Other chronic cystitis Dehydration Personal history of other lymphatic and hematopoietic neoplasms Personal history of malignant neoplasm of breast Migraine unspecified without mention of intractable migraine without mention of status migrainosus Aortic valve disorders Do not resuscitate status Other chronic pain Backache unspecified Cervicalgia History of fall
 
Name:  ___                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
Sulfa (Sulfonamide Antibiotics)
 
Attending: ___.
 
Chief Complaint:
fall
 
Major Surgical or Invasive Procedure:
none
 
History of Present Illness:
___ year old female with past medical history of follicular 
lymphoma in CR and recurrent UTI presenting with fall and 2 days 
of fatigue.  She is very active normally, yesterday during 
practice for a play she felt very fatigued and not herself.  She 
has been going to the bathroom more frequently than usual, 
denies dysuria.  Early this morning she woke up to urinate and 
felt very lightheaded, tried walking back to the bed and fell 
down to the ground, hit the back of her head, denies losing 
consciousness.  Brought to ED, head and neck CT, CXR 
unremarkable.  U/A was mildly positive, she was given IV cipro. 
 
Past Medical History:
1.  Follicular lymphoma in CR s/p bendamustine and rituxamab
2.  Lumbar spinal stenosis status post XLIF (extreme lateral
interbody fusion).
3.  Cervical spinal stenosis.
4.  Recurrent urinary tract infections with chronic cystitis.
5.  Hypertension.
6.  History of breast cancer requiring a lumpectomy, 
chemotherapy and radiation
7.  History of migraine headaches.
8.  History of right upper extremity "nerve damage" following a
surgical procedure of the right shoulder
9.  History of left shoulder shingles.
10.  Moderate aortic regurgitation and aortic root dilatation
with an EF of 60%.
 
Social History:
___
Family History:
Migraines in mother and daughter. Unknown cancer in paternal 
grandparents.
 
Physical Exam:
Admission Physical Exam:
T: 97.3 HR 77 BP 146/76 RR 18 100% RA
Gen: NAD, resting comfortably in bed
HEENT: EOMI, PERRLA, MMM, OP clear
CV: RRR nl s1s2 no m/r/g
Resp: CTAB no w/r/r
Abd: Soft, NT, ND +BS
Ext: no c/c/e
Neuro: CN II-XII intact, ___ strength throughout

Discharge Physical Exam:
T: 97.8 HR 73 BP 149/78 RR 20 99% RA
Gen: NAD, resting comfortably in bed
HEENT: EOMI, PERRLA, MMM, OP clear
CV: RRR nl s1s2 no m/r/g
Resp: CTAB no w/r/r
Abd: Soft, NT, ND +BS
Ext: no c/c/e
Neuro: CN II-XII intact, ___ strength throughout
 
Pertinent Results:
___ 06:00AM URINE  BLOOD-NEG NITRITE-POS PROTEIN-NEG 
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 
LEUK-MOD
___ 06:00AM URINE  RBC-0 WBC-7* BACTERIA-MANY YEAST-NONE 
EPI-0 TRANS EPI-<1
___ 03:00AM   GLUCOSE-110* UREA N-17 CREAT-0.8 SODIUM-134 
POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-20* ANION GAP-22*
___ 03:00AM   ALT(SGPT)-26 AST(SGOT)-45* ALK PHOS-58 TOT 
BILI-0.3
___ 03:00AM   LIPASE-57
___ 03:00AM   ALBUMIN-4.9 CALCIUM-10.2 PHOSPHATE-3.3 
MAGNESIUM-1.8
___ 03:00AM   WBC-13.8*# RBC-4.81 HGB-15.7 HCT-44.9 MCV-93 
MCH-32.7* MCHC-35.1* RDW-13.5

CT head:  
IMPRESSION:  
  
Atrophy.  No evidence of fracture, hemorrhage or infarction. 

CT C-spine: 
 
IMPRESSION: 
1. No evidence of fracture. 
2. Severe degenerative changes, mildly progressed since ___. 
3. 9mm right thyroid nodule increased in size from prior, a non 
emergent 
thyroid ultrasound can be obtained if clinically indicated. 
4. Enlarged descending thoracic aorta measuring up to 3.4 cm. 

ECG: sinus rhythm RBBB, no ST-T wave abnormalities, no change 
from prior
 
Brief Hospital Course:
___ year old female with past medical history of follicular 
lymphoma in CR and recurrent UTI presenting with fall and 2 days 
of fatigue.

1. UTI: Mildly positive urinalysis with increased urinary 
frequency. No history of resistent infections.
-Continue PO cipro for 3 day course.
-Urine culture pending on discharge, will call if growing 
resistant organism.

2. Fall: Likely due to infection and dehydration, no concerning 
findings on ECG, no loss of consciousness. CT head and C-spine 
showing no acute abnormlities.  ___ was consulted and she was 
able to ambulate using rolling walker without dizziness or 
significant difficulties. Home ___ was recommended.

3. Migraines: Continue Tylenol

4. FEN/PPX: regular diet, heparin SC, ___ protocol

DNR/DNI

HCP: ___ (daughter)  ___
 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H 
2. cranberry extract unknown  oral daily 
3. Multivitamins W/minerals 1 TAB PO DAILY 

 
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H 
2. Ciprofloxacin HCl 500 mg PO Q12H 
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice 
a day Disp #*4 Tablet Refills:*0
3. cranberry extract 1 tablet ORAL DAILY 
4. Multivitamins W/minerals 1 TAB PO DAILY 

 
Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Urinary tract infection

 
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:
You were admitted after a fall and found to have a urinary tract 
infection and dehydration.  You were started on ciprofloxacin 
for the infection.  You were given IV fluids for the 
dehydration.
 
Followup Instructions:
___

{'fatigue': ['Other chronic cystitis', 'Dehydration'], 'fall': ['Other chronic cystitis', 'Dehydration', 'History of fall'], 'urinary frequency': ['Other chronic cystitis', 'Dehydration'], 'lightheaded': ['Other chronic cystitis', 'Dehydration'], 'headache': ['Migraine']}