Inpatient Case 2

 Inpatient sample charts / Inpatient sample cases / Inpatient DRG coding / DRG coding sample charts

DISCHARGE SUMMARY

PRIMARY DIAGNOSES:

1. Cardiogenic shock.

2. End-stage systolic congestive heart failure.  Ejection fraction 3 months ago was 25%.

 

SECONDARY DIAGNOSES:

1. Chronic kidney disease.

2. Hyperuricemia.

3. Depression.

4. Diabetes mellitus.

 

PERTINENT LABS, IMAGING AND PROCEDURES:

The patient did not undergo any invasive procedures.

Pertinent images include the following:  02/22/2022, chest x-ray showed cardiac enlargement with central vascular congestion.  Dependent atelectasis.  Underlying infiltrate not excluded.  Followup recommended.

Pertinent laboratory data on or near the time of death include the following:  WBC 6.6, hemoglobin 10.7, platelets 98.  Sodium 131, potassium 3.0, BUN 83, creatinine 2.8.  Lactic acid 5.4, ALT 17, AST 20, total bilirubin 1.3, phosphorus 4.8, uric acid 8.8.

HOSPITAL COURSE:

The patient was an 95-year-old female who presented with low blood pressure and signs and symptoms concerning for cardiogenic shock.  The patient had been seen periodically by her PCP and cardiologist in the outpatient setting and they did share the same concerns.  The patient has had progressive congestive heart failure over some time now.  The patient was actually doing fairly well until about 48 to 72 hours before presentation.  The patient was noted to have progressive lethargy and weakness and decreased responsiveness.  The patient was directly admitted and basic workup was done.  The patient's blood pressure was low and so she was started on empiric dobutamine therapy.  The patient was also noted to be in severe congestive heart failure and so a Bumex drip was attempted.  The patient remained very uncomfortable throughout the whole process and the family quickly opted to stop aggressive measures and to make her comfort care.  The patient was put on comfort care and passed very shortly after.

 

 

H&P

 

Chief Complaint

Lethargy, weakness

History of Present Illness

Pt is an 95 y/o female with a h/o dm, systolic chf, depression and HTN who was brought for the above. Pt had a few days to a week of weakness that persisted. Workup at her pcp and cardiologist showed some escalating crt, lowering bp, and there was concern for worsening clinical status. She was admitted for further care.

 

Review of Systems

All other systems were reviewed and are negative except for what is mentioned in the hpi.

Physical Exam

Vitals & Measurements

T: 35.9  °C (Tympanic)  HR: 102(Monitored)  RR: 31  BP: 85/36  SpO2: 95%  WT: 56.100 kg   

General: conscious, semi coherent, uncomfortable

Eye: anicteric sclerae, pink palpebral conjunctivae

Neck: supple, non-tender, large L jvd seen

Respiratory: symmetrical chest expansion, bilat crackling all fields

Chest: rrr, no mrg

Gastrointestinal: nabs, Soft, Non-tender

Integumentary: warm, dry, good capillary refill

Extremities: 2+ pulses distally, no c/c/e

Lymphatics: no lymphadenopathy appreciated, neck normal

Neurologic: alert to voide, follows commands

Psychiatric: not homicidal, not suicidal

 

Problem List/Past Medical History

Ongoing

CHF (congestive heart failure)

Depression

DM (diabetes mellitus)

Gout

History of TIAs

HLD (hyperlipidemia)

HTN (hypertension)

MI (myocardial infarction)

RA (rheumatoid arthritis)

Tremor

Historical

No qualifying data

 

Procedure/Surgical History

•Eye

•Hysterectomy

Medications

Inpatient

atropine ophthalmic, 2 drop(s), Sublingual, q1hr, PRN

Dilaudid (hydromorphone), 0.5 mg= 0.5 mL, IV, q1hr, PRN

Dilaudid (hydromorphone), 2 mg, IV Push, Once

DOBUTamine additive 250 mg [4 mcg/kg/min] + Dextrose 5% Premix Diluent 250 mL

haloperidol, 2 mg= 0.4 mL, IV Push, q2hr, PRN

Lidocaine Jelly, 1 app, TOP, Once, PRN

LORazepam, 0.5 mg= 0.25 mL, IV Push, q1hr, PRN

morphine, 1 mg= 0.5 mL, IV Push, q2hr, PRN

morphine, 2 mg= 1 mL, IV Push, q2hr, PRN

morphine, 2 mg= 1 mL, IV Push, q1hr, PRN

ondansetron, 4 mg= 2 mL, IV Push, q6hr, PRN

scopolamine transderm, 1.5 mg= 1 patch(es), TOP, q72hr, PRN

Tylenol, 650 mg= 2 tab(s), Oral, q6hr, PRN

 

Home

allopurinol, 100 mg, Oral, Daily

aspirin, 81 mg, Oral, HS

atorvastatin, 10 mg, Oral, Daily

benzonatate, 100 mg, Oral, TID, PRN

carvedilol, 3.125 mg, Oral, BID

escitalopram, 10 mg, Oral, Daily

Farxiga, 5 mg, Oral, Daily

furosemide, 20 mg, Oral, BID, resume in 5 days

linagliptin, 5 mg, Oral, Daily

omeprazole, 10 mg, Oral, Daily, PRN

ondansetron, 4 mg, Oral, q8hr, PRN

Plavix, 75 mg, Oral, Daily

primidone, 50 mg, Oral, Daily

 

Allergies

No Known Allergies

Social History

Alcohol- Never

Electronic Cigarette/Vaping-Electronic Cigarette Use: Never.

Substance Abuse-Never

Tobacco- Former smoker, quit more than 30 days ago Tobacco Use:.- Comments: Quit 30 years ago

Family History

Family history is unknown

Deceased Family Member(s):

Lab Results

Labs (Last four charted values)

WBC      6.6   (FEB 22)

Hgb      L 10.7   (FEB 22)

Hct      L 33.5   (FEB 22)

Plt      L 98   (FEB 22)

Na      L 131   (FEB 22)

K      L 3.0   (FEB 22)

CO2      L 18   (FEB 22)

Cl      L 93   (FEB 22)

Cr      H 2.8   (FEB 22)

BUN      H 83   (FEB 22)

Glucose Random        H 280   (FEB 22)

Mg      1.8   (FEB 22)

Phos      H 4.8   (FEB 22)

Total CK        51   (FEB 22

Assessment/Plan

Cardiogenic shock - ef 25% 2021

 End stage systolic chf

 CKD

 Hyperuricemia

 Depression

 DM

Initially started bumex gtt and dobutamine for inotropic support but pt remained uncomfortable with little chance of meaningful improvement. Family has decided against further aggressive measures and opted for comfort care instead. Order set initiated.

d/w family and pt at bedside - pt son, daughter and grandson

Images

CXR today

IMPRESSION:

1.  Cardiac enlargement with central vascular congestion.

2.  Dependent atelectasis.  Underlying infiltrate not excluded.  Followup

recommended.

 

PROGRESS NOTES

1300 Pt on comfrort care per family request. Comfort care set initiated.

1420 TOD pronounced by Dr Fernandez

1440 Midwest called

1458 Called coroner and informed that pt placed to comfort care. Body release by Coroner.