Other pulmonary embolism and infarction Intestinal infection due to Clostridium difficile Dysthymic disorder Obesity unspecified
 
Name:  ___            Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___
 
Chief Complaint:
left flank pain
 
Major Surgical or Invasive Procedure:
none

 
History of Present Illness:
History of Present Illness: ___ with PCOS on OCP admitted with 
left flank pain. Felt well until 3 weeks ago when she developed 
loose watery stools after eating any food (not just fatty or 
dairy). No associated fever, chills, sweats, weight loss, 
abdominal pain, nausea, melena, or hematochezia. One week ago 
developed cold symptoms - nasal congestion, runny nose, sore 
throat, and nonproductive cough. Had a fall last week onto her 
side while walking on slippery steps. No head trauma or LOC. 
Three days prior to admission felt left-sided intermittent flank 
pain for which she took ibuprofen without relief. Attributed 
pain to the recent fall. Pain exacerbated by deep inspiration. 
No dizziness, lightheadedness, chest pain, palpitations, 
shortness of breath, dysuria, urinary frequency, or calf pain or 
swelling. Pain worsened today so came to the ED.  
In the ED, initial vs 96.8 89 161/101 18 100% RA. WBC# 10.9 
D-dimer 560. U/A showed trace blood rare bacteria. CTA showed 
left lower lobe segmental PE. Given heparin IV, morphine, and 
tylenol. V/S prior to transfer 75 132/99 16 98%RA.  

 
Past Medical History:
PCOS c/b menorrhagia  
Depression  
Anxiety  
Fatty liver  

 
Social History:
___
Family History:
Dad died of a brain aneurysm. No history of VTE
 
Physical Exam:
On admission:
V/S: T 96.6 BP 125/74 HR 66 RR 16 O2sat 99%RA Wt 282.3 lbs  
GEN: Appears well  
NECK: JVD difficult to assess  
LUNGS: Clear  
CV: reg rate nl S1S2 no m/r/g  
ABD: soft NTND guaiac neg in ED  
EXT: warm, dry no calf tenderness or edema  

 

 
Pertinent Results:
Labs on admission:

___ 08:20PM BLOOD WBC-10.9 RBC-4.17* Hgb-13.2 Hct-36.7 
MCV-88 MCH-31.6 MCHC-35.9* RDW-13.4 Plt ___
___ 08:20PM BLOOD Neuts-54.0 ___ Monos-4.0 Eos-5.9* 
Baso-0.8
___ 08:20PM BLOOD Plt ___
___ 08:20PM BLOOD Glucose-80 UreaN-11 Creat-0.8 Na-141 
K-3.9 Cl-105 HCO3-26 AnGap-14
___ 08:20PM BLOOD ALT-41* AST-28 AlkPhos-33* TotBili-0.3
___ 08:20PM BLOOD Lipase-32
___ 08:20PM BLOOD cTropnT-<0.01 proBNP-29
___ 08:20PM BLOOD Albumin-4.0
___ 08:20PM BLOOD D-Dimer-560*
___ 08:20PM BLOOD tTG-IgA-4

Imaging:
CTA-Chest
IMPRESSION: 
  
Segmental left lower lobe pulmonary emboli. 

 
Brief Hospital Course:
___ with PCOS on OCP admitted with LLL segmental PE likely the 
result of cig smoking, obesity, OCPs. Also now found to have 
c-diff positive diarrhea with episode of diarrhea overnight.  
.  
#PE - hemodynamically stable, satting well on room air; risk 
factors for provoked VTE are OCPs and obesity; no R heart strain 
by EKG or CT. Patient was started on IV heparin bridge to 
coumadin. OCPs were held.
.  
#Diarrhea - found to be C-diff positive and treated with flagyl 
to be continued as outpatient.  
.  
#Depression/anxiety. 
-cont celexa (counseled about theoretical increased bleeding 
risk)  
-cont xanax prn  
.  
#Transaminitis - ___ RUQ U/S and abd CT showed fatty 
infiltration  
-outpatient f/u  
.  
#Sore throat: No LAD, no fever, no pharyngeal exudate, symptoms 
were monitored and subsided.  
.  
#Depression/anxiety  
-cont celexa (counseled about theoretical increased bleeding 
risk)  
-cont xanax prn  
.  
#Transaminitis - ___ RUQ U/S and ABD CT showed fatty 
infiltration, Hepatitis panel showed HepB SAB + from 
vaccination; Hep A IgG+,  
-outpatient f/u  

 
Discharge Medications:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO QAM (once a 
day (in the morning)).  
2. citalopram 20 mg Tablet Sig: 0.5 Tablet PO QPM (once a day 
(in the evening)).  
3. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO three times 
a day as needed as needed for anxiety.  
4. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, 
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Disp:*15 Tablet, Rapid Dissolve(s)* Refills:*0*
5. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 
hours) as needed for pain.  
6. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 
8 hours) for 6 days.
Disp:*18 Tablet(s)* Refills:*0*
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 
6 hours) as needed for pain.  
8. warfarin 5 mg Tablet Sig: 1.5 Tablets PO once a day: It is 
very important that ___ take this medication as it will prevent 
your clots from worsening.
Disp:*45 Tablet(s)* Refills:*2*

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary: PE
         Clostridium Difficile Diarrhea
         

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

 
Discharge Instructions:
Mrs. ___,

___ were admitted to the ___ for 
anticogulation for a pulmonary embolism seen on imaging studies 
in the emergency department. During ___ stay ___ also received 
medication to treat your intermittent back, chest and abdominal 
crampy pain. ___ also received medications to help with nausea. 
At night ___ received trazodone to help with sleep. There was no 
evidence that your pulmomary embolism was interfering with your 
lung or heart function. ___ were deemed stable for discharge 
home on a blood thinner to be taken for several months. ___ will 
have follow-up appointments to monitor your anticoagulation 
status and your blood thinner (coumadin) will be adjusted 
accordingly. 

Some of your medications were stopped on admission. ___ should 
STOP taking the following medications when ___ are discharged 
from the hospital:
-Oral contraceptive pills (birth control) 

___ should START taking the following medications as prescribed:
-Coumadin (also known as Warfarin) until told to stop by your 
PCP
-___ (also known as Metronidazole) for 10 days
-Ondansetron (zofran) as needed for nausea

Please also take all your other medications as prescribed by 
your physicians.

Please also note that smoking is a major risk factor for 
developing clots such as pulmonary embolisms and that it is very 
important that ___ stop smoking entirely. Please discuss this 
issue with your primary care physician if ___ find yourself 
needing help with quitting smoking. 

 
Followup Instructions:
___

{'left flank pain': ['Other pulmonary embolism and infarction'], 'loose watery stools': ['Intestinal infection due to Clostridium difficile'], 'cold symptoms': [], 'sore throat': [], 'transaminitis': [], 'depression': ['Dysthymic disorder'], 'anxiety': [], 'fatty liver': ['Obesity']}