DISCHARGE DIAGNOSES:
1. Right chin hematoma, status post incision and drainage.
2. Hemophilia.
3. End-stage renal disease, on hemodialysis.
4. Hypertension.
CONSULTANTS:
1. Hematology-Oncology.
2. General Surgery.
3. Cardiology.
PROCEDURES AND TESTS: Troponin I, three sets, negative. CT of the soft tissue of the neck showed two masses anterior to the right of the mandibular mentum, most likely reflective of a hematoma, but a full abscess could not be ruled out. Also, as an incidental finding, a large right pleural effusion and a smaller left pleural effusion with evidence for adenopathy in the mediastinum. CT of the brain without contrast, no acute intracranial abnormality. This CT brain was done because the patient complained of severe headache at one moment during the hospitalization.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old gentleman, unfortunately with history of multiple comorbidities, including history of end-stage renal disease, on dialysis; hemophilia; hepatitis C; and hypertension who presented to the emergency room complaining of having left-sided chest pain, 8/10 in intensity, nonradiating, that started the night before the admission.
The patient had history of multiple admissions for the same complaint, but at that moment, denied any other associated symptoms like nausea, vomiting, diarrhea, fever, cough, dizziness, shortness of breath, palpitations, or any other complaints.
HOSPITAL COURSE: During the admission, Cardiology was consulted. Myocardial infarction was ruled out. Also, General Surgery was consulted, and the patient had an incision and drainage done with no complications. The patient was found to have a hematoma on the chin. The patient also had hemodialysis per his regular schedule.
DISCHARGE PHYSICAL EXAMINATION:
VITAL SIGNS: Stable. Temperature 98.2 degrees, pulse 64, respirations 20, oxygen saturation 99%, and blood pressure 94/54.
GENERAL: NAD, conversant.
HEENT: Eyes: Anicteric sclerae. No lid lag or proptosis. PERRLA. Atraumatic head. Tonsils not visible. Surgical wound noted on his chin with no signs of active bleeding or infection.
NECK: Nontender, no masses.
HEART: PMI nondisplaced, S1 and S2 heard, no bipedal edema.
LUNGS: Clear to auscultation, normal respiratory effort.
ABDOMEN: Soft, BS normal, no HSM.
EXTREMITIES: Exam is normal.
PSYCHIATRIC: A&O x3, normal affect.
LYMPHATICS: No palpable LN in neck or groin.
SKIN: No rash, no indurations.
NEUROLOGICAL: Nonfocal, central nerves intact. Normal motor and sensory exams.
DISCHARGE CONDITION: The patient at this moment is stable and asymptomatic and willing to follow with his doctors as an outpatient.
DISPOSITION: Home with home care services.
DISCHARGE MEDICATIONS: Brimonidine 0.15% 1 drop in both eyes 3 times a day, carvedilol 25 mg p.o. twice a day, citalopram 10 mg p.o. daily, docusate 100 mg p.o. at bedtime, Trusopt 1 drop in eyes 3 times a day, Vasotec 10 mg p.o. every 12 hours, Dilaudid 1 mg p.o. at bedtime as needed for pain, Imdur 30 mg p.o. daily, latanoprost 1 drop at bedtime, minoxidil 10 mg p.o. daily, Renagel 800 mg p.o. 3 times a day with meals, tramadol 50 mg p.o. every 8 hours as needed, Prilosec over-the-counter 20 mg p.o. daily, vitamin C 500 mg p.o. twice a day, vitamin D 5000 units p.o. every day, amiodarone 200 mg p.o. daily, amlodipine 5 mg p.o. twice a day, diphenhydramine 50 mg every 6 hours as needed, gabapentin 300 mg p.o. every 8 hours as needed, ranitidine 150 mg p.o. daily, and zinc sulfate 220 mg p.o. daily.
NEW MEDICATION ORDERS:
1. Minoxidil 10 mg p.o. daily.
2. Levofloxacin 500 mg p.o. every 48 hours, only 3 pills.
3. We provided a prescription for Dilaudid 1 mg p.o. at bedtime only for 20 days with no refills.
DISCHARGE INSTRUCTIONS: Diet: Cardiac, renal. Activity: As tolerated. Follow up care: Dr. John Doe in two weeks and Dr. Jane Doe in 1 week.
FINAL DIAGNOSES:
1. Right chin hematoma.
2. Hemophilia.
3. Hypertension.
4. End-stage renal disease, on hemodialysis.
