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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
PCPs 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/ced ___. 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: Patients 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 PI3Kδ] 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/endoscopypatient to receive outpatient endoscopy within 3
weeks to investigate healing of gastric ulcers
Heparininitial concern for HIT, serotonin release assay
negative which ruled out diagnosis. Heparin has been removed
from allergy list
- Amiodarone loadpatient 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:
___
|
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