Age: 15.0
Sex: M
Vaccine: COVID19
Symptoms: Carbon dioxide normal, Central venous catheterisation, Chest X-ray normal, Condition aggravated, Dehydration
Clinical narrative: Date of Admission Admit Date: Mar-10-2022 Date of Discharge Date of discharge Mar-11-2022 Allergies No Known Allergies Chief Complaint CC: Dehydration Final diagnoses: Decreased oral intake Hypokalemia, likely secondary to poor oral intake Poor peripheral venous access Muscular dystrophy Lab Results Mar-11-2022 0500 Chemistry  GLUCOSE 87 BUN 14 CREAT 0.2 (L) MDRD GFR 639 NA 148 (H) K 3.2 (L) CL 111 (H) CALCIUM 8.9  CO2 25.6 OSMO 294.1 ANION GP 14.6 BUN/CRE 70.0 (H) MAGNESIU 2.0 Mar-11-2022 0012 Serology  COVID Pos INFLUA Neg INFLUB Neg CVD1TEST N CVDEMPHC N CVDSYMP N CVDSYMDT N CVDHOSP N  CVDICU N CVDRESID N CVDPREG N Mar-10-2022 1945 Chemistry  GLUCOSE 114 (H) BUN 18 CREAT 0.4 MDRD GFR 287 NA 146 (H) K 3.2 (L) CL 105 CALCIUM 9.7  ALK PHOS 116 CO2 25.5 AST 52 (H) ALT 78 AST/ALT 0.7 (L) TL PROT 7.7 ALBUMIN 4.4  TBILI 0.6 OSMO 293.3 ANION GP 18.7 BUN/CRE 45.0 (H) Mar-10-2022 1945 Hematology  WBC 7.7 RBC 5.04 HGB 14.3 HCT 42.4 MCV 84.1 MCH 28.4 MCHC 33.7 RDW 15.3 (H) RDWSD 47.9  PLT 174 MPV 10.8 (H) MANDIFF Y BAND % 1 (H) SEG % 71 LYMPH % 23 MONO % 3  META % 2 (H) HGB/HCT 3.0 Imaging Results Postprocedural chest x-ray shows proper positioning of the catheter, and no evidence of pneumothorax. Social History marital status  Single Vital Signs Mar-11-2022 0543  T 97.8 HR 109 (H) RR 19 BP 90 (L) / 51 O2Sat 96 1 of2 Name Withheld DOB (Withheld) (M) MRN (Withheld)  Mar-11-2022 1201 Attending Encounter  Discharge Summary  Admitted Discharged Mar-10-2022 Mar-11-2022 Date of Service Primary Withheld PHYSICAL EXAM Constitutional: Patient is lying in bed resting during my examination, calm and in no acute distress. He is pleasant and conversive. Skin: Warm and dry, normal skin turgor Eyes: Sclera anicteric, no conjunctival injection noted Neurological: Alert and oriented x4. No gross focal neurological deficits observed. Cardiovascular: Heart regular rate and rhythm, no murmurs or gallops noted. Radia pedis pulses +2/4 bilaterally. No significant peripheral edema appreciated. Respiratory: Respirations even and unlabored. Breath sounds clear to auscultation bilaterally, no wheezes, crackles, or other adventitious sounds noted. Gastrointestinal: Bowel sounds present and normoactive. Abdomen soft and nondistended, no apparent tenderness to palpation or percussion. Musculoskeletal: Bilateral extremity contractures noted, stable. Psychiatric: Answers questions appropriately and cooperative on exam. Mood and affect appropriate for age and situation. Hospital Course Patient is a 16 year old male with muscular dystrophy admitted early this morning with dehydration, poor oral intake, and poor peripheral venous access. He was resuscitated with IV fluids, and arrangements were made to place a VAP given his extremely difficult IV access and intermittent need for fluids due to poor oral intake. His procedure was performed without complication. He returned to the floor post-operatively, and allowed to recover from anesthesia. The patient reported feeling improved, and he was deemed stable to discharge home under the care of his grandmother. Additional instructions were provided, summarized below. Discharge Medications lisinopril 10 mg tab 1 TAB ORALLY ONCE A DAY multivitamin tab 1 CAP ORALLY ONCE A DAY Vitamin D3 unknown Continue taking same as home Plan Discharge Instructions: 1. Discharge to home 2. Follow up with Dr. next week to recheck lab values 3. Follow up with Dr.  4. Diet as tolerated 5. Instructions provided for port care 6.Contact Dr. problems, questions, concerns Primary Care Provider Withheld Electronically signed by Withheld on Mar-11-2022 1334