March 31, 2020
For educational institutions
⟶ Updated 1 months ago ⟶
List of edits
Admission-Pulmonary Group Generalized Weakness, Abdominal Pain & Recurrent Falls (3:00pm)
Admission Medical ICU -Septic Shock secondary to UTI
Admission Medical ICU- Generalized Weakness & Altered Mental Status
Admission by Pulmonary Group- Altered Mental Status
Discharged from the ED with Diagnosis of UTI & Levaquin 500 mg po
Discharged to LTAC for completion of IV Antibiotics for a period of one week
Emergency Room Visit LE Edema, patient was discharged the same day w/ negative DVT workup
Discharged 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 use
ED 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 unremarkable
Per NP Note -Ordered Syncope Workup Carotid Doppler Echocardiogram Orthostatic Vitals Imaging was never performed and patient was discharged with antibiotics for UTI
Resident 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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