Iatrogenic pulmonary embolism and infarction Other chronic pulmonary heart diseases Body Mass Index 40.0-44.9 adult Acute venous embolism and thrombosis of deep vessels of proximal lower extremity Morbid obesity Anxiety state unspecified Unspecified essential hypertension Esophageal reflux Headache Tobacco use disorder Depressive disorder not elsewhere classified Borderline personality disorder Constipation unspecified Aftercare for healing traumatic fracture of other bone Personal history of venous thrombosis and embolism Other specified surgical operations and procedures causing abnormal patient reaction or later complication without mention of misadventure at time of operation
 
Name:  ___            Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
chest discomfort, DOE

 
Major Surgical or Invasive Procedure:
Thrombolysis 
 
History of Present Illness:
___ year old woman with a history of PE in ___ now 5 weeks s/p 
recent ORIF for L medial malleolus fx p/w with worsening SOB and 
chest discomfort since ___. Pt stated that prior to onset of 
SOB, she experienced dizziness, lightheadedness and nausea on 
exertion on ___. Also notes sweating but was outside on a 
hot day. On ___ morning she developed sudden onset chest pain 
and shortness of breath after attempting to climb a hill on the 
scooter she is using for transportation(she is ___ LLE). She 
fell off the scooter, injuring her knee, elbow, and hand and 
reports being SOB with central chest pressure when she reached 
the top of the hill. She used her inhaler and these sx improved 
with rest. She also reports that a bilateral headache started at 
this time and has persisted. She denies striking her head or 
losing consciousness. Her chest discomfort and SOB have been 
present with minimal activity since this episode on ___, 
always resolving after 5min of rest.  Pt localizes her pain to 
___ chest, it does not radiate, describes the pain as 
"pressure" and discomfort. There was pressure with moderate 
exertion which intensified to pain when she was SOB.

She remained sedentary all day ___ with continued SOB and 
chest discomfort crutching on flat ground ___ within her 
house. ___ morning she awoke and noted tachycardia upon going 
downstairs from her apartment. She called her PCP office and was 
told to go to ED for HR > 100. She went to ___ Ed at 3pm.

She is s/p ORIF L medial malleolus fx (___) following MVA 
(___). She was started on prophylactic enoxaparin after her 
ankle surgery (40 mg daily) and reports good compliance, missing 
only 2 doses and not in succession. 

Prior history of DVT/PE in ___. Presenting symptoms included L 
flank pain and productive cough. CTA demonstrated segmental left 
lower lobe pulmonary emboli. Hospital course complicated by C. 
Diff infxn. Her PE was considered provoked based on smoking and 
OCP. She was discharged on ___ year Warfarin therapy, Flagyl, and 
Zofran PRN in addition to her home medications. OCPs 
discontinued, she has not taken them since.

In the ED initial vitals were: ___ 78 145/92 20No chest 
pain while at rest in ED on floor, but she did report having 
mild SOB and lightheadedness when talking. Pt also reports 
having a headache. She was given Percocet and ibuprofen for the 
headache. 
- Labs were significant for WBC 12, d-dimer 4640.  
- Patient was given IV heparin 6500 units bolus and started on 
an infusion of 1620 at 11 pm.   

Vitals prior to transfer were: 00:43 (___) 98.3 79 143/86 18 99% 
RA. On the floor, she reports tolerating warfarin well in the 
past. She has been much less mobile since having her surgery 
given that she was previously employed as a ___ and 
is now ___ LLE. She received Warfarin 5mg at 0300 with coags 
11.2 70.5* 1.0 at 0630. She is comfortable but tired, not SOB at 
rest.

 
Past Medical History:
PCOS c/b menorrhagia  
Depression  
Anxiety  
Fatty liver  
Borderline personality disorder  
gastroparesis, bacterial overgrowth, and pelvic floor  
dyssynergy  
Asthma  
GERD  
Ankle fracture s/p surgery x2 with pins  
Finger surgery ___
C. diff infection ___ (hospital-acquired)
 
Social History:
___
Family History:
Dad died of a brain aneurysm. No history of VTE in any family 
member. 
 
Physical Exam:
ADMISSION:
Vitals: 97.9 - 138/98 - 76 - 18 - 98RA, standing weight 124.9kg  

GENERAL: well nourished tan young lady with several piercings 
and LLE cast on, sitting in bed, comfortable, no respiratory 
distress  
HEENT: AT/NC, EOMI, anicteric sclera, MMM, good dentition, 
several facial piercings  
NECK: not assessed.
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs  
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably 
without use of accessory muscles  
ABDOMEN: (not assessed yet); bruising LLQ 
EXTREMITIES: moving all extremities well, no edema, unable to 
examine LLE which is in a hard ankle cast, no erythema, 
swelling, eccyhmoses.  
NEURO: face symmetric, speech fluent, mores all extremities 
equally  
SKIN: warm and well perfused, no excoriations or lesions, 
several tattoos  

