Intestinal infection due to other organism not elsewhere classified Thoracic or lumbosacral neuritis or radiculitis unspecified Other chronic pain Raynaud's syndrome Arthrodesis status Other postprocedural status
 
Name:  ___                Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
Latex / Morphine And Related
 
Attending: ___.
 
Chief Complaint:
Nausea/vomiting
 
Major Surgical or Invasive Procedure:
none

 
History of Present Illness:
___ h/o chronic LBP s/p spinal cord stimulator with pulse 
generator revision ___ p/w nausea and vomiting since 5am this 
morning.
.
Was in USOH the night prior then awoke feeling unwell, began to 
have nausea and vomiting (non-bloody, non-bilious). Has been 
having band-like burning abdominal ___ in-between incision 
sites since stimulator revision but no new abdominal ___ and no 
change with PO intake. Denies fevers, chills, or sweats, 
diarrhea, dysuria, CP, SOB, palpitations. Back ___ is same as 
baseline but notes that as unable to tolerate POs and take oral 
___ meds it has become worse during the day. Denies sick 
contacts although later found out that her daughter developed 
nausea and vomiting today. No known ingestion spoiled or 
questionable food products. Presented initially to ___ 
___ where she was afebrile and labs notable for WBC 11.4, 
normal LFTs and lipase, negative U/A and urine hCG, normal ECG, 
and KUB with ? air-fluid levels and distended stomach. 
Transferred to ___ out of concern for possible problem with 
stimulator and for continuity of care with ___ ___ service.
.
Regarding spinal cord stimulator, she is f/b Dr. ___ 
the ___ Service and has responded well but required 
multiple revisions due to battery failure and possible foreign 
body reaction at initial site. On ___ the pacemaker generator 
was moved from the right to left abdominal wall ___ poor wound 
healing. Since this time she reports occasional lightheadedness. 
Last seen by Dr. ___ ___ for dermatitis at ___ 
site and monitoring of post-operative seroma which was 
improving.
.
In the ___ ED, afebrile with stable vitals. Labs notable for 
WBC 8.1 w/ PMN predominance but no bands, normal LFTs and 
lipase, lactate 1.3. KUB from OSH reviewed and deemed not to 
have air-fluid levels and no concern for obstruction (passing 
gas and stool) so therefore not repeated. Dr. ___ 
___ regarding stimulator but thought unlikely to be 
attributed to symtoms. ___ and nausea improved with dilaudid 
and zofran but remained unable to tolerate POs. Admitted to 
medicine.
 
Past Medical History:
1. Longstanding LBP and associated multifocal burning ___, 
numbness, and weakness in both legs since ___ that began during 
nursing school after lifting a heavy patient, s/p intra-disc 
electro-thermo therapy which improved the leg weakness and 
numbnesss, s/p spinal cord stimulator since ___, replaced on 
several occasions due to battery failure and FB reaction, last 
___ (Dr. ___
2. S/P L5/S1 fusion ___
3. S/P CCY
4. Undergoing work-up for ?MS with Dr. ___
 
Social History:
___
Family History:
Mother with HTN, hypercholesterolemia. Father alive and well.
 
Physical Exam:
Afebrile, VSS
General: NAD
HEENT: PERRL, EOMi, anicteric sclera, conjunctivae pink
Neck: supple
Cardiac: RRR, s1s2 normal, no m/r/g, no JVD
Pulmonary: CTAB
Abdomen: +BS, soft, abdominal binder present
Extremities: warm, 2+ DP pulses, no edema
Neuro: A&Ox3, speech clear and logical, CNII-XII intact, moves 
all extremities
 
Pertinent Results:
Admission:

___ 06:00PM BLOOD WBC-8.1 RBC-4.16* Hgb-12.5 Hct-37.5 
MCV-90 MCH-30.0 MCHC-33.2 RDW-12.7 Plt ___
___ 06:00PM BLOOD Glucose-109* UreaN-9 Creat-0.8 Na-142 
K-3.9 Cl-107 HCO3-23 AnGap-16
___ 06:00PM BLOOD ALT-14 AST-22 AlkPhos-55 TotBili-1.0
___ 06:00PM BLOOD Lipase-24
___ 08:00AM BLOOD Calcium-7.4* Phos-2.7 Mg-1.7
___ 06:04PM BLOOD Lactate-1.3
-----------
Discharge:

___ 08:00AM BLOOD WBC-3.4*# RBC-3.60* Hgb-11.0* Hct-32.2* 
MCV-90 MCH-30.7 MCHC-34.2 RDW-12.3 Plt ___
___ 08:00AM BLOOD Glucose-104 UreaN-7 Creat-0.8 Na-141 
K-3.5 Cl-108 HCO3-23 AnGap-14
___ 08:00AM BLOOD ALT-13 AST-24 AlkPhos-44 TotBili-0.___ h/o chronic LBP s/p spinal cord stimulator p/w nausea and 
vomiting.
.
# Nausea, vomiting: Likely viral gastroenteritis, improved with 
supportive care and antiemetics.  She was tolerating a bland 
diet on discharge.  
.
# Acute on chronic radiculopathy: No change in chronic symptoms. 
 Chronic ___ service came by to offer reassurance, and felt 
stimulator change was unlikely to be causing nausea/vomiting.  
She will follow up with them as an outpatient.

 
Medications on Admission:
Neurontin 600 mg QAM, 600 mg Qafternoon, 1800 mg QHS
Vicodin ___ mg ___ tabs Q6H prn
Valium 5 mg QHS prn leg cramping
Motrin prn
 
Discharge Disposition:
Home
 
Discharge Diagnosis:
1. viral gastroenteritis
2. chronic back ___ with spinal cord stimulator

 
Discharge Condition:
stable, nausea improved, tolerating bland diet.

 
Discharge Instructions:
You were hospitalized with nausea and vomiting, which was 
probably viral gastroenteritis ("stomach bug").  Please call 
your primary care doctor for questions and concerns, and return 
to the emergency department with recurrent nausea, vomiting, 
fever greater than 101, blood in your stool, increased ___ or 
any other alarming symptoms.
 
Followup Instructions:
___

{'nausea': ['viral gastroenteritis'], 'vomiting': ['viral gastroenteritis'], 'abdominal ___': ['thoracic or lumbosacral neuritis or radiculitis'], 'back ___': ['chronic back ___ with spinal cord stimulator']}