Other chest pain Blood in stool End stage renal disease Kidney replaced by transplant Diastolic heart failure unspecified Diabetes with neurological manifestations type I [juvenile type] uncontrolled Gastroparesis Polyneuropathy in diabetes Diabetes with ophthalmic manifestations type I [juvenile type] uncontrolled Background diabetic retinopathy Coronary atherosclerosis of native coronary artery Esophageal reflux Unspecified acquired hypothyroidism Gout unspecified Congestive heart failure unspecified Diaphragmatic hernia without mention of obstruction or gangrene Systemic sclerosis Other and unspecified nonspecific immunological findings Urinary incontinence unspecified Anemia in chronic kidney disease Personal history of venous thrombosis and embolism Old myocardial infarction Percutaneous transluminal coronary angioplasty status Long-term (current) use of anticoagulants Personal history of tobacco use Family history of ischemic heart disease Family history of other lymphatic and hematopoietic neoplasms Family history of malignant neoplasm of kidney
 
Name:  ___             Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
Penicillins
 
Attending: ___
 
Chief Complaint:
chest pain, hematochezia 
 
Major Surgical or Invasive Procedure:
none.

 
History of Present Illness:
    ___ year old female with complex PMH including DM, CAD, s/p 
LURT ___, p/w angina and blood in stool. She reports ___ months 
of right chest pain associated with shortness of breath (her 
anginal equivalent), worse with exertion and relieved by rest 
and nitroglycerin. She feels that these symptoms are occurring 
more frequently than previous.  
  
    She also reports chronic diarrhea with intermittent blood, 
occurring at increased frequency. There is also a new report of 
nocturnal bedwetting, occur only with deep sleep.  
  
    In the ED, vital signs initially were T 98.3, BP 130/61, P 
87, RR 18, Sat 98% RA. Labs significant for mildly elevated 
creatinine (1.4 from b/l circa 1.0). Cardiac enzymes negative x 
1. EKG showed no acute ST changes, NSR. D-dimer not elevated at 
250. INR therapeutic at 2.8. She received . Rectal tone was 
reported as normal and she was guaiac negative. The patient was 
admitted for work up of these complaints.  

Currently she is not c/o chest pain, SOB, has not had any 
diarrheal symptoms or incontinent episodes overnight.

 
Past Medical History:
# Living-unrelated kidney transplant on ___.  
# End-stage renal disease secondary to diabetes.  
# History of CREST syndrome and antiphospholipid antibody  
positivity with remote history of PE and on Coumadin since  
___  
# CAD status post MI and status post PTCA, EF 60%  
# type 1 diabetes w/ neuropathy, retinopathy and insulin pump  
# Gastroparesis  
# scleroderma  
# GERD  
# hiatal hernia  
# hypothyroidism  
# CHF EF 60% ___  
# gout  
# s/p appendectomy  
# s/p cholecystectomy  
# hypothyroidism  
# herniated disk  
# gout  
# sleep apnea  
# Left ring finger trigger finger release ___  
# Left cubital and carpal tunnel release ___  
# PPD negative ___  
# E coli UTI ___ ___ to cipro  
# Enterococcus UTI ___ amp ___
 
Social History:
___
Family History:
Nephews x2: alopecia  
Sister: RA  
Daughter: ___ and celiac - adopted  
Nephew: addisons  
Sister and brother: sarcoid  
 
Physical ___:
General: Caucasian female sitting up in bed in NARD.  
HEENT: NCAT, EOMI, no scleral icterus  
Neck: supple, no significant JVD, no hepatojugular reflux noted  

Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales  
Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated  
Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or 
organomegaly noted  
Extremities: No edema, 2+ radial, DP pulses b/l  
Lymphatics: No cervical, supraclavicular, axillary or inguinal 
lymphadenopathy noted  
Skin: no rashes or lesions noted.  
Neurologic: Alert, oriented x 3. Able to relate history without 
difficulty. Cranial nerves II-XII intact. Normal bulk, strength 
and tone throughout. Pt has decreased sensation in b/l lower 
extremities from ankle down (baseline), 2+ biceps, 1+ knee 
reflexes bilaterally. Plantar response was flexor bilaterally. 
Pt able to ambulate with adequate locomotion, tandem arm swing, 
gait distance even. Pt able to walk on tip-toes and heels with 
no deficits. + rectal tone in ER.  

 
Pertinent Results:
___ 09:00AM BLOOD WBC-9.4 RBC-3.87* Hgb-11.7* Hct-35.7* 
MCV-92 MCH-30.4 MCHC-32.9 RDW-14.0 Plt ___
___ 10:50PM BLOOD WBC-8.1 RBC-4.02* Hgb-12.2 Hct-37.9 
MCV-94 MCH-30.3 MCHC-32.1 RDW-13.8 Plt ___
___ 12:30AM BLOOD ___ PTT-32.4 ___
___ 09:00AM BLOOD Glucose-78 UreaN-24* Creat-1.5* Na-142 
K-4.4 Cl-106 HCO3-28 AnGap-12
___ 10:50PM BLOOD Glucose-414* UreaN-24* Creat-1.4* Na-139 
K-4.9 Cl-102 HCO3-26 AnGap-16
___ 09:00AM BLOOD ALT-44* AST-27 AlkPhos-141* TotBili-0.3
___ 10:50PM BLOOD CK(CPK)-54
___ 10:50PM BLOOD CK-MB-NotDone cTropnT-<0.01
___ 09:00AM BLOOD Albumin-4.2 Calcium-9.8 Phos-2.5* Mg-1.7
___ 10:50PM BLOOD %HbA1c-11.2*
___ 10:50PM BLOOD TSH-0.12*
 
Brief Hospital Course:
___ y.o. Female with DMI, ESRD s/p renal transplant, CREST 
syndrome, CAD s/p MI w/ PTCA presented with chest pain, 
hematochezia with negative cardiac work up.

