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10168835-DS-11 | 10,168,835 | 26,590,592 | DS | 11 | 2185-06-15 00:00:00 | 2185-06-15 18:07:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Renal failure
Major Surgical or Invasive Procedure:
___ Pacemaker placement
History of Present Illness:
___ h/o acute on CKD4, HTN, AV conduction disease, who came in
to ED due to worsening kidney failure. Patient had a ___
visit ___ with his nephrologist for evaluation of his kidney
function. At that visit, the patient was noted to be bradycardic
into ___ and hypotensive to SBP90s while standing (baseline SBP
at home 140s-150s). He was also noted to have worsened Cr 4.0
(baseline 2.9 on ___, which was thought due to hypotension
and bradycardia leading to poor perfusion of kidneys, and
increased dose of lisinopril. Patient was told to stop his
lisinopril and chlorthalidone, with plan to recheck labs ___.
Due to bradycardia and concern for possible third degree AV
block, cardiology was consulted at his nephrology appointment.
Per cardiology, the patient's EKG was representative of stable
AV
conduction disease without 3rd degree AV block, and that there
was no urgent indication for pacemaker at this time. Patient was
sent home with ___ of Hearts monitor.
The patient states that he did stop taking lisinopril and
chlorthalidone over the weekend prior to admission. He also says
he was eating/drinking less in an attempt to follow renal diet
restrictions. Denies any new medications. He underwent lab draw
on ___, which showed that Cr was 4.7, and he was told to come
into the ED. The patient states he did note decreased urinary
frequency on ___. Denies dysuria, hematuria. Patient denied
chest pain, palpitations, shortness of breath, lower extremity
edema. He denies fever, chills, cough, abdominal pain. Had 1
episode of diarrhea day prior to admission, no nausea/vomiting.
In the ED, initial vitals were: T98.0, HR61, BP123/44, RR18,
O2Sat 100% RA.
- Exam unremarkable.
- Labs notable for: WBC 8.6, Hgb 10.6, Plt 225, K5.5 > 4.6, AGMA
with HCO3 11, BUN/Cr 138/4.5, Phos 7.0. UA with moderate blood,
RBC>182, trace protein.
- Imaging was notable for:
EKG with conduction disease - stable since ___.
- Patient was given:
___ 14:20 IV Insulin (Regular) for Hyperkalemia 10
___ 14:20 IV Dextrose 50% 25 gm
___ 14:20 IVF 1L NS
Notably, while in ED, the patient triggered for bradycardia to
33. There was initially concern for 3rd degree AV block, however
EP was consulted and stated that the patient's EKG demonstrated
known conduction disease with junctional rhythm and sinus
bradycardia with occasional appropriate conduction. Unlikely
that
bradycardia contributing to renal dysfunction given his
conduction disease has been stable since ___. They
recommended decreasing tele parameters for HR <30 (baseline HR
is
35), and to obtain venous mapping studies such that PPM can be
placed on contralateral side of potential AV fistula.
Upon arrival to the floor, patient reports that he feels overall
well. Says he has been urinating well since he got IVF in the
ED.
Denies dysuria, hematuria. Denies CP, SOB, palpitations, lower
extremity edema. Denies any fevers, chills, runny nose, sore
throat, cough, abdominal pain, nausea, vomiting, diarrhea
(except
1 episode on ___, constipation.
Past Medical History:
Hypertension
DM II - diet controlled
CKD III
TIA ___ (microvascular brain disease)
Memory Loss
2nd degree Heart Block
Social History:
___
Family History:
Brother died from heart attack at ___. No
arrhythmias or SCD.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: T___.4 BP150/64 HR43 O2Sat96%RA
GENERAL: Well appearing man in no acute distress.
HEENT: PERRL, MMM.
NECK: Supple.
CARDIAC: Bradycardic, regular rate, no murmurs, rubs, or
gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, nontender, mildly distended. No guarding.
EXTREMITIES: Trace lower extremity edema bilaterally.
NEUROLOGIC: A&Ox3, DOWB with ease, responding to questions
appropriately, moving all extremities with purpose.
SKIN: No rashes noted.
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 629)
Temp: 97.5 (Tm 98.2), BP: 157/78 (137-178/60-78), HR: 67
(___), RR: 18 (___), O2 sat: 98% (97-98), O2 delivery: Ra,
Wt: 197.75 lb/89.7 kg (197.75-197.8)
GENERAL: Well appearing. NAD.
HEENT: PERRL, MMM.
NECK: Supple.
CARDIAC: Normal rate, paced regular rhythm. No murmurs, rubs, or
gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, nontender, mildly distended. No guarding.
EXTREMITIES: Trace lower extremity edema bilaterally.
NEUROLOGIC: AOx3. Moving extremities w/ purpose.
SKIN: No rashes.
Pertinent Results:
ADMISSION LABS
==============
___ 12:30PM BLOOD WBC-8.6 RBC-3.25* Hgb-10.6* Hct-31.9*
MCV-98 MCH-32.6* MCHC-33.2 RDW-13.4 RDWSD-47.8* Plt ___
___ 12:30PM BLOOD Neuts-69.2 Lymphs-14.3* Monos-9.9 Eos-5.7
Baso-0.7 Im ___ AbsNeut-5.91 AbsLymp-1.22 AbsMono-0.85*
AbsEos-0.49 AbsBaso-0.06
___ 12:30PM BLOOD ___ PTT-28.7 ___
___ 02:25PM BLOOD UreaN-139* Creat-4.7* Na-137 K-5.1 Cl-105
HCO3-11* AnGap-21*
___ 06:35AM BLOOD ALT-6 AST-6 LD(LDH)-149 AlkPhos-64
TotBili-0.3
___ 02:25PM BLOOD Phos-6.6* Mg-3.3* Iron-96
___ 02:25PM BLOOD calTIBC-248* Ferritn-550* TRF-191*
___ 10:53AM BLOOD ___ pO2-144* pCO2-25* pH-7.29*
calTCO2-13* Base XS--12 Comment-GREEN TOP
PERTINENT LABS
==============
___ 02:25PM BLOOD UreaN-139* Creat-4.7* Na-137 K-5.1 Cl-105
HCO3-11* AnGap-21*
___ 12:30PM BLOOD Glucose-149* UreaN-140* Creat-4.6* Na-137
K-5.5* Cl-106 HCO3-10* AnGap-21*
___ 03:20PM BLOOD Glucose-144* UreaN-138* Creat-4.5* Na-137
K-4.6 Cl-107 HCO3-11* AnGap-19*
___ 06:35AM BLOOD Glucose-95 UreaN-126* Creat-4.2* Na-140
K-5.3 Cl-111* HCO3-11* AnGap-18
___ 06:50AM BLOOD Glucose-95 UreaN-114* Creat-3.8* Na-143
K-5.3 Cl-118* HCO3-12* AnGap-13
___ 07:08AM BLOOD Glucose-108* UreaN-106* Creat-3.2* Na-146
K-5.4 Cl-117* HCO3-12* AnGap-17
___ 06:40AM BLOOD Glucose-93 UreaN-81* Creat-2.5* Na-146
K-4.9 Cl-116* HCO3-15* AnGap-15
MICROBIO
========
UCX ___ Negative
REPORTS
=======
Renal US ___
1. No hydronephrosis or suspicious renal lesion.
2. New nonobstructing stones in the right lower pole measuring
up to 1.8 cm.
Vein Mapping BUE ___
Patent central veins. Small diameter right upper extremity
veins. The left cephalic vein is small in the forearm and is
not seen in the upper arm. Moderately calcified radial arteries.
Please see technologist worksheet for detailed measurements.
CXR ___
R-sided pacemaker with leads in place.
Brief Hospital Course:
Mr. ___ is an ___ year-old man with CKD Stage IV, HTN, and AV
conduction disease who presented to the ED at nephrologist's
advice for rising Creatinine, found to have pre-renal ___.
ACUTE ISSUES
============
# Prerenal Acute Kidney Injury, improving
# CKD Stage 4
Baseline on ___ of 2.9, increased to peak of 4.7 on day
prior to admission ___. Reports decreased PO intake and FeNa
1% consistent with possible prerenal etiology; additionally
given NSAID use could exacerbate prerenal picture. Renal
consulted;
spun urine and no sign of ATN or white cells. Urinating well and
ultrasound without obstruction. IVF given as needed with robust
improvement in Cr. Nutrition consulted and assisted with low K &
low Phos diet.
# AV Conduction Disease
# Mobitz 1 Heart Block with Junctional Rhythm, s/p PPM
History of conduction disease since ___ with baseline
HR 40-60. Cardiology has consulted as outpatient and ED and felt
no indications of 3rd degree block at this time; bradycardia
unlikely contributing to ___ and unlikely due to ___. However,
given persistent bradycardia, PPM placed on ___. Given
prophylactic antibiotics for ___nion Gap Metabolic Acidosis
Likely primarily due to renal disease. Appeared clinically well.
Started on oral bicarb with improvement in acidosis and
chemistries.
# HTN with elevated BP's in house: in the setting of holding
home Lisinopril and Chlorthalidone.
# Macrocytic anemia: stable
- for further out patient w/u
# micro-hematuria with kidney US showing large non-obstructing
stones in the right lower pole measuring up to 1.8 cm and 1.5
cm.
- repeat UA post d/c. for PCP ___.
CHRONIC ISSUES
==============
# Anemia
Hb at baseline ___. Iron studies reflect anemia of chronic
kidney disease.
# Hypertension
Lisinopril and Chlorthalidone on hold given ___ prior to
admission.
# h/o TIA
Continued home ASA/dipyridamole, pravastatin.
# T2DM
Diet-controlled.
TRANSITIONAL ISSUES
===================
----Regarding Pacemaker----
[ ] Discharged with Keflex to complete 3 day prophylactic
course.
[ ] Leave the dressing on for 3 days. On ___, outer
dressing can be removed. Steri strips should remain on until
they fall off on their own.
[ ] Should call to schedule appointment with ___ clinic in 1
week, Has previous cardiology appointment in ___ which he
should also keep.
----Regarding Renal Disease----
# Discharge Cr: 2.5
[ ] Bicarb low here, should get repeat Chem-7 within the next
week.
[ ] Continued to hold lisinopril and chlorthalidone on
discharge. At PCP ___ if ___ still stable/improving, and
BPs elevated, can consider restarting lisinopril or
chlorthalidone.
[ ] Recommend repeat UA as outpatient given isomorphic RBC seen
on urine sediment. If persistent blood, consider cystoscopy v.
other bladder cancer screening given prior tobacco use.
----Miscellaneous----
[ ] Macrocytosis noted on CBC. Stable, but should consider
further workup as an outpatient if persistent.
# Code Status: Full, confirmed
# Emergency Contact: Wife, ___ (___)
Daughter, ___ (___)
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO BID
2. aspirin-dipyridamole ___ mg oral BID
3. Pravastatin 10 mg PO QPM
4. Cyanocobalamin Dose is Unknown PO DAILY
5. Ascorbic Acid Dose is Unknown PO DAILY
6. Fish Oil (Omega 3) Dose is Unknown PO DAILY
7. Vitamin D Dose is Unknown PO DAILY
8. coenzyme Q10 Dose is Unknown oral DAILY
9. turmeric root extract Dose is Unknown oral DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Cephalexin 250 mg PO Q8H Duration: 3 Days
RX *cephalexin 250 mg 1 capsule(s) by mouth every eight (8)
hours Disp #*7 Capsule Refills:*0
3. Sodium Bicarbonate 1300 mg PO TID
RX *sodium bicarbonate 650 mg 2 tablet(s) by mouth three times a
day Disp #*180 Tablet Refills:*0
4. amLODIPine 5 mg PO BID
5. Ascorbic Acid 1 tab PO DAILY
6. aspirin-dipyridamole ___ mg oral BID
7. coenzyme Q10 1 tab oral DAILY
8. Cyanocobalamin 1 tab PO DAILY
9. Fish Oil (Omega 3) 1 tab PO DAILY
10. Pravastatin 10 mg PO QPM
11. turmeric root extract 1 tab oral DAILY
12. Vitamin D 1 tab PO DAILY
13.Outpatient Lab Work
Chronic Kidney Disease (N18)
Chem-7
Nephrologist Dr. ___
___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- Chronic kidney disease
- Acute kidney injury
- Bradycardia
SECONDARY DIAGNOSES:
- Anion Gap Metabolic Acidosis
- Anemia of Chronic Disease
- Hypertension
- H/o TIA
- Type 2 Diabetes
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 ___.
WHY WAS I IN THE HOSPITAL?
- Your labs showed that your kidney function was worse
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We gave you fluids and watched your kidneys improve.
- We looked for other causes of your abnormal kidney function
and did not see any concerning causes.
- The cardiology team decided you would benefit from a
pacemaker; you tolerated the procedure well and the pacemaker is
in position and working appropriately.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- As we discussed, there are several things you should focus on
with your diet. It is ok to drink as much fluid as you want.
However, you should make an effort to limit foods that are high
in potassium, high in protein, or high in phosphorus.
- As noted below, please call the cardiac device clinic at
___ on ___ to schedule an appointment for later in
the week.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10168921-DS-23 | 10,168,921 | 20,241,674 | DS | 23 | 2173-06-22 00:00:00 | 2173-06-22 13:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
allopurinol
Attending: ___.
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with a past medical history
of
CKD, HFpEF, hypertension, pulmonary hypertension. Her last
known
normal was ___. A welfare check was performed
subsequently
as the patient had not been seen since ___ she was found
down covered in urine and feces and possibly coffee-ground
emesis
per report. She was taken to ___, where CT showed L MCA
infarct. She was then transferred here. She was nonverbal on
interview and not able to give any meaningful responses.
Intubation was considered in the ___ however her level of
consciousness improved and this was deferred. Per ___ note, she
is
DNR DNI per ___ discussion with the patient's son.
Past Medical History:
1. CAD s/p cath
2. dyslipidemia
3. hypertension
4. cataracts
5. RLE vascular surgery on veins
6. tonsillectomy
7. appendectomy
8. BCC excision
9. vertebrae tumor excision in late ___
Social History:
___
Family History:
One brother had "heart and kidney problems;" one had a stroke
more than a decade ago.
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: She arouses to voice, regards examiner. She
does not follow appendicular or axial commands. She is
nonverbal
and does not state where she is.
- Cranial Nerves: PERRL 3->2 brisk. VF intact to threat. Left
gaze preference does not cross midline. no facial movement
asymmetry. Palate elevation symmetric. Tongue midline.
- Motor: She moves the left upper extremity spontaneously and
purposefully at least antigravity. She moves the left lower
extremity spontaneously and at least antigravity. There is
spontaneous movement of the right lower extremity in the plane
of
the bed. The right arm withdraws to noxious stimuli
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 2+ 1
R 2+ 2+ 2+ 2+ 1
Plantar response flexor bilaterally
- Sensory: Withdraws to pain in all 4 extremities
- Coordination: Unable to assess
- Gait: Deferred
DISCHARGE PHYSICAL EXAM:
Patient CMO, sleeping comfortably on exam this morning in no
apparent respiratory distress or pain. Per family, had woken up
for a few minutes earlier and recognized her grandson.
Pertinent Results:
___ 05:46AM BLOOD WBC-14.2* RBC-4.46 Hgb-13.2 Hct-41.7
MCV-94 MCH-29.6 MCHC-31.7* RDW-14.0 RDWSD-46.5* Plt ___
___ 12:44AM BLOOD Glucose-135* UreaN-31* Creat-1.4* Na-148*
K-3.1* Cl-103 HCO3-29 AnGap-16
___ 05:46AM BLOOD ALT-17 AST-36 LD(LDH)-439* CK(CPK)-514*
AlkPhos-105 TotBili-0.5
___ 05:46AM BLOOD GGT-11
___ 05:46AM BLOOD CK-MB-12* MB Indx-2.3 cTropnT-0.04*
___ 05:46AM BLOOD TotProt-6.6 Albumin-3.8 Globuln-2.8
Cholest-162
___ 05:46AM BLOOD Triglyc-103 HDL-50 CHOL/HD-3.2 LDLcalc-91
___ 05:46AM BLOOD TSH-0.72
___ 05:46AM BLOOD CRP-34.1*
CT head ___
" 1. Left MCA distribution infarct.
2. Type patchy periventricular and subcortical
hypodensities, likely small vessel disease.
3. Vascular calcification.
4. Paranasal sinus mucosal thickening."
Brief Hospital Course:
Pt is a ___ female with a past medical history of CKD,
HFpEF,
hypertension, and pulmonary hypertension who was found down at
her home and subsequently found to have large L MCA infarct on
CT at OSH. She was transferred to ___ and admitted to Neuro
ICU for monitoring. Prior to admission, pt was noted to be
DNR/DNI by son in ___.
ICU COURSE (___):
Upon arrival to ICU, pt was monitored on telemetry and with q4
neurochecks. She was maintained on ASA and PPI. She was seen to
have hazy urine with urine studies suggestive of UTI, with pt
being started on Ceftriaxone. GOC discussion held with family at
bedside during ___ of ___ with family (particularly son who is
next-of-kin) who wished for pt to be made comfort measures only.
She was subsequently transferred to the floor due to stable
clinical status and no need for ICU level of care.
Mrs. ___ was made ___ care by her family, and started on
morphine, lorazepam, and Zofran for comfort. She was transferred
to hospice ___, consistent with her goals of comfort.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack - patient CMO early on, so several core measures not
completed due to her goal of comfort.
1. Dysphagia screening before any PO intake? (X) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? () Yes - (X) No
3. Antithrombotic therapy administered by end of hospital day 2?
() Yes - (X) No
4. LDL documented? () Yes (LDL = ) - (X) No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) () Yes - (X) No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ X] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
--patient CMO
[ ] LDL-c less than 70 mg/dL
]
6. Smoking cessation counseling given? () Yes - (X) No [reason
(X) non-smoker - (X) 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 >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist -
patient CMO
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? () Yes [Type: ()
Antiplatelet - () Anticoagulation] - (X) No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - (X) No - () N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 2.5 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Clopidogrel 75 mg PO DAILY
5. Torsemide 100 mg PO DAILY
6. Potassium Chloride 20 mEq PO DAILY
Discharge Medications:
1. LORazepam 0.5-2 mg PO Q4H:PRN anxiety/distress
Take as needed every 4 hours for anxiety or agitation
RX *lorazepam 2 mg/mL 0.5 to 1 mL by mouth every four (4) hours
Refills:*0
2. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL ___
mg PO Q4H:PRN Pain or respiratory
Take ___ Q4H as needed for pain or shortness of breath. ___
use every hour if in crisis.
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 0.25 to 1 mL by
mouth every four (4) hours Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left MCA infarct
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear ___,
___ were hospitalized due to symptoms of right sided weakness
and confusion, 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.
While ___ were in the hospital, your family decided to pursue
comfort measures only for your care. ___ were given only
medications to keep ___ comfortable.
It was a pleasure taking care of ___.
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10169160-DS-21 | 10,169,160 | 22,053,865 | DS | 21 | 2184-04-21 00:00:00 | 2184-04-21 21:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tetanus Vaccines & Toxoid
Attending: ___
Chief Complaint:
=======================================================
HMED ADMISSION NOTE
Date of admission: ___
=======================================================
PCP: ___, MD
CC: ___ distension
Major Surgical or Invasive Procedure:
Paracentesis x2
Omental biopsy
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
___ woman with history of hypertension who presented to the ED
with progressive abdominal distension.
She reports that she has been feeling "great" up until about 4
days ago. She reports feeling in her usual state of health until
___ when she noticed increased pressure in her abdomen and
her jeans not feeling as comfortable as before. She indicates
that since last ___ she has lost 35 lbs intentionally. She
diligently checks her weight daily with ___ (fitbit scale)
which syncs to her phone and I reviewed all of her weights for
the past year which corroborates this history. Since the last
week in ___ her fitbit recordings demonstrate about a 5lb
weight gain. She says that she has been wearing her "skinny"
jeans but while driving home from the ___ on ___ she had
so much pressure and the waist band was so tight she had to
unbutton her jeans while driving. She does report one episode of
diarrhea and vomiting after eating baby carrots 1.5 weeks ago
but otherwise no other symptoms, in fact over ___ she took
her children and grandchildren out to eat several nights in the
row and had no problems.
She reports daily, normal bowel movements without a change
(aside from this morning she has not gone yet). Denies fever,
chills, sweats, diarrhea, nausea, vomiting, burping/belching,
chest pain, GERD. She reports regular follow up with
colonoscopies.
She called her PCP on ___ when she returned home who
referred her to urgent care. She presented to urgent care
___ on ___ where she was initially discharged home.
When CT findings returned concerning for metastatic cancer of
gastric primary origin her PCP called her at home to come
directly to the ED. She waited to come to the ED until her puppy
was cared for and her son could take her in from the ___.
In the ED, initial vitals were: 98.6 124 172/87 18 96% RA. Exam
was notable for abdominal distension. Labs were notable for
hyponatremia, hypokalemia, leukocytosis. CT A/P showing gastric
wall thickening and concern for peritoneal carcinomatosis. She
was given IVFs and admitted to medicine for expedited oncology
work up.
On the floor, she appears well, is comfortable, without pain or
nausea but reports some pressure like she needs to have a BM.
She is in good humor, and in no acute distress.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. No dysuria. Denies arthralgias or
myalgias. Otherwise ROS is negative.
Past Medical History:
HYPERTENSION
HYPERLIPIDEMIA
ASTHMA
Social History:
___
Family History:
Relative Status Age Problem Comments
Mother ___ ___ STROKE
CORONARY ARTERY
DISEASE
ALZHEIMER'S DISEASE
BREAST CANCER Postmenopausal
Father ___ ___ HYDROCEPHALUS
MGM Deceased
MGF Deceased
PGM Deceased
PGF Deceased APPENDICITIS
Brother ___ ___
Son Living ___
Son Living ___
Daughter Living ___
Son Living ___ CORONARY ARTERY s/p stent
DISEASE
Comments: 6 grandchildren - 5 girls and 1 boy. The boy is
autistic.
Physical Exam:
Vitals: 98.1 PO 136 / 81 95 18 96 ra
Pain Scale: ___
General: Patient appears well, she is seated on edge of bed,
interactive, pleasant and in good humor. Alert, oriented and in
no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP low, no LAD appreciated
Lungs: Clear to auscultation bilaterally, moving air well and
symmetrically, no wheezes, rales or rhonchi appreciated
CV: Regular rate and rhythm, S1 and S2 clear and of good
quality, no murmurs, rubs or gallops appreciated
Abdomen: distended but soft, not tense, tympanic to percussion
anteriorly, +fluid wave, hypoactive bowel sounds throughout, no
rebound or guarding
Ext: Warm, well perfused, full distal pulses, no clubbing,
cyanosis or edema
Neuro: CN2-12 grossly in tact, motor and sensory function
grossly intact in bilateral UE and ___, symmetric
VITALS: 98.7 102/60 85 18 100% RA
GEN: Sitting up in a chair, comfortable appearing, NAD
HEENT: EOMI, sclerae anicteric, MMM, OP clear
NECK: No LAD, no JVD
CARDIAC: RRR, no M/R/G
PULM: normal effort, no accessory muscle use, LCAB
GI: Mildly distended, non-tender, active bowel sounds
MSK: No visible joint effusions or deformities.
DERM: No visible rash. No jaundice.
NEURO: AAOx3. No facial droop, moving all extremities.
PSYCH: Full range of affect
EXTREMITIES: WWP, no edema
Pertinent Results:
Admission Labs:
___ 01:15PM BLOOD WBC-11.0* RBC-4.05 Hgb-12.9 Hct-38.4
MCV-95 MCH-31.9 MCHC-33.6 RDW-11.9 RDWSD-41.5 Plt ___
___ 01:15PM BLOOD Neuts-83.1* Lymphs-7.5* Monos-8.4
Eos-0.5* Baso-0.2 Im ___ AbsNeut-9.15* AbsLymp-0.83*
AbsMono-0.92* AbsEos-0.06 AbsBaso-0.02
___ 01:15PM BLOOD Glucose-102* UreaN-15 Creat-0.7 Na-132*
K-3.2* Cl-92* HCO3-28 AnGap-15
___ 01:15PM BLOOD ALT-12 AST-34 AlkPhos-47 TotBili-0.5
___ 01:15PM BLOOD Albumin-3.4* Calcium-8.7 Phos-3.8 Mg-1.7
___ 01:15PM BLOOD Lipase-35
Imaging:
CT A/P ___:
1. Omental thickening or caking concerning neoplastic disease,
particularly metastatic disease. The wall of the gastric antrum
appears thickened and gastric carcinoma should be considered.
2. Massive abdominal and pelvic ascites
3. Portacaval, mesenteric and retroperitoneal lymphadenopathy.
4. 4 mm, indeterminate subpleural nodule along the
posterolateral aspect of the right lung base.
5. Colonic diverticulosis without evidence of acute
diverticulitis.
___ CT Chest
IMPRESSION:
1. Scattered bilateral pulmonary nodules measuring up to 5 mm.
Clinical and imaging follow-up recommended.
2. Heterogeneous right thyroid with a prominent right upper
mediastinal lymph node. Thyroid ultrasound is recommended.
Right axillary and right internal mammary adenopathy worrisome
for metastatic disease.
3. Extensive intra-abdominal ascites well as omental caking
compatible with metastatic disease, better assessed on CT
abdomen from 1 day prior.
4. Heavy atherosclerotic calcifications in the coronary
arteries.
5. Small hiatal hernia.
6. Atelectasis and airspace disease left lung base which could
be related to pneumonia or possible tumor infiltration of the
lung.
RECOMMENDATION(S): Thyroid ultrasound.
Pertinent Interval:
___ 07:10AM BLOOD CEA-0.4 CA125-___*
___ 07:10AM BLOOD CA ___ -Test
___ 02:30PM ASCITES TNC-1221* RBC-176* Polys-24* Lymphs-38*
___ Mesothe-3* Macroph-32* Other-3*
___ 02:30PM ASCITES TotPro-5.5 Albumin-2.6
___ 2:30 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
Peritoneal fluid cytology (prelim): Adenocarcinoma
Omental biopsy: Pending
Discharge Labs:
___ 07:10AM BLOOD WBC-9.1 RBC-4.04 Hgb-12.5 Hct-38.6 MCV-96
MCH-30.9 MCHC-32.4 RDW-11.9 RDWSD-41.5 Plt ___
___ 07:10AM BLOOD Glucose-86 UreaN-13 Creat-0.6 Na-137
K-4.8 Cl-99 HCO3-26 AnGap-17
___ 07:10AM BLOOD Calcium-8.6 Phos-3.5 Mg-1.8
Brief Hospital Course:
Ms. ___ is a ___ woman with a history of HTN and asthma who
presents to the ED with progressive abdominal distension, rapid
weight gain and CT findings with new ascites, with preliminary
pathology consistent with adenocarcinoma.
# New Ascites
# Omental caking
# Gastric wall thickening
# Adenocarcinoma: Initial CT imaging was concerning for gastric
thickening. She underwent EGD which was unrevealing, though
biopsies were obtained. She underwent diagnostic paracentesis.
Fluid was sent for cytology, preliminary positive for
adenocarcinoma. CEA and CA ___ WNL, though CA125 significantly
elevated. High suspicion for ovarian malignancy. A total of 8.5L
fluid were removed in the span of two days with two separate
paracentesis procedures. She will be set up for GYN follow up.
Stains on the peritoneal fluid and pathology from the omental
biopsy are pending on discharge.
# Heterogenous thyroid: Noted incidentally on staging CT of the
chest. Thyroid ultrasound was not pursued as suspicion for
primary thyroid cancer is low.
# HTN: HCTZ held on admission given mild hyponatremia. She
remained normotensive during her admission and HCTZ held on
discharge.
# HLD: Continued home statin
# Asthma: Continued home Flovent
#CONTACT: Proxy name: ___
Relationship: Daughter Phone: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Pravastatin 40 mg PO QPM
2. Fluticasone Propionate 110mcg 2 PUFF ___ BID
3. Aspirin 81 mg PO DAILY
4. Loratadine 10 mg PO DAILY
5. Hydrochlorothiazide 12.5 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. Loratadine 10 mg PO DAILY
4. Pravastatin 40 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Malignant ascites
Adenocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted for workup of abdominal distention. You were
found to have fluid in your abdomen. This is due to a cancer,
though we do not yet know what type it is. Our highest suspicion
is that this is a gynecologic cancer. You had the fluid in your
abdomen removed. You are scheduled for follow up with the
gynecology team to discuss the next steps in your treatment
plan.
It was a pleasure to be a part of your care,
Your ___ treatment team
Followup Instructions:
___
|
10169389-DS-5 | 10,169,389 | 22,067,161 | DS | 5 | 2181-03-27 00:00:00 | 2181-04-01 12:23:00 |
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:
___ - Splenectomy
History of Present Illness:
___ Year old male who complains of Abd pain. Pt reports he was dx
with Mono at the beginning of ___ and last night tripped and
fell and landed on his stomach and had abd pain. He reports no
loss of consciousness no neck pain no numbness tingling,
weakness, back pain dysuria or chest pain or chest wall pain.
Pain continued this am and he called his PCP office at ___ and
was told to present to the ED. Here, he reported some abd pain
in triage but was tachycardic to the 130s with systolic blood
pressure off 115/65. He was receiving blood products with a
positive FAST exam, grossly distended abdomen, severe pain now
diffusely. Despite receiving 2 units of packed red blood cells,
blood pressure remained low, and he was very tachycardic. Given
a recent history of mononucleosis, we suspected splenic rupture,
and given his incomplete response to 2 units of blood, he was
taken urgently to the operating room for exploration.
Past Medical History:
Recent h/o mononucleosis, laparoscopic appendectomy
Social History:
___
Family History:
Noncontributory
Physical Exam:
PHYSICAL EXAMINATION
Temp: 96.9 HR: 130 BP: 115/65 Resp: 18 O(2)Sat: 100
Constitutional: weakness, fatigued
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Oropharynx within normal limits, C-spine has no midline
tenderness, full range of motion of neck no tenderness to
palpation over facial bones
Chest: Clear to auscultation anteriorly, no chest wall
tenderness, no crepitus
Cardiovascular: Regular Rate and Rhythm, tachy, Normal first
and second heart sounds
Abdominal: Nondistended, tenderness to palpation over the
left anterior and upper abdominal area with no voluntary
guarding or rebound no left or right flank tenderness normal
bowel sounds x4, Soft
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema no tenderness over
shoulder upper extremity or lower extremity joints pelvis
stable
Skin: No rash, Warm and dry
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
___: No petechiae
ON DISCHARGE:
VS: 98.0, 95, 130/66, 16, 99%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. Incision: clean, dry and intact,
dressed and closed with staples.
EXTREMITIES: Warm, well perfused, pulses palpable, (-) edema
Pertinent Results:
___ 08:20AM BLOOD WBC-8.1 RBC-3.45* Hgb-10.8* Hct-29.9*
MCV-87 MCH-31.4 MCHC-36.1* RDW-14.4 Plt ___
___ 07:10AM BLOOD WBC-9.2 RBC-3.58* Hgb-11.1* Hct-30.9*
MCV-86 MCH-31.0 MCHC-35.9* RDW-14.3 Plt ___
___ 07:05AM BLOOD WBC-12.0* RBC-3.31* Hgb-10.4* Hct-29.3*
MCV-89 MCH-31.6 MCHC-35.6* RDW-14.2 Plt ___
___ 06:45AM BLOOD WBC-12.4* RBC-3.00* Hgb-9.5* Hct-26.5*
MCV-88 MCH-31.8 MCHC-36.0* RDW-14.4 Plt ___
___ 07:45PM BLOOD WBC-9.7 RBC-2.88* Hgb-9.1* Hct-25.6*
MCV-89 MCH-31.7 MCHC-35.7* RDW-14.9 Plt ___
___ 05:31AM BLOOD WBC-7.5# RBC-3.06* Hgb-9.5* Hct-27.5*
MCV-90 MCH-31.1 MCHC-34.5 RDW-15.1 Plt ___
___ 07:50PM BLOOD WBC-15.8* RBC-3.36* Hgb-10.8* Hct-29.5*
MCV-88 MCH-32.2* MCHC-36.5* RDW-15.0 Plt ___
___ 02:12PM BLOOD WBC-16.6* RBC-4.07* Hgb-13.1* Hct-36.6*
MCV-90 MCH-32.1* MCHC-35.7* RDW-14.9 Plt ___
___ 11:30AM BLOOD WBC-11.1* RBC-4.35* Hgb-13.8* Hct-39.9*
MCV-92 MCH-31.7 MCHC-34.5 RDW-14.7 Plt ___
___ 08:20AM BLOOD Glucose-108* UreaN-3* Creat-0.5 Na-137
K-4.0 Cl-106 HCO3-24 AnGap-11
___ 07:10AM BLOOD Glucose-96 UreaN-3* Creat-0.5 Na-134
K-4.1 Cl-100 HCO3-24 AnGap-14
___ 07:05AM BLOOD Glucose-72 UreaN-3* Creat-0.5 Na-132*
K-3.9 Cl-97 HCO3-24 AnGap-15
___ 06:45AM BLOOD Glucose-77 UreaN-5* Creat-0.5 Na-133
K-3.9 Cl-100 HCO3-24 AnGap-13
___ 07:45PM BLOOD Glucose-94 UreaN-6 Creat-0.6 Na-138 K-3.5
Cl-103 HCO3-23 AnGap-16
___ 05:31AM BLOOD Glucose-105* UreaN-8 Creat-0.7 Na-135
K-4.1 Cl-104 HCO3-27 AnGap-8
___ 02:12PM BLOOD Glucose-138* UreaN-11 Creat-0.6 Na-136
K-4.4 Cl-109* HCO3-19* AnGap-12
___ 11:30AM BLOOD Glucose-114* UreaN-14 Creat-0.7 Na-136
K-4.2 Cl-102 HCO3-20* AnGap-18
IMAGING:
___ - Limited Bedside Ultrasound: Hepatorenal: Anechoic
Collection, Perisplenic: Anechoic Collection, Pelvic: Anechoic
Collection, Subcostal:No Fluid Chest: No Fluid. splenic lac with
___ hematoma at dome and lower pole with
intraparenchymal
hematoma, free fluid at the liver tip and large free fluid with
hematoma at pelvic window
___ CXR
Heart size is normal. Mediastinum is normal. NG tube tip is in
the stomach. Lungs are essentially clear. There is no pleural
effusion or pneumothorax.
___ KUB/CXR
No evidence of retained foreign body.
Mild pulmonary vessel congestion, increased from ___.
___ ECG
Sinus tachycardia Rate 123
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
BLOOD CULTURES: No growth to date
Brief Hospital Course:
The patient was admitted to the Acute Care Trauma Surgery
service and was taken urgently to the operating room for
suspected ruptured spleen. He underwent an exploratory
laparotomy and splenectomy, 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 and remained NPO with an NGT, on IV fluids, and an
epidural and PCA for pain control. The patient was mildly
hypotensive and tachycardic but otherwise hemodynamically
stable.
The patient spiked a fever on POD1 and POD2; fever work-up
(chest x-ray, blood cultures, urine cultures) was negative. On
POD3, the nasogastric tube and Foley catheter was discontinued
and the patient was started on a clear liquid diet. WBC was
monitored daily and trending down.
When tolerating a diet, the patient was converted to oral pain
medication with continued good effect. 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 his vaccinations at the time of discharge.
The patient and his family received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. He had follow-up scheduled
with his PCP and in the ___ clinic.
Medications on Admission:
This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
Do not take more than 3000 mg daily.
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*90 Tablet Refills:*0
2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Do not drink or drive while taking narcotic pain medications.
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID constipation
Take with meals. Stop for loose or watery stools.
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Blunt abdominal trauma
Splenic rupture
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 ___ after
injury to your spleen that required removal of your spleen. You
have recovered well from surgery and are now ready to be
discharged. Please follow the instructions below:
*AVOID contact sports and/or any activity that may cause injury
to your abdominal area for the next ___ weeks.
*If you suddenly become dizzy, lightheaded, feeling as if you
are going to pass out go to the nearest Emergency Room as this
could be a sign that you are having internal bleeding from your
liver or spleen injury.
*AVOID any blood thinners such as Motrin, Naprosyn, Indocin,
Aspirin, Coumadin or Plavix for at least ___ days unless
otherwise instructed by the MD/NP/PA.
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 Your staples should stay in for about 10 days.
o Your incisions may be slightly red around the staples. 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.
***We recommend that asplenic patients wear medical jewelry and
carry medical information cards identifying them as asplenic to
alert future healthcare providers under the circumstance that
you are unable to do so.
*You should have annual influenza vaccinations
Followup Instructions:
___
|
10169726-DS-10 | 10,169,726 | 24,468,740 | DS | 10 | 2160-09-10 00:00:00 | 2160-09-10 13:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Occult positive stool
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old male with past medical
history of hypertension, hyperlipidemia, diabetes mellitus, and
bladder cancer s/p cystoscopic resection X3, chronic kidney
disease, and multiple hospitalizations for GI bleeds. He had a
CABG with Dr. ___ on ___ and was discharged to home on
___. He has done well at home but became weaker over the
past
few days. His wife urged him to have his hct checked and it was
23 at CC hosp. He denies melena the ___ MD did ___ rectal and his
stool was guiaic +. He has been on Coumadin for postoperative
atrial fibrillation and he received 10 mg Vit K and was
transfused 1 UPRBC.
He was transferred to ___ and here his hct was 22. He will be
admitted, transfused, and have a GI consult.
Past Medical History:
CAD
CKD
HTN
rheumatic heart disease-many years ago
arthritis
DM-insulin dependent
diabetic neuropathy
left knee replacement ___
foot surgeries ___ and ___, unclear what kind
Social History:
___
Family History:
father: CAD/quadruple bypass, stroke in his ___, deceased in
his
___
brother: deceased ___ from pancreatitis
paternal grandmother: CAD
Physical ___:
Pulse: 67/SR Resp: 16 O2 sat: 96% RA
B/P Left: 114/67
Height: 68 in Weight: 92.85 kg
General:
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
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 [] _____
Varicosities: None [] Left lower leg
Neuro: Grossly intact []
Pulses:
Femoral Right: 1+ Left: 1+
DP Right: Faint/Doppler Left: Faint/Doppler
___ Right: Faint/Doppler Left: Faint/Doppler
Radial Right: 1+ Left: 1+
Discharge Exam:
T 98.0 HR 60-62 SR BP: 111-125/70 RR: 16 Sats: 95 RA
General: NAD
Cardiac: RRR
Resp: CTA
GI: benign
Extr: warm no edema
Wound: sternal clean dry intact
Neuro: awake, alert oriented
Pertinent Results:
Admission Labs:
___ WBC-5.1 RBC-3.18* Hgb-9.7* Hct-29.4* MCV-93 MCH-30.5
MCHC-33.0 RDW-15.3 RDWSD-51.7* Plt ___
___ WBC-4.7 RBC-2.39* Hgb-7.2* Hct-22.5* MCV-94 MCH-30.1
MCHC-32.0 RDW-14.5 RDWSD-49.9* Plt ___
___ ___ PTT-29.4 ___
___ ___ PTT-32.4 ___
___ Glucose-82 UreaN-44* Creat-2.3* Na-144 K-4.4 Cl-102
HCO3-29
Discharge Labs:
___ WBC-5.2 RBC-3.10* Hgb-9.4* Hct-28.1* MCV-91 MCH-30.3
MCHC-33.5 RDW-14.6 RDWSD-48.0* Plt ___
___ ___ PTT-28.3 ___
___ Glucose-129* UreaN-39* Creat-2.5* Na-144 K-4.5 Cl-105
HCO3-25
Echocardiogram: ___
CONCLUSION:
The left atrial volume index is mildly increased. No
thrombus/mass is seen in the body of the left atrium.
The left atrial appendage is not visualized. The right atrium is
mildly enlarged. The estimated right atrial
pressure is ___ mmHg. There is normal left ventricular wall
thickness with a normal cavity size. There
is normal regional left ventricular systolic function. Global
left ventricular systolic function is low
normal. Quantitative biplane left ventricular ejection fraction
is 53 %. Left ventricular cardiac index is low normal (2.0-2.5
L/min/m2). 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 18mmHg). Normal
right ventricular cavity size with low normal free wall motion.
The
aortic sinus diameter is normal for gender with normal ascending
aorta diameter for gender. The aortic arch diameter is normal.
The aortic valve leaflets (3) appear structurally normal. There
is no aortic valve
stenosis. There is mild [1+] aortic regurgitation. The mitral
leaflets appear structurally normal with nomitral valve
prolapse. There is moderate [2+] mitral regurgitation. The
tricuspid valve leaflets appear
structurally normal. There is mild to moderate [___] tricuspid
regurgitation. There is mild pulmonary
artery systolic hypertension. There is a very small
circumferential pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes, regional systolic
function. Global biventricular
systolic function is low normal. Moderate mitral regurgitation.
Mild-moderate tricuspid regurgitation.
Mild pulmonary artery systolic hypertension. Mild aortic
regurgitation. Increased PCWP.
Compared with the prior TEE (images reviewed) of ___ ,
the estimated PA systolic pressure is
now much lower. Global left ventricular systolic function is
similar.
Brief Hospital Course:
___ M with DM, HTN, HL, CKD, CAD s/p recent CABG on ___, Afib
(on coumadin started recently) who presented with weakness,
found to have worsening anemia. He had a CABG with Dr. ___
on ___ and was discharged to home on ___. He has done
well at home but became weaker over the past few days. His wife
urged him to have his hct checked and it was 23 ___
from 29 at the time of discharge. He
received 10 mg Vit K and was transfused 1 U PRBC at ___. He was
transferred to ___ for further work up. He got 2 additional
units here at ___ and his Hct is stable around 32. He has had
anemia and guaiac positive stools for a few years. He has been
taking iron supplementation for quite some time. He has been
recently evaluated at ___ with an upper endoscopy
and colonoscopy, capsule
endoscopy and push enteroscopy. The reports of these are not
available to us but per the patient they found a source of
bleeding in the jejunum but could not reach it. Was supposed to
see gastroenterology at ___ as an outpatient but had not done
that so far. Serial HCTs were done. GI was consulted. Per
GI:likely an angioectasia related bleed with most likely
location being small bowel. Gi is to perform an additional
capsule study results pending.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Pantoprazole 40 mg PO Q24H
3. Docusate Sodium 100 mg PO BID
4. Metoprolol Tartrate 75 mg PO BID
5. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
6. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
7. Atorvastatin 80 mg PO QPM
8. Ferrous Sulfate 325 mg PO DAILY
9. Gabapentin 300 mg PO BID
10. Magnesium Oxide 400 mg PO DAILY
11. Senna 17.2 mg PO DAILY
12. Glargine 38 Units Breakfast
Humalog 10 Units Breakfast
Humalog 8 Units Lunch
Humalog 10 Units Dinner
Discharge Medications:
1. Amiodarone 400 mg PO BID
x 2 weeks then 200 bid x 2 weeks then 200 daily
RX *amiodarone 200 mg 400 tablet(s) by mouth twice a day Disp
#*90 Tablet Refills:*1
2. Furosemide 40 mg PO DAILY
3. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO Q12H
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*60 Tablet Refills:*3
5. Multivitamins 1 TAB PO DAILY
6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
7. Glargine 38 Units Breakfast
Humalog 10 Units Breakfast
Humalog 8 Units Lunch
Humalog 10 Units Dinner
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 80 mg PO QPM
10. Ferrous Sulfate 325 mg PO DAILY
11. Gabapentin 300 mg PO BID
12. Magnesium Oxide 400 mg PO DAILY
13. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*90
Tablet Refills:*3
14. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Occult positive stool
Secondary Diagnosis:
CAD s/p recent CABG on ___, Afib (on coumadin started recently)
Diabetes Mellitus
Hypertension
Hyperlipidemia
CKD (baseline CRE 2.3
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Discharge Instructions:
1. Shower daily including washing incisions gently with mild
soap,
2. No baths or swimming until incision completely healed.
3. Look at your incisions daily for redness or drainage
4. No lifting more than 10 pounds for 10 weeks
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
10169726-DS-9 | 10,169,726 | 22,012,406 | DS | 9 | 2160-08-26 00:00:00 | 2160-08-26 14:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
CABG X
History of Present Illness:
Mr. ___ is a ___ man with a history of CAD, DMII, CKD
IV, bladder cancer s/p cystoscopic resection X3 with BCG (no
chemo) who presented to the ___ ED with a week of weakness and
decreased functional capacity. He was initially referred to ___
___ ED on ___ by his cardiologist for concerning
symptoms and EKG changes. In the ___ ED, he reportedly had
negative Tpn but signed out AMA to seek care at ___.
Patient reported one week of weakness and fatigue, especially
with exertion. He has had episodes of dyspnea with minimal
exertion. On ___, he was playing golf but almost passed
out with shortness of breath. Per cardiology fellow assessment,
he has had no angina or chest pressure. He continued to deny
chest pain in the ___ ED.
Patient reportedly had multiple hospitalizations over the past
year for GI bleeding, with no source yet found. Per outside
records (provided by patient's wife), there was a 2-point
hemoglobin drop in the last month.
Of note, the patient was last admitted at ___ in ___ when
he underwent cardiac cath by Dr. ___ reportedly having had
a positive ett / mibi for inferior infarct septal ischemia.
Unfortunately this report is not in the ___ system.
On cath in ___, the patient was found to have 40% stenosis
of distal LMCA. The LAD with mid 50% diffuse apical disease non
critical
The Circumflex with 50% proximal stenosis. RCA is subtotally
occluded with right to right antegrade collaterals , the R PDA
fills via left to right collaterals. No stents were placed at
this time and the patient was referred to cardiac Surgery.
Surgery was recommend to reduce the pts risk of future MI and/or
death.
Past Medical History:
CAD
CKD
HTN
rheumatic heart disease-many years ago
arthritis
DM-insulin dependent
diabetic neuropathy
left knee replacement ___
foot surgeries ___ and ___, unclear what kind
Social History:
___
Family History:
father: CAD/quadruple bypass, stroke in his ___, deceased in
his
___
brother: deceased ___ from pancreatitis
paternal grandmother: CAD
Physical ___:
Admission Physical Exam:
========================
VITALS: T 98.1 | BP 105/56 | HR 64 | RR 16 | O2 96% RA
GENERAL: Well-developed, well-nourished. NAD. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with flat neck veins, no JVD when seated upright.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, normal S1, S2. No murmurs/rubs/gallops.
LUNGS: Resp were unlabored, no accessory muscle use. Scant
basilar crackles. No wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Warm. No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
Discharge Physical Exam:
========================
Temp: 98.7 (Tm 98.9), BP: 105/67 (103-147/63-79), HR: 73
(60-74), RR: 14 (___), O2 sat: 94% (94-97), O2 delivery: Ra
Wt: 96.4kg (97.7kg)
In/Out: 1050/2665
Physical Examination:
General/Neuro: NAD [x] A/O x3 [x] non-focal []
Cardiac: RRR [x] Irregular [] Nl S1 S2 []
Lungs: diminished at bases. No resp distress [x] CT to sxn -AL
Abd: NBS [x]Soft [x] ND [x] NT [x]
Extremities: warm with trace lower extremity edema R>L. Pulses
doppler [] palpable [x]
Wounds: Sternal: CDI [] no erythema or drainage []
Sternum stable [] Prevena [x]
Leg: Right [x] Left[] CDI [] no erythema or drainage [x]
Pertinent Results:
Admission Labs:
===============
___ 12:53PM BLOOD WBC-4.7 RBC-2.85* Hgb-9.2* Hct-27.1*
MCV-95 MCH-32.3* MCHC-33.9 RDW-14.4 RDWSD-48.7* Plt ___
___ 12:53PM BLOOD Neuts-56.6 ___ Monos-12.6 Eos-5.6
Baso-0.6 Im ___ AbsNeut-2.64 AbsLymp-1.13* AbsMono-0.59
AbsEos-0.26 AbsBaso-0.03
___ 12:53PM BLOOD ___ PTT-26.9 ___
___ 12:53PM BLOOD Glucose-126* UreaN-40* Creat-3.0* Na-141
K-4.6 Cl-101 HCO3-24 AnGap-16
___ 12:53PM BLOOD CK-MB-2 proBNP-4120*
___ 09:48PM BLOOD Calcium-8.7 Phos-4.8* Mg-2.2
___ 07:20AM BLOOD %HbA1c-7.1* eAG-157*
___ 01:08PM BLOOD Lactate-1.7
Cardiac Enzymes:
================
___ 12:53PM BLOOD cTropnT-0.92*
___ 04:31AM BLOOD CK-MB-2 cTropnT-0.92*
___ 01:10PM BLOOD CK-MB-2 cTropnT-0.77*
Reports:
=======
TTE ___:
The left atrial volume index is mildly increased. There is no
evidence for an atrial septal defect by 2D/color Doppler. The
estimated right atrial pressure is ___ mmHg. There is mild
symmetric left ventricular hypertrophy with a normal cavity
size. There is mild regional left ventricular systolic
dysfunction with akinesis of the inferior wall and hypokinesis
of the distal septum and apical cap. Global left ventricular
systolic function
is mildly depressed. The visually estimated left ventricular
ejection fraction is 40%. No ventricular septal defect is seen.
There is no resting left ventricular outflow tract gradient. A
left ventricular thrombus/mass
cannot be excluded. Tissue Doppler suggests an increased left
ventricular filling pressure (PCWP greater than 18mmHg). There
is Grade III diastolic dysfunction. Normal right ventricular
cavity size with normal free wall
motion. The aortic sinus diameter is normal with normal
ascending aorta diameter. The aortic arch diameter is normal.
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 mild [1+] aortic regurgitation. The
mitral leaflets are mildly thickened with no mitral valve
prolapse. There is an eccentric, inferolateral directed jet of
mild to moderate [___] mitral regurgitation. The tricuspid
valve leaflets appear structurally normal. There is mild [1+]
tricuspid regurgitation. The estimated pulmonary artery systolic
pressure is SEVERELY elevated. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. MIld to moderate regional
left ventricular systolic dysfunction most consistent with
multivessel coronary artery disease. Severe pulmonary artery
systolic hypertension. Mild to
moderate mitral regurgitation. Mild aortic regurgitation.
Renal US ___:
IMPRESSION:
1. No evidence of significant renal artery stenosis.
2. Cortical thinning of the renal parenchyma bilaterally
compatible with mild atrophy. No hydronephrosis or renal
masses.
CXR ___:
FINDINGS:
There is cephalization of the pulmonary vasculature suggestive
of pulmonary
vascular congestion. There are no pleural effusions. The heart
is at the
upper limits of normal in size. The trachea is midline.
Degenerative changes
are evident in the spine.
IMPRESSION:
Cephalization of the pulmonary vasculature suggestive pulmonary
vascular
congestion.
.
Date: ___
Date of Birth: ___ Sex: M
Surgeon: ___, MD ___
PREOPERATIVE DIAGNOSIS: Coronary artery disease.
POSTOPERATIVE DIAGNOSIS: Coronary artery disease.
OPERATION PERFORMED: Coronary artery bypass grafting x 4,
left internal mammary artery graft to left anterior
descending, reverse saphenous vein graft to the marginal
branch, posterior descending artery, and diagonal branch.
ASSISTANT: ___, M.D.
ANESTHESIA: General endotracheal.
CLINICAL NOTE: Mr. ___ is a ___ man with
worsening symptoms related to severe three-vessel disease
presenting for revascularization.
DESCRIPTION OF PROCEDURE: After anesthesia was achieved with
the patient supine, he was prepped and draped in the usual
sterile manner. Median sternotomy was performed through which
the pericardium was opened. The mammary artery was harvested
on the left side and divided distally after heparin was given.
The saphenous vein was harvested endoscopically and prepared
in the usual fashion. He was cannulated in the standard
fashion, placed on bypass. A retrograde sinus cannula was
placed. Aorta clamped, heart arrested, antegrade blood
cardioplegia followed by multiple retrograde doses. The aorta
was grafted with a segment of vein in end-to-side fashion with
___ Prolene. Lateral wall had a marginal branch that was
similarly grafted to the diagonal branch with a segment of
vein as well. LAD was grafted to the mammary artery. The
three veins were anastomosed to the aorta through three punch
aortotomies with running ___ Prolene. Warm cardioplegia was
given retrograde. Crossclamp released with the patient's head
down while de-airing the root that was maintained on low vent
suction. Epicardial pacing wires placed. He was weaned from
bypass and decannulated after protamine administration. Once
the field was dry, a left pleural and two mediastinal tubes
were placed. Sternotomy was closed with heavy steel wires.
Presternal layers closed with Vicryl suture. Dry dressing was
applied. He tolerated the procedure well and left the OR in
stable condition.
.
Discharge Labs:
===============
___ 04:40AM BLOOD WBC-5.8 RBC-2.64* Hgb-8.1* Hct-24.7*
MCV-94 MCH-30.7 MCHC-32.8 RDW-14.8 RDWSD-50.2* Plt ___
___ 04:40AM BLOOD ___
___ 04:40AM BLOOD Glucose-72 UreaN-68* Creat-2.6* Na-142
K-4.1 Cl-101 HCO3-23 AnGap-18
___ 04:40AM BLOOD Mg-2.3
Brief Hospital Course:
Pt was admitted ___ and was taken to the operating room on
___ and underwent CABG X4. Please see operative note for full
details. Pt tolerated the procedure well and was transferred to
the CVICU in stable condition for recovery and invasive
monitoring.
Pt was weaned from sedation, awoke neurologically intact, and
was extubated on POD 1. Pt was weaned from inotropic and
vasopressor support. Beta blocker was initiated and pt was
diuresed toward his preoperative weight. Pt remained
hemodynamically stable and was transferred to the telemetry
floor for further recovery. Patient creatinine peaked at 3.2.
The day of discharge creatinine was approaching baseline of 2.3,
and making good urine. Pt was evaluated by the physical therapy
service for assistance with their strength and mobility. By the
time of discharge on POD 8 pt was ambulating freely, all wounds
were healing, and pain was controlled with oral analgesics.
Patient's right leg incision was well approximated, appeared red
with no drainage. He was prescribed Keflex for 5 days. His nurse
wound check was moved to ___ for further evaluation. Pt was
discharged to home in good condition with appropriate follow up
instructions.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 50 mg PO DAILY
2. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
3. Furosemide 40 mg PO DAILY
4. Gabapentin 300 mg PO BID
5. Atorvastatin 80 mg PO DAILY
6. Glargine 50 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
7. Ferrous Sulfate 65 mg PO DAILY
8. Magnesium Oxide 500 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Ranexa (ranolazine) 500 mg oral daily
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 325 mg ___ tablet(s) by mouth every six (6)
hours Disp #*60 Tablet Refills:*0
2. Aspirin EC 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*2
3. Bisacodyl ___AILY:PRN constipation
RX *bisacodyl 10 mg 1 suppository(s) rectally once a day Disp
#*3 Suppository Refills:*0
4. Cephalexin 500 mg PO Q8H Duration: 5 Days
RX *cephalexin 500 mg 1 capsule(s) by mouth every eight (8)
hours Disp #*15 Capsule Refills:*1
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*10 Capsule Refills:*0
6. Glucose Gel 15 g PO PRN hypoglycemia protocol
RX *dextrose [Dex4 Glucose] 15 gram/33 gram 33 gram by mouth
once a day Disp #*2 Packet Refills:*0
7. Metoprolol Tartrate 75 mg PO Q8H
RX *metoprolol tartrate 75 mg 1 tablet(s) by mouth every eight
(8) hours Disp #*90 Tablet Refills:*2
8. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*2
9. Senna 17.2 mg PO DAILY
RX *sennosides [senna] 8.6 mg 2 tablets by mouth once a day Disp
#*30 Tablet Refills:*0
10. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*60 Tablet Refills:*0
11. Warfarin 2 mg PO DAILY16 Atrial Fib
Dose to be determined daily by provider.
RX *warfarin 2 mg 1 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*2
12. ___ MD to order daily dose PO DAILY16
13. Furosemide 20 mg PO BID
RX *furosemide 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
14. Glargine 38 Units Breakfast
Humalog 10 Units Breakfast
Humalog 8 Units Lunch
Humalog 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
15. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*2
16. Ferrous Sulfate 65 mg PO DAILY
17. Gabapentin 300 mg PO BID
18. Magnesium Oxide 500 mg PO DAILY
19. HELD- Isosorbide Mononitrate (Extended Release) 30 mg PO
DAILY This medication was held. Do not restart Isosorbide
Mononitrate (Extended Release) until seen by cardiologist
20. HELD- Multivitamins 1 TAB PO DAILY This medication was
held. Do not restart Multivitamins until seen by PCP
___:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
==================
CAD
Diabetes
Dyslipidemia
History of GI bleed
Secondary Diagnosis
===================
Bladder Cancer s/p cystoscopic resection X3 and BCg (no chemo)
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right - erythema, no drainage. Extends behind knee.
No Edema
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.
****call MD if weight goes up more than 3 lbs in 24 hours or 5
lbs over 5 days****.
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
Encourage full shoulder range of motion, unless otherwise
specified
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
10169796-DS-21 | 10,169,796 | 29,617,004 | DS | 21 | 2151-06-13 00:00:00 | 2151-06-13 18:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
breakthrough seizures in the setting of illness
Major Surgical or Invasive Procedure:
- Lumbar puncture, ___
- Lumbar puncture, ___
History of Present Illness:
Mr. ___ is a ___ ___ man with a history of epilepsy s/p
surgical resection of anterior left temporal lobe who presents
today s/p seizures in the setting of
concomitant infection. He had been in his USOH until four days
PTA, when he began feeling ill: he states that he began having
diaphoresis, coughing and vomiting (post-tussive). He also
complained of diffuse abdominal pain and nausea. Denies
diarrhea. No documented fevers at home. Did c/o neck pain two
days prior to admission, but stated that it resolved.
Complained
about a diffuse HA, but usually associated with vomiting. Has
also complained of lower back pain intermittently as well, but
has had no difficulty walking. Concerned about his symptoms, he
presented to an OSH ED (___). There, he was diagnosed with
gastroenteritis and was sent home after having received IVF. He
continued to take his AEDs, though he had frequent vomiting
during this time.
Over the next few days, he continued to have these
symptoms.
On the AM of admission, he continued to have emesis. He noted
that he seemed to have bitten his lip overnight, which was
concerning for seizure, though he had no incontinence. He did
miss his AM AED dose because of his ongoing nasuea and emesis.
Concerned, he presented again to ___ for evaluation. There, he
again received IVF. Concerned about an acute abdominal process,
he was about to undergo an CT of chest and abdomen when he had a
thirty second GTC seizure. No more information is known about
it, but it terminated on its own. He was subsequently given 2mg
of IV ativan. CT chest was concerning for possible LLL PNA.
Abdomen CT was negative. NCHCT was read as unchanged from
___. Given that his neurology f/u is here (epileptologist =
Dr. ___, he was transferred to the ___ ED for
urgent
evaluation. It is in that setting that neurology was called.
Past Medical History:
L temporal lobe epilepsy, s/p splenectomy after MVC trauma
- ADHD
Social History:
___
Family History:
Family Hx: Parents both abused drugs, additional history
unknown.
History of a paternal first cousin with seizures.
Physical Exam:
Physical exam on admission:
VS: 100.4 116 115/72 18 100%
Genl: Awake, alert, but somewhat ill-appearing. NAD.
HEENT: Sclerae anicteric, no conjunctival injection, oropharynx
clear
Neck: supple with FROM
CV: tachycardic, Nl S1, S2, no murmurs, rubs, or gallops
Chest: CTA bilaterally, no wheezes, rhonchi, rales
Abd: soft, NTND, NABS
Ext: No lower extremity edema bilaterally
Neurologic examination:
Mental status: Awake and alert, cooperative with exam generally,
though was upset because of significant pain and nausea. normal
affect. Oriented to person, place, and date. Attentive, says ___
backwards. Speech is fluent with normal comprehension and
repetition. No dysarthria. Registers ___, recalls ___ in 5
minutes despite. No evidence of neglect.
Cranial Nerves: Pupils equally round and reactive to light, 3 to
2 mm bilaterally. No RAPD. Visual fields are full to
confrontation. Extraocular movements intact bilaterally without
nystagmus. Sensation intact V1-V3. Facial movement symmetric.
Palate elevation symmetric. Sternocleidomastoid and trapezius
full strength bilaterally. Tongue midline, movements intact.
Motor: Normal bulk and tone bilaterally. No observed myoclonus,
asterixis, or tremor. No pronator drift.
Del Tri Bi WE FE FF IP H Q DF PF TE
R ___ ___ ___ ___
L ___ ___ ___ ___
Sensation: Intact to light touch, vibration, and cold sensation
throughout.
Reflexes: 1+ and symmetric throughout. Toes downgoing
bilaterally.
Coordination: finger-nose-finger normal without dysmetria
Gait: Deferred
At discharge:
Neuro: Neck is supple with minimal meningismus. No deficits on
neurological exam.
Pertinent Results:
CBC:
___ 04:07PM BLOOD WBC-22.3* RBC-4.84 Hgb-14.6 Hct-43.7
MCV-90 MCH-30.2 MCHC-33.5 RDW-13.1 Plt ___
___ 04:30AM BLOOD WBC-11.5* RBC-4.16* Hgb-12.8* Hct-37.5*
MCV-90 MCH-30.7 MCHC-34.1 RDW-12.9 Plt ___
___ 06:00AM BLOOD WBC-9.8 RBC-4.40* Hgb-13.7* Hct-41.8
MCV-95 MCH-31.1 MCHC-32.7 RDW-12.7 Plt ___
DIFFERENTIAL
___ 04:07PM BLOOD Neuts-89.5* Lymphs-5.6* Monos-4.5 Eos-0.1
Baso-0.2
___ 05:25AM BLOOD Neuts-59.0 ___ Monos-6.4 Eos-7.0*
Baso-1.2
CHEMISTRY:
___ 04:07PM BLOOD Glucose-94 UreaN-10 Creat-1.0 Na-137
K-4.5 Cl-100 HCO3-23 AnGap-19
___ 01:00PM BLOOD Glucose-97 UreaN-4* Creat-0.9 Na-137
K-4.2 Cl-97 HCO3-30 AnGap-14
___ 06:00AM BLOOD Glucose-98 UreaN-7 Creat-1.0 Na-140 K-4.7
Cl-102 HCO3-31 AnGap-12
___ 05:10AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.0
___ 06:00AM BLOOD Calcium-10.0 Phos-4.7* Mg-2.2
LIVER ENZYMES:
___ 05:25AM BLOOD ALT-14 AST-19 LD(LDH)-131 AlkPhos-104
TotBili-0.3
SERUM TOXICOLOGY:
___ 05:10AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
URINE TOXICOLOGY:
___ 12:12AM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
URINALYSIS:
___ 06:00PM URINE Color-Straw Appear-Clear Sp ___
___ 06:00PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-150 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR
___ 06:00PM URINE RBC-7* WBC-6* Bacteri-NONE Yeast-NONE
Epi-<1
___ 06:00PM URINE Mucous-RARE
CSF HEMATOLOGY:
___ 09:50PM CEREBROSPINAL FLUID (CSF) WBC-72 RBC-1* Polys-0
___ Monos-1 Other-2
___ 09:50PM CEREBROSPINAL FLUID (CSF) WBC-97 RBC-5* Polys-0
___ Monos-6 Other-3
___ 02:54PM CEREBROSPINAL FLUID (CSF) WBC-125 RBC-3*
Polys-1 ___ Monos-0 Atyps-2
___ 0 2:54PM CEREBROSPINAL FLUID (CSF) WBC-185 RBC-28*
Polys-0 ___ Monos-2
CSF CHEMISTRY:
___ 09:50PM CEREBROSPINAL FLUID (CSF) TotProt-83*
Glucose-63
___ 02:54PM CEREBROSPINAL FLUID (CSF) TotProt-76*
Glucose-64
CSF VIRAL STUDIES:
___ 10:55PM CEREBROSPINAL FLUID (CSF) ENTEROVIRUS PCR-NEG
___ 10:55PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-NEG
BLOOD CULTURES:
Blood Culture, Routine (Final ___: NO GROWTH
URINE CULTURE:
URINE CULTURE (Final ___: NO GROWTH.
LUMBAR PUNCTURE ___ 9:50 pm CSF;SPINAL FLUID #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 (Final ___: NO GROWTH.
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
LUMBAR PUNCTURE ___:
CRYPTOCOCCAL ANTIGEN (Final ___: CRYPTOCOCCAL ANTIGEN NOT
DETECTED.
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.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
IMAGING:
___ CXR: Subtle opacity in the left lung base may represent
atelectasis or
a very early pneumonia.
___ CXR: Heart size and mediastinum are stable. Lungs are
essentially clear. No
pleural effusion or pneumothorax noted.
___ MR HEAD W/ AND W/O CONTRAST:
1. Postoperative changes in the form of left temporal craniotomy
and
resection cavity in the left temporal lobe. Postoperative mild
dural
enhancement underlying the craniotomy site and along the
resection cavity.
2. Decrease in size of the left hippocampus with increased FLAIR
signal as
compared to the MRI study of ___, this may represent changes
of retrograde
degeneration. No signal abnormality is noted in the right
hippocapus; however
small in size. Correlate with EEG and followup.
3. No evidence of acute infarct or intracranial hemorrhage.
4. Stable developmental venous anomalies in the right frontal
lobe and left cerebellum.
___ EEG: This is an abnormal routine EEG due to persistent
left
temporal slowing indicative of subcortical dysfunction in this
region.
No clear epileptiform discharges were present in the record.
___ EEG: This is an abnormal video EEG monitoring session
which
captured one pushbutton activation with no clinical or EEG
evidence of
seizures. There was left temporal slowing and rare epileptiform
discharges, indicative of structural abnormality and
epileptogenic
cortex in this region. A breach rhythm was seen over the left
frontocentral region, consistent with the patient's history of
craniotomy for left temporal lobectomy. There were no
electrographic
seizures.
___ EEG: This is an abnormal video EEG monitoring session with
no
pushbutton activations and no electrographic seizures. Focal
slowing
with occasional sharp waves was seen in the left frontal central
and
temporal region indicative of structural abnormality and
epileptogenic
cortex in this region. A breach rhythm was seen over the left
frontocentral region, consistent with the patient's history of
craniotomy for left temporal lobe surgery. There were no
electrographic
seizures.
Brief Hospital Course:
___ yo RHM with a history of complex partial seizures, s/p left
anterior temporal lobe resection in ___, who presented with a
seizure in the setting of a likely gastroenteritis with
prominent nausea and vomiting. He was found to have an
inflammatory CSF pattern consistent with likely viral aseptic
meningitis.
#) Seizure: Presentation was consistent with seizure, likely
multifactorial ___ to effectively missed doses of AED in the
setting of ~5 days of frequent vomiting and no tolerating of
POs; poor sleep as trigger; and CSF pattern pointing to aseptic
meningitis in the setting of likely viral gastroenteritis. EEG
monitoring revealed rare left frontocentral spikes so it was
unlikely that there was a new hemispheric focus that led to this
seizure.
- Home dose of Lacosamide 125 mg PO BID was maintained
- Home dose of Lamictal 300 mg PO BID was maintained
#) Aseptic meningitis: Exam was notable for meningismus,
headache, nausea, photophobia, and fevers. Blood cultures
consistently showed no growth. Likely viral meningitis given CSF
pattern of elevated lymphs and protein with normal glucose and
negative gram stain. The LP was repeated after prolonged fevers.
The patient received empiric IV Acyclovir for 8 days, until 2
HSV PCRs were negative (and viral cultures). All CSF assays have
been negative thus far. At discharge he was afebrile x 72-96
hours and his symptomss had improved significantly, although he
still had an intermittent headache and some nausea.
- Infectious disease was consulted and they recommended a brief
course of IV ceftriaxone and vancomycin in the setting of fever
of unclear origin in an a splenic patient. He continued to
improve after these medications were discontinued.
- He was briefly treated with ampicillin to cover for the
unlikely possibility of listeria. He continued to improve after
this medication was discontinued.
- Mr. ___ was discharged on medications for symptom
control, including metoclopramide ___ po 30 minutes prior to
meals; Flexeril 5mg po q8hr prn back spasm, lidoderm patches for
back pain, and ibuprofen/acetaminophen for headache control.
Currently the pending tests are:
CSF VDRL
CSF BORRELIA BURGDORFERI ANTIBODY INDEX
Final CSF culture results
Medications on Admission:
Vimpat 125mg BID, LTG 300mg BID, zofran prn
Discharge Medications:
1. lacosamide 50 mg Tablet Sig: 2.5 Tablets PO BID (2 times a
day): 125mg po bid.
2. lamotrigine 100 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day): 300mg po bid.
3. metoclopramide 5 mg Tablet Sig: ___ Tablets PO three times a
day as needed for nausea: Please take 30 minutes before meals to
avoid nausea. As appetite and nausea improves, please wean off
medicine.
Disp:*30 Tablet(s)* Refills:*1*
4. cyclobenzaprine 5 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours as needed for back pain.
Disp:*30 Tablet(s)* Refills:*0*
5. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for headache.
Disp:*30 Tablet(s)* Refills:*0*
6. acetaminophen 500 mg Tablet Sig: ___ Tablets PO every six (6)
hours as needed for headache: Do not exceed 4 grams per day.
7. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One
(1) patch Topical once a day: apply to lower back, 12 hours on,
12 hours off.
Disp:*10 patches* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
aseptic meningitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neuro: Neck is supple with minimal meningismus. No deficits on
neurological exam.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you during your stay. You were
admitted to the hospital for concern for fevers, headaches, and
seizures in the setting of vomiting. After thorough evaluation,
it has been determined that most likely cause of your symptoms
is a virus that resulted in aseptic (viral) meningitis. We
treated you with medicines to cover the most concerning of viral
meningitis until repeat testing showed that this was unlikely to
be the culprit. Over the past week your fevers have stopped and
your lab work has returned to normal. You are still experiencing
some headaches and intermittent nausea but we expect this to
improve over the next few weeks. Please use the medications
provided as needed for your continued symptoms.
These include metoclopramide ___ by mouth 30 minutes prior to
meals for nausea/decreased appetite; cyclobenzaprine 5mg by
mouth up to 3 times a day for back pain; and ibuprofen or
acetaminophen for headaches. You may also use a lidoderm patch
on your back for your back pain.
Please follow up with Dr. ___ in clinic to ensure all your lab
work that is pending currently has been reviewed and finalized.
Followup Instructions:
___
|
10170435-DS-10 | 10,170,435 | 22,423,777 | DS | 10 | 2175-09-08 00:00:00 | 2175-09-21 21:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Keflex / Atenolol / ciprofloxacin / Flagyl
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___ Exploratory laparatomy, lysis of adhesions, reduction of
hernia, primary repair, mesh overlay
History of Present Illness:
___ F with a known ventral hernia and a prior episode of SBO
(___) who has had diffuse abdominal pain for 1 day. The patient
developed a constant pain the morning prior to admission which
she reports as a ___ and similar to pain she felt during her
previous episode of SBO. She describes the pain as being all
over
her abdomen but most pronounced in the lower portion and around
the umbilicus. She had a normal bowel movement prior to the
onset
of the pain but has not had a bowel movement or passed gas in
the
last 36 hours. She felt nauseated and attempted to induce
herself
to vomit but produced only minimal, white, mucousy vomitus. She
has not eaten and only had sips of ginger ale and water since 2
days prior to admission. She notes that her abdomen feels
distended. She describes having sweats and a subjective fever.
She saw her PCP on the day of admission because of the pain at
which time an abdominal x-ray was taken showing dilated loops of
bowel. She was then sent to the ED.
Of note the patient is also recovering from S. pyogenes
pharyngitis and is currently on antibiotics for this infection
as
well as a short course of prednisone for difficulty breathing
associated with this infection.
Past Medical History:
PMH:
Hypertension
Hyperlipidemia
Anxiety
Obesity
PSH:
cesarean section x 2
cervical dysplasia s/p partial cervical resection
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM:
VS:98.0 66 125/69 16 100% RA
Gen: morbidly obese, NAD, AOx3
___: RRR, normal S1 and S2
Pulm: lungs clear to auscultation bilaterally
Abd: obese abdomen with diffuse tenderness to palpation.
tenderness is most pronounced just to the right of the umbilicus
where there is a large, firm, partially-reducible mass measuring
approximately 10 x 15 cm. no rebound or guarding
Neuro: motor and sensory function grossly intact
DISCHARGE EXAM:
VSS
Gen: morbidly obese, NAD, AOx3
___: RRR, normal S1 and S2
Pulm: lungs clear to auscultation bilaterally
Abd: obese abdomen with midline surgical incision stapled, with
some surrouding erythema, no drainage. JP bulb in place draining
serosanguinous fluid. Soft, Nontender to palpation
Neuro: motor and sensory function grossly intact
Pertinent Results:
ADMISSION LABS:
___ 04:15PM BLOOD WBC-13.5* RBC-5.31 Hgb-14.6 Hct-42.6
MCV-80* MCH-27.5 MCHC-34.3 RDW-13.2 Plt ___
___ 04:15PM BLOOD Neuts-70.8* ___ Monos-5.6 Eos-0.7
Baso-0.6
___ 08:30PM BLOOD ___ PTT-28.7 ___
___ 04:15PM BLOOD UreaN-20 Creat-0.9 Na-137 K-4.5 Cl-96
HCO3-25 AnGap-21*
___ 04:15PM BLOOD ALT-20 AST-15 AlkPhos-94
___ 04:54AM BLOOD Calcium-9.6 Phos-3.9 Mg-1.8
___ 04:15PM BLOOD HCG-<5
___ 08:54PM BLOOD Lactate-1.4
DISCHARGE LABS:
___ 04:00AM BLOOD WBC-7.6 RBC-3.73* Hgb-10.1* Hct-30.3*
MCV-81* MCH-27.0 MCHC-33.3 RDW-14.7 Plt ___
___ 04:00AM BLOOD Neuts-65.1 ___ Monos-6.5 Eos-3.8
Baso-0.3
___ 06:12AM BLOOD Glucose-107* UreaN-4* Creat-0.5 Na-139
K-4.6 Cl-106 HCO3-29 AnGap-9
___ 06:12AM BLOOD Calcium-8.3* Phos-1.2* Mg-1.9
___ 06:12AM BLOOD ALT-19 AST-21 AlkPhos-87 TotBili-0.4
___ CT ABD/PELVIS:
1. Multiple dilated loops of small bowel are seen, with a
transition point identified corresponding to the entry of small
bowel into a large anterior abdominal wall hernia.
Additionally, loops of small bowel within the anterior abdominal
wall hernia defect appear dilated and fecalized. Given the
presence
of two distinct transition points, closed loop obstruction not
excluded. No free fluid.
2. Fat stranding is seen surrounding bowel within the anterior
abdominal wall hernia.
3. No evidence of free intra-abdominal fluid or air.
4. Chololithiasis without evidence of gallbladder-wall
thickening.
___ CT ABD/PELVIS:
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest
performed on the same day for description of the thoracic
findings.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout.
There is no evidence of focal lesions. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. There is
cholelithiasis without evidence of acute cholecystitis. The
portal vein is patent.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of focal lesions or pancreatic ductal
dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram.
There is no evidence of stones, focal renal lesions, or
hydronephrosis. There are no urothelial lesions in the kidneys
or ureters. There is no perinephric abnormality.
GASTROINTESTINAL: A nasoenteric tube is present within the
stomach. Oral
contrast remains in the stomach and proximal duodenum. Again
seen are
multiple dilated loops of small bowel measuring up to 3.6 cm
with a transition point within a large and complex ventral
hernia defect (series 2, image 88).
Distal to the transition point terminal ileum is completely
decompressed. The large bowel is also decompressed. The
appendix is not visualized but there are no secondary signs of
appendicitis within the right lower quadrant. There is mild
mesenteric edema, increased from prior. There is no evidence of
free air or pneumatosis. There is no portal venous gas. There
is no abdominal free fluid.
RETROPERITONEUM: There is no evidence of retroperitoneal
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is no
calcium burden in the abdominal aorta and great abdominal
arteries.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no evidence of pelvic or inguinal lymphadenopathy.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: Reproductive organs are within normal
limits.
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions.
Abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Persistent high-grade small bowel obstruction with a
transition point in a large complex ventral hernia (series 2,
image 88). No evidence of free air or pneumatosis although mild
mesenteric edema has increased since ___.
2. Cholelithiasis.
___ CT ABD/PELVIS:
Patient is status post ventral hernia repair with associated
postsurgical
changes and radiopaque midline sutures. A 5.6 cm fat containing
left
paramidline ventral hernia which is adjacent some drainage
catheters is
unchanged in appearance from previous examination with a 2.6 cm
peritoneal defect/neck in the abdominal wall (2: 74)
Moderate amount of fat stranding is seen at the midline surgical
site without definite fluid collection. Mild 4 mm skin
thickening at surgical site is present. (2:85) Locules of air
at the surgical site anterior to the abdominal wall are seen
surrounding the suture material as well as a few locules of gas
which are anterior to the right lateral abdominal wall (2:66)
with an underlying 3.8 x 2.9 cm heterogeneous focus (2:66, 68)
which appears to be extending and expanded the abdominal wall.
There is possible intra-abdominal extension although study is
severely limited due to body habitus. Locules of gas are
slightly out of proportion for 1 week post operative at the site
of collection and worrisome for infection, although there is no
drainable fluid collection this time.
IMPRESSION:
Limited evaluation due to motion and patient body habitus.
1. Status post ventral hernia repair with associated post
surgical changes including intra-abdominal fat stranding, suture
material and locules of gas in the subcutaneous tissue.
2. 3.8 x 2.9 cm focus expanding the right anterolateral
abdominal wall with possible intra-abdominal extension unclear
whether this is a thickened rectus abdominus muscle versus a
small locular all of fluid. Differential includes postoperative
seroma, resolving hematoma with postoperative change, or
prominence of the rectus abdominis muscle. Clinical correlation
is recommended. Consider dedicated evaluation with ultrasound
if this the region of erythema/fluctuance.
3. Anterior abdominal wall skin thickening worrisome for
cellulitis.
4. Left lower lobe atelectasis.
Brief Hospital Course:
Ms. ___ is a ___ F who presented with SBO secondary to ventral
hernia. Pt was initially managed with NPO/IVF/NGT with some
symptomatic improvement. Due to the high grade nature of her SBO
however and demonstration of persistent SBO on repeat CT scan
despite conservative management, pt underwent exploratory
laparotomy with lysis of adhesions and reduction of hernia with
primary repair and mesh overlay on ___. Her immediate post-op
course was complicated by soft systolic blood pressures in the
90's with low UOP requiring IVF boluses as well as albumin. She
was managed in the ICU for two days immediately post-op for
pressor support to maintain adequate BP's. Pt was ___
transferred to the floor for the remainder of her
hospitalization. For pain control, pt initially was managed with
an epidural post-operatively then was transitioned to oral
analgesics during the admission. By POD 7, pt was passing
flatus, having bowel movements, and tolerating a regular diet
without symptoms. Her surgical incision was noted to have some
surrounding erythema which was treated with oral antibiotics.
She received a repeat CT scan that did not show any fluid
collections. She will follow up in surgery clinic for continued
post-op care.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. Nadolol 40 mg PO QAM
4. Nadolol 20 mg PO QPM
5. Omeprazole 20 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. Nadolol 40 mg PO QAM
4. Nadolol 20 mg PO QPM
5. Omeprazole 20 mg PO BID
6. Bisacodyl ___AILY
7. Docusate Sodium 100 mg PO BID
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 10 mg 1 tablet(s) by mouth q4-6hr Disp #*20 Tablet
Refills:*0
9. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
RX *triamcinolone acetonide 0.1 % apply to affected are twice a
day Disp #*1 Tube Refills:*0
10. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 7 Days
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear ___,
___ were hospitalized for a small bowel obstruction due to a
hernia that required surgery. ___ have recovered well enough to
be discharged home and follow-up with us in our surgery clinic
for continued care. Please follow the instruction below and call
our surgery clinic to make a follow-up appointment. ___ can also
call the ___ clinic number for a followup appointment.
================================================
ACTIVITY:
o Do not drive until ___ have stopped taking pain medicine and
feel ___ could respond in an emergency.
o ___ may climb stairs.
o ___ may go outside, but avoid traveling long distances until
___ 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 ___ may start some light exercise when ___ feel comfortable.
o ___ will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when ___
can resume tub baths or swimming.
HOW ___ MAY FEEL:
o ___ may feel weak or "washed out" for a couple of weeks. ___
might want to nap often. Simple tasks may exhaust ___.
o ___ may have a sore throat because of a tube that was in your
throat during surgery.
o ___ might have trouble concentrating or difficulty sleeping.
___ might feel somewhat depressed.
o ___ 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 ___ may shower and remove the gauzes over your
incisions. Under these dressing ___ 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 ___ 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 ___ were told
otherwise.
o ___ 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 ___ may shower. As noted above, ask your doctor when ___ may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, ___ may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. ___ can get both of these
medicines without a prescription.
o If ___ 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 ___ find the pain
is getting worse instead of better, please contact your surgeon.
o ___ 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 ___ take it before your
pain gets too severe.
o Talk with your surgeon about how long ___ 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 ___ are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when ___
cough or when ___ are doing your deep breathing exercises.
If ___ 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 ___ were on before the operation just as
___ did before, unless ___ have been told differently.
If ___ have any questions about what medicine to take or not to
take, please call your surgeon.
=
=
=
================================================================
Followup Instructions:
___
|
10170562-DS-14 | 10,170,562 | 25,879,071 | DS | 14 | 2181-10-05 00:00:00 | 2181-10-05 17:45:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
S/p motorcycle crash
Major Surgical or Invasive Procedure:
___: Operative treatment left femoral fracture with IM nail
#2 his washout and repair knee wound possibly 6 cm in length.
History of Present Illness:
A ___ yo male with unknown medical history who is brought in by
EMS after a
motorcycle collision. Patient was found collided with a vehicle,
unhelmeted.
Unresponsive. Here patient withdraws to pain, but is unable to
provide any
history. History is limited by patient acuity and mental status.
Past Medical History:
PMH: None
PSH: None
Social History:
___
Family History:
Family History:
Non-Contributory
Physical Exam:
Physical Exam on Admission:
Constitutional: Lying on stretcher, minimally responsive
Head/Eyes: Superficial Lac over L cheek, Anisocoria (L 6mm, R
4mm), both reactive to light, Ecchymosis over R eye
ENT: Trachea midline
Resp: Breath sounds present and equal bilaterally
Cards: RRR. No chest wall crepitus
Abd: S/NT/ND, Pelvis stable
Skin: Abrasion over the posterior R shoulder, Abrasion over the
RU lateral arm, Superficial abrasion to the R lateral arm below
the elbow, 3 cm superficial lac to L posterior shoulder
Ext: Bilateral femoral pulses intact, L leg deformity with
external rotation, Deformity of L femur, 6 cm lac below the L
knee with no visible fracture, No step off or deformity of the
spine, Abrasion on the R medial calf, No blood at
meatus, bilateral radial and distal pulses 2+
Neuro: GCS 7
Psych: non-verbal
Physical Exam on Discharge:
97.5, 120/84, 88, 18, 99% Ra
Gen: [x] NAD, [x] AAOx3
CV: [x] RRR, [] murmur
Resp: [x] breaths unlabored, [x] CTAB, [] wheezing, [] rales
Abdomen: [x] soft, [] distended, [x] tender over LUQ,
[]rebound/guarding
Wound: [] incisions clean, dry, intact
Ext: [x] warm, [] tender, [] edema
Pertinent Results:
___ 05:26AM BLOOD WBC-7.6 RBC-2.90* Hgb-9.0* Hct-26.5*
MCV-91 MCH-31.0 MCHC-34.0 RDW-12.7 RDWSD-41.9 Plt ___
___ 04:20AM BLOOD Neuts-67 Bands-2 ___ Monos-5 Eos-0*
___ Myelos-2* NRBC-0.1* AbsNeut-14.15* AbsLymp-4.92*
AbsMono-1.03* AbsEos-0.00* AbsBaso-0.00*
___ 04:20AM BLOOD ___ PTT-25.9 ___
___ 05:26AM BLOOD Glucose-110* UreaN-11 Creat-0.7 Na-140
K-3.8 Cl-107 HCO3-25 AnGap-8*
___ 04:20AM BLOOD Lipase-39
___ 05:26AM BLOOD Calcium-8.3* Phos-2.5* Mg-1.8
___ 04:20AM BLOOD ASA-NEG ___ Acetmnp-NEG
Tricycl-NEG
___ 01:49PM BLOOD Lactate-1.8
CT HEAD W/O CONTRAST ___:
1. Dental amalgam streak artifact limits study.
2. Multifocal probable hemorrhagic contusions as described.
3. No midline shift.
4. No definite evidence of acute calvarial fracture.
5. Bilateral age-indeterminate nasal bone fractures.
CT C-SPINE W/O CONTRAST ___:
1. Patient body habitus and dental amalgam streak artifact
limits study as
described.
2. Within limits of study, no definite evidence of acute
cervical spine
fracture.
3. Nondisplaced fracture of first right posterior rib.
4. Multifocal dental disease as described.
5. Biapical pneumothoraces, better demonstrated on concurrently
obtained torso CT.
6. Dense opacification of right upper lobe concerning for
pulmonary
contusion, with aspiration not excluded on the basis of this
examination.
Please see concurrently obtained torso CT for further evaluation
of thoracic findings.
7. Soft tissue emphysema along the upper chest, better
demonstrated on same day torso CT.
CT TORSO W/CONTRAST ___:
1. A 4 cm splenic laceration with perisplenic hemorrhage as
described above. The main splenic artery and vein are intact.
Within the central spleen is a small area of hyperdensity which
is not well characterized on single contrast phase examination.
This may represent arterial or venous hemorrhage. If there is
concern for active arterial extravasation a arterial phase CT
scan is recommended.
2. A 3.0 x 1.9 hyperdensity intimately associated with the right
adrenal gland is concerning for adrenal hemorrhage
3. Small medial right pneumothorax with apical and basilar
components. No
evidence of tension. Trace left apical pneumothorax.
4. Multiple areas of dense opacifications throughout the right
lung are
concerning for pulmonary contusion in the setting of trauma. A
couple of
small pulmonary lacerations/traumatic cysts are noted, filled
with hemorrhage.
5. Within the hepatic dome is a 7 mm area of hypodensity which
may represent hepatic contusion.
6. Small left hemothorax is likely secondary to splenic
laceration.
7. Comminuted fracture of the left femur (incompletely imaged).
8. Minimally displaced fracture of the mid right clavicular
shaft.
9. Multiple nondisplaced rib fractures including the right
posterior first and fourth ribs, and right anterolateral second
and third ribs.
10. Multiple moderately displaced right transverse process
fractures of L5-L2.
11. At least three areas of short-segment intussusception are
demonstrated
throughout the small bowel in the upper abdomen without
obstruction.
TRAUMA #3 (PORT CHEST ONLY) ___:
1. Patchy opacifications seen to the right hemithorax are
consistent with
pulmonary contusion.
2. The comminuted displaced fracture of the midclavicular shaft
is
demonstrated.
3. An endotracheal tube projects 3.3 cm above the carina.
PELVIS AP ___ VIEWS ___:
1. Comminuted fracture of the shaft of the mid femur
demonstrated 15 cm
butterfly fragment.
2. The distal femoral fracture fragment demonstrates complete
posterolateral displacement and 13 mm of overlap with the more
proximal fracture fragment.
CT HEAD W/O CONTRAST ___:
1. Please note evaluation for intracranial hemorrhage is limited
due to
circulating intravascular contrast from same day contrast torso
CT.
2. Multiple punctate foci of intraparenchymal
hemorrhage/contusion within the bilateral frontal and parietal
lobes, grossly stable compared to study from 8 hours.
3. Within limits of study, no definite evidence of new acute
intracranial
hemorrhage.
CTA ABD & PELVIS ___:
1. Stable appearances of left splenic laceration. No active
extravasation of arterial blood. Stable perisplenic hematoma.
2. Stable right adrenal hematoma.
3. A subtle area of linear hypoattenuation identified in the
dome of the
liver on the previous study is no longer seen and may have been
artifactual.
4. Interval resolution of multiple transient intussusceptions
demonstrated on previous study.
5. Interval internal fixation of left femoral neck fracture is
noted.
CHEST (PORTABLE AP) ___:
Lungs are low volume with improving bilateral parenchymal
opacification which most likely represents improving contusions.
Cardiomediastinal silhouette is stable. No pneumothorax. No
effusions.
Brief Hospital Course:
Mr. ___ is a ___ yo male, who presented to the emergency
department on ___ as a trauma after a motorcycle crash. He
was evaluated by the trauma team upon arrival. Imaging done
showed that he sustained multiple injuries: Left femur fracture,
Right clavicle fracture, Right rib ___ fractures, L2-L5 right
transverse process fracture, Small right pneumothorax, Small
left hemothorax, Grade 4 splenic laceration, and Right adrenal
gland hemorrhage. Given findings, the patient was admitted to
the acute care surgery service for further management and
treatment of his injuries. He was also intubated in the ED for
GCS 7 and sent to the intensive care unit for close monitoring.
The orthopedic surgery service was consulted. They recommended
surgical intervention for his left femur fracture. He taken to
the operating room on ___ for IM nail
#2 of left femur and washout and repair knee wound. There were
no adverse events in the operating room; please see the
operative note for details. Neurosurgery was also consulted for
TBI. They recommended 7 days of Keppra (end ___ and no need
for follow up in clinic. The patient's blood counts were closely
watched for signs of bleeding especially after splenic
laceration and were stable. The patient was extubated on POD1
and transferred to the floor in stable condition.
The patient was tolerating a regular diet. His foley catheter
was removed on POD2 and he was found to be retaining urine, with
a bladder scan > 500mL, Straight catheterization was ordered
however patient able to void ___ on his own prior to catheter
insertion. His pain was well controlled on oral pain
medications. He was evaluated by physical therapy and
occupational therapy who recommend a rehabilitation facility.
Patient also met with social work. He was started on
subcutaneous heparin prophylactically per neurosurgery.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. 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. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
please limit to 4000mg in 24 hour period.
2. Bisacodyl 10 mg PR ONCE Duration: 1 Dose
may refuse. hold for loose stool.
3. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
may refuse. hold for loose stool.
4. Famotidine 20 mg PO BID
5. Gabapentin 100 mg PO TID
RX *gabapentin 100 mg 1 capsule(s) by mouth three times a day
Disp #*6 Capsule Refills:*0
6. Heparin 5000 UNIT SC TID
may discontinue when ambulating frequently.
7. LevETIRAcetam 1000 mg PO BID
this medication is for 7 days. Last dose ___
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*8 Tablet Refills:*0
8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
this medication may cause drowsiness.
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*5 Tablet Refills:*0
9. Senna 8.6 mg PO BID:PRN Constipation - Second Line
may refuse. hold for loose stool.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left femur fracture
Right clavicle fracture
Right rib ___ fractures
L2-L5 right transverse process fracture
Small right pneumothorax
Small left hemothorax
Grade 4 splenic laceration
Right adrenal gland hemorrhage
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 ___ for
evaluation after you were involved in a motorcycle crash.
Testing done here showed that you sustained multiple injuries:
left femur fracture, right clavicle fracture, right rib
fractures, spinal fractures, pulmonary contusion, bilateral
brain contusions, small right pneumothorax, small left
hemothorax, and spleen laceration. 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 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.
Followup Instructions:
___
|
10170781-DS-13 | 10,170,781 | 22,569,220 | DS | 13 | 2143-12-06 00:00:00 | 2143-12-07 15:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
APC 1 pelvis injury
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male presents with APC1 pelvis fracture s/p pedestrian
struck. Initially presented to OSH, and transferred for trauma
evaluation. Currently localizes pain to the pelvis. Denies any
numbness or paresthsias. No sensation of instability.
Past Medical History:
None
Social History:
___
Family History:
NC
Physical Exam:
Temp: 98.0 PO BP: 141/77 HR: 71 RR: 18 O2 sat:
97% O2 delivery: RA GEN: AOx3, WN, in NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR
PULM: unlabored breathing with symmetric chest rise, no
respiratory distress
EXT:
Left lower externally:
Fires ___
SILT sural, saphenous, superficial peroneal, deep peroneal and
tibial distributions
Dorsalis pedis pulse 2+ with distal digits warm and well
perfused
Right lower extremity:
Fires ___
SILT sural, saphenous, superficial peroneal, deep peroneal and
tibial distributions
Dorsalis pedis pulse 2+ with distal digits warm and well
perfused
Pertinent Results:
See OMR
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 anterior posterior compression type I pelvis fracture
and was admitted to the orthopedic surgery service due to
concern for downtrending hematocrit. The patient's hematocrit
was trended and stabilized appropriately without intervention.
His pelvis injury is a nonoperative injury that can be treated
with weightbearing as tolerated and outpatient follow-up. He
worked with physical therapy, who cleared him to go home with
crutches. He is weightbearing as tolerated in bilateral lower
extremities and will follow-up in the orthopedic trauma clinic
per 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 Q6H:PRN Pain - Mild/Fever
2. Enoxaparin Sodium 40 mg SC QHS Duration: 30 Days
RX *enoxaparin 40 mg/0.4 mL 1 syringe subcutaneous once a day
Disp #*30 Syringe Refills:*0
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
APC 1 pelvis fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(crutches, walker or cane).
Discharge Instructions:
- You were in the hospital for evaluation and treatment of your
pelvic fracture.
- Resume your regular activities as tolerated, but please
follow your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Weightbearing as tolerated in bilateral lower extremities with
assistance of crutches or walker
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock for pain.
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
Physical Therapy:
Weightbearing as tolerated bilateral lower extremities
with the support of a walker or crutches
Functional mobility and safety
Treatments Frequency:
No incisions
Followup Instructions:
___
|
10171405-DS-23 | 10,171,405 | 26,373,120 | DS | 23 | 2131-07-23 00:00:00 | 2131-07-23 14:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Levofloxacin / IV Dye, Iodine Containing Contrast Media
Attending: ___.
Chief Complaint:
hematuria, dysuria
Major Surgical or Invasive Procedure:
None this hospitalization.
History of Present Illness:
Ms. ___ is a ___ yo F w/ PMHx of ___ with metastatic
disease to lung and cervical LN, LIJ thrombus on prophylactic
lovenox ___ clot resolution, admitted ___ to ___ with
painful hematuria due to the passage of blood clots with
resolution until last night when her hematuria and clot passage
recurred. She was seen by urology who recommended CBI, and
deferred debulking nephrectomy at that time. She did not do well
with CBI, finding it painful and had less painful passage of
large blood clots without the foley, with subsequent resolution
of clot passage. She was discharged on prophlactic lovenox 40mg
daily. She was scheduled for follow up today in the ___
clinic with nephrology and oncology, however presented this
morning to the ED with several hours of painful hematuria. She
had one episode of pink urine yesterday but otherwise no
symptoms since her last discharge. She denies all other
symptoms. In the ED beside ultrasound showed obstructing clot in
the bladder. Bladder irrigation removed significant clot and
fibrinous compound, with bladder now decompressed by foley.
Foley d/c was attempted, however she reclotted, could not
urinate and was reirrigated and put on CBI and admitted to OMED
for further management.
Initial VS were 98.3 88 137/61 16 98%. Labs notable for hct
30.8.She recieved haldol 5mg, lorazepam 2mg, and dilaudid 6mg.
On arrival to the floor she is still complaining of bladder
spasms and cramping. She is passing pink tinged urine.
Past Medical History:
PAST ONCOLOGIC HISTORY:
ONCOLOGIC HISTORY:
- ___: Began noticing a "bulge" in her left flank which slowly
grew in size and discomfort.
- ___: CT abdomen/pelvis showed a very large left renal mass
about 16 cm in largest diameter with question of invasion of the
left renal vein. The lung bases showed multiple pulmonary
nodules, the largest of which was 15 mm in diameter, concerning
for pulmonary metastases.
- ___: CT chest confirmed multiple pulmonary nodules, the
largest of which was 16 x 16 mm in the left lung base. There
were also scattered subcentimetric nodules in the remainder of
both lungs.
- ___: Began sunitinib 50 mg daily; hospitalized few days
later with severe left abdominal pain and hematuria. Eventually
discharged home ___. Hospitalization complicated by atrial
fibrillation with RVR, fevers, and hypoxia, necessitating a
brief
ICU admission. Sunitinib was intermittently held during the
hospitalization.
- ___: resumed therapy with Sunitinib 37.5 mg 2 weeks on 1
week off.
- ___ a repeat CT torso showed overall decrease size of lung
nodules and kidney mass
- ___ CT showed overall stable disease
- ___ CT torso shows stable disease
- ___ CT torso shows stable disease
- ___ CT torso shows stable disease
- ___ CT torso shows stable disease
- ___ CT torso shows progressive disease
- ___ Initiated axitinib 5 mg BID
- ___ CT torso, slight interval progression of disease.
- ___ CT torso, stable disease
- ___ CT torso, stable renal mass, slight progression of
mediastinal LNs.
- ___ CT torso, stable disease
- ___ CT torso, interval increase of lung nodule and LAD
PAST MEDICAL HISTORY:
Hypertension
___ Successful Aflutter Ablation
Atrial Fibrillation
Asthma
Chronic low back pain
Arthritis
Hysterectomy
Tonsillectomy
Anxiety
Social History:
___
Family History:
Her father died of cardiovascular disease. She has five
siblings, all of whom are healthy to the best of her knowledge.
Her mother passed away last year. She denies any known
malignancies in a first or second-degree relative.
Physical Exam:
=================================
admission
=================================
VITALS: 97.8 122/80 126 22 97% RA
General: appears uncomfortable
HEENT: PERRLA, EOMI, no LAD
Neck: supple, no JVD
CV: RRR, no murmurs appreciated
Lungs: CTAB
Abdomen: +BS, +LUQ TTP, mild TTP just superior to groin
bilaterally, no CVAT
GU: +CBI, +pink urine draining
Ext: no peripheral edema
===========================
discharge
===========================
VITALS: 97.8 132/76 77 16 95%RA
General: appears uncomfortable
HEENT: PERRLA, EOMI, no LAD
Neck: supple, no JVD
CV: RRR, no murmurs appreciated
Lungs: CTAB
Abdomen: +BS, +LUQ TTP, ND
GU: no foley
Ext: no peripheral edema
Neuro: CN II-XII intact
Pertinent Results:
===========================
admission
===========================
___ 02:04AM BLOOD WBC-7.7 RBC-3.91* Hgb-8.8* Hct-30.3*
MCV-78* MCH-22.5*# MCHC-29.1* RDW-17.5* Plt ___
___ 02:04AM BLOOD Neuts-80.5* Lymphs-13.4* Monos-4.7
Eos-0.9 Baso-0.4
___ 02:04AM BLOOD Glucose-157* UreaN-18 Creat-1.0 Na-135
K-4.3 Cl-96 HCO3-27 AnGap-16
___ 08:00AM BLOOD Calcium-9.0 Phos-4.2 Mg-1.9
===========================
discharge
===========================
___ 07:05AM BLOOD WBC-5.9 RBC-3.92* Hgb-8.9* Hct-31.0*
MCV-79* MCH-22.6* MCHC-28.6* RDW-17.6* Plt ___
___ 07:05AM BLOOD Glucose-149* UreaN-18 Creat-1.1 Na-136
K-5.0 Cl-96 HCO3-27 AnGap-18
___ 07:05AM BLOOD Calcium-9.9 Phos-5.7*# Mg-2.1
===========================
pertinent
===========================
___ 07:00PM URINE RBC->182* WBC-12* Bacteri-FEW Yeast-NONE
Epi-0
___ 07:00PM URINE Color-Straw Appear-Clear Sp ___
___ 6:55 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
================================
imaging
================================
___ CT CHEST: prelim
IMPRESSION: Compared to the most recent prior study of ___, there has been interval disease progression with increased
mediastinal and hilar adenopathy as well as interval increase in
the number and size of multiple bilateral pulmonary nodules.
___ MR UROGRAM
IMPRESSION:
1. No IVC thrombosis. Patent renal veins.
2. Slight interval increase in size of large left renal mass
since ___. However, no pseudoaneurysm, hydronephrosis, or
filling defect within the collecting system to provide a
specific explanation for hematuria other than the presence of
this mass.
3. Limited assessment of the bladder with a Foley catheter in
place.
However, no bladder abnormality identified to suggest an
additional possible source of patient's hematuria.
4. Right lower lobe pulmonary nodule can be better assessed at
the time of restaging on a chest CT. This is most likely
metastatic disease given the patient's history.
Brief Hospital Course:
___ yo F w/ PMHx of metastatic renal cell carcinoma and LIJ
thrombis on lovenox p/w sudden onset dysuria, hematuria, and
passage of clots in her urine
# hematuria - most likely her hematuria occured in the setting
of lovenox for LIJ thrombus with known renal cell carcinoma. She
most likely bled from her underlying malignancy which caused the
blood to pool in her bladder and for a clot. Differential
diagnosis includes UTI or interstitial cystitis. Pt started on
CBI with manual flushing of foley and clot passage. Pt continued
to have intermittent periods of worsening with clot passage.
Urine eventually cleared, foley was removed and pt passed clear
urine. She will undergo nephrectomy to avoid future recurrences
of hematuria.
# L IJ thrombus - On treatment since ___ when thrombus was
discovered and pt admitted to the OMED service. CT head negative
for bleed and MRI was negative for metastasis. Has been on outpt
lovenox therapy at a prophylactic dose since clot has since
resolved on repeated imaging. She was continued on lovenox. The
importance of lovenox was emphasized to her and her family.
# anemia - likely blood loss from hematuria in addition to
anemia of chronic disease from underlying metastatic renal cell
carcinoma. Did require one unit of pRBCs during her last
hospitalization for dropping hct. Stable during this
hospitalization.
# metastatic renal cell carcinoma - Will undergo nephrectomy
next week with chemotherapy most likely afterwards. Continued
home medication for pain control. Had MRI urogram and CT chest
for pre-operative evaluation.
# anxiety - continued alprazolam as needed
# HTN - verapamil dose decreased secondary to hypotension to
240mg PO daily.
# hypothyroidism - continued levothyroxine
# asthma -continued montelukast
=================================
transitional issues
=================================
* OR date to be called to pt
* pt will have instructions about holding lovenox
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 20 mg PO DAILY
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. Enoxaparin Sodium 40 mg SC DAILY
4. Ferrous Sulfate 325 mg PO BID
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Montelukast Sodium 10 mg PO DAILY
7. Morphine SR (MS ___ 30 mg PO Q12H
8. Morphine Sulfate ___ ___ mg PO Q8H:PRN pain
9. Omeprazole 20 mg PO BID
10. Prochlorperazine 10 mg PO Q8H:PRN nausea
11. Verapamil SR 360 mg PO Q24H
12. ALPRAZolam 0.5 mg PO TID:PRN anxiety, nausea
13. LOPERamide 2 mg PO TID:PRN diarrhea
14. Zolpidem Tartrate 5 mg PO HS
Discharge Medications:
1. ALPRAZolam 0.5 mg PO TID:PRN anxiety, nausea
2. Citalopram 20 mg PO DAILY
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Enoxaparin Sodium 60 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
5. Ferrous Sulfate 325 mg PO BID
6. Levothyroxine Sodium 100 mcg PO DAILY
7. LOPERamide 2 mg PO TID:PRN diarrhea
8. Montelukast Sodium 10 mg PO DAILY
9. Morphine SR (MS ___ 30 mg PO Q12H
10. Morphine Sulfate ___ ___ mg PO Q8H:PRN pain
11. Omeprazole 20 mg PO BID
12. Prochlorperazine 10 mg PO Q8H:PRN nausea
13. Verapamil SR 240 mg PO Q24H
RX *verapamil 240 mg 1 tablet extended release(s) by mouth daily
Disp #*30 Tablet Refills:*0
14. Zolpidem Tartrate 5 mg PO HS
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
1. hematuria
2. renal cell carcinoma
3. atrial fibrillation
4. bladder spasm
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 into the ___
because you were having blood and clots in your urine again.
This is from your underlying kidney cancer which bleeds easily.
The blood is pooling in your bladder and clotting, causing a lot
of pain. While you were here, this resolved. However, we can't
predict when it might happen again. That is why you will undergo
a surgery to take out your kidney. You underwent an MRI and a CT
scan for pre-operative evaluation. The surgeons decided that
they wanted to do your operation next week. They will call you
with these details. Be sure to ask them about your lovenox and
when to hold it.
We kept you on lovenox. This is because this medication is very
important to prevent clots from forming. Even though the clot in
your neck has gone away, you are at a very high risk of a new
clot forming. If this happens, and a new clot forms, you are at
risk of having this travel to your lung and causing you to feel
short of breath, or even die. That is why lovenox is such an
important medication for you to be on. Before surgery, the
surgeons will tell you when to hold your lovenox.
We decreased the dosing of your verapamil. This is because your
blood pressure was very low on the 360mg dose. You are now on
240mg.
Thank you for choosing ___.
Followup Instructions:
___
|
10171405-DS-25 | 10,171,405 | 27,306,920 | DS | 25 | 2131-10-15 00:00:00 | 2131-10-16 09:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Levofloxacin / IV Dye, Iodine Containing Contrast Media
Attending: ___.
Chief Complaint:
Abdominal pain with nausea/vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ woman with history significant
for metastatic renal cell carcinoma, s/p left radical
nephrectomy (___), abdominal hysterectomy (___), h/o atrial
flutter s/p atrial ablation (not on anticoagulation), presents
with abdominal pain with nausea and vomiting. ACS was consulted
given concern for small bowel obstruction. Pt was in usual ___
of health until 2am today when she felt sudden epigastric pain
that "waxes and wanes", which she rated ___ in severity. She
began vomiting "clear white" emesis every ___ minutes after
the onset of abdominal pain. Endorsed sweats and chills,
chronic constipation (last normal BM 3 days ago). Has not passed
flatus; unable to recall last time she passed flatus. Had one
small volume BM with brown and "mauve" appearing
stool--different from her baseline of hard, well-formed brown
stool. No prior history of SBO. Denies fever, HA, CP,
palpitations, dyspnea, dysuria, hematuria, melena, hematochezia,
BRBPR, history of IBD, trauma, GERD or PUD (on omeprazole for
history of epigastric pain). She presented to the ED for
persistence of symptoms.
Past Medical History:
PAST MEDICAL HISTORY:
metastatic renal cell ca (mets to lung; cervical LN FNA
positive for malignant cells
left IJ thrombus (discharged ___ on lovenox until
___
Hypertension
___ Successful Aflutter Ablation
Atrial Fibrillation
Asthma
Chronic low back pain
Arthritis
Hysterectomy
Tonsillectomy
Anxiety
PSH:
-s/p L radical nephrectomy (___)
-hysterectomy, abdominal approach (___)
Social History:
___
Family History:
Her father died of cardiovascular disease. She has five
siblings, all of whom are healthy to the best of her knowledge.
Her mother passed away last year. She denies any known
malignancies in a first or second-degree relative.
Physical Exam:
Admission PE: ___
General: Anxious elderly woman, uncomfortable, in no acute
distress.
Vitals: T-97.9 HR 75 BP 120/77 RR 18 96%RA
HEENT: PERRL, mucus membranes moist, no lymphadenopathy.
CV: Regular rate, irregular rhythm, nl S1 and S2, no m/r/g.
Pulm: Non-labored breathing. Clear anteriorly, mild inspiratory
crackles at bases. No wheeze/rhonchi.
Abdomen: +BS, mildly tympanitic and distended. Midline,
well-healed scar running from umbilicus to suprapubic area; two
1cm well-healed scar on right and left abdomen. TTP throughout,
worse at epigastric and suprapubic area. Nontender to light
percussion. No rigidity, guarding, rebound tenderness.
Extremities: WWP, DP pulses 2+ bilaterally. No calf tenderness
or edema.
Discharge PE: ___
Vitals: 97.8, HR 75, BP 122/72, 18, 95% on RA
General: comfortable appearing woman, NAD
Lungs: clear bilaterall, diminished at the bases
CV: RRR
Abd: obese, soft, nontender
Extrem: warm, well perfused, no edema, +PP
Neuro: alert and oriented, MAE to command
Pertinent Results:
___ 07:30PM PLT COUNT-305
___ 07:30PM NEUTS-82.2* LYMPHS-14.0* MONOS-2.9 EOS-0.8
BASOS-0.2
___ 07:30PM WBC-8.1 RBC-5.16 HGB-12.2 HCT-39.1 MCV-76*#
MCH-23.6* MCHC-31.1 RDW-14.9
___ 07:30PM GLUCOSE-187* UREA N-23* CREAT-0.9 SODIUM-131*
POTASSIUM-6.2* CHLORIDE-92* TOTAL CO2-22 ANION GAP-23*
___ 07:38PM LACTATE-1.1 K+-4.6
___ 10:10AM ___ PTT-28.0 ___
___ 09:45PM URINE COLOR-Yellow APPEAR-Clear SP ___
___: CT Abd/Pelvis: 1. Findings consistent with a small
bowel obstruction with a transition point in the mid pelvis,
probably an adhesion related mechanical obstruction. There is
no pneumatosis, free air or portal venous gas. Small volume
ascites.
2. Known metastatic renal disease has progressed compared to
the prior
staging CT ___. Specifically the number and size of
multiple
pulmonary nodules have increased, there is new soft tissue
nodularity superior to the urinary bladder and the lytic lesion
in the left iliac wing has increased in size.
Brief Hospital Course:
Ms. ___ is a ___ y.o. woman with PMH significant for
metastatic renal cell cancer s/p left nephrectomy and atrial
fibrillation s/p ablation who presented to Emergency Department
on ___. On admission, patient stated that she has been
having severe diffuse colicky abdominal pain with associated
nausea and vomiting. She has not had a BM in 3 days. CT of the
abdomen and pelvis showed worsening metastatic disease and a
small bowel obstruction with transition point in the pelvis.
Initially, she was admitted to the floor and made NPO with a
nasogastric tube to low wall suctions and intravenous fluid. On
___, she was found to be in atrial fibrillation with RVR with
heart rates into the 120-140's and systolic blood pressure in
the 70's. She was given multiple pushes of IV metoprolol and
diltiazem without effect. She was then was transferred to the
ICU on ___ and was placed on esmolol gtt and spontaneously
converted with rate control within ___ hrs. She was transitioned
from Esmolol to Metoprolol and trasferred to the floor on ___.
On ___, she went back into Atrial Fibrillation with RVR, was
given multiple doses of diltiazem, and was transferred back to
the ICU for an Esmolol drip. She subsequently converted back to
sinus rhythm and she was restarted on her home regimen of Toprol
XL 100 mg BID. She was transferred back to the floor on ___.
Throughout this time nasogastric tube output remained high until
in taper on ___. On ___, the NGT was discontinued and the
patient had a bowel movement. On ___, her diet was advanced
from clears to regular and she tolerated this without nausea or
vomitting.
At the time of discharge, the patient was alert and oriented.
She is on chronic opiods for pain related to her metastatic
cancer and she was restarted on her home regimen. She was in
normal sinus rhythm on her home Toprol XL 100 mg PO BID and
remained hemodynmaically stable. Her abdomen was soft and non
tender. She was tolerating a regular diet and having loose
bowel movements. She will restart her home bowel regimen once
her stool bulks up given her chronic opiod use. Her appetite
was fair, which is patient baseline and she was discharged on
her home compazine for nausea. She remained afebrile with a
normal white blood cell count. Physical Therapy evaluated
patient and she is ambulating independently with a cane. She
will have nursing and physical therapy services at home as she
did pre admission. She will follow up with Hematology and
Oncology on ___ to discuss restarting her
Everolimus, which she will hold at this time. She will follow
up with Acute Care Surgery on ___.
Medications on Admission:
1. Levothyroxine Sodium 112 mcg PO DAILY
2. Metoprolol Succinate XL 100 mg PO BID
3. Montelukast 10 mg PO DAILY
4. Morphine SR (MS ___ 30 mg PO Q12H
5. Omeprazole 20 mg PO DAILY
6. Polyethylene Glycol 17 g PO DAILY
please start when your diarrhea resolves
7. Senna 8.6 mg PO BID:PRN constipation
Please restart once your diarrhea has resolved
8. Prochlorperazine 10 mg PO Q8H:PRN nausea
9. Morphine Sulfate ___ ___ mg PO Q4H:PRN pain
10. Everolimus 10 mg PO
Discharge Medications:
1. Levothyroxine Sodium 112 mcg PO DAILY
2. Metoprolol Succinate XL 100 mg PO BID
3. Montelukast 10 mg PO DAILY
4. Morphine SR (MS ___ 30 mg PO Q12H
5. Omeprazole 20 mg PO DAILY
6. Polyethylene Glycol 17 g PO DAILY
please start when your diarrhea resolves
7. Senna 8.6 mg PO BID:PRN constipation
Please restart once your diarrhea has resolved
8. Prochlorperazine 10 mg PO Q8H:PRN nausea
9. Morphine Sulfate ___ ___ mg PO Q4H:PRN pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted to ___ with a small bowel obstruction.
Whiile you were admitted, you went back into atrial fibrillation
but you are now on your home medications with good control of
your heart rhythm. You are ready to recover at home.
You will not start on your Everolimus until you have a follow up
appointment with your oncologists. Otherwise you can restart
your home medications as you were taking prior to admission.
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 get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
You take narcotic pain medications for your chronic pain. It is
important to take stool softeners while on these medications to
prevent constipation and obstruction. Avoid driving or
operating heavy machinery while taking pain medications.
Followup Instructions:
___
|
10171525-DS-11 | 10,171,525 | 21,263,495 | DS | 11 | 2115-12-13 00:00:00 | 2115-12-13 21:59:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hydroxychloroquine overdose
Major Surgical or Invasive Procedure:
Intubation - ___
History of Present Illness:
Ms. ___ is a ___ y/o woman with a PMH of SLE and bipolar
disorder, who presented from ___ with
intentional hydroxychloroquine overdose with cocaine and alcohol
co-ingestion. Per ___ records, she was found by EMS at her
apartment laying on her side in bed. She was complaining of
chest pain and reported that she had been drinking alcohol all
day and took ~30 tablets at 11:30 this morning. Reportedly
stated that she wanted to harm herself.
Collateral from her aunt: She had just moved out of her Aunt's
house in the past three weeks ago; had been going through a
break-up recently. Did not know about heavy drug use. Mother
lives in ___.
She reportedly had a bottle of 160 tablets, of which the patient
reported that she took 30. There were 20 tablets left in the
bottle. EKG from OSH notable for prolonged QRS. Received IV KCl
and NaBicarb. One presentation, she was awake, but lethargic.
Intubated and sedated. At ___, on 0.1mcg/kg/min epi, MAPS
60's. EKG HR 103, QRS 83, QTc 486 (off bicarb).
In the ED, labs were notable for CBC w/ WBC 26.5, H/H
10.8/34.2, PLT 195, Diff 86%N, 10%L, 3%M, 0%E. Chemistries with
Na 144, K 3.2, Cl 112, HCO3 14, BUN 9, Cr 0.7. Ca 7.4, Mg 1.6, P
4.4. ALT 18, AST 29, Alk phos 74, Tbili 0.2, Alb 3.5, lipase 20.
Troponin negative x1. Serum EtOH 68. Serum ASA, APAP, benzos,
barbiturates, and TCAs were negative.
- CXR showed ETT tube in standard position, low lung volumes,
and patchy opacities in lung bases representing atelectasis vs.
aspiration vs. infection.
- Patient was given:
___ 21:11 IVF 1000 mL NS 1000 mL
___ 21:11 IV DRIP Fentanyl Citrate Started 50 mcg/hr
___ 21:11 IV DRIP Midazolam Started 2 mg/hr
___ 21:11 IV DRIP EPINEPHrine Started 0.1 mcg/kg/min
___ 21:36 IV Potassium Chloride 20 mEq Partial
Administration
- Consults: toxicology
In the ED, she was lethargic but neurologically intact,
following commands and communicated. This was reportedly an
intentional overdose. she was induced with succinylcholine,
etomidate, and fentanyl, and she was intubated. She was
initiated on an epinephrine infusion with MAPs in ___. She had a
femoral line in place from ___. She was
given two amps of bicarbonate, and her hypokalemia was treated
with 40 mEq over 2 hours. Initially had an OG tube placed, which
she pulled out.
On arrival to the MICU, she was intubated and sedated.
Responsive to loud voice; following commands.
Past Medical History:
- bipolar disorder
- SLE
- placenta previa
- Chlamydia, age ___ (treated)
- G3P1, 1 SAB, 1 TAB
Social History:
___
Family History:
Unable to obtain given altered mental status on admission
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM
=======================
Vitals: T 98.1F BP 106/54 mmHg P ___ RR 21 O2 100% on CMV 50%
FiO2
___: Intubated and sedated.
HEENT: Pupils pinpoint.
CV: Tachycardic, regular. No MRGs. Normal S1/S2.
Pulm: CTA anteriorly bilaterally.
Abd: Soft, non-tender, non-distended, NABS.
GU: Foley in place, draining clear urine.
Ext: Warm and well-perfused. R femoral CVL in place, c/d/I. 2+
pulses bilaterally. No edema.
Neuro: Sedated. Following one-step commands.
Skin: Multiple tattoos on chest.
=======================
DISCHARGE PHYSICAL EXAM
=======================
VS - 98.5 95/50 83 16 99%RA
Gen - sleeping, awaking to voice
Eyes - EOMI
ENT - OP clear, MMM
Heart - RRR no mrg
Lungs - CTA bilaterally
Abd - soft nontender, normoactive bowel sounds
Ext - no edema
Skin - no rashes
Vasc - 2+ DP/radial pulses
Neuro - AOx3, moving all extremities
Psych - appropriate
Pertinent Results:
ADMISSION LABS
==============
___ 08:32PM BLOOD WBC-26.5* RBC-3.76* Hgb-10.8* Hct-34.2
MCV-91 MCH-28.7 MCHC-31.6* RDW-13.1 RDWSD-43.2 Plt ___
___ 08:32PM BLOOD Neuts-85.9* Lymphs-9.7* Monos-3.1*
Eos-0.2* Baso-0.2 Im ___ AbsNeut-22.78* AbsLymp-2.56
AbsMono-0.81* AbsEos-0.06 AbsBaso-0.06
___ 08:32PM BLOOD ___ PTT-24.7* ___
___ 08:32PM BLOOD Glucose-71 UreaN-9 Creat-0.7 Na-144
K-3.2* Cl-112* HCO3-14* AnGap-21*
___ 08:32PM BLOOD ALT-18 AST-29 AlkPhos-74 TotBili-0.2
___ 08:32PM BLOOD cTropnT-<0.01
___ 08:32PM BLOOD Albumin-3.5 Calcium-7.4* Phos-4.4 Mg-1.6
___ 08:03AM BLOOD calTIBC-303 Ferritn-13 TRF-233
___ 11:35PM BLOOD Osmolal-299
___ 08:32PM BLOOD ASA-NEG Ethanol-68* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 09:28PM BLOOD Type-ART Rates-15/ Tidal V-450 FiO2-100
pO2-524* pCO2-42 pH-7.18* calTCO2-16* Base XS--12 AADO2-135 REQ
O2-34 -ASSIST/CON Intubat-INTUBATED
___ 09:03PM BLOOD K-3.1*
___ 11:45PM BLOOD Lactate-6.9*
DISCHARGE LABS
==============
___ 06:20AM BLOOD WBC-8.1 RBC-3.62* Hgb-10.2* Hct-31.7*
MCV-88 MCH-28.2 MCHC-32.2 RDW-12.8 RDWSD-40.6 Plt ___
___ 06:23AM BLOOD Glucose-85 UreaN-6 Creat-0.7 Na-137 K-4.2
Cl-104 HCO3-24 AnGap-13
IMAGING/STUDIES
===============
CHEST (PORTABLE AP) (___):
1. Endotracheal tube in standard position.
2. Low lung volumes. Patchy opacities in lung bases may reflect
areas of atelectasis. Aspiration or infection, however, cannot
be completely excluded in the correct clinical setting.
.
ECHO (___):
Findings
LEFT ATRIUM: Normal LA and RA cavity sizes.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
The patient is mechanically ventilated. Cannot assess RA
pressure.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). False LV tendon
(normal variant). TDI E/e' < 8, suggesting normal PCWP
(<12mmHg). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Eccentric MR jet. Mild (1+) MR. ___ to the eccentric MR jet, its
severity may be underestimated (Coanda effect).
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium and right atrium are normal in cavity size. 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%). Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). 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. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. An eccentric, posterolaterally directed jet of at
least mild (1+) mitral regurgitation is seen. ___ to the
eccentric nature of the regurgitant jet, its severity may be
significantly underestimated (Coanda effect). The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: Normal biventricular global and regional systolic
function. At least mild eccentric mitral regurgitation.
MICROBIOLOGY
============
___ 10:50 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PREDOMINATING ORGANISM.
INTERPRET RESULTS WITH CAUTION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
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---- =>16 R
Brief Hospital Course:
This is a ___ year old female with past medical history of
bipolar and SLE admitted ___ w intentional
hydroxychloroquine overdose in the setting of alcohol and
cocaine intoxication, initially requiring intubation and pressor
support, subsequently improving, course also notable for urinary
tract infection status post 5 day course of antibiotics with
resolution of symptoms, discharged to inpatient psychiatric
facility.
# Intentional Overdose of Hydroxychloroquine / Cocaine Abuse
Complicated Ongoing / Alcohol Abuse Complicated Ongoing / Acute
toxic encephalopathy - admitted in setting of intoxication and
altered mental status in setting of above overdose. She
required intubation, vasopressors, and ICU admission for
monitoring and treatment of severe encephalopathy. Initially
she was started on a sodium bicarbonate drip, and monitored for
QRS and QTc prolongation ___ sodium and potassium channel
blockade with q2h EKGs. QRS remained <100ms. She did not
demonstrate signs of withdrawal or require benzodiazepines. Her
hydroxychloroquine was held (patient reported not seeing her
rheumatologist for > 6 months), and should not be restarted
until she is seen by her rheumatologist Dr. ___. Started
on folate, thiamine, multivitamin.
# Acute Depressive Episode with Suicide attempt - Has history of
bipolar disorder, and has had significant psychosocial stressors
recently, now with intentional ingestion of hydroxychloroquine
as above, as well as alcohol and cocaine co-ingestion.
