SUBJECTIVE: 60 y/o AAM presented in ER from nursing home with fever and chills.

Patient was suctioned three times yesterday and he had moderate amount of thick
yellow secretion. Patient is non verbal and has flat/withdrawn mood. Patient had
stroke with left sided weakness around October. It is hard to get detailed history
since patient does not respond to questions. He was admitted to hospital for stroke
and he was also diagnosed w pneumonia. Patient had fever of 104.3 as per
daughter at nursing home. PMH: HTN, CVA, Left hemiplegia, renal dysfunction.
Physical
General Patient is conscious but unable to answer questions.
HEENT - Normocephalic, PERRLA, EOMI, scar on back of his head, Bilateral orbital
swelling
Neck Tracheal tube in place
Cardiovascular RRR, S1S2 +, No JVD
Respiratory Normal breath sounds, Rales heard on right lung.
Gastrointestinal - Abdomen symmetric w/o distention, normal bowel sounds, No
splenomegaly or hepatomegaly. Patient is on feeding tube.
Musculoskeletal Edema on left leg > right leg
Neurological Encephalopathy, left hemiplegia, right facial weakness with right 6 th
nerve palsy.
Genitourinary Patient is on Foley catheter.
Extremities - Edema on left leg > right leg, No cyanosis, clubbing, or edema are
noted
Assessment:
A) Aspiration Pneumonia
B) Sepsis
C) r/o Intracranial infection
D) CKD
E) Vegatative state s/p CVA
F) HTN
G) Previous CVA
H) BPH/Prostate cancer
I) Normocytic normochromic anemia
J) Assess Vancomysin toxicity
K) Hypernatremia
Plan:
A) Chest xray, CBC, sputum gram stain, Vancomycin IV 1gm every 72 hours,
Cefepime IV 2 gm every 12 hours
B) Blood cultures, CBC, IV antibiotics
C) Non contrast head CT, CBC, IV antibiotics
D) IV fluids
E) Bilateral lower extremity venous doppler, NPO, Dextrose 5 0.45 Saline
100ml/hr IV * 2L, Oxepa
F) Continue HTN medication - Hydralazine 10 mg G tube Every 8 hours as
needed, Amiodarone 200 mg G tube everyday, Carvedilol 2.125 mg G tube
twice a day
G) Consider putting patient on Aspirin 81 mg everyday

H)
I)
J)
K)

Normal PSA level

Omeprazole 20 mg G tube everyday
Draw vancomysin trough
Hydration

SUBJECTIVE: 83 y/o AAF who is a resident at Alden Wentworth nursing home with blood in
stool and diarrhea. Patient is unable to respond to questions. Patient denied any pain or
complaints. Her blood pressure has been elevated since admission to ER. Patient was set to be
discharged on 11/21/12 but she couldnt be discharged because of elevated blood pressure.
PMH HTN, CHF, DM, anemia of chronic kidney disease, dementia and dyslipidemia.
Surgical hx PEG tube placement
Vitals: BP: 214/100 P: 88 R: 20 O2 Sat: 100%Temp: 98 F axillary
Physical
General: AAA *3
HEENT: Normocephalic. PERLLA, EOMI
CVS: RRR, Ejection systolic murmur on left side, S1S2, No JVD.
RESP: Chest air entery bilaterally equal, normal respiration, no wheezes/crackles, normal on
percussion.
ABD: Unremarkable except PEG tube placement.
EXTREMITIES: No edema,
NEURO: Cranial nerve exam is unremarkable, 3+ strength of legs, 4 + strength for arms, Minimental physical exam score 7/30
Labs:RBC 4.16,MCHC 33.0,RDW 17.6 H, CA 8.7,ALB 2.2 L,ALP 88,TBILI 0.4
ASSESSMENT
A) HTN/CHF
B) DM
C) Dyslipidemia
D) GI prophylaxis
E) DVT prophylaxis
F) Normocytic normochromic anemia
G) Dementia
PLAN:

A) HTN/CHF
Hydralazine 100 mg every 8 hours
Methyldopa 500 mg 1 tab every 8 horus
Metoprolol Tartrate 50 mg twice a day
Clonidine 0.1 mg every 8 horus
Nifedipine daily 120 mg
Isosorbide mononitrate 30 mg daily
Hydralazine 20 mg/1ml every 6 hours PO
B) DM
Insulin regular human 2 unit/0.02 ml

Lantus 25 units/0.25 ml subcutaneously at bed time

C) Dyslipidemia
Simvastatin Daily 10 mg

D) Normocytic normochromic anemia

Monitor Hb, consider EPO, Transfused patient w 2 PRBC and then check Hb and Hct
levels after 2 horus