DISCHARGE:
Vital signs: VS: T=97.6 BP=112/99 HR= ___ O2 sat=95% 
on RA  
General Appearance: NAD, sitting up in bed
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: S1 and S2 normal, No M/R/G. 
Respiratory: Clear to auscultation
Abdominal: Soft, Non-tender, Bowel sounds present, Obese
Extremities: LLE in cast, left wrist in brace
Skin:  Warm
Neurologic: Oriented: person, place and time
 
Pertinent Results:
ADMISSION:

___ 03:37PM BLOOD WBC-12.0* RBC-4.42 Hgb-15.5 Hct-43.3 
MCV-98# MCH-35.1* MCHC-35.7* RDW-12.6 Plt ___
___ 03:37PM BLOOD Neuts-59.4 ___ Monos-3.7 Eos-7.5* 
Baso-0.8
___ 03:37PM BLOOD ___ PTT-27.7 ___
___ 03:20PM BLOOD ___ 03:37PM BLOOD Glucose-92 UreaN-9 Creat-0.9 Na-138 K-3.7 
Cl-106 HCO3-23 AnGap-13
___ 03:37PM BLOOD proBNP-692*
___ 03:37PM BLOOD cTropnT-0.02*
___ 06:50AM BLOOD Calcium-9.1 Phos-5.3* Mg-1.9
___ 03:41PM BLOOD D-Dimer-4640*
___ 05:00PM URINE Color-Yellow Appear-Hazy Sp ___
___ 05:00PM URINE Blood-LG Nitrite-NEG Protein-30 
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 05:00PM URINE RBC-2 WBC-2 Bacteri-FEW Yeast-NONE Epi-2
___ 05:00PM URINE CastHy-9*
___ 05:00PM URINE UCG-NEGATIVE

CXR ___: No acute cardiopulmonary process.  No significant 
interval change. 
  
CTA ___: Saddle pulmonary embolism in the bifurcation of the 
main pulmonary artery which is not completely occlusive, but 
which extends into multiple lobar and segmental pulmonary 
arteries bilaterally. No evidence of acute pulmonary infarct or 
right heart strain at this time. 

ECHO ___: The left atrium and right atrium are normal in cavity 
size. No atrial septal defect is seen by 2D or color Doppler. 
Left ventricular wall thicknesses and cavity size are normal. 
Due to suboptimal technical quality, a focal wall motion 
abnormality cannot be fully excluded. Overall left ventricular 
systolic function is normal (LVEF>55%). Right ventricular 
chamber size is normal. Tricuspid annular plane systolic 
excursion is normal (1.9 cm; nl>1.6cm) consistent with normal 
right ventricular systolic function. The diameters of aorta at 
the sinus, ascending and arch levels are normal. The number of 
aortic valve leaflets cannot be determined. There is no aortic 
valve stenosis. No aortic regurgitation is seen. The mitral 
valve leaflets are structurally normal. There is no mitral valve 
prolapse. No mitral regurgitation is seen. There is mild 
pulmonary artery systolic hypertension. There is no pericardial 
effusion. 

IMPRESSION: Normal right ventricular chamber size and systolic 
function by ___. Mild to moderate pulmonary artery 
hypertension.  

BILATERAL LENIS ___: 
1.  Nearly occlusive DVT in the distal left popliteal vein.  
Left calf veins could not be assessed due to overlying cast. 
2.  No DVT in the right leg. 

Discharge Labs:
___ 07:42AM BLOOD WBC-7.6 RBC-3.86* Hgb-13.2 Hct-37.8 
MCV-98 MCH-34.2* MCHC-35.0 RDW-12.6 Plt ___
___ 03:10PM BLOOD PTT-74.9*
___ 07:42AM BLOOD Plt ___
___ 07:42AM BLOOD Glucose-101* UreaN-11 Creat-1.0 Na-142 
K-4.0 Cl-106 HCO3-29 AnGap-11
 
Brief Hospital Course:
HOSPITAL COURSE: ___ year female with history of PE and recent L 
ankle ORIF presenting with worsening SOB and chest pain, saddle 
PE on CT, DVT in LLE s/p heparin with evidence of mild PAH on 
echo transferred to CCU for systemic lysis who did well with 
improvement in dyspnea.  

