Would you service that you provide be able to help me on a daily basis with something like this report? I would hope that if you can help, that I would be taught as well from my mistakes. Thank you for any help, suggestions, and/ or advice!
DISCHARGE DIAGNOSIS
1. Hyperosmolar, nonketotic state.
2. Newly diagnosed diabetes.
3. Alcoholism.
4. Gastroesophageal reflux disease. [2]
5. Pancreatitis.
6. Weight loss.
PROCEDURES: [3]Barium swallow per preliminary report is
negative.
DATE OF ADMISSION: . ___ [DATE]
DATE OF DISCHARGE: ___ [DATE]
CONSULTATIONS: [4]None.
Please see the history and physical in the chart for complete details, but in brief, patient is a 54-year-old gentleman with a history of significant alcoholism and a remote history of a GI bleed in ___ [DATE], who presents to the . emergency department on ___ [DATE], secondary to a 3-month history of symptoms consistent with diabetes including polyuria, polydipsia, dry mouth, intermittent blurred vision, and weight loss. Patient states that he knew it was diabetes as he has 3 siblings out of 7 with diabetes diagnosed at approximately his same age. Patient decided the evening of admission that he needed to have his diabetes taken care of secondary to the continued .. symptoms. Additionally, patient has a history of alcoholism and has been binge drinking since his teenage years. About 2 years ago, patient quit the weekend binge drinking secondary to blackouts and episodes of severe epigastric pain that caused nausea, vomiting, and would radiate to his back. Patient states these episodes would last for approximately a week each time. Patient states that he currently drinks approximately 2 beers in the morning with breakfast on the weekends, but is not drinking on Friday, Saturday, and Sunday nights like he had prior. Patient states that with drinking he still has this intermittent pain; however, it is not as severe Three days prior to admission, patient had gone out with friends and had significant alcohol intake and noted mild ... epigastric pain the morning after that episode of binge drinking, some nausea, vomited several times without hematemesis. However, these symptoms have resolved, and patient currently has no nausea, vomiting, no abdominal pain, no fevers or chills, and has been tolerating p.o. ' s at home.
REVIEW OF SYSTEMS: Significant for the following: Patient states that he has lost approximately 48 pounds .. over the last several months. However, this is not documented in the chart. Additionally, patient states that he has had 3-4 episodes of sharp pain, which can occur either over his left or right side of the chest, with no associated symptoms. However, it is associated with stress. Again, this has happened 3-4 times over the last year. Patient states he does have a chronic cough with yellow sputum and does state that he smokes marijuana approximately every .. day. Patient denies any fevers, chills, no night sweats, does have a history of incarceration, but the patient states he has had no history of TB. Patient does complain of GERD symptoms that have ... been self-treated with Maalox for years, and patient states over the last year he has noted a dysphagia with solids greater than liquids. Patient denies any blood in his emesis or stools and denies any dysuria.
PAST MEDICAL HISTORY
1. Includes alcoholism. Patient has had blackouts. Patient has had DUIs and has been incarcerated for his alcoholism.
Patient ' s last drink was 3 days prior to admission. Patient does have a history of tremulousness with withdrawal, no seizures, no DTIs, and no recent withdrawal symptoms reported.
2. Patient has a GI bleed which sounds to be secondary to gastritis that occurred in ___ [DATE].
3. Patient has a remote right ankle fracture and repair secondary to a remote motor vehicle accident
4. Patient has a questionable history of chronic pancreatitis per his report.
ALLERGIES: Patient is allergic to TOPICAL NEOSPORIN.
SOCIAL HISTORY: Patient is divorced. He has 2 children.
He is a musician and a loan officer. He lives alone, does do marijuana, denies any other illicit drug use.
FAMILY HISTORY: Patient ' s father died at the age of 42 from alcoholism..
His mother is alive and healthy at the age of 76. Patient states 3 out of his 7 siblings were diagnosed with diabetes in their 40s to 50s.
ACTIVE MEDICATIONS: Patient takes Excedrin, Maalox, and over-the-counter laxatives as needed.
PHYSICAL EXAMINATION: His vital signs on admission include a blood pressure of 110/74, pulse of 88, a respiratory rate of 18, temperature of 97.6, and patient was satting above 90 percent on room air. His weight is 185.6 pounds, and he is 66 inches. In general, he was not in acute distress, pleasant gentleman.
HEENT was unremarkable. Patient ' s oropharynx was clear and moist. Cardiovascular exam revealed a
regular rate and rhythm. No murmurs, rubs or
gallop. Pulmonary exam: His lungs were clear to auscultation bilaterally. Abdominal exam: Patient had positive bowel sounds.
It was soft, nontender, nondistended. No hepatosplenomegaly, and he was mildly obese.
