Urinary tract infection site not specified Other and unspecified Escherichia coli [E. coli] Asymptomatic human immunodeficiency virus [HIV] infection status Chronic hepatitis C without mention of hepatic coma Other chronic pain Lumbago Unspecified essential hypertension Esophageal reflux Personal history of allergy to penicillin Arthrodesis status Need for prophylactic vaccination and inoculation against influenza
 
Name:  ___               Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
Darvon / Penicillins / Codeine / Motrin
 
Attending: ___.
 
Chief Complaint:
Pain at ___ Site
 
Major Surgical or Invasive Procedure:
None

 
History of Present Illness:
___ y/o M PMH significant for HIV, HCV, low back pain on chronic 
narcotics, urinary retention s/p foley placement who has had 
numerous admissions this month in relation to the foley now 
found to have  complicated UTI. 

The patient was discharged from the ED, the morning of admission 
and returned because he was having discomfort at the site of the 
foley. He was told by his ___ that he should go to the ED. He 
reports that he may have been having fevers, but is unclear. 
Denies chills, chest pain, SOB, Nausea, vomiting, abdominal 
pain.

In the ED, initial vitals: 97.4 67 154/58 18 94% RA. Patient's 
labs were ntoable for Chem 7, CBC WNL. UA showed large # WBC, + 
leukocytes, + nitrates. Lactate 1.1. Blood cultures were sent. 
He received actemainophen, ciprofloxacin, phenazopyridine, 
vancomycin (given that previous urine culture positive for 
corynebactermium) and oxycodone. He failed a voiding trial in ED 
and foley was placed. Vitals prior to transfer:  98.0 73 152/83 
18 98% RA  

Currently, Patient reports that he has ___ back pain. 
 
ROS: per HPI, 10 pt ROS neg except for above. Of note, +pain at 
___ site. 

 
Past Medical History:
Depression  
? mild dementia  
HIV on HAART  
Hepatitis C, reportedly s/p interferon treatment 
self-administered for ___ year  
Hypertension  
Lumbar Stenosis s/p spinal fusion in ___ for back pain  
Sciatica  
BPH  
urinary retention  
anxiety  
B12 deficiency
 
Social History:
___
Family History:
As per OMR:
Father was an alcoholic and died of complications, unsure of how 
mother died
 
Physical ___:
ADMISSION PHYSICAL EXAM:
========================
Vitals- 98.3 170/64 82 20 97%RA 
General- AOx3 no NAD  
HEENT- Sclera anicteric, MMM, oropharynx clear,   
Neck- supple, JVP not elevated, no LAD  
Lungs- CTAB no wheezes, rales, rhonchi  
CV- RRR, Nl S1, S2, No MRG 
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness 
or guarding 
GU- + foley  
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or 
edema  
Neuro- CNs2-12 intact, fluent speech

DISCHARGE PHYSICAL EXAM:
========================
Vitals- 98.5 149/68 74 18 98%RA 
General- AOx3 no NAD  
HEENT- Sclera anicteric, MMM, oropharynx clear,   
Neck- supple, JVP not elevated, no LAD  
Lungs- CTAB no wheezes, rales, rhonchi  
CV- RRR, Nl S1, S2, No MRG 
Abdomen- soft, NT/ND bowel sounds present 
GU- + foley  
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or 
edema  
Neuro- CNs2-12 intact, fluent speech

 
Pertinent Results:
ADMISSION LABS:
=====================
___ 04:00PM BLOOD WBC-10.1 RBC-4.03* Hgb-12.5* Hct-37.9* 
MCV-94 MCH-30.9 MCHC-33.0 RDW-13.5 Plt ___
___ 04:00PM BLOOD Glucose-113* UreaN-10 Creat-0.9 Na-139 
K-3.5 Cl-98 HCO3-30 AnGap-15

IMAGING:
===========
None

MICRO:
============
URINE CULTURE (Final ___: 
      ESCHERICHIA COLI.    >100,000 ORGANISMS/ML.. 
         Cefazolin interpretative criteria are based on a dosage 
regimen of
         2g every 8h. 

                              SENSITIVITIES: MIC expressed in 
MCG/ML
                      
_________________________________________________________
                             ESCHERICHIA COLI
                             |   
AMPICILLIN------------  =>32 R
AMPICILLIN/SULBACTAM--  =>32 R
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN--------  <=16 S
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S

DISCHARGE LABS:
===================
___ 06:10AM BLOOD WBC-7.9 RBC-3.70* Hgb-11.6* Hct-34.2* 
MCV-92 MCH-31.5 MCHC-34.1 RDW-14.0 Plt ___
___ 04:00PM BLOOD Glucose-113* UreaN-10 Creat-0.9 Na-139 
K-3.5 Cl-98 HCO3-30 AnGap-___ y/o M PMH significant for HIV, HCV, low back pain on chronic 
narcotics, urinary retention s/p foley placement who has had 
numerous admissions this month in relation to the foley now 
found to have complicated UTI. 
 
