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10189661-DS-16 | 10,189,661 | 28,061,726 | DS | 16 | 2197-07-08 00:00:00 | 2197-07-08 11:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
recurrent sciatica pain
Major Surgical or Invasive Procedure:
___- L4-5 laminectomy discectomy of recurrent disc
History of Present Illness:
Mr. ___ is a ___ y.o. male s/p Right MIS L4-5
microdiscectomy last ___ who was doing well
postoperative until 3 days ago when he developed recurrent right
L5 radiculopathy. No significant event, but report that he had
increase pain with sitting up or leaning forward. No loss of
bladder or bowel control. He is still able to walk without
issues. No fever or chills.
Past Medical History:
Positive for proteinuria and irritable bowel syndrome,
right L4-5 Herniated disc
ALLERGIES: No known drug allergies.
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAM:
O: T: 99.3 89 121/86 18 100% RA
Gen: WD/WN, comfortable, NAD.
HEENT: head atraumatic, normocephalic, eyes: clear, nose patent
Neck: Supple.
Lungs: no accessory muscle use
Cardiac: RRR
Abd: Soft, NT
Extrem: Warm and well-perfused.
back: right incision with dermabond, swelling right paraspinal
muscle
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
IP Q H AT ___ G
Sensation: Intact to light touch
Pertinent Results:
Lumbar MRI: ___
IMPRESSION:
1. Postsurgical changes after right-sided L4-L5 hemilaminotomy.
The fluid
collection at the laminal defect most likely represents a
seroma. There is no rim enhancement or evidence of CSF leak.
2. Substantial amount of residual disc material at L4-L5 that
continues to
cause severe spinal stenosis, not significantly changed in
degree since the pre-operative study.
3. No epidural fluid collection.
Brief Hospital Course:
Mr. ___ was taken to the OR on ___ for a L4-5
laminectomy/discectomy of recurrent disc herniation. His
intraoperative course was uneventful, please refer to the
intraoperative note for further information. He was extubated
and transferred to the PACU for recovering, and did well. His
was transferred to the neurosurgical floor in stable conditions.
He was tolerating po intake and his pain was under control on
his current pain regimen. He remained stable over night. On the
morning of ___ the patient expressed readiness to go home, and
the patient was discharged home in stable conditions. All
discharged instructions and follow up appointments were given
prior to discharge.
Medications on Admission:
amitriptyline 20mg Q HS, gabapentin 200mg QHS, vicodin, and
valsartan 40 mg
Discharge Medications:
1. Amitriptyline 20 mg PO HS
2. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth Q8hrs Disp #*90
Tablet Refills:*0
3. Gabapentin 200 mg PO HS
4. Valsartan 40 mg PO DAILY
5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
Please do not drive or operate mechanical machinery while taking
narcotics.
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4hrs Disp #*140
Tablet Refills:*0
6. Bisacodyl 10 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Recurrent L4-5 HNP
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Lumbar Laminectomy/Discectomy
Dr. ___
Your large dressing may be removed the second day after
surgery. PLease have someone assist you with removing the
dressing.
You have dissolvable stures and dermabond. PLease keep it dry
and clean for 5 days.
No tub baths or pool swimming for two weeks from your date of
surgery.
Do not smoke.
No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
Limit your use of stairs to ___ times per day.
Have a friend or family member check your incision daily for
signs of infection.
Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort. Pain medication should
be used as needed when you have pain. You do not need to take it
if you do not have pain.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. for two weeks.
Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
Pain that is continually increasing or not relieved by pain
medicine.
Any weakness, numbness, tingling in your extremities.
Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
Fever greater than or equal to 101.5° F.
Loss of control of bowel or bladder functioning
Followup Instructions:
___
|
10189774-DS-15 | 10,189,774 | 25,424,241 | DS | 15 | 2133-09-24 00:00:00 | 2133-09-27 00:20:00 |
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
Major Surgical or Invasive Procedure:
Lumbar puncture at ___
History of Present Illness:
___ no sig PMH presents for eval of headache. Patient states
that last ___ she had sudden onset of worst headache of her life,
located behind her right eye, associate with nausea and
vomiting. Attempted ibuprofen and excedrin without relief.
Denies any blurr/double vision, weakness/parasthesia/anesthesia
of any of the extremities. States that she has had a "low grade
temperature," to 99dF although no true fevers. Endorses
subjective neck stiffness.
She was seen at ___ and underwent a lumbar
puncture which was positive for RBCs (128tube 1 and 213 tube 4)
and WBCs (300 tube 1 and 500tube 4), glucose 48 and protein 56.
No organisms were seen on gram stain but positive for PMNs. The
CSF sample was not run for xanthochromia. She was started on
Ceftriaxone and Acyclovir at the OSH and transferred to ___
for further evaluation.
She does spend time outside at her son's ___, no
recollection of tick bite but does have mosquito expsoure.
Denies any rash or arthralgias.
In the ED, initial vs were: pain ___ T99.5 HR 92 BP 125/68 16
99%RA. Labs were remarkable for crit 33.4, no leukocytosis.
Repeat head CTA was negative. Patient was given dilauded and
lorazepam and transferred to the floor.
On the floor, vs were: T 99.0 BP 130/66 HR 71 RR 18 O2 98%RA.
She still had headache and nausea, vomited 1 cup green fluid.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies rhinorrhea or congestion. Denies cough, shortness
of breath. Denies chest pain or tightness, palpitations. Denies
diarrhea, constipation or abdominal pain. No dysuria. Denies
arthralgias or myalgias. Ten point review of systems is
otherwise negative.
Past Medical History:
no significant PMH, increased vaginal bleeding and takes
multivitamin with Fe
Social History:
___
Family History:
No h/o aneurysm in family
Physical Exam:
ADMISSION EXAM:
Vitals- T 99.0 BP 130/66 HR 71 RR 18 O2 98%RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM
Neck- supple, can shake head ~3x/second, chin to chest intact
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, S4 present, no
murmurs, rubs, gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- No rash, warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema
Neuro- CNs2-12 intact, motor function grossly normal strength
___ bialteral upper/lower
DISCHARGE EXAM:
Vitals- Tm98.5 Tc 98.5 BP 112/60 P 52 RR16 O2 100%RA
I/O- 2760 in/ ___ out in 9 hours yesterday, 1250 out in 6 hours
this AM
Gen- Well appearing, comfortable in bed, NAD
HEENT- MMM, PERRL, EOMI
Neck- Supple, no LAD
CV- RRR, physiologically split S2, no m/r/g
Lungs- CTAB, no wheezes/rales/rhonchi
Abd- Soft, NTTP
Ext- WWP, no edema
Neuro- CN II-XII intact, ___ upper and lower ext strength
Pertinent Results:
ADMISSION LABS:
___ 11:15PM PLT COUNT-282
___ 11:15PM NEUTS-74.2* ___ MONOS-5.6 EOS-0.4
BASOS-0.5
___ 11:15PM WBC-7.3 RBC-3.93* HGB-11.2* HCT-33.4* MCV-85
MCH-28.6 MCHC-33.6 RDW-13.8
___ 11:15PM GLUCOSE-119* UREA N-7 CREAT-0.6 SODIUM-137
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-17* ANION GAP-19
___ 11:22PM LACTATE-0.9
PERTINENT LABS:
___ 07:05AM BLOOD Glucose-118* UreaN-9 Creat-0.9 Na-135
K-3.5 Cl-104 HCO3-25 AnGap-10
___ 07:45AM BLOOD UreaN-8 Creat-1.4* Na-143 K-3.9 Cl-109*
HCO3-23 AnGap-15
___ 07:10AM BLOOD Glucose-87 UreaN-6 Creat-1.2* Na-143
K-3.5 Cl-109* HCO3-25 AnGap-13
___ 08:16AM BLOOD ALT-12 AST-16 LD(LDH)-146 AlkPhos-37
TotBili-0.2
___ 08:00PM BLOOD Vanco-17.1
___ 01:00PM URINE Color-Straw Appear-Clear Sp ___
___ 01:00PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 01:00PM URINE RBC-2 WBC-3 Bacteri-FEW Yeast-NONE Epi-2
___ 01:00PM URINE Hours-RANDOM UreaN-125 Creat-44 Na-87
K-12 Cl-102
___ 01:00PM URINE Osmolal-270
DISCHARGE LABS:
___ 06:35AM BLOOD WBC-6.5 RBC-3.40* Hgb-9.9* Hct-29.4*
MCV-87 MCH-29.0 MCHC-33.5 RDW-13.8 Plt ___
___ 06:35AM BLOOD Glucose-87 UreaN-8 Creat-1.1 Na-140
K-3.2* Cl-108 HCO3-25 AnGap-10
___ 06:35AM BLOOD Mg-2.0
IMAGING:
CT and CTA of Head (___):
There is no evidence of acute intracranial process or
hemorrhage. Essentially normal CTA of the head with no evidence
of flow
stenotic lesions or aneurysms larger than 3 mm in size.
Brief Hospital Course:
___ yo F with no significant PMH presented to ___
on ___ for headache, then transferred to ___, and found to
have aseptic meningitis.
# Aseptic meningitis: The pt presented to ___
with a severe headache which started suddenly while at work the
previous evening. A head CT was negative for intracranial bleed.
A lumbar puncture was performed and showed 300-500 WBCs with
neutrophilic predominance. CSF glucose was in the normal range.
She was transferred to ___ on empiric coverage for bacterial
and viral meningitis (ceftriaxone and acyclovir) for further
management. A repeat head CT was again negative for bleed.
Vancomycin was added. She was symptomatically treated with
antiemetics, NSAIDs, and IVF. The CSF cultures returned
negative. All the viral titers (CMV, HSV, EEE, VZV, ___
also returned negative. Lyme titers were negative.
# Acute Kidney Injury: After 3 days of acyclovir, vancomycin,
and ketorolac, the patient's creatinine rose from a baseline of
0.5 to 1.4. Nephrotoxic drugs were stopped, IVF was given
aggressively for goal urine output > 200 cc/hr, and urine
testing was performed. The sediment was bland. Urine
electrolytes and urine osms pointed to an intrinsic renal
pathology. Cr downtrended 1.4 --> 1.2 --> 1.1 on day of
discharge. Renal was consulted and recommended that a repeat
urinalysis and Cr be obtained as an outpatient. The patient was
counseled to avoid NSAIDs until Cr back at baseline. She was
also encouraged to stay well hydrated post-discharge.
CHRONIC STABLE DIAGNOSES:
# Chronic anemia: The patient has a history of anemia, most
likely secondary to menstrual loss. Her Hct remained stable
throughout hospitalization. She should ___ with her PCP.
TRANSITIONAL ISSUES:
-Repeat urinalysis and creatinine at PCP ___ appointment.
-Pt to avoid NSAIDs until creatinine back to baseline of 0.5.
-Arbovirus titers (drawn at ___ were pending at the time of
discharge.
Medications on Admission:
Ibuprofen PRN menstrual cramping
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
-Aseptic meningitis
-Acute kidney injury
SECONDARY:
-Chronic anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure to care for you during your hospitalization at
___.
You were transferred from ___ with a diagnosis
of meningitis. You were empirically treated with antibiotics and
antivirals, but in the end, the culture of your cerebral spinal
fluid was negative (ruling out bacterial meningitis) and your
illness resolved quickly. Your symptoms were treated with pain
medications and anti-emetics and you were given IV fluids. Your
labs showed an elevation in your creatinine (up to 1.4, from
baseline 0.5) after a few days on medicines which are known to
be hard on the kidneys (vancomycin, acyclovir, and ketorolac).
Those medications were stopped and you were aggressively
hydrated to help flush your kidneys. You were seen by the kidney
doctors who suggested ___ a repeat urinalysis and
creatinine/electrolytes when you see your primary care doctor
following this hospitalization. Your creatinine on the day of
discharge was 1.1 which was improved but still elevated. You
should continue to stay very well hydrated, avoid non-steroidal
anti-inflammatories like Advil and Naproxen until your doctor
tells you otherwise. Please drink a variety of fluids including
liquids with electrolytes and sugars, like gatorade, pedialyte,
and orange juice and try to eat a banana a day (to maintain your
potassium levels, which were low after aggressive hydration).
Followup Instructions:
___
|
10189889-DS-18 | 10,189,889 | 24,397,884 | DS | 18 | 2146-05-03 00:00:00 | 2146-05-05 23:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex / nickel / eucalyptus
Attending: ___
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with asthma, OSA, HTN, chronic anemia, NIDDM, p/w
lightheadedness with positional changes over the past week. Seen
by PCP with changes to BP meds as pt hypertensive at ___. Pt
denies f/c, n/v, CP, SOB. Diarrhea for past 2 days. Decreased PO
intake. Hx of abdominal pain with BM d/t multiple adhesions s/p
pelvic surgery, no hx SBO, no current abd pain.
In the ED, initial VS were ___ headache 97.8 84 135/34 22 96%
Nasal Cannula
Exam notable for distended, firm, nontender abdomen
Labs showed lactate rising from 3.3 to 5.7 and anemia of 9.3
Imaging showed CXR with costophrenic angles partially obscured
due to overlying soft tissue/ patient body habitus. Given this,
no acute cardiopulmonary process seen.
Received 7L total NS, 4g IV magnesium, 30mg toradol, home
gabapentin, metformin, pravastatin, labetalol, duonebs, IV 125mg
methylprednisolone, prednisone 60mg, amlodipine 10mg, lisinopril
40mg, lamictal 200, sertraline, glimepride, Tylenol and thiamine
500mg IV.
Negative UA, EKG in NSR, no ST changes.
In the ED, headache resolved and patient was comfortable on
transfer with concern for elevated lactate.
On arrival to the floor, patient reports a week history of
lightheadedness/unsteadiness with head movement particularly
moving head down/bending over. She has some baseline tinnitus
and hearing loss from previous occupation. She denies fever,
chills, diarrhea, or constipation. Has been eating without pain.
No word finding difficulties, no weakness.
Past Medical History:
Notable for obstructive sleep apnea,
diabetes, hypertension, neuropathy, TAH and removal of one ovary
due to fibroids and a cyst and had subsequent ovary removed in
___. She has had asthma with multiple hospitalizations, but
had
never required intubation. She has a history of a pituitary
tumor, iron deficiency anemia, chronic gastritis and ulcers seen
on EGD, hoarding disorder, depression, prior suicide attempt and
hospitalization in ___.
Social History:
___
Family History:
Father w/ emphysema, MI @ ___
___ siblings with lung CA (___), leukemia (___)
Meniere's disease in grandfather and cousin
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97.9 141/55 81 18 96%
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, fair dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, no nystagmus, negative test of skew,
+horizontal nystagmus on ___
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
VS - 98.4 155/71 73 18 95RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, fair dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, no nystagmus, negative test of skew,
+horizontal nystagmus on ___
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
___ 04:30PM BLOOD WBC-5.1 RBC-3.30* Hgb-9.3* Hct-28.4*
MCV-86 MCH-28.2 MCHC-32.7 RDW-15.8* RDWSD-48.8* Plt ___
___ 04:30PM BLOOD Neuts-60.3 ___ Monos-8.6 Eos-1.6
Baso-0.2 Im ___ AbsNeut-3.10 AbsLymp-1.44 AbsMono-0.44
AbsEos-0.08 AbsBaso-0.01
___ 04:30PM BLOOD ___ PTT-33.9 ___
___ 04:30PM BLOOD Glucose-189* UreaN-17 Creat-0.6 Na-142
K-3.6 Cl-105 HCO3-27 AnGap-14
___ 04:30PM BLOOD ALT-28 AST-22 AlkPhos-77 TotBili-0.1
___ 04:30PM BLOOD Albumin-4.0 Calcium-8.7 Phos-3.6 Mg-1.5*
LACTATE TREND
___ 04:41PM BLOOD Lactate-3.3*
___ 06:33PM BLOOD Lactate-2.9*
___ 05:31AM BLOOD Lactate-4.7*
___ 03:20PM BLOOD Lactate-5.7*
___ 01:04AM BLOOD Lactate-4.3*
___ 06:39AM BLOOD Lactate-2.6*
DISCHARGE LABS
___ 06:10AM BLOOD WBC-7.5 RBC-3.38* Hgb-9.0* Hct-29.0*
MCV-86 MCH-26.6 MCHC-31.0* RDW-15.9* RDWSD-48.9* Plt ___
___ 06:10AM BLOOD Glucose-147* UreaN-21* Creat-0.7 Na-138
K-4.1 Cl-101 HCO3-25 AnGap-16
___ 06:10AM BLOOD Calcium-9.4 Phos-2.5* Mg-1.6
CXR ___
IMPRESSION:
Costophrenic angles partially obscured due to overlying soft
tissue/ patient
body habitus. Given this, no acute cardiopulmonary process
seen.
URINE Culture NO growth
Brief Hospital Course:
___ with asthma, OSA, HTN, chronic anemia, NIDDM, p/w headache
and lightheadedness with positional changes over past week who
was admitted for persistently elevated lactate.
#Lactic Acidosis: Patient with lactate to 5.7, resolved without
intervention to 2.6. No signs of
hypotension/hypoperfusion/shock. She did receive albuterol nebs
in ED which has previously caused her to have lactates in the 5s
(prior D/C sum ___. Patient was eating comfortably so
mesenteric ischemia was unlikely. No excessive work of
breathing. Her thiamine was repleted in the ED. No signs of DKA
on UA or chemistry panel. There was concern for decreased
lactate clearance in setting of large liver and borderline low
platelets. A ___ fibrosis score was calculated at 2.14. Given
this score, referral placed to hepatology, Dr. ___.
#Vertigo: Patient provided story of approximately 1 week of
episodic vertigo, most exacerbated with bending over and putting
her head down. Peripheral source suspected given nystagmus,
lightheadedness with movement of head in extreme positions as
well as ___. Low suspicion for posterior stroke given
negative HINTS (head impulse, nystagmus, test of skew) exam. An
Epley maneuver was attempted with minimal improvement, though
suboptimal given positioning challenges. Pt was counseled on
vestibular ___. Orthostatic signs were negative. Of note, patient
does have a family history of Meniere's, but denied
tinnitus/nausea/vomiting with vertiginous symptoms.
#Asthma: While in ED, patient had episode of wheezing and
received nebs and IV steroids. On arrival to floor, patient was
without wheeze and did not require further nebulizers and
steroids were not continued
#Headache: Resolved with 30mg toradol and did not recur. Patient
indicated primary location in back of neck that worsened with
neck extension and improved with massage. Suspected to be
primarily musculoskeletal/tension.
TRANSITIONAL ISSUES
===================
-Consider alternative to metformin given transient lactic
acidosis
-Recommend further outpatient workup of vertigo along with
continued vestibular therapy.
-Patient gets transient lactic acidosis with frequent nebulizer
treatment
-Patient may benefit from maintenance inhaler for her asthma
-Enlarged liver seen on prior CT. Given concern for ___, pt
was referred to specialist, Dr. ___
- ___ fibrosis score is 2.14
Emergency Contact: ___
___
Code:DNR/ok for intubation
>30 minutes spent in coordination of care and counseling
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Gabapentin 800 mg PO TID
3. LamoTRIgine 200 mg PO DAILY
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Tizanidine 2 mg PO QHS:PRN muscle spasms
6. amLODIPine 10 mg PO DAILY
7. Pravastatin 40 mg PO QPM
8. Ferrous Sulfate 325 mg PO DAILY
9. Sertraline 250 mg PO DAILY
10. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN asthma
11. Loratadine 10 mg PO DAILY
12. Labetalol 100 mg PO BID
13. glimepiride 2 mg oral DAILY
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
2. Ferrous Sulfate 325 mg PO DAILY
3. Gabapentin 800 mg PO TID
4. Labetalol 100 mg PO BID
5. LamoTRIgine 200 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. Loratadine 10 mg PO DAILY
8. Pravastatin 40 mg PO QPM
9. Sertraline 250 mg PO DAILY
10. Tizanidine 2 mg PO QHS:PRN muscle spasms
11. glimepiride 2 mg ORAL DAILY
12. albuterol sulfate 90 mcg/actuation INHALATION Q6H:PRN asthma
13. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Peripheral Vertigo
Lactic Acidosis ___ B-agonism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for a headache and lightheadedness.
This is believed to be due to vertigo. You also had an abnormal
lab value (lactate) that normalized quickly. This was thought to
be from one of your medications, albuterol. It is not dangerous
to continue to take your albuterol. You should follow up with
your PCP regarding your vertigo. Talk with your PCP about
further options to treat your vertigo. Call your doctor if you
get fevers, chills, dizziness, abdominal pain, nausea, or
vomiting.
Additionally, on review of imaging your liver was noted to be
large. We made an appointment with Dr. ___ to further
investigate the cause.
Wishing you the best of health moving forward,
Your ___ team
Followup Instructions:
___
|
10189889-DS-20 | 10,189,889 | 28,110,950 | DS | 20 | 2146-12-07 00:00:00 | 2146-12-07 15:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex / nickel / eucalyptus
Attending: ___.
Chief Complaint:
dyspnea, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ woman with a history of T2DM, asthma,
anemia, and depression, who presents with 2 weeks of productive
cough and dyspnea.
She initially presented to her PCP ~14 days ago, and was
thought to have an asthma exacerbation in the setting of a viral
respiratory infection. She was treated with a steroid taper
(60mg x3 days, then 40mg x3 days, then 20mg x3 days). She
completed the taper on ___. She initially developed improvement
in her symptoms, but her symptoms worsened as the steroid was
tapered. She currently reports a cough productive of minimal
whitish sputum and shortness of breath. She has had to use her
albuterol nebulizer 2 times today. She has not had any fevers or
chills. Mild nausea but no abdominal pain. No myalgias or
arthralgias. No chest pain. Also endorses head congestion and
sore throat.
- In the ED, initial vitals: 98.1 110 178/82 20 97% RA
- Labs were significant for: WBC 11.7, lactate 3.4 -> 4.9, Na
130 w/ glucose 325
- Imaging showed: RML pneumonia
- In the ED, she received:
* Viscous lidocaine
* Ipratropium Nebs
* Levofloxacin 750mg at ___, then at ___
* Prednisone 60mg at ___, then Prenisone 40mg at ___
* 1L NS
* 2gm Mg
* Home medications
- Vitals prior to transfer: 85 128/57 20 94% RA
Currently, she feels okay. She continues to have a cough, and
gets short of breath with minimal movement. She says this feels
different than just her typical asthma exacerbation.
Past Medical History:
- Obstructive sleep apnea
- T2DM
- HTN
- Neuropathy
- TAH & removal of 1 ovary ___ fibroids & a cyst
- Asthma, multiple hospitalizations never intubated
- Pituitary tumor
- Iron deficiency anemia
- Chronic gastritis with ulcers on EGD
- Hoarding disorder
- Depression with prior suicide attempt and hospitalization in
___
Social History:
___
Family History:
Father w/ emphysema, MI @ ___, ___ siblings with lung CA (___),
leukemia (___). Meniere's disease in grandfather and cousin
Physical Exam:
=====================
ADMISSION EXAM
=====================
VS: 97.8 PO 140 / 66 L Lying 85 20 95 RA
GEN: Alert, obese woman, sitting comfortably in bed, NAD
HEENT: no scleral icterus, mmm
NECK: Supple without LAD, no JVD
PULM: normal work of breathing on room air, good air movement,
lungs clear without wheezes or crackles
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, obese non-tender, non-distended, +BS
EXTREM: Warm, well-perfused, no ___ edema
NEURO: CN II-XII grossly intact, motor function grossly normal,
sensation grossly intact
=====================
DISCHARGE EXAM
=====================
Vitals: 98.0 PO 114 / 72 73 18 94 RA
General: pleasant obese woman, alert, oriented, no acute
distress
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: breathing comfortably on room air, no wheezing
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
Pertinent Results:
===============
ADMISSION LABS
===============
___ 06:55PM BLOOD WBC-10.5* RBC-4.31 Hgb-11.8 Hct-37.7
MCV-88 MCH-27.4 MCHC-31.3* RDW-13.9 RDWSD-44.2 Plt ___
___ 06:55PM BLOOD Neuts-74.1* Lymphs-17.0* Monos-6.4
Eos-1.1 Baso-0.4 Im ___ AbsNeut-7.80*# AbsLymp-1.79
AbsMono-0.67 AbsEos-0.12 AbsBaso-0.04
___ 06:55PM BLOOD Glucose-134* UreaN-24* Creat-0.8 Na-138
K-5.0 Cl-96 HCO3-24 AnGap-23*
___ 06:55PM BLOOD Triglyc-534* HDL-51 CHOL/HD-3.3
LDLmeas-62
___ 07:13PM BLOOD Lactate-3.4*
___ 09:43AM BLOOD Lactate-4.9*
===============
IMAGING
===============
CXR ___: IMPRESSION: Right middle lobe pneumonia. Followup
radiographs are recommended after treatment to ensure resolution
of this finding
===============
MICRO
===============
Blood cultures negative.
===============
DISCHARGE LABS
===============
___ 06:00AM BLOOD WBC-8.8 RBC-4.11 Hgb-11.3 Hct-35.7 MCV-87
MCH-27.5 MCHC-31.7* RDW-13.7 RDWSD-43.2 Plt ___
___ 06:00AM BLOOD Glucose-138* UreaN-27* Creat-0.7 Na-137
K-4.2 Cl-96 HCO3-25 AnGap-20
___ 03:42PM BLOOD Lactate-2.3*
Brief Hospital Course:
Ms. ___ is a ___ with history of asthma, obesity, and
diabetes mellitus, who presents with 2 weeks of cough and
dyspnea, and was found to have a right middle lobe community
acquired pneumonia and asthma exacerbation. She never required
oxygen. She was treated with a five day course of levofloxacin,
which completed on ___. She was also treated with prednisone
for asthma exacerbation (peak flow was 230 from baseline in high
300s). Her respiratory status improved, and ambulatory
saturations were above 90%. She was seen by the social worker
and a plan was worked out to allow her to obtain inhaled
corticosteroids for minimal cost, which she had been unable to
obtain as an outpatient. As a result, she was started on
fluticasone inhaler for her severe persistent asthma. She will
also be discharged with a prednisone taper. She should follow-up
with her primary care physician and pulmonologist.
===================
ACUTE ISSUES
===================
# COMMUNITY ACQUIRED PNEUMONIA: Patient presented with 2 weeks
of dyspnea and productive cough, that initially got better, and
subsequently got worse. Admission CXR showed RML lobe pneumonia.
Flu swab was negative. She was treated with a 5 day course of
levofloxacin, with improvement. She was able to ambulate
comfortably without desaturations prior to discharge.
# ASTHMA EXACERBATION: She has faint wheezing and her peak flow
is below her baseline (current 230, baseline high 300s),
consistent with exacerbation in the setting of infection. She
was treated with prednisone 40mg po daily with improvement in
her respiratory status. She will be discharged with a taper of
prednisone (see below). She also reported difficulty in
affording inhaled corticosteroids as an outpatient, which is
likely contributing to repeated exacerbations and ED
visits/hospitalizations. With the help of social work and
financial counseling she was able to get a fluticasone inhaler
for free and will be able to get refills at the ___
pharmacy.
===================
CHRONIC ISSUES
===================
# ELEVATED LACTATE: She had an elevated lactate on admission of
4.9. She had no signs of hypoperfusion. This was likely due to
albuterol administration and subsequently resolved.
# Pseudo-hyponatremia: Na 130 on admission but with glucose of
325, corrects to 134. Resolved with improved glycemic control.
# Diabetes mellitus: Glycemic control likely worsened in the
setting of steroid administration. She was treated with an
insulin sliding scale with improvement in her glycemic control.
Her home metformin/glimepiride were held while inpatient but
restarted on discharge. Home gabapentin was continued.
# OSA: Continued CPAP.
# HTN: continued amLODIPine 10 mg PO DAILY, Labetalol 100 mg PO
BID, Lisinopril 40 mg PO DAILY
# Bipolar disorder: she was hospitalized for this in ___.
Continued Perphenazine 8 mg PO daily, LamoTRIgine 200 mg PO
DAILY
===================
TRANSITIONAL ISSUES
===================
-started fluticasone 220mcg IH BID with spacer
-discharged with prednisone taper: she will take 30mg x 2 days,
then 20mg x 2 days, then 10mg x 2 days, then stop.
-f/u with pulmonary as previously scheduled
-repeat x-ray in ___ weeks to ensure resolution of findings
#Emergency Contact: ___
___
#Code: DNR/ok for intubation (confirmed this admission)
>30 min spent on discharge coordination on day of discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH DAILY:PRN asthma exacerbation
2. amLODIPine 10 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Gabapentin 800 mg PO TID
5. glimepiride 2 mg oral QAM
6. Labetalol 100 mg PO DAILY
7. Lisinopril 40 mg PO DAILY
8. LamoTRIgine 200 mg PO DAILY
9. Tizanidine 2 mg PO BID:PRN back pain
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Perphenazine 8 mg PO DAILY
12. glimepiride 1 mg oral QPM
Discharge Medications:
1. Fluticasone Propionate 110mcg 2 PUFF IH BID
RX *fluticasone [Flovent HFA] 220 mcg 2 puffs IH twice a day
Disp #*1 Inhaler Refills:*12
2. PredniSONE 40 mg PO DAILY
This will be tapered down.
RX *prednisone 10 mg ___ tablet(s) by mouth daily Disp #*12
Tablet Refills:*0
3. Albuterol Inhaler 2 PUFF IH DAILY:PRN asthma exacerbation
4. amLODIPine 10 mg PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. Gabapentin 800 mg PO TID
7. glimepiride 1 mg oral QPM
8. glimepiride 2 mg oral QAM
9. Labetalol 100 mg PO DAILY
10. LamoTRIgine 200 mg PO DAILY
11. Lisinopril 40 mg PO DAILY
12. MetFORMIN (Glucophage) 1000 mg PO BID
13. Perphenazine 8 mg PO DAILY
14. Tizanidine 2 mg PO BID:PRN back pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
-Community Acquired Pneumonia
-Asthma Exacerbation
SECONDARY DIAGNOSIS:
-diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized at ___
because of pneumonia and asthma exacerbation.
You were given antibiotics and completed a five day course while
in the hospital.
You will be discharged with a prednisone taper and a new inhaled
steroid. Make sure to wash your mouth out with water after using
the inhaled steroid.
Please follow-up with your primary care physician.
We wish you the best!
-Your ___ Team
Followup Instructions:
___
|
10189889-DS-22 | 10,189,889 | 20,136,408 | DS | 22 | 2147-05-13 00:00:00 | 2147-05-22 17:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex / nickel / eucalyptus
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
Ms. ___ is a ___ female with medical history notable for
T2DM, anemia, OSA, asthma complicated by recurrent
hospitalizations who presents to the ED via EMS with shortness
of breath.
Per patient, approximately x1 week ago she noticed increased
cough associated with sputum production. She had worsening
shortness of breath and wheezing at rest and with exertion. She
thinks her symptoms were triggered by exposure to a woman's
perfume. She reports that, on night prior to admission, she felt
increased shortness of breath and had difficulty speaking. She
tried her proair without improvement, prompting her to call EMS.
Per EMS report: "Pt states she has had a productive cough and
SOB for three days. Pt was speaking in full sentences, was not
positional and did not have an increased work of breathing. Pt
had noted expiratory wheezing throughout all fields. Pt denies
intubation, steroid usage and recent hospitalization for her
asthma. Vitals assessed, BLS canceled ALS. Pt was given an
albuterol neb en route with improvement per pt. Pt had noted
rhonchi upon reassessment. Pt monitored en route."
In the ED, initial VS were 97.2 84 130/60 17 100%
___
-Peak Flow (Pre) 270
-Exam notable for:
"GEN: Sitting in bed with facemask on alert and oriented ×3
CV: Regular rate and rhythm no murmurs
P: Wheezes throughout all lung fields, no crackles, good air
movement throughout
Extremities: 1+ pitting edema bilaterally, no tenderness"
-Labs showed
6.2>12.___/37.9<176
Na 138 K 3.9 Cl 96 HCO3 24 BUN 20 Cr 0.7 Gluc 155
pH7.44 pC___
Lactate trend: 3.4 (12:35) -> 6.1 (17:51) -> 7.9 (20:48) -> 7.5
(21:44)
-Imaging showed:
CXR (___): no acute cardiopulmonary process
-Received:
___ 13:29 IH Albuterol 0.083% Neb Soln 1 NEB
___ 13:29 IH Ipratropium Bromide Neb 1 NEB
___ 13:48 IH Albuterol 0.083% Neb Soln 1 NEB
___ 13:48 IH Ipratropium Bromide Neb 1 NEB
___ 13:48 PO PredniSONE 40 mg
___ 14:49 IH Albuterol 0.083% Neb Soln 1 NEB
___ 14:49 IH Ipratropium Bromide Neb 1 NEB
___ 15:16 IVF NS
___ 15:20 PO/NG Gabapentin 800 mg
___ 17:35 IH Albuterol 0.083% Neb Soln 1 NEB
___ 17:35 IH Ipratropium Bromide Neb 1 NEB
-Transfer VS were 104 130/60 20 95% RA
On arrival to the floor, patient reports feeling "much better"
and denies any shortness of breath. She is upset because her
cane was lost on her transfer to the hospital. She reports her
normal peak flows are in the 300s, but did not check prior to
her presentation. She reports she is on fluticasone because
other inhaler medications have not been approved by her
insurance in the past. She denies f/c,
lightheadedness/dizziness, CP/palp, abd pain/N/V, dysuria,
changes in BM, sick contacts.
Past Medical History:
- Obstructive sleep apnea
- T2DM
- HTN
- Neuropathy
- TAH & removal of 1 ovary ___ fibroids & a cyst
- Asthma, multiple hospitalizations never intubated
- Pituitary tumor
- Iron deficiency anemia
- Chronic gastritis with ulcers on EGD
- Hoarding disorder
- Depression with prior suicide attempt and hospitalization in
___
Social History:
___
Family History:
Father w/ emphysema, MI @ ___, ___ siblings with lung CA (___),
leukemia (___). Meniere's disease in grandfather and cousin
Physical Exam:
ADMISSION PHYSICAL EXAM
=========================
VS: 98.2 126/76 94 20 96 RA
GENERAL: NAD, sitting up in bed
HEENT: AT/NC, EOMI, PERRL, MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: (+) expiratory wheeze in R base, good air movement
throughout, speaking in full sentences, no accessory muscle use
ABDOMEN: obese, nondistended, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: trace edema bilaterally, no cyanosis, clubbing
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
=========================
Vital Signs: 98.2 110 / 67 76 14 97 Cpap
General: Alert, oriented, obese.
HEENT: Sclera anicteric. EOMI. PERRL.
Heart: RRR, no murmurs, rubs or gallops
Lungs: mild scattered wheezing and rhonchi
Abdomen: NTND no HSM
Extremities: warm, trace ___ edema bilaterally
Neuro: Not examined
Psych: Normal affect
Pertinent Results:
ADMISSION LABS
=================
___ 09:44PM ___
___ 08:48PM ___
___ 06:40PM URINE ___
___ 06:40PM URINE ___
___ 06:40PM URINE ___ SP ___
___ 06:40PM URINE ___
___
___
___ 06:40PM URINE RBC-<1 ___
EPI-<1
___ 06:40PM URINE ___
___ 05:51PM ___
___ 12:35PM ___ TOTAL ___
BASE ___
___ 12:35PM ___
___ 12:35PM O2 ___
___ 12:32PM ___ UREA ___
___ TOTAL ___ ANION ___
___ 12:32PM ___ this
___ 12:32PM ALT(SGPT)-30 AST(SGOT)-31 ALK ___ TOT
___
___ 12:32PM ___
___
___ 12:32PM ___
___ IM ___
___
___ 12:32PM PLT ___
___ 12:32PM PLT ___
___ 12:32PM PLT ___
___ 12:32PM PLT ___
DISCHARGE LABS
===============
___ 10:56AM BLOOD ___
___ Plt ___
___ 10:56AM BLOOD ___
___
___ 10:56AM BLOOD ___
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a past medical history
of T2DM, anemia, OSA, bipolar disorder, and asthma complicated
by recurrent hospitalizations who was admitted for an asthma
exacerbation lasting one week likely secondary to medication
noncompliance
Acute issues:
1) Asthma exacerbation: received Fluticasone Propionate,
___ Diskus, Guaifenesin, Prednisone,
Albuterol, ___ with clinical improvement.
Chest X ray showed no evidence of pulmonary pathology.
Ambulatory oxygen saturations reached 91% nadir. Placed on
nonrebreather mask to optimize oxygenation. Counseled to comply
with medications and avoid environmental triggers. At time of
discharge patient was breathing comfortably on room air. Her
ambulatory saturdations were ~95%. Discharged on home inhalers
and prednisone taper.
Prednisone 40mg x5 days (___)
2) Hyperlactatemia: likely type B secondary to albuterol use.
Improved with fluid administration over the course of admission
(5.2 --> 3.2). An infectious workup was negative (chest X ray,
urinalysis, blood/urine cultures pending).
Chronic Issues:
1) Type 2 diabetes mellitus: placed on insulin sliding scale
(held home metformin and glimepiride), diabethic neuropathy
controlled with gabapentin.
2) OSA: Continued BiPAP at night.
3) HTN: Continued amlodipine, Labetalol, Lisinopril.
4) Bipolar disorder: Continued Perphenazine, Lamotrigine.
Transitional issues:
1) F/U appointments with PCP and pulmonologist
2) Must receive appropriate community resource specialist to
help finance home medications.
MEDICATIONS:
- New Meds: Prednisone 40 mg PO/NG DAILY Duration: 4 Doses
- Stopped Meds: Labetalol 100 mg PO DAILY
___
- Follow up: PCP
- ___ required after discharge: Pulmonary function testing
- Incidental findings: None
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. amLODIPine 10 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Fluticasone Propionate NASAL 1 SPRY NU DAILY
5. Gabapentin 800 mg PO TID
6. Labetalol 100 mg PO DAILY
7. LamoTRIgine 200 mg PO DAILY
8. Lisinopril 40 mg PO DAILY
9. Tizanidine 2 mg PO BID:PRN back pain
10. Perphenazine 8 mg PO DAILY
11. Fluticasone Propionate 110mcg 2 PUFF IH BID
12. Albuterol Inhaler 2 PUFF IH DAILY:PRN asthma exacerbation
13. Omeprazole 20 mg PO DAILY
14. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. ___ Diskus (250/50) 1 INH IH BID
RX ___ [Advair Diskus] 250 ___ mcg/dose 1
puff Inhaled twice a day Disp #*1 Disk Refills:*0
2. PredniSONE 40 mg PO DAILY Duration: 4 Doses
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*6 Tablet
Refills:*0
3. Albuterol Inhaler 2 PUFF IH DAILY:PRN asthma exacerbation
RX *albuterol sulfate [ProAir HFA] 90 mcg 2 puffs INH Every 6
hours Disp #*1 Inhaler Refills:*0
4. amLODIPine 10 mg PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY
7. Gabapentin 800 mg PO TID
8. Hydrochlorothiazide 25 mg PO DAILY
9. LamoTRIgine 200 mg PO DAILY
10. Lisinopril 40 mg PO DAILY
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Omeprazole 20 mg PO DAILY
13. Perphenazine 8 mg PO DAILY
14. Tizanidine 2 mg PO BID:PRN back pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Asthma exacerbation.
Secondary: Obstructive sleep apnea on BiPAP
- T2DM
- HTN
- Neuropathy
- Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came to ___ because you had worsening shortness of breath
and coughing. You were found to have an asthma exacerbation.
Please see more details listed below about what happened while
you were in the hospital and your instructions for what to do
after leaving the hospital.
It was a pleasure participating in your care. We wish you the
best!
Sincerely,
Your ___ Care Team
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL:
- We gave you medication and oxygen to improve your breathing.
With this treatment you improved and were ready to leave the
hospital.
- You were started on a short course of prednisone (5 days
total) during your stay in the hospital and you will need to
finish this course after you leave
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL:
- Please follow up with your primary care doctor and other
health care providers (see below)
- Please take all of your medications as prescribed (see below).
- Seek medical attention if you have difficulty breathing or
other symptoms of concern.
- Please try and avoid dust, allergens, mites, and mold as best
as possible. these may exacerbate your asthma
Followup Instructions:
___
|
10189939-DS-19 | 10,189,939 | 22,003,018 | DS | 19 | 2180-08-22 00:00:00 | 2180-08-28 17:00:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
ERCP ___
Evidence of prior sphincterotomy was noted
Successful biliary cannulation with balloon catheter
The intrahepatics appeared sparse/pruned, consistent with known
diagnosis of PSC.
The previously treated left intrahepatic stricture looked
somewhat improved, although there was slight upstream dilation
of the left intrahepatics with some delayed contrast drainage.
The CBD appeared more narrow than before and a 1.5cm stricture
was noted in the mid/low CBD.
Cytology/FISH samples were taken at the stricture
Although the patients LFTs are normal, given the RUQ pain,
fever, and worsening stricture in the CBD, the decision was made
to place a short term biliary stent as a trial to evaluate for
symptom resolution
A 7cm x ___ plastic stent was placed into the CBD
Otherwise normal ERCP to ___ part of duodenum.
History of Present Illness:
___ male with hx of crohn's disease, s/p subtotal colectomy,
primary sclerosing cholangitis here with abdominal pain and
fevers. Pt reports that in the past 1 week he has been having
increasing pain located in a band across the B upperquads with
radiation into the epigastric region and chest. In the past 24
hours it has worsened and became quite severe. He began to
have fever, nausea, and vomiting with dry heaves in the past 12
hours and therefore presented to medical care. He has also been
having shakes intermittently, worse since his procedure today.
He denies any bloody stools or mucus in the stools, he has
chornic loose stools. He is also worried about recent retinal
detachment and has decrease in vision in the left eye.
