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10152086-DS-18
10,152,086
24,825,843
DS
18
2159-07-04 00:00:00
2159-07-04 17:44:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Sudden onset of headache Major Surgical or Invasive Procedure: ___ Diagnostic cerebral angiogram ___ Right EVD placement History of Present Illness: ___ y/o M with past medical history significant for ___ disease presents today for ___ after sudden onset of headache. Patient states that he has been experiencing ___ intermittent headaches since ___. He states that he was bending over to put on his boots when he felt a ___ headache in which he took advil to relieve the pain with no success. While in the ambulance, patient reported dizziness and had one episode of vomiting. He also reports photophobia, but denies any dysarthria, changes in vision, or weakness. He was transferred to ___ after a head CT revealed diffuse SAH with intraventricular extension. Past Medical History: ___ disease Social History: ___ Family History: Denies any history of brain aneurysms or vascular malformations. Physical Exam: Exam on admit ___: ___ and ___: 2 Fisher: 4 GCS E: 4 V: 5 Motor: 6 O: T:97.5 BP:148/92 HR: 49 R: 14 O2Sats98% Gen: WD/WN, comfortable, NAD. HEENT: atraumatic, normocephalic Pupils: 3-2mm bilaterally EOMs: intact Neck: mild nuchal rigidity Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: ___ objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to finger rub bilaterally. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Intact to light touch On Discharge: neurologically intact emotionally labile strength full no pronator drift pupils equal and reactive alert and oriented x 3 Pertinent Results: ___ 08:00PM BLOOD WBC-8.9 RBC-4.48* Hgb-13.3* Hct-38.6* MCV-86 MCH-29.6 MCHC-34.4 RDW-13.6 Plt ___ ___ 12:44PM BLOOD WBC-10.2 RBC-4.91 Hgb-14.2 Hct-41.9 MCV-85 MCH-28.9 MCHC-33.8 RDW-13.5 Plt ___ ___ 08:00PM BLOOD Plt ___ ___ 12:44PM BLOOD ___ PTT-26.3 ___ ___ 08:00PM BLOOD Glucose-106* UreaN-12 Creat-0.9 Na-138 K-4.7 Cl-106 HCO3-21* ___ CTA head and neck: 1. Diffuse acute subarachnoid hemorrhage with intraventricular extension. No hydrocephalus. 2. Dilation of distal intracranial left vertebral artery after left ___ ___, raising the possibility of dissection. ___ CXR Monitoring and support devices in appropriate position. Left greater than right basilar atelectasis and possible small left pleural effusion. ___ Non-contrast CT head 1. Interval placement of a ventriculostomy catheter via a right frontal burr hole. The catheter terminates at the superior aspect of the anterior body of the right lateral ventricle. 2. Unchanged appearance in distribution of extensive subarachnoid and intraventricular hemorrhages 3. The ventricles are unchanged in configuration from prior examination. 4. No acute infarct. ___ CT Head without Contrast: 1. Stable subarachnoid and intraventricular hemorrhage. No new hemorrhage. 2. Interval decrease in caliber of the lateral ventricles. 3. Unchanged position of right frontal approach ventriculostomy catheter terminating at the superior aspect of the anterior body of the right lateral ventricle. ___ CT Head without Contrast: 1. Stable subarachnoid and intraventricular hemorrhage. 2. No new focus of hemorrhage. 3. Stable ventricular size. 4. Stable right frontal approach ventriculostomy catheter. 5. Paranasal sinus disease as described. ___ CTA Head: HEAD CTA: Minimal diffuse vasospasm remains although it appears to be slightly improved compared to CTA from ___. CTA HEAD W&W/O C & RECONS ___ 1. New vasospasm of the distal left posterior communicating artery just prior to the junction with the P2 segment. 2. Fetal origin of the left PCA. 3. Unchanged appearance of left distal vertebral artery vasospasm. 4. Unchanged appearance of dependent subarachnoid hemorrhage. Interval increase extent of hemorrhage within the occipital horns of lateral ventricles, potentially from the distribution. 5. No evidence of acute infarct. 6. Additional findings described above. CXR ___: As compared to the previous radiograph, the patient has been extubated and the nasogastric tube was removed. The left subclavian line remains in situ. As expected, the lung volumes have decreased, causing areas of atelectasis at both the left and the right lung base. No pleural effusions. No pneumonia, no pulmonary edema. Head CT ___ IMPRESSION: 1. Decreasing subarachnoid and intraventricular hemorrhage. No new hemorrhage. 2. Stable enlargement of the lateral and third ventricles. Stable position of the ventriculostomy catheter. Cerebral Angiogram ___: This diagnostic cerebral angiography did not show any evidence of aneurysm, AVM, dural AV fistula or other vascular abnormalities compatible with the vasculopathy/vasculitis. We found a moderate vasospasm in the right A1 and A2 branches. The right ACA is the dominant and only ACAs in this patient which fills bilateral A2 via a patent anterior communicating artery.In comparison to previous angiography, we have a moderate ACA vasospasm. We injected 10 mg of verapamil to treat this vasospasm. The left vertebral artery is coming off directly from the aortic arch. The left PCA is the fetal-type PCAs. The previously suspected area of the left V4 segment to that dissection is well open and there is no flow limitation in the posterior circulation. The patient has remained neurologically fine. No procedure-related thromboembolic complication was seen in this patient and the patient remained neurologically stable afterwards. CTA abd/pelvia ___: 1. No evidence of retroperitoneal hematoma, active extravasation or other active bleeding. 2. Small amount of acute thrombus in the left distal external iliac and common femoral artery, likely related to sheath removal. Left Groin Ultrasound ___: No evidence of left groin pseudoaneurysm or hematoma ___ CT Head without Contrast: Slight decrease in hyperdense material in the occipital horns of the lateral ventricles since the previous study. Unchanged ventricular size. Ventricular catheter. No acute hemorrhage. Radiology Report MRA NECK W/CONTRAST Study Date of ___ 3:02 ___ IMPRESSION: No significant abnormalities on MR angiography of the neck. MRA of the head again demonstrates focal dilatation of the V4 segment of the left vertebral artery adjacent to the origin of posterior inferior cerebellar artery. No aneurysm greater than 3 mm in size seen. MR HEAD W & W/O CONTRAST ___ 1. The study is motion degraded. 2. Allowing for the limitations, there is no evidence of intra or extra-axial mass or evidence of occult vascular malformation. 3. Residual in bilateral occipital parietal predominant superficial siderosis/subarachnoid hemorrhage is noted. 4. Stable enlargement of the lateral and third ventricles. 5. No acute infarct or new hemorrhage. CT HEAD W/O CONTRAST ___ Unchanged mild ventriculomegaly following clamping of the EVD. Brief Hospital Course: Mr. ___ was transferred to ___ after a head CT revealed diffuse SAH with intraventricular extension. He was admitted to the Neurosurgery service for further management and evaluation. While in the emergency department, an external ventricular device was inserted. There were no complications. A repeat head CT revealed that the device was in good position. The patient was later taken to the angiography suite for a cerebral angiogram. The exam showed no aneurysm or vascular malformation. Mr. ___ remained intubated overnight and was transferred to the ICU for further care. He was started on Keppra for seizure prophylaxis and nimodipine for vasospasm prophylaxis. Later in the morning, Mr. ___ was extubated. On the evening of ___, Mr. ___ experienced worsening headaches. A STAT head CT was obtained and was negative. On ___, the patient remained neurologically stable. He underwent TCDs which were negative for vasopasm. On ___, the patient remained neurologically stable on examination. He was noted to be -300cc negative and he received a 500cc bolus of NS in the morning. He became increasingly negative throughout the day and was aggressively repleted to an even fluid status. He experienced severe headaches in the afternoon and underwent a STAT CTA of the brain to evaluate for vasospasm. The CTA showed minimal diffuse vasospasm, slightly improved compared to his prior CTA. TCDs were performed and were negative for vasospasm. On ___ Mr. ___ was confused, oriented only to self, but MAE while on Clonidine and a Precedex infusion. The EVD waveform was lost, so the catheter was flushed without results. A NCHCT was performed which revealed an intact EVD with slightly enlarged lateral ventricles bilaterally compared to the previous scan on ___. Upon return from CT scan the EVD waveform returned with an ICP of 12. Transcranial doppler was performed on ___ which revealed severe basilar artery vasospasm , therefore his blood pressure was maintained 140-180 to promote perfusion and he continued on Nimodipine. On ___ repeat TCD was performed which showed basilar vasospasm and mild vs hyperemia L ACA. Mr. ___ continued to be febrile at 102.4, so a CSF specimen was obtained and he continued on Cefepime and Vancomycin. His sputum culture grew staph aureus in moderate growth and prelim CSF was negative. On ___, patient had oozing from EVD site which a suture was placed. Patient continued on vanc/cefepime for staph aureus in sputum. His vanc dose was increased after a low vanc trough. TCDs were abnormal with low velocities in the R MCA and bilateral verterbral arteries, but he was unable to visualize the basilar artery. He was started on decadron 4mg Q6H for headaches. On ___, patient remained stable on exam. Na was 130 and salt tabs were started. He continued to receive boluses to keep I/Os even. TCDs performed were limited due to patient's agitation, but revealed possible vasospasm in the L ACA. On ___ he had TCDs, his neuro exam was stable, and NRI of the braion and C-spine were postponed given his agitation. On ___ a He remained stable. His EVD was raised to 15cm above the tragus. Patient complained of pain and needed pain med adjustment. His Dexamethasone was discontinued. Overnight he became confused and a CT head was done which was stable. His serum NA was 130 and salt tabs increased and started 3%. On ___ his serum NA was 129 and 3% was increased. Surveillance CSF was sent - gram stain was negative. On ___ he remained stable on exam. His sodium was 137 at 02:00 then 132 later that morning. He underwent an angiogram which showed ACA vasospasm and he recieved 10mg of verapamil. His sheath remained in post-angio incase he rwquired further intervention on ___. In the evenign he pulled out his angio sheath traumatically and pressure was held. On ___ he underwent a CTA of the abdomen and pelvis which showed no evidence of hematoma or other groin site complication. He subsequently underwent an ultrasound of his left groin to assess for pseudoaneurysm or hematoma. On ___ his 3% saline was increased to 70cc/hr, his EVD was increased to 15. On ___, the patient remained neurologically stable. He underwent a non-contrast head CT which showed a decrease in the area of hyperdensity; no acute hemorrhage was noted. A CSF culture was obtained and showed.... On ___, The patient was mobilized out of bed to the chair. The cerebral spinal fluid was clear. The external ventricular drain remained at 10 and open. Vasopressors were attempted to wean and blood pressure goals were libralized to 120-180. On ___, MRI head was performed and showed no vascular abnormailites or masses. He was transferred to the step down unit after he has been off pressors and 3% NS /x 24 hours. His EVD remained at 15. Overnight, he was triggered for agigtation and received haldol x 2. He was placed on standing haldol BID and prn IV. On ___, EVD was flushed for no drainage and began to drain appropriately. K was low ans was repleted. Na was stable at 141 and his EVD remained at 15. Overnight, his EVD was leaking from distal tubing and tubing was replaced. On ___, his EVD remains at 15 and was clamped. CSF cultures were sent for evaluation and his Na remained stable at 142. He continued to remain intact on exam with some mild agigtation. On ___, EVD remained clamped overnight. Head CT performed in the morning showed no changes in ventricular size and EVD was removed. Nimodipine and keppra were discontinued and patient was stable on examination. On ___, The patient was reevaluated by physical and occupational therapy and the patient was deemed safe for home w/ home OT and script for outpatient ___ following. The family was expressing that they would like disposition home and to come back for the angiogram on ___. The patient's serum sodium was 141 and the sodium chloride tablets were weaned to 2grams BID. The patients potassium was repleted. On the evening of ___, the patient was verbalizing her desire to go home and did not want to remain inpatient any longer. After discussion with the Neurosurgery team, he was discharged home in the care of his wife with 24 hour supervision. He was told to call Dr. ___ the morning of ___ to make arrangements for a cerebral angiogram on ___ patient will follow up with his primary care doctor within the next week to discuss the continuation of haldol, sodium chloride tablets and Fludrocortisone Acetate, all medications that were initated in the hospital. At the time of discharge, Mr. ___ was afebrile, hemodynamically and neurologically stable. Per his discharge instructions, the patient will need to not only follow up with Dr. ___ also his PCP for ongoing management of his sodium and agitation level (as he was discharged on Haldol). Medications on Admission: Protonix Discharge Medications: 1. Acetaminophen-Caff-Butalbital ___ TAB PO Q4H:PRN pain RX *butalbital-acetaminophen-caff [Fioricet] 50 mg-300 mg-40 mg ___ capsule(s) by mouth q4 Disp #*60 Capsule Refills:*0 2. Fludrocortisone Acetate 0.1 mg PO BID discuss the continued use of this with your primary care physcian RX *fludrocortisone 0.1 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 3. Haloperidol 0.5 mg PO BID discuss the continued use of this with your primary care physbcian, check EKG this week for QTC RX *haloperidol 0.5 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 4. Pantoprazole 40 mg PO Q12H 5. Senna 8.6 mg PO BID RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp #*30 Capsule Refills:*0 6. Sodium Chloride 2 gm PO BID RX *sodium chloride 1 gram 2 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*1 7. Outpatient Occupational Therapy outpatient OT 8. Outpatient Physical Therapy Discharge Disposition: Home Discharge Diagnosis: Non-aneurysmal subarachnoid hemorrhage Hyponatremia Cerebral vasospasm VAP delerium aggitation Discharge Condition: neurologically intact emotionally labile strength full no pronator drift pupils equal and reactive alert and oriented x 3 Discharge Instructions: Discharge Instructions Brain Hemorrhage without Surgery Activity You will have 24 hour supervision at home arranged by your family while you continue to recover. •We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. •You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. •No driving while taking any narcotic or sedating medication. •If you experienced a seizure while admitted, you are NOT allowed to drive by law. •No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications •Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. •***You have been discharged on Keppra (Levetiracetam). This medication helps to prevent seizures. Please continue this medication as indicated on your discharge instruction. It is important that you take this medication consistently and on time. •***You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP’s office, but please have the results faxed to ___. •You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: •You may have difficulty paying attention, concentrating, and remembering new information. •Emotional and/or behavioral difficulties are common. •Feeling more tired, restlessness, irritability, and mood swings are also common. •Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Headaches: •Headache is one of the most common symptom after a brain bleed. •Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. •Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. •There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. Followup Instructions: ___
10152086-DS-19
10,152,086
29,640,006
DS
19
2159-07-12 00:00:00
2159-07-12 10:02:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: headache Major Surgical or Invasive Procedure: ___ Diagnostic Angiogram ___ - aborted left verterbal artey pipeline embolization History of Present Illness: Mr. ___ is a ___ year old man who was admitted to ___ on ___ after experiencing a severe headache and was found to have diffuse SAH with intraventricular extension. He underwent EVD placement on ___ and an cerebral angiogram was performed which was negative for aneurysm or vascular malformation. A repeat angiogram on ___ demonstrated ACA vasospasm for which he recieved 10mg of verapamil. His EVD was removed on ___ and he was discharged to home on ___. He states that today he took a nap around noon and woke around 3:30 to 4pm with a severe headache, described as pressure behind the eyes and in his head, as well as abdominal pain, nausea, and vomiting. He took a fiorcet for this. His family brought him to the ED. Currently he states that he still has cramps in his stomach but the pain is mostly resolved. His headache is still severe however. He does not have any focal numbness or weakness or changes in vision. He and has family state that he has been sleeping poorly at home in the evenings, and has been suffering from anxiety. He also has headaches on a daily basis, treated with the fioricet. He saw his PMD two days ago, who switched him off haldol and put him on seroquel. He also has not been taking salt tabs at home. He states he did have chills and sweats last night. When asked, he does say that his neck hurts. He denies any photophobia. He has been having regular bowel movements. Past Medical History: ___ disease Social History: ___ Family History: Denies any history of brain aneurysms or vascular malformations. Physical Exam: O: T: 99.2 BP: 106/80 HR: 88 R 24 O2Sats 100% Gen: WD/WN HEENT: Pupils: 3mm to 2mm bilaterally EOMs intact Neck: Supple. Mental status: Awake and alert, cooperative with exam, anxious appearing. Orientation: Oriented to person, place, month and year, (not date). Language: Speech fluent with good comprehension. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Intact to light touch bilaterally. Coordination: normal on finger-nose-finger, rapid alternating movements Pertinent Results: ___ CT Head: Unchanged mild ventriculomegaly. No acute intracranial abnormality otherwise demonstrated. ___ Cerebral angio: 1. Focal vertebral artery dissection at the vertebral basilar junction with pseudo aneurysm formation, given the patient's recent subarachnoid hemorrhage in pattern of bleed this likely represents the source of this hemorrhage. Given the clinical history he is at a higher risk for hemorrhagic Re rupture in this will elected treat the patient with flowed over stent in the near future. ___ CT head: Stable appearance of the intracranial compartment without evidence for acute hemorrhage or other acute abnormalities. Brief Hospital Course: Patient was seen in the emregnecy deopartment and admitted to the floor for planned diagnostic angiogram. Neurologically he was at his baseline on admission and he remained stable overnight into ___. On ___ he was stable and underwent a diagnostic angiogram which showed a left vertebral artery dissection. He was given Plavix and Aspirin and planned for pipeline embolization for ___. On ___ decision was made given case volume to defer his pipeline embolization to ___. He underwent a CT scan which was stable. His neuro exam remained stable as well. On ___, the patient was scheduled to undergo pipeline embolization which was aborted due to his vascular anatomy. He was stable post operatively and remained in the ICU over night. On ___, the patient was stable on exam and there were no evnts over night. The decision was made to DC the patient to home on his 325mg aspirin with NO plavix. He was cheduled to return in 4 weeks with a CTA the morning of his appointment with Dr. ___. Medications on Admission: fludrocortisone 0.1mg bid quetiapine 50mg ___ tabs qhs prn agitation fioricet 50-300-40 ___ tabs q4h prn pain senna 1 bid Discharge Medications: 1. Acetaminophen-Caff-Butalbital ___ TAB PO Q4H:PRN headache 2. Aspirin 325 mg PO DAILY 3. Fludrocortisone Acetate 0.1 mg PO Q12H 4. QUEtiapine Fumarate 50 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: headache Left Veretebral Artery Dissection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Activity •You may gradually return to your normal activities, but we recommend you take it easy for the next ___ hours to avoid bleeding from your groin. •Heavy lifting, running, climbing, or other strenuous exercise should be avoided for ten (10) days. This is to prevent bleeding from your groin. •You make take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. •Do not go swimming or submerge yourself in water for five (5) days after your procedure. •You make take a shower. Medications •Resume your normal medications and begin new medications as directed. •You have been instructed by your doctor to take one ___ a day. Do not take any other products that have aspirin in them. If you are unsure of what products contain Aspirin, as your pharmacist or call our office. •You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. •If you take Metformin (Glucophage) you may start it again three (3) days after your procedure. Care of the Puncture Site •You will have a small bandage over the site. •Remove the bandage in 24 hours by soaking it with water and gently peeling it off. •Keep the site clean with soap and water and dry it carefully. •You may use a band-aid if you wish. What You ___ Experience: •Mild tenderness and bruising at the puncture site (groin). •Soreness in your arms from the intravenous lines. •Mild to moderate headaches that last several days to a few weeks. •Fatigue is very normal •Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. When to Call Your Doctor at ___ for: •Severe pain, swelling, redness or drainage from the puncture site. •Fever greater than 101.5 degrees Fahrenheit •Constipation •Blood in your stool or urine •Nausea and/or vomiting •Extreme sleepiness and not being able to stay awake •Severe headaches not relieved by pain relievers •Seizures •Any new problems with your vision or ability to speak •Weakness or changes in sensation in your face, arms, or leg Followup Instructions: ___
10152121-DS-21
10,152,121
24,401,913
DS
21
2185-09-11 00:00:00
2185-09-12 09:58:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: metformin / lisinopril Attending: ___. Chief Complaint: No acute events. Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is an ___ with a hx of T3N0 esophageal cancer s/p MIE c/b recurrent anastomotic stricture and stent placement ___, underwent EGD and stent removal today and developed rigors and chills several hours later. This morning ~9am Mr. ___ underwent an uncomplicated EGD and stent removal. The procedure was done under MAC anesthesia. He reports feeling totally well this morning before the procedure and was also feeling well following the procedure. He went out for lunch with his family and was feeling fine during lunch. Around 1pm he was back in his hotel room when he started having big shaking chills and felt very cold, put on extra layers of clothing and lay under the covers but was not able to warm himself up. He called Dr. ___ told him to go to the ___ ED. In the ED, initial VS were 100.0 (which has been his Tmax) 114 146/73 18 94% RA. Labs were significant for WBC 15.8 (85.7% PMNs) and a lactate of 2.8. BMP was unremarkable. CXR showed patchy opacities within the lung bases concerning for aspiration and a small right pleural effusion. Blood cultures were drawn. He received 1L NS, 1g PO acetaminophen and 4.5g IV Pip-Tazo. Transfer VS were 98.5 110 108/71 18 93% RA. Decision was made to admit to medicine for further management. On arrival to the floor, patient reports that he is feeling remarkably well. He says that his rigors and chills ceased soon after he received medication in the ED. He notes that recently he has had mild rhinorrhea, denies itchy/watery eyes. Regarding his esophageal cancer, he underwent neoadjuvant chemoXRT and surgical resection 5mo ago, he has had a productive cough and says that he coughs up "mucus" and also sometimes regurgitates a small amount of food. He says the last time he regurgitate food was 3 days ago. He says that he has no pain with swallowing, and usually has no difficulty with swallowing has occasional problems if he doesn't chew his food properly. He reports decreased appetite since his surgery 5 months ago and has lost 30lbs since his surgery. Otherwise, he reports mild chronic back pain that he has had for years, unchanged from his baseline. He has no headache, no change in cough, no shortness of breath, no chest pain or palpitations, no abdominal pain, diarrhea, nausea, vomiting, no muscle aches or joint pains, no rash, no dysuria or increased urinary frequency. Past Medical History: PAST MEDICAL HISTORY: Hypertension, type II DM, hyperlipidemia, renal insufficiency, BPH, basal and squamous cell carcinoma of the skin, gout, vitamin D insufficiency PSH: bilateral inguinal hernia repair Social History: ___ Family History: Father died of unknown malignancy Physical Exam: Admission exam VS - Tc 98.4, 111/54, 105, 20, 97RA GENERAL: Elderly appearing man lying in med in NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, mildly dry mucus membranes NECK: nontender supple neck, no LAD, CARDIAC: RRR, S1/S2, ?systolic murmur LUNG: Good air movement. Crackles in lung bases bilaterally. Breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose PULSES: DP pulses intact bilaterally NEURO: Grossly intact SKIN: warm and well perfused, no excoriations or lesions, no rashes Discharge exam VS - Tc 97.9 HR 87-105 BP 104/60 RR 20 02sat 95% on RA GENERAL: Elderly appearing man lying in med in NAD HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva, mildly dry mucus membranes NECK: nontender supple neck, no LAD, CARDIAC: RRR, systolic murmur LUNG: Good air movement. Faint crackles in lung bases bilaterally. Breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no ___ edema, moving all 4 extremities with purpose PULSES: DP pulses intact bilaterally NEURO: Grossly intact SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: Admission labs ___ 04:39PM BLOOD WBC-15.8* RBC-4.94# Hgb-13.8# Hct-43.5# MCV-88# MCH-27.9 MCHC-31.7* RDW-17.9* RDWSD-57.0* Plt ___ ___ 04:39PM BLOOD Neuts-85.7* Lymphs-7.1* Monos-6.3 Eos-0.3* Baso-0.3 Im ___ AbsNeut-13.56* AbsLymp-1.12* AbsMono-1.00* AbsEos-0.05 AbsBaso-0.04 ___ 04:39PM BLOOD Glucose-168* UreaN-16 Creat-1.0 Na-141 K-4.5 Cl-103 HCO3-26 AnGap-17 ___ 04:47PM BLOOD Lactate-2.8* Imaging CXR ___ Patchy opacities within the lung bases concerning for aspiration and a small right pleural effusion. Micro Blood and urine cultures no growth to date Discharge labs ___ 06:30AM BLOOD WBC-15.6* RBC-3.95* Hgb-11.1* Hct-35.2* MCV-89 MCH-28.1 MCHC-31.5* RDW-16.8* RDWSD-54.4* Plt ___ ___ 06:30AM BLOOD Glucose-108* UreaN-14 Creat-1.0 Na-140 K-3.4 Cl-104 HCO3-29 AnGap-10 ___ 06:30AM BLOOD Calcium-8.9 Phos-3.0 Mg-1.6 ___ 10:21AM BLOOD Lactate-1.5 Brief Hospital Course: Summary ___ with a hx of T3N0 esophageal cancer s/p surgical resection complicated by recurrent anastomotic stricture and stent placement ___, underwent EGD and stent removal the day of admission (___) and developed rigors and chills several hours later. Acute issues # Rigors and chills # Aspiration pneumonitis The patient went to the ___ ED where his max temperature was ___. He got 1 dose of 4.5g IV zosyn, 1g Tylenol and some IV fluids. He got a chest x-ray that showed bibasilar patchy opacities, stable from prior imaging. His rigors and chills resolved while he was in the ED. He was admitted to the medicine floor for observation. He remained afebrile and had no focal signs of infection and was well appearing, although his white count remained elevated at 15.6. His presentation was most consistent with aspiration pneumonitis in the setting of MAC sedation for his stent removal. He was well appearing, afebrile, euvolemic and discharged home after 24h observation without additional antibiotics. Chronic issues #Esophageal stricture s/p stent removal ___. Pt has no pain, no dysphagia or odynophagia at present, low concern for perforation. Will follow with Dr. ___ as outpatient. # T2DM: Last A1C 7.3%. Recently stopped insulin due to well controlled sugars. - Put on HISS while in house # HTN: currently well controlled - SBPs were 110s during this admission. His amlodipine was stopped (was taking 2.5mg daily); his atenolol was reduced by 50% (was taking 50mg qHS, reduced to 25mg qHS). The atenolol can be further tapered as outpatient if he remains normotensive. TRANSITIONAL ISSUES: - Pt is s/p stent removal. Has had recurrent structuring of esophagus. Monitor for signs of stricture. - should continue on 30mg lazoprazole BID s/p EGD and stent removal to prevent stomach acid irritation. - Patient had been taking furosemide 20mg daily, which was started due to post-operative ankle edema. Given no edema here, this medication was stopped. - SBPs were 110s during this admission. His amlodipine was stopped (was taking 2.5mg daily); his atenolol was reduced by 50% (was taking 50mg qHS, reduced to 25mg qHS). The atenolol can be further tapered as outpatient if he remains normotensive. CODE: Full (confirmed) COMMUNICATION: Patient EMERGENCY CONTACT HCP: ___ (wife) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 2.5 mg PO DAILY 2. Atenolol 50 mg PO QHS 3. Atorvastatin 10 mg PO QPM 4. GlipiZIDE XL 2.5 mg PO DAILY 5. Furosemide 20 mg PO DAILY 6. lansoprazole 30 mg oral BID Discharge Medications: 1. Atorvastatin 10 mg PO QPM 2. GlipiZIDE XL 2.5 mg PO DAILY 3. lansoprazole 30 mg oral BID 4. Atenolol 25 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: Primary: Aspiration pneumonitis Secondary: Esophageal stricture and cancer, HTN, T2DM Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were recently admitted to the ___. Why were you admitted to the hospital? - You were admitted to the hospital because you developed shaking and chills after your outpatient EGD and stent removal. - We think that you developed rigors and chills because you aspirated some stomach acid into your lungs. What was done in the hospital? - You were given 1 dose of antibiotics, some IV fluids, and some Tylenol. - You were monitored and did not show any signs of infection. What should you do when you leave the hospital? - You should continue taking all your medications as prescribed - You should follow up with your primary care physical within a week after discharge - You should seek medical attention if you develop rigors/chills or fevers It was a pleasure taking care of you in the hospital. We wish you the best of health. Sincerely, Your ___ Team Followup Instructions: ___
10152275-DS-8
10,152,275
27,295,862
DS
8
2172-02-03 00:00:00
2172-02-03 16:38:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: nausea/vomitting, headache Major Surgical or Invasive Procedure: ___ left craniotomy for tumor resection History of Present Illness: ___ discharged from ___ ED yesterday with newly-diagnosed left vertex meningioma, now re-presents for increased nausea and vomitting. As outlined in Neurosurgery consult note dated ___, the patient reports 1 month history of nausea and anorexia, and 5 day history of severe headaches, L>R extremity weakness, and gait difficulty. CT-head 4 days ago demonstrated 3.9 x 2.6 x 2.2 extra-axial homogeneously enhancing mass in the left vertex, likely a meningioma. She was seen by neurosurgery in the ED on ___ and, given absence of hemorrhage, mass effect, or hydrocephalus, she was advised to follow-up with Dr. ___ in 1 week with out-patient MRI. The patient re-presented on ___, 8 hours after prior ED discharge, with nausea, emesis x4, and inability to tolerate POs overnight. She also reports worsening of headache, worst over left temple ("like 4 machetes and 10,000 pounds on my head"). Subjective chills but did not take her temperature. No bowel or bladder changes; of note, patient was told earlier this week based on CT scan that she had either a kidney infection or kidney stone and received ciprofloxacin for several days, but no urinary symptoms or renal colic. No visual field cuts or double-vision, but reports intermittent "dark spots" for several weeks. Past Medical History: HTN, asthma Social History: ___ Family History: Colon cancer in father. Physical Exam: PHYSICAL EXAMINATION UPON ADMISSION: 97.4 67 110/59 18 96%RA Uncomfortable-appearing female Respirations non-labored A&Ox3, comprehension intact, speech fluent, no dysarthria Face symettric, no droop tongue midline PERRL (4-->2 bilaterally), +EOMI, no visual field cuts No pronator drift RUE and RLE: ___ strength throughout LUE: ___ grip/B/T/D LLE: ___ ___ ___ IP Sensation intact to light touch all 4 extremities PHYSICAL EXAM ON DISCHARGE: AVSS A&Ox3, comprehension intact, speech fluent, no dysarthria Face symettric, no droop tongue midline PERRL (4-->2 bilaterally), +EOMI, no visual field cuts No pronator drift Motor exam: right upper ext tri/grip ___ otherwise full strength, right IP ___, Q 5-, H 5, AT 4, ___ 5-, ___ on left upper and lower extremities. Incision: clean, dry, intact with sutures in place. No erythema, drainage Pertinent Results: ___ 11:15PM NEUTS-65.9 ___ MONOS-6.0 EOS-1.3 BASOS-1.0 ___ 11:15PM PLT COUNT-304 ___ 11:15PM GLUCOSE-108* UREA N-15 CREAT-0.5 SODIUM-138 POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-26 ANION GAP-14 CT head with contrast ___, 12:30am): Within the left vertex, there is a well-circumscribed ovoid homogenously enhancing mass which abuts the falciform ligament and measures 3.9 x 2.6 x 2.2 (AP x TV x CC). There is local mass effect on the adjacent brain parenchyma, with minimal surrounding edema. There is 3mm of rightward shift of normally midline structures. Most consistent with meningioma. CT head without contrast ___, 12:30pm): Stable mass. Stable surrounding edema. Stable 3mm MLS. No evidence of herniation. MRI Brain ___: IMPRESSION: Avidly enhancing 4.6 cm left frontal vertex mass adjacent to the falx abutting the superior sagittal sinus without evidence of obstruction. A few flow voids are identified within this mass lesion. Findings are suggestive of a meningioma; a hemangiopericytoma can have a similar appearance. ___ CXR Heart size is top normal. Mediastinum is grossly unremarkable. Lungs are essentially clear except for right basal opacity which unclear if represents a true lesion or summation of shadows. Repeated radiograph preferably with full inspiration is required. If finding is persistent, assessment with chest CT would be necessary. ___ ECG Sinus rhythm. Normal tracing. Compared to the previous tracing of ___ no significant change. Intervals Axes Rate PR QRS QT/QTc P QRS T 60 150 82 ___ 11 ___ MRI HEAD IMPRESSION: Lobulated intensely enhancing left frontoparietal mass again identified. The examination was performed for surgical planning. There is no significant change in size and appearance of the brain otherwise compared to the previous MRI. ___ NON CONTRAST HEAD IMPRESSION: 1. Expected postoperative changes status post resection of left vertex mass, with persistent 3 mm rightward shift of normally midline structures, not signifiantly changed since preoperative CT from ___. There is no evidence of herniation or obstruction. ___ NON CONTRAST HEAD CT IMPRESSION: 1. No significant interval change following craniotomy and resection of left vertex meningioma. There is no evidence of large vascular territory infarction. There is a more conspicuous hypodensity in the left vertex which is extra-axial and likely represents a postoperative fluid collection. If high clinical concern for acute stroke recommend MRI. 2. No new areas of hemorrhage. No change in minimal shift of midline structures to the right. Similar degree of pneumocephalus compared to yesterday's CT. ___ MRI W/WO CONTRAST IMPRESSION: Status post left vertex meningioma resection with expected post-surgical changes. There are small amount of blood products in the surgical bed and a small focus of slow diffusion in the subcortical white matter of the left frontal lobe, but close attention in this area in the followup examinations is advised. There is no evidence of abnormal enhancement to suggest residual mass lesion. Unchanged minimal shifting of midline towards the right, residual pneumocephalus identified in the frontal regions. Brief Hospital Course: The patient presented to the ___ ED on ___ as noted in HPI. She was admitted to the Neurosurgery service for pain control and inability to take PO at home. ___, she required oxycodone and fioricet for headache control. She was nauseated with no vomiting, and took light PO. MRI was performed showing a large mass consistent with a meningioma. On ___, Mrs. ___ underwent a MRI wand study in preparation for her meningioma resection with Dr. ___ on the same day. Post operatively the patient was extubated in the operating room and tranferred to the ICU for observation. on ___ patient was experiencing a lot of nausea and discomfort and remained in the intesive care unit for further observation. Repeat head CT was stable. Post operative MRI showed no residual tumor or stroke. On ___ the patient was stable and more awake. She continued to have right upper and lower extremity weakness, however improved strength. On ___ she worked with ___ who recommended rehab. The patient was discharged to rehab in stable condition. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing 2. Lisinopril 10 mg PO DAILY 3. Omeprazole 20 mg PO DAILY 4. Acetaminophen-Caff-Butalbital ___ TAB PO Q4H:PRN headache 5. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN headache 6. Diazepam 5 mg PO Q8H:PRN headache Discharge Medications: 1. Acetaminophen-Caff-Butalbital ___ TAB PO Q4H:PRN headache 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing 3. Omeprazole 20 mg PO DAILY 4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN headache RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp #*40 Tablet Refills:*0 5. Acetaminophen 325 mg PO Q6H:PRN pain 6. Dexamethasone 3 mg PO Q6H Duration: 6 Doses 7. Dexamethasone 2 mg PO Q6H Duration: 8 Doses 8. Dexamethasone 2 mg PO Q12H Duration: 2 Doses 9. Dexamethasone 2 mg PO DAILY Duration: 1 Dose 10. Docusate Sodium 100 mg PO BID 11. Senna 1 TAB PO BID 12. Diazepam 5 mg PO Q8H:PRN headache 13. Lisinopril 10 mg PO DAILY 14. Polyethylene Glycol 17 g PO DAILY 15. LeVETiracetam 500 mg PO BID 16. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 17. Famotidine 20 mg PO Q12H Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Intercranial Meningioma Cerebral Edema Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, You were recently admitted to the Neurosurgery Service at ___ following your Craniotomy for Tumor Excision by Dr. ___ ___. Please find discharge instructions below: •Have a friend/family member check your incision daily for signs of infection. •Take your pain medicine as prescribed. •Exercise should be limited to walking; no lifting, straining, or excessive bending. •Your wound was closed with non-dissolvable sutures then you must wait until after they are removed to wash your hair. You may shower before this time using a shower cap to cover your head. •Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) & Senna while taking narcotic pain medication. •Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. •You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. •If you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. •Clearance to drive and return to work will be addressed at your post-operative office visit. •Make sure to continue to use your incentive spirometer while at home. Followup Instructions: ___
10152346-DS-20
10,152,346
24,720,735
DS
20
2128-07-12 00:00:00
2128-07-12 15:01:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: pravastatin Attending: ___ Chief Complaint: Nausea, vomiting Major Surgical or Invasive Procedure: Thoracentesis, right ___ Thoracentesis, left ___ History of Present Illness: ___ year old man with a history of HTN, CKD and new diagnosis of cirrhosis (undergoing work up for etiology) presenting to the ED with vomiting and tachycardia. Patient reports for the past two nights he has been having difficulty tolerating PO intake and having significant vomiting and nausea. He has been unable to take his medications. The patient had a paracentesis on ___ and had 2L removed. The day of his para he had loose bowel movements. These resolved. He did well after the procedure but he did note feeling dehydrated and his son notes that his oral intake has been limited. His grand daughter at home has been sick with a viral illness (no nausea or vomiting). In the ED, initial vital signs were: 98.2 135 (HR ___ (132-177/72-110) 22 100% RA. He denied any abdominal pain, change in bowel habits or diarrhea (apart from one episode earlier in the week). No fevers, chills chest pain or SOB. On arrival to the ED the patient was tachycardic and hypertensive, thought to be to because the patient could not take his oral medications because of his nausea and vomiting. He was treated with IV metoprolol in the ED and his symptoms improved. He also had an episode of desaturation to the mid ___ on tele. His CXR showed bilateral pleural effusions, with no evidence of PNA, no concurrent cough, fever or chills. - Labs were notable for: 12.9 15.1>--< 455 39.7 N:80.5 L:11.2 M:7.1 E:0.3 Bas:0.2 ___: 0.7 141 91 26 -------------< 119 3.1 36 1.9 Ca: 9.3 Mg: 2.0 P: 4.3 ALT: 8 AP: 49 Tbili: 0.8 Alb: 3.8 AST: 16 Lip: 68 Lactate:1.9 ___: 13.7 INR: 1.3 UA positive for small bili, negative leuks, neg blood, neg nitrites, 100 protein, neg glucose 10 ketone, 5 RBC, 3WBC, few bacteria 10 casts - Studies performed include: CXR: Low lung volumes. New left moderate left pleural effusion and left lower lobe atelectasis or consolidation. New small right pleural effusion. - Patient was given: ___ 10:17 IV Ondansetron 4 mg ___ ___ 10:17 IV Metoprolol Tartrate 5 mg ___ ___ 13:01 PO Potassium Chloride 40 mEq ___ ___ 14:01 IV Lorazepam .5 mg ___ ___ 14:45 PO/NG amLODIPine 10 mg ___ ___ 15:24 PO Metoprolol Succinate XL 200 mg ___ ___ 15:31 IV Lorazepam .5 mg ___ Patient was monitored in the ED and he was having difficulty tolerating PO and able to take his pills slowly. He was felt to be unsafe to discharge and decision was made to ___ for further evaluation. - Vitals on transfer: 98.4 106 152/83 24 97% Nasal Cannula Upon arrival to the floor, the patient reports feeling better. States he is hungry but does not want to push himself. He is on oxygen but denies any chest pain or shortness of breath. Denies any abdominal pain or discomfort. No fevers or chills. Review of Systems: (+) per HPI, 10 point review of system otherwise negative Past Medical History: ANXIETY BACK PAIN CENTRAL RETINAL VEIN OCCLUSION ___ (right) CHRONIC KIDNEY DISEASE HYPERALDOSTERONISM -- probable secondary htn, ___ hx nephrology eval, venous sampling of adrenals HYPERCHOLESTEROLEMIA HYPERTENSION LEFT EVENTRATION DIAPHRAGM CIRRHOSIS-- work up on going Social History: ___ Family History: Father had lung cancer. Mother died of an MI at age ___. Son with leukemia There is no family history of liver disease, heart disease, cancer or diabetes Physical Exam: ADMISSION: Vitals- 98.7 142 / 80 Sitting 117 18 90 Ra GENERAL: AOx3, NAD, comfortable, sitting in chair HEENT: Normocephalic, atraumatic. anicteric sclera, dry lips CARDIAC: Regular rhythm, normal rate, no murmurs LUNGS: Clear to auscultation bilaterally w/appropriate breath sounds appreciated in all fields. No wheezes, no crackles ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. EXTREMITIES: No clubbing, or edema SKIN: no rash NEUROLOGIC: grossly normal strength and sensation in upper and lower extremities. DISCHARGE: 98.0 131 / 79 71 16 94 RA GENERAL: AOx3, NAD, comfortable, sitting in chair HEENT: Normocephalic, atraumatic. anicteric sclera, dry lips CARDIAC: Regular rhythm, normal rate, no murmurs LUNGS: Decreased bibasilar breath sounds. No wheezes, no crackles ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. EXTREMITIES: No clubbing, or edema SKIN: no rash NEUROLOGIC: grossly normal strength and sensation in upper and lower extremities. Pertinent Results: ====================== ADMISSION LABS ====================== ___ 10:04AM BLOOD WBC-15.1*# RBC-4.93 Hgb-12.9* Hct-39.7* MCV-81* MCH-26.2 MCHC-32.5 RDW-14.1 RDWSD-41.0 Plt ___ ___ 10:04AM BLOOD Neuts-80.5* Lymphs-11.2* Monos-7.1 Eos-0.3* Baso-0.2 Im ___ AbsNeut-12.18* AbsLymp-1.70 AbsMono-1.08* AbsEos-0.05 AbsBaso-0.03 ___ 10:04AM BLOOD Plt ___ ___ 04:53PM BLOOD ___ ___ 10:04AM BLOOD Glucose-119* UreaN-26* Creat-1.9* Na-141 K-3.1* Cl-91* HCO3-36* AnGap-17 ___ 10:04AM BLOOD ALT-8 AST-16 AlkPhos-49 TotBili-0.8 ___ 10:04AM BLOOD Albumin-3.8 Calcium-9.3 Phos-4.3 Mg-2.0 ___ 12:00PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 12:00PM URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-NEG Ketone-10 Bilirub-SM Urobiln-4* pH-6.0 Leuks-NEG ___ 12:00PM URINE RBC-5* WBC-3 Bacteri-FEW Yeast-NONE Epi-0 ___ 12:00PM URINE CastHy-10* ====================== DISCHARGE LABS ====================== ___ 04:31AM BLOOD WBC-10.3* RBC-4.09* Hgb-10.3* Hct-32.8* MCV-80* MCH-25.2* MCHC-31.4* RDW-14.1 RDWSD-41.1 Plt ___ ___ 04:31AM BLOOD Plt ___ ___ 04:31AM BLOOD ___ PTT-26.2 ___ ___ 04:31AM BLOOD Glucose-127* UreaN-20 Creat-1.4* Na-136 K-3.4 Cl-93* HCO3-33* AnGap-13 ___ 04:31AM BLOOD ALT-<5 AST-8 AlkPhos-33* TotBili-0.4 ___ 04:31AM BLOOD Calcium-8.7 Phos-2.8 Mg-2.1 ======================= KEY INTERIM STUDIES ======================= ___ 01:56PM PLEURAL ___ RBC-___* Polys-80* Lymphs-0 ___ Meso-3* Macro-17* ___ 02:14PM PLEURAL TNC-3146* ___ Polys-3* Lymphs-47* ___ Meso-3* Macro-44* Other-3* ___ 01:56PM PLEURAL TotProt-4.4 Glucose-125 LD(___)-287 Albumin-2.8 Cholest-70 ___ 02:14PM PLEURAL TotProt-4.1 Glucose-139 LD(LDH)-194 Albumin-2.5 ====================== IMAGING ====================== CXR ___: Improved multifocal pneumonia. Decrease in bilateral pleural effusions. No evident pneumothorax CT Chest ___: Multifocal infection as described primarily involving left lung Bilateral pleural effusion, Atelectasis of the left lower lobe, Anemia, Coronary calcifications, No definitive evidence of intrathoracic neoplasm but assessment is limited giving the lack of IV contrast, Ascites, Liver hypodensity partially characterized and mesenteric stranding Echo ___: The left atrium is mildly dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with normal free wall contractility. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. ======================= MICROBIOLOGY ======================= No growth to date on any cultures ___ PLEURAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-PRELIMINARY; ANAEROBIC CULTURE-PRELIMINARY INPATIENT ___ MRSA SCREEN MRSA SCREEN-PENDING INPATIENT ___ URINE Legionella Urinary Antigen -FINAL INPATIENT ___ PLEURAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL; ANAEROBIC CULTURE-PRELIMINARY INPATIENT ___ URINE URINE CULTURE-FINAL EMERGENCY WARD ___ BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY WARD Brief Hospital Course: SUMMARY: ___ h/o HTN, CKD and new diagnosis of cirrhosis who presented initially with nausea and vomiting. This was thought to be a viral gastroenteritis. He was subsequently hypoxic and found to have bilateral pleural effusions, with bilateral thoracenteses performed showing exudative effusions. A CT scan showed multifocal pneumonia which was treated with vancomycin/ceftriaxone/azithromycin that was transitioned to levofloxacin on discharge. # Pneumonia #Pleural effusion L>R: Patient presented with pleural effusions and hypoxia. Subsequent CT chest showed multifocal infection with primarily L lung involvement; echo without interval change from prior to suggest prior cause. Patient underwent L and R thoracentesis for bilateral pleural effusions with pleural fluid analysis showing exudative effusions consistent with uncomplicated parapneumonic effusion. He was treated with vancomycin/ceftriaxone/azithromycin starting on ___ for a planned 7-day course, transitioning to levofloxacin on discharge. MRSA swab was pending at time of discharge. He also received two days of IV furosemide for diuresis before transitioning to his home furosemide 60mg PO and spironolactone 250mg daily. #Cirrhosis: Recently diagnosed, MELD 16, decompensated with ascites s/p paracentesis on ___. No evidence of further ascites during this admission. Etiology unclear but likely NASH given no history of significant alcohol use, negative ___ serologies. MRI negative for HCC. EGD was performed this admission with esophagitis but no evidence of varices. - Ascites: On PO furosemide/spironolactone 60mg/250mg. - Varices: s/p screening EGD on ___ with no varices. - HE: No evidence of HE currently #Acute on chronic kidney disease- patient has baseline CKD (baseline Cr 1.3-1.6), with acute worsening to 1.9 likely from poor PO intake on admission. Responded to albumin with improvement to 1.6 and stable through diuresis. #Nausea/Vomiting #Hypochloremic metabolic alkalosis: Unclear trigger though likely viral GI illness with sick contact in granddaughter. This resolved on its own and patient was advanced to regular diet. CHRONIC ISSUES: #Hypertension: Has history of hyperaldosteronism. Medications were initially held in setting ___ and possible infection, by time of discharge all medications had been restarted. #Depression: Continued citalopram. TRANSITIONAL ISSUES: - Pleural fluid cytology pending at time of discharge - Patient should complete a 7-day course of levofloxacin (last day ___. MRSA swab still pending at time of discharge but given negative for >24 hours, likely negative. If patient worsens consider therapy with MRSA coverage. - EGD done on ___ showing no varices - Discharged on home antihypertensive regimen which include furosemide 60mg and spironolactone 250mg daily - Consider chronic potassium repletion given need for daily K repletion during this hospital stay, complicated by hyperaldosteronism - Plan for hepatology follow up with Dr. ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Calcitriol 0.25 mcg PO DAILY 3. Citalopram 10 mg PO DAILY 4. Furosemide 60 mg PO DAILY 5. HydrALAZINE 25 mg PO BID 6. Metoprolol Succinate XL 200 mg PO BID 7. Spironolactone 250 mg PO DAILY 8. Omeprazole 20 mg PO DAILY Discharge Medications: 1. Levofloxacin 500 mg PO Q48H RX *levofloxacin 500 mg 1 tablet(s) by mouth every 48 hours Disp #*2 Tablet Refills:*0 2. amLODIPine 10 mg PO DAILY 3. Calcitriol 0.25 mcg PO DAILY 4. Citalopram 10 mg PO DAILY 5. Furosemide 60 mg PO DAILY 6. HydrALAZINE 25 mg PO BID 7. Metoprolol Succinate XL 200 mg PO BID 8. Omeprazole 20 mg PO DAILY 9. Spironolactone 250 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: Multifocal pneumonia Pleural effusions Cirrhosis Acute kidney injury SECONDARY DIAGNOSIS: Hyperaldosteronism Hypertension Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You came to ___ with nausea and vomiting. This was thought to be a viral illness. You had an endoscopy that did not show any source of bleeding. We found that you had a pneumonia, an infection of the lungs, as well as pleural effusions. You had procedures done to drain these fluid and were given antibiotics. There are still some laboratory studies that are pending, so please follow this up with your outpatient doctors. Please continue to take antibiotics at home as prescribed. You will have a visiting nurse to ensure that your oxygen level at home continues to be normal. See below. Please also follow up with your hepatologist Dr. ___ your primary care doctor. We wish you all the ___! - your ___ care team Followup Instructions: ___
10152346-DS-21
10,152,346
28,245,979
DS
21
2128-07-25 00:00:00
2128-07-25 15:24:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: pravastatin / pravastatin Attending: ___. Chief Complaint: Vomiting Major Surgical or Invasive Procedure: ___ Diagnostic paracentesis History of Present Illness: Mr. ___ is a ___ yo M with hypertension, CKD and recent diagnosis of cirrhosis (Childs A, etiology unknown) who presented to the ED on ___ with nausea and vomiting. Of note, the patient was recently admitted from ___ to ___ with nausea/vomiting thought to be viral gastroenteritis. He was subsequently hypoxic and found to have bilateral pleural effusions, with bilateral thoracenteses performed showing exudative effusions. A CT scan showed multifocal pneumonia which was treated with vancomycin/ceftriaxone/azithromycin that was transitioned to levofloxacin on discharge (last day ___. In the ED, initial vitals were: 96.2 94 158/79 24 96% RA Labs were notable for: WBC 17.9, H/H 11.7/37.1, platelets 607, BUN 42, Cr 2.2, Trop < .01 Imaging was notable for: CXR: "Upper lobe pneumonia resolved since ___. Small to moderate left pleural effusion and left lower lobe atelectasis, less likely pneumonia, unchanged since ___ Hepatology was consulted and recommended: Admission for infectious work up Patient was given: IV ondansetron 4 mg x2, IV pantoprazole 80 mg x1, PO amlodipine 10 mg, PO Calcitriol .25 mcg, PO metoprolol succinate mx 100 mg, PO spironolactone 250 mg x1, PO furosemide 60 mg x1 Diagnostic paracentesis was attempted but no pocket was found so it was differed. Transfer vitals were: 97.9 76 121/64 16 93% Nasal Cannula Upon arrival to the floor, patient reported that he was feeling ok. He noted the night prior to his admission, after taking his metoprolol and hydralazine, he became nauseous and had 2 small episodes of vomiting liquid brown material. Upon arrival to the emergency room he had a larger episode of vomiting also with liquid brown material. The patient's son reports no coffee grounds or frank blood in the emesis. He felt better since then. He did have mild nausea this morning with administration of his medications again, but did not have emesis. Before these episodes of vomiting the patient was eating small amounts, but does endorse recent decrease in appetite and weight loss. He has declined a screening colonoscopy before (concern over renal function with the prep). He denies any sick contacts. He denies any blood in his stool (his son states a guaiac in the ED was positive) or urine. He denies fevers, headache, chills, sore throat, cough, rhinorrhea, congestion, abdominal pain, shortness of breath, chest pain, diarrhea, or constipation. No orthopnea or PND. No dysuria. No swelling of the legs. ROS as above. Past Medical History: ANXIETY CENTRAL RETINAL VEIN OCCLUSION ___ (right) CHRONIC KIDNEY DISEASE HYPERALDOSTERONISM -- probable secondary htn, ___ hx nephrology eval, venous sampling of adrenals HYPERCHOLESTEROLEMIA HYPERTENSION LEFT EVENTRATION DIAPHRAGM CIRRHOSIS-- work up on going Social History: ___ Family History: Father had lung cancer. Mother died of an MI at age ___. Son with leukemia There is no family history of liver disease, heart disease, cancer or diabetes Physical Exam: ADMISSION PHYSICAL EXAM: ============================ VS: 98.0, 133/75, 73, 18 1.5L NC Weight: (admit wt:142 kg) GENERAL: Pleasant, well-appearing, in no apparent distress. HEENT: normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear, dry MM. NECK: Supple, no LAD, no thyromegaly, JVP flat. HEART: RRR, normal S1/S2, no murmurs rubs or gallops. LUNGS: Clear to auscultation bilaterally, without wheezes or rhonchi. ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, mass palpated in upper left quadrant. EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or edema. SKIN: Without rash. NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation, with strength ___ throughout. DISCHARGE PHYSICAL EXAM: VS: 97.3, 134/84, 84, 16 95%RA Weight: (admit wt:142 kg) GENERAL: Pleasant, well-appearing, in no apparent distress. HEENT: normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear, dry MM. NECK: Supple, no LAD, no thyromegaly, JVP flat. HEART: RRR, normal S1/S2, no murmurs rubs or gallops. LUNGS: Clear to auscultation bilaterally, without wheezes or rhonchi. Decreased breath sounds at bases. ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, mass palpated in upper left quadrant. EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or edema. SKIN: Without rash. NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation, with strength ___ throughout. Pertinent Results: ADMISSION LABS: ___ 01:20AM BLOOD WBC-17.9* RBC-4.69 Hgb-11.7* Hct-37.1* MCV-79* MCH-24.9* MCHC-31.5* RDW-15.5 RDWSD-43.9 Plt ___ ___ 01:20AM BLOOD Neuts-86.1* Lymphs-7.5* Monos-5.3 Eos-0.1* Baso-0.3 Im ___ AbsNeut-15.44*# AbsLymp-1.35 AbsMono-0.95* AbsEos-0.02* AbsBaso-0.05 ___ 01:20AM BLOOD ___ PTT-26.3 ___ ___ 01:20AM BLOOD Plt ___ ___ 01:20AM BLOOD Glucose-154* UreaN-42* Creat-2.2* Na-138 K-4.1 Cl-91* HCO3-24 AnGap-27* ___ 01:20AM BLOOD ALT-23 AST-28 AlkPhos-49 TotBili-0.8 ___ 01:20AM BLOOD Albumin-4.1 Calcium-9.7 Phos-4.1 Mg-2.3 DISCHARGE LABS: ___ 05:08AM BLOOD WBC-14.2* RBC-4.42* Hgb-11.0* Hct-35.1* MCV-79* MCH-24.9* MCHC-31.3* RDW-15.2 RDWSD-43.5 Plt ___ ___ 05:08AM BLOOD ___ PTT-25.6 ___ ___ 05:08AM BLOOD Plt ___ ___ 05:08AM BLOOD Glucose-104* UreaN-39* Creat-1.6* Na-137 K-3.7 Cl-91* HCO3-31 AnGap-19 ___ 05:08AM BLOOD ALT-14 AST-15 AlkPhos-31* TotBili-1.1 ___ 05:08AM BLOOD Albumin-5.0 Calcium-10.3 Phos-3.6 Mg-2.1 MICROBIOLOGY: ___ Urine culture - pending ___ Blood cultures - pending ___ Peritoneal fluid - pending IMAGING STUDIES: ___ CXR FINDINGS: Small to moderate left pleural effusion and left basal consolidation are persistent since ___. Severe elevation of the left hemidiaphragm has been present since at least ___. There is no pneumothorax. Previous left upper lobe consolidation has resolved. No new or residual focus of consolidation is seen. The cardiac and mediastinal silhouettes are stable. IMPRESSION: Upper lobe pneumonia resolved since ___. Small to moderate left pleural effusion and left lower lobe atelectasis, less likely pneumonia, unchanged since ___. Chronic elevation and presumed dysfunction of the left hemidiaphragm may contribute to both chronic atelectasis and persistent left pleural effusion. ___ Abdominal US FINDINGS: LIVER: The hepatic parenchyma appears coarsened. The contour of the liver is nodular, consistent with cirrhosis. There is a lobulated hyperechoic 2.6 x 1.9 x 2.6 cm lesion in the left lobe of the liver, stable from prior. An anechoic lesion in the right lobe of the liver measuring up to 1.9 cm likely represents a simple cyst. The main portal vein is patent with hepatopetal flow. There is perihepatic ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 7 mm. GALLBLADDER: Cholelithiasis without gallbladder wall thickening. PANCREAS: The pancreas is not well visualized, largely obscured by overlying bowel gas. SPLEEN: Normal echogenicity, measuring 12.2 cm. There is perisplenic ascites. KIDNEYS: The right kidney measures 8.3 cm. The left kidney measures 9.9 cm. Normal cortical echogenicity and corticomedullary differentiation is seen bilaterally. There is no evidence of masses, stones, or hydronephrosis in the kidneys. Bladder is moderately well distended and unremarkable. RETROPERITONEUM: The aorta is not well visualized. Left and right pleural effusions are noted. IMPRESSION: 1. Cirrhosis with ascites. Patent main portal vein with hepatopetal flow. 2. Hyperechoic focus in the left lobe of the liver is seen on prior ultrasound from ___ and was not fully characterized on prior limited MRI. Consider nonurgent multiphasic CT as previously recommended. 3. Cholelithiasis without evidence of cholecystitis. 4. No hydronephrosis. 5. No splenomegaly. 6. Right and left pleural effusions noted. Brief Hospital Course: Mr. ___ is a ___ yo M with hypertension, CKD and recent diagnosis of cirrhosis (Childs A, unknown etiology) who presented to the ED on ___ with nausea and vomiting with leukocytosis likely secondary to a viral gastritis. ACUTE MEDICAL PROBLEMS: #Leukocytosis; The patient had a WBC of 17 on admission. Het was recently admitted and treated for multifocal pneumonia, but this cleared by CXR, except two pleural effusions that were tapped on the prior admission and found to be benign, thus his infection was unlikely pulmonary. His last day of antibiotics were 7 days prior to admission, but he had no diarrhea so CDiff was unlikely. His focal symptoms of nausea and vomiting could have been indicative of SBP, gastritis or UTI. The patient has not been eating/drinking well thus volume depletion should also be considered with his current clinical picture. Ultimately, SBP and UTI were ruled and the patient improved on his own with albumin treatment, PO intake, and time, thus this was likely a viral gastritis with volume depletion. #Vomiting: The patient had 3 episodes of vomiting just prior to and at the onset of his admittance to the Emergency Department. There was some concern for blood in the emesis, but his H&H was stable during the admission and he has no history of varices. It is most likely the vomiting is ___ a viral gastritis. The nausea and vomiting improved early in his admission. #Acute on chronic kidney disease. The patient has baseline Cr at 1.3-1.6, on this admission his creatinine increased >2. He has a history of stage III chronic kidney disease and hypertension-related hyperaldosteronism. ___ likely pre renal in setting of poor PO intake and n/v. After treatment with albumin his creatinine improved. #Cirrhosis. The patient has been newly diagnosed with cirrhosis, Child's Class A. The current cause is unknown, but he has undergone extensive workup in the outpatient setting. His ascites is minimal on this admission and no SBP was found. He has no gastric varices as noted on recent EGD. He has had no episodes of hepatic encephalopathy. His PO intake has been decreased resulting in weight loss, thus he may require nutritional supplementation in the future. #Weight loss Patient has not had a screening colonoscopy. He was guaiac positive in the ED. A new RUQ ultrasound demonstrated a hepatic lesion that was not characterized well by a prior MRI and will require further workup. He has an iron deficiency anemia, atypical cells in pleural fluid, SAAG <1.1, and a weight loss from 175 in mid ___ all of which could be concerning for malignancy. During his stay, we sent the peritoneal fluid for analysis to better establish an etiology of the current process. #Anemia: He was found on last admission to have a low TIBC and high Ferritin level and a low MCV. Together that may indicate both anemia of chronic disease and iron deficiency anemia. #Bilateral Pleural Effusions: He was found on the last admission to have bilateral pleural effusions that were exudative in quality. Cytology after thoracentesis returned as non-malignant. CXR demonstrated stable effusions on this admission and patient was without dyspnea or hypoxia. CHRONIC MEDICAL PROBLEMS: #Hypertension: Due to his abdominal discomfort and history of nausea, vomiting, and ___ his diuretics were held until his creatinine improved. He continued his home metoprolol, but it was fractionated for better in hospital monitoring. He continued hydralazine, and amlodipine at his home doses. Furosemide and spironolactone were held until after discharge. #Depression: He was continued on his home citalopram. TRANSITIONAL ISSUES: CHANGES IN MEDICATION: NONE OUTSTANDING LAB RESULTS: Blood, urine, and peritoneal cultures are pending PENDING PROBLEMS: - New abdominal US with hepatic finding that was not well characterized by prior MRI that needs to be followed up, radiology recommends a nonurgent multiphasic CT - Unintentional weight loss, anemia, SAAG < 1.1 are all concerning signs for malignancy. Patient has not had a colonoscopy and this should be scheduled as an outpatient. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Calcitriol 0.25 mcg PO DAILY 3. Citalopram 10 mg PO DAILY 4. Furosemide 60 mg PO DAILY 5. HydrALAZINE 25 mg PO BID 6. Metoprolol Succinate XL 200 mg PO BID 7. Omeprazole 20 mg PO DAILY 8. Spironolactone 250 mg PO DAILY Discharge Medications: 1. amLODIPine 10 mg PO DAILY 2. Calcitriol 0.25 mcg PO DAILY 3. Citalopram 10 mg PO DAILY 4. HydrALAZINE 25 mg PO BID 5. Metoprolol Succinate XL 200 mg PO BID 6. Omeprazole 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Leukocytosis Vomiting Cirrhosis Acute on chronic kidney disease SECONDARY DIAGNOSIS Weight loss Anemia Bilateral Pleural Effusions Hypertension Depression Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: Dear Mr. ___, Why were you admitted to ___? You were having nausea and vomiting and had a high white blood cell count. What did we do while you were in the hospital? We ran tests to see if you have an infection, those tests have all been negative. We completed a diagnostic paracentesis to test your ascites for infection as well. There were no signs of bacterial infection. You had been dehydrated so your kidney function was impaired so we gave you albumin to improve it. What do you have to do when you go home? - Continue taking your medications as prescribed. We did not change any medications. - Follow up with your liver doctor to better characterize a ultrasound finding not well characterized by your prior MRI - Follow up results of ascites fluid. Followup Instructions: ___
10152950-DS-23
10,152,950
24,564,462
DS
23
2177-09-03 00:00:00
2177-09-09 06:25:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Percocet Attending: ___. Chief Complaint: Continuous headaches and episodes of unresponsiveness Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ year-old right-handed woman with a history of olfactory groove meningioma s/p resection in ___, visual impairment, diabetes, asthma, bipolar disorder, and OSA who presented with 1 week of continuous headache and episodes of unresponsiveness. On ___ she developed a bitemporal, piercing headache that she described as like her "head being in a vice grip". It was associated with photophobia, phonophobia, mild nausea, scalp tenderness and one episode of emesis. At baseline, she has ___ headaches per month. They were more frequent ___ before she was started on Depakote and Topamax. They are also bitemporal and throbbing, but not associated with nausea, photophobia, phonophobia, nor scalp tenderness. The day after the headaches started, on ___, she started having episodes of unresponsiveness ___ wherein she would stop speaking and stare (usually towards the right)for ___ minutes. She would not lose tone, nor have any shaking movements. She returns to baseline over the course of ~30 seconds. She described knowing what she wanted to say, but being unable to say it, and being unable to comprehend what others were saying to her. However, she also describes amnesia for the duration of the episode, and only being aware that it occurred due to the recovery period. The morning of presentation she was trying to get out of bed to go to the bathroom when suddenly her body just stopped working and she could not move so she ended up wetting the bed. During the episode she could hear her son trying talk to her but said that the words made no sense and she could not respond in any way. According to the patient's son this episode lasted about two minutes, then all symptoms resolved, the patient has full recall of these events. She has had at least two more episodes both witnessed by EMS in which the patient stared blankly, had a facial droops and was unresponsive for a period of less than two minutes. Past Medical History: MENINGIOMA s/p resection ___ IMPAIRED VISION DIABETES MELLITUS RHINITIS ENDOMETRIOSIS ASTHMA BIPOLAR DISORDER OBSTRUCTIVE SLEEP APNEA MORBID OBESITY DEEP VENOUS THROMBOSIS Social History: ___ Family History: === FAMILY Hx: Relative Status Age Problem Onset Comments MGM BREAST CANCER age ~___ Aunt BREAST CANCER postmenopausal Brother DRUG ABUSE Mother DIABETES TYPE II HYPERTENSION UTERINE CANCER Physical Exam: ADMISSION PHYSICAL EXAM === EXAM: -Vitals: T:98.8 BP:124/69 HR:94 RR:20 SaO2:99% Wt:361 Ht:64" BMI:62.0 -General: Awake, cooperative, NAD. Friendly and talkative. Does not appear to be in any headache pain. Obese. -HEENT: NC/AT. No scleral icterus noted. MMM. No lesions noted in oropharynx. -Neck: Supple. -Cardiac: Well perfused. -Pulmonary: Breathing comfortably on room air. -Abdomen: Soft, NT/ND. -Extremities: No cyanosis, clubbing, or edema bilaterally. -Skin: No rashes or other lesions noted. NEUROLOGIC EXAM: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There are no paraphasic errors. Able to name both high and low frequency objects. Able to read without difficulty. Speech is not dysarthric. Able to follow both midline and appendicular commands. Able to register 3 objects and recall ___ at 3 minutes. There is no evidence of apraxia or neglect. * During my evaluation, she had two episodes of unresponsiveness while obtaining history. She stopped responding to questions and would not follow midline or appendicular commands. She maintained her posture as it had been. She continued chewing gum, but more slowly. Her head and eyes were facing right (I was standing on her right, so her head position did not change, but her eyes lowered and looked further to the right). I turned her head to the left and there was no resistance, but she returned to the right after I let go. Her pupils were reactive to light, but she did not blink to avoid a very bright light. She did not react to moderate nailbed pressure on the right hand (the episode resolved as I moved to stimulate her lower extremities)After ~2 minutes she began to regard, and was able to answer orientation questions with some delay. There was no dysarthria. Within about 30 seconds she was at her baseline. She said that she could not remember what I was doing during the period she was unresponsive. A brief cranial nerve and motor exam following the episode was unchanged. * At one point during evaluation she expressed a sensation of ___. She suddenly said "I've been here before. I remember you" (we'd never met), "I remember you gave me medicine". She said to her boyfriend said "You were right there too." -Cranial Nerves: I: Olfaction not tested. II: PERRL 5 to 4mm and sluggish. VFF to confrontation and no extinction. Dilated fundoscopic exam revealed no papilledema. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing grossly intact to speech. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline and equal strength bilaterally. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO OP IP Quad Ham TA ___ L 5 ___ ___ ___ 5 5 5 5 5 R 5 ___ ___ ___ 5 5 5 5 5 -Sensory: No deficits to light touch throughout. No extinction to DSS. Able to localize doubly stimulated locations on all extremities and face. Graphesthesia intact on left hand, but impaired on right -- unable to identify 2,3,5,8 drawn on right hand. Able to indicate direction of stimulus on right hand. -DTRs: Difficult to ascertain due to obesity. Bi Tri ___ Pat Ach L Tr 0 0 0 0 R Tr 0 0 0 0 Plantar response was flexor bilaterally. -Coordination: No intention tremor. No dysmetria on FNF. Rapid finger and toe tapping with excellent speed and cadence bilaterally. -Gait: Good initiation. Narrow-based, normal stride and arm swing. DISCHARGE Physical Exam: Tmax: 98.5 BP: 105-125/66-82 HR: ___ RR: ___ SPO2: 98-99% Gen: Obese, lying in bed comfortably with cvEEG in place. CV: RRR Lungs: Breathing comfortably on room air. Abd: NTND, no r/g Ext: well perfused NEURO: MS: oriented to date. Names high frequency and low frequency objects without errors. Can follow three step commands. CN: legally blind at baseline, Pupils minimally reactive 2->1.5 bilaterally, EOMI convergence intact. Motor: Strength intact throughout Sensation: Intact to light touch, no extinction to DSS Coordination: FNF intact Pertinent Results: Discharge Labs ___ 05:25AM BLOOD WBC-7.7 RBC-4.40 Hgb-11.8 Hct-37.5 MCV-85 MCH-26.8 MCHC-31.5* RDW-13.7 RDWSD-42.2 Plt ___ ___ 07:30PM BLOOD Neuts-65.3 ___ Monos-8.8 Eos-4.8 Baso-0.3 Im ___ AbsNeut-5.61 AbsLymp-1.75 AbsMono-0.76 AbsEos-0.41 AbsBaso-0.03 ___ 05:25AM BLOOD Plt ___ ___ 05:25AM BLOOD Glucose-86 UreaN-11 Creat-1.0 Na-141 K-4.2 Cl-104 HCO3-22 AnGap-15 ___ 05:25AM BLOOD Calcium-9.3 Phos-3.9 Mg-2.0 ___ 05:25AM BLOOD Valproa-77 MRI Head w/ and w/o contrast 1. No acute interval change/acute pathology compared to most recent prior MRI done ___. 2. The apparent cortical high signal intensity in the right frontal and temporal areas on the diffusion-weighted imaging does not have any correlate on ADC, T2 or FLAIR sequences and is most likely secondary to susceptibility artifact. Follow-up imaging may be performed if clinically warranted. 3. Residual/recurrent disease appears very similar compared to most recent comparison, but mild progression is more evident when compared to older studies. Brief Hospital Course: Ms. ___ is a ___ year-old right-handed woman with a history of olfactory groove meningioma s/p resection in ___, visual impairment, diabetes, asthma, bipolar disorder, and OSA who was admitted for one week of continuous headache and unresponsive episodes found to be partial anterior temporal seizures on EEG. Multiple events were captured. Her Depakote level on admission was low and she reported not taking it consistently. Her valproate dosing was titrated to a level where no seizures were occurring, she was then converted to nightly only dosing per her preference (2250 mg divalproex qhs). Her seizures were likely due to her past meningioma resection. Her valproate level on admission was 24, not in the therapeutic range. On 2250 mg qhs it was 77. MRI brain w/ and w/o contrast was performed and was essentially unchanged from previous. Acute Issues #R partial anterior temporal seizures -EEG monitoring ___ -titrated to valproic acid ___ Q6h but then switched to divalproex (Extended release) 2,250 mg PO. 2250 is equivalent to 500 q6h due to bioavailability differences. The change was made to once a day dosing based on patient preference, as Depakote causes her blurry vision, so she prefers taking it at night. # Headache: Resolved during the hospitalization -Continued home topiramate 200mg BID -PRN flexeril was given while hospitalized Chronic issues: #Bipolar disorder: - Continued lurasidone 40mg DAILY. - her Depakote dosing was increased to also treat her seizures continued home medications for other chronic issues Transitional Issues Increased the dose valproate to 2250 mg night for anti-seizure effect (previously the patient had been taking for a mood stabilizing effect). Consider down titrating if she remains stable. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Cetirizine 10 mg PO DAILY 2. Sulfameth/Trimethoprim SS 1 TAB PO BID 3. calcium carbonate 500 mg calcium (1,250 mg) oral DAILY 4. Centrum Complete (multivitamin-iron-folic acid) ___ mg-mcg oral DAILY 5. Divalproex (DELayed Release) 1500 mg PO QHS 6. ClonazePAM 1 mg PO QHS 7. Latuda (lurasidone) 40 mg oral DAILY 8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN 9. Vitamin D 5000 UNIT PO 1X/WEEK (MO) 10. Cyanocobalamin 1000 mcg PO DAILY 11. HydrOXYzine 25 mg PO DAILY:PRN anxiety 12. Omeprazole 40 mg PO DAILY 13. Topiramate (Topamax) 200 mg PO BID 14. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 15. TraZODone 100 mg PO QHS 16. zaleplon 10 mg oral QHS Discharge Medications: 1. Divalproex (EXTended Release) 2250 mg PO QHS RX *divalproex ___ mg 4 tablet(s) by mouth nightly Disp #*120 Tablet Refills:*2 RX *divalproex ___ mg 1 tablet(s) by mouth nightly Disp #*30 Tablet Refills:*2 2. calcium carbonate 500 mg calcium (1,250 mg) oral DAILY 3. Centrum Complete (multivitamin-iron-folic acid) ___ mg-mcg oral DAILY 4. Cetirizine 10 mg PO DAILY 5. ClonazePAM 1 mg PO QHS 6. Cyanocobalamin 1000 mcg PO DAILY 7. HydrOXYzine 25 mg PO DAILY:PRN anxiety 8. Latuda (lurasidone) 40 mg oral DAILY 9. Omeprazole 40 mg PO DAILY 10. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN 11. Sulfameth/Trimethoprim SS 1 TAB PO BID 12. Topiramate (Topamax) 200 mg PO BID 13. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 14. TraZODone 100 mg PO QHS 15. Vitamin D 5000 UNIT PO 1X/WEEK (MO) 16. zaleplon 10 mg oral QHS Discharge Disposition: Home Discharge Diagnosis: Right Anterior Temporal Seizures Headache secondary to muscle contraction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were hospitalized because you were having headache and periods of unresponsiveness. We did brain imaging, which was basically unchanged from your previous imaging. We monitored you on EEG (machine that looks at brainwaves), which showed you were having seizures, because of this we increased the dose of your valproate (which you had been mainly taking for mood), which also has an anti-seizure effect. On the current dose of valproate you were no longer having seizures. Your dose will be 2250 mg nightly. You mentioned that you were feeling more drowsy on this dose, your body should adjust to this over time. If you are still feeling this way in a couple weeks, you can discuss with your neurologist whether or not the dose could be decreased. You should continue taking your topiramate as well. It is important to take your medications every day, otherwise you could have more seizures. Find a way to remind yourself to take it everyday, for example placing your medication box next to your toothbrush, or using a pill box. Your seizures were most likely a result of your past surgery/meningioma. Having these puts you at a higher risk for seizures. You should follow up with Dr. ___ seizures. You should also follow up with your psychiatrist as well. You should seek medical attention if you have seizures of a different type (where you lose awareness/consciousness) or have many more seizures than normal. Sincerely, Your ___ neurology team Followup Instructions: ___
10153623-DS-20
10,153,623
29,622,693
DS
20
2114-05-05 00:00:00
2114-05-05 19:40:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Alcohol intoxication, withdrawal Major Surgical or Invasive Procedure: None History of Present Illness: This is a ___ year old male with PMHx alcohol abuse, HTN, depression, presenting with alcohol intoxication. He has had multiple ED admissions here and per the record at ___ for alcohol intoxication. He reports that for the past ___ days he has been drinking approximately 3 bottles of wine. He was found today lying in a plant bed with a shopping bag full of cooking wine. Per chart review, he was responsive to loud verbal and painful stimuli for EMS. In the ED, initial vitals were: 98.8 104 120/64 20 99% RA - Labs were significant for: Na 150, K 4.0 Cl 111 CO2 23 BUN 10 Cr 0.8, Osms 449 - Imaging revealed: CXR - No acute cardiopulmonary process. - EKG: sinus tachycardia - The patient was given: Thiamine, Folate, IVF, 10 mg Diazepam Vitals prior to transfer were: 98.0 115 143/89 20 95% RA Past Medical History: Hypertension Alcohol abuse Depression Social History: ___ Family History: Reports family history significant for CAD. Mother had MI in ___. Physical Exam: ON ADMISSION Vitals: 98.5 159/84 110 20 97% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Bilateral resting tremor. tongue deviates towards right, right sided facial droop, ___ strength upper/lower extremities. ON DISCHARGE Vitals: Tc 97.8, Tm 98.7, HR 70-95, BP 137-150/88-96, RR ___, SaO2 95-100% on RA General: Alert, oriented, mildly diaphoretic, in no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear Neck: supple Lungs: Increased bronchial sounds. No wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops. Chest pressure was reproducible over L ribs. Abdomen: soft, non-tender, non-distended, no rebound tenderness or guarding Ext: warm, well perfused, no cyanosis, trace pitting edema to upper shins Neuro: motor function grossly normal Pertinent Results: ON ADMISSION ___ 03:50PM BLOOD WBC-6.2 RBC-4.23* Hgb-13.6* Hct-39.7* MCV-94 MCH-32.2* MCHC-34.3 RDW-14.7 RDWSD-50.9* Plt ___ ___ 03:50PM BLOOD Neuts-55.1 ___ Monos-6.1 Eos-0.2* Baso-1.0 Im ___ AbsNeut-3.42 AbsLymp-2.32 AbsMono-0.38 AbsEos-0.01* AbsBaso-0.06 ___ 03:50PM BLOOD Plt ___ ___ 03:50PM BLOOD Glucose-194* UreaN-10 Creat-0.8 Na-150* K-4.0 Cl-111* HCO3-23 AnGap-20 ___ 06:12AM BLOOD ALT-52* AST-62* LD(LDH)-343* AlkPhos-150* TotBili-0.4 ___ 03:50PM BLOOD Calcium-8.5 Phos-3.0 Mg-1.8 ON DISCHARGE ___ 06:48AM BLOOD WBC-10.4*# RBC-4.99 Hgb-15.9 Hct-46.2 MCV-93 MCH-31.9 MCHC-34.4 RDW-14.6 RDWSD-49.1* Plt Ct-90* ___ 06:48AM BLOOD Plt Ct-90* ___ 06:48AM BLOOD Glucose-87 UreaN-15 Creat-0.9 Na-136 K-3.9 Cl-97 HCO3-21* AnGap-22* ___ 03:40PM BLOOD ALT-62* AST-78* AlkPhos-189* TotBili-1.1 ___ 06:48AM BLOOD Calcium-9.7 Phos-3.4 Mg-1.9 IMAGING/STUDIES: ___ CXR PA and Lateral Heart size and mediastinum are stable. Lungs are clear. No pleural effusion or pneumothorax is seen. Increased densities projecting over the right acromioclavicular joint, unchanged in the prior study in might represent evidence of prior trauma. ___ RUQ US Normal abdominal ultrasound, with patent hepatic vasculature. ___ CT Head Without Contrast 1. Normal brain CT. 2. Convexity scalp thickening of uncertain etiology. Correlation with physical examination is recommended to exclude the possibility of a neoplasm. Brief Hospital Course: This is a ___ year old male with past medical history of alcohol abuse presenting with acute alcohol intoxication and admitted for detoxification. He was placed on a CIWA with diazepam with eventual transition off. He was provided with substance use and housing resources upon discharge. Active Issues: # Alcohol Abuse He presented initially intoxicated but developed symptoms of withdrawal. He has no known withdrawal seizure history, but only anxiety, shakes, and headaches in the past. He was monitored with a CIWA and diazepam with eventual downtitration and discontinuation. He was received thiamine, folate, and a multivitamin. Social work provided him with substance use services. Of note, he had a court-mandated substance abuse program for prior DUI. He called this program on the day of discharge and confirmed he was able to present for intake on the day after discharge. # Thrombocytopenia His platelets have downtrended the days after admission from 176 to 91. 4T score was 2. He had no bleeding. This was felt to represent marrow suppression from alcohol use. He had no splenomegaly on exam or ultrasound. HIT antibody was negative. # Chest pain Patient endorsed chest pain on admission that was reproducible. ECG showed no ischemia. This was felt to be musculoskeletal and was treated with as needed acetaminophen and ibuprofen. Chronic Issues: # Depression - continued fluoxetine # Hypertension - continued amlodipine and lisinopril Transitional Issues: - CT head showed: "Convexity scalp thickening of uncertain etiology. Correlation with physical examination is recommended to exclude the possibility of a neoplasm." No correlation seen on physical examination, please monitor as outpatient, recommend dermatology referral given his history of skin cancer. The need for outpatient dermatology follow-up was discussed with the patient. - Patient was discharged in the evening, instructed to call PCP ___ ___ to arrange for follow-up - Platelets down to 90 on discharge. 4T score 2. Likely myelosuppression from chronic alcohol use. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 20 mg PO DAILY 2. Amlodipine 5 mg PO DAILY 3. Fluoxetine 20 mg PO DAILY 4. TraZODone 50 mg PO QHS:PRN insomnia Discharge Medications: 1. Amlodipine 5 mg PO DAILY 2. Fluoxetine 20 mg PO DAILY 3. Lisinopril 20 mg PO DAILY 4. TraZODone 50 mg PO QHS:PRN insomnia 5. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 6. Multivitamins 1 TAB PO DAILY RX *multivitamin [Daily Multiple] 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary: alcohol intoxication, alcohol withdrawal Secondary: hypertension, alcohol abuse Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking part in your care at ___ ___. You came in because you were intoxicated and had alcohol withdrawal symptoms. You were given diazepam to help control the withdrawal. It is now safe for you to be off of this medication. You spoke with our social worker and were given resources for housing, mental health, and your mandatory substance abuse treatemnt which you can complete an intake for tomorrow. Please call your PCP ___ tomorrow to arrange for routine follow-up. Alcohol is causing you healh problems, and we strongly encourage you to stop drinking. Your can find resources for this through your PCP and AA. Sincerely, Your ___ Team Followup Instructions: ___
10153623-DS-21
10,153,623
29,406,708
DS
21
2115-06-11 00:00:00
2115-06-11 18:30:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: brought in from street Major Surgical or Invasive Procedure: none History of Present Illness: ___ y.o M brought in by ambulance after being found down, found to have an elevated serum alcohol level and lactate, now in alcohol withdrawal. The patient reports that he recently was discharged on ___ from "the hospital in ___ He reports that he was there for over a month and diagnosed with "c.dificile and MRSA." He states that he was discharged on antibiotics but his backpack got stolen and he did not fill them. He reports that he received acamprosate while he was admitted there. He reports that he lost 15 pounds in the setting of these infections. He reports that he has been a heavy drinker for approximately ___ years. He identifies depression as a possible contributor to his heavy drinking. He is unable to identify positive motivators that help him maintain sobriety. He reports diarrhea which has improved and has now become soft stool. He denies BRBPR, melena, hematemesis. He reports some abdominal pain, which he describes as moderate. In the ED, initial vitals were: 99.9 112 156/86 16 96% RA Exam notable for abrasions over chest, back, bottom of right first toe. Labs notable for CBC of 7.1, H/H 12.___, Plt 157. BMP initially notable for Na of 152, Cl 111, HCO3 20 and lactate of 5.4. Subsequent BMP with Na 145, 3.4, Cl 107, HCO3 18, BUN 8 Cr 0.6. Lactate 4.7. Serum alcohol level was 461, otherwise negative serum toxicology. CT head and CT c-spine negative. CXR negative. Patient was given 3L NS, 10 mg diazepam, and 4 mg Zofran. Decision was made to admit for EtoH w/d Vitals prior to transfer: 98 132/73 18 97% RA On the floor, the patient tells the story as above. He endorses current headache, chest tenderness over his anterior chest, abdominal pain. ROS: (+) Per HPI (-) Denies fever, chills, Denies cough, shortness of breath. Denies nausea, vomiting, constipation. No dysuria. He denies suicide ideation or homicidal ideation. Past Medical History: Alcohol abuse Hx Alcohol w/d seizures Depression HTN Hx ___ colitis s/p PO Vancomycin (___) Hx MRSA Bacteremia w/o endocarditis s/p IV Vancomycin (___) Hx Pancreatitis (___) Basal Cell Carcinoma of Skin GERD Chronic Right Shoulder Pain ___ Hx Fracture Social History: ___ Family History: Reports family history significant for CAD. Mother had MI in ___. Physical Exam: ADMISSION PHYSICAL EXAM: ======================= VS: T98.2 BP151-154/71-75 HR90-110 RR18 100 RA General: Alert, oriented, unkempt man, slightly diaphoretic and flushed HEENT: Sclera anicteric, mucous membranes dry, oropharynx clear, poor dentition, EOMI, PERRL, neck supple, JVP not elevated, no LAD; ecchymosis/scab on forehead CV: tachycardic rate, regular rhythm, -m/r/g Chest: ttp anterior +ecchymosis small Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, bowel sounds present, tenderness to palpation throughout without rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema; onchomycosis b/l toes Neuro: CNII-XII intact, ___ strength upper/lower extremities, resting tremor, finger to nose testing normal DISCHARGE PHYSICAL EXAM: ====================== VS - T98.1 BP120/80 HR82 RR18 98 RA RA General: Alert, oriented, no distress, resting comfortably lying in bed HEENT: Sclera anicteric, MMM, EOMI, PERRL CV: RRR, -m/r/g Lungs: CTAB Abdomen: Soft, normoactive BS, nondistended, non tender Ext: Warm, well perfused, 2+ pulses, no edema; onchomycosis b/l toes Neuro: no focal neurologic deficits, moving all extremties Pertinent Results: ADMISSION LABS: ============== ___ 04:30PM BLOOD WBC-7.1 RBC-4.18* Hgb-12.9* Hct-38.0* MCV-91 MCH-30.9 MCHC-33.9 RDW-13.2 RDWSD-43.9 Plt ___ ___ 04:30PM BLOOD Neuts-68.2 ___ Monos-5.6 Eos-0.0* Baso-1.0 Im ___ AbsNeut-4.86 AbsLymp-1.75 AbsMono-0.40 AbsEos-0.00* AbsBaso-0.07 ___ 04:30PM BLOOD Plt ___ ___ 06:05AM BLOOD ___ PTT-26.7 ___ ___ 04:30PM BLOOD Glucose-100 UreaN-8 Creat-0.7 Na-152* K-3.5 Cl-111* HCO3-20* AnGap-25* ___ 10:40PM BLOOD ALT-66* AST-74* AlkPhos-106 TotBili-0.3 ___ 10:40PM BLOOD Lipase-40 ___ 04:30PM BLOOD cTropnT-<0.01 ___ 04:30PM BLOOD Calcium-8.2* Phos-3.3 Mg-1.8 ___ 04:30PM BLOOD ASA-NEG ___ Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 04:43PM BLOOD Lactate-5.4* INTERVAL LABS: ============== ___ 06:05AM BLOOD WBC-5.7 RBC-3.41* Hgb-10.5* Hct-30.9* MCV-91 MCH-30.8 MCHC-34.0 RDW-13.2 RDWSD-44.0 Plt Ct-95* ___ 12:48PM BLOOD WBC-7.3 RBC-3.97* Hgb-12.2* Hct-35.4* MCV-89 MCH-30.7 MCHC-34.5 RDW-12.7 RDWSD-42.0 Plt ___ ___ 01:07PM BLOOD WBC-9.7 RBC-4.29* Hgb-13.2* Hct-38.3* MCV-89 MCH-30.8 MCHC-34.5 RDW-12.8 RDWSD-41.9 Plt Ct-67* ___ 05:27AM BLOOD WBC-5.1 RBC-3.88* Hgb-11.9* Hct-35.2* MCV-91 MCH-30.7 MCHC-33.8 RDW-12.7 RDWSD-41.8 Plt Ct-81* ___ 12:48PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL ___ 05:40AM BLOOD ___ PTT-28.3 ___ ___ 10:40PM BLOOD Glucose-93 UreaN-8 Creat-0.6 Na-145 K-3.4 Cl-107 HCO3-18* AnGap-23* ___ 05:40AM BLOOD Glucose-169* UreaN-6 Creat-0.8 Na-131* K-3.2* Cl-94* HCO3-22 AnGap-18 ___ 05:27AM BLOOD Glucose-96 UreaN-8 Creat-0.7 Na-138 K-3.8 Cl-104 HCO3-23 AnGap-15 ___ 06:05AM BLOOD ALT-51* AST-55* LD(LDH)-274* AlkPhos-87 TotBili-0.5 ___ 12:48PM BLOOD DirBili-0.2 ___ 05:40AM BLOOD ALT-52* AST-51* AlkPhos-113 TotBili-0.8 ___ 06:25AM BLOOD ALT-35 AST-29 AlkPhos-100 TotBili-0.5 DirBili-<0.2 IndBili-0.5 ___ 06:25AM BLOOD Lipase-40 ___ 12:48PM BLOOD Calcium-8.3* Phos-1.9* Mg-2.7* Iron-264* ___ 12:48PM BLOOD calTIBC-265 Hapto-17* Ferritn-228 TRF-204 ___ 12:48PM BLOOD TSH-6.9* ___ 06:10AM BLOOD Free T4-1.0 ___ 12:48PM BLOOD HBsAg-Negative HBsAb-Negative HBcAb-Negative ___ 12:48PM BLOOD HCV Ab-Negative ___ 11:31PM BLOOD Lactate-4.7* ___ 06:24AM BLOOD Lactate-3.9* ___ 01:00PM BLOOD Lactate-1.6 ___ 10:35AM BLOOD Lactate-1.0 DISCHARGE LABS: =============== IMAGING: ======= ___ CT-HEAD W/O CON No acute intracranial process. ___ CT-CSPINE W/O CON No acute fracture or traumatic malalignment. ___ CXR No focal consolidation is seen. There is no pleural effusion or pneumothorax. The cardiac and mediastinal silhouettes are unremarkable. Deformity at the distal right clavicle appears chronic. ___ GLENO-HUMERAL SHOULDER XR Chronic appearing deformity the distal right clavicle likely due to a the prior displaced fracture with 4.3 cm of bony overriding; an acute component is difficult to exclude, although none is definitely seen. No evidence of acute fracture or dislocation of the right glenohumeral joint. ___ RUQ U/S Coarse hepatic architecture however no concerning liver lesion identified. ___ CTA CHEST 1. No evidence of pulmonary embolism or aortic abnormality. 2. 1.8 cm right adrenal nodule is partially visualized. Although this nodule is indeterminate on this examination, this statistically most likely represents an adrenal adenoma. 3. Chronic appearing right clavicular fracture is partially imaged. ___ CT A/P W/ AND W/O CONTRAST 1. Bowel wall thickening and pericolonic inflammatory changes involving the transverse colon through the rectum, likely in keeping with infectious colitis given the provided clinical history. No pneumoperitoneum or free fluid. 2. Bilateral renal hypodensities, too small to characterize, however likely reflecting cysts. MICRO: ===== ___ UCX NO GROWTH ___ STOOL C. difficile POSITIVE ___ BCX PENDING ___ BCX PENDING ___ BCX NO GROWTH Brief Hospital Course: ___ yo M w/ PMHx homelessness, EtOH abuse, recent treated MRSA bacteremia and ___ colitis, p/w acute alcohol intoxication and admitted for detoxification: # Alcohol withdrawal: During the first 24 hours, CIWA consistently >15 and the patient required diazepam every 4 hours for symptom control. His symptoms were headache (though had recent head strike prior to admission with negative CT head/Cspine), sweating, tremors, anxiety, tachycardia, and HTN. After 48 hours, his CIWA <10 and he no longer required diazepam. By discharge, the patient had objective and subjective improvement in his withdrawal symptoms. He was given thiamine, folate, and a multivitamin. His major barrier to sobriety is his depression and homelessness and he uses alcohol to cope. He was seen by social work during admission who offered him resources for sobriety maintenance. Patient plans on reestablishing care at ___ upon discharge. # Elevated AG lactic acidosis: Patient admitted with lactate 5.4 that resolved with IVF. Etiology likely alcohol use/abuse + starvation ketosis (type B lactic acidosis). # Electrolyte derangements: Patient admitted with hypokalemia, hypomagnaesmeia, hypophosphatemia, hypocalcemia, hyponatremia in the setting of acute intoxication, alcohol withdrawal, and chronic alcoholism. His electrolytes were monitoring and repleted aggressively. Once he was no longer in severe withdrawal, his electrolytes normalized. For his hypovolemic hyponatremia (nadir 129), urine lytes were obtained (UNa <20, Uosm 254). His hyponatremia was felt to be secondary to diarrhea extrarenal losses. Electrolytes were normal on discharge. # ___ colitis: Patient endorses loose bowel movements with crampy abdominal pain (not bloody, not melena). He was diagnosed with ___ at ___, unclear trigger, and was discharged on PO vancomycin that he never completed. On admission to ___ ___ for EtoH intoxication & MRSA bacteremia, the patient completed PO vancomycin course with taper that ended on ___. Of note, his MRSA bacteremia was TEE negative and treated with 6 weeks of IV vancomycin that ended on ___. ___ stool positive during admission, and because of his symptoms, the patient was started PO vanco (___) with plan to treat for 14 days. CTAP showed inflammatory colitis. # Anemia: The patient's admission H/H was 12.9/38.0 and remained stable during admission. No signs or symptoms of active bleeding. Given significant alcohol abuse, he is at risk for bone marrow suppression. Hemolysis labs & peripheral smear normal. Fe studies normal. Retic index 1. # Thrombocytopenia: His admission plt 157k, nadir in ___ but recovered prior to discharge. Unknown baseline. Was thrombocytopenic in ___, HIT negative. No signs or symptoms of active bleeding during admission. At risk for BM suppression given significant EtOH abuse. Hepatitis serologies negative. # Tachycardia: During the first 48 hours of admission, he was consistently tachycardic. Multiple etiologies were considered including acute withdrawal, hypovolemia (high urine output and diarrhea), potential PE given new pleuritic CP on inspiration. A CTA Chest was negative for PE. Tachycardia resolved prior to discharge when diarrhea and abdominal pain improved and PO intake was adequate. # Transaminitis: Admission ALT/AST 66/74, with normal alkaline phosphatase and bilirubin, consistent with prior values. Hepatocellular injury likely secondary to alcohol use as above. Hepatitis serologies negative, RUQUS unremarkable as was CTAP except for inflammatory colitis. # Depression: Patient has been prescribed different SSRIs in past. Recently started on Sertraline & Acamprosate during ___ MICU admission at ___ by psychiatry. Patient was continued on sertraline in house but was not given acamprosate. Depression is a trigger for his alcohol abuse. # Hypertension: Early in hospital course, his blood pressure was elevated in setting of alcohol withdrawal. He had previously been on lisinopril and amlodipine, but reports he is only taking amlodipine at home. He was continued on amlodipine during his hospitalization. *****TRANSITIONAL ISSUES***** - Discharge Hgb: 11.6 - Discharge Plts: 143K - Medications added: PO Vancomycin 125mg Q6 (___) plan for 14 day treatment, end ___ Thiamine 100mg PO QD ongoing - Medications discontinued: Acamprosate ___ TSH 6.9, FT4 1.0 ___ ___ TSH 2.77) - Health Maintenance: Received Hep ___ ___ on ___. Hep B#2 offered but patient declined during admission to ___ ___. - Incidental Finding of CTA Chest ___: 1.8 cm right adrenal nodule is partially visualized. Although this nodule is indeterminate on this examination, this statistically most likely represents an adrenal adenoma. - Given recurrent ___ colitis and inflammatory colitis seen on CTAP, patient may benefit from GI work up to evaluate for non infectious contributors to his recurrent C. diff colitis. # CODE: Full (confirmed) # CONTACT: ___ ___ do not contact unless lifethreatening emergency Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. TraZODone 50 mg PO QHS 3. Sertraline 100 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Acamprosate 333 mg PO TID 6. FoLIC Acid 1 mg PO DAILY Discharge Medications: 1. Thiamine 100 mg PO DAILY RX *thiamine HCl (vitamin B1) [Vitamin B-1] 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Vancomycin Oral Liquid ___ mg PO/NG Q6H RX *vancomycin 125 mg 1 capsule(s) by mouth Q6hours Disp #*24 Capsule Refills:*0 3. amLODIPine 10 mg PO DAILY RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Multivitamins 1 TAB PO DAILY RX *multivitamin [Daily Multi-Vitamin] 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 6. Sertraline 100 mg PO DAILY RX *sertraline 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 7. TraZODone 50 mg PO QHS RX *trazodone 50 mg 1 tablet(s) by mouth at night for sleep Disp #*30 Tablet Refills:*0 8. HELD- Acamprosate 333 mg PO TID This medication was held. Do not restart Acamprosate until your visit with your primary care doctor Dr. ___ ___ Disposition: Home Discharge Diagnosis: Primary Diagnosis: Alcohol Withdrawal Secondary Diagnoses: Moderate ___ colitis Tachycardia HTN Anemia Thrombocytopenia Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking part in your care at ___ ___. You came in because you were intoxicated and had alcohol withdrawal symptoms. You were given diazepam to help control the withdrawal. You had diarrhea while in the hospital and your stool tested positive for ___ infection. Although you had been treated for ___ in the past and although ___ testing can stay positive even after treatment, we started you on a two week course of oral antibiotics to treat ___ infection. Please follow up with your primary care doctor Dr. ___ discharge! We made an appointment for you! If your diarrhea returns shortly after finishing your antibiotic course for ___, DO NOT HESITATE to call Dr. ___ primary care doctor) or seek medical attention. We wish you luck! Your ___ Team Followup Instructions: ___
10153740-DS-5
10,153,740
21,432,113
DS
5
2144-04-29 00:00:00
2144-04-29 19:33:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Painful perirectal bulge and fever Major Surgical or Invasive Procedure: Incision and drainage of right ___ abcess History of Present Illness: This is a ___ year-old female with history of ___ abscess that lead to septic shock requiring intensive care and pressors, then drainage and ___ placement with subsequent ligation of intersphincteric fistulous tract, presenting with worsening rectal pain and fever. Patient was last seen in clinic earlier this week, as her previously resolved perianal symptoms had recurred (rectal pain and drainage) following a trip to ___ that reportedly involved a lot of walking. She has been taking a significant amount of Advil, which have helped by improving her pain, as well as decreasing the amount of drainage. After examination in her clinic visit, it was thought that her symptoms were more likely the result of an atypical fissure in the right lateral position, and not due to recurrence of her fistula. She was advised to continue with symptomatic treatment and hot soaks. Patient endorses slight interval improvement until earlier today, when she noticed a tender bulge in the perirectal area while showering. Concomitantly, she reports low-grade temperature but no other concomitant symptom. Given similarity of presentation with her initial abscess five months ago, she was instructed to present to the Emergency Department for further evaluation. Past Medical History: PMH: Perirectal abscess, fistula-in-ano, hypothyroidism PSH: Tonsillectomy, extraction of wisdom teeth, cesarean section (x2). Anorectal exam under anesthesia, drainage of ischiorectal abscess and placement of a non-cutting ___ ___ ligation of intersphincteric fistular tract, and exam under anesthesia (___) Social History: ___ Family History: non-contributory Physical Exam: Discharge Physical exam: Vitals: 98 71 93/54 16 98% RA Heart: s1,s2 no m/r/g Lungs: CTAB Abdomen: soft, NT, ND Right perirectal abcess: no drainage, no pus or blood. Mild induration appreciated. Extremety: No edema. + DP/PP Pertinent Results: ___ 03:10PM GLUCOSE-81 UREA N-8 CREAT-0.7 SODIUM-139 POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-27 ANION GAP-10 ___ 03:10PM CALCIUM-8.4 PHOSPHATE-3.0 MAGNESIUM-1.7 ___ 11:30PM WBC-9.5 RBC-4.34 HGB-12.9 HCT-37.6 MCV-87 MCH-29.7 MCHC-34.4 RDW-13.5 ___ 11:30PM PLT COUNT-205 ___ 11:30PM ___ PTT-30.2 ___ MRI: ( pending official reading) Our impression is that there is no abcess collection but significant edema consistent with her I&D. Final reading will be f/y by Dr. ___ in clinic with patient on ___ Brief Hospital Course: Mrs. ___ presented to ___ on ___ due to complains of a right ___ abcess. She had the area I&D without drainage of pus. her WBC were WNL (9.5), patient was afebrile with normal vital signs. She had a MRI (final reading still pending) but apperantly without any significant abcess or drainable collection. Patient was started on iv C/F and was d/c home on ___ with close f/u with Dr. ___ on ___ Neuro: no events CV: no events Pulm: no events GI: no events GU: no events ID: Patietn was started on C/F for empiric txt of an abcess. She was d/c home w an additional 12 days of PO antibiotic (to complete a total course of 14 days). She will f/y w Dr. ___ at the end of the week. Heme: no events On ___, the patient was discharged to home. At discharge, she was tolerating a regular diet, passing flatus, stooling, voiding, and ambulating independently. She will follow-up in the clinic in ___ weeks. This information was communicated to the patient directly prior to discharge. Include in Brief Hospital Course for Every Patient and check of boxes that apply: Post-Surgical Complications During Inpatient Admission: [ ] Post-Operative Ileus resolving w/o NGT [ ] Post-Operative Ileus requiring management with NGT [ ] UTI [ ] Wound Infection [ ] Anastomotic Leak [ ] Staple Line Bleed [ ] Congestive Heart failure [ ] ARF [ ] Acute Urinary retention, failure to void after Foley D/C'd [ ] Acute Urinary Retention requiring discharge with Foley Catheter [ ] DVT [ ] Pneumonia [ ] Abscess [x] None Social Issues Causing a Delay in Discharge: [ ] Delay in organization of ___ services [ ] Difficulty finding appropriate rehabilitation hospital disposition. [ ] Lack of insurance coverage for ___ services [ ] Lack of insurance coverage for prescribed medications. [ ] Family not agreeable to discharge plan. [ ] Patient knowledge deficit related to ileostomy delaying discharge. [x] No social factors contributing in delay of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 125 mcg PO DAILY 2. Ibuprofen 400 mg PO Q8H:PRN pain Discharge Medications: 1. Levothyroxine Sodium 125 mcg PO DAILY 2. Acetaminophen 650 mg PO Q6H:PRN pain 3. Ciprofloxacin HCl 500 mg PO Q12H 4. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H abcess 5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain Discharge Disposition: Home Discharge Diagnosis: Perirectal abcess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital due to a perirectal abcess that was incised and drainaged. You had a MRI completed that did not show any concerning sigs. We felt that is safe to discharge you home with close follow-up. Please follow the instructions below: Diet: Regular Activity: As tolerated Meds: Can resume all home meds. Please take the pain medication as prescribed. Do not drive or drink if taking this narcotic. You might develop constipation as a result so it is important to take the prescribed bowel regimen. In addition take all the antibiotic as prescribed Wound: Please keep the area clean and dry. You can do daily ___ bath ___ times a day. Gently pad and dry the area. Do no apply any product to avoid obstructing the area. Follow-up: Please follow up with Dr. ___ in clinic on ___ this upcoming ___. Our clinic will call tomorrow to confirm your appointment. Followup Instructions: ___
10154074-DS-8
10,154,074
28,722,607
DS
8
2162-07-09 00:00:00
2162-07-09 11:25:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: apples Attending: ___ ___ Complaint: left knee hematoma Major Surgical or Invasive Procedure: ___: I&D left knee, polyliner exchange, evacuation of hematoma History of Present Illness: Mr. ___ is a ___ year old male who is s/p Left knee arthroplasty in ___ c/b fungal periprostehtic joint infection s/p two stage I&D and reimplantation who is now post-op from his reimplantation surgery presenting with LLE cellulitis and hematoma. Past Medical History: alcohol abuse, depression Social History: ___ Family History: Non-contributory Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Incision healing well with staples * Scant serosanguinous drainage * Thigh full but soft * No calf tenderness * ___ strength * SILT, NVI distally * Toes warm Pertinent Results: ___ 09:00AM BLOOD WBC-8.4 RBC-3.61* Hgb-9.2* Hct-29.7* MCV-82 MCH-25.5* MCHC-31.0* RDW-15.9* RDWSD-47.7* Plt ___ ___ 07:30AM BLOOD WBC-6.8 RBC-3.30* Hgb-8.4* Hct-26.9* MCV-82 MCH-25.5* MCHC-31.2* RDW-16.0* RDWSD-47.5* Plt ___ ___ 06:55AM BLOOD WBC-8.2 RBC-3.15* Hgb-7.9* Hct-25.6* MCV-81* MCH-25.1* MCHC-30.9* RDW-16.2* RDWSD-47.5* Plt ___ ___ 06:38AM BLOOD WBC-6.7 RBC-3.08* Hgb-8.0* Hct-25.2* MCV-82 MCH-26.0 MCHC-31.7* RDW-16.2* RDWSD-48.0* Plt ___ ___ 06:20PM BLOOD WBC-7.0 RBC-3.12* Hgb-8.0* Hct-25.6* MCV-82 MCH-25.6* MCHC-31.3* RDW-16.5* RDWSD-48.3* Plt ___ ___ 06:20PM BLOOD Neuts-56.1 Lymphs-18.5* Monos-13.7* Eos-10.0* Baso-0.3 NRBC-0.4* Im ___ AbsNeut-3.95 AbsLymp-1.30 AbsMono-0.96* AbsEos-0.70* AbsBaso-0.02 ___ 09:00AM BLOOD Plt ___ ___ 07:30AM BLOOD Plt ___ ___ 06:55AM BLOOD Plt ___ ___ 06:38AM BLOOD Plt ___ ___ 06:20PM BLOOD Plt ___ ___ 06:20PM BLOOD ___ PTT-31.5 ___ ___ 09:00AM BLOOD Glucose-141* UreaN-17 Creat-1.0 Na-137 K-4.5 Cl-97 HCO3-26 AnGap-19 ___ 06:38AM BLOOD Glucose-141* UreaN-11 Creat-1.1 Na-136 K-4.3 Cl-97 HCO3-25 AnGap-18 ___ 06:25AM BLOOD Glucose-106* UreaN-13 Creat-1.0 Na-139 K-4.6 Cl-102 HCO3-25 AnGap-17 ___ 06:20PM BLOOD Glucose-107* UreaN-18 Creat-1.1 Na-136 K-4.7 Cl-99 HCO3-25 AnGap-17 ___ 06:38AM BLOOD Calcium-8.5 Phos-3.6 Mg-1.8 ___ 06:25AM BLOOD Calcium-8.9 Phos-3.7 Mg-1.9 ___ 09:00AM BLOOD CRP-129.2* ___ 06:20PM BLOOD CRP-176.0* ___ 06:30PM BLOOD Lactate-1.6 Brief Hospital Course: The patient was admitted to the orthopedic surgery service via the Emergency Department. He was admitted to the floor and on POD#1, an aspiration was taken in Interventional Radiology. He was ultimately taken to the OR for an I&D of the left knee and polyliner exchange. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient remained on his oral Fluconazole post-operatively. Postoperative course was remarkable for the following: Otherwise, pain was controlled with a oral pain medications. The patient received Lovenox for DVT prophylaxis starting on HD#1. The overlying surgical dressing was changed and the incision was found to be clean and intact without erythema or abnormal drainage. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity. Mr. ___ is discharged to home with services in stable condition. Medications on Admission: 1. Cephalexin ___ mg PO ONCE 2. Fluconazole 400 mg PO Q24H 3. OxyCODONE (Immediate Release) 5 mg PO DAILY:PRN Pain - Moderate 4. Cetirizine 10 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Docusate Sodium 100 mg PO BID stop taking if having loose stools 3. Enoxaparin Sodium 40 mg SC DAILY Start: ___, First Dose: First Routine Administration Time 4. Senna 8.6 mg PO BID stop taking if having loose stools 5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate 6. Cephalexin ___ mg PO ONCE 7. Cetirizine 10 mg PO DAILY 8. Fluconazole 400 mg PO Q24H Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: left knee hematoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as Colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon's office to schedule or confirm your follow-up appointment in *** weeks. 7. SWELLING: Ice the operative joint 20 minutes at a time, especially after activity or physical therapy. Do not place ice directly on the skin. You may wrap the knee with an ace bandage for added compression. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as Celebrex, ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by your physician. 8. ANTICOAGULATION: Please continue your Lovenox for four (4) weeks to help prevent deep vein thrombosis (blood clots). 9. WOUND CARE: It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. You may place a dry sterile dressing on the wound, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by at your follow-up visit in *** weeks. 10. ___ (once at home): Home ___, dressing changes as instructed, and wound checks. 11. ACTIVITY: Weight bearing as tolerated on the operative extremity. Mobilize. ROM as tolerated. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: WBAT LLE No range of motion restrictions Wean assistive device as tolerated Mobilize frequently Treatments Frequency: daily dressing changes as needed for drainage wound checks daily ice, elevation staple removal and replace with steri-strips (at follow up visit) Followup Instructions: ___
10154271-DS-15
10,154,271
25,314,369
DS
15
2149-11-18 00:00:00
2149-11-19 07:04:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Cardizem CD Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ y/o F w/ PMH Afib on Coumadin and ___ who presents with 3 days of R sided chest pain, R sided abdominal pain, R sided back pain. The pain comes and goes, feels like a "pressing pain." Never had pain like this before. Brought on my eating. Also feels this pain when she takes a deep breath. She has not tried any medications for her pain. Patient denies F/C, N/V, change in diet. Denies hx of clots. Endorses 3 days of loose stool, no blood in stool. Patient also says she's been urinating more than baseline for the past 3 days. Denies burning with urination. In the ED initial vitals were: 98.3 53 191/104 18 100% RA EKG: Atrial fibrillation with ventricular rate 77, no acute ischemic changes Labs/studies notable for: elevated BNP 3461, total bilirubin of 1.7, lipase 129, INR 2.3, trop negative x2, UA contaminated with epithelial cells. CT chest/abd/pelvis with contrast showed dilated pulmonary artery, no PE, nodular thyroid enlargement, cardiomegaly, and heterogenous enhancement of the liver. RUQUS was negative for cholelithiasis. Patient was given: no medications Vitals on transfer: 98.6 60 140/103 18 99% RA On the floor pt reports she feels the R-sided chest pain intermittently when she takes a deep breath, when she is eating, and also when she is getting out of bed or walking to the bathroom. At baseline, she walks around her house with a cane but does not climb any stairs in her daily life. She has a ___ who sees her twice a week and has noted her BP has been elevated. She has also noted mildly increased ankle edema over the past few days. Past Medical History: HTN Eczema Fibroids Headache Heart murmur Heavy menstrual bleeding Right knee osteoarthritis Gout Psoriasis Stasis dermatitis Back pain Hallucinations Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM: ========================= VS: T 97.3 PO BP 151/89 HR 71 RR 18 SPO2 98% on RA GENERAL: Obese woman in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with JVP of 11 cm. CARDIAC: Irregularly irregular, normal S1, S2. No murmurs/rubs/gallops. No thrills, lifts. LUNGS: Bibasilar crackles. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: 1+ pitting edema of ankles. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Distal pulses palpable and symmetric DISCHARGE PHYSICAL EXAM: ========================= Tele: atrial fibrillation with brief episodes to ___ and a 4 beat run of VT Is/Os: 1320/___ (___) Weight: 125.8kg (124.9) PHYSICAL EXAM: VS: T 97.5 BP 134/92 (120-160/60-90) HR 57 (50-70) O2Sat 97% RA GENERAL: Obese woman sitting comfortably on side of bed, alert and awake, speaking in full sentences, in NAD. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple, unable to appreciate JVP CARDIAC: Irregularly irregular, normal S1, S2. No murmurs/rubs/gallops. No thrills, lifts. LUNGS: Decreased breath sounds at bases, otherwise CTA. ABDOMEN: +BS, soft, NTND, no rebound or guarding. EXTREMITIES: trace edema of ankles. No clubbing or cyanosis. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: ADMISSION LABS: ================ ___ 10:20AM BLOOD WBC-7.7 RBC-4.78 Hgb-13.4 Hct-41.2 MCV-86 MCH-28.0 MCHC-32.5 RDW-15.0 RDWSD-46.7* Plt ___ ___ 10:20AM BLOOD Neuts-63.9 ___ Monos-11.4 Eos-3.8 Baso-0.4 Im ___ AbsNeut-4.91# AbsLymp-1.54 AbsMono-0.88* AbsEos-0.29 AbsBaso-0.03 ___ 10:20AM BLOOD ___ PTT-46.3* ___ ___ 10:20AM BLOOD Glucose-86 UreaN-21* Creat-1.1 Na-142 K-3.5 Cl-104 HCO3-27 AnGap-15 ___ 10:20AM BLOOD ALT-14 AST-16 AlkPhos-115* TotBili-1.7* ___ 10:20AM BLOOD cTropnT-<0.01 proBNP-3461* ___ 10:20AM BLOOD Albumin-4.1 ___ 10:28AM URINE Color-Straw Appear-Clear Sp ___ ___ 10:28AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD ___ 10:28AM URINE RBC-0 WBC-8* Bacteri-NONE Yeast-NONE Epi-5 TransE-<1 ___ 10:28AM URINE Mucous-RARE NOTABLE LABS: ============== ___ 10:20AM BLOOD ___ PTT-46.3* ___ ___ 08:00AM BLOOD ___ PTT-41.0* ___ ___ 07:45AM BLOOD ___ ___ 10:20AM BLOOD ALT-14 AST-16 AlkPhos-115* TotBili-1.7* ___ 08:00AM BLOOD ALT-12 AST-15 AlkPhos-109* TotBili-1.6* DirBili-0.4* IndBili-1.2 ___ 07:45AM BLOOD ALT-12 AST-15 AlkPhos-111* TotBili-1.1 ___ 10:20AM BLOOD Lipase-129* ___ 10:20AM BLOOD cTropnT-<0.01 proBNP-3461* ___ 04:36PM BLOOD cTropnT-<0.01 ___ 08:00AM BLOOD cTropnT-<0.01 DISCHARGE LABS: ================ ___ 07:45AM BLOOD ___ ___ 07:45AM BLOOD Glucose-93 UreaN-20 Creat-1.1 Na-147* K-3.8 Cl-108 HCO3-23 AnGap-20 ___ 07:45AM BLOOD ALT-12 AST-15 AlkPhos-111* TotBili-1.1 ___ 07:45AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.2 IMAGING: ========= ___ Imaging CTA CHEST AND CT ABDOME 1. No pulmonary embolism or acute aortic process. 2. Dilated main pulmonary artery, correlate for pulmonary arterial hypertension. 3. Mild to moderate cardiomegaly with biatrial chamber enlargement. 4. Nodular thyroid enlargement, likely goiter, correlate clinically and with ultrasound in the absence of prior work-up. 5. Slightly heterogeneous enhancement of the liver, possibly due to passive congestion, correlate clinically. 6. Calcified uterine fibroids. ___ Imaging LIVER OR GALLBLADDER US 1. No evidence of gallbladder pathology. 2. Stable appearance of hemangioma at the hepatic dome. Brief Hospital Course: Ms. ___ is a ___ year old woman with history of atrial fibrillation (on warfarin), HFpEF (EF 50-55% on ___, poorly controlled HTN, and HLD who presented with atypical R-sided, pleuritic chest pain, back pain, and abdominal pain. #Atypical chest pain: Upon presentation, patient with vaguely characterized chest pain with associated right-sided abdominal and back pain. Troponin was negative x2 and EKG without any changes. CTA torso was notable for no evidence of PE or aortic dissection or any acute abdominal processes. She also underwent a RUQ US without any evidence of cholelithiasis or cholecystisis. Patient continued to have intermittent R-sided pleuritic pain during admission, mostly with movement and deep breathing, that improved with GI cocktail. #HTN crisis: #Acute HFpEF (EF 50-55%) Patient noted to have difficult to control pressures as an outpatient despite frequent medication titrations. She had pressures in the 190s/100s on admission. She also endorsed dietary indiscretions prior to admission. She was also noted to be fluid overloaded on exam. She was diuresed with 40mg IV Lasix with some improvement in her pressures. Amlodipine 5mg daily was added to her anti-hypertensive regimen when her metoprolol was decreased (as below). She was then restarted on her home torse___. #Bradycardia: Patient had several, brief episodes of bradycardia on telemetry. Episodes of bradycardia reportedly correlated with brief episodes of R-sided chest pressure. Her metoprolol succinates was decreased from 150mg BID to ___ BID. #Bilirubinemia: Patient found to have elevated bilirubin upon admission. RUQ US negative for cholelithiasis/cholecystitis and CT abd showed signs of possible congestive hepatophaty. Patient was diuresed (as above) and her bilirubin normalized. TRANSITIONAL ISSUES: ===================== #Medication Changes: - decreased metoprolol succinate from 150mg BID to ___ BID - started on amlodipine 5mg daily [] Nodular thyroid enlargement seen on CT. Please work up as outpatient. [] Will need outpatient TTE to evaluate LVEF and valvular function [] Started on amlodipine 5mg daily for HTN. Please uptitrate as needed for better BP control. [] Pt with brief episodes of bradycardia to ___ on telemetry. Metop succinate decreased to 100mg BID. Please monitor HR as outpatient and consider further downtitrating metoprolol as clinically indicated. # CODE: DNR/DNI (confirmed) # CONTACT: HCP: ___, ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. Ketoconazole 2% 1 Appl TP BID 3. Losartan Potassium 100 mg PO DAILY 4. Metoprolol Succinate XL 150 mg PO BID 5. Torsemide 10 mg PO DAILY 6. Warfarin 7.5 mg PO 3X/WEEK (___) 7. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild 8. DiphenhydrAMINE ___ mg PO Q6H:PRN allergies 9. melatonin 3 mg oral QHS 10. Warfarin 5 mg PO 4X/WEEK (___) Discharge Medications: 1. amLODIPine 5 mg PO DAILY RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Metoprolol Succinate XL 100 mg PO BID RX *metoprolol succinate 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 3. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild 4. Atorvastatin 40 mg PO QPM 5. DiphenhydrAMINE ___ mg PO Q6H:PRN allergies 6. Ketoconazole 2% 1 Appl TP BID 7. Losartan Potassium 100 mg PO DAILY 8. melatonin 3 mg oral QHS 9. Torsemide 10 mg PO DAILY 10. Warfarin 7.5 mg PO 3X/WEEK (___) 11. Warfarin 5 mg PO 4X/WEEK (___) Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES: =================== Hypertensive crisis Chronic heart failure with preserved ejection fraction Thyroid nodule SECONDARY DIAGNOSES: ==================== Atrial fibrillation Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were recently admitted to ___ ___. Why I was here? - You had right sided chest, back, and belly pain. - You were also found to have high blood pressures. What happened while I was here? - You had a CT of your torso which showed an enlarged thyroid but was otherwise normal. - You were monitored on the heart monitor, which showed some episodes of slow heart rate. Your metoprolol was decreased to help prevent this. - You were started on a new medication, amlodipine, to help control your blood pressure. - You were given a medication by IV, Lasix, to help remove extra fluid. What I should do at home? - Please continue to take all of your medications as directed. - Follow up with your primary care doctor and with the cardiologist. - Weigh yourself every morning, call your doctor if your weight goes up more than 3 lbs. Thank you for allowing us to care for you, Your ___ Care Team Followup Instructions: ___
10154473-DS-18
10,154,473
24,152,652
DS
18
2189-03-02 00:00:00
2189-03-02 14:55:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Dilaudid (PF) / Morphine Attending: ___. Chief Complaint: Slurred speech; word-finding difficulties Major Surgical or Invasive Procedure: None History of Present Illness: ___ with a PMHx of IDDM who presented with headache and slurred speech. He describes having a mechanical fall ___ while descending the stairs at home. He hit his buttocks, hip, and head and did not have LOC. He went to his ___ appt ___ where he felt slightly confused and had word-finding difficulty. He was referred to the ED to r/o CVA. He denied weakness, numbness, vision change, incoordination, or vision changes. In the ED, - Initial VS were: HR 73 BP 136/82 RR 16 SaO2 97% RA Glc 110 - A code Stroke was called. He was evaluated by neurology who felt that there was no indication for head MRI. They recommended treatment for cellulitis, pain control, and medical workup including infectious (UA, UCX, CXR, blood cultures) and cardiac (ECG, enzymes). - Labs were notable for H/H 10.8/32.0, Plt 162, Cr 1.4, UA neg leuk/nitrite - CT Head showed no acute process. CT C/T/L-spine showed no fracture but multiple healed right posterior rib fractures, postsurgical changes related to L1 through L5 posterior fusion construct with no evidence of hardware related complication. - He was thought to have BLE cellulitis so received 1g IV vancomycin. He also received 1L IVF and 5mg PO oxycodone. - He was admitted for cellulitis treatment, pain control, and further workup; the stroke team will continue to follow On the floor, he reported ongoing back pain, improved speech and confusion. Review of Systems: (+) per HPI; he admits to urinary frequency (-) fever, chills, night sweats, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: - Type 2 diabetes: followed at ___. Dx at ___. A1c 6.4 ___ - Obesity - HLD - Tremor - Peripheral neuropathy - Sleep apnea - Memory difficulties - IPMN (diagnosed on EUS ___ - Bipolar mood disorder - Chronic back pain - Anxiety - Chronic venous stasis - Cataracts bilaterally - H/o lower extremity cellulitis - Hx of prior L3/4, L4/5 and L5/S1 diskectomies with residual left leg weakness Social History: ___ Family History: Mother died at age ___ of a stroke. History of ___ disease on mother's side of the family. Father died at age ___ of dementia. Sister age ___ living. 5 brothers ages ___, one with DM 2. Physical Exam: ADMISSION EXAM: Vitals - T: 98.8 BP:146/88 HR:78 RR:18 02 sat:98 ___ GENERAL: appears well and in NAD HEENT: Atraumatic, anicteric sclera, pink conjunctiva, MMM, good dentition NECK: no JVD CARDIAC: RRR, S1/S2, ___ HSM, no gallops, nor rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: There are erythematous patches over both anterior tibiae, with a few dark eschars over right tibia. Non-tender. Mild warmth. Woody texture bilaterally. Hyperkeratosis of both feet. MSK: Heberden's nodes b/l. Hallux valgus of right foot. PULSES: 2+ DP pulses bilaterally NEURO: Alert, oriented, normal speech latency with some searching for words initially. No paraphasic errors. Speech fluent without dysarthria. Good eye contact. Fair historian. CN2-12 intact. 4+/5 in LEs. ___ in UEs throughout. FNF with bilateral intention tremor but not significant dysmetria. Also has resting tremor in R hand. Pronator drift negative. DISCHARGE EXAM: VITALS: 98.7 140/75 64 20 97/RA GENERAL: Appears well and in NAD when sitting HEENT: NCAT, anicteric sclera, MMM, good dentition NECK: no JVD CARDIAC: RRR, S1/S2, ___ HSM, no g/r LUNG: CTAB, no w/r/r EWOB w/o use of accessory muscles ABDOMEN: nondistended, +BS, nontender, no hepatosplenomegaly EXTREMITIES: Erythematous patches over both anterior tibiae, with a few dark eschars over right tibia. Non-tender. Mild warmth. Woody texture bilaterally. Hyperkeratosis of both feet. MSK: Heberden's nodes b/l. Hallux valgus of right foot. PULSES: 2+ DP pulses bilaterally NEURO: AAOx3, normal speech latency. No paraphasic errors. No evidence of word finding difficulties. Speech fluent with mild dysarthria. Good eye contact. CN2-12 intact. 4+/5 in LEs. ___ in UEs throughout. FNF with bilateral intention tremor but not significant dysmetria. Also has resting tremor in R hand. Pertinent Results: ADMISSION LABS: ============ ___ 03:25PM BLOOD WBC-5.6 RBC-3.75* Hgb-10.8* Hct-32.0* MCV-85 MCH-28.9 MCHC-33.8 RDW-14.0 Plt ___ ___ 03:25PM BLOOD ___ PTT-34.7 ___ ___ 03:25PM BLOOD UreaN-29* Creat-1.4* ___ 03:25PM BLOOD Creat-1.5* ___ 03:25PM BLOOD Calcium-9.2 Phos-3.7 Mg-1.9 ___ 03:34PM BLOOD Glucose-97 Lactate-1.4 Na-138 K-5.4* Cl-97 calHCO3-29 ___ 05:08PM URINE Color-Straw Appear-Hazy Sp ___ ___ 05:08PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG MICROBIOLOGY: =========== ___ 6:40 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date ___ 3:25 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date IMAGING/RESULTS: ============= CT C-Spine w/o Contrast (___): FINDINGS: Alignment is normal. No fractures are identified. There is no pre vertebral soft tissue edema. Mild multilevel degenerative changes are present, most prominent at the C6-7 level, where there is disc space narrowing, anterior and posterior osteophytosis, endplate sclerosis, subchondral cystic change. There is no critical central canal stenosis. Thyroid is diffusely heterogeneous. IMPRESSION: No evidence of cervical spine fracture or acute malalignment. CT Head w/o Contrast (___): FINDINGS: There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles and sulci are normal in size and configuration. No fractures are identified. There is scattered opacification of the inferior left mastoid air cells (3:7), as well as mucosal thickening in the bilateral maxillary sinuses and ethmoid air cells. The frontal sinuses, sphenoid sinuses, right mastoid air cells, and bilateral middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: 1. No acute intracranial process. 2. Mild paranasal sinus inflammatory changes, and mild left mastoid air cell opacification as described above. CT T-Spine, L-Spine w/o Contrast (___): IMPRESSION: 1. No evidence of acute fracture or traumatic malalignment in the thoracic or lumbar spine. 2. Multiple healed right posterior rib fractures. 3. Postsurgical changes related to L1 through L5 posterior fusion construct, with no evidence of hardware related complication. 4. Bilateral adrenal adenomas, unchanged. 5. Non-obstructing 1-2 mm right renal stone. 6. Top-normal ascending thoracic aorta and main pulmonary artery, as well astortuous and prominent bilateral iliac arteries. FINDINGS: MRI Brain: There is no evidence of hemorrhage, edema, masses or infarction. There is no pathologic enhancement. There is mild generalized prominence of the cerebral sulci and cisterns. The ventricles are normal in size. Prominent cisterna magna. Major intravascular flow voids are preserved. There is normal enhancement of the major intracranial arteries and dural venous sinuses following contrast administration. There is mild ethmoid and moderate maxillary sinus mucosal thickening. The paranasal sinuses otherwise appear clear. There is fluid in the mastoid air cells, left greater than right, as seen on recent CT. Status post left lens replacement. MRA brain: The intracranial vertebral and internal carotid arteries and their major branches appear normal without evidence of stenosis, occlusion, or aneurysm more than 3 mm within the resolution of the study. There is likely fenestration of the proximal basilar artery. The anterior inferior cerebellar arteries are not well seen. Mild contour irregularity of the cavernous carotid segments on both sides. MRA neck: The common, internal and external carotid arteries appear patent without focal flow-limiting stenosis or occlusion. 3 vessel arch pattern. There is no evidence of internal carotid artery stenosis by NASCET criteria. The origins of the great vessels, subclavian and vertebral arteries appear normal bilaterally. There is 3 vessel aortic arch anatomy. The visualized aortic arch is normal. Degenerative changes in the cervical spine, not adequately assessed. IMPRESSION: 1. No hemorrhage or acute infarct. No evidence of chronic small vessel ischemic disease. 2. No focal flow-limiting stenosis or occlusion on MRA head. 3. Normal MRA neck with no internal carotid artery stenosis by NASCET criteria and no vertebral artery stenosis. Other details as above. DISCHARGE LABS: =========== ___ 07:50AM BLOOD WBC-4.0 RBC-3.42* Hgb-9.7* Hct-29.2* MCV-86 MCH-28.4 MCHC-33.2 RDW-14.6 Plt ___ ___ 07:50AM BLOOD Plt ___ ___ 07:50AM BLOOD Glucose-103* UreaN-19 Creat-1.1 Na-139 K-4.0 Cl-102 HCO3-29 AnGap-12 Brief Hospital Course: PATIENT This is a ___ with a PMHx of T2DM, and peripheral neuropathy, and recent fall causing back pain who presented from ___ ___ to ED for concern for CVA which was deemed unlikely and being admitted for possible ___ cellulitis. ACUTE ISSUES: # Slurred Speech/Word finding difficulty: The patient presented from ___ due to concern for CVA given some word-finding difficulties and slurred speech. NIHHS of 1 with stable language impairment. In the ED, NCCTH normal. No clear toxic/metabolic disorder. Neurology evaluated the patient and felt based on presentation that stroke was unlikely. Tox screen negative. He reports chronic poor sleep (3 hrs nightly) and takes sedatives that may cause cognitive slowing, and may be contributing to current situation. Neuro recommended MRI/MRA for further evaluation which was without evidence of hemorrhage, acute infarct, or chronic small vessel ischemic disease. Patient had no further neurologic events/concerns during his hospitalization. # Hypotension: On ___, noted to be hypotensive with SBP in the ___. The patient was asymptomatic and mentoring well. Heart rate was normal, and ECG without acute change. He was given IVF and lisinopril was held with improvement of pressures. Blood pressure corrected and remained in the normal range. Lisinopril was discontinued on admission. # Leg rash: Pt presented with multiple eschars with some surrounding erythema. Most predominant on the LLE. Eschars secondary to report of falls at home. Left lower extremity possibly represents cellulitis given increased pain and redness. Also likely to be consistent with venous stasis dermatitis. Given his increased erythema and diabetes, he was given vancomycin 1gm IV x 1 in the ED, and then continued on cephalexin to complete a 7-day course. # Falls: Pt with a history of multiple falls at home, most recently on ___. Unclear etiology, although patient may have peripheral neuropathy in the setting of his diabetes. TSH normal and RPR negative. Evaluated by physical therapy, who recommended rehab. Patient had no falls while in house. # ___: Pt presented with elevated creatinine to 1.5. Likely prerenal as it improved to 1.1 with fluids. # Back Pain/Fall: Occurred ___. The fall sounds mechanical in nature. He has known neuropathy from his diabetes. He did not have syncope, presyncope, vertigo, or transient vision change. For pain he was treated with acetaminophen and oxycodone 5mg po q6h for breakthrough pain. CHRONIC ISSUES: # T2DM: Takes metformin and glargine 8 units at home. Metformin was held given increased creatinine, and insulin with sliding scale was continued during admission. Metformin was restarted with resolution ___ and ___ blood sugars corrected to acceptable levels. # INSOMNIA: Continued on home seroquel and trazodone. ***TRANSITIONAL ISSUES*** -Please continue to take cephalexin to complete a 7-day course for cellulitis (last day ___ -Patient was profoundly Vitamin B12 deficient and received 4 days of IM Cyanocobalamin and before being switched to 1000mg PO at time of discharge. Please continue therapy until blood work demonstrates adequate repletion. - Please follow up with iron studies pending at time of discharge and replete as needed given his anemia. - General Neurology to independently schedule follow up with Dr ___ in the near future. -Please continue to dress R shin wound with wound cleaner, adaptic dressing, and kerlix daily. -Lisinopril was discontinued given a few episodes of asymptomatic systolic pressures in the ___ and normotensive otherwise. Held at time of DC -Code: Full -Contact: ___ ___ (wife) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. BusPIRone 10 mg PO TID 2. ClonazePAM 0.5 mg PO QHS 3. Finasteride 5 mg PO DAILY 4. LaMOTrigine 50 mg PO TID 5. LaMOTrigine 100 mg PO QHS 6. Zenpep (lipase-protease-amylase) 25,000-85,000- 136,000 unit oral WITH MEALS 7. Lisinopril 30 mg PO DAILY 8. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 9. QUEtiapine Fumarate 300 mg PO QHS 10. Simvastatin 10 mg PO QPM 11. TraZODone 150 mg PO QHS:PRN insomnia 12. Aspirin 81 mg PO DAILY 13. Cyanocobalamin 1000 mcg PO DAILY 14. Glargine 8 Units Bedtime 15. Gabapentin 400 mg PO TID Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. BusPIRone 10 mg PO TID 3. ClonazePAM 0.5 mg PO TID 4. Finasteride 5 mg PO DAILY 5. Gabapentin 400 mg PO TID 6. Glargine 8 Units Bedtime 7. LaMOTrigine 50 mg PO TID 8. LaMOTrigine 100 mg PO QHS 9. QUEtiapine Fumarate 150 mg PO QHS 10. Simvastatin 10 mg PO QPM 11. TraZODone 150-200 mg PO QHS insomnia 12. Cephalexin 500 mg PO Q6H Duration: 6 Days RX *cephalexin 500 mg 1 capsule(s) by mouth every six (6) hours Disp #*10 Capsule Refills:*0 13. MetFORMIN XR (Glucophage XR) 1000 mg PO BID Do Not Crush 14. Zenpep (lipase-protease-amylase) 25,000-85,000- 136,000 unit oral WITH MEALS 4 with meals and 2 with snacks 15. Cyanocobalamin 1000 mcg PO DAILY RX *cyanocobalamin (vitamin B-12) 1,000 mcg 1 tablet(s) by mouth DAILY Disp #*90 Tablet Refills:*2 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis: Cellulitis, Slurred Speech Secondary Diagnosis: IDDM, Falls, ___, Back pain, fall. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, You were admitted to the hospital after an episode of slurred speech. You had CT scans of your head and spine that showed no acute change. You were evaluated by the neurology team who did not feel your symptoms were due to a stroke. You had some redness on your right shin that was concerning for possible infection. Therefore, you were treated with antibiotics. You should continue to take all of your antibiotics to complete a 7 day course (last day = ___. You should follow up with Dr. ___ as below. Be well and take care, Your ___ Team Followup Instructions: ___