ACTIVE ISSUES:

# Acute saddle PE: Patient presented with her second "provoked" 
PE after immobilization from fracture. Though she was on 
prophylactive enoxaparin after ankle surgery, she may have been 
underdosed, given her severe obesity. PESI score (Predicts 
30-day outcome of patients with pulmonary embolism using 11 
clinical criteria) is 29, Class I, Very Low Risk: ___ 30-day 
mortality in this group. Elevated BNP/trop associated with 
higher mortality in PE patients. BNP >600 with 16X increased 
risk of mortality (pt BNP 692). However she was hemodynamically 
stable inspite of a large clot burden on her CTA. RV function 
was preserved but had trop leak and given youg age and saddle 
embolus, high risk of developing pulmonary hypertension. 
Cardiology was consulted who recommended transfer to CCU for 
intra vascular TPA thrombolysis. Remained hemodynamically stable 
with good O2 saturation on room air. There was no evidence of 
right heart strain on EKG or CT though is evidence of pulmonary 
hypertension on TTE. Started rivaroxaban 15 BID x3 weeks then 20 
daiy (dose appropriately for BMI) 
 
#?Hypercoagulability: Heme has seen patient and concerned about 
possible malignancy so recommended age appropriate cancer 
screening as well as hypercoaguability work-up as outpatient.  
Pt was transitioned to rivaroxaban. Hypercoagulability work up 
should be done on an outpatient basis including: Factor V 
Leiden, prothrombin gene mutation, ACA and b2 glycoprotein Abs, 
protein C & S, ATIII. Patient will need pap smear/pelvic exam to 
exclude malignancy. We encourage weight loss and smoking 
cessation. We arranged for follow up in the coagulation clinic 
upon discharge. At the present time, we would recommend longterm 
anticoagulation, but this can be readdressed in the future based 
on the presence or absence of chronic risk factors, as discussed 
above.

# BRBPR  s/p 1 bloody bowel movement. Patient hemodynamically 
stable.  No other bloody bowel movements reported.

INACTIVE ISSUES:

# Hypertension: Will monitor for return to baseline in next few 
days.  
Likely secondary to PE.  Medication is not necessary at this 
time as blood pressure is currently well controlled.  

#Tobacco use: Likely a contributing factor to her past two DVTs. 
Will continue to encourage cessation.  Continue nicotine patch  

# Ankle fracture s/p surgery x2 with pins:  Continue NWB, 
mobilize w/ crutches.  ___ order in place.
 
# Depression/anxiety/borderline personality disorder:  
continue home psych meds.  

# GERD :omeprazole while in house as no dexilant on formulary  

#Anxiety: ativan qhs and if anxiety  

#Chronic headaches, no h/o head strike; tylenol with codeine 
prn, zofran for nausea.

#Undiagnosed sleep apnea - will need sleep study as an 
outpatient  

TRANSITIONAL ISSUES:  
- Sleep study as outpatient  
- F/up re: headaches and ?further evaluation  
- Hypercoaguable work-up  

 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LaMOTrigine 300 mg PO HS 
2. Mirtazapine 45 mg PO HS 
3. CloniDINE 0.3 mg PO HS 
4. Dexilant (dexlansoprazole) 60 mg oral daily 
5. OxycoDONE (Immediate Release)  5 mg PO Q4H-Q6H:PRN pain 
6. Ibuprofen 800 mg PO Q6H-Q8H:PRN pain 

 
Discharge Medications:
1. Rivaroxaban 15 mg PO BID Duration: 3 Weeks 
RX *rivaroxaban [___] 15 mg 1 tablet(s) by mouth twice a day 
Disp #*42 Tablet Refills:*0
2. Rivaroxaban 20 mg PO DAILY 
to begin after 3 weeks of 15 mg BID 
RX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth daily Disp 
#*30 Tablet Refills:*0
3. CloniDINE 0.3 mg PO HS 
RX *clonidine 0.3 mg take one tablet(s) by mouth every night 
Disp #*30 Tablet Refills:*0
4. LaMOTrigine 300 mg PO HS 
5. Mirtazapine 45 mg PO HS 
6. Nicotine Patch 14 mg TD DAILY 
RX *nicotine [Nicoderm CQ] 7 mg/24 hour Please replace daily 
daily Disp #*30 Patch Refills:*3
RX *nicotine [Nicoderm CQ] 14 ___ on skin, replace 
daily daily Disp #*30 Patch Refills:*0
7. Dexilant (dexlansoprazole) 60 mg oral daily 
RX *dexlansoprazole [Dexilant] 60 mg 60 mg capsule(s) by mouth 
daily Disp #*30 Capsule Refills:*0
8. OxycoDONE (Immediate Release)  5 mg PO Q4H-Q6H:PRN pain 

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary Diagnosis: Pulmonary Embolism
Secondary Diagnosis: Hypertension

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

 
Discharge Instructions:
Dear ___,
It was a pleasure caring for you during your recent admission to 
the ___.  You were admitted 
with shortness of breath and chest pain and found to have a 
blood clot in your lung.  We treated you with medications to 
dissolve the blood clot and your symptoms improved. You must 
remain on medications to keep your blood thin.  You should 
follow up with Dr. ___ in ___ weeks and have a repeat 
echocardiogram (ultrasound) of your heart in 6 weeks. 
Additionally, It is very important that you stop smoking, we 
provided you with information on smoking cessation.  You should 
follow up with your primary care doctor within the next week to 
discuss treatment options. 

Be Well,

Your ___ Doctors 
 
___ Instructions:
___

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