10 systems reviewed and are negative except where noted in HPI
above
Past Medical History:
PAST MEDICAL HISTORY:
- Crohn's disease: since age ___
- Primary sclerosing cholangitis
- Hypertension
- Depression
- Anxiety
- GERD
- Hx Pancreatic cysts
- s/p subtotal colectomy
-retinal detachment L eye
Social History:
___
Family History:
No history of autoimmune diseases or inflammatory bowel disease.
Physical Exam:
temp 100. 82 116/60 98%ra
Cons: NAD, lying in bed +rigors
Eyes: EOMI, no scleral icterus
ENT: MMM
Neck: nl ROM, no goiter
Lymph: no cervical LAD
Cardiovasc: rrr, no murmur, no edema
Resp: CTA B
GI: +hypoactive bs,soft,nt, nd
MSK: no significant kyphosis
Skin: no rashes
Neuro: no facial droop
Psych: normal range of affect
Pertinent Results:
___ 09:00AM PLT COUNT-297
___ 09:00AM NEUTS-86.1* LYMPHS-8.0* MONOS-4.7 EOS-0.6
BASOS-0.6
___ 09:00AM WBC-13.8* RBC-4.49* HGB-13.4* HCT-41.3 MCV-92
MCH-29.8 MCHC-32.3 RDW-14.4
___ 09:00AM ALBUMIN-3.6
___ 09:00AM ALT(SGPT)-21 AST(SGOT)-19 ALK PHOS-46 TOT
BILI-1.1
___ 09:00AM estGFR-Using this
___ 09:00AM GLUCOSE-111* UREA N-10 CREAT-0.8 SODIUM-140
POTASSIUM-3.7 CHLORIDE-108 TOTAL CO2-25 ANION GAP-11
___ 09:14AM LACTATE-1.8
Blood cx from ___- no growth
Blood cx from ___ - +Ecoli.
Brief Hospital Course:
___ male with hx of PSC and crohn's disease here with
abdominal pain, fever.
He was diagnosed with cholangitis likely due to biliary
stricture from PSC. He underwent ERCP which showed biliary
stricture and he is now s/p stent placement.
He was placed on zosyn for cholangitis.
Over time, pt had clinical improvement with resolution of his
abdominal pain, improvement in the fevers, and resolution of
genearlized malaise that he had been experiencing for the past
few weeks. He did note having increase in abd distention and
feeling bloated, exascerbated by eating. The pt develop a mild
ileus, but with return to PO fluids only this improved. The ___
abdominal distention improved and he was able to take good PO
again. The ___ blood cx at ___ grew e.coli, ___ to
bactrim, zosyn, resistant to cipro and unasyn. His blood cx
here remained negative.
After discussed with ___ GI MD, plan to d/c to home with
bactrim and for the pt to return to the cipro and flagyl as well
until seen in the clinic.
Pt was d/ced to home in good condition.
Also of note, due to hx of herpes eye infection and retinal
detachment/cyst the pt was seen by optho due to complaint of
painful eyes with tearing . They felt that he had dryness and
rec artificial tears which were helpful.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Ciprofloxacin HCl 500 mg PO Q12H
3. MetRONIDAZOLE (FLagyl) 500 mg PO BID
4. Alendronate Sodium 70 mg PO QSUN
5. DiCYCLOmine 10 mg PO DAILY:PRN abd cramping
6. Lorazepam 0.5 mg PO Q8H:PRN anxiety
7. Apriso (mesalamine) .750 g oral daily
8. Nortriptyline 10 mg PO HS
9. Omeprazole 40 mg PO DAILY
10. PredniSONE 20 mg PO DAILY
11. Ursodiol 300 mg PO DAILY
12. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE HS
13. Zirgan (ganciclovir) 0.15 % ophthalmic five times a day
Discharge Medications:
1. DiCYCLOmine 10 mg PO DAILY:PRN abd cramping
2. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE HS
3. Lorazepam 0.5 mg PO Q8H:PRN anxiety
4. Nortriptyline 10 mg PO HS
5. PredniSONE 20 mg PO DAILY
6. Ursodiol 300 mg PO DAILY
7. Artificial Tears Preserv. Free ___ DROP BOTH EYES Q4H
8. Alendronate Sodium 70 mg PO QSUN
9. Apriso (mesalamine) .750 g oral daily
10. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
11. Omeprazole 40 mg PO DAILY
12. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*20 Tablet Refills:*0
13. MetRONIDAZOLE (FLagyl) 500 mg PO TID
please use the higher dose (three times a day) until you see
___
___ *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
cholangitis
Discharge Condition:
alert, oriented, ambulatory
Discharge Instructions:
You were hospitalized with a cholangitis (infection in the
biliary tree).
Having a stent placed help the bile to drain and to relieve
infection.
You were found to have E.Coli in the blood, but repeat blood
cultures were negative.
You have a mild post-infection ileus with slowness of the GI
system. this has improved.
Followup Instructions:
___
|
10189939-DS-20 | 10,189,939 | 24,110,862 | DS | 20 | 2180-10-25 00:00:00 | 2180-10-27 11:13:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending: ___.
Chief Complaint:
abd pain
Major Surgical or Invasive Procedure:
NG tube placement
History of Present Illness:
___ w/Crohn's s/p subtotal colectomy, and primary sclerosing
cholangitis presents with fever, diarrhea, nausea and RUQ pain.
He has been taking cipro/flagyl since ___. He stopped
prednisone last week. 3 days after stopping prednisone he began
to have abdominal pain. The next day he had non-bloody diarrhea
and felt fatigued. 2 days ago he developed fever to 101, nausea,
anorexia and epigastric/RUQ abd pain. He is passing gas and has
had multiple watery BMs today. No emesis.
In ED pt tachy to 126, normotensive. HR improved with 2L bolus.
Stool sent for O&P, culture and Cdiff. LFTs wnl. GI consulted.
CT scan with SBO. Surgery consulted, no need for acute
intervention or NGT, will staff in am.
On arrival to floor pt complained of palpitations and bilateral
elbow joint pain.
ROS: +as above, otherwise reviewed and negative
Past Medical History:
Crohn's disease: since age ___
- s/p subtotal colectomy ___
- partial SBO ___
Primary sclerosing cholangitis
- s/p ERCP stenting and stent removal (___)
Hypertension
Depression
Anxiety
GERD
Hx Pancreatic cysts
Retinal detachment L eye
Social History:
___
Family History:
No history of autoimmune diseases or inflammatory bowel disease.
Physical Exam:
Admission Physical Exam:
Vitals: T:99.0 BP:119/77 P:96 R:18 O2:96%ra
PAIN: 0
General: nad
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, high pitched, soft, distended,
tender epigastrium
Ext: no e/c/c
Skin: no rash
Neuro: alert, follows commands
Pertinent Results:
Admission Labs:
___ 02:35PM BLOOD WBC-10.5 RBC-5.69 Hgb-16.6 Hct-52.0
MCV-91 MCH-29.2 MCHC-32.0 RDW-14.4 Plt ___
___ 02:35PM BLOOD Neuts-75.9* Lymphs-14.7* Monos-7.5
Eos-0.9 Baso-1.0
___ 02:35PM BLOOD Glucose-104* UreaN-13 Creat-1.0 Na-136
K-4.5 Cl-99 HCO3-22 AnGap-20
___ 02:35PM BLOOD ALT-32 AST-38 AlkPhos-63 TotBili-0.5
___ 02:35PM BLOOD Lipase-34
___ 02:35PM BLOOD Albumin-4.6
___ 09:00PM BLOOD ESR-27*
___ 04:43AM BLOOD Triglyc-75
___ 07:10AM BLOOD TSH-2.4
___ 06:40AM BLOOD Cortsol-28.1*
___ 09:00PM BLOOD CRP-24.1*
TPMT ACTIVITY 21 nmol/hr/mL RBC (WNL)
Discharge Labs:
___ 06:00AM BLOOD WBC-24.0* RBC-4.23* Hgb-12.6* Hct-39.0*
MCV-92 MCH-29.7 MCHC-32.3 RDW-15.3 Plt ___
___ 06:00AM BLOOD Glucose-90 UreaN-17 Creat-0.5 Na-139
K-4.2 Cl-106 HCO3-26 AnGap-11
___ 06:00AM BLOOD ALT-18 AST-16 AlkPhos-58 TotBili-0.7
___ 06:00AM BLOOD Calcium-8.0* Phos-2.9 Mg-2.0
MICROBIOLOGY:
Blood Cx NEGATIVE x 5, PENDING x ___ - Stool Cx NEGATIVE, Cdiff negative
___ - Stool Cx NEGATIVE
___ - Stool Cx NEGATIVE, Cdiff negative
___ - Cdiff negative
___ - PICC Tip Cx NEGATIVE x 2
ECG (___) - Sinus tachycardia. Possible left atrial
abnormality. Left axis deviation
consistent with left anterior fascicular block. Compared to the
previous
tracing of ___ the rate is faster and axis is slightly more
to the left.
CT A/P (___)
IMPRESSION:
1. Findings concerning for early partial small bowel
obstruction extending to
the level of focal narrowing along the bowel in the right lower
quadrant
(601B:24) with increased caliber of the small bowel from
___. Fluid seen
in the small bowel distal to this level.
2. Chronic findings including multiple pancreatic IPMN,
multiple hepatic
hypodensities and persistent dilatation of the left intrahepatic
biliary tree
stable in comparison to the most recent prior CT of ___ and MRI
of ___.
U/S (___)
IMPRESSION:
1. Multiple hepatic cystic areas in left lateral segments of
the liver,
similar to the prior study. Mild intrahepatic biliary
dilatation in the right
lobe. Similar findings were seen on the prior CT.
2. Normal gallbladder with no stones
KUB (___)
IMPRESSION: Findings suggest small bowel obstruction, worse than
on ___.
KUB (___)
IMPRESSION: One frontal upright and two frontal supine views of
the abdomen
are compared to ___:
Nasogastric tube has been removed. Although there is moderate
distention of
bowel loops in the upper abdomen that are probably colon, the
majority of
distended loops are small bowel containing air and fluid,
usually indicating
stasis. There has been a slight increase in the number of these
distended
small bowel loops, but the distension of these loops is not
nearly as severe
as it was on ___. For example, in the left upper
quadrant, 36 mm
today and 48 mm on ___, in the left flank, 51 mm today
and 65 mm on
___. The most reasonable explanation is that there is
continued
partial small-bowel obstruction. There is no free
subdiaphragmatic gas, and
no mass effect in the upper or mid abdomen.
MRE (___)
IMPRESSION:
1. No evidence of current bowel obstruction. Chronic changes
related to
Crohn's disease, without active inflammation evident. Widely
patent
ileosigmoid anastomosis Mild tethering and angulation of
central small bowel
loops from adhesions.
2. Numerous pancreatic cysts, likely side-branch IPMN, with
mild interval
enlargement of the dominant cysts since ___. Follow up
MRCP in ___
year is recommended.
3. Numerous simple hepatic cysts. Known changes of primary
sclerosing
cholangitis, predominant in the left hepatic lobe are better
assessed on the
prior MRCP studies.
Flex Sig (___)
Granularity, friability and erythema in the rectum. There was no
obstructing lesion to explain the small bowel obstruction at the
level of the anastamosis. (biopsy)
Otherwise normal sigmoidoscopy to splenic flexure
PATHOLOGIC DIAGNOSIS:
Rectum, biopsy:
Superficial fragments of colonic mucosa with mild crypt
architectural
disarray and focal surface hyperplastic features.
Brief Hospital Course:
___ with Crohn's disease, PSC, hypertension, depression, anxiety
who presented with fever, diarrhea, nausea and abdominal pain.
# Partial small bowel obstruction: Complicated by persistent
ileus following resolution of the bowel obstruction. He
presented with a CT scan concerning for partial bowel
obstruction. GI and surgery were consulted. He was treated with
bowel rest, IV fluids and pain control. He did require NGT for
decompression x2, TPN with PICC placement, antibiotics and IV
steroids. Surgery felt that no surgery was indicated. GI did a
flexible sigmoidoscopy without evidence of obstruction or
stricture. He underwent an MRE which did not show evidence of
obstruction or significant small bowel inflammation. His diet
has been advanced slowly and he is currently tolerating a full
liquid diet. He is passing small semi formed stools as well as
flatus.
# Crohn's disease:
He had no evidence of active colitis on CT imaging or MRE. He
was treated initially with steroids and antibiotics per GI
consult recommendations. However, steroids are now being tapered
given no evidence of active colitis. GI has recommended d/c of
antibiotics; however, he remains on cipro and flagyl given
ongoing leukocytosis of unclear etiology (see below).
# Leukocytosis:
He had significant leukocytosis without fevers. The etiology was
not clear. He was empirically switched to meropenem and had his
PICC discontinued with improved in his WBC. He was subsequently
changed back to cpiro/flagyl given no positive culture data. WBC
has begun to increase again, but this was happening prior to
switch back to cipro/flagyl. No localizing signs of infection.
No fevers. CXR and UA were negative. PICC removed, cx with no
growth. C.diff negative. As described below, pt is being
discharged to an outpatient ophtho appt; however, he will be
readmitted later today for further workup of this leukocytosis.
# Retinopathy: Pt gets monthly intraoccular Avastin injections
for a retinopathy. He is followed by Dr. ___ in ___.
Pt noted worsening vision on ___, prompting ophtho exam on
___. Retinal images were taken and were transmitted to
patient's outpatient ophthalmologist. On ___, this writer was
contacted by pt's outpt ophthalmologist who, after reviewing the
retinal images, felt that his retina looked much worse and
recommended either Avastin or Lucentis intra-occular injection
as soon as possible. Inpatient ophthalmology team was contact,
who recommended retinal consult. Case was discussed with
inpatient retinal consult service who felt that the need for
injection was less urgent and recommended fluorescein
angiography on ___ with possible injection vs laser therapy
next week depending on what was found. On discussion with the
patient, he expressed significant concern about the potential
loss of vision should the retinopathy progress. Given these
concerns, the patient adamantly wished to go to his outpatient
___ clinic so that he would be able to get his injection same
day. Plan was made that patient would be discharged so that he
could go to this clinic. It was felt that he was stable to go to
his outpatient appointment. He would then return to the hospital
to be readmitted for further management. The patient was in
agreement with this plan, as was his brother who was also
present.
#Primary sclerosing cholangitis- He had a very low suspicion for
cholangitis given normal LFTs and more diffuse abdominal pain.
Pt has undergone prior ERCPs. LFTs were trended. Pt was
continued on ursodiol when tolerating PO.
#anxiety/depression-continued home meds. Social work was
consulted.
#fatigue/deconditioning-TSH WNL, cortisol WNL. Not anemic.
Likely due to several recent hospitalizations and poor PO
intake. SW was consulted to assist with coping.
#pt reports of exertional tachycardia-Likely due to
deconditioning, dehydration, and malnutrition. Advised pt to
discuss with his PCP whether he may benefit from an echo,
cardiology consultation, or Holter Monitoring. Discussed the
use of Valsalva to help lower heart rate.
TRANSITIONAL ISSUES:
MRE showing "Numerous pancreatic cysts, likely side-branch IPMN,
with mild interval enlargement of the dominant cysts since ___. Follow up MRCP in ___ year is recommended."
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. DiCYCLOmine 10 mg PO EVERY OTHER DAY abd cramping
2. Lorazepam 0.5 mg PO Q8H:PRN anxiety
3. Nortriptyline 10 mg PO HS
4. Ursodiol 1200 mg PO DAILY
5. Alendronate Sodium 70 mg PO QSUN
6. Apriso (mesalamine) .750 g oral daily
7. Ciprofloxacin HCl 500 mg PO Q12H
8. Omeprazole 40 mg PO DAILY
9. MetRONIDAZOLE (FLagyl) 500 mg PO BID
10. Hydrocortisone Acetate 10% Foam 1 Appl PR HS
11. Fluconazole Dose is Unknown PO Q24H
12. Atenolol 25 mg PO DAILY
Discharge Medications:
1. Ursodiol 1200 mg PO DAILY
2. Acetaminophen IV 1000 mg IV Q6H:PRN pain
3. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
4. Calcium Carbonate 500 mg PO QID:PRN heartburn
5. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN sore throat
6. Ciprofloxacin 400 mg IV Q12H
7. Fat Emulsion 20% 250 mL IV ONCE Duration: 1 Dose
8. Heparin 5000 UNIT SC TID
9. Lorazepam 0.5 mg IV Q6H:PRN nausea/anxiety
10. Mesalamine 250 mg PO TID
11. Metoclopramide 10 mg PO/IV QID:PRN Nausea
12. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
13. Nystatin Oral Suspension 5 mL PO QID
14. Pantoprazole 40 mg IV Q24H
15. PredniSONE 40 mg PO DAILY
16. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
17. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
partial small bowel obstruction
nausea, vomiting, diarrhea
crohn's disease
PSC
depression
retinopathy
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 with nausea,
vomiting, and diarrhea. Your imaging revealed a partial bowel
obstruction. You were treated with an NG tube, bowel rest,
antibiotics, and medication for pain and nausea and your
symptoms improved. You were evaluated by the GI and surgical
teams as well. You received IV steroids and then switched to
steroids by mouth as your diet was advanced. During your
admission, you noted worsening of her vision. You were seen by
our opthalmologists, who, on discussion with our
ophthalmologists, felt that there was worsening of your
retinopathy. You are being discharged to your ophthalmologist's
clinic for an eye injection. YOU MUST RETURN TO THE HOSPITAL TO
BE READMITTED FOR FURTHER MANAGEMENT OF YOUR MEDICAL CONDITIONS.
Followup Instructions:
___
|
10189939-DS-23 | 10,189,939 | 27,145,991 | DS | 23 | 2181-08-15 00:00:00 | 2181-08-15 21:04:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
___ line placement ___
History of Present Illness:
___ year old male with past medical history significant for
crohn's disease (s/p subtotal colectomy), primary sclerosing
cholangitis, c/b recurrent cholangitis/bactermia , h/o DVT/PE (
on coumadin) with recent admission for cholangitis now
presenting with fever. The patient was recently admitted to
___ from ___ for e.coli bactermia and cholangitis
treated w/ ctx and flagyl. His abx ended on ___ with subsquent
intiation of rifaxamin for ppx. He was feeling well since
discharge until the day of admission when he had the onset of
chills around 2 pm. He took his temperature and it was 101.___ referred him to the ED.
In the ED, initial vitals were 100.8 104 126/72 18 97%
-Labs notable for ALT 281, AST 223, alkp 485, tibii 2.3 ( all up
from discharge), normal lipase wbc of 15, INR 2.3, lacate 2.2.
blood cx x 2 were also sent
-Imaging: CXR clear, RUQ ultrasound showed irregular dilated
bile ducts throughoutcompatible with known primary sclerosing
cholangitis and Prominent gallbladder with sludge similar to
prior studies without evidence of cholecystitis
-Liver was consulted in the ED and recommneded admission, and
treatement with CTX, flagyl, and MRCP to eval for e/o of
cholangitis
- he was given 1L NS, 1gm tylenol, flagyl and CTX
ROS: per HPI, denies night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- Crohn's disease: since age ___ s/p subtotal colectomy ___
partial SBO ___ --Has been off Humira for ___ years. Had been
on prednisone 40 for months, recently tapered to prednison 10
for last few months.
- Primary sclerosing cholangitis c/b strictures s/p multiple
ERCPs stenting and stent removal (___)
- ___ for partial SBO which resolved with conservative
treatment
- ___ for cholangitis and E.coli bacteremia treated with a
course of Zosyn.
- ___ and ___ for abd pain/fevers; however, a source
was never determined.
- ___ he required hospitalization at ___ for RUE DVT, LLE DVT and PE.
-depression/anxiety
-multiple pancreatic cysts
-h/o GBS bacteremia ___, unclear source, neg TEE, tx'd w/PCN
x2 weeks
- Hypertension
- Depression
- Anxiety
- GERD
- Hx Pancreatic cysts
Retinal detachment L eye
Social History:
___
Family History:
Sisters with breast cancer. No h/o GI, liver, biliary cancers.
No h/o of Crohn's in other members of family. No h/o autoimmune
conditions in family (type 1 diabetes, thyroid, pernicious
anemia)
Physical Exam:
PHYSICAL EXAM ON ADMISSION
VS: T:99 BP 109/52 P 58 RR 20 98% RA
General: non-toxic appear in NAD
HEENT: EOMI, no scleral icterus
Neck: supple
CV: nl s1 s2
Lungs: CTAB
Abdomen: soft, NTND, normoactive BS
GU: no foley
Ext: no edema
Neuro: AOx 3, no asterixis
PHYSICAL EXAM ON DISCHARGE
afebrile, 109/62 50 16 98%RA
General: well appearing, AAOX3, appropriate mentation
HEENT: anicteric
Neck: supple
CV: RRR, no mrg
Lungs: CTAB no w/r/r
Abdomen: soft, NTND, normoactive BS
GU: no foley
Ext: no edema
Neuro: ___ strength throughout
Pertinent Results:
LABS ON ADMISSION
------------------
___ 02:15PM BLOOD WBC-10.9 RBC-4.66 Hgb-14.2 Hct-42.5
MCV-91 MCH-30.4 MCHC-33.4 RDW-15.4 Plt ___
___ 02:15PM BLOOD Neuts-69.1 ___ Monos-7.6 Eos-2.1
Baso-0.9
___ 02:15PM BLOOD ___
___ 02:15PM BLOOD Plt ___
___ 06:53PM BLOOD Glucose-107* UreaN-11 Creat-0.7 Na-137
K-4.2 Cl-104 HCO3-23 AnGap-14
___ 02:15PM BLOOD ALT-284* AST-211* CK(CPK)-51 AlkPhos-483*
TotBili-1.1
___ 02:15PM BLOOD Albumin-3.8
LABS ON DISCHARGE
--------------------
___ 05:49PM BLOOD Lactate-2.2*
___ 06:00AM BLOOD WBC-8.4 RBC-4.22* Hgb-12.5* Hct-38.8*
MCV-92 MCH-29.5 MCHC-32.1 RDW-15.6* Plt ___
___ 10:55AM BLOOD ___ PTT-93.9* ___
___ 06:00AM BLOOD Glucose-86 UreaN-9 Creat-0.6 Na-143 K-3.7
Cl-109* HCO3-27 AnGap-11
___ 06:00AM BLOOD ALT-256* AST-152* AlkPhos-434*
TotBili-1.2
___ 06:00AM BLOOD Albumin-3.3* Calcium-8.5 Phos-3.0 Mg-2.0
___ 02:15PM BLOOD CA ___ -Test
___ 06:55PM URINE Color-Yellow Appear-Clear Sp ___
___ 06:55PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
MICROBIOLOGY
-------------
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
___ VANCOMYCIN RESISTANT
ENTEROCOCCUS-FINALINPATIENT
___ CULTUREBlood Culture,
Routine-PRELIMINARY {ESCHERICHIA COLI}; Anaerobic Bottle Gram
Stain-FINALEMERGENCY WARD
___ 6:00 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
ESCHERICHIA COLI.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
Anaerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___. ___ (___)
___ @
11:26 AM.
___ CULTUREBlood Culture, Routine-FINAL
{ESCHERICHIA COLI}; Aerobic Bottle Gram Stain-FINALEMERGENCY
WARD
___ 5:35 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI. FINAL SENSITIVITIES.
___ ___ (___) REQUESTED ERTAPENEM
SENSITIVITIES
___.
Ertapenem SUSCEPTIBLE sensitivity testing performed by
___
___.
Piperacillin/Tazobactam sensitivity testing confirmed
by ___
___.
DORIPENEM , TETRACYCLINE AND DOXYCYCLINE SENSITIVITES
REQUESTED BY
___. ___ ___.
RESISTANT TO TETRACYCLINE AND DOXYCYCLINE.
TETRACYCLINE AND DOXYCYCLINE sensitivity testing
performed by
___. SENSITIVE TO DORIPENEM. DORIPENEM MIC
0.094 MCG/ML.
DORIPENEM Sensitivity testing performed by Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- =>128 R
TETRACYCLINE---------- R
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
Aerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___. ___ (___)
___ @
11:26 AM.
Brief Hospital Course:
___ year old male with history of Crohn's disease on chronic
steroid therapy complicated by primary schlerosing cholangitis
with history of recurrent ascending cholangitis accompanied with
several episodes of bacteremia while on suppressive
cipro/metronidazole and/or amox/clav, representing with
cholangitis and E. coli bacteremia.
BRIEF HOSPITAL COURSE
ACTIVE ISSUES
# E. COLI BACTEREMIA ___ CHOLANGITIS: The patient was recently
admitted with E.coli bacteremia secondary to cholangitis on ___
and finished a two week course of ceftriaxone/metronidazole
therapy on ___/. He started rifaximin at that time for
prophlyaxis against cholangitis. Four days after finishing his
course of CTX/metronidazole, he represented with rigors and high
temperatures. Work up showed E.coli bacteremia with MDR
organism sensitive to meropenem/ertapenem and gentamycin. Repeat
MRCP showed interval improvement in previous areas of
cholangitis within the right lobe and segment II of the left
lobe of the liver and no hepatic abscess with unchanged
irregularity and moderate intrahepatic and common bile duct
dilation, without new areas of biliary obstruction or
inflammation. It was felt that there was no dominant stricutre
that could be intervened upon.
He was initially treated with piperacillin/tazobactam but once
sensitivity known transitioned to meropemen while inpatient with
plans to transition to ertapenem as outpatient for a minimum of
4 weeks of therapy. He received his first dose of ertapnem
in-house without any signs of anaphylaxis.
# ANTICOAGULATION: Patient with history of recurrent PE/DVTs. He
has an INR goal of 2.5 -3.5 for unclear reasons. His warfarin
was suspended and he was reversed for purposes of placing a PICC
line for ongoing antibiotic treatment. He was anticoagulated
with heparin gtt. On day of discharge he was restarted on
warfarin and sent home on ___.
# ELEVATED CA ___: Patient with history of elevated CA ___,
drawn during acute episode of cholangitis. Repeat lab redrawn
immediately prior to admission with interval decrease. These is
reassuring against malignancy. The patient was informed of the
results by his outpatient hepatologist, Dr. ___.
CHRONIC ISSUES:
# Crohn's disease: Patient was continued on home dose Apreso and
prednisone 10 mg.
#Anxiety: Patient was continued on home dose Ativan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lorazepam 0.5 mg PO Q8H:PRN anxiety
2. Omeprazole 40 mg PO DAILY
3. PredniSONE 10 mg PO DAILY
4. Ursodiol 900 mg PO DAILY
5. Warfarin 8 mg PO DAILY16
6. Apriso (mesalamine) 0.750 gm oral daily
7. Rifaximin 550 mg PO BID
Discharge Medications:
1. PredniSONE 10 mg PO DAILY
2. Ursodiol 900 mg PO DAILY
3. Omeprazole 40 mg PO DAILY
4. Lorazepam 0.5 mg PO Q8H:PRN anxiety
5. Apriso (mesalamine) 0.750 gm oral daily
6. Ertapenem Sodium 1 g IV DAILY Duration: 1 Dose
RX *ertapenem [Invanz] 1 gram 1 g IV once a day Disp #*25 Vial
Refills:*0
7. Heparin Flush (10 units/ml) 2 mL IV ONCE MR1 and PRN, line
flush Duration: 1 Dose
RX *heparin lock flush (porcine) [heparin lock flush] 10 unit/mL
2 mL IV ONCE MR1 Disp #*25 Syringe Refills:*0
8. Rifaximin 550 mg PO BID
9. Enoxaparin Sodium 80 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
Patient to STOP administering shots when at goal INR 2.5-3.5.
RX *enoxaparin 80 mg/0.8 mL 0.8 mL SQ q12hr Disp #*30 Syringe
Refills:*0
10. Warfarin 8 mg PO DAILY16
11. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
Peripheral IV - Inspect site every shift
RX *sodium chloride 0.9 % 0.9 % ___ mL IV once a day Disp #*30
Syringe Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
E-coli bacteremia
Cholangitis
Secondary diagnoses:
Crohn's disease
Primary sclerosing cholangitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a privilege to provide care for you here at the ___
___. You were admitted because you had
fevers. You were found to have a persistent cholangitis, and E
coli in a blood culture. You were treated with IV antibiotics,
and will have a PICC line to continue your antibiotic therapy
for a minimum of four weeks.
Your condition has improved and you can be discharged to home.
Please keep your follow-up appointments as scheduled below.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10189939-DS-24 | 10,189,939 | 27,334,098 | DS | 24 | 2181-09-06 00:00:00 | 2181-09-12 10:56:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending: ___.
Chief Complaint:
fever, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with Crohn's disease s/p subtotal colectomy in ___, PSC,
h/o DVT and PE, multiple prior admissions for Crohn's flares and
acute bacterial cholangitis, recent bacteremia with ESBL EColi
now on daily ertapenem through ___ line, presenting with 1 day
of diffuse abdominal pain and diarrhea.
He was feeling well at home since his discharge from the
hospital several weeks ago. One day prior to today's admission,
he developed sudden onset diffuse abdominal pain with 12
episodes of watery-green diarrhea in the past day. Last BM was
in the ED. He has had nausea and several bouts of nonbloody
vomiting. He had fever to T100.3 with chills at home. He denies
any dysphagia or odynophagia, no hematochezia or melena.
He went to ___ earlier today and had UA which was
negative, Cdiff is pending. In the ___ ED, initial vitals were
98.9 90 118/71 18 96%. CXR with patchy opacity in the right
lower lobe, likely atelectasis. Labs notable for WBC 18.0 (92%
PMN), Hct 44.8, Plt 437. Chem-7 normal, Cr 0.7. AST 205, ALT 269
(both near baseline), AP up 528, TB up to 4.4. Lipase 96. INR
4.3. Lactate 1.3. In the ED, he was given 1L NS, lorazepam 1mg
IV x1, and Zofran IV.
I evaluated him in the ED. He had two episodes of nonbloody
pale-yellow emesis while I interviewed him. He also had to step
out to have a bout of watery diarrhea in the bathroom.
ROS: +Abdominal pain diffuse, watery diarrhea, nausea, nonbloody
vomiting, fever, chills. Denies melena, hematochezia. Denies
chest pain, dypsnea, dysuria, frequency.
Past Medical History:
- Crohn's disease: since age ___ s/p subtotal colectomy ___
partial SBO ___ --Has been off Humira for ___ years. Had been
on prednisone 40 for months, recently tapered to prednisone 10
for last few months.
- Primary sclerosing cholangitis c/b strictures s/p multiple
ERCPs stenting and stent removal (___)
- ___ for partial SBO which resolved with conservative
treatment
- ___ for cholangitis and E.coli bacteremia treated with
Zosyn.
- ___ and ___ for abd pain/fevers; however, a source
was never determined.
- ___ he required hospitalization at ___
___ for RUE DVT, LLE DVT and PE.
- depression/anxiety
- multiple pancreatic cysts
- GBS bacteremia ___, unclear source, neg TEE, rx PCN x2
weeks
- Hypertension
- Depression
- Anxiety
- GERD
- Retinal detachment L eye
Social History:
___
Family History:
Sisters with breast cancer. No h/o GI, liver, biliary cancers.
No h/o of Crohn's in other members of family. No h/o autoimmune
conditions in family (type 1 diabetes, thyroid, pernicious
anemia)
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T98.4 93 125/81 18 95% RA
GENERAL: Ill appearing, middle aged man, hunched over vomiting
in emesis bin, not in any pain
HEENT: Sclera anicteric, MMM, tongue without lesions
HEART: RRR, normal S1 S2, no murmurs
LUNGS: Clear, no wheezes, rales, or rhonchi
ABD: Normal bowel sounds, well healed midline scar, multiple
purpuric patches RLQ and LLQ from recent enoxaparin injections,
mildly tender to palpation diffusely, no rebound or guarding,
negative ___ sign
EXT: No ___ edema, 2+ DP and ___ pulses
SKIN: No jaundice, R PICC line in place
NEURO: Alert and oriented
DISCHARGE PHYSICAL EXAM:
VS: Tc 98.9 Tm 99.5 BP 100/53 (100-120s) HR 62 RR 18 O2 98RA
GENERAL: NAD
HEENT: Sclera anicteric, MMM, tongue without lesions
HEART: RRR, normal S1 S2, no murmurs
LUNGS: Clear, no wheezes, rales, or rhonchi
ABD: hyperactive bowel sounds, well healed midline scar,
multiple purpuric patches RLQ and LLQ from recent enoxaparin
injections, nontender, no rebound or guarding
EXT: No ___ edema, 2+ DP and ___ pulses
SKIN: No jaundice, R PICC line in place without edema or
erythema
NEURO: Alert and oriented
Pertinent Results:
ADMISSION LABS:
___ 08:30PM BLOOD WBC-18.0*# RBC-5.10 Hgb-15.5 Hct-44.8
MCV-88 MCH-30.3 MCHC-34.5 RDW-15.2 Plt ___
___ 08:30PM BLOOD Neuts-91.7* Lymphs-4.2* Monos-3.5 Eos-0.3
Baso-0.3
___ 12:49AM BLOOD ___ PTT-53.4* ___
___ 08:30PM BLOOD Glucose-113* UreaN-15 Creat-0.7 Na-137
K-4.0 Cl-102 HCO3-22 AnGap-17
___ 08:30PM BLOOD ALT-269* AST-205* AlkPhos-528*
TotBili-4.4* DirBili-3.5* IndBili-0.9
___ 08:30PM BLOOD Lipase-96*
___ 08:30PM BLOOD Albumin-4.2
___ 08:30PM BLOOD CRP-41.3*
___ 08:36PM BLOOD Lactate-1.3
DISCHARGE LABS:
___ 06:20AM BLOOD WBC-7.2 RBC-4.01* Hgb-12.0* Hct-36.5*
MCV-91 MCH-30.0 MCHC-33.0 RDW-15.1 Plt ___
___ 06:20AM BLOOD ___ PTT-40.7* ___
___ 06:20AM BLOOD Glucose-87 UreaN-12 Creat-0.5 Na-140
K-3.4 Cl-105 HCO3-27 AnGap-11
___ 06:20AM BLOOD ALT-209* AST-143* AlkPhos-380*
TotBili-2.9*
___ 06:20AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.9
___ 05:05AM BLOOD VitB12-1321*
___ 05:05AM BLOOD 25VitD-24*
MICRO:
___ 07:45PM URINE Color-AMBER Appear-Clear Sp ___
___ 07:45PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-10 Bilirub-LG Urobiln-2* pH-6.0 Leuks-TR
___ 07:45PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
___ 06:13PM STOOL NOROVIRUS RNA, PCR-Test Negative
___ 7:43 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 3:07 am STOOL CONSISTENCY: WATERY
ADD-ON REQUEST FROM ___ FOR C.DIFFICILE ON
___
@0900.
**FINAL REPORT ___
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final ___:
No VRE isolated.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
___ 1:15 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool. MICROSPORIDIUM AND CYCLOSPORA ADDED PER
FAX.
**FINAL REPORT ___
MICROSPORIDIA STAIN (Final ___: NO MICROSPORIDIUM
SEEN.
CYCLOSPORA STAIN (Final ___: NO CYCLOSPORA SEEN.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
CMV Viral Load (Final ___:
CMV DNA not detected.
Performed by Cobas Ampliprep / Cobas Taqman CMV Test.
Linear range of quantification: 137 IU/mL - 9,100,000
IU/mL.
Limit of detection 91 IU/mL.
This test has been verified for use in the ___ patient
population.
___ Blood culture x 2 no growth
___ Blood culture no growth
IMAGING:
___ MRE:
IMPRESSION:
1. Three new inflammatory strictures are identified in the
small bowel as described above compatible with active, probably
on chronic, Crohn's disease.
2. Dilated small bowel containing fluid compatible with history
of diarrhea.
3. No evidence of perforation or abscess.
4. Intrahepatic and extrahepatic bile duct dilation with
beading compatible with primary sclerosing cholangitis. The
overall appearance is grossly stable from the prior exam last
month; however, contribution of cholangitis to the patient's
symptoms cannot be excluded.
___ CXR: Patchy opacity RLL, likely atelectasis.
___ CT ABD PELVIS WITH IV CONTRAST:
1. Foci of gas within the portal and superior mesenteric veins,
new from the prior examination. There is no definite evidence of
bowel ischemia or pneumatosis. Findings could potentially be
related to history of inflammatory bowel disease or
bacteremia/ongoing infection. Clinical correlation is
recommended and close imaging followup is suggested.
2. Intrahepatic biliary ductal irregularity and dilatation, and
proximal common bile duct dilatation with stricturing in its mid
portion, largely unchanged from prior examination and secondary
to the patient's primary sclerosing cholangitis. No hepatic
abscess is identified.
3. Diffusely fluid-filled and distended small bowel, colon, and
rectum, likely reflective of gastroenteritis given the patient's
clinical presentation. No transition point or bowel obstruction
is identified.
4. 2 focal areas of apparent bowel wall thickening in the right
lower quadrant, 1 presumably at the anastomosis of the ileum
with the sigmoid colon, and another within the ileum, without
adjacent inflammatory changes. These findings may be secondary
to bowel underdistension, although mild bowel inflammation is
difficult to exclude. If clinically warranted, MRI enterography
could be performed for further evaluation.
5. Numerous hepatic cysts/ biliary hamartomas and pancreatic
cystic lesions, likely side branch IPMNs, unchanged and better
evaluated on the recent MRCP.
Brief Hospital Course:
___ with Crohn's disease s/p subtotal colectomy in ___ on
chronic prednisone, PSC, h/o DVT and PE on warfarin, recent
bacterial cholangitis with ESBL EColi bacteremia on ertapenem,
presenting with one day of diffuse abdominal pain, watery
diarrhea, and leukocytosis.
# Fever - He met SIRS criteria on admission including
leukocytosis, borderline tachycardia, and recent low-grade
fever. Most likely due to an infection. Suspected source
included gastroenteritis vs C.difficile colitis (recent
antibiotic, qualifies as severe CDI due to >6 stools/24hrs,
WBC>15k, known IBD) vs. recurrent cholangitis. No new or
worsening biliary dilatation from baseline, no abscess or SBO
seen on CT. He had recent cholangitis and ESBL EColi bacteremia
now on daily ertapenem (sensitive only to meropenem/ertapenem
and gentamycin) through ___ line and was on 4-week course (last
day ___. CXR negative for pneumonia. He is
immunocompromised on chronic prednisone and mesalamine, so there
is low threshold for infection and we cannot rule out Crohn's
flare. Elevated TBili and DBili concerning for obstruction, but
no evidence on CT. Initially received IV vanc, IV ___, PO vanc
and IV flagyl. IV vanc was DCed given low suspicion for GPC. C
diff returned negative so PO vanc and IV flagyl DCed in am on
___. Leukocytosis resolved on ___. However patient spiked a
fever to 102.7 overnight on ___. No new symptoms. Differential
includes cholagnitis vs. bacterial or viral gastroenteritis.
Stool cultures negative to date. Given worsening clinical status
PO vanc was restarted. Initial C diff sample was brought in from
home and it is unclear how long sample sat around for prior to
processing. The C diff sample inpatient was also an add on. C
diff test is usually highly sensitive. However, given that
patient improved once again after restarting PO vanc, it was
continued until ID follow up. Patient improved clinically and
felt much better on day of discharge. Given that patient
improved in the setting of holding his prednisone, it was felt
that his symptoms were likley infectious from recurrent
cholangitis vs. gastroenteritis vs. C diff. He was discharged on
IV ertapenem and PO vanc until follow up in ___ clinic.
- follow up BCx, norovirus PCR
# HISTORY OF DVT AND PE. INR goal of 2.5-3.5 due to recurrent
DVT and PE. Last INR 2.7 ___ at ___, but supratherapeutic
at 4.3 here at ___. No evidence for bleeding. Hct at baseline.
INR 3.7 on ___. INR 2.5 on ___ so restarted at 10mg daily
with repeat INR testing as outpatient.
# CROHN'S DISEASE. Current clinical course seems more consistent
with sepsis due to GI source rather than active Crohn's flare,
but this cannot be ruled out entirely. Prednisone was held on
admission given concern for infectious process. Continued to
hold prednisone during admission and patient improved with no
futher fevers, resolution of abdominal pain and distention, and
overall feeling better which argues against a Crohn's flair
being the etiology of current symptoms. Continued mesalamine
(Apriso) and ursodiol. Restarted home prednisone on discharge.
CHRONIC ISSUES:
# ANXIETY. Stable. Continued on home lorazepam.
# GERD. Continued home omeprazole PRN.
#CODE: Full
#CONTACT: wife ___ ___
___ Issues*
- Started on PO vancomycin daily until seen in ___ clinic on
___, please reassess need at this visit and refill
prescription if continued
- Continued on ertapenem until ___
- Norovirus pending on discharge
- Please follow up patient's Crohns disease and consider
alternative agents
- please follow up with pending blood cultures
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 10 mg PO DAILY
2. Ursodiol 900 mg PO DAILY
3. Omeprazole 40 mg PO DAILY:PRN acid reflux
4. Lorazepam 0.5 mg PO Q8H:PRN anxiety
5. Apriso (mesalamine) 0.750 gm oral daily
6. Ertapenem Sodium 1 g IV DAILY
7. Warfarin 7.5 mg PO DAILY16 some days 10mg
Discharge Medications:
1. Ertapenem Sodium 1 g IV DAILY Duration: 4 Doses
RX *ertapenem [Invanz] 1 gram 1 G IV Daily Disp #*4 Vial
Refills:*0
2. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
RX *sodium chloride 0.9 % [Normal Saline Flush] 0.9 % ___ mL
IV daily and PRN line flush Disp #*15 Syringe Refills:*0
3. Apriso (mesalamine) 0.750 gm oral daily
4. Lorazepam 0.5 mg PO Q8H:PRN anxiety
5. Omeprazole 40 mg PO DAILY:PRN acid reflux
6. PredniSONE 10 mg PO DAILY
7. Ursodiol 900 mg PO DAILY
8. Warfarin 7.5 mg PO DAILY16 some days 10mg
9. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin 125 mg 1 capsule(s) by mouth Q6hr Disp #*20
Capsule Refills:*0
10. Vitamin D 1000 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: gastroenteritis
Secondary diagnosis: recurrent cholangitis, Crohns disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to take care of you at ___
___. You were admitted with a fever, nausea,
vomiting, and diarrhea. You were kept on a similar medication
for your cholangitis and started on an oral medication to treat
a possible infection known as C diff. It is possible that your
underlying Crohns disease was also contributing to your symptoms
so you were restarted on your prednisone and will follow up with
your gastroenterologist. Some tests were still pending at
discharge and will be followed up by your outpatient physicians.