10154473-DS-21
10,154,473
27,559,862
DS
21
2190-08-02 00:00:00
2190-08-02 18:04:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Dilaudid (PF) / Morphine Attending: ___ Chief Complaint: right finger pain Major Surgical or Invasive Procedure: Amputation of right distal middle finger Revision Amputation of right distal middle finger L tunneled internal jugular line placement History of Present Illness: Mr. ___ is a ___ y/o gentleman with hx of OSA, depression, DM2, CAD, HTN with hx of prior R index finger abscess and osteomyelitis ___ Group G strep s/p multiple I and Ds and distal R index finger amputation/revision amputations in ___ presents today with complaints of an infected R ___ digit. According to the patient, he ripped off the fingernail on his R ___ finger by accident (states he does not remember mechanism) several months ago. He states it had never been infected or been erythematous or painful. He states he has been bandaging his finger since then without any issues. However, yesterday, he states that he was in the shower and an entire sheath of skin pulled off from his R ___ fingertip, which then began to bleed profusely. He states that shortly after the bleeding stopped, his fingertip turned black, and over the course of the day, his digit became increasingly swollen and erythematous, spreading proximally down into his hand. His PCP started him on doxycycline and Keflex. Noting that these did not help and presented to the ED today. He reports no nausea, vomiting, fevers, chills, or any other systemic symptoms. No numbness or tingling in his fingers or lower extremities. Endorses lower extremity swelling In the ED, initial vitals: 99.6, 73, 144/67, 18, 96% RA, ___ pain - Exam notable for:well appearing, RRR, CTAB, abd s/nt/nd R long finger: black tip with fusiform swelling, erythema of digit to MCP, able to actively range finger though w/pain, held in slight flexion - Labs notable for: lactate 1.4, WBC, 9.2, - Imaging notable for: FINGER(S),2+VIEWS RIGHT:Soft tissue swelling at the long finger without soft tissue gas. Subtle cortical regularity tuft of the terminal phalanx of the long finger raises potential concern for very early osteomyelitis versus periostitis. - Pt given: IV 1000mg Vancomycin, Blood cultures and wound swabs were obtained - Vitals prior to transfer: 98.6, 72, 130/64,18, 97% RA On arrival to the floor, pt reports pain in his right hand s/p amputation. Of note, the patient's story differs from what is documented in notes, which indicate he has been to multiple primary care appointments where he was found to have been biting at his finger. Past Medical History: - Type 2 diabetes: followed at ___. Dx at ___. A1c 6.4 ___ - Obesity - HLD - Tremor - Peripheral neuropathy - Sleep apnea - Memory difficulties - IPMN (diagnosed on EUS ___ - Bipolar mood disorder - Chronic back pain - Anxiety - Chronic venous stasis - Cataracts bilaterally - H/o lower extremity cellulitis - Hx of prior L3/4, L4/5 and L5/S1 diskectomies with residual left leg weakness - R finger osteomyelitis - Pancreatic cysts Social History: ___ Family History: Mother died at age ___ of a stroke. History of ___ disease on mother's side of the family. Father died at age ___ of dementia. Sister living. 5 brothers ages ___, one with DM 2. Physical Exam: PHYSICAL EXAM ON ADMISSION ========================== Vitals: 98.4, 129 / 76, 68, 18, 98% ra General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: CTAB no wheezes, rales, rhonchi CV: RRR, Nl S1, S2, No MRG Abdomen: soft, NT/ND bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema MSK: s/p right ___ digit amputation: Right arm is in sterile gauze and bandage, and in a volar resting splint. PE per hand (plastics) prior to amputation:R hand reveals erythema and swelling of the ___ R digit extending promixally into the palm. Skin is intact, tip of finger appears necrotic. Digit tender to palpation down to level of MCP. Loss of sensation at fingertip overlying necrotic area. All motor functions intact. No drainage or open wound. No fingernail; scarring of exposed nail bed. PHYSICAL EXAM ON DISCHARGE ========================== 98.4 150 / 76 manual 58 18 99 RA 104.55kg General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear Neck: R tunneled IJ site c/d/I with minimal erythema and tenderness around line site (c/w expected inflammation/irritation from procedure), supple, JVP not elevated, no LAD Lungs: CTAB no wheezes, rales, rhonchi CV: RRR, Nl S1, S2, No MRG Abdomen: soft, NT/ND bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. Trace to 1+ ___. MSK: s/p right ___ digit amputation: incision site is c/d/I with mild bruising/blood blistering around incision site without discharge LUE without any swelling/erythema/induration B hands with intact sensation/strength (other than that which is limited by R ___ digit pain) Pertinent Results: LABS ON ADMISSION ================= ___ 01:26PM PLT COUNT-169 ___ 01:26PM NEUTS-74.3* LYMPHS-11.3* MONOS-12.3 EOS-1.3 BASOS-0.2 IM ___ AbsNeut-6.63*# AbsLymp-1.01* AbsMono-1.10* AbsEos-0.12 AbsBaso-0.02 ___ 01:26PM WBC-8.9 RBC-3.89* HGB-11.2* HCT-33.4* MCV-86 MCH-28.8 MCHC-33.5 RDW-13.8 RDWSD-42.6 ___ 01:26PM CRP-63.4* PERTINENT INTERVAL LABS ============== ___ 04:46PM LACTATE-1.4 ___ 06:20AM BLOOD WBC-5.8 RBC-3.55* Hgb-10.0* Hct-30.9* MCV-87 MCH-28.2 MCHC-32.4 RDW-13.7 RDWSD-42.5 Plt ___ ___ 07:11AM BLOOD Neuts-48.6 ___ Monos-10.5 Eos-6.4 Baso-0.6 Im ___ AbsNeut-2.35 AbsLymp-1.59 AbsMono-0.51 AbsEos-0.31 AbsBaso-0.03 ___ 07:07AM BLOOD ___ PTT-41.5* ___ ___ 07:23AM BLOOD Glucose-94 UreaN-13 Creat-1.0 Na-140 K-3.9 Cl-102 HCO3-29 AnGap-13 ___ 06:05AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.0 ___ 01:26PM BLOOD CRP-63.4* ___ 04:32PM BLOOD CRP-135.1* ___ 06:20AM BLOOD CRP-4.7 ___ SED RATE 16 ___ 06:20 SED RATE 2 IMAGING ======= ___: AP, lateral, oblique views of the right long finger. There has been prior amputation at the index finger at the level of the mid phalanx. Flexion at the DIP joint of the right long finger is unchanged from prior. There is severe degenerative disease at the DIP joint of the long finger. There is significant soft tissue swelling at the long finger without soft tissue gas or osseous destruction to suggest the presence of osteomyelitis. Subtle cortical irregularity at the dorsal aspect of the distal phalangeal tuft on the lateral view raises potential concern for early osteomyelitis versus periosteal reaction. IMPRESSION: Soft tissue swelling at the long finger without soft tissue gas. Subtle cortical regularity tuft of the terminal phalanx of the long finger raises potential concern for very early osteomyelitis versus periostitis. MICRO ===== ___ 6:41 pm TISSUE Source: Distal R ___ finger. **FINAL REPORT ___ GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final ___: Reported to and read back by ___ ___ AT 1604. BETA STREPTOCOCCUS GROUP C. SPARSE GROWTH. Sensitivity testing per ___ ___. STAPH AUREUS COAG +. SPARSE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # ___ (___). STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. MIXED BACTERIAL FLORA. Due to mixed bacterial types [>=3] an abbreviated workup is performed; all organisms will be identified and reported but only select isolates will have sensitivities performed. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ BETA STREPTOCOCCUS GROUP C | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.12 S PENICILLIN G----------<=0.06 S VANCOMYCIN------------ 0.5 S ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. Pathology report of amputated finger ___: "Long finger," right hand amputation: Gangrene with underlying acute osteomyelitis, focally present at the bone resection margin ___ 6:51 pm SWAB Source: Distal R ___ digit SOURCE:DISTAL R ___ DIGIT FLUID 1. **FINAL REPORT ___ GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final ___: MIXED BACTERIAL FLORA. This culture contains mixed bacterial types (>=3) so an abbreviated workup is performed. Any growth of P.aeruginosa, S.aureus and beta hemolytic streptococci will be reported. IF THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT in this culture. STAPH AUREUS COAG +. SPARSE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. BETA STREPTOCOCCUS GROUP C. SPARSE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # ___ (___). STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. ___ 6:51 pm SWAB Source: Distal R ___ digit fluid 2 SOURCE:DISTAL ___ DIGIT FLUID 2. **FINAL REPORT ___ GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final ___: BETA STREPTOCOCCUS GROUP C. SPARSE GROWTH. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # ___ (___). STAPH AUREUS COAG +. RARE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # ___ (___). MIXED BACTERIAL FLORA. This culture contains mixed bacterial types (>=3) so an abbreviated workup is performed. Any growth of P.aeruginosa, S.aureus and beta hemolytic streptococci will be reported. IF THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT in this culture. ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. BCX ___: all final negative RADIOLOGY ============== LUE US ___: FINDINGS: There is normal flow with respiratory variation in the left subclavian vein. The left internal jugular and axillary veins are patent, show normal color flow and compressibility. The left brachial and basilic veins are patent, compressible and show normal color flow and augmentation. There is thrombus within the left cephalic vein from the antecubital fossa extending proximally, near the junction with the axillary vein. IMPRESSION: 1. Left cephalic vein thrombus originating at the antecubital fossa and extending proximally, near the junction with the axillary vein. 2. No deep vein thrombus. LUE US ___: FINDINGS: There is normal flow with respiratory variation in the left subclavian vein. Note is made of blunted phases City in the right subclavian vein with respect to the left. The left internal jugular and axillary veins are patent, show normal color flow and compressibility. The left brachial, and basilic veins are patent, compressible and show normal color flow. The left cephalic vein remains thrombosed and noncompressible, in unchanged distribution compared to the prior study. IMPRESSION: 1. No change in thrombosis of the left cephalic vein with no evidence of deep vein thrombosis in the left upper extremity. 2. Asymmetry of phasicity within the right subclavian vein waveform compared to the left, a finding that is of uncertain significance but could indicate a more proximal relative impedance to blood flow on the right, and could be further evaluated with chest CT if clinically indicated. RECOMMENDATION(S): Chest CTV could be performed for assessment of asymmetric phasicity of the subclavian vein waveforms (i.e. to exclude more central venous stenosis, compression or thrombosis) if clinically relevant. CT Venogram chest ___: FINDINGS: NECK, THORACIC INLET, AXILLAE, CHEST WALL: There are multiple bilateral hypodense millimetric nodules in an enlarged thyroid. No supraclavicular or axillary lymphadenopathy. UPPER ABDOMEN: Hiatal hernia is small. Innumerable cystic lesions throughout the pancreas, bilateral adrenal adenomas, and bilateral renal cysts are similar to and better evaluated on prior MRI. MEDIASTINUM: No mediastinal mass or lymphadenopathy. There is an 8 mm lower right paratracheal lymph node. HILA: No hilar lymphadenopathy. HEART and PERICARDIUM: Heart size is normal. There is coronary artery calcification. No pericardial effusion. PLEURA: Trace right pleural effusion with mild associated atelectasis. No left effusion or pneumothorax. LUNG: 1. PARENCHYMA: There is a 2 mm ground-glass nodule in the right upper lobe (04:49) and a 3 mm fissural nodule on the left (4:78), of doubtful clinical significance. No focal consolidation. 2. AIRWAYS: The airways are patent to subsegmental levels. 3. VESSELS: The main pulmonary artery measures up to 3.3 cm, similar to prior. The great vessels are otherwise normal caliber. There is severe compression of the right subclavian vein near the junction with the internal jugular vein, likely due to a narrow thoracic inlet. No mass or thrombus. Otherwise no significant stenosis of the imaged portions of the axillary, subclavian, internal jugular, and brachiocephalic veins bilaterally. No SVC stenosis. CHEST CAGE: No suspicious lytic or sclerotic lesion. No acute fracture. Old posterior right rib fractures are seen. Spinal hardware is partially imaged. IMPRESSION: 1. Severe compression of the right subclavian vein near the junction with the internal jugular vein, likely due to a narrow thoracic inlet. No mass or thrombus. Otherwise no significant stenosis of the imaged portions of the axillary, subclavian, internal jugular, and brachiocephalic veins bilaterally. No SVC stenosis. 2. Mild enlargement of the main pulmonary artery raises the question of possible pulmonary hypertension. . ___ INTERVENTIONAL RADIOLOGY FINDINGS IMPRESSION: Successful placement of a ___ single lumen Hickman tunneled line via the right internal jugular venous approach. The tip of the catheter terminates in the right atrium. The catheter is ready for use. Brief Hospital Course: ___ with PMHx of OSA, DM2, CAD, HTN, sp L5-S1 fusion, R index finger abscess and osteomyelitis ___ Group G strep s/p I&D x 3 in ___, reinfection of R index finger sp distal amputation at DIP, sp Cefepime/ Vanc who presented with R ___ finger cellulitis and osteomyelitis and is sp ___ digit DIP amputation. Course also complicated by HTN, extensive superficial thrombophlebitis (L), discovery of thoracic INLET syndrome and mild acute kidney injury. # R ___ digit acute osteomyelitis and cellulitis: noted to have Group C strep and MSSA. Partial amputation to level of DIP was performed in ED on ___. Subsequently pt underwent revision amputation and closure on ___. Abx narrowed from Vanc/Cefepime to IV Unasyn ___. Pathology w + morgins so abx recommended for 6-week course (___) of Unasyn 3g IV q6h to be followed by ID. Given LUE superficial thrombosis and RUE subclavian stenosis (see below for both), pt received tunneled IJ without issue instead of PICC. # Rash: Noted to have erythema in nasolabial folds. Derm evaluated and felt this was most cw seborrheic dermatitis. Started on short course of desonide as per discharge medications. # LUE superficial thrombosis: Noted on ___. Likely precipitated by PIV. Given how extensive, hematology was consulted and recommended against systemic anticoagulation. As a result of this, did not receive PICC on L. Swelling and induration in LUE along phlebitis resolved prior to discharge. # Thoracic inlet (not outlet) syndrome: noted on imaging, asymptomatic. Per hematology, he is potentially at risk for DVT on R side because of this. He continues to have none. Hematology advised that if he does have DVT on RUE he should receive normal therapy but would then need referral to hematology and consideration of surgical intervention # DM2: Glargine and ISS continued. Metformin held during admission, but resumed on discharge. # CAD/HLD: Contiued ASA, simvastatin. Pt's low heart rate prevents him from receiving beta blocker. # HTN: patient had well controlled hypertension through most of admission, though occasionally when anxious would become worse. Noted in last few days of hospitalization to have intermittent episodes of asymptomatic hypertension up to 180s systolic requiring intermittent dosing of captopril. In this setting, home lisinopril was uptitrated from 10mg to 20mg over a few days. Given an episode of BP of 180 on day of discharge, he received a single dose of captopril 12.5mg with resolution of BP, but HCTZ was initiated (this was chosen over amlodipine given his intermittent lower extremity edema). # mild pre-renal state, ___: during early admission, pt had his furosemide increased to daily, which led to a mild ___ (peak creatinine 1.1 and peak BUN 18), but after stopping standing furosemide and giving very gentle hydration, reduced to 1.0 and 13 and stable on discharge (likely some elevation from ACE inhibitor uptitration too. # Psych: anxiety treated with home buspirone, lamotrigine, quetiapine, trazodone Transitional Issues: - Continue eval of anemia - All questions regarding outpatient parenteral antibiotics after discharge should be directed to the ___ R.N.s at ___ or to the on-call ID fellow when the clinic is closed. - PLEASE NOTIFY THE ID SERVICE OF ANY QUESTIONS REGARDING THESE RECOMMENDATIONS OR WITH ANY MEDICATION CHANGES THAT OCCUR AFTER THE DATE/TIME OF THIS OPAT INTAKE NOTE. - Please obtain and fax weekly labs to ___ clinic as prescribed - Please monitor for sx of subclavian stenosis; as above, if has a RUE DVT would need normal anticoagulation therapy but also eval by hematology and consideration of surgical repair > 30 minutes spent on transition of care/communication/patient care on day of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 10 mg PO DAILY 2. BusPIRone 10 mg PO TID 3. QUEtiapine Fumarate 150 mg PO QHS 4. MetFORMIN (Glucophage) 1000 mg PO BID 5. Cephalexin 500 mg PO Q8H 6. Glargine 10 Units Bedtime 7. Furosemide 20 mg PO DAILY: PRN leg swelling 8. Simvastatin 10 mg PO QPM 9. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) 600 mg(1,500mg) -200 unit oral daily 10. Aspirin 81 mg PO DAILY 11. Doxycycline Hyclate 100 mg PO Q12H 12. Cyanocobalamin ___ mcg PO DAILY 13. Vitamin D 400 UNIT PO DAILY 14. TraZODone 150 mg PO QHS 15. Zenpep (lipase-protease-amylase) ___ unit oral 7 tablets TID with meals 16. LamoTRIgine 50 mg PO TID 17. LamoTRIgine 100 mg PO QHS 18. Zenpep (lipase-protease-amylase) ___ unit oral 2 with meals PRN take with snacks 19. Acetaminophen 1000 mg PO TID:PRN pain 20. Senna 8.6 mg PO DAILY:PRN constipation Discharge Medications: 1. Acetaminophen 1000 mg PO TID:PRN pain 2. Aspirin 81 mg PO DAILY 3. BusPIRone 10 mg PO TID 4. Cyanocobalamin ___ mcg PO DAILY 5. Furosemide 20 mg PO DAILY: PRN leg swelling 6. Glargine 10 Units Bedtime 7. LamoTRIgine 50 mg PO TID 8. LamoTRIgine 100 mg PO QHS 9. QUEtiapine Fumarate 150 mg PO QHS 10. Senna 8.6 mg PO DAILY:PRN constipation 11. Simvastatin 10 mg PO QPM 12. TraZODone 150 mg PO QHS 13. Vitamin D 400 UNIT PO DAILY 14. Zenpep (lipase-protease-amylase) ___ unit oral 7 tablets TID with meals 15. Zenpep (lipase-protease-amylase) ___ unit oral 2 with meals PRN take with snacks 16. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) 600 mg(1,500mg) -200 unit oral daily 17. MetFORMIN (Glucophage) 1000 mg PO BID 18. Desonide 0.05% Cream 1 Appl TP BID BID x 10 days; then daily x 1 week RX *desonide 0.05 % 1 appplication twice a day Refills:*0 19. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN moderate pain RX *oxycodone 10 mg 1 tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 20. Ampicillin-Sulbactam 3 g IV Q6H RX *ampicillin-sulbactam 3 gram 3 g iv every six (6) hours Disp #*136 Vial Refills:*0 21. Outpatient Lab Work Fax to ATTN: ___ CLINIC - FAX: ___ WEEKLY: CBC with differential, BUN, Cr, ESR, CRP Dx: Osteomyelitis 22. Hydrochlorothiazide 25 mg PO DAILY 23. Lisinopril 20 mg PO DAILY 24. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush 25. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line flush Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: - Right third digit osteomyelitis - DM II - Superficial thrombophlebitis - Thoracic outlet syndrome - Hypertensive urgency - Acute kidney injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you here at ___. You were admitted with an infection in your right middle finger at the tip that extended to the bone. Plastic surgery performed an amputation and you were treated with IV antibiotics in consultation with our infectious disease team. There was still evidence of infection at the bone margin so further antibiotics were recommended. Please follow up with your primary care provider ___ as below as well as plastic surgery and infectious disease as below. Best wishes, Your ___ team Followup Instructions: ___
10154479-DS-11
10,154,479
29,648,489
DS
11
2138-03-28 00:00:00
2138-03-28 13:11:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Odynophagia Major Surgical or Invasive Procedure: Fiber optic nasopharyngeal exam History of Present Illness: ___ F with h/o smoking, anxiety, essential tremor who is admitted with glottic inflammation. . Patients first developed ST and odynophagia on ___ evening. Presented to OSH ED last night due to continued odynophagia, fever and inability to take PO's. Had fever to 102 w/oleukocytosis, CT of the neck was performed to rule out abscess and was read as normal. Cultures were not obtained. She was discharged home on antibiotics which she did not fill. Her imaging was rereviewed today and now read as showing evidence of supraglottic and glottic edema/inflammation with mild airway narrowing. Patient was called back to the ED. On presentation she reported persistent symptoms including fever and ST, able to swallow secretions but has had poor been PO intake d/t pain. Also reports 1 day of productive cough but unable to produce sputum. Had some nausea, small amount vomiting. Also notes hoarsness. Denies SOB, stridor, droolig, stiff jaw or stiff neck. No abdominal pain or diarrhea. Has not taken any recent Abx. Denies any recent dental or other oral procedure. Denies new medication, inhalations or mouth washes. No sick contacts. She does work in a ___ and is therby exposed to fumes. . Of note patient notes that she has been experiencing mild intermittent hoarsness over the past ___ months. She saw an ENT specialist at ___ 6 weeks ago who performed fiber-optic exam which she says was unremarkable. She was told this was age related hoarsness. She denies any recent weight loss or other constitutional symptoms. Patient also endorses significant heartburn for which she has been taking omeprazol for years but is still symptomatic. She has never had EGD. . ED Course - Initial Vitals: 101.2 110 139/43 20 98% [x] labs: WBC 5.2 with 21% bands [x] blood cultures + throat cultures sent [x] IVF NS 2L [x] abx - unasyn 1g at 17:30 [x] solumedrol 125mg at 18:40 [X] got acetaminophen 650mg + IV morphine 4mg for pain [x] ENT bed side fibroscope- pooling of secretions, vocal cord/subglottic edema, small airway likely baseline. exudative process R cord. supraglottic and glottic edema with mild airway narrowing. The patient does not complain of airway compromise symptoms, however given the location of her infection/inflammation, would worry about the potential to get worse without close monitoring and therapy. --> needs abx, steroids, plan to rescope tomorrow. [X]in the ED dropped stas to 90-91% on room air which improved to 97% with 2L NC. Per ED signout did not become tachypnic or dyspnic at any point and did not complain of symptoms of airway compromise. . transfer vitals: 98.2, Pulse: 90, RR: 18, BP: 125/58, O2Sat: 97%, O2Flow: ra . On arrival to the MICU, . Review of systems: (+) Per HPI (-) Denies chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: anxiety depression benign essential tremor s/p left cervical lipoma excision ___ years ago Social History: ___ Family History: N/C Physical Exam: Admission physical exam: General: Alert, oriented, no acute distress. Breathing comfortably with no stridor, tachypnea or dyspnea, able to complete sentences, slightly hoarse voice. HEENT: Sclera anicteric, mild pallor, MMM, oropharynx clear, EOMI, PERRL Neck: supple, bil anterior cervical lymphadenopathy, JVP not elevated, no LAD CV: Regular rate and rhythm, no murmurs, rubs, gallops Lungs: reduced air entery bilaterally with increased expiratory phase, few scattered wheezes and some coarse left basillar crackles at end inspiration. Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, no clubbing, cyanosis or edema Neuro: CN grossly intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, normal tone. . Discharge physical exam: Vitals: T 98.2 HR 90 BP 138/60 RR 16 O2 Sat 94-95% RA General: Patient sitting up in bed in NAD without stridor. Voice hoarse. HEENT: EOMI. PERRL. MMM. No swelling in the OP. OP without erythema, exudate, and ulcerations. Neck: Symmetrical, supple, with no tenderness to palpation, no cervical LAD, or other sweelings appreciated. CV: RRR. No M/R/G Lungs: Crackles at the bases bilaterally, otherwise clear to auscultation bilaterally. Abdomen: NABS+. Soft. NT/ND. No rebound/guarding. Ext: WWP. Trace pitting edema. 2+ DPs bilaterally. Pertinent Results: ADMISSION LABS: ___ 03:00AM BLOOD WBC-5.1 RBC-3.37* Hgb-11.3* Hct-32.5* MCV-96 MCH-33.6* MCHC-34.9 RDW-16.5* Plt ___ ___ 05:15PM BLOOD WBC-5.2 RBC-3.28* Hgb-10.6* Hct-31.1* MCV-95 MCH-32.3* MCHC-33.9 RDW-16.3* Plt ___ ___ 03:27AM BLOOD WBC-5.1 RBC-2.96* Hgb-10.0* Hct-28.6* MCV-97 MCH-33.7* MCHC-34.9 RDW-16.9* Plt ___ ___ 03:00AM BLOOD Neuts-82.0* Lymphs-12.7* Monos-3.2 Eos-1.4 Baso-0.7 ___ 05:15PM BLOOD Neuts-62 Bands-21* Lymphs-10* Monos-7 Eos-0 Baso-0 ___ Myelos-0 ___ 03:00AM BLOOD Glucose-111* UreaN-21* Creat-1.0 Na-139 K-4.0 Cl-102 HCO3-25 AnGap-16 ___ 03:27AM BLOOD Glucose-157* UreaN-19 Creat-0.9 Na-141 K-3.8 Cl-108 HCO3-23 AnGap-14 ___ 03:27AM BLOOD Calcium-7.4* Phos-3.3 Mg-1.8 ___ 05:26PM BLOOD Lactate-1.6 . DISCHARGE LABS: ___ 03:27AM BLOOD WBC-5.1 RBC-2.96* Hgb-10.0* Hct-28.6* MCV-97 MCH-33.7* MCHC-34.9 RDW-16.9* Plt ___ ___ 03:27AM BLOOD Neuts-90.1* Lymphs-7.5* Monos-2.0 Eos-0.2 Baso-0.1 ___ 03:27AM BLOOD Glucose-157* UreaN-19 Creat-0.9 Na-141 K-3.8 Cl-108 HCO3-23 AnGap-14 ___ 03:27AM BLOOD Calcium-7.4* Phos-3.3 Mg-1.8 . PA AND LATERAL CHEST RADIOGRAPHS: The cardiomediastinal and hilar contours are normal. The lungs are hyperinflated. No consolidation, pleural effusion or pneumothorax is seen. A large hiatal hernia is present. IMPRESSION: Hyperinflated lungs suggestive of COPD. No acute abnormality. . CT NECK W/CONTRAST FINDINGS: The nasopharynx, oropharynx and hypopharyngeal spaces are normal, without evidence of deep cervical infection. There is no evidence of a retropharyngeal abscess. The larynx and airway are normal in the imaged portion. No significant cervical adenopathy is seen. The parotid and submandibular salivary glands are normal. The thyroid gland is normal. The imaged portion of the brain appears unremarkable. The cervical vessels are normal. Moderate atherosclerotic calcification is seen in the aortic arch. The imaged lung apices demonstrate mild centrilobular emphysema and minimal bi-apical pleural parenchymal scarring. The imaged paranasal sinuses and mastoid air cells are clear. No periapical lucency is identified. Extensive dental implants with streak artifacts are noted. There is reversal of normal cervical lordosis with moderate degenerative changes at C4-C5, C5-C6 and C6-C7 levels. Mild anterolisthesis of C3 on C4 is noted. IMPRESSION: No acute abnormality identified in the neck, especially no retropharyngeal abscess. NOTE ADDED AT ATTENDING REVIEW: There is diffuse supraglottic and to lesser extent glottic swelling. The epiglottis appears normal, there is no evidence of adenopathy, and no abscess is identified. This does not appear focal enough to suggest a neoplasm and appears more likely to be due to inflammation. The airway is somewhat narrowed, most markedly at the level of the true cords, series 2 image 56. Given this appearance, we suggest the patient return for evaluation by ENT. This revised interpretation was discussed by telephone with the ED QA nurse, ___, at 11 am on ___ by Dr. ___ ___: Blood Culture, Routine (Pending): Blood Culture, Routine (Pending): R/O Beta Strep Group A (Pending): MRSA SCREEN (Pending): Brief Hospital Course: #. Epiglottitis/supraglottitis: Based on scope and CT scan, the patient found to have swelling involving epiglottis, false vocal cords and some supraglottic narrowing, also noted to have exudative process surrounding the right false vocal cord. Given her fever and bandemia on admission this is most likely to be infectious and concerning for bacterial infection. Patient was therefore started on IV Unasyn and also given high-dose IV steroids due to concern for airway narrowing. Patient at no point developed symtpoms of respiratory compromise, she continued to breath comfortably, and handled her secretions well throughout her admission. She was able to take food and drink. She was discharged on empiric PO Augmentin 875mg BID for completion of a 10-day course of antibiotics and on PO prednison 60mg for completion of a 5-day course per ENT recommendations. . # Hoarseness: This is most likely due to prolonged uncontrolled GERD due to chronic aspiration and laryngeal irritation. Omeprazole was switched to Pantoprazole 40 mg BID. On day of discharge, the patient was tolerating her secretions, swallowing with less pain, tolerating an oral diet, saturating well on room air, and afebrile. . # Hypoxia: Patient had desaturations down to 91% on RA without any symtpoms of dyspnea. Patient has a history of smoking, hyperinflation on chest x-ray and some centrilobular bulous findings at lung apices on CT of the neck all of which are suggestive of emphysema. Likely has mild hypoxia at baseline and probably not related to laryngeal issues. On day of discharge, patient was saturating well on room air without signs of symptoms of airway compromise. . CHRONIC STABLE ISSUES: . # Anemia: Normocytic anemia with Hct 31.1 from unkonwn baseline, MCV on the high side at 98. Patient's hematocrit remained stable through the admission. . # Axiety/depression: Continued home ativan and mirtazapin. . # Benign essential tremor: Continued propanolol 20 mg every AM, 10 mg every day at Noon. . TRANSITIONAL ISSUES: - Continue antibiotics and prednisone as above. - Follow-up with ENT scheduled. - Follow-up with gastroenterology regarding GERD (scheduled). ___ need EGD. - Consider outpatient PFTs given borderline hypoxia. Medications on Admission: Propanolol 20mg QAM, 10mg QPM Mirtazapin 7.5mg QHS Ativan 0.5mg QHS Omeprazol 20mg QAM Discharge Medications: 1. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. Disp:*15 Tablet(s)* Refills:*0* 2. prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day for 5 days. Disp:*15 Tablet(s)* Refills:*0* 3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. propranolol 10 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 5. propranolol 10 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 6. mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 7. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for sleep. 8. codeine-guaifenesin ___ mg/5 mL Syrup Sig: Five (5) ML PO Q4H (every 4 hours) as needed for cough. Disp:*100 ML(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS Epiglottitis SECONDARY DIAGNOSIS: Essential tremor Anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of your ___ ___. You were admitted to ___ for a sore throat and pain with swallowing. You were found to have swelling in your airway, and you were treated with intravenous steroids and antibiotics. You will need to continue taking oral antibiotics and steroids once you leave the hospital. It is *VERY* important that you continue antibiotics and steroids as an outpatient. . Please take all medications as instructed. Please note the following medication changes: 1. *START* Prednisone 60mg daily for 4 more days. 2. *START* Augmentin *TWICE* daily for 7 more days; you will need to take 1 dose after you leave the hospital on day of discharge. 3. *START* pantoprazole 40mg twice daily to help with your symptoms of acid reflux. 4. Codeine-guaifenesin syrup as needed for your cough. Take 5mL every four (4) hours as needed for cough **You have been provided with a script for these new medications.** Please keep all follow-up appointments; your upcoming appointments are listed below. Followup Instructions: ___
10154578-DS-7
10,154,578
29,824,487
DS
7
2153-08-17 00:00:00
2153-08-17 16:17:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: right hip pain, avascular necrosis of the hip Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old man with a PMH of hepatitis C, PE, DVT, peptic ulcer with known avascular necrosis of the right hip, presents with persistent right hip pain. Patient was admitted for this pain in early ___ at which point septic joint was ruled out. Patient left AMA at that time because "they wouldn't feed me." Has been living with this pain for the past several month now, using crutches to get around, and presents now to have his hip repaired. Fell yesterday on right side, feels unsteady with hip pain at baseline. Denies hitting head. No increase in pain, managed well on oxycodone 10mg Q4h, though notes having taken some of his roommate's methadone (?20mg) which "works better than oxycodone." . In the ED, VS 98.7 46 150/93 16 100% RA. Right hip xray showed no change from ___ xray. Given nicotine patch, lovenox 30mg, oxycodone 5mg, gabapentin 600mg. Ortho Trauma was consulted and signed off as this is an outpatient evaluation. . Vitals on transfer: 98.1 61 18 133/92 95%. On the floor, his pain is over the right hip, going into his groin, worse with wlking, no loss of sensation, no hematomas. Notes some pain of his right knee as well. Past Medical History: Hepatitis C PE DVT 3 pins in his L ankle Peptic Ulcer - inactive for the last ___ Depression/Anxiety ?prolonged Qtc in the past (Qtc in the ___ during admission) Social History: ___ Family History: prostate cancer in GF, Lung cancer in other GF. Denies DM, MI, stroke. Physical Exam: Admission Exam: Vitals: T: 97.9 BP: 130/80 P: 53 R: 18 O2: 100%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, dry poor dentition Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular (slightly bradycardic) rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. tender to palpation and movement over right hip. right knee is nontender, ROM minimally limited ___ radiating hip pain. Skin: intact skin Neuro: A&Ox3, muscles ___ strength throughout though somwhat limited in RLE ___ hip pain. sensation intact throughout to light touch. Discharge Exam: Vitals: 98.2 ___ 16 100%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, dry poor dentition Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular (slightly bradycardic) rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. tender to palpation and movement over right hip. right knee is nontender, ROM minimally limited ___ radiating hip pain. Skin: intact skin Neuro: A&Ox3, muscles ___ strength throughout though somwhat limited in RLE ___ hip pain. sensation intact throughout to light touch. Pertinent Results: Admission Labs: ___ 12:00AM BLOOD WBC-5.5 RBC-4.18* Hgb-12.8* Hct-36.5* MCV-87 MCH-30.7 MCHC-35.2* RDW-14.9 Plt ___ ___ 12:00AM BLOOD Neuts-48.7* ___ Monos-4.8 Eos-9.1* Baso-0.4 ___ 12:00AM BLOOD ___ PTT-28.4 ___ ___ 12:00AM BLOOD Glucose-90 UreaN-10 Creat-0.7 Na-143 K-4.3 Cl-108 HCO3-29 AnGap-10 ___ 12:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 12:50AM URINE Color-Yellow Appear-Clear Sp ___ ___ 12:50AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG ___ 12:50AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 ___ 12:50AM URINE CastHy-3* ___ 12:50AM URINE Mucous-FEW ___ 12:50AM URINE bnzodzp-POS barbitr-NEG opiates-NEG cocaine-POS amphetm-NEG mthdone-POS LFTs/Albumin: ___ 07:40AM BLOOD ALT-15 AST-17 LD(LDH)-157 AlkPhos-78 TotBili-0.2 ___ 07:40AM BLOOD Albumin-3.6 Calcium-9.0 Phos-3.2 Mg-2.0 Labs prior to discharge: ___ 07:40AM BLOOD WBC-6.2 RBC-4.47* Hgb-13.6* Hct-39.0* MCV-87 MCH-30.5 MCHC-34.9 RDW-14.6 Plt ___ ___ 07:40AM BLOOD Glucose-99 UreaN-15 Creat-0.8 Na-142 K-3.9 Cl-106 HCO3-28 AnGap-12 ___ 07:40AM BLOOD ALT-15 AST-17 LD(LDH)-157 AlkPhos-78 TotBili-0.2 ___ 07:40AM BLOOD Albumin-3.6 Calcium-9.0 Phos-3.2 Mg-2.0 Imaging: ___ hip xray: Exam appears largely unchanged with bone-on-bone contact of the right femoral head and acetabulum. Right femoral head is flattened and laterally subluxed in regards to the acetabulum. There is stable patchy sclerosis within the femoral head. No new fracture lines are identified. The remainder of the pelvis and left hip are unremarkable. IMPRESSION: Largely unchanged exam with a markedly abnormal right femoroacetabular joint with flattening, sclerosis and a lateral superior subluxation of the femoral head. As before the differential diagnosis includes septic arthritis versus AVN. ___ CXR: Chest PA and lateral radiograph demonstrates a tortuous aorta with questionable prominence of the ascending aortic contour. Heart size is normal. Th previously noted right lower lung opacity has largely resolved with minimal residual linear opacities evident on the lateral view, likely post-inflammatory. There has been interval resolution of the previously identified right lower lung opacity. Multiple calcified nodules identified, the largest located in the left upper lung. No pleural effusion or pneumothorax evident. IMPRESSION: Tortuous aorta with prominence of ascending aortic contour. If clinical conern, could be further evaluated with chest CT. Multiple calcified granulomas. Brief Hospital Course: ___ year old man with a PMH of hepatitis C, PE, DVT with known avascular necrosis of the right hip, presents with persistent right hip pain. . # Hip pain: Due to known avascular necrosis of the right hip. Hip xray was unchanged from prior. Patient was admitted in ___ and ruled out for septic hip joint. He did not have fevers or leukocytosis during this admission and suspicion for septic joint was low. He was seen by orthopedic surgery and he was informed that he should be scheduled in the outpatient setting for total hip replacement of the right hip to correct this problem. He was continued on his home gabapentin and oxycodone with good pain control. Ibuprofen was also added. He was evaluated by ___ who recommended acute rehab, but given patient's insurance coverage, he was discharged to ___ ___ ___ with outpatient ___. During his hospitalization, he was put on lovenox for DVT prophylaxis given hip fracture. He was ambulating with a walker/crutches and so DVT prophylaxis was not continued on discharge due to concern for his noncompliance and possible falls. . # History of PE/DVT: Pt reported hx of PE/DVT ___ years ago and stated noncompliance with blood thinners including lovenox injections. Circumstances surrounding these prior VTEs was unclear; pt stated that he was told he should be on life long anticoagulation. During hospitalization, he was on lovenox at DVT prophylaxis doses. Given his polysubstance abuse, noncompliance with medications and medical care, potential for falls, and likely upcoming surgery for hip repair, he was not started on blood thinners for prevention of PE/DVT. . # Hepatitis C: Patient denies previous treatment. LFTs WNL this admission, INR 1.3. Not active issue. . # Anemia: Hct improved from 36.5->39.0, stable from previous admission, MCV 87. Likely anemia of chronic disease given HCV. . # Social Issues: Patient was positive for methadone, cocaine, benzos. Acknowledges depression and anxiety. Does not have good social support. States his roommate bribes him with methadone and benzos. Social work consult was obtained and met with patient. Psychiatry also evaluated pt as he endorsed depression and occasional SI on admission. He did not have active suicidal ideation and felt mood was largely stable while in hospital. He was counseled on following up at ___. Of note, if he is started on antidepressants as outpatient, he should be monitored for QTc prolongation, and SSRIs should likely be avoided or used with extreme caution as he does have hx of this syndrome. As he was homeless, he was discharged to ___ for further care. . # History of prolonged Qtc: Took methadone recently prior to admission. Over admission, Qtc remained between 424 and 462. . Transitional Issues: Patient has many social issues that have prevented him from pursuing outpatient evaluation and management of the avascular necrosis of his right hip. He missed his last ortho appointment for unclear reasons. Patient is being discharged to ___ and has ortho and PCP follow up. ___ hope is that he will make his appointments more reliably in these living circumstances. Medications on Admission: Gabapentin 600 mg TID Oxycodone 5mg ___ (prescribed by ___ at ___ Discharge Medications: 1. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). Disp:*90 Capsule(s)* Refills:*0* 2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every ___ hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* 5. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) packet PO DAILY (Daily) as needed for constipation. Disp:*30 packets* Refills:*0* 6. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain for 1 weeks. Disp:*30 Tablet(s)* Refills:*0* 7. Outpatient Physical Therapy Physical therapy. WBAT. 8. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) patch Transdermal once a day: Do not use when smoking. Disp:*30 patches* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Avascular necrosis of the right hip Secondary Diagnosis: Hepatitis C PE DVT 3 pins in his L ankle Peptic Ulcer - inactive for the last ___ Depression/Anxiety prolonged Qtc in the past Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at ___ ___. You were admitted for right hip pain and management of this problem. You pain was well controlled on your outpatient pain regimen of oxycodone. Physical therapy was able to work with you and did not feel you were very stable. They felt you would benefit from rehabilitation. Additionally, the orthopedic trauma specialists saw you and recommended that you come see them in clinic to talk about options for treatment and scheduling your hip replacement. It is very important that you keep this appointment so that you can have this problem fixed permanently. You were also seen by our social workers for your substance abuse and counseled on possible resources to help you quit. You were also seen by our psychiatry team as you expressed feelings of sadness. You can follow up with psychiatry at ___ for further care. The following changes were made to your medications: 1) START ibuprofen 600mg every 8 hours as needed for pain for one week 2) START nicotine patch 21mg transdermal daily 3) START docusate, senna, miralax for constipation 4) CONTINUE gabapentin and oxycodone Please discuss with your doctor if you need to restart blood thinners for your history of blood clots. Please also take docusate sodium 1 tablet twice daily to ensure your bowel movements are regular, as oxycodone can cause constipation. If you have not had a bowel movement in over a day, you should additionally take 1 tablet of senna twice daily until you have a bowel movement. You may also take miralax powder if you are constipated. Followup Instructions: ___
10155329-DS-7
10,155,329
21,745,132
DS
7
2128-06-01 00:00:00
2128-06-02 14:55:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: bullet in buttocks Major Surgical or Invasive Procedure: exam under anesthesia, rigid & flex proctoscopy, and removal of bullet. History of Present Illness: This patient is a ___ year old male who complains of Gunshot wound, Transfer. pt from ___ has a GSW to buttocks now with sacral fracture ? rectal perf. ___- year-old male transferred in for evaluation after a gunshot wound. Patient was seated in a moving vehicle, approximately 10 shots were fired at the vehicle, he sustained a gunshot wound to his left buttock,, and was taken to an outside hospital for evaluation. He was found there to have a retained bullet and a sacral fracture on CT and was transferred for trauma surgery evaluation. He received Cipro and Flagyl prior to transfer. Past Medical History: ___ ___ sp splenectomy and nephrectomy Social History: ___ Family History: noncontributory Physical Exam: Physical Exam at Admission: General: Well-appearing male in no acute distress. CV: RRR Abd: soft, nontender Bilateral lower extremity: - Entrance wound L glut, palpable bullet subcutaneous in R glut - Tolerates passive ROM of hip and knee - Fires ___ - SILT S/S/SP/DP/T distributions - 1+ ___ pulses, WWP Physical Exam at discharge: VS: 98.7, 127/86, 75, 15, 98%Ra Head: normocephalic, atraumatic CV: RRR Abd: soft, nontender, nondistended Buttock: dressing c/d/i, no surrounding erythema around right gluteal wound Extrem: warm, well perfused, good ROM Neuro: no gross deficits Pertinent Results: ___ 01:00AM BLOOD WBC-21.8* RBC-4.58* Hgb-12.1* Hct-38.8* MCV-85 MCH-26.4 MCHC-31.2* RDW-14.4 RDWSD-44.2 Plt ___ ___ 01:10AM BLOOD Glucose-128* Lactate-1.2 Na-139 K-3.6 Cl-105 CT Abd/Pelvis ___: IMPRESSION: 1. No extraluminal contrast extravasation of the rectum. 2. Presacral hematoma noted with comminuted minimally displaced fracture of S5 with possible extension to S4-S5. 3. Stable scattered foci of soft tissue air is noted in the bullet tract with a 1.7 cm bullet fragment the right buttock subcutaneous tissues within adjacent subcutaneous hematoma. 4. Well-circumscribed multi-cystic structure lateral to the right of the IVC with calcifications incompletely characterized on this noncontrast scan. Differential includes mesenteric cyst, carcinoid, or lymphangioma. Recommend further evaluation with contrast-enhanced study. CXR Abd/Pelvis ___: IMPRESSION: Chest radiograph: Normal chest radiograph. Abdominal radiograph: Bullet fragment noted projecting over the right buttocks measuring 1.7 cm Brief Hospital Course: Mr. ___ is a ___ male with pM/SHx significant for MVC sp nephrectomy and splenectomy in ___ now sp GSW with a S5 fx and superficial bullet in R buttock. He was admitted to the ACS service at ___ and received prophylactic IV Abx. He underwent a bedside rectal exam which was poorly tolerated. Later was taken to the OR for examination under anesthesia, ridged sigmoidoscopy, flexible sigmoidoscopy, and removal of bullet from right lateral buttock. No damage to the sigmoid/rectum was noted during the procedure. The bullet was removed. He was kept overnight for observation. He discharged in the morning in stable condition, voiding well, ambulating well and with adequate pain control. Medications on Admission: none Discharge Medications: 1. Acetaminophen 650 mg PO Q6H RX *acetaminophen 325 mg 2 tablet(s) by mouth every 6 hours Disp #*40 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: gun shot wound Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to ___ and under went an exam under anesthesia, rigid & flex proctoscopy, and removal of bullet. You were monitored overnight for symptoms of rectal injury. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips ___ days after surgery. Thank you for allowing us to be involved with your care. Sincerely, Your ___ Team Followup Instructions: ___
10155336-DS-5
10,155,336
22,060,295
DS
5
2187-05-27 00:00:00
2187-05-28 11:46:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: right facial/hemibody numbness Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ year old man who presents with three episodes of transient right sided sensory disturbance. He has a history of occasional headaches (a few times per year) which are right sided, periorbital, and pulsatile/throbbing with some right eye blurriness and sometimes tearing (one which he called a proper "migraine" three months ago that was severe). He had a similar headache last night around 12:30 AM as he was getting ready to go to sleep which lasted about 20 minutes with no other new features. However, after about 20 minutes, he noticed a sensory disturbance in his face that he calls "tingling" which he explains is like "thousands of ants crawling in side me" on that side. It started in his right face, traveled down his arm and torso, and then down his leg to his feet over the course of ___ minutes. The entire sensation lasted 20 minutes, and it resolved in the same order as it started. He became very anxious and started breathing heavily and became short of breath, but this spontaneously resolved. He went to sleep but woke up at his usual time around 0530 this morning with another episode of the exact same sensation (same order, timing, and characterization). There was no noticeable headache with this episode. This concerned him and his wife and they took him to ___ ___ where he had basic laboratory testing and an ___ which were interpreted as normal. As the physician was telling him this, he had a third episode (around 1000 AM). He says "I'm glad I had that episode in front of the doctor)" to which the physician described to him that this sort of recurrent course can happen with some dangerous conditions such as stroke. He was then transferred to ___ for further evaluation. He did not have any further episodes although he thought one might come on as this evaluation began (it did not). Interestingly, he retracted the notion that the symptoms resolved in the same order as they progressed after being explained that this pattern is most consistent with migraines with aura. He denies any recent illness, sleep deprivation, drug use, etc. On neurologic review of systems, the patient endorses headache. Denies lightheadedness or confusion. Denies difficulty with producing or comprehending speech. Endorses blurred vision. Denies loss of vision, diplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or dysphagia. Endorses muscle weakness. Endorses loss of sensation. Denies bowel or bladder incontinence or retention. Denies difficulty with gait. On ___ review of systems, the patient denies fevers, rigors, night sweats, or noticeable weight loss. Denies chest pain, palpitations, dyspnea, or cough. Denies nausea, vomiting, diarrhea, constipation, or abdominal pain. Denies dysuria or hematuria. Denies myalgias, arthralgias, or rash. Past Medical History: None Social History: ___ Family History: No stroke. No migraines or recurrent headaches. Intracranial aneurysm (father, died in his ___. Epilepsy (brother, since childhood, controlled on anticonvulsant therapy). Physical Exam: ADMISSION EXAM: VS T: 97.8 HR: 64 BP: 138/88 RR: 20 SaO2: 99% RA ___: NAD, lying in bed comfortably. / Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions / Neck: Supple, no nuchal rigidity, no bruits / Cardiovascular: RRR, no M/R/G / Pulmonary: Equal air entry bilaterally, no crackles or wheezes / Abdomen: Soft, NT, ND, +BS, no guarding / Extremities: Warm, no edema, palpable radial/dorsalis pedis pulses / Skin: Scratch under left eye, otherwise no rashes or lesions / Psychiatric: Anxious, flat affect, somewhat angry, "I cannot let this stop me from working" Neurologic Examination: - Mental Status - Awake, alert, oriented x 3. Attention to examiner easily attained and maintained. Recalls a coherent history. Structure of speech demonstrates fluency with full sentences, intact repetition, and intact verbal comprehension. Content of speech demonstrates intact naming (high and low frequency) and no paraphasias. Normal prosody. No dysarthria. No apraxia. No evidence of hemineglect. No left-right agnosia. - Cranial Nerves - [II] PERRL 3.5->2 brisk. VF full to number counting. [III, IV, VI] EOMI, no nystagmus. [V] V1-V3 without deficits to light touch bilaterally but with 90% pin sensation on right compared to left. [VII] No facial asymmetry at rest or with movement. [VIII] Hearing intact to finger rub bilaterally. [IX, X] Palate elevation symmetric. [XI] SCM/Trapezius strength ___ bilaterally. [XII] Tongue midline. - Motor - Normal bulk and tone. No pronation, no drift. No tremor or asterixis. *Giveway weakness [ Direct Confrontational Strength Testing ] Arm Deltoids [C5] [R 5*] [L 5] Biceps [C5] [R 5*] [L 5] Triceps [C6/7] [R 5*] [L 5] Extensor Carpi Radialis [C6] [R 5*] [L 5] Extensor Digitorum [C7] [R 5*] [L 5] Flexor Digitorum [C8] [R 5*] [L 5] Leg Iliopsoas [L1/2] [R 5*] [L 5] Quadriceps [L3/4] [R 5*] [L 5] Hamstrings [L5/S1] [R 5*] [L 5] Tibialis Anterior [L4] [R 5*] [L 5] Gastrocnemius [S1] [R 5*] [L 5] Extensor Hallucis Longus [L5] [R 5*] [L 5] Extensor Digitorum Brevis [L5] [R 5*] [L 5] Flexor Digitorum Brevis [S1] [R 5*] [L 5] **Testing strength bilaterally results in giveway weakness on both sides. - Sensory - No deficits to light touch or proprioception bilaterally. Endorses slight sensory diminishment to pin sensation on right side (90% on right compared to the left). - Reflexes =[Bic] [Tri] [___] [Quad] [Gastroc] L 2 2 2 2 2 R 2 2 2 2 2 Plantar response flexor on right, withdrawal response on left. - Coordination - No dysmetria or dysdiadochokinesia. - Gait - Deferred due to interruption of examination by emergent consultation ========================== DISCHARGE EXAMINATION: GEN: appears comfortable, sitting up in bed. Unchanged. NEURO: CN: Slightly decreased palpebral fissure on the right side, otherwise normal. MOTOR: good strength throughout Pertinent Results: ADMISSION LABS: ___ 01:58PM BLOOD WBC-5.9 RBC-4.52* Hgb-13.6* Hct-39.8* MCV-88 MCH-30.1 MCHC-34.1 RDW-12.9 Plt ___ ___ 01:58PM BLOOD Neuts-66.6 ___ Monos-6.6 Eos-1.7 Baso-0.6 ___ 01:58PM BLOOD Glucose-98 UreaN-14 Creat-0.9 Na-135 K-3.8 Cl-103 HCO3-26 AnGap-10 TOX SCREEN: ___ 01:58PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 02:29PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG UA: ___ 01:58PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 01:58PM URINE Color-Straw Appear-Clear Sp ___ IMAGING: MRI/MRA HEAD/NECK ___: No evidence of hemorrhage or infarction. No vascular abnormalities are detected. Scattered white matter hyperintensities on FLAIR, unlikely to be of clinical significance. Brief Hospital Course: TRANSITIONAL ISSUES: [] uptitration of amitryptyline as outpatient for migraine prophylaxis and also for pain modulation =============== ___ yo M with prior recurrent headaches presented with transient episodes of right face and hemibody sensory disturbance lasting minutes accompanied by severe headaches. Given history of contact sports, MRI/MRA were obtained to rule out dissection and did not show any abnormalities. EEG was also obtained to rule out seizures and was normal. It was explained to the patient that this process most likely represents complex migraine with aura. He was treated with tylenol and toradol for pain, with addition of tizanidine given some pain and ?muscle spasm radiating from neck to head. He was also started on amitryptyline for migraine prophylaxis with plan to uptitrate the medication as outpatient. There was concern for medication seeking behavior as patient requested opiates as well as IV benadryl for his headache (as he gets pruritus from opiates). He did receive 1 dose of oxycodone-acetaminophen with PO benadryl, and also 1 dose of valium for his muscle/tension headache, but these were not continued at discharge given concern for medication seeking behavior. No recorded history of addiction or medication abuse, but no records available at ___. Medications on Admission: None Discharge Medications: 1. Acetaminophen 500 mg PO Q4H:PRN headache Do not take more than 3 grams of acetaminophen/tylenol in a day. Avoid alcohol if you're taking tylenol. 2. Tizanidine 2 mg PO BID RX *tizanidine 2 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*1 3. Amitriptyline 25 mg PO HS RX *amitriptyline 25 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*2 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: complex migraine, tension headache Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital because of sensory changes and headaches you were having. MRI of your brain was done and did not show any stroke. MRA (study of your blood vessels in your head and neck) did not show any dissection or blood clots. EEG was done and did not show any seizures. You are likely having combination of tension headache and complex migraine (sensory changes). Followup Instructions: ___
10155734-DS-22
10,155,734
20,692,891
DS
22
2133-04-20 00:00:00
2133-04-24 09:14:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: methadone / oxycodone Attending: ___. Chief Complaint: nausea, lightheadedness, melena Major Surgical or Invasive Procedure: GASTRIC ULCER CAUTERIZATION VATS VAGOTOMY History of Present Illness: ___ is a ___ year old man with history of pAF with ischemic stroke on Eliquis, gastric bypass surgery ___ years ago, alcohol abuse, CKD, ?sarcoidosis, chronic aspiration, who initially to OSH presented with lightheadedness, black stools, initially found to be hypotensive, with melena, and elevated lactate to 2.5. At OSH Managed with IVF, 1u pRBC. Patient reports that he first developed black stools on ___. He has been having ___ black stools daily since. He developed lightheadedness starting on new years eve which he states had progressed and that he was lightheaded even while laying down. He reports worsening nausea which provokes his chronic aspiration and cough. He denies abdominal pain. He states he last took his Eliquis yesterday evening after work. He denies NSAIDs, denies aspirin, denies cigarette smoking. His last drink was on New years eve (drinking ___ pint vodka daily). He endorses history of acid reflux. He reports prior colonoscopy ___ years ago with polyps. He was transferred to ___ with initial plan for MICU given concern for hypotension and shock. In the ___ ED: - Initial vital signs were notable for: 0722 T97.8 HR 90 BP 112/78 RR 20 O2 95% RA - Exam notable for: "Oropharynx is clear Regular rate and rhythm Clear to auscultation bilateral Soft mild tenderness to palpation in the left upper quadrant Cranial nerves II through XII are intact No edema 2+ pulses bilaterally Rectal: Melena that is guaiac positive" ___ LABS ___, 3:10 am: PTT: 29.9 INR: 1.31 Prothrombin Time: 14.7 Sec HGB: 8.4*, WBC: 11.5*, PLT: 198, HCT: 26.2* Neut: 78* L: 13* M: 8 E: 0 Bas: 1 ALT: 12 AP: 43 Alb: 3.7 Tbili: 0.7 AST: 17 Dbili: ~#60; 0.2 TProt: 6.0 Na: 141, Cl: 108*, Bun: 73*, Glucose: 164*, Anion Gap: 17, K+: 5.9*, CO2: 16*, Creat: 1.6* Ca: 8.5* Troponin T: < 0.01 Ng/Ml Lactate (Reflexes): 2.5 Mmol/L - ___ ED Labs were notable for: WBC 14.5, Hgb 8.5, Plt 174; neutrophil predominance CO2 16, BUN 69, Cr 1.6 Lactate 2.2 ALT 12, AST 16, AP 44, T. Bili, Alb 3.7 ___ 13.6, INR 1.3, PTT 27.8 - Studies performed include: EGD with no source or stigmata of recent bleeding - Patient was given: 1u pRBC at 11:19 AM ___ 09:58 IV Metoclopramide 10 mg ___ 11:34 IV Morphine Sulfate 4 mg ___ 11:34 IV Ondansetron 4 mg ___ 13:27 IV Pantoprazole 40 mg - Consults: GI: performed EGD which did not demonstrate stigmata of upper GI bleed, and recommend starting colonoscopy prep with Moviprep and NPO at MN for colonoscopy +/- capsule endoscopy Bariatric Surgery: No evidence of upper GI bleed. Recommend obtaining nutrition labs, giving banana bag if has not already received one, agree with colonoscopy and IV PPI, when able to receive a diet needs to be bariatric stage 3 diet, and he needs a psych referral for alcoholism after gastric bypass. Agree with admission to medicine. Full note to follow. Vitals on transfer: 97.7 PO 101 / 72 L Lying ___ Ra Upon arrival to the floor, patient reports feeling better. He denies lightheadedness. He denies nausea. He denies abdominal pain. He provides history as detailed above. He reports his last BM was 11AM and was black in color. On ROS he denies chest pain, endorses 1 day shortness of breath, cough, denies abdominal pain. He reports unintentional 30 pound weight loss over past year. Past Medical History: CKD sarcoidosis positive PPD epiglottic thickening (thought possibly ___ sarcoidosis) c/b chronic aspiration COPD/asthma Gout Obesity status post gastric bypass, which was curative of pre-existing diabetes OSA Gunshot wound in childhood unknown details Social History: ___ Family History: From prior records, "Significant for cancer, diabetes, heart disease, lung disease, and joint disease/arthritis." Physical Exam: ADMISSION PHYSICAL EXAM: ====================== VITALS: 97.7 PO 101 / 72 L Lying ___ Ra GENERAL: Alert and interactive. In no acute distress. HEENT: NCAT. PERRL, Sclera anicteric and without injection. MMM. CARDIAC: Irregular, Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Faint rales of left lower lung, no rhonchi no wheezing, no increased work of breathing. ABDOMEN: Surgical scar over right mid abdomen. Normal bowels sounds, non distended, mild tenderness to left upper quadrant. No organomegaly. EXTREMITIES: Limited range of motion with left ankle due to surgery, some muscle wasting of left leg worse than right SKIN: Warm. Cap refill <2s. No rash. DISCHARGE PHYSICAL EXAM: ====================== 24 HR Data (last updated ___ @ 655) Temp: 98.6 (Tm 99.1), BP: 97/64 (91-108/53-71), HR: 78 (72-89), RR: 18 (___), O2 sat: 96% (93-99), O2 delivery: Ra HEENT: Sclera anicteric and without injection. MMM. CARDIAC: irregular, S1 and S2, no murmurs appreciated LUNGS: crackles bilaterally, right> left ABDOMEN: BS+ non-distended, non tender to palpation EXTREMITIES: Large soft hematoma over ventral surface of left arm that has expanded beyond initial border demarcation. No edema SKIN: Warm. Pertinent Results: ADMISSION LABS: ============= ___ 09:50AM BLOOD WBC-14.5* RBC-2.54* Hgb-8.5* Hct-27.5* MCV-108* MCH-33.5* MCHC-30.9* RDW-16.5* RDWSD-64.0* Plt ___ ___ 09:50AM BLOOD Neuts-85.6* Lymphs-5.9* Monos-7.2 Eos-0.1* Baso-0.1 NRBC-0.3* Im ___ AbsNeut-12.42* AbsLymp-0.86* AbsMono-1.04* AbsEos-0.01* AbsBaso-0.02 ___ 09:50AM BLOOD ___ PTT-27.8 ___ ___ 09:50AM BLOOD Glucose-143* UreaN-69* Creat-1.6* Na-143 K-5.0 Cl-114* HCO3-16* AnGap-13 ___ 09:50AM BLOOD ALT-12 AST-16 AlkPhos-44 TotBili-1.0 ___ 09:50AM BLOOD Albumin-3.7 Calcium-8.2* Phos-3.8 Mg-2.0 ___ 10:11AM BLOOD Lactate-2.2* DISCHARGE LABS: ============== ___ 04:52AM BLOOD WBC-9.0 RBC-2.44* Hgb-7.6* Hct-25.6* MCV-105* MCH-31.1 MCHC-29.7* RDW-18.9* RDWSD-73.0* Plt ___ ___ 11:31AM BLOOD ___ PTT-69.6* ___ ___ 04:52AM BLOOD Glucose-101* UreaN-17 Creat-1.3* Na-137 K-4.5 Cl-112* HCO3-21* AnGap-4* ___ 04:52AM BLOOD Calcium-7.4* Phos-3.0 Mg-1.8 RELEVANT LABS: ============= ___ 05:15PM BLOOD ___ pO2-164* pCO2-40 pH-7.27* calTCO2-19* Base XS--7 Comment-GREEN TOP ___ 12:46PM BLOOD ___ pO2-88 pCO2-42 pH-7.27* calTCO2-20* Base XS--7 Comment-GREEN TOP ___ 09:33AM BLOOD pO2-131* pCO2-35 pH-7.29* calTCO2-18* Base XS--8 Comment-GREEN TOP ___ 05:15PM BLOOD Lactate-1.3 ___ 12:46PM BLOOD Lactate-1.0 ___ 09:33AM BLOOD Lactate-1.9 ___ 12:28AM BLOOD Lactate-1.5 ___ 01:59PM BLOOD Lactate-2.3* ___ 06:19AM BLOOD calTIBC-179* VitB12-791 Folate-16 TRF-138* ___ 05:55AM BLOOD calTIBC-259* VitB12-233* Folate->20 Ferritn-104 TRF-199* ___ 05:55AM BLOOD PTH-126* ___ 05:55AM BLOOD 25VitD-18* ___ 05:55AM BLOOD proBNP-4003* ___ 12:02PM BLOOD cTropnT-<0.01 IMAGING/PROCEDURES: =================== EGD - ___: Impressions: - Normal mucosa in the whole esophagus - Few upper esophageal venous blebs without stigmata of bleeding - Evidence of prior Roux-en-y gastric bypass surger - Small area of heaped up mucosa in the stomach - Normal anastomotic limb - Normal mucosa in blind limb Colonoscopy - ___: - Diverticulosis of the whole colon - Polyp (10 mm) in the cecum - There were a few (<5) 2-3 mm polyps in the rest of the colon without bleeding - 5cm of terminal ileum appeared normal Single Ballon Enteroscopy - Upper -___: - Normal esophagus - The G-J and J-J anastomosis were seen and appeared normal. No stigmata of bleeding were seen at these locations. The efferent limb was examined and appeared normal. The pacreaticobiliary limb was examined and was normal up to the pylorus. The excluded stomach had multiple superficial and cratered ulcers with overlying exudate. There was a large amount of blood clots in the stomach. Several ulcers had overlying clots and one appeared to have slight oozing. BICAP was successfully applied to the highest risk ulcers successfully. No active bleeding was seen at the end of the procedure. CXR - ___: IMPRESSION: Compared to chest radiographs since ___ most recently ___. Mild interstitial edema is new. Loss of volume in the left lower lobe has improved, but there is still dense consolidation there and there is more consolidation at the right lung base, both concerning for pneumonia. Small pleural effusions are stable. Heart not enlarged. Stress Test - ___: IMPRESSION : No anginal symptoms or ST segment changes. Nuclear report sent separately. Cardiac Perfusion Pharm - ___: IMPRESSION: 1. Fixed, medium sized, moderate severity perfusion defect involving the RCA territory. 2. Increased left ventricular cavity size. Mild systolic dysfunction with hypokinesis of the mid and basal inferolateral wall. TTE - ___: The left atrial volume index is mildly increased. The right atrium is moderately enlarged. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is ___ mmHg. There is normal left ventricular wall thickness with a normal cavity size. There is mild regional left ventricular systolic dysfunction with hypokinesis of the basal and mid inferior, inferoseptal, and inferolateral walls (see schematic). The visually estimated left ventricular ejection fraction is 40-45%. There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Diastolic parameters are indeterminate. Mildly dilated right ventricular cavity with mild global free wall hypokinesis. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is mild [1+] mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is moderate [2+] tricuspid regurgitation. There is moderate pulmonary artery systolic hypertension. There is a trivial pericardial effusion. IMPRESSION: Mild regional left ventricular systolic dysfunction consistent with multivessel coronary artery disease. Mildly dilated, mildly hypokinetic right ventricle. Moderate tricuspid regurgitation. Moderate pulmonary hypertension. Brief Hospital Course: BRIEF HOSPITAL COURSE: ==================== ___ is a ___ year old man with PMH notable for pAF, stroke on Eliquis, gastric bypass ___ years ago, alcohol abuse who presented with >1 week melena, worsening lightheadedness with capsule study demonstrating diffuse gastric ulceration with active bleeding now s/p ulcer cauterization and vagotomy. Course complicated by new diagnosis HFrEF on echo, likely aspiration PNA s/p antibiotic course, ongoing melena now improved, asymptomatic hypotension. CORE MEASURES ============= #CODE: Full, confirmed #CONTACT: ___, wife, HCP ___ #DISPO: Home with Home ___ and ___ TRANSITIONAL ISSUES: ===================== NEW Medications: Vitamin B12, Lansoprazole BID, Lidocaine patch, short-course oxycodone, Multivitamin with iron BID, rosuvastatin 20 daily. HELD Medications: Metoprolol 25 mg bid STOPPED Medications: Vitamin D 1000u [] PCP: patient needs close follow-up with GI and with Cardiology for his GIB and new diagnosis of HFrEF. [] Patient with worsening cardiac function based on echo and stress test performed during this hospitalization. Patient initiated on statin. However, patient's outpatient cardiologist should continue to work with patient on optimizing his medication regimen given this new finding. [] Consider initiating patient on aspirin given above findings. Held during this hospitalization in the setting of GI bleeding and anticoagulation with apixaban. [] Patient with hypotension throughout hospitalization, requiring discontinuation of metoprolol. Please follow up as outpatient to ensure appropriate rate control and no additional hypotensive episodes. [] Serum selenium, zinc and copper pending at discharge [] H. pylori stool antigen pending at time of discharge. [] Patient was strongly advised to stop drinking alcohol altogether. Please continue to encourage abstinence in the outpatient setting. [] Patient should follow up with his Bariatric surgery team given GIB requiring vagotomy and ongoing alcohol use ACUTE ISSUES: ============= #Diffuse gastric ulcerations #Melena #Lightheadedness #s/p L VATS vagotomy Patient presented with 2 weeks melena, lightheadedness, nausea. Patient was supported with IV PPI and fluids/blood products as needed. GI was consulted who performed EGD, colonoscopy without source of bleeding discovered. Capsule study demonstrated diffuse gastric ulcerations with active bleeding. Per GI, potential etiologies include PPI noncompliance, poor PPI absorption, gastrinoma, ___. Patient underwent cauterization of large gastric ulcer on ___. Given the extent of ulceration, GI unable to cauterize numerous smaller ulcers. After gastric ulcer cauterization, patient continued to have melena, requiring blood transfusion. Thoracic surgery was consulted who proceeded with L VATS vagotomy on ___, without adverse events. Patient was reinitiated on heparin gtt with stable H&H. He was transitioned back to home eliquis prior to discharge home. #Fever ___ hospital course was complicated by fevers and hypotension. On initial febrile episode, there was concern for infectious etiology, with possible contribution of ongoing bleed and metoprolol (on board for known a fib) to hypotension. Full infectious work up was pursued and fluids/blood products were administered. Infectious work up was notable for CXR findings consistent with possible aspiration PNA given patient's noted high aspiration risk (secondary to epiglottal thickening in the setting of sarcoidosis). Patient received 7 day course of CTX and flagyl (end date ___ with improvement in CXR findings. Speech and swallow were consulted who recommended aspiration precautions and PO medications crushed. Patient spiked second fever on ___ with no localizing infectious symptoms. Initial portable CXR raised concern of surgical site infection or pneumonia but lateral x ray then more suggestive of atelectasis. Blood cultures initially with GPC in clusters so patient started on vancomycin. This speciated to coag negative staph and was felt to be a contaminant. Patient's home metoprolol often held due to borderline asymptomatic blood pressures. Patient will be discharged home with metoprolol held. This should be considered at first outpatient visit. Discussed with patient that ideally he would stay in hospital for an additional 24 hours to allow follow up blood culture data to speciate. Patient expressed strong preference to go home given lack of negative work up thus far and his feeling well and multiple other negative blood cultures. He was counseled that should he develop a fever he should return to the hospital and that if a later blood culture were to turn positive he would need to return to the hospital. #Reduced EF #Wall motion abnormalities #Decreased functional status Patient's wife reported worsening of functional status over past few months (unable to climb single flight of stairs without several breaks). Of note, patient denied this. Echo was obtained as part of risk stratification for planned vagotomy which demonstrated reduced EF (45%), increased MR/TR, new wall motion abnormalities compared to echo obtained in ___, concerning for missed event. Stress test demonstrated a fixed, medium-sized, moderate severity perfusion defect involving the RCA territory. Of note, patient intermittently required oxygen and had evidence of pulmonary congestion but only received diuresis once due to soft blood pressures. He remained asymptomatic and was discharged off oxygen with normal saturations. He was also started on a statin and at___ cardiology was consulted who recommended outpatient follow up. Mr ___ follows with Dr. ___ and should follow up closely as outpatient. #Hemoptysis #Aspiration PNA Patient demonstrated one episode of low volume hemoptysis. We suspected aspiration PNA as the etiology as patient had findings on CXR consistent with aspiration PNA and high aspiration risk (as above). Other etiologies considered were numerous and included PE, pulmonary edema, pulmonary infection, CHF. We had low suspicion for PE; however obtained LENIs, which were negative. Patient had no recurrence of hemoptysis. He completed a 7 day course of ceftriaxone and flagyl for aspiration pneumonia with improvement of leukocytosis and resolution of fevers #High fall risk #Weakness after prolonged hospitalization Patient seen by Physical Therapy who evaluated patient for fall risk and functional independence. He was recommended to be discharged to an ___ rehab. The patient declined rehab and reported that he would have adequate family assistance with activities of daily living including showering. ___ recommended home ___ to improve endurance and higher level balance. #Metabolic acidosis pH 7.22 with bicarb 17 and mildly elevated lactate. VBG with respiratory compensation (appropriate). No ketones in urine. Lactate trending down. HCO3 remains low. Unclear etiology. Possibly RTA given known kidney disease. Remained stable on recheck prior to discharge. #Left Arm Hematoma Patient had large left arm hematoma in the setting of pulled pIV. We monitored the hematoma closely. There was no concern for compartment syndrome on physical exam. #Ischemic Stroke on Eliquis #Atrial fibrillation Patient with history of ischemic stroke on eliquis in ___. Anticoagulation was held throughout majority of hospitalization given GI bleed. Once GI bleeding stabilized, we reinitiated heparin gtt without adverse event. Prior to discharge, patient was transitioned to home eliquis 5mg BID. Patient's metoprolol was initially held in the setting of hypotension but reinitiated early in hospital course. Given hypotensive episodes, metoprolol dose was held and should be revisited as outpatient. #Alcohol Use Patient with history of alcohol use. No evidence of withdrawal on this hospitalization. Patient received Thiamine 100mg daily and Folic acid 1mg daily. PATIENT WAS STRONGLY ADVISED TO ABSTAIN FROM ALCOHOL USE GIVEN ADDED RISK OF COMPLICATIONS WITH GASTRIC BYPASS. #Chronic Kidney Disease Patient with diagnosis of CKD with baseline Cr 1.5-1.7. Patient's creatinine was monitored daily. On discharge, patient's Cr was 1.4. #Gastric Bypass ___ surgery was consulted and provided dietary recommendations. Nutrition also saw the patient and recommended increasing multivitamin to twice daily and increasing vitamin D. Serum copper, selenium and zinc were pending at time of discharge. #Sarcoidosis Seen in documentation, not currently on medications #Depression/anxiety Not currently on celexa. #Cataracts Home eye drops were not confirmed and were held during hospitalization. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. The eye drops were not confirmed. 1. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE DAILY 2. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE DAILY 3. Ketorolac 0.5% Ophth Soln 1 DROP RIGHT EYE DAILY 4. Apixaban 5 mg PO BID 5. Gabapentin 400 mg PO DAILY:PRN pain 6. FoLIC Acid 1 mg PO DAILY 7. Thiamine 100 mg PO DAILY 8. Vitamin D 1000 UNIT PO DAILY 9. Metoprolol Tartrate 25 mg PO BID Discharge Medications: 1. Cyanocobalamin 100 mcg PO DAILY RX *cyanocobalamin (vitamin B-12) 100 mcg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 2. Lansoprazole Oral Disintegrating Tab 30 mg PO BID RX *lansoprazole 30 mg 1 capsule(s) by mouth Twice Daily Disp #*60 Capsule Refills:*0 3. Lidocaine 5% Ointment 1 Appl TP BID:PRN rib pain RX *lidocaine 5 % 1 patch daily as needed Disp #*15 Patch Refills:*0 4. Multivitamins W/minerals Chewable 1 TAB PO BID RX *pediatric multivit-iron-min [Multi-Vitamins with Iron] 1 tablet(s) by mouth Twice daily Disp #*60 Tablet Refills:*0 5. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Severe Duration: 2 Days RX *oxycodone 5 mg 1 capsule(s) by mouth As needed every 8 hours Disp #*6 Capsule Refills:*0 6. Rosuvastatin Calcium 20 mg PO QPM RX *rosuvastatin [Crestor] 20 mg 1 tablet(s) by mouth Nightly Disp #*30 Tablet Refills:*0 7. Apixaban 5 mg PO BID 8. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE DAILY 9. FoLIC Acid 1 mg PO DAILY 10. Gabapentin 400 mg PO DAILY:PRN pain 11. Ketorolac 0.5% Ophth Soln 1 DROP RIGHT EYE DAILY 12. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE DAILY 13. Thiamine 100 mg PO DAILY 14. Vitamin D 1000 UNIT PO DAILY 15. HELD- Metoprolol Tartrate 25 mg PO BID This medication was held. Do not restart Metoprolol Tartrate until your cardiologist recommends starts it. 16.Rolling Walker ICD R26.89 Patient demonstrated decreased footclearance, decreased step length, and increased hip flexion throughout. Anticipate good prognosis. Length of Need 13 months Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES: ================= DIFFUSE GASTRIC ULCERATION MELENA HFrEF HYPOTENSION SECONDARY DIAGNOSES: =================== CKD A FIB HISTORY OF CVA HISTORY OF GASTRIC BYPASS Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at the ___ ___. Why did you come to the hospital? - You came to the hospital because you were passing a lot of blood in your stool. What did you receive in the hospital? - In the hospital we performed several tests to find where you were bleeding from. We found that you have many ulcers in your stomach. We performed an intervention to stop one of the larger ulcers from bleeding. Thoracic surgeons who performed a surgery called a vagotomy to minimize the amount of acid your stomach produces and minimize the risk of bleeding. We started a medication to treat acid levels in your stomach and prevent future bleeding. While you were still actively bleeding, we gave you several blood transfusions to keep your counts up. - While performing tests to see if you could tolerate surgery, we found that your heart function has worsened and you have a condition called 'heart failure'. We started you on a cholesterol medication to keep the arteries that bring blood to your hear open. We also involved our cardiologists and recommend close follow up with Dr ___ will continue to manage your heart failure. - You developed a fever which raised concern for an infection. We performed tests and evaluated your surgical site which did not show infection. You received antibiotics due to concern of a blood infection but this ended up not being a true infection. What should you do once you leave the hospital? - Continue to take your medications as prescribed and follow up with your outpatient providers. - If you develop any fevers, chills, dizziness, trouble breathing, worsening cough, chest pain, or bloody/black stools, please go to the emergency room right away. We wish you all the best! - Your ___ Care Team Followup Instructions: ___
10155734-DS-24
10,155,734
20,778,459
DS
24
2134-01-13 00:00:00
2134-01-13 15:30:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: methadone / oxycodone Attending: ___ Chief Complaint: Lightheadedness Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ M with PMH significant for CKD, Afib on apixaban, HFrEF (last TTE ___ with EF 40-45%), who presents for weakness and presyncope, Of note, patient had prolonged hospitalization earlier this year for ___ iso overdiuresis and GI bleed, among other issues. He was discharged ___ to a rehab facility. The patient notes that at home he had worsening weakness over the last 2 weeks. He often became dizzy while walking to the bathroom as well as short of breath. Over the last 3 days however symptoms become worse. He now notes that became severely dizzy and lightheaded with just sitting up. He denies significant headache, visual changes, chest pain, dyspnea, abdominal pain, nausea, vomiting. Denies fevers, chills, urinary symptoms (including frequency or dysuria). He does note that around 2 weeks ago he started taking metolazone every other day for lower extremity edema per his PCP, which dramatically improved his edema. He otherwise feels that he is in his normal state of health currently. In the ED, - Initial Vitals: 98.1 99 ___ 19 99% RA - Labs: Cr 2.1. UA + for leuk esterase - Imaging: CXR without any acute pathology - Interventions: Vanc/Zosyn, 2 250 cc NS On arrival to the ICU he endorses the above history. ROS: Positives as per HPI; otherwise negative. Past Medical History: Atrial Fibrillation Adrenal Insufficiency CKD sarcoidosis positive PPD epiglottic thickening (thought possibly ___ sarcoidosis) c/b chronic aspiration COPD/asthma Gout Obesity status post gastric bypass, which was curative of pre-existing diabetes OSA Gunshot wound in childhood unknown details Social History: ___ Family History: Patient endorses family history of heart disease Physical Exam: GEN: Well appearing, NAD HEENT: Conjunctiva clear, PERRL, MMM NECK: No JVD. LUNGS: CTAB HEART: Irregular, nl S1, S2. No m/r/g. ABD: NT/ND, normal bowel sounds. EXTREMITIES: 2+ ___ edema SKIN: No rashes. NEURO: AOx3. Pertinent Results: ADMISSION LABS ============== ___ 06:22PM BLOOD WBC-7.0 RBC-3.45* Hgb-10.5* Hct-30.8* MCV-89 MCH-30.4 MCHC-34.1 RDW-17.2* RDWSD-54.9* Plt ___ ___ 06:22PM BLOOD Neuts-77.1* Lymphs-13.9* Monos-7.5 Eos-0.6* Baso-0.3 Im ___ AbsNeut-5.37 AbsLymp-0.97* AbsMono-0.52 AbsEos-0.04 AbsBaso-0.02 ___ 06:22PM BLOOD ___ PTT-44.6* ___ ___ 06:22PM BLOOD Glucose-46* UreaN-21* Creat-2.1* Na-140 K-3.6 Cl-94* HCO3-29 AnGap-17 ___ 04:44AM BLOOD ALT-20 AST-33 AlkPhos-146* TotBili-1.0 ___ 06:22PM BLOOD Calcium-7.7* Phos-2.8 Mg-1.5* ___ 06:36PM BLOOD pO2-18* pCO2-50* pH-7.40 calTCO2-32* Base XS-3 Intubat-NOT INTUBA ___ 06:36PM BLOOD Lactate-2.4* K-3.3* INTERIM LABS: ========== ___ 05:32AM BLOOD ___ PTT-40.9* ___ ___ 06:47AM BLOOD Ret Aut-2.2* Abs Ret-0.05 ___ 06:47AM BLOOD Albumin-1.5* Calcium-7.1* Phos-2.8 Mg-1.9 Iron-50 ___ 06:47AM BLOOD calTIBC-52* VitB12-844 Ferritn-222 TRF-40* ___ 05:36AM BLOOD 25VitD-17* ___ 04:44AM BLOOD Cortsol-3.4 ___ 05:45AM BLOOD PEP-NO SPECIFI IgG-1053 IgA-750* IgM-62 IFE-NO MONOCLO ___ 06:24AM BLOOD freeCa-1.07* ___ 12:40PM BLOOD VITAMIN K (SPIN/PLASMA)-PND ___ 12:40PM BLOOD C-PEPTIDE- 1.63 (0.80-3.85 ng/mL) ___ 12:40PM BLOOD INSULIN- 1.5 L (2.0-19.6 uIU/mL) ___ 05:36AM BLOOD INSULIN- 2.1 ___ 05:36AM BLOOD C-PEPTIDE-Test ___ 05:36AM BLOOD VITAMIN E-PND ___ 05:36AM BLOOD VITAMIN A-PND DISCHARGE LABS ============== MICRO ===== Stool culture ___: PENDING Stool culture ___: Negative for Shigella, Salmonella, Campylobacter; viral culture pending Blood culture x2 ___: No growth (final) Urine culture ___: E.coli and Proteus ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. PROTEUS MIRABILIS. 10,000-100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML ESCHERICHIA COLI | PROTEUS MIRABILIS | | AMPICILLIN------------ =>32 R <=2 S AMPICILLIN/SULBACTAM-- 4 S <=2 S CEFAZOLIN------------- =>64 R =>64 R CEFEPIME-------------- R <=1 S CEFTAZIDIME----------- 16 I <=1 S CEFTRIAXONE----------- =>64 R <=1 S CIPROFLOXACIN--------- =>4 R <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- 32 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S IMAGING/STUDIES =============== ___ CXR Central pulmonary vascular engorgement without overt pulmonary edema. Chronic blunting of the right costophrenic angle. Re-demonstrated bibasilar chronic fibrotic changes. ___ TTE IMPRESSION: Suboptimal image quality. Mild LVH with mild LV systolic dysfunction and regional wall motion abnormality. RV not well imaged however appears dilated with moderate systolic dysfunction from subcostal view. Moderate mitral regurgitation. Probable moderate tricuspid regurgitation. Mild pulmonary hypertension. Compared with the prior TTE (images reviewed) of ___ LV function is less vigorous (regional wall motion similar). Image quality insufficient to perform adequate strain evaluation. Severity of MR has increased. RV function appears less vigorous. If clinically indicated and suspicison for TTR amyloidosis is high, can consider pyrophsophate scan or CMR. Brief Hospital Course: Mr. ___ is a ___ yo man with CKD, chronic atrial fibrillation on Apixaban, ischemic cardiomyopathy, chronic HFrEF, COPD, adrenal insufficiency, UGIB in ___ (s/p ulcer cauterization and vagotomy), recently hospitalized ___ with ARF, hypoxia, suspected dumping syndrome from gastric bypass, LUE DVT, and recurrent GIB, who presented from home with lightheadedness and hypoglycemia, hypotension, initially in MICU, improved with stress dose steroids, IVF, and antibiotics. Course complicated by ___, ESBL UTI s/p 10d antibiotics, chronic diarrhea, recurrent hypoglycemia likely ___ dumping syndrome. ACUTE/ACTIVE PROBLEMS: # Hypotension: Initially ___ prior to presentation. Admitted to MICU, received stress dose steroids, IVF, antibiotics for possible sepsis. Ultimately hypotension likely due to hypovolemia from decreased oral intake with increased diuresis (recently restarted on metolazone as outpatient for lower extremity edema). After initial improvement he had increased diarrhea which led to more hypovolemia/hypotension then pressures normalized. Diuretics were held. Orthostatics were repeatedly negative. # Hypoglycemia # Dumping Syndrome Glucose 26 on admission. He had intermittent recurrent hypoglycemia pre and post-prandially. Endocrine was consulted and suspected dumping syndrome related to rapid absorption of simple sugars and subsequent insulin hypersecretion worse after eating carbs. Recommended for high protein, high fat, very low carb diet (<50g daily total, <15g with meals, must be complex integrated carbs). Hypoglycemia protocol adjusted for dumping syndrome, to avoid PO glucose. Home omeprazole, cholestyramine, psyllium discontinued per endocrine. Has outpatient endocrine followup scheduled. # Acute on chronic diarrhea: Seen previously by GI. Chronic diarrhea thought related to fat malabsorption from chronic pancreatic insufficiency and dumping syndrome. Started Creon and Cholestyramine. Negative C. difficile test ___. Negative stool cultures this and last admission. Standing Imodium with marginal benefit. # Severe protein malnutrition # Hypoalbuminemia # Deconditioning Albumin very low, 1.5, which is likely due to malnutrition secondary to dumping syndrome. Nutrition consult followed, PO intake encouraged. Started on Vitamin A and E supplementation. # Lower extremity edema: Chronic per patient. Suspect significant component of malnutrition/hypoalbuminemia with this as he does not have other signs of volume overload on exam. He repeatedly declined compression then ultimately accepted ace wraps. Held diuretics as above due to hypotension. # Acute on chronic anemia: # Thrombocytopenia Suspect significant hemoconcentration on CBC upon arrival as his counts were much lower last admission. On last admission, no clear etiology identified, RUQ US without any evidence of cirrhosis. Suspected component of bone marrow suppression. B12, folate, iron studies all WNL, hemolysis labs normal last admission. Could have undiagnosed MDS and was recommended to see heme/onc as an outpatient for consideration of this. Received 1u pRBC for Hb 6.9. # Multiple electrolyte derangements Thought likely related to diarrhea, improved with repletion (K, Mag, Phos). # Chronic adrenal insufficiency: Likely secondary to exogenous steroids in the past. Received stress dose steroids in MICU as above. Transitioned to Hydrocortisone 20mg QAM and 10mg QPM, which he will continue. Stopped home Prednisone. He would need stress dose steroids for critical illness, surgery. # ___ on CKD Baseline Cr ~2 based on last admission and increased to 2.7. Improved to 1.6-1.8. Suspect multifactorial from pre-renal in setting of over-diuresis, given persistence probably some ATN from hypotension. SPEP/UPEP negative. Sodium bicarb continued. # E. coli/Proteus UTI Urine culture ___ w E. coli and Proteus. E. coli is ESBL. Negative blood cultures. Initially on Ceftriaxone for 3 days, then switched to Zosyn, then Bactrim to complete 10 day course for complicated infection. CHRONIC/STABLE PROBLEMS: # Atrial fibrillation, Chads2Vasc 5 (HF, history of ischemic stroke, age). Continued apixaban. Held metoprolol due to hypotension, generally rates were well controlled. # Vitamin D deficiency with secondary hyperparathyroidism: Started vitamin D ___ units daily. Level was low. # Alcohol abuse Patient endorsed drinking 0.5 pint/day since being home for last few weeks. No history of withdrawal. Continued home thiamine, folate. # LUE DVT # Superficial thrombophlebitis He was diagnosed with multiple LUE DVT in ___ (venous access associated), initially non-occlusive, then became occlusive based on ultrasound on ___. Repeat LUE ultrasound on ___ showed occlusive thrombus without appreciable change and new occlusive thrombus of distal cephalic vein. Apixaban as above. # Chronic HFrEF: # Ischemic cardiomyopathy History of EF reduced to 40's in past, but most recent ECHO ___ with recovery of EF > 60% but persistent focal wall motion abnormalities. TTE on ___ showed LVEF 43%, regional wall motion abnormality, RV dilation with moderate systolic dysfunction, moderate mitral regurgitation, probable moderate TR, mild pulmonary HTN. Per TTE report, if clinically indicated and suspicison for TTR amyloidosis is high, can consider pyrophsophate scan or CMR. Diuretics held as above. # COPD Continued duonebs PRN ========================== TRANSITIONAL ISSUES: =================== - Recommended high protein, high fat, very low carb diet as above; continue to encourage, reinforce. - Needs medical alert bracelet for adrenal insufficiency - Consider stopping Creon if diarrhea improves with dietary changes - Needs close nutrition followup - Ace wraps for edema if he will allow - Sodium bicarb tabs continued. Would readdress at renal followup given high frequency. - Determine if/when can restart diuretic - Restart Metoprolol for Afib and HF if BP allows - Monitor CBC, BMP, Ca, Mg, Phos within next 1 week - Ensure adequate home services upon discharge from rehab Clinically stable for discharge today. The total time spent today on discharge planning, counseling and coordination of care today >30 minutes. Medications on Admission: The Preadmission Medication list may be inaccurate and requires further investigation. 1. Apixaban 5 mg PO BID 2. FoLIC Acid 1 mg PO DAILY 3. Mirtazapine 15 mg PO QHS 4. Rosuvastatin Calcium 20 mg PO QPM 5. Thiamine 100 mg PO DAILY 6. Cholestyramine 8 gm PO BID 7. Creon 12 1 CAP PO Q6H:PRN WITH SNACKS 8. Creon 12 3 CAP PO TID W/MEALS 9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of breath 10. LOPERamide 2 mg PO QID:PRN diarrhea 11. Multivitamins W/minerals 1 TAB PO DAILY 12. Sodium Bicarbonate ___ mg PO QID 13. Vitamin B Complex 1 CAP PO DAILY 14. PredniSONE 5 mg PO DAILY 15. PredniSONE 2.5 mg PO QPM 16. Omeprazole 40 mg PO DAILY 17. Vitamin D ___ UNIT PO 1X/WEEK (FR) 18. Naltrexone 50 mg PO DAILY 19. Metoprolol Tartrate 12.5 mg PO BID Discharge Medications: 1. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 2. Hydrocortisone 20 mg PO QAM 3. Hydrocortisone 10 mg PO QPM 4. Psyllium Powder 2 PKT PO BID 5. Vitamin A ___ UNIT PO DAILY Duration: 7 Days STOP after 4 days. 6. Vitamin E 400 UNIT PO DAILY 7. LOPERamide 2 mg PO QID diarrhea 8. Vitamin D ___ UNIT PO DAILY 9. Apixaban 5 mg PO BID 10. Cholestyramine 8 gm PO BID 11. Creon 12 1 CAP PO Q6H:PRN WITH SNACKS 12. Creon 12 3 CAP PO TID W/MEALS 13. FoLIC Acid 1 mg PO DAILY 14. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of breath 15. Mirtazapine 15 mg PO QHS 16. Multivitamins W/minerals 1 TAB PO DAILY 17. Omeprazole 40 mg PO DAILY 18. Rosuvastatin Calcium 20 mg PO QPM 19. Sodium Bicarbonate ___ mg PO QID 20. Thiamine 100 mg PO DAILY 21. Vitamin B Complex 1 CAP PO DAILY 22. HELD- MetOLazone 2.5 mg PO QOD:PRN leg swelling This medication was held. Do not restart MetOLazone until you discuss with your primary care doctor 23. HELD- Metoprolol Tartrate 12.5 mg PO BID This medication was held. Do not restart Metoprolol Tartrate until directed by your primary doctor 24. HELD- Naltrexone 50 mg PO DAILY This medication was held. Do not restart Naltrexone until discuss with your PCP ___: Extended Care Facility: ___ ___ Diagnosis: Hypotension Chronic adrenal insufficiency Acute kidney injury on CKD Acute on chronic diarrhea Severe protein malnutrition E. coli/Proteus UTI Chronic atrial fibrillation Hypophosphatemia Hypokalemia Hypomagnesemia Hypoglycemia Left upper extremity DVT HFrEF/ischemic cardiomyopathy Chronic anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were hospitalized with low blood pressure, which most likely due to dehydration, and improved with IV fluids. Your metolazone (which causes you to urinate to get rid of excess fluid) has been held - do not restart until instructed by your doctor. You were seen by endocrinologists for your adrenal insufficiency and you have been switched from prednisone to hydrocortisone and will need to see endocrinology as an outpatient. As discussed with endocrinology, you should triple the dose for 3 days in case of an illness. You should receive stress dose steroids in case of surgery or critical illness. In addition, you should wear a medical alert bracelet. You had a kidney injury, likely due to dehydration, so you were given IV fluid resuscitation and this improved to your baseline kidney function. You had diarrhea of unclear cause - infectious studies of your stool did not show specific infection. You can use the Imodium as needed. The increased diarrhea could be a side effect of the antibiotic you were receiving. If this persists or worsens, please talk with your primary doctor. Your nutrition is low, likely due to not being able to eat well before admission. You were seen by nutrition specialists. You were treated for urinary tract infection and had no signs of blood infection. You were kept on Apixaban blood thinner for your atrial fibrillation and blood clot in left arm. Your Metoprolol has been temporarily held due to your blood pressure being low or the low end of normal. Please discuss with your primary doctor when to restart. You had low phosphorus, magnesium and potassium levels, which were likely due to diarrhea and you were given supplements. Please have these levels rechecked in the next 1 week. You had low glucose levels and the endocrinologists recommend seeing a specialist at ___. You were started on vitamin D supplement for deficiency. Followup Instructions: ___
10155766-DS-10
10,155,766
29,723,268
DS
10
2143-05-25 00:00:00
2143-05-25 15:39:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal Pain, Cholelithiasis Major Surgical or Invasive Procedure: ___: ERCP ___: Laparoscopic cholecystectomy History of Present Illness: ___ year old Male who presents after initially presenting to ___ on ___ with RUQ Abdominal pain, diagnosed with cholelithiasis, who now presents to the ___ ED with continued abdominal pain, subjective fevers, nausea and vomitting. The patient was referred to a surgeon at ___ but has not been seen yet. His initial presentation to ___ was preceeded by many hours of severe crampy ___ RUQ abdominal pain, worst while eating seafood, and accompanied by subjective fevers, nausea/vomitting and diaphoresis. A RUQ ultrasound there was notable for cholelithiasis. He was started on ondansetron and percocet and discharged. Since discharge he has had continued pain at a ___ level, but no nausea/vomitting with the ondansetron, and he has been able to eat. He notes his urine has become dark brown and his stools have become light colored. In the ED his initial vitals 96, 77, 146/78, 16, 96% RA. An ultrasound was notable for significant cholelithiasis without cholecystitis or choledocolithiasis. He was given dilaudid and IV fluids, and on arrival on the ward is now pain free. Past Medical History: Chondromalacia patella Medial meniscus tear s/p knee surgery x2 on the left knee Food allergies (epi pen) Angioedema Cholelithiasis Social History: ___ Family History: cancer, coronary artery disease Mother: ___ s/p cholecystectomy Physical Exam: ROS: GEN: - fevers, - Chills, - Weight Loss EYES: - Photophobia, - Visual Changes HEENT: - Oral/Gum bleeding CARDIAC: - Chest Pain, - Palpitations, - Edema GI: - Nausea, - Vomitting, - Diarhea, + Abdominal Pain, + Constipation, - Hematochezia, + light colored stools PULM: - Dyspnea, - Cough, - Hemoptysis HEME: - Bleeding, - Lymphadenopathy GU: - Dysuria, - hematuria, - Incontinence, + biliuria SKIN: - Rash ENDO: - Heat/Cold Intolerance MSK: - Myalgia, - Arthralgia, - Back Pain NEURO: - Numbness, - Weakness, - Vertigo, - Headache PHYSICAL EXAM: VSS: 98.2, 126/76, 81, 16, 78% GEN: NAD Pain: ___ HEENT: EOMI, MMM, - OP Lesions PUL: CTA B/L COR: RRR, S1/S2, - MRG ABD: - TTP, mild distension/tympanic, soft, - Rebound, - Guarding, ___, ND, +BS, - CVAT EXT: - CC, pedal edema (long standing) NEURO: CAOx3, Motor: ___ ___ flex/ext/Finger Spread Discharge Physical Exam: VS: 98.0, 99, 151/96, 20, 98%ra GEN: AA&O x 3, NAD, calm, cooperative. HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI, PERRL. CHEST: Clear to auscultation bilaterally, (-) cyanosis. ABDOMEN: (+) BS x 4 quadrants, soft, mildly tender to palpation incisionally, non-distended. Incisions: clean, dry and intact, dressed and closed with steristrips and gauze dressing EXTREMITIES: Warm, well perfused, pulses palpable, (-) edema. Pertinent Results: ___ 05:25PM BLOOD WBC-8.1 RBC-4.88 Hgb-15.2 Hct-45.5 MCV-93 MCH-31.3 MCHC-33.5 RDW-13.5 Plt ___ ___ 05:25PM BLOOD Neuts-69.6 ___ Monos-5.3 Eos-2.8 Baso-0.3 ___ 05:25PM BLOOD Glucose-95 UreaN-14 Creat-1.0 Na-137 K-4.0 Cl-103 HCO3-24 AnGap-14 ___ 05:25PM BLOOD ALT-465* AST-364* AlkPhos-228* TotBili-3.7* DirBili-2.8* IndBili-0.9 ___ 05:25PM BLOOD Lipase-147* ___ 05:25PM BLOOD Albumin-4.6 ___ 07:02AM BLOOD WBC-8.0 RBC-4.98 Hgb-15.5 Hct-44.8 MCV-90 MCH-31.1 MCHC-34.5 RDW-12.8 Plt ___ ___ 07:36AM BLOOD WBC-9.0 RBC-4.90 Hgb-15.4 Hct-44.7 MCV-91 MCH-31.3 MCHC-34.4 RDW-12.9 Plt ___ ___ 06:35AM BLOOD WBC-7.5 RBC-4.72 Hgb-14.7 Hct-42.7 MCV-91 MCH-31.1 MCHC-34.3 RDW-13.8 Plt ___ ___ 07:02AM BLOOD Glucose-88 UreaN-11 Creat-1.0 Na-141 K-4.1 Cl-105 HCO3-25 AnGap-15 ___ 07:36AM BLOOD Glucose-92 UreaN-12 Creat-0.9 Na-141 K-4.1 Cl-105 HCO3-25 AnGap-15 ___ 06:35AM BLOOD Glucose-90 UreaN-10 Creat-0.9 Na-141 K-3.9 Cl-104 HCO3-28 AnGap-13 ___ 07:02AM BLOOD ALT-458* AST-224* AlkPhos-264* Amylase-107* TotBili-1.8* ___ 07:36AM BLOOD ALT-291* AST-79* AlkPhos-248* TotBili-0.8 ___ 06:35AM BLOOD ALT-218* AST-53* AlkPhos-209* TotBili-0.9 LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___ 4:43 ___ IMPRESSION: Substantial cholelithiasis without evidence of cholecystitis. Possible focal area of wall adenomyomatosis. ___: ERCP: There was a filling defect that appeared like sludge in the lower third of the common bile duct. Otherwise normal biliary tree. The pancreatic duct: limited exam in the head of the pancreas was normal. A sphincterotomy was performed. Sludge extracted successfully using a balloon. (sphincterotomy, stone extraction) Otherwise normal ercp to third part of the duodenum Brief Hospital Course: The patient was admitted to the Medicine Service on ___ for evaluation and treatment of abdominal pain with elevated LFTs. Admission abdominal ultra-sound revealed substantial cholelithiasis without evidence of cholecystitis. On HD2 the patient underwent ERCP with sphincterotomy and stone extraction. The patient was transferred to the General Surgery Service and underwent laparoscopic cholecystectomy, which went well without complication (reader referred to the Operative Note for details). After a brief, uneventful stay in the PACU, the patient arrived on the floor tolerating sips, on IV fluids, and IV dilaudid for pain control. The patient was hemodynamically stable. . Pain was well controlled. Diet was progressively advanced as tolerated to a regular diet with good tolerability. The patient voided without problem. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. . At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Viagra (sildenafil) 50 mg oral As needed 2. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL (1:1,000) injection PRN Anaphylaxis Discharge Medications: 1. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL (1:1,000) injection PRN Anaphylaxis 2. Viagra (sildenafil) 50 mg oral As needed 3. Acetaminophen 500 mg PO Q6H:PRN pain 4. Docusate Sodium 100 mg PO BID 5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain 6. Senna 8.6 mg PO BID:PRN Constipation Discharge Disposition: Home Discharge Diagnosis: Acute Cholecystitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with acute cholecystitis. You were taken to the operating room and had your gallbladder removed laparoscopically. You tolerated the procedure well and are now being discharged home to continue your recovery with the following instructions. Please follow up in the Acute Care Surgery clinic at the appointment listed below. ACTIVITY: o Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. o You may climb stairs. o You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. o Don't lift more than ___ lbs for 4 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. o You may start some light exercise when you feel comfortable. o You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. HOW YOU MAY FEEL: o You may feel weak or "washed out" for a couple of weeks. You might want to nap often. Simple tasks may exhaust you. o You may have a sore throat because of a tube that was in your throat during surgery. o You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. o You could have a poor appetite for a while. Food may seem unappealing. o All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your surgeon. YOUR INCISION: o Tomorrow you may shower and remove the gauzes over your incisions. Under these dressing you have small plastic bandages called steri-strips. Do not remove steri-strips for 2 weeks. (These are the thin paper strips that might be on your incision.) But if they fall off before that that's okay). o Your incisions may be slightly red around the stitches. This is normal. o You may gently wash away dried material around your incision. o Avoid direct sun exposure to the incision area. o Do not use any ointments on the incision unless you were told otherwise. o You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your surgeon. o You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. YOUR BOWELS: o Constipation is a common side effect of narcotic pain medications. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. o If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. PAIN MANAGEMENT: o It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". o Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. o You will receive a prescription for pain medicine to take by mouth. It is important to take this medicine as directed. o Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. o Your pain medicine will work better if you take it before your pain gets too severe. o Talk with your surgeon about how long you will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your surgeon has said its okay. o If you are experiencing no pain, it is okay to skip a dose of pain medicine. o Remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the following, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. If you have any questions about what medicine to take or not to take, please call your surgeon. Followup Instructions: ___
10155766-DS-11
10,155,766
23,391,823
DS
11
2144-09-06 00:00:00
2144-09-11 20:51:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: All allergies / adverse drug reactions previously recorded have been deleted Attending: ___. Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: ___: Exploratory laparoscopy converted to open laparotomy with incision and drainage of right upper quadrant abscess, removal of dropped gallstones, and incision and drainage of pericystic and pericolonic abscesses. ___: Successful US-guided aspiration of a right lower quadrant collection. ___: Re-exploration laparotomy with removal of dropped gallstones and wash out. ___ PICC line placement History of Present Illness: ___ male presents to ED with several weeks worsening abdominal/right flank pain. Patient denies nausea, vomiting, change in bowel habits, or appetite. +fever (103 in ED) and sweats at home. Denies previous episodes. Denies history of diverticulitis. Past Medical History: Chondromalacia patella Medial meniscus tear s/p knee surgery x2 on the left knee Angioedema Cholelithiasis Social History: ___ Family History: cancer, coronary artery disease Mother: ___ s/p cholecystectomy Physical Exam: Admission Physical Exam: 98 72 103/60 18 99% RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, no rebound or guarding, mild right flank tenderness Ext: No ___ edema, ___ warm and well perfused Discharge Physical Exam: VS: 98.4, 72, 126/73, 18, 99% RA Gen: Alert, sitting up in chair with brother at bedside. HEENT: no deformity. PERRL, EOMI. mucus membranes pink/moist. Neck supple, trachea midline. CV: RRR Pulm: Clear to auscultation bilaterally. Abdom: Soft, mildly tender at midline incision as anticipated. Active bowel sounds x 4 quadrants. Skin: Midline abdominal surgical wound with vac. RLQ JP drain to continuous bulb suction putting out small amount of serousanginous drainage. Ext: Warm and dry. no edema. 2+ ___ pulses. Neuro: A&Ox3. Follows commands, moves all extremities equal and strong. Speech is clear and fluent. Pertinent Results: ___ 06:26AM BLOOD WBC-12.3* RBC-3.39* Hgb-9.4* Hct-30.4* MCV-90 MCH-27.7 MCHC-30.9* RDW-14.7 RDWSD-46.6* Plt ___ ___ 05:40AM BLOOD WBC-14.2* RBC-3.32* Hgb-9.3* Hct-29.8* MCV-90 MCH-28.0 MCHC-31.2* RDW-14.8 RDWSD-48.2* Plt ___ ___ 05:15AM BLOOD WBC-17.5* RBC-3.29* Hgb-9.3* Hct-29.0* MCV-88 MCH-28.3 MCHC-32.1 RDW-14.5 RDWSD-46.0 Plt ___ ___ 06:40AM BLOOD WBC-16.1* RBC-3.29* Hgb-9.2* Hct-29.4* MCV-89 MCH-28.0 MCHC-31.3* RDW-14.4 RDWSD-46.5* Plt ___ ___ 06:10AM BLOOD WBC-24.2* RBC-3.61* Hgb-10.1* Hct-32.0* MCV-89 MCH-28.0 MCHC-31.6* RDW-14.7 RDWSD-47.5* Plt ___ ___ 05:15AM BLOOD WBC-19.0* RBC-3.33* Hgb-9.5* Hct-29.2* MCV-88 MCH-28.5 MCHC-32.5 RDW-14.7 RDWSD-46.5* Plt ___ ___ 05:20AM BLOOD WBC-16.3* RBC-3.34* Hgb-9.4* Hct-29.6* MCV-89 MCH-28.1 MCHC-31.8* RDW-14.6 RDWSD-46.8* Plt ___ ___ 05:30AM BLOOD WBC-12.6* RBC-3.47* Hgb-9.7* Hct-30.4* MCV-88 MCH-28.0 MCHC-31.9* RDW-14.5 RDWSD-45.1 Plt ___ ___ 05:40AM BLOOD WBC-13.6* RBC-3.42* Hgb-9.8* Hct-30.4* MCV-89 MCH-28.7 MCHC-32.2 RDW-14.4 RDWSD-46.1 Plt ___ ___ 05:45AM BLOOD WBC-14.0* RBC-3.46* Hgb-9.8* Hct-30.7* MCV-89 MCH-28.3 MCHC-31.9* RDW-14.2 RDWSD-45.5 Plt ___ ___ 06:25AM BLOOD WBC-13.3* RBC-3.46* Hgb-9.8* Hct-30.6* MCV-88 MCH-28.3 MCHC-32.0 RDW-14.4 RDWSD-45.8 Plt ___ ___ 12:35AM BLOOD WBC-13.1* RBC-3.49* Hgb-9.9* Hct-30.5* MCV-87 MCH-28.4 MCHC-32.5 RDW-14.3 RDWSD-44.5 Plt ___ ___ 06:55AM BLOOD WBC-15.5* RBC-3.68* Hgb-10.5* Hct-32.5* MCV-88 MCH-28.5 MCHC-32.3 RDW-14.0 RDWSD-44.9 Plt ___ ___ 11:37PM BLOOD WBC-16.5* RBC-3.63* Hgb-10.4* Hct-32.4* MCV-89 MCH-28.7 MCHC-32.1 RDW-14.1 RDWSD-45.6 Plt ___ ___ 07:49AM BLOOD WBC-21.8* RBC-3.85* Hgb-10.8* Hct-34.0* MCV-88 MCH-28.1 MCHC-31.8* RDW-13.9 RDWSD-44.7 Plt ___ ___ 09:30PM BLOOD WBC-17.6* RBC-3.74* Hgb-10.6* Hct-31.5* MCV-84 MCH-28.3 MCHC-33.7 RDW-13.6 RDWSD-42.1 Plt ___ ___ 07:45PM BLOOD WBC-19.5*# RBC-4.12* Hgb-11.7* Hct-36.3* MCV-88 MCH-28.4 MCHC-32.2 RDW-13.8 RDWSD-44.5 Plt ___ ___ 07:45PM BLOOD Neuts-83.5* Lymphs-8.9* Monos-6.0 Eos-0.3* Baso-0.4 Im ___ AbsNeut-16.30* AbsLymp-1.73 AbsMono-1.16* AbsEos-0.05 AbsBaso-0.07 ___ 06:26AM BLOOD Plt ___ ___ 06:40AM BLOOD ___ PTT-30.9 ___ ___ 05:15AM BLOOD ___ PTT-29.0 ___ ___ 05:30AM BLOOD ___ ___ 05:45AM BLOOD ___ PTT-30.9 ___ ___ 06:55AM BLOOD ___ ___ 11:11AM BLOOD ___ PTT-28.3 ___ ___ 02:06PM BLOOD ___ ___ 06:26AM BLOOD Glucose-84 UreaN-9 Creat-0.7 Na-137 K-4.4 Cl-103 HCO3-26 AnGap-12 ___ 05:40AM BLOOD Glucose-102* UreaN-8 Creat-0.7 Na-139 K-4.4 Cl-100 HCO3-29 AnGap-14 ___ 06:40AM BLOOD Glucose-97 UreaN-9 Creat-0.7 Na-133 K-4.3 Cl-97 HCO3-29 AnGap-11 ___ 06:10AM BLOOD Glucose-99 UreaN-12 Creat-1.0 Na-131* K-4.4 Cl-97 HCO3-27 AnGap-11 ___ 05:15AM BLOOD Glucose-99 UreaN-10 Creat-0.7 Na-136 K-4.0 Cl-102 HCO3-25 AnGap-13 ___ 05:30AM BLOOD Glucose-98 UreaN-9 Creat-0.6 Na-139 K-4.1 Cl-105 HCO3-28 AnGap-10 ___ 05:40AM BLOOD Glucose-90 UreaN-9 Creat-0.6 Na-138 K-4.3 Cl-104 HCO3-28 AnGap-10 ___ 05:45AM BLOOD Glucose-106* UreaN-8 Creat-0.7 Na-136 K-4.1 Cl-100 HCO3-28 AnGap-12 ___ 06:25AM BLOOD Glucose-90 UreaN-10 Creat-0.8 Na-137 K-3.8 Cl-102 HCO3-27 AnGap-12 ___ 12:35AM BLOOD Glucose-100 UreaN-9 Creat-0.8 Na-137 K-3.9 Cl-101 HCO3-26 AnGap-14 ___ 06:55AM BLOOD Glucose-92 UreaN-8 Creat-0.6 Na-139 K-4.0 Cl-103 HCO3-25 AnGap-15 ___ 07:49AM BLOOD Glucose-120* UreaN-11 Creat-0.6 Na-140 K-4.6 Cl-105 HCO3-26 AnGap-14 ___ 07:18AM BLOOD Glucose-117* UreaN-11 Creat-0.8 Na-132* K-4.0 Cl-97 HCO3-23 AnGap-16 ___ 09:30PM BLOOD Glucose-103* UreaN-10 Creat-0.7 Na-134 K-3.8 Cl-98 HCO3-23 AnGap-17 ___ 07:45PM BLOOD Glucose-91 UreaN-10 Creat-0.8 Na-137 K-4.0 Cl-98 HCO3-25 AnGap-18 ___ 07:45PM BLOOD ALT-58* AST-48* AlkPhos-240* TotBili-0.9 ___ 06:26AM BLOOD Calcium-8.6 Phos-4.1 Mg-2.1 ___ 05:40AM BLOOD Calcium-8.7 Phos-4.2 Mg-2.3 ___ 06:40AM BLOOD Calcium-8.2* Phos-3.4 Mg-2.1 ___ 06:10AM BLOOD Calcium-8.4 Phos-4.2 Mg-1.9 ___ 05:15AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.0 ___ 05:30AM BLOOD Calcium-8.3* Phos-3.7 Mg-2.0 ___ 05:40AM BLOOD Albumin-2.3* Calcium-8.1* Phos-3.3 Mg-2.1 ___ 05:45AM BLOOD Calcium-7.9* Phos-3.0 Mg-2.0 ___ 06:25AM BLOOD Calcium-7.6* Phos-3.4 Mg-2.0 ___ 12:35AM BLOOD Calcium-7.7* Phos-2.9 Mg-2.0 ___ 06:55AM BLOOD Calcium-7.7* Phos-2.7 Mg-1.8 ___ 07:49AM BLOOD Calcium-8.7 Phos-4.2 Mg-2.0 ___ 07:49AM BLOOD Calcium-8.7 Phos-4.2 Mg-2.0 ___ 07:18AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.0 ___ 09:30PM BLOOD Calcium-8.4 Phos-3.2 Mg-2.0 ___ 07:54PM BLOOD Lactate-1.2 Micro: Blood Culture, Routine (Final ___: NO GROWTH. Blood Culture, Routine (Final ___: NO GROWTH. URINE CULTURE (Final ___: NO GROWTH. GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: ESCHERICHIA COLI. SPARSE GROWTH. OF TWO COLONIAL MORPHOLOGIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- =>64 R CEFTAZIDIME----------- 16 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ 2 S TRIMETHOPRIM/SULFA---- =>16 R ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: Ertapenem Sensitivity testing per ___ ___ ___. ESCHERICHIA COLI. SPARSE GROWTH. CEFEPIME sensitivity testing performed by ___. SENSITIVE TO Ertapenem. Ertapenem sensitivity testing performed by ___. ESCHERICHIA COLI. SPARSE GROWTH. SECOND MORPHOLOGY. CEFEPIME sensitivity testing performed by ___. SENSITIVE TO Ertapenem. Ertapenem sensitivity testing performed by ___. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | ESCHERICHIA COLI | | AMPICILLIN------------ =>32 R =>32 R AMPICILLIN/SULBACTAM-- =>32 R =>32 R CEFAZOLIN------------- =>64 R =>64 R CEFEPIME-------------- R R CEFTAZIDIME----------- 16 R 16 R CEFTRIAXONE----------- =>64 R =>64 R CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN/TAZO----- 8 S <=4 S TOBRAMYCIN------------ 8 I =>16 R TRIMETHOPRIM/SULFA---- =>16 R =>16 R ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. ___ ECG: Baseline artifact. Sinus rhythm. T wave abnormalities. Compared to the previous tracing of ___ the rate is now faster. T wave abnormalities are now more prominent. ___ CT abd/pelvis: Baseline artifact. Sinus rhythm. T wave abnormalities. Compared to the previous tracing of ___ the rate is now faster. T wave abnormalities are now more prominent. ___ CXR: No comparison. The lung volumes are low. Mild cardiomegaly without pulmonary edema. Bilaterally at the lung bases parenchymal opacities with air bronchograms are visualized. In the appropriate clinical setting these opacities reflect pneumonia. No pleural effusions. No pneumothorax. Normal hilar and mediastinal contours. ___ CT abd/pelvis: The impression 2 and 3 were discussed with ___, N.P. by ___, M.D. on the telephone on ___ at 3:00 ___, 10 minutes after discovery of the findings. ___ ultrasound abdomen: Persistent retrohepatic/right flank collection measuring 8.9 x 5.1 x 2.8 cm which was for the most part solid, with only small amounts of fluid noted centrally. There were 2 hyperechoic foci noted within this collection measuring up to 1.3 cm, concerning for dropped gallstones. ___ ultrasound intra op: No retained stones could be identified sonographically. ___ CXR: In comparison to ___ radiograph, lung volumes are extremely low, accentuating the cardiac silhouette and bronchovascular structures. Allowing for this factor, bibasilar atelectasis is probably relatively similar to the prior study. Probable small bilateral pleural effusions. ___ Abd Xray: Dilated small bowel loops with air-fluid level measuring up to 5.6 cm in the left upper quadrant, concerning for partial or early complete small bowel obstruction. ___ CXR: New right PICC ends at the cavoatrial junction. ___ 08:00PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG ___ 07:33AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 07:33AM URINE RBC-5* WBC-1 Bacteri-FEW Yeast-NONE Epi-0 ___ 08:00PM URINE RBC-2 WBC-2 Bacteri-FEW Yeast-NONE Epi-0 Brief Hospital Course: Mr. ___ is a ___ yo M who was admitted to the Acute Care Surgery Service on ___ with abdominal pain and fevers. He had a CT scan that showed multiple cystic lesions in the posterolateral abdominal wall and the superior dome of the bladder concerning for dropped gallstones in the peritoneal cavity from a prior cholecystectomy. His white blood cell count was elevated at 19.5. Informed consent was obtained and he was taken to the operating room on ___ for an exploratory laparotomy and wash out. See operative report for details. He was extubated, taken to the PACU until stable, then transferred to the surgical floor for further management. His post operative course was complicated by a persistently elevated white blood cell count despite IV antibiotic treatment, poor PO tolerance, and night sweats. Cultures from the surgical drains grew Eschierichia Coli and he was given IV antibiotics. On POD3 he abdominal incision was noted to be not well approximated and therefore a wound vac was placed. On POD5 he had a repeat CT scan that showed new fluid collections in the right abdomen. On POD6 he went to interventional radiology for an ultra sound guided aspiration of these collections. On ultrasound, he was noted to have 2 hyperchoic foci within the collection measuring 1.3 cm concerning for dropped gallstones. On POD8 he was taken to the operating room for re-exploration, removal of 2 gallstones, intraoperative ultrasonography, and incision and drainage of a perihepatic access. Please see operative report for details. He tolerated the procedure well, was extuabed, taken to the PACU until stable and then transferred to the surgical floor for further management. On POD12 from the initial surgery, he was tolerating a regular diet, pain was well controlled on oral medication, and he was ambulating independently. His white blood cell count was trending down and he was afebrile. He received IV ertopenem with no acute reaction. On POD13 he had a PICC line placed for long term antibiotic treatment. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled on oral medication. The patient was discharged home with visiting nursing services to assist in wound vac management and IV antibiotic administration. He was given a 10 day course of antibiotics. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Follow up appointments were scheduled. Medications on Admission: none Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain DO not exceed 4 grams of acetaminophen per 24 hours 2. Docusate Sodium 100 mg PO BID hold for diarrhea RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*40 Capsule Refills:*0 3. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose RX *ertapenem [___] 1 gram 1 gram IV once a day Disp #*8 Vial Refills:*0 4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain take lowest effective dose RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills:*0 5. Senna 8.6 mg PO BID:PRN constipation RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*40 Tablet Refills:*0 6. Sodium Chloride 0.9% Flush 10 mL IV BID and PRN, line flush flush PICC with 10 Ml before and after medication administration. RX *sodium chloride 0.9 % 0.9 % 10 ml IV twice a day Disp #*30 Syringe Refills:*0 7. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line flush Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: multiloculated intra-abdominal abscess secondary to dropped gallstones Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the Acute Care Surgery Service at ___ on ___ with abdominal pain. You had a CT scan that showed multiple abscesses in your abdomen. You were given IV antibiotics and taken to the operating room and had the infection removed surgically. After surgery, your white blood cell count, a marker of infection, remained elevated and you continued to have night sweats. You had an ultra sound of your abdomen and more retained stones were found. You were taken back to the operating room on ___ and had the remaining stones removed. You had a wound vac applied to your midline abdominal surgical incision to help with healing. You will go home and continue to have this dressing changed by the visiting nurse. You had a PICC line inserted in your arm to continue IV antibiotics at home. The visiting nurse ___ assist and teach you to administer your medication. You are now doing better, tolerating a regular diet, and pain is better controlled. You are now ready to be discharged to home to continue your recovery. Please note the following discharge instructions. Please ___ your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. ___ or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please ___ your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips ___ days after surgery. JP Drain Care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *Maintain suction of the bulb. *Note color, consistency, and amount of fluid in the drain. ___ the doctor, ___, or ___ nurse if the amount increases significantly or changes in character. *Be sure to empty the drain frequently. Record the output, if instructed to do so. *You may shower; wash the area gently with warm, soapy water. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself in water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. PICC line Instructions: *Please monitor the site regularly, and ___ your MD, nurse practitioner, or ___ Nurse if you notice redness, swelling, tenderness or pain, drainage or bleeding at the insertion site. * ___ your MD or proceed to the Emergency Room immediately if the PICC Line tubing becomes damaged or punctured, or if the line is pulled out partially or completely. DO NOT USE THE PICC LINE IN THESE CIRCUMSTANCES. Please keep the dressing clean and dry. Contact your ___ Nurse if the dressing comes undone or is significantly soiled for further instructions. Followup Instructions: ___
10155841-DS-15
10,155,841
22,166,204
DS
15
2161-10-20 00:00:00
2161-10-20 17:10:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Codeine Attending: ___. Chief Complaint: Left hip pain Major Surgical or Invasive Procedure: Left dynamic hip screw ___, ___ History of Present Illness: ___ female with 1 week of left hip pain, unable to bear full weight on left leg, after fall onto left hip. Patient had syncopal event 1 week ago, did not seek medical attention then, has been using a walker with partial weightbearing left lower extremity, unable to walk unassisted; prior to the fall she was ambulatory using a cane for balance only. X-rays at urgent care showed possible femoral neck fracture. Past Medical History: Atrial fibrillation on Xarelto Tinea pedis Seborrheic keratosis Pelvic organ prolapse Social History: ___ Family History: none Physical Exam: Exam: resting quietly on arrival but alert for exam Vitals: ___ 0435 Temp: 97.9 PO BP: 112/63 HR: 73 RR: 18 O2 sat: 95% O2 delivery: RA General: Well-appearing, breathing comfortably MSK: LLE dressing c/d/I; fires TA, ___, ___, FHL; foot warm, perfused Pertinent Results: ___ 05:20AM BLOOD WBC-8.9 RBC-3.06* Hgb-9.6* Hct-28.8* MCV-94 MCH-31.4 MCHC-33.3 RDW-13.5 RDWSD-46.1 Plt ___ ___ 06:17AM BLOOD Hct-28.1* ___ 05:20AM BLOOD Plt ___ ___ 05:20AM BLOOD Glucose-113* UreaN-13 Creat-0.6 Na-141 K-3.8 Cl-102 HCO3-28 AnGap-11 ___ 05:50AM BLOOD Calcium-8.9 Phos-3.5 Mg-1.7 Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have left occult hip fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for left dynamic hip screw, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is weightbearing as tolerated in the left lower extremity, and will be discharged on her home Xarelto for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: Metoprolol, Xarelto, simvastatin, vitamin D, multivitamin, Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H RX *acetaminophen 500 mg 2 tablet(s) by mouth q8hr Disp #*80 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 3. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain RX *oxycodone 5 mg 0.5 to 1 tablet(s) by mouth every eight (8) hours Disp #*20 Tablet Refills:*0 4. Senna 8.6 mg PO BID RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp #*60 Tablet Refills:*0 5. Vitamin D 400 UNIT PO DAILY RX *ergocalciferol (vitamin D2) 400 unit 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 6. Metoprolol Succinate XL 50 mg PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Rivaroxaban 20 mg PO DINNER Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Left occult femoral neck fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: -Weightbearing as tolerated to left lower extremity MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take your home dose of Xarelto WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Please remain in your dressing and do not change unless it is visibly soaked or falling off. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB FOLLOW UP: Please follow up with your Orthopaedic Surgeon, Dr. ___. You will have follow up with ___, NP in the Orthopaedic Trauma Clinic 14 days post-operation for evaluation. Call ___ to schedule appointment upon discharge. Please follow up with your primary care doctor regarding this admission within ___ weeks and for and any new medications/refills. Physical Therapy: Weightbearing as tolerated to left lower extremity Treatments Frequency: Staples to remain for at least 2 weeks postoperatively. Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. You may shower and allow water to run over the wound, but please refrain from bathing for at least 4 weeks postoperatively. Followup Instructions: ___
10155841-DS-16
10,155,841
21,958,750
DS
16
2163-07-23 00:00:00
2163-07-23 23:41:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Codeine / Cipro / oxycodone Attending: ___ Chief Complaint: Transient facial droop, difficulty speaking Major Surgical or Invasive Procedure: None History of Present Illness: Time/Date the patient was last known well: 1145 ___ Stroke Scale Score: 1 t-PA administered: [] Yes - Time given: __ [x] No - Reason t-PA was not given or considered: NIHSS 1 Thrombectomy performed: [] Yes [x] No - Reason not performed or considered: no LVO NIHSS performed within 6 hours of presentation at: 1340 time/date ___ NIHSS Total: 1 1a. Level of Consciousness: 0 1b. LOC Question: 0 1c. LOC Commands: 0 2. Best gaze: 0 3. Visual fields: 0 4. Facial palsy: 0 5a. Motor arm, left: 0 5b. Motor arm, right: 0 6a. Motor leg, left: 0 6b. Motor leg, right: 0 7. Limb Ataxia: 0 8. Sensory: 0 9. Language: 0 10. Dysarthria: 1 11. Extinction and Neglect: 0 REASON FOR CONSULTATION: code stroke HPI: ___ F w/ PMH afib, presents with transient facial droop, difficulty speaking, POD1 from R TKR at ___. Patient was hospitalized at ___ yesterday for elective R TKA, this occurred yesterday without complication. Performed by Dr. ___. She felt fine after the procedure. EBL 100 cc. Case performed under general anesthesia. INR 1.4, Cr 1.0 this morning at ___. Per nursing notes at ___ at 1216, nursing went to do routine check on her and the following was noted: "Pt appeared to have trouble with wording finding but answers appropriate. Slight R facial droop noted, no pronator drift, good arm strength, +tongue deviation to R. Dr ___ called in to see patient, code green called. 911 called and plan for pt to transfer to BI to rules out CVA. Pt aphasic for ___. By 1225 pt answering questions appropriately, slightly slurred speech, A&Ox4. Pt states 'This seems like overkill, I'm fine'." She was last seen normal around ___. Per nursing notes, patient was scheduled to start warfarin last night, patient refused however as she wanted to start ___. After further clarification, her orthopedist preferred warfarin in the short term (4 weeks per notes) over ___ for ease of reversability if needed. The plan was to start warfarin tonight, which patient was ok with. In speaking with the patient she tells me that she has been off ___ since ___ in preparation for surgery. She states during this episode earlier today, she understood everything people was saying to her. She couldn't get words out that she wanted, but could gesture still. She states that this lasted 10 minutes maybe and she feels fine, back at baseline now. She does not feel her speech is dysarthric at the moment or in the ED. She tells me that around 2 weeks ago she had a dental procedure for which ___ was held, and had a 2 minute period where she had difficulty getting words out post procedurally. She had 2 teeth extracted under local anesthesia then. In the emergency room, the ED resident noted she was not oriented to date, despite having been oriented earlier, and her speech was dysarthric, so code stroke was activated. She did not feel her speech was dysarthric at the time of this evaluation. At the time of my evaluation her family was with her and also did not feel her speech seemed significantly different than baseline. The most recent progress note from today from ___ has recs as follows: ___, warfarin for INR ___, for 4 weeks, resume ___ 5 mg BID when warfarin discontinued, complete periop abx, regular diet, PO pain control, WBAt, ___, dispo pending pain control and therapy. Notes at ___ indicate that EKG in PACU showed afib. She was cardioverted here in ___, with post EKG no longer showing afib. Other labs from ___ this am: CBC: wbc 11.9 Hgb 11.2 Hct 34.2 plt 203 Sodum 139 potassium 4.8 chloride 104bicarb 25 glucose 11 BUn 20 cr 1.0 ca 8.4 mg 1.8 ___ 15.6 INR 1.4 ROS: On neurological review of systems, the patient denies headache, confusion, difficulties producing or comprehending speech, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the patient denies recent fever, chills, night sweats, or recent weight changes. Denies cough, shortness of breath, chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. Denies dysuria, or recent change in bowel or bladder habits. Denies arthralgias, myalgias, or rash. CURRENT MEDICATIONS: metoprolol succinate 50 mg daily simvastatin 40 mg daily vit D ___ units daily omeprazole ___ MVI ___ 5 mg BID (on hold since ___ for surgery) ALLERGIES: Allergies (Last Verified ___ by ___: Cipro Codeine oxycodone Past Medical History: Atrial fibrillation on ___, s/p cardioversion Tinea pedis Seborrheic keratosis Pelvic organ prolapse L acoustic neuroma s/p XRt with bilateral hearing aids GERD L hip fracture ___ R TKR ___ L TKR ___ Social History: Lives alone; husband died of C. difficile infection following surgery in ___ Used to work with husband on his businesses Tobacco use: Former smoker Tobacco Use Quit ___ yrs ago. Modified Rankin Scale: [ ] 0: No symptoms [x] 1: No significant disability - able to carry out all usual activities despite some symptoms [ ] 2: Slight disability: able to look after own affairs without assistance but unable to carry out all previous activities [ ] 3: Moderate disability: requires some help but able to walk unassisted [] 4: Moderately severe disability: unable to attend to own bodily needs without assistance and unable to walk unassisted [] 5: Severe disability: requires constant nursing care and attention, bedridden, incontinent [] 6: Dead Family History: reviewed and noncontributory to current presentation Physical Exam: ADMISSION PHYSICAL EXAMINATION: Vitals: T97.3 HR74 BP146/76 R16 SpO2 97% RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx. Neck: Supple, no carotid bruits appreciated. No nuchal rigidity. Pulmonary: Normal work of breathing. Cardiac: RRR, warm, well-perfused. Abdomen: Soft, non-distended. Extremities: No ___ edema. MSK: R knee in dressing, c/d/i Skin: No rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented ___. Able to relate history without difficulty. Gets to ___ with MOYB, but then gets stuck at ___. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Able to name both high and low frequency objects. Able to read without difficulty. No dysarthria. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. Aware of current events from this week (impeachment inquiry, ___. Slight dysarthria. easily understood. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. Strength full with tongue-in-cheek testing. -Motor: Normal bulk and tone throughout. No pronator drift or orbiting. No adventitious movements, such as tremor or asterixis noted. [Delt][Bic][Tri][ECR][FEx][IO] [___] L 5 5 5 5 4+ 5 5 5 5 5 5 5 R 5 5 5 5 4+ 5 >4 5 5 5 full strength testing of R leg deferred given recent surgery -Sensory: No deficits to light touch, pinprick, temperature, vibration, or proprioception throughout. No extinction to DSS. -Reflexes: [Bic] [Tri] [___] [Pat] [Ach] L 2 2 2 2 1 R 2 2 2 1 Plantar response was flexor bilaterally. -Coordination: No intention tremor. Normal finger-tap bilaterally. No dysmetria on FNF or HKS bilaterally. -Gait: deferred =============================================== DISCHARGE PHYSICAL EXAMINATION General: Awake, cooperative, NAD. Pulmonary: Normal work of breathing. Cardiac: RRR, warm, well-perfused. Abdomen: Soft, non-distended. MSK: R knee in dressing, c/d/i Neurologic: -Mental Status: Alert, oriented to self, place and date. Language is fluent with normal prosody and no paraphasic errors. Dysarthria especially with glottal sounds (per patient, this was at baseline on presentation but appears improved today). Her speech is easily understood. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to conversation bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. -Motor: Normal bulk and tone throughout. No pronator drift or orbiting. No adventitious movements, such as tremor or asterixis noted. [Delt][Bic][Tri][ECR][FEx][IO] [___] L 5 5 5 5 4+ 5 5 5 5 5 5 5 R 5 5 5 5 4+ 5 >4 5 5 5 full strength testing of R leg deferred given recent surgery -Sensory: No deficits to light touch, pinprick, temperature, vibration, or proprioception throughout. No extinction to DSS. -Reflexes: [Bic] [Tri] [___] [Pat] [Ach] L 2 2 2 2 1 R 2 2 2 1 Plantar response was flexor bilaterally. -Coordination: No intention tremor. Normal finger-tap bilaterally. No dysmetria on FNF bilaterally -Gait: deferred Pertinent Results: LABORATORY DATA: ___ 01:45PM BLOOD WBC: 10.1* RBC: 3.54* Hgb: 10.8* Hct: 32.9* MCV: 93 MCH: 30.5 MCHC: 32.8 RDW: 14.2 RDWSD: 48.1* Plt Ct: 169 ___ 01:45PM BLOOD Neuts: 79.4* Lymphs: 10.5* Monos: 9.2 Eos: 0.2* Baso: 0.4 Im ___: 0.3 AbsNeut: 8.01* AbsLymp: 1.06* AbsMono: 0.93* AbsEos: 0.02* AbsBaso: 0.04 ___ 01:45PM BLOOD ___: 15.3* PTT: 28.0 ___: 1.4* ___ 01:45PM BLOOD Glucose: 152* UreaN: 18 Creat: 0.8 Na: 135 K: 4.7 Cl: 102 HCO3: 23 AnGap: 10 ___ 01:45PM BLOOD ALT: 47* AST: 61* AlkPhos: 87 TotBili: 0.6 ___ 01:45PM BLOOD cTropnT: <0.01 ___ 01:45PM BLOOD Albumin: 3.6 Calcium: 8.9 Phos: 3.1 Mg: 1.8 ___ 01:45PM BLOOD ASA: NEG Ethanol: NEG Acetmnp: NEG Tricycl: NEG ___ 06:00AM BLOOD %HbA1c-5.6 eAG-114 ___ 06:00AM BLOOD Triglyc-105 HDL-41 CHOL/HD-3.0 LDLcalc-59 ___ 06:00AM BLOOD TSH-0.98 ___ 06:25AM BLOOD WBC-9.9 RBC-3.68* Hgb-11.1* Hct-34.6 MCV-94 MCH-30.2 MCHC-32.1 RDW-14.1 RDWSD-48.3* Plt ___ ___ 06:25AM BLOOD ___ PTT-33.9 ___ ___ 06:25AM BLOOD Glucose-97 UreaN-12 Creat-0.8 Na-141 K-4.6 Cl-105 HCO3-23 AnGap-13 ___ 06:25AM BLOOD ALT-26 AST-33 ___ 06:25AM BLOOD Calcium-8.9 Phos-2.5* Mg-1.9 IMAGING: CTA ___ CT HEAD: No evidence of acute intracranial hemorrhage or large territorial infarction. Punctate hyperdensity in the R MCA region may represent aneurysm. CTA head: A 4 mm saccular aneurysm (measured in the transverse dimension) is seen at the bifurcation of the M1-M2 segment of the right MCA (3; 230). There is no evidence of subarachnoid hemorrhage. Consultation with Neurosurgery is advised. There is a small area of hypoattenuation in the area of the basal ganglia, likely representing lacunar ischemic changes. Periventricular and subcortical white matter hypoattenuation is related to microvascular atherosclerotic disease. Otherwise, there is no evidence of acute hemorrhage or large territorial infarction. Dural venous sinuses are patent. Mucosal thickening is seen in the ethmoidal sinuses. Prominence of ventricles and sulci are associated with age related involutional change. CTA neck: Calcification is seen at the bifurcation of the bilateral carotid arteries with no evidence of stenosis according to NASCET criteria. Severe calcification is seen in the thoracic aortic arch. In the lungs, there are mosaic changes, pleural scarring, and bullous emphysema in the apices with a small left pleural effusion. There are also areas of pleural thickening, retraction, and fibrous changes in the right lung. Moderate degenerative changes are seen along the cervical spine, including mild anterolisthesis of C2-3 and retrolisthesis of C4-5. Final report pending completion of 3D reconstructions. ___ MRI: 1. Multiple foci of diffusion abnormality with correlating FLAIR hyperintensity is concerning for subacute infarcts due to a embolic source. 2. Focus of enhancement and susceptibility in the left temporal lobe consistent with late subacute infarction, with potential petechial hemorrhage and/or in combination with cortical laminar necrosis. No significant change compared to the prior head CT. 3. 4 mm right MCA aneurysm better assessed on prior CTA. Brief Hospital Course: TRANSITIONAL ISSUES [] Coumadin started this hospitalization. Last INR was 5.3 on ___ therefore Coumadin was not given on ___. Next level to be drawn on ___, with results sent to Dr. ___ at ___. [] Incidentally discovered 4mm right MCA aneurysm. Evaluated by Neurosurgery with recommendations for outpatient follow-up. This is an ___ year old woman with atrial fibrillation who presents with transient facial droop, difficulty speaking. At the time of her symptom she was post-op day #1 from a right total knee replacement, done at ___. Symptoms essentially resolved within ___ minutes. At ___, exam unremarkable except for slight dysarthria, which she reports is chronic. MRI brain showed multiple small infarcts in different vascular distributions, suggestive of cardioembolic etiology. Etiology of her stroke is likely cardiac embolism, in the setting of stopped anticoagulation. Other stroke work-up was notable for: A1c 5.6%, LDL 59, CTA head/neck showed moderate atherosclerotic calcifications of the bilateral carotid bulbs but no significant stenosis. At the preference of her orthopedic surgeon, anticoagulation was transitioned to Coumadin. AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (x) Yes, confirmed done - () Not confirmed () No. If no, reason why: 2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not (I.e. bleeding risk, hemorrhage, etc.) 3. Antithrombotic therapy administered by end of hospital day 2? (x) Yes - () No. If not, why not? (I.e. bleeding risk, hemorrhage, etc.) 4. LDL documented? (x) Yes (LDL = 59) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [x] LDL-c less than 70 mg/dL 6. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given in written form? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No. If no, why not? (I.e. patient at baseline functional status) 9. Discharged on statin therapy? (x) Yes - () No [if LDL >70, reason not given: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL 10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) Antiplatelet - (x) Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? (x) Yes - () No - If no, why not (I.e. bleeding risk, etc.) () N/A Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 5 mg PO BID 2. Simvastatin 40 mg PO QPM 3. Omeprazole 20 mg PO DAILY 4. Metoprolol Succinate XL 50 mg PO DAILY 5. amLODIPine 2.5 mg PO DAILY 6. Vitamin D ___ UNIT PO DAILY 7. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. ___ MD to order daily dose PO DAILY16 RX *warfarin 1 mg ___ tablet(s) by mouth once a day Disp #*60 Tablet Refills:*2 2. amLODIPine 2.5 mg PO DAILY 3. Metoprolol Succinate XL 50 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Simvastatin 40 mg PO QPM 7. Vitamin D ___ UNIT PO DAILY 8.Outpatient Physical Therapy Evaluate and treat Diagnosis: Osteoarthritis Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Acute ischemic stroke Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were hospitalized due to symptoms of difficulty speaking and facial droop resulting from an ACUTE ISCHEMIC STROKE, a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. Stroke can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: Atrial fibrillation High blood pressure We are changing your medications as follows: STOP Apixaban for now START Coumadin. However because your INR (Coumadin level) is too high today, please DO NOT take any Coumadin on ___. You will have your level checked tomorrow (___), and will receive further instructions. Please take your other medications as prescribed. Please follow up with Neurology and your primary care physician as listed below. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology Team Followup Instructions: ___
