Syncope and collapse Urinary tract infection site not specified Dysphagia unspecified Aortic valve disorders Sicca syndrome Unspecified acquired hypothyroidism Unspecified essential hypertension Anemia unspecified
 
Name:  ___               ___ No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
Syncope
 
Major Surgical or Invasive Procedure:
None
 
History of Present Illness:
Ms. ___ is a ___ w/hx of AR, hypothyroidism, Sjogrens, HTN, 
PNA who presents as a transfer from ___ after a syncopal 
episode on ___ AM. She was standing and speaking with her 
daughter when she began to feel weak, lightheaded, and nauseous. 
She has had a few syncopal episodes in the past, which she 
reports were concurrent with other health problems such as a 
recent PNA in ___ with hemoptysis treated at ___ (CT scan 
showed RML brochiectasis and some consolidation; bronch showed 
copious mucoid secretions RML>lingula>RUL with some blood, pt 
was scheduled for rpt CT scan on ___.
.
On ___, she sat down in her chair and then passed out, and was 
unresponsive for a few seconds. The pt denies prodrome or 
palpitations, and regained consciousness quickly with no 
confusion afterwards. No seizure like activity witnessed, no 
lose of bowel or bladder. Denies any recent exertion or 
miturition prior to episode. Denies CP, palpitations, SOB prior 
or after the episode. She remembers the episode. She states she 
has been coughing for the past few days, occasionally productive 
with phlegm, nonbloody, but has otherwise been well, with no 
fevers/chills. Her last echo for AR ___ years ago.
.
In the ED, initial vitals were 98.5 96 145/86 20 97%. Labs were 
notable for WBC 12.0 (with N 76.5%, L 17.3%), Hct 32.6.  UA 
showed lg leuk and 18 WBC. Vitals prior to transfer were 
98-85-146/75-25-98.
.
Currently on the medicine floor, she feels "fine" and does not 
feel dizzy or lightheaded. She denies fever, chills, vision 
changes, shortness of breath, chest pain, abdominal pain, 
nausea, vomiting, diarrhea, constipation, BRBPR, melena, 
hematochezia, dysuria, hematuria. She does say she lost a few 
pounds in the last few weeks and has not had a great appetite 
for about a month.
 
Past Medical History:
HTN
Hypothyroidism
Sjo___'s Syd

 
Social History:
___
Family History:
Long history of hypertension in her family.  She does report 
that her father's family has a history of multiple cancers.  She 
has a grandfather with a history of stomach cancer and an uncle 
with a history of throat cancer.  She denies any history of 
colon cancers. Father had stroke. No family h/o MI. Mother had a 
heart valve replaced (pt not sure which one).

 
Physical Exam:
ADMISSION EXAM:

VS - Temp 98.1F, BP 112/70, HR 96, R 18, O2-sat 96% RA
GENERAL - thin-appearing woman in NAD, comfortable, appropriate
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, carotid bruits (likely 
radiating sounds from aortic regurgitation)
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp 
unlabored, no accessory muscle use
HEART - RRR, 3+ mid-systolic murmur loudest at LLS border, 
radiates to axilla, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no 
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
NEURO - awake, A&Ox3, muscle strength ___ b/l.
.
DISCHARGE EXAM: Unchanged with previous, except for the 
following:
VS - Temp 97.8F, BP 123/74, HR 82, R 16, O2-sat 98% RA
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp 
unlabored, no accessory muscle use
HEART - RRR, 3+ mid-systolic murmur loudest at ___ border, 
radiates to ___, ___ S1-S2

 
Pertinent Results:
ADMISSION LABS:
___ 05:50PM BLOOD WBC-12.0*# RBC-3.48* Hgb-11.4* Hct-32.6* 
MCV-94 MCH-32.7* MCHC-34.9 RDW-13.4 Plt ___
___ 05:50PM BLOOD Neuts-76.5* Lymphs-17.3* Monos-5.2 
Eos-0.7 Baso-0.4
___ 05:50PM BLOOD Plt ___
___ 05:50PM BLOOD Glucose-101* UreaN-15 Creat-0.7 Na-135 
K-4.4 Cl-101 HCO3-26 AnGap-12
___ 05:50PM BLOOD cTropnT-<0.01
___ 08:05AM BLOOD cTropnT-<0.01
.
DISCHARGE LABS:
___ 08:05AM BLOOD WBC-6.0 RBC-3.62* Hgb-11.8* Hct-34.1* 
MCV-94 MCH-32.7* MCHC-34.7 RDW-13.3 Plt ___
___ 08:05AM BLOOD Plt ___
___ 08:05AM BLOOD Glucose-100 UreaN-12 Creat-0.8 Na-136 
K-4.4 Cl-101 HCO3-28 AnGap-11
___ 08:05AM BLOOD Calcium-9.3 Phos-3.3 Mg-1.9
___ 11:00AM BLOOD Iron-98
___ 11:00AM BLOOD calTIBC-354 VitB12-1270* Folate-GREATER 
TH Ferritn-80 TRF-272
.
MICROBIOLOGY:
___ Blood Cx: Pending
___ Urine Cx: pending
.
IMAGING:
___ Video swallow study: Not likely aspiration. 
RECOMMENDATIONS: 1. PO diet of thin liquids and soft solids 2. 
Aspiration precautions including: 
a) keep solids soft and moist  b) use liquid wash to clear 
solids as needed
 c) alternate bites and sips 3. Meds whole with water 4. Regular 
oral care
5. Suggest nutritional supplements at home given reports of 
recent weight loss.
 