Psychiatry was consulted, and she was held under ___.
Patient was seen by psychiatry, who after working with the
patient over several days felt that ___ could be lifted
and patient could be discharged to an open unit inpatient
psychiatric facility.
# SLE - Hydroxychloroquine held given the setting above. Of
note, her UA showed microscopic hematuria and proteinuria in the
setting of her UTI (unclear if related to her SLE). Would plan
on rechecking as outpatient to ensure resolution.
# Acute Bacterial UTI secondary to ___ course
complicated by development of urinary urgency on ___. UA
concerning for UTI and urine culture grew proteus. Patient was
treated with Ciprofloxacin with improvement in symptoms. She
completed 5 day course of antibiotics during her inpatient
admission.
===================
TRANSITIONAL ISSUES
===================
# Code status: FULL
# Communication: Aunt, ___ Mother,
___, ___
___ Issues
- Please schedule for PCP follow up at time of discharge from
facility
- Hydroxychloroquine not restarted given her overdose--she
should have follow up to consider restarting this medication
with PCP and rheumatologist
- Had microscopic hematuria on UA in the setting of a UTI--would
consider repeating to ensure resolution and rule out kidney
involvement of SLE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydroxychloroquine Sulfate 400 mg PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Thiamine 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
# Intentional Overdose of Hydroxychloroquine / Cocaine Abuse
Complicated Ongoing / Alcohol Abuse Complicated Ongoing
# Acute bacterial UTI / Proteus Infection
# Alcohol abuse
# SLE
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 ___ at ___. ___ were admitted
after overdosing on hydroxychloroquine, as well as cocaine and
alcohol. ___ were initially very sick and required treatment in
the ICU. ___ also had a urinary tract infection that was
treated with antibiotics. ___ were seen by psychiatrists and
medical doctors. ___ improved and are now ready for discharge
to an inpatient psychiatric facility.
Followup Instructions:
___
|
10172206-DS-18 | 10,172,206 | 26,783,176 | DS | 18 | 2185-05-25 00:00:00 | 2185-05-25 23:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cardiac arrest
Major Surgical or Invasive Procedure:
s/p ICD generator change ___
History of Present Illness:
Mr. ___ is a ___ yoM with hx of DM2, COPD, non-ischemic
cardiomyopathy with EF ___ s/p dual chamber ICD, CAD s/p MI
___ ___ and 3V CABG (LIMA-LAD and separate SVGs to fist diag and
right PLVB), and hx of cocaine use who presented to ___
___ ___ the setting of multiple ICD shocks.
___ the ___, he was noted to be ___ a wide complex
tachycardia but was initially awake and was receiving shocks
from his device. It is unclear when he became pulseless but he
received CPR intermittently (reportedly 8 minutes) during which
time he was receiving internal shocks from his device ___ per
report) as well as multiple external shocks ___ per report)
and he was intubated. He was also reportedly treated for "PEA
arrest" during this time as well as lidocaine (~300 mg) and was
then started on amiodarone gtt at 1 mg/min and lidocaine gtt at
2 mg/min. He also received epi x 5. He was given rectal aspirin
and received a bolus of heparin, and 5L IVF. Labs at ___
___ notable for CK 124, Cr 1.5, Hct 49, pts 158, WBC 11.1.
He was medflighted to ___ during which time he had additional
wide complex tachycardia during transport and became pulseless
requiring CPR. Since arrival to ___ he has had no further wide
complex tachycardia. He has remained hemodynamically stable with
sBP 100-110s since transport but has been persistently hypoxic
despite high PEEP (up to 20) and 100% FiO2. Bedside TTE upon
arrival to ___ demonstrated an EF of ___. Pacemaker
interrogated and showed clsoe to 60 shocks beginning 3 days ago
(2 shocks 3 days ago, an episode of VT that he was ATP'd out of,
followed by multiple shocks over the last day). His CXR showed
patchy infiltrates bilaterally and cardiomegaly. CT head was
negative for acute process. Urine tox screen was positive for
cocaine. Labs notable for WBC of 14.2, pts 118, Cr 1.8, Ca 7.3,
TnT 0.47, Lactate 6.2, BNP ___.
REVIEW OF SYSTEMS:
Unable to obtain
Past Medical History:
- Non-ischemic cardiomyopathy with EF ___ s/p dual chamber
ICD
- CAD s/p MI ___ ___ and 3V CABG (LIMA-LAD and separate SVGs to
fist diag and right PLVB)
- IDDM
- COPD
- Chronic Back Pain
- CKD ___ Bright's disease
- Anxiety
- HLD
Social History:
___
Family History:
Early CAD ___ brother, father
Physical ___:
Admission exam:
===============
General: Intubated, sedated
HEENT: Pupils 1-2mm minimally reactive
Neck: ET tube ___ place, no masses
CV: RRR, difficult to appreciate
Lungs: Rhonchorous
Abdomen: Soft
GU: Foley ___ place
Ext: Cool to touch, dopplerable DP 2+ (only appreciate L radial
pulse), no edema
Neuro: Moving L extremity purposelessly, withdrew to pain for
A-line placement
Discharge exam:
===============
VS: 97.6, 115-125/71, 52-70, 20, 100% RA
I/O's: 24hr: not recorded, 8hr: 180-975
Wt: 81.1 (80.5 ___
Neuro: Oriented to location but not to year (___), poor short
term memory. Follows commands. MAE against gravity (L > R) .
___ strength LUE, LLE, RLE. 4+ strength RUE.
General: Awake, alert, interactive.
HEENT: PERRL
Neck: supple, no JVD
CV: RRR S1S2, no murmurs
Lungs: CTAB
Abdomen: Soft, nontender, nondistended. Bowel sounds present
Ext: Warm, no edema. DP 2+, black eschars on great toes
bilaterally
Skin: Blanching erythematous patch with mild scale over right
scapula. Erythematous, lichenified patch on left elbow and
bilateral calfs.
Pertinent Results:
Admission:
===============
___ 03:51AM BLOOD WBC-14.7* RBC-5.12 Hgb-15.4 Hct-49.0
MCV-96 MCH-30.0 MCHC-31.4 RDW-13.0 Plt ___
___ 08:55AM BLOOD Neuts-86.2* Lymphs-6.4* Monos-6.7 Eos-0.2
Baso-0.6
___ 03:51AM BLOOD ___ PTT-105.6* ___
___ 08:55AM BLOOD Glucose-388* UreaN-24* Creat-2.0* Na-136
K-5.3* Cl-106 HCO3-20* AnGap-15
___ 08:55AM BLOOD ALT-127* AST-231* CK(CPK)-633* AlkPhos-66
TotBili-0.7
___ 03:51AM BLOOD proBNP-___*
___ 03:51AM BLOOD cTropnT-0.47*
___ 03:51AM BLOOD Calcium-7.3* Phos-4.8* Mg-2.1
___ 03:51AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:28AM BLOOD Type-ART Temp-36.3 Rates-/14 PEEP-12
FiO2-100 pO2-112* pCO2-69* pH-7.11* calTCO2-23 Base XS--9
AADO2-543 REQ O2-89 Intubat-INTUBATED Vent-CONTROLLED
Pertinent labs:
===============
___ 03:51AM BLOOD proBNP-___*
___ 03:51AM BLOOD cTropnT-0.47*
___ 08:55AM BLOOD CK-MB-58* MB Indx-9.2* cTropnT-0.91*
___ 08:58PM BLOOD CK-MB-72* MB Indx-7.1* cTropnT-1.27*
___ 04:09AM BLOOD CK-MB-13* MB Indx-1.1 cTropnT-1.81*
MICROBIOLOGY:
Blood cultures ___ and ___ negative
Urine culture ___ negative
Sputum culture ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
STREPTOCOCCUS PNEUMONIAE. MODERATE GROWTH.
Note: For treatment of meningitis, penicillin G MIC
breakpoints
are <=0.06 ug/ml (S) and >=0.12 ug/ml (R) Note: For
treatment of
meningitis, ceftriaxone MIC breakpoints are <=0.5 ug/ml
(S), 1.0
ug/ml (I), and >=2.0 ug/ml (R) For treatment with oral
penicillin,
the MIC break points are <=0.06 ug/ml (S), 0.12-1.0 (I)
and >=2
ug/ml (R). CEFTRIAXONE (0.25 MCG/ML).
STAPH AUREUS COAG +. MODERATE 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.
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.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE.
MODERATE GROWTH.
Beta-lactamse negative: presumptively sensitive to
ampicillin.
Confirmation should be requested ___ cases of treatment
failure ___
life-threatening infections..
MORAXELLA CATARRHALIS. MODERATE GROWTH.
Sputum culture ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): PLEOMORPHIC GRAM NEGATIVE
ROD(S).
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND ___ SHORT
CHAINS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
STREPTOCOCCUS PNEUMONIAE. MODERATE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 38___ ON
___.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE.
MODERATE GROWTH.
Beta-lactamse negative: presumptively sensitive to
ampicillin.
Confirmation should be requested ___ cases of treatment
failure ___
life-threatening infections..
STAPH AUREUS COAG +. MODERATE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___ ON
___.
MORAXELLA CATARRHALIS. MODERATE GROWTH.
Discharge:
===============
___ 06:46AM BLOOD WBC-6.8 RBC-4.90 Hgb-14.2 Hct-44.4 MCV-91
MCH-29.0 MCHC-31.9 RDW-13.3 Plt ___
___ 06:46AM BLOOD Plt ___
___ 06:46AM BLOOD ___
___ 06:46AM BLOOD Glucose-146* UreaN-24* Creat-1.4* Na-134
K-5.2* Cl-97 HCO3-28 AnGap-14
___ 06:46AM BLOOD Calcium-9.5 Phos-3.5 Mg-1.9
Imaging:
===============
___ Echo
Conclusions
The left atrial volume is severely increased. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is moderately dilated. There is severe regional left
ventricular systolic dysfunction with akinesis of the inferior
wall and distal ___ of the septum and inferolateral walls,
and distal anterior and lateral walls. The apex is aneurysmal
and dyskinetic. The remaining segments are hypokinetic (LVEF
20%). Left ventricular cardiac index is depressed
(<2.0L/min/m2). No masses or thrombi are seen ___ the left
ventricle. Doppler parameters are most consistent with Grade
III/IV (severe) left ventricular diastolic dysfunction. Right
ventricular chamber size is normal. with mild global free wall
hypokinesis. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve leaflets are mildly
thickened. Mild to moderate (___) mitral regurgitation is seen.
There is borderline pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Symmetric left ventricular hypertrophy with marked
cavity dilation and extensive regional systolic dysfunction c/w
multivessel CAD or other diffuse process. Moderate to severe
mitral regurgitation.
CLINICAL IMPLICATIONS:
The left ventricular ejection fraction is <40%, a threshold for
which the patient may benefit from a beta blocker and an ACE
inhibitor or ___.
___ CXR
IMPRESSION: Moderate to severe cardiomegaly.
___ CT head
IMPRESSION: No acute intracranial process.
___ EEG:
IMPRESSION: This is an abnormal 24 hour video EEG recording due
to the very low voltage theta frequency background slowing seen
___ the initial portion of the recording which improves as the
study progresses and becomes more continuous by the evening,
reaching up to ___ Hz with bursts of generalized ___ Hz delta
frequency slowing. These findings are consistent with a severe
encephalopathy which is etiologically non-specific. No
epileptiform discharges or electrographic seizures are seen.
___ CT head
IMPRESSION:
1. Interval development of hypodensities ___ the left occipital
and parietal lobes ___ a watershed distribution, concerning for
infarction.
2. Hypodensities ___ the left medial temporal lobe may represent
partial
volume averaging with the choroidal fissure, or areas of
infarction. If they are areas of infarction, they would be
usual for a watershed distribution.
3. No hemorrhage is identified.
___ CXR
Moderate-to-severe cardiomegaly is stable. Pacer leads are ___ a
standard
position. Right IJ catheter tip is ___ the upper right atrium.
There is no pneumothorax. There is mild vascular congestion.
There are no large pleural effusions. Sternal wires are
aligned.
___ Echo
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
moderately dilated. There is moderate to severe regional left
ventricular systolic dysfunction with akinesis of the
inferior/infero-lateral, distal/apical segments. No masses or
thrombi are seen ___ the left ventricle. There is no ventricular
septal defect. with depressed free wall contractility. The
ascending aorta is mildly dilated. The aortic valve is not well
seen. There is no aortic valve stenosis. No aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. An
eccentric, posteriorly directed jet of moderate (2+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
the LVEF has improved (___)
___ CTA Head and neck
IMPRESSION:
Sequela from old left parietal occipital infarcts and
age-related involutional with chronic microangiopathic changes
without acute hemorrhage or mass effect.
Moderate narrowing of the proximal left cavernous ICA just
beyond it's exit of the petrous segment. Otherwise unremarkable
CTA of the head and neck without evidence of significant
stenosis, aneurysm, pseudoaneurysm, or dissection.
Enlarged main pulmonary artery which may reflect pulmonary
hypertension.
Asymmetric soft tissue fullness about the right piriform sinus
to above the true vocal cords; further evaluation as clinically
warranted.
Brief Hospital Course:
___ with DM2, COPD, non-ischemic cardiomyopathy with EF ___
s/p dual chamber ICD, CAD s/p MI ___ ___ and 3V CABG (LIMA-LAD
and separate SVGs to fist diag and right PLVB), and hx of
cocaine use who presents s/p cardiac arrest ___ the setting of VT
storm, now found to have L occipital/parietal watershed infarct.
# Cardiac arrest: Patient presented to OSH with VT storm s/p
close to 60 total ICD shocks, multiple rounds of CPR with
unclear down/pulseless time. Differential for VT could be
cocaine abuse, hypokalemia, new or worsened heart failure, and
acute myocardial ischemia. Initial antiarrythmics included IV
Amiodarone and IV Lidocaine. Per EP recommendations, lidocaine
was weaned off and amiodarone was continued. Patient treated
with cooling protocol given comatose state after ROSC. He was
successfully extubated on ___ and was switched to PO Amiodarone,
now on maintenance dose. Metoprolol and Lisinopril were titrated
during admission. He had a few episodes of NSVT but no further
significant arrhythmias with optimization of fluid and
electrolyte status. He underwent an ICD generator change on
___. He was started on Vancomycin IV s/p generator change for a
10d course and transitioned to PO Clindamycin given concern for
possible rash/itchiness - pt w/ hx of MRSA. Will need follow up
with EP for consideration of VT ablation.
# Heart failure: Patient has severe biventricular heart failure
(EF ___ with BiV/ICD. He is on medical management with
lisinopril and metoprolol. Following aggressive diuresis of
pulmonary edema, he is being continued on PO lasix 20mg daily.
Continued on aspirin and statin for history of CAD s/p MI and
now stroke. Repeat TTE ___ 3 months to eval ventricular function.
# Hypoxemic respiratory failure: ABG 7.___/112/23 on
admission. Patient with bilateral infiltrates on CXR with P:F
92. Likely due to pulmonary edema and significantly improved
with aggressive diuresis. There was an interval concern for
pneumonia and he was treated on a 7d course of Vancomycin and
Cefepime. Sputum cultures grew only commensal flora. He was
successfully extubated on ___ and had no further respiratory
issues.
#Stroke/AMS: With weaning of sedation, patient was found to have
preferential movement of left side without significant right
side movement. Found to have interval development of L
occipital/parietal watershed infarction on CT (___). Deficits
predominantly of right side neglect and NOT right hemiparesis as
originally thought (exam confounded by right side neglect). CTA
of head/neck showed moderate narrowing of proximal L cavernous
ICA. EEG was abnormal with non-specific encephalopathy and focal
dysfunction ___ L temporal region, but no epileptiform
discharges. He showed interval improvement ___ neurological
status and was able to sit unassisted, feed himself with his
left hand and stand/walk with minimal assistance. He will need
ongoing ___ rehabilitation. He was medically managed
with aspirin, statin and permissive hypertension. He was
maintained on quetiapine BID and lorazepam PRN for agitation. He
should have follow up with Neurology for ongoing management.
# Acute kidney injury: Cr 1.8 on admission (unknown baseline) ___
a patient with assumed baseline renal insufficiency likely due
to DM. Initial acute increase ___ creatinine (peak Cr 3.9) likely
due to poor forward flow ___ setting of EF of 20% and hypotension
related to cooling process with contribution from distributive
shock/sepsis. Resolved with improvement ___ clinical status and
now below admission value at 0.9-1.1.
# DM: Glucose 400s on admission, patient managed with ISS and
normoglycemic throughout stay.
# Aneurysmal LV: Was initially on heparin gtt, switched to
Lovenox and bridged to warfarin. Will need Warfarin x 3months.
TRANSITIONAL ISSUES:
# The patient was deemed to not currently have capacity for
medical decision making, as he is not consistently oriented to
place or situation, cannot articulate his condition or decisions
that are being asked of him. His brother ___ (___)
has been appointed his Health Care Proxy.
# Full Code per discussion with HCP and pt, as patient recovers
cognitive function.
# Clindamycin 300mg TID for total of 1 week of antibiotics at
time of DC, first day ___.
# Continue titration of warfarin for INR goal 2.0-3.0 x3 months.
# Repeat LFTs ___ 1 month s/p initiation of statin given slight
LFT elevations during admission (ALT 50, AST 44).
# Amiodarone: Will need PFTs as outpt, TSH during admission wnl.
# TTE should be ordered ___ 3 month to eval ventricular function.
# Follow up with EP Dr ___ ___ ___ for device management
and consideration for VT ablation
# Follow up with Neurology for post-stroke management.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol-Ipratropium ___ PUFF IH Q6H:PRN dyspnea
2. Lorazepam 0.5 mg PO HS:PRN sleep
3. Aspirin 325 mg PO DAILY
4. Furosemide 40 mg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. Metoprolol Tartrate 100 mg PO TID
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
9. Ezetimibe 10 mg PO BID
10. Simvastatin 80 mg PO DAILY
11. Glargine 90 Units Bedtime
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units DinnerMax Dose Override Reason: home dose
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. Lisinopril 5 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Atorvastatin 40 mg PO DAILY
6. Spironolactone 25 mg PO DAILY
7. Sarna Lotion 1 Appl TP TID
8. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
9. Amiodarone 200 mg PO DAILY
10. DiphenhydrAMINE 25 mg PO Q6H:PRN itching
11. Thiamine 100 mg PO DAILY
12. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID
13. Warfarin 5 mg PO DAILY
dose for INR goal 2.0-3.0
14. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
15. Albuterol-Ipratropium ___ PUFF IH Q6H:PRN dyspnea
16. Clindamycin 300 mg PO Q8H
Stop after 3rd dose on ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Non-ischemic cardiomyopathy EF ___ s/p ___ generator
change ___
s/p VT cardiac arrest from cocaine use
s/p Stroke, left occipital/parietal watershead infarct on
___
Aneurysmal LV
Secondary:
Coronary artery disease s/p CABG ___
Diabetes type II
COPD
Pneumonia
s/p MI ___ ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent, 1 assist out of bed
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
for treatment of your arrhythmia (an irregular heart beat). ___
this setting you suffered a cardiac arrest and required CPR and
medications to restore your heart beat and blood pressure. You
remained ___ a medical coma and and required a breathing tube
until your respiratory status improved. We treated your
arrhythmia with medications. We also performed a battery change
for your internal defibrillator.
It is also very important that you avoid illegal drugs at they
can cause changes ___ your heart rhythm which can lead to another
episode of your heart stopping. Please take all your
medications as prescribed.
You were also treated for heart failure with medications. Heart
failure is the inability for the heart to meet the needs of the
body. We have changed your medicaitons and your heart failure
symtpoms have continued to improve along with careful monitoring
of your diet and fluid intake.
You were also diagnosed and treated for pneumonia with a course
of antibiotics which has resolved.
You also suffered from a stroke. Your funcitoning has continued
to improve and you will be followed by a nueurologist as an
outpatient.
You were found to have an anurysm ___ the left ventricle of your
heart which puts you at increased risk for another stroke so you
have been placed on Coumadin. It is very important that you take
your Coumadin exactly as directed (every evening, dose will be
adjusted by Dr. ___ and take blood tests to ensure
that it is working appropriately. The rehab facility will
manage your Coumadin levels.
For your diagnosis of heart failure it is important that you
weigh yourself every morning, call Dr. ___ your weight
goes up more than 3 lbs ___ 2 days.
Please continue to take your medications as prescribed on
discharge. You will have close follow up with Dr. ___ Dr.
___ ensure that you keep these appointments. It is
very important that you follow up with cardiology at regular
intervals so that your defibrillator can be tuned up.
Followup Instructions:
___
|
10172240-DS-19 | 10,172,240 | 29,600,520 | DS | 19 | 2126-06-30 00:00:00 | 2126-06-30 13:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
Cipro
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
___: Bedside placement of a pigtail catheter in left chest
History of Present Illness:
Patient is a ___ with hx Sjogren's syndrome, well controlled
asthma, pulm nodules s/p VATS left lung wedge resection x2 who
presents with 2 days of worsening dyspnea upon exertion. Patient
underwent an uncomplicated L VATS and wedge resection biopsy of
2 pulmonary nodules by Dr. ___ on ___ ___ and
was discharged home after 2 days of uneventful hospital stay.
She did have an intraoperative chest tube which was removed on
the day of her discharge with a unremarkable chest x-ray. Of
note, the pathology of the biopsied pulmonary nodules came back
as amyloidosis. Patient reports since her discharge, she has
been feeling generally well however with increasing shortness of
breath upon walking starting 2 days ago and was unable to walk
more than 10 steps without stopping to catch her breath last
night. SHe called our clinic and was asked to come to the ED.
Patient reports she has baseline low threshold for dyspnea due
to her astha (inhalers ~ 1x/wk, syndisk BID) and sedentary
lifestyle but this is much worse than her baseline. She also
endorses mild production on pinkish sputum. She denies any
fevers, chills, chest pain or hemoptysis or sick contacts.
ED course: Patient presented with good O2 saturations in 98% on
room air. However upon ambulation, her O2 saturation was
descreased to 91%. She was hemodynamically stable. She was
placed on nasal cannula oxygen for comfort and CXR has been
taken.
Past Medical History:
Past Medical History: Lupus, Sjogrens, diverticulosis, asthma,
cholelithiasis, depression
Past Surgical History: Lap CCY, last C-scope ___ -
diverticulosis
Social History:
___
Family History:
Mother breast cancer, CAD
Father lung cancer secondary to asbestos exposure
Physical Exam:
Vitals: 98.7, 124/75, 88, 18, 98% RA (admission)
GEN: NAD, WDWN, on NC O2, obese
HEENT: MMM, EOMI, neck supple, no LAD
CV: RRR, no M/R/G
PULM: Decreased breath sounds on the left basilar area,
otherwise clear, no W/R/R. L surgical incision sites with
dermabond, intact, ___ and ___
ABD: soft, NTND, no masses
Ext: WWP, no edema
Pertinent Results:
ADMISSION:
7.2 > 11.1/34.7 < ___
================< 101
4.0 27 0.8
Calcium-8.8 Phos-3.8 Mg-2.3
IMAGING:
(___): at presentation
IMPRESSION:
Interval increase in amount of left pleural effusion which is
loculated
laterally. Post wedge resection changes again seen in the left
mid lung
field. Bibasilar atelectasis.
(___): post L pigtail placement
FINDINGS: Comparison is made to previous study from ___.
There has been placement of a left-sided pigtail pleural
catheter. There are again seen opacities at the left base and
left mid lung field, stable. The heart size is within normal
limits. There are low lung volumes. There are no
pneumothoraces. The right lung is clear
(___): HD2, prior to Pigtail removal
FINDINGS: Comparison is made to previous study from ___.
There is a left-sided pigtail catheter at the base. This is
unchanged in
position. Again seen are opacities in the left mid and lower
lung zones. There is some atelectasis at the right base. There
are no pneumothoraces. Heart size is within normal limits.
Pathology (Left pulmonary nodules/Wedge resection ___:
PATHOLOGIC DIAGNOSIS:
1. Lung, left upper lobe, wedge resection:
- Nodular pulmonary amyloidosis (2 foci, 1.0 and 0.6 cm), see
Note.
- Uninvolved lung parenchyma with scattered non-necrotizing
granulomas and patchy airway centered chronic inflammation, see
Note.
- There is no evidence of malignancy.
2. Lung, left upper lobe, wedge resection #2:
- Nodular pulmonary amyloidosis (0.6 cm), see Note.
- Uninvolved lung parenchyma with scattered non-necrotizing
granulomas and patchy airway centered chronic inflammation, see
Note.
- GMS and AFB stains are negative for microorganisms.
- The amyloid deposits are highlighted by trichrome and ___
Red stains.
- There is no evidence of malignancy.
Brief Hospital Course:
Please refer to the HPI for details of the patient's history.
Upon presentation to the ED, Patient has good oxygen saturations
upto 98% in room air. However upon ambulation in the eD, her O2
saturation was noted to decrease to 91%.She was hemodynamically
stable. She was placed on nasal cannula oxygen for comfort. A
chest x-ray showed interval development of left sided small to
moderate pleural effusion and bibasial atelectasis without any
signs of pneumothorax. Patient was admitted to the thoracic
surgery serviced with continuous oxygen monitoring. Her
laboratory workup was within normal limits without any signs of
infection. She remained stable throughout HD1 on room air and on
a regular diet. Oh HD2, a left sided pleural pigtail catheter
was placed by interventional pulmonology with immediate drainage
of 400 ccs of serosanguinous fluid from the left pleural cavity.
The pigtail was left in place overnigt given large volume of
initial drainage and her body habitus. The pigtail was left on
waterseal without any signs of an airleak. Patient reported
almost immediate improvement of symptoms after her procedure and
was able to ambulate the halls without any signs of dyspnea.
Patiet remained stable on room air overnight without complaints.
On HD3, patient continued to improve with decrease in the
pleural effusion on CXR. The pigtail was removed on HD3 with a
unremarkable post-removal CXR. Patient was again able to
ambulate with great symptomatic improvement and she expressed
full comfort to continue her recovery at home. Patient is to
follow up with Thoracic surgery clinic, her ___
and Pleural clinic as detailed in her discharge instructions.
Medications on Admission:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
2. Aspirin 162 mg PO DAILY
3. cevimeline 30 mg oral QID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*20 Capsule Refills:*0
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Hydroxychloroquine Sulfate 200 mg PO BID
7. Hyoscyamine 0.125 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet
extended release(s) by mouth Q6hrs prn Disp #*20 Tablet
Refills:*0
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
3. Aspirin 162 mg PO DAILY
4. cevimeline 30 mg oral QID
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*20 Capsule Refills:*0
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. Hydroxychloroquine Sulfate 200 mg PO BID
9. Hyoscyamine 0.125 mg PO BID
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 capsule(s) by mouth Q4hrs prn Disp #*20
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left pleural effusion
Dyspnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for shortness of breath and a finding of a
small amount of fluid collection in the left side of your chest
cavity. The fluid has been removed by what's called a pigtail
catheter in the hospital with good improvement of your symtpoms.
You are now ready to return home. You will be prescribed a small
amount of pain medication to help with your pain. Please take
them exactly as prescribed and avoid driving and operating heavy
machinery within 6 hours of taking the pain medication.
You may shower starting tomorrow. THe dressing over your
catheter removal site is waterproof and you can let water run
over it. Please do not bath for at least 1 week. You may remove
the dressings in 2 days.
Please follow up in the thoracic surgery clinic and Pleural
clinic as shown below.
Please call us at ___ or go to the nearest emergency
department if you experience any of the following symptoms:
Shortness of breath
Pain with breathing
Coughing up blood
Wheezing
Fever greater than 101
Redness that is spreading
Pain not adequately relieved with medication
Drainage from wound
Opening of incision
Nausea and vomiting
Followup Instructions:
___
|
10172264-DS-17 | 10,172,264 | 25,992,198 | DS | 17 | 2117-05-29 00:00:00 | 2117-06-01 13:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / Calcium Channel Blocking Agents-Benzothiazepines /
Calcium Channel Blocking Agents-Dihydropyridines / Calcium
Channel Blocking Agents-Phenylalkylamines / Calcium Channel
Blocking-Diarylaminopropylamines
Attending: ___
Chief Complaint:
Right leg swelling
Major Surgical or Invasive Procedure:
Right calf muscle biopsy and fasciotomy
History of Present Illness:
___ year old female with recurrent right lower extremity swelling
and pain of unclear etiology. This pain has recurred about 5
times in the last few years, the first time ___ years ago. She was
admitted ___ with similar complaints and was seen by
Rheumatology who recommended MRI and biopsy, the patient
preferred to have workup as outpatient and was discharged home.
Her pain improved over the course of the next month and a repeat
MRI showed continued swelling and inflammation. Beginning four
days ago, her pain came on again and was unable to be relieved
by ice and NSAIDs. Attempts at obtaining an outpatient muscle
biopsy were unsuccessful, and patient was sent to the ED to be
admitted for muscle biopsy.
.
In the ED, initial vs were: 97.2 97 135/76 20 100%. Labs were
remarkable for a normal ESR and CK, and otherwise normal labs.
Right leg xray was unremarkable. Transfer vitals 98.9 °F (37.2
°C) (Oral), Pulse: 83, RR: 16, BP: 111/72, O2Sat: 99%.
.
On the floor, patient is feeling well. She has some mild pain,
particularly with walking on her R leg.
Past Medical History:
HTN
Social History:
___
Family History:
Mother - diabetes
No history of muscle disease or clots. No history of cancer.
Physical Exam:
GEN: AOx3, NAD
CV: RRR no murmurs
LUNGS: CTA b/l
ABD: soft, NT ND
EXT: R calf significantly swollen, mildly tender, slight pain
with passive motion of ankle, warm. L leg wnl. Good pulses
bilaterally
NEURO: no numbness in ___, strength intact
Pertinent Results:
___ 03:25PM BLOOD WBC-7.1 RBC-4.37 Hgb-12.5 Hct-35.5*
MCV-81* MCH-28.5 MCHC-35.1* RDW-16.0* Plt ___
___ 03:25PM BLOOD Neuts-49.6* Bands-0 ___ Monos-4.0
Eos-25.7* Baso-0.8
___ 03:25PM BLOOD Glucose-95 UreaN-11 Creat-1.0 Na-142
K-3.5 Cl-103 HCO3-29 AnGap-14
___ 03:25PM BLOOD CK(CPK)-112
___ 03:25PM BLOOD CRP-13.6*
___ MRI
Marked edema involving the right soleus muscle and medial head
of
the right gastrocnemius muscle with edema along the fascial
planes. These are similar to the findings from ___. On the ___ MRI, these findings had resolved.
The appearances are again nonspecific and could result from
muscles strain, infection, or other causes of myositis. Given
the patient's operating room findings of increased compartment
pressures, the edema could also be seen in the setting of
compartment syndrome.
Brief Hospital Course:
___ yo F with recurrent RLE pain, concerning for myositis. She is
readmitted with the same pain she experienced on previous
admission.
.
# Myositis
MRI performed showing edema in the calf again. Taken to the OR
by General Surgery service and underwent a muscle biopsy. Also
found to have elevated compartment pressures to 46, and
underwent a fasciotomy. Discharged same day as biopsy.
Instructed to elevate and wrap leg for 48 hours. Will followup
with local rheumatologist for further evaluation.
# Hypertension - continued Chlorthalidone 25 mg
Medications on Admission:
Chlorthalidone 25 mg
Ibuprofen 600 mg
Discharge Medications:
1. chlorthalidone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO
Q4H (every 4 hours) as needed for pain: do not drive while
taking this medication.
Disp:*10 Tablet(s)* Refills:*0*
3. ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Right leg swelling
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted to the hospital due to swelling in your right
leg and underwent a biopsy and small fasciotomy of your right
leg. You should follow up with your rheumatologists to discuss
the results.
Please keep leg wrapped for 48 hours. Elevate the leg while when
lying or sitting. Ambulate as tolerated. Can remove dressing
after 48 hours.
START Oxycodone-acetaminophen (percocet) for pain
Followup Instructions:
___
|
10172358-DS-6 | 10,172,358 | 22,629,909 | DS | 6 | 2129-12-24 00:00:00 | 2129-12-27 19:59:00 |
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:
___ F with recent EGD one month ago for gastric ulcer and
alcoholic hepatitis at OSH presents with ruq abd pain ongoing
for past month, no relation to food. She has had intermittent
diarrhea, nausea and occasional vomiting. She reports consuming
___ bottle of wine nightly, increasing with the deteriorating
health of her husband.
In the ED, she had negative RUQ u/s and CT that showed liver
capsule inflammation with elevated LFT's and lipase.
Past Medical History:
Gastric ulcers
h/o EtOH abuse c/b alc hepatitis
Social History:
___
Family History:
No cancer, no early MI
Physical Exam:
Vitals- 98.5 141/94 81 18 97%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,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, mild RUQ tenderness, no epigastric tenderness,
pos bowel sounds. non-distended, no rebound tenderness or
guarding, no organomegaly.
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
___ 01:39PM BLOOD WBC-5.3 RBC-4.59 Hgb-16.3* Hct-47.1
MCV-103* MCH-35.5* MCHC-34.5 RDW-13.6 Plt ___
___ 08:00AM BLOOD WBC-2.8* RBC-3.96* Hgb-14.1 Hct-42.8
MCV-108* MCH-35.7* MCHC-33.1 RDW-13.4 Plt ___
___ 08:20AM BLOOD WBC-3.0* RBC-3.89* Hgb-13.9 Hct-41.6
MCV-107* MCH-35.8* MCHC-33.5 RDW-13.8 Plt ___
___ 07:40AM BLOOD WBC-3.8* RBC-4.14* Hgb-14.6 Hct-44.1
MCV-107* MCH-35.4* MCHC-33.2 RDW-13.9 Plt ___
___ 07:07AM BLOOD ___ PTT-29.5 ___
___ 01:39PM BLOOD Glucose-136* UreaN-7 Creat-0.6 Na-138
K-3.7 Cl-96 HCO3-27 AnGap-19
___ 08:20AM BLOOD Glucose-122* UreaN-3* Creat-0.6 Na-140
K-3.3 Cl-106 HCO3-24 AnGap-13
___ 01:39PM BLOOD ALT-108* AST-207* AlkPhos-160*
TotBili-0.8
___ 07:07AM BLOOD ALT-89* AST-197* AlkPhos-121* TotBili-1.0
___ 08:00AM BLOOD ALT-86* AST-166* AlkPhos-121* TotBili-1.0
___ 08:20AM BLOOD ALT-74* AST-146* AlkPhos-124* TotBili-1.1
___ 07:40AM BLOOD ALT-72* AST-121* AlkPhos-131* TotBili-1.1
___ 01:39PM BLOOD Lipase-144*
___ 07:07AM BLOOD Calcium-8.4 Phos-4.4 Mg-1.9
___ 08:20AM BLOOD Vit___-___* Folate-7.7
___ 07:07AM BLOOD Triglyc-108
___ 07:07AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE IgM
HAV-NEGATIVE
___ 07:07AM BLOOD HCV Ab-NEGATIVE
MICRO
C. difficile DNA amplification assay-NEG; FECAL CULTURE-NEG;
CAMPYLOBACTER CULTURE- NEG
IMAGINING
RUQ U/S
1. Echogenic liver suggestive of hepatic steatosis. More
advanced forms of
liver disease including cirrhosis cannot be excluded on the
basis of
ultrasound.
2. Otherwise, unremarkable examination without evidence of
cholecystitis or
cholelithiasis.
CT ABD/PELVIS
FINDINGS: There is mild bibasilar atelectasis in the imaged
lung bases as
well as nonspecific patchy areas of ground glass density in the
left lung
base. The heart size is normal.
CT ABDOMEN: There are large geographic areas of hypodensity
within the liver
compatible with fatty infiltration. The gallbladder is
distended but
thin-walled and unremarkable without stones or pericholecystic
fluid or
stranding. The spleen, pancreas, and adrenal glands are
unremarkable in
appearance. Note is made of pancreatic divisum. No
peripancreatic
inflammation noted. The kidneys present symmetric nephrograms
without focal
solid or cystic lesions, pelvicaliceal dilatation or perinephric
abnormality.
The stomach, duodenum and remainder of the small bowel is
unremarkable in
appearance without evidence of obstruction. The large bowel is
unremarkable
in appearance. A normal appendix is visualized in the right mid
abdomen
(2:41).
The abdominal aorta is of normal caliber with patent celiac
axis, SMA,
bilateral renal arteries and ___. There are no enlarged
mesenteric or
retroperitoneal lymph nodes by CT size criteria. There is no
ascites,
pneumoperitoneum or hernia.
CT PELVIS: The bladder, rectum, and ovaries are unremarkable in
appearance.
There is mild thickening of the endometrium to 1 cm. There is
no free pelvic
fluid or air. There are no enlarged pelvic wall or inguinal
lymph nodes by CT
size criteria.
OSSEOUS STRUCTURES: There are no focal blastic or lytic lesions
in the
visualized osseous structures concerning for malignancy.
IMPRESSION:
1. Areas of focal fatty infiltration in the liver.
2. Nonspecific ground glass densities in the left lung base
could be
infectious or inflammatory.
3. Pancreatic divisum without CT evidence of pancreatitis.
4. Mildly thickened endometrium at 1 cm could be normal if the
patient is
premenopausal. Correlate clinically.
Brief Hospital Course:
This is a ___ year-old woman with h/o gastric ulcer presenting
with several months of RUQ/epigastric abdominal pain,
unintentional weight loss, and loose stool.
# Alcoholic hepatitis, with concomitant gastric ulcers, recently
both diagnosed: Most likely alcoholic hepatitis with capsule
distention given drinking history, ALT/AST ratio, macrocytosis,
and capsulitis. Other contributors include pancreatitis, peptic
ulcer disease (recent EGD pos for ulcers, cauterized, started
protonix and carafate which stopped taking, also admitted for
EtOH hepatitis). Hepatitis serologies neg, LFT's trended
downwards over the course of the admission. Pain controlled with
PO morphine and PPI. Patient tolerated solid food, discharged
with GI followup for EGD and endoscopic ultrasound of pancreas.
# Diarrhea: Now resolved. No BM since ___ night. Possibly
malabsorption due to pancreatitis vs. EtOH abuse. C diff
negative.
# EtOH Abuse: Patient reports increased consumption, concern for
minimizing intake. No withdrawal features this admission. Met
with social work and given resources for quitting and
maintaining abstinence, which was stressed with her over the
course of the admission. She did not previously have a PCP, and
we assisted her in arranging this, to expedite her planned
follow-up for her resolving alcoholic hepatitis and ulcer
disease.
TRANSITIONAL ISSUES:
- Started PPI
- We suggested that she may require further endoscopy if her
abdominal pain does not continue to resolve while she abstains
from alcohol and takes her acid blocking medicine.
- Recommended EtOH abstinence support.
- Will follow up with GI for EGD and EUS of pancreas, based on
outpatient evaluation of the need for these studies.
Medications on Admission:
None reported.
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 650 mg 1 tablet extended release(s) by mouth
every 6 hours as needed for pain Disp #*30 Tablet Refills:*0
2. Docusate Sodium (Liquid) 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet by mouth once daily Disp
#*30 Capsule Refills:*0
3. Morphine Sulfate ___ 15 mg PO Q6H:PRN pain
RX *morphine 15 mg 1 tablet extended release(s) by mouth once
every ___ hours only as needed for pain Disp #*8 Tablet
Refills:*0
4. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet,delayed release (___) by
mouth once daily Disp #*30 Tablet Refills:*0
5. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth once daily while
taking morphine Disp #*30 Tablet Refills:*0
6. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth once daily Disp
#*30 Tablet Refills:*0
7. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Alcoholic hepatitis
Alcoholic pancreatitis
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 participating in your care at ___
___.
You were admitted with abdominal pain that was caused by an
injury to your liver from drinking too much alcohol. You were
observed, your pain reduced, and it was determined that your
liver injury will resolve, but only if you stop drinking. You
met with a social worker who provided you with resources to quit
drinking. It is very important for your health that you quit.
You have some ulcers in your stomach that require omeprazole,
and this has been restarted for you as well. You will see a
gastroenterologist to address these ulcers, as well as to
examine your pancreas. Your pancreas has been injured by
alcohol, and may be responsible for your pain.
You have been provided an appointment with a primary care
physician who can help you to quit alcohol and stay healthy. You
should also avoid nonsteroidal antiinflammatory drugs like
ibuprofen, motrin, or alleve.
For pain, please take Tylenol, no more than 4,000 mg daily. You
are provided a short course of morphine. If your pain worsens,
call your primary care physsician.
You have some inflammation in your arm at the site of your IV.
Please place hot towel on the arm. If pain increases or you have
limited range of motion in the arm, call your primary care
physician.
Followup Instructions:
___
|
10172388-DS-17 | 10,172,388 | 26,694,448 | DS | 17 | 2180-02-14 00:00:00 | 2180-02-14 14:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
Abdominal pain, hemodynamically unstable
Major Surgical or Invasive Procedure:
emergent exploratory laparotomy and left salpingectomy
History of Present Illness:
Ms. ___ is a ___ yo G3P1011 who presented to ___ with
sudden-onset abdominal pain about 2.5 hours ago. She was
driving and had to pull over due to pain. she then presented to
___. On presentation to ___, ___ was positive and SBP was
80. Note, patient previously unaware of pregnancy. PIV x 2 was
placed and she was sent to ___ without further work-up. No
labs were sent.
In ___, VS notable for tachycardia to 120s, SBPs in ___ on
arrival. FAST scan was positive for intra-abdominal fluid and
patient was quite uncomfortable. Ultrasound was attempted and
abandoned due to patient discomfort. Two units of blood were
hung given VS abnormalities. She triggered on two occasions for
VS abnormalities during her first 30 minutes of arrival.
Past Medical History:
POBHx:
SAB x1 no comps
SVD x1
PGynHx: LMP ___. Regular menses. Denies history of
abnormal Paps or STIs.
PMH: Denies
PSH: LSC appy, breast reduction
Social History:
___
Family History:
Non-contributory.
Physical Exam:
In ___:
VS: Afeb ___ 118 comfortable on room air
Gen: NAD
Abd: Soft, +guarding, +rebound, maximal in RLQ
Speculum: Deferred
Bimanual: Deferred
Ext: NT, NE
Pertinent Results:
___ 01:24AM WBC-13.9* RBC-1.79* HGB-5.4* HCT-16.9* MCV-94
MCH-30.4 MCHC-32.3 RDW-13.4
___ 01:24AM PLT COUNT-195
___ 01:24AM HCG-1876
Brief Hospital Course:
Ms. ___ was taken emergently from the ___ to the OR for
exploratory laparotomy, evacuation of 2.5L hemoperitenuem, and
partial left salpingectomy. She was transfused 7 units of
PRBCs. Post-operatively she was stable and admitted to the
gynecology service. She remained hemodynamically stable with
stable labs. Her post-operative course was overall
uncomplicated. She was discharged home on POD 2.
Medications on Admission:
None
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
2. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
ruptured ectopic pregnancy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted for emergent surgery with a ruptured ectopic
(tubal pregnancy). You had extensive bleeding and were
transfused 7 units of packed red blood cells. Part of your left
fallopian tube was removed in order to remove the pregnancy.
Post-operatively you did well.
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* 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), no
heavy lifting of objects >10lbs for 6 weeks.
* You may eat a regular diet
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No bath tubs 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.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Call your doctor for:
* fever > 100.4
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
Followup Instructions:
___
|
10172505-DS-2 | 10,172,505 | 26,509,910 | DS | 2 | 2142-09-10 00:00:00 | 2142-09-10 11:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Polytrauma
Major Surgical or Invasive Procedure:
Left Medial Malleolus Fracture ORIF ___
History of Present Illness:
Ms. ___ is a ___ y/o female who presents s/p MVC in which
she was a restrained driver struck on the passenger side by an
oncoming car at ~30 mph, then ran head-on into a boulder. no
intrusion. No head strike or LOC. Was taken to ___
where she was found to have L3 compression fx, L ankle fx, R
foot
fx's, and was transferred to BI ED for further eval.
Past Medical History:
PMH:
THYROID NODULE
PSH:
Appendectomy
Wisdom teeth extraction
Hemorrhoidectomy
Basal cell carcinoma from lip
Social History:
___
Family History:
NC
Physical Exam:
Per medical record, in ED:
Vital Signs: 98.3 78 101/59 18 97%
Gen: NAD, A&O x 3, Calm and comfortable
Upper Extremities:
BUE skin clean and intact
Left dorsal hand ecchymoses but no tenderness
No other tenderness, deformity, erythema, edema, induration or
ecchymosis
Arms and forearm compartments soft
No pain with passive motion
SILT in the Axillary, Radial, Median, Ulnar nerve distributions
motor intact for EPL FPL EIP EDC FDP FDI
2+ radial pulses
Lower Extremities:
Pelvis stable to AP and lateral compression.
Left knee abrasion
BLE skin otherwise clean and intact
Right lateral foot ecchymoses, swelling, and tenderness
Left medial ankle ecchymoses, swelling, and tenderness
No other tenderness, deformity, erythema, edema, induration or
ecchymosis
Thighs and leg compartments soft
No pain with passive motion
Saphenous, Sural, Deep peroneal, Superficial peroneal SILT
___ FHS ___ TA Peroneals Fire
1+ ___ and DP pulses
Pertinent Results:
___ 02:05AM GLUCOSE-91 UREA N-14 CREAT-0.7 SODIUM-140
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-26 ANION GAP-13
___ 02:05AM estGFR-Using this
___ 02:05AM WBC-5.9 RBC-3.95* HGB-12.1 HCT-37.2 MCV-94
MCH-30.7 MCHC-32.6 RDW-12.8
___ 02:05AM NEUTS-74.0* ___ MONOS-4.9 EOS-0.2
BASOS-0.8
___ 02:05AM PLT COUNT-177
___ 02:05AM ___ PTT-28.1 ___
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have an ankle fracture and spine fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF L medial malleolus fracture,
which the patient tolerated well (for full details please see
the separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after 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 perioperative antibiotics and anticoagulation
per routine. The patients 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 was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is:
- RLE: WBAT in ACB for transfers only, otherwise TDWB in ACB.
Must sleep with Right ACB.
- LLE: WBAT in strirrup splint at all times. ___ take off to
sleep.
- TLSO brace for L3 compression fx
The patient will be discharged on Lovenox for DVT prophylaxis.
The patient will follow up in two weeks per routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course, and all questions were answered
prior to discharge.
Medications on Admission:
Meds:
CALCIUM - Dosage uncertain - (Prescribed by Other Provider)
LACTOBACILLUS COMBINATION NO.4 [PROBIOTIC] - Dosage uncertain -
(Prescribed by Other Provider)
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC DAILY Duration: 2 Weeks
Start: Today - ___, First Dose: Next Routine Administration
Time
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4-6 hours Disp #*70
Tablet Refills:*0
5. Senna 8.6 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L3 compression fx, L ankle medial
malleolus fracture, and R foot ___ metatarsal fractures
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:
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:
- 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.
ACTIVITY AND WEIGHT BEARING:
- RLE: WBAT in ACB for transfers only, otherwise TDWB in ACB.
Must sleep with Right ACB.
- LLE: WBAT in air splint at all times. ___ take off to sleep.
- TLSO brace for L3 compression fx
Physical Therapy:
- RLE: WBAT in ACB for transfers only, otherwise TDWB in ACB.
Must sleep with Right ACB.
- LLE: WBAT in air splint at all times. ___ take off to sleep.
- TLSO brace for L3 compression fx
Treatments Frequency:
Dry sterile dressing to surgical wound, change daily.
Followup Instructions:
___
|
10173480-DS-6 | 10,173,480 | 21,165,338 | DS | 6 | 2200-09-25 00:00:00 | 2200-09-25 16:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Prochlorperazine
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
___ w/ hx of HL who presents w/ chest pain which started ___
around 11am. Developed deep left sided chest pain radiating up
jaw, with left arm numbness. Had short-lived dyspnea as well as
diaphoresis at the time. No nausea. This recurred on the drive
to the ED, but resolved after nitro in the ED and by about 4pm
on ___ was completely resolved. No leg swelling, blood clots,
surgeries, long plane rides.
In the ED, initial vitals: ___ 75 127/76 16 98% at noon
on ___ pt has remained in ED for rule out MI since that time.
Labs were significant for trop neg x2, last at 18:30 on ___.
Other labs were wnl. CXR was normal. ETT was concerning for
ischemic changes with ST depressions in inferolateral leads.
Vitals prior to transfer: 97.7 79 135/73 20 96% RA.
Currently, pt is chest pain free and has no complaints.
Past Medical History:
-HLD
-DEPRESSION
-ANAL FISSURE
Social History:
___
Family History:
Mother died from MI at age ___ uncle underwent CABG; grandfather
had MI x3 and died in ___.
Physical Exam:
ADMISSION EXAM
Vitals- 98.7 135/85 71 18 96% 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
DISCHARGE EXAM
Vitals- 98.7 135/85 71 18 96% 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
Pertinent Results:
ADMISSION LABS
___ 06:20PM cTropnT-<0.01
___ 12:45PM GLUCOSE-95 UREA N-15 CREAT-0.8 SODIUM-142
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-26 ANION GAP-17
___ 12:45PM cTropnT-<0.01
___ 12:45PM CALCIUM-10.2 PHOSPHATE-3.4 MAGNESIUM-2.0
___ 12:45PM WBC-7.4 RBC-4.39 HGB-13.5 HCT-37.7 MCV-86
MCH-30.7 MCHC-35.8* RDW-14.1
___ 12:45PM NEUTS-65.7 ___ MONOS-4.7 EOS-2.8
BASOS-0.4
___ 12:45PM PLT COUNT-206
___ 12:45PM ___ PTT-30.8 ___
DISCHARGE LABS
___ 11:15AM BLOOD WBC-6.0 RBC-4.30 Hgb-12.7 Hct-37.0 MCV-86
MCH-29.6 MCHC-34.4 RDW-14.5 Plt ___
___ 11:15AM BLOOD Plt ___
___ 11:15AM BLOOD Glucose-113* UreaN-14 Creat-0.8 Na-140
K-4.2 Cl-103 HCO3-27 AnGap-14
___ 11:15AM BLOOD Calcium-9.4 Phos-3.8 Mg-2.0
IMAGING
ETT ___
INTERPRETATION: This ___ year old woman with h/o HLD and family
h/o
CAD was referred to the lab for evaluation of chest pain and
left arm
discomfort. The patient exercised for 6.0 minutes of ___
protocol
(~ ___ METS), representing an average exercise tolerance for her
age. The
test was stopped due to fatigue and dyspnea. Prior to exercise,
the
patient noted left hand tingling, unchanging throughout the
study. No
other chest, neck, back, or arm discomforts were reported by the
patient
throughout the study. At peak exercise, there was 0.5-1.5 mm of
horizontal ST segment depression in the inferolateral leads,
returning to baseline by minute 12 of recovery. The rhythm was
sinus
with frequent, isolated APBs during early exercise/early
recovery.
Appropriate blood pressure and heart rate responses to exercise.
IMPRESSION: Average functional exercise capacity. Non-anginal
type
symptoms in the presence of ischemic EKG changes to achieved
workload.
Normal hemodynamic response to exercise.
CARDIAC CATHETERIZATION ___
Coronary angiography: right dominant and normal
LV: Normal wall motion with EF 65% and no mitral regurgitation
Assessment & Recommendations
1.Normal coronary arteries.
2.Normal systolic LV function.
Brief Hospital Course:
___ woman with h/o HLD presenting with chest pain with left arm
numbness and changes on ETT concerning for ischemia in the
inferolateral distribution, cath shows normal coronary arteries
and normal LV systolic function.
ACTIVE ISSUES
#Chest pain: Cardiac enzymes negative in ED but ETT concerning
for inferolateral ischemia, so admitted for cath. Pain resolved
and pt asymptomatic by the time of admission. Cath negative for
obstructive coronary artery disease. Resting EKG without
changes. Given transient nature of pain, unlikely to be a
serious continuing process such as PE, dissection. Patient
discharged home with plan to follow up with PCP.
CHRONIC ISSUES
# HLD: continued home simvastatin.
TRANSITIONAL ISSUES
None.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 100 mg PO DAILY
2. Simvastatin 40 mg PO QPM
Discharge Medications:
1. Sertraline 100 mg PO DAILY
2. Simvastatin 40 mg PO QPM
3. Aspirin 81 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
1. Atypical chest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
It was a pleasure taking care of you while you were admitted at
___. You were admitted due to chest pain with a concerning
stress test. However, you had a cardiac catheterization which
showed that you do not have coronary artery disease, and your
heart function looks normal.
You should follow up with your primary doctor regarding the
numbness in your fingers; we suspect this is related to
something called a peripheral neuropathy.
You should start taking 81mg aspirin daily for prevention
purposes. This prevents stroke in women.
Followup Instructions:
___
|
10173672-DS-23 | 10,173,672 | 21,851,308 | DS | 23 | 2151-10-11 00:00:00 | 2151-10-13 23:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Nifedipine / Corgard / IV Dye, Iodine Containing /
Hydrochlorothiazide / amlodipine / lisinopril / cilostazol
Attending: ___.
Chief Complaint:
hypertensive urgency
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old woman with hypertension, CKD (stage ___, and DM2
who presented to her primary care physician's office for routine
evaluation today. She was found to have SBP >200 and possible
EKG changes. She was asymptomatic at that time. PCP was
concerned about adjustment and titration of medications as
outpatient as well as medication non-compliance so she was sent
to ED for admission. In the ED the patient was not symptomatic.
Her EKG changes did not meet criteria for STEMI and trp neg. She
does report approximately 2 months of mild dyspnea on exertion
that she noticed when doing things like lifting heavy objects,
but not when walking for long periods of time.
She denies complaint of chest pain, nausea or vomiting,
diaphoresis, or any dyspnea at rest. She denies orthopnea, PND,
leg swelling or pain. She denies cough or fever. Denies
hematuria. Denies headache, new back pain, visual changes.
In the ED, initial vitals were:
T 97.0, HR 88, BP 215/110, RR 16, O2 100% RA
ranged from: BP 188-220/96-108, HR 70-80, RR ___, O2 100% RA
Exam otherwise notable for lungs CTAB, no JVD ___ edema.
Labs notable for proBNP 3118, Trop-T < 0.01, Cr 1.7, BUN 33. CBC
wnl.
Imaging notable for:
chest radiograph (PA & lat) ___ 12:10 ___ - negative for
acute cardiopulmonary process.
Patient was given:
___ 11:33 PO Aspirin 243 mg
___ 11:33 TP Nitroglycerin Ointment 2%
___ 15:58 PO Metoprolol Tartrate 100 mg
___ 18:08 TP Nitroglycerin Ointment 2%
Decision was made to admit for hypertensive urgency.
On the floor, patient remains asymptomatic. She corroborates the
above story and reports feeling in her usual state of health.
She denies SOB, chest pain, changes in vision, changes in
urinary habits. She does report some weight loss and decreased
appetite since having her knee replacement last ___. She
reports full compliance with anti-HTN medications, but is unable
to tell me what medications she takes.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough. 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:
Hypertension
Hyperlipidemia
Asthma
osteoarthritis knee and hip,
DM 2
Obesity
Chronic low back pain
OSA
?___
Social History:
___
Family History:
She reports that her mother had heart disease of unclear
etiology. Two brothers had a heart attack, one of the two died
at age ___ from complications of heart surgery. Her son also had
a heart attack at age ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
VS: 97.9 198/77 70 18 98 RA
Gen: resting comfortably in bed, NAD
HEENT: NC/AT
CV: RRR, normal S1/S2, no M/R/G
Pulm: CTAB on anterior auscultation
Abd: soft, obese, NT, ND
GU: no foley
Ext: WWP, trace ankle edema
Skin: no rashes
Neuro: alert, oriented, moves all extremities w/ purpose
Psych: euthymic affect
DISCHARGE PHYSICAL EXAM:
========================
VS: 97.9 PO 172/76 (SBP 130s-180s) 65 18 99 RA
HEENT: NC/AT
CV: RRR, normal S1/S2, no M/R/G
Pulm: CTAB on anterior auscultation
Abd: soft, obese, NT, ND
Ext: WWP, trace ankle edema
Skin: no rashes
Neuro: alert, oriented, moves all extremities w/ purpose
Psych: affect euthymic
Pertinent Results:
ADMISSION LABS:
==============
___ 11:05AM GLUCOSE-140* UREA N-33* CREAT-1.7* SODIUM-140
POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-24 ANION GAP-21*
___ 11:05AM estGFR-Using this
___ 11:05AM cTropnT-<0.01 proBNP-3118*
___ 11:05AM WBC-8.1 RBC-4.51 HGB-13.3 HCT-40.4 MCV-90
MCH-29.5 MCHC-32.9 RDW-12.6 RDWSD-41.1
___ 11:05AM NEUTS-55.1 ___ MONOS-7.9 EOS-2.3
BASOS-0.7 IM ___ AbsNeut-4.45# AbsLymp-2.72 AbsMono-0.64
AbsEos-0.19 AbsBaso-0.06
___ 11:05AM PLT COUNT-285
DISCHARGE LABS:
===============
___ 06:35AM BLOOD WBC-6.1 RBC-3.97 Hgb-11.1* Hct-35.6
MCV-90 MCH-28.0 MCHC-31.2* RDW-12.2 RDWSD-40.4 Plt ___
___ 06:35AM BLOOD Glucose-134* UreaN-38* Creat-1.8* Na-139
K-4.1 Cl-100 HCO3-26 AnGap-17
___ 06:35AM BLOOD Calcium-9.0 Phos-4.0 Mg-1.8
___ 06:35AM BLOOD %HbA1c-6.7* eAG-146*
IMAGING/STUDIES:
================
#ECHO ___
The left atrium is normal in size. The estimated right atrial
pressure is ___ mmHg. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with basal to mid inferor and basal inferoseptal
hypokinesis. 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 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 no pericardial
effusion.
IMPRESSION:
1) Moderate left ventricular hypertrophy with mild regional LV
systolic dysfunction in the distribution of the RCA. However,
the regional wall motion may be abnormal due to significant
hypertrophy in these myocardial segements.
2) Grade II diastolic dysfunction with elevated LVEDP. RV
afterload could not be measured.
Compared with the prior study (images reviewed) of ___,
findings are likely similar (image qualilty of prior study very
poor). The basal to mid inferior wall is mildly less contractile
on the current study
#EKG:
Sinus rhythm. Baseline artifact. Left ventricular hypertrophy.
Lateral
ST segment depressions with T wave inversions. Changes could be
consistent
with ischemia, although repolarization changes are associated
with hypertrophy cannot be excluded. Compared to the previous
tracing of ___ the ST segment changes and T wave inversions
are more pronounced across the precordium and the presence of
premature ventricular contractions are no longer seen. Other
findings are similar.
Brief Hospital Course:
___ with h/o HTN, CKD stage ___, HLD, DM2, OSA and asthma
presents from her PCP's office with asymptomatic hypertensive
urgency (SBP 215) and ST depression vs early repolarization
associated w/ LVH.
#Hypertensive Urgency v. Emergency
Patient presents with SBP >180 w/ proBNP 3118 on admission,
though w/o signs of volume overload. No prior proBNP to compare.
Trops x2 neg. Echo showed Grade II diastolic dysfunction with
elevated LVEDP, EF 50% w/ moderate left ventricular hypertrophy,
and mild regional LV systolic dysfunction in the distribution of
the RCA. Unclear if these are new changes vs poor windows on
prior TTE in ___.
Patient reports full compliance with all blood pressure
medications. However, investigation into her pharmacy records
revealed she was not filled clonidine or metoprolol. Patient was
enrolled in PACT program and anti-hypertensive medications,
amlodipine 10 mg and losartan 100 mg, were started. She was
discharged on metoprolol succinate XL 100 mg qday and
spironolactone 12.5 mg qday, after weighing the risks of
hyperkalemia with the benefits of BP reduction and to minimize
the more frequently administered medications such as clonidine
and hydralazine. Her BPs were 150-170s over last 24 hrs prior to
dc. She will have close PCP to monitor electrolytes, renal
function iso of starting spironolactone. This regimen was
reviewed with her nephrologist prior to discharge and close
follow up was arranged.
- Please repeat chemistries on follow up to assess potassium and
renal function
CHRONIC ISSUES:
==========================
#DM2 controlled
Per pharmacy records patient has not filled any of her diabetic
medication (Novolog, metformin, glimepiride). She reports this
is because she is managing her sugars with diet. Her A1c here is
6.7 and her BG ranged from 100-200. We did not resume her DM2
medications on discharge ___ seemingly appropriate control w/
lifestyle.
#Asthma: continued home regimen.
#OSA: used CPAP for sleep.
#CKD stage ___
She had a mild ___ over admission, Cr 1.8 on DC, mildly above
baseline. Recommend continued nephrology ___ as outpatient.
___ (___): continued on aspirin, clopidogrel and statin.
#HLD: continued home statin.
TRANSITIONAL ISSUES:
====================
# MEDICATION CHANGES: Metoprolol Tartrate 50 mg PO BID changed
to metoprolol succinate XL 100mg daily
# STOPPED MEDICATIONS: clonidine .3 mg TID, MetFORMIN
(Glucophage) 500 mg PO BID, glimepiride 1 mg oral DAILY
# NEW MEDICATIONS: Spironolactone 12.5 mg daily
[] Please continue ongoing titration of blood pressure
medications, has outpt ___ with PCP and ___
[] Ensure compliance with medications and availability of
resources
[] Consider stress test as outpatient for possible stable angina
and potentially new WMA and diastolic dysfunction
[] Please check basic metabolic panel at PCP ___ within ___ of
DC to ensure no hyperkalemia as started on low dose Aldactone
[] If c/f CAD, could consider high intensity statin
[] Please consider resuming metformin vs. glimepiride as
outpatient pending BG monitoring. A1c 6.7 here.
# DISCHARGE Cr: 1.8
# CODE: full
# CONTACT: ___daughter) - ___
# DISCHARGE WEIGHT: 83 kg
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4-6HR:PRN
2. amLODIPine 10 mg PO DAILY
3. Qvar (beclomethasone dipropionate) 80 mcg/actuation
inhalation BID
4. Calcitriol 0.25 mcg PO 2X/WEEK (MO,TH)
5. CloNIDine .3 mg PO BID
6. Clopidogrel 75 mg PO DAILY
7. Dorzolamide 2% Ophth. Soln. 1 DROP LEFT EYE BID
8. Estrace (estradiol) 0.01 % (0.1 mg/gram) vaginal 2X/WEEK
9. glimepiride 1 mg oral DAILY
10. Losartan Potassium 100 mg PO DAILY
11. MetFORMIN (Glucophage) 500 mg PO BID
12. Metoprolol Tartrate 50 mg PO BID
13. Oxybutynin 2.5 mg PO Q6H:PRN urinary incont
14. oxybutynin chloride 10 mg oral QPM
15. Pravastatin 20 mg PO QPM
16. Torsemide 40 mg PO DAILY
17. TraMADol 50 mg PO Q8H
18. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
2. Spironolactone 12.5 mg PO DAILY
RX *spironolactone 25 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*15 Tablet Refills:*0
3. amLODIPine 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Calcitriol 0.25 mcg PO 2X/WEEK (MO,TH)
6. Clopidogrel 75 mg PO DAILY
7. Dorzolamide 2% Ophth. Soln. 1 DROP LEFT EYE BID
8. Estrace (estradiol) 0.01 % (0.1 mg/gram) vaginal 2X/WEEK
9. Losartan Potassium 100 mg PO DAILY
10. oxybutynin chloride 10 mg oral QPM
11. Oxybutynin 2.5 mg PO Q6H:PRN urinary incont
12. Pravastatin 20 mg PO QPM
13. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4-6HR:PRN
14. Qvar (beclomethasone dipropionate) 80 mcg/actuation
inhalation BID
15. Torsemide 40 mg PO DAILY
16. TraMADol 50 mg PO Q8H
17. HELD- CloNIDine .3 mg PO BID This medication was held. Do
not restart CloNIDine until your PCP tells you to take it.
18. HELD- glimepiride 1 mg oral DAILY This medication was held.
Do not restart glimepiride until told to do so by your PCP.
19. HELD- MetFORMIN (Glucophage) 500 mg PO BID This medication
was held. Do not restart MetFORMIN (Glucophage) until told to do
so by your PCP
___:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Hypertensive Urgency
Heart Failure with Preserved Ejection Fraction
SECONDARY DIAGNOSIS:
Chronic kidney disease
DM2
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:
Ms. ___,
You were in the hospital because your blood pressure was very
high. We did blood work which showed you did not have a heart
attack.
We adjusted some of your home medications for blood pressure and
set you up with a pharmacy team who will check in on your once
you go home.
Please take your medications exactly as prescribed in this
worksheet. We are working to schedule appointments with your
doctors. ___ call a doctor if you experience any of the
danger signs/warnings in this paperwork. Please check your
weights daily and call your doctor if your weight increases more
than 5 lbs, as you were newly diagnosed with heart failure over
this admission.
It was a pleasure being involved in your care.
- Your ___ Team
Followup Instructions:
___
|
10173851-DS-2 | 10,173,851 | 24,747,618 | DS | 2 | 2174-07-15 00:00:00 | 2174-07-15 17:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Prilosec
Attending: ___.
Chief Complaint:
Fever of unknown origin
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old Male brought in for severe fevers of unknown origin.
Patient is a previously healthy male who presents with 2 weeks
of fevers and myalgias. The patient apparently went to ___ a
week prior to admission, where he presented with a fever to 106.
He was started on doxycycline for presumed lyme disease, got IV
fluids and ultimately was discharged. The patient reports one
week of anorexia, nausea, diarrhea, along with 3 days of
non-productive cough and some mild abdominal pain. The patient
came to the ___ today and while walking from the garage
was apparently too weak to continue so EMS transported him to
the ED.
Looking at his ___ ED notes, on ___ he was described as having
a maculopapular rash. On that exam his knees are tender on
lateral palpation bilaterally
Initial vitals in the ___ ED were 103.9, 115, 122/86, 16, 99%.
He was given 2L of IV fluids, ondansetron, Tylenol and
ketorolac. With improvement in his fever curve. He underwent a
chest x-ray and CT abd/pelvis which were non-revealing for
cause.
Past Medical History:
No Past Medical History
Social History:
___
Family History:
Mother: healthy
Father: healthy
Grandmother: ___ CA
Physical Exam:
ADMISSION PHYSICAL EXAM:
VSS: 101.1, 101/66, 92, 18, 99%
GEN: NAD
Pain: ___
HEENT: anicteric, non-injected, PERRLA EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, I/VI HSM, wide split S2
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: CAOx3, Motor: ___ ___ Spread Flex/Ext
DISCHARGE PHYSICAL EXAM
Gen: NAD
HEENT: no icterus, PERRL, OP clear without erythema or lesions
Neck: mild tender anterior cervical lymphagenopathy, no
posterior cervical adenopathy
Chest: CTAB, normal WOB
Cards: RR, no m/r/g
Abd: S, ND, NT, BS+
MSK: right elbow with limited aROM due to pain and is tender to
palpation between the olecranon and the medial epicondyle
without palpable effusion, without erythema, without warmth,
without induration or other overlying skin changes; other joints
with normal aROM/pROM
Neuro: AAOx4, clear speech, conversant, tongue is midline, face
symmetric, has some lateral strabismus of right eye, otherwise
EOMI
Skin: no rashes appreciated on face, chest, abdomen, back, and
legs
Pertinent Results:
=================================
PERTINENT DATA
WBC 8->6->8->10->13->13
Hgb 11.7-12.9, MCV ___, RDW ___
Plts 200s-300s
INR 1.6->1.4->1.3->1.2
Fibrinogen 300s-400s
BMPs wnl
ALT 28->134->236->166->110
AST 80->241->275->112->60
Alk Phos 80->117->138->134->121
TB 0.4-0.6
___ ___
LDH 1015->1151
Trig 141
TSH 1.8
Parasite smear + for anaplasma in neutrophils
Anaplasma and babesia PCR negative
Hep B nonimmune, hep A neg, Hep C serology neg, HIV neg
CMV serology neg
GC/CT neg from throat and urine
Lyme neg
___, ANCA, ___, RF neg
RPR-prozone neg
Strongyloides Ab neg
Quant gold neg
Parvo
Stool culture neg
EBV IgG + IgM -
PENDING STUDIES: O&P pending, soluble IL2 receptor, anaplasma
serology, CMV and HSV PCR, hep C viral load
___ records:
Erlichia, Babesia, and Lyme negative
CT A/P ___. No focal abnormalities identified within the abdomen or
pelvis
to correlate
with patient's symptoms.
2. Diverticulosis without diverticulitis.
CT chest ___
Mildly prominent bilateral axillary lymph nodes, likely
reactive;
otherwise
unremarkable study of the chest.
RUQUS ___
IMPRESSION:
No acute sonographic findings. Stable left simple renal cyst.
Echogenic liver consistent with steatosis. Other forms of liver
disease and more advanced liver disease including
steatohepatitis
or significant hepatic fibrosis/cirrhosis cannot be excluded on
this study.
=================================
Brief Hospital Course:
___ year old previously healthy man who initially presented to
___ on ___ with fevers, arthralgias, and maculopapular rash,
started empirically on doxycycline (although 'tick panel' sent
at ___ ultimately returned negative), who presented to ___ on
___ with persistent fevers to 102-103 range despite 9 days of
doxycycline, anorexia, and weight loss, found to have ferritin
of 37,000 and +anaplasma on blood smear. He defervesced early in
his admission and once anaplasma was discovered doxy was
restarted on ___. He had initially presented with mild isolated
AST elevation (also seen at ___) but subsequently developed
transaminase to 200s and alk phos elevation that peaked ___ and
then improved. Also developed worsening leukocytosis that peaked
at 13.3 on ___ and was 13.0 on ___.
Ultimately it remained uncertain whether or not anaplasma
infection was the only process causing his constellation of
findings. Rash is not typically seen in anaplasma, ferritin is
not typically so high, and his very slow response to doxycycline
as well as late developing findings such as LFT surge,
leukocytosis, and persistent myalgias and borderline fever would
not be expected ~2 weeks into therapy. It is possible that he
experienced a secondary inflammatory process due to the
anaplasma or that the anaplasma was a red herring. Stills and
HLH were considered, but neither felt to be likely. It is
conceivable that he had HLH-like inflammation but not severe
enough to meet criteria for HLH. Soluble IL-2 receptor and
several other studies pending at discharge. One other
consideration would ___ Syndrome, which usually presents
with fevers, arthralgias (particularly with ankle involvement in
men), hilar adenopathy, and erythema nodosum. He did not present
with all of those findings, but did present with some of them
(fever, polyarthralgia involving ankles, and ?EN--reported
maculopapular rash on admission, but not reported on any exam
here at ___, so it would be something to consider if his
symptoms continue to smolder despite resolution of anaplasmosis.
He will follow-up next week in infectious disease and also has
an establish care appointment in primary care at ___. He will
likely follow-up in ___ clinic as well. He will take
doxycycline through ___ to complete a total of 14 days of
therapy per the ID team recommendations. He has close follow-up
scheduled in ___ clinic on ___.
Of note, anaplasma PCR was negative, but the pathologist who
read the smear felt that the findings on smear were sufficiently
specific to make the diagnosis. Anaplasma PCR is only a
moderately sensitive test, particularly given the patient had
already been on appropriate therapy for over a week by the time
the PCR specimen was obtained.
Problem list:
#Anaplasmosis
#Fevers - improving
#Nausea - improved
#Weight loss
#Transaminitis - improving
#Myalgias - improving
#Polyarthralgias (migratory) - improving (b/l ankle pain has
resolved), though currently with right elbow pain
#Leukocytosis - stable
#Suspected hepatic steatosis
#Coagulopathy (INR elevation) - improving
#Severe ferritin elevation - improving
===================================
TRANSITIONAL ISSUES:
- ID appointment on ___ at 10:00 AM
- New PCP appointment on ___ at 2:40 ___
- Pending studies at discharge: stool O&P pending; serum soluble
IL2 receptor, anaplasma serology, CMV and HSV PCRs, hep C viral
load,
- recheck CBC, BMP, LFT, ferritin as outpatient at either ___
or ___ f/u appointment
- restarted doxycycline ___ (had been treated ___, plan
for treatment through ___ for total 14 days
- outpatient RUQUS after recovery from illness given ?steatosis
- will need outpatient vaccination for hepatitis B
===================================
Time in care:
[x] Greater than 30 minutes in discharge-related activities
today.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate
2. Doxycycline Hyclate 100 mg PO Q12H
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q8H:PRN Pain
2. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*3 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
# Anaplasmosis
# Elevated transaminases
# Leukocytosis
# Extreme elevation of ferritin
# Fevers
# Myalgias
# Arthralgias (migratory polyarthralgia)
# Coagulopathy
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 fevers, chills, nausea,
and weight loss. We sent many lab tests in an attempt to
diagnose the cause of your symptoms. We found evidence of an
infection called anaplasmosis, a tick-borne illness. At this
time we suspect this may be the cause of all of your symptoms.
However, anaplasmosis usually improves more quickly, and so we
are still considering the possibility that there could be
another process occurring, such as an inflammatory process
brought on by the anaplasma but which has continued despite
effective treatment. At this point most of your labs and
symptoms are improving, so it is safe to return home and
follow-up in clinic this week as noted below. Should you have
worsening symptoms or fever persistently > 101, please call Dr.
___ office to discuss or return to the ___ ED to be
evaluated.
Please plan to take the antibiotics (doxycycline) through ___.
Please plan to see Dr. ___ in ___ ___ Disease
clinic at your scheduled appointment on ___ at 10:00 AM.
Please plan to establish care with your new primary care
physician, ___, at your scheduled appointment on
___ @ 2:40 ___.
Followup Instructions:
___
|
10174363-DS-18 | 10,174,363 | 20,224,039 | DS | 18 | 2120-02-27 00:00:00 | 2120-02-27 23:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodine / Hibiclens / Levaquin / Flagyl
Attending: ___.
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
flexible sigmoidoscopy
History of Present Illness:
Ms. ___ is a ___ yo F with history of recurrent episodes of
diverticulitis who is admitted with syncopal episode followed by
episode of BRBPR and diarrhea. For the syncope, she reports
that she remembers she fainted while walking INTO the bathroom.
She did have loss of consciousness and thinks that she hit her
left shoulder and possibly her right cheek since this is red.
She denied having any warning that this was going to happen,
including no strange smells, no sense of doom, no vision
changes, no palpitations, no chest pain or shortness of breath
or sweating or clamminess. This has happened to her twice
before, most recently in ___. Work-up had determined that
the cause of other episodes were low blood pressure and her
diovan and carvedilol were discontinued then. She was placed on
florinef.
For the BRBPR, she reports LLQ abdominal pain x1 month. She was
being treated as outpatient for diverticulitis with antibiotics
(doesn't remember their names) with improvement in the pain but
she finished these about 2 weeks ago and the pain has returned.
Today was the first episode of BRBPR. She noticed it on the
toilet paper and maybe also in the water of the toilet but she
is not sure on that. She has only had one bowel movement today
and no more bloody either since this morning.
She initially presented to ___ where rectal exam there is
recorded as blood, with labs there showing hematocrit 40, with
WBC 15. INR 1.6. CT non-con (allergy to contrast) from OSH
showing diverticulitis without perforation.
In the ED, she had repeat rectal exam with fresh blood. She
recieved pip/tazo prior to transport.
Past Medical History:
PMH: CAD with MI ___, cardiac cath ___: complete occlusion
of the LAD (EF 42%)
hypercholesterolemia
Raynaud disease
hypothyroidism
? intraventricular thrombus
carotid artery occlusion s/p R CEA, on warfarin
breast cancer ___ s/p lumpectomy on anastrazole
h/o several melanomas s/p excisions
early Alzheimer's
reflux
anemia due to B12 deficiency
s/p bilateral TKAs in the ___
Social History:
___
Family History:
Family history is notable for a mother who died from pancreatic
cancer. Her father has extensive coronary artery disease, and
her brother also had extensive coronary artery disease and has
had a prior carotid endarterectomy.
Physical Exam:
ADMISSION
98.5, 140/63, 85, 18, 98% RA
GEN: NAD, resting comfortably in bed, no conjunctival pallor
HEENT: moist oropharynx, no LAD
LUNG: CTA B, no rales or wheezes
CV: RRR, no murmurs, rubs, gallops
Abdomen soft, tender to palpation in the left lower quadrant
without rebound or guarding, no hepatosplenomegaly
EXT: no edema
NEURO: alert and oriented x 3, no focal deficits, gait deferred
Pertinent Results:
___ 01:25PM BLOOD WBC-13.5*# RBC-4.27# Hgb-12.3# Hct-38.5#
MCV-90 MCH-28.9 MCHC-32.0 RDW-13.8 Plt ___
___ 01:25PM BLOOD Neuts-94.3* Lymphs-2.2* Monos-2.5 Eos-0.9
Baso-0.1
___ 01:25PM BLOOD ___ PTT-29.4 ___
___ 01:25PM BLOOD Glucose-139* UreaN-16 Creat-0.9 Na-135
K-4.1 Cl-101 HCO3-20* AnGap-18
___ 02:41PM BLOOD Lactate-3.1*
___ CT abd/pelvis without contrast from ___:
. LEFT COLONIC WALL THICKENING. NO ABSCESS IS IDENTIFIED. WITH
THE
PATIENT APPARENTLY HAVING A HISTORY OF DIFFUSE VASCULAR
DISEASE THE
DISTRIBUTION OF THIS PROCESS FROM THE DISTAL TRANSVERSE
COLON THROUGH
THE DISTAL DESCENDING COLON WOULD SUGGEST THE POSSIBILITY
OF A
VASCULAR ETIOLOGY. THE FINDINGS ARE NOT CLASSIC FOR
DIVERTICULITIS.
___ CT head non-contrast:
There is no acute intracranial hemorrhage, or acute
transcortical infarction. There is no midline shift or mass
effect. Ventricles and sulci are age appropriate. No fracture.
IMPRESSION: NO POST TRAUMATIC HEMORRHAGE OR OTHER ACUTE
ABNORMALITIES.
___ CT C spine:
FINDINGS: There is no loss of vertebral body height or
malalignment. There is a periodontoid calcified soft tissue.
Multilevel degenerative changes.
IMPRESSION: NO ACUTE FRACTURE OR MALALIGNMENT. MULTILEVEL
DEGENERATIVE CHANGES. THERE IS MILD SCARRING AT THE LUNG APICES.
DILATION OF THE ESOPHAGUS COULD BE RELATED TO REFLUX DISEASE.
.
carotid doppler
IMPRESSION:
1. CENTRAL OCCLUSION OF THE RIGHT COMMON CAROTID ARTERIES.
2 APPROXIMATELY 60% STENOSIS OF THE LEFT ICA. ELEVATED LEFT ICA
VELOCITIES ARE
DUE IN PART TO COMPENSATION FOR THE OCCLUDED RIGHT COMMON
CAROTID ___
Brief Hospital Course:
Ms. ___ is a ___ yo F with h/o recurrent abdominal pain who
presents with a syncopal event and bright red blood per rectum.
.
# Syncope: ?related to symptomatic carotid disease vs. vasovagal
vs. orthostasis. CT head was negative for intracranial bleed.
Telemetry did not reveal arrhythmia. HCT remained stable.
Carotid disease by u/s did not appear significantly changed
since ___. No further events occurred during admission. Could
have been due to orthostasis at home. Event preceeded brbpr. Pt
wlll f/u with vascular surgery upon discharge. Considered
whether recurrent syncope could be leading to recurrent ischemic
colitis (see below).
.
# Bright red blood per rectum, likely ischemic colitis with h.o
recurrent abdominal pain presumed in outpt setting to be due to
diverticulitis-pt with h.o recurrent lower abdominal pain. Has
been awhile since last colonoscopy. Pt presented with brbpr and
pain after syncopal episode. Likely ischemic colitis per CT from
___. Stool studies unrevealing. Pt had 2 episodes of
slightly bloody stool. HCT remained stable. She was started on
IV unasyn for colitis and converted to PO augmentin upon
discharge to continue for a 7 day course of antibiotic therapy.
The GI service was consulted given her reports of recurrent
lower abdominal and LLQ crampy pain in the setting of GI
bleeding. Flexible sigmoidoscopy revealed diverticulosis but no
evidence of colitis. It is possible that her crampy intermittent
abdominal pain is due to spasms related to diverticulosis.
Therefore, she was started on dicyclomine with good effect. She
returned to having normal BM's and her diet was successfully
advanced to regular. She will be following up with her PCP and
gastroenterology upon discharge. She will need to be arranged to
have a colonoscopy in the outpatient setting. Pt did not have
any further bleeding while on her aspirin therapy.
.
# h/o carotid artery occlusion: she reports that she is on
warfarin, INR subtherapeutic on admission. Held warfarin during
work up for GIB. HCT stable and warfarin was restarted on the
day of discharge. She will need her INR monitored closely. The
patient was asked to have her INR rechecked with 1 week of
discharge. Carotid dopplers showed similiar degree of carotid
disease compared to prior in ___. The patient was seen by the
vascular surgery service who did not feel that intervention was
needed at this time. The patient will be following up in
vascular surgery clinic upon discharge.
# h/o CAD:
- continued home ASA 81, metoprolol, atorvastatin
# Hypothyroidism: continued home levothyroxine
# Early Alzheimer's: continued donepizil and buproprion.
FEN: clears, advanced to regular low residue.
Code: DNR/DNI confirmed
.
Transitional care
1.complete antibiotic therapy
2.outpt GI F/u and arrangement of colonoscopy
3.INR monitoring
4outpatient vascular f/u regarding carotid disease
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin Dose is Unknown PO DAILY16
2. Atorvastatin 40 mg PO DAILY
3. Pantoprazole 40 mg PO Q12H
4. Levothyroxine Sodium 75 mcg PO DAILY
5. anastrozole 1 mg oral daily
6. Donepezil 10 mg PO HS
7. BuPROPion 100 mg PO TID
8. Metoprolol Succinate XL 100 mg PO DAILY
9. Nitroglycerin SL 0.3 mg SL PRN chest pain
10. Aspirin 81 mg PO DAILY
11. Cyanocobalamin 1000 mcg IM/SC 1X/WEEK (___)
12. Fish Oil (Omega 3) 1000 mg PO DAILY
13. Ascorbic Acid ___ mg PO DAILY
14. Vitamin D 1000 UNIT PO BID
15. Calcium Carbonate 500 mg PO BID
16. Lorazepam 0.5 mg PO HS:PRN anxiety
17. Fludrocortisone Acetate 0.1 mg PO BID
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. BuPROPion 100 mg PO TID
5. Cyanocobalamin 1000 mcg IM/SC 1X/WEEK (___)
6. Donepezil 10 mg PO HS
7. Fish Oil (Omega 3) 1000 mg PO DAILY
8. Fludrocortisone Acetate 0.1 mg PO BID
9. Levothyroxine Sodium 75 mcg PO DAILY
10. Lorazepam 0.5 mg PO HS:PRN anxiety
11. Metoprolol Succinate XL 100 mg PO DAILY
12. Pantoprazole 40 mg PO Q12H
13. Vitamin D 1000 UNIT PO BID
14. anastrozole 1 mg oral daily
15. Nitroglycerin SL 0.3 mg SL PRN chest pain
16. Warfarin 1 mg PO DAILY16
17. DiCYCLOmine 10 mg PO BID
RX *dicyclomine 10 mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
18. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 2 Days
RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1 pill
by mouth twice a day Disp #*4 Tablet Refills:*0
19. Calcium Carbonate 500 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
likely ischemic colitis
diverticulosis
syncope
carotid vascular disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for evaluation of abdominal pain, bloody
stools and passing out. Your passing out was likely due to lower
blood pressure upon standing. For this, be sure to drink plenty
of fluids and stay hydrated. Your bloody stools were likely due
to colitis which may have been caused from passing out. For
this, you underwent a sigmoidoscopy that revealed
diverticulosis. You will need to have an outpatient full
colonscopy. Please see the GI clinic number below. You were
evaluated by the vascular surgery service due to your carotid
disease. You should follow up with them in clinic (See below) to
discuss ongoing care. Your coumadin will be restarted today.
Please follow up with your PCP for an INR check next week.
.
You were started on an antibiotic (augmentin) which you will
need to continue for 2 more days.
Followup Instructions:
___
|
10174481-DS-10 | 10,174,481 | 28,378,496 | DS | 10 | 2186-06-08 00:00:00 | 2186-06-08 17:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
azithromycin / Bactrim
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS
==============
___ 03:42AM BLOOD WBC-5.0 RBC-4.43 Hgb-12.4 Hct-38.9 MCV-88
MCH-28.0 MCHC-31.9* RDW-12.9 RDWSD-41.0 Plt ___
___ 03:42AM BLOOD Neuts-58.4 ___ Monos-14.9*
Eos-2.4 Baso-0.2 Im ___ AbsNeut-2.91 AbsLymp-1.18*
AbsMono-0.74 AbsEos-0.12 AbsBaso-0.01
___ 03:42AM BLOOD ___ PTT-27.2 ___
___ 03:42AM BLOOD Glucose-113* UreaN-31* Creat-1.1 Na-135
K-3.9 Cl-97 HCO3-24 AnGap-14
___ 03:42AM BLOOD ALT-19 AST-28 CK(CPK)-63 AlkPhos-120*
TotBili-0.4
___ 03:42AM BLOOD Lipase-47
___ 03:42AM BLOOD cTropnT-<0.01
___ 03:42AM BLOOD proBNP-2992*
___ 03:42AM BLOOD Albumin-3.7 Calcium-9.1 Phos-4.0 Mg-2.0
___ 03:42AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 03:47AM BLOOD Lactate-1.2
___ 05:30AM URINE Color-Yellow Appear-CLEAR Sp ___
___ 05:30AM URINE Blood-NEG Nitrite-NEG Protein-50*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NORMAL pH-5.5
Leuks-SM*
___ 05:30AM URINE RBC-1 WBC-14* Bacteri-FEW* Yeast-NONE
Epi-0
___ 05:30AM URINE CastHy-7*
___ 05:30AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG fentnyl-NEG
___ 06:45AM OTHER BODY FLUID FluAPCR-NEG FluBPCR-NEG
PERTINENT INTERVAL LABS
========================
___ 07:54AM BLOOD %HbA1c-5.9 eAG-123
___ 07:20AM BLOOD Triglyc-81 HDL-58 CHOL/HD-3.0 LDLcalc-99
DISCHARGE LABS
================
MICROBIOLOGY
==============
**FINAL REPORT ___
URINE CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. 10,000-100,000 CFU/mL.
BETA STREPTOCOCCUS GROUP B. 10,000-100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN--------- 2 I
GENTAMICIN------------ 2 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
No growth to date on all blood cultures from ___ (finalized)
and ___ (pending at discharge).
IMAGING
===========
CXR ___
No acute intrathoracic or osseous abnormality.
CT C-SPINE ___
1. The bones are diffusely demineralized which may decrease
sensitivity for acute nondisplaced fractures. Within this
confine: No fracture or traumatic malalignment.
2. Unchanged thyroid nodules measuring up to 1.8 cm in the right
lobe.
NOTIFICATION: Thyroid nodule. Ultrasound follow up
recommended.
___ College of Radiology guidelines recommend further
evaluation for
incidental thyroid nodules of 1.0 cm or larger in patients under
age ___ or 1.5 cm in patients age ___ or ___, or with suspicious
findings.
Suspicious findings include: Abnormal lymph nodes (those
displaying
enlargement, calcification, cystic components and/or increased
enhancement) or invasion of local tissues by the thyroid nodule.
___, et al, "Managing Incidental Thyroid Nodules Detected on
Imaging: White Paper of the ACR Incidental Findings Committee".
J ___ ___ 12:143-150.
CT HEAD ___
No acute intracranial abnormality on noncontrast CT head. No
acute displaced calvarial fracture.
CT HEAD ___
1. No acute intracranial abnormality, specifically no evidence
of intracranial hemorrhage.
MRI HEAD ___
1. Acute infarct of the left basal ganglia/corona radiata. No
evidence of
intracranial hemorrhage or significant mass effect.
2. There are moderate involutional changes as well as
periventricular FLAIR hyperintensities compatible with moderate
chronic small vessel ischemic changes.
MRA HEAD ___
1. There are 2 aneurysms of the right internal carotid artery
measuring 5 x 3 mm and 3 x 3 mm in width and height within the
right cavernous and
supraclinoid ICA, respectively.
2. Multifocal irregular luminal narrowing involving the
bilateral internal
carotid arteries, MCAs, PCAs and left greater than right ACAs
suggestive
prominent atherosclerotic disease.
CXR ___
Interval increase in the degree of opacification at the right
lower lung base adjacent to the right heart border, concerning
for a right middle lobe pneumonia in the appropriate clinical
setting.
TTE ___
Moderate symmetric left ventricular hypertrophy with normal
cavity size and
regional/global biventricular systolic function. No prior study
available for comparison. In the absence of a history of
prominent hypertension and left ventricular hypertrophy on the
ECG, an infiltrative process (e.g. amyloid, ___,
etc.) should be considered.
CXR ___
1. Previously noted opacification at the right lower lung base
adjacent to the right heart border is less defined on today's
study. No new focal
consolidations.
2. Mild biapical scarring is noted, unchanged.
CXR ___
1. Interstitial lung markings are more prominent since ___, concerning for new mild pulmonary edema.
2. The right lower lung base opacity is unchanged since ___ but
improved since ___, consistent with improving
aspiration/pneumonia.
Brief Hospital Course:
Ms. ___ is a ___ with history of HTN, osteoporosis c/b prior
hip fracture, and TIA who presents as a referral from ___ ALF after a fall, with evidence of stroke on exam.
TRANSITIONAL ISSUES:
====================
[] Discharged with new hypoxia, stable at ___ NC O2 support, in
setting of aspiration pneumonitis and atelectasis. Consider
further work-up for hypoxia if persistent at follow-up
[] Cardiac monitoring for atrial fibrillation deferred on
discharge, as would not plan to initiate anticoagulation for AF
based on discussion with patient and family. Based on goals of
care and potential treatment plan, consider outpatient cardiac
monitoring for atrial fibrillation given stroke history.
[] Head imaging showing extensive intra-cranial atherosclerosis,
recommended for dual-antiplatelet therapy with aspirin and
clopidogrel by neurology. Based on overall prognosis and
bleeding risks of DAPT, addition of clopidogrel was deferred
while inpatient. Consider re-assessment of benefits and risks of
adding clopidogrel.
[] Carotid US deferred while inpatient as patient not a good
candidate for intervention. Consider US if
[] CT C-spine with unchanged thyroid nodules measuring up to 1.8
cm in the right lobe. Recommend outpatient ultrasound for
follow-up.
[] Markedly elevated blood pressures from baseline in setting of
recent CVA. Follow-up BP control.
ACTIVE ISSUES:
===============
# Acute L MCA stroke
Presented with fall, found to have clear right-sided deficits
consistent with L MCA stroke. CT head without evidence of acute
infarct, but with substantial periventricular white matter
disease, likely in the setting of longstanding hypertension. Not
a candidate for tPA or advanced interventions. Repeat head CT
stable on
___. MRI/MRA confirmed acute CVA involving corona radiata.
Neurology consulted. Started ASA, high-dose statin per
neurology. Deferred addition of clopidogrel given bleeding
risks, history of falls, and overall prognosis. TTE with LVH but
normal EF, no evidence of intra-atrial thrombus, valvular
pathology. Intermittent short runs of likely AT on telemetry,
but no evidence of AF. Given overall prognosis and per
discussion with daughter, would not anticoagulate if found to
have AF, so deferred Ziopatch at this time. Some improvement in
RLE movement prior to discharge, may have potential for
significant benefit from ___. Evaluated by ___ while inpatient,
recommended for rehab. Noted to have significant dysarthria and
dysphagia in setting of recent CVA, complicated by aspiration
pneumonitis (see below).
# Aspiration Pneumonitis
# Hypoxia
Febrile to 100.8 on ___, somnolent, hypoxic, with CXR showing
new R lung base opacification c/f aspiration. No leukocytosis on
labs. Mental status subsequently improved, no dyspnea.
Subsequently remaining afebrile with no symptoms or exam
findings to suggest pneumonia. However, having continued hypoxia
to ___.
Likely atelectasis +/- continued effects of aspiration
pneumonitis. No known history of heart failure, TTE showed
normal EF with moderate LVH. Remaining hypoxic on ___ at
discharge with no evidence of infection. Last CXR on ___
showing mild interstitial edema, although appearing euvolemic to
dry on exam; further diuresis deferred given rising BUN and
limited PO intake, stable respiratory status. Evaluated by ___
team for swallowing evaluation, underwent video swallow on ___
to further evaluation. Placed on modified diet and aspiration
precautions per SLP, to be continued on discharge.
# Fall
Was recently seen in the ED in ___ for fall, now
re-presenting with another reported fall. Etiology may be in the
setting of known gait disturbance vs. likely acute-onset stroke
with right-sided weakness, as above. Evaluated by ___ and
recommended for rehab.
# Hypertension
Noted to have severe asymptomatic hypertension while inpatient,
likely in setting of dysregulation ___ recent CVA. BP improved
with uptitration of lisinopril to 40 and amlodipine to 10 on
discharge, although SBP remaining elevated to 150s-190s at
discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO/PR Q6H:PRN Pain - Mild/Fever
2. amLODIPine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. GuaiFENesin ___ mL PO Q6H:PRN congestion
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
7. Senna 8.6 mg PO BID
8. Lisinopril 40 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Stroke
R-Sided Hemiparesis
SECONDARY DIAGNOSIS
===================
Aspiration Pneumonitis
Hypoxia
Fall
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You had a fall and right-sided weakness.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were found to have an acute stroke.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10174935-DS-12 | 10,174,935 | 23,150,740 | DS | 12 | 2151-08-06 00:00:00 | 2151-08-06 14:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
ACE Inhibitors / adhesive tape / Statins-Hmg-Coa Reductase
Inhibitors
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___ Cardiac cath with Impella insertion and 2 DES
___ Impella repositioning, unsuccessful impella removal
___ 1. Coronary artery bypass grafting x1 with left internal
mammary artery to the left anterior descending artery. 2.
Removal of Impella device with aortotomy.
History of Present Illness:
___ with hx of HTN and high cholesterol who is presenting as a
transfer from ___ with NSTEMI on heparin and nitro.
She started having exertional chest pain for 2 days. Pain
progressed to severe rest pain on morning (___). Pain was
described as constant, heavy, and in the ___ her chest
that radiated up to her neck. She presented to ___ ED and was
transferred to BI ED.
She has no cardiac history and has never had this chest pain
before. She denies shortness of breath, fever, chills, abdominal
pain, nausea, vomiting, diarrhea or other symptoms.
In the ED initial vitals were: 98.8, 75, 136/70, 14, 97% Nasal
Cannula
EKG:STE in II, III, aVF, STD in V1-V3 with T wave inversions
Labs/studies notable for:
CBC: 9.3/12.7/39.5/280
BMP: ___
Trop: 0.11
CK-MB: 21
CK:211
Patient was given:
___ 18:55 IV Heparin Started 12 units/hr
___ 18:55 IV DRIP Nitroglycerin (0.35-3.5 mcg/kg/min
ordered)Started 0.4 mcg/kg/min
___ 18:55 PO/NG TiCAGRELOR 180 mg
She was taken to the cath lab found 90% occlusion of proximal
LAD which was not thought to be culprit lesion so was not
revascularized. Proximal RCA was totally occluded and was
revascularized with DES x2.
Patient became hypotensive and dopamine was started, she went
into complete heart block with bradycardia and a RV temp wire
was placed. Temp wire was subsequently pulled.
She remained hypotensive (SBP 85 mmHg) so IABP was inserted. She
then developed polymorphic VT requiring Lidocaine, Amiodarone, 3
shocks, and ~5min CPR. Hemodynamic support was escalated to
Impella. Was in SVT, and then a fib with RVR (rates in 120s).
On arrival to the CCU patient on levo 0.03 and heparin drip,
alert and oriented breathing comfortably on NC. Initially
patient was in a fib but converted to NSR with rates in ___.
Right sided cordis, swan, and a line were placed.
Per family, patient has no cardiac history and only takes
medication for hypertension and hyperlipidemia. They do not
remember the names of her medications.
Past Medical History:
1. CARDIAC RISK FACTORS
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- Coronaries CAD: unknown
- Pump ECHO CHF: unknown
- Rhythm: LBBB (new)
3. OTHER PAST MEDICAL HISTORY
- Osteoporosis
- Basal cell carcinoma
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION EXAM
VS: T HR 59 BP 108/77 RR 12 O2 SAT 99% on NC
GENERAL: Well developed, well nourished 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. Cordis in place on right side, dressing in place
is clean.
NECK: Supple. JVP of ____ cm.
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE EXAM
Vital Signs and Intake/Output:
Tmax: 98.9 Tcurrent: 98.3 B/P: 112/63 HR/Rhythm: 86
RR:
18
SaO2:92 Oxygen: RA FSBG: n/a
Date: 73.1 (74 kg)
In Out: ___
Physical Examination:
General/Neuro: NAD [x] A/O x3 [x] non-focal [x]
Cardiac: RRR [x] Irregular [] Nl S1 S2 [x]
Lungs: CTA [x] No resp distress [x]
Abd: NBS [x]Soft [x] ND [x] NT [x]
Extremities: 1+ CCE[x] Pulses doppler [x] palpable [], r foot
paresthesias continue
Wounds: Sternal: CDI [x] no erythema or drainage [x]
Sternum stable [] Prevena [x]
R groin: Staples intact
Pertinent Results:
___ 04:50AM BLOOD WBC-8.3 RBC-3.23* Hgb-9.6* Hct-28.6*
MCV-89 MCH-29.7 MCHC-33.6 RDW-15.5 RDWSD-49.5* Plt ___
___ 04:50AM BLOOD Glucose-98 UreaN-26* Creat-0.7 Na-141
K-3.7 Cl-101 HCO3-27 AnGap-13
TTE ___
The left atrium is elongated. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thicknesses and
cavity size are normal. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is mildly depressed (LVEF= 50
%). Right ventricular chamber size and free wall motion are
normal. There is abnormal septal motion/position. The aortic
valve leaflets (?#) appear structurally normal with good leaflet
excursion. There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Mildly reduced left
ventricular systolic function. Unable to assess for regional
dysfunction. Mild aortic and tricuspid regurgitation. Borderline
pulmonary hypertension.
PA and Lateral ___
-Trace bilateral pleural effusions, otherwise good aeration
Brief Hospital Course:
___ with history of HTN and high cholesterol who is presenting
as a transfer from ___ with NSTEMI on heparin and
nitro found to have inferior STEMI successfully
revascularization of RCA, remaining 90% LAD occlusion
complicated by reperfusion VT and cardiogenic shock requiring
mechanical support with Impella.
In CCU, ___ catheter placed. Attempted echo verification
of placement of impella, however this appeared somewhat shallow
so bedside advancement was attempted. This was complicated by
coiling of impella in LV. Attempted to withdraw the impella
unsuccessfully, and so CSurg was consulted. Patient was taken to
the the OR on ___ for impella removal and concomitant coronary
artery bypass graft x 1. Please see operative note for surgical
details. Following surgery she was transferred to the CVICU for
invasive monitoring. Arrived from OR intubated and sedated on on
Epi infusion for hramodynamic support. On POD#1 was noted to
have a cold right foot and loss of pedal pulses. Vascular
surgery was consulted and the patient was taken tot he operating
room for a Right femoral exploration and thrombectomy. She
underwent a thrombectomy on ___ and pedal pulses returned and
systemic anticoagulation with heparin was maintained for
profusion. The patient will not require anticoagulation and will
be discharged on Plavix and aspirin. She will follow up with the
vascular surgery team as an outpatient. She has groin staples in
place which should be removed 2 weeks after placement (___).
Her perfusion returned after surgery, however she has moderate
right foot sensation loss. She will be discharged with a
multi-podus boot and will need follow up with physical therapy.
CT's were removed and patient developed a right PTX-a pigtail as
placed with lung re-expansion. Water seal trial was successful
and Pigtail was removed without incident on ___. Her discharge
CXR shows no residual PTX. She was started on Lopressor prior to
discharge but was not started on a statin due to allergy. A
foley was replaced on ___ due to acute urinary retention. She
was started on Flomax and will be discharged with a foley
catheter in place. A UA was obtained and was negative. A voiding
trial should be attempted at rehab. The patient was evaluated by
physical therapy and was deemed appropriate for rehab. The
patient should have aggressive physical and occupational therapy
at rehab to help facilitate recovery of strength in her right
foot. She will be discharged to ___ at
___ on ___ on POD 5.
Medications on Admission:
Asa 81'
Losartan 50'
Discharge Medications:
1. Bisacodyl ___AILY:PRN constipation
2. Clopidogrel 75 mg PO DAILY
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Furosemide 40 mg PO DAILY Duration: 10 Days
5. Metoprolol Tartrate 25 mg PO BID
6. Pantoprazole 40 mg PO Q24H Duration: 30 Days
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Potassium Chloride 20 mEq PO DAILY Duration: 10 Days
9. Tamsulosin 0.4 mg PO QHS
10. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
11. Aspirin EC 81 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Myocardial infarction, coronary artery disease s/p Coronary
artery bypass graft x 1, drug-eluting stent placement x 2
Past medical history:
Hypertension
LBBB
Osteoporosis
Hyperlipidemia
Basal cell carcinoma of skin
b/l total knee replacement
Cataract extraction
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
1+ Edema
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 ___
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
10174994-DS-19 | 10,174,994 | 20,229,162 | DS | 19 | 2118-06-30 00:00:00 | 2118-06-30 15:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins / Codeine / Proparacaine / clindamycin / lovastatin
/ Bactrim
Attending: ___
Chief Complaint:
left side numbness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
NIHSS 0
Neurology at bedside for evaluation after code stroke activation
within: 5 min
Time/Date the patient was last known well: ___ 1500
___ Stroke Scale Score: 0
Pre-stroke mRS: 0
t-PA Administration
[] Yes - Time given:
[x] No - Reason t-PA was not given/considered: outside tpa
window, low NIHSS
Thrombectomy
[] Yes
[x] No - low NIHSS
I was present during the CT scanning and reviewed the images
within 20 minutes of their completion. NIHSS performed within 6
hours of presentation.
Home Meds: see below
___ Stroke Scale - Total [0]
1a. Level of Consciousness - 0
1b. LOC Questions - 0
1c. LOC Commands - 0
2. ___ 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 - 0
11. Extinction and Neglect - 0
HPI:
The pt is a ___ year old man with history of hypertension,
hyperlipidemia, OSA noncompliant with CPAP, obesity, anxiety,
who
presents with acute onset left sided numbness.
The patient reports he was in his usual state of health today;
just before 3pm he decided to take a nap after watching TV. He
awoke at 3pm, and immediately after awakening, felt onset of
numbness in his face/scalp, as well as left ___ fingertips,
left shoulder, and left flank. Onset occurred over a few minutes
before being maximal in nature. He also felt generalized
weakness
but no other symptoms. He was concerned initially for a heart
attack and therefore drove himself to ___.
Apparently CT there showed ? of subacute stroke, so he was
transferred to ___. Of note, TSH was 0.009.
While at ___ ED, code stroke was called. He reported that the
numbness in his fingertips was gone and that the numbness in his
face was reduced to only his forehead and parietal scalp area.
Later on during interview, symptoms intermittently fluctuated.
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, lightheadedness, vertigo,
tinnitus or hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness or 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 rash.
Of note, he was recently started on atorvastatin 10mg but
stopped
this himself due to myalgias.
Past Medical History:
PMH:
Problems (Last Verified ___ by ___:
ANXIETY
BENIGN PROSTATIC HYPERTROPHY
CARPAL TUNNEL SYNDROME
CHRONIC LOW BACK PAIN
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
DEGENERATIVE JOINT DISEASE
GASTROESOPHAGEAL REFLUX
HERPES ZOSTER
HYPERLIPIDEMIA
HYPERTENSION
KIDNEY STONES
NARCOTICS AGREEMENT
OBSTRUCTIVE SLEEP APNEA - noncompliant with CPAP
OSTEOARTHRITIS
TINNITUS
CERVICAL RADICULITIS
DEPRESSION
Social History:
Social Hx:
Works as ___ parttime, although chronic back pain
impairs his ability to carry out usual activities. Quit smoking
a
few months ago but had worsening anxiety due to this. No alcohol
or illicit substance use.
- Modified Rankin Scale:
[] 0: No symptoms
[] 1: No significant disability - able to carry out all usual
activities despite some symptoms
[x] 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:
non contributory
Physical Exam:
ADMISSION EXAM:
Physical Exam:
Vitals: temp 98.5, HR 84, BP 156/89, RR 18, spO2 97% RA, glucose
85
General: awake, cooperative obese man, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: supple, no nuchal rigidity
Pulmonary: breathing comfortably on room air
Cardiac: RRR, nl
Abdomen: soft, NT/ND
Extremities: warm, well perfused
Skin: no rashes or lesions noted
Neurologic:
-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 were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. 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 pinprick throughout. Reports 20%
of
normal sensation over left V2 only.
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: Reports decreased sensation to light touch over left
shoulder, flank, and distal phalanges ___ only. However, intact
to pinprick, proprioception, graphesthesia, etc. 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: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Romberg absent.
Discharge Exam:
___ 1134 Temp: 97.9 PO BP: 134/75 R Lying HR: 87 RR: 20 O2
sat: 95% O2 delivery: Ra
General: awake, cooperative obese man, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: supple, no nuchal rigidity
Pulmonary: breathing comfortably on room air
Cardiac: RRR, nl
Abdomen: soft, NT/ND
Extremities: warm, well perfused
Skin: no rashes or lesions noted
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, Language is fluent with intact
repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Speech
was not dysarthric. Able to follow both midline and appendicular
commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: Pupils 6->4 left, 5>3 on the right briskly
reactive. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to pinprick and light touch
throughout but reports numbness sensation.
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: normal sensation to light touch over left
shoulder, flank, and distal phalanges ___ but subjective
numbness. intact
to pinprick, proprioception, graphesthesia, etc. 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: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Romberg absent.
Pertinent Results:
___ 07:18PM BLOOD WBC: 6.9 RBC: 5.16 Hgb: 15.6 Hct: 44.8
MCV: 87 MCH: 30.2 MCHC: 34.8 RDW: 11.9 RDWSD: 38.___
___ 07:18PM BLOOD Neuts: 56.5 Lymphs: ___ Monos: 9.2 Eos:
1.7 Baso: 0.3 Im ___: 0.3 AbsNeut: 3.89 AbsLymp: 2.20 AbsMono:
0.63 AbsEos: 0.12 AbsBaso: 0.02
___ 07:18PM BLOOD ___: 10.5 PTT: 32.0 ___: 1.0
___ 07:23PM BLOOD Glucose: 90 Na: 142 K: 3.7 Cl: 100
calHCO3: 30
___ 07:18PM BLOOD UreaN: 21* Creat: 0.7
___ 07:18PM BLOOD ALT: 39 AST: 23 AlkPhos: 87 TotBili: 0.4
___ 07:18PM BLOOD TSH: <0.01*
___ 07:18PM BLOOD T3: 202* Free T4: 2.0*
EKG: sinus rhyth
Radiologic Data:
NONCONTRAST HEAD CT:
No acute intracranial abnormality. A 6 mm round hyperdense focus
in the firm area ___ (02:19) is compatible with a colloid
cysts. There is no evidence of hydrocephalus.
CTA HEAD NECK:
The circle of ___ and its principal branches are patent,
without evidence of dissection or aneurysm formation. The dural
venous sinuses are patent. The carotid and vertebral arteries
are patent, without evidence of dissection or aneurysm
formation.
Brief Hospital Course:
Mr. ___ is a ___ year old man with history of hypertension,
hyperlipidemia, OSA noncompliant with CPAP, obesity, anxiety,
who presented with acute onset left sided numbness. Examination
is notable for patchy numbness without objective sensory
symptoms. Based on distribution etiology most likely related to
cervical radiculopathy. Head CT showed no acute intracranial
abnormality. TIA considered less likely. A 6 mm round hyperdense
focus in the firm area ___ (___:19) is compatible with a
colloid cysts. There was no evidence of hydrocephalus. CTA HEAD
NECK showed The circle of ___ and its principal branches are
patent, without evidence of dissection or aneurysm formation.
The dural venous sinuses are patent. The carotid and vertebral
arteries are patent, without evidence of dissection or aneurysm
formation. UA was negative. Trop negative. Urine tox was
positive for opiates consistent with patients home pain
medications. Patient was unable to tolerate brain and cervical
spine MRI due to claustrophobia so this was scheduled for
outpatient. He has self discontinued his atorvastatin at home
because of myalgias, which appears to have been a reasonable
decision given that his symptoms started after initiation of
statin and improve within 1 week from discontinuation. Aspirin
was started for secondary stroke prevention. A1c 5.2%. LDL 131.
TSH was incidentally found to be <1.0 with T3 202, free T4 2.0.
Endocrinology was consulted for evaluation of asymptomatic
hyperthyroidism. Thyroid ultrasound was recommended which will
be performed outpatient. TPO and TSI antibodies were ordered and
ESR was checked. He was started on atelolol or tachycardia and
to inhibit conversion of T4 to T3. He will have repeat TFTs in 1
week with outpatient follow up with endocrinology.
Transitional issues
[ ] outpatient endocrinology follow up
[ ] TSI Ab, TPO Ab, ESR pending - endocrinology to follow up
[ ] TFTs in 1 week
[ ] outpatient thyroid ultrasound
[ ] outpatient brain and cervical spine MRI; request faxed to
___ at ___
[ ] PCP to consider starting ezetimibe for hyperlipidemia
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
2. Atorvastatin 10 mg PO QPM
3. BuPROPion XL (Once Daily) 300 mg PO DAILY
4. Doxazosin 8 mg PO HS
5. Escitalopram Oxalate 20 mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. Gabapentin 600 mg PO TID
8. Hydrochlorothiazide 25 mg PO DAILY
9. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain -
Moderate
10. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
11. Omeprazole 20 mg PO DAILY
12. Sildenafil 50 mg PO DAILY:PRN prior to sex
___. Nicotine Patch 14 mg TD DAILY
14. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
2. Atenolol 25 mg PO DAILY
RX *atenolol 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
4. BuPROPion XL (Once Daily) 300 mg PO DAILY
5. Doxazosin 8 mg PO HS
6. Escitalopram Oxalate 20 mg PO DAILY
7. Finasteride 5 mg PO DAILY
8. Fish Oil (Omega 3) 1000 mg PO DAILY
9. Gabapentin 600 mg PO TID
10. Hydrochlorothiazide 25 mg PO DAILY
11. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain
- Moderate
12. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
13. Nicotine Patch 14 mg TD DAILY
14. Omeprazole 20 mg PO DAILY
15. Sildenafil 50 mg PO DAILY:PRN prior to sex
Discharge Disposition:
Home
Discharge Diagnosis:
Suspected cervical radiculopathy
Hyperthyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of numbness that are
likely related to some mild compression of nerves in your neck.
You were not able to tolerate an MRI of your brain and neck so
these will be done as an outpatient. You also were found to have
hyperthyroidism for which you will have outpatient follow up
with endocrinology and an outpatient thyroid ultrasound.
We are changing your medications as follows:
Start atenolol 25 mg daily for control of your heart rate given
hyperthyroidism.
It is okay to stop your atorvastatin given adverse side effects.
Start Aspirin 81 mg daily
Please take your other medications as prescribed.
Please follow up with Neurology, endocrinology, 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:
___
|
10175097-DS-4 | 10,175,097 | 29,552,546 | DS | 4 | 2182-02-20 00:00:00 | 2182-02-20 16:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
difficult airway
Attending: ___.
Chief Complaint:
aphasia and R sided weakness
Major Surgical or Invasive Procedure:
tPA (0010 on ___
History of Present Illness:
Ms. ___ is a ___ speaking ___ woman with
history of HTN, RA, and TB exposure s/p treatment who was
admitted ___ for post tPA care after presenting with aphasia
and right sided weakness to OSH. She was in her usual state of
health when she was eating dinner with her husband at 9:50pm
when she had difficulty swallowing, inability to speak, and
subjective R sided weakness. NIHSS at OSH was 6 and tPA
administered at 0010 on ___. She was subsequently
transferred to ___ for further care and evaluation. CTA head
and neck at ___ was negative. Around 3am morning, she was
starting to speak better. At baseline, she is unable to taste
her food and R great toe is numb. Also of note, she has had a
lot of stress at home. Her sister and nephew died last month,
and her husband is sick. She was admitted to Neuro ICU for post
tpa care.
Past Medical History:
- HTN
- RA
- TB infection s/p treatment
- Similar episode to current presention in ___ ___ years ago
where she choked and aspirated but was not weak afterwards. She
never saw a doctor for this.
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98 HR 73 HR 136/91 RR 16 O2 98% RA
General: AAOx3, resting comfortably, smiling
HEENT: atraumatic
CV: RRR, no m/r/g
Lungs: CTAB
Abdomen: soft, NTND
Neuro:
MS: AAOx3, no dysarthria or word finding difficulties, no
aphasia. Able to read, write, follow commands.
CN: PERRL 3->2 brisk. EOMI, no nystagmus. No facial movement
asymmetry. tongue midline
Motor: normal bulk, increased tone throughout. UE: R UE 4+/5
throughout, difficult to assess intrinsic hand muscles ___ RA. L
UE ___ throughout. ___: bilateral hip flexion ___, ___ DF ___
otherwise ___ throughout b/l ___. Give way weakness noted, pain
limited exam.
DTRs: hyperreflexic throughout with crossed adductor responses.
Skin: no issues
MSK: RA changes noted in bilat hands and feet
DISCHARGE PHYSICAL EXAM:
Tmax: 36.6 °C (97.9 °F)
T current: 36.6 °C (97.8 °F)
HR: 69 (60 - 93) bpm
BP: 131/74(88) {105/53(62) - 145/76(99)} mmHg
RR: 25 (9 - 25) insp/min
SPO2: 96%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 75.8 kg (admission): 75.8 kg
General: AAOx3, resting comfortably, smiling
HEENT: atraumatic
CV: RRR, no m/r/g
Lungs: CTAB
Abdomen: soft, NTND
Neuro:
MS: AAOx3, no dysarthria or word finding difficulties, no
aphasia. Able to read, write, follow commands.
CN: PERRL 3->2 brisk. EOMI, no nystagmus. No facial movement
asymmetry. tongue midline
Motor: normal bulk, increased tone throughout. UE: R UE 4+/5
throughout, difficult to assess intrinsic hand muscles ___ RA. L
UE ___ throughout. ___: bilateral hip flexion ___, ___ DF ___
otherwise ___ throughout b/l ___. Give way weakness noted, pain
limited exam.
DTRs: hyperreflexic throughout with crossed adductor responses.
Pertinent Results:
___ 02:18AM BLOOD %HbA1c-5.2 eAG-103
___ 02:18AM BLOOD Triglyc-100 HDL-47 CHOL/HD-3.9
LDLcalc-114
___ 02:18AM BLOOD TSH-0.86
___ 01:55AM ___ PTT-34.9 ___
___ 01:55AM PLT COUNT-186
MRI brain without contrast and MRA brain without contrast from
___:
IMPRESSION:
No acute infarcts or other significant abnormalities on MRI
brain without
gadolinium. No significant abnormalities are seen on MRA of the
head.
MRI of the cervical ___ from ___:
IMPRESSION:
Changes of cervical spondylosis with mild spinal stenosis at
C3-4 moderate
spinal stenosis at C4-5 and mild to moderate spinal stenosis at
C5-6 level. Deformity of the spinal cord by disc bulging at C4-5
level with spinal cord contact by disc bulging at C3-4 and C5-6
levels. No abnormal signal within the spinal cord. Foraminal
changes as described above.
Brief Hospital Course:
#Non fluent aphasia with right sided weakness: Patient presented
with acute onset dysphagia followed by dysarthria and right
sided weakness, and was admitted to Neuroscience ICU for BP
monitoring post tPA (tPA given at 0010 on ___. She was
monitored with q1 hour neurologic checks and BP monitored and
within ranges per post tPA protocol. Glucose remained well
controlled. She had significant improvement and resolution of
her presenting complaints within 24 hours of arrival. Her
dysarthria and aphasia resolved, and she passed bedside swallow
evaluation. She was advanced to regular diet on ___ and
tolerated well. In terms of her neurologic exam, she did not
have any focal deficits, apart from mild weakness in distal UE
and symmetric proximal ___ weakness, increased tone and
hyperreflexia, which is consistent with patient's cervical
myelopathy. Her weakness was difficult to assess given
significant joint pain at baseline from her history of RA. She
did not have a clinical exam consistent with stroke given her
improvement. She had an MRI performed ___ which revealed no
acute infarcts or other significant abnormalities on MRI brain.
It did reveal a small area of left frontal FLAIR hyperintensity
but this was not felt to be clinically significant. Given upper
motor neuron signs on exam and concern for cervical myelopathy,
MRI of cervical ___ was performed which revealed changes of
cervical spondylosis, with "mild spinal stenosis at C3-4,
moderate spinal stenosis at C4-5, and mild to moderate spinal
stenosis at C5-6 level; deformity of the spinal cord by disc
bulging at C4-5 level with spinal cord contact by disc bulging
at C3-4 and C5-6 levels. No abnormal signal within the spinal
cord." There were no indications for inpatient neurosurgical
intervention given her exam was back to her baseline. On day of
discharge (___) patient continued to have clinical improvement,
and reported feeling back to her baseline. She was ambulated
around unit without difficulty. She was evaluated by physical
therapy who felt that she could benefit from outpatient physical
therapy, which patient was already arranged for via ___ per
family and case management. Patient was discharged on ___ at
her baseline condition. No medication changes were made. She was
given referral to follow up with neurosurgical ___ surgery and
stroke team after discharge for further workup/evaluation of
cervical myelopathy.
#HTN: Patient's BP was maintained per post tPA protocol with SBP
less than 180 and DBP less than 105. Given clinical stability
over next ___ hours, patient's BP was allowed to autoregulate
<160 systolic and was well controlled. Patient was resumed on
home propranolol 60mg daily upon discharge.
#Hyperlipidemia: Patient was continued on home statin once
swallow evaluation was passed.
#Rheumatoid arthritis: Patient has a history of RA, and reported
joint pain on arrival but no evidence of acute flair. Her home
methotrexate was held until she passed swallow evaluation, then
resumed upon discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Propranolol LA 60 mg PO DAILY
3. Simvastatin 20 mg PO QPM
4. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Propranolol LA 60 mg PO DAILY
4. Simvastatin 20 mg PO QPM
5.Outpatient Physical Therapy
Resume previously arranged physical therapy through ___ program
Discharge Disposition:
Home
Discharge Diagnosis:
Cervical spondylosis
Spinal stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to the hospital with difficulty speaking,
swallowing and muscle weakness. After evaluation by the medical
teams, there was a concern that these symptoms could be caused
by a stroke. For this reason, you were given tPA (the "clot
___ medication, and you were admitted to the ICU for close
monitoring after receiving this medication. Your symptoms
improved over 24 hours. We had an MRI of the brain, which did
not reveal any evidence of stroke. You had an MRI of your ___
to see if this could explain any of your symptoms. It did show
narrowing in some areas of the ___, which we recommend you see
a Neurosurgeon in clinic after you leave the hospital to look
at. Finally, you were seen by physical therapy team who felt
that you could continue to build up strength with outpatient
physical therapy.
Followup Instructions:
___
|
10175301-DS-12 | 10,175,301 | 21,582,456 | DS | 12 | 2127-02-01 00:00:00 | 2127-02-04 17:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / barium iodide
Attending: ___.
Chief Complaint:
Symptomatic Anemia
Major Surgical or Invasive Procedure:
CT-guided biopsy of pelvic mass (___)
History of Present Illness:
Mr. ___ is a ___ year old gentleman with a h/o symptomatic
internal hemorrhoids, muscular dystrophy, HTN, and iron
deficiency anemia with recent imaging findings of pelvic massess
concerning for advanced baldder cancer who presents with several
weeks of weakness and fatigue and is being admitted for blood
transfusion and bladder biopsy.
Per the patient, he intially noticed weakness ad fatigue around
___. He also noticed worsening heamtochezia from his
hemorrhoids with large bout of blood in the toilet. When his PCP
noted his ___ had dropped from a baseline of 32 to 25, he was
started him on oral iron supplement which reportedly did not
resolve his symptoms. Sometime last week (week of ___, he
returned to a different provider in ___ who ordered a
CT-Abd/Pelvis after the patient had noted anorexia and
weight-loss. The CT was remarkable for pelvic masses concerning
for bladder cancer and his Hct had dropped to 21, at which point
he was referred to the ED for transfusion and biopsy of the
lesions found on his bladder.
On arrival to the ED, his vital signs were: 98.1 88 132/72 20
99% RA with an H/H of 6.2/ 20.1.
Of note, Mr. ___ has had several weeks shortness of breath on
exertion and has started taking afternoon naps, which he never
did prior to the ___. He has also had several weeks of
intermittent fevers, at one point reaching ___, but they
respond to tylenol. He endorses BRBPR on admission and also
reports that he was treated for presumed lyme disease in late
___ of this year. He denies blood in urine, but notes that his
urine stream is intermittently weak. He denies chest pain,
fevers, chills, or sick contacts.
Past Medical History:
- presumed Lyme disease, recently treated with doxycycline in
___
- Anemia, iron deficiency
- Symptomatic Internal hemorrhoids
- h/o adenomatous polyp of colon
- Rotator Cuff Syndrome
- Winged scapula
- Kyphosis
- dropped head syndrome c/b chronic neck pain and dysphagia
- Anxiety
Social History:
___
Family History:
- Daughter died of NHL at age ___
- no FH of bladder cancer, prostate ca, rectal cancer, or colon
cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: T 98.7 BP 157/83 HR 81 RR 18 100%RA
General: Cachectic-appearing but pleasant gentleman lying in
bed, in no NAD
HEENT: Moderate Conjunctival palor, with anicteric sclera. Moits
mucous membranes.