10155841-DS-17
10,155,841
27,706,701
DS
17
2163-08-05 00:00:00
2163-08-05 16:42:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine / Cipro / oxycodone Attending: ___. Major Surgical or Invasive Procedure: None attach Pertinent Results: ADMISSION LABS: =============== ___ 12:00PM BLOOD WBC-17.6* RBC-3.35* Hgb-10.2* Hct-29.6* MCV-88 MCH-30.4 MCHC-34.5 RDW-15.1 RDWSD-47.3* Plt ___ ___ 12:00PM BLOOD Neuts-89.9* Lymphs-4.1* Monos-4.8* Eos-0.0* Baso-0.1 Im ___ AbsNeut-15.81* AbsLymp-0.73* AbsMono-0.85* AbsEos-0.00* AbsBaso-0.02 ___ 12:13PM BLOOD ___ PTT-38.0* ___ ___ 12:00PM BLOOD Glucose-135* UreaN-23* Creat-1.2* Na-135 K-4.7 Cl-102 HCO3-17* AnGap-16 ___ 12:00PM BLOOD Calcium-8.7 Phos-2.1* Mg-1.6 ___ 12:15PM BLOOD ___ pO2-48* pCO2-17* pH-7.63* calTCO2-19* Base XS-0 ___ 12:15PM BLOOD Lactate-2.8* ___ 12:15PM BLOOD O2 Sat-89 OTHER NOTABLE LABS: =================== ___ 05:18AM BLOOD ALT-27 AST-36 AlkPhos-151* TotBili-0.9 ___ 07:27AM BLOOD freeCa-1.14 INR TREND: ___ 12:13PM BLOOD ___ PTT-38.0* ___ ___ 05:09AM BLOOD ___ ___ 05:18AM BLOOD ___ PTT-32.9 ___ ___ 05:19AM BLOOD ___ PTT-33.2 ___ VBG TREND: ___ 12:15PM BLOOD ___ pO2-48* pCO2-17* pH-7.63* calTCO2-19* Base XS-0 ___ 04:31PM BLOOD ___ pO2-31* pCO2-32* pH-7.46* calTCO2-23 Base XS--1 ___ 07:27AM BLOOD pO2-120* pCO2-18* pH-7.51* calTCO2-15* Base XS--5 ___ 03:20PM BLOOD Type-ART pO2-102 pCO2-25* pH-7.55* calTCO2-23 Base XS-0 LACTATE TREND: ___ 07:27AM BLOOD Lactate-4.9* Creat-0.9 Na-132* K-4.4 Cl-104 ___ 12:06PM BLOOD Lactate-2.0 ___ 03:20PM BLOOD Lactate-1.2 IMAGING: ___ Imaging CTA CHEST 1. No evidence of pulmonary embolism to the segmental level. 2. Severe emphysema with chronic scarring of the right upper lobe. 3. Mild cardiomegaly. Brief Hospital Course: TRANSITIONAL ISSUES: =================== [] Patient prescribed 10 day course of ciprofloxacin for GNR bacteremia (last day ___. [] Patient was supratherapeutic on arrival (INR 4.6 on ___. She was restarted on 0.5mg warfarin on ___ with the plan to give her 0.5mg every other day. She will need close follow-up as outpatient especially as her INR will likely increase while on ciprofloxacin. [] Hemoglobin 10 on day of discharge. [] Patient had blood pressures SBP 160s. Would consider increasing amlodipine from 2.5mg to 5mg. [] CTA on ___ showed severe emphysema with chronic scarring of the right upper lobe and mild cardiomegaly. SUMMARY: Ms. ___ is an ___ year old woman with a history of AF (on coumadin), recent right TKR ___ @ ___ and admission @ ___ ___ for TIA, who presented with dysuria, foul-smelling urine, fevers and chills, found to have sepsis and GNR bacteremia that was suspected to be from urinary source. Hospital course complicated by afib with RVR and acute pulmonary edema. ACUTE ISSUES: ============= # Sepsis # EColi bacteremia # UTI Patient presented with dysuria, foul-smelling urine, vomiting and fevers with UA demonstrating pyuria and moderate bacteria consistent with UTI. Blood cultures positive for E. Coli. While urine culture did not grow any bacteria, we suspect this may have been due to partial treatment with initiation of outpatient Bactrim prior to hospitalization. At admission, she received CTX in the ED and 2L IVF. She will be treated with total 10 day course of antibiotics for EColi bacteremia and UTI and was discharged on ciprofloxacin. # AF with RVR # Supratherapeutic INR Patient with known history of AF, for which she was started on Coumadin during last admission. She presented with supratherapeutic INR to 4.6, and she was also supratherapeutic to 5.3 on ___. She developed AF with RVR in the ED likely iso sepsis. RVR responded to IV metoprolol. Warfarin was initially held in setting of supratherapeutic INR and was restarted at a lower dose on ___. Plan to give warfarin 0.5mg every other day (next dose ___. She will need close monitoring of INR especially while on ciprofloxacin, which can increase risk of bleeding. # Dyspnea in setting of acute pulmonary edema # Respiratory alkalosis # RUL Scarring/severe emphysema on CT scan Patient with recent surgery so she had a CTA chest, which was negative for embolism. No known h/o lung disease but CT showing subpleural scarring of the RUL possibly from prior infectious process and severe emphysema. Flu testing negative in the ED. Patient with acute pulmonary edema on morning of ___ that improved with IV Lasix 20mg on ___ and ___. Pulmonary edema was likely flash in setting of afib with RVR. # ___ Creatinine 1.2 on admission from baseline ~.7. Likely pre-renal iso volume loss from vomiting and insensible losses since febrile and improved s/p 2L IVF. # Recent R TKR # Right lower extremity swelling Right TKA done at ___ (___). Per patient, swelling in right leg has gone down since surgery. Deferred RLE US, as no PE on CTA and already anticoagulated for afib, so would not change management. Seen by orthopedics in the ED who recommended WBAT with walker and outpatient orthopedist for post-operative management. # Normocytic anemia Hgb 10.2 on admission, from 11.1 on last discharge. No signs of active bleeding. Stable throughout admission. # Nutrition Patient concerned regarding poor appetite. Nutrition was consulted who recommended Ensure TID and a multivitamin with minerals. CHRONIC ISSUES: =============== # H/o TIA MRI last admission showed small infarcts in different vascular distributions suggestive of cardioembolic etiology. CTA head/neck showed moderate atherosclerotic calcifications of b/l carotid bulbs but w/o stenosis. # HLD Patient continued on home simvastatin 40mg nightly Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Warfarin 1 mg PO DAILY16 2. amLODIPine 2.5 mg PO DAILY 3. Metoprolol Succinate XL 50 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Omeprazole 20 mg PO DAILY:PRN heart burn 6. Simvastatin 40 mg PO QPM 7. Vitamin D ___ UNIT PO DAILY Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO BID RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice a day Disp #*13 Tablet Refills:*0 2. Warfarin 0.5 mg PO EVERY OTHER DAY 3. amLODIPine 2.5 mg PO DAILY 4. Metoprolol Succinate XL 50 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Omeprazole 20 mg PO DAILY:PRN heart burn 7. Simvastatin 40 mg PO QPM 8. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY: GNR Bacteremia UTI Acute pulmonary edema Afib with RVR Supratherapeutic INR HTN Respiratory alkalosis ___ SECONDARY: Recent R TKR Normocytic anemia HLD H/o TIA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: ====================== DISCHARGE INSTRUCTIONS ====================== Dear Ms. ___, It was a pleasure caring for ___ at ___ ___. WHY WAS I IN THE HOSPITAL? - ___ were in the hospital because ___ were having pain with urination and shaking chills. WHAT HAPPENED TO ME IN THE HOSPITAL? - ___ were found to have a bacteria in your blood, which was treated. - ___ had fast heart rates that were slowed down. - ___ had some extra fluid that got into your lungs, which we helped ___ pee out with a medication called Lasix. - Your INR was too high when ___ first came to the hospital. This puts ___ at an increased risk for bleeding. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Please only take 0.5mg warfarin every other day until ___ speak to your doctor. ___ not take it on ___, ok to take half a pill on ___ Your INR was high, and it will likely be even higher on the antibiotic we prescribed ___. - Your blood pressures were a bit high during your admission. Please speak to your doctor about going up on your amlodipine. - Please take your medications and go to your follow up appointments as described in this discharge summary. - If ___ experience any of the danger signs listed below, please call your primary care doctor or go to the emergency department immediately. We wish ___ the best! Sincerely, Your ___ Team Followup Instructions: ___
10155915-DS-9
10,155,915
20,393,363
DS
9
2126-05-26 00:00:00
2126-05-28 18:05:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Lamictal / Tegretol Attending: ___. Chief Complaint: diarrhea Major Surgical or Invasive Procedure: Flexible sigmoidoscopy (___) Esophagogastroduodenoscopy (___) Colonoscopy (___) Plasmapheresis Line Placement (___) Plasmapheresis (___) History of Present Illness: ___ w/h/o chronic pain, question of SLE, presents from OSH with ___ months of diarrhea, worsening over past 2 weeks. Patient in ___ until ___, when she developed chronic cough, started on abx. Developed diarrhea at around the same time, which has been progressively worsening. For past 2 weeks reports approx 15 episodes of diarrhea per day with abdominal cramping, N/V. Three days prior to presentation diarrhea became bloody, mucousy. Also c/o chills, night sweats. No fevers athome. She feels nauseated "all the time." She reports vomiting 3 days ago, nonbloody nonbilious. Of note, just prior to the onset of her symptoms, she had traveled to ___. She denies eating any unusual foods, camping, drinking stream water, or sick contacts during the trip. She occasionally has regular BMs. Her BMs are occasionally ___ colored. Were previously black due to iron supp but are now back to normal. She reports losing 6 lbs since ___ according to her home scale but that her weight here only shows her down 1 lb. Of note, pt has chronic pain syndrome, diffuse body aches incl crampy intermittent chest pain occuring at rest over past several months, increasing in frequency over past two weeks; currently CP free. She believes her CP is worse with eating. Also reports SOB with activity for past few months which is currently being worked up as an outpatient by her pulmonologist. Of note, her test for coccidiomycosis was negative. Pt presented to OSH, where CT showed colitis and she was given phenergan, dilaudid, and received cipro and flagyl at 8pm. Her H pylori test was negative and the remainder of her labs were negative. In the ED, initial vs were: T 99, HR 61, BP 101/61, RR 18, O2 sat 99% RA . Labs were remarkable for lactate 0.8, no leukocytosis, chem 7 w/n/l, INR 1.0. No imaging here. Patient was given 1 L NS, ordered for levofloxacin and flagyl to be administered w/ reference to prior abx given at OSH (8 pm). Stool cxs, ova and parasites, Cdiff ordered. GI consulted, concern for IBD. The recommended admission for flex sig. On the floor, vs were wnl. Pt complained of migraine and nausea. She requested percocet for both. Past Medical History: - Migraines - Torn labrum of the L hip - GERD - Chronic pain in back and legs - s/p B/l knee arthroscopic surgery with cadaveric ACLs - Lipomas resected from L buttock, chest - ?SLE - Bipolar disorder - Vasovagal episodes Social History: ___ Family History: Daughter w/ seizure disorder Physical Exam: Admission Physical Exam: Vitals: 98.2, 121/55, 66, 18, 100% on RA General: well appearing middle aged white female in NAD HEENT: MMM. EOMI. PERRL. Neck: supple Lungs: CTAB, no w/r/r CV: RRR, no m/g/r Abdomen: NABS. S, ND, TTP in LLQ with voluntary guarding. No rigidity. Ext: no e/e/c Skin: mild old bruises on R hip and thigh Neuro: CNs grossly intact. no focal deficits. Discharge Physical Exam: 98.5 111/43 (110-130 / 50-70s) 67 (60-70s) 16 97RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, supple neck, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV- RRR, normal S1 + S2, no m/r/g Abdomen- soft, slight tenderness to deep palpation in LLQ and suprapubic region, non-distended, +BS, no rebound tenderness or guarding, no organomegaly Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal Skin: Ecchymoses on abdomen, arms, no new petechiae. Pertinent Results: Admission Labs: ___ 12:10AM WBC-6.2 RBC-4.26 HGB-12.9 HCT-36.6 MCV-86# MCH-30.2 MCHC-35.2* RDW-12.7 ___ 12:10AM NEUTS-59.6 ___ MONOS-8.1 EOS-3.3 BASOS-1.0 ___ 12:10AM PLT COUNT-245 ___ 12:10AM ___ PTT-29.4 ___ ___ 12:10AM GLUCOSE-90 UREA N-7 CREAT-0.7 SODIUM-140 POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-26 ANION GAP-14 ___ 12:17AM LACTATE-0.8 ___ 07:35AM SED RATE-8 ___ 07:35AM CRP-3.8 Pertinent labs (CBC trend) ___ 08:00AM BLOOD WBC-4.4 RBC-4.28 Hgb-13.0 Hct-37.7 MCV-88 MCH-30.4 MCHC-34.5 RDW-12.5 Plt ___ ___ 08:05AM BLOOD WBC-5.1 RBC-4.15* Hgb-12.5 Hct-35.7* MCV-86 MCH-30.1 MCHC-35.1* RDW-12.9 Plt ___ ___ 07:50AM BLOOD WBC-5.3 RBC-4.02* Hgb-12.4 Hct-34.3* MCV-85 MCH-30.8 MCHC-36.1* RDW-13.2 Plt Ct-80*# ___ 07:22AM BLOOD WBC-4.7 RBC-3.65* Hgb-11.1* Hct-31.6* MCV-87 MCH-30.4 MCHC-35.1* RDW-13.2 Plt Ct-57* ___ 01:49AM BLOOD WBC-5.8 RBC-3.27* Hgb-9.9* Hct-27.9* MCV-85 MCH-30.3 MCHC-35.4* RDW-13.7 Plt Ct-46* ___ 10:20AM BLOOD WBC-4.9 RBC-3.43* Hgb-10.4* Hct-29.9* MCV-87 MCH-30.3 MCHC-34.8 RDW-14.0 Plt Ct-52* ___ 04:10PM BLOOD WBC-5.6 RBC-3.19* Hgb-9.5* Hct-27.6* MCV-87 MCH-29.9 MCHC-34.5 RDW-14.0 Plt Ct-43* ___ 07:30AM BLOOD WBC-4.6 RBC-2.91* Hgb-9.0* Hct-24.8* MCV-85 MCH-31.0 MCHC-36.4* RDW-13.8 Plt Ct-49* ___ 03:09AM BLOOD WBC-9.5 RBC-2.60* Hgb-7.8* Hct-22.1* MCV-85 MCH-30.0 MCHC-35.4* RDW-13.9 Plt Ct-62* ___ 01:30PM BLOOD WBC-7.4 RBC-2.54* Hgb-7.7* Hct-22.3* MCV-88 MCH-30.2 MCHC-34.4 RDW-13.9 Plt ___ ___:00AM BLOOD WBC-7.6 RBC-2.53* Hgb-7.8* Hct-22.1* MCV-88 MCH-30.6 MCHC-35.0 RDW-14.2 Plt ___ ___ 07:00AM BLOOD WBC-5.9 RBC-2.39* Hgb-7.4* Hct-20.7* MCV-87 MCH-31.1 MCHC-35.9* RDW-14.0 Plt ___ LDH and Tbili trend: ___ 12:17PM BLOOD ALT-35 AST-54* LD(___)-500* AlkPhos-48 TotBili-1.2 ___ 01:49AM BLOOD LD(___)-411* TotBili-0.6 ___ 10:20AM BLOOD ALT-35 AST-52* LD(___)-424* AlkPhos-42 TotBili-0.7 ___ 04:10PM BLOOD ALT-35 AST-51* LD(___)-393* CK(CPK)-71 AlkPhos-38 TotBili-0.5 ___ 07:30AM BLOOD LD(LDH)-389* TotBili-0.5 ___ 03:09AM BLOOD LD(LDH)-290* ___ 07:00AM BLOOD LD(___)-272* TotBili-0.2 ___ 07:00AM BLOOD LD(___)-209 TotBili-0.2 Discharge Labs: ___ 07:00AM BLOOD WBC-5.9 RBC-2.39* Hgb-7.4* Hct-20.7* MCV-87 MCH-31.1 MCHC-35.9* RDW-14.0 Plt ___ ___ 07:00AM BLOOD Glucose-85 UreaN-13 Creat-1.1 Na-142 K-3.9 Cl-105 HCO3-33* AnGap-8 ___ 07:00AM BLOOD LD(___)-209 TotBili-0.2 ___ 07:00AM BLOOD Calcium-7.7* Phos-3.7 Mg-2.2 ___ 07:00AM BLOOD Hapto-120 Pertinent Micro: C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: NO E.COLI 0157:H7 FOUND. VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary): No Cytomegalovirus (CMV) isolated. Pertinent Imaging: OSH Abdominal CT ___ ___ Radiology Read Below_) FINDINGS: The visualized lung bases are clear. There is no pleural or pericardial effusion. Within the left hepatic lobe, there is a lobulated 1.9-cm hypodensity with the attenuation of a simple cyst. No prior imaging is available from ___ to assess for stability. The remainder of the liver is normal and no focal concerning liver lesion is identified. There is no intra- or extra-hepatic bile duct dilation. The gallbladder, spleen, pancreas and bilateral adrenal glands are normal. The kidneys enhance symmetrically and excrete contrast promptly without hydronephrosis. There is no bowel obstruction. The appendix is visualized and is normal (3:98). There is no free fluid and no free air. The abdominal aorta is of normal caliber throughout. The main portal vein, splenic vein and SMV are patent. Para-aortic and aortocaval lymph nodes are not enlarged by CT size criteria, measuring up to 9 mm in the left paraaortic (602:34, 3:81) and aortocaval stations (3:71). CT PELVIS: The rectum is normal. Bowel wall thickening with mild adjacent stranding in the sigmoid is noted. The bladder and uterus are normal. The right ovary is normal. Within the left adnexa, there is a 3.1 x 3.7 cm simple cyst, within the physiologic range if the patient is premenopausal. There is no free fluid. A left iliac node (3:108) is borderline enlarged to 10 mm and a 9mm node is seen at the right pelvic side wall. There is a small fat-containing left inguinal hernia. BONE WINDOWS: No bone finding suspicious for infection or malignancy is seen. IMPRESSION: 1. Mild sigmoid colitis, which may be infectious or inflammatory. Borderline pelvic and retroperitoneal lymph nodes are likely reactive. Repeat CT with rectal volumen or MRI may be helpful if further imaging is going to be performed. 2. Left adnexal 3.7-cm cyst. If the patient is premenopausal, this is within the physiologic range. If the patient is postmenopausal, followup with dedicated pelvic ultrasound is recommended in one year. 3. 1.9-cm left hepatic lobe simple cyst. No prior imaging is available from ___ to compare, but it does not have concerning features on this study and no specific follow up is required. Flexible sigmoidoscopy ___ Erythema and friability in the sigmoid colon and rectum (biopsy, biopsy) Otherwise normal sigmoidoscopy to splenic flexure EGD ___ Impressions: Normal mucosa in the whole esophagus Gastritis in the stomach antrum (biopsy) Normal mucosa in the whole duodenum (biopsy) Otherwise normal EGD to third part of the duodenum Colonoscopy ___ Impressions: Grade 1 internal hemorrhoids Erythema in the mid rectum (biopsy) Normal mucosa in the sigmoid colon, descending colon, transverse colon, ascending colon, cecum and terminal ileum (biopsy, biopsy, biopsy, biopsy, biopsy, biopsy) Otherwise normal colonoscopy to cecum Brief Hospital Course: ___ with history of chronic pain, migraines, and ?rheumatological process presented with several months of diarrhea with acute worsening ___ colitis of unclear etiology. Her hospitalization was complicated by anemia and thrombocytopenia with a hemolytic component of unclear etiology. ACTIVE DIAGNOSES: #Colitis: Patient presented with 2 months of chronic diarrhea with acute worsening over a week with up to 15 bowel movements a day. Mild colitis was seen in sigmoid colon on OSH CT (confirmed by ___ radiology read). Pt started on cipro/flagyl at OSH (first day ___, d/c’ed ___. Extensive infectious work-up was negative. Although there was initially a broad differential, gastroenterology was consulted and performed a flexible sigmoidoscopy indicating inflamed sigmoid mucosa with rectal involvement, which was originally suspicious for ulcerative colitis. Patient was started on mesalamine and hydrocortisone foam on ___. The biopsy, however, taken from sigmoidoscopy was not indicative of ulcerative colitis. Mesalamine was discontinued on ___ out of concern that it may have been causing thrombocytopenia (see below). The patient continued to have diarrhea, nausea, and abdominal pain in house with trace amounts of blood in stools. Given persistent symptoms, she was taken for colonoscopy on ___ indicating minimal erythema in the rectum with several biopsies within normal limits. Patient had improvement in abdominal exam with decreased frequency of bowel movements. On day of discharge ___, she reported minimal abdominal discomfort with one bowel movement with more formed stool over the prior 24 hours. While etiology remains unclear, her sudden resolution of symptoms suggests a possible infectious etiology. She will have follow-up with gastroenterology in 3 weeks. #Thrombocytopenia and Anemia: Patient’s platelets started falling on ___ to 160 (b/l >200), to 80k on ___, to 50k on ___. During this time, she was noted to have a downtrending hematocrit as well. Out of concern for culprit medications, mesalamine and heparin were held starting on ___. There was an initial suspicion of HIT (T4 score ___, but PF4 antibody was negative. Hematology was consulted. It appears that the drop may have been due to a recent medication (mesalamine, cipro, flagyl) or an autoimmune process not otherwise specified, but the etiology was not immediately clear. Of note, patient had a blood dyscrasia after starting Tegretol in ___, but there may have been cross-reactivity with a medication such as mesalamine. Hemolysis labs were sent on ___, indicating hemolytic process with elevated LDH and decreased haptoglobin. The hematology team followed with daily smears, and on ___ her smear was notable for increasing quantity of schistocytes. Given the increase in schistocytes in the setting of thrombocytopenia and hemolytic anemia, she was suspected to have TTP. The patient was started on prednisone 60mg po qd, and she was transferred to the MICU for initiation of plasmapheresis. ADAMSTS13 testing was sent out at this time. She had a pheresis line placed and received 2 courses of plasmapheresis (___). She was transferred back to the floor for further management. As of ___, her PLTs were noted to be uptrending to >100 with stable Hct ~ 22. Given that her ADAMSTS13 had come back within normal limits, there was less concern for TTP, and instead the patient was believed to have medication-induced thrombocytopenia/hemolytic reaction vs. ITP (diagnosis still unclear). She did not receive further plasmapheresis. The patient could not tolerate steroids (hallucinations, lower extremity edema and insomnia), and this was d/c'ed after ___ dose (after 3 days), especially in light of increasing suspicion of medication effect. Her PLTs continue to trend favorably (PLT 182 on ___, 242 on ___ with stable Hct. On ___, her Hct was 20.7, and she was transfused with 1 unit of pRBC prior to discharge. The patient was instructed to have a CBC drawn in 2 days on ___. She was arranged to have hematology follow-up at ___ in 2 weeks. #Pneumonia: The patient has felt subjective shortness of breath for several months, although she was saturating well on room air throughout the hospitalization. On ___, the patient had leukocytosis to 13.4 with low-grade fever 100.5. She had a chest x-ray revealing diffuse parenchymal opacity with air bronchograms in the left upper lobe. The opacities consistent with possible pneumonia. The patient received one dose of vancomycin, cefepime and Flagyl on ___, and then switched to levofloxacin alone. The patient was afebrile with resolved WBC for rest of hospitalization. The patient was instructed to take levofloxacin through ___ to complete a 5 day course. #Gastroesophageal reflux disease/Gastritis: Patient reports that she has been previously diagnosed with GERD. She noted a burning sensation in the back of her throat. She was started on omeprazole on ___. This was discontinued on ___ because of concern that it could contribute to thrombocytopenia. Of note, the patient underwent an esophagogastroduodenoscopy ___, which indicated mild gastritis but otherwise normal. #?Systemic lupus erythamatosus / ? Rheumatological disease NOS: Patient has had a panoply of symptoms over the past few years with a question of possible rheumatological process. She described prior “flares”, which included rashes, oral lesions, myalgias and generalized weakness and fatigue. Based upon prior records, the patient is weakly positive ___ with negative anti-dsDNA. Rheumatology was consulted during the hospitalization, and they did not believe that there was an active rheumatological process. In agreement with her outpatient rheumatologist, hydroxychloroquine was stopped. The patient will be following up with her outpatient rheumatologist. #Left adnexal cyst: Patient was noted to have 3.7cm left adnexal cyst on abdominal CT from OSH on ___. This should be followed-up in one year with pelvic ultrasound. #DVT prophylaxis: The patient was given heparin ___. After discontinuation of heparin on ___, the patient had DVT ppx with strict pneumoboots and ambulation as possible. CHRONIC DIAGNOSES: # Bipolar/Depression: The patient has a documented history of bipolar and depression. She was continued on duloxetine, which has been primarily used for control of chronic pain. # Chronic pain: The patient takes percocet at home for her chronic pain, and she also has diazepam though she does not use this. During her hospitalization, she took acetaminophen with good pain control. #Liver cyst: Noted on OSH CT. On ___ radiology read, appears benign and no need for further work up. # Vitamin D def: Patient is on vitamin D supplementation, and this was continued during the hospitalization. TRANSITIONAL ISSUES: #Colitis: sx resolved, will follow up with ___ gastroenterology at scheduled appointment on ___. #Thrombocytopenia and Anemia: Platelets had recovered to >200 with Hct 21 (given one unit prior to discharge). Can have CBC drawn at next visit with PCP to make sure counts still stable. Will follow up with heme/onc on ___ #?Rheumatological disease: hydroxychloroquine was discontinued, will follow up with rheum in ___ #Left adnexal cyst: Patient was noted to have 3.7cm left adnexal cyst on abdominal CT from OSH on ___. This should be followed-up in one year with pelvic ultrasound. #FULL CODE Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Flector *NF* (diclofenac epolamine) 1.3 % Transdermal daily 2. Promethazine ___ID:PRN nausea 3. Duloxetine 60 mg PO HS 4. Ferrous Sulfate 325 mg PO DAILY 5. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob or wheeze 6. Diazepam 10 mg PO BID:PRN muscle spasm 7. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO BID:PRN pain 8. Hydroxychloroquine Sulfate 400 mg PO DAILY In AM 9. Ascorbic Acid ___ mg PO DAILY 10. Vitamin D 6000 UNIT PO DAILY Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob or wheeze 2. Diazepam 10 mg PO BID:PRN muscle spasm 3. Flector *NF* (diclofenac epolamine) 1.3 % Transdermal daily 4. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO BID:PRN pain 5. Ascorbic Acid ___ mg PO DAILY 6. Duloxetine 60 mg PO HS 7. Ferrous Sulfate 325 mg PO DAILY 8. Promethazine ___ID:PRN nausea 9. Vitamin D 6000 UNIT PO DAILY 10. FoLIC Acid 1 mg PO DAILY 11. Levofloxacin 750 mg PO DAILY Duration: 1 Days You will need to take levofloxacin one more time on ___ to complete your course of antibiotics. Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: Colitis NOS, Chronic diarrhea, Thrombocytopenia, Hemolytic Anemia Secondary diagnoses: Chronic pain, Migraines, Depression, Gastroesophageal reflux disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at the ___ ___. You were admitted because you have had several months of diarrhea that had significantly worsened over the past ___ days prior to coming here. You had several tests sent out of your stool for possible infections which were all negative. While you were here, you had an sigmoidoscopy which indicated some inflammation in your bowels. You were started on two medications (mesalamine and a steroid foam) to treat this, but we had to stop mesalamine because of a drop in your blood counts. Since you continued to have diarrhea, you had a colonoscopy which only showed a little redness in your rectum but without other significant findings. While we are still not sure why you had such diarrhea, it may have been an infection from which your body is recovering now. We have arranged for you to follow-up with the gastroenteroloy team here. While you were here, you had several of your blood counts falling. We worked with the hematology team to try to figure out why this was occurring. After an extensive workup, the reason for this occurring was still not exactly clear. You were thought to have a condition called TTP (Thrombotic Thrombocytopenic Purpura), for which you had a procedure called plasmapheresis, which cleaned your blood. Thankfully, it now appears unlikely that you had TTP. Instead, it seems as though you were more likely to have a medication-related effect that caused your blood counts to fall. We have arranged for you to follow-up with hematology so that they can continue to look into this matter. We gave you one bag of blood before on the day you left the hospital. You should have your blood drawn within 2 days (___) to check your blood counts. Since you had a cough, you had a chest x-ray which showed a possible pneumonia. You were started on an antibiotic for this, and you should take this for one more dose on ___. Finally please note that you should have follow-up with a gynecologist in the near future. You had a little vaginal bleeding, and you should talk to your gynecologist about this. Furthermore, you were noted to have a cyst in your left ovary on a CT scan, and this should be followed with a pelvic ultrasound in one year. Thank you very much for allowing us to be a part of your care. Followup Instructions: ___
10156068-DS-2
10,156,068
24,238,743
DS
2
2114-11-14 00:00:00
2114-11-21 10:18:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: laparoscopic appendectomy History of Present Illness: HPI: Mr. ___ is a ___ year old man presenting with "crampy aching" abdominal pain which began gradually yesterday afternoon and localized to the periumbilical region initially. He subsequently experienced diarrhea (3 loose stools) and NBNB vomiting (___). He reports that his abdominal pain has now migrated to the RLQ and is constant in nature. He reported subjective fever and chills. He denied any anorexia as patient had some crackers in the ED this morning. He denies any recent sick contacts and travel. Past Medical History: Past Medical History: GERD Social History: ___ Family History: nc Physical Exam: Physical Exam: upon admission: ___ Vitals: 98.7 57 126/74 17 100% RA GEN: A&O, NAD ABD: Soft, nondistended, tender to palpation in the RLQ at ___, negative Rosving's sign, negative psoas sign, no rebound or guarding, no palpable masses, no hepatosplenomegaly Physical examination upon discharge: ___: Vital signs: t=98.7, hr=55, bp= 126/78, oxygen saturation 97% room air General: NAD CV: ns1, s2, -s3, -s4 Lungs: diminished throughout Abdomen: port sites with dry gauze, soft, + tenderness Ext: + dp bil., no pedal edema bil. no calf tenderness Pertinent Results: ___ 05:00AM BLOOD WBC-13.2* RBC-4.55* Hgb-14.4 Hct-41.2 MCV-90 MCH-31.6 MCHC-35.0 RDW-12.5 Plt ___ ___ 05:00AM BLOOD Neuts-89.7* Lymphs-7.7* Monos-2.1 Eos-0.3 Baso-0.2 ___ 05:00AM BLOOD Glucose-139* UreaN-16 Creat-0.9 Na-139 K-3.4 Cl-101 HCO3-23 AnGap-18 ___ 05:00AM BLOOD ALT-14 AST-21 AlkPhos-38* TotBili-0.7 ___ 05:00AM BLOOD Lipase-119* ___: cat scan abdomen and pelvis: IMPRESSION: 1. Dilated fluid-filled appendix with a proximal obstructing appendicolith consistent with acute appendicitis. 2. Small hypodense lesion in the right kidney, too small to characterize but most likely a cyst. Brief Hospital Course: ___ year old gentleman admitted to the acute care service with abdominal pain. Upon admission, he was made NPO, given intravenous antibiotics and underwent radiographic imaging which showed a dilated fluid-filled appendix with a proximal obstructing appendicolith consistent with acute appendicitis. With these findings, he was taken to the operating room where he underwent a laparoscopic appendectomy. His operative course was stable with minimal blood loss. He was extubated after the procedure without incident. On POD #1, he was started on a regular diet. His intravenous antibiotics were discontinued. His intravenous analgesia was changed to oral agents. His vital signs are stable and he is afebrile. His hematocrit is stable at 41. He is voiding without difficulty. He has maintained an oxygen saturation of 97% on room air. He is preparing for discharge home with instructions to follow up with the actue care service in 2 weeks. Medications on Admission: Meds: pepcid Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 2. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain: may cause increased drowsiness, avoid driving while on this medication. Disp:*30 Tablet(s)* Refills:*0* 3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: hold for diarrrhea. 4. famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: acute appendicitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with abdominal pain. You had a cat scan done of your abdomen which showed appendicitis. You were taken to the operting room where you had your appendix removed. You are now preparing for discharge home with the following instructions: Please call your doctor or return to the emergency room if you have any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. Activity: No heavy lifting of items ___ pounds for 6 weeks. You may resume moderate exercise at your discretion, no abdominal exercises. Wound Care: You may shower, no tub baths or swimming. If there is clear drainage from your incisions, cover with clean, dry gauze. Your steri-strips will fall off on their own. Please remove any remaining strips ___ days after surgery. Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: ___
10156269-DS-14
10,156,269
22,026,410
DS
14
2191-07-15 00:00:00
2191-07-15 17:11:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Cefepime / Ragweed Attending: ___. Chief Complaint: cough, congestion Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ woman with a history of lymphoblastic blast crisis of CML day ___ after a double cord transplant who presented to the ED with productive cough, headache, sinus and ear congestion. Patient reports acute onset of symptoms x4 d ago, since then little relief with flonase, sudafed 30mg bid, allegra. Patient has a history of sinus infections in the past, previously seen by ENT, intermittently treated with Augmentin. Pt went to ENT today for appt, but was told that her insurance expired, and was referred here to the ER for eval. In the ED, initial vitals were: 96.5 118 115/68 20 95%. Labs were significant for WBC 17, Cr 1.7 (baseline 1.3-1.5), lactate 2.1. CXR was concerning for multifocal PNA. Patient was given 750mg po levoflox, Zofran, 650mg acetaminophen, an albuterol neb, and Tesselon pearles as well as 1L NS. Case was discussed with Dr. ___ recommended admission. Vitals prior to transfer were 98.1 104 134/69 18 97% Review of Systems: (+) Endorses congestion, nose bleeds, nausea, and vomiting (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies blurry vision, diplopia, loss of vision, photophobia. Denies chest pain or tightness, palpitations, lower extremity edema. Denies dysuria, stool or urine incontinence. Denies arthralgias or myalgias. Denies rashes or skin breakdown. No numbness/tingling in extremities. All other systems negative. Past Medical History: BREAST CANCER ___: L infiltrating ductal ca dx ___ and tx lumpectomy, axillary node dissection, chemo and XRT. Followed by ___. Has declined Tamoxifen. s/p prophylactic BSO in ___. . CML 1. CML diagnosed ___, started on imatinib on ___, went into CHR and had a partial cytogenetic and major molecular response. 2. Noticed to have blasts on peripheral blood smear on ___ - bone marrow biopsy ___ showed lymphoblastic blast phase of chronic myelogenous leukemia. The blast count was 43% on the aspirate and 60-70% on the core biopsy. 3. Part A of hyper-CVAD from ___, part B of hyper-CVAD on ___. 4. Bone marrow biopsy on ___ showed no evidence of leukemia involvement. Cytogenetics were negative for ___ chromosome. 5. High dose cyclophosphamide on ___ as conditioning for allogenic bone marrow transplant, transplant aborted because her stem cell donor refused to have his stem cell collected. She was discharged home and restarted on dasatinib. 6. Allogenic double cord HSCT on ___, conditioning with Cyclophosphamide/TBI/Fludarabine. Hospitalized ___. Her hospital stay was complicated by fever on day -5 and, in the post-transplant setting by HHV-6 viremia and BK viruria. HHV-6 viremia cleared. 7. Hospitalization with severe sinusitis ___. 8. Hospitalization for shortness of breath ___. 9. Hospitalization after a seizure episode between ___ and ___. 10. Maintenance Dasatinib started end ___ - stopped ___. Other PMH: CERVICAL SPONDYLOSIS CHRONIC RENAL FAILURE (baseline Cr ~1.5) GLAUCOMA INSOMNIA OSTEOPOROSIS EAR, NOSE & THROAT SEIZURES BASAL CELL CARCINOMA SINUSITIS, chronic rhinitis Social History: ___ Family History: Patient's mother died ___ years old, had a history of melanoma. Patient's father is alive. A maternal grandmother died from ovarian cancer at the age of ___. ___ had 2 brothers and one died in a car accident. One brother is alive and well. She has a son and a daughter. Physical Exam: ADMISSION EXAM PHYSICAL EXAM: VS: 98.6, 131/77, 106, 18, 97% on RA GENERAL: NAD HEENT: Mucous membranes moist NECK: No cervical, submandibular, or supraclavicular LAD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTA bilaterally, dullness at bases ABDOMEN: +BS, non-tender, non-distended, no rebounding or guarding EXTREMITIES: Moving all extremities well, no cyanosis, clubbing or edema, no obvious deformities PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: Warm and well perfused, no excoriations or lesions, no rashes DISCHARGE EXAM VS: 98.4 114/62 105 18 100RA GENERAL: NAD HEENT: Mucous membranes moist NECK: No cervical, submandibular, or supraclavicular LAD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTA bilaterally, dullness at bases ABDOMEN: +BS, non-tender, non-distended, no rebounding or guarding EXTREMITIES: Moving all extremities well, no cyanosis, clubbing or edema, no obvious deformities PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: Warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS: ___ 02:45PM BLOOD WBC-17.0*# RBC-3.37* Hgb-10.1* Hct-31.4* MCV-93 MCH-29.9 MCHC-32.1 RDW-13.9 Plt ___ ___ 04:18PM BLOOD Glucose-125* UreaN-29* Creat-1.7* Na-133 K-4.1 Cl-97 HCO3-25 AnGap-15 ___ 04:23PM BLOOD Lactate-2.1* DISCHARGE LABS: ___ 07:55AM BLOOD WBC-12.9* RBC-3.09* Hgb-9.3* Hct-28.6* MCV-93 MCH-30.2 MCHC-32.6 RDW-13.8 Plt ___ ___ 07:55AM BLOOD Neuts-82.6* Lymphs-10.6* Monos-6.2 Eos-0.5 Baso-0.1 ___ 07:55AM BLOOD Calcium-7.9* Phos-2.2* Mg-1.9 CXR ___ FINDINGS: Patchy bilateral lower lobe opacities are seen, worrisome for multifocal pneumonia. No pleural effusion is seen. The cardiac and mediastinal silhouettes are unremarkable. No evidence of pneumothorax is seen. IMPRESSION: Patchy bilateral lower lobe opacities worrisome for multifocal pneumonia. Brief Hospital Course: Ms. ___ is a ___ with Hx of Lymphoblastic blast crisis of CML day ___ after a double cord transplant who presented to the ED with productive cough, headache, sinus and ear congestion, found to have possible multifocal PNA on CXR. # PNA: Patient with multifocal pneumonia, leukocytosis, though no documented fevers. She endorses a history of congestion and cough prior to this episode as well as nausea/vomiting; possible that she had a viral URI and now has a super-imposed PNA. Although do not need to treat with Tamiflu (as has had symptoms for more than 48 hours), a nasal swab was performed but did not have adequate cells for evaluation. She was discharged on levofloxacin to finish a ___nd a 5 day course of tamiflu. # CML: In remission. Continue follow-up with outpatient providers. # TACHYCARDIA: likely secondary to acute inflammatory response to pneumonia. Resolved with fluid resuscitation. # ACUTE ON CHRONIC KIDNEY INJURY: Basline 1.1-1.3, Unclear etiology of CKD. Patient has been encouraged to see nephrology in the past, but is does not appear as if she has gone. Her medications were renally dosed and her ___ improved back to its baseline with fluids. # INURANCE: Patient lost her insurance prior to this visit and was notified in ___ clinic. Case management and social work consults performed, and she obtained her insurance again. TRANSITIONAL ISSUES: PCP should ___ blood cultures Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Alendronate Sodium 70 mg PO Frequency is Unknown 2. Astelin *NF* (azelastine) 137 mcg NU QD 3. Estring *NF* (estradiol) 2mg Vaginal Every 3 months 4. Fluticasone Propionate NASAL 2 SPRY NU DAILY 5. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE HS 6. Venlafaxine XR 150 mg PO DAILY 7. Calcium Carbonate 500 mg PO QID 8. Vitamin D 800 UNIT PO DAILY Discharge Medications: 1. Astelin *NF* (azelastine) 137 mcg NU QD 2. Calcium Carbonate 500 mg PO QID 3. Fluticasone Propionate NASAL 2 SPRY NU DAILY 4. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE HS 5. Venlafaxine XR 150 mg PO DAILY 6. Vitamin D 800 UNIT PO DAILY 7. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN Cough RX *codeine-guaifenesin 100 mg-10 mg/5 mL ___ ml by mouth q6 Disp #*200 Milliliter Refills:*0 8. Levofloxacin 250 mg PO Q24H Duration: 5 Days RX *levofloxacin 250 mg 1 tablet(s) by mouth daily Disp #*5 Tablet Refills:*0 9. Alendronate Sodium 70 mg PO QMON 10. Estring *NF* (estradiol) 2mg Vaginal Every 3 months 11. Oseltamivir 75 mg PO Q12H RX *oseltamivir [Tamiflu] 75 mg 1 capsule(s) by mouth twice a day Disp #*6 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Community Acquired Pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ for pneumonia. You were given Levofloxacin and your symptoms improved, and your white count went down. Please continue to take Levofloxacin for 5 more days. Return to the hospital or clinic if you develop fevers, worsening of your symptoms, trouble breathing, or diarrhea. Followup Instructions: ___
10156886-DS-18
10,156,886
24,201,568
DS
18
2129-08-09 00:00:00
2129-08-09 12:37:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ___ Attending: ___. Chief Complaint: Fatigue. Major Surgical or Invasive Procedure: None. History of Present Illness: ___ yo M with a history of stage IV clear cell renal carcinoma who complains of increasing fatigue. The patient has known metastases to the liver. The patient was diagnosed with a renal cell carcinoma 9 months ago and is status post left nephrectomy. He has lost a large amount of weight since that time. The patient has low appetite and has recently started taking Marinol for this. Recently, he has become much more fatigued. He is so fatigued today that he could not walk and was slumping over. His eyes continued close and he was falling asleep at the kitchen table so his wife called EMS. His mental status is much more fatigued, but he is able to recount his history. He has had high calcium levels and gotten "a shot" for treatment. The patient also complains of some abdominal pain and the sensation of a new mass on the left side of his abdomen. Additionally, he reports some neck pain. He has baseline nausea but no recent vomiting. The patient has been stooling normally. No fevers or chills. No urinary symptoms. In the ED, initial vitals were T97.9F, HR 98 NSR, BP 131/74, RR 23, O2Sat 96% 2LNC. Labs showed leukocytosis to 17.7, IRN 1.4 (not on anticoagulation), hyponatremia to 130, elevated lactate of 3.5, hypercalcemia 10.8, ALT 67, AST 159, Alk Phos 431, Albumin 1.9. He underwent CT head and CT abdomen/pelvis were performed. His pain was treated successfully with ibuprofen. He was started on IVF for treatment of hypercalcemia. Following the administration of 2.5L NS, his lactate remained elevated at 3.6. Blood cultures were drawn. UA was negative for signs of infection. Past Medical History: Hypertension Hyperlipemia Prostate nodule, negative biopsy Left nephrectomy and adrenelectomy, ___ Social History: ___ Family History: No family history of GU malignancy. Father died from colon cancer at age ___. Mother deceased from lung cancer at age ___. Brother deceased from pancreatic cancer at age ___. 2 sisters with breast cancer. Physical Exam: Admission exam VS - 98.7, 82, 120/70, 16, 97%RA GENERAL - Thin ___ M who appears appropriate and in NAD HEENT - NC/AT, sclerae anicteric, mucus membranes dry, OP clear NECK - supple, no thyromegaly, no JVD, no lymphadenopathy LUNGS - Lungs are clear to ausculatation bilaterally, moving air well and symmetrically, resp unlabored, no accessory muscle use HEART - RRR, S1-S2 clear, ___ systolic ejection murmur heard best at the right and left second intercostal space ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) NEURO - awake, A&Ox2, CNs II-XII grossly intact, muscle strength ___ throughout Pertinent Results: Admission labs ___ 01:00PM BLOOD WBC-17.4* RBC-4.28* Hgb-9.4* Hct-34.4* MCV-80* MCH-21.9* MCHC-27.3* RDW-20.3* Plt ___ ___ 01:00PM BLOOD ___ PTT-35.9 ___ ___ 01:00PM BLOOD Glucose-93 UreaN-16 Creat-0.7 Na-130* K-4.8 Cl-98 HCO3-28 AnGap-9 ___ 01:00PM BLOOD ALT-67* AST-159* AlkPhos-431* TotBili-1.1 ___ 01:00PM BLOOD Lipase-20 ___ 01:00PM BLOOD Albumin-1.9* Calcium-10.6* Phos-2.1* Mg-2.0 ___ 01:08PM BLOOD Lactate-3.5* . Studies: ___ CT HEAD: IMPRESSION: No definite enhancing lesions identified. No acute intracranial hemorrhage. . ___ CT ABD: IMPRESSION: 1. Stable pulmonary nodules at bilateral lung bases. Bilateral pleural effusions. 2. Interval progression of extensive hepatic metastases. 3. Anasarca, mild ascites, and mesenteric edema likely secondary to hepatic dysfunction in the setting of diffuse hepatic metastases. 4. Splenomegaly likely secondary to increasing portal hypertension in the setting of widespread hepatic metastasis. . ___ MRI/MRA BRAIN: IMPRESSION: 1. No acute intracranial process or acute infarction. 2. No evidence of intracranial metastasis. 3. Normal MRA head. . DISCHARGE LABS: ___ 05:31AM BLOOD WBC-14.5* RBC-3.86* Hgb-8.5* Hct-30.6* MCV-79* MCH-21.9* MCHC-27.7* RDW-20.2* Plt ___ ___ 06:00AM BLOOD Neuts-66.6 ___ Monos-8.9 Eos-3.3 Baso-0.8 ___ 06:00AM BLOOD ___ PTT-35.7 ___ ___ 05:31AM BLOOD Glucose-80 UreaN-12 Creat-0.6 Na-130* K-4.4 Cl-97 HCO3-24 AnGap-13 ___ 05:31AM BLOOD ALT-56* AST-151* LD(LDH)-634* AlkPhos-401* TotBili-1.2 ___ 07:45AM BLOOD Calcium-9.8 Phos-1.8* Mg-1.8 ___ 08:00AM BLOOD Calcium-9.9 Phos-2.1* Mg-2.0 ___ 06:55AM BLOOD Calcium-9.4 Phos-1.7* Mg-1.9 ___ 06:00AM BLOOD Calcium-10.1 Phos-1.7* Mg-1.9 ___ 05:31AM BLOOD Albumin-1.9* Calcium-9.2 Phos-2.0* Mg-1.9 ___ 06:00AM BLOOD Ammonia-4* ___ 07:45AM BLOOD TSH-4.6* ___ 08:00AM BLOOD T4-10.2 ___ 06:00AM BLOOD T3-73* Free T4-1.3 ___ 07:45AM BLOOD PTH-<6* ___ 07:45AM BLOOD Cortsol-19.9 ___ 06:55AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE IgM HAV-NEGATIVE ___ 06:55AM BLOOD HCV Ab-NEGATIVE Brief Hospital Course: ___ man with HTN and metastatic renal cell CA admitted for weakness, altered mental status, and hypercalcemia. Mental status and calcium improved with IV hydration. . # Weakness/metabolic encephalopathy: Likely due to hypercalcemia given history of waxing and waning course coinciding with calcium correction. Calcium and mental status have improved during this admission and he and his wife feel that he is ready and would be safe for discharge. Lactulose started, but no evidence of hepatic encephalopathy - no asterixis, normal ammonia level. AM cortisol normal. Corrected calcium as outlined below. - Blood cultures PENDING. . # Hypercalcemia: Due to renal cell carcinoma mets. PTH <6. Allergic to bisphosphonates. IV fluids given with plan to continue this at home. Denosumab will be given as an outpatient, due to insurance issues limiting in-patient use. Started calcitonin PRN, but not continuous consider tachyphylaxis. . # Renal cell carcinoma: Continued axitinib until everolimus (Afinitor) arrives (already ordered, but can take a week to come in). Progressed through gemcitabine/sunitinib and now axitinib. Anti-emetics PRN. . # Anemia: Chronic, mild, stable. . # Leukocytosis: No evidence for infection. Likely due to malignancy. U/A negative. - Blood cultures PENDING. . # Abnormal LFTs: Due to liver mets. Hepatitis serologies negative. Stable. . # Hypothyroidism: Normal T4. TSH mildly elevated 4.6, low T3, normal free T4. Started low-dose levothyroxine. . # Hyponatremia: High Una 116 consistent with SIADH, probably exacerbated by poor PO intake. Stable on IV normal saline. . # FEN: Regular diet. Continued outpatient dronabinol for anorexia/wght loss. IV fluids; continued IV fluids at home. Repleted hypophosphatemia. . # DVT PPx: Heparin SC. . # GI PPx: H2 blocker. Bowel regimen. . # Pain (neck/chest/abdomen): Due to cancer. Acetaminophen (limited doses considering LFT abnormalities). Tramadol PRN. . # IV access: Peripheral IV. ___ placed ___ for home IV hydration. . # Precautions: None. . # CODE: FULL. . TRANSITIONAL ISSUES: - F/U BLOOD CULTURES. - Denosumab to be given as outpatient. - Chemotherapy to be changed from axitinib to everolimus as outpatient. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientFamily/Caregiver. 1. axitinib *NF* 5 mg Oral BID 2. Dronabinol 2.5 mg PO BID Take before lunch and dinner. 3. Ondansetron 8 mg PO BID 4. Ranitidine 150 mg PO BID 5. Polyethylene Glycol 17 g PO DAILY 6. denosumab *NF* 120 mg/1.7 mL (70 mg/mL) Subcutaneous ONCE Next due on ___ Discharge Medications: 1. Hydration Dx: Hypercalcemia, metastatic renal cell carcinoma. IV normal saline 2L/d at 150mL/hr. Dispense: 14L. Refills: 4. 2. axitinib *NF* 5 mg Oral BID 3. Lactulose 30 mL PO BID please titrate to 2 BMs RX *lactulose 10 gram/15 mL 30 mL by mouth twice a day Disp #*1800 Milliliter Refills:*1 4. Ondansetron 8 mg PO Q8H:PRN Nausea 5. denosumab *NF* 120 mg/1.7 mL (70 mg/mL) Subcutaneous ONCE Next due on ___ 6. Polyethylene Glycol 17 g PO DAILY 7. Senna 1 TAB PO BID:PRN cpnstipation 8. Dronabinol 2.5 mg PO BID Take before lunch and dinner. 9. Ranitidine 150 mg PO BID 10. Prochlorperazine 10 mg PO Q6H:PRN nausea RX *prochlorperazine maleate 5 mg ___ tablet(s) by mouth q6HR Disp #*20 Tablet Refills:*1 11. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain RX *tramadol 50 mg 1 tablet(s) by mouth q4HR Disp #*50 Tablet Refills:*0 12. Levothyroxine Sodium 25 mcg PO DAILY RX *levothyroxine 25 mcg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*1 13. Calcitonin Salmon 200 UNIT NAS DAILY:PRN High calcium Do not take for more than one week. RX *calcitonin (salmon) 200 unit/dose 1 spray NAS Daily Disp #*1 Bottle Refills:*1 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Hypercalcemia (elevated calcium level). Weakness/fatigue. Altered mental status (confusion). Metastatic kidney cancer. Hyponatremia (low sodium level). Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were hospitalized for fatigue, altered mental status (confusion), and hypercalcemia (elevated calcium levels). The high calcium is likely the cause of the fatigue and confusion. Also, your blood sodium level was low. You were treated with intravenous fluids and your symptoms and calcium improved. Additionally, CT of the head and abdomen were unrevealing other than progressing cancer in the liver. MRI of the brain was normal. Because the current chemotherapy is not working, you will be changed to a new chemotherapy medication called everolimus (Afinitor), which has been ordered and should arrive in approximately one week. In the meantime, you should continue the previous chemotherapy axitinib. You have also been set up for home IV fluids to maintain a low calcium level. You were started on calcitonin a nasal spray to help bring your calcium levels down. This should be used sparingly as it does not continue to work long-term (>1 week). You can use it when you suspect the calcium levels are elevated (worsening fatigue/weakness, confusion, or confirmed high calcium on blood work). You will need to continue monthly denosumab (Xgeva) injections in the clinic. While you were hospitalized, you were evaluated by a nutritionist. The following recommendations were made by the nutritionist: 1. Please start drinking Ensure Plus three times per day. 2. Please continue eating and drinking as much as possible. Followup Instructions: ___
10157167-DS-7
10,157,167
29,327,446
DS
7
2158-05-31 00:00:00
2158-05-31 18:03:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: palpitations Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a ___ yo male with a past history of anxiety who presents with palpitations. Patient states that he was in his usual state of health until ___ at around 4 am when he woke from sleep with a racing heart beat. This sensation was associated with dyspnea, mild non-radiant chest pain and dizziness and resolved spontaneously after a few hours. He has had these episodes in the past, most remarkably ___ year ago and 2 months ago. Both these episodes were short lived and were after a night of 3+ beers. He denies any EtOH intake yesterday though did have 3 beers 2 nights ago. . In the ED, initial vitals were 97.8, 120 BPM, 172/97 and RR 20 100% on RA. An EKG was performed which was read as an irregular tachycardia in the 130s, intermittently sinus vs junctional arrythmia and frequent PVCs. Patient was given diltiazem 50 mg IV x2, Adenosine 6 mg and magnesium 2g along with vagal maneuvers without a change in his baseline rhythm. Patient also had several runs of monomorphic Vtach while in the ED. . Labs and imaging significant for hypokalemia of 3.0 which was repleated in the ED as well as a clear CXR. . Vitals on transfer were 100 BPM, 123/78, 22, 99RA. . On arrival to the floor, patient was still in afib with a rate in the 80-90s. He was complaining of palpitations, but no other symptoms. . REVIEW OF SYSTEMS On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: HDL deficency 2. CARDIAC HISTORY: None 3. OTHER PAST MEDICAL HISTORY: -___ disease -Depression with anxiety Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM: VS: T=98.2 BP=126/93 HR= 72 RR= 20 O2 sat= 99RA GENERAL: in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP at the clavicle, no thyromegaly. CARDIAC: PMI located in ___ intercostal space, midclavicular line. irregular rate, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. . DISCHARGE PHYSICAL EXAM: afebrile, vital signs unchanged, HR ___ and in sinus rhythm on telemetry exam unchanged Pertinent Results: ADMISSION LABS: ___ 06:00AM BLOOD WBC-6.1 RBC-5.29 Hgb-16.6 Hct-45.9 MCV-87 MCH-31.3 MCHC-36.1* RDW-11.8 Plt ___ ___ 06:00AM BLOOD Neuts-45.1* Lymphs-48.3* Monos-4.0 Eos-1.0 Baso-1.7 ___ 06:00AM BLOOD Glucose-123* UreaN-15 Creat-1.0 Na-141 K-3.0* Cl-103 HCO3-22 AnGap-19 ___ 09:11PM BLOOD cTropnT-<0.01 ___ 06:00AM BLOOD Calcium-9.5 Phos-0.6* Mg-1.9 ___ 06:00AM BLOOD TSH-2.6 ___ 06:10AM BLOOD Ethanol-NEG Barbitr-NEG Tricycl-NEG ___ 09:05PM URINE barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG . DISCHARGE LABS: ___ 06:10AM BLOOD Glucose-108* UreaN-16 Creat-1.2 Na-138 K-5.0 Cl-103 HCO3-26 AnGap-14 ___ 06:10AM BLOOD Calcium-9.6 Phos-4.5# Mg-2.7* . IMAGING: ___ CXR: PORTABLE FRONTAL CHEST RADIOGRAPH: The lungs are clear. There is no focal consolidation or pneumothorax. There is no vascular congestion or pleural effusions. Cardiomediastinal and hilar contours are within normal limits. IMPRESSION: No acute cardiopulmonary process. . ___ TTE: LEFT ATRIUM: Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global systolic function (LVEF >55%). Transmitral Doppler E>A and TDI E/e' <8 suggesting normal diastolic function, and normal LV filling pressure (PCWP<12mmHg). No resting LVOT gradient. No VSD. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal diameter of aorta at the sinus, ascending and arch levels. No 2D or Doppler evidence of distal arch coarctation. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Elongated mitral valve leaflets. Normal mitral valve supporting structures. Normal LV inflow pattern for age. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. Conclusions The left atrium is elongated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are elongated. There is no pericardial effusion. IMPRESSION: Normal regional and global biventricular systolic function. Normal diastolic function. No pathologic valvular abnormalities. Mild biatrial enlargement. Brief Hospital Course: Mr. ___ is a ___ year old male with past history only notable for anxiety who presented with sudden onset of afib with rapid ventricular response (Afib with RVR). . ACTIVE ISSUES: # Afib with RVR: EKGs upon admission were consistant with Afib, unfortunately patient's rate did not respond to either IV or PO diltiazem, magnesium or adenosine. On hospital day 1 overnight, he did respond well to PO metoprolol at 25 mg BID, with control of rate and actually conversion from afib to sinus rhythm. He then developed a few episodes of bradycardia after the metoprolol loading and so we decided to halve the dose to 25 mg daily of metoprolol. Because he converted to sinus rhythm spontaneously, he did not require electrical cardioversion. His TSH was normal and urine tox screen was negative as potential etiologies of his afib. His ECHO was negative for structural heart disease which might have caused afib. It was also thought possible that his citalopram (celexa) was causing the afib and so he was told to taper this per discussion with his outpatient doctor if possible. He was dicharged on metoprolol succinate XL 25 mg daily and started on ___ 325 mg daily as well for anticoagulation of lone, paroxysmal Afib. Outpatient issues: - taper celexa outpatient . # Hyperkalemia: No clear etiology and not hypertensive on exam to suggest hyperaldostronism/renin. Should be further monitored as an outpatient. . # ANXIETY: Will try to taper celexa as an outpatient because may be contributing to tachycardia. Continued alprazolam prn. . TRANSITIONAL ISSUES: - taper celexa outpatient - recheck potassium at follow-up Medications on Admission: -Citalopram 20 mg daily -Alprazolam 0.5 mg daily PRN Discharge Medications: 1. citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. 2. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO once a day as needed for anxiety. 3. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 4. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS atrial fibrillation . SECONDARY DIAGNOSIS anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, . You were admitted to the hospital because you had a rapid and irregular heart rate, called atrial fibrillation. We investigated possible causes of this including thyroid problems and structural problems with your heart using ultrasound, however these were all normal. Sometimes patients with anxiety and patients taking celexa can develop atrial fibrillation. You were treated with a medication to slow down your heart rate and you returned to a normal rate and rhythm. You should continue to take this medication, called metoprolol, to control the heart rate. Also, you can talk with your outpatient doctor about tapering your celexa. . The following changes were made to your medications: - START taking metoprolol succinate (extended-release Toprol XL) 25 mg once daily - START taking aspirin 325 mg daily - discuss with your outpatient doctor to see if you can taper your celexa as this might contribute to afib . Please keep all of the follow-up appointments listed below. . It was a pleasure taking care of you in the hospital! Followup Instructions: ___
10157362-DS-15
10,157,362
29,651,209
DS
15
2187-06-01 00:00:00
2187-06-02 20:45:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: ___ gentleman with history of schizophrenia, hypertension, glucose intolerance, GERD, tobacco use, RCC status-post RFA and HCV status-post treatment p/w dyspnea, tachypnea, wheeze, abd pain. He reports that over the past 2 days he has had worsening cough as well as pain in his epigastric area. Cough is productive of white sputum. Endorses a fever last night, but no persistent fevers. No nausea, vomiting. No chest pain. States that this feels similar to his previous pneumonia. Triggered for tachypnea on arrival. Of note admitted to ___ from ___ with symptoms of cough, sputum production, fever. Treated empirically with levofloxacin 750 mg daily per his report. He underwent CT chest, which demonstrated evidence of esophageal thickening (patient report), with plan to pursue inpatient endoscopy to assess for underlying etiology. He declined endoscopy at that time, in favor of performing this as an outpatient. He was ultimately discharged to complete his 5 day course of levofloxacin. He was also given a diagnosis of COPD exacerbation during his hospitalization. He was seen by PCP ___ ___ with improvement in his cough and sputum production. In the ED: Initial vital signs were notable for: 98.4 97 162/109 20 96% RA Exam notable for: AVSS Comfortable, alert, oriented. Mild expiratory wheezes bilaterally, no focal findings. Speaking in full sentences. Coughing, nonproductive on exam. Labs were notable for: Flu swab negative, WBC 12.4, Hb 14.3, platelets 155, Na 133, Cr 1.1, Trop negative. Latate 1.5, pCO2 61. UA with few bacteria otherwise negative. Studies performed include: CXR- no e/o pneumonia Patient was given: Methylpred 125mg IV, Azithromycin, Ipratropium, albuterol, LR 500mg IV. Vitals on transfer: 98.4 89 123/72 18 94% RA Upon arrival to the floor, Patient with significant improvement in breathing after nebulizers received in the ED. Reports significant sputum production. He has pain in his abdominal muscles, chest and back with coughing. Pain not present without cough. Reports chills, no fevers at home. Past Medical History: HYPERCHOLESTEROLEMIA HYPERTENSION SCHIZOPHRENIA TOBACCO ABUSE SHOULDER PAIN BACK PAIN H/O POLYSUBSTANCE ABUSE H/O SEXUALLY TRANSMITTED DISEASE H/O POSITIVE C DIFF H/O ATYPICAL CHEST PAIN H/O HEPATITIS C S/P TREATMENT WITH SVR H/O RENAL CELL CARCINOMA H/O RIGHT THUMB PAIN/NUMBNESS H/O ULNAR NEUROPATHY H/O DYSPHAGIA Social History: ___ Family History: NONCONTRIBUTORY Physical Exam: ADMISSION PHYSICAL EXAM: VITALS:98.6PO 139 / 86 94 20 90 RA GENERAL: Alert and interactive. In no acute distress. HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without injection. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Significant wheezing throughout lung fields. BACK: No spinous process tenderness. No CVA tenderness. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal sensation. AOx3. DISCHARGE PHYSICAL EXAM: ___ 1550 Temp: 98.5 PO BP: 144/86 L Sitting HR: 113 RR: 18 O2 sat: 95% O2 delivery: Ra GENERAL: NAD HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without injection. CARDIAC: Regular rhythm, normal rate. No murmurs/rubs/gallops. LUNGS: CTAB, no inc wob BACK: tender to palpation along lateral ribs on left side, L upper back ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal sensation. AOx3. Pertinent Results: NOTABLE LABS: ================ ___ 06:30PM BLOOD WBC-12.4* RBC-5.63 Hgb-14.3 Hct-46.1 MCV-82 MCH-25.4* MCHC-31.0* RDW-13.7 RDWSD-40.5 Plt ___ ___ 06:40AM BLOOD WBC-16.9* RBC-5.23 Hgb-13.4* Hct-42.7 MCV-82 MCH-25.6* MCHC-31.4* RDW-13.9 RDWSD-41.3 Plt ___ ___ 10:38AM BLOOD WBC-11.1* RBC-4.97 Hgb-12.9* Hct-41.9 MCV-84 MCH-26.0 MCHC-30.8* RDW-13.9 RDWSD-42.8 Plt ___ ___ 06:40AM BLOOD Glucose-122* UreaN-14 Creat-0.9 Na-138 K-4.7 Cl-95* HCO3-32 AnGap-11 ___ 06:30PM BLOOD Glucose-126* UreaN-12 Creat-1.1 Na-133* K-4.3 Cl-89* HCO3-32 AnGap-12 ___ 06:30PM BLOOD ALT-10 AST-15 AlkPhos-75 TotBili-0.3 NO POSITIVE MICRO CXR AP portable upright view of the chest. Overlying EKG leads are present. Lung volumes are low. Allowing for this, the lungs are clear. There is no focal consolidation, effusion, or pneumothorax. The cardiomediastinal silhouette is normal. Imaged osseous structures are intact. IMPRESSION: No signs of pneumonia. Brief Hospital Course: ___ gentleman with history of schizophrenia, hypertension, glucose intolerance, GERD, tobacco use, RCC status-post RFA and HCV status-post treatment p/w dyspnea, tachypnea consistent with COPD exacerbation, now improved after prednisone and azithro with ongoing L back and flank pain. ACUTE ISSUES: ============= #COPD exacerbation Patient presented with dyspnea, tachypnea, wheezing x 2 days. Has ongoing tobacco use. Maintained O2 sats >94% on room air, initially with tachypnea which improved with nebulizer treatments. Flu swab negative, CXR with no e/o pneumonia. Of note was recently hospitalized at ___ in ___ for presumed pneumonia/COPD exacerbation with 5 day course of levofloxacin. S/p azithromycin, IV Methylpred and nebulizer treatment in ED with improvement. Will treat for total of 5 days of prednisone 40 mg and azithro. Started tiotropium inhaler. PFTs already scheduled as outpatient. #Esophageal thickening: Report of esophageal thickening on CT chest performed during a recent hospitalization. He has declined endoscopy previously. Not worked up further during this hospitalization. CHRONIC ISSUES: =============== #HTN Holding HCTZ given hyponatremia. Will restart prior to d/c. Continued lisinopril 20 mg. # Tobacco use: Ongoing tobacco use. Counseled him on the importance of tobacco cessation, especially in the context of chronic obstructive pulmonary disease exacerbation/pneumonia. # Schizophrenia: Reports following with Arbour, has not been hospitalized for many years. Continued Risperdal 4mg TRANSITIONAL ISSUES ==================== [ ] Please assess improvement following steroid course and consider longer taper if indicated. [ ] Discharged on tiotropium inhaler. Would reinforce correct usage. [ ] Nocturnal desaturations, would consider sleep study for ? OSA [ ] Continues to have ongoing likely MSK pain which has been ongoing for ___ months per patient. Would follow up at next visit. #CODE:Full presumed #CONTACT:Name of health care proxy: ___ Relationship: Wife Phone number: ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath 2. ammonium lactate 12 % topical DAILY 3. Fluticasone Propionate NASAL 2 SPRY NU DAILY 4. lisinopril-hydrochlorothiazide ___ mg oral DAILY 5. Patanol (olopatadine) 0.1 % ophthalmic (eye) BID 6. Omeprazole 20 mg PO DAILY 7. RisperiDONE 4 mg PO DAILY 8. Simvastatin 40 mg PO QPM 9. TraMADol 50 mg PO Q8H 10. Nicotine Polacrilex 4 mg PO Q4H:PRN nicotine Discharge Medications: 1. Azithromycin 250 mg PO DAILY Duration: 4 Doses RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*1 Tablet Refills:*0 2. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough RX *codeine-guaifenesin 10 mg-100 mg/5 mL 5 ml by mouth every 6 hours Refills:*0 3. PredniSONE 40 mg PO DAILY RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*2 Tablet Refills:*0 4. Tiotropium Bromide 1 CAP IH DAILY RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 cap inh daily Disp #*30 Capsule Refills:*0 5. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath 6. ammonium lactate 12 % topical DAILY 7. Fluticasone Propionate NASAL 2 SPRY NU DAILY 8. lisinopril-hydrochlorothiazide ___ mg oral DAILY 9. Nicotine Polacrilex 4 mg PO Q4H:PRN nicotine 10. Omeprazole 20 mg PO DAILY 11. Patanol (olopatadine) 0.1 % ophthalmic (eye) BID 12. RisperiDONE 4 mg PO DAILY 13. Simvastatin 40 mg PO QPM 14. TraMADol 50 mg PO Q8H 15.Cane Cane diagnosis: Lumbago M54.5 prognosis good ___ 13 months Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: COPD exacerbation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you during your stay at ___. WHY WAS I HERE? - You were having a lot of coughing and trouble breathing WHAT WAS DONE WHILE I WAS HERE? - You were given steroids and antibiotics to treat your COPD exacerbation - You were started on a new inhaler WHAT SHOULD I DO WHEN I GO HOME? - You should use your new inhaler - You should go to see your PCP ___ well! Your ___ Care Team Followup Instructions: ___
10157454-DS-7
10,157,454
25,401,199
DS
7
2181-11-18 00:00:00
2181-11-19 07:09:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ___ Attending: ___. Chief Complaint: Chest pain and rib fractures Major Surgical or Invasive Procedure: Epidural ___ History of Present Illness: ___ years old gentleman with past medical history of DM with neuropathy, afib on Coumadin, COPD, Charcot foot, gout, kidney injury, CHF, alcoholism and recent pneumonia and bacteriemia who presents to the ED after a mechanical fall. Patient refers he was in a rehab facility for IV antibiotics course for staph bacteriemia and had a mechanical fall this morning. Since then he has been complaining of severe ___ right anterior chest pain, not associated with nausea, vomit, fever or chills. He was taken to an outside hospital where he was found to have 3 through ___ right rib fractures and T12 compression fracture so he was transferred to ___ for spine consultation. Spine evaluated the patient and determined TLSO brace for comfort and follow up in outpatient clinic in 2 weeks. Trauma surgery consulted for trauma evaluation and recommendations. Past Medical History: PAST MEDICAL HISTORY: Afib on Coumadin CHF (last ECHO 3 weeks ago, doesn't know EF) DM with neuropathy Charcot foot Gout Alcoholism Ventral hernia COPD PAST SURGICAL HISTORY: Back surgery, discectomy Toe amputations Social History: ___ Family History: Mother: breast cancer Physical Exam: PHYSICAL EXAM on admission: VITAL SIGNS: 99, 116, 167/99, 19, 94% RA GENERAL: AAOx3 NAD HEENT: NCAT, EOMI, PERRLA, No scleral icterus, mucosa moist, no LAD CARDIOVASCULAR: irregularly irregular, S1/S2, NO M/R/G PULMONARY: tenderness to palpation in right anterior chest wall, CTA ___, No crackles or rhonchi GASTROINTESTINAL: S/NT/ND. No guarding, rebound, or peritoneal signs. +BSx4 EXT/MS/SKIN: No C/C/E; Feet warm. Good perfusion. NEUROLOGICAL: Reflexes, strength, and sensation grossly intact CNII-XII: WNL -- Physical exam on discharge: Vitals: 97.3 PO 154 / 99 107 24 90 2___ GENERAL: Awake and Resting comfortably lying in bed HEENT: moist mucous membranes, no ulcers / lesions / thrush CARD: S1/S2, irregular rhythm with no murmurs. CHEST: Scattered rhonchi. Decreased air movement ABD: Soft, nontender, multiple large ventral hernias. EXTREMITIES trace edema. warm and well perfused. SKIN: No rash; heavy tattoes over upper extremities and chest NEURO: Answers questions fluently and apparently with accuracy, with a normal affect and attentiveness. CNs grossly intact. Moving all four extremities. Pertinent Results: ADMISSION LABORATORY STUDIES ======================================= ___ 03:08PM BLOOD WBC-8.8 RBC-3.33* Hgb-10.2* Hct-31.9* MCV-96 MCH-30.6 MCHC-32.0 RDW-14.4 RDWSD-50.5* Plt ___ ___ 03:08PM BLOOD Neuts-72.1* Lymphs-18.9* Monos-7.7 Eos-0.7* Baso-0.3 Im ___ AbsNeut-6.31* AbsLymp-1.65 AbsMono-0.67 AbsEos-0.06 AbsBaso-0.03 ___ 03:08PM BLOOD ___ PTT-42.8* ___ ___ 03:08PM BLOOD Glucose-131* UreaN-27* Creat-2.3* Na-137 K-4.7 Cl-100 HCO3-26 AnGap-11 ___ 03:08PM BLOOD Calcium-9.4 Phos-3.3 Mg-2.0 DISCHARGE LABORATORY STUDIES ======================================= ___ 05:05AM BLOOD WBC-8.7 RBC-3.13* Hgb-9.5* Hct-30.0* MCV-96 MCH-30.4 MCHC-31.7* RDW-14.6 RDWSD-50.7* Plt ___ ___ 05:05AM BLOOD ___ ___ 05:05AM BLOOD Glucose-120* UreaN-24* Creat-1.8* Na-137 K-3.7 Cl-101 HCO3-27 AnGap-9* ___ 05:05AM BLOOD Calcium-9.0 Phos-2.7 Mg-1.8 IMAGING/REPORTS ======================================= -L-SPINE ___ FINDINGS: AP and lateral views of the lumbar spine were provided. There are neutral, flexion and extension lateral views. Patient has a known compression deformity at T12. There is no additional fracture seen. There is no abnormal motion with flexion or extension. No malalignment. IMPRESSION: As above. CXR ___ IMPRESSION: 1. PICC is not seen. 2. Multifocal opacities are compatible with multifocal pneumonia as seen on recent CT chest. MICROBIOLOGY ======================================= ___ 3:05 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. Brief Hospital Course: BRIEF SUMMARY ============= ___ w/ pAF (warfarin), HFpEF, HTN, HLD, T2DM, COPD, CKD3, OSA, chronic pain (on oxycontin and fentanyl patch) with a recent admission for falls and hypertensive urgency w/ course c/b MSSA bacteremia (on cefazolin) and influenza, and Afib w/ RVR who was admitted w/ T12 compression fracture and multiple rib fractures after a fall. ACTIVE ISSUES ============= #) ACUTE ON CHRONIC PAIN: Patient has a history of chronic opioid use for chronic back pain. Prior to this hospitalization, he was on pain management with fentanyl 25mcg/hr TD patch, and oxycontin 30mg PO BID. He developed worsening pain during the hospitalization in the setting of the mechanical fall with rib fractures and T12 compression fracture. The patient was managed with his home oxycontin and fentanyl patch (fentanyl patch increased), oxycodone and acetaminophen but developed sedation with these large doses of opioid medications. Acute pain was consulted. The patient underwent placement of epidural on ___ with only mild relief, which was removed on ___. Patient was discharged on oxycontin, fentanyl patch, oxycodone and acetaminophen. Could consider consolidating to one long-acting opioid as an outpatient. #) RIB FRACTURES Noted to have right-sided acute and subacute rib fractures (___) secondary to the mechanical fall. Patient reported significant pain with deep inspiration during admission. Please see above for pain management. TLSO brace for comfort. #) T12 COMPRESSION FRACTURE Patient was transferred after a fall and found to have a T12 compression fracture. There was a low suspicion for pathologic fracture or osteomyelitis based on the CT findings, so MRI was not pursued. Pain management as above. Patient can wear TLSO brace for comfort. Needs to follow up with Dr. ___ with orthopedic spine. # MECHANICAL FALL It appears the patient continues to have mechanical falls related to significant diabetic peripheral neuropathy and toe amputations. Evaluated by ___ and discharged to rehab. # ATRIAL FIBRILLATION Patient with paroxysmal atrial fibrillation, CHADS2vasc score 4, on Coumadin at home presenting with rates that are relatively well controlled with supratherapeutic INR. No signs of bleeding but did receive vitamin K during admission. Coumadin was held while patient received epidural. Continued on home diltiazem and carvedilol. # PULMONARY INFILTRATES: Patient noted on outside hospital imaging to have bilateral multifocal consolidations with a distribution was consistent with aspiration. It appears that the patient also had consolidations in the lower lung fields during his previous admission to ___ on ___. During the current admission, patient remained afebrile without leukocytosis and denied cough or sputum production. Given the absent clinical evidence of pneumonia, the infiltrates were thought to be due resolving influenza from previous hospitalization or aspiration pneumonitis (given recent fall, distribution of opacities, and recurrent somnolence from narcotic use). Antibiotics were held (aside from the cefazolin for treatment of MSSA bacteremia). Patient will need repeat CT chest as an outpatient # MSSA BACTEREMIA: MSSA bacteremia was recently diagnosed during previous admission with unclear source. Continued IV cefazolin during admission (planned course ___. PICC was removed because it was not positioned correctly, and midline was placed. Patient needs to follow up with Dr. ___ at ___. Needs weekly CBC, BUN/Cr and ALT while on cefazolin. CHRONIC ISSUES ============== # Chronic kidney disease: remained stable at baseline # HFpEF: appeared euvolemic during admission. Continued home torsemide and carvedilol # HTN: continued home amlodipine, carvedilol and torsemide # ETOH use disorder: no signs of withdrawal during admission # COPD: albuterol nebs as needed while inpatient # OSA: would benefit from CPAP - not using at home # DM2: ISS while inpatient # Gout: continued home colchicine # BPH: continued home tamsulosin TRANSITIONAL ISSUES =========================================== #) Need to complete course of cefazolin (last day ___. Patient needs to follow up with Dr. ___ at ___ (scheduled for ___ at 11:20 AM. ___ MEDICAL SPECIALTIES - ___ ___. ___. Needs weekly CBC, BUN/Cr and ALT while on cefazolin. Midline in place. #) Next INR check ___. Discharge INR 1.3. #) Patient would benefit from using CPAP at home. Patient currently not using CPAP at home #) Needs repeat CT chest to monitor for resolution of multifocal infiltrates. If does not resolve on repeat CT chest, will need further evaluation #) Patient should have outpatient workup for osteoporosis. Consider DEXA. Started on vitamin D during admission. Consider calcium and bisphosphonate. #) Patient should wear TLSO brace for comfort. #) Patient needs to follow up with Dr. ___ with orthopedic spine. # contact: ___ Phone number: ___ # Code: Full Medications on Admission: MEDICATIONS: albuterol sulfate HFA 90 mcg/actuation aerosol inhaler, amlodipine 5 mg tablet, carvedilol 25 mg tablet, cefazolin 1 gram, colchicine 0.6 mg tablet, Cardizem 120 mg tablet, folic acid 1 mg tablet, insulin lispro (U-100) 100 unit/mL, ipratropium-albuterol, GlycoLax 17 gram/dose, rosuvastatin 20 mg tablet, warfarin 2 mg tablet oral, OxyContin 30 mg tablet, fentanyl 25 mcg/hr, oxycodone 5 mg tablet oral, torsemide 10 mg tablet oral Discharge Medications: 1. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 10 mg 1 tablet(s) by mouth Q4H:PRN Disp #*18 Tablet Refills:*0 2. Senna 8.6 mg PO BID:PRN Constipation - First Line 3. Vitamin D 800 UNIT PO DAILY 4. Acetaminophen 1000 mg PO Q8H 5. Fentanyl Patch 37 mcg/h TD Q72H RX *fentanyl 37.5 mcg/hour Apply 1 patch TD Q72H Disp #*1 Patch Refills:*0 6. amLODIPine 5 mg PO DAILY 7. Carvedilol 25 mg PO BID 8. CeFAZolin 2 g IV Q8H 9. Colchicine 0.6 mg PO DAILY 10. Diltiazem Extended-Release 240 mg PO DAILY 11. FoLIC Acid 1 mg PO DAILY 12. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin 13. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dysnpea 14. Lidocaine 5% Patch 1 PTCH TD QAM 15. Multivitamins 1 TAB PO DAILY 16. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H RX *oxycodone [OxyContin] 30 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*6 Tablet Refills:*0 17. Polyethylene Glycol 17 g PO DAILY 18. ProAir HFA (albuterol sulfate) 90 UNK inhalation Q6H:PRN SOB 19. Rosuvastatin Calcium 20 mg PO QPM 20. Torsemide 10 mg PO DAILY 21. Warfarin 4 mg PO 3X/WEEK (___) 22. Warfarin 6 mg PO 4X/WEEK (___) Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY: - Right ___ rib fractures - T2 compression fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure caring for you at ___. You were admitted because of the rib fractures and thoracic spine compression fracture. You were treated with pain medications. It is important for you to continue taking medications as prescribed. ADVICE REGARDING YOUR RIB FRACTURES: * Your injury caused rib fractures which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener and increase your fluid and fiber intake if possible. * Do NOT smoke * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs (crepitus). Sincerely, Your ___ team Followup Instructions: ___
10157454-DS-8
10,157,454
23,978,280
DS
8
2181-12-17 00:00:00
2181-12-18 08:14:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ___ Attending: ___. Chief Complaint: Fever and AMS Major Surgical or Invasive Procedure: ___ PLACEMENT ___ b/l Chest Tube Placement ___ History of Present Illness: Mr. ___ is a ___ h/o DM w/ neuropathy, A fib on warfarin, COPD, Charcot foot, gout, kidney injury, CHF, alcohol use disorder w/ recent admission for MSSA bacteremia who now presents as a transfer from rehab facility for elevated WBC and new mental status changes. The patient himself is a somewhat poor historian and is unable to give a clear account of recent hospitalizations. Per records, the patient was first admitted at ___ from ___ with hypertensive emergency and multiple falls at home. He was diagnosed with influenza and was given Tamiflu. His hospital course was complicated by atrial fibrillation with rapid ventricular response, delirium with somnolence after benzodiazepine administration, and acute kidney injury. During the hospital course he had a leukocytosis to 17 for which blood cultures were drawn. He was found to have MSSA bacteremia and was placed on cefazolin for a planned four week course from ___. TTE showed mild-moderate MR without obvious vegetation. Given concern for osteo, MRI pelvis was attempted twice but the patient was not able to tolerate the study. He was scheduled to follow up with Dr. ___ infectious disease at ___ on ___. The patient presented after a fall at the ___ in the bathroom from standing. He reports he fell onto his back. He was found to have right-sided acute and subacute rib fractures (___). He was given a TLSO brace for comfort. Pain control was attempted with an epidural, but was only marginally effective. Ultimately, he was discharged back to rehab with oxycontin, oxycodone, Tylenol, and a fentanyl patch. Of note, patient was found to be occasionally somnolent, and attempts were made to reduce his regimen. He was also found to have chest imaging findings concerning for pneumonia. However, given his clinical picture was felt more likely to be aspiration in the setting of somnolence. He was continued on cefazolin throughout this hospitalization for his MSSA bacteremia, as noted above. Patient was discharged back to rehab on ___. He completed his antibiotics course on ___ as planned. However, since ___ was noted by staff to be altered. No known fevers at rehab. His labs were drawn and notable for a leukocytosis to 17.7. Therefore, he was transferred to the ED for further management. The patient himself reports no new symptoms. He states that his back pain is severe and is concerned that the rehab reduced his pain regimen. He has not noticed any fevers. He denies feeling short of breath or coughing. He does not remember feeling confused, and has no headaches. Past Medical History: Afib on Coumadin, Diastolic CHF DM with neuropathy, Charcot foot Gout Alcoholism Ventral hernia COPD Back surgery, discectomy Toe amputations Social History: ___ Family History: Mother: breast cancer Physical Exam: ADMISSION EXAM: Alert to person and palce HEENT: PERRLA, EOMI; no erythema in posterior pharynx with no exudate; no cervical LAD, no neck tenderness with full ROM CV: irregularly irregular w/ nl S1S2 no MRG Resp: CTAB with increased work of breathing - using abdominal muscles; no intercostal or suprasternal retractions Chest wall: mild tenderness over R chest wall Abd: +BS, NTND Skin: no erythema or rashes Neuro: - normal motor throughout - normal senation throughout - CN intact Rectal: no external lesions; normal tone; brown stool guiac negative DISCHARGE EXAM: GEN: awake, alert, sitting up in bed watching TV CV: irregular, no appreciable murmurs PULM: CTA x2, mildly decreased at the bases CHEST: prior site of left chest tube w/ gauze bandage and no visible drainage GI: obese, soft, non-tender, non-distended, no erythema under pannus MSK: no ___ edema, warm SKIN: many tattoos, PICC c/d/i NEURO: A+O X 3, BUE/BLE ___ Pertinent Results: ADMISSION LABS: =============== ___ 07:05PM BLOOD WBC-17.6* RBC-2.59* Hgb-7.8* Hct-24.8* MCV-96 MCH-30.1 MCHC-31.5* RDW-14.0 RDWSD-49.1* Plt ___ ___ 07:05PM BLOOD Neuts-84.7* Lymphs-7.7* Monos-6.3 Eos-0.1* Baso-0.2 Im ___ AbsNeut-14.87* AbsLymp-1.36 AbsMono-1.11* AbsEos-0.02* AbsBaso-0.03 ___ 07:05PM BLOOD ___ PTT-48.9* ___ ___ 07:05PM BLOOD Glucose-172* UreaN-49* Creat-2.8* Na-132* K-5.4 Cl-96 HCO3-23 AnGap-13 ___ 07:05PM BLOOD ALT-13 AST-33 CK(CPK)-45* AlkPhos-172* TotBili-0.3 ___ 07:05PM BLOOD Lipase-10 ___ 05:00AM BLOOD Calcium-8.9 Phos-4.1 Mg-2.3 INTERVAL LABS: ============== ___ 05:00AM BLOOD CRP-188.7* ___ 07:05PM BLOOD cTropnT-0.07* ___ 11:08PM BLOOD cTropnT-0.05* DISCHARGE LABS: =============== ___ 05:53AM BLOOD WBC-11.5* RBC-2.80* Hgb-8.2* Hct-25.8* MCV-92 MCH-29.3 MCHC-31.8* RDW-14.0 RDWSD-47.1* Plt ___ ___ 05:12AM BLOOD ___ PTT-29.9 ___ ___ 05:53AM BLOOD Glucose-129* UreaN-42* Creat-2.1* Na-133* K-4.7 Cl-101 HCO3-23 AnGap-9* MICROBIOLGY: ___ 7:05 pm BLOOD CULTURE(Final ___: STAPH AUREUS COAG +. SENSITIVITIES: MIC expressed in MCG/ML CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 1 S TRIMETHOPRIM/SULFA---- <=0.5 S RADIOLOGY/REPORTS: ___ CT HEAD: 1. No evidence of acute intracranial abnormality. 2. Focal hypodensity within the left basal ganglia, likely compatible with prior lacunar infarct. 3. Moderate mucosal thickening of the left maxillary sinus suggests ongoing inflammation. ___ CT ABD/PELVIS: 1. Compared with the outside hospital chest CT from ___, progression of the T12 vertebral body compression deformity, now with increased lucency, cortical destruction, paravertebral soft tissue, and enlarged lucency within the inferior T11 vertebral body. Findings are concerning for infection resulting in osteomyelitis and discitis, given the rapid progression. Further assessment with MRI is recommended. 2. Heterogeneous hyperdense asymmetric enlargement of the left psoas muscle at the level of the inferior left kidney, compatible with a hematoma in the setting of known anticoagulation. 3. New moderate right pleural effusion with adjacent right lung base consolidation and atelectasis. Superimposed infection is considered in the appropriate clinical setting. Small left pleural effusion is relatively unchanged. ___ MRI SPINE: 1. The study is degraded by motion artifact. 2. Pathological fracture of the T12 vertebral body with relative preservation of the anterior and posterior vertebral body heights. The central aspect of the vertebral body does not enhance in keeping with a pathological fracture most likely secondary to infection. There is enhancement of the adjacent paravertebral soft tissue and there is involvement of the inferior aspect of the T11 vertebral body. These findings are most consistent with a pathological fracture secondary to/destruction of the T12 vertebral body by osteomyelitis. 3. There is and associated mixed intensity collection the left psoas muscle most likely representing a psoas abscess. The signal intensity of the collection is slightly atypical for an abscess being T2 mixed Iso and hyperintense with a surrounding T2 hypointense rim and a psoas hematoma secondary to a pathological fracture should be considered in the differential diagnosis. 4. Moderate severe spinal canal stenosis at the L3-___s moderate severe left L3-4 neural foraminal narrowing described above. 5. No compromise of the thoracic cord in the thoracic spinal canal. 6. Small epidural collection at T11-12. ECHO: Suboptimal image quality. 1) Image quality poor with this limitation in mind no echocardiographic evidence of endocarditis seen. 2) Moderate pulmonary systolic arterial hypertension in setting of mild RV dilation and normal RV systolic longitudinal function. There is moderate tricuspid regurgitation and severe RA dilaton. LV e' velocities are high arguing against primary LV pathology as cause of pulmonary hypertension. -The patient has a mildly dilated ascending aorta. Based on ___ ACCF/AHA Thoracic Aortic Guidelines, if not previously known or a change, a follow-up echocardiogram is suggested in ___ year; if previously known and stable, a follow-up echocardiogram is suggested in ___ years. ___ MRI LEFT SHOULDER 1. No findings specific for septic arthritis of the glenohumeral joint. Trace to small glenohumeral joint effusion, could be related to rotator cuff pathology and biceps tendon tear, superimposed infection cannot be excluded. If clinical concern for septic arthritis, joint fluid sampling could be obtained. 2. Moderate to high-grade articular surface tearing of the supraspinatus tendon with additional full-thickness tear along the leading edge. 3. Moderate tendinosis and interstitial tearing of the infraspinatus tendon with probable calcific tendinitis near its insertion. Recommend correlation with left shoulder radiographs. 4. Likely complete tear of the intra-articular portion of the biceps tendon with retraction. 5. Small amount of subacromial subdeltoid bursal fluid. 6. Moderate degenerative type changes of the acromioclavicular joint. No findings specific for septic arthritis. 7. Diffuse red marrow changes. ___ SHOULDER XRAY: Degenerative changes. No acute fracture is seen. Some narrowing of the acromial humeral interval raises possibility of rotator cuff tear. ___ CXR: Right PICC line tip most likely terminates in the proximal right atrium and should be pulled back 4 cm. Patient is in pulmonary edema. Right pleural effusion is moderate. Left pleural effusion is small. No pneumothorax. Cardiomegaly. ___: MRI T/L-SPINE 1. Discitis and osteomyelitis are again demonstrated T11-T12. Severe collapse of T12 vertebral body and minimal T11 vertebral body loss of height are unchanged. Contrast enhancement in the posterior aspect of the T11-T12 disc has increased. Small right anterior epidural phlegmon has slightly increased, displacing the spinal cord without compression. 2. Unchanged T12-L1 disc edema without enhancement, a nonspecific finding which may be reactive. New mild edema and contrast enhancement in the superior endplate of L1 may be reactive, though spread of infection cannot be excluded definitively. 3. Persistent edema and contrast enhancement of the left psoas from T12 through S1, with stable peripherally enhancing fluid pockets between L3 and L5 which may in part be related to hematomas. However, superimposed infection and abscess formation cannot be excluded. 4. Stable mild bilateral posterior paravertebral edema from L2 through L5. 5. Multilevel degenerative changes in the lumbar spine, with moderate to severe spinal canal stenosis at L3-L4, are again demonstrated. 6. Bilateral pleural effusions and bibasilar atelectasis are again partially visualized. Brief Hospital Course: Mr. ___ is a ___ year old male with PMH Of DM w/ neuropathy, A fib on warfarin, COPD, Charcot foot, gout, kidney injury, CHF, alcohol use disorder, w/ recent admission for MSSA bacteremia, readmission for rib fractures, who now presents as a transfer from rehab facility for elevated WBC and new mental status changes, found to have vertebral osteomyelitis. # Osteomyelitis # Fever, Leukocytosis # Sepsis Patient presented with new leukocytosis and fever having just completed a 4 week course of cefazolin on ___ for MSSA bacteremia. MRI showed osteomyelitis at T12 with associated compression fracture. He was treated with vancomycin (day 1 = ___ ) and zosyn (day 1 ___ changed to cefepime (___) and then transitioned to just cefazolin with planned course ___. Ortho spine was consulted and felt that the patients spine was stable recommending TLSO when OOB for support. He received a TTE which was negative for endocarditis. ___ placed ___. # Shortness of breath # acute on chronic HFpEF Initially held home diuretics due to ___, which improved, but patient became acutely short of breath on ___ and diuresed with IV lasix until euvolemic. His home carvedilol was initially held and then restarted. Torsemide was held on discharge due to mild ___ with good self diuresis. #RTC tear: patient with left shoulder pain after recent fall found to have RTC tear on imaging. Will need follow up with ___ and orthopedics as outpatient #Pneumonia Patient presented to hospital on increase O2 from baseline, and imaging is concerning for PNA. However, review of records suggests that patient often has imaging findings suggestive of pneumonia, which seem to be more likely from aspiration. Possibly related to bacteremia will be treated with coverage as above. MRSA swab negative, legionella, and strep negative # Psoas muscle hematoma: Discovered on imaging in context of supratherapeutic INR possibly related to previous fall. Hgb is down from discharge (7.8 from 9.5) but stable since admission. ___ was consulted and felt no need to drain. # Acute encephalopathy: Noted to be altered at rehab, somnolent on arrival but alert and oriented x2 here daily. Unable to say year which is apparently baseline per daughter who says she has been concerned about dementia for some time. Tox screen significant for opiates, which he is prescribed at rehab. No signs of retention. No hypoglycemic episodes. Likely related to infection given correlation with new leukocytosis. Also possibly from high doses of opioids he is requiring for back pain. Recommend neurology follow up as an outpatient as his daughter reports ongoing concern for dementia. # ___ on CKD: Cr peaked at 2.8 from 1.8 but downtrended to baseline after receiving IV fluids in ED and having his torsemide held for several days. Creatinine remained at 2.1 on torsemide which was discontinued prior to discharge. # Hematuria/proteinuria: Noted on u/a from last month and on admission # A-fib: Usually on warfarin but held as supratherapetuic on admission, which was restarted once it was clear patient would not require procedures. Patient received diltiazem fractionated to short acting. # HTN: Initially held anti-hypertensives due to concern for sepsis but restarted once patient stable. # ETOH use disorder: No recent use given transfer from rehab. Continued multivitamin, folate, thiamine # COPD: VBG without excessive Co2 retention. Continued home Spiriva and duo nebs PRN. # OSA: would benefit from CPAP - not using at home # DM2: ISS while inpatient # Gout: Held home colchicine in setting ___ TRANSITIONAL ISSUES: LABS: [] Please obtain weekly CBC with differential, BUN, Creatinine, CRP and fax results to ATTN: ___ CLINIC - FAX: ___ [] Please check BMP ___. If creatinine improved can resume torsemide, recommend low dose 5 mg. [] Please check INR ___ and adjust warfarin dose as needed. []He has a mildly dilated ascending aorta. Based on ___ ACCF/AHA Thoracic Aortic Guidelines, if not previously known or a change, a follow-up echocardiogram is suggested in ___ year; if previously known and stable, a follow-up echocardiogram is suggested in ___ years. []TTE with pulmonary hypertension and LV e' velocities suggesting against LV failure. Consider workup for pulmonary hypertension []Had shoulder pain and found to have RTC ___ need follow up with ___ and orthopedics as outpatient []He has baseline cognitive dysfunction per his daughter and was often unable to identify the year. He would benefit from neurology follow up as an outpatient as he does have a family history of early onset dementia. []He has asymptomatic hematuria and smoking history. Could benefit from referral to urology for outpatient work up. []Could benefit from sleep study and use of CPAP given OSA []Discharged off torsemide []*Needs f/u MRI T/L-spine ~ ___ wks); please order atOPAT f/u so it can be followed by correct OPAT team. #CONTACT: ___ (daughter) ___ >30 minutes spent on discharge planning. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q8H 2. amLODIPine 10 mg PO DAILY 3. Carvedilol 25 mg PO BID 4. Colchicine 0.6 mg PO DAILY 5. Diltiazem Extended-Release 240 mg PO DAILY 6. Fentanyl Patch 25 mcg/h TD Q72H 7. FoLIC Acid 1 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H 10. Polyethylene Glycol 17 g PO DAILY 11. Rosuvastatin Calcium 20 mg PO QPM 12. Torsemide 10 mg PO DAILY 13. Warfarin 4 mg PO 3X/WEEK (___) 14. Warfarin 6 mg PO 4X/WEEK (___) 15. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dysnpea 16. Lidocaine 5% Patch 1 PTCH TD QAM 17. ProAir HFA (albuterol sulfate) 90 UNK inhalation Q6H:PRN SOB 18. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Moderate 19. Senna 8.6 mg PO BID:PRN Constipation - First Line 20. Vitamin D 800 UNIT PO DAILY 21. MetFORMIN (Glucophage) 500 mg PO DAILY 22. Milk of Magnesia 30 mL PO DAILY:PRN constipation 23. TraZODone 50 mg PO QHS:PRN insomnia 24. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID Discharge Medications: 1. CeFAZolin 2 g IV Q8H 2. Carvedilol 12.5 mg PO BID 3. Acetaminophen 1000 mg PO Q8H 4. amLODIPine 10 mg PO DAILY 5. Diltiazem Extended-Release 240 mg PO DAILY 6. Fentanyl Patch 25 mcg/h TD Q72H RX *fentanyl 25 mcg/hour Apply to back q72h Disp #*1 Patch Refills:*0 7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 8. FoLIC Acid 1 mg PO DAILY 9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dysnpea 10. Lidocaine 5% Patch 1 PTCH TD QAM 11. MetFORMIN (Glucophage) 500 mg PO DAILY 12. Milk of Magnesia 30 mL PO DAILY:PRN constipation 13. Multivitamins 1 TAB PO DAILY 14. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 10 mg 1 tablet(s) by mouth every four (4) hours Disp #*18 Tablet Refills:*0 15. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H RX *oxycodone 30 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*6 Tablet Refills:*0 16. Polyethylene Glycol 17 g PO DAILY 17. ProAir HFA (albuterol sulfate) 90 UNK inhalation Q6H:PRN SOB 18. Rosuvastatin Calcium 20 mg PO QPM 19. Senna 8.6 mg PO BID:PRN Constipation - First Line 20. TraZODone 50 mg PO QHS:PRN insomnia 21. Vitamin D 800 UNIT PO DAILY 22. Warfarin 4 mg PO 3X/WEEK (___) 23. Warfarin 6 mg PO 4X/WEEK (___) 24. HELD- Colchicine 0.6 mg PO DAILY This medication was held. Do not restart Colchicine until your doctor tells you to 25. HELD- Torsemide 10 mg PO DAILY This medication was held. Do not restart Torsemide until instructed to by your doctor Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis: Vertebral Osteomyelitis Secondary Diagnosis: Diastolic CHF, Loculated Pleural Effusion, Coagulopathy, Atrial Fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Mr. ___, You were admitted to ___ from your rehab because you were confused and having fevers. We found that you had an infection in your spine bones and your blood. We treated you with IV antibiotics and you improved. You also had a decrease in the function of your kidneys and you were treated for your heart failure and heart arrhythmia (atrial fibrillation). You required a procedure to remove fluid from your lungs. Please take all of your medication as prescribed and attend all of your follow up appointments. Sincerely, Your ___ Care Team Followup Instructions: ___
10157674-DS-18
10,157,674
23,215,474
DS
18
2166-06-19 00:00:00
2166-06-20 18:19:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Tetracycline Attending: ___. Chief Complaint: cough Major Surgical or Invasive Procedure: none History of Present Illness: ___ yo F with NHL, admitted with concern for pneumonia. She reports that over the last few days she has had URI like symptoms, including nasal congestion, sore throat, and then recently developed a cough. She took her temp today and noted it to be 102 so she called her oncology NP who sent her to ___ for a CXR. The CXR showed a RML pneumonia, so she was given a prescription for azithromycin and told to go to the ED. In the ED, vitals were 100.2 93 131/70 16 99% RA. She was given cefepime and admitted to the oncology service. On arrival to the floor, she looks very well and is without complaint. She is doing multiple labs around the unit. Review of Systems: (+) Per HPI. (-) Denies malaise, myalgias, N/V/D. Past Medical History: ONCOLOGIC HISTORY: # Follicular lymphoma: - in ___, at the time of her mastectomy for right-sided breast cancer, a right axillary lymph node dissection was performed with 3 of 8 lymph nodes biopsy showing involvement with non-Hodgkin's follicular lymphoma, grade I/III. Subsequent staging by PET CT showed extensive mesenteric, retroperitoneal, inguinal, axillary and pelvic FDG avid lymphadenopathy. Her disease was staged as a low-grade stage IIIA intermediate risk follicular lymphoma. Because she was asymptomatic at the time of diagnosis in ___, she did not require treatment until ___, at which point a repeat PET CT showed significant increase in lymphadenopathy. - Under the care of Dr. ___, Mrs. ___ received six cycles of fludarabine and Rituxan, completing in ___. - Her disease recurred in ___. She was treated with four cycles of R-CHOP, completing in ___. She tolerated this treatment well, although with an episode of shingles. - A PET scan on ___ showed changes concerning for progression of disease. Ms. ___ underwent fine needle core biopsy of her retroperitoneal lymph node on ___, which showed a follicular lymphoma, grade 1/II with immunostaining showing tumor cells positive for CD20, CD10, and Bcl-2 and negative for cyclin D1, MIB1 was positive of approximately 20% of the cells. This was consistent with her low-grade follicular lymphoma with no evidence of transformation. Mrs. ___ then underwent further evaluation with bone marrow aspirate and biopsy on ___, which showed a cellular marrow with ___ cellularity with trilineage maturation and no evidence of lymphoma by morphology or immunohistochemistry. Further evaluation by PET CT imaging on ___ showed interval increase in the size and degree of hypermetabolic activity within the retroperitoneum, left cervical, supraclavicular, subcarinal and hilar lymphadenopathy. The size of the lymph nodes remained approximately 2 cm at most. - The decision was made after discussion of treatment option is to move forward with ibritumomab/rituximab and she received her rituximab on ___. # Breast cancer, right-sided DCIS, ER/PR positive, status post right mastectomy in ___. . OTHER MEDICAL HISTORY: History of zoster. Iron deficiency anemia, negative GI workup. Osteoporosis. Right knee arthritis. Torn right rotator cuff. GERD. Social History: ___ Family History: Mother had breast cancer age ___. Maternal grandmother had breast cancer age ___. No known history of ovarian cancer. She is of ___ origin. Brother has prostate cancer. Physical Exam: ADMISSION EXAM: Vitals: 100.4 108/70 96 20 96%RA General: well appearing, NAD, walking around the unit HEENT: MMM Neck: suppled CV: RRR no murmurs Lungs: CTA b/l Abdomen: soft non tender non distended GU: no foley Ext: no edema Neuro: A+Ox3, normal gait, moving all 4 extremities DISCHARGE EXAM: Vitals: 98.9 (also Tm), 136/70, 78, 18, 98% RA General: well appearing, NAD, HEENT: MMM, no erythema or lesion noted Neck: supple, no appreciable ___ CV: RRR, no m/r/g Lungs: CTA b/l, no w/r/r Abdomen: soft non tender non distended. Normal bowel sounds, no rebound or guarding. No organomegaly GU: no foley Ext: WWP. Pulses 2+ bilaterally. No cyanosis, clubbing or edema Neuro: A+Ox3, normal gait, moving all 4 extremities with purpose. Pertinent Results: ADMISSION LABS: ___ BLOOD WBC-4.6# RBC-3.51* Hgb-12.1 Hct-37.3 MCV-106* MCH-34.5* MCHC-32.5 RDW-14.1 Plt ___ ___ BLOOD Neuts-29* Bands-10* ___ Monos-18* Eos-5* Baso-1 ___ Metas-1* Myelos-0 ___ BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL Poiklo-NORMAL Macrocy-2+ Microcy-NORMAL Polychr-OCCASIONAL Stipple-OCCASIONAL ___ BLOOD UreaN-12 Creat-0.6 Na-140 K-4.2 Cl-99 ___ BLOOD Phos-3.7 Mg-1.7 ___ BLOOD Calcium-9.9 Phos-3.5 Mg-1.8 ___ BLOOD IgG-208* ___ BLOOD Lactate-1.5 DISCHARGE LABS: ___ BLOOD WBC-2.0* RBC-3.09* Hgb-10.7* Hct-32.2* MCV-104* MCH-34.6* MCHC-33.2 RDW-13.8 Plt ___ ___ BLOOD Neuts-18* Bands-0 ___ Monos-28* Eos-9* Baso-1 Atyps-2* ___ Myelos-0 NRBC-1* ___ BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL ___ BLOOD Glucose-101* UreaN-18 Creat-0.6 Na-141 K-4.1 Cl-106 HCO3-26 AnGap-13 ___ BLOOD Calcium-9.4 Phos-3.5 Mg-1.9 MICRO: ___ BLOOD CULTURE x2 - PENDING ___ BLOOD CULTURE - PENDING ___ BLOOD CULTURE - PENDING ___ Rapid Respiratory Viral Screen & Culture Respiratory Viral Culture (Pending): Respiratory Viral Antigen Screen (Final ___: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. IMAGING: ___ CHEST (PA & LAT) FINDINGS: Frontal and lateral chest radiograph demonstrates an opacification of the right middle lobe concerning for pneumonia. The left lung is clear with no focal consolidation. There is no pleural effusion or pneumothorax. The cardiomediastinal and hilar silhouettes are within normal limits. A left sided Port-A-Cath extends to the lower superior vena cava. IMPRESSION: Right middle lobe pneumonia. Brief Hospital Course: ___ yo F with NHL currently on rituxan and history of breast cancer, admitted with a pneumonia. ACTIVE ISSUES: # CAP: Symptoms most consistent with a viral URI but given the onset of fevers and ?CXR findings there was concern for superimposed community acquired pneumonia. At time of admission, pt was not neutropenic, however, WBC did fall to 1.5. This acute drop was felt to be secondary to marrow suppression from her acute viral infection. She had no risk factors for HCAP and thus was only treated with 5 days of levofloxacin. She received first dose of levofloxacin on ___. Nasopharyngeal swab was sent to rule out influenza and other respiratory viruses, all of which came back negative. Her IgG was 200 so she was given IVIg on ___ with rigors, muscle pain and fever a few hours later. The fever was likely due to infusion of IVIG and resolved after the infusion was completed. Patient was up walking the hallways without difficulty or shortness of breath. She was discharged to home with close follow up the day following discharge. CHRONIC ISSUES: # NHL: Patient remained clinically stable while in house. She is s/p C1 rituxan in ___. Plan for rituxan Q3 months. She was continued on acyclovir ppx. TRANSITIONAL ISSUES: #Code status: FULL CODE Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Multivitamins 1 TAB PO DAILY 2. Acyclovir 400 mg PO Q8H Discharge Medications: 1. Acyclovir 400 mg PO Q8H 2. Multivitamins 1 TAB PO DAILY 3. Cepastat (Phenol) Lozenge 1 LOZ PO Q4H:PRN cough 4. Levofloxacin 750 mg PO DAILY RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*4 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: primary diagnosis: community acquired pneumonia secondary diagnosis: non-Hodgkin's Lymphoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the ___ for concern for pneumonia. As you know, you felt very well but you did have a fever. You also had low blood counts. You received IVIg and levofloxacin, the latter is an antibiotic. You improved. We wish you all the best. Followup Instructions: ___
10157674-DS-20
10,157,674
22,623,459
DS
20
2168-09-30 00:00:00
2168-09-30 18:35:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Tetracycline / ceftriaxone Attending: ___. Chief Complaint: Fever Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a pleasant ___ w/ non-Hodgkins follicular lymphoma that is currently responding well to idelalisib [Zydelig, Potent small molecule inhibitor of the delta isoform of phosphatidylinositol 3-kinase PI3K&#948;] presenting with fever which started abruptly at 5pm. She checked her temp at home and it reached 102.6F and reported to the ED. She states she has otherwise been well. She was in a home with healthy small children recently but was not in direct contact w/ them. She denied any other localizing symptoms (no URI, no cough, no CP/SOB, no abd pain/N/V/D/C, no rashes). In ED, she appeared well. Flu swab negative. She received 2L NS and 30 mg Ketorolac. Her tmax in ed 100.9 and persistently otherwise 99.9. She did not receive abx. REVIEW OF SYSTEMS: 10 point ROS reviewed in detail and negative except for what is mentioned above in HPI Past Medical History: ONCOLOGIC HISTORY: # Follicular lymphoma: - in ___, at the time of her mastectomy for right-sided breast cancer, a right axillary lymph node dissection was performed with 3 of 8 lymph nodes biopsy showing involvement with non-Hodgkin's follicular lymphoma, grade I/III. Subsequent staging by PET CT showed extensive mesenteric, retroperitoneal, inguinal, axillary and pelvic FDG avid lymphadenopathy. Her disease was staged as a low-grade stage IIIA intermediate risk follicular lymphoma. Because she was asymptomatic at the time of diagnosis in ___, she did not require treatment until ___, at which point a repeat PET CT showed significant increase in lymphadenopathy. - Under the care of Dr. ___, Mrs. ___ received six cycles of fludarabine and Rituxan, completing in ___. - Her disease recurred in ___. She was treated with four cycles of R-CHOP, completing in ___. She tolerated this treatment well, although with an episode of shingles. - A PET scan on ___ showed changes concerning for progression of disease. Ms. ___ underwent fine needle core biopsy of her retroperitoneal lymph node on ___, which showed a follicular lymphoma, grade 1/II with immunostaining showing tumor cells positive for CD20, CD10, and Bcl-2 and negative for cyclin D1, MIB1 was positive of approximately 20% of the cells. This was consistent with her low-grade follicular lymphoma with no evidence of transformation. Mrs. ___ then underwent further evaluation with bone marrow aspirate and biopsy on ___, which showed a cellular marrow with ___ cellularity with trilineage maturation and no evidence of lymphoma by morphology or immunohistochemistry. Further evaluation by PET CT imaging on ___ showed interval increase in the size and degree of hypermetabolic activity within the retroperitoneum, left cervical, supraclavicular, subcarinal and hilar lymphadenopathy. The size of the lymph nodes remained approximately 2 cm at most. - The decision was made after discussion of treatment option is to move forward with ibritumomab/rituximab and she received her rituximab on ___. # Breast cancer, right-sided DCIS, ER/PR positive, status post right mastectomy in ___. . OTHER MEDICAL HISTORY: History of zoster. Iron deficiency anemia, negative GI workup. Osteoporosis. Right knee arthritis. Torn right rotator cuff. GERD. Social History: ___ Family History: Mother had breast cancer age ___. Maternal grandmother had breast cancer age ___. No known history of ovarian cancer. She is of Jewish origin. Brother has prostate cancer. Physical Exam: =========================== EXAM ON ADMISSION =========================== General: NAD, Resting in bed comfortably HEENT: MMM, no OP lesions, + R>L cervical/supraclavicular adenopathy that is non-tender CV: RR, NL S1S2 ___ SEM throughout precordium PULM: CTAB, + crackles b/l bases, No respiratory distress ABD: BS+, soft, NTND, no palpable masses or HSM LIMBS: WWP, no ___, no tremors SKIN: No rashes on the extremities, no petechiae, no splinter hemorrhages CHEST: L port site appears intact, accessed NEURO: Grossly normal =========================== EXAM ON DISCHARGE =========================== VITAL SIGNS: 98.6, 90, 110/60, 18, 99%RA General: NAD, well-appearing CV: RR, NL S1S2 ___ SEM, early-peaking, best heard in RUSB PULM: CTAB, no crackles, No respiratory distress ABD: BS+, soft, NTND, no palpable masses or HSM SKIN: Diffuse erythematous itchy rash on torso CHEST: L port site appears intact, accessed NEURO: Grossly normal Pertinent Results: =========================== LABS ON ADMISSION =========================== ___ 08:40PM BLOOD WBC-5.7 RBC-2.96* Hgb-9.4* Hct-28.7* MCV-97 MCH-31.8 MCHC-32.8 RDW-16.3* RDWSD-57.8* Plt ___ ___ 08:40PM BLOOD Glucose-106* UreaN-17 Creat-0.9 Na-138 K-4.3 Cl-100 HCO3-25 AnGap-17 ___ 06:00AM BLOOD ALT-20 AST-28 LD(___)-207 AlkPhos-108* TotBili-0.6 ___ 06:00AM BLOOD Albumin-3.6 Calcium-9.3 Phos-3.1 Mg-1.7 ___ 08:43PM BLOOD Lactate-0.9 =========================== LABS ON DISCHARGE =========================== ___ 12:00AM BLOOD WBC-5.8 RBC-2.24* Hgb-7.1* Hct-22.0* MCV-98 MCH-31.7 MCHC-32.3 RDW-16.7* RDWSD-59.1* Plt Ct-70* ___ 12:00AM BLOOD Neuts-47 Bands-2 ___ Monos-12 Eos-2 Baso-0 ___ Myelos-0 AbsNeut-2.84 AbsLymp-2.15 AbsMono-0.70 AbsEos-0.12 AbsBaso-0.00* ___ 12:00AM BLOOD ___ PTT-71.3* ___ ___ 12:00AM BLOOD Glucose-106* UreaN-21* Creat-0.9 Na-134 K-4.6 Cl-103 HCO3-21* AnGap-15 ___ 12:00AM BLOOD ALT-20 AST-25 LD(___)-232 AlkPhos-106* TotBili-0.3 ___ 12:00AM BLOOD Calcium-9.0 Phos-2.9 Mg-1.8 UricAcd-7.0* =========================== MICROBIOLOGY =========================== ___ Blood cultures - NGTD ___ Urine culture - No growth ___ Rapid Respiratory Viral Screen & Culture - negative screen, culture prelim no growth (final pending), flu negative ___ Lyme - negative =========================== IMAGING =========================== ___ CXR (PA & Lat): PA and lateral views of the chest provided. Port-A-Cath resides over the left chest wall with catheter tip in the region of the lower SVC. Lungs are clear. Clips are noted in the right axilla with absence of the right breast shadow. Lungs are clear. There is no focal consolidation, effusion, or pneumothorax. The cardiomediastinal silhouette is normal. Imaged osseous structures are intact. No free air below the right hemidiaphragm is seen. IMPRESSION: No acute intrathoracic process. Port-A-Cath positioned appropriately. ___ TTE: The left atrial volume index is mildly increased. The estimated right atrial pressure is ___ mmHg. Normal left ventricular wall thickness, cavity size, and global systolic function (3D LVEF = 67 %). Doppler parameters are most consistent with Grade I (mild) left ventricular diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. There are three aortic valve leaflets. No masses or vegetations are seen on the aortic valve. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. No masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild aortic stenosis. No valvular vegetations were visualized however there was poor visualization of the right sided cardiac valves. If clinically suggested, the absence of a vegetation by 2D echocardiography does not exclude endocarditis. Compared with the prior study (images reviewed) of ___, basal LV systolic dysfunction was not present in the current study, which is similar to stress echocardiographic findings in ___. ___ CT abd/pelvis w/ contrast: 1. No acute intra-abdominal pathology. 2. Slightly decreased size of diffuse mesenteric and retroperitoneal lymphadenopathy consistent with known lymphoma. 3. Incidental nonobstructive jejunal lipomas. ___ CT chest w/ contrast: - No evidence of active intrathoracic infection - Stable right lower lobe lung nodule - Diffuse lymphadenopathy with minimally increased in size of periaortic lymph node as described above Brief Hospital Course: ___ w/ non-Hodgkins follicular lymphoma that is currently responding well to idelalisib p/w isolated fevers. # Fever - Patient presented to the ED with fever to 102.6 and no other localizing symptoms. In the ED, her Tmax was 100.9. She was not neutropenic with a white count of 5.7. She was found to have a lactate of 0.9. Blood cultures were drawn. LFTs were normal, a u/a showed no signs of a UTI, and a CXR was clear for pneumonia. Flu PCR negative. She was therefore not started on antibiotics. The patient was noted to have a systolic ejection murmur, which had not been documented in previous exams. She underwent a TTE, showing mild aortic stenosis and no vegetations (though the report notes that the right-sided heart valves were not well-visualized). The patient continued to spike fevers to 102 and 103, though was feeling well otherwise. She was started on ceftriaxone, but developed a pruritic rash, and so it was stopped after one dose. She then underwent a CT torso, with no signs of infection. A viral respiratory screen was negative, with cultures pending, and a test for Lyme was also negative Of note, Zydelig itself has been shown to cause fevers in around 30% of patients. It was held on admission. On ___, the patient had a tmax of 100.2, and she had no additional fevers afterwards. The fever was felt most likely to be a drug fever from Zydelig, and she was discharged with instructions to restart it, with close outpatient followup to see if she has additional fevers with the medication. # Recurrent non-Hodgkin's Lymphoma - According to the patient, disease now seems to be improving on Zydelig as evident by resolution of fatigue and lymphadenopathy. Zydelig was not on formulary, and as patient was discharged the following day, it was held on admission. She was continued on prophylaxis with Bactrim. The patient reported that she was not currently taking acyclovir as she felt it may have been contributing to her thrombocytopenia. This was restarted in the hospital per her outpatient oncologist. As part of the infectious workup, the patient had a CT torso, which did show minimal decrease in the size of the patient's lymph nodes. Also as above, the patient's zydelig was held as it was felt that it may be the cause of the patient's fevers. It was restarted on discharge. # Heart Murmur - The patient was found to have a grade ___ SEM, which had not been previously documented. There were no clinical symptoms of CHF nor valvular stenosis. The patient underwent a TTE, showing mild aortic stenosis, no signs of vegetations (though the report notes that the right-sided heart valves were not well-visualized). # Anemia: The patient presented with a hgb of 9.4, which is stable from prior. However, it continued to downtrend in the inpatient setting. There were no signs of active bleeding or hemolysis. She received 1u pRBCs on ___ prior to discharge. Her anemia will continue to be monitored in the outpatient setting. ============================= TRANSITIONAL ISSUES ============================= - The patient was discharged home with instructions to continue her Zydelig until meeting with her outpatient oncologist. - The patient was found to have worsening anemia, with no signs of active bleeding or hemolysis. She received a unit of pRBC on day of discharge. Her h/h should be rechecked at her outpatient oncology appointment. - The patient had not been on acyclovir at home, and it was restarted during this hospitalization. - Final blood cultures and respiratory viral cultures will be followed up by her inpatient team. - The patient was found to have mild aortic stenosis on echo. Followup with outpatient cardiology could be considered for further monitoring. CODE STATUS: Full code HCP: Health Care Proxy: ___ Phone number: ___ Cell phone: ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. idelalisib 100 mg oral Q12H 2. Sulfameth/Trimethoprim SS 1 TAB PO DAILY Discharge Medications: 1. Acyclovir 400 mg PO TID 2. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 3. idelalisib 100 mg oral Q12H Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis - fevers Secondary Diagnoses - follicular lymphoma - mild aortic stenosis - anemia - thrombocytopenia - history of shingles Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure to be a part of your care team at ___ ___. You were admitted because you had a fever. We did lab tests, a chest x-ray, an ultrasound of your heart (echocardiogram), and a CT scan to look for the source of your infection, but everything was normal, which is good. We think your fevers may have been caused by your zydelig. Dr. ___ you to restart it this evening (___), and you will see him in clinic soon to see if you are having fevers again. You also developed a rash while in the hospital, which we think is from the ceftriaxone. You can take over-the-counter Benadryl or Allegra if you are still itching. We have restarted you on your acyclovir. Please see below for more information about your medications. Please see below for details about your upcoming appointments. Again, it was very nice to meet you, and we wish you all the best! Sincerely, Your ___ Care Team Followup Instructions: ___
10157940-DS-11
10,157,940
21,051,857
DS
11
2169-10-06 00:00:00
2169-10-08 15:59:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: aspirin Attending: ___. Chief Complaint: Primary Diagnosis - Erosive gastritis - Melena and hematochezia Major Surgical or Invasive Procedure: EGD and colonoscopy (___) History of Present Illness: PATIENT SUMMARY ___ yo M with PMHx PUD and H. Pylori s/p triple therapy and hx diverticulosis who presented with melena of 2 days duration, hemodynamically stable and no longer actively bleeding, awaiting EGD and colonoscopy with GI. ACTIVE ISSUES # GI Bleed # Hx peptic ulcer disease and h. pylori infxn # Hx bleeding diverticulosis Hg 14.5 on admission. Guaiac positive brown stool on rectal in ED. Has had prior episodes of guaiac positive stool. Was previously thought to be diverticular in etiology as was found to have diffuse diverticulosis on colonoscopy on ___ with active bleeding out of one diverticulum. Also with hx of PUD and h. pylori so received both ___ and EGD while inpatient. Of note, did have confirmatory testing showing eradicated H.Pylori "a few months ago" at ___ per wife and daughter. Patient should be on omeprazole 20mg daily but has not been taking it. Patient complains of ongoing dizziness with standing consistent with orthostasis that he notes has been an issue for years. Per wife, patient does not hydrate enough, so this sx unlikely to be related to GIB. Hgb and vitals stable throughout hospitalization. Had normal, brown BM on evening of ___, and prepped for ___ without any bleeding noted. EGD w some erosive gastritis, colonoscopy w diffuse diverticulosis but no active bleeding on either scope. Discharged on omeprazole 20mg BID with instruction to follow-up with PCP. CHRONIC ISSUES # Benign prostatic hypertrophy Follows at ___ with Urology. s/p LUTS in ___. Previously on tamsulosin 0.8mg QHs but no longer needed per recent urology note. Patient denies urinary complaints, voids without issues. No active mgmt. required inpatient. # Renal cell carcinoma Follows at ___ with Urology for small renal mass with biopsy proven RCC. Most recent PSA on ___ was 6.5. Last CT done ___, repeat planned for ___. Has monitoring with CT every ___ months. No active mgmt. required inpatient. # Hx of hypertension - not currently on medications, normotensive while inpatient. # HLD - not currently on medications per patient. TRANSITIONAL ISSUES [] Re-enforce practices to avoid gastric irritation including: heavy NSAID use, EtOH use. [] Taper and discontinue PPI when appropriate, likely ___ weeks post-discharge Past Medical History: PAST MEDICAL/SURGICAL HISTORY: ============================== - HTN - HLD - RCC - BPH - Bullet lodged in left thigh - s/p right knee operation - s/p hernia surgery Social History: ___ Family History: FAMILY HISTORY: =============== Mother - died ___ likely ruptured cerebral aneurysm Father - died ___ lung problems Sibs - 2 brother died - 1 died after stroke in ___ and MI, other was shot; ___nd ___hildren - 4 all well Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: temp 97.3, BP 137/70, HR 62, RR 18, 98% RA GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. +Frank's sign. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rashes. NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs spontaneously. ___ strength throughout. Normal sensation. DISCHARGE PHYSICAL EXAM: ======================== VITALS: Temp: 98.5 (Tm 98.5), BP: 127/74 (127-146/74-87), HR: 61 (59-74), RR: 18, O2 sat: 96% (96-98), O2 delivery: Ra General: alert, oriented, no acute distress Eyes: Sclera anicteric HEENT: MMM, oropharynx clear Neck: supple, no LAD Resp: clear to auscultation bilaterally, no wheezes, rales, ronchi CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops GI: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly MSK: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNs2-12 intact, motor function grossly normal Pertinent Results: ADMISSION LABS: ___ 08:05AM BLOOD WBC-5.8 RBC-4.81 Hgb-14.5 Hct-44.1 MCV-92 MCH-30.1 MCHC-32.9 RDW-13.7 RDWSD-46.5* Plt ___ ___ 08:05AM BLOOD Neuts-48.4 ___ Monos-10.3 Eos-8.3* Baso-0.5 Im ___ AbsNeut-2.78 AbsLymp-1.86 AbsMono-0.59 AbsEos-0.48 AbsBaso-0.03 ___ 10:19AM BLOOD ___ PTT-31.1 ___ ___ 08:05AM BLOOD Glucose-77 UreaN-23* Creat-1.0 Na-141 K-5.1 Cl-105 HCO3-22 AnGap-14 ___ 08:05AM BLOOD ALT-26 AST-25 AlkPhos-93 TotBili-0.5 ___ 08:05AM BLOOD Albumin-3.7 PERTINENT INTERVAL LABS: none IMAGING/PROCEDURES: ___ COLONOSCOPY: IMPRESSIONS: - Diverticulosis of the whole colon but were most notable and frequent in the sigmoid. - The right colon was carefully evaluated twice in forward view. - Prep sufficient to rule out active bleeding and large malignancy but not to rule out smaller (<1cm) polyp. ___ UPPER ENDOSCOPY: IMPRESSIONS: - Normal esophagus - Erythema and erosions in the stomach compatible with erosive gastritis. (Biopsy). - Erosions in the second part of the duodenum MICRO: none DISCHARGE LABS: ___ 06:28AM BLOOD WBC-4.9 RBC-4.75 Hgb-14.4 Hct-43.5 MCV-92 MCH-30.3 MCHC-33.1 RDW-13.4 RDWSD-45.2 Plt ___ ___ 06:28AM BLOOD Glucose-90 UreaN-9 Creat-0.9 Na-144 K-4.9 Cl-107 HCO3-27 AnGap-10 ___ 06:28AM BLOOD Calcium-9.5 Phos-3.2 Mg-1.8 Brief Hospital Course: PATIENT SUMMARY ___ yo M with PMHx PUD and H. Pylori s/p triple therapy and hx diverticulosis who presented with melena of 2 days duration, hemodynamically stable and no longer actively bleeding, awaiting EGD and colonoscopy with GI. ACTIVE ISSUES # GI Bleed # Hx peptic ulcer disease and h. pylori infxn # Hx bleeding diverticulosis Hg 14.5 on admission. Guaiac positive brown stool on rectal in ED. Has had prior episodes of guaiac positive stool. Was previously thought to be diverticular in etiology as was found to have diffuse diverticulosis on colonoscopy on ___ with active bleeding out of one diverticulum. Also with hx of PUD and h. pylori so received both ___ and EGD while inpatient. Of note, did have confirmatory testing showing eradicated H.Pylori "a few months ago" at ___ per wife and daughter. Patient should be on omeprazole 20mg daily but has not been taking it. Patient complains of ongoing dizziness with standing consistent with orthostasis that he notes has been an issue for years. Per wife, patient does not hydrate enough, so this sx unlikely to be related to GIB. Hgb and vitals stable throughout hospitalization. Had normal, brown BM on evening of ___, and prepped for ___ without any bleeding noted. EGD w some erosive gastritis, colonoscopy w diffuse diverticulosis but no active bleeding on either scope. Discharged on omeprazole 20mg BID with instruction to follow-up with PCP. CHRONIC ISSUES # Benign prostatic hypertrophy Follows at ___ with Urology. s/p LUTS in ___. Previously on tamsulosin 0.8mg QHs but no longer needed per recent urology note. Patient denies urinary complaints, voids without issues. No active mgmt. required inpatient. # Renal cell carcinoma Follows at ___ with Urology for small renal mass with biopsy proven RCC. Most recent PSA on ___ was 6.5. Last CT done ___, repeat planned for ___. Has monitoring with CT every ___ months. No active mgmt. required inpatient. # Hx of hypertension - not currently on medications, normotensive while inpatient. # HLD - not currently on medications per patient. TRANSITIONAL ISSUES [] Re-enforce practices to avoid gastric irritation including: heavy NSAID use, EtOH use. [] Taper and discontinue PPI when appropriate, likely ___ weeks post-discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Omeprazole 20 mg PO BID possible upper GI bleed, hx ulcers RX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*2 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis - Erosive gastritis - Melena and hematochezia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ================================================ MEDICINE Discharge Worksheet ================================================ Dear Mr. ___, It was a pleasure taking part in your care here at ___! Why was I admitted to the hospital? - You were admitted to the hospital because you had blood in your stool. What was done for me while I was in the hospital? - We checked your blood levels and your blood pressure and they were both stable during your stay. - We used a camera to see inside your stomach and colon to check for causes of bleeding. We saw a small amount of inflammation in your stomach, but no signs of active bleeding, which is good. What should I do when I leave the hospital? - Please go to your follow up appointments as scheduled in the discharge papers. Most of them already have a specific date & time set. If there is no specific time specified, and you do not hear from their office in ___ business days, please contact the office to schedule an appointment. - Please monitor for new/or worsening symptoms. If you do not feel like you are getting better or have any other concerns, please call your doctor to discuss or return to the emergency room. -Please note any new medications in your discharge worksheet. Sincerely, Your ___ Care Team Followup Instructions: ___
10157940-DS-8
10,157,940
21,734,583
DS
8
2163-10-21 00:00:00
