rCase #1: The following documentation is from the

health record of a 71yearold male patient.

Discharge Summary
History and Physical Findings: This 71yearold male is a
nursing home resident as a result of a cerebrovascular accident
two years ago. He has had numerous hospital admissions for
pneumonia and other infectious complications. On the day of
admission, the patient was noted to be clammy, with tachypnea,
to
have decreased level of responsiveness, and to show increased
fever. He was seen in the ER, where evaluation revealed the
presence of probable urinary tract infection and sepsis. The
patient was also found to have renal insufficiency with BUN and
creatinine elevated. His WBC count was 23,000 with decreased
hemoglobin and hematocrit. He was admitted for treatment of E.
coli sepsis. Physical examination revealed an elderly male who
was aphasic and had rightsided hemiplegia (he is righthanded),
both from a previous CVA. The heart had
a regular rhythm. The lungs were clear. The abdomen was soft.
Significant Lab, Xray, and Consult Findings: Followup
chemistry showed progressive decline in the BUN and creatinine
to near normal levels. Initial white blood cell count was 23,700.
Final blood count was 9,000. The urinalysis showed too numerous
to count white cells. The urine culture had greater than 100,000
colonies of E.coli and Group B strep, which revealed the cause of
the UTI. Repeated blood cultures grew E. coli with the same
sensitivities as that of the urine. There were no acute
abnormalities noted. EKG showed sinus
tachycardia and low lead voltage, otherwise was normal and
unchanged.
Course in Hospital: The patient was initially started empirically
on Primaxin. He underwent fluid rehydration and his electrolytes
were followed closely. Electrolytes improved through his hospital
stay. He was continued

on IV Primaxin until the date of discharge, when he was changed

to Cipro by tube. All of the bacteria grown in the urine and in the
blood were sensitive to the Cipro. The chest xray showed no
change from previous admissions, and he was followed closely
with additional oxygen as needed. The patient does have a history
of chronic obstructive lung disease and has required intermittent
oxygen therapy at the nursing home. At this time, the patient had
reached maximal hospital benefit. He was switched to oral
antibiotics. He was to continue on tube feedings, which he was
tolerating quite well. The patient was discharged back to the
nursing home on 5/4.
Discharge Diagnoses:
1. E. coli sepsis
2. UTI, due to E. coli, and Group B strep
3. Renal insufficiency
4. Chronic obstructive lung disease
5. CVA with right hemiplegia

Case #2: The following documentation is from the health record

of a 58yearold male patient.
Discharge Diagnoses:
1. Carcinoma of the lung, right upper lobe, currently undergoing
chemotherapy
2. Type 2 diabetes, with neuropathy and nephropathy
3. Hyperlipidemia
4. Hepatomegaly
History: This patient is a 58yearold male who presented for
outpatient chemotherapy. He had surgery for lung cancer three
months ago and is now undergoing chemotherapy with Taxol and
carboplatin, including
dexamethasone as part of his chemotherapy and prophylaxis for
nausea. He has done very well with the outpatient chemotherapy.
When he presented for treatment on the day of admission, he was

found to be hypoglycemic. He is a known type 2 diabetic which is

also complicated by neuropathy and nephropathy. Due to his
blood glucose levels, it was decided to postpone this
chemotherapy session and he was admitted for control of his
diabetes. Dr. Johnson consulted with the patient to manage his
diabetes regimen. He has been on 70/30 insulin, 25 units in the
morning and 15 units in the evening for several years. An IV
insulin drip was started and he also had q 1 hour AccuChecks. His
hepatomegaly has enlarged from the last time that I saw him.
Question whether this is fatty infiltration due to poor diabetes
control, or whether there is now some
Involvement with metastatic carcinoma.
Lab Data: Sodium 128, potassium 5.5, chloride 89, BUN 13,
creatinine 0.8, glucose range 30460, with final glucose of 210.
Calcium 9.4, WBC 9.8, hemoglobin 11.6, hematocrit 34.3,
platelets 277,000. Plan: One difficulty here is the cyclic nature of
his chemotherapy treatment regimen, likely to produce major
shifts in his glucose, which is already difficult to control. The
patient will need to monitor his glucose levels closely. He is
discharged on 70/30 insulin, 35 units in the morning and 20 units
in the evening. He is to follow up with me for further
chemotherapy in the oncology clinic next week.
Procedure Performed: Fiberoptic bronchoscopy