You will receive a phone call tomorrow if your test was positive
for norovirus. In the meantime, please make sure you wash your
hands frequently and do not share food or drinks with anyone.
Please call your gastroenterologist if your develop another high
fever >100.4, nausea, vomiting, worsening diarrhea, or bloody
bowel movements.
We wish you the best!
Sincerely,
Your ___ medical team
Followup Instructions:
___
|
10189939-DS-28 | 10,189,939 | 21,069,641 | DS | 28 | 2186-08-01 00:00:00 | 2186-08-02 19:53:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending: ___
Chief Complaint:
fevers, chills, abdominal pain
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
Patient is a ___ male with a history of Crohn's disease,
primary sclerosing cholangitis, DVTs/PEs recurrent on lovenox
who
presents for fevers and chills.
Of note, the patient is status post subtotal colectomy, and his
PSC is comp gated by recurrent cholangitis requiring multiple
ERCPs. The patient has scheduled ERCP in ___ which showed
nodularity in the common bile duct, no signs of malignancy. The
2 biliary stents that were previously placed were removed at
this
time. His CA ___ was at times elevated to 90,000, and is now
down trended to 70. ___ MRCP show stable disease with no new
biliary strictures, or masses. With regard to Crohn's disease,
the patient had a colonoscopy in ___ showing no active
flaring, mild mucosal erosions. The patient has no known liver
disease. Patient was last admitted ___ for cholangitis, dc'ed
on ertapenem. Notably at that time ERCP felt cholangitis was
diagnosis despite e/o cholestasis.
Of note, in ___ patient had ESBL E. coli bacteremia, requiring
extended course of treatment with carbapenems (initially
meropenem, transitioned to ertapenem at discharge).
For this most recent admission, patient notes 4 days of fevers,
chills, and mild abdominal pain. In the morning of presentation
his temperature was 102.5. He also endorsed upper respiratory
tract symptoms including cough, rhinorrhea, and headaches. He
uses to over the past 4 days, nonbloody. He denies chest pain,
urinary color changes, jaundice, nausea, vomiting, pale stool,
mental status changes.
In the ED initial vitals: Patient was afebrile, heart rate 59,
blood pressure 122/65, respiratory rate 17, saturating well on
room air. His physical exam was notable for, but increased in
the epigastrium, no rebound, no guarding, no right upper
quadrant
tenderness, no jaundice, with intact mental status.
Laboratory work-up is notable for ALT 83, AST 53, normal alk
phos, normal bilirubin, no leukocytosis, 7.6 eosinophils, INR
3.2, unremarkable UA, normal lactate. C. difficile PCR was
positive, C. difficile toxin was negative. Blood and urine
cultures were obtained, which showed no growth to date. Chest
x-ray showed no acute cardiopulmonary abnormality, right upper
quadrant ultrasound showed stent placement in right and left
hepatic ducts, no evidence of acute cholecystitis, no evidence
of
biliary dilatation. The patient was started on Vanco/Zosyn IV
and p.o. vancomycin. Hematology was consulted and they
recommended obtaining cultures and ultrasound as above, and
admission to the liver service.
REVIEW OF SYSTEMS: Positive per HPI, remaining 10 point ROS
reviewed and negative.
Past Medical History:
- Crohn's disease: since age ___ s/p subtotal colectomy ___
partial SBO ___ --Has been off Humira for years. Had been
on prednisone 40 for months, now down to prednisone 6 mg
- Primary sclerosing cholangitis c/b strictures s/p multiple
ERCPs stenting and stent removal
- ___ for partial SBO which resolved with conservative
treatment
- ___ for cholangitis and E.coli bacteremia treated with
Zosyn. ___ treated with ertapenem and transitioned to
doxycycline and rifaximin
- ___ and ___ for abd pain/fevers; however, a source
was never determined.
- ___ he required hospitalization at ___
___ for RUE DVT, LLE DVT and PE - CTA chest ___ with
saddle embolus within the left pulmonary artery extending into
the upper and lower lobes as well as the lingula with lobar and
segmental PEs within the right upper and lower lobes, without
evidence of right heart strain
- depression/anxiety
- multiple pancreatic cysts
- GBS bacteremia ___, unclear source, neg TEE, rx PCN x2
weeks
- Hypertension
- Depression
- Anxiety
- GERD
- Retinal detachment L eye
Social History:
___
Family History:
Sisters with breast cancer. No h/o GI, liver, biliary cancers.
No h/o of Crohn's in other members of family. No h/o autoimmune
conditions in family (type 1 diabetes, thyroid, pernicious
anemia)
Physical Exam:
ADMISSION PHYSICAL EXAM
=========================
VS: afebrile, 98.0 PO 155/75 HR: 54 RR: 18 O2: 96
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, ttp in epigastrium and RUQ, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
=========================
VS: ___ 0756 Temp: 98.1 PO BP: 111/66 L Sitting HR: 51 RR:
18 O2 sat: 96% O2 delivery: Ra
GENERAL: NAD, well-appearing
HEENT: PERRL, anicteric sclera, pink conjunctiva, MMM
NECK: supple, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: soft, BS+, non-distended, non-tender to deep palpation
throughout
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
===============
___ 08:27PM WBC-9.6 RBC-5.11 HGB-15.9 HCT-47.1 MCV-92
MCH-31.1 MCHC-33.8 RDW-14.5 RDWSD-49.1*
___ 08:27PM NEUTS-73.3* LYMPHS-15.7* MONOS-9.0 EOS-1.0
BASOS-0.6 IM ___ AbsNeut-7.06* AbsLymp-1.51 AbsMono-0.87*
AbsEos-0.10 AbsBaso-0.06
___ 08:27PM ___ PTT-51.7* ___
___ 08:27PM GLUCOSE-103* UREA N-13 CREAT-0.9 SODIUM-138
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-20* ANION GAP-17
___ 08:27PM ALT(SGPT)-115* AST(SGOT)-82* ALK PHOS-126 TOT
BILI-0.5 ALBUMIN-4.2
___ 08:39PM LACTATE-1.3
___ 01:05AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 01:05AM URINE BLOOD-SM* NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 01:05AM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 01:05AM URINE MUCOUS-RARE*
___ 02:52PM STOOL CDIFPCR-POS* CDIFTOX-NEG
DISCHARGE LABS
================
___ 06:25AM BLOOD WBC-8.1 RBC-4.52* Hgb-14.0 Hct-42.2
MCV-93 MCH-31.0 MCHC-33.2 RDW-13.7 RDWSD-46.0 Plt ___
___ 06:25AM BLOOD ___ PTT-30.5 ___
___ 06:25AM BLOOD Glucose-93 UreaN-11 Creat-1.0 Na-145
K-4.3 Cl-108 HCO3-26 AnGap-11
___ 06:25AM BLOOD ALT-41* AST-30 AlkPhos-108 TotBili-1.1
___ 06:25AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.1
ADDITIONAL LABS/MICRO
=======================
___ 08:10AM BLOOD CRP-9.6*
___ 08:10AM BLOOD SED RATE-6
___ Blood Cultures x2 - no growth
___ Urine Culture - no growth
MRSA Swab negative
PERTINENT STUDIES
===================
Liver/Gallbladder US ___
IMPRESSION:
1. The patient is status post ERCP and stent placement in the
right and left hepatic ducts.
2. Cholelithiasis without evidence of acute cholecystitis.
3. No sonographic evidence of intrahepatic biliary ductal
dilatation.
4. Limited sonographic evaluation of the pancreas, with 5 mm
cyst of the
pancreas, grossly unchanged compared to prior study of ___
EKG ___
Sinus rhythm
Left atrial enlargement
Left anterior fascicular block
Probable anterior infarct, age indeterminate
MRCP ___
FINDINGS:
- Dilatation with multifocal strictures of intrahepatic biliary
ducts, most striking in the left lobe, appear very similar to
the recent prior study. There are no severely dilated ducts and
the pattern is very similar. Extensive biliary wall thickening
and early persistent hyperenhancement is again striking among
ducts in the left lateral segments with more patchy involvement
of ducts in the right lobe, including in segment V. The main
change is new ill-defined early hyperenhancement in segment V
accompanied by increased signal on T2-weighted imaging and
suggestion of relative restricted diffusion compared to the
background liver. Increased background signal of liver
parenchyma in the left lobe on T2 weighted images appears very
similar to the prior study. No fluid collection is found.
Several cysts of varying sizes, mostly located in the left
lateral segments, appear unchanged. Extrahepatic biliary ducts
show similar diffuse mild wall thickening without focal mass.
- Gallbladder is only partly full without stones. Numerous
pancreatic cysts, most confluent in the body and tail, appear
unchanged, the largest again measuring up to 35 mm. The spleen
is normal in size and appearance. Adrenals are unremarkable.
Kidneys also appear within normal limits.
- Major vascular structures appear widely patent. There is no
lymphadenopathy or ascites.
IMPRESSION:
- Very little short-term change aside from an area of increased
enhancement and edema in the fifth segment of the liver in
addition to pre-existing finding suggesting active cholangitis.
ERCP ___
- Biliary plastic stent was successfully removed
- The biliary duct was deeply cannulated with a sphincterotome.
The cannulation was moderately difficult. Both right and left
sides were selectively cannulated and guidewire was placed in
each of them.
- Two cytology brushings of CBD performed and sent for cytology
and FISH separately
- A 10 ___, 5 cm double pigtail plastic biliary stent was
placed successfully in both right and left side (biliary
stenting)
Impression
- Successful ERCP with brushing and stent exchange as described
above.
Brief Hospital Course:
SUMMARY: Patient is a ___ male with a history of PSC
with known CBD stricturing, Crohn's disease, DVTs on warfarin,
who presented with fevers, chills, abdominal pain concerning for
cholangitis. Patient was initiated on vancc/Zosyn and narrowed
to Zosyn monotherapy for treatment of cholangitis. He underwent
MRCP showing enhancement concerning for infection and given his
known history of PSC for which he obtains interval ERCP and
stent replacements, he underwent ERCP on ___ with two stents
replaced. He remained afebrile for duration of hospital course
and was discharged on PO antibiotics with plan for total ___dditionally, discharged on ___ bridge for his
anticoagulation given subtherapeutic INR
TRANSITIONAL ISSUES
====================
[ ] discharged on PO antibiotics: ciprofloxacin 500mg BID,
metronidazole 500mg TID - to be continued until ___
[ ] ERCP in 10 weeks for stent removal and re-evaluation
[ ] Cytology and FISH results from ERCP samples pending at time
of discharge, will be communicated with patient in ___ weeks
[ ] discharged on lovenox bridge as well as home warfarin 10mg
alternating with 7.5mg - will need to continue lovenox until
therapeutic on warfarin (INR goal 2.5-3.5)
[ ] Discharged on ciprofloxacin and flagyl for antibiotic course
through ___
[ ] INR check in 3 days post-discharge (___)
ACTIVE ISSUES
=============
# Cholangitis
Patient presented with fever, chills and abdominal pain. Given
hx of PSC, strictures s/p multiple stents, recent biliary
instrumentation and transaminitis as well as prior admissions
with cholangitis, presentation was overall c/f cholangitis. Pt
was started on IV Vanc/Zosyn and symptomatically improved. Vanc
was later d/c'd in setting of negative MRSA swab.ERCP ___
successful with brushing and stent exchange. Stent was placed in
both right and left sides. Patient remained afebrile for
duration of hospital course and Zosyn was transitioned to
Ciprofloxacin 500mg BID and Metronidazole 500mg TID for total
antibiotic course of 14 days, to be completed on ___.
Results pending at time of discharge were cytology and FISH from
ERCP samples, which will be discussed with patient in ___ weeks.
Additionally, plan for ERCP in 10 weeks for stent removal and
re-evaluation.
# Diarrhea - resolved
Patient presented with diarrhea, although by the time the
patient was on the floor the diarrhea had improved both in
quantity and this will consistency was back to the patient's
baseline. Patient stated that this was not similar to his prior
Crohn's flares. No history chronic diarrhea and no history of
C.diff infections. C.diff PCR positive, however toxin negative,
not consistent with acute infection. PO vanc was initially
started, however discontinued with this result. Patient did not
have any further episodes of diarrhea.
CHRONIC ISSUES
==============
# Crohn's disease: continued on home mesalamine
# Recurrent DVT/PE: warfarin held during hospitalization. placed
on lovenox day prior to ERCP and restarted on lovenox and
warfarin the day after the procedure. Plan to discharge on
lovenox bridge and warfarin with plan for INR check 3 days after
discharge (___) and d/c lovenox once INR therapeutic.
Discharge INR 1.2.
# Anxiety: patient was given lorazepam 0.5mg BID prn for
anxiety, home dose is 1mg BID.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Mesalamine 375 mg PO BID
2. LORazepam 1 mg PO BID:PRN Anxiety
3. Warfarin 10 mg PO EVERY OTHER DAY
4. Ursodiol 900 mg PO Q24H
5. LevoFLOXacin 500 mg PO Q24H
6. Warfarin 7.5 mg PO EVERY OTHER DAY
Discharge Medications:
1. Apriso (mesalamine) 0.75 g oral DAILY
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 17 Doses
until ___. Enoxaparin Sodium 90 mg SC Q12H
4. MetroNIDAZOLE 500 mg PO Q8H Duration: 26 Doses
until ___. LORazepam 1 mg PO BID:PRN Anxiety
6. Ursodiol 900 mg PO Q24H
7. Warfarin 7.5 mg PO EVERY OTHER DAY
8. Warfarin 10 mg PO EVERY OTHER DAY
alternating with 7.5mg (take on opposite days that you take
7.5mg)
Discharge Disposition:
Home
Discharge Diagnosis:
Cholangitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came to the hospital with fevers, abdominal pain and
diarrhea believed to be related to an infection of your liver
called cholangitis. To treat this, you had an ERCP to exchange
the stent in your common bile duct, and two new stents were
placed. You will be discharged antibiotics, which you will take
until ___ (next ___. The GI doctors ___ contact ___
about the results of the samples obtained during your ERCP.
Please continue to use the lovenox shots until your INR is
therapeutic.
Please seek medical care if you develop fevers, abdominal pain,
blood in your stool, black stools, vomiting, bloody vomit, or
yellowing of the skin.
It was a pleasure taking care of you!
-Your ___ Liver Team
Followup Instructions:
___
|
10190445-DS-10 | 10,190,445 | 27,005,502 | DS | 10 | 2174-08-16 00:00:00 | 2174-08-16 17:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Seizures, personality changes
Major Surgical or Invasive Procedure:
intubation,
History of Present Illness:
Patient is a ___ year old man with a PMHx s/f newly diagnosed DM
and recent admission ___ for HHS/DKA who presented to
the ___ Emergency Room with a tonic clonic seizure
after acting inappropriate at home with periods of inattention
and depersonalization. Today Mr. ___ was found by his family
to be violent and acting inappropriately after several episodes
of "staring into space" and arm flailing. EMS was called after a
witnessed seizure, and upon EMS arrival he was found to be
seizing.
At the ___ ED, he was found to have persistent
tonic-clonic seizures. He was found to be acidemic to 6.8 with a
bicarb of 8. He was intubated for airway protection in light of
his mental status, was given 1gm of dilantin and 6mg of ativan
as well as 2L IV NS. He was also found to have a leukocytosis to
17.6. Urine was negative for ketones, and glucose elevated at
338. He was then transitioned to propofol and bicarbonate drips
and transferred to the ___ ED. ___ Med flight gave him
fentanyl 200mcg,
.
In the ED, He was seen by neurology who felt his seizures were
secondary to poorly controlled DM and recommended admission to
the MICU.
.
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.
Past Medical History:
DM
OSA non-compliant with CPAP
HTN
HLD
B12/Vit D deficiency
Social History:
___
Family History:
Father with DM and epilepsy
Physical Exam:
Upon Admission:
Vitals: T: 99.2 BP: 131/82 P: 76 R: 18 O2: 99% on PSV ___, FiO2
100%
___: intubated sedated gentleman, does not respond to verbal
or painful stimuli
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI,
pinpoint pupils/midline,
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation anteriorly bilaterally, no wheezes,
rales, ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley inserted with copious amounts of clear urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Intubated/sedated, pinpoint pupils, doll's head maneuver
with EOMI, no clonus, appropriate bulk/tone
Pertinent Results:
Admission Labs:
___ 02:16AM BLOOD WBC-13.6* RBC-3.36* Hgb-10.4* Hct-30.9*
MCV-92 MCH-30.8 MCHC-33.5 RDW-12.5 Plt ___
___ 02:16AM BLOOD UreaN-12 Creat-1.4*
___ 06:21AM BLOOD Glucose-124* UreaN-13 Creat-1.7* Na-140
K-3.9 Cl-108 HCO3-24 AnGap-12
___ 02:16AM BLOOD CK(CPK)-4566*
___ 06:21AM BLOOD Calcium-7.4* Phos-4.5 Mg-3.0*
___ 02:31AM BLOOD freeCa-0.97*
___:31AM BLOOD Glucose-200* Lactate-4.9* Na-136 K-4.1
Cl-107
___ 07:55AM BLOOD %HbA1c-16.5* eAG-427*
___ 06:02PM BLOOD calTIBC-168* VitB12-1117* Folate-9.3
Hapto-218* Ferritn-1103* TRF-129*
Discharge Labs:
___ 06:50AM BLOOD WBC-8.8 RBC-3.66* Hgb-11.3* Hct-32.9*
MCV-90 MCH-30.9 MCHC-34.4 RDW-13.3 Plt ___
___ 06:50AM BLOOD Glucose-92 UreaN-10 Creat-2.5* Na-148*
K-3.8 Cl-113* HCO3-25 AnGap-14
___ 06:50AM BLOOD CK(CPK)-2947*
Pertinent Results:
Chest X ray: Previous mild pulmonary edema has cleared. Lungs
are low in volume, but caliber of the pulmonary vasculature and
cardiac silhouette is probably normal. Left infrahilar
consolidation could be pneumonia or atelectasis and should be
followed. ET tube is in standard placement. Nasogastric tube
passes into the stomach and out of view. No pneumothorax or
pleural effusion.
MRI Head (preliminary read): No acute intracranial abnormality.
No abnormality identified on the MRI to explain the patient's
seizures.
Renal Ultrasound:
The right kidney measures 12.1 cm, the left kidney measures 10.6
cm without evidence of hydronephrosis, stones, or masses. The
urinary bladder is normal. IMPRESSION: No hydronephrosis.
CT sinus/mandible: FINDINGS: There is anterior dislocation of
the right mandibular condyle and anterior subluxation of the
left mandibular condyle, which appears partially reduced
compared to yesterday's outside hospital head CT. There is no
evidence of fracture.
Aerosolized secretions are seen in the left frontal sinus and
left ethmoid air cells. Mucosal thickening is seen in the
ethmoid air cells bilaterally and maxillary sinuses bilaterally.
Air-fluid levels and mucosal thickening are seen in the sphenoid
sinuses bilaterally. The ostiomeatal complexes are occluded
bilaterally. Soft tissue thickening of the uvula and posterior
pharynx is noted.
This study is not optimized for evaluation of intracranial
structures; within this limitation, no large abnormalities are
detected.
IMPRESSION:
1. Anterior dislocation of the right mandibular condyle and
anterior
subluxation of the left mandibular condyle without evidence for
acute
fracture.
2. Aerosolized secretions in the left frontal sinus and left
ethmoid air
cells with air-fluid levels in the sphenoid sinuses bilaterally,
which are
likely secondary to retained secretions from recent intubation.
However,
acute sinusitis cannot be excluded.
3. Soft tissue thickening of the uvula and posterior pharynx,
which likely
represents edema secondary to recent intubation.
EEG: No evidence of seizure activity. Focal slowing consistent
with toxic metabolic syndrome.
___ 02:16AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 02:16AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
Blood cultures: PENDING
Uurine culture: No growth (FINAL)
Brief Hospital Course:
Mr. ___ is a ___ year old with a past medical history
significant for newly diagnosed diabetes and recent admission
for HHS versus DKA at an OSH who presented with status
epilepticus and poorly controlled diabetes.
# Status Epilepticus: Presumed secondary to electrolyte
disturbances secondary to DKA/HHS decreasing the patient's
seizure threshold. There was no clear source of infection and
the patient was without localizing symptoms; infection was not
thought to explain the patient's symptoms, and no lumbar
puncture was done. Preliminary read of the EEG shows generalized
slowing while on propofol drip. Neurology followed the patient
through hospital course. Patient was weaned from Keppra through
the hospitalization, and on day of discharge this medication was
discontinued. Brain MRI was done which showed no structural
abnormality of the brain to explain seizures. Patient had no
further seizure activity while hospitalized. He was discharged
with outpatient neurology ___ scheduled.
# Altered Mental Status: Patient was admitted intubated and
sedated. He was weaned off sedation, and upon arrival to the
floor, the patient's mental status was noted to have
waxing/waning attention. Patient's mental status improved
through the admission with correction of his hyperglycemia.
# DM: Excellent control was maintained through hospital
admission with 20 units of NPH/Regualr (70/30) twice daily.
Patient received teaching regarding the importance of compliance
and careful control of his blood sugars. Patient is being
discharged home on above regimen with ___ arranged at
___.
# Acute Kidney Injury: Patient admitted with serum creatinine
1.4 which increased to 3.1. Acute kidney injury was thought to
be multifactorial related to poor oral intake and rhabdomyolysis
in the setting of tonic-clonic seizures. CK was elevated in the
5000s was noted to be down trending on day of discharge.
However, the Cr slowly rose and then slowly improved, suggesting
possible ATN, although there is no prolonged hypotension
documented, and he never required pressors. Patient made good
urine output in the latter part of the admission. Renal
ultrasound showed no hydronephrosis. ___ regarding serum
creatinine will need to be done on an outpatient basis. By day
of discharge, patient's serum creatinine had trended down to
2.5.
# Mild Thrombocytopenia: Etiology is unclear but may be related
to critical illness. Platelets trended up to 167 by time of
discharge. He was not on medications that would cause
thrombocyotpenia. Of note, thrombocytopenia developed prior to
heparin administration so is unlikely secondary to HIT. Patient
without evidence of DIC on labs. TTP/HUS in the setting of renal
failure was ruled out.
# Anemia: Previously diagnosed with B12 deficiency though
baseline was unknown. Records of the patient's
hematocrit/hemoglobin were unable to be obtained during the
admission. B12 level was high on this admission. Iron studies
are consistent with anemia of chronic inflammation. Folate was
within normal limits. Anemia remains stable through admission
with H/H 11.0/32.4. It is unclear why this apparently healthy
host would have anemia of chronic disease. Retic count is
depressed with suggestive a myelosuppressive state, though the
patient is not currently on medications that would cause a
myelosuppressive state.
# Fever and leukocytosis: Afebrile since admission to the floor.
Patient had fever to 100.2 at midnight on ___. Likely
secondary to seizures, but differential also includes infectious
etiology such as pneumonia (given possible RUL infiltrate on CXR
with poor inspiration). However, his respiratory status markedly
improved and he his on RA, and there was no indication for
further work-up. Leukocytosis was thought to be secondary to
stress response from seizure and DKA/HHS. WBC trended down on
day of admission. Urine culture was negative. Final blood
cultures were still pending on day of discharge.
# Jaw dislocation: Likely occurred during intubation. There is
no fracture see on CT of the mandible. OMFS was consulted during
the admission. No acute intervention was warranted. The patient
was placed on a soft, pureed diet while in house with
instructions to continue this while at home. Patient will be
contacted with ___ appointment by ___.
# rule out ACS: Given acute neurologic event, cardiac risk
factors, and diffuse ST elevations on EKG there was concern for
ACS. Troponins were negative times three during this admission,
so no further action was taken, especially in absence of chest
pain.
# OSA: He carries a diagnosis of OSA but is not compliant with
CPAP. Encouraged compliance with CPAP during hospitalization.
#Transition of Care Issues:
- ___ with Neurology as an outpatient regarding seizure
activity. Patient will also have outpatient routine EEG done.
These appointments have been scheduled.
- ___ with ___ regarding patient's diabetes.
- ___ with primary care physician on ___
regarding recent hospitalization and ___ of patient's
chemistry panel with serum creatinine to ensure that serum
creatinine continues to trend down.
- ___ with Oral/Maxillary/Facial Surgery regarding jaw
dislocation. Patient will be contacted by ___ with appointment
time and date.
- ___ of pending blood cultures
Medications on Admission:
ASA 81mg
Insulin 70/30 20 units BID
Vitamin B12 500mg daily
Calcium plus Vitamin D
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Vitamin B-12 500 mcg Tablet Sig: One (1) Tablet PO once a
day.
3. Calcium 500 With D 500 mg(1,250mg) -400 unit Tablet Sig: One
(1) Tablet PO once a day.
4. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: Twenty (20) units Subcutaneous at breakfast daily.
5. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: Twenty (20) units Subcutaneous at dinner daily.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Tonic-clonic seizures
Secondary diagnosis:
Rhabdomyolysis
Acute kidney injury
Insulin dependent diabetes
Hypertension
Hyperlipidemia
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ because of seizures. We believe
the cause of your seizures was due to electrolyte imbalance
influenced by your underlying diabetes. An MRI of your head was
done to determine if there was a brain abnormality that was
causing your seizures, but no abnormality was identified. You
are not being discharged home on anti-seizure medications.
However, you do have ___ with neurology for a routine EEG
as an outpatient (once discharged from the hospital). Your EEG
has been scheduled for ___ at 3:00PM. Your hair
must be clean and dry. Please eat lunch before the EEG. The
office is located on ___.
Given that you recently had a seizure, you are NOT permitted to
operate a motor vehicle for the next 6 months unless you are
medically cleared by the neurologist, with whom you have
___.
When you were intubuated, your jaw was dislocated. You were seen
by the oral surgeons who had recommended correcting the
dislocation however before the procedure could be performed your
jaw returned to normal position without surgical intervention.
For the next two weeks, it is important that you do not eat
foods that require chewing and that you avoid yawning. The oral
surgeons will call you regarding a ___ appointment in the
next 2 weeks.
Your kidneys sustained an injury after the seizures known as
rhabdomylosis. Your serum creatinine, a marker of your kidney
function, is improving. Please avoid taking ibuprofen whiel your
kidneys recover from injury. Please have your primary care
doctor ___ your kidney function at your next appointment
on ___.
Please take all medications as instructed. Note the following
medication changes: NONE.
Please keep all ___ appointments as scheduled.
Followup Instructions:
___
|
10190580-DS-20 | 10,190,580 | 24,021,799 | DS | 20 | 2121-05-30 00:00:00 | 2121-05-30 17:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
seasonal / Iodinated Contrast- Oral and IV Dye
Attending: ___
Chief Complaint:
right sided weakness, dysarthria
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ yo woman with history of HTN, migraine who
presents as transfer from ___ with R sided
weakness and speech change.
She was working overnight as ___ at ___ when approx.
0345 coworkers noted slurred speech. She sat down and coworkers
noted she ___ move the R side of her body. Speech difficult
to understand per EMS. Brought to ___.
Initial NIHSS 11 including 4 ___nd 4 for RLE. She had
NChCT and CTA head/neck, which were unremarkable, and after
coming out of CT scanner, deficits were dramatically improved.
Tele-neurology involved and felt less likely stroke and more
likely seizure vs pseudoseizure. She was transferred per family
request to ___.
Her mental status has been unchanged throughout time at ___ through my evaluation per family.
She received ASA 324 and lorazepam 1mg (for agitation, not
seizure) at ___.
Family reports episodes of LOC in past, all brief LOC with
subsequent return to baseline. Further details unknown. No
history of seizures. Longstanding history of migraine headaches
per mother, other details unknown. No history of TBI, head
trauma, severe MVC. No history of meningitis/encephalitis. Per
husband and daughter, no known history of prenatal nor birth
problems, and no known history of febrile seizures in childhood.
No family history of epilepsy.
Unable to obtain ROS due to mental status.
Past Medical History:
HTN (untreated)
Migraine w/o aura
3 miscarriages (2 without heart beats and other pregnancy was
twins with unclear complications).
Social History:
___ at ___, works nights. Lives with 3 daughters.
Also helps care for mother and maternal grandmother. ___.
Current <1ppd smoker. EtOH <1/wk. No illicits.
- Modified Rankin Scale:
[x] 0: No symptoms
[] 1: No significant disability - able to carry out all usual
activities despite some symptoms
[] 2: Slight disability: able to look after own affairs without
assistance but unable to carry out all previous activities
[] 3: Moderate disability: requires some help but able to walk
unassisted
[] 4: Moderately severe disability: unable to attend to own
bodily needs without assistance and unable to walk unassisted
[] 5: Severe disability: requires constant nursing care and
attention, bedridden, incontinent
[] 6: Dead
Family History:
No family history of seizures. Daughter has MS.
___ Exam:
ADMISSION PHYSICAL EXAM:
=========================
Vitals: T: 96.6 HR: 55 BP: 132/80 RR: 18 SaO2: 99% RA
General: Sleepy, cooperative, NAD.
HEENT: L conjunctival injection. no scleral icterus, MMM, no
oropharyngeal lesions.
Pulmonary: Breathing comfortably, no tachypnea nor increased WOB
Cardiac: Skin warm, well-perfused.
Abdomen: soft, ND
Extremities: Symmetric, no edema.
Neurologic Examination:
- Mental status: Sleepy, EO for ___ sec with voice and/or
tactile stim. Unable to relate history. Speech largely
incomprehensible, though approx. ___ can be understood and
are
real words. No clear paraphasic errors. Follows some simple
midline and appendicular commands inconsistently. Fluent.
-Cranial Nerves: PERRL 3->2. BTT bilaterally. EOMI without
nystagmus. R facial droop. Hearing intact to conversation. Mild
dysarthria.
- Motor: Normal bulk and tone. Briskly antigravity x4. Able to
participate in limited fashion inconsistently in motor exam.
Required add'l coaxing to participate in exam on RUE, and this
exam was more limited.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 5 ___ 5 5 5 5 5
R 4* ___ 5 5 5 5
*Limited participation, strength at least this much.
-DTRs:
Bi Tri ___ Pat Ach Pec jerk Crossed Adductors
L 1 1 2 0 0
R 1 1 2 0 0
Plantar response was flexor bilaterally.
-Sensory: Reacts to tickle x4.
- Coordination: UTA
- Gait: UTA
DISCHARGE PHYSICAL EXAM:
========================
Exam:
Gen: thin female lying comfortably in bed, conversational with
team
Pulm: breathing comfrtably on RA
Ext: clubbing of fingers
Psych: lability mood, anxious appearing
Neurologic:
MS- alert and oriented to interval history, speech is fluent,
conversational
CN: +horizontal diplopia better with far, can bury to R and L,
reduced nystagmus, pupils L ___ R 4.5-3, L mildly flat
nasolabial fold.
Motor: no pronation or drift bilaterally.
Delt ___ bilaterally
Bi ___ bilaterally
WEx ___ bilaterally
FEx ___ bilaterally
IP ___ bilaterally
TA ___ bilaterally
Finger tapping slightly slower and clumsier on the left
Coordination: no dysmetria on FNF bilaterally
Pertinent Results:
ADMISSION LABS:
===============
___ 12:45PM BLOOD WBC: 9.3 RBC: 4.21 Hgb: 12.7 Hct: 38.7
MCV: 92 MCH: 30.2 MCHC: 32.8 RDW: 15.6* RDWSD: 52.1* Plt Ct: 247
___ 12:45PM BLOOD Neuts: 59.0 Lymphs: ___ Monos: 8.8 Eos:
1.4 Baso: 0.6 Im ___: 0.2 AbsNeut: 5.49 AbsLymp: 2.80 AbsMono:
0.82* AbsEos: 0.13 AbsBaso: 0.06
___ 12:45PM BLOOD ___: 12.4 PTT: 31.1 ___: 1.1
___ 12:45PM BLOOD Glucose: 82 UreaN: 6 Creat: 1.1 Na: 140
K:
4.2 Cl: 104 HCO3: 24 AnGap: 12
___ 12:45PM BLOOD ALT: 7 AST: 14 CK(CPK): Pending AlkPhos:
109* TotBili: 0.4
___ 12:45PM BLOOD Lipase: 40
___ 12:45PM BLOOD cTropnT: <0.01
___ 12:45PM BLOOD ASA: NEG Ethanol: NEG Acetmnp: NEG
Tricycl: NEG
___ 12:45PM BLOOD HCG: <5
___ 01:04PM BLOOD Lactate: 0.8
PERTINANT IMAGING:
====================
MR HEAD W & W/O CONTRAST Study Date of ___ 12:00 AM
FINDINGS:
The study is degraded by motion artifact: Especially the MP rage
postcontrast imaging.
There is a 7 x 5 mm acute infarct in the left ventral medial
thalamus. No
hemorrhagic transformation.
The rest of the brain is normal in volume, signal intensity and
morphology. No intracranial mass or hemorrhage. The
intracranial arteries demonstrate normal T2 flow void. The
orbits appear normal. Mild mucosal thickening involving the
paranasal sinuses. The pituitary appears normal. The
craniocervical junction appears normal.
IMPRESSION:
Small acute infarct in the left ventral medial thalamus. No
hemorrhagic
transformation. The rest of the brain is normal in volume,
signal intensity and morphology. Mild mucosal thickening
involving the paranasal sinuses.
BILAT LOWER EXT VEINS Study Date of ___
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
TTE ___
IMPRESSION: Probable aortic valve mass on the noncoronary
leaflet suggestive of a papillary fibroelastoma, large Lambl's
excrescence, or less likely thrombus/vegetation (clinical
correlation is
advised). Mild-moderate [___] aortic regurgitation. Patent
foramen ovale with premature appearance of agitated saline in
the left atrium after intravenous injection with maneuvers.
Grossly normal biventricular systolic function.
MRV PELVIS W&W/O CONTRAST Study Date of ___
IMPRESSION:
No evidence of proximal deep venous thrombosis in the abdomen
and pelvis.
UNILAT UP EXT VEINS US Study Date of ___
IMPRESSION:
No evidence of deep vein thrombosis in the left upper extremity.
Superficial thrombophlebitis in a branch of the basilic vein.
DISCHARGE LABS
===============
___ 05:20AM BLOOD WBC-11.1* RBC-4.20 Hgb-12.5 Hct-38.1
MCV-91 MCH-29.8 MCHC-32.8 RDW-15.5 RDWSD-51.2* Plt ___
___ 05:20AM BLOOD Plt ___
___ 05:20AM BLOOD Glucose-87 UreaN-18 Creat-1.1 Na-137
K-4.3 Cl-103 HCO3-21* AnGap-13
___ 05:20AM BLOOD Calcium-9.2 Phos-4.0 Mg-1.9
Brief Hospital Course:
___ is a ___ yo woman with history of HTN, migraine who
presents as transfer from ___ with acute
onset R sided weakness and speech change found to have a left
thalamic ischemic stroke.
#Acute left thalamic ischemic stroke
She had sudden onset dysarthria and right sided weakness while
working and was taken to ___. Her exam initially was
notable for NIHSS 11. She had a normal CT/CTA and her exam
improved to NIHSS 1 (right facial droop). She was transferred to
___ for further care. MRI notable for left inferior paramedian
thalamic stroke. She was found to have small vessel risk factors
(cigarette smoking, LDL 146, untreated hypertension) but she
also had a high NIHSS at presentation which makes a possible
artery-artery or cardioembolic event a possibility as well
(perhaps top of the basilar artery). Her work-up included APLS
negative, ESR normal, D-Dimer normal, ANCA neg, protein C and S
normal. Her stroke risk factors were checked with A1c 5.3, LDL
146. She underwent TEE which showed small PFO without aneurysm
and also possible thrombus vs. lambls excrescence on aortic
valve with mild-moderate aortic regurgitation. There were no
fevers, chills, leukocytosis to suggest endocarditis and it was
thought this could represent sterile thrombus. Blood cultures x3
were no growth to date. LENIs showed no DVT. Telemetry during
hospitalization was without atrial fibrillation. She was treated
with aspirin 81mg and atorvastatin 80 mg daily initially but
then switched to Coumadin given possible aortic thrombus vs.
excrescence contributing to her stroke. She is scheduled for
repeat TEE on ___ and will require cardiac monitoring as
an outpatient.
#Hypertension
She reportedly was treated for hypertension several years ago
but no longer. She had elevated SBP up to 170s during
hospitalization. She was started on lisinopril 10 mg daily.
Verapamil 120 mg SR daily was started for migraine ppx but may
have additional antihypertensive benefits. SBP 120s at time of
discharge.
#Migraines
She has a several year history of migraines with throbbing
character, nausea, vomiting and photophobia. She was started on
verapamil 120 SR daily for migraine prophylaxis. She was also
treated with as needed acetaminophen and Compazine, resolved at
time of discharge.
TRANSITIONAL ISSUES:
====================
[] please check INR at next PCP visit and arrange follow-up in
___ clinic (started Coumadin ___, see warfarin
worksheet) . PCP appointment scheduled for ___ with Dr.
___ at 3:20pm
[] f/u repeat TEE scheduled for ___ to assess aortic valve
[] will need cardiac monitoring (ordered at time of discharge)
[] 3 mm nodule on chest CT. "With a <6 mm solid nodule, further
follow-up is not typically required; for a patient with a
relevant risk factor for cancer (eg, smoking history), a CT at
12 months is optional, bearing in mind that cancer risk is
considerably less than 1 percent even in patients at high risk"
[] Please follow up in the Stroke Neurology Department on
___ at 4:00pm with Dr. ___
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No. If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? (x) Yes (LDL = 146) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? (x) Yes - () No [reason
() non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - If no, why not (I.e.
bleeding risk, etc.) (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth at bedtime Disp #*90
Tablet Refills:*3
2. Cyanocobalamin ___ mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 2,000 mcg 1 tablet(s) by mouth
DAILY Disp #*90 Tablet Refills:*3
3. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth DAILY Disp #*90 Tablet
Refills:*3
4. Nicotine Patch 7 mg TD DAILY
RX *nicotine [Nicoderm CQ] 7 ___ one patch daily
daily Disp #*14 Patch Refills:*6
5. Verapamil SR 120 mg PO DAILY
RX *verapamil 120 mg 1 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*3
6. Warfarin 3 mg PO/NG ONCE Duration: 1 Dose
RX *warfarin [Coumadin] 3 mg 1 tablet(s) by mouth daily Disp
#*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
L Thalamic Infarct
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of right sided weakness
and numbness resulting from an ACUTE ISCHEMIC STROKE, a
condition where a blood vessel providing oxygen and nutrients to
the brain is blocked by a clot. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain from being deprived of its blood supply
can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
1. High Cholesterol
2. Cigarette smoking
3. High Blood Pressure
4. Receiving <8 hours of sleep
5. Migraine headaches
We are changing your medications. Please start to take the
following medications:
1. Coumadin dosed by your doctors ___ keep your blood thin to
prevent stroke)
2. Atorvastatin 80mg daily (for your high cholesterol, also
prevents stroke)
3. Verapamil 120mg daily (for migraine)
4. Nicotine Patch
5. Lisinopril 10 mg daily (for high blood pressure)
Please take your other medications as prescribed. You will have
an ultrasound of your heart in ___ as listed below. 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:
___
|
10191175-DS-21 | 10,191,175 | 20,771,137 | DS | 21 | 2185-07-11 00:00:00 | 2185-07-13 10:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a ___ year-old R-handed man with PMHx of migraines
without aura who presents with 1 day of double vision, dizziness
and difficulty walking ___ imbalance. Interview was done
through
a ___ interpreter. Pt reports that he woke up this
morning
at 6:30am, went to the kitchen, ate breakfast, had coffee then
went back to bed at around 9am. At 9:30am he woke up, opened
his
eyes and had double vision. He reports that the 2 images he saw
were one on top of the other and that he had a hard time
focusing
on anything. He didn't feel nauseated at the time, but did feel
like he was "drunk". He reports "strange eye movements" that he
felt were moving from the L to the front of his vision, and that
they would "come and go quickly". He denies associated H/A,
vision loss, numbness/tingling, focal weakness, difficulty
swallowing, or difficulty with producing or comprehending
speech.
His wife noticed that during this he looked "very white", and he
felt "very shaky", but that all of the above sx lasted for 15
mins then improved. However, he felt that the sx never fully
went away. They would wax and wane throughout the day, and
sometimes standing up made them better and other times it made
it
worse. He can't think of any time he moved his head that made
it
better or worse, but in discussion he moved his head
side-to-side
and felt that it exacerbated his sx. He had one episode of
nausea with some dizziness at around 4pm today, but the nausea
resolved prior to the dizziness. He reports that 2 weeks ago he
had diarrhea (non-bloody) x3 days, but no recent fevers/chills
or
viral sx. He decided to come to the ED because his sx were not
resolving.
.
On neuro ROS, the pt reports current blurred vision and current
but denies current headache, loss of vision, 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:
migraines w/out aura starting in his teens, but becoming less
frequent as he aged
Social History:
___
Family History:
father died of a stroke at age ___, mother died of a
stroke at age ___
Physical Exam:
Physical Exam:
Vitals: T: 97.3 P: 71 R: 16 BP: 121/76 SaO2: 96% RA
General: mildly somnolent but easily arousable, cooperative.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx. ___ negative bilaterally.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
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.
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.
