Notes

This is a 52-year-old female with a past medical history significant for hypertension, generalized anxiety disorder, and tobacco use disorder who presented from a freestanding emergency department with acute onset chest pain and markedly elevated blood pressures consistent with hypertensive emergency. The patient described the chest pain as sharp and radiating between the shoulder blades, prompting evaluation where initial troponin was found to be elevated and blood pressure significantly elevated, reportedly up to the 240s systolic. EKG demonstrated sinus rhythm with T-wave inversions diffusely but without ST elevation. CT angiography of the chest, abdomen, and pelvis showed no evidence of aortic dissection but did reveal mild atherosclerotic disease of the thoracic and abdominal aorta as well as hepatic steatosis with hepatomegaly. The patient was transferred for higher level of care and was started on heparin infusion for concern for acute coronary syndrome and placed on nitroglycerin infusion for blood pressure control and chest pain. Cardiology was consulted on admission. Troponins were trended and noted to peak and subsequently downtrend, and the patient’s chest pain resolved during hospitalization. She was continued on aspirin and statin therapy, and further evaluation including coronary CT angiography demonstrated minimal coronary artery stenosis with low calcium score, consistent with non-obstructive coronary disease. Echocardiogram demonstrated preserved ejection fraction with evidence of grade 2 diastolic dysfunction and moderate concentric left ventricular hypertrophy, consistent with long-standing hypertension.

During the hospital course, the patient’s hypertensive emergency was managed with transition from intravenous to oral antihypertensive therapy, including adjustment of her home regimen with discontinuation of clonidine and initiation of a more optimized regimen consisting of losartan, hydrochlorothiazide, amlodipine, and continuation of beta-blocker therapy. Her chest pain resolved completely, and elevated troponins were attributed to demand ischemia in the setting of severe hypertension rather than obstructive coronary disease. Nitroglycerin infusion was discontinued due to headache, and heparin infusion was stopped once acute coronary syndrome was ruled out. Tobacco cessation counseling was provided and nicotine replacement therapy was initiated. Her generalized anxiety disorder was managed with continuation of home fluoxetine. The patient remained hemodynamically stable with improved blood pressure control and no recurrence of chest pain. Cardiology cleared the patient for discharge with recommendation for close outpatient follow-up. At the time of discharge, the patient was stable, tolerating oral medications, and ambulating without difficulty. She was discharged home with instructions to follow up with primary care and cardiology, continue prescribed antihypertensive regimen, aspirin, and statin, and to pursue smoking cessation. Return precautions were discussed, and the patient verbalized understanding and agreement with the discharge plan.


Here’s a tighter, hospitalist-style condensed A/P that still keeps the clinical signal:

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Assessment & Plan

1. Acute metabolic encephalopathy likely secondary to UTI
88F with dementia presenting with increased confusion and functional decline, found to have UTI. No acute intracranial pathology on CT.
• Continue ceftriaxone → transition to PO based on clinical response/cultures
• Delirium precautions, reorientation, avoid sedating meds
• Monitor mental status for return to baseline

2. Chronic hypoxic respiratory failure / advanced COPD (no clear acute exacerbation)
Baseline 2L NC with reported increased O2 needs on ambulation; CXR without acute process, ABG without significant hypercapnia/acidosis.
• Continue baseline O2, titrate to maintain sats >88–92%
• Scheduled DuoNebs, budesonide nebs
• No steroids at this time (no clear exacerbation)
• Pulmonary consulted, no escalation needed

3. UTI (primary driver of admission)
UA positive, no signs of sepsis.
• Continue IV antibiotics, de-escalate per cultures
• Monitor for clinical improvement

4. Right arm pain s/p fall, hematoma
No fracture on imaging.
• Supportive care, analgesia
• PT/OT evaluation

5. Advanced dementia
Baseline cognitive impairment with acute worsening.
• Treat underlying causes (UTI)
• Maintain structured environment, minimize delirium triggers

6. Hypertension / chronic conditions
• Resume home medications as appropriate

7. DVT prophylaxis
• Heparin SQ

8. Goals of care / disposition
Elderly patient with advanced COPD and dementia; would benefit from ongoing goals-of-care discussion.
• Consider palliative care consult
• Anticipate discharge once mental status and infection improve (likely home with support vs rehab depending on functional status)

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If you want, I can make this even sharper into your personal “signature A/P style” (the one you use in your notes that reads fast but hits billing + clarity perfectly).