Patient Information/Student Instructions
You are an intern caring for Mr./ Ms. Leslie. He/ She is preparing to be discharged today. You are responsible for developing and communicating a discharge plan to him/ her. Please address relevant information so that he may be discharged safely.
Below is the transfer summary note left by the intern who just rotated off the service.
CC: "I noticed that I was short of breath when I was watching the television this afternoon."
HPI: Mr./ Ms. Leslie is a 76 yr old male/ female smoker admitted 3 days ago for shortness of breath and a spiral CT revealed a pulmonary embolus. He/ She was also found to have a right lower extremity DVT. He/ she had no predisposing factors like trauma or stasis but does have a low grade prostate cancer/ h/o breast cancer.
PMH:
Tobacco abuse, smokes 1-2 pks/day.
Prostate cancer Gleason 3+3 diagnosed 3 years ago; no treatment OR Breast cancer s/p lumpectomy, XRT and tamoxifen for 5 years. No longer on meds.
CAD with MI 10 years ago. No angina.
COPD, no PFTs available. No O2 at baseline.
Mild cognitive impairment, MMSE 25/30 by PCP 6 months ago
CURRENT MEDS:
ASA 81mg daily
Metoprolol 50mg BID
Lisinopril 20mg daily
Combivent MDI 2 puffs TID
Lovenox 60mg SQ BID
Coumadin 5mg daily
NKDA
SH: Lives alone, wife/ husband deceased. Baseline able to perform all ADLs independently. Smokes 1-2 ppd, no alcohol.
FH: Mother died from breast cancer. Father diedfrom stroke (age 85). Brother died from heart attack (age 62).
Hospital Course: He/She has been treated with enoxaparin 60mg BID and has received 2 doses of warfarin 5mg without change in INR (1.2 today). He remains on O2 since admission. Room air saturation 86%, drops to 82% with activity, 92% 2LPM. He should be ready for discharge tomorrow.
Consults:
1. Physical therapy has seen once. Says he/she is safe but has some concerns about endurance to complete all tasks at home without assistance. He/She has an appointment with occupational therapy this morning.
2. Dietician consult has been placed, not sure if he/she has been seen.
3. Hematology does not think he/she needs a hypercoagulability work-up.
Plan: Expect discharge tomorrow. Site of discharge- home with home health is the plan. Needs discharge education still.