2163-10-22 06:43:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: aspirin Attending: ___. Chief Complaint: Vertigo with left arm numbness Major Surgical or Invasive Procedure: None. History of Present Illness: Mr. ___ is a ___ right handed man with a history of hypertension and hyperlipidemia as well as a lumbar radiculopathy who presented to the ED following an episode of vertigo with left arm numbness. Today, he recapitulated his history, and explained that he has had episodes which sound like typical positional vertigo, brought on by quick torsional movements of his trunk and head. He presented to the ED yesterday because of a one hour long episode of such vertigo that didn't resolve by keeping his head still. It was also associated with left arm numbness. He reports also previous episodes of numbness and tingling in his left arm that radiates proximal-distally. He also has on review of systems chronic numbness along the lateral aspect of his left leg/shin suggestive of an L5 radiculopathy. He has not had any falls. Past Medical History: - HTN - HLD - Episodes of what sound like BPPV since an ear infection ___ years ago. Last a few seconds brought on by movements happens 2x/month - Bullet lodged in left thigh - s/p right knee operation - s/p hernia surgery Social History: ___ Family History: Mother - ___ ___ likely ruptured cerebral aneurysm Father - died ___ lung problems Sibs - 2 brother died - 1 died after strokein ___ and MI, other was shot; ___nd ___hildren - 4 all well Physical Exam: Physical Exam on ___: Vitals: T:97.6 P:72 R:16 BP:123/72 SaO2:98% RA General: Awake, cooperative, NAD bu notes not ___ and notes left arm numbness. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx. Otoscopy slight erythema in right ear no exudate and clear tympanic membrane and left normal. Neck: Supple, no carotid/vertebral bruits appreciated. No nuchal rigidity. Full range of motion. Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C and slight ankle oedema bilaterally, 2+ radial, DP pulses bilaterally. Calves SNT bilaterally. Skin: slight erythematous papular lesion left anterior shin and otherwise no rashes or lesions noted. Neurological examination on ___: Mental Status: Examnation somewhat limited by language barrier but familyinterpreting. Alert, oriented x person, place and time The pt. knows ___ is president. Able to relate history with some degree of difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Speech was not dysarthric. Pt. was able to name both high and low frequency objects. Able to read without difficulty. Attentive, able to name ___ backward without difficulty. Pt. was able to register 3 objects and recall ___ at 3 minutes ___ with cateory prompting. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. - Cranial Nerves: I: Olfaction not tested. II: PERRL 4 to 3mm and brisk. VFF to confrontation. Funduscopic exam reveals no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI wih slight right endgaze horizontal nystagmus and slightly jerky eye movements. V: Facial sensation intact to light touch. Good power in muscles of mastication. VII: No facial weakness, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline with normal velocity movements. Head thrust with nystagmus on thrust to the left with no symptoms. - Motor: Normal bulk, tone throughout. No pronator drift bilaterally. Slight left>right postural tremor noted worse with action. No asterixis noted. SAb SAdd ElF ElE WrE FFl FE IO HipF HipE KnF KnE AnkD ___ L 5 5 ___ ___ 5 ___ ___ R 5 5 ___ ___ 5 ___ ___ EDB ___ on left. - Sensory: Light touch ecreasd to the elbow worse on the lateral aspect and in the ___ to the left lateral calf and asymmetric to the midshin medially. Temperaature and pinprick decreased to he left elbow and to the upper shin below the knee on the left. Vibration slightly decreaed at the left fingertip and to the knees bilaterally. Proprioception appears normal. No extinction to DSS. - DTRs: BJ SJ TJ KJ AJ L ___ 3 1 R ___ 3 1 There was no evidence of clonus. ___ negative. Plantar response was flexor bilaterally. - Coordination: Possible mild left rebound. Left intention tremor, relatively normal finger tapping. No clear dysdiadochokinesia noted. Possibly slight left dysmetria with slightly reduced mirroring on the left and questionable slight decreased HKS on the left. - Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem admirably without difficulty. Romberg with slight sway. Neurological exam on ___: Neuro exam on ___: MS: alert and oriented x3, intact fluency and comprehension CN: perrla, eomi, intact light touch and facial strength bilaterally, no nystagmus in primary gaze, two beats of nystagmus with end gaze to either side, vfftc, no visual extinction, during head thrust manuever he resisted turning his head to the right, during head thrust manuever to the left there were no saccadic intrusions. Motor: normal tone, bulk, and ___ strength of all four extremities Sensory: decreased light touch and pinprick of the left dorsal foot and left lateral calf, otherwise there is intact light touch, pinprick of all four ext, intact proprio of the toes bilaterally Reflexes: 2+ biceps, patella, 1+ ankles, toes downgoing bilaterally Pertinent Results: ___ 05:50PM GLUCOSE-105 NA+-143 K+-4.2 CL--104 TCO2-29 ___ 05:48PM CREAT-1.0 ___ 05:48PM estGFR-Using this ___ 05:45PM GLUCOSE-111* UREA N-20 CREAT-1.1 SODIUM-143 POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-27 ANION GAP-12 ___ 05:45PM estGFR-Using this ___ 05:45PM ALT(SGPT)-27 AST(SGOT)-24 ALK PHOS-82 TOT BILI-0.9 ___ 05:45PM cTropnT-<0.01 ___ 05:45PM ALBUMIN-4.1 CALCIUM-9.2 PHOSPHATE-3.8 MAGNESIUM-2.0 ___ 05:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 05:45PM WBC-7.3 RBC-4.91 HGB-15.3 HCT-44.8 MCV-91 MCH-31.2 MCHC-34.3 RDW-13.3 ___ 05:45PM NEUTS-58.3 ___ MONOS-7.3 EOS-4.2* BASOS-0.6 ___ 05:45PM PLT COUNT-228 ___ CT brain: No acute or chronic stroke seen. No bleed or mass CTA brain/neck: Moderate focal stenosis of the proximal origin of the left vertebral artery. Mild ICA stenosis bilaterally ___ TTE: normal EF. + PFO with right to left shunt ___: No deep vein thrombosis within the right or left lower extremity. Brief Hospital Course: ___: As a part of a code stroke protocol, Mr. ___ received a CTA/CTP in the ED that identified no acute intracranial abnormality, no occlusive thrombo-embolic arterial filling defect and no focal CT perfusion abnormality. Patient unable to do MRI of his brain, as he has had a bullet lodged in his thigh. He was admitted to the neurology stroke service where his examination remained stable and he remained hemodynamically unchanged. Since an MRI could not be done, we thought about the possibility of repeating a NCHCT to identify a possible new hypodensity. In interviewing the patient again, we decided to treat his new symptom episode as a likely TIA. - He was initiated on plavix for secondary prophylaxis - He was counseled on healthy eating habits and the importance of exercise. - Screening labs for DMII and HLD showed an A1c of 5.4 and lipid panel of 142/152/38/94. - An echocardiogram showed a widely patent PFO with a right-left flow. LENIs were pursued, and identified no lower extremity DVT. On the day of discharge, he appeared well. He was safely discharged home with instructions to follow up with his PCP and Dr. ___ the ___ Neurology division. Medications on Admission: Medications - OTC Simvastatin 10mg qd started 1 week ago due to concern for possible strokes ACETAMINOPHEN [TYLENOL] - Dosage uncertain - (Prescribed by Other Provider) OMEGA-3 FATTY ACIDS-FISH OIL [OMEGA 3 FISH OIL] - Dosage uncertain - (Prescribed by Other Provider) Discharge Medications: 1. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Simvastatin 10 mg PO DAILY RX *simvastatin 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Transient ischemic attack Cervical radiculopathy Lumbar radiculopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, Thank you for allowing us to care for you in the Neurology ___. You were admitted to us for the evaluation of new onset symptoms of dizziness with left arm numbness that were concerning for a stroke. Through a series of neurological examinations and laboratory testing, we determined that your symptoms were likely caused by a TIA or transient ischemic attack. Part of your left arm numbness may also be related arthritis in your cervical spine, which, by compressing nerve ___ cause occasional numbness and tingling along your left arm. To help with this, we recommend that you purchase (over the counter) a soft cervical collar that will help immobilize your neck. We checked an ultrasound of your heart (echocardiogram). This identified a PATENT FORAMEN OVALE, which is an abnormal connection between the right and left-sided cavities of your heart, which can sometimes predispose individuals to stroke. We will communicate this information to your primary care physician. It is important that you follow up with your appointments as listed below. To prevent future strokes or TIAs, we started you on a medication called PLAVIX or clopidogrel. Please take this daily. Also continue your fish oil and simvastatin 10mg daily to lower your blood cholesterol levels. Followup Instructions: ___
10158230-DS-17
10,158,230
28,089,795
DS
17
2149-09-26 00:00:00
2149-10-04 11:21:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Penicillins / Codeine / Bactrim DS Attending: ___. Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: none History of Present Illness: Mrs. ___ is a ___ year old female with hx of ventral hernia repair, open appendectomy, partial followed by total hysterectomy, unprovoked DVTs on Xarelto who presents to the ED with 1 week of abdominal pain, nausea, vomiting. She has never had any pain like this before. It started ___, and over the week, she had intermittent nausea with occasional emesis. She thought she had a intestinal infection, but the pain worsened by the end of the week, so her husband urged her to seek care. She reports her last BM and flatus on ___. She feels well otherwise, no fever, chills, or chest pain, weight loss, but does endorse occasional shortness of breath secondary to the pain. She has had history of polyps removed, but her last colonoscopy was otherwise unremarkable. Of note, she last took her Xarelto morning of presentation (___). Past Medical History: Past Medical History: HTN, GERD, back pain, h/o DVTs, "brain clots" Past Surgical History: ventral hernia repair (without mesh per patient), appendectomy, partial then total hysterectomy, colon polypectomy Social History: ___ Family History: HTN, no clotting disorders Father - brain cancer Physical Exam: Admission Physical Exam: Vitals: T 98, HR 76, BP 119/89, RR 13, SaO2 92% RA GEN: Alert and oriented, no acute distress, conversant and interactive, overall well appearing HEENT: Sclerae anicteric, mucous membranes moist, oropharynx is clear. CV: Regular rate and rhythm, no audible murmurs. PULM/CHEST: Clear to auscultation bilaterally, respirations are unlabored on room air. ABD: Soft, distended and tympanic. Tense on palpation and diffusely tender. Midline incision well-healed. Ext: No lower extremity edema, distal extremities feel warm and appear well-perfused. Discharge Physical Exam: VS: 98.4, 70, 121/80, 16, 98 RA Gen: Pleasant and interactive. HEENT: No deformity. Mucus membranes pink/moist. Neck supple, trachea midline. CV: RRR Pulm: Clear to auscultation bilaterally. Abdom: Soft, non-distended, non-tender. Active bowel sounds. Ext: Warm and dry, no edema. 2+ ___ pulses. Neuro: A&Ox3. Moves all extremities equal and strong. Speech is clear and fluent. Pertinent Results: ___ 06:06AM BLOOD WBC-7.3# RBC-3.72* Hgb-11.7 Hct-35.7 MCV-96 MCH-31.5 MCHC-32.8 RDW-12.1 RDWSD-42.3 Plt ___ ___ 06:20AM BLOOD WBC-4.1 RBC-3.55* Hgb-11.2 Hct-34.2 MCV-96 MCH-31.5 MCHC-32.7 RDW-12.1 RDWSD-42.6 Plt ___ ___ 06:10PM BLOOD WBC-6.1 RBC-4.12 Hgb-12.9 Hct-37.8 MCV-92 MCH-31.3 MCHC-34.1 RDW-11.9 RDWSD-39.9 Plt ___ ___ 06:20AM BLOOD ___ PTT-26.5 ___ ___ 06:10PM BLOOD ___ PTT-30.5 ___ ___ 06:06AM BLOOD Glucose-126* UreaN-3* Creat-0.7 Na-137 K-4.1 Cl-102 HCO3-26 AnGap-13 ___ 06:20AM BLOOD Glucose-116* UreaN-6 Creat-0.8 Na-135 K-4.1 Cl-98 HCO3-24 AnGap-17 ___ 06:10PM BLOOD Glucose-105* UreaN-9 Creat-0.8 Na-131* K-4.1 Cl-93* HCO3-24 AnGap-18 ___ 06:06AM BLOOD Calcium-8.9 Phos-3.0 Mg-2.2 ___ 06:20AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.8 ___ CT Ab/Pelvis: Findings concerning for small bowel obstruction with transition point at the low anterior abdominal wall. No ascites or bowel wall thickening. Brief Hospital Course: Ms. ___ is a ___ yo F admitted to the Acute Care Surgery Service on ___ with 1 week of abdominal pain, nausea, and vomiting. She has a past medical history significant for a ventral hernia repair, open appendectomy, partial hysterectomy, and DVT on Xarelto. She was made NPO, given IV fluids, had a nasogastric tube placed and admitted to the surgical floor for further management. Her Xarelto was held and she was started on a heparin drip which was titrated to therapeutic PTT. On HD2 she had flatus and the nasogastric tube was removed. She was started on clears and had some abdominal discomfort and nausea but no vomiting. On HD3 her diet was advanced to regular with good tolerability. She continued to pass flatus. Throughout this hospitalization she remained alert and oriented. The patient voided without problem. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient was maintained on a heparin drip for anticoagulation and venodyne boots were used during this stay. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Upon discharge, she was instructed to resume her home dose of xarelto. Medications on Admission: omeprazole 20 BID, metoprolol 50XL daily, paroxetine 20mg daily, xarelto 20mg daily, multivitamin daily, D3 biotin and fish oil Discharge Medications: 1. Docusate Sodium 100 mg PO BID hold for diarrhea 2. Metoprolol Succinate XL 50 mg PO DAILY 3. Omeprazole 20 mg PO BID 4. PARoxetine 20 mg PO DAILY 5. Rivaroxaban 20 mg PO DAILY Okay to resume this evening. 6. biotin 1 mg oral DAILY 7. Fish Oil (Omega 3) 1000 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Small Bowel Obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the acute care surgery service on ___ with abdominal pain. You had a CT scan that was concerning for a small bowel obstructions. You were given IV fluids and bowel rest. Your xarelto was held in the event that you needed surgery and you were maintained on a short acting IV blood thinner drip called heparin. The heparin was stopped, and you may resume your xarelto medication this evening and take as directed. You are now doing better, tolerating a regular diet, and abdominal pain is improved. You are now ready to be discharged to home to continue your recovery. Please note the following discharge instructions. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Followup Instructions: ___
10158488-DS-19
10,158,488
29,409,510
DS
19
2156-06-03 00:00:00
2156-06-08 20:30:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Penicillins Attending: ___. Chief Complaint: Right lower quadrant pain Major Surgical or Invasive Procedure: ___ abscess drainage History of Present Illness: ___ female presents with diffuse abdominal pain localized to RLQ x2 days. She also endorses some anorexia and nausea without emesis. She denies changes to bowel function, passing flatus. She had a low grade fever at home to 100 but no chills. She was supposed to be traveling to ___ in a few days to visit her son. Past Medical History: Osteoporosis s/p L2 compression fx DMII (diet controlled) HTN Hypercholesteremia Colonic adenoma GERD, HIATUS HERNIA prev upper endo shatski's ring dilation x2, and active neutrophillic esophagitis Remote h/o mild tricupsid & moderate aortic regurgitation Social History: ___ Family History: non-contributory Physical Exam: Physical Exam: ___: upon admission Vitals:98.5 84 110/55 18 95% RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, non-distended, RLQ tenderness, + rebound, neg rovsing neg psoas sign Ext: No ___ edema, ___ warm and well perfused Pertinent Results: ___ 03:45AM BLOOD WBC-8.5 RBC-3.86* Hgb-11.0* Hct-33.0* MCV-86 MCH-28.5 MCHC-33.3 RDW-13.3 RDWSD-41.6 Plt ___ ___ 08:45AM BLOOD WBC-11.9* RBC-4.04 Hgb-11.9 Hct-35.2 MCV-87 MCH-29.5 MCHC-33.8 RDW-13.5 RDWSD-43.3 Plt ___ ___ 03:40PM BLOOD WBC-17.0* RBC-4.39 Hgb-12.9 Hct-38.2 MCV-87 MCH-29.4 MCHC-33.8 RDW-13.6 RDWSD-43.0 Plt ___ ___ 03:40PM BLOOD Neuts-84.7* Lymphs-8.9* Monos-5.2 Eos-0.2* Baso-0.2 Im ___ AbsNeut-14.43* AbsLymp-1.52 AbsMono-0.88* AbsEos-0.03* AbsBaso-0.04 ___ 03:45AM BLOOD ___ ___ 03:40PM BLOOD ALT-13 AST-13 AlkPhos-67 TotBili-1.1 ___ 03:45AM BLOOD Calcium-8.6 Phos-2.5* Mg-1.8 ___ 03:49PM BLOOD Lactate-1.6 CT abd/pelvis: 1. Findings consistent with perforated appendicitis and small air and fluid collection at the tip consistent with abscess and visible hole at the tip. 2. Indeterminate liver lesions although probably hemangiomas. When clinically appropriate evaluation with MR or less preferably multiphasic CT is recommended. These findings and recommendations were discussed between Dr. ___ Dr. ___ at 21:05 pm in person. ___: ___ drainage: Successful CT-guided placement of an ___ pigtail catheter into collection in right lower quadrant. Samples were sent for microbiology evaluation. Brief Hospital Course: ___ year old female admitted to the hospital with right lower quadrant abdominal pain and decreased appetite. Upon admission, the patient was made NPO, given intravenous fluids, and underwent cat scan imaging which showed a perforated appendix and a fluid collection at the tip consistent with abscess and visible hole at the tip. The patient was started on a course of ciprofloxacin and flagyl and underwent ___ placement of a drain into the collection. Approximately 5cc of purulent fluid was aspirated. The drain was left in place. The patient's vital signs remained stable and she was afebrile. She was tolerating a regular diet and voiding without difficulty. Her white blood cell count normalized. The patient was discharged on HD #2 with ___ services for assistance with the drain. The patient was instructed to complete a eight day course of ciprofloxacin and flagyl. A follow-up appointment was made in the acute care clinic. Discharge instructions were reviewed and questions answered. Medications on Admission: LOSARTAN-HYDROCHLOROTHIAZIDE - losartan 50 mg-hydrochlorothiazide 12.5 mg tablet. TAKE 1 TABLET BY MOUTH EVERY DAY ROSUVASTATIN - rosuvastatin 5 mg tablet. 1 tablet(s) by mouth once a day - (Not Taking as Prescribed: did not start) Medications - OTC COENZYME Q10 [CO Q-10] - Co Q-10 200 mg capsule. capsule(s) by mouth - (Prescribed by Other Provider) MANY, MANY HERBS AND SUPPLEMENTS - Many, many herbs and supplements . Per patient - (OTC) Events: Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 8 Days last dose ___ RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0 RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*17 Tablet Refills:*0 3. MetroNIDAZOLE 500 mg PO Q8H Duration: 8 Days last dose ___ RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth q8hr Disp #*30 Tablet Refills:*0 RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*25 Tablet Refills:*0 4. Hydrochlorothiazide 12.5 mg PO DAILY 5. Losartan Potassium 50 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: perforated appendicitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ and underwent drainage of an abscess. This had formed as a result of your perforated appendicitis. You are recovering well on oral antibiotics and are now ready for discharge. You are tolerating a regular diet and your pain is well controlled. Please follow the instructions below to continue your recovery: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips ___ days after surgery. General Drain Care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *If the drain is connected to a collection container, please note color, consistency, and amount of fluid in the drain. Call the doctor, ___, or ___ nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output, if instructed to do so. *Wash the area gently with warm, soapy water. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself in water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. Followup Instructions: ___
10158991-DS-14
10,158,991
23,796,890
DS
14
2131-09-21 00:00:00
2131-09-22 21:47:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Left arm and face paresthesiae Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year old left-handed retired ___ officer with hypertension, hyperlipidemia, and depression who presents with stuttering symptoms of word-finding difficulty, left-sided weakness, and left-sided numbness and tingling. His symptoms initially began yesterday morning, when he developed RIGHT sided numbness along his mouth and tongue with decreased sensation. Although he has had several symptoms like this in the past, with numbness/tingling, his episode yesterday persisted (whereas his prior episodes in the past reportedly self-resolve). Based on the increased duration of his episode, he presented to the ___ hospital (did not have time to clarify which ___ hospital) for further evaluation, where he was reportedly worked up for a stroke and discharged home after being told that he had "a small aneurysm" and would need "neurology follow-up." Since being sent home from the ___ yesterday, he reports feeling tired and was dizzy throughout most of the day today. He also endorses transient episodes of numbness and tingling, this time on the left side of his face and body. He was at home (or at his son's house?) and reported feeling just "very tired and weak and dizzy" so he lied down on the couch to take a nap. At around 18:15, his son noticed that he "did not look right" and woke up him, at which point he started repsonding in nonsensical speech. The patient himself thinks that he knew he wasn't making sense at the time (he could hear himself talk nonsense) but was unable to clarify his speech output. EMS was called and he was brought to ___, where code stroke was activated (NIHSS 5, given pt for left facial) after which he was transferred to ___ for further management. On arrival to ___, the patient and his family reports that his symptoms were already improving, noting that the patient is able to speak much more coherently. He still had residual tingling along his left side, which he notes "comes and goes" with transient sensory deficits ongoing for the past ___ years. On neuro ROS, the pt denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: Depression Hypertension Hyperlipidemia B12 deficiency Social History: Lives at home with his wife and son. Retired ___. No alcohol. ~40 pack year tobacco history, not currently a smoker. No illicit drug use. - Modified Rankin Scale: [] 0: No symptoms [x] 1: No significant disability - able to carry out all usual activities despite some symptoms [] 2: Slight disability: able to look after own affairs without assistance but unable to carry out all previous activities [] 3: Moderate disability: requires some help but able to walk unassisted [] 4: Moderately severe disability: unable to attend to own bodily needs without assistance and unable to walk unassisted [] 5: Severe disability: requires constant nursing care and attention, bedridden, incontinent [] 6: Dead Family History: no history of known brain aneurysm or seizure Physical Exam: ADMISSION EXAMINATION ===================== General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Normal work of breathing Cardiac: RRR, warm, well-perfused Abdomen: soft, non-distended Extremities: No ___ edema. Skin: scattered echymoses, petechia. Medial aspect of right upper arm with patch of raised erythematous papular lesion. Neurologic: -Mental Status: Alert, oriented x 3. Can only relate history with vague details, noting "sometimes I feel on/off numbness" without providing significant detail re: timing of episodes and duration of events, noting that "his wife doesn't know because [he] doesn't bother her with his symptoms." Attentive to conversation and course of events. Subtle deficits in repetition (Today is a sunny day = "Today is ___ day." Normal prosody. No paraphasic errors. Some difficulty with high frequency and low frequency objects (even when glasses were donned), naming "chair" as "ladder" and unable to name cactus, noting it as "that plant in the dessert with the thorns." Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia. No clear neglect, although patient kept attributing left sided weakness to pain. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation and finger counting. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. -Motor: Normal bulk, tone throughout. Left sided pronator drift. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FE IP Quad Ham TA ___ ___ L 4* 4+ ___ 3* 4* 3* 4* 3* 3* R 5 ___ 5 5 5 5 5 5 5 *Limited by pain with effort secondary to "muscle cramping" -Sensory: Decreased sensation to light touch, pinprick, cold on left half of face and entire left side of body. (Becomes decreased approximately ___ over left eyebrow, so does not split midline). No extinction to DSS. DTRs: ___ response was flexor bilaterally. -Coordination: No intention tremor. No dysmetria on FNF or HKS bilaterally. -Gait: Deferred DISCHARGE EXAMINATION ===================== Vitals: T: 97.8 HR: 59 [59-74] BP: 131/77 [119-174/57-97] RR: 11 SpO2: 95% RA General: awake, cooperative, NAD HEENT: NC/AT, no scleral icterus noted, MMM Pulmonary: breathing comfortably, no tachypnea or increased WOB Cardiac: skin warm, well-perfused Abdomen: soft, ND Extremities: symmetric, no edema Neurologic: -Mental Status: Alert, oriented x 3. Language is fluent with intact repetition and comprehension. Naming intact to high and low frequency objects. Able to follow both midline and appendicular commands. -Cranial Nerves: PERRL. EOMI without nystagmus. Facial sensation intact to light touch. Face symmetric with activation. Hearing intact to conversation. Palate elevates symmetrically. Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE IP L 4+ 5- 4+ 4+ 4+ R 5 ___ 5 -Sensory: Intact to PP throughout. No extinction to DSS. -DTRs: ___. -Coordination: No dysmetria on FNF bilaterally. Pertinent Results: ___ 06:10AM BLOOD WBC-5.1 RBC-4.27* Hgb-14.1 Hct-40.3 MCV-94 MCH-33.0* MCHC-35.0 RDW-12.3 RDWSD-42.5 Plt ___ ___ 06:10AM BLOOD Neuts-56.0 ___ Monos-9.6 Eos-3.1 Baso-0.6 Im ___ AbsNeut-2.84 AbsLymp-1.54 AbsMono-0.49 AbsEos-0.16 AbsBaso-0.03 ___ 06:10AM BLOOD ___ PTT-30.1 ___ ___ 09:00AM BLOOD Glucose-132* UreaN-15 Creat-0.7 Na-142 K-4.7 Cl-104 HCO3-25 AnGap-13 ___ 06:10AM BLOOD ALT-20 AST-16 CK(CPK)-51 AlkPhos-68 TotBili-0.6 ___ 09:00AM BLOOD Calcium-9.1 ___ 06:10AM BLOOD %HbA1c-5.6 eAG-114 ___ 06:10AM BLOOD Triglyc-58 HDL-42 CHOL/HD-3.0 LDLcalc-71 ___ 06:10AM BLOOD TSH-1.5 ___ 09:00AM BLOOD CRP-0.5 ESR-5 ___ 09:26PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 11:15PM URINE Color-Straw Appear-Clear Sp ___ ___ 11:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG ___ 11:15PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG ___ 11:15 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: < 10,000 CFU/mL. ___ 5:42 AM MR HEAD W/O CONTRAST 1. No acute infarction. 2. Minimal T2 signal abnormalities in the supratentorial white matter are nonspecific but likely sequela of mild chronic small vessel ischemic disease in this age group. Portable TTE (Complete) Done ___ at 9:36:00 AM Mild symmetric left ventricular hypertrophy with preserved regional and global systolic function. No valvular pathology or pathologic flow identified. Increased PCWP. Brief Hospital Course: ___ left-handed man with history notable for HTN, hyperlipidemia, and depression presenting with an episode of fluent aphasia as well as ongoing "tingling" paresthesiae on his right face and left side of his body. Further clarification of history revealed that sensory symptoms had been intermittently present over the last few years, though speech disturbance was new during this presentation. Imaging with CT and MRI did not reveal ischemia, hemorrhage, or mass as the cause of Mr. ___ symptoms. Suspicion was therefore raised for a transient ischemic attack, so treatment was continued with once-daily 81 mg aspirin and continuation of statin therapy. Cardiac monitoring for atrial fibrillation was also recommended, and as Mr. ___ reported undergoing ___ monitoring in the past, an implanted loop recorder may be considered for outpatient monitoring. Mr. ___ was advised that he should have this monitoring done by his ___ PCP/cardiologist. TRANSITIONAL ISSUES [ ] Outpatient cardiac monitoring for atrial fibrillation as discussed above. [ ] Continue on aspirin and atorvastatin for stroke prevention. Medications on Admission: 1. amLODIPine 5 mg PO DAILY 2. Lisinopril 40 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. TraZODone 50 mg PO QHS:PRN insomnia 5. Atorvastatin 40 mg PO QPM 6. FLUoxetine Dose is Unknown PO DAILY Discharge Medications: 1. FLUoxetine N/A mg PO DAILY 2. amLODIPine 5 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Lisinopril 40 mg PO DAILY 6. TraZODone 50 mg PO QHS:PRN insomnia Discharge Disposition: Home Discharge Diagnosis: Transient ischemic attack Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to ___ due to an episode of difficulty speaking. Brain imaging with a CT scan and MRI did not show evidence of a stroke, hemorrhage, or mass cuasing your symptoms. Other causes of your symptoms were also investigated including blood glucose, heart problems, and kidney and liver function which were found to be normal as well. It is possible that your symptoms were due to a brief blockage of blood flow to your brain (a transient ischemic attack or TIA), for which you will need to undergo heart rhythm monitoring after leaving the hospital to look for an abnormal heart rhythm (atrial fibrillation) that could predispose you to strokes or TIAs. Your ___ PCP ___ cardiologist may be able to arrange for this monitoring. Please follow up with your primary care provider ___ ___ weeks of discharge. Please also follow up with your cardiologist and with a neurologist in the next ___ months. It was a pleasure taking care of you at ___. Sincerely, Neurology at ___ Followup Instructions: ___
10159772-DS-14
10,159,772
22,350,855
DS
14
2136-12-07 00:00:00
2137-01-01 11:06:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fall at home Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a ___ pt w/ hx of hemorhagic stroke residual R sided paralysis/parasthesias at baseline s/p mechanical fall from wall 4 ft on ___, per pt landed on head, no LOC. pain over L face/head. Reports pain over L side of face and over R hip, hip pain persisting x 3 wks. Denies neck pain. Baseline parasthesias/immobility. Past Medical History: Hemorrhagic Stroke ___ - residual mild motor aphasia, right sided sensory deficits and left sided weakness (per patient report) Depression Hyperlipidemia Social History: ___ Family History: No history of SCD, early MI. Father had MI in ___. Physical Exam: PE: T 98.9 P61, BP 96/51 R16 98% RA Gen- A&Ox3, NAD, pleasant HEENT- healing laceration in the lateral aspect of the L eyebrow. Resolving L superior eyelid ecchymosis. Resp - CTAB CV - RRR no MRG Neuro - MAES, sensation preserved throughout Ext - no edema Pertinent Results: Admission labs ___ 01:45PM BLOOD WBC-14.0*# RBC-4.22 Hgb-13.0 Hct-39.7 MCV-94# MCH-30.8 MCHC-32.7 RDW-13.4 Plt Ct-29 Discharge labs ___ WBC-7.5 RBC-3.65* Hgb-10.9* Hct-34.5* MCV-94 MCH-29.9 MCHC-31.7 RDW-13.5 Plt ___ Glucose-94 UreaN-15 Creat-0.7 Na-140 K-4.1 Cl-104 HCO3-30 AnGap-10 Brief Hospital Course: Patient was evaluated by ___ and admitted for observation and pain management. Plastic was consulted for multiple facial fractures including L lateral orbital fracture, L orbital floor fracture, and anterior/lateral wall L maxillary sinus fractures. The fractures were deemed nondisplaced and non-operative. She remained afebrile, pain well controlled, hemodynamically and neurologically stable during the hospitalization. She was discharged on HD#3 on a soft diet and sinus precaution with plastic follow up as outpatient. Medications on Admission: ASA 81, Dexedrine XR, omeprazole, citalopram, clonazepam Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN pain do no take more than 3000mg in a 24 hour period RX *acetaminophen 500 mg 1 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*0 2. Aspirin 81 mg PO DAILY 3. Citalopram 20 mg PO DAILY 4. Atorvastatin 40 mg PO DAILY 5. ClonazePAM 0.5 mg PO Q6H:PRN anxiety 6. Docusate Sodium 100 mg PO BID hold for diarrhea RX *docusate sodium 100 mg 1 capsule(s) by mouth once a day Disp #*20 Capsule Refills:*0 7. LaMOTrigine 100 mg PO DAILY 8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain Do not drive while taking RX *oxycodone 10 mg 1 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*0 9. Zolpidem Tartrate 10 mg PO HS Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: L lateral orbital fracture, L orbital floor fracture, and anterior/lateral wall L maxillary sinus fractures Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General Surgery: Sinus precautions: no nose blowing, open mouth sneezing, no straws, nosmoking. Until follow up. Maintain a soft diet for 6 weeks. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *If you are vomiting and cannot keep down fluids or your medications. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights Avoid driving or operating heavy machinery while taking pain medications. Followup Instructions: ___
10159832-DS-13
10,159,832
28,812,774
DS
13
2118-06-12 00:00:00
2118-06-13 09:41:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Tetracyclines Attending: ___. Chief Complaint: Fever, foamy urine Major Surgical or Invasive Procedure: Ultrasound guidance for percutaneous left kidney biopsy ___ History of Present Illness: Ms. ___ is a ___ female with history of high risk MDS ___ and +WT-1 mutatation) ___ myeloablative MUD allo HSCT on ___ c/b GVHD of skin/eyes currently in CR who presents with fever. She reports low-grade fevers to 100.3. She was feeling very emotional this morning so took her temperature. She denies any chills. No localizing symptoms. She was also recently found to have nephrotic range proteinuria and scheduled for initial nephrology evaluation on ___. She continues to have foamy urine. She notes some back discomfort after eating. Reports dry mouth with metallic taste. On arrival to the ED, initial vitals were 98.3 93 120/78 18 100% RA. Exam was notable for non-tender abdomen and no CVA tenderness. Labs were notable for WBC 10.7, H/H 12.7/37.3, Plt 355, Na 142, K 4.1, BUN/Cr ___, LFTs wnl, lactate 0.7, and UA negative. Blood and urine cultures were sent. CXR was negative for pneumonia. No medications given. ___ was consulted and recommended holing antibiotics unless febrile and admission for expedited work-up of nephrotic syndrome. Prior to transfer vitals were 98.4 86 114/62 16 98% RA. On arrival to the floor, patient reports feeling well. No acute issues or concerns. She denies chills, headache, vision changes, dizziness/lightheadedness, weakness/numbness, shortness of breath, cough, hemoptysis, chest pain, palpitations, abdominal pain, nausea/vomiting, diarrhea, hematemesis, hematochezia/melena, dysuria, hematuria, and new rashes. REVIEW OF SYSTEMS: A complete 10-point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History: MDS ___ - she was hospitalized for this at age ___ and ___, sees counselor ___ in ___ Hx herniated disc PAST ONCOLOGIC HISTORY: "Presented with gradually worsening anemia, BM biopsy c/w MDS, found to have 3;5 and WT1 mutation. Received 2 cycles decitabine (5 days), last ending ___ Social History: ___ Family History: She is adopted, she is not aware of any siblings and is not aware of her biological parents health. Physical Exam: ADMISSION PHYSICAL EXAM ========================== VS: Temp 98.5, BP 108/60, HR 87, RR 18, O2 sat 96% RA. GENERAL: Pleasant woman, in no distress, lying in bed comfortably. HEENT: Anicteric, PERLL, OP clear. CARDIAC: RRR, normal s1/s2, no m/r/g. LUNG: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi. ABD: Soft, non-tender, non-distended, positive bowel sounds. EXT: Warm, well perfused, trace lower extremity edema. NEURO: A&Ox3, good attention and linear thought, CN II-XII intact. Strength full throughout. Sensation to light touch intact. Able to state ___ backwards. DISCHARGE PHYSICAL EXAM ======================== ___ 0716 Temp: 97.9 PO BP: 107/71 HR: 76 RR: 18 O2 sat: 97% O2 delivery: RA GENERAL: no acute distress, pleasant and conversant HEENT: Anicteric, conjunctival erythema bilaterally, PERLL, oropharynx clear. CARDIAC: regular rate and rhythm, no RMG LUNG: CTABL, no wheezes rales or ronchi ABD: soft, nontender, nondistended, bowel sounds present EXT: Warm, well perfused, trace lower extremity edema. NEURO: A&Ox3, gait normal, ___ motor strength upper and lower extremities, sesnsation to light touch intact. Pertinent Results: ADMISSION LABS =============== ___ 03:48PM BLOOD WBC-10.7* RBC-4.05 Hgb-12.7 Hct-37.3 MCV-92 MCH-31.4 MCHC-34.0 RDW-13.5 RDWSD-45.8 Plt ___ ___ 03:48PM BLOOD Neuts-42.4 ___ Monos-12.0 Eos-5.0 Baso-0.8 Im ___ AbsNeut-4.53 AbsLymp-4.22* AbsMono-1.28* AbsEos-0.54 AbsBaso-0.09* ___ 03:48PM BLOOD Plt ___ ___ 03:48PM BLOOD Glucose-95 UreaN-11 Creat-0.5 Na-142 K-4.1 Cl-103 HCO3-27 AnGap-12 ___ 03:48PM BLOOD ALT-21 AST-26 AlkPhos-71 TotBili-0.5 ___ 03:48PM BLOOD Albumin-2.9* Cholest-224* ___ 03:48PM BLOOD Triglyc-339* HDL-31* CHOL/HD-7.2 LDLcalc-125 ___ 04:00PM BLOOD Lactate-0.7 INTERVAL LABS ============== ___ 10:15AM BLOOD ANCA-NEGATIVE B ___ 10:15AM BLOOD ___ ___ 01:25PM BLOOD IgG-1296 ___ 03:30PM BLOOD C3-150 C4-25 ___ 10:15AM BLOOD CMV VL-NOT DETECT DISCHARGE LABS ================= ___ 06:30AM BLOOD WBC-9.6 RBC-3.83* Hgb-11.9 ___ MCV-92 MCH-31.1 MCHC-33.9 RDW-13.5 RDWSD-45.3 Plt ___ ___ 06:30AM BLOOD Neuts-38.3 ___ Monos-12.3 Eos-5.9 Baso-0.7 Im ___ AbsNeut-3.66 AbsLymp-4.06* AbsMono-1.18* AbsEos-0.56* AbsBaso-0.07 ___ 06:30AM BLOOD Plt ___ ___ 06:30AM BLOOD ___ PTT-27.9 ___ ___ 06:30AM BLOOD ___ ___ 06:30AM BLOOD Glucose-97 UreaN-8 Creat-0.5 Na-143 K-4.5 Cl-108 HCO3-24 AnGap-11 ___ 06:30AM BLOOD ALT-17 AST-21 LD(LDH)-202 AlkPhos-65 TotBili-0.4 ___ 06:30AM BLOOD Calcium-8.2* Phos-4.6* Mg-2.1 Brief Hospital Course: Ms. ___ is a ___ female with history of high risk MDS ___ and +WT-1 mutatation) ___ myeloablative MUD allo HSCT on ___ c/b GVHD of eyes currently in CR who presents with fever and proteinuria consistent with nephrotic syndrome. Problems addressed during her hospitalization are as follows: #Nephrotic syndrome: Proteinuria and foamy urine first noted in outpatient setting. Also had preceding swelling in hands and feet. Presentation consistent with nephrotic syndrome (nephrotic range proteinuria, hand/foot edema, hypoalbuminemia, hyperlipidemia). Workup notable for normal IgG, C3, C4, negative ___, ANCA, anti-GBM. EBV, CMV, PLA2R pending. Differential includes membranous nephropathy, GVHD membranous, amyloid. Less likely etiologies include infectious, autoimmune, FSGS, minimal change disease. Renal biopsy performed ___, pathology pending at time of discharge. Did not start ___ in setting of soft BPs throughout admission (SBP 90-low 100s). #Fever: Reported low-grade fever at home measured with oral thermometer x1 (100.3). Remained afebrile throughout admission, lactate normal, no leukocytosis, CXR and UA unremarkable. No localizing symptoms to suggest infection. Did not administer antibiotics. #High Risk MDS ___ MUD allo HSCT: Complicated by GVHD of skin/eyes. Continued home restasis eye drops. #Anxiety: continued home ativan #Asthma: continued home albuterol PRN TRANSITIONAL ISSUES: ====================== [] f/u renal biopsy pathology [] consider ___ initiation if BP tolerates CODE: Full Code (confirmed) EMERGENCY CONTACT HCP: ___ (husband) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath/wheezing 2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 3. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN congestion 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID:PRN shortness of breath 5. LORazepam 1 mg PO Q8H:PRN anxiety 6. Montelukast 10 mg PO DAILY:PRN shortness of breath 7. Multivitamins 1 TAB PO DAILY 8. Nystatin Oral Suspension 5 mL PO QID:PRN thrush 9. Polyethylene Glycol 17 g PO DAILY:PRN constipation 10. Senna 8.6 mg PO BID:PRN constipation 11. Vitamin D 1000 UNIT PO DAILY 12. Sarna Lotion 1 Appl TP QID:PRN itching 13. TraZODone 50 mg PO QHS:PRN insomnia 14. Restasis 0.05 % ophthalmic (eye) BID Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath/wheezing 2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 3. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN congestion 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID:PRN shortness of breath 5. LORazepam 1 mg PO Q8H:PRN anxiety 6. Montelukast 10 mg PO DAILY:PRN shortness of breath 7. Multivitamins 1 TAB PO DAILY 8. Nystatin Oral Suspension 5 mL PO QID:PRN thrush 9. Polyethylene Glycol 17 g PO DAILY:PRN constipation 10. Restasis 0.05 % ophthalmic (eye) BID 11. Sarna Lotion 1 Appl TP QID:PRN itching 12. Senna 8.6 mg PO BID:PRN constipation 13. TraZODone 50 mg PO QHS:PRN insomnia 14. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: nephrotic syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure to care for you at the ___ ___. You came to the hospital because you developed fevers at home. You also had protein in your urine noted at previous doctor visits. We evaluated you in the hospital and found that you did not have an infection. You also did not have any fevers during your hospital course. We took a sample, or "biopsy", of your kidney tissue to determine why you have protein in your urine. The results from this biopsy are pending. You will review them at you next scheduled appointment with your kidney doctor ("nephrologist"). Please continue to take all of your medications as prescribed and continue seeing your doctors as ___. We wish you all the best, Your ___ care team Followup Instructions: ___
10160202-DS-5
10,160,202
27,812,768
DS
5
2153-10-17 00:00:00
2153-10-17 20:05:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old male with history of hypertension, hyperlipidemia, diabetes mellitus type 2, and peripheral vascular disease who presents from his PCP's office with hypoxia. At Dr. ___ ___, the patient was noted to be hypoxic to 90% on room air and then 77% with ambulation. This was a routine appointment and patient denied any symptoms although may be a poor historian given advanced Alzheimer's disease. Pt's wife corroborates this history and notes that pt was establishing care w/ Dr. ___ ___ not had a PCP in recent years, though is followed by a cardiologist, rheumatologist and neurologist for his various medical conditions. Of note, the patient was seen recently (___) working with physical therapy and noted to be hypertensive (184/92) and desaturating to 88% at rest. His blood pressures and O2 saturations improved to SBP162, O2 sat 92-93% with some functional mobility exercises. His wife notes this was the first time he had worked w/ ___. The patient's amlodipine was restarted (stopped in ___ for low blood pressures), and simvastatin 80mg switched to lipitor to prevent drug interaction in discussions with his cardiologist, Dr. ___. In the ED, initial vs were: T97.6 P65 BP81/56 R20 O2 sat 100% 2L NC. CXR initally demonstrated left basilar pneumonia and the patient received Ceftriaxone 1 grams X1, Azithromycin 500mg IV. Final read of the CXR was negative for pneumonia. Chem 7 was normal (aside from blood sugar 215), CBC stable (Hct 34.8, baseline) and blood cultures were drawn. On transfer, vitals were: T98.3, HR61, RR19, BP140/68, O2 sat 100%2L. On the floor patient appears comfortable sat-ing in the mid ___ on room air and denies any h/o cough, SOB, or discomfort. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: 1. Hypertension. 2. Hyperlipidemia. 3. Diabetes. 4. Obesity. 5. Ongoing tobacco abuse. 6. History of hyponatremia. 7. Cardiovascular disease, stable. 8. Peripheral vascular disease, right renal artery stenosis with preserved renal function and controlled hypertension. 9. Peripheral vascular disease of lower extremities, moderate to severe. 10. Aortic stenosis, normal EF (reportedly) 11. Gout Social History: ___ Family History: Denies early coronary artery disease or stroke. Physical Exam: Admission exam: Vitals: T: 98.2 BP: 149/80 P: 80 R: 18 O2: 94-96% on RA at rest, 79% on RA with ambulation General: pleasant elderly man, alert, oriented to self, lying comfortably in bed, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: diminished BS throughout, but CTAB w/o wheezes, rales, ronchi CV: II/VI crescendo-decrescendo murmur loudest at RUSB, RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Discharge exam - unchanged from above Pertinent Results: Admission labs: ___ 06:10PM BLOOD WBC-5.4 RBC-4.00* Hgb-11.7* Hct-34.8* MCV-87 MCH-29.3 MCHC-33.6 RDW-14.5 Plt ___ ___ 06:10PM BLOOD Neuts-73.5* Lymphs-17.9* Monos-3.7 Eos-4.3* Baso-0.6 ___ 06:10PM BLOOD Glucose-215* UreaN-24* Creat-1.0 Na-134 K-4.8 Cl-95* HCO3-24 AnGap-20 ___ 06:10PM BLOOD proBNP-1221* Discharge labs: ___ 08:50AM BLOOD WBC-4.2 RBC-3.98* Hgb-11.3* Hct-34.7* MCV-87 MCH-28.4 MCHC-32.6 RDW-15.0 Plt ___ ___ 08:50AM BLOOD Glucose-229* UreaN-20 Creat-0.9 Na-136 K-4.3 Cl-98 HCO3-26 AnGap-16 Imaging: -CXR (___): No acute intrathoracic process. Brief Hospital Course: ___ with HTN, HLD, T2DM, PVD, RAS and Alzheimer's presenting w/ hypoxia. #Hypoxia: Patient reports stable dyspnea on exertion over many years with no recent changes. There are no prior O2 sats in recent records and no way to evaluate whether this hypoxia is new. Most likely cause would be COPD given his significant smoking history and DOE. He does not have any symptoms of heart failure and no clinical signs of heart failure on exam. BNP slightly elevated but CXR unremarkable for edema. PE was also considered but seemed unlikely given his clinical picture and further diagnostic testing was not pursued. Given his likely COPD, he was started on spiriva and albuterol inhalers. His ambulatory sat was 79% on room air with ambulation and we offered to arrange for him to have home oxygen therapy. This was discussed with the patient and his wife, including risks of untreated hypoxia (worsening lung disease, worsening cardiac disease, pulmonary hypertension and potentially death) and they refused home O2. We strongly encouraged smoking cessation and the patient's wife stated she will stop bringing him cigarettes, he was started on nicotine patches at discharge. He will need PFTs as an outpatient to further evaluate his presumed COPD. --Inactive issues-- #HTN: BP remained fairly well controlled with slight hypertension, SBPs mostly in the 140-150s. He was continued on his home amlodipine, lisinopril, metoprolol and Lasix. #Aortic stenosis: Appeared euvolemic this admission. He has no recent TTEs in our system, valve area and EF are not known. He was continued on the above medications to control his BP. #Diabetes mellitus: No recent A1c in our records. His home metformin and glyburide were held this admission which will be restarted at discharge. He was covered with an insulin sliding scale as an inpatient. #Alzheimer's dementia: He appeared to be at his baseline per his wife who was present with him, which is A&Ox1 (name only) and pleasant but confused. He was continued on his home memantine and donepezil. #Hyperlipidemia: Continued on home atorvastatin #Code status this admission: FULL #Transitional issues: -Started on 7mg nicotine patches since his wife is going to stop bringing him cigarettes, will need to be stopped as an outpatient -Will need PFTs as anoutpatient to assess his presumed COPD -Started on albuterol PRN and Spiriva for his presumed COPD -Would qualify for home O2 given ambulatory O2 sat of 79% on room air, but patient and his wife did not feel comfortable with this and refused home O2. Would continue to discuss this as an option after discharge, they are aware of risks of not using home O2. Medications on Admission: * Amlodipine 2.5mg daily * Atorvastatin 40mg daily * Calcitriol 0.25mcg every other day * Donepezil 10mg qHS * Dutasteride 0.5mg ___ * Furosemide 20mg twice daily * Glyburide-metformin ___ twice daily * Lisinopril 40mg daily * Memantine 10mg twice daily * Metoprolol succinate 200mg daily * Omeprazole 40mg daily * Aspirin 81mg daily * B complex vitamins daily * Ferrous sulfate 325mg twice daily Discharge Medications: 1. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 3. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY OTHER DAY (Every Other Day). 4. donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. dutasteride 0.5 mg Capsule Sig: One (1) Capsule PO ___ and ___. 6. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. glyburide-metformin ___ mg Tablet Sig: One (1) Tablet PO twice a day. 8. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 9. memantine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily). 11. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. Vitamin B Complex Tablet Sig: One (1) Tablet PO once a day. 14. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:*1 inhaler* Refills:*0* 16. inhalational spacing device Spacer Sig: One (1) spacer Miscellaneous once a day: Use with albuterol inhaler. Disp:*1 spacer* Refills:*0* 17. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) capsule Inhalation once a day. Disp:*30 capsules* Refills:*0* 18. nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) patch Transdermal once a day for 10 days. Disp:*10 patches* Refills:*0* Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnoses: Presumed COPD Secondary diagnoses: Type 2 diabetes Dementia Aortic stenosis Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you during your admission to ___ for low oxygen saturation. Given your extensive smoking history, you likely have COPD, also called emphysema. You will need further testing as an outpatient. We have started you on two different inhalers. Take the Spiriva every day and the albuterol only when you feel short of breath or have wheezing. Your oxygen level is dangerously low when you walk and we offered you home oxygen, which you refused. You will follow-up with your PCP. It is EXTREMELY importent for you to stop smoking. We have given you a nictoine patch to help reduce your cravings for cigarettes. Replace the patch with a new one each day, discuss with your PCP how long you should continue the patches. The following changes were made to your medications: START Spiriva (tiotropium) 1 capsule inhaled daily START albuterol 2 puffs every 4 hours as needed for shortness of breath or wheezing START nicotine patch 7mg 1 patch daily Followup Instructions: ___
10160202-DS-6
10,160,202
24,455,932
DS
6
2154-11-14 00:00:00
2154-11-14 22:38:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: weakness, fever Major Surgical or Invasive Procedure: None History of Present Illness: ___ M with a history of Alzheimer's dementia, DM II, HLD/HTN, and AS who presented to the ED due to inability to ambulate. Per patient's wife, he was in usual state of health until the day of presentation ___, in fact was seen by his PCP the day prior and was doing well. Patient was able to ambulate in the morning of ___. He took a nap in the early afternoon, and upon awakening from his nap by his wife, he was able to sit and stand up, but immediately sat down saying he was weak. His wife took him to the ED because of concern of weakness. Of note, he was able to move all limbs normally. He did have poor po intake the past couple days. At baseline, per wife, the patient does not walk more than a few steps at a time. He requires assistance with all adls. He is frequently lethargic, napping most of the day. He is incontinent and wears diapers. He is able to eat with assistance and has had an episode of choking in the distant past. On arrival to the ED, his vital signs were 98.5 75 125/68 20 100% 4L NC. Labs were notable for WBC 3, Hct 33.7, normal lactate and a bland urine. A CXR was unremarkable for an acute process. He was kept overnight for ___ evaluation and possible rehab placement. At 0800 on ___ he spiked a fever to 102.8. CXR was repeated an unchanged but given history of Alzheimer's dementia, patient was empirically treated for an aspiration pneumonia, initially with vancomycin, ceftriaxone and azithromycin, later given one dose of piperacillin-tazobactam. He received a total of 2L IVF and was admitted for further monitoring. On the floor, initial vitals were: 97.6 91/57 70 18 94%RA. He was lethargic in bed with wife at bedside who provided the above history. Review of Systems: (+) per HPI (-) chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: 1. Hypertension. 2. Hyperlipidemia. 3. Diabetes. 4. Obesity. 5. Ongoing tobacco abuse. 6. History of hyponatremia. 7. Cardiovascular disease, stable. 8. Peripheral vascular disease, right renal artery stenosis with preserved renal function and controlled hypertension. 9. Peripheral vascular disease of lower extremities, moderate to severe. 10. Aortic stenosis, normal EF (reportedly) 11. Gout Social History: ___ Family History: Denies early coronary artery disease or stroke. Physical Exam: Admission Physical Exam: Vitals- 97.6 91/57 70 18 94%RA General: Elderly man, asleep in bed, arousable to sternal rub or loud voice, but quickly falls back asleep. Answers simple questions with one work answers. NAD. HEENT: Patient opens eyes, but not long enough to examine pupillary constriction. He does close eye if I try to open lids. No facial droop. Tongue without fasiculations. Poor dentition with multiple likely cavities, no clear infection. Neck: Unable to assess. CV: RRR, ___ crescendo-decrescendo murmur heard best at RUSB, radiating to carotids Lungs: clear on anterior auscultation Abdomen: Soft, NTND, +BS Ext: warm, well perfused, no edema Neuro: Unable to assess given mental status. His is moving all four limbs symmetrically. Discharge Physical Exam: VS: 93%RA 60-70 90/50-110/60 General: AOx1, confused but able to answer simple questions, pleasant and follows directions HEENT: no JVD CV: regular rate, ___ systolic murmur heard best at LUSB radiating to carotids Lungs: CTAB, no w/r/r Abd: S/NT/ND, normal BS Ext: no edema GU: Foley in place draining yellow urine Pertinent Results: ADMISSION LABS: ___ 08:05PM BLOOD WBC-3.0* RBC-3.94* Hgb-11.4* Hct-33.7* MCV-86 MCH-28.9 MCHC-33.8 RDW-15.0 Plt ___ ___ 08:05PM BLOOD Neuts-77.7* Lymphs-14.7* Monos-6.4 Eos-0.8 Baso-0.5 ___ 08:05PM BLOOD Plt ___ ___ 03:29PM BLOOD UreaN-30* Creat-1.3* Na-137 K-5.0 Cl-98 ___ 08:13PM BLOOD Lactate-1.3 DISCHARGE LABS: ___ 10:45AM BLOOD WBC-8.1 RBC-2.74* Hgb-7.8* Hct-24.9* MCV-91 MCH-28.4 MCHC-31.3 RDW-16.0* Plt ___ ___ 10:45AM BLOOD ___ PTT-32.0 ___ ___ 09:30AM BLOOD Glucose-137* UreaN-62* Creat-1.8* Na-142 K-4.7 Cl-102 HCO3-26 AnGap-19 ___ 09:30AM BLOOD Calcium-8.9 Phos-4.3 Mg-2.5 ============================ URINE: ___ 09:48PM URINE Color-Straw Appear-Clear Sp ___ ___ 09:48PM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG ___ 09:48PM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 ============================ MICROBIOLOGY BLOOD CULTURE ___, Urine culture ___, Cdiff negative ___ ============================ IMAGING: CXR: ___: AP and lateral views of the chest are compared to previous exam from ___. Again seen is elevation of the left hemidiaphragm with eventration posteriorly as previously seen. Streaky right basilar opacity suggestive of atelectasis versus scarring. Elsewhere, the lungs are clear. The cardiomediastinal silhouette is unchanged. Extensive degenerative and potentially post-traumatic changes seen at the left humerus. IMPRESSION: No definite acute cardiopulmonary process. CT chest w/o contrast ___: 1. There is no explanation for the widening of the mediastinum. There is no dilation of the aorta. 2. Small bilateral pleural effusions. 3. Left lower lobe opacification is mainly due to atelectasis, which is relatively unchanged since the chest ___ superimposed infection or aspiration can be considered in appropriate clinical settings. 4. Stigmata of chronic calcified pancreatitis. 5. Severe aortic valve and coronary artery calcification. Brief Hospital Course: ___ with a history of Alzheimer's dementia, DM II, HLD/HTN, and AS who presented to the ED on ___ because of inability to ambulate. In the ED, was found to be febrile to 102.8 without localizing source. ACTIVE ISSUES: =============== #A Fib: On the morning of ___ patient he was noted to have worsening hypoxia with atrial fibrillation and rapid ventricular response. He was given IV lasix 40 mg x 1 without any effect. At this time patient was transfered to the CCU and intubated. Patient was cardioverted on ___ and ___ unsuccessfully with brief periods of spontaneous conversion. IV Heparin was started at this time. Patient was maintained on pressors and amiodarone drips to maintain SBP. Pt went back into sinus rhythm on ___ and was weaned off of pressors. On the floor, patient remained in sinus on amiodarone. He is to continue 400mg amiodarone BID until ___ then 400mg daily for one week then 200mg daily as his maintenance dose. Continued metoprolol at half-dose. Patient was started on coumadin for anticoagulation and was therapeutic at discharge. #Hypoxic respiratory Failure:On the morning of the ___ patient became hypoxic ___ pulmonary edema. He was intubated in the CCU and diuresed successfully. When he left the CCU, he had been extubated and was satting well on room air. Remained on room air at discharge. # Fever: He initially presented with weakness and inability to ambulate thought ___ lethargy and ?back pain. Fever to 102.8F with leukopenia concerning for infectious etiology. Sources include: pulmonary (unlikely bc CXR negative), urinary (unlikely bc UA negative), GI, CNS, endocarditis (given poor denition), osteomyelitis/abscess (high likelihood because of back pain and poor dentition), malignancy (less likely given extreme of fever). Blood cultures and urine cultures taken. Was given antibiotics in ED ___ (vancomycin, ceftriaxone and azithromycin, piperacillin-tazobactam). However, in setting of poorly localized infection, abx were discontinued upon admission to floor on ___. He spiked a fever to 100.9 on ___, given long history of AMS/lethargy, an aspiration event was thought to be most likely, and piperacillin tazobactam was restarted. Antibiotics were stopped on ___ given final read of CT which was less suggestive of infection and given clinical improvement. All cultures were negative at discharge and he remained afebrile. # Hypotension: On ___ he was triggered for hypotension with SBP in the ___. His antihypertensives were discontinued and his pressure responded to IVF resuscitation. Overnight on ___ however he was triggered for increased O2 requirement s/p 3.4 L of IVF. Fluids were discontinued and furosemide was given. Later on ___ he became tachycardic to the 160s (atrial fibrillation) and SBP in the 70-80s. 12 lead EKG revealed atrial fibrillation with RVR. 10 mg IV metoprolol was pushed on the floor but failed to slow his rate. With his history of aortic stenosis of unknown severity (no TTEs in our system), and his increasingly tenuous pressures, the patient was transferred to the CCU for further care on ___. Phenylephrine was titrated to support BP. He was weaned from pressors by the time of discharge from the CCU on ___. After arrival on the floor on ___ he had an episode of atrial fibrillation with RVR and a HR of 140. He SBP dropped to the mid ___ and he received a 200 cc bolus with 10 mg IV metoprolol. He spontaneously converted and had no further episodes. #Hematuria: Pt had hematuria with blood clots during stay, thought to be due to anticoagulation and traumatic foley insertion. Resolved with continuous bladder irrigation. Per urology, patient should have Foley in place until ___ and bladder should be backfilled prior to voiding trial and removal. #Delirium/dementia: Patient is AOx1 at baseline. Pt became agitated, requiring Haldol and restraints in the CCU. Patient has been stable and redirectable since resuming quetiapine, which he had been taking at home. Continued donepizil Has poor nutritional intake but per family, feeding tube is not within goals of care. # ___ on CKD: Cr 1.2 on admission trended up to 1.8 on ___, likely due to hypotension. Remained stable for several days so likely new baseline. Held ACE due to new ___ and ___ pressures were fine off this medication. CHRONIC ISSUES: =============== #Diabetes mellitus 2: Poorly controlled at first. Improved on lantus and humalog sliding scale. Metformin and glyburide were discontinued due to ___. #COPD: Stable, continued spiriva and ipratropium prn. Avoided albuterol given issues with atrial fibrillation. # BPH: Incontinent at baseline, uses diapers. Tamsulosin was held but this can be restarted. # Hyperlipidemia: Stable. Continued atorvastatin. TRANSITIONAL ISSUES: -Code Status: Full, but should continue to address this in future as wife had difficulty making decision. -___ (wife) ___ ___ (daughter) ___ -Patient was started on amiodarone for rhythm control and coumadin for anticoagulation and will need to be titrated as above -Patient will need a voiding trial on ___ -Patient had increased creatinine at discharge which could be a new baseline so ACE was held. Consider restarting if hypertensive -Metformin and glyburide was discontinued due to ___ and ___ was started on insulin for improved blood sugar control. Consider restarting these medications if creatinine improves Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Donepezil 10 mg PO HS 2. Aspirin 81 mg PO DAILY 3. Metoprolol Succinate XL 200 mg PO DAILY hold for SBP<100, HR<60 4. Memantine 10 mg PO BID 5. Atorvastatin 40 mg PO DAILY 6. Furosemide 20 mg PO DAILY 7. Lisinopril 20 mg PO DAILY hold for SBP<100 8. glyBURIDE-metformin *NF* ___ mg Oral BID 9. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOb 10. Tiotropium Bromide 1 CAP IH DAILY 11. QUEtiapine Fumarate 12.5 mg PO HS:PRN insomnia 12. Tamsulosin 0.4 mg PO HS Discharge Medications: 1. Atorvastatin 20 mg PO DAILY 2. Donepezil 10 mg PO HS 3. Memantine 10 mg PO BID 4. Metoprolol Succinate XL 100 mg PO DAILY 5. Acetaminophen 650 mg PO TID 6. Amiodarone 400 mg PO BID 7. Docusate Sodium 100 mg PO BID constipation 8. Miconazole Powder 2% 1 Appl TP BID 9. QUEtiapine Fumarate 12.5 mg PO QHS delirium, insomnia 10. Senna 1 TAB PO BID:PRN constipation 11. Warfarin 0.5 mg PO DAILY16 12. Ferrous Sulfate 325 mg PO DAILY 13. Furosemide 20 mg PO DAILY 14. Glargine 20 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 15. Ipratropium Bromide MDI 2 PUFF IH BID 16. NexIUM *NF* (esomeprazole magnesium) 40 mg Oral daily 17. rivastigmine *NF* 4.6 mg/24 hour Transdermal daily 18. Tamsulosin 0.4 mg PO HS 19. Vitamin B Complex 1 CAP PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY Acute hypoxic respiratory failure Atrial fibrillation Hematuria Acute kidney injury SECONDARY Alzheimer's dementia Diabetes mellitus Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to ___ due to weakness. You developed a fast heart rate and had trouble breathing so needed a breathing tube in the intensive care unit. You were given a medicine called amiodarone and your heart rates returned to normal. You were started on a blood thinner to prevent strokes. You developed some bleeding at the site of a Foley catheter but this improved with time. You were started on insulin to manage your diabetes better. Followup Instructions: ___
10160202-DS-7
10,160,202
24,494,866
DS
7
2155-04-22 00:00:00
2155-04-22 14:52:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Altered Mental status, Hematemesis Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old male with past medical history of alzheimer's disease, DMII, carotid and aortic stenosis presenting to the ED due to hematemesis and altered mental status. Wife was feeding him dinner and he had 3 episodes vomiting. EMS was called but patient signed refusal. Later in evening, had repeat large volume hematemesis. EMS reports ~100cc of bloody appearing emesis. On arrival he has mental status altered from his baseline in which he is conversant. In the ED, initial vitals were 101.2 98 99/45 22 99% NRB. Tmax was 104. The patient was found to have progressive solmnolence. He is evaluated with labwork notable for signs of urinary tract infection, Lactate of 5.0, leukopenia, and elevated LFTs. CXR with left lung opacities and moderate left sided effusion, CT head, abdomen, pelvis with no acute abnormality. The patient is intubated for airway protection and increasing solmnolence. He is treated with Vancomycin and Zosyn for broad spectrum coverage and is given aggressive fluid resuscitation with 3 L of IVF. A right subclavian CVL is placed and the patient is started on norepinephrine. On the floor, the patient is intubated and sedated, unable to provide history. Review of systems: (+) Per HPI Past Medical History: 1. Hypertension. 2. Hyperlipidemia. 3. Diabetes. 4. Obesity. 5. Ongoing tobacco abuse. 6. History of hyponatremia. 7. Cardiovascular disease, stable. 8. Peripheral vascular disease, right renal artery stenosis with preserved renal function and controlled hypertension. 9. Peripheral vascular disease of lower extremities, moderate to severe. 10. Aortic stenosis, normal EF (reportedly) 11. Gout Social History: ___ Family History: Denies early coronary artery disease or stroke. Physical Exam: ADMISSION PHYSICAL EXAM ======================== Vitals: 104/47 61 18 99% 40% FiO2 PEEP 5 General: Intubated, sedated, no response to voice or noxious stimuli HEENT: Sclera anicteric, MMM, ETT in place, pinpoint pupils Neck: supple, JVP not elevated, no LAD Lungs: Coarse breath sounds, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema DISCHARGE PHYSICAL EXAM ======================== Vitals: 97.5 122/50 70 20 100%2L I/Os: ___ General: Awake, lying in bed, unable to follow commands, NAD HEENT: Eyes closed, MMM, oropharynx clear Neck: Supple Lungs: Crackles at bilateral bases, coarse breath sounds, no wheezes CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: Foley in place Ext: Grossly edematous but WWP, 2+ pulses, no clubbing or cyanosis Pertinent Results: ADMISSION LABS =============== ___ 08:29AM WBC-10.2# RBC-4.03* HGB-10.6* HCT-33.6* MCV-84 MCH-26.3* MCHC-31.6 RDW-15.8* ___ 08:29AM PLT COUNT-161 ___ 08:29AM CALCIUM-7.7* PHOSPHATE-3.0 MAGNESIUM-1.4* ___ 08:29AM CK-MB-10 cTropnT-0.08* ___ 08:29AM ALT(SGPT)-616* AST(SGOT)-944* ALK PHOS-218* TOT BILI-1.0 ___ 08:29AM GLUCOSE-177* UREA N-23* CREAT-1.4* SODIUM-130* POTASSIUM-3.7 CHLORIDE-97 TOTAL CO2-23 ANION GAP-14 ___ 08:49AM freeCa-1.10* ___ 08:49AM ___ TEMP-37.3 PH-7.33* ___ 05:14AM LACTATE-3.9* ___ 03:45PM LACTATE-2.8* ___ 03:45PM ___ TEMP-36.9 RATES-/___ TIDAL VOL-250 PEEP-5 O2-50 PO2-46* PCO2-43 PH-7.35 TOTAL CO2-25 BASE XS--1 -ASSIST/CON INTUBATED-INTUBATED PERTINENT RESULTS ================== ___ 02:04AM BLOOD WBC-26.4* RBC-3.84* Hgb-10.2* Hct-32.3* MCV-84 MCH-26.6* MCHC-31.6 RDW-16.2* Plt ___ ___ 02:04AM BLOOD Neuts-77* Bands-18* Lymphs-1* Monos-4 Eos-0 Baso-0 ___ Myelos-0 ___ 02:04AM BLOOD Hypochr-2+ Anisocy-OCCASIONAL Poiklo-1+ Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-OCCASIONAL Burr-OCCASIONAL ___ 02:04AM BLOOD ___ PTT-39.4* ___ ___ 02:04AM BLOOD Glucose-173* UreaN-22* Creat-1.4* Na-129* K-3.8 Cl-100 HCO3-20* AnGap-13 ___ 02:04AM BLOOD ALT-623* AST-509* CK(CPK)-692* AlkPhos-177* TotBili-0.7 ___ 02:04AM BLOOD Calcium-7.7* Phos-3.5 Mg-1.9 ___ 06:08PM BLOOD Vanco-16.8 ___ 03:30AM BLOOD WBC-27.0* RBC-3.52* Hgb-9.1* Hct-29.4* MCV-84 MCH-25.7* MCHC-30.8* RDW-16.1* Plt ___ ___ 03:30AM BLOOD ___ PTT-35.1 ___ ___ 03:30AM BLOOD Glucose-151* UreaN-28* Creat-1.5* Na-126* K-3.5 Cl-102 HCO3-22 AnGap-6* ___ 03:30AM BLOOD ALT-505* AST-280* LD(LDH)-236 AlkPhos-126 TotBili-0.5 ___ 06:00PM BLOOD Calcium-7.6* Phos-2.8 Mg-2.0 ___ 03:41AM BLOOD Lactate-1.7 ___ 04:01AM BLOOD WBC-16.9* RBC-3.26* Hgb-8.6* Hct-27.5* MCV-84 MCH-26.3* MCHC-31.2 RDW-16.1* Plt ___ ___ 04:01AM BLOOD Glucose-174* UreaN-33* Creat-1.3* Na-128* K-3.9 Cl-98 HCO3-23 AnGap-11 ___ 04:01AM BLOOD ALT-376* AST-114* AlkPhos-141* TotBili-0.7 ___ 04:01AM BLOOD Albumin-2.4* Calcium-7.4* Phos-2.6* Mg-2.0 ___ 06:07AM BLOOD Vanco-26.2* ___ 04:16AM BLOOD WBC-7.9# RBC-3.27* Hgb-8.5* Hct-27.8* MCV-85 MCH-26.1* MCHC-30.8* RDW-15.9* Plt ___ ___ 04:16AM BLOOD Glucose-139* UreaN-34* Creat-1.3* Na-127* K-3.9 Cl-96 HCO3-22 AnGap-13 ___ 04:16AM BLOOD ALT-259* AST-56* AlkPhos-143* TotBili-0.6 ___ 04:16AM BLOOD Calcium-7.9* Phos-3.1 Mg-2.0 ___ 06:50AM BLOOD WBC-6.1 RBC-3.32* Hgb-8.9* Hct-28.5* MCV-86 MCH-26.7* MCHC-31.1 RDW-16.0* Plt ___ ___ 06:50AM BLOOD Glucose-206* UreaN-25* Creat-1.0 Na-131* K-3.6 Cl-99 HCO3-24 AnGap-12 ___ 06:50AM BLOOD ALT-184* AST-35 AlkPhos-124 TotBili-0.5 ___ 01:26PM BLOOD Calcium-7.1* Phos-3.0 Mg-1.9 ___ 05:14AM BLOOD WBC-6.1 RBC-3.24* Hgb-8.5* Hct-27.6* MCV-85 MCH-26.3* MCHC-30.9* RDW-16.0* Plt ___ ___ 05:14AM BLOOD Glucose-177* UreaN-19 Creat-0.9 Na-134 K-3.9 Cl-102 HCO3-25 AnGap-11 ___ 12:27PM BLOOD Calcium-8.0* Phos-3.0 Mg-1.8 DISCHARGE LABS =============== ___ 07:30AM BLOOD WBC-6.2 RBC-3.42* Hgb-9.2* Hct-29.2* MCV-85 MCH-27.0 MCHC-31.6 RDW-16.3* Plt ___ ___ 07:30AM BLOOD Glucose-119* UreaN-15 Creat-0.9 Na-137 K-3.6 Cl-101 HCO3-28 AnGap-12 ___ 07:30AM BLOOD Calcium-7.8* Phos-3.5 Mg-1.7 REPORTS ======== ___ CHEST X-RAY The patient is markedly rotated, limiting evaluation of the cardiac and mediastinal contours. However, the heart still remains enlarged. There has been interval appearance of mild pulmonary edema. There are likely layering effusions with patchy bibasilar opacities, left greater than the right, likely Reflecting compressive lower lobe atelectasis. Pneumonia cannot be excluded. No pneumothorax. Calcification of the aorta consistent with atherosclerosis. Interval extubation and removal of the nasogastric tube. Right subclavian central line is unchanged in position with the tip in the distal SVC. ___ CHEST X-RAY As compared to the previous radiograph, a nasogastric tube has been pulled back. The sidehole is now at the level of the gastroesophageal junction, the tube should be advanced by approximately 5 cm. The Position of the endotracheal tube is unchanged. Also unchanged is the right subclavian access line. Moderate cardiomegaly, right perihilar atelectasis and left pleural effusion with retrocardiac atelectasis are unchanged. On the right, at the lung bases, the radiolucency has increased, likely caused by improved right lower lung ventilation. ___ CHEST X-RAY ET tube tip is 6.4 cm above the carina in a standard position. Cardiomegaly and tortuous aorta are unchanged. Increasing opacities in the retrocardiac region are consistent with increasing large area of atelectasis, almost collapse of the left lower lobe. Mild interstitial edema is unchanged. NG tube tip is coiled in the stomach. The left hemidiaphragm is elevated. Small right effusion has minimally increased. ___ LIVER OR GALLBLADDER US (SINGLE ORGAN) 1. No biliary dilatation identified. 2. Patent hepatic vasculature. ___ CHEST (PORTABLE AP) Chronic atelectasis with more pronounced left lower lobe volume loss likely reflecting collapse. This could be further evaluated with chest CT. ___ CT HEAD W/O CONTRAST 1. No evidence of hemorrhage or other acute intracranial process. 2. Global atrophy and sequelae of chronic small vessel ischemic disease. 3. Acute-on-chronic inflammatory disease in the paranasal sinuses; correlate clinically. Brief Hospital Course: ___ Alzheimer's disease, DMII, carotid and aortic stenosis who presented with hematemesis and was found to have sepsis from urinary source. # Urinary tract infection complicated by Sepsis: On admission, patient had ___ SIRS criteria (leukopenia to WBC 3.4k, fever to T104, tachypnea to RR 27) for which patient was admitted to medical ICU and required vasopressor support for several days (last day ___. He was initially treated with broadly with Vancomycin and Zosyn. When urine and blood cultures grew pan-sensitive Klebsiella Pneumoniae, antibiotics were narrowed to IV Ceftriaxone then PO Ciprofloxacin on ___ to complete a 14 day course (last day ___. # Hyponatremia: Na 127 on admission, which normalized with IV fluids. At the time of discharge, Na was 137. # Respiratory Failure/Hypoxemia: Patient was intubated on admission for airway protection in the setting of vomiting and altered mental status. He was successfully extubated on ___. On ___, he developed hypoxemia to mid-80s on room air with chest X-ray on ___ showing pulmonary edema. He was administered IV Lasix boluses with significant diuresis. At the time of discharge, supplemental O2 was weaned down to ___ and he was restarted on his home dose of PO Lasix. # Nutritional status: Per family, patient was able to take POs at home prior to admission(he was on a liquid/soft mechanical diet and could take pills in apple sauce). During this admission, the patient's main barrier to oral intake was his mental status. Per wife, patient would want to eat despite risk of aspiration so he was placed on pureed diet with pills crushed in apple sauce prior to discharge. # Type II Diabetes: The patient was maintained on a basic insulin sliding scale during this admission. # Aortic stenosis: Last ___ ECHO with LVEF >55%. Patient's fluid status was managed carefully given preload dependence. # Transaminitis: Likely shock liver in teh setting of sepsis, with LFTs downtrending when transferred to the medical floor and normalization at the time of discharge. # Troponinemia: On admission, found to have troponinemia with Trop-T peak at 0.12 likely due to demand in the setting of sepsis. No further intervention was taken. # Paroxysmal AFib: Home amiodarone medications initially held in the setting of clarifying goals of care, restarted prior to discharge. # Goals of Care: Prior to admission, patient was on home hospice ___ Hospice). Instead of calling the hospice nurse, the patient's wife called ___ prior to admission, after which patient was brought to the hospital, intubated, and transferred to MICU. On ___, a family meeting was conducted with the wife and ___ interpreter where the patient's goals of care were confirmed as a code status of DNR/DNI, "do not rehospitalize" policy, okay for antibiotics but no feeding tube. A MOLST form was filled out and copies were provided for the family. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO BID 2. Miconazole Powder 2% 1 Appl TP BID:PRN yeast in groin 3. Amiodarone 200 mg PO BID 4. esomeprazole magnesium 40 mg oral daily 5. Furosemide 20 mg PO DAILY 6. Glargine 12 Units Bedtime Insulin SC Sliding Scale using UNK Insulin 7. Ipratropium Bromide MDI 2 PUFF IH BID 8. Tamsulosin 0.4 mg PO HS 9. TraZODone 25 mg PO HS 10. Senna 1 TAB PO QAM Discharge Medications: 1. Glargine 12 Units Bedtime Insulin SC Sliding Scale using UNK Insulin 2. Miconazole Powder 2% 1 Appl TP BID:PRN yeast in groin 3. Acetaminophen 650 mg PO BID 4. Amiodarone 200 mg PO BID 5. esomeprazole magnesium 40 mg oral daily 6. Furosemide 20 mg PO DAILY 7. Ipratropium Bromide MDI 2 PUFF IH BID 8. Senna 1 TAB PO QAM 9. Tamsulosin 0.4 mg PO HS 10. TraZODone 25 mg PO HS 11. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth Every 12 hours (2 time a day) Disp #*12 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY Sepsis from urinary source Pulmonary edema SECONDARY Atrial fibrillation Aortic stenosis Type II Diabetes Mellitus Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Dear Mr. ___, It was a pleasure to take care of you during this hospitalization. You were admitted to ___ ___ after you developed vomiting and confusion at home. You were found to have an infection of your urine causing low blood pressure. For this, you were admitted to the ICU where you were placed on a breathing tube as well as treated with medications to increase your blood pressure and your infection. After the breathing tube was removed, you were taken care of on the medical floor where you remained stable until you were discharged home. We talked to your wife and daughter about your medical desires. We confirmed that you would not want a breathing tube down your throat if you were to have difficulty breathing or chest compressions/electrical shocks if your heart were to stop or a feeding tube to help you eat. Your wife expressed that it would be your desire to spend you remaining time at home with your family, so it was decided that you would not come back to the hospital. You are now going home on "hospice care," where the focus will be to make you as comfortable as possible. Followup Instructions: ___
10160622-DS-22
10,160,622
28,663,041
DS
22
2180-06-30 00:00:00
2180-07-01 07:14:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Tetanus Toxoid,Adsorbed / Codeine / Insulin,Beef / Ace Inhibitors / Rifampin / Heparin Agents / Protonix / Beta-Blockers (Beta-Adrenergic Blocking Agts) / adhesive tape / Latex / meropenem / clindamycin HCl / Bactrim / brimonidine Attending: ___. Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: ___ placement ___ Thoracentesis with chest tube placement ___ Transthoracic echocardiogram ___ Central line placement ___ Bronchial lavage ___ Intubation ___ History of Present Illness: ___ woman with PMHx notable for CAD s/p DES x1, type 1 diabetes, a-fib, diastolic heart failure, peripheral vascular disease s/p L BK amputation and multiple right toe amputations, reactive airway disease, hypertension, and recent admission for hypoxic respiratory failure presenting from rehab for worsening hypoxia. Of note, patient was recently hospitalized for hypoxemic respiratory failure requiring MICU for BiPAP. Mixed picture etiology, overall thought to include RLL pneumonia (s/p unspecified antibiotic course), reactive airway disease for which she received 7-day course of prednisone and levofloxacin, and diastolic heart failure with TTE demonstrating severe pulmonary hypertension due to elevated left sided pressures. Further noted to have bilateral pleural effusions however declined therapeutic thoracentesis. Ultimately discharged to rehab on 3L NC with maintenance diuresis on torsemide 40 BID. She then was noted at her facility today to be hypoxic to the ___ and transferred to the emergency room today for further evaluation. At time of evaluation she denies any chest pain, no fevers or chills, no abdominal pain, no nausea vomiting. In ED initial VS: 101.4 85 101/52 20 98% NRM Labs significant for: WBC 17.1, abs. neutrophils 14.2, Na 131, bicarb 38, lactate 1.4, UA with >182 WBC, 68 RBC, few bacteria. Influenza negative. Patient was given: Tylenol, vancomycin, cefepime, azithromycin, and 40 IV Lasix Imaging notable for CXR with probable moderate to large right pleural effusion. With superimposed mild pulmonary edema. More dense opacity in the left lung which could also represent edema though infection would be possible. Past Medical History: # Type 1 diabetes c/b nephropathy and neuropathy # Coronary artery disease, s/p MI ___ PCI w/ DES x1 # PVD s/p fall SFA to AT bypass, R SFA stent, s/p R TMA at ___ # Reactive airways and asthma # Hypertension # Chronic Staph aureus osteomyelitis of spine and pelvis on chronic Levaquin suppression # s/p lumbar spine surgery x2 with hardware revision for infection # Diabetic foot ulcers with associated cellulitis # Depression # Insomnia # s/p right Colles fracture # Restless legs associated with autonomic neuropathy # Iron deficiency # Ovarian cysts. F/b Dr. ___ at ___ ___. Felt to be benign serous cystadenomas. Followed expectantly. #? CHF (TTE ___ with EF > 55%) Social History: ___ Family History: Father - MI in ___. Mother - vocal cord cancer. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: T98.8, HR 83, BP 140/59, RR 21, 93% NRB GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM NECK: supple, JVP not elevated LUNGS: Poor inspiratory effort but generally clear. No crackles, wheezes. CV: Irregular rhythm, normal rate, distant heart sounds with normal S1/S2 ABD: soft, non-tender, non-distended EXT: Left below-knee amputation and several right toe amputations with gauze dressing c/d/i DISCHARGE PHYSICAL EXAM: ___ ___ Temp: 98.9 PO BP: 142/63 HR: 99 RR: 20 O2 sat: 96% O2 delivery: 2l FSBG: 278 Is and Os: Weight: 199.29 --> 201.72 HEENT: Normocephalic, atraumatic. Sclera anicteric and without injection. dentition. Oropharynx is clear. NECK: Supple. No JVD CARDIAC: irregularly irregular. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Breathing unlabored, faint wheezes. No crackles. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. EXTREMITIES: No clubbing, cyanosis, or edema. LLE amputated below knee. SKIN: Warm. NEUROLOGIC: CN2-12 grossly intact. A&Ox2 Pertinent Results: ADMISSION LABS: =============== ___ 03:40PM BLOOD WBC-17.1* RBC-4.49 Hgb-10.2* Hct-34.5 MCV-77* MCH-22.7* MCHC-29.6* RDW-21.1* RDWSD-58.0* Plt ___ ___ 03:40PM BLOOD Neuts-82.9* Lymphs-7.5* Monos-6.1 Eos-2.5 Baso-0.5 Im ___ AbsNeut-14.16* AbsLymp-1.29 AbsMono-1.05* AbsEos-0.43 AbsBaso-0.09* ___ 04:23AM BLOOD ___ PTT-49.8* ___ ___ 03:40PM BLOOD Glucose-196* UreaN-31* Creat-0.8 Na-131* K-4.4 Cl-83* HCO3-38* AnGap-10 ___ 03:40PM BLOOD proBNP-4725* ___ 03:40PM BLOOD Calcium-8.5 Phos-3.5 Mg-1.6 ___ 03:46PM BLOOD ___ pO2-64* pCO2-71* pH-7.36 calTCO2-42* Base XS-10 ___ 03:46PM BLOOD Lactate-1.4 ___ 03:40PM URINE RBC-68* WBC->182* Bacteri-FEW* Yeast-NONE Epi-0 ___ 03:40PM URINE Blood-SM* Nitrite-POS* Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG* ___ 04:22AM URINE Streptococcus pneumoniae Antigen Detection-Test ___ 05:10PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE DISCHARGE LABS: ================= ___ 04:30AM BLOOD WBC-11.8* RBC-2.85* Hgb-8.0* Hct-26.7* MCV-94 MCH-28.1 MCHC-30.0* RDW-19.5* RDWSD-66.4* Plt ___ ___ 04:30AM BLOOD Glucose-213* UreaN-19 Creat-1.0 Na-138 K-4.4 Cl-94* HCO3-35* AnGap-9* IMAGING REPORTS: ================ CXR ___: IMPRESSION: Probable moderate to large right pleural effusion. With superimposed mild pulmonary edema. More dense opacity in the left lung which could also represent edema though infection would be possible. CXR ___: IMPRESSION: In comparison with the study of ___, there has been some decrease in the opacification at the right base with the hemidiaphragm slightly better seen. Although this could represent improvement in the pleural effusion, it may merely be a manifestation of a more upright position of the patient. The remainder the study is essentially unchanged. TTE ___: Conclusions The left atrium is dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF = 65%). The right ventricular free wall is hypertrophied. The right ventricular cavity is moderately dilated with mild global free wall hypokinesis. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The aortic arch is mildly dilated. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is mild posterior leaflet mitral valve prolapse. Mild (1+) mitral regurgitation is seen. Severe [4+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is no pericardial effusion. A right pleural effusion is present. No vegetations seen (but suboptimal image quality). Compared with the prior study (images reviewed) of ___, tricuspid regurgitation ios increased. CXR ___: IMPRESSION: Tip of PICC line in the right the cavoatrial juncture. No pneumothorax. Increased vascular congestion in the left lung. Large right effusion as previously. MICROBIOLOGY: ============= ___ 3:40 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: ENTEROBACTER CLOACAE COMPLEX. >100,000 CFU/mL. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. ENTEROCOCCUS SP.. 10,000-100,000 CFU/mL. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROBACTER CLOACAE COMPLEX | ENTEROCOCCUS SP. | | AMPICILLIN------------ =>32 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S LINEZOLID------------- 2 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I 128 R PIPERACILLIN/TAZO----- <=4 S TETRACYCLINE---------- =>16 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S VANCOMYCIN------------ =>32 R ___ 5:20 pm BLOOD CULTURE Blood Culture, Routine (Preliminary): STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. FINAL SENSITIVITIES. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. RIFAMPIN should not be used alone for therapy. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . LINEZOLID Daptomycin AND CEFTAROLINE Sensitivity testing per ___ ___ ___. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R LINEZOLID------------- 2 S OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 2 S Anaerobic Bottle Gram Stain (Final ___: Reported to and read back by ___ @ 0717 ON ___ - ___. GRAM POSITIVE COCCI IN CLUSTERS Brief Hospital Course: SUMMARY: ===================== ___ w/ CAD (s/p DES), T1DM, Afib, HFpEF, PVD (s/p L BKA, R transmetatarsal amputation and chronic RLE ulcers), HTN, reactive airway disease admitted with respiratory failure (initially secondary to pneumonia and later due to volume overload, extubated ___, with course complicated by MRSA bacteremia (possibly secondary to pneumonia, on linezolid), ___ (secondary to ATN in setting of sepsis). After extensive multidisciplinary discussion between patient, her family/HCP, Palliative Care, the patient requested transition of her care to hospice. ACTIVE ISSUES: ===================== GOALS OF CARE: Patient was clear in her wishes to leave the hospital and was not interested in further medical care of her multiple conditions. Multiple times throughout the hospitalization she refused interventions. After discussion with patient, her family/HCP, and Palliative Care, she transitioned her care to hospice. HYPOXIC RESPIRATORY FAILURE VOLUME OVERLOAD RIGHT APICAL HYDROPNEUMOTHORAX Recent admission for hypoxic respiratory failure. Presented from her rehab with hypoxia secondary to MRSA pneumonia and required intubation. Treated with antibiotics and chest tube placement for a a small right apical hydropneumothorax. She was extubated for 48 hours and subsequently reintubated for hypoxia and tachypnea secondary primarily to volume overload, though pulmonary hypertension and COPD contributed as well. She was diuresed on a bumex drip, given standing nebs along with a few days of velitiri and was successfully extubated ___. Her chest tube was removed and she continued to require diuresis with lasix IV boluses and a lasix drip for pulmonary edema. Her hospital course was complicated by ongoing hypoxic respiratory failure - multifactorial due to pulmonary edema, atelectasis, mucus plugging - and she received aggressive diuresis, chest ___, and nebulizer therapy. Near the end of her hospital stay, she pulled out all of her IV access (she had been on a Lasix gtt) and refused all further IV meds. She was discharged to hospice and also made clear to the hospice liaison that she would not want anything IV in hospice. ACUTE RENAL FAILURE Baseline creatinine 0.7-0.8, peaked in the ICU to 3.2 and was nearing anuria. Developed significant volume overload and third spacing. Continued to diurese with a bumex drip in addition to dopamine. Pt declined renal replacement therapy and kidney function improved without it. SEPTIC SHOCK MRSA BACTEREMIA Required pressor support from ___ to ___. Found to have MRSA bacteremia thought to be secondary to pneumonia. TEE unrevealing. Initially treated w/ vancomycin but pt developed VRE and she was switched to Linezolid (___). LEUKOCYTOSIS Persistent throughout ICU stay, etiology remained unclear, thought to be stress reaction. ANEMIA Baseline hemoglobin around 9, developed anemia secondary to chronic disease and likely poor nutrition. No signs of active bleeding, guaiac negative. Required 2 units of pRBCs in the ICU and additional RBC once on the medicine floor. THROMBOCYTOPENIA Attributed to poor nutritional status and overwhelming infection, trough of 71, resolved on it's own. CATHETER ASSOCIATED UTI Speciated to VRE, required changing vancomycin to Linezolid. She then had an additional catheter associated UTI which was enterobacter sensitive to Bactrim which was treated. COAGULOPATHY: Likely secondary to antibiotics, malnutrition and congestive hepatopathy. No e/o bleed DIABETES MELLITUS (TYPE 1): maintained on insulin sliding scale during her hospital stay. ATRIAL FIBRILLATION CHA2DS2-Vasc score is 6 Intermittently in stable atrial fibrillation during ICU stay. On agatroban drip while unable to tolerate PO, reported heparin allergy and potential need for further procedure. Her home metoprolol was held in the setting of ongoing infections. Her apixiban was restarted but discontinued on discharge as she was discharged to hospice. LOWER EXTREMITY WOUNDS BILATERAL BKAs Chronic. Wound was consulted given excoriations. ID was not concerned re: cellulitis while in ICU though warm and erythematous right extremity and already on Linezolid. CHRONIC ISSUES ===================== CORONARY ARTERY DISEASE Remained on home ASA, Pravastatin, stopped clopidogrel during this hospital stay. All were not continued on discharge as she was discharged to hospice. GERD: PPI not continued on discharge as she was discharged to hospice. HYPERTENSION: held home losartan initially due to hypotension, then due to ___ DEPRESSION: held home amitriptyline, initiated on Seroquel which was continued on discharge. TRANSITIONAL ISSUES: ===================== [] Patient was discharged to hospice care [] Code status change to DNR/DNI/Do not transfer to ICU [] Amitriptyline HELD during hospitalization (interact w/linezolid) - consider restarting [] Did not restart levofloxacin on discharge for infectious ppx per ID [] Dedicated pelvic ultrasound could be considered for evaluation of cystic ovarian/adnexal masses if within goals of care. # CODE: DNR/DNI, do not transfer to ICU # CONTACT: ___ (brother: ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 4. Montelukast 10 mg PO DAILY 5. Pravastatin 40 mg PO QPM 6. Omeprazole 20 mg PO DAILY 7. Amitriptyline 50 mg PO QHS 8. Losartan Potassium 50 mg PO DAILY 9. Metoprolol Succinate XL 12.5 mg PO DAILY 10. Ferrous GLUCONATE 324 mg PO DAILY 11. TraZODone 50 mg PO QHS:PRN insomnia 12. Torsemide 40 mg PO BID 13. Sarna Lotion 1 Appl TP QID:PRN itchiness 14. OxyCODONE (Immediate Release) 2.5-5 mg PO Q6H:PRN BREAKTHROUGH PAIN 15. Miconazole Powder 2% 1 Appl TP TID groin rash 16. Acetaminophen 650 mg PO Q8H 17. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing 18. Apixaban 5 mg PO BID 19. Docusate Sodium 100 mg PO BID 20. Glargine 6 Units Bedtime Insulin SC Sliding Scale using UNK Insulin Discharge Medications: 1. Acetylcysteine 20% ___ mL NEB Q4H:PRN SOB RX *acetylcysteine 200 mg/mL (20 %) ___ nebulized every four (4) hours Disp #*20 Vial Refills:*0 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 3. Gabapentin 100 mg PO QHS RX *gabapentin 100 mg 1 capsule(s) by mouth at bedtime Disp #*5 Capsule Refills:*0 4. Gabapentin 100 mg PO BID RX *gabapentin 100 mg 1 capsule(s) by mouth twice a day Disp #*10 Capsule Refills:*0 5. Ipratropium-Albuterol Neb 1 NEB NEB Q4H RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 2.5 mg NEB every four (4) hours Disp #*20 Ampule Refills:*0 6. LORazepam ___ mg PO Q4H:PRN anxiety RX *lorazepam 1 mg ___ tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills:*0 7. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL ___ mg PO Q2H:PRN Pain - Severe RX *morphine concentrate 100 mg/5 mL (20 mg/mL) ___ mg by mouth q2h Refills:*0 8. Nystatin Cream 1 Appl TP BID 9. Ondansetron 4 mg PO Q8H:PRN nausea RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*10 Tablet Refills:*0 10. QUEtiapine Fumarate 75 mg PO QHS insomnia RX *quetiapine 50 mg 1.5 tablet(s) by mouth at bedtime Disp #*5 Tablet Refills:*0 11. QUEtiapine Fumarate 25 mg PO BID agitation RX *quetiapine 25 mg 1 tablet(s) by mouth twice a day Disp #*8 Tablet Refills:*0 12. rOPINIRole 1 mg PO QAM RX *ropinirole 1 mg 1 tablet(s) by mouth qAM Disp #*3 Tablet Refills:*0 13. Senna 8.6 mg PO BID:PRN Constipation 14. Sulfameth/Trimethoprim DS 1 TAB PO BID Last day ___ 15. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 16. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN wheezing RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 NEB INH q2h Disp #*40 Vial Refills:*0 17. Glargine 6 Units Bedtime Insulin SC Sliding Scale using UNK Insulin 18. Torsemide 80 mg PO DAILY RX *torsemide 20 mg 4 tablet(s) by mouth daily Disp #*12 Tablet Refills:*0 19. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 20. Sarna Lotion 1 Appl TP QID:PRN itchiness Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS ==================== Hypoxic and hypercarbic respiratory failure SECONDARY DIAGNOSIS ==================== Septic shock, MRSA bactermia MRSA pneumonia, volume overload, hydropneumothorax, pulmonary HTN, COPD Acute renal failure Catheter associated urinary tract infection, VRE Leukocytosis, anemia ,thrombocytopenia Coagulopathy, malnutrition Atrial fibrillation, coronary artery disease, hypertension Diabetes mellitus type 1, bilateral BKAs Gastroesophgeal reflux disease Depression Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. ___, You came to ___ because you are feeling short of breath. You were treated for multiple infections. After discussions with you you decided to transition your care to hospice care. It was a pleasure participating in your care. We wish you the best! Sincerely, Your ___ Care Team Followup Instructions: ___
10160622-DS-24
10,160,622
20,002,800
DS
24
2180-07-19 00:00:00
2180-07-19 19:28:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Tetanus Toxoid,Adsorbed / Codeine / Insulin,Beef / Ace Inhibitors / Rifampin / Heparin Agents / Protonix / Beta-Blockers (Beta-Adrenergic Blocking Agts) / adhesive tape / Latex / meropenem / clindamycin HCl / Bactrim / brimonidine Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. ___ is a ___ woman with CAD (s/p DES), T1DM, Afib, HFpEF, PVD (s/p L BKA, R transmetatarsal amputation and chronic RLE ulcers), HTN, reactive airway disease, with several recent admissions for respiratory failure ___ secondary to pneumonia and later due to volume overload, ___ right sided pleural effusion and lung white out likely ___ pleural effusion as well as mucous plugging with improvement of symptoms s/p pleurx placement and diuresis) discharged on ___ with pleurx catheter in place for large R sided effusion who presented to ___ ED on ___ after an episode of shortness of breath found to have R sided pneumothorax. Pt presented with dyspnea. Attempted drainage of the Pleurx catheter resulted in only 2 mL at rehab. A CXR was performed at 12:07 ___, demonstrating a "lateral right pneumothorax." She was also noted to be 86% on RA. Thus, she was brought to the hospital. En route, her Pleurx catheter was completely dislodged (removed intact), and the patient reports that the exit site was not immediately covered. In the ED, initial vitals were: 98.2 78 125/58 20 98% 2L NC - Exam notable for: Diminished breath sounds on the right versus the left. - Labs notable for: WBC 11.5, Hb 10.9, Plt 203, proBNP 1064 - Imaging was notable for: CXR 2:19 pm: Small right apical pneumothorax without evidence of tension. CXR 4:32 pm: Unchanged small right apical pneumothorax, no tension - Patient was given: 80 mg IV furosemide Past Medical History: # Type 1 diabetes c/b nephropathy and neuropathy # Coronary artery disease, s/p MI ___ PCI w/ DES x1 # PVD s/p fall SFA to AT bypass, R SFA stent, s/p R TMA at ___ # Reactive airways and asthma # Hypertension # Chronic Staph aureus osteomyelitis of spine and pelvis on chronic Levaquin suppression # s/p lumbar spine surgery x2 with hardware revision for infection # Diabetic foot ulcers with associated cellulitis # Depression # Insomnia # s/p right Colles fracture # Restless legs associated with autonomic neuropathy # Iron deficiency # Ovarian cysts. F/b Dr. ___ at ___ ___. Felt to be benign serous cystadenomas. Followed expectantly. #? CHF (TTE ___ with EF > 55%) Social History: ___ Family History: Father - MI in ___. Mother - vocal cord cancer. Physical Exam: ADMISSION EXAM ============== VS: 98.3 PO 118 / 66 R Lying 67 18 97 6L General Appearance: NAD, resting comfortably HEENT: MMM, O/P clear, sclera anicteric Neck: supple Chest: CTA Bilaterally, no wheezes or rales Cardiovascular: reg rate, nl S1/S2, no MRG Abdomen: soft, NT/ND, NABS Extremities: LLE BKA; RLE erythema and edema Neurological: alert Psychiatric: intermittent agitation Skin: RLE erythema DISCHARGE EXAM ================ 24 HR Data (last updated ___ @ 630) Temp: 97.9 (Tm 98.3), BP: 109/52 (109-122/52-68), HR: 63 (61-67), RR: 18, O2 sat: 100% (96-100), O2 delivery: weaned to 1L (2L-6L) General Appearance: NAD, resting comfortably HEENT: MMM, O/P clear, sclera anicteric Neck: supple Chest: CTA Bilaterally, no wheezes or rales Cardiovascular: reg rate, nl S1/S2, no MRG Abdomen: soft, NT/ND, NABS Extremities: LLE BKA; RLE erythema and edema Neurological: alert Skin: RLE erythema Pertinent Results: ADMISSION LABS =============== ___ 05:00PM BLOOD WBC-11.5* RBC-4.05 Hgb-10.9* Hct-36.2 MCV-89 MCH-26.9 MCHC-30.1* RDW-15.8* RDWSD-51.8* Plt ___ ___ 05:00PM BLOOD Neuts-70.3 Lymphs-16.0* Monos-8.3 Eos-4.5 Baso-0.6 Im ___ AbsNeut-8.09* AbsLymp-1.84 AbsMono-0.95* AbsEos-0.52 AbsBaso-0.07 ___ 05:00PM BLOOD Glucose-107* UreaN-13 Creat-0.7 Na-140 K-3.5 Cl-95* HCO3-26 AnGap-19* ___ 05:00PM BLOOD proBNP-1064* ___ 06:30AM BLOOD Calcium-8.3* Phos-4.4 Mg-1.7 DISCHARGE LABS ================ ___ 05:00PM BLOOD WBC-11.5* RBC-4.05 Hgb-10.9* Hct-36.2 MCV-89 MCH-26.9 MCHC-30.1* RDW-15.8* RDWSD-51.8* Plt ___ ___ 06:30AM BLOOD Glucose-96 UreaN-15 Creat-0.8 Na-141 K-3.1* Cl-94* HCO3-32 AnGap-15 IMAGING ========== ___ CXR Small right apical pneumothorax without evidence of tension. ___ CXR 1. Stable moderate right pneumothorax. Increasing right lung base atelectasis and small right pleural effusion. 2. Mild left pulmonary vascular congestion. Brief Hospital Course: ___ woman with CAD (s/p DES), T1DM, Afib, HFpEF, PVD (s/p L BKA, R transmetatarsal amputation and chronic RLE ulcers), HTN, reactive airway disease, with several recent admissions for respiratory failure, with a pleurex catheter placed on discharge who was admitted for hypoxia and found to have a R sided pneumothorax likely due to entrapment from catheter track. ACUTE PROBLEMS: # Pneumothorax Chest radiographs on admission were notable for a 2.5 cm right apical pneumothorax with complete dislodgement of the Pleurx catheter. The pneumothorax is most likely from air entrainment from the TPC track. The patient was given 100% O2 via NC. Interventional pulmonology was consulted and recommended against further intervention or repeat chest tube placement. She was hemodynamically stable and near her baseline O2 requirement (room air to 1L). Serial chest x rays were done which showed that the pneumothorax was stable on repeat imaging. Per IP, would expect 2 weeks or more for it to completely resolve. The patient was discharged with IP follow up and plans for repeat imaging. # Hypoxic respiratory failure The patient has a history of multiple admissions for hypoxia related to pneumonia, volume overload due to HFpEF, and pleural effusions. Most recently she was hospitalized ___ for dyspnea and underwent a right Pleurx catheter placement for drainage of transudative effusion. It was unclear if the patient was actually very hypoxic or dyspneic on admission, and furthermore the clinical significance of the small pneumothorax above in causing hypoxia is questionable. In the past, the patient has been diuresed and is on a home regimen of PO torsemide. Chest x rays showed only small pleural effusion. The patient was continued on her home torsemide dose and given nebulized bronchodilators as needed. She was asymptomatic and only requiring minimal supplemental O2 on discharge. # RLE warmth/erythema On exam the patient had right lower extremity erythema and warmth with several open wounds concerning for cellulitis though from review of prior records seems more chronic. She remained afebrile, without pain, and her leukocytosis from admission resolved. Antibiotics were deferred and the patient was monitored clinically and stable from prior. CHRONIC ISSUES: # HFpEF Last echo on ___ with EF 71%, RV dysfunction, mild MR ___ be underestimated), 3+TR, mod pulmonary hypertension. Her prior pleural effusions were transudative and thought to be due to CHF. She was recently discharged with a pleurex catheter for drainage and on torsemide 80 mg daily. She also had a ___ O2 requirement on her last discharge. The patient was continued on home metoprolol and torsemide. She appeared euvolemic on discharge. Per IP, there were no plans for repeat chest tube placement as the pleural effusion had mostly resolved. # Urinary retention The patient has a history of urinary retention requiring straight cath. She had a foley at first that was then discontinued. # DM1 The patient was continued on her home glargine as well as an insulin sliding scale and gabapentin for a neuropathy. # Atrial fib CHADS2-VASC 6. The patient was continued on home apixaban and Metoprolol. # HTN Antihypertensives stopped at previous admission. Remained normotensive during hospital stay. # Depression # Severe Agitation # Delirium The patient has had episodes of delirium during previous hospitalizations with behavioral issues, in which she was evaluated by psychiatry. She was continued on home risperidone and hydroxazine as needed. # Restless leg syndrome She was continued on home ropinirole. # Goals of care Patient discharged on ___ to hospice after extensive involvement and discussion with palliative care. Code status changed to full code on ___ after conversation with palliative care. Pt at the time was interested in regaining her strength and discharge to rehab. Goals of care were not readdressed this admission, but should be considered if clinical status changes or patient expresses inconsistent preferences regarding care. TRANSITIONAL ISSUES: ====================== [] Please ensure that the patient goes to her follow up interventional pulmonology appointment as listed and obtains repeat chest imaging. # CODE: Full (confirmed) # CONTACT: Name of health care proxy: ___ and ___ ___: Brothers Phone number: ___ ___ on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 2. Acetylcysteine 20% ___ mL NEB Q4H:PRN SOB 3. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN wheezing 4. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 5. Ipratropium-Albuterol Neb 1 NEB NEB Q4H 6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 7. LORazepam 0.5-1 mg PO Q6H:PRN Severe Anxiety 8. Nystatin Cream 1 Appl TP BID 9. Ondansetron 4 mg PO Q8H:PRN nausea 10. rOPINIRole 1 mg PO QAM 11. Sarna Lotion 1 Appl TP QID:PRN itchiness 12. Senna 8.6 mg PO BID:PRN Constipation 13. Torsemide 80 mg PO DAILY 14. Apixaban 5 mg PO BID 15. Aspirin 81 mg PO DAILY 16. HydrOXYzine 25 mg PO BID:PRN anxiety 17. Gabapentin 100 mg PO TID 18. Metoprolol Tartrate 6.25 mg PO BID 19. RisperiDONE 1 mg PO BID 20. Ramelteon 8 mg PO QHS 21. Lidocaine 5% Patch 1 PTCH TD QPM 22. insulin glargine 100 unit/mL subcutaneous QHS Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 2. Acetylcysteine 20% ___ mL NEB Q4H:PRN SOB 3. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN wheezing 4. Apixaban 5 mg PO BID 5. Aspirin 81 mg PO DAILY 6. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 7. Gabapentin 100 mg PO TID 8. HydrOXYzine 25 mg PO BID:PRN anxiety 9. insulin glargine 100 unit/mL subcutaneous QHS 10. Ipratropium-Albuterol Neb 1 NEB NEB Q4H 11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 12. Lidocaine 5% Patch 1 PTCH TD QPM 13. LORazepam 0.5-1 mg PO Q6H:PRN Severe Anxiety 14. Metoprolol Tartrate 6.25 mg PO BID 15. Nystatin Cream 1 Appl TP BID 16. Ondansetron 4 mg PO Q8H:PRN nausea 17. Ramelteon 8 mg PO QHS 18. RisperiDONE 1 mg PO BID 19. rOPINIRole 1 mg PO QAM 20. Sarna Lotion 1 Appl TP QID:PRN itchiness 21. Senna 8.6 mg PO BID:PRN Constipation 22. Torsemide 80 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: PRIMARY ========= Pneumothorax SECONDARY ========= HFpEF DMI HTN Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at ___ ___. Why were you admitted to the hospital? - You had lower levels of oxygen than usual. - A chest x ray showed that you had free air in your chest (outside of your lungs), which is called a pneumothorax. What was done for you while you were in the hospital? - You were given oxygen through a nasal cannula - We obtained several chest x rays which showed that the pneumothorax was improving. What should you do when you go home? - Please take all your medications as directed. - You should follow up with all your outpatient doctors as below. Wishing you the best! Your ___ Care Team Followup Instructions: ___
10160990-DS-15
10,160,990
27,707,315
DS
15
2121-09-10 00:00:00
2121-09-10 13:35:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Cough and right sided chest pain Major Surgical or Invasive Procedure: ___ Right pleural pigtail catheter placement ___ Right VATS, blebectomy, pleurodesis History of Present Illness: Mr. ___ is a ___ man with history of smoking 1 pack of cigarettes every other day for ___ years presents with one day of cough and chest/back pain, found to have a large right pneumothorax. Patient reports that he began coughing this morning at 3am, and began experiencing intense chest and back pain around 9am, which intensified, leading him to present to the ED. This is the first episode of its kind. He denies any recent illnesses, denies travel. Denies fevers. Past Medical History: PMH: none PSH: L wrist surgery Social History: ___ Family History: non contributory Physical Exam: Vitals: 99.1 110 134/84 16 94% RA GEN: NAD, CV: RRR Pulm: nonlabored breathing, comfortable. Pigtail insertion site in R midaxillary line, covered with occlusive dressing. Tidaling well with respirations, subtle air leak with cough. Very small amount of serosanguinous output in tubing. Lung sounds appreciated bilaterally, non-diminished. No evidence of trauma on chest wall. Abd: soft, nontender, nondistended Pertinent Results: ___ CXR : Large right pneumothorax with mild leftward mediastinal shift ___ Chest CT : 1. A percutaneous pigtail catheter tip terminates in a small right apical pneumothorax. 2. Moderate emphysema, severe however at the lung bases. 3. Geographic linear ground-glass opacity along the paravertebral aspect of the left lower lobe is nonspecific. Finding may represent small airways disease. Brief Hospital Course: Mr. ___ was evaluated by the Thoracic Surgery service in the Emergency Room. A right pleural pigtail catheter was placed by the ER physician with some resolution of his right pneumothorax and he was admitted to the hospital for further management. His tube remained on suction and serial chest xrays showed a right apical pneumothorax but his air leak persisted. He was taken to the Operating Room on ___ where he underwent a right VATS blebectomy and pleurodesis. He tolerated the procedure well and returned to the PACU in stable condition. He maintained stable hemodynamics and his pain was controlled with Oxycodone and Tylenol. His tube remained on suction for 48 hrs and he had no air leak. Following removal of his tube on ___ his post pull chest xray showed a small left apical pneumothorax. His room air saturations were 96%. His port sites were healing well and he was much more comfortable. He was also on a nicotine patch to help him with smoking cessation. After an uneventful recovery he was discharged to home on ___ and will follow up with Dr. ___ in 2 weeks at which time his sutures will be removed. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) hours Disp #*100 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 3. Milk of Magnesia 30 mL PO Q12H:PRN Constipation - First Line 4. Nicotine Patch 21 mg/day TD DAILY RX *nicotine 21 mg/24 hour 1 patch once a day Disp #*28 Patch Refills:*0 5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX *oxycodone 5 mg 1 patch by mouth every six (6) hours Disp #*10 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Spontaneous right pneumothorax Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: * You were admitted to the hospital with a cough and chest pain and your chest xray showed a collapsed right lung. A chest tube was placed to help reinflate the lung but you had a persistent air leak and eventually required surgery. You have recovered well and are now ready for discharge. * Continue to use your incentive spirometer 10 times an hour while awake. * Check your incisions daily and report any increased redness or drainage. Cover the area with a gauze pad if it is draining. * Your chest tube dressing may be removed in 48 hours. If it starts to drain, cover it with a clean dry dressing and change it as needed to keep site clean and dry. You have some stitches in place that will be removed at your post op appointment with Dr. ___. * You may need pain medication once you are home but you can wean it over the next week as the discomfort resolves. Make sure that you have regular bowel movements while on narcotic pain medications as they are constipating which can cause more problems. Use a stool softener or gentle laxative to stay regular. * No driving while taking narcotic pain medication. * Take Tylenol on a standing basis to avoid more opiod use. * Continue to stay well hydrated and eat well to heal your incisions * Shower daily. Wash incision with mild soap & water, rinse, pat dry * No tub bathing, swimming or hot tubs until incision healed * No lotions or creams to incision site * Walk ___ times a day and gradually increase your activity as you can tolerate. Call Dr. ___ ___ if you experience: -Fevers > 101 or chills -Increased shortness of breath, chest pain or any other symptoms that concern you. Followup Instructions: ___
10161042-DS-22
10,161,042
27,538,146
DS
22
2176-07-29 00:00:00
2176-07-29 22:19:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine / Betadine Attending: ___. Chief Complaint: Headache, hypertension Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old woman with past medical history of severe OSA, COPD on home oxygen and still smoking, pulmonary artery hypertension, hypertension, type 2 diabetes, chronic renal failure, chronic lower back pain/sciatica who presents with headache. The patient states that her boyfriend has been sick with a cold recently (rhinorrhea, nasal congestion, chills, headaches). She woke up this morning with headache "right on the top of her head." Denies vision changes, nuchal rigidity, fevers/chills, nausea/vomiting, chest pain, shortness of breath, hemoptysis. She states she has been compliant with all her medications recently but feels she is coming down with her boyfriend's cold (stuffy nose, rhinorrhea, sinus congestion/pain, headache). Thus, she started taking sudafed ~2 days ago. Her chronic lower back pain has intensified in the last three months, and particularly the last few weeks. She was evaluated at ___ ___ and underwent steroid injections recently. They also started her on nabumetone. The patient denies any other new medications (other NSAIDs, Afrin, illicits). She does endorse significant recent stressors regarding her ___ year old daughter but becomes tearful prior to elaborating. She has not checked her blood pressure lately because the batteries have run out/died in her home monitor. In the ED, initial VS: T98.3, HR80, BP227/110, RR20, 93% on 4L NC. The patient's pain was initially ___ --> ___ with morphine 5mg IV X1. Non-contrast CT head was normal. The patient received hydralazine 10mg IV X2, labetalol 20mg IV X1, metoprolol tartrate 25mg PO X1, lorazepam 1mg IV X1. Labs were notable for Chem 7 with Cr1.7 (baseline 1.7-2.2), normal CBC. Currently, the patient is tearful in bed trying to blow her nose. Complains of lower back pain, headache, sinus congestion. Past Medical History: 1. Severe obstructive sleep apnea - the patient is being followed by Dr. ___ in the pulmonary clinic. 2. Diastolic CHF 3. Pulmonary artery hypertension 4. Hypertension 5. Diabetes mellitus type 2 6. Narcolepsy 7. GERD 8. COPD on home O2 9. Sciatica Social History: ___ Family History: Mother had breast cancer. Physical Exam: Admission exam: VS - Temp 98.6F, BP 208/153 --> 182/98, HR 114 --> 78, R 18, O2-sat 92% on 4L NC with mouth breathing GENERAL - Well-appearing woman in NAD, uncomfortable, appropriate but tearful HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, rhinorrhea/nasal congestion with mild TTP in sinus regions NECK - Supple, no thyromegaly, no nuchal rigidity LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, strength and sensation grossly intact Discharge exam: VSS, SBP 140-150s O2 sat ___ on 3LNC Exam otherwise unchanged from admission Pertinent Results: Admission labs: ___ 07:15PM BLOOD WBC-7.4 RBC-5.03 Hgb-13.6 Hct-43.1 MCV-86 MCH-27.0 MCHC-31.5 RDW-17.3* Plt ___ ___ 07:15PM BLOOD Neuts-69.9 ___ Monos-6.4 Eos-2.4 Baso-0.7 ___ 07:15PM BLOOD Glucose-86 UreaN-14 Creat-1.7* Na-142 K-4.3 Cl-100 HCO3-37* AnGap-9 ___ 05:35AM BLOOD Calcium-9.2 Phos-3.4 Mg-1.8 ___ 07:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Discharge labs: ___ 05:35AM BLOOD WBC-8.6 RBC-5.26 Hgb-13.9 Hct-45.0 MCV-86 MCH-26.4* MCHC-30.8* RDW-17.3* Plt ___ ___ 06:50AM BLOOD Glucose-187* UreaN-17 Creat-2.0* Na-136 K-4.3 Cl-95* HCO3-30 AnGap-15 Microbiology: None Imaging: CT head w/o contrast ___ IMPRESSION: No evidence of acute intracranial process. Small hypodensity in the left basal ganglia, for which a prior small lacunar infarct or normal perivascular space could be considered. CXR ___: IMPRESSION: 1. Mild central venous engorgement suggestive of hypervolemia. 2. No evidence of decompensated congestive heart failure or pneumonia. Brief Hospital Course: ___ year old woman with past medical history of severe OSA, COPD on home oxygen and still smoking, pulmonary artery hypertension, hypertension, type 2 diabetes, chronic renal failure, chronic lower back pain/sciatica who presents with headache, found to be hypertensive with SBP>200. # Hypertensive urgency: Likely multi-factorial, causing a headache. The patient has been in worsened pain recently, stressed regarding daughter and some psychosocial issues, taking nabumetone and sudafed. BP initially controlled with IV labetalol and hydralazine in the setting of headache without neurological deficits. After sudafed and nabumetone was discontinued, SBP 150-160s on home PO BP meds including furosemide, metoprolol succinate, lisinopril, and losartan. Started HCTZ on discharge for better BP control. Plan to follow up BP and electrolytes as outpatient. Can also consider DC losartan given already on lisinopril 40. # Headache: Possible due to elevated blood pressures given the patient's description. Also may be due to the URI she is currently experiencing as her boyfriend had similar symptoms. Also possible that her chronic pain, recent stressors and URI is stressing her enough to cause a tension headache. Headache improved after BP controlled. # Upper respiratory infection: Stable, new onset recently. Stopped sudafed due to hypertension. Guaifenesin/dextromethorphan PRN for cough # Chronic lower back pain/sciatica: Patient is no longer eligible for narcotics contract with ___. Is being seen at ___ and recently received injections. Occasionally after injections, pain intensifies before resolving. Continued home gabapentin. Minimized narcotics and NSAIDs. Plan to follow up with ___ pain ___. # Severe OSA: Not compliant with CPAP at home. Continued 3LNC (home level). # GERD: Stable. Continued omeprazole. # Hyperlipidemia: Stable. Continued home rosuvastatin. # COPD on home oxygen: The patient continues to smoke but is trying to decrease/quit. Continue home flovent, tiotropium, albuterol prn. # Type 2 diabetes: Stable. Continued home lantus 25 units qHS. Stopped ___ CKD. # Chronic renal failure: Recently her creatinine has started to climb into the 2s. Possibly due to long-standing hypertension and diabetes. Continued home lisinopril. # Transitional issues: - code status: full code - new meds: HCTZ - follow up at ___ and ___ pain clinic Medications on Admission: * Proventil inhaler PRN * Flovent 220mcg 2 puffs twice dialy * Furosemide 60mg ___ y * Gabapentin 800mg three times daily * Lantus 25 units qHS * Lisinopril 40mg daily * Losartan 25mg ___ y * Metformin XR 1000mg twice daily * Metoprolol succinate 50mg daily * Nystatin powder 100,000 units under breasts daily * Omeprazole 40mg daily * Rosuvastatin 20mg ___ y * Tiotropium 18mcg daily * Trazodone 100mg qHS * Aspirin 81mg daily * Docusate 100mg twice daily * Ketotifen fumarate 0.025% eye gtts twice daily Discharge Medications: 1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB 2. Fluticasone Propionate 110mcg 2 PUFF IH BID 3. Furosemide 60 mg PO DAILY 4. Gabapentin 800 mg PO TID 5. Glargine 25 Units Bedtime 6. Lisinopril 40 mg PO DAILY 7. Metoprolol Succinate XL 50 mg PO DAILY hold for SBP<100, HR<55 8. Losartan Potassium 25 mg PO DAILY 9. Omeprazole 40 mg PO DAILY 10. Rosuvastatin Calcium 20 mg PO DAILY 11. Tiotropium Bromide 1 CAP IH DAILY 12. traZODONE 100 mg PO HS 13. Aspirin 81 mg PO DAILY 14. Docusate Sodium 100 mg PO BID hold for loose stools, patient may refuse 15. Guaifenesin-Dextromethorphan ___ mL PO Q6H:PRN cough, congestion RX *Adult Robitussin Peak Cold DM 100 mg-10 mg/5 mL ___ ML by mouth every six (6) hours Disp #*1 Bottle Refills:*0 16. Hydrochlorothiazide 25 mg PO DAILY hold for SBP<90 RX *hydrochlorothiazide 25 mg 1 Tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY: Hypertensive urgency Viral Upper Respiratory Infection SECONDARY CHRONIC OBSTRUCTIVE PULMONARY DISEASE - on 3L NC at home baseline HEART FAILURE - Diastolic, LVEF 55% on ___ ECHO HYPERTENSION PULMONARY HYPERTENSION TYPE 2 DIABETES Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, You were admitted because you had a headache and high blood pressure. Your high blood pressure is partially a result of sudafed and nabumetone. Your blood pressure and headache got better after stopping these medications. We also started a new medication for high blood pressure called hydrochlorothiazide. We made the following changes to your medications: - STARTED guaifenesin/dextromethorphan ___ as needed for cough - STARTED hydrochlorothiazide - STOPPED Sudafed - STOPPED nabumetone - STOPPED metformin Followup Instructions: ___
10161042-DS-27
10,161,042
23,203,523
DS
27
2178-06-14 00:00:00
2178-06-14 15:04:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine / Betadine / Tylenol-Codeine #3 Attending: ___. Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: ___: intubation (extubated ___ History of Present Illness: ___ y/o F with COPD on 3L home O2presenting with SOB. Patient lives at the ___ ___. She reportedly developed shortness of breath and respiratory distress this morning. Had audible wheezes. Still smoking. FBG 154. VS 98.0, 83, 18, 114/65, 83-85% on 3L. She stated that she also had some mild chest pressure that was consistent with her usual COPD exacerbations. She denied fevers or chills. No cough. Reports RLE swelling x1 week with no pain or trauma. Per EMS, patient initially wheezy on exam but improved after neb. In the ED, VS 98.0, 81, 126/64, 20, 89% on 4L NC. On exam pt had no wheezing, desatted to ___ on 3LNC, had mild swelling in the RLE with pitting edema, ab soft nontender, RRR/S1S2. Pt was tried on bipap but became increasingly somnolent and acidotic so was intubated and started on prop/fent. She was given prednisone 60mg, azithro, nebs. RLE U/S for DVT was neg (prelim). Of note pt states her CPAP has been in storage so she has not been using it at ___. On arrival to the MICU, VS 99.1, 81, 151/78, 21, 93% on CMV 100% fio2, PEEP 5, Tv 500. Past Medical History: . Severe obstructive sleep apnea - the patient is being followed by Dr. ___ in the pulmonary clinic. 2. Diastolic CHF 3. Pulmonary artery hypertension 4. Hypertension 5. Diabetes mellitus type 2 6. Narcolepsy 7. GERD 8. COPD on home O2 9. Sciatica Social History: ___ Family History: Mother had breast cancer. Physical Exam: Admission Exam Vitals- VS 99.1, 81, 151/78, 21, 93% on CMV 100% fio2, PEEP 5, Tv 500. GENERAL: intubated, sedated, withdraws to painful stimuli but doesn't follow commands HEENT: PEERL NECK: large, obese LUNGS: coarse, junky breath sounds bilaterally but diminished on left CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, obese, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+ bilateral lower extremity edema, symmetric. Discharge physical: Vitals: Tm 98.6 Tc 97.7, HR 66, 121/58, RR 18, 99% on 3L NC General: Sitting propped up in a chair sleeping, easily arousable Neck: Supple Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi, breathing comfortably without accessory muscle use, nasal cannula in place CV: Regular rate and rhythm, no murmurs, rubs, gallops Abdomen: Obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ___ 09:27AM BLOOD WBC-10.2 RBC-4.03* Hgb-11.0* Hct-36.1 MCV-90 MCH-27.3 MCHC-30.5* RDW-18.7* Plt ___ ___ 09:27AM BLOOD Neuts-67.6 ___ Monos-6.3 Eos-4.8* Baso-0.9 ___ 04:00PM BLOOD ___ PTT-29.4 ___ ___ 09:27AM BLOOD Glucose-197* UreaN-44* Creat-2.4* Na-135 K-5.9* Cl-102 HCO3-25 AnGap-14 ___ 04:00PM BLOOD ALT-21 AST-22 CK(CPK)-99 AlkPhos-122* TotBili-0.4 ___ 04:00PM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-221* ___ 04:00PM BLOOD Calcium-9.2 Phos-4.2 Mg-1.9 ___ 04:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 09:39AM BLOOD ___ pO2-83* pCO2-69* pH-7.23* calTCO2-30 Base XS-0 ___ 09:39AM BLOOD Lactate-1.4 ___ 02:22AM BLOOD freeCa-1.23 ___ 01:15PM URINE Color-Straw Appear-Clear Sp ___ ___ 01:15PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 01:15PM URINE RBC-1 WBC-<1 Bacteri-FEW Yeast-NONE Epi-0 ___ 03:50PM URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-NEG amphetm-NEG mthdone-NEG ___ 05:15PM OTHER BODY FLUID Polys-32* Lymphs-2* Monos-2* Macro-8* Other-56* ___ 5:35 pm BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. SMEAR REVIEWED; RESULTS CONFIRMED. ___ 5:35 pm Rapid Respiratory Viral Screen & Culture Respiratory Viral Culture (Pending): Respiratory Viral Antigen Screen (Final ___: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture for further information. ___ 5:35 pm Rapid Respiratory Viral Screen & Culture **FINAL REPORT ___ Respiratory Viral Culture (Final ___: No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at ___ within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final ___: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture for further information. **FINAL REPORT ___ GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final ___: 10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora. STAPH AUREUS COAG +. ___. SENSITIVITIES PERFORMED ON REQUEST.. Isolates are considered potential pathogens in amounts >=10,000 cfu/ml. HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE. 10,000-100,000 ORGANISMS/ML.. Beta-lactamse negative: presumptively sensitive to ampicillin. Confirmation should be requested in cases of treatment failure in life-threatening infections.. ___ 3:50 pm URINE Source: Catheter. **FINAL REPORT ___ Legionella Urinary Antigen (Final ___: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. Urine cx: negative Blood cx: pending Imaging: ___ EKG Sinus rhythm. Normal ECG. No major change from the previous tracing. TRACING #2 ___ ___ IMPRESSION: No evidence of DVT in the right lower extremity veins. ___ CXR Portable AP radiograph of the chest was reviewed in comparison to a prior study obtained on ___. The ET tube tip is currently 4.5 cm above the carina. The NG tube tip passes below the diaphragm, not clearly seen. Although there is improvement of the left upper lobe aeration, there is still presence of left lower lobe atelectasis as well as right basal atelectasis. Small amount of pleural effusion cannot be excluded. No pneumothorax is seen. Discharge labs: ___ 06:10AM BLOOD WBC-10.1 RBC-3.96* Hgb-11.1* Hct-34.8* MCV-88 MCH-28.1 MCHC-32.0 RDW-19.0* Plt ___ ___ 04:00PM BLOOD Neuts-86.6* Lymphs-10.4* Monos-1.8* Eos-1.0 Baso-0.3 ___ 06:10AM BLOOD Glucose-78 UreaN-37* Creat-1.8* Na-143 K-4.2 Cl-104 HCO3-29 AnGap-14 ___ 06:10AM BLOOD Calcium-8.7 Phos-4.8* Mg-2.0 Brief Hospital Course: Ms. ___ is a ___ y/o F with COPD on 3L home O2 who presented with shortness of breath with hypercarbic respiratory failure likely due to COPD exacerbation. MICU course: ___ # hypercarbic resp failure: While in the ED she was retaining CO2 and was intubated there, CXR showed possible infiltrate and given her recent hospitalization was initially covered with antibiotics for HCAP coverage. She had a bronch which was negative. She was extubated on HD #2 without difficulty and was treated with levofloxacin and a steroid burst. #Acute on Chronic Kidney Injury- baseline Cr of 1.8 and was elevated to 2.4 on admission likely secondary to prerenal as it improved. Her meds were initially titrated according to her renal function and then restarted back on her home meds prior to discharge. # OSA: plan to resume CPAP once extubated # dCHF: cont atorvastatin. may benefit from diuresis due to ___ edema but given acute decompensation and PNA on CXR will give gentle fluids for sepsis # Hypertension: amlodipine 10mg daily, carvedilol 25mg BID, held lisinopril 40mg daily for hyperkalemia # Diabetes mellitus type 2: SSI; aspirin 81mg daily # GERD: famotidine 20mg po daily while intubated # Sciatica: hold home meds while intubated/sedated # ? gout: allopurinol renally dosed # ? depression: cont Venlafaxine XR 225 mg PO DAILY Medicine course: ___ Ms. ___ is a ___ with COPD on 3L home oxygen and OSA off CPAP who initially presented on ___ with shortness of breath, subsequently intubated for hypercarbic respiratory failure due to presumed COPD exacerbation, now s/p extubation ___ and transferred to the floor for further care. She was medically stable for discharge on ___ but did not have a bed at ___ ___. # Hypercarbic respiratory failure presumed due to COPD exacerbation/HIB infection: Required intubation in the ED due to worsening acidosis presumed secondary to COPD exacerbation following initial trial of BiPAP. Precipitant of her COPD exacerbation is not entirely clear in the absence of preceding URI symptoms, though she endorses sick exposures at ___ ___ (later positive for HIB, however). Initially treated with vancomycin, cefepime, and azithromycin and underwent bronchoscopy with negative BAL; transitioned to levofloxacin on ___. There are no clearly suggestive radiographic findings of HCAP, however. At the time of discharge, respiratory status was back to baseline and she was on 3L nc. BAL showed HIB and S. aureus. She completed a 5-day prednisone burst 40mg daily (day 1 = ___, last day ___ likely no need for extended taper, given relative infrequency of COPD exacerbations (last several months ago by her report). She was discharged to complete 7-day course of levofloxacin 750mg q48h (day 1 = ___, last day ___. Smoking cessation was encouraged. # Acute kidney injury: Resolved. She presented with creatinine of 2.4, up from 1.8-2.2 at baseline, back to baseline following IV fluids. # Hyperkalemia: Resolved. She presented with K of 7.1 without associated EKG changes, felt to be attributable to acute kidney injury and responsive to medical therapy without recurrence. Resolved at time of discharge and home lisinopril restarted. # Acute normocytic anemia: Hct is down to 33 to 35 on hospital day 2 to 3, from 36 to 40 at baseline, likely reflecting IV fluids and frequent phlebotomy in the absence of history of blood loss. HCT stabilized during hospital stay. # OSA: She is prescribed CPAP, but has not been using it consistently at ___ ___. She refused CPAP as an inpatient and was kept on continuous oxygen saturation monitoring. # Compensated dCHF: She appeared grossly euvolemic on exam at the time of transfer out of the ICU, without diuresis on this admission. Continued home aspirin 81mg daily and carvedilol 25mg bid. Returned to home dose lisinopril 40mg daily from 20mg daily on ___ as acute kidney injury and hyperkalemia had resolved. ___ consider outpatient TTE as needed for re-evaluation. # Hypertension: Continued home amlodipine 10mg daily, HCTZ 25mg daily, and carvedilol and lisinopril as above. # Diabetes mellitus type 2: Continued glargine with Humalog ISS. # GERD: Resumed home omeprazole 20mg bid in place of famotidine now that extubated. # Sciatica: Resumed home cyclobenzaprine and hydrocodone/acetaminophen as needed at discharge. Did not require aggressive pain control as an inpatient # Gout: Continued renally dosed allopurinol ___ daily. # Depression: Discontinued short-acting venlafaxine in favor of home venlafaxine XR 225mg daily in the morning. # CODE: Full Transitional issues: -She will take a last dose of levofloxacin on ___. -Ms. ___ should have a BMP drawn at her ___ appointment on ___ to ensure no recurrence of hyperkalemia on home dose of lisinopril. -___ consider outpatient TTE as needed for re-evaluation of CHF. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze 2. Allopurinol ___ mg PO DAILY 3. Acetaminophen 650 mg PO Q8H:PRN pain 4. Amlodipine 10 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Carvedilol 25 mg PO BID 7. Cyclobenzaprine 10 mg PO TID:PRN back pain 8. Fluticasone Propionate 110mcg 2 PUFF IH BID 9. Lisinopril 40 mg PO DAILY 10. Omeprazole 20 mg PO BID 11. Polyethylene Glycol 17 g PO DAILY:PRN constipation 12. Ropinirole 0.5 mg PO BID 13. Tiotropium Bromide 1 CAP IH DAILY 14. TraZODone 150 mg PO HS:PRN insomnia 15. Venlafaxine XR 225 mg PO DAILY 16. Hydrochlorothiazide 25 mg PO DAILY 17. FoLIC Acid 1 mg PO DAILY 18. Thiamine 100 mg PO DAILY 19. Gabapentin 300 mg PO BID 20. Atorvastatin 40 mg PO DAILY 21. Multivitamins 1 TAB PO DAILY 22. Glargine 25 Units Bedtime 23. Norco (HYDROcodone-acetaminophen) ___ mg oral q4h:PRN pain Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN pain 2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze 3. Allopurinol ___ mg PO DAILY 4. Amlodipine 10 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 40 mg PO DAILY 7. Carvedilol 25 mg PO BID 8. FoLIC Acid 1 mg PO DAILY 9. Hydrochlorothiazide 25 mg PO DAILY 10. Glargine 25 Units Bedtime 11. Lisinopril 40 mg PO DAILY 12. Multivitamins 1 TAB PO DAILY 13. Omeprazole 20 mg PO BID 14. Polyethylene Glycol 17 g PO DAILY:PRN constipation 15. Thiamine 100 mg PO DAILY 16. TraZODone 150 mg PO HS:PRN insomnia 17. Venlafaxine XR 225 mg PO DAILY 18. Levofloxacin 750 mg PO Q48H Duration: 1 Day Please take tablet on ___ RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*1 Tablet Refills:*0 19. Cyclobenzaprine 10 mg PO TID:PRN back pain 20. Fluticasone Propionate 110mcg 2 PUFF IH BID 21. Gabapentin 300 mg PO BID 22. Norco (HYDROcodone-acetaminophen) ___ mg oral q4h:PRN pain 23. Ropinirole 0.5 mg PO BID 24. Tiotropium Bromide 1 CAP IH DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnoses: #Hypercarbic respiratory failure secondary to COPD exacerbation #Acute kidney injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure caring for you at ___. You were admitted for a COPD exacerbation and needed to spend some time in the ICU. We treated you with oxygen, nebulizers, steroids, and antibiotics and your symptoms improved. We strongly recommend that you stop smoking, as this is the best way to prevent yourself from having another COPD exacerbation. Take care, and we wish you the best. Sincerely, Your ___ medicine team. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Followup Instructions: ___
10161112-DS-10
10,161,112
20,020,549
DS
10
2184-11-23 00:00:00
