DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
ADMISSION DIAGNOSES:
1. Leukocytosis.
2. Fever.
3. Parkinsonism.
4. Dementia.
5. Depression.
6. History of cerebrovascular accident.
7. History of lung cancer.
8. Rule out sepsis.
9. Dehydration.
10. Acute renal failure, possibly secondary to dehydration.
DISCHARGE DIAGNOSES:
1. Resolved leukocytosis.
2. Ruled out sepsis.
3. History of lung cancer.
4. Parkinsonism.
5. Dementia.
6. Resolved dehydration.
7. History of cerebrovascular accident.
HOSPITAL COURSE: Please refer to the H&P for detailed description of history and for more information. The patient is a pleasant (XX)-year-old male who has been admitted for evaluation of pyrexia to rule out sepsis associated with acute renal failure with dehydration. He had been admitted to progressive care unit, recommended Zosyn, intravenous antibiotics, and IV hydration.
Initially, the patient had been kept NPO, and the patient was, later on, evaluated with swallow study, and once he was cleared by the swallow evaluation team, he was readjusted on his nursing home medications. The patient has been followed with blood cultures, which have been negative. However, the patient improved his white count from 16,000 on admission to 10,000 before the time of discharge. The patient required potassium protocol for hypokalemia, and once clinically more stable, IV Zosyn was discontinued. He was started on oral Augmentin.
The patient had been maintained on full DNR state with full active treatment protocol during this hospitalization. Once the patient was clinically more stable, he was discharged with the below discharge instructions to the extended care facility.
DISCHARGE INSTRUCTIONS: The patient has been transferred to the extended care facility. The patient has been recommended pureed diet with honey thick liquids.
DISCHARGE MEDICATIONS: Sinemet 25/100 mg 1-1/2 tablets 5 times a day, Aricept 10 mg once a day, Mirapex 0.25 mg 4 tablets 3 times a day, Ditropan 5 mg once in the morning, Protonix 40 mg once a day, zinc sulfate 220 mg once a day, vitamin C 500 mg once a day, Namenda 10 mg twice a day, Lexapro 10 mg once a day, Lasix 20 mg once a day, potassium chloride 10 mEq once a day, and Augmentin 875 mg twice a day.