Speech
was not dysarthric. Able to follow both midline and appendicular
commands. The pt. had good knowledge of current events. 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 revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI showed R beating nystagmus on R and L lateral
gaze and downbeating nystagmus when pt looking up, and upbeating
nystagmus when looking down. Nystagmus did not fatigue in any
gaze position. Pt also had R-beating nystagmus in primary gaze.
He c/o seeing "1 and ___ fingers with the images next to each
other when looking ahead", which became 1 finger when covering
each eye.
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.
Very mild tremor with arms outstretched noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
.
-Sensory: No deficits to light touch, pinprick, cold sensation,
proprioception throughout. No extinction to DSS. Pt did have
diminished vibratory sensation on the R leg from foot to
mid-shin.
.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2+ 1
R 2 2 2 2+ 1
Plantar response was flexor on the R and extensor on the L.
.
-Coordination: Mild intention tremor bilaterally, no
dysdiadochokinesia noted. Mild dysmetria on FNF bilaterally.
.
-Gait: Slow initiation. Narrow-based, unsteady. Unable to walk
in tandem without significant difficulty. Romberg grossly
positive, with pt falling to L on exam.
***************
At discharge:
Neuro: right nystagmus only on right ward gaze. Brisk refelxes
throughout. No dysmetria on FNF. Turns right on Untenberger.
Head thrust has 2 corrective saccades on right. Able to walk
normally. Able to tandem with very little difficulty.
Pertinent Results:
___ 09:15PM WBC-11.3* RBC-5.32 HGB-14.4 HCT-44.2 MCV-83
MCH-27.0 MCHC-32.6 RDW-12.6
___ 05:35AM %HbA1c-5.6 eAG-114
___ 05:35AM TRIGLYCER-78 HDL CHOL-37 CHOL/HDL-4.2
LDL(CALC)-104
___ 05:35AM TSH-0.89
___ 05:35AM CALCIUM-8.7 PHOSPHATE-3.9 MAGNESIUM-2.4
CHOLEST-157
___ 05:35AM ALT(SGPT)-21 AST(SGOT)-20 LD(LDH)-160
CK(CPK)-53 ALK PHOS-63 TOT BILI-0.2
___ 05:35AM CK-MB-2 cTropnT-<0.01
CTA head and neck:
IMPRESSION: Unremarkable CTA of the head and neck.
CXR - 2 view:
PA and lateral upright chest radiographs were reviewed with no
prior studies
available for comparison.
Heart size is normal/minimally enlarged. Tortuous aorta is
demonstrated. The
mediastinum is not widened. Hila are unremarkable. Lungs are
clear with no
pleural effusion or pneumothorax.
NCHCT:
IMPRESSION: No acute intracranial process.
MRI brain:
IMPRESSION:
No acute abnormality is seen. No evidence for acute infarction
in the
posterior circulation.
Brief Hospital Course:
The patient was admitted with episode of dizziness that was
improving. He reported no vertigo but a sensation of
unsteadiness and double vision (although he reports that the
vision was more two objects moving back and forth than true
double vision). He was also nauseous. When he arrived to ___ he
was very unsteady on his feet, could not tandem walk. Had
severe nystagmus towards the right in primary gaze and in all
direcitons, and possible dysmetria. While the exam seemed most
consistent with a peripheral cause there were enough signs
concerning that we wanted to rule out a posterior circulation
stroke
He had a CTA which was normal. His MRI was normal with no
evidence of stroke. His secondary risk factors were pending at
time of discharge including LDL and HgbA1c.
He will follow up with his PCP.
Medications on Admission:
excedrin migraine PRN migraine HA
Discharge Medications:
1. Excedrin Migraine 250-250-65 mg Tablet Sig: One (1) Tablet PO
PRN as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
peripheral vertigo
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
CN: eomi, pupils equal and reactive, face symmetric, sensation
intact, very slight right beating nystagmus on right gaze
(improved from initial exam)
Motor: full
sensory: intact
mild past pointing toward right
able to walk in tandem with some difficulty
Discharge Instructions:
Mr. ___,
You were admitted with dizziness and trouble walking, based on
your exam there was concern that you may have had a stroke
causing these symptoms. We admitted you to the hospital for
further workup. We got a CTA (an image of the vessels of your
head and neck) which was normal. We also got an MRI which did
not show any evidence of stroke. We also performed blood tests
to assess your risk for future strokes. Your blood cholesterol
and HgbA1c (a test for diabetes) were pending at time of
discharge.
Your medications were not changed.
Please take all medications as prescribed. Please make all
follow up appointments.
If you have any of the symptoms listed below please call your
doctor or come to the nearest emergency room
Followup Instructions:
___
|
10191316-DS-10 | 10,191,316 | 22,285,904 | DS | 10 | 2188-12-19 00:00:00 | 2188-12-21 13:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
CT guided anterior mediastinal biopsy
History of Present Illness:
Mr ___ is a ___ M with minimal PMH presenting with 2 days
of substernal chest pain, found to have a recently identified
large anterior mediastinal mass.
Pt states he developed pain in his chest after performing light
cardio exercise (rowing) the morning of ___. About 30 mins
after
exercising, he began experiencing a dull substernal chest pain,
took 1,000mg Tylenol, but did not gain much relief from the
Tylenol. He got on the T to go to work, but the chest pain
continued and he began experiencing heaviness in his legs. He
was
worried he was having a heart attack and so was brought in by
ambulance to ___.
He does report experiencing this pain 1 week ago while reaching
up to grab something at work (works in ___).
However, the pain quickly subsided and did not return until
___.
At ___, a CT revealed an 11.9cm enhancing mediastinal mass with
potential liver involvement. He was discharged from ___ and went
to his PCP the morning of ___, where the decision was made to
come to the ___ ___ for admission and expedited workup. Today
pt
continues to experience chest pain. It is worse with any amount
of movement. Any positional change (e.g. leaning forward,
getting
up, walking) makes the pain worse. If he stays still, the pain
is
not as bad. The pain does not radiate. Denies SOB, syncope, loss
of consciousness, and no longer has heaviness in legs. He denies
fevers/night sweats/weight loss or history of malignancy.
In the ___, initial vital signs were notable for:
T 98.1; HR 109; BP 144/91; Resp 18; O2 100% RA
Exam notable for:
Substernal chest pain without radiation otherwise unremarkable
Labs were notable for:
___ = 12.6; INR = 1.2; K = 5.8; Cr = 1.4 (baseline = 1.5 in
___ LDH 661
Studies performed include:
ECG X2 which were considered unremarkable except for sinus
bradycardia (HR 52) on the most recent.
Consults:
Thoracic surgery and Heme/Onc
Vitals on transfer:
T 98.9; BP 129/75; HR 100; RR 18; O2 Sat 96% RA
Upon arrival to the floor, patient was stable but reported
having
a temperature of 100.0F for which he received 1000mg of Tylenol.
He is currently afebrile.
Past Medical History:
- Ongoing microscopic hematuria since ~age ___ - closely followed
with renal workup as recent as ___. Considered stable.
- Elevated Cr, stable
- Vasectomy (___)
- Severe flat foot/excessive pronation; Left worse than right
(Dx
___ - treated with orthotics and subsequently surgery in
___.
Social History:
___
Family History:
Renal Cell Carcinoma - Father (died age ___
___ Cell Trait - Father
Type ___ Mellitus - Father, Mother, and Sister
___ - Father
___ Cancer - Sister (age ___
Physical Exam:
ADMISSION PHYSICAL EXAM
VITALS: T 98.9; BP 129/75; HR 100; RR 18; O2 Sat 96% RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
DISCHARGE PHYSICAL EXAM
Vitals: T 99.6 BP 110/65 HR 109 RR 17 O2Sat 94 RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: Sclera anicteric and without injection. MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
Pertinent Results:
ADMISSION LABS
___ 01:31PM ___ PTT-32.4 ___
___ 12:40PM GLUCOSE-133* UREA N-13 CREAT-1.4* SODIUM-139
POTASSIUM-5.8* CHLORIDE-99 TOTAL CO2-26 ANION GAP-14
___ 12:40PM estGFR-Using this
___ 12:40PM LD(LDH)-661*
___ 12:40PM CALCIUM-10.2 PHOSPHATE-3.8 MAGNESIUM-1.8 URIC
ACID-6.3
___ 12:40PM HBsAg-NEG HBs Ab-NEG HBc Ab-NEG
___ 12:40PM HCG-<5
___ 12:40PM AFP-3.0
___ 12:40PM HIV Ab-NEG
___ 12:40PM HCV Ab-NEG
___ 12:40PM WBC-6.8 RBC-5.20 HGB-14.5 HCT-44.6 MCV-86
MCH-27.9 MCHC-32.5 RDW-14.4 RDWSD-44.9
___ 12:40PM NEUTS-82.0* LYMPHS-8.9* MONOS-8.4 EOS-0.3*
BASOS-0.3 IM ___ AbsNeut-5.55 AbsLymp-0.60* AbsMono-0.57
AbsEos-0.02* AbsBaso-0.02
___ 12:40PM PLT COUNT-250
___ 12:40PM G6PD QUAL-NORMAL
___ 12:40PM RET AUT-1.3 ABS RET-0.07
DISCHARGE LABS
N/A
IMAGING
___ LIVER OR GALLBLADDER US
1. 2.3 cm heterogeneous lesion within segment III of the liver,
present on the
MR dated ___, but appears to have increased in size.
This does
not have the classic appearance of a metastatic lesion and may
represent an
atypical hemangioma, however dedicated liver MR with contrast
should be
obtained for further characterization.
2. Diffuse gallbladder adenomyomatosis with multiple gallbladder
wall polyps
measuring up to 6 mm.
3. Small right pleural effusion.
___ CT GUIDED ANTERIOR MEDIASTINAL BIOPSY - PENDING
Brief Hospital Course:
Mr. ___ is a ___ M with PMH of HTN who presents with
2 days of substernal chest pain in the setting of a newly
identified large anterior mediastinal mass on ___, admitted for
expedited workup of mass:
ACUTE ISSUES:
=============
#Chest pain likely due to mediastinal mass:
Patient presented with chest pain and 11.9 cm enhancing anterior
mediastinal mass first discovered at ___ on ___. The
differential includes thymoma, lymphoma, and teratoma/germ cell
tumor. Notable lab findings include LDH (elevated 661), AFP
(normal 3.0) and bHCG (negative). These results make a malignant
germ cell tumor less likely. Elevated LDH is often seen in
lymphoma, though the patient has not had classic symptoms of
fever, chills, or weight loss. The patient's chest pain is
likely due to mass effect of the mediastinal mass given the lack
of evidence of cardiogenic causes and risk factors in his PMH.
The patient underwent a CT guided biopsy on ___ to obtain
pathologic diagnosis - results pending. Hematology oncology is
following.
#Liver mass:
CT scan at OSH also revealed potential liver involvement. RUQ
ultrasound was completed on ___ to further characterize the
potential of liver metastases. Final read of the ultrasound is
pending.
CHRONIC ISSUES:
===============
#Microscopic Hematuria
#Elevated Creatinine
Patient presented with elevated Cr 1.4 which is actually at his
baseline. Etiology of elevated Cr and microscopic hematuria
unknown, but he is being followed by outpatient nephrology.
Renal function was stable throughout admission. Continue
follow-up with outpatient nephrology team.
#Hepatitis B nonimmune
Patient was found to be hepatitis B non-immune. Recommend PCP
follow up for hepatitis B vaccination.
TRANSITIONAL ISSUES:
NO CHANGES made to home medications
[ ] follow up on results of CT guided anterior mediastinal mass
biopsy
[ ] follow up on results of RUQ ultrasound to evaluate for liver
metastases
[ ] follow up in ___ clinic if biopsy positive
for malignancy
[ ] hepatitis B vaccination with PCP given patient found to be
non-immune
[ ] follow up with outpatient nephrologist Dr. ___ for
routine visit to follow up on microscopic hematuria
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Discharge Disposition:
Home
Discharge Diagnosis:
Anterior mediastinal mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came into the hospital with chest pain and to get a biopsy
of your chest mass.
During your stay, you had a biopsy of the chest mass as well as
an ultrasound of your liver. It may take several days for the
results of the biopsy and imaging studies to come back. You have
a doctors ___ on ___ at 4 pm to discuss these
results.
Please keep your appointments. It was a pleasure caring for you
at ___.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10191404-DS-19 | 10,191,404 | 24,966,201 | DS | 19 | 2163-08-12 00:00:00 | 2163-08-13 14:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Allergies/ADRs on File
Attending: ___
Chief Complaint:
Trauma
Major Surgical or Invasive Procedure:
___ Intubation
History of Present Illness:
___ fall down escalator, +EtOH with BAC of 390. Pt combative and
spitting in the ED, underwent difficult intubation for airway
protection. Pt has scalp lacerations, right forhead abrasion,
bilateral black eyes, abrasions to the right hip, and abrasions
to the left shoulder blade. CT Scan demonstrated a nondisplaced
nasal bone fracture, likely chronic, but no other acute
injuries.
Past Medical History:
Unknown
Social History:
___
Family History:
NC
Physical Exam:
Admission:
Temp: Afebrile HR: 85 BP: 1:30 systolic Resp: 22 O(2)Sat:
98% room air Normal
Constitutional: The patient is boarded and collared in
awake but quite intoxicated
HEENT: Extraocular muscles intact with normal
pupils.
He has some abrasions on the right side of his forehead
He has no obvious neck tenderness but is quite intoxicated
Chest: Clear to auscultation without chest wall tenderness
Cardiovascular: Normal first and second heart sounds
Abdominal: The abdomen is soft without apparent tenderness
Extr/Back: No spine tenderness.
All 4 extremities
are without obvious trauma
Skin: Warm and dry
Neuro: His speech is slurred due to alcohol but he moves
all 4 extremities equally and strongly
Psych: He is intoxicated
Discharge exam:
HEENT: Extraocular muscles intact with normal
pupils.
abrasions on the right side of his forehead
Chest: Clear to auscultation without chest wall tenderness
Cardiovascular: Normal first and second heart sounds, NO MRG
Abdominal: Soft, NT, ND
Extr/Back: No spine tenderness.L ___ digit in splint
Skin: Warm and dry
Neuro: Gait normalall 4 extremities equally and strongly
Psych: ax0x3
Pertinent Results:
___ 05:46PM BLOOD WBC-7.8 RBC-5.59 Hgb-17.2 Hct-51.8 MCV-93
MCH-30.8 MCHC-33.2 RDW-13.6 Plt ___
___ 12:00AM BLOOD WBC-7.5 RBC-4.56* Hgb-14.1# Hct-42.6
MCV-93 MCH-30.9 MCHC-33.1 RDW-13.7 Plt ___
___ 12:00AM BLOOD Glucose-86 UreaN-7 Creat-0.6 Na-149*
K-4.0 Cl-115* HCO3-23 AnGap-15
___ 12:00AM BLOOD Calcium-7.3* Phos-3.7 Mg-2.0
___ 05:46PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:54AM BLOOD Type-ART Temp-36.6 PEEP-5 pO2-189*
pCO2-44 pH-7.32* calTCO2-24 Base XS--3 Intubat-INTUBATED
___ 09:12PM BLOOD Type-ART Rates-14/ Tidal V-500 PEEP-5
FiO2-100 pO2-442* pCO2-49* pH-7.28* calTCO2-24 Base XS--3
AADO2-225 REQ O2-45 -ASSIST/CON Intubat-INTUBATED
___ 05:59PM BLOOD Glucose-91 Lactate-1.5 Na-152* K-3.8
Cl-103 calHCO3-27
Imaging:
___ CT head
IMPRESSION:
No evidence of acute intracranial process.
Bilateral minimally displaced nasal bone fractures are noted,
age
indeterminate, likely chronic.
___ CT neck
IMPRESSION:
No evidence of acute fracture or malalignment.
___ CT torso
IMPRESSION:
1. No evidence of acute visceral injury in the chest, abdomen,
or pelvis.
2. Small bibasilar posterior/dependent consolidations, most
likely aspiration
in the setting of intubation.
3. Nasogastric tube terminates at the level of the
gastroesophageal junction
and should be advanced so that it is well within the stomach.
4. Mild compression deformities of T10 and T11 superior
endplates of
indeterminate age.
___ X-ray L hand
IMPRESSION:
Oblique fracture of proximal phalanx of the ___ digit.
Brief Hospital Course:
The patient was admitted to surgery under the trauma service.
He was intubated in the ED for airway protection but otherwise
comprehensive physical survey and radiologic imaging revealed no
other injuries other than a L ___ proximal phalanx fracture. He
was extubated on hospital day #2 and transferred to the floor.
A splint was placed on his L ___ digit, and he will need Hand
surgery follow up. He was noted to be unsteady on his feet.
Pt admitted to the general floor due to unsteady gait from ETOH
intoxication. Pt was observered over night and on day of
discharge pt gait was stable and there was no signs of
withdrawals.
Medications on Admission:
None
Discharge Medications:
Non
Discharge Disposition:
Home
Discharge Diagnosis:
S/p Fall
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call Dr. ___ hand surgery follow up for your
left pinky finger fracture. The number is ___
You were admitted to the hospital after a fall. You were
evaluated in the Emergency department and then transferred to
the hospital floor to ensure that you continued to do well. You
have since done well and are ready to be discharged.
Please call your doctor or nurse practitioner if you experience
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 is 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.
.
General Discharge Instructions:
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, who will instruct you further regarding activity
restrictions.
Followup Instructions:
___
|
10191971-DS-9 | 10,191,971 | 29,690,819 | DS | 9 | 2133-10-07 00:00:00 | 2133-10-07 14:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
Dyspnea.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. ___ is a ___ male with past medical history of
COPD, HTN, hypothyroidism, OSA (not on home O2 or CPAP), with
recently diagnosed peripheral T-cell lymphoma who presented with
cough and SOB.
Patient noted approximately ___ day history of progressive
shortness of breath and dry cough. He had a temp of 100.3 a few
days PTA, but otherwise denied f/c/s. Was seen in clinic on DOA
for the above noted concerns, CT chest showed thickening of
bronchial walls, c/f lymphomatous spread. Initial plan was for
direct admit for bronchoscopy. However, while in waiting room in
clinic while waiting for bed, became hypoxic, desatted to ___ in
RA, low ___ on 4L by NC. Sent to ED for emergent eval.
Of note, patient was diagnosed with peripheral T-cell in ___
of this year after presenting for evaluation erythematous rash,
shortness of breath, lower extremity edema and diffuse bulky
cervical and inguinal lymphadenopathy. He was initiated on
dose-adjusted EPOCH from ___ through the ___ and
received Neulasta on ___. Patient denies recent sick
contacts.
In ED, initally noted to by hypoxic 86% on RA, tachypneic 24;
___ set of full vitals (1hr after triage): 98.8 HR 130 BP
144/78, RR 30, 96% on Bipap, last set of ED vitals HR 119, BP
130/72, RR 21, 95% on NC. Meds received: ASA 325mg, Lasix,
methylpred 125mg x2, Duonebs, SL nitro 0.4 mg. EKG with sinus
tachycardia, c/w prior.
On arrival to the MICU, initial vitals were T:98.1 BP:120/81
P:112 R:23 SaO2:86% on 5L. Patient switched to venturi mask with
improvement in sats. Was in NAD, reported his SOB had improved.
Started on vanc, cefepime, and levaquin for empiric HCAP
treatment, and standing nebs/steroids for possible COPD
exacerbation. Was able to be weaned to 1L by NC with sats in
upper ___ on first night in the MICU.
Past Medical History:
- Periphearl T Cell Lymphoma
- Hypothyroidism
- HTN
- COPD
- OSA
- Bilateral cataract surgery
- H/o hepatitis B (core Ab +, viral load negative per report)
Social History:
___
Family History:
-Brother: Cancer (unknown type) at ___ years of age
-Sister's son: ___ at age ___
-Mother: DM
Physical ___:
ADMISSION PHYSICAL EXAM
========================
Vitals: T 98.1 BP 120/81 P ___ R 20 SaO2 100% on 35% shovel mask
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Bibasilar crackles, worse at right lung base
CV- tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen- soft, mild diffuse tenderness/soreness to palpation,
mildly distended, tympanic, bowel sounds present, no rebound
tenderness or guarding, no rigidity, no organomegaly
GU- foley in place draining clear yellow urine
Ext- warm, well perfused, 1+ DP and raidal pulses, no clubbing,
cyanosis; 2+ pitting edema to the knees bilaterally; enlarged
right supraclavicular lymph node, enlarged left inguinal lymph
node
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARG PHYSICAL EXAM
=======================
Vitals: T 98.3 BP 122/81 P 98 R 20 SaO2 96% on RA
General: Sitting up in chair, NAD, appears comfortable
HEENT: MMM, no OP lesions
CV: RRR, nl S1 and S2, no MGR
PULM: Improved RLL crackles, otherwise CTAB
ABD: BS+, soft, NT, ND
EXT: 2+ ___ edema b/l
NEURO: Alert and oriented x 3
SKIN: No rashes or skin breakdown
Pertinent Results:
ADMISSION LABS
===============
___ 11:35AM BLOOD WBC-35.8*# RBC-3.31* Hgb-10.3* Hct-30.8*
MCV-93 MCH-31.1 MCHC-33.4 RDW-18.2* Plt ___
___ 05:50PM BLOOD WBC-60.4*# RBC-3.20* Hgb-9.8* Hct-30.3*
MCV-95 MCH-30.6 MCHC-32.3 RDW-18.3* Plt ___
___ 09:38PM BLOOD WBC-38.7* RBC-2.99* Hgb-9.2* Hct-27.4*
MCV-92 MCH-30.7 MCHC-33.4 RDW-18.5* Plt ___
___ 11:35AM BLOOD Neuts-72* Bands-2 Lymphs-9* Monos-15*
Eos-0 Baso-0 ___ Myelos-1* Other-1*
___ 05:50PM BLOOD Neuts-67 Bands-2 ___ Monos-7 Eos-1
Baso-0 ___ Metas-2* Myelos-2* NRBC-1* Other-1*
___ 11:35AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL Schisto-NORMAL Envelop-OCCASIONAL
___ 11:35AM BLOOD ___
___ 05:50PM BLOOD Glucose-141* UreaN-10 Creat-1.1 Na-130*
K-4.2 Cl-90* HCO3-25 AnGap-19
___ 09:38PM BLOOD Glucose-137* UreaN-12 Creat-1.1 Na-131*
K-3.5 Cl-89* HCO3-30 AnGap-16
___ 06:05PM BLOOD ___ PTT-31.4 ___
___ 11:35AM BLOOD ALT-10 AST-15 AlkPhos-132* TotBili-0.7
___ 05:50PM BLOOD cTropnT-<0.01 proBNP-573*
___ 06:01PM BLOOD Lactate-3.5*
___ 07:07PM BLOOD Lactate-1.8
___ 10:15PM BLOOD Lactate-1.1
___ 06:20PM URINE Color-Yellow Appear-Clear Sp ___
___ 06:20PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 06:20PM URINE RBC-10* WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
___ 10:13PM URINE RBC-3* WBC-5 Bacteri-NONE Yeast-NONE
Epi-0
PERTINENT LABS
===============
___ 06:10AM BLOOD IgG-829
___ 06:10AM BLOOD QG6PD-21.7*
___ 06:10AM BLOOD Ret Aut-5.3*
___ 09:36PM BLOOD Hapto-164
DISCHARGE LABS
===============
___ 12:00AM BLOOD WBC-4.0# RBC-2.49* Hgb-7.8* Hct-24.9*
MCV-100* MCH-31.4 MCHC-31.4 RDW-20.3* Plt ___
___ 12:00AM BLOOD Neuts-81.0* Lymphs-17.3* Monos-1.4*
Eos-0.2 Baso-0
___ 12:00AM BLOOD Glucose-283* UreaN-32* Creat-0.9 Na-135
K-3.3 Cl-96 HCO3-28 AnGap-14
___ 12:00AM BLOOD Calcium-8.0* Phos-3.3 Mg-2.3 UricAcd-3.2*
___ 12:00AM BLOOD LD(LDH)-167
MICRO
======
URINE CULTURE (Final ___: NO GROWTH.
URINE CULTURE (Final ___: NO GROWTH.
Blood Culture, Routine (Final ___: NO GROWTH.
Blood Culture, Routine (Final ___: NO GROWTH.
Blood Culture, Routine (Final ___: NO GROWTH.
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further
information.
ASPERGILLUS AG,EIA,SERUM Not Detected
B-D-Glucans 45 pg/mL (Negative=Less than 60 pg/mL)
IMAGING
========
EKG ___: Sinus tachycardia with occasional PVCs.
CXR ___
Right lower lobe consolidation, concerning for early pneumonia.
CT CHEST ___. New extensive air wall thickening is concerning for diffuse
metastatic disease involving the airways; also with
post-obstructive atelectasis, as in the lingula.
2. There are also multiple bilateral lung nodules, some larger
since ___ which are likely metastasis.
3. Interval response of peripheral and central lymphadenopathy,
which is smaller since ___.
4. No signs of PE or bone involvement.
CT A/P ___. Diffuse widespread lymphadenopathy in the abdomen and pelvis,
most of which are stable or smaller in size compared to scan
from ___.
2. Splenomegaly with old splenic infarct.
CXR ___
Improvement in right perihilar opacity consistent with improving
infection.
Brief Hospital Course:
___ male with past medical history of COPD, HTN,
hypothyroidism and OSA who was diagnosed with peripheral T-cell
lymphoma, NOS, CD30 negative, in ___ who is now s/p C1
EPOCH and s/p neulasta ___ who presented to ___
clinic on DOA with cough and SOB found to be hypoxic.
# Hypoxic respiratory distress, now resolved: At the time of
admission, the patient was noted to be significantly hypoxic on
room air. He subsequently worsened and required BiPAP and brief
ICU stay. In terms of the cause of his hypoxic respiratory
distress, the differential included interval worsening of
malignancy vs pneumonia, +/- COPD exacerbation. It was felt to
be unlikely that his acute change in his respiratory status was
due to interval worsening of disease, although it may have
contributed some. His decompensation was more likely thought to
be due to pneumonia, which caused an acute COPD exacerbation
resulting in hypoxemic respiratory distress.
On arrival to MICU, patient was started on empiric antibiotics
with vanc/cefepime/levofloxacin for possible HCAP. Patient was
also started on treatment for possible COPD exacerbation with
standing duonebs and prednisone. Overnight in the MICU, the
patient's oxygen requirement decreased and shortness of breath
improved. He was subsequently transferred from the ICU to the
floor and at that time was able to maintain oxygen saturations >
94% on RA. Once on the ___ service, the patient was switched
from vanc/cefepime/levofloxacin to zosyn and levofloxacin. At
that point, the plan had been to proceed with bronchoscopy, but
as patient had improved significantly, bronchoscopy would not
have contributed much information and was, therefore, not done.
Nasopharyngeal swab and cultures had returned negative. B-glucan
and galactomannan were also negative. The patient remained on
zosyn and levofloxacin throughout the remainder of his stay, and
his respiratory status remained stable. The patient did not
endorse any further SOB and his cough resolved by the time of
discharge. Upon discharge, the patient was instructed to
continue levofloxacin through ___, to complete a two-week
course.
# T-cell lymphoma: ___ Stage IV with an IPI score of 3
(high-intermediate risk group). Patient has had a substantial
response to EPOCH based on decrease in LAD seen on current CT
scan. In general, the plan from the patient's primary oncologist
was to give the patient a total of six cycles of dose-adjusted
EPOCH with plan to obtain a PET-CT scan after the second cycle.
In terms of CNS prophylaxis, the patient will likely receive
intrathecal methotrexate starting with the third cycle. At the
time of admission, the patient was scheduled to receive his
second cycle of EPOCH. Given his respiratory status, however,
chemotherapy was initially held. Once the patient's respiratory
status improved (discussed further below), the patient received
his second cycle of EPOCH on ___ without complications. He was
continued on allopurinol for tumor lysis prevention. For
infection prophylaxis, the patient was continued on lamivudine
(Hepatitis B Core Ab positive, VL negative consistent with
resolved infection), fluconazole for fungal ppx, and acyclovir
for viral ppx. The patient was not on PCP ppx, as he had
developed a rash after taking Bactrim SS daily prior to
admission. During this admission his G6PD level was checked and
was 21, which is not deficient, so the patient was started on
dapsone for PCP ___. The patient was discharged with
instructions to follow-up with Dr. ___ on ___. At that
time he will receive Neulasta. Discussion should also be had at
that time about timing of port placement.
# Anemia: Patient with normocytic anemia on admission, which was
at baseline. During the course of his hospital stay, the
patients H/H slowly down-trended, but the patient did not
require any transfusions. Patient was tachycardic, but without
any signs of bleeding and with stable blood pressures throughout
his stay. Hemolysis labs were checked and were negative. Anemia
was thought to be secondary to chemotherapy and will be
monitored as an outpatient.
# Hyponatremia: Patient was hyponatremic on admission to 131.
Thought to potentially be from diuretic use. No mental status
changes were noted. The patient sodium level normalized without
any intervention and was 135 at the time of discharge.
CHRONIC ISSUES
# Hypertension: Stable.
# Hypothyroidism: Stable. Continue levothyroxine.
TRANSITIONAL ISSUES
- Patient was admitted in hypoxic respiratory distress thought
to be secondary to atypical pneumonia. The patient was started
on zosyn and levofloxacin during his admission and quickly
improved. He will be discharged on levofloxacin to complete a
two week course on ___.
- Once the patient improved from an infectious standpoint, he
was able to complete cycle two of his EPOCH chemotherapy during
this admission.
- Med changes:
1. Started dapsone for PCP ___.
2. Started levofloxacin for atypical pneumonia - to be continued
through ___.
3. Started on prednisone taper: 60 mg PO ___, 40 mg PO ___,
and 20 mg PO ___, then stop.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Ipratropium bromide 17 mcg/actuation inhalation Q4:prn
sob/wheezing
3. LaMIVudine 100 mg PO DAILY
4. Fluconazole 400 mg PO Q24H
5. Furosemide 40 mg PO DAILY
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Nystatin 1,000,000 UNIT PO BID
8. Tiotropium Bromide 1 CAP IH DAILY
9. Acyclovir 400 mg PO Q8H
10. Albuterol sulfate 90 mcg/actuation inhalation Q4:PRN
SOB/Wheezing
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
2. Allopurinol ___ mg PO DAILY
3. Fluconazole 400 mg PO Q24H
4. Furosemide 40 mg PO DAILY
5. LaMIVudine 100 mg PO DAILY
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Dapsone 100 mg PO DAILY
8. Levofloxacin 750 mg PO DAILY
9. Albuterol sulfate 90 mcg/actuation inhalation Q4:PRN
SOB/Wheezing
10. ipratropium bromide 17 mcg/actuation inhalation Q4:prn
sob/wheezing
11. Tiotropium Bromide 1 CAP IH DAILY
12. PredniSONE 60 mg PO ONCE Duration: 1 Day
Start: Tomorrow - ___ - First Routine Administration Time
Please take 60 mg ___, 40 mg ___, 20 mg ___, then stop.
13. PredniSONE 40 mg PO ONCE Duration: 1 Day
Start: After 60 mg tapered dose
Please take 60 mg ___, 40 mg ___, 20 mg ___, then stop.
14. PredniSONE 20 mg PO ONCE Duration: 1 Day
Start: After 40 mg tapered dose
Please take 60 mg ___, 40 mg ___, 20 mg ___, then stop.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
- Pneumonia
- Hypoxic respiratory distress
- T-cell lymphoma
Secondary:
- HTN
- Hypothyroidism
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 from clinic because you were
found to be extremely short of breath and your oxygen levels had
decreased significantly. You needed to stay in the intensive
care unit (ICU) for a brief period before you were stable enough
to come to the floor. Once your breathing improved, you were
able to be transferred to the Hematology service.
We believe that you likely had either a bacterial infection in
your lungs, called pneumonia, or a non-specific viral syndrome
that caused your symptoms. You were started on antibiotics and
you quickly improved. You should continue taking an antibiotic,
called levofloxacin, until ___.
During your hospitalization, you also received your second cycle
of chemotherapy for your T-cell lymphoma. You tolerated this
very well.
Please follow-up at your scheduled appointments, as below.
Followup Instructions:
___
|
10192095-DS-16 | 10,192,095 | 26,617,869 | DS | 16 | 2197-01-01 00:00:00 | 2197-01-01 15:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea on exertion, cough
Major Surgical or Invasive Procedure:
___ EBUS
___ Fine-needle biopsy of preauricular mass
History of Present Illness:
Mr. ___ is a ___ yo man w/ COPD and 60 pack-year smoking hx
who presented with a 2 month history of dry cough and slowly
worsening DOE, and a 2 week history of productive cough with
blood tinged sputum. Pt was in his normal state of health until
about 2 months ago, when he began to have a dry cough with
fever. He saw his PCP, who ordered CXR that showed 'spots' that
were thought to be infection or pneumonia. He was given
antibiotics and the fever subsided, but the cough continued.
Over the past 2 weeks, his cough became productive with flecks
of blood in his sputum. He also began to get SOB with
activities such as walking down the hall. He says that last
week he had a CXR that he says showed pneumonia and fluid, and
he was started on levofloxacin (for PNA) and torsemide (for pulm
edema). He was scheduled to have a CT on ___ (presumably to
further evaluate) but experienced worsening SOB and weakness
that brought him to the ED.
Accompanying these symptoms were a 4cm preauricular mass that
appeared rapidly over the past 1 month; a stiff back pain behind
his L shoulder that made it difficult for him to sleep at night
over past few months; 10 pound weight loss over the past 1.5
months; some weakness and dizziness ("not spinning, just weak")
and feeling like he was going to pass out; palpitations;
constipation ___ weeks); perioral numbness/tingling (episodes
once daily for a few weeks); and R hand tremor/shakiness.
Past Medical History:
-COPD
-HTN
-GERD
Social History:
___
Family History:
Mother: Died ___, traumatic hip fx
Father: Died in war
No siblings
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T: 98.2 BP: 155/96 P: 88 R: 18 O2: 92% RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear. Non-tender,
immobile mass about 4 cm at R preauricular space.
NECK: supple, JVP not elevated, no LAD
LUNGS: Diminished breath sounds in L upper and lower lung
fields. Otherwise clear to auscultation with no wheezes, rales,
or rhonchi.
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present
EXT: Warm, well perfused, no clubbing, cyanosis or edema
SKIN: 1.5 cm ecchymosis on R forearm.
NEURO: Finger-to-nose intact. Strength ___ in UE and ___
bilaterally. Sensation intact to light touch in UE and ___
bilaterally.
DISCHARGE PHYSICAL EXAM
VS:97.9 100/60 88 24 99RA
IsOs 24 hr: 1840/2250
GENERAL: lying in bed, pleasant, NAD
HEENT: EOMI, PERRLA, has +cervical adenopathy, firm on right
side, has right sided pre auricular soft tissue mass that is
firm to touch and size of golf ball, OP clear but poor dentition
CARDIAC: RRR no m/r/g, normal S1/S2
LUNG: CTA b/l, with exception of left lower lobe which has
decreased breath sounds. no increased WOB
ABD: Normoactive BS, Soft, NT, ND
EXT: warm and well perfused
NEURO: Aox3, no focal deficits, PERRLA
SKIN: warm dry
Pertinent Results:
ADMISSION LABS:
---------------
___ 12:25PM BLOOD WBC-9.5 RBC-4.01* Hgb-13.0* Hct-38.4*
MCV-96 MCH-32.4* MCHC-33.9 RDW-13.0 RDWSD-45.7 Plt ___
___ 12:25PM BLOOD Neuts-74.0* Lymphs-15.9* Monos-8.3
Eos-1.2 Baso-0.3 Im ___ AbsNeut-7.03* AbsLymp-1.51
AbsMono-0.79 AbsEos-0.11 AbsBaso-0.03
___ 12:25PM BLOOD Glucose-141* UreaN-42* Creat-1.4* Na-138
K-3.3 Cl-95* HCO3-29 AnGap-17
___ 12:25PM BLOOD proBNP-470
___ 12:25PM BLOOD cTropnT-<0.01
___ 12:25PM BLOOD Calcium-9.6 Phos-2.2* Mg-1.3*
___ 12:25PM BLOOD D-Dimer-642*
___ 12:25PM BLOOD GreenHd-HOLD
PERTINENT LABS:
---------------
___ 06:20AM BLOOD ALT-12 AST-20 LD(LDH)-194 AlkPhos-63
TotBili-0.4
___ 06:20AM BLOOD calTIBC-251* Ferritn-722* TRF-193*
DISCHARGE LABS:
---------------
___ 07:25AM BLOOD WBC-6.5 RBC-3.74* Hgb-11.7* Hct-35.9*
MCV-96 MCH-31.3 MCHC-32.6 RDW-13.3 RDWSD-47.5* Plt ___
___ 07:25AM BLOOD ___ PTT-23.6* ___
___ 07:25AM BLOOD Glucose-95 UreaN-36* Creat-1.0 Na-136
K-4.1 Cl-100 HCO3-28 AnGap-12
___ 07:25AM BLOOD LD(___)-184
___ 07:25AM BLOOD Albumin-3.4* Calcium-8.7 Phos-4.1 Mg-2.0
UricAcd-7.2*
MICROBIOLOGY:
-------------
None
STUDIES:
--------
___ CTPA:
IMPRESSION:
1. Severe emphysema with large left hilar mass concerning for
primary lung
malignancy with peripheral band like opacity in the left upper
lobe. Apparent invasion of the pericardium with tumor thrombus
extending into the left atrium. Significant mass effect and
tumor encasement of the left hilar bronchovasculature.
2. No central pulmonary embolism or acute aortic process.
3. Left pleural effusion.
4. Indeterminate nodular opacity adjacent to the pancreatic tail
for which
MRCP is recommended to further evaluate.
___ US of preauricular mass
IMPRESSION:
A 3.4 cm heterogeneous vascular lesion corresponds the area of
palpable
abnormality in the right temporal region. Recommend
ultrasound-guided fine
needle aspiration for further evaluation.
RECOMMENDATION(S): A 3.4 cm heterogeneous vascular lesion
corresponds the
area of palpable abnormality in the right temporal region.
Recommend
ultrasound-guided fine needle aspiration for further evaluation.
___ MRI head
IMPRESSION:
1. Three enhancing lesions with slow diffusion and surrounding
FLAIR signal abnormality, most likely in keeping with
intracranial metastasis.
___ CT abd pelvis:
IMPRESSION:
1. Multiple intraperitoneal, serosal, retroperitoneal, and
intramuscular
metastatic implants described above. No evidence of bowel
obstruction. No hydronephrosis. No ascites.
2. Nodular medial limb of the left adrenal gland, indeterminate.
3. Nonobstructing left renal calculi.
4. Interval increase in the left pleural effusion as well as
pericardial
effusion.
___ TTE:
The left atrium is dilated. The estimated right atrial pressure
is ___ mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). Right
ventricular chamber size and free wall motion are normal. The
mitral valve leaflets are mildly thickened. The mitral valve
leaflets are elongated. There is no mitral valve prolapse.
Trivial mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is a small to moderate
sized pericardial effusion. The effusion appears
circumferential. There are no echocardiographic signs of
tamponade.
IMPRESSION: Mild to moderate pericardial effusion with no
echocardiographic signs of tamponade.
Brief Hospital Course:
Mr. ___ is a ___ man with 60-pack-year smoking
history who recently presented with dry cough, hemoptysis,
weight loss, who was found to have a large central lung mass
encasing major arteries and invading into the left atrium.
# Extensive Small Cell Lung Cancer:
Patient had slow decline over last month with increasing
shortness of breath and new hemoptysis. He presented to ___
where a CT scan showed significant for large left hilar mass
with apparent invasion of the pericardium with tumor extending
into the left atrium. Staging MRI head significant for three
enhancing lesions with slow diffusion and surrounding FLAIR
signal abnormality, most likely representative of intracranial
metastasis. Further staging with CT torso significant for
multiple intraperitoneal, serosal, retroperitoneal, and
intramuscular metastatic implants. EBUS was performed on ___
for tissue sample, which revealed small cell lung cancer with
high proliferation index (___). He also had an FNA for a new
right preauricular mass that showed malignancy as well. A TTE
was performed which revealed mild-moderate pericardial effusion
without evidence of tamponade, and LVEF >75%. Palliative care
was consulted. The patient was initiated on chemotherapy with
cisplatin and etoposide (___), which he tolerated well with
minimal GI complaints. He is scheduled for follow up with the
Multi-Specialty Thoracic Clinic. He will be scheduled for port
placement prior to the next round of chemotherapy.
# Acute kidney injury: Patient presented with creatinine of 1.4.
This improved to his baseline of 0.9 with fluid resuscitation,
consistent with prerenal etiology. After initiating
chemotherapy, he again developed ___ that was felt to be
secondary to cisplatin. On discharge his creatinine was 1.0.
# New oxygen requirement:
Patient has a long smoking history and known severe COPD. He
developed worsening dyspnea in the setting of impingement of the
mass into the left sided bronchovasculature. He was managed
with Advair, tiotropium, and Albuterol nebs as needed. He was
discharged with home oxygen therapy.
# Anemia:
No known baseline. Iron studies were sent and were consistent
with anemia of chronic disease, likely secondary to his
underlying malignancy. He did not require a blood transfusion
during hospitalization.
# Suspected BPH:
Patient endorsed difficulty initiating a stream and reports
previous history of prostate issues, but no longer on
medication. He was started on tamsulosin 0.4mg PO QHS with
improvement.
CHRONIC:
# HLD: continued home Simvastatin 40 mg PO QPM and Ezetimibe 10
mg PO DAILY
# Gout: continued home Allopurinol ___ mg PO DAILY
# GERD: continued home Omeprazole 40 mg PO DAILY
# Leg pain: held Naproxen 500 mg PO Q24H for ___
# Claudication: discontinued home Cilostazol as it interacts
with many medications including omeprazole possibly causing
toxic levels.