Neck: Supple with no LAD
Lungs: CTAB, no wheezes/rales/rhonchi
CV: RRR, normal S1/S2, no MRG
Abdomen: Soft scaphoid abdomen with normoactive bowel sounds
GU: No Foley
Ext: Warm, well-perfused, no cyanosis/clubbing/edema, 2+ pulses
Neuro: AAOx3, CN II-XII grossly intact, ___ strength in UE and
___. Gait assessment deferred
DISCHARGE PHSYICAL EXAM:
========================
Vitals: Tc:99.2 HR: 93 BP:140/74 18 97%RA
General: Cachectic-appearing but pleasant gentleman lying in
bed, in no NAD
HEENT: PERRL, EOMI, with anicteric sclera. Moist mucous
membranes.
Neck: Supple with no LAD
Lungs: Anterior chest with significant convexity, otherwise
CTAB, no wheezes/rales/rhonchi
CV: RRR, normal S1/S2, no MRG
Abdomen: Soft scaphoid abdomen with normoactive bowel sounds
GU: No Foley
Ext: Warm, well-perfused, no cyanosis/clubbing/edema, 2+ pulses
Neuro: AAOx3, CN II-XII grossly intact, ___ strength in UE and
___. Gait assessment deferred
Pertinent Results:
ADMISSION LABS:
==============
___ 12:58PM BLOOD WBC-9.7# RBC-2.33*# Hgb-6.2*# Hct-20.1*#
MCV-86 MCH-26.6# MCHC-30.8*# RDW-16.0* RDWSD-48.8* Plt ___
___ 12:58PM BLOOD ___ PTT-30.4 ___
___ 12:58PM BLOOD Plt ___
___ 12:58PM BLOOD ___
___ 12:58PM BLOOD Ret Aut-2.2* Abs Ret-0.05
___ 12:58PM BLOOD Glucose-91 UreaN-22* Creat-1.2 Na-130*
K-4.3 Cl-92* HCO3-24 AnGap-18
___ 12:58PM BLOOD ALT-14 AST-38 LD(LDH)-537* AlkPhos-114
TotBili-0.3
___ 12:58PM BLOOD Albumin-3.3* Calcium-8.6 Phos-3.4 Mg-2.4
Iron-11*
DISCHARGE LABS:
===============
___ 06:20AM BLOOD WBC-9.2 RBC-2.83* Hgb-7.4* Hct-24.0*
MCV-85 MCH-26.1 MCHC-30.8* RDW-16.0* RDWSD-48.8* Plt ___
___ 06:20AM BLOOD Plt ___
___ 06:20AM BLOOD Glucose-79 UreaN-18 Creat-1.1 Na-131*
K-4.3 Cl-94* HCO3-25 AnGap-16
___ 06:20AM BLOOD TotProt-5.4* Calcium-8.4 Phos-2.9 Mg-2.0
OTHER PERTINENT LABS:
=====================
___ 06:25AM BLOOD Ret Aut-1.5 Abs Ret-0.04
___ 06:20AM BLOOD LD(LDH)-408*
___ 06:20AM BLOOD Hapto-337*
___ 06:25AM BLOOD calTIBC-203* VitB12-1172* Folate-14.4
Ferritn-143 TRF-156*
___ 06:25AM BLOOD PSA-5.1*
URINE LABS:
===========
___ 10:14AM URINE Color-Yellow Appear-Clear Sp ___
___ 10:14AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 10:14AM URINE RBC-4* WBC-2 Bacteri-FEW Yeast-NONE
Epi-<1
___ 10:14AM URINE CastGr-1*
MICRO LABS:
===========
1) UCx: ___ 10:14 am <10,000 organisms/ml.
2) BCx: pending on discharge
IMAGING/PROCEDURES:
===================
___ CT PELVIS Interventional Radiology:
1. Enhancing pelvic mass extending along the left lateral aspect
of the
bladder wall, with involvement of the seminal vesicles and
prostate,
superiorly extending in the retroperitoneum, abutting the left
common iliac artery and vein. The left common iliac vein
appears obstructed. Distal left ureteric obstruction.
2. Ascites.
3. Multiple sclerotic osseous lesions concerning for metastases.
*****Uneventful core biopsy excision******
Brief Hospital Course:
Mr. ___ is a ___ year old man with h/o iron-deficiency anemia
and symptomatic internal hemorrhoids who presented with several
weeks of worsening fatigue, shortness of breath and intermittent
fevers with recent image findings concerning for locally
advanced pelvic malignancy likely bladder cancer vs prostate
cancer, and was susequently admitted for pRBC transfusion and
work-up of pelvic masses. Patient subsequently left AMA on ___.
#ANEMIA:
He reported several weeks of shortness of breath and fatigue and
a one week history in ___ where he passed large bouts of blood
in the toilet, which he had alluded to internal hemorrhoids.
Given that he is an avid Hiker, he had initially been treated
with a course of doxycyline for presumed lyme and started on
iron supplements, but when his symptoms did not resolve, he
re-presented to ___ where his Hct was found to be 21
and a CT scan was concerning for malignancy (see below)
prompting him to be sent to the ___ ED immediately. Upon
admission, his HgB was noted to be 6.2. Etiology of anemia was
thought to be likely multifactorial including, acute blood loss
from symptomatic hemorrhoids, iron deficiency as evidenced by
the very low serum iron of 10 and low normal ferritin, and
potentially occult GI Bleeding although hemooccult attempt was
unsuccessful given insufficient sample on digictal rectal exam.
Following 1U pRBCs transfusion, HgB rose from 6.2 and remained
stable at 7.4 during his course here.
#PELVIC MASSES: Per the pt, Abdominal/Pelvic CT was obtained
following concerns for anorexia and weight loss. CT report
obtained ___ on ___ showed multiple pelvic
masses and lymphadenopathy. Images were reviewed by the ___
___ medical team and i/s/o a previous smoker presenting
with symptoms of obstructive uropathy etiology was likely
bladder cancer vs prostate cancer. Digital rectal exam done on
___ revealed extensive hard nodules anteriorly. Given history
of intermittent fevers and family history of daughter who passed
away from NHL, a primary lymphoma was also considered as a
potential etiology. UA done on ___ was negatrive for hematuria.
On ___, he underwent an ___ CT-guided biopsy of the pelvic
masses, but patient subsequently left AMA while the pathology
results were pending. We discussed that it would be safer to
stay inpatient to obtain diagnosis given possible need for
urgent transfer to oncology service, but patient delicned
stating he felt more comfortable at home. We discussed the risks
and benefits of leaving (family was also present for some of the
conversations). He had decision-making capacity at time of
discharge and also understood that the most likely diagnosis was
cancer. He was not evaluated by an oncologist while inpatient as
he did not want to stay for this.
#FEVERS, SOB: Patient reported several weeks of intermittent
fevers, sometime spiking to ___ but resolving with
acetaminophen. He continued to have these spikes during his
hospitalization. In the setting of known pelvic masses and
adenopathy, etiolgy includes B-symptoms from lymphoma vs.
PE-syndrome from pulmonary microthrombi. Given presumed Lyme
infection in ___, coinfection with Babesia Microti could have
potentially caused high spiking fevers and anemia. Work-up not
completed as patient left AMA.
TRANSITIONAL ISSUES:
====================
1) Patient set up to follow-up with ___ oncology team next
week; we also set up follow up with his PCP. We communicated
plan via phone to his ___ covering MD.
2) His H/H will need to be trended for resolution of anemia.
3) Initial hemoccult test while inpatient was inconclusive and
pt left AMA before
another attempt could be made. Given h/o adenomatous polyps,
will likely need
colonoscopy
4) Biopsy result pending on discharge
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Ferrous Sulfate 325 mg PO DAILY
2. Ascorbic Acid ___ mg PO BID
3. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Ascorbic Acid ___ mg PO BID
2. Ferrous Sulfate 325 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Outpatient Lab Work
Please check CBC.
ICD-9: 285.9. Anemia unspecified.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Symptomatic anemia
Secondary diagnosis: Pelvic tumor s/p biopsy
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. You came in with
symptomatic anemia and for workup of your pelvic tumors. We
treated you with a blood transfusion which resulted in
improvement in your anemia. You underwent a biopsy of your
pelvic tumor, and the result of your biopsy was pending on
discharge. We are not sure what this represents, but it is most
likely a form of cancer. We wanted to keep you in the hospital
until fully ruling out lymphoma, but you elected to leave the
hospital against medical advice.
We have given you a prescription for a CBC (blood counts).
Please go to your ___ office by the end of the week
(___) to have a CBC checked.
Followup Instructions:
___
|
10175457-DS-9 | 10,175,457 | 20,436,733 | DS | 9 | 2127-07-15 00:00:00 | 2127-07-18 10:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Tetracycline / Nabumetone
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Lumar Puncture
History of Present Illness:
Ms. ___ is a ___ year old right handed woman with history
of
rapidly progressive glomerulonephritis in ___ c/b CKD (baseline
Cr ~1.9), hypothyroidism, and HLD who presents for evaluation of
headache x10 days. She first developed a headache on ___.
Earlier that day, she had gone to the dentist and taken
amoxicillin. In the evening, she developed a bifrontal headache
which was throbbing, no photophobia/phonosensitivity, no nausea,
no diplopia. The headache was a ___ in severity. She did not
take anything for it. The headache became less severe, a ___,
but was constant. It was bifrontal and occasionally occipital.
Does endorse some neck stiffness, denies meningismus. Not worse
in the mornings, not exacerbated with valsalva, not interrupting
sleep. Patient does not have migraines and does not typically
have headaches. After 2 days of constant headache, Ms.
___
went to her PCP who recommended that she try Tylenol. She took
in twice, but it did not help, so she stopped taking it. As the
headache persisted, she went to the hospital for further
evaluation. There, they did blood work and a head CT which was
reportedly normal. They prescribed her Tramadol. Pt took
tramadol several times, but it did not help, so she stopped.
The
headache persisted, but was not becoming more severe. She went
to
see her PCP again who prescribed fiorocet, which again, did not
help. Has had depressed appetite, but taking in plenty of
fluids. Feels overall tired/weak and has had some chills. Feels
that her walking is a little bit more difficult than usual. She
is not falling to one side or the other. Did have a left knee
replacement in ___. No history of blood clots. Last
mammogram in ___, last colonoscopy ___ years ago, both were
normal per patient.
On neuro ROS, the pt denies 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:
Osteoporosis
Lithotripsy for renal stones ___ years ago
Hyperlipidemia
COPD/emphysema
Hypothyroid
Social History:
___
Family History:
Non-contributory
Physical Exam:
Vitals: T 97.4 HR 81 BP 145/86 RR 16 O2 100 RA
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated; surgical scar on left
knee
Skin: no rashes or lesions noted.
Neurologic:
-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 were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall ___ at 5 minutes. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
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 4+ ___ ___ 4+* 5 5 5 5 5
R 5 ___ ___ 5- 5 5 5 5 5
*limited by pain
-Sensory: No deficits to light touch, proprioception. Slightly
decreased sensation to pinprick, cold sensation in distal lower
extremities to knee bilaterally and distal upper extremities to
elbow bilaterally. 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: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Gait narrow based, steady, but places
most of weight on right leg (knee replacement on L). Romberg
mildly present.
DISCHARGE EXAM
Normal neurologic exam, alert and awake with intact cranial
nerves and full strenegth throughout.
Pertinent Results:
___ 12:10AM BLOOD WBC-9.0 RBC-4.13*# Hgb-12.7# Hct-36.6#
MCV-89 MCH-30.7 MCHC-34.7 RDW-13.6 Plt ___
___ 01:10PM BLOOD ESR-39*
___ 10:00PM BLOOD Glucose-73 UreaN-27* Creat-1.8* Na-134
K-4.1 Cl-104 HCO3-18* AnGap-16
___ 01:10PM BLOOD CRP-38.6*
Brief Hospital Course:
___ woman who was admitted with headache x 10 days, with
a normal neurologic exam and no significant MRI findings,
diagnosed with aseptic meningitis.
#ASEPTIC MENINGITIS - Initially placed on vancomycin,
ampicillin, ceftriaxone and acyclovir until CSF gram stain
negative and culture negative x72 hours, Lyme and HSV negative.
Arbovirus is pending upon discharge. Her ___ was negative, ESR
and CRP mildly elevated consistant with mild inflammation
secondary to aseptic meningitis.
INACTIVE ISSUES
# Cardiology - continued home simvastatin 20mg qd
#Hematology - Anemic, at baseline, this remained stable.
# Pulm - continued home spiriva
# Renal: CKD ___ RPGN, baseline Cr 1.9. Given IVF and creatinine
monitored while on acyclovir, it remained at baseline. Continued
home dose calcium acetate for low Ca and phosphate.
# Endo - continued home levothyroxine
OUTSTANDING ISSUES
- F/U arbovirus
- Has neurology follow up to monitor for resolution of symptoms
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tiotropium Bromide 1 CAP IH DAILY
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Simvastatin 40 mg PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 75 mcg PO DAILY
2. Simvastatin 40 mg PO DAILY
3. Tiotropium Bromide 1 CAP IH DAILY
4. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
Do not drive, drink alcohol or operate heavy machinery while
taking this medication.
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*40 Tablet Refills:*0
5. Outpatient Physical Therapy
Discharge Disposition:
Home
Discharge Diagnosis:
Viral meningitis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were seen in the hospital for headaches and malaise. You
were found to have a viral meningitis. This will likely resolve
on it's own with rest.
We made the following changes to your medications:
Please continue to take your other medications as previously
prescribed.
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:
___
|
10175944-DS-11 | 10,175,944 | 28,061,875 | DS | 11 | 2155-08-29 00:00:00 | 2155-08-30 21:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Compazine / MIDRIN / Clindamycin / Cephalosporins /
Donnatal / Imitrex / Zomig / Nsaids / Codeine / Morphine /
tramadol / Hydrocodone / vancomycin / vanco
Attending: ___.
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
EGD with intubation (___) and extubation (___)
History of Present Illness:
___ hx of NASH and EtOH cirrhosis, GI bleed txf from OSH with
anemia and concern for GI bleed. Patient presented there with
several days of generalized fatigue. She denied shortness of
breath, chest pain, fevers, vomiting. She has not noticed blood
in her stools or melena. She admited to drinking yesterday. At
the outside hospital she was noted to have a hematocrit of 17
with guaiac positive stool. She dropped her pressure at one
point to 70 systolic. She was given 2 units of red blood cells
and her blood pressure improved to 110 systolic. She was given
Protonix and transferred to ___ for further evaluation.
In the ED, initial vitals: T 97.8 P 94 BP 95/60 R 14 O2 Sat
100% nasal cannula.
Labs notable for H/H 7.6/22.4, ALT 41, AST 190, Tbili 8.8, Tn
0.02, lactate 3.5, serum EtOH 235.
-exam notable for no asterixis, abdomen soft, NT.
-abdominal u/s showed patent portal veins, cirrhotic liver with
portal HTN, splenomegaly, and massive ascites.
-patient underwent traumatic tap in ED, with results pending.
Patient endorses that she went to ___ due to
worsening fatigue over the past few weeks. She denies any recent
melena, BRBPR, hemoptysis or hematemesis. She denies abdominal
pain, CP, LH, or dizziness. No NSAID use. Pt fell last ___
in the bathroom after getting up too quickly. Landed on b/l
knees, no head strike or LOC. Her last drink of alcohol was last
night, denies a history of delirium tremens or withdrawal
seizures.
On arrival to the MICU, pt endorses b/l shoulder pain ___ OA.
Past Medical History:
PAST MEDICAL HISTORY:
asthma, diverticulitis, MRSA surgical site infection
PAST SURGICAL HISTORY:
sigmoidectomy with ileostomy s/p reversal , hysterectomy,
appendectomy, cholecystectomy, ventral hernia repair, wrist
surgery, cataract surgery, tonsillectomy, elbow surgery, s/p
TAH-BSO
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION EXAM:
==================
General: Alert, NAD
HEENT: NC/AT, EOMI, sclera icteric
COR: RRR, no m/r/g
Lungs: CTAB anteriorly
Abdomen: Soft, NT, distended,
Extremities: WWP, ecchymosis on b/l knees, wwp
Neuro: CN III-XII intact
DISCHARGE EXAM:
===================
Physical Exam:
Vitals: RR 7
General- Somnolent, appears comfortable in no acute distress
Pertinent Results:
ADMISSION LABS:
==================
___ 07:50PM BLOOD WBC-10.3*# RBC-2.08*# Hgb-7.6* Hct-22.4*#
MCV-108* MCH-36.5* MCHC-33.9 RDW-22.2* RDWSD-83.6* Plt Ct-50*#
___ 07:50PM BLOOD Neuts-83* Bands-0 Lymphs-14* Monos-3*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-8.55* AbsLymp-1.44
AbsMono-0.31 AbsEos-0.00* AbsBaso-0.00*
___ 07:50PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-OCCASIONAL
Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL Tear ___
___
___ 07:50PM BLOOD ___ PTT-42.7* ___
___ 07:50PM BLOOD Glucose-83 UreaN-30* Creat-0.9 Na-125*
K-3.9 Cl-86* HCO3-18* AnGap-25*
___ 07:50PM BLOOD ALT-41* AST-190* LD(LDH)-310* AlkPhos-91
TotBili-8.8* DirBili-4.7* IndBili-4.1
___ 07:50PM BLOOD Lipase-101*
___ 07:50PM BLOOD Albumin-2.8*
___ 07:50PM BLOOD Hapto-72
___ 07:50PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:01PM BLOOD Lactate-3.5*
PERTINENT LABS:
===================
___ 02:20AM BLOOD ALT-34 AST-141* AlkPhos-74 TotBili-9.6*
___ 07:50PM BLOOD cTropnT-0.02*
___ 12:46AM BLOOD CK-MB-2 cTropnT-0.02*
___ 07:50PM BLOOD Hapto-72
___ 01:16AM BLOOD Lactate-2.7*
___ 01:01AM URINE Color-DkAmb Appear-Hazy Sp ___
___ 01:01AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-4* pH-6.0 Leuks-SM
___ 01:01AM URINE RBC-15* WBC-102* Bacteri-NONE Yeast-NONE
Epi-0
___ 01:01AM URINE CastHy-1*
___ 09:45PM ASCITES WBC-230* ___ Polys-72* Bands-1*
Lymphs-10* Monos-1* Mesothe-1* Macroph-15*
___ 09:45PM ASCITES TotPro-2.3 Glucose-94
DISCHARGE LABS:
===================
___ 03:10PM BLOOD Hgb-6.6* Hct-18.9*
___ 01:56AM BLOOD ___ PTT-45.9* ___
___ 01:56AM BLOOD Glucose-114* UreaN-43* Creat-2.2* Na-126*
K-4.1 Cl-87* HCO3-20* AnGap-23*
___ 01:56AM BLOOD ALT-22 AST-75* TotBili-9.2*
___ 01:56AM BLOOD Calcium-9.2 Phos-2.5* Mg-2.2
___ 03:19PM BLOOD ___ pO2-50* pCO2-40 pH-7.38
calTCO2-25 Base XS-0
IMAGING:
===================
ECG (___):
Baseline artifact. Sinus rhythm. Early R wave progression.
Diffuse
non-specific ST-T wave changes. No previous tracing available
for comparison. Clinical correlation is suggested.
Rate PR QRS QT QTc (___) P QRS T
95 160 75 ___ 40 4 107
Abd U/S with Doppler (___):
1. Patent portal veins with reversed flow.
2. Cirrhotic liver with sequela of portal hypertension,
including splenomegaly and massive ascites.
CXR (___):
1. ET tube is located the origin of the right mainstem bronchus,
and should be pulled back 4 cm for more standard positioning.
2. Worsening left upper lobe pneumonia.
EGD (___):
Erythema and friability in the middle third of the esophagus and
upper third of the esophagus compatible with esophagitis
No esophageal varices seen
Varices at the fundus (injection, injection)
Granularity, friability, erythema, congestion and mosaic
appearance in the fundus and stomach body compatible with portal
hypertensive gastropathy
Blood in the stomach body and antrum
Otherwise normal EGD to second part of the duodenum
MICROBIOLOGY:
=================
___ 7:50 pm BLOOD CULTURE: No growth to date
GRAM STAIN (Final ___:
1+ (<1 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 (Preliminary):
ANAEROBIC CULTURE (Preliminary):
STAPH AUREUS COAG +. >100,000 ORGANISMS/ML..
Brief Hospital Course:
___ hx of NASH vs alcoholic cirrhosis, hepatic encephalopathy,
and prior GI bleeds who was transferred from ___ ___
with anemia and concern for GI bleed.
She was initially admitted to the MICU for urgent endoscopy. She
underwent EGD ___ which showed no bleeding esophageal varices,
but large gastric varices without stigmata of recent bleeding.
These were treated with glue injections. She required 3 RBC
transfusions over a few days. She was initially on octreotide
and an IV PPI. She was also given ciprofloxacin for infection
prophylaxis in the setting of cirrhosis and UGIB.
While in the ICU she had progressive acute renal failure and was
treated for hepatorenal syndrome. She became more
encephalopathic and an NG tube was placed to administer
lactulose. Diagnostic + therapeutic paracentesis showed no
evidence of peritonitis. In the setting of worsened renal
failure (Cr 2.2), encephalopathy, ongoing slow blood loss
causing transfusion dependent anemia, and high MELD score
suggestive of high 3 month mortality, the health care proxy
(sister, ___ decided that Ms. ___ would not want further
interventions and had given up hope of improvement (ineligible
for transplantation due to ongoing alcohol use). She was
transitioned to comfort measures only and transferred out of the
ICU with narcotics for pain and respiratory distress. Case
management had ___ enrolled in hospice to pursue
inpatient hospice given anticipated rapid deterioration from
cirrhosis, renal failure, and encephalopathy.
BY PROBLEM:
#UGIB due to gastric varices: s/p EGD ___ with glue injection
into varices. Received 2U pRBC transfusion with stable H/H. She
was continued on octreotide gtt for 72 hours, IV PPI BID, and
ciprofloxacin for prophylaxis.
___: Cr 1.3 from 0.9. Likely in setting of
pre-renal/hypovolemia. No episodes of hypotension to suggest HRS
at this time.
#Elevated anion gap: unclear of pH, though PCO2 low ___
yesterday likely due to restrictive physiology from ascites and
AG may be elevated from acute on chronic kidney disease.
#Staph Aureus Bacteriuria: new, associated with Foley. Held off
an antibiotics given no symptoms. Foley catheter was
discontinued.
#Decompensated Cirrhosis: MELD 25. Decompensated in the setting
of ascites, asterixis, and bleeding gastric varices.
#Hyponatremia: Hypervolemic. Most likely due to ADH secretion in
setting of low SVR and poor effective renal blood flow due to
cirrhosis. On diuretics that are currently on hold.
#Alcohol abuse: EtOH 235 on admission with evidence of
macrocytosis. She was started on multivitamin, thiamine, and
folate.
#Asthma: continued on albuterol and Advair.
# Osteoarthritis: continued lidocaine patch, APAP
#Code: CMO DNI/DNR
#Communication: ___ (sister) ___ (cell), (home)
___ & ___ (son, age ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
2. albuterol sulfate 90 mcg/actuation INHALATION Q4H SOB
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Furosemide 40 mg PO DAILY
5. Spironolactone 50 mg PO DAILY
6. Pantoprazole 40 mg PO Q12H
Discharge Medications:
1. HYDROmorphone (Dilaudid) 0.5-1.5 mg/hr SUBCUT INFUSION
INFUSION
Bolus 1 mg SQ q15min PRN pain
Concentration 5mg/mL
Dispense 6 bags
100mL bags
Hospice
RX *hydromorphone 2 mg/mL 0.5-1.5 mg SQ infusion continuous Disp
#*6 Bag Refills:*1
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. Glycopyrrolate 0.1 mg IV Q6H:PRN excess secretions
4. Lorazepam 0.5-2 mg IV Q2H:PRN anxiety/distress
5. Ondansetron 4 mg IV Q8H:PRN nausea
6. Lidocaine 5% Patch 1 PTCH TD QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Acute blood loss anemia
Multi-organ failure
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ after having bleeding in your GI
tract from abnormal blood vessels in your stomach. You received
many units of blood and a procedure to try and stop the bleeding
but this wasn't effective. Your organs began to fail and you and
your family decided further invasive procedures would not be in
your goals of care. You were transferred out of the ICU and
your pain was treated with a pain medicine IV. Hospice was
contacted and we transferred your care to hospice services. It
was an honor to take part in your medical care. Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10176087-DS-11 | 10,176,087 | 21,498,645 | DS | 11 | 2116-07-13 00:00:00 | 2116-07-18 13:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Pulmonary embolism
Major Surgical or Invasive Procedure:
IVC filter placement ___
History of Present Illness:
___ yr old male with pmhx severe depression/anxiety, HLD who
presents with progressive dyspnea on exertion for the last 2
weeks. Initially started after playing tennis, but worsened to
simple tasks like mowing the lawn and most recently running
in/out of house to get wallet. He is normally a very active
person, playing tennis and doing yard/house work, although
recently since depression has been sitting at home all day (per
daughter). He admits to recurring chest tightness/soreness and
palpitations associated with anxiety (baseline) and denies any
new chest discomfort associated with the dyspnea. He also admits
to nervous cough, but no new cough, fevers/chills. He denies any
lower extremity edema/pain or recent ___. He has traveled
frequently recently: 1 flight to ___ 1.5 months ago,
5 hr car trip 3 weeks ago, and 1 car trip to ___ 2 weeks
ago.
He went to his PCP ___. CXR was negative, however, D-Dimer
was elevated to 6003 and he was referred to ___.
In the ED, patient was hemodynamically stable, with vitals T
99.3 HR 98 BP 136/84 RR 18 O2 96% on RA. EKG showed TWI V1-V3.
Troponins were negative x1, INR 1.1, and CBC and BMP were
unremarkable. CTA showed large saddle pulmonary embolus with
mild straightening of the interventricular septum suggestive of
heart strain. He was bolused with IV heparin and started on a
heparin gtt.
On arrival to the ICU, his vital signs were noteable for HR 89
BP 138/78, RR 23, 93% RA. He denied any shortness of breath at
rest. He also denies any recent weight loss (although he
previously had 20# wt loss in ___ attributable to
depression; has been stable since), no
hematochezia/melena/change in bowel habits, F/C/night sweats.
His last colonoscopy in ___ showed diverticulosis and internal
hemorrhoids, with recommended repeat in ___ (has not had).
Past Medical History:
DEPRESSION
ANXIETY
DIVERTICULOSIS
LACTOSE INTOLERANCE
HYPERCHOLESTEROLEMIA (Last Chol in ___: Total cholest 151,
HDL 49, LDL 93, ___ 43)
ESOPHAGEAL RING
GERD
HYPOTESTOSTERONISM
SLEEP DISORDER, NON-ORGANIC
OSTEOARTHRITIS
GLUCOSE INTOLERANCE
Social History:
___
Family History:
Father died from MI. Mother died from lymphosarcoma. No blood
clots or bleeding disorder in the family. Sister has factor V
heterozygosity.
Physical Exam:
ADMITTING EXAM:
Vitals- T: 99.7 BP: 138/75 P: 93 R: 24 O2: 95% 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,
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. Palpable,
firm, non-fixed 2-3 cm lesion under right costal margin at the
mid-axillary line.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema , no palpable or tender cords
Skin: Scattered hemangiomas over torso. 3 circular purpura on
left forearm.
DISCHARGE EXAM:
Vitals: T 99.3, HR 90, BP 123/65, RR 20, 95% 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, distended, nontender, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
___ 04:42PM BLOOD WBC-9.9 RBC-4.67 Hgb-15.9 Hct-47.8
MCV-102* MCH-34.1* MCHC-33.3 RDW-13.5 Plt ___
___ 04:42PM BLOOD Neuts-76.9* Lymphs-13.8* Monos-8.2
Eos-1.0 Baso-0.3
___ 04:42PM BLOOD ___ PTT-25.2 ___
___ 04:42PM BLOOD Glucose-139* UreaN-16 Creat-0.9 Na-136
K-4.3 Cl-101 HCO3-25 AnGap-14
___ 11:21PM BLOOD CK(CPK)-75
___ 04:42PM BLOOD proBNP-776*
___ 04:42PM BLOOD Calcium-8.9 Phos-2.3* Mg-2.3
DISCHARGE LABS:
___ 07:50AM BLOOD WBC-9.9 RBC-4.13* Hgb-14.3 Hct-42.1
MCV-102* MCH-34.7* MCHC-34.0 RDW-12.7 Plt ___
___ 07:50AM BLOOD ___ PTT-28.9 ___
___ 07:50AM BLOOD Glucose-118* UreaN-9 Creat-0.9 Na-139
K-4.2 Cl-102 HCO3-29 AnGap-12
___ 07:50AM BLOOD Calcium-8.6 Phos-2.6* Mg-2.3
EKG (___): Baseline artifact. Sinus rhythm. Diffuse
non-specific ST segment flattening in the limb leads and the
right and mid-precordial leads. Delayed anterior R wave
progression in leads V1-V4 with slight T wave inversions of
uncertain significance, but recent anterior wall myocardial
infarction in evolution cannot be excluded. Compared to the
previous tracing of ___ T wave inversions are less deeply
inverted in leads V3-V4.
IMAGING:
CTA (___):
Extensive bilateral pulmonary emboli including saddle embolism
with greatest clot burden in the right lower lobe. Probable
early infarction in the right lower lobe, possibly also in the
left lower lobe. No definite evidence of right heart strain.
Bilateral lower extremity doppler (___):
Nonocclusive thrombus extending from the mid femoral vein
through the
popliteal vein and involving the anterior peroneal vein within
the left lower extremity.
ECHO: The left atrium is normal in size. No atrial septal defect
is seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). The estimated
cardiac index is normal (>=2.5L/min/m2). Diastolic function
could not be assessed. 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 structurally normal. There is no mitral valve
prolapse. No mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Normal biventricular cavity size and global/regional
systolic function. No pathologic valvular abnormalities. Normal
estimated pulmonary artery systolic pressure.
Brief Hospital Course:
Mr. ___ is a ___ year old man with a past medical history
significant for severe depression and hyperlipidemia who
presents with progressive dyspnea on exertion and found to have
a saddle pulmonary embolus.
# PULMONARY EMBOLUS: PE was likely provoked in the setting of
immobilization and recent travel and possibly related to
testosterone replacement. He may have factor V heterozygosity
given family history. Patient has had no recent trauma,
surgeries, or previous VTE/family history of VTE. He is also
without signs of occult malignancy (e.g. weight loss, f/c, night
sweats), and last colonoscopy was without polyps. On admission,
patient was hemodynamically stable, an echocardiogram showed no
evidence of right heart strain, and troponins were negative.
Patient was started on a heparin drip. A lower extremity
doppler revealed a thrombus in the left femoral vein so an IVC
filter was placed by cardiology. He was discharged on warfarin
5mg daily with an enoxaparin bridge. His oxygen saturation on
discharge was 90-05% on room air at rest and while ambulating.
# DEPRESSION/ANXIETY: Patient was continued on home
medications. He expressed significant concern regarding new
diagnosis of PE and prognosis. He has an outpatient psychiatry
appointment scheduled for several days post-discharge.
TRANSITIONAL ISSUES:
- He was discharged on warfarin 5mg with a lovenox bridge.
- Patient was set up with a PCP appointment and ___ need his
warfarin dose monitored as an outpatient.
- He also has an appointment with psychiatry several days after
discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. fluvoxaMINE 100 mg oral qAM
2. Fluvoxamine Maleate 50 mg PO QD @ 1400
3. Simvastatin 20 mg PO QPM
4. Lorazepam 1 mg PO TID:PRN insomnia
5. Amphetamine Salt Combo (dextroamphetamine-amphetamine) 5 mg
oral TID PRN decreased alertness
6. QUEtiapine Fumarate 12.5 mg PO QHS:PRN insomnia
7. Aspirin 81 mg PO DAILY
8. Testosterone Cypionate 300 mg IM Q MONTHLY hypotestosteronism
9. BuPROPion (Sustained Release) 100 mg PO QD @ 1500
10. BuPROPion (Sustained Release) 150 mg PO QAM
11. Wellbutrin XL (buPROPion HCl) 150 mg oral qAM
Discharge Medications:
1. Amphetamine Salt Combo (dextroamphetamine-amphetamine) 5 mg
oral TID PRN decreased alertness
2. BuPROPion (Sustained Release) 100 mg PO QD @ 1500
3. BuPROPion (Sustained Release) 150 mg PO QAM
4. Fluvoxamine Maleate 50 mg PO QD @ 1400
5. Lorazepam 1 mg PO TID:PRN insomnia
6. QUEtiapine Fumarate 12.5 mg PO QHS:PRN insomnia
7. Simvastatin 20 mg PO QPM
8. Acetaminophen ___ mg PO Q8H:PRN pain
RX *acetaminophen 500 mg ___ tablet(s) by mouth Every 8 hours
Disp #*60 Tablet Refills:*0
9. Enoxaparin Sodium 80 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 80 mg/0.8 mL 80 mg SC Twice daily Disp #*14
Syringe Refills:*0
10. Warfarin 5 mg PO DAILY16
RX *warfarin 1 mg 5 tablet(s) by mouth Daily Disp #*100 Tablet
Refills:*0
11. fluvoxaMINE 100 mg oral qAM
12. Wellbutrin XL (buPROPion HCl) 150 mg ORAL QAM
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
# Saddle pulmonary embolism
# Deep vein thrombosis
Secondary diagnoses:
# Depression
# Hyperlipidemia
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___. You were admitted
after having a pulmonary embolism. We treated you with
medications to prevent your blood from coughing and you required
observation in the ICU for a night. Your symptoms improved and
we discharged you on lovenox injections and warfarin tablets.
It is very important for you to keep your appointments to
monitor your INR levels, which determine how well your warfarin
is working. You will only need the lovenox shots for a short
period of time. You may resume normal physical activity but be
aware that you are at higher risk of bleeding if you should
injure yourself.
Take care, and we wish you the best.
Sincerely,
Your ___ medicine team
Followup Instructions:
___
|
10176494-DS-13 | 10,176,494 | 21,768,537 | DS | 13 | 2149-03-18 00:00:00 | 2149-03-24 18:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins / Aspirin
Attending: ___
Chief Complaint:
shaking spell
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old male, with a past medical history of ankylosing
spondylitis, htn, b12 deficiency who is presenting with a
shaking
episode early this morning. Per the patient, he woke up around
3am (because his wife had woken up) and was having trouble
talking. He remembers being confused, and being brought into the
emergency room. He cannot recount any further details, and
defers
to his wife, who was there at the time. Family members were
contacted with the aid of a telephone interpreter. Wife was not
available for contact (non-working phone number, and a phone
number with no voicemail service). His step daughter, ___, who lives one floor above the patient and his wife, was
reached for further details. She states that she did not witness
the shaking, but his wife told her that he was moving all 4
limbs
and it lasted "around a minute or so." She came downstairs
shortly thereafter. She notes that his tongue was shaking, and
he
was very out of it, as if he had fainted. No incontinence or
tongue biting. When he came to, he was confused, and his speech
was off, like his tongue was entangled, he was just making
sounds, not words. When asked what is happening, he touched his
chest, asked if he had chest pain and he nodded yes. EMS was
called at this time. They asked him many questions and he didnt
remember what year he was born, didn't remember the date. Did
not
appear tired or somnolent.
At home, the patient is unable to walk on his own without
walker,
and has had issues with balance for the past ___ years, he has
been
seeing physical therapy for this. He was evaluated in the
emergency room by neurology in ___, who thought he may be
orthostatic and recommended reducing his lisinopril dose from 40
to 20mg daily. His exam at this time was notable for no
nystagmus, narrow-based gait, no dysmetria, full strength and
normal sensation to all modalities. Per stepdaughter, he falls
quite often, and has hit his head a lot. Has been getting worse
over the past year, she is not able to quantify his falls with a
number. Patient states that he falls because his leg becomes
stiff, he always falls to the left. At homedoes his own cooking
and cleaning, etc. He takes his medications on his own.
Past Medical History:
Arthritis, gout, depression/anxiety, htn, insomnia, sleep apnea.
Social History:
___
Family History:
Mother deceased with breast cancer,
father deceased with stomach cancer. Seven sisters and seven
brothers are apparently alive and well. No neurological
problems.
Physical Exam:
Vitals - 98.7, 150/82, 73, 97% RA
**NEUROLOGICAL EXAM**
Mental status - awake and alert. Oriented to name, hospital,
states date is ___, does not know the year. Language
is fluent with no paraphrasic errors, normal prosody and no
dysarthria. Naming to high and low frequency objects is intact.
Calculation intact. Can name days of the week forwards and
backwards in ___ without difficulty and no errors. Verbal
registration and recall ___. No apraxia. No evidence of
hemineglect. No left-right agnosia.
- Cranial Nerves - [II] PERRL 3->2 brisk. VF full to number
counting. [III, IV, VI] EOMI, nystagmus on rightward gaze,
fatigues after 5 seconds. No diplopia. [V] V1-V3 without
deficits
to light touch bilaterally. [VII] No facial movement asymmetry.
[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.
=[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[___]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1] [L5]
L 5 5 5 5 4 5 5 5 5 5 5
R 5 5 5 5 4 5 5 5 5 5 5
- Sensory - No deficits to light touch, pin, or proprioception
bilaterally. Vibration sense mildly decreased bilateral toes.
- Reflexes
=[Bic] [Tri] [___] [Quad] [Gastroc]
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response flexor bilaterally.
- Coordination - No dysmetria with finger to nose and heel shin
testing bilaterally. Good speed and intact cadence with rapid
alternating movements.
- Gait - Very unsteady, wide based. No sway with romberg.
Exam was unchanged at time of discharge
Pertinent Results:
EEG:
FINDINGS:
BACKGROUND: Consisted of a low voltage fast background seen
throughout the
recording. On occasion, a low voltage 11 Hz posterior dominant
rhythm was
seen.
HYPERVENTILATION: Not performed.
INTERMITTENT PHOTIC STIMULATION: Produced no activation of the
record.
SLEEP: No state changes were seen.
CARDIAC MONITOR: Showed an irregularly irregular rhythm.
IMPRESSION: This is a normal routine EEG in the waking state. No
focal or
epileptiform features were seen.
CT HEAD:
TECHNIQUE: Contiguous axial MDCT images were obtained through
the brain
without administration of IV contrast. Multiplanar reformatted
images in
coronal and sagittal axes and thin-section bone algorithm
reconstructed images
were acquired.
DLP: 898 mGy-cm
CTDIvol: 64 mGy.
COMPARISON: None available
FINDINGS:
There is no evidence of acute hemorrhage, edema, mass effect or
acute major
vascular infarction. Moderate prominence of the ventricles and
sylvian
fissures, and milder prominence of the sulci, indicate
parenchymal atrophy.
The left lateral ventricle is larger than the right, likely a
congenital or
developmental finding. The basal cisterns appear patent.
No fracture is identified. The visualized paranasal sinuses and
mastoid air
cells are clear.
IMPRESSION:
No evidence of acute intracranial process.
MRI/MRA head and neck
TECHNIQUE: Sagittal T1 imaging was performed followed by axial
diffusion,
FLAIR, T2, gradient echo, and 3 dimensional time-of-flight MRA.
Neck MRA was
performed during infusion of 13 cc of MultiHance intravenous
contrast.
COMPARISON: Head CT ___.
FINDINGS:
Images of the brain demonstrate no evidence of hemorrhage,
edema, masses, mass
effect, or infarction. The ventricles and sulci are mildly
prominent in an
atrophic pattern.
The brain MRA is of somewhat limited technical quality due to
motion artifact.
Within this limitation, no definite abnormalities are
demonstrated. The left
vertebral artery is hypoplastic and appears to terminate in the
posterior
inferior cerebellar artery. There is no evidence of aneurysm or
stenosis.
The MRA of the neck appears normal. The origins of the great
vessels,
subclavian, carotid, and cervical vertebral arteries appear
normal. The right
vertebral artery is dominant. There is no evidence of internal
carotid artery
stenosis by NASCET criteria.
IMPRESSION:
Hypoplastic left vertebral artery. No other abnormalities
detected.
Brief Hospital Course:
Mr. ___ was admitted to the general neurology service.
EEG was normal. MRI/MRA did not reveal any acute intracranial
processes to account for the paitent's symptoms. He was not
started on anti-convulsive medicine as if this spell was due to
seizure activity it would be the patient's first seizure. He
will be followed in neurology clinic.
Medications on Admission:
Active Medication list as of ___:
Medications - Prescription
ALLOPURINOL - allopurinol ___ daily - NOT TAKING
CHLORTHALIDONE - chlorthalidone 25 mg tablet. 1 Tablet(s) by
mouth qam (replaced hydrochlorothiazide)
COLCHICINE [COLCRYS] - Colcrys 0.6 mg tablet. 1 Tablet(s) by
mouth daily only during gout attacks
LIDOCAINE - lidocaine 5 % (700 mg/patch) Adhesive Patch. apply
to
lower back 12 hours on, 12 hours off
LISINOPRIL - lisinopril 40 mg tablet. 1 Tablet(s) by mouth daily
NAPROXEN - naproxen 375 mg tablet,delayed release. 1 tablet(s)
by
mouth twice daily
TRAZODONE - trazodone 50 mg tablet. 1 Tablet(s) by mouth at
bedtime as needed for insomnia
Medications - OTC
ACETAMINOPHEN - acetaminophen 500 mg tablet. 2 tablet(s) by
mouth
three times a day as needed for for pain
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 + D] - Calcium 500 + D
500 mg(1,250 mg)-400 unit chewable tablet. 1 Tablet(s) by mouth
twice a day
CYANOCOBALAMIN (VITAMIN B-12) - cyanocobalamin (vitamin B-12)
1,000 mcg tablet. 2 tablet(s) by mouth once a day
METHYLCELLULOSE (LAXATIVE) [CITRUCEL SUGAR FREE] - Citrucel
Sugar
Free Oral Powder. 1 scoop Powder(s) by mouth with water BID
OMEPRAZOLE - omeprazole 20 mg tablet,delayed release. 1
Tablet(s)
by mouth once a day
--------------- --------------- --------------- ---------------
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN pain
2. Chlorthalidone 25 mg PO DAILY
3. Cyanocobalamin ___ mcg PO DAILY
4. Lidocaine 5% Patch 1 PTCH TD Q 12H
5. Lisinopril 40 mg PO DAILY
6. TraZODone 50 mg PO HS:PRN insomnia
7. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth
Daily Disp #*30 Tablet Refills:*5
8. Omeprazole 40 mg PO DAILY
RX *omeprazole 20 mg 2 capsule,delayed ___ by
mouth Daily Disp #*60 Capsule Refills:*5
9. Allopurinol ___ mg PO DAILY:PRN gout attack
10. calcium carbonate-vit D3-min 600 mg calcium- 400 unit Oral
BID
11. Citrucel (methylcellulose (laxative);<br>methylcellulose
(with sugar)) 1 scoop Oral BID
12. Naproxen 375 mg PO Q12H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
First time seizure
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 ___,
You were admitted to the neurology service at ___ for
suspected seizure. You had an EEG which was normal. You also had
an MRI of your brain which did not show any problems to explain
your symptoms. You were evaluated by physical therapy who felt
that you were safe to go home.
We made the following changes to your medications:
1) STARTED ASPIRIN 81mg daily
2) INCREASED OMEPRAZOLE to 40mg daily
It was a pleasure taking care of you during this hospital stay.
Please follow up with your primary care physician in the next
___ weeks. Please follow up in Neurology clinic as below.
Followup Instructions:
___
|
10176494-DS-14 | 10,176,494 | 28,734,584 | DS | 14 | 2151-01-11 00:00:00 | 2151-01-14 18:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Aspirin
Attending: ___.
Chief Complaint:
unresponsive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o M with PMH of ETOH abuse, HTN, and arthritis who was
found unresponsive in his car by his wife. She called ___ and he
brought in by EMS. Found to have pinpoint pupils and decreased
respiratory effort with pt receiving 2mg narcan and intubated
before arriving to the ED in ___. He has no known history of
DTs or seizures based on review of records. Of note, recently
had ED visit on ___ and ___ for similar ETOH intoxication
episodes before discharge in a 24h period.
In the ED, initial vitals: 98.1 56 130/93 18 100% Intubation
ETOH significant for 546. Negative serum, UTox.
pH 7.49 pCO2 26 pO2 473 HCO3 20 BaseXS -1 on FiO2
In the ED, he had a CT head performed that was unremarkable and
CXR that was unremarkable for any acute process.
On transfer, vitals were: 60 159/97 16 100% intubation. When he
arrived in the MICU, he had vital signs 98.3 F, HR 69, BP
143/93, RR 18, O2 sat 99% on CMV FiO2 40% PEEP 5 TV 400 RR 16.
He was extubated on the early morning of ___ and
Past Medical History:
ETOH Abuse
Arthritis
Gout
Depression/anxiety
HTN
Insomnia
Sleep apnea
Ankylosing Spondylitis
Obesity
Vit B12 Anemia
Osteopenia
Social History:
___
Family History:
Mother deceased with breast cancer, father deceased with stomach
cancer. Seven sisters and seven brothers are apparently alive
and well. No neurological problems.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: 98.3 69 143/93 18 99% on ___ FiO2 40% PEEP 5 TV 400 RR
16.
GENERAL: Intubated, moving extremities with purposeful but no
directable movements when sedation withdrawn
HEENT: Sclera anicteric, ET tube in place, eyes pinpoint
NECK: supple
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
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
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: No e/o external trauma
NEURO: Unable to fully assess given sedation. Moves extremities
freely.
DISCHARGE PHYSICAL EXAM
Vitals: T: 98.9 F BP: 120/69 P: 65 R: 18 O2: 95% 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: RRR, no murmurs
Abdomen: soft, NTND, bowel sounds present, no rebound tenderness
or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: EOMI, moving all limbs equally
Pertinent Results:
___ 09:27PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 09:27PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 09:00PM UREA N-22* CREAT-1.1 SODIUM-146*
POTASSIUM-3.7 CHLORIDE-112* TOTAL CO2-21* ANION GAP-17
___ 09:00PM ALT(SGPT)-13 AST(SGOT)-23 LD(LDH)-197 ALK
PHOS-44 TOT BILI-0.2
___ 09:00PM LIPASE-40
___ 09:00PM ALBUMIN-3.7 CALCIUM-9.1 PHOSPHATE-2.3*
MAGNESIUM-2.1
___ 09:00PM ASA-NEG ___ ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 09:00PM WBC-8.4 RBC-4.44* HGB-13.0* HCT-39.7* MCV-89
MCH-29.3 MCHC-32.7 RDW-14.5 RDWSD-47.2*
___ 09:00PM ___ PTT-28.2 ___
___ 10:08PM TYPE-ART RATES-18/ TIDAL VOL-450 PEEP-5
O2-100 PO2-473* PCO2-26* PH-7.49* TOTAL CO2-20* BASE XS--1
AADO2-214 REQ O2-44 -ASSIST/CON INTUBATED-INTUBATED
Brief Hospital Course:
___ year old male with past medical history of EtOH abuse, HTN,
and arthritis who presented unresponsive, found to have EtOH
intoxication. His ETOH level presenting here was 546. He has had
two other admissions with similar presentation in the last two
weeks.
ACTIVE ISSUES
- Altered mental status ___ acute alcohol intoxication:
Workup revealed EtOH level of 546. CT head showed no acute
process and no other revealing etiology for his change mental
status. LFTs and lipase were within normal limits. Lactate was
elevated at 2.5 and downtrended to 2.1. CIWA protocol, MVI,
folate and thiamine were started for history of alcohol abuse.
Given concern for withdrawal while on CIWA scale, he was started
on phenobarbital withdrawal protocol with a loading dose in the
ICU. No seizure activity was noted. Social work was consulted
for active substance abuse but unable to see pt before he left
AMA.
- Airway protection requiring intubation:
He remained intubated and mechanically ventilated in the MICU on
___ for airway protection. Fentanyl and propofol were weaned in
the morning and he was extubated without incident to room air on
the early morning of ___. He remained on room air and was
hemodynamically stable the rest of his hospital stay.
CHRONIC ISSUES
- Hypertension:
Initially his home antihypertensives were held while intubated.
He remained normotensive. Following extubation on ___, he was
restarted on his home medications.
- Arthritis:
Naproxen was held during his hospital stay.
- Gout:
Home allopurinol was held in the setting of intubation and
restarted on ___.
TRANSITIONAL ISSUES
-AMA:
The patient left on ___ against medical advice on day 2 of
his 7 day phenobarbitol taper. He was counseled about the risks
of leaving the hospital while being treated for alcohol
withdrawal, which included seizures and death, as well as the
increased sensitivity to alcohol in the next week owing to
residual phenobarbital in his system. The patient insisted on
leaving and did not receive a prescription for phenobarbitol due
to the risk of respiratory depression if he were to drink again.
-Need for EtOH substance abuse counseling:
The patient is pre-contemplative about his EtOH abuse but would
benefit from being seen by a social worker. We recommended that
he f/u with his PCP and be seen by a social worker to discuss
his EtOH abuse.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Chlorthalidone 25 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. Naproxen 500 mg PO Q12H:PRN pain
6. Acetaminophen 1000 mg PO Q8H:PRN pain
7. Amlodipine 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Allopurinol ___ mg PO DAILY
3. Amlodipine 10 mg PO DAILY
4. Chlorthalidone 25 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. Naproxen 500 mg PO Q12H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
ETOH intoxication
Secondary diagnosis:
HTN
Gout
Arthritis
Spondylosing ankylosis
Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ because of alcohol intoxication. You
were intubated (had a breathing tube put in) and required
medication to prevent alcohol withdrawal. We encourage you to
seek substance abuse counseling when you feel ready to stop
drinking. We wish you all the best.
Sincerely,
Your ___ treatment team
Followup Instructions:
___
|
10176643-DS-10 | 10,176,643 | 25,918,580 | DS | 10 | 2143-11-12 00:00:00 | 2144-01-06 15:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
bacitracin / Aquaphor / adhesive / Latex, Natural Rubber /
Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
rash
Major Surgical or Invasive Procedure:
I+D ___ of leg hematoma
History of Present Illness:
___ with a past medical history notable for recurrent PEs and
DVT is currently on Coumadin and who has an IVC filter presents
with 2 days of right lower extremity pain as well as one day of
rash. Approximately 2 months ago the patient had 2 basal cell
carcinomas removed from the right lower extremity. Since that
time one of the incision site has been oozing from an underlying
hematoma. The patient reports that she developed right medial
thigh pain 2 days ago and saw her PCP. She had a DVT study which
was negative at that time. Today she developed a splotchy rash
over her right lower extremity and saw her primary care
physician who started her on Keflex which she has taken one dose
thus far. The rash rapidly progressed and she saw another
physician today who told her to come to the emergency department
for further evaluation and IV antibiotics. She denies any fever,
chills, chest pain, shortness of breath, abdominal pain, cough,
nausea, vomiting, dysuria, bowel changes.
In ED pt given vancomycin. ___ duplex without VTE.
Past Medical History:
plasminogen activating factor inhibitor (PAF1) complicated by
recurrent PEs and DVTs s/p IVC filter on anticoagulation
hyperlipidemia
gout
Social History:
___
Family History:
Non contributory
Physical Exam:
Vitals: 98.5, 122/65, 81, 20, 94% RA
PAIN:
General: Pleasant Caucasian female in no distress
EYES: anicteric
Lungs: clear bilaterally
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd
Ext: no e/c/c
Skin: erythematous rash along right lower extremity overlying
tibia extending up to knee with no associated joint swelling,
relatively nontender, 2 X 2 cm fluctuant area overlying tibia
with wick in place non-draining currently
Neuro: alert, follows commands
Pertinent Results:
___ 07:10PM GLUCOSE-89 UREA N-17 CREAT-1.0 SODIUM-137
POTASSIUM-3.6 CHLORIDE-96 TOTAL CO2-29 ANION GAP-16
___ 07:11PM LACTATE-1.3
___ 07:10PM WBC-11.3* RBC-4.31 HGB-14.2 HCT-42.7 MCV-99*
MCH-32.9* MCHC-33.3 RDW-12.8 RDWSD-46.4*
___ 07:10PM NEUTS-79.3* LYMPHS-12.5* MONOS-6.5 EOS-1.0
BASOS-0.4 IM ___ AbsNeut-9.00* AbsLymp-1.42 AbsMono-0.74
AbsEos-0.11 AbsBaso-0.04
___ 07:10PM PLT COUNT-171
___ 07:10PM ___ PTT-53.5* ___
___ 07:10PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 07:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-TR
___ 07:10PM URINE RBC-<1 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-1
___ 07:10PM URINE MUCOUS-OCC
Brief Hospital Course:
___ year old female with recent history of removal of 2 basal
cell carcinomas in ___ presenting with progressive pain
and swelling in right lower extremity now with acute development
of cellulitic rash overlying right tibia.
Improved on IV antibiotics. General surgery saw her and
performed I+D in ID with wick placement - they will see her in
outpatient clinic.
.
# PAF-1 inhibitor - continued warfarin
.
# Gout - allopurinol
.
# Hyperlipidemia - continued simvastatin
.
# Hypertension - continued spironolactone and bumex
.
___ ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
You were admitted for a rash on your leg. To treat this, we
performed drainage of the area, and started you on IV
antibiotics. Please continue oral antibiotics (Augmentin) -
see prescription attached. You will also need to be seen by
surgery in about 10 days to get this area re-examined. Please
call ___ on ___ to get this appointment scheduled
for approximately 10 days from now.
Followup Instructions:
___
|
10176833-DS-6 | 10,176,833 | 20,607,200 | DS | 6 | 2122-08-03 00:00:00 | 2122-08-03 14:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R tibial plateau fx
Major Surgical or Invasive Procedure:
ORIF R tibial plateau fx with anterior compartment release
History of Present Illness:
___ transferred from OSH s/p ATV rollover p/w right proximal
tibia fracture. No numbness, intermittent tingling but no
definite paresthesias. Denies injury elsewhere.
Past Medical History:
None
Social History:
___
Family History:
non-contributory
Physical Exam:
NVI distally in RLE
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 tibial plateau fx and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF right tibia with anterior
compartment release, 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
NVI distally in the right lower 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 EC 325 mg PO DAILY Duration: 2 Weeks
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Multivitamins 1 TAB PO DAILY
5. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*65 Tablet Refills:*0
6. Senna 8.6 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
right Shatzker VI tibial plateau fracture s/p ORIF with anterior
compartment release
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:
- TDWB RLE in unlocked ___, ROMAT
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 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 do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
Followup Instructions:
___
|
10176871-DS-8 | 10,176,871 | 28,364,588 | DS | 8 | 2162-05-13 00:00:00 | 2162-05-13 18:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
latex
Attending: ___
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
Patient is a ___ year odl female with PMHx significant for
DVT/PE on Coumadin as well as HTN who presented to an OSh on
___ for headache and underwent CT head showing pituitary
hemorrhage. She Was instructed to followup for an outpatient MRI
to further assess the lesion. This morning she was in
excruciating pain and returned to the OSH ED and underwent MRI
scan that showed a subacute pituitary hemorrhage. She was
transferred to ___ for further management and care as well as
neurosurgical evaluation.
Past Medical History:
Rotator cuff surgery, HTN, Depression, anxiety, DVT/PE on
coumadin
Social History:
___
Family History:
N/A
Physical Exam:
On admission:
PHYSICAL EXAM:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs intact without nystagmus
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
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, 3mm to
2mm bilaterally. Visual fields are grossly 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.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Proximal LUE deferred secondary to recent rotator cuff
surgery, distal LUE full, RUE and BLE full strength. Normal bulk
and tone bilaterally. No abnormal movements, tremors.No pronator
drift
Sensation: Intact to light touch bilaterally
Coordination: normal on finger-nose-finger
On discharge:
Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious
Orientation: [x]Person [x]Place [x]Time
Follows commands: [ ]Simple [x]Complex [ ]None
Pupils: Right ___ Left ___
EOM: [ ]Full [x]Restricted
Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No
Pronator Drift [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No
Comprehension intact [x]Yes [ ]No
Motor:
TrapDeltoidBicepTricepGrip
___
IPQuadHamATEHLGast
Right___
Left5 5 5 5 5 5
Pertinent Results:
Please see OMR for pertinent results.
Brief Hospital Course:
___ yo female patient presents with HA and found to have small
pituitary hemorrhage. She was Neurologically intact and
hemorrhage was stable. She was admitted for Neurosurgical and
Endocrine work up.
#Pituitary Hemorrhage - Stable small hemorrhage. No mass effect
on the optic chiasm. Patient will follow up as outpatient with
repeat imaging. On HD4 the patient reported ___ retroorbital
pain similar to the pain she presented with initially. SBP was
209 at the corresponding time. Patient remained neurologically
intact throughout the entirety of the episode. Stat NCHCT was
done and was unremarkable as compared to CT 4 days prior.
Patient's headache and blood pressure were treated and the
patient was back to her baseline after several hours. Patient
was discharged home on ___ in stable condition.
#Endocrine - the patient remained hemodynamically stable. AM
cortisol was borderline low at 5 and so ACTH stim test was
ordered per Endocrine recommendations. ACTH stim test was
normal; endocrine recommended a retest to be done in 2 weeks as
an outpatient. In addition, the patient will follow up with an
endocrinologist in ___ weeks.
#Anticoagulation
The patient's Coumadin was held upon admission given her
pituitary bleed. She may restart the Coumadin two weeks
following discharge; she will work with her PCP to bridge
appropriately to the Coumadin. IVC filter was placed on ___
because of the patient's extensive history of DVT/PE and her
upcoming period of time without anticoagulation therapy.
Medications on Admission:
Lisinopril
HCTZ
Zoloft
Klonopin
Coumadin
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
Don't take more than 4 g total in 24 hours.
2. Docusate Sodium 100 mg PO BID
3. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth once a day Disp #*10
Tablet Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
Take ___ pills every ___ hours as needed for pain.
RX *oxycodone 5 mg 1 tablet(s) by mouth every ___ hours Disp #*5
Tablet Refills:*0
5. Senna 8.6 mg PO BID:PRN constipation
6. ClonazePAM 1 mg PO QHS
7. Hydrochlorothiazide 25 mg PO DAILY
8. Lisinopril 10 mg PO DAILY
9. Sertraline 200 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
pituitary hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
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.
___ 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) for two weeks after you are
discharged. You may resume your Coumadin in two weeks.
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.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
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
You had a normal cortisol stimulation test while you were here
as an inpatient. You need to be retested with another cortisol
stimulation test in 2 weeks as outpatient. Follow up in ___
weeks with endocrinologist. Please call ___ if you need
to make an appointment with ___ endocrinology.
You are cleared to undergo rotator cuff surgery if deemed
necessary by your orthopedic surgeon.
Followup Instructions:
___
|
10177053-DS-5 | 10,177,053 | 25,406,284 | DS | 5 | 2175-02-05 00:00:00 | 2175-02-16 10:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
rib pain and multiple head lacerations after fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This patient is a ___ year old male with history of alcohol abuse
complained of a fall from 2 stories, altered. He was found on
the ground 20 ft from a 2 floor high fire escape. There was a
large pool of blood at the bottom of the
fire escape.
Past Medical History:
- HCV cirrhosis s/p IFN+Riavirin ___
- HCV thrombocytopenia
- Cervical Stenosis: central stenosis C4-C5, C5-C6, C6-C7,and
foraminal stenosis at C5-C6,C6-C7, and C7-T1
- Lumbar spinal stenosis
- Degenerative joint disease
- Tooth avulsion x2 ___ @ ___
- Left posterior T10-T11 rib fractures ___ @ ___
- L1-L4 TVP fractures (non-op per ___ team) ___ @ ___
Social History:
___
Family History:
unknown
Physical Exam:
PHYSICAL EXAMINATION: Upon admission ___
Constitutional: Somnulent but awakens to verbal and tactile
stimuli. Boarded and collarred
HEENT: Dried blood on face.
L anterior scalp
laceration (3cm), L eyebrow laceration (2.5 cm). No step
offs, no mid face instability
c-collar in place, no stridor, trachea midline
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: L flank ecchymosis, , Soft, Nontender,
Nondistended
Extr/Back: L shoulder pain and abrasions, numerous abrasion
LUE and b/l ___.
Skin: abrasions as above
Neuro: GCS 15 when awoken
Psych: somnulence
___: No petechiae
PHYSICAL EXAMINATION: Upon discharge ___
Constitutional: comfortable and alert
HEENT: healing lacerations, EOMs intact, trachea midline
Chest: Clear bilaterally
Cardiovascular: Regular Rate and Rhythm
Abdominal: Left flank ecchymosis,Soft, Nontender,
Nondistended, pos bowel sounds X4 quadrants
Extr/Back: Left shoulder pain and healing abrasions
no edema of the extremities, pos pedal pulses bilaterally,
intact sensation distally.
Neuro: alert and oriented X3
Pertinent Results:
___ 11:28AM URINE HOURS-RANDOM
___ 11:28AM URINE HOURS-RANDOM
___ 11:28AM URINE GR HOLD-HOLD
___ 11:28AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 11:28AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 11:28AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 08:20AM PH-7.46* COMMENTS-GREEN TOP
___ 08:20AM GLUCOSE-96 LACTATE-1.8 NA+-138 K+-3.6 CL--98
TCO2-25
___ 08:20AM freeCa-1.02*
___ 08:15AM UREA N-7 CREAT-0.7
___ 08:15AM estGFR-Using this
___ 08:15AM LIPASE-42
___ 08:15AM ASA-NEG ___ ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 08:15AM WBC-4.0 RBC-4.06* HGB-12.1* HCT-37.3* MCV-92
MCH-29.8 MCHC-32.4 RDW-14.7
___ 08:15AM PLT SMR-LOW PLT COUNT-87*
___ 08:15AM ___ PTT-29.5 ___
___ 08:15AM ___ W/O CONTRAST Study Date of
___
IMPRESSION: No evidence of fracture or malalignment.
Degenerative changes of the cervical ___ as described above.
Radiology Report CT HEAD W/O CONTRAST Study Date of ___
IMPRESSION: No evidence of acute intracranial process.
Laceration in the scalp overlying the left superior frontal
region.
Brief Hospital Course:
The patient presented to hospital on ___. He was evaluated
and found to have right ___ rib fractures and multiple wound
lacerations. Other imaging og the ___, head, abdomen, pelvis
and glenohumeral joint were done which were all negative.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with a IV pain
medication and then transitioned to oral pain medication once
tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient is tolerating a regular diet. Patient's
intake and output were closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
Social work did address the patient's alcohol abuse in the past
and how he is doing currently. The patient denied any referrals
to assist him with his alcohol use. The patient's primary
concerns such as getting medication
refills, transportation home, and having clothes to wear home
were all addressed and managed.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
ARIPIPRAZOLE [ABILIFY] - Abilify 5 mg tablet. tablet(s) by mouth
- (Prescribed by Other Provider)
GABAPENTIN - gabapentin 800 mg tablet. 1 tablet(s) by mouth
three
times a day taking more than prescribed - (Prescribed by Other
Provider)
LAMOTRIGINE - Dosage uncertain - (Prescribed by Other Provider)
MIRTAZAPINE [REMERON] - Remeron 15 mg tablet. 1 (One) tablet(s)
by mouth once a day - (Prescribed by Other Provider)
OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1
capsule(s) by mouth daily - (Prescribed by Other Provider)
OXYCODONE - oxycodone 5 mg tablet. 1 tablet(s) by mouth every 6
hours as needed for pain - (Prescribed by Other Provider: Dr.
___
Medications - OTC
FOLIC ACID - folic acid ___ mcg tablet. 1 tablet(s) by mouth
daily - (OTC)
IBUPROFEN - ibuprofen 600 mg tablet. 1 tablet(s) by mouth up to
3
times a day - (OTC)
THIAMINE HCL - thiamine 100 mg tablet. 1 tablet(s) by mouth
daily
- (OTC)
Discharge Medications:
1. Aripiprazole 5 mg PO DAILY
2. Cyclobenzaprine 10 mg PO HS:PRN back pain
3. Docusate Sodium 100 mg PO BID
stop taking if having loose stool
4. Gabapentin 800 mg PO Q8H
5. Mirtazapine 15 mg PO HS
6. Omeprazole 20 mg PO DAILY
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
do not drive while taking this medication. Do not mix this
medication with alcohol
Discharge Disposition:
Home
Discharge Diagnosis:
fractures of the posterolateral right ribs # 3,4 and 5, as well
as old Left sided rib fracures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted to ___ following an assault and were found
to have rib fractures, vetebral fractures, chin laceration and
you lost some teeth. You have been cleared by physical therapy
to return home and your acute pain has been controlled.
We are sending you home on narcotic pain medication, oxycodone,
in addition to your chronic pain regimen. Please do not drive or
drink alcohol while on this medication. You will need to take a
stool softener while on this medication to avoid constipation
that it can cause.
You have sutures in your lip and chin. Please make an
appointment with your PCP on ___ or ___ to have those
removed and to follow up after this hospitalization.
You have multiple rib fractures.
* Your injury caused Left ___ and 10th 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 twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
You have chronic cervical bulging discs. You were not found to
have any new injury related to this assault. The ortho ___
team will follow up with you regarding your long term management
of this. You may wear a soft collar for comfort.
There is no restriction on your activity. Slowly increase you
activity daily and rest intermittantly.
We recommend you follow up with your dentist regarding your lost
teeth and filing down the tooth has is now jutting out.
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:
___
|
10177094-DS-13 | 10,177,094 | 28,906,835 | DS | 13 | 2175-11-26 00:00:00 | 2175-11-27 09:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hemorrhage from cervical/cesarean scar ectopic
Major Surgical or Invasive Procedure:
dilation and curettage
History of Present Illness:
Ms. ___ is a ___, gravida 7, para 2, who had a
known ectopic pregnancy located either a high in her cervix
or low in her cesarean section scar or both. She had
previously been admitted to the obstetric service and treated
with a multidose methotrexate injection directly into the
pregnancy sac. After 4 doses of intra pregnancy methotrexate
injection, her HCG dropped appropriately and she was observed
in the inpatient service. She remained stable and was
discharged home on ___. She developed an acute hemorrhage
approximately 10 days after discharge and presented
immediately to the emergency department on ___. On
arrival, her
blood pressure was 77/50 and heart rate was 89. She was
resuscitated and received 1 unit of emergency release blood
in the emergency department. An exam at the bedside was
attempted but the cervix was not able to be visualized given
the profuse hemorrhage, an attempts to place an intracervical
Foley balloon catheter to tamponade her bleeding was
attempted, but not possible due to the lack of dilation of
her external os. She was therefore taken emergently to the
operating room for exam under anesthesia, curettage of the
pregnancy under ultrasound guidance, and possible further
procedures including laparotomy and hysterectomy.
Past Medical History:
PMH: depression/anxiety
PSH: C/S x 2, D&C x 4
GynH: no STIs or abnormal Paps
OBH: ___ - 1LTCS, CPD, term, 9lb 3oz
___ - RLTCS, term, 9lb 13oz
___ trimester SAB with D&C x 2
___ trimester TAB with D&C x 2
Social History:
___
Family History:
non-contributory
Physical Exam:
On discharge:
Gen: NAD
CV: RRR
Lungs: CTAB
Abdomen: soft, nontender, no r/g
GU: voiding spontaneously, minimal spotting on pad
Ext: non-tender
Pertinent Results:
___ 06:30AM BLOOD WBC-6.2 RBC-2.55* Hgb-8.0* Hct-23.7*
MCV-93 MCH-31.3 MCHC-33.6 RDW-13.9 Plt ___
___ 02:10AM BLOOD WBC-8.4 RBC-2.73* Hgb-8.4* Hct-25.3*
MCV-93 MCH-30.8 MCHC-33.2 RDW-13.9 Plt ___
___ 09:20PM BLOOD WBC-9.7 RBC-2.90* Hgb-8.7* Hct-27.1*
MCV-93 MCH-30.1 MCHC-32.2 RDW-13.8 Plt ___
___ 11:20AM BLOOD WBC-7.0 RBC-3.66* Hgb-11.2* Hct-34.1*
MCV-93 MCH-30.6 MCHC-32.9 RDW-13.3 Plt ___
Brief Hospital Course:
Ms. ___ was taken from the emergency department to the
operating room for an ultrasound guided D&C which resulted in
the removal of the suspected gestational sac. Ultrasound showed
a think cervical stripe and c-section scar at the end of the
case. She was admitted for observation overnight. Her bleeding
was minimal. Serial HCTs were drawn and were stable. She had no
symptoms of anemia. She was discarged home on post-operative day
#1 in good condition with outpatient follow-up.
Medications on Admission:
bone
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain
do not take over 4000mg in 24 hours
RX *acetaminophen 500 mg ___ tablet(s) by mouth q6h:prn Disp
#*40 Tablet Refills:*0
2. Ibuprofen 600 mg PO Q6H:PRN pain
take with food
RX *ibuprofen 600 mg 1 tablet(s) by mouth q6h:prn Disp #*60
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
ectopic pregnancy
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 hospital for observation after your
procedure. Please follow the instructions below.
General instructions:
* Take your medications as prescribed.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs
* Nothing in the vagina (no tampons, no douching, no sex) for 2
weeks
* Use a reliable form of contraception at least until you follow
up with your primary OB/GYN doctor.
* No heavy lifting of objects >10 lbs for 2 weeks.
* You may eat a regular diet
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
10177158-DS-7 | 10,177,158 | 23,456,006 | DS | 7 | 2177-07-23 00:00:00 | 2177-07-23 21:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dysuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old ___ male with a h/o nephrolithiasis
s/p L PCN and nephrolithotripsy and nephrouretral stent
placement by ___ also at ___ sometime around ___,
presenting with dysuria since last ___. He reports
increasing pain and buring sensation with urination, but denies
enlraged prostate. In the ED, the patient was denying fever,
flank pain, chills, hematuria, N/V.
Reportedly, he was seen at ___ by Dr. ___ in ___ for
bilateral staghorn stones. Per discharge summary: "patient
underwent L percutaneous nephrolithotripsy on ___ and residual
stones were removed. Patient was admitted for pain control and
post op recover after a nephrophsto tube was inserted by ___ on
___. A nephrostogram was done on ___ to check residual stone
load and removal of the nephrostomy tube leaving a
nephroureteral stent. Foley catheter was inserted during the
PCNL and was removed on ___. He was discharged improved."
In the ED, initial vitals were: 97.6, hr 82, BP 116/72, RR 16,
99%
- WBC 6.4, Hgb 11.9, plts 205, Na 126, K 3.7, Cr 1.1, LFTs wnl,
lactate 1.6, UA significant for cloudiness with large leuks,
moderate blood, positive nitrites, >182 WBCs, moderate bacteria,
42 RBCs, 3 epis
- Imaging was notable for: s/p interval left lithotripsy, mild
left hydronephrosis, no perinephric starnding, perc nephrostomy
tube in place, unchanged R staghorn calculus, and increasing
left periaortic lymphadenopathy
- Patient was given: IV CTX 1 g
Urology saw him in the ED. CTU showed significant interval
improvement in stone burden, and urology did not think he needed
admission for nephrolithiasis and recommended discharge on
nitrofurantoin.
Upon arrival to the floor, patient reports that he is not in
pain right now. He denies fevers, N/V, hematuria, diarrhea. He
still has dysuria, pain with urination. He feels relatively well
and asks if he is going to get the tube taken out during this
hospital stay.
Past Medical History:
HTN
Social History:
___
Family History:
No history of kidney stones or other medical problems
Physical Exam:
ADMISSION/DISCHARGE EXAM:
===========================
VITALS:98.3 118/75 66 18 96 Ra
GENERAL: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
NECK: Supple, JVP not elevated, no LAD
RESP: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
ABD: +BS, soft, nondistended, nontender to palpation. No
hepatomegaly. Left lower back with nephrostomy tube in place, no
sutures, no erythema or tenderness, no drainage, currently
capped. No CVA or suprapubic tenderness.
GU: no foley
EXT: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: CNs2-12 intact, motor function grossly normal
Pertinent Results:
LABS:
=========
___ 12:22PM BLOOD WBC-6.4 RBC-3.78* Hgb-11.9* Hct-36.2*
MCV-96# MCH-31.5 MCHC-32.9 RDW-13.6 RDWSD-48.0* Plt ___
___ 12:22PM BLOOD Glucose-100 UreaN-18 Creat-1.1 Na-136
K-3.7 Cl-98 HCO3-26 AnGap-16
___ 12:22PM BLOOD ALT-16 AST-17 AlkPhos-88 TotBili-0.5
___ 06:07AM BLOOD Calcium-8.9 Phos-3.2 Mg-2.0
___ 12:22PM BLOOD Albumin-4.1
___ 02:30PM BLOOD Lactate-1.3
IMAGING:
=============
___ CTU:
1. Status post interval left lithotripsy, with few
nonobstructing residual calcifications/stones. Mild left
hydronephrosis. No perinephric stranding.
2. Left nephroureteral stent and percutaneous nephrostomy in
what appears to be appropriate position.
3. Unchanged right staghorn calculus.
4. Left periaortic lymphadenopathy, slightly increased in size
compared to ___.
SUMMARY OF OUTSIDE RECORDS/___:
No urine culture data at ___
___
Urine cytology- atypical cells (true papillary clusters present
with or without nuclear atypia. Abnormal finding may indicate
low grade papillary tumor or can be seen in association with
calculi.
CT Abdomen/Pelvis: large bilateral staghorn calculi, with b/l
hydronephrosis, moderately dilated proximal L. ureter may
reflect mural thickening and/or intraluminal solid component.
Attention to this finding on contrast enhanced renal CT
recommended. 1.2 cm hydpodense lesion in right lobe of liver
likely a cyst. Calcifications in pancreas likely chronic panc.
Brief Hospital Course:
Mr. ___ is a ___ year old man with a history of recent bilateral
staghorn calculi (at ___) s/p left PCN and nephrolithotripsy,
as well as nephroureteral stent placement who presented with
dysuria.
He is in the process of transitioning his care to ___. His UA
was strongly suggestive of UTI, so he received a dose of
ceftriaxone in the ED. He was transitioned to
PO ciprofloxacin. He was feeling well and wished to go home. He
otherwise was well appearing without any signs or symptoms of
worsening infection or pyelonephritis. Given that his
nephrostomy tube is still in place, urology was contacted who
agreed with outpatient follow up with Dr. ___ other
inpatient intervention at this time. He will no longer need
repeat CT imaging as he had his scan when admitted.
We will monitor urine cultures and follow up with him if
necessary.
#HTN: home amlodipine and HCTZ continued
TRANSITIONAL ISSUES:
=====================
-New medication: Ciprofloxacin 500 mg BID for 7 days
-PLan for outpatient urology followup
-Urine culture pending at discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*14 Tablet Refills:*0
2. amLODIPine 5 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
- Urinary tract infection
- ___ Calculi
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 ___ on ___ with a urine infection.
Your labs were normal and you had no fevers. You were initially
treated with an IV antibiotic which was changed to a pill form
(oral antibiotic) for you to take at home.
You will need to follow up with the urologists at ___. We have
called them, but we were unable to make an appointment. Please
call them at the number below in the next ___ days. Please make
sure to keep
If your tube has fluid draining around it, or you have pain,
please call the urologist or return to the hospital.
PLEASE TAKE YOUR ANTIBIOTIC
Best,
Your ___ care team
Followup Instructions:
___
|
10177415-DS-5 | 10,177,415 | 24,337,996 | DS | 5 | 2157-03-19 00:00:00 | 2157-03-20 17:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending: ___.
Chief Complaint:
Right shoulder pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yoF with a PMH of diabetes and HTN,
___ speaking, who presents with right shoulder and back pain.
Patient states the pain has gradually worsened since ___ when
she was hospitalized in ___ ___ and
had
fluid from her right lung drained. She notes receiving a CT
scan,
and was in the hospital for ___ days, but is unsure what the
result of her work up was. Since that time she has had worsening
pain in her right shoulder and back with swelling over the
drainage site, but without the same amount of SOB. She describes
the pain as a dull, constant pain that becomes sharp with
movement or deep inspiration. She also reports nightsweats,
which
is chronic per patient, and a recent 30 lb weight loss,
unintentional. She also occasionally feels slightly short of
breath and has occasional difficulty with ambulation because she
is unable to stand upright secondary to pain.
Past Medical History:
PAST MEDICAL AND SURGICAL HISTORY:
Hypertension
Type II DM
Hypothyroidism
Previous hospitalization with thoracentesis as above
Social History:
___
Family History:
No family history of lung disease or lung malignancy
Physical Exam:
ADMISSION EXAM
VS: 97.8 148/79 93 18 98% 2L (92% RA) pain ___
GENERAL: NAD, A&Ox3
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, MMM
NECK: supple, diffuse submandibular LAD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Breathing comfortably, absent sounds over the R middle
and
lower lung fields. No wheezing. Normal sounds over the left
lung.
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding
BACK: swelling below the right scapula, and hard nodule, ~1cm
palpated in the mid-right back. No shoulder deformity or
limitation of motion.
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose, CNII-XII
intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM
VS: Reviewed in OMR
GENERAL: A&Ox3 patient seated at bedside in no pain or distress
HEENT: EOM grossly Intact, PERRL, anicteric sclera, MMM
NECK: supple
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Breathing comfortably, decreased breath sounds over the R
lung fields. No wheezing. Normal sounds over the left lung.
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: no cyanosis, clubbing, or edema
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Admission Labs:
___ 09:08PM PTT-150*
___ 01:55PM GLUCOSE-100 UREA N-5* CREAT-0.5 SODIUM-140
POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-27 ANION GAP-15
___ 01:55PM estGFR-Using this
___ 01:55PM CK-MB-<1 cTropnT-<0.01 proBNP-38
___ 01:55PM WBC-4.5 RBC-4.32 HGB-12.6 HCT-38.5 MCV-89
MCH-29.2 MCHC-32.7 RDW-13.7 RDWSD-45.0
___ 01:55PM NEUTS-64.2 ___ MONOS-5.8 EOS-3.5
BASOS-0.2 IM ___ AbsNeut-2.90 AbsLymp-1.17* AbsMono-0.26
AbsEos-0.16 AbsBaso-0.01
___ 01:55PM PLT COUNT-209
___ 01:55PM ___ PTT-26.4 ___
___ 12:13PM ___ COMMENTS-GREEN TOP
___ 12:13PM LACTATE-1.6
___ 12:10PM WBC-4.6 RBC-4.66 HGB-13.7 HCT-42.6 MCV-91
MCH-29.4 MCHC-32.2 RDW-14.4 RDWSD-47.2*
___ 12:10PM NEUTS-66.1 ___ MONOS-5.0 EOS-3.0
BASOS-0.4 IM ___ AbsNeut-3.06 AbsLymp-1.17* AbsMono-0.23
AbsEos-0.14 AbsBaso-0.02
___ 12:10PM PLT COUNT-198
___ 11:56AM URINE HOURS-RANDOM
___ 11:56AM URINE UHOLD-HOLD
___ 11:56AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 11:56AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-SM*
___ 11:56AM URINE RBC-<1 WBC-4 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 11:56AM URINE MUCOUS-RARE*
Imaging/Studies:
___ CXR
IMPRESSION:
Significant opacification in the right middle lower lung with
collapsed right
middle and lower lobes. Recommend CT to further assess as
findings are
concerning for malignancy.
___: CT CHEST
IMPRESSION:
1. Left upper and lower lobe segmental pulmonary emboli with
mild flattening
of the interventricular septum, which may represent mild right
heart strain.
2. Large mass in the right lower lung concerning for primary
lung cancer with
diffuse right pleural thickening consistent with metastatic
disease and
scattered pulmonary nodules. Prominent mediastinal lymph nodes
also noted as
well as sites of potential metastatic disease within the right
posterior chest
wall and liver.
CT ABD/PELVIS
IMPRESSION:
1. Ill-defined hepatic dome hypodensities measure up to 2.0 cm
most concerning
for metastases although infection or infiltrative tumor from
adjacent pleura
could possibly have this appearance.
2. Linear soft tissue enhancing nodules in the right posterior
chest wall may
represent track metastasis from prior biopsy or possibly
infection/inflammatory change.
3. Left-sided segmental pulmonary emboli, diffuse hyperenhancing
right pleural
rind/thickening, moderate sized loculated right pleural
effusion, right lower
and middle lobe atelectasis redemonstrated. Previously described
right lung
mass is better assessed on dedicated CT chest performed the day
prior.
4. Left renal cyst with septations could be further assessed
with dedicated
renal ultrasound if clinically indicated. No definite renal
mass.
5. Enlarged multi-fibroid uterus.
___ MRI BRAIN
IMPRESSION:
1. Extensive intracranial metastatic disease involving the
supratentorial and
infratentorial brain, pons, and midbrain. Mild associated
vasogenic edema is
seen surrounding several dominant lesions.
2. No evidence for mass effect or hemorrhagic transformation.
3. No vascular territorial ischemia or infarction.
ECHO ___
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). Tissue
Doppler imaging suggests a normal left ventricular filling
pressure (PCWP<12mmHg). Right ventricular chamber size and free
wall motion are normal. The ascending aorta is mildly dilated.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis. Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Preserved biventricular systolic function. Mildly
dilated ascending aorta. Normal pulmonary artery systolic
pressure.
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.
Microbiology:
BLood Culture neg. x2, ___
Urine cx mixed flora growth only ___
Discharge Labs:
___ 06:45AM BLOOD WBC-4.0 RBC-4.07 Hgb-11.9 Hct-36.8 MCV-90
MCH-29.2 MCHC-32.3 RDW-14.2 RDWSD-46.5* Plt ___
___ 07:10AM BLOOD ___ PTT-79.2* ___
___ 06:45AM BLOOD Glucose-102* UreaN-5* Creat-0.5 Na-138
K-4.3 Cl-97 HCO3-27 AnGap-14
___ 07:00AM BLOOD ALT-16 AST-24 LD(LDH)-332* AlkPhos-52
TotBili-0.3
___ 06:45AM BLOOD Calcium-9.5 Phos-5.0* Mg-2.1
Brief Hospital Course:
Key Information for Outpatient ___ woman with
5 months of progressive right back pain, mild SOB and weight
loss found to have pulmonary embolism and mass concerning for
lung malignancy with records obtained from ___
confirming lung adenocarcinoma. During her hospital stay, she
was evaluated by hematology/oncology, radiology/oncology,
neuro/oncology and a multi-disciplinary plan was made about her
treatment (see below). Regarding her pulmonary embolism, she was
started on heparin gtt and transitioned to warfarin, as
obtaining a long-term supply of enoxaparin was not possible.
However, a short-term (14-day supply) was obtained prior to
discharge, and she was sent out on this with instructions to
follow-up in ___ clinic to start warfarin if
longer-term enoxaparin could not be obtained.
ACTIVE ISSUES:
==============
#Metastatic Stage IV lung adenocarcinoma. Patient with large
right lung mass consistent with EGFR mutated (exon 19 deleted)
lung adenocarcinoma with diffuse metastasis to brain and liver.
Formal tissue diagnosis occurred at ___
though the exact reason for her delay in seeking further care
and treatment is not entirely clear. Patient was evaluated by
hematology/oncology, radiation oncology, and neuro-oncology
during her stay. She will begin initiation of palliative
Osimertinib, which we anticipate will afford brisk and durable
treatment effect-- both with regards to extra-CNS and CNS
disease burden. The alternative would be to start with WBRT
prior to starting systemic therapy, but patient expresses
reticence about treatment-related toxicities (including
alopecia, cognitive impairment) associated with WBRT. She has
previously opted to defer cancer care in past due to concerns
about toxicity and quality of life. At this time it is felt that
there is no need for additional tissue biopsy or need for whole
brain radiation as the TKI has excellent CNS penetration. She
will be seen in ___ clinic on ___ to discuss
initiation of this therapy.
#Pulmonary embolism. CT chest on admission showing L upper and
lower lobe segmental pulmonary emboli, likely secondary to
malignancy. Patient had remained hemodynamically stable without
signs of shock, hypotension, tachycardia or significant
hypoxemia during her stay. She was initially treated with
Lovenox but due to her lack of insurance, the cost of the
medication was not within the patient's financial means. She was
subsequently started on a heparin gtt as bridging to Coumadin.
We are attempting to obtain a 90-day supply of Lovenox for the
patient given the strong indication in the setting of her
malignancy; efforts are currently under-way with Case Management
and Financial Services. In the meantime, she will be followed by
___ clinic on discharge. She will be discharged
on Lovenox to be given by the patient BID while she is away on
her upcoming trip to ___. When she returns from her trip the
plan is for her to be seen at ___ by the ___ clinic and
transition her back to warfarin (she only has a 14 day supply of
lovenox). SHE WILL NEED TO BE BRIDGED AGAIN in the outpatient
setting, a target dose to which she responded in the hospital
was 10mg of warfarin. This is crucial since she only has a
limited supply of lovenox. INR GOAL ___.
#R shoulder pain/swelling. Appears to be soft tissue swelling.
Treated symptomatically with standing APAP, lidocaine patch,
morphine IV PRN for breakthrough pain
#Latent TB. Patient with prior positive tuberculin skin test
without history
of treatment. She was getting yearly CXRs for this. Treatment of
this matter will require discussions with hematology/oncology
given the concern for reactivation with starting osimertinib
therapy.
TRANSITIONAL ISSUES
====================
[ ] Discharged on Lovenox BID over the weekend plan for her to
follow up with ___ ___ clinic should she require
re-initiation on warfarin
[ ] Patient will need to be bridged back to warfarin while on
lovenox, she responded to 10mg warfarin (pt. only has 2 week/14
day supply of lovenox)
[ ] Will be followed by the ___ clinic on
discharge
[ ] Attempting to obtain Lovenox supply for treatment of her PE
long term. Efforts are currently underway with Case Management
and Financial Services
[ ] Patient with prior positive tuberculin skin test without
history of treatment. She was getting yearly CXRs for this.
Treatment of this matter will require discussions with
hematology/oncology given the concern for reactivation with
starting osimertinib therapy.
[ ] Has follow-up with hematology/oncology on ___
[ ] 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.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 100 mcg PO DAILY
2. MetFORMIN (Glucophage) 500 mg PO BID
3. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Enoxaparin Sodium 80 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 80 mg/0.8 mL 0.8 ml SC every twelve (12) hours
Disp #*28 Syringe Refills:*0
2. Warfarin 5 mg PO DAILY16
RX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2
3. Hydrochlorothiazide 25 mg PO DAILY
4. Levothyroxine Sodium 100 mcg PO DAILY
5. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses
#Pulmonary Embolism
#Adenocarcinoma of the lung
Secondary Diagnosis:
#Latent TB
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 on this admission at ___.
What Happened on This Hospital Stay:
- You were admitted for right neck and back pain. The cause of
your symptoms is likely related to the cancer in your lungs,
which has unfortunately spread to your brain
- You also were found to have blood clots in your lungs, which
can happen as a result of the cancer
- You were treated with blood thinning medications to prevent
the formation of future blood clots
- You were seen by the cancer doctors and the ___ is to start a
medication to treat this cancer after you leave the hospital
What you Need to Do Once Leave the Hospital:
- It is important that you see your new cancer doctors at ___
(appointment details listed below)
- You must inject yourself with Lovenox (enoxaparin) twice a day
starting today ___ one dose in the hospital and one dose
tonight at 10:30pm.
- Take (inject yourself) with lovenox over the weekend ___
to ___ when you see your blood thinning Doctors at ___
___ and they will plan to put you back on warfarin pill
- You have been started on a blood thinning medication called
warfarin/coumadin and it is VERY IMPORTANT that you avoid eating
food high in vitamin K (examples are greens, Kale, broccoli,
spinach etc.). You MUST ALSO have your blood checked regularly
to make sure your Coumadin/warfarin is within the normal range.
THIS MEDICATION WILL BE RESUMED WHEN YOU RETURN TO ___ AND
SEE YOUR BLOOD THINNING DOCTORS AT ___.
*****You should start injecting yourself today ___ twice a
day with lovenox once you leave the hospital. We will plan to
have you use lovenox over the weekend while you are on your
trip. This medication is injected in your stomach once in the
morning and once at night (twice daily). When you return to
___ you should see your Doctor on ___, ___, and
they will help to restart you on Warfarin.********
Please make sure that during any long flights, you are walking
up and down the aisles every hour. Given the blood clots in your
lungs, you are at higher risk for the development of future
blood clots.
If you do not take your Lovenox as prescribed and if you miss
your appointment this next week on ___, you are at risk of
DEATH as these blood clots are life threatening. It is very
important that you take your lovenox injections over the weekend
and follow up with your doctor in ___ for your warfarin
dosing. If you do not have your blood levels checked for this
medication as directed, you are at risk of DEATH.
MEDICATIONS ADDED: Coumadin, Enoxaparin
MEDICATIONS STOPPED: None
MEDICATIONS CHANGED: None
We wish you the best,
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10177799-DS-6 | 10,177,799 | 28,993,766 | DS | 6 | 2172-02-08 00:00:00 | 2172-02-08 21:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Zithromax Z-Pak
Attending: ___.
Chief Complaint:
Right eye decreased visual acuity
Major Surgical or Invasive Procedure:
No
History of Present Illness:
Mr. ___ is a ___ year old male with DM2, HTN, HLD and h/o
idiopathic ___ ___ who presents with partial vision loss for
three weeks. He was playing golf when he realized he had trouble
tracking his ball on the right. He closed his left eye and
noticed a grey crescent shape obscuring his vision in the right
upper quadrant, resolved when closing the right eye. He reported
mild eye pain that first day, but none since. Vision loss has
been constant or improving since. No headache. Denies
dysarthria,
aphasia, confusion, weakness, numbness. Reports longstanding
balance problems which he attributes to his peripheral
neuropathy
___ DM. Scheduled ophthalmology appointment for this, concern
for
retinal artery occlusion, sent to ___
In the ED, evaluated by ophtho:
hemiretinal inferior arteriolar occlusion of the right eye with
severe attenuation of the inferior retinal
arterioles and presence of an arteriolar plaque on the optic
nerve head. However, exam does not reveal any significant
retinal
whitening (though patient does have a relatively blonde fundus),
nor a cherry-red spot.
Not a code stroke
Time/Date the patient was last known well: 3 weeks ago
I was not present during the CT scanning as the patient was not
a
code stroke
___ Stroke Scale Score:0
t-PA administered:
[] Yes - Time given: __
[x] No - Reason t-PA was not given or considered: NIHSS 0, LKW 3
weeks ago
Thrombectomy performed:
[] Yes
[x] No - Reason not performed or considered: retinal artery, no
LVO, LKW 3 weeks ago
NIHSS performed within 6 hours of presentation at: ___
NIHSS Total: 0
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: 0
11. Extinction and Neglect: 0
Past Medical History:
hypercholesterolemia
DM 2
Social History:
___
Family History:
Sister with stroke in ___
Physical Exam:
Physical exam at the day of admission ___
Vitals reviewe in ED dash
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: warm, well-perfused.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-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 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.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. Right ptosis. EOMI
without nystagmus. Normal saccades. VFF to confrontation. Visual
acuity ___ bilaterally. Fundoscopic exam revealed no
papilledema, exudates, or hemorrhages.
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. No
adventitious movements, such as tremor or asterixis noted.
[___]
L 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch vibration, or
proprioception throughout. Reduced temperature in the feet,
unable to distinguish pinprick in feet L>R. No extinction to
DSS.
[Bic] [Tri] [___] [Pat] [Ach]
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: Intention tremor bilaterally L>R. No dysmetria.
Some trouble with HKS.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Difficulty with tandem gait
Physical exam at the day of discharge ___
Vitals reviewe in ED dash
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: warm, well-perfused.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-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 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.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. Right ptosis. EOMI
without nystagmus. Normal saccades. VFF to confrontation. Right
upper quadrant decreased vision acuity, able to identify finger
wiggling. Fundoscopic exam revealed no
papilledema, exudates, or hemorrhages.
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. No
adventitious movements, such as tremor or asterixis noted.
[___]
L 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch vibration, or
proprioception throughout. Reduced temperature in the feet,
unable to distinguish pinprick in feet L>R. No extinction to
DSS.
[Bic] [Tri] [___] [Pat] [Ach]
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: Intention tremor bilaterally L>R. No dysmetria.
Some trouble with HKS.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Difficulty with tandem gait
Pertinent Results:
___ 06:25AM BLOOD WBC-6.6 RBC-3.92* Hgb-12.0* Hct-35.5*
MCV-91 MCH-30.6 MCHC-33.8 RDW-12.5 RDWSD-40.5 Plt ___
___ 04:16PM BLOOD WBC-7.6 RBC-3.99* Hgb-12.1* Hct-35.8*
MCV-90 MCH-30.3 MCHC-33.8 RDW-12.4 RDWSD-40.5 Plt ___
___ 04:16PM BLOOD Neuts-53.6 ___ Monos-9.4 Eos-2.1
Baso-0.8 Im ___ AbsNeut-4.09 AbsLymp-2.57 AbsMono-0.72
AbsEos-0.16 AbsBaso-0.06
___ 06:25AM BLOOD Plt ___
___ 06:25AM BLOOD ___ PTT-31.5 ___
___ 04:16PM BLOOD Plt ___
___ 04:16PM BLOOD ___ PTT-30.8 ___
___ 06:25AM BLOOD Glucose-208* UreaN-20 Creat-1.0 Na-141
K-4.4 Cl-103 HCO3-26 AnGap-12
___ 04:16PM BLOOD Glucose-190* UreaN-21* Creat-1.1 Na-139
K-4.1 Cl-102 HCO3-24 AnGap-13
___ 06:25AM BLOOD ALT-26 AST-26 AlkPhos-39* TotBili-0.4
___ 04:16PM BLOOD ALT-30 AST-32 AlkPhos-41 TotBili-0.3
___ 06:25AM BLOOD Calcium-9.4 Phos-3.0 Mg-1.6 Cholest-161
___ 04:16PM BLOOD Albumin-4.6
___ 06:25AM BLOOD %HbA1c-9.3* eAG-220*
___ 06:25AM BLOOD Triglyc-208* HDL-36* CHOL/HD-4.5
LDLcalc-83
___ 04:16PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 06:25AM BLOOD TSH-2.4
___ 04:16PM BLOOD CRP-2.7
___ 04:16PM BLOOD GreenHd-HOLD
___ 06:25AM BLOOD
___ 04:16PM BLOOD
___ 04:24PM BLOOD SED RATE-Test
Brief Hospital Course:
Mr. ___ is a ___ year old male with DM2, HTN, HLD and h/o
perimesencephalic SAH in ___ who presented with painless right
monocular vision loss 3 weeks ago and admitted for stroke
work-up.
He reported sudden onset decreased vision in the upper quadrant
of right eye. On dilated eye exam by optho there was no retinal
whitening or cherry red spot but inferior arcade arterioles
severely attenuated, presence of plaque in inferior arteriole on
optic nerve head was seen. The remainder of the neurologic exam
was normal. CTA showed atheromatous 30% stenosis of the
bilateral proximal internal carotid arteries by NASCET criteria
and moderate stenosis at the origin of the left vertebral
artery, otherwise patent bilateral cervical carotid and
vertebral arteries without evidence of stenosis, occlusion, or
dissection, paranasal sinus mucosal thickening. MRI showed no
areas of ischemia. TTE showed no definite structural cardiac
source of embolism identified. Normal left ventricular wall
thickness and left ventricular cavity sizes and regional/global
biventricular
systolic function. Mild right ventricular dilatation. Stroke
risk factors: A1c 9.3, LDL 83. ESR/CRP was normal. Etiology was
felt to be atheroembolic. Aspirin 81 mg daily was started after
approval by neurosurgery given prior non-aneurysmal SAH.
Atorvastatin was increased to 80 mg daily. His cardiologist
office was contacted for report of loop recorder but had not
sent report at time of discharge. Will follow-up ILR recordings
to see if patient has atrial fibrillation. If he does have afib,
would recommend discontinuation of aspirin 81 mg daily and
initiation of apixaban 5 mg bid.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO DAILY
2. Citalopram 20 mg PO DAILY
3. Fenofibrate 200 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. Lisinopril 5 mg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. GlipiZIDE XL 5 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*3
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*90
Tablet Refills:*3
3. Atenolol 50 mg PO DAILY
4. Citalopram 20 mg PO DAILY
5. Fenofibrate 200 mg PO DAILY
6. GlipiZIDE XL 5 mg PO DAILY
7. Lisinopril 5 mg PO DAILY
8. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Right retinal artery branch occlusion
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of decreased visual right
eye acuity resulting from right retinal artery branch occlusion,
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 - diabetes
- high cholesterol
- high blood pressure
We are changing your medications as follows:
- start aspirin 81 mg daily
- increase atorvastatin to 80 mg daily
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:
___
|
10178145-DS-18 | 10,178,145 | 25,544,280 | DS | 18 | 2198-10-28 00:00:00 | 2198-10-28 21:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
encephalopathy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mrs. ___ is a ___ with histoy of dementia, depression who had
an episode of unresponsiveness for 30 minutes at her ___
home. Per nursing home report patient was laying on her bed,
awake but non-verbal. Per report she became responsive without
any intervention. No truama. She is bed bound. EMS was called
to transfer patient to ___.
In the ED, patient was awake, alert and oriented x1 which is her
baseline. Labs were remarkable for positive UA. CT head without
any acute process. CXR without any pneumonia. She was given
ceftriaxone for UTI and admitted for further care.
Currently patient is sleeping, difficult to awaken. Answer
yes/no questions. No chest pain, no shortness of breath.
Past Medical History:
- Depression
- Dementia
- Hypertension
Social History:
___
Family History:
Unable to obtain.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - 97.9 64 140/53 20 98% RA
GENERAL: sleeping
HEENT: Not examined
CARDIAC: Irregular rhytym, S1/S2, no murmurs
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
NEURO: oriented x1(name)
SKIN: warm and well perfused
DISCHARGE PHYSICAL EXAM:
Vitals - t97.7 143/60 61 16 100%RA
GENERAL: sleeping, easily arousable and responsive
HEENT: L eye cataract, arcus senilis, right eye pupil round,
reactive to light, oropharynx with poor dentition, no exudates
CARDIAC: RRR with frequent ectopic beats, S1/S2, no murmurs
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
NEURO: oriented x1 (name), states yes or no and mumbles but
difficult to undestand. facial movements are symmetric.
sensation intact to light touch. lying in bed.
SKIN: warm and well perfused
Pertinent Results:
ADMISSION LABS:
___ 09:17PM BLOOD WBC-8.0 RBC-4.77 Hgb-13.9# Hct-41.7#
MCV-87 MCH-29.2 MCHC-33.4 RDW-13.8 Plt ___
___ 09:17PM BLOOD Neuts-65.8 ___ Monos-8.9 Eos-2.2
Baso-0.7
___ 01:30AM BLOOD Glucose-84 UreaN-16 Creat-0.8 Na-145
K-4.0 Cl-106 HCO3-26 AnGap-17
___ 01:30AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.4
___ 01:32AM BLOOD Lactate-1.1
DISCHARGE LABS:
___ 07:35AM BLOOD WBC-6.4 RBC-4.24 Hgb-12.0 Hct-36.7 MCV-87
MCH-28.2 MCHC-32.6 RDW-13.7 Plt ___
___ 02:40PM BLOOD Neuts-53.9 ___ Monos-9.5 Eos-3.8
Baso-0.6
___ 07:35AM BLOOD Glucose-83 UreaN-10 Creat-0.7 Na-142
K-3.7 Cl-106 HCO3-27 AnGap-13
___ 07:35AM BLOOD Calcium-8.5 Phos-3.3 Mg-2.3
PERTINENT LABS:
___ 01:30AM BLOOD cTropnT-<0.01
___ 01:32AM BLOOD Lactate-1.1
URINE:
___ 08:47PM URINE Color-Yellow Appear-Hazy Sp ___
___ 08:47PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
___ 08:47PM URINE RBC-3* WBC-22* Bacteri-FEW Yeast-NONE
Epi-10
___ 10:52PM URINE Color-Yellow Appear-Clear Sp ___
___ 10:52PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
___ 10:52PM URINE RBC-30* WBC-19* Bacteri-NONE Yeast-NONE
Epi-0
__________________________________________________________
___ 1:30 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
Time Taken Not Noted Log-In Date/Time: ___ 10:52 pm
URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 9:17 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 8:47 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
CT HEAD WITHOUT CONTRAST
FINDINGS:
There is no acute intra-axial or extra-axial hemorrhage, mass,
midline shift,
or territorial infarct. The ventricles and sulci are prominent
compatible
with global volume loss. Periventricular white matter
hypodensities are
likely sequelae of chronic small vessel disease. Basilar
cisterns are patent.
Gray-white matter differentiation is preserved.
Mucosal thickening seen within the ethmoid air cells. Other
included
paranasal sinuses and mastoids are clear. Skull and
extracranial soft tissues
are unremarkable.
IMPRESSION:
No acute intracranial process.
CXR: FINDINGS: AP and lateral views of the chest. Linear
opacities identified at
the lung bases, right greater than left, most suggestive of
atelectasis.
There is no confluent consolidation worrisome for infection.
Cardiomediastinal silhouette is within normal limits.
Atherosclerotic
calcifications are noted at the aortic arch. No acute osseous
abnormality is
identified.
IMPRESSION: Linear opacities at the lung bases, left greater
than right, most
suggestive of atelectasis without definite acute cardiopulmonary
process.
MRI HEAD WITHOUT CONTRAST
IMPRESSION:
There is no evidence of acute intracranial process. Scattered
foci of high
signal intensity detected on FLAIR and T2 weighted images,
distributed in the
subcortical and periventricular white matter, are nonspecific
and may reflect
changes due to small vessel disease.
Brief Hospital Course:
___ with histoy of dementia, depression who had an episode of
unresponsiveness for 30 minutes at her nursing home likely due
to hypoactive delirium.
# HYPOACTIVE DELIRIUM: Per report and discussion with staff at
___, patient was awake but non-verbal during this
episode and became responsive without any intervention. She had
been getting treatment for a recent UTI, and had been started on
levofloxacin on ___ for 10-day course. During the time she had
the period of unresponsiveness she was also noted to be
hypotensive to SBP in ___. Per nursing home, patient returned
to baseline of responsiveness with intermittent responses. She
was back to her baseline mental status of A&O x 1 on arrival,
and CT head was negative. She was monitored on telemetry
without any events. Patient was bedbound so orthostatics was
not likely, and she was not hypoglycemic. Differential included
TIA, and MRI was done with prelim showing age-related atrophy
and chronic small vessel disease without any acute findings.
Hypotension resolved and BPs stable during the admission.
Treatment course for UTI completed.
INACTIVE ISSUES
# HTN: stable
continue metoprolol and amlodipine
# Dementia: Continue memantine.
TRANSITIONAL ISSUES:
- Unclear why patient is on prednisone 2mg (staff at ___
___ did not know, and sister HCP did not know).
- MRI prelim read was negative, pending at discharge
- Patient completed 10-day course of antibiotic
- Code status is full per ___ and HCP but would
recommend re-addressing code status with HCP
- HCP ___ (___) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
2. Amlodipine 5 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Lactulose 15 mL PO DAILY
5. Fluoxetine 10 mg PO DAILY
6. Potassium Chloride 10 mEq PO DAILY
7. PredniSONE 2 mg PO DAILY
8. Mirtazapine 15 mg PO HS
9. Metoprolol Tartrate 50 mg PO BID
10. Memantine 10 mg PO BID
11. Senna 8.6 mg PO BID
12. TraZODone 150 mg PO HS
13. Acetaminophen 500 mg PO Q4H:PRN pain
Discharge Medications:
1. Acetaminophen 500 mg PO Q4H:PRN pain
2. Amlodipine 5 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Fluoxetine 10 mg PO DAILY
5. Memantine 10 mg PO BID
6. Metoprolol Tartrate 50 mg PO BID
7. Mirtazapine 15 mg PO HS
8. Potassium Chloride 10 mEq PO DAILY
9. PredniSONE 2 mg PO DAILY
10. Senna 8.6 mg PO BID
11. TraZODone 150 mg PO HS
12. Lactulose 15 mL PO DAILY
13. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
hypoactive delirium
urinary tract infection
SECONDARY DIAGNOSIS:
hypertension
dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were brought to the hospital due to a period of not
responding to the staff at the nursing home while you were still
awake. This was thought to be due to delirium in the setting of
a resolving bladder infection as well as low blood pressure.
An MRI of your head showed no acute issues. You were back to
your baseline mental status by the time you arrived here and you
completed the antibiotic course for the bladder infection.
Followup Instructions:
___
|
10178145-DS-19 | 10,178,145 | 29,414,887 | DS | 19 | 2199-04-21 00:00:00 | 2199-04-23 12:37:00 |
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:
NONE
History of Present Illness:
___ her old female with past medical history of dementia, HTN and
depresion who comes in from a nursing home after having an
episode of unresponsiveness. Per the nursing home the patient
was grunting, drooling does not answer questions appropriately
for a brief period of time. When asked what was wrong she said
"I think I'm going to die." This is different than her baseline
where she is normally oriented to person place and can answer
questions. Seems this episode lasted for approximately 5 minutes
and the patient was still somewhat confused in the immediate
aftermath. EMS and nursing home deny any recent history of
fevers, chills, nausea, vomiting, diarrhea, change in p.o.
intake, abdominal pain.
Past Medical History:
- Depression
- Dementia
- Hypertension
Social History:
___
Family History:
Unable to obtain.
Physical Exam:
ADMISSION
Vitals: 98.2 138/53 50 16 100%RA
General: ___ woman laying comfortably in hospital bed
HEENT: NCAT EOMI MMM
Lymph: No LAD, neck supple
CV: S1/S2 RRR No M/R/G
Lungs: CTAB
Abdomen: +BS obese, soft NT/ND
GU: No foley catheter in place
Ext: No c/c/e
Neuro: AAOx2, responsive to questions, pleasant affect,
CNIII-XII intact, grossly moving all four extremities
Skin: Warm, frail, dry, intact
DISCHARGE
VSS
General: ___ woman laying comfortably in hospital bed
HEENT: NCAT EOMI MMM
Lymph: No LAD, neck supple
CV: S1/S2 RRR No M/R/G
Lungs: CTAB
Abdomen: +BS obese, soft NT/ND
GU: No foley catheter in place
Ext: No c/c/e
Neuro: AAOx2, responsive to questions, pleasant affect,
CNIII-XII intact, grossly moving all four extremities
Skin: Warm, frail, dry, intact
Pertinent Results:
ADMISSION/PERTINENT LABS
___ 01:08PM BLOOD WBC-7.9 RBC-4.85 Hgb-14.1 Hct-41.2 MCV-85
MCH-29.0 MCHC-34.2 RDW-15.6* Plt ___
___ 01:08PM BLOOD Neuts-60.6 ___ Monos-6.2 Eos-2.5
Baso-0.4
___ 01:08PM BLOOD ___ PTT-32.3 ___
___ 01:08PM BLOOD Plt ___
___ 01:08PM BLOOD UreaN-17
___ 01:12PM BLOOD Creat-1.2*
___ 06:40PM BLOOD Glucose-115* UreaN-15 Creat-0.8 Na-143
K-4.3 Cl-104 HCO3-29 AnGap-14
___ 06:40PM BLOOD ALT-12 AST-21 LD(LDH)-194 AlkPhos-103
TotBili-0.7
___ 01:08PM BLOOD cTropnT-<0.01
___ 06:40PM BLOOD Calcium-9.3 Phos-3.7 Mg-2.3
___ 01:09PM BLOOD Glucose-99 Lactate-2.4* Na-142 K-3.7
Cl-105 calHCO3-26
___ 06:23AM BLOOD WBC-5.2 RBC-4.70 Hgb-13.0 Hct-39.1 MCV-83
MCH-27.7 MCHC-33.4 RDW-15.7* Plt ___
___ 06:23AM BLOOD Plt ___
___ 06:23AM BLOOD Glucose-77 UreaN-13 Creat-0.7 Na-142
K-4.0 Cl-106 HCO3-27 AnGap-13
___ 06:23AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
MICROBIOLOGY
___ 12:36PM URINE Color-Straw Appear-Clear Sp ___
___ 12:36PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD
___ 12:36PM URINE RBC-1 WBC-5 Bacteri-FEW Yeast-NONE Epi-1
___ 12:36PM URINE Mucous-RARE
___ 12:36PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
IMAGING
___ Non-contrast head CT IMPRESSION:
No evidence of acute intracranial process. If there is clinical
concern for stroke, consider obtaining MRI which is more
sensitive.
___ CXR IMPRESSION:
In comparison with the study ___, the cardiac silhouette
remains at the upper limits of normal in size and there is again
tortuosity of the descending thoracic aorta. No evidence of
pneumonia, vascular congestion, or pleural effusion. Basilar
atelectatic changes are again suggested on the left.
___ CXR IMPRESSION:IMPRESSION:
In comparison with the study ___, the cardiac silhouette
remains at the upper limits of normal in size and there is again
tortuosity of the descending thoracic aorta. No evidence of
pneumonia, vascular congestion, or pleural effusion. Basilar
atelectatic changes are again suggested on the left.
___ Abdominal X-ray IMPRESSION:
Patient motion somewhat obscures detail. The bowel gas pattern
is essentially within normal limits. Pneumoperitoneum cannot be
assessed in the absence an upright view. Of incidental note is
severe degenerative change in the lumbar spine.
Brief Hospital Course:
___ y/o F w hx of dementia, HTN, depression presented from her
nursing home with concern for altered mental status. Per nursing
home report, pt grunting/drooling and not answering questions
appropriately for a period of time. Her mental status resolved
albeit with continued confusion. On arrival to the hospital,
patient evaluated by Neurology-Stroke service who, after
negative non-contrast head CT, determined that this was unlikely
to be an acute stroke event and recommended the patient be
admitted for further work-up of toxic metabolic encephalopathy.
During her admission, patient's serologic and urine testing
returned largely normal. Chest X-ray showed no evidence of
pneumonia, vascular congestion, or pleural
effusion with mild atelectatic changes. On hospital day #2,
patient found to be moaning/groaning audibly and appearing
paranoid. Vital signs were stable, labwork, chest x-ray,
abdominal x-ray all unremarkable. Behavior-self resolved and
patient again became closer to baseline. After discussion with
health care proxy, found that the patient will occasionally
display this behavior at her baseline. Telemetry was removed and
attempted to minimize interventions/checks and patient remained
calm and pleasant until discharge.
# AMS: Per report, patient was grunting, drooling does not
answer questions appropriately for a brief period of time and
transferred for concern of this AMS. Similarly altered for a
brief time in ED per documentation. Following evaluation
including negative head CT, Neurology service feels this episode
not reflect acute stroke, but possible encephalopathy which
required broader work-up. Of note, pt had similar admission in
___ with similar presentation of intermittent unresponsiveness
which was thought to be secondary to UTI. Currently appears well
without complaints and appears to be at baseline. Troponin
negative. EKG unremarkable on floor. Infectious workup with CXR,
LFTs unrevealing. Serum tox unremarkable. UA also negative.
Neurology noted potential for hypotension precipitating
episodes. Patient stable on antihypertensive regimen and SBPs
stable through documented ED and hospital course. Delirium
precautions were continued during hospital course, including
avoiding tethers and re-orienting frequently. Patient was
monitored on telemetry for over 24 hours before discontinuation.
___: Cr on presentation 1.2 from baseline 0.7-0.8. Most likely
pre-renal in setting of decreased PO intake given hypoactive
delirium, resolved after 1 L NS. Continued to encourage PO
intake.
CHRONIC ISSUES
# HTN:
Stable throughout admission. Continue metoprolol and amlodipine.
# Dementia:
Continued home memantine
# Depression:
Continued Fluoxetine 10 mg and Mirtazapine 15 mg
TRANSITIONAL ISSUES
-Patient has baseline dementia with known periods of confusion
per health care proxy. Further neuropsychological testing may be
warrented to assess baseline cognitive function and predicate
intervention if warranted
-Unclear why patient is on prednisone 2mg (staff at ___
___ did not know previously, and sister, HCP did not know last
admission) but continued as inpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Lactulose 10 mg PO DAILY
3. Fluoxetine 10 mg PO DAILY
4. Lidocaine 5% Patch 1 PTCH TD QAM
5. Memantine 10 mg PO DAILY
6. PredniSONE 2 mg PO DAILY
7. TraZODone 50 mg PO QHS
8. Metoprolol Tartrate 50 mg PO BID
9. Mirtazapine 7.5 mg PO QHS
10. TraZODone 12.5 mg PO QHS:PRN agitation
11. Acetaminophen 975 mg PO TID
12. magnesium hydroxide 30 mL oral daily:PRN constipation
13. ergocalciferol (vitamin D2) 50,000 unit oral ___
14. Hydrocortisone Cream 1% 1 Appl TP BID:PRN itch
15. Miconazole Nitrate Vag Cream 2% 1 Appl VG BID:PRN redness
Discharge Medications:
1. Acetaminophen 975 mg PO TID
2. Amlodipine 5 mg PO DAILY
3. Fluoxetine 10 mg PO DAILY
4. Hydrocortisone Cream 1% 1 Appl TP BID:PRN itch
5. Lactulose 10 mg PO DAILY
6. Lidocaine 5% Patch 1 PTCH TD QAM
7. Memantine 10 mg PO DAILY
8. Metoprolol Tartrate 50 mg PO BID
9. Miconazole Nitrate Vag Cream 2% 1 Appl VG BID:PRN redness
10. Mirtazapine 7.5 mg PO QHS
11. PredniSONE 2 mg PO DAILY
12. TraZODone 50 mg PO QHS
13. TraZODone 12.5 mg PO QHS:PRN agitation
14. ergocalciferol (vitamin D2) 50,000 unit oral ___
15. magnesium hydroxide 30 mL oral daily:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY: Hypoactive Delirium
SECONDARY: Dementia, Hypertension, 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. ___,
It was a pleasure treating ___ at ___
were admitted with concern for your change in mental status.
While in the hospital, ___ were evaluated by the neurology team
who determined that ___ were not having a stroke. By the time
___ were admitted to the floor, your mental status appeared to
be near your described baseline. ___ were worked-up for other
infectious causes of your change in mental status, which all
returned negative. After discussion with your health care proxy,
it was apparent that ___ had returned to your baseline mental
status. Its important to take your medications as prescribed at
your facility as they will help keep ___ healthy.
Wishing ___ the best of health,
Your ___ team
Followup Instructions:
___
|
10178217-DS-13 | 10,178,217 | 23,446,429 | DS | 13 | 2182-09-17 00:00:00 | 2182-09-17 18:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac catheterization ___
History of Present Illness:
___ h/o HTN, HLD, pre-DMII, obesity and PVD who presented with 3
days of chest pain. The pain woke her up on ___ morning,
she describes a sharp, intense, non-radiating left-sided chest
pain. She denies any associated sx such as SOB, N/V,
diaphoresis, pre-syncope. She did not identify alleviating or
worsening factors but felt that moving could trigger the pain.
The pain was continuous for 3 days but of decreasing intensity
and she has been pain-free since her stress test. The patient
went to see her PCP ___ morning where she was found to have
TWI in V3-V6 in infero-lateral leads compared to ___ EKG. She
was sent to the ED and had 2 negative troponin but had a
exercise echo stress that showed inducible hypokinesis in the
distal LAD territory.
In the ED, initial vitals were: 97 67 178/94 18 100% ra. Pain
___. Labs were notable for BUN/Cr: ___, Trop <0.01 x2. Given
ASA 325mg, Lisinopril 40mg, HCTZ 25mg, nadolol 40mg, dilaudid
1mg IV, amlodipine 5mg, rosuvastatin 40mg, Ezetimibe 10mg, KCl
20mEq.
REVIEW OF SYSTEMS:
(+) Per HPI.
(-) Cardiac: Denies chest pain, palpitations, dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, peripheral
edema/swelling, syncope or presyncope.
(-) General: Denies subjective fevers at home, chills, rigors,
diplopia, prior history of stroke or TIA, cough, nausea,
vomiting, diarrhea, melena, hematochezia, hematemesis.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: Diabetes -, Dyslipidemia +,
Hypertension +
2. CARDIAC HISTORY: none
3. OTHER PAST MEDICAL HISTORY:
Obesity
PVD
Anemia
Glaucoma
Hyperparathyroidism
Retinal venous occlusion
S/p appendectomy
Social History:
___
Family History:
FAMILY HISTORY:
Brother had MI at age ___. Mother had MI at age ___. Nephew has
diabetes.
Physical Exam:
ADMISSION EXAM:
VS: T=98 BP=120/62 HR=62 RR=20 O2 sat=100%
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple. No JVD.
CARDIAC: RR, 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 obese.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Radial 2+ Femoral 2+ Popliteal 2+ DP 1+ ___ not felt
Left: Radial 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ not felt
DISCHARGE EXAM:
VS: BP 143/76, HR 68, RR 18, Sat 100% RA
Radial pulse check: nl.
Pertinent Results:
ADMISSION LABS:
___ 08:15PM BLOOD WBC-7.6 RBC-4.71 Hgb-14.1 Hct-42.6 MCV-91
MCH-29.9 MCHC-33.0 RDW-14.8 Plt ___
___ 08:15PM BLOOD Neuts-48* Bands-0 ___ Monos-10
Eos-3 Baso-0 ___ Myelos-0
___ 08:15PM BLOOD ___ PTT-29.6 ___
___ 08:15PM BLOOD Glucose-96 UreaN-22* Creat-0.9 Na-143
K-4.5 Cl-102 HCO3-30 AnGap-16
___ 08:15PM BLOOD cTropnT-<0.01
___ 02:30AM BLOOD cTropnT-<0.01
DISCHARGE LABS:
___ 07:05AM BLOOD WBC-6.3 RBC-4.20 Hgb-12.2 Hct-37.9 MCV-90
MCH-29.2 MCHC-32.3 RDW-14.7 Plt ___
___ 07:05AM BLOOD Glucose-99 UreaN-31* Creat-1.0 Na-144
K-3.9 Cl-108 HCO3-27 AnGap-13
IMAGING:
___ CXR:No acute cardiopulmonary process. Prominent
anterior osteophytes along the thoracic spine with increase in
prominence as compared to the prior chest radiographs.
___: STRESS ECHO
The patient exercised for 8 minutes and 15 seconds according to
a Modified ___ treadmill protocol ___ METS) reaching a peak
heart rate of 118 bpm and a peak blood pressure of 194/80 mmHg.
The test was stopped because of fatigue. This level of exercise
represents an average exercise tolerance for age. In response to
stress, the ECG showed non-diagnostic ST changes (see exercise
report for details). There was moderate resting hypertension.
The blood pressure response to exercise was normal.
.
Resting images were acquired at a heart rate of 72 bpm and a
blood pressure of 166/80 mmHg. These demonstrated mild global
left ventricular hypokinesis (LVEF = 50-55%). Right ventricular
free wall motion is normal. There is no pericardial effusion.
Doppler demonstrated no aortic stenosis, aortic regurgitation or
significant mitral regurgitation or resting LVOT gradient.
Echo images were acquired within 44 seconds after peak stress at
heart rates of 115 - 98 bpm. These demonstrated mild inducible
hypokinesis of the distal anterior segment (dLAD territory),
with appropriate augmentation of all other left ventricular
segments. There was augmentation of right ventricular free wall
motion.
IMPRESSION: Average functional exercise capacity. Non-specific
ECG changes. Echocardiographic evidence of inducible ischemia in
the distal LAD territory. Resting hypertension.
.
IMPRESSION: Abnormal baseline EKG with further non-specific EKG
changes. Non-anginal symptoms. Resting hypertension. Echo report
sent
separately.
.
CATH: (PRELIM NEED TO FOLLOW UP ON FINAL REPORT):
No angiographically apparent CAD.
.
___ RKG:
Sinus rhythm. Left ventricular hypertrophy. Anterolateral ST-T
wave
depression consistent with strain and/or ischemia. No
significant change from earlier tracing of ___.
Brief Hospital Course:
___ with HTN, HL, PVD, pre-DM, obesity and FH of CAD who
presented with atypical chest pain, new infero-lateral TW
changes, flat troponins, found to have inducible hypokinesis in
distal LAD territory on exercise stress echo but with clean
coronaries on cardiac cath. Her chest pain was unlikely cardiac
in origin, it remains unclear what it was related to. She was
found to be hypertensive inpatient and therefore her amlodipine
was increased from 5 to 7.5mg. She will continue her home ASA
81mg daiy, lisinopril 40mg, rosuvastatin 40mg and nadolol. She
was intructed to follow with her PCP.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Nadolol 40 mg PO DAILY
Hold for HR <55 or SBP <100
2. Aspirin 81 mg PO DAILY
3. Ezetimibe 10 mg PO DAILY
4. Rosuvastatin Calcium 40 mg PO DAILY
5. Amlodipine 5 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. Hydrochlorothiazide 50 mg PO DAILY
Discharge Medications:
1. Amlodipine 7.5 mg PO DAILY
RX *amlodipine 5 mg 1.5 tablet(s) by mouth daily Disp #*45
Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. Ezetimibe 10 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. Rosuvastatin Calcium 40 mg PO DAILY
6. Hydrochlorothiazide 50 mg PO DAILY
7. Nadolol 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Chest pain, non-cardiac.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came in the hospital because you had chest pain. You had an
abnormal cardiac stress test and underwent a cardiac coronary
catheterization. Luckily, your coronaries were not affected by
coronary heart disease. In order to prevent heart disease in the
future, your blood pressure should be better controlled. We
recommend for you to increase your amlodipine dose ot 7.5mg per
day. You should follow closely with you PCP.
Followup Instructions:
___
|
10178472-DS-12 | 10,178,472 | 24,177,409 | DS | 12 | 2168-11-16 00:00:00 | 2168-11-16 23:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
carbamazepine / phenobarbital / Depakote / phenytoin
Attending: ___
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
intubated
History of Present Illness:
Eu Critical ___ is a ___ year old woman with a
history of TBI ___ and subsequent seizure disorder on Lamictal
outpatient, recent fall with head strike and SDH (partly
chronic) s/p crani in ___, presenting with a seizure
lasting > 30 minutes at her nursing home.
Per discussion with husband, the patient had a MVC in TBI with
subsequent R sided weakness and seizures. The initial ___ years
after the injury she had seizures, but then she was able to come
off seizure medications and became seizure free for several
years. However, the last ___ years her seizures have become more
frequent again. She was initially started on Keppra but this
made her agitated, so she was switched to Lamictal ___ years
ago. Recently she has had a seizure once every 3 months or so.
