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Created byRaul Tovar-Castro
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Admission-Pulmonary Group
Generalized Weakness, Abdominal Pain & Recurrent Falls
(3:00pm)Admission Medical ICU -Septic Shock secondary to UTIAdmission Medical ICU- Generalized Weakness & Altered Mental StatusAdmission by Pulmonary Group- Altered Mental StatusDischarged from the ED with Diagnosis of UTI & Levaquin 500 mg poDischarged to LTAC for completion of IV Antibiotics
for a period of one weekEmergency Room Visit LE Edema, patient was discharged the same day w/ negative DVT workupDischarged by Pulmonary Group-Discharged with Levaquin,
patient refuses LTAC placement and prefers Physical Therapy with Home Health.Discharged w/ diagnosis pf HCAP &
Acute Metabolic Encephalopathy
and likely secondary to Seroquel useED Physician Workup Patient for Recurrent Falls
-CT Head w/o Contrast (Head Injury)
-CT of the Cervical Spine (Trauma)
-CT of the Abdomen and Pelvis w/ Contrast (Trauma)
-X-Ray of the Right Forearm
-XR Shuntgram Nonvascular
All Exams were unremarkablePer NP Note
-Ordered Syncope Workup
Carotid Doppler
Echocardiogram
Orthostatic Vitals
Imaging was never performed and patient
was discharged with antibiotics for UTIResident admitted patient to the Medical ICU for
Septic Shock secondary to UTI.Patient was discharged to LTAC with no clear indication.
Poor documentation by attending Physician regarding
plan of care.
Patient was given multiple MBSS regardless of patient
continuing to have altered mental status. On the day
of discharged an EEG was read by neurologist
indicating that encephalopathy continued to be present.AMS secondary to Septic Shock likely due to Pneumonia
I received the patient during this admission.
At this time, AMS continued to be present regardless of Septic Shock resolving. Neurology and Neurosurgery were consulted. Neurosurgery believed that patient did not have
any problems with VP shunt and therefore signed off. After analyzing all the CT scans and comparing them. It was cleared that patient had cerebral edema. Attending agreed to begin 3% Sodium in the Medical ICU.
After 2 days of patient b
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