History of Present Illness
A 72-year-old Vietnamese-speaking woman with HLD, HTN, CKD stage II (baseline creatinine 1.3), and cholelithiasis is admitted for severe gallstone pancreatitis.
Past Medical / Surgical History
| Condition |
| Hyperlipidemia |
| Hypertension |
| Cholelithiasis |
| CKD stage II |
| History of positive PPD |
Family History
| Relative |
Condition |
| First-degree relatives |
Heart disease |
|
Diabetes |
Social History
| Factor |
Details |
| Tobacco |
Former smoker |
| Alcohol |
1–2 drinks daily |
| Living situation |
Lives with son & daughter-in-law |
| Marital status |
Widowed |
| Occupation |
Former textile factory manager |
| Insurance |
Commercial |
Home Medications on Admission
| Medication |
Dose |
Frequency |
Notes |
| Atorvastatin |
40 mg |
qHS |
|
| Lisinopril |
5 mg |
qD |
|
| Ibuprofen |
400–800 mg |
qD PRN |
For joint pain |
Physical Exam on Admission
| Vital Sign |
Value |
| Temperature |
101.3 °F |
| Heart Rate |
112 bpm |
| Blood Pressure |
98/52 mm Hg |
| SpO₂ |
93 % RA |
| Respiratory Rate |
24 /min |
| System |
Findings |
| General |
Alert, oriented, NAD, appears very fatigued |
| HEENT |
Mild scleral icterus |
| CV |
Tachycardic, regular rhythm, no m/r/g |
| Lungs |
Bilateral basal crackles |
| Abdomen |
Soft, mildly distended, TTP RUQ/peri-umbilical |
| Extremities |
No LE edema |
| MSK |
No joint swelling |
Admission Data
| Test |
Result |
| CBC |
WBC 17.3 K, Hgb 10.2 g/dL, Plt 345 K |
| BMP |
Cr 1.8 mg/dL, BUN 45 mg/dL |
| LFTs |
Alk P 102 U/L, Tbili 3.2 mg/dL |
| Lipase |
603 U/L |
| CT A/P |
Peripancreatic stranding; cholelithiasis; intrahepatic biliary ductal dilatation |
Hospital Course Highlights
- Severe sepsis & ARDS → 6 L O₂ → ICU → broad spectrum antibiotics
- CXR: lung nodule → outpatient biopsy recommendation
- DVT → heparin drip → apixaban
- Respiratory failure → intubation → 57-day stay → gradual recovery
- Lung nodule plan deferred → severe deconditioning → rehab
Discharge Medications
| Medication |
Dose & Timing |
Notes |
| Atorvastatin |
40 mg qHS |
|
| Lisinopril |
5 mg qD |
On HOLD until PCP follow-up |
| Ibuprofen |
400–800 mg qD PRN |
On HOLD due to AKI on CKD |
| Acetaminophen |
1000 mg q8h PRN |
|
| Potassium chloride |
20 mEq daily |
|
| Apixaban |
5 mg BID |
|
Discharge Physical Exam
| Vital Sign |
Value |
| Temperature |
97.3 °F |
| Heart Rate |
85 bpm |
| Blood Pressure |
142/75 mm Hg |
| SpO₂ |
95 % RA |
| Respiratory Rate |
18 /min |
| System |
Findings |
| General |
Alert, oriented, NAD, appears weak |
| HEENT |
No scleral icterus; no oral lesions |
| CV |
RRR; no m/r/g |
| Lungs |
CTAB; no c/r/w |
| Abdomen |
Soft, non-distended, non-tender |
| Extremities |
No LE edema |
| MSK |
No joint swelling |
Discharge Labs
| Test |
Result |
| WBC |
10.5 K |
| Hgb |
8.3 g/dL |
| Plt |
473 K |
| Sodium |
137 meq/L |
| Potassium |
3.4 meq/L |
| Chloride |
104 meq/L |
| Bicarbonate |
21 meq/L |
| BUN |
26 mg/dL |
| Creatinine |
1.5 mg/dL |
Decision-Making
As you prepare discharge paperwork, you recall the lung nodule. No biopsy plan exists but PCP follow-up within 7 days is possible, and rehab offers transport. You discuss inpatient biopsy versus outpatient management; the patient prefers conservative management and defers to your recommendation.
Decision: Would you discharge the patient at this time?