Her last seizure was 3 weeks ago and was a "small seizure", the
husband describes whole body stiffening, eyes rolling up, and
unresponsiveness x 30 seconds, with postictal confusion. Her
most recent larger seizures was in ___ when she had a GTC
with rigidity, shaking, drooling, and eye rolling.
Three weeks ago per husband the patient fell in the kitchen and
hit her head against a cabinet, requiring multiple head stitches
and prompting eval in the ED with ___. This reportedly showed
mostly "old" blood in a SDH. Per the husband, he has been told
the patient had some amount of blood in her brain for ___ years.
Neurosurgery evaluated the scans and took the patient for crani
and ___ evacuation 2 weeks ago. She did well and was discharged
to a rehab, then to a nursing home.
Per discussion with ___, the patient only
arrived a few days before ___ so they don't know her
that well. She mostly lies in bed and doesn't talk much,
although she likes to talk about her dog. She plays with things
in her bed and presses the nurses call button a lot, and holds
onto her ___ bear. She requires supervised feeds. She is
incontinence of stool and urine but is able to ambulate with
assistance and a walker, but otherwise she uses a wheelchair. On
___ her temp was 100 so they gave her Tylenol and she has
not had any further temps since then. They sent a UA which was
negative, UCx still pending.
On ___ night the nurses went in to change her and noted that
she had a R sided gaze deviation, with bilateral shaking of her
arms and feet. EMS was called, and when they arrived the seizure
had been going on for 30 minutes. She got Valium 2.5 x 2 and the
shaking stopped. She was taken to ___ and loaded with
keppra 1 gram. Her mental status did not improve rapidly enough,
with GCS < 8, which was an indication for them to intubate,
which they did with Ketamine and succ. She did have a low grade
temp to 100.8, with WBC 17.9. NCHCT stable from priors. UA
negative. She was transferred to the ___ where she woke up a
little requiring sedation with midaz and fentanyl. Here she was
afebrile, with WBC down to 11.5.
ROS: unable to obtain
Past Medical History:
PMH/PSH:
- TBI s/p MVC in ___ with subsequent R sided weakness and
seizures
- subsequent seizure disorder with GTCs for ___ years after TBI,
with some years of seizure freedom, followed by recurrent
seizures in the last ___ years. Occurring approx every 3 months
with GTC activity
- chronic SDH (?at least x ___ years per husband report)
- s/p crani for ___ evacuation 2 weeks ago at ___
- gait abnormality
- depression
- psychosis
- back surgery
- ankle surgery
- s/p G tube and Trach placement and removal ___ years ago
Social History:
___
Family History:
unable to obtain
Physical Exam:
Admission Physical Exam
VS 99 69 92/56 16 100% Intubation
General: NAD, intuabed
Neck: limited ROM
- Mental Status -
Off sedation x 10 minutes. Does not open eyes. Bilateral grasp
reflex but does not demonstrably follow commands.
- Cranial Nerves -
R pupil 3 mm nonreactive, L pupil 2 mm nonreactive. VORs
supressed. + Corneals. + Cough.
- Motor and Sensory -
Tone increased throughout R arm and leg > L side. L arm
withdraws
antigravity to noxious stimulation. R arm extends to noxious
stimulation. Legs withdraw to noxious bilaterally.
- DTRs -
Bic Tri ___ Quad Gastroc
L 3 3 3 3 2
R 3 3 3 3 2
Plantar response extensor bilaterally.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Discharge Physical Examination:
General: calm, left arm and leg with active repetitive movements
HEENT: AT/NC
Lungs: no increased WOB
Neck: supple
Adb: soft, nt, nd
extremities: well perfused
Neurologic Examination:
- Mental Status -
opens eyes spontaneously, simple commands, single words only.
waved hello to examiner with left hand after prompting
- Cranial Nerves -
R pupil 4mm-3.5mm, L pupil 3->2.5mm. EOMI with saccadic
intrusions. mildly disconjugate. + Corneals. + Cough.
- Motor and Sensory -
Tone increased throughout R arm and leg > L side. Spontaneously
moves left arm antigravity. Moves BLE antigravity and crosses
legs spontaneously bilaterally.
- DTRs -
Bic Tri ___ Quad Gastroc
L 3 3 3 3 2
R 3 3 3 3 2
Plantar response extensor bilaterally.
Pertinent Results:
___ 05:25AM BLOOD WBC-11.5* RBC-4.79 Hgb-12.9 Hct-38.0
MCV-79* MCH-26.9* MCHC-33.9 RDW-16.1* Plt ___
___ 05:25AM BLOOD Neuts-86.7* Lymphs-9.1* Monos-3.3 Eos-0.7
Baso-0.3
___ 05:25AM BLOOD Glucose-122* UreaN-14 Creat-0.6 Na-136
K-4.9 Cl-102 HCO3-24 AnGap-15
___ 05:25AM BLOOD cTropnT-<0.01
___ 02:13AM BLOOD Calcium-8.2* Phos-2.4* Mg-1.___t OSH: subacute on chronic L sided SDH with
bilateral frontal lobe hypo intensities. Per OSH radiology read
this scan is similar to priors.
___ CXR: with a ? retrocardiac opacity
MRI ___
1. Left subdural hematoma measuring 7 mm in maximum thickness,
unchanged from CT earlier the same day. There is flattening of
the underlying left cerebral hemisphere and 2 mm rightward shift
of midline structures.
2. Extensive encephalomalacia and gliosis of the bilateral
frontal and right temporal lobes, as well as small area of
gliosis in left temporal lobe, with hemosiderin deposition in
the frontal lobes, compatible with sequela of traumatic injury.
3. Global enlargement of the ventricles, without associated
sulcal
enlargement, which may be related to sequela of prior traumatic
injury, such as intraventricular hemorrhage, rather than
cerebral atrophy.
4. Mild cerebellar atrophy, which may be related to
anticonvulsive
medications, given the clinical history.
Liver U/S ___
Unremarkable appearance of the liver, bile ducts and
gallbladder. Note is made that this is a limited study.
Brief Hospital Course:
___ is a ___ year old woman with a history of TBI ___
and subsequent seizure disorder on lamictal outpatient, recent
fall with head strike and SDH (partly chronic) s/p crani in
___, presenting with a seizure lasting > 30 minutes at
her nursing home. Her shaking resolved with Valium and the
patient was loaded with keppra, but her mental status remained
persistently poor so she was intubated and sent to ___. She
was noted to have low grade temp to 100.5 at OSH. Retrocardiac
opacity read on CXR here was not impressive for PNA, and she was
no longer febrile. There was no other evidence of infection. On
neuro exam off sedation x 10 minutes, she was not waking up
appropriately or following commands. She was started on Keppra
and Lamictal (increased to 200/150 from her home dose of
150BID). EEG was obtained which showed 10+ seizures, each ___
seconds, with intermittent left hemisphere PLEDs with occasional
right PLEDs. She was bolused and started on a midazolam gtt.
Overnight, she continued to have activity on EEG so her
midazolam gtt was increased to 8. MRI showed stable SDH, no
acute stroke, chronic encephalomalacia b/l frontal lobes and R
temporal lobe. By the morning, her EEG had less activity and a
midazolam wean was initiated. During the wean, her PLEDs became
slightly more organized so she was loaded with Vimpat. By the
next day, her EEG showed fewer low amplitude PLEDs and her
background improved. She was extubated. She then had some
agitation and there was no enteral access. Her keppra was
increased to 1.5BID, vimpat increased to 150BID, and she was
sedated with precedex. EEG showed increased PLEDs at 0.5-1hz
with no epileptiform activity. She subsequently passed her
swallow study (pureed diet) and was able to take PO with no
issues. Lamictal was restarted and her other AEDs were
transitioned to PO. Her EEG was markedly improved. A keppra wean
was initiated. She had elevated LFTS so a liver U/S was ordered
which was normal and her LFTs trended back to normal ranges. She
was found to have UTI. UA showed >100,000 klebsiella pneumoniae.
She was treated with ceftriaxone and bactrim while inpatient.
She will continue to be treated with Bactrim DS BID through
___. Prior to discharge, she was re-evaluated by speech
(formal recommendations below). She was discharged back to her
nursing home in stable condition.
Transitional Issues:
- DIET RECOMMENDATIONS:
1. PO diet: pureed solids, teaspoon sized sips of nectar thick
liquids
2. Meds: crushed in puree
3. TID oral care
4. 1:1 supervision/assist with meals for:
- sit fully upright for all POs
- feed only when awake/alert
- ensure small sips (5ccs or less) to reduce risk for
aspiration
- alternate each bite of purees with a sip of liquid
- slow rate of intake. Watch to make sure pt has swallowed
first bite before offering the next
- consider 6 small meals rather than 3 large ones, given
emesis observed today.
5. Swallow f/u in SNF setting. Consider a compensatory feeding
device to limit sip size and reduce caregiver burden.
- the patient continues to have left arm repetative movements.
These have been captured on EEG and are not seizure events.
- the patient is being treated for UTI: please continue to give
Bactrim DS BID through ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral Daily
2. Docusate Sodium 100 mg PO BID
3. LaMOTrigine 150 mg PO BID
4. omeprazole 20 mg oral daily
5. Theragran-M Premier 50 Plus (mv,mn-FA-coQ10-lycopene-lutein)
___ mcg oral Daily
6. Senna 8.6 mg PO DAILY:PRN constipation
7. Acetaminophen 650 mg PO Q4H:PRN pain
8. Milk of Magnesia 30 mL PO DAILY:PRN constipation
9. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO Q4H:PRN
heartburn
10. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Docusate Sodium 100 mg PO BID
4. Senna 8.6 mg PO DAILY:PRN constipation
5. LaMOTrigine 200 mg PO BID
6. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN wheeze
7. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN Wheezing
8. LACOSamide 150 mg PO BID
9. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO Q4H:PRN
heartburn
10. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral Daily
11. Milk of Magnesia 30 mL PO DAILY:PRN constipation
12. omeprazole 20 mg oral daily
13. Theragran-M Premier 50 Plus (mv,mn-FA-coQ10-lycopene-lutein)
___ mcg oral Daily
14. TraZODone 25 mg PO QHS:PRN sleep
15. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 4 Days
LAST DOSE ON ___
16. Ondansetron 4 mg IV Q8H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
seizure
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 ___
You were admitted to ___ after you were found having
seizures at your nursing home. You were sedated and intubated
and treated with multiple AEDs including Vimpat, Keppra, and
Midazolam. Your seizures stopped and you were extubated. A
formal speech and swallow exam was performed with the following
recommendations:
RECOMMENDATIONS:
1. PO diet: pureed solids, teaspoon sized sips of nectar thick
liquids
2. Meds: crushed in puree
3. TID oral care
4. 1:1 supervision/assist with meals for:
- sit fully upright for all POs
- feed only when awake/alert
- ensure small sips (5ccs or less) to reduce risk for
aspiration
- alternate each bite of purees with a sip of liquid
- slow rate of intake. Watch to make sure pt has swallowed
first bite before offering the next
- consider 6 small meals rather than 3 large ones, given
emesis observed today.
5. Swallow f/u in SNF setting. Consider a compensatory feeding
device to limit sip size and reduce caregiver burden.
You were weaned off Keppra. Your AEDs were changed to
lamotrigine 200BID and lacosamide 150BID. Please continue to
take these medications daily and follow up with your outpatient
epileptologist for the management of your seizure disorder. It
was a pleasure caring for you during your stay.
Followup Instructions:
___
|
10178557-DS-7 | 10,178,557 | 20,990,620 | DS | 7 | 2184-12-20 00:00:00 | 2184-12-20 17:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
Abd ___, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with h/o possible IBD, possible IBS and perirectal
fistula s/p fistulotomy with ___ placement (Dr. ___ on
___, now presenting with abd ___ and diarrhea x 7 days. The
patient reports a history of Crohn's disease (diagnosed ___,
treated with Pentasa, Asacol and steroids from ___ she saw
a new gastroenterologist in ___ (Dr. ___ in ___ who
doubted the diagnosis of Crohn's. She is currently not taking
any IBD medications.
She was seen by Dr. ___ underwent fistulotomy and ___
placement on ___. She did well until last ___,
with usual daily abdominal ___ ___ and multiple bowel
movements (baseline). Since that time, she has had increased
abdominal ___ and increased diarrhea. She describes her ___
as ___, with burning in the upper quadrants and cramping in the
lower quadrants. It lasts for hours/days. She reports diarrhea
every 30 minutes that begins upon awakening and continues
throughout the day. Stool is sometimes formed but usually
liquid. She describes urgency but no tenesmus; her ___ is
unrelated to her bowel movements. She also reports intermittent
nausea over the last week. She has taken ibuprofen and naproxen
without significant improvement in her ___. She denies any
dietary changes; she has no change in symptoms with lactose
ingestion.
She presented to the ED today for further evaluation.
Of note, she has an appointment scheduled for ___ with an oral
surgeon for evaluation of a fractured molar; she is hoping to be
discharged prior to that appointment.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: As per HPI
HEENT: As per HPI
RESPIRATORY: [X] All Normal
CARDIAC: [X] All Normal
GI: As per HPI
GU: [X] All Normal
SKIN: [X] All Normal
MS: Chronic LBP
NEURO: [X] All Normal
ENDOCRINE: [X] All Normal
HEME/LYMPH: [X] All Normal
PSYCH: [X] All Normal
[X] all other systems negative except as noted above
Past Medical History:
Possible IBD
Possible IBS
s/p fistulotomy & ___ placement ___
Anxiety/depression
Hepatic steatosis
s/p cholecystectomy
s/p C-section
Fractured molar
LBP
Social History:
___
Family History:
No IBD or GI neoplasm
Physical Exam:
Pt. seen with ___, RN
VS: T = 97.6 P = 64 BP = 111/66 RR = 12 O2Sat = 100% on RA
GENERAL: NAD
Mentation: Alert, speaks in full sentences.
Eyes: Nonicteric
Ears/Nose/Mouth/Throat: MMM
Neck: supple
Respiratory: CTA bilat
Cardiovascular: RRR, nl S1S2
Gastrointestinal: Soft; min diffuse tenderness.
Perianal suture without discharge/bleeding.
Skin: no rashes or lesions noted
Extremities: No edema
Lymphatics/Heme/Immun: No cervical lymphadenopathy noted.
Neurologic:
-mental status: Alert, oriented x 3
-motor: normal bulk, strength and tone throughout
___ SCALE: ___ location: Abd
Pertinent Results:
___ 11:36AM WBC-7.2 RBC-4.22 HGB-13.1 HCT-36.6 MCV-87
MCH-31.1 MCHC-35.9* RDW-12.9
___ 11:36AM NEUTS-60.8 ___ MONOS-4.1 EOS-1.3
BASOS-0.4
___ 11:36AM PLT COUNT-174
___ 11:36AM GLUCOSE-139* UREA N-15 CREAT-0.8 SODIUM-137
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-22 ANION GAP-15
___ 11:36AM ALT(SGPT)-16 AST(SGOT)-26 ALK PHOS-108* TOT
BILI-0.3
___ 11:36AM LIPASE-51
___ 11:36AM ALBUMIN-3.8
___ 11:36AM CRP-3.5
___ 11:36AM URINE UCG-NEGATIVE
Abd CT:
1. No acute intra-abdominal or intrapelvic process.
2. There is no CT evidence for active Crohn's disease.
Examination limited by underdistention of the small bowel.
3. Mild intrahepatic biliary duct dilation likely relates to
prior
cholecystectomy, given normal LFTs at the time of presentation.
4. ___ within a partially visualized left perianal fistula.
No obvious
fluid collection detected.
EKG:
NSR at 66 bpm.
Brief Hospital Course:
___ yo F with acute on chronic abd ___, diarrhea and nausea.
1. GI - Pt with one week h/o abd ___, diarrhea and nausea,
increased from her baseline. She has no sick contacts or other
symptoms to suggest acute infection. She had no evidence for
bleeding, perforation, or pregnancy. GERD, gastritis:
Her ___ was worsened with naproxen, and consistent with
gastritis/GERD. She was treated symptomatically and improved
with intervention - omeprazole,
ranitidine, acetaminophen, zofran and oxycodone. She will
follow-up with GI on ___.
Dr. ___ the patient and also recommended GI
follow-up.
2. Molar fracture - F/U with outpatient OMFS on ___ as noted
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lidocaine 5% Ointment 1 Appl TP TID:PRN discomfort
2. Naproxen 500 mg PO BID:PRN ___
3. Ranitidine 300 mg PO DAILY
4. Ibuprofen 800 mg PO Q8H:PRN ___
Discharge Medications:
1. Lidocaine 5% Ointment 1 Appl TP TID:PRN discomfort
2. Ranitidine 300 mg PO DAILY
3. Acetaminophen 1000 mg PO Q8H:PRN ___
4. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN ___
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*15 Tablet Refills:*0
6. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
GERD
Gastritis
IDB
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted to ___ for worsening abdominal ___ and
loose stools. Your abdominal ___ was consistent with gastritis
and acid reflux - likely worsened by anti-inflmmatory
medications. You were treated with ___ medication, acid
suppression, and fluids with improvement. Please adhere to your
medication regimen and keep your appointments as below.
Followup Instructions:
___
|
10178639-DS-14 | 10,178,639 | 22,455,006 | DS | 14 | 2179-11-03 00:00:00 | 2179-11-08 19:32:00 |
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/palpitations
Major Surgical or Invasive Procedure:
Electrophysiology study ___
History of Present Illness:
In brief this is an ___ with a recent hospitalization for chest
pain and catheterization showing 40% stenosis of LCx only
presenting with acute chest pain and dyspnea at home,
hypotension to 70/30, and VTach in the 200s on tele recorded by
EMS. Was shocked en route and recovered immediately, without
recurrence of chest pain. Did not have a reccurence of Vtach.
Past Medical History:
1. CARDIAC RISK FACTORS: (+)Dyslipidemia, (+)Hypertension,
(+)Diabetes
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
Prostate cancer
HBsAb and HBcAb positivity
Asthma
H/o cellulitis
H/o MVA
S/p right knee arthroplasty
S/p ulnar surgery
Social History:
___
Family History:
MOther with history of CVA at age of ___
Physical Exam:
Admission exam:
PHYSICAL EXAMINATION:
VS: T=97.3 BP=133/85 HR=58 RR=18 O2 sat=95%RA
General: WD WN male, appears younger than stated age, in NAD
HEENT: NCAT, PERRL, EOMI, sclera anicteric, MMM, OP clear
Neck: supple, no JVD, no LAD
CV: RRR, S1, S2, no murmur
Lungs: normal respiratory effort , CTAB no wheezes, rales,
rhonchi
Abdomen: soft NT, ND, +BS
GU: no foley
Ext: WWP no c/c/e
Neuro: appropriate mood and affect, no focal deficits, moving
all 4 extremities
Skin: no rashes or lesions
PULSES: 2+ radial, DP pulses
Discharge exam:
VS: T=98 BP=140/59 HR=61 RR=20 O2 sat=99% RA
GENERAL: WDWN NAD.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with JVP 3 cm above clavicle
CARDIAC: Regular with no murmurs, rubs or gallops
LUNGS: Unlabored, CTAB
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: Clean, dry, intact
NEURO: Alert and oriented x 4
Pertinent Results:
___ 07:36AM BLOOD WBC-4.5 RBC-4.02* Hgb-12.4* Hct-37.2*
MCV-93 MCH-30.9 MCHC-33.4 RDW-13.1 Plt ___
___ 09:00AM BLOOD WBC-5.0 RBC-4.36* Hgb-13.3* Hct-40.6
MCV-93 MCH-30.5 MCHC-32.7 RDW-12.9 Plt ___
___ 07:55PM BLOOD WBC-6.4 RBC-4.51* Hgb-14.3 Hct-41.9
MCV-93 MCH-31.7 MCHC-34.1 RDW-12.6 Plt ___
___ 07:36AM BLOOD Plt ___
___ 09:00AM BLOOD Plt ___
___ 09:00AM BLOOD PTT-150*
___ 09:00AM BLOOD PTT-150*
___ 02:28AM BLOOD PTT-74.9*
___ 09:15PM BLOOD ___ PTT-29.9 ___
___ 07:55PM BLOOD ___ PTT-UNABLE TO ___
___ 07:36AM BLOOD
___ 09:00AM BLOOD
___ 07:36AM BLOOD Glucose-122* UreaN-20 Creat-1.2 Na-143
K-4.0 Cl-109* HCO3-25 AnGap-13
___ 09:00AM BLOOD Glucose-120* UreaN-17 Creat-1.4* Na-140
K-4.3 Cl-104 HCO3-26 AnGap-14
___ 07:25AM BLOOD Glucose-112* UreaN-19 Creat-1.3* Na-140
K-4.1 Cl-104 HCO3-26 AnGap-14
___ 07:55PM BLOOD Glucose-283* UreaN-23* Creat-1.8* Na-136
K-3.9 Cl-97 HCO3-24 AnGap-19
___ 07:25AM BLOOD CK(CPK)-160
___ 02:28AM BLOOD CK(CPK)-184
___ 09:00AM BLOOD CK-MB-9 cTropnT-0.21*
___ 07:25AM BLOOD CK-MB-9 cTropnT-0.21*
___ 02:28AM BLOOD CK-MB-9 cTropnT-0.25*
___ 07:55PM BLOOD cTropnT-0.03*
___ 07:36AM BLOOD Calcium-9.3 Phos-3.3 Mg-1.9
___ 09:00AM BLOOD Calcium-9.6 Phos-3.1 Mg-2.0
___ 07:25AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.1
___ 07:55PM BLOOD GreenHd-HOLD
Brief Hospital Course:
Mr. ___ is a ___ year old gentleman with a history of CAD,
hypertension, hyperlipidemia, and NIDDM who presented with chest
pain and dyspnea found to be in VT s/p cardioversion in the
field, unknown cause of arrhythmia.
# Monomorphic Ventricular Tachycardia: Pt with chest pain and
dyspnea in setting of hemodynamically unstable vtach. He is s/p
cardioversion and lidocaine gtt in setting of possible
myocardial ischemia as a trigger, though this is unlikley. He is
currently hemodynamically stable. The precipitant of his
ventricular tachycardia is unclear at this time; MRI shows no
scar. Other possible precipitants are drug toxicity, electrolyte
disturbances, or new or worsening heart failure, or dislodging
of clot from catheterization. Echo shows global borderline
hypokinesis, EF 50-55%, mild LVH. EP study performed and several
sites ablated. However, these were not symptomatic and therefore
may not have been the cause of his symptomatic VTach. Patient
also transiently went into atrial fibrillation in the procedure.
- aspirin 81 mg daily, no other anticoagulation given unlikely
ischemia
- keep pacer pads in room
- Post procedure recs pending
- Consideration of anticoagulation, though his CHADS score is
only 2, if Holter monitor reveals continued atrial fibrillation.
# Hypertension: On atenolol 50 mg daily, Nifedipine CR 90 mg PO
DAILY and HCTZ 25 mg PO daily at home. Restarted.
# Hyperlipidemia: atorvastatin 80mg daily
# NIDDM: On Metformin 500 BID at home. Last A1c was 5.6%.
- Hold Metformin while in house
- Insulin sliding scale
# AoCKD: Pt with acute on chronic CKD with Cr of 1.8. Now 1.2
(baseline 1.4). Likely from acute hypotension.
# Asthma: No current exacerbation
- continue home albuterol PRN
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB or wheeze
2. Aspirin 81 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Atorvastatin 40 mg PO DAILY
5. NIFEdipine CR 90 mg PO DAILY
6. Lumigan (bimatoprost) 0.01 % ophthalmic 1 drop to both eyes
QHS
7. MetFORMIN (Glucophage) 500 mg PO BID
8. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. MetFORMIN (Glucophage) 500 mg PO BID
3. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Metoprolol Succinate XL 50 mg PO BID
RX *metoprolol succinate 50 mg 1 tablet extended release 24
hr(s) by mouth Twice daily Disp #*60 Tablet Refills:*0
5. Lumigan (bimatoprost) 0.01 % ophthalmic 1 drop to both eyes
QHS
6. NIFEdipine CR 90 mg PO DAILY
7. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB or wheeze
8. Atorvastatin 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Ventricular tachycardia
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 in the hospital. You came
to the hospital because you had chest pain and were found to
have a dangerous rhythm called ventricular tachycardia. You were
shocked, and did well since. On ___, you had an electrical
study of your heart that showed the most likely cause of your
bad rhythm, which was burned off. When you go home, you will
wear the ___ of Hearts monitor as instructed to make sure that
your heart is beating at a normal rhythm. The MRI of your heart
showed that it was beating well, but not ___, so we have
changed your medications to optimize how your heart works.
Followup Instructions:
___
|
10178639-DS-15 | 10,178,639 | 29,170,797 | DS | 15 | 2180-06-04 00:00:00 | 2180-06-05 07:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
Presyncope
Major Surgical or Invasive Procedure:
Pacemaker placement, direct current cardioversion
History of Present Illness:
Mr. ___ is a ___ year old male with PMH of HTN, HLD, hx of
VT s/p ablation, non-obstructive CAD, DM2, paroxysmal atrial
fibrillation with wide ventricular escape who presents with a 6
month history of presyncopal episodes. Patient states that these
episodes started back in ___ after he had a myocardial
infarction in ___. The episodes occur usually in the
morning when he is getting up from bed (i.e. when he rises from
a supine position). He describes the episodes as a momentary
lapse in awareness similar to "nodding off" for a second or two.
The episodes usually occur once or twice a week and only lasts
for 1 to 2 seconds each time. He denies any prodromal symptoms
like headache, vertigo, nausea, or shortness of breath. He does
report having orthopnea but denies any PND, he usually sleeps on
3 pillows at night. These episodes resolve quickly and have no
lasting sequelae. He denies any associated symptoms of chest
pain, shortness of breath, or changes in his vision. He had been
given a Holter monitor which showed afib with wide ventricular
escape with HR in the ___.
In the ED, initial vitals were temp = 97.8, HR 60, 135/71, RR
16, 98% RA.
On arrival to the floor, pt remained stable. Vitals: 98.6,
122/72, HR 52, RR 16, 97% on RA. Patient was asymptomatic,
denies any chest discomfort, SOB, lightheadedness or dizziness.
Past Medical History:
1. CARDIAC RISK FACTORS: (+)Dyslipidemia, (+)Hypertension,
(+)Diabetes
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
Prostate cancer
HBsAb and HBcAb positivity
Asthma
H/o cellulitis
H/o MVA
S/p right knee arthroplasty
S/p ulnar surgery
Social History:
___
Family History:
Mother with history of CVA at age of ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.6, 122/72, HR 52, RR 16, 97% RA
General: NAD, comfortable, pleasant, A&O x3
HEENT: NCAT, PERRL, EOMI
Neck: supple, JVD 3cm above clavicle @ 90 degrees
CV: regular rhythm, no m/r/g
Lungs: CTAB, no w/r/r
Abdomen: soft, NT/ND, BS+
Ext: WWP, no clubbing or cyanosis, 1+ pitting edema up to
mid-calf bilaterally, 1+ distal pulses bilaterally
Neuro: moving all extremities grossly
DISCHARGE PHYSICAL EXAM:
Pertinent Results:
ADMISSION LABS:
___ 07:38PM BLOOD WBC-5.4 RBC-4.27* Hgb-13.0* Hct-39.7*
MCV-93 MCH-30.5 MCHC-32.8 RDW-14.6 Plt ___
___ 07:38PM BLOOD ___ PTT-32.5 ___
___ 07:38PM BLOOD Plt ___
___ 07:38PM BLOOD Glucose-105* UreaN-22* Creat-1.6* Na-139
K-4.6 Cl-101 HCO3-28 AnGap-15
___ 07:38PM BLOOD Calcium-9.4 Mg-1.9
PERTINENT LABS:
CBC:
___ 07:38PM BLOOD WBC-5.4 RBC-4.27* Hgb-13.0* Hct-39.7*
MCV-93 MCH-30.5 MCHC-32.8 RDW-14.6 Plt ___
___ 07:05AM BLOOD WBC-5.3 RBC-4.25* Hgb-12.9* Hct-39.8*
MCV-94 MCH-30.5 MCHC-32.6 RDW-14.7 Plt ___
___ 06:55AM BLOOD WBC-6.1 RBC-4.17* Hgb-12.8* Hct-38.4*
MCV-92 MCH-30.7 MCHC-33.4 RDW-14.5 Plt ___
CHEMISTRY:
___ 07:38PM BLOOD Glucose-105* UreaN-22* Creat-1.6* Na-139
K-4.6 Cl-101 HCO3-28 AnGap-15
___ 07:05AM BLOOD Glucose-115* UreaN-18 Creat-1.5* Na-142
K-4.4 Cl-103 HCO3-29 AnGap-14
___ 06:55AM BLOOD Glucose-112* UreaN-16 Creat-1.4* Na-142
K-3.7 Cl-101 HCO3-27 AnGap-18
IMAGING:
CHEST PA/LATERAL (___):
IMPRESSION:
As compared to the previous radiograph, the patient has received
the new left pectoral pacemaker system. 1 lead projects over
the right atrium and 1 over the right ventricle. No evidence of
complications, notably no pneumothorax. Minimal bilateral areas
of atelectasis. No pulmonary edema. No pneumonia.
PROCEDURAL NOTE:
Reason for interrogation: post-implant device check
Device Brand: ___
Model: Accent ___ / Serial ___. ___
Date of Implant: ___
Presenting rhythm: AP-VP
Intrinsic Rhythm: NSR
Programmed Mode: DDD 60-130 ppm / sAVD 150 / pAVD 200 ms
___: 2.98 V
Battery Life: ___ yrs
RA lead:
Model Brand/Number: MD___-52cm / ___
Intrinsic amplitude: 0.7 mV
Pacing impedance: 480 Ohms
Pacing threshold: 0.5 V at 0.5 ms
% Pacing: 0%
RV lead:
Model Brand/Number: MDT 4076 - 58cm / BBL90___
Intrinsic amplitude: 3.2 mV
Pacing impedance: 530 Ohms
Pacing threshold: 0.5 V at 0.5 ms
%pacing: 99%
Diagnostic information:
- AT/AF burden 94%
Programming changes: none
Summary: normal device function
Overnight events: none
Subjective: feels well
Objective: focused exam
VS: T 97.9F; HR 70 bpm; BP 131/88 mmHg; RR 18/min; O2 98% RA
Gen: pleasant, NAD
Neck: JVP not elevated. Normal carotid upstroke without bruits.
Chest: lungs CTAB, no crackles or wheezing.
CV: RRR, nl S1,S2, no S3/S4. No murmurs, rubs, or gallops. L
deltopectoral pocket c/d/i.
Abdomen: soft, NT, ND, BS+
Extremities: wwp, 2+ pulses bilaterally. No femoral bruits.
Plan:
- Keep NPO for ___ today
- Please obtain CXR (PA/Lateral) for lead positioning; ECG today
- Continue IV antibiotics while inpatient, change to PO upon
discharge
- Continue amiodarone 400mg PO bid, rivaroxaban 20mg daily
- Please arrange for device clinic follow-up in 1 week; f/u with
Dr. ___ in 1 month.
CARDIOVERSION REPORT:
The patient was sedated by a member of the anesthesia staff with
50 mg IV propofol and when appropriate was shocked with 200J
external biphasic synchronized energy with prompt return to
sinus
rhythm. He had runs of atrial tachycardia with a cycle length of
460 and rate of 130 bpm and so his upper tracking rate was
lowered from 130bpm to 120bpm. The atrial tachycardia continued
but at rates of 120bpm. The patient tolerated the procedure well
and left the cardioversion room awake and in stable condition.
Pre-DCCV ECG: Atrial fibrillation, 70 bpm
Post-DCCV ECG:Sinus rhythm 60 bpm
IMPRESSION:
Successful electrical cardioversion of atrial fibrillation to
sinus rhythm, with subsequent runs of atrial tachycardia.
RECOMMENDATIONS:
Clinical follow-up with Dr. ___ prior medications
Atrial tracking rate lowered from 130bpm to 120bpm
___, MD
___
___ pager
Brief Hospital Course:
Mr. ___ is a ___ w/ PMH of HTN, HLD, non-obstructive CAD,
DM2, paroxysmal afib w/ wide ventricular escape who presents
with a 6 month history of presyncopal episodes, here for PPM
placement.
# Afib with wide ventricular escape rhythm: pt presented for
pacemaker placement. Initially had episodes of bradycardia at
night with HR as low as the ___ but remained asymptomatic. He
did not have any episodes of presyncope during his admission. He
underwent placement of a dual-chamber ___ pacemaker. He
also underwent subsequent cardioversion with successful
conversion of afib into NSR with occasional atrial tachycardia.
He is being discharged on another loading course of amiodarone,
metoprolol succinate, furosemide 60mg (up from 40mg), and a
3-day course of keflex as antibiotic prophylaxis.
# CAD: kept on home cardiac medications. Increased lasix dose
from 40mg daily to 60mg daily on discharge.
# DM: patient kept on SSI during admission. No active issues
with blood glucose levels during this admission.
# Transitions in care:
-Furosemide increased to 60mg from 40mg
-Stopped atenolol, starting metoprolol succinate 50mg daily
-Increasing amiodarone to 400mg twice daily for 1 week, then
switch back to 200mg daily
-Need outpatient lab draw for a CHEM 7 on ___ at device clinic
-Take Keflex ___ three times daily for a total of 3 days
-Follow up in cardiac device clinic on ___
-Follow up with Dr. ___ EP on ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Rivaroxaban 20 mg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Furosemide 40 mg PO DAILY
6. Lumigan (bimatoprost) 0.01 % ophthalmic QPM
7. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
8. Atorvastatin 20 mg PO DAILY
9. NIFEdipine CR 90 mg PO DAILY
10. Lisinopril 5 mg PO DAILY
11. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Atorvastatin 20 mg PO DAILY
2. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
3. Lisinopril 5 mg PO DAILY
4. Rivaroxaban 20 mg PO DAILY
5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth EVERY 4 HOURS Disp #*16
Tablet Refills:*0
6. Lumigan (bimatoprost) 0.01 % ophthalmic QPM
7. MetFORMIN (Glucophage) 500 mg PO BID
8. NIFEdipine CR 90 mg PO DAILY
9. Furosemide 60 mg PO DAILY
RX *furosemide 40 mg 1.5 tablet(s) by mouth DAILY Disp #*45
Tablet Refills:*0
10. Amiodarone 400 mg PO BID
Take this dose for ONE WEEK, then go back to taking 200mg daily.
RX *amiodarone 400 mg 1 tablet(s) by mouth TWICE DAILY Disp #*14
Tablet Refills:*0
11. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth DAILY Disp
#*30 Tablet Refills:*0
12. Outpatient Lab Work
Patient needs blood to be drawn for a CHEM 7 (sodium, potassium,
chloride, bicarbonate, BUN, creatinine, glucose) on ___.
Fax results to Dr. ___: ___
ICD 9 code: 427.3
13. Cephalexin 500 mg PO Q8H
RX *cephalexin [Keflex] 500 mg 1 capsule(s) by mouth THREE TIMES
DAILY Disp #*9 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: atrial fibrillation with wide ventricular
escape rhythm
Secondary diagnosis: coronary artery disease, type 2 diabetes,
hypertension, hyperlipidemia, asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were seen at the ___ ___ ___ because you
were having episodes of low heart rate leading to
light-headedness. We had a pacemaker placed to prevent your
heart rate from getting that low again. We also did a
cardioversion to get your heart back into a regular rhythm.
Please follow up at the cardiac Device Clinic on ___.
It was a pleasure taking care of you.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10179119-DS-13 | 10,179,119 | 26,992,464 | DS | 13 | 2164-05-28 00:00:00 | 2164-05-31 17:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Tylenol / Tegretol
Attending: ___
Chief Complaint:
rash and grimacing
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ male with history of cerebrtal palsy, MR, seizure
disorder on dilantin, scoliosis s/p spine surgery,
spastic quadriplegic, GERD and anemia initially presented to
___ with facial gimacing, twitching movement in his face
___. Per patient's history of seizures for which he is
prescribed phenytoin 125 mg bid, nursing staff was concerned
that this increased grimmacing represented increased seizure
activity, though patient has grimacing above baseline.
Before leaving the nursing home, patient's temperature was
100.4C @ 0430. He was given 100mg IV doxycycline Q12 h out of
concern for LLE cellulitis, unclear how many doses he recieved.
Patient was sent to ___. His temperature was 101.7
he
was tachycardic to 99 with blood pressures ranging from 100
systolic to 130 systolic. His urine was clear, white count was
10.2, sodium 132, and the remainder of his labs were
unremarkable. He was started on meropenem and vancomycin, given
1L NS, and given a 1x dose of 1mg ativan. Lactate was 1.1, LFTs
were unremarkable
The patient is not verbal at baseline and is not able to provide
any information. The patient is not accompanied by any family or
staff members. All history was obtained from the records.
In the ED, initial vitals: 98.2 ___ 16 99% RA
Labs were significant for subtherpeutic phenytoin level of 8.5
(goal ___, creatine of 0.4, AST 51, Hgb 13.4 and Hct 36.5.
In the ED patient recieved 1L NS bolus, 1mg lorazepam, and
Levetiracetam (Keppra) 1000 mg. 2x Blood Cultures were sent
Imaging showed no acute cardiopulmonary process on a limited CXR
w/o priors for comparison.
Vitals prior to transfer: 98.3 97 109/69 28 94% RA
Past Medical History:
Mental Retardation
seizure disorder on dilantin
scoliosis s/p spine surgery
spastic quadriplegic
GERD
anemia
left thigh cellulitis
Social History:
___
Family History:
Deferred.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.8 105/63 96 18 99% RA
GEN: Asleep, lying in bed, non-responsive to exam. does grimace
with repositioning
HEENT: MMM
NECK: Supple without LAD
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, midline surigcal scar, J-tube leaking
with small rim of ___ redness w/o clear borders
EXTREM: Hands and feet cool to touch, rest of body warm.
Bilateral non-pitting pedal edema
SKIN: Right arm - ___, blanching rash on lateral surface
Left arm - PIV, no rash
Left Inner thigh - Erythematous, continuous, blanching,
warm pink rash with clear demarcations, no sign of skin
breakdown
Right Outer thigh - Erythematous, continuous, blanching,
warm pink rash with clear demarcations, no sign of skin
breakdown
NEURO: Not fully assessed, patient asleep. PERRL. pt
quadriplegic with contractures
DISCHARGE PHYSICAL EXAM:
VS: T98-99.0 HR 93-104 BP ___ RR 18 O2Sat 93-94% RA
GEN: Awake lying in bed, non-responsive to conversation. does
grimace with repositioning and palpation of thigh rashes
HEENT: MMM
NECK: Supple without LAD
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, midline surigcal scar, J-tube clean dry
and intact dressing
EXTREM: Bilateral non-pitting pedal edema.
SKIN: Right arm - no rashes
Left arm - PIV, no rash
Left Inner thigh - Rash has resolved from demarkaed area,
still warm to touch
Left Outer thigh - Rash has resolved from demarkaed area,
still warm to touch
Right Outer thigh - Rash has resolved from demarkaed area,
still warm to touch
Pertinent Results:
___ 10:05AM BLOOD WBC-3.0* RBC-3.56* Hgb-12.5* Hct-35.1*
MCV-99* MCH-35.1* MCHC-35.6* RDW-13.1 Plt ___
___ 09:50AM BLOOD WBC-3.3* RBC-3.69* Hgb-12.9* Hct-36.0*
MCV-98 MCH-35.1* MCHC-35.9* RDW-13.1 Plt ___
___ 07:00AM BLOOD WBC-6.1 RBC-3.63* Hgb-13.0* Hct-35.5*
MCV-98 MCH-35.8* MCHC-36.6* RDW-13.1 Plt ___
___ 03:26PM BLOOD WBC-9.2 RBC-3.71* Hgb-13.4* Hct-36.5*
MCV-98 MCH-36.2* MCHC-36.8* RDW-13.4 Plt ___
___ 09:50AM BLOOD Neuts-50.2 ___ Monos-7.7 Eos-3.5
Baso-0.6
___ 07:00AM BLOOD Neuts-70.4* ___ Monos-7.3 Eos-2.2
Baso-0.3
___ 03:26PM BLOOD Neuts-84.4* Lymphs-8.2* Monos-6.2 Eos-0.9
Baso-0.2
___ 10:05AM BLOOD Plt ___
___ 09:50AM BLOOD Plt ___
___ 07:00AM BLOOD Plt ___
___ 03:26PM BLOOD Plt ___
___ 03:26PM BLOOD ___ PTT-25.4 ___
___ 07:25AM BLOOD Glucose-102* UreaN-9 Creat-0.3* Na-134
K-5.0 Cl-100 HCO3-26 AnGap-13
___ 09:50AM BLOOD Glucose-141* UreaN-7 Creat-0.3* Na-144
K-3.9 Cl-103 HCO3-30 AnGap-15
___ 07:00AM BLOOD Glucose-92 UreaN-8 Creat-0.3* Na-138
K-3.5 Cl-99 HCO3-30 AnGap-13
___ 03:26PM BLOOD Glucose-105* UreaN-8 Creat-0.4* Na-135
K-4.1 Cl-97 HCO3-28 AnGap-14
___ 07:00AM BLOOD ALT-29 AST-33 AlkPhos-84 TotBili-0.3
___ 03:26PM BLOOD ALT-34 AST-51* AlkPhos-94 TotBili-0.4
___ 03:26PM BLOOD Lipase-18
___ 07:25AM BLOOD Calcium-8.5 Phos-3.7 Mg-2.0
___ 09:50AM BLOOD Calcium-8.6 Phos-2.9 Mg-1.9
___ 03:26PM BLOOD Albumin-3.6
___ 04:58PM BLOOD Phenyto-9.8*
___ 03:26PM BLOOD Phenyto-8.5*
___ 03:33PM BLOOD Lactate-1.3
___ 08:03PM URINE Color-Yellow Appear-Clear Sp ___
___ 08:03PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 8:03 pm URINE Source: Catheter.
**FINAL REPORT ___ URINE CULTURE (Final
___: NO GROWTH.
___ - Bilateral Lower Extremity Vein Ultrasound
FINDINGS:
Grayscale, color, and spectral doppler imaging was obtained of
the right and left common femoral, femoral, and popliteal veins.
Normal flow,
compressibility, augmentation, and waveforms are demonstrated.
No intraluminal thrombus is identified. Normal color flow is
demonstrated in the posterior tibial and peroneal veins. There
is normal respiratory variation in both common femoral veins. No
___ cyst is seen.
IMPRESSION:
No evidence of deep vein thrombosis in right or left lower
extremity
___ Imaging CHEST (PORTABLE AP)
___ ___ M ___ ___
Radiology Report CHEST (PORTABLE AP) Study Date of ___
11:38 AM
Exam is limited secondary to degree of the thoracic scoliosis
with posterior fixation hardware and rotation to the left.
There is no visualized consolidation noting that a significant
portion of the lungs is obscured. The cardiomediastinal
silhouette is unremarkable. No acute osseous abnormalities
identified.
IMPRESSION:
Limited exam especially without priors without definite acute
cardiopulmonary process.
Brief Hospital Course:
___ male with history of cerebral palsy, MR, seizure
disorder on dilantin, scoliosis s/p spine surgery,
spastic quadriplegic, GERD and anemia initially presented to ___ with facial grimacing, twitching movement in his face
___ with cellulitis improving on ABX.
# Cellulitis - Patient presented with an erythematous,
blanching, and warm rash on his right outer thigh, left inner
thigh, and left outer thigh consistent with cellulitis. At ___
___, patient was given one dose of doxycycline then was
started on IV vancomycin at ___ and continued here.
His cellulitis improved. He was transitioned from IV vancomycin
to PO cephalexin and doxycycline ___ and continued to improve.
He will continue taking CEPHALEXIN 500 mg PO Q6hr and
doxycycline 100mg PO Q12 to complete a 10 day total course of
antibiotics that ends ___. He was afebrile the entire time he
was here at ___.
# Seizure - Suspicion for seizures was ___ patient's increased
grimacing at his home. Patient has a history of seizure
disorder. His phenytoin level was sub therapeutic ___ @ 8.5. He
was loaded with 1 mg Keppra. Phenytoin remained sub therapeutic
on ___ @ 9.8. Patient was not witnessed grimacing or showing
any other signs of seizures while here at ___. He was
discharged on four AED's: Dilantin 125 mg BID, Lamictal 175 mg
BID, Phenobarbital 60 mg BID, and Keppra 500mg BID. Neurology
recommended considering discontinuing dilantin to avoid
long-term osteoperosis, but that was deferred to the outpatient
setting. Patient has follow up scheduled with Dr. ___.
#Non-pitting Lower Extremity Edema - Patient had bilateral ___
swelling, new onset according to patient's father. Lower
extremity ultrasound found no DVT. Improved with treatment of
cellulitis.
#GERD - Patient was put on lansoprazole per ___ pharmacy. Will
continue on home PPI.
#Nutrition - NPO. Tube feeding: Recommend initiate Vital 1.5 @
35mL/hr w/ x2 pkg Beneprotein BID, flush G/J-tube w/ 200mL free
water flush q4hrs (provides 1260 kcal, 85 grams protein, 1842 mL
free water); consistent w/ nursing home kcal/protein/fluid
administration
Transitional Issues:
- Consider discontinuing dilantin and continuing him on Keppra
given risk of osteoporosis. will follow up with outpatient
neurologist
- Patient needs to complete PO antibiotic course for cellulitis
- PO CEPHALEXIN 500 mg PO Q6hr and doxycycline 100mg PO Q12 to
complete a 10 day total course that ends ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Cyanocobalamin 1000 mcg IM/SC MONTHLY
2. Multivitamins 1 TAB PO DAILY
3. Furosemide 20 mg PO DAILY
4. Loratadine 10 mg PO DAILY
5. omeprazole 15 mL oral BID
6. Docusate Sodium (Liquid) 100 mg PO BID
7. Lactulose 30 mL PO BID
8. LaMOTrigine 175 mg PO BID
9. Minocycline 100 mg PO Q12H
10. Phenytoin (Suspension) 100 mg PO Q12H
11. Baclofen 10 mg PO TID
12. DiphenhydrAMINE 25 mg PO Q6H:PRN congestion, allergies
13. Bisacodyl ___VERY OTHER DAY: PRN constipation
14. Ibuprofen Suspension 400 mg PO Q6H:PRN pain, fever
15. Prochlorperazine 10 mg PO Q6H:PRN nausea
16. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dyspnea, wheeze
17. Doxycycline Hyclate 100 mg IV Q12H
Discharge Medications:
1. Baclofen 10 mg PO TID
2. Bisacodyl ___VERY OTHER DAY: PRN constipation
3. Docusate Sodium (Liquid) 100 mg PO BID
4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dyspnea, wheeze
5. Lactulose 30 mL PO BID
6. LaMOTrigine 175 mg PO BID
7. Phenytoin (Suspension) 125 mg PO Q12H
8. Cephalexin 500 mg PO Q6H Duration: 6 Days
9. Doxycycline Hyclate 100 mg PO Q12H Duration: 6 Days
10. Cyanocobalamin 1000 mcg IM/SC MONTHLY
11. DiphenhydrAMINE 25 mg PO Q6H:PRN congestion, allergies
12. Ibuprofen Suspension 400 mg PO Q6H:PRN pain, fever
13. Loratadine 10 mg PO DAILY
14. Minocycline 100 mg PO Q12H
15. Multivitamins 1 TAB PO DAILY
16. Omeprazole 15 mL ORAL BID
17. Prochlorperazine 10 mg PO Q6H:PRN nausea
18. Furosemide 20 mg PO DAILY
19. PHENObarbital 64.8 mg PO BID
20. LeVETiracetam Oral Solution 500 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
cellulitis
seizure
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Mr. ___,
It has been a pleasure taking care of you here at ___
___. You were transfered to our
hospital because your caregivers were concerned that you were
having seizures and had a skin infection. We treated your skin
infection infection and it improved. You have not had a fever
since we initiated therapy.
When you came into the hospital, the amount of the
anti-seizure medication phenytoin in your body was low. We
started you on a new anti-epileptic drug called Keppra. While
you have been in the hospital, you have not had the grimacing or
any other signs of a seizure. You are now on 4 antiepyleptic
drugs. We encourage you to discuss with your neurologist Dr.
___ whether you should discontinue your dilantin
(phenytoin).
We wish you all the best,
-Your Care Team at ___
Followup Instructions:
___
|
10179438-DS-7 | 10,179,438 | 26,517,964 | DS | 7 | 2136-03-22 00:00:00 | 2136-03-22 16:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Benadryl / bacitracin
Attending: ___.
Chief Complaint:
Fall
Face pain
Right arm pain
Major Surgical or Invasive Procedure:
right lower eyelid laceration was repaired with 2 running ___
gut sutures and 5 interrupted ___ gut sutures. Some devitalized
skin was removed.
History of Present Illness:
This patient is a ___ year old female who complains of Facial
fracture, Facial
swelling, s/p Fall. Patient transferred for facial fractures and
R humerus fracture after trip and fall. Ambulates with a walker
at baseline. Was at ophthalmology appointment where her eyes
were dilated. Tripped and fell after she left. No
anticoagulation. Had CT of head, neck and facial bones prior to
transfer. ___ fracture by report. No CP, SOB, abdominal
pain, back pain. No weakness. Large amount of ecchymosis to
face. CC being evaluated: Facial fracture, Facial swelling, s/p
Fall
Past Medical History:
PMH: Dialysis ___
PSH: mastectomy, skin cancer removal, retina cancer surgery,
colon cancer surgery
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
Temp: 98 HR: 74 BP: 180/74 Resp: 18 O2 Sat: 98 Normal
Constitutional: elderly female
Head / Eyes: Extraocular muscles intact, Pupils equal, round and
reactive to light, dilated
pupils
ENT / Neck: extensive ecchymosis to face, mid face mobile
Chest/Resp: no chest wall tenderness or crepitus
Cardiovascular: Regular Rate and Rhythm
GI / Abdominal: Soft, Nontender, Nondistended
GU/Flank: No costovertebral angle tenderness
Musc/Extr/Back: + pulses, deformity R humerus, pelvis stable,
FROM, no deformity lower
extremities
Pertinent Results:
ADMISSION LABS:
=============
___ 07:20PM BLOOD WBC-13.0* RBC-3.56* Hgb-11.6 Hct-36.0
MCV-101* MCH-32.6* MCHC-32.2 RDW-13.0 RDWSD-47.8* Plt ___
___ 07:20PM BLOOD Neuts-89.4* Lymphs-2.2* Monos-7.3
Eos-0.4* Baso-0.2 Im ___ AbsNeut-11.58* AbsLymp-0.29*
AbsMono-0.95* AbsEos-0.05 AbsBaso-0.03
___ 07:20PM BLOOD ___ PTT-24.0* ___
___ 07:20PM BLOOD Glucose-137* UreaN-62* Creat-3.5* Na-134*
K-4.8 Cl-94* HCO3-22 AnGap-18
___ 07:20PM BLOOD Calcium-9.5 Phos-4.2 Mg-1.7
RELEVANT LABS:
============
___ 06:01AM BLOOD Ret Aut-1.0 Abs Ret-0.03
___ 06:47PM BLOOD CK-MB-8 cTropnT-0.49*
___ 10:05PM BLOOD CK-MB-7 cTropnT-0.45*
___ 06:01AM BLOOD CK-MB-5 cTropnT-0.45*
___ 03:46PM BLOOD cTropnT-0.45*
___ 03:46PM BLOOD VitB12-586 Folate-18
RELEVANT IMAGING:
===============
RADIOLOGY
___ CT Head, Foot, and spine: imaging at OSH
___ CT chest/abd/pelvis:
1. Acute, impacted fracture of the surgical neck of the right
humerus. No other definite acute fractures identified.
2. Multiple chronic appearing right-sided rib deformities, along
with a chronic appearing rib deformity of the lateral left
eighth
rib. Chronic sternal fracture.
3. Multiple, nodular ground-glass opacities within the left
lower
lobe, which may be infectious or inflammatory in etiology.
4. No acute intra-abdominal or intrapelvic abnormality.
5. 5 mm hypodense lesion within the pancreatic tail.
6. Fusiform, infrarenal abdominal aortic aneurysm, measuring 3.0
cm. No evidence of impending rupture.
7. Chronic appearing compression deformities of the T11 and L1
vertebral bodies.
8. Bilateral adnexal cystic lesions, measuring up to 1.9 cm. A
nonemergent pelvic ultrasound may be obtained for further
evaluation, if clinically appropriate.
___ R shoulder: Redemonstrated impacted fracture of the
surgical
neck of the right humerus.
___ knee xray
No acute fractures or dislocations are seen. There is mild
medial and lateral
joint space narrowing and small spurs in the three compartments.
There is
faint chondrocalcinosis which is nonspecific but can be seen
with CPPD
arthropathy and/or osteoarthritis.There is mild
demineralization. There are
vascular calcifications. There is a small joint effusion.
___ RT elbow
IMPRESSION:
There is demineralization which limits evaluation for subtle
fractures. No
displaced fractures are seen of the distal humerus or elbow.
There are
degenerative changes of the radiocapitellar joint with joint
space narrowing,
spurring, and subchondral cystic changes. There is spurring
along the lateral
epicondyle. Evaluation for elbow joint effusion is limited due
to the
overlying soft tissue swelling and projection.
___ CXR
IMPRESSION:
No acute cardiopulmonary abnormality.
___ LFT foot X-ray
IMPRESSION:
Diffusely demineralized bones. No acute displaced fracture
identified.
___ TTE
IMPRESSION: Moderately depressed left ventricular systolic
function consistent with extensive/ multivessel coronary artery
disease. Increased left ventricular filling pressure. Moderate
mitral and tricuspid regurgitation. Moderate pulmonary
hypertension.
Brief Hospital Course:
Ms. ___ is a ___ yo F with CKD on HD, who tripped an fell landing
on her right arm and face. She was transferred from an outside
hospital with CT scan concerning for ___ type fracture
pattern. On presentation she was alert and oriented with stable
vital signs. On trauma assessment she was noted to have an
impacted fracture of the surgical neck of the right humerus.
___ was consulted and initially recommended non-operative
management with prophylactic antibiotics, erythromycin topical
ointment, and sinus precautions. The patient was seen and
evaluated by orthopedic surgery who recommended non-operative
management in a sling for the right humerus fracture. The
patient was admitted to the trauma service for pain control and
ongoing monitoring.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with oral Tramadol
and Acetaminophen.
CV: The patient remained hemodynamically stable throughout
hospitalization. After hemodialysis the patient reported chest
pain. Her vitals were stable at that time. EKG showed evidence
of multivessel disease. Troponins were elevated at .49 with MB
8. Cardiology was consulted and recommended TTE that showed
multi-vessel disease and HFrEF 35%. Cardioprotective medications
-> metoprolol, lisinopril were initiated. Atorvastatin was
continued. Spironolactone can be considered as an outpatient.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was given a full liquid diet and
maintained on sinus precautions. Nephology was consulted and her
hemodialysis schedule was maintained ___,
___. Patient's intake and output were closely monitored.
She skipped her final ___ session and was dialyzed on
___ prior to DC.
ID: The patient had no fevers.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
The patient was seen and evaluated by physical and occupational
therapy who recommended the patient go to rehab for recovery.
___ w hx ESRD on HD, remote CVA w/o deficits, who presented
after
mechanical fall with facial frx, eye lac, R arm frx, and acute
on
chronic chest discomfort with troponinemia who is transferred to
Medicine
MEDICINE COURSE
==============
#Goals of Care
#Dialysis intolerance
Patient does not tolerate dialysis well with episodes of nausea,
chest discomfort, tachycardia, and hypotension. She has not been
tolerating inpatient or outpatient. Dialysis was initiated ___
years ago when patient had HF exacerbation and was in the ICU.
She was unable to speak for self and daughter felt it would be
within her wishes. They had been having extensive outpatient
conversations prior to this episode about dialysis with PCP who
felt that with her age dialysis would be a poor option. The
patient states "I am a fighter" and is not interested in
discontinuing dialysis at this time. She is ok though and
accepts the risk that at some time during a session her heart
may stop and she does not want CPR to restart her heart. She is
ok with a short course of intubation, but never wants prolonged
or trach. Daughter ___ present for these conversations.
Palliative care introduction provided during this admission as
well as she has had intolerance of dialysis.
#Atrial fibrillation
#Sinus conversion pause
First ever incidence. ___ have been non-tolerance of dialysis.
Will monitor and if she does not break out of fib will have to
discuss anticoagulation. Patients need > 200 falls/ year in
order to get subdurals, but pt w/ massive fall recently and
extensive ecchymosis thus risk appears greater. She converted
back to sinus w/ a large pause, thus nodal agents no longer
option for her. If back into atrial fibrillation will have to
consider other agents
(still w/ increased risk) or letting her ride at increased
rates. Dialysis will need to be used w/ caution going forward.
#diarrhea
Concerning for Cdiff w/ getting cefazolin, but Cdiff negative
thus started imodium.
# Type ___ NSTEMI
Chest discomfort and emesis ___ post-HD with trop 0.49, EKG w
ST depressions lateral leads c/w demand ischemia. Cards
consulted. ECG today unchanged from yesterday--demonstrates AV
delay, LVH w repol abnormality more pronounced going at faster
rate, e/o past inferior infarct, all suggesting multivessel dz.
EF 35% on TTE w/ multivessel disease. Patient does not desire
interventions and is elderly ESRD thus appropriate to manage
with medical therapies. Metop 12.5 mg XL, lisinopril 2.5 mg
daily, atorvastatin 80 mg daily. Consider 81 mg ASA w/ OMFS.
Consider spironolactone as outpatient.
# Thrombocytopenia
Likely consumption iso bleeding. Getting heparin SQ. 4T score 0.
Improved during her stay.
# Macrocytic Anemia
Hgb downtrending likely d/t facial frx, epistaxis. No melena. No
reason to suspect hemolysis. ___ have slowed marrow response d/t
age, ESRD. Macrocytosis may be due to retics vs nutritional
deficiency. No EtOH. B12/folate normal. Has extensive bruising
that is likely contributing and was concentration on admission.
She had stable counts by discharge.
# Facial Fractures
S/p mechanical fall. Conservatively managing per OMFS, with plan
for outpt discussion of surgical options. She was maintained on
sinus precautions. She had ice on her face. She had a liquid
diet. She was treated w/ cefazolin ***. Peridex mouth rinse BID.
Pain control w/ tylenol and oxycodone.
# Eye Laceration
- Erythromycin 0.5% ointment 4 times per day for 1 week from the
day of admission (___)
- Follow up with Dr. ___ or existing eye doctor at
___ within ___ weeks of discharge.
# Right Arm Fractures
- Activity: NWB right upper extremity in a sling
- Repeat Xray R shoulder in 1 week, prior to outpatient follow
up
with orthopedics.
- follow-up with ___ in 10 days for repeat
x-rays of her right shoulder on arrival
# Right ___ metatarsal fracture
- WBAT, Hard soled shoe
CHRONIC/STABLE ISSUES:
======================
# ESRD on HD
HD T, Th, S.
- cont HD TThS
- cont lasix 40mg BID
# GERD
Bubble in chest feeling past yr which improves with simethicone.
- cont pantoprazole 40mg BID (omeprazole 40 BID at home)
- cont simethicone
# Peripheral neuropathy
- cont gabapentin
# Hx CVA
- cont secondary prevention with atorva 80
- consider asa 81 as above
TRANSITIONAL ISSUES:
=================
[] - Activity: NWB right upper extremity in a sling
[] Repeat Xray R shoulder in 1 week, prior to outpatient follow
up with orthopedics.
[] follow-up with ___ in 10 days for repeat
x-rays of her right shoulder on arrival
[] Erythromycin 0.5% ointment 4 times per day for 1 week from
the day of admission (___)
[] Follow up with Dr. ___ or existing eye doctor at
___ within ___ weeks of discharge.
[] consider spironolactone as an outpatient
[] uptitrate cardiac medications as tolerated
[] No nodal blocking agents in the future
Code: DNR/ok to intubate
HCP: ___, daughter ___
>30 minutes spent on Complex discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone Propionate NASAL 2 SPRY NU DAILY
2. Fexofenadine 60 mg PO BID
3. Pantoprazole 40 mg PO Q12H
4. Docusate Sodium 100 mg PO BID
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Furosemide 40 mg PO BID
7. Simethicone 250 mg PO BID:PRN after meals
8. Acetaminophen 325 mg PO DAILY:PRN Pain - Mild/Fever
9. Gabapentin 100 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*3
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
RX *chlorhexidine gluconate 0.12 % twice a day Refills:*0
4. Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE QID
RX *erythromycin 5 mg/gram (0.5 %) 1 drop to eye four times a
day Refills:*2
5. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. sevelamer CARBONATE 800 mg PO TID W/MEALS
RX *sevelamer carbonate 800 mg 1 tablet(s) by mouth three times
a day with meals Disp #*90 Tablet Refills:*0
7. Acetaminophen 325 mg PO DAILY:PRN Pain - Mild/Fever
8. Docusate Sodium 100 mg PO BID
9. Fexofenadine 60 mg PO BID
10. Fluticasone Propionate NASAL 2 SPRY NU DAILY
11. Furosemide 40 mg PO BID
12. Gabapentin 100 mg PO DAILY
13. Ipratropium Bromide MDI 2 PUFF IH QID
14. Levothyroxine Sodium 50 mcg PO DAILY
15. Linzess (linaCLOtide) 72 mcg oral DAILY
16. Pantoprazole 40 mg PO Q12H
17. Simethicone 250 mg PO BID:PRN after meals
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
___ fracture pattern
Right proximal humerus fracture
Eyelid Laceration
Ectropion due to closing eyelid laceration
NSTEMI ___
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. ___,
WHY WERE YOU IN THE HOSPITAL:
You were admitted to the Acute Care surgery Service on ___
after a fall sustaining several injuries including: multiple
facial fractures (maxillary, pterygoid, and nasal bones), and a
right upper arm (humerus bone) fracture. You have a laceration
near your right eye that was sutured by the ophthalmology
doctor.
WHAT WAS DONE IN THE HOSPITAL:
While you were in the hospital you had these fractures fixed by
our surgical team. You were then transferred to the internal
medicine service for management of your heart rates and for
dialysis. You tolerated dialysis well and were sent back to
___.
WHEN YOU LEAVE THE HOSPITAL:
- You should make sure to take all of your medications as
prescribed. See the list below for a complete list of
medications and instructions.
- You should go to all of your follow up appointments as
described below.
WOUND CARE INSTRUCTIONS:
Facial Fractures:
-Sinus precautions (no nose blowing, no straws, no
bending/lifting, keep head of bed >30 degrees, sneeze with your
mouth open)
-Peridex mouth rinse BID
Right Arm Fracture:
Continue to wear your sling when out of bed. When in bed you may
rest arm on pillows to keep in a comfortable position. You will
follow up in the ___ clinic in about 1 week to evaluate
how you are healing.
Eye Laceration:
You should continue to put erythromycin ointment on the
laceration 4 times a day for 1 week. You should also put
erythromycin in your eye at bedtime for protection. Please
follow up in the ophthalmology clinic in about 1 week to have
your eye checked and sutures removed. You may follow up at ___
or with your own ophthalmologist.
After a dialysis session you had abdominal pain. An EKG was
obtained that showed similar findings from before. You had an
ECHO that was also similar to before. Your heart does not
squeeze quiet as well as it should, but it has not changed at
all. You were started on new cardiac medications that will help
your heart. You will follow up with the cardiology doctors on
___.
It was a pleasure taking care of you!
Your ___ care team
Followup Instructions:
___
|
10180139-DS-20 | 10,180,139 | 29,190,188 | DS | 20 | 2116-08-29 00:00:00 | 2116-08-29 19:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Hydroxyzine / Sulfa(Sulfonamide Antibiotics) / lisinopril /
metformin / doxycycline / Latex
Attending: ___.
Chief Complaint:
NSTEMI, UTI ?, Worsening SDH.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ woman with a history of HTN, HL, CAD s/p STEMI, CHF,
DM type II, CKD, breast CA s/p L mastectomy, rectal cancer s/p
hemicolectomy, and recent admission from ___ for R SDH
s/p fall who presents from rehab with increasing lethargy. Per
her rehab facility, she is usually alert and conversant at
baseline but tonight has been more somnolent and moaning. EMS
was called and she was taken to an outside hospital where a CT
head showed expansion of her prior SDH to approximately 16mm.
No reported new fall or trauma, not anticoagulated. Labs were
significant for troponin of 3.2, Hct 26.6, and K 5.3. UA was
negative. She was transferred to ___ for further management.
Of note, during her prior admission she was followed by
neurosurgery for her SDH with serial CT scans. She was started
on Keppra for seizure prophylaxis which she was continued on.
Her course was also complicated by an NSTEMI thought to be
related to demand ischemia which was medically managed. She
also developed an upper GI bleed with hematemesis requiring
transfusion of 1u PRBC.
In the ED inital vitals were, temp 97 HR 126 BP 145/49 RR 12
100% 2L
Labs notable for trop 1.56 (prior was 0.5) , Cr 2.1 (prior 2.4),
WBC 6, HCT 28 (baseline 30), Hb 9, PLT 270, INR1.2. UA was
positive (unclear sample collection) On exam, she is somewhat
lethargic but arousable to voice and able to state her name and
follow some simple commands. She complains of headache but is
unable to provide further history at this time. She was guaiac
negative on exam with green stool. She was seen by neurology
and neurosurgey who recommended for medical management and
confirmed not a surgical candidate. Vitals prior to transfer:
151/51 66 RR 13 sat 100% RA, foley, access x1 20.
On arrival to the ICU, patient was moaning, respond to name.
Past Medical History:
DM2 (A1c 5.5 ___
HTN
Hyperlipidemia
CAD (s/p STEMI, medically managed)
CHF EF 30%
CKD, Cr 2.3 in ___
Peripheral neuropathy
Atypical chest pain
Depression
Osteoarthritis
Mitral valve prolapse
h/o Atrial fibrillation
Obesity
Anemia, h/o iron and B12 deficiency, on epogen
h/o breast cancer s/p L mastectomy
h/o rectal cancer s/p hemicolectomy ___ years ago
Nephrolithiasis
Diverticulosis
Osteosclerosis
s/p hernia repair
s/p cataract surgery
s/p hysterectomy, oophrectomy
Social History:
___
Family History:
Daughter had heart disease, DM.
Physical Exam:
On Admission:
Vitals: T: 98 BP:149/47 P:66 R: 16 O2: 100% 2L
General: in moderate distress, not answering
HEENT: abrasions/echymosis on right side of head with dried
blood, steri-strips in place, no active bleeding, pupils equal,
~2mm, and minimally reactive, EOMI, sclera anicteric, dry mucous
membranes
Neck: supple, no LAD
CV: regular, normal S1 + S2, no rubs, gallops, faint systolic
murmur along lower sternal border
Lungs: bibasilar inspiratory crackles, no wheezes, good air
movement, respirations unlabored
Abdomen: soft, non-distended, bowel sounds present
GU: foley
Ext: warm, well perfused, 2+ pulses, trace-1+ edema bilaterally
On Discharge:
VS: afeb, T 97.2, BP 159/66, HR 69, RR 20, O2 95% on RA
Gen: Chronically ill appearing woman but in no immediate
distress, intermittently responding
CV: RRR, no M/R/G
Pulm: Clear to auscultation anteriorly, in no distress
Abd: Soft, NT, ND
Neuro: Intermittently responding slowly to simple questions,
tracking voices and individuals
Pertinent Results:
===================
LABORATORY RESULTS
===================
WBC-6.2 RBC-3.21* Hgb-9.0* Hct-28.1* MCV-88 RDW-15.5 Plt ___
--Neuts-74.0* Lymphs-17.2* Monos-4.5 Eos-3.6 Baso-0.7
___ PTT-22.5* ___
Glucose-116* UreaN-93* Creat-2.1* Na-136 K-4.7 Cl-100 HCO3-25
LD(LDH)-242 DirBili-0.2
CK(CPK)-50 CK-MB-3 cTropnT-1.56*
Hapto-252*
===============
OTHER STUDIES
===============
ECG ___:
Baseline artifact. Probable sinus rhythm. ST-T wave
abnormalities. Compared to tracing #1 probably no significant
change but there is more artifact on the present tracing.
Chest Radiograph ___:
IMPRESSION: No pneumonia or edema.
CT head ___:
IMPRESSION:
1. Stable right subdural hematoma with stable mass effect on the
adjacent
sulci, but no shift of midline structures or uncal herniation.
2. Stable areas of subarachnoid hemorrhage and possible cortical
contusions in the bilateral frontal lobes.
3. No new foci of hemorrhage.
Brief Hospital Course:
___ woman with a history of HTN, HL, CAD s/p STEMI, CHF,
DM type II, CKD, breast CA s/p L mastectomy, rectal cancer s/p
hemicolectomy, and recent admission from ___ for R ___
s/p fall who presents from rehab with increasing lethargy.
# Goals of Care/Transition to Comfort Focused Care: The patient
presented with increasing encephalopathy in the context of
increased edema around SDH. Case discussed with neurosurgery
and family. Given her multiple medical problems, family and
surgery agreed she was not appropriate surgical candidate and
she would not want an invasive surgery given her age and
previous decline from her previous functionality. Therefore,
life prolonging therapy stopped and patient transferred from ICU
to medical ward. After her transition to the medical ward I had
an extensive conversation with the family including HCP ___
___. Family in agreement that Ms. ___ would not want
further aggressive life prolonging therapies such as feeding
tube that would be necessary to feed safely given her waxing and
waning encephalopathy (overall relatively stable after decline
at presentation). I explained that without such measures the
patient would likely succumb to one of her other chronic medical
conditions, be unable to be adequately fed or hydrated, or
possibly re-bleed or re-swell around her SDH leading to her
demise. I explained that given goals of care and desire to
avoid invasive procedures there would be very little we would be
able to do to postpone or prolong her life and all agreed that
focus of her care should be comfort. Therefore, IV access not
pursued and patient was allowed to comfort feed if awake and
take PO meds as tolerated (Keppra/Metoprolol) with understanding
if she was too somnolent to swallow no efforts would be made to
give them. If patient decompensated patient would be made
comfortable but no life prolonging measures would be pursued.
Patient receiving SL morphine PRN for pain. Mental status at
discharge is waxing between reasonably responsive though
speaking slowly and briefly with relatively appropriate
responses to somnolent. Given she was not imminently dying and
was overall quite hemodynamically stable decision was made to
transfer to facility with hospice involved and focus on
patient's comfort. Family is in agreement that goal should be
to make comfortable and avoid hospitalizations unless absolutely
necessary to make patient comfortable.
# SDH: Occurred after her fall earlier this month, readmitted as
the size of the SDH has increased (despite formal read in
discussion with neuroradiology edema increasing though size of
bleed unchanged). Evaluated by neurosurgery who did not feel
she was a surgical candidate. This information was conveyed to
her family and they made the decision to keep her comfortable
and not pursue further aggressive measures. Continued on
levetiracetam as tolerated.
# recent NSTEMI: Multiple serial EKGs were done which showed
inferior ischemia with one isolated ST elevation in III upon
admission that later resolved with rate control. There were also
rate related ST depressions in leads I and aVL that improved
with time. The patient never complained of any symptoms of
ischemia including chest pain or shortness of breath (although
her abdominal pain may have been related to ischemia, this
resolved by the time she arrived on the floor). She had recent
medically managed STEMI in ___. BB continued if patient able to
take and patient could receive SL NTG for chest pain. Statin
stopped when goals of care shifted purely to comfort.
# Acute on chronic sCHF: Pt appeared euvolemic in hospital. EF
35-40% by report. She was continued on BB. Not on standing
diuretics though could consider furosemide PRN for dyspnea along
with morphine.
# Iron/B12 / CKD related anemia: Per report, patient has history
of iron and B12 deficiency and is on both ferrous sulfate and
cyanocobalamin as an outpatient. CKD also likely contributing
to anemia, and patient on epogen as outpatient. Supplements
stopped when goals of care shifted to comfort. No following of
Hct or plans for transfusion. No signs of active bleeding in
house.
Transitional Issues:
Primary Contact and HCP: ___ ___ (HCP)
Patient discharged to ___ with hospice care. Medications should
be adjusted to focus on comfort and patient feeling well.
Family in agreement to avoid rehospitalization unless necessary
to make patient comfortable.
Medications on Admission:
1. hydralazine 20 mg Tablet PO every eight (8) hours.
2. pravastatin 80 mg Tablet PO once a day.
3. acetaminophen 500 mg Tablet PO every six (6) hours.
4. alprazolam 0.25 mg Tablet Sig: 0.5 Tablet PO twice a day.
5. bumetanide 2 mg Tablet Sig: 1.5 Tablets PO once a day.
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
7. Epogen 20,000 unit/mL Solution (1) Injection weekly.
8. iron 325 mg (65 mg iron) Tablet PO twice a day.
9. Flonase 50 mcg/Actuation Spray Two (2) Nasal once a day.
10. isosorbide mononitrate 15 mg Tablet ER 24 hr PO daily.
11. metoprolol tartrate 50 mg PO twice a day.
12. nitroglycerin 0.4 mg One (1) Sublingual once a day prn
pain.
13. nystatin 100,000 unit/g Powder topical once a day as needed.
14. omeprazole 20 mg Tablet PO twice a day.
15. Vitamin B-12 1,000 mcg Tablet PO once a day.
16. levetiracetam 500 mg Tablet PO twice a day.
17. aspirin 81 mg Tablet, Chewable PO once a day.
Discharge Medications:
1. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2
times a day).
3. senna 8.8 mg/5 mL Syrup Sig: ___ Tablets PO BID (2 times a
day) as needed for constipation.
4. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
5. levetiracetam 100 mg/mL Solution Sig: Five (5) mL PO BID (2
times a day).
6. lorazepam 0.5 mg Tablet Sig: ___ Tablets PO Q4H (every 4
hours) as needed for severe anxiety, agitation, insomnia.
7. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig:
2.5-5 mg PO Q2H (every 2 hours) as needed for dyspnea, pain.
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
9. lorazepam 1 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours)
as needed for seizure activity.
10. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary Diagnosis:
Encephalopathy secondary to subdural hemorrhage with increased
edema
Secondary Diagnoses:
Coronary Artery Disease
Chronic Kidney Disease
Chronic Systolic Heart Failure
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Pt admitted with increased edema around subdural hemorrhage and
encephalopathy. Case discussed with family and decided she
would not wish to have surgery or any invasive or burdensome
life prolonging procedures including feeding tube. Goal shifted
to comfort focused care and after discussion she is being
discharged to ___ with hospice services to focus on comfort at
the end of her life.
Followup Instructions:
___
|
10180407-DS-22 | 10,180,407 | 25,091,963 | DS | 22 | 2173-02-03 00:00:00 | 2173-02-06 16:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Possible lamotrigine toxicity
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old man with past medical history
of right frontal meningioma s/p stereotactic surgery (___) &
resection (___) complicated memory loss and seizures (CPS, GTC,
has refractory epilepsy with multiple seizures per month) who
presents to the ED ___ from his assisted living facility after
being found down with decreased responsiveness.
Upon assessment, pt stated he felt like his normal self apart
from minimal unsteadiness with walking. Pt reported that, over
the past 2 days, he had noted a mild "loss of equilibrium"
leading to difficulty with walking. Symptoms worsened yesterday
and he had to grab onto the wall and objects to keep from
falling. He had a sensation of being "over medicated". He stated
that "if someone saw me in public they would have thought I was
drunk". He denied falling to a particular side or any sensation
of room spinning. He denied any double or blurry vision, any
nausea/vomiting, any previous URI symptoms, or any tinnitus or
hearing loss. These had symptoms resolved evening prior to
presentation to ED apart from minimal unsteadiness of walking.
Pt
reports having similar symptoms prior and always related the
symptoms to his medicatons.
Pt had presented to the ED primarily because, around 08:50, he
was found laying down in the fetal position by an aid at his
assisted living facility in his bathroom with vomit next to him.
Pt reports waking but and feeling nauseated. He then ran to the
bathroom but did not make it to the toilet in time to vomit. The
aid reported that pt could not talk and was mumbling when aid
found pt. The aid did not note any seizure-like activity but was
concerned pt was post-ictal. EMS was called and pt was brought
to
the ED emergently.
Of note, pt is followed by epileptologist Dr. ___
refractory epilepsy. He is currently on Onfi and Lamictal with
plans to possibly decreased Lamictal in ___.
On neurologic review of systems, pt reports blurred vision and
diplopia but states this is because he does not have his glasses
with him and this is chronic. Pt denies headache,
lightheadedness, or confusion. Denies difficulty with producing
or comprehending speech. Denies loss of vision, vertigo,
tinnitus, hearing difficulty, dysarthria, or dysphagia. Denies
focal muscle weakness, numbness, parasthesia. Denies loss of
sensation. Denies bowel or bladder incontinence or retention.
On general review of systems, the patient denies fevers, rigors,
night sweats, or noticeable weight loss. Denies chest pain,
palpitations, dyspnea, or cough. Denies diarrhea, constipation,
or abdominal pain. No recent change in bowel or bladder habits.
Denies dysuria or hematuria. Denies myalgias, arthralgias, or
rash.
Past Medical History:
- Depression
- Hyperlipidemia
- Right frontal meningioma s/p stereotactic surgery ___ &
meningioma resection ___ c/b memory loss, seizures
- Seizure disorder (CPS, GTC first in ___, has refractory
epilepsy with multiple seizures per month)
- Macular telangiectasia in the left eye ___ vision) s/p grid
laser photocoagulation, intravitreal Avastin
- Melanoma s/p removal from nose
- Nephrolithiasis
- Osteoporosis
Social History:
___
Family History:
Brother - ___
Father - ___
No seizures or stroke in family.
Physical Exam:
PHYSICAL EXAMINATION
Vitals: T: 97.1 HR: 65 BP: 124/63 RR: 14 SaO2: 97% RA
General: NAD, comfortable
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status - Awake, alert, oriented to person place and
time. Attention to examiner maintained, but tangential at times
with history-taking. Able to recite months of year forwards, but
not backwards. Speech is fluent 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 - PERRL 3->2 brisk. VF full to number counting.
Left eye esotropic with decreased acuity (not wearing his
glasses). Nystagmus at lateral end gaze bilaterally. V1-V3
without deficits to light touch bilaterally. No facial movement
asymmetry. Hearing intact to finger rub bilaterally. Palate
elevation symmetric. SCM/Trapezius strength ___ bilaterally.
Tongue midline.
- Motor - Normal bulk and tone. No drift. No asterixis. Coarse
intention tremor bilaterally.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
- Sensory - No deficits to light touch, pin, or proprioception
bilaterally.
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 3 3
R 3 3 3 3 3
Plantar response extensor on the right, flexor on the left.
- Coordination - No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait - Normal initiation. Negative Romberg. Some unsteadiness
with small steps (however, when I asked pt about what was
limiting his walking and what his normal gait looked like, he
was
able to demonstrate a completely normal gait for ___ steps. He
stated that he just subjectively felt unsteady and was concerned
with walking normally).
Pertinent Results:
___ 09:45AM BLOOD WBC-8.7 RBC-4.52* Hgb-13.8* Hct-40.3
MCV-89 MCH-30.4 MCHC-34.1 RDW-13.4 Plt ___
___ 09:45AM BLOOD Neuts-87.0* Lymphs-9.6* Monos-2.6 Eos-0.6
Baso-0.1
___ 06:51AM BLOOD ___ PTT-31.8 ___
___ 06:51AM BLOOD Glucose-74 UreaN-15 Creat-0.9 Na-143
K-3.9 Cl-104 HCO3-26 AnGap-17
___ 06:51AM BLOOD ALT-50* AST-42* AlkPhos-81
___ 12:24AM BLOOD CK-MB-4 cTropnT-<0.01
___ 06:51AM BLOOD Albumin-4.7 Calcium-9.6 Phos-3.8 Mg-2.1
___ 09:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 11:50AM BLOOD Lactate-1.8
___ 11:55AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
NCHCT ___: No acute intracranial hemorrhage or mass effect
or significant change since
___ study.
EEG ___: This is an abnormal video EEG monitoring session due
to the
presence of occasional blunted broad based right anterior to
mid-temporal
sharp wave discharges during sleep indicative of potentially
epileptogenic cortex in the right temporal region. There is
continuous right hemispheric focal theta and delta frequency
slowing maximal in the temporal region with higher amplitude and
accentuation of faster frequencies indicative of mild to
moderate focal cerebral dysfunction and breech artifact related
to the patient's known skull defect in that region.
Brief Hospital Course:
Mr ___ is a ___ yo man with past medical history significant
for right frontal meningioma s/p resection (___) complicated by
memory loss and seizures (CPS and GTC) which habe been
refractory to medications with multiple seizures per month, who
presented from his assisted living facility after being found
down with decreased responsiveness. There was initial concern
for lamotrigine toxicity given report of gait unsteadiness and
loss of equilibrium over the past 2 days, however these symptoms
largely resolved in the ED. The patient was going to be
discharged from the ED however he displayed bizarre behavior
(per ED notes "trying to reach for a cup that was not there and
saying bizarre things") concerning for new seizure type and he
was admited to the neurology service. The pt was placed on cvEEG
monitoring to quantify and localize his seizure onsets. Pt's
lamictal was stopped along with his a decrease in his Onfi.
Overnight on ___ and on the following morning of ___ the pt
had mult seizures which correlated with onset in the right
frontal and temporal regions. He was then discharged home on his
baseline Lamictal XR ___ mg 3 times daily, and an
increased Onfi dose of 15 mg in the morning and 20 mg at night,
in response to the increase in seizure frequency which prompted
the admission.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clobazam 10 mg PO QAM
2. LaMOTrigine 200 mg PO BID
3. LaMOTrigine 400 mg PO QHS
4. Simvastatin 20 mg PO DAILY
5. Cyanocobalamin 250 mcg PO DAILY
6. Clobazam 20 mg PO QHS
7. Cyclobenzaprine 5 mg PO TID:PRN spasm
8. Ferrous Sulfate 325 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Clobazam 15 mg PO QAM
2. Clobazam 20 mg PO QHS
3. Cyclobenzaprine 5 mg PO TID:PRN spasm
4. LaMOTrigine 200 mg PO BID
5. LaMOTrigine 400 mg PO QHS
6. Simvastatin 20 mg PO DAILY
7. Cyanocobalamin 250 mcg PO DAILY
8. Ferrous Sulfate 325 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Primary Diagnosis: epilepsy
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 in the hospital. You were
admitted due to seizures and we monitored you on EEG during
which we captured a few seizures, and then increased your Onfi
(clobazam) to 15 mg in the morning and 20 mg at night. Your
Lamictal (lamotrigine) has stayed the same. Your pharmacy is
delivering your new bubble packs with increased dose of Onfi to
your assisted living facility, so start taking the new bubble
pack tomorrow.
Please continue taking your medications as prescribed and follow
up with Dr. ___.
Followup Instructions:
___
|
10180796-DS-21 | 10,180,796 | 22,296,135 | DS | 21 | 2181-11-25 00:00:00 | 2181-11-25 21:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache, tachycardia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo FTM depression, PTSD, migraine, ?___, recent
multiple medical visits for HA, now with recurrent headaches and
sinus tachycardia.
He had been seen in the ED multiple times recently (once at
___, had LP without infection) once at ___. He was admitted
___, at which time, he was seen by chronic pain service
who performed a nerve block, which improved his pain.
Pt reports that current HA begun 3 weeks ago and is different
from his usual migraines. The pain started from base of the
skull bilaterally and radiates up to his parietal area w/o
reaching the frontal area. He notes the quality is squeezing,
"like his skull is too small". He reports when it began it was
___ in intensity which was tolerable. One week later the pain
escalated to ___ when sitting upright, while he was visiting
family in ___ so he was taken to ___ for further w/u. There he
was r/o for meningitis w/ an LP. At the time he was treated with
toradol which improved the symptoms so he returned to ___.
Several days later (one week ago) he felt his headache worsened
to ___ when upright. He presented to the ___ ED on ___, was
treated with toradol, IVF and Zofran. Then he re-presented on
___ with the same symptoms but this time worse with sitting up
and lying back.
He also had several bouts of nausea and vomiting. He was then
admitted to the medicine service w/ chronic pain service consult
who performed a nerve block, which per records "dramatically
improved his pain". He had nausea with poor PO intake, which was
moderately improved with reglan which he was discharged on
(___). He was followed by pain clinic on ___ for a
possible blood patch but instead a repeat occipital nerve block
was performed. He was also prescribed fioricet which he has been
taking TID. Pt also reports increased naproxen use. It would
appear that nerve block did not provide sustained pain relief.
Pt present to the ED on day of admission and was evaluated by
neurology team.
After evaluation, neurology thinks that the HA is a combination
of poorly managed migraine, as well as medication related HA in
the setting of increased fioricet and naproxen use.
Neuro recommended the following
"- Defer chronic migraine management to his primary neurologist
Dr. ___. This said, We do believe Topamax is under dosed,
we
recommend 100mg total daily dose.
- Discontinue fioricet and naproxen.
- Consider Medrol dose pack for abortive treatment.
- Defer recs for blood patch to Chronic pain clinic."
Pt was discharged home from the ED, but returned with
persistent HA. He reports that he could feel the firocet wearing
off, and thought that discontinuing firocet was a bad idea.
In the ED, initial vitals were:
98.2 134 142/71 18 100% RA
EKG showed
Sinus tachy in 120s, NANI, and diffuse repol abnormalities.
Labs were notable for:
K 5.9 > 3.4 after fluid. HgB 13.
Patient was given:
___ 23:05 IV Ketorolac 30 mg ___
___ 23:05 IVF 1000 mL NS 1000 mL ___
Neuro was consulted again, with unchanged rec.
On the floor, pt reports pain at back of head 6.5/10. he also
reports that light bothers him. He denies feeling confused. He
denies fever. no n/v. He reports poor PO today ___ headache. He
denies vision change. He does endorse mild ringing in his ears.
He denies sig. stressor at home, lives with 5 roommates, reports
that they all get along.
Review of systems:
(+) Per HPI, otherwise negative
Past Medical History:
- Female to male transgender undergoing testosterone treatment
w/50mg SC once per week
- Depression
- PTSD
- ? Fibromyalgia
- ? Elhers Danlos - pt has a questionable history of Ehlers
Danlos, and is followed by a rheumatologist at ___ but there is
no clear clinical evidence of this
- Exercise induced asthma
- Reportedly has a h/o Gastroparesis
- Pt has a h/o "small fiber neuropathy" but neuro exam is not
suggestive of this and so were the EMG from ___ and
cutaneous analysis of nerve fibers on ___, which showed no
evidence of polyneuropathy or decreased density of epidermal and
dermal nerve fibers.
- Insomnia
- pyelonephritis
- conversion disorder
Social History:
___
Family History:
Mother- died of ? vascular causes at age ___. Had seizures,
lupus, wheelchair bound.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.2 129/70 89 16 98RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple
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: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE PHYSICAL EXAM:
Vitals: 97.9 122/77 73 16 98 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple
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: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, able to
ambulate with a walker.
Pertinent Results:
LABORATORY STUDIES ON ADMISSION
=======================================
___ 10:30AM BLOOD WBC-7.3 RBC-4.19* Hgb-13.0* Hct-38.5*
MCV-92 MCH-31.0 MCHC-33.8 RDW-13.7 RDWSD-45.6 Plt ___
___ 10:30AM BLOOD Neuts-53.4 ___ Monos-6.7 Eos-0.0*
Baso-0.7 Im ___ AbsNeut-3.90 AbsLymp-2.84 AbsMono-0.49
AbsEos-0.00* AbsBaso-0.05
___ 10:30AM BLOOD Glucose-86 UreaN-8 Creat-0.7 Na-139
K-5.9* Cl-106 HCO3-21* AnGap-18
___ 10:30AM BLOOD Calcium-9.2 Phos-3.7# Mg-2.0
LABORATORY STUDIES ON DISCHARGE
=======================================
___ 10:30AM BLOOD WBC-7.3 RBC-4.19* Hgb-13.0* Hct-38.5*
MCV-92 MCH-31.0 MCHC-33.8 RDW-13.7 RDWSD-45.6 Plt ___
___ 06:10AM BLOOD Glucose-94 UreaN-10 Creat-0.7 Na-142
K-3.6 Cl-104 HCO3-23 AnGap-19
___ 06:10AM BLOOD Calcium-10.5* Phos-4.9* Mg-2.1
___ 10:40AM BLOOD VitB___-___ Folate-10.6
___ 10:40AM BLOOD 25VitD-57
MICROBIOLOGY
=======================================
___ 1:30 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING
=======================================
___ MR HEAD
IMPRESSION: Small area of high signal intensity demonstrated on
FLAIR and T1 postcontrast is images, localized in the left
temporal lobe, measuring approximately 4 x 4 mm in transverse
dimension, with no evidence of mass effect or edema, this lesion
apparently is adjacent to cortical venous vascular structures,
and apparently there is a punctate calcification demonstrated by
prior head CT. The possibility of small venous thrombus on a
cortical vein, versus a small granuloma are considerations,
follow-up MRI in 2 weeks or as clinically warranted is
recommended to demonstrate stability or any further change.
NOTIFICATION: The findings were discussed by Dr. ___
with Dr. ___ on the telephoneon ___ at 11:04 AM,
5 minutes after discovery of the findings.
RECOMMENDATION(S): Punctate area of enhancement identified in
the left Temporal lobe as described detail above, with no
evidence of mass effect or edema, follow-up MRI with and without
contrast in two weeks, or as clinically warranted is recommended
to demonstrate stability or any further change.
___ MR SPINE
IMPRESSION:
1. Minimal degenerative changes identified at C6/C7 level,
consistent with disc bulge, there is no evidence of neural
foraminal narrowing or spinal canal stenosis.
2. The MRI of the thoracic spine appears normal with no
evidence of neural foraminal narrowing or spinal canal stenosis,
no signal abnormalities are seen throughout the thoracic spinal
cord.
3. Anatomical variation identified in the lumbar spine,
consistent with transitional segment. There is no evidence of
spinal canal stenosis or neural foraminal narrowing, mild
articular joint facet hypertrophy is noted at L5/L6 level.
4. Area of low signal is identified in the expected location of
the gallbladder, suggestive of gallstone, correlation with
abdominal ultrasound is recommended for further
characterization.
RECOMMENDATION(S): Area of low signal is identified in the
expected location of the gallbladder, suggestive of gallstone,
correlation with abdominal ultrasound is recommended for further
characterization.
Brief Hospital Course:
___ FTM transgender (on testosterone) w/ PMHx depression, PTSD,
question of fibromyalgia, reportedly Ehlers ___, and
migraines, admitted with persistent headache, likely secondary
to medication overuse.
ACTIVE ISSUES
=============
# Medication overuse headache:
Pt presented with 3-week h/o of persistent headache. Neurologic
examination was significant only for bilateral V1 distribution
numbness. Pt was seen by neurology, who felt the headache was
likely multifactorial secondary to medication overuse headache
(increased Fiorcet and Naproxen use), with low suspicion for low
pressure headache (possibly ___ CSF leak post LP). Per
neurology, Fioricet and Naproxen were discontinued, Topamax was
increased to 50mg BID. Pt also treated with Medrol dose pak. Pt
discharged with close follow up scheduled with neurology and PCP
and short course of tramadol for breakthrough pain. MRI
head/spine were performed to r/o low pressure headache and was
unremarkable except for incidental findings listed below.
# Malnutrition
Pt is underweight and severely malnourished in setting of
anorexia and reported gastroparesis as evidenced by loss of 26%
body weight in ___ year. Pt was seen by nutrition. Pt recommended
to have supplements, and start multivitamin with minerals daily.
Pt also received 100mg thiamine for three days for refeeding
risk.
CHRONIC ISSUES
==============
# Fibromyalgia: continued home lyrica 125 mg TID
# Asthma: continued home Fluticasone Propionate 110mcg 2 PUFF IH
BID
# Depression/PTSD: continued home fluoxetine
# GERD: Continue home ranitidine.
TRANSITIONAL ISSUES
=============================
1. Pt needs to complete Medrol taper. Pt to take Medrol 4mg on
___.
2. Pt may benefit from starting an albuterol inhaler in the
future for treatment of exercise-induced asthma
3. Area of low signal is identified in the expected location of
the gallbladder, suggestive of gallstone, correlation with
abdominal ultrasound is recommended for further
characterization.
4. Punctate area of enhancement identified in the left temporal
lobe, with no evidence of mass effect or edema, follow-up MRI
with and without contrast in two weeks, or as clinically
warranted is recommended to demonstrate stability or any further
change.
# CODE: Full
# CONTACT: ___ ("like a step mom to me") ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 200 mg PO BID
2. Fluoxetine 40 mg PO DAILY
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Metoclopramide 10 mg PO TID
5. Omeprazole 40 mg PO BID
6. Pregabalin 125 mg PO TID
7. Ranitidine 150 mg PO BID
8. Tizanidine ___ mg PO BID:PRN muscle spasms
9. Topiramate (Topamax) 25 mg PO QHS
Discharge Medications:
1. Docusate Sodium 200 mg PO BID
2. Fluoxetine 40 mg PO DAILY
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Metoclopramide 10 mg PO TID
RX *metoclopramide HCl 10 mg 1 mg by mouth three times daily
Disp #*21 Tablet Refills:*0
5. Omeprazole 40 mg PO BID
6. Pregabalin 125 mg PO TID
7. Ranitidine 150 mg PO BID
8. Tizanidine ___ mg PO BID:PRN muscle spasms
9. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
10. Topiramate (Topamax) 50 mg PO BID
RX *topiramate [Topamax] 50 mg 1 tablet(s) by mouth twice daily
Disp #*30 Tablet Refills:*0
11. TraMADOL (Ultram) ___ mg PO Q4H:PRN pain
Please attempt to wean over the week as it can cause worsening
rebound headache.
RX *tramadol [Ultram] 50 mg 1 tablet(s) by mouth every 4 hours
Disp #*20 Tablet Refills:*0
12. Methylprednisolone 4 mg PO DAILY Duration: 1 Dose
This is dose # 4 of 4 tapered doses
RX *methylprednisolone [Medrol] 4 mg 1 tablet(s) by mouth once
Disp #*1 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
- Medication overuse headache
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 ___,
It was a pleasure caring for you at ___. You were admitted
because of your worsening headaches. Your headaches are likely
from medication overuse from too much Fioricet and Naproxen.
Overuse of analgesic medications (like Fioricet and Naproxen)
can cause medication overuse headaches. It is important to
continue to hold these medications to prevent future medication
overuse headaches. You were treated with steroids (Medrol dose
pak), which you should continue. You will take Medrol 4mg on
___.
You underwent an MRI of the head and MRI spine which ruled out a
low pressure headache. There was an incidental finding of
punctate lesion in the temporal lobe of the brain which is
likely unrelated to your headaches. Repeat MRI of the head will
be arranged by your PCP ___ 2 weeks.
Please see below "recommended follow-up" section for your
upcoming appointments.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10180971-DS-10 | 10,180,971 | 21,774,892 | DS | 10 | 2181-01-06 00:00:00 | 2181-01-07 20:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
"Left Lower Quadrant Pain"
Major Surgical or Invasive Procedure:
Laparascopic Left salpingo-oophorectomy
History of Present Illness:
___ yo G2P1 LMP ___ presents to the ED with LLQ pain. Pt reports
hx of left ovarian cyst (had LLQ pain, US showed cyst around
___. She was started on OCP by Primary OB for this cyst.
Since then, she continued to experience intermittent left lower
quadrant pain and back pain, intensity and frequency
increasing. The OCP did not have any effect on the pain. The
pain was most intense this morning, constant and sharp, ___,
radiates to the back and down her left leg. She took Alleve
earlier, and with minimum effect. She also vomit once earlier
this morning. In addition, pt reported abnormal vaginal bleeding
since she was started on the OCP in ___ (menstruation q 2 wks).
ROS: reports
night sweat for the past few months, no wt loss, no change of
appetite, no fever, no chills, no HA, no SOB, no CP, no dysuria,
no constipation.
Past Medical History:
PObHx: G2P1, uncompliated SVD x1 at full term in ___ TAB at 7
wks GA with D&C in ___.
PGynHx: menarche age ___, Q6 wks, light, ?hx of fibroid, denies
dysmenorrhea, menorrhagia, however she started to experience
abnormal vaginal bleeding since she started taking the OCP;
denies Hx abnormal Paps; denies history of STIs; Has used the
following contraceptive methods: IUD ___ yr ago (removed d/t
discomfort).
PMHx: anxiety, ADHD
PSHx: D&C x1
Social History:
___
Family History:
Non-contributory
Physical Exam:
Physical Examination by Dr. ___
___:
VS: T98.3 BP 120/73 HR 68 RR 18 O2 sat 100%RA
General: NAD (after 2 dose of morphine 4 mg IV)
Neuro: alert, appropriate, oriented x 3
Cardiac: RRR, no m/g/r
Pulm: CTAB
Abdomen: soft, no rebound, no guarding, TTP in LLQ
Pelvic: Normal external anatomy, pink vaginal mucosa, bright red
blood in the vaginal vault, cleared with 3 scopettes, no active
bleeding
Bimanual: AV uterus, normal size, mobile; no CMT; no right
adnexal mass; left adnexal mass appreciated, nodular, immediate
next to the uterus, tender to deep palpation.
Ext: NTTP, warm
Pertinent Results:
___ 11:50AM ___ PTT-21.8* ___
___ 11:20AM GLUCOSE-106* UREA N-15 CREAT-0.9 SODIUM-139
POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-27 ANION GAP-13
___ 11:20AM estGFR-Using this
___ 11:20AM WBC-6.4 RBC-4.04* HGB-13.4 HCT-38.5 MCV-95
MCH-33.2* MCHC-34.8 RDW-11.2
___ 11:20AM NEUTS-62.3 ___ MONOS-2.4 EOS-5.5*
BASOS-0.9
___ 11:20AM PLT COUNT-242
___ 11:00AM URINE HOURS-RANDOM
___ 11:00AM URINE HOURS-RANDOM
___ 11:00AM URINE UCG-NEGATIVE
___ 11:00AM URINE GR HOLD-HOLD
___ 11:00AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 11:00AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 11:00AM URINE RBC-1 WBC-5 BACTERIA-FEW YEAST-NONE
EPI-5 TRANS EPI-<1
___ 11:00AM URINE MUCOUS-RARE
Pelvic Ultrasound:
IMPRESSION:
1. Large complex left ovarian cystic structure, largely
unchanged from prior studies. Consider further evaluation with
MRI if not already performed. GYN follow-up.
2. Arterial and venous flow demonstrated in both ovaries.
3. Trace amount of pelvic free fluid.
Brief Hospital Course:
Ms. ___ was admitted into the gynecology service for serial
abdominal examinations. However, her pain was not improved and
getting worse in severity. The decision was made to proceed with
surgery. Her surgery was uncomplicated and she came back to the
floor for routine post-operative care. She did very well and was
discharged on hospital day 2 with adequate pain control, voiding
and ambulating without difficulty. She was scheduled for a
follow up appointment with Dr. ___.
Medications on Admission:
- Paxil 25mg daily
Discharge Medications:
1. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
2. hydrocodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO
Q4H (every 4 hours) as needed for pain: please do not exceed 4g
of acetaminophen in 24 hours.
Disp:*30 Tablet(s)* Refills:*0*
3. paroxetine HCl 25 mg Tablet Extended Release 24 hr Sig: One
(1) Tablet Extended Release 24 hr PO daily ().
4. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Disp:*20 Tablet, Rapid Dissolve(s)* Refills:*0*
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*10 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Left Complex Ovarian cyst
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* 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
* No heavy lifting until cleared by your physician
* Please keep your scheduled follow up appointment.
Followup Instructions:
___
|
10180971-DS-11 | 10,180,971 | 21,438,695 | DS | 11 | 2187-07-03 00:00:00 | 2187-07-03 20:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Laparoscopic cholecystectomy with intraoperative cholangiogram
History of Present Illness:
HPI: RUQ abdominal pain and nausea that started last night at
3am. She was woken up by her pain that is mainly RUQ but
radiates
to the LUQ and R back. She had nausea and non-bilious vomiting.
She reports that this feels very similar to her prior episodes
for which she was told that she had "biliary colic" and that she
should get "her gall bladder taken out". At the time, she did
not
want to have surgery and so declined it and the next two times
happened while she was pregnant (recently gave birth) and so
declined as well. She reports that her symptoms have improved
after taking apple cider vineger but is still there. Surgery was
consulted for potential cholecystitis/biliary colic.
Past Medical History:
PObHx: G2P1, uncompliated SVD x1 at full term in ___ TAB at 7
___ GA with D&C in ___.
PGynHx: menarche age ___, Q6 wks, light, ?hx of fibroid, denies
dysmenorrhea, menorrhagia, however she started to experience
abnormal vaginal bleeding since she started taking the OCP;
denies Hx abnormal Paps; denies history of STIs; Has used the
following contraceptive methods: IUD ___ yr ago (removed d/t
discomfort).
PMHx: anxiety, ADHD
PSHx: D&C x1
Social History:
___
Family History:
Non-contributory
Physical Exam:
AFVSS
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, NT,
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 08:00AM BLOOD WBC-4.7 RBC-3.35* Hgb-11.0* Hct-32.3*
MCV-96 MCH-32.8* MCHC-34.1 RDW-12.4 RDWSD-43.5 Plt ___
___ 07:10AM BLOOD WBC-5.6 RBC-3.43* Hgb-11.2 Hct-33.1*
MCV-97 MCH-32.7* MCHC-33.8 RDW-12.3 RDWSD-43.3 Plt ___
___ 10:53AM BLOOD WBC-7.9 RBC-4.00 Hgb-13.3 Hct-38.2 MCV-96
MCH-33.3* MCHC-34.8 RDW-12.1 RDWSD-42.1 Plt ___
___ 08:00AM BLOOD Glucose-117* UreaN-6 Creat-0.8 Na-142
K-3.8 Cl-105 HCO3-25 AnGap-12
___ 10:53AM BLOOD Glucose-100 UreaN-9 Creat-0.8 Na-141
K-4.5 Cl-103 HCO3-26 AnGap-12
___ 10:53AM BLOOD ALT-142* AST-271* AlkPhos-164*
TotBili-0.9
___ 07:30AM BLOOD ALT-269* AST-351* AlkPhos-170*
TotBili-2.2*
___ 07:10AM BLOOD ALT-303* AST-193* AlkPhos-222*
TotBili-0.7 DirBili-0.3 IndBili-0.4
___ 08:00AM BLOOD ALT-302* AST-160* AlkPhos-228*
TotBili-0.5
___ 08:00AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.5*
___ 07:10AM BLOOD Calcium-8.3* Phos-3.8 Mg-1.7
Brief Hospital Course:
Mrs ___ was admitted on ___ under the acute care
surgery service for management of her acute cholecystitis. She
was taken to the operating room and underwent a laparoscopic
cholecystectomy. Her bilirubin was elevated to 2.2, therefore an
IOC was performed which did not demonstrate a filling defect in
the CBD. Please see operative report for details of this
procedure. She tolerated the procedure well and was extubated
upon completion. She was subsequently taken to the PACU for
recovery.
Her LFTs were trended after surgery. On POD1 her Tbili was
decreased to 0.7 but her other LFTs were mildly elevated
therefore, she was kept overnight to make sure her Tbili remains
low and there are no signs of retained CBD stone. ERCP service
was consulted intraop and after reviewing the intraop IOC, they
agreed there are no signs on CBD stone.
She was transferred to the surgical floor hemodynamically
stable. Her vital signs were routinely monitored and she
remained afebrile and hemodynamically stable. She was initially
given IV fluids postoperatively, which were discontinued when
she was tolerating PO's. Her diet was advanced on the morning of
POD1 to regular, which she tolerated without abdominal pain,
nausea, or vomiting. She was voiding adequate amounts of urine
without difficulty. She was encouraged to mobilize out of bed
and ambulate as tolerated, which she was able to do
independently. Her pain level was routinely assessed and well
controlled at discharge with an oral regimen as needed.
On ___, she was discharged home with scheduled follow up in
___ clinic .
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg ___
tablet(s) by mouth Every 8 hours Disp #*45 Tablet Refills:*0
2. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
RX *oxycodone 5 mg 1 tablet(s) by mouth Every 4 hours Disp #*10
Tablet Refills:*0
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:
Ms. ___,
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:
___
|
10181023-DS-27 | 10,181,023 | 25,467,628 | DS | 27 | 2146-04-30 00:00:00 | 2146-05-02 15:13:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cefepime / Lasix / Levofloxacin
Attending: ___.
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
Lumbar puncture
Bone marrow aspiration and biopsy
History of Present Illness:
Pt's a ___ gentleman ___ after allogeneic transplant
for Multiple Myeloma with recent admission for sinus infection
and possible PNA now presenting with progressive worsening
cough. The patient had been doing well with minimal evidence of
disease and no evidence of disease progression since transplant.
He has overall been clinically well, but noted in the last two
to three months, repeated episodes of upper respiratory
infections where he had cough, congestion productive of yellow
to green sputum, sinus discomfort. This includes an admit to OSH
in ___ with fever/cough that improved with abx. Two weeks
following that treated with azithro as an outpt for recurrent
symptoms. Total of ___ episodes in last several months, and then
with admission 2 weeks prior findings concerning for sinus
infx/possible PNA which he received tx with levofloxacin for 10d
course. Around time of discharge pt states having developed
current new cough.
Pt states cough progressive, dry, for past week or so no
associated fevers/chills, SOB only with cough otherwise none, no
DOE, no CP, no plueritic CP, no palpitations, n/v/ ab pain. Pt
contacted clinic ___ with continue and worsening dry cough, Rx
3 days of prednisone 40mg daily - sx not improving with calling
early on ___ with new chills/sweats but no fevers - told to
come to ED for eval. Pt being admitted for further w/u of cough,
chest CT done in ED. Noted pt does get mild transient relief
from albuterol, but otherwise feels tessalon pearls and
guiafenasin-codeine suspension without much relief of cough.
For ROS: no immunosuppression, felt to have only minimal GVH
(only cramping in hands/feet, felt to be GVH-related). Had L
submaxiallary LAD last admission - decreased with abx tx - with
with EBV unremarkable. Other lab w/u from admission SPEP, FLC,
EBV VL negative. UPEP trace free lambda (2%, 10 mg/day).
Otherwise no HA, fever, stool or urinary changes, no rash.
Past Medical History:
PAST MEDICAL HISTORY:
-neuropathic pain
-hypertension
-OSA
-Hypercholesterolemia
-Pulmonary embolism
-Recurrent sinus infections/pneumonia's
ONCOLOGIC HISTORY: Mr. ___ is a ___ man who was
diagnosed with multiple myeloma on ___.
.
___ thalidomide and dexamethasone
___ was admitted to a local hospital with pulmonary emboli
and Thalomid was discontinued. Anticoagulated with heparin and
sent home on Coumadin, which he continued to ___.
___, he started on Velcade, however, discontinued in ___
due to grade III peripheral neuropathy.
*Pulsed with 20 mg of dexamethasone x4 days weekly for a short
time
___ Revlimid at 10 mg a day x 1 cycle-discontinued due to
rising urinary paraprotein.
___ 1000 mg /m2 of Cytoxan
___ pulse of dexamethasone on (20 mg a day x4 days)
___ admit for Cytoxan for stem cell mobilization,
collected 18.05 X 10 ^6 CD34+ cells.
___ admitted for high dose chemotherapy with autologous
stem
cell rescue
___ began vaccinations per protocol ___
___ treatment with Revlimid (25 mg), Velcade, and
dexamethasone.
___ s/p allogeneic stem cell transplant for multiple
myeloma from an unrelated donor.
Social History:
___
Family History:
Adopted and does not know information on biological family.
Physical Exam:
Admission PE:
VS Tm/Tc 97.7 P 71 BP 146/84 RR 20 %O2 Sat 96% on RA
.
GEN: AAOx3, NAD frequent coughs
HEENT: EOMI, MMM, no thrush, no OP erythema or lesions
NECK: supple, no sig LAD, no JVD
___: RRR, no m/r/g
LUNGS: reg resp rate, breathing unlabored, no accessory muscle
use, lungs clear to auscultation bilaterally thoughout, no
crackles
ABD: soft, NT, ND, NABS
ext: 2+ pulses, no c/c/e
Skin: no rashes
neuro: grossly intact
Discharge PE:
VS: 97.7 112/72 (111-136/63-72) 65 (65-80) 16 97RA
GEN: Well appearing overweight male in NAD
HEENT: EOMI, MMM, oropharynx clear
___: RRR, no m/r/g
LUNGS: Breathing comfortable, no accessory muscle use. CTA ___ no
wheezes/rales/ronchi.
ABD: soft, NT, ND, NABS
ext: 2+ pulses, warm well perfused, no ___ edema
Skin: no rashes
neuro: muscle strength and sensation grossly intact
Pertinent Results:
Admission labs:
___ 08:20AM BLOOD WBC-8.1 RBC-4.96 Hgb-14.1 Hct-43.7 MCV-88
MCH-28.4 MCHC-32.2 RDW-14.1 Plt ___
___ 05:30PM BLOOD Neuts-71.2* ___ Monos-4.0 Eos-0.1
Baso-0.3
___ 05:30PM BLOOD Glucose-201* UreaN-19 Creat-0.8 Na-141
K-4.3 Cl-102 HCO3-27 AnGap-16
___ 08:20AM BLOOD Glucose-81 UreaN-19 Creat-0.8 Na-141
K-4.1 Cl-103 HCO3-28 AnGap-14
___ 06:50AM BLOOD Phos-4.0 Mg-1.9
___ 05:49PM BLOOD Lactate-2.7*
Discharge labs:
___ 06:45AM BLOOD WBC-8.3 RBC-5.04 Hgb-14.8 Hct-44.2 MCV-88
MCH-29.3 MCHC-33.4 RDW-14.7 Plt ___
___ 06:45AM BLOOD Neuts-63.9 ___ Monos-8.2 Eos-1.8
Baso-0.5
___ 06:45AM BLOOD Glucose-100 UreaN-14 Creat-0.7 Na-137
K-4.4 Cl-101 HCO3-27 AnGap-13
___ 06:45AM BLOOD Calcium-9.4 Phos-4.3 Mg-1.9
galactomanan, beta-glucan negative
CSF serology:
Adenovirus, HHV6, CMV, toxo, EBV, HSV, ___ virus negative
Brief Hospital Course:
Mr. ___ is ___ with MM s/p allogenic transplant ___ years
ago, recurrent sinus infection, here with nonproductive cough,
found to have seizure d/o s/p LP and EEG.
# cough: The patient reports having a persistent cough for the
last couple of weeks, despite mutiple antibiotic courses.
Unclear etiology of his cough, but given his allogenic
transplant, there was concern for pulmonary graft versus host
disease. The patient was initially started on Levofloxacin out
of concern for infectious etiology, but given possible seizure
disorder (see below), he was switched to Azithro. Because there
was also some concern for pertussis as etiology of his cough, ID
recommended completing a five day course of Azithromycin.
The patient was also seen by pulmonary who thought that cough
could be related to either post nasal drip and/or GERD, and he
was started on both Flonase and PPI. They also suggested a
possible outpatient sleep study. The patient reports that his
symptoms improved a little with these therapies.
The patient also had PFTs done, which were normal; this is
reassuring as pulmonary GVH will typically present with
obstructive PFTs, as well as possible decreased DLCO. Because
he was s/p five days of Azithro at this time and there was no
longer a concern for infection, the patient was discharged on
prednisone due to concerns for pulmonary GVH despite normal
PFTs. He will follow up with Dr. ___ as an ___ in one
week, at which point steroid course can be determined. Of note,
the patient was never febrile during this hospitalization and
was also never hypoxic.
# Seizure disorder: The patient reports having episodes of
"spacing out" over the last few weeks. He had a few episodes
while in house, one while in the MRI suite. The patient was
evaluated by Neuro-onc who thought that the patient could be
having complex partial seizures. MRI of the brain was negative
for any acute pathology; the patient also had an LP done, with
all CSF studies, including CMV, HHV6, Toxo, HSV, adenovirus
being negative. Gram stain was also negative.
An EEG was ordered, which was not able to capture any seizures.
As mentioned above, the patient was also on Levofloxacin
initially out of concern for infectious etiology for his cough.
Because of levofloxacin can decrease seizure threshold, the
patient was switched to Azithromycin, as detailed above. He was
also started on Keppra 500 mg BID. Because of his new clinical
diagnosis of seizures, the patient was instructed that he cannot
drive for six months. He was instructed to take Keppra
indefinitely and he will follow up with Dr. ___ in ___
clinic in three weeks, at which point Keppra duration can be
delineated.
# Syncope: The patient had episodes of syncope during this
admission, in the setting of coughing episodes. Specifically,
the patient passed out during PFTs after having an episode of
coughing. Based on this context, it was thought that this
syncope was most likely related to a vasovagal event. The
patient was monitored on telemetry and put on fall precautions.
# MM s/p allogenic transplant ___ years ago: Initially treated
with thalidomide, velcade, cytoxan with various complications
and is now s/p unrelated donor allogenic transplant in ___.
The patient had a bone marrow biopsy prior to discharge. The
results of this bone marrow biopsy will have to be followed up
as an outpatient.
# h/o GVH: The patient has history of GVH in his joints,
symptoms including mild joint stiffness in his hands and feet.
# Neuropathy: Developed in the setting of velcade administration
and has not worsened after patient self-discontinued cymbalta.
This was stable during this admission.
# HTN: The patient was continued on his nefedipine and
metoprolol.
Transitional Issues:
- The patient had a bone marrow biopsy prior to discharge which
will need to be followed up.
- The patient was discharged on prednisone; the course of this
will have to be determined by his primary oncologist, Dr.
___.
- The patient was instructed to not drive because of newly
diagnosed seizure disorder. He was also instructed to continue
Keppra for now; he will have follow up with Dr. ___ as an
outpatient in three weeks.
Medications on Admission:
-Folic acid 1 mg QD
-Metoprolol tartrate 25 mg BID
-nifedipine ER 60 mg QD
-pravastatin 20 mg QD
-Multivitamin QD
-codeine-guaifenesin ___ MLs PO Q6H prn
-benzonatate 100 mg TID for cough
-albut inhal q6h prn for cough
-Valtrex ___ bid (pt states recently recently started taking
again by Dr. ___
Discharge Medications:
1. Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
2. prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a day for
1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. nifedipine 60 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO DAILY (Daily).
6. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Guaifenesin AC ___ mg/5 mL Liquid Sig: ___ mL PO every
six (6) hours as needed for cough.
9. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
10. Valtrex ___ mg Tablet Sig: One (1) Tablet PO twice a day.
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
12. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
Disp:*1 bottle* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
seizures
possible pulmonary graft versus host disease
multiple myeloma status post transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr ___,
It was a pleasure taking care of you in your hospital stay at
___. As you know, you were admitted for cough, you were seen
by pulmonology who recommended a medications to reduce acid in
the stomach and medication to reduce nasal drip as these can
contribute to chronic cough. We also had the infectious disease
doctors ___ and they recommended antibiotic treatments for a
possible bacterial infection.
You complained of episodes of inattentiveness and were seen by
Neurology and evaluated with an EEG. We did not see seizure
activity however your symptoms are concerning for seizure
related to levofloxacin. As we discussed, you remain at higher
risk of having another seizure.
Because of this seizure risk, it will be VERY important that you
do not drive cars for now. We are also starting you on an
anti-seizure medication; this should be continued until you see
Dr. ___ in clinic.
You also had a bone marrow aspiration and biopsy performed while
you were in the hospital. Dr. ___ will follow up with you
regarding the results.
We made the following changes to your medications:
START Keppra 500 mg by mouth twice daily
START prednisone 20 mg daily
STOP benzonatate
Followup Instructions:
___
|
10181426-DS-10 | 10,181,426 | 29,167,589 | DS | 10 | 2121-10-27 00:00:00 | 2121-11-12 20:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Numbness
Major Surgical or Invasive Procedure:
HD (___)
History of Present Illness:
The pt is a ___ year-old left-handed man with Hx of HTN,ESRD ___
___ on the kidney tx list, who presents with 2 episodes of
transient left side hemiplegia, hemisensory loss and difficulty
in his speech.
He noted that today he woke up in the morning and felt well, at
1130 he was on his way driving to the hospital with her
step-daughter as she had an appointment with her doctor, when
they arrived at the hospital he felt that his face was weird:
like lidocaine injection for tooth procedure. He felt that his
face is heavy and secs later it went down to his left arm and
left leg: it was numb and heavy, then he could not walk and
could
not control his left hand and leg, his girlfriend( long term
partner) helped him to sit and then they went to ED. He did not
remember if his face was droopy, but his girlfriend noted to him
that his speech was different and did not make sense, but he
said
he did not feel that.
He is able to remember every events in details. There CT was
performed which did not show ICH, he said in 20 minutes he went
back to his baseline and about 40 minutes later he developed
another episode which lasted about 10 min.
He said about ___ years ago this happened to him once but he did
not pat attention to that.
He did not have LOC, fall, tongue bite, any abnormal movement,
incontinence or post event confusion.
But his girlfriend noted that when it happened the second time,
she noted that his face was droopy on the left side, he was
talking like confused patient but after that he went back to
normal.
He could remember every details of the changes that happened to
him.
At the time that these events happened his BP was around 120s.
So he was tx to ___ but as he is on list of kidney transplant
here he was tx here.
When I saw him for the first time his exam was intact, I did
not
check his gait as his BP was 110s, I flattened the head of the
bed and wanted to admit him to step down, but at ___, when his
family arrived and they elevate the head of the bed 60 degree,
his symptoms came back, at this point his BP was 104, I went
there flattened the head of the bed and gave him 500 cc of NS,
his symptoms resolved after 3 min, his BP went back to 123 and
plan was changed to tx him to ICU to monitor him closely and
keep
the BP more than 120, he also received 325 mg of aspirin.
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:
ESRD ___ polycyctic kidney disease AD, started on
hemodialysis a week ago, had 4 session of HD from an AVF in his
right upper ext.
Last HD was ___, he is making urine.
Chronic back pain s/p surgery, HTN
Social History:
___
Family History:
His father and his sister have ___, and HTN.
There is no history of seizures, developmental disability,
learning disorders, migraine headaches, strokes less than 50,
neuromuscular disorders, or movement disorders.
Physical Exam:
Admission exam:
Vitals:97.4 79 120/81 16 98% 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.
Full range of motion OR decreased neck rotation and
flexion/extension.
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/E bilaterally, 2+ radial, DP pulses
bilaterally. Calves SNT bilaterally. No tenderness at HD cath,
Good thrill on immature graft
Skin: no rashes or lesions noted.
Neurological examination:
___ Stroke Scale score was 0
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: 0
11. Extinction and Neglect: 0
- Mental Status:
ORIENTATION - Alert, oriented x 3
The pt. had good knowledge of current events.
SPEECH
Able to relate history without difficulty.
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors.
Speech was not dysarthric.
NAMING Pt. was able to name both high and low frequency objects.
READING - Able to read without difficulty
ATTENTION - Attentive, able to name ___ backward without
difficulty.
REGISTRATION and RECALL
Pt. was able to register 3 objects and recall ___ at 5 minutes.
COMPREHENSION
Able to follow both midline and appendicular commands
There was no evidence of apraxia or neglect
- Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Blinks to
threat bilaterally. Funduscopic exam reveals no papilledema,
exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal pursuits and
saccades.
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.
- Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
SAbd SAdd ElF ElE WrE FFl FE IO HipF HipE KnF KnE AnkD ___
L 5 5 ___ ___ 5 5 5 5 5 5 5
R 5 5 ___ ___ 5 5 5 5 5 5 5
- Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout in UE and ___. No
extinction to DSS.
- DTRs:
BJ SJ TJ KJ AJ
L ___ 2 1
R ___ 2 1
There was no evidence of clonus.
___ negative. Pectoral reflexes absent.
Plantar response was flexor bilaterally.
- Coordination: No intention tremor, normal finger tapping. No
dysdiadochokinesia noted. No dysmetria on FNF or HKS
bilaterally.
.
.
.
Discharge Exam:
His exam is completely normal, no weakness, numbness, dysmetria,
visual deficit. BP is stable ranging 120-140mmHg systolic.
Pertinent Results:
Admission labs:
___ 09:20PM BLOOD WBC-7.5 RBC-3.17* Hgb-9.3* Hct-27.6*
MCV-87 MCH-29.5 MCHC-33.9 RDW-13.5 Plt ___
___ 09:20PM BLOOD Neuts-61.8 ___ Monos-5.9 Eos-5.2*
Baso-0.5
___ 02:00AM BLOOD ___ PTT-28.8 ___
___ 09:20PM BLOOD Plt ___
___ 09:20PM BLOOD Glucose-92 UreaN-36* Creat-5.6* Na-139
K-4.2 Cl-101 HCO3-27 AnGap-15
___ 02:00AM BLOOD ALT-13 AST-13 AlkPhos-48
___ 06:35AM BLOOD ALT-14 AST-15 CK(CPK)-69 TotBili-0.2
___ 02:00AM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:35AM BLOOD CK-MB-1 cTropnT-<0.01
___ 09:20PM BLOOD Calcium-8.9 Phos-3.9 Mg-1.7
___ 02:00AM BLOOD Albumin-4.1 Calcium-8.9 Phos-3.4 Mg-1.7
Cholest-190
___ 02:00AM BLOOD %HbA1c-5.2 eAG-103
___ 02:00AM BLOOD Triglyc-221* HDL-33 CHOL/HD-5.8
LDLcalc-113
___ 02:00AM BLOOD TSH-1.9
___ 02:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
MR head:
There is no evidence of acute intracranial hemorrhage or
infarct. There is a small focus of high T2/FLAIR signal within
the left frontal lobe which is nonspecific. Gray-white matter
differentiation is otherwise preserved. There is a posterior
fossa arachnoid cyst ___ cisterna magna. Ventricles and
extra-axial spaces are otherwise within normal limits for age.
.
The paranasal sinuses demonstrate scattered allergic
inflammatory changes with a large mucous retention cyst within
the left maxillary sinus. The mastoid air cells demonstrate
normal signal. The sella turcica, craniocervical junction, and
orbits are grossly unremarkable.
.