2184-11-25 23:49:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Cough/SOB Major Surgical or Invasive Procedure: Diagnostic Bronchoscopy ___ History of Present Illness: ___ h/o Squamou Cell Lung cancer, COPD, DM2, HTN/HL, h/o Left thoracotomy and left upper lobe sleeve lobectomy in ___ p/w fever and cough. Pt reports increased productive cough with sputum in the pas 2 weeks. She also has new onset supp O2 requirement per PCP referral note (unclear what amount). She denies f/c at home. She denies CP, SOB, or orthopnea. She denies wheezing. no sick contact. no myalgia/arthralgia. She has gotten her flue shot 3 weeks ago. no n/v, d/c. no dysuria. no skin rashes. Patient was seen at ___ and sent into the ED after CXR showed LLL consolidation. Hs has not been hospitalized in the last 3 month, did not receive chemotherapy or HD. She is not getting wound care. She denies recent IV antibiotics. She lives at home. In the ED initial vitals were: - Labs were significant for 98.0 74 153/100 20 97% 3L > 100.8 97 144/73 18 100% Nasal Cannula - CXR showed: Focal opacification within the left mid lung field concerning for pneumonia, but recurrent malignancy is not excluded. Recommend followup radiographs after treatment to assess for interval resolution. - CT chest showed: 1. Diffuse ground-glass opacities occupying the left lower lobe are new since prior examination, and could reflect an infectious process. In the setting of known cancer, short interval followup recommended to document resolution. 2. Moderate emphysema. 3. Large infrarenal aortic aneurysm, incompletely evaluated although relatively stable as compared to prior examination. - Patient was given IV CeftriaXONE 2 gm, IV Azithromycin 500 mg, PO Acetaminophen 650 mg On the floor, pt reports productive cough, but otherwise doing well. she reports breathing well w/o wheezing. Review of Systems: (+) per HPI (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: COPD PVD HTN HLD GERD T2DM incidentally found AAA macrocytosis hematuria proteinuria unspecified anemia osteopenia benign pancreatic cyst Raynaud's pnenomenon Gout + PPD, treated with INH x ___ yr age ___ PSHx: EUS bronchoscopy hysterectomy ___ Social History: ___ Family History: Mother had TB, died of colon cancer. She does not know her father's history. She has a brother that has esophageal cancer, bladder cancer, and renal cell carcinoma. Daughter w childhood leukemia/graft vs host disease died in ___ of ovarian cancer. Physical Exam: ADMISSION PHYSICAL PHYSICAL EXAM: Vitals - 97.8 116/60 78 22 95RA GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, good dentition NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: good airway entry b/l, +egophony at Left middle/lower fields, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL PHYSICAL EXAM: Vitals - Tmax 98.3, BP 90-135/50-63, HR68-75, RR18 O295-100% 1L O2 GENERAL: NAD; A+O x4, breathing comfortably HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, good dentition NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: good airway entry b/l, +egophony at Left middle/lower fields, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS ___ 06:50PM LACTATE-1.2 ___ 06:35PM GLUCOSE-102* UREA N-13 CREAT-0.9 SODIUM-139 POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-28 ANION GAP-15 ___ 06:35PM estGFR-Using this ___ 06:35PM WBC-5.6# RBC-3.52* HGB-11.6* HCT-34.9* MCV-99* MCH-33.1* MCHC-33.3 RDW-12.6 ___ 06:35PM NEUTS-69.1 ___ MONOS-7.6 EOS-3.9 BASOS-0.3 ___ 06:35PM PLT COUNT-228 STUDIES ___ - CXR showed: Focal opacification within the left mid lung field concerning for pneumonia, but recurrent malignancy is not excluded. Recommend followup radiographs after treatment to assess for interval resolution. - CT chest showed: 1. Diffuse ground-glass opacities occupying the left lower lobe are new since prior examination, and could reflect an infectious process. In the setting of known cancer, short interval followup recommended to document resolution. 2. Moderate emphysema. 3. Large infrarenal aortic aneurysm, incompletely evaluated although relatively stable as compared to prior examination. Brief Hospital Course: ___ h/o Squamous Cell Lung cancer, COPD, DM2, HTN/HL, h/o Left thoracotomy and left upper lobe sleeve lobectomy in ___ p/w sob and cough. ACUTE PROBLEMS # Concern for pneumonia vs pneumonitis - Pt initially presented with fever, cough, and opacification within the left mid lung field on CXR, concerning for PNA. The patient had previously finished a course of radiation for her SCLC. This put her at risk for developing pneumonitis. Pt was afebrile with good respiratory status on arrival to floor. CURB 65 was 1. Pt had no risk factor for ___ we cover for community acquired PNA. We continued IV antibiotics (ceftriaxone and azithromycin) for presumed PNA until bronch on ___. Remains comfortable with overall improvement in respiratory status since arrival. Patient had bronchoscopy on ___ and it did not show any signs concerning for bacterial pneumonia. Since the patient did improve on antibiotics during her hospital stay she was transitioned to levofloxacin and started on predinisone 60mg for presumed radiation pneumonitis with underlying CAP. The patient was afebrile, with normal BP and HR and was on her home dose of O2. She was discharged home on Levofloxacin, Prednisone, Bactrim for PCP ___, calcium and vitamin D for prevention of osteopenia. OF NOTE: After discharge Pathology sent urgent page. Hyphae were seen on the bronch brushing concerning for infective aspergillus. Dr. ___ Dr. ___ notified via email. Dr. ___ contacted the patient directly since patient had left the hospital and informed her to stop her Prednisone. She will follow up with Dr. ___ in his clinic for further evaluation and management. The cxr was also concerning for possible recurrent malignancy and will have to have followup bronch as outpatient with Dr. ___. Pt will need follow up bronch and follow up imaging to assure no recurrent malignancy as outpatient with Dr. ___. CHRONIC PROBLEMS # COPD - h/o Bronchiectasis. Pt does report increased cough and sputum production, which suggest some level of exacerbation, likely in the setting of a respiratory tract infection. Continued albuterol nebs, O2 supplementations PRN (titrate O2 sat > 93%). We treated PNA as above and used Benzonatate 100 mg PO TID: PRN for cough. We continued Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID. # squamous cell lung cancer - Pt is s/p Left thoracotomy and left upper lobe sleeve lobectomy in ___. As above, pt will need follow up bronch and imaging to assure resolution of LLL opacity. # DM2 - Pt on metformin at home. BS 102 on admission, remains low 100's. Metformin held while inpatient and pt started on ISS # HTN Continued home meds: - Atenolol 25 mg PO DAILY - Lisinopril 40 mg PO DAILY - Amlodipine 2.5 mg PO DAILY # HL Continued home meds: - Simvastatin 20 mg PO/NG DAILY # GERD Continued home meds: - cont. Omeprazole 40 mg PO DAILY TRANSITIONAL ISSUES -finish 7 day course of antibiotics for CAP: Levofloxacin 750mg PO Daily x2days (last day on ___ -pt to begin 4 week course of Predinsone for radition pneumonitis 60mg PO x 1 (___) week; 50mg PO x 1 (___) week; 40mg PO x 2 (___) weeks ***this was held once fungal forms identified -Bactrim SS 1 tab Daily for PCP ___ during prednisone treatment ***this was held once fungal forms identified -pt also will start Calcium 500mg BID and Vit D 1000u daily for osteopenia prevention while on predinisone -pt will continue her home oxygen and home nebulizer therapy -pt will continue all of her home medications -pt will follow up with PCP and Dr. ___ IP -___ tests include bronch lavage cultures and brushing; resp viral screen; and blood cultures -CHEM 7 and FSBS should be check at PCP visit to ensure no electrolyte abnormalities and to check her blood sugars. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Benzonatate 100 mg PO TID 2. Simvastatin 20 mg PO DAILY 3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 4. Atenolol 25 mg PO DAILY 5. Lisinopril 40 mg PO DAILY 6. Amlodipine 2.5 mg PO DAILY 7. fenofibrate 54 mg oral daily 8. Omeprazole 40 mg PO DAILY 9. Tiotropium Bromide 1 CAP IH DAILY 10. MetFORMIN (Glucophage) 250 mg PO DAILY 11. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, SOB 12. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Amlodipine 2.5 mg PO DAILY 2. Atenolol 25 mg PO DAILY 3. Benzonatate 100 mg PO TID 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. Lisinopril 40 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Omeprazole 40 mg PO DAILY 8. Simvastatin 20 mg PO DAILY 9. Tiotropium Bromide 1 CAP IH DAILY 10. Calcium Carbonate 500 mg PO BID RX *calcium carbonate [Calcium 500] 500 mg calcium (1,250 mg) 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 11. Levofloxacin 750 mg PO DAILY RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*2 Tablet Refills:*0 ******12. PredniSONE 60 mg PO DAILY *****(STOPPED POST DISCHARGE)***** RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*54 Tablet Refills:*0 13. Sulfameth/Trimethoprim SS 1 TAB PO DAILY RX *sulfamethoxazole-trimethoprim [Bactrim] 400 mg-80 mg 1 tablet(s) by mouth Daily Disp #*28 Tablet Refills:*0 14. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, SOB 15. fenofibrate 54 mg oral daily 16. MetFORMIN (Glucophage) 250 mg PO DAILY 17. Vitamin D 1000 UNIT PO DAILY 18. Vitamin D 1000 UNIT PO DAILY RX *cholecalciferol (vitamin D3) 1,000 unit 1 capsule(s) by mouth daily Disp #*28 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: ACUTE ISSUES Radiation Pneumonitis Community Acquired Pneumonia CHRONIC PROBLEMS Anemia Osteopenia PVD GERD GOUT Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, ___ was a pleasure taking part of your care during your stay at ___. You came to the hospital with cough and shortness of breath. A chest x-ray done at your outpatient provider made us concerned for a pneumonia. You were started on antibiotics when you arrived to the floor. You were seen by the pulmonologist during your stay. You also had a bronchoscopy on ___ ___, which did not show any sign of bacterial infection. You will also have a follow up bronchoscopy with Dr. ___ as an outpatient. You have follow-up scheduled with your PCP and with your Pulmonologist after your leave the hospital. You were started on a medication called Prednisone. You will take this medication for 4 weeks. For the first week you will take 60mg, the second week 50mg, and then 40mg for the last two weeks. You should also take calcium and vitamin D supplements, while taking prednisone in addition to your normal multi-vitamin. You will also be started on a medication called Bactrim which you will take every day while on prednisone to prevent further infection of your lungs. You will stop this medication when you finish your course of prednisone. You will also finish a course of antibiotics for your pneumonia. You will take Levofloxacin for two days after leaving the hospital with your last dose on ___. It is possible that while on prednisone, you blood sugars will fluctuate more than usual. You should check your blood sugars in the morning and if they are over 250 for more than three days in a row you should call your primary care physician's office. If you are concerned about your blood sugar you should call your PCP. Thank you for allowing us to participate in your care during your stay in the hospital. Sincerely, Your ___ Team Followup Instructions: ___
10161112-DS-12
10,161,112
24,848,241
DS
12
2188-02-18 00:00:00
2188-02-18 20:41:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old female with past medical history of juxtarenal abdominal aneurysm s/p fenestrated endovascular aneurysm repair ___, ___ of left lung s/p resection, COPD, who presents with abdominal pain and subacute constipation. Patient recently admitted ___ for AAA repair (EVAR with physician modified graft). Course complicated by volume overload/pulmonary edema and increased O2 requirement, and she was discharged on new medications including DAPT and furosemide 40 mg daily. Patient reports that since her surgery, she has had diffuse abdominal pain which is crampy, associated with constipation. In the last few days, her pain has changed position to bilateral lower quadrant. There is no associated fevers or chills, and she denies any hematochezia or melena. She has not been able to tolerate much by mouth, mostly because she is afraid that her abdomen will hurt more after eating, and she is worried that she won't be able to have bowel movements. She has tried sipping water and having some banana, toast, and applesauce. In terms of her constipation, she noted that she really did not have any BM during her last hospitalization for AAA repair (___). After going home, she took daily miralax with minimal effect, and one dose of milk of magnesia on ___, with diarrhea x 6 episodes at that time that then resolved. She denies a history of GI bleeds and does not recall an abnormal colonoscopy in her past with her last one being greater than ___ years ago. She also does note that she has had decreased urinary output in the last several days. Past Medical History: PMH: Stage I squamous cell carcinoma, PDT and XRT COPD Hypertension DM2 Peripheral vascular disease Abdominal aortic aneurysm PSH: - LUL sleeve resection - Hysterectomy, RSO Social History: ___ Family History: Mother had TB, died of colon cancer. She does not know her father's history. She has a brother that has esophageal cancer, bladder cancer, and renal cell carcinoma. Daughter w childhood leukemia/graft vs host disease died in ___ of ovarian cancer. Physical Exam: ADMISSION PHYSICAL EXAM: =========================== VS: ___ 0112 BP: 135/72 L Lying HR: 67 RR: 18 O2 sat: 98% O2 delivery: 3L GENERAL: NAD, rounded faces HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles, diminished breath sounds throughout ABDOMEN: nondistended, mildly tender in bilateral lower quadrants LLQ>RLQ, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSCIAL EXAM ========================== Physical exam: VS: 24 HR Data (last updated ___ @ 945) Temp: 98.2 (Tm 98.5), BP: 132/64 (92-132/54-64), HR: 66 (61-71), RR: 18 (___), O2 sat: 97% (94-98), O2 delivery: 3L, Wt: 140 lb/63.5 kg GENERAL: NAD, rounded faces HEENT: AT/NC, pink conjunctiva, MMM NECK: no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles, diminished breath sounds throughout ABDOMEN: nondistended, mildly tender to deep palpation, no rebound/guarding NEURO: A&Ox3, moving all 4 extremities with purpose Pertinent Results: ADMISSION LABS ==================== ___ 01:30PM BLOOD WBC-14.9*# RBC-3.22* Hgb-10.1* Hct-33.5*# MCV-104* MCH-31.4 MCHC-30.1* RDW-13.3 RDWSD-51.3* Plt ___ ___ 01:30PM BLOOD Neuts-78.6* Lymphs-13.4* Monos-6.0 Eos-0.9* Baso-0.2 Im ___ AbsNeut-11.69* AbsLymp-1.99 AbsMono-0.89* AbsEos-0.14 AbsBaso-0.03 ___ 01:30PM BLOOD Plt ___ ___ 03:14PM BLOOD ___ PTT-36.1 ___ ___ 01:30PM BLOOD Glucose-85 UreaN-29* Creat-1.3* Na-144 K-4.4 Cl-98 HCO3-31 AnGap-15 ___ 01:30PM BLOOD ALT-9 AST-11 LD(LDH)-238 AlkPhos-51 TotBili-0.3 ___ 01:30PM BLOOD Albumin-3.6 Calcium-9.8 Phos-3.9 Mg-2.2 DISCHARGE LABS ==================== ___ 04:45AM BLOOD WBC-8.7 RBC-2.56* Hgb-8.0* Hct-26.8* MCV-105* MCH-31.3 MCHC-29.9* RDW-13.4 RDWSD-51.8* Plt ___ ___ 04:45AM BLOOD Plt ___ ___ 04:45AM BLOOD ___ PTT-35.4 ___ ___ 04:45AM BLOOD Glucose-76 UreaN-22* Creat-1.1 Na-144 K-4.2 Cl-103 HCO3-28 AnGap-13 ___ 04:45AM BLOOD ALT-8 AST-9 LD(LDH)-170 AlkPhos-39 TotBili-0.2 ___ 04:45AM BLOOD Albumin-3.1* Calcium-9.2 Phos-4.0 Mg-2.0 MICROBIOLOGY ==================== ___ 8:30 pm BLOOD CULTURE 2 OF 2. Blood Culture, Routine (Pending): ___ 4:20 pm URINE Source: ___. URINE CULTURE (Pending): IMAGING ====================== ___ CXR IMPRESSION: -Interval improved aeration of the remaining left lung and right base compared to ___. -Persistent left upper lung opacity and small pleural effusion. ___ CTA IMPRESSION: 1. Mild fat stranding around the bladder with mild wall thickening, suggestive of cystitis in the right clinical setting. Correlation with urinalysis is suggested. 2. Status post aorto bi-iliac stenting from the descending aorta with additional stents in the celiac, superior mesenteric and bilateral renal arteries, which all remain patent. No evidence of endoleak. Stable aneurysm sac size. 3. Stable pancreatic cystic lesions measuring up to 2.0 cm, likely side branch IPMN. Mild pancreatic duct dilatation is also unchanged. 4. Moderate hiatal hernia. 5. Overall stable appearance of the left hemithorax with postoperative and post radiation changes re-demonstrated in the remaining left lower lobe. 13 mm nodular area in the periphery of the remaining left lower lobe is nonspecific and may represent focal atelectasis, however, close attention on follow-up is recommended with follow-up chest CT in 3 months. Brief Hospital Course: ___ year old female with past medical history of juxtarenalabdominal aneurysm s/p fenestrated endovascular aneurysm repair ___, SCC of left lung s/p resection, COPD on 3L home O2, who presents with abdominal pain most likely from subacute constipation. # Abdominal pain # Leukocytosis CTA torso without evidence of complication of endovascular repair, including no mesenteric ischemia. All stents appear patent, and there is no evidence of endoleak. Was also seen by vascular surgery who did not suspect complications of her recent graft repair. In the setting of leukocytosis, cramping lower quadrant pain and questionable diverticulitis on initial radiology wet read, was covered for intra-abdominal source with ceftriaxone and metronidazole in the ER, then cipro/flagyl. Final read of CT abdomen was without evidence of colitis or diverticulitis on imaging, so antibiotics were discontinued. LFTs WNL. Was ultimately suspected to be ___ to constipation. Improved with supportive care, slow advancement of diet, and standing bowel regimen. # Constipation Timing seems to coincide with recent surgery/ hospitalization. No stool ball on rectal exam in ED. Patient passing gas, no evidence of obstruction. Started on docusate, senna, miralax, and bisacodyl suppository standing. # ___ Baseline Cr 0.9, at 1.3 on admission. Likely pre-renal in the setting of known decreased PO intake, and new initiation of diuretic (furosemide 40 mg) during last hospitalization. Otherwise, no evidence of UTI. No history to suggest post-renal etiology/retention. Improved to 1.1 with fluids. Her lisinopril and furosemide were held while in house. # History of pulmonary edema Per review of prior notes, patient with pulmonary edema during last hospitalization, likely due to IVF administration in setting of surgery. Did have CTA torso showing have enlarged main pulmonary artery up to 3.1 cm and also some evidence of pulmonary hypertension on ___ TTE w/ PASP 38 mmHg + RAP. Remained euvolemic while in house. # ?Weight loss: Noted documented weight loss of ~12 lbs since last admission 14 days ago likely ___ to ongoing diuresis and poor PO intake. # Peripheral vascular disease # AAA s/p repair Was seen by vascular surgery who did not suspect complications of recent repair. Continued home aspirin 81 mg and clopidogrel 75 mg daily # Hypertension - Holding lisinopril in setting ___ - Continue home amlodipine 2.5 mg daily # COPD - Continued prednisone 10 mg daily, albuterol, tiotropium # Diabetes mellitus - Diet controlled, fingersticks, SSI while in house # Hyperlipidemia: Continued home simvastatin 20 mg TRANSITIONAL ISSUES ==================== []CTA torso she does have enlarged main pulmonary artery up to 3.1 cm and also some evidence of pulmonary hypertension on ___ TTE w/ PASP 38 mmHg + RAP. Consider TTE for further evaluation. [] Per patient, has been greater than ___ years since colonoscopy. Can consider repeat if ongoing weight loss and GI distress [ ] 13 mm nodular area in the periphery of the remaining left lower lobe is nonspecific and may represent focal atelectasis, however, close attention on follow-up is recommended with follow-up chest CT in 3 months. [ ] Holding Lasix and lisinopril going forward due to normotension and poor PO intake. Can readdress as an outpatient. - Please follow up patients symptoms of early satiety and abdominal fullness. If symptoms recurrent, please consider GI referral and colonoscopy. #CODE: Full with limited trial #CONTACT: ___ Relationship: Husband Phone number: ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 2.5 mg PO HS 2. Atenolol 25 mg PO QHS 3. Fluticasone Propionate 110mcg 4 PUFF IH BID use with spacer 4. Lisinopril 40 mg PO DAILY 5. Omeprazole 40 mg PO DAILY:PRN Indigestion 6. PredniSONE 10 mg PO DAILY 7. Simvastatin 20 mg PO QPM 8. tiotropium bromide 18 mcg inhalation DAILY 9. albuterol sulfate 90 mcg/actuation inhalation DAILY:PRN SOB/Wheezing 10. Fenofibrate 54 mg PO DAILY 11. Multi Complete with Iron (multivitamin-iron-folic acid) ___ mg-mcg oral DAILY 12. sodium chloride 0.9 % inhalation DAILY:PRN SOB/wheezing 13. Aspirin EC 81 mg PO DAILY 14. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 15. Clopidogrel 75 mg PO DAILY 16. Furosemide 40 mg PO DAILY Discharge Medications: 1. Bisacodyl 10 mg PR QHS:PRN constipation RX *bisacodyl 10 mg 1 suppository(s) rectally QHS:PRN Disp #*30 Suppository Refills:*0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*3 3. Multivitamins 1 TAB PO DAILY 4. Polyethylene Glycol 17 g PO DAILY Hold for frequent bowel movements RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily:PRN Disp #*30 Packet Refills:*2 5. Senna 8.6 mg PO BID constipation Hold for frequent bowel movements RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*60 Tablet Refills:*0 6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 7. albuterol sulfate 90 mcg/actuation inhalation DAILY:PRN SOB/Wheezing 8. amLODIPine 2.5 mg PO HS 9. Aspirin EC 81 mg PO DAILY 10. Atenolol 25 mg PO QHS 11. Clopidogrel 75 mg PO DAILY 12. Fenofibrate 54 mg PO DAILY 13. Fluticasone Propionate 110mcg 4 PUFF IH BID use with spacer 14. Omeprazole 40 mg PO DAILY:PRN Indigestion 15. PredniSONE 10 mg PO DAILY 16. Simvastatin 20 mg PO QPM 17. sodium chloride 0.9 % inhalation DAILY:PRN SOB/wheezing 18. tiotropium bromide 18 mcg inhalation DAILY 19. HELD- Furosemide 40 mg PO DAILY This medication was held. Do not restart Furosemide until You see your PCP and oral intake improves 20. HELD- Lisinopril 40 mg PO DAILY This medication was held. Do not restart Lisinopril until Your oral intake improves. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Constipation Abdominal pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at ___! You were admitted to the hospital because you were having stomach pain. While you were here, you had a scan of your stomach which did not show signs of infection in your colon and the sites of your surgery look great. Your stomach pain improved and you were able to tolerate a normal diet. Initially, you were given antibiotics, but we stopped these when your stomach improved. We think constipation is causing your pain. When you go home, it is important to follow-up with your PCP and vascular surgeons. If you have severe abdominal pain, nausea, vomiting, diarrhea, or persistent constipation, please come back to the ER. We wish you the best of luck! Your ___ Care Team Followup Instructions: ___
10161682-DS-10
10,161,682
24,238,867
DS
10
2168-01-11 00:00:00
2168-01-15 16:05:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Lisinopril / pravastatin Attending: ___. Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Thoracentesis Thoracoscopy ___ History of Present Illness: Mr. ___ is a ___ with history of afib on coumadin, DM2 (A1c 10.1%), HTN, HLD, Morbid obesity, OSA, CKD (baselkine Cr 1.6) who presents with progressively worsening shortness of breath. Patient reports over the course of 3 months he has noticed shortness of breath with climbing 1 flight of stairs or taking a shower. These symptoms have progressively worsened to the point that he feels short of breath with talking for prolonged periords of time or bending over to tie his shoes. At baseline, patient reports he is very active in his ___ business and constantly walking around; more than 1 miles per day without any problems. These symptoms of shortness of breath are also associated with exertional lower abdominal pain as well as pain in his bilateral legs which resolve after 5 minutes of resting. No palpitations, chest pain or exertional chest pain. No orthopnea, PND or peripheral edema. No prior history of MI. Patient also reports an episode of syncope about ___ weeks ago. He reports he was walking to his chair when all of sudden he lost consciousness for few seconds and fell to the ground. No LOC and no confusion afterwards. He has had 2 similar syncopal episodes in the past. No prodromal symptoms. Over the course of past week, patient also reports worsening productive cough, nasal congestion and pleuritic chest pain on the right side of his chest. No fevers, chills or night sweats. No sick contacts or travel history. He was seen for regular follow up in the ___ clinic today and noted to be hypoxemic therefore sent to the ED for further evalaution. In the ED, initial vitals were: 99.2 75 140/72 18 95% ra. - Labs were significant for WBC 7.2, HCT 39, PLT 147. BUN/Cr ___ which is baseline; INR 3.3. Trop <0.01. Lactate 1.4. Blood culture sent. - CT head showed no acute intracranial process. CXR revealed multifocal right-sided pneumonia along with some vascular congestion. - The patient was given 750mg IV Levaquin and admitted for management of syncope and pneumonia. REVIEW OF SYSTEMS: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History: - Atrial Fibrillation on coumadin - Type II Diabetes A1c 10.1 on ___ - Hypertension - Hyperlipidemia - Morbid Obesity - CKD Stage III with baseline Cr 1.6 - GERD - Allergic Rhinitis - Obstructive Sleep Apnea - Sexual Dysfunction - Hx of sessile colon adenomas; colonoscopy ___ - Hx of iron deficiency anemia - BPH - mild COPD on PFTs ___ - Sickle cell trait Social History: ___ Family History: Prostate cancer in dad. Mom lived till ___ Physical Exam: Admission Physical: Vitals: 98.2 179/116 76 91%RA General: Alert, oriented, no acute distress, speaking in full sentences HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, unable to visulize JVP, no LAD CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur at apex Lungs: Decreased breath sounds in the right lung bases, with few crackles in the bilateral lung bases. No rhonchi. + few scattered wheezes. Abdomen: Obese, Soft, non-tender, non-distended, bowel sounds present GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Alert and oriented Discharge Physical: Pertinent Results: Admission Labs: ___ 05:00PM BLOOD WBC-7.2 RBC-5.02 Hgb-13.6* Hct-39.0* MCV-78* MCH-27.1 MCHC-34.9 RDW-16.9* Plt ___ ___ 05:00PM BLOOD Glucose-293* UreaN-22* Creat-1.6* Na-141 K-3.7 Cl-101 HCO3-30 AnGap-14 ___ 07:30AM BLOOD CK(CPK)-396* ___ 05:00PM BLOOD cTropnT-<0.01 ___ 07:30AM BLOOD CK-MB-4 cTropnT-0.01 proBNP-158 ___ 08:30AM BLOOD CK-MB-3 cTropnT-<0.01 ___ 05:00PM BLOOD Calcium-9.5 Phos-3.3 Mg-1.9 ___ 08:20AM BLOOD HIV Ab-NEGATIVE ___ 10:38AM BLOOD Type-ART pO2-48* pCO2-53* pH-7.42 calTCO2-36* Base XS-7 ___ 05:04PM BLOOD Lactate-1.4 Discharge Labs: ___ 07:22AM BLOOD WBC-7.5 RBC-4.43* Hgb-11.6* Hct-35.8* MCV-81* MCH-26.2 MCHC-32.4 RDW-16.4* RDWSD-48.0* Plt ___ ___ 07:22AM BLOOD Glucose-212* UreaN-22* Creat-1.6* Na-141 K-4.7 Cl-101 HCO3-29 AnGap-16 ___ 07:22AM BLOOD Calcium-9.1 Phos-4.2 Mg-2.0 Other pertinent Studies ___ 4:00 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES R PLEURAL FLUID. **FINAL REPORT ___ Fluid Culture in Bottles (Final ___: NO GROWTH. ___ 4:00 pm PLEURAL FLUID R PLEURAL FLUID. LEAKING SPECIMEN INTERPRET RESULTS WITH CAUTION. GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): ___ 04:00PM PLEURAL WBC-1288* RBC-3188* Polys-15* Lymphs-51* Monos-2* Eos-14* Meso-12* Macro-6* Other-0 ___ 04:00PM PLEURAL TotProt-4.2 Glucose-250 LD(LDH)-347 Albumin-2.6 ___ Misc-PRO BNP = ___ 10:44 pm SPUTUM Source: Induced. GRAM STAIN (Final ___: <10 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final ___: TEST CANCELLED, PATIENT CREDITED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): ___ 6:27 am SPUTUM Source: Induced. GRAM STAIN (Final ___: <10 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final ___: TEST CANCELLED, PATIENT CREDITED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): GRAM STAIN (Final ___: <10 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final ___: TEST CANCELLED, PATIENT CREDITED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): Pertinent Imaging: ============ CT Chest IMPRESSION: Apparent large right apical lung mass is difficult to differentiate from adjacent loculated component of large right pleural effusion. In conjunction with right paratracheal and right hilar lymph node enlargement as well as pleural nodularity, the constellation of findings is concerning for primary lung cancer with potential malignant pleural effusion and lymph node involvement. Considering the limitations of this unenhanced scan, further evaluation could be performed either with initial contrast-enhanced CT or, alternatively, a PET-CT, which could simultaneously evaluate the mass and assist with staging. Small sclerotic focus in right third rib is potentially due to bone island but could be correlated with PET-CT. CT abdomen pelvis IMPRESSION: 1. No evidence of malignancy in the abdomen or pelvis. Please refer to the chest CT dictation regarding intrathoracic findings. 2. Multiple benign-appearing bilateral renal cysts, better characterized on prior abdominal ultrasound. 3. Diverticulosis without evidence of diverticulitis. 4. Moderate BPH. MRI Head: IMPRESSION: 1. Image quality is degraded by motion artifact. No definite evidence of acute infarction, acute hemorrhage, or enhancing mass lesion 2. Extensive T2/FLAIR signal hyperintensity in the periventricular, subcortical, and deep white matter which is nonspecific but likely on the basis of chronic small vessel ischemic disease. Brief Hospital Course: ___ with history of afib on coumadin, DM2 (A1c 10.1%), HTN, HLD, Morbid obesity, OSA, CKD (baselkine Cr 1.6) who presents with progressively worsening shortness of breath found to have a RUL mass. BRIEF MICU COURSE: Patient was transfered to the MICU on ___ for hypotension and hypoxemia. His hypotension resolved on the floor, and was likely due to oxycodone and cyclobenzabrine co-administration. His hypoxemia resolved with 40mg IV lasix given on the floor, with downtitration of his O2 back to 4L. His pulmonary edema may have been re-expansion from thoracentesis, or fluid accumulation in the setting of his new ___. His urine output was adequate during his ICU stay without further diuresis. His ___ was attributed to pre-renal etiology based on his urine lyte studies. By the time of his transfer back to the floor, his creatinine was improving. # Shortness of breath/Hypoxemia: The patient was initially treated for pneumonia with levofloxacin. He continued to be dyspneic requiring oxygen. Pulmonary was consulted and given history of working as a ___ in ___ TB ___, suggested he be ruled out for TB. He had 3 negative AFB smears. They also recommended CT chest for the RUL opacity seen on chest x ray. This was visualized on CT and was concerning for malignancy. The CT chest also redemonstrated pleural fluid. The levofloxacin was discontinued. Given suspicion for malignancy, a thoracentesis was performed looking for malignant cells. The pleural fluid studies were suggestive of exudate however no malignant cells were found. The patient then underwent a thoracoscopy to sample tissue from the mass and had placement of a PleurX drain. The patient continued to be hypoxic desaturating to ___ on ambulation on room air with improvement to the ___ with oxygen. On ambulation with 5L NC O2, the patient was able to maintain sats in the ___. Although no diagnosis of cancer was confirmed on this admission, the profound hypoxia was thought to be related to potential lymphangitic spread of malignant cells. # Syncope: The patient reports 3 syncopal episodes over a ___ year period most recently 2 weeks prior to admission. Cardiology was consulted and ultimately though syncope could be related to sinus conversion pauses. They did not think there would be utility in ___ of ___ monitor since the episodes happen so infrequently. Given that syncope happened i/s/o concern for malignancy, the patient had an MRI head which was normal and showed no evidence of metastatic disease. # Atrial Fibrillation: The patient has paroxysmal a fib and was intermittently in sinus rhythm while admitted. His anticoagulation was held given multiple procedures while inpatient. Per cardiology, he did not require bridging therapy. He was restarted on coumadin on discharge. He was continued on diltiazem and labetalol throughout this admission. # CKD Stage III: Cr remained at baseline. He was continued on calcitriol. # Type II Diabetes: A1c 10.1%. The patient had persistently low morning glucose readings of low ___ on admission. He also reported feeling dizzy at home in the morning often due to low sugars. His Lantus was initially kept at 60 units but was decreased due to low BGs. # Hypertension: The patient was intermittently hypertensive during admission but bps were stable and he did not require additional agents for control. He was continued on his home medications of losartan, diltiazem, chlorthalidone, and labetalol. # Hyperlipidemia: pravastatin dced recently give side effects. # Microcytic Anemia: Liekly ___ CKD. continue ferrous sulfate # OSA: The patient was continued on CPAP although he was not always compliant with it. Transitional Issues: ============ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 100 mg PO DAILY 2. Tiotropium Bromide 1 CAP IH DAILY 3. Labetalol 600 mg PO TID 4. Diltiazem Extended-Release 180 mg PO DAILY 5. Fluticasone Propionate NASAL 2 SPRY NU DAILY 6. Warfarin 12.5 mg PO 4X/WEEK (___) 7. Warfarin 10 mg PO 3X/WEEK (___) 8. Ferrous Sulfate 325 mg PO BID 9. tadalafil 5 mg oral 1 tablet(s) by mouth ___ hour before sexual activity 10. Chlorthalidone 25 mg PO DAILY 11. Calcitriol 0.5 mcg PO DAILY 12. Glargine 60 Units Breakfast 13. albuterol sulfate 90 mcg/actuation inhalation ___ inhalations po up to QID prn shortness of breath Discharge Medications: 1. Calcitriol 0.5 mcg PO DAILY 2. Ferrous Sulfate 325 mg PO BID 3. Fluticasone Propionate NASAL 2 SPRY NU DAILY 4. Glargine 30 Units Breakfast 5. albuterol sulfate 90 mcg/actuation INHALATION ___ INHALATIONS PO UP TO QID PRN shortness of breath 6. tadalafil 5 mg oral 1 tablet(s) by mouth ___ hour before sexual activity 7. Tiotropium Bromide 1 CAP IH DAILY 8. Warfarin 12.5 mg PO 4X/WEEK (___) 9. Warfarin 10 mg PO 3X/WEEK (___) 10. Labetalol 400 mg PO BID 11. Losartan Potassium 50 mg PO DAILY 12. Senna 17.2 mg PO HS Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Stage 4 non-small cell lung carcinoma Small bowel obstruction Paroxysmal Atrial fibrillation AoCKD Stage III Type 2 diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, Thank you for letting us participate in your care. You were admitted to the hospital here at ___ because you were experiencing worsening shortness of breath. You were found to have a mass in your lung and fluid in the area around your lung. We placed a PleurX catheter in your lung to help drain the fluid that was removed before discharge. The mass was found to be stage 4 non-small cell lung carcinoma. For this, you will follow up as an outpatient at the ___ Cancer ___. You were also experiencing increased abdominal pain and distension from a small bowel obstruction. We placed an NG-tube and foley to help relieve the obstruction, which gradually resolved. We are sending you home with home oxygen. Please also follow-up with your appointment at ___ for your cancer treatment. During your hospitalization we have made several changes to your medications: -lantus 30Uqam -stopped diltiazem -decreased losartan to 50mg daily -decreased labetalol to 400mg twice daily Please continue to take your medications as directed and follow up with your appointments below. It was a pleasure taking care of you. Your ___ Care Team Followup Instructions: ___
10161722-DS-20
10,161,722
29,288,854
DS
20
2181-05-08 00:00:00
2181-05-14 16:19:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Ace Inhibitors Attending: ___. Chief Complaint: leg pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year old gentleman with history of idiopathic polyneuropathy, ETOH abuse, chronic bilateral ___ edema and xerosis on furosemide who presented with pain and swelling in the right lower extremity. Patient has had 9 days of redness, clear/yellow drainage and tenderness in the back of the right calf. He says he has had this swelling for many years but that the redness is new. He had recent fall 2 weeks ago, no other recent falls or trauma. He has not had fevers or chills. He has been trying to clean the wound with hydrogen peroxide without significant improvement. Additionally he stopped taking his lasix on ___ because he was concerned about affecting his kidneys. He has noted shortness of breath with walking, can walk approximately 10 feet. He has not had chest pain or palpitations. He denies orthopnea though sleeps sitting up in a recliner, no PND. His weight is up approximately 10lbs from his recent baseline. He has not had increased fluid intake, increased salty foods. Given pain and non healing wound patient presented to the ED for further evaluation. In the ED, initial vital signs were: 97.5 88 170/76 20 100% Per ED nursing, his right outer thigh was red and oozing to the point where his jeans were sopping wet and his R foot was soaked and his skin on his foot is sloughing off. The smell was reportedly "toxic." His ex wife left because she couldn't take the smell and took his clothing with her to clean them, his socks were thrown out and the ED nurse cleansed his skin and sloughed off some skin from his foot. - Exam notable for: bilateral ___ edema with venous stasis changes. red, warm, tender area in the right posterior calf with weeping drainage, no crepitus. - Labs were notable for WBC 4.9, HCT 33, cre 1.5, glucose 160, lactate 2.3. -No additional studies were performed Blood cultures were obtained, patient received 2G IV vancomycin, 500cc IVF and was admitted to medicine for further evaluation and treatment. - Vitals on transfer: 98.1 76 130/60 18 100% RA Upon arrival to the floor, the patient is feeling well. He has intermittent burning pain at R leg wound site, ___ on pain scale, no radiation. He reports he is unsteady on his feet and walks with a walker at home, last fell 2 weeks ago. He has not had any recent travel or prolonged flights. He endorses shortness of breath with exertion but no shortness of breath at rest. No other complaints. Past Medical History: ACUTE RENAL FAILURE BREAST ENLARGEMENT CHEST PAIN COUGH ON ACE HEADACHES HYPERTENSION L EAR FLAKING ALCOHOL ABUSE Chronic lower extremity edema of unclear etiology, likely venous stasis Lower extremity xerosis vs. stasis dermatitis Idiopathic polyneuropathy Hypothyroidism Social History: ___ Family History: notable for hypertension in a sibling, no CAD, no diabetes, no cancer. Physical Exam: ADMISSION EXAM: Vitals- T 98.8 HR 88 BP 151/69 RR 18 O2 sat 100% on RA Weight: 369 lbs General: obese black male lying in bed speaking in full sentences very comfortable appearing, NAD HEENT: PERRL, MMM, no scleral icterus or conjunctival pallor, oropharynx with poor dentition no erythema or exudate Neck: supple with JVP elevated 10cm to earlobe CV: RRR, S1, S2 with II/VI systolic murmur best appreciated at ___, no rubs or gallops Lungs: CTAB, no crackles, wheezes, rhonchi Abdomen: obese, soft, non distended, non tender to deep palpation, +BS, no hepatosplenomegaly appreciated GU: no CVA tenderness, no foley in place Ext: bilateral lower extremities with massive pitting edema to knee, overlying chronic venous stasis changes and dry flaking skin, DP pulses 2+ bilaterally, RIGHT lower extremity with 13cmx 9cm open superficial wound on lateral surface with granulation tissue, foul smelling without warmth, no surrounding erythema or induration, no purulent drainage; negative ___ sign Neuro: axox3, CNII-XII grossly intact, freely moving all 4 extremities, difficulty moving bilateral lower extremities secondary to weight of legs Skin: well healed lateral scars on chest, Right lower extremity wound as detailed above DISCHARGE EXAM: Vitals: 98.3 max and current 66 (60s-70s) 114/66 (110s-120s/40s-60s) Weight: 175.5 kg (386.9 lbs) General: obese black male lying in bed speaking in full sentences very comfortable appearing, NAD HEENT: PERRL, MMM, no scleral icterus or conjunctival pallor, oropharynx with poor dentition no erythema or exudate Neck: supple with difficult to assess JVP, no significant JVD CV: RRR, S1, S2 with II/VI systolic murmur best appreciated at LLSB, no rubs or gallops Lungs: CTAB, no crackles, wheezes, rhonchi Abdomen: obese, soft, non distended, non tender to deep palpation, +BS, no hepatosplenomegaly appreciated Ext: bilateral lower extremities with massive non pitting edema to knee, overlying chronic venous stasis changes and improving dry flaking skin, DP pulses 2+ bilaterally, RIGHT lower extremity with improving approx 32 x 13 cm open superficial wound on lateral surface with granulation tissue, improved foul smell, without warmth, no surrounding erythema or induration, no purulent drainage; negative ___ sign R calf 24inches L calf 22inches with RIGHT ___ appearing more swollen than LEFT lower extremity Left lower extremity with swollen erythematous ankle with swollen foot, warm to touch though same temperature bilaterally, 2+ DP, no pain with active or passive motion Neuro: AOx3, CNII-XII grossly intact, freely moving all 4 extremities, difficulty moving bilateral lower extremities secondary to weight of legs, no asterixis Skin: well healed lateral scars on chest, Right lower extremity wound as detailed above, gynecomastia, no palmar erythema or spider angiomata Pertinent Results: LABS ON ADMISSION: ___ 03:50PM BLOOD WBC-4.9 RBC-3.42* Hgb-10.6* Hct-33.0* MCV-97 MCH-31.0 MCHC-32.1 RDW-17.5* Plt ___ ___ 03:50PM BLOOD Neuts-81.5* Lymphs-8.4* Monos-8.3 Eos-1.3 Baso-0.5 ___ 03:50PM BLOOD Glucose-160* UreaN-24* Creat-1.5* Na-135 K-4.8 Cl-97 HCO3-23 AnGap-20 ___ 03:50PM BLOOD ALT-17 AST-33 LD(LDH)-283* AlkPhos-85 TotBili-0.5 ___ 03:50PM BLOOD Albumin-4.1 Calcium-9.2 Phos-1.1*# Mg-1.8 ___ 03:50PM BLOOD Lactate-2.3* PERTINENT LABS: ___ 03:50PM BLOOD proBNP-2531* ___ 11:00AM BLOOD Calcium-8.8 Phos-2.7 Mg-1.6 UricAcd-12.0* Iron-18* ___ 11:00AM BLOOD calTIBC-230* VitB12-1154* Ferritn-926* TRF-177* ___ 03:50PM BLOOD %HbA1c-5.2 eAG-103 ___ 03:50PM BLOOD TSH-11* ___ 08:20AM BLOOD T4-5.2 ___ 03:50PM BLOOD 25VitD-5* DISCHARGE LABS: ___ 08:45AM BLOOD WBC-4.8 RBC-3.18* Hgb-9.7* Hct-29.7* MCV-93 MCH-30.7 MCHC-32.8 RDW-16.9* Plt ___ ___ 08:45AM BLOOD Glucose-94 UreaN-21* Creat-1.4* Na-136 K-4.1 Cl-99 HCO3-30 AnGap-11 ___ 08:45AM BLOOD Calcium-9.2 Phos-3.6 Mg-1.8 EKG: ___: Sinus rhythm. Compared to the previous tracing of ___ the rate is slower. IntervalsAxes ___ ___ TTE: ___: The left atrium is normal in size. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of ___, Optison contrast allows assessment of regional systolic function which appears normal. Other findings are similar. IMAGING: Right Lower Extremity U/S with doppler ___: No evidence of deep venous thrombosis in the right lower extremity veins; the right peroneal veins, however, are not visualized. MICRO: Blood culture ___: No growth Brief Hospital Course: Mr. ___ is a ___ year old gentleman with history of idiopathic polyneuropathy, ETOH abuse, hypothyroidism, chronic bilateral lower extremity edema and xerosis who presented with increased lower extremity swelling, open right leg wound without purulent drainage, erythema or induration which was likely non-infectious skin break down secondary to worsening lower extremity edema. He was seen by wound care and physical therapy with plan to go home with increased services to improve self care and mobility. #Right lower extremity wound: Patient noted to have large superficial open wound on right lower extremity without purulent drainage, warmth, erythema, or leukocytosis to suggest cellulitis. Patient's wound likely secondary to massive lower extremity edema, chronic xerosis/venous stasis, and poor self care. Lower extremity ultrasound with doppler negative for deep vein thrombosis. Blood cultures negative. Patient was evaluated by wound care and with implementation of regular dressing changes noted to have significant improvement in wound pain and wound healing. Patient discharged home with ___ services to assist with further wound care. #Lower extremity swelling: Patient with history of chronic lower extremity swelling and xerosis thought to be secondary to venous insufficiency, likely component of lymphedema. Patient was initially treated with IV lasix for diuresis, however as surface echocardiogram showed no evidence of systolic or diastolic heart failure, diuretic therapy was discontinued. Patient was counseled to elevate legs to assist with swelling and will have continued home ___ services to assist with self care. #Left ankle swelling: Patient noted to have sudden onset left ankle and foot swelling and pain in setting of diuresis, thought to be secondary to acute gout flare. Patient's symptoms did not improve with colchecine and as he has not previously had gout, this was thought to be unlikely new onset presentation. Patient's symptoms likely secondary to dependent edema as patient noted to have foot hanging off bed on multiple occasions. Patient was treated with acetaminophen. #Vitamin D deficiency: Patient noted to have low vitamin D, 5, started on oral replacement 50,000IU once/week x 8 weeks. Patient will need to switch to maintenance dose after this time, ___. CHRONIC MEDICAL ISSUES: #Chronic Kidney Injury: Patient appears to have baseline Cr 1.2-1.5. Patient's creatinine remained at baseline during this admission. No evidence of nephropathy with normal urine protein/creatinine ratio. #HTN: Well controlled, continued outpatient metoprolol succinate 25mg PO daily # ETOH abuse: Patient with history of etoh abuse, reports drinking 5 drinks each weekend day, no drinks on weekend, last drink 5 days prior to admission. No signs or symptoms of withdrawal during admission. Patient was continued on multivitamin, thiamine, and counseled by social work. # Idiopathic polyneuropathy: Unclear underlying etiology. Has documented neuromotor deficits based on previous EMG. B12 replete, no evidence of DM2 with A1c 5.2%. Likely related to ongoing alcohol abuse. Patient was counseled on importance of abstaining from alcohol. Discovered patient is not taking home gabapentin as directed, made adjustments to 300mg PO BID with 600mg PO qhs and emphasized importance of taking this medication regularly for symptom control with patient. # Anemia: No active signs of bleeding. Hgb/Hct stable throughout admission. Iron studies with low iron, low tsat, elevated ferritin most consistent with mixed anemia of chronic disease and iron deficiency. Patient is due for repeat colonoscopy ___ (sessile polyp ___. Consider starting oral iron supplementation. #Hypothyroidism: Patient found to have elevated TSH 11, same as last ___, T4 within normal limits. Patient will need repeat thyroid function tests and consider uptitrating home levothyroxine based on results. TRANSITIONAL ISSUES ==================== - We stopped furosemide. Please check weight at PCP ___ appointment to ensure stability, as well as chem-7 to ensure improvement in creatinine. - Due for ___ ___, sessile polyp ___ - Please involve social work as you are doing to help with transport to appointments (patient applied to the Ride) - Discharged on Vit D 50,000 units/week; please transition to daily vitamin D in 7 weeks (___). - Increased gabapentin to 300, 300, 600. Please uptitrate as necessary (patient previously not taking at home regularly) - Please monitor for gout; we initially thought patient had gout flare of L ankle but exam not consistent, and so we discontinued colchicine. - Decreased B12 as supratherapeutic. # Code Status: FULL, confirmed with patient # Emergency Contact: daughter ___ ___, ex wife ___ ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Gabapentin 600 mg PO TID 2. Metoprolol Succinate XL 25 mg PO DAILY 3. Furosemide 20 mg PO DAILY 4. Levothyroxine Sodium 112 mcg PO DAILY 5. Cyanocobalamin 1000 mcg PO DAILY 6. FoLIC Acid 1 mg PO DAILY 7. Thiamine 100 mg PO DAILY 8. Aspirin 81 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Cyanocobalamin 100 mcg PO DAILY RX *cyanocobalamin (vitamin B-12) 100 mcg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. FoLIC Acid 1 mg PO DAILY 4. Levothyroxine Sodium 112 mcg PO DAILY 5. Metoprolol Succinate XL 25 mg PO DAILY 6. Thiamine 100 mg PO DAILY 7. Acetaminophen ___ mg PO Q8H:PRN pain, fever 8. Lactic Acid 12% Lotion 1 Appl TP ASDIR RX *ammonium lactate 12 % Moisturize B/L ___ and feet, periwound tissue twice a day Refills:*0 9. Multivitamins 1 TAB PO DAILY 10. Vitamin D 50,000 UNIT PO 1X/WEEK (FR) RX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by mouth once a week on ___ Disp #*7 Capsule Refills:*0 11. Gabapentin 300 mg PO BID Give at 8 am, 2 pm. 12. Gabapentin 600 mg PO QHS 13. ___ walker. DxCellulitis / 682.6, PROG: good, length of need 13 months Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Right lower extremity wound Chronic lymphedema and venous stasis Vitamin D deficiency Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, It was a pleasure taking part in your care at ___. You were admitted to ___ because of a wound on your left leg, which likely occurred because you had skin breakdown and venous stasis (poor blood flow in your veins). It does not appear to be an infection, but we think you would really benefit from more help at home to improve your mobility and to help care for your legs. We changed some of your medications. Stop taking your furosemide as you do not need it. Take your levothyroxine (thyroid med) only on an empty stomach. We increased your gabapentin to 2 pills at night to help with foot pain. We started you on vitamin D; you should always be on vitamin D from now on. Followup Instructions: ___
10161722-DS-21
10,161,722
24,926,366
DS
21
2182-03-05 00:00:00
2182-03-05 16:04:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Ace Inhibitors Attending: ___. Chief Complaint: foot bleeding Major Surgical or Invasive Procedure: None History of Present Illness: HISTORY OF PRESENTING ILLNESS: Mr. ___ is a ___ male with morbid obesity, history of alcohol use, chronic lower extremity edema, CKD stage III, and venous stasis dermatitis with recurrent lower extremity cellulitis who presents with right toe pain and bleeding. On ___ the patient bumped his right big toe against the leg of a table in his home. He began to notice a little pain in the toe but it was not bothersome. On ___ he noticed spots of blood on the floor in his home. He then looked at his right foot and noticed some blood staining in the area of the right big toe. He said the pain got progressively worse. He did not know if there was swelling as he could not see the toe due to body habitus. A neighbor came and dressed the toe and put a sock over it. Denies fever or chills. He had a regularly scheduled appointment with his PCP on ___ (___), where the PCP was concerned for infection and the patient's inability to care for the wound himself at home. He was sent to the ED. Of note the patient also describes dyspnea on exertion. He says that he is unable to ambulate to and from the bathroom in his home without feeling fatigued and short of breath. Per the patient this is consistent with his baseline. He has had significant fatigue and SOB with minimal activity for many years and feels that his current symptoms are no different. He ambulates with a cane or walker. He denies any chest pain with exertion. Denies PND or orthopnea. In the ED, initial vital signs were: T 98.0 HR 78 BP 153/76 RR 20 O2Sat 100%RA - Exam was notable for: - Labs were notable for: WBC 4.5, H/H 8.5/26.1, Plt 83, BUN 23, Cr 1.4, K 3.7, CRP 5.2, Lactate 2.0, coags wnl - Imaging: CXR normal, R toe XR without e/o osteomyelitis - The patient was given: IV vancomycin 1000 mg and IV Zosyn 4.5 grams - Consults: Podiatry evaluated and no urgent surgical intervention recommended Upon arrival to the floor, the patient was comfortable. He endorsed stable pain in his right big toe that was not bothersome and was not requiring any analgesics. Patient denied fevers. REVIEW OF SYSTEMS: [+] per HPI [-] Denies headache, visual changes, pharyngitis, rhinorrhea, nasal congestion, cough, fevers, chills, sweats, weight loss, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, hematochezia, dysuria, rash, paresthesias Past Medical History: ACUTE RENAL FAILURE BREAST ENLARGEMENT CHEST PAIN COUGH ON ACE HEADACHES HYPERTENSION L EAR FLAKING ALCOHOL ABUSE Chronic lower extremity edema of unclear etiology, likely venous stasis Lower extremity xerosis vs. stasis dermatitis Idiopathic polyneuropathy Hypothyroidism Social History: ___ Family History: notable for hypertension in a sibling, no CAD, no diabetes, no cancer. Physical Exam: ADMISSION: VITALS - 98.0 113/47 74 18 98%RA GENERAL - pleasant, well-appearing, obese man, in no apparent distress HEENT - normocephalic, atraumatic, no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear NECK - supple, no LAD, JVP not appreciated CARDIAC - regular rate & rhythm, ___ systolic murmur heard best at the RUSB, no rubs or gallops PULMONARY - clear to auscultation bilaterally, distant lung sounds, without wheezes or rhonchi ABDOMEN - obese abdomen, normal bowel sounds, soft, non-tender, non-distended, no organomegaly EXTREMITIES - warm, well-perfused, 2+ DP pulses bilaterally, right hallux with trauma to the medial portion of the nail, there is dried blood with surrounding erythema and skin that is warm to the touch extending to the level of the distal joint of the hallux, zone of erythema demarcated SKIN - lower extremities with hyperpigmentation bilaterally and scaling of the skin, most prominent between the knees and ankles NEUROLOGIC - A&Ox3, CN II-XII intact, sensation diminished bilaterally on the plantar aspect of the feet, moves all extremities spontaneously PSYCHIATRIC - listen & responds to questions appropriately, pleasant DISCHARGE: VS: 97.3 117/71 68 99% RA I/O: 1240/BRP, BM x3 General: obese male in NAD, cheeks are thin Neck: supple, no LAD, JVP not able to be appreciated due to habitus Cardiac: regular rate & rhythm, no rubs or gallops Pulmonary: clear to auscultation bilaterally, distant lung sounds, without wheezes or rhonchi Abdomen: obese abdomen, normal bowel sounds, soft, non-tender, non-distended, no organomegaly Extremities: warm, well-perfused, 2+ DP pulses bilaterally, right big toe with medial portion of nail removed, dried blood, erythema extending to the IP joint and is demarcated, no bluish hue to nail, other nails without deformities Skin: lower extremities with hyperpigmentation bilaterally and scaling of the skin, most prominent between the knees and ankles Pertinent Results: ADMISSION LABS: ___ 07:47PM BLOOD WBC-4.5 RBC-2.56* Hgb-8.5* Hct-26.1* MCV-102*# MCH-33.2* MCHC-32.6 RDW-17.3* RDWSD-65.1* Plt Ct-83*# ___ 07:47PM BLOOD Neuts-63.5 ___ Monos-7.8 Eos-3.3 Baso-0.7 Im ___ AbsNeut-2.85 AbsLymp-1.10* AbsMono-0.35 AbsEos-0.15 AbsBaso-0.03 ___ 07:25AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-NORMAL Polychr-1+ Target-1+ Schisto-1+ Tear Dr-OCCASIONAL ___ 07:47PM BLOOD ___ PTT-30.0 ___ ___ 07:25AM BLOOD Ret Aut-1.3 Abs Ret-0.03 ___ 07:47PM BLOOD Glucose-89 UreaN-23* Creat-1.4* Na-137 K-3.7 Cl-98 HCO3-23 AnGap-20 ___ 07:25AM BLOOD ALT-12 AST-28 LD(LDH)-148 AlkPhos-43 TotBili-0.4 ___ 07:25AM BLOOD Albumin-3.5 Calcium-9.1 Phos-3.6 Mg-1.4* Iron-46 ___ 07:25AM BLOOD calTIBC-204* VitB12-349 Hapto-160 Ferritn-850* TRF-157* ___ 07:47PM BLOOD TSH-9.7* ___ 07:25AM BLOOD Free T4-0.99 ___ 07:47PM BLOOD CRP-5.2* ___ 08:00PM BLOOD Lactate-2.0 DISCHARGE LABS: ___ 08:19AM BLOOD WBC-3.3* RBC-2.42* Hgb-7.9* Hct-25.4* MCV-105* MCH-32.6* MCHC-31.1* RDW-18.1* RDWSD-69.5* Plt Ct-99* ___ 08:19AM BLOOD Glucose-88 UreaN-24* Creat-1.5* Na-136 K-3.3 Cl-99 HCO3-25 AnGap-15 ___ 08:19AM BLOOD Albumin-3.7 Calcium-9.0 Phos-3.7 Mg-1.9 ___ 08:19AM BLOOD ALT-14 AST-28 LD(LDH)-133 AlkPhos-43 TotBili-0.2 IMAGING TOE XRAY ___ No radiographic evidence of osteomyelitis. CXR ___ No acute cardiopulmonary process. RUQ US ___ Echogenic liver consistent with steatosis. Other forms of liver disease including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded on the basis of this examination. Brief Hospital Course: Mr. ___ is a ___ male with morbid obesity, history of alcohol use, chronic lower extremity edema, CKD stage III, and venous stasis dermatitis with recurrent lower extremity cellulitis who presents with right toe pain after likely bumping it on unknown object. Treated with antibiotics with podiatry follow up scheduled. Also noted to be pancytopenic likely d/t alcohol. Investigations/Interventions: 1. RLE cellulitis: patient reported bumping toe on unknown object. Had erythema and purulence on presentation. Podiatry evaluated and removed part of nail. Initially treated with Vanc/Zosyn then switched to Keflex/clindamycin on ___ for a planned total course of 7 days (stop ___. Follow up arranged with podiatry 1 week after d/c. 2. Pancytopenia: patient newly leukopenic, anemic, and thrombocytopenic on admission. Guaiac negative. Lab work and smear indicated likely bone marrow suppression, and this was attributed to patient's history of alcohol use. He remained hemodynamically stable and we encourage PCP to recheck CBC soon after discharge to ensure uptrend. Outpatient hematology contacted and will call the patient for appointment. 3. Alcohol abuse: patient reports drinking ___ nips of gin and a few beers per day. Maintained initially on CIWA but did not require diazepam. Alcohol abuse likely cause of pancytopenia above. 4. Acute on chronic kidney disease: baseline CKD likely due to HTN, and patient suffered acute injury likely due to poor po intake. Resolved. 5. Dyspnea on exertion: patient has long history of DOE despite normal echo. Possibly due to anemia. PCP well aware and will monitor. 6. Diarrhea: patient developed 2 episodes of diarrhea on ___ and 2 episodes on ___ in the s/o antibiotic administration (most concerningly clindamycin). Cdiff PCR pending on discharge. Pt encouraged to contact PCP or return to the ER if diarrhea worsens or does not resolve. Transitional Issues [] Appt with liver, may need fibroscan for fatty liver [] monitor CBC for pancytopenia [] Outpatient ___ clinic will contact patient for appointment [] Needs to see ___ from podiatry ~1 week after d/c [] Would benefit from social work/alcohol counseling [] Follow up Cdiff PCR from ___ [] Follow up blood cultures from ___ [] Keflex/Clinda ___ # CONTACT: ___ (Daughter), ___ # CODE STATUS: Full Code Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Cyanocobalamin 100 mcg PO DAILY 3. FoLIC Acid 1 mg PO DAILY 4. Levothyroxine Sodium 112 mcg PO DAILY 5. Metoprolol Succinate XL 25 mg PO DAILY 6. Thiamine 100 mg PO DAILY 7. Acetaminophen ___ mg PO Q8H:PRN pain, fever 8. Lactic Acid 12% Lotion 1 Appl TP ASDIR 9. Multivitamins 1 TAB PO DAILY 10. Vitamin D 50,000 UNIT PO 1X/WEEK (FR) 11. Gabapentin 300 mg PO BID 12. Gabapentin 600 mg PO QHS 13. Docusate Sodium 100 mg PO BID Constipation 14. Senna 8.6 mg PO DAILY:PRN Constipation Discharge Medications: 1. Acetaminophen ___ mg PO Q8H:PRN pain, fever 2. Aspirin 81 mg PO DAILY 3. Cyanocobalamin 100 mcg PO DAILY 4. Docusate Sodium 100 mg PO BID Constipation 5. FoLIC Acid 1 mg PO DAILY 6. Gabapentin 300 mg PO BID 7. Gabapentin 600 mg PO QHS 8. Lactic Acid 12% Lotion 1 Appl TP ASDIR 9. Levothyroxine Sodium 112 mcg PO DAILY 10. Metoprolol Succinate XL 25 mg PO DAILY 11. Multivitamins 1 TAB PO DAILY 12. Senna 8.6 mg PO DAILY:PRN Constipation 13. Thiamine 100 mg PO DAILY 14. Vitamin D 50,000 UNIT PO 1X/WEEK (FR) 15. Cephalexin 500 mg PO Q6H Duration: 5 Days RX *cephalexin 500 mg 1 capsule by mouth every 6 hours Disp #*14 Capsule Refills:*0 16. Clindamycin 450 mg PO Q6H Duration: 5 Days RX *clindamycin HCl 150 mg 3 capsules by mouth every 6 hours Disp #*42 Capsule Refills:*0 17. Polyethylene Glycol 17 g PO DAILY:PRN constipation Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: RLE cellulitis Pancytopenia Acute on chronic kidney disease Alcohol abuse Secondary: Dyspnea on exertion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Mr. ___, You were hospitalized for an infection around your right big toe. We treated this with antibiotics and you will follow up with the podiatrist to ensure appropriate recovery. Your blood counts were also noted to be low which is likely related to alcohol use. Because of this we are ensuring close PCP follow up. ___ was a pleasure taking care of you! Your ___ team Followup Instructions: ___
10161722-DS-25
10,161,722
27,424,829
DS
25
2183-11-06 00:00:00
2183-11-10 13:21:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Ace Inhibitors / prednisone Attending: ___. Chief Complaint: Left hand pain Major Surgical or Invasive Procedure: ___ EGD ___ Colonoscopy History of Present Illness: ___ with hx of HTN, CKD, neuropathy, alcohol abuse (w/ liver steatosis), anemia and recurrent hand cellulitis with possible flexor tenosynovitis requiring multiple hospitalizations for IV antibiotics who presents with left hand pain and swelling. Four days ago, he developed L hand pain and swelling which has progressively worsened. Three days ago, he noticed redness developing. Pain is worst with movement of the wrist, but also has severe pain with movement of all fingers except the thumb. In the past day, he noticed pain in the third and fourth digits of his right hand as well. He has had subjective fevers, chills. He has also had worsening of his chronic shortness of breath, rhinorrhea and cough productive of white/clear sputum and associated with b/l chest and back soreness. No hemoptysis. He endorses black stools recently. He notes he was supposed to get a colonoscopy in ___ but got nervous and did not present for the procedure. He denies abdominal pain, n/v/d, urinary symptoms or decreased urinary output. He drank one 8 oz beer two weeks ago, but denies excessive drinking recenty. No reported history of withdrawal. He has had prior similar episodes of hand swelling in the past involving both right and left hands at different times. He has been treated for cellulitis and ?flexor tenosynovitis with antibiotics and symptoms resolved. He was most recently hospitalized in ___ for left hand cellulitis treated with vanc and then PO doxycycline for 10-day course. His pain was controlled with acetaminophen and oxycodone. Of note, he says he has not eaten in ___ days due to inability to get up from his recliner. Last BM on ___. He was seen by the hand service in the ED and refused a joint tap. In the ED, initial vital signs were: 98.9 89 156/60 16 100% RA Exam notable for: Crackles at the bases bilaterally. RRR. NTND abd. 3+ pitting edema of the ___ bilaterally with stasis changes. Left dorsal and volar hand and distal radius swelling and redness and warmth, decreased ROM, distal CSM intact. Labs were notable for: WBC 8.1, Hgb 7.4, Ca: 8.7 Mg: 1.2 P: 3.6, Lactate:1.2 Studies performed include: WRIST(3 + VIEWS) LEFT Non-specific soft tissue swelling, without radiographic evidence of osteomyelitis. ELBOW LEFT XRAY No evidence of an osseous abnormality of the left elbow. RIGHT HAND XRAY Soft tissue swelling around the hand but most pronounced over the third and fourth digits without radiographic evidence of osteomyelitis. CXR: No acute cardiopulmonary process identified. Patient was given: IV Vancomycin (1500 mg ordered), OxyCODONE (Immediate Release) 5 mg Consults: Hand Surgery Vitals on transfer: 98.1 176 / 81 84 18 98 Ra Upon arrival to the floor, the patient endorses significant left hand pain. He also notes left elbow pain and right ___ and ___ finger pain. Past Medical History: ACUTE RENAL FAILURE BREAST ENLARGEMENT CHEST PAIN COUGH ON ACE HEADACHES HYPERTENSION L EAR FLAKING NEUROPATHY ALCOHOL ABUSE LOWER EXTREMITY EDEMA HOME SERVICES CHRONIC KIDNEY DISEASE HYPOTHYROIDISM MACROCYTIC ANEMIA Social History: ___ Family History: Per OMR, notable for hypertension in a sibling, no CAD, no diabetes, no cancer. Does not feel other family members have had recurrent cellulitis Physical Exam: ADMISSON PHYSCIAL EXAM ====================== Vitals: 98.1 176 / 81 84 18 98 Ra General: NAD CV: RRR, no murmurs Lungs: CTA anteriorly. Patient unable to sit up for posterior auscultation. Abdomen: Soft, NTND, +BS Left Upper extremity: Erythema of dorsal left hand extending toward radial side beyond borders marked in ED. Refuses passive rom, unable to tolerate active rom of wrist or fingers. Can move thumb with minimal pain. Left elbow tender to palpation. Refuses active/pass rom of elbow, no erythema of elbow or forearm Right Upper Extremity: TTP in right ___ and ___ digit with erythema over ___ digit. Refuses passive rom, unable to tolerate active rom. Lower Extremities: WWP, 1+ pitting edema to knees b/l, tender to palpation of b/l feet which he describes as pins and needs sensation, xerosis of b/l lower extremities but no erythema DISCHARGE PHYSICAL EXAM ======================= VS: 97.9, 149/63, 59, 18, 98% Ra GENERAL: Obese man, sitting comfortably in bed, NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva NECK: nontender supple neck, no LAD, JVP slightly elevated at 45 degrees HEART: RRR, Normal S1/S2, systolic ejection murmur heart at upper sternal border LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: obese abdomen, +BS, nontender in all quadrants, no rebound/guarding MSK: Swelling on dorsum of left hand has dramatically improved. Mild tenderness to palpation and passive/active wrist flexion and extension. No pain in L elbow, slight pain in L shoulder. No pain on right arm. Area of infiltration on right forearm is mildly tender but improving NEURO: CN II-XII intact EXTREMITIES: warm and well perfused, chronic stasis dermatitis in bilateral lower extremities, 2+ pedal pulses. Pertinent Results: ADMISSON LABS ============= ___ 10:25AM BLOOD WBC-8.1 RBC-2.51* Hgb-7.4* Hct-22.6* MCV-90# MCH-29.5# MCHC-32.7 RDW-15.9* RDWSD-50.9* Plt ___ ___ 10:25AM BLOOD Neuts-74.6* Lymphs-3.6* Monos-20.1* Eos-0.0* Baso-0.0 Im ___ AbsNeut-6.19* AbsLymp-0.30* AbsMono-1.67* AbsEos-0.00* AbsBaso-0.00* ___ 10:25AM BLOOD Hypochr-NORMAL Anisocy-1+* Poiklo-OCCASIONAL Macrocy-1+* Microcy-NORMAL Polychr-OCCASIONAL Schisto-OCCASIONAL ___ 08:10AM BLOOD Ret Aut-0.9 Abs Ret-0.02 ___ 10:25AM BLOOD Glucose-117* UreaN-26* Creat-1.8* Na-137 K-3.7 Cl-96 HCO3-21* AnGap-20* ___ 10:25AM BLOOD ALT-8 AST-29 LD(LDH)-215 AlkPhos-63 TotBili-0.7 ___ 10:25AM BLOOD Albumin-3.1* Calcium-8.7 Phos-3.6 Mg-1.2* UricAcd-11.3* ___ 10:31AM BLOOD Lactate-1.2 IMPORTANT INTERVAL LABS ======================= ___ 08:10AM BLOOD calTIBC-118* Ferritn-1264* TRF-91* ___ 08:10AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-POS* ___ 10:25AM BLOOD CRP-273.3* ___ 09:00PM BLOOD HIV Ab-NEG ___ 08:10AM BLOOD HCV Ab-NEG DISCHARGE LABS =============== ___ 08:20AM BLOOD WBC-6.8 RBC-2.98* Hgb-8.6* Hct-26.9* MCV-90 MCH-28.9 MCHC-32.0 RDW-15.9* RDWSD-51.8* Plt ___ ___ 08:20AM BLOOD Glucose-93 UreaN-55* Creat-1.7* Na-138 K-4.0 Cl-99 HCO3-22 AnGap-17 ___ 08:20AM BLOOD Calcium-8.6 Phos-2.8 Mg-2.0 ___ 08:45AM BLOOD VitB12-961* Folate-8 MICRO ====== ___ RPR negative ___ blood culture: pending ___ blood culture: pending IMAGINIG ======= ___ WRIST(3 + VIEWS) LEFT Non-specific soft tissue swelling, without radiographic evidence of osteomyelitis. ___ ELBOW LEFT XRAY No evidence of an osseous abnormality of the left elbow. ___ RIGHT HAND XRAY Soft tissue swelling around the hand but most pronounced over the third and fourth digits without radiographic evidence of osteomyelitis. ___: No acute cardiopulmonary process identified. ___ EGD: Normal mucosa in the esophagus, Erosions in the antrum Erythema in the duodenal bulb compatible with duodenitis Otherwise normal EGD to third part of the duodenum ___ colonoscopy: Normal mucosa in the colon, Stool in the whole colon, Otherwise normal colonoscopy to cecum Brief Hospital Course: ___ with hx of HTN, CKD, neuropathy, alcohol abuse (w/ liver steatosis), anemia and recurrent hand cellulitis with presents with left hand pain/swelling, right finger pain/swelling, and left elbow pain concerning for polyarticular gout. ACUTE ISSUES: ============= #Left hand and right finger swelling: #Inflammatory polyarthropathy: Mr. ___ presented to the hospital with worsening left hand pain, left elbow and shoulder pain, right finger pain, and bilateral ankle pain. He had multiple prior admissions for similar pain in the past that was thought to possibly represent recurrent cellulitis versus tenosynovitis. Initial differential included polyarticular gout VS pseudogout VS septic arthritis versus viral versus reactive arthritis. He was initially started on IV vancomycin due to worry that this represented a recurrent episode of presumed cellulitis. Rheumatology was consulted and felt that given his serum uric acid of 11.3, elevated CRP to 237.3, and recurrent episodes involving both hands at this most likely represented a gout flare. Hand surgery was also consulted and felt this was unlikely to be flexor tenosynovitis and recommended DC vancomycin. We were unable to sample joint fluid because patient refused joint aspiration. Prior aspirate from ___ admission was negative for crystals. Imaging of hand and elbow were negative for any fracture or acute dislocation and no evidence of osteomyelitis. Antibiotics were discontinued on hospital day 2. He was started on a prednisone taper at 60 mg for 7 days and 1 dose of colchicine. He was also started on urate lowering therapy with Febuxostat 40 mg daily (GFR too low for allopurinol). It was felt that it was best to start uric acid lowering therapy while in hospital even though there is a risk of exacerbating acute flare because patient has a history of being lost to follow-up. Workup for polyarthritis for negative (hep C negative, hep B immune from prior infection, HIV negative, RPR negative, RF negative, and CCP negative). Patient improved dramatically with prednisone taper. He was unable to complete full taper course d/t agitation and hallucinations. At time of discharge his mental status was improved and he was clear and coherent. Reaction to prednisone was added to allergy list. # Normocytic Anemia #Gastric Ulcers: Hemoglobin on admission was 7.4. From last admission hemoglobin was 8.8 in ___. He has been endorsing maroon colored stools in the past and currently endorsing dark/black colored stools. In review of records it seems that his PCP has been trying to get him into a colonoscopy but patient has not followed up. Last, he was in ___ where a sessile polyp was removed. He was supposed to follow-up in ___ years but never did. Etiology of normocytic anemia thought to be most likely multifactorial in the setting of anemia of chronic disease, iron deficiency/nutritional deficiency, CKD, and possible slow GI bleed (ulcer vs colon). Acute drop in hemoglobin was thought to possibly be secondary to GI bleed versus infection. Hemolysis labs were negative. Stool was guaiac negative ×2 during hospitalization. Hemoglobin continued to drop to 6.8 morning after admission. He was given total of 2 unit PRBCs with appropriate increase in Hgb. Iron studies were suggestive of anemia of chronic disease with reduced iron stores. Vit B12 and folate were both within normal limits. Patient got EGD with GI and found multiple bleeding gastric ulcers. They were unable to complete colonoscopy d/t poor prep. He was started on oral PPI BID and should follow up as an outpatient with GI for repeat EGD in 6 weeks. We were unable to get H.pylori test during hospitalization but patient has very close follow up with PCP and need for this test was communicated with him. In addition he was discharged on oral iron supplements. # Thrombocytopenia: Per records patient has a history of thrombocytopenia. This may be secondary to liver synthetic dysfunction given low albumin and elevated INR on presentation, or nutritional deficiency. From prior hospitalizations he had a right upper quadrant ultrasound that showed liver steatosis. Possibly caused by prior alcohol abuse and likely a component of NASH given obesity. Plt count improved during hospitalization. In addition, INR normalized suggesting elevation was most likely d/t nutritional deficiencies. #Home Safety: In discussions with patient it is unclear how well he is able to care for himself while at home. He lives with his family that helps out but he is alone most of the day and he reported being unable to move to get food or to go to the bathroom due to joint pains. He endorsed not eating for the past few days because he didn't want to have to go to the bathroom because he would be unable to get to and up from the toilet. ___ saw him while he was in the hospital and initially recommended rehab due to pain limiting mobility. He had a bed at a rehab facility but refused to go. Pt was seen again by ___ after joint pains improved with prednisone course and ___ felt that he would be safe to return home as he was better able to move around and care for self. Pt was set up with continued home ___ services and home ___. CHRONIC ISSUES: =============== #HTN: He was continued on home metoprolol and amlodipine #Hypothyroidism: He was continued home levothyroxine #CKD: Cr 1.8, approximately at baseline ~1.5-1.8. #Neuropathy: Continued home gabapentin TRANSITIONAL ISSUES =================== MEDICATIONS STARTED: Febuxostat 40 mg PO DAILY, Ferrous Sulfate 325 mg PO DAILY, Pantoprazole 40 mg PO Q12H [] Should get colonoscopy as an outpatient for cancer screening [] Follow up with your PCP, ___. [] Should get H.pylori testing done as an outpatient [] Follow up with Rhuematology for your gout [] Follow up with GI [] Should get repeat EGD in ___ weeks to evaluate your gastric ulcers [] Consider addiction rehab as an outpatient or alcohol abuse counseling #Name of health care proxy: ___ ___: daughter Phone number: ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Vitamin D ___ UNIT PO 1X/WEEK (MO) 3. FoLIC Acid 1 mg PO DAILY 4. Gabapentin 600 mg PO DAILY:PRN neuropathic pain 5. Levothyroxine Sodium 112 mcg PO DAILY 6. Metoprolol Succinate XL 25 mg PO DAILY 7. Cyanocobalamin 100 mcg PO DAILY 8. Thiamine 100 mg PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 2. Febuxostat 40 mg PO DAILY RX *febuxostat [Uloric] 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Ferrous Sulfate 325 mg PO DAILY RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth Twice a day Disp #*60 Tablet Refills:*0 5. amLODIPine 5 mg PO DAILY 6. Cyanocobalamin 100 mcg PO DAILY 7. FoLIC Acid 1 mg PO DAILY 8. Gabapentin 600 mg PO DAILY:PRN neuropathic pain 9. Levothyroxine Sodium 112 mcg PO DAILY 10. Metoprolol Succinate XL 25 mg PO DAILY 11. Thiamine 100 mg PO DAILY 12. Vitamin D ___ UNIT PO 1X/WEEK (MO) Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis ================= GOUT FLARE Normocytic anemia PUD Secondary Diagnosis =================== CKD HTN Thrombocytopenia Hypothyroidism Neuropathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Mr. ___, It was a pleasure to take care of you at ___. WHY WAS I HERE? You were admitted to the hospital because you had pain and swelling in your left hand. WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL - While you were in the hospital imaging of your hands that did not show any fracture or acute injury. –You are seen by rheumatology who felt that her symptoms are most likely due to gout. –You were started on prednisone to decrease the inflammation in your hands and you were started on a medication to treat her gout longterm. -Your blood counts were found to be very low in the hospital. You were given back some blood. - You had an EGD to look for source of bleeding from your GI tract. They found small ulcerations in your stomach. You were started on a Proton pump inhibitor to reduce the acid in your stomach to heal the ulcerations. WHAT SHOULD I DO WHEN I GET HOME? 1) Follow up with your Primary Care Doctor. 2) Follow up with GI 3) Follow up with Rheumatology (Dr. ___ 4) Take your new medications, protonix for 6 weeks, also continue to take your febuxostat to prevent flares of your gout. 5) You should still get a colonoscopy as an outpatient for cancer screening. 6) continue to work on cutting down on your drinking. This will help your gout and prevent flareups that cause pain similar to what brought him to the hospital. We wish you the best! Your ___ Care Team Followup Instructions: ___
10161764-DS-17
10,161,764
26,863,664
DS
17
2118-12-24 00:00:00
2118-12-28 08:08:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: UROLOGY Allergies: Demerol / Fosamax Attending: ___ Chief Complaint: fever Major Surgical or Invasive Procedure: NONE during this admission S/p ___ outpatient cystoscopy, ureteral stent removal S/p ___ OR PROCEDURE: Left ureteroscopy, laser lithotripsy, left ureteral stent placement. History of Present Illness: ___. female POD 6 from left URS/LL now with sepsis following ureteral stent removal in clinic. She likely has an active Urinary Tract Infection given new onset incontinence in setting of recent urinary tract manipulation and fever 103. Past Medical History: Past Medical History noted ___: : 1. Breast cancer treated with surgery and XRT and Arimidex. 2. Essential thrombocytosis, platelet count 656. 3. Hypercholesterolemia. 4. Spinal stenosis. 5. Right arm lymphedema following node dissection. 6. Osteopenia. 7. History of psoriasis, apparently resolved. 8. Rectal cancer treated with a low anterior resection. 9. Hypertension. 10. Low back pain. 11. ___ neuroma, bilateral feet. 12. Obesity. BMI greater than 30. 13. Cholelithiasis (asymptomatic). Past Surgical History: 1. Back surgery ___. 2. Chamberlain procedure mediastinoscopy for what turned out to be benign disease, ___. 3. Low anterior resection for adenocarcinoma of the rectum. 4. Right lumpectomy, axillary lymph node dissection for breast cancer. 5. Bilateral foot neuroma excision. ABDOMINAL PAIN BREAST CANCER DYSPNEA ESSENTIAL THROMBOCYTOSIS HYPERCHOLESTEROLEMIA SPINAL STENOSIS LYMPHEDEMA MENOPAUSE PSORIASIS RECTAL CANCER RIGHT FOOT FX HYPERTENSION LEG PAIN LOW BACK PAIN FEET NEUROMA B/L HERNIA REPAIR HYPERCALCEMIA OSTEOPOROSIS CATARACTS Surgical History (Last Verified ___ by ___, RN): INCISIONAL HERNIA REPAIR WITH MESH ___ INCISIONAL HERNIA REPAIR ___ LAPAROSCOPIC INCISIONAL HERNIA REPAIR ___ Ventrlight mesh BACK SURGERY ___ LUMPECTOMY ___ LOW ANTERIOR RESECTION Social History: Socially, she does not smoke, drink excessively or use drugs. She is a retired ___. Domestic violence: Denies Contraception: N/A Contraception Footnote: not sexually active, comments: postmenopausal Tobacco use: Never smoker Alcohol use rarely comments: Recreational drugs Denies (marijuana, heroin, crack pills or other): Depression: Based on a PHQ-2 evaluation, the patient does not report symptoms of depression Exercise: Activities Exercise comments: Footnote: walking Diet: n Seat belt/vehicle Always restraint use: Family History: Family history is significant for colonic polyps and diabetes (mother) Physical Exam: Gen: No acute distress, alert & oriented CHEST: no tachypnea or audible wheezing BACK: Non-labored breathing, mild left CVA tenderness. ABD: Soft, non-tender, non-distended, no guarding or rebound EXT: Moves all extremities well. No l/e e/p/c/d. no calf pain bilat. PSY: Appropriately interactive Pertinent Results: ___ 06:47AM BLOOD WBC-4.5 RBC-3.13* Hgb-10.2* Hct-32.7* MCV-105* MCH-32.6* MCHC-31.2* RDW-13.6 RDWSD-51.8* Plt ___ ___ 04:45PM BLOOD WBC-6.4 RBC-2.88* Hgb-9.5* Hct-29.2* MCV-101* MCH-33.0* MCHC-32.5 RDW-13.4 RDWSD-49.8* Plt ___ ___ 06:38AM BLOOD WBC-6.9 RBC-3.03* Hgb-9.8* Hct-30.8* MCV-102* MCH-32.3* MCHC-31.8* RDW-13.5 RDWSD-50.1* Plt ___ ___ 02:00PM BLOOD WBC-13.9* RBC-3.64* Hgb-12.4 Hct-36.8 MCV-101* MCH-34.1* MCHC-33.7 RDW-13.6 RDWSD-49.4* Plt ___ ___ 11:24AM BLOOD WBC-12.7* RBC-3.70* Hgb-12.2 Hct-38.0 MCV-103* MCH-33.0* MCHC-32.1 RDW-13.3 RDWSD-50.4* Plt ___ ___ 04:45PM BLOOD Glucose-117* UreaN-10 Creat-0.5 Na-139 K-3.9 Cl-106 HCO3-21* AnGap-12 ___ 11:24AM BLOOD UreaN-18 Creat-0.6 Na-140 K-5.1 Cl-101 HCO3-23 AnGap-16 ___ 11:25 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. CEFTAZIDIME test result confirmed by ___. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 8 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ___ 5:11 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 8 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: ___. female who was status post left URS/LL now with sepsis following ureteral stent removal in clinic. Admitted with concern for sepsis, likely active urinary tract infection given new onset incontinence in setting of recent urinary tract manipulation and fever 103 (rectal). She was empirically started on iv antibiotics (Ceftriaxone and IV Vancomycin), IV fluids and appropriate home medications while her culture data processed. She was placed on sliding scale insulin and an indwelling urinary catheter placed for decompression. She spiked fever to 103 and repeat cultures were sent on ___, HD2. He culture data came back with cefazolin and penicillin resistant E. Coli. She was converted to oral ciprofloxacin and discharged home with a ten-day course. Her IUC was removed and she voided without difficulty. She was provided instructions for follow up in clinic. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Magnesium Oxide 400 mg PO DAILY 2. Gabapentin 300 mg PO BID 3. Hydroxyurea 500 mg PO DAILY 4. Phenazopyridine 100 mg PO TID:PRN Bladder pain/spasms 5. Atenolol 25 mg PO DAILY 6. MetFORMIN (Glucophage) 1000 mg PO BID 7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line 8. Atorvastatin 20 mg PO QPM 9. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe 10. Aspirin 81 mg PO DAILY 11. Salsalate 500 mg PO BID:PRN pain 12. Cetirizine 10 mg PO DAILY 13. Tamsulosin 0.4 mg PO QHS 14. Levothyroxine Sodium 25 mcg PO DAILY 15. Vitamin D 5000 UNIT PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever 2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 10 Days RX *ciprofloxacin HCl 500 mg ONE tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID 4. Lactobacillus combo ___ billion cell oral BID RX *Lactobacillus combo no.23 ___ Probiotic] 14 billion cell ONE capsule(s) by mouth twice a day Disp #*28 Capsule Refills:*0 5. Senna 17.2 mg PO QHS 6. Aspirin 81 mg PO DAILY 7. Atenolol 25 mg PO DAILY 8. Atorvastatin 20 mg PO QPM 9. Cetirizine 10 mg PO DAILY 10. Gabapentin 300 mg PO BID:PRN drowsiness 11. Hydroxyurea 500 mg PO DAILY 12. Levothyroxine Sodium 25 mcg PO DAILY 13. Magnesium Oxide 400 mg PO DAILY 14. MetFORMIN (Glucophage) 1000 mg PO BID 15. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line 16. Salsalate 500 mg PO BID:PRN pain 17. Vitamin D 5000 UNIT PO DAILY 18.INTESTINAL MODIFIER Obtain any over the counter (if Rx not filled by pharmacy) LACTOBACILLUS formulation and use twice per day for 14 days. Discharge Disposition: Home Discharge Diagnosis: Urosepsis Urinary tract infection (E. Coli) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -You may experience some pain associated with spasm of your ureter.; This is normal. Take the narcotic pain medication as prescribed if additional pain relief is needed. -Do not lift anything heavier than a phone book (10 pounds) -Resume your pre-admission/home medications EXCEPT as noted. You should ALWAYS call to inform, review and discuss any medication changes and your post-operative course with your primary care doctor. -Ibuprofen should always be taken with food. Please discontinue taking and notify your doctor should you develop blood in your stool (dark, tarry stools) -You may be given “prescriptions” for a stool softener and/or a gentle laxative. These are over-the-counter medications that may be “health care spending account reimbursable.” -Colace (docusate sodium) may have been prescribed to avoid post-surgical constipation or constipation related to use of narcotic pain medications. Discontinue if loose stool or diarrhea develops. Colace is a stool-softener, NOT a laxative. -Senokot (or any gentle laxative) may have been prescribed to further minimize your risk of constipation. -Do not eat constipating foods for ___ weeks, drink plenty of fluids to keep hydrated Followup Instructions: ___
10161801-DS-21
10,161,801
23,990,616
DS
21
2196-10-25 00:00:00
2196-10-25 13:47:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: right arm pain after mechanical fall Major Surgical or Invasive Procedure: Open reduction internal fixation of right midshaft humerus fracture History of Present Illness: Ms. ___ is a ___ s/p mechanical fall at home, transferred from ___ for management of a R midshaft humerus fracture with radial nerve palsy. She tripped over a rug at home, no headstrike or loss of consciousness, no pain elsewhere. At initial evaluation at ___, she had no neurologic deficits. She was placed in a coaptation splint, then discharged. About a half hour post-splinting, while sitting in the hospital lobby waiting to be picked up, the patient noticed paresthesias in the radial nerve distribution. She then returned to the ___ and was found to have a new radial nerve palsy. Splint was removed without improvement in neuro exam. She was transferred to ___ for further management. She continues to have paresthesias in radial nerve distribution. Past Medical History: Hypothyroidism Social History: ___ Family History: Noncontributory Physical Exam: PHYSICAL EXAMINATION AT DISCHARGE: General: NAD Vitals: Afebrile, vital signs are stable Right upper extremity: - Dressing in place. Clean, dry, and intact. - Hand has moderate amount of swelling - Unable to fire EPL/EIP/EDC/extensor carpi. Fires FPL/FDS/FDP/AP - Diminished sensation in radial distribution of hand. SGILT in ulnar and median nerve distributions - 2+ radial pulse Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have right midshaft humerus fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for open reduction and internal fixation, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home with services was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is nonweightbearing in the right upper extremity extremity, and will be discharged on aspirin for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: None Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Aspirin 325 mg PO DAILY RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID 4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Right midshaft humerus fracture with radial nerve palsy at outside hospital Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery for your right humerus fracture. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - Nonweight-bearing right upper extremity - minimal range of motion at shoulder, elbow, and wrist. MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take Aspirin 325mg daily for 2 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining. - Splint must be left on until follow up appointment unless otherwise instructed - Do NOT get splint wet DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns Followup Instructions: ___
10161986-DS-5
10,161,986
29,944,305
DS
5
2138-04-26 00:00:00
2138-04-26 23:00:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: metformin Attending: ___. Chief Complaint: Dizziness, malaise, abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ F with DM and HTN, who presented with 5 days of malaise, dizziness, nausea, and vague abdominal pain. She was feeling well until 5 days ago, when she developed a sharp epigastric pain radiating to her R flank and below her R breast, associated with nausea and one episode of NBNB emesis, after which she was seen at the ___ ED. In the ED, labs were notable for Cr 0.9, LFTs wnl, RUQ US with partially distended gallbladder but without specific signs of acute cholecystitis, no gallstones, wall edema, or fluid. She had normal troponin and EKG negative for ischema, as well as an unremarkable nuclear stress test. CTU showed no acute abdominal process, no e/o nephrolithiasis, but did reveal hepatic/pancreatic cysts. The patient was sent home and her chest/flank pain slowly resolved, however she continued to feel ill with malaise, fatigue, lack of appetite, nausea without vomiting, and dizziness. She was not eating but did drink some fluids (3 small water bottles/day). On the day of admission, she reports feeling lightheaded and weak, and had a fall ___ dizziness while getting out of the shower. She did not experience LOC and was able to catch herself but did hit her head lightly. This prompted her to come to the ED. For the past two days she has noted foul-smelling, dark urine and increasing suprapubic pain. She also reported several night sweats over the past few days. She denies vision changes, URI symptoms, continuing chest pain, dysuria, hematuria, hematochezia. In the ED, initial VS were T 97.0 HR 106 BP 95/66 RR 16 SpO2 99% RA. Exam was notable for normal neuro and ___. Labs were notable for Cr 1.8 (baseline 0.8-1.0), Hct 50.2 (from ___, K 3.1, Na 132, UA w 9WBCs, few bacteria. CT head w/o acute process. Neuro was consulted who felt this likely did not represent an acute neurologic process and recommended treating UTI and ___. Pt given 2L NS, one dose macrobid and was admitted to medicine service. VS prior to transfer were T: 97.2, HR 89 BP 115/72 RR 18 SpO2 100%. On arrival to floor, the patient is comfortable, denies dizziness, and feels mildly improved with IV fluids. Her chest/RUQ pain is barely present. Has mild headache since admission. Up to date on colonoscopy, mammography, and pap smears. Past Medical History: #DM, type 2, complicated by retinopathy (s/p laser on left), microalbuminuria #HTN #Breast mass, removed in ___- benign #Colon polyps- hypreplastic and adenomatous, removed in ___, due for repeat in ___ #Right knee surgery (meniscal tear) #Iron-deficiency anemia Social History: ___ Family History: Mother with DM, stroke, passed in ___ from PNA. Father passed in ___ from pancreatic CA. ___ siblings with stroke. One brother with MI. 3 daughters, all with HTN. Physical Exam: Physical exam on admission: VITALS: T 98.6 HR 88 BP 145/68 RR 18 SpO2 99% RA GENERAL: laying in bed, NAD HEENT: PERRL, EOMI, OP clear NECK: no carotid bruits, no JVD LUNGS: CTAB, no crackles, rhonchi, or wheezes HEART: RRR, normal S1 S2, II/VI systolic murmur at LUSB ABDOMEN: +BS, soft, TTP in RLQ, positive murphys, no hepatosplenomegaly EXTREMITIES: wwp, 2+ pt pulses equal b/l, no c/c/e NEUROLOGIC: CN II-XII wnl, moving all extremities, gait deferred Physical exam on discharge: VS: Tc 98.0 Tm 98.2 HR ___ BP 142/82 (108-142/56-82)RR 20 99%RA I/O: MN NR; 24hrs 1230/BRP FSBG: ___: ___: 8am 176 12pm 255 5pm 236 9pm 192; Gen: NAD, non-toxic, non-diaphoretic HEENT: sclera anicteric; oropharynx clear without erythema or exudate Cardio: RRR, nl S1 S2, no m/r/g Pulm: CTAB, no crackles/wheezes/rhonchi Abd: soft, non-distended. negative ___ sign. Mild suprapubic tenderness to deep palpation R>L improved from ___ exam Ext: wwp, no edema, nontender Pertinent Results: Labs on admission: ___ 12:02AM BLOOD WBC-7.2 RBC-6.16* Hgb-16.6* Hct-50.4* MCV-82 MCH-26.9* MCHC-32.8 RDW-13.8 Plt ___ ___ 12:02AM BLOOD Neuts-70.0 ___ Monos-3.7 Eos-1.5 Baso-0.5 ___ 12:02AM BLOOD Glucose-269* UreaN-34* Creat-1.8* Na-132* K-3.1* Cl-92* HCO3-27 AnGap-16 ___ 12:02AM BLOOD ALT-19 AST-21 AlkPhos-87 TotBili-0.6 ___ 07:35AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.3 Pertinent results: ___ 12:30PM BLOOD WBC-17.6*# RBC-4.82# Hgb-13.3# Hct-39.8# MCV-83# MCH-27.6# MCHC-33.4 RDW-13.7 Plt ___ ___ 08:20AM BLOOD WBC-19.3* RBC-4.43 Hgb-12.2 Hct-36.8 MCV-83 MCH-27.5 MCHC-33.1 RDW-13.9 Plt ___ ___ 07:20AM BLOOD WBC-13.9* RBC-4.29 Hgb-12.0 Hct-36.3 MCV-85 MCH-27.9 MCHC-33.0 RDW-14.2 Plt ___ ___ 12:02AM BLOOD cTropnT-0.02* ___ 07:35AM BLOOD cTropnT-0.02* ___ 07:35AM BLOOD VitB12-GREATER TH Folate-10.9 ___ 07:35AM BLOOD TSH-0.91 Labs on discharge: ___ 05:35AM BLOOD WBC-8.4 RBC-4.22 Hgb-11.6* Hct-35.8* MCV-85 MCH-27.5 MCHC-32.4 RDW-14.4 Plt ___ ___ 05:35AM BLOOD Glucose-156* UreaN-5* Creat-0.9 Na-141 K-4.8 Cl-105 HCO3-29 AnGap-12 ___ 05:35AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.2 Microbiology: ___ 12:03 am URINE CULTURE (Final ___: GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. ___ 10:15 am BLOOD CULTURE Blood Culture, Routine (Pending): ___ 10:30 am BLOOD CULTURE SET#2. Blood Culture, Routine (Pending): ___ 5:56 pm URINE Source: ___. (Final ___: GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. ___ 11:04 am URINE Source: ___. URINE CULTURE (Final ___: NO GROWTH. Imaging: Head CT w/o Contrast ___: There is no evidence of hemorrhage, infarction, shift of midline structures or mass effect. The ventricles and sulci are normal in size and configuration. The visible paranasal sinuses and mastoid air cells are well aerated. Chest Xray PA and Lateral ___: The lungs are clear. Mediastinal and cardiac contours are unchanged. There is no pneumothorax or pleural effusion. Brief Hospital Course: ___ F with DM and HTN p/w malaise, dizziness, nausea, labs notable for ___ and UTI on UA, with subsequent fever to 102.9 suggestive of pyelonephritis, improving clinically on IV ceftriaxone with negative UCx from ___. Active issues: #UTI/Pyelonephritis: The patient received Macrobid in the ED and was initially treated with Bactrim x1 day for presumed uncomplicated cystitis on the floor, however, after spiking fever to 102.9, her antibiotic coverage was switched to ampicillin x1 day (given initial GPC on urine culture), with later transition to CTX on ___ as urine culture showed growth of mixed flora. Her WBC peaked at 19.3 on ___ but decreased after initiation of ceftriaxone to 8.4 on discharge. Her fever trended down and she was afebrile since ___ in the ___. The final urine culture from ___ was no growth. However, given the high fever and leukocytosis, it is presumed that patient had a pyelonephritis. Her initial CTU was reassuring for lack of stones or abscess. She was discharged with a plan of total 14 day course for antibiotics, to be completed on ___. # Orthostatic hypotension - the patient was admitted following a fall while getting out of the shower ___ dizziness. She caught herself on the way down but lightly hit her head. Head CT negative. She had symptomatic orthostatic hypotension on admission to the floor that resolved after IV fluid and oral fluid hydration. # RUQ/Epigastric pain, possibly ___ gastritis vs. pyelonephritis. The patient presented with intermittent chest/epigastric pain radiating to R flank. CTU on previous ED visit ___ was negative for nephrolithiasis, but did show several hepatic and pancreatic cysts/hypodensities. Cardiac workup in the ED was negative (troponin 0.02 x2, normal EKG). LFTs normal. The patient's RUQ pain quickly resolved on PPI within ___ days. The incidental findings of hepatic and pancreatic hypodensities on CT should be further worked up in the outpatient setting. # Suprapubic pain - On HD2 the patient developed significant suprapubic tenderness to palpation, much more pronounced on the right than left. While likely ___ her UTI, the asymmetric nature of the pain was concerning for possible gynecologic malignancy, but she had a reassuring bimanual exam without CMT or adnexal tenderness. She subsequently developed light vaginal spotting likely related to mild trauma of atrophic vaginal mucosa; this resolved spontaneously before discharge. # Acute renal failure- The patient was admitted with Creatinine 1.8 (baseline 0.8-1.0) in the setting of dehydration due to poor PO intake. Nephrotoxic medications were avoided. Her antihypertensive medications were held initially, but were re-introduced over the course of her hospital course as her creatinine improved. Creatinine improved from 1.8 to 1.0 with adequate IV and PO hydration and treatment of her UTI. Chronic issues: # TYPE 2 DM: The patient was started on her home insulin regimen on admission. She was switched to glargine for therapeutic interchange while in house. Elevated blood sugar in house is likely result of underlying infection. Glargine was uptitrated. She was switched to diabetic diet while in house. It is expected that her blood sugar improve after resolution of her infection. The patient's glucose the morning of admission was 156 and she was discharged on her home insulin regimen, with the reminder that if blood sugar is persistently high, she will likely need to have her insulin dose adjusted. # HYPERTENSION: The patient's home atenolol was held x1 on admission due to the patient's orthostasis and ARF. It was restarted on HD2. The patient's home losartan and hydrochlorothiazide were held due to her acute renal failure. As her renal function improved her losartan was restarted. Her HCTZ was restarted on discharge. Her blood pressures were stable throughout her admission, ranging SBP 100s-140s. Transitional issues: #FOLLOW-UP: -Primary care: patient will call to schedule a post-discharge follow-up appointment with her primary care physician, ___. ___. # Things to be followed up [] glycemic control [] hepatic and pancreatic hypodensity on CT should be further worked up Medications on Admission: Preadmissions medications listed are incomplete and require futher investigation. Information was obtained from Patient. 1. Atenolol 50 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Hydrochlorothiazide 25 mg PO DAILY 4. Losartan Potassium 50 mg PO BID 5. Levemir insulin 18 Units Breakfast, 6 Units Bedtime 6. Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atenolol 50 mg PO DAILY 3. Losartan Potassium 50 mg PO BID 4. Cepacol (Menthol) 1 LOZ PO Q2H:PRN throat pain RX *Cepacol Sore Throat 15 mg-4 mg 1 tab every 2 hours Disp #*30 Tablet Refills:*0 5. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every 12 hours Disp #*24 Tablet Refills:*0 6. Phenazopyridine 100 mg PO TID Duration: 3 Days RX *phenazopyridine 100 mg 1 tablet(s) by mouth three times a day Disp #*6 Tablet Refills:*0 7. Omeprazole 20 mg PO DAILY RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30 Tablet Refills:*0 8. Other 18 Units Breakfast Other 6 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 9. Acetaminophen 650 mg PO Q6H:PRN pain, fever RX *acetaminophen 325 mg ___ tablet(s) by mouth every 6 hours Disp #*30 Tablet Refills:*0 10. Hydrochlorothiazide 25 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: -pyelonephritis Secondary diagnoses: -Acute renal insufficiency -Hypertension -Diabetes Mellitus Type 2 Discharge Condition: Mental status: Clear and coherent Level of consciousness: Awake and alert Ambulatory status: ambulating without assistance Discharge Instructions: Dear Ms. ___, You were admitted to the ___ on ___ for weakness, tiredness, and abdominal pain. You had a urine test that showed you likely had a urinary tract infection. On your second day in the hospital you also developed a high fever which indicated that the infection likely involved your kidneys. For this you were started on an intravenous antibiotic medicine. Your fever improved, as well as your abdominal pain, and you were switched to an oral antibiotic medicine, which you will continue at home. In addition, we think that you may have had a mild inflammation of your stomach, so we started you on a medicine to reduce the acid. You should continue taking the antibiotic medicine Ciprofloxacin twice a day through the end of the day on ___. Your blood sugar was noted to be high while you were in the hospital. This can occur in the setting of infection. You should monitor your blood sugar closely. If it is persistently high, you should talk to your doctor about adjusting your insulin dose. You should make sure to follow up with your primary care doctor as mentioned below. Followup Instructions: ___
10162137-DS-14
10,162,137
20,936,550
DS
14
2172-08-23 00:00:00
2172-08-30 18:59:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: unresponsiveness Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ woman with HTN, COPD, dementia and a strong family history of epilepsy who presents unresponsive today after a coughing fit. Very little is known about her history. She had been living in ___ but now lives with her brother in ___. She has been spending the last 2 weeks with her niece and nephew'n'law. At baseline, she is able to carry on a conversation but cannot remember things for more than a few minutes and is only oriented to familiar places. Today, she was sitting on the couch when at 6pm she had a coughing fit. Her nephew brought her some water and noticed that she was quite unresponsive to his words and gestures. She was observed to be like this for at least a minute then developed shaking of her right arm and leg (it is unclear from the description if this was rhythmic) that eventually spread to the left side and lasted several minutes; it was associated with foaming at the mouth. EMS was called and brought her to the ED where apparently initially there was a question of a left gaze preference and a code stroke was called. When I initially saw her, she was moving all extremities but had no verbal output. Quickly after being stimulated, she started to speak but said nonsenical repetitive things ("what's the trouble?"). As she was brought to CT, she became very agitated and was moving all extremities vigorously and stripping off her clothes. Past Medical History: Family does not truly know other than dementia, but based on her medications, they believe she has HTN, HL, COPD and dementia. Per her niece, she has been refusing to take her medications recently. Social History: ___ Family History: Two sister's with epilepsy. No strokes. Physical Exam: General: Awake but eyes closed, uncooperative, agitated, trying to pull off clothes and jump off table HEENT: NC/AT, anicteric, MMM, Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: CTABL but prolonged expiratory phase, small expiratory grunts and breathing rapidly Cardiac: RRR, no murmurs, distant heart sounds Abdomen: soft, nontender, nondistended Extremities: no edema, pulses palpated Skin: no rashes or lesions noted. Neurologic: -Mental Status: On initial exam awakens to tactile but not verbal stimuli. Will not give name or follow any commands. On serial exams over 2 hours in the ED, she does become more awake and starts to respond to just verbal stimuli. She can give full name though not date or location. She can follow simple commands (thumbs up; show left hand). Language with many paraphsic errors and cannot repeat. Frequent seems to be confused. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. Blinks to threat in all quadrants. III, IV, VI: EOMI without nystagmus. Eventually tracks objects. Normal saccades. V: Withdraws to light touch. VII: No facial droop, facial musculature symmetric. VIII: Responds to loud stimuli bl. IX, X: Palate elevates symmetrically. XI: not tested XII: Tongue protrudes in midline. -Motor: Decreased bulk, normal tone throughout. Could not perform formal testing but vigorously moves all extremities antigravity and tries to climb out of bed. -Sensory: Responds brisk to light touch. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 - R 2 2 2 2 - Withdraws briskly; no clonus. -Coordination: Will not sit up or reach for objects. Pertinent Results: Head CT: TECHNIQUE: Axial MDCT images were obtained through the brain without the administration of IV contrast. Axial bone algorithm reconstructed images were acquired. FINDINGS: There is no evidence of acute intracranial hemorrhage, edema, mass effect, or acute large vascular territory infarction. The ventricles and sulci are normal in size and configuration for age. Periventricular and subcortical white matter hypodensities are nonspecific but likely sequela of chronic small vessel ischemic disease. Left basal ganglia and corona radiata hypodensities are consistent with prior infarcts. The basal cisterns appear patent. There is no fracture. Left frontal 12 mm ossified extra-axial mass may represent a meningioma, without mass effect on the brain. The visualized paranasal sinuses and mastoid air cells are clear. IMPRESSION: 1. No evidence of an acute intracranial abnormality. 2. Left frontal 12 mm ossified extra-axial mass, likely a meningioma, without mass effect on the brain. MRI: TECHNIQUE: Sagittal T1 weighted imaging was performed through the brain. After administration of 5 cc of Gadavist intravenous contrast, axial imaging was performed with diffusion, gradient echo, FLAIR, T2, and T1 technique. Sagittal MP rage imaging was performed in re-formatted in axial and coronal orientations. COMPARISON: Head CT ___. FINDINGS: Again seen is a left frontal mass adjacent to the inner table. This appears to be dural based and enhances after contrast administration. This likely represents a meningioma. A second small mass arises from the falx anteriorly, best seen on MIP image 14 of series 13 and image 20 of series 101. This also appears to represent a small meningioma. Images of the remainder of the brain demonstrate no other masses. The ventricles and sulci are normal in caliber and configuration for a patient of this age. There is extensive periventricular and to a lesser extent subcortical white matter hyperintensity on FLAIR. This finding is usually attributed to chronic small vessel ischemia. There is no evidence of hemorrhage or infarction. Except for the dural based lesions noted above, and there are no other areas of abnormal enhancement. IMPRESSION: Left frontal enhancing mass along the inner table and right frontal enhancing mass arising from the falx. These likely represent small meningiomas. Changes suggesting white matter chronic small vessel ischemia. EEG: FINDINGS: ABNORMALITY #1: There were occasional bursts of focal slowing seen in the left temporal region, the left hemisphere more broadly, and the right temporal region. ABNORMALITY #2: The background was slow and disorganized throughout the recording reaching a maximum 7 Hz frequency at times. There were occasional bursts of generalized polymorphic delta slowing at times. BACKGROUND: As described above in Abnormalities #1 and 2 above. HYPERVENTILATION: Not performed. INTERMITTENT PHOTIC STIMULATION: Not performed. SLEEP: The patient progressed through drowsiness into stage II sleep with normal symmetric sleep morphologies seen. CARDIAC MONITOR: Showed a generally regular rhythm. IMPRESSION: This is an abnormal routine EEG in the awake and asleep states due to the presence of multifocal slowing seen on a background that was slow and disorganized throughout the recording. These findings indicate multiple regions of subcortical dysfunction and a diffuse encephalopathy. No epileptiform features were seen. Knee Xray AP, lateral and skyline views of the right knee are submitted. There are no comparison studies. IMPRESSION: The bony mineralization is diminished consistent with osteoporosis. There are mild degenerative changes. No suprapatellar joint effusion. No evidence of displaced fracture or dislocation. Prominent arterial calcifications consistent with atherosclerosis. Brief Hospital Course: Ms. ___ quickly returned to her baseline mental status following admission. MRI demonstrated left frontal meningioma. She was started on Keppra 500 mg BID. Right knee xray was obtained given the patient's pain, but was negative for any acute process. Medications on Admission: Donepezil 10mg QD HCTZ 25mg QD Simvastatin 40mg QD Losartan 25mg QD Flurbiproton QD Sertraline 50mg QD Discharge Medications: 1. Donepezil 10 mg PO HS 2. Hydrochlorothiazide 25 mg PO DAILY 3. Losartan Potassium 25 mg PO DAILY 4. Sertraline 50 mg PO DAILY 5. Simvastatin 40 mg PO DAILY 6. flurbiprofen 50 mg Oral BID PRN pain 7. LeVETiracetam 500 mg PO BID RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*6 8. pediatric rolling walker Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Seizure Meningioma Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were seen in the hospital because you had a seizure. We think that the reason for this is a benign growth in your head called a meningioma. This can irritate the brain and this irritation can cause seizures. We have put you on and anti-seizure medication called Keppra to help prevent seizures in the future. We made the following changes to your medications: - We STARTED you on KEPPRA 500mg twice a day. This is to treat your seizures. Please continue to take your other medications as previously prescrbied. If you experience any of the below listed Danger Signs, please contact your doctor or go to the nearest Emergency Room. It was a pleasure taking care of you on this hospitalization. Followup Instructions: ___
10162298-DS-20
10,162,298
26,554,971
DS
20
2188-07-17 00:00:00
2188-07-18 16:39:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Atovaquone / Latex / Flecainide / dapsone Attending: ___. Chief Complaint: "Dyspnea." Major Surgical or Invasive Procedure: None History of Present Illness: ___ w/ sarcoidosis on high dose steroids since ___ presents with cough & SOB x5-6 days. The patient was started on 60 mg prednisone QD in ___ for her sarcoid-related lung disease. At that time she was also started on Mepron for prophylaxis. Her steroids were decreased to 40 mg prednisone in ___. Around the same time that she started Mepron, she was also started on flecainide for atrial fibrillation. She developed a rash; her doctors were unable to determine if it was due to mepron or flecainide; as such both drugs were discontinued. The patient was started on dapsone for prophylaxis but there was a period where she was off her bacterial prophylaxis for approximately ___ days. At the beginning of ___ she was also treated with a Z-pack for a sinus infection. . The patient developed acute onset of cough & sputum production roughly 5 days ago. She also felt short of breath at that time. Since then, her SOB has worsened & she has developed a wheeze. She went to see her PCP today to be evaluated; she was found to have a low O2 sat that did not improve with a nebulizer so she was advised to go the the ED. She states that her SOB had worsened to the point that she found it difficult to complete her ADLs. . She has had a cough productive of several tablespoons of green sputum since the onset of her symptoms. She has also had intermittent headaches & nausea. She reports some L-sided back pain which she relates to coughing. She denies fevers, chills, night sweats, but states that she feels "like I have an infection". Vital signs in ED: 99.5 111 126/72 20 92% . In the ED, a CXR was performed. The patient was given 500 mg IV azithromycin & duonebs. . On the floor, the patient continues to complain of SOB, worse with talking. Past Medical History: - Sarcoidosis diagnosed ___ years ago - Paroxysmal atrial fibrillation (not on anticoagulation) - Alopecia areata - Leiomyoma - Vitamin D deficiency - Osteopenia - Hypothyroidism Social History: ___ Family History: - Mother: Died at ___ when she was ___ months pregnant - Father: Died at ___ with CHF - 1 son (___), 1 daughter (___ on ___ - ___ history of autoimmune disease in siblings (2 sisters with lupus, 1 with graves) Physical Exam: ADMISSION EXAM: 99.5 111 126/72 20 92% GEN: Appears dyspneic, but breathing comfortably. HEENT: Dry MM. Some central cyanosis of tongue & lips. OP clear NECK: Supple. COR: +S1S2, tachycardic, regular, no m/g/r. PULM: Diminished breath sounds in right upper zones. Crackles & wheeze heard diffusely, L > R. No increased fremitus. ___: +NABS in 4Q. Soft, NTND EXT: WWP, no c/c/e. NEURO: PERRL, EOMI. MAEE. Strength ___ in bilateral upper & lower extremities. . DISCHARGE EXAM: GEN: Breathing comfortably, NAD. HEENT: MMM. Improved central cyanosis of tongue & lips. COR: +S1S2, RRR, no m/g/r. PULM: Diminished breath sounds in right upper zones. Crackles & polyphonic wheeze heard throughout L lung field (more wheezey than yesterday). Right lung field with scattered crackles ___: +NABS in 4Q. Soft, NTND EXT: WWP, no c/c/e. NEURO: MAEE Pertinent Results: LABS: CBC: ___ 04:23PM BLOOD WBC-18.6*# RBC-4.30 Hgb-12.6 Hct-37.1# MCV-86# MCH-29.2 MCHC-33.9 RDW-14.6 Plt ___ ___ 06:35AM BLOOD WBC-9.0 RBC-3.81* Hgb-10.9* Hct-32.5* MCV-85 MCH-28.7 MCHC-33.6 RDW-15.4 Plt ___ . BMP: ___ 04:23PM BLOOD Glucose-139* UreaN-13 Creat-0.8 Na-137 K-4.3 Cl-99 HCO3-26 AnGap-16 ___ 06:35AM BLOOD Glucose-70 UreaN-11 Creat-0.7 Na-135 K-4.1 Cl-97 HCO3-30 AnGap-12 . MISC: ___ 06:30AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.8 ___ 06:35AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.1 . ABG: ___ 09:45PM BLOOD Type-ART pO2-113* pCO2-37 pH-7.48* calTCO2-28 Base XS-3 Comment-ADD-ON MET ___ 11:31PM BLOOD Type-ART pO2-71* pCO2-40 pH-7.47* calTCO2-30 Base XS-4 ___ 09:16AM BLOOD Type-ART Temp-36.7 FiO2-21 pO2-84* pCO2-38 pH-7.45 calTCO2-27 Base XS-2 Intubat-NOT INTUBA . IMAGING: ___ CT CHEST W/O CONTRAST: 1. Extensive perihilar consolidations, bronchiectasis and architectural distortion compatible with sarcoidosis and show gross stability compared with ___ and ___. 2. Pan-lobar compensatory emphysema/hyperinflation of normal lung. . ___ CXR: No significant interval change in bilateral perihilar consolidation/fibrosis in this patient with history of sarcoidosis. No definite new focal consolidation seen. Brief Hospital Course: ASSESSMENT: ___ F with sarcoidosis on prednisone p/w productive cough & progressive SOB x5-6 days and found to have methemoglobinemia. . # SOB, COUGH: Initially concerning for PNA in immunosuppressed individual and CXR with possible abcess. Started on Vanc/Cefepime/azithromycin. CT scan was not concerning for infectious process and ABG showed methemoglobinemia of 19. G6PD was negative in ___ clinic, but repeated here and wnl. Dapsone was discontinued once results came back. ___ was consulted and methylene blue was given on the floor. Repeat ABG showed improvement of methemoglobin 1.6, but serial ABG showed rise to 3 and received another dose of methylene blue. With treatment, her oxygen requirement went from 5L to room air over and hour. She remained afebrile and leukocytosis resolved. Her antibiotics were pulled off on ___ and vanc/cef/azithro changed to levofloxacin 750mg. Sputum growing H. Flu. Also treated for URI and tracheobronchitis. Her prednsione was continued at 40mg PO Daily and no need for a burst of steroids. Given her chronic steroid use, she will need PCP ___, but cannot use dapsone, had reaction to atovaquone and there is some concern that sulfa containing drugs can also cause methemoglobinemia so recieved inhaled pnetamidine and will receive another dose in 4 weeks. She will follow up with Dr. ___ Dr. ___ in ___ clinic. Will complete 4 additional days of levofloxacin. beta glucan, galactomannan and blood cultures were negative. Sputum cultures showed sparse h. influenza. . # Hypothyroidism: Continue home levothyroxine. . # Hypertension: Held valsartan initially, but restarted once stabilized. . TRANSITIONAL ISSUES: - Inhaled pentamidine 4 weeks after discharge, follow up with pulmonary and PCP ___ on ___: - Prednisone 40 mg QD - Dapsone 100 mg QD - Levothyroxine 125 mcg QD - Valsartan 160 mg QD - Advair 500-50 mcg/dose 1 puff BID - Vitamin D2 50,000 units ___ - Risedronate 35 mg QWEEK - Ergocalciferol, Vitamin D2, (VITAMIN D) 50,000 unit Oral Capsule 1 -- Levalbuterol Tartrate 45 mcg 2 puffs QID PRN - Multivitamin . Discharge Medications: 1. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO 1X/WEEK (___). 4. valsartan 160 mg Tablet Sig: One (1) Tablet PO once a day. 5. Advair Diskus 500-50 mcg/dose Disk with Device Sig: One (1) Inhalation twice a day. 6. risedronate 35 mg Tablet Sig: One (1) Tablet PO at bedtime. 7. multivitamin Tablet Sig: One (1) Tablet PO once a day. 8. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 4 days. Disp:*4 Tablet(s)* Refills:*0* 9. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough. Disp:*30 Capsule(s)* Refills:*2* 10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 11. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO once a day. 12. Nebulizer Machine Diagnosis: Sarcoidosis 13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation every four (4) hours as needed for wheezing. Disp:*2 bottles* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: Methemoglobinemia secondary to dapsone Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you at ___! You were admitted due to a condition called methemoglobinemia which was causing low oxygen levels in your blood. In the hospital you were seen by our lung doctors and your condition was treated. You are now ready for discharge home with close out-patient follow-up. See below for changes to your home medication regimen: 1) Please STOP Dapsone 2) Please START Levofloxacin and continue for 4 additional days 3) You will need another dose of inhaled pentamidine 4 weeks after discharge. Please follow-up with your pulmonologist regarding this medication. 4) Please STOP Levalbuterol 5) Please START Albuterol via nebulizer as needed for wheezing See below for instructions regarding follow-up care: Followup Instructions: ___
10162298-DS-21
10,162,298
29,210,265
DS
21
2190-11-05 00:00:00
2190-11-10 19:30:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Atovaquone / Latex / Flecainide / dapsone / pentamidine inhaled Attending: ___. Chief Complaint: dyspnea, cough Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old woman with history of pulmonary sarcoidosis presents with 1 week of dyspnea and tachypnea. She was on a steroid taper, down to 20mg prednisone daily, which was increased via phone to 30mg daily by her pulmonologist at the beginning of her symptoms. She presented to urgent care yesterday and had prednisone dose increased to 40mg, and was started on azithromycin. She continued to worsen, with increasing productive cough and dyspnea. She is severely limited in her exertional capacity, cannot make her own bed. She denies any fevers/chills, but did note some nightsweats and fatigue. She works in a pediatric neurology office, thus may have had sick contacts there. Recalls some URI symptoms prior to symptoms. No myalgias/arthralgias. No nausea, vomiting, abdominal pain or diarrhea. Past Medical History: - Sarcoidosis diagnosed ___ years ago - Paroxysmal atrial fibrillation (not on anticoagulation) - Alopecia areata - Leiomyoma - Vitamin D deficiency - Osteopenia - Hypothyroidism Social History: ___ Family History: - Mother: Died at ___ when she was ___ months pregnant - Father: Died at ___ with CHF - 1 son (___), 1 daughter (nurse on ___ - ___ history of autoimmune disease in siblings (2 sisters with lupus, 1 with graves) Physical Exam: ADMISSION PHYSICAL EXAM: Temp: 98.8 HR: 109 BP: 127/78 Resp: 36O2 Sat: 94 Gen: pleasant and interactive. NAD but using accessory muscles to breathe and talking in clipped sentences HEENT: sclera anicteric, conjunctiva clear. OP mildly injected. Neck: supple, no lymphadenopathy Lungs: Poor air movement with expiratory wheezes and end inspiratory crackles throughout, prominent centrally and in the bases CV: regular rhythm, no murmurs Abdomen: soft, non-tender, non-distended. bowel sounds present Ext: no edema. no joint swelling Neuro: Ox3, CN2-12 intact DISCHARGE PHYSICAL EXAM: Vitals: 98.6, 110/87, 80, 16, 97% RA General: alert, interactive, pleasant. Sitting up comfortably HEENT: sclera anicteric, conjunctiva clear. Mucous membranes moist. Neck: supple, no lymphadenopathy or thyromegaly Lungs: expiratory wheezes throughout, inspiratory crackles centrally. Improved air movement. no use of accessory muscles. Speaking in full sentences CV: regular rhythm, no murmurs Abdomen: soft, non-tender, non-distended. bowel sounds present Ext: no edema. no joint swelling Neuro: Ox3, CN2-12 intact Pertinent Results: Admission labs: ___ 10:30AM GLUCOSE-96 UREA N-14 CREAT-0.8 SODIUM-134 POTASSIUM-3.5 CHLORIDE-95* TOTAL CO2-30 ANION GAP-13 ___ 10:30AM WBC-12.5* RBC-4.46 HGB-13.5 HCT-40.5 MCV-91 MCH-30.3 MCHC-33.4 RDW-13.7 ___ 10:30AM NEUTS-89.8* LYMPHS-6.4* MONOS-3.6 EOS-0.1 BASOS-0.2 ___ 10:30AM PLT COUNT-229 ___ 10:50AM LACTATE-1.5 Discharge labs: ___ 08:20AM BLOOD WBC-7.1 RBC-4.09* Hgb-12.6 Hct-36.1 MCV-88 MCH-30.7 MCHC-34.8 RDW-13.4 Plt ___ ___ 08:20AM BLOOD UreaN-18 Creat-0.7 Na-134 K-4.3 Cl-96 HCO3-28 AnGap-14 Micro: Blood Culture, Routine (Final ___: NO GROWTH. DIRECT INFLUENZA A ANTIGEN TEST (Final ___: Negative for Influenza A. DIRECT INFLUENZA B ANTIGEN TEST (Final ___: Negative for Influenza B. Legionella Urinary Antigen (Final ___: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS. RESPIRATORY CULTURE (Final ___: SPARSE GROWTH Commensal Respiratory Flora. Imaging: CXR ___ IMPRESSION: No significant change compared to ___ of findings consistent with massive perihilar fibrosis/consolidation in this patient with known history of sarcoidosis. No new consolidation. Chest CT ___ IMPRESSION: 1. Extensive perihilar consolidations with bronchiectasis and architectural distortion is not significantly changed from the prior exams in ___ and ___. This is in keeping with sarcoidosis. 2. Scattered prominent mediastinal lymph nodes are stable from the prior exam, and also in keeping with sarcoidosis. 3. Compensatory emphysema and hyperinflation is stable. 4. No new opacities to suggest a superimposed infection. Brief Hospital Course: ___ year old woman with pulmonary sarcoid on prednisone, presenting with cough and dyspnea for 1 week. # SOB, COUGH: Acute dyspnea and cough, in setting of known pulmonary sarcoid on chronic steroids represents sarcoid exacerbation +/- bronchitis/pneumonia. Patient is at risk for post-obstructive PNA given chronic pulmonary parenchymal compromise, though chest imaging read as without new consolidations. Good response of symptoms to IV steroid in ED, increased prednisone dose and levofloxacin. Sputum sample grew mixed flora, while flu swab and legionella were negative. Given risk of bacterial superinfection and somewhat immunocompromised state from chronic steroids, decision to complete course of antibiotics. She was hypoxic on admission, but weaned off of supplemental O2 by time of discharge and was able to maintain O2 saturations >95% on room air with ambulation. - continue Prednisone at 60mg daily until follow up with pulmonologist Dr ___ in 1 week - continue levofloxacin for likely 7 day course (day 1: ___ - benzonatate, Guaifenesin-Dextromethorphan prn cough - albuterol IH prn - she will continue to use the acepella device to help clear secretions Chronic issues: # Hypothyroidism: Continuedd home levothyroxine # Hypertension: continue home valsartan Transitional issues: #Continue Levofloxacin through ___ #Discharge on Prednisone 60mg daily for 7 days. Needs titration as outpatient. #Follow up with outpatient pulmonologist Dr ___ in 1 week # Code: FULL. confirmed # Emergency Contact: Husband ___ ___, Daughter ___ ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. hydrocodone-homatropine ___ mg oral HS cough 2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, cough 3. Valsartan 160 mg PO DAILY 4. Levothyroxine Sodium 125 mcg PO DAILY 5. PredniSONE 40 mg PO DAILY 6. fluticasone-salmeterol 500-50 mcg/dose inhalation bid 7. Tiotropium Bromide 1 CAP IH DAILY 8. Vitamin D 50,000 UNIT PO 1X/WEEK (___) 9. Aspirin 81 mg PO DAILY 10. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, cough 2. Aspirin 81 mg PO DAILY 3. Levothyroxine Sodium 125 mcg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. PredniSONE 60 mg PO DAILY RX *prednisone 20 mg 3 tablet(s) by mouth once a day Disp #*21 Tablet Refills:*0 6. Tiotropium Bromide 1 CAP IH DAILY 7. Valsartan 160 mg PO DAILY 8. Benzonatate 100 mg PO TID RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day Disp #*20 Capsule Refills:*0 9. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough RX *dextromethorphan-guaifenesin 100 mg-10 mg/5 mL 5 ml by mouth every six (6) hours Refills:*0 10. Levofloxacin 750 mg PO DAILY Duration: 5 Days RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth daily Disp #*4 Tablet Refills:*0 11. fluticasone-salmeterol 500-50 mcg/dose INHALATION BID 12. Vitamin D 50,000 UNIT PO 1X/WEEK (___) Discharge Disposition: Home Discharge Diagnosis: Primary: Sarcoidosis Bronchitis Secondary: Hypertension Hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms ___ ___ was a pleasure taking care of you at ___ ___. You were admitted with shortness of breath, likely due to an exacerbation of your sarcoid as well as a bronchitis. You were treated with steroids and antibiotics. You required oxygen for much of your stay, but improved and was not requiring it by discharge. Thank you for allowing us to participate in your care. Followup Instructions: ___
10162298-DS-22
10,162,298
29,455,384
DS
22
2190-11-20 00:00:00
2190-11-20 16:29:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Atovaquone / Latex / Flecainide / dapsone / pentamidine inhaled / Demerol Attending: ___. Chief Complaint: DOE, SOB Major Surgical or Invasive Procedure: None History of Present Illness: This is a ___ y/o female with a h/o pulmonary sarcoid, pAF, vit D deficiency, who presents here today with ongoing SOB at rest and dyspnea with even mild exertion. Of note, patient was just admitted from ___ with similar symptoms and during that time, work-up was negative for influenza, legionella, and any obvious consolidations. She was treated with high-dose prednisone (60 mg daily) and a 7-day course of levofloxacin. She was discharged with plans to follow-up with her primary pulmonologist on ___. Since that discharge, she has had no improvement ___ her symptoms. At baseline, she reports a "good" day as being one ___ which she can make her bed at home and have no symptoms while doing this. For the last few weeks however, she has been unable to do this without feeling very short of breath or coughing. After discharge, she was ___ contact with Dr. ___ given ongoing symptoms. She was started on the z-pak on ___ and her prednisone was increased to 80 mg on ___, tapered down back to 60 mg on ___. She saw him ___ clinic today and due to the degree of her dyspnea (not even able to walk across the room), she was sent to the ED for further evaluation. She reports sweats, no fevers or chills. She had palpitations briefly the last few nights without chest pain, dizziness or lightheadedness. Reports some nasal congestion and an ongoing cough which is now dry ___ nature. No GI symptoms ___ edema. 12-pt ROS otherwise negative ___ detail except for as noted above. Past Medical History: - Sarcoidosis diagnosed ___ years ago - Paroxysmal atrial fibrillation (not on anticoagulation) - Alopecia areata - Leiomyoma - Vitamin D deficiency - Osteopenia - Hypothyroidism Social History: ___ Family History: - Mother: Died at ___ when she was 6 months pregnant - Father: Died at ___ with CHF - 1 son (___), 1 daughter (___ on ___ - ___ history of autoimmune disease ___ siblings (2 sisters with lupus, 1 with graves) Physical Exam: VS: Tc 97.5, BP 118/64, HR 85, RR 22, SaO2 94/RA General: fatigued-appearing female, who coughs intermittently during the visit, AO x 3. Able to speak full sentences with slight dyspnea noted. HEENT: Anicteric sclerae, MM dry, OP clear Neck: supple, no LAD Chest: bronchial BS bilaterally, with bibasilar rhonchi and occasional exp wheezes throughout CV: RRR s1 s2 normal, no m/g/r Abd: soft, NT/ND, NABS Ext: no c/c/e Skin: warm, dry, no rashes Exam on discharge: Vitals: 97.5 BP: 126/74 HR: 64 R: 18 O2: 94% RA Ambulatory oxygen saturation 94% on room air Thin well appearing female ___ NAD. HEENT: Anicteric sclerae, MM dry, OP clear Chest: Bilateral wheezing throughout. CV: RRR s1 s2 normal, no m/g/r Abd: soft, NT/ND, NABS Ext: no c/c/e Skin: warm, dry, no rashes Pertinent Results: ___ 12:25PM WBC-23.5*# RBC-4.38 HGB-12.9 HCT-38.5 MCV-88 MCH-29.5 MCHC-33.6 RDW-13.7 ___ 12:25PM NEUTS-96.4* LYMPHS-1.1* MONOS-2.0 EOS-0.5 BASOS-0.1 ___ 12:25PM PLT COUNT-347 ___ 12:25PM GLUCOSE-114* UREA N-11 CREAT-0.6 SODIUM-130* POTASSIUM-4.1 CHLORIDE-94* TOTAL CO2-24 ANION GAP-16 ___ 01:44PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-MOD ___ 02:19PM ___ PTT-29.2 ___ ========== MICRO: ___ 4:18 pm Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. Respiratory Viral Culture (Preliminary): Respiratory Viral Antigen Screen (Final ___: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture for further information. ============= ___ 9:53 am SPUTUM Source: Induced. GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. 3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND SINGLY. RESPIRATORY CULTURE (Preliminary): SPARSE GROWTH Commensal Respiratory Flora. STREPTOCOCCUS PNEUMONIAE. SPARSE GROWTH. MOLD. 1 COLONY ON 1 PLATE. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final ___: NEGATIVE for Pneumocystis jirovecii (carinii). ___ EKG: NSR, no acute ST-T wave changes ___ CXR: PA and lateral views of the chest were provided. Extensive scarring ___ the mid lungs again noted without significant change ___ overall appearance from prior exam. There is no new consolidation. There is blunting of the left CP angle which could indicate a small effusion versus pleural thickening. The heart size appears grossly stable. The mediastinal contour is unchanged. No acute bony abnormalities are seen. CT chest: ___ IMPRESSION: 1. New consolidation at the left lower lobe which may be secondary to pneumonia. Redemonstrated are extensive perihilar consolidations with bronchiectasis and architectural distortion ___ keeping with patient's known history of sarcoidosis. 2. Scattered stable mediastinal lymph nodes. 3. Stable compensatory emphysema and hyperinflation. Echocardiogram: ___ The left atrium is normal ___ size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Moderate pulmonary hypertension. Normal global and regional biventricular systolic function. Moderate functional tricuspid regurgitation. Brief Hospital Course: This is a ___ y/o female with pulmonary sarcoid, re-presenting with ongoing shortness of breath at rest, dyspnea with minimal exertion, and cough. #Pulmonary Sarcoidosis #Pneumonia, bacterial Ms. ___ was admitted from pulmonary clinic with subacute shortness of breath, dyspnea on exertion and cough. She was managed with the help of the pulmonary consult team. It was thought her continued symptoms were due to infection (viral, bacteria or PJP), worsening sarcoid or possible right sided heart failure ___ the setting of significant pulmonary disease. The patient underwent an Echocardiogram which showed preserved biventricular systolic function with moderate pulmonary hypertension. Induced sputum was negative for PJP, but was positive for Strep Pneumonia. RVP was negative- culture is pending on discharge. The patient also had a CT chest without contrast which showed new left lower lobe consolidation concerning for pneumonia. Given these findings, the patient was started on Augmentin for a 14 day course. The decision was made not to start HCAP coverage given patient was overall non-toxic appearing and induced sputum sample was positive for strep pneumonia. Finally, given no evidence of worsening sarcoid on her CT scan, her steroids were also tapered. She will be discharged on 40mg and will decrease my 10mg every 3 days stopping when she gets to 10mg. She will transition her care to Dr. ___ discharge. #PJP prophylaxis Discussed with ___ attending, Dr. ___ regarding options for PJP prophylaxis. The patient has a number of drug allergies and will likely need to be on high doses of steroids ___ the future. The patient was set up with outpatient follow up with Dr. ___. #Paroxysmal atrial fibrillation The patient was currently ___ NSR, seems unlikely to be cause of her symptoms. She had no evidence of paroxysmal atrial fibrillation while hospitalized. #Hyponatremia The patient presented with mild hyponatremia which improved with IV fluids. Chronic issues: #Hypothyroid Continue levothyroxine #Hypertension, benign Continue Valsartan Transitional issues: - Patient will continue to taper steroids by 10 mg every three days, stopping at 10mg - Follow up with allergy to discuss PJP prophylaxis - Continue antibiotics x 14 days - Patient will follow up with pulmonary ___ the next ___ weeks - ___ need further evaluation of pulmonary hypertension - Code - full - Communication - Husband ___ ___, Daughter ___ ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 2. Aspirin 81 mg PO DAILY 3. Levothyroxine Sodium 125 mcg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. PredniSONE 60 mg PO DAILY 6. Tiotropium Bromide 1 CAP IH DAILY 7. Valsartan 160 mg PO DAILY 8. Benzonatate 100 mg PO TID 9. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough 10. Azithromycin 250 mg PO Q24H 11. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 12. Vitamin D 50,000 UNIT PO 1X/WEEK (___) Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 2. Aspirin 81 mg PO DAILY 3. Benzonatate 100 mg PO TID 4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 5. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough 6. Levothyroxine Sodium 125 mcg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. PredniSONE 40 mg PO DAILY Duration: 1 Day Tapered dose - DOWN 9. Valsartan 160 mg PO DAILY 10. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth Q12 hrs Disp #*25 Tablet Refills:*0 11. Tiotropium Bromide 1 CAP IH DAILY 12. Vitamin D 50,000 UNIT PO 1X/WEEK (___) 13. PredniSONE 40 mg PO DAILY Duration: 1 Day Start: Tomorrow - ___, First Dose: First Routine Administration Time RX *prednisone 10 mg 4 tablet(s) by mouth daily Disp #*35 Tablet Refills:*0 14. PredniSONE 30 mg PO DAILY Duration: 3 Days Start: After 40 mg tapered dose 15. PredniSONE 20 mg PO DAILY Duration: 3 Days Start: After 30 mg tapered dose 16. PredniSONE 10 mg PO DAILY Duration: 14 Days Start: After 20 mg tapered dose Discharge Disposition: Home Discharge Diagnosis: Pnuemonia, bacterial Pulmonary sarcoid Pulmonary hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you during your recent admission to ___. You were admitted with woresening cough and shortness of breath. You were seen by the pulmonologists who helped manage your care while you were hospitalized. You had an echocardiogram (ultrasound of your heart) which showed normal function. Your pulmonary artery pressure was high. You can discuss this further with your pulmonologist. You also had a CT of your chest which showed a possible new pneumonia. You were started on antibiotics to treat pneumonia and you will need to continue these antibiotics for 2 weeks total. Finally, your steroids are being tapered down. You should take 40mg of prednisone tomorrow, then decrease your dose by 10mg every three days until you get to 10mg. Then continue to take 10mg of prednisone. Followup Instructions: ___
10162540-DS-4
10,162,540
22,309,712
DS
4
2138-02-13 00:00:00