Case #3: The following documentation is from the health record

of an 87yearold female patient.
Discharge Summary
History of Present Illness: The patient is an 87yearold female
who was admitted from a nursing home with congestive heart
failure, dehydration as well as urinary tract infection and
thrombocytopenia. On admission she was found to have a platelet
count of 77,000 and a Hematology consult was done. The patient
denied any bleeding diathesis in the past. She stated that she had

recent bruising of the hands related to needle sticks, but

otherwise has not had any past history of any bleeding disorder.
No specific history of hematuria, hematemesis, gross rectal
bleeding, or black stools.
Past Medical History: Significant for congestive heart failure,
diabetes
Medications: Coreg, isosorbide, Actos, digoxin, glyburide,
hydralazine, furosemide, Ditropan, and potassium
Family History: No family history of any bleeding disorder
Physical Examination: She is an elderlyappearing white
female, somewhat short of breath, using supplemental oxygen.
Examination of the head and neck revealed no scleral icterus.
Throat was clear. Tongue was papillated. There was no
thyromegaly or JVD. There was no cervical supraclavicular,
axillary, or inguinal adenopathy. Chest examination revealed
rales, bilaterally. There were decreased breath sounds at the right
base. There were coarse rales heard in the right midlung field.
Heart exam showed rhythm was irregular. Abdomen exam was
difficult to perform. I was unable to palpate the liver or spleen.
Bowel sounds were active. Extremities revealed no clubbing,
cyanosis, or edema. There were diffuse ecchymoses, especially in
the dorsum of the right hand.
Laboratory Studies: Hematocrit was 43, white count 9,000 with
82% neutrophils, and the platelet count 77,000. The MCCV was
102. Creatinine was 1.7. Bilirubin was 1.7. The alkaline
phosphatase was 122. AST 498,
ALT 493, and albumin 3.6. The prothrombin time was 18 seconds,
the PTT was 25 seconds. The chest xray showed a right pleural
effusion.
Course in Hospital: The patient was admitted and started on IV
fluids. Her diuretics were increased, and she showed a good
response and better control of her congestive heart failure.
Hematology consult recommended holding platelet transfusion

unless there was evidence of active bleeding. No platelets were

given during this admission. The patient was discharged back to
the nursing home on day six in improved condition to continue
with the same medication regimen as previous to hospitalization.
Final Diagnoses:
1. Acute on chronic systolic congestive heart failure
2. Dehydration
3. Primary thrombocytopenia
4. Urinary tract infection
5. Type 2 diabetes mellitus
Procedure performed: Left cardiac cath with left
ventriculogram.

Case #4: The following documentation is from the health record

of an 85yearold female patient.
Discharge Diagnoses:
1. Hypertensive left heart failure with acute pulmonary edema
2. Myocardial infarction ruled out
3. Chronic obstructive pulmonary disease
4. Pseudomonas pneumonia
History of Present Illness: This 85yearold female was
admitted via the Emergency Room from the nursing home with
shortness of breath, confusion, and congestion. There was no
history of fever or cough noted.
Patient also has a history of COPD. Prior to admission, the patient
was on the following medications:

Prednisone, Lasix, Benicar, and Colace. Patient had a long history

of tobacco dependence prior to admission to the nursing home.
Physical Examination: Blood pressure 140/70, heart rate of 125
per minute, respirations were 30, temperature of 101.4. The eyes
showed postsurgical eyes, nonreactive to light. The lungs showed
bilaterally bibasilar crackles. The heart showed S1 and S2, with no
S3. The abdomen was soft and nontender. The
extremities showed leg edema. The neurological exam revealed
no deficits and she was alert 3.
Hospital Course: Basically, this patient was admitted to the
coronary care unit with acute pulmonary edema, rule out
myocardial infarction. Serial cardiac enzymes were done, which
were within normal limits, therefore
ruling out myocardial infarction. A chest xray performed on the
day before admission confirmed left heart failure and pneumonia.
The patient was started on Unasyn and Tobramycin for the
pneumonia, which improved. The left heart failure, however, was
not improving with administration of Lasix. The patient was not
taking foods and liquids well, and, at the familys request, she was
made DNR. On hospital day 12, she was found without
respirations, with no heart sounds, and pupils were fixed. She was
declared dead by the physician, and the family was notified.