##. Atypical Chest pain: Patient admitted for atypical chest 
pain. During hospitalization pt's chest pain work up showed 
negative troponin, no acute EKG changes or arrhythmic events on 
telemetry; during hospitalization pt denied any further chest 
pain episodes. Based on her clinic symptoms and work-up it is 
unlikely that the chest pain was cardiac in nature. Pt has been 
undergoing a lot of stress and her chest pain frequency has 
increased with the increase in stressors. Pt was continued on 
her outpatient medications and set up for close follow up with 
Dr. ___.
 
## Diarrhea: Patient endorsed a one week history of a small 
amount of bloody diarrhea but was noted to be Guaiac negative in 
the ED. During hospitalization pt reported no further bloody 
bowel movements, her Hct remained stable and no leukocytosis or 
fevers were noted. Her symptoms of diarrhea also appear to have 
an onset similar to her recent stressors, it may also have been 
an episode of viral gastroenteritis as the episode resolved 
quickly. Pt will likely need a colonoscopy as an outpatient to 
follow up. 
  
##. Nocturnal Urinary Incontinence: Pt has been having episodes 
of nocturnal urinary incontinence when she is deeply asleep, she 
is also taking two sleep medications. During hospitalization pt 
did not experience any nocturnal incontinence whilst on a 
reduced sleep medication regimen. With no signs or symptoms of 
cord compression episodes may be a combination of a progression 
of her  diabetes causing decreased bladder sensation on top of 
her use of sleeping medications.   
 
##. Renal transplant, Scleroderma: Pt was continued on her 
outpatient immunosuppressant regimen of Prograf, Cellcept, 
Prednisone.   
  
##. DM 1: Pt's Hgb A1C noted to be elevated at 11.2%. Pt was 
continued on her insulin pump and neurontin for her neuropathy. 

##. h/o PE/APA: Pt was continued on her Coumadin with a 
therapeutic INR.  
 
##. PVD: Pt was continued on her outpatient cilostazol  

 
Medications on Admission:
1. Insulin as prescribed.  
2. CellCept 500 mg tablets two per day.  
3. Prograf 2 mg once daily.  
4. Warfarin 2 mg once daily.  
5. Trazodone 25 mg as needed.  
6. Cilostazol 50 mg once daily.  
7. Reglan 5 mg with meals.  
8. Cymbalta 60 mg once daily.  
9. Synthroid ___ mg once daily.  
10. Desipramine 50 mg once daily.  
11. Lipitor 80 mg once daily.  
12. Neurontin 600 mg b.i.d.  
13. Ambien 5 mg once daily.  
14. Lasix 40 mg once daily.  
15. Prednisone 7.5 mg once daily.  
16. Bactrim 80/160 once daily.  
17. Procardia-XL 30 mg once daily.  
18. Ativan 1 mg p.r.n.  
19. Betaxolol 30 mg once daily.  
20. Nitroglycerin as needed.  
21. Cipro 500 mg b.i.d.  
22. Phenergan 25 mg once daily.  
23. Vicodin 7.5/750 p.r.n.  
24. Aspirin 81 mg daily  

 
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) 
Capsule, Delayed Release(E.C.) PO BID (2 times a day).  
2. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO three times a 
day.  
3. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) 
as needed for insomnia.  
4. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY 
(Daily).  
5. B Complex Vitamins     Capsule Sig: One (1) Cap PO DAILY 
(Daily).  
6. Allopurinol ___ mg Tablet Sig: One (1) Tablet PO once a day.  

7. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) 
Capsule, Delayed Release(E.C.) PO DAILY (Daily).  
8. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
9. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day.  
10. Prednisone 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).  
11. Betaxolol 20 mg Tablet Sig: One (1) Tablet PO daily ().  
12. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
13. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) 
Tablet Sustained Release PO DAILY (Daily).  
14. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO 
BID (2 times a day).  
15. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 
 
16. Cilostazol 50 mg Tablet Sig: 1.5 Tablets PO daily ().  
17. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 
___ hours).  
18. Cholecalciferol (Vitamin D3) 1,000 unit Capsule Sig: One (1) 
Capsule PO once a day.  
19. Ascorbic Acid ___ mg Tablet, Chewable Sig: One (1) Tablet, 
Chewable PO once a day.  

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Atypical Chest Pain

 
Discharge Condition:
Stable, Afebrile

 
Discharge Instructions:
You were admitted to the hospital for chest pain and bloody 
diarrhea. During your hospital stay your blood work and your EKG 
showed that it was unlikely this pain was due to a new heart 
attack. Your blood level also remained the same from previous 
studies.

Please drink a lot of fluids. If you experience chest pain again 
please return to the ER.

Weigh yourself every morning, call MD if weight > 3 lbs.
Adhere to 2 gm sodium diet

 
Followup Instructions:
___

{'Chest pain': ['Other chest pain', 'Diastolic heart failure', 'Coronary atherosclerosis of native coronary artery', 'Congestive heart failure'], 'Blood in stool': ['Blood in stool'], 'Diarrhea': ['Gastroparesis'], 'Nocturnal bedwetting': ['Urinary incontinence']}