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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 = = = = = = = = = = = = = = = = = = = = = ================================================================ 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: ___