.
Extremities: He had no cyanosis, no clubbing, and no edema. Palpable pulses throughout.
Neuro was grossly nonfocal. Patient exhibited no asterixis and no tremor. His skin revealed no stigmata of chronic liver disease.
LABORATORY VALUES:
Include the following: A sodium of 126, potassium of 4.6, chloride of 92, a bicarb of 20, creatinine of 1.1, glucose of 653, a GAP of .. 14, a corrected sodium of 135, a phos of 4.0, calcium of 9.7, an amylase of .. 91, a lipase of 455, an ALT of 59, an albumin of 4.2, an alk phos of 103, a bilirubin total of 0.8, a total protein of 7.0, an LDH of 155. A urinalysis revealed greater than 1000 glucose, a specific gravity of 1.0, and +15 ketones, no evidence of infection. Serum ketones were negative. An EKG was normal sinus rhythm. No evidence of acute ST elevation or depression. Chest x-ray was within normal limits.
HOSPITAL COURSE BY PROBLEMS
1. Newly diagnosed diabetes with a hyperosmolar nonketotic state. Patient was not .. orthostatic by vital signs. After 1 liter of fluid in the emergency department, he was given 10 units of subcutaneous insulin, and a fingerstick blood sugar 2 hours later revealed a level of 423. He was continued on IV fluids throughout the evening, and his electrolytes were repleted as needed. His subsequent fingerstick blood sugars were 261 and 193. Patient was placed on 5 units of NPH before breakfast and before dinner, and patient was given instructions that if his fingerstick blood sugars were greater than 250, to give himself 4 units of Regular insulin, and if they were greater than 350, to give himself 6 .. units of insulin. Patient was sent to diabetic teaching and was given a glucometer, as well as all of his diabetic supplies. Patient was instructed to check and record his fingerstick blood sugars before meals and at bedtime ..., and will be followed up on OBMTTuesday at 9 o ' clock in the morning to review his fingerstick blood sugars and his glucose control. A C-peptide and a hemoglobin A1c are pending at the time of this dictation. Patient has been given the number of the emergency department, should his fingerstick blood sugars become greater than 450, for instructions, and patient was instructed to take juice and crackers with any fingerstick blood sugars less than 70.
2. Pancreatitis. Patient initially had a lipase on admission of 455, which was slightly elevated, and an amylase of 91, which was at the high limit of normal
Patient had no symptoms of pancreatitis by physical exam, and his lipase was repeated the morning after admission with a value of 236 and an amylase of 63. Per patient ' s report he may have episodes of pancreatitis secondary to his alcoholism, and patient was given instructions on how to become connected with the outpatient substance abuse treatment program. Patient states he .. will make an appointment upon discharge with them. Patient had no signs or symptoms of alcohol withdrawal during his
hospitalization and will be discharged home on thiamine and folate.
3. Symptoms of GERD and dysphagia. Patient had a barium swallow the morning after admission which, per preliminary report, is negative for any evidence of obstruction . .. Patient will be discharged home on an H2 blocker, and his symptoms will be followed up in OBMT clinic ... Because patient has had symptoms of severe GERD for years without H2 blocker or PPI treatment, outpatient appointment .. with GI for an EGD has been scheduled to rule out Barrett esophagus.
4 .. Chronic cough. This is most likely secondary to patient ' s smoking history. A chest
x-ray was negative. A PPD was placed during patient ' s hospitalization as patient does have an incarceration history; however, has ... been told in the past that he has been negative for PPDs and TB. Patient will follow up with OBMT concerning his symptoms of chronic cough.
5. Weight loss. Patient states he has lost 48 pounds since the onset of his symptoms; however, this has not been documented in his chart. A TSH is pending, and ... this will be followed in an outpatient clinic as the above issues are subsequently addressed. Patient will follow in OBMT clinic until a PCP appointment can be arranged.
DISCHARGE INSTRUCTIONS: Medications on discharge include the following: thiamine 100 mg p.o. q. day; folate .. 1 mg p.o. q. day; NPH insulin 5 units before breakfast and before dinner; sliding scale insulin: for sugars greater than 250, patient is to administer 4 units of subcutaneous insulin(Regular), and for fingerstick .. blood sugars greater than 350, patient is to administer 6 units of subcutaneous Regular insulin. Patient has been given insulin syringes, alcohol pads, lancets, a Precision Glucometer and Precision test strips. Additionally, patient has been placed on ranitidine 300 mg p.o. b.i.d. Patient will follow up in OBMT clinic at 9 o ' clock. Patient has been instructed to call the emergency department for sugars greater than 450. Diet: Patient has been given instructions on an ADA diet. Activity: As tolerated. Patient is competent .. to handle his VA funds