Recurrent Pleural Effusion Discharge Summary Sample Report



REASON FOR ADMISSION: Severe shortness of breath, increasing with time.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female who developed severe shortness of breath, which was increasing with time. She resides in an assisted living facility. She was sent to the emergency room, evaluated, and admitted. The examination at the emergency room revealed that the patient has large left pleural effusion, which is compromising her respiratory function.

PAST MEDICAL HISTORY: Significant because of history of non-insulin-dependent diabetes mellitus, coronary artery disease, chronic atrial fibrillation, sick sinus syndrome with a pacemaker, severe spinal stenosis, degenerative joint disease, degenerative disk disease, and also right breast mass. She also suffers from chronic depression. She used to be on Coumadin because of her chronic atrial fibrillation, but because of her advanced age and the risk of bleeding in case of fall, the Coumadin was discontinued. There is also history of previous acute congestive heart failure with left pleural effusion, which was aspirated, yielding 600 mL of fluid during her previous hospitalization. There is also history of acute myocardial infarction, urinary tract infection with E. coli.

ALLERGIES: The patient is allergic to multiple medications. See list in chart.

MEDICATIONS: At the assisted living facility, the patient was on Lopressor 12.5 mg twice a day, Altace 2.5 mg daily, Lasix 20 mg daily, potassium supplement Micro-K 10 daily, Actos 15 mg a day, Starlix 120 mg 3 times a day before meals, and nitroglycerin 0.4 mg daily sublingual as needed for chest discomfort, Paxil 10 mg daily, and Deplin 7.5 mg daily.

REVIEW OF SYSTEMS: The patient complains of being extremely weak, having no ambition.

PHYSICAL EXAMINATION: Reveals a well-developed, frail-looking Hispanic female in acute distress due to shortness of breath and left-sided chest discomfort. Vital signs showed temperature 97.8, respirations 20, blood pressure 172/84, pulse 60 per minute and regular, and pulse oximetry on 2 liters per minute oxygen by nasal cannula at 99%. Her head appeared to be normocephalic. She appears to be alert and oriented x3. Ears, nose, and throat showed no lesion. Pupils are equal and reactive to light. Extraocular movements are intact. Neck is supple. No lymphadenopathy. Chest symmetric and well developed. There is a mass in the right breast. Heart shows regular rate at 60 per minute with systolic murmur. Lungs show presence of scattered rhonchi and dullness to percussion. Abdomen was soft, nontender. Bowel sounds are present. No masses, no organomegaly. Extremities showed trace pedal edema. Neurologically, grossly, the patient had no focal motor deficits.

1. Severe left pleural effusion, unknown etiology.
2. Acute congestive heart failure.
3. Critical aortic stenosis.
4. Non-insulin-dependent diabetes mellitus.
5. Chronic atrial fibrillation.
6. Sick sinus syndrome with a pacemaker.
7. Spinal stenosis per history.
8. Osteoarthritis.
9. Facet joint arthritis.

PERTINENT LABORATORY AND DIAGNOSTIC DATA: CBC on admission showed hemoglobin 11.6, hematocrit 33.2, RBC 3.74, WBC 6.2, platelet count 116,000, and white cell differential was normal. On MM/DD/YYYY, CBC showed hemoglobin 11.2, hematocrit 33.2, RBC 3.7, WBC 6.8, platelet count normal 172,000. Chemistry on admission showed sodium 142, potassium 3.4, chloride 106, CO2 of 29, creatinine 1.4, BUN 18, GFR calculated 37, abnormally low. Serum calcium was normal at 9.0. Magnesium level 1.7. Liver enzymes were normal. Troponin level was normal. C-reactive protein 2.0, elevated. BNP was elevated at 2270 and albumin was slightly low at 3.2. Random glucose was 106. Repeat BNP on MM/DD/YYYY was 1192, which showed improvement of the initial values and serum electrolytes on MM/DD/YYYY showed sodium 139, potassium 4.4, chloride 105, CO2 of 27, BUN 31, creatinine 1.6, and GFR 32, still abnormally low. Chest x-ray on admission showed increasing pleural effusion and atelectatic changes. CT scan of the chest was done on MM/DD/YYYY and showed left-sided pleural effusion, which is mildly increased when compared to prior study. Chest x-ray done on MM/DD/YYYY showed partial reaccumulation of the left pleural effusion with cardiomegaly. Electrocardiogram on admission showed electronic ventricular pacemaker, and no further interpretation was possible. Echocardiogram was done on this patient and showed mild to moderate decreased left ventricular systolic function, abnormal left ventricular diastolic function, critical aortic stenosis, mild mitral regurgitation, moderate tricuspid regurgitation, moderate pulmonary hypertension, left atrial diameter was 4.5, which is normal.

Consultation was obtained from Cardiology. They felt that the patient will benefit from thoracentesis and their suggestions were followed up. Also, pulmonary consultation was obtained. They did not believe that she is a candidate for VATS or invasive procedures and also agreed that thoracentesis would help. So, on MM/DD/YYYY, thoracentesis was performed under ultrasound guidance and 1100 mL of clear, frothy, yellow-colored fluid was successfully drained. That was sent for pathology, and pathology examination revealed that it was negative for malignancy with a few mesothelial cells in the background and numerous small lymphocytes.

While in the hospital, the patient was placed on the following medications: Furosemide 40 mg daily, Actos 15 mg daily, Lanoxin 0.125 mg daily, Paxil 10 mg daily, Deplin 7.5 mg daily, metoprolol tartrate 12.5 mg twice a day, Starlix 120 mg 3 times a day before meals, nitroglycerin 0.4 mg as needed for chest pain, potassium chloride 10 mEq daily every 8 hours. She also received nasal oxygen 2 liters per minute. She remained comfortable and became stable and asked to be discharged from the hospital.

1. Recurrent large left pleural effusion.
2. Acute congestive heart failure.
3. Critical aortic stenosis.
4. Chronic atrial fibrillation.
5. Non-insulin-dependent diabetes mellitus.
6. Chronic renal insufficiency.
7. Coronary artery disease.
8. Old myocardial infarction.
9. Chronic depression.
10. Spinal stenosis.
11. Osteoarthritis.
12. Facet joint osteoarthritis.

DISCHARGE INSTRUCTIONS: The patient is being transferred to a skilled nursing care facility on the following diet and medications; 1800 calorie ADA diet and Actos 15 mg a day, Starlix 120 mg 3 times a day before meals, Paxil 10 mg a day, metoprolol tartrate 12.5 mg twice a day, Lasix 40 mg daily, Micro-K 10 mEq daily, Lasix 40 mg daily, as well as Mycostatin powder under the breast twice a day and digoxin 0.125 mg daily. The patient will be followed up by us in the nursing home.