TRANSITIONAL ISSUES:
1. Patient discharged on anti-emetic regimen of Compazine/Zofran
but did not have really any nausea s/p chemotherapy. If he
becomes more nauseas as outpatient, would consider alternating
between Zofran/Compazine, or adding Ativan as well.
2. Patient will need to attend outpatient thoracic oncology
appointments to assess response to chemotherapy and continue
planning for further care
3. Patient will need to obtain port for further chemotherapy.
4. Patient was discharged with home oxygen therapy and visiting
nurse service
5. Patient will need CHEM10, Uric Acid, LDH checked at next
outpatient appointment on ___
6. Pt has no family in ___, so was referred to
___ care clinic for continued coping, discussion of
community resources, and end of life care.
7. Cilastazol was discontinued as it interacts with many meds
including omeprazole possibly causing toxic levels. Also it is
QTc prolonging and would put patient at risk if he got further
Zofran doses.
# CODE: Full, confirmed
# CONTACT: Friend and HCP - ___ ___ or ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levofloxacin 500 mg PO Q24H
2. Torsemide 20 mg PO DAILY
3. Potassium Chloride 10 mEq PO BID
4. Simvastatin 40 mg PO QPM
5. Allopurinol ___ mg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Naproxen 500 mg PO Q24H
8. Ezetimibe 10 mg PO DAILY
9. Cilostazol 100 mg PO DAILY
10. Tiotropium Bromide 1 CAP IH DAILY
11. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Ezetimibe 10 mg PO DAILY
3. Omeprazole 40 mg PO DAILY
4. Simvastatin 40 mg PO QPM
5. Tiotropium Bromide 1 CAP IH DAILY
6. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation DAILY
7. Prochlorperazine 10 mg PO Q6H:PRN nausea and vomiting
RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth q6h:prn
Disp #*30 Tablet Refills:*0
8. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
9. Acetaminophen 650 mg PO Q8H:PRN Pain
RX *acetaminophen 650 mg 1 tablet(s) by mouth q8h:prn Disp #*100
Tablet Refills:*0
10. Senna 8.6 mg PO BID constipation
hold for loose stool
RX *sennosides [senna] 8.6 mg 1 capsule by mouth BID:prn Disp
#*60 Capsule Refills:*0
11. Bisacodyl ___AILY:PRN constipation
RX *bisacodyl 10 mg 1 suppository(s) rectally daily:prn Disp
#*12 Suppository Refills:*2
12. Docusate Sodium 100 mg PO BID Constipation
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth
q12h:prn Disp #*60 Capsule Refills:*0
13. Polyethylene Glycol 17 g PO BID:PRN constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 powder(s)
by mouth daily Refills:*0
14. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth q6h:prn Disp #*25 Tablet
Refills:*0
15. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth q8h:prn Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Extensive small cell lung cancer
___ ___ chemotherapy toxicity
Secondary:
Chronic Obstructive Pulmonary Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of ___ while ___ were at ___
___.
___ first came to the hospital because ___ were experiencing
shortness of breath and a bloody cough. A CT scan of your chest
showed ___ had a mass in your lungs. Biopsy of the mass showed a
type of cancer called small cell lung cancer. This cancer has
also spread to the brain and heart as well.
___ were started on chemotherapy with cisplatin and etoposide.
___ tolerated these medications very well with the exception of
some kidney damage which had resolved by the time ___ were
discharged.
The chemotherapy can cause nausea, so we have given ___ several
new medications to treat nausea (Zofran, Compazine and Ativan).
If ___ have nausea, ___ can take Zofran every 8 hours.
___ are scheduled for follow-up with the Thoracic ___
___ (see below section for further details). ___ will have
your next chemotherapy in a few weeks. ___ will find out more
details about your chemotherapy at your upcoming appointments.
Please seek medical attention if ___ develop fevers, chills,
chest pain, worsening shortness of breath, night sweats,
lightheadedness, or any other symptom that concerns ___.
We wish ___ all the best,
Your ___ health care team
Followup Instructions:
___
|
10192095-DS-17 | 10,192,095 | 29,836,985 | DS | 17 | 2197-03-20 00:00:00 | 2197-03-21 14:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w hx of metastatic small cel lung ca to brain who
presents w/ vertigo for past 4 days. He states that he has
had progressively worsening feeling of room spinning for 4
days. Worse when lying down but always there. Denies HA,
vision changes, vomiting, or abdominal pain. Has also had
nausea and increased urinary frequency over the past 4 days
w/ no dysuria, fever, chest pain, dyspnea. Last chemo tx was
5 days ago for 3 days. No headache. Seen yesterday for L
shoulder pain, and had a CTA chest which showed no PE and a
stable lung mass. Referred here by oncology for evaluation.
In the ED, vitals notable for Temp: 98.3 HR: 110 BP: 112/65
Resp:
20 O(2)Sat: 97, lactate of 2.3, and given 2L NS.
On the floor, patient further elucidated on history that he has
dizziness for seconds while turning his head, primarily to the
left, which is recurrent, multiple times per day and improved
with lying down. After his most recent chemo he has had reduced
appetite, but no nausea/vomiting. He recalls episode of vertigo
___ years prior, treated at ___, but does not recall
treatment regimen.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
Hospitalized ___ for his worsening symptoms, and
his course was notable for CT scan showed significant for CT
evidence of a large left hilar mass with apparent invasion of
the
pericardium with tumor extending into the left atrium; Staging
MRI head significant for three enhancing lesions with slow
diffusion and surrounding FLAIR signal abnormality, most likely
representative of intracranial metastasis; further staging with
CT torso significant for multiple intraperitoneal, serosal,
retroperitoneal, and intramuscular metastatic implants. EBUS was
performed on ___ which revealed small cell lung cancer with
high proliferation index (___), and an FNA of his
right preauricular mass also showed malignancy as well. A TTE
was performed which revealed mild-moderate pericardial effusion
without evidence of tamponade, and LVEF >75%.
- ___ - C1D1 chemotherapy with cisplatin 75mg/m2 and
etoposide 100mg/m2 - complicated by severe neutropenia and mild
___
- ___ - C2D1 chemotherapy with carboplatin 5AUC and
etoposide 80mg/m2 with neulasta support
- ___ - C3D1 carboplatin 5AUC and etoposide 80mg/m2
- ___ - C4 D3 carboplatin/etoposide
- ___ - Neulasta
PMH: Gout, HLD, COPD, BPH, constipation
Social History:
___
Family History:
Mother: Died ___, traumatic hip fx
Father: Died in war
No siblings
Physical Exam:
DISCHARGE EXAM:
Gen: alert, NAD
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact no nystagmus
Chest: Poor air movement but clear nonlabored
Cardiovascular: Regular Rate and Rhythm, nl S1/S2 no murmur
Abdominal: Soft, Nontender, Nondistended
Skin: No rash, Warm and dry
Neuro: strength ___, sensation intact to light touch, no
dysmetria w/ FTN or HTS testing. Gait steady
Pertinent Results:
ADMISSION LABS:
___ 11:25AM BLOOD WBC-61.0*# RBC-3.28* Hgb-10.9* Hct-32.7*
MCV-100* MCH-33.2* MCHC-33.3 RDW-18.4* RDWSD-67.8* Plt ___
___ 11:25AM BLOOD Neuts-92* Bands-2 Lymphs-4* Monos-2*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-57.34*
AbsLymp-2.44 AbsMono-1.22* AbsEos-0.00* AbsBaso-0.00*
___ 11:25AM BLOOD Glucose-99 UreaN-46* Creat-1.1 Na-138
K-4.1 Cl-100 HCO3-22 AnGap-20
___ 11:25AM BLOOD ALT-12 AST-18 AlkPhos-68 TotBili-0.6
___ 11:25AM BLOOD Albumin-4.1 Calcium-9.6 Phos-3.5 Mg-1.4*
___ 12:00PM BLOOD Lactate-1.7
IMAGING:
IMAGING: HEAD CT - FINDINGS:
Known brain metastatic lesions are not visualized in this study.
There is no evidence of infarction, hemorrhage, or edema.
There is prominence of the ventricles and sulci suggestive of
involutional changes. There is no evidence of fracture. The
visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
Evidence of prior maxillary sinus sugery is noted. The
visualized portion of the orbits are unremarkable.
IMPRESSION: No acute intracranial process. MRI is more
sensitive indetecting small intracranial lesions.
CXR:
Large left hilar mass and peripheral left upper lobe pulmonary
nodule/mass seen on CT 1 day prior were better assessed on CT.
Chronic interstitial lung disease. No new opacity identified.
Brain MRI:
IMPRESSION:
No evidence of tumor progression or recurrence. The
intraparenchymal
enhancing masses noted on ___ are no longer
detected. The right scalp mass appears unchanged.
Brief Hospital Course:
Mr. ___ is a ___ man with COPD, 60-pack-year
smoking history and extensive stage small cell lung carcinoma,
currently status post four cycles of
platinum/etoposide, presenting with dizziness/vertigo.
#Vertigo, likely BPPV - new onset vertigo x 4 days. Orthostatics
negative. Head CT negative for acute intracranial abnormality.
most consistent with BPPV given positive ___. No
dysmetria w/ cerebellar testing. Intracranial cause such as CVA
or brain mets appears less likely but brain MRI obtained to r/o
and showed ongoing resolution of prior intracranial mets, only
residual is R temporal scalp lesion.
- pt repeatedly declined repeat Epley attempts by providers or
___
- given script for meclizine prn max 25mg TID
- he prefers to f/u w/ his PCP who has performed maneuvers for
him in past. He was given referral to vestibular therapy
although at this time states he declines to attend.
- pt was independent w/ ambulation, gait steady. he was advised
not to drive until vertigo resolves and had a friend/neighbor
take him home from hospital
# Extensive stage small cell lung carcinoma: extensive stage on
diagnosis inc brain mets. Currently C4D7 cis/etoposide recent
imaging shows overall stable disease in chest. Brain MRI
___ showing resolution of prior brain lesions.
Repeat this admission showed ongoing resolution as above.
# HLD: continued home Simvastatin 40 mg PO QPM and Ezetimibe 10
mg PO DAILY
# GERD: continued home Omeprazole 40 mg PO DAILY
# BPH: on Flomax, reports persistent nocturia, advised to
discuss finasteride w/ his PCP, was given urology appointment
but next available not til ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ezetimibe 10 mg PO DAILY
2. Omeprazole 40 mg PO DAILY
3. Simvastatin 40 mg PO QPM
4. Tiotropium Bromide 1 CAP IH DAILY
5. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation DAILY
6. Prochlorperazine 10 mg PO Q6H:PRN nausea and vomiting
7. Acetaminophen 650 mg PO Q8H:PRN Pain
8. Senna 8.6 mg PO BID constipation
9. Bisacodyl ___AILY:PRN constipation
10. Docusate Sodium 100 mg PO BID Constipation
11. Polyethylene Glycol 17 g PO BID:PRN constipation
12. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
13. Ondansetron 4 mg PO Q8H:PRN nausea
14. Allopurinol ___ mg PO DAILY
15. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain
2. Allopurinol ___ mg PO DAILY
3. Bisacodyl ___AILY:PRN constipation
4. Docusate Sodium 100 mg PO BID Constipation
5. Ezetimibe 10 mg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Ondansetron 4 mg PO Q8H:PRN nausea
8. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
9. Polyethylene Glycol 17 g PO BID:PRN constipation
10. Prochlorperazine 10 mg PO Q6H:PRN nausea and vomiting
11. Senna 8.6 mg PO BID constipation
12. Simvastatin 40 mg PO QPM
13. Tamsulosin 0.4 mg PO QHS
14. Tiotropium Bromide 1 CAP IH DAILY
15. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION DAILY
16. Meclizine 25 mg PO BID
RX *meclizine 25 mg 1 tablet(s) by mouth TID prn Disp #*30
Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Benign paroxysmal positional vertigo
Metastatic small cell lung carcinoma
Benign prostatic hypertrophy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr ___ it was a pleasure caring for you during your stay
at ___. You were admitted with new dizziness. Head CT and
brain MRI was done and there are no tumors other than the one
that remains on your scalp. There was also no sign of stroke.
The dizziness is due to a condition called benign paroxysmal
positional vertigo. And your eye movements when we did head
maneuvers confirm this is the cause. You have also experienced
this is in the past. You can continue to take meclizine to
diminish the symptoms. You can also come for therapy if you
choose, call ___.
Followup Instructions:
___
|
10192358-DS-7 | 10,192,358 | 24,835,138 | DS | 7 | 2155-05-28 00:00:00 | 2155-05-28 14:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea on exertion, sore throat
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is an ___ year old man w/hx CAD, HTN, HLD,
presenting with shortness of breath. Over the past week, the
patient has experienced new onset difficulty catching his breath
when walking and talking. He notes that this is occasionally
worse after eating. He has had to decrease the distance that he
walks because of the dyspnea. He denies chest pain, cough,
fever,
and lower extremity swelling.
In the ED initial vitals were: T 97.1 HR 105 BP 136/61 RR 18 O2
sat 94% RA
EKG: NSR, rate 68, RBBB, inferior axis deviation.
Labs/studies notable for: Hgb 13.2 WBC 6.8 Cr 1.0 pBNP 325 Trop
<0.01 D-dimer 869
CXR: L diaphragm elevation and bowel contents in L hemithorax
CTA: No evidence of PE, 1.3 nodular opacity in RUL
pharmacologic nuclear stress: probably normal myocardial
perfusion (poor image quality), normal LV size and systolic
function
Patient was given: Lisinopril 10mg x2, Carvedilol 6.25mg, ASA
81mg, amlodipine 2.5mg
Vitals on transfer: T 98 HR 88 BP 151/74 RR 18 O2 sat 96% RA
On the floor, patient endorses the above history. He is not
currently experiencing any chest pain or shortness of breath. Of
note, patient had a hospitalization at ___ in ___ for
syncope. During this admission, he had a pharmacologic nuclear
stress test which did not show evidence of ischemia. TTE at this
time showed normal LV function, mild to moderate mitral
regurgitation, moderate pulmonary hypertension. He was
discharged
with outpatient cardiac monitoring, which showed NSR rates
77-79,
isolated APB and one 4 beat run of AIVR at 80 BPM. He had
positive orthostatic vital signs and this was thought to be the
cause of his syncope.
REVIEW OF SYSTEMS:
Positive per HPI.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope, or presyncope.
On further review of systems, denies fevers or chills. 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. Denies exertional
buttock or calf pain. All of the other review of systems were
negative.
Past Medical History:
1. CARDIAC RISK FACTORS
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- CAD s/p stent ___
3. OTHER PAST MEDICAL HISTORY
- Prostate surgery ___
- Congenital hiatal hernia
Social History:
___
Family History:
CAD
CVA
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
===============================
___ 1820 Temp: 99.0 PO BP: 127/69 L Sitting HR: 88 RR:
16
O2 sat: 93% O2 delivery: Ra
GENERAL: Well developed, well nourished man 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.
NECK: Supple. JVP 6-8 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. Decreased breath sounds
on left. No wheezes or rales.
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.
DISCHARGE PHYSICAL EXAMINATION:
===============================
GENERAL: Well developed, well nourished man in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. PERRL. MMM.
NECK: Supple. JVP at clavicle when sitting at 45 degrees.
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 wheezes or rales.
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.
Pertinent Results:
ADMISSION LABS:
===============
___ 03:49PM cTropnT-<0.01
___ 11:08AM D-DIMER-869*
___ 11:00AM GLUCOSE-116* UREA N-21* CREAT-1.0 SODIUM-132*
POTASSIUM-5.3 CHLORIDE-96 TOTAL CO2-25 ANION GAP-11
___ 11:00AM cTropnT-<0.01
___ 11:00AM proBNP-325
___ 11:00AM WBC-6.8 RBC-4.23* HGB-13.2* HCT-39.8* MCV-94
MCH-31.2 MCHC-33.2 RDW-12.8 RDWSD-44.1
___ 11:00AM NEUTS-72.5* LYMPHS-11.5* MONOS-11.5 EOS-3.4
BASOS-0.7 IM ___ AbsNeut-4.91 AbsLymp-0.78* AbsMono-0.78
AbsEos-0.23 AbsBaso-0.05
___ 11:00AM PLT COUNT-202
STUDIES:
========
EKG: NSR, rate 68, RBBB, inferior axis deviation. PR 172 QRS
134 QTc 451
PHARMACOLOGIC STRESS ___
The image quality is poor due to soft tissue and left arm
attenuation. There is activity adjacent to the heart in the
stress and rest images. Left ventricular cavity size is normal.
Rest and stress perfusion images reveal probably uniform tracer
uptake throughout the left ventricular myocardium in the setting
of poor image quality. Gated images reveal normal wall motion.
The left ventricular ejection fraction could not be accurately
calculated due to poor image quality. The visually estimated
systolic function is normal.
IMPRESSION:
1. Probably normal myocardial perfusion in the setting of poor
image quality.
2. Normal left ventricular cavity size and systolic function.
EXERCISE STRESS TEST ___
INTERPRETATION: This ___ year old man with a h/o CAD, HTN, HLD
s/p
PCI in ___ at ___ with mild centrilobular emphysema on CTA and
normal
myocardial perfusion study on ___ was referred to the lab
for
evaluation of exertional dyspnea and hemodynamic response to
exercise.
The patient exercised for 6.5 minutes on a ramping treadmill
protocol,
stopping at his request for shortness of breath and fatigue (~3
METS;
poor functional capacity). There were no chest, neck, arm or
back
discomforts reported by the patient throughout the study. At
peak
exercise, the patient reported a "stronger" version of the
exertional
dyspnea he was referred for, which resolved by 5 minutes of
recovery.
There were no significant ST segment changes seen during
exercise or in
recovery. The rhythm was sinus with rare isolated VPBs.
Appropriate
blood pressure response to exercise with a blunted heart rate
response
to exercise in the setting of beta blockade.
IMPRESSION: No anginal type symptoms or ischemic EKG changes.
Appropriate blood pressure response to exercise. Poor functional
capacity.
DISCHARGE LABS:
===============
___ 07:55AM BLOOD WBC-6.5 RBC-4.07* Hgb-12.6* Hct-38.1*
MCV-94 MCH-31.0 MCHC-33.1 RDW-12.8 RDWSD-43.8 Plt ___
___ 07:55AM BLOOD Glucose-94 UreaN-27* Creat-1.0 Na-138
K-4.9 Cl-98 HCO3-27 AnGap-13
___ 07:55AM BLOOD Calcium-9.2 Phos-3.6 Mg-1.9
___ 07:55AM BLOOD TSH-1.3
___ 07:55AM BLOOD Cortsol-14.5
Brief Hospital Course:
TRANSITIONAL ISSUES:
====================
- New medications: Imdur 30 mg was started as an inpatient and
provided on discharge.
- Medication changes: Lisinopril was discontinued. Carvedilol
was increased to 6.25 mg BID. Amlodipine was increased to 5 mg
daily.
SUMMARY STATEMENT:
==================
___ is an ___ year old man w/hx CAD, HTN, HLD,
presenting with one week of increasing dyspnea on exertion.
Patient was admitted for a cardiac work-up and found to have a
normal myocardial perfusion study and unremarkable non-imaging
exercise stress test.
DESCRIPTION OF HOSPITAL COURSE:
===============================
# Dyspnea on exertion
Patient presented with a one-week history of progressive dyspnea
on exertion in the setting of a euvolemic exam, non-ischemic
EKG, and negative troponin levels x 2. Pharmacologic stress was
without evidence of inducible perfusion defects. No evidence of
CHF/volume overload on exam. CTA was without evidence of
pulmonary embolism or other primary pulmonary process that could
be contributing to symptoms (pleural effusion, pneumonia,
pulmonary edema). CXR showed stable hiatal hernia with markedly
elevated left hemidiaphragm. An exercise stress test showed an
appropriate blood pressure response without production of
anginal sympptoms or evidence of ischemia on EKG. Patient was
started on imdur 30, which was provided on discharge.
# CAD
Continued ASA 81mg daily and atorvastatin 10mg daily
# HTN
Increased amlodipine to 5mg daily and carvedilol to 6.25mg BID.
Discontinued lisinopril 10mg daily to reduce polypharmacy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO DAILY
2. Lisinopril 10 mg PO DAILY
3. CARVedilol 6.25 mg PO DAILY
4. amLODIPine 2.5 mg PO DAILY
5. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
2. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. CARVedilol 6.25 mg PO BID
RX *carvedilol 6.25 mg 1 tablet(s) by mouth Two times per day
Disp #*60 Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 10 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Dyspnea on exertion
Hypertension
Coronary Artery Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because of worsening
shortness of breath.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- A nuclear medicine stress test was performed and showed normal
heart function.
- An exercise stress test was performed and showed no evidence
of heart vessel blockages and a normal blood pressure response
to exercise.
- Your blood pressure medications were changed to better control
your blood pressure.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
- If you are having worsening shortness of breath with exertion,
please call Dr. ___.
- Return to the emergency department if you have left-sided
chest pain that moves down your left arm or up to your jaw.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10192402-DS-16 | 10,192,402 | 26,455,078 | DS | 16 | 2184-04-06 00:00:00 | 2184-04-06 20:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ w/ a history of AF on no AC,
IDDM,
HTN, HLD, BPH, & blindness who presents with altered mental
status, found to have acute on subacute subdural hematoma.
The patient was recently hospitalized from ___ ___ with
a
right-sided subdural hematoma after several falls over the
preceding few weeks. On that hospitalization, he underwent
placement of a subdural evacuating port system ___ which was
subsequently removed ___. He was stably discharged to a rehab
facility upon discharge.
In rehab, the patient was reportedly doing well although the
preceding few days he was noted to have increasing confusion. He
was sent to ___ and was found on repeat ___ to have
increased subdural bleed w/ mild right to left midline shift.
She
was thus transferred to ___ for NSG evaluation.
In the ED,
-Initial vitals were:
97.5 F, BP 135/67, HR ___, RR 16, 99% RA
HRs were transiently in the ___ but not captured on EKG.
- Exam notable for:
"AOx2
Benign general and neurologic exams"
- Labs notable for:
Trop 0.04 at ___, 0.02 on arrival to ___ 5.6, Hgb 11, plts 152
Na 146, Cr 0.9
- Imaging was notable for:
___ ___:
"There is slightly increased size of extra-axial fluid
collection
of the right cerebral complexity which appears to be
predominantly hypodense but as previously seen there are
peripheral lesions of isodensity and therefore again consistent
with subacute on chronic subdural hematoma. There is slight
increase in midline shift to the left which currently measures 6
mm and previously measured 4 mm."
___ ___ AM:
"2.5 cm subacute on chronic right subdural hematoma, unchanged
compared to most recent prior and similar to the prior from ___. 7 mm of leftward midline shift is stable compared to
the most recent prior but increased compared to ___
Upon arrival to the floor, patient reports confirms the above
history. He states that he is confused. He states that he does
not know where he is, and specifically whether he is in a rehab
place or a hospital. He has no further complaints and
specifically denies fevers, chills, chest pain, shortness of
breath, abdominal pain, difficulties with bowel movements or
urination.
Past Medical History:
PMHx:
Afib, on Plavix and Coumadin
BPH
HTN
HLD
DMII
hearing loss
legally blind
PSHx: Reports cataract surgery.
Social History:
___
Family History:
NC
Physical Exam:
Vital signs reviewed.
GENERAL: Elderly male, NAD.
HEAD: Bandage over right scalp from prior falls.
NECK: Supple.
CARDIAC: Irregular, S1S2 w/o m/r/g.
LUNGS: CTABL.
ABDOMEN: Soft, NT, +BS.
EXTREMITIES: Warm, no edema.
NEUROLOGIC: Alert to person and time, for place states he is not
sure whether he is in a rehab or hospital. Pupils 2mm and
responsive, EOMI, eyebrows raise equally, weakness on puffing
out
cheeks bilaterally, on smile there is right-sided facial
weakness, tongue protrudes midline, no drift, strength ___ in
all
extremities, sensation grossly intact.
Pertinent Results:
ADMISSION:
==========
___ 06:58AM BLOOD WBC-5.6 RBC-3.62* Hgb-11.0* Hct-34.7*
MCV-96 MCH-30.4 MCHC-31.7* RDW-16.8* RDWSD-59.0* Plt ___
___ 06:58AM BLOOD Neuts-70.4 Lymphs-18.1* Monos-6.6 Eos-4.1
Baso-0.4 Im ___ AbsNeut-3.98 AbsLymp-1.02* AbsMono-0.37
AbsEos-0.23 AbsBaso-0.02
___ 06:58AM BLOOD ___ PTT-27.3 ___
___ 06:58AM BLOOD Glucose-161* UreaN-16 Creat-0.9 Na-146
K-4.6 Cl-109* HCO3-22 AnGap-15
___ 06:58AM BLOOD ALT-5 AST-12 AlkPhos-96 TotBili-0.5
___ 06:58AM BLOOD Lipase-27
___ 06:58AM BLOOD cTropnT-0.02*
___ 06:58AM BLOOD Albumin-3.5 Calcium-8.9 Phos-2.5* Mg-2.0
___ 06:58AM BLOOD Digoxin-0.8
DISCHARGE:
==========
___ 09:05AM BLOOD WBC-5.9 RBC-3.94* Hgb-11.9* Hct-37.3*
MCV-95 MCH-30.2 MCHC-31.9* RDW-16.9* RDWSD-58.4* Plt ___
IMAGING:
========
1. 2.5 cm wide subacute on chronic right subdural hematoma,
unchanged compared
to most recent prior from earlier in the day and similar to the
prior
examination from ___.
2. 7 mm of leftward shift of normally midline structures and
mild effacement
of the right lateral ventricle is unchanged compared to the most
recent prior
from the same day, but slightly increased compared to ___.
Brief Hospital Course:
Mr. ___ is a ___ w/ a history of AF on no AC,
IDDM, HTN, HLD, BPH, & blindness who presents with altered
mental status, found to have acute on subacute subdural
hematoma.
The patient was recently hospitalized from ___ ___ with
a right-sided subdural hematoma after several falls over the
preceding few weeks. On that hospitalization, he underwent
placement of a subdural evacuating port system ___ which was
subsequently removed ___. He was stably discharged to a rehab
facility upon discharge.
In rehab, the patient was reportedly doing well although the
preceding few days he was noted to have increasing confusion. He
was sent to ___ and was found on repeat ___ to have
increased subdural bleed w/ mild right to left midline shift. He
was thus transferred to ___ for NSG evaluation.
He received a repeat CT scan which showed 2.5 cm subacute on
chronic right subdural hematoma, unchanged compared to most
recent prior and similar to the prior from ___. 7 mm
of leftward midline shift is stable compared to the most recent
prior but increased compared to ___.
Upon arrival to the floor, patient reports confirms the above
history. He states that he is confused. He states that he does
not know where he is, and specifically whether he is in a rehab
place or a hospital. He has no further complaints and
specifically denies fevers, chills, chest pain, shortness of
breath, abdominal pain, difficulties with bowel movements or
urination. He was monitored overnight w/o and complications.
His metoprolol was briefly held given reports of bradycardia in
the ED. His telemetry was reviewed and he his rates were at
times ___ but mostly averaged ___ he will thus be restarted on
metoprolol upon discharge.
TRANSITIONAL ISSUES:
====================
# AF:
[] Continue to hold all anticoagulation.
[] Continued titration of beta-blockade given heart rates.
# Care coordination:
He will require follow up with the following:
[] With Dr. ___ in 4 weeks (___),
with CT head at that time- the ___ clinic was called,
and they will contact with an appointment. If you do not hear
within 2 days, please call the phone number above
[] With Dr. ___ in ___ clinic (___)- scheduled
for ___ at 1 ___
[] With Dr. ___ within 1 week- they are aware of
your discharge and should call with follow up plan
[] With Dr. ___ after seeing Dr. ___.
CODE: FULL W/ LIMITED TRIAL OF LIFE SUSTAINING MEASURES,
CONFIRMED
CONTACT: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Digoxin 0.125 mg PO DAILY
3. Finasteride 5 mg PO DAILY
4. GlipiZIDE XL 2.5 mg PO DAILY
5. Pravastatin 10 mg PO QPM
6. Prolensa (bromfenac) 0.07 % ophthalmic (eye) DAILY
7. Senna 8.6 mg PO BID:PRN constipation
8. Tamsulosin 0.4 mg PO QHS
9. Ramelteon 8 mg PO QHS
10. Simethicone 40-80 mg PO QID:PRN gas pain
11. BusPIRone 5 mg PO BID
12. Fluticasone Propionate NASAL 1 SPRY NU DAILY
13. Magnesium Oxide 400 mg PO DAILY
14. Metoprolol Succinate XL 25 mg PO DAILY
15. Milk of Magnesia 30 mL PO Q8H:PRN constipation
16. Multivitamins 1 TAB PO DAILY
17. omeprazole 20 mg oral DAILY
18. Phosphorus 250 mg PO ASDIR
19. TraZODone 50 mg PO QHS:PRN sleep
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. BusPIRone 5 mg PO BID
3. Digoxin 0.125 mg PO DAILY
4. Finasteride 5 mg PO DAILY
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. GlipiZIDE XL 2.5 mg PO DAILY
7. Magnesium Oxide 400 mg PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Milk of Magnesia 30 mL PO Q8H:PRN constipation
10. Multivitamins 1 TAB PO DAILY
11. omeprazole 20 mg oral DAILY
12. Phosphorus 250 mg PO ASDIR
13. Pravastatin 10 mg PO QPM
14. Prolensa (bromfenac) 0.07 % ophthalmic (eye) DAILY
15. Ramelteon 8 mg PO QHS
16. Senna 8.6 mg PO BID:PRN constipation
17. Simethicone 40-80 mg PO QID:PRN gas pain
18. Tamsulosin 0.4 mg PO QHS
19. TraZODone 50 mg PO QHS:PRN sleep
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
Subdural hematoma
SECONDARY:
Atrial fibrillation
Heart failure with reduced ejection fraction
Diabetes
Coronary artery disease
BPH
Blindness
Insomnia
Depression
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___.
WHY WERE YOU ADMITTED?
-Your assisted living facility thought that you are acting more
confused.
-We did a CT scan of your head which showed that the bleed in
your head was overall quite similar to ___. Our neurosurgeons
evaluated you and did not think that you needed further
surgeries. However, you should follow up with them within 1
month with further imaging at that time.
-Otherwise, you did not have an infection or any particular
medications that would make you more confused.
WHAT HAPPENED WHEN YOU WERE HERE?
-We monitored you to make sure that you did not need any
treatments or surgeries.
WHAT SHOULD YOU DO WHEN YOU GO HOME?
-Continue to take all of your medications as prescribed.
-Go to all of your appointments.
We wish you the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10192644-DS-22 | 10,192,644 | 20,872,956 | DS | 22 | 2127-12-14 00:00:00 | 2127-12-16 16:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Hydrochlorothiazide / Simvastatin
Attending: ___.
Chief Complaint:
Right leg pain, swelling, redness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/h/o CHF (EF 15%), Afib on Coumadin, HLD, HTN, h/o chronic
venous stasis, and h/o MRSA cellulitis in L buttock (___) now
presents with R lower extremity swelling, pain, and erythema.
Patient woke up this morning and found his right leg became
swollen, red, and skin tender to touch. The erythema has
extended through today. Otherwise, he denied any fevers, chills,
chest pain, shortness of breath, GI or GU symptoms. Notably,
patient stayed at ___ for L shoulder pain in late ___.
In the ED, VS: 98.8 80 124/82 16 96%RA. Lab notable for WBC 20.2
(88%N). Patient was given 1L NS and started on vancomyin. ___
showed no evidence of DVT (though right peroneal veins are not
well seen). He was admitted for further management.
ROS: (+) per HPI, also endorses some nasal congestion
No fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
Allergic rhinitis
Anemia
AFib- rate controlled, on coumadin
BPH
Chronic back pain
___
CAD
Hyperlipidemia
Hypertension
Hypothyroidism
Obstructive sleep apnea
Osteoarthritis
Pseudogout
Skin cancer
R MCA stroke ___ with small hemorrhagic conversion
Social History:
___
Family History:
Father had lung cancer.
Physical Exam:
Physical exam on admission:
VS: 98.6 105/66 108 18 89%RA (90%2L, 92%3L, 97%4L)
General: NAD, pleasant, lying in bed
HEENT: NCAT, sclera anicteric, PERRL, EOMF, MMM
Neck: soft, no LAD, JVP elevated to just below angle of mandible
Lungs: dull in L hemithorax, and crackles b/l, no
wheezes/rhonchi
CV: fairly regular, nl S1 S2, no murmurs/gallops/rubs
Abd: soft/NT/ND, BS+, no rebound/guarding/masses
Ext: 1+ pitting edema b/l. Motor L < R.
Skin: An area of erythema, tender to touch, with warmth in right
medial aspect of upper leg up to the level of mid-thigh,
demarcated by a purple marker. A closed wound seen medial to the
knee cap. Chronic venous stasis with hyperpigmentation on both
lower extremities. Callouses in both feet, toes with deformity,
no open wounds or ulcers.
Physical exam on discharge:
VS: 97.4-98.2 ___ ___ 18 96%RA
General: NAD, pleasant, lying in bed
HEENT: NCAT, sclera anicteric, PERRL, EOMF, MMM
Neck: soft, no LAD, JVP elevated to just below angle of mandible
Lungs: dull in L hemithorax, no wheezes/rhonchi, crackles b/l?
CV: fairly regular, nl S1 S2, no murmurs/gallops/rubs
Abd: soft/NT/ND, BS+, no rebound/guarding/masses
Ext: 1+ pitting edema b/l. Motor L < R.
Skin: Chronic venous stasis with hyperpigmentation on both lower
extremities. Callouses in both feet, toes with deformity, no
open wounds or ulcers.
An warm, erythematous area in R medial upper leg, now smaller
compared to a few hours ago with redness 1-2 cm within the area
demarcated by a purple marker.
Pertinent Results:
Admission labs:
___ 05:10PM LACTATE-1.8
___ 12:49PM ___ COMMENTS-GREEN TOP
___ 12:49PM LACTATE-3.2*
___ 12:48PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 12:48PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-TR
___ 12:48PM URINE RBC-7* WBC-2 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 12:48PM URINE HYALINE-3*
___ 12:48PM URINE MUCOUS-RARE
___ 12:30PM GLUCOSE-91 UREA N-28* CREAT-0.9 SODIUM-135
POTASSIUM-5.8* CHLORIDE-98 TOTAL CO2-23 ANION GAP-20
___ 12:30PM estGFR-Using this
___ 12:30PM WBC-20.2* RBC-6.28* HGB-16.9 HCT-53.6* MCV-85
MCH-26.9* MCHC-31.6 RDW-16.7*
___ 12:30PM NEUTS-88.3* LYMPHS-5.7* MONOS-3.2 EOS-2.4
BASOS-0.5
___ 12:30PM PLT COUNT-317
___ 12:30PM ___ PTT-40.0* ___
*
RED CELL MORPHOLOGY (___)
Hypochromia NORMAL
Anisocytosis NORMAL
Poikilocytosis NORMAL
Macrocytes NORMAL
Microcytes NORMAL
Polychromasia NORMAL
*
___
___
IMPRESSION:
Right peroneal veins are not well seen, otherwise no evidence of
deep vein thrombosis in the right lower extremity veins.
*
___
Portable AP radiograph of the chest was compared to ___.
Cardiomegaly is severe and unchanged. Left basal consolidation
is most likely
reflecting atelectasis due to elevated left hemidiaphragm. As
compared to the
prior study, there is slight interval worsening of upper zone
vascular
redistribution as well as interstitial opacities consistent with
mild-to-moderate interstitial edema. No definitive pleural
effusion is
demonstrated.
*
URINE CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
OF TWO COLONIAL MORPHOLOGIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
*
Brief Hospital Course:
___ w/h/o CHF (EF 15%), Afib on Coumadin, HLD, HTN, h/o chronic
venous stasis, and h/o MRSA cellulitis in L buttock (___) now
presents with R lower extremity swelling, pain, and erythema c/f
cellulitis with new O2 requirement likely ___ volume overload
*
# R leg MRSA cellulitis: The diagnosis is consistent with his
h/o chronic venous stasis, presentation, and potential entry
wound in R leg. Given his h/o MRSA cellulitis (___) and given
the cellulitis emergence while he was on cefpodoxime for
sinusitis, this is likely MRSA cellulitis. He was started on
vancomycin (day 1: ___, and leg elevation. Blood cultures were
pending. Since admission, the area of warmth/redness in his
right leg has decreased significantly. Patient was switched from
IV vancomycin to PO bactrim on HD#4, and he was discharged home
with PO ciprofloxacin 6 days.
*
# Bacteriuria: Urine culture grew pseudomonas aeruginosa
(10,000-100,000 organisms/ml). He was started on ciprofloxacin
on HD#4 and was discharged home with PO ciprofloxacin for 6
days.
*
# Hypoxemia: After arrival on the floor from the ED, O2 desat
from 96%RA to 89%RA (and 97%4L). It is unclear if this relates
to 1L NS given in the ED, leading to pulmonary edema.
Nevertheless, patient was asymptomatic. Portable CXR was
consistent with worsening pulmonary edema. ACS was unlikely
given no chest pain, no acute ST changes on EKG. PE was unlikely
given negative ___ and therapeutic INR. Overnight, his
hypoxemia resolved, and his O2 sat improved with diuresis using
lasix 20mg IV.
*
# Leukocytosis/polycythemia: WBC at presentation was similar to
his baseline for many months WBC(~13-~20). Pt also p/w
polycythemia (Hct 54). Blood smear showed red cell morphology
wnl. Patient was scheduled for an outpatient hematology
follow-up.
*
# CHF/CAD/AFib: stable. Patient was continued on home med
lisinopril, amiodarone, metoprolol, aspirin, atorvastatin, and
warfarin.
*
# Hypothyroidism: stable. Patient was continued on home med
levothyroxine.
*
#BPH: stable. Patient was continued on home med tamsulosin.
*
#L scapular pain: stable. Patient was continued on home med
hydrocodone-Acetaminophen (5mg-500mg) Q8H:PRN.
*
#Bacterial sinusitis: resolved. On the day of admisison, he was
on ___ day of cephodoxime. He finished his last day of
cephodoxime here.
*
Transitional issues:
PCP
-___ follow up on patient's blood culture
-Please draw lab and follow up on patient's INR.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Lisinopril 2.5 mg PO DAILY
6. Metoprolol Tartrate 12.5 mg PO BID
7. Tamsulosin 0.4 mg PO HS
8. Cefpodoxime Proxetil 100 mg PO Q12H sinusits
9. Warfarin 2 mg PO DAILY16
10. Furosemide 20 mg PO DAILY
11. HYDROcodone-acetaminophen *NF* 7.5-500 mg Oral QID:PRN pain
(15 day supply)
12. Fluticasone Propionate NASAL 2 SPRY NU HS
13. Docusate Sodium 100 mg PO DAILY
14. Milk of Magnesia 5 mL PO HS:PRN constipation
15. Polyethylene Glycol 17 g PO DAILY
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Docusate Sodium 100 mg PO DAILY
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Lisinopril 2.5 mg PO DAILY
Hold for SBP < 100
7. Metoprolol Tartrate 12.5 mg PO BID
Hold for SBP < 100, HR < 55
8. Tamsulosin 0.4 mg PO HS
9. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q8H:PRN pain
10. Milk of Magnesia 5 mL PO HS:PRN constipation
11. Polyethylene Glycol 17 g PO DAILY
12. Fluticasone Propionate NASAL 2 SPRY NU HS
13. Warfarin 1 mg PO 5X/WEEK (___)
14. Warfarin 2 mg PO 2X/WEEK (___)
15. Ciprofloxacin HCl 500 mg PO Q12H UTI Duration: 6 Days
Last day on ___. Sulfameth/Trimethoprim DS 1 TAB PO BID cellulitis Duration:
6 Days
Last day on ___. Furosemide 20 mg PO DAILY
hold if SBP < 100
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Right leg cellulitis
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 found to have right leg cellulitis. Given your current
symptoms and your history of MRSA cellulitis in the past, we
gave you antibiotics to treat this infection: initially IV
vancomyin, which was then switched to PO bactrim. You were also
found to have hypoxemia when you arrived on the floor. We gave
you lasix for diuresis to improve your symptoms. Now we think
that you are safe to go home. You were also found to have
substantial amount of bacteria (pseudomonas aeruginosa) in your
urine, and we gave you another antibiotics (ciprofloxacin) to
treat your urinary tract infection. Now we think it is safe for
you to be discharged.
*
Please take all your medications as prescribed. We have made the
following changes in your medication regimen:
(Batrim) Sulfameth/Trimethoprim DS 1 TAB PO/NG BID (last day
___
Ciprofloxacin HCl 500 mg PO/NG Q12H for 6 days (last day ___
*
Please follow up with your primary care doctor as follows:
PRIMARY CARE:
When: ___ 11:00AM
With: ___, MD ___
Building: ___) ___ Floor
Campus: OFF CAMPUS Best Parking: Free Parking on Site
*
Please also follow up with your hematologist for your blood cell
count.
HEMATOLOGY/ONCOLOGY:
When: ___ 4:00p.m.
With: ___, ___
Building: ___ Ctr ___ Floor
Campus: ___ Best Parking: ___
*
Please weigh yourself every morning, and call your doctor if
your weight goes up by more than 3 lbs. Also, please call your
doctor or go to the emergency room if you have the following
symptoms:
Increased redness, swelling or pain
Bleeding or drainage from wound
Fever > ___
Chills
Feeling more tired
Swelling in the ankle legs or belly
Discomfort in the chest
Trouble breathing
Weight gain more than 3 lbs
Any other symptoms that concern you
Followup Instructions:
___
|
10192644-DS-24 | 10,192,644 | 28,208,401 | DS | 24 | 2129-06-04 00:00:00 | 2129-06-04 21:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Hydrochlorothiazide / Simvastatin
Attending: ___.
Chief Complaint:
hyperkalemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old male hx. AF on coumadin, CHF (EF15%), CAD,
polycythemia, s/p R MCA stroke (___) presenting with
hyperkalemia.