MRA head:
Normal flow signal is noted in the petrous, cavernous, and
supraclinoid
portions of the internal carotid arteries. The anterior
cerebral, middle
cerebral, and anterior communicating arteries are unremarkable.
.
The posterior cerebral, basilar, superior cerebellar arteries
are
unremarkable. The intradural segments to the vertebral arteries
are
unremarkable. There is ___ termination of the left vertebral
artery. The
right vertebral artery is dominant. Both posterior communicating
arteries are seen.
.
MRA neck:
.
The origins of the innominate, left common carotid, and left
subclavian
arteries appear unremarkable. The common, internal, and
external carotid
arteries demonstrate normal flow signal. The vertebral artery
origins appear unremarkable. The right vertebral artery is
dominant; the left vertebral artery origin is hypoplastic.
.
IMPRESSION :
No evidence of acute hemorrhage or infarct.
Unremarkable MRA of the head and neck.
.
.
TTE
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. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF 60%). 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. There is no mitral
valve prolapse. There is no pericardial effusion.
Brief Hospital Course:
___ year-old left-handed man with Hx of HTN,ESRD ___ ___ on
the kidney tx list, who presents with 2 episodes of transient
left side hemiplegia, hemisensory loss and difficulty in his
speech; he was treated for TIA.
.
ACTIVE ISSUES:
# TIA: The patient's first symptom was feeling that his face was
heavy with some left weakness, "like a lidocaine injection for
tooth procedure". He felt that his face was heavy and secs later
it progressed to his left arm and left leg and was associated
with the sensation of numbness and heaviness. He could not walk
and could
not control his left hand and leg, his girlfriend( long term
partner) helped him to sit and then they went to ED. He did not
remember if his face was droopy, but his girlfriend noted that
his speech was different. Whole episode lasted 20 mins. He was
able to remember events in detail. CT was performed which did
not show ICH, or infarct.
.
After 20 minutes he was back to his baseline and about 40
minutes later he developed another episode which lasted about 10
min. At the time that these events happened his BP was around
120s. So he was tx to ___ but as he is on list of kidney
transplant here, he was transferred. When I saw him for the
first time his exam was intact, I did not check his gait as his
BP was 110s, I flattened the head of the bed and wanted to admit
him to step down, but at 2315, when his family arrived and they
elevated the head of the bed 60 degree, his symptoms came back,
at this point his BP was 104, I went there flattened the head of
the bed and gave him 500 cc of NS, his symptoms resolved after 3
min, his BP went back to 123 and plan was changed to tx him to
ICU to monitor him closely and keep the BP more than 120, he
also received 325 mg of aspirin.
.
He was admitted to the stroke service and started on aspirin 81
and rosuvastatin. MRI was negative and it was thought that he
had a stuttering thalamic lacune. His blood pressure regimen was
discussed with neurology. Stroke packet dispensed. Non-smoker.
Overall it is likely that he indeed suffered a small thalamic
lacune that was not evident in MRI, causing recurrent
paresthesias. There was no evidence of intra- or extra- cranial
stenosis to explain recurrent uniform symptoms. No evident
source of embolism and his risk factor profile (long-standing
kidney disease with hypertension) more compatible with small
vessel disease.
.
# HTN: on nifedipine and valsartan at home. However, blood
pressures were relatively low in house with recurrence of
symptoms correlated with pressure drop. These were held at
discharge. This will be followed by and modified by Nephrology.
Normotension is the long-term goal
.
INACTIVE ISSUES
# ESRD ___ polycyctic kidney disease AD, started on hemodialysis
a week ago, had 4 session of HD from an AVF in his right upper
ext. Last HD was the day PTA (___)
# Chronic back pain s/p surgery
.
TRANSITIONAL ISSUES
# Stroke: Follow for risk factor reduction and recurrence of
symptoms. Ordered TTE with bubbles but in retrospect it does
appear that agitated saline contrast was used.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. NIFEdipine CR 30 mg PO BID
2. Valsartan 160 mg PO DAILY
3. Paricalcitol 1 mcg IV QHD
4. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Omeprazole 20 mg PO DAILY
2. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet,delayed
release (___) by mouth daily Disp #*30 Tablet Refills:*3
3. Rosuvastatin Calcium 10 mg PO DAILY
RX *rosuvastatin [Crestor] 10 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*3
4. Paricalcitol 1 mcg IV QHD
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: transient ischemic attack (TIA)
Secondary diagnoses: polycystic kidney disease, 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 caring for you while you were hospitalized at
the ___. As you recall, you were admitted for
several episodes of sensory change and spasm with weakness on
one side of your body. We found that these were likely due to a
transient ischemic attack in the setting of low blood pressure
during dialysis.
Call ___ or your physician if you experience any of the "danger
signs" below.
Please note that some of your medications might have changed
during this hospitalization.
START
- aspirin 81mg daily
- rosuvastatin 10mg daily
Your nifedipine and valsartan are being temporarily held based
on normal blood pressures in the hospital; ask your kidney
doctors ___ should resume this at dialysis tomorrow.
We will order an ultrasound of your heart to be done sometime in
the near future. Call ___ tomorrow to arrange the
appointment.
Followup Instructions:
___
|
10181426-DS-12 | 10,181,426 | 23,798,578 | DS | 12 | 2123-01-24 00:00:00 | 2123-01-24 14:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
event concerning for seizure, LOC + L sided weakness/numbness +
mutism
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year-old left-handed man with a history
of ___ s/p renal tx ___ and HTN who presents to the ED
after sudden onset loss of consciousness, left arm and leg
weakness, left hemibody numbness, and speech arrest. Neurology
is
consulted as part of a code stroke protocol.
The patient was last seen well by his partner at 11:30am.
___ he was at work in the convenience store of a gas
station and was reportedly in an argument on the phone. Unclear
duration between the phone conversation and the event in
question, but he was found by a bystander on the floor, unable
to
move his left side. The patient communicated later that he may
have lost consciousness. EMS arrived and found him to be
noncommunicative, lethargic, and unable to move the left side.
He was taken to ___ were ___ was negative for
hemorrhage or early signs of ischemia. Ativan 1mg IV was given
around 1400 as seizure was on the differential. Initial lab
work
was nonrevealing including negative troponin. EKG normal. He
was
then sent to ___ for further eval. At ___, code stroke was
called at 15:47 and initial NIHSS was 14 (see above). The
patient was awake, yet inattentive and lethargic, and there was
initially ___ movements on the left side. His exam improved
over
the course of the next ___ minutes (see below) and he was able to
communicate via writing and nod yes and no appropriately.
His partner (unclear if wife or girlfriend) was present in the
ED
and provided additional details. Over the past ___ years, the
patient has had multiple episodes of left hemibody numbness and
weakness with preserved consciousness that lasted under 3
mintues
and with post-event lethargy and a feeling of "heaviness over
his
shoulders." He was admitted to the ___ stroke service for a
transient episode of left hemibody numbness and weakness in
___ where MRI brain was negative for stroke. MRA head
and neck showed patent vessels. Routine EEG was normal. He was
placed on aspirin and statin and discharged home. Per his
partner (although not in our system) the patient had 48 hour EEG
monitoring with one push button for left sided numbness that did
not have a correlate. His partner notes that the episodes
seemed
to have started around the time of dialysis initiation and would
frequently coincide with life stressors and poor sleep. During
the time of dialysis his events occured almost weekly.
Importantly, today's event is different in that he has the most
profound weakness and his symptoms are lasting the longest
(hours
rather than minutes). Furthermore, prior events have never
caused
speech arrest.
We did discuss that Mr. ___ is anxious at baselinea and has
intermittent insomnia. His partner does not know of traumatic
recent or childhood events. He has not seen a therapist. His
partern's daughter (with whom he lives) does have a seizure
disorder with LOC, shaking, and foaming at the mouth.
Otherwise,
his partner notes that they have a "normal life" together.
On limited ROS, given poor verbal output, he denies headache,
confusion, change in vision, change in hearing, urinary
incontinence, chest pain, abdominal pain, diarrhea,
constipation,
fevers.
Past Medical History:
PMH: ESRD ___ polycystic kidney disease AD, started on
hemodialysis ___, he is making urine, Chronic back pain s/p
surgery, HTN
PSH: liposuction, RUE AV fistula
Social History:
___
Family History:
His father and his sister have ___, and HTN.
There is no history of seizures, developmental disability,
learning disorders, migraine headaches, strokes less than 50,
neuromuscular disorders, or movement disorders.
Physical Exam:
ON ADMISSION:
Vitals: 98.4 91 127/83 16 99% RA
General: Lethargic, but arousal level improves over 2hours in
ED, NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination (initial exam at 15:50)
- Mental status- Somnolent, arousable to voice, inattentive,
requires frequent stimulation and encouragement, nods head yes
and no but not reliably at first. Nonverbal. No evidence of
neglect.
- CN: PERRL, blinks to threat bilaterally, EOMI, Face symmetric
with movement and at rest. Tongue midline.
- Motor: Right side full strength. Left arm and leg drop to the
bed within 1 second. Did not participate in confrontational
strength testing. Right leg and arm appears full strength.
Left
leg and arm with subtle movements primarily distally. Negative
Hoover.
- Reflexes 2+ and symmetric. Toes mute.
Neurologic Examination (second exam at 16:40) - Please note,
this
examination had multiple suggestible features with variable
strength effort. Also he cried at one point.
- Mental Status - Awake, alert, oriented to person, place and
time with nodding yes/no. Attentive. Follows multistep
commands
reliably. At first wispers "ahhh" and then able to say "ahhh"
and "maa" if repeatedly encouraged. Does not say more than one
syllable. Appropriately points to items on BNT stroke card. No
hemineglect.
- Cranial Nerves - PERRL 4->2 brisk. VF full to finger wiggle.
EOMI, no nystagmus. Via nodding, he communicates that left face
feels more numb than right to pin and light touch. No facial
movement asymmetry. Hearing intact to finger rub bilaterally.
Palate elevation not visualized as he did not open his mouth
wide
enough. Shoulder shrug symmetric and strong. Tongue midline.
- Motor - Normal bulk and tone. Left arm and leg drift to the
bed, but able to hold leg in air for one second prior to drift.
No tremor or asterixis. Confrontational strength exam is highly
variable effor on the left side with give way weakness. I have
recorded the best effort, but not that over the course of 5
minutes with muscle groups repeated there was ___ efforts of
same
muscle groups. Still negative Hoover sign.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 2 ___ 5 4+ 4+ 3- 3+ 3+ 3 4
R 5 ___ ___ 5 5 5 5 5
- Sensory - Decreased sensation on left side to pin and light
touch. Did not assess proprioception.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response mute bilaterally.
- Coordination - No dysmetria with finger to nose testing on
right. Could not perform on the left. finger tapping intact on
right, slowed on left.
- Gait - deferred
ON DISCHARGE
Afebrile, VSS
Gen - cooperative and pleasant, NAD, reports that he believes he
is at his normal baseline
CV - RRR
RESP - normal WOB, CTAB
ABD - soft, non-tender, non-distended
EXTR - warm and well perfused
Neurological Exam
MS - A&Ox3, recounts history accurately (though has told
different versions at different times?), speech is fluent and
within normal limits for language (native ___ speaker but
fluent in ___, comprehension / naming / repetition intact,
short term and long term memory intact, no e/o apraxia
CN - VFF, EOMI, facial motor and sensation are intact any
symmetric, tongue movements are full
MOTOR - normal bulk and tone, no focal weakness, full power
throughout, no tremors or asterixis
SENSATION - intact to LT, temperature throughout
COORD - no evidence of truncal or appendicular ataxia
GAIT - normal initiation, narrow based
Pertinent Results:
___ 04:00PM BLOOD WBC-7.0 RBC-5.03 Hgb-15.4 Hct-46.6 MCV-93
MCH-30.7 MCHC-33.1 RDW-13.2 Plt ___
___ 04:00PM BLOOD Neuts-80.3* Lymphs-9.4* Monos-8.3 Eos-1.5
Baso-0.4
___ 04:00PM BLOOD ___ PTT-25.4 ___
___ 04:00PM BLOOD Glucose-100 UreaN-21* Creat-1.0 Na-137
K-4.8 Cl-103 HCO3-25 AnGap-14
___ 04:00PM BLOOD VitB12-485 Folate-17.7
___ 04:00PM BLOOD TSH-0.80
___ 04:00PM BLOOD T4-6.0
___ 05:00PM BLOOD PEP-PND
___ 04:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:00PM BLOOD PARANEOPLASTIC AUTOANTIBODY
EVALUATION-PND
___ EEG
This is an abnormal video EEG monitoring session because of (1)
the presence of faster frequencies throughout the record which
can be seen as side effects from administration of
sedatives-hypnotics; (2) rare right temporal focal slowing is
indicative of focal subcortical dysfunction of non- specific
etiology; and (3) rare right anterior and mid-temporal
discharges indicate increased focal cortical irritability in
these regions with an increased risk of epileptogenesis.
___ MRI AND MRA BRAIN AND MRA NECK
1. No acute infarction. No intracranial mass.
2. Coronal FSTIR images are limited by motion artifact. The
right temporal horn is larger than the left, as are all
components of the right lateral ventricle. There is no definite
evidence of right hippocampal atrophy. These findings suggest
congenital or developmental etiology. Correlation with EEG
findings could be helpful, given the clinical concern for a
seizure focus.
3. MRA of the brain is significantly degraded by motion
artifact, and
evaluation for aneurysms is limited. No large aneurysm is seen.
Major
intracranial arteries appear patent.
4. Unremarkable MRA of the neck.
Brief Hospital Course:
___ year-old left-handed man with a history of ___ s/p renal
tx ___, HTN, and multiple lifetime events of left hemibody
numbness and weakness who presents to the ED after sudden onset
loss of consciousness, left arm and leg weakness, left hemibody
numbness, and speech arrest. Ddx includes: seizures vs
pseudo-seizures vs migraines. Had deficits of L sided sensation
and motor in the ED, as well as difficulty speaking - though was
somewhat suggestible and effort dependent. Symptoms quickly
improved after admission. Patient reported that he had returned
to his baseline <24 hours after admission.
To evaluate for seizure, cvEEG was placed. Initial EEG shows few
R sided spikes, no seizures. MRI is questionable for assymetry
of hippocampal volume. LP performed for reported cognitive
changes (episodes of confusion that usually precede episodes of
L sided tingling and numbness). Preliminary studies are
unremarkable.
Started on Zonisamide for tx of seizure vs migraine disorder.
Will follow up with cognitive neurology and epilepsy. Will also
keep follow up appointment with stroke neurology after previous
hospitalization.
Remained afebrile and with stable vital signs throughout
admission.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Alendronate Sodium 70 mg PO QMON
3. Enalapril Maleate 10 mg PO DAILY
4. Mycophenolate Mofetil 1000 mg PO BID
5. Omeprazole 40 mg PO DAILY
6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
7. Tacrolimus 1 mg PO Q12H
Discharge Medications:
1. Alendronate Sodium 70 mg PO QFRI
2. Aspirin 81 mg PO DAILY
3. Enalapril Maleate 10 mg PO DAILY
4. Mycophenolate Mofetil 1000 mg PO BID
5. Omeprazole 40 mg PO DAILY
6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
7. Zonisamide 100 mg PO QHS
Please take for two weeks and if well tolerated, increase to
200mg each night
RX *zonisamide 100 mg 1 capsule(s) by mouth at bedtime Disp #*60
Capsule Refills:*3
8. Tacrolimus 1 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: episodes concerning for seizure vs migraine
Secondary: ADPKD s/p renal transplant, hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized for events concerning for seizure. EEG did
not show any seizure activity and MRI was within normal limits.
The preliminary results from your lumbar puncture are normal as
well. We recommend starting Zonisamide - a medication that is
effective for seizures and migraines. Please take 100mg each
night at bedtime. If you tolerate this medication well, please
increase to 200mg after 2 weeks.
We recommend keeping your regular follow up appointments and
also following with cognitive neurology for neuropsychiatric
testing (see below).
It was a pleasure caring for you during this hospitalization.
Followup Instructions:
___
|
10181426-DS-13 | 10,181,426 | 27,814,694 | DS | 13 | 2123-12-26 00:00:00 | 2123-12-28 16:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Right flank pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ gentleman w/ PCKD s/p LUR kidney
transplant in ___ transferred from ___ with
pyelonephritis.
Patient had ___ days of right sided back pain. This morning,
felt pressure on right flank and over his transplanted kidney on
his right side. +night sweats, chills, nausea without vomiting.
No fevers, dysuria, constipation, diarrhea, BRBPR, CP, SOB,
fatigue, rash, or recent travel. Taking all medications.
Went to ___. They did a UA and told him that he had a UTI.
Given 2g CTX and 4mg morphine and transferred here. No imaging
performed. Never had UTI after transplant.
In the ___, initial vitals were: ___, HR 80, 114/73, 18, 99% RA
Labs were notable for: UA w/ many bacteria, WBC, ___
Renal US was normal.
Patient was given: Tacrolimus 1.5mg, Mycophenolate Mofetil 500mg
daily, 1L NS
Consults: Renal transplant fellow saw pt in ___ and recommended
cont CTX, renal US, immunosuppresion, and tacro level.
Currently, feels ok w/ some tenderness in R flank and RLQ
Past Medical History:
PMH: ESRD ___ polycystic kidney disease AD, started on
hemodialysis ___, he is making urine, Chronic back pain s/p
surgery, HTN
PSH: liposuction, RUE AV fistula
Social History:
___
Family History:
His father and his sister have ___, and HTN.
There is no history of seizures, developmental disability,
learning disorders, migraine headaches, strokes less than 50,
neuromuscular disorders, or movement disorders.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
General: Well appearing Hispanic male
HEENT: EOMI, PERRL, sclera anicteric, MMM
Neck: Soft, no JVD
CV: RRR, Normal S1/S2, no carotid bruits, no m/r/g
Lungs: CTA b/l w/o w/r/r
Abdomen: Soft mild TTP in RLQ (site of transplant) w/ b/l CVA
tenderness (R>L), no rebound or guarding
Ext: No c/c/e
Neuro: CNII-XII, AOx3, moving all extremities
Skin: No rashes, warm and well perfused
DISCHARGE PHYSICAL EXAM:
VITALS: 99.1 108-120/60-70 50-70 18 97% RA, had a BM last night.
General: Well appearing Hispanic male, pleasant and
conversational
HEENT: EOMI, PERRL, sclera anicteric, MMM
Neck: Soft, no JVD
CV: RRR, Normal S1/S2, no carotid bruits, no m/r/g
Lungs: CTA b/l w/o w/r/r
Abdomen: No TTP in RLQ (site of transplant), no CVA tenderness.
Has tenderness to palpation in lower paraspinal muscles
bilaterally. No other abdominal pain, non-distended.
Ext: No edema
Neuro: CNII-XII, AOx3, moving all extremities
Skin: No rashes, warm and well perfused
Pertinent Results:
ADMISSION LABS:
___ 07:03AM BLOOD WBC-12.3*# RBC-5.16 Hgb-15.4 Hct-46.2
MCV-90 MCH-29.8 MCHC-33.3 RDW-12.0 RDWSD-39.4 Plt ___
___ 07:03AM BLOOD Glucose-113* UreaN-14 Creat-1.1 Na-139
K-4.1 Cl-105 HCO3-23 AnGap-15
___ 07:03AM BLOOD tacroFK-7.7
___ 08:30PM URINE Color-Yellow Appear-Hazy Sp ___
___ 08:30PM URINE Blood-MOD Nitrite-POS Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 08:30PM URINE RBC-37* WBC-107* Bacteri-FEW Yeast-NONE
Epi-<1
DISCHARGE LABS:
___ 07:29AM BLOOD WBC-10.0 RBC-5.35 Hgb-16.0 Hct-47.5
MCV-89 MCH-29.9 MCHC-33.7 RDW-12.0 RDWSD-38.7 Plt ___
___ 07:29AM BLOOD Glucose-107* UreaN-13 Creat-0.9 Na-138
K-4.1 Cl-103 HCO3-26 AnGap-13
___ 07:29AM BLOOD Calcium-9.8 Phos-3.2 Mg-1.6
___ 07:29AM BLOOD tacroFK-7.5
STUDIES:
Renal transplant ultrasound ___: Normal renal transplant
ultrasound.
MICRO:
___ urine culture ___ growing >100,000 colonies of E.coli,
pan-sensitive
___ urine culture ___ no growth
___ blood culture ___ pending, NGTD
Brief Hospital Course:
Mr. ___ is a ___ male with hx of PCKD s/p living, unrelated
kidney transplant (___) who presented with chills and graft
tenderness, found to have pyelonephritis.
ACUTE ISSUES:
# Pyelonephrtiis: Urine culture from ___ grew E. coli,
pan-sensitive. He was initially started on ceftriaxone which was
transitioned to cefpodoxime at discharge. He will complete a 14
day course of antibiotics (last day is ___. Blood cultures
were negative at discharge. Renal function remained at baseline.
CHRONIC ISSUES:
# Renal Transplant: His renal function remained at baseline and
renal ultrasound was normal. His tacrolimus and mycophenolate
mofetil were continued.
# HTN: continued enalapril 10mg qhs
# Bone Density Disease: continued vitamin D; alendronate 70mg
weekly resumed at discharge
# GERD: Continued omeprazole 40mg daily
TRANSITIONAL ISSUES:
- Cefpodoxime until ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enalapril Maleate 10 mg PO DAILY
2. Mycophenolate Mofetil 500 mg PO BID
3. Tacrolimus 1.5 mg PO Q12H
4. Omeprazole 40 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Vitamin D ___ UNIT PO DAILY
7. Alendronate Sodium 70 mg PO QMON
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Enalapril Maleate 10 mg PO DAILY
3. Mycophenolate Mofetil 500 mg PO BID
4. Omeprazole 40 mg PO DAILY
5. Tacrolimus 1.5 mg PO Q12H
6. Vitamin D ___ UNIT PO DAILY
7. Alendronate Sodium 70 mg PO QMON
8. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 11 Days
Take for 11 days starting the day after leaving the hospital
(last day is ___
RX *cefpodoxime 200 mg 1 tablet(s) by mouth q12hr Disp #*22
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Pyelonephritis
SECONDARY:
PKD s/p kidney transplant in ___
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 during your stay. You were
admitted for a kidney infection. Your urine culture grew E.coli.
You were initially treated with an IV medication (ceftriaxone),
which was transitioned to oral antibiotic on discharge
(cefpodoxime). You will need to take antibiotics until ___.
Please follow-up with your appointments listed below. PLEASE
MAKE AN APPOINTMENT FOR within ___
leaving the hospital (Week of ___ - CALL ___
We wish you the best!
Your ___ care team
Followup Instructions:
___
|
10181426-DS-14 | 10,181,426 | 29,600,070 | DS | 14 | 2124-05-02 00:00:00 | 2124-05-02 15:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Flank Pain, Hematuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with w/ PCKD s/p LUR kidney
transplant in ___ presenting to the ED with hematuria.
The patient reports over past 2 days he developed gross
hematuria that seems to be worsening. Today he passed a few
clots. He reports associated right flank pain. Denies any
fevers, chest pain, SOB, abdominal pain, vomiting, or dysuria.
Of note, the patient saw urology ___ to workup his
recurrent UTIs and persistent pyuria and microscopic hematuria.
There, he endorsed voiding ___ times a day, has nocturia x 1
and generally has a weak stream. They recommended native kidney
ultrasound and restarting Bactrim for UTI prophylaxis. The
patient reports that he had a UTI in ___ that was treated
with 10 days of po cipro and that after completing the course of
cipro he started on prophylactic Bactrim. That UTI had no flank
pain, dysuria, frequency or urgency, but was found due to foul
odor of the urine and a "more yellow" color to the urine. He
also reports that he had an ultrasound of his native kidneys at
___ that he thinks was normal.
In the ED, initial vital signs were: 97.7, 96, 152/97, 16, 99%
RA
- Exam was notable for: Mild tenderness over transplant site
- Labs were notable for: Cr 1.3 (baseline 0.9-1.0), nml CBC, UA
w/ > 182 RBCs, 50 WBCs, few bacteria, negative nitrites, 0 Epis
- Imaging: transplant ultrasound was normal
- The patient was given:
___ 00:39 IVF 1000 mL NS 1000 mL
___ 00:39 IV CeftriaXONE 1 gm
- Consults: Renal was consulted and recommended admission and
touching base with transplant surgery regarding need for 3 way.
Transplant surgery said ok to irrigate with 3 way. Pt refusing
foley at this time. can urinate without difficulty, no
retention.
Vitals prior to transfer were: 98.1 72 140/70 16 100% RA
Upon arrival to the floor, he complains of ___ R flank pain.
REVIEW OF SYSTEMS:
[+] per HPI
[-] Denies headache, visual changes, pharyngitis, rhinorrhea,
nasal congestion, cough, fevers, chills, sweats, weight loss,
dyspnea, chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, hematochezia, dysuria, rash, paresthesias,
weakness
Past Medical History:
PMH: ESRD ___ polycystic kidney disease AD, started on
hemodialysis ___, he is making urine, Chronic back pain s/p
surgery, HTN
PSH: liposuction, RUE AV fistula
Social History:
___
Family History:
His father and his sister have ___, and HTN. Renal disease
and prostate cancer in an uncle. There is no history of
seizures, developmental disability, learning disorders, migraine
headaches, strokes less than 50, neuromuscular disorders, or
movement disorders.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VITALS - 97.6 124/87 80 18 99%RA 81.1kg standing wt
GENERAL - pleasant, well-appearing, in no apparent distress
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear
NECK - supple
CARDIAC - regular rate & rhythm, normal S1/S2, no murmurs rubs
or gallops
PULMONARY - clear to auscultation bilaterally, without wheezes
or rhonchi
ABDOMEN - normal bowel sounds, soft, non-tender, non-distended,
no organomegaly, no graft tenderness
BACK - no CVA tenderness
EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or
edema. Fistula at R forearm with good thrill and bruit
SKIN - without rash
RECTAL - normal prostate, no prostatic tenderness, brown stool
GU - urine in bedside urinal light orange colored, no clots
NEUROLOGIC - A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout. Gait assessment deferred
PSYCHIATRIC - listen & responds to questions appropriately
DISCHARGE PHYSICAL EXAM:
==========================
VITALS: Tm98.2 BP100s-120s/60s-80s HR80s-90s RR18 100% RA
I/O 24H: 1122/___, post void residual 25 cc
GENERAL: pleasant, well-appearing, in no apparent distress
HEENT: PERRLA, EOMI, OP clear
CARDIAC: regular rate & rhythm, normal S1/S2, no murmurs rubs or
gallops
PULM: CTAx2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no organomegaly, no graft tenderness, no right flank and no CVA
tenderness
EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or
edema. Fistula at R forearm with good thrill
NEUROLOGIC - A&Ox3, no focal deficits.
Pertinent Results:
ADMISSION LABS:
===============
___ 10:55PM BLOOD WBC-8.2 RBC-5.12 Hgb-15.1 Hct-45.5 MCV-89
MCH-29.5 MCHC-33.2 RDW-12.6 RDWSD-41.3 Plt ___
___ 10:55PM BLOOD ___ PTT-30.5 ___
___ 10:55PM BLOOD Glucose-95 UreaN-21* Creat-1.3* Na-139
K-4.2 Cl-103 HCO3-23 AnGap-17
___ 10:55PM BLOOD Calcium-10.2 Phos-3.0 Mg-1.5*
___ 10:55PM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
___ 10:55PM URINE Color-DKAMB Appear-Hazy Sp ___
___ 10:55PM URINE RBC->182* WBC-50* Bacteri-FEW Yeast-NONE
Epi-0
PERTINENT LABS:
================
___ 11:22AM URINE Color-Yellow Appear-Clear Sp ___
___ 11:22AM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 11:22AM URINE RBC->182* WBC-12* Bacteri-NONE Yeast-MANY
Epi-0
Blood and urine cultures pending at discharge.
DISCHARGE LABS:
================
___ 05:00AM BLOOD WBC-6.6 RBC-5.06 Hgb-14.8 Hct-45.7 MCV-90
MCH-29.2 MCHC-32.4 RDW-12.9 RDWSD-42.3 Plt ___
___ 05:00AM BLOOD Glucose-120* UreaN-18 Creat-1.0 Na-139
K-4.3 Cl-103 HCO3-26 AnGap-14
___ 05:00AM BLOOD tacroFK-9.0
___ 05:00AM BLOOD Calcium-9.5 Phos-3.7 Mg-1.7
IMAGING and STUDIES:
=====================
___ CT abdomen/pelvis:
IMPRESSION:
1. No evidence of stone or CT findings to explain the patient's
right flank pain or hematuria within the limitations of a
nonenhanced CT.
2. Enlarged bilateral native kidneys with innumerable cysts
compatible with known history of present wall dominant
polycystic kidney disease. Multiple hypodense lesions in the
liver likely reflective of cysts given known clinical history.
___ Renal Tx US w/ dopplers: Normal renal transplant
ultrasound. Normal resistive indices.
Brief Hospital Course:
Mr. ___ is a ___ with w/ PCKD s/p LUR kidney
transplant in ___ presenting to the ED with hematuria and right
flank pain.
#Flank Pain/Hematuria: The differential included nephrolithiasis
(given gross hematuria and lack of dysuria, fever, leukocytosis)
vs rupture of a cyst vs pyelonephritis, given similar
presentation to ___ admission. Although hemorrhage into a
cyst can lead to hematuria, the typical presentation may be pain
as in this case, since many cysts do not communicate with the
collecting system. He has had at least two E. coli UTIs in the
last year (one in OMR ___ UCx, the other from ___
admission for pyelo), both pan-sensitive. Other differential for
hematuria includes other renal structural disease.
hypercalciuria, malignant HTN, renal vein thrombosis, renal
infarct being very unlikely. He may have ureteral or bladder
obstruction, appears less likely given patient currently
minimally symptomatic. Sediment was not consistent with
glomerular pathology. CT Abdomen/Pelvis without contrast did not
show any clear anomaly. He was continued on ceftriaxone and then
switched to cipro for a two week course. He was given IV fluids
for renal dysfunction and Tylenol for pain.
___: Cr was 1.3 from baseline 0.9-1.0, resolved with IV fluids.
This was likely pre-renal given likely infection and
concentrated urine (Sp ___ 1.022). Post-renal unlikely given
renal transplant ultrasound w/o hydronephrosis.
#Pyuria/Hematuria: Pyuria has been present on the last 5 UAs in
the system going back to ___. He has also had microscopic
hematuria dating back to that time, but gross hematuria was new.
BK PCR in the urine negative last week. Normal prostate exam
without evidence of BPH or prostatitis. He has had at least two
E. coli UTIs as above. This may have been be due to
pyelonephritis vs cyst rupture. It was unlikely to be glomerular
given minimal proteinuria on dipstick. Urine culture was pending
at discharge.
#S/p LURT, Polycystic kidney disease: Transplant on ___, was on dialysis for about 8 months prior. We continued
immunosuppression at home doses.
#HTN: Enalapril was held initially due to ___ and restarted at
discharge
#GERD: Continued omeprazole
#Osteoporosis: diagnosed on BMD ___, was briefly on
alendronate. Continued vitamin D ___ units/daily).
Chronic Issues:
-Simple partial seizures: noted history of paroxysmal left eye
lacrimation, left rhinorrhea, and left-sided paresthesias
lasting up to 10 minutes, was followed by neurology, previously
on zonisamide, but this was discontinued in ___ due to side
effect of drowsiness.
Transitional
=============
-continue cipro for total two week course
-unclear if he needs to be on aspirin. He was started on this
for possible TIA by neurology, though his symptoms may be
epilepsy. Given blood in his urine he should follow up with his
outpatient providers about discontinuing this medications
-Recheck labs (CBC, Chemistry panel) this ___
-Follow up with Dr. ___ in two weeks
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Enalapril Maleate 10 mg PO DAILY
3. Mycophenolate Mofetil 500 mg PO BID
4. Omeprazole 40 mg PO DAILY
5. Tacrolimus 1.5 mg PO Q12H
6. Vitamin D ___ UNIT PO DAILY
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Enalapril Maleate 10 mg PO DAILY
3. Mycophenolate Mofetil 500 mg PO BID
4. Omeprazole 40 mg PO DAILY
5. Tacrolimus 1.5 mg PO Q12H
6. Vitamin D ___ UNIT PO DAILY
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
8. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*24 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
-Hematuria
-UTI
Secondary Diagnosis:
-Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ after you had right flank pain and
blood in your urine. We are treating you for a possible
infection. You should take your antibiotics for two weeks. It
could be that you had a cyst in your kidneys that ruptured that
could cause pain and is common and not dangerous.
You should hear from the ___ about an appointment
with Dr. ___ will be within the next two weeks.
Please call if you do not hear from them this week. You should
have your blood tests repeated this ___. You should also
ask you neurologist if it's ok to stop aspirin as you have had
some blood in the urine.
Followup Instructions:
___
|
10182104-DS-3 | 10,182,104 | 25,194,454 | DS | 3 | 2123-06-10 00:00:00 | 2123-06-10 20:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Demerol / morphine / meperidine
Attending: ___.
Chief Complaint:
Nausea and right upper quadrant pain
Major Surgical or Invasive Procedure:
Open cholecystectomy
History of Present Illness:
Mr. ___ is a ___ man with a past history of CABG who
presents with RUQ pain. Five days ago (___), he
experienced three episodes of severe vomiting after eating a
___ at a restaurant. He initially thought that this was an
episode of food poisoning. He had some residual nausea, which
subsided over the course of the following day. On ___, he began experiencing nausea again, which worsened
over the next two days, prompting him to go to the urgent care
clinic at ___ on ___. He endorses
loss of appetite but no vomiting at that time.
At ___, he experienced severe RUQ pain and
tenderness to palpation on physical exam. He had an ultrasound
showing a thickened gallbladder wall, multiple gallstones, and a
positive sonographic ___ sign. He also had a CT scan,
which showed a dilated gallbladder with multiple gallstones.
Labs were drawn, which showed liver enzyme elevations. He was
given medication to alleviate his nausea. After he was given IV
fluids
and one dose of Zosyn, he was transferred to ___ for concern
of possible stones in the common bile duct. Mr. ___ reports
that his pain decreased greatly after the dose of Zosyn.
On presentation to ___, he is currently not experiencing any
RUQ pain at rest. He denies fever, chills, night sweats,
shortness of breath, chest pain, and diarrhea. He endorses loss
of appetite.
Of note, he has had one prior episode of epigastric abdominal
pain in ___, for which he presented to ___.
This episode resolved on its own after several hours. Abdominal
CT performed at that time showed some signs of gallbladder
inflammation and edema.
ROS:
(+) easy bleeding
Past Medical History:
Coronary artery disease
GERD
Past Surgical History:
CABG ___
Social History:
___
Family History:
Brother: rheumatic fever, enlarged heart
Father: Died at ___
Mother: Died at ___, possibly of MI
Physical Exam:
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, non tender, normal bowel sounds. No
palpable masses.
Ext: No ___ edema. ___ warm and well perfused.
Pertinent Results:
MRCP (MR ABD ___- ___
IMPRESSION:
1. Acute cholecystitis with gallstones and biliary sludge.
2. No choledocholithiasis or evidence of cholangitis.
3. Incidentally noted aberrant biliary anatomy with posterior
right biliary duct draining into the left biliary duct.
4. Moderate hepatic steatosis.
___ 01:00AM BLOOD WBC-16.7* RBC-4.10* Hgb-13.0* Hct-38.4*
MCV-94 MCH-31.7 MCHC-33.9 RDW-14.5 RDWSD-50.4* Plt ___
___ 08:00AM BLOOD WBC-14.0* RBC-4.11* Hgb-13.3* Hct-39.4*
MCV-96 MCH-32.4* MCHC-33.8 RDW-14.6 RDWSD-51.0* Plt ___
___ 05:00AM BLOOD WBC-13.0* RBC-4.02* Hgb-12.8* Hct-38.3*
MCV-95 MCH-31.8 MCHC-33.4 RDW-14.6 RDWSD-51.0* Plt ___
___ 06:14AM BLOOD WBC-10.3* RBC-4.15* Hgb-13.4* Hct-39.9*
MCV-96 MCH-32.3* MCHC-33.6 RDW-14.5 RDWSD-51.4* Plt ___
___ 01:00AM BLOOD ALT-92* AST-54* AlkPhos-77 TotBili-1.5
___ 08:00AM BLOOD ALT-102* AST-61* AlkPhos-81 TotBili-1.5
Brief Hospital Course:
The patient was admitted to the ___ Surgical Service on
___ for evaluation and treatment of abdominal pain.
History, physical exam, laboratory studies and imaging were all
consistent with acute cholecystitis. The patient underwent open
cholecystectomy, which went well without complication (reader
referred to the Operative Note for details). A JP drain was left
in place. After a brief, uneventful stay in the PACU, the
patient arrived on the floor tolerating and 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. The patient was given
a four day course of antibiotics.
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. Atorvastatin 20 mg PO QPM
2. Aspirin 325 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H *AST Approval Required*
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*3 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*5 Tablet Refills:*0
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*6 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY
7. Sarna Lotion 1 Appl TP TID:PRN itching
8. Aspirin 325 mg PO DAILY
9. Atorvastatin 20 mg PO QPM
10. Metoprolol Succinate XL 50 mg PO DAILY
11. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
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. 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.
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. 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.
*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.
Followup Instructions:
___
|
10182665-DS-7 | 10,182,665 | 29,411,152 | DS | 7 | 2126-01-17 00:00:00 | 2126-01-18 11:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
ONCOLOGY HOSPITALIST ADMISSION ___, 4pm
Hypertension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o F with ovarian cancer recently started on protocol with
cediranib and olaparib who comes in today with complaints of
intractable nausea and vomiting along with headache and
hypertension. The patient reports that since starting on the
protocol drugs she has had increase in blood pressure and has
had to titrate up meds. When her BP (usually the diastolic) is
elevated, she gets headaches, along with SOB, nausea, vomiting
and diarrhea, all together. She has noticed several
particularly bad days before once when he BP was 137/110 and she
started on nifedipine then, feeling better. Later with BP of
112/85. Today she had her friend take her BP and it was
148/110. She has had a constant headache that is now ___,
intractable nausea, not able to keep anything down until just
now that she is eating crackers, along with about 10 episodes of
diarrhea today. This is the worst of these episodes she has had
since starting on the protocol. HA is R sided fronto-temporal
and over R eye, no tearing, no visual changes (except blurry
vision) Today she also reported blurry vision on the R eye which
has resolved, denies any weakness or numbness. Symptoms started
___ mins after taking meds. Tylenol did not help the pain,
hot compress was good. Full ten point ROS is only positive for
decreased UOP, no other symptoms.
Past Medical History:
PAST MEDICAL HISTORY: Significant for multiple sclerosis-like
syndrome
hypertension.
ovarian cancer
PAST SURGICAL HISTORY:
Chole ___
Expl. Lap, TAH/BSO,Inracolic omentectomy,retroperitoneal
lymph node sampling and tumor debulking - ___nd catheter placement- ___
Lap removal port- ___
.
ONCOLOGIC/TREATMENT HISTORY:
1. On ___, diagnoses with stage IIIC, grade 3,
poorly differentiated serous endometrial carcinoma of the ovary.
She presented with vaginal bleeding and pelvic heaviness. She
underwent optimal debulking on 12 cm ovarian mass, 4 cm omental
mass, and 3 cm paracaval lymph node. She underwent IV/IP
paclitaxel and platinum therapy completed on ___.
2. On ___, human proteomics trial involving
surveillance.
3. On ___, testing for BRCA1 and 2 were negative.
4. On ___, local resection of inguinal lymph node
conglomerate, which confirmed metastatic ovarian carcinoma.
CA-125 normalized after this resection. We had extensive
discussions and decision was made not to pursue chemotherapy at
that juncture.
5. On ___, CA-125 again rising. Treatment with
carboplatin and gemcitabine initiated. She completed six cycles
of treatment complicated by low blood counts and fatigue but
otherwise well tolerated.
6. On ___, initiation of anastrozole as form of
maintenance therapy per the patient's request, last dose
___.
7. ___ CT evidence of isolated recurrence RLQ mesenteric
soft tissue mass, CA-125 28
7. Started on Protocol ___ (Cediranib 30mg po daily and
Olaparib 200mg po twice daily)
Social History:
___
Family History:
FAMILY HISTORY: Significant for a paternal aunt with breast
cancer at age ___.
Physical Exam:
Exam
Gen: In NAD.
HEENT: EOMI. No scleral icterus. No conjunctival injection.
Mucous membranes moist. No oral ulcers.
Neck: Supple, no LAD, no JVP elevation.
Lungs: CTA bilaterally, no wheezes, rales, rhonchi. Normal
respiratory effort.
CV: RRR, no murmurs, rubs, gallops.
Abdomen: soft, NT, ND, NABS, no HSM.
Extremities: warm and well perfused, no cyanosis, clubbing,
edema.
Neurological: alert and oriented X 3, CN II-XII intact.
strenght ___ UE B, lower extremity feet limited due to recent
trauma/pain, proximal ___ ___ symmetric, sensation intact in face
and extremities
Skin: No rashes or ulcers.
Psychiatric: Appropriate.
GU: deferred.
Pertinent Results:
___ 02:48PM ___ PTT-30.1 ___
___ 02:00PM SODIUM-138 POTASSIUM-4.3 CHLORIDE-105 TOTAL
CO2-21* ANION GAP-16
___ 12:45PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-MOD
___ 12:45PM URINE RBC-0 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-1
___ 12:15PM WBC-8.3 RBC-5.28 HGB-16.9* HCT-51.1* MCV-97
MCH-32.0 MCHC-33.1 RDW-15.6*
___ 12:15PM NEUTS-69.6 ___ MONOS-3.9 EOS-1.0
BASOS-0.7
___ 12:15PM PLT COUNT-170
.
MRI brain ___:
IMPRESSION:
1. No acute intracranial abnormality.
2. No abnormal enhancement.
3. Few scattered FLAIR hyperintense foci in bilateral frontal
white matter, which are unchanged since the prior study and are
non specific.
Brief Hospital Course:
___ y/o Fw ith Stage IIIC Ovarian ca with recent recurrence,
admitted on cycle 2 day 13 of Protocol ___, with Cediranib
(VEGF inhibitor) and Olaparib with headache, intractable
nausea/vomiting and uncontrolled hypertension.
.
# Nausea/vomiting/Headache: Likely related to uncontrolled BP,
hypertensive urgency. Held protocol drugs, and titrated BP
meds, now much improved after BP control.
-Nifedipine was changed to amlodipine as nifedipine can cause
HAs, dose of amlodipine 10mg to be taken at night and lisinopril
in the morning
-prn fioricet, antiemetics
.
# Uncontrolled hypertension: particularly elevated diastolic
pressure. VEGF inhibitors known to cause HTN, so protocl drugs
were held during admission.
- MRI to evaluate for PRES syndrome was negative
- BP now better controlled, continuing with Lisinopril 40mg
daily, and changed nifedipine to amlodipine 10mg at night. Pt
should continue to monitor BP at home.
.
# Diarrhea: also known side effect of Cediranib, monitored off
drug. Decreased in quantity since admission, pt will cont to
monitor and inform primary oncologist as outpt.
.
# Polycythemia: could be related to Cediranib as noted after
starting drug. carboxyhemoglobin normal, repeat value hct
better could have been some component of dehydration, cont oupt
f/u
.
# Ovarian Ca: hold protocol meds, seen by primary oncologist
here, to restart meds tonight
Medications on Admission:
Medications - Prescription
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once daily
LORAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth once a day
NIFEDIPINE - 10 mg Capsule - 1 Capsule(s) by mouth bid
PROCHLORPERAZINE MALEATE - 5 mg Tablet - 1 Tablet(s) by mouth
three times a day as needed for nausea
SERTRALINE - 100 mg Tablet - 1 Tablet(s) by mouth twice a day
TOPIRAMATE - 100 mg Tablet - 1 Tablet(s) by mouth once a day
Medications - OTC
ACETAMINOPHEN [TYLENOL] - (Prescribed by Other Provider) -
Dosage uncertain
ASPIRIN - (Prescribed by Other Provider) - Dosage uncertain
Discharge Medications:
1. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. topiramate 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: ___
Tablets PO Q4H (every 4 hours) as needed for headache.
Disp:*60 Tablet(s)* Refills:*0*
7. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
8. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea/vomiting.
Discharge Disposition:
Home
Discharge Diagnosis:
Uncontrolled secondary hypertension
Headache
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with nausea, vomiting, headache and
uncontrolled hypertension thought to be a side effect from your
protocl medication, cideranib. Both your protocol medications
were held and we adjusted your BP medications, with improved
control of the blood pressure and symptoms. You should continue
this dose of blood pressure medications and monitor your BP and
symptoms. Please contact your oncologist if you have repeat
symptoms. restart your protocol drugs this pm.
MEDICATION CHANGES:
-Stop Nifedipine
-Start Amlodipine 10mg po 5pm
-Fioricet ___ po prn headache
Followup Instructions:
___
|
10182930-DS-3 | 10,182,930 | 25,621,352 | DS | 3 | 2118-09-21 00:00:00 | 2118-09-21 09:40:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
cervical radiculpathy
Major Surgical or Invasive Procedure:
Anterior Cervical Decompression and Fusion with instrumentation
at C6/C7
History of Present Illness:
This is a ___ F a ___ month history of vague left arm and
neck pain. This is insidious in onset. Denies trauma. Pain began
in the left elbow and was intiially thought to be lateral
epicondylitis. She did OT with no relief. She continued to have
pain, but this was manageable.
About one month ago the pain worsened and she began taking
narcotic pain medications and lyrica. These have made only a
mild
difference and she finds the side effects intolerable. She also
reports some weakness in her grip and using her arm. She feels a
hot, burning feeling near her wrist.
She otherwise is well and has no pain in the right arm, or
bilateral lower extremities. She does not have any problems with
her bowel or bladder. She ambulates well without ataxia.
Past Medical History:
Type II diabetes, hypothyroid, Sarcoidosis
Social History:
___
Family History:
non-contributory
Physical Exam:
VS: T: 98.2 HR: 65 BP: 128/78 RR: 16 O2Sats: 98 on RA
Gen: WD/WN, comfortable, NAD.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
Delt Biceps Tri WE WF IP Quad Ham AT ___ G
R 5 5 5 5 5 5 5 5 5 5 5
L 5 5 3+ 4 5 5 5 5 5 5 5
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: 2+ patellar tendon reflexes bilaterally. 3+ biceps on
left and 2+ on right No clonus.
Toes downgoing bilaterally. Negative ___ bilateraly.
Rectal exam normal sphincter control
Anterior neck wound c/d/i. neck is supple
Pertinent Results:
___ 04:10PM BLOOD WBC-13.2* RBC-4.36 Hgb-13.4 Hct-36.3
MCV-83 MCH-30.7 MCHC-36.9*# RDW-12.7 Plt ___
___ 04:10PM BLOOD ___ PTT-27.8 ___
___ 04:10PM BLOOD Glucose-159* UreaN-7 Creat-0.7 Na-139
K-3.9 Cl-103 HCO3-28 AnGap-12
___ 04:10PM BLOOD ALT-15 AST-15 AlkPhos-88
___ 04:10PM BLOOD Calcium-9.0 Phos-3.1 Mg-1.9
Brief Hospital Course:
Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery
was without complication and the patient was transferred to the
PACU in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA. Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO diet. Foley was removed on POD#1. Physical
therapy was consulted for mobilization OOB to ambulate.
Hospital course was otherwise unremarkable. On the day of
discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating a regular diet.
Medications on Admission:
Levemir *NF* (insulin detemir) 12 units Subcutaneous daily
Atorvastatin 20 mg PO/NG HS
MetFORMIN XR (Glucophage XR) 500 mg PO DINNER
Dilaudid 2 mg Q4H:PRN pain
liraglutide 1.2 mg Subcutaneous Daily
Levothyroxine Sodium 125 mcg
Discharge Medications:
1. diazepam 2 mg Tablet Sig: ___ Tablets PO Q8H (every 8 hours)
as needed for spasm.
Disp:*30 Tablet(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
4. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
5. acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours).
6. Levemir 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous daily ().
7. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) Pen Injector Sig: 1.2
mg Subcutaneous daily ().
8. metformin 500 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO QPM (once a day (in the
evening)).
Discharge Disposition:
Home
Discharge Diagnosis:
Herniated nucleus puplosus at C6-7 with LUE radiculopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You have undergone the following operation: Anterior Cervical
Decompression and Fusion at C6/C7
Activity: You should not lift anything greater than 10 lbs for 2
weeks. You will be more comfortable if you do not sit in a car
or chair for more than ~45 minutes without getting up and
walking around.
Rehabilitation/ Physical Therapy:
___ times a day you should go for a walk for ___ minutes as
part of your recovery. You can walk as much as you can
tolerate.
Isometric Extension Exercise in the collar: 2x/day x ___xercises as instructed.
Swallowing: Difficulty swallowing is not uncommon after this
type of surgery. This should resolve over time. Please take
small bites and eat slowly. Removing the collar while eating
can be helpful however, please limit your movement of your
neck if you remove your collar while eating.
Cervical Collar / Neck Brace: You need to wear the brace at all
times until your follow-up appointment which should be in 2
weeks. You may remove the collar to take a shower. Limit your
motion of your neck while the collar is off. Place the collar
back on your neck immediately after the shower.
Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry
then you can leave the incision open to the air. Once the
incision is completely dry (usually ___ days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Call the office at that
time. If you have an incision on your hip please follow the same
instructions in terms of wound care.
You should resume taking your normal home medications.
You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on ___ 2.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
Follow up:
Please Call the office and make an appointment for 2 weeks after
the day of your operation if this has not been done already.
At the 2-week visit we will check your incision, take baseline x
rays and answer any questions.
We will then see you at 6 weeks from the day of the operation.
At that time we will most likely obtain Flexion/Extension X-rays
and often able to place you in a soft collar which you will wean
out of over 1 week.
Followup Instructions:
___
|
10183012-DS-18 | 10,183,012 | 28,787,562 | DS | 18 | 2125-03-04 00:00:00 | 2125-03-05 00:03:00 |
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 weakness and numbness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a past history of significant HLD, AF on dabigatran
(not taken for 3 days) presents with acute onset left arm
numbness and weakness on awakening this am and a code stroke was
called.
Patient had some alcohol last night and went to bed feeling well
at just after modnight. He then awoke lying on his left arm at
0700 and noticed that his entire arm was weak and numb so much
so that he had to support it with his right arm. He initially
attributed this to lying on his arm and this improved but when
it did not go away entirely, he became concerned and presented
to the ED. Currently he feels his arm is still weak but much
better and sensory disturbance os only on the dorsum and ___
fingers of the left hand and he can now lift his arm.
Patient had not taken dabigatran for the past ___ days as he had
left it in his office having not refilled his prescription after
a business trip. He has also recently been treated for
bronchitis vs lower respiratory tract infection for past 2 weeks
and had been recently started on cefuroxime. He has also
noticed increasing leg swelling over the past few days.
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. No bowel or bladder
incontinence or retention. Denies difficulty with gait.
On general review of systems, the pt notes increasing leg
swelling as above and 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:
- HLD
- Atrial fibrillation s/p failed cardioversion x2 now chronic.
Preiously on wararin now changed to dabigatran in ___ - as
above had not taken for 3 days
- Tachycardia-induced cardiomyopathy during his initial
presentation of AF, now with normal LV function.
- Mitral regurgitation graded 2+
- Cardiac cath years ago
- Recent lower respiratory tract infection
- Alcohol abuse
Social History:
___
Family History:
Mother - ___ well HTN
Father - died ___ MI age ___
Sibs - ___ sibs - sister died ___ of breast ca, brother had MI age
___ and is s/p CABGx3
There is no history of seizures, developmental disability,
learning disorders, migraine headaches, strokes less than 50,
neuromuscular disorders, or movement disorders.
Physical Exam:
Admission Physical Exam:
Vitals: T:98.4 P:88 AF R:16 BP:149/84 SaO2:99% RA
General: Awake, cooperative notes left arm weakness and
numbness. Smells of alcohol. Has bilateral fine tremor.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
Pulmonary: few tiny crackles left base
Cardiac: nl. S1S2 AF
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: ___ pitting edema to just above knees bilaterally.
Normal cap refill. 2+ radial, DP pulses bilaterally. Calves SNT
bilaterally.
Skin: no rashes or lesions noted.
Neurological examination:
- Mental Status:
ORIENTATION - Alert, oriented x 3
The pt. had good knowledge of current events.
SPEECH
Able to relate history without difficulty.
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors.
Speech was not dysarthric.
NAMING Pt. was able to name both high and low frequency objects.
READING - Able to read without difficulty
ATTENTION - Attentive, able to name ___ backward without
difficulty.
REGISTRATION and RECALL
Pt. was able to register 3 objects and recall ___ at 5 minutes
but ___ with category prompts.
COMPREHENSION
Able to follow both midline and appendicular commands
There was no evidence of apraxia or neglect
- Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam deferred.
III, IV, VI: EOMI without nystagmus. Normal pursuits and
saccades.
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.
- Motor: Normal bulk, tone throughout. Mildleft pronnator drift.
Bilateral tremor noted. No asterixis noted.
Profound weakness in left wrist extension (___), finger
extension (___-) and APB (4-) in addition to mild weakness in
___ DIO and ADM/lumbricals (4+) on the left. Full power in LLE
and right side.
- Sensory: Patchy reduced sensation on the dorsum of the left
hand and up to the radial forearm to pinprick, light touch and
temperature (not on the palmar aspect) and mild pinprick/temp
sensory loss to the mid shins bilaterally. Otherwise normal
sensation. No extinction to DSS.
- DTRs:
___ present and brisker on left with pectoral and adductor
on this side, more so in the left leg (3+ reflexes) and absent
AJs. There was no evidence of clonus.
___ negative.
Plantar response was flexor bilaterally.
- Coordination: No ataxia but intention tremor bilaterally and
clumsy finger tapping on the left. No dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
- Gait: Good initiation. Unsteady tandem and walking on heels
and sways to left with Romberg.
.
.
Discharge examination:
Patient no longer has a left wrist drop and wrist extension is
now stronger but still weak. Still has significant weakness in
left finger extension and APL. Ulnar innervated muscles are
strong and has slight left ADM weakness. Triceps weakness
improvd now full power. Mild pain/temp sensory loss to the mid
shins bilaterally. Patient is hyper-reflexic on the left and
plantar is extensor on the left. He has no aphasia or neglect.
Pertinent Results:
Laboratory investigations:
Admission labs:
___ 09:15AM BLOOD WBC-4.7 RBC-4.05* Hgb-13.0* Hct-40.8
MCV-101* MCH-32.2* MCHC-31.9 RDW-13.2 Plt ___
___ 09:15AM BLOOD ___ PTT-44.6* ___
___ 09:15AM BLOOD UreaN-12
___ 09:15AM BLOOD Creat-1.2
___ 09:21AM BLOOD Glucose-84 Lactate-1.9 Na-143 K-4.1
Cl-102 calHCO3-26
.
Other pertinent labs:
___ 05:40PM BLOOD Thrombn-100.5*
___ 06:55AM BLOOD ALT-92* AST-46* CK(CPK)-90 AlkPhos-46
TotBili-1.3
___ 06:55AM BLOOD CK-MB-1 cTropnT-<0.01
___ 06:55AM BLOOD Albumin-4.0 Calcium-9.4 Phos-3.0 Mg-2.2
Cholest-294*
___ 06:55AM BLOOD Triglyc-105 HDL-97 CHOL/HD-3.0
LDLcalc-176*
___ 06:55AM BLOOD %HbA1c-5.4 eAG-108
___ 06:55AM BLOOD VitB12-335 Folate-14.3
___ 09:15AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
Discharge labs:
___ 04:20AM BLOOD WBC-5.1 RBC-4.22* Hgb-13.5* Hct-42.4
MCV-100* MCH-32.1* MCHC-31.9 RDW-12.8 Plt ___
___ 04:20AM BLOOD Glucose-92 UreaN-11 Creat-1.0 Na-139
K-4.2 Cl-101 HCO3-28 AnGap-14
.
.
Urine:
___ 10:25AM URINE Color-Straw Appear-Clear Sp ___
___ 10:25AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 10:25AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
.
Radiology:
CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS ___
9:11 AM
IMPRESSION:
1. No evidence of hemorrhage on CT. Hypodensity in the right
frontal
subcortical white matter could be due to small vessel disease.
MRI can help for further assessment to exclude subcortical
infarct if clinically indicated.
2. CT angiography of the neck demonstrates patent vascular
structures without stenosis, occlusion or dissection.
3. CT angiography of the head demonstrates patent vascular
structures in the anterior and posterior circulation without
stenosis or occlusion.
Degenerative changes in the cervical spine and increased fat in
the mediastinum indicative of mediastinal lipomatosis.
.
CHEST (PA & LAT)Study Date of ___ 4:15 ___
IMPRESSION:
1. Cardiomegaly without evidence of congestive heart failure.
2. Patchy left lower lobe opacity, which may reflect patchy
atelectasis,
focal aspiration, and less likely an early infectious pneumonia.
Followup
radiographs would be helpful to assess for resolution.
.
TTE (Complete) Done ___ at 11:43:35 AM FINAL
Conclusions
The left atrium is moderately dilated. The right atrium is
moderately dilated. No atrial septal defect or patent foramen
ovale is seen by 2D, color Doppler or saline contrast with
maneuvers. There is mild symmetric left ventricular hypertrophy
with normal cavity size. Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. The mitral valve
leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. Due to the eccentric nature of the
regurgitant jet, its severity may be significantly
underestimated (Coanda effect). There is mild pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal global and regional biventricular systolic function.
Moderate mitral regurgitation. Mild pulmonary artery systolic
hypertension.
Compared with the prior study (images reviewed) of ___,
mitral severity appears moderate on the current study (though
could be UNDERestimated on both).
.
BILAT LOWER EXT VEINSStudy Date of ___ 1:09 ___
IMPRESSION: No bilateral lower extremity DVT.
.
MR HEAD W/O CONTRASTStudy Date of ___ 9:31 ___
FINDINGS:
There is no evidence of acute infarct or hemorrhage. There is a
T2 FLAIR
hyperintensity in the right inferior subcortical white matter
likely
representing an old lacunar infarction or an area of stenosis
due to prior
injury. There is mild volume loss. No evidence of mass effect
or midline
shift. The major intracranial flow voids are preserved. There
is fluid in
the bilateral mastoid air cells, worse on the left and a mucus
retention cyst
in the left maxillary sinus. The orbits are unremarkable.
IMPRESSION:
1. No evidence of acute infarct or hemorrhage.
2. Focal area of increased T2 FLAIR signal in the right
inferior frontal
subcortical white matter likely representing an old lacunar
infarction.
3. No specific fluid in the bilateral mastoid air cells, worse
on the left.
Mucosal thickening/mucus retention cyst in the left maxillary
sinus.
Brief Hospital Course:
___ with a past history of significant HLD, AF on dabigatran
(not taken for 3 days prior to presentation) and alcohol abuse
presented to the ___ on ___ for acute left arm weakness
and numbness which was initially profound (could not lift arm)
but latterly had improved roughly 9 hours after last known well
at midnight the preceding evening. He was admitted to the stroke
neurology service from ___ until ___.
A Code Stroke was called and NIHSS on arrival was 2 (sensory
deficit and subtle left drift). On examination, patient had
profound weakness in left wrist extension, finger extension and
APL in addition to mild weakness in ADM and and patchy reduced
sensation on the dorsum of the left hand and up to the radial
forearm and mild pain/temp sensory loss to the mid shins
bilaterally. Patient was slightly hyper-reflexic on the left and
plantars were flexor bilaterally. He had no other deficits but
was noted to have bilateral tremor. He was not given IV tPA as
he was outwith the time window and had minimal deficits.
CT showed a small area of hypodensity in the white matter
underlying the junction of the right pre-central gyrus with the
premotor region. He proceeded to MRI which showed no evidence
of acute stroke but there was a FLAIR hyperintensity in the
right inferior frontal subcortical white matter which could be
compatible with an old infarct. On further history, the patient
does recall an episode of gait unsteadiness ___ years or so ago
when he felt that hs left side was weak but he was not imaged at
that time.
He was monitored on telemetry which showed persistent AF and no
other arrhythmias. He was placed on a HISS with a goal of
normoglycemia. Stroke risk actors were assessed and lipid panel
revealed Chol 294 TGCs105 HDL 97 LDL 176 and HbA1c was normal
at 5.4%. Vitamin B12 was 335 and folate 14.3, urine and serum
tox were negative save an alcohol level of 159. UA was negative.
Other labs revealed a thrombin time of 100.3 with elevated LFTs
likely secondary to his alcohol use with ALT 92 and AST 46. CEs
were negative.
He was further evaluated with an echo which was unchanged from
prior study in ___ wth no clot seen and at least moderate MR
with normal biventricular function EF >70%.He had evidence of
bilateral pitting edema and doppler U/S of both legs revealed no
evidence of DVT.
Given his alcohol history, elevated alcohol level and tremor on
admission, the patient was started on a CIWA scale for risk of
alcohol withdrawal. He had minimal alcohol withdrawal and
received one dose of diazepam 10mg due to tachycardia albeit in
the setting of us holding his rate control agents which were
latterly continued and heart rate normalised.
His exam latterly had elements of a radial nerve palsy (with
finger extension, wrist extension, APL weakness with previous
triceps involvement occuring after a night of drinking [alcohol
level 159] sleeping in a chair initially then in bed and lying
on left arm on awakening) without clear features of median or
ulnar neuropathy (ADM mildly affected in light of finger
extension weakness). However, given concomitant slight left
deltoid weakness and slightly atypical sensory disturbance (does
involve the dorsum of the hand but also the radial forearm) and
a CT and MRI lesion compatible with his deficit, it is difficult
to rule out recrudescence of a prior stroke.
He was advised to lead a more healthy life-style with reducing
his ETOH intake, working out on a regular(daily) basis and
adhering to a heart-healthy diet. We counselled him about
adhering to his dabigatran and and gave him a 6 dose emergency
prescription in case he runs out again to keep with him. Given
his lipid abnormalities and evidence of old stroke, we increased
his atorvastatin to 40mg. His strength improved and he was seen
by OT who advised o/p OT.
We have requested an o/p MRI w and w/o contrast to better
delineate his scan findings to ensure this lesion is in fact an
old stroke and this has been scheduled for the afternoon of ___ after his PCP ___. He was discharged home with o/p OT
on ___. He has stroke ___ with Dr ___ PCP
___.
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
puffs(s) inhaled every four (4) hours - no longer taking as was
not working
ATENOLOL - 50 mg Tablet - 2 (Two) Tablet(s) by mouth twice a day
ATORVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth once a day
CEFUROXIME AXETIL - 500 mg Tablet - 1 Tablet(s) by mouth twice a
day
DIGOXIN - 125 mcg Tablet - one Tablet(s) by mouth daliy
DILTIAZEM HCL - (Prescribed by Other Provider) - 240 mg Tablet
Extended Release 24 hr - 1 Tablet(s) by mouth once a day
PREDNISONE - 20 mg Tablet - 2 Tablet(s) by mouth now and each
morning - no longer taking
Medications - OTC
MULTIVITAMIN - (Prescribed by Other Provider) - Tablet - 1
Tablet(s) by mouth once a day
THIAMINE HCL - (Prescribed by Other Provider) - 100 mg Tablet -
1 Tablet(s) by mouth once a day
Discharge Medications:
1. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. digoxin 125 mcg Tablet Sig: One (1) Tablet PO ONCE (Once).
6. cefuroxime axetil 500 mg Tablet Sig: One (1) Tablet PO twice
a day for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
7. diltiazem HCl 240 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
8. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO
every twelve (12) hours for 6 doses: Emergency supply.
Disp:*6 Capsule(s)* Refills:*0*
9. atenolol 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
10. Outpatient Occupational Therapy
Patient requires outpatient occupational therapy
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
1. Possible recrudescence of right precentral gyrus stroke.
2. Left radial nerve palsy caused by compression at the axilla
.
Secondary diagnoses:
1. Atrial fibrillation
2. Hyprlipidmia
3. Moderate mitral regurgitation
4. Possible left lower lobe community acquired pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neurologic: Patient no longer has a left wrist drop and wrist
extension is now stronger but still weak. Still has significant
weakness in left finger extension and APL. Ulnar innervated
muscles are strong and has slight left ADM weakness. Triceps
weakness improvd now full power. Mild pain/temp sensory loss to
the mid shins bilaterally. Patient is hyper-reflexic on the left
and plantar is extensor on the left. He has no aphasia or
neglect.
Discharge Instructions:
It was a pleasure taking care of you during your stay at the
___. You presented after an
episode of left arm weakness and numbness on waking. You had
also not taken your Pradaxa (dabigatran) for 3 days prior. Your
weakness improved but was still persistent. You had a CT head
scan which showed a small stroke on the right side of your brain
which appears old. You also had an MRI of your head which did
not show a new stroke.
Although you did not have a new stroke, your MRI shows evidence
of an old stroke and it is uncertain whether your event may
indicate reactivation of an old stroke and to better tell
whether this is in fact an old stroke you should have a repeat
MRI as an outpatient which will be on ___ on the same day as
your PCP ___. Assuming this is an old stroke, this may
have been caused by a blood clot travelling from your heart to
your brain due to your irregular heart rhythm (atrial
fibrillation) as this predisposes to clots forming. This is
normally prevented from heppening by taking blood thinners like
warfarin or dabigatran (Pradaxa). If you do not take your
Pradaxa, your blood will not sufficiently thin to avoid strokes.
You MUST take this TWICE DAILY EVERY DAY as after one dose, the
blood thinning effect stops after approximately 12 hours. In
case this happens, we have given you a 6 dose emergency
prescription. Your cholesterol is also not controlled and you
were changed to a higher dose of your cholesterol lowering
medication.
Given that you had awoken on your left arm on the morning in
question, this may represent a radial nerve palsy caused by
compressing your nerves by sleeping on your arm in an awkward
position. This should improve over the next days.
You were seen by physical therapy who felt that you would
benefit from outpatient OT for your hand weakness. We have given
you a prescription for this.
You had an echocardiogram (cardiac ultrasound) which was
unchanged from your recent prior study. You had an ultrasound of
your legs due to increased swelling which showed no videbnce of
blood clots. A chest X-ray showed a possible resolving chest
infection in your left lung base and you were continued on
antibiotics for this.
Medication changes:
You MUST take your dabigatran (Pradaxa) 150mg TWICE DAILY - this
is VERY IMPORTANT to prevent future STROKES
We INCREASED atorvastatin to 40mg daily
CONTINUE cefuroxime for a further 3 days until assessment by
your PCP
___ continue your other medications as prescribed.
Followup Instructions:
___
|
10183012-DS-22 | 10,183,012 | 20,897,479 | DS | 22 | 2127-02-03 00:00:00 | 2127-02-03 19:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fatigue, BRBPR
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with afib on pradaxa and
metastatic pancreatic cancer s/p 4 cycles of FOLFIRINOX
chemotherapy and 1 cycle of Gem/Abraxane, currently day 12 of
cycle 1, who presents with a chief complaint of fatigue,
epistaxis and BRBPR. He states that he did have a temp of 101.2
on ___, 4 days ago, which self-resolved. He called his
oncologist about this on ___ and the thought was that it may
have been related to his transfusion. He denies any further
fevers or chills. He reports more fatigue yesterday and on the
day of admission he was sleeping much more. He also reports
blood on the outside of his stool and more bleeding with bowel
movements today. In addition, he had an episode of epistaxis.
The bleeding is what prompted him to come to the ER.
In the emergency department, initial vitals: 100.2 87 95/60 16
100% RA. Blood and urine cultures were obtained. The patient
was given emperic Vanc/Cefepime for febrile neutropenia and
admitted for further workup.
On arrival to the floor, he reports some dryness in his throat
but no sore throat, congestion, nausea, vomiting, diarrhea, or
constipation. He has been straining with bowel movements.
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:
PAST ONCOLOGIC HISTORY:
- ___: Diagnosed with pancreatic adenocarcinoma after
presenting with dark urine and painless jaundice and was noted
to have a bilirubin of 7.
- ___: MRCP demonstrated a 4 x 1.5 cm
hypoenhancing pancreatic mass as well as intra and extrahepatic
biliary in the lower common bile duct with postobstructive
dilatation and stent placed. Cytology demonstrated malignant
cells consistent with adenocarcinoma
- ___: Whipple procedure
- ___ Patient consented for trial ___, was randomized
to SOC adjuvant therapy + vaccine and started treatment
- ___: pt received standard adjuvant treatment
with gemcitabine, ___, followed by gemcitabine (total of 4
cycles)
- ___: MRCP shows multiple hepatic lesions
- ___ - ___: 4 cycles of FOLFIRINOX; dose-reduced due
to pancytopenia
- ___: Gem/Abraxane cycle 1; complicated by thrombocytopenia
- ___: single-agent Abraxane at 20% dose reduction
OTHER PAST MEDICAL HISTORY:
1. Atrial fibrillation status post cardioversion in ___.
2. History of ETOH and abnormal LFTs, liver biopsy in ___
showed Severe panlobular steatosis, large droplet type; mild
steatohepatitis (mild lobular neutrophilia with occasional
apoptotic hepatocytes). Also Stellate cell hyperplasia..
3. Basal cell carcinoma s/p resection ___.
4. Hyperlipidemia.
5. Bronchospasm.
6. Upper respiratory infection.
7. Seborrheic keratosis.
8. Tinea pedis.
9. Radial nerve palsy.
Social History:
___
Family History:
Breast cancer in mid ___, one brother with significant cardiac
disease requiring bypass at age ___. Mother: Died at age ___.
Father: Died at ___ of ___ disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T97.8 BP 115/65 HR 82 RR18 100% RA
GENERAL: alert and oriented, NAD, appears pale and tired
HEENT: No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck
Supple, No LAD.
CARDIAC: irregularly irregular. Normal S1, S2. No m/r/g.
LUNGS: CTA B, good air movement bilaterally.
ABDOMEN: NABS. Soft, non-tender. Distended without clear
ascites.
EXTREMITIES: 2+ peripheral edema with chronic skin changes and
thickening, 2+ dorsalis pedis/ posterior tibial pulses.
NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Preserved
sensation throughout. ___ strength throughout. ___ reflexes,
equal ___. Gait assessment deferred
DISCHARGE PHYSICAL EXAM:
Vitals T98.6 (tmax 99.1) HR 91 BP 118/61 RR18 99%RA
GENERAL: NAD
SKIN: no rashes
HEENT: EOMI, PERRLA, anicteric sclera, MMM
NECK: nontender supple neck, JVD +10 cm
CARDIAC: irregularly, irregular, no murmurs
LUNG: CTAB no wheezes.
ABDOMEN: Distended but soft/NT. +tympanic.
Extremities: ACE wraps in place. 1+ bilateral lower extremity
edema symmetric. 2+ bilateral sacral edema.
NEURO: CN II-XII intact
Pertinent Results:
LABS ON ADMISSION:
___ 05:35PM BLOOD WBC-1.2*# RBC-2.54* Hgb-8.4* Hct-26.5*
MCV-104* MCH-32.9* MCHC-31.5 RDW-15.9* Plt Ct-85*
___ 05:35PM BLOOD Neuts-40* Bands-2 Lymphs-52* Monos-2
Eos-4 Baso-0 ___ Myelos-0
___ 05:35PM BLOOD ___ PTT-53.3* ___
___ 05:35PM BLOOD Glucose-98 UreaN-12 Creat-0.5 Na-136
K-3.7 Cl-108 HCO3-23 AnGap-9
___ 05:35PM BLOOD ALT-14 AST-21 AlkPhos-100 TotBili-1.1
___ 05:35PM BLOOD Albumin-2.5*
LABS ON DISCHARGE:
___ 06:00AM BLOOD WBC-1.8* RBC-2.34* Hgb-7.9* Hct-23.6*
MCV-101* MCH-33.6* MCHC-33.4 RDW-15.5 Plt Ct-97*
___ 06:00AM BLOOD Neuts-33* Bands-1 Lymphs-54* Monos-6
Eos-4 Baso-0 Atyps-2* ___ Myelos-0
___ 06:00AM BLOOD ___ PTT-46.2* ___
___ 06:00AM BLOOD Glucose-79 UreaN-6 Creat-0.5 Na-137 K-3.9
Cl-109* HCO3-23 AnGap-9
___ 05:35PM BLOOD ALT-14 AST-21 AlkPhos-100 TotBili-1.1
___ 06:00AM BLOOD Calcium-7.1* Phos-2.1* Mg-1.9
___ 05:06AM BLOOD Albumin-2.0* Calcium-7.2* Phos-2.3*
Mg-1.8
Meds/Labs/Micro:
RED CELL MORPHOLOGY
Hypochromia NORMAL
Anisocytosis 1+
Poikilocytosis NORMAL
Macrocytes 1+
Microcytes NORMAL
Polychromasia NORMAL
BASIC COAGULATION ___, PTT, PLT, INR)
Platelet Smear VERY LOW
Platelet Count 76* 150 - 440 K/uL
___ 9:26 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
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.
Imaging:
CT A/P ___ enlargement of the largest hepatic
metastasis in the right inferior lobe, currently measuring 4.9 x
4.6 x 6.5 cm compared to 3.5 x 4.2 x 4.2 cm on ___. 2
new hepatic metastases measuring up to 1.2 cm in the right
hepatic lobe. Similar appearance of other scattered hepatic
metastases. Mild increase in perihepatic and left paracolic
gutter free fluid.
CT chest (___): 1. New T6 lytic lesion with focal posterior
cortical disruption, consistent with metastatic disease. If
warranted clinically, MRI of the spine could be obtained for
more
complete assessment. 2. New very small pleural effusions, left
greater than right. 3. Please see separately dictated CT of the
abdomen and pelvis for complete description of subdiaphragmatic
findings.
CXR ___: No acute intrathoracic process. Mild cardiomegaly.
Echo: ___: IMPRESSION: Mild symmetric left ventricular
hypertrophy with normal global and regional biventricular
systolic function. Moderate mitral regurgitation. Mild pulmonary
artery systolic hypertension.
Compared with the prior study (images reviewed) of ___,
mitral severity appears moderate on the current study (though
could be UNDERestimated on both).
Echo: ___:
The left atrium is moderately dilated. The right atrium is
markedly dilated. Left ventricular wall thickness, cavity size,
and global systolic function are normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. An eccentric, posteriorly directed jet of
moderate to severe (3+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. The tricuspid regurgitation jet
is eccentric and may be underestimated. There is mild pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: normal regional and global biventricular systolic
function. Moderate to severe, posteriorly directed, mitral
regurgitation. Moderate, laterally directed tricuspid
regurgitation. At least mild elevation of pulmonary artery
systolic pressure.
Compared with the report of the prior study (images unavailable
for review) of ___, the severity of mitral and tricuspid
regurgitation have increased.
Brief Hospital Course:
Mr. ___ is a ___ year old man with afib on pradaxa and
metastatic pancreatic cancer s/p 4 cycles of FOLFIRINOX
chemotherapy and 1 cycle of Gem/Abraxane, currently day 12 of
cycle 1, who presented with a chief complaint of fatigue,
epistaxis and BRBPR. He did spike a fever ___ of 101.2 (4
days ago prior to admission). His fever had self resolved. He
was experiencing several loose bowel movements. He was treated
with vanc/cefepime x 48 hours. His stool and urine cultures were
negative. His blood cultures were negative on discharge x 48
hours.
In addition, he had significant 3+ bilateral pitting edema. His
BNP was elevated to 1768 and his echo showed worsening 3+ MR and
2+ TR in addition to mild pulmonary artery systolic
hypertension. He was diuresied 20 ml IV x 2 days and was
discharged with 20 mg/day of lasix with labs and PCP appointment
on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 100 mg PO BID
2. Diltiazem Extended-Release 240 mg PO DAILY
3. Dabigatran Etexilate 150 mg PO BID
4. Pantoprazole 40 mg PO Q24H
5. Potassium Chloride (Powder) 20 mEq PO BID
6. Digoxin 0.125 mg PO DAILY
7. Atorvastatin 40 mg PO DAILY
8. Lorazepam 0.5 mg PO Q4H:PRN nausea, anxiety
9. Ondansetron 8 mg PO Q8H:PRN nausea
10. Prochlorperazine 10 mg PO Q6H:PRN nausea
Discharge Medications:
1. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Atenolol 100 mg PO BID
3. Atorvastatin 40 mg PO DAILY
4. Dabigatran Etexilate 150 mg PO BID
5. Digoxin 0.125 mg PO DAILY
6. Diltiazem Extended-Release 240 mg PO DAILY
7. Lorazepam 0.5 mg PO Q4H:PRN nausea, anxiety
8. Ondansetron 8 mg PO Q8H:PRN nausea
9. Pantoprazole 40 mg PO Q24H
10. Potassium Chloride (Powder) 20 mEq PO BID
11. Prochlorperazine 10 mg PO Q6H:PRN nausea
12. Outpatient Lab Work
ICD-9 code 428.30 and 288.00 Please draw CBC with diff and chem
10 on ___. Results faxed to ___ to be followed by
Dr. ___.
Discharge Disposition:
Home
Discharge Diagnosis:
Neutropenic fever
Pancreatic Cancer
Diastolic Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted to the hospital for neutropenic fever. Your
neutrophil count recovered here in the hospital. You remained
afebile. Your stool and urine cultures were negative and nothing
grew in your blood by discharge. You do not need further
antibiotics at this time. If you have any fevers, chills or
other symptoms that concern you please come back to the ED.
In addition, we have started furosemide 20 mg/day. Please
continue to take this medication until you follow-up with Dr.
___ (a colleague of Dr. ___ this ___. Hold your dose if
your blood pressure is <90/60.
Followup Instructions:
___
|
10183551-DS-22 | 10,183,551 | 23,839,683 | DS | 22 | 2145-05-25 00:00:00 | 2145-06-04 05:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
shortness of breath, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of asthma, long-standing GIST on gleevec who
presents with one day of SOB and cough since waking this
morning. The cough is productive of white sputum. She denies
chest pain. She says this "feels like my bronchitis." She says
she caught a draft on ___ at church and always gets
"bronchitis" after this. She has no known sick contacts, but
attends church frequently. She has no fevers/chills. She has no
myalgias. She has good appetite no n/v/d. This morning when she
woke up she was gasping, and coughing, she needed to get some
air and tried to open a window to help her breath. She did not
try her inhaler this morning but came straight to the ED. She
usually does not have trouble sleeping flat.
Of note one month ago she went to ___ for syncopal
feelings and collapse. She said she had tests of her heart done,
including what sounds like and ECHO and a stress test and she
was told that their was no abnormalities. No known cardiac
disease, never a smoker.
In the ED, initial vital signs were 100.6 99 144/75 24 99% .
Patient was given albuterol and ipratropium nebs, prednisone,
azithromycin, and tamiflu.
On the floor, the patient was comfortable. She said her
shortness of breath was much improved.
Past Medical History:
Hypercalcemia
Hypertension
Hyperlipidemia
Gastrointestinal Stromal Tumor
Asthma
Hayfever
Total Abdominal Hysterectomy
Ectopic pregnancy x2
Social History:
___
Family History:
asked and none
Physical Exam:
Admission Physical
==================
Vitals- 99.2 ___ 18 100%RA
General: NAD, well appearing woman
HEENT: wet mucous membranes
Neck: no elevated JVD, scars on neck, no LAD
CV: RRR, ___ SEM at RUSB
Lungs: wheezes bilaterally, no rhonchi, no rales, no increased
work of breathing, no accessory muscle use, no
Abdomen: soft, nontender, nondistended, normoactive BS
GU: no foley
Ext: warm well perfused, no edema
Neuro: CN2-12 intact, upper/lower strength grossly normal
Skin: no rashes
Discharge Physical
===================
Vitals- 99.2 ___ 18 100%RA
General: NAD, well appearing woman
HEENT: wet mucous membranes
Neck: no elevated JVD, scars on neck, no LAD
CV: RRR, ___ SEM at ___
Lungs: wheezes bilaterally, no rhonchi, no rales, no increased
work of breathing, no accessory muscle use, no
Abdomen: soft, nontender, nondistended, normoactive BS
GU: no foley
Ext: warm well perfused, no edema
Neuro: CN2-12 intact, upper/lower strength grossly normal
Skin: no rashes
Pertinent Results:
Admission Labs
================
___ 09:00AM BLOOD WBC-5.7 RBC-4.59 Hgb-12.5 Hct-39.5 MCV-86
MCH-27.3 MCHC-31.7 RDW-13.7 Plt ___
___ 09:00AM BLOOD Neuts-82.2* Lymphs-10.2* Monos-4.3
Eos-3.0 Baso-0.3
___ 09:00AM BLOOD Glucose-140* UreaN-9 Creat-0.7 Na-136
K-5.4* Cl-101 HCO3-23 AnGap-17
___ 09:00AM BLOOD Calcium-10.1 Phos-2.4* Mg-2.0
___ 09:22AM BLOOD Lactate-1.3 K-4.7
Discharge Labs
==============
___ 05:55AM BLOOD WBC-4.2 RBC-4.21 Hgb-11.5* Hct-36.3
MCV-86 MCH-27.3 MCHC-31.7 RDW-13.9 Plt ___
___ 05:55AM BLOOD Glucose-133* UreaN-17 Creat-0.7 Na-142
K-4.6 Cl-108 HCO3-27 AnGap-12
___ 05:55AM BLOOD Calcium-10.4* Phos-2.9 Mg-2.0
Urinalysis
============
___ 09:00AM URINE Color-Straw Appear-Clear Sp ___
___ 09:00AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-TR
___ 09:00AM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE
Epi-<1
Microbiology
============
___ 9:00 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 9:00 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 11:30 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Imaging
==========
Chest Xray ___
IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
___ with history of asthma who presents with two days of
shortness of breath and found to be febrile in the ED likely a
viral infection causing an asthma exacerbation.
# Shortness of breath - Patient initially presented very short
of breath in the ED. Her chest xray was unremarkable for a
pneumonia. She had no pain and no concerning EKG abnormalities.
She had no physical exam findings consistent with heart failure.
She was initially very wheezy on exam, but this improved
initially with nebulizers and then inhalers. Her initial peak
flow was 150-170, but on discharge her peak flow was 220-240. It
is unclear what her baseline was. However, she was satting
appropriately on room air, and she had ambulatory sats >96%. She
was sent with a spacer, and was given a five day steroid burst
for her presumed asthma exacerbation.
# Fever - Unknown etiology. Her chest xray was inconsistent with
pneumonia. Her flu swab returned as a contaminated specimen. She
was having no myalgias, and had no other documented fever
besides the one in the ED. Her UA was negative, with a negative
urine culture. Her blood cultures were negative. She was
initially on tamiflu but this was discontinued due to low
suspicion that she had the flu.
# GIST - Per outpatient heme/onc notes patient stabilized for
years on gleevec. Her gleevec was held during her stay.
# Hypertension - Her blood pressure was well controlled on her
home dose of lisinopril and amlodipine.
# Hypothyroid - She appeared euthyroid and continued her home
dose of synthroid.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. IMatinib Mesylate 400 mg PO DAILY
3. Fluticasone Propionate 110mcg 1 PUFF IH BID
4. Amlodipine 10 mg PO DAILY
5. Ranitidine 150 mg PO DAILY:PRN for heartburn
6. Pravastatin 20 mg PO DAILY
7. Albuterol Inhaler 2 PUFF IH Q6H:PRN asthma, sob
8. Levothyroxine Sodium 75 mcg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Fluticasone Propionate 110mcg 1 PUFF IH BID
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Ranitidine 150 mg PO DAILY:PRN for heartburn
6. Albuterol Inhaler 2 PUFF IH Q6H:PRN asthma, sob
7. IMatinib Mesylate 400 mg PO DAILY
8. Pravastatin 20 mg PO DAILY
9. PredniSONE 40 mg PO DAILY Duration: 5 Days
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*6 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Viral URI with reactive airway exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted for trouble breathing, you were found to be
very wheezy on your exam. You most likely had a viral infection
that caused your breathing to get worse. You were given
breathing treatments and your wheezing got better. You received
treatment for flu in case you had the flu. We will ask you to
continue taking your home breathing treatments.
Followup Instructions:
___
|
10183775-DS-9 | 10,183,775 | 23,475,081 | DS | 9 | 2155-07-30 00:00:00 | 2155-07-31 21:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Beta-Blockers (Beta-Adrenergic Blocking Agts) / gabapentin
Attending: ___.
Chief Complaint:
Need for peritoneal dialysis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is an ___ yo M with AF on warfarin, CAD s/p CAB, ESRD
on peritoneal dialysis, polyneuropathy, and other medical issues
transferred from ___ for peritoneal dialysis and
recent intraventricular hemorrhage ___ fall.
.
Patient states frequent falls, every other week since back
surgery in ___. He reports a fall about 10 days ago and caused
posterior scalp laceration s/p stapling. His INR was not
checked and he had not had Coumadin dose changed for the past
several months. He states taking warfarin 4 mg daily except for
___ when he takes 7 mg. About 4 days prior to admission,
staples were removed, but has been oozing. He noticed that his
pillow was stained with blood, so he went to ___ to
get suture where his INR was found to be 9.2 and 10 point Hct
drop compared to about 1 week prior. Per report, he received
FFP and vitamin K there. However, since ___ does not do PD
and his wife has not been able to help him with it due to recent
hospitalization (d/c'ed home yesterday), he is transferred to
___.
.
In the ED, initial VS were: 98.4 60 139/60 16 98% 2L Nasal
Cannula. Guaiac negative. He received 1 unit of pRBC, 10 mg IV
vitamin K, and about 500 cc NS. Labs were drawn right after the
___ with Hct 22 and INR of 2.2. CT head showed a small left
intraventricular bleed in the posterior horn. Neurosurgery felt
that patient did not require any surgical intervention. Per ED,
neurology thought patient was stable. Renal was contacted and
felt that he could get PD tomorrow. Has 18G x2 IV on the right
arm. VS upon transfer were 98.2, 77, 140/63, 18, 95% RA.
.
On arrival to the MICU, currently feeling well. He states that
he falls at least once but no more than 5 times a month. He
thinks it is a balance problem, but would lose consciousness and
find himself on the ground. He denies prodrome or post-ictal
symptoms.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes. He denies tingling, numbness, diplopia.
Past Medical History:
- CAD s/p CABG
- Afib on Coumadin
- HTN
- HLD
- ESRD on peritoneal dialysis
- Chronic LBP s/p discectomy in ___
- Chronic anemia
- h/o strokes
- BPH s/p TURP
- psoriasis
- carotid stenosis, most recent carotid ultrasound in ___
- h/o GIB
- T2DM
- anxiety
Social History:
___
Family History:
No premature CAD, brother and sister with DM.
DM in aunt, sisters, and brother
Physical ___:
ADMISSION PHYSICAL EXAM:
Vitals: T98.8 HR 76, BP 132/51, RR 21, O2Sat 94% RA
General: Alert, oriented, no acute distress
HEENT: + hematoma in the posterior occipital scalp, s/p suture,
sclera anicteric, PERRLA, MMM, OP clear
Neck: supple, JVP not elevated, no LAD, + carotid bruits L>R
CV: irregularly irregular, normal S1 and S2, no m/r/g
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, dialysis line in place, area clean without
erythema or drainage
GU: no foley
Ext: warm, well perfused, 1+ pulses, no edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
diminished sensation to light touch in the left foot, gait
deferred
.
Pertinent Results:
ADMISSION LABS:
___ 08:45PM BLOOD WBC-9.2 RBC-2.32*# Hgb-7.3*# Hct-22.5*#
MCV-97# MCH-31.2# MCHC-32.2 RDW-14.3 Plt ___
___ 08:45PM BLOOD Neuts-75.0* Lymphs-16.0* Monos-4.7
Eos-4.1* Baso-0.2
___ 08:45PM BLOOD ___ PTT-31.6 ___
___ 08:45PM BLOOD Glucose-192* UreaN-52* Creat-5.4*# Na-144
K-3.7 Cl-100 HCO3-33* AnGap-15
___ 06:25AM BLOOD Calcium-8.0* Phos-3.6 Mg-1.8
___ 11:38AM BLOOD Type-ART pO2-81* pCO2-46* pH-7.48*
calTCO2-35* Base XS-9 Intubat-NOT INTUBA
.
IMAGING:
___ CT HEAD: FINDINGS: A small amount of intraventricular
hemorrhage layers posteriorly in the occipital horn of the left
lateral ventricle. No additional intra- or extra-axial
hemorrhage is identified. Ventricular dilatation is unchanged
since ___, with prominence of the sulci, likely due to atrophy.
Focal hypodensities in the right thalamus and left lentiform
nucleus are unchanged since ___, and likely reflect lacunes.
Confluent periventricular and subcortical white matter
hypoattenuation is compatible with the sequela of chronic
microvascular infarction. A large posterior parietal subgaleal
hematoma is present. No fractures are seen. Visualized paranasal
sinuses and mastoid air cells are well aerated. Calcification of
the cavernous carotid arteries is present.
IMPRESSION: Small amount of intraventricular hemorrhage in the
occipital horn of left lateral ventricle. Large posterior
parietal subgaleal hematoma.
.
___ CXR: IMPRESSION:
1. Status post median sternotomy for CABG with stable cardiac
enlargement and calcification of the aorta consistent with
atherosclerosis. Relatively lower lung volumes with no focal
airspace consolidation appreciated. Crowding of the pulmonary
vasculature with possible minimal perihilar edema, but no overt
pulmonary edema. No pleural effusions or pneumothoraces.
Brief Hospital Course:
Mr. ___ is an ___ year old male with end-stage renal disease
(ESRD) on peritoneal dialysis (PD), atrial fibrillation (AFib)
on warfarin, coronary artery disease (CAD) status post bypass
surgery who presented with intraventricular bleed transferred to
MICU for neurological monitoring.
.
ACTIVE ISSUES BY PROBLEM:
# Intraventricular bleed was secondary to recent fall in the
setting of being on warfarin and with supratherapeutic INR.
Based on CT head without contrast. ___ have some mild sensation
deficit in the ___ L>R, could be chronic given underlying
diabetes. Currently asymptomatic and stable from
intraventicular bleed. He did recieve one unit packed RBCs
before transfer and his hematocrit was maintained above 25. His
warfarin was held and he was given vitamin K which brought his
INR to therapeutic levels quickly. Neurosurgery was consulted
and they recommended that he be closely monitored.
He was discharged with instructions to continue antiepileptic,
dilantin x 10days and to follow up with ___ clinic in
___ weeks with repeat head imaging. Given multiple falls, would
not recommend restarting anticoagulation.
.
# Anemia: Likely chronic in nature with acute intraventricular
bleed as mentioned above. Recieved one unit packed RBCs and
warfarin was held.
.
# Falls/Syncope: Based on history, concerning for cardiogenic
arrhythmia given no prodrome with drop attacks in the setting of
underlying CAD requiring CABG. Also could be due to gait
instability from peripheral neuropathy from T2DM. Also, patient
had history of CVA and has carotid stenosis, although symptoms
unlikely from TIA. Monitored on tele with no significant
arrhythmias. ___ saw patient and felt that he could safely be
discharged home with services.
.
# ESRD on PD: Creatinine at 5.4. No significant electrolyte
derangement at this time. He did continue on PD while an
inpatient. Continued renal cap and calcitriol. He gets epo
20,000 unit every other week. Followed by Dr. ___,
___, ___ as an outpatient
.
# Chronic AF: High risk for bleed given frequency of
falls/syncopes; however, with CHADS 5 is also at high risk of
stroke. Given ICH, warfarin was stopped and coagulopathy was
aggressively reversed in the ED. At time of discharge, INR was
1.0. Decision whether to resume anticoagulation was deferred to
cardiologist but is strongly not recommended given frequent
falls. at this time.
.
# CAD s/p CABG/HTN/HLD (hypertension and hyperlipidemia):
Continued home Diovan, isosorbide, furosemide, amlodipine.
Would recommend switching simvastatin to atorvastatin 40 mg
given higher risk of rhabdo with simvastatin on amlodipine.
.
# Diabetes mellitus type 2 (T2DM): On insulin, continued home
regimen.
.
# Anxiety: continued citalopram 20 mg as at home
.
TRANSITONAL ISSUES:
ICH: antiepileptic x 10 days, follow up with head imaging in
___ clinic in ___ weeks
afib: stopped coumadin given recent ICH, will need to discuss
possible initiation of antiplatelts
Medications on Admission:
- Diovan 160 mg BID
- isosorbid 30 mg daily
- furosemide 40 mg BID
- simvastatin 80 mg daily
- amlodipine 10 mg daily
- calcitriol 0.25 every other day
- renal cap daily
- folic acid daily
- B6 100 mg daily
- vitamin D 1000 IU daily
- 20 mg citalopram
- ISS with Humalog
- 12 units of Lantus qHS
- tums 1 TID
- Epo 20,000 unit every other week
- Ferrex without food daily
- warfarin 4 mg every day except ___, 6 mg on ___
Discharge Medications:
1. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
3. valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
6. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. pyridoxine 50 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. insulin aspart 100 unit/mL Solution Sig: per sliding scale
Subcutaneous per sliding scale.
13. phenytoin 125 mg/5 mL Suspension Sig: One (1) PO Q8H (every
8 hours) for 9 days.
Disp:*27 tablets* Refills:*0*
14. Lantus 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous at bedtime.
15. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
16. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
intraventricular hemorrhage
supratherapeutic INR
mechanical fall
Secondary Diagnosis:
atrial fibrillation
end stage renal disease on peritoneal dialysis
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 a fall with blood in
your brain. You were seen by the neurosurgeons, your coumadin
was stopped and you were given products to reverse your blood
thinning. The bleeding in your head stopped but you will need
to take medications to prevent seizure for the next 9 days. You
will also need to follow up with the neurosurgery team with a
repeat CT scan of your head in the next 4 -6 weeks.
Please make the following changes to your medication regimen:
STOP coumadin. Do NOT restart this medication. Talk to your
cardiologist about other options, like aspirin, for your atrial
fibrillation
START dilantin 100mg three times daily for the next 9 days (end
date ___
Please take all of your other medications as previously
prescribed
Followup Instructions:
___
|
10184005-DS-21 | 10,184,005 | 21,449,438 | DS | 21 | 2144-03-15 00:00:00 | 2144-03-19 14:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
perforated sigmoid diverticulitis
Major Surgical or Invasive Procedure:
exploratory laparotomy, sigmoid colectomy, ___ procedure
History of Present Illness:
___ presents from ___ with perforated
diverticulitis. He underwent screening colonoscopy one month
previously which noted sigmoid diverticulosis and one polyp.
Following this, he had diverticulitis treated with a two week
course of cipro/flagyl with symptomatic relief. He presented
again on ___ of this week with continued left lower quadrant
pain. Of note, he was also in the process of completing a pulse
dose of steroids for interstitial lung disease. He was admitted
to ___ for IV antibiotics. He continued to
experience pain without relief and repeat CT scan ___
demonstrated perforated sigmoid diverticulitis. He left AMA and
presents to the ___ ED. In the ED he is febrile to 101 and in
obvious
discomfort but hemodynamically stable.
Past Medical History:
Interstitial lung disease
Paroxsymal Atrial fibrillation
Social History:
___
Family History:
Mother diverticulitis, CAD, DM
Father diverticulitis
Physical ___:
Admission Physical Exam:
Vitals: Temp 101.7 HR 63 BP 121/63 RR18 94% 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, diffusely tender, rebound and guarding
left lower quadrant, peritoneal
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
97.7 78 105/61 18 96% RA
General: No acute distress, alert, oriented
Heart: Regular rate and rhythm
Lungs: Clear to auscultation bilaterally
Abdomen: soft, nontender, nondistended, with midline incision
open to air, clean, dry, and intact, ostomy bag in place, with
brown stool
Extremities: no clubbing, cyanosis, or edema
Pertinent Results:
___ 11:00PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 11:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-80 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 11:00PM URINE RBC-0 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 11:00PM URINE MUCOUS-RARE
___ 08:37PM LACTATE-0.9
___ 08:28PM GLUCOSE-108* UREA N-4* CREAT-0.8 SODIUM-138
POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-29 ANION GAP-14
___ 08:28PM estGFR-Using this
___ 08:28PM ALT(SGPT)-12 AST(SGOT)-24 ALK PHOS-45 TOT
BILI-0.6
___ 08:28PM ALBUMIN-3.4*
___ 08:28PM WBC-8.2 RBC-4.19* HGB-11.6* HCT-34.6* MCV-83
MCH-27.8 MCHC-33.6 RDW-13.0
___ 08:28PM NEUTS-87.7* LYMPHS-8.0* MONOS-3.0 EOS-1.2
BASOS-0.1
___ 08:28PM PLT COUNT-259
___ 08:28PM ___ PTT-31.9 ___
DIAGNOSIS:
Colon, sigmoid, colectomy (A-L):
1. Segment of colon with diverticular disease, associated
peridiverticular inflammation, mesenteric fibrosis, and abscess
formation consistent with previously ruptured diverticula.
2. Three unremarkable lymph nodes.
Clinical: Specimen submitted: Sigmoid colon. Clinical
diagnosis: Perforated diverticulitis.
Gross: The specimen is received fresh in a container labeled
with the patient's name, ___, the medical record
number, and "sigmoid colon". It consists of a segment of colon
that measures 21 cm x 19 x 2.8 cm overall. The colonic segment
measures 21 cm in length x 4.8 cm in diameter and there is a
portion of attached mesenteric fat that measures 21 cm x 5 x 2.8
cm. The segment is unoriented but there is a staple line (#1) at
one end that measures 4 cm and a staple line (#2) at the
opposite end that measures 4 cm as well. The mesentery is
erythematous and focally hemorrhagic with areas of gray/white
fibrinous material overlying its surface that measure 4 x 4 cm
that are 15 cm from staple line 1 and 4 cm from staple line 2.
The specimen is opened along the antimesenteric surface to
reveal pink-tan mucosa and the specimen is serially sectioned to
reveal several diverticula with normal intervening mucosal
folds. No overt perforation is identified. The specimen is
represented as follows: A= staple line 1, B = staple line 2,
C-F = representative sections of diverticula, G = representative
sections of uninvolved colon, H-L = mesenteric fat containing
potential lymph nodes.
CT of the abdomen and pelvis from ___ provided for
___
reading.
COMPARISON: Reference CT abdomen and pelvis from ___
FINDINGS: There is fibrosis at the bases of the bilateral lungs
concerning for
interstitial lung disease. The visualized heart and pericardium
are
unremarkable.
CT abdomen: There are locules of perihepatic free air. The
liver enhances
homogeneously without focal lesions or intrahepatic biliary
dilatation. The
gallbladder is unremarkable and the portal vein is patent. The
pancreas,
spleen and adrenal glands are unremarkable. The kidneys present
symmetric
nephrograms and excretion of contrast with no pelvicaliceal
dilation or
perinephric abnormalities.
The stomach, duodenum and small bowel are unremarkable. There
is a segment of
colonic wall thickening in the transverse colon. There is
thickening of the
sigmoid colon with surrounding fat stranding and a perisigmoid
fluid
collection measuring 4.3 x 2.3 x 2.7 cm, likely representing an
abscess from a
contained perforation. The fat plane is visualized between the
fluid
collection in the bladder, so there is no obvious fistula at
this time. The
appendix is visualized and there is no evidence of appendicitis.
The
intraabdominal vasculature is unremarkable with no evidence of
thrombophlebitis. There is no mesenteric or retroperitoneal
lymph node
enlargement by CT size criteria. There is a small fat
containing umbilical
hernia.
CT pelvis: The urinary bladder is unremarkable. There are
locules of free
air within the pelvis. The prostate is normal in size. There
is no inguinal
or pelvic wall lymphadenopathy.
Osseous structures: No lytic or sclerotic lesions suspicious
for malignancy
is present.
IMPRESSION:
1. Complicated diverticulitis with perisigmoid fluid collection
and free air
within the pelvis and upper abdomen.
2. Focal thickening of the transverse colon. Colonoscopy is
recommended
following treatment to rule out underlying mass.
2. Bibasilar pulmonary fibrosis is concerning for interstitial
lung disease.
Recommend non-emergent dedicated high-resolution CT scan of the
chest for
further evaluation if not already done elsewhere.
Brief Hospital Course:
___ was admitted on ___ under the acute care
surgery service for management of his perforated diverticulitis.
He was taken to the operating room and underwent an exploratory
laparotomy, sigmoid colectomy, and ___ procedure. Please
see operative report for details of this procedure. He tolerated
the procedure well and was extubated upon completion. He we
subsequently taken to the PACU for recovery.
He was transferred to the floor hemodynamically stable. His
vital signs were routinely monitored and he remained afebrile
and hemodynamically stable. He was initially given IV fluids
postoperatively, which were discontinued when he was tolerating
PO's. His diet was advanced on the morning of ___ to
regular, which he tolerated without abdominal pain, nausea, or
vomiting. He was voiding adequate amounts of urine without
difficulty. He was encouraged to mobilize out of bed and
ambulate as tolerated, which he was able to do independently.
His pain level was routinely assessed and well controlled at
discharge with an oral regimen as needed. The patient was
provided ostomy teaching while inpatient. Patient will need
visiting nursing to assist with ostomy needs following
discharge. On ___, he was discharged home with instructions
to schedule follow up in ___ clinic within the next two weeks.
Medications on Admission:
prednisone taper completed, metoprolol 50", aspirin 81', MVI
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*24 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
3. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone 2 mg 1 to 2 tablet(s) by mouth every three
hours Disp #*40 Tablet Refills:*0
4. Metoprolol Tartrate 50 mg PO BID
5. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*36 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
perforated diverticulitis, now status post exploratory
laparotomy, sigmoid colectomy, and ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
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.
*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.
Monitoring Ostomy output/Prevention of Dehydration:
*Keep well hydrated.
*Replace fluid loss from ostomy daily.
*Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
*Try to maintain ostomy output between 1000mL to 1500mL per day.
*If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with
each episode of loose stool. Do not exceed 16mg/24 hours.
Followup Instructions:
___
|
10184327-DS-26 | 10,184,327 | 21,280,059 | DS | 26 | 2137-01-14 00:00:00 | 2137-01-18 23:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Generalized weakness, Left Leg Pain
Major Surgical or Invasive Procedure:
___: Transesophageal Echocardiogram
___: Temporary dialysis line placement - left
___: Tunnelled dialysis line - left
___: placement of ___ pacemaker 2240
History of Present Illness:
Mr. ___ is an ___ year old male with PMH notable for ___ V,
HCM s/p septal ablation and ICD, ESRD on HD (initiated recent
admission ___, HTN, HLD, T2DM, and enterococcal bacteremia
with L psoas abscess s/p drainage, spinal osteomyelitis, and
pacer lead vegetation (___) now on chronic amoxicillin who
presents with generalized weaness and fever.
Patient and his wife report that he was weaker than normal
yesterday evening after dialysis. At that time, pt. was using
the bathroom and was unable to helped off the toilet seat,
causing his wife to call ___ who sent them to the ED for further
evaluation. At triage he was noted to have a temp of ___. He
had not previously noted fevers, subjective or objective, and
had his temperature taken several times at HD that AM.
He has a chronic cough that his wife states sounds productive,
but he rarely produces any phlegm. This is old and unchanged,
although hard to get specific details about how long it has been
going on and if it always sounds productive.
At this time, Mr. ___ denies chills, chest pain, shortness
of breath, sputum production, abdominal pain, diarrhea, urinary
symptoms or headaches. He still produces urine and urinates on
a daily basis.
No known sick contacts. Wife reports one bout of suspected
aspiration pneumonia last year.
Vitals in the ED: ___ 16 98% RA
Labs notable for: WBC 13, H/H 9.___.7, Creatinine 3.3, BUN 27,
glucose 323, protein +, glucose +, flu negative, lactate 1.6,
Patient given: Levofloxacin 750mg x1, acetaminophen 1G x1
Vitals prior to transfer: 98.1 71 117/53 16 98% RA
On the floor, he has no complaints.
Review of Systems:
(+) per HPI
(-) 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. v
Past Medical History:
- ___, stage V with mature RUE avf placed ___, HD initiated
___. wife reports ___ due to gentamycin use for bacteremia.
- Hypertrophic cardiomyopathy with two septal ablations in ___
and ___, s/p ICD, c/b line infection and endocarditis (see
below)
- Enterococcal bacteremia with L psoas abscess s/p drainage,
spinal osteomyelitis, and pacer lead vegetation (___) -
treated with ampicillin / gentamicin, then transitioned to
chronic amoxicillin for antibiotic suppression
- h/o Pseudomonas bacteremia due to cholecystitis ___
- ___ disease
- DM2 c/b peripheral neuropathy on insulin
- Hypertension
- Hyperlipidemia
- GERD
- Hyperparathyroidism
- Osteoporosis
- Thyroid nodule
- Osteoporosis s/p bisphosphonate therapy
- BPH
- Actinic keratoses, seborrheic keratoses, and lentigines
- H/o nephrolithiasis
PAST SURGICAL HISTORY
- R radiocephalic AVF
- Ligation of L forearm AV fistula
- L radiocephalic AVF
- Cataract surgery
- Septal ablation
Social History:
___
Family History:
Father with DM2 died from MI in ___. Son and daughter both with
HOCM.
Physical Exam:
ADMISSION PHYSICAL EXAM
==============================
Vitals - T: 98.3 BP:154/73 HR:85 RR:18 02 sat: 100% on RA
GENERAL: NAD, resting in bed with eyes closed. Awakens to voice.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM. Notable for masked facies and assymmetric smile.
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, ___ systolic murmur best heard at ___ with
radiation into neck consistent with AS; no gallops or rubs. Left
sided ICD without erythema, tenderness.
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles. Large lipoma noted on right
upper back.
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: Right forearm fistula with bandange in place. Bruit
and palpable thrill present. No erythema or tenderness on
overlying skin around bandage, dressing is CDI. no cyanosis,
clubbing, moving all 4 extremities with symmetric mild erythema
around ankles.
PULSES: 2+ DP pulses bilaterally
NEURO: EOMI, PERRLA, tongue protrusion midline. Smile assymetric
with left lower facial droop. Eyebrows rise symmetrically.
SCM/trap ___. Distal and proximal extremity strength 4+/5
throughout. Alert and oriented x 3. Responds with short phrases
___ word sentences).
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
==============================
Physical Exam:
VS: 98.3/97.7 HR ___ RR 16 BP ___ O2 sat 99% RA
Weight: bed scale <-97.8kg<-98.6
I/O's:
24h: 900/600
8h: 100/400
BM
___: ___
Tele: V paced
Neuro: Alert and oriented x 3
CV: RRR, systolic ejection murmur heard best over RUSB, no
gallops. right sided pacemaker without bruising or hematoma.
Left sided tunnulled catheter with some local bleeding around
site.
RSP: clear bilat
GI: ABD soft, NT ND +BS.
GU: foley draining yellow urine.
VASC: mild ankle edema only, feet warm.
Labs: see below
Pertinent Results:
ADMISSION LABS
___ 11:35PM BLOOD WBC-13.0*# RBC-3.35*# Hgb-9.4*#
Hct-29.7*# MCV-89 MCH-28.1 MCHC-31.7 RDW-16.3* Plt ___
___ 11:35PM BLOOD Neuts-91.3* Lymphs-5.1* Monos-2.5 Eos-0.7
Baso-0.2
___ 11:35PM BLOOD Glucose-323* UreaN-27* Creat-3.3* Na-138
K-4.5 Cl-101 HCO3-24 AnGap-18
___ 10:40AM BLOOD Calcium-9.1 Phos-3.1 Mg-1.8
___ 11:33PM BLOOD Lactate-1.6
PERTINENT LABS
___ 12:00PM BLOOD ___ PTT-30.6 ___
___ 04:40AM BLOOD ALT-2 AST-15 AlkPhos-147* TotBili-0.3
___ 07:26AM BLOOD CRP-146.0*
___ 05:35PM BLOOD SED RATE-43
DISCHARGE LABS
___ 05:56AM BLOOD WBC-9.4 RBC-3.14* Hgb-8.6* Hct-28.6*
MCV-91 MCH-27.3 MCHC-30.0* RDW-17.0* Plt ___
___ 05:56AM BLOOD Glucose-360* UreaN-35* Creat-4.6* Na-134
K-4.3 Cl-96 HCO3-29 AnGap-13
___ 05:56AM BLOOD Calcium-9.2 Phos-3.3 Mg-2.0
___ 05:56AM BLOOD Vanco-24.2*
MICROBIOLOGY
Nasopharyngeal Flu PCR - Negative
___ 11:20 pm BLOOD CULTURE
Blood Culture, Routine (Final ___:
ENTEROCOCCUS FAECALIS.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___-
___, ___.
Aerobic Bottle Gram Stain (Final ___:
THIS IS A CORRECTED REPORT 1135AM, ___.
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
PREVIOUSLY REPORTED UNDER ANAEROBIC BOTTLE GRAM STAIN (ON
___ AT
2230).
___ 12:23 am BLOOD CULTURE
Blood Culture, Routine (Final ___:
ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES.
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
gentamicin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details.
HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to
1000mcg/ml of
streptomycin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details..
Sensitivity testing performed by Sensititre.
Daptomycin 1
MCG/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECALIS
|
AMPICILLIN------------ =>16 R
DAPTOMYCIN------------ S
PENICILLIN G---------- =>16 R
VANCOMYCIN------------ <=1 S
___ 7:10 pm BLOOD CULTURE
Blood Culture, Routine (Final ___:
ENTEROCOCCUS FAECALIS.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___-
___, ___.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI.
IN CLUSTERS.
___ 8:09 am BLOOD CULTURE
Blood Culture, Routine (Final ___: NO GROWTH.
___ 5:35 pm BLOOD CULTURE
Blood Culture, Routine (Final ___: NO GROWTH.
___ 5:35 pm BLOOD CULTURE
Blood Culture, Routine (Final ___: NO GROWTH.
___ 6:35 am URINE Source: ___.
URINE CULTURE (Final ___: NO GROWTH.
___ 4:40 am BLOOD CULTURE
Blood Culture, Routine (Final ___: NO GROWTH.
___ 11:06 am BLOOD CULTURE
Blood Culture, Routine (Final ___: NO GROWTH.
___ 11:06 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Final ___: NO GROWTH.
___ 6:55 am BLOOD CULTURE
Blood Culture, Routine (Final ___: NO GROWTH.
___ 6:26 am BLOOD CULTURE Source: Line-dialysis.
Blood Culture, Routine (Final ___: NO GROWTH.
___ 6:02 am BLOOD CULTURE Source: Line-dialysis X 1.
Blood Culture, Routine (Final ___: NO GROWTH.
___ 6:14 am MRSA SCREEN Source: Nasal swab.
MRSA SCREEN (Final ___: No MRSA isolated.
___ 9:00 pm URINE Source: Catheter.
URINE CULTURE (Final ___: NO GROWTH.
CARDIOLOGY
Cardiovascular ReportECGStudy Date of ___ 11:49:28 ___
A wide copmlex paced rhythm is present with ventricular response
rate of 104. It is hard to ascertain atrial pacemaker spikes but
they are most prominent may be in lead aVL. This looks like an
atrial tachycardia with ventricular sensed mechanism.
IntervalsAxes
___
___
___ - TTE
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy (somewhat more prominent basal septal
hypertrophy) with normal cavity size and regional/global
systolic function (LVEF>55%). There is a mild resting left
ventricular outflow tract obstruction (25 mmHg). 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 aortic valve leaflets are
moderately thickened. There is mild aortic valve stenosis (valve
area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are moderately thickened. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Symmetric LVH with vigorous biventricular systolic
function. Mild LVOT obstruction. Mild aortic stenosis. Mild
aortic regurgitation. Mild mitral regurgitation. Moderate
pulmonary hypertension. Compared with the prior study (images
reviewed) of ___, the findings are similar.
___ - TEE
No thrombus/mass is seen in the body of the left atrium. A small
mobile echodensities associated with a pacing wire is seen in
the the body of the right atrium, near the tricuspid valve, and
in the right ventricle. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the descending thoracic aorta. There are three aortic valve
leaflets. The aortic valve leaflets are moderately thickened. No
masses or vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve.
Mild (1+) mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of tricuspid regurgitation may be
significantly UNDERestimated.] There is no pericardial effusion.
IMPRESSION: Small mobile echodensities as described above c/w
endocarditis. Normal biventricular systolic function. Mild
mitral regurgitation. At least mild-to-moderate tricuspid
regurgitation. Compared with the prior study (images reviewed)
of ___, the echodensities near the tricuspid valve and in
the right ventricle are new and the tricuspid regurgitation is
now worse.
ECG Study Date of ___ 12:30:18 ___
Baseline artifact is present. Ventricularly paced rhythm, rate
60, most likely underlying atrial fibrillation. Compared to the
previous tracing of ___ the morphology of the paced rhythm
has changed. TRACING #1
ECG Study Date of ___ 9:49:30 AM
Atrial sensed, ventricular paced rhythm. Compared to tracing #1
P waves are now apparent with prolonged A-V conduction. TRACING
#2
Intervals Axes
Rate PR QRS QT/QTc P QRS T
60 0 ___ 0 -66 83
ECG Study Date of ___ 7:59:20 AM
Atrial fibrillation with left bundle-branch block. Compared to
the previous tracing of ___ the left bundle-branch block and
atrial fibrillation seems to have replaced a native atrial
rhythm and paced rhythm.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
69 0 ___ 0 -2 151
RADIOLOGY
CT LOWER EXT W/C LEFT Study Date of ___ 12:49 AM
FINDINGS:
There is no evidence of fracture. Diffuse demineralization
noted. There are mild degenerative changes of the left hip.
Mild degenerative changes are also noted about the knee with
subchondral cystic changes and medial joint space narrowing.
There is a small knee joint effusion.
A lytic lesion within the anterior femoral head is unchanged
from ___ as is a mildly sclerotic lesion within the posterior
acetabulum. There is no evidence of abscess. There is mild
nonspecific soft tissue stranding involving the medial and
lateral thigh. Limited views of the vessels
demonstrate atherosclerotic disease with both calcified and
noncalcified
thrombus within the popliteal artery. The muscles are within
normal limits for the patient's age.
IMPRESSION:
1. No drainable fluid collection.
2. No evidence of fracture.
3. Atherosclerotic disease within the left lower extremity
arterial vessels.
CHEST (PA & LAT) Study Date of ___ 1:00 AM
FINDINGS:
Transvenous pacing leads ending in the right atrium and right
ventricle. Mild cardiomegaly is unchanged. There is no pleural
effusion or pneumothorax. There is increased opacification
posteriorly on the lateral view corresponding to the left
basilar opacity. Additionally, interstitial markings are mildly
increased from prior.
IMPRESSION:
Left lower lobe pneumonia.
___ - CT L-Spine with contrast
FINDINGS:
Scoliosis and straightening of lumbar spine. There is scoliosis
of the lumbar spine convex to the right at L3-4. Again seen are
multilevel, multifactorial degenerative changes of the lumbar
spine with partial fusion of L3-4 and severe disc space
narrowing at L2-3 and L4-5. Large osteophytes are seen
throughout the lumbar spine. There is cortical irregularity at
the endplates L4-5 and at L5-S1. Multilevel, multifactorial
degenerative changes are noted, with disk bulge, posterior
osteophytes, facet degenerative changes and mild ligamentum
flavum thickening causing mild canal and mild to moderate
foraminal and lateral recess narrowing from L2-3 to L5-S1
levels. Limited assessment of intra canalicular/intrathecal
details on CT. No acute fractures or suspicious osseous lesions.
No surrounding fluid collections. There is no evidence of psoas
abscess. Partially visualized left pleural effusion. Renal cysts
and marked vascular calcifications.
IMPRESSION:
Multilevel, multifactorial degenerative changes of the lumbar
spine, significantly worsened compared to ___ with mild
canal, mild to
moderate foraminal and lateral recess narrowing. Irregularity of
the endplates of L4-5 and L5-S1 with surrounding fat stranding,
this is likely the result of severe degenerative changes however
cannot entirely rule out discitis/osteomyelitis at these levels
though less likely. No fluid collection or suggestion of abscess
on non-contrast study. Correlate clinically to decide on the
need for further workup or followup.
Partially visualized left pleural effusion. Renal cysts and
marked vascular calcifications.
HIP UNILAT MIN 2 VIEWS RIGHT Study Date of ___ 4:35 ___
IMPRESSION:
Severe right hip joint degenerative change, but no evidence of
bone
destruction. Septic arthritis is not excluded by this study.
CHEST (PORTABLE AP) Study Date of ___ 11:17 AM
IMPRESSION:
In comparison with the study of ___, the dual-channel
pacer device is been removed and replaced with a right IJ
single-lead device that extends to the region of the apex of the
right ventricle. There is increasing opacification at the left
base with poor definition of the hemidiaphragm. This could well
reflect volume loss in the lower lobe and pleural effusion,
though in the appropriate clinical setting superimposed
pneumonia would have to be considered.
CHEST (PORTABLE AP) Study Date of ___ 4:32 ___
IMPRESSION:
1. Left lower lobe collapse and/or consolidation, probably
slightly worse.
2. Vascular plethora, suggestive of CHF, but likely accentuated
by low lung volumes.
CHEST (PORTABLE AP) Study Date of ___ 9:06 AM
IMPRESSION:
1. Left lower lobe collapse and/or consolidation, essentially
unchanged.
2. Interval improvement CHF findings. Mild residual vascular
plethora present.
UNILAT UP EXT VEINS US RIGHT Study Date of ___ 11:50 AM
IMPRESSION:
Widely patent right upper extremity AV fistula without evidence
of thrombus.
CHEST (PA & LAT) Study Date of ___ 12:17 ___
IMPRESSION:
1. Partial interval clearing of retrocardiac density. No new
focal infiltrate identified.
2. Poor visualization of a portion of the tracheal air column.
Question
artifact. Clinical correlation requested.
AV FISTULOGRAM SCH (___):
FINDINGS:
1. Very small proximal outflow vein with findings of poor
maturation. The
outflow vein was also noted to bifurcate at its midportion.
2. Focal thrombosis and extravasation of the distal radial
artery.
Extravasation controlled with stent graft placement.
3. Preservation of flow to the right hand demonstrated by
filling of the
palmar arch via the ulnar artery.
IMPRESSION:
Non-usable right upper extremity AV fistula despite aggressive
attempts to establish good flow. The procedure was complicated
by distal radial artery thrombosis and rupture requiring stent
graft placement. Hand perfusion was maintained via an intact
ulnar artery.
VENOUS DUP UPPER EXT BILATERAL Study Date of ___ 1:58 ___
IMPRESSION:
Intraluminal thrombus was noted in the left subclavian vein and
distal
segments of the right cephalic vein. Diameters of the cephalic
and basilic veins as described above. Occlusion of the right
radial artery.
TEMP DIALYSIS LINE PLCT Study Date of ___ 3:15 ___
IMPRESSION:
Successful placement of a temporary triple lumen dialysis
catheter with VIP port via the left internal jugular venous
approach. The tip of the catheter terminates in the distal
superior vena cava. The catheter is ready for use.
CHEST (PORTABLE AP) Study Date of ___ 5:49 ___
IMPRESSION:
New opacification at the left lung base obscures the left
hemidiaphragm, may be accompanied by mild leftward mediastinal
shift indicating a component of atelectasis, but pneumonia
particularly due to aspiration is of great concern, since there
is a also a new smaller region of consolidation at the medial
aspect of the right lower lobe. Small bilateral pleural
effusions are presumed. The heart is not enlarged and there is
no pulmonary edema. New left supraclavicular dual channel
hemodialysis catheter ends in the low SVC. There is no
associated mediastinal widening, pleural effusion, or
pneumothorax.
ECG Study Date of ___ 9:51:30 AM
Ventricular paced rhythm. Compared to the previous tracing of
___ pacing is now seen.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
60 0 ___ 0 -68 94
Tunnelled Dialysis Line ___:
Successful placement of a 27cm tip-to-cuff length tunneled
dialysis line via left IJ access. The tip of the catheter
terminates in the right atrium. The catheter is ready for use.
ECG Study Date of ___:
Ventricular pacing. Atrial activity is uncertain. P waves are
seen deforming the early part of the QRS complex on the seventh
beat and on. Compared to the previous tracing of ___
ventricular pacing is at a rate slower than the sinus rate and
dissociated.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
60 0 ___ 0 -63 101
Video Swallow ___: Preliminary Report
FINDINGS:
Barium passes freely through the oropharynx and esophagus
without evidence of obstruction. There is no gross aspiration.
There is penetration with thin and nectar thick liquids which
resolved with chin tuck technique. Mild degenerative changes
including grade 1 anterolisthesis of C2 on C3 are noted.
IMPRESSION:
Penetration with thin and nectar thick liquids which resolved
with chin-tuck technique. No gross aspiration.
Brief Hospital Course:
Mr. ___ is an ___ year old male with PMH notable for HCM s/p
septal ablation and ICD, ESRD on HD (initiated recent admission
___, HTN, HLD, T2DM, and history of enterococcal bacteremia
in ___ (c/b L psoas abscess, spinal osteomyelitis, and pacer
lead vegetation) who presented with generalized weakness+fever
and was found to have recurrent enterococcus feacalis pacemaker
endocarditis.
# CCU Course:
Patient admitted to CCU for blood pressure monitoring after
episode of hypotension s/p pacemaker removal and screw in pacer
wire w/ temporary pacemaker placement requiring neo drip.
Patient brought to floor, otherwise stable. Neo drip weaned
overnight with no further hypotensive episodes. Further
management of infection guided by ID and plan per primary team.
Of note, during CCU course patient was persistently febrile and
ceftazidime was started in consultation with ID (in conjunction
with gentamycin and vancomycin) to empirically cover for
pseudomonas. Repeat CXR's were initially cocnerning for possible
opacification, but on repeat imaging on ___ patient was noted
to have interval clearing of retrocardiac density. In addition,
on ___, it was noted that patient had high venous
pressures during HD, and on aspirating from R AVF clots were
drawn; patient had a RUE U/S on ___ which showed patent AVF.