2138-02-13 18:33:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: gabapentin Attending: ___ Chief Complaint: RLE pain Major Surgical or Invasive Procedure: ORIF R periprosthetic femur fracture History of Present Illness: Mr. ___ is an ___ year old male with multiple medical comorbidities who presents to ___ ED as a OSH transfer with a right periprosthestic femur fracture. The patient and his wife state he was pulling his pants up and fell backwards landing on his right hip with immediate pain, and inability to ambulate. The patient denies head strike, LOC, other injuries. He denies any numbness or tingling distally. At time of examination, he denies CP/SOB/F/C/N/V/diarrhea Past Medical History: CAD w/hx of MI s/p stent several years ago (still on Plavix) Moderate AS (per note in ___ ? PACEMAKER (not seen on CXR) HLD HTN OTHER PAST MEDICAL HISTORY: Diabetes Type 2 Hx PsychConditions: DEPRESSION, ANXIETY GOUT CHRONIC BACK ISSUES VERTIGO Social History: ___ Family History: NC Physical Exam: ADMISSION PHYSICAL EXAM: Gen: ill appearing. in no distress Alert and oriented x 3 CV: RRR Lungs: breathing room air comfortably. Right upper extremity: - Skin intact - No deformity, erythema, edema, induration or ecchymosis - Soft, non-tender arm and forearm - Full, painless AROM/PROM of shoulder, elbow, wrist, and digits - EPL/FPL/DIO (index) fire - SILT axillary/radial/median/ulnar nerve distributions - 2+ radial pulse Left upper extremity: - Skin intact - No deformity, erythema, edema, induration or ecchymosis - Soft, non-tender arm and forearm - Full, painless AROM/PROM of shoulder, elbow, wrist, and digits - EPL/FPL/DIO (index) fire - SILT axillary/radial/median/ulnar nerve distributions - 2+ radial pulse Right lower extremity: - Skin intact, swelling about thigh - Full, painless AROM/PROM of ankle - ___ fire - SILT SPN/DPN/TN/saphenous/sural distributions - 1+ ___ pulses, foot warm and well-perfused Left lower extremity: - Skin intact - No deformity, erythema, edema, induration or ecchymosis - Soft, non-tender thigh and leg - Full, painless AROM/PROM of hip, knee, and ankle - ___ fire - SILT SPN/DPN/TN/saphenous/sural distributions - 1+ ___ pulses, foot warm and well-perfused DISCHARGE PHYSICAL EXAM VITALS: 98.3 152/68 64 16 94RA GENERAL: Alert, oriented x2, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear RESP: Basilar crackles bilaterally, no wheezes CV: RRR, faint systolic murmur. ABD: +BS, soft, nondistended, nontender to palpation. No hepatomegaly. GU: no foley EXT: Swollen and ecchymotic proximal thigh and abdomen, improved from prior. Significant RLE edema SKIN: No rashes/lesions. Pertinent Results: ADMISSION LABS: =============== ___ 09:02PM BLOOD WBC-11.0* RBC-3.22* Hgb-8.5* Hct-28.3* MCV-88 MCH-26.4 MCHC-30.0* RDW-13.2 RDWSD-42.6 Plt ___ ___ 09:02PM BLOOD Neuts-85.8* Lymphs-6.2* Monos-7.2 Eos-0.1* Baso-0.1 Im ___ AbsNeut-9.45* AbsLymp-0.68* AbsMono-0.79 AbsEos-0.01* AbsBaso-0.01 ___ 09:02PM BLOOD ___ PTT-28.0 ___ ___ 09:02PM BLOOD Glucose-148* UreaN-27* Creat-1.2 Na-138 K-3.8 Cl-100 HCO3-25 AnGap-17 PERTINENT LABS ============== ___ 12:17AM BLOOD cTropnT-0.09* ___ 06:08AM BLOOD cTropnT-0.11* ___ 09:23AM BLOOD CK-MB-6 proBNP-5407* ___ 01:13PM BLOOD cTropnT-0.13* ___ 05:45PM BLOOD CK-MB-4 ___ 05:45AM BLOOD CK-MB-6 cTropnT-0.12* ___ 04:20AM BLOOD Calcium-8.9 Phos-1.8* Mg-2.1 ___ 05:45AM BLOOD Hapto-195 DISCHARGE LABS: =============== ___ 04:20AM BLOOD WBC-8.6 RBC-2.66* Hgb-7.7* Hct-24.4* MCV-92 MCH-28.9 MCHC-31.6* RDW-14.6 RDWSD-49.1* Plt ___ ___ 04:20AM BLOOD Glucose-105* UreaN-29* Creat-1.1 Na-141 K-3.9 Cl-107 HCO3-24 AnGap-14 MICROBIOLOGY: ============= ___ 6:19 am URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: KLEBSIELLA PNEUMONIAE. 10,000-100,000 CFU/mL. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S REPORTS: ======== ___ Hip XRay IMPRESSION: Status post right total hip arthroplasty with periprosthetic fracture involving the femoral stem. No additional fractures identified. ___ Femur XRay IMPRESSION: Status post right total hip arthroplasty with periprosthetic fracture involving the femoral stem. No additional fractures identified. ___ IMPRESSION: No acute cardiopulmonary abnormality. Moderate cardiomegaly. ___ Echo Conclusions The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Doppler parameters are most consistent with Grade II (moderate) left ventricular diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal biventricular regional/global systolic function. Mild aortic stenosis. Mild aortic regurgitation. Elevated PCWP. ___ Fluoro IMPRESSION: Several fluoroscopic images of the right femur from the operating room demonstrate placement of a lateral fracture plate and screws fixating a periprosthetic fracture round the right total hip arthroplasty. Total intraservice fluoroscopic time was 30.1 seconds. Please refer to the operative note for additional details. ___ Femur Xray IMPRESSION: Several fluoroscopic images of the right femur from the operating room demonstrate placement of a lateral fracture plate and screws fixating a periprosthetic fracture round the right total hip arthroplasty. Total intraservice fluoroscopic time was 30.1 seconds. Please refer to the operative note for additional details. ___ CXR IMPRESSION: Decreased pulmonary vascularity. No pulmonary edema. ___ CT A/P IMPRESSION: 1. No evidence for retroperitoneal hematoma. Subcutaneous stranding along the right flank, posttraumatic. No organized hematoma. 2. Mild circumferential bladder thickening, may be reactive or inflammatory. Brief Hospital Course: ___ w/pmh CAD, HTN, HLD presents to ___ ED as a OSH transfer with a right periprosthestic femur fracture now s/p ___ transferred to medicine for management of hypotension, delirium and CAD. #Post-op delirium: Improved. Pt AOx2, conversant, somewhat sluggish. Likely multifactorial including post-anesthesia state, UTI, pain and narcotics. Approximately at baseline per family on day of discharge. His pain was controlled with his home fentanyl patch and tylenol and oxycodone PRN. His UTI was treated as below. #UTI: Foley catheter in place perioperatively. UA consistent with infection and delirium thought to be partially driven by infection. Started on ceftriaxone. Urine culture grew klebsiella sensitive to cephalosporins and fluoroquinolones. He was switched to ciprofloxacin at the time of discharge to complete a 7 day total course. #NSTEMI/CAD: Has history of un-revascularized mild coronary disease per his cardiologist's report from ___. Mild trop elevations in setting of stress and anemia suggest type 2 (demand) ischemia rather than ACS. His home antihypertensives were initially held for post-op hypertension, but gradually resumed as his blood pressure normalized. Orthopedic surgery cleared the patient to resume anti-platelet therapy on ___. Per cardiology, his clopidogrel was stopped, given the increased bleeding risk and long period of time since his last PCI. His aspirin was continued. His home simvastatin was continued. ___: Likely pre-renal, improved with blood and crystalloid. Lisinopril and Lasix were initially held, but resumed when creatinine normalized. #Anemia: Required transfusion for hyptension related to acute blood loss anemia postoperatively. Slow decline thereafter was thought to be dilutional with a small amount of ongoing surgical blood loss. Chronic Issues #Chronic diastolic CHF: No evidence of decompensation at this time. Comfortable on room air. Significant RLE pitting edema is appropriate post-operatively per orthopedics. His home furosemide was held initially for ___ and resumed when creatinine normalized. #Depression: continued home sertraline #HTN: Initially held home meds as above, reintroduce as tolerated. All appropriate to continue on discharge. #BPH: continue home finasteride TRANSITIONAL ISSUES: #Clopidogrel was discontinued by our cardiology team given the increased risk of bleeding and the amount of time since his last PCI. #Patient will take an additional 5 days of ciprofloxacin for UTI after discharge #Patient will continue lovenox injections for 10 days, until ___ #Consider stopping oxybutynin and meclizine, tapering and ultimately stopping fentanyl patch and tramadol, all of which can increase confusion in patients with cognitive decline and increase risk of falls in the elderly #Consider stopping indomethacin. NSAIDs are not recommended for patients with CAD and it increases risk of bleeding in combination with aspirin. Colchicine might be a better choice for pain control in gout flares. #Consider starting a low dose antipsychotic, such as Seroquel or olanzepine qhs +/- PRN as patient's family report intermittent difficulty with anxiety and agitation that are not well controlled with his current medication regimen Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Pramipexole 0.25 mg PO TID 2. Simvastatin 40 mg PO QPM 3. Ezetimibe 10 mg PO DAILY 4. Carvedilol 12.5 mg PO BID 5. Finasteride 5 mg PO DAILY 6. Furosemide 20 mg PO DAILY 7. HydrALAZINE 25 mg PO BID 8. Lisinopril 40 mg PO DAILY 9. Clopidogrel 75 mg PO DAILY 10. Meclizine 25 mg PO BID 11. NIFEdipine CR 30 mg PO DAILY 12. Sertraline 100 mg PO DAILY 13. Tamsulosin 0.4 mg PO QHS 14. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 15. Fentanyl Patch 100 mcg/h TD Q48H 16. Aspirin 81 mg PO DAILY 17. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY 18. Oxybutynin 10 mg PO QHS 19. Fluticasone Propionate NASAL 1 SPRY NU DAILY 20. Nitromist (nitroglycerin) 400 mcg/spray translingual q5min prn chest pain 21. Nystatin-Triamcinolone Cream 1 Appl TP BID:PRN rash 22. TraMADol 50 mg PO TID:PRN Pain - Moderate 23. Indomethacin 25 mg PO TID:PRN gout 24. Clobetasol Propionate 0.05% Gel 1 Appl TP PRN psoriasis 25. Senna 8.6 mg PO BID constipation 26. Docusate Sodium 100 mg PO BID Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Aluminum-Magnesium Hydrox.-Simethicone ___ ml PO Q6H:PRN Dyspepsia 3. Ciprofloxacin HCl 250 mg PO Q12H Duration: 5 Days 4. Docusate Sodium 100 mg PO BID 5. Enoxaparin Sodium 30 mg SC Q12H 6. Milk of Magnesia 30 ml PO BID:PRN Constipation 7. Senna 8.6 mg PO BID 8. Aspirin 81 mg PO DAILY 9. Carvedilol 12.5 mg PO BID 10. Clobetasol Propionate 0.05% Gel 1 Appl TP PRN psoriasis 11. Ezetimibe 10 mg PO DAILY 12. Fentanyl Patch 100 mcg/h TD Q48H RX *fentanyl 100 mcg/hour Remove old patch and apply new patch to skin Every 48 hrs Disp #*5 Patch Refills:*0 13. Finasteride 5 mg PO DAILY 14. Fluticasone Propionate NASAL 1 SPRY NU DAILY 15. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 16. Furosemide 20 mg PO DAILY 17. HydrALAZINE 25 mg PO BID 18. Indomethacin 25 mg PO TID:PRN gout 19. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY 20. Lisinopril 40 mg PO DAILY 21. Meclizine 25 mg PO BID 22. NIFEdipine CR 30 mg PO DAILY 23. Nitromist (nitroglycerin) 400 mcg/spray translingual q5min prn chest pain 24. Nystatin-Triamcinolone Cream 1 Appl TP BID:PRN rash 25. Oxybutynin 10 mg PO QHS 26. Pramipexole 0.25 mg PO TID 27. Sertraline 100 mg PO DAILY 28. Simvastatin 40 mg PO QPM 29. Tamsulosin 0.4 mg PO QHS 30. TraMADol 50 mg PO TID:PRN Pain - Moderate RX *tramadol 50 mg 1 tablet(s) by mouth three times a day Disp #*30 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: R femur periprosthetic fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - touch down weight bearing, range of motion as tolerated RLE MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take lovenox daily for 2 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Please remain in your dressing and remove on post operation day 5 Followup Instructions: ___
10162540-DS-5
10,162,540
27,114,590
DS
5
2138-03-25 00:00:00
2138-03-26 08:34:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: gabapentin / acetaminophen Attending: ___. Chief Complaint: Hypotension, hypoxemia Major Surgical or Invasive Procedure: None History of Present Illness: ___ w/ CAD h/o MI s/p 4 stents, HTN, HLN, depression, anxiety, gout, mild dementia, DM2 who was transferred from ___ for hypotension & hypoxia in setting of +influenza A & ?PNA. Patient has been at ___ for approximately 1 month for physical therapy after experiencing a broken femur after a fall. History obtained from patient, daughter, and ___. Patient reports a 2 day history of cough productive of yellow sputum. At ___, he was diagnosed with the flu and started on oseltamivir. He was noted to be hypotensive to ___ and hypoxic to mid-80s and taken to ___. He received 1L NS, started on O2, and a nebulizer treatment with improvement in his SBP to 100s and sat to ___. Patient was positive for Flu-A. CXR with areas concerning for PNA and he was started on vanc/zosyn. Labs were notable for Trop-I 0.32, EKG NSR without any acute ischemic changes. Creat also noted to be 2.2 (baseline 1.1-1.2). While waiting to be admitted to the floor, he became hypotensive to ___. He was given a fluid bolus and transferred to ___ for potential ICU level of care. In the ___ ED, initial VS were T 96.8 HR 50 BP 105/61 RR 24 Sat 98% 3L NC. Exam was not documented. ___ ED Labs were notable for: WBC 6.7,Hgb 8.1, plt 145 Cr 1.9 Troponin 0.08, CK 181, MB 2, Lactate 0.8 INR 1.1 He received IVF @ 100cc/hr, ASA 81mg, finasteride 5mg, oxybutynin 5mg, sertraline 25mg, zosyn 4.5mg, and Lasix 20mg. Decision was made to admit to medicine for further management and stabilization. On arrival to the floor, patient reports continued cough. He notes SOB with cough. He also noted chest pressure, worse with cough and deep breaths. He also reports some dizziness with fast movement of his head and feels the room is spinning around him. Past Medical History: CAD w/hx of MI s/p stent several years ago (still on Plavix) Moderate AS (per note in ___ ? PACEMAKER (not seen on CXR) HLD HTN OTHER PAST MEDICAL HISTORY: Diabetes Type 2 Hx PsychConditions: DEPRESSION, ANXIETY GOUT CHRONIC BACK ISSUES VERTIGO Social History: ___ Family History: NC Physical Exam: ADMISSION PHYSICAL EXAM: ========================== VS: 98.0 HR 55, BP 91/61, RR 18, Sat 93% 2L NC GENERAL: elderly man, lying comfortably in bed, speaking in full sentences, alert and awake, in NAD. HEENT: anicteric sclera, pink conjunctiva, MMM HEART: bradycardic, RR, nml S1/S2, no murmurs, gallops, or rubs LUNGS: decrease breath sounds throughout, diffuse crackles, no wheezes; breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose NEURO: CN II-XII intact SKIN: warm and well perfused, decubitus ulcer at coccyx with excoriation marks, meriplex in place over ulcer, no rashes. DISCHARGE PHYSICAL EXAM: ======================== VS: 98.0 120-190s/50-80s 60 98% 2L NC GENERAL: elderly man, lying comfortably in bed, anxious appearing, alert and awake, speaking in full sentences, in NAD. HEENT: anicteric sclera, pink conjunctiva, MMM HEART: RRR, nml S1/S2, no murmurs, gallops, or rubs LUNGS: diffuse crackles and course breath sounds, no wheezes; breathing comfortably without use of accessory muscles ABDOMEN: +BS, nondistended, nontender in all quadrants, no rebound/guarding EXTREMITIES: R knee with warmth, limited active range of motion, mild effusion; no cyanosis, clubbing or edema, moving all 4 extremities with purpose NEURO: CN II-XII intact SKIN: warm and well perfused, no rashes. Pertinent Results: ADMISSION LABS: ================= ___ 06:18AM BLOOD WBC-6.7 RBC-2.86* Hgb-8.1* Hct-27.0* MCV-94 MCH-28.3 MCHC-30.0* RDW-14.6 RDWSD-50.6* Plt ___ ___ 06:18AM BLOOD Neuts-69.3 Lymphs-17.8* Monos-12.2 Eos-0.0* Baso-0.1 Im ___ AbsNeut-4.64# AbsLymp-1.19* AbsMono-0.82* AbsEos-0.00* AbsBaso-0.01 ___ 06:18AM BLOOD ___ PTT-32.1 ___ ___ 06:18AM BLOOD Glucose-84 UreaN-37* Creat-1.9* Na-137 K-3.8 Cl-103 HCO3-23 AnGap-15 ___ 06:18AM BLOOD CK(CPK)-181 ___ 06:18AM BLOOD CK-MB-2 ___ 06:18AM BLOOD cTropnT-0.08* ___ 06:18AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.8 ___ 06:17AM BLOOD Lactate-0.8 NOTABLE LABS: ============== ___ 06:18AM BLOOD UreaN-37* Creat-1.9* ___ 06:50AM BLOOD UreaN-28* Creat-1.4* ___ 06:35AM BLOOD UreaN-21* Creat-1.1 ___ 08:20AM BLOOD UreaN-15 Creat-1.0 ___ 08:20AM BLOOD UreaN-15 Creat-1.0 ___ 07:00AM BLOOD UreaN-12 Creat-1.1 ___ 07:10AM BLOOD UreaN-10 Creat-0.9 ___ 06:10AM BLOOD UreaN-10 Creat-1.0 ___ 06:18AM BLOOD cTropnT-0.08* ___ 01:41PM BLOOD cTropnT-0.08* ___ 09:56PM BLOOD cTropnT-0.08* ___ 06:50AM BLOOD cTropnT-0.06* ___ 06:10AM BLOOD TSH-3.0 ___ 06:10AM BLOOD VitB12-1082* DISCHARGE LABS: =============== ___ 06:10AM BLOOD WBC-6.1 RBC-3.11* Hgb-8.7* Hct-27.9* MCV-90 MCH-28.0 MCHC-31.2* RDW-13.8 RDWSD-45.4 Plt ___ ___ 06:10AM BLOOD Glucose-106* UreaN-10 Creat-1.0 Na-141 K-3.7 Cl-104 HCO3-27 AnGap-14 ___ 06:10AM BLOOD Calcium-9.2 Phos-2.2* Mg-2.0 MICRO: ======= ___ 10:15 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT ___ MRSA SCREEN (Final ___: POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. IMAGING: ========= ___ Imaging CHEST (PORTABLE AP) Heart size and mediastinum are unchanged. Lungs are well inflated. No focal consolidations to suggest infectious process demonstrated. No pneumothorax or pleural effusion is noted. Minimal interstitial prominence is noted and might be consistent with some degree of pulmonary edema. Pulmonary nodule projecting over the right mid lung most likely represents pleural plaque, 8 mm in diameter, but correlation with chest CT is to be considered for it is precise characterization. ___ Imaging FEMUR (AP & LAT) RIGHT FINDINGS: Right total hip arthroplasty. Side plate, screws, cerclage wires across periprosthetic proximal femoral fracture. Fracture is not well seen. Small ossification along the medial margin middle third femoral diaphysis is stable. Degenerative changes right knee. Arterial calcifications. Surgical staples have been removed. IMPRESSION: No significant change. Brief Hospital Course: Mr. ___ is an ___ yo male with history of CAD (MI s/p 4 stents), HTN, HLN, depression, anxiety, gout, mild dementia, DM2 who was transferred from ___ for hypotension & hypoxemia in setting of +influenza A & pneumonia. Upon admission, patient's hypertensive medications were held and he was given fluids. He was continued on Tamiflu and started on vanc/ceftazidime for pneumonia. He was also noted to have ___, which improved with fluids. Patient improved with Tamiflu and antibiotics and required less O2 throughout the admission. He was also noted to have increasing anxiety. He was initially started on trazadone, then switched to olanzapine with minimal effect. Geriatrics was consulted for help with treating anxiety in patient with history of dementia. Geriatrics recommended non-pharmacological interventions to help reorient patient and decrease anxiety, formal dementia workup as an outpatient, and to decrease poly-pharmacy by discontinuing unnecessary medications. #Hypoxemia #Influenza with pneumonia #Healthcare associated pneumonia (MRSA): Patient with hypoxia and new O2 requirement in setting of flu and suspicion for superimposed bacterial pneumonia on CXR. Patient was given fluid resuscitation and started on vanc/ceftaz for CAP coverage. Patient's MRSA screen positive so patient was continued on vancomycin for duration of therapy (7 days total). He was also continued on oseltamivir for influenza A infection (5 days total). Patient was given duonebs for wheezing. Throughout the course of admission, his lung exam improved and he required less O2. However, the patient continued to complain of cough and was placed on guaifenesin and tessalon pearls for symptom control. #Anxiety: throughout the admission, the patient was noted to have marked anxiety (above his baseline per family). He had been started on trazadone at rehab facility, which was continued during this admission without much improvement. He was then switched to olanzapine without effect. Geriatrics was consulted for help in management of anxiety given patient's dementia. He did not have delirium during this admission. Geriatrics service recommended non-pharmacological interventions for patient's anxiety, including reorientation and reassurances. Also recommended decreasing poly-pharmacy and patient's oxybutynin, Colace, ascorbic acid, folate, and vit b12 were discontinued. He was started on a multivitamin. Patient also may benefit from formal dementia workup as outpatient. #Gout: patient with history of gout, notes increased R knee pain similar to gout pain. Increased warmth, but with intact active and passive range of motion, minimal effusion on exam, reassuring against septic arthritis. He was given a loading dose of colchicine 1.2mg PO followed by 0.6mg PO within 1 hour on ___. He should continue colchicine 0.6mg PO BID starting on ___ until 2 days after symptoms resolve. #HTN: patient with history of hypertension, on multiple agents. Originally held ___ hypotension in setting of infection. However, once patient's infection improved, he became hypertensive and his home medications were sequentially restarted. #Constipation: Patient was noted to be constipated, requiring disimpaction on ___. Given long-standing narcotic use (fentanyl patch), he was started on a standing bowel regimen. #Troponinemia: Patient with reported chest pain at rehab, worse with deep breathing, resolved spontaneously. Trop-I 0.32 at ___ trop-T 0.08. On the floor, patient with chest pressure. EKG with bradycardia, no ST segment elevations. Patient with known history of un-revascularized mild coronary disease per his cardiologist's report from ___. Trops downtrended (0.08->0.06). Likely type II NSTEMI. ___: Upon admission, patient's creatinine elevated to 2.2 in ___ ___ 1.9 in ___ ED s/p 2L IVF. Likely prerenal in setting of hypotension. Patient received IVF and his creatinine returned to baseline 1.0. #Thrush: patient noted to have oral thrush. Was started on Nystatin swish and swallow and thrush resolved. #R hip fracture: patient with traumatic fall, diagnosed with femur fracture during last admission. He had a repeat R hip xray without any significant interval changes. He was seen by ___ who recommended patient would benefit from further rehab. Patient is touch down weight bearing, range of motion as tolerated right lower extremity. TRANSITIONAL ISSUES: ===================== [] Patient with reported history of dementia, although with long alcohol history and no formal dementia workup. Please perform formal work-up for dementia and treat as clinically indicated. [] Patient with early gout flare of R knee. Given colchicine 1.2mg and 0.6mg on ___. Please continue colchicine 0.6mg BID until 2 days after resolution of symptoms. [] While on colchicine, please monitor patient for colchicine toxicity since patient also on carvedilol. Check for muscle weakness, numbness, tingling in fingers or toes, unusual bleeding or bruising, abdominal pain, nausea, vomiting, and diarrhea. [] Could consider allopurinol for gout prevention in the outpatient setting after resolution of his gout flare. [] Per geriatric recommendations, no current need for pharmacological interventions to treat anxiety as patient is not delirious and redirectible. Please reorient patient frequently. [] Per geriatric recommendations, patient's oxybutynin, docusate, and ascorbic acid were discontinued. [] Patient's folic acid and cyanocobalamin supplementation were discontinued and he was started on a multivitamin. [] Consider rechecking patient's iron panel and stopping ferrous sulfate if no longer clinically indicated -CODE: DNR, ok for short intubations; MOLST signed -CONTACT/HCP: ___ (wife) ___ Anticipated rehab stay is <30 days. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Docusate Sodium 100 mg PO TID 2. Senna 8.6 mg PO QHS 3. Fentanyl Patch 100 mcg/h TD Q48H 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. Furosemide 20 mg PO DAILY 6. HydrALAZINE 25 mg PO BID 7. Lisinopril 40 mg PO DAILY 8. Oxybutynin 5 mg PO DAILY 9. Pramipexole 0.25 mg PO TID 10. Sertraline 100 mg PO DAILY 11. Aspirin 81 mg PO DAILY 12. Carvedilol 12.5 mg PO BID 13. Ezetimibe 10 mg PO DAILY 14. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY 15. Simvastatin 40 mg PO QPM 16. Finasteride 5 mg PO DAILY 17. Tamsulosin 0.4 mg PO DAILY 18. Cyanocobalamin 1000 mcg PO DAILY 19. Ferrous GLUCONATE 324 mg PO DAILY 20. FoLIC Acid 1 mg PO DAILY 21. Ascorbic Acid ___ mg PO BID 22. Fluticasone Propionate NASAL 1 SPRY NU DAILY 23. Vitamin D ___ UNIT PO 1X/WEEK (MO) 24. TraMADol 50 mg PO TID:PRN Pain - Moderate 25. Nystatin-Triamcinolone Cream 1 Appl TP TID:PRN pruritis 26. NIFEdipine CR 30 mg PO DAILY 27. TraZODone 25 mg PO BID Discharge Medications: 1. Benzonatate 100 mg PO TID 2. Colchicine 0.6 mg PO BID 3. GuaiFENesin ___ mL PO Q6H:PRN cough 4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H shortness of breath, wheezing 5. Multivitamins 1 TAB PO DAILY 6. Nystatin Oral Suspension 5 mL PO QID 7. Polyethylene Glycol 17 g PO DAILY 8. Senna 8.6 mg PO BID 9. Aspirin 81 mg PO DAILY 10. Carvedilol 12.5 mg PO BID 11. Ezetimibe 10 mg PO DAILY 12. Fentanyl Patch 100 mcg/h TD Q48H 13. Ferrous GLUCONATE 324 mg PO DAILY 14. Finasteride 5 mg PO DAILY 15. Fluticasone Propionate NASAL 1 SPRY NU DAILY 16. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 17. Furosemide 20 mg PO DAILY 18. HydrALAZINE 25 mg PO BID 19. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY 20. Lisinopril 40 mg PO DAILY 21. NIFEdipine CR 30 mg PO DAILY 22. Nystatin-Triamcinolone Cream 1 Appl TP TID:PRN pruritis 23. Pramipexole 0.25 mg PO TID 24. Sertraline 100 mg PO DAILY 25. Simvastatin 40 mg PO QPM 26. Tamsulosin 0.4 mg PO DAILY 27. TraMADol 50 mg PO TID:PRN Pain - Moderate 28. Vitamin D ___ UNIT PO 1X/WEEK (MO) Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnoses: =================== Influenza Pneumonia (MRSA) Acute Kidney Injury SECONDARY DIAGNOSES: ==================== Dementia with anxiety Gout Hypertension Constipation Right hip fracture Coronary Artery disease Hyperlipidemia Diabetes Mellitus, type II Depression Chronic pain Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dr. ___, You were admitted to the ___ in ___ for the flu and trouble breathing and you were found to have a pneumonia and acute kidney injury. What happened while I was here: ================================ - You were given an anti-viral medication to treat your flu - You were given antibiotics for your pneumonia - You were given IV hydration and your kidney function returned to normal. - You were seen by the Geriatrics doctors for your ___. What Should I Do When I Get Home: ================================== - Continue taking your medications as prescribed - Follow-up with your primary care doctor when you are discharged from rehab. - Follow-up with Geriatrics as an outpatient for formal dementia testing. It was a pleasure taking care of you, Your ___ care team Followup Instructions: ___
10162861-DS-8
10,162,861
26,205,742
DS
8
2170-03-17 00:00:00
2170-03-27 10:56:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: gabapentin / amitriptyline Attending: ___ Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: ___: ERCP with stent placement. History of Present Illness: Ms. ___ is an ___ year old woman presenting as a transfer from OSH with abdominal pain, CT abd/pelvis c/f choledocholithiasis and sigmoid colitis. Patient has been having upper abdominal pain associated with loose watery stool over the past two days. She denies nausea/vomiting. On the morning of ___, patient states that she fainted at her assisted living facility. EMS had arrived per report and found her to be hypotensive with BP 56 systolic and diaphoretic. She presented to OSH and was found to be afebrile, WBC 10, T bili 0.4, D bili 0.2, AST 16, ALT 8, and lactic acidosis 9.9 which came down to 1.7 after hydration with 4L IVF. Patient had a CT abd/pelvis that showed choledocholithiasis with CBD dilation at 12mm, along with mildwall thickening and inflammatory changes surrounding the gallbladder which may reflect acute cholecystitis. In addition her scan showed sigmoid and descending colitis, with diverticuli seen at the sigmoid colon. She was started on Zosyn. Patient was transferred to ___ ED for further evaluation. She was afebrile T 96.4, BP 114/73, HR 96. She had WBC 13.3, Lactate 1.2, T bili 0.3, AST 18, ALT 6, AP 78. RUQ ultrasound showed cholelithiasis without evidence of cholecystitis. Patient states that her pain is across her lower abdomen. She has not had pain like this before. She has been tolerating food and drink. She does endorse a remote history of diverticulitis. She states her last colonoscopy was about ___ years ago and was normal. Past Medical History: PMH: HTN, Stroke ___ (on Plavix), dementia, diverticulitis PSurgHx: salpingooophorectomy ___ Social History: ___ Family History: FH: Non-contributory Physical Exam: PHYSICAL EXAM ON ADMISSION: Vitals - T 96.4; BP 114/73; HR 96; RR 16; SPO2 98% RA GEN - Well appearing, no acute distress HEENT - NCAT, EOMI, sclera anicteric CV - HDS PULM - No signs of respiratory distress. ABD - soft, focally tender LLQ, mild tenderness RLQ. Minimally tender RUQ, negative ___ sign. No rebound or guarding. EXT - Warm, well-perfused PHYSICAL EXAM ON DISCHARGE: VS: 97.6 PO 132 / 72 R Sitting 72 18 96 RA GEN: awake, alert, pleasant and interactive. CV: RRR PULM: Clear bilaterally. ABD: Soft, mildly tender LLQ, non-distended, active bowel sounds. EXT: Warm and dry. no edema. NERUO: A&O. follows commands and moves all extremities equal and strong. Speech is clear and fluent. Pertinent Results: LIVER OR GALLBLADDER US (SINGLE ORGAN)Study Date of ___ Cholelithiasis without gallbladder-wall thickening. MRCP (MR ABD ___ Date of ___ 1. Limited examination due to motion artifact. The previous CT showed a very small calcified stone or group of stones layering in the distal common bile duct, but not necessarily obstructing. Persistent filling defects such as these cannot be excluded by this examination. No biliary dilatation given patient age, however. 2. Cholelithiasis. 3. Limited imaging suggesting wall thickening of the lower sigmoid which may indicate colitis. Clinical correlation is suggested. This is not fully evaluated with this technique. 4. Retroperitoneal lymphadenopathy. The largest node, an aortocaval node, measures up to 18 mm in shortest dimension which is suspicious. Evaluation with PET-CT or short-term reimaging may be appropriate for followup versus consideration of biopsy. This may be related to a suspicious medial right lower lobe nodule (02:14) with spiculations measuring up to 12 x 12 mm, not well visualized on this study but depicted on the recent CT. This is concerning for primary malignancy. This could also perhaps benefit from PET evaluation as a first step. 5. Left adnexal cyst. Evaluation with follow-up ultrasound is recommended when clinically appropriate. CT ABD & PELVIS WITH CONTRASTStudy Date of ___ 1. Abnormal mural thickening and mucosal hyperenhancement extending from the rectum to the splenic flexure. Additional mural thickening and mucosal hyperemia within a long segment of the mid to distal small bowel. Findings are non-specific and suggest an enterocolitis. Etiology is indeterminate. Although there is atherosclerotic disease, origins of the SMA and ___ are patent. SMV is patent. No gross perforation is noted. 2. There is no evidence of rectal wall abscess. 3. Bulky retroperitoneal lymph nodes are seen, measuring up to 1.6 cm in short axis. These could be reactive in nature. 4. CBD is dilated. There are multiple stones within the CBD. Note that the MRCP performed ___ confirmed presence of stones. 5. Large nodule measuring 13 mm in the posterior basal segment of the right lower lobe. Second flatter nodule over the right hemidiaphragm. Due to the Size of these nodules, are dedicated CT of the chest is recommended for further characterization. Brief Hospital Course: ___ PMHx HTN, stroke (Plavix), dementia, diverticulitis, presented to OSH with abdominal pain, syncope, and hypotension. Hypotension resolved after fluid resuscitation. CT scan showed possible cholecystitis, choledocholithiasis with CBD 12mm, and descending colitis. She was started on PipTazo and transferred to BI. Patient was transferred to ___ ED for further evaluation. She was afebrile T 96.4, BP 114/73, HR 96. She had WBC 13.3, Lactate 1.2, T bili 0.3, AST 18, ALT 6, AP 78. RUQ ultrasound showed cholelithiasis without evidence of cholecystitis. The patient was made NPO, continued on antibiotics, and admitted to the acute care surgical service. On HD1 she underwent MRCP which was concerning for common bile duct stones. ERCP with placement of common bile duct and pancreatic duct stents was done given recent Plavix. She was continued on antibiotics for treatment of presumed diverticulitis. Her left lower quadrant pain and abdominal distention gradually improved. Her diet was advanced to regular with good tolerability and therefore she was transitioned to oral antibiotics. She was evaluated by physical therapy who recommended discharge back to her assisted living facility. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. On HD9, at the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: The Preadmission Medication list may be inaccurate and requires further investigation. 1. Clopidogrel 75 mg PO DAILY 2. Donepezil 5 mg PO QHS 3. Famotidine 20 mg PO BID 4. Lisinopril 5 mg PO DAILY 5. Memantine 10 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Ciprofloxacin HCl 500 mg PO BID Duration: 6 Days RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*12 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID 4. MetroNIDAZOLE 500 mg PO TID RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day Disp #*18 Tablet Refills:*0 5. Clopidogrel 75 mg PO DAILY 6. Donepezil 5 mg PO QHS 7. Famotidine 20 mg PO BID 8. Lisinopril 5 mg PO DAILY 9. Memantine 10 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: Choledocholithiasis Diverticulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ for evaluation of abdominal pain and were found to have an infection in your abdomen. You were thought to have inflammation in your gallbladder. You underwent endoscopy and had a stent placed to allow the bile to drain. You will need to have a repeat endoscopy to remove the stent once your Plavix is held. You continued to have abdominal pain after this procedure and it was thought that you had an infection in your intestine called colitis. You were given antibiotics for this and your pain got better. You diet was gradually advanced and well tolerated. You were seen and evaluated by the physical therapist who recommend continuing physical therapy at home. You are recovering well and are now ready for discharge. Please follow the instructions below to continue your recovery: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid driving or operating heavy machinery while taking pain medications. Followup Instructions: ___
10163609-DS-10
10,163,609
21,722,804
DS
10
2125-10-02 00:00:00
2125-10-02 15:33:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal/flank pain Major Surgical or Invasive Procedure: None History of Present Illness: PCP: Name: ___ ___: ___ Address: ___ Phone: ___ Fax: ___ ___ with obesity, OSA, GERD, HL, p/w L flank pain x 1 hour duration starting today. She reports sudden onset of her pain with nausea and slight emesis. Pt reports that the discomfort is similar to prior nephrolithiasis. s/p gastric bypass 1 mo ago. She was well last night until symptoms started this morning. Her pain radiates to the LLQ and bladder. She can't find a comfortable position. SHe denies fever/chills, HA, CP, SOB, cough, dysuria, leg pain, swelling, or rash. Up until her symptoms she was tolerating a diet well. In the ED, underwent US and CT scan showing left sided hydronephrosis and nephrolithiasis. She was given multiple doses of dilaudid and morphine as well as zofran with little benefit. SHe currently describes ___ pain and is tearful. She did pass one of the stones Review of systems: 10 point review of systems otherwise negative except as listed above Past Medical History: PMH: sleep apnea, recently prescribed CPAP, gastroesophageal reflux disease, hyperlipidemia, back pain, knee pain, and gallstones, recently diagnosed on ultrasound. PSH: repair of deviated septum of nose, Laparoscopic Roux-en-Y gastric bypass. Laparoscopic cholecystectomy. Social History: ___ Family History: Family history is noted for father living age ___ with stroke; mother living age ___ with diabetes, hyperlipidemia, arthritis and obesity; brother living age ___ with diabetes and son living age ___ with asthma. Physical Exam: VS: T 97, BP 122/80, HR 56, RR 16 Gen: tearful in moderate pain HEENT: MMM, OP clear, anicteric sclera, MM moist Neck: supple no LAD Heart: RRR no MRG Lung: CTAB no wheezes or crackles Abd: obese, soft, mild suprapubic tenderness, no rebound or guarding. surgical scars noted Back: Mild CVA tenderness on Left Ext: warm well perfused no pitting edema Skin: no rashes or lesions noted Neuro: no focal deficits Pertinent Results: 140 / 100 / 5 162 AGap=28 2.9 / 15 / 0.7 95 9.9 \ 13.4 / 308 /43.4 ___ \ N:45.7 L:47.5 M:4.2 E:1.4 Bas:1.1 UCG negative UA: 25 rbc, 5 WBC, 150 ketones Renal US: IMPRESSION: Mild left hydronephrosis along with absence of the left ureteral jet is suggestive of a stone in the left collecting system. However, no distinct stones are noted in the visualized portions of the left collecting system. CT ABD: IMPRESSION: Mild left hydronephrosis secondary to 3mm stone in the left ureteropelvic junction. Additional 3 mm non-obstructing stone in the left kidney. Preliminary Report2. 3 mm non-obstructing stone in the lower calix of the left kidney. Brief Hospital Course: ___ with GERD, HL, s/p gastric bypass 1 month ago presents with acute L flank pain with nausea and vomiting, and L nephrolithiasis and hydronephrosis Flank pain/Nephrolithiasis/Hydronephrosis/Hematuria. Consistent with kidney stones given imaging above and classic symptoms with hematuria. No signs of infection at present. Renal function stable. Patient appears to have passed one of the stones. She was treated with aggressive IVF and pain control with tylenol and opiates (NSIADS not used given recent bariatric surgery). She did appear to pass one of the stones, unfortunately it was NOT saved and thus analysis could not be sent. She had no evidence of infection. - she was discharged with liquid oxycodone and instructions to stay well hydrated and to follow up with her outpatient Urologist. Hypokalemia/Acidosis: Related to emesis with volume depletion. Improved with IVF and electolyte repletion. GERD: continued PPI Medications on Admission: Multivitamin with Iron-Mineral Oral Tablet, Chewable 1 tab daily Omeprazole 20 mg Oral Capsule, Delayed Release(E.C.) Take 1 capsule twice daily MIRENA 20 MCG/24 HR INTRAUTERINE DEVICE (LEVONORGESTREL) For insertion in department Vitamin D Calcium Vitamin B 12 Discharge Medications: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. calcium citrate 200 mg (950 mg) Tablet Sig: Two (2) Tablet PO once a day. 6. oxycodone 5 mg/5 mL Solution Sig: Five (5) mL PO every ___ hours as needed for pain. Disp:*50 mL* Refills:*0* 7. Tylenol ___ mg Tablet Sig: ___ Tablets PO every six (6) hours as needed for pain. Discharge Disposition: Home Discharge Diagnosis: Left flank pain Nephrolithiasis Hydronephrosis GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for pain control caused by 2 small left kidney stones, causing mild swelling of the kidney and small amount of blood with your urine. Ther was no evidence of infection. Please stay well hydrated for the next few weeks, save your kidney stone if you pass it. Please resume all other home medications. Do NOT use narcotic medications with alcohol or driving Followup Instructions: ___
10163774-DS-17
10,163,774
25,837,438
DS
17
2127-10-13 00:00:00
2127-10-13 13:13:00
Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: CARDIOTHORACIC Allergies: lisinopril / atorvastatin / Crestor / spironolactone / doxycycline / Entresto Attending: ___. Chief Complaint: fever and general malaise Major Surgical or Invasive Procedure: No procedures this admit ___: Epicardial left ventricular lead placement via left thoracotomy History of Present Illness: History of Present Illness: ___ s/p LV lead placement ___- post-op course uneventful, d/c home on POD 2. Called today (POD 4) with fever 102degF. Presents for further evaluation. She denies burning with urination. She has been using IS at home. Reports one episode of diarrhea this am. Past Medical History: Past Medical History: Sternal fracture s/p fall ___ Non-ischemic Cardiomyopathy, LVEF ___ Left Bundle Branch Block CAD s/p POBA ___ Hyperlipidemia Hypertension Arthritis Spinal arthrodesis Depression Anxiety GERD Past Surgical History: Carpal Tunnel surgery bilaterally Sternum fracture s/p fixation in ___ ___, Dr. ___ Total knee replacement Hysterectomy Spinal Fusion Past Cardiac Procedures: ___ DTBA1D4 BiV ICD implanted ___ POBA ___ Social History: ___ Family History: Family History:Premature coronary artery disease- non contributory Physical Exam: Physical Exam Temp 100.6 Pulse: 93 Resp: 14 O2 sat: B/P Right: Left: 142/45 Height: Weight: General: NAD Skin: Dry [x] intact [x] left thoracotomy- healing well, no erythema or drainage HEENT: PERRLA [] EOMI [] Neck: Supple [] Full ROM [] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] _trace_ Varicosities: None [] Neuro: Grossly intact [] Pulses: Femoral Right: Left: DP Right: Left: ___ Right: Left: Radial Right: Left: Carotid Bruit Right: Left: Pertinent Results: ___ 03:17PM NEUTS-82.2* LYMPHS-9.3* MONOS-7.7 EOS-0.2* BASOS-0.1 IM ___ AbsNeut-6.95* AbsLymp-0.79* AbsMono-0.65 AbsEos-0.02* AbsBaso-0.01 ___ 03:17PM WBC-8.5 RBC-3.49* HGB-9.6* HCT-30.2* MCV-87 MCH-27.5 MCHC-31.8* RDW-13.0 RDWSD-40.9 ___ 03:17PM GLUCOSE-110* UREA N-11 CREAT-0.6 SODIUM-135 POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-20* ANION GAP-19 ___ 04:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD Brief Hospital Course: Ms. ___ was admitted to ___ for observation after reporting fever and chills at home. Her WBC was 4.9. She remained afebrile. Her urinalysis was noteable for few bacteria and trace leukocytes. She denies dysuria. She received one dose of zosyn in the ED upon arrival and was started on po cipro while awaiting urine culture. She will be treated conservatively with oral antibiotics for one week in the absence of obvious infection given her recent implantation of pacing leads. Her thoracotomy incision is healing well without erythema or drainage. She admits to not taking pain medication at home and was unable to cough and deep breathe due to pain. We discussed the need for pain medication to allow for good pulmonary hygiene to prevent atelectasis and pneumonia. She will be sent home on ultram as an alternative to oxycodone. Medications on Admission: Medications at home: pre-op Gabapentin 300 mg TID PRN Ativan 0.5-1 mg BID PRN Losartan 100 mg Daily Lovastatin 10 mg Daily Metoprolol Succinate ER 100 mg Daily Omeprazole 40 mg Daily PRN Sertraline 100 mg Daily Aspirin 81 mg Daily Colace 100 mg Daily Ferrous Sulfate 325 mg Daily d/c meds: 1. Docusate Sodium 100 mg PO DAILY 2. Gabapentin 300 mg PO TID RX *gabapentin 300 mg 1 capsule(s) by mouth every eight (8) hours Disp #*90 Capsule Refills:*0 3. Omeprazole 40 mg PO DAILY:PRN GERD 4. Sertraline 100 mg PO DAILY 5. Acetaminophen 1000 mg PO Q6H:PRN pain 6. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*50 Tablet Refills:*0 7. Aspirin 81 mg PO DAILY 8. Ferrous Sulfate 325 mg PO DAILY 9. LORazepam 0.5-1 mg PO BID:PRN anxiety 10. Lovastatin 10 mg ORAL DAILY 11. Metoprolol Succinate XL 100 mg PO DAILY 12. Losartan Potassium 25 mg PO DAILY RX *losartan 25 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 Allergies: Spironolactone (hives), Rosuvastatin (myopathy), Atorvastatin (myopathy), Lisinopril (hives), Doxycycline (shortness of breath), Entresto (facial edema, dyspnea, BLE edema) Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. Aspirin 81 mg PO DAILY 3. Docusate Sodium 100 mg PO DAILY 4. Ferrous Sulfate 325 mg PO DAILY 5. Gabapentin 300 mg PO TID 6. Losartan Potassium 25 mg PO DAILY 7. Lovastatin 10 mg ORAL DAILY 8. Metoprolol Succinate XL 100 mg PO DAILY 9. Omeprazole 40 mg PO DAILY:PRN GERD 10. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain - Moderate 11. Sertraline 100 mg PO DAILY 12. Ciprofloxacin HCl 500 mg PO Q12H Duration: 6 Days RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*12 Tablet Refills:*0 13. TraMADol 50 mg PO Q6H:PRN Pain - Moderate RX *tramadol 50 mg 1 tablet(s) by mouth every 6 hours Disp #*54 Tablet Refills:*0 14. LORazepam 0.5-1 mg PO Q4H:PRN anxiety Discharge Disposition: Home Discharge Diagnosis: Re-admitted w/ fever and general malaise s/p Epicardial left ventricular lead placement via left thoracotomy. Sternal fracture s/p fall ___, Non-ischemic Cardiomyopathy, LVEF ___, LBBB, CAD s/p POBA ___, Hyperlipidemia, HTN, arthritis, Spinal arthrodesis, Depression, Anxiety, GERD s/p Carpal Tunnel surgery bilaterally, Sternum fracture s/p fixation, Bilateral Total knee replacement, Hysterectomy, Spinal Fusion ___ DTBA1D4 BiV ICD implanted ___ Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oxycodone and tylenol Incisions: Left thoracotomy - healing well, no erythema or drainage Edema -none Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns ___ **Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours** Followup Instructions: ___
10163793-DS-13
10,163,793
24,579,886
DS
13
2194-08-02 00:00:00
2194-08-02 21:23:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: UROLOGY Allergies: Codeine / Wheat Attending: ___. Chief Complaint: Left flank pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ with hx of nephrolithiasis who comes to the ED with 3 days of left flank pain, as well as dysuria and chills. The patient first noted pain on ___. Her pain was located in her left flank with radiation to the LLQ and left inguinal region. It was initially crampy in character, severe, and intermittent. Her pain resolved that evening, but returned the following day and was more sharp in character. She developed bladder pressure and some discomfort with voiding on ___. She felt at this point her pain was consistent with prior stone pain, so she attempted to drink plenty of fluids and give it time to pass. On ___, she developed urinary frequency and more dysuria. On ___, her pain worsened, she developed chills, as well as nausea and vomiting. She saw her PCP who suggested she go to the ED given concern for infection and kidney stone. Past Medical History: PMH: -Nephrolithiasis ___ with confirmed calcium oxalate stone, possible stones at age ___ and ___. All stones have passed spontaneously. - Asthma - Seasonal allergies - Gluten intolerance PShx: 2 c sections Social History: ___ Family History: no stones Physical Exam: AVSS NAD WWP Unlabored breathing Abd soft, ND, NT Ext WWP Pertinent Results: ___ 06:00AM BLOOD WBC-6.8 RBC-3.51* Hgb-10.7* Hct-31.6* MCV-90 MCH-30.5 MCHC-33.9 RDW-12.4 Plt ___ ___ 11:30AM BLOOD WBC-12.5* RBC-4.06* Hgb-12.5 Hct-35.4* MCV-87 MCH-30.7 MCHC-35.2* RDW-12.4 Plt ___ ___ 06:00AM BLOOD Glucose-49* UreaN-9 Creat-0.8 Na-140 K-4.0 Cl-108 HCO3-16* AnGap-20 ___ 11:30AM BLOOD Glucose-95 UreaN-12 Creat-0.9 Na-137 K-3.5 Cl-99 HCO3-22 AnGap-20 Brief Hospital Course: The patient was admitted to Dr. ___ service from the ___ ED for overnight observation, IV antibiotics, pain control, and IV fluids. On HD2 the patient passed a stone in her urine. Her pain improved after passage of the stone and a KUB confirmed passage. Her stone was sent for analysis. Her WBC improved to 6.8 on the morning of HD2 and urine culture was negative. She was discharged on HD2 in stable condition with pain significantly improved. Despite a negative urine culture, she was given a course of antibiotics due to the possibility of infected urine behind the obstructing stone. At discharge, patient's pain well controlled with oral pain medications, tolerating regular diet, ambulating without assistance, and voiding without difficulty. She is given explicit instructions to call Dr. ___ follow-up. Medications on Admission: See OMR Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN pain 2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth q4-6 hours Disp #*20 Tablet Refills:*0 3. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 4. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp #*20 Capsule Refills:*0 5. Ibuprofen 400 mg PO Q8H:PRN pain Discharge Disposition: Home Discharge Diagnosis: Left ureteral stone Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -You can expect to see occasional blood in your urine and to possibly experience some urgency and frequency over the next month -You may experience some pain associated with spasm of your ureter.; This is normal. Take the narcotic pain medication as prescribed if additional pain relief is needed. -Do not lift anything heavier than a phone book (10 pounds) -Resume all of your pre-admission medications, except HOLD aspirin until you see your urologist in follow-up -IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken even though you may also be taking Tylenol/Acetaminophen. You may alternate these medications for pain control. For pain control, try TYLENOL FIRST, then ibuprofen, and then take the narcotic pain medication as prescribed if additional pain relief is needed. -Ibuprofen should always be taken with food. Please discontinue taking and notify your doctor should you develop blood in your stool (dark, tarry stools) -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication. Discontinue if loose stool or diarrhea develops. Colace is a stool softener, NOT a laxative, and available over the counter. The generic name is DOCUSATE SODIUM. It is recommended that you use this medication. -Do not eat constipating foods for ___ weeks, drink plenty of fluids to keep hydrated Followup Instructions: ___
10164104-DS-10
10,164,104
21,297,346
DS
10
2142-02-20 00:00:00
2142-02-20 14:53:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: PODIATRY Allergies: Penicillins Attending: ___ Chief Complaint: right foot infection Major Surgical or Invasive Procedure: Right foot debridement History of Present Illness: ___ y/o DM M with a hx of Charcot, HTN, and midfoot fusion L, who presents to the ED with a concern of a worsening right foot infection. His ___ stated today his wound looked worse than the day before with increased redness and drainage, and advised him to come to the ER today. He saw Dr. ___ ___ clinic last week and had his foot debrided. He states this problem started about ___ weeks ago when he was given the wrong shoe size ___ clinic. He is currently on oral antibiotics (bactrim/cipro) He denies pain, denies n/v/f/c. No other complaints. . Past Medical History: DM, Charcot, HTN, s/p R Hallux IP fusion, s/p L cataract sx, s/p L triple, midfootfusion, TAL ___, s/p RLE angio ___ ___ and right foot debridement and closure ___ Social History: ___ Family History: NC Physical Exam: ADMISSION EXAM: Vitals: Afebrile, VSS Gen: Pleasant, NAD, A&Ox3 CV: RRR Pulm: CTAB, no respiratory distress Abd: Soft, ND, NT ___: Large dorsolateral ulceration with necrotic center and scant seropurulent drainage to right lateral ___ MT head ~3cm x 2cm x 1cm. CFT brisk to digits. Erythema surrounding ulcer and extending dorsal forefoot. AROM intact to digits. Sensation grossly diminished. Pertinent Results: ___ 06:30AM BLOOD WBC-7.5 RBC-3.81* Hgb-10.5* Hct-33.2* MCV-87 MCH-27.7 MCHC-31.8 RDW-13.6 Plt ___ ___ 06:56AM BLOOD WBC-9.2 RBC-3.76* Hgb-10.7* Hct-32.6* MCV-87 MCH-28.5 MCHC-32.9 RDW-13.4 Plt ___ ___ 06:45AM BLOOD WBC-9.2 RBC-3.77* Hgb-10.4* Hct-32.9* MCV-87 MCH-27.7 MCHC-31.7 RDW-13.6 Plt ___ ___ 03:50PM BLOOD WBC-12.3* RBC-3.72* Hgb-10.2* Hct-32.6* MCV-88 MCH-27.5 MCHC-31.4 RDW-13.6 Plt ___ ___ 03:50PM BLOOD Neuts-76.7* Lymphs-13.8* Monos-6.5 Eos-2.5 Baso-0.6 ___ 06:30AM BLOOD Plt ___ ___ 06:56AM BLOOD Plt ___ ___ 06:45AM BLOOD Plt ___ ___ 03:50PM BLOOD Plt ___ ___ 06:30AM BLOOD ESR-78* ___ 06:30AM BLOOD Glucose-220* UreaN-18 Creat-1.4* Na-136 K-4.6 Cl-99 HCO3-28 AnGap-14 ___ 06:56AM BLOOD Glucose-190* UreaN-21* Creat-1.5* Na-135 K-5.1 Cl-99 HCO3-27 AnGap-14 ___ 06:45AM BLOOD Glucose-231* UreaN-26* Creat-2.0* Na-134 K-5.5* Cl-99 HCO3-24 AnGap-17 ___ 03:50PM BLOOD Glucose-235* UreaN-31* Creat-2.3* Na-134 K-4.9 Cl-97 HCO3-20* AnGap-22* ___ 06:30AM BLOOD Calcium-9.1 Phos-3.6 Mg-2.0 ___ 06:56AM BLOOD Calcium-9.2 Phos-4.7* Mg-1.8 ___ 06:45AM BLOOD Calcium-9.2 Phos-4.1 Mg-2.0 ___ 06:30AM BLOOD CRP-21.3* ___ 06:30AM BLOOD Vanco-20.0 ___ 06:04AM BLOOD Vanco-19.5 ___ 06:56AM BLOOD Vanco-15.8 ___ 5:25 pm SWAB R FOOT ULCER. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND SINGLY. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). WOUND CULTURE (Preliminary): This culture contains mixed bacterial types (>=3) so an abbreviated workup is performed. Any growth of P.aeruginosa, S.aureus and beta hemolytic streptococci will be reported. IF THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT PRESENT ___ this culture.. WORK-UP PER ___ ___ (___). STAPH AUREUS COAG +. MODERATE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # ___ ___. PSEUDOMONAS AERUGINOSA. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # ___ ___. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). MODERATE GROWTH. ENTEROCOCCUS SP.. SPARSE GROWTH. ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. FINDINGS: There has been interval resection of the distal aspect of the right fifth metatarsal. There has also been resection of the base of the proximal phalanx of the right fifth toe. Prominent marginal erosions are present along the medial and lateral aspects of the distal head of the right first metatarsal. A prominent marginal erosion is again present along the medial aspect of the proximal phalanx of the right great toe. There is an overlying post operative soft tissue defect. There is joint space narrowing with subchondral sclerosis and osseous spurring of the third metatarsophalangeal joint. Incidental note is made of a type 3 os naviculare measuring approximately 1.3 cm ___ AP dimension. There is a small plantar calcaneal spur. Prominent atherosclerotic calcifications are present within the right foot. IMPRESSION: 1. Status post surgical resection of the distal aspect of the right fifth metatarsal and base of the proximal phalanx of the right fifth toe. 2. Prominent marginal erosions again present within the proximal phalanx of the right great toe as well as the distal head of the first metatarsal. Findings are suggestive of gouty arthritis, recommend clinical correlation. 3. Severe degenerative changes of the third metatarsophalangeal joint again present and unchanged. Brief Hospital Course: Mr. ___ was admitted on the evening of ___ from the Emergency Department for a worsening right foot infection. A wound culture swab was taken ___ the ED. He was started on broad spectrum IV antibiotics. He refused pneumoboots for DVT prevention. Of note, his SCr was elevated to 2.3, above his baseline of 1.3-1.5. He was given IVF and was started on Vanc/Cipro/Flagyl. He was kept NPO at ___ for OR ___ AM with Dr. ___. He was taken to the OR for a Right ___ met head resection. Please see op note for full details of procedure. The patient had no complications during the procedure and the ulceration was excised and left open. The wound was packed with a wet to dry packing and left open to drain. He will be getting d/c with a wound VAC. Of note during his hospital course, the wound culture grew back cipro resistant pseudomonas and MRSA. ID was consulted and recommended Cefepime and Vanc, and to discontinue Flagyl. The patient also recieved a PICC and will get a course of 6 weeks IV antibiotics. The patient was discharged ___ stable condition, with VS intact. He will follow up ___ podiatry clicic with Dr. ___ ___ ___s outpatient ___ clinic.He will have a vanc trough drawn by the ___ a well. Medications on Admission: Amlodipine 5 mg', Quinapril 20 mg', NPH 30 units qam & 6 units qpm, Humalog SS Discharge Medications: 1. Vancomycin 1000 mg IV Q 12H RX *vancomycin 1 gram 1 g IV q12hrs Disp #*84 Vial Refills:*0 2. Amlodipine 5 mg PO DAILY 3. NPH 30 Units Breakfast NPH 6 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 4. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth q4-6h Disp #*40 Tablet Refills:*0 5. CefePIME 2 g IV Q12H Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Right foot ulcer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to ___ for your right foot ulcer. You received IV antibiotics while you were here and you were taken to the operating room for a debridement. We placed a wound vac and you will go home with visiting nurses to help with dressing changes. You should keep your dressing clean, dry, and intact. Please remain nonweightbearing on your right foot ___ a surgical shoe. You will be given prescriptions for antibiotics and pain medication, which you should take as directed. Please keep all follow up appointments. If you notice any of the following, please call the office or return to the ER immediately: increased redness/swelling/drainage/pain/nausea /vomiting/fever > 101/chills or any other concerning symptoms. Followup Instructions: ___
10164104-DS-11
10,164,104
27,075,752
DS
11
2142-03-01 00:00:00
2142-03-01 21:35:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / vancomycin Attending: ___. Chief Complaint: Diarrhea and fever Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo M with PMH DM, charcot foot, and HTN p/w feeling unwell and diarrhea. Pt felt fine until the day before admission when he felt tired and began having diarrhea. also had a fever to 100.8 and "felt like crap." today his ID doctor called to tell him that his abx needed to be switched (he was on vanc/cefepime). ___ told pt to not take his insulin because he was unwell so he didnt/ his brother urged him to come in because he was so lethargic. ROS neg for SOB, CP, N/V, abd pain, dysuria. In the ED initial VS 100.2 105 120/72 16 96% RA. Labs significant for WBC 23 with 88% PMN and 1% bands. Glucose in 274 with anion gap of 17 which corrected to 12 with 6 units insulin and IVF. K WNL but mild hyponatremia to 128. Cr 1.8 on admission from baseline of 1.4-1.5 which corrected to 1.5 with 3L LR. Hct 36.1 which is similar to baseline. INR 1.2. ID and podiatry consulted in ED. Started on dapto/flagyl/cefepime for foot ulcer. Pods said "Right foot ulcer with healthy granular base and no signs of local infection. Agree with ID recs - admit to medicine, IV dapto/cefepime, and podiatry will follow while in house." Past Medical History: DM Charcot HTN s/p R ___ met head resection (___) s/p R Hallux IP fusion s/p L cataract sx s/p L triple midfootfusion TAL ___ s/p RLE angio in ___ right foot debridement and closure ___ Social History: ___ Family History: NC Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.6, 100/52, 101, 20, 96% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, No edema/erythema. Skin: 2.1cm x 2.7cm x 1.3cm ulcer at R ___ met with granular base. No ASOI at foot including erythema, purulence, malodor, or pain upon palpation. PICC site R- no erythema, drainage, malodor or other ASOI. Peripheral line sites L, no erythema, drainage, malodor, or other ASOI. Neuro: Epictritic and protective sensation diminished from feet b/l. CNII-XII grossly intact, handgrip and foot extension ___ strength, gait deferred. DISCHARGE PHYSICAL EXAM: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, No edema/erythema. Skin: 2.1cm x 2.7cm x 1.3cm ulcer at R ___ met with granular base. No ASOI at foot including erythema, purulence, malodor, or pain upon palpation. PICC site R- no erythema, drainage, malodor or other ASOI. Peripheral line L, no erythema, drainage, malodor, or other ASOI. Neuro: Epictritic and protective sensation diminished from feet b/l. CNII-XII grossly intact, handgrip and foot extension ___ strength, gait deferred. Pertinent Results: ADMISSION LABS: ============ ___ 04:20PM BLOOD WBC-23.0*# RBC-4.16* Hgb-12.1* Hct-36.1* MCV-87 MCH-29.0 MCHC-33.4 RDW-14.2 Plt ___ ___ 04:20PM BLOOD Neuts-88* Bands-1 Lymphs-3* Monos-8 Eos-0 Baso-0 ___ Myelos-0 ___ 04:20PM BLOOD ___ PTT-34.1 ___ ___ 04:20PM BLOOD Glucose-274* UreaN-35* Creat-1.8* Na-128* K-5.9* Cl-93* HCO3-19* AnGap-22* ___ 04:20PM BLOOD Calcium-9.2 Phos-4.3 Mg-1.8 ___ 04:20PM BLOOD ALT-23 AST-44* AlkPhos-81 TotBili-0.3 ___ 04:32PM BLOOD Lactate-1.6 ___ 04:20PM BLOOD Lipase-18 ___ 04:20PM BLOOD cTropnT-<0.01 RELEVANT LABS: =========== ___ 06:13AM BLOOD CK(CPK)-51 ___ 06:13AM BLOOD ESR-70* ___ 06:13AM BLOOD CRP-109.0* DISCHARGE LABS: ============ ___ 06:13AM BLOOD WBC-13.0* RBC-3.46* Hgb-9.7* Hct-30.3* MCV-87 MCH-28.2 MCHC-32.2 RDW-14.3 Plt ___ ___ 06:13AM BLOOD Glucose-104* UreaN-23* Creat-1.4* Na-138 K-3.9 Cl-103 HCO3-27 AnGap-12 ___ 06:13AM BLOOD Calcium-8.7 Phos-2.6* Mg-1.9 PERTINENT MICRO: ============ ___: C. Diff: negative ___: Urine culture: no growth PERTINENT IMAGING: ============= Right foot XR ___: No significant interval change in the appearance of the foot compared to the previous exam. No new areas of cortical destruction to suggest osteomyelitis. CXR ___: Right PICC tip within the upper SVC. No acute cardiopulmonary process. Brief Hospital Course: ___ yo M with PMH Type 1 DM, charcot foot, and HTN presented with fever and diarrhea in the setting of being treated with Vanc/Cefepime as outpatient for foot ulcer, found to have diabetic ketoacidosis and right foot infection. ACUTE ISSUES: ============= # Sepsis: Pt met ___ SIRS criteria on admission with tachycardia and WBC count. Possible infectious sources were discussed including diarrhea vs foot ulcer vs PICC line. Pt received total 6L IV fluids. For antibiotics, pt had been on vanc/cefepime since ___ as outpatient, was changed to Dapto/Cefepime/Flagyl ___ on admission. Flagyl was discontinued on ___ due to negative c diff, and pt was continued on Dapto/Cefepime. His foot was evaluated by Podiatry and they thought it was healing well. ID was consulted and recommended continuing Dapto/Cefepime. Pt's foot swab from ___ grew out VRE, MRSA and Pseudomonas, and on further review the VRE was found to be sensitive to daptomycin. Though the outside of the surgery site looked good clinically, the VRE grown from the wound cx from ___ was not being appropriately treated and may be part of the reason he presented with signs of infection. Another possible source of infection was the PICC line, although there was no surrounding erythema or pain. Cultures off the line were NGTD so the line was kept in. Pt's diarrhea improved and given Cdiff negative, his symptoms were thought to be likely gastroenteritis or antibiotic-associated diarrhea. Pt's symptoms resolved and pt felt much better after one night in hospital, so he was discharged on Dapto/Cefepime with close ID and podiatry follow-up. # Type 1 DM c/b DKA: Pt's anion gap was 17 on admission. He was treated with insulin and fluids and his anion gap corrected to normal. Likely due to missing insulin in setting of infection. Pt's sugars remained ~250 despite home NPH and Humalog SS, so ___ was consulted and uptitrated his NPH and sliding scale. # Right Foot Ulcer: Pt had met head resection for osteomyelitis on ___. Podiatry was consulted and felt that that the wound site did not appear infected. Pt's antibiotics were changed to Dapto/Cefepime (see #sepsis above), and a wound VAC was applied on ___. We considered an MRI of foot to rule out osteomyelitis, but it was felt that an MRI would be difficult to interpret given recent surgery. Pt was discharged with close follow-up with podiatry and ID, and his physicians ___ consider whether an MRI should be done in a few weeks. CHRONIC ISSUES: ============= # HTN: Documented history of this issue. Continued home amlodipine and quinapril. TRANSITIONAL ISSUES: ================ - ID: Follow weekly CBC, chem 7, LFT's and CK given infection and on daptomycin. - Podiatry: Patient had wound vacuum applied by podiatry on ___. Wound vac should not be removed until further advised by podiatry. Pt has podiatry f/u on ___. - Consider MRI in the coming weeks to rule out osteomyelitis. - The following microbiology studies are pending and must be followed up: ___ 02:45 STOOL FECAL CULTURE; CAMPYLOBACTER CULTURE ___ 02:45 BLOOD CULTURE Blood Culture, Routine ___ 16:39 BLOOD CULTURE Blood Culture, Routine ___ 16:39 BLOOD CULTURE Blood Culture, Routine Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Vancomycin 1000 mg IV Q 12H 2. NPH 30 Units Breakfast NPH 6 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain 4. CefePIME 2 g IV Q12H 5. Amlodipine 5 mg PO DAILY hold for SBP < 100, HR < 60 6. Quinapril 20 mg PO DAILY hold for SBP < 100, HR < 60 Discharge Medications: 1. Daptomycin 550 mg IV Q24H RX *daptomycin [CUBICIN] 500 mg 550 mg IV Q24 hours Disp #*42 Vial Refills:*0 2. Amlodipine 5 mg PO DAILY 3. CefePIME 2 g IV Q12H RX *cefepime [Maxipime] 2 gram 2 grams every twelve (12) hours Disp #*84 Vial Refills:*0 4. Quinapril 20 mg PO DAILY 5. NPH 32 Units Breakfast NPH 12 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 6. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Diabetic keotoacidosis, right foot infection Secondary: Type I diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, It was a pleasure treating you at ___. You came in to the hospital after feeling unwell with diarrhea, as well as having fevers. You were diagnosed with having diabetic ketoacidosis as well as an ongoing infection in your foot. You were treated with insulin and IV antibiotics and you felt much better. We are discharging you home on a different antibiotic called daptomycin that will take the place of vancomycin. You will continue with the cefepime through your IV. You have follow up with podiatry and infectious disease this week. It is very important that you keep these appointments. Followup Instructions: ___
10164104-DS-16
10,164,104
21,111,081
DS
16
2147-09-18 00:00:00
2147-09-18 20:13:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / vancomycin Attending: ___. Chief Complaint: Acute osteomyelitis (R foot) Major Surgical or Invasive Procedure: PICC Line placement (L arm) ___ History of Present Illness: ___ is a ___ with a history of T1DM, Charcot foot, CKD3, HFrEF (EF 26% ___ ___ now presenting with R foot ulcer, pain, and erythema. He noticed an ulcer on the plantar R second toe ___ weeks ago, tried to keep it clean and dress with saline and gauze. The toe became progressively more painful and the surrounding skin became and pink and red last week. He was unable to get an appointment with his podiatrist at ___ so saw his PCP ___ ___, who prescribed doxycycline. He took doxycycline ___ but developed fever/chills and worsening R foot pain so presented to ___ on ___, where he was admitted for R foot cellulitis and concern for osteomyelitis. He says that he had a R foot MRI and was treated with IV ceftriaxone/flagyl then meropenem. He signed himself out of ___ this morning and presented to ___ ___ because he would like to be treated by ___ Podiatry. ___ the ___: Vitals on presentation: Pain 0 T 96.2 HR 83 BP 138/86 RR 16 pO2 97% RA ___ course: Afebrile, VSS, lactate 0.8, WBC 9.7. Appears euvolemic, Cr at baseline. Per Podiatry eval, significant cellulitis ___ distal R foot with wounds at R ___ digit plantar IPJ and R ___ interspace that probe to bone, no frank purulence. Foot XR c/f osteomyelitis of R ___ digit. Started dapto/cipro/flagyl (penicillin and vanc allergies), plan for OR for R ___ toe amputation ___. Of note, has a history of R ___ MT head resection and debridement with wound culture growing MRSA, VRE, and Pseudomonas ___ ___, as well as R ___ MT head resection with wound culture growing Pseudomonas, E. coli, and Enterococcus. Podiatry was consulted who recommended amputation of R ___ toe on ___ and continued IV antibiotics. He received the amputation and two subsequent debridements, although pathology was positive for acute osteomyelitis. The patient had a PICC line placed for prolonged IV Daptomycin treatment (6 weeks total) Past Medical History: - Diabetes, type I - Hypertension - Dyslipidemia - CAD - Last cath ___: Coronary Anatomy- Left dominant. LM: No disease. LAD: Calcified vessel. Diffuse 30% mid and distal disease. D1 is occluded and collateralized via L to L collaterals. LCx: Large vessel, OM1 is ostially occluded. OM2 has severe diffuse disease. LPDA is subtotally occluded. RCA: Small, non-dominant. Diffuse disease. - HFrEF, last EF 26% - GERD Social History: ___ Family History: + HTN No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: ADMISSION PHYSICAL EXAM: General: Well-appearing older man, obese, lying back ___ bed, NAD HEENT: Scleral anicteric, MMM Neck: no lymphadenopathy, no thyromegaly, JVP @ 13 cm at level of mandible when lying at 60 degrees Lungs: CTAB, no rales, ronchi or wheezes CV: Distant heart sounds, RRR, no murmurs, rubs or gallops GI: Obese, mildly distended, normoactive bowel sounds, nontender to palpation ___ all four quadrants Ext: 1+ edema RLE > L (with trace edema) b/l to knee, b/l DP pulses 1+ palpable, R foot bandaged with betadine Neuro: CNII-XII grossly intact, moving all extremities appropriately DISCHARGE PHYSICAL EXAM: Vitals: 98.2 123 / 67 77 18 97 Ra General: Well appearing, sitting ___ chair eating breakfast HEENT: Sclera anicteric, MMM Lungs: diminished lung sounds at bases b/l, otherwise CTAB. no rales, rhonchi or wheezes CV: RRR, no murmurs, rubs or gallops ABDOMEN: Obese, normoactive bowel sounds, nontender to palpation ___ all four quadrants. Nondistended. Ext: No bilateral lower extremity edema. R foot bandaged with dried blood on underside of dressing. LUE IV site wrapped ___ gauze c/d/I. Neuro: CNII-XII grossly intact, moving all extremities appropriately. Pertinent Results: ADMISSION LABS: ___ 05:40PM BLOOD WBC-9.7 RBC-4.08* Hgb-12.2* Hct-38.2* MCV-94 MCH-29.9 MCHC-31.9* RDW-14.6 RDWSD-50.6* Plt ___ ___ 05:40PM BLOOD Neuts-70.2 Lymphs-13.4* Monos-12.6 Eos-2.5 Baso-0.5 Im ___ AbsNeut-6.78* AbsLymp-1.29 AbsMono-1.22* AbsEos-0.24 AbsBaso-0.05 ___ 05:40PM BLOOD ___ PTT-38.9* ___ ___ 05:40PM BLOOD Glucose-114* UreaN-42* Creat-1.7* Na-138 K-4.3 Cl-102 HCO3-24 AnGap-12 ___ 06:59AM BLOOD CK(CPK)-48 ___ 06:10AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.0 ___ 05:40PM BLOOD %HbA1c-8.8* eAG-206* ___ 06:59AM BLOOD CRP-106.4* ___ 05:47PM BLOOD Lactate-0.8 DISCHARGE LABS: ___ 11:45AM BLOOD WBC-6.6 RBC-4.06* Hgb-11.9* Hct-37.5* MCV-92 MCH-29.3 MCHC-31.7* RDW-14.6 RDWSD-49.6* Plt ___ ___ 05:46AM BLOOD Neuts-38.2 ___ Monos-15.8* Eos-9.5* Baso-1.0 Im ___ AbsNeut-2.20 AbsLymp-2.03 AbsMono-0.91* AbsEos-0.55* AbsBaso-0.06 ___ 11:45AM BLOOD Plt ___ ___ 11:45AM BLOOD Glucose-217* UreaN-45* Creat-1.7* Na-138 K-4.9 Cl-101 HCO3-28 AnGap-9* ___ 05:46AM BLOOD CK(CPK)-67 ___ 11:45AM BLOOD Calcium-9.3 Phos-4.0 Mg-2.3 MICROBIOLOGY: Tissue: BONE FRAGMENT(S), OTHER THAN PATHOLOGIC FRACTURE ___ PATHOLOGIC DIAGNOSIS: "second metatarsal bone": Acute osteomyelitis. Tissue: BONE FRAGMENT(S), OTHER THAN PATHOLOGIC FRACTURE ___ PATHOLOGIC DIAGNOSIS: Right second toe proximal margin: Acute osteomyelitis. ___ 6:04 pm SWAB RIGHT SECOND TOE CULTURES. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND SINGLY. WOUND CULTURE (Final ___: STAPH AUREUS COAG +. SPARSE GROWTH. Susceptibility testing performed on culture # ___ ___. ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): A swab is not the optimal specimen for recovery of mycobacteria or filamentous fungi. A negative result should be interpreted with caution. Whenever possible tissue biopsy or aspirated fluid should be submitted. FUNGAL CULTURE (Final ___: NO FUNGUS ISOLATED. A swab is not the optimal specimen for recovery of mycobacteria or filamentous fungi. A negative result should be interpreted with caution. Whenever possible tissue biopsy or aspirated fluid should be submitted. POTASSIUM HYDROXIDE PREPARATION (Final ___: Test cancelled by laboratory. PATIENT CREDITED. Inappropriate specimen collection (swab) for Fungal Smear (___). ___ 6:12 pm TISSUE RIGHT SECOND TOE. GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND SINGLY. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. TISSUE (Final ___: STAPH AUREUS COAG +. SPARSE GROWTH. Susceptibility testing performed on culture # ___ ___. ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Final ___: NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final ___: NO FUNGAL ELEMENTS SEEN. ___ 8:14 pm BLOOD CULTURE 2 OF 2. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 5:40 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 7:00 pm SWAB Source: Right foot ___ digit wound. **FINAL REPORT ___ GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. SMEAR REVIEWED; RESULTS CONFIRMED. WOUND CULTURE (Final ___: STAPH AUREUS COAG +. MODERATE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. RIFAMPIN should not be used alone for therapy. Daptomycin AND CEFTAROLINE Susceptibility testing requested per ___ ___ ___. Daptomycin MIC = 0.5 MCG/ML. Daptomycin test result performed by Etest. CEFTAROLINE = SUSCEPTIBLE. CEFTAROLINE test result performed by ___. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R DAPTOMYCIN------------ S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. IMAGING: +CXR ___ IMPRESSION: The tip of the left PICC line projects over the distal SVC. No pneumothorax. +TTE ___ The left atrial volume index is mildly increased. The right atrium is mildly enlarged. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is ___ mmHg. There is normal left ventricular wall thickness with a moderately increased/dilated cavity. There is moderate-severe regional left ventricular systolic dysfunction with akinesis of the anteroseptum and hypokinesis of all other segments; the basal and mid inferior/inferolateral segments contract best (see schematic). Quantitative biplane left ventricular ejection fraction is 35 %. Due to severity of mitral regurgitation, intrinsic left ventricular systolic function likely is lower. There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Tissue Doppler suggests an increased left ventricular filling pressure (PCWP greater than 18 mmHg). Mildly dilated right ventricular cavity with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch is mildly dilated. There is no evidence for an aortic arch coarctation. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is trace aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is an eccentric, inferolateral directed jet of moderate [2+] mitral regurgitation. Due to the Coanda effect, the severity of mitral regurgitation could be UNDERestimated. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Moderately dilated left ventricle with moderate to severe regional dysfunction consistent with multivessel coronary artery diease. Increased left ventricular filling pressure. Moderate mitral regurgitation. Mild pulmonary hypertension. +FOOT AP, LAT, OBL ___ IMPRESSION: There are postsurgical changes from amputation of the second toe. New erosive changes ___ the second metatarsal head may represent postsurgical debridement. There are postsurgical changes from previous partial resection of the fourth and fifth digits. No acute fracture or dislocation is identified. Arthropathic changes of the midfoot and forefoot are unchanged from prior study. There is a small plantar calcaneal spur. Atherosclerotic calcifications are noted. +FOOT AP,LAT & OBL RIGHT ___ IMPRESSION: Lucency involving the base of the second digit middle phalanx may be due to fracture and/or osteomyelitis. Re-demonstrated chronic findings ___ the foot. Brief Hospital Course: ___ is a ___ with a history of T1DM on insulin, Charcot foot, CKD Stage 3, HFrEF (EF 35% ___ ___ presented with an acute R foot ulcer, pain, and erythema concerning for cellulitis with osteomyelitis of the R second digit s/p amputation, debridement X2, and wound closure with proximal bone margin positive for osteomyelitis, now on IV daptomycin. ACTIVE ISSUES ================= #RLE second digit osteomyelitis: Patient presented with a R foot ulcer and imaging concerning for acute osteomyelitis. His R second toe was amputated on ___ with cultures growing MRSA. He was placed on IV daptomycin. During his hospital course, he had two debridements with delayed primary ___ and ___. Proximal margin pathology was positive for acute osteomyelitis both times. A PICC line was placed for a total 6-week course of IV daptomycin per ID recommendations (end date ___. Foot pain was well controlled with tylenol. Upon discharge patient was touchdown weightbearing to right heel and wheelchair for mobility, with disposition to home with services. He was scheduled with close follow up with podiatrist Dr. ___. #Acute Exacerbation of HFrEF: Patient with a known diagnosis of HFrEF. TTE on ___ revealed LVEF of 35% with elevated PCWP. Patient initially presented with volume overload with BNP >11,000, likely ___ the setting of active osteomyelitis infection and volume resuscitation prior to ___ admission. Patient received diuresis with IV furosemide, PO torsemide, and PO furosemide. He continued to have significant urine output (>2L) off diuretics, which was thought to be due to post-ATN diuresis. He was initially placed on a 1.5L fluid restriction which was liberalized at discharge. Patient was also given losartan and carvedilol. Weight was 229 on admission and 209 lbs at discharge. He will not be discharged on a diuretic given his large UOP, and was instructed to call his cardiologist/PCP if he has weight gain >3 lbs. #Left Charcot foot pain Patient has a history of charcot foot, and reported pain ___ his left foot on the day prior to discharge. The pain was attributed to having all of his weight offloaded on his L foot after his R toe amputation and non-weightbearing status. He had marked dryness and a linear fissure on heel, which was tender to palpation. There was no surrounding erythema or evidence of acute infection. Patient had been prescribed ammonium lactate (AmLactin) cream from podiatry although this was not on hospital formulary; he will resume use upon discharge. CHRONIC ISSUES =================== #Depression: Patient endorsed several signs of depression and loneliness, difficulty coping with stressors ___ personal/professional life. He was given citalopram 10mg (previously took ___ ___ and saw a social work consult with good effect. He should continue this medication as an outpatient with close PCP follow up. #Elevated INR: Patient presented with INR 1.6, not on anticoagulation. Given normal LFTs, no sign of hepatic dysfunction, the most likely cause was his inflammatory state and long-term antibiotic therapy. Vit K administered with good effect, INR downtrended to 1.3 prior to discharge. There were no signs/symptoms of bleeding during hospitalization. #Insomnia: Patient initially endorsed insomnia and had good response to trazodone, given prn while ___ house. #Anemia: Admission Hgb at 10.9 slightly downtrended from baseline 12. Likely anemia of chronic disease given infection and hypoproduction with chronic renal disease. Hgb stable at 12 throughout admission. #CKD Stage 3: Baseline Cr 1.7-2.0. Admission Cr 1.6 at baseline. Meds were renally dosed, renal toxins avoided. Cr 1.8 on day of discharge. #IDDM: Poorly controlled with A1C 8.8 on admission ___ the setting of infection as above. Continued to titrate his insulin regimen while ___ house. He will be discharged on his home insulin regimen. #CAD: Patient continued on home ASA, carvedilol, atorvastatin. #HTN: Patient continued on home Losartan. TRANSITIONAL ISSUES: ===================== Discharge Hb: 11.7 Discharge Cr: 1.8 Discharge INR: 1.3 Discharge Weight: 209 lbs []Encourage patient to take daily weights []Patient discharged without PO diuretic due to evidence of significant post-ATN diuresis. However, he will need close follow up to re-establish a diuretic regimen. Consider starting with torsemide ___ daily and uptitrating PRN (prior home dose was furosemide 60mg BID). Of note, patient requested to have doses consolidated to daily as opposed to BID if possible. []Consider starting spironolactone given HFrEF (EF 35% on ___ []F/u with outpatient cardiologist re: education on prevention of heart failure exacerbation (reducing alcohol drinking) []FYI: patient with elevated PASP to 36 mmHg likely from volume overload []Repeat CBC with diff ___ 1 week and f/u normocytic anemia. Patient with stable low Hgb of ___ on this admission. Also noted to have mild peripheral eosinophilia (Abs Eos: 550). []Repeat INR ___ 1 week (elevated during admission) []Per ID recommendations while on Daptomycin Repeat safety labs once weekly • Check CBC with diff • Lytes/renal function • LFTs • check CPK BC x 2 for any fever []FYI SWAB ACID FAST CULTURE and TISSUE ACID FAST CULTURE pending at discharge []TDWB to R heel []Discharged with wheelchair (non weight bearing on L foot) []Wound Care Instructions: Right Foot: -Frequency: every 3 days -Apply betadine-soaked gauze across incision site -Then, apply gauze, kerlix and ACE wrap []Further discuss mood/coping as outpatient. Evaluate response to Celexa that was started on admission Code: Full (confirmed) Contact: HCP/Brother ___ ___ ; ___ (sister, alternate) ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Carvedilol 12.5 mg PO BID 3. Furosemide 60 mg PO BID 4. Atorvastatin 80 mg PO QPM 5. AmLactin (ammonium lactate;<br>ammonium,pot.and sodium lactat) topical DAILY 6. Doxycycline Hyclate 100 mg PO Q12H 7. Glargine 32 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 8. Losartan Potassium 25 mg PO DAILY Discharge Medications: 1. Citalopram 10 mg PO DAILY RX *citalopram [Celexa] 10 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet Refills:*0 2. Daptomycin 600 mg IV Q24H RX *daptomycin 350 mg 600 mg IV q24h Disp #*30 Vial Refills:*0 3. AmLactin (ammonium lactate;<br>ammonium,pot.and sodium lactat) 1 appl topical DAILY 4. Glargine 32 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 80 mg PO QPM 7. Carvedilol 12.5 mg PO BID 8. Losartan Potassium 25 mg PO DAILY RX *losartan [Cozaar] 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 9. HELD- Furosemide 60 mg PO BID This medication was held. Do not restart Furosemide until you see your PCP 10.standard manual wheelchair Dx: R foot osteomyelitis Px: good ___: 13 months Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: ============== Acute right second toe osteomyelitis Acute on chronic heart failure with reduced ejection fraction Secondary Diagnoses: ================ Insulin Dependent Diabetes Type II Normocytic anemia Major depressive disorder Insomnia Coagulopathy Chronic Kidney Disease Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, It was a pleasure caring for you at ___ ___. WHY WAS I ___ THE HOSPITAL? - You were ___ the hospital because you had an infected ulcer ___ your right second toe. WHAT HAPPENED TO ME ___ THE HOSPITAL? - You had an amputation and additional debridements for your right second toe. We started you on an antibiotic (Daptomycin), which you will continue to take through your PICC line after you are discharged. - You also had extra fluid ___ your body and lungs, which was felt to be due to your heart failure. We gave you a diuretic medication, IV Lasix, which helps to remove this extra fluid. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. - Weigh yourself every morning. Your weight on discharge is 209 lbs. Please seek medical attention if your weight goes up more than 3 lbs (increases to a weight of 212 lbs). - Seek medical attention if you have new or concerning symptoms or you develop swelling ___ your legs, abdominal distention, or shortness of breath at night. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
10164309-DS-6
10,164,309
25,927,595
DS
6
2134-11-17 00:00:00
2134-11-17 13:08:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Penicillins / Phenergan / vancomycin Attending: ___. Chief Complaint: ovarian torsion Major Surgical or Invasive Procedure: right IJ tunneled dialysis line ___ laparoscopic right ovarian cystectomy History of Present Illness: ___ G1P1 with ESRD secondary to IgA nephropathy on daily PD, HTN and s/p TAH for fibroids presents as ED transfer from ___ with acute onset RLQ pain this afternoon at 1300, radiating to back and gradually worsening throughout the day. Does not wax or wane. Pain is sharp. Associated with nausea. No fevers. On presentation to ___, ___. Labs demonstrated stable kidney function, Cr 15.8, K 5.2. WBC 10.3, PMN 77. Abd and pelvic u/s were obtained which showed findings consistent with right ovarian torsion. Per OSH report, "in the right adnexa, there is a complex mass which is echogenic measuring 6 x 5.2 x 5.7 cm. This could represent a hemorrhagic cyst or a solid ovarian mass. Color doppler shows a trace amount of color flow." She was given 1.5mg IV dilaudid. Given complex h/o ESRD on PD, pt was transferred to ___ for further management. On arrival to ___, she now states that her pain has decreased to ___. No fevers, nausea. She is unsure if she is having her period, but she does endorse breast tenderness over the last several days. Past Medical History: GYN HISTORY: LMP: s/p hysterectomy HISTORY of Abnormal pap smears: yes, h/o LSIL HISTORY of STIs: denies ISSUES: fibroids; denies h/o ovarian cysts OB HISTORY: G1P1 - pLTCS for worsening renal IgA nephropathy at 29w6d, c/b intrapartum hemorrhage (2L) secondary to bleeding from multiple fibroids at hysterotomy site, requiring transfusion. Required ICU stay for respiratory failure, non-anion gap acidosis. Also had GDM PAST MEDICAL HISTORY: - Hypertension - History of hematuria - ESRD - IgA nephropathy diagnosed when patient was noted to have worsening proteinuria during pregnancy. Treated with steroids through pregnancy and then progressed to ESRD - h/o gestational diabetes - Depression/anxiety PAST SURGICAL HISTORY: - TAH, ___, for fibroid uterus - LSC PD cathether placement, ___ - pLTCS, as above, ___ - renal biopsy, ___ - labiaplasty, ___ Social History: ___ Family History: Brother with polycythemia ___. No family members with IgA nephropathy or renal disease. Physical Exam: PHYSICAL EXAM: 98.0 88 180/110 16 99% RA 98.2 81 166/98 16 98% RA Pain 0 98.3 78 162/100 16 98% RA CONSTITUTIONAL: NAD, AOx3 ABDOMEN: PD catheter in place RLQ port site dressing c/d/i. soft, completely nontender to deep palpation, no r/g PELVIC: Normal external genitalia, smooth vaginal epithelium, physiologic leukorrhea, intact apex both with visual inspection and on digital palpation, no left adnexal mass palpated, no left adnexal tenderness, mild right adnexal tenderness associated with right adnexal fullness Discharge physical exam Vitals: VSS BP 140s/80s Gen: NAD, A&O x 3 Neck: tunneled right IJ c/d/i CV: RRR Resp: no acute respiratory distress Abd: soft, mildly distended, appropriately tender, no rebound/guarding, incision c/d/i Ext: no TTP Pertinent Results: PUS ___ IMPRESSION: 1. Right pelvic mass with only peripheral flow and no demonstrable internal flow, unchanged in size or appearance compared with recent exam may represent a right adnexal neoplasm versus a residual broad ligament fibroid partially seen in pre-hysterectomy MRI from ___. Further assessment with a pelvic MRI with contrast is recommended for complete evaluation. 2. Ascites slightly increased compared with recent exam. MRI ___ IMPRESSION: -Heterogenous 5.7 cm right adnexal mass with layering hemorrhage/ debris. This was not visualized on the prior renal MRA, with limited evaluation of the pelvis. Considerations include a degenerated or torsed broad ligament fibroid or degenerated ovarian neoplasm. Ovarian torsion, however, cannot be excluded, especially since the right ovary is not identified. -Small to moderate amount of free pelvic fluid, which may be secondary to the patient's peritoneal dialysis. Time Taken Not Noted Log-In Date/Time: ___ 4:05 am URINE Site: NOT SPECIFIED **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 10:56 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES PERITONEAL FLUID. Fluid Culture in Bottles (Preliminary): NO GROWTH. ___ 09:20AM BLOOD WBC-9.5 RBC-2.47* Hgb-7.8* Hct-22.7* MCV-92 MCH-31.6 MCHC-34.5 RDW-15.7* Plt ___ ___ 04:33AM BLOOD WBC-8.8 RBC-2.61* Hgb-8.2* Hct-23.9* MCV-91 MCH-31.2 MCHC-34.2 RDW-15.5 Plt ___ ___ 06:55AM BLOOD WBC-9.6 RBC-2.79* Hgb-8.9* Hct-25.6* MCV-92 MCH-31.9 MCHC-34.7 RDW-15.2 Plt ___ ___ 12:58AM BLOOD WBC-12.2*# RBC-2.81* Hgb-9.0* Hct-26.3* MCV-94 MCH-32.0 MCHC-34.1 RDW-16.1* Plt ___ ___ 09:20AM BLOOD Neuts-85.7* Lymphs-7.7* Monos-4.6 Eos-1.7 Baso-0.2 ___ 06:55AM BLOOD Neuts-76.1* Lymphs-14.8* Monos-5.2 Eos-3.4 Baso-0.5 ___ 12:58AM BLOOD Neuts-76.9* Lymphs-14.5* Monos-5.8 Eos-2.3 Baso-0.5 ___ 04:33AM BLOOD ___ PTT-27.4 ___ ___ 09:20AM BLOOD Glucose-94 UreaN-74* Creat-15.2* Na-135 K-5.1 Cl-98 HCO3-22 AnGap-20 ___ 04:33AM BLOOD Glucose-109* UreaN-74* Creat-15.2*# Na-135 K-5.1 Cl-99 HCO3-23 AnGap-18 ___ 06:55AM BLOOD Glucose-78 UreaN-69* Creat-16.4*# Na-138 K-4.9 Cl-100 HCO3-23 AnGap-20 ___ 12:58AM BLOOD Glucose-95 UreaN-65* Creat-14.9*# Na-135 K-5.0 Cl-95* HCO3-21* AnGap-24* ___ 09:20AM BLOOD Calcium-7.9* Phos-12.2* Mg-2.3 ___ 04:33AM BLOOD Calcium-8.2* Phos-10.7* Mg-2.5 ___ 06:55AM BLOOD Calcium-8.1* Phos-11.5* Mg-2.7* ___ 12:58AM BLOOD Calcium-8.1* Phos-10.9*# Mg-2.6 ___ 09:20AM BLOOD HBsAg-PND HBsAb-PND HBcAb-PND ___ 01:09AM BLOOD Lactate-1.0 ___ 09:20AM BLOOD HCV Ab-PND ___ 01:46AM URINE Color-Straw Appear-Hazy Sp ___ ___ 01:46AM URINE Blood-TR Nitrite-NEG Protein->600 Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-TR ___ 01:46AM URINE RBC-9* WBC-42* Bacteri-MOD Yeast-NONE Epi-9 TransE-1 ___ 01:46AM URINE CastHy-2* ___ 09:20AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE ___ 09:20AM BLOOD HCV Ab-NEGATIVE Brief Hospital Course: On ___, Ms. ___ was admitted to the gynecology service for management of her likely right ovarian torsion. Her ovary likely spontaneously de-torsed as her pain had resolved by the time she arrived to the ___ emergency department. Repeat pelvic US showed right pelvic mass with only peripheral flow and no demonstrable internal flow, concerning for a right adnexal neoplasm versus a residual broad ligament fibroid. Follow up MRI showed possible degenerated or torsed broad ligament fibroid or degenerated ovarian fibroma or other neoplasm. Given the possibility of torsion and in order to prevent infectious sequelae of torsion, decision was made to proceed to the OR ___ for removal of the mass with laparoscopic RSO, possible laparotomy. Renal and transplant surgery were consulted for optimization of her ESRD in the setting of requiring surgical intervention. Her creatinine remained stable. She received peritoneal dialysis starting the evening of ___ until her surgery. She also received an right IJ tunneled dialysis line ___ by ___ for planned hemodialysis after her operation. She continued her home losartan and had asymptomatic, elevated blood pressures to the 180s/110s overnight on ___. She was restarted on labetolol 150mg PO BID per renal recommendations with improvement of her blood pressures. On ___, she underwent laparoscopic right ovarian cystectomy. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV Dilaudid and Zofran for narcotic related nausea. On post-operative day 1, she was voiding spontaneously. Her diet was advanced without difficulty and she was transitioned to PO Dilaudid/Zofran/acetaminophen. She was followed by Renal and Transplant surgery and she received her first hemodialysis on ___ and is scheduled for her next dialysis on ___. Her hematocrit and electrolytes remained stable. She declined social work consultation for resources during her stay. By post-operative day 2, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. She will follow up with Dr. ___ for her ESRD, anemia and blood pressure management. Medications on Admission: 1. Calcitriol 0.25 mcg PO DAILY 2. Calcium Acetate 1334 mg PO TID W/MEALS 3. Cinacalcet 30 mg PO DAILY 4. Losartan Potassium 100 mg PO DAILY 5. Nephrocaps 1 CAP PO DAILY Discharge Medications: 1. Calcitriol 0.25 mcg PO DAILY 2. Calcium Acetate 1334 mg PO TID W/MEALS 3. Cinacalcet 30 mg PO DAILY 4. Losartan Potassium 100 mg PO DAILY 5. Nephrocaps 1 CAP PO DAILY 6. Acetaminophen ___ mg PO Q6H:PRN pain not to exceed 4 grams in 24 hours RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills:*0 7. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain do not drink alcohol or drive RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 8. Labetalol 150 mg PO BID RX *labetalol 100 mg 1.5 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 9. Ondansetron 4 mg PO Q8H:PRN nausea RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*40 Tablet Refills:*1 10. Docusate Sodium 100 mg PO BID constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*1 Discharge Disposition: Home Discharge Diagnosis: Right adnexal mass ESRD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the gynecology service with right sided abdominal pain and concern for ovarian torsion and underwent surgery. You have recovered well and the team believes you are ready to be discharged home. Please call the OB/GYN office ___ with any questions or concerns. Please follow up with Dr. ___ for your dialysis care and for your high blood pressure. Please follow the instructions below. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Take a stool softener such as colace while taking narcotics to prevent constipation. * Do not combine narcotic and sedative medications or alcohol. * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs. * No strenuous activity until your post-op appointment. * Nothing in the vagina (no tampons, no douching, no sex) for 6 weeks. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. * If you have staples, they will be removed at your follow-up visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Followup Instructions: ___
10164613-DS-9
10,164,613
27,642,370
DS
9
2172-03-28 00:00:00
2172-03-28 18:58:00
Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: None this hospitalization. History of Present Illness: Ms. ___ is a ___ year old woman with a history of schizoprenia, anxiety, depression and HTN, recently admitted from with gall stone ileus status post ex-lap for duodenal gallstone removal and loop gastrojejunostomy, presenting from her nursing facility with abdominal pain and leukocytosis. The patient was admitted from ___ with gallstone ileus s/p ex lap, takedown of cholecystenteric fistula with exploration of duodenum, extraction of enormous gallstone, fulguration of gallbladder mucosa, primary closure of duodenal fistula, omental flap for protection of fistula closure, pyloric exclusion, loop gastrojejunostomy and placement of gastrojejunostomy, with subsequent balloon retention gastrojejunostomy exchange. The patients post op course was complicated by right lateral aspect wound infection, and multifocal pneumonia and hypoxia requiring ICU transfer, treated with Vanc/Zosyn for presumed aspiration PNA. Additionally the patient was noted to have J tube migration into the stomach, ultimately requiring G/J tube exchange to balloon gastrostomy tube. The patient is presenting with concern for decline from her nursing facility. She was first noted to have a distended abdomen on ___, and a KUB was noted to have a large bowel ileus. Tube feeds were held and repeat KUB ___ and ___ revealed unchanged mild colonic ileus despite suppositories and loose BM. Appears to have had TF on hold since ___. The patient was noted to have a uptrending WBC count with worsening hyopnatremia. She has had diarrhea x 3 days, as well as intermittent nausea and vomiting, with intermittent adbominal pain, but per nursing staff no fevers or chills. Per nursing facility notes the patients abdominal fistula appears larger with green white drainage. In the ED, initial vitals were 97.6 HR 74 BP 134/55 RR 18 98 RA. Labs were notable for WBC 15.3 (N 86, 0 bands, 9 L, ___ M) H.H 9.6/30.3 plt 508, albumin 2.7, lipase 74, Chem 10 notable for Na 128, Cl 91, cr 1.0, lactate 1.6. Straight cath UA was unremarkable. The patient received 1 L NS bolus and 1 L NS @ 125 cc/hr. CT abdomen pelvis was notable for inflammatory changes of pylorus and duodenum at the site of prior surgical repair, without fistulous tract involving colon and bile ducts, as well as interval increase in multiple foci of air in the subcutaneous tissue from duodenum to skin c/w fistula, without drainable collection identified. Also with new nodular opacities within the R lung base which may be secondary to aspiration/infection. CXR with mild pulmonary edema and small bilateral pleural effusions. The patient was seen by ACS who recommended no need for surgical intervention and besides the known fistula tract there was no surgical source of leukocytosis. On the floor, the patient was in no acute distress, lying comfortably in bed. She denies being in any pain. The patient is alert and oriented to self only, and is unable to answer any other questions. Review of systems: (+) Per HPI. Past Medical History: Schizophrenia anxiety depression HTN Hypothyroidism Type 2 DM Gallstone Ileus s/p: ___ 1. Exploratory laparotomy. 2. Takedown of cholecystenteric fistula with exploration of the duodenum. 3. Extraction of enormous gallstone. 4. Fulguration of gallbladder mucosa. 5. Primary closure of duodenal fistula. 6. Omental flap for protection of fistula closure. 7. Pyloric exclusion. 8. Loop gastrojejunostomy. 9. Placement of gastrojejunostomy. ___: Balloon retention gastrojejunostomy exchange Social History: ___ Family History: Non-contributory. Physical Exam: ============================ PHYSICAL EXAM ON ADMISSION ============================ Vital Signs: T 98.1 BP 165/52 HR 71 RR 20 98 RA General: Alert, oriented to self only, no acute distress HEENT: NCAT, Sclera anicteric, PERRL, JVP not elevated, CV: Regular rate and rhythm, normal S1 + S2 Lungs: Clear to auscultation anteriorly, no respiratory distress or increased WOB Abdomen: Soft, mildly distended, bowel sounds present, no rebound or guarding, j tube site without drainage, right sided abdominal wound with minimal white/green drainage GU: No foley Ext: Warm, well perfused, no clubbing, cyanosis or edema Neuro: alert and oriented to person only, moving all extremities with purpose ============================ PHYSICAL EXAM ON DISCHARGE ============================ Vital Signs: T 97.9 HR 69 (64-107) BP 150/56 (134-160/52-66) RR 18 98 RA General: Alert, oriented to self only, no acute distress HEENT: NCAT, Sclera anicteric, PERRL, JVP not elevated, CV: Regular rate and rhythm, normal S1 + S2, soft heart sounds, faint ___ holosystolic murmur appreciated at LUSB Lungs: Clear to auscultation anteriorly, no respiratory distress or increased WOB Abdomen: Soft, bowel sounds present, no rebound or guarding, non tender G tube soft, without drainage. Right sided abdominal wound bandage c/d/I without leakage, non tender. GU: No foley Ext: Warm, well perfused, no clubbing, cyanosis or edema Neuro: alert and oriented to person only, bilateral hand shaking Pertinent Results: =================== LABS ON ADMISSION =================== ___ 07:50PM BLOOD WBC-15.3*# RBC-3.39* Hgb-9.6* Hct-30.3* MCV-89# MCH-28.3 MCHC-31.7* RDW-15.9* RDWSD-51.8* Plt ___ ___ 07:50PM BLOOD Neuts-86* Bands-0 Lymphs-9* Monos-3* Eos-2 Baso-0 ___ Myelos-0 AbsNeut-13.16* AbsLymp-1.38 AbsMono-0.46 AbsEos-0.31 AbsBaso-0.00* ___ 07:50PM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL Tear Dr-OCCASIONAL ___ 07:50PM BLOOD Glucose-104* UreaN-25* Creat-1.0 Na-128* K-4.4 Cl-91* HCO3-24 AnGap-17 ___ 07:50PM BLOOD ALT-10 AST-36 AlkPhos-82 TotBili-0.2 ___ 07:50PM BLOOD Albumin-2.7* Calcium-9.1 Phos-4.3 Mg-1.8 ___ 07:50PM BLOOD Osmolal-274* ___ 07:58PM BLOOD Lactate-1.6 =================== PERTINENT INTERVAL LABS =================== ___ 05:45AM BLOOD TSH-4.3* ___ 05:45AM BLOOD Free T4-1.3 ___ 07:17PM BLOOD Lactate-1.1 ___ 12:59AM URINE Color-Straw Appear-Clear Sp ___ ___ 12:59AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 12:59AM URINE Hours-RANDOM UreaN-276 Creat-36 Na-30 K-19 Cl-20 ___ 12:59AM URINE Osmolal-231 =================== LABS ON DISCHARGE =================== ___ 06:30AM BLOOD WBC-8.5 RBC-3.43* Hgb-9.6* Hct-31.3* MCV-91 MCH-28.0 MCHC-30.7* RDW-15.9* RDWSD-52.3* Plt ___ ___ 06:30AM BLOOD Glucose-161* UreaN-15 Creat-0.5 Na-135 K-4.1 Cl-100 HCO3-27 AnGap-12 ___ 06:30AM BLOOD Calcium-9.0 Phos-2.0* Mg-1.6 =================== MICROBIOLOGY =================== ___ - Wound Culture - Gram Stain: 1+ PMNs, No Microorganisms Seen, Culture: Mixed Bacterial Types ___ Blood Culture - No Growth ___ Blood Culture - No Growth ___ Urine Culture - No Growth ___ Blood Culture - Proteus Mirabilis AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ___ - Blood Culture - No Growth ___ - Blood Culture - No Growth ___ - Blood Culture - No Growth =================== IMAGING/STUDIES =================== CXR ___ FINDINGS: Mild cardiomegaly has been stable compared to prior exams dated back to at least ___. There is mild pulmonary vascular congestion as well as mild pulmonary edema. Small bilateral pleural effusions are new. There is no pneumothorax. The visualized osseous structures are unremarkable. IMPRESSION: Mild pulmonary edema. New small bilateral pleural effusions. CT Abdomen/Pelvis w/ Contrast ___ 1. Inflammatory changes involving the pylorus and duodenum at the site of the prior surgical repair remains extensive and persistent with a fistula from the duodenum laterally to the skin surface contacting the bile ducts and colon with increased gas compared to prior. There is no definite open fistula involving the colon. No definite underlying drainable collection identified. 2. New nodular opacities within the right lung base, may be secondary to aspiration/infection. CXR ___ Right-sided PICC possibly in right brachiocephalic vein, at least 9 cm proximal to estimated position of cavoatrial junction. No complications. KUB ___ Dilated sigmoid colon appears stable and likely secondary to ileus. This finding is somewhat similar to multiple prior abdominal films making the diagnosis of a sigmoid volvulus unlikely however if there is clinical concern, CT abdomen and pelvis is recommended. Brief Hospital Course: Ms. ___ is a ___ year old woman with a history of schizoprenia, anxiety, depression and HTN, recently admitted with gallstone ileus status post ex-lap for duodenal gallstone removal and loop gastrojejunostomy, presenting from her nursing facility with hyponatremia, leukocytosis, and question of worsening fistula. ============== ACTIVE ISSUES: ============== # Sepsis Secondary to Pan-Sensitive Proteus Mirabilis: The patient presented with decline from rehab with increasing leukocytosis with neutrophil predominance. She remained afebrile throughout, but met SIRS criteria with leukocytosis and RR >20. Blood cultures grew Gram negative rods ultimately speciated to pan sensitive proteus mirabilis, and the patient was initially started on IV cefepime which was narrowed to IV ceftriaxone. The etiology of the infection was likely GI in etiology secondary to her duodenal inflammation and abdominal wound from her prior surgery with translocation of bacteria into the bloodstream. It was thought to be unlikely pulmonary in etiology despite nodular opacities at the right lung base given stability on room air without respiratory complaints. Urine culture was negative. She remained hemodynamically stable and afebrile throughout. On discharge the patient was transitioned to PO Ciprofloxacin to continue at total of 14 days (___). # Nutrition/Ileus: The patient came after having an episode of ileus at her rehab facility in which tube feeds were stopped. Tube feeds were restarted with clearance from her surgeon as above. Speech and swallow evaluation cleared the patient for pureed solids and thin liquid, with plans to advance at SNF back to regular diet and thin liquids however she had no desire to eat and this has been a longstanding issue. The patient continued to have issues with high residuals with her tube feeds. Ultimately she required very slow uptitration and transition to semi elemental diet which she tolerated well to goal. Please continue bowel regimen with goal bowel movements daily to prevent ileus and problems with high residuals on tube feeds. Family meeting was held to discuss possibility that patient may not tolerate tube feeds in the near future as she has had continued issues in the past with high residuals leading to nausea and vomiting. At this point no further options for tube feed changes as patient has failed multiple formulas of tube feeds and she is not a candidate for a surgical Jejunostomy tube (and has failed prior G-tube advancement under radiologic guidance). Should patient fail tube feeds at her current rate, please discuss options with family of decreasing rate of tube feeds or discontinuing altogether with transition to hospice. Discussed role of hospice with patient during meeting and they are potentially interested in this in the future. # Abdominal Wound: The patient presented from rehab with noted increasing drainage from her right sided abdominal wound form prior surgery, with imaging findings concerning for fistula on CT scan. However her surgeon was consulted, and noted that the patient had no clinical evidence of fistula on examination, with no biliary or other drainage from the wound. The air seen on imaging could be a likely result of wound packing and prior VAC therapy. A wound VAC was placed for treatment of her abdominal wound during the admission. The patient's wound vac was removed prior to discharge with plans for wound packing per wound nurse recommendations and cleared with surgery. Please see wound care recommendations below. # Toxic Encephalopathy/Hypoactive Delirium: Per family at bedside patient has been increasingly somnolent since her initial surgery but has had some improvement since she was initiated on Ritalin at ___, however she is still not back to baseline. Her presentation is likely multifactorial given sepsis, ileus, hyponatremia, prolonged hospital course on underlying schizophrenia. Her hyponatremia resolved and her TSH was within normal limits. She was continued on previous regimen of Ritalin BID and Seroquel QHS, and her mirtazapine dose was halved due to concern for contribution to sedation. The patient will need follow up with psychiatry as an outpatient for further assessment and titration of her medications. # Hyponatremia: The patient presented with a worsening hyponatremia with a Na of 132 on admission. This was thought likely to be hypovolemic in the setting of her ileus and held tube feeds, as the patient had a FeNa of 0.7% on admission. She had improvement with 2L NS IVF and her hyponatremia resolved and she had stable Na levels throughout her hospital course. # Goals of Care: The patient had a code status of full code on admission. A discussion was held with the patients son ___ (___) and wife regarding the goals of care for the patient. Her clinical status was described in depth. The family decided that it would be within the patient's goals of care to be made DNR/DNI. =============== CHRONIC ISSUES: =============== # HTN: The patient continued home HCTZ, lisinopril and atenolol. She remained normotensive. # Hypothyroidism: The patient's TSH was checked due to concern for somnolence and was within normal limits. She was continued on home levothyroxine. # T2DM: The patient was placed on sliding scale insulin until her tube feeds were at goal, and her glargine was held. # Anemia: Patient continued ferrous sulfate. # GERD: Patient was transitioned from omeprazole to lansoprazole given her GI tube. She continued BID dosing. # Depression/Anxiety: Patient's home mirtazapine dose was decreased from 30 mg to 15 mg due to concern for somnolence as above. # Schizophrenia: Patient continued on Seroquel while in-house. She will need follow up after discharge with psychiatry for further assessment and medication titration. ==================== TRANSITIONAL ISSUES: ==================== - Patient to continue PO Ciprofloxacin for Proteus bacteremia with plan for 14-day course (Day 1 ___ and to be completed ___. Do not give ciprofloxacin for at least 2 hours before or 6 hours after oral cations (Aluminum magnesium hydroxide, iron). - Please continue to trend electrolytes and replete as needed given recent reinitiation of tube feeds. Has been needing phosphate and magnesium repletion. Recommend checking electrolytes next on ___ and replete as needed. - Please continue to monitor tube feeds and residuals. If patient is unable to tolerate tube feeds (due to nausea/vomiting or high residuals) at current rate, please discuss options with family of decreasing rate of tube feeds or discontinuing altogether with transition to hospice. Discussed role of hospice with family during meeting and they are potentially interested in this in the future. No further options for tube feed changes as patient has failed multiple formulas of tube feeds and she is not a candidate for a surgical Jejunostomy tube (and has failed prior G-tube advancement under radiologic guidance). - Current tube feed recommendations: Vital 1.5 Full strength. Starting rate: 10 ml/hr; Advance rate by 5cc q4h; Goal rate: 50 ml/hr. Residual Check: q4h, Hold feeding for residual >= :200 ml. Flush w/ 200 ml water q6h. - Please continue bowel regiment with goal one to two bowel movements per day to help with success of tube feeds and prevent high residuals due to constipation. - Please follow blood sugars. If remain elevated with tube feeds at goal, would restart standing glargine (was previously on 8 units glargine, had been held in the setting of ileus and uptitration of tube feeds). Would continue with sliding scale insulin for coverage as needed while on tube feeds. - Patient will need continued wound care per wound care recommendations. At discharge abdominal wound recommendations: Cleanse ulcer with wound cleanser set to "stream". Pat dry, use cotton tip swab as needed to remove excess cleanser. Prep periwound tissues with No Sting Barrier Wipe. Fill ulcer with moistened AMD ___ inch packing strip (manf ___. Cover with dry gauze. Secure with Medipore H soft cloth tape. Change daily. - Patient to follow-up with Dr. ___ as an outpatient regarding abdominal wound and surgery. - Patient to follow-up with psychiatry as an outpatient regarding evaluation and treatment of her schizophrenia and evaluation of mental status. # CODE: DNR/DNI (per MOLST in chart) # CONTACT: ___ (son/HCP) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 25 mg PO DAILY 2. Omeprazole 40 mg PO BID 3. Docusate Sodium (Liquid) 200 mg PO BID 4. FoLIC Acid 1 mg PO DAILY 5. Hydrochlorothiazide 25 mg PO DAILY 6. Lisinopril 10 mg PO DAILY 7. Levothyroxine Sodium 75 mcg PO DAILY 8. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO BID 9. QUEtiapine Fumarate 12.5 mg PO QHS 10. senna 8.6 mg oral BID 11. Cyanocobalamin 1000 mcg PO DAILY 12. MethylPHENIDATE (Ritalin) 10 mg PO BID 13. Mirtazapine 30 mg PO QHS 14. Potassium Chloride 20 mEq PO DAILY 15. Glargine 8 Units Bedtime Discharge Medications: 1. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO BID 2. Atenolol 25 mg PO DAILY 3. Docusate Sodium (Liquid) 200 mg PO BID 4. Hydrochlorothiazide 25 mg PO DAILY 5. Insulin SC Sliding Scale Fingerstick Q6H Insulin SC Sliding Scale using HUM Insulin 6. Levothyroxine Sodium 75 mcg PO DAILY 7. Lisinopril 10 mg PO DAILY 8. Mirtazapine 15 mg PO QHS 9. MethylPHENIDATE (Ritalin) 10 mg PO BID 8 AM and 12 ___ 10. QUEtiapine Fumarate 12.5 mg PO QHS 11. senna 8.6 mg oral BID 12. Lansoprazole Oral Disintegrating Tab 30 mg G TUBE BID 13. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days Plan 14-day course (Day 1 ___, completed ___. Not taken within 2 hrs iron or Al/Mg/OH. 14. Nystatin Cream 1 Appl TP BID PRN buttock itch 15. Cyanocobalamin 1000 mcg PO DAILY 16. FoLIC Acid 1 mg PO DAILY 17. Multiple Vitamins Liq. 5 mL PO DAILY 18. Ferrous Sulfate (Liquid) 300 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Primary Diagnoses: ================== - Proteus blood stream infection with sepsis - Ileus - Toxic metabolic encephalopathy - Post-op wound healing by secondary intention Secondary Diagnoses: ==================== - Cholecystenteric fistula s/p duodenotomy, stone extraction, gastrojejunostomy, PEG ___ - Schizophrenia - Hypertension - Hypothyroidism - GERD - Depression/Anxiety Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. ___, It was a pleasure caring for you during your stay at ___ ___. You were admitted to the hospital for abdominal pain and an elevated white blood cell count. You were found to have an infection in your blood stream that was most likely from your abdominal infection and you were treated with IV antibiotics. You were switched to pill antibiotics which you will need to continue after you leave the hospital for a total of 14 days. You were also evaluated by the surgery team who helped take care of your abdominal wound. Your tube feeds were slowly restarted, as you had issues with your bowel slowing. Your formulations were changed which you tolerated well. Your follow appointments are listed below. Your new medication list is attached to your discharge paperwork. We Wish You The Best! - Your ___ Care Team Followup Instructions: ___
10164665-DS-21
10,164,665
26,362,325
DS
21
2136-09-01 00:00:00
2136-09-03 21:13:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chest Heaviness and Shortness of Breath Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ with PMH significant for 2 vessel CAD s/p CABG (LIMA->LAD, SVG->OM1, SVG PDA in ___, HTN, HLD who presented to an OSH (___) from rehab with chest heaviness and SOB. Of note, pt. recently admitted from ___ to ___ following transfer from ___ where pt. was found to have 60% mid LAD lesion with subtotal RCA occlusion on cath. Pt. was evaluated at ___ and underwent CABG 3x LIMA->LAD, SVG->OM1, SVG -> PDA. Pt. had recovered well since surgery and was discharged on ___ to rehab. Pt. had been asymptomatic at rehab and in the evening 1 day prior to presentation, pt. developed substernal chest heaviness at rest associated with SOB. Pt called this to the attention of his medical staff. He was then transferred to ___. Pt. does note ongoing sharp lower chest pain that has been present since the time of his surgery. He describes worsening of this pain with movement, deep breathing, and coughing, consistent with pleuritic type chest pain. Pt. states that this episode of chest pain was different than the chest pain that brought the pt. to ___ on ___ prior to CABG. This pain was more of a substernal sharp CP associated with diaphoresis and lightheadedness. Pt. denies any orthopnea, PND, ___ swelling. At OSH, vitals were 99.0, 80, 112/65, 16, 98% on 3L NC. Pt. received x2 SL NTG with no improvement in his pain. He then received IV morphine for which he notes improvement. He also had a negative troponin x1 at OSH. Given recent surgery, pt. was transferred to ___. In the ED intial vitals were 98.2, 80, 124/77, 20, 98% on RA. Pt. found to have anemia with Hct 33 and an anion gap acidosis AG of 18. Lactate returned 1.2. Troponin negative x2. D-dimer returned elevated to >20,000, however in the setting of recent CABG, this is not unexpected. CTA PE revealed no evidence of PE to segmental branches with small amount of fluid in the pericardium consistent with recent CABG, trace right effusion, and small to moderate left effusion (non-hemorrhagic). Given recent CABG, CT surgery was consulted and felt that there was a low likelihood for graft occlusion. Given high risk ACS/unstable angina, pt. was admitted for further observation, evaluation, and possible stress. ROS: Positive for prior deep venous thrombosis (seems unprovoked by history, was on coumadin for several years, d/c'ed ___. Pt. also does not increased flatus, loose stools, and Otherwise, pt. denies any prior history of stroke, TIA, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: ___: s/p cardiac catheterization at ___ (60 % mid LAD lesion with subtotal RCA occlusion) ___: CABG x3, left internal mammary artery to left anterior descending artery, reverse saphenous vein grafts to the posterior descending artery and the first obtuse marginal artery 1. Coronary artery disease 2. Type 2 DM 3. DVT (unprovoked, per. pt, hypercoag work-up was positive for some type of genetic mutation, previously on Coumadin d/c'ed in ___ 4. Portal Hypertension, -denies liver disease 5. Hyperlipidemia 6. CHF: unknown diastolic vs systolic 7. CKD stage 3 Social History: ___ Family History: Father: died of CV disease in his ___ Mother: died from complications of type 2 DM in her ___, ___ younger brother with CAD in his ___, ___ siblings with type 2 DM Physical Exam: ADMISSION PHYSICAL EXAMINATION: ================================= VS: 98.5, 80, 131/68, 18, 95 on 2L GENERAL: NAD, Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with JVP of 10-12cm CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Diffuse mild inspiratory rales but otherwise CTAB, ABDOMEN: Soft, tender to deep palpation diffusely throughout the abdomen, greatest in the right lower quadrant. No HSM or tenderness. No abdominal bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: RP and DP 2+ bilaterally and symmetrically DISCHARGE PHYSICAL EXAMINATION: ================================== VS: 98.5 110/55 72 18 95% on RA Exam unchanged Pertinent Results: ADMISSION LABS ================= ___ 07:00AM BLOOD WBC-9.5# RBC-3.40* Hgb-11.1* Hct-33.0* MCV-97 MCH-32.7* MCHC-33.6 RDW-12.7 Plt ___ ___ 07:00AM BLOOD Neuts-72.2* ___ Monos-4.2 Eos-2.0 Baso-0.5 ___ 07:00AM BLOOD Glucose-133* UreaN-21* Creat-1.2 Na-139 K-6.1* Cl-105 HCO3-16* AnGap-24* ___ 01:00PM BLOOD ALT-16 AST-23 LD(LDH)-216 AlkPhos-45 TotBili-0.4 ___ 09:22AM BLOOD ___ ___ 01:00PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 04:10PM BLOOD Lactate-1.2 NOTABLE LABS ============= ___ 06:55PM BLOOD UreaN-19 Creat-1.2 Na-139 K-4.9 Cl-100 HCO3-29 AnGap-15 ___ 07:00AM BLOOD cTropnT-<0.01 ___ 01:00PM BLOOD cTropnT-<0.01 ___ 07:13PM BLOOD ___ pO2-38* pCO2-56* pH-7.35 calTCO2-32* Base XS-3 Comment-GREEN TOP ___ 07:13PM BLOOD Lactate-1.5 DISCHARGE LABS ================= ___ 05:01AM BLOOD WBC-7.8 RBC-3.40* Hgb-11.1* Hct-33.1* MCV-97 MCH-32.5* MCHC-33.4 RDW-12.6 Plt ___ ___ 05:01AM BLOOD Glucose-118* UreaN-19 Creat-1.1 Na-140 K-4.4 Cl-101 HCO3-28 AnGap-15 ___ 05:01AM BLOOD Calcium-8.7 Phos-4.0 Mg-1.9 STUDIES ========= CXR (___): IMPRESSION: No acute cardiopulmonary process with post-CABG changes. CTA PE (___): IMPRESSION: 1. No evidence of pulmonary embolism. 2. Small amount of fluid tracking along the pericardium and in the anterior mediastinum likely represents post-surgical changes related to recent CABG. Trace right and small-to-moderate left non-hemorrhagic pleural effusions. 3. Several locules of gas are present superficial to the left pectoralis major muscle and are probably post surgical in etiology; however, infection cannot be excluded and should be correlated with clinical examination. Brief Hospital Course: Mr. ___ is a ___ with PMH significant for 2 vessel CAD s/p CABG (LIMA->LAD, SVG->OM1, SVG PDA in ___, HTN, HLD who presented to an OSH (___) from rehab with chest heaviness and SOB. Pt. was later transferred to ___ given recent CABG. He had no elevated troponins and no concerning EKG changes. He also had a negative CTA PE. CT surgery evaluated and thought his presentation was unlikely related to his recent CABG. He had some lightheadedness on admission which was thought to be from aggressive BP control. His meds were titrated appropriately and he was discharged back to his rehab facility. # Chest Pain/Shortness of Breath: Did not recur. One episode occurred at OSH which resolved with morphine. CT surgery evaluated and there was no concern about graft occlussion of recent CABG. EKG unchanged and troponins were negative. CTA performed without evidence of PE. Likely ___ some type of ongoing musculoskeletal process. # Lightheadedness/Relative ___: This was felt to be medication related. The patient's imdur was discontinued and coreg was decreased to 12.5 mg BID. The patient's lightheadedness and low blood pressure resolved. # Abdominal Discomfort and Loose stools: Given simethicone. Pt's stool was formed. No evidence of diarrhea. # Normocytic Anemia: Likely related to operative blood loss. This was not worked up as inpatient. # Chronic Systolic CHF: Continue lasix, lisinopril, and carvedilol at reduced dose. # CAD: Continue aspirin, atorvastatin, lisinopril, and carvedilol at reduced dose. Increased atorvastatin to 80 mg. Stopped imdur. # Hypertension: Continue lisinopril and carvedilol at reduced dose due to lightheadedness and relative hypotension. # Type 2 DM: Restart home diabetic meds TRANSITIONAL ISSUES ======================= # Med Changes: Atorvastatin increased to 80mg daily, carvedilol decreased to 12.5mg PO BID, imdur was stopped. # Anemia: Pt. should have repeat CBC in ___ weeks to ensure resolution of normocytic anemia likely ___ operative blood loss and anemia of chronic disease related to current recovery. # CODE: Full Confirmed # CONTACT: Patient, ___ (wife, ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. glimepiride 4 mg oral BID 2. Aspirin EC 81 mg PO DAILY 3. Atorvastatin 10 mg PO DAILY 4. Carvedilol 25 mg PO BID 5. Furosemide 20 mg PO DAILY 6. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY 7. MetFORMIN (Glucophage) 500 mg PO BID 8. Docusate Sodium 100 mg PO BID 9. Milk of Magnesia 30 mL PO DAILY 10. Potassium Chloride 20 mEq PO DAILY 11. Multivitamins 1 TAB PO DAILY 12. Lisinopril 5 mg PO DAILY 13. Nitroglycerin SL 0.3 mg SL PRN Chest Pain 14. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN Pain Discharge Medications: 1. Aspirin EC 81 mg PO DAILY 2. Atorvastatin 80 mg PO DAILY 3. Carvedilol 12.5 mg PO BID 4. Docusate Sodium 100 mg PO BID 5. Furosemide 20 mg PO DAILY 6. Lisinopril 5 mg PO DAILY 7. glimepiride 4 mg ORAL BID 8. MetFORMIN (Glucophage) 500 mg PO BID 9. Milk of Magnesia 30 mL PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Nitroglycerin SL 0.3 mg SL PRN Chest Pain 12. Acetaminophen 650 mg PO Q6H:PRN Pain 13. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN Pain RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*0 14. Simethicone 40-80 mg PO QID:PRN Gas Pain Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES ==================== # Hypotension # Chest Pain # Anion Gap Metabolic Acidosis SECONDARY DIAGNOSES ===================== # Chronic Systolic Congestive Heart Failure # Coronary Artery Disease # Hypertension # Type 2 Diabetes Mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, It was a pleasure to meet and care for you during your hospitalization at ___. You were admitted from an outside hospital following an acute episode of chest pain and shortness of breath. We did not feel that your symptoms were related to a heart attack or problems with your recent heart surgery. You had some lightheadedness during your visit which was thought to be from over-aggressive blood pressure control. We stopped your imdur and decreased your carvedilol to help allow your blood pressure to be in a better range for you. You were discharged back to rehab to continue your recovery. All the best, Your ___ Care Team Followup Instructions: ___
10164996-DS-22
10,164,996
26,794,754
DS
22
2136-09-08 00:00:00
2136-09-08 17:45:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Penicillins Attending: ___. Chief Complaint: Incarcerated recurrent inguinal hernia Major Surgical or Invasive Procedure: Repair of incarcerated recurrent inguinal hernia History of Present Illness: ___ year old male w/ HTN and HLD w/ history of SBO and previous open right inguinal hernia repair with mesh presents with progressive right groin buldge for the last month and episodic abdominal pain for the last few days. Patient has experienced a right groin buldge that has progressively become larger for the last month. It is intermittently tender with movement and to touch. There are no associated overlying skin changes. Patient has had normal bowel movements and is passing flatus but did notice some difficulty with bowel movements recently. Concurrently for the last few days he has experienced episodic abdominal pain in the RLQ and ___. Although not associated with eating, he has attempted to reduce his PO intake. He denies fevers, chills, night sweats, constipation, diarrhea, weight loss, bloody or dark stool. No nausea, emesis. Past Medical History: PMH: OSA (no tx), glucose intolerance, dyslipidemia, h/o colonic adenoma on colonoscopy ___ PSH: left inguinal herniorrhaphy ___ (___), exploratory laparotomy for peritonitis ___ Social History: ___ Family History: Non-contributory Physical Exam: T: 97.4 HR:90 BP: 130/70 RR: 18 O2: 99% RA Gen: NAD. A&Ox3. well appearing. comfortable CV: RRR. no m/r/g Lungs: no respiratory distress. CTAB Abd: soft, NTTP, ND. incision c/d/i. No rebound or guarding. Ext: WWP. 2+ ___ pulses. Brief Hospital Course: The patient was admitted to the ___ Surgical Service on ___ and had repair of incarcerated recurrent inguinal hernia. The patient tolerated the procedure well. For more detail about the procedure please see the operative note. . Neuro: Post-operatively, the patient received oral and IV pain medications with good effect. . CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. WHen tolerating PO the pain resumed his home medications. . Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. . GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. His diet was advanced when appropriate, which was tolerated well. He was also started on a bowel regimen to encourage bowel movement. Intake and output were closely monitored. . ID: ___, the patient was started on IV cefazolin, The patient's temperature was closely watched for signs of infection. . Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. . At the time of discharge on POD#1, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 10 mg PO QPM 2. Hydrochlorothiazide 12.5 mg PO DAILY 3. Aspirin 81 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 10 mg PO QPM 3. Hydrochlorothiazide 12.5 mg PO DAILY 4. Acetaminophen 650 mg PO TID 5. Docusate Sodium 100 mg PO BID 6. OxycoDONE (Immediate Release) 5 mg PO Q3H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*50 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Incarcerated recurrent inguinal hernia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ___ 3 DISCHARGE INSTRUCTIONS: Dear Mr. ___, It was a pleasure taking care of you here at ___ ___. You were admitted to our ___ after undergoing repair of your incarcerated inguinal hernia. You have recovered from surgery and are now ready to be discharged to home. Please follow the recommendations below to ensure a speedy and uneventful recovery. ACTIVITY: - Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. - You may climb stairs. - You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. - Don't lift more than 10 lbs for 6 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. - You may start some light exercise when you feel comfortable. - You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. - Heavy exercise may be started after 6 weeks, but use common sense and go slowly at first. - You may resume sexual activity unless your doctor has told you otherwise. HOW YOU MAY FEEL: - You may feel weak or "washed out" for 6 weeks. You might want to nap often. Simple tasks may exhaust you. - You may have a sore throat because of a tube that was in your throat during surgery. - You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. - You could have a poor appetite for a while. Food may seem unappealing. - All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your surgeon. YOUR INCISION: - Your incision may be slightly red around the edges. This is normal. - If you have steri strips, do not remove them for 2 weeks. (These are the thin paper strips that are on your incision.) But if they fall off before that that's okay). - You may gently wash away dried material around your incision. - It is normal to feel a firm ridge along the incision. This will go away. - Avoid direct sun exposure to the incision area. - Do not use any ointments on the incision unless you were told otherwise. - You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your surgeon. - You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. - Over the next ___ months, your incision will fade and become less prominent. YOUR BOWELS: - Constipation is a common side effect of medicine such as Percocet or codeine. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. - If you go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. - After some operations, diarrhea can occur. If you get diarrhea, don't take anti-diarrhea medicines. Drink plenty of fluitds and see if it goes away. If it does not go away, or is severe and you feel ill, please call your surgeon. PAIN MANAGEMENT: - It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". - Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your surgeon. -You will receive a prescription from your surgeon for pain medicine to take by mouth. It is important to take this medicine as directied. - Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. - Your pain medicine will work better if you take it before your pain gets too severe. - Talk with your surgeon about how long you will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your surgeon has said its okay. - If you are experiencing no pain, it is okay to skip a dose of pain medicine. - Remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the folloiwng, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: - Take all the medicines you were on before the operation just as you did before, unless you have been told differently. - If you have any questions about what medicine to take or not to take, please call your surgeon. Followup Instructions: ___
10165018-DS-15
10,165,018
23,251,005
DS
15
2132-07-07 00:00:00