Patient presented for PCP visit on ___ with c/o neck pain, was
ordered for plain films of his neck, started on naproxen BID,
and had routine labs done which revealed a potassium of 6.2.
Patient was advised to stop spironolactone and start metolazone.
He had repeat labs checked ___ which revealed a potassium of
7.0 for which he was referred to the ED. Of note, patient
reports never starting the metolazone.
The patient himself endorses no new changes to his medical
issues except for the development of a mild headache over the
last few days. Denies fevers/chills, numbness/tingling or
weakness, no n/v/diarrhea, no chest pain or dyspnea.
In the ED initial vitals were: 97.5 80 135/80 16 99%.
- Labs were significant for CBC with WBC 19, H/H 18.3/64.2, pt
462. Potassium was 7.3 (moderately hemolyzed) and 5.3 on
recheck. No EKG changes. Labs also notable for LDH 77, ast 71,
AP 158. INR 1.9.
- Patient was given sorbitol 15cc and kayexelate as well as 1L
NS.
On the floor, patient currently c/o right sided back pain he has
had for several days since changing his bed at home, as well as
chronic left shoudler pain. Also with pain on his left heel at
the site of an open skin defect. Otherwise no complaints.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
Allergic rhinitis
Anemia
AFib- rate controlled, on coumadin
BPH
Chronic back pain
___
CAD
Hyperlipidemia
Hypertension
Hypothyroidism
Obstructive sleep apnea
Osteoarthritis
Pseudogout
Skin cancer
R MCA stroke ___ with small hemorrhagic conversion
Social History:
___
Family History:
Father had lung cancer.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
Vitals - 97.8 144/98 hr 89 18 96% RA
GENERAL: awake, alert, oriented, NAD
HEENT: EOMI, PERRLA, OMM no lesions
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: irregular, no m/r/g
LUNG: CTABL no wheezing
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no c/c/e
SKIN: brawny changes in ___ b/l, left shin with 2 subcm black
eschar type wounds, 2 subcm shallow/clean based ulcers with
dressing overlying, left heel with small skin defect no pus or
drainage
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, moves all fours
PHYSICAL EXAM ON DISCHARGE:
Vitals: T: 97.8 BP: 144/98 P: 89 R: 18 O2: 96% RA
GENERAL: awake, alert, oriented, NAD
HEENT: EOMI, PERRLA, OMM no lesions
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: irregular, no m/r/g
LUNG: CTAB bilaterally, no wheezing
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no c/c/e
SKIN: brawny changes in ___ b/l, left shin with 2 subcm black
eschar type wounds, 2 subcm shallow/clean based ulcers with
dressing overlying, left heel with small skin defect no pus or
drainage
PULSES: 2+ DP pulses bilaterally
NEURO: moves all extremities well
Pertinent Results:
ADMISISON LABS
===============
___ 10:55PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 10:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 10:55PM URINE RBC-4* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-1
___ 08:12PM K+-5.3*
___ 08:10PM GLUCOSE-107* UREA N-29* CREAT-1.0 SODIUM-131*
POTASSIUM-7.3* CHLORIDE-99 TOTAL CO2-22 ANION GAP-17
___ 08:10PM ALT(SGPT)-22 AST(SGOT)-71* LD(LDH)-757* ALK
PHOS-158* TOT BILI-0.8
___ 08:10PM CALCIUM-9.2 PHOSPHATE-3.8 MAGNESIUM-2.5
___ 08:10PM WBC-19.1* RBC-7.80* HGB-18.3* HCT-64.2*
MCV-82 MCH-23.5* MCHC-28.5* RDW-18.3*
___ 08:10PM NEUTS-79.7* LYMPHS-7.5* MONOS-6.8 EOS-4.1*
BASOS-1.8
___ 08:10PM PLT COUNT-462*
___ 09:15AM SODIUM-133 POTASSIUM-7.0* CHLORIDE-97
___ 09:15AM MAGNESIUM-2.6
___ 09:15AM ___
DISCHARGE LABS
==============
___ 07:25AM BLOOD WBC-18.4* RBC-7.56* Hgb-17.7 Hct-63.9*
MCV-84 MCH-23.2* MCHC-27.8* RDW-18.5* Plt ___
___ 07:25AM BLOOD Neuts-79.3* Lymphs-7.1* Monos-8.3
Eos-4.4* Baso-1.0
___ 07:25AM BLOOD ___
___ 07:25AM BLOOD Glucose-61* UreaN-22* Creat-0.8 Na-138
K-5.9* Cl-101 HCO3-26 AnGap-17
___ 07:25AM BLOOD ALT-23 AST-31 LD(LDH)-419* AlkPhos-159*
TotBili-1.1
___ 02:40PM BLOOD Na-135 K-5.3* Cl-97
___ 07:25AM BLOOD Mg-2.1
MICROBIOLOGY
============
NONE
IMAGING/STUDIES
===============
___ NONCON HEAD CT
No acute intracranial hemorrhage or mass effect or obvious new
major acute infarct. Encephalomalacia of the right MCA
territory is again noted and unchanged. Correlate clinically.
Brief Hospital Course:
BRIEF SUMMARY
==============
___ year old male h/o AF on coumadin, CHF (EF15%), CAD,
polycythemia, s/p R MCA stroke (___) presenting with
hyperkalemia.
ACUTE ISSUES
============
# Hyperkalemia: Patient presented with hyperkalemia to 7.0 in
the setting of recent spironolactone and lisinopril use. Had
also been switched to metolazone as an outpatient but had not
taken this medication despite filling his prescription. Given
polycythemia with increased LDH, there was concern for hemolytic
process as well. He did not have any EKG changes on arrival to
ED and repeat K was 5.9, s/p kayexelate and sorbitol x1. He
received 20 mg Lasix x 1 with improvement of K to 5.3. The
decision was made to discharge the patient given downtrending
potassium and lack of symptoms. He was given a script to
follow-up for repeat electrolyte check on ___ with the results
faxed to his PCP. He was instructed to start the home metolazone
and to discontinue lisinopril until his PCP sees him in
outpatient follow-up.
# ?Polycythemia: Patient's H/H ___ on admission, has had
borderline elevated H/H since ___. Of note, has a chronic
leukocytosis since ___, now with leukocytosis and
thrombocytosis. He does not have history concerning for chronic
CO poisening and is a nonsmoker. EPO level ___ 1.3 (low)
making polycythemia ___. No atypicals noted on
automated diff on admission. Heme-onc was consulted on ___ and
recommended checking EPO level and JAK2 V617F mutation analysis.
They recommended starting aspirin 81 mg as an outpatient but
this was deferred to the patient's PCP given the patient's
history of a rectus sheath hematoma in ___. He will be
contacted regarding a follow-up outpatient heme-onc appointment
for further management and work-up of his abnormal blood counts.
CHRONIC ISSUES
==============
# CAD: Stable. Continued metoprolol 12.5 mg BID, atorvastatin 20
mg qhs.
# sCHF: EF 20% last ECHO ___ with ?___ tachycardia mediated CM,
did not appear volume overloaded at this admission. He was
instructed to avoid spironolactone and start metolazone as
instructed by his PCP.
# Afib: Stable. INR subtherapeutic on AM labs (1.9). Patient
appears to have some difficulty with adhering to coumadin dose.
He was continued on PCP's regimen of 2 mg coumadin 5x/week, 1 mg
2x/week. He was given a script to have repeat INR check on
___.
TRANSITIONAL ISSUES
===================
# Heme-onc recommends aspirin 81 mg given likelihood of
polycythemia ___. However, patient is on coumadin, so please
consider starting this if you do not feel patient will be at
substantial risk of bleeding given he is also on coumadin (has
h/o rectus sheath hematoma in ___.
# Patient will be contacted by heme-onc re. outpatient follow-up
for work-up of possible polycythemia ___. Has JAK2 V617F
mutation level pending.
# Patient has had difficult compliance with warfarin (admits to
taking less than prescribed amount). INR was 1.9 on day of
discharge. Patient will have follow-up electrolytes and INR
check on ___.
# Lisinopril held at discharge and will need to be restarted in
outpatient setting.
# CODE: Full
# CONTACT: ___ Relationship: Son, phone number:
___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain
2. Hyoscyamine 0.125 mg SL DAILY:PRN gi upset
3. Levothyroxine Sodium 100 mcg PO DAILY
4. Lisinopril 2.5 mg PO DAILY
5. Metoprolol Tartrate 12.5 mg PO BID
6. Tamsulosin 0.4 mg PO HS
7. Warfarin 2 mg PO 5X/WEEK (___)
8. Warfarin 1 mg PO 2X/WEEK (___)
9. Atorvastatin 20 mg PO HS
10. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID:PRN itchy
skin
11. Metolazone 5 mg PO DAILY
Discharge Medications:
1. Atorvastatin 20 mg PO HS
2. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain
3. Levothyroxine Sodium 100 mcg PO DAILY
4. Metoprolol Tartrate 12.5 mg PO BID
5. Tamsulosin 0.4 mg PO HS
6. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID:PRN itchy
skin
7. Warfarin 2 mg PO 5X/WEEK (___)
8. Warfarin 1 mg PO 2X/WEEK (___)
9. Hyoscyamine 0.125 mg SL DAILY:PRN gi upset
10. Metolazone 5 mg PO DAILY
11. Outpatient Lab Work
Patient will need chem-7 and INR checked on ___. Please fax
results to Dr. ___ at ___.
ICD-9 code: ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
# Hyperkalemia
# Leukocytosis
# Erythrocytosis
SECONDARY DIAGNOSIS
===================
# Systolic heart failure
# Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your hospitalization
at ___. You were admitted
because you were found to have elevated potassium levels. You
received medications to lower your potassium and your level
normalized. We have held one of your blood pressure medications
(lisinopril). Your PCP ___ instruct you on when to restart this
medication. You should start metolazone as prescribed by your
doctor.
Because you had elevated abnormal blood cell counts in your
blood, we have asked the hematology-oncology doctors to ___
you while you were in the hospital. They have recommended that
you follow-up as an outpatient with them in clinic and will
contact you regarding an appointment.
We have written you for a script so that you can have a repeat
lab draw tomorrow ___ to check your potassium level and INR.
Please weigh yourself every morning, call MD if weight goes up
more than 3 lbs.
We wish you the ___,
Your ___ Care Team
Followup Instructions:
___
|
10192644-DS-25 | 10,192,644 | 28,053,646 | DS | 25 | 2129-07-01 00:00:00 | 2129-07-02 11:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Hydrochlorothiazide / Simvastatin
Attending: ___.
Chief Complaint:
R acetabular fracture
R supracondylar humerus fracture
C1 fracture
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with a PMHx of atrial fibrillation on coumadin, heart
failure with reduced EF ___ on echo in ___,
membranoproliferative disorder (likely PCV but with 2 lineages
affected) who was orignally admitted to the orthopedic surgery
service on ___ with an acetabular fracture, pubic ramus
fracture, and supracondylar humeral fracture. He was initially
managed non-opertaively but because of persistent pain, the
decision was made to proceed with operative management. He
underwent screw fixation of his pelvic on ___. His
hospitalization has been complicated by poor nutritional status,
constipation, and hyponatremia. He was transferred to medicine
for further workup of his hyperbilirubinemia of unclear etiology
and his volume status needs to be optimized prior to discharge.
Past Medical History:
Allergic rhinitis
Anemia
AFib- rate controlled, on coumadin
BPH
Chronic back pain
sCHF
CAD
Hyperlipidemia
Hypertension
Hypothyroidism
Obstructive sleep apnea
Osteoarthritis
Pseudogout
Skin cancer
R MCA stroke ___ with small hemorrhagic conversion
Social History:
___
Family History:
Father had lung cancer.
Physical Exam:
ADMISSION PHYSCIAL EXAM
=======================
Vitals: T: 98.0, BP: 90/69, P: 90, R: 18, O2: 95%
General: NAD, A+Ox3 (name, date, location)
HEENT: anicteric sclera, EOMI, PERRLA, dry MM, mild thrush
Neck: hard collar in place, unable to assess JVP
CV: irregularly irregular, soft systolic murmur
Lungs: CTA anteriorly
Abdomen: +BS, soft, NT/ND
GU: foley draining dark urine
Ext: Right upper extremity: +Tenderness at the elbow Full ROM of
the elbow is limited ___ pain. Tenderness over the R hip,
PROM/AROM of the hip and knee limited ___ pain, arthritic
deformities of the toes (chronic, bilateral)
Neuro: Limited by slings and pain. Left hand contracted with ___
strength, right hand with ___ strength, LLE with ___ strenght,
RLE ___ strength.
Skin: intact with chronic venous statsis changes bilaterally,
hematoma at right elbow
Psych: normal mood and affect with poor insight into health
DISCHARGE PHYSICAL EXAM
=======================
Vitals: Tm: 98.7, Tc: 98.0, BP: 90-133/43-52, P: 83-105, R:
___, O2: 95-98%, I: 1200cc, O: 770.
General: NAD, A+Ox3 (name, date, location)
HEENT: anicteric sclera, EOMI, PERRLA, dry MM, mild thrush
Neck: hard collar in place, unable to assess JVP
CV: irregularly irregular, soft systolic murmur
Lungs: CTA anteriorly
Abdomen: +BS, soft, NT/ND
GU: foley draining dark urine
Ext: WWP, no pitting edema, +2 ___ pulses, chronic venous
stasis changes bilaterally
Neuro: Limited by slings and pain. Left hand contracted with ___
strength, right hand with ___ strength, LLE with ___ strenght,
RLE ___ strength.
Skin: intact with chronic venous statsis changes bilaterally,
hematoma at right elbow
Psych: normal mood and affect with poor insight into health
Pertinent Results:
ADMISSION LABS
==============
___ 10:00AM BLOOD ___-29.9* RBC-7.38* Hgb-18.0 Hct-59.6*
MCV-81* MCH-24.4* MCHC-30.3* RDW-19.3* Plt ___
___ 10:00AM BLOOD Neuts-90.3* Lymphs-3.7* Monos-4.5 Eos-1.1
Baso-0.4
___ 10:00AM BLOOD ___ PTT-40.8* ___
___ 10:00AM BLOOD Glucose-104* UreaN-41* Creat-0.8 Na-134
K-6.4* Cl-95* HCO3-28 AnGap-17
___ 11:07PM BLOOD Calcium-8.8 Phos-2.9 Mg-1.9
NOTABLE LABS
============
___ 06:40AM BLOOD WBC-32.2* RBC-5.52 Hgb-13.4* Hct-45.9
MCV-83 MCH-24.3* MCHC-29.2* RDW-20.3* Plt ___
___ 06:40AM BLOOD Neuts-86.9* Lymphs-4.6* Monos-6.1 Eos-2.2
Baso-0.2
___ 06:40AM BLOOD ___
___ 06:40AM BLOOD Glucose-75 UreaN-16 Creat-0.5 Na-132*
K-4.5 Cl-96 HCO3-30 AnGap-11
___ 06:40AM BLOOD Calcium-7.9* Phos-2.6* Mg-1.9
MICRO
=====
None.
IMAGING/STUDIES
===============
R hip / pelvis ___: There is a displaced discontinuity of
the cortex
along the medial acetabulum and lateral superior pubic ramus
suggesting fracture that is otherwise difficult to assess the
extent. The patient is status post right hip hemiarthroplasty.
A
remodeled appearance to the right greater trochanter suggests a
prior healed fracture. The left hip joint space appears
preserved. Degenerative changes are incompletely characterized
along the lower lumbar spine. The bones appear demineralized.
Vascular
calcifications are widespread.
R elbow ___: There is a non-displaced supracondylar
fracture
associated with a faint lucency. Moderate degenerative changes
affect both the ulnar trochlear and radial capitellar joints
including moderate osteophytes about the radial head. Overlying
soft tissues are prominent. It is difficult to assess for an
effusion due bony spurs and background soft tissue attenuation.
CXR ___: No evidence of acute cardiopulmonary disease or
injury.
CT head: No acute intracranial hemorrhage. Unchanged
encephalomalacia of the right frontoparietal region.
CT C spine: There is an unstable C1 fracture at the anterior
ring
and left lamina, which were also present in the head CT from
___. The C1 fractures are not entirely imaged in the
prior
head CT and thus evaluation of chronicity is limited, however
the
fractures may have been acute at that point. In current study,
there is associated posterior subluxation of C1 over C2.
Anterior
subluxation of C3 over 4 and C5 over 6 appear chronic and
related
to degenerative disease.
CT pelvis: There is extensive right acetabulum fracture
propagating through the right iliac wing. There is fracture of
superior and inferior pubic ramus. There is heterotopic bone
along the right proximal femur. The bone is generally
demineralized. There is a large hematoma in the pelvis along
the
right pelvic wall. The hematoma is extravesicular and
retroperitoneal and courses along the course of right the iliac
vessels. Active bleeding cannot be excluded.
Reanl U/S ___: Minimally complex cyst without worrisome
features is incidentally noted in the right kidney. No findings
to suggest a cause of hematuria.
Speech and swallow ___
FINDINGS:
Barium passes freely through the oropharynx and esophagus
without evidence of obstruction. There was aspiration with thin
liquids and penetration with nectar thick liquids.
IMPRESSION:
Aspiration with thin liquids and penetration with nectar thick
liquids.
PELVIS (AP ONLY); HIP UNILAT MIN 2 VIEWS RIGHT
There is a right hip hemiarthroplasty which is intact. There are
screws within the right hemipelvis without complications.
Fractures of the right iliac wing extending into the medial
acetabulum are again seen. Contrast material is seen in the
small bowel. There are degenerative changes of the lower lumbar
spine and bilateral sacroiliac joints.
DISCHARGE LABS
==============
___ 07:15AM BLOOD WBC-31.5* RBC-5.67 Hgb-13.9* Hct-47.7
MCV-84 MCH-24.4* MCHC-29.1* RDW-20.2* Plt ___
___ 10:35AM BLOOD ___ PTT-38.4* ___
___ 07:15AM BLOOD Glucose-55* UreaN-22* Creat-0.5 Na-134
K-4.7 Cl-92* HCO3-28 AnGap-19
___ 07:15AM BLOOD ALT-11 AST-26 LD(LDH)-724* AlkPhos-260*
TotBili-2.4* DirBili-1.0* IndBili-1.4
___ 07:15AM BLOOD Albumin-2.7* Calcium-8.0* Phos-3.2 Mg-2.4
___ 07:15AM BLOOD Hapto-<5*
Brief Hospital Course:
ASSESSMENT AND PLAN: ___ yo M with PMHx of heart failure with
reduced ejection fraction, myeloproliferative disorder, coronary
artery disease who was admitted to the orthopedic surgery
service on ___ after sustaining a fall. He is now POD #4
from a right acetabular ORIF, transferred to medicine for
hyperbilirubinemia, hyponatremia, and decreased PO intake.
# Fractures: The patient was found to have a right acetabular
fracture and right supracondylar humerus and was admitted to the
orthopedic surgery service. He was initially managed
non-opertaively but because of persistent pain, the decision was
made to proceed with operative management. Percutaneous screw
fixation of the right acetabular fracture was completed on ___. After the surgery, he was evaluated by ___ who recommended
rehab. 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 through a Foley
and moving bowels spontaneously. The patient is nonweightbearing
in the right upper extremity and nonweightbearing in the right
lower extremity. The patient will follow up in two weeks per
routine. Pain medication scripts have been written on discharge.
He should also be continued on an aggressive bowel regimen while
taking pain medications.
# Hyponatremia: The patient's hyponatremia had noted improvement
with IVF overnight and holding metolazone/lisinopril, which
supported this under-resuscitation and overdiuresis, fitting a
clinical picture of hypovolemic hyponatremia. Given
normonatremia on discharge, the patient's metolazone and
lisinopril were resumed on discharge.
# Decreased PO intake: After ORIF, the pt had decreased PO
intake. Pt also reports painful lesions in the mouth with
possible thrush. He was started on Nystatin suspension and had a
speech and swallow evaluation, by which he was cleared for
pureed (dysphagia); nectar prethickened liquids. The pt was
encouraged to increase PO intake, which improved dramatically on
discharge.
# Mixed hyperbilirubinemia: Etiologies could be multiple in the
setting of his erythrocytosis, leukocytosis, and recent trauma.
Possibly related to a diagnosis of polycythemia ___. Hematoma
resorption could increase the indirect bili, while possible PCV
could affect production of indirect (hemolysis demonstrated by
increased LDH and decreased haptoglobin) and clearance of the
bili as well. Further workup as an outpatient is recommended.
# Atrial fibrillation: He remains therapeutically
anticoagulated. His INR is elevated likely secondary to
malnutrition as he has not had anything PO except liquids. In
the absence of bleeding, we would recommend against vitamin K.
The patient's INR was reversed with FFP, and he was taken to ___
OR for surgical fixation of his right acetabulum fracture, which
the patient tolerated well.
His INR goal is between ___ because of his CHADS2 of 5 requiring
anticoagulation. As his PO intake improved and coumadin
continued to be held, his INR decreased to 2.4. His coumadin
will be resumed on discharge.
# S/p fall: C1 fracture on CT in the ED for which Neurosurgery
was consulted. The patient was placed in a c-collar, and the
neurosurgical service recommended nonoperative management, with
follow up in 2 months - c-collar to be worn at all times except
during periods of hygiene until follow up in outpatient
___
clinic.
# Painless hematuria: The patient was found to have painless
hematuria. Renal ultrasound was performed which revealed no
evidence of renal injury. Per Urology service, the patient
should follow up as an outpatient in ___ clinic for further
evaluation of his painless hematuria.
# Chronic sysotlic CHF: The patient did not have any
exacerbation of his symptoms. He had daily weights and Is&Os
checked. There were no worsening signs of fluid overload on
exam. He was instructed to monitor his weights daily on
discharge and to call an MD if weight changes more than 3lbs.
# Hyperlipidemia: Atorvastatin was continued in-house and at
discharge.
# Hypertension: Lisinopril was initally held due to soft
pressures, but was resumed on discharge.
# Hypothyroidism: Levothyroxine was continued in-house and at
discharge.
# BPH: Tamsulosin was continued in-house and at discharge.
TRANSITIONAL ISSUES
===================
# Restart warfarin ___ and check INR on ___
# Home metolazone and home lisinopril should be restarted at
rehab
# He was started on ascorbic acid and zinc for 10 days to
facilitate wound healing
# He was admitted while tapering down Prednisone in the setting
of a pseudogout flare. On discharge, prednisone is being
restarted at 30mg, please decrease by 10mg every 3 days (3 days
x 30mg, 3 days x 20mg, 3 days x 10mg, then stop).
# The pt should follow-up with ___, NP in the
orthopedic trauma clinic ___ days post-operation for
evaluation. Call ___ to schedule appointment upon
discharge.
# Pt should follow-up with Dr. ___ in ___
clinic in two months, at which time a non-contrast CT of the
cervical spine should be scheduled prior to the appointment. The
cervical collar should stay on until this follow up appointment.
# Pt should follow up with PCP regarding this admission and any
new medications/refills.
# CODE: FULL
# CONTACT: ___, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain
3. Levothyroxine Sodium 100 mcg PO DAILY
4. Metoprolol Tartrate 12.5 mg PO BID
5. Tamsulosin 0.4 mg PO QHS
6. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID:PRN itching
7. Warfarin 1 mg PO 2X/WEEK (___)
8. Warfarin 2 mg PO 5X/WEEK (___)
9. Hyoscyamine 0.125 mg SL DAILY:PRN GI upset
10. Metolazone 5 mg PO DAILY
Discharge Medications:
1. Atorvastatin 20 mg PO QPM
2. Metoprolol Tartrate 12.5 mg PO BID
3. Tamsulosin 0.4 mg PO QHS
4. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID:PRN itching
5. Docusate Sodium 200 mg PO BID
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Milk of Magnesia 15 mL PO QHS:PRN constipation
8. Polyethylene Glycol 17 g PO BID
9. Acetaminophen 325-650 mg PO Q6H
10. Zinc Sulfate 220 mg PO DAILY
11. Ascorbic Acid ___ mg PO BID
12. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
13. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
14. Senna 8.6 mg PO BID
15. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
16. Lisinopril 2.5 mg PO DAILY
17. Metolazone 5 mg PO DAILY
18. Warfarin 2 mg PO 2X/WEEK (___)
19. Warfarin 1 mg PO 5X/WEEK (___)
20. PredniSONE 30 mg PO TAPER
Please take 30mg for 3 days, and then decrease to 20mg for 3
days, and 10mg for 3 days
Tapered dose - DOWN
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right acetabular fracture
Right supracondylar humerus fracture
C1 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:
Dear Mr. ___,
It was a pleasure caring for you during your stay at ___. You
were admitted for a fracture of your pelvis, which was
subsequently repaired with an operation, as well as a humeral
fracture, which was managed conservatively. You had some
difficulty eating after your surgery, but this improved. You are
being discharged to rehab for further physical therapy and
medical treatment.
We wish you the best!
Your ___ care team
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 continue to take your home dose of warfarin.
ACTIVITY AND WEIGHT BEARING:
- No weight bearing in the right arm, with sling
- No weight bearing in the right leg
- Cervical collar to remain on at all times except during
periods of hygiene, until follow up with Neurosurgery
Physical Therapy:
NWB RUE in sling
NWB RLE
Followup Instructions:
___
|
10192748-DS-22 | 10,192,748 | 28,500,595 | DS | 22 | 2139-11-24 00:00:00 | 2139-11-25 17:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Shellfish
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Thorascentesis (___)
History of Present Illness:
___ yo woman with a history of CLL with no evidence of disease
since treatment ___ ___ now with bladder cancer and LPL vs.
marginal zone lymphoma s/p rituximab with only minimal response
and recent fall with liver laceration and duodenal tear, s/p
operative closure with ___, s/p recent initiation of
R-bendamustine on ___, presents to the ER with shortness of
breath. She has been her usual state of health at her rehab
when she was told she was hypoxic at rehab the morning of
admission. She had labs drawn which showed an Hct of 23. She
denies any fevers, chills, sweats, cough, PND, orthopnea, chest
pain, tightness, and states that her breathing improved when she
was walking around. She states that she feels her depresion and
anxiety have gotten more difficult over the past few days but
denies any SI/HI. ___ the ED, initial VS 98.7 84 114/59 16 100%
2L. She received Maalox. She also had a surgery consult who
thought that her anemia was not from her J tube site but from
chemotherapy and agreed with admission to ___.
Review of Systems:
(+) Per HPI and constipation for 4 days, anasarca
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies blurry vision, diplopia, loss of vision,
photophobia. Denies sinus tenderness, rhinorrhea or congestion.
Denies chest pain or tightness, palpitations. Denies cough or
wheezes. Denies nausea, vomiting, diarrhea, abdominal pain,
melena, hematemesis, hematochezia. Denies dysuria, stool or
urine incontinence. Denies arthralgias or myalgias. Denies
rashes. No numbness/tingling ___ extremities. All other systems
negative.
Past Medical History:
Oncology history:
- Longstanding history of CLL, which dates back to either ___
___ or early ___. Initially she was on chlorambucil, though
it is not clear as to how long she was on this medication. Most
recent treatment was with the Rituxan. She completed four
weekly doses ___. White count with dramatic improvement at
that time and has been stable since.
- Patient was found to have bladder cancer following hematuria.
During evaluation of bladder cancer was also noted to have a
large retroperitoneal mass that on biopsy was consistent with an
indolent lymphoma possible LPL or marginal zone lymphoma.
Interval increase ___ mass over the last month with now palpable
liver secondary to tumor compression of liver.
- ___ Rituximab
- ___ Rituximab
- ___ Rituximab
- ___ Rituximab
- ___ Rituxan-Bendamustine C1
- Transitional cell bladder CA s/p TURB (___), anticipating
radiation
Other medical history:
-Depression
-Anxiety
-Hypothyroidism
-Dyspepsia
-Herpes zoster
-Right bundle-branch block.
-HTN
-Hyperlipidemia
Past Surgical History:
-Lobular breast CA s/p resection ___
-Mechanical fall requiring R arm hardware
-Two spinal surgeries for scoliosis, s/p hysterectomy for
fibroid
Social History:
___
Family History:
Denies any known family history of any blood disorders or cancer
that she is aware of
Physical Exam:
On Admission
VS: T 98 bp 120/70 HR 86 RR 18 SaO2 100 on 2L NC0
GEN: anxious, awake, alert
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP moist and
without lesion
NECK: Supple, no JVD appreciated
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Resp unlabored, +wheezing bl, no accessory muscle use.
decreased breath sounds at the left base, no crackles or
rhonchi.
ABD: Tense but ___, bowel sounds present, J tube ___ place
with some redness surrounding site
MSK: normal muscle tone
EXT: normal perfusion, anasarca
NEURO: oriented x 3, no focal deficits, intact sensation to
light touch
PSYCH: anxious, circumstantial thought process, normal thought
content
On Discharge
VS: ___ RA
GEN: very anxious, awake, alert
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP mildly
dry, but without lesion
NECK: Supple, no JVD appreciated
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Resp unlabored, no accessory muscle use, no crackles or
rhonchi.
ABD: Tense but non-tender, bowel sounds present, previous J tube
site w a small 0.3 cm opening, with scant purulent drainage. No
purulence at lower abdominal wound site.
MSK: normal muscle tone
EXT: normal perfusion, 2+ edema bilateral extremities
NEURO: oriented x 3, no focal deficits, intact sensation to
light touch
PSYCH: anxious, circumstantial thought process
Pertinent Results:
___ 06:00PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 06:00PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 06:00PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0 TRANS EPI-<1
___ 05:30PM GLUCOSE-130* UREA N-35* CREAT-1.1 SODIUM-136
POTASSIUM-3.2* CHLORIDE-94* TOTAL CO2-29 ANION GAP-16
___ 05:30PM ___
___ 05:30PM CALCIUM-9.2 PHOSPHATE-4.1 MAGNESIUM-2.1 URIC
ACID-5.0
___ 05:30PM WBC-0.6*# RBC-2.64* HGB-8.8* HCT-26.0* MCV-98
MCH-33.5* MCHC-34.0 RDW-20.0*
___ 05:30PM NEUTS-37* BANDS-5 LYMPHS-4* MONOS-50* EOS-4
BASOS-0 ___ MYELOS-0
___ 05:30PM PLT COUNT-256
___ 05:20PM cTropnT-0.08*
On Discharge:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
___ 8.1 2.95* 9.8* 29.0* 99* 33.2* 33.7 19.0* 196
Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 89 28* 1.0 130* 4.5 94* 31 10
ALT AST LD(LDH) CK(CPK) AlkPhos TotBili DirBili
___ 200* 0.6
.
Pleural Fluid:
___ 12:58PM PLEURAL WBC-78* RBC-203* Polys-0 Lymphs-6*
___ Macro-94*
___ 12:58PM PLEURAL TotProt-3.2 Glucose-113 LD(LDH)-83
Amylase-49 Albumin-2.4 Triglyc-371
.
Micro:
___ 6:00 pm SWAB Source: Abdominal wound.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
VIRIDANS STREPTOCOCCI. MODERATE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
.
___ 12:58 pm PLEURAL FLUID PLEURAL FUID.
**FINAL REPORT ___
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 (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
.
IMAGING:
Admission CXR:
Large left-sided pleural effusion with increased aeration of the
left upper lobe when compared to prior. Decrease ___ size of
right-sided pleural effusion. Presumed left lower lobe and
right base atelectasis with infection not excluded
.
___ CXR (sp thorascentesis):
Interval reduction ___ size of left-sided pleural effusion with
possible new moderate-sized right pleural effusion.
IMPRESSION:
1. Loculated small left pleural effusion has decreased ___ size,
and a
drainage catheter is within the anterior component of the
effusion.
2. Right-sided effusion has decreased considerably ___ size.
3. Pneumothorax is no longer apparent.
.
Echo:
Suboptimal image quality. Normal biventricular cavity size with
preserved biventricular systolic function. No significant
valvular disease. Borderline pulmonary hypertension.
.
CT CHEST/ABDOMEN ___
Wet Read: ___ ___ 5:49 ___
Compared with ___, there are decreased now moderate
non-hemorrhagic, non- serous pleural effusions. There is a new
small focus of consolidation ___ the lingula (2;42). The bulk of
the retroperitoneal nodal mass is unchanged ___ size (9.9 x 4.3
cm), with a second focus also similar measuring 6.7 x 3.7cm. The
fluid collection with a focus of enhancement previously seen ___
the left flank is decreased ___ size, with rim calcification,
likely reflecting resolving hematoma. Right hydronephrosis and
hydroureter is unchanged, the result of enhancement and
thickening of the bladder wall c/w known tumor.
Delayed excretion from the right kidney is new indicated
worsening fuction. Gallstones are unchanged, no evidence of
acute cholecystitis.
Brief Hospital Course:
Ms. ___ is an ___ yo lady w/ hx of CLL (tx/remission
___, now with bladder cancer and LPL vs. marginal zone
lymphoma (s/p rituximab with only minimal response) and with a
recent fall, resulting ___ a liver laceration and duodenal tear
(s/p operative closure with ___ ___ s/p recent
initiation of R-bendamustine on ___, who presented to the ED
w/ SOB found to be anemic with worsening pleural effusion;
hospital course complicated by surgical site infection.
.
# Shortness of Breath. Thought to be secondary to pleural
effusion with contribution from worsening anemia. Upon
consultation with interventional pulmonology, it was felt that a
thorascentesis would be helpful for diagnosis and treatment.
650cc of chylous fluid was drained and found to contain 371
triglycerides and a fluid:serum LDH ration of 0.52. This was
thought to be due to a chylothorax, likely secondary to
malignant obstruction. Pleurex catheter was placed and fluid was
drained. Shortly before discharge decision was made to pull
catheter. Breathing remained stable thereafter and CXR
demonstrated stable effusion. The patient's diet was changed to
minimize triglycerides by the consulting nutritionist. Patient
will follow-up with IP for close monitoring of pleural effusion.
She will be discharged on "Fat restricted Nutrition Therapy"
(from the ___ Dietetic Association's Nutrition Care Manual)
diet to help prevent reaccumulation of pleural fluid.
.
# G-tube Malposition.
Gastrostomy tube was found to be displaced on examination of the
patient's abdominal dressings. Surgery was consulted and advised
that, since the patient was eating well, the tube should be left
out and the wound to heal while calorie counts were monitored to
ensure patient's nutrition.
.
# Left infiltrate.
On screening CT chest evidence of small lung infiltrate.
Decision made to treat with levofloxacin for seven day course
(start date ___ end date ___
# Surgical Site Infection
Surgical site (previous ex-lap ___ ___ was found to be draining
purulent fluid and erythematous. Cephalexin treatment was
initiated ___ - ___. Fluid culture demostrated S.
aureus and pt was started on vancomycin 1g IV q12h (day 1 =
___. Patient completed 8day course of antibiotics for soft
tissue infection on ___.
.
#LPL vs. Marginal Zone Lymphoma. SP R-bendamustine on ___.
Granulocyte count improved so neupogen was discontinued on
___. Scanning CT torso was obtained on ___. Results
demonstrated persistent disease. Plan to follow-up with Dr
___ on ___.
.
#Depression/Anxiety. Acute on chronic. Patient maintained on
Mirtazapine, Zoloft, Wellbutrin. Patient and family will
continue to benefit from social work at ___.
#Constipation. Continued on Colace, senna, miralax.
.
#Hypothyroidism. Continued on synthroid at dose of 125mcg QD
.
#HTN - HCTZ discontinued ___ house. Normotensive on amlodipine
and losartan.
.
#Hyperlipidemia - Chronic. Decision made to hold statin at time
of discharge.
.
#PPx.
Subcutaneous heparin TID as long as platelets are > 100 as
patient is relatively immobilize. If mobilization improves with
physical therapy can consider discontinuation of medication.
#DNR/DNI
Transitional Issues:
[] Follow-up final CT abdomen pelvis (obtained for staging)
[] Monitor surgical site; ensure that area is kept clean, dry,
intact.
[] Follow Up ___ Interventional Pulmonary to future mgmt of
pleural effusion
[] Follow-up with Dr ___ on ___ to discuss
future plans ___ regards to lymphoma
Medications on Admission:
Tylenol ___ q4 PRN pain, fever
Ducolax 10mg PR daily PRN constipation
Lasix 40mg PO daily
Allopurinol ___ mg PO/NG DAILY ___ @ 2325 View
Levofloxacin 250 mg PO/NG Q24H (scheduled from ___
BuPROPion 112.5 mg PO BID ___ @ 2325 View
Sertraline 25 mg PO/NG DAILY ___ @ 2325 View
Ondansetron 4 mg PO Q8H:PRN nausea ___ @ 2325 View
Levothyroxine Sodium 125 mcg PO/NG DAILY ___ @ 2325 View
Vitamin D 800 UNIT PO/NG DAILY ___ @ 2325 View
Maalox/Diphenhydramine/Lidocaine 5 mL PO QID:PRN mouth pain
___ @ ___ View
Acyclovir 400 mg PO/NG TID ___ @ 2325 View
Sodium Chloride Nasal ___ SPRY NU TID ___ @ 2325 View
Calcium Carbonate 1000 mg PO/NG HS ___ @ 2325 View
Losartan Potassium 50 mg PO/NG DAILY ___ @ 2325 View
Amiodarone 200 mg PO/NG DAILY ___ @ 2325 View
TraMADOL (Ultram) 50 mg PO Q6H:PRN pain ___ @ ___ View
Aspirin 81 mg PO/NG DAILY ___ @ ___ View
Amlodipine 5 mg PO/NG DAILY ___ @ ___ View
Ipratropium Bromide Neb 1 NEB IH Q6H:PRN dyspnea ___ @ ___
View
Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN wheezing ___ @
___ View
Mirtazapine 15 mg PO/NG HS ___ @ ___ View
Senna 1 TAB PO/NG BID:PRN constipation ___ @ ___ View
Milk of Magnesia 30 mL PO/NG Q6H:PRN heartburn ___ @ ___
View
Discharge Medications:
1. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*0 Tablet(s)* Refills:*0*
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every six (6) hours as
needed for wheezing.
Disp:*qs * Refills:*0*
3. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for dyspnea.
Disp:*qs * Refills:*0*
4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection three times a day.
Disp:*30 syringes* Refills:*0*
5. acyclovir 400 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*0 Tablet(s)* Refills:*0*
6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*0 Tablet(s)* Refills:*0*
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
Disp:*0 Tablet, Chewable(s)* Refills:*0*
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain: Hold for sedation, RR<12.
Disp:*0 Tablet(s)* Refills:*0*
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO three
times a day as needed for constipation.
Disp:*0 Capsule(s)* Refills:*0*
10. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*0 Tablet(s)* Refills:*0*
11. sertraline 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*0 Tablet(s)* Refills:*0*
12. bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*0 Tablet(s)* Refills:*0*
13. allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*0 Tablet(s)* Refills:*0*
14. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*0 Tablet(s)* Refills:*0*
15. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
Disp:*0 Tablet(s)* Refills:*0*
16. levothyroxine 125 mcg Capsule Sig: One (1) Capsule PO once a
day.
17. Miralax 17 gram Powder ___ Packet Sig: One (1) PO once a day
as needed for constipation.
18. calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit
Tablet Sig: One (1) Tablet PO twice a day.
19. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours) for 7 days: start date ___/ End date
___.
20. losartan 50 mg Tablet Sig: One (1) Tablet PO once a day:
hold for sbp<100, hr<50.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Pleural effusion
Secondary: Marginal Zone Lymphoma vs. LPL
Discharge Condition:
Mental Status: Alert and Oriented
Ambulatory Status: To chair with assistance
General: Improved
Discharge Instructions:
Dear Ms. ___, It was a pleasure to take care of you at
___.
You were admitted with shortness of breath which was though
secondary to your anemia (low red blood cell count) and pleural
effusion (fluid collection around the lung). ___ treatment of
your anemia you were tranfused. The interventional pulmonolgists
helped treat your effusion with a catheter to drain the
collection and a change ___ diet to slow fluid build-up. The
pulmonary team of doctors ___ this ___ until it
resolved. You were also found to have infection around the site
of the former G-tube, and you were treated with antibiotics.
Please note the following medication changes:
# Several of your home medications had dose alterations:
MIRTAZAPINE. Increased from 7.5mg to 15mg. Please take one 15mg
tablet at night
LEVOTHYROXINE. Increased from 100mcg to 125mcg. Please take one
125mcg tablet daily
SERTALINE. Decreased from 100mg to 25mg. Please take one 25mg
tablet daily.
Medications that were started ___ house:
LOSARTAN. Please start taking 50mg tablets. Take one daily.
BUPROPION. Please start taking 75mg tablets twice daily.
ALLOPURINOL. Please start taking 100mg tablets. Take one daily.
CALCIUM-VITAMIN D SUPPLEMENTATION. Take one tablet twice daily
PROCHLORPERAZINE. Take one 10mg tablet every 6hrs as needed for
nausea
LEVOFLOXACIN. Please take one 750mg tablet every other day for
7days ___ treatment of potential lung infection (start date ___,
end date ___
Medications that were stopped:
STOP taking Atorvastatin and Hydrochlorothiazide.
Continue taking all other medication as prescribed
Again it was a pleasure taking care of you. Please contact with
questions or concerns.
Followup Instructions:
___
|
10192748-DS-25 | 10,192,748 | 28,902,887 | DS | 25 | 2140-04-29 00:00:00 | 2140-04-29 19:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Shellfish
Attending: ___.
Chief Complaint:
Lethargy / Hypoxia
Major Surgical or Invasive Procedure:
Intubated in ICU
Temporary bilateral chest tubes, subsequently removed
Right Pleurx catheter
History of Present Illness:
The patient is a ___ with history of CLL in remission since
___, transitional cell carcinoma of bladder (s/p resection and
radiation), newly diagnosed retroperitoneal lymphoma (recently
tx with chlorambucil) who presents from rehab with hypoxia and
lethargy.