After ___ fistulogram (arterial and venous anastomoses
ballooned), patient developed thrombosis of the right radial
artery. He subsequently received tPA to artery with ballon pull
throw, stent graft placed, 2 purse string sutures, and coil
embolization of small accessory branch that was bleeding. Ulnar
artery and arch intact. Patient on ___ underwent placement of
a temporary triple lumen dialysis catheter with VIP port via the
L IJ. After the procedure, the patient was found to have SBP in
___. He was subsequently readmitted to the ICU, where he
received 1u of pRBCs and 250 cc NS; SBPs subsequently stable in
100s-110s afterwards. He stablized in the CCU and was
transferred to the floor.
# Enteroccocus Faecalis pacemaker lead endocarditis: On
admission was treated for pneumonia with levofloxacin, however
when gram positive cocci grew from blood cultures, he was
started on vanc and zosyn on ___. His chronic Amoxicillin
suppresion therapy was stopped. CT L-Spine revealed an area
concerning for infection in L4/5 and L5/S1 endplates. CRP 146,
ESR 43 on presentation and trended down each week on
antibiotics. TEE showed worsening vegetations on his pacemaker
lead as compared to prior TEE. On ___, patient's dual chamber
ICD was successfully explanted, and a single chamber
externalized pacemaker was placed via the R IJ. PPM was
implanted on ___ on the right side with no complications. He
received a 2-week course of gentamicin (___), and was
continued on vancomycin at discharge to complete an 8 week
course (day 1: ___- estimated completion date ___.
# R radial artery thrombosis/rupture: patient was unable to
complete dialysis (via R radiocephalic AV fistula) on ___
(___), with reported clots withdrawn from fistula at
termination of dialysis run. AV fistulogram performed on ___ was
c/b distal radial artery thrombosis (during ___ pull through
in an attempt to improve flow). Continued attempt to restore
patency of the distal radial artery (heparin, TPA, Angiojet
pulse spray device) led to focal rupture with extravasation
noted. A 6 mm x 5 cm stent graft was placed, after which
extravasation resolved. An additional area of extravasation
noted in a muscular/epicondylar branch was treated with
embolization. RUE arteriography revealed an intact palmar arch
and retrograde filling of the distal radial artery, as well as
symmetric profusion of the fingers bilaterally.
# ESRD: was on HD TTS via R radiocephalic AV fistula, until HD
session unable to be completed on ___ because of AVF issues
(see above). L IJ temp dialysis line successfully placed on
___, and was replaced with tunneled line on ___. Decision
was made to defer AV graft while inpatient, and the patient was
set up with follow-up with the transplant clinic for further
evaluation.
# Pneumonia: LLL opacification on CXR. Treated with Levoflox
initially, transitioned to vanc/zosyn due to bacteremia, see
above.
# Anemia: H/H now stable, pattern c/w ACD (likely from anemia of
renal disease).
- Trend H/H daily
- Epo with dialysis
#Left lung Base Opacification: Noted on CXR from ___,
concerning for aspiration. Patient has been predominantly bed
bound and flat in bed for duration of hospitalization, at risk
for aspiration. No evidence of aspiration on bedside speech and
swallow evaluation ___, however could not rule out
microaspiration. Obtained a speech and swallow evaluation and
recommended crushed pills in applesauce and performing chin tuck
with all swallowing.
#Dry cough: Reported a dry cough during hospitalization.
Possibly due to microaspiration as above. Started on benzonatate
TID and omeprazole 20mg po daily with improvement.
CHRONIC ISSUES
===============
# Hypertrophic cardiomyopathy: Furosemide 80mg daily was held
during admission and patient's fluids were managed through
dialysis. This was held at discharge. Metoprolol tartrate 50 mg
PO BID was continued.
# DM: ISS + Glargine long acting. Increased glargine to 8 units.
# ___ Disease: Continue on carbidopa-levodopa. Unable to
obtain rotigotine 2 mg/24 hour transdermal QHS in house.
# BPH: Continued finasteride
# HLD: continued simvastatin
# GERD : continued omeprazole
# Code: DNR/DNI, confirmed with patient, wife and consistent
with previous documentation
# Emergency Contact: wife/HCP ___ ___
=============================
TRANSITIONAL ISSUES
=============================
- qweekly esr/crp
- needs device clinic around ___, stiches out around ___
[x] Vanc to end ___ - will get with HD so does not need
PICC,
[x] follow-up with OPAT
- based on swallow studies, should have thin liquids, regular
solids, pills crushed in applesauce. Needs to do chin tuck with
all swallowing.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H:PRN pain, fever
2. Amoxicillin 500 mg PO Q24H
3. Ascorbic Acid ___ mg PO DAILY
4. Calcium Acetate 667 mg PO TID W/MEALS
5. Carbidopa-Levodopa (___) 2.5 TAB PO TID
6. Cyanocobalamin 50 mcg PO DAILY
7. Docusate Sodium 100 mg PO BID:PRN constipation
8. Carbidopa-Levodopa (___) 1 TAB PO QHS
9. Finasteride 5 mg PO DAILY
10. Furosemide 80 mg PO DAILY
11. Glucose Gel 15 g PO PRN hypoglycemia protocol
12. Metoprolol Tartrate 50 mg PO BID
13. Omeprazole 20 mg PO DAILY
14. rotigotine 2 mg/24 hour transdermal QHS
15. Senna 8.6 mg PO BID:PRN constipation
16. Simvastatin 10 mg PO DAILY
17. Nephrocaps 1 CAP PO DAILY
18. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150
mg-unit-mg-mg oral daily
19. Glargine 7 Units Dinner
20. HumaLOG (insulin lispro) 100 unit/mL subcutaneous as
directed
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain, fever
2. Carbidopa-Levodopa (___) 2.5 TAB PO TID
3. Carbidopa-Levodopa (___) 1 TAB PO QHS
4. Cyanocobalamin 50 mcg PO DAILY
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Finasteride 5 mg PO DAILY
7. Glucose Gel 15 g PO PRN hypoglycemia protocol
8. Metoprolol Tartrate 50 mg PO BID
9. Nephrocaps 1 CAP PO DAILY
10. Omeprazole 20 mg PO DAILY
11. rotigotine 2 mg/24 hour transdermal QHS
family has been providing the patches
12. Senna 8.6 mg PO BID:PRN constipation
13. Simvastatin 10 mg PO DAILY
14. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150
mg-unit-mg-mg oral daily
15. Outpatient Lab Work
Please draw the following labs on a weekly basis:
-CBC with differential
-BUN
-Cr
-Vancomycin trough
-ESR
-CRP
-ESR
-CRP
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
16. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
17. Benzonatate 100 mg PO TID
18. Heparin 5000 UNIT SC TID
19. Neomycin-Polymyxin-Bacitracin 1 Appl TP ONCE Duration: 1
Dose
20. Polyethylene Glycol 17 g PO DAILY
21. TraMADOL (Ultram) ___ mg PO Q12H:PRN pain
22. Lisinopril 5 mg PO DAILY
23. Vancomycin IV Sliding Scale Duration: 38 Days
Start: Today - ___, First Dose: Next Routine Administration
Time
24. Ascorbic Acid ___ mg PO DAILY
25. Heparin Dwell (1000 Units/mL) ___ UNIT DWELL PRN
dialysis
Dwell to CATH Volume
26. Calcium Acetate 667 mg PO TID W/MEALS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary
Enterococcus Faecalis bacterial ___
___ Acquired Pneumonia
Secondary
ESRD on HD
Parkinsons Disease
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 being a part of your care at ___
___. You were evaluated for weakness and
back/leg pain and found to have a recurrence of the blood
infection with infection on the ICD lead. We discussed the risks
and benefits of removing the lead and decided to remove the
device and replace it with a pacemaker. These procedures went
well and you are on antibiotics to treat the infection. You were
also treated successfully for a pneumonia
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10184327-DS-28 | 10,184,327 | 22,570,171 | DS | 28 | 2138-09-16 00:00:00 | 2138-09-19 19:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypotension
REASON FOR MICU: C/f septic shock
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ PMH ESRD on HD, hypotrophic cardiomyopathy s/p multiple
ablations, CHB, ICD and pacemaker placement, IDDM, HTN, HLD,
___, presenting with hypotension to ___ systolic
from dialysis.
Patient noted to be hypotensive after dialysis today. Reportedly
systolics in the ___ and ___. Completed his dialysis session but
was given IV fluid of at unknown amount due to hypotension prior
to being sent to the emergency department. Of note, the patient
was recently diagnosed as an outpatient for pneumonia, with
cough productive of sputum with onset about 10 days ago. Started
on zpack by PCP, first dose last ___. Denies fever, chills,
nausea, vomiting, chest pain, shortness of breath, abdominal
pain, diarrhea, melena, hematochezia, dysuria, hematuria.
In the ED, initial vitals: 36.2 93/58 67 18 93/RA
Exam unremarkable
Labs:
16.7>12.4/39.1<232
136 | 92 | 29
-------------<266
4.2 | 22 | 3.4
INR 1.2
ALT 6 AST 23 AP 165 Tbili 0.4 Alb 4.3
Trop 0.3, MB 8
Lactate 2.5
EKG v paced
CXR w/ atelectasis in LUL base, present ___ year ago
Started vanc/zosyn, 500cc NS; no pressors
On transfer, vitals were: 98.0 97/55 70 22 98/RA
On arrival to the MICU, patient reports ongoing cough but
otherwise feels well.
Past Medical History:
- ICD lead infection with enterococcal bacteremia from left
psoas abscess in ___ treated with chronic antibiotic
suppression.
- History of hypertrophic cardiomyopathy with two septal
ablations in ___ and ___.
- Complete heart block.
- ICD placement in ___ with generator change in ___ and
subsequent generator change again in ___.
- End stage renal disease now on HD
- Hypertension
- Diabetes
- ___
- Hyperlipidemia
- S/p left sided ICD and lead extraction due to infection
followed by temporary lead placement and then reimplantation of
a
permanent pacing system on the right (___).
- GERD
- Hyperparathyroidism
- Osteoporosis
- Thyroid nodule
- Osteoporosis s/p bisphosphonate therapy
- BPH
- Actinic keratoses, seborrheic keratoses, and lentigines
- H/o nephrolithiasis
Social History:
___
Family History:
Father with DM2 died from MI in ___. Son and daughter both with
HOCM.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.7 ___ 20 97/RA
GENERAL: Alert, oriented (not to year but yes to pres
candidates, self, place), no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated
LUNGS: Crackles RLL base, rhonchi L lower and middle fields
CV: Regular rate and rhythm, normal S1 S2, holosystolic murmur,
no rubs, gallops
ABD: 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
NEURO: CN ___, strength and sensation grossly intact
DISCHARGE EXAM
VITALS: 98.3
PO 108 / 66 92 16 93 RA
GENERAL: Alert, no acute distress
GEN: Lying in bed receiving HD via subclavian line.
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated
CHEST: left tunneled subclavian line currently in access
LUNGS: No increased WOB. CTA anteriorly
CV: Regular rate and rhythm, normal S1 S2, holosystolic murmur,
no rubs, gallops
ABD: 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
Pertinent Results:
Admission/Pertinent labs:
___ 06:35PM BLOOD WBC-16.7*# RBC-3.87* Hgb-12.4* Hct-39.1*
MCV-101*# MCH-32.0# MCHC-31.7* RDW-14.7 RDWSD-54.2* Plt ___
___ 06:35PM BLOOD Neuts-86.2* Lymphs-3.6* Monos-7.1
Eos-0.8* Baso-0.4 Im ___ AbsNeut-14.42* AbsLymp-0.61*
AbsMono-1.19* AbsEos-0.13 AbsBaso-0.07
___ 06:35PM BLOOD ___ PTT-30.7 ___
___ 06:35PM BLOOD Glucose-266* UreaN-29* Creat-3.4*# Na-136
K-4.2 Cl-92* HCO3-22 AnGap-26*
___ 06:35PM BLOOD ALT-6 AST-23 CK(CPK)-89 AlkPhos-165*
TotBili-0.4
___ 06:35PM BLOOD Albumin-4.3 Calcium-8.9 Phos-3.9 Mg-1.7
___ 06:39PM BLOOD Lactate-2.5*
Troponin trend:
___ 06:35PM BLOOD cTropnT-0.30*
___ 04:07AM BLOOD CK-MB-7 cTropnT-0.52*
___ 09:18AM BLOOD CK-MB-6 cTropnT-0.57*
___ 02:24PM BLOOD cTropnT-0.46*
Microbiology:
___ Blood culture x2: Negative
___ MRSA screen: Negative
___ Rapid respiratory viral screen and culture: Negative
___ Blood culture x2: No growth to date
___ Cdif: Negative
Discharge labs:
___ 05:15AM BLOOD WBC-11.4* RBC-3.51* Hgb-11.4* Hct-36.4*
MCV-104* MCH-32.5* MCHC-31.3* RDW-15.2 RDWSD-57.2* Plt ___
___ 05:15AM BLOOD Glucose-141* UreaN-21* Creat-4.3*# Na-141
K-4.2 Cl-98 HCO3-29 AnGap-18
___ 05:15AM BLOOD Calcium-9.0 Phos-3.6 Mg-1.9
Imaging:
___ CXR:
FINDINGS:
Right-sided pacer is noted with leads terminating in the right
atrium and
right ventricle, unchanged. Left-sided central venous catheter
tip terminates in the proximal right atrium. Mild enlargement
of the cardiac silhouette is present. Aortic knob
calcifications are noted. The mediastinal and hilar contours
are unremarkable. A small left pleural effusion is
substantially decreased in size compared to the previous study.
Subsegmental atelectasis or scarring accounts for the linear
opacity within the left mid lung field. There is minimal left
basilar atelectasis. Right lung is clear. No pulmonary edema
or pneumothorax is present.
IMPRESSION:
Small left pleural effusion with minimal left basilar
atelectasis and
subsegmental atelectasis or scarring in the left mid lung field.
___ TTE: There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There is a small to moderate (0.9-1.4cm) sized
circumferential pericardial effusion without echocardiographic
signs of tamponade.
Compared with the prior study (images reviewed) of ___,
the effusion is snow slightly smaller.
___ TTE: Conclusions
There is symmetric left ventricular hypertrophy. Overall left
ventricular systolic function is normal (LVEF=70-75%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are severely thickened. Significant aortic
stenosis is present (not quantified because there is likley an
LVOT gradient that is not well quantified so continuity equation
will not be accurate and no 2D images are available for
planimetry). No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is systolic anterior motion
of the mitral valve leaflets with flow acceleration across the
LVOT c/w hypertensive HOCM. Mild (1+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] There is a
small to moderate sized pericardial effusion. The effusion
appears circumferential. There are no echocardiographic signs of
tamponade.
IMPRESSION: Significant LVH with hypertensive obstructive
cardiomyopathy. Peak gradient across the aortic valve 49mmHg.
This is in part due to LVOT obstruction ___ visualized) but
there is certainly valvular AS and the continuos wave spectral
profile is more consistent with AS than dynamic outflow
obstruction. A TEE could help sort out relative contributions by
planimetering the aortic valve orifice.
Compared with the prior study (images reviewed) of ___
the pericardial effusion is similar in size. Other findings are
similar.
Brief Hospital Course:
___ PMH ESRD on HD, hypotrophic cardiomyopathy s/p multiple
ablations, CHB, ICD and pacemaker placement, IDDM, HTN, HLD,
___, presenting with hypotension to ___ systolic
from dialysis ISO c/f sepsis from PNA, as well as contribution
from hypovolemia in setting of left ventricular outflow tract,
hypertrophic obstructive cardiomyopathy and aortic stenosis.
# HYPOTENSION: Initially improved with fluids in the ICU. This
was initially attributed to volume removal from HD and sepsis
from PNA. He did, however, have another episode of hypotension
to 60/40s post HD on ___ without any fluid removal at HD. This
too resolved with fluid. Given TTE findings of possible LVOT,
___ and aortic stenosis, sensitivity to preload and hypovolemia
from initial HD session on day of admission likely contributed
to the recurrent hypotension. After receiving several fluid
boluses for his hypotension, he tolerated HD on ___ without
issue (note post-HD dry weight was increased to 75.1).
Additional contributors may be dysautonomia from ESRD and
___ disease/diabetes. Blood cultures were negative up to
day of discharge.
# SEPSIS:
# HEALTHCARE ASSOCIATED PNEUMONIA: Attributed to PNA given
reported cough and leukocytosis on admission, although CXR
without definitive opacity. He was given vanco/zosyn initially,
which was changed to vanco/cefepime, then ceftazidime on
discharge with planned course of 8 days (___). Blood
cultures no growth to date. Respiratory viral culture negative.
# ELEVATED TROPONIN: Unclear if secondary to ESRD or type II
NSTEMI secondary to hypotension. Patient is not on aspirin,
although several risk factors. He continued simvastatin. Would
consider aspirin if there is no contraindication.
# ESRD on HD: Patient without acute indication for dialysis on
admission. He continued HD ___ and calcium
acetate/nephrocaps. Dry weight increased given preload
sensitivity.
# ___ DISEASE: He continued carbidopa/levodopa and
rotigotine patch.
# HLD: He continued simvastatin.
# HYPERTROPHIC CARDIOMYOPATHY/COMPLETE HEART BLOCK: Has
pacemaker and ICD. EKG V paced. He appears to be sensitive to
preload, caution with fluid removal at HD. See TTE results.
# DM: Glargine and Humalog sliding scale PRN while inpatient.
TRANSITIONAL ISSUES:
-**PATIENT VERY SENSITIVE TO VOLUME CHANGES GIVEN LVOT SEEN ON
TTE**
-Last post-HD weight was 75.1 kg (previous dry weight 70).
Recommend keeping dry weight closer to 75 and no more given
sensitivity to preload due his structural cardiac disease.
-LAST DAY ABX: Ceftazidime with HD (last day ___ for total
8 days)
-Patient with elevated troponin (flat MB, no recent baseline
since on HD), which may be type II STEMI from hypotension. Given
risk factors for CAD, would recommend baby aspirin daily unless
he has contraindications
-HCP: Wife, Phone number: ___, Cell phone: ___
# Code: DNR, Ok to intubate with limited trial
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. Lactobacillus acidophilus 1 Tab oral DAILY
3. Carbidopa-Levodopa (___) 2.5 TAB PO TID
4. Carbidopa-Levodopa (___) 1 TAB PO QHS
5. Simvastatin 5 mg PO QPM
6. Glargine 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. rotigotine 2 mg/24 hour transdermal QHS
8. Calcium Acetate 1334 mg PO TID W/MEALS
9. Nephrocaps 1 CAP PO DAILY
10. Cyanocobalamin 250 mcg PO DAILY
11. Ascorbic Acid ___ mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary
Hypotension
Healthcare associated pneumonia
Left Venctricular Outflow Tract Obstruction
Hypertrophic cardiomyopathy
Aortic Stenosis
Secondary
Type II Diabetes
End-stage renal disease
___ disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___
Why were you here:
-You had very low blood pressure after dialysis
-We diagnosed you with pneumonia
What was done:
-You were treated for pneumonia with antibiotics
-You were given fluids for your low blood pressure
-You had an ultrasound that showed that the structure of your
heart and heart valves may also be contributing to your low
blood pressure
-Your "dry weight" was increased so they do not take too much
fluid off at dialysis in the future
What to do next:
-Take all your medications as prescribed and go to your doctor's
appointments
-Follow-up with your cardiologist
We wish you all the best!
Your ___ team
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10185295-DS-11 | 10,185,295 | 25,419,883 | DS | 11 | 2186-04-22 00:00:00 | 2186-04-22 18:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Doxycycline / Lipitor
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Coronary angiogram ___
History of Present Illness:
Patient is a ___ with a PMHx of CAD and NSTEMI s/p DES to ___
___ who presents with substernal chest pain.
At 1600 on ___, patient experienced ___ substernal chest
pressure while walking from kitchen to living room. She had
associated nausea and diaphoresis. She states that the pain is
similar to her prior MI, except at that time she also had arm
numbness. She took Xanax, full dose ASA and nitro in ambulance.
Her pain on evaluation to the ED was ___. She also feels more
dyspneic over the last several months but can still climb ___
steps at home before SOB. Takes Xanax 5x daily for anxiety.
She denies PND, orthopnea, and leg swelling. She generally
feels weaker over the last two months but can still climb ___
steps at home before SOB. Takes Xanax 5x daily for anxiety. In
the ED, she also noted loose stools for the past month.
In the ED initial vitals were:
98 105 119/78 20 97% RA
Exam in ED was notable for no JVP or hepatojugular reflex.
Rectal exam guaiac negative.
EKG: sinus 98, LAD, no ST changes, consistent with prior
Labs/studies notable for: normal CBC, Cr 1.4, trop neg x1
Patient was given: 0.5mg xanax, mIVF at 100cc/hr, and heparin
gtt.
Cardiology fellow was consulted who recommended admission and
plan for likely cath on ___.
Vitals on transfer:
98.0 88 128/57 12 99% RA
On the floor patient reports that chest pain/discomfort
resolved. She endorses DOE and significant fatigue. She states
that she talked to Dr. ___ these symptoms when she was
seen for follow up in ___. At that time, she continues to
have dyspnea with minimal fatigue, felt to be angina equivalent
despite medical therapy with ASA/Plavix/Metoprolol/Statin. There
was plan for stress echo. She was felt to be euvolemic at that
time. No orthopnea. States that weight fluctuates, but no clear
weight gain. No leg swelling.
Patient denies using recent ibuprofen, motrin, advil, etc but
does take diclofenac. She states that she has decreased appetite
recently. She states that she has been having diarrhea for two
months. She states that her diarrhea has improved since she
decreased her metformin dose from BID to daily. She has had
alternating constipation and diarrhea in the past. This was
previously attributed to IBS, but she was later told that she
doesn't have IBS.
Patient states that she has been having dysuria. She had a
UA/UCx sent at ___ for these symptoms. She states that
her symptoms are consistent with prior UTI. No fevers but +
chills.
Past Medical History:
1. CARDIAC RISK FACTORS
+ Hypertension
+ Dyslipidemia
+ DM2 on insulin
2. CARDIAC HISTORY
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: NSTEMI s/p DES to LCx
___
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
PMR
Vertigo
anxiety
depression
IBS
h/o sinus tachyucardia
Non alcoholic fatty liver disease
Lumbar radiculopathy
Right sided sacroiliitis
Right sided piriformis syndrome
S/p D&C in ___ for dysfunctional uterine bleeding
Osteoarthritis
Social History:
___
Family History:
Father with MI in ___. Uncle with MI (unknown age). Cervical
cancer in her mother.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T98.3 BP134/64 HR86 RR18 O2 SAT98/RA
GENERAL: WDWN female 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 no JVP elevation.
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. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM:
========================
VS: Tmax 98.2, BP 120-139/59-78, HR 98-115, RR 20, O2 sat
96-100% RA
Weight: 81.9
GENERAL: Lying comfortably in bed, no acute distress
NECK: JVP below clavicle
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: CTAB, no w/r/r
ABDOMEN: Soft, NTND.
EXTREMITIES: No ___ edema
Pertinent Results:
ADMISSION LABS:
================
___ 07:45PM BLOOD WBC-8.6 RBC-4.11 Hgb-11.8 Hct-38.0 MCV-93
MCH-28.7 MCHC-31.1* RDW-14.3 RDWSD-48.0* Plt ___
___ 07:45PM BLOOD Glucose-81 UreaN-29* Creat-1.4* Na-138
K-4.4 Cl-102 HCO3-19* AnGap-21*
___ 07:45PM BLOOD cTropnT-<0.01
___ 02:53AM BLOOD CK-MB-5 cTropnT-<0.01
DISCHARGE LABS:
================
___ 08:45AM BLOOD WBC-7.6 RBC-3.58* Hgb-10.2* Hct-32.8*
MCV-92 MCH-28.5 MCHC-31.1* RDW-14.5 RDWSD-48.0* Plt ___
___ 08:45AM BLOOD Glucose-140* UreaN-12 Creat-1.1 Na-140
K-3.6 Cl-103 HCO3-20* AnGap-21*
___ 08:45AM BLOOD CK-MB-12* cTropnT-1.42*
IMAGING/STUDIES:
================
TTE ___:
The left atrial volume index is normal. Left ventricular wall
thicknesses and cavity size are normal. There is mild symmetric
left ventricular hypertrophy with normal cavity size. There is
mild regional left ventricular systolic dysfunction with mild
inferior hypokinesis. The remaining segments contract normally
(LVEF = 45-50%). Right ventricular chamber size is normal with
significant basal free wall hypokinesis. 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. Mild (1+) aortic regurgitation
is seen. The mitral valve appears structurally normal with
trivial mitral regurgitation. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction
and moderate regional right ventricular systolic dysfunction,
both c/w RCA disease. Mild aortic regurgitation. No pericardial
effusion.
Compared with the prior study (images reviewed) of ___,
right ventricular systolic dysfunction is new.
CARDIAC CATHETERIZATION ___:
Coronary Anatomy Dominance: Co-dominant
RCA: The RCA could not be engaged using 5 ___ Jacky
catheter. It was engaged using a 5 ___ JR5 catheter which sat
slightly deeply, but seemingly coaxially without dampening of
the pressure waveform. Initial angiography showed a modest
caliber vessel with a mid 70% stenosis between 2 AM branches
with distal perfusion of the RPDA and a RPL. There was TIMI 2
pulsatile flow. Contrast staining of the proximal and mid RCA
was seen immediately after the first injection with an abrupt
cutoff at the proximal-mid RCA indicative of a
catheter/injection-induced dissection. Repeat injection showed
minimal flow beyond the 70% stenosis with contrast hang up
proximally and slow filling of the RPDA and RPL. The patient
reported right upper extremity discomfort extending to the chest
and throat, initially at ___, with diaphoresis. This
subsequently progressed to ___ with the patient moaning with ST
segment elevation on monitor lead III.
LMCA: The LMCA could not be engaged using 5 ___ JL3.5,
Jacky or AL-1 diagnostic catheters (with the AL-1 preferentially
entering the LV when pushed forward). It was engaged with
difficultly using a 5 ___ XB-LAD-3.5 guiding catheter
(slightly too short and also preferring the LV). The patient
reported chest pain with every left coronary angiographic
injection. The LMCA had mild plaquing, but the diameter of the
LMCA lumen was about the same as the internal diameter of the 5
___ guiding catheter, suggesting at least mild-moderate
diffuse disease.
LAD: The ostial LAD had a 50% stenosis. The proximal LAD
had mild calcific plaquing to 35%. The LAD had minimal luminal
irregularities and delayed, pulsatile flow consistent with
microvascular dysfunction.
LCX: The retroflexed CX had an ostial 50% stenosis. There
was a modest caliber high OM1 with mild diffuse plaquing. The
stent in the mid CX after this OM1 was patent. OM2 was tiny; OM3
was of modest caliber with a mild origin plaque and a tortuous
terminal vessel. There was delayed pulsatile flow (consistent
with microvascular dysfunction) into a tortuous OM4/LPL1, a
modest caliber LPL2 and a large LPL3. There were several modest
caliber LPLs or possibly a LPDA.
Interventional Details
Right femoral arterial access was obtained under ultrasound
imaging guidance using a MicroPuncture needle. The RCA was
engaged using a 6 ___ JR4 catheter, which provided limited
support. Additional heparin was given for an initial ACT of 224
secs. A ChoICE ___ Floppy wire was delivered via a Caravel
catheter initially into what appeared to be the slightly larger
AM1 and the subsequently redirected more distally with a loop at
the tip. There was no antegrade perfusion of contrast beyond the
proximal RCA on hand injection angiography. The Caravel was then
delivered into the mid RCA well past the original 70% stenosis.
Hand injection angiography through the Caravel confirmed a
vascular location, but there was a large extravascular contrast
blush consistent with perforation and what appeared to be
propagation of a spiral dissection into the distal RPDA with
slow flow into the RPL.
A fresh ChoICE ___ Floppy was then delivered through the
Caravel into the RPDA. Angiography showed a spiral dissection
extending from the proximal RCA past the 70% stenosis (with loss
of all the acute marginal branches) extending down the mid RCA
(with an oblong contrast stain with fresh extravasation in the
mid RCA). The dissection was not so apparent into the RPDA, but
there was no flow into the RPL.
A Stat bedside echo was obtained which showed only a tiny
pericardial effusion. The ACT was 288 secs.
A 2.5x15 mm RX Apex could not be delivered past the
proximal RCA and was inflated at 7 atms just outside the guiding
catheter. A 6 ___ Guideliner was then introduced. A 2.5x28 mm
RX Promus Premier DES would not deliver past the proximal RCA.
Even with the Guideliner telescoped forwards over the stent into
the proximal RCA, the stent would not deliver much further
without buckling the guiding catheter back.
At this point, the patient became more agitated, moving her
arms and her legs (pulling the radial arterial sheath almost all
the way out). She moaned less vigorously than before and was
unable to answer questions for a short period of time. She
subsequently answered a few questions and made some efforts to
follow instructions, but was clearly not as interactive as
earlier in the case. She appeared to be spontaneously moving all
extremities. Rather than exchange for an AL-1 guiding catheter,
the 2.5x15 mm RX Apex was delivered into the RCA for a total of
5 inflations from the mid RCA (at the site of the perforation)
back to the proximal RCA at mostly 6 atms. There was limited
runoff into the RPDA and RPL, so stenting was deferred. Final
angiography with the wire out showed slight contrast staining in
the proximal RCA with a spiral dissection proximally, a 50%
residual stenosis where the original 70% stenosis had been,
slight reconstitution of the lost AM/RV branches, a spiral
dissection in the mid-distal RCA with no evidence of the
adjacent prior contrast extravasation, and TIMI 1 flow into the
RPDA and even slower into the RPL.
A Terumo Radial Band was placed on the RRA but had to be
readjusted to achieve good hemostasis. A 6 ___ AngioSeal
device was deployed in the right femoral artery with good
hemostasis.
A Code Stroke was called, and the patient was sent for CT scan
of the head and CTA of the head and neck.
Intra-procedural Complications:
___ Coronary artery perforation, transient
___ Coronary artery dissection, catheter induced
___ Likely acute right ventricular and inferior MI
___ Mental status changes/obtundation
Impressions:
1. Moderate three vessel coronary artery disease with diagnostic
catheter induced spiral dissection of the RCA exacerbated by
subsequent intracoronary angiography, likely resulting in a
clinically apparent type 4 post-PCI right ventricular and
inferior myocardial infarction.
2. Low LVEDP at baseline.
3. Unsuccessful attempt to rescue the spirally dissected
co-dominant RCA with balloon angioplasty alone due to difficulty
delivering stents, complicated by likely small mid RCA
perforation with contained contrast extravasation that seemed to
have resolved by the conclusion of the case. 4. Mental status
changes with relative obtundation and markedly less
interactivity at the conclusion of the procedure.
Recommendations
1. Follow-up on neurology Code Stroke assessment and
recommendations.
2. Cycle troponin-T and CK-MB
3. ASA 81 mg daily.
4. Clopidogrel 75 mg daily if no evidence of intracranial
hemorrhage.
5. D/C heparin.
6. Low threshold to obtain stat echo tonight to R/O tamponade
from coronary artery perforation.
7. Echocardiogram tomorrow to assess for RV and inferior infarct
and pericardial effusion.
8. Aggressive post-procedure hydration with NS given diabetes
mellitus, CKD (eGFR 37 mL/min/1.73m2), 130 mL of contrast
administered, low filling pressures at case start, and likely
right ventricular infarction.
9. Routine post-TR Band care.
10. Routine post-AngioSeal care.
11. Cefazolin 1 gm IV on arrival to the CCU to cover skin flora
in this diabetic with a femoral artery vascular closure device.
12. Reinforce secondary preventative measures against CAD,
NSTEMI, and diabetes mellitus with CKD.
13. Referral to outpatient cardiac rehabilitation.
14. F/U with Dr. ___.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a history of
CAD and NSTEMI s/p DES to ___ ___ who presented initially to
the ED with substernal chest pain on ___ and was admitted to
___ with unstable angina and underwent cardiac catheterization
complicated by RCA dissection and STEMI secondary to dissection.
# CORONARIES: ___ catheterization: LCx w/ patent stent &
50% ostial stenosis; 50% ostial LAD, proximal LAD 35%, 70% RCA
lesion
# PUMP: EF 45-50% ___
#TYPE IV MI/RCA DISSECTION: Underwent cath for presentation of
unstable angina complicated by RCA Type 4 - Spiral dissection,
and resultant STEMI. Angioplasty and stenting of dissection
unsuccessfully attempted, with resulting small RCA perforation
that resolved intraprocedurally. Also with AMS during cath,
initial concern for stroke but mental status returned to
baseline. Was evaluated by neurology who recommended no MRI to
assess for stroke, AMS may have been anesthesia related. TTE
post-procedurally w/ RV basal free wall hypokinesis, no
pericardial effusion. CK-MB peaked at 56 and downtrended to 12
on admission, Troponin t still rising, 1.42 on discharge. Chest
pain free post procedurally. Continued on aspirin and Plavix.
***Metoprolol succinate decreased to 25mg daily on discharge
given RV dyskinesis and transient orthostasis.***
#UTI: patient with dysuria, UA consistent with UTI. Had UCx done
as outpatient on ___, which showed pan-sensitive E coli,
repeat culture here also growing E. coli. Treated with 3 days
ceftriaxone/cefpodoxime
TRANSITIONAL ISSUES:
[] Metoprolol succinate decreased to 25mg daily in setting of RV
dyskinesis. Orthostasis resolved on day of discharge. Consider
increasing metop back to pre-admission dose if normotensive and
not orthostatic in follow up.
[] Consider repeat TTE to evaluate RV function
[] Consider whether future PCI warranted based on cath findings
# CODE: Full, confirmed
# CONTACT: ___ (husband) ___ ___ (daughter)
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.5 mg PO 5X PER DAY PRN ANXIETY anxiety
2. Clopidogrel 75 mg PO DAILY
3. Desipramine 30 mg PO QHS
4. Arthrotec 75 (diclofenac-misoprostol) 75-200 mg-mcg oral
TID:PRN pain
5. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN Pain -
Moderate
6. Glargine 18 Units Bedtime
Novolog 8 Units Breakfast
7. Lidocaine 5% Patch 1 PTCH TD QAM:PRN pain
8. Meclizine 25 mg PO Q12H:PRN vertigo
9. MetFORMIN (Glucophage) 1000 mg PO DAILY
10. Metoprolol Succinate XL 100 mg PO DAILY
11. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
12. Rosuvastatin Calcium 20 mg PO QPM
13. Aspirin 81 mg PO DAILY
14. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L.
acidophilus-L. rhamnosus;<br>L.acidophilus-Bif.
animalis;<br>L.rhamn ___
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 20 billion cell
oral DAILY
15. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
16. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
17. nystatin 100,000 unit/gram topical DAILY
Discharge Medications:
1. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
2. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
3. ALPRAZolam 0.5 mg PO 5X PER DAY PRN ANXIETY anxiety
4. Aspirin 81 mg PO DAILY
5. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
6. Clopidogrel 75 mg PO DAILY
7. Desipramine 30 mg PO QHS
8. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN Pain
- Moderate
9. Glargine 18 Units Bedtime
Novolog 8 Units Breakfast
10. Lidocaine 5% Patch 1 PTCH TD QAM:PRN pain
11. Meclizine 25 mg PO Q12H:PRN vertigo
12. MetFORMIN (Glucophage) 1000 mg PO DAILY
13. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
14. nystatin 100,000 unit/gram topical DAILY
15. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L.
acidophilus-L. rhamnosus;<br>L.acidophilus-Bif.
animalis;<br>L.rhamn ___
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 20 billion cell
oral DAILY
16. Rosuvastatin Calcium 20 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Unstable angina
Right coronary artery dissection during catheterization
Urinary tract infection
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 were you admitted to the hospital?
-You were having chest pain
What happened while you were in the hospital?
-You blood work showed you did not have a heart attack
-You had a "cardiac catheterization" that showed a blockages in
several of your heart arteries
-The procedure caused a tear in one of your arteries that caused
a heart attack
-You were evaluated by physical therapy
What you should do when you leave the hospital:
===============================================
-Follow-up with Dr. ___ as scheduled below
-Follow a heart healthy diet
-Attend cardiac rehab
Thank you for allowing us to be involved in your care, we wish
you all the ___!
Your ___ Healthcare Team
Followup Instructions:
___
|
10185295-DS-9 | 10,185,295 | 22,821,991 | DS | 9 | 2183-04-13 00:00:00 | 2183-04-14 20:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Doxycycline / Lipitor
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
___ - cardiac catheterization with DES to LCx
History of Present Illness:
___ old Female with PMH significant for hypertension,
hyperlipidemia, anxiety, irritable bowel syndrome, lumbar
radiculopathy (with prior corticosteroid injections),
non-alcoholic fatty liver disease, history of sinus tachycardia
(on beta-blockade), tobacco abuse, polymyalgia rheumatica and
subclinical hypothyroidism who presented with chest pain.
She reports an episode of chest pressure at approximately 10 ___
on ___ while laying on the couch at rest; this pain
radiated to the right ear and she had tingling of the right hand
with associated nausea. She also began sweating profusely which
lasted for one hour. EMS was notifed and gave patient chewable
ASA 325 mg and sublingual Nitroglycerin which relieved the
pressure. She denies palpitations, dizziness, lightheadedness.
No known cardiac history of ischemic cardiomyopathy.
In the ED, initial VS 98.0 109 114/77 18 98% 2L NC. EKG
demonstrated ST-depressions in the inferior leads and cardiology
was consulted. Cardiac biomarkers were elevated with Troponin-T
of 0.25. Creatinine 1.1. Leukocytosis to 12.2. She received
clopidogrel 600 mg PO loading dose, heparinization and
alprazolam 0.5 mg PO. Her urine culture was noted to be positive
and she was given Ceftriaxone 1 gram IV. She was transferred to
the cardiology service for management of her NSTEMI.
On arrival to the floor, the pt denies any residual chest pain.
She is resting comfortabley in bed.
Past Medical History:
Depression
Anxiety
IBS
Osteoarthritis
PUD, patient unsure
H/o Sinus tachycardia
Vertigo
HTN
Hyperlipidemia
Colonic polyps
Non alcoholic fatty liver disease
Lumbar radiculopathy
Right sided sacroiliitis
Right sided piriformis syndrome
S/p D&C in ___ for dysfunctional uterine bleeding
Social History:
___
Family History:
Cervical cancer in her mother.
Physical Exam:
==========================
ADMISSION PHYSICAL
==========================
VS: AF 94-117/49-64 ___ 18 95% RA
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: supple, no JVD
CV: regular rhythm, no murmurs
Lungs: CTAB
Abdomen: soft, NT/ND, BS+
Ext: WWP, no c/c/e, 2+ distal pulses bilaterally
Neuro: moving all extremities grossly
============================
DISCHARGE PHYSICAL
============================
Vitals: 97.8 97-107/56-60 ___ RA Wt 83.6 kg (83.6
kg ___ I/O NR
HEENT: EOMI, PERRLA, no LAD appreciated
CV: No JVD. No peripheral edema. Pulses 2+ distally in 4
extremities. S1 and S2, with more prominent S2. No murmurs or
adventisious sounds appreciated.
PULM: Diminished breath sounds in RLL. Otherwise vesicular
sounds with good air movment.
ABD: Sounds present. Soft, non-tender.
Neuro: Fully alert, oriented and attentive. CNI-XII intact with
no asymetry, loss of sensation or weakness noted in face or
extremities.
Pertinent Results:
=================================
ADMISSION LABS
=================================
___ 02:15AM BLOOD WBC-12.2* RBC-4.66 Hgb-14.5 Hct-44.8
MCV-96 MCH-31.1 MCHC-32.3 RDW-14.4 Plt ___
___ 10:50AM BLOOD ___ PTT-73.1* ___
___ 02:15AM BLOOD Glucose-112* UreaN-25* Creat-1.1 Na-144
K-3.7 Cl-100 HCO3-28 AnGap-20
___ 02:15AM BLOOD cTropnT-0.25*
___ 10:50AM BLOOD Calcium-10.9* Phos-3.9 Mg-1.4*
===============================
PERTINENT LABS
===============================
___ 02:15AM BLOOD cTropnT-0.25*
___ 10:50AM BLOOD CK-MB-46* cTropnT-1.51*
___ 05:23PM BLOOD CK-MB-31* MB Indx-10.0* cTropnT-0.94*
___ 06:05AM BLOOD cTropnT-0.49*
___ 10:27AM BLOOD PTH-28
================================
DISCHARGE LABS
================================
___ 06:05AM BLOOD Hct-42.8 Plt ___
___ 06:05AM BLOOD Glucose-116* UreaN-19 Creat-1.1 Na-140
K-4.2 Cl-102 HCO3-25 AnGap-17
===============================
MICROBIOLOGY
===============================
___ 11:35 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 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-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
================================
IMAGING
================================
___ ECHO:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is mildly depressed (LVEF= 50 %). The aortic valve
leaflets are mildly thickened (?#). There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The pulmonary artery systolic pressure could not be determined.
There is a very small to small pericardial effusion measuring
from 0.2 to 0.9 centimeters anteriorly. There is an anterior
space which most likely represents a prominent fat pad. No right
atrial diastolic collapse is seen.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with mildly depressed global left
ventricular systolic dysfunction. Very small to small anterior
pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of ___, the very small to small pericardial
effusion is new. The right ventricle is not well seen on the
current study, but was previously normal.
___ CXR:
FINDINGS: Frontal and lateral radiographs of the chest were
acquired.
Elevation of the right hemidiaphragm is not significantly
changed compared to
the prior study from ___. There is minimal
atelectasis/scarring in
the right mid to upper lung. The lungs are otherwise clear.
The heart is
normal in size. The mediastinal contours are normal. There are
no pleural
effusions. No pneumothorax is seen.
IMPRESSION:
1. No acute cardiac or pulmonary process.
2. Unchanged elevation of the right hemidiaphragm.
==================================
___ CCATH
===================================
Procedures: Catheter placement, Coronary Angiography,
drug-eluting stent in the LCx
Coronary angiography: right dominant
LMCA: Distal 40% stenosis
LAD: Mild luminal irregularities
LCX: Mid vessel ulcerated mid circumflex ___ lesion at OM2 and
OM3. (OM1 is 0.5 mm).
RCA: Tubular 60% lesion mid vessel.
Assessment & Recommendations
1. ASA 81 mg PO QD indefinitely
2. Plavix 75 mg PO QD x 12 months uninterrupted
3. Secondary prevention CAD.
Brief Hospital Course:
___ with PMH significant for hypertension,
hyperlipidemia,tobacco abuse, anxiety, history of sinus
tachycardia (on beta-blockade), polymyalgia rheumatica who
presented ___ with chest pain and evidence of inferior NSTEMI
and is now stable post LCX coronary artery stent. Planned
discharge to home today.
# Inferior NSTEMI - Presented with right sided chest pressure
and ear pain and elevated troponins. Medically managed with
heparin drip, aspirin, and plavix until cardiac catheterization.
Catheterization revealed LCx with 90% stenosis and DES was
placed, RCA with 60% stenosis to be managed medically. TTE
showed mildly depressed LV systolic dysfunction with a 50% EF.
She was medically optimized with rosuvastatin (myalgias to
atorvastatin), lisinopril, metoprolol, aspirin, and plavix. She
remained free of cardiac symptoms after stent placement.
# Urinary tract infection- Urine grew klebsiella. Treated with
ceftriaxone and transitioned to ciprofloxacin. Completed a
course of antibiotics while hospitalized.
# cervical radiculopathy - held arthrotec.
==========================
CHRONIC ISSUES
==========================
# Hypertension - Controlled. Continued on metoprolol,
lisinopril..
# Hyperlipidemia - continued rosuvastatin.
# sinus tachycardia - on atenolol prior to admission,
transitioned to metoprolol. Remained tachycardiac to low 100's
at discharge.
# fibromyalgia - Pain controlled with home medications. Held
arthrotec at discharge.
# PMR - continued on prednisone.
==========================
TRANSITIONAL ISSUES
==========================
# Smoking cessation - Patient is motivated to quit and reports
good response to nicotine patch thus far. Given rx for nicotine
patch at discharge. Interested in exploring further options for
smoking cessation as an outpatient.
# sinus tachycardia - Noted on prior EKGs. Uptitrate metoprolol
as tolerated
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.5 mg PO QID:PRN anxiety
2. Atenolol 12.5 mg PO DAILY
3. Cyclobenzaprine 10 mg PO HS back pain/stiffness
4. Desipramine 30 mg PO HS
5. Gabapentin 600 mg PO HS
6. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO DAILY:PRN pain
7. Meclizine 25 mg PO BID
8. Rosuvastatin Calcium 5 mg PO DAILY
9. Vitamin D 3000 UNIT PO DAILY
10. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
11. Arthrotec 50 (diclofenac-misoprostol) 50-200 mg-mcg Oral TID
12. glucosamine-chondroitin 500-400 mg Oral daily
13. Lidocaine 5% Patch 1 PTCH TD DAILY
14. PredniSONE 10 mg PO DAILY
15. Ferrous Sulfate 325 mg PO DAILY
16. Calcium Carbonate 1500 mg PO BID
17. Alendronate Sodium 70 mg PO QWED
18. Cyanocobalamin 1000 mcg PO DAILY
19. Acetaminophen 650 mg PO PRN pain
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
2. ALPRAZolam 0.5 mg PO QID:PRN anxiety
3. Cyclobenzaprine 10 mg PO HS back pain/stiffness
4. Ferrous Sulfate 325 mg PO DAILY
5. Gabapentin 600 mg PO HS
6. Lidocaine 5% Patch 1 PTCH TD DAILY
7. Meclizine 25 mg PO BID
8. PredniSONE 10 mg PO DAILY
9. Vitamin D 3000 UNIT PO DAILY
10. Aspirin 81 mg PO DAILY
RX *aspirin [Children's Aspirin] 81 mg 1 tablet,chewable(s) by
mouth daily Disp #*30 Tablet Refills:*0
11. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
12. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
13. Metoprolol Succinate XL 75 mg PO DAILY
RX *metoprolol succinate 25 mg 3 tablet extended release 24
hr(s) by mouth daily Disp #*90 Tablet Refills:*0
14. Nicotine Patch 14 mg TD DAILY
RX *nicotine 7 mg/24 hour one patch daily Disp #*30 Unit
Refills:*0
15. Acetaminophen 650 mg PO PRN pain
16. Alendronate Sodium 70 mg PO QWED
17. Calcium Carbonate 1500 mg PO BID
18. Cyanocobalamin 1000 mcg PO DAILY
19. glucosamine-chondroitin 500-400 mg Oral daily
20. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO DAILY:PRN
pain
21. Rosuvastatin Calcium 10 mg PO DAILY
RX *rosuvastatin [Crestor] 10 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
22. Desipramine 10 mg PO 3 TABS AT NIGHT
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
1. Acute myocardial infarction
2. Sinus tachycardia
3. Urinary tract infection
SECONDARY
4. Cervical radiculopathy
5. Hypertension
6. Polymyalgia rheumatica
7. Osteoarthritis
8. Tobacco abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you at the ___
___. You were admitted because you had a
heart attack. You underwent cardiac catheterization which showed
a blocked artery which was limiting blood flow to your heart
muscle. A stent was placed in the blocked artery to restore
blood flow. You will be on aspirin and plavix which will help
prevent the stent from becoming blocked. If any doctor tries to
stop your aspirin and plavix, call your cardiologist and
continue taking them.
We also treated you for a urinary tract infection while you were
hospitalized. You completed a course of antibiotics.
Your heart rate continued to be elevated while you were
hospitalized, like it has been in the past. You should follow
this up with your primary care doctor and cardiologist for
___ management.
Thank you for choosing ___.
Followup Instructions:
___
|
10185323-DS-4 | 10,185,323 | 24,626,364 | DS | 4 | 2121-06-30 00:00:00 | 2121-06-30 20:00:00 |
Name: ___ Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / sea food
Attending: ___
Chief Complaint:
Dyspnea, hypoxemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ M h/o chronic thromboembolic pulmonary HTN
on rivaroxaban who presented to his outpatient pulmonologist
today for check up and found to be short of breath,
light-headed, and hypoxemic (satting 83% on his baseline 2L O2
for several weeks).
In ___, pt had a syncopal episode in ___. Pt felt fine,
played bingo, got up to walk and then woke up on the floor. He
was evaluated by his outpatient pulmonologist and told to use
his oxygen more consistently. Per pt, he has had dyspnea on
exertion (sits and rests twice on his way to dining room) w/
standing 2L pulsed O2. Pt reports that the dyspnea has been
worsening recently. Pt denies fevers, chills, wheezing, cough,
and chest pain with exertion. Pt has been prescribed Lasix PRN
but has not been using it. Pt denies increased consumption of
salt. His last right heart catheterization was ___ year ago, after
which he has developed a significant fear of the procedure.
In addition to hypoxemia, at the pulmonologist's office today,
pt was also found to have BLE edema (___), which he says began
~3 days ago. According to measurements made by his
pulmonologist, pt was 179.4 lb in ___, now ___ lb. His O2
was increased to 6L NC (pt improved to 93-96% O2 sat), and then
he was ordered for a chest CT, and sent to the ED.
Chest CT was notable for:
1. Small area of consolidation in the posterior right lower lobe
with new small right pleural effusion is suspicious for
pneumonia.
2. Enlarged pulmonary arteries and veins are consistent with
history of pulmonary artery hypertension.
3. Mild pulmonary emphysema.
4. Bilateral pulmonary ground-glass opacities and peripheral
parenchymal scarring appear stable from before.
In the ED, initial vitals: 97.8, 69, 95/58, 18, 95% NC 6 L O2.
- Labs revealed negative Trop-T, and unremarkable UA
- In the ED, pt received azithromycin and levofloxacin.
- L lower extremity Doppler did not reveal a DVT
- Vitals prior to transfer: 98.6, 67, 104/62, 18, 93% NC 6 L O2
Upon arrival to the floor, pt was in ___ acute distress, stable,
and breathing comfortably on NC 6 L O2.
Past Medical History:
-Chronic thromboembolic pulmonary hypertension (CTEPH). Chronic
PE seen on chest CTA in ___, started on warfarin,
eventually changed to Xarelto. VQ scan consistent in ___,
diffuse disease. Abnormal echo since at least ___ RHC
performed ___ (mPAP 34, PVR 6.5 ___. Not interested in
surgical evaluation for PTE.
-Exertional and nocturnal hypoxemia, with borderline resting
oxygen saturations. Adherent to nocturnal oxygen but poorly
adherent to daytime O2.
-Smoking history: ___ pack years, quit around ___
-Positive ___ (1:640), ___
-Nephrolithiasis, with uric acid stones, s/p left ureteroscopy,
lithotripsy, and stent placement ___. Put on potassium
citrate
though not recently taking.
-Acinetobacter leg infection requiring hospitalization/IV
antibiotics and drainage ___
-Erectile dysfunction
-Osteoarthritis
-Glaucoma
Social History:
___
Family History:
Father with CAD, and also had post-operative DVT/PE in his ___.
There is ___ family history of pulmonary hypertension or other
lung disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital Signs: 97.8 114/66 70 28 91% on 6L NC
General: Alert, oriented, ___ acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, neck supple,
JVP elevated to jaw.
CV: RRR, normal S1 + S2, ___ murmurs, rubs, gallops
Lungs: Mild crackles on base of R lung.
Abdomen: Soft, non-tender, non-distended, bowel sounds present
Ext: Warm, well perfused, 2+ pulses, 2+ edema
Neuro: AAOx3, EOMI, PERRL, equal facial sensation and auditory
sensitivity bilaterally, can smile to show teeth without gross
asymmetry. Grossly normal motor function and sensorium.
DISCHARGE PHYSICAL EXAM:
Vitals: T 98.1 BP ___ HR ___ 91% 3LNC
General: alert, oriented, ___ acute distress
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP 4cm above clavicle
Lungs: clear to auscultation bilaterally
CV: RRR, normal S1 + S2, ___ murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present
GU: ___ foley
Ext: WWP, ___ edema in lower extremities.
Neuro: Motor function and sensorium grossly normal
Pertinent Results:
ADMISSION LABS:
___ 11:33AM BLOOD WBC-6.7 RBC-4.44* Hgb-10.9*# Hct-36.7*
MCV-83# MCH-24.5*# MCHC-29.7*# RDW-18.6* RDWSD-54.8* Plt ___
___ 11:33AM BLOOD Neuts-74.8* Lymphs-15.5* Monos-8.4
Eos-0.4* Baso-0.6 Im ___ AbsNeut-5.00 AbsLymp-1.04*
AbsMono-0.56 AbsEos-0.03* AbsBaso-0.04
___ 11:33AM BLOOD Plt ___
___ 11:33AM BLOOD Glucose-89 UreaN-17 Creat-1.0 Na-139
K-4.1 Cl-105 HCO3-24 AnGap-14
___ 11:33AM BLOOD ALT-5 AST-26 LD(LDH)-459* AlkPhos-85
TotBili-0.6
___ 11:33AM BLOOD cTropnT-<0.01
___ 11:33AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.7
DISCHARGE LABS:
___ 07:35AM BLOOD WBC-5.8 RBC-4.93 Hgb-12.1* Hct-39.6*
MCV-80* MCH-24.5* MCHC-30.6* RDW-18.6* RDWSD-53.5* Plt ___
___ 07:35AM BLOOD Glucose-100 UreaN-31* Creat-1.1 Na-141
K-4.5 Cl-102 HCO3-23 AnGap-21*
___ 07:35AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.2
MICROBIOLOGY:
Urine culture: negative
Legionella urine antigen: negative
2x blood cultures: negative
IMAGING:
CT CHEST W/O CONTRAST
IMPRESSION:
1. Small area of consolidation in the posterior right lower lobe
with new
small right pleural effusion is suspicious for pneumonia.
2. Enlarged pulmonary arteries and veins are consistent with
history of
pulmonary artery hypertension.
3. Mild pulmonary emphysema.
4. Bilateral pulmonary ground-glass opacities and peripheral
parenchymal
scarring appear stable from before.
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
IMPRESSION:
___ evidence of deep venous thrombosis in the left lower
extremity veins.
TTE with bubble study
Echocardiographic Measurements
ResultsMeasurementsNormal Range
Left Atrium - Long Axis Dimension:3.4 cm<= 4.0 cm
Left Atrium - Four Chamber Length:4.6 cm<= 5.2 cm
Right Atrium - Four Chamber Length:*6.4 cm<= 5.0 cm
Left Ventricle - Septal Wall Thickness:
*1.3 cm0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness:
*1.2 cm0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension:
4.7 cm<= 5.6 cm
Left Ventricle - Systolic Dimension:
3.2 cm
Left Ventricle - Fractional Shortening:
0.32>= 0.29
Left Ventricle - Ejection Fraction:
55% to 60%>= 55%
Left Ventricle - Stroke Volume:
95 ml/beat
Left Ventricle - Cardiac Output:
5.61 L/min
Left Ventricle - Cardiac Index:
2.80>= 2.0 L/min/M2
Right Ventricle - Diastolic Diameter:
*4.7 cm<= 4.0 cm
Aorta - Sinus Level:3.3 cm<= 3.6 cm
Aorta - Ascending:*3.8 cm<= 3.4 cm
Aortic Valve - Peak Velocity:
1.0 m/sec<= 2.0 m/sec
Aortic Valve - LVOT VTI:
25
Aortic Valve - LVOT diam:
2.2 cm
Mitral Valve - E Wave:0.4 m/sec
Mitral Valve - A Wave:0.6 m/sec
Mitral Valve - E/A ratio:0.67
Mitral Valve - E Wave deceleration time:*286 ms140-250 ms
TR ___ (+ RA = PASP):
*65 mm Hg<= 25 mm Hg
Findings
This study was compared to the prior study of ___.
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. ___ ASD
by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%). Estimated cardiac
index is normal (>=2.5L/min/m2). Diastolic function could not be
assessed. ___ resting LVOT gradient.
RIGHT VENTRICLE: Mildly dilated RV cavity. Moderate global RV
free wall hypokinesis. Abnormal septal motion/position
consistent with RV pressure/volume overload.
AORTA: Normal aortic diameter at the sinus level. Mildly dilated
ascending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). ___ AS.
Trace AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. ___
MVP. LV inflow pattern c/w impaired relaxation.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to
moderate [___] TR. Eccentric TR jet. Severe PA systolic
hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
___ PS. Physiologic PR.
PERICARDIUM: ___ pericardial effusion.
GENERAL COMMENTS: Contrast study was performed with intravenous
injection of 8 ccs of agitated normal saline at rest. ___
contrast related complications. Suboptimal image quality - poor
apical views.
Conclusions
The left atrium is normal in size. The right atrium is
moderately dilated. ___ atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Diastolic function could not be assessed. The
right ventricular cavity is mildly dilated with moderate global
free wall hypokinesis. There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
___ mitral valve prolapse. The left ventricular inflow pattern
suggests impaired relaxation. The tricuspid regurgitation jet is
eccentric and may be underestimated. There is severe pulmonary
artery systolic hypertension. There is ___ pericardial effusion.
IMPRESSION: Suboptimal image quality. Dilated and hypokinetic
right ventricle with signs of pressure/volume overload. Severe
pulmonary hypertension. Mild symmetric left ventricular
hypertrophy with preserved global and regional LV systolic
function.
Compared with the prior study (images reviewed) of ___,
the degree of valvular regurgitation is lower; overall findings
are similar.
Brief Hospital Course:
Mr. ___ is a ___ year old man with a history of chronic
thromboembolic pulmonary hypertension (on riociguat, selexipag,
and rivoroxaban) who presented to his pulmonologist for check up
and found to be short of breath and hypoxemic, with clear signs
of volume overload (now diuresed with lasix down to his dry
weight), suspicion for community-acquired pneumonia (treated
with ceftriaxone and azithromycin), found to have iron and
B12-deficiency anemia (treated with IV iron and B12
supplementation).
ACTIVE ISSUES:
============
#Decompensated right-sided heart failure: Patient has a history
of CTEPH and presented initially with shortness of breath,
significant weight gain, and hypoxemia. At admission patient
required 6L O2 by nasal cannula with oxygen saturation in the
mid ___ (above his baseline O2 requirement of 2L NC) and was
noted to have 3+ pitting edema of the lower extremities
bilaterally on exam. Pulmonology was consulted during the
admission. Pt was diuresed >40lb with IV furosemide boluses.
During this time, patient's oxygen requirement also decreased to
3L NC, 4L NC with ambulation. He was discharged on 20mg
furosemide daily.
#Suspected community-acquired pneumonia (CAP): Patient presented
without clinical signs of pneumonia (i.e., absent fever, cough
or leukocytosis) but findings on chest CT were suspicious for
CAP. He was treated empirically with a 5-day course of
ceftriaxone and azithromycin.
#Chronic thromboembolic pulmonary hypertension: Patient's recent
syncopal episode with fall and loss-of-consciousness in ___
is concerning for worsening pulmonary hypertension. His
outpatient pulmonologist was consulted and in communication with
inpatient pulmonology consulting service. Patient had previously
refused surgical management of CTEPH and so his condition was
being managed medically using riociguat, selexipag, and
rivaroxaban. Patient declined inpatient right heart catheter
study for medication optimization. A TTE with bubble study was
inconclusive for shunting.
#Iron, B12-deficiency anemia: During the patient's admission, he
was found to be anemic, with a significant decrease in his
hemoglobin compared to ___ years prior (14.7 -> ___, and also
found to be iron and B12-deficient. The etiology of his iron,
B12-deficiencies was unclear. The patient was given IV iron and
IM B12 supplementation, which he tolerated well. Upon discharge,
patient should have further investigation of his iron,
B12-deficiencies, including clarification of prior colonoscopies
and potential workup for pernicious anemia.
CHRONIC ISSUES:
==============
#Glaucoma: continued on home med eye drops
#GERD: continued on omeprazole
TRANSITIONAL ISSUES:
==================
- Pt discharged on PO Lasix 20mg daily. Please monitor volume
status and consider adjustment of dose if appropriate.
- Please check complete metabolic panel twice per week starting
___ and adjust diuretic and potassium dose accordingly.
- Pt noted to have worsening chronic anemia during admission
secondary to B12 and iron deficiency (of unclear underlying
etiology). Started on IV iron and oral B12 1000mg daily. Pt
needs to continue IV iron and oral B12 as an outpatient with
monitoring of his CBC, iron studies, and B12 level. Consider
outpatient endoscopy/colonoscopy given iron deficiency and
further workup for the underlying etiology of the B12
deficiency.
- Pt will take his own supply of his riociguat and selexipag
which is prescribed by his former pulmonologist Dr. ___
___. She is agreeable to providing a 3-month interval supply
until he sees his new pulmonologist Dr. ___ and is
able to renew the prescriptions.
- DISCHARGE WEIGHT: 78.38kg
- DISCHARGE BUN/CREATININE: ___
- DISCHARGE POTASSIUM: 4.5
# CODE STATUS: Full
# CONTACT: Health care proxy: Sister, ___ (___
___ C ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
2. Omeprazole 20 mg PO BID
3. riociguat 2 mg oral TID
4. Rivaroxaban 20 mg PO DAILY
5. selexipag 1,200 mcg oral BID
6. Tamsulosin 0.4 mg PO DAILY
7. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
Discharge Medications:
1. Furosemide 20 mg PO DAILY
2. Potassium Chloride 20 mEq PO DAILY
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
5. Omeprazole 20 mg PO BID
6. riociguat 2 mg oral TID
7. Rivaroxaban 20 mg PO DAILY
8. selexipag 1,200 mcg oral BID
9. Tamsulosin 0.4 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Right ventricular heart failure exacerbation
Community acquired pneumonia
Iron deficiency and B12-deficiency anemia
Secondary:
Chronic thromboembolic pulmonary 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 taking care of you during your hospital stay
at ___. You were hospitalized
for significant fluid retention for which you needed more
oxygen. We gave you Lasix to remove excess fluid from your body
and antibiotics for a possible pneumonia. While you were here,
you were also found to be anemic with iron and vitamin B12
deficiency. You were treated with B12 and intravenous iron
supplementation, although the cause of your deficiencies is
unclear and should be followed up with your primary care doctor.
You should take your furosemide (diuretic) and potassium pill
every day. You should also track your weight every day and tell
your doctor if you gain >3lb in 2 days or >5lb in 5 days. You
should talk to your doctor about IV iron supplementation when
you leave the hospital as well.
Take Care,
Your ___ Team.
Followup Instructions:
___
|
10185405-DS-17 | 10,185,405 | 21,571,821 | DS | 17 | 2184-03-18 00:00:00 | 2184-03-18 18:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___ with right carotid aneurysm incidentally found to have a
ruptured descending thoracic aneurysm
Major Surgical or Invasive Procedure:
___ TEVAR
___ Interposition Lt SVG for R carotid pseudoaneurysm
History of Present Illness:
Mr. ___ is a ___ who was transferred from ___ for management
of his thoracic aneurysm. He is reporting back pain that is
different from normal that he is unsure how long has been going
on. He was evaluated by his PCP for ___ neck mass and on CTA he
was found to have a "7mm carotid bifurcation aneurysm" after
this report she urged him to go to the emergency department. He
did report neck pain a few months ago and was sick this past
___ however he denies any syncopal episodes, problems
swallowing or hoarseness.
Mr. ___ has monthly appointments at his PCPs office for
follow up for chronic pain issues. On ___, he reported 10
days of generalized flu-like symptoms with fatigue, poor energy
and decreased po intake. He was fully recovered by that visit
and no testing was done. He was seen at his PCPs office on ___
and c/o sore throat pain and neck pain. Rapid strep test was
negative.
Monospot was negative. Wbc was 9.9. He had a L ankle x-ray at
___ for a recent minor trauma that was reportedly
negative. He had a neck
USG at ___ on ___ with "no sonographic correlate to the
palpable neck mass."
He was referred to Dr. ___, ___) for
follow up of sore throat and R neck mass and was seen on
___. He had an endoscopic examination that was reportedly
negative and was prescribed clindamycin 300 mg po q8h for 10
days. Mr. ___ reports that he was given a pill to take once
a day for 30 days. Clindamycin per patient
He was followed up with his PCPs office on ___ for a
routine visit. A neck mass was noted and he was sent for a CT
scan which was done on ___ showing multiple outpouchings at the
R common carotid bifurcation c/w pseudoaneurysm and irregularity
of the descending thoracic aorta
with fat stranding. He was seen in ___ where he had
chest/upper GI pain. Chest/abdomen CT showed a focal
outpouching in the posterior descending thoracic aorta 7 cm
distal to the origin of the L subclavian artery with a rim of
soft tissue density suggestive of pseudoaneurysm or penetrating
ulcer/dissection. Colon showed extensive diverticulosis. He
was then transferred to ___ for urgent procedure.
Past Medical History:
MH: hepatitis C, IDDM, HTN, pancreatitis, ?GI cancer-pt is
unclear as to the history of this and reports he had polyps
SH: ___
Family History:
grandmother had an aneurysm
Physical Exam:
VS: T99 HR100 BP159/84 RR19 SpO2 96%onRA
GENL: NAD
EENT: PERRL, EOMI, sclerae anicteric, moist mucous membranes
NECK: supple, staples in place along R neck
CARD: RRR, normal S1, S2, no murmurs
PULM: clear to auscultation bilaterally w/o wheezes
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
MSK: no joint swelling or erythema
EXTR: warm and well perfused, no edema, 2+ DP pulses palpable
bilaterally
Pulses: R: P/P/P/P L: P/P/P/P
SKIN: no rashes, no jaundice
NEURO: awake, alert and oriented x3
PSYCH: non-anxious, normal affect
Pertinent Results:
___ 09:30AM BLOOD WBC-6.7 RBC-2.86* Hgb-9.5* Hct-30.4*
MCV-106* MCH-33.2* MCHC-31.3* RDW-14.2 RDWSD-55.1* Plt ___
___ 07:12AM BLOOD Neuts-69.1 Lymphs-14.0* Monos-13.2*
Eos-2.8 Baso-0.7 Im ___ AbsNeut-3.94# AbsLymp-0.80*
AbsMono-0.75 AbsEos-0.16 AbsBaso-0.04
___ 09:30AM BLOOD Glucose-134* UreaN-18 Creat-1.2 Na-136
K-4.2 Cl-100 HCO3-28 AnGap-12
___ 03:30PM BLOOD ALT-9 AST-19 AlkPhos-159* TotBili-0.8
___ 09:30AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.8
___ 06:23AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 06:23AM URINE Color-Yellow Appear-Clear Sp ___
Brief Hospital Course:
The patient was brought to the operating room on ___ and
underwent TEVAR. The procedure was without complications. He was
closely monitored in the PACU and then transferred to the floor
in stable condition where he remained hemodynamically stable. On
POD#1, his images sent from his outside hospital demonstrated
focal saccular dilation of his right common carotid artery. He
was brought to the operating room for immediate operation and
carotidectomy and interposition for R carotid aneurysm. He was
placed on empiric vanc/zosyn for possible mycotic aneurysm.
During his admission he presented with the following issues :
Vascular surgery:
On POD-6 The patient had CTA of his chest to f/u on the Aortic
endovascular graft; a Small contained endo-leak, was noticed and
after discussion it has been decided to follow this finding in a
CTA 3 weeks post discharge, the patient had no neurologic signs.
His Rt neck incision - clean non pulsating , no SSI. Lt groin
incision (SVG donor site) still with staples, clean, no signs of
infection, pseudoaneurism or bleeding. He is scheduled for a
visit in Dr. ___ after CTA is done within 3 weeks.
ID:
As a purulent material was discovered when dissecting the
internal carotid aneurism, and the appearance of 2 aneurisms at
presentation , a source of blood born infection was thoroughly
investigated with the following modalities:
TTE and later TEE, CT brain, MRI of ankle(d/t old injury as a
possible source of infection), tagged WBC whole body scan, blood
urine and purulent material cultures all did not point towards
the pathogen taking the fact the patient was treated with
clindamycin for at least 10 days prior to his admission. the
patient also had an investigation for a past syphilis infection,
HIV which came back negative
The carotid purulent material was sent to universal PCR.
few days prior to his discharge the PCR came back positive for
Strep viridance.
The patient was treated with empirical Abx; Vanco zosyn than
Vanco, Levofloxacin and Flagyl which was changed to Rocephin
once the PCR result came back. he had Picc line insertion and
due to have Rocepohin for 4 more weeks. he is afebrile no
leukocytosis and no apparent active infection and he is set to
receive 6 weeks of Abx total for an aortic graft was placed in
presumably bacteremic state.
He will be f/u weekly with blood test for CBC LFT's, Renal
functions and ESR/CRP in the out patient setting.
Speech and Swallow:
The patient experienced swallowing difficulties and was assessed
by S&S team, video swallow test and ENT examination- which
concluded that he has a high risk of aspiration with every
consistency of intake which attributed to either postoperative
changes/edema or for CN injury during surgery. therefore he was
bridged with NGT before undergoing a PEG insertion 3 days prior
to discharge. he is been fed by boluses with good tolerance and
he is scheduled for a visit with S&S as an out patient.
Rheumatology consult:
Concluded that while his presentation is concerning for possible
vasculitis, given the multiple location and simultaneous timing
of his aneurysms. This seems to be less likely given the
purulent materials seen in the OR, normal for age ESR (tough
elevated CRP(48)) together with the lack of other systemic signs
(vasculitic rash)
rending it less likely. Furthermore, upon review of his carotid
arterial wall path, it is reported that there is no evidence of
an active arteritis or inflammatory vasculitis.
The patient c/o Rt inguinal pain US showed Rt inguinal hernia
containing fat and probably SB. Clinically not incarcerated or
strangulated. He will be checked as an outpatient in the ACS
service.
The patient needs a dentist examination for possible oral
odontodonic infection.
He is being Discharged home with services and will be called for
staple removal in a week.
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. CefTRIAXone 2 gm IV Q 24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 gr IV Q24 Disp
#*30 Intravenous Bag Refills:*0
3. OxyCODONE--Acetaminophen (5mg-325mg) 2 TAB PO Q4H pain
for 2 days only
RX *oxycodone-acetaminophen 5 mg-325 mg 2 tablet(s) by mouth
every four (4) hours Disp #*24 Tablet Refills:*0
4. amLODIPine 10 mg PO DAILY
5. Lisinopril 20 mg PO DAILY
6. MetFORMIN (Glucophage) 500 mg PO BID
7.isosource 1.5
Isosource 1.5 bolus 5 cans /day via PEG
dispense one month supply with 5 refills
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right carotid mycotic aneurysm with purulence within the wall of
the artery.
Ruptured thoracic aortic aneurysm.
Dysphagia and silent aspiration post Rt carotid surgery
Rt inguinal hernia
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 ___
___. You were was transferred from ___ for
management of your thoracic aneurysm. you had a procedure for a
placement of a stent graft in your aorta to strengthen the part
of the artery that was weakened by an aneurysm. To perform this
procedure small punctures were made in the arteries on both
sides of your groin. You tolerated the procedure well. One day
later you had a repair of your right carotid aneurysm using the
greater saphenous vein (from your Lt leg) during which a
purulent material was discharged form the aneurysm surrounding.
During your admission you had a though workup for the source of
this infection which included US of your heart through your
chest and esophagus, head CT, MRI of old injury in your Lt ankle
and a Tagged WBC whole body scan. You also had blood and urine
culture and the purulent material surrounding your carotid
aneurysm was sent for a specific Bacterial DNA amplification and
sequencing. The latter suggested an infection with a bacteria
named: strep. viridance for which you were treated and will be
treated at home for the next 4 weeks. For this reason an
intravenous line was inserted to your Rt arm (picc line)and this
will serve you at home. During your stay you had problems
swallowing liquids and solid food and were evaluated for the
risk for aspiration during eating and drinking. You were found
to be in a high risk for aspiration so anso gastric tube was
inserted for feeding as a bridge to PEG insertion you had 3 days
ago. You are now tolerating PEG bolus feeding well. during your
stay you complained of a Rt groin pain and a non incarcerated Rt
inguinal hernia was clinically and sonographicaly diagnosed. You
will be schedule for a visit for an elective repair. in terms of
your vascular repairs, you tolerated the procedure well, a CT
scan of your chest during your stay revealed a suspicion for a
small contained leak form the Aortic stent. a decision was made
to follow this with another CT scan in 3 weeks. You are now
ready to be discharged from the hospital. Please follow the
recommendations below to ensure a speedy and uneventful
recovery.
PLEASE NOTE: After thoracic endovascular aortic repair (TEVAR),
it is very important to have regular appointments (every ___
months) for the rest of your life. These appointments will
include a CT (CAT) scan for your graft. If you miss an
appointment, please call to reschedule.
WHAT TO EXPECT:
Bruising, tenderness, and a sensation of fullness at the groin
puncture sites (or incisions) is normal and will go away in
one-two weeks
CARE OF THE GROIN PUNCTURE SITES:
It is normal to have mild swelling, a small bruise, or small
amounts of drainage at the groin incision/puncture sites. In
two weeks, you may feel a small, painless, pea sized knot at the
puncture site on your Rt groin. This too is normal. You may
notice swelling in the scrotum. The swelling will get better
over one-two weeks.
Look at the area daily to see if there are any changes. Be
sure to report signs of infection. These include: increasing
redness; worsening pain; new or increasing drainage, or drainage
that is white, yellow, or green; or fever of 101.5 or more. (If
you have taken aspirin, Tylenol, or other fever reducing
medicine, wait at least ___ hours after taking it before you
check your temperature in order to get an accurate reading.)
FOR SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
If you have sudden, severe bleeding or swelling at either of
the groin puncture sites:
-Lie down, keep leg straight and apply (or have someone apply)
firm pressure to area for ___ minutes with a gauze pad or
clean cloth.
-Once bleeding has stopped, call your surgeon to report what
happened.
-If bleeding does not stop, call ___ for transfer to closest
Emergency Room.
You may shower. Let the soapy water run over the puncture
sites, then rinse and pat dry. Do not rub these sites and do
not apply cream, lotion, ointment or powder.
Wear loose-fitting pants and clothing as this will be less
irritating to the groin puncture sites.
MEDICATIONS
Take aspirin daily. Aspirin helps prevent blood clots that
could form in your repaired artery.
It is very important that you never stop taking aspirin or
other blood thinning medicines-even for a short while- unless
the surgeon who repaired your aneurysm tells you it is okay to
stop. Do not stop taking them, even if another doctor or nurse
tells you to, without getting an okay from the surgeon who first
prescribed them.
You will be given prescriptions for any new medication started
during your hospital stay.
Before you go home, your nurse ___ give you information about
new medication and will review all the medications you should
take at home. Be sure to ask any questions you may have. If
something you normally take or may take is not on the list you
receive from the nurse, please ask if it is okay to take it.
PAIN MANAGEMENT
Most patients do not have much pain following this procedure.
Your puncture and groin incision sites may be a little sore.
This will improve daily. If it is getting worse, please let us
know.
You will be given instructions about taking pain medicine if
you need it.
ACTIVITY
You must limit activity to protect the puncture sites in your
groin. For ONE WEEK:
-Do not drive
-Do not swim, take a tub bath or go in a Jacuzzi or hot tub
-Do not lift, push, pull or carry anything heavier than five
pounds
-Do not do any exercise or activity that causes you to hold your
breath or bear down with your abdominal muscles.
-Do not resume sexual activity
Discuss with your surgeon when you may return to other regular
activities, including work. If needed, we will give you a
letter for your workplace.
It is normal to feel weak and tired. This can last six-eight
weeks, but should get better day by day. You may want to have
help around the house during this time.
___ push yourself too hard during your recovery. Rest when
you feel tired. Gradually return to normal activities over the
next month.
We encourage you to walk regularly. Walking, especially
outdoors in good weather is the best exercise for circulation.
Walk short distances at first, even in the house, then do a
little more each day.
It is okay to climb stairs. You may need to climb them slowly
and pause after every few steps.
DIET
It is normal to have a decreased appetite. Your appetite will
return over time.
Follow a well balance, heart-healthy diet, with moderate
restriction of salt and fat.
Eat small, frequent meals with nutritious food options (high
fiber, lean meats, fruits, and vegetables) to maintain your
strength and to help with wound healing.
BOWEL AND BLADDER FUNCTION
You should be able to pass urine without difficulty. Call you
doctor if you have any problems urinating, such as burning,
pain, bleeding, going too often, or having trouble urinating or
starting the flow of urine. Call if you have a decrease in the
amount of urine.
You may experience some constipation after surgery because of
pain medicine and changes in activity. Increasing fluids and
fiber in your diet and staying active can help. To relief
constipation, you may talk a mild laxative. Please take to
your pharmacist for advice about what to take.
SMOKING
If you smoke, it is very important that you STOP. Research
shows smoking makes vascular disease worse. This could increase
the chance of a blockage in your new graft. Talk to your
primary care physician about ways to quit smoking.
CALLING FOR HELP/DANGER SIGNS
If you need help, please call us at ___. Remember,
your doctor, or someone covering for your doctor, is available
24 hours a day, seven days a week. If you call during
nonbusiness hours, you will reach someone who can help you reach
the vascular surgeon on call.
Call your surgeon right away for:
Pain in the groin area that is not relieved with medication,
or pain that is getting worse instead of better
Increased redness at the groin puncture/incision sites
New or increased drainage from the groin puncture sites, or
white yellow, or green drainage
Any new bleeding from the groin puncture/incision sites. For
sudden, severe bleeding, apply pressure for ___ minutes. If
the bleeding stops, call your doctor right away to report what
happened. If it does not stop, call ___
Fever greater than 101.5 degrees
Nausea, vomiting, abdominal cramps, diarrhea or constipation
Any worsening pain in your chest back or abdomen
Problems with urination
Changes in color or sensation in your feet or legs
CALL ___ in an EMERGENCY, such as
Any sudden, severe pain in the back, abdomen, or chest
A sudden change in ability to move or use your legs
Sudden, severe bleeding or swelling at either groin site that
does not stop after applying pressure for ___ minutes
Followup Instructions:
___
|
10185454-DS-13 | 10,185,454 | 28,615,334 | DS | 13 | 2196-06-01 00:00:00 | 2196-06-01 13:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Morphine / Motrin
Attending: ___
___ Complaint:
R knee pain and swelling
Major Surgical or Invasive Procedure:
___ s/p R knee arthroscopic I&D
___ s/p R knee arthroscopic I&D
___ s/p R knee arthroscopic I&D
History of Present Illness:
Mr. ___ is a ___ year-old gentleman who is most recently s/p
right knee arthroscopy one week ago during which he underwent
repair of his lateral meniscus and debridement of his medial
meniscus. Initially post-operatively he was doing well with
minimal pain. He was discharged home on the day of surgery and
has been ambulating around his house with the assistance of
crutches. He has been doing stairs to get to his restroom. He
states that 3 days ago, he began to have worsening pain about
the knee. He denies new injury, but states that subsequently the
knee has become increasingly swollen and painful with movement.
He continues to use crutches. He called Dr. ___ office
earlier today because he was concerned that the percocet was no
longer offering any pain relief. He also endorses a small amount
of serosanguinous drainage from his knee that happened when the
EMTs came today. He denies any fevers or chills. He does state
that the knee is hot, but denies any spreading erythema.
Past Medical History:
OSA, OA, Gout, HTN, HL, GERD, Fatty Liver
Social History:
___
Family History:
n/c
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:
___ 08:50AM BLOOD WBC-7.2 RBC-4.22* Hgb-12.0* Hct-37.9*
MCV-90 MCH-28.4 MCHC-31.6 RDW-13.2 Plt ___
___ 06:00AM BLOOD WBC-7.0 RBC-4.06* Hgb-11.6* Hct-35.9*
MCV-89 MCH-28.6 MCHC-32.3 RDW-14.3 Plt ___
___ 06:20AM BLOOD WBC-6.8 RBC-4.11* Hgb-12.1* Hct-37.4*
MCV-91 MCH-29.5 MCHC-32.4 RDW-13.3 Plt ___
___ 08:50AM BLOOD Neuts-75.2* Lymphs-14.6* Monos-8.0
Eos-1.5 Baso-0.8
___ 01:00PM BLOOD Neuts-75.1* Lymphs-15.2* Monos-7.0
Eos-2.2 Baso-0.4
___ 11:40PM BLOOD Neuts-78.0* Lymphs-14.6* Monos-6.4
Eos-0.5 Baso-0.5
___ 09:25AM BLOOD ___ PTT-32.6 ___
___ 06:20AM BLOOD ESR-105*
___ 09:00AM BLOOD ESR-60*
___ 06:30AM BLOOD ESR-45*
___ 06:20AM BLOOD CRP-228.7*
___ 08:50AM BLOOD Glucose-118* UreaN-12 Creat-0.8 Na-137
K-4.4 Cl-99 HCO3-29 AnGap-13
___ 06:05AM BLOOD Glucose-105* UreaN-12 Creat-0.9 Na-136
K-4.1 Cl-97 HCO3-31 AnGap-12
___ 06:00AM BLOOD Glucose-101* UreaN-12 Creat-0.8 Na-138
K-4.3 Cl-98 HCO3-34* AnGap-10
___ 08:50AM BLOOD Calcium-8.9
___ 06:05AM BLOOD Calcium-8.7 Phos-4.1 Mg-2.1
___ 05:05AM BLOOD Calcium-8.3* Phos-3.5 Mg-2.1
___ 11:55PM BLOOD Lactate-1.4
___ 05:00PM JOINT FLUID ___ HCT,Fl-11.0* Polys-96*
___ ___ 08:20PM JOINT FLUID ___ Polys-96*
___ Macro-2
___ 06:53AM JOINT FLUID ___ HCT,Fl-5.0* Polys-94*
___ Monos-3 Eos-1*
___ 5:01 pm JOINT FLUID Site: RIGHT KNEE JOINT FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Final ___:
WORKUP REQUESTED BY ___. ___ ___.
ENTEROBACTER AEROGENES. SPARSE GROWTH.
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.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER AEROGENES
|
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
Brief Hospital Course:
The patient was admitted to the orthopaedic surgery service and
was taken to the operating room for above described procedures.
Please see separately dictated operative reports for details.
The surgeries were uncomplicated and the patient tolerated the
procedure well. Patient received perioperative IV antibiotics.
Postoperative course was remarkable for the following:
1. ID consult - Enterobacter aerogenes growing x 3 cultures -
patient to recieve continued treatment with Ertapenem 1 gram
daily x 4 wks after discharge. Fax weekly safety labs
(CBC/diff, chem 7, LFT's, ESR, CRP) to ___
Otherwise, pain was initially controlled with a PCA followed by
a transition to oral pain medications. The patient received
lovenox for DVT prophylaxis starting on the morning of POD#1.
The foley was removed on POD#2 and the patient was voiding
independently thereafter. The surgical dressing was changed on
POD#2 and the surgical incision was found to be clean and intact
without erythema or abnormal drainage. The patient was seen
daily by physical therapy. 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 rehab in stable condition.
Medications on Admission:
1. Aspirin 81 mg PO DAILY
2. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
3. Metoprolol Tartrate 12.5 mg PO DAILY
4. Simvastatin 20 mg PO DAILY
5. Ranitidine 150 mg PO PRN stomach upset
6. Lisinopril 10 mg PO DAILY
Discharge Medications:
1. Metoprolol Tartrate 12.5 mg PO DAILY
2. Ranitidine 150 mg PO BID:PRN stomach upset
3. Simvastatin 20 mg PO DAILY
4. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
5. Aspirin 81 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Enoxaparin Sodium 40 mg SC DAILY Duration: 4 Weeks (Last
dose: ___
8. Gabapentin 600 mg PO Q8H
9. Lisinopril 10 mg PO DAILY
10. Oxycodone SR (OxyconTIN) 20 mg PO Q12H Duration: 14 Days
RX *oxycodone [OxyContin] 20 mg 1 tablet(s) by mouth twice a day
Disp #*28 Tablet Refills:*0
11. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone [Dilaudid] 4 mg ___ tablet(s) by mouth Q3H-Q4H
Disp #*120 Tablet Refills:*0
12. ertapenem 1g IV DAILY Duration: 4 Weeks (Estimated end date:
___
13. Acetaminophen 500 mg PO Q6H - Max 2g/day.
14. Bisacodyl 10 mg PO DAILY:PRN constipation
15. Cyclobenzaprine 10 mg PO TID:PRN pain
16. Fleet Enema ___AILY:PRN constipation
17. Polyethylene Glycol 17 g PO DAILY
18. Senna 1 TAB PO BID
Discharge Disposition:
Extended Care
Facility:
___
for Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
Right knee infection
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 keep your wounds clean. You may shower starting five
(5) days after surgery, but no tub baths or swimming for at
least four (4) weeks. No dressing is needed if wound continues
to be non-draining. Any stitches or staples that need to be
removed will be taken out at your follow-up visit in three (3)
weeks after your surgery.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment in three (3) weeks.
8. Please DO NOT take any non-steroidal anti-inflammatory
medications (NSAIDs such as celebrex, ibuprofen, advil, aleve,
motrin, etc).
9. ANTICOAGULATION: Please continue your lovenox for four (4)
weeks to help prevent deep vein thrombosis (blood clots). If
you were taking aspirin prior to your surgery, it is OK to
continue at your previous dose while taking this medication.
___ STOCKINGS x 6 WEEKS.
10. WOUND CARE: Please keep your incision clean and dry. 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. Please place a dry sterile dressing on the wound
each day if there is drainage, otherwise leave it open to air.
Check wound regularly for signs of infection such as redness or
thick yellow drainage. Staples will be removed at your follow-up
visit in three (3) weeks.
11. ___ (once at home): Home ___, dressing changes as
instructed, wound checks, PICC line management, and IV
antibiotics.
12. ACTIVITY: Weight bearing as tolerated on the operative
extremity. Mobilize. ROM as tolerated. No strenuous exercise or
heavy lifting until follow up appointment.
13. ANTIBIOTICS: You are to be discharged on Ertapenem 1 gram
daily x 4 wks. Please Fax weekly safety labs (CBC/diff, chem 7,
LFT's, ESR, CRP) to ___. ___ transition to oral Cipro
per ID depending on clinical presentation.
Physical Therapy:
RLE WBAT
ROMAT
Mobilize
Treatments Frequency:
Dry sterile dressing daily as needed for drainage
Wound checks
Ice and elevation
TEDs
PICC line management per facility protocol
IV antibiotic via ___
Labs
- Check weekly and fax results to ID at ___
- Check CBC/diff, Chem 7, LFTs, ESR/CRP
Followup Instructions:
___
|
10185829-DS-10 | 10,185,829 | 24,391,963 | DS | 10 | 2165-01-05 00:00:00 | 2165-01-05 18:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Aspirin / Metoprolol Tartrate
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ s/p type A dissection repair (___), COPD, presenting with
left lower quadrant abdominal pain and urinary retention. The
patient reports some urinary issues in the past that are
consistent with urinary retention. His abdominal pain has been
better since he started antibiotics. This pain is consistent
with
his diverticulitis that he has experienced before. He states
this
is consistent with his BPH. He has required a Foley in the past.
He states that his left lower quadrant abdominal pain is
consistent with prior episodes of diverticulitis. LLQ abdominal
pain for 1 day. Patient is a transfer from ___.
Past Medical History:
Hypertension
Tobacco use
Social History:
___
Family History:
N/C
Physical Exam:
Admission physical:
PE: 97.7 88 131/70 20 93% RA
___: comfortable
___: RRR
Pulm: no respiratory distress
Abdomen: soft, TTP LLQ and suprapubic area
-urine is leaking around the foley
Ext: all pulses in the lower extremities are palpable
bilaterally
Discharge physical:
98.5PO 127 / 50L Lying 60 18 94 RA
___: NAD
___: RRR
Pulm: NRD
Abdomen: Soft, non-tender, no masses
Extremities: WWP
Pertinent Results:
Admission labs
___ 11:35PM WBC-20.8* RBC-4.51*# HGB-13.6*# HCT-41.1#
MCV-91 MCH-30.2 MCHC-33.1 RDW-14.7 RDWSD-49.5*
___ 11:35PM GLUCOSE-102* UREA N-16 CREAT-1.1 SODIUM-136
POTASSIUM-3.9 CHLORIDE-97 TOTAL CO2-22 ANION GAP-17*
___ 11:40PM ___ PTT-29.7 ___
___ 11:52PM LACTATE-2.2*
___ 10:45AM LACTATE-1.4
CT Scan ___:
1. Stable extension of the type B aortic dissection, with
involvement of the
celiac, SMA, left renal and left common iliac arteries. The
distal branches
of the SMA are supplied by the true lumen and remain patent.
2. Acute uncomplicated sigmoid diverticulitis, without evidence
of perforation
or abscess.
3. New small bowel dilatation, with gradual tapering up to the
level of the
distal ileum, where there are few focal more abrupt changes in
bowel caliber.
Overall, this likely represents an ileus secondary to the
sigmoid
diverticulitis.
4. Focally thickened segment of proximal ileum in the pelvis,
without adjacent
inflammatory changes, likely reactive. There is no pneumatosis
or portal
venous gas. No signs of bowel ischemia on the present study.
5. Small volume of ascites which has increased since the
previous study.
6. Uncomplicated cholelithiasis.
7. Prominent prostatic enlargement. Correlate with PSA.
8. Severe emphysema.
Discharge Labs:
___ 07:16AM BLOOD WBC-10.4* RBC-4.36* Hgb-13.4* Hct-40.5
MCV-93 MCH-30.7 MCHC-33.1 RDW-15.4 RDWSD-52.7* Plt ___
___ 07:20AM BLOOD ___
Brief Hospital Course:
The patient was admitted to the vascular surgery inpatient
service from the ED after being transferred from ___
___ for management of 5.1 cm chronic Type B thoracic
dissection and SMA thrombus as well as acute diverticulitis. He
was started on IVF, NPO, a heparin drip, and IV antibiotics. At
that time he had been having LLQ pain for 2 days.
The following day, the patient's pain was improving but still
present. He had multiple bowel movements. He was advanced to CLD
but tolerated only small amounts of PO intake. He was started on
PO Coumadin with heparin gtt continued as a bridging therapy.
HD3-4, the patient was tolerating CLD and his IVF were
discontinued. By HD5, the patient was tolerating a regular diet
and his pain had resolved. He was switched to PO antibiotics
which he tolerated well. On the day of discharge, HD6, the
patient's vital signs were stable. He was tolerating regular
diet, urinating spontaneously, had no abdominal pain, and was
ambulating without difficulty. His INR was therapeutic. He was
discharged with instructions to take 2mg Warfarin ___ and
follow up with his PCP, who was contacted, on ___ for INR check
and ongoing warfarin dosing. He was also scheduled for one month
follow up with the outpatient vascular surgery clinic. The
discharge plan was discussed with the patient, who expressed
understanding and agreement.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Bystolic (nebivolol) 5 mg oral DAILY
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every 12 hours
Disp #*21 Tablet Refills:*0
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*19 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*32 Tablet Refills:*0
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*29 Tablet Refills:*0
3. ___ MD to order daily dose PO DAILY16
RX *warfarin 2 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Bystolic (nebivolol) 10 mg oral DAILY
5. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
Discharge Disposition:
Home
Discharge Diagnosis:
1. Diverticulitis
2. Chronic type B aortic dissection
3. SMA thrombus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Dr. ___ were admitted to ___ for
diverticulitis and SMA thrombus. ___ have now progressed well
and are ready to be discharged. Please follow the instructions
below to continue your recovery:
Please call our office at ___ if ___ have any questions
or concerns. Please see follow up information below regarding
warfarin management.
Please take 2mg Warfarin once a day from ___ and
follow up with your PCP ___ ___ for ongoing management.
Followup Instructions:
___
|
10186442-DS-17 | 10,186,442 | 25,331,778 | DS | 17 | 2167-11-26 00:00:00 | 2167-11-28 15:45:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with history of hypertension,
hyperlipidemia, noninsulin-dependent diabetes ___, and
chronic kidney injury (stage 3) who presents with progressive
dyspnea. History is obtained entirely from the patient as Atrius
link is not enabled at this time. She was in her usual state of
health until approximately 4 months prior to admission, when she
was visiting ___ and developed insidious-onset progressive
shortness of breath at rest, exacerbated by minimal exertion; by
this point, she can ambulate no more than ___ minutes on level
ground and ascend no more than 1 flight of stairs without
becoming profoundly dyspneic. Over the same period, she has
experienced increasing typically symmetric lower extremity edema
(occasionally seemingly left greater than right), abdominal
distention, and 2-pillow orthopnea, as well as lightheadedness
and perhaps a sensation of chest discomfort or fluttering when
bending. She endorses a prolonged "flu-like" illness
characterized by nasal congestion, rhinorrhea, productive cough,
and myalgias, since resolved, while in ___, but denies
recent fevers, chills, sweats, weight change, nausea, vomiting,
chest pain, pleuritic chest pain, abdominal pain, calf pain, or
recent travel/immobilization apart from travel to ___.
Baseline exercise tolerance was previously essentially
unlimited. Furosemide 10mg daily was initiated by her primary
care physician ___ months ago in the setting of visible
peripheral edema, without symptomatic relief. She has not
undergone echocardiography or stress testing in the recent or
distant past. She does not necessarily adhere to a low-Na diet.
In the ED, initial vital signs were as follows: 97.6, 87,
123/56, 26, 97% RA. Labs were significant for Hct of 34.9
(versus uncertain baseline), essentially unremarkable Chem7 with
the exception of bicarbonate of 21, TnT of 0.03 (versus
uncertain baseline), lactate of 2, and proBNP of 11585; repeat
TnT approximately 3 hours later was 0.03, but coagulation panel
was unavailable due to challenging lab draw. EKG was interpeted
as negative for acute ischemic changes. CXR PA/lateral revealed
bilateral pleural effusions with opacities likely attributable
to atelectasis and suspected mild cardiomegaly. She received
aspirin 324mg and furosemide 40mg IV with uncertain urine
output, though robust according to the patient, with some
symptomatic relief. Vital signs at transfer were: 87, 130/74,
18, 95% RA.
On the floor, she is briefly comfortably in bed, propped up by 2
pillows. She denies chest pain or palpitations.
ROS: On review of systems, she 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. She denies recent
fevers, chills or rigors. She denies exertional buttock or calf
pain. All of the other review of systems were negative.
Past Medical History:
1. CARDIAC RISK FACTORS: (+)Diabetes, (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
Hypothyroidism
Chronic kidney injury (stage 3)
Chronic normocytic anemia
Allergic rhinitis
Social History:
___
Family History:
Mother, deceased, with diabetes ___ and hypertension.
Father, deceased, with unknown medical history. Daughter and
multiple other family members with diabetes ___. No known
family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 99.4, 82, 113/70, 18, 97% RA
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclerae anicteric. PERRL, EOMI.
NECK: Supple with JVP to mandible.
CARDIAC: RR. Ill-defined II/VI murmur throughout precordium,
pericardial friction rub, +kussmauls
LUNGS: No chest wall deformities, scoliosis or kyphosis.
Respirations were unlabored, no accessory muscle use. Faint
bibasilar crackles.
ABDOMEN: Softly distended, tympanitic, no clearly appreciable
fluid wave/shifting dullness, nontender.
EXTREMITIES: 2+ peripheral edema to thighs bilaterally, sacrum
unassessed.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
.
DISCHARGE PHYSICAL EXAM
VS: 98.9; 98/55-110/58 ___ on RA
WT: 55.9kg
GEN: NAD, resting comfortably in bed with head elevated
HEENT: EOMI, conjunctiva pink, sclera anicteric
NECK: supple, no LAD, JVD is 10 cm
CV: RRR, reg s1 s2, pericardial rub is gone, PMI not displaced
LUNG: +bibasilar rales
ABD: +BSx4, soft, ntnd, no hepatomegaly
EXT: pitting edema decreased to mid shin
NEURO: grossly intact
Pertinent Results:
ADMISSION LABS
___ 05:45PM BLOOD WBC-9.6 RBC-3.93* Hgb-10.7* Hct-34.9*
MCV-89 MCH-27.3 MCHC-30.8* RDW-16.5* Plt ___
___ 05:45PM BLOOD Neuts-81.5* Lymphs-9.7* Monos-6.1 Eos-2.2
Baso-0.5
___ 05:45PM BLOOD Plt ___
___ 05:45PM BLOOD Glucose-190* UreaN-9 Creat-1.1 Na-134
K-5.0 Cl-101 HCO3-21* AnGap-17
___ 05:45PM BLOOD CK(CPK)-91
___ 05:45PM BLOOD CK-MB-2
___ 05:45PM BLOOD cTropnT-0.03*
___ 08:40PM BLOOD ___
___ 08:40PM BLOOD cTropnT-0.03*
___ 06:35AM BLOOD CK-MB-2 cTropnT-0.03*
.
DISCHARGE LABS
___ 07:45AM BLOOD WBC-6.7 RBC-3.79* Hgb-10.4* Hct-33.1*
MCV-88 MCH-27.5 MCHC-31.4 RDW-15.7* Plt ___
___ 07:45AM BLOOD Plt ___
___ 07:45AM BLOOD Glucose-155* UreaN-16 Creat-1.5* Na-134
K-3.9 Cl-95* HCO3-29 AnGap-14
___ 07:45AM BLOOD Calcium-9.7 Phos-3.0 Mg-2.1
.
CARDIAC PHARMACOLOGICAL PERFUSION STUDY:
1. Fixed, severe, small perfusion defect involving the RCA
territory.
2. Normal left ventricular cavity size. Moderate systolic
dysfunction with global hypokinesis and akinesis of the basal
inferior and inferolateral walls.
.
ECHO: EF 45-50%
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with basal to mid
inferior/inferolateral hypokinesis. Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is no ventricular septal defect. with mild
global free wall hypokinesis. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Moderate to
severe (3+) mitral regurgitation is seen. The left ventricular
inflow pattern suggests a restrictive filling abnormality, with
elevated left atrial pressure. There is moderate pulmonary
artery systolic hypertension. There is a trivial pericardial
effusion.
IMPRESSION: Symmetric LVH with a speckled appearance,
restrictive filling pattern, diastolic dysfunction and low A
wave velocity - all suggestive of cardiac amyloidosis. Regional
left ventricular systolic function that may be due to inferior
ischemia/infarction. Moderate to severe mitral regurgitation.
Moderate pulmonary hypertension. Biatrial dilation. Large left
pleural effusion.
Brief Hospital Course:
Ms. ___ is a ___ yo ___ female with history of
hypertension, diabetes ___, and hypothyroidism who presents
with subacute progressive dyspnea in the context of
hypervolemia, and an echo showing LVH with a speckled
appearance, restrictive filling pattern, diastolic dysfunction
suggestive of cardiac amyloidosis and new CHF.
.
>> ACTIVE ISSUES
#CHF ___ cardiac amyloidosis: Pt presented with DOE, edema and
was found to have elevated JVP, pericardial friction rub, a
Kussmaul's pulse, and peripheral edema c/w CHF. An echo showed
LVH with a speckled appearance, restrictive filling pattern,
diastolic dysfunction and low A wave velocity - all suggestive
of cardiac amyloidosis. Given a wall motion abnormality on TTE,
a MIBI was also performed to identify areas of reversible
ischemia and revealed global hypokinesis with akinesis of the
basal inferior and inferolateral walls in the distribution of
the RCA. The patient was given bolus lasix (responded well to
80mg IV) on admission and HD1 and HD2 and then started on a drip
at 5mg/hr with good diuresis. After <24hr of lasix gtt, her
volume status appeared improved and Cr started to bump so gtt
was stopped and she was transitioned to PO lasix the following
day (40mg). To optimize at CHF regimen, she was started on
lisinopril 2.5 mg (captopril in house), spironolactone 25 mg. Pt
had soft SBPs in high ___ and Cr bumped slightly on day of
discharge likely from overdiuresis. Thus, lasix dose decreased
to 20mg daily on discharge and spironolactone to 12.5mg daily.
Pt on atenolol as OP but beta-blockers held as part of CHF
regimen and can be considered as an OP.
.
# CAD: MIBI demonstrated a fixed inferior perfusion defect
suggestive of prior MI consistent with the echocardiogram.
Given no active ischemia and no symptoms suggestive of ongoing
angina, cardiac cath was not pursued at this time.
# Acute on chronic kidney injury: Baseline Cr 1.1. Cr bumped to
1.5 on day of discharge likely from overdiuresis. Lytes will
need monitored in close f/u
.
>> CHRONIC ISSUES
#HTN: Pt on lasix/atenolol as an OP, adjusted to optimize CHF
regimen per abvoe.
.
#DMII: the patient was placed on an insulin sliding scale in
house. Discharged back on glipizide.
.
#HLD: the patient was continued on her home rosuvastatin
.
#Hypothyroidism: on admission her TSH was elevated at 8.1 but
her FT4 was normal at 1.2. These results were consistent with
sick euthyroid syndrome and she was continued on her home dose
of levothyroxine 150 mcg PO qd.
.
#Normocytic anemia: Hct is 34.9 on arrival versus uncertain
baseline, likely related to chronic kidney injury. There are no
signs or symptoms of blood loss. The patient continued her home
ferrous sulfate.
.
>> TRANSITIONAL ISSUES:
# full code
# Please titrate lasix as needed as an outpatient, dose may need
uptitrated given good UOP to dose of 80mg IV (and not 40 IV)
# Please monitor lytes closely in f/u and monitor renal function
closely
# Please monitor renal function and consider alternative to
glipizide if Cr remains elevated
# Pt to establish in ___ heart failure clinic. Pt set up with
home ___ for telemonitoring
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO DAILY
2. GlipiZIDE 5 mg PO BID
3. Levothyroxine Sodium 150 mcg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atenolol 25 mg PO DAILY
6. Rosuvastatin Calcium 40 mg PO DAILY
7. Fluticasone Propionate NASAL 1 SPRY NU DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Ferrous Sulfate 325 mg PO DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Furosemide 20 mg PO DAILY
5. Levothyroxine Sodium 150 mcg PO DAILY
6. Rosuvastatin Calcium 40 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. GlipiZIDE 5 mg PO BID
9. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
10. Spironolactone 25 mg PO DAILY
RX *spironolactone 25 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses: CHF, amyloid cardiomyopathy, CAD
Secondary diagnoses: diabetes, CKD
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 in the hospital. You were
admitted with swelling in your legs and trouble breathing. You
were found to have a condition called heart failure, which is
when you heart does not fill with blood easily and does not pump
normally. You were started on a number of new medicines. You
were also given medicines to help you pee off the extra fluid.
You were feeling better.
Please follow-up at the appointments listed below.
Please note the following changes to your home medications:
- START lisinopril 2.5mg daily
- START spironolactone 25mg daily
- STOP atenolol
Please weigh yourself daily. If you weight increases by 3 or
more pounds, please call your doctor.
Followup Instructions:
___
|
10186442-DS-19 | 10,186,442 | 27,911,046 | DS | 19 | 2168-01-23 00:00:00 | 2168-01-26 11:19:00 |
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:
None
History of Present Illness:
___ is an ___ female with a PMHx of HTN, HLD, DM, CKD
stage 3, amyloid cardiomyopathy (LVEF 42%), and admission on
___ for R MCA clot s/p tPA and subsequent hemorrhagic
transformation who now presents from ___ rehab with ~1
week of decreased responsiveness. ___ prelim in ED shows
interval increase in hemorrhage without apparent mid-line shift.
She initially presented as code stroke on ___ with symptoms
of acute onset of confusion, left sided facial droop, and
left-sided weakness. Pt received tPA within the 3 hour window
and monitoring in the ICU. CTA showed a clot in the M1 branch of
the right MCA. Stroke presumed to be cardioembolic in nature
due given pt's history of cardiomyopathy and secundum type ASD
with L-to-R shunt at rest, and absent atrial contribution to LV
filling. Pt was started on xarelto ten days after stroke.
During that admission, patient had multiple episodes of aberrent
atrial complexes lasting ___ seconds. She was evaluated by
cardiology and started on metoprolol 75 Q6. Also during recent
admission, PEG was placed.
She was discharged to ___ rehab on ___ on new xarelto
(started ___. Her neurological exam at that time was notable
for minimal speaking (single words, yes/no answers) and
intermittently following simple commmands. She had a right gaze
deviation but could cross midline; left facial weakness, with
LUE flaccid paralysis with grimacing to noxious stimuli with
extensor posturing, LLE triple flexion, RLE briskly withdrawing
against gravity to noxious stimuli. According to her family
(daughter-in-law and son), Ms. ___ had been participating in
therapy as recently as ___, when she was able to state the
date and location with multiple choice. They state since
discharge, her baseline she had been interactive, but using only
___ word utterances in the proper context. She has been A&O x 1
since discharge to ___. They state that since ___, Ms.
___ has been sleepy and too lethargic to participate in
therapy. They have alsonoted her to be less vocal and
interactive over the past week.
Over the last 3 days, Ms. ___ has been not been verbal, with
intermittent drops in her O2 sats ___ NC at baseline), and had
1 episode of hypotension with SBP in the ___ that responded to
1L
IVF. Ms. ___ daughters state that they do not think she has
had a temperature at rehab, but do recall recent several
occassion when she was "soaked in a cold sweat." Daughter also
states that rehab has been titrating down the dose of Ms.
___ beta blocker - yesterday dose was decreased from 50 to
25. In ED, pt has elevated WBC with PMN predominance. A U/A is
positive for ___ and bacteria, urine WBC elevated at 29. CXR
shows increase in B/L pleural effusions.
In the ED initial vitals were: 91 95/64 24 90% 2L NC
- Labs were significant for WBC 12.1 (82.9% PMNs, 10.7% lymphs),
H/H 9.5/31.4 (at baseline), troponin 0.11, BNP 13275 (11585 on
___ during ED visit for CHF exacerbation)
- Patient was given Cefepime 2g IV, Vancomycin 1g IV. BPs in the
___ Received 500cc with stabilization of SBPs to the ___.
- CT Head wet-read with interval increase in subarachnoid
hemorrhage in the right MCA distribution, at the site of the
patient's recent infarction. No evidence of midline shift or
herniation.
- Neurology recommend admission to medicine with neurology
consult service following. Recommend 24hr vEEG to r/o seizures
in setting of SAH and sepsis.
Vitals prior to transfer were: 98.6 85 127/65 19 100% NC
Review of Systems:
(+) per HPI
(-) Unable to assess due to mental status
Past Medical History:
- Type II Diabetes
- Hyperlipidemia
- Hypertension
- Hypothyroidism
- Chronic kidney injury (stage 3)
- Chronic normocytic anemia
- Allergic rhinitis
- Ayloid Cardiomyopathy
- Paroxysmal Atrial Fibrillation
- R MCA infarct s/p tPA with hemorrhage ___
Social History:
___
Family History:
Mother, deceased, with diabetes ___ and hypertension.
Father, deceased, with unknown medical history. Daughter and
multiple other family members with diabetes ___. No known
family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION EXAM:
Vitals - T:97.4 BP:99/69 HR:95 RR: 16 02 sat: 96% on 2L NC
GENERAL: Eyes closed, occasionally opening them, no tracking,
noisy breathing, cold and diaphoretic, cannot follow commands,
no verbalizations, few groans in response to noxious stimuli on
R side
HEENT: AT/NC, PERRL, anicteric sclera, pink conjunctiva, patent
nares, MMM, does not open mouth
NECK: able to flex approximately ___annot
touch
chin to chest, no grimace, full rotation, no LAD, JVP ~10 cm
CARDIAC: Regular rhythm with frequent ectopic beats, S1/S2, no
murmurs, gallops, or rubs
LUNG: Audible upper airway noise, decreased breath sounds
at left lung base > right lung base, with bibasilar crackles
ABDOMEN: distended, tympanic, non-tender, +BS, no
rebound/guarding, PEG in place without erythem
EXTREMITIES: LUE and LLE limp without movement, RUE and RLE
nonpurposeful movements, pitting edema to the knee B/L
PULSES: 2+ DP pulses bilaterally
NEURO: Eyes closed, opens eyes to noxious stimuli. Pupils equal
and sluggishly reactive bilaterally, does not track examiner,
left forehead smooth, left eye closure weaker, R side with
grossly normal bulk and tone. L side flaccid. Pt moves RUE
spontaneously antigravity. RLE with intact response to noxious
stimuli. No response to noxious stimuli in LLE or LUE.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes, sacral decubitus ulcer present
DISCHARGE EXAM:
Vitals - Tmax 98.5 97.9 89-111 50-65 95-100 % on 2L, 89% OXYGEN
SATURATION ON ROOM AIR
BS: ___ 228 158
___ MD-6AM: 70/700 24 ___: 2455/925 BM x2
GENERAL: laying in bed with eyes close, NAD, appears comfortable
resting
HEENT: pink conjunctiva, MMM
CARDIAC: Regular rhythm, S1/S2, no murmurs, gallops, or rubs
LUNG: Decreased breath sounds at L lung bases with crackles,
stable, clear to auscultation on R
ABDOMEN: Distended, tympanic, non-tender, +BS, no
rebound/guarding, PEG in place without erythema
EXTREMITIES: LUE and LLE w/o tone, moving RUE, stable 2+ pitting
edema to knee bilaterally
PULSES: 2+ DP pulses bilaterally
NEURO: Eyes opens, tracks examiner, R UE with purposeful
movements
SKIN: Warm and well perfused, sacral decubitus ulcer present
Pertinent Results:
ADMISSION LABS:
==========
___ 11:25PM WBC-12.1* RBC-3.45* HGB-9.5* HCT-31.4* MCV-91
MCH-27.7 MCHC-30.3* RDW-17.0*
___ 11:25PM NEUTS-82.9* LYMPHS-10.7* MONOS-4.2 EOS-2.1
BASOS-0.1
___ 11:25PM GLUCOSE-72 UREA N-41* CREAT-0.9 SODIUM-142
POTASSIUM-3.4 CHLORIDE-95* TOTAL CO2-42* ANION GAP-8
___ 11:25PM CALCIUM-9.3 PHOSPHATE-2.4* MAGNESIUM-2.5
___ 11:25PM ___ PTT-27.1 ___
___ 11:25PM CK-MB-4 ___
___ 11:25PM ALT(SGPT)-55* AST(SGOT)-78* CK(CPK)-191 ALK
PHOS-139* TOT BILI-0.6
___ 11:33PM LACTATE-1.6
PERTINENT LABS:
==========
___ 11:54PM TYPE-ART PO2-107* PCO2-48* PH-7.53* TOTAL
CO2-41* BASE XS-15
___ 06:03PM TYPE-ART PO2-120* PCO2-48* PH-7.48* TOTAL
CO2-37* BASE XS-11
___ 03:17PM BLOOD ___ pO2-46* pCO2-47* pH-7.42
calTCO2-32* Base XS-4
___ 11:25PM cTropnT-0.11*
___ 05:40AM cTropnT-0.10*
___ 05:10AM BLOOD calTIBC-189* Hapto-384* Ferritn-868*
TRF-145*
DISCHARGE LABS:
==========
___ 06:15AM BLOOD WBC-11.3* RBC-2.92* Hgb-8.0* Hct-26.3*
MCV-90 MCH-27.4 MCHC-30.5* RDW-19.6* Plt ___
___ 06:15AM BLOOD Glucose-127* UreaN-37* Creat-0.7 Na-144
K-3.5 Cl-103 HCO3-34* AnGap-11
___ 06:15AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.4
IMAGING:
======
CT Head w/o Contrast ___ Final Read
IMPRESSION:
1. Interval increase in subarachnoid hemorrhage in the right
MCA
distribution, at the site of the patient's recent infarction.
No evidence of midline shift or herniation. If there is further
clinical concern for an acute ischemia, an MRI would be
recommended for further evaluation.
2. Interval increase in fluid-opacification of the mastoid air
cells and middle ear cavities, bilaterally, likely secondary to
worsening sinus disease.
NOTE ADDED IN ATTENDING REVIEW: Given the appearance of the
original right MCA territorial infarction on the ___ MR
study, as well as the time course, the gyriform hyperattenuating
process in this distribution, which appears cortical rather than
sulcal, more likely represents dystrophic mineralization at
sites of cortical "pseudolaminar necrosis," rather than
subarachnoid blood. There is no evidence of intra- or
extra-axial hemorrhage or new infarction. The
fluid-opacification of the mastoid air cells and middle ear
cavities, bilaterally, new or significantly worse, may relate to
protracted supine positioning.
CXR ___:
1. Interval increase in large left pleural effusion with
adjacent atelectasis and mild residual aeration at the left
upper lung.
2. Interval increase in moderate right-sided pleural effusion
with adjacent atelectasis.
3. Moderate pulmonary edema.
CXR ___:
IMPRESSION:
Significant worsening of the left pleural effusion with
associated severe left lower lobe atelectasis. Vascular
congestion and interstitial pulmonary edema not significantly
worsened from the previous exam.
CXR ___
FINDINGS:
Combination of left pleural fluid and consolidation at the left
base
completely obscure the left hemidiaphragm but the opacity
appears to be more related to lung consolidation or edema than
to fluid currently. Cardiomegaly appears unchanged.
Hemidiaphragm on the right is obscured as well though there is
better aeration of the right lung compared to the previous film.
Right-sided PICC line is in unchanged position.
___ EEG:
IMPRESSION: This is an abnormal video EEG monitoring session
because of
generalized slowing bilaterally, more so on the right, as well
as amplitude attenuation over the right hemisphere, along with
rare rhythmic delta bursts. These findings are suggestive of
mild-moderate encephalopathy of non-specific etiology as well as
hemispheric cerebral dysfunction. Amplitude attenuation can be
seen in ischemia and is likely congruent with the patient's
known history of right MCA stroke. Epileptiform discharges noted
predominantly in the left mid-temporal region are likely due to
focal cortical irritability. No electrographic seizures are
seen.
___ Chest U/S:
POST PROCEDURE DIAGNOSIS:Small left pleural effusion
PLAN:Given that patient is on rivaroxiban, with higher risk of
stroke
if stopping and chronicity of pleural effusion, medical team
will
pursue medical diuresis and will not pursue thoracentesis at
this
time.
MICROBIOLOGY:
==========
___ 11:25PM URINE RBC-25* WBC-29* BACTERIA-FEW YEAST-NONE
EPI-<1 TRANS EPI-2
___ 11:25PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-8.5*
LEUK-MOD
___ Blood Culture x 2 - Pending
___ Urine Culture FINAL:
ENTEROCOCCUS SP.>100,000 ORGANISMS/ML (S- Amp, Vanc,
Nitro)
Brief Hospital Course:
ID: ___ female w/ recent admission for R M1 stroke s/p tPA c/b
hemorrhagic transformation presenting w/ ~1 week of decreased
responsiveness found to have Enterococcus UTI, course
complicated by acute on chronic CHF, hypo- and hyperglycemia,
increasing O2 requirement, and anemia.
ACUTE ISSUES:
# Toxic Metabolic Encephalopathy ___ Complicated UTI and
Metabolic Alkalosis: Patient noted to be lethargic and
unresponsive on admission to ___ from her rehab facility.
Final ___ read showed no increased subarachnoid blood. EEG
showed no seizures. Labs notable for metabolic alkalosis,
leukocytosis, uremia, and elevated BNP with urine culture growth
of Enterococcus (S-Amp). Etiology is most likely multifactorial
(UTI, dehydration, and diuresis w/ home lasix and metolazone).
Her diuretics were held, and she received gentle IVF with
correction of her metabolic alkalosis. Her foley was removed,
however she failed a voiding trial and a new foley was placed.
She completed a 7-day course of IV Ampicillin (___)
for her complicated UTI. Her mental status improved to baseline
per family. She responds to voice and tracks examiner and
responds with head nods and shakes to questions.
# Acute on Chronic Systolic CHF Exacerbation: Her lasix and
metolazone were held on admission given metabolic alkalosis and
low volume status as above. Following gentle IVF and restarting
G-tube feeds, patient was noted to be tachynpneic with increased
O2 requirement, and a CXR concerning for pulmonary edema,
consistent with a CHF exacerbation. She was diuresed with IV
lasix with improvement in her respiratory status. Her home PO
lasix dose was increased from 20 mg BID to 60 mg BID, and her
home metalozone was discontinued, on which she was able to
maintain a stable euvolemic volume status. Her home metoprolol
was originally held in the context of infection but was
restarted during her hospitalization.
# Type 2 Diabetes ___ Uncontrolled with Complications c/b
Hypoglycemia and Hyperglycemia: Patient noted to have
significant hyperglycemia with glucose fingersticks in the high
200s to 300s range. Nutrition evaluted her and recommend
switching to low-carbohydrate Pulmocare feeds. Following switch,
she was noted to be hypoglycemic in the 50-90s range which was
subsequently corrected with a decrease in her insulin regimen.
This was thought to be due to a relative ___ from
continuous high-carbohydrate feeds >1 month that induced
hypoglycemia when feeds were switched. Due to family's wishes to
take the patient home, she was started on bolus feeds for ease
of feeding with an insulin regimen recommended by the ___
Diabetes team with normalization and stabilization of her blood
sugars. She will follow-up with ___ after discharge.
# New Hypoxemia: Following her stroke, she developed an O2
requirement which has been intermittently between 1L-3L during
hospitalization with documented desaturations to 85% on RA ___.
This was thought to be likely multifactorial from pleural
effusions ___ heart failure and atelectasis from shallow breaths
and an inability to participate in incentive spirometry. She was
evaluted by intervention pulmonology who performed a L chest U/S
notable for a chronic-appear L pleural effusion. Given risk of
stopping anticoagulation for several days, thoracentesis for
pleural effusion drainage was deferred. She will be discharged
on home O2.
# Normocytic Anemia: Her baseline anemia was most likely ___ CKD
and anemia of chronic disease. Baseline Hgb in ___.
Patient was noted to have downtrending Hgb to 6.9 and guaiac +
stools s/p 1uRBC on ___. Hemolysis labs unremarkable.
Differential includes blood loss from slow GI bleed or
sequestration. Hgb remained stable in the ___ range post
transfusion. She will need frequent monitoring her hemoglobin/
hematocrit following discharge. She required transfusions at
rehab so likely is becoming transfusion dependent.
# Goals of Care: Unfortunately, Ms. ___ is an extremely ill
patient. She has multiple co-morbidities including heart failure
with reduced ejection fraction, persistent, new, and increasing
O2 requirement (from before her stroke), anemia of chronic
disease and slow blood loss, and diabetes. Because of her
medical complexity, the preferred discharge facility would be to
an LTAC because of her L hemiparesis and 100% dependency on
others for ADLs. However, her family is insistent that the pt
return home because of a bad experience at the rehab facility.
After family discussion, it was decided that tentatively she
will return home with support from her family. Her family,
including HCP, are aware that they will be in charge of all
medications, turning the pt to avoid pressure ulcers, monitoring
her tube feeds and foley catheter care (with the support of home
___. If this were to fail, she would return to the hospital for
placement to a rehab facility. On the day of discharge, we again
emphasized the preferred discharge facility would be an LTAC,
but the family continued to express their wishes to take the
patient home with the understanding she may need to return to
the hospital should her medical needs increase. She was
discharged with a home hospital bed, a ___ lift, bedside
commode, wheelchair, home O2, and Pulmocare G-tube feeding
supplies. She will have monitoring labs and will follow-up with
her PCP.
CHRONIC/ INACTIVE ISSUES:
# Leukocytosis: Mild intermittent leukocytosis in the ___
range noted throughout hospitalization following treatment of
her Enterococcus UTI. She had no fevers or obvious source of
infection. The most likely etiology is a transient reactive
leukocytosis.
# Dysphagia ___ recent R MCA Stroke: On previous admission ___
-___, patient was evaluated by Speech and Swallow who noted
patient had poor oral phase of swallowing and somnolence. She
was kept NPO due to significant aspiration risk and inability to
PO, and a PEG tube was placed for tube feeds. Patient remains
intermittently somnolent on admission and requires tube feeding.
Given family's desire for home care, she will continue bolus
feeds for ease of feeding.
# Sacral Wound: She was noted to have a 0.5 cm Stage II pressure
ulcer on left gluteal area on admission ___ fecal incontinence.
She was evaluated by the wound care team, and she was maintained
on daily dressing changes and Q2H turns.
# CKD stage 2: Her renal function was stable at Cr 0.9 on
admission, at baseline.
# HTN: Her home lasix dose was increased to 60 mg BID as above.
Her home metoprolol was initially held and restarted following
resolution of her UTI as above. Her home metalozone and
lisinopril was discontinued due to her stable volume status on
lasix and risk of metabolic alkalosis.
# HLD: She was continued on her home rosuvastatin.
# Hypothyroidism: She was continued on her home levothyroxine.
TRANSITIONAL ISSUES:
[ ] ___ labs: Chem7, CBC labs ___
[ ] Continuous Jevity 1.5 feeds changed to bolus TID Pulmocare
feeds
[ ] Insulin changed from Lantus 28 BID to Lantus 12 BID + ISS w/
bolus feeds
[ ] Lasix was increased from 20 PO BID to 60 PO BID
[ ] Metalozone and lisinopril were stopped
[ ] Follow-up with PCP, ___
[ ] ___ Recommendations:
Lift for all mobility including transfers to chair 3x/day.
Please use pressure relieving air cushion / chair alarm when out
of bed.
Elevation of L UE on pillows for joint protection and minimize
edema.
