucose-80 UreaN-12 Creat-0.8 Na-143 
K-3.9 Cl-111* HCO3-21* AnGap-11
___ 06:00AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.7
___ 05:45AM BLOOD Hapto-126
___ 07:20AM BLOOD TSH-1.1
___ 05:50AM BLOOD CEA-1.9
___ 03:30AM BLOOD IgA-162

Colonoscopy:
Circumferential mass of malignant appearance was found in the 
distal rectum completely encircling the rectal verge. There were 
local ulcerations in the 12 o'clock position. Multiple cold 
forceps biopsies were performed for histology in the rectal 
mass.

EGD:
Normal erythema in the whole esophagus. Erythema in the antrum 
with gastritis. Erythema in the duodenum compatible with 
duodenitis.
 
Brief Hospital Course:
Hospital Medicine Attending Progress Note

Time patient seen and examined today

HPI on Admission:
Mr. ___ is a ___ male with a PMHX of partial aortic 
dissection, HTN, who presents w/ HA & fever x2d concerning for 
meningitis.

Patient reports that 3 days ago, he developed malaise and 
terrible headache: constant, dull, diffuse. The following day, 
headache was relenting ___ pain. Also had fever of 102 and 
took tylenol/ibuprofen without relief of symptoms. He reports 
nausea and decreased PO intake. Denies vision changes, 
sensitivity to light, syncope, URI sx, chest pain, shortness of 
breath, abd pain, diarrhea/constipation, sick contacts. Has mild 
neck stiffness as well. He lives in ___, does a lot of
yardwork. Has had exposure to ticks, mosquitoes, but none he 
memorably recalls recently. No recent travel hx. No rash. He was 
feeling entirely well prior to onset of these symptoms. Given 
terrible headache and fever, he presented to the ED. 

Hospital Course to Date:

The pt was admitted for acute onset headache and fever. LP 
showed a cell count of 141 with lymphocytic predominance and 
elevated protein to 100. He was initially started on bacterial 
meningitis coverage, then narrowed to acyclovir based on 
negative CSF stain and cultures. Doxycycline was added to cover 
potential lyme
meningitis. The pt's CSF came back positive for HSV PCR. Per ID 
recommendations from ___: "Would recommend continuing on 
Acyclovir for now but when safe for discharge can change to 
Valtrex 1 gram po three times per day to complete 14 day course.
In setting of only low positive HSV 2 PCR and extensive outdoor 
activity would also complete 14 day course of doxycycline even 
though lyme is less likely." The pt improved dramatically. His 
headache resolved. Throughout his hospitalization, he had no 
confusion or neurologic deficits. He was transitioned to oral 
acyclovir the day before discharge and discharged on PO 
acyclovir + PO doxycycline for a total 14 day course.

Of note, the pt was incidentally found to have an abnormally low 
Hb on admission. He required 1u PRBC transfusion ___. He denies 
any known bleeding. GI was consulted and recommended EGD + 
colonoscopy, performed ___. EGD showed diffuse erythema of 
the mucosa with no bleeding noted in the antrum, consistent with 
gastritis. Colonoscopy showed a circumferential mass of 
malignant appearance in the distal rectum completely encircling 
the rectal verge. There were local ulcerations in the 12:00 
position. Colorectal surgery was consulted. They recommended 
follow up at the colorectal cancer clinic. Follow up was 
arranged prior to discharge and the pt was aware of the 
diagnosis and need for follow up. The clinic and colorectal 
surgery asked for a baseline CEA which was normal. They asked 
for a staging MRI pelvis which did not show any spread of the 
presumed cancer. Pathology was sent by GI. Initial pathology 
showed superficial fragments of tubulovillous adenoma. This was 
pending at the time of discharge, though initial reports had 
shown the same diagnosis, so the pt was instructed to follow up 
with GI. The GI phone number was shared with the patient and he 
was instructed to call them directly if he did not hear from the 
clinic within 24 hours. The pt received a total of 2u PRBCs this 
hospitalization. Hb was 7.2 on the morning of discharge and the 
pt received 1u PRBCs (the second unit this stay) on the day of 
discharge after the Hb of 7.2 in order to ensure that his Hb did 
not drop below 7.0 at home. Close follow up was arranged prior 
to discharge. The pt had no active bleeding at the time of 
discharge. Return to ER precautions such as dizziness and 
increased bleeding were reviewed with the patient.

The pt's BP meds were held on admission but restarted prior to 
discharge.
 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraZODone 50 mg PO QHS:PRN insomnia 
2. Citalopram 20 mg PO DAILY 
3. Lisinopril 20 mg PO DAILY 
4. Metoprolol Succinate XL 50 mg PO DAILY 

 
Discharge Medications:
1.  Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever  
2.  Doxycycline Hyclate 100 mg PO Q12H 
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day 
Disp #*12 Capsule Refills:*0 
3.  Pantoprazole 40 mg PO DAILY 
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30 
Tablet Refills:*0 
4.  ValACYclovir 1000 mg PO TID 
RX *valacyclovir [Valtrex] 1,000 mg 1 tablet(s) by mouth three 
times a day Disp #*18 Tablet Refills:*0 
5.  Citalopram 20 mg PO DAILY  
6.  Lisinopril 20 mg PO DAILY  
7.  Metoprolol Succinate XL 50 mg PO DAILY  
8.  TraZODone 50 mg PO QHS:PRN insomnia  

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Viral meningitis ___ HSV
Iron deficiency anemia
Rectal cancer

 
Discharge Condition:
Stable for outpatient follow up

 
Discharge Instructions:
Dear ___,

You came to the hospital with severe headache and fevers.  You 
were found to have a viral meningitis with testing showing 
herpes simplex virus to be the cause.  Please continue taking 
Valtrex and doxycycline until ___ to treat this infection.

When you were in the hospital, you were found to have iron 
deficiency anemia.  You were seen by the Gastroenterologists.  
You underwent an EGD and a colonoscopy. The EGD showed a little 
stomach irritation. Avoid ibuprofen, higher dose aspirin, and 
naproxen. Take pantoprazole to help with the irritation. There 
was no cancer found in the stomach. The colonoscopy showed a 
rectal cancer. Please follow up as instructed with 
gastroenterology for a better pathology sample and with the 
multi-disciplinary colorectal cancer team as instructed.

Your appointment with the multi-disciplinary team has already 
been set up.

Call the ___ clinic to set up an appointment 
with them, in order for them to get a better sample of the 
tumor. This is needed for the pathologists and oncologists. If 
you do not hear from the office within 48 hours, call them at: 
___.

We wish you the best in your recovery.
-- Your medical team
 
Followup Instructions:
___

{'headache': ['Herpesviral meningitis'], 'fever': ['Herpesviral meningitis'], 'malaise': ['Herpesviral meningitis'], 'nausea': ['Herpesviral meningitis'], 'neck stiffness': ['Herpesviral meningitis'], 'malignant neoplasm of rectum': ['Malignant neoplasm of rectum'], 'ulcer of anus and rectum': ['Ulcer of anus and rectum'], 'gastritis': ['Other gastritis without bleeding'], 'duodenitis': ['Duodenitis without bleeding'], 'hypertension': ['Essential (primary) hypertension'], 'depressive disorder': ['Major depressive disorder, single episode, unspecified'], 'anemia': ['Other iron deficiency anemias']}