According to the patient's son, the patient has reported feeling
tired with decreased appetite over the past week. She has been
less engaged in verbal conversation. On the day of presentation,
SNF notes document an inability to maintain O2 sat > 86% on 2.5L
NC with a change in response to verbal command. Upon
presentation to ___ ED, VS: 97 73 140/58 18 86% 2L. Patient
was A+OX3 in ED with mild dyspnea. While being straight cathed,
the patient was noted to be hypoxic at 75% on 5LNC, and was
placed on 100%NRB. She was weaned to 5LNC. Labs were significant
for WBC 3.2 (79% N, 9% B), plts 142, lactate 1.3. The patient
underwent diagnostic thoracentesis, with removal of 70 cc fluid.
Fluid was transudative. UA negative. VS on transfer: 97.6 86
135/59 18 98% 4L.
Of note, the patient was admitted to ___ from ___ with
neutropenic fever following treatment with R-bendamustine C2.
Her hospital course was complicated by a coccyx pressure ulcer,
VRE UTI, and c.diff colitis. She was subsequently discharged to
rehab, where she has remained until the current time. Clinic
notes in ___ report increasing dyspnea on exertion over the last
several weeks. She is in wheelchair most of the time, but when
she does walk short distances with a walker, she finds herself
short of breath. She was referred to ___ for work-up of pleural
effusions, and was seen in clinic on ___ thoracentesis was
performed with 1000 mL removed. Transudate, cytology negative.
Follow-up CXR on ___ revealed reaccumulation of the fluid.
Review of systems:
Unable to provide
Past Medical History:
Oncology history:
- Longstanding history of CLL, which dates back to either late
___ or early ___. Initially she was on chlorambucil, though
it is not clear as to how long she was on this medication. Most
recent treatment was with the Rituxan. She completed four
weekly doses ___. White count with dramatic improvement at
that time and has been stable since.
- Patient was found to have bladder cancer following hematuria.
During evaluation of bladder cancer was also noted to have a
large retroperitoneal mass that on biopsy was consistent with an
indolent lymphoma possible LPL or marginal zone lymphoma.
Interval increase in mass over the last month with now palpable
liver secondary to tumor compression of liver.
- ___ Rituximab
- ___ Rituximab
- ___ Rituximab
- ___ Rituximab
- ___ Rituxan-Bendamustine C1
- Transitional cell bladder CA s/p TURB (___), anticipating
radiation
.
Other medical history:
-Depression
-Anxiety
-Hypothyroidism
-Dyspepsia
-Herpes zoster
-Right bundle-branch block.
-HTN
-Hyperlipidemia
.
Past Surgical History:
-Lobular breast CA s/p resection ___
-Mechanical fall requiring R arm hardware
-Two spinal surgeries for scoliosis, s/p hysterectomy for
fibroid
Social History:
___
Family History:
No blood disorders or cancers in her family of which she is
aware.
Physical Exam:
Admission exam:
General: Opens eyes to loud voice, oriented X3
HEENT: MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: RR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: crackles bilaterally, dullness at bases
Abdomen: soft, non-tender, non-distended, bowel sounds present,
midline vertical incision c/d/i
Ext: 2+ pulses, 2+ edema
Neuro: CNII-XII intact
.
Discharge exam:
General: Sitting in chair in NAD. Anxious.
Vitals: T: 97.4 BP:148/61 HR: 72 R: 18 O2: 100% 2LNC
HEENT: MMM, Some crusting over right eye.
Lungs: Breathing comfortably, able to speak in full sentences.
EXT: + Edema upper and lower extremity edema
Pertinent Results:
ADMISSION LABS
___ 06:00PM BLOOD WBC-3.2*# RBC-3.43* Hgb-11.7* Hct-36.8#
MCV-107* MCH-34.0* MCHC-31.7 RDW-17.2* Plt ___
___ 06:00PM BLOOD Neuts-79* Bands-9* Lymphs-6* Monos-5
Eos-0 Baso-0 ___ Metas-1* Myelos-0
___ 06:00PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+
Macrocy-2+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ MacroOv-1+
___ 06:00PM BLOOD Plt ___
___ 10:24PM BLOOD ___ 10:24PM BLOOD ___ 05:14AM BLOOD Ret Aut-2.5
___ 06:00PM BLOOD Glucose-125* UreaN-29* Creat-0.7 Na-144
K-5.0 Cl-101 HCO3-37* AnGap-11
___ 06:00PM BLOOD LD(LDH)-165
___ 05:14AM BLOOD ALT-19 AST-14 LD(LDH)-120 CK(CPK)-13*
AlkPhos-138* TotBili-0.6 DirBili-0.2 IndBili-0.4
___ 05:14AM BLOOD CK-MB-4 cTropnT-0.03*
___ 10:24PM BLOOD CK-MB-3 cTropnT-0.04*
___ 04:43AM BLOOD CK-MB-3 cTropnT-0.06*
___ 03:28PM BLOOD CK-MB-3 cTropnT-0.07*
___ 09:03PM BLOOD CK-MB-4 cTropnT-0.08*
___ 03:34AM BLOOD CK-MB-3 cTropnT-0.08*
___ 02:39PM BLOOD CK-MB-2 cTropnT-0.09*
___ 06:00PM BLOOD TotProt-5.8*
___ 05:14AM BLOOD TotProt-5.1* Albumin-3.9 Globuln-1.2*
Calcium-9.6 Phos-4.3 Mg-2.1
___ 03:18AM BLOOD Hapto-55
___ 05:14AM BLOOD Triglyc-86
___ 04:43AM BLOOD TSH-0.97
___ 09:03PM BLOOD CEA-1.2 ___ CA125-65*
___ 10:24PM BLOOD IgG-189* IgA-12* IgM-155
___ 02:29AM BLOOD Type-ART pO2-393* pCO2-119* pH-7.19*
calTCO2-48* Base XS-12 Intubat-NOT INTUBA Comment-NON-REBREA
___ 06:12PM BLOOD Lactate-1.3 K-5.1
.
MICROBIOLOGY
___ URINE URINE CULTURE-FINAL INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ URINE URINE CULTURE-FINAL {ENTEROCOCCUS
FAECIUM} INPATIENT
___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL {YEAST, STAPH AUREUS COAG +}; FUNGAL CULTURE-FINAL
{YEAST} INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ URINE URINE CULTURE-FINAL {GRAM POSITIVE
BACTERIA} INPATIENT
___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL {STAPH AUREUS COAG +, YEAST}; LEGIONELLA
CULTURE-FINAL; FUNGAL CULTURE-FINAL {YEAST} INPATIENT
___ PLEURAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL; ANAEROBIC CULTURE-FINAL INPATIENT
___ PLEURAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL; ANAEROBIC CULTURE-FINAL EMERGENCY WARD
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-FINAL
.
IMAGING & STUDIES
___ CXR: Large bilateral pleural effusions, similar
compared to the prior study with associated bibasilar
atelectasis. Mild pulmonary vascular congestion.
.
___ Pleural Fluid Cytology: NEGATIVE FOR MALIGNANT CELLS
.
___ Pleural Fluid Cytoloty: NEGATIVE FOR MALIGNANT CELLS
.
___ CTA Chest/Abd/Pelvis: IMPRESSION: 1. No pulmonary
embolism or acute aortic pathology. 2. Large left pleural
effusion causing near complete collapse of the left lower lobe.
3. Right lower and middle lobe and to a lesser degree lingular
ground-glass opacities could reflect aspiration or infectious
process. Trace right pneumothorax likely due to right basal
chest tube. 4. Decreased size of retroperitoneal nodal
conglomeration encasing the aorta as well as infrarenal lesion
in the left retroperitoneum. 5. Bladder lesion is not as well
assessed as on the previous study.
.
___ Pleural Fluid Cytology: NEGATIVE FOR CARCINOMA. Small
lymphocytes, few mesothelial cells and few histioyctes. Note: A
low grade lymphoproliferative process cannot be entirely
excluded based on morphology. See also recent flow cytometry
report ___.
.
___ ECHO: IMPRESSION: Severe hypokinesis to akinesis of
the left ventricular septum, anteroseptum, anterior, and
anterolateral walls, suggesting infarct in the LAD territory,
with overall moderately reduced LV ejection fraction. Borderline
right ventricular systolic function.
.
___ Left Upper Extremity U/S: IMPRESSION: No DVT in the
left upper extremity.
.
___ CT Head: CONCLUSION: No evidence of hemorrhage or
mass effect.
.
___ CXR: The bilateral chest tubes are in unchanged
position. There is no evidence of current pneumothorax.
Scoliosis with subsequent asymmetry of the rib cage is
unchanged. Unchanged size of the cardiac silhouette. The
extent of the bilateral pleural effusions has not substantially
changed. The right PICC line is constant.
.
___ ECHO: Severe hypokinesis/near-akinesis of the left
ventricular septum, anterior, and anterolateral walls,
consistent with a large left anterior descending artery infarct.
Overall moderately reduced left ventricular ejection fraction.
EF ___.
.
___ CXR:
Complete whiteout of the left hemithorax is unchanged, is a
combination of large areas of atelectasis and unknown amount of
pleural effusion. Right PICC tip is in the low SVC. Cardiac
size cannot be evaluated. Cardiomediastinum is obscured by the
left lung opacities, is deviated towards the left. Large right
effusion is unchanged. Severe right scoliosis is again noted.
Right chest tube is in place
Brief Hospital Course:
The patient was ___ woman with a past medical history of
breast cancer and CLL. She also has bladder TCC with residual
disease following cystoscopic resection, s/p XRT, and refractory
retroperitoneal lymphoma. She presented to the ___ ED with
hypoxia and lethargy.
.
ACTIVE ISSUES:
#Goals of care/family meetings:
Multiple family meetings were held during the admission to
explore the patient's and family's goals of care. The first, on
___, included the patient's sons, husband, Drs. ___
___, and social worker where her DNR status was
reaffirmed, but would accept intubation given the patient's
respiratory status. On ___, an additional family meeting was
held with patient's sons and husband, SW, and Dr. ___. At
the meeting, hospice was discussed, but the family expressed
desire for inpatient hospice, and a Palliative Care consult
would be pursued. The patient was also made DNR/DNI at this
meeting. Finally, on ___, a family meeting with patient's
sons, husband, SW, Palliative Care, and Dr. ___. At this
meeting, it was decided to transition all meds to po, to look
for a ___ facility with goal of avoiding readmission, and to
continue to titrate meds for comfort.
.
# Hypoxia: Patient's admission chest x-ray was stable from
prior with large bilateral pleural effusions. Patient was
initially intubated for respiratory failure, which was most
likely secondary to a myocardial infarction and subacute
development of bilateral pleural effusions in the setting of
severe pre-existing kyphoscoliosis. She had no firm evidence of
pulmonary infection, including no fevers, cough, or sputum
production. However, given the severity of her illness she was
treated with a broad-spectrum empiric antibiotic course for 7
days. She underwent thoracentesis of her large left effusion
with pigtail placement on ___ and ~1L out initially. Multiple
pleural fluid samples were sent for cytology, which did not show
evidence of malignancy. There were likewise no indications of
malignancy by flow cytometry. Malignant effusion vs. cardiogenic
effusion in setting of NSTEMI remained at the top of the
differential. Patient had bilateral chest tubes placed by IP.
She was extubated on ___. She was diuresed aggressively,
with improvement in respiratory status to saturations of 98% on
___. Nevertheless, some fluid did reaccumulate on chest X-ray
so her chest tubes were temporarily left in place. Chest tubes
were removed after several days of low output, though due to
recurrence on the right side a right Pleurx was placed for
drainage as needed. She developed significant left-sided
atelectasis likely secondary to mucus plugging. At a family
meeting, evaluation of left lung by bronchoscopy was deferred
given the patient's stable repiratory status, lack of symptoms,
and minimal oxygen requirement. Her right-sided pleural effusion
was followed by CXR for change and drained as needed for
symptomatic relief. Pt R.sided pleurex catheter was last drained
on ___ for about 300 ccs.
.
# Systolic heart failure/Myocardial infarction: A previous TTE
from ___ showed an EF of 60%. However, when this study was
repeated here to rule out cardiac causes of hypotension the EF
was reduced to approximately ___. Though there was a mild
elevation in her troponin, this was stable and the CK-MB ___
unremarkable. It was thought that her ejection fraction had
decreased secondary to a myocardial infarction in the LAD
distribution. She was medically optimized on beta-blockade,
statin, ace-inhibitor, though aspirin was held due to
thrombocytopenia.
.
# Pancytopenia: The patient was admitted with pancytopenia,
which worsened over the course of her hospitalization. There was
minimal atypia and no evidence of schistocytes. LDH and
haptoglobin were normal making TTP unlikely. DIC was also
considered but thought likely considering smear results and
normal fibrinogen. Marrow suppressive process from drugs,
infection possible, malignancy in marrow.
.
In regard to her thrombocytopenia specifically, she was an
intermediate risk category in the 4T score based on temporality,
the possibility of clot (left hand, arm had swollen but
ultrasound of LUE negative for clot the following day), current
platelet level. Arguing against HIT, she was pancytopenic.
Nevertheless, her subcutaneous heparin was stopped (further
details below), and a HIT antibody sent though was negative. She
was not high risk and as such, no direct thrombin inhibitor was
initiated.
.
# Elevated PTT: The patient was admitted to the FICU with a PTT
of 43 despite being on only subcutaneous heparin (5000 U TID).
There was a question of whether this was secondary to heparin
sensitivity or an acquired inhibitor. Heparin was stopped and
her PTT declined to 34 by the time she left the intensive care
unit. Her thrombin time was essentially at the upper end of
normal when heparin was stopped and her PTT was down-trending,
so a mixing study was done which was borderline with a negative
lupus anticoagulant. In light of her clinical condition and
discussions with family, no further interventions were
performed.
.
# Anemia: likely related to underlying cancer in combination
with urinary blood loss from TCC as well as CLL and recent
chemotherapy. She did have some serosanguinous discharge from
her chest tubes in the post-placement time frame. There was one
episode of frank bleed from the left chest tube, but this did
not result in an appreciable hematocrit drop. The patient was
transfused for a hematocrit less than 21 on one occasion while
in the intensive care unit.
.
# Retroperitoneal lymphoma: Lymphoplasmacytic lymphoma vs
marginal zone lymphoma or less likely a CD10 negative follicular
lymphoma. Has not responded to R-bendamustine. Recently started
a short course of chlorambucil 6 mg X 5 days (___). Per
hematology/oncology recommendation: gave 1 dose IVIg on ___
with no resulting complications. Pt is not a candidate for any
further chemotherapy.
.
# Vancomycin-Resistant Enterococcus Urinary Tract Infection:
Discovered during work-up for waxing and waning mental status.
Treated with 2 doses of fosfomycin without complication.
.
# Depression/anxiety: Noted to have debilitating anxiety during
last admission. Psychiatry felt delirium contributing to
anxiety. We continued sertraline 50 mg daily and mirtazapine
15mg qhs. A psychiatry consult was requested this admission for
re-evaluation and it was recommended that sertraline be
continued. This was titrated up during the hospitalization to
discharge dose of 62.5mg.
.
# Peripheral edema: Believed to be related to mechanical
obstuction of lymphatics from worsening retroperitoneal LAD. TTE
from ___ with normal EF. See further details as above in
"systolic heart failure."
.
# Upper extremity skin ecchymosis: ecchymosis most likely from
low platelets in the context of movement / bumping arms against
the bed, et cetera. No frank skin breakdown while in the
intensive care unit.
.
# Upper extremity edema: This was attributed to hypoalbuminemia
and volume accumulation. The patient did receive ultrasound to
rule out deep vein thrombosis, but no such cause was identified.
This did resolve somewhat with diuresis.
.
# Lethargy: The patient was initially alert and interactive
while markedly hypercarbic. Despite decreasing the patient's
CO2, her mental status declined and she became less responsive.
However, after coming off of the ventilator her mental status
had fully recovered. The cause for her transiently depressed
mental status was not elucidated while in the intensive care
unit.
.
INACTIVE ISSUES
# Transitional cell carcinoma of the bladder: s/p palliative XRT
for the urgent management of hydronephrosis with recent imaging
demonstrating stabilization of disease. No acute treatment was
undertaken while hospitalized in the intensive care unit.
.
# Chronic lymphocytic leukemia: Stable. No cytogentic comparison
to new retroperitoneal lymphoma. IgG and IgA are both low (as
they have been for several years, though these are record low
values). There was no change in her clinical status or treatment
given.
.
# Hypothyroidism: Recent history of elevated TSH to 17.
Levothroxine increased to 150mcg daily during admission in
___. The patient was continued on levothyroxine 150 mcg
daily (or the IV dose equivalent while intubated) during her ICU
stay.
.
# Distal R arm nodule: Bx by derm on ___. Neutrophilic
infiltrate with bacteria (bacterial abscess) with overlying
edema. Started on Keflex with an intended course from ___ -
___. However, the patient was transitioned to broad spectrum
antibiotics on admission (see above), obviating the need for
cephalexin.
.
TRANSITIONAL ISSUES:
# can continue to drain fluid from right sided plurex catheter
for symptom management.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acyclovir 400 mg PO Q8H
2. Vitamin D 400 UNIT PO DAILY
3. Levothyroxine Sodium 150 mcg PO DAILY
4. Mirtazapine 15 mg PO HS
5. Nystatin Oral Suspension 5 mL PO Frequency is Unknown
6. Sertraline 50 mg PO DAILY
7. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
8. Cephalexin 500 mg PO Q8H
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acyclovir 400 mg PO Q8H
2. Vitamin D 400 UNIT PO DAILY
3. Levothyroxine Sodium 150 mcg PO DAILY
4. Mirtazapine 15 mg PO HS
5. Nystatin Oral Suspension 5 mL PO Frequency is Unknown
6. Sertraline 50 mg PO DAILY
7. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
8. Cephalexin 500 mg PO Q8H
Discharge Medications:
1. Levothyroxine Sodium 150 mcg PO DAILY
RX *levothyroxine 150 mcg 1 tablet(s) by mouth once a day Disp
#*15 Tablet Refills:*0
2. Artificial Tears ___ DROP BOTH EYES PRN eye dryness
RX *dextran 70-hypromellose [Artificial Tears] ___ drops in
each eye As needed Disp #*1 Bottle Refills:*0
3. Metoprolol Tartrate 12.5 mg PO BID
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
twice a day Disp #*7 Tablet Refills:*0
4. Ondansetron ___ mg PO Q8H:PRN nausea
RX *ondansetron 4 mg ___ tablet(s) by mouth every eight (8)
hours Disp #*5 Tablet Refills:*0
5. Docusate Sodium (Liquid) 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 100 mg by mouth BIDPRN Disp #*60
Capsule Refills:*0
6. Acyclovir 400 mg PO Q8H
RX *acyclovir 400 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*45 Tablet Refills:*0
7. Mirtazapine 15 mg PO HS
RX *mirtazapine 15 mg 1 tablet(s) by mouth at bedtime Disp #*15
Tablet Refills:*0
8. Sertraline 62.5 mg PO DAILY
RX *sertraline 50 mg 1 tablet(s) by mouth once a day Disp #*15
Tablet Refills:*0
RX *sertraline 25 mg 0.5 (One half) tablet(s) by mouth once a
day Disp #*15 Tablet Refills:*0
9. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth once a day Disp #*15
Tablet Refills:*0
10. Sodium Chloride Nasal ___ SPRY NU BID:PRN nasal dryness
RX *sodium chloride [Nasal Spray (sodium chloride)] 0.65 % ___
spray nasal twice a day Disp #*1 Bottle Refills:*0
11. Morphine Sulfate (Concentrated Oral Soln) 5 mg PO Q4H:PRN
pain or breathlessness
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 5 mg by mouth
every four (4) hours Disp ___ Milliliter Refills:*0
12. Lorazepam 1 mg PO Q6H:PRN anxiety
RX *lorazepam 1 mg 1 mg by mouth every six (6) hours Disp #*16
Tablet Refills:*0
13. Atropine Sulfate 1% 2 DROP SL Q4H:PRN secretions
RX *atropine [Atropine-Care] 1 % 2 drops SL every four (4) hours
Disp ___ Milliliter Refills:*0
14. Fluconazole 200 mg PO Q24H
RX *fluconazole 200 mg 1 tablet(s) by mouth Q24H Disp #*15
Tablet Refills:*0
15. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
RX *lansoprazole 30 mg 1 capsule(s) by mouth once a day Disp
#*15 Capsule Refills:*0
16. Levofloxacin 750 mg PO Q48H Duration: 1 Doses
Last dose ___.
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth Q48 Disp
#*1 Tablet Refills:*0
17. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
RX *sodium chloride 0.9 % [Saline Flush] 0.9 % 10ml QDay Disp
#*15 Syringe Refills:*0
18. Heparin Flush (10 units/ml) 2 mL IV DAILY
followed by normal saline
RX *heparin lock flush (porcine) [heparin lock flush] 10 unit/mL
2ml once a day Disp #*1 Bottle Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Hypercapneic respiratory failure.
Secondary Diagnosis:
Pleural effusions s/p bilateral chest tubes, now with right
Pleurx
Pneumonia
Mucus plugging with atelectasis
Urinary tract infection
Delirium
Discharge Condition:
Mental Status: Clear and coherent. Occasionally confused
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear ___,
It was a pleasure to care for you during your hospitalization.
You were admitted on ___ for difficulty breathing. This
required the temporary placement of chest tubes to drain fluid
from outside of your lungs. You were found to have decreased
heart function as well as a lung infection. These conditions
caused fluid to build-up around your lungs.
Chest tubes were placed to help drain this fluid around your
lungs. After they were removed, a small tube was placed to allow
the fluid on the right lung to be removed as needed.
You also developed a urinary tract infection in addition to
pneumonia, which were treated with antibiotics.
Many meetings were held with you, the palliative care team, and
the oncology team to decide to transition your care to focus on
comfort and symptom management.
You will be discharged to a hospice house where they can work
closely on symptom managment.
Followup Instructions:
___
|
10192912-DS-10 | 10,192,912 | 25,917,825 | DS | 10 | 2120-03-24 00:00:00 | 2120-03-21 16:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Left prosthetic hip dislocation
Major Surgical or Invasive Procedure:
___: OR for closed reduction left hip under anesthesia
History of Present Illness:
___ female with recent left hip replacement on ___
at ___ with ___. The patient was using her normal
precautions, preparing to put her pants on, when she twisted
slightly to the right and then returned to the left. At this
time, she felt a pop and pain in her left leg. She has been
unable to ambulate since that time. She denies any falls,
paresthesias.
Past Medical History:
HTN, GERD
L hip replacement ___ ___, Dr. ___
___ History:
___
Family History:
NC
Physical Exam:
Discharge Exam:
Gen: NAD, AOx3
CV: RRR
Resp: CTAB
Abd: Soft, NT/ND
Extrem:
LLE:
SILT s/s/sp/dp/t nerve distributions
Firing ___
2+ ___ pulses
Foot wwp, good cap refill
Pertinent Results:
___ L Hip XR:
Images show total bilateral hip arthroplasty with reduction of
the left hip now in anatomic alignment.
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left prosthetic hip dislocation and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for closed reduction of left hip under
anesthesia 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 given anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. ON POD 0 she was on oral pain
medications only. The patient did not need to work with ___, was
fitted with abduction brace, 30 degrees abduction and ___
degrees of flexion. 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
weight bearing as tolerated in the left lower extremity with
abduction brace 30 in degrees abduction and ___ degrees of
flexion at all times. The patient will follow up with Dr. ___
___ routine in 2 weeks. 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:
AmLODIPine 2.5 mg PO DAILY
LORazepam 0.5 mg PO QHS:PRN insomnia
Nadolol 20 mg PO DAILY
Omeprazole 20 mg PO BID
Simvastatin 20 mg PO QPM
Discharge Medications:
1. Acetaminophen 650 mg PO TID
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
3. OxyCODONE (Immediate Release) 5 mg PO Q3H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
4. amLODIPine 2.5 mg PO DAILY
5. LORazepam 0.5 mg PO QHS:PRN insomnia
6. Nadolol 20 mg PO DAILY
7. Omeprazole 20 mg PO BID
8. Simvastatin 20 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left prosthetic hip dislocation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- weight bearing as tolerated in hip abduction brace at all
times, 30 degrees of abduction, ___ degrees of flexion
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:
- None needed
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
- 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
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___ in 2
weeks. Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Followup Instructions:
___
|
10193065-DS-22 | 10,193,065 | 23,797,594 | DS | 22 | 2128-10-10 00:00:00 | 2128-10-11 12:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx dCHF with suspicion of cardiac amyloid (awaiting
appointment with ___, plasma cell dyscrasia, AFib, HTN, HLD, DM,
hx hemorrhagic CVA, CKD, dementia (oriented to self), p/w
dyspnea.
Per ED dashboard & call-in, he resides at ___. He was
more dyspneic and confused, and was brought in by son for high
concern. Accompanying symptoms were onset at rest, substernal
chest pressure. Also endorsed occasional PND and ___ edema.
Denied f/c, cough, urinary symptoms. He had scheduled ___
tomorrow with H/O. Was placed on torsemide BID in ___, with no
reported recent changes to medications.
In the ED, initial vital signs were: 98.8 70 150/88 24 100% NC
- Exam was notable for: Diastolic murmur, JVD, ___ edema,
Diminished breath sounds
- Labs were notable for: No leukocytosis. H/H 9.4/31.3. Bicarb
33. BUN 21 (Cr 1.2). Trop negative. Lactate 1.6.
Past Medical History:
-Diabetes Mellitus
-HLD
-HTN
-Dementia
-Congestive heart failure
-CVA x2
-CKD Stage III
-BPH
-Vitamin D deficiency
-Abdominal aortic aneurysm
Social History:
___
Family History:
Father: ___
Physical ___:
ADMISSION PHYSICAL EXAM:
==========================
VITALS: T98 BP 157/86 HR 72 RR 18 Sats 94 RA
Weight 99.6 kg
GENERAL: well-appearing, in no apparent distress.
HEENT: normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear.
NECK: Supple, no LAD, no thyromegaly, JVP flat.
CARDIAC: Irregularly irregular, 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.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing. 1+
pitting edema bilaterally up to knees.
SKIN: Without rash.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
DISCHARGE PHYSICAL EXAM:
===========================
Weight 95.4 kg
VITALS: 98.3 136/77 65 18 95%RA
I/O: 1L output in ED; ___
GENERAL: well-appearing, in no apparent distress.
HEENT: normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear.
NECK: Supple, no LAD, no thyromegaly, JVP flat.
CARDIAC: Irregularly irregular, 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.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing. 1+
pitting edema bilaterally up to knees.
SKIN: Without rash.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
Pertinent Results:
ADMISSION LAB VALUES:
======================
___ 11:31PM URINE HOURS-RANDOM
___ 11:31PM URINE HOURS-RANDOM
___ 11:31PM URINE UHOLD-HOLD
___ 11:31PM URINE GR HOLD-HOLD
___ 11:31PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 11:31PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 11:31PM URINE RBC-42* WBC-1 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 11:31PM URINE HYALINE-3*
___ 11:31PM URINE MUCOUS-RARE
___ 10:12PM LACTATE-1.6
___ 08:55PM GLUCOSE-98 UREA N-21* CREAT-1.2 SODIUM-141
POTASSIUM-3.3 CHLORIDE-101 TOTAL CO2-33* ANION GAP-10
___ 08:55PM estGFR-Using this
___ 08:55PM cTropnT-<0.01
___ 08:55PM proBNP-1456*
___ 08:55PM WBC-5.6 RBC-3.59* HGB-9.4* HCT-31.3* MCV-87
MCH-26.2 MCHC-30.0* RDW-15.2 RDWSD-48.6*
___ 08:55PM NEUTS-69.2 ___ MONOS-7.3 EOS-2.0
BASOS-0.5 IM ___ AbsNeut-3.87 AbsLymp-1.15* AbsMono-0.41
AbsEos-0.11 AbsBaso-0.03
___ 08:55PM PLT COUNT-203
DISCHARGE LAB VALUES:
======================
___ 07:30AM BLOOD WBC-6.3 RBC-3.92* Hgb-10.3* Hct-33.7*
MCV-86 MCH-26.3 MCHC-30.6* RDW-15.4 RDWSD-48.0* Plt ___
___ 07:30AM BLOOD Plt ___
___ 03:55PM BLOOD Glucose-129* UreaN-24* Creat-1.3* Na-144
K-4.1 Cl-103 HCO3-32 AnGap-13
___ 03:55PM BLOOD Calcium-9.7 Phos-3.1 Mg-2.4
___ 07:30AM BLOOD CK-MB-5 cTropnT-<0.01
___ 08:55PM BLOOD cTropnT-<0.01
MICROBIOLOGY:
===============
___
BCx: no growth to date
PERTINENT IMAGING/STUDIES:
==========================
___ Imaging CHEST (PA & LAT)
IMPRESSION:
1. New pulmonary vascular congestion and mild pulmonary edema.
2. Previously noted nodular opacity projecting over left heart
border is
obscured on current exam. However, agree with the prior
recommendation of ___ for nonemergent chest CT for
further evaluation, once the acute symptoms resolve.
Brief Hospital Course:
Mr. ___ is a ___ w/hx dCHF with suspicion of cardiac amyloid
(awaiting appointment with ___, plasma cell dyscrasia, AFib,
HTN, HLD, DM, hx hemorrhagic CVA, CKD, dementia (oriented to
self), p/w acute dCHF in setting of poor dietary compliance w/
contribution from ?underlying cardiac amyloid.
# Dyspnea:
# Acute on Chronic Diastolic CHF (EF: 50%) with Suspicion of
Cardiac Amyloid:
Pt presenting with mild dyspnea and slight volume overload with
pro-BNP elevated on admission, but lower than recent ___ labs
in ___ clinic. Objectively pt on admission was mildly volume
overloaded and dyspneic w/CXR showing mild volume overload.
Given mildness of exacerbation, trigger is likely poorly
controlled diet at ___, family states that while they bring him
low salt food there is no supervision at Landmark and he will
liberally use salt on food and high PO free water intake.
Possible lower threshold for decompensation especially in the
setting of poor substrate if there is actual cardiac amyloid.
Bone marrow pathology w/o amyloid in BM, but that does not
exclude peripheral deposition.
Put out high volume of urine to single 80mg IV dose of lasix
over first night of admission, subsequently transitioned back to
home Torsemide (40mg PO BID) and discharged euvolemic. Note that
had mild hypernatremia around time of discharge w/peak of 147.
___ sodium at d/c was 144.
D/c weight:
Discharged on home regimen w/o changes to medication list.
===============
CHRONIC ISSUES:
===============
#Afib:
CHADsvasc=6. The patient has history of documented atrial
fibrillation not on anticoagulation at this time ___ history of
hemorrhagic stroke.
-continued metoprolol
-continued aspirin
# Hx of CVA:
- Aspirin 325 mg PO DAILY
# DM:
-Discharged on home lantus and metformin
# HTN:
- Lisinopril 2.5 mg PO DAILY
# HLD:
- Simvastatin 20 mg PO QPM
# GERD:
- Omeprazole 20 mg PO DAILY
# BPH:
-Tamsulosin 0.4 mg PO QHS
# Dementia:
- Donepezil 10 mg PO QHS
*****TRANSITION ISSUES*****
# HCP/Contact: ___ ___
# Code: Full
# Needs PCP ___ in ___ days
# Need Cardiology ___ in ___ days
# If suspect amyloid, would consider alternative to Metoprolol
# Trend sodium while on torsemide BID, discharge was 144 (peak
147)
# CXR finding showing previously described nodular opacity
projecting the left mid to lower lung is obscured by the edema.
However, agree with the prior recommendation of ___
for nonemergent chest CT evaluation of this nodular opacity.
# Discharge Weight: 95.4kg
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Donepezil 10 mg PO QHS
2. Vitamin D ___ UNIT PO 1X/WEEK (WE)
3. Glargine 10 Units Breakfast
4. Lisinopril 2.5 mg PO DAILY
5. MetFORMIN (Glucophage) 250 mg PO BID
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Simvastatin 20 mg PO QPM
9. Tamsulosin 0.4 mg PO QHS
10. Torsemide 40 mg PO BID
11. Aspirin 325 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Donepezil 10 mg PO QHS
3. Glargine 10 Units Breakfast
4. Lisinopril 2.5 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Simvastatin 20 mg PO QPM
9. Tamsulosin 0.4 mg PO QHS
10. Torsemide 40 mg PO BID
11. MetFORMIN (Glucophage) 250 mg PO BID
12. Vitamin D ___ UNIT PO 1X/WEEK (WE)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Acute on Chronic Congestive Diastolic Heart Failure
with Preserved Ejection Fraction
Secondary: Atrial Fibrillation, Hypertension, Hyperlipidemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. ___,
You were admitted to the ___
for shortness of breath and weight gain. It was determined that
this was due to excess sodium in your diet when at Landmark.
We gave you intravenous medications to help you remove this
extra fluid which was successful.
You were discharged without any medication changes.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
It was a pleasure taking part in your care, Mr. ___.
___,
Your ___ ___ Team
Followup Instructions:
___
|
10193065-DS-25 | 10,193,065 | 20,678,041 | DS | 25 | 2129-04-15 00:00:00 | 2129-04-15 17:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall, SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with a history of HFrEF (EF 40%),
HTN, HL, DM, AFib not on AC d/t hemorrhagic stroke, CKD, and
dementia admitted for CHF exacerbation and rib fracture. He was
recently admitted ___ for acute decompensated heart
failure, discharged home on torsemide 20 mg at 202 lbs. At his
follow-up appointment on ___ he was noted to be 212 pounds, his
torsemide was increased to 20mg BID. Per ___ clinic note, it
appears there was concern over dietary indiscretions at his
rehab facility. He was seen again in ___ clinic ___ with stable
weight of 212 with mild JVP elevation. Was also in persistent
afib with more rapid ventricular rates, and his metoprolol succ
was increased from 50mg to 75mg daily. Due to his recent gain
and concerns about medications and diet at the nursing home Dr.
___ him to the ED for admission.
He has also had recent falls, at least 2 within the past week at
his rehab facility. He was seen at ___ on ___ for a
fall with R rib fracture. The ED note states there are no bed
alarms at his rehab facility (___) and case management
reported not being able to transfer him to a facility with bed
alarms.
In the ED initial vitals were: T 98.5 HR 73 BP 149/90 RR 18 O2
99% RA
He was seen by trauma.
CTA C/A/P revealed:
-Posterolateral tenth and eleventh rib fractures, similar to the
CT from ___. No evidence of new traumatic injury
-New right lower lobe subsegmental pulmonary embolism.
-15 mm left lower lobe pulmonary nodule. Recommend PET-CT for
further evaluation.
-Bilateral adrenal nodules are incompletely evaluated and
statistically likely to reflect adenomas.
-Similar aneurysmal dilation of the ascending thoracic aorta to
4.6 cm and aneurysm dilation of the left common iliac artery.
-Dilated pulmonary artery suggestive of pulmonary hypertension.
-Cardiomegaly and trace bilateral pleural effusions.
EKG:
Labs/studies notable for:
Patient was given: IV Lasix 40mg, torsemide 20mg PO, lisinopril
40mg, metoprolol succinate 50mg
Vitals on transfer: T 98.2 HR 78 BP 161/87 RR 18 O2 98% RA
On the floor he appears comfortable, resting, in no acute
distress. Reports his breathing is better but is unable to give
much history about his symptoms or what brought him to the
hospital. Denies any chest pain, SOB.
Past Medical History:
- HFrEF- EF 40% ___ ? of cardiac amyloid, biopsy deferred per
cardiology notes
- Diabetes
- Hypertension
- Dyslipidemia
-Plasma cell dyscrasia, smoldering multiple myeloma (10% yearly
risk of progression to active MM requiring treatment)
-Dementia (A&O to self)
-Hemorrhagic CVA per OMR in ___- left frontal hemorrhage s/p 2
EVDs
-Ischemic stroke ___
-CKD Stage III
-BPH
-Vitamin d deficiency
-Abdominal aortic aneurysm
Social History:
___
Family History:
Non-contributory. Father with hypertension.
Physical Exam:
ADMISSION EXAM:
=====================
VS: T 98.7 BP 164/85 HR 77 RR 18 O2 98% SAT
Weight on admission: 98.2kg
Prior discharge weight: 91.9 kg
GENERAL: Lying flat in NAD. Oriented to person, place, and time
but unable to give much history. Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. JVP of 10 cm at 30 degrees.
CARDIAC: Irregular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops. No thrills or lifts.
LUNGS: Tenderness to palpation R lower ribs. 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. 1+ pitting edema to mid calf
bilaterally
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE EXAM:
=====================
VS: 98.4 ___ BP 96-108/60s RR 18 97% RA
Weight: 91.9 (___) <- 92.8 <- 92.3 <- 90.7 <- 90.4 <- 93.5 <-
93.1 <- 92.5 <- 92.6, (weight was 91.9 kg ___ d/c from ___
service)
I/O: ___
GENERAL: Laying in bed comfortably in NAD. Oriented to person,
place, and time but unable to give much history.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
NECK: Supple. JVP not appreciated
CARDIAC: Irregular rate and rhythm. Normal S1, S2. II/VI
diastolic murmur at apex, no rubs or gallops. No thrills or
lifts.
LUNGS: Tenderness to palpation R lower ribs. Respiration is
unlabored with no accessory muscle use. Minimal bibasilar
crackles.
ABDOMEN: suprapubic ttp
Pertinent Results:
ADMISSION LABS:
===================
___ 09:54PM BLOOD WBC-6.4 RBC-3.56* Hgb-9.0* Hct-30.0*
MCV-84 MCH-25.3* MCHC-30.0* RDW-17.1* RDWSD-52.4* Plt ___
___ 09:54PM BLOOD Glucose-129* UreaN-17 Creat-1.0 Na-140
K-3.5 Cl-101 HCO3-31 AnGap-12
___ 09:54PM BLOOD proBNP-1602*
___ 04:35PM BLOOD ALT-12 AST-14 AlkPhos-85 TotBili-0.3
___ 08:49PM BLOOD ___ pO2-77* pCO2-60* pH-7.33*
calTCO2-33* Base XS-3 Comment-GREEN TOP
DISCHARGE LABS:
===================
___ 04:42AM BLOOD WBC-4.7 RBC-4.23* Hgb-10.6* Hct-34.6*
MCV-82 MCH-25.1* MCHC-30.6* RDW-17.4* RDWSD-51.0* Plt ___
___ 04:42AM BLOOD Plt ___
___ 04:35AM BLOOD ___ PTT-31.2 ___
___ 04:42AM BLOOD Glucose-122* UreaN-57* Creat-1.7* Na-141
K-4.2 Cl-94* HCO3-28 AnGap-23*
___ 01:19PM BLOOD Glucose-262* UreaN-52* Creat-1.9* Na-134
K-4.2 Cl-92* HCO3-24 AnGap-22*
___ 04:42AM BLOOD Calcium-9.2 Phos-3.9 Mg-2.6
MICRO:
======
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
PROTEUS MIRABILIS. 10,000-100,000 CFU/mL.
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| PROTEUS MIRABILIS
| |
AMPICILLIN------------ <=2 S <=2 S
AMPICILLIN/SULBACTAM-- <=2 S <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN--------- =>4 R 2 I
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R <=1 S
IMAGING:
===================
CT C/A/P ___:
1. Minimally displaced right posterolateral tenth and eleventh
rib fractures, similar to the CT from ___. No
evidence of new traumatic injury in the chest, abdomen or
pelvis.
2. New right lower lobe subsegmental pulmonary embolism.
3. 15 mm left lower lobe pulmonary nodule. Recommend PET-CT for
further
evaluation.
4. Bilateral adrenal nodules are incompletely evaluated and
statistically
likely to reflect adenomas.
5. Similar aneurysmal dilation of the ascending thoracic aorta
to 4.6 cm and aneurysm dilation of the left common iliac artery.
6. Dilated pulmonary artery suggestive of pulmonary
hypertension.
7. Cardiomegaly and trace bilateral pleural effusions.
___ US ___:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
CT HEAD ___:
1. There are no acute findings.
2. There are chronic multiple infarcts which are stable.
MRI BRAIN W/O CONTRAST ___:
1. No acute infarct or acute hemorrhage.
2. Numerous chronic infarcts with associated volume loss, as
described.
3. Numerous scattered areas of chronic microhemorrhage in the
bilateral basal ganglia, bilateral thalamus, brainstem and
bilateral cerebellar hemispheres in a distribution suggestive of
chronic hypertensive encephalopathy.
4. Moderate global atrophy with diffuse white matter signal
abnormality
suggestive of chronic small vessel ischemic disease.
Brief Hospital Course:
___ male with a history of HFrEF (EF 40%), HTN, HL, DM,
AFib not on AC d/t hemorrhagic stroke, CKD, and dementia
admitted for CHF exacerbation and new R subsegmental PE.
#ACUTE ON CHRONIC SYSTOLIC HEART FAILURE EXACERBATION: After
last discharge in ___ gained approx. ___ pounds with
increasing edema and JVD. Despite cardiology instructions to
increase diuretics, it appears there were concerns about nursing
home medication compliance and dietary adherence. On admission
BNP 1600, stable from ___ admission for CHF. Patient was
diuresed with IV Lasix and transitioned to PO regimen of
torsemide 40 mg BID. For afterload, patient discharged on
lisinopril 30 mg (previous dose 40 mg; decreased for lower blood
pressures). Metoprolol succinate XL was increased from 75 mg
daily to 75 mg QAM and 50 mg ___ for better heart rate control.
Discharge weight 91.9 kg.
#R SUBSEGMENTAL PE: New subsegmental PE seen on CT angiogram
performed in the Emergency Department. He has atrial
fibrillation but has only been on aspirin due to a history of
cerebral hemorrhage ___. HDS, no O2 requirement, no signs of R
heart strain on ECG on admission. Neurology was consulted given
history of intracranial hemorrhage. Recommended heparin drip w/o
bolus and MRI to help in determine risks of longterm
anticoagulation. However, based on discussions with patient's
outpatient cardiologist (Dr. ___ and patient's son, the
decision was made to defer antiocoagulation due to patients CVA
hemorrhage and frequent falls. Patient remained HDS throughout
hospital course.
# UTI: Patient had complaint of abdominal pain in RLQ to
suprapubic region. UA, UCx revealed E. coli and proteus. Patient
initially started on IV ceftriaxone ___ but narrowed to
ampicillin when sensitivities resulted. He will complete course
of ampicillin ___.
#AFIB: History of afib, recently persistent. CHADSVASC of 6,
however has not been on full anticoagulation given history of
intracranial hemorrhage in ___. Patient was monitored on
telemetry during hospital course and had rates up to 140s. The
decision was made to increased Metoprolol succinate XL from 75
mg daily to 75 mg QAM and 50 mg QPM for better rate control.
#RIB FRACTURE: Reported frequent falls at rehab, and per OSH
records no bed alarms at rehab facility. s/p rib fracture from a
fall. Stable R rib fracture with pain on exam. Pain controlled
with Tylenol and lidocaine patch as needed.
___ on CKD stage 3: baseline 1.1-1.6. Cr monitored while
inpatient. Did have rise in Cr to 1.9. Improved by withholding
Lasix dose. Cr on discharge 1.7. Please check BMP day after
discharge and fax to ___ clinic: ___.
CHRONIC ISSUES:
===============
#HYPERLIPIDEMIA: Continued simvastatin
#HYPERTENSION: Patient initially had high blood pressures to
150-160 early in hospital course. Hydralazine was added
initially. Then with uptitration of metoprolol, patient had
borderline low blood pressures (SBP ___. Hydralazine was
stopped and lisinopril was decreased 40 mg to 30 mg.
#DEMENTIA: Continued donepezil
#DEPRESSION: Continued sertraline
#BPH: Continued tamsulosin
TRANSITIONAL ISSUES:
====================
[] 15 mm left lower lobe pulmonary nodule. Recommend PET-CT for
further evaluation as outpatient.
[] Please continue to have risk/benefit discussion of no
anticoagulation in patient with afib, PE but previous h/o CVA
hemorrhage and frequent falls, pt continued on 325 ASA
[] Ampicillin 500 mg PO Q6H end date for UTI ___
[] Follow-up of BMP ___
[] Discharged on torsemide 40 BID, spironolactone 25 and metop
XL 25 BID
[] Discharge weight: 91.9 kg
[] Discharge Cr: 1.7
# Contact: ___ (HCP/son) ___
# Code Status: Full Code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glargine 10 Units Breakfast
2. Lisinopril 40 mg PO DAILY
3. Torsemide 20 mg PO BID
4. Aspirin 325 mg PO DAILY
5. Donepezil 10 mg PO QHS
6. MetFORMIN (Glucophage) 250 mg PO BID
7. Metoprolol Succinate XL 75 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Sertraline 100 mg PO DAILY
11. Simvastatin 20 mg PO QPM
12. Tamsulosin 0.4 mg PO QHS
13. Vitamin D ___ UNIT PO 1X/WEEK (WE)
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H
2. Ampicillin 500 mg PO Q6H
END DATE ___, will complete 7 day course for UTI then
3. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN Rib pain
4. Spironolactone 25 mg PO DAILY
5. Glargine 10 Units Breakfast
6. Lisinopril 30 mg PO DAILY
7. Metoprolol Succinate XL 50 mg PO BID
8. Torsemide 40 mg PO BID
9. Aspirin 325 mg PO DAILY
10. Donepezil 10 mg PO QHS
11. MetFORMIN (Glucophage) 250 mg PO BID
12. Multivitamins 1 TAB PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Sertraline 100 mg PO DAILY
15. Simvastatin 20 mg PO QPM
16. Tamsulosin 0.4 mg PO QHS
17. Vitamin D ___ UNIT PO 1X/WEEK (WE)
18.Outpatient Lab Work
Please check electrolytes on ___ (Na, K, Cl, HCO3, BUN, Cr,
Mg) and fax them to ___ at ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
=====================
Acute on chronic systolic heart failure exacerbation
Right subsegmental pulmonary embolism
Secondary Diagnoses:
======================
Right rib fracture
Dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___!
Why was I admitted to the hospital?
-You were admitted to the hospital because your weight had
increased
-You also had a blood clot in your lung
What happened while I was in the hospital?
-You received medicine to remove fluid and decrease your weight
-You received medicine to thin your blood
What should I do after leaving the hospital?
- Continue to take your medicines as prescribed. The people at
your rehab facility will help you with this.
- Please weigh yourself every morning, call MD if weight goes up
more than 3 lbs.
Thank you for allowing us to be involved in your care.
Sincerely,
Your ___ healthcare team
Followup Instructions:
___
|
10193065-DS-30 | 10,193,065 | 29,152,780 | DS | 30 | 2130-11-04 00:00:00 | 2130-11-05 10:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ (wheel chair bound, living at nursing home)
w/hx of vascular dementia, Afib (not on Coumadin due to history
of ICH), HTN, HLD, DM2, recurrent CVA, HFpEF p/w dyspnea
Patient is poor historian given his dementia and records are
obtained from his transfer facility. Per report patient noted to
have tachypnea this morning and seem to be belly breathing with
exhalation and inhalation. In questioning patient he denies any
pain.
In the ED, initial VS were: 98.6 78 151/78 26 100% 2L NC
- Exam notable for: tachypneic, mild bibasilar crackles, AAOx1,
no ___ edema
- ECG: AFib, HR 68, new TWI V5-V6 otherwise similar to prior
- Labs showed: WBC 7.6, Hb 9.4, pBNP 6118, BUN/Cr ___, Trop
x2
neg, UA Lg Bld/Neg Leuk, LFTs wnl
- Imaging showed: CXR w/RLL consolidation c/f PNA, bilateral
perihilar opacities may be edema vs. infection
- Patient received: Duonebs, IV Lasix 40, Zosyn 4.5g, Vanc
1250mg
Transfer VS were: T98.5 66 165/94 30 100% RA
On arrival to the floor, patient unable to answer questions
appropriately, despite use of phone interpreter.
Past Medical History:
- HFpEF- LVEF 50-55% ___
- Aortic Insufficiency
- Diabetes
- Hypertension
- Dyslipidemia
- Plasma cell dyscrasia, smoldering multiple myeloma (10% yearly
risk of progression to active MM requiring treatment)
- Dementia (A&O to self)
- Hemorrhagic CVA per OMR in ___- left frontal hemorrhage s/p 2
EVDs
- Ischemic stroke ___ with hemorrhagic conversion
- CKD Stage III
- BPH
- Vitamin d deficiency
- Abdominal aortic aneurysm
- subsegmental PE
- urine cytology suspicious for urothelial cell carcinoma
Social History:
___
Family History:
Father with hypertension.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98 PO 164 / 75 R Lying 62Afib 17 with 25 sec apnea, Chyne
Stoke 98 RA
GENERAL: +tachypnea, audible wheezes, mild agitated at times,
otherwise pleasant, not answering questions with or w/o phone
interpreter
HEENT: AT/NC, PERRL, anicteric sclera, pink conjunctiva, MMM
NECK: supple, +JVD
HEART: irreg irreg, S1/S2, +ii/vi diastolic murmur LUSB non-rads
LUNGS: +tachypnea, audible wheezes, otherwise ant exam benign
ABDOMEN: soft, NDNT, no rebound/guarding
EXTREMITIES: 1+ ___ edema b/l (mild sacral edema)
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox0, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 348)
Temp: 97.5 (Tm 99.1), BP: 129/71 (110-144/71-86), HR: 69
(66-78), RR: 18 (___), O2 sat: 93% (90-100), O2 delivery: RA,
Wt: 175.04 lb/79.4 kg (175.04-175.93)
Gen: Well-appearing, NAD
Head/Eyes: NC/AT. EOMI. PERRL.
ENT: Supple, nontender.
CV: NR, irregularly irregular rhythm. Nl S1, S2.
Resp: Dec BS bilaterally to mid-back, bibasilar crackles
GI: Soft, nontender, nondistended.
Msk: No ___ or sacral edema.
Skin: No rashes, lesions.
Neuro: Alert, but not oriented to time or location
Pertinent Results:
ADMISSION LABS
==============
___ 12:08PM BLOOD WBC-7.6 RBC-3.46* Hgb-9.4* Hct-30.6*
MCV-88 MCH-27.2 MCHC-30.7* RDW-17.1* RDWSD-55.4* Plt ___
___ 12:08PM BLOOD Neuts-78.8* Lymphs-11.8* Monos-6.7
Eos-1.6 Baso-0.8 Im ___ AbsNeut-5.99 AbsLymp-0.90*
AbsMono-0.51 AbsEos-0.12 AbsBaso-0.06
___ 12:08PM BLOOD Glucose-88 UreaN-15 Creat-0.8 Na-140
K-5.3 Cl-103 HCO3-23 AnGap-14
___ 12:08PM BLOOD ALT-8 AST-28 AlkPhos-70 TotBili-0.5
___ 07:43PM BLOOD CK(CPK)-69
___ 12:08PM BLOOD proBNP-6118*
___ 12:08PM BLOOD cTropnT-<0.01
___ 07:43PM BLOOD CK-MB-<1 cTropnT-<0.01
___ 07:43PM BLOOD Calcium-8.7 Phos-3.5 Mg-1.9
MICROBIOLOGY
============
___
Legionella UAg negative
UCX negative
BCX NGTD
DISCHARGE LABS
==============
___ 12:35PM BLOOD WBC-5.3 RBC-3.69* Hgb-10.1* Hct-32.8*
MCV-89 MCH-27.4 MCHC-30.8* RDW-16.9* RDWSD-54.3* Plt ___
___ 12:35PM BLOOD Glucose-131* UreaN-17 Creat-0.9 Na-146
K-3.7 Cl-102 HCO3-31 AnGap-13
___ 09:00AM BLOOD Calcium-9.2 Phos-4.0 Mg-1.8
___ 09:00AM BLOOD TSH-4.3*
___ 09:00AM BLOOD VitB12-396
REPORTS
=======
CXR ___
Large right lower is lobe consolidation, worrisome for
pneumonia. Bilateral perihilar opacities may be due to pulmonary
edema, but additional site of infection are not excluded.
___ ___
1. No acute intracranial abnormality with no definite evidence
of acute large territorial infarct. Please note MRI of the
brain is more sensitive for the detection of acute infarct.
2. Atrophy, probable small vessel ischemic changes, multiple
chronic
infarcts, and atherosclerotic vascular disease as described.
3. Nonspecific partial right mastoid air cell opacification.
TTE ___
Adequate image quality. Low normal global LV systolic function
without regional wall motion abnormalities. LV diastolic
function was difficult to be assessed due to presence of atrial
fibrillation however myocardial velocities low suggesting
impaired LV relaxation, which is most likely
cause of significant ___. Mild to moderate eccentric
posteriorly directed aortic regurgitation.
Brief Hospital Course:
Mr. ___ is a ___ year-old man with h/o combined systolic and
diastolic heart failure, vascular dementia, permanent A Fib not
on AC due to hemorrhagic stroke brought here from his nursing
home with dyspnea and found to have pneumonia.
ACUTE ISSUES
============
# Community Acquired Pneumonia
# Respiratory Distress
# Systolic Heart Failure (recovered function)
# Diastolic Heart Failure (ongoing)
Presented with new-onset SOB from ___. Dyspneic on
arrival, and CXR with consolidation c/f pneumonia and initially
c/f pulmonary edema. Received IV Lasix in ED and on the floor
and received Vanc/Zosyn. pBNP slightly elevated from prior.
Trops x2 negative. Quickly stabilized without further dyspnea
and with stable vitals. After initial Lasix doses subsequently
clinically euvolemic and transitioned to maintenance torsemide.
Transitioned from Vanc/Zosyn to Ceftriaxone and Azithromycin,
then Cefpodoxime and Azithromycin to complete a ___ontinued on home Lisinopril and metoprolol.
# Toxic Metabolic Encephalopathy
# ___ as a second langue
Reportedly language is restricted at baseline, but initially
more inattentive with minimal interaction here. Of note, on
admission, was decribed as ___ speaking only, however, as
infection improved his mental status cleared and spoke ___
quite fluently, albeit in simple sentences. Thus, felt to be
toxic metabolic encephalopathy from infection on substrate of
vascular dementia. Felt unlikely to be ___ new TIA/CVA.
Speech/Swallow did see him later in course and felt he would
benefit from puree solids and nectar thickened liquids.
CHRONIC ISSUES
==============
# Atrial Fibrillation
No anticoagulation given prior hemorrhagic stroke; continued
metoprolol as above.
# History of Stroke
Continued Atorvastatin, ASA as above.
# CKD stage III
B/l Cr 1.1 to 1.2. Stable.
# Type II DM
Continued Lantus 8U. Hold oral antiglycemics
# BPH
Continued Tamsulosin
TRANSITIONAL ISSUES
===================
[ ] Given concern for dysphagia and slow swallow initiation,
Speech and Swallow recommended downgrading diet to pureed
solids and nectar thick liquids. If mental status improves, can
re-assess and upgrade diet as tolerated.
[ ] Family reporting desire to change nursing homes; per case
management this is best initiated after he returns to his
current site for now.
[ ] ___ chest X ray in 6 weeks to assess for resolution
of pneumonia.
[ ] Follow up chem-7 next week to assess potassium given
restarting torsemide (home dose)
[ ] aspiration precautions when eating all meals
# Code Status: Full, confirmed
# Emergency Contact: Son, ___ (___)
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Donepezil 10 mg PO QHS
5. Lisinopril 5 mg PO DAILY
6. Metoprolol Succinate XL 150 mg PO ONCE
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Sertraline 100 mg PO DAILY
10. Sodium Chloride Nasal 1 SPRY NU BID:PRN dry nose
11. Tamsulosin 0.4 mg PO QHS
12. TraZODone 50 mg PO QHS:PRN anxiety/insomnia
13. MetFORMIN (Glucophage) 500 mg PO DAILY
14. Vitamin D ___ UNIT PO MONTHLY
15. Glargine 8 Units Breakfast
16. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB
17. Potassium Chloride 20 mEq PO DAILY
18. TraZODone 25 mg PO Q8H:PRN anxiety
Discharge Medications:
1. Azithromycin 250 mg PO DAILY Duration: 2 Doses
2. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 3 Days
3. Torsemide 20 mg PO DAILY
4. Glargine 8 Units Breakfast
5. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild
6. Aspirin 325 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Donepezil 10 mg PO QHS
9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB
10. Lisinopril 5 mg PO DAILY
11. MetFORMIN (Glucophage) 500 mg PO DAILY
12. Metoprolol Succinate XL 150 mg PO ONCE
13. Multivitamins 1 TAB PO DAILY
14. Omeprazole 20 mg PO DAILY
15. Potassium Chloride 20 mEq PO DAILY
Hold for K >
16. Sertraline 100 mg PO DAILY
17. Sodium Chloride Nasal 1 SPRY NU BID:PRN dry nose
18. Tamsulosin 0.4 mg PO QHS
19. TraZODone 50 mg PO QHS:PRN anxiety/insomnia
20. Vitamin D ___ UNIT PO MONTHLY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
- Community Acquired Pneumonia
SECONDARY:
- Vascular Dementia
- Atrial Fibrillation
- History of Stroke
- Systolic Heart Failure
- Diastolic Heart Failure
- Type 2 Diabetes
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 Mr. ___,
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You had difficulty breathing
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We did a chest X ray and saw a pneumonia
- We treated you with antibiotics
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:
___
|
10193071-DS-18 | 10,193,071 | 25,403,919 | DS | 18 | 2171-06-29 00:00:00 | 2171-06-29 18:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMHX OA, BPH, and lactose intolerance who is s/p
routine colonoscopy at 10AM, presenting with abdominal pain that
began around 1100AM and increased gradually. He reports that
this feels like "ripping" and is diffuse, but worse in the LLQ.
He reports that it feels somewhat like his typical abdominal
pain (which is related to lactose intolerance), but much more
severe. Denies fever, chills, sweats. Notes some abdominal
distension. Reports nausea and one episode of clear vomit.
Denies having any bowel movements since his colonoscopy, reports
that he has passed gas once, which helped his pain somewhat. He
called the GI office that performed his colonoscopy, and in
discussion with his PCP referred him to the ED for further
evaluation.
In the ED initial vitals were: 97.6 57 125/69 18 100% RA
- Labs were significant for normal labs other than a total bili
1.6
- Patient was given morphine, zofran. CT abdomen with no
evidence of bowel perforation or solid organ injury, dilated
small bowel without clear transition point, suggestive of ileus
vs early partial SBO.
Vitals prior to transfer were: 98.4 57 122/80 18 100% RA
On the floor, patient complaining of continued abdominal pain.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
- Benign prostatic hypertrophy
- Osteoarthritis
- Low back pain
- Mild obstructive sleep apnea
- IBS
- Lactose intolerance
- s/p appendectomy
Social History:
___
Family History:
- Father died of colon cancer at age ___
- Mother died of complications of asthma at age ___
- Uncle with prostate cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals- 99.3, 139/84, 54, 18, 100%/RA
General- well appearing, NAD
HEENT- MMM
Neck- no JVD
Lungs- CTA bilaterally
CV- RRR, no murmurs
Abdomen- soft, nondistended. hypoactive but present bowel
sounds. Diffuse tenderness to deep palpation, no rebound or
guarding.
Ext- warm, well perfused, no edema
Neuro- A and O x3, nonfocal
DISCHARGE PHYSICAL EXAM
Vitals: 98.2 112/64 63 18 99% on 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, mild tenderness to deep palpation
___, non-tender, slightly hypoactive bowel sounds,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: dry, no rash or lesions
Neuro: face is symmetric, moves all 4 extremities equally
Pertinent Results:
ADMISSION LABS
===========================
___ 02:50PM BLOOD WBC-6.5 RBC-5.45 Hgb-16.4 Hct-49.4 MCV-91
MCH-30.2 MCHC-33.3 RDW-12.6 Plt ___
___ 02:50PM BLOOD Neuts-79.5* Lymphs-16.0* Monos-3.2
Eos-0.5 Baso-0.9
___ 02:50PM BLOOD Glucose-91 UreaN-15 Creat-0.9 Na-142
K-4.0 Cl-104
HCO3-29 AnGap-13
___ 02:50PM BLOOD ALT-31 AST-30 AlkPhos-76 TotBili-1.6*
DirBili-0.3 IndBili-1.3
___ 02:50PM BLOOD Lipase-34
___ 02:50PM BLOOD Albumin-5.0
___ 03:08PM BLOOD Lactate-1.1
IMAGING/STUDIES
===========================
___ CT A/P W/ CONTRAST
LUNG BASES: The imaged lung bases are clear. Limited imaging
of the heart demonstrates normal size without pericardial
effusion. The distal esophagus and descending thoracic aorta
are within normal limits.
ABDOMEN: The liver enhances homogeneously without focal hepatic
lesions. Hypodensity in the right inferior tip of the liver
(3:21) is thought to
represent artifact. The portal, splenic and superior mesenteric
veins are well opacified with intravenous contrast. No
intrahepatic or extrahepatic biliary ductal dilation is seen.
The gallbladder, pancreas, spleen, accessory spleen and
bilateral adrenal glands are within normal limits. Both kidneys
enhance symmetrically and excrete contrast normally without
evidence of hydronephrosis. A left parapelvic cyst measures 3.4
x 2.4 cm (601B:43). There is a 1.9 cm hypodensity in the cortex
of the mid-to-lower left kidney compatible with a renal cyst.
No suspicious renal lesions are identified.
The stomach and duodenum are unremarkable. The jejunum is
collapsed. There are multiple borderline dilated air- and
fluid-filled loops of distal small bowel without transition
point, but gradual decreased caliber in the left lower quadrant.
The large bowel is diffusely air-filled, but otherwise
unremarkable. Suture material in the right lower quadrant
(3:52) most likely represents evidence of prior appendectomy.
No free air or ascites is present. There are no pathologically
enlarged retroperitoneal or mesenteric lymph nodes by CT size
criteria. The abdominal aorta is normal in caliber throughout.
PELVIS: The urinary bladder, prostate, seminal vesicles, the
rectum and
sigmoid colon are within normal limits. There is no free pelvic
fluid or
inguinal/pelvic lymphadenopathy.
OSSEOUS STRUCTURES: There are no osseous destructive lesions
concerning for malignancy. Mild degenerative changes are noted
in the lumbar spine.
IMPRESSION:
1. No evidence of bowel perforation or solid organ injury.
Suture material in the right lower quadrant is compatible with
prior appendectomy.
2. Diffusely air-filled large bowel, compatible with recent
colonoscopy.
3. Multiple dilated loops of small bowel without transition
point, but
gradual return to normal caliber in the left lower quadrant most
likely
represents ileus and, less likely, early partial small-bowel
obstruction.
___ PORTABLE CXR
FINDINGS:
There are relatively low lung volumes and likely bibasilar
atelectasis. No definite focal consolidation is seen. There is
no large pleural effusion or evidence of pneumothorax. The
cardiac silhouette is top-normal. The aorta is slightly
tortuous. There is gaseous distention of the partially imaged
bowel, presumed related to recent colonoscopy.
IMPRESSION:
Low lung volumes. Gaseous distention of the partially imaged
bowel.
No evidence of free air.
DISCHARGE LABS
=========================
___ 07:45AM BLOOD WBC-4.6 RBC-4.87 Hgb-14.6 Hct-43.6 MCV-89
MCH-30.0 MCHC-33.5 RDW-12.3 Plt ___
___ 07:45AM BLOOD Glucose-97 UreaN-17 Creat-0.8 Na-144
K-3.7 Cl-108 HCO3-27 AnGap-13
___ 07:45AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.5
Brief Hospital Course:
This is a ___ yo M presenting with abdominal pain following
colonoscopy, with imaging suggestive of ileus vs early partial
SBO. He was NPO and received IV pain medications with
significant improvement in pain. The morning after admission his
pain was minimal, he tolerated a liquid diet and regular diet,
and was discharged home without symptoms.
ACTIVE ISSUES
# Abdominal pain:
His abdominal pain occurred within an hour after leaving from
his colonoscopy. There was no evidence of perforation or solid
organ injury on imaging, but he did have dilated small bowel
loops suggestive of ileus or early partial small bowel
obstruction. He did not have peritoneal signs. Besides his
history of appendectomy, he did not have any other risk factors
for SBO or ileus. This was a complication of the colonoscopy. He
was kept NPO and received IV morphine and acetaminophen for pain
control. The morning after admission his pain had improved
significantly and he was passing much more gas. He tolerated a
full liquid breakfast, had a bowel movement, and tolerated a
regular lunch. He was discharged symptom-free.
# Benign prostatic hyperplasia
Stable, continued tamsulosin and finasteride.
TRANSITIONAL ISSUES
- Total bilirumin mildly elevated at 1.6. F/u as outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tamsulosin 0.4 mg PO HS
2. Finasteride 5 mg PO DAILY
3. Naproxen 500 mg PO Q12H:PRN low back pain
Discharge Medications:
1. Finasteride 5 mg PO DAILY
2. Tamsulosin 0.4 mg PO HS
3. Naproxen 500 mg PO Q12H:PRN low back pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: small bowel ileus
Secondary: benign prostatic hypertrophy
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 during your stay at ___.
You were admitted with severe abdominal pain after a
colonoscopy. CT scan of your stomach showed mild dilation of
your small bowel. We rested your bowels by not letting you eat
and you received IV pain medications. Your pain improved
significantly the morning after the procedure. You tolerated a
regular diet prior to discharge.
Please follow up with your doctors as listed below.
Followup Instructions:
___
|
10193074-DS-11 | 10,193,074 | 22,392,305 | DS | 11 | 2121-02-22 00:00:00 | 2121-02-22 10:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OTOLARYNGOLOGY
Allergies:
fentanyl / Percocet
Attending: ___.
Chief Complaint:
left sided neck pain
History of Present Illness:
Ms. ___ is a ___ y/o female with a h/o recent wisdom tooth
extraction on ___, 3 days prior to presentation who presnts
with left neck pain and swelling. She reports a fever to ___
yesterday. She also has associated pain with swallowing and sore
throat, however was able to tolerate her secretions. On the day
of presentation she felt that the swelling was increasing and
for this reason sought care at the ED
In the ED, intial VS 99.7 112 116/66 18 99% RA.
Labs were notable for WBC 18.2 with 94% PMNs, normal lactate,
and unremarkable electrolytes. CT scan obtained that showed
___ angina with no drainable fluid collection. She recieved
10mg IV decadron, Unasyn, and clindamycin for concern for
Ludwig's angina. Additionally she recieved lorazepam, ketorolac,
and benadryl. Given rapidly increasing submandibular swelling
and concern for airway compromise, the patient was taken to the
OR for intubation by anesthesia with ENT surgery available if
needed. She was given midaz, precedex, and ketamine in the OR
and underwent a nasopharyngeal intubation by ENT without
complications. Following intubation, the patient was transfered
to the MICU. VS prior to transfer, 120 112/66 17 100%
On arrival to the MICU, patient is intubated and sedated and
appears comfortable.
Review of systems:
unable to obtain
Past Medical History:
-Anxiety
-Bipolar Disorder II, per OMR
-none, per father
Social History:
___
Family History:
DM runs in family.
Paternal Grandmother with leukemia and breast cancer.
Father healthy.
Physical Exam:
Admission Physical Exam:
Vitals: T: 99.5 BP: 104/65 P: 106 R: 23 O2: 100% on 100% FiO2
General: intubated, sedated, appears comfortable
HEENT: Sclera anicteric, intubated, PERRL, significant edema
below tongue
Neck: left sided neck swelling but soft to palpation
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: diffuse coarse breath sounds with transmitted upper
airway noises, no wheezes, rales, ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: intubated and sedated, PERRL
Pertinent Results:
Admission labs:
Labs:
Lactate:1.8
Na 134, K 3.4, Cl 97, HCO3 26, BUN 5, Cr 0.7, Glc 144
UCG: Negative
WBC 18.2, Hgb 13.4, Hct 40.0, Plt 196, MCV 95
N:94.0 L:3.4 M:2.0 E:0.3 Bas:0.3
UA: SpecGr 1.022, pH 6.0, Nit Neg, Leuk neg, Prot Tr, Glu Tr,
Ket 10,
RBC 1, WBC 10, Bact Few, Yeast None
Micro:
___ MRSA SCREEN MRSA SCREEN-PENDING INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ URINE URINE CULTURE-PENDING EMERGENCY WARD
Images:
CT Neck ___: IMPRESSION:
1. Phlegmonous changes and multiple locules of gas tracking down
from the
right pterygoid muscles into the right side of the floor of the
mouth
compatible with Ludwig angina. Significant stranding and edema
of the soft
tissues is present, extending into the lower anterior neck,
obliterasting the fat plane of the right parapharyngeal space
and tracking posteriorly along right neck with a possible focus
of retropharyngeal edema.
2. No definite mediastinal involvement. No drainable fluid
collection.
3. There is displacement of the airways to the left, without
significant
compression. Bilateral cervical lymphadenopathy is likely
reactive.
CXR ___: 1. Tube and lines are in adequate position.
2. The remaining of the exam is normal.
Abd Xray ___: IMPRESSION: Non-obstructive bowel gas pattern.
CT Neck ___: IMPRESSION:
1. Continued organization with decrease in loculated gas of a
right submental phlegmon, with unchanged area of extends and
surrounding stranding and edema. No evidence of mediastinal
invasion. There is still no drainable fluid collection. Close
follow up is advised.
2. Previously identified possible focus of retropharyngeal edema
has resolved.
Brief Hospital Course:
Ms. ___ is a ___ y/o female with a h/o recent wisdom tooth
extraction on ___, 3 days prior to presentation, who presented
with left neck pain and swelling and found to have ludwigs
angina. She was intubated for airway protection and admitted to
the MICU.
# Ludwig's Angina: The patient developed a submandibular space
infection in the setting of recent wisdom teeth extraction. CT
scan shows no drainable collection and no definite involvement
of mediastinum. Pt recieved clindamycin + unasyn and steroids in
the ED on ___. She was intubated (nasopharyngeal) for airway
protection and admitted to the MICU. The patient was intially
continued on clindamycin + unasyn and then broadened to add
vancomycin when spike a fever on HOD 2 given healthcare worker.
ID was consulted. Antibiotics were eventually narrowed to only
unasyn. ENT was consulted and co-managed the patient, including
performing a transoral I&D on ___ and a transcervical I&D on
___. She had two penroses that were placed after the latter
surger that were discontinued once ENT felt risk of
reaccumulation was satisfactory. OMFS was also consulted and
followed while in hospital. She was extubated on ___. Steroids
were stopped on ___. Blood and urine cultures showed mixed
flora and then no growth. WBC was noted to fall from 18 to 4
over the course of her admission. Antibiotics course will be
ertapenem for total of two weeks until ___.
# Pain/Anxiety: Pt has history of anxiety and takes PRN ativan
at home. She recieved 1mg-boluses of Ativan while intubated w/
good anxiolysis. Pain was initially controlled with fentanyl gtt
and then stopped. She was given tyelenol and ice packs.
# Nausea/vomiting: Pt vomited ___ when receiving tube feeds and
OGT was lost. Pt refused replacement of OG. She was given Zofran
with some relief. CXR showed significant amount of air in
stomach. KUB ___ without signs of obstruction. She was given
Reglan and PR bisacodyl. She had dry heaves overnight ___ that
she attributed to irritation from ETT. Resolved upone
extubation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. NuvaRing *NF* (etonogestrel-ethinyl estradiol) 0.12-0.015
mg/24 hr Vaginal q 4 weeks for 3 weeks
2. Lorazepam 0.5-1 mg PO Q4H:PRN anxiety
3. Vitamin B Complex 1 CAP PO DAILY
4. flaxseed oil *NF* 1,000 mg Oral daily
5. Ibuprofen Dose is Unknown PO Frequency is Unknown
6. melatonin *NF* unknown Oral qhs
Discharge Medications:
1. Lorazepam 0.5-1 mg PO Q4H:PRN anxiety
2. NuvaRing *NF* (etonogestrel-ethinyl estradiol) 0.12-0.015
mg/24 hr Vaginal q 4 weeks for 3 weeks
3. Vitamin B Complex 1 CAP PO DAILY
4. melatonin *NF* 0 unknown ORAL QHS
5. Sodium Chloride Nasal ___ SPRY NU 5X/DAY:PRN Nasal dryness
6. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
7. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
as needed
8. ertapenem *NF* 1 gram Injection once Duration: 1 Doses Reason
for Ordering: patient is to be discharged on ertapenem, and ID
would like patient to receive one dose before she is discharged
Will take once a day until ___
RX *ertapenem [Invanz] 1 gram 1 gram IV daily Disp #*10 Gram
Refills:*0
9. Senna 1 TAB PO BID:PRN Constipation
as needed
10. Peridex *NF* (chlorhexidine gluconate) 0.12 % Mucous
Membrane TID Reason for Ordering: s/p I&D of oral abscess
RX *chlorhexidine gluconate 0.12 % Swish and spit three times a
day Disp #*2 Bottle Refills:*3
11. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth q4 hours Disp #*40
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
- ___ Angina
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 at ___. You were admitted
for neck swelling, pain, and fever. You were found to have an
infection in the space below your tongue, called "Ludwigs
Angina." You required breathing support from a machine
("intubation") on two different occasions. You received
antibiotics through the vein. And you also had the infection
drained by the Ear/Nose/Throat doctors.
Please keep your incision dry until followup with Dr.
___. No strenuous activity, no heavy lifting. The neck
dressing should be changed three times a day with a dry sterile
dressing.
Followup Instructions:
___
|
10193295-DS-3 | 10,193,295 | 21,361,871 | DS | 3 | 2132-02-05 00:00:00 | 2132-02-06 07:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Epigastric Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ with a medical history significant for
chronic abdominal pain and recurrent UTI who presents with
severe ___ epigastric pain which she says is more severe than
normal and
radiates to the epigastrum from the back. Pain began last night
after having bowl of noodles. Pain is sharp and radiates to
back. Associated with nausea and sensation of bloating.She had
one episode of yellow emesis. Last BM and flatus within 24h.
She began to notice this pain, though less in severity, just
before ___, first noting back pain after ingesting
sweet foods. The pain was sudden in onset and prevented her from
sleeping. Vomiting began after ___. She would feel
nauseous just after ingesting a large meal.
She presented to ___ ___ complaining of epigastric and
back pain that comes on most often after meals. Diagnosis was
unclear at that time and an US was ordered that showed Prominent
CBD measuring 8 mm with no intrahepatic biliary dilatation.
She denies any fatigue or additional constitutional
symptoms. She does not currently believe she has a UTI (takes
prophylactic cipro after sex). Denies recent travel or abnormal
foods.
In the ED, initial vs were: 97.4 72 100/74 16 97% ra. Labs were
remarkable for WBC 6.8, lactate 0.9, normal LFTs, lipase. CT
abdomen showed massive gastric distention. Surgery was consulted
who recommended NGT for decompression. Patient was given
morphine and ondansetron. Vitals on Transfer: 98 76 98/54 16
98% NGt drained 250 cc and then patient self-d/c'ed.
Review of sytems:
(+) Per HPI + weight loss of a couple pounds
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath. Denies chest pain or tightness, palpitations. No recent
change in bladder habits. No dysuria. Denies arthralgias or
myalgias. Ten point review of systems is otherwise negative.
Past Medical History:
recurrent UTI, chronic abdominal pain, mild
mitral regurg, No past surgical history
Social History:
___
Family History:
negative for GI malignancy
Physical Exam:
ON ADMISSION
Vitals: T:98.3 BP:102/64 P:67 R:16 O2:99RA
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: +BS, soft, non-tender, mild distension with no guarding
in epigastrium, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN II-XII intact, moves all 4 extrem, 2+ patellar and
chilles reflexes b/l
ON DISCHARGE
Vitals: T:98.5 BP:96/58 P:66 R:18 O2:99RA
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: +BS, soft, non-tender, no distension, no tenderness,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN II-XII intact, moves all 4 extrem, 2+ patellar and
chilles reflexes b/l
Pertinent Results:
ON ADMISSION
___ 09:00AM BLOOD WBC-6.4 RBC-4.59 Hgb-14.2 Hct-41.3 MCV-90
MCH-31.0 MCHC-34.4 RDW-12.6 Plt ___
___ 09:00AM BLOOD Glucose-103* UreaN-16 Creat-0.8 Na-143
K-3.9 Cl-108 HCO3-26 AnGap-13
___ 09:00AM BLOOD ALT-14 AST-17 AlkPhos-36 TotBili-0.6
___ 09:00AM BLOOD Albumin-4.7 Calcium-9.4 Phos-3.6 Mg-2.2
___ 05:30AM BLOOD TSH-1.4
___ 05:30AM BLOOD %HbA1c-PND
___ 09:18AM BLOOD Lactate-0.8
ON DISCHARGE
___ 05:30AM BLOOD WBC-5.5 RBC-3.92* Hgb-12.2 Hct-35.6*
MCV-91 MCH-31.2 MCHC-34.4 RDW-12.3 Plt ___
___ 01:00PM BLOOD Hct-36.6
___ 05:30AM BLOOD Glucose-85 UreaN-11 Creat-0.8 Na-138
K-4.0 Cl-111* HCO3-20* AnGap-11
___ 05:30AM BLOOD ALT-11 AST-14 LD(LDH)-122 AlkPhos-31*
TotBili-0.8
___ 05:30AM BLOOD Albumin-3.8 Mg-2.1
US GALLBLADDER/LIVER
IMPRESSION: Normal gallbladder and intra- and extra-hepatic
biliary ducts.
Marked gastric distention, new since the prior exam. Consider
radiograph or
CT if there is concern for bowel obstruction.
CT Abdomen
IMPRESSION: Marked gastric distention and dilation concerning
for gastric
outlet obstruction. No cause identified. Correlation with
endoscopy is
recommended.
Brief Hospital Course:
___ with no significant past medical history presents with
worsening epigastric pain- found to have massive gastric
dilation of US and CT scan.
#Epigastric Pain with Gastric Dilation
NG Tube was placed and air and 250cc fluid removed from the
stomach. Patient felt much better afterwards, and then asked for
tube to be removed. Patient was observed overnight where she
received IVF. Her diet was advanced as tolerated and before
discharge she was able to tolerate solid foods. Labs remained
unremarkable. Cause of this distension remains unclear. She may
have a dysmotility disorder or a structural abnormality. Causes
could include tumor or gallstone ileus. She has ___ with her
Primary Care Physician on ___.
Transitional Issues
-___ with Primary Care Physician ___
-Will need EGD as an outpatient
-___ HgA1c
-___ Final CT Abdomen Read
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Gastric Distension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital with belly pain and nausea. You were
found to have a very distended stomach. After removing fluid
with a nasogastic tube and giving you bowel rest, you improved.
The cause of the stomach distension is unclear. You will see a
Gastroenterologist as an outpatient to further evaluate. They
will likely need to perform more tests/procedures to determine
the ultimate cause of your symptoms.
When you see your Primary care physician on ___, she should
refer you to a Gastroenterologist.
It was a pleasure taking care of you, Ms ___.
Followup Instructions:
___
|
10193755-DS-8 | 10,193,755 | 22,813,869 | DS | 8 | 2167-07-13 00:00:00 | 2167-07-13 14:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
___ L4-S1 ALIF
___ Right L1-4 XLIF
___ T11-ilium posterior lumbar fusion
History of Present Illness:
___ with a history of breast cancer s/p lumpectomy (___) on
anastrazole, hypertension, DM2, CKD III, and spinal stenosis who
has had low back pain and difficulty ambulating for 6 months
which has acutely worsened in the last ___ weeks. She has
received 2 "spine injections" at OSH most recently in ___. She
does get relief from these. Over the last several weeks she
feels
her pain has worsened to the point that she requires a
wheelchair
and is not able to ambulate. No radicular symptoms. No bowel or
bladder incontinence or saddle anesthesia. CRP is elevated to
54,
WBC is wnl and she is afebrile.
Past Medical History:
HTN, DMII, lipid, lumbar stenosis, scoliosis
Social History:
___
Family History:
nc
Physical Exam:
PHYSICAL EXAMINATION:
General:
NAD, A&Ox4
nl resp effort
RRR
Sensory:
___
L2 L3 L4 L5 S1 S2
(Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh)
R SILT SILT SILT SILT SILT SILT
L SILT SILT SILT SILT SILT SILT
Motor:
___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___
R 4+ 5 5 5 equiv 5
L 4+ 5 5 5 equiv 5
Reflexes
Pat(L3-4)
R 1
L 1
___: Negative
Babinski: Downgoing
Clonus: No beats
rectal exam deferred due to low suspicion
post-op
PO 163 / 104
L Lying ___ ra
drain: 100 ml
Exam
General: NAD. AAO x3. Lying awake in bed.
Skin: warm, dry, no rash
CV: RRR, s1 and S2 nl
Pulm: normal effort, lungs are clear
Abd: soft, NT/ND, + BS
Wound: C/D/I. No swelling, redness, or warmth
Extremities: calves are soft, no edema
Neurologic: PERRL. Face symmetrical. Speech clear and fluent.
Tongue ML. EOMs intact. Negative pronator drift. Normal tone and
bulk universally.
Motor Strength:
Delt Bi Tri BR WF/WE HI
Right 5 5 5 5 5 5
Left 5 5 5 5 5 5
IP Quad Ham TA Gas ___
Right 5 5 5 5 5 5
Left 5 5 5 5 5 5
Sensation: intact to light touch
Pertinent Results:
___ 05:30PM URINE HOURS-RANDOM
___ 05:30PM URINE UHOLD-HOLD
___ 05:30PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-100* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 05:19PM LACTATE-2.3*
___ 05:02PM GLUCOSE-185* UREA N-20 CREAT-0.9 SODIUM-138
POTASSIUM-5.2 CHLORIDE-96 TOTAL CO2-28 ANION GAP-14
___ 05:02PM estGFR-Using this
___ 05:02PM CRP-54.9*
___ 05:02PM WBC-7.2 RBC-3.65* HGB-11.5 HCT-34.3 MCV-94
MCH-31.5 MCHC-33.5 RDW-12.3 RDWSD-42.2
___ 05:02PM NEUTS-75.8* LYMPHS-14.9* MONOS-8.4 EOS-0.4*
BASOS-0.1 IM ___ AbsNeut-5.44 AbsLymp-1.07* AbsMono-0.60
AbsEos-0.03* AbsBaso-0.01
___ 05:02PM PLT COUNT-278
Brief Hospital Course:
Patient was admitted to Orthopedic Spine Service on ___ for
further management. Starting on ___ she underwent the above
stated procedure(s) on consecutive days. Patient tolerated the
procedures well without complication. Please review dictated
operative report for details. Patient was extubated without
incident and was transferred to PACU then floor in stable
condition.
During the patient's course ___ 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 in routine fashion and
patient voided without incident. Lumbar epidural catheter was
removed on POD#1. Hemovac was removed in routine fashion once
the output per 8 hours became minimal.
Physical therapy and Occupational therapy were consulted for
mobilization OOB to ambulate and ADL's. Hospital course was very
slow to progress from 3 stage surgery. She had acute anemia and
was monitored closely. On ___ her HCT dropped to 19% which
required 2 units. Her last HCT was 28%.
Now, Day of Discharge, patient is afebrile, VSS, and neuro
intact. Patient tolerated a good oral diet and pain was
controlled on oral pain medications. Patient was able to get up
with assist. Patient's wound is clean, dry and intact. Patient
noted improvement in radicular pain. Patient is set for
discharge to acute rehab in stable condition.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. MetFORMIN (Glucophage) 500 mg PO BID
3. Acetaminophen w/Codeine ___ TAB PO Q6H:PