DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
DISCHARGE DIAGNOSES:
1. Decompensated congestive heart failure secondary to dilated cardiomyopathy, ejection fraction of 15%.
2. Fecal impaction.
3. Urinary tract infection.
4. Hypertension.
5. Type 2 diabetes, uncontrolled.
6. Hypothyroidism.
7. Hyperlipidemia.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old lady with dilated cardiomyopathy, ejection fraction of 15% , who presented to the emergency room with shortness of breath, difficulty voiding, and severe constipation. This patient has been followed by home physicians and is managed on a diuretic and low dose of angiotensin receptor blocker at home. Over the last few days, prior to admission, she has had weight gain, increased shortness of breath, and leg swelling. She had difficulty voiding as well as constipation. She denied any fevers, chills or dysuria.
PHYSICAL EXAMINATION: GENERAL: The patient was found to be alert, in mild respiratory distress. VITAL SIGNS: Blood pressure 102/66, pulse rate 74, respiratory rate 22 to 24, afebrile. HEENT: Unremarkable. NECK: Supple. Mild jugular venous distention at 6 cm of water. LUNGS: Bilateral scattered wheezing and crackles at both bases. HEART: S1, S2 soft. Regular rate and rhythm. No murmur or gallop. ABDOMEN: Soft, distended with positive bowel sounds but diminished. No organomegaly or masses. EXTREMITIES: There is 2+ bilateral pitting edema, pulses preserved.
LABORATORY DATA: Upon admission, CBC revealed WBC 8.6, hemoglobin 13.4, hematocrit 41.4, platelets 208, and normal differential. Chemistry showed sodium 139, potassium 4.6, chloride 100, bicarbonate 30, BUN 30, creatinine 1.1, glucose 134. Liver function tests normal. Albumin 3.5, troponin less than 0.4, calcium 8.1, magnesium 2.1. BNP upon admission 1014, upon discharge BNP of 484. TSH high at 13, free T4 normal, free T3 low. Hemoglobin A1c is 7.5%.
DIAGNOSTIC DATA: Echo Doppler showed dilated cardiomyopathy, ejection fraction of 15%. Acute abdominal series showed fecal impaction but no obstruction. Chest x-ray showed pleural effusion, especially on the right, and congestive heart failure. Urinalysis: Positive nitrites, large leukocytes. Upon discharge, urine culture negative. EKG: Sinus rhythm, premature ventricular complexes, left bundle branch block, which is chronic.
HOSPITAL COURSE: The patient was seen in the emergency room when she was found to have stool impaction. It was manually disimpacted, and the patient received a bowel regimen with MiraLax and Colace around the clock. She achieved good bowel evacuation throughout hospitalization.
For congestive heart failure, she was diuresed with intravenous Bumex, and upon discharge, the Bumex dose was increased from 1 to 2 mg daily. Potassium supplementation was also added to the patient’s regimen. Due to the patient’s relative hypertension, she is not able to tolerate any bigger dose of angiotensin receptor blocker or beta blocker. The patient achieved excellent diuresis throughout hospitalization and with resolution of leg edema and shortness of breath. Oxygen was weaned off.
In regards to other issues, she was diagnosed with a urinary tract infection, treated with five full days of intravenous Levaquin. Upon discharge, urine culture was already normal. Also, she was found to be mildly hypothyroid and a low dose of thyroid supplementation, levothyroxine at 25 mcg, was started during hospitalization.
On MM/DD/YYYY, the patient was hemodynamically stable, afebrile, and ready for discharge home. Diet and activity as tolerated.
MEDICATIONS AT HOME: Novolin insulin 70/30, 25 units subcu q.a.m., 15 units subcu q.p.m.; Zocor 20 mg daily; Bumex 2 mg daily; potassium chloride 20 mEq daily; Diovan 80 mg half tablet daily; FiberCon one tablet daily; levothyroxine 0.025 mg daily; glycerin suppository daily p.r.n.; Fleet enema daily p.r.n.; and Dulcolax tablet 10 mg daily p.r.n.
BNP to be done in about one to two weeks and TSH in two months.
FOLLOWUP: The patient is to follow up with home doctor.