ACTIVE ISSUES:
===================
# Complicated UTI: foley removed in ED, failed voiding trial. 
Therefore another foley was placed in the ED. The patient had a 
positive UA and given that patient is symptomatic with pain at 
the foley, it was determined to treat for complicated UTI. Given 
that he had previously had a urine culture with corynebacterium 
he was started on vancomycin/cipro while cultures were pending. 
His cultures revealed E.coli with variable sensitivities, but 
resistant to ciprofloxacin. The patient was switched to bactrim 
with a plan treatment duration of 7 days with the last day being 
on ___. His foley was removed given that his E.coli was not 
being treated with ciprofloxacin and he passed the voiding 
trial.

# Urinary Retention requiring foley. Failed voiding trial in ED. 
He was continued on finasteride and tamsulosin was not started 
given the interactions with ritonavir. He passed the voiding 
trial on the floor and the patient was discharged without a 
foley catheter.

CHRONIC ISSUES:
==================
# Low Back Pain/sciatica:Patient was continued on oxycontin 10mg 
q12h and oxycodone.

# HIV: Patient was continued on darunavir, emtricitabine, 
ritanovir, raltegravir, and acyclovir.

# HTN: He was continued on amlodipine, metoprolol.

# GERD: He was continued on omeprazole.

TRANSITIONAL ISSUES:
========================
# Urinary retention: he was discharged without a foley
 
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires 
futher investigation.
1. Zolpidem Tartrate 5 mg PO HS 
2. Lidocaine 5% Patch 1 PTCH TD QAM 
3. Amlodipine 10 mg PO DAILY 
4. Metoprolol Succinate XL 100 mg PO DAILY 
5. Cyanocobalamin 1000 mcg IM/SC ONCE 
6. Acyclovir 400 mg PO Q12H 
7. LOPERamide 2 mg PO QID:PRN diarrhea 
8. Finasteride 5 mg PO DAILY 
9. Omeprazole 20 mg PO DAILY 
10. Fish Oil (Omega 3) 1000 mg PO BID 
11. Darunavir 600 mg PO BID 
12. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H 
13. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain 
14. Raltegravir 400 mg PO BID 
15. Emtricitabine 200 mg PO Q24H 
16. RiTONAvir 100 mg PO BID 

 
Discharge Medications:
1. Acyclovir 400 mg PO Q12H 
2. Amlodipine 10 mg PO DAILY 
3. Darunavir 600 mg PO BID 
4. Emtricitabine 200 mg PO Q24H 
5. Finasteride 5 mg PO DAILY 
6. Lidocaine 5% Patch 1 PTCH TD QAM 
7. Metoprolol Succinate XL 100 mg PO DAILY 
8. Omeprazole 20 mg PO DAILY 
9. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H 
10. Raltegravir 400 mg PO BID 
11. RiTONAvir 100 mg PO BID 
12. Zolpidem Tartrate 5 mg PO HS 
13. Cyanocobalamin 1000 mcg IM/SC ONCE 
14. Fish Oil (Omega 3) 1000 mg PO BID 
15. LOPERamide 2 mg PO QID:PRN diarrhea 
16. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain 
17. Sulfameth/Trimethoprim DS 1 TAB PO BID 
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1 
tablet(s) by mouth twice a day Disp #*11 Tablet Refills:*0

 
Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Primary: Complicated UTI

Secondary: HIV, HTN, Chronic low back pain

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

 
Discharge Instructions:
Dear Mr. ___,

It was a pleasure taking care of you here at ___ 
___ ___.

You came to the hospital because you were having pain at the 
location of your foley. This most likely was caused by a urinary 
tract infection. You were given antibiotics called bactrim that 
you will need to take for a total of 7 days with your last day 
being on ___. Your foley catheter was removed and you were 
able to urinate afterwards.

Our physical therapists evaluated you and believed you were safe 
to go home with physical therapy at home.
 
Followup Instructions:
___

{'Pain at ___ site': ['Urinary tract infection', 'Other chronic pain'], 'Fever': ['Urinary tract infection'], 'Discomfort at the site of the foley': ['Urinary tract infection'], 'Back pain': ['Other chronic pain'], 'Low back pain': ['Other chronic pain'], 'HIV': ['Asymptomatic human immunodeficiency virus [HIV] infection status'], 'HCV': ['Chronic hepatitis C without mention of hepatic coma'], 'Hypertension': ['Unspecified essential hypertension'], 'GERD': ['Esophageal reflux']}