[ ]Wound care:
0.5 cm Stage II pressure ulcer
Left gluteal area
Pink base, Periwound skin intact
Mepilex Sacrum foam dressing to coccygeal area
q 2 hour turning schedule is imperative
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg NG DAILY
2. Bethanechol 5 mg NG TID
3. Chlorhexidine Gluconate 0.12% Oral Rinse 5 mL ORAL BID
4. Docusate Sodium (Liquid) 200 mg NG/OG BID
5. Ferrous Sulfate (Liquid) 300 mg NG DAILY
6. Furosemide 20 mg NG BID
7. Glargine 28 Units Breakfast
Glargine 28 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
8. Levothyroxine Sodium 175 mcg NG QAM
9. Lisinopril 5 mg NG QHS
10. Metolazone 2.5 mg PO QAM
11. Nystatin Oral Suspension 5 mL PO QID
12. Omeprazole 20 mg PO BID
13. Potassium Chloride (Powder) 10 mEq NG DAILY
14. Rosuvastatin Calcium 40 mg PO QAM
15. Senna 17.2 mg NG BID
16. Vitamin D 1000 UNIT NG DAILY
17. Metoprolol Tartrate 25 mg PO Q6H
18. Bisacodyl ___ID:PRN Constipation
19. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Discomfort
20. Rivaroxaban 15 mg PO DINNER
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Discomfort
2. Aspirin 81 mg NG DAILY
3. Bethanechol 5 mg NG TID
4. Bisacodyl ___ID:PRN Constipation
5. Chlorhexidine Gluconate 0.12% Oral Rinse 5 mL ORAL BID
6. Docusate Sodium (Liquid) 200 mg NG/OG BID
7. Ferrous Sulfate (Liquid) 300 mg NG DAILY
8. Levothyroxine Sodium 175 mcg PO QAM
9. Rosuvastatin Calcium 40 mg PO QAM
10. Vitamin D 1000 UNIT NG DAILY
11. Senna 17.2 mg NG BID
12. Rivaroxaban 15 mg PO DINNER
13. Nystatin Oral Suspension 5 mL PO QID
14. hospital bed
diagnosis: FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT
SIDE
ICD-9 code: ___
15. ___ lift
diagnosis: FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT
SIDE
ICD-9 code: ___
16. bedside commode
diagnosis: FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT
SIDE
ICD-9 code: ___
17. continuous O2 supplementation @ ___ NC
hypoxia to 85% on room air
maintain O2 saturations >90% with ___ NC continuously
lifelong need
18. Furosemide 60 mg PO BID
19. Metoprolol Tartrate 25 mg PO Q6H
20. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Wheezing/SOB
21. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
22. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
23. Simethicone 80 mg PO QID:PRN gas pain
24. Potassium Chloride (Powder) 10 mEq NG DAILY
25. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
=====
Complicated Urinary Tract Infection
Metabolic Alkalosis
Acute on Chronic Congestive Heart Failure
Secondary:
=======
Pleural Effusion
Diabetes Type 2
Anemia
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 taking care of you during your admission to
the ___. You were admitted for
lethargy and decreased responsiveness. You were found to have a
urinary tract infection and metabolic alkalosis or excess base
in your blood, and you were treated with IV fluids and
antibiotics.
During your hospitalization, you also had an exacerbation of
your heart failure, and you were treated with IV lasix. Your
metalozone was stopped due to concerns of metabolic akalosis or
excess base, and we increased your lasix dose.
You were also noted to have both low and high blood sugars. The
low blood sugars were thought to be switching to
low-carbohydrate feeds. The high blood sugars were thought to be
due to a combination of your acute illness and inadequate
insulin. You were switched from continuous feeds to bolus feeds,
and the ___ Diabetes team saw you and recommended a
long-acting insulin as well as an insulin sliding scale regimen.
Your blood sugars normalized on this feeding and insulin
regimen.
You were also evaluated for your increased oxygen requirement.
Chest ultrasound showed a chronic left pleural effusion, or
fluid in your chest. Due to the risk of stopping your
anticoagulation for a potential drainage of the fluid, the
decision was made to defer drainage and continue your on oxygen.
You will follow-up with your primary care physician,
___, and ___ diabetes endocrinologist after
discharge.
Sincerely,
Your ___ Team
TRANSITIONAL ISSUES:
[ ] Continuous Jevity 1.5 G-tube feeds changed to bolus three
times a day Pulmocare feeds
[ ] Insulin changed from Lantus 28 BID to Lantus 12 BID +
Insulin sliding scale with bolus feeds
[ ] Lasix was increased from 20 PO BID to 60 PO BID
[ ] Metalozone and lisinopril were stopped
[ ] Follow-up with PCP, ___
Followup Instructions:
___
|
10186442-DS-20 | 10,186,442 | 21,537,662 | DS | 20 | 2168-02-13 00:00:00 | 2168-02-14 20:22:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Intubation, EGD, paracentesis x2, thoracentesis
History of Present Illness:
Ms. ___ is an ___ y/o female with a history of HTN, HLD, CKD
stage III, amyloid cardiomyopathy (EF 42%), DM and recent R MCA
stroke s/p tPA ___ (which lead to hemorrhagic
transformation) who presents with altered mental status,
hypotension and hypoxemia. Patient was recently admitted from
___ with AMS. In brief, AMS was attributed to enterococcus
UTI (treatment with IV ampicillin for a 7-day course) and
dehydration on admission. Patient received IVF and and developed
an O2 requirement ___ CHF exacerbation. Patient was diuresed and
restarted on her home lasix. Patient also had poorly controlled
glucose with both hypo and hyperglycemic episodes. She also
developed new hypoxemia which was attributed to atelectasis,
pleural effusions and shallow breathing. IP was consulted and
thoracentesis was deferred due to hemorrhage risk in the setting
of anticoagulation. Patient was ultimately discharged on home
O2. In addition, patient was noted to have a normocytic anemia
likely ___ CKD. Patient was noted to have guiaic positive stools
and there was concern for a possible UGIB, however workup was
not pursued.
Patient was discharged home on ___ and was doing well per her
sister. Yesterday, there was an acute change in her mental
status from her baseline. Patient complained of pain at her
foley catheter site and had two episodes of loose stools that
were black per the sister. She also complained of chest and back
discomfort at rest (unclear if patient complains of this at
baseline). Today, the visiting nurse went to change her foley
catheter and at that time the patient was noted to be altered,
not responding to questions, with SBPs ___, sating 60% on RA.
EMS was called and patient was transferred to the ED.
In the ED, initial vitals: T 99.8, HR 101, BP 94/41, RR 34, 100%
NRB (desats to 70% on RA). Patient was not responding to painful
stimuli and was altered. CT head was obtained and prelim read
showed progression encephalomalacia in the right MCA region but
no evidence of new hemorrhage or infarction. CXR was performed
and showed bilateral hazy opacities and bilateral pleural
effusions, slightly improved from prior (not read by radiology).
Urine was grossly bloody and UA showed large leuks, moderate
bacteria. UCx and BCx were sent. Rectal exam was notable for
brown stool, heme+. Given the concern for sepsis, patient
received approximately 3L IVF and was placed on broad spectrum
abx with vancomycin/zosyn. Levophed was initiated. Patient
continued to do poorly a respiratory standpoint and required
intubation.
On arrival to the MICU, VS T 98.9, HR 107, BP 112/60 on
levophed, 100% on CMV Vt 450, RR 14, PEEP 5, FiO2 50%. Patient
was sedated and unable to repsond to voice or painful stimuli.
Past Medical History:
- Type II Diabetes
- Hyperlipidemia
- Hypertension
- Hypothyroidism
- Chronic kidney injury (stage 3)
- Chronic normocytic anemia
- Allergic rhinitis
- Ayloid Cardiomyopathy
- Paroxysmal Atrial Fibrillation
- R MCA infarct s/p tPA with hemorrhage ___
Social History:
___
Family History:
Mother, deceased, with diabetes ___ and hypertension.
Father, deceased, with unknown medical history. Daughter and
multiple other family members with diabetes ___. No known
family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL:
Vitals- T 98.9, HR 107, BP 112/60 on levophed, 100% on CMV Vt
450, RR 14, PEEP 5, FiO2 50%
GENERAL: intubated and sedated, not responding to painful
stimuli
HEENT: Sclera anicteric, MMM, with ET tube, right EJ
NECK: supple, JVP not elevated, no LAD
LUNGS: mechanical breath sounds anteriorly, bibasilar crackles
CV: irregular rhythym, regular rate, normal S1 and S2, ___
systolic murmur heard best at the LUSB w/o radiation to carotids
or axillae
ABD: soft, non-tender, distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: warm, 1+ pulses, no clubbing, cyanosis, trace pitting edema
up to knees b/l
GU: per report, brown guiaic positive stool
NEURO: unable to assess ___ intubation and sedation
DISCHARGE PHYSICAL EXAM
GENERAL: Eyes open
HEENT: Sclera anicteric, MMM
NECK: supple, JVP not elevated
LUNGS: clear anteriorly, bibasilar crackles
CV: irregular rhythym, regular rate, normal S1 and S2, ___
systolic murmur heard best at the LUSB w/o radiation to carotids
or axillae
ABD: distended abdomen but soft, bowel sounds hyperactive, no
rebound tenderness or guarding, no organomegaly, +ascites
EXT: warm, 1+ pulses, no clubbing, cyanosis, 1+ pitting edema up
to knees b/l NEURO: able to follow some commands
Pertinent Results:
ADMISSION LABS:
___ 12:04AM ___ PTT-28.3 ___
___ 12:04AM PLT SMR-NORMAL PLT COUNT-359
___ 12:04AM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL
TEARDROP-OCCASIONAL
___ 12:04AM NEUTS-85.7* LYMPHS-8.1* MONOS-4.7 EOS-1.0
BASOS-0.4
___ 12:04AM WBC-13.2* RBC-2.44* HGB-6.6* HCT-22.8* MCV-93
MCH-26.9* MCHC-28.8* RDW-18.5*
___ 12:04AM CALCIUM-9.0 PHOSPHATE-4.0 MAGNESIUM-2.6
___ 12:04AM estGFR-Using this
___ 12:04AM GLUCOSE-253* UREA N-52* CREAT-1.0 SODIUM-146*
POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-30 ANION GAP-17
___ 12:06AM LACTATE-3.5*
___ 01:09AM ___ PO2-30* PCO2-38 PH-7.26* TOTAL
CO2-18* BASE XS--10
___ 01:20AM TYPE-ART ___ TIDAL VOL-450 PEEP-5
O2-100 PO2-421* PCO2-53* PH-7.38 TOTAL CO2-33* BASE XS-5
AADO2-236 REQ O2-47 -ASSIST/CON INTUBATED-INTUBATED
___ 02:00AM URINE MUCOUS-FEW
___ 02:00AM URINE GRANULAR-130* HYALINE-65*
___ 02:00AM URINE RBC->182* WBC->182* BACTERIA-MOD
YEAST-NONE EPI-0
___ 02:00AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-LG
___ 02:00AM URINE COLOR-RED APPEAR-Cloudy SP ___
___ 02:00AM URINE UHOLD-HOLD
___ 02:00AM URINE HOURS-RANDOM
___ 08:22AM PLT COUNT-286
___ 08:22AM WBC-12.3* RBC-2.58* HGB-7.2* HCT-23.5* MCV-91
MCH-27.9 MCHC-30.6* RDW-18.0*
___ 08:22AM CALCIUM-8.4 PHOSPHATE-3.4 MAGNESIUM-2.4
___ 08:22AM CK-MB-3 cTropnT-0.13* ___
___ 08:22AM ALT(SGPT)-109* AST(SGOT)-109* CK(CPK)-102 ALK
PHOS-114* TOT BILI-0.4
___ 08:22AM GLUCOSE-186* UREA N-47* CREAT-0.9 SODIUM-145
POTASSIUM-3.5 CHLORIDE-107 TOTAL CO2-31 ANION GAP-11
___ 08:54AM LACTATE-1.7
___ 01:30PM PLT COUNT-308
___ 01:30PM WBC-11.8* RBC-2.63* HGB-7.4* HCT-24.3* MCV-93
MCH-28.1 MCHC-30.4* RDW-17.6*
___ 01:30PM CK-MB-3 cTropnT-0.14*
___ 08:00PM PLT COUNT-299
___ 08:00PM WBC-14.1* RBC-2.69* HGB-7.6* HCT-25.1* MCV-93
MCH-28.1 MCHC-30.1* RDW-17.6*
___ 08:00PM CALCIUM-8.8 PHOSPHATE-3.7 MAGNESIUM-2.4
___ 08:00PM CK-MB-3 cTropnT-0.14*
___ 08:00PM GLUCOSE-119* UREA N-39* CREAT-0.8 SODIUM-145
POTASSIUM-4.0 CHLORIDE-109* TOTAL CO2-30 ANION GAP-10
MICRO
UCx ___ Mixed flora
Sputum ___ Mixed flora
Pleural fluid ___ No growth
Peritoneal fluid ___ No growth
BCx ___ No growth
BCx ___ No growth
C diff ___ Negative
Ucx ___ No growth
IMAGING:
___ CT HEAD
IMPRESSION:
Progression of encephalomalacia in the patient's right MCA
infarction. The cortical gyriform hyperattenuating areas are
most consistent with dystrophic mineralization at sites of
pseudolaminar necrosis. No evidence of hemorrhage or new
infarction.
___
CXR
IMPRESSION:
Stable moderate to severe pulmonary edema.
Slight interval increase in moderate layering bilateral pleural
effusions.
___ KUB
IMPRESSION:
1. No evidence of obstruction.
2. Cardiomegaly and small left pleural effusion.
___ RUQ US
IMPRESSION:
Moderate ascites and a right pleural effusion.
___ ECHO
Conclusions
There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is mildly depressed (LVEF= 40%) secondary to
mild global hypokinesis. Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. The pulmonary
artery systolic pressure could not be determined. The
end-diastolic pulmonic regurgitation velocity is increased
suggesting pulmonary artery diastolic hypertension. There is a
trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of ___,
findings are overall similar.
___ CXR
IMPRESSION:
As compared to the previous radiograph, there is increasing
evidence of
pulmonary edema with increasing bilateral pleural effusions and
appearance ofmultiple air bronchograms, predominantly in the
right perihilar lung zones.The size of the cardiac silhouette is
unchanged. Unchanged position of theright PICC line.
___ KUB
Nonspecific bowel gas pattern. No evidence for obstruction or
ileus.
___ RENAL US
1. No hydronephrosis, large stones or worrisome masses in
either kidney.
2. Echogenic kidneys consistent with chronic medical renal
disease.
3. Gallbladder sludge without signs of acute cholecystitis.
CYTOLOGY
___ PLEURAL FLUID NEG FOR MALIGNANT CELLS
DISCHARGE LABS
___ 03:01AM BLOOD WBC-10.4 RBC-2.76* Hgb-7.6* Hct-24.3*
MCV-88 MCH-27.6 MCHC-31.3 RDW-16.8* Plt ___
___ 03:51AM BLOOD ___ PTT-32.9 ___
___ 03:01AM BLOOD Glucose-189* UreaN-80* Creat-4.5* Na-130*
K-4.8 Cl-88* HCO3-26 AnGap-21*
___ 03:01AM BLOOD Calcium-8.6 Phos-6.7* Mg-3.2*
Brief Hospital Course:
___ y/o female with a history of HTN, HLD, CKD stage III, amyloid
cardiomyopathy (EF 42%), DM and recent R MCA stroke s/p tPA
___ who presented with altered mental status, septic shock
and hypoxemic respiratory failure. Hospital course was
complicated by refractory shock ___ severe cardiomyopathy. After
multiple family discussions the decision was made to discharge
the patient home with hospice services. Hospital course is
outlined below by problem:
# Septic shock likely ___ UTI - presented with dysuria,
hematuria and urine concerning for a urinary tract infection.
Alternative etiologies include hospital acquired pneumonia given
hypoxemic respiratory failure (see below) and recent
hospitalization. She had enterococcus UTI was sensitive to
vancomycin, was treated with ampicillin during her last
hospitalization, She was treated with vancomycin and cefepime
for broad gram negative coverage. Her blood pressure was
maintained on levophed, for MAPS >65, and then switched to neo
in the setting of atrial tachycardia (see below).
# Cardiogenic shock ___ amyloid cardiomyopathy: patient
continued to have a pressor requirement despite treatment of her
sepsis. Cardiology was consulted and her shock was attributed to
hypovolemia and severe amyloid cardiomyopathy. The team
attempted to wean her neo however she continued to have a
pressor requirement. Cardiology expressed their concerns
regarding her poor prognosis in the setting of amyloid
cardiomyopathy. She was started on midodrine in an attempt to
discharge her home with hospice services. Hospice unfortunately
was unable to provide neo and alternative IV pressors would not
be appropriate in the setting of amyloid cardiomyopathy. She was
started on pseudoephedrine in an attempt to decrease her IV
pressor requirement.
# Hypoxemic respiratory failure requiring intubation: patient
has had multiple episodes of hypoxemia during her previous
hospitalizations which were attributed to acute pulmonary edema
in the setting of CHF secondary to amyloid. CXR on admission
with pulmonary edema and bilateral pleural effusions. She was
treated with vancomycin and cefepime for HCAP coverage. PE was
a consideration, however patient had been on anticoagulation
therapy for months given recent stroke. Of note, patient has a
known left sided pleural effusion that had not been tapped due
to concern for hemorrhage during procedure. Patient's
anticoagulation (rivaroxaban) was held and a L chest tube was
placed to drain the pleural effusion. Patient also was found to
have ascites, for which a therapeutic paracentesis was
performed. She was aggressively diuresed with IV lasix.
Patient's hypoxemia improved, and she was extubated. Patient
continued to have a 2L NC oxygen requirement due to pulmonary
edema and pleural effusions from her cardiomyopathy.
# Altered mental status - likely due to hypoxemia, hypotension
and sepsis. Patient's mental status remained poor, following
commands intermittently and inconsistently, during her
admission.
# Anemia - likely multifactorial, from anemia of chronic disease
and renal failure. There was concern for a potential upper GI
bleed, as she had a guiaic positive stool, with Hb 6.6 in the
ED. She was started on a PPI and Rivaroxaban was held and an EGD
performed, which was negative. Her anticoagulation was held as
the patient was at high risk for bleeding and her Hct remained
stable throughout the rest of her hospitalization.
# DMII: Patient was on home lantus 12U BID, which was reduced
when Patient was NPO, and then held in the setting of
hypoglycemia. It was restarted when she began tube feeds. She
was discharged on lantus 8U qHS and sliding scale.
# CHF (amyloid): Echo showed LVEF= 40% secondary to mild global
hypokinesis. Patient was diuresed with IV lasix as above. Her
home metoprolol was initially held in the setting of
hypotension/sepsis. The patient developed anasarca and
hypotension and therefore cardiology was consulted to assist
with management of her cardiomyopathy. She was treated with
lasix boluses, then gtt and transitioned to bumex gtt and
metolazone as she was refractory to lasix. She was maintained on
neo as levophed resulted in tachyarrhytmias. She developed ___
___ ATN due to cardiorenal syndrome and hypotension. After
discussion with cardiology, her prognosis was deemed to be quite
poor. The decision was made to send the patient home with
hospice services and manage her blood pressure with oral
medications.
# Paroxysmal atrial fibrillation with RVR/frequent ectopy/atrial
tachycardia - Patient was normally maintained on AV nodal
agents, which were held in the setting of sepsis. She developed
afib with RVR, with rates in the 120s. Her systolic pressures
continued to be in the ___. She was seen by Cardiology, who
recommended she be loaded with amiodarone. She was continued on
amiodarone and her AV nodal agents were discontinued due to
hypotension and amyloid cardiomyopathy.
# ___ ___ cardiorenal syndrome, toxic/ischemic ATN: patient
developed ___ in the setting of severe hypotension, high pressor
requirement, and high levels of vancomycin. Her creatinine
unfortunately did not improve and her UOP decreased despite
attempts to diurese with IV diuretics. Renal was consulted and
she was considered to be a poor candidate for dialysis due to
her pressor requirement and overall poor prognosis from her
cardiomyopathy (as she was very sensitive to fluid shifts).
# Recurrent ascites: ___ heart failure. Underwent two
paracentesis due to tense ascites. Her symptoms improved with
this intervention.
# Pleural effusion: underwent left thoracentesis at the
beginning of her hospitalization. Pleural effusion was
attributed to cardiomyopathy.
# Hypothyroidism: continued home levothyroxine
# Recent MCA stroke: patient was initially on anticoagulation
with rivaroxaban. This was held in the setting of a potential
UGIB. She was restarted on rivaroxaban. There was concern about
the interaction b/w rivaroxaban and amiodarone and therefore was
started on pradaxa. Pradax was discontinued in the setting of
___. As the goals of care transitioned, the decision was made to
stop anticoagulation as heparin/warfarin was her only option.
# Goals of care: patient remained in the hospital for 3 weeks
and unfortunately did not show signs of clinical improvement
despite attempts at aggressive medical management of her
multiple co-morbidities. Multiple family meetings were held to
determine what her goals were. We expressed the severity of her
illnesses and that unfortunately her prognosis was quite poor as
multiple organ systems were failing. Palliative care was
consulted to help with this difficult time. The decision was
made to discharge the patient home with hospice. We tried to
provide her with IV pressors at home, but unfortunately hospice
was unable to provide neo. We expressed that since the goal is
to not perform any aggressive life sustaining measures and not
to place her on life support should her organ systems fail, that
it would be appropriate to make her DNR/DNI, as attempts at
resuscitation would be futile and harmful. The family understood
and her husband ___ agreed with this. Her healthcare proxy
___ was also aware of the plan to discharge her home with
hospice services and she agreed with discharge home. She was
discharged home with hospice on ___.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Discomfort
2. Aspirin 81 mg NG DAILY
3. Bethanechol 5 mg NG TID
4. Bisacodyl ___ID:PRN Constipation
5. Chlorhexidine Gluconate 0.12% Oral Rinse 5 mL ORAL BID
6. Docusate Sodium (Liquid) 200 mg NG/OG BID
7. Levothyroxine Sodium 175 mcg PO QAM
8. Rosuvastatin Calcium 40 mg PO QAM
9. Senna 17.2 mg NG BID
10. Rivaroxaban 15 mg PO DINNER
11. Nystatin Oral Suspension 5 mL PO QID
12. Furosemide 60 mg PO BID
13. Metoprolol Tartrate 25 mg PO Q6H
14. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
15. Simethicone 80 mg PO QID:PRN gas pain
16. Potassium Chloride (Powder) 10 mEq NG DAILY
17. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
18. Glargine 12 Units Breakfast
Glargine 12 Units Dinner
Insulin SC Sliding Scale using UNK Insulin
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Discomfort
2. Aspirin 81 mg NG DAILY
3. Docusate Sodium (Liquid) 200 mg NG/OG BID
4. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
5. Glargine 0 Units Breakfast
Glargine 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Nystatin Oral Suspension 5 mL PO QID
7. Rosuvastatin Calcium 40 mg PO QAM
8. Senna 17.2 mg NG BID
9. Amiodarone 200 mg PO DAILY
10. Levothyroxine Sodium 175 mcg PO QAM
11. Midodrine 20 mg PO TID
12. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
13. Pseudoephedrine 30 mg PO Q6H
14. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: cardiogenic/septic shock
Secondary diagnosis: hypoxemic respiratory failure, anemia,
acute renal failure, amyloid cardiomyopathy, pleural effusion
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you during your
hospitalization. You came in with a bad urinary tract infection,
trouble breathing and low blood pressure. While you were here we
treated you for an infection and we helped your breathing. Your
blood pressure remained low and we think this is because of your
heart failure. Our goal is to get you home so you can be with
your family.
Followup Instructions:
___
|
10186513-DS-7 | 10,186,513 | 24,621,624 | DS | 7 | 2133-02-24 00:00:00 | 2133-02-24 17:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine
Attending: ___
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
ERCP with sphincterotomy on ___
History of Present Illness:
___ pmh HTN, hypothyroidism presents to ED with intermittent
abdominal pain x 6 days. 6 days she developed chills and
generalized severe abdominal pain with dry heaves. She didn't
want to seek medical care so she waited for it to subside. It
resolved without intervention. She developed nausea, decreased
appetite, brown urine and ___ colored stools which prompted her
to see her PCP 2 days later. She had bloodwork and an US done
which demonstrated gallstones. Her PCP also started her on
amoxicillin. She saw Dr. ___ in clinic who referred her to
___. For the past 6 days she has not had any abdominal pain.
At this time she does not have any pain or nausea. No fevers. No
emesis. Found to have cholelithiasis on U/S, choledocholithiasis
on CT scan with biliary and hepatic ductal dilitation.
.
In ER: (Triage Vitals:0 99.6 101 154/90 18 96% RA )
Meds Given: none
Fluids given: 2L NS
Radiology Studies:RUQ US:
1. 9 x 9 mm obstructing stone in the distal CBD with dilatation
of the CBD to
up to 11mm.
consults called: general surgery
.
PAIN SCALE: ___
________________________________________________________________
REVIEW OF SYSTEMS: 10 or 2 with "all otherwise negative"
CONSTITUTIONAL: [] All Normal
[ ] Fever [+ ] Chills [ ] Sweats [ ] Fatigue [ ] Malaise
[ ]Anorexia [ ]Night sweats
[+ ] _1-2____ lbs. weight loss
Eyes
[X] All Normal
[ ] Blurred vision [ ] Loss of vision [] Diplopia [ ]
Photophobia
ENT [X]WNL
[ ] Dry mouth [ ] Oral ulcers [ ] Bleeding gums [ ] Sore throat
[] Sinus pain [ ] Epistaxis [ ] Tinnitus
[ ] Decreased hearing [ ] Other:
RESPIRATORY: [X] All Normal
[ ] Shortness of breath [ ] Dyspnea on exertion [ ] Can't
walk 2 flights [ ] Cough [ ] Wheeze [ ] Purulent sputum
[ ] Hemoptysis [ ]Pleuritic pain
[ ] Other:
CARDIAC: [X] All Normal
[ ] Palpitations [ ] Edema [ ] PND [ ] Orthopnea [ ]
Chest Pain [ ] Dyspnea on exertion [ ] Other:
GI: [] All Normal
[ +] Nausea [-] Vomiting [+] Abd pain [] Abdominal swelling
[ ] Diarrhea [ ] Constipation [ ] Hematemesis
[ ] Blood in stool [ ] Melena [ ] Dysphagia: [ ] Solids
[ ] Liquids [ ] Odynophagia [ ] Anorexia [ ] Reflux
[ ] Other:
GU: [X] All Normal
[ ] Dysuria [ ] Incontinence or retention [ ] Frequency
[ ] Hematuria []Discharge []Menorrhagia
SKIN: [X] All Normal
[ ] Rash [ ] Pruritus
MS: [X] All Normal
[ ] Joint pain [ ] Jt swelling [ ] Back pain [ ] Bony pain
NEURO: [X] All Normal
[ ] Headache [ ] Visual changes [ ] Sensory change [
]Confusion [ ]Numbness of extremities
[ ] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo
[ ] Headache
ENDOCRINE: [X] All Normal
[ ] Skin changes [ ] Hair changes [ ] Heat or cold
intolerance [ ] loss of energy
HEME/LYMPH: [X] All Normal
[ ] Easy bruising [ ] Easy bleeding [ ] Adenopathy
PSYCH: [X] All Normal
[ ] Mood change []Suicidal Ideation [ ] Other:
ALLERGY:
[+ ]Medication allergies - morphine -> itchy [ ] Seasonal
allergies
[X]all other systems negative except as noted above
________________________________________________________________
Past Medical History:
Psxh:
S/p tonsillectomy at age ___
s/p totth extraction
S/p tubal ligation at age ___
---
Mitral valve prolapse
HTN
HLD
hypothyroidism
-----
Dislocated jaw from yawning at age ___
Social History:
Cigarettes: [ ] never [X ] ex-smoker [x] current Pack-yrs: 30
quit: ___ years ago____
ETOH: [x] No [ ] Yes drinks/day: _____
Drugs: rare
Occupation: ___
Marital Status: [ X] Married [] Single
Lives: [ ] Alone [X] w/ family [ ] Other:
Her husband has dementia and she takes care of him. He is ___.
They go dancing every ___ night and they go to the gym 3x
per week.
Received influenza vaccination in the past 12 months [X ]Y [ ]N
Received pneumococcal vaccinationin the past 12 months [ X]Y [
]N
>65
ADLS:
Independent of all ADLS:
IADLS: Independent of all IADLS
At baseline walks: [X ]independently [ ] with a cane [
]wutwalker [ ]wheelchair at ___
H/o fall within past year: []Y [X]N
Visual aides [+]Y [ ]N
Dentures [+ ]Y [ ]N
Hearing Aides [ ]Y [ X] N
She has 3 stepsons and a dtr. She is very close to all of them.
Family History:
Mother died at ___ with atrial fibrillation and a blood clot.
Father died at age ___ with PVD s/p amputation. Sister with
___ requiring ERCP with Dr. ___ being
s/p CCY.
Physical Exam:
PHYSICAL EXAM: I3 - PE >8
PAIN SCORE ___
1. VS: T= 98.3 P = 70 BP = 156/62 RR 18 O2Sat on __95% RA__
UOP = 250 cc
GENERAL: Well appearing very tanned petite female
Nourishment: good
Grooming: good
Mentation
2. Eyes: [X] WNL
EOMI without nystagmus, Conjunctiva: clear
3. ENT [] WNL
[X] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____
cm
[] Dry [] Poor dentition [] Thrush [] Swelling [] Exudate
4. Cardiovascular [X] WNL
[] Regular [] Tachy [X] S1 [X] S2 [] Systolic Murmur /6,
Location:
[] Irregular []Brady []S3 [] S4 [] Diastolic Murmur /6,
Location:
[X] Edema RLE None [] Bruit(s), Location:
[X] Edema LLE None [] PMI
[] Vascular access [X] Peripheral [] Central site:
5. Respiratory [X] WNL
[x] CTA bilaterally [ ] Rales [ ] Diminshed
[] Comfortable [ ] Rhonchi [ ] Dullness
[ ] Percussion WNL [ ] Wheeze [] Egophony
6. Gastrointestinal [X] WNL
[X] Soft [] Rebound [] No hepatomegaly [] Non-tender [] Tender
[] No splenomegaly
[] Non distended [] distended [] bowel sounds Yes/No []
guiac: positive/negative
7. Musculoskeletal-Extremities [X] WNL
[ ] Tone WNL [X]Upper extremity strength ___ and symmetrical [
]Other:
[ ] Bulk WNL [X] Lower extremity strength ___ and symmetrica
[ ] Other:
[] Normal gait []No cyanosis [ ] No clubbing [] No joint
swelling
8. Neurological [X] WNL
[X] Alert and Oriented x 3 [ ] Romberg: Positive/Negative [ ]
CN II-XII intact [ ] Normal attention [ ] FNF/HTS WNL []
Sensation WNL [ ] Delirious/confused [ ] Asterixis
Present/Absent [ ] Position sense WNL
[ ] Demented [ ] No pronator drift [] Fluent speech
9. Integument [X] WNL
Very tanned skin
[X] Warm [X] Dry [] Cyanotic [] Rash:
none/diffuse/face/trunk/back/limbs
[ ] Cool [] Moist [] Mottled [] Ulcer:
None/decubitus/sacral/heel: Right/Left
10. Psychiatric [X] WNL
[X] Appropriate [] Flat affect [] Anxious [] Manic []
Intoxicated [] Pleasant [] Depressed [] Agitated [] Psychotic
[] Combative
11. Hematologic/Lymphatic [X]WNL
[X] No cervical ___
TRACH: []present [X]none
PEG:[]present [X]none [ ]site C/D/I
COLOSTOMY: :[]present [X]none [ ]site C/D/I
Pertinent Results:
___ 07:20PM LACTATE-2.2*
___ 07:18PM GLUCOSE-104* UREA N-13 CREAT-0.9 SODIUM-141
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-29 ANION GAP-14
___ 07:18PM estGFR-Using this
___ 07:18PM ALT(SGPT)-167* AST(SGOT)-84* ALK PHOS-565*
TOT BILI-1.1
___ 07:18PM LIPASE-41
___ 07:18PM WBC-7.6 RBC-4.69 HGB-14.8 HCT-44.3 MCV-94
MCH-31.5 MCHC-33.4 RDW-13.4
___ 07:18PM NEUTS-71.1* ___ MONOS-6.3 EOS-0.7
BASOS-0.6
___ 07:18PM PLT COUNT-393
___ 07:18PM ___ PTT-30.8 ___
___ 07:18PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 07:18PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-2* PH-5.5 LEUK-SM
___ 07:18PM URINE RBC-2 WBC-3 BACTERIA-NONE YEAST-NONE
EPI-<1 TRANS EPI-1
___ 07:18PM URINE HYALINE-7*
___ 07:18PM URINE CA OXAL-OCC
___ 07:18PM URINE MUCOUS-FEW
......
OSH RUQ US: ___
Cholelithiasis, No wall thickening or pericholecystic fluid
-----
Abdominal CT scan: ___
Choledolithiasis, cholelithiasis, ductal dilatation of the
cystic duct, common hepatic duct, intrhepatic biliary
dilatation.
------
___
Tbili = 2.4
ALK P = 791
ALT = 273
AST = 113
-----
___
AST = 73, ALT = 141
----
___
ALT = 84
WBC = 8.5 K with 75% PMNS
HCT = 46.2
----
normal LFTs in ___
----
ERCP (___):
- A large duodenal diverticulum was noted. The major papilla was
found to be located at the lower margin of the diverticulum.
- Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique.
- A diffuse dilation of the CBD was noted. The CBD measured 12
mm. The cystic duct was also noted to be dilated.
- The gall bladder was filled with contrast and demonstrated
multiple filling defects consistent with stones.
- The cystic duct had a filling defect consistent with stone.
This stone was noted to compress the bile duct suggestive of
Mirrizzi syndrome. Rest of the bile duct appeared unremarkable.
- A sphincterotomy was performed in the 12 o'clock position
using a sphincterotome over an existing guidewire.
- A sphincteroplasty was performed using a balloon that was
dilated from 10-12 mm.
- Two stones and some sludge were extracted successfully using a
balloon. Given the presentation of Mirizzi syndrome with CBD
compression, a 5cm by 5mm double pig tail biliary stent was
placed successfully.
- Mild oozing was noted from the sphincterotomy site. Five 5 cc
epinephrine ___ injections were applied for hemostasis with
success. A gold probe was applied for hemostasis successfully in
the sphincterotomy. No more oozing was noted.
- Otherwise normal ercp to third part of the duodenum
Brief Hospital Course:
Ms. ___ is a ___ year old woman who presents with abdominal
pain and nausea and is found to have a choledolithiasis. She had
ERCP upon admission, which showed CBD dilatation, cystic duct
dilatation, cholelithiasis, and Mirrizzi syndrome. A
sphincterotomy and sphincteroplasty were done. Two stones and
sludge were extracted with a balloon. A biliary stent was
placed. After the ERCP, she was kept NPO and on IV fluids
overnight. She was not given antibiotics during this admission,
nor was she sent out on any. Patient denied having any pain or
nausea whatsoever prior to and after the procedure. Her diet was
advanced the following morning without problem. Arrangements
were made for her to have cholecystectomy by Dr. ___
at ___ on ___ at 11am. The
patient was informed of the appointment details verbally and in
her discharge instructions.
.
TRANSITIONAL ISSUES:
- Patient was advised to hold her Aspirin until after her
surgery.
- Patient was advised to stay NPO after midnight on ___ night
and that she can take her chronic medications on the day of her
procedure.
- Will need repeat ERCP in 2 months for stent pull and
evaluation for remaining cystic duct stones. She has a follow-up
GI appointment already scheduled.
- FULL CODE confirmed during this admission.
Medications on Admission:
Amoxcillin /Clavunate 875/125 T bid
Levothyroxine 75 mcg daily
amlodipine 5 mg daily
Spironolactone 25 mg daily - but pt denies heart failure /heart
disease
doxycycline 100 mg every other day for psoriasis
Vitamin D ___ IU daily
Omega 3
Calcium
ASA 81 mg daily ( takes a large ASA 325 mg and cuts it into 4)
Discharge Medications:
1. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. cholecalciferol (vitamin D3) 2,000 unit Tablet Sig: One (1)
Tablet PO once a day.
5. Omega 3 350-400 mg Capsule Sig: One (1) Capsule PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Choledocholithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ for
treated of a stone in your common bile duct, which was causing a
blockage. You had a procedure which relieved the blockage. You
did very well after the procedure. You can take Tylenol for
pain.
.
MEDICATON CHANGES:
- You can stop taking Augmentin, the antibiotic you were taking
before coming into the hospital.
- Please stop taking Aspirin until your surgeon or primary
doctor tell you it's ok to restart it.
- Avoid any anti-inflammatory pain relievers, such as Ibuprofen,
Motrin, or Aleve.
Followup Instructions:
___
|
10186925-DS-24 | 10,186,925 | 22,558,971 | DS | 24 | 2193-04-25 00:00:00 | 2193-04-25 18:23:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Azathioprine
Attending: ___.
Chief Complaint:
Right Flank Abscess, Hypotension
Major Surgical or Invasive Procedure:
___ guided drainage of abscess x2
Bedside ulcer debridement
History of Present Illness:
___ y/o F with ESRD s/p failed kidney transplant (HD ___ and
DM presents with right flank pain and mass. Patient reports
worsening right sided flank pain with tender mass x 5 days. No
fevers or chills. No abdominal pain, nausea, or vomiting. Does
not make any urine at baseline. No chest pain, SOB, or cough.
Evaluation in the ED showed stable labwork, normal WBC and
normal lactate. Baseline Cr. between 3 and 6. CT imaging showed
a large right flank mass. Transplant surgery was consulted who
recommended medicine admission for ___ guided drainage. Dialysis
nurses were notified of admission for need for HD. While
awaiting a bed in the ED, around 11am today, the patient became
hypotensive to the 80's systolic. Noted to be mentating well.
Was given a 500cc bolus, blood cultures x2 were drawn and she
was started on IV Vanc/Zosyn. and bed changed to the ICU.
Uses Home O2, 2L.
Initial Vital Signs: Temp: 99.3 °F (37.4 °C), Pulse: 102, RR:
21, BP: 107/52, O2 sat: 97, O2 flow: 3L
11AM Vital Signs: Temp: 98.8 °F (37.1 °C) (Oral), Pulse: 85, RR:
15, BP: 80/48, O2 sat: 98, O2 flow: 3 (Nasal Cannula), Pain: 2.
On transfer, vitals were: HR 91, BP 117/54, RR 18
On arrival to the MICU, patient felt at her baseline. Complains
of right flank pain, but denies fevers, chills, n/v, diarrhea,
chest pain, SOB.
Past Medical History:
ESRD s/p living unrelated renal transplant ___, c/b Chronic
allograft nephropathy with transplant glomerulopathy
DMII ___ years c/b retinopathy and neuropathy, nephropathy
HTN
CAD s/p CABG ___, stent in OSH in ___
diastolic heart failure w/ nl EF 60% on echo ___
A fib/flutter s/p ablation in ___ on coumadin
hyperlipidemia
PVD
h/o chronic ___ ulcerations s/p several toe amputations and
debridements - h/o pseudomonas and VRE.
s/p ___ revascularization ___
OSA- scheduled to start BIPAP as an outpt
hypothyroidism
current smoker
COPD on 2L home O2
Obesity
h/o DVT on coumadin
Anxiety
Depression
CVA ___- no residual deficits
urinary incontinence
Social History:
___
Family History:
Brother with diabetes ___. Father died of bulbar palsy,
mother died of MI but per chart had ALS.
Physical Exam:
ADMISSION PHYSICAL EXAM
=========================
Vitals- BP:100/41 P:81 R:18 O2:95% NC
GENERAL: Alert, oriented, no acute distress, obese
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, very limited by body
habitus. no wheezes, rales, rhonchi
CV: Afib, normal S1 S2, no murmurs, rubs, gallops
ABD: Obese, soft, non-tender, non-distended
EXT: Warm, well perfused. S/P right BKA. LLE with chronic
wound in heel.
SKIN: Multiple areas in hands of small 1mm black appear spots,
felt not to be infectious and have been swabbed in the past.
DISCHARGE PHYSICAL EXAM
=========================
Vitals: Tm 98.9, 74-84, 101-118/43-56, 100 on 2L
General: Alert, oriented; NAD, flat affect
HEENT: Sclera anicteric, MMM
Neck: supple
Lungs: Clear to auscultation other than bibasilar crackles
CV: Regular rate and rhythm, II/VI holosystolic murmur heard
throughout precordium
Abdomen: distended but soft. Nontender, hypoactive bowel sounds
Ext: s/p R BKA; LLE warm, ___ pitting edema to knee
Pertinent Results:
ADMISSION LABS
==============
___ 07:27PM BLOOD WBC-8.6 RBC-3.26* Hgb-10.9* Hct-34.9*
MCV-107* MCH-33.4* MCHC-31.2 RDW-13.9 Plt ___
___ 07:27PM BLOOD ___ PTT-35.6 ___
___ 07:27PM BLOOD Glucose-173* UreaN-30* Creat-4.2* Na-138
K-4.7 Cl-95* HCO3-30 AnGap-18
___ 06:35AM BLOOD Calcium-8.0* Phos-4.4 Mg-2.1
___ 07:31PM BLOOD Lactate-1.2
DISCHARGE LABS
===============
___ 08:25AM BLOOD WBC-3.8* RBC-3.01* Hgb-10.4* Hct-32.9*
MCV-109* MCH-34.6* MCHC-31.6 RDW-15.9* Plt ___
___ 08:25AM BLOOD ___ PTT-40.7* ___
___ 08:25AM BLOOD Glucose-101* UreaN-25* Creat-2.9*# Na-134
K-4.8 Cl-96 HCO3-27 AnGap-16
___ 08:25AM BLOOD Calcium-9.1 Phos-3.8 Mg-2.2
MICROBIOLOGY
============
___ 4:59 pm ABSCESS
**FINAL REPORT ___
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
ENTEROCOCCUS SP.. RARE GROWTH.
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
gentamicin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details .
HIGH LEVEL GENTAMICIN SCREEN REQUESTED BY ___
___
___ AT 1014.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 1 S
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ =>32 R
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
RADIOLOGY
=========
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 12:10 AM
1. Large right flank abscess measuring 13.3 cm x 6.3 cm x 9.2
cm.
2. Severe native renal atrophy with transplant kidney in the
right iliac
fossa.
3. Mild mesenteric and subcutaneous edema likely from volume
overload.
CHEST (PORTABLE AP) Study Date of ___ 11:11 AM
Moderate pulmonary edema.
CHEST (PORTABLE AP) Study Date of ___ 3:58 AM
As compared to the previous radiograph, there is unchanged
evidence of mild cardiomegaly as well as mild fluid overload.
No new parenchymal opacities. No larger pleural effusions. No
pneumonia, no pneumothorax.
CT ABD & PELVIS WITH CONTRAST ___
IMPRESSION:
1. Significant interval decrease in size of the large right
flank abscess collection, with small residual dense collection
remaining, measuring 6.6 x 2.0 cm.
2. Renal cortical atrophy with a transplant kidney in the right
iliac fossa.
3. Trace bilateral pleural effusions.
4. Few prominent retroperitoneal lymph nodes, dominant in left
para-aortic region, nonspecific in etiology. Short-term CT
followup of these lymph nodes is recommended.
___ Hip Xray ___
IMPRESSION: Bones appear osteopenic. There is no definite
evidence of acute fracture. Slight irregularity of the right
inferior pubic ramus may be due to an old healed fracture.
Clinical correlation is recommended.
L foot xray ___
IMPRESSION: Soft tissue swelling. No definite evidence of
osteomyelitis. MRI may be helpful for further evaluation.
Limited study as described.
CXR ___
FINDINGS: Frontal and lateral views of the chest demonstrate
peribronchial cuffing, cardiomegaly, and upper zone vascular
redistribution consistent with mild to moderate pulmonary edema.
There are no new parenchymal opacities. There is no large
pleural effusion or pneumothorax.
Head CT w/o contrast ___
IMPRESSION: No acute intracranial abnormality. If clinical
concern for intracranial mass is high, MRI is more sensitive.
TTE ___
Conclusions
The left atrium is mildly dilated. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. 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 are moderately thickened. There is a minimally
increased gradient consistent with minimal aortic valve
stenosis. No aortic regurgitation is seen. There is severe
mitral annular calcification but no functional mitral stenosis.
Mild to moderate (___) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] Moderate [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension.
IMPRESSION: Mild moderate mitral regurgitation with mildly
thickened mitral leaflets and prominent MAC. Normal
biventricular cavity sizes with preserved global biventricular
systolic function. Moderate tricuspid regurgitation. Minimal
mitral stenosis. Very prominent mitral annular calcification. No
discrete vegetation identified.
Compared with the prior study (images reviewed) of ___ the
severity of mitral regurgitation has now increased, and the
rhythm now appears to be atrial fibrillation. The severity of
aortic stenosis is similar.
If the clinical suspicion for endocarditis is moderate or high,
a TEE is suggested due to the increase in mitral regurgitation.
MRI L Foot ___
IMPRESSION:
1. No convincing evidence of osteomyelitis.
2. Edema of the third, fourth, and fifth metatarsals is most
consistent with subacute fractures given the linear low signal
seen at the metatarsal necks.
3. Moderate subcutaneous edema.
4. Degenerative change in the midfoot.
___ CT ABDOMEN/PELVIS WITH CONTRAST
FINDINGS:
CT ABDOMEN: The visualized lung bases demonstrate tiny
bilateral pleural
effusions with adjacent atelectasis, left more than right. Dense
mitral
annular calcifications are seen.
The liver is unremarkable without focal liver lesion identified.
The
gallbladder is absent. The spleen is unremarkable. The pancreas
is atrophic but otherwise unremarkable. Bilateral adrenal glands
are normal. The native kidneys are atrophic.
Small and large bowel are normal in course and caliber without
obstruction. A dilated bowel loop is seen adjacent to an
anastomosis in the left lower quadrant, similar to prior
studies. There is large colonic fecal loading. No free fluid
and no free air. Dense atherosclerotic calcifications are noted
throughout the mesenteric and renal vasculature as well as the
normal caliber abdominal aorta. The main portal vein, splenic
vein and SMV are patent. Prominent retroperitoneal lymph nodes,
predominantly in the left para-aortic region, are unchanged from
___ and nonspecific.
The right retroperitoneal fluid collection in the right flank
subcutaneous tissues and muscle has nearly completely resolved
with minimal residual fluid collection (5:32). The catheter is
in place.
CT PELVIS: The rectum, sigmoid colon, and bladder are
unremarkable. The
transplanted kidney is seen in the right lower hemipelvis
similar to prior
studies. Numerous clips are noted in the pelvis. There is no
free fluid and no pelvic or inguinal lymphadenopathy.
BONE WINDOWS: Bones are diffusely demineralized. No bone
finding suspicious for infection or malignancy is seen. Loss of
height of the L5 vertebral body is unchanged. Fixation hardware
is noted within the left femur.
IMPRESSION:
1. Near complete resolution of right retroperitoneal abscess
with minimal
residual fluid collection.
2. Small bilateral pleural effusions, left larger than right
,with bibasilar atelectasis.
3. Nonspecific prominent retroperitoneal lymph nodes,
predominantly in the left para-aortic region, are unchanged from
___. As suggested on the prior study, short-term CT
followup of these lymph nodes could be performed.
___ KUB
IMPRESSION:
Large dilated bowel loop in the central abdomen. Otherwise
nonspecific bowel gas patterns. No free area. The quality of
the exam, however, is limited. Therefore, if the clinical
concerns for obstruction persist, CT should be obtained.
Multiple clips and postsurgical material is visible. Status
post sternotomy. No abnormalities at the lung bases.
___ CT ABDOMEN/PELVIS
IMPRESSION: Small-bowel obstruction involving the proximal
jejunum with a transition point in the left lower quadrant. No
sign of bowel ischemia or pneumoperitoneum.
The drain from the right flank abscess has been pulled and a 7 x
3.3 cm fluid collection is now seen there.
___ U/s:
IMPRESSION:
10.1 x 2.6 x 7.1 cm hypoechoic right flank fluid collection.
___ U/s drainage:
IMPRESSION:
Successful US-guided placement of ___ pigtail catheter into
the right
flank subcutaneous complex fluid collection. 42 cc of purulent
fluid
aspirated. Samples was sent for microbiology evaluation
___ KUB:
IMPRESSION:
Dilated bowel loops without air-fluid levels. A small bowel
obstruction
cannot be excluded, and CT is recommended for further
evaluation.
___ KUB:
IMPRESSION:
Minimally decreased caliber of dilated small and large bowel.
Brief Hospital Course:
___ y/o woman with complicated PMHx, including ESRD s/p failed
kidney transplant, COPD, DM, PVD, s/p R BKA, presented with
right flank pain found to have a VRE flank abscess. Hosp course
c/b hypotension, pulm edema from fluid resuscitation, and
myoclonic episodes.
ACTIVE ISSUES:
#VRE abscess: Large flank abscess without obvious source of
direct extension, now s/p drainage with drain in place. The
drain was removed after CT abdomen showed near resolution of her
abscess. Possible sources for endovascular seeding were
evaluated. MRI of foot at site of non-healing ulcer without
osteo. TTE negative for vegetations and patient declined TEE.
The patient was treated with linezolid initially. However,
because of downtrending platelet count, the patient was switched
to daptomycin 600 mg q48h at discharge. Repeat CT abdomen
demonstrated reaccumulation of fluid at the site of the abscess.
Pt. underwent repeat drainage and was discharged with the drain
in place and plans to follow-up with Dr. ___ in 2 weeks for
evaluation for drain removal.
# SBO: The patient developed a small bowel obstruction while
being; the transition point was localized to the site of a prior
anastomamosis in her left lower quadrant. The patient was
evaluated by Transplant Surgery and felt she did not require
surgical intervention; CT abdomen initially showed no evidence
of ischemia or free air. The patient underwent nasogastric
decompression and conservative management for SBO. She did well
with resolution of the SBO. She was tolerating a full diet and
having normal bowel movements by discharge.
#L heel ulcer: Pt. underwent bedside debridement by podiatry.
Low suspicion of infectious process. MRI without osteo.
#Myoclonus: Pt had an episode of severe myoclonus resulting in
tongue biting, responsive to benzo tx. Eval'd by neurology who
did not think it was a seizure. Likely toxic/metabolic given
ESRD and COPD.
#Hypotension: SBPs in 80-90's several times during this
admission that resolved with gentle volume resuscitation.
Suspect that these were related to hypovolemia or possibly
transient bacteremia.
#ESRD: Continued on dialysis in house.
#Afib: Well rate controlled, even with reduced metoprolol dose.
Warfarin dose decreased while on antibiotics and transitioned to
heparin gtt while NPO due to SBO.
TRANSITIONAL ISSUES:
#Drain removal by Dr. ___ as outpatient 2 weeks after
discharge
#Continue Daptomycin with HD for 1 week following drain removal
pending ID recs
# Monitor abdominal exam: Mild tenderness and distention ok if
having bowel movements/passing gas
# Ensure continues to have bowel movements
#Warfarin dose decreased while on antibiotics. Titrate with INRs
goal 2.0-3.0
#Consider Midodrine prior to dialysis if patient becomes
hypotensive consistently with no other cause
#Citalopram dose decreased while on linezolid (___).
Reassess dose when antibiotic course complete
#Follow up with podiatry
# CT finding of prominent retroperitoneal lymph nodes, recommend
short-term CT followup
# Per ID, please obtain TTE 1 month after completion of
antibiotics
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ciprofloxacin HCl 250 mg PO Q12H
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
3. Omeprazole 20 mg PO DAILY
4. Warfarin 6 mg PO DAILY16
5. Citalopram 40 mg PO DAILY
6. ClonazePAM 0.5 mg PO TID
7. Pregabalin 75 mg PO BID
8. Metoprolol Succinate XL 50 mg PO DAILY
9. sevelamer CARBONATE 1600 mg PO BID
10. Simvastatin 10 mg PO QPM
11. NovoLOG FLEXPEN (insulin aspart) 100 unit/mL subcutaneous
QID
12. Multivitamins 1 TAB PO DAILY
13. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. ClonazePAM 0.5 mg PO TID:PRN anxiety
3. Multivitamins 1 TAB PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Pregabalin 75 mg PO BID
6. sevelamer CARBONATE 1600 mg PO BID
7. Simvastatin 10 mg PO QPM
8. Warfarin 6 mg PO DAILY16
9. Lidocaine 5% Patch 2 PTCH TD QAM pain
RX *lidocaine [Lidoderm] 5 % (700 mg/patch) 2 patch qam Disp
#*20 Patch Refills:*0
10. Nephrocaps 1 CAP PO DAILY
RX *B complex-vitamin C-folic acid [Nephrocaps] 1 mg 1
capsule(s) by mouth daily Disp #*30 Capsule Refills:*0
11. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
12. NovoLOG FLEXPEN (insulin aspart) 100 unit/mL subcutaneous
QID
13. Miconazole Powder 2% 1 Appl TP QID:PRN intertrigo/skin
irritation
RX *miconazole nitrate [Anti-Fungal] 2 % apply to affected
regions four times a day Refills:*0
14. Daptomycin 600 mg IV Q48H
Patient will receive a total of 3 doses per week, each dosed at
hemodialysis.
RX *daptomycin [Cubicin] 500 mg 1.2 IV q48h Disp #*3 Vial
Refills:*0
15. Outpatient Lab Work
ICD-9 567.22. Patient will need CK check on ___. Patient will
also need blood cultures 1 week and 2 weeks (on ___ and ___.
Please fax results to PCP:
Name: ___ MD
Address: ___
Phone: ___
Fax: ___
16. Citalopram 20 mg PO DAILY
17. Acetaminophen 1000 mg PO Q8H
18. Bisacodyl ___ID
Please change to prn as patient starts having more bowel
movements
19. Collagenase Ointment 1 Appl TP DAILY
20. Docusate Sodium 100 mg PO BID
21. Metoprolol Succinate XL 25 mg PO DAILY
22. TraMADOL (Ultram) 50 mg PO Q6H:PRN breaththrough pain
23. Simethicone 80 mg PO QID:PRN bloating
24. Polyethylene Glycol 17 g PO DAILY
25. Senna 8.6 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Vancomycin resistant enterococcal flank abscess
Left heel ulcer
End stage renal disease
Myoclonus
Atrial fibrillation
Small bowel obstruction
Secondary:
Diabetes
Coronary artery disease
Chronic obstructive pulmonary disease
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:
Ms ___,
It was a pleasure taking care of you at ___
___. You were admitted with a large abscess in your
back, which you had drained. You were started on an antibiotic
to treat this. We removed the drain once it stopped draining,
but unfortunately the abscess reaccumulated and had to be
drained again and the antibiotic course was lengthened. Please
follow-up with Dr. ___ drain removal and with the
infectious disease specialists to discuss when to discontinue
the antibiotics.
You had your heel ulcer cleaned out by podiatrists while you
were in the hospital. An MRI of the foot showed that the bone
under the heel ulcer was not infected. Please follow up with Dr
___ in 1 week from discharge.
You had an episode of severe twitching while you were here, and
was evaluated by neurologists who did not think that you were
having a seizure. We think that they were muscle spasms. You
were treated with benzodiazepines and this seemed to help. If
these episodes continue to occur, please follow up with your
primary care doctor to have them addressed.
During your hospital course, you also had a bowel obstruction
that required placement of a nasogastric tube with suction. This
resolved without further intervention, and you were toelrating a
regular diet with normal bowel movements by discharge.
It was a pleasure taking care of you. We wish you all the best.
Sincerely,
Your medicine team at ___
Followup Instructions:
___
|
10187053-DS-15 | 10,187,053 | 25,403,067 | DS | 15 | 2142-08-11 00:00:00 | 2142-08-06 13:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Ataxia extremity weakness
Major Surgical or Invasive Procedure:
ACDF
Posterior Cervical Fusion
History of Present Illness:
___ PMH asthma, prostate CA with several month history of
atraumatic progressive gait instability, weakness, and loss of
fine motor dexterity. Patient reports several months ago he
noted onset of right lower extremity generalized weakness and
difficulty with right foot dorsiflexion. He also reports that he
has had gait instability secondary to a combination of weakness
and imbalance. Patient also reports difficulty with handling
his keys, buttoning his shirts, and other fine motor tasks. He
denies any bowel or bladder issues. He denies any saddle
anesthesia. He has had progressive inability to walk and has not
walked now for a few weeks. Patient also notes that his lower
extremities have been "twitching" more frequently. Patient also
sustained a car accident in ___ of this year due to a
syncopal episode with unknown etiology, however he is
generalized weakness and gait instability predates this MVC. He
was seen by neurology proximately 3 weeks ago who felt that his
symptoms were likely spinal in etiology and obtained a cervical
MRI which at the time demonstrated C3-5 stenosis. He called his
neurologist today stating that he felt his symptoms were
progressing and was directed to present to the emergency
department. MRI imaging from 3 weeks prior demonstrates central
compression at C3-5 with cord signal change
Past Medical History:
Asthma
Prostate CA s/p resection
Social History:
___
Family History:
NC
Physical Exam:
VSS
Well appearing, NAD, comfortable
BUE: SILT C5-T1 dermatomal distributions
BUE: ___ Del/Tri/Bic/WE/WF/FF/IO
BUE: tone normal, negative ___, 2+ symmetric DTR
bic/bra/tri
All fingers WWP, brisk capillary refill, 2+ distal pulses
BLE: SILT L1-S1 dermatomal distributions
BLE: ___ ___
BLE: tone normal, no clonus, toes downgoing, 2+ DTR knee/ankle
All toes WWP, brisk capillary refill, 2+ distal pulses
Pertinent Results:
___ 07:06AM BLOOD WBC-13.7* RBC-4.55* Hgb-12.7* Hct-40.4
MCV-89 MCH-27.9 MCHC-31.4* RDW-12.5 RDWSD-40.4 Plt ___
___ 04:24PM BLOOD WBC-14.0* RBC-4.79 Hgb-13.5* Hct-40.5
MCV-85 MCH-28.2 MCHC-33.3 RDW-12.3 RDWSD-37.7 Plt ___
___ 07:50AM BLOOD WBC-15.2* RBC-4.75 Hgb-13.1* Hct-39.3*
MCV-83 MCH-27.6 MCHC-33.3 RDW-12.3 RDWSD-37.5 Plt ___
___ 07:20AM BLOOD WBC-9.0 RBC-4.27* Hgb-12.0* Hct-37.2*
MCV-87 MCH-28.1 MCHC-32.3 RDW-12.4 RDWSD-39.3 Plt ___
___ 06:57AM BLOOD WBC-8.9 RBC-3.93* Hgb-11.2* Hct-33.9*
MCV-86 MCH-28.5 MCHC-33.0 RDW-12.0 RDWSD-38.2 Plt ___
___ 06:23AM BLOOD WBC-7.8 RBC-4.43* Hgb-12.6* Hct-39.3*
MCV-89 MCH-28.4 MCHC-32.1 RDW-12.2 RDWSD-39.6 Plt ___
___ 05:41AM BLOOD WBC-13.0* RBC-4.15* Hgb-11.8* Hct-36.5*
MCV-88 MCH-28.4 MCHC-32.3 RDW-12.3 RDWSD-39.5 Plt ___
___ 06:41PM BLOOD WBC-11.4* RBC-4.85 Hgb-13.8 Hct-42.4
MCV-87 MCH-28.5 MCHC-32.5 RDW-12.6 RDWSD-40.5 Plt ___
___ 06:41PM BLOOD Neuts-76.6* Lymphs-12.7* Monos-9.2
Eos-0.9* Baso-0.3 Im ___ AbsNeut-8.76* AbsLymp-1.45
AbsMono-1.05* AbsEos-0.10 AbsBaso-0.04
___ 07:06AM BLOOD Plt ___
___ 04:24PM BLOOD Plt ___
___ 07:50AM BLOOD Plt ___
___ 07:20AM BLOOD Plt ___
___ 06:57AM BLOOD Plt ___
___ 06:23AM BLOOD Plt ___
___ 05:41AM BLOOD Plt ___
___ 07:06AM BLOOD Glucose-172* UreaN-17 Creat-0.8 Na-136
K-5.0 Cl-105 HCO3-13* AnGap-17
___ 04:24PM BLOOD Glucose-125* UreaN-15 Creat-0.7 Na-139
K-4.4 Cl-101 HCO3-25 AnGap-13
___ 07:50AM BLOOD Glucose-155* UreaN-17 Creat-0.6 Na-136
K-4.5 Cl-101 HCO3-22 AnGap-13
___ 07:20AM BLOOD Glucose-124* UreaN-14 Creat-0.7 Na-141
K-5.1 Cl-104 HCO3-26 AnGap-11
___ 06:57AM BLOOD Glucose-138* UreaN-20 Creat-0.6 Na-137
K-4.4 Cl-101 HCO3-25 AnGap-11
___ 06:23AM BLOOD Glucose-143* UreaN-15 Creat-0.7 Na-138
K-4.3 Cl-102 HCO3-26 AnGap-10
___ 05:41AM BLOOD Glucose-177* UreaN-15 Creat-0.7 Na-140
K-4.8 Cl-105 HCO3-24 AnGap-11
___ 06:41PM BLOOD Glucose-116* UreaN-14 Creat-1.0 Na-142
K-4.2 Cl-102 HCO3-25 AnGap-15
___ 04:24PM BLOOD ALT-25 AST-19 LD(LDH)-184 AlkPhos-90
TotBili-0.3
___ 06:41PM BLOOD ALT-12 AST-15 AlkPhos-62 TotBili-0.3
___ 04:24PM BLOOD cTropnT-<0.01
___ 06:41PM BLOOD cTropnT-<0.01
___ 07:06AM BLOOD Calcium-8.5 Phos-2.9 Mg-2.0
___ 07:50AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.0
___ 07:50AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.0
___ 04:24PM BLOOD CRP-61.7*
___ 05:15PM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-7.5 Leuks-TR*
___ 09:34PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR*
___ 05:15PM URINE RBC-2 WBC-4 Bacteri-NONE Yeast-NONE Epi-0
___ 09:34PM URINE RBC-1 WBC-5 Bacteri-NONE Yeast-NONE Epi-0
___ 05:15PM URINE Color-Yellow Appear-Clear Sp ___
Brief Hospital Course:
Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure.Refer to the
dictated operative note for further details.The surgery was
without complication and the patient was transferred to the PACU
in a stable ___ were used for postoperative
DVT prophylaxis.Intravenous antibiotics were continued for 24hrs
postop per standard protocol.Initial postop pain was controlled
with oral and IV pain medication.Diet was advanced as
tolerated.Foley was removed on POD#2. Physical therapy and
Occupational therapy were consulted for mobilization OOB to
ambulate and ___ is a ___ y/o male s/p cervical fusion c/b dysphagia
requiring dobhoff tube placement and tube feeds for alternative
means of nutrition.Post op course also now complicated by RLL
pneumonia seen on CXR ___ and likely due to aspiration given
his dysphagia issues. He and was started on Levofloxacin on
___. Mr. ___ should follow up with PCP ___ ___ weeks for
follow up check given pneumonia. Vitals and labs are all WNL's
this morning and his cough is now productive.Hospital course was
otherwise unremarkable. On the day of discharge the patient was
afebrile with stable vital signs, comfortable on oral pain
control and tolerating a regular diet.
Medications on Admission:
NC
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
3. Cyclobenzaprine 10 mg PO DAILY:PRN spasm
crushed in NGT
4. Docusate Sodium (Liquid) 100 mg PO BID
NGT
5. Famotidine 20 mg PO Q12H
crushed in NGT
6. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN wheezing
7. LevoFLOXacin 750 mg PO Q24H
10 days crushed in NGT
8. OxyCODONE Liquid ___ mg PO Q4H:PRN Pain - Moderate
RX *oxycodone 5 mg/5 mL ___ ml by mouth every ___ hours
Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Cervical Stenosis
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:
-Activity:You should not lift anything greater than 10 lbs for 2
weeks.You will be more comfortable if you do not sit in a car or
chair for more than~45 minutes without getting up and walking
around.
-Rehabilitation/ Physical ___ times a day you should go
for a walk for ___ minutes as part of your recovery.You can
walk as much as you can tolerate.Limit any kind of lifting.
-Cervical Collar / Neck Brace:You need to wear the brace at all
times until your follow-up appointment which should be in 2
weeks.You may remove the collar to take a shower.Limit your
motion of your neck while the collar is off.Place the collar
back on your neck immediately after the shower.
-Wound Care: Keep the incision covered with a dry dressing on
until follow up appointment. If the incision is draining cover
it with a new sterile dressing.Once the incision is completely
dry (usually ___ days after the operation) you may take a shower
and place a new dry dressing on. Do not soak the incision in a
bath or pool.If the incision starts draining at anytime after
surgery, do not get the incision wet.Cover it with a sterile
dressing.Call the office.
-Medications: You should resume taking your normal home
medications. You have also been given Additional Medications to
control your pain.Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead.You can either have them
mailed to your home or pick them up at the clinic located on
___.We are not allowed to call in narcotic prescriptions
(oxycontin,oxycodone,percocet) to the pharmacy.In addition,we
are only allowed to write for pain medications for 90 days from
the date of surgery.
-Follow up:Please Call the office and make an appointment for 2
weeks after the day of your operation if this has not been done
already.
-Please call the office if you have a fever>101.5 degrees
Fahrenheit,drainage from your wound,or have any questions.
Physical Therapy:
Activity: Ambulate twice daily if patient able collar when oob,
may remove when upright for hygeine
Treatments Frequency:
Keep the incision covered with a dry dressing on until follow up
appointment. If the incision is draining cover it with a new
sterile dressing.Once the incision is completely dry (usually
___ days after the operation) you may take a shower and place a
new dry dressing on. Do not soak the incision in a bath or
pool.If the incision starts draining at anytime after surgery,
do not get the incision wet.Cover it with a sterile
dressing.Call the office.
Followup Instructions:
___
|
10187092-DS-6 | 10,187,092 | 20,968,686 | DS | 6 | 2182-11-04 00:00:00 | 2182-11-05 10:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex / clindamycin
Attending: ___.
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
intubation at OSH, extubated at ___
History of Present Illness:
___ is a ___ year old female with a history of
restrictive lung disease, COPD, advanced dementia (nonverbal),
aspiration pneumonia, with chronic ___ and 2L home O2
requirement, presenting transferred from OSH with respiratory
failure.
Per the pt's daughter, she is normally stable on 2L home O2.
Over the last week she has required intermittent increases in O2
to 3L, which she is able to slowly wean down. She has also had
increasing sneezing, runny, red eyes, and wheezing. She is not
good at clearing her secretions but gets suctioned with the
yankauer at home and per the daughter the secretions have
continued to be clear. The pt also has had some bleeding from
one nostril and the daughter has had to suction clots of blood
from her throat on occasion.
Today the pt had some increasingly labored breathing (noted by
daughter as pt is nonverbal and unable to communicate). EMS was
called and found the pt to be satting 94% on home O2. On RA she
dropped to roughly the ___, so the O2 was increased to 4Lnc and
sats remained at 95%.
On arrival to ___, she was initially awake and
alert but then began to get progressively more somnolent. Her
respiratory status quickly deteriorated and she was observed to
go from 94% to 77% O2 sat on 4 L O2 NC. An ambu bag was applied
with return of sats to 90-93%. A blood gas revealed pH 7.11
pCO2 171 pO2 80, so rapid endotrachial intubation was performed.
The pt was sedated with propofol and transferred on A/C, RR 14,
TV 400, FIO2 40%, satting 92%. There were no available beds in
the AJ MICU so the pt was transferred to ___.
At ___, the pt had a CXR which showed mild vascular
congestion, ET tube in place, though slightly low. She was not
given any medications or treatments. ABG 7.38 pCO2 86 pO2 339
HCO3 53. On arrival to the floor, the pt was afebrile, 91 84/59
satting 100%. Vent settings AC, FiO2 100%, TV 450, RR 20, PEEP
5.
RECENT MEDICAL COURSE:
___: Admitted to ___ from ___ for "fluid
overload." Felt not to be due to CHF based on clinical exam,
lack of pulmonary edema on CXR, and normal BNP (240.)
Early ___: Admitted to ___ and ___
___ with pneumonia and pulmonary failure.
___: Admitted to ___ from ___ for vague
complaints of joint pain with her admission complicated by
respiratory distress.
Past Medical History:
- Dysphagia s/p G-tube (___)
- COPD
- Restrictive lung disease due to dorsal kyphoscoliosis
- Aspiration pneumonia
- Sacral ulcer (7.0 x 4.0 x 2.0) s/p debridement and wound vac
(___)
- DVT of right leg (___)
- Advanced dementia
- Hypertension
- Total abdominal hysterectomy
- Benign thyroid tumors
Social History:
___
Family History:
Patient's father and son have a history of diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
___: Intubated, sedated.
HEENT: EOMI
Neck: No JVD
CV: RRR, no m/r/g.
Lungs: Clear anteriorly but exam limited.
Abdomen: Soft, nontender. No masses
GU: Foley in place.
Ext: Nonedematous
Neuro: Moving all four limbs spontaneously.
DISCHARGE PHYSICAL EXAM:
VS - 98.0 155/90 100 22 100% 2L
___ - the patient is non-verbal at baseline. sleeping this
morning, arousable. NAD, breathing not labored
HEENT - NC/AT, MMM, OP clear, neck supple without elevation in
JVP
LUNGS - the patient is sleeping with mild snoring, air movement
bilaterally, no wheezes or rhonchi appreciated
HEART - PMI non-displaced, RRR, S1-S2
ABDOMEN - soft/NT/ND, obese, no masses or HSM, no
rebound/guarding, grimaces on deep palpation diffusely
EXTREMITIES - WWP, trace edema L>R, 2+ peripheral pulses (DPs)
NEURO - awake and alert, non-verbal (baseline), does not follow
commands. unable to assess extra-occular muscles formally, seems
to look in all directions spontaneously without gaze deviation.
no glabellar reflex present. Moves b/l upper extremeites
minimally.
Pertinent Results:
ADMISSION LABS:
___ 09:00PM PLT SMR-NORMAL PLT COUNT-279
___ 09:00PM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
___ 09:00PM NEUTS-86* BANDS-0 LYMPHS-8* MONOS-5 EOS-0
BASOS-0 ATYPS-1* ___ MYELOS-0 NUC RBCS-1*
___ 09:00PM WBC-12.8* RBC-3.89* HGB-11.8* HCT-37.9 MCV-97
MCH-30.5 MCHC-31.3 RDW-16.1*
___ 09:13PM LACTATE-3.0*
___ 09:16PM freeCa-1.11*
___ 09:16PM HGB-12.1 calcHCT-36 O2 SAT-98
___ 09:16PM GLUCOSE-116* LACTATE-2.3* NA+-145 K+-4.8
CL--86*
___ 09:16PM TYPE-ART RATES-14/ TIDAL VOL-400 PEEP-5
O2-100 PO2-339* PCO2-86* PH-7.38 TOTAL CO2-53* BASE XS-20
AADO2-290 REQ O2-55 INTUBATED-INTUBATED
Influenza - negative
___ Blood culture: no growth (final)
___ 9:30 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES.
Daptomycin Sensitivity testing performed by Etest.
Daptomycin = SENSITIVE ( 0.75 MCG/ML ).
PROTEUS MIRABILIS. FINAL SENSITIVITIES.
ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES.
Daptomycin Sensitivity testing performed by Etest.
Daptomycin = SENSITIVE ( 0.094 MCG/ML ).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECALIS
| PROTEUS MIRABILIS
| | ENTEROCOCCUS
FAECIUM
| | |
AMPICILLIN------------ <=2 S <=2 S =>32 R
AMPICILLIN/SULBACTAM-- <=2 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 2 I
DAPTOMYCIN------------ S
GENTAMICIN------------ <=1 S
LINEZOLID------------- 2 S
MEROPENEM------------- <=0.25 S
PENICILLIN G---------- 1 S =>64 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
VANCOMYCIN------------ 1 S =>32 R
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
GRAM NEGATIVE ROD(S).
Reported to and read back by ___. (CC6D) ___ AT
1225.
Blood culture ___ x 2: no growth (final)
Blood culture ___ x 2: no growth (final)
Blood culture ___: pending
___ 9:30 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
STAPH AUREUS COAG +. >100,000 ORGANISMS/ML..
OF TWO COLONIAL MORPHOLOGIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- =>4 R
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
IMAGING
CXR ___
1. Low lung volumes. Left basilar opacity may reflect
atelectasis though
aspiration or infection is not excluded.
2. Mild pulmonary vascular congestion.
3. Endotracheal tube is slightly low lying, terminating 2.8 cm
from the
carina.
CXR ___
As compared to the previous radiograph, there is a slight
increase
in size of the cardiac silhouette and a newly appeared
plate-like atelectasis on the right. Moderate retrocardiac
atelectasis. The presence of a small left pleural effusion
cannot be excluded. Unchanged position of the endotracheal
tube.
CXR ___
ET tube is low tip 1.7 cm above the carina. Right PICC tip is
in the upper right atrium/cavoatrial junction, has been
withdrawn from prior study. There are persistent low lung
volumes. Mild cardiomegaly and widened mediastinum are stable.
Right upper lobe atelectasis and right lower lobe perihilar
consolidations are stable. There is no pneumothorax. If any,
there is a small left pleural effusion.
CXR ___
There is no significant change since previous exam.
1. The patient has been extubated.
2. The lung volumes are very low.
ECHO ___
The left atrium is mildly 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%). There is no ventricular septal defect. RV with
normal free wall contractility. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
masses or vegetations are seen on the aortic valve. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
RENAL AND BLADDER US ___. No evidence of hydronephrosis, stones, or masses in the
kidneys
bilaterally.
2. Incomplete assessment of bladder secondary to minimal
distention.
DISCHARGE LABS
Discharge ABG showed O2 82 CO2 74 pH 7.41
___ 06:20AM BLOOD WBC-7.8 RBC-3.67* Hgb-10.8* Hct-35.0*
MCV-95 MCH-29.5 MCHC-31.0 RDW-16.0* Plt ___
___ 06:20AM BLOOD Plt ___
___ 06:20AM BLOOD Glucose-158* UreaN-21* Creat-0.4 Na-140
K-3.7 Cl-93* HCO3-40* AnGap-11
___ 06:20AM BLOOD Calcium-7.8* Phos-2.5* Mg-2.2
Brief Hospital Course:
___ is a ___ year old female with a history of
restrictive lung disease, COPD, advanced dementia (nonverbal),
aspiration pneumonia, with chronic ___ and 2L home O2
requirement, presenting transferred from OSH with respiratory
failure
#) HYPERCARBIC RESPIRATORY FAILURE: Pt with a history of COPD on
2L home O2, restrictive lung disease, prior aspiration events,
chronically pegged, who presented to the ED with worsening
dyspnea and hypoxia, and was intubated for hypercarbia with pCO2
171. The etiology of her respiratory failure was thought to be
secondary to a viral URI leading to a COPD exacerbation. She was
treated with high-dose steroids, antibiotics, nebulizers, and
diuretics. Her ABG showed post-hypercapnic alkalosis, and her
vent settings were altered to bring her back to her baseline
hypercarbia to restore her respiratory drive. Further ABGs
showed a respiratory acidosis (pCO2 in ___ with compensatory
metabolic alkalosis (HCO3 in the ___ while patient maintains
92-94% on 2L. Initially the patient was started on azithromycin
and steroids as a presumptive COPD exacerbation prior to her
blood culture data returning. With culture data that she was
switched to CTX and Vanc, then Vanc was changed to Linezolid
(see below). The patient was maintained on PSV while
mechanically ventilated and appeared to maintain her native
blood gas saturations without any signs of respiratory effort.
She was successfully extubated on ___, and post-extubation
blood gasses exhibited similar profiles to those previously. She
maintained adequate oxygen saturations between 88-95% on 2L at
discharge. She had several episodes of desaturation to the ___
which responded to chest physical therapy and nasal suctioning,
no episodes of desaturation within 48 hours of discharge.
Discharge ABG showed O2 82 CO2 74 pH 7.41. She was discharged on
a prednisone taper and continued antibiotics.
#) GOALS OF CARE: Goals of care were addressed multiple times
during the hospitalization. The daughter is the patient's health
care proxy, and maintains that the patient should be full code.
The patient's advanced dementia, age of ___, clinical decline in
the past several months with multiple hospitalizations during
the past year with respiratory failure, as well as the patient's
overall poor prognosis, were discussed with the daughter.
However, the daughter said that "we like to think this is not
the end of her life", and that her goal was to "get my mother
back home". The patient remained Full Code during
hospitalization.
#) Presumed Septicemia: One set of blood cultures grew
enterococcus, proteus, and VRE, her urine culture grew staph
aureus. Her azithromycin was discontinued and she was started on
CTX/Vanc, than transitioned to CTX/linezolid when sensitivities
returned and VRE was discovered. Other blood cultures were
negative, including a blood culture drawn on the same day. While
these positive cultures were suspected to be a contaminant,
infectious disease consult advised the team that the patient
needed to be treated for presumptive bacteremia due to the
virulent nature of the pathogens isolated and the patient's
initial presentation with respiratory failure. Echo showed no
signs of endocarditis, and renal US did not show any kidney
abscess or nidus of infection.
- The patient will complete a total of 14 day course of
linezolid and CTX.
#)PRESUMPTIVE UTI: UA showed large leukesterase, positive
nitrates, and moderate bacteria. Although it was not possible to
determine if she was experiencing symptoms from these findings,
given the positive urine culture she will complete a total of 14
days of treatment with CTX and linezolid.
#)HYPERNATREMIA: On admission she was noted to have a sodium
level of 146. She was treated with free-water flushes given with
her tube feeds. Her serum sodium slowly improved.
#)ADVANCED DEMENTIA: At her baseline she is non-verbal, she will
sometimes babble with her family members, or sing to a song. Per
the patient's daughter she does not follow commands at baseline.
#)DYSPHAGIA s/p ___: She was maintained on her home regimen of
tube feeds.
TRANSITIONAL ISSUES:
- complete a total of 14 day course of CTX and linezolid
- continue O2 2L NC to keep O2 sat 88-95%
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 40 mg PO DAILY
2. Furosemide 20 mg PO HS
3. Potassium Chloride Dose is Unknown PO Frequency is Unknown
Duration: 24 Hours
4. Clopidogrel 75 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Levothyroxine Sodium 100 mcg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Furosemide 40 mg PO DAILY
4. Furosemide 20 mg PO HS
5. Levothyroxine Sodium 100 mcg PO DAILY
6. CeftriaXONE 2 gm IV Q24H
RX *ceftriaxone 2 gram infuse 2 grams daily Disp #*7 Bag
Refills:*0
7. Linezolid ___ mg IV Q12H VRE
RX *linezolid [Zyvox] 600 mg/300 mL infuse 600mg/300mL IV twice
a day (every 12 hours) Disp #*20 Bag Refills:*0
8. Potassium Chloride 0 mEq PO DAILY Duration: 24 Hours
Hold for K > 5
9. PredniSONE 20 mg ___ daily Duration: 2 Days
RX *prednisone 10 mg ___ tablet(s) by mouth daily Disp #*6
Tablet Refills:*0
10. PredniSONE 10 mg ___ Duration: 1 Days Start: After 20
mg tapered dose.
11. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
12. Guaifenesin 10 mL PO BID
RX *guaifenesin 100 mg/5 mL 10 Liquid(s) by mouth twice a day
Disp #*1 Bottle Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
respiratory failure, intubated, now s/p extubation
COPD exacerbation
positive blood and urine cultures
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted for respiratory failure after
being intubated at an outside hospital. You were sucessfully
weaned off the ventilator and extubated. Your respiratory
failure was likely because of an exacerbation of your COPD, and
you were treated with antibiotics, and you will continue a
prednisone taper after discharge (a steroid). You also had a set
of positive blood and urine cultures, which were likely a
contaminant, but you will be treated for 14 days for these
bacteria in case they were ever in your blood stream.
It is important that you take all medications as prescribed, and
keep all follow up appointments.
Followup Instructions:
___
|
10187254-DS-2 | 10,187,254 | 23,049,675 | DS | 2 | 2183-09-16 00:00:00 | 2183-09-17 04:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Neck and b/l arm pain
Major Surgical or Invasive Procedure:
___ seroma aspiration
Lumbar puncture x 2
___ lumbar puncture
History of Present Illness:
Mr. ___ is a ___ who presents 4 days post-op after C3-C7
spine fusion at ___, where he left AMA last night over a
confrontation about pain medication. He now presents with severe
neck pain. His pain prior to surgery was sharp and shooting, and
radiated down both arms and legs.
Post-operatively, he said his pain is predominently in his
shoulders, extending from his neck to his mid-arms and crampy in
nature. He also has crampiy pain in his quads, and sharp,
shooting pains down his legs. He endorses a pins and needles
sensation in b/l finger tips.
Patient endorses a productive cough, shortness of breath, and
subjective fevers several months. He had been coughing green
phlegm for 3 months and had a severe dry cough prior to surgery,
but denies chest pain. He had been hospitalized twice within
that period of time at ___ for migraine headaches, once for two
days and once for six days. He states that his eating is fine
and he has not coughed or aspirated while eating.
Of note, the patient was seen by ___ in ___. Their assessment (Dr. ___ was that the patient's
neck pain was likely due to degenerative cervical spine disease
and help through pain specialists. The surgeons did mention that
sursurgery on the neck would not be the best option for treating
the neck pain. He was presented with the option of physical
therapy, but the patient had reservations about its usefulness.
He was also advised to avoid narcotic pain medications for his
pain and was advised to seek gery would be indicated for
persistent arm pain or weakness.
.
In the ED, initial VS: 100.4 117 130/90 18 90% without
documented O2. CXR showed a LLL opacity, especially visible on
lateral view. Given concomitant leukocytosis and post-op
setting, patient was covered with CTX/Azithromycin for CAP and
admitted for fever and pneumonia. He was also given Percocet x2
tabs as well as 1 L NS. Efforts were made to gather information
from the ___ spine team overnight without success. Vitals on
transfer: T 99, HR 86, RR 17, BP 135/78, 02 sat 98% 2L, pain
___.
.
On arrival to the floor, VS: 98.3 ___ 97(RA),
patient complaining of severe neck pain and abdominal
tenderness. He has not had a bowel movement for 5 days and
feels very constipated. His chest also feels a little tight,
"like it just needs to open up." But, he denies chest
pain/pressure, diaphoresis, nausea, vomiting, or radiation of
pain. Patient states he has taken inhalers intermittently in
the past for these symptoms. He also has a severe sharp
headache in his forehead, which he states is his chronic
headache.
.
REVIEW OF SYSTEMS:
Denies night sweats, vision changes, rhinorrhea, congestion,
sore throat, chest pain, nausea, vomiting, diarrhea, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
Cervical Stenosis
Chronic Headaches
Low back pain
depression with psychotic characteristics
Polysubstance abuse
Borderline Diabetes Mellitus type 2
PTSD
Social History:
___
Family History:
denies family hx of diabetes, heart disease, stroke, htn, or
malignancy
Physical Exam:
Physical Exam on Admission:
VS: 98.3 ___ 97(RA)
GENERAL - Alert, interactive, in severe pain whenever he moves
neck or shoulders
Mental Status - usually linear thought process, but
occassionally speaks about ___ who he recognizes is a
person he hallucinates about; was hiding a percocet in a cup
because he wasn't sure what medication it was when the nurse
gave it to him
HEENT - normocephalic
NECK - cervical collar in place
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - diminished BS over LLL, otherwise no r/rh/wh, good air
movement, resp unlabored, no accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
PHYSICAL EXAM ON DISCHARGE:
VS: Tc 98.7 Tm 98.7 BP 140-187/81-126 HR ___ RR 18 O2 sat
97(RA)
GENERAL - Alert, interactive, sitting in bed
Mental Status - completely linear and coherent this morning;
very cheerful affect
HEENT - normocephalic, MMM, oropharynx clear, after removal
c-collar, incision site looks good, no erythema, but is boggy to
palpation and draining serous fluid staining gauze bandage
overlying
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, otherwise no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no edema, 2+ peripheral pulses
NEURO - alert, oriented x 3, ___ strength upper and lower
extremities, but pain with examination, normal gait
Pertinent Results:
Labs on Admission:
___ 01:47AM BLOOD WBC-15.5* RBC-4.12* Hgb-11.9* Hct-34.7*
MCV-84 MCH-28.9 MCHC-34.3 RDW-13.9 Plt ___
___ 01:47AM BLOOD Neuts-82.8* ___ Monos-4.1
Eos-1.3 Baso-0.5
___ 01:47AM BLOOD ___ PTT-29.6 ___
___ 01:47AM BLOOD Glucose-130* UreaN-15 Creat-1.1 Na-139
K-4.3 Cl-100 HCO3-31 AnGap-12
___ 07:00AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.3
___ 07:05AM BLOOD ALT-36 AST-27 AlkPhos-86 TotBili-0.3
Anemia labs:
___ 01:47AM BLOOD Iron-16*
___ 01:47AM BLOOD calTIBC-308 Ferritn-292 TRF-237
___ 01:47AM BLOOD Ret Aut-1.7
Inflammatory markers:
___ 06:36PM BLOOD ESR-63*
___ 06:36PM BLOOD CRP-29.5*
Vancomycin levels:
___ 08:24AM BLOOD Vanco-4.6*
___ 11:14PM BLOOD Vanco-21.3*
___ 07:06AM BLOOD Vanco-10.1
___ 03:03PM BLOOD Vanco-10.1
Seroma chemistry:
___ 01:03PM CEREBROSPINAL FLUID (CSF) Glucose-1
LP cell count, protein, glucose:
___ 01:49PM CEREBROSPINAL FLUID (CSF) WBC-105 RBC-10*
Polys-1 ___ ___ 01:48PM CEREBROSPINAL FLUID (CSF) TotProt-91*
Glucose-63
Imaging:
Chest PA/Lateral ___:
FINDINGS: AP upright and lateral chest radiographs were
obtained. Lung
volumes are low. A retrocardiac opacity projects over the spine
on the
lateral view. No effusion or pneumothorax is present. The heart
and
mediastinal contours are normal. The lower edge of cervical
pedicular screws is present.
IMPRESSION: Left lower lobe pneumonia
Cspine MRI ___:
IMPRESSION: Post-surgical changes from prior laminectomy and
fusion surgery. A fluid collection is seen in the posterior
paraspinal soft tissues, which would not be unexpected in the
postoperative phase. No definite communication is seen within
the spinal canal to suggest a CSF leak.
___ paraspinal seroma aspiration ___:
TECHNIQUE AND FINDINGS: Written informed consent was obtained
from the
patient after explaining the risks, benefits and alternatives to
the
procedure. The patient was brought into the fluoroscopic suite
and laid prone on the fluoroscopic table. A preprocedure timeout
was performed confirming the patient's identity and the
procedure to be performed.
The procedure was planned according to the MR ___ dated
___. Using ultrasound, the paraspinal or subcutaneous
fluid collection was redemonstrated at the C6-C7 level.
Following local anesthesia of the overlying skin using 1%
lidocaine, a 20-gauge 1-inch needle was advanced into the
septated fluid collection under ultrasound guidance. 14 cc of
bloody, non-cloudy and non-smelling fluid was aspirated. The
patient tolerated the procedure well without complications. The
aspirated fluid was sent for microbiology and
chemistry for further assessment.
IMPRESSION: Uncomplicated ultrasound-guided aspiration of
bloody, non-cloudy fluid from paraspinal fluid collection at the
C6-C7 level.
CXR line placement ___:
FINDINGS: Comparison is made to prior study from ___.
There has been placement of a left-sided PICC line with distal
lead tip at the cavoatrial junction. Heart size is normal. Lungs
are grossly clear.
___ Lumbar Puncture ___:
PROCEDURE/FINDINGS: Written informed consent was obtained from
the patient after explaining the risks, benefits and
alternatives to the procedure. The patient was brought into the
fluoroscopic suite and laid prone on the fluoroscopic table. A
preprocedure timeout was performed confirming the patient's
identity and the procedure to be performed. Under fluoroscopic
guidance, and after the administration of 1% lidocaine for local
anesthesia, access to the thecal sac was obtained at the L2-L3
level. Four vials containing a total of 12 cc of CSF were sent
for requested laboratory analysis. The patient tolerated the
procedure well. There were no immediate complications.
IMPRESSION: Successful fluoroscopic-guided lumbar puncture. 12
cc of clear CSF divided into four vials and sent for laboratory
evaluation.
Micro:
Blood culture x2 ___: no growth final
Blood culture ___: No growth to date
___ 12:41 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
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.
___ 3:30 pm CSF;SPINAL FLUID Source: LP.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
___ 11:45 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 ___ blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST CULTURE (Preliminary):
The sensitivity of an AFB smear on CSF is very low..
If present, AFB may take ___ weeks to grow..
___ 3:00 am URINE Source: ___.
**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.
Labs on Discharge:
___ 07:05AM BLOOD WBC-13.1* RBC-4.18* Hgb-12.0* Hct-35.2*
MCV-84 MCH-28.6 MCHC-34.0 RDW-13.8 Plt ___
___ 07:05AM BLOOD Glucose-110* UreaN-13 Creat-0.7 Na-141
K-4.2 Cl-105 HCO3-28 AnGap-12
___ 07:05AM BLOOD Calcium-8.5 Phos-3.6 Mg-1.8
Brief Hospital Course:
Primary Reason for Admission: Patient is a ___ yo male with
recent cervical spinal fusion at ___ who left AMA last night and
presented to ___ for pain management, subsequently found to
have a pneumonia.
Active Diagnoses:
#s/p cervical spinal laminectomy and fusion/ suspicion of
meningitis: Patient had surgery at ___ on ___ and still
endorses significant cramping pain in b/l shoulders and arms.
Appears to have persistent neurologic deficits from fusion with
tingling in fingertips, which ortho spine consultant believe is
a normal post-op course due to inflammation and muscle spasm at
the surgical site. Pain in shoulders managed with gabapentin
800 bid, oxycodone 15mg q4h and ibuprofen 600mg q6h. Cspine MRI
shows fluid collection from C3-C7 paraspinal muscles. Initial
consultation w/ radiologist suggested possible dural tear or
fistula with thecal sac, so sent patient for ___ guided
aspiration, glucose in fluid collection was 1, consistent with
seroma. Fluid gram stain showed 3+ PMN, no growth on culture at
the time of discharge, but patient had been on antibiotics for a
long time to treat HCAP prior to culture. ___ LP was
performed to assess for meningitis, CSF cell count shows wbc
115, 86 ___ be consistent with partially-treated
meningitis or post-operative change. CSF culture from lumbar
puncture is also no growth to date at the time of discharge.
Antibiotic regimen was not changed because patient looked well,
and did not clinically suspect listeria to start ampicillin.
Patient was started on ceftriaxone 2g q12h for meningitis
dosing. Patient will take ceftriaxone until ___. At the
time of discharge, patient had been afebrile for five days but
still had a persistent ___ count, which may be attributed to
post-op inflammation on top of infections we are currently
treating. Seroma around surgical site had been draining
serosanguinous fluid, soaking 2 gauze bandages and onto pillow
at peak drainage, but now has tapered and is only wetting one
gauze/day. Per ortho spine consultants, if drainage picks up
again, may consider putting a drain into the site to facilitate
healing. But, with tapering fluid output, patient was
discharged with just monitoring.
#Pneumonia: Patient endorses 3 months of productive cough,
fever, and mild shortness of breath. PCP records show that
patient has had RLL pneumonia since ___, getting outpatient
treatment with Zpack. Lab work reveals leukocytosis and CXR
this admission shows LLL consolidation. Given how well patient
looks, good oxygen saturation and lack of respiratory distress,
lack of profuse sputum production, initially treated for CAP
with cefpodoxime/azithromycin. Patient spiked temprature to
101.3 through this regimen, so expanded coverage for HCAP
because he has been hospitalized three times in last 3 months,
vanc, cefepime, azithromycin. Sputum culture had upper
respiratory contamination and patient had no more sputum to
provide another sample. ___, per ID recommendations, patient
switched to vanc, ceftriaxone, azithromycin. Ceftriaxone was
increased on ___ to 2g q12h to treat meningitis. Azithromycin
was dc'd on ___ as urine legionella antigen returned
negative. Patient will remain on vancomycin and ceftriaxone
until ___.
# Anemia. Unclear time course of anemia, but last data point in
system from ___ shows Hct 39. Microcytic anemia with
MCV 84. Iron level low this admission, but Ferritin and TIBC
normal. This could be iron deficiency anemia with elevated
ferritin from post-op inflammation. Patient was not started
iron supplementation based on patient's low likelihood of
compliance with therapy, but this issue can be further discussed
in primary care follow-up.
# Depression with psychotic features: Patient was very agitated
on presentation, occassionally speaking of ___ and
behaving suspciously, coveting a percocet pill from ___ in a
plastic bottle because he wasn't sure what it was. After
speaking with PCP, became evident that patient has been dealing
with PTSD from traumatic childhood and hallucinations for many
years, stably managed when he is on risperdal. Risperidone 2mg
daily is home dose of antipsychotic, but patient states he only
takes this intermittently at home. Psychiatry team assessed
him, felt that he was not in acute danger of harming himself or
others or acutely psychotic.
# HTN: Patient had a slightly elevated blood pressure on
admission, which could be secondary to pain. He was started on
home Toprol 125mg daily and Losartan 100mg daily. Diastolic
pressures consistenly ran high in the 100s-120s, but systolic
was 140s-150s. Patient's blood pressure has now normalized with
uptitration of losartan. His losartan was then increased to
150mg daily, and his diatolic blood pressures came down to
___.
Chronic Diagnoses:
# Wheezing/SOB: Patient occassionally complains of tightness in
his chest and is noted to have b/l wheezing. Most likely
consistent with reactive airway disease or COPD given patient's
smoking hx. EKG looked unchanged from prior with no ST-T
changes, so cardiac etiology unlikely. Patient was maintained on
albuterol nebs and flovent inhaler prn.
# Borderline Diabetes, Type 2. Patient states he has had some
hyperglycemia recently but has not officially been diagnosed
with diabetes. He does not tolerate metformin because it gives
him diarrhea. Patient was initially put on an ISS, but FSG was
in 100s day after admission, did not require insulin, so ISS was
dc'd.
# Constipation: Patient stated on admission that he had not had
a bowel movement in 5 days. After receiving lactulose, he had
a large BM yesterday. Throughout hospitalization, he was
maintained on senna, colace, miralax and lactulose prn.
Transitional issuse:
- Please follow up on pending blood culture and pending seroma
and LP CSF cultures, which are all still no growth to date at
the time of discharge
- Please encourage patient to follow-up with spine surgeon at
___ for wound check and post-operative check
# Contact: Wife ___ ___
___ on Admission:
Patient's home meds, per PCP, as of ___, but unclear what
patient actually takes at home:
albuterol inhaler puffs q6h prn cough
clotrimazole 1% cream q app topical bid
compazine 10mg PO q8h prn migraine nausea
diphenhydramine PO 25mg qhs
doxepin ___ PO qhs
ergocalciferol 50000U PO weekly
Flonase 2 sprays nasal qd
Flovent 44mcg INH bid 2puffs
hydrocodone+homatropine 5ml PO q4h
Ibuprofen 600mg PO TID
Lisinopril 40mg PO daily
Loratadine 10mg PO daily
Metformin 1000mg PO qAM
Neurontin 600mg PO daily
Omeprazole 20mg PO bid
Oxycodone 10mg/acetaminophen 325 PO q8h
Prednisone 40mg PO daily
Risperdal 2mg PO qhs
Simvastatin 5mg PO qhs
Sumatriptan 25mg prn
terbinafine cream 1% topical bid
Toprol XL 150 daily
Triamcinolone 0.1% 1 app bid
Viagra 100mg PO prn
Vitamin D 1000U daily
Discharge Medications:
1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
___ puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
2. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram
Intravenous Q 8H (Every 8 Hours) for 7 days: please end
antibiotics on ___.
Disp:*21 grams* Refills:*0*
3. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig:
Two (2) grams Intravenous Q12H (every 12 hours) for 7 days:
please end on ___.
Disp:*28 grams* Refills:*0*
4. gabapentin 800 mg Tablet Sig: One (1) Tablet PO twice a day.
5. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation BID (2 times a day).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
7. risperidone 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*0*
8. simvastatin 5 mg Tablet Sig: One (1) Tablet PO once a day.
9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
Five (5) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*150 Tablet Extended Release 24 hr(s)* Refills:*0*
10. losartan 50 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*0*
11. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*0*
12. oxycodone 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
15. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily).
Disp:*30 Powder in Packet(s)* Refills:*0*
16. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
17. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Meningitis
Healthcare Associated Pneumonia
s/p Cervical Spine Laminectomy and Fusion
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 ___
___. You were admitted to the hospital for a
pneumonia, found after you came for pain management after a
cervical spine fusion and laminectomy done at an outside
hospital. While you were here, we treated your pneumonia with
antibiotics. We also suspected you may have meningitis based on
your fevers, headaches and drainage from your neck surgical
site. You underwent a seroma drainage and a lumbar puncture to
assess the spinal fluid around your brain. Although we do not
have culture evidence that you have an infection in your spinal
fluid, your symptoms suggest this as a possibiity. Because
meningitis is a serious condition that can be life threatening,
we are treating you for this with antibiotics as well. We feel
that your clinical course is now stable, and you may finish the
rest of your antibiotics at a rehab facility.
Please note that the following change have been made to your
medications:
- please continue to take vancomycin 1000mg every 8 hours for 7
more days for a total of 14 days (last day will be ___
- please continue to take ceftriaxone 2g every 12 hours for 7
more days for a total of 14 days (last day will be ___
- please take Losartan 150mg daily and Toprol XL 125mg daily for
your high blood pressure
- please take oxycodone 15mg every four hours and ibuprofen
600mg every 6 hours as needed for pain control
- please take senna, colace twice a day and miralax daily for
your constipation
- please change your gabapentin dose to 800mg twice a day
- please continue to take Risperdal 2mg every night
**Please take all other medications as prescribed in your
medication list. Please follow-up with Dr. ___ to adjust your
medications as necessary.
Followup Instructions:
___
|
10187422-DS-12 | 10,187,422 | 22,024,813 | DS | 12 | 2188-07-30 00:00:00 | 2188-08-16 18:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
ciprofloxacin
Attending: ___.
Chief Complaint:
RUQ abdominal pain
Major Surgical or Invasive Procedure:
Laparoscopic Cholecystectomy
History of Present Illness:
___ is a ___ year old healthy male who has had multiple days of
RUQ abdominal pain. The pain started on ___, improved on
___, and again got worse ___ night and has been
constant until today. He went to his PCP on ___ who sent labs
and an abdominal Xray which were normal. The pain became severe
___ night and he was eating minimally throughout the prior
days. He came to the ED today for evaluation. Says he has been
nauseated, anorexic and dehydrated. No known history of
gallbladder disease but multiple family members have required
cholecystectomy.
Past Medical History:
Lactose sensitivity
Social History:
___
Family History:
Multiple family members with gallbladder disease
Physical Exam:
Temp: 97.9 4 HR: 73 BP: 134/85 Resp: 18 O(2)Sat: 97% RA
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Extraocular muscles intact
Oropharynx within normal limits
Abdominal: Soft, Nontender, Nondistended, small laparoscopic
surgical incisions with no evidence of infection
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: no redness, warmth, discharge from surgical incisions
Psych: Normal mood, Normal mentation
___: No petechiae
Brief Hospital Course:
Mr. ___ is a ___ year-old-M who was admitted to ___ on the
night of ___ after having five days of RUQ
abdominal pain. He went to his PCP on ___ who sent
labs and an abdominal x-ray which were normal. He came to the ED
after a bout of severe pain, nausea, and anorexia. A abdominal
US was performed at the ED demonstrating a distended gallbladder
with lodged gallstone in the neck with positive sonographic
___ sign consistent with acute cholecystitis. The US showed
splenomegaly measuring 15.2 cm as well. Mr. ___ was admitted
to the Acute Care Surgery service. He was placed NPO with IV
fluids and IV antibiotics (ciprofloxacin and flagyl), pain
control, and added on to the OR schedule for laparoscopic
cholecystectomy. On admission his WBC, liver function tests, and
lipase were WNL. WBC = 8; Tbili = 1.1; AST = 36; ALT = 42; ALP =
77; Lipase: 19. His pain was treated with IV Dilaudid and
received Zofran single dose for nausea.
In the morning of ___, Mr. ___ was taken to the
OR for laparoscopic cholecystectomy. A foley catheter was
placed. The postoperative diagnosis was advanced acute on
chronic cholecystitis with early necrosis of the gallbladder.
The patient tolerated the procedure without any incident and was
returned to the PACU in a satisfactory condition. He was later
on transferred to the floor in a stable condition. His pain was
adequately controlled with oxycodone q3 PRN ,standing tylenol
q8, and IV breakthrough Dilaudid. IV Zofran q8 PRN was
prescribed for nausea. His Foley catheter placed in the OR was
removed that same day at 14:43 and was due to void at
___. The patient voided twice (100cc and 250cc) with a
post void residual of 715 at 20:21. We waited one more hour
within which he voided two more times (175cc and 175cc) but had
a post void residual of 840 at 21:37 and a Foley catheter was
replaced given his urinary retention and inability to empty the
bladder. 700cc came out after replacing the Foley catheter. At
22:30 the Foley was removed and he was due to void at
___. He was taking adequate amount of POs and IV fluids
were discontinued.
On ___ he voided 350cc at midnight but kept
retaining urine with bladder scan showing 455cc. He was straight
cath at 07:07 for 625cc and was due to void at ___. He
kept voiding 100-300cc throughout the day retaining smaller
amounts as the day went by. He voided 300cc at 16:18 with post
void residual of 248. He was then sent home with Phenazopyridine
and tamsulosin (Flomax) and asked to return to the Emergency
Department in case of urinary retention.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Docusate Sodium 100 mg PO BID
4. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone [Oxaydo] 5 mg 1 (One) tablet(s) by mouth every
four (4) hours Disp #*20 Tablet Refills:*0
5. Phenazopyridine 200 mg PO TID Duration: 2 Days
RX *phenazopyridine 200 mg 1 (One) tablet(s) by mouth three
times a day Disp #*6 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
7. Senna 8.6 mg PO BID
8. Tamsulosin 0.4 mg PO DAILY
RX *tamsulosin [Flomax] 0.4 mg 1 (One) capsule(s) by mouth once
a day Disp #*7 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute cholecystitis status post laparoscopic cholecystectomy
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:
___
|
10187935-DS-12 | 10,187,935 | 26,149,070 | DS | 12 | 2158-01-26 00:00:00 | 2158-01-29 23:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / metoprolol / clonidine / Insulins / Januvia /
Statins-Hmg-Coa Reductase Inhibitors / amlodipine
Attending: ___.
Chief Complaint:
lightheadedness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ man with a past medical history of
type 2 diabetes, hypertension, obesity, and hyperlipidemia who
presents with presyncope and lightheadedness. Patient reports
that he has been having intermittentlightheadedness over the
past 10 days. These symptoms started after he started taking a
new antihypertensive, hydralazine. On the day prior to
presentation, he awoke from a nap around 3:30 ___ and felt
lightheaded, "like I'm walking on a cloud". His eyes felt heavy
and he felt like he had a "lump in my throat". He also had
intermittent bilateral finger tingling. Symptoms are worse with
standing. He also reports being diaphoretic
intermittently.
Patient initially presented to ___ where he
was referred to ___ for evaluation of carotid
stenosis, after carotid ultrasound on ___ revealed greater
than 70% stenosis of the right internal carotid artery.
Vascular surgery recommended neurology consult for further
evaluation.
Of note, patient has multiple recent admissions in ___ and ___
to ___ for presyncope, lightheadedness,
shortness of breath, and chest pain. He has been in atrial
fibrillation during prior admissions but he has refused
anticoagulation or antiplatelet therapy since having a GI bleed
in ___. He actually left against medical advice the day prior
to current presentation.
Past Medical History:
Type II diabetes
OSA
Stage III CKD
CHF
Iron deficiency anemia requiring iron infusion
Hypertension
Obesity
Paroxysmal atrial fibrillation (previously on Coumadin, although
patient has refused to take Coumadin or aspirin since ___ when
he had a GI bleed)
Social History:
___
Family History:
Mother: Stomach cancer, diabetes
Father: Lung cancer, heart disease
No family history of stroke or neurologic disorders.
Physical Exam:
Admission Physical Exam:
Vital Signs: 98.1 PO 151 / 55 73 18 91 RA
General: Alert, oriented, no acute distress. . Obese
HEENT: Sclerae anicteric, MMM HINTs exam negative, ___
negative
Neck: Supple. JVP not elevated. no LAD
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Bibasilar crackles
Back: Stuck on papules on back c/w SKs
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, significant B/L edematous
ertyheamtous raised rash (per patient baseline, ___ DM)
==================================================
Discharge Physical Exam:
VS: Temp 97.5 (98.2) BP 140s-160s/60s-70s, HR 64-79, RR 18,
O2Sat 94-95% RA
GENERAL: NAD, alert, interactive, looks well
HEENT: NC/AT, sclerae anicteric, MMM
LUNGS: b/l crackles in b/l lung fields with deep inspiration,
otherwise no wheezes or rhonchi
HEART: S1/S2, No m/r/g
ABDOMEN: NABS, soft/NT/ND.
EXTREMITIES: WWP, erythematous, papular rash on b/l shins, 1+
pitting b/l ankle edema
NEURO: awake, A&Ox3, CNs II-XII intact, full strength in upper
and lower extremities
Pertinent Results:
ADMISSION LABS
=====================
___ 04:25PM BLOOD WBC-4.9 RBC-3.57* Hgb-8.6* Hct-30.3*
MCV-85 MCH-24.1* MCHC-28.4* RDW-22.4* RDWSD-67.9* Plt ___
___ 04:25PM BLOOD Neuts-69.7 Lymphs-12.6* Monos-12.2
Eos-4.5 Baso-0.6 Im ___ AbsNeut-3.42 AbsLymp-0.62*
AbsMono-0.60 AbsEos-0.22 AbsBaso-0.03
___ 04:25PM BLOOD ___ PTT-32.4 ___
___ 04:25PM BLOOD Glucose-126* UreaN-37* Creat-1.8* Na-139
K-4.9 Cl-106 HCO3-21* AnGap-17
___ 06:15AM BLOOD ALT-16 AST-17 LD(LDH)-185 AlkPhos-62
TotBili-0.2
___ 06:15AM BLOOD TotProt-5.9* Albumin-3.6 Globuln-2.3
Calcium-8.7 Phos-3.1 Mg-2.9*
___ 04:25PM BLOOD VitB12-434
___ 10:58PM BLOOD %HbA1c-5.3 eAG-105
___ 04:25PM BLOOD Triglyc-61 HDL-48 CHOL/HD-2.8 LDLcalc-73
___ 04:25PM BLOOD TSH-1.3
DISCHARGE LABS
======================
___ 06:45AM BLOOD WBC-5.0 RBC-3.34* Hgb-8.2* Hct-28.9*
MCV-87 MCH-24.6* MCHC-28.4* RDW-22.4* RDWSD-69.8* Plt ___
___ 06:45AM BLOOD Glucose-152* UreaN-41* Creat-2.0* Na-139
K-4.9 Cl-104 HCO___ AnGap-17
___ 06:45AM BLOOD Calcium-8.5 Phos-2.9 Mg-2.5
IMAGING
======================
MRI C-SPINE ___ IMPRESSION:
1. Study is limited secondary to moderate motion artifact.
2. Focal T2/STIR hyperintense signal is seen anterior to the C3
and C4
vertebral body, which may be secondary to ligamentous injury,
however no
definite disruption is seen.
3. Subtle increased signal within the left aspect of the C1/C2
articulation
(3;11) may be sequelae of degenerative changes vs traumatic
injury.
4. Diffusely hypointense bone marrow may be sequelae of chronic
systemic
changes such as anemia, however a diffusely infiltrative
neoplastic process
cannot be excluded. Please correlate clinically.
5. No cord signal abnormalities identified.
6. Cervical spondylosis, with moderate to severe spinal canal
stenosis is seen
at C2-C3, C4-C5, C5-C6, and C6-C7.
CXR ___ IMPRESSION:
No previous images. There is enlargement of the cardiac
silhouette without
appreciable vascular congestion. Moderate pleural effusion on
the left with
underlying compressive atelectasis. No evidence of acute focal
pneumonia.
CAROTID US ___ IMPRESSION:
80-99% stenosis of the right ICA.
40-59% stenosis of the left ICA.
Brief Hospital Course:
___ yo gentleman with a history of paroxysmal atrial
fibrillation, HFpEF, CKD, T2DM, HTN, HLD, obesity, and carotid
stenosis who presented with lightheadedness and tingling in his
hands and feet. Patient's lightheadedness was difficult to
characterize but did not seem consistent with vertigo or with
presyncope. Orthostatics negative on home BP regimen and no
focal neurologic deficit on exam. Telemetry without signs of
arrhythmia causing lightheadedness. MRI C-spine showed cervical
spondylosis and severe stenosis, which may be the etiology of
tingling in fingers. Carotid US showed known near-complete
stenosis of right ICA, but as symptoms were not thought to be
consistent with symptomatic carotid stenosis, vascular surgery
recommended ___ medical management with outpatient
follow-up.
#Lightheadedness: Presyncope is a possible cause, given the
onset of his light-headedness coincided temporally with his
starting hydralazine 100 mg TID, and that he sometimes endorses
that the sensation is worse when he stands up and walks.
However, he denies visual blurring or feeling that he's going to
pass out, which would be expected in lightheadedness caused by
presyncope. Cardiac etiology considered, but telemetry
uneventful. Neurologic etiology, especially vertigo and
disequilibrium are unlikely, given no vestibular symptoms or
coordination issues on neuro exam. Symptoms resolved during
admission. Home medications were continued on discharge.
#Tingling in hands and feet. No clear etiology. Patient endorses
that it starts and stops with episodes of lightheadedness,
suggesting there may be common cause. Patient describes
sensation as different to what he feels with baseline diabetic
neuropathy. Cervical spondylosis possible explanation, given MR
cervical spine showed moderate to severe spinal canal stenosis
at C2-C3, C4-C5, C5-C6, and C6-C7. However, waxing and waning
nature of tingling that coincides with light headedness make
cervical nerve compression etiology less likely. No spinal
chord impingement.
#Diffusely hypointense bone marrow on cervical MR: ___ be
sequelae of chronic systemic changes such as anemia, however a
diffusely infiltrative neoplastic process is a possibility
especially given his renal failure and history of MGUS could be
signs of multiple myeloma. SPEP and UPEP were sent and were
pending on discharge.
#T2DM. HbA1c 5.3. Controlled. Hypoglycemia theoretically could
be contributing to sensation of lightheadedness, though patient
reports that episodes do not correspond to measured
hypoglycemia. Home glipizide held during admission but restarted
on discharge.
#Carotid Stenosis: Asymptomatic, given he denies sudden-onset
weakness, blurred vision, severe headache, and has intact neuro
exam. For risk reduction was started on aspirin and atorvastatin
on discahrge, and was continued on home antihypertensive
regimen.
#HTN: patient developed severely elevated BP after holding home
antihypertensive regimen. Improved on home regimen, and no
recurrence of lightheadedness after home meds restarted.
Anti-hypertensive options limited by drug allergy history. SBP
goal of 140 as per JNC8. Home Lasix, carvedilol and hydralazine
continued on discharge.
**CHRONIC ISSUES***
#Afib: Per patient discharge summary from ___ (___).
Patient was in NS on arrival to ED, and HR well-controlled
throughout admission. CHADS-VASc Score of 5. No anticoagulation
as part of home regimen.
#HFpEF: Per patient discharge summary from ___. Patient denies
SOB. CXR shows appreciable vascular congestion and moderate
pleural effusion on the left. Initially home furosemide was held
but restarted on discharge, and home carvedilol continued.
#RA/OA. Home Arava non-formulary; held during admission but
restarted on discharge.
#Vitamin D deficiency: Home Vitamin D 200 units PO daily
continued.
Transitional Issues:
[] C-spine MRI showed diffuse marrow hypoattenuation, consistent
with chronic anemia or with marrow infiltrative process. SPEP to
evaluate for monoclonal gammapathy obtained during admission and
pending on discharge.
[] Patient continued on outpatient anti-hypertensive regimen of
carvedilol, hydralazine, and Lasix. Consider transition to
thiazide diuretic for more stable BP control with daily dosing
(patient has history of allergy to calcium channel blockers)
[] Patient has paroxysmal atrial fibrillation, previously on
warfarin, which had been stopped for GI bleed. Please continue
to evaluate risks/benefits of restarting anticoagulation given
Chads-Vasc of 5.
[] A1C noted to be 5.3% during admission; please continue to
monitor glycemic control and downtitrate oral hypoglycemic as
tolerated.
[] based on severe carotid stenosis seen on carotid US, started
patient on aspirin 325 mg and atorvastatin 40 mg. Neurology
recommends follow up US in 6 months for consideration of CEA.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. HydrALAZINE 100 mg PO Q8H
2. Carvedilol 25 mg PO BID
3. GlipiZIDE 10 mg PO BID
4. Furosemide 20 mg PO DAILY
5. leflunomide 10 mg oral DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Carvedilol 25 mg PO BID
4. Furosemide 20 mg PO DAILY
5. GlipiZIDE 10 mg PO BID
6. HydrALAZINE 100 mg PO Q8H
7. leflunomide 10 mg oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Lightheadedness
Secondary Diagnosis:
Atrial fibrillation
Cervical spondylosis
Hypertension
Type 2 DM
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 ___
because you were feeling lightheaded. We monitored your heart
and did not find any evidence of anything concerning. Your labs
were normal. Your blood pressure was also normal.
We do not know what was causing your lightheadedness. It may be
related to narrowing in your spine causing a feeling of
numbness. This is likely why you have tingling in your hands as
well.
It was a pleasure participating in your care. We wish you all
the best in the future!
Sincerely,
Your ___ team
Followup Instructions:
___
|
10188275-DS-22 | 10,188,275 | 29,197,045 | DS | 22 | 2144-12-06 00:00:00 | 2144-12-09 11:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
Bronchoscopy
Upper endoscopy
History of Present Illness:
___ with h/o recent tracheoplasty and bronchoplasty at ___ on
___, COPD, and CHF presented to the ED reporting hemopytsis.
He reports that this first began on ___ when he was
coughing up blood. He has been unable to keep food down and woke
up last night due to gagging from blood in his throat. He was
seen in the emergency room on ___ (4 days PTA), however he
left the hospital prior to the planned bronchoscopy.
He has been having an on going cough for the base few weeks. It
is nonproductive. He denies recent fevers or chills. He has also
noted increased wheezing and ___ swelling. He denies lasps in his
medication administration or dietary noncomplance. He has not
been experiencing heart burn, but reports that he recently
stopped taking his omeprazole a few days ago. He denies changes
in his stool habits. He has not noted diarrhea or experienced
constipation. His stools have not changes colors, are not black
or bright red.
In the ED, initial vitals: 97, 64, 115/50, 16, 94%. His exam was
notable for wheezes and bilateral ___ swelling. His labs were
significant for hct of 43.5 and were otherwise within normal
limits. He was evaluated by thoracic surgery who recommended CTA
of the chest and evaluation by IP for possibly bronchoscopy.
Currently, the patient reports experiencing a sore throat and
adominal pain, which he feels began in the ED. He continues to
feel wheezy. No CP, no sensation that he has blood in his
mouth/throat, but feels like he has a bad taste in his mouth.
ROS:
per HPI, denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, dysuria, hematuria.
Past Medical History:
-Hypertension
-CHF
-COPD/asthma pn home O2
-PTSD/depression
-OSA on CPAP
-Chronic back pain
-Hypothyroidism
-Hyperlipidemia
-Back surgery with rod in L spine after trauma
-B/L rotator cuff surgery
-Abdominal hernia repair
-Left hand surgery post trauma
-Right thoracotomy, tracheoplasty, and bronchoplasty with med
and left brochoplasty with mesh on ___ at ___
-tracheobronchomalacia
Social History:
___
Family History:
Grandfather with ___, brother deceased from ___. Also with DM in
family. Reports he is up to date with colonoscopy.
Physical Exam:
Admission:
VS - Temp 98.4F, BP 132/76, HR 59, R 18, O2-sat 98% on3L
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, difficult to assess JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - good air movement, resp unlabored, no accessory muscle
use, diffuse low pitched wheezes.
ABDOMEN - NABS, soft/ND, mild epigastric tenderness, no masses
or HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c. Trace-1+ b/l
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Discharge:
VS- 98.5, 106/59, 64, 18, 100% on 3L
GENERAL- Well appearing, NAD, ___ and interactive
CARDS- RRR, nl s1s2, no m/r/g
PULM- Pt with unlabored respirations, and good air entry. No
wheezes appreciated this morning.
ABD- Soft, mild distension. Mildly diffusely tender, worse when
coughing. NABS.
EXT- WWP, trace edema b/l
NEURO- AAOx3
Pertinent Results:
Admission:
___ 09:50AM BLOOD WBC-6.9 RBC-5.08 Hgb-14.3 Hct-43.5 MCV-86
MCH-28.2 MCHC-32.9 RDW-13.8 Plt ___
___ 09:50AM BLOOD Neuts-70.0 ___ Monos-6.0 Eos-2.2
Baso-0.8
___ 09:50AM BLOOD ___ PTT-32.7 ___
___ 09:50AM BLOOD Glucose-114* UreaN-16 Creat-1.0 Na-142
K-3.9 Cl-102 HCO3-26 AnGap-18
___ 07:00AM BLOOD Calcium-8.7 Phos-2.7 Mg-1.9
___ 06:50AM BLOOD ALT-21 AST-19 AlkPhos-156* TotBili-0.4
___ 07:00AM BLOOD LD(LDH)-143
___ 07:00AM BLOOD TSH-20*
___ 06:50AM BLOOD Lipase-45
___ 09:50AM BLOOD proBNP-10
Discharge:
___ 07:25AM BLOOD WBC-6.9 RBC-4.70 Hgb-13.4* Hct-39.5*
MCV-84 MCH-28.4 MCHC-33.8 RDW-13.7 Plt ___
___ 07:25AM BLOOD Glucose-88 UreaN-11 Creat-1.1 Na-139
K-3.3 Cl-98 HCO3-32 AnGap-12
___ 07:25AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.7
Studies:
-CXR (___)
PA and lateral views of the chest were provided. There is a
small right pleural effusion again noted. Scattered areas of
plate-like atelectasis are noted. Lung volumes are low. A
chronic right fifth rib resection is again seen.
Cardiomediastinal silhouette is stable. No acute bony
abnormalities are detected.
-CTA chest (___)
1. There is no pulmonary embolism and no acute aortic syndrome.
2. Minimal pulmonary edema
3. Moderate right loculated pleural effusion.
4. Mild thickening of posterior wall of the trachea could be
related to recent tracheoplasty.
-CTA abd/pelvis (___)
Splenomegaly, measuring 15 cm.
No evidence of intra-abdominal or pelvic collections.
Small bilateral pleural effusions, right greater than left with
associated
atelectasis.
-RUQ u/s (___)
1. No gallstones or biliary obstruction.
2. Echogenic liver consistent with fatty liver. Other forms of
liver disease including cirrhosis/fibrosis cannot be excluded on
this study. Focal hypogenicity near hepatic hilum is consistent
in appearance with focal sparing.
-Pleural fluid cytology (___)
NEGATIVE FOR MALIGNANT CELLS. Mesothelial cells, histiocytes
and lymphocytes.
-Bronchoscopy (___)
Black rigid bronchoscope inserted in the trachea with slight
difficulty. No evidence of bleeding seen in the airway. A
complete airway examination was completed. Post tracheoplasty
the airway looks healthy no signs of erosion seen. The rigid
scope was removed and patient intubated with the LMA. No
bleeding seen in the hypopharynx or supraglottic area. Patient
tolerated the procedure well.
-Upper endoscopy (___)
There was white exudate in the distal ___ of the esophagus.
(biopsy)
Antral gastritis.
Bulb and D1 duodenitis
Irregular Z line.
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
___ with h/o recent tracheoplasty and bronchoplasty at ___ on
___, COPD, and CHF presented to the ED reporting hemoptysis.
#. Hemoptysis/hematemsis
Pt with reported coughing up blood for four days prior to
admission. His hct remained stable. Bronchoscopy was without
signs of active or old blood. A subsequent endoscopy revealed
gastritis, but no ulcers or signs of bleeding were noted. A
whitish exudate was noted in his esophagus and biopsies were
taken. His omeprazole was uptitrated. The etiology of his
hemoptysis was not entirely clear on discharge. He had one
unwitnessed episode of "vomiting with blood in it" but no
additional bleeding was reported.
#. Abdominal pain
Reports it began on arrival to the ED. Pt with diffuse
tenderness on exam at one point with involuntary guarding (no
rebound). CT abd/pelvis was significant for splenomegaly, but
was otherwise with normal limits. Pt labs were reassuring,
beyond a slight increase in alk phos. RUQ u/s wnl. Patients
tenderness was increased while coughing. There was concern
constipation was playing a role. The patient moved his bowels
without significant change. The patient was able to tolerate a
full diet prior to discharge.
#. Chronic COPD/asthma
On presentation, the patient reported feeling "wheezy" with
diffuse low pitched wheezes. His BNP was 10 on admission. Pt
on 3L home oxygen. His cough persisted but the wheezes improved
with standing nebulizers. He was continued on his home
medication regimen.
#. Chronic CHF, unclear etiology
Pt with report of CHF, unclear if systolic/diastolic dysfxn. No
TTE within the BI system. Pt reported an increase in his ___
edema. No orthopnea was noted and his BNP was 10. No
intervention beyond continuing his home torsemide.
#. Depression/PTSD
Pt mood/affect were within normal limits. He was continued on
his home regimen.
#. Hypothyroidism
TSH from ___ 31 and repeat was 20. The dosing of his
levothyroxine is unclear. As his PCP listed dose was different
from the dose from the ___ pharmacy, and the patient reported he
had not had to fill it in some time. He was continued on 175
mcg daily as it was unclear if he was compliant with the
medication.
#. HTN
Pt currently normotensive. He was continued on his home
regimen.
#. HLD
Lipid control unclear. He had conflicting reports of which
statin preparation he is taking. It appears that he has been
most recently been taking atorvastatin 80 mg daily and was
continued on that.
#. Back pain
Pt with chronic back pain, s/p fusion. Pain regimen is
complicated by using multiple pharmacies. He was continued on
his home regimen.
#. OSA
Uses CPAP at home, does not want to use hospital's machine. His
sats were monitored overnight and his stay was without incident.
#. Med rec
Recent discharge med list does not match PCPs recent note and
neither matched what patient reports. The patient goes to at 3
pharmacies. His medications were investigated and the lists
reconciled. This information will be transmitted to his primary
care doctor.
==============================================
Transitions of care:
-Pt with elevated TSH and unclear reports of compliance with his
medication or the exact dose.