Brief Hospital Course:
Ms. ___ is a pleasant ___ w/ a h/o aortic regurgitation, 
hypothyroidism, Sjogrens, and HTN who presents as a transfer 
from ___ after a syncopal episode on ___ AM. Upon admission, 
she was hemodynamically stable, but was found to have 
asymptomatic pyuria, cough, and a WBC of 12.0.
.
ACTIVE ISSUES:
.
#Syncope: Pt's syncopal episode appears to be c/w vasovagal 
syncope, likely in the setting of her asymptomatic pyuria. She 
also had a ___ in which her Tn's were negative X2 and EKG's 
were c/w and unchanged from previous. She was hemodynamically 
stable and received fluids and bactrim (see below). Given her 
h/o aortic regurgitation, an Echo was ordered but will be 
obtained by the pt on an outpatient basis.
.
#Pyuria: She had 18 WBC and Lg leuk esterase on UA on admission, 
although she had no bacteria on UA or Sx of burning/dysuria. 
Given her syncopal episode in the setting of a UTI, treatment 
with bactrim was started in the ED and continued for a total of 
4 days.
.
#Leukocytosis: Her WBC of 12.0 is likely in the setting of her 
UTI. She was treated with PO bactrim as above. 
.
INACTIVE ISSUES:
.
#Anemia: Hct ___ is 32.6, slightly down from baseline of ~35. 
Her Iron studies, B12, and Folate were within normal limits.
.
#HTN: Her home lisinopril was decreased to 10mg PO qday, in the 
setting of her syncope in order to ensure her BP does not drop 
too low.
.
#Hypothyroidism: continued home levothyroxin.
.
TRANSITIONS OF CARE:
- ___ Iron studies wnl, B12 1270, and Folate >20.
- Pt will obtain Echo as outpt.
 
Medications on Admission:
Lisinopril 20mg PO qday
Levothyroxine 50mcg PO qday

 
Discharge Medications:
1. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
2. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) 
Tablet PO BID (2 times a day) for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
4. Fish Oil  Oral
5. calcium  Oral

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary diagnosis:
Syncope

Secondary diagnoses:
Hypothyroidism
Hypertension

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 
Discharge Instructions:
Dear Ms. ___,

It was a pleasure providing care for you here at the ___ 
___.  You were admitted after having a syncopal 
(fainting) episode on ___.  You were found to have some 
evidence of a urinary tract infection and were treated with an 
antibiotic called Bactrim.  Your chest x-ray at the other 
hospital did not show evidence of a pneumonia.  We monitored 
your heart rhythm overnight and did not note any abnormalities.  
Your electrocardiogram did not show any changes.  Your blood 
pressure remained stable.  You will need an ultrasound of the 
heart for further evaluation (echocardiogram), but this can be 
done after you leave the ___. 

Your condition has improved and you can be discharged to home.

The following changes were made to your medications:

NEW: 
-Bactrim double-strength tab, 1 tab by mouth twice daily for 2 
more days (to treat urinary tract infection)

CHANGED:
- DECREASED Lisinopril to 10mg by mouth daily

Please keep your follow-up appointments as scheduled below.  We 
are also working to schedule your echocardiogram.

Of note, while you were here you had a video swallow study that 
did not show evidence that you are aspirating when you swallow.  
You can continue to eat a regular diet.
 
Followup Instructions:
___

{'weakness': ['Syncope and collapse', 'Unspecified acquired hypothyroidism'], 'lightheaded': ['Syncope and collapse', 'Unspecified acquired hypothyroidism'], 'nausea': ['Syncope and collapse', 'Unspecified acquired hypothyroidism'], 'cough': ['Urinary tract infection', 'site not specified'], 'hemoptysis': ['Urinary tract infection', 'site not specified'], 'brochiectasis': ['Urinary tract infection', 'site not specified'], 'consolidation': ['Urinary tract infection', 'site not specified'], 'mucoid secretions': ['Urinary tract infection', 'site not specified'], 'lost pounds': ['Unspecified acquired hypothyroidism'], 'not great appetite': ['Unspecified acquired hypothyroidism']}