Dehydration Anemia unspecified Dizziness and giddiness Hypotension unspecified Depressive disorder not elsewhere classified Anxiety state unspecified Other chronic pain Tension type headache unspecified
 
Name:  ___                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
lightheadedness
 
Major Surgical or Invasive Procedure:
none
 
History of Present Illness:
___ y/o with hx diffuse burns, depression/anxiety who awoke from 
sleep this am and felt lightheaded.  She called EMS and was 
brought to ED where sbp was in ___, this responded well to 3 
litres IVF - sbp now over 100.  Guaiac negative, tox negative, 
no fevers, hcg neg.  Hct 30 (unknown baseline), ct head and cxr 
negative.  Etiology unknown.  Admitted for further e and m.

ROS - has mild headache, no visual changes, no st, cough, 
fevers, no chest pain, no sob, no abd pain, no n/v/d, no blood 
pr.  no arthralgias or rash.  Pt. recently had menorrhagia, now 
completed cycle - no bleeding at current.
 
Past Medical History:
Depression, anxiety, burns.
 
Social History:
___
Family History:
states parents/family have no medical problems.
 
Physical Exam:
AF and VSS - sbp is now 97/64  HR 72
Diffuse scaring from burns
RRR no MRG
MMM
CTA t/o 
S/NT/ND/BS present
No edema or rash
Alert, oriented.

Strange affect, laughs inappropriately, will not share details 
of history, medical or psychiatric.  Endorses depression, 
passive suicidality, anxiety.  States she 'does not care to live 
anymore'.

 
Pertinent Results:
___ 05:23AM   ___ PTT-25.4 ___
___ 05:23AM   PLT COUNT-274
___ 05:23AM   NEUTS-33.9* LYMPHS-54.4* MONOS-5.5 EOS-5.4* 
BASOS-0.8
___ 05:23AM   WBC-4.2 RBC-3.61* HGB-10.1* HCT-30.9* MCV-86 
MCH-27.9 MCHC-32.5 RDW-15.7*
___ 05:23AM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG 
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 05:23AM   ALBUMIN-4.6 CALCIUM-9.4 PHOSPHATE-3.8 
MAGNESIUM-1.8
___ 05:23AM   LIPASE-28
___ 05:23AM   ALT(SGPT)-9 AST(SGOT)-13 ALK PHOS-32* TOT 
BILI-0.2
___ 05:23AM   estGFR-Using this
___ 05:23AM   GLUCOSE-92 UREA N-17 CREAT-0.6 SODIUM-140 
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-29 ANION GAP-12
___ 05:36AM   LACTATE-0.4*
___ 07:05AM URINE  UCG-NEGATIVE
___ 07:05AM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG 
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 07:05AM URINE  HOURS-RANDOM
___ 08:10AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG 
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 
LEUK-NEG
___ 08:10AM URINE  COLOR-Straw APPEAR-Clear SP ___
___ 08:10AM URINE  GR HOLD-HOLD
___ 08:10AM URINE  HOURS-RANDOM

CXR and CT head negative, reviewed reports.
 
Brief Hospital Course:
Impression - 

Lightheadedness with hypotension, likely due to dehydration, 
relative anemia given recent menorrhagia.  

No evidence of sepsis - no fevers, leukocytosis, rash.
- ECG reportedly normal from ED (report to RN) - but I cannot 
find this.  Will attempt to get copy from ED or will repeat - 
repeated, normal.
- RN to examine pt. now for presence of tampon - need to make 
sure this is out in case this could have been evolving toxic 
shock although threre is no other evidence to suggest/support 
this etiology at current - no tampon present
- orthostatics now and daily - if positive, will bolus IVF
- guaiac all stools
- PO ad lib

Anemia - baseline unclear.  Follow.  UCG negative. 

Depression/anxiety - pt. actively depressed, anxious, passively 
suicidal.  Psychiatry consultation now for assistance in 
evalution of the above and for recommendations in medication 
mgmt, ? need for psychiatric hospitalization if medically 
stable.  Continue prozac for now to avoid the SSRI withdrawal 
syndrome.

Psychiatry saw pt. and felt that pt. had no indications for 
inpatient hospitalization, and that she should continue on with 
her current outpatient psychiatrist.  No medication changes were 
recommended and none were made.

Chronic pain, with description consistent with trigeminal 
neuropathy?  Continue gabapentin for now - withdrawal from this 
agent can cause seizures.  Tylenol prn.

I suspect that this pt. has not been eating and drinking well 
given depression and developed a relative anemia from 
menorrhagia which was likely symptomatic overnight (orthostasis) 
and will do well with hydration.

Hospital course - 

Pts bp stabilized with hydration alone.  Hct stable.  No 
bleeding seen.  Orthostatics negative.  Discharged home with new 
pcp ___. arranged as below.
 
Medications on Admission:
Gabapentin 100 bid and 300 hs.
Prozac 10 daily
 
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 
6 hours) as needed for pain: for headache; do not combine this 
medication with tylenol.
Disp:*60 Tablet(s)* Refills:*0*

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
dehydration, anemia
 
Discharge Condition:
Stable.  BP 100-110.  No menstrual bleeding ongoing.  
Orthostatics negative.  Pt. without complaints at time of 
discharge.  Ambulatory independently, tolerating po intake and 
voiding independently.
 
Discharge Instructions:
Return to the emergency room for: lightheadedness, significant 
vaginal bleeding
 
Followup Instructions:
___

{'lightheadedness': ['Dehydration', 'Hypotension'], 'hypotension': ['Dehydration', 'Hypotension'], 'anxiety': ['Anxiety state', 'Depressive disorder'], 'depression': ['Anxiety state', 'Depressive disorder'], 'headache': ['Other chronic pain', 'Tension type headache']}