-Pt uses at least three pharmacies for his medications.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Oxycodone SR (OxyconTIN) 40 mg PO Q12H
2. VICOdin ES *NF* (HYDROcodone-acetaminophen) 7.5-300 mg Oral
q4h pain
3. CloniDINE 0.1 mg PO BID
4. Clonazepam 1 mg PO TID
5. Quetiapine Fumarate 400 mg PO BID
6. Quetiapine Fumarate 25 mg PO TID
7. Amitriptyline 25 mg PO DAILY
8. Aripiprazole 20 mg PO DAILY
9. Levothyroxine Sodium 175 mcg PO DAILY
10. Diazepam 5 mg PO Frequency is Unknown
11. Torsemide 80 mg PO DAILY
12. Valsartan 80 mg PO DAILY
13. Valsartan 40 mg PO QPM
14. Sertraline 300 mg PO DAILY
15. Montelukast Sodium 10 mg PO DAILY
16. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
17. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation BID
18. Atorvastatin 80 mg PO DAILY
19. traZODONE 100 mg PO HS:PRN insomnia
20. Prazosin 10 mg PO DAILY
21. Omeprazole 20 mg PO DAILY
22. BuPROPion 100 mg PO DAILY
Discharge Medications:
1. Amitriptyline 25 mg PO DAILY
2. Aripiprazole 20 mg PO DAILY
3. Clonazepam 1 mg PO TID
4. CloniDINE 0.1 mg PO BID
5. Levothyroxine Sodium 175 mcg PO DAILY
6. Montelukast Sodium 10 mg PO DAILY
7. Oxycodone SR (OxyconTIN) 40 mg PO Q12H
8. Quetiapine Fumarate 400 mg PO BID
9. Quetiapine Fumarate 25 mg PO TID
10. Sertraline 300 mg PO DAILY
11. Torsemide 80 mg PO DAILY
12. Valsartan 80 mg PO DAILY
13. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
14. Atorvastatin 80 mg PO DAILY
15. BuPROPion 100 mg PO DAILY
16. Diazepam 5 mg PO QHS
17. Prazosin 10 mg PO DAILY
18. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION BID
19. traZODONE 100 mg PO HS:PRN insomnia
20. Valsartan 40 mg PO QPM
21. VICOdin ES *NF* (HYDROcodone-acetaminophen) 7.5-300 mg Oral
q4h pain
22. Polyethylene Glycol 17 g PO BID
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 packet by
mouth twice a day Disp #*28 Packet Refills:*0
23. Senna 1 TAB PO BID:PRN Constipation
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*60 Capsule Refills:*0
24. Simethicone 40-80 mg PO QID:PRN abdominal pain
RX *simethicone [Gas-X] 80 mg 1 tablet by mouth four times a day
Disp #*30 Tablet Refills:*0
25. Omeprazole 20 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Hemoptysis
Abdominal pain
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 were
coughing up blood and were admitted for further evaluation. A
bronchoscopy did not reveal bleeding in your lungs. You also
underwent an endoscopy, which revealed some inflammation in your
esophagus and stomach. Please follow up with your primary care
doctor. The gastroenterologists will follow up with you
regarding your biopsies.
Attached is your list of medications, please review it carefully
with your primary care doctor.
Followup Instructions:
___
|
10188275-DS-25 | 10,188,275 | 25,433,697 | DS | 25 | 2145-04-14 00:00:00 | 2145-04-14 18:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
fish derived / shellfish derived
Attending: ___
Chief Complaint:
Dyspnea, Wheezing, Hypoxia
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ M with history of tracheobronchomalacia, COPD on 3 L home O2,
asbestosis, and multiple psychiatric issues, who presented to
the ED because of increasing dyspnea and weakness.
Of note, the patient was triggered in triage, as he was
witnessed to have a syncopal episode outside of our emergency
department. He fainted into the arms of a neurology resident -
there was on headstrike. In ED, intial vitals 10 98.1 77 108/70
26 94% neb. In ED, patient dyspneic, speaking in single word
sentences. Patient desated to 82% on RA, given racemic epi, was
placed on BIPAP.
Recent admission to our MICU ___ to ___ for episodes of stridor
without desaturation, though to have a large psychogenic
component, during which received Botox injection of the vocal
cords by ENT for paroxysmal vocal cord movements. Reports
worsened pain in throat and sub-sternal chest following vocal
cord injection, as well as hoarsness. Pain is non-radiating and
constant, described as more of a "tightness". Reports he was
unable to make follow up with ___ psychiatrist and social worker
on ___ due to inability to talk. Has a lot of depression and
anxiety surrounding health problems. Has had SI in past, denies
currently.
Additionally, patient notes 44 lb. unintentional weight loss in
past 6 months, although the total seems closer to 15 based on
records.
Past Medical History:
-Hypertension
-CHF
-COPD/asthma pn home O2
-PTSD/depression
-OSA on CPAP
-Chronic back pain
-Hypothyroidism
-Hyperlipidemia
-Back surgery with rod in L spine after trauma
-B/L rotator cuff surgery
-Abdominal hernia repair
-Left hand surgery post trauma
-Right thoracotomy, tracheoplasty, and bronchoplasty with med
and left brochoplasty with mesh on ___ at ___
-tracheobronchomalacia
Social History:
___
Family History:
Grandfather with ___, brother deceased from ___. Also with DM in
family.
Physical Exam:
On Admission:
General- A&Ox3, no acute distress, whispers responses,
occasionally has episodes of head bobbing/should heaving
w/hoarse stridor, during which he states he can't breath
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- diffuse wheeze bilaterally with some crackles at R lower
lung.
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
Neuro- CNs2-12 intact, motor function grossly normal
On Discharge:alert and oriented x3. NAD
VSS. Afebrile
Respiratory: comfortable.
occassional expiratory wheeze
bilaterally
bibasilar rales. good air entry
CARDIAC : RRR. No murmurs
EXT: No edema or cyanosis
Pertinent Results:
On admission:
___ 03:03PM GLUCOSE-93 UREA N-15 CREAT-1.3* SODIUM-139
POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-29 ANION GAP-16
___ 03:03PM WBC-7.4 RBC-5.39 HGB-15.0 HCT-43.3 MCV-81*
MCH-27.8 MCHC-34.5 RDW-13.1
___ 03:03PM NEUTS-69.2 ___ MONOS-5.9 EOS-2.3
BASOS-0.7
___ 03:03PM ___ PTT-35.7 ___
___ 03:03PM PLT COUNT-278
___ 03:40PM TYPE-ART PO2-32* PCO2-35 PH-7.55* TOTAL
CO2-32* BASE XS-7
___ 05:42PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 05:42PM URINE COLOR-Yellow APPEAR-Clear SP ___
Microbiology:
Urine culture: negative
Blood cultures x2: pending
Imaging:
CXR ___: No acute cardiopulmonary process. Persistent right
base
atelectasis with probable right pleural effusion. The study and
the report were reviewed by the staff radiologist.
CXR ___: The atelectasis of the right base is improved, but
with persistent small pleural effusion. The vascular congestion
is improved.
CXR ___: New opacification within the right lung base
concerning for infection or aspiration. Small right pleural
effusion. Low lung volumes.
DISCHARGE LABS
___ 06:35AM BLOOD WBC-6.1 RBC-4.47* Hgb-12.5* Hct-36.6*
MCV-82 MCH-27.9 MCHC-34.1 RDW-13.0 Plt ___
___ 06:35AM BLOOD Glucose-84 UreaN-16 Creat-1.1 Na-141
K-3.9 Cl-100 HCO3-34* AnGap-11
___ 01:40PM BLOOD pO2-113* pCO2-64* pH-7.37 calTCO2-38*
Base XS-9
Brief Hospital Course:
Pt is a ___ y/o male with history of tracheobronchomalacia, COPD
on 3 L home O2, asbestosis, and multiple psychiatric issues
(PTSD/depression), who presented to the ED because of increasing
dyspnea and weakness.
# RESPIRATORY DISTRESS/ANXIETY/DEPRESSION: History of
tracheobronchomalacia, COPD on home ___ presenting with dyspnea,
wheezing, and increased oxygen need in ED (4.5L from 3L
baseline) s/p thoracentesis for a chronic R-sided pleural
effusion ___ and vocal cord botox injection on ___. Last
admission, patient had respiratory distress w/episodes of
"stridor," thought largely to be psychogenic - patient had a lot
of concern/anxiety surrounding his lungs w/recurrent plural
effusions, was supposed to have psych follow-up after this
admission that he missed due to hoarseness. CXR unchanged from
prior admission. On arrival to MICU, taken off BiPAP, satting
97% on 3L NC, his home O2 dosages. Has several episodes of
hoarse stridor, but is able to interrupt them to request food
and drink. Never desats. Pt was treated with NC oxygen and
albuterol/ipratropium neb Q6hr. He was placed on ativan and his
home dose valium 5mg for anxiety. Pychiatry consultation was
obtained. Psychiatry did not think that his respiratory distress
is due to psychiatric conditions, commenting that he has PTSD
and depression and not necessarily anxiety/panic disorders.
Based on psych recommendations, we discontinued his home
bupropion, mirtazapine, and seroquil. Pt was upset about psych
med changes. He sees multiple psych providers, ___ at the
___ follow up with his outpatient physicians.
Interventional pulmonology was also consulted and recommended
prednisone 40mg x3 days but patient reported history of
psychosis w/ steroids; thus; pt was given fluticasone inhaler.
IP also recommended an outpatient cardiopulmonary excercise
test. Pt complained of throat pain. Pain was managed with
tylenol and home dose oxycodone.
On day of discharge, patient was seen and examined and stable
with comfortable breathing, full saturation on room air,
tolerating light excercise in the room. His bicarb was noted to
be rising. ABG was done and consistent with compensated
metabolic contractile alkalosis due to diuretic use and
decreased po intake, with respiratory compensation. Discussed
results with pulmonary fellow.
# ___: Cr 1.3 on admission; 1.1 baseline. Likely pre-renal;
encouraged PO intake and renal function improved.
# Hypothyroidism: continue home levothyroxine.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Bisacodyl 10 mg PO DAILY
3. BuPROPion 100 mg PO DAILY
4. Diazepam 5 mg PO QHS
5. Docusate Sodium 100 mg PO BID
6. Levothyroxine Sodium 175 mcg PO DAILY
7. Montelukast Sodium 10 mg PO DAILY
8. Valsartan 80 mg PO DAILY
9. TraZODone 100 mg PO HS:PRN sleep
10. Torsemide 80 mg PO DAILY
11. QUEtiapine Fumarate 25 mg PO TID
12. Sertraline 300 mg PO DAILY
13. Senna 1 TAB PO BID:PRN Constipation
14. Rosuvastatin Calcium 20 mg PO DAILY
15. Prazosin 10 mg PO DAILY
16. Oxycodone SR (OxyconTIN) 40 mg PO Q12H
17. Omeprazole 20 mg PO BID
18. Albuterol Inhaler ___ PUFF IH Q6H:PRN dyspnea
19. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Bisacodyl 10 mg PO DAILY
3. Diazepam 5 mg PO QHS
4. Docusate Sodium 100 mg PO BID
5. Levothyroxine Sodium 175 mcg PO DAILY
6. Montelukast Sodium 10 mg PO DAILY
7. Omeprazole 20 mg PO BID
8. Oxycodone SR (OxyconTIN) 40 mg PO Q12H
9. Prazosin 10 mg PO HS
10. QUEtiapine Fumarate 100 mg PO QHS
11. Rosuvastatin Calcium 20 mg PO DAILY
12. Senna 1 TAB PO BID:PRN Constipation
13. Sertraline 300 mg PO HS
14. Torsemide 80 mg PO DAILY
15. Valsartan 80 mg PO DAILY
16. Fluticasone Propionate 110mcg 2 PUFF IH BID
17. Lorazepam ___ mg PO Q4H:PRN anxiety
18. Albuterol Inhaler ___ PUFF IH Q6H:PRN dyspnea
19. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION BID
20. QUEtiapine Fumarate 50 mg PO HS:PRN Insomnia
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PTSD/depression
Vocal cord dysfunction
Trachobronchomalacia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Hello Mr. ___,
It was a pleasure taking care of you at the ___
___. You came because of increased work of
breathing and weakness. Here we monitored your breathing and
gave you breathing treatments. The psychiatrists also saw you in
order to adjust some medications. You have lung disease but we
believe that the reason you become acutely short of breath is
related to anxiety and its connection to your vocal cords. The
pulmonary doctors ___ and ___ the same way.
Please follow up with your primary care doctor, pulmonary
doctor, ___.
Here are adjustments to your medications:
Stop taking mirtazapine, buproprion, trazodone
Start seroquel 100 mg at bedtime. You may take 50mg in addition
if you need to for insomnia.
Please continue to take the rest of your medications.
Please follow up with your PCP within one week of your discharge
Please follow up with your pscychiatrists within two weeks to
review your recent medication changes.
Followup Instructions:
___
|
10188275-DS-29 | 10,188,275 | 25,261,717 | DS | 29 | 2148-02-17 00:00:00 | 2148-02-18 07:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
fish derived / shellfish derived / Beta-Blockers
(Beta-Adrenergic Blocking Agts)
Attending: ___.
Chief Complaint:
weight gain
Major Surgical or Invasive Procedure:
Right Heart Cath (___)
History of Present Illness:
Mr. ___ is a ___ w/Hx of dCHF, HTN, HLD, TBM w/prior
tracheoplasty, hypothyroidism, PTSD, and depression who presents
from clinic for significant weight gain and edema c/w
decompensation of
CHF exacerbation.
Pt reports that he has gained 23 lbs since his last DC on
___, his DC weight at that time was 255 lbs. Pt had recent
surgery for ulnar nerve decompression on ___, weight at that
time was up to 268 lbs. Per the patient, he has notable ___
edema, worsening orthopnea (4 pillows now, prior ___, abdominal
bloating, DOE with minimal effort.
Patient called into ___ clinic with these Sx, was recommended
for direct admission. Unfortunately, patient appeared confused
on presentation to ___ lobby. A first aid was called,
and patient was escorted to the ED for expedited w/u of his
confusion. Patient AMA'd from the ED as was upset that he hadn't
gotten his insulin while in the waiting room. Attempted to
redirect patient back to the waiting room of the ED to be seen.
However, pt threatened to AMA if he had to return to the ED.
On the floor after admission, patient endorses some minimal
increase in dyspnea. Overall he feels bloated and edematous.
His appetite has been poor. He feels his abdomen is distended
and that he has to urinate but can't. He straight caths at home
for urinary retention. He does note a fall that he sustained two
days ago while in the bathtub. The fall was unwitnessed and
patient does not think he lost consciousness. He did not seek
medical attention afterwards. He denies any deficits post fall
and says that he fell because he slipped.
On review of systems, 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.
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,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +HTN, +HLD, +DM2
2. CARDIAC HISTORY: +dCHF
- CABG/PCI: none
- PUMP FUNCTION: EF = 75%
- PACING/ICD: sinus
3. OTHER PAST MEDICAL HISTORY:
-Hypertension
-CHF (although normal systolic and diastolic function on TTE
___
-COPD/asthma pn home O2
-PTSD/BIPAP
-OSA on CPAP
-Chronic back pain
-Hypothyroidism
-Hyperlipidemia
-Diabetes Mellitus
-Back surgery with rod in L spine after trauma
-B/L rotator cuff surgery
-Abdominal hernia repair
-Left hand surgery post trauma
-tracheobronchomalacia s/p Right thoracotomy, tracheoplasty,
and bronchoplasty with med and left brochoplasty with mesh on
___ at ___
Social History:
___
Family History:
Grandfather with ___, brother deceased from ___. Also with DM in
family.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMIT EXAM
==========
Vitals: 98.2 152/83 112 18 98%RA blood sugar 95
Weight: 125.1kg
General: Obese male, in NAD
HEENT: PERRL, EOMI, ecchymoses present under left eye. No
sunken orbits. MMM.
Neck: Supple, JVP ~12cm.
CV: RRR, no m/r/g appreciated
Lungs: distant breath sounds, occasional expiratory wheezes, no
crackles appreciated
Abdomen: + distension but soft, dull to percussion at flanks
c/w ascites
GU: Foley in place
Extr: 2+ pitting edema to knees bilaterally, legs are warm,
well perfused
Neuro: A&Ox3, speech is slightly slowed but coherent. CN
II-XII intact with mild left lower facial droop appreciated.
Sensation intact to light touch. LLE weakness on exam, chronic
per patient, otherwise full strength throughout.
Skin: no skin breakdown appreciated
DISCHARGE EXAM
==============
Vitals: 98.2| 100/40-50| 60's| 18| 96% on RA
Weights: 124.1<- 123.5 <- 123.6< - 127.7 <- 127.9 <- 127.6<-
126.6 <- 125.0 <- 124.1 <- 125.1kg
I/Os:
8hrs: ___
24: 151___
General: Obese male, in NAD, AAox3
HEENT: ecchymoses present under left eye.
Neck: Supple, JVP ~9 cm at 90 degrees.
CV: RRR, no m/r/g appreciated
Lungs: distant breath sounds, decreased breath sounds in bases.
No wheezes, rhonchi
Abdomen: +distension, non TTP
Ext: 1+ pitting edema to knees bilaterally, wwp
Neuro: A&Ox3
Pertinent Results:
ADMIT LABS
==========
___ 08:52PM BLOOD WBC-7.8 RBC-4.57* Hgb-12.7* Hct-38.6*
MCV-85 MCH-27.8 MCHC-32.9 RDW-14.3 RDWSD-43.4 Plt ___
___ 08:52PM BLOOD Neuts-56.8 ___ Monos-7.7 Eos-1.7
Baso-0.6 Im ___ AbsNeut-4.40 AbsLymp-2.54 AbsMono-0.60
AbsEos-0.13 AbsBaso-0.05
___ 06:50AM BLOOD ___ PTT-32.8 ___
___ 08:52PM BLOOD Glucose-90 UreaN-15 Creat-1.2 Na-139
K-3.5 Cl-100 HCO3-21* AnGap-22*
___ 08:52PM BLOOD ALT-31 AST-25
___ 07:15AM BLOOD CK(CPK)-55
___ 08:52PM BLOOD CK-MB-4 cTropnT-<0.01
___ 06:50AM BLOOD proBNP-<5
___ 08:52PM BLOOD Calcium-9.3 Phos-3.0 Mg-1.7
___ 03:10PM BLOOD Ammonia-41
___ 08:21AM BLOOD FreeKap-20.1* ___ Fr K/L-1.43
___ 01:00PM BLOOD PEP-NO SPECIFI b2micro-3.6* IgG-798
IgA-148 IgM-38*
___ 09:16PM BLOOD Lactate-1.3
___ 01:59PM URINE Color-Yellow Appear-Hazy Sp ___
___ 01:59PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 01:59PM URINE RBC-112* WBC-80* Bacteri-NONE Yeast-NONE
Epi-<1
___ 11:30AM URINE Hours-RANDOM UreaN-538 Creat-224 Na-<20
K-56 Cl-<20
___ 12:24PM URINE U-PEP-NO PROTEIN
PERTINENT LABS:
================
___ 01:00PM BLOOD Glucose-133* UreaN-28* Creat-2.1* Na-140
K-4.5 Cl-99 HCO3-30 AnGap-16
___ 07:15AM BLOOD Glucose-107* UreaN-39* Creat-2.7* Na-135
K-6.2* Cl-95* HCO3-27 AnGap-19
___ 03:15PM BLOOD UreaN-44* Creat-3.0* Na-136 K-4.6 Cl-97
HCO3-28 AnGap-16
___ 08:21AM BLOOD Glucose-92 UreaN-42* Creat-2.1* Na-135
K-5.0 Cl-96 HCO3-26 AnGap-18
___ 10:22AM BLOOD Glucose-97 UreaN-28* Creat-1.1 Na-136
K-4.3 Cl-98 HCO3-28 AnGap-14
___ 09:16PM BLOOD ___ pO2-132* pCO2-36 pH-7.50*
calTCO2-29 Base XS-5 Comment-GREEN TOP
___ 04:18PM BLOOD Type-ART pO2-77* pCO2-59* pH-7.32*
calTCO2-32* Base XS-1
___ 09:16PM BLOOD Lactate-1.3
___ 04:18PM BLOOD Lactate-1.1
MICRO
====
Urine Culture ___, 18): Negative
IMAGING
======
ECG (___):
Sinus rhythm. Probable inferior wall myocardial infarction, age
undetermined. Somewhat early R wave progression. Possible
posterior involvement. Compared to the previous tracing of
___ the rate is now faster. QTc interval shorter. Otherwise,
unchanged.
NCCTH (___)
1. No acute intracranial abnormality.
2. Inflammatory sinus disease as described.
CXR (___)
Comparison to ___. Stable borderline size of the
cardiac silhouette. No pulmonary edema, no pneumonia, no
pleural effusions. Known right middle lung parenchymal
scarring, associated with an area of pleural thickening. Stable
position of the spinal catheter.
RUQ U/S (___)
Diffuse hepatic steatosis and splenomegaly, relatively unchanged
since the prior scan. Minimal gravel in an otherwise
normal-appearing gallbladder.
KUB (___)
1. Nonobstructive bowel gas pattern.
2. Assessment for free intraperitoneal air is limited on supine
radiographs, however there is no gross pneumoperitoneum. If
there is clinical concern for pneumoperitoneum, advise upright
or left lateral decubitus radiograph.
CXR (___)
Compared to chest radiographs since ___, most recently
___. Pulmonary vasculature is slightly more distended
but there is no pulmonary edema. Bands of subsegmental
atelectasis have increased. Heart is normal size, obscured by
right mediastinal fat collection. No appreciable pleural
effusion. No pneumothorax. No pneumoperitoneum.
TTE (___)
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). 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 appears structurally normal with trivial mitral
regurgitation. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___, no
change.
RHC (___)
Hemodynamic Comments: The right and left heart filling pressures
were elevated. The impaired right
ventricular filling is consistent with a restrictive
cardiomyopathy or right ventricular diastolic dysfunction. There
was no evidence of an intracardiac shunt by oximetry.
Impressions: Elevated right and left heart filling pressures
DISCHARGE LABS
===========
___ 07:10AM BLOOD WBC-5.7 RBC-5.17 Hgb-14.3 Hct-43.8 MCV-85
MCH-27.7 MCHC-32.6 RDW-14.6 RDWSD-44.3 Plt ___
___ 07:10AM BLOOD Glucose-80 UreaN-21* Creat-1.3* Na-139
K-4.1 Cl-97 HCO3-33* AnGap-13
___ 07:10AM BLOOD Calcium-9.8 Phos-3.5 Mg-2.3
Brief Hospital Course:
Mr. ___ is a ___ w/Hx of dCHF, HTN, HLD, TBM w/prior
tracheoplasty, hypothyroidism, PTSD, and depression who presents
from clinic for significant weight gain and edema c/w
decompensation of diastolic CHF exacerbation.
# Acute on Chronic Diastolic CHF Exacerbation:
Patient reported worsening edema, DOE, orthopnea, weight gain.
On admission, exam appeared c/w CHF exacerbation, specifically
with right sided failure- cardiac ascites and lower extremity
swelling. Pt took Torsemide 80/100 bid. Was on 4L O2 at home,
without increased O2 requirement on admission. He was warm on
exam, pBNP <5. CXR w/o signs of volume overload. Pt's weight on
admission was 10kg above DC weight in ___. Repeat TTE with
mild Pulm HTN, preserved EF similar to prior, cMRI not possible
___ spinal stimulator. Unclear etiology to dysfunction,
SPEP/UPEP/serum free light chains negative. B2 microglobulin
mildly elevated. Was initially diuresed successfully on lasix
gtt @ 5mg/hr. However, he quickly developed low UOP and
worsening ___ while on Lasix gtt. Sensitivity to initial Lasix
dose was thought most likely ___ very preload dependent state
and possible increased renal vein pressures ___ abdominal
distention leading to very delicate diuresis situation and need
for only gentle UOP. Due to ___, diuresis was held with Lasix
gtt, Spironolactone, Valsartan DC'd. Valsartan was restarted
with recovering Cr. He was given IVF back with improvement in
his renal function. Had a repeat RHC later in admission which
showed elevated Rt sided filling pressures consistent with Rt
sided diastolic dysfxn/restrictive physiology. Lasix gtt was
resumed at 5 mg/hr with good output. He then was decreased to
2mg/hr and finally stopped. Torsemide was started at 80mg daily
before being transitioned to Torsemide 100mg daily on discharge.
He was continued on valsartan. No beta blockers due to reported
allergy.
# Encephalopathy: Intermittent confusion/lethargy this
admission. Thought to be in part related to narcotics regimen.
NCCTH neg, LFTs wnl, VBG with signs of resp alk. Most likely iso
controlled substances use. Ammonia wnl. CXR/ABG/KUB/RUQ U/S
without acute causes for lethargy. Further episodes of lethargy
over admission thought ___ opiates, PRN doses were initially
held, chronic pain service consulted, recommeneded decreased
oxycontin to 20mg BID and restarting PRN oxycodone. Patient
tolerated this regimen but was still noted to be intermittently
somnolent at times.
CHRONIC ISSUES
==============
# HLD/CAD: c/w home atorvastatin 80 mg daily and aspirin 81 mg
daily.
# IDDM2: c/w home insulin regimen, including lantus/Humalog and
HISS
# GERD: c/w home omeprazole 40mg BID. Neg RUQ U/S, KUB. Got
simethicone, bowel reg for abd discomfort
# HTN: Was on valsartan 120mg qd at presentation, held when pt
developed ___, restarted once Cr normalized
# PTSD: c/w home prazosin 10mg
# Chronic back pain: initially on home OxyContin at 40 mg bid
and oxycodone prn, Diazepam 10mg q8hrs prn. Also has spinal
stimulator in place. Consulted chronic pain per above, decreased
oxycontin to 20mg BID and oxycodone ___ q4h prn
# Hypothyroidism: c/w home levothyroxine 112 mcg qd
# COPD/asthma. c/w home Tiotropium Bromide 1 CAP IH DAILY,
budesonide-formoterol 160-4.5 mcg/actuation inhalation BID,
montelukast 10 mg qhs, loratidine. Albuterol PRN. Unclear COPD
Dx and requirement for 4L O2 at home, as pt with ambulatory sat
on ___ without desaturation, sats 93% on RA
# Depression/anxiety: His outpatient psychiatric medications are
prescribed by Dr. ___ (Nova Psychiatry,
___.
-c/w home clonidine 0.1mg tid, diazepam 10mg q8h PRN:anxiety,
quetiapine 25mg TID, venlafaxine 300mg daily, escitalopram 20mg
qd
# OSA: continued home CPAP
TRANSITIONAL ISSUES
=============
-Weaned down patient's narcotic use to Oxycontin 20mg BID with
Oxycodone prn for breakthrough pain with recommendations of
chronic pain service. Patient prescribed Naloxone at discharge
and instructed on use. He was advised to continue the reduced
dose of Oxycontin at home and to discuss this regimen further
with his PCP.
-Pt unable to get cMRI as has spinal stimulator in place,
thought to be ___ Mini (though not confirmed) per spinal
surgery team, and unlikely to be MRI compatible per their team
and patient
# DC DIURETIC: Torsemide 100mg daily (reduced from 100mg BID)
- labs to be drawn on ___
# DC WEIGHT: 123.5kg
# CODE: FULL (confirmed)
# CONTACT: Patient, HCP Mother ___ ___,
___, wife - ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Prazosin 10 mg PO QHS
2. Valsartan 120 mg PO DAILY
3. Tiotropium Bromide 1 CAP IH DAILY
4. Atorvastatin 80 mg PO QPM
5. Glargine 50 Units Bedtime
Humalog 15 Units Breakfast
Humalog 15 Units Lunch
Humalog 15 Units Dinner
Humalog 15 Units Bedtime
6. Montelukast 10 mg PO DAILY
7. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
8. Loratadine 10 mg PO DAILY
9. Omeprazole 40 mg PO BID
10. Torsemide 100 mg PO BID
11. Aspirin 81 mg PO DAILY
12. Levothyroxine Sodium 112 mcg PO DAILY
13. Escitalopram Oxalate 20 mg PO DAILY
14. Venlafaxine XR 300 mg PO DAILY
15. CloNIDine 0.1 mg PO TID
16. Diazepam 10 mg PO Q8H:PRN spasm
17. QUEtiapine Fumarate 25 mg PO TID
18. Spironolactone 25 mg PO DAILY
19. OxyCODONE SR (OxyconTIN) 40 mg PO Q12H
20. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN breakthrough
pain
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. CloNIDine 0.1 mg PO TID
4. Diazepam 10 mg PO Q8H:PRN spasm
5. Escitalopram Oxalate 20 mg PO DAILY
6. Glargine 50 Units Bedtime
Humalog 15 Units Breakfast
Humalog 15 Units Lunch
Humalog 15 Units Dinner
Humalog 15 Units Bedtime
7. Levothyroxine Sodium 112 mcg PO DAILY
8. Loratadine 10 mg PO DAILY
9. Montelukast 10 mg PO DAILY
10. Omeprazole 40 mg PO BID
11. Prazosin 10 mg PO QHS
12. QUEtiapine Fumarate 25 mg PO TID
13. Spironolactone 25 mg PO DAILY
14. Tiotropium Bromide 1 CAP IH DAILY
15. Valsartan 120 mg PO DAILY
16. Venlafaxine XR 300 mg PO DAILY
17. budesonide-formoterol 160-4.5 mcg/actuation INHALATION BID
18. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
19. Torsemide 100 mg PO DAILY
20. HYDROcodone-acetaminophen 7.5-300 mg oral Q4H:PRN pain
21. Narcan (nalOXone) 4 mg/actuation nasal ONCE MR2
RX *naloxone [Narcan] 4 mg/actuation 4mg spray NAS every ___
minutes as needed Disp #*2 Spray Refills:*0
22. Outpatient Lab Work
Please check Chem10 and CBC on ___ and send results to Attn:
Dr. ___: ___ Fax: ___. ICD 9
code 428.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
======
Acute on Chronic Diastolic CHF exacerbation
Opiate induced encephalopathy
Chronic Back Pain
SECONDARY
========
IDDM2
HTN
PTSD
ANXIETY
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were directly admitted to ___ from home after you
developed worsening shortness of breath and weight gain. We
started you on IV diuretic medications, but you quickly
developed kidney damage with low urine output. We stopped giving
you diuretics for a few days and your kidney function recovered.
We did a right heart cath which showed that the right side of
your heart wasn't working properly, making you very sensitive to
the presence and absence of fluids in your body. We were a
little concerned several times during your admission that you
appeared a little confused. We think this might have been due to
your opiate use, and we recommend that you continue to use less
amounts of these medications for your back pain at home and that
you continue to discuss these doses with your PCP. We are also
sending you home with a new medication called Narcan which you
should use in the setting of an emergency if you breathing rate
slows from using too many narcotics.
We think that your "dry weight" is: 123.5kg
Please weigh yourself every morning, and call your PCP or
___ if your weight goes up more than 3 lbs in a 24 hour
period or 5lbs in a 72 hour period.
Please have your labs checked at a lab that is convenient for
you on ___. These should be sent to Dr. ___
review.
It was a pleasure taking care of you!
Your ___ Cardiology Team
Followup Instructions:
___
|
10188374-DS-15 | 10,188,374 | 25,651,180 | DS | 15 | 2164-04-13 00:00:00 | 2164-04-13 15:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Vomiting
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with a history of dementia presenting with nausea and
vomiting. A nurse at his ALF noticed the pt "vomiting up phlegm"
and "thought he had pneumonia." He went to ___ and was found to
have a dilated, fluid-filled stomach as well as a large hiatal
hernia with sliding and paraesophageal components. NGT was
placed, revealing 700cs of brown output per report, and he was
transferred here for thoracic eval.
Pt's daughter is unsure if he was complaining of any abdominal
pain during this time, although states that he rarely complains
of anything.
Upon arrival to the floor, pt denies any complaints besides some
pain after reinsertion of NGT. Denies fevers or chills, cough,
dyspnea, abdominal pain, nausea, loose stools, blood in stool.
Last BM was at ___ after NGT insertion, it was loose which is
his baseline.
Past Medical History:
Polymyalgia rheumatic - not currently on treatment
Dementia -moderate
Paget's disease
Osteoporosis,
Hypercholesterolemia
Carpal tunnel syndrome
Carotid artery stenosis and occlusion - no prior carotid surgery
Cataracts
RBBB (right bundle branch block)
Glaucoma
Seborrheic keratosis
Left inguinal hernia repair
Social History:
___
Family History:
Father died of MI. Mother with diabetes.
Physical Exam:
ADMISSION EXAM:
Vital Signs: T 99.1 bp 122 / 65 HR 82 RR 20 SPO2 93
General: Alert, conversant, but not oriented to place or date.
Answers questions appropriately. Follows basic commands.
HEENT: Sclerae anicteric, MMM, NG tube coiled in mouth. EOMI,
PERRL, neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Diminished breath sounds with poor air movement
diffusely. Rhonchi at bases. Wet cough.
Abdomen: Soft, non-distended, bowel sounds present. NG tube in
place. Mildly tender right inguinal hernia
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:
Vitals: 97.8 126/59 83 20 95%RA
General: alert in bed, no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear
Lungs: Clear to auscultation bilaterally.
CV: Distant heart sounds. Regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Abdomen: Soft, non-tender, non-distended, no rebound tenderness
or guarding
Ext: no clubbing, cyanosis or edema, 2+ pulses
Neuro: Somnolent, PERRLA, face symmetric, tongue midline, moving
all four extremities.
Pertinent Results:
ADMISSION LABS:
___ 10:00PM GLUCOSE-131* UREA N-30* CREAT-1.4* SODIUM-144
POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-27 ANION GAP-16
___ 10:00PM estGFR-Using this
___ 10:00PM CALCIUM-9.3 PHOSPHATE-3.5 MAGNESIUM-2.0
___ 10:00PM WBC-13.8* RBC-2.81* HGB-7.7* HCT-25.1* MCV-89
MCH-27.4 MCHC-30.7* RDW-16.5* RDWSD-54.0*
___ 10:00PM NEUTS-87.8* LYMPHS-4.8* MONOS-6.5 EOS-0.0*
BASOS-0.1 IM ___ AbsNeut-12.07* AbsLymp-0.66* AbsMono-0.89*
AbsEos-0.00* AbsBaso-0.02
___ 10:00PM PLT COUNT-321
___ 10:00PM ___ PTT-28.3 ___
MICROBIOLOGY:
BLOOD CULTURE: Pending
URINE CULTURE: Clean
PATHOLOGY: None
IMAGING:
CHEST X-RAYS, ___:
#1. IMPRESSION:
On the later image taken at 01:45 (image # 2), the tip of the NG
tube is approximately 7.3 cm above the hemidiaphragm
(costovertebral angle). However, there is likely also a
relatively large hiatal hernia, with the GE junction resultantly
lying in the lower chest. If clinically indicated, a lateral
view may be helpful in better demonstrating that. Please see
comment above. The nature of hiatal hernia is not fully
characterized on the basis of this radiograph.
Probable mild cardiomegaly. Mild bibasilar atelectasis. Given
slight indistinctness of the left hemidiaphragm, continued
attention to the left base is recommended to exclude changes
related to aspiration pneumonitis.
#2. FINDINGS:
Rotated positioning.
NG tube tip lies approximately 7.3 cm above the left
cardiophrenic angle/medial diaphragm. The NG tube tip may lie
near the GE junction with the hiatal hernia, but this is
difficult to confirm on these views. If clinically indicated, a
lateral view may help for further assessment.
Otherwise, doubt significant interval change.
#3. FINDINGS:
Rotated positioning.
An NG tube is present. It has been advanced distal to the
position seen on the on the chest x-ray from 01:40 on ___. The tip now lies immediately below the level of the
hemidiaphragm. It likely lies within the hiatal hernia, given
relative lucency in this area on the edge enhanced image. If
clinically indicated, a lateral view could help to confirm this.
Given complex anatomy, a CT scan could also help for more
complete evaluation.
Cardiomediastinal silhouette and parenchymal findings are
similar to prior.
4. IMPRESSION:
No significant interval change since the prior chest radiograph.
CT ABDOMEN PELVIS (___)
IMPRESSION:
1. Large paraesophageal hernia is redemonstrated with enteric
tube terminating
within the stomach which is located above the diaphragm.
Interval resolution
of the gastric distension.
2. Increased amount of stool impacted within the rectum.
3. Consolidative opacities in both lower lobes could be related
to aspiration.
4. Appearances of the left hemipelvis raises concern for Paget
disease.
CHEST X RAY ___:
IMPRESSION:
Increasing infrahilar opacities bilaterally, likely reflecting
developing
infection. Small bilateral pleural effusions.
TTE ___:
The left atrium is elongated. 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%). 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 appears structurally normal with
trivial mitral regurgitation. The tricuspid valve leaflets are
mildly thickened. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
DISCHARGE LABS:
___ 06:16AM BLOOD WBC-6.9 RBC-3.04* Hgb-8.5* Hct-26.7*
MCV-88 MCH-28.0 MCHC-31.8* RDW-16.3* RDWSD-52.7* Plt ___
___ 06:16AM BLOOD Glucose-89 UreaN-21* Creat-1.3* Na-142
K-4.1 Cl-107 HCO3-25 AnGap-14
___ 06:16AM BLOOD Calcium-8.7 Phos-3.6 Mg-PND
Brief Hospital Course:
___ with a history of dementia presenting with nausea and
vomiting, now with gastric outlet obstruction ___ hiatal hernia
and GI bleed.
ACUTE ISSUES:
#Obstruction and GI bleed: Pt presented with one day of
abdominal pain and vomiting "molasses-like" fluid. He was found
to have a large hiatal hernia with sliding and paraesophageal
components, with a dilated and fluid-filled stomach. He was
thought to be obstructed by the hiatus at either the herniated
stomach itself or at a loop of small bowel that may have
herniated through the hiatus. An NGT was placed, which drained
dark brown liquid. In addition, the patient's hemoglobin was
dropping, raising concern for a GI bleed. Likely etiology was
thought to be peptic ulcer disease versus ___ tears
versus ___ lesions (ulceration of gastric mucosa where
herniated stomach passes through hiatus). Endoscopic
intervention was deferred and patient was transfused 1U of
pRBCs. Diet was advanced and tolerated. After resolution of
symptoms and imaging consistent with resolution of obstruction,
his NGT was removed and his diet was advanced successfully.
Patient was started on BID PPI.
#Aspiration pneumonia: Pt had a leukocytosis and concern for
aspiration pneumonia on imaging and was treated with
levofloxacin (7 days total, day ___.
___ vs CKD: Pt's creatinine was 1.4 on admission, with unknown
baseline. Thought to be prerenal in the context of anemia. On
discharge, his creatinine was 1.3.
TRANSITIONAL ISSUES:
___ vs CKD: Unknown baseline in this system. Peaked at 1.4.
#Anemia: Discharged with hemoglobin of 8.5. Thought to be due to
GI bleed due to ischemia of stomach herniated through diaphragm,
but also considered peptic ulcer disease.
New Medications:
-Levofloxacin 500mg PO Q48h
-Omeprazole 40mg PO BID
Transitional Issues:
-f/u with PCP
-___ one dose of levofloxacin on ___ to complete a
7-day course
-Continue omeprazole 40mg PO BID indefinitely
-AVOID NSAIDS given recent UGIB
-f/u H&H within one week after discharge (8.5/26.7 on the day of
discharge)
-f/u Chem-10 within one week after discharge given that
omeprazole was started
-f/u creatinine one week after discharge to establish
baseline-was 1.4 on arrival with no known baseline in our
system. Cr was 1.3 on the day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 200 mg PO DAILY
2. Polyethylene Glycol 17 g PO DAILY
3. Cyanocobalamin 1000 mcg IM/SC ONCE PER MONTH
4. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
5. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild
Discharge Medications:
1. Levofloxacin 500 mg PO Q48H
RX *levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth q48h
Disp #*1 Tablet Refills:*0
2. Omeprazole 40 mg PO BID
3. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild
4. Cyanocobalamin 1000 mcg IM/SC ONCE PER MONTH
5. Docusate Sodium 200 mg PO DAILY
6. Polyethylene Glycol 17 g PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES: PARAESOPHAGEAL HIATAL HERNIA, GASTRIC
OBSTRUCTION, GASTROINTESTINAL BLEED.
SECONDARY DIAGNOSES: ASPIRATION PNEUMONIA, ACUTE KIDNEY INJURY,
DEMENTIA
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were seen in the hospital because you had an obstruction of
your gastrointestinal tract. This happened because your stomach,
which has risen into your chest, was blocked off by your
diaphragm (which normally is above the stomach). We treated this
by putting a tube into your stomach through your nose, which
drained your stomach. You also had some bleeding into your
gastrointestinal tract. We treated this by giving you a blood
transfusion.
You also had a pneumonia, which we treated with antibiotics.
When you get home, you should take care to follow-up with your
doctors and take your medicines as they are prescribed. You
should take one dose of your antibiotic (levofloxacin) on
___. Please avoid nonsteroidal anti-inflammatory
medications like ibuprofen and naproxen as they can increase
your risk of bleeding from your stomach.
For your diet, you should start eating softer foods. You can
begin introducing firmer foods (like steak), but you should
start with small amounts at a time.
It was our pleasure to care for you. We wish you the very best!
--Your care team at ___
Followup Instructions:
___
|
10188463-DS-7 | 10,188,463 | 21,111,707 | DS | 7 | 2166-08-21 00:00:00 | 2166-08-21 15:09:00 |
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:
___ ERCP with ampillary brushings
___ Laparoscopic cholecystectomy
History of Present Illness:
The patient is a ___ year old man ___ only) without
significant contributing medical history who presents with
abdominal pain to an OSH and found to have choledochololithiasis
transferred for ERCP. He is also suspected to have cholecystitis
at the time of transfer.
Pt c/o abdominal pain on ___ at midnight that woke him up.
Pain is mid-epigastric, non-radiating, ___ at its worst,
relieved by iv morphine/dilaudid that he received at OSH. No
n/v, f/c, d/c, melena/brbpr, cp, sob, jaundice, rash, weight
loss.
At ___ labs showed lipase 246, ast/aslt 561/930,
Tbili 3.3. US with obstructive cholelithiasis, thickened
gallbladder wall.
At ___, 97.8 80 122/76 16 100% RA. US showed gallbladder w/
stones, thickened gallbladder wall w/ edema and mild
pericholecystic fluid, thick septation or soft tissue density
coursing across the mid-gallbadder, and dilated CBD 8mm. He
received unasyn. ERCP and surgery were c/s.
Currently, pain is 0.
ROS: 14 point ROS is otherwise negative.
Past Medical History:
No contributing medical or surgical history
Social History:
___
Family History:
Mother- ___
Father- Kidney disease, was on dialysis
Notes a strong family history of biliary disease.
Physical Exam:
Admission examination
T 98.8, BP 128/77, HR 70, RR 16, O2 100% RA
Gen: NAD
HEENT: OP clear, sclera icteric
Neck: supple, no LAD
CV: rr, no mrg
Pulm: CTAB, no wrr
Abd: Soft, NT/ND, no organomegaly
Ext: wwp, no edema
Neuro: A&Ox3
On discharge:
VS 98.2, 70, 110/58, 16, 98% on room air
Pertinent Results:
___ 04:20PM GLUCOSE-100 UREA N-11 CREAT-1.1 SODIUM-140
POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-30 ANION GAP-13
___ 04:20PM estGFR-Using this
___ 04:20PM ALT(SGPT)-852* AST(SGOT)-389* ALK PHOS-127
TOT BILI-3.5*
___ 04:20PM LIPASE-53
___ 04:20PM ALBUMIN-4.1
___ 04:20PM WBC-6.9 RBC-5.41 HGB-14.6 HCT-45.1 MCV-83
MCH-27.0 MCHC-32.3 RDW-13.0
___ 04:20PM NEUTS-67.3 ___ MONOS-7.2 EOS-1.2
BASOS-0.4
___ 04:20PM PLT COUNT-236
___ 03:20PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 03:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 03:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
US:
-Gallbladder filled with stones
-Thickened gallbladder wall with possible edema and mild
pericholecystic fluid
-Negative Sonographic ___ sign
-Thick septation or soft tissue density coursing across the
mid-gallbadder
-Dilated CBD measuring up to 8 mm. No definite intrahepatic
ductal dilatation
___ Distal CBD brushings: Atypical
___ ERCP (wet read)
1. No biliary obstrution.
2. Cholelithiasis with a fold in the mid gall-bladder with a
thickened wall that avidly enhances and distorts the GB
morphology. Most likely dx is focal adenomyomatosis with
carcinoma being much less likely.
___ Gallbladder Pathology: PENDING
Brief Hospital Course:
The patient is a ___ year old man without prior significant
medical history who presents with abdominal pain and is found to
have choledochololithiasis as well as concern for acute
cholecystitis. He is initiated on antibiotics, and ultimately
underwent an ERCP which revealed a swollen ampulla. Brushings
were taken, with pathology pending at the time of transfer. He
will also require a follow-up ERCP in 4 weeks per Dr ___ to
ensure that his swelling has resolved.
Choledochololithiasis, with suspected cholecystitis: Multiple
gallstones seen on US, w/ dilated CBD (no stone noted on prelim
read- may have passed). US also notable for gallbladder
thickened, hyperemia w/ pericholecystic fluid), suggestive of
cholecystitis, though no leukocytosis and no fevers. His
gallbladder did not fill well on ERCP, further suggestive of
cholecystitis. The ___ team consulted on the patient, while IV
antibiotics were continued and his LFTs trended downwards.
Mr. ___ was transferred to the Acute Care Surgery service on
___. On the same day, the patient was taken to the operating
room for a laparoscopic cholecystectomy. He tolerated the
procedure well. Please see the operative report for further
details. The patient was recovered in PACU and transferred to
the surgical ward for further management.
Mr. ___ was transferred to the surgical floor
hemodynamically stable. His vital signs were routinely monitored
and he remained afebrile and hemodynamically stable. He was
initially given IV fluids postoperatively, which were
discontinued when he was tolerating an oral diet. His diet was
advanced on the morning of ___ to regular, which he tolerated
without abdominal pain, nausea, or vomiting. He was voiding
adequate amounts of urine without difficulty. He was encouraged
to mobilize out of bed and ambulate as tolerated, which he was
able to do independently. His pain level was routinely assessed
and well controlled at discharge with an oral regimen as needed.
On the afternoon of ___, Mr. ___ was hemodynamically
stable, afebrile and in no acute distress. His total bilirubin
decreased from a max of 4 to today's value of 1.5. He was
provided with an appointment to follow up in ___ clinic in 2 to
3 weeks. He was also told to expect a call from Dr. ___
___ for a follow-up ERCP in approximately 4 weeks.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Choledocholithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ on
___ with complaints of abdominal pain. You had an ultrasound
of your gallbladder done at the outside hospital, which showed
gallstones in your bile duct. Because your pain improved on
admission to ___ and you had no gallbladder irritation, you
were managed conservatively initially. You were given bowel
rest (nothing to eat or drink), IV fluids and IV pain
medications as needed. Your labwork was monitored closely.
Because your liver enzymes were not decreasing, you had an ERCP
on ___, where they did a sphincterotomy and samples of tissue
were sent for biopsy. You will need to have a repeat ERCP in
approximately 4 weeks. Dr. ___ will call you to
schedule.
Again, your liver enzymes were not decreasing after the ERCP, so
you had a MRCP to make sure there was no physical reason for
your liver enzymes to be increasing. It showed that your
gallbladder was abnormal, so on ___, you underwent a
laparoscopic cholecystectomy. You tolerated the procedure well.
You have recovered well and are now being discharged 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:
___
|
10188472-DS-7 | 10,188,472 | 28,041,885 | DS | 7 | 2185-07-26 00:00:00 | 2185-07-28 10:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ h/o metastatic grade 3 neuroendocrine tumor, HTN, afib,
GERD,presents to ER with c/o fever. Last Chemo ___.
Patient reports that she had a temperature of ___ at home
which
is why she called her oncology office and she was asked to come
to the ER.
In ER, she received IV vancomycin and IV cefepime, her VS were
stable and afebrile. Her Flu PCR was negative and her CXR showed
opacity in R lung base which could be early pneumonia.
On floor, she feels well. She reports that over past ___ days
she is having sputum production from nose and mouth but No
cough.
She mentioned about occasional blood in her nose when she blows
her nose hard. No chest pain or SOB.
She denies sick contacts. She saw a small reddish bump in her R
forearm a few days ago which is non tender. She has good
appetite
and normal BM. she ambulates well. No other sx.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
___ is a ___ woman whose oncologic history
begins in ___ when she presented with several weeks
of abdominal and epigastric pain.
___: CT ABD/Pelvis - showed multiple liver lesions,
concerning for metastases, as well as a duodenal lesion and RP
lymphadenopathy. She also had a right renal mass measuring
3.0x3.3 cm.
___: CT chest showed an 8mm left upper lobe nodule as well
as multiple nodules <5mm in diameter, concerning for metastases
___: Needle biopsy of the liver showed Grade III
neuroendocrine carcinoma. Ki 67 index was 30% and the tumor's
mitotic rate was ___. The tumor was noted to be positive
for
CAM 5.2, positive for cytokeratin, positive for chromogranin,
positive for synaptophysin, and positive for CDX2. This in
conjunction with the radiographic finding of a duodenal mass,
seemed most consistent with metastatic neuroendocrine tumor of
duodenal origin.
___: She established care in outpatient GI clinic and the
decision was made to treat her with carboplatin/etoposide.
Her treatment history is as follows:
___: C1D1 ___
___: C1D2 Etoposide
___: C1D3 Etoposide
___: C2D1 ___
PAST MEDICAL HISTORY
1. Hypertension.
2. Atrial fibrillation.
3. GERD.
4. Obstructive sleep apnea.
5. Status post gastric bypass surgery ___.
6. Status post hysterectomy in ___.
7. Status post breast reduction surgery.
Social History:
___
Family History:
Father: passed at ___ of alcoholic cirrhosis
Mother: respiratory disease
No known hx of cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: NAD
VITAL SIGNS: 97.6 PO 127 / 79 60 20 98 RA
HEENT: NC AT. MMM.
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: BS+, soft, NTND,
LIMBS: No edema, clubbing, tremors, or asterixis;
SKIN: r forearm dorsal surface has a small swollen reddish
area,
circular 3X 3 cm, non tender to touch.
NEURO: No focal deficits
DISCHARGE PHYSICAL EXAM essentially unchanged from admission
exam
Pertinent Results:
LABORATORY ANALYSIS:
WBC: 10.8*. RBC: 3.60*. HGB: 10.7*. HCT: 32.6*. MCV: 91. RDW:
14.5. Plt Count: 77*.
Neuts%: 63. Lymphs: 21. MONOS: 5. Eos: 0. BASOS: 0. Atyps: 2*.
Metas: 0. Myelos: 2*.
___: 12.6*. INR: 1.2*. PTT: 31.0.
Na: 136. K: 6.9* (HEMOLYSIS FALSELY ELEVATES K; REPORTED TO AND
READ BACK BY ___ 0217 ___. Cl: 99. CO2: 24.
BUN:
10. Creat: 0.7. Ca: 8.7. Mg: 2.1. PO4: 5.2* (Hemolysis falsely
elevates this test).
IMAGING:
___ Imaging CHEST (PA & LAT)
No definite focal consolidation. Subtle opacity at the right
base
likely represents atelectasis, but early pneumonia cannot be
excluded in the right clinical setting.
R ARM superficial US ___:
Superficial thrombophlebitis and moderate soft tissue edema
corresponding to
the area of palpable concern and tenderness on exam reported by
the patient in
the right ventral lateral forearm. No evidence for abscess.
Brief Hospital Course:
___ w/ h/o metastatic grade 3 neuroendocrine tumor, HTN, afib,
GERD who initially presented with fever.
# Fever-- Pt presented with c/o temp of 100.0 at home. She did
not have a measured fever here. She further denied any
localizing symptoms. UA, flu, CXR negative. She was briefly
started on levaquin but this was d/c'ed as pt did not have any
respiratory symptoms. She was discharged in good condition with
stipulation to call her PCP/oncologist if she were to develop
another fever or any localizing symptoms.
# R arm lump-- Pt very concerned about small lump on distal R
arm, anxious that it could be cancer. Obtained RUE superficial
US which showed that it was likely superficial thrombophlebitis.
Pt counseled to use hot compresses.
# Neuroendocrine tumor-- ___- C2D1 carboplatin/etoposide.
Received Neulasta on ___
# Thrombocytopenia/Anemia- Platelets in ___'s-80's range, Hb ~10
on admission. Thrombocytopenia and anemia felt to be from
Chemotherapy. Pt needs outpt CBC in a few days after DC.
# Afib-- Continued Xarelto and Sotalol.
# HTN-- Continued lisinopril and amlodipine.
Billing: greater than 30 minutes spent on discharge counseling
and coordination of care.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
3. Sotalol 120 mg PO BID
4. amLODIPine 5 mg PO DAILY
5. Rivaroxaban 20 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Vitamin D 800 UNIT PO DAILY
8. Cyanocobalamin 100 mcg PO DAILY
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
2. Cyanocobalamin 100 mcg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Rivaroxaban 20 mg PO DAILY
6. Sotalol 120 mg PO BID
7. Vitamin D 800 UNIT PO DAILY
8. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Borderline fever
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came in with a fever. We did some tests which did no show
any obvious infections. It is possible that this fever might
have been from your chemotherapy. You do not need any
antibiotics at this time. Please call your Oncologist if you
have more fevers, shortness of breath, cough, diarrhea,
vomiting, or burning in your urine.
Followup Instructions:
___
|
10188582-DS-7 | 10,188,582 | 29,645,280 | DS | 7 | 2170-07-28 00:00:00 | 2170-07-31 08:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
Admission Labs
___ 12:20PM BLOOD WBC-3.0* RBC-4.12* Hgb-12.3* Hct-37.5*
MCV-91 MCH-29.9 MCHC-32.8 RDW-12.6 RDWSD-41.5 Plt ___
___ 12:20PM BLOOD Neuts-40.4 ___ Monos-8.4
Eos-14.8* Baso-0.7 Im ___ AbsNeut-1.20* AbsLymp-1.05*
AbsMono-0.25 AbsEos-0.44 AbsBaso-0.02
___ 12:20PM BLOOD Plt ___
___ 12:20PM BLOOD Glucose-103* UreaN-17 Creat-0.9 Na-139
K-4.3 Cl-106 HCO3-23 AnGap-10
___ 07:02AM BLOOD ALT-9 AST-15 LD(LDH)-126 CK(CPK)-70
AlkPhos-77 TotBili-0.3
___ 07:02AM BLOOD Albumin-3.3* Calcium-8.0* Phos-3.4 Mg-1.8
Iron-55
___ 07:02AM BLOOD calTIBC-222* Ferritn-421* TRF-171*
Microbiology
___ 3:15 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
PROTEUS MIRABILIS. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
Mr. ___ is a ___ year-old man with poorly controlled HIV
who presented with ongoing LUTS and found to have chronic
bacterial prostatitis.
TRANSITIONAL ISSUES
===================
[ ] Will need to continue Levofloxacin for a 6 week course for
prostatitis. F/U scheduled with PCP and ID for lab & EKG
monitoring. Will need EKG at next f/u to assess QTc and
CBC/Chem-7/LFTs for safety monitoring.
[ ] Should f/u CD4 & VL in 1 month on current ART to determine
if need to switch.
ACUTE ISSUES
============
# Chronic Bacterial Prostatitis
Presented with several months of LUTS including frequency,
incontinence, and dysuria. Has undergone multiple UA & UCX at
one point revealing Proteus and has had several short courses of
various antibiotics. UCX here w/ pansensitive proteus, started
on Levofloxacin given once-daily dosing. EKG stable. Plan made
for PCP & ID f/u for labs and EKG monitoring.
CHRONIC ISSUES
==============
# HIV, Poorly-controlled
Most recent CD4 29, VL 121 million ___. Continued on
Bictegrav-Emtricit-Tenofov & Darunavir-Cobicistat. Continued
prophylaxis (Azithro, Fluc, Dapsone).
# Constipation: continued home bowel regimen
# Mood: continued bupropion
# Emergency Contact: HCP/Brother ___ (___)
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Ketoconazole Shampoo 1 Appl TP ASDIR
2. Gabapentin 300 mg PO QHS
3. Prezcobix (darunavir-cobicistat) 800-150 mg-mg oral daily
4. Oxybutynin XL (*NF*) 10 mg Other daily
5. dutasteride 0.5 mg oral daily
6. Dapsone 100 mg PO DAILY
7. BuPROPion XL (Once Daily) 300 mg PO DAILY
8. Bictegrav-Emtricit-Tenofov Ala 1 TAB PO DAILY
9. Fluconazole 100 mg PO Q24H
10. Psyllium Powder 1 PKT PO QHS
11. Azithromycin 1200 mg PO 1X/WEEK (___)
Discharge Medications:
1. LevoFLOXacin 500 mg PO DAILY Duration: 6 Weeks
RX *levofloxacin 500 mg 1 tablet(s) by mouth once a day Disp
#*40 Tablet Refills:*0
2. Nicotine Patch 21 mg/day TD DAILY
3. Phenazopyridine 100 mg PO TID Improve dysuria Duration: 3
Days
RX *phenazopyridine 100 mg 1 tablet(s) by mouth three times a
day Disp #*21 Tablet Refills:*0
4. Azithromycin 1200 mg PO 1X/WEEK (___)
5. Bictegrav-Emtricit-Tenofov Ala 1 TAB PO DAILY
6. BuPROPion XL (Once Daily) 300 mg PO DAILY
7. Dapsone 100 mg PO DAILY
8. dutasteride 0.5 mg oral daily
9. Fluconazole 100 mg PO Q24H
10. Gabapentin 300 mg PO QHS
11. Ketoconazole Shampoo 1 Appl TP ASDIR
12. Oxybutynin XL (*NF*) 10 mg Other daily
13. Prezcobix (darunavir-cobicistat) 800-150 mg-mg oral daily
14. Psyllium Powder 1 PKT PO QHS
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Chronic Bacterial Prostatitis
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 were having urinary symptoms
What did you receive in the hospital?
- We found you had prostatitis (an infection of your prostate)
- We started you on antibiotics
- We gave you a medicine to help with your urinary symptoms
What should you do once you leave the hospital?
- Please take your medications as prescribed and go to your
future appointments which are listed below.
- You need to take levofloxacin every day for 6 weeks to treat
your infection. You will need to see your PCP and an infectious
disease doctor as well to monitor labs.
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
10188935-DS-5 | 10,188,935 | 22,289,170 | DS | 5 | 2164-05-07 00:00:00 | 2164-05-07 17:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cardiac arrest
Major Surgical or Invasive Procedure:
Cardiac Catheterization
s/p dual chamber ___ ICD for secondary prevention via L
cephalic
History of Present Illness:
___ w/CAD, CHF w/ EF ___, presenting for further managment
s/p Vtach arrest. The reports he was moving snow off his car
this morning and felt well. He then proceeded into his kitchen
and started to make breakfast when he began to feel very weak
and diaphoretic. He did not have chest pain, palpitations, or
difficulty breathing. Out of concern for his new onset weakness
his wife called EMS. When EMS arrived the patient continued to
be responsive to questions and mentating well. Further
examinations found the patient to be in vtach with HRs in the
150s-160s and he was noted to have a thready pulse. He was
loaded with 150 of amiodarone, and shortly thereafter, became
unconscious, pulseless. He received ___ minutes of CPR, a shock
at 200 J ROSC. He was bradycardiac in ___, became conscious,
mentating well. There was no evidence of STEMI on EKG.
He was brought to ___, where he remained in sinus brady,
talking, then returned to ___ in 150s without provokation.
During this episode he was feeling lightheaded. He was given a
lidocaine bolus and ___ seconds later, became unconscious,
pulseless. He got about 10 sec of CPR, getting ready to shock,
but did not get a shock, ROSC. The decision was made to intubate
the patient however the attempt was unsuccessful due to a
challenging airwau. An oral airway was temporarily placed and
eventually he regained spontaneous respirations and regained
consciousness. Prior to transfer from ___ he was noted to be
bradycardic to ___. EKG showed partial LBBB, nonspecific
changes, and no ST elevations. Continued on amiodarone here and
given aspirin 325. ___ labs showed normal CBC, creatinine
1.4, trop 0.16 at ___-MB 3.6-3.8. CK was in ___.
On arrival to CCU vital signs were 97.5 141/71 90 12 97% on 2L
NC. The patient was mentating well and was in no distress. The
patient denied chest pain/pressure, palpitations, shortness of
breath, or ongoing weakness and diaphoresis.
REVIEW OF SYSTEMS: + urinary frequency & see HPI; Denies recent
fevers, chills, headaches, changes in vision, abdominal pain,
nausea, vomitting, changes in bowel habits, new joint pains or
skin changes.
Past Medical History:
MYOCARDIAL INFARCT in ___
HYPERLIPIDEMIA
ISCHEMIC HEART DISEASE - OTHER CHRONIC
DUPUYTREN'S CONTRACTURE
ESOPHAGEAL REFLUX
Exudative senile macular degeneration of retina
BPH w urinary obs/LUTS
Bladder diverticulum
Systolic heart failure
Thrombocytopenia
Social History:
___
Family History:
Father: died after MI at age ___
Mother: HTN, died at age ___
1 daughter healthy
Physical ___:
ADMISSION PHYSICAL EXAM:
97.5 141/71 90 12 97% on 2L NC.
General - No acute distress, alert and oriented.
HEENT - NC/AT. Non-icteric sclerae. Moist mucous membranes
without pallor or cyanosis. Superficial bruising around mouth
and on tongue
Skin - Warm, no rash, ecchymosis.
Neck - Supple. No significant JVD. Carotids without bruits.
Chest - Speaking in complete sentences. Clear to auscultation
bilaterally with the exception of scant crackles in L base. No
rales/wheezes.
CV - faint heart sounds. No palpable S3/S4.
Abdomen - Soft, NT/ND, + BS. No hepatomegaly, masses, or bruits.
No rebound/guarding.
Extremities - +1 edema to upper calves bilaterally. No cyanosis
or clubbing.
Psych - Pleasant and conversant, mood and affect appropriate.
.
DISCHARGE PHYSICAL EXAM:
Vitals - Tm/Tc:99/___.6 HR: 60-67 RR:18 BP:98-115/55-64 02
sat:94% RA
In/Out:
Last 24H: /___
Last 8H: NPO/350
GENERAL: Pleasant in NAD. Alert and interactive.
NECK: supple without lymphadenopathy, JVD at clavicle. Bruise at
left upper lip from intubation. Left sided pacer site with
intact steri strips, no drainage, tenderness or redness.
___: RRR. No S3 or S4 no rubs or gallops.
RESP: No accessory muscle use. Lungs CTA, decreased at bases.
ABD: soft, NT/ND, normoactive bowel sounds.
EXTR: no edema.
NEURO: Alert and oriented x 3. Poor short term memory at times
but not agitated or overtly confused. Denies pain.
Pertinent Results:
ADMISSION LABS:
___ 01:50PM BLOOD WBC-8.4 RBC-4.03* Hgb-13.3* Hct-40.8
MCV-101* MCH-33.0* MCHC-32.5 RDW-12.5 Plt ___
___ 01:50PM BLOOD Neuts-84.6* Lymphs-11.2* Monos-3.1
Eos-0.8 Baso-0.2
___ 01:50PM BLOOD ___ PTT-32.6 ___
___ 01:50PM BLOOD Glucose-356* UreaN-20 Creat-1.4* Na-137
K-4.7 Cl-100 HCO3-24 AnGap-18
___ 01:50PM BLOOD CK-MB-46* MB Indx-11.4*
___ 04:45AM BLOOD Calcium-8.2* Phos-4.0 Mg-2.1
.
OTHER RELEVANT LABS:
___ 05:28AM BLOOD ALT-35 AST-57* AlkPhos-53 TotBili-0.6
___ 01:50PM BLOOD CK-MB-46* MB Indx-11.4*
___ 01:50PM BLOOD cTropnT-0.29*
___ 11:30PM BLOOD CK-MB-80* cTropnT-2.05*
___ 04:45AM BLOOD CK-MB-57* cTropnT-1.62*
___ 05:38AM BLOOD CK-MB-5 cTropnT-2.26*
___ 06:00PM BLOOD CK-MB-4 cTropnT-1.98*
___ 05:28AM BLOOD TSH-2.2
___ 03:11PM BLOOD Type-ART pO2-58* pCO2-32* pH-7.46*
calTCO2-23 Base ___ 03:57PM BLOOD Type-ART pO2-60* pCO2-33*
pH-7.45 calTCO2-24 Base ___ 03:11PM BLOOD Lactate-1.3
___ 03:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 03:00PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-2* pH-7.0 Leuks-TR
___ 08:04PM URINE Color-Straw Appear-Clear Sp ___
___ 08:04PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 08:04PM URINE RBC-2 WBC-<1 Bacteri-FEW Yeast-NONE Epi-0
___ 08:04PM URINE Hours-RANDOM UreaN-176 Creat-26 Na-52
K-32 Cl-76
___ 08:04PM URINE Osmolal-240
___ 12:10AM URINE Color-Yellow Appear-Clear Sp ___
___ 12:10AM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-6.5 Leuks-TR
___ 12:10AM URINE Eos-POSITIVE
___ 12:10AM URINE Hours-RANDOM UreaN-518 Creat-53 Na-39
K-45 Cl-41
.
DISCHARGE LABS:
___ 06:05AM BLOOD WBC-5.3 RBC-3.41* Hgb-11.2* Hct-33.4*
MCV-98 MCH-33.0* MCHC-33.6 RDW-12.0 Plt ___
___ 12:50PM BLOOD ___
___ 12:50PM BLOOD Glucose-87 UreaN-29* Creat-1.7* Na-136
K-4.8 Cl-98 HCO3-27 AnGap-16
___ 06:05AM BLOOD Calcium-8.3* Phos-3.6 Mg-2.3
.
MICRO:
BLOOD CULTURE ___: NEGATIVE
URINE CULTURE ___: NEGATIVE
.
REPORTS:
CXR ___:
FINDINGS: There is mild enlargement of the heart, stable
compared to multiple prior exams dating back to at least
___. The hilar and mediastinal contours are
stable. There has been interval improvement of the right lower
lobe opacity compared to the prior exam. There is a small right
pleural effusion. No new consolidations are seen. There is no
pneumothorax.
IMPRESSION:
Interval improvement of the right lower lobe pneumonia.
.
EKG ___:
Sinus bradycardia. P-R interval prolongation. Consider left
atrial
abnormality. Left axis deviation. Intraventricular conduction
delay. Since
the previous tracing the rate is slower. The QRS complex width
is narrower. Q-T interval more prolonged. Premature ventricular
beat is new. Clinical correlation is suggested.
.
CATH ___:
COMMENTS:
1. Selective coronary angiography of this right-dominant system
demonstrated severe 3 vessel CAD. The LMCA was normal. The LAD
was
totally occluded at the ostium. The distal LAD filled via
right-to-left
collaterals. The LCX had 30% ostial stenosis in a large
bifurcating OM1.
There was 80% ostial stenosis in a small (approx 2mm diameter)
lower
pole branch. The proximal RCA was totally occluded. The distal
RCA
filled via left-to-right collaterals.
2. Limited resting hemodynamics revealed elevated systemic
arterial
pressures with a measured central aortic pressure of 144/72/99.
3. Left ventriculography was deferred.
4. Successful RCFA arteriotomy closure with an Angioseal closure
device.
FINAL DIAGNOSIS:
1. Three vessel CAD.
2. Stable CAD compared with prior catheterization in ___.
3. Elevated systemic arterial pressure.
4. Successful RCFA arteriotomy closure with Angioseal device.
.
___ ___:
IMPRESSION: No evidence of DVT in the right or left leg.
.
TTE ___:
There is severe regional left ventricular systolic dysfunction
with akinesis of the anterior wall, septum and apex (proximal
LAD distribution). The remaining segments contract normally
(LVEF = ___. Right ventricular chamber size and free wall
motion are normal. There is no aortic valve stenosis. No aortic
regurgitation is seen. Moderate (2+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] There is no
pericardial effusion.
IMPRESSION: Severe regional left ventricular systolic
dysfunction, c/w prior LAD infarction. Moderate mitral
regurgitation.
.
EKG ___:
Sinus bradycardia. First degree A-V block. Left bundle-branch
block.
Compared to the previous tracing of ___ the left
bundle-branch block is now new.
.
CXR PA/LATERAL ___:
Left transvenous pacemaker leads terminate in standard position,
in the right atrium and right ventricle. There is no evident
pneumothorax. If any, there is a small left effusion. There is
mild cardiomegaly. Compared to ___, mild interstitial
edema has almost completely resolved.
.
EKG ___:
Sinus rhythm. A-V conduction delay. Intraventricular conduction
delay.
Compared to the previous tracing of ___ sinus rhythm has
appeared.
.
Brief Hospital Course:
Mr. ___ is a ___ man with a h/o remote anterior
wall MI with reduced LV function for many years (EF ~30%), who
presented with an episode of sustained VT leading to PEA arrest.
He was stabilized prior to transfer from ___ and arrived on
amiodarone drip for further evaluation.
.
# Sustained VT followed by PEA arrests:
This was thought to be ___ scar from old MI's. CE elevation (TnT
peak 2.05, CKMB peak 80) was thought to be most likely ___ chest
compressions in the field. Heparin was started given ddx
including ACS (small STE in V1-3 and elevated TnT as above). Pt
was also loaded with plavix. Catheterization showed no new
blockages and ECHO showed old LV dysfunction. PE was also
considered as a possibility as an etiology but was thought to be
less likely. Patient had no evidence of DVT on ___ imaging.
Heparin gtt and plavix were discontinued after cardiac cath
showed no evidence of new ischemic disease to account for PEA
arrest. An ICD was placed on ___. Pt was transitioned to PO
amiodarone.
.
#CAD/CHF: As above, there was no evidence of new ischemia. Pt's
statin was changed to atorvastatin 40 mg in setting of
amiodarone use. Aspirin and carvedilol were coNtinued. Nitro
patch was held on arrival. Pt was also started on captopril for
CHF. Echo showed: severe regional left ventricular systolic
dysfunction with akinesis of the anterior wall, septum and apex
(c/w prior LAD infarction). LVEF = ___ with moderate MR. ___
was started on spironolactone 12.5 daily. Lasix should be every
other day instead of daily before admission for worsened renal
failure. Weight at discharge is 142 pounds.
.
# PNA: On ___, pt was noted to be febrile to 100.8 with some
evidence of confusion/delirium. There were no focal neurological
deficits, blood and urine CX were sent but there was no evidence
of UTI on UA. Pt received olanzapine 5 mg SL x 1 for delerium.
CXR was concerning for pulmonary edema with hypoxemia and pt was
diuresed with Lasix IV. Given some concern for possible
aspiration PNA, Levofloxacin was started for a 7d course to
treat aspiration PNA (___).
.
# Atrial Fibrillation: Pt was noted to have one brief episode of
atrial fibrillation but reverted spontaneously to sinus rhythm.
This was thought to be in the setting of electrolyte abnormality
(hypokalemia) and did not recur. He was started on
anticoagulation with warfarin.
.
# Acute Kidney injury: Cr was elevated during admission, this
was thought to be ___. FeNA (<1%) was suggestive of pre-renal
process but FeUN (55) suggested intra renal process (and pt was
on diuretics at the time). There were trace leukocytes and rare
eosinophils on UA. Cr peaked at 1.8. Day of discharge is 1.7.
.
# Hyponatremia: Pt was noted to be hyponatremic with Na of 129
during the hospitalization. This was thought to be ___ CHF and
pt was diuresed with lasix IV, with improvement in Na.
.
# HYPERLIPIDEMIA: Switched simvastatin to atorvastatin 40mg in
the setting of amiodarone use.
.
#ESOPHAGEAL REFLUX: Continued Omeprazole 40 mg daily
.
# BPH with urinary rention: foley placed on admission with
failed voiding trial in CCU with 1L of urine noted in bladder.
Foley was replaced and repeat voiding trial approx 3d later
again failed. Talked with urology who reported pt needs to
maintain foley at least 7d after retaining 1L of urine. Foley
replaced ___ and should be kept in 7d.
.
TRANSITIONAL ISSUES:
CODE STATUS: Full
EMERGENCY CONTACT: ___ (wife)
- Please note, on amiodarone, pt will need yearly TFT and CXR
- Please continue Amiodarone PO 400 TID x 3d (___), 200
TID (___) and then transition to amiodarone 200mg po qd
until follow-up with cardiology
# FOLLOW-UP with PCP/cardiologist (not made)
# Follow up in device clinic for ICD (made)
# Follow-up with OP urologist approx ___ for voiding trial,
this appt has not been made due to holiday weekend.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carvedilol 3.125 mg PO BID
2. FoLIC Acid 1 mg PO DAILY
3. Omeprazole 40 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Nitroglycerin SL 0.4 mg SL PRN chest discomfort
6. Lorazepam 0.5 mg PO HS:PRN insomina or anxiety
7. Fish Oil (Omega 3) 1000 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Nitroglycerin Patch 0.1 mg/hr TD Q24H
10. Furosemide 20 mg PO DAILY
11. Simvastatin 80 mg PO DAILY
12. Vitamin D 400 UNIT PO DAILY
13. Tamsulosin 0.4 mg PO HS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Carvedilol 3.125 mg PO BID
3. Fish Oil (Omega 3) 1000 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Lorazepam 0.5 mg PO HS:PRN insomina or anxiety
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 40 mg PO DAILY
8. Tamsulosin 0.4 mg PO HS
9. Vitamin D 400 UNIT PO DAILY
10. Amiodarone 200 mg PO TID Duration: 2 Weeks
last day ___, then decrease to 200 mg daily
11. Atorvastatin 40 mg PO DAILY
12. Warfarin 3.5 mg PO DAILY
13. Nitroglycerin SL 0.4 mg SL PRN chest discomfort
14. Benzonatate 100 mg PO TID:PRN cough
15. Docusate Sodium 100 mg PO BID
16. Nystatin Cream 1 Appl TP BID ___ anal area
17. Polyethylene Glycol 17 g PO DAILY:PRN constipation
18. Spironolactone 12.5 mg PO DAILY
19. Furosemide 20 mg PO EVERY OTHER DAY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Ventricular tachycardia
PEA arrest
Transient Atrial fibrillation
Acute on Chronic Kidney Injury
Aspiration pneumonia
Acute on chronic systolic heart failure
Urinary retention
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you at ___.
You had an episode of a dangerous heart rhythm called
ventricular tachycardia which then led to a cardiac arrest. You
developed a small pneumonia during this arrest. An internal
cardiac defibrillator was placed which will shock your heart out
of this rhythm in the future. Call ___ if your ICD fires and you
feel sick. A cardiac catheterization was done which did not
show any change in the blockages in your heart arteries. You
also had some fluid buildup in your lungs that was treated with
diuretic medicines. Your kidneys were worse after the
cathterization but are improving now.
When the foley catheter was removed, you were unable to urinate.
The foley was replaced and you will need to keep it in until
___. Dr. ___ office is making an appt with a urologist for
you to see around that time.
Followup Instructions:
___
|
10189149-DS-15 | 10,189,149 | 24,478,128 | DS | 15 | 2159-05-20 00:00:00 | 2159-05-23 15:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Ace Inhibitors
Attending: ___.
Chief Complaint:
abdominal pain/ constipation, type A aortic dissection found on
OSH CT scan
Major Surgical or Invasive Procedure:
___:
Complete exclusion of pseudoaneurysm with a thoracic
endovascular stent graft. Right common femoral artery
exploration with patch
angioplasty.
History of Present Illness:
This patient is an ___ woman who has had intermittent
chest pain and back pain and constipation and was evaluated at
an OSH. She had a CT scan that demonstrated a type A aortic
dissection, with the origin of dissection just
distal to the left subclavian artery, with proximal and distal
extension of her dissection. There was noted to be a contained
rupture reported as a pseudoaneurysm just distal to the
subclavian artery that was concerning for contained rupture. In
the setting of her chest pain and apparent blood
in the chest, it was determined that she needed an emergent
thoracic endograft repair.
Past Medical History:
Palpitations, ? history of depression, Back pain, Hypertension,
Hyperlipidemia, Dyspepsia, Fasting glucose intolerance
PSH:
appendectomy
Social History:
___
Family History:
Denies family history of diabetes mellitus, vascular disease,
and specifically no family history of aortic disease.
Physical Exam:
Gen: WDWN, ___ speaking woman in NAD. Alert and
oriented x3
Card: RRR
Lungs: CTA bilat
Abd: Soft no m/t/o
Wound: Groin puncture sites c/d/i
Extremities: Warm, no edema
Pulses: Fem Pop Dp Pt
R p p d d
L p p p p
Pertinent Results:
___ 07:00AM BLOOD WBC-12.0* RBC-4.01* Hgb-10.7* Hct-31.9*
MCV-80* MCH-26.6* MCHC-33.4 RDW-12.5 Plt ___
___ 07:00AM BLOOD Glucose-111* UreaN-17 Creat-0.9 Na-135
K-3.8 Cl-96 HCO3-26 AnGap-17
___ 07:20AM BLOOD Glucose-113* UreaN-14 Creat-0.8 Na-134
K-3.9 Cl-96 HCO3-27 AnGap-15
___ 09:30AM BLOOD Glucose-117* UreaN-17 Creat-0.7 Na-136
K-3.5 Cl-99 HCO3-24 AnGap-17
___ 02:07AM BLOOD ALT-9 AST-19 AlkPhos-45 TotBili-0.2
___ 10:10AM BLOOD ALT-8 AST-17 AlkPhos-53
___ 10:10AM BLOOD CK-MB-2 cTropnT-<0.01
___ 04:59AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD ___ PTT-32.3 ___
___ 07:20AM BLOOD Plt ___
___ 07:20AM BLOOD ___ PTT-33.9 ___
___ 01:05PM BLOOD ___
___ 09:30AM BLOOD Plt ___
___ 09:30AM BLOOD ___ PTT-54.8* ___
___ 12:00AM BLOOD PTT-108.9*
___ 10:16AM BLOOD PTT-63.5*
___ 04:23AM BLOOD ___ PTT-39.0* ___
___ 01:00AM BLOOD PTT-53.9*
___ 01:47AM BLOOD ___ PTT-57.6* ___
___ 07:10PM BLOOD ___ PTT-28.1 ___
___ 02:09PM BLOOD ___ PTT-45.2* ___
___ 02:07AM BLOOD ___ PTT-28.3 ___
___ 01:54PM BLOOD ___ PTT-32.9 ___
___ 10:10AM BLOOD ___ PTT-150* ___
___ 04:59AM BLOOD ___ PTT-28.7 ___
___ CTA Aorta Bifem-iliac:
1. Right popliteal artery occluded with reconstitution below
knee.Findings may represent embolus as the vessels otherwise
appear without significant
thrombus.
2. Bilateral anterior tibials, posterior tibials and peroneals
traced to the level of the midcalf where they taper off, likely
due to slow perfusion.
3. Calcification in right adnexa
4. Ascites.
___ CTA chest w/ & w/out recon:
Type A aortic dissection with 3 cm pseudoaneurysm arising from
the distal aortic arch. Small left sided pleural effusion.
___ Echo:
The left atrium is normal in size, w/ moderate symmetric left
ventricular hypertrophy. LV function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
descending thoracic aorta is mildly dilated. No thoracic aortic
dissection is seen, however, an aortic dissection cannot be
excluded based on this study. Concern for descending aortic wall
hematoma. There are three aortic valve leaflets. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. There is a
trivial/physiologic pericardial effusion.
Brief Hospital Course:
Mrs. ___ was taken emergently to the hybrid OR and underwent:
1. Bilateral ultrasound-guided access to common femoral
arteries.
2. Catheterization of aortic arch.
3. Arteriogram of the aortic arch and branch vessels.
4. Complete exclusion of pseudoaneurysm with a thoracic
endovascular stent graft.
5. Bilateral femoral arteriotomy closures with Perclose
devices.
6. Right common femoral artery exploration with patch
angioplasty.
She tolerated the procedure well, was extubated and taken to the
CVICU. She was placed on esmolol and nitro drips to help with BP
control with SBP goals 90-140. Her pain was well controlled and
she was neurovascularly intact with palpable distal pulses,
making steady progress. She was weaned off the gtts. On ___ she
was transfered to the VICU, where it was noted that her right
foot became cool and the palpable pulse was lost, with only a
dopplerable signal. She had a CTA which showed right popliteal
artery occluded with reconstitution below knee. She was started
on a therapeutic heparin gtt and her foot became warmer. On ___
cardiology was consulted to help with BP management. They
recommened stopping metoprolol and hctz and starting atenolol
and chlorthiadone, and diuresing with lasix 20mg iv. The patient
responded well to these interventions. She was out of bed to
chair, and pain was controlled with oral meds. SHe was
tolerating a regular diet. She was started on coumadin for her
popliteal occlusion. On ___ her bp was still elevated slightly,
and her cozar was increased from 50mg to 100mg qd. She had a
good response to this adjustment. She ambulated with ___ and was
a bit unsteady. Her foley was removed and she voided without
difficulty. On ___ she again worked with ___ and was recommended
to go home with ___ services. Her INR was supratherapeutic at
4.4, and her heparin gtt was stopped and coumadin was held. She
was otherwise making good progress. She is discharged in stable
condition, on coumadin. F/U made with PCP to follow.
Medications on Admission:
losartan 50 mg daily, hydrochlorothiazide 12.5 mg daily,
pravastatin 40 mg QHS, omeprazole 20 mg daily, ibuprofen 600
mg TID PRN pain, acetaminophen 500 mg TID PRN pain,
oxycodone-acetaminophen 5 mg-325 mg x ___ tab QID PRN pain
triamcinolone acetonide 0.1 % topical BID PRN rash
methyl salicylate-menthol topical to shoulder BID
Discharge Medications:
1. atenolol-chlorthalidone 100-25 mg Tablet Sig: One (1) Tablet
PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. losartan 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day): while on pain meds.
7. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain.
8. Outpatient Lab Work
INR check twice per week and as needed,
Results to PCP
___
Location: ___
Address: ___
Phone: ___
Fax: ___
PCP ___ see pt on ___ and draw first INR
9. warfarin 3 mg Tablet Sig: One (1) Tablet PO daily at 4PM.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Type A aortic dissection with a contained rupture just distal
to the subclavian artery.
2. Right popliteal artery occluded with reconstitution below
knee
3. Hypertension
4. Hyperlipidemia
5. GERD
6. Chronic low back pain
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:
Division of Vascular and Endovascular Surgery
Endovascular Aortic Aneurysm Repair
Discharge Instructions
You were admitted with an aortic dissection and underwent
emergent endovascular repair. Post operatively you were found
to have a blood clot in the popliteal artery in your leg.
Because of this, you were started on blood thinners. You are
being discharged on two blood thinners, lovenox (an injection
twice daily) and coumadin (a pill once daily). You will have a
blood test at least once a week to check your INR , this number
will tell your doctor, how thin your blood is. Once your INR is
greater than 2.0, you can stop the lovenox injection and
continue with coumadin only.
Medications:
Take Aspirin once daily. Take yoru lovenox and coumadin as
instructed. Your PCP ___ be following your INR (blood test) and
will instruct you on the approprite dosage of coumadin.
Do not stop Aspirin or Coumadin unless your Vascular Surgeon
instructs you to do so.
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart (use ___
pillows or a recliner) every ___ hours throughout the day and at
night
Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
Drink plenty of fluids and eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
When you go home, you may walk and go up and down stairs
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
After 1 week, you may resume sexual activity
After 1 week, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking pain medications
Call and schedule an appointment to be seen in ___ weeks for
post procedure check and CTA
What to report to office:
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call ___ for
transfer to closest Emergency Room.
Followup Instructions:
___
|
10189149-DS-16 | 10,189,149 | 28,231,983 | DS | 16 | 2159-11-22 00:00:00 | 2159-11-24 17:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ with a history of Type A aortic dissection
status post surgical repair ___ who presents with one week
of sporadic chest pain, mildy worse today.
.
patient states that since ___ of this year she has had mild
sharp sub sternal and right shoulder pain that is intermittent,
lasts for a few seconds and resolves. The patient has not
noticed any worsening in these symptoms since ___, but did
report at her presurgical eval for carpal tunnel surgery today
that the episodes were slightly longer. These symptoms are not
associated with ambulation. Denies dizziness, lightheadedness,
diaphoreis, nausea or vomiting and do not require analgesics.
Patient was sent from clinic to the ED for further evaluation.
.
In the ED, initial vitals were 97.2 43 145/65 16 100%. Initial
Troponin was negative. EKG: sinus 53, LAD, QTC480, LVH, no ST
change from prior. A CTA chest showed no acute findings and
stability of her graft. She was admitted after EKG showed
asymptomatic sinus bradycardia.
.
Vitals on transfer were 97.1, 44, 14, 131/72, 100% RA. patient
not complaining of any chest pain.
.
REVIEW OF SYSTEMS:
On review of systems, she 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. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
.
Past Medical History:
- Type A aortic dissection arising from the distal aortic arch
(just distal to the subclavian artery) with 3 cm pseudoaneurysm
(contained rupture) s/p complete exclusion of pseudoaneurysm
with a thoracic endovascular stent graft ___.
- Right popliteal artery embolism ___ (complication of
aortic dissection repair).
- Hypertension
- hyperlipidemia
- GERD
- chronic back pain
- DVT? (listed in some places)
- S/p appendectomy
- Glucose intolerance
Social History:
___
Family History:
The patient reports that she had 5 or so children that have
heart issues. One son died at the age of ___ from a heart
problem. Her other children also had heart issues and died.
She is uncertain of the etiology. She states that they did not
receive extensive medical care in ___ and when they came
to the ___ it was too late to help their condition.
Physical Exam:
PHYSICAL EXAMINATION on Admission:
VS: T97.7 , BP 132/68, HR 52, RR 20, SpO2 100
GENERAL: NAD. Oriented x3. Mood, affect appropriate. Portugese
only speaking.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with JVP of 7 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, 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.
NEURO: CN II-XII tested and intact, strength ___ throughout,
sensation grossly normal. Gait not tested.
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
PHYSICAL EXAMINATION:
VS: 97.2 118/66 49 18 100 RA
i/o: NR,
62.1 -> 61.7kg
GENERAL: NAD. Oriented x3. Mood, affect appropriate. Portugese
only speaking.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with JVP of 7 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, 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.
NEURO: CN II-XII tested and intact, strength ___ throughout,
sensation grossly normal. Gait not tested.
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
.
Pertinent Results:
Labs on Admission:
___ 11:00AM BLOOD WBC-7.6 RBC-5.10 Hgb-12.8 Hct-40.5
MCV-79* MCH-25.1* MCHC-31.7 RDW-14.3 Plt ___
___ 11:00AM BLOOD ___
___ 11:00AM BLOOD Glucose-79 UreaN-19 Creat-1.0 Na-138
K-3.5 Cl-99 HCO3-27 AnGap-16
___ 05:11PM BLOOD CK(CPK)-144
___ 11:00AM BLOOD cTropnT-<0.01
___ 05:11PM BLOOD CK-MB-2 cTropnT-<0.01
___ 01:15PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 01:15PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-<1
Labs on DC:
___ 08:50AM BLOOD WBC-6.8 RBC-4.97 Hgb-12.7 Hct-39.2
MCV-79* MCH-25.5* MCHC-32.3 RDW-14.4 Plt ___
___ 08:50AM BLOOD ___
___ 08:50AM BLOOD Glucose-124* UreaN-19 Creat-1.1 Na-137
K-4.4 Cl-100 HCO3-28 AnGap-13
ECG ___:
Sinus bradycardia. Left atrial abnormality. Occasional
ventricular ectopy.
Voltage for left ventricular hypertrophy. Q-T interval
prolongation. Compared to the previous tracing of ___ the
rate has slowed. There is occasional ventricular ectopy.
Otherwise, no diagnostic interim change.
IntervalsAxes
___
___
CXR: ___
No acute cardiopulmonary process.
CTA ___ Interval dilation of the descending thoracic aorta involving
the segment
covered by the stent, now up to 4.3 cm. Recommend vascular
surgical consult.
2) No pulmonary embolism.
Brief Hospital Course:
Ms. ___ is an ___ with a history of Type A aortic dissection
status post surgical repair ___ who presents with sinus
bradycardia and stable chest pain.
Active Diagnoses:
# Non-ischemic Non-cardiac Stable Chest Pain: Pt with
intermittent, non-exertional chest pain and euvolemia in the
setting of a stable aortic dissection on CTA is unlikely to be
ischemic or vascular in origin. Prior ECHO in ___ was normal.
Given her aortic dissection and need to maintain lo BPs, cannot
stress test. Also, ight BP control with Chlorthalidone and
Losartan. D/Ced the BB given bradycardia and risk for AV block.
Symptomatic treatment with Tylenol was recommended.
.
# Sinus Bradycardia: Patient presented bradycardic with chest
pain. EKG with long QT but no heart block. No evidence of
heart block on EKG. BB was ___. BP control with
chlorthalidone and Losartan alone. ___ QT prolonging drugs.
.
# HYPERTENSION: Patient hypertensive to the 170s upon arrival
to the floor. We continued chlorthalidone and losartan for bp
control. (BB was ___. Pt did not require Nitro drip.
Chronic Diagnoses:
# Stable Type A Aortic Dissection: stable on CTA chest, not
likely to be causing patient's chest pain. No evidence of
asymmetric pulses or systolic pressures in the arms.
.
# GERD: Stable, Continued omeprazole 20 mg daily.
Transitional Issues:
-Non ___ speaking, from ___ remain off BB if continues to be bradycardic.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from webOMR.
1. Acetaminophen 500 mg PO TID:PRN pain
2. Losartan Potassium 100 mg PO DAILY
hold for SBP < 100
3. atenolol-chlorthalidone *NF* 100-25 mg Oral daily
4. Docusate Sodium 100 mg PO TID
while on pain medication
5. Warfarin 4.5 mg PO DAYS (___)
6. Warfarin 3 mg PO DAYS (___)
7. Pravastatin 40 mg PO HS
8. Acetaminophen w/Codeine ___ TAB PO TID:PRN pain/cough
9. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO TID:PRN pain
2. Docusate Sodium 100 mg PO TID
while on pain medication
3. Losartan Potassium 100 mg PO DAILY
hold for SBP < 100
4. Omeprazole 20 mg PO DAILY
5. Pravastatin 40 mg PO HS
6. Warfarin 4.5 mg PO DAYS (___)
7. Warfarin 3 mg PO DAYS (___)
8. Chlorthalidone 25 mg PO DAILY
Hold for sbp<100
RX *chlorthalidone 25 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
9. Acetaminophen w/Codeine ___ TAB PO TID:PRN pain/cough
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
-non-ischemic non-cardiac chest pain
-stable type A aortic disection
-sinus brady cardia
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 while you were in the
hospital. You were admitted for evaluation of your chest pain
which was concerning given your history of an aortic dissection.
You had a repeat CTA scan of your chest which was unchanged
from the prior. It was felt that your chest pain was not
related to your heart which is very good news. You were also
noted to have a slow heart rate, which did not seem to be
causing you any symptoms. You will need to call your surgeons
to determine when your carpal tunnel surgery can go forward.
Followup Instructions:
___
|
10189149-DS-18 | 10,189,149 | 20,717,975 | DS | 18 | 2166-02-05 00:00:00 | 2166-02-06 16:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Ace Inhibitors
Attending: ___
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ ___ - ___ speaking woman
with Alzheimer's disease, hypertension, diastolic heart failure,
type A aortic dissection s/p repair now on daily aspirin 81 mg
who presented with 1 week of fatigue and confusion with vomiting
since last night. She is currently being treated for a UTI
diagnosed by her PCP ___ ___.
Last night she developed nausea and vomiting so her family
brought her in for evaluation given ongoing confusion.
Head CT was obtained in evaluation of altered mental status and
she was found to have a right temporal intraparenchymal
hemorrhage. Neurology was consulted for recommendations
regarding
management.
ROS: On neurologic review of systems, the patient denies
headache, lightheadedness. Family reports confusion. Denies
difficulty with producing or comprehending speech but sometimes
is repetitive with her answers and questions. Denies loss of
vision, blurred vision, diplopia, vertigo, tinnitus, hearing
difficulty, dysarthria, or dysphagia. Denies focal muscle
weakness, numbness, parasthesia. Denies loss of sensation.
Denies
bowel or bladder incontinence or retention. Baseline difficulty
with gait.
On general review of systems, the patient denies fevers, rigors,
night sweats, or noticeable weight loss. Denies chest pain,
palpitations, dyspnea, or cough. She has had nausea and
vomiting.
No diarrhea, constipation, but does have abdominal pain. No
recent change in bowel or bladder habits. Unknown if she has had
dysuria. Denies myalgias, arthralgias, or rash
Past Medical History:
- Type A aortic dissection arising from the distal aortic arch
(just distal to the subclavian artery) with 3 cm pseudoaneurysm
(contained rupture) s/p complete exclusion of pseudoaneurysm
with a thoracic endovascular stent graft ___.
- Right popliteal artery embolism ___ (complication of
aortic dissection repair).
- Hypertension
- hyperlipidemia
- GERD
- chronic back pain
- DVT? (listed in some places)
- S/p appendectomy
- Glucose intolerance
Social History:
___
Family History:
The patient reports that she had 5 or so children that have
heart issues. One son died at the age of ___ from a heart
problem. Her other children also had heart issues and died.
She is uncertain of the etiology. She states that they did not
receive extensive medical care in ___ and when they came
to the ___ it was too late to help their condition.
Physical Exam:
Admission
General: NAD
HEENT: NCAT, neck supple
___: warm, well perfused
Pulmonary: CTAB, no distress
Abdomen: Soft, mildly tender, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: opens eyes to voice, speaks ___, oriented to Person, place but not month or year, able to
name ___ backwards from ___ to ___ but then stops. Per
family speech is somewhat slow. Able to follow some simple
midline and appendicular commands with prompting and
demonstration.
- Cranial Nerves: PRRL left 3->2, R 2.5->2 and brisk.
Inconsistent VF testing given inattention but seems to be full
to
number counting. EOMI, no nystagmus. V1-V3 without deficits to
light touch bilaterally. No facial movement asymmetry. Hearing
intact to finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No drift. No tremor or
asterixis.
[Delt][Bic][Tri][ECR][FEx][IO][IP][Quad][Ham][TA][Gas]
L 5- 5 5- 5- 4+ 5- 5 5 5 5 5
R 5- 5 5- 5- 4+ 5- 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 3+ 1
R 2+ 2+ 2+ 3+ 1
Plantar response flexor bilaterally
- Sensory: No deficits to light touch. No extinction to DSS.
- Coordination: No dysmetria with finger to nose testing
bilaterally.
- Gait: Did not assess
==============
DISCHARGE
Vitals: afebrile BP 100s/70s HR60s-70s
General: NAD, very thin, ___ appearing but appropriate for
age
HEENT: NCAT, neck supple
___: warm, well perfused
Pulmonary: CTAB, no distress
Abdomen: Soft, mildly tender, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: opens eyes to voice, speaks ___, oriented to Person, place but not month or year. Some
paraphasic errors with naming (hand instead of glove). Able to
follow some simple midline and appendicular commands with
prompting and demonstration, but difficulty with most
confrontational testing.
- Cranial Nerves: PRRL left 3->2, R 2.5->2 and brisk.
Inconsistent VF testing given inattention but seems to be full
to
number counting. EOMI, no nystagmus. V1-V3 without deficits to
light touch bilaterally. No facial movement asymmetry. Hearing
intact to finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No drift. No tremor or
asterixis.
All four extremities are antigravity. Difficultly with
confrontational testing
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 3+ 1
R 2+ 2+ 2+ 3+ 1
Plantar response flexor bilaterally
- Sensory: No deficits to light touch. No extinction to DSS.
- Coordination: No dysmetria with finger to nose testing
bilaterally.
- Gait: Did not assess
Pertinent Results:
___ 02:21PM BLOOD WBC-8.6 RBC-5.33* Hgb-12.8 Hct-41.7
MCV-78* MCH-24.0* MCHC-30.7* RDW-17.5* RDWSD-48.8* Plt ___
___ 06:20AM BLOOD WBC-9.5 RBC-5.15 Hgb-12.5 Hct-40.4
MCV-78* MCH-24.3* MCHC-30.9* RDW-17.5* RDWSD-48.4* Plt ___
___ 09:55PM BLOOD ___ PTT-28.1 ___
___ 06:20AM BLOOD ___ PTT-27.5 ___
___ 02:21PM BLOOD Glucose-124* UreaN-12 Creat-0.9 Na-137
K-3.8 Cl-96 HCO3-27 AnGap-14
___ 06:20AM BLOOD Glucose-118* UreaN-15 Creat-0.7 Na-139
K-3.6 Cl-99 HCO3-23 AnGap-17
___ 06:34AM BLOOD ALT-9 AST-25 LD(LDH)-292* AlkPhos-69
TotBili-1.0
___ 02:21PM BLOOD Calcium-9.7 Phos-3.3 Mg-1.9
___ 06:20AM BLOOD Albumin-4.2 Calcium-9.3 Phos-2.4* Mg-1.8
IMAGING:
CTA ___:
FINDINGS:
CT HEAD WITHOUT CONTRAST: 4.8 cm x 3.4 cm right temporal lobe
intraparenchymal hematoma is similar to prior, mild surrounding
edema. Probable small volume adjacent subarachnoid hemorrhage.
Small chronic infarcts cerebellum. Midline low-attenuation
change at these cerebellar vermis, mass be sequela of prior
infarcts. Chronic infarcts left parietal, left temporal, left
occipital, and probably right parietal lobes. Findings
consistent with moderate to severe chronic small vessel ischemic
changes. Intraventricular hemorrhage, no hydrocephalus. Chronic
lacunar infarcts basal ganglia. No midline shift. No herniation.
Brain parenchymal atrophy. The visualized portion of the
paranasal sinuses, mastoid air cells,and middle ear cavities are
clear. The visualized portion of the orbits are unremarkable.
CTA HEAD: No abnormal vascularity surrounding hematoma.
Asymmetric filling left cavernous sinus, there is also
asymmetric enhancement of the left cavernous sinus on the MRA
brain, cavernous carotid fistula could have this appearance,
correlate for clinical symptoms and left orbital findings if
present. Probable 1.5 mm aneurysm right paraclinoid ICA. 2 mm
laterally projected aneurysm versus infundibulum cavernous
segment ICA.. 2 infundibula posteriorly projecting right
supraclinoid ICA.. Tiny infundibulum, posteriorly projecting,
left supraclinoid ICA The vessels of the circle of ___ and
their principal intracranial branches appear normal without
stenosis, occlusion, or aneurysm formation. There is duplication
of the right M1 segment. The dural venous sinuses are patent.
CTA NECK: There is beading of the bilateral distal cervical
internal carotid arteries, consistent with fibromuscular
dysplasia, with 1 mm medially projected pseudoaneurysm high
cervical right ICA. Findings consistent with fibromuscular
dysplasia V2, V3 segment right vertebral artery, with areas of
ectasia, including 1 mm broad-based V2 segment pseudoaneurysm.
Otherwise, the carotidandvertebral arteries and their major
branches appear normal with no evidence of stenosis or
occlusion. There is no evidence of internal carotid stenosis by
NASCET criteria. The visualized aortic arch aneurysmal with a
partially visualized aortic stent. A larger volume of
extraluminal contrast anterior to the aortic stent is concerning
for a worsening endoleak. Postsurgical change versus 6 mm
superiorly directed aneurysm aortic arch next to the left
subclavian artery origin.
OTHER: The visualized portion of the lungs are clear. Multiple
low-attenuation lesions, with the largest measuring 1 cm, are
seen in both thyroid lobes, unchanged. Prominent, subcentimeter
mediastinal lymph nodes are seen.
IMPRESSION: 1. 4.8 cm right temporal lobe intraparenchymal
hematoma. No evidence of mass, increased vascularity or enlarged
veins. 2. Intraventricular hemorrhage. Probable small volume
subarachnoid hemorrhage. 3. Proximal descending aortic stent in
place, with findings consistent with worsening endoleak. 4. Mild
left pleural effusion, potential complexity of the pleural
effusion cannot be assessed given adjacent stent. CT chest
without contrast recommended. 5. Postsurgical change versus 6 mm
aneurysm adjacent to subclavian artery origin, stable.. 6.
Bilateral high cervical ICA fibromuscular dysplasia. 1.2 mm
pseudoaneurysm right high cervical ICA. Fibromuscular dysplasia
right cervical vertebral artery, with tiny pseudoaneurysm. 7.
Probable 1.5 mm aneurysm right paraclinoid ICA.. Aneurysm versus
infundibulum lateral wall right cavernous ICA. 8. Possible left
cavernous carotid fistula, correlate with ocular symptoms. 9. No
significant stenosis CTA neck, head.
MRI ___
1. 5 cm right temporal lobe subacute parenchymal hematoma,
similar. No evidence of mass or vascular malformation.
2. Stable small volume intraventricular hemorrhage, no
hydrocephalus.
3. Probable subarachnoid hemorrhage.
4. Possible mild leptomeningeal or surface enhancement at the
cerebellum, post gadolinium images are motion degraded,
follow-up
brain MRI without contrast recommended to document resolution.
5. Extensive chronic infarcts, as above.
6. 2 mm infundibulum versus aneurysm lateral wall cavernous
segment right ICA.
7. Findings consistent with high cervical ICA bilateral
fibromuscular dysplasia.
Brief Hospital Course:
Ms. ___ is an ___ woman with Alzheimer's disease,
hypertension, diastolic heart failure, type A aortic dissection
s/p endovascular stent graft c/b popliteal artery occlusion,
lumbar spinal stenosis and osteoarthritis presenting with one
week of altered mental status and found to have a right lobar
intraparenchymal hemorrhage.
#Right temporoparietal IPH
Patient presented with one week of altered mental status and was
found to have right lobar intraparenchymal hemorrhage. Given
history of Alzheimer's, there was concern for amyloid angiopathy
though MRI did not show any evidence of microbleeds. Suspect
hypertensive bleed given SBP 190s on admission to ED. CT also
with chronic microvascular angiopathy and encephalomalacia in
the
left parietal and occipital lobes. Continued on home
antihypertensives for goal SBP<150. Hold ASA, NSAIDs, other
anti-platelet agents
-Her statin was also held and should not be re-started until 3
months post bleed.
#Alzheimer's Dementia
Physical examination notable for waxing and waning mental
status. She was continued on donepezil 5mg daily and gabapentin
100mg qHS. She was also given quietapine 6.25mg PRN for
agitation. She was given a one time dose of 12.5mg Seroquel
which caused too much sedation.
#Lumbar stenosis
Physical examination notable for lower extremity hyperreflexia
likely secondary to severe lumbar spinal stenosis. Concern for
deconditioning secondary to pain, age and generalized weakness
on
exam. Will need rehabilitation for physical therapy.
#Hypertension
SBP 190s on admission briefly requiring nicarpine gtt. SBPs have
been 100s on home medications of carvedilol 25mg BID, furosemide
40mg daily and losartan 100mg daily. His furosemide was stopped
while she was refusing PO. Resume when patient is taking
adequate fluids.
#Type A Aortic dissection s/p endovascular repair
- Continue afterload reduction with carvedilol. Holding
pravastatin given her hemorrhage
#ID
UA dirty without leuks; urine culture ___
negative. Discontinued nitrofurantoin.
Transitional Issues:
-Patient to be discharged home with home services. ___
recommended rehab however family felt that patient would be
better at home
-Continue to monitor fluid intake to decide when to restart
furosemide
-SBP goal <150, continue to have PCP monitor
-___ with Neurology on ___ with Dr. ___ at 10:30
AM
-Holding pravastatin for 3 months post bleed
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AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No.
If no, reason why:
2. DVT Prophylaxis administered? () Yes - x() No. If no, why not
(bleeding risk, hemorrhage, etc.) -Hemorrhage
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
4. 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
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No. If no, why not? (I.e. patient at
baseline functional status)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Alendronate Sodium 70 mg PO TAKE 1 TABLET EVERY WEEK IN THE
MORNING ___ HOUR BEFORE FIRST MEAL
2. Carvedilol 25 mg PO BID
3. Donepezil 5 mg PO QHS
4. Furosemide 40 mg PO DAILY
5. Gabapentin 100 mg PO QHS
6. Losartan Potassium 100 mg PO DAILY
7. Nitrofurantoin (Macrodantin) 50 mg PO BID
8. Pravastatin 40 mg PO QPM
9. Omeprazole 20 mg PO DAILY
10. Betamethasone Dipro 0.05% Cream 1 Appl TP BID:PRN itching
Discharge Medications:
1. Alendronate Sodium 70 mg PO TAKE 1 TABLET EVERY WEEK IN THE
MORNING ___ HOUR BEFORE FIRST MEAL
2. Betamethasone Dipro 0.05% Cream 1 Appl TP BID:PRN itching
3. Carvedilol 25 mg PO BID
4. Donepezil 5 mg PO QHS
5. Gabapentin 100 mg PO QHS
6. Losartan Potassium 100 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. HELD- Furosemide 40 mg PO DAILY This medication was held. Do
not restart Furosemide until you are taking in enough liquid and
your PCP tells you it's okay
9. HELD- Pravastatin 40 mg PO QPM This medication was held. Do
not restart Pravastatin until 3-months post bleed
Discharge Disposition:
Home with Service
Facility:
___
Discharge Diagnosis:
Acute hemorrhagic stroke
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of confusion resulting
from an ACUTE HEMORRHAGIC STROKE, a condition where a blood
vessel bleeds into your 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.
Please take your other medications as prescribed. We have
stopped your cholesterol medication pravastatin as this can
increase your risk of bleeding for the next three months. We
will re-start this medication in 3-months when you come to see
us in the neurology clinic.
We have scheduled you for a neurology appointment with Dr.
___ on ___.
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:
___
|
10189377-DS-18 | 10,189,377 | 20,333,459 | DS | 18 | 2142-12-31 00:00:00 | 2143-01-02 19:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right sided rib pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr ___ is a ___ p/w R rib pain after walking into a metal
door. Two days ago he reports that he got trapped between a
heavy
door and the frame as it was closing. He had difficulty sleeping
that night due to the pain but the following morning he was able
to go about his normal daily activities. His pain increased in
the evening with lying down, and he was not able to find a
comfortable position. Pain is dull and worse with deep breath.
Currently having R flank pain. Denies fevers, chills, sweats,
chest pain, trouble breathing, cough, nausea, vomiting,
lightheadedness, dizziness. No LOC, remembers entire event. No
fall or recent increase in falls.
Past Medical History:
none
Social History:
___
Family History:
non-contributory
Physical Exam:
Physical Exam: upon admission
Vitals: 99.4 | 75 | 145/56 | 22 | 96% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: systolic murmur at LUSB, RRR
PULM: slightly reduced breath sounds on R lower thorax.
Grimacing
with movement and deep inspiration on the right middle/lower
chest wall. Minimally tender along R chest wall.
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
Physical examination upon discharge: ___:
vital signs: t=97.5, hr=63, bp=144/74, rr=16, 98% room air
GENERAL: NAD
CV: ns1, s2, + Grade ___ systolic murmur ___ ICS, LSB, RSB
LUNGS: BS clear left side, diminished BS right, no wheezes, no
crepitus bil
ABDOMEN: soft, non-tender
EXT: no calf tenderness, no pedal edema bil
NEURO: alert and oriented x 3, speech clear, no tremors
Pertinent Results:
___ 07:40PM BLOOD WBC-11.0* RBC-4.15* Hgb-12.8* Hct-38.5*
MCV-93 MCH-30.8 MCHC-33.2 RDW-12.5 RDWSD-42.7 Plt ___
___ 07:40PM BLOOD Neuts-69.3 Lymphs-11.8* Monos-15.5*
Eos-2.5 Baso-0.5 Im ___ AbsNeut-7.63* AbsLymp-1.30
AbsMono-1.70* AbsEos-0.27 AbsBaso-0.05
___ 07:40PM BLOOD Plt ___
___ 07:40PM BLOOD ___ PTT-27.9 ___
___ 07:40PM BLOOD Glucose-107* UreaN-18 Creat-0.9 Na-138
K-4.7 Cl-99 HCO3-23 AnGap-16
___ 07:40PM BLOOD ALT-11 AST-28 AlkPhos-71 TotBili-0.6
___ 07:40PM BLOOD Albumin-4.1
Chest x-ray: ___
1. There are mildly displaced fractures of the anterior lateral
right
seventh, eighth, and ninth ribs. Right ___ through 12th ribs
are not well evaluated on this exam given penetration of the
image.
2. Opacity at the right lung base is concerning for hemothorax
in the setting of trauma rather than simple effusion,
atelectasis, pneumonia, or mass. No definite pneumothorax is
identified, however right lung apex is obscured given patient
positioning. Dedicated chest radiograph is recommended for
further evaluation of a pneumothorax. Right lung base opacity
should be followed to resolution with subsequent radiographs.
RECOMMENDATION(S): Dedicated chest radiographs. Right lung base
opacity
should be followed to resolution with subsequent radiographs
___: CT chest:
1. Multiple acute right anterolateral rib fractures involving
ribs 5 through 9 with a segmental fracture of the right ___
anterolateral rib.
2. Trace right hemothorax. No pneumothorax, pulmonary
contusion, or pulmonary laceration.
3. Findings suggestive of Paget's disease of the right
hemipelvis.
4. Punctate pancreatic calcifications suggestive chronic
pancreatitis.
5. Severe lumbar spondylosis with high-grade central canal
narrowing at L4-5.
___: chest x-ray:
In comparison with the chest radiograph and CT scan dated ___, the
anterolateral rib fractures on the right are difficult to see.
Opacification at the right base is consistent with pleural fluid
and atelectatic changes at the right base. There is no evidence
of pneumothorax.
The left lung remains essentially clear.
Brief Hospital Course:
___ year old male admitted to the hospital with right sided rib
pain. The patient reportedly got trapped between a heavy door
and the frame as it was closing. ___ hours after the
injury, the patient reported right sided rib pain. Upon
admission the patient was made NPO, given intravenous fluids,
and underwent imaging. A CT of the chest was done which showed
multiple acute right anterolateral rib fractures involving ribs
5 through 9 with a segmental fracture of the right ___
anterolateral rib. In addition to these findings, a trace right
hemo-thorax was identified. There was no pneumothorax,
pulmonary contusion, or pulmonary
laceration. The patient did not require placement of a chest
tube for drainage of the hemo-thorax. The patient was admitted
to the hospital for pain management and pulmonary toilet.
During the patient's hospitalization, chest x-ray's were ordered
to evaluate the status of hemo-thorax. The patient's rib pain
was controlled with analgesia. He was instructed in the use of
the incentive spirometer. The patient was evaluated by physical
therapy and cleared for discharge home with ___ services for
pulmonary assessment.
The patient was discharged home on HD #1. His vital signs were
stable and he was afebrile. He was tolerating a regular diet
and voiding without difficulty. His chest x-ray showed
opacification at the right base consistent with pleural fluid
and atelectatic changes at the right base. The patient's oxygen
saturation was 98 % on room air. Discharge instructions were
reviewed with the patient and family member. A follow-up
appointment was made in the Acute care clinic with repeat
imaging.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO TID
RX *acetaminophen 325 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
3. Lidocaine 5% Patch 1 PTCH TD DAILY
RX *lidocaine 5 % 1 patch to right side rib cage once a day Disp
#*12 Patch Refills:*0
4. Senna 17.2 mg PO HS
5. TraMADol 25 mg PO Q6H:PRN Pain - Moderate
may cause dizziness
RX *tramadol [Ultram] 50 mg 0.5 (One half) tablet(s) by mouth
every six (6) hours Disp #*12 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right rib fractures ___ non-displaced
left small HTX
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - with cane/walker, ___ recommends
use of walker
Discharge Instructions:
You were admitted to the hospital with right sided rib pain.
You reportedly had fallen a few days prior to coming to the
hospital. You underwent imaging and you were reported to have
right sided ___ rib fractures. You were admitted to the
hospital for pain management for the rib fractures. Your rib
pain has been controlled with oral analgesia and you are
preparing for discharge 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.
*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.
As a result of the fall, you sustained rib fractures. The
following information may help with your recovery:
* Your injury caused right sided 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 twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non steroidal antiinflammatory drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ).
*
Followup Instructions:
___
|
10189377-DS-20 | 10,189,377 | 26,604,060 | DS | 20 | 2144-08-09 00:00:00 | 2144-08-09 06:32:00 |
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 hip pain
Major Surgical or Invasive Procedure:
R hip TFN
History of Present Illness:
___ male otherwise healthy former cardiologist presents with
the above fracture s/p mechanical fall. Patient was walking
towards the door with his walker, tripped and fell. He was on
the floor for approximately 30 minutes. Family members found
him, and brought him to the ___ emergency
room.
Of note, the patient uses a walker at baseline. He is mostly a
household ambulator now.
Past Medical History:
Frequent falls
Social History:
___
Family History:
Father with 'heart disease'
7 sibilings, one died as a baby, the rest with no known medical
issues.
Physical Exam:
CV: RRR
Resp: Unlabored, symmetric chest rise
ABD: soft, non-distended
RLE:
Dressing C/D/I
Firing ___
SILT S/S/DP/T
WWP
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 intertrochanteric hip fracture and was admitted
to the orthopedic surgery service. The patient was taken to the
operating room on ___ for right TFN, 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. The patient is
weightbearing as tolerated in the right lower extremity, 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.
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC QPM
RX *enoxaparin 40 mg/0.4 mL 1 syringe subcu once a day Disp #*28
Syringe Refills:*0
4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone [Oxaydo] 5 mg ___ tablet(s) by mouth every four
(4) hours Disp #*20 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
7. Ipratropium-Albuterol Neb 1 NEB NEB ONCE MR1 Wheezing
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right intertrochanteric hip 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 right lower extremity
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.
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 ___ DAYS OF REHAB
Physical Therapy:
Activity: Activity: Activity as tolerated
Right lower extremity: Full weight bearing
Encourage turn, cough and deep breathe q2h when awake
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:
___
|
10189427-DS-2 | 10,189,427 | 28,497,058 | DS | 2 | 2125-04-18 00:00:00 | 2125-04-20 08:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p stab assault
Major Surgical or Invasive Procedure:
___ (___)
Anterior thoracotomy
Exploratory left thoracotomy
Suture of anteriolateral ventricle wall
___ (___)
Re-exploration of left anterior thoracotomy.
Oversewing of myocardial injury to left ventricle.
Placement of mediastinal and pleural chest drains.
History of Present Illness:
Mr. ___ is a ___ year-old gentleman man who presented to an
outside hospital after a stab wound to the left anterior chest.
He was taken to the
operating room by the thoracic surgeons at the outside hospital
where he was noted to have a wound to the left ventricle
anteriorly. This was repaired with a large suture; however,
there was concern conveyed by the thoracic surgeons for possible
papillary muscle laceration, traumatic VSD, and involvement of
the coronaries, particularly the left anterior descending. The
patient was, therefore, stabilized and transferred to the
emergency room at ___ for re-
exploration and further management.
Past Medical History:
None.
Family History:
Non-contributory.
Physical Exam:
On admission:
HR: 84 BP: 137/80 Resp: 19 O(2)Sat: 100% V Normal
Constitutional: intubated sedated
HEENT: Normocephalic, atraumatic, pupils minimially
reactive
Chest: Laceration over L chest wall, closed with staples. L
CT in place with minimal blood output. CTA bilaterally
Cardiovascular: Regular Rate and Rhythm
Abdominal: soft, non distended
Rectal: decreased rectal tone (but received paralytics for
surgery)
Extr/Back: No cyanosis, clubbing or edema
Neuro: intubated, sedated, GCS 3T
Psych: intbuated sedated
On discharge:
VS 98.6, 90, 110/74, 18, 98%
Gen: NAD.
HEENT: Sutures in place to bridge of nose.
Chest: Chest tube dressing cdi to left lateral chest wall.
Dressing to prior mediastinal tube CDI.
Pulm: Lungs clear bilaterally.
Abd: Soft, non-tender, non-distended.
Pertinent Results:
___ 09:25AM BLOOD WBC-13.1* RBC-4.82 Hgb-14.4 Hct-42.6
MCV-88 MCH-29.8 MCHC-33.8 RDW-14.1 Plt ___
___ 12:43PM BLOOD Neuts-75.5* ___ Monos-6.4 Eos-0.1
Baso-0.2
___ 09:25AM BLOOD ___ PTT-32.3 ___
___ 09:25AM BLOOD ___
___ 12:43PM BLOOD Glucose-110* UreaN-11 Creat-0.9 Na-146*
K-3.9 Cl-116* HCO3-20* AnGap-14
___ 12:43PM BLOOD Calcium-6.6* Phos-4.0 Mg-1.7
___ 09:25AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:57AM BLOOD WBC-10.9 RBC-3.84* Hgb-11.3* Hct-34.5*
MCV-90 MCH-29.3 MCHC-32.7 RDW-14.2 Plt ___
___ 05:57AM BLOOD Plt ___
___ 05:57AM BLOOD Glucose-104* UreaN-12 Creat-0.9 Na-140
K-4.3 Cl-103 HCO3-30 AnGap-11
___ 05:57AM BLOOD Calcium-8.3* Phos-0.7* Mg-2.1
Imaging:
___ ECG
Sinus rhythm. Slight ST segment straightening/elevation in leads
I and aVL as well as V6. In the context of penetrating chest
trauma, consider injury to the obtuse margin of the heart.
Clinical correlation and repeat tracing are suggested.
___ Echocardiogram
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is 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 leaflets are structurally normal. Mild (1+) mitral
regurgitation is seen.
___ CXR
Endotracheal tube has its tip approximately 6 cm above the
carina. There is a nasogastric tube seen coursing below the
diaphragm with the tip projecting over the stomach. A left
chest tube is in place. Skin staples overlying the left upper
abdomen in this patient status post recent surgery. There is a
tiny left apical pneumothorax. There is retrocardiac patchy
opacity which may represent an area of contusion or atelectasis.
No pleural effusions are appreciated. No acute bony
abnormality is appreciated.
___ CXR (repeat)
The endotracheal tube continues to have its tip approximately 4
cm above the carina. A nasogastric tube is seen coursing below
the diaphragm with the tip not identified. Two left chest tubes
and a third catheter are seen overlying the left hemithorax.
There continues to be retrocardiac consolidation with probable
associated effusion likely reflecting partial lower lobe
atelectasis, although pneumonia or aspiration cannot be entirely
excluded. The right lung is grossly clear, although the right
costophrenic angle is not entirely included on the study. A
left subclavian central line has its tip in the proximal SVC.
No pneumothorax is seen. The cardiac and mediastinal contours
are stable.
___ CXR
1. Retrocardiac opacity and right basilar opacity, likely
atelectases.
2. No pneumothorax.
___ CXR
Left chest tube is in place. The inferior left chest tube has
been
disconnected. Mediastinal drain is in place. Cardiomediastinal
silhouette is stable. No definitive pneumothorax is seen.
Improved aeration of the right lung is noted. Left basal
atelectasis is unchanged.
___ CXR
The left chest tube is in place. Compared to the prior study
there is slight interval increase in the left apical
pneumothorax, small. Heart size and mediastinum are stable.
Right basal opacity is new and might reflect interval
development of atelectasis versus aspiration.
Brief Hospital Course:
The patient was transferred to the trauma ICU after his
operation for close monitoring. His ICU course by system was as
follows:
N: He was initially intubated and sedated after his operation.
His sedation was weaned and he was appropriately alert and
responsive. His pain was controlled with a dilaudid PCA. Toradol
was added.
CV: He remained hemodynamically stable.
Pulm: He was successfully extubated POD 1 and O2 sats were
stable on NC. His O2 was weaned. He had 3 L sided chest tubes in
place and they were kept to suction.
GI: He was initially kept NPO and then his diet advanced once he
was extubated. He was on a bowel regimen.
GU: His urine output was adequate.
ID: No issues.
Heme: The patient received five units of PRBCs pre-operatively
and three units of FFP post-operatively. His hematocrit and
coagulation status was stable since that time.
On ___, Mr. ___ was transferred to the surgical floor for
further management. He arrived with two left lateral chest
tubes and one mediastinal tube in place, all to water seal. He
was hemodynamically stable and had no respiratory issues.
Serial chest x-rays were obtained. One lateral chest tube was
discontinued on hospital day 4 as it had little drain output.
His mediastinal tube was discontinued on hospital day 5. On the
same day, a routine follow up chest radiograph showed a new left
apical pneumothorax. As a result, the second chest tube
remained in place and was placed onto suction.
On hospital day 6, Mr. ___ left chest tube was
discontinued after being on water seal. A repeat chest
radiograph shows a left small pneumothorax, decreased in size
from prior exam. The patient is saturating well and in no
respiratory distress. He has no subjective dyspnea, shortness
of breath.
At the time of discharge, the patient was hemodynamically
stable, in no acute distress and ambulating well. His surgical
staples were removed at the thoracotomy site. He has been
instructed to follow up with his original surgeon at ___
___, Dr. ___, once he returns home.
He will also need to follow up at ___ in regards to
the removal of his nasal bridge sutures. Other discharge
instructions were provided by myself and the bedside RN.
Medications on Admission:
None.
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN fever/pain
2. Docusate Sodium 100 mg PO BID
3. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
4. Senna 1 TAB PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Left ventricular laceration s/p thoracotomy and repair.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___
(___) after you were stabbed in the chest during an assault.
You initally underwent surgery at ___ where it was
found that you had a laceration of your left ventricle (lower
portion of your heart). It was repaired at that time. A chest
tube was also placed to drain extra fluid and air from your
chest. You were given some blood and required IV medication to
maintain your blood pressure at a safe level. Because there was
further concern of severe cardiac injury, you were transferred
to ___ for further management and observation. The cardiac
surgery service was initially consulted to evaluate your
injuries further.
On admission to ___, you were taken to the operating room for
re-exploration of your left anterior (front) surgical wound,
additional repair (oversewing) of your ventricle laceration, and
insertion of drainage tubes (2 pleural and 1 mediastinal).
After your surgery, you were taken to the ICU for recovery. You
were initially on a ventilator (breathing machine) but removed
from it shortly thereafter. Once you were stabilized in the
ICU, you were transferred to the medical floor for further
recovery.
___ INSTRUCTIONS
* 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 will continue to need pain medication once you are home
but you can wean it over a few weeks 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 ___ mg every 6 hours in between your narcotic.
If your doctor allows you may also take Ibuprofen to help
relieve the pain.
* 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 is healed
* No lotions or creams to incision site
* Walk ___ times a day and gradually increase your activity as
you can tolerate.
* No heavy lifting (> 10 lbs) for 2 weeks
Followup Instructions:
___
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