2132-07-09 09:07:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: hemoptysis Major Surgical or Invasive Procedure: rigid bronschoscopy x 2 broncholith resection and biopsy lymph node biopsy History of Present Illness: ___ year old F with no significant past pulmonary history who was admitted to ___ on ___ with increasing hemoptysis. She was recently admitted to ___ with fevers, neck stiffness, chest pain, and headache. She underwent an extensive work-and treated empirically for CAP. She was thought to have had a viral infection. . Since she has left the hospital, she has continued to have fever, night sweats, and has had 8lbs weight loss. She has also in the last week developed hemopysis. She first noted one episode one week ago. She had recurrent episodes three days, every night this week. Episodes occurred at night so she was unable to quanititate the amount of blood loss, until the day of admission when she had two episodes of approximately ___ cup of bright red blood. Patient reports today that the volume of blood did not change over the course of the week, and was more concerned about the increasing frequency of symptoms. However, per HCA note on ___ patient as reporting one tablespoon of hemoptysis prior to recent outpatient visit. Patient denies any chest pain, shortness of breath. She denies , nausea, vomiting, hematemesis, or blood in stools. . Of note, patient's recent evaluation for fevers, chest pain, headache and neck stiffness eventually attributed for viral syndrome included the following workup. She underwent extensive workup including rule out for ACS, CHF, PE, and pericardial effusion. She also had an extensive infectious workup with head and neck imaging, EGD, fiberoptic endoscopy, LP which were overall unrevealing. CT chest showed evidence calcified lymph nodes near the airways suggestive of prior histoplasmosis. Patient as treated for CAP with ceftriaxone and azithromycin. She was followed by the ID team. . In the ED, initial VS were stable. She was initially admitted to the medical floor. She was evaluated by pulmonology, however given increasing volume of hemoptysis, patient was transferred to the MICU for monitoring. . On arrival to the MICU, patient appeared well, complained of a headache and mild nausea without emesis. Bedside basin with three to four quarter sized block clots from hemoptysis. She was shortly after taken away for CT Chest. . Review of systems: (+) Per HPI (-) Denies sinus tenderness, rhinorrhea or congestion. Denies shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies vomiting, diarrhea, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. . Past Medical History: - Duodenitis - Tonsillectomy at age ___ Social History: ___ Family History: - Schizophrenia - No heart disease - No lung disease - No cancer - unknown if vasculitis. Physical Exam: ADMISSION EXAM: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation DISCHARGE EXAM: afebrile, SBP 110s/70s, HR 70-80s, 96 RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: ___ 07:50PM BLOOD WBC-11.0 RBC-3.66* Hgb-10.8* Hct-33.8* MCV-92 MCH-29.6 MCHC-32.1 RDW-13.3 Plt ___ ___ 07:50PM BLOOD Neuts-83.4* Lymphs-11.0* Monos-4.8 Eos-0.5 Baso-0.3 ___ 07:50PM BLOOD ___ PTT-31.6 ___ ___ 07:50PM BLOOD Glucose-97 UreaN-15 Creat-0.7 Na-136 K-3.8 Cl-103 HCO3-23 AnGap-14 ___ 07:50PM BLOOD ALT-10 AST-15 LD(LDH)-167 AlkPhos-67 TotBili-0.3 ___ 07:00AM BLOOD Calcium-8.2* Phos-2.9 Mg-1.7 ___ 10:57PM BLOOD ANCA-POSITIVE * ___ 10:57PM BLOOD ___ ___ 08:00PM BLOOD Lactate-0.8 CXR ___: IMPRESSION: Findings suggestive of right lower lobe pneumonia. CT TORSO ___: IMPRESSION: 1. No evidence of pulmonary embolism. 2. Increase in size of partly calcified subcarinal lymph node, new partly Preliminary Reportcalcified right hilar lymph node and right infrahilar lymph node. 3. New consolidation involving the anterior basal segment of the right lower Preliminary Reportlobe. 4. Multiple peribronchial opacities and multiple ___ opacities Preliminary Reportthroughout the right lobe which is a nonspecific finding which has a wide differential including infection. 5. Multiple areas of ground-glass opacity diffusely throughout the right lung. 6. Interval decrease in size of right pleural effusion. RIGID BRONCH ___: ___ yo female with likely fibrosing mediastinitis and submassive hemoptysis underwent Rigid bronchoscopy, flexible bronchoscopy, showing Splayed main and right main carinas. At the distal BI, there was a rounded area of mucosal extrinsic compression that bled easily to light bronchoscopic contact. Evaluation of all airways to subsegmental level and with application of suction did not show evidence of parenchymal origin of hemoptysis. There was no evidence of a broncholith and no endobronchial lesions or thrombus. EBUS showed a large calcified station 7 node, not sampled. Station 11R enlarged lymph node underwent EBUS TBNA with minimal bleeding. Argon plasma coagulation to the mucosa at the BI that was bleeding was used to control bleeding with complete hemostasis. MRI HEAD: Normal brain MRI. No evidence of infection or mass. FLOW CYTOMETRY IMMUNOPHENOTYPING The following tests (antibodies) were performed: ___, ___-7, Kappa, Lambda, 2, 3, 4, 5, 7, 8, 10, 16, 19, 20, 23, 45 and 56. RESULTS: Three color gating is performed (light scatter vs. CD45) to optimize lymphocyte yield. T cells comprise 90% of lymphoid gated events. INTERPRETATION Non-specific T cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by leukemia/lymphoma are not seen in specimen. Correlation with clinical findings and morphology (see ___ is recommended. Flow cytometry immunophenotyping may not detect all lymphomas due to topography, sampling or artifacts of sample preparation. RIGHT BRONCH INTERMEDIUS BX: Right bronchus intermedius endobronchial lesion, biopsy: - Bronchial mucosa with ulceration and squamous metaplasia of the respiratory epithelium; see note. EBUS-TBNA, Lymph node 11R: NEGATIVE FOR MALIGNANT CELLS. Polymorphous lymphocytes, consistent with lymph node sampling. Bronchial cells. DISCHARGE LABS: ___ 07:00AM BLOOD WBC-6.6 RBC-3.52* Hgb-10.3* Hct-32.9* MCV-94 MCH-29.3 MCHC-31.3 RDW-13.7 Plt ___ ___ 06:45AM BLOOD Neuts-64.6 ___ Monos-5.0 Eos-2.6 Baso-0.6 ___ 07:00AM BLOOD Glucose-88 UreaN-13 Creat-0.7 Na-138 K-4.1 Cl-103 HCO3-27 AnGap-12 ___ 07:00AM BLOOD Calcium-8.8 Phos-3.9 Mg-2.0 OTHER TESTS: ___ 06:45AM BLOOD HCG-<5 ___ 07:00AM BLOOD ANCA-PND ___ 10:57PM BLOOD ANCA-POSITIVE * ___ 06:45AM BLOOD AFP-1.8 ___ 10:57PM BLOOD ___ MICRO: ___ 11:53AM URINE HISTOPLASMA ANTIGEN-NEG ___ 03:10PM OTHER BODY FLUID UNIVERSAL PCR FOR FUNGI-PND ___ 03:10PM OTHER BODY FLUID UNIVERSAL PCR FOR BACTERIA-PND ___ 03:10PM OTHER BODY FLUID UNIVERSAL PCR FOR AFB-PND ___ 3:10 pm TISSUE (R) BRONDUS INTERMEDIUS ENDOBRONCHIAL LESION SUSPECTED HYSTO. GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): POTASSIUM HYDROXIDE PREPARATION (Final ___: TEST CANCELLED, PATIENT CREDITED. Log In error TEST NOT ON REQUISITION. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. Time Taken Not Noted Log-In Date/Time: ___ 11:19 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. ___ 6:44 pm TISSUE IIR EBUS TBNA. GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ___ SEROLOGY/BLOOD CRYPTOCOCCAL ANTIGEN-NEG ___ BLOOD CULTURE Blood Culture, Routine- NEG ___ BLOOD CULTURE Blood Culture, Routine-NEG Brief Hospital Course: ___ year old female with calcified pulmonary lumph nodes and moderate hemoptysis concerning for chronic histoplasmosis # Hemoptysis: Pt presented with hemoptysis, and transferred to the MICU for monitoring shortly after arrival. She subsequently underwent CT torso on ___ which showed increase in size of partly calcified subcarinal lymph node, as well as a new partly calcified right hilar lymph node and right infrahilar lymph node. It was generally thought that this could be a presentation of histoplasmosis, perhaps on some spectrum of fibrosing mediastinitis vs mediastinal granuloma as opposed to active pulmonary histo. She underwent bronchoscopy on ___ which revealed a rounded area of mucosal extrinsic compression in the distal bronchus intermedius that bled easily to light bronchoscopic contact. This could also be seen on the CT and was consistent with a broncholith extruding from the calcified subcarinal lymph node. Evaluation of all airways to subsegmental level and with application of suction did not show evidence of parenchymal origin of hemoptysis. She underwent biopsy of a station 11R enlarged lymph node with minimal bleeding. She underwent Argon plasma coagulation to the mucosa at the bronchus intermedius with hemostasis. Biopsies were taken and showd normal lymph node tissue. She was transferred to the floor after this procedure where she remained stable and her hemoptysis had decreased to scant amounts. Consults were obtained from ID, pulm, IP, and CT surgery and extensive discussions were held regarding the likely underlying etiology of the mediastinal process and the risk of bleeding if broncholith was fully resected. Since the area had only been cauterized as a temporizing measure, it was considered likely that bleeding would recur due to the continued presence of the broncholith underlying the eroded airway. IP returned for second bronchoscopy on ___ in an effort to resect the broncholith in the most minimally invasive approach. Broncholith was removed and sent for path and the underlying subcarinal node was biopsied. The area was cauterized. Her hemoptysis resolved after this measure. The path report on the biopsy was unremarkable, showing ulcerated mucosa, extensive granulation tissue but no granulomas, and no evidence of viral inclusions. It was sent for special stains and universal PCR on viruses, bacteria, and fungus which were pending at the time of discharge. Extensive discussion was held with ID (involving outside consultation to specialist in histoplasmosis) and determination was made that this was most likely a form of mediastinal granuloma secondary to histoplasmosis. Work up had been negative for malignancy, including bHCG, AFP, and LDH to r/o germ cell tumor. PPD neg x 2. While the histoplasma ab and ag tests were negative except for one mildly positive yeast phase antibody during her first hospitalization, these tests lack sensitivity and numerous ID physicians agreed that a floridly positive serology panel was not required to make the diagnosis of histoplasma. Due to the calcifications, the process seemed to be rather long-standing, however, her presentation was relatively acute (past 2 months) and had, in fact, developed new calcifications over the course of a few weeks on CT. Therefore, it is difficult to say if this was entirely acute or something acute on top of a chronic process. She grew up in ___ so could have been exposed to histo decades ago. One possible explanation proposed was that the calcified subcarinal node was chronic, but had enlarged and ruptured, leading to acute inflammation, fevers, chest pain, and protrusion of and subsequent growth of the broncholith into the airway that led to her hemoptysis. After extensive discussion, decision was made to treat with itraconazole empirically despite the negative serologies for the reasons above. Per ID, some people with mediastinal granuloma will respond to the therapy and experience shrinkage of the nodes. She was started on itraconazole and counseled on proper use and potential interactions. She will follow up with her PCP, IP for repeat bronchi in 6 weeks, CT surg in 3 weeks, and ID for routine blood tests on itraconazole. She felt well at the time of discharge. # PNA: due to fevers and new ground glass opacities and consolidations on CT, pt was suspected to have a post-obstructive PNA in the setting of compressive hilar lymphadenopathy. She was given a 5 day course of levofloxacin. Her fevers had resolved and she felt better. # Coagulopathy: pt had slight elevation of INR in house, thought to be nutritional deficiency ___ prolonged illness. She was vitamin K in the MICU and her INR normalized. # Headache: pt complained of chronic HA while in house. She states the HA began about 2 months ago and was present before the first hospitalization. At that time she had a CT sinus that was negative and an LP which was negative. Due to the chronic nature of her HA, an MRI was obtained during this hospitalization to rule out CNS disease and was normal. She variably described it as a facial pain on the right vs bifrontal ache. She was tried on gabapentin due to suspicion for trigeminal neuralgia for the right facial pain but this did not improve her symptoms. She had also tried tylenol, NSAIDs, fiorecet, and oxycodone throughout her hospitalization to little effect. Ultimately no cause was identified and it was thought that this may be ___ chronic illness/inflammatory state with a possible rebound component in the setting of frequent analgesic use. TRANSITIONAL ISSUES: - follow up final pathology special stains and universal PCR for bacteria, fungus, and virus on biopsy specimen - cont itraconazole for ___ months per ID with routine blood work per their recs - follow up with CT surgery in 3 weeks - follow up with IP for repeat bronchoscopy in 6 weeks (___) - repeat CT chest in 3 months (___) - repeat echocardiogram in 6 months (___) - follow up for improvement of HA and consider withdrawal of all pain medication if suspect rebound HA Medications on Admission: - Omeprazole 20mg daily - Motrin prn Discharge Medications: 1. itraconazole 100 mg Capsule Sig: Two (2) Capsule PO as directed for 6 months: Take 2 tabs three times a day until the evening of ___. Take 2 tabs twice daily after that. Disp:*120 Capsule(s)* Refills:*0* 2. tramadol 50 mg Tablet Sig: One (1) Tablet PO every ___ hours as needed for pain. Disp:*21 Tablet(s)* Refills:*0* 3. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily) as needed for constipation. Disp:*30 Powder in Packet(s)* Refills:*0* 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. Disp:*60 Tablet(s)* Refills:*0* 6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Mediastinal Granuloma secondary to Histoplasmosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came to the hospital because you were coughing up blood. You were evaluated with bronchoscopy and found to have a calcified mass eroding into your bronchus, causing the bleeding. This was removed and the area was cauterized to prevent further bleeding. The tissue was sent to pathology and was unremarkable. It was also sent for special studies to evaluate for infection, which are pending. It is most likely that this was caused by histoplasmosis, so you were started on itraconazole to treat this. You should always take this medication with something acidic, such as coke AND orange juice (alternatively you could drink orangina), to improve the absorption. You should avoid alcohol while on this medication, because it can be toxic to your liver. Do not start ANY other medications while you are on itraconazole without talking to your doctor due to the high risk of medication interactions on this. Your new medication list is attached. Please note that omeprazole has been stopped. Followup Instructions: ___
10165220-DS-27
10,165,220
23,060,728
DS
27
2148-05-27 00:00:00
2148-05-27 18:35:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: finger pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ with IDDM, 1 month post I&D of volar sheath and soft tissue of right index finger, presents with increasing redness, pain and swelling of the same digit. She initially presented with this complaint on ___ of this year at which time she was found to have an infection of the soft tissue of the right index finger. I&D was performed with some success, although she required re-exploration and drainage 1 week later on ___. She then underwent antibiotic therapy with Bactrim and Augmentin for 10 days after discharge. She completed this therapy with good results. On ___, she was noted to have no further erythema or pain at the site, although she did have stiffening of the MCP and PIP joints. The day prior to admission she noted increasing pain and swelling, particularly over the PIP joint. She denies any new trauma, and in fact cannot recall any trauma a month ago that initiated this infection. She denies any other pain, chills, fever, or other joint involvement. On arrival to the ED, her initial vitals were 97.0 113 141/70 16 97% RA. Labs revealed a lactate of 3.5. XR hand revealed signs of osteomyelitis. Hand Surgery saw the patient in the ED and recommended IV antibiotics and planned amputation. On arrival to the floor she complains of pain in the finger, but is otherwise in her normal state of good health. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies shortness of breath, cough, dyspnea or wheezing. Denies chest pain, chest pressure, palpitations. Denies constipation, abdominal pain, diarrhea, dark or bloody stools. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: IDDM (Dx ___ Diabetic retinopathy Anxiety Hypertension Atypical ductal hyperplasia of breast Depression Panic Attacks Hemorrhoid Hyperlipidemia (___) Stress incontinence Multiple falls, unclear etiology s/p Left Total Knee Replacement s/p cholecystectomy (___) s/p partial hysterectomy s/p right finger I&D (___) s/p b/l cataracts Social History: ___ Family History: Father with esophageal ___, Mother with ___, Grandfather with DM. No other family history of cancer or heart disease Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.6 113/58 85 18 95% RA weight 101.1kg FSBS 141 GENERAL: NAD, awake and alert HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva, patent nares, MMM, OP clear, good dentition NECK: nontender and supple, no LAD, no JVD CARDIAC: RRR, nl S1 S2, no MRG LUNG: CTAB, no rales wheezes or rhonchi, no accessory muscle use ABDOMEN: +BS, soft, non-tender, non-distended, no rebound or guarding, no HSM EXT: warm and well-perfused, no cyanosis, clubbing or edema RUE ___ finger very swollen, erythematous, and painful on the dorsal surface extending from the DIP to just proximal to PIP, no involvement of MCP. Skin intact to exam. PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII tested and intact, strength ___ throughout, sensation grossly normal, gait not tested SKIN: warm and well perfused, no excoriations or lesions (other than finger noted above), no rashes DISCHARGE PHYSICAL EXAM: HEENT: NC/AT, EOMI, PERRL, anicteric sclerae, MMM, OP clear CV: RRR, nl S1 S2, no MRG Resp: CTAB, no rales wheezes or ronchi Abd: soft, non-tender, non-distended Ext: warm, well-perfused, no cyanosis clubbing or edema save for RUE ___ finger. This finger is swollen, erythematous and painful as described on admission exam with slight improvement in degree of swelling and erythema. Pertinent Results: Admission Labs: ___ 02:20PM BLOOD WBC-8.4 RBC-4.77 Hgb-13.1 Hct-41.1 MCV-86 MCH-27.6 MCHC-32.0 RDW-14.0 Plt ___ ___ 02:20PM BLOOD Neuts-55.6 ___ Monos-3.5 Eos-4.6* Baso-0.9 ___ 02:20PM BLOOD Glucose-242* UreaN-20 Creat-0.8 Na-132* K-4.3 Cl-95* HCO3-24 AnGap-17 ___ 02:39PM BLOOD Lactate-3.5* Interim Labs: ___ 08:00AM BLOOD ___ PTT-27.2 ___ ___ 08:00AM BLOOD ESR-20 ___ 08:00AM BLOOD CRP-18.1* ___ 08:00AM BLOOD Osmolal-294 ___ 07:10AM BLOOD Vanco-9.5* ___ 09:01PM URINE Color-Yellow Appear-Cloudy Sp ___ ___ 09:01PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-1000 Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG ___ 09:01PM URINE RBC-6* WBC->182* Bacteri-MANY Yeast-NONE Epi-1 ___ 09:01PM URINE Hours-RANDOM Creat-103 Na-58 K-45 Cl-36 TotProt-25 Prot/Cr-0.2 ___ 09:01PM URINE Osmolal-626 Discharge Labs: ___ 06:18AM BLOOD WBC-5.6 RBC-4.20 Hgb-11.7* Hct-36.4 MCV-87 MCH-27.8 MCHC-32.1 RDW-14.0 Plt ___ ___ 06:18AM BLOOD Neuts-45.6* ___ Monos-3.6 Eos-7.7* Baso-1.1 ___ 06:18AM BLOOD Glucose-251* UreaN-17 Creat-0.6 Na-133 K-4.3 Cl-97 HCO3-27 AnGap-13 ___ 06:18AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.0 Microbiology: urine culture ___ negative blood cultures ___ pending, NGTD ___ 4:10 pm SWAB JOINT FLUID. **FINAL REPORT ___ GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final ___: A swab is not the optimal specimen collection to evaluate body fluids. Reported to and read back by ___ ___ ___ 220PM. STAPH AUREUS COAG +. SPARSE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _____________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=0.5 S Imaging: Finger XR ___: FINDINGS: There is increased lucency at the second proximal interphalangeal joint with worsening joint space narrowing, cortical irregularity of the distal aspect of the proximal phalanx and base of the middle phalanx, and increased surrounding soft tissue swelling. No acute fracture or dislocation is detected, but there may be increased ulnar subluxation of the joint. Degenerative changes of the PIP and DIP joints are noted with osteophyte formation and joint space narrowing. IMPRESSION: Findings highly concerning for osteomyelitis and septic joint of the second PIP joint. Brief Hospital Course: ___ with IDDM, 1 month post I&D of volar sheath and soft tissue of right index finger, presents with increasing redness, pain and swelling of the same digit and radiographic evidence of osteomyelitis. # Finger osteomyelitis: The patient is s/p 2 I&Ds, treatment course with Bactrim/Augmentin. Prior cultures grew MRSA. Despite good medical therapy her infection has recurred in the DIP joint with XR evidence of osteomyelitis. Lactate was elevated in the ED, indicating severe infection. CRP elevated. Her joint was drained in the ED and cultures sent that grew MRSA, consistent with prior infection. She is at risk for polymicrobial infection given her poorly-controlled diabetes, thus she was treated with Zosyn in addition to vancomycin for MRSA. Hand Surgery followed the patient and preferred to avoid amputation if possible given the high morbidity of losing an index finger in this young and highly functional patient. As her infection did not disseminate or worsen after IV ABX, they suggested discharge with long-term IV antibiotics and close follow-up. Infectious Disease was consulted to set up outpatient antibiotics. Given her risk of renal dysfunction, they recommended switching to daptomycin for long-term antibiotic therapy. This was started the evening of ___. Home antibiotic therapy was set up with regular lab monitoring by the Infectious Disease outpatient antibiotics clinic. # IDDM: Last A1c 10.5% in ___. Prior to that she has had periods of better control, but this has been a continued challenge for the patient. As an inpatient her FSBS ranged from 160-250, largely due to reduced Lantus dosing from periodic NPO status as well as holding metformin. She will require close outpatient management to reduce her HbA1c to aid healing and prevent further infection. Continued her lisinopril. # Hyponatremia: Most likely hypovolemic given recent pain and finger injury. She resolved with IVF and increase PO intake. # Eosinophilia: 4.6% eosinophils on peripheral smear may be consistent with allergy or asthma. She had no symptoms. On discharge labs she continued to have peripheral eosinophilia, unlikely related to antibiotics given timing and lack of symptoms. Daptomycin is not typically associated with eosinophilia. # HTN: Well-controlled on lisinopril. Continued home ASA. # HLD: Total cholesterol elevated to 236 in ___ (HDL 67, LDL 90). Continued statin. # Anxiety: Episodes of panic attacks, managed by clonazepam at home. This was continued as inpatient. # Depression: Continued home fluoxetine, imipramine. # Code: FULL Transitional Issues: - long-term home antibiotic therapy with follow-up by Infectious Disease and Hand Surgery - improve diabetes control given recent elevated HbA1c and risk of infection Medications on Admission: CLONAZEPAM 2 mg four times a day, usually takes ___ times/day FLUOXETINE 60 mg daily IMIPRAMINE 300 mg at bedtime NOVOLOG 15 units TID LEVEMIR 35 units BID LISINOPRIL 30 mg daily METFORMIN 1000 mg BID SIMVASTATIN 20 mg daily ASPIRIN 81 mg daily Discharge Medications: 1. clonazepam 1 mg Tablet Sig: Two (2) Tablet PO every six (6) hours as needed for anxiety. 2. fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 3. imipramine HCl 50 mg Tablet Sig: Six (6) Tablet PO at bedtime. 4. Novolog 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous three times a day. 5. Levemir 100 unit/mL Solution Sig: ___ (35) units Subcutaneous twice a day. 6. lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day. 7. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 8. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain: no more than 9 tablets / day. Disp:*300 Tablet(s)* Refills:*0* 11. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush for 4 weeks. Disp:*48 ml* Refills:*0* 12. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 13. daptomycin 500 mg Recon Soln Sig: Six Hundred (600) mg Intravenous Q24H (every 24 hours) for 6 weeks. ___ mg* Refills:*0* 14. Outpatient Lab Work Weekly lab draw: CBC with diff, Chem7, AST, ALT, Alk Phos, total bili, CPK, ESR, CRP. FAX results to ___. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: osteomyelitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you at ___ ___. You came to the hospital with a recurrent infection of your right index finger. You were evaluated by the Plastic Surgery team who had previously drained this infection. You were provided IV antibiotics to attempt to treat the infection medically without amputation. We made the following changes to your medications: - START daptomycin, an IV antibiotic to treat MRSA infection The course of this antibiotic will be adjusted by the Infectious Disease clinic in cooperation with the hand surgeons. - START Tylenol for pain, no more than 3 g/day - START oxycodone as needed for pain; please use Tylenol first Please follow-up with your physicians as listed below. Followup Instructions: ___
10165220-DS-28
10,165,220
22,079,223
DS
28
2150-11-12 00:00:00
2150-11-14 20:54:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: lisinopril / Glucophage Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ year old woman with very poorly controlled type 2 diabetes (a1c 9.7), obesity, hypertension, depression, known portal vein thrombosis (not on anticoagulation per Dr. ___ in Heme/Onc) who presented to the ED with sudden onset lower pelvic pain radiating to epigastric area beginning around 9pm ___. Pt reports pain is crampy and constant, originally in her mid abdomen, now mostly her lower abdomen. Has had frequent small loose bowel movements. Yesterday felt nauseous but this has resolved. Several of her grandchildren are sick with n/v/d. No recent antibiotic use. Denies f/c/s, cp/sob, urinary sx. Denies blood in stool or melena. Denies etoh. In the ED initial vitals were: 96.6 76 139/68 14 97% 2L - Labs were significant for normal white count, mildly elevated transaminiases (AST 52, ALT 41), lipase 206 and bicarbonate 19. Lactate was 2.3. - CT Abd/Pelvis with contrast showed: changes consistent with colitis; stable nonocclusive thrombus within the right posterior and anterior portal veins; hepatic steatosis and no inflammatory changes surroudning the pancreas - Patient was given 4mg zofran and 1L LR Vitals prior to transfer were: 98 97 155/77 16 93% RA On the floor continues to have ___ lower abdominal pain, no new complaints. Review of Systems: (+) per HPI (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: IDDM (Dx ___ c/b osteomyelitis (s/p amputation of right index finger), neuropathy; she sees Dr. ___ at the ___ ___ Portal vein thrombosis - not on anticoagulation, stable, unclear etiology of hypercoagulability Diabetic retinopathy Anxiety Hypertension Atypical ductal hyperplasia of breast Depression Panic Attacks Hemorrhoid Hyperlipidemia (___) Stress incontinence Multiple falls, unclear etiology Achilles tendonitis s/p Left Total Knee Replacement s/p cholecystectomy (___) s/p partial hysterectomy s/p right finger I&D (___) s/p b/l cataracts Social History: ___ Family History: Father with esophageal ___, Mother with ___, Grandfather with DM. No other family history of cancer or heart disease Physical Exam: ADMISSION PHYSICAL EXAM: ================== Vitals - 98 97 155/77 16 93% RA GENERAL: WD, NAD, laying in bed HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, dry mouth, good dentition NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, ___ systolic murmur upper sternal border, gallops, or rubs LUNG: CTAB anteriorly ABDOMEN: nondistended, +BS, mildly ttp in lower abdomen, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: =================== VSS Gen: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, dry mouth NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no M/R/G/C LUNG: CTAB anteriorly ABDOMEN: nondistended, +BS, mildly ttp in lower abdomen, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS ============= ___ 11:20PM BLOOD WBC-9.0# RBC-4.89 Hgb-14.1 Hct-43.2 MCV-88 MCH-28.8 MCHC-32.6 RDW-13.3 Plt ___ ___ 11:20PM BLOOD Neuts-54.9 ___ Monos-6.7 Eos-1.3 Baso-1.1 ___ 11:20PM BLOOD Glucose-239* UreaN-20 Creat-0.9 Na-134 K-3.8 Cl-98 HCO3-19* AnGap-21* ___ 11:20PM BLOOD ALT-41* AST-52* AlkPhos-71 TotBili-0.2 ___ 11:20PM BLOOD Lipase-206* ___ 04:47AM BLOOD Lactate-2.3* NOTABLE LABS =========== ___ 08:10PM BLOOD WBC-11.4* RBC-4.49 Hgb-12.7 Hct-38.8 MCV-86 MCH-28.4 MCHC-32.9 RDW-13.3 Plt ___ ___ 07:00AM BLOOD WBC-8.8 RBC-4.03* Hgb-11.4* Hct-36.0 MCV-89 MCH-28.4 MCHC-31.8 RDW-13.3 Plt ___ ___ 09:11AM BLOOD ALT-41* AST-35 AlkPhos-75 TotBili-0.4 ___ 09:11AM BLOOD Lipase-19 ___ 08:49AM BLOOD Lactate-1.3 DISCHARGE LABS ============= ___ 03:55PM BLOOD WBC-6.8 RBC-4.08* Hgb-11.8* Hct-36.1 MCV-89 MCH-28.9 MCHC-32.7 RDW-13.1 Plt ___ ___ 03:55PM BLOOD Glucose-142* UreaN-11 Creat-0.7 Na-140 K-3.4 Cl-102 HCO3-29 AnGap-12 STUDIES ====== CT ABD/PELVIS (___) 1. Thickened bowel wall of the distal descending and sigmoid colon with surrounding inflammatory changes consistent with colitis. This is a nonspecific finding which includes infectious, ischemic and inflammatory etiologies. Recommend follow up to resolution to exclude underlying malignancy. 2. Pancreatic cystic lesion previously characterized on MR to most likely represent serous microcytic pancreatic adenoma, stable in size. No pancreatic ductal dilation or surrounding inflammatory changes. 3. Stable nonocclusive thrombus within the right posterior and anterior portal veins. 4. Hepatic segment VI focal 1.5cm ill defined hypodensity not fully characterized on current examination and not definitely appreciated on prior MR dated ___. Nonemergent ultrasound is recommended as a first step for further evaluation. 5. Hepatic steatosis. 6. Several collateral vessels along the left aorta and left kidney incidentally noted as well as retroperitoneal stranding. Retroperitoneal fibrosis should be considered and if symptoms persist, follow up CT in 6 months time is recommended. Brief Hospital Course: BRIEF SUMMARY STATEMENT: Ms. ___ is a ___ year old female with PMH obesity, poorly controlled type 2 DM, HTN, HLD, and previous cholecystectomy who presents with acute onset abdominal pain, loose stools found to have evidence of colitis on CT Abd/Pelvis. Of note, pt. had spent significant time with grandchildren with recent GI illnesses. During hospital course, pt. developed several episodes of BRBPR, concerning for hemorrhagic infectious colitis. ACS was consulted and were not concerned for ischemic colitis at this time. Pt. was started on ciprofloxacin with rapid improvement in symptoms. She was discharged with close outpatient follow-up. ACTIVE ISSUES ================ # Infectious Hemorrhagic Colitis: Pt. presented with abdominal pain. CT scan showed evidence of colitis in the sigmoid colon. Given multiple sick contacts with similar symptoms, her presentation was thought ___ infectious colitis. Overnight into second hospital day, pt. had several bowel movements of BRBPR. At that time, ACS evaluated the pt. and felt there was no evidence for ischemic colitis or surgical intervention. As such, she was started on ciprofloxacin with marked improvement in abdominal pain and bloody diarrhea. By time of discharge, pt's vitals and H/H were stable. She was tolerating PO without difficulty and discharged on a 5 day course of ciprofloxacin. CHRONIC ISSUES ================ # DM: Continued on home insulin regimen. # HTN: Initially held losartan, restarted on discharge. # Depression/Insomnia: Stable. Continued on fluoxetine, imipramine, clonazepam. # Stroke/CAD Prevention: Continued on aspirin 81 daily. TRANSITIONAL ISSUES ===================== # Infectious colitis: CT Abd Pelvis showed thickened bowel wall of the distal descending and sigmoid colon with surrounding inflammatory changes. Given pt's age, would recommend follow-up to resolution to exclude underlying malignancy. # Antibiotic Course: Continue ciprofloxacin for total of 5 day course through ___. # Incidental Findings on CT Abd/Pelvis: 1) Hepatic segment VI focal 1.5cm ill defined hypodensity not fully characterized on current examination and not definitely appreciated on prior MR dated ___. Nonemergent ultrasound is recommended as a first step for further evaluation. 2) Several collateral vessels along the left aorta and left kidney incidentally noted as well as retroperitoneal stranding. Retroperitoneal fibrosis should be considered and if symptoms persist, follow up CT in 6 months time is recommended. #Code: Full, confirmed #Emergency Contact: Daughter, ___ ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. ClonazePAM 2 mg PO QID 2. Fluoxetine 60 mg PO DAILY 3. Imipramine 150 mg PO HS 4. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous 0.3mL daily 5. Losartan Potassium 25 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Humalog 30 Units Breakfast Humalog 30 Units Lunch Humalog 30 Units Dinner Levemir 35 Units Breakfast Levemir 35 Units Dinner 8. fenofibrate nanocrystallized 145 mg oral by mouth daily Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. ClonazePAM 2 mg PO QID 3. Fluoxetine 60 mg PO DAILY 4. Imipramine 150 mg PO HS 5. Humalog 30 Units Breakfast Humalog 30 Units Lunch Humalog 30 Units Dinner Levemir 35 Units Breakfast Levemir 35 Units Dinner 6. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp #*5 Tablet Refills:*0 7. fenofibrate nanocrystallized 145 mg oral by mouth daily 8. liraglutide 0.6 (18 mg/3 mL) SUBCUTANEOUS 0.3ML DAILY 9. Losartan Potassium 25 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES ================== Infectious Hemorrhagic Colitis SECONDARY DIAGNOSES =================== Diabetes Hypertension Depression Anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, It was a pleasure caring for you during your recent hospitalization at ___ ___. You were admitted with abdominal pain. A CT scan of your belly showed some inflammation in your colon. Given your history of expsoure to your grandchildren who have similar symptoms and your CT scan, we diagnosed you with a GI infection. Because you developed bloody diarrhea, your infection may have been caused by a bacteria. As such, we started you on an antibiotic, ciprofloxacin. Please continue this antibiotic through ___. If you develop fevers, worsening symptoms, or continue to have symptoms following completion of the medication please contact your doctor immediately. We wish you a speedy recory and all the best, Your ___ Care Team Followup Instructions: ___
10165494-DS-25
10,165,494
21,439,323
DS
25
2198-11-17 00:00:00
2198-11-21 22:35:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Beta-Blockers (Beta-Adrenergic Blocking Agts) / Ciprofloxacin / ceftriaxone Attending: ___. Chief Complaint: nausea, vomiting, lightheadedness Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ with history of psoriatic arthritis, CKD, CAD s/p PCI in ___, afib (on ___) who presents from cardiology clinic with nausea, vomiting, and lightheadedness. She presented to her PCP's office on ___ with complaints of intermittent nausea, fatigue, and SOB for 3 months. Bloodwork on ___ revealed WBC 17.2 and UA showed large leuks, mod bacteria, and 85 WBC. Antibiotic choice was complicated by co-morbid illness and allergies: she is allergic to cipro and PCN. Macrodantin was contraindicated due to CKD. Bactrim, even renally dosed, could not be given with lisinopril due to risk of hyperkalemia. Her cipro allergy was reported to be skin peeling. After discussion with patient, decision was made to begin levofloxacin 750mgs every 48 hours for 3 doses under close supervision. She took her first dose on ___. On ___ she presented to cardiology clinic and reported continued nausea and increased SOB with exertion. She denied syncope, orthopnea, and PND. She was found to be hypotensive (87/54 repeat 100/54), began vomiting, and was sent to the ED. In the ED, initial VS were 97.6 80 92/41 16 100%. Physical exam significant for severe psoriatic excoriations, cardiopulmonary exam WNL, abdomen soft and benign, no elevated JVD or lower extremity edema. CXR was without evidence of infection or pulmonary edema. CT head was obtained (due to sub-acute history of nausea) which showed no acute abnormality. Labs significant for leukocytosis to 16 (86% N) and elevated Cr to 3.8 (baseline 2.2). She was given IV ceftriaxone x 1 and 500 cc IV fluids. Vitals on transfer were: 98.0 67 113/44 16 96% RA. Upon arrival to the floor, the patient reports feeling better. She denies any recent dysuria, urgency, or frequency. She denies any more vomiting since this morning. She endorses some constipation, with no bowel movement for the past 2 days. She denies any fevers or chills. She does report increased weakness and shortness of breath over the past few weeks per above. Past Medical History: - CAD: IMI with PCI to PDA ___, re thrombosis and restenting in past - AFib: s/p TEE and DCCV in ___, on rivaroxiban - CHF: Echo ___ with mild LV systolic dysfunction (EF 45%) c/w CAD. Mild mitral regurgitation. Mild pulmonary artery systolic hypertension. Metoprolol and lasix increased at that point. - CKD Stage IV: Secondary to analgesic nephropathy. Baseline Cr ~2. - Psoriasis and Psoriatic arthritis: Was previously on etanercept and methotrexate. Trialed on Remicade but with allergic reaction. Will resume etanercept soon. - Type 2 Diabetes: On glipizide. Last HbA1c 6.2. - Hypertension - HLD - GERD - Obstructive sleep apnea (does not use her CPAP) - Osteoarthritis of the knees s/p left total knee replacement - S/p bilateral carpal tunnel surgery - S/p appendectomy Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Her mother passed away at the age of ___ from heart disease. Her father passed away at the age of ___ from pneumonia. Physical Exam: ADMISSION EXAM: ====================== Vitals: 97.7 122/58 76 16 98/ra GENERAL: NAD, sitting comfortably in bed HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, dry mucous membranes NECK: nontender supple neck, no appreciable JVD CARDIAC: irregular rythym, normal S1/S2, no murmurs rubs or gallops LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose BACK: No CVA tenderness PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact. no asterixis SKIN: diffuse, severe psoriatic lesions throughout the body, with several areas of excoriation and dried blood DISCHARGE EXAM: ======================= Vitals: 98.2 (98.2) 118/53 (100-150/40-50) 72 (50-90) 18 96%RA I/O: 1180/BR // 40/BR Weight: 78.8 kg BS: ___ // 159 GENERAL: NAD, sitting up comfortably in bed. HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, dry mucous membranes NECK: nontender supple neck, no appreciable JVD CARDIAC: irregular rythym, normal S1/S2, no murmurs rubs or gallops LUNG: decreased BS in bases. no crackles ABDOMEN: nondistended, +BS, no ttp, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose BACK: No CVA tenderness PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact. no asterixis SKIN: diffuse, severe psoriatic lesions throughout the body, with several areas of excoriation and dried blood. R arm with demarcated area of erythema with no overlying purulent discharge. abd with chronic scar with granulation tissue Pertinent Results: ADMISSION LABS: ======================= ___ 01:30PM BLOOD WBC-16.2* RBC-3.48* Hgb-11.0* Hct-34.5* MCV-99* MCH-31.6 MCHC-31.9 RDW-12.9 Plt ___ ___ 01:30PM BLOOD Neuts-85.9* Lymphs-7.6* Monos-3.9 Eos-2.2 Baso-0.3 ___ 03:20PM BLOOD ___ PTT-35.2 ___ ___ 01:30PM BLOOD Glucose-120* UreaN-76* Creat-3.8*# Na-137 K-5.6* Cl-95* HCO3-25 AnGap-23* ___ 01:30PM BLOOD ALT-26 AST-27 AlkPhos-82 TotBili-0.4 ___ 01:30PM BLOOD Albumin-3.0* ___ 03:28PM BLOOD Lactate-1.9 PERTINENT LABS: ======================== ___ 05:10PM BLOOD ___ PTT-136.4* ___ ___ 08:00AM BLOOD ___ PTT-62.8* ___ ___ 07:22AM BLOOD Glucose-192* UreaN-63* Creat-2.6* Na-137 K-5.7* Cl-101 HCO3-25 AnGap-17 ___ 07:00AM BLOOD Glucose-141* UreaN-45* Creat-1.7* Na-136 K-5.6* Cl-101 HCO3-26 AnGap-15 ___ 08:00AM BLOOD Glucose-259* UreaN-40* Creat-1.6* Na-138 K-5.2* Cl-100 HCO3-29 AnGap-14 ___ 08:00AM BLOOD Triglyc-57 HDL-35 CHOL/HD-2.4 LDLcalc-38 ___ 12:45PM URINE Color-Yellow Appear-Clear Sp ___ ___ 12:45PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG DISCHARGE LABS: ======================== ___ 08:20AM BLOOD WBC-14.8* RBC-3.36* Hgb-10.8* Hct-31.9* MCV-95 MCH-32.0 MCHC-33.8 RDW-13.5 Plt ___ ___ 08:20AM BLOOD Glucose-134* UreaN-35* Creat-1.4* Na-139 K-4.8 Cl-101 HCO3-28 AnGap-15 ___ 08:20AM BLOOD Calcium-8.9 Phos-3.7 Mg-1.4* IMAGING: ======================== ECG (___): Atrial fibrillation with a controlled ventricular response. Significant artifact. Otherwise, no significant change compared to the previous tracing of ___. CXR (___): No acute intrathoracic process. CT Head (___): 1. No acute intracranial process. 2. Moderate small vessel disease. Gastric Emptying Study (___): IMPRESSION: Probably delayed gastric emptying with some overlap of small bowel and stomach activity making accurate separation of activity in the stomach difficult. MICROBIOLOGY: ======================== ___ 3:10 pm BLOOD CULTURE: NO GROWTH x 2 ___ 1:09 am URINE CULTURE: <10,000 organisms/ml ___ 12:45 pm URINE CULTURE: NO GROWTH ___ 1:10 pm BLOOD CULTURE: NO GROWTH PATHOLOGY: ========================== SKIN BIOPSY: Skin, right forearm, biopsy: - Psoriasiform dermatitis with neutrophils and eosinophils, favor acute generalized exanthomatous pustulosis in a patient with psoriasis. Note: Sections show psoriassiform epidermal hyperplasia with subcorneal and intraepidermal pustules containing neutrrophils. There is also a superficial perivascular infiltrate of lymphocytes, neutrophils and eosinophils. PAS stain is negative for fungi. The presence of eosinophils favors a psoriasiform drug reaction or AGEP in a patient with psoriasis. Brief Hospital Course: This is a ___ yo woman with a history of CAD s/p PCI with CHF, Afib (on xarelto), CKD, psoriasis w/ psoriatic arthritis, and recently diagnosed UTI (___) who presents with several days of nausea, vomiting, and hypotension found to be hypotensive with ___. # nausea/vomiting: Chronic in nature over last ___ months. Patient did endorse symptoms of early satiety and "food getting stuck", thus a gastric emptying studying was performed with evidence of delayed emptying. Throughout her hospitalization, she did not any further episodes of N/V. Patient will follow-up with PCP to determine utility of initiating pro-motility agents #Acute on Chronic Kidney Injury: Cr of 3.8 on admission from baseline ~2 attributed to analgesic-induced nephropathy. Thought to be pre-renal in setting of recent history of vomiting, poor PO intake, and hypotension. SCr continues to improve back to baseline while holding her home lisinopril. #pustular psoriatic Arthritis: She is followed by rheumatology at ___ and dermatology at ___. Given leukocytosis as below, patient was evaluated by dermatology and thought to have worsening pustular psoriasis vs AGEP from ceftriaxone for which a punch skin biopsy was obtained. She was continued on her home clobetasol cream with follow-up with Dr. ___ ___ dermatologist. #leukocytosis: Patient with chronic leukocytosis, however was above baseline of ___. Infectious w/u negative and thought to be from psoriasis. Derm evaluated rash and believe rash is consistent with pustular psoriasis which could explain the elevated WBC with no evidence of overlying cellulitis/infection. #complicated UTI: UA on ___ consistent with cystitis. Given hx of chronic immunosuppresion for psoriasis, she met ___ guidelines for complicated UTI and was treated with CTX however developed rash as described above. Ceftriaxone was then listed as an allergy in setting of AGEP. #Afib: CHADS = 3. Currently in Afib and rate controlled. Anti-coagulation with rivoroxaban which was initially held in setting ___ that was restarted prior to admission. #chronic compensated sCHF: Most recent echo ___ with EF 45% and WMA c/w IMI. Lungs clear. No edema. #Type 2 Diabetes: last A1c 7.4 in ___. - hold home glipizide - HISS Transitional Issues: -given evidence of gastroparesis, would consider initiating a pro-motility agent (Regalan) in the outpatient setting -will need f/u with dermatology for pustular psoriasis and f/u derm biopsy; dermatology team considering starting retinoin therapy per outpatient dermatologist based on skin biopsy -given reaction to CTX, would avoid administering this medication in the future -continue to monitor renal function -home lisinopril held in setting of ___ can consider restarting as outpatient -home HCTZ held in setting of hypotension; can consider restarting as outpatient if BP remain stable or elevated -code status: full -contact: ___ (___) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. Lisinopril 20 mg PO DAILY 3. Sodium Bicarbonate 650 mg PO BID 4. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID as needed for psoriasis, avoid face skin folds and groin 5. Mupirocin Ointment 2% 1 Appl TP BID 6. Metoprolol Succinate XL 100 mg PO DAILY 7. Rivaroxaban 15 mg PO DAILY 8. tacrolimus 0.1 % topical DAILY:PRN psoriasis 9. TraMADOL (Ultram) 50 mg PO 1 TO 2 TABLETS PO FOUR TIMES A DAY 10. Aspirin 81 mg PO DAILY 11. Levofloxacin 750 mg PO Q48H 12. Hydrochlorothiazide 25 mg PO DAILY 13. GlipiZIDE XL 2.5 mg PO DAILY 14. Furosemide 40 mg PO DAILY 15. Vitamin D 50,000 UNIT PO 1X/WEEK (___) 16. Vitamin B Complex 1 CAP PO DAILY 17. Amiodarone 200 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID Apply generously over plaque lesions and wrap with Saran wrap 4. Mupirocin Ointment 2% 1 Appl TP BID apply to open lesion in abdomen 5. Rivaroxaban 15 mg PO DAILY 6. Sodium Bicarbonate 650 mg PO BID 7. TraMADOL (Ultram) 50 mg PO 1 TO 2 TABLETS PO FOUR TIMES A DAY 8. Vitamin B Complex 1 CAP PO DAILY 9. Vitamin D 50,000 UNIT PO 1X/WEEK (___) 10. GlipiZIDE XL 2.5 mg PO DAILY 11. Metoprolol Succinate XL 100 mg PO DAILY 12. tacrolimus 0.1 % topical DAILY:PRN psoriasis 13. Furosemide 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: -acute kidney injury -pustular psoriasis -gastroparesis Secondary Diagnosis: -atrial fibrillation -chronic compensated systolic heart failure -diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at the ___ ___. You came to the hospital with nausea/vomiting. Your lab tests showed that your kidneys were injured, most likely from dehydration. You underwent a test called a gastric emptying study to see if food passed through your stomach appropriately and it showed that there was evidence of slowing of food passing through. This could potentially explain your nausea and vomiting, which improved throughout your hospitalization. You were also evaluated by the dermatologists who recommended continuing your steroid creams with follow-up with your outpatient dermatologist, Dr. ___. Given your reaction to the antibiotic ceftriaxone, please avoid taking this in the future. Please follow-up with the appointments listed below and take your medications as instructed. Wishing you the best, Your ___ team Followup Instructions: ___
10165522-DS-10
10,165,522
26,098,931
DS
10
2154-05-28 00:00:00
2154-05-28 21:05:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Bactrim / Flagyl / Levaquin / Wellbutrin / Amitriptyline / Trazodone / erythromycin / Subutex / Omeprazole / Fioricet / Tricyclic Compounds / Sudafed / Caffeine / Gluten / Cymbalta / lisinopril / Seroquel / Lyrica / clindamycin / Topamax / heparin Attending: ___. Chief Complaint: abdominal pain, weight loss Major Surgical or Invasive Procedure: EGD/colonoscopy ___ Right heart catheterization ___ (swan removed ___ History of Present Illness: ___ year old male with non ischemic cardiomyopathy, HFrEF (EF 17%) s/p ICD ___, afib on apixaban, s/p VT ablation x 2, celiac disease, chronic abdominal pain, presenting with post-prandial abdominal pain. Patient was recently admitted from ___ for CHF exacerbation and acute kidney injury. Patient's discharge weight was 214 pounds, discharge creatinine of 1.2, and he was discharged on bumetanide 4mg PO BID, eplerenone 25mg PO daily, losartan 25mg PO daily, metolazone 2.5mg PO twice per week, metoprolol succinate 75mg PO. He was seen in ___ clinic on ___ where weight was noted to be 206 pounds (below EDW of 212) and Cr was 2.8 with BUN 58, after he had 10mg bumex on ___, metolazone 2.5mg with 100mg lasix on ___, and 8mg bumex on ___. He also felt like he was getting cramping from bumex, and requested to switch back to lasix. He had a diuretic holiday x 1 day, and then was started on lasix 120mg BID, with increase in weight to ~208 pounds. He was then instructed to increase lasix to 160mg BID which he did, however he subsequently developed hypotension and had "ringing in his ears," and thus decreased back to 120mg BID. Two weeks ago, the patient developed nausea and sinus congestion. He had no episodes of emesis or diarrhea. One week ago, the patient saw his PCP, who diagnosed him with a sinus infection and started Augmentin (d1 ___. His sinus symptoms subsequently improved, and patient develop more of an appetite. Around that time, he started developing epigastric and L-sided abdominal pain, which he rated ___. His pain was worse after eating, associated with nausea, and would last for ___ hours. It was alleviated by not eating. He has tried his home sucralfate, antacids, gabapentin, and vicodin, without improvement in the pain. He has been able to have small amounts of water and white rice without severe pain, but more significant meals have caused pain. He has been losing weight and has lost ~9 pounds over the last ___ weeks. He said the pain is similar to his chronic abdominal pain but more severe and constant. He also says it reminds him of the pain he had before his cholecystectomy. He does note that his outpatient GI has mentioned the possibility of chronic mesenteric ischemia to him in the past. He did not take any diuretic over the past two days, and took only 80mg daily on the prior two days. He has not taken his losartan at all over the past week, as his BP has been low. He has been taking his eplerenone and metoprolol. He ran out of apixaban ~3 days ago and has not taken it since. He denies any fevers, chills, chest pain, shortness of breath, or urinary symptoms. He denies any hemoptysis, leg swelling, recent travels or surgeries, history of blood clots. He is scheduled to have an endoscopy on ___ as part of heart transplant evaluation. Of note, he has been followed in GI clinic for abdominal pain since ___ with no distinct etiology ever determined. Last EGD was ___, found to have gastritis, ___, otherwise normal. He had a negative SIBO study in ___. In the ED initial vitals were: 96.2, 109, 108/83, 28, 100% RA Exam notable for: TTP in epigastrium, lungs clear Labs notable for: TropT < 0.01 x2 Lactate 3.1 -> 2.1 after 1.5L IVF BUN/Cr ___ AST/ALT 56/72, tbil 1.8 C. Diff negative Images notable for: #CT A/P with contrast - small right pleural effusion, hepatic steatosis, scattered subcentimeter hyperdensities throughout the right hepatic lobe are incompletely characterized but could represent flash-filling hemangiomas or perfusional anomalies #CXR - Stable mild cardiomegaly. EKG: NSR @102bpm, LAD, NI. RBBB, poor R wave progression. No ST-T changes. Patient was given: 1.5L IVF, Vicodin, pravastatin 10, gabapentin 200, ranitidine 300, Lasix PO 40mg, Mg Oxide 280, Guaifenesin ER 600mg, Lorazepam PO 1mg. Vitals on transfer: 82 ___ 97% RA On the floor, he reports no current abdominal pain. Past Medical History: - Dyslipidemia - Cardiomyopathy, nonischemic ___ s/p ICD implant ___ - Atrial Fibrillation - H/o tachycardia, s/p VT ablation x2 - Hypodensity in the pancreas consistent with a cystic lesion currently being worked up - EUS ___ Simple 4X4 mm cyst in the body of the pancreas. - Depressive disorder - GERD - Celiac disease - Cervical Spondylosis and Cervical Radiculitis - Myofascial pain syndrome - Cholecystitis s/p lap-chole ___ - Chronic pancreatitis ___ - Fatty liver elevated LFT's - Ventral Hernia needing repair - Umbilical hernia repair as a child - Chronic sinus infection on augmentin - Suprascapular nerve entrapment - IBS - HSV - Hepatitis A and B - ___ years ago in his late ___ - Tonsillectomy/ adenoids as a child Social History: ___ Family History: Father died of an MI at ___ but first at age ___. Mother died of ___ disease at ___. His younger sister has familial polyposis, other sister is healthy. Mother's sister has COPD and emphysema. Maternal aunt died of lung cancer. Paternal uncle died in World War II. Paternal and maternal grandfather died young. Paternal and maternal grandmothers died old. Physical Exam: ADMISSION PHYSICAL EXAM: ======================= VS: reviwed in eflowsheets GENERAL: Sitting up in bed in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. Slightly dry MM. NECK: Supple. JVP of ~8 cm. CARDIAC: RRR. Normal S1, S2 with S3. No murmurs or rubs. No thrills or lifts. LUNGS: No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, mildly distended. Hyperactive BS. EXTREMITIES: Lukewarm extremities. No clubbing, cyanosis, or peripheral edema. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. DISCHARGE PHYSICAL EXAM: ======================== VITALS: 24 HR Data (last updated ___ @ 754) Temp: 97.7 (Tm 98.8), BP: 112/74 (89-112/58-77), HR: 95 (85-95), RR: 20 (___), O2 sat: 98% (97-99), O2 delivery: RA, Wt: 204.37 lb/92.7 kg I/Os: Fluid Balance (last updated ___ @ 500) Last 8 hours Total cumulative -50ml IN: Total 400ml, PO Amt 400ml OUT: Total 450ml, Urine Amt 450ml Last 24 hours Total cumulative -525ml IN: Total 1800ml, PO Amt 1800ml OUT: Total 2325ml, Urine Amt 2325ml GENERAL: Lying in bed, NAD. NECK: Supple. JVP ~8cm. CARDIAC: RRR. Normal S1, S2. No murmurs, rubs, or gallops. LUNGS: No accessory muscle use. CTAB, no wheezes rales or rhonchi. ABDOMEN: Mildly distended, soft, mild discomfort on palpation of epigastric region. EXTREMITIES: No clubbing, cyanosis, or peripheral edema. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. Pertinent Results: ADMISSION LABS: ============== ___ 10:24AM BLOOD WBC-7.5 RBC-5.36 Hgb-16.9 Hct-49.4 MCV-92 MCH-31.5 MCHC-34.2 RDW-15.1 RDWSD-48.3* Plt ___ ___ 10:24AM BLOOD Neuts-66.5 ___ Monos-11.5 Eos-0.8* Baso-0.5 Im ___ AbsNeut-4.98 AbsLymp-1.53 AbsMono-0.86* AbsEos-0.06 AbsBaso-0.04 ___ 12:28PM BLOOD Glucose-100 UreaN-19 Creat-1.4* Na-142 K-4.7 Cl-106 HCO3-22 AnGap-14 ___ 12:28PM BLOOD ALT-72* AST-56* AlkPhos-56 TotBili-1.8* ___ 12:28PM BLOOD Lipase-60 ___ 10:24AM BLOOD cTropnT-<0.01 ___ 03:35PM BLOOD cTropnT-<0.01 ___ 12:28PM BLOOD proBNP-6264* PERTINENT LABS/MICRO/IMAGING: ============================ ___ 06:56AM BLOOD ALT-39 AST-26 TotBili-1.1 ___ 04:50AM BLOOD calTIBC-382 Ferritn-52 TRF-294 ___ 06:56AM BLOOD calTIBC-363 VitB12-513 Ferritn-46 TRF-279 ___ 06:56AM BLOOD TSH-2.3 ___ 06:56AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-POS* HAV Ab-POS* ___ 07:00PM BLOOD IgG-671* IgA-160 IgM-161 ___ 07:00PM BLOOD HIV Ab-NEG ___ 06:56AM BLOOD HCV Ab-NEG ___ 10:28AM BLOOD Lactate-3.1* ___ 12:40PM BLOOD Lactate-2.1* ___ 01:56PM BLOOD Lactate-1.4 ___ 03:10PM BLOOD Lactate-1.2 Platelet trend: ___ 10:24AM BLOOD Plt ___ ___ 05:14AM BLOOD Plt ___ ___ 05:55AM BLOOD Plt ___ ___ 06:43AM BLOOD Plt ___ ___ 04:50AM BLOOD Plt ___ ___ 06:03AM BLOOD Plt ___ ___ 09:17AM BLOOD Plt ___ ___ 02:54PM BLOOD Plt ___ ___ 05:05AM BLOOD Plt Ct-96* ___ 03:05PM BLOOD Plt Ct-91* ___ 05:21AM BLOOD Plt Ct-82* ___ 01:11PM BLOOD Plt Smr-VERY LOW* Plt Ct-65* ___ 06:56AM BLOOD Plt Ct-95* ___ 06:37AM BLOOD Plt ___ ___ 06:47AM BLOOD Plt ___ GASTRIN - FROZEN Test Result Reference Range/Units GASTRIN 138 H <=100 pg/mL HEPARIN DEPENDENT ANTIBODIES TEST RESULT REFERENCE RANGE UNITS _____________________ ______ _______________ _____ PF4 Heparin Antibody Equivocal 0.00 - 0.39 OD Inhibition of a positive reaction by less tha 50% is an equivocal result. This type of reaction is given by a small percentage of antibodies in patients who are suspected of having Type II HIT. The significance of this type of reaction is not yet established. It has not yet been determined whether it is safe to re-administer heparin to patients whose serum gives an equivocal reaction. ___ 7:00 pm SEROLOGY/BLOOD **FINAL REPORT ___ HELICOBACTER PYLORI ANTIBODY TEST (Final ___: NEGATIVE BY EIA. (Reference Range-Negative). MICRO: --------- ___ 10:24 am BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 11:30 am BLOOD CULTURE 2 OF 2. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 10:50 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ C. difficile PCR (Final ___: NEGATIVE. ___ 10:50 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ FECAL CULTURE (Final ___: NO ENTERIC GRAM NEGATIVE RODS FOUND. NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: No E. coli O157:H7 found. ___ 3:35 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 3:05 pm BLOOD CULTURE Source: Line-CVP #1. Blood Culture, Routine (Pending): No growth to date. ___ 3:30 pm BLOOD CULTURE #2. Blood Culture, Routine (Pending): No growth to date. IMAGING: ------------ ___ CXR: IMPRESSION: No acute intrathoracic process. Stable mild cardiomegaly. ___ CT A/P w/ contrast: IMPRESSION: 1. No acute findings to explain the patient's reported symptoms. 2. Small right nonhemorrhagic pleural effusion. 3. Hepatic steatosis. 4. Scattered subcentimeter hyperdensities throughout the right hepatic lobe are incompletely characterized but could represent flash-filling hemangiomas or perfusional anomalies. Nonurgent MRI would further assess. ___ CXR: IMPRESSION: Lungs are clear. Left-sided pacemaker and right-sided Swan-Ganz catheter are unchanged. Cardiomediastinal silhouette is stable. There is no pleural effusion. No pneumothorax is seen ___ CT A/P w/ and w/o contrast: IMPRESSION: 1. Previously seen foci of hyperenhancement within the liver are re-demonstrated without correlate on more delayed imaging series likely representing transient hepatic attenuation differences. No suspicious liver lesion is present. 2. Hepatic steatosis. 3. Nodularity along the greater curvature of the stomach is stable from at least ___. DISCHARGE LABS: =============== ___ 06:47AM BLOOD WBC-5.8 RBC-4.56* Hgb-14.2 Hct-41.0 MCV-90 MCH-31.1 MCHC-34.6 RDW-13.4 RDWSD-44.0 Plt ___ ___ 06:47AM BLOOD Glucose-116* UreaN-32* Creat-1.2 Na-136 K-4.2 Cl-100 HCO3-21* AnGap-15 ___ 06:47AM BLOOD Calcium-8.9 Phos-4.6* Mg-2.2 Brief Hospital Course: PATIENT SUMMARY: ================ ___ year old male with non ischemic cardiomyopathy with mild CAD, HFrEF (EF 17%) s/p ICD ___, pAF on apixaban, hx VT s/p VT ablation x 2, celiac disease, chronic abdominal pain thought to be secondary to low flow state, who presents with acute on chronic abdominal pain in the setting of fluctuating diuretic doses and weight loss. Found to have worsening gastritis on EGD with pain now improved s/p changing of PPI. Also with fairly rapid re-accumulation of fluid, s/p IV Lasix and brief Lasix gtt, now transitioned back to PO lasix. S/p right heart catheterization with low CI, patient not amenable to inotropes, continuing workup for VAD/transplant. Course complicated by thrombocytopenia, possible HIT vs. drug-induced, platelets now uptrending with continuing workup. # CORONARIES: RCA with 50-60% stenosis # PUMP: EF 17%, moderate MR, mild TR (___) # RHYTHM: pAF ACUTE ISSUES: ============= #Non-ischemic HFrEF (EF 17%): Patient with most recent TTE ___ with EF 17%. On admission, he was thought to be volume down given history of a few weeks of nausea and abdominal pain and poor PO intake, had soft SBPs in the ED. In that setting, he was given 1.5L of IVF. He then became volume overloaded and was started on boluses of IV Lasix, was briefly on Lasix gtt but then stopped in setting of SBP ___ (asymptomatic). Once euvolemic, he was transitioned back to Lasix 120mg PO BID, which was his most recent home diuretic dose. He was continued on his home losartan and eplerenone. His metoprolol was discontinued and he was started on amiodarone for his history of VT (see below). During this admission, his ICD (placed in ___ was interrogated which revealed an episode of described NSVT on ___ for 14 seconds, rates to 197 bpm. He also had a right heart catheterization with leave-in swan on ___ (swan removed ___ which showed mild congestion and low cardiac output and index. Attempted to start low-dose beta blocker, but patient continued to have frequent PVCs on this and thus metoprolol was discontinued and amiodarone was started. Discussed starting inotropes with patient, but patient is not amenable at this time. He feels this would significant limit his independence, and his ability to drive, which he values. His workup for VAD/transplant was also continued during this admission. He had a CT abdomen/pelvis on admission which showed hyperdensities in the liver that could represent flash-filling hemangiomas vs. perfusion defects; repeat CT abdomen pelvis with contrast ___ showed no concerning liver lesions. He also had an EGD/colonoscopy ___ which showed gastritis and benign-appearing colonic polyps that were biopsied. Immunologic workup given recurrent sinopulmonary infections revealed mildly increased IgG with normal IgM and IgA with no intervention required at this time. He also had a dental evaluation and panorex scan with recommendation for routine dental cleaning. #Acute on chronic post-prandial abdominal pain: High suspicion for chronic mesenteric ischemia due to low flow state in setting of HFrEF with EF 17%. Acute worsening of pain likely multifactorial. He was noted to have poor PO intake for the past few weeks and in that setting may have been overdiuresed. Some mild hypotension in ED with lactate of 3 on arrival, received 1.5L IVF in ED, and pain subsequently improved a little with normalization of lactate. Patient also has history of Barretts and dyspepsia, on maximal medical therapy, however recently switched from Prevacid to pantoprazole, which may coincide with worsening of symptoms. EGD/colonoscopy on ___ revealed antral erosions and superficial ulcers, which is uncommon given on max PPI therapy. GI thinks high likelihood that this is contributing to current abdominal pain and recommended switch PPI back to Prevacid, and abdominal pain now much improved following the switch. Gastrin was elevated but likely in setting of being on a PPI (could consider rechecking the level when patient is OFF a PPI). He has an H. pylori antibody pending in setting of gastritis and thrombocytopenia (see below). Will follow up with Dr. ___ as outpatient. #Thrombocytopenia: Patient's platelet count had slowly downtrended since admission to a nadir of 65, now uptrending with 106 today (had been 176 on admission). Had been on short course of SQ heparin (___) in setting of holding apixaban for procedures. Prior to that, received heparin bolus during cardiac cath on ___. Seen by hematology, who thinks drug-induced ITP (maybe augmentin, which he was on for sinus infection prior to admission) vs. H.pylori vs. HIT. Serum H.pylori antibody pending. Initial PF4 came back equivocal, will likely need serotonin release assay to determine if definitely HIT (in setting of likely VAD/transplant in future), but for now blood bank recommends repeat PF4 before sending SRA. He was continued on apixaban. #History of VT During this admission, his ICD (placed in ___ was interrogated which revealed an episode of described NSVT on ___ for 14 seconds, rates to 197 bpm. His Metoprolol was discontinued and he was started on amiodarone 400mg BID on ___ ___. He will need a total of 10gm loading (25 doses) and then his amiodarone can be decreased to 400mg daily. This means that he should be continued on amiodarone 400mg BID through ___ and then transition to 400mg daily. Of note, he was told that he could not drive given his VT, but now that he is on amiodarone, we have recommended that patient can drive if absolutely necessary, but should attempt alternate means of transportation whenever possible. CHRONIC ISSUES: =============== #Paroxysmal atrial fibrillation: He has a CHADS2VASC of 3 (CHF, Age, Vascular disease). He was continued on Apixaban 5mg BID. #COPD: Continued home flovent, umeclidinium NF (can replace w/Spiriva if patient develops symptoms). #Dyspepsia and IBS: Continued home methocarbamol, ranitidine, sucralfate. As above, his pantoprazole was switched back to Prevacid in the setting of worsening gastritis. #Chronic back pain: Continued home gabapentin 200 mg TID and Hydrocodone-tylenol 5 mg-325 mg ___ tab q8h prn. #HLD: Continued home pravastatin 10 mg qd. #Allergies: Continued home loratadine, fluticasone. #Anxiety: Continue home ativan 1 mg ___ tabs qpm prn. #h/o HSV: Home valacyclovir 500 mg qd changed to acyclovir 400mg BID inpatient for formulary purposes - will resume valacyclovir on discharge. #CKD: Cr 1.4 on arrival, down to 1.2 at discharge. TRANSITIONAL ISSUES: ==================== DISCHARGE WEIGHT: 92.7 kg (204.37 lb) DISCHARGE Cr: 1.2 [] Regarding thrombocytopenia/HIT: repeat PF4 heparin antibody from ___ (initial result on ___ equivocal) still pending on discharge. WILL NEED TO FOLLOW THIS UP AT NEXT HEART FAILURE APPOINTMENT!! If still equivocal, will need serotonin release assay done to determine if this is definitely HIT or not given likely VAD/transplant in the future and need for heparin. [] If HIT not present, please remove heparin from list of allergies. [] Follow-up H.pylori antibody from ___ with regards to thrombocytopenia workup. [] Continue amiodarone 400mg BID through ___ (that will be a total of 10gm = 25 doses from ___ ___ start date) and then can switch to 400mg daily. [] Patient will need dental cleaning for VAD/transplant workup. [] Patient was instructed to NOT drive after NSVT event on ___ - no further episodes since then. Pt reports that he is not able to go without driving as he has no other means of transportation. Patient can drive if absolutely necessary, but should attempt alternate means of transportation whenever possible. [] Patient will need to follow up with Dr. ___ regarding possible gastrin level off PPI. [] Please do not restart Augmentin as could have caused drug-induced ITP. NEW MEDICATIONS: -Amiodarone 400mg PO BID CHANGED MEDICATIONS: -Pantoprazole 40 mg PO Q12H to Lansoprazole Oral Disintegrating Tab 30 mg PO/NG BID HELD MEDICATIONS: -Augmentin 875mg PO BID (in setting of resolution of symptoms and possible drug-induced ITP) -Metolazone 2.5 mg PO TWICE PER WEEK PRN weight gain (not needed, can re-discuss with Dr. ___ as outpatient) -Metoprolol Succinate XL 75 mg PO DAILY (now on amiodarone for rhythm control) #CODE STATUS: Full code #CONTACT: ___: ___ (___) ___, ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 5 mg PO BID 2. Creon ___ CAP PO TID W/MEALS 3. Docusate Sodium 200 mg PO DAILY:PRN constipation 4. Eplerenone 25 mg PO DAILY 5. Fluticasone Propionate 110mcg 2 PUFF IH BID 6. Gabapentin 200 mg PO TID:PRN pain 7. GuaiFENesin ER 1200 mg PO BID:PRN cough 8. HYDROcodone-Acetaminophen (5mg-325mg) ___ TAB PO Q8H:PRN Pain - Moderate 9. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN hemorrhoid 10. Loratadine 10 mg PO DAILY:PRN allergies 11. LORazepam ___ mg PO DAILY:PRN anxiety 12. Losartan Potassium 25 mg PO DAILY 13. Magnesium Oxide 500 mg PO DAILY 14. Methocarbamol 250-500 mg PO BID:PRN muscle spasms 15. Metoprolol Succinate XL 75 mg PO DAILY 16. Pantoprazole 40 mg PO Q12H 17. Pravastatin 10 mg PO QPM 18. Ranitidine 300 mg PO DAILY 19. Sucralfate 2 gm PO QHS PRN 20. ValACYclovir 500 mg PO Q24H 21. Vitamin B Complex w/C 1 TAB PO DAILY 22. Vitamin D 5000 UNIT PO DAILY 23. azelastine 137 mcg (0.1 %) nasal DAILY:PRN 24. ipratropium bromide 0.03 % nasal DAILY:PRN 25. Metolazone 2.5 mg PO TWICE PER WEEK PRN weight gain 26. Potassium Chloride 80 mEq PO DAILY 27. umeclidinium 62.5 mcg/actuation inhalation DAILY 28. Furosemide 120 mg PO BID 29. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Discharge Medications: 1. Amiodarone 400 mg PO BID RX *amiodarone 400 mg One tablet(s) by mouth Twice a day Disp #*21 Tablet Refills:*0 RX *amiodarone 400 mg One tablet(s) by mouth Once a day Disp #*30 Tablet Refills:*0 2. Lansoprazole Oral Disintegrating Tab 30 mg PO BID 3. Apixaban 5 mg PO BID 4. azelastine 137 mcg (0.1 %) nasal DAILY:PRN 5. Creon ___ CAP PO TID W/MEALS 6. Docusate Sodium 200 mg PO DAILY:PRN constipation 7. Eplerenone 25 mg PO DAILY 8. Fluticasone Propionate 110mcg 2 PUFF IH BID 9. Furosemide 120 mg PO BID 10. Gabapentin 200 mg PO TID:PRN pain 11. GuaiFENesin ER 1200 mg PO BID:PRN cough 12. HYDROcodone-Acetaminophen (5mg-325mg) ___ TAB PO Q8H:PRN Pain - Moderate 13. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN hemorrhoid 14. ipratropium bromide 0.03 % nasal DAILY:PRN 15. Loratadine 10 mg PO DAILY:PRN allergies 16. LORazepam ___ mg PO DAILY:PRN anxiety 17. Losartan Potassium 25 mg PO DAILY 18. Magnesium Oxide 500 mg PO DAILY 19. Methocarbamol 250-500 mg PO BID:PRN muscle spasms 20. Potassium Chloride 80 mEq PO DAILY Hold for K > 5 21. Pravastatin 10 mg PO QPM 22. Ranitidine 300 mg PO DAILY 23. Sucralfate 2 gm PO QHS PRN 24. umeclidinium 62.5 mcg/actuation inhalation DAILY 25. ValACYclovir 500 mg PO Q24H 26. Vitamin B Complex w/C 1 TAB PO DAILY 27. Vitamin D 5000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY: -Acute on chronic abdominal pain -Heart failure with reduced ejection fraction SECONDARY: -Thrombocytopenia -Ventricular tachycardia -Paroxysmal atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, It was a pleasure taking care of you at ___. WHY WAS I ADMITTED TO THE HOSPITAL? You were admitted to the hospital because you were having worsening of your abdominal pain, lower blood pressures, and weight loss. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? -You initially received IV fluids in the emergency room because you seemed a little dehydrated. -You then became more volume overloaded and were given IV diuretics that were transitioned back to oral diuretics. -You had a right heart catheterization to get a better idea of the pump function of your heart and your volume status. -You had an endoscopy (which showed worsening gastritis for which your PPI was switched back to Prevacid) and colonoscopy (during which some polyps were removed). -Your platelets slowly decreased and then increased over the course of your hospitalization. Hematology evaluated you as well, and think that this could be related to a medication, possibly heparin. Further workup is being done to evaluate this. -You have a history of ventricular tachycardia, so you were started on a medication to treat that (amiodarone). -Your VAD/transplant workup was continued, which included getting imaging of your abdomen, a dental evaluation, and the endoscopy/colonoscopy (as above). WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL? -Continue to take all of your medications as prescribed. -Please attend all ___ clinic appointments. -Weigh yourself every morning, and call your heart failure doctor ___ ___ if weight goes up more than 3 lbs in a day or 5 lbs in a week. -Please schedule a dental cleaning in the next few weeks per your inpatient dental evaluation. -Continue to take amiodarone twice a day through the end of the day on ___ - starting ___, you will start taking amiodarone just once a day. -Given your history of non-sustained VT, we recommend that you minimize how much time you spend behind the wheel - ideally, we would like you to not drive at all, if you can arrange other transportation. We wish you all the best, Your ___ Care Team Followup Instructions: ___
10165522-DS-11
10,165,522
24,549,025
DS
11
2154-06-11 00:00:00
2154-06-12 20:06:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Bactrim / Flagyl / Levaquin / Wellbutrin / Amitriptyline / Trazodone / erythromycin / Subutex / Omeprazole / Fioricet / Tricyclic Compounds / Sudafed / Gluten / Cymbalta / lisinopril / Seroquel / Lyrica / clindamycin / Topamax Attending: ___. Chief Complaint: Abdominal pain, nausea, poor PO intake Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year old male with non ischemic cardiomyopathy, HFrEF (EF 17%) s/p ICD ___, afib on apixaban, s/p VT ablation x 2, celiac disease, chronic abdominal pain, presenting with a chief complaint of worsening abdominal pain, nausea, poor PO intake. Of note, patient was recently admitted both ___ (CHF exacerbation and ___ and ___ for chronic abdominal pain thought d/t chronic mesenteric ischemia with acutely superimposed gastritis & antral ulcerations(seen on EGD) which improved modestly to prevacid. This last hospital course was also complicated by positive HIT test currently being treated with apixaban. During the most recent admission he was felt to be volume down d/t poor PO intake ___ abd pain & nausea, was given IVF and became overloaded and diuresed back to euvolemia. His pacemaker showed NS-VT so his metoprolol was exchanged for amiodarone. He also had a RHC which showed mild congestion and low cardiac index. He was not amenable to inotrope therapy due to concern it would limit his independence and mobility. He was discharged ___ and in the interim felt weak and unwell. Five days prior to admission he began to have an unsettled stomach. The next day his abdominal pain returned, generalized and associated with nausea and watery yellow-green stool. His pain progressed over the next few days despite reducing his PO intake, taking Maalox, and increasing his sucralfate. The night before his admission the pain became unbearable and he called the clinic to discuss admission. He was staking ___ into the hospital when he became very nauseous so he got out of the car and took an ambulance the remainder of the way. On the floor he feels nauseous and has generalized abdominal pain. He denies bloody stools, fevers, chills, chest pain. He feels that his breathing is better than it has been in a long time. Past Medical History: - Dyslipidemia - Cardiomyopathy, nonischemic ___ s/p ICD implant ___ - Atrial Fibrillation - H/o tachycardia, s/p VT ablation x2 - Hypodensity in the pancreas consistent with a cystic lesion currently being worked up - EUS ___ Simple 4X4 mm cyst in the body of the pancreas. - Depressive disorder - GERD - Celiac disease - Cervical Spondylosis and Cervical Radiculitis - Myofascial pain syndrome - Cholecystitis s/p lap-chole ___ - Chronic pancreatitis ___ - Fatty liver elevated LFT's - Ventral Hernia needing repair - Umbilical hernia repair as a child - Chronic sinus infection on augmentin - Suprascapular nerve entrapment - IBS - HSV - Hepatitis A and B - ___ years ago in his late ___ - Tonsillectomy/ adenoids as a child Social History: ___ Family History: Father died of an MI at ___ but first at age ___. Mother died of ___ disease at ___. His younger sister has familial polyposis, other sister is healthy. Mother's sister has COPD and emphysema. Maternal aunt died of lung cancer. Paternal uncle died in World War ___. Paternal and maternal grandfather died young. Paternal and maternal grandmothers died old. Physical Exam: ADMISSION PHYSICAL EXAMINATION: ============================= VS: T 97.8 BP 95/64 HR 87 RR 18 SaO2 96 Ra GENERAL: Lying in bed, NAD. NECK: Supple. JVP 10 cm. CARDIAC: RRR. Normal S1, S2. Systolic murmur best heard at ___. rubs, or gallops. LUNGS: No accessory muscle use. CTAB, no wheezes rales or rhonchi. ABDOMEN: Mildly distended, soft, mild discomfort on palpation of epigastric region. EXTREMITIES: No clubbing, cyanosis, or peripheral edema. SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. DISCHARGE PHYSICAL EXAMINATION: =============================== VITALS: 24 HR Data (last updated ___ @ 1139) Temp: 99.0 (Tm 99.0), BP: 95/58 (86-102/51-72), HR: 82 (70-94), RR: 20 (___), O2 sat: 94% (94-98), O2 delivery: Ra, Wt: 198.41 lb/90 kg Fluid Balance (last updated ___ @ 922) Last 8 hours Total cumulative -21.7ml IN: Total 578.3ml, PO Amt 520ml, IV Amt Infused 58.3ml OUT: Total 600ml, Urine Amt 600ml Last 24 hours Total cumulative -982.7ml IN: Total 2067.3ml, PO Amt 1720ml, IV Amt Infused 347.3ml OUT: Total 3050ml, Urine Amt 3050ml GENERAL: Lying in bed, NAD. NECK: Supple. JVP 10-11cm CARDIAC: RRR. Normal S1, loud S2. S3+ LUNGS: No accessory muscle use. Clear to auscultation bilaterally with no wheezes or rhonchi. ABDOMEN: mildly distended, soft, normoactive BS EXTREMITIES: No clubbing, cyanosis, or peripheral edema. Lukewarm extremities SKIN: No significant skin lesions or rashes. PULSES: Distal pulses palpable and symmetric. Pertinent Results: ADMISSION LABS: ============== ___ 01:22PM BLOOD WBC-9.7 RBC-4.56* Hgb-14.1 Hct-42.1 MCV-92 MCH-30.9 MCHC-33.5 RDW-13.4 RDWSD-45.5 Plt ___ ___ 01:22PM BLOOD Neuts-84.6* Lymphs-6.3* Monos-8.2 Eos-0.1* Baso-0.2 Im ___ AbsNeut-8.24* AbsLymp-0.61* AbsMono-0.80 AbsEos-0.01* AbsBaso-0.02 ___ 01:22PM BLOOD ___ PTT-27.5 ___ ___ 01:22PM BLOOD Glucose-122* UreaN-26* Creat-1.6* Na-136 K-4.6 Cl-100 HCO3-23 AnGap-13 ___ 01:22PM BLOOD ALT-76* AST-40 LD(LDH)-177 AlkPhos-60 Amylase-89 TotBili-1.0 ___ 01:22PM BLOOD Albumin-4.0 Calcium-9.5 Phos-3.6 Mg-2.3 ___ 01:22PM BLOOD ___ pO2-43* pCO2-38 pH-7.38 calTCO2-23 Base XS--1 Comment-GREENTOP OTHER PERTINENT LABS: ==================== ___ 08:40AM BLOOD ALT-83* AST-46* AlkPhos-61 TotBili-0.9 Serotonin release assay ___ – negative DISCHARGE LABS: =============== ___ 05:57AM BLOOD WBC-5.7 RBC-4.26* Hgb-13.0* Hct-38.4* MCV-90 MCH-30.5 MCHC-33.9 RDW-13.2 RDWSD-43.2 Plt ___ ___ 05:57AM BLOOD Glucose-153* UreaN-24* Creat-1.4* Na-138 K-3.5 Cl-97 HCO3-24 AnGap-17 ___ 05:57AM BLOOD ALT-27 AST-20 AlkPhos-58 TotBili-0.9 ___ 05:57AM BLOOD Calcium-8.6 Phos-4.1 Mg-2.2 IMAGING/STUDIES: ================ TTE ___: IMPRESSION: Severe left ventricular systolic dysfunction (the septal segments contract best). Moderate right ventricular dysfunction. Moderate to severe mitral regurgitation. Moderate tricuspid regurgitation. Severe pulmonary hypertension. Compared with the prior TTE ___ , the severity of mitral regurgitation tricuspid regurgitation has increased. The pulmonary pressure is severely elevated (indeterminate previously). Brief Hospital Course: Mr. ___ is a ___ year old man with non ischemic cardiomyopathy, HFrEF (EF 17%) s/p ICD ___, afib on apixaban, s/p VT ablation x 2, celiac disease, chronic abdominal pain, presenting with a chief complaint of worsening abdominal pain, nausea, poor PO intake c/f mesenteric ischemia iso low flow state ___ HF. # CORONARIES: RCA with 50-60% stenosis # PUMP: EF 17%, moderate MR, mild TR (___) # RHYTHM: pAF ACTIVE ISSUES: ============== #Acute on chronic post-prandial abdominal pain: Last admission EGD with gastritis and antral erosions (unusual given max PPI rx), H pylori negative & gastrin elevated (granted while on PPI). Plan was for GI f/u outpatient and consideration of repeat gastrin while off a PPI. CT A/P most ___ without explanatory pathology. Negative C. diff and H. pylori. Pain most likely secondary to mesenteric ischemia related to low cardiac index. GI was consulted, and agreed with assessment. Patient was started on milrinone drip, with improvement of symptoms. Trended LFTs-ALT elevated to ___ on admission, which down trended with diuresis. Patient was continued on home creon, lansoprazole, ranitidine, sucralfate. PICC was placed for discharge with home milrinone. #Non-ischemic HFrEF: EF 17% with ICD placed ___. Repeat TTE this admission with stable EF. He was trialed on dobutamine but he felt unwell, flushed, with stably uncomfortable abdominal symptoms on this medication. He was then started on milrinone 0.25 to improve perfusion with plan for PICC and home infusion for bridge to VAD. He tolerated this medication well and his abdominal symptoms improved. Stopped home losartan on admission. Losartan was then attempted to be restarted given that he felt unwell on ___ AM that may have been related to increased afterload however he developed hypotension that was symptomatic that evening and the medication was discontinued given hypotension after receiving one dose. He presented with admission weight of 203.7 lb, similar to prior discharge weight of 92.7 kg (204.37 lb). After diuresis with IV Lasix at doses of 120mg BID then 160mg BID, he was transitioned to torsemide at 100mg BID, his discharge weight was 198.41 lb. He appeared close to euvolemic on exam with PICC-transduced CVP at 16. Symptomatically he was feeling well and was discharged on the above torsemide regimen. Plan for VAD/transplant workup as an outpatient. He had a repeat echocardiogram that showed mod-severe TR with elevated PASP to 61. #Hypotension -Hypotensive to ___ after dobutamine was stopped. Patient was asymptomatic and improved without intervention. Losartan was held after hypotension to ___ after single dose. BMP was significant for bicarbonate of 19, likely ___ diarrhea given that lactate was 1.6. # VAD/Transplant work up Notable for: Hyperdensities in liver (flash filling hemangiomas vs perfusion defects) but repeat CT showed no concerning lesions. ___ with gastritis and benign colonic polyps. Immunologic w/u given recurrent sinopulmonary infxn: mildly increased IgG w/ normal IgM & IgA. Dental evaluation & panorex with recommendation for routine dental cleaning. GI consulted, with recs for repeat EGD in 3 weeks and repeat colonoscopy in ___ years. Ulcers not high risk for bleeding and should not require any interventions prior to VAD operation. #Concern for HIT: Serotonin release assay negative. PF4 assay borderline, but serotonin release assay negative ruling out diagnosis of HIT. Will remove heparin from documented allergies. Continued on apixaban 5mg BID for atrial fibrillation. Platelet count recovered and were stable throughout this admission. #Acute kidney injury: Creatinine improved from 1.6 on admission, baseline 1.2. Likely in the setting of poor PO intake, which improved after. Creatinine stable at 1.4. #History of VT - Continued amiodarone 400mg BID through ___, 400mg daily until ___ when switched to 200mg daily now that he has completed a 10g load. CHRONIC ISSUES: ============== #Paroxysmal atrial fibrillation: CHADS2VASC of 3 (CHF, Age, Vascular disease). Continued Apixaban, amiodarone as above. #COPD: Continued home flovent, umeclidinium NF (can replace w/Spiriva if patient develops symptoms). #Dyspepsia and IBS: Continued home methocarbamol, PPI, ranitidine, sucralfate. -as above, switched from pantoprazole to prevacid during the prior admission. #Chronic back pain: Continued home gabapentin 200 mg TID and Hydrocodone-tylenol 5 mg-325 mg ___ tab q8h prn #HLD: Continued home pravastatin 10 mg qd #Allergies: Continued home loratadine, fluticasone #Anxiety: Continued home ativan 1 mg ___ tabs qpm prn #h/o HSV: Home valacyclovir 500 mg qd changed to acyclovir 400mg BID inpatient. Transitional issues: ============== - GI/endoscopy–patient to receive outpatient endoscopy within 3 weeks to investigate healing of gastric ulcers – Heparin–initial concern for HIT, serotonin release assay negative which ruled out diagnosis. Heparin has been removed from allergy list - Amiodarone load–patient being continued on 200 mg daily now that he is s/p 10 gram load - Monitor electrolytes and volume status and adjust torsemide, Eplerenone, and electrolyte replacement as needed. Should get electrolytes check by ___ Repeat lytes Medication changes: –Started milrinone 0.25 mcg/kg/min –Increased Marinol 25 mg daily to twice daily –Stopped losartan 25 mg daily -held at discharge given hypotension when it was re-initiated as an inpatient #CODE STATUS: Full #CONTACT: HCP: ___, HCP/sister, ___ DISCHARGE WEIGHT: 90 kg (198.41 lb). DISCHARGE CREATININE: 1.4 DISCHARGE DIURETICS: Torsemide 100mg BID Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 5 mg PO BID 2. Creon ___ CAP PO TID W/MEALS 3. Docusate Sodium 200 mg PO DAILY:PRN constipation 4. Eplerenone 25 mg PO DAILY 5. Fluticasone Propionate 110mcg 2 PUFF IH BID 6. Furosemide 120 mg PO BID 7. Gabapentin 200 mg PO TID:PRN pain 8. GuaiFENesin ER 1200 mg PO BID:PRN cough 9. HYDROcodone-Acetaminophen (5mg-325mg) ___ TAB PO Q8H:PRN Pain - Moderate 10. Loratadine 10 mg PO DAILY:PRN allergies 11. LORazepam ___ mg PO DAILY:PRN anxiety 12. Losartan Potassium 25 mg PO DAILY 13. Magnesium Oxide 500 mg PO DAILY 14. Methocarbamol 250-500 mg PO BID:PRN muscle spasms 15. Pravastatin 10 mg PO QPM 16. Ranitidine 300 mg PO DAILY 17. Sucralfate 2 gm PO QHS PRN 18. Vitamin B Complex w/C 1 TAB PO DAILY 19. Vitamin D 5000 UNIT PO DAILY 20. Amiodarone 400 mg PO BID 21. Lansoprazole Oral Disintegrating Tab 30 mg PO BID 22. azelastine 137 mcg (0.1 %) nasal DAILY:PRN 23. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN hemorrhoid 24. ipratropium bromide 0.03 % nasal DAILY:PRN 25. Potassium Chloride 80 mEq PO DAILY 26. umeclidinium 62.5 mcg/actuation inhalation DAILY 27. ValACYclovir 500 mg PO Q24H Discharge Medications: 1. Amiodarone 200 mg PO DAILY RX *amiodarone 200 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 2. Milrinone 0.25 mcg/kg/min IV DRIP INFUSION RX *milrinone 1 mg/mL 0.25 mcg/kg/min IV continuous Disp #*100 Vial Refills:*0 3. Ondansetron 4 mg PO Q8H:PRN nausea RX *ondansetron 4 mg 1 tablet(s) by mouth twice a day as needed Disp #*10 Tablet Refills:*0 4. Torsemide 100 mg PO BID RX *torsemide 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 5. Eplerenone 25 mg PO BID RX *eplerenone 25 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 6. Sucralfate 1 gm PO LUNCH RX *sucralfate 1 gram 1 tablet(s) by mouth LUNCH AND DINNER Disp #*60 Tablet Refills:*0 7. Sucralfate 1 gm PO DINNER 8. Apixaban 5 mg PO BID 9. azelastine 137 mcg (0.1 %) nasal DAILY:PRN 10. Creon ___ CAP PO TID W/MEALS 11. Docusate Sodium 200 mg PO DAILY:PRN constipation 12. Fluticasone Propionate 110mcg 2 PUFF IH BID 13. Gabapentin 200 mg PO TID:PRN pain 14. GuaiFENesin ER 1200 mg PO BID:PRN cough 15. HYDROcodone-Acetaminophen (5mg-325mg) ___ TAB PO Q8H:PRN Pain - Moderate 16. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN hemorrhoid 17. ipratropium bromide 0.03 % nasal DAILY:PRN 18. Lansoprazole Oral Disintegrating Tab 30 mg PO BID 19. Loratadine 10 mg PO DAILY:PRN allergies 20. LORazepam ___ mg PO DAILY:PRN anxiety 21. Magnesium Oxide 500 mg PO DAILY 22. Methocarbamol 250-500 mg PO BID:PRN muscle spasms 23. Potassium Chloride 80 mEq PO DAILY 24. Pravastatin 10 mg PO QPM 25. Ranitidine 300 mg PO DAILY 26. Sucralfate 2 gm PO QHS PRN 27. umeclidinium 62.5 mcg/actuation inhalation DAILY 28. ValACYclovir 500 mg PO Q24H 29. Vitamin B Complex w/C 1 TAB PO DAILY 30. Vitamin D 5000 UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnoses: ============== Nonischemic heart failure with reduced ejection fraction Acute on chronic postprandial abdominal pain Hypertension Ventricular assist device workup History of ventricular tachycardia Acute kidney injury on chronic kidney disease history of ventricular Secondary diagnoses: ================ Paroxysmal atrial fibrillation Chronic obstructive pulmonary disease Dyspepsia Irritable bowel syndrome Chronic back pain Hyperlipidemia Anxiety History of herpes simplex virus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, It was a pleasure caring for you at ___. WHY WAS I IN THE HOSPITAL? ========================== - You were admitted because of abdominal pain and shortness of breath. WHAT HAPPENED IN THE HOSPITAL? ============================== - Your abdominal pain was felt to be due to low blood flow to your GI tract due to your heart failure. The pain improved significantly when we started a medication called milrinone to increase the blood flow. - You were also feeling short of breath and were found to have fluid in your lungs. This was due to a condition called heart failure, where your heart does not pump hard enough and fluid backs up into your lungs, legs, and gut. - We performed blood tests and a CT scan of your abdomen which did not show any other urgent problems. - You were also given a diuretic medication to help get extra fluid out. You improved considerably and were ready to leave the hospital. WHAT SHOULD I DO WHEN I GO HOME? ================================ - Please do not stop taking either medication without talking to your heart doctor. - Your weight at discharge is 90 kg (198.41 lb). Please weigh yourself today at home and use this as your new baseline - Please weigh yourself every day in the morning. Call your doctor if your weight goes up by more than 3 lbs. Thank you for allowing us to be involved in your care, we wish you all the best! Your ___ Healthcare Team Followup Instructions: ___
10165522-DS-9
10,165,522
20,042,475
DS
9
2154-04-28 00:00:00
2154-04-29 23:34:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Bactrim / Flagyl / Levaquin / Wellbutrin / Amitriptyline / Trazodone / erythromycin / Subutex / Omeprazole / Fioricet / Tricyclic Compounds / Sudafed / Caffeine / Gluten / Cymbalta / lisinopril / Seroquel / Lyrica / clindamycin / Topamax Attending: ___. Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old male with PMH of non ischemic cardiomyopathy, HFrEF (EF 17%) s/p ICD ___, afib on apixaban, s/p VT ablation x 2, who presents from home with 1 day of increased dyspnea/wheezing and diminished urine output. He was recently discharged from ___ on ___ after a hospitalization for r/o ACS, found to have serial 50-60% lesions in moderately small RPDA, but otherwise clean. CPET with reduced VO2 peak, elevated VCO2 slope, no angina symptoms, no ST changes. Of note, Torsemide and eplerenone were held in house, as patient received IV contrast for cath. He resumed them upon discharge. On ___ the ___, pt reports that he gained a pound, so he increased his Torsemide to 280 total daily. He continued gaining weight over the ensuing days, up to 217 lb from EDW 211 lb, and his urine output continued to drop despite increasing doses of Torsemide (took 300 total today). He was going to present to clinic on the morning of ___, but he became acutely more short of breath associated with chest fullness and wheezing this evening at 11pm, so he presented to the ED. In the ED initial vitals were: 97.8 104 126/86 18 100% RA Exam notable for: -Gen: NAD, mildly tachypneic -CV: Tachycardic, S3 gallop -Lungs: bibasilar crackles -Abd: soft, distended, nontender -Ext: no peripheral edema, no erythema or warmth Labs notable for: BUN 25/Cr 1.9 CBC: Plt 137, otherwise wnl proBNP 5200 Trop <0.01 Images notable for: CXR: Cardiomegaly with moderate pulmonary edema. EKG: SR, RAD, RBBB, sub-mm STE II, III aVF, STDs V4-V6, unchanged from prior Patient was given: Lasix 120 mg IV Vitals on transfer: 86 94/68 16 98% RA On the floor, patient endorsed the above history. Currently has some mild shortness of breath, but is otherwise without orthopnea, PND, chest pain, palpitations. He suspects the current exacerbation might be due to dietary indiscretion, stating he ate two salads that he later found out had more sodium content than he has previously thought. REVIEW OF SYSTEMS: Positive per HPI. Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope, or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS - No Diabetes - No Hypertension - Dyslipidemia 2. CARDIAC HISTORY # Cardiomyopathy nonischemic ___ s/p ICD implant ___, revised 2 weeks ago, ejection fraction of ___ # Atrial Fibrillation # H/o tachycardia, s/p VT ablation x2 # S/p cath ___ with clean coronaries 3. OTHER PAST MEDICAL HISTORY # Hypodensity in the pancreas consistent with a cystic lesion currently being worked up - EUS ___ Simple 4X4 mm cyst in the body of the pancreas. # Depressive disorder # GERD # Celiac disease # Cervical Spondylosis and Cervical Radiculitis # Myofascial pain syndrome # Cholecystitis s/p lap-chole ___ # Chronic pancreatitis ___ # Fatty liver elevated LFT's # Ventral Hernia needing repair # Umbilical hernia repair as a child # Chronic sinus infection on augmentin # Suprascapular nerve entrapment # IBS # HSV # Hepatitis A and B - ___ years ago in his late ___ # Tonsillectomy/ adenoids as a child Social History: ___ Family History: Father died of an MI at ___ but first at age ___. Mother died of ___ disease at ___. His younger sister has familial polyposis, other sister is healthy. Mother's sister has COPD and emphysema. Maternal aunt died of lung cancer. Paternal uncle died in World War ___. Paternal and maternal grandfather died young. Paternal and maternal grandmothers died old. Physical Exam: ADMISSION EXAM ============= PHYSICAL EXAMINATION: T98.2 BP 104 / 74 HR 91RR 20 SPO2 98 GENERAL: Well developed, well nourished male in NAD. Oriented x3. Mood, affect appropriate. HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Dry MM. NECK: Supple. JVP of 14-16 cm. CARDIAC: Irregularly irregular, tachycardic, no murmurs appreciated. LUNGS: Mild dyspnea while speaking. Bibasilar crackles, no wheezing ABDOMEN: Distended, firm, no fluid wave, non-tender EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or peripheral edema. DISCHARGE EXAM ============== 24 HR Data (last updated ___ @ 1124 ) Temp: 97.4 (Tm 97.4), BP: 100/75 (___), HR: 91 (77-95), RR: 20 (___), O2 sat: 98% (92-98), O2 delivery: RA, Weight: 214 lb/ 97.07 kg (Admission: 216.2 lb Dry weight: 212 lb) Fluid Balance (last updated ___ @ 1009) Last 8 hours: total cumulative -1105 ml IN: Total 120 ml, PO Amt 120 ml, IV Amt Infused 0 ml OUT: Total 1225 ml, Urine Amt 1225 ml Last 24 hours Total cumulative - 244 ml IN: Total 1801 ml, PO Amt 1801 ml, IV Amt Infused 0 ml OUT: Total 2420 ml, Urine Amt 2420 ml General: Well developed, gentleman lying in bed in NAD. Neck: JVP 10 cm. Supple. CV: Regular rate, arrhythmic, S1/S2, +S3, no murmurs or rubs. Lungs: Clear breath sounds bilaterally. No crackles, no wheezing. GASTROINTESTINAL: non-tender, mildly distended, no organomegaly. EXTREMITES: warm, no pitting edema, 2+ distal pulses CNS: Alert and oriented, face symmetric, moves all 4 with purpose Pertinent Results: ADMISSION LABS ___ 12:48AM BLOOD WBC-5.4 RBC-4.72 Hgb-14.8 Hct-42.7 MCV-91 MCH-31.4 MCHC-34.7 RDW-14.2 RDWSD-47.2* Plt ___ ___ 12:48AM BLOOD Neuts-64.2 ___ Monos-11.7 Eos-0.7* Baso-0.9 Im ___ AbsNeut-3.46 AbsLymp-1.19* AbsMono-0.63 AbsEos-0.04 AbsBaso-0.05 ___ 12:48AM BLOOD Plt ___ ___ 12:48AM BLOOD Glucose-122* UreaN-25* Creat-1.9* Na-139 K-3.9 Cl-102 HCO3-23 AnGap-14 ___ 06:41AM BLOOD ALT-60* AST-32 LD(LDH)-182 AlkPhos-65 TotBili-0.9 ___ 12:48AM BLOOD proBNP-5200* ___ 12:48AM BLOOD cTropnT-<0.01 ___ 06:41AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 06:41AM BLOOD Calcium-9.6 Phos-3.8 Mg-2.0 DISCHARGE LABS ___ 06:37AM BLOOD Glucose-111* UreaN-26* Creat-1.2 Na-139 K-3.6 Cl-101 HCO3-25 AnGap-13 ___ 06:37AM BLOOD ALT-49* AST-26 LD(LDH)-169 AlkPhos-55 TotBili-1.5 ___ 06:37AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.3 Brief Hospital Course: SUMMARY STATEMENT: ================== ___ man with history of non-ischemic cardiomyopathy, heart failure with reduced ejection fraction with EF 17%, afib on apixaban who presented with dyspnea, reduced urine output, volume overload concerning for HFrEF exacerbation. ACUTE ISSUES: ============= #Acute decompensated HF (HFrEF) Mr. ___ was admitted on ___, with dyspnea, orthopnea, and 6lb weight gain from discharge weight, 5 days prior. He has been taking his torsemide 120mg BID at home, although admits that he has not been compliant with a low-salt diet or fluid restriction since discharge. On admission, exam was positive for bibasilar crackles and abdominal distention. CXR showed moderate pulmonary edema. He was subsequently diuresed with IV Lasix drip, then transitioned to Bumex 4mg BID PO with Metolazone PRN prior to discahrge. Otherwise, heart failure regimen was continued. He remains on home metoprolol, losartan, and eplerenone. On discharge, he is down from 216lbs on admission, to 214lbs. While this is not back to his prior discharge weight, his symptoms have resolved. He would prefer to be at home for further diuretic titration, and we have arranged follow up with heart failure clinic on ___. He was instructed to weigh himself daily and notify his cardiologist if he gains > 3lbs. During this admission we also discussed the possibility of pursuing CRT, given underlying RBBB morphology with Class III symptoms. EP team was consulted, however they believe there is no sufficient evidence to support an ICD upgrade to CRT at the moment. Patient understands and agrees. ___ on CKD Creatinine up from baseline (1.9 from 1.2) on admission. Likely ___ cardio-renal ___ related to volume overload as above. Creatinine downtrended to baseline with IV diuresis. Discharge Cr 1.2. CHRONIC ISSUES: =============== #Atrial fibrillation: CHADS2VASC of 2. Continued home apixaban. #COPD/smoking: Continue home flovent and umeclidinium #Dyspepsia and IBS: Continued home methocarbamol, PPI, ranitidine, sucralfate. #Chronic back pain: Continued home gabapentin 200 mg TID and Hydrocodone-tylenol 5 mg-325 mg ___ tab q8h prn #HLD: Continued home pravastatin 10 mg qd #Allergies: Continued home loratadine, fluticasone #Anxiety: Continued home ativan 1 mg ___ tabs qpm prn #h/o HSV: Continued home valacyclovir 500 mg qd ==================== Transitional Issues: ==================== [] F/u with heart failure clinic on ___ as scheduled for titration of PO diuretics [] Please ensure patient is weighing himself daily and notifying cardiologist if he gains > 3lbs [] If patient continues to gain weight, or symptoms recur, consider scheduling of Metolazone (currently PRN). Mr. ___ has had cramping with thiazides in the past, but is open to retrying it if necessary. # CODE: Full, confirmed # CONTACT: HCP: ___, HCP/sister, ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Creon ___ CAP PO TID W/MEALS 2. Docusate Sodium 200 mg PO DAILY:PRN constipation 3. Fluticasone Propionate 110mcg 2 PUFF IH BID 4. Gabapentin 200 mg PO TID:PRN pain 5. GuaiFENesin ER 1200 mg PO BID:PRN cough 6. HYDROcodone-Acetaminophen (5mg-325mg) ___ TAB PO Q8H:PRN Pain - Moderate 7. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN hemorrhoid 8. Loratadine 10 mg PO DAILY:PRN allergies 9. LORazepam ___ mg PO DAILY:PRN anxiety 10. Methocarbamol 250-500 mg PO BID:PRN muscle spasms 11. Pantoprazole 40 mg PO Q12H 12. Pravastatin 10 mg PO QPM 13. Ranitidine 300 mg PO DAILY 14. Sucralfate 2 gm PO QHS PRN 15. ValACYclovir 500 mg PO Q24H 16. Vitamin B Complex w/C 1 TAB PO DAILY 17. Vitamin D 5000 UNIT PO DAILY 18. Apixaban 5 mg PO BID 19. azelastine 137 mcg (0.1 %) nasal DAILY:PRN 20. Eplerenone 25 mg PO DAILY 21. ipratropium bromide 0.03 % nasal DAILY:PRN 22. Losartan Potassium 25 mg PO DAILY 23. Magnesium Oxide 500 mg PO DAILY 24. Metolazone 2.5 mg PO TWICE PER WEEK PRN weight gain 25. Metoprolol Succinate XL 75 mg PO DAILY 26. Potassium Chloride 80 mEq PO DAILY 27. Torsemide 120 mg PO BID 28. umeclidinium 62.5 mcg/actuation inhalation DAILY Discharge Medications: 1. Bumetanide 4 mg PO BID RX *bumetanide 2 mg 2 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. Apixaban 5 mg PO BID 3. azelastine 137 mcg (0.1 %) nasal DAILY:PRN 4. Creon ___ CAP PO TID W/MEALS 5. Docusate Sodium 200 mg PO DAILY:PRN constipation 6. Eplerenone 25 mg PO DAILY 7. Fluticasone Propionate 110mcg 2 PUFF IH BID 8. Gabapentin 200 mg PO TID:PRN pain 9. GuaiFENesin ER 1200 mg PO BID:PRN cough 10. HYDROcodone-Acetaminophen (5mg-325mg) ___ TAB PO Q8H:PRN Pain - Moderate 11. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN hemorrhoid 12. ipratropium bromide 0.03 % nasal DAILY:PRN 13. Loratadine 10 mg PO DAILY:PRN allergies 14. LORazepam ___ mg PO DAILY:PRN anxiety 15. Losartan Potassium 25 mg PO DAILY 16. Magnesium Oxide 500 mg PO DAILY 17. Methocarbamol 250-500 mg PO BID:PRN muscle spasms 18. Metolazone 2.5 mg PO TWICE PER WEEK PRN weight gain 19. Metoprolol Succinate XL 75 mg PO DAILY 20. Pantoprazole 40 mg PO Q12H 21. Potassium Chloride 80 mEq PO DAILY Hold for K > 4 22. Pravastatin 10 mg PO QPM 23. Ranitidine 300 mg PO DAILY 24. Sucralfate 2 gm PO QHS PRN 25. umeclidinium 62.5 mcg/actuation inhalation DAILY 26. ValACYclovir 500 mg PO Q24H 27. Vitamin B Complex w/C 1 TAB PO DAILY 28. Vitamin D 5000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses ================== Acute decompensated heart failure Acute kidney injury Persistent atrial fibrillation on anticoagulation Secondary diagnoses ================== IBS Chronic back pain HLD Anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at the ___ ___! Why was I admitted to the hospital? -You were admitted because you had shortness of breath. What happened while I was in the hospital? - You were given medications (diuretics) through your IV to help reduce the fluid in your lungs and body. - With the IV diuretics, your kidney function is improving. What should I do after leaving the hospital? - Please take your medications as listed in discharge summary and follow up at the listed appointments. - Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Thank you for allowing us to be involved in your care, we wish you all the best! Sincerely, Your ___ Healthcare Team Followup Instructions: ___
10165672-DS-22
10,165,672
27,153,626
DS
22
2157-03-09 00:00:00
2157-03-10 22:44:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fever Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ PMHx significant for stage IV CKD (with deceased donor graft in ___, complicated by chronic allograft nephropathy, followed by Dr. ___, AFib, HTN, and anemia presenting with fever. He developed symptoms of chills, myalgias, and occasional cough 5 days ago. He denies any associated chest pain, SOB, diarrhea, new rash, swollen joints, or headache. He also denies any n/v or diarrhea. He lives at home and works as an ___; he has not had any sick exposures recently. He has been on his MMF and prednisone regularly. He does report some decreased appetite, but reports that he has been keeping up with hydration. In the ED, VS 103.2 90 175/100 18 97%. On exam, patient had inspiratory crackles diffusely throughout his lung fields. Labs were notable for Cr 4.1 (has been uptrending steadily from 1.5 in ___, last Cr 3.8 on ___. WBC 6.6 (84.8 N, 8.9 L), Hct 23.3. UA showed significant proteinuria, 19 granular casts and 16 hyaline casts. Lactate 1.0. CXR showed increased interstitial markings with more confluent R lung base consolidation. The patient received Tylenol, was started on oseltamivir, and given 1L MIVF. The patient was seen by transplant surgery as well as renal transplant who recommended low threshold for noncontrast CT chest and diuresis if patient appeared to have worsening volume overload. The patient was admitted to medicine for poor PO intake in the setting Ili/URI. Upon transfer, VS 100.3 79 163/93 18 100% RA. Patient reports that he did not take his Lasix for the past 4 days because of difficulty tolerating PO. Has not noticed any change with his breathing or his BLE edema (has been stable). Reports that his weight is also unchanged. Review of Systems: (+) (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: Gout HTN Stage 4 CKD, s/p deceased donor kidney transplant in ___ Hypercholesterolemia Sciatica Appendix removal ___ Social History: ___ Family History: no known family history Physical Exam: EXAM ON ADMISSION: ============================= Vitals- 99, 170/92, 94, 22, 95% on 2L General: elderly male in NAD HEENT: MMM, NCAT, EOMI Neck: supple, JVP at 8cm CV: RRR, nml S1 and S2, no m/r/g Lungs: faint crackles diffusely bilaterally, no accessory muscle use, no tachypnea Abdomen: soft, NTND, well-healed surgical incision over RLQ GU: no Foley Ext: 1+ pitting edema of BLE to mid-tibia, WWP, 2+ DP pulses, RUE graft with palpable thrill and no TTP or overlying erythema Neuro: AOx3, grossly nonfocal, + mild asterixis Skin: no rash or lesions EXAM ON DISCHARGE: ============================= Vitals- T 97.5, 153/86 (136-153/56-79), 65-85, 18, 98% RA (96-100%) General: elderly male, resting comfortably in bed, very pleasant HEENT: MMM, NCAT, EOMI Neck: supple CV: RRR, nml S1 and S2, nonradiating II/VI soft systolic murmur at RUSB Lungs: mild bibasilar crackles, no accessory muscle use, no tachypnea, good air movement Abdomen: soft, well-healed surgical incision over RLQ. Mild tenderness in epigastrium, otherwise nontender to palpation, nontender graft GU: no Foley Ext: 1+ bilateral lower ext edema, WWP, 2+ DP pulses, RUE graft with palpable thrill and no TTP or overlying erythema Neuro: AOx3, grossly nonfocal, no asterixis noted Skin: no rash or lesions Pertinent Results: ADMISSION LABS: =============================== ___ 02:32PM LACTATE-1.0 ___ 02:00PM GLUCOSE-106* UREA N-96* CREAT-4.1* SODIUM-139 POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-21* ANION GAP-19 ___ 02:00PM WBC-6.6 RBC-2.57* HGB-7.3* HCT-23.3* MCV-91 MCH-28.4 MCHC-31.3 RDW-14.1 ___ 02:00PM NEUTS-84.8* LYMPHS-8.9* MONOS-5.5 EOS-0.4 BASOS-0.3 ___ 02:00PM PLT COUNT-181 ___ 02:00PM ___ PTT-33.1 ___ ___ 02:00PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 02:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN->600 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 02:00PM URINE RBC-1 WBC-3 BACTERIA-FEW YEAST-NONE EPI-0 TRANS EPI-<1 ___ 02:00PM URINE GRANULAR-19* HYALINE-16* PERTINENT LABS: =============================== ___ 08:35AM BLOOD WBC-11.1* RBC-2.53* Hgb-7.0* Hct-22.9* MCV-91 MCH-27.5 MCHC-30.4* RDW-14.3 Plt ___ ___ 08:05AM BLOOD WBC-6.3 RBC-2.54* Hgb-7.1* Hct-23.4* MCV-92 MCH-28.1 MCHC-30.4* RDW-14.4 Plt ___ ___ 08:35AM BLOOD Glucose-112* UreaN-115* Creat-6.0*# Na-136 K-4.1 Cl-99 HCO3-23 AnGap-18 ___ 08:30AM BLOOD Glucose-105* UreaN-130* Creat-6.5* Na-139 K-3.9 Cl-102 HCO3-23 AnGap-18 ___ 08:05AM BLOOD Glucose-107* UreaN-135* Creat-6.3* Na-140 K-4.1 Cl-103 HCO3-20* AnGap-21* ___ 08:30AM BLOOD Cyclspr-142 ___ 08:30AM BLOOD Cyclspr-210 ___ 08:10AM BLOOD Cyclspr-186 ___ 08:35AM BLOOD Lipase-84* DISCHARGE LABS: =============================== ___ 06:11AM BLOOD WBC-6.2 RBC-2.34* Hgb-6.5* Hct-21.5* MCV-92 MCH-27.9 MCHC-30.3* RDW-14.4 Plt ___ ___ 06:11AM BLOOD Glucose-99 UreaN-136* Creat-5.9* Na-141 K-4.2 Cl-103 HCO3-20* AnGap-22* ___ 06:11AM BLOOD Calcium-7.3* Phos-6.8* Mg-2.6 ___ 06:11AM BLOOD Cyclspr-94* MICROBIOLOGY: =============================== URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION Respiratory Viral Culture (Final ___: No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at ___ within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final ___: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture for further information. CMV Viral Load (Final ___: CMV DNA not detected. IMAGING: ================================ CXR ___: IMPRESSION: Increased interstitial markings throughout the lungs with more confluent consolidation at the right lung base. Findings could be seen in the setting of pulmonary edema with possible superimposed right base infection or an atypical infection is possible. ___ ___: IMPRESSION: No evidence of deep venous thrombosis in the left lower extremity veins. Brief Hospital Course: Mr. ___ is a ___ PMHx significant for stage IV CKD (with deceased donor graft in ___, complicated by chronic allograft nephropathy), AFib, HTN, and anemia presenting with fever. ACTIVE ISSUES: =========================== # URI: Patient presented with fever, myalgias and CXR showing a possible right sided pneumonia. Patient was initially started on Oseltamivir while ruling out influenza. He continued to have fevers/chills/rigors as well as an O2 requirement, so Levofloxacin was subsequently started to cover CAP given patient's clinical appearance and chronic immunosuppresion. He improved on this regimen. After ruling out for Influenza, Oseltamivir was stopped. Patient completed a 5 day course of Levofloxacin 750mg for pneumonia. # Stage 4 CKD. Cr 4.1 on admission, uptrending steadily from 1.5 since ___. Has been on regimen of MMF and prednisone, cyclosporine with ketoconazole (decreases toxicities and cost as ketoconazole increases serum level of cyclosporine). On admission, patient appeared slightly volume overloaded in setting of being unable to take home medications. Initially Lasix, MMF, Prednisone and Cyclosporine were restarted at home dosing. Cyclosporine level up trended in setting of worsening renal function so held dose until trough was downtrending. Transplant Nephrology followed patient throughout admission and recommended increasing Prednisone to 10mg daily as well as decreasing MMF frequency. His renal function subsequently stabilized. There were no acute indications for HD this admission. Plan for follow up as outpatient, patient still with good AV fistula for HD in the future. CHRONIC ISSUES: ========================== # HTN. Stable this admission. Held home Losartan and Lasix in setting of worsening renal failure. Patient continued Amlodipine, Doxazosin, Labetalol. # HLD: Patient continued home Rosuvastatin. # Gout: Decreased home Allopurinol to 100mg daily (renal dosing). Asymptomatic. TRANSITIONAL ISSUES: =========================== - please check Cyclosporine Trough, Chem 10, CBC to be done ___ and sent to Dr. ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB 2. Allopurinol ___ mg PO DAILY 3. Amlodipine 2.5 mg PO DAILY 4. Calcitriol 0.25 mcg PO 6X/WEEK (___) 5. Colchicine 0.6 mg PO DAILY:PRN gout 6. CycloSPORINE (Sandimmune) 25 mg PO Q12H 7. Aranesp (in polysorbate) (darbepoetin alfa in polysorbat) 100 mcg/0.5 mL injection q2weeks 8. Doxazosin 4 mg PO HS 9. Vitamin D 50,000 UNIT PO 1X/WEEK (___) 10. Furosemide 240 mg PO BID 11. Ketoconazole 200 mg PO DAILY 12. Labetalol 200 mg PO BID 13. Losartan Potassium 50 mg PO DAILY 14. Mycophenolate Mofetil 500 mg PO QID 15. PredniSONE 5 mg PO DAILY 16. Rosuvastatin Calcium 5 mg PO DAILY 17. sevelamer CARBONATE 1600 mg PO TID W/MEALS 18. Sildenafil 100 mg PO PRN 1 hr before sexual activity Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB 2. Amlodipine 2.5 mg PO DAILY 3. Calcitriol 0.25 mcg PO 6X/WEEK (___) 4. Colchicine 0.6 mg PO DAILY:PRN gout 5. Doxazosin 4 mg PO HS 6. Ketoconazole 200 mg PO DAILY 7. Allopurinol ___ mg PO DAILY 8. Labetalol 200 mg PO BID 9. Mycophenolate Mofetil 500 mg PO BID 10. PredniSONE 10 mg PO DAILY RX *prednisone 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 11. Rosuvastatin Calcium 5 mg PO DAILY 12. sevelamer CARBONATE 1600 mg PO TID W/MEALS 13. Aranesp (in polysorbate) (darbepoetin alfa in polysorbat) 100 mcg/0.5 mL injection q2weeks 14. Sildenafil 100 mg PO PRN 1 hr before sexual activity 15. Vitamin D 50,000 UNIT PO 1X/WEEK (___) 16. CycloSPORINE (Sandimmune) 25 mg PO Q12H 17. Outpatient Lab Work CBC, Comprehensive Metabolic Panel including Mag, Phos, Ca, Cyclosporine Trough. ICD-9 code ___. Send results to: Dr. ___: ___ Fax: ___ Discharge Disposition: Home Discharge Diagnosis: Primary: ESRD Pneumonia Secondary: Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure participating in your care at ___ ___. You were admitted for fevers and on chest X-ray it appeared that you had a pneumonia. We treated you with antibiotics and Tamiflu in case you had exposure to Influenza. Your breathing improved and your fevers resolved. While you were here, your kidneys were not working as well as they had been. The Transplant Nephrology team followed you closely and made some recommendations on your immunosuppressant medications. Please note the changes made to your medications during this admission and continue to take them as prescribed. You will be contacted to set up a follow up appointment with Dr. ___. Please follow up with the appointments listed below. We wish you the best. Sincerely, Your ___ Team Followup Instructions: ___
10165672-DS-25
10,165,672
23,785,684
DS
25
2158-10-29 00:00:00
2158-11-04 17:07:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: chest pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo M w/ h/o ESRD on HD MWF, paroxysmal AF (not on AC), HTN who presents with CP with AF w/ RVR. The patient states he woke up about 2 hours prior to arrival to the ED with left-sided chest pain associated with left arm and jaw pain. Describes the pain as dull. Relieved with metoprolol given in ED. Felt "heavy," lightheaded, SOB. He states his symptoms are currently significantly improved. He has never had symptoms like this before. He denies nausea, diaphoresis, dizziness or additional complaints at this time. Denies aspirin use within the past week. Of note, patient had a normal stress echo on ___. In the ED, initial vitals: 98.2 124 110/63 16 100% RA Patient was triggered for tachycardia and was given IV metoprolol 5mg x 4 and 25 mg PO metoprolol tartrate. Patient was feeling lightheaded and nauseated during event. Trops were obtained and were initially 0.04 and rose to 0.30 ___KMB; he was started on heparin IV. K was noted to be 5.3 (received HD yesterday) and was given IV calcium gluconate and insulin/dextrose. On arrival to the floor he stated his symptoms were resolved, no complaints. On review of systems, he endorsed leg cramping after dialysis the day prior to presentation. He denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain prior to this morning, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema (since starting dialysis), syncope or presyncope. Past Medical History: #Gout #HTN #Stage 4 CKD, s/p deceased donor kidney transplant ___. He's had progressive renal insufficiency with recent Cr baseline in the ___ range. -immunosuppression prednisone 5mg, MMF 500mg BID, CSA 25mg q12h -access: has AV fistula from prior dialysis -bone mineral: on sevelamer -anemia: on EPO analogue #Hypercholesterolemia #Sciatica #s/p appendectiny ___ #s/p AV fistula placement RUE Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death Father d. lymphoma age ___ M: has had TB, stroke Physical Exam: ADMISSION PHYSICAL EXAMINATION: Vitals: T 98.2, BP 122/89, HR 119, RR 20, 99% on RA General: ___ man appears stated age, Lying in bed, appears comfortable, calm, interactive HEENT: sclerae clear, anicteric, PERRL, OP clear Neck: supple CV: Heart rate tachy, rhythm irregular, no murmurs, rubs, gallops Lungs: Coarse breath sounds at bases, clear in upper lobes. Breathing symmetric, non-labored. Abdomen: Soft, non-distended, non-tender to palpation GU: no CVA tenderness Extr: warm, well-perfused, no c/c/e, fistula with bruits in right forearm Neuro: moving all extremities, speech clear Skin: diffuse hyperpigmented papules and macules DISCHARGE PHYSICAL EXAM VS: T=98.2 BP= 134/76 HR 58/119 RR= ___ O2 sat= 98-99% General: ___ man appears stated age, Lying in bed, appears comfortable, calm, interactive HEENT: sclerae clear, anicteric, PERRL, OP clear Neck: supple CV: Heart rate tachy, rhythm irregular, no murmurs, rubs, gallops, JVP to 3 cm Lungs: Coarse breath sounds at bases, clear in upper lobes. Breathing symmetric, non-labored. Abdomen: Soft, non-distended, non-tender to palpation GU: no CVA tenderness Extr: warm, well-perfused, no c/c/e, fistula with bruits in right forearm. 2+ radial, dorsalis, tibial pulses Neuro: moving all extremities, speech clear Skin: diffuse hyperpigmented papules and macules Pertinent Results: ADMISSION LABS ___ 08:50PM PTT-56.1* ___ 02:32PM ___ ___ 11:51AM CK(CPK)-182 ___ 11:51AM cTropnT-0.30* ___ 11:51AM CK-MB-8 ___ 04:59AM NA+-138 K+-3.9 CL--97 TCO2-25 ___ 04:35AM GLUCOSE-89 UREA N-45* CREAT-5.5*# SODIUM-139 POTASSIUM-4.1 CHLORIDE-97 TOTAL CO2-23 ANION GAP-23* ___ 04:35AM CK(CPK)-123 ___ 04:35AM cTropnT-0.04* ___ 04:35AM CK-MB-2 ___ 04:35AM CALCIUM-8.0* PHOSPHATE-4.9* MAGNESIUM-1.9 ___ 04:35AM WBC-7.3 RBC-3.59* HGB-11.6*# HCT-36.7*# MCV-102*# MCH-32.3*# MCHC-31.6* RDW-13.2 RDWSD-49.6* ___ 04:35AM NEUTS-72.7* LYMPHS-18.0* MONOS-8.1 EOS-0.5* BASOS-0.4 IM ___ AbsNeut-5.30 AbsLymp-1.31 AbsMono-0.59 AbsEos-0.04 AbsBaso-0.03 ___ 04:35AM PLT COUNT-188 DISCHARGE LABS ___ 03:48AM BLOOD TSH-2.9 ___ 03:48AM BLOOD Albumin-4.1 Mg-2.2 ___ 03:48AM BLOOD ALT-12 AST-24 AlkPhos-124 TotBili-0.3 ___ 03:48AM BLOOD Glucose-90 UreaN-68* Creat-8.3*# Na-138 K-4.4 Cl-98 HCO3-22 AnGap-22* ___ 04:35AM BLOOD Neuts-72.7* Lymphs-18.0* Monos-8.1 Eos-0.5* Baso-0.4 Im ___ AbsNeut-5.30 AbsLymp-1.31 AbsMono-0.59 AbsEos-0.04 AbsBaso-0.03 ___ 03:48AM BLOOD WBC-5.4 RBC-3.38* Hgb-10.9* Hct-33.8* MCV-100* MCH-32.2* MCHC-32.2 RDW-13.5 RDWSD-49.8* Plt ___ Portable Chest X-Ray ___ There is no focal consolidation, effusion, or pneumothorax. Heart size is top-normal. Imaged osseous structures are intact. No acute intrathoracic process. ECG ___ Sinus rhythm with low amplitude P waves. Left ventricular hypertrophy with ST-T wave changes. The rate has slowed and sinus rhythm has appeared as compared with prior ECG of ___. Followup and clinical correlation are suggested. ___ Rate PR QRS QT QTc (___) P QRS T 73 ___ 454 16 57 106 Brief Hospital Course: Mr. ___ is a ___ year old man with a history of end stage renal disease on hemodialysis, post kidney transplant that failed now listed for second transplant, who presented to ___ ___ with chest pain and was found to have elevated troponins and atrial fibrillation with rapid ventricular response. He was treated with metoprolol and a heparin drip. He converted to sinus rhythm and became asymptomatic on monitoring over night. He was also hyperkalemic at 5.3 one day after dialysis and was given calcium gluconate, insulin and dextrose. Cardiac catheterization was indicated by positive troponins in the setting of ischemic changes seen on EKG during AF with RVR. The patient chose to return home and schedule the procedure for the following week. Amiodarone was started in hospital for prevention of atrial fibrillation. TSH and liver function enzymes were ordered and are pending upon discharge. The patient was instructed to start taking Coumadin 5 mg on ___ and to follow up for a Coumadin check with his primary care office on ___. Transitional issues: -please help arrange for outpatient cardiac cath -patient initiated on warfarin (start date = ___ dose = 5 mg) and will need continued monitoring at PCP's office -will need ___ in 6 months given initiation of amiodarone. -Name of health care proxy: ___ Relationship: daughter Phone number: ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 2.5 mg PO DAILY 2. Rosuvastatin Calcium 5 mg PO QPM 3. sevelamer CARBONATE 800 mg PO TID W/MEALS 4. Allopurinol ___ mg PO DAILY 5. PredniSONE 5 mg PO DAILY 6. Labetalol 200 mg PO BID 7. Doxazosin 4 mg PO HS 8. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H Discharge Medications: 1. Allopurinol ___ mg PO DAILY 2. Amlodipine 2.5 mg PO DAILY 3. Doxazosin 4 mg PO HS 4. Labetalol 200 mg PO BID 5. PredniSONE 5 mg PO DAILY 6. Rosuvastatin Calcium 5 mg PO QPM 7. sevelamer CARBONATE 800 mg PO TID W/MEALS 8. Warfarin 5 mg PO DAILY16 Please follow up with your PCP for regular blood tests. RX *warfarin 1 mg 5 tablet(s) by mouth daily Disp #*150 Tablet Refills:*0 9. Amiodarone 200 mg PO BID Please take 200 mg two times per day. RX *amiodarone 200 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 10. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis non-ST elevation myocardial infarction Secondary diagnosis Atrial Fibrillation with Rapid Ventricular Response End-stage renal failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, Thank you for coming to ___. It was a pleasure to meet you. You came to the hospital because you had chest pain. We learned that you were having a type of heart attack (called an NSTEMI) that is usually caused by blocked arteries in your heart. Your heart was also being strained by being in atrial fibrillation, which causes part of your heart to vibrate rapidly. Atrial fibrillation can cause blood clots and strokes. You received medications that relieved your pain, however you elected to come back at another time to fix the blockages in your heart with a procedure called cardiac catheterization. To help prevent more episodes of atrial fibrillation, you started a medication called amiodarone. It will be important for you to take amiodarone every day to prevent more episodes of atrial fibrillation. When you have your kidney transplant, you and your doctor ___ discuss whether to switch to a different medication. While on this medication, you will need to have your thyroid function, liver function, and lung function monitored. You will also start a new medication called Coumadin (also called warfarin). Coumadin helps prevent blood clots and strokes. You will need to have your blood levels measured regularly at your primary care doctor's office. It will also be important for you to talk to your doctor's office about changes in the foods you eat while you are taking Coumadin. Please follow-up with the medications listed below and follow-up with the appointments listed below. Wishing you the best, Your ___ team Followup Instructions: ___
10165672-DS-26
10,165,672
26,115,205
DS
26
2159-06-09 00:00:00
2159-06-09 15:21:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: chest pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ w/ ESRD s/p ___ renal transplant now on HD, pAF, p/w chest pain radiating to left jaw/arm, w/ epigastric abdominal pain, mild nausea, and mild SOB. The pain woke him up at 0530, and felt similar to the pain back in ___ when he had atrial fibrillation w/ VR 120s and NSTEMI per OMR. Reports epigastric pain, 3 weeks of non-bloody diarrhea, and poor PO intake. Denies fevers, vomiting. On ROS, noted to have been on a plane trip from ___ 1 month ago, and had been off Coumadin for 1 week recently for a dental procedure. Last walked 1 mile without any difficulty last night. In the ED initial vitals were: 98.1 59 171/91 18 100% RA. EKG: sinus rhythm, 1st degree block (PR 255 ms), LVH Labs/studies notable for: trop <0.01 -> 0.02 Hg 10.6 (above baseline of ___, Cr 6.2 (above baseline ___, K 5.7 -> 4.9. PE notable for epigastric tenderness. Patient was given: ASA 243, nitro x2, nitro gtt Vitals on transfer: On the floor, patient reports no relief of pain w/ nitro. When taken off the drip, does not report worsening of pain. Past Medical History: #Gout #HTN #Stage 4 CKD, s/p deceased donor kidney transplant ___. He's had progressive renal insufficiency with recent Cr baseline in the ___ range. -immunosuppression prednisone 5mg, MMF 500mg BID, CSA 25mg q12h -access: has AV fistula from prior dialysis -bone mineral: on sevelamer -anemia: on EPO analogue #Hypercholesterolemia #Sciatica #s/p appendectiny ___ #s/p AV fistula placement RUE Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death Father d. lymphoma age ___ M: has had TB, stroke Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: T 98.4 BP 150/78 HR 67 RR 18 O2 SAT 90% RA GENERAL: In NAD, appears uncomfortable. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with JVP of <8 cm. CARDIAC: PMI located in ___ intercostal space, midclavicular line. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Mild crackles at RLL. No wheezes or rhonchi. ABDOMEN: Soft, NABS. Mild epigastric TTP, moderate RUQ TTP, positive ___ sign. No guarding/rebound. No HSM. EXTREMITIES: No c/c/e. No femoral bruits. RUE w/ fisulta. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Distal pulses palpable and symmetric. DISCHARGE PHYSICAL EXAMINATION: VS: 98.4 60-90S ___ 18 97%ra GENERAL: In NAD, appears uncomfortable. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with JVP of <8 cm. CARDIAC: PMI located in ___ intercostal space, midclavicular line. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Mild crackles at RLL. No wheezes or rhonchi. ABDOMEN: Soft, NABS. Mild epigastric TTP EXTREMITIES: No c/c/e. No femoral bruits. RUE w/ fisulta. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Distal pulses palpable and symmetric. Pertinent Results: Admission Labs: ___ 07:46AM BLOOD WBC-9.4# RBC-3.59* Hgb-10.6* Hct-36.2* MCV-101* MCH-29.5 MCHC-29.3* RDW-15.5 RDWSD-58.1* Plt ___ ___ 07:46AM BLOOD Neuts-77.3* Lymphs-15.4* Monos-5.5 Eos-1.2 Baso-0.3 Im ___ AbsNeut-7.28*# AbsLymp-1.45 AbsMono-0.52 AbsEos-0.11 AbsBaso-0.03 ___ 07:57AM BLOOD ___ PTT-30.2 ___ ___ 07:46AM BLOOD Glucose-104* UreaN-51* Creat-6.2* Na-132* K-8.9* Cl-93* HCO3-23 AnGap-25* ___ 07:46AM BLOOD cTropnT-<0.01 ___ 10:00AM BLOOD cTropnT-0.02* ___ 06:30AM BLOOD CK-MB-<1 cTropnT-0.04* ___ 10:00AM BLOOD Lipase-63* ___ 10:00AM BLOOD ALT-18 AST-12 AlkPhos-165* TotBili-0.5 ___ 06:30AM BLOOD Calcium-8.3* Phos-4.6* Mg-2.3 ___ 07:33PM BLOOD D-Dimer-583* ABDOMINAL US: 1. No evidence of gallstones, biliary obstruction, or cholecystitis. 2. Atrophic native kidneys bilaterally, with right-sided simple renal cyst. CTA CHEST: No evidence of pulmonary embolism. The main pulmonary artery and the ascending thoracic aorta measured dilated at 4.3 cm and 4.5 cm respectively, similar compared to ___. Moderate cardiomegaly. DISCHARGE LABS: ___ 06:30AM BLOOD WBC-7.3 RBC-3.31* Hgb-10.0* Hct-32.0* MCV-97 MCH-30.2 MCHC-31.3* RDW-15.9* RDWSD-56.8* Plt ___ ___ 06:30AM BLOOD Glucose-105* UreaN-66* Creat-8.3*# Na-136 K-5.5* Cl-95* HCO3-24 AnGap-23* Brief Hospital Course: ___ y/o M w/ ESRD on HD, HTN, HLD, pAfib, and CAD, presenting w/ atypical chest pain. #Atypical chest pain: Constant, located more in epigastrum than chest, not relieved by nitro and not worse with exertion. No EKG changes. Troponin minimally elevated to 0.04 in the setting of ESRD and demand from high blood pressure likely precipitated by pain. Abdominal US negative and CTA negative for PE. Ultimately unable to diagnose etiology of pain. However, pain remitted without intervention and he did not require any pain medications while admitted. #Diarrhea: Diarrhea x 2 weeks prior to admission. No loose stools here so unable to send sample for analysis. #HTN: continued home amlodipine 2.5mg QD, labetalol 200mg TID #paroxysmal atrial fibrillation: currently in sinus rhythm and on warfarin. No evidence of afib on telemetry. Given elevated alkphos and TSH, amiodarone was decreased from 200 to 100mg daily. INR subtherapeutic on discharge 1.2. No bridging given CHADS2 of 1. #ESRD: ___ schedule. Received dialysis here without issue. #Transitional Issues: -Amiodarone decreased from 200mg daily to 100mg daily given elevation in TSH and alkphos. Please recheck TSH and LFTs in 3 months to evaluate response. -Warfarin continued at home dose (5mg M/F and 10mg all other days) without bridging. Should have next INR drawn on ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 2.5 mg PO DAILY 2. Doxazosin 4 mg PO HS 3. Labetalol 200 mg PO TID 4. PredniSONE 5 mg PO DAILY 5. Rosuvastatin Calcium 5 mg PO QPM 6. sevelamer CARBONATE 2400 mg PO TID W/MEALS 7. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 8. Warfarin 10 mg PO 5X/WEEK (___) 9. Warfarin 5 mg PO 2X/WEEK (MO,FR) 10. Amiodarone 200 mg PO DAILY Discharge Medications: 1. Amiodarone 100 mg PO DAILY RX *amiodarone 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Amlodipine 2.5 mg PO DAILY 3. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H 4. Doxazosin 4 mg PO HS 5. Labetalol 200 mg PO TID 6. PredniSONE 5 mg PO DAILY 7. Rosuvastatin Calcium 5 mg PO QPM 8. sevelamer CARBONATE 2400 mg PO TID W/MEALS 9. Warfarin 10 mg PO 5X/WEEK (___) 10. Warfarin 5 mg PO 2X/WEEK (MO,FR) Discharge Disposition: Home Discharge Diagnosis: Chest Pain Abdominal Pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital because of chest and stomach pain. We did not figure out exactly what was causing your pain, but it does not appear that there is anything wrong with your heart, lungs or gallbladder. Please talk to your doctor if this pain returns. Also, because you had an ultrasound of your gallbladder here, you do not need to have it done again tomorrow. We will make sure that your PCP has the results. We have already canceled the radiology appt. Please have your INR checked on ___ in ___. Sincerely, Your ___ Team Followup Instructions: ___
10165875-DS-13
10,165,875
22,545,966
DS
13
2116-09-10 00:00:00
2116-09-10 16:00:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Cetacaine Attending: ___. Chief Complaint: Anaphylaxis Major Surgical or Invasive Procedure: Laryngoscopy by ENT x2 ___ and ___ History of Present Illness: She has history of laryngeopharyngeal reflux since ___ with hoarseness. Seen at ___ ENT today for ___ removal of lesion of L vocal cord with reconstruction and local tissue flap in ___, on path no malignant cells seen. On day of admission patient had received a laryngoscopy and post-operatively received 1% lidocaine, Afrin and cetecaine (never had this medication) after the procedure. Patient then went to the parking lot, and then felt an acute onset of dyspnea, throat swelling, and urticarial with pruritus. Patient then went back to urgent care and received Benadryl 50 mg, Benadryl 25 mg (10:07), and then received 2 doses of epi-pen (9:15 and 9:58), and solumedrol IV (10:06 AM). Patient then referred to the ___ ED given persistent symptoms. In the ED, initial vitals: T 97, BP 131/100, RR 15, 100% RA On exam: BUE urticarial, no wheeze, hydrops uvula Labs were significant for: wbc 7.7, hgb 14, Cr 1.2 (baseline 0.8-1), AG 23, ast 43, tn < 0.01 Imaging was significant for: No acute cardiopulmonary process on CXR. EKG w/ HR 96, NSR, LAD, LAFB, borderline RBBB, no STE/STD/TWI Consults: ENT Patient received: Patient was given DuoNeb and albuterol nebs, started on epinephrine gtt, glycopyrrolate, famotidine, racemic epinephrine, IV Tylenol, dexamethasone 10mg x2 and epinephrine pen x 2. Her stridor and rash initially improved, but then she had new voice changes concerning for worsening airway edema. She was seen emergently by ENT who did laryngoscopy revealing anterior swelling (tongue and uvula) with normal glottis. Intubation was deemed unnecessary at the time. She was transferred to the ICU for airway monitoring. Past Medical History: Laryngeopharyngeal reflux since ___ with hoarseness HTN DM last A1C 9.6 ___ obesity HL Mild asthma Social History: ___ Family ___: Not assessed Physical Exam: ADMISSION PHYSICAL EXAM ====================== Vitals: T: Afebrile BP: 160/70 P: 122 R: 17 O2: 94% GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, ___ swelling and hoarseness, nasal trumpet in place NECK: supple, JVP not elevated, no LAD LUNGS: Mild wheeze bilaterally CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: No foley in place EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: No lesions. No urticarial. NEURO: A&O x3. CN II-XII intact. Sensation, strength intact. DISCHARGE PHYSICAL EXAM ====================== VS: 97.3 146 / 85 82 18 95 RA GENERAL: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, Mild asymmetric lip swelling. No tongue or uvula swelling visualized. NECK: supple, JVP not elevated, no LAD LUNGS: CTAB CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: No foley in place EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: No lesions. No urticarial. NEURO: A&O x3. CN II-XII intact. Sensation, strength intact. Pertinent Results: ADMISSION LAB RESULTS ==================== ___ 10:20AM BLOOD WBC-7.7 RBC-4.89 Hgb-14.1 Hct-42.6 MCV-87 MCH-28.8 MCHC-33.1 RDW-13.4 RDWSD-41.4 Plt ___ ___ 10:20AM BLOOD Neuts-31.9* Lymphs-60.2* Monos-6.6 Eos-0.9* Baso-0.1 Im ___ AbsNeut-2.44 AbsLymp-4.62* AbsMono-0.51 AbsEos-0.07 AbsBaso-0.01 ___ 10:20AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-1+ Ovalocy-OCCASIONAL ___ 04:20AM BLOOD ___ PTT-26.7 ___ ___ 10:20AM BLOOD Glucose-205* UreaN-28* Creat-1.2* Na-134 K-5.7* Cl-91* HCO3-20* AnGap-29* ___ 04:20AM BLOOD Glucose-200* UreaN-36* Creat-1.2* Na-138 K-4.3 Cl-97 HCO3-24 AnGap-21* ___ 10:20AM BLOOD ALT-23 AST-43* AlkPhos-47 TotBili-0.4 ___ 10:20AM BLOOD Lipase-41 ___ 10:20AM BLOOD cTropnT-<0.01 ___ 04:20AM BLOOD Albumin-4.5 Calcium-9.2 Phos-2.8 Mg-1.5* ___ 04:26AM BLOOD ___ pO2-94 pCO2-40 pH-7.44 calTCO2-28 Base XS-2 ___ 04:26AM BLOOD Lactate-3.8* DISCHARGE LAB RESULTS ==================== ___ 10:20AM PLT SMR-NORMAL PLT COUNT-279 ___ 06:00AM BLOOD WBC-9.2 RBC-4.09 Hgb-11.5 Hct-35.7 MCV-87 MCH-28.1 MCHC-32.2 RDW-13.6 RDWSD-43.0 Plt ___ ___ 06:00AM BLOOD Plt ___ ___ 06:00AM BLOOD Glucose-262* UreaN-33* Creat-0.9 Na-137 K-4.4 Cl-95* HCO3-26 AnGap-20 ___ 06:00AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.3 IMAGING/STUDIES: ============== CXR ___: No acute cardiopulmonary process. Fiberoptic exam (___): In the context of the patient's clinical presentation and the need to visualize the regions in close proximity, the decision was made to proceed with an endoscopic exam. Accordingly, after verbal consent, the fiberoptic scope was passed to visualize the regions of concern. The findings were: Nasal cavity: Turbinate mucosa pink, moist, no pus or polyps, significant clear mucous in nasopharynx and nasal cavity, Nasopharynx: Watery edema of soft palate Oropharynx: Symmetric soft palatal elevation, no mucosal lesions, masses, or erythema, tongue base without lesions Hypopharynx: No masses or lesions in vallecula, mild edema of piriform sinuses, no post-cricoid edema; no erythema; mild pooling of secretions Larynx: Epiglottis crisp, mild edema just at the tip of the epiglottis; True vocal cords symmetric with normal movement bilaterally; Arytenoids without erythema, normal movement of vocal processes, crisp arytenoids. MICROBIOLOGY: ============= none Brief Hospital Course: ___ w/ PMH of asthma, HTN, DM, HLD admitted for anaphylaxis. She presented with shortness of breath, throat swelling, urticaria thought to be reaction to topical cetecaine applied to the airway during an outpatient ENT procedure. She was treated with diphenhydramine, epipen, IV solumedrol then placed on a epinephrine gtt in the ED. Repeat ENT scope in the ED showed swelling of the uvula and soft palate, but clear airway. Patient was admitted to ICU for airway monitoring but never required intubation. She was treated with cetirizine and IV dexamethasone in the ICU. Repeat laryngoscope on ___ showed resolved edema. She was subsequently transferred to the floor on ___, then discharged on ___ with plan for outpatient follow up with her PCP and ___. She was discharged on a steroid taper, cetirizine, and with an Epi-Pen. She was also instructed to check her fingerstick qAM while on steroids and report values >350 to her PCP. ACUTE ISSUES: # Anaphylaxis: as above. # ___: Mildly elevated on admission, likely pre-renal in setting of hypotension from anaphylaxis. Resolved and returned to baseline 1.0. CHRONIC ISSUES: #Asthma: cont flovent 110 mcg. duonebs q6h. #DM: holding home metformin 1g BID in the setting of ___. ISS #HTN: Held home chlorthalidone 25 mg qd and erbesartan 300 mg qd while on epinephrine gtt. Restarted on discharge #HLD: Continued home pravastatin 80 mg qd #GERD: Continued home omeprazole 20 mg qd TRANSITIONAL ISSUES: - Discharged on 5-day prednisone taper (30mg x2 days, then 20mg x 2 days, then 10mg x1 day), as well as cetirizine daily. - Discharged with Epi-Pen x2. - Blood sugars were in the 200s during admission in the setting of IV steroids, controlled with insulin sliding scale. Patient discharged with instructions to check fingerstick using glucometer at home and call PCP ___ >350. Please re-check sugar at next clinic visit. - Plan for outpatient follow up in allergy clinic (appointment scheduled for ___ # Code: Full Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze 2. Pravastatin 80 mg PO QPM 3. Omeprazole 20 mg PO DAILY 4. MetFORMIN (Glucophage) 1000 mg PO BID 5. Chlorthalidone 25 mg PO DAILY 6. irbesartan 300 mg oral DAILY Discharge Medications: 1. Cetirizine 10 mg PO DAILY RX *cetirizine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection BID:PRN RX *epinephrine [EpiPen 2-Pak] 0.3 mg/0.3 mL 1 injection INJ PRN Disp #*2 Each Refills:*0 3. OneTouch Ultra Test (blood sugar diagnostic) miscellaneous BID:PRN RX *blood sugar diagnostic [OneTouch Ultra Test] PRN Disp #*50 Strip Refills:*0 4. OneTouch Ultra2 (blood-glucose meter) miscellaneous DAILY RX *blood-glucose meter daily Disp #*1 Kit Refills:*0 5. OneTouch UltraSoft Lancets (lancets) miscellaneous BID:PRN RX *lancets [OneTouch UltraSoft Lancets] PRN Disp #*100 Each Refills:*0 6. PredniSONE 30 mg PO DAILY Duration: 2 Doses This is dose # 1 of 3 tapered doses RX *prednisone 10 mg ___ tablet(s) by mouth daily Disp #*11 Tablet Refills:*0 7. PredniSONE 20 mg PO DAILY Duration: 2 Doses This is dose # 2 of 3 tapered doses 8. PredniSONE 10 mg PO DAILY Duration: 1 Dose This is dose # 3 of 3 tapered doses 9. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze 10. Chlorthalidone 25 mg PO DAILY 11. irbesartan 300 mg oral DAILY 12. MetFORMIN (Glucophage) 1000 mg PO BID 13. Omeprazole 20 mg PO DAILY 14. Pravastatin 80 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Anaphylaxis SECONDARY DIAGNOSIS: Hypertension Laryngeopharyngeal reflux Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, You were admitted to ___ because you were having an allergic reaction called anaphylaxis. We believe this was due to a drug called "cetecaine" that you got during your ENT procedure. You were treated with steroids and monitored in the ICU, and you improved. After you leave the hospital: - You should see an allergy doctor and your ENT doctor again. Please see the appointments we made for you below. - Please check your pre-breakfast blood sugars using your glucometer every day until you see your doctor again. If the value is more than 350, please call your primary care doctor Dr. ___ at ___ - Please take 30mg of prednisone on ___ and ___, 20mg on ___ and ___, 10mg on ___ and then stop taking it entirely. We wish you all the best! - Your ___ care team Followup Instructions: ___
10165902-DS-17
10,165,902
25,888,675
DS
17
2152-09-30 00:00:00
2152-10-07 14:16:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Confusion Major Surgical or Invasive Procedure: None History of Present Illness: ___ is an ___ RH F with h/o MCI, hypertension, hyperlipidemia, hypothyroidism and remote lung cancer who is referred from Neurology clinic for worsening word-finding difficulties in the setting of paranoia and perseverative behavior surrounding Social Security/Medicaid issues. Per her daughter ___, who provides majority of history, patient has had difficulties finding words for the past ___ years (see below for details). However, things became acutely worse on ___, ___, when Ms. ___ received a package of medications in the mail. She became increasingly anxious and obsessive about drug coverage and health insurance. The following morning, her daughter visited her and found her extremely concerned and consumed by the insurance issue. She was taken the the ED, where she had a head CT that was unrevealing except for mild global atrophy. Seen by neurology who noted perseverative thoughts but no significant aphasia. She was discharged with scheduled neurology followup. Today, she was seen by Dr. ___ in clinic who noted an anomia (couldn't name ___ or "Superbowl" or any items on ___ stroke card), impaired repetition, and trouble following complex commands. She sent pt to ED for stroke workup. Per pt's daugher's report, Ms. ___ had neurocognitive testing ___ ago that revealed issues in memory. ___ ago she was told that she could not drive because of "difficulty follwing directions." Ms. ___ family has not noticed any glaring memory deficits or functional impairments, but they have noted occasional inability to remember names and difficulty with word finding over the past ___ years. Of note, there was documentation from ___ of a cognitive evaluation showing difficulties at that time. Although it is documented as ___, the MOCA is out of 30 and given the difficulties reported I suspect it was ___.. "performed a ___ Cognitive Assessment exam, on which she scored ___. She had deficits on the visuospatial/executive portion with the trails and cube drawing. Her naming was mildy impaired - she was able to name ___ low frequency objects She was unable to register 5 words or recall them at 5 minutes Attention was intact, with 5-digit forward and 3-digit reverse digit span and serial 3s. On language, repeptition was impaired but fluency was intact Abstraction was intact. She was oriented to day of week, month, year, place, city, and self." Neuro and General ROS: positive per above, otherwise negative. No changes to her medications recently except for starting Klonopin two days ago (rx by PCP) which made her sleepy. Past Medical History: PAST MEDICAL HISTORY - HTN: lisinopril increased from 5 -> 10 mg in ___ - HLD: Controlled on simva ___ lipids TC 177 HDL 97 LDL 64) - Hypothyroidsim: TSH in ___ = 2.4 - Lung cancer s/p resection in ___ - Hepatitis B (apparently not an active issue) - Osteoporosis: On alendronate from ___ - ___ and was restarted in ___. Takes Ca citrate and Vitamin D. - Word finding issues: long-standing problem. According to the daughter, no e/o other cognitive problems - RBBB, PVCs - Cholelithiasis - GERD - Glaucoma - Intertrigo Social History: ___ Family History: Father died age ___ MI Mother died age ___ heart failure brother died age ___ due to MI, had DM son h/o addiction to dexadrine, h/o depression Physical Exam: ADMISSION EXAM - Vitals: 97.6 61 158/59 18 100% RA - General: appears younger than stated age, NAD - HEENT: NC/AT - Neck: Supple, no carotid bruits appreciated. - Pulmonary: CTABL - Cardiac: RRR, no murmurs - Abdomen: soft, nontender, nondistended - Extremities: no edema, pulses palpated - Skin: no rashes or lesions noted. NEURO EXAM: - Mental Status: Awake, alert, oriented x 3. Inattentive on ___ backward (stops at ___ but can complete ___ backward. Perseverates obsessively on perceived issues surrounding her medicare coverage. When discussing this, she speaks in a slow and halting manner and has difficulty retrieving the words to describe her situation. However, when distracted to discuss other things (e.g. her grandchildren) she speaks more fluently, in mostly full sentences with fewer pauses. She has an extremely mild anomia to low-frequency objects (misses "cuticle"). Repetition is intact except for trouble saying "no ifs ands or buts". Follows midline and appendicular commands. Reading and writing are intact. No dysarthria. No paraphasic errors. Normal prosody. Mild ideomotor apraxia without frontal signs. No neglect. - Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to finger counting. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. - Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 5 - Sensory: No deficits to light touch throughout. No extinction to DSS. - DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. - Coordination: Subtle dysmetria on FNF bilaterally. No intention tremor. - Gait: Not tested. DISCHARGE EXAM: Unchanged. Pertinent Results: ___ 03:53PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 12:32PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 12:32PM WBC-5.7 RBC-4.79 HGB-14.5 HCT-43.4 MCV-91 MCH-30.3 MCHC-33.4 RDW-13.0 MRI FINDINGS: There is no acute infarct or intracranial hemorrhage. There are nonspecific small scattered T2/FLAIR high signal foci throughout the brain which may be sequela of chronic microvascular changes. Gray white matter differentiation is maintained. Ventricular, cisternal, sulcal prominence may be a function of age-related parenchymal volume loss. The major intracranial vessels exhibit the expected signal void related to vascular flow. No abnormal enhancement is appreciated. The paranasal sinuses demonstrate scattered areas of mucosal thickening. The mastoid air cells demonstrate normal signal. The sella turcica, craniocervical junction, and orbits are unremarkable. IMPRESSION: Age-related involutional and chronic microvascular angiopathic changes without acute infarct, hemorrhage, mass effect, or abnormal enhancement appreciated. Brief Hospital Course: Ms. ___ was admitted to the stroke service to rule out stroke as a cause of her recent confusion and acutely worsened word-finding difficulties. Upon admission, she was started on a baby aspirin in addition to her other home medications. Toxic/metabolic/infectious workup, including thyroid studies and calcium were all wnl. MRI brain with and without contrast was performed that showed no abnormalities. Therefore, aspirin was discontinued. Her klonopin, recently started by her PCP, ___. As she was noted to be quite perseverative on her healthcare insurance issues (confirmed to be delusional by daughter), which provoked much anxiety, she was started on PRN seroquel 12.5mg BID, which she tolerated well. When distracted, Ms. ___ did exhibit some moderate cognitive deficits but was still able to carry on conversation and remember things such as the names of her home medications. It was confirmed by her daughter that until ___ she had been very independent at home, able to cook and clean for herself, as well as take her medications on her own. She was seen by occupational therapy for cognitive and home safety evaluation, and it was determined that she would need 24 hour supervision upon discharge. This was set up upon discharge, with her daughter. OUTSTANDING ISSUES [ ] Has cognitive neurology evaluation scheduled next week [ ] Titrate seroquel as needed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 20 mg PO DAILY 2. Levothyroxine Sodium 50 mcg PO DAILY 3. ClonazePAM 0.5 mg PO TID 4. Alendronate Sodium 70 mg PO 1X/WEEK (MO) 5. brinzolamide 1 % ophthalmic BID 6. Calcipotriene 0.005% Cream 1 Appl TP BID 7. ciclopirox 8 % topical DAILY to nail 8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 9. Timolol Maleate 0.5% 1 DROP BOTH EYES QAM 10. Multivitamins 1 TAB PO DAILY 11. Fish Oil (Omega 3) 1000 mg PO DAILY 12. Atorvastatin 10 mg PO DAILY Discharge Medications: 1. Atorvastatin 10 mg PO DAILY 2. brinzolamide 1 % ophthalmic BID 3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 4. Levothyroxine Sodium 50 mcg PO DAILY 5. Lisinopril 20 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Timolol Maleate 0.5% 1 DROP BOTH EYES QAM 8. QUEtiapine Fumarate 12.5 mg PO BID:PRN agitation RX *quetiapine 25 mg 0.5 (One half) tablet(s) by mouth QHS PRN Disp #*30 Tablet Refills:*0 9. Alendronate Sodium 70 mg PO 1X/WEEK (MO) 10. Calcipotriene 0.005% Cream 1 Appl TP BID 11. ciclopirox 8 % topical DAILY to nail 12. Fish Oil (Omega 3) 1000 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Dementia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the stroke service at ___ to rule out stroke as a cause of your recent confusion. MRI was performed which showed that there was no stroke. Your laboratory studies, including electrolytes, blood counts, thyroid studies, calcium and an infectious workup was negative. Your recent confusion was determined to be secondary to a stress reaction superimposed on a chronicly progressive dementia. We started a medication called seroquel to be used as needed for agitation, and we have scheduled you with a follow up in the cognitive neurology clinic as listed below. It was a pleasure taking care of you during this hospital stay. Followup Instructions: ___
10165902-DS-18
10,165,902
28,082,290
DS
18
2154-10-06 00:00:00
2154-10-06 12:29:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: altered mental status Major Surgical or Invasive Procedure: Lumbar puncture History of Present Illness: ___ is a ___ F with history of Dementia (MoCA ___ with word finding difficulty (AAOx3 at baseline), HTN, HLD who presented to the ED with confusion and worsened productive speech. History obtained from her daughter as pt is unable given her AMS. Per her daughter,Ms. ___ was in her usual state of health (some cognitive delay but AAOx3, interactive, receptive to commands, largely functional) until approximately 2 days ago. She notes that her mother was intermittently sluggish, but usually her normal self. The morning of admission, a new ___ worked with her and per report, had a "good session." Her home health aid who knows her saw her at 10am. Per her report, the pt was interactvie but "confused." The home health aid cannot be reached for further clarification. Her daughter came back home at 1pm and which time saw her mother behaving oddly: she did not have on her coat (as was expected as they were going to a clinic apt), and her pills were astrewn on the desk table. When asked why her pills were like this, her mother began ___ about a woman but did not relate this woman to the pills. Her daughter brought the pt gloves, and the pt was not able to put on the glove. They went to her scheduled Cognitivie Neurologist appt, but upon arrival realized he did not have hearing aids, which is very unusual for the pt. Due to this, they returned home. Her daughter states that she began to further perserverate about an unknown woman and reciting her phone numver repeatedly. Of note, the pt had an episode ___ years ago, where she kept ___, thought to be secondary to stress. Given this, her daughter brought her to the ED. Denies any trauma, physical or emotional. In the ED 97.9 73 161/74 20 99% RA Labs notable for: CBC WNL, Lytes WNL, lactate 3.2 --> 1.6 with fluids. U/A with ketones. Tox negative Physical exam notable for: Awake, alert, not oriented, marked word finding difficulty w/repetition of thoughts. Able to follow commands. ___ strength in all extremities, symmetric facies, CN II-XII intact. Symmetric reflexes, sensation grossly intact Imaging: CTH without acute pathology; CXR with ?PNA Neuro consulted in ED: pt noted to be alert but inattentive with mild anomia, intact repeition, following commands. PE: Awake, alert, not oriented, marked word finding difficulty w/repetition of thoughts. Able to follow commands. ___ strength in all extremities, symmetric facies, CN II-XII intact. Symmetric reflexes, sensation grossly intact Patient was given ___ 00:20 IVF 1000 mL NS 500 mL ___ 00:20 IV CeftriaXONE 1 gm ___ 01:32 IV Levofloxacin 750 mg Upon arrival, pt noted to be sitting in bed, looking attentively at her daughter at the foot of the bed, leaning on her R elbow -- a position her daughter states she has been holding for 4 hours, with her L arm outstretched to her daughter. When questioned, she makes mumbling sounds, but is unable to offer her name. She can repeat back some words, but cannot identify a pen or other objects. Daughter endorses history as above, denies constipation or any infectious symptoms preceding her change in mental status. Past Medical History: PAST MEDICAL HISTORY - HTN: lisinopril increased from 5 -> 10 mg in ___ - HLD: Controlled on simva ___ lipids TC 177 HDL 97 LDL 64) - Hypothyroidsim: TSH in ___ = 2.4 - Lung cancer s/p resection in ___ - Hepatitis B (apparently not an active issue) - Osteoporosis: On alendronate from ___ - ___ and was restarted in ___. Takes Ca citrate and Vitamin D. - Word finding issues: long-standing problem. According to the daughter, no e/o other cognitive problems - RBBB, PVCs - Cholelithiasis - GERD - Glaucoma - Intertrigo Social History: ___ Family History: Father died age ___ MI Mother died age ___ heart failure brother died age ___ due to MI, had DM son h/o addiction to dexadrine, h/o depression Physical Exam: ADMISSION: VITALS - 96.2 155/80 60 26 97%RA GENERAL - elderly female, lying in bed sitting on R elbow, L arm outstretched HEENT - normocephalic, atraumatic, NECK - supple, no LAD, no thyromegaly, JVP flat CARDIAC - regular rate & rhythm, normal S1/S2, no murmurs rubs or gallops PULMONARY - poor inspiratory effort, relatively clear, transmitted upper airway sounds ABDOMEN - normal bowel sounds, soft, non-tender, non-distended, no organomegaly GU: with diaper EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or edema SKIN - without rash NEUROLOGIC/Psych - moving all extremites with stimulus without purpose; able to repeat "cherry". Cannot state hername. cannot repeat "car". Cannot identify pen. Tremulous. DISCHARGE: Vitals: 97.9 106-119/39-53 ___ 18 97RA General: frail, wakes up to voice and makes eye contact, speaking HEENT: PERRL Neck: supple, no ___ ___: Clear to auscultation bilaterally, few crackles in bases CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: no lesions noted Neuro: able to follow commands, strength ___ in all extremities, able to say short phrases and answers questions appropriately Pertinent Results: ADMISSION LABS: ___ 05:56PM BLOOD WBC-6.4 RBC-4.99 Hgb-14.8 Hct-44.9 MCV-90 MCH-29.7 MCHC-33.0 RDW-13.8 RDWSD-45.7 Plt ___ ___ 08:18PM BLOOD ___ PTT-35.1 ___ ___ 05:56PM BLOOD Glucose-110* UreaN-25* Creat-1.0 Na-140 K-4.3 Cl-103 HCO3-27 AnGap-14 ___ 08:18PM BLOOD Albumin-4.8 Calcium-10.1 Phos-3.7 Mg-2.1 ___ 08:18PM BLOOD ALT-31 AST-34 AlkPhos-83 TotBili-0.6 ___ 07:00AM BLOOD VitB12-1106* ___ 08:18PM BLOOD TSH-2.0 ___ 08:18PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 08:32PM BLOOD Lactate-3.2* ___ 01:43AM BLOOD Lactate-1.2 OTHER PERTINENT LABS: ___ 01:12PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-80* Polys-0 ___ ___ 01:13PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-10* Polys-27 ___ ___ 01:12PM CEREBROSPINAL FLUID (CSF) TotProt-42 Glucose-82 ___ 01:12PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS PCR-NEGATIVE DISCHARGE LABS: = = = = = = = = = = ================================================================ IMAGING CT HEAD ___ No evidence of acute large territorial infarction or hemorrhage. MR is a more sensitive modality in the detection of acute ischemia. CXR ___ Nodular opacities within the right lung may reflect vessels on end although infectious etiology is difficult to exclude. EEG ___ IMPRESSION: This is an abnormal apparently waking EEG due to the presence of a slower than normal, but otherwise symmetric, background. This finding can be seen in patients with significant bilateral or deeper midline subcortical dysfunction. Given the significant muscle and movement artifact present in this recording, subtle findings may have been obscured. CTA CHEST ___ No evidence of pulmonary embolism or aortic dissection. No signs of aspiration or pneumonia. MRI HEAD W & W/O CONTRAST ___ 1. Parenchymal involutional changes, as well as signal abnormalities in the supratentorial white matter and pons which are likely secondary to chronic small vessel ischemic disease in this age group, are similar to ___. 2. No evidence for acute infarction, other acute intracranial abnormalities, or intracranial mass. = = = = = = = = = = ================================================================ CYTOLOGY- CSF ___ CEREBROSPINAL FLUID: NEGATIVE FOR MALIGNANT CELLS. = = = = = = = = = = ================================================================ ___ 11:08 am CSF;SPINAL FLUID Source: LP #3. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Preliminary): NO GROWTH. Enterovirus Culture (Pending): Brief Hospital Course: Mrs. ___ ___ yo F with history of word-finding difficulties, HTN, HLD who presents from home after her daughter found her to be more confused, unable to perform IADLs, and unable to speak. Extensive work up revealed no identifiable cause of altered mental status, though patient improved towards end of hospitalization. Discharged to rehab with neurology follow up. Investigations/Interventions: 1. Toxic/metabolic encephalopathy: patient with history of word finding difficulties but had acute worsening in addition to confusion. Differential diagnosis included hemorrhagic vs ischemic stroke, seizure, metabolic abnormality, encephalitis, meningitis. Extensive workup included EEG, CT head, MRI head, lumbar puncture. Lab work routinely normal to rule out metabolic process. Neurology consulted and also suggested Hashimoto encephalopathy as possibility, but serology for anti-TPO and thyroglobulin antibodies negative. Ultimately no cause of encephalopathy was identified. She required occasional Zydus for agitation/insomnia at night. She did show improvement through hospitalization, with day of discharge showing ability to answer appropriately to questions, speak in short phrases, walk, control urination, and swallow ground solids/thin liquids. Discharged to rehabilitation with follow up with outpatient neurologist Dr. ___. Transitional Issues [] Patient had soft blood pressures (100s-110s systolic) so home lisinopril discontinued; restart as needed at rehab [] Patient started on Zydus 5mg qhs prn insomnia to assist in sleep-wake cycle; please continue/discontinue as needed at rehab [] Enterovirus culture from CSF prelim negative at time of discharge [] Patient should follow up with neurologist Dr. ___ on ___, ___ [] Patient should engage in discussion with PCP regarding use of Asa for prevention of MI # CODE: Full # CONTACT: ___ (DAUGHTER) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 30 mg PO DAILY 2. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY 3. Alendronate Sodium 70 mg PO QSUN 4. Atorvastatin 10 mg PO QPM 5. brinzolamide 1 % ophthalmic 1 drop both eyes twice daily 6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 7. Levothyroxine Sodium 50 mcg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Alendronate Sodium 70 mg PO QSUN 2. Atorvastatin 10 mg PO QPM 3. brinzolamide 1 % ophthalmic 1 drop both eyes twice daily 4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 5. Levothyroxine Sodium 50 mcg PO DAILY 6. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY 7. Multivitamins 1 TAB PO DAILY 8. Vitamin D 1000 UNIT PO DAILY 9. OLANZapine (Disintegrating Tablet) 5 mg PO QHS:PRN agitation or insomnia Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Toxic-metabolic encephalopathy Secondary: Hypertension Hyperlipidemia Hypothyroidism Discharge Condition: Activity Status: Ambulatory - requires assistance or aid (walker or cane). Level of Consciousness: Lethargic but arousable. Mental Status: Confused - sometimes. Discharge Instructions: Mrs. ___, ___ were hospitalized for difficulty finding words and confusion. We performed an extensive workup and ultimately were unable to find a definitive reason for your confusion. ___ were improving so we discharged ___ to a rehabilitation facility to help facilitate your recovery. It was a pleasure taking care of ___! Your ___ teamm Followup Instructions: ___
10165902-DS-19
10,165,902
21,807,075
DS
19
2155-04-08 00:00:00
2155-04-08 17:17:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: right hip pain after fall Major Surgical or Invasive Procedure: trochanteric fixation nail ___ History of Present Illness: ___ with hx osteoporosis, dementia presenting with right hip pain after a fall. She lives in an assisted living and walks without assistance at baseline. She fell out of bed this morning and onto her right side. She had immediate right hip pain and was unable to stand at that time. Brought to ED where she continued to complain of right hip pain. Notably has word finding difficulties which per her daughter is at her baseline. Got head and neck CT scans in the ED which were negative for acute traumatic injuries. Past Medical History: PAST MEDICAL HISTORY - HTN: lisinopril increased from 5 -> 10 mg in ___ - HLD: Controlled on simva ___ lipids TC 177 HDL 97 LDL 64) - Hypothyroidsim: TSH in ___ = 2.4 - Lung cancer s/p resection in ___ - Hepatitis B (apparently not an active issue) - Osteoporosis: On alendronate from ___ - ___ and was restarted in ___. Takes Ca citrate and Vitamin D. - Word finding issues: long-standing problem. According to the daughter, no e/o other cognitive problems - RBBB, PVCs - Cholelithiasis - GERD - Glaucoma - Intertrigo Social History: ___ Family History: Father died age ___ MI Mother died age ___ heart failure brother died age ___ due to MI, had DM son h/o addiction to dexadrine, h/o depression Physical Exam: ADMISSION PHYSICAL EXAM: =================== Vitals: AFVSS General: A&Ox3, NAD, some word finding difficulties Heart: Regular rate and rhythm peripherally Lungs: Breathing comfortably on room air. Skin: 2x skin tears to right lateral elbow with no pain with AROM/PROM Right lower extremity: - Skin intact - Shortened 1cm, externally rotated - Soft, non-tender thigh and leg with tenderness at greater trochanter - Full, painless ROM at ankle - Fires ___ - SILT S/S/SP/DP/T distributions - 2+ ___ pulses, WWP DISCHARGE PHYSICAL EXAM: ==================== VS - T 98.6-98.8, BP 119-127/44-47, P 73-79, RR ___, O2sat 95-97% on RA General: Awake, sitting up in bed. Oriented to self, not to place or time; although unclear whether this is due to word finding difficulty HEENT: Normocephalic, atraumatic. EOMI, PERRL. MMM. Neck: No evidence of JVD CV: RRR, no murmurs, rubs, or gallops Lungs: CTA anteriorly Abdomen: Soft, +abdominal bruit Ext: Surgical site c/d/i. Neuro: Oriented to person, not to place or time. Attention unable to be assessed due to patient's waxing and waning nature and baseline word finding difficulties. CN grossly intact. Pertinent Results: ADMISSION LABS: =============== ___ 07:20AM BLOOD WBC-5.3 RBC-4.70 Hgb-13.7 Hct-41.8 MCV-89 MCH-29.1 MCHC-32.8 RDW-13.7 RDWSD-44.9 Plt ___ ___ 07:20AM BLOOD Neuts-66.3 ___ Monos-7.3 Eos-0.8* Baso-0.4 Im ___ AbsNeut-3.54 AbsLymp-1.31 AbsMono-0.39 AbsEos-0.04 AbsBaso-0.02 ___ 08:38AM BLOOD ___ PTT-29.9 ___ ___ 07:20AM BLOOD Glucose-151* UreaN-29* Creat-1.0 Na-140 K-4.2 Cl-100 HCO3-24 AnGap-20 ___ 10:00AM URINE Color-Yellow Appear-Clear Sp ___ ___ 10:00AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG DISCHARGE LABS: =============== ___ 04:42AM BLOOD WBC-6.7 RBC-3.54* Hgb-10.0* Hct-32.0* MCV-90 MCH-28.2 MCHC-31.3* RDW-14.3 RDWSD-47.9* Plt ___ ___ 04:42AM BLOOD Plt ___ ___ 04:42AM BLOOD Glucose-123* UreaN-19 Creat-0.8 Na-139 K-3.7 Cl-102 HCO3-27 AnGap-14 ___ 04:42AM BLOOD Calcium-8.1* Phos-2.5* Mg-1.9 IMAGING: =============== Pelvis Femur X-ray (___) IMPRESSION: Acute, intratrochanteric fracture of the right femoral neck. CT Head without contrast (___) IMPRESSION: No fracture or acute intracranial process. CT C-spine without contrast (___) IMPRESSION: No fracture or malalignment in the C-spine. Degenerative changes as detailed above. CXR (___) IMPRESSION: No acute intrathoracic process LOWER EXTREMITY FLUORO (___) IMPRESSION: Fluoroscopic images show placement of a fixation device about fracture of the femur. Further information can be gathered from the operative report. Hip Xray (___): IMPRESSION: Fluoroscopic images show placement of a fixation device about fracture of the femur. Further information can be gathered from the operative report. Brief Hospital Course: ___ female with hx osteoporosis and dementia presenting with right hip pain after a fall s/p surgical fixation on ___ and subsequently transferred to the medicine service for ongoing delirium. The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a right intertrochanteric and a right subtrochanteric fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for a trochanteric fixation nail, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. She was then transferred to the medicine service for management of delirium, as seen below: #Delirium- Patient has a history of dementia, and at baseline has word finding difficulties. However, patient had acute onset of delirium post-surgery with visual hallucinations and more confusion. This could have been precipitated by the surgical procedure itself vs oxycodone use post-procedure. Patient was discontinued from oxycodone and started on tramadol. However, even standing doses of tramadol were discontinued because they were also felt to precipitate the patient's delirium and not relieve her pain effectively. #Intertochanteric fracture s/p surgical fixation- Patient is s/p fall and was taken to the OR on ___. The patient tolerated the trochanteric fixation nail well. Pain was controlled initially with oxycodone and then with acetaminophen and tramadol. ___ also evaluated the patient during this hospital stay. Patient initially was on lovenox that was transitioned to SC heparin for anticoagulation post-procedure due to decreased renal function. However, after her renal function returned to baseline patient was switched to Lovenox, 30mg SC QPM. This should be continued for two weeks after discharge. #Urinary retention- Patient had an episode of urinary retention post-surgery that required a foley catheter. A voiding trial was attempted the following day but patient retained 800 cc and experienced overflow incontinence. Thus, foley was reinserted and patient has been producing yellow urine without issue. Foley should be left in until ___, at which point another voiding trial can be attempted. #Anemia- Patient had a drop in her hemoglobin post-procedure likely due to blood loss during the procedure. She was given 2U pRBCs and her hemoglobin remained stable during the rest of her hospitalization. TRANSITIONAL ISSUES: =================== - Medications added: lovenox, acetaminophen - Medications stopped: alendronate. Consider restarting in outpatient setting. - Keep foley in place until ___, at which point a voiding trial can be attempted. - Follow-up in the Orthopaedic Trauma Clinic 14 days post-operation for evaluation. Call ___ to schedule appointment upon discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 10 mg PO QPM 2. brinzolamide 1 % ophthalmic 1 drop both eyes twice daily 3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 4. Levothyroxine Sodium 50 mcg PO DAILY 5. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY 6. Vitamin D 1000 UNIT PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Alendronate Sodium 70 mg PO weekly Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Atorvastatin 10 mg PO QPM 3. brinzolamide 1 % ophthalmic 1 drop both eyes twice daily 4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 5. Levothyroxine Sodium 50 mcg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY 8. Vitamin D 1000 UNIT PO DAILY 9. HELD- Alendronate Sodium 70 mg PO weekly. This medication was held. Do not restart Alendronate Sodium until you see your PCP. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Delirium Intertrochanteric fracture Anemia Secondary: HTN Osteoporosis Hypothyroidism Hyperlipidemia GERD Glaucoma Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - Weight bearing as tolerated MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take Lovenox daily for 2 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining. Followup Instructions: ___
10165963-DS-7
10,165,963
28,362,771
DS
7
2157-04-25 00:00:00
2157-04-25 17:55:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: surgical tape Attending: ___. Chief Complaint: Hypotension, chills and nausea Major Surgical or Invasive Procedure: ___ ERCP with stent placement . ___ placement of the right ___ internal-external biliary drain. Re-demonstration of bile leak in upper CBD . ___: Exploratory laparotomy and drainage of abscess cavity and lysis of adhesions History of Present Illness: ___ well known to the transplant surgery service who presents one day after discharge with worsening chills, hypotension, and mild nausea. He was admitted from ___ through ___ after routine labs noted a leukocytosis to 18,000 elevated LFTs. During this admission, he was noted to have a narrowing around the extrahepatic biliary anastomosis on MRCP, and ERCP was performed with metal stent placement as well as liver biopsy that found there were no findings of rejection. His LFTs increased further and were accompanied by fever, so he went for repeat ERCP with removal of prior previous stent and evidence of pus with extravasation of contrast from the bile duct on cholangiogram. A plastic stent was placed and he was treated with vancomycin, cefepime, and Flagyl. He was also found to have a small fluid collection around the porta hepatis but was not amenable to drainage due to its proximity to the portal vessels. He was discharged on oral antibiotics. Last night, he had 2 episodes of nausea and this morning his wife found him to be hypotensive with systolics in the ___. He also complained of chills and did not want to get out of bed. He did not have any accompanied fevers, abdominal pain, cough, chest pain, shortness of breath. He was taken to the ___ emergency room where he was found to have an elevated lactate to 2.3, T bili 3.1 from ___ yesterday, and white count of 12.6. He was given 1 L of IV fluids, blood cultures were drawn, and he was given 1 g of ertapenem. He was then transferred to ___. Upon evaluation in the ED, Mr. ___ is ill-appearing, and has ongoing chills without fever. Repeat labs showed increased lactate of 3.7, normal white count, and stable LFTs from ___ with total bilirubin of 3.0. He is nauseated and has had one episode of small bilious emesis while in the emergency. He is making minimal urine dark and concentrated. He had a bowel movement yesterday. Past Medical History: NONALCOHOLIC STEATOHEPATITIS DIABETES MELLITUS HYPERTENSION IDIOPATHIC THROMBOCYTOPENIA PURPURA Spinal fracture . PSH: bilateral carpal tunnel surgery ___ bilateral meniscus repair left trigger finger release cataract surgery ___ Deceased donor liver transplant ___ Social History: ___ Family History: Mother with history of breast cancer. No known hepatic cancer in family. Physical Exam: Admission PE: Vitals: 98.1 107 115/64 40 95% RA Gen: Ill-appearing, lying in bed with multiple blankets HEENT: NC/AT, EOMI CV: Tachycardic, regular rhythm Pulm: Tachypnea, satting well on RA, normal chest rise Abd: soft, nontender, nondistended, no palpable masses or hernias Ext: warm and well perfused Discharge PE: 24 HR Data (last updated ___ @ 2349) Temp: 98.0 (Tm 98.5), BP: 129/71 (129-154/71-89), HR: 82 (72-82), RR: 18 (___), O2 sat: 97% (95-98), O2 delivery: RA, Wt: 204.6 lb/92.81 kg Fluid Balance (last updated ___ @ 2357) Last 8 hours Total cumulative -485ml IN: Total 240ml, PO Amt 240ml OUT: Total 725ml, Urine Amt 475ml, R PTBD 250ml Last 24 hours Total cumulative -929.5ml IN: Total 1395.5ml, PO Amt 980ml, IV Amt Infused 415.5ml OUT: Total 2325ml, Urine Amt 1700ml, R PTBD 605ml, JP 20ml GENERAL: [x ]NAD [ x]A/O x 3 CARDIAC: [x ]RRR LUNGS: [ x]no respiratory distress ABDOMEN: [x ]soft [ x]Nontender [x ]no rebound/guarding WOUND: [x ]CD&I [x ]JP with scant serous drainage (removed prior to discharge) EXTREMITIES: [x ]no CCE Pertinent Results: Labs on Admission: ___ WBC-5.5 RBC-2.98* Hgb-8.3* Hct-27.4* MCV-92 MCH-27.9 MCHC-30.3* RDW-15.3 RDWSD-50.9* Plt ___ PTT-29.8 ___ Glucose-132* UreaN-18 Creat-1.4* Na-137 K-5.3 Cl-105 HCO3-22 AnGap-10 ALT-74* AST-43* AlkPhos-599* TotBili-2.0* Lipase-20 Calcium-9.1 Phos-3.0 Mg-1.7 Albumin-3.0* tacroFK-7.2 . Labs at Discharge: ___ WBC-3.0* RBC-2.55* Hgb-7.3* Hct-23.8* MCV-93 MCH-28.6 MCHC-30.7* RDW-16.6* RDWSD-56.1* Plt ___ PTT-27.8 ___ Glucose-102* UreaN-13 Creat-1.0 Na-135 K-4.8 Cl-102 HCO3-20* AnGap-13 ALT-112* AST-62* AlkPhos-965* TotBili-6.0* Calcium-8.9 Phos-3.1 Mg-1.5* tacroFK-7.6 . Micro: ___ 4:05 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. . ___ 10:10 am TISSUE ABCESS CAVITY TISSUE. **FINAL REPORT ___ GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI IN CLUSTERS. Reported to and read back by ___. ___ ON ___ AT 12:40 ___. TISSUE (Final ___: STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH. Susceptibility testing performed on culture # ___ ___. STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH. SECOND MORPHOLOGY. Susceptibility testing performed on culture # ___-___ ___. MIXED BACTERIAL FLORA. Due to mixed bacterial types [>=3] an abbreviated workup is performed; all organisms will be identified and reported but only select isolates will have sensitivities performed. LACTOBACILLUS SPECIES. SPARSE GROWTH. ENTEROCOCCUS SP.. SPARSE GROWTH. test result performed by Sensititre. Daptomycin MIC OF 1 MCG/ML. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ =>16 R DAPTOMYCIN------------ S LINEZOLID------------- 2 S PENICILLIN G---------- =>8 R VANCOMYCIN------------ =>128 R ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. Brief Hospital Course: ___ with PMH of type II DM, ITP, NASH cirrhosis and HCC s/p DDLT ___ p/w biliary stricture s/p ERCP, fluid collection surrounding hepatic duct admitted from ___ with nausea, chills, hypotension concerning for cholangitis. He was admitted to the SICU and started on broad spectrum IV abx - vanc/cefe/flagyl after pan-culturing. He was given IV hydration and CT scan was done demonstrating decreased size of hepatic hilar fluid collection with new air in collection concerning for bile leak. There was persistent stranding in the perihepatic space, biliary stent was in correct place and right effusion was stable. Of note, platelet count was 36 (previously 59, 90). HIT Ab was negative. . He was stabilized and transferred out of the SICU. On ___, blood cultures from ___ isolated ESBL, resistant to cefepime. ID was consulted and Meropenem was recommended. Vancomycin was discontinued. Blood cultures remained negative to date ___ and ___. LFT decreased. . On ___, ERCP was performed noting extravasation at the mid CBD and a placed ___ plastic stent was placed. ID recommended IV antibiotics for 2 weeks. ___, rising LFTs were noted s/p ERCP on ___. Liver doppler showeed patent vasculature; MRCP was ordered and done that showed microabscesses, ongoing bile leak. On ___, ___ successfully placed a right ___ internal-external biliary drain for re-demonstration of bile leak in upper CBD. LFTs continued to rise and the plan was for OR on ___ for HJ revision. . On ___, he underwent exploratory laparotomy and drainage of abscess cavity and lysis of adhesions. However, there were significant omental adhesions to the underside of the liver and around the portal structures. These were dissected. Tissues were extremely friable and it was difficult to identify the course of the hepatic artery. Given this difficulty, revision of the HJ was not performed. . Postop, LFTs continued to be elevated. An MRCP was done there is a new segment 8 abscess (0.7 x .8 cm) The other collections are stable. Cholangiogram showed complete occlusion of the right PTBD and leaking proximal CBD. A ___ Fr PTBD exchange was done, bag left to gravity drainage. CT scan done on ___ showed no fluid and the JP drain was removed prior to discharge. . Patient continued immunosuppression, Tacro levels were monitored daily and dosage adjusted per level. Mycophenolate was decreased to 500 mg BID and prednisone was tapered per protocol. . Will discharge to home to complete the Dapto/Ertapenem course on ___. LFTs have remained stably elevated. . Patient was cleared by ___ for haome and did review with wife prior to his discharge for safe home maneuvers and patient self care. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild 2. Aspirin 81 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Famotidine 20 mg PO BID 5. Fluconazole 400 mg PO Q24H 6. Gabapentin 300 mg PO BID 7. Metoprolol Tartrate 12.5 mg PO BID 8. Mycophenolate Mofetil 1000 mg PO BID 9. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate 10. Polyethylene Glycol 17 g PO DAILY 11. Senna 8.6 mg PO QHS 12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 13. ValGANCIclovir 900 mg PO DAILY 14. Atorvastatin 20 mg PO QPM 15. calcium carbonate-vit D3-min 1 tab oral QHS 16. immun glob G(IgG)-pro-IgA ___ 110 g injection monthly 17. Romiplostim ___ mcg SC EVERY OTHER WEEK hematologist to manage 18. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN elevated potassium 19. Ciprofloxacin HCl 500 mg PO Q12H 20. MetroNIDAZOLE 500 mg PO Q8H 21. Tacrolimus 1 mg PO Q12H 22. PredniSONE 12.5 mg PO DAILY 23. Glargine 25 Units Breakfast Glargine 5 Units Dinner Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Daptomycin 400 mg IV Q24H Duration: 7 Days End date ___ RX *daptomycin 500 mg 400 mg IV once a day Disp #*7 Vial Refills:*0 2. ertapenem 1 gram injection DAILY End date ___ RX *ertapenem 1 gram 1 gram IV once a day Disp #*7 Vial Refills:*0 3. Ursodiol 500 mg PO TID RX *ursodiol 500 mg 1 capsule(s) by mouth three times a day Disp #*90 Tablet Refills:*5 4. Acetaminophen 500 mg PO Q6H Maximum 4 of the 500 mg tablets daily 5. Glargine 12 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 6. Mycophenolate Mofetil 500 mg PO BID 7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 8. PredniSONE 5 mg PO DAILY Duration: 6 Days Continue transplant clinic taper as prescribed. Decrease to 2.5 mg on ___. Senna 8.6 mg PO QHS:PRN Constipation - Second Line 10. Tacrolimus 2 mg PO Q12H 11. Aspirin 81 mg PO DAILY 12. calcium carbonate-vit D3-min 1 tab oral QHS separate from mycophenolate by 2 hours 13. Docusate Sodium 100 mg PO BID 14. Famotidine 20 mg PO BID 15. Fluconazole 400 mg PO Q24H 16. Gabapentin 300 mg PO BID 17. Metoprolol Tartrate 12.5 mg PO BID hold for sbp <110 or HR <60 18. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate No driving if taking this medication 19. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN elevated potassium take only when instructed by the transplant coordinator or MD 20. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 21. ValGANCIclovir 900 mg PO DAILY 22. HELD- Atorvastatin 20 mg PO QPM This medication was held. Do not restart Atorvastatin until follow up appointment with the transplant pharmacist 23. HELD- immun glob G(IgG)-pro-IgA ___ 110 g injection monthly This medication was held. Do not restart immun glob G(IgG)-pro-IgA ___ until cleared to be given by transplant clinic Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: h/o liver transplant sepsis bile leak hilar collection E.coli, ESBL bacteremia (OSH) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - with assist Discharge Instructions: ___ Home Health Care - Phone Number: ___ Fax Number: ___ . Home Infusion Referral ID: ___ ___ Infusion Phone: ___ Fax Number: ___ Please call the transplant clinic at ___ for fever of 101 or greater, chills, nausea, vomiting, diarrhea, constipation, inability to tolerate food, fluids or medications, yellowing of skin or eyes, increased abdominal pain, incision/PTBD/JP insertion site redness, drainage or bleeding, dizziness or weakness, increased output from PTBD, JP drain output appears bilious, decreased urine output or dark, cloudy urine, swelling of abdomen or ankles, weight gain of 3 pounds in a day or any other concerning symptoms. Bring your pill box and list of current medications to every clinic visit. You will need to have labs drawn on ___ then have labwork drawn twice weekly as arranged by the transplant clinic, with results to the transplant clinic (Fax ___ . CBC, Chem 10, AST, ALT, Alk Phos, T Bili, Trough Tacro level. . *** On the days you have your labs drawn, do not take your Tacrolimus until your labs are drawn. Bring your Tacrolimus with you so you may take your medication as soon as your labwork has been drawn. . Follow your medication card, keep it updated with any dosage changes, and always bring your card with you to any clinic or hospital visits. . Continue IV antibiotics through ___. Keep PICC line in place until assured no more antibiotics are needed. . Drain and record the bile drain output twice daily and as needed so that the drain is never more than ½ full. Call the office if the drain output increases by more than 100 cc from the previous day, becomes bloody or develops a foul odor. . Change the drain dressing once daily or after your shower. Do not allow the drain to hang freely at any time. Inspect the site for redness, drainage or bleeding. Make sure there is a stitch at the drain site and the stat lock in place. . You may shower, but no tub baths or swimming . No driving if taking narcotic pain medications, and not until cleared by your surgeon . Avoid direct sun exposure. Wear protective clothing and a hat, and always wear sunscreen with SPF 30 or higher when you go outdoors. . Drink enough fluids to keep your urine light in color. Your appetite will return with time. Eat small frequent meals, and you may supplement with things like carnation instant breakfast or Ensure. . Check your blood glucoses and treat with insulin as directed by your regimen. . Check blood pressure at home. Report consistently elevated values above 160 or less than 110 systolic to the transplant clinic . Do not increase, decrease, stop or start medications without consultation with the transplant clinic at ___. There are significant drug interactions with anti-rejection medications which must be considered in medication management following transplant. Refer to your transplant binder Followup Instructions: ___
10166010-DS-19
10,166,010
29,873,733
DS
19
2186-02-16 00:00:00
2186-02-18 07:57:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abd Pain, Abnormal Ct, Transfer from ___ Major Surgical or Invasive Procedure: None History of Present Illness: ___ male past medical history significant for unprovoked DVT in ___, ankylosing spondylitis on humira, severe OSA (previously on CPAP), bochdalek hernia, GERD presenting w/ epigastric pain. Patient states the pain started suddenly overnight while he was sleeping. He had two episodes of emesis. Since the pain started he has had 2 normal bowel movements and is passing flatus. He states the pain is in his epigastrium, denies back pain. States the pain is in the middle and not more on one side or the other. He has never had pain like this in the past. Pt was seen at ___ and found to have bochdalek hernia, sliding hiatal hernia and transferred here for thoracic surgery evaluation. Patient denies any fevers, chills. Patient denies any black or bloody emesis. Patient denies any diarrhea or dysuria. Patient has significant pain with breathing. Of note, per ___ records, patient had chest CT in ___ that demonstrated large, right-sided Bochdalek's hernia. At the time, he was referred to General Surgery for possible surgical management of Bochdalek's hernia. No operative intervention recommended. - In the ED, initial vitals were: 96.8 HR 73 BP 125/79 RR 18 96% RA - Exam was notable for: Uncomfortable. Abdominal: firm, nontender, nondistended, no masses - Labs were notable for: ALT 110, AST 133, Lactate 1.0 - Studies were notable for:CT abdomen pelvis with contrast showed moderate right posterior diaphragmatic hernia which contains peritoneal fat - The patient was given: Morphine 4mg, Zofran 4mg, 1L NS, Pantoprazole 40mg On arrival to the floor, patient reports ___ pleuritic epigastric pain. He states unable to tolerate PO ___ emesis. He denies fevers, chills. Otherwise, he corroborates the above history. Past Medical History: Unprovoked DVTs Bochdalek Hernia Gerd Severe OSA Social History: ___ Family History: Denies family history of soft or connective tissue disorders Physical Exam: Admission Physical Exam: ======================== VITALS:99.3 149 / 80 67 18 96 RA GENERAL: Alert and interactive. Appears uncomfortable. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. BACK: No CVA tenderness. ABDOMEN: Hyperactive bowels sounds, non distended, tender to deep palpation in epigastric area and ___. No organomegaly. EXTREMITIES: No clubbing, cyanosis. +++Swelling unilateral of left leg (per patient, chronic). Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rashes. NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs spontaneously. ___ strength throughout. Normal sensation. Discharge Physical Exam: ========================= 24 HR Data (last updated ___ @ 348) Temp: 97.8 (Tm 98.7), BP: 112/75 (112-148/75-89), HR: 59 (52-85), RR: 18 (___), O2 sat: 98% (96-98), O2 delivery: Ra GENERAL: Pt comfortably lying in bed. HEENT: Sclera anicteric and without injection. MMM. CARDIAC: Regular rhythm, normal rate. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Soft and non distended, no tenderness to palpation. EXTREMITIES: No clubbing, cyanosis. unilateral swelling of left leg (per patient, chronic). SKIN: Warm. NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. Pertinent Results: Admission Labs: ================ ___ 06:50PM BLOOD WBC-6.2 RBC-4.93 Hgb-14.6 Hct-44.3 MCV-90 MCH-29.6 MCHC-33.0 RDW-12.3 RDWSD-40.1 Plt ___ ___ 06:50PM BLOOD Neuts-62.1 ___ Monos-9.0 Eos-1.8 Baso-0.3 Im ___ AbsNeut-3.88 AbsLymp-1.64 AbsMono-0.56 AbsEos-0.11 AbsBaso-0.02 ___ 06:50PM BLOOD ___ PTT-29.1 ___ ___ 06:50PM BLOOD D-Dimer-700* ___ 06:50PM BLOOD Glucose-87 UreaN-10 Creat-1.1 Na-138 K-3.9 Cl-102 HCO3-25 AnGap-11 ___ 06:50PM BLOOD ALT-110* AST-133* AlkPhos-91 TotBili-1.1 ___ 06:50PM BLOOD Lipase-25 ___ 05:14AM BLOOD cTropnT-<0.01 proBNP-116 ___ 06:50PM BLOOD Albumin-3.9 ___ 05:14AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.0 ___ 05:14AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG ___ 05:14AM BLOOD HCV Ab-NEG ___ 06:57PM BLOOD Lactate-1.0 Imaging: ========== CTA Chest ___ Impression: Right upper lobe subsegmental pulmonary emboli. LLE US: ___ Impression: Minimal nonocclusive DVT within the proximal left common femoral and deep femoral veins, and more extensive partially occlusive acute DVT within the left distal femoral and popliteal veins. No evidence of DVT in the right lower extremity. CT Abd&Pelvis ___ Impression: 1. No obstruction, thrombus or dissection within the intra-abdominal arterial, venous or portal venous vessels. 2. No acute process within the abdomen or pelvis. No substantial interval change from the prior CT from the outside hospital from ___. 3. Moderate hiatal hernia and right-sided posterior diaphragmatic hernia are unchanged. Discharge Labs: ================ ___ 06:25AM BLOOD WBC-5.3 RBC-5.25 Hgb-15.6 Hct-47.0 MCV-90 MCH-29.7 MCHC-33.2 RDW-12.3 RDWSD-40.3 Plt ___ ___ 06:25AM BLOOD ___ PTT-33.8 ___ ___ 06:25AM BLOOD Glucose-85 UreaN-12 Creat-1.2 Na-142 K-4.0 Cl-103 HCO3-26 AnGap-13 ___ 07:45AM BLOOD ALT-73* AST-41* AlkPhos-86 TotBili-0.5 ___ 06:25AM BLOOD Calcium-9.4 Phos-4.0 Mg-2.0 Brief Hospital Course: SUMMARY: ======== Mr. ___ is a ___ man with past medical history significant for unprovoked DVT in ___ (not on AC), ankylosing spondylitis on Humira, severe OSA (previously on CPAP), bochdalek hernia, GERD, who presented w/ epigastric pain. CT scan from outside hospital revealed previously known posterior diaphragmatic hernia now with entrapped peritoneal fat. However, on further review of imaging with thoracic surgery, this is thought to be unlikely to cause his acute pain. Patient describes a pleuritic component to his pain on admission. Given his history of an unprovoked DVT in the ___, a CTA chest was obtained which revealed a RUL subsegmental PE. Lower extremity Doppler ultrasounds subsequently revealed acute LLE DVT. Patient was started on heparin IV for anticoagulation. Prior to initiation of heparin hypercoagulability work-up was sent. CTA abdomen was obtained to rule out acute thrombosis of the mesenteric vasculature, which as negative. Started on high-dose PPI for presumed gastritis. Over the course of admission patient's abdominal pain resolved without further intervention. He was transitioned to apixaban before discharge for long-term anticoagulation. . TRANSITIONAL ISSUES: ==================== Follow Up Appointments: PCP, ___ Medications: Apixiban 10mg (end ___ then Apixiban 5mg BID [] Hypercoagulability work-up sent and pending prior to discharge including: Anticardiolipin antibodies, lupus anticoagulant, protein C profile, Antithrombin, beta-2 glycoprotein antibodies, protein S profile [] H. pylori stool antigen pending at discharge [] ___ require additional work-up (EGD) for gastritis/H. pylori as patient already on PPI therapy one stool antigen sent. [] Should ___ with thoracic surgery for eventual repair of diaphragmatic hernia [] Likely requires lifelong anticoagulation as now with second instance of unprovoked DVT . ACUTE/ACTIVE ISSUES: ==================== #RUL Subsegmental PE #LLE DVT History of 1 prior unprovoked DVT while living in ___ in the ___. Unclear medical treatment as unable to access records from that time. CTA chest here revealed RUL subsegmental PE. Also found to have an acute non-occlusive DVT of the LLE. Will likely need lifelong AC as now with ___ unprovoked thrombosis. Basic hypercoagulability work-up was sent prior to heparin initiation with results pending at discharge. Patient was started on apixaban loading dose of 10 mg twice daily prior to discharge. . #Epigastric pain: #Posterior diaphragmatic hernia with entrapped peritoneal fat Etiology of pain throughout admission unclear . Initially thought to be related to hernia but on further review of imaging with thoracic surgery this was felt to be less likely. CT abdomen was obtained without evidence of acute mesenteric thrombosis. Gastritis was also felt to be a strong possibility given location of patient's abdominal pain and tenderness on exam. He was started on high-dose PPI. H. pylori stool antigen was sent, resulted as negative after discharge (however patient was on PPI therefore possible that this could be a false negative). His abdominal pain improved without further intervention and had resolved by the time of discharge. Thoracic surgery recommended outpatient ___ for eventual correction of his diaphragmatic hernia. Recommend outpatient EGD. . CHRONIC/STABLE ISSUES: ====================== #Ankylosing spondylitis Last Humira dose was ___, next after discharge due ___. . #GERD PPI as above He was discharged to home on ___ with close PCP ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Omeprazole Dose is Unknown PO DAILY 2. Humira (adalimumab) 10 mg/0.2 mL subcutaneous EVERY 2 WEEKS Discharge Medications: 1. Apixaban 10 mg PO BID RX *apixaban [Eliquis] 5 mg AS DIR tablet(s) by mouth twice a day Disp #*72 Tablet Refills:*0 2. Humira (adalimumab) 10 mg/0.2 mL subcutaneous EVERY 2 WEEKS 3. Pantoprazole 40mg PO q24h Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: ================== Pulmonary embolism Deep vein thrombosis left leg Abdominal pain Posterior diaphragmatic hernia with entrapped peritoneal fat Gastritis SECONDARY DIAGNOSIS: ==================== Ankylosing spondylitis GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___ , It was a privilege taking care of you at ___ ___. WHY WAS I ADMITTED TO THE HOSPITAL? =================================== - You were admitted to the hospital because you are having abdominal pain and outside hospital imaging was concerning for entrapment of your known diaphragmatic hernia which needed surgical evaluation. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? ========================================== -Imaging from the outside hospital was reviewed with thoracic surgery and they thought that there is no need for surgical intervention at this time. You should ___ with them as an outpatient for further evaluation of your hernia. – Because of your history of blood clot in the past a special CT scan was obtained on admission to look for blood clots in your lungs. This revealed a blood clot the upper portion of your right lung. Further imaging revealed this clot likely came from a blood clot in your left leg. – He was started on a medication called heparin to thin your blood and prevent future clots from forming. Before leaving the hospital he will transition to a medication called apixaban for the same purpose. – We were unable to definitively determine the cause of your abdominal pain while you are in the hospital. Most likely your abdominal pain was either caused by a blood clot blocking blood flow to your intestines which moved on its own, or a condition known as gastritis which is inflammation of the lining of your stomach and intestines. – Imaging of your abdomen was obtained similar to the imaging that revealed a blood clot in your lungs. This scan did not reveal any blood clots in your abdomen. –You were started on medication to reduce the amount of acid your stomach and intestines to help treat gastritis. -Your pain improved, all your lab work was stable, you are felt safe to leave the hospital and ___ as an outpatient. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? ============================================ - Please continue to take all your medications and follow up with your doctors at your ___ appointments. We wish you all the best! Sincerely, Your ___ Care Team Followup Instructions: ___
10166356-DS-7
10,166,356
22,421,715
DS
7
2170-10-17 00:00:00
2170-10-19 12:18:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: S/p scooter accident with facial trauma Major Surgical or Invasive Procedure: ___: Bedside lip laceration repair/alveolar ridge splinting History of Present Illness: ___ on scooter vs. dumptruck, helmeted, +LOC, GCS 14->5 in ED after fentanyl and was subsequently intubated without complication in the ED. She was found to have left rbital wall/maxillary sinus fractures with maxillary fractures extending to the alveolar ridge. Past Medical History: PMH: anxiety, ADHD PSH: b/l ear reduction/reflections ___: ritalin 30' (___), ativan 0.5 prn, trazodone 50 qhs prn Social History: ___ Family History: Non-contributory Physical Exam: Upon discharge: VS: Afebrile, VSS General: young white Caucasian female in sitting up in bed comfortably. Conversant, appropriate. HEENT: left ___ ecchymosis, EOM intact, PEERLA 4->3 bilaterally. Slight malocclusion s/p splinting of left maxillary/alevolar ridge fracture. Associated swelling of left buccal area. Two small lip lacerations s/p repair with chromic, stable. CV: regular rate, rhythm Pulm: CTAB. Mild reproducible chest pain. Stable without crepitus. Abd: soft, nontender, nondistended. No lacerations, ecchymosis. MSK: small R ___ digit laceration, small dorsum of left hand laceration. No obvious deformities of the extremities with scattered abrasions overlying the left patella and tibia. Palpable pedal pulses. ___ upper/motor strength. Neuro: AAOx3 Pertinent Results: ___ 01:36PM BLOOD WBC-10.5 RBC-4.67 Hgb-14.2 Hct-42.2 MCV-90 MCH-30.3 MCHC-33.6 RDW-13.3 Plt ___ ___ 02:32AM BLOOD WBC-11.5* RBC-3.95* Hgb-12.1 Hct-35.1* MCV-89 MCH-30.5 MCHC-34.4 RDW-13.7 Plt ___ ___ 02:32AM BLOOD Neuts-77.1* Lymphs-16.7* Monos-5.2 Eos-0.6 Baso-0.5 ___ 01:36PM BLOOD ___ PTT-27.7 ___ ___ 02:32AM BLOOD ___ PTT-34.0 ___ ___ 02:32AM BLOOD Glucose-84 UreaN-5* Creat-0.6 Na-139 K-3.6 Cl-103 HCO3-27 AnGap-13 ___ 01:36PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Diagnostics: ___: CXR: 1. Low lying endotracheal tube which was subsequently withdrawn to appropriate position by the clinical team as seen on subsequent CT torso and discussed with Dr. ___. Otherwise, no acute intrathoracic process. ___: CT Sinus: Multiple left-sided facial fractures are present, including a slightly displaced fracture of the left orbital floor with no evidence of extraocular muscle entrapment (400:67). Additionally, fractures seen through the medial, anterior, and posterolateral walls of the left maxillary sinus, which is filled with blood and small locules of air (400b:75). A small locule of air is seen adjacent to a linear fracture through the antral floor of the left maxillary sinus (400b:71). Additionally there are fractures extending into the maxillary alveolar ridge, at the level of the ___ molar on the left and more anteriorly between the central incisors (400b:60, 400b:40 respectively). The bilateral zygomatic arches are intact. There is overlying soft tissue swelling and hematoma are noted along the left maxilla (3:111, 3:90). The globes are intact bilaterally. The left ostiomeatal unit is opacified, as is the the left maxillary sinus. The right ostiomeatal unit is patent. The cribriform plates are intact. The right maxillary sinus, frontal sinuses, and the sphenoid sinuses are clear. The nasal bones are intact. There is a mild thickening within the ethmoid air cells. The left nasal cavity is filled with fluid. The nasal septum is intact. There are aerosolized secretions within the ___- and oropharynx, likely secondary to endotracheal tube placement. ___: CT head: 1. No evidence of acute intracranial process. 2. Multiple left-sided facial fractures, described in detail on the concurrent CT of the face. ___: CT torso: 1. No acute pathology is identified within the torso. 2. Nasogastric tube terminates just below the level of the gastroesophageal junction and should be advanced several centimeters. 3. Possible septate or arcuate uterus. ___: CT C-spine: 1. No fracture or malalignment within the cervical spine. For facial fractures, please see CT face. 2. 1.1 cm ill-defined hypodensity within the right lobe of the thyroid for which follow up ultrasound is recommended. Brief Hospital Course: Ms. ___ is a ___ s/p scooter accident vs. stationary dump truck who was brought to ___ ED with ___ 14, with repetitive speech + LOC who was intubated for GCS 5 after receiving a moderate dose of fentanyl for pain. She subsequently underwent radiologic studies given her LOC and mechanism of injury which revealed the following injuries: Left orbital floor fracture without muscle entrapment Left medial/lateral maxillary sinus fractures Left maxillary fracture including the alveolar ridge She in addition also had two lip lacerations and small lacerations of the hands. The former were repaired by the ___ service. The patient was transferred to the Trauma ICU. She remained hemodynamically stable with no other acute pathology within her chest or abdomen. ___ evaluated the patient at bedside for her alveolar ridge fractures and lip lacerations and underwent splinting/primary repair respectively. The patient was uneventfully extubated the same evening, her cervical collar cleared. Tertiary survey the next day did not reveal additional injuries. By system: N: the patient was found to have no acute intracranial pathology. She was found to have aforementioned fractures, of which the alveolar ridge fracture was splinted by OMFS. The day of discharge, she became non-responsive though protecting her airway. This episode lasted for approximately 30 minutes, after which she woke up spontaneously and admitted to taking her OTC GHB-like medications at beside before a head CT could be performed. This was later deferred. The patient's ritalin and ativan were resumed at home doses. CV: the patient remained stable without issue. Pulm: the patient likely received a high dose of fentanyl which subsequently caused respiratory depression and sedation. She was intubated in the ED but was later extubated without incident the same evening. There were otherwise no other issues. FEN/GI: the patient was cleared for full liquids only by OMFS. She tolerated this well. There were no other intra-abdominal injuries noted, FAST was negative. GU: foley catheter was removed, and the patient voided without incident. For her incidental septate/arcuate uterus, the patient was advised to follow-up with her PCP for further imaging. Prophylaxis: the patient received SQH for DVT prophylaxis. Medications on Admission: ___: ritalin 30' (___), ativan 0.5 prn, trazodone 50 qhs prn Discharge Medications: 1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain, fever RX *acetaminophen 650 mg/20.3 mL 650 mg by mouth every 6 hours Disp #*1 Bottle Refills:*0 2. Lorazepam 0.5 mg PO Q12H:PRN anxiety 3. OxycoDONE Liquid 5 mg PO Q4H:PRN pain RX *oxycodone 5 mg/5 mL 5 mg by mouth every 4 to 6 hours Disp #*1 Bottle Refills:*0 4. Docusate Sodium 100 mg PO BID:PRN constipation RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice daily Disp #*28 Capsule Refills:*0 5. traZODONE 50 mg PO HS:PRN insomnia 6. MethylPHENIDATE (Ritalin) 20 mg PO QAM 7. MethylPHENIDATE (Ritalin) 10 mg PO QPM 8. Peridex *NF* (chlorhexidine gluconate) 0.12 % Mucous Membrane BID Duration: 2 Weeks RX *chlorhexidine gluconate [Peridex] 0.12 % swish/spit twice daily Disp #*1 Bottle Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Status-post scooter accident vs. dump truck with left maxillary, left orbital wall fractures Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were brought to the hospital after sustaining a scooter accident. You were intubated in the ED because you were very somnolent and unable to respond to commands. You underwent imaging of your head, spine, abdomen/pelvis which revealed acute findings of a fracture left maxilla (area above your teeth). You were found to have two lip lacerations which were repaired by the Oral/Maxillofacial surgeons. Your maxillary fracture was also splinted by this service. You are allowed to have full liquids as described in the provided list, and should continue to take this for at least two weeks until after your follow-up appointment next week. Please see follow-up section below for directions and time of appointment. Your orbital wall fractures were also evaluated, with no need for operation at this time. You can continue to apply ice packs to the eye and mouth for pain, and should take pain medication as prescribed. Sinus precautions: no blowing nose/straws/spitting X 7 days Amoxicillin X 7 days Peridex rinse bid Cold packs for comfort Full liquid diet X 2 weeks On the mentioned scans, you were found to have an incidental 1.1 centimeter hypodensity in your right thyroid lobe and a septate or arcuate uterus. These are both non-urgent findings and can be followed-up with additional imaging through your PCP. Followup Instructions: ___
10166498-DS-19
10,166,498
23,259,648
DS
19
2118-03-29 00:00:00
2118-03-29 13:02:00
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: RIGHT tibial plateau fracture Major Surgical or Invasive Procedure: ORIF R tibial plateau ___, ___ History of Present Illness: ___ male, presenting status post bicycle accident. Patient fell off his bike and hit his head and right knee. Wearing a helmet. No loss of consciousness. Had pain in his right knee and a small abrasion to his kneecap. On x-ray evidence of a tibial plateau fracture. Orthopedics was consulted. A my evaluation patient is having minimal pain. No numbness or tingling. He denies any other traumatic injuries. Patient is not on any blood thinners. Past Medical History: HLD Vitamin D deficiency Primary parathyroidism, sp parathyroidectomy ___ Social History: ___ Family History: na Physical Exam: Right lower extremity fires ___ Right lower extremity SILT sural, saphenous, superficial peroneal, deep peroneal and tibial distributions Right lower extremity dorsalis pedis pulse 2+ with distal digits warm and well perfused Pertinent Results: ___ 06:25AM BLOOD WBC-6.7 RBC-4.38* Hgb-12.9* Hct-38.6* MCV-88 MCH-29.5 MCHC-33.4 RDW-13.3 RDWSD-42.9 Plt ___ ___ 06:44AM BLOOD WBC-7.6 RBC-4.52* Hgb-13.4* Hct-40.5 MCV-90 MCH-29.6 MCHC-33.1 RDW-13.5 RDWSD-44.0 Plt ___ Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a right tibial plateau fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for ORIF R tibial plateau fx, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. A two-week course of Keflex was started for some trace erythema along his incision. The patient is touch down weight bearing right lower extremity, range of motion as tolerated, and will be discharged on lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: 1. Zyrtec 10 mg daily 2. Aspirin 81 mg daily 3. Cholecalciferol (vitamin D3) 5,000 unit daily 4. Simvastatin 20 mg QHS Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC QPM RX *enoxaparin 40 mg/0.4 mL 40 mg SC Nightly Disp #*28 Syringe Refills:*0 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*50 Tablet Refills:*0 5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First Line 6. Senna 8.6 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Simvastatin 20 mg PO QPM 9. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Right tibial plateau fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: NSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - Touch down weight bearing right lower extremity, range of motion as tolerated MEDICATIONS: 1) Take Tylenol ___ every 6 hours around the clock. This is an over the counter medication. 2) Add oxycodone as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: Take 1 tablet every 3 hours as needed x 1 day, then 1 tablet every 4 hours as needed x 1 day, then 1 tablet every 6 hours as needed x 1 day, then 1 tablet every 8 hours as needed x 2 days, then 1 tablet every 12 hours as needed x 1 day, then 1 tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3) Do not stop the Tylenol until you are off of the narcotic medication. 4) Per state regulations, we are limited in the amount of narcotics we can prescribe. If you require more, you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5) Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. 6) Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. 7) Please take all medications as prescribed by your physicians at discharge. 8) Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION: - Please take lovenox daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. - Splint must be left on until follow up appointment unless otherwise instructed. - Do NOT get splint wet. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB FOLLOW UP: Please follow up with Dr. ___ in the ___ Trauma Clinic ___ days post-operation for evaluation. Please call ___ to schedule appointment. Please follow up with your primary care doctor regarding this admission within ___ weeks and for and any new medications/refills. Physical Therapy: WBAT RLE, ROMAT Treatments Frequency: Any staples or superficial sutures you have are to remain in place for at least 2 weeks postoperatively. Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. You may shower and allow water to run over the wound, but please refrain from bathing for at least 4 weeks postoperatively. Followup Instructions: ___
10166682-DS-3
10,166,682
28,100,196
DS
3
2112-04-16 00:00:00
2112-04-18 20:45:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ibuprofen Attending: ___. Chief Complaint: Vomiting, failure to thrive Major Surgical or Invasive Procedure: None History of Present Illness: ___ hx Stage V CKD (unclear etiology: hypertensive nephrosclerosis, uric acid nephropathy and/or FSGS), CAD hx NSTEMI s/p balloon angioplasty to distal LAD (80% RCA lesion not intervened upon), asthma, tophaceous gout, presents for multiple symptoms, adm AoCRF. ED s/o reports him as a disordered historian, but who reports difficulty eating, vomiting after eating, and concerns regarding his renal status. He reported making urine with a BM yesterday. Denied f/c. Had leg swelling. He was extremely pruritic. In the ED, initial vital signs were: 97.7 81 156/95 18 100% RA - Labs were notable for: WBC 10.6. H/H 10.___. INR 1.4. Lactate 1.2. BUN 220/Cr 13.1. P 8.6. Chemistries otherwise unremarkable. AG 33. UA negative for infection. - Imaging: (my read) unremarkable CXR - EKG: NSR, L axis, LAE, ?LBBB, QTc 513. - The patient was given: Reglan 10mg IV. - Renal was consulted: recommended admission to medicine for initiation of dialysis this stay, continue home anti-hypertensives and diuretics, Low K/PO4 diet, check LFTs and Lipase Vitals prior to transfer were: 98.2 76 121/84 18 100% RA. On the floor, patient is pleasant, cooperative and oriented. He has had a few days of vomiting and malaise. He additionally has had HA, cough and arthritic pains, the last from his gout. He has had constipation too. No fevers, chills, cp/pressure, sob, abdominal pain, muscle pains or skin lesions other than his gout. Denies confusion. Currently, he does feel some itchiness and jumpiness in his legs. Past Medical History: Hypertension CKD of unknown etiology Gout Asthma Social History: ___ Family History: Father with MI at age ___ Physical Exam: ADMISSION EXAM: ================= VITALS: 97.7 118/78 79 20 97%RA GENERAL: Pleasant, well-appearing, in no apparent distress. HEENT: NCAT, pupils symmetric, sclera anicteric, clear OP CARDIAC: RRR, no r/g/m PULMONARY: CTAB ABDOMEN: Soft NT ND +BS EXTREMITIES: WWP, no edema. L forearm fistula w/apropos thrill and bruit. SKIN: Tophaceous deposits on all the fingers bilaterally. NEUROLOGIC: A&Ox3, conversing appropriately, face symmetric, moving all limbs on command. DISCHARGE EXAM: ================= VITALS: Tm 98.7 117/70 79 18 97%RA GENERAL: Pleasant, well-appearing, in no apparent distress. A&O x 3 HEENT: NCAT, pupils symmetric, sclera anicteric, clear OP CARDIAC: RRR, no r/g/m PULMONARY: CTAB ABDOMEN: Soft NT ND +BS EXTREMITIES: WWP, no edema. L forearm fistula w/apropos thrill and bruit. SKIN: Tophaceous deposits on all the fingers bilaterally. NEUROLOGIC: A&Ox3, conversing appropriately, face symmetric, moving all limbs on command. No asterixis Pertinent Results: ADMISSION LABS: ================= ___ 01:10AM BLOOD WBC-10.6* RBC-3.84* Hgb-10.1* Hct-31.0*# MCV-81* MCH-26.3 MCHC-32.6 RDW-16.5* RDWSD-46.2 Plt ___ ___ 01:10AM BLOOD Neuts-91.0* Lymphs-4.2* Monos-3.7* Eos-0.0* Baso-0.0 Im ___ AbsNeut-9.66* AbsLymp-0.45* AbsMono-0.39 AbsEos-0.00* AbsBaso-0.00* ___ 01:10AM BLOOD ___ PTT-26.9 ___ ___ 01:10AM BLOOD Glucose-115* UreaN-220* Creat-13.1*# Na-136 K-4.0 Cl-83* HCO3-24 AnGap-33* ___ 07:15AM BLOOD ALT-33 AST-15 AlkPhos-144* TotBili-1.3 DirBili-0.7* IndBili-0.6 ___ 01:10AM BLOOD Calcium-8.8 Phos-8.6*# Mg-1.8 ___ 01:25PM BLOOD calTIBC-283 Ferritn-735* TRF-218 ___ 01:25PM BLOOD PTH-1281* ___ 01:25PM BLOOD 25VitD-15* ___ 01:25PM BLOOD HBsAg-Negative HBsAb-Negative ___ 10:21AM BLOOD HBcAb-Negative ___ 10:21AM BLOOD HCV Ab-Negative ___ 01:26AM BLOOD Lactate-1.2 DISCHARGE LABS: ================= ___ 06:24AM BLOOD WBC-11.3* RBC-3.75* Hgb-9.7* Hct-31.8* MCV-85 MCH-25.9* MCHC-30.5* RDW-16.7* RDWSD-50.6* Plt ___ ___ 06:24AM BLOOD Glucose-95 UreaN-109* Creat-8.7*# Na-137 K-3.4 Cl-90* HCO3-31 AnGap-19 ___ 06:24AM BLOOD Calcium-8.8 Phos-6.3*# Mg-1.9 UricAcd-6.7 IMAGING: ========= CXR (___): FINDINGS: There is mild cardiomegaly. There is prominence of the vascularity in the upper lobes bilaterally, suggestive of mild to moderate pulmonary edema. There is no focal consolidation, pleural effusion or pneumothorax. IMPRESSION: Mild to moderate pulmonary edema. EKG (___): Sinus rhythm. Borderline atrio-ventricular conduction delay. Premature ventricular complex. Right atrial abnormality. Delayed R wave transition. Non-specific ST segment changes. Compared to the previous tracing of ___ ventricular ectopy is now appreciated. QTC 458. Brief Hospital Course: Mr. ___ is a ___ with a history of stage V CKD, CAD hx NSTEMI, asthma, tophaceous gout who presented with nausea and vomiting and was found to have acute on chronic kidney failure. # Acute on chronic kidney failure: Patient presented to the ED after not feeling well with nausea/vomiting for several days. He was found to have a BUN>200, Cr 13. Renal was consulted in ED, who recommended admission for initiation of inpatient dialysis. Patient underwent three HD sessions, which he tolerated well. He developed confusion during the second session, concerning for HD encephalopathy, but this resolved. Sevelamer dose was increased and he received three days of aluminum hydroxide for elevated phosphate. Given QTC of 450, he was given lorazepam prn for nausea. Nausea improved after HD initiation. First outpatient HD will be on ___. # Gout: Per rheumatology, allopurinol was discontinued. Prednisone 10 mg daily was continued. Pegloticase can be initiated as an outpatient if necessary (rheumatology did not think that inpatient initiation was necessary). Outpatient rheumatologist will send HPRT gene sequencing test. # CAD: Continued home ASA, Plavix, amlodipine, statin, and carvedilol. Transitional Issues ==================== -Patient to initiate outpatient dialysis on ___ (see appointment above). HD session will be ___. -Patient to have rheumatology follow up with labs within one week of discharge. -Allopurinol was stopped during this admission per outpatient rheumatologist. Outpatient rheumatologist will consider initiation of pegloticase. -Home Sevelamer dose increased to 2400mg TID. ___ consider decreasing dose as outpatient as phos level continues to drop. -Outpatient rheumatologist to send HPRT gene sequencing test. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. PredniSONE 10 mg PO DAILY 2. Sodium Bicarbonate ___ mg PO TID 3. Allopurinol ___ mg PO DAILY 4. Carvedilol 50 mg PO DAILY 5. Amlodipine 10 mg PO DAILY 6. Atorvastatin 80 mg PO QPM 7. Torsemide 80 mg PO DAILY 8. sevelamer CARBONATE 1600 mg PO TID W/MEALS 9. Clopidogrel 75 mg PO DAILY 10. Aspirin 81 mg PO DAILY 11. Metolazone 5 mg PO 2X/WEEK (WE,SA) 12. Calcitriol 0.5 mcg PO DAILY Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Calcitriol 0.5 mcg PO DAILY 5. Carvedilol 50 mg PO DAILY 6. Clopidogrel 75 mg PO DAILY 7. Metolazone 5 mg PO 2X/WEEK (WE,SA) 8. PredniSONE 10 mg PO DAILY 9. Torsemide 80 mg PO DAILY 10. sevelamer CARBONATE 2400 mg PO TID W/MEALS RX *sevelamer carbonate [Renvela] 800 mg 3 tablet(s) by mouth tid with meals Disp #*270 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis =================== Acute on Chronic Renal Failure Secondary Diagnosis ==================== Gout Coronary Artery Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure caring for you at ___. You were admitted with nausea, vomiting and fatigue and were found to have acute kidney failure. You were seen by the kidney doctors and ___ on dialysis. You underwent 3 sessions of dialysis while inpatient and you are scheduled for a ___ session on ___ at your outpatient ___ facility. You should follow up with your outpatient primary care doctor and rheumatologist. We wish you all the best! Sincerely, Your ___ Care Team Followup Instructions: ___
10166688-DS-10
10,166,688
21,606,055
DS
10
2151-01-12 00:00:00
2151-01-12 15:41:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Sulfa (Sulfonamide Antibiotics) / Vicodin Attending: ___. Chief Complaint: headache with left visual change Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ year-old right-handed woman with a history of rheumatoid arthritis and biopsy-proven polymyositis who presents following a severe holocranial and then left retrobulbar stabbing headache associated with left eye discomfort and unilateral blurred vision. . The patient was last well eight days ago, on ___. The date represented the end of her vacation. She engaged in sexual activity and then went to sleep. On the morning of ___, she awakened to "the worst headache of her life." The discomfort encompassed the entire head, and was constant and non-throbbing. At peak intensity, it rated > ___. There was no clear trigger prior to headache onset. Lights exacerbated the discomfort. Ibuprofen and excedrin with caffeine failed to provide relief. The head pain was associated with photophobia, nausea, and exhasution. There were no concomitant autonomic symptoms or vomiting, visual changes, or sensorimotor changes. She has never had a similar headache in the past. Ultimately, she called in sick and was able to sleep. . The following day, ___ she awakened to a "dull" headache. She presented to her PCP who suggested she had suffered from a migraine and prescribed imitrex. Ms. ___ actually did not try the imitrex as the headache seemed to be resolving. By ___, the headache seemed to have compltely dissipated. . However, on ___ while driving home from work at 6 pm she developed the gradual onset of pain behind the left eye. The pain had a "stabbing" or ice pick quality. The pain reached ___ at peak intensity. The pain was associated with left-sided lid droop, lid swelling and redness, tearing, and nasal congestion; there was no clear scleral injection or pupillary asymmetry. She might also have had neck discomfort and pain "like an air pocket" behind the left scapula. There was no clear trigger. Light exacerbated the discomfort. A hot shower, ibuprofen, and sleep provided near complete relief. . On ___, the headache was a much milder "ache" in the left retro-orbital region rating ___. The pain was constant, non-throbbing, and non-radiating. It was not exertional or positional. The associated left ptosis persisted. . By ___, she noticed some left jaw discomfort associated with the left retro-orbital pain. She specifically denies difficulty with her vision at that time. She denies trouble/fatigue with chewing. . While driving down the highway on ___, her vision felt blurry. (She specifically denies double vision and change in the visual difficulty with distance and direction of gaze.) She tried covering and uncovering the eyes and discovered only the left eye was affected. She wondered if the left lid droop was making it difficult to see well. She called her PCP from the highway to make an appointment this morning. While parking her car, she accidentally bumped the car behind her (which is an uncharacteristic mistake). On her way in to see her doctor, she felt as though her "equilibrium was off." However, she specifically denies tripping, falling, or lilting in one dirtection vs another. She did not fall. She did not feel pushed or pulled in one direction. She does not think that bystanders could recognize a balance problem, and her PCP made no comment. However, she did refer the patient to the ED for further evaluation and care. . By the time of the neurology consultation, the headache remains a dull ache in the left retrobulbar region. It is now associated with the left lid droop and pain with moving just the left eye in certain directions (most notably upwards). Ms. ___ wonders if she might have had trouble "rolling the left eye back" in the past day. She has no ongoing neck discomfort. She denies recent motor vehicle collisions (other than the very subtle bumper contact this am), chiropractic visits, athletic injuries, etc. She denies pulsatile tinnitus. She denies recent illnesses and sick contacts. She denies personal and family bleeding/clotting disorders and multiple pregnancy losses. She does not use OCPs or smoke. The prednisone dose has been constant for a long time. She denies other recent medication changes. She She denies similar symptoms in the past. . NEUROLOGICAL REVIEW OF SYSTEMS - Positive for: as above - Negative for: vertigo, lightheadedness, vision loss, double vision, difficulty hearing, tinnitus, trouble swallowing, focal weakness, numbness, tingling, bowel incontinence, urinary incontinence or retention, difficulties with gait. . GENERAL REVIEW OF SYSTEMS: - Positive for: as above, fevers associated with RA (baseline) - Negative for: chest discomfort, shortness of breath, dysuria, rash. Past Medical History: - rheumatoid arthritis, on prednisone 8 mg po daily - biopsy-proven polymyositis - raynaud's - bilateral hip replacements (left hip replacement complicated by hematoma) - c-section - left hammer toe procedure - ulcers Social History: ___ Family History: - negative for: migraine, stroke, seizure - positive for: hyperthyroidism (mother), CAD/MI (father) Physical Exam: At admission: Vitals: T: 97.4 P: 77 R: 14 BP: 118/76 SaO2: 99% RA General: Awake, cooperative, NAD. HEENT: Normocepahlic, atruamatic, no scleral icterus noted. No chemosis, proptosis, or scleral injection. Mucus membranes moist, no lesions noted in oropharynx. There is no significant tenderness to palpation of the left temple. There is tenderness to palpation of the left globe. There is no orbital bruit appreciated. Neck: Supple. No carotid bruits appreciated. Cardiac: Regular rate, normal S1 and S2. Pulmonary: Lungs clear to auscultation bilaterally. Abdomen: Round. Normoactive bowel sounds. Soft. Non-tender, non-distended. Extremities: Warm, well-perfused. Skin: no rashes or concerning lesions noted. MSK: there is a muscular knot that is tender to palpation behind the left scapula (accessed with patient's arms crossed in front of the body with back rounded), there is no tenderness to palpation of the neck. . NEUROLOGIC EXAMINATION: Mental Status: * Degree of Alertness: Alert. Able to relate history without difficulty. * Orientation: Oriented to person, place, day, month, year, situation * Attention: Attentive. Able to name the days of the week forwards and backwards without difficulty. * Memory: Pt able to repeat ___ words immediately and recall ___ unassisted at 30-seconds and 5-minutes. Pt demonstrates knowledge of current events. * Language: Language is fluent without evidence of paraphasic errors. Repetition is intact. Comprehension appears intact; pt able to correctly follow midline and appendicular commands. Prosody is normal. Pt able to name high (___) and low frequency objects (knuckles) without difficulty. Reading and writing abilities intact. * Calculation: Pt able to calculate number of quarters in $1.50 * Neglect: No evidence of neglect. * Praxis: No evidence of apraxia. . Cranial Nerves: * I: Olfaction not evaluated. * II: PERRL in both the light and dark. Visual fields full to confrontation testing eyes individually with a red pin. Fundi are not well-visualized. There is no red desaturation. Visual acuity is ___ bilaterally while wearing glasses. * III, IV, VI: EOMI without nystagmus. Normal saccades. There is a left lid droop (although not a true ptosis at this time as lid does not cover 50% of pupil) * V: Facial sensation intact to light touch in the V1, V2, V3 distributions. * VII: No facial droop, facial musculature symmetric. * VIII: Hearing intact to finger-rub bilaterally. * IX, X: Palate elevates symmetrically. * XI: ___ strength in trapezii bilaterally. * XII: Tongue protrudes in midline. Motor: * Tone: Normal. * Drift: No pronator drift. Strength: * Left Upper Extremity: breakable Delt, breakable Biceps, 4+ Triceps, ___ Wrist 5 Flex, 4+ Finger Ext, 5 Finger Flex * Right Upper Extremity: breakable Delt, breakable Biceps, 4+ Triceps, ___ Wrist 5 Flex, 4+ Finger Ext, 5 Finger Flex * Left Lower Extremity: 4+ Iliopsoas, 5 throughout Quad, Ham, Tib Ant, Gastroc, Ext Hollucis Longis * Right Lower Extremity: 4+ Iliopsoas, 5 throughout Quad, Ham, Tib Ant, Gastroc, Ext Hollucis Longis Reflexes: * Left: 2 throughout Biceps, Triceps, Bracheoradialis, difficult to elicit at Patella, Achilles * Right: 2 throughout Biceps, Triceps, Bracheoradialis, difficult to elicit at Patella, Achilles * Babinski: flexor bilaterally . Sensation: * Pinprick: intact bilaterally in lower extremities, upper extremities, trunk, face * Temperature: intact bilaterally in lower extremities, upper extremities, trunk, face * Vibration: intact (> 12 sec) bilaterally at level of great toe * Proprioception: intact bilaterally at level of great toe * Extinction: No extinction to double simultaneous stimulation . Coordination * Finger-to-nose: intact bilaterally * Heel-to-shin: intact bilaterally * Rapid Alternating Movements: quick, slightly faster on right than left (although right-handed) * Mirroring: normal, symmetric * Rebound: normal Gait: * Description: Good initiation. Narrow-based with normal-length stride and symmetric arm-swing. Able to heel and toe walk. * Tandem: Able to tandem walk without difficulty * Romberg: negative At discharge: Neuro: No deficits other than mild paroxysmal weakness symmetrically, which the patient says is her baseline due to polymyositis. Pertinent Results: ___ 11:35AM WBC-4.9 RBC-4.11* HGB-12.0 HCT-36.7 MCV-89 MCH-29.2 MCHC-32.7 RDW-13.7 ___ 11:35AM NEUTS-73.4* ___ MONOS-5.7 EOS-1.1 BASOS-0.4 ___ 11:35AM PLT COUNT-254 ___ 11:35AM SED RATE-27* ___ 11:35AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 11:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR ___ 11:35AM URINE RBC-<1 WBC-<1 BACTERIA-NONE YEAST-NONE EPI-2 ___ 11:35AM URINE MUCOUS-RARE ___ 11:35AM URINE UCG-NEGATIVE ___ 11:35AM CRP-2.5 ___ 11:35AM TSH-1.5 ___ 11:35AM CK(CPK)-69 ___ 11:35AM GLUCOSE-80 UREA N-13 CREAT-0.5 SODIUM-137 POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-26 ANION GAP-7* MRI Brain and Orbit with and without contrast: Preliminary Report !! WET READ !! No acute infarct or intracranial abnormality. Normal orbits, no myositis or compressive lesion. CTA Head and Neck with and without contrast: Preliminary Report !! WET READ !! neck cta: no occlusion, flow limiting stenosis, or dissection. head cta: no occlusion, flow limiting stenosis or aneurysmal dilatation. CT Head without contrast: Preliminary Report !! WET READ !! NO ACUTE FINDINGS. Brief Hospital Course: ___ year-old right-handed woman with a history of rheumatoid arthritis and biopsy-proven polymyositis who presents following a severe holocranial and then left retrobulbar stabbing headache associated with left eye discomfort and unilateral blurred vision. Neurological examination revealed left eyelid droop, pain with movement of the left eye, mild pain with palpation of the left globe, subtle symmetric predominently proximal weakness, and absent reflexes in the lower extremities. CTA Head and Neck, MRI Brain and MRI orbits all were normal. Given the automonic symptoms with the unilateral eye pain, most likely the patient is having a headache that falls into the category of TACs (Trigeminal Autonomic Cephalgias). Given the duration of the pain and that the patient is a ___ yo woman, most likely the headache syndrone is consistent with a paroxysmal hemicranias. The treatment for this is typically a medicine called Indomethacin. Since currently her symptoms are resolved, we do not think Indomethacin is needed at this time. If she again experiences a similar headache, we suggest she takes ibuprofen 800mg again as this provided her relief previously. If this does not work, at that point it may be advisible to consider Indomethacin. Given that she is on daily prednisone and have a history of stomach ulcers, we advised Ms. ___ to please use care when using medicines like ibuprofen or Indomethacin. Medications on Admission: - prednisone 8 mg po daily - nifedical XL 30 mg po daily - valcyclovir 1 gram prn Discharge Medications: 1. prednisone 1 mg Tablet Sig: as directed Tablet PO DAILY (Daily): 8mg po daily. 2. nifedipine 30 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO DAILY (Daily). 3. ibuprofen 800 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for headache. Discharge Disposition: Home Discharge Diagnosis: Paroxysmal hemicrania (Trigeminal Autonomic Cephalgias) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Neuro: No deficits other than mild paroxysmal weakness symmetrically, which the patient says is her baseline due to polymyositis. Discharge Instructions: Dear Ms. ___, It was a pleasure caring for you during your stay. You were admitted to the hospital for evaluation of headache and vision disturbance. After evaluation, we have determined that most likely you are experiencing a type of headache that falls into the category of TACs (Trigeminal Autonomic Cephalgias). Cluster headaches fall within this category but we feel that you more likely have a headache called paroxysmal hemicranias. The treatment for this is typically a medicine called Indomethacin, which is similiar to the ibuprofen you have at home. Since your symptoms are currently resolved, we do not think Indomethacin is needed at this time. If you again experience a similar headache like this one, please try taking ibuprofen again. If this does not work, at that point it may be advisible to consider Indomethacin. Given you are already on daily prednisone and have a history of stomach ulcers, please use care when using medicines like ibuprofen. Followup Instructions: ___
10167784-DS-11
10,167,784
26,706,672
DS
11
2165-11-14 00:00:00
2165-11-15 13:58:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Penicillins / Macrodantin / Lialda / erythromycin base Attending: ___. Chief Complaint: Right IPH Major Surgical or Invasive Procedure: decompressive right hemicraniectomy ___ History of Present Illness: Eu Critical ___ is a ___ female with a PMHx of colitis versus IBD with rectal bleeding as well as hypothyroidism who presents who was found down at home and subsequently found to have a right-sided IPH. She spoke to her boyfriend on the phone at 8:30am (___), at which time she was complaining of "GI upset" and felt like she needed to lie down (not unusual for her). She sounded like her normal self at that time. Later, he tried to call her, and the home phone was "off the hook" (has happened before). She did not respond to cell phone calls. Her cousin called her boyfriend at 5:00pm asking where the patient was, sine the patient was supposed to accompany her aunt to get a hip replacement. Her cousin and boyfriend then met at the apartment, could not get in, and called ___ to gain entrance. She was found lying on her left side in the "TV room;" she was conscious but "groggy." She was complaining of her left side feeling cold, and she did not have any clothes on. Her boyfriend noticed bandages in the bathroom, which was unusual. He did notice if her speech had changed or if she was weak on one side. She was brought to the ___ ED, where she was noted to have left-sided weakness and right gaze preference. A ___ demonstrated a 9.5 by 5.1 right-sided IPH with edema, mass affect on the right lateral ventricle, and 6mm MLS. No IVH. Patient unable to complete ROS Past Medical History: ACTINIC KERATOSIS ABDOMINAL GASEOUS DISTRESS HEMORRHOIDS ULCERATIVE PROCTITIS DRY EYE SYNDROME LEFT CAROTID BRUIT with negative carotid ultrasound in ___ GALLSTONES HIP PAIN HYPOTHYROIDISM *S/P HYSTERECTOMY INSOMNIA MITRAL VALVE PROLAPSE OSTEOPENIA PSORIASIS RENAL INSUFFICIENCY SHINGLES ECZEMATOUS DERMATITIS CHONDRODERMATITIS HELICES PAST SURGICAL HISTORY: CARPAL TUNNEL SURGERY HYSTERECTOMY ARTHROSCOPIC KNEE SURGERY Social History: ___ Family History: Relative Status Age Problem Comments Mother ___ ___ DEMENTIA Father ___ ___ MYOCARDIAL INFARCTION Brother Living ___ CARDIAC ISSUES CELIAC DISEASE Above per OMR. Boyfriend denies any known Family History. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: not available (have asked ED to obtain) P: 96 R: 16 BP: 144/94 SaO2: 99%RA General: Lying in bed, breathing comfortably, WWP, no CCE, ecchymosis on left half of face with hematoma on left forehead ecchymosis as well as left hemibody MS: Awake but drowsy and requires verbal stimulation to keep eyes open. Oriented to name, BI, ___. Disoriented to year and date. Disoriented to situation. Perseverating on needing to go to bathroom despite repeated explanations about Foley with full sentences, e.g., "I need to go to the bathroom" and "Will you help me go to the bathroom?" Follows simple midline commands (close eyes, stick out tongue) and some appendicular commands (lift right arm, squeeze fingers); does not cooperate with certain commands (e.g., EOM testing, manual motor testing). Able to repeat some friends (thanks, ___ but did not participate in repeating all stroke card words. Did not cooperate with reading, naming, or description of stroke card tasks. CN: PERRL 3-->2 ___, No BTT on left, Right gaze preference, crosses to left of midline with VORs, +corneals, left facial droop. Motor: Increased tone on left. Normal bulk. Spontaneously moving both sides but not to command. LUE is at least in the plane of the bed. LLE is at least antigravity. Kicking the right leg up vigorously. Did not cooperate with formal manual motor testing. Sensory: Withdrew to noxious in all four extremities Reflexes: 2 globally except 1 at Achilles. No clonus. L toe up, R toe down. Coordination and gait: deferred =============================================== DISCHARGE PHYSICAL EXAM: MS: Patient opens eyes to verbal stimulation. SHe is able to follow simple commands using the right side of her body such as "thumbs up" or "show two fingers". Able to follow midline commands. She at times did not follow commands when she was anxious etc. No language output. CN: Left visual field cut, does not blink to threat on left, subtle left facial droop. Motor: Able to move right sided briskly and spontaneously. Left side triple flexes to noxious in the lower extremity, upper extremity hyper-extends. Reflexes: No clonus, L toe is up. Pertinent Results: ADMISSION LABS: ___ 07:26PM BLOOD WBC-19.2* RBC-4.61 Hgb-14.0 Hct-42.1 MCV-91 MCH-30.4 MCHC-33.3 RDW-14.2 RDWSD-47.6* Plt ___ ___ 07:26PM BLOOD ___ PTT-27.7 ___ ___ 07:26PM BLOOD Glucose-166* UreaN-13 Creat-0.8 Na-135 K-4.4 Cl-99 HCO3-22 AnGap-18 ___ 07:26PM BLOOD ALT-38 AST-110* CK(CPK)-5710* TotBili-0.8 ___ 07:26PM BLOOD cTropnT-0.21* ___ 01:25AM BLOOD CK-MB-58* MB Indx-1.0 cTropnT-0.18* ___ 07:26PM BLOOD Calcium-10.0 Phos-3.2 Mg-2.0 ___ 01:25AM BLOOD TSH-1.5 ___ 03:10PM BLOOD TSH-11* ___ 01:25AM BLOOD T4-6.9 ___ 03:10PM BLOOD Free T4-0.9* ___ 07:58PM BLOOD Vanco-9.0* ___ 07:26PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 04:20PM BLOOD Type-ART pO2-190* pCO2-30* pH-7.42 calTCO2-20* Base XS--3 IMAGING: CT HEAD ___: 1. Motion degraded study. 2. A 7.5 x 4.1 cm parenchymal hemorrhage centered in the right parietal lobe with associated edema, mass effect on the right lateral ventricle and approximately 9 mm leftward midline shift. Small amount of intraventricular hemorrhage. 3. Basilar cisterns are not particularly well assessed but there is no evidence of frank herniation and there is no evidence of obstructive hydrocephalus. CXR ___: ET and enteric tubes in appropriate position. CTA HEAD AND NECK ___: 1. No significant interval change in the extent of the large right parietal intraparenchymal hemorrhage measuring up to 7.2 cm and midline shift to the left of approximately 4 mm. Stable intraventricular hemorrhage. 2. New left subarachnoid hemorrhage along the left frontoparietal convexities near the vertex, series 3, image 29. 3. No aneurysms or vascular abnormalities identified. Intracranial atherosclerotic disease. CTA chest 1. Pulmonary emboli within the segmental pulmonary arteries supplying the lateral right middle lobe and filling subsegmental pulmonary arteries supplying the right upper lobe. 2. Centrilobular opacities within the right upper lobe and bilateral lower lobes dependently may reflect sequelae of aspiration or pneumonia. Right basilar wedge-shaped hypoattenuation admidst atelectasis suggests consolidation and is concerning for underlying pneumonia. 3. Bilateral nonhemorrhagic and layering pleural effusions are small, right greater than left, and increased since prior examination dated ___. KUB Air distended loops of small bowel and gas filled large bowel not definitely obstructive in pattern, may reflect ileus. LENIs Acute DVT in the right lower extremity involving several gastrocnemius veins but nothing more proximally. Femoral and popliteal veins are fully patent. No thrombosis is seen in the left leg. TTE ___: The left atrium is normal in size. No thrombus/mass is seen in the body of the left atrium. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve leaflets are structurally normal. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the prior study (images reviewed) of ___, no clear change. CT HEAD ___: 1. Interval right frontal craniotomy. Due to technical factors direct comparison of the size of the right frontal hemorrhage is difficult but grossly unchanged. Mass effect on the right lateral ventricle is mildly decreased, but leftward midline shift is unchanged. No large territorial infarction. 2. Re- demonstrated intraventricular extension, now with new hemorrhage layering in the fourth ventricle. Interval increase in the size of the lateral ventricles and third ventricle may be partially due to decreased mass effect but given the increase in size of the left lateral ventricle hydrocephalus should be considered. 3. Unchanged left frontoparietal subarachnoid hemorrhage. MRI BRAIN ___: 1. Grossly unchanged large right frontoparietotemporal intraparenchymal hemorrhage with surrounding vasogenic edema, decompressed by a right-sided craniectomy. No definite underlying enhancing mass. 2. Unchanged areas of subarachnoid hemorrhage and intraventricular extension of hemorrhage. Please note, due to technical factors, assessment for ischemia/infarct cannot be assessed. 3. Few scattered, punctate areas of microhemorrhage, though no definite evidence for amyloid angiopathy. 4. Unchanged mild prominence of the ventricles which may relate to background atrophy, though hydrocephalus remains a possibility. CEREBRAL ANGIOGRAM ___: 1. No evidence of dural AV fistula, arteriovenous malformation or aneurysm, underlying the patient's large right fronto-parietal intraparenchymal hemorrhage. U/S ___ ___: No evidence of deep venous thrombosis in the right or left lower extremity veins. CTA CHEST ___: 1. No evidence of acute pulmonary embolism. 2. Bilateral lower lobe consolidations, compatible with known pneumonia. 3. A 5 mm nodule in the superior segment of the right lower lobe is likely inflammatory, but attention on followup is advised. 4. Small bilateral pleural effusions. CT HEAD ___: Compared with the study of ___, no significant change in the large right frontal intraparenchymal hemorrhage with associated edema and brain herniation through the right frontal craniectomy. Ventricular size is grossly unchanged. CXR ___: Right PICC line tip is in the proximal right atrium and should be pulled back 1 cm to secure it position at the cavoatrial junction or above. ET tube tip is 4 cm above the carinal. NG tube tip is in the stomach. Heart size and mediastinum are stable. Left basal consolidation appears to be similar since the prior study concerning for infection. Right basal opacity is overall unchanged as well. No pneumothorax. Small pleural effusion. ___ NCHCT: 1. Decreased size of right frontal/parietal parenchymal hematoma compared to ___. Surrounding edema persists, but the extent of parenchymal herniation through the right hemi craniectomy defect has decreased. 2. Stable intraventricular hemorrhage and stable enlargement of the lateral and third ventricles. 3. Stable left greater than right subarachnoid hemorrhage. 4. Decreased small extra-axial hematoma along the right hemi craniectomy defect. 5. No CT evidence for new intracranial abnormalities. ___. No evidence pulmonary embolism. 2. Bilateral lower lobe consolidations with associated compressive atelectasis. ___ Chest xray: In comparison to previous radiograph of 1 day earlier, endotracheal tube terminates 2.4 cm above the carina. Cardiomediastinal contours are stable. Bibasilar atelectasis has improved in the interval, but a new area of opacification has developed in the right juxta hilar region, likely in the superior segment of the right lower lobe. This could reflect focal atelectasis, aspiration, or developing pneumonia. ___ CXR: No relevant change is noted. Minimal decrease in extent and severity of a platelike atelectasis on the right. No pulmonary edema. No pleural effusions. No pneumothorax. ___ Right upper extremity Doppler ultrasound 1. Possible small eccentric thrombus in the right subclavian vein adjacent to the indwelling central line as demonstrated by echogenicity with lack of wall to wall color flow. 2. Superficial thrombosis of the right basilic vein surrounding the venous catheter. ___: CTA CHEST 1. Pulmonary emboli within the segmental pulmonary arteries supplying the lateral right middle lobe and filling subsegmental pulmonary arteries supplying the right upper lobe. 2. Centrilobular opacities within the right upper lobe and bilateral lower lobes dependently may reflect sequelae of aspiration or pneumonia. Right basilar wedge-shaped hypoattenuation admidst atelectasis suggests consolidation and is concerning for underlying pneumonia. 3.Bilateral nonhemorrhagic and layering pleural effusions are small, right greater than left, and increased since prior examination dated ___. ___ LENIS: Acute DVT in the right lower extremity involving several gastrocnemius veins but nothing more proximally. Femoral and popliteal veins are fully patent. No thrombosis is seen in the left leg. Brief Hospital Course: Ms. ___ is a ___ old woman with a past medical history of hypothyroidism, prior smoker who presented with lethargy, left hemiparesis, with right parietal IPH s/p decompressive hemicraniectomy, rhabodmyolysis, troponin leak and pseudomonas VAP. Cause of bleed was extensively investigated with amyloid angiopathy vs. hypertension as likely cause. #Right parietal IPH: Patient had a CT head which showed a 7.5 x 4.1 cm in the right parietal lobe with associated edema, mass effect on the right lateral ventricle and approximately 9 mm leftward midline with IVH. On ___, she underwent a right decompressive hemicraniectomy without complication. Etiology of the IPH was thought secondary to hypertension, though no obvious history of this. She underwent MRI, which did not show any evidence of amyloid angiopathy. She also had an angiogram which did not show any underlying AVM. Her SBP was kept less than <140mm Hg with a nicardipine drip. Serial CT scans were stable. Her neurologic exam remained poor, with left facial droop, left sided plegia and right gaze preference. She was awake and alert off sedation, but would not follow commands. She was maintained on Keppra 500mg BID for seizure prophylaxis, which was subsequently discontinued for persistent encephalopathy. There was no evidence of seizures on EEG. Patient appeared to be markedly agitated with resulting respiratory alkalosis. For this, she was initially treated with fentanyl and propofol. Seroquel was added to attempt to wean off sedation with some effect. PEG/tracheostomy were placed on ___ without complications. She was weaned off the ventilator and was placed on trach mask which she tolerated well. At this point, we were able to discontinue sedation which led to an improved mental status and decreased agitation. The patient was transferred out of the neuro ICU down to the intermediate monitoring unit. Neurosurgery was notified of a sunken skull flap on ___. She had neurosurgery follow up scheduled prior to discharge to have this monitored in the outpatient setting. Overall, the patient was more alert and interactive at the time of discharge with brisk right sided movements and ability to follow commands. She will need rehabilitation and frequent follow-up for continued assessments. #Pulmonary embolism Patient was transferred to the step down unit on ___, after tracheostomy and PEG placement, on trach collar support only. However, on ___ patient became acutely hypoxic and tachypneic, requiring ventilator support. Blood pressures were stable. D-dimer was elevated to 4000, ABG showed marked A-a gradient. Urgent CTPA showed pulmonary embolus. Given the large intraparenchymal hemorrhage, we did not attempt anticoagulation. Lower extremity Doppler ultrasound showed deep vein thrombosis of the right gastrocnemius veins. ___ was consulted for IVC filter placement, which was done on ___. The ventilator was subsequently weaned off, and the patient remained on trach collar support. Sinus tachycardia to 150 on ___ was treated with 5mg of metoprolol. #NSTEMI: Patient's troponin initially elevated to 0.21, CK-MB 58, likely in the setting of stroke and rhabdomyolysis. EKG with no evidence of ischemic changes. Troponin trended down without any evidence of wall motion abnormality on TTE. No other cardiac issues during the rest of the hospitalization. #Ventilator dependent respiratory failure: Patient was initially intubated in the setting of altered mental status secondary to stroke. She was unable to be weaned from the ventilator initially due to agitation and inability to follow commands and then later secondary to pseudomonas pneumonia, as well as persistent tachypnea. CTA chest was negative for PE. She also received intermittent Lasix given significant volume received while in the ICU. Tracheostomy placed on ___. Weaned off ventilator on ___ without further complications. Patient continued to have tachypnea with respiratory alkalosis, which was thought to be due to a central breathing pattern. Subsequently, she developed a PE as stated above. After IVC filter was placed, patient remained tachypneic but maintained good saturations and was able to tolerate a tracheostomy mask. #Anemia: Her H/H trended down, thought to be secondary to critical illness, blood draws and infection. She did not require transfusions in the ICU nor on the floor. #Thrombocytosis Patient had steadily rising platelets which was thought to be reactive given active infection as well as recent invasive procedures. However, due to the degree of thrombocytosis and concerns for possible thrombotic complications, we started low-dose aspirin as prophylaxis. Patient can be followed up once infection is cleared to monitor platelet counts. She can be seen by pcp and heme onc if thrombocytosis persists. #Hypothyroidism: Patient was continued on home Synthroid initially, then TFTs checked - TSH 11, free T4 0.9 so this was increased to 100mcg daily. #Pseudomonas pneumonia: Patient spiked intermittent fevers with BAL and sputum cultures growing pan-sensitive pseudomonas on ___. She was initially treated with Cefepime within continued fevers and increased vent requirement. Subsequent sputum grew out Pseudomonas while on Cefepime. She was switched to Gentamycin briefly, but this was stopped due to potential for kidney injury. On ___, she was transitioned to Meropenem on extended infusion for total 14 day course with improvement in her fever curve. #Oral herpes Treated with oral acyclovir for total 5 day course for good effect. #Chipped tooth Incidentally discovered after an tracheostomy/PEG placement, which required urgent ___ reintubation for dislodged endotracheal tube. This was explained to the patient's health care proxy and a dental consult was obtained; outpatient dental follow-up was recommended. #Ulcerative proctitis Patient had loose stool throughout her ICU course. C.diff was negative. She was treated with home mesalamine. #Ileus An ileus was identified on KUB after TFs were suctioned from the trach, and the patient as treated with a bowel regimen with resultant bowel movements. Her abdomen was soft and distended without apparent tenderness. #Insomnia/agitation: She was treated with Seroquel as needed and in the evening for agitation and insomnia. Ms. ___ had a prolonged and complicated hospital course however she recovered well and was successfully discharged to rehab on ___. She will require extensive rehabilitation and have close neurology, neurosurgery, and primary care follow-up. Transitions of Care Issues: 1. Hemorrhage: Patient will need a repeat MRI with and without contrast looking for underlying mass and further elucidation about the bleed. She has stroke follow-up scheduled 2. Continue aspirin 81 mg 3. Started amlodipine 4. Patient will be discharged on a trach and peg 5. Neurosurgery follow up scheduled for craniectomy monitoring 6. Thrombocytosis and anemia to be followed up outside of the hospital 7. Monitor TSH as her synthroid dose was increased during hospitalization AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (x) Yes, confirmed done - () Not confirmed – () No 2. DVT Prophylaxis administered? (x) Yes - () No 3. Antithrombotic therapy administered by end of hospital day 2? (x) Yes - () No 4. LDL documented? (x) Yes (LDL = ) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (x) No [if LDL >100, reason not given: ] 6. Smoking cessation counseling given? () Yes - () No [reason (x) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No 9. Discharged on statin therapy? () Yes - (x) No [if LDL >100, reason not given: ] 10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) Antiplatelet - () Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - () No - (x) N/A Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Clobetasol Propionate 0.05% Soln 1 Appl TP DAILY 2. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID 3. Levothyroxine Sodium 75 mcg PO DAILY 4. LORazepam 0.5 mg PO QHS 5. Mesalamine (Rectal) 1000 mg PR QHS 6. mometasone 0.1 % topical ASDIR 7. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN fever or pain 2. amLODIPine 5 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. QUEtiapine Fumarate 12.5 mg PO Q8H:PRN agitation 5. QUEtiapine Fumarate 12.5 mg PO QHS 6. QUEtiapine Fumarate 12.5 mg PO QHS 7. Senna 17.2 mg PO QHS:PRN constipation 8. Levothyroxine Sodium 100 mcg PO DAILY 9. Mesalamine (Rectal) 1000 mg PR QHS 10. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Right parietal intracerebral hemorrhage Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Dear Ms. ___, You were hospitalized due to symptoms of left sided weakness resulting from an INTRACEREBRAL HEMORRHAGE, a condition with bleeding from a blood vessel in the brain causing injury to the brain. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. Stroke can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: High blood pressure We are changing your medications as follows: 1. Quetiapine 12.5mg for anxiety 2. Amlodipine 5mg PO /NG Daily 3. Acyclovir 400mg PO for Q8H 4. Levothyroxine 100mcg PO Please take your other medications as prescribed. Please followup with Neurology and your primary care physician. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology Team Followup Instructions: ___
10167837-DS-8
10,167,837
20,665,754
DS
8
2169-11-12 00:00:00
2169-11-18 18:03:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old male who presented to the hospital with 4 days of nausea, decreased stool, and abdominal pain. No fever, or leukocytosis. A cat scan of the abdomen showed a partial small bowel obstruction. The patient was placed on bowel rest and had a ___ tube placed for bowel decompression. Past Medical History: PAST MEDICAL/SURGICAL HISTORY: -Benign prostatic hyperplasia -Hypertension goal BP (blood pressure) < 140/90 -Spermatocele -Vertigo -Diverticulosis -Obesity -Renal calculus -Osteoarthritis of Knee -S/P total knee replacement Right ___ -Complete tear of right rotator cuff -Hypercholesteremia -Arthritis, shoulder region -Bilateral pseudophakia Social History: ___ Family History: Family History: Non-contributory Physical Exam: PHYSICAL EXAMINATION upon admission: Constitutional: Comfortable HEENT: Normocephalic, atraumatic, MMM Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, diffusely distended, diffuse mild tenderness Extr/Back: No cyanosis, clubbing or edema Skin: Warm and dry Neuro: Speech fluent Physical exam on Discharge: Constitutional: Comfortable HEENT: Normocephalic, atraumatic, MMM Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, non distended, non tender Extr/Back: No cyanosis, clubbing or edema Skin: Warm and dry Neuro: Speech fluent Pertinent Results: ___ 06:22AM BLOOD WBC-6.7 RBC-4.96 Hgb-16.1 Hct-48.4 MCV-98 MCH-32.5* MCHC-33.3 RDW-13.1 RDWSD-46.9* Plt ___ ___ 01:25AM BLOOD WBC-5.4 RBC-5.26 Hgb-16.9 Hct-50.4 MCV-96 MCH-32.1* MCHC-33.5 RDW-13.1 RDWSD-46.2 Plt ___ ___ 01:25AM BLOOD Neuts-64.2 Lymphs-13.5* Monos-19.3* Eos-2.4 Baso-0.4 Im ___ AbsNeut-3.44 AbsLymp-0.72* AbsMono-1.03* AbsEos-0.13 AbsBaso-0.02 ___ 06:22AM BLOOD Glucose-79 UreaN-18 Creat-0.8 Na-143 K-3.7 Cl-101 HCO3-28 AnGap-14 ___ 01:25AM BLOOD Glucose-132* UreaN-19 Creat-1.0 Na-139 K-4.8 Cl-102 HCO3-22 AnGap-15 ___ 01:25AM BLOOD ALT-35 AST-29 AlkPhos-53 TotBili-1.8* DirBili-0.3 IndBili-1.5 ___ 06:22AM BLOOD Calcium-9.1 Phos-2.9 Mg-1.8 ___: cat scan abdomen and pelvis: Minimal mesenteric inflammatory changes about diverticula of the distal descending colon may represent early findings of uncomplicated diverticulitis. 2. Fluid distension of small bowel and ascending colon are consistent with diarrhea. No evidence of bowel obstruction. 3. 4 mm nonobstructing stone within the right ureterovesicular junction. 4. Indeterminate 3.0 cm cyst with irregular wall thickening within the lower pole of the left kidney. Nonemergent MRI is recommended for further evaluation. 5. Hepatic steatosis. Brief Hospital Course: ___ year old male admitted to the hospital with lower abdominal pain, diarrhea, and distention concerning for gastroenteritis. Upon admission, the patient was made NPO, given intravenous fluids, and underwent imaging. A cat scan of the abdomen showed minimal mesenteric inflammatory changes suggestive of enteritis. Additional findings reported on the cat scan were 4 mm non-obstructing stone within the right uretero-vesicular junction and a 3.0 cm cyst with irregular wall thickening within the lower pole of the left kidney. The patient's white blood cell count was monitored. After return of bowel function and decreasing ___ tube output, the ___ tube was removed and the patient was started on sips and advanced to a regular diet. He was voiding without difficulty and ambulatory. He was discharged home on HD #3 with instructions to provide a stool specimen to his PCP for culture. Medications on Admission: oxazosin 1 mg tablet Take 1 tablet by mouth at bedtime ketotifen (ZADITOR) 0.025 % Drops Instill 1 drop in both eyes twice daily spaced ___ hours apart; available over the counter aspirin 81 mg tablet, chewable Chew 81 mg daily FINASTERIDE 5 MG TAB Take 1 tablet by mouth daily ATORVASTATIN 20 MG TAB Take 1 tablet by mouth daily Discharge Medications: 1. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*14 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: enteritiis fatty liver right kidney stone, cyst left kidney Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital with lower abdominal pain, distention, and diarrhea. You underwent a cat scan and you were reported to have early diverticulitis. You were placed on bowel rest and had a ___ tube placed for bowel decompression. After return of bowel function, you had the ___ tube removed and you were started on a regular diet. You were discharged from the hospital with the following instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Followup Instructions: ___
10168247-DS-9
10,168,247
29,293,693
DS
9
2173-03-28 00:00:00
2173-03-29 13:18:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fall Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old female who presents s/p Fall. Patient with history of ___ transferred from ___ after trauma evaluation for a fall down stairs. + LOC. Had CT head, C spine and chest. Found to have a SAH, Right rib fractures, small apical pneumothorax and Right clavicle fracture. Awake and alert on arrival to ___. Mental status at baseline as per husband. No visual changes, neck pain. No abdominal pain. No new weakness. Past Medical History: - ___ Disease - Celiac Disease - Left ophthalmic artery aneurysm s/p coiling (___) - Osteoporosis - Raynaud's Disease - Tinnitus - Anxiety Social History: ___ Family History: Not available. Physical Exam: PHYSICAL EXAM ON ADMISSION: VS: Temp: 98.3 HR: 92 BP: 109/74 Resp: 18 O2 Sat: 98% RA Constitutional: Comfortable Head / Eyes: Extraocular muscles intact ENT / Neck: ecchymosis to face, no midface instability, no C spine tenderness, crepitus or step off Chest/Resp: Clear to auscultation, R chest wall tenderness Cardiovascular: Regular Rate and Rhythm GI / Abdominal: Soft, Nontender, Nondistended GU/Flank: no midline tenderness Musc/Extr/Back: + pulses Skin: No rash, Warm and dry Neuro: Speech fluent, non focal exam Psych: baseline dementia PHYSICAL EXAM ON DISCHARGE: VS: Temp: 98.0, BP: 129/83, HR: 94, RR: 18, O2Sat: 96 RA GENERAL: NAD. NEURO: alert and oriented x 3. Speech is clear. PULM: CTA Bilat. CV: RRR. ABD: BS x4. Soft, non-tender. MSK: Shoulder with guarding, limited rom r/t pain. EXT: PPP. No edema. SKIN: Ecchymosis noted to R shoulder. Pertinent Results: ___ - Portable AP view of the Chest: Acute mildly displaced midclavicular fracture. Right anterior first rib fracture. Subtle opacity at the right lung apex corresponds with known contusion on outside hospital CT chest. Please refer to outside hospital CT Chest for further details. ___ - Chest X-ray: In comparison with the study of ___, any residual pneumothorax would be very small. Cardiomediastinal silhouette is stable and there is no evidence of vascular congestion or acute focal pneumonia. Generalized dilatation of gas-filled loops of bowel is consistent with an a dynamic ileus pattern. ___ - Cat scan Abdomen and Pelvis: 1. No evidence of traumatic bowel injury. There is no bowel obstruction. Large amount of gas and stool within a highly redundant large colon. 2. Right basilar atelectasis with trace pleural fluid. Buckle deformity of a posterior right ninth rib is likely chronic. ___ - Right Shoulder X-ray: Mid to distal right clavicle fracture. ___: Head Cat scan: 1. Grossly stable appearance of the bilateral fronto-parietal subarachnoid hemorrhage. 2. No evidence of new intracranial hemorrhage or acute fracture. _ _ _ _ _ ________________________________________________________________ LAB WORK: ___ Brief Hospital Course: ___ year old female who presented to ___ emergency room as transfer from ___ after she suffered a fall with unknown loss of consciousness. Patient had imaging completed at ___ and was found to have found to have a ___, right ___ rib fractures, small apical pneumothorax and right clavicle fracture. Patient was awake and alert on arrival here and mental status at baseline as per husband. Patient was evaluated by orthopedics, neurosurgery, and acute care surgery and found to be non operative. Physical therapy and occupational therapy were consulted and the patient was determined to need rehabilitation as part of discharge planning. Throughout admission, the patient experienced intermittent periods of confusion which she experienced prior to her admission. She also reported right shoulder pain for which shoulder x-ray was completed and consistent with right subclavian fracture. Case management able to facilitate transfer to ___ for ongoing care and rehabilitation. Outpatient follow up with neurology, concussion clinic, and acute care surgery planned. At time of discharge, the patient's vital signs were stable and her pain was well managed with oral analgesics. She tolerated sitting in the chair. She was tolerating a regular diet and had return of bowel function. She did sustain a fall while attempting to get out of bed with reported head strike on the day of discharge. Cat scan imaging of the head was done which showed no changes to prior studies, therefore she was cleared for discharge. Follow-up appointments were made with the Orthopedic and acute care surgery clinic. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amantadine 100 mg PO TID 2. BusPIRone 15 mg PO BID 3. Carbidopa-Levodopa (___) 2 TAB PO 5X/DAY 4. Ibuprofen Dose is Unknown PO Frequency is Unknown 5. Escitalopram Oxalate 20 mg PO DAILY 6. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO TID Please limit to 3000mg in 24 hour period. 2. Bisacodyl 10 mg PO DAILY Please hold for diarrhea/loose stool. 3. Bisacodyl ___AILY:PRN Constipation - Second Line Duration: 1 Dose Please hold for diarrhea/loose stool. 4. Cyclobenzaprine 10 mg PO TID:PRN muscle spasms This medication may make you feel drowsy. 5. Docusate Sodium 100 mg PO BID Please hold for diarrhea/loose stool. 6. Gabapentin 300 mg PO TID 7. Heparin 5000 UNIT SC BID ___ discontinue when ambulating consistently. 8. Lidocaine 5% Patch 1 PTCH TD QAM R scapula 9. Lidocaine 5% Patch 1 PTCH TD QAM right rib fx's Please place on for 12 hours and then remove for 12 hours. 10. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate This medication may cause drowsiness. Do not operate heavy machinery while on this medication. RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*10 Tablet Refills:*0 11. Polyethylene Glycol 17 g PO DAILY Please hold for diarrhea/loose stool. 12. Senna 17.2 mg PO BID Please hold for diarrhea/loose stool. 13. Carbidopa-Levodopa CR (___) 2 TAB PO BID 14. Carbidopa-Levodopa CR (___) 1 TAB PO TID 15. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild Please take with food. 16. Amantadine 100 mg PO TID 17. BusPIRone 15 mg PO BID 18. Carbidopa-Levodopa (___) 2 TAB PO 5X/DAY 19. Escitalopram Oxalate 20 mg PO DAILY 20. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Right sylvian fissure subarachnoid hemorrhage, Right ___ and ___ rib fractures, Right clavicular fracture, and small Right apical pneumothorax. Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: ###Discharge paperwork TBI information### Activity • We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. • You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. Don't try to do too much all at once. • You make take a shower 3 days after surgery. • No driving while taking any narcotic or sedating medication. • If you experienced a seizure while admitted, you are NOT allowed to drive by law. What You ___ Experience: • You may have difficulty paying attention, concentrating, and remembering new information. • Emotional and/or behavioral difficulties are common. • Feeling more tired, restlessness, irritability, and mood swings are also common. • Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Headaches: • Headache is one of the most common symptoms after traumatic brain injury. Headaches can be long-lasting. • Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. • Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. • There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. More Information about Brain Injuries: • You were given information about headaches after TBI and the impact that TBI can have on your family. • If you would like to read more about other topics such as: sleeping, driving, cognitive problems, emotional problems, fatigue, seizures, return to school, depression, balance, or/and sexuality after TBI, please ask our staff for this information or visit ___ When to Call Your Doctor at ___ for: • Fever greater than 101.5 degrees Fahrenheit • Nausea and/or vomiting • Extreme sleepiness and not being able to stay awake • Severe headaches not relieved by pain relievers • Seizures • Any new problems with your vision or ability to speak • Weakness or changes in sensation in your face, arms, or leg Call ___ and go to the nearest Emergency Room if you experience any of the following: • Sudden numbness or weakness in the face, arm, or leg • Sudden confusion or trouble speaking or understanding • Sudden trouble walking, dizziness, or loss of balance or coordination • Sudden severe headaches with no known reason Followup Instructions: ___
10168400-DS-17
10,168,400
23,945,347
DS
17
2133-01-26 00:00:00
2133-01-26 12:53:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: hypoxia and tachycardia Major Surgical or Invasive Procedure: N/A History of Present Illness: ___ female with a history of asthma, COPD, atrial fibrillation, right breast cancer, abnormal recent PET scan with thickened endometrial stripe, HFpEF, who originally presented to ___ from her group home due to hypoxia and tachycardia. The patient was scheduled to undergo endometrial biopsy on ___ here at ___. Because of this, her anticoagulation has been held. Reportedly, patient was noted to be tachycardic with oxygen saturations in the ___ at her group facility. The patient herself denied chest pain, shortness of breath, cough, and reported she felt well. She underwent CT PE which was a limited study due to motion artifact, however showed no proximal pulmonary embolus. It did show a new round low density in the head of the pancreas as well as gallbladder wall calcification. In the ___, the history was obtained from the patient's two sisters, who are her legal guardians. They reported that her cardiologist recently decreased her Lasix dosing (which she receives for chronic lower extremity edema), as there were concerns the patient was becoming dehydrated on her 40 mg a day dose. However her group home, where patient resides, this lower dose had not been delivered from the pharmacy as of today and she is continuing to receive the 40 mg. In the ___, initial VS were 98.0 100 ___ 98% 2L NC. Labs significant for a WBC of 9.4, H/H of 10.6/35.2, platelets pending. Troponin negative ×1. BMP was not obtained. LFTs WNL. ProBNP 1454. CXR notable for bibasilar atelectasis and small left pleural effusion. Otherwise no focal consolidation or pulmonary edema. In the ___, she received 60 mg prednisone, ipratropium ×2, levofloxacin 500 mg p.o. Prior to coming up to the floor, she found to have Afib with RVR with rates in the 120s, and received 25mg Metoprolol tartate PO and 5 mg IV Metoprolol with improvement in her rates. Upon arrival to the floor, the patient tells the story as follows. She reports that she is feeling completely fine. She states she came here because of her heart rate beating too fast. She denies feelings of chest pain, palpitations, shortness of breath, abdominal pain, dysuria, or any pain. She denies any difficulty while lying flat. she reports she is eating and drinking well. There are no known fevers, chills, runny nose, cough. She has a raised erythematous lesion along the lateral surface of both index fingers, which she reports happened from when she picked up a hot cup of coffee and/or hot plate from the microwave. In speaking with her sisters, they report that the patient has continued to be sleepy since her last discharge from the hospital in mid ___. They feel that her shortness of breath has worsened. They report that they worry that she minimizes symptoms because she does not like to be in the hospital. They are aware of the new lesion in her pancreas seen on CAT scan and are asking about the next steps. ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History: - developmental delay with intellectual disability - Right breast invasive ductal carcinoma, ER/PR pos, HER-2 neg - COPD - atrial fibrillation - CHF - HTN - Hypothyroidism - Urinary incontinence - Obstructive Sleep Apnea - Abnormal PET scan of the uterus - ___ Lumpectomy for invasive ductal carcinoma ___) - Partial thyroidectomy - Hyperparathyroidism s/p parathyroidectomy - ___ Cataract surgery - Endometrial Stripe seen on PET scan Social History: ___ Family History: Mother with breast cancer at age ___. Sister with ovarian cancer at age ___. Physical Exam: ======================= EXAM ON ADMISSION ======================= VITALS: Afebrile and vital signs stable (see eFlowsheet) GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate. Mucous membranes moist CV: Heart irregular, normal rate RESP: Lungs with decreased breath sounds in the bilateral bases, no expiratory wheeze, no crackles or rails GI: Abdomen soft, non-distended, non-tender to palpation MSK: moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: Mild erythematous rash in the groin area, raised erythematous lesion along the lateral surface of both index fingers NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs Extremities: 3+ pitting edema in her bilateral legs up to the level of the knee PSYCH: pleasant, appropriate affect ======================= EXAM ON DISCHARGE ======================= AF HR 90-100s BP 100/60 Gen: Obese female, NAD Lung: No wheezes, improved air entry from prior CV RRR Abd: Obese, soft Ext: ___ edema bilateral ___ Pertinent Results: ================================ LABS ON ADMISSION ================================ ___ 02:16AM BLOOD WBC-9.4 RBC-3.93 Hgb-10.6* Hct-35.2 MCV-90 MCH-27.0 MCHC-30.1* RDW-17.3* RDWSD-56.7* Plt ___ ___ 02:16AM BLOOD Neuts-65.9 Lymphs-15.4* Monos-15.0* Eos-2.8 Baso-0.2 Im ___ AbsNeut-6.17* AbsLymp-1.44 AbsMono-1.40* AbsEos-0.26 AbsBaso-0.02 ___ 06:50AM BLOOD Glucose-128* UreaN-15 Creat-0.8 Na-141 K-4.5 Cl-97 HCO3-30 AnGap-14 ___ 06:50AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.1 ___ 01:24AM BLOOD ALT-9 AST-17 CK(CPK)-30 AlkPhos-54 TotBili-0.3 ___ 06:50AM BLOOD ___ PTT-28.9 ___ ___ 01:24AM BLOOD Lipase-78* ___ 01:24AM BLOOD CK-MB-<1 proBNP-1454* ___ 01:24AM BLOOD cTropnT-<0.01 ___ 01:24AM BLOOD TSH-3.6 ================================ PERTINENT INTERVAL LABS ================================ Hemoglobin a1c pending ================================ LABS ON DISCHARGE ================================ ___ 06:55AM BLOOD WBC-13.8* RBC-4.02 Hgb-11.0* Hct-36.2 MCV-90 MCH-27.4 MCHC-30.4* RDW-17.1* RDWSD-56.2* Plt ___ ___ 06:55AM BLOOD Glucose-111* UreaN-22* Creat-0.8 Na-143 K-4.7 Cl-99 HCO3-31 AnGap-13 ================================ MICROBIOLOGY ================================ Blood cultures negative on discharge. ================================ IMAGING ================================ ## ___ chest x-ray Pa + lat Bibasilar atelectasis and small left pleural effusion. Otherwise no focal consolidation or pulmonary edema. CT AP 1. Ill-defined 1.2 cm hypoattenuating area in the pancreas uncinate process is incompletely characterized. Recommend further evaluation with MRCP with and without contrast. 2. Endometrial thickening up to 1.0 cm is abnormal in a postmenopausal woman. Recommend pelvic ultrasound and consultation with Gynecology. 3. Similar appearance of the calcifications within the wall of the gallbladder. Brief Hospital Course: ___ female with a history of asthma, COPD, atrial fibrillation, developmental delay, right breast cancer, abnormal recent PET scan with endometrial stripe, HFpEF, who originally presented to ___ from her group home due to hypoxia and tachycardia, with CT imaging significant for a new pancreatic head mass, admitted for COPD exacerbation and atrial fibrillation with RVR. ACUTE/ACTIVE PROBLEMS: # Acute Hypoxic Respiratory Failure: # COPD Exacerbation: Patient presenting with dyspnea, increased wheeze, with a limited CT PE negative for pulmonary embolus, significant for atelectasis, small left pleural effusion, and nonspecific ground-glass in bilateral lung fields. When evaluated by the ___ physician, they reported "tight" air movement most consistent with COPD exacerbation, for which she received nebulizers, prednisone, and antibiotics. She improved dramatically with treatment for a COPD exacerbation, which included prednisone 60 mg for five days, azithromycin and bronchodilators. Her hypoxia improved, and maintained oxygen saturations above 90% on RA at rest, and improved with ambulation. Her hypoxia at present likely due to atelectasis, some element of CHF, as well as obesity hypoventilation. She will continue on ___, LAMA and prn bronchodilator for her COPD. # Thickened Endometrial Stripe: Patient due to undergo endometrial biopsy on ___ as an outpatient, which is needed in order to advance care for breast cancer. She should have this done as an outpatient. She can have this done at ___ ___ or ___. She would likely require sedation prior to this procedure. # Atrial fibrillation with RVR: Patient with multiple episodes of RVR occurring in our ___ and the ___. Of note, she was recently hospitalized at ___ in ___ for RVR. She was continued on her home dose of Diltiazem 180 mg daily and her Metoprolol dose was increased from 50 mg daily to 75 mg daily. We recommend that her Metoprolol XL 75 mg every morning, and to give the Diltiazem 180 mg in the evening. Her blood pressures were 90-100s systolic on this regimen, and she did not endorse dizziness or orthostasis. Should she develop symptoms of dizziness, would reduce dose of either agent. She should followup with her cardiologist at ___, either while a patient at ___ or after discharge. # Chronic diastolic CHF: Her Lasix dose had been increased to 40 mg recently as an outpatient so we will continue this dose. Her chemistries should be rechecked later this week to ensure that they are stable. # New pancreatic head mass: CT scan notable for 1.3 cm round low density in the head of the pancreas. - CT a/p w/ contrast ___ cm hypoattenuating lesion in uncinate process, recommended MRCP for further visualization. She should have an MRCP as an outpatient. # Porcelain Gallbladder: Noted on CT-PE. She should outpatient surgical evaluation to determine if she should have CCY given association with malignancy. CHRONIC/STABLE PROBLEMS: # Hypothyroidism: - Continue levothyroxine 75 mcg daily # Psych: - Continue citalopram 20 mg daily - Continue divalproex ___ mg PO BID # Hyperlipidemia: - Continue simvastatin 10 mg daily Greater than ___ hour spent on care on day of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 50 mg PO DAILY 2. Furosemide 20 mg PO DAILY 3. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 4. Apixaban 5 mg PO BID 5. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea 6. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild 7. Citalopram 20 mg PO DAILY 8. Levothyroxine Sodium 75 mcg PO DAILY 9. Diltiazem Extended-Release 180 mg PO DAILY 10. Simvastatin 10 mg PO QPM 11. Divalproex (DELayed Release) 375 mg PO BID 12. Vitamin D ___ UNIT PO DAILY 13. Polyethylene Glycol 17 g PO BID 14. GuaiFENesin ___ mL PO Q4H:PRN cough 15. Nystatin Cream 1 Appl TP BID Discharge Medications: 1. Diltiazem Extended-Release 180 mg PO QPM 2. Metoprolol Succinate XL 75 mg PO QAM 3. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild 4. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea 5. Apixaban 5 mg PO BID 6. Citalopram 20 mg PO DAILY 7. Divalproex (DELayed Release) 375 mg PO BID 8. Furosemide 40 mg PO DAILY 9. GuaiFENesin ___ mL PO Q4H:PRN cough 10. Levothyroxine Sodium 75 mcg PO DAILY 11. Nystatin Cream 1 Appl TP BID 12. Polyethylene Glycol 17 g PO BID 13. Simvastatin 10 mg PO QPM 14. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 15. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: COPD Obesity HFpEF Breast cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure caring for you at ___ ___. WHY WAS I IN THE HOSPITAL? - Your oxygen levels were low and your heart rates were fast - You had a cat scan at another hospital showing possibly a new mass in the pancreas WHAT HAPPENED TO ME IN THE HOSPITAL? - We treated you for COPD and your oxygen levels improved - We started a new medication for your heart rates - You had another cat scan to look at your pancreas. This showed a mass, but probably is not a cancer. You should have another study, called an MRCP to monitor it. - The cat scan showed a "porcelain gallbladder" which may indicate need for removal. You should followup with a surgeon as an outpatient. You are being discharged to ___ so that you can work on increasing your strength and endurance. Followup Instructions: ___