Cellulitis and abscess of leg except foot Other acute and subacute forms of ischemic heart disease other Thrombocytopenia unspecified Hyposmolality and/or hyponatremia Jaundice unspecified not of newborn Unspecified essential hypertension Coronary atherosclerosis of unspecified type of vessel native or graft Aortocoronary bypass status Other and unspecified hyperlipidemia Long-term (current) use of aspirin Hypopotassemia Disorders of phosphorus metabolism Disorders of magnesium metabolism
 
Name:  ___                    Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
Penicillins
 
Attending: ___.
 
Chief Complaint:
CHIEF COMPLAINT: Headache, RLE cellulitis
 
Major Surgical or Invasive Procedure:
None

 
History of Present Illness:
HISTORY OF PRESENT ILLNESS: 
Pt is a ___ year old ___ speaking M w/ PMH of CAD s/p CABG, 
HTN and HLD presenting to the ED with hypertension recorded at 
home, found to have RLE cellulitis. Per pt, on the day prior to 
admission, he began to experience RLE leg pain that was 
described as more discomfort. This was followed one hour later 
by an acute onset of headache, chills, shivering/shaking and 
felt feverish. Pt felt warm to the touch but Temp taken at home 
was not elevated. Pt took Excedrin at the time of symptom onset, 
checked his BP at home which showed a reading of 211/110. Pt 
took 2 doses of Captopril 25mg tablets, and came into the ___ 
ED for further evaluation. Of note, pt reports that he has had 
well controlled BP on a beta blocker (trade name: ___ 25mg 
x1 a day, a Bblocker not available in the US), with baseline BPs 
in the 120s/50s per home readings. Pt had been fasting for 
___ in the day-light hours, but of note, he has been fasting 
for ___ but states he has been taking his BP meds, as well 
as his Aspirin 81mg and Lipitor 40mg.

In the ED, initial vitals were: 97.7 98 ___  
- Labs were significant for Labs were significant for initial 
Wbc of 9.6 which increased to 17.8 (initial Diff 93.2%N), low 
Phos at 1.4, low Mg of 1.5 but otherwise normal Mg and lactate 
of 1.6. Pt received ___, CT head, and Chest CXR were negative 
for acute process.  
- The patient was given 500NS bolus, 125ml/hr maintenance. 
Cefazolin, Vanc, Ceftriaxone, Tylenol and , IV Mag, IV Phos + 3 
packets NeutraPhos, Potassium Chloride 40 mEq
- EKG was notable for 1mm STD V3-V4 and TWI when BP was in 200's 
systolic. First trop neg and second value .02. Repeat ECG after 
control of BP shows sub-1mm STD in V3-V4. Trop resolved.
- Cards was consulted who believed patient had demand ischemia 
in setting of febrile cellulitis and hypertensive emergency 
which resolved. They had no suspicion of plaque rupture and no 
need for anticoagulation.

While in the ED he spiked to T100.5 HR 81 BP 103/50 RR 24 SpO2 
96% RA. Pt continued to improve on IV Abx therapy, with vitals 
prior to transfer T 97.8 HR 73 BP 106/53 RR 24 SpO2 97% RA.

Upon arrival to the floor, pt was afebrile with stable VS: 
T99.4, HR 68 BP 124/59 RR 18 and Spo2 of 99% on RA. Pt was 
comfortable sitting in bed, with no pain in the LLE, resolution 
of his headache symptoms and no chills or shakes. Pt did endorse 
feeling subjectively warm, and endorsed 2x episodes of diarrhea.

REVIEW OF SYSTEMS:  
(+) Per HPI  
(-) Denies recent weight loss or gain. Denies sinus tenderness, 
rhinorrhea or congestion. Denies cough, shortness of breath. 
Denies chest pain or tightness, palpitations. Denies nausea, 
vomiting, diarrhea, constipation or abdominal pain. No recent 
change in bowel or bladder habits. No dysuria. Denies 
arthralgias or myalgias.

 
Past Medical History:
HLD  
HTN  
CAD s/p CABG  

 
Social History:
___
Family History:
Denies family history of CAD  

 
Physical Exam:
PHYSICAL EXAM:  
Vitals:  VS: T99.4, HR 68 BP 124/59 RR 18 and Spo2 of 99% on RA
General: Alert, oriented, sitting upright in bed, in no acute 
distress  
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL  
Neck: Supple, JVP not elevated, no LAD  
CV:  Systolic murmur, regular rate and rhythm, audible S1 S2 
Lungs: Clear to auscultation bilaterally, no wheezes, rales, 
rhonchi  
Abdomen: Soft, non-tender, non-distended, bowel sounds present, 
no organomegaly, no rebound or guarding  
GU: No foley  
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or 
edema. Full ROM of RLE at knee and ankle.
Skin: Warm, smooth, erythematous area extending from ankle to 
upper calf just below knee. Area marked. Warm to touch, with 
minimal tenderness to palpation
Neuro: CNII-XII intact, ___ strength upper/lower extremities, 
grossly normal sensation, 2+ reflexes bilaterally, gait 
deferred.
 
Pertinent Results:
Admission
==========
___ 05:10PM   GLUCOSE-106* UREA N-15 CREAT-1.0 SODIUM-134 
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-20* ANION GAP-16
___ 05:10PM   CALCIUM-8.7 PHOSPHATE-3.2# MAGNESIUM-2.0
___ 01:00PM   cTropnT-<0.01
___ 06:45AM   cTropnT-0.02*
___ 10:30AM   ALT(SGPT)-28 AST(SGOT)-30 LD(LDH)-146 
CK(CPK)-50 ALK PHOS-47 TOT BILI-2.4* DIR BILI-0.2 INDIR BIL-2.2
___ 10:30AM   WBC-17.8*# RBC-4.95 HGB-14.4 HCT-41.6 MCV-84 
MCH-29.1 MCHC-34.6 RDW-12.9 RDWSD-39.2

___ 01:09AM URINE  HOURS-RANDOM
___ 01:09AM URINE  UHOLD-HOLD
___ 01:09AM URINE  COLOR-Yellow APPEAR-Clear SP ___
___ 01:09AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG 
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 
LEUK-NEG

Discharge
===========
___ 07:17AM BLOOD Glucose-94 UreaN-12 Creat-0.9 Na-135 
K-3.8 Cl-102 HCO3-22 AnGap-15
___ 07:17AM BLOOD Calcium-8.4 Phos-1.5*# Mg-1.8
___ 07:17AM BLOOD ALT-28 AST-37 AlkPhos-49 TotBili-1.4
___ 07:17AM BLOOD WBC-11.9* RBC-4.73 Hgb-13.9 Hct-40.0 
MCV-85 MCH-29.4 MCHC-34.8 RDW-13.2 RDWSD-40.7 Plt ___

Imaging
==========
Chest Xray ___
IMPRESSION:  
No acute cardiopulmonary abnormality. 

CT Head ___
IMPRESSION:  
Mild involutional change.  No evidence of hemorrhage. 

___ ___
IMPRESSION:  
No evidence of deep venous thrombosis in the right lower 
extremity veins.  The peroneal veins are not visualized. 
 
Brief Hospital Course:
This is a ___ year old ___ male recently immigrated 
to ___ with past medical history of CAD s/p CABG presenting 
___ with headache, chills, and subjective fever in setting 
of fasting for ___, as well as hypertension on check at 
home, in ED found to have RLE cellulitis and hypertensive 
emergency (SBP 211mmHg with EKG changes concerning for demand 
ischemia), with quick normalization of blood pressures on oral 
regimen (and normalization of EKG changes), treated with 
antibiotics with significant improvement, discharged home with 
scheduled appointment to establish care at ___.  

# Acute Cellulitis right leg: patient presented after acute 
onset of RLE pain, swelling and progressively worsening 
erythema; exam consistent with acute cellulitis; otherwise 
notable for leukocytosis WBC 17.9, afebrile.  He was started on 
Cefazolin 2G IV Q8H with rapid improvement, receding from the 
area marked in the ED, WBC downtrending to 11.9.  He was 
transitioned to PO Cephalexin 2GM Q8H prior to discharge with an 
expected ___nding on ___.

# Malignant Hypertensive / Accelerated Hypertension - patient 
admitted with SBP 211mmHg; during that time he had nonspecific 
ST/Twave changes noted and troponin peaking at 0.02.  His blood 
pressures rapidly improved with oral metoprolol.  Repeat EKG 
improved, troponins downtrended.  Underlying etiology felt to 
relate to possible missed doses of home antihypertensive.  On 
day of discharge BP ranged 110s-120s/60s-70s. Patient on 
nabivolol from ___ (not available here), declined transition 
to blood pressure agent sold here, but willing to discuss when 
establishing with PCP.

# Hyponatremia / Hypokalemia / Hypophosphatemia / Hypomagnesemia 
- Na of 132, K of 3.4, Phos 1.0 and Mg 1.5 on presentation, all 
thought to related to insensible losses from infection as well 
as ongoing fasting during ___.  He was repleted with 
improvement.  Counseled patient that due to his acute illness, 
team advised against additional fasting which could pose a risk 
to his health.  

#CAD s/p 3 vessel CABG - as above, he had evidence of cardiac 
strain in setting of hypertension that resolved with blood 
pressure control; while inpatient he was given metoprolol (as 
nabivolol is not available here), home Aspirin and Atorvastatin. 
See above re: blood pressure management medications. 

Transitional
-------------
- In setting of fasting for ___, he was noted to have some 
electrolyte deficiencies - he was counseled that, given his 
illness, would avoid fasting
- To complete a 10 day course of antibiotics end date ___
- Noted to have mild thrombocytopenia during this admission, 
stable; could consider outpatient workup
 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM 
2. nebivolol 25 ng oral DAILY 
3. Aspirin 81 mg PO DAILY 

 
Discharge Medications:
1. Atorvastatin 40 mg PO QPM 
2. Acetaminophen 325-650 mg PO Q6H:PRN fever 
RX *acetaminophen 500 mg 1 tablet(s) by mouth every 6 hours Disp 
#*20 Tablet Refills:*0
3. Cephalexin 500 mg PO Q6H 
RX *cephalexin 500 mg 1 tablet(s) by mouth every 6 hours Disp 
#*33 Tablet Refills:*0
4. Aspirin 81 mg PO DAILY 
5. nebivolol 25 ng oral DAILY 

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary Diagnosis
Cellulitis
Hypertensive emergency

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

 
Discharge Instructions:
Mr. ___,

It was our pleasure caring for you in ___ 
___. You came to the hospital because you were 
feeling unwell and had high blood pressure. You were found to 
have a skin infection and we gave you antibiotics and you 
improved. Your blood pressure improved as well. You were doing 
better so you were able to go home.
 
Followup Instructions:
___

{'headache': ['Other acute and subacute forms of ischemic heart disease'], 'chills': ['Other acute and subacute forms of ischemic heart disease'], 'shivering/shaking': ['Other acute and subacute forms of ischemic heart disease'], 'felt feverish': ['Other acute and subacute forms of ischemic heart disease'], 'leg pain': ['Cellulitis and abscess of leg, except foot'], 'erythematous area': ['Cellulitis and abscess of leg, except foot'], 'tenderness': ['Cellulitis and abscess of leg, except foot'], 'warm to touch': ['Cellulitis and abscess of leg, except foot'], 'hypertension': ['Unspecified essential hypertension'], 'elevated blood pressure': ['Unspecified essential hypertension'], 'demand ischemia': ['Other acute and subacute forms of ischemic heart disease'], 'ST/Twave changes': ['Other acute and subacute forms of ischemic heart disease'], 'troponin peaking': ['Other acute and subacute forms of ischemic heart disease'], 'hyponatremia': ['Hyposmolality and/or hyponatremia'], 'hypokalemia': ['Hypopotassemia'], 'hypophosphatemia': ['Disorders of phosphorus metabolism'], 'hypomagnesemia': ['Disorders of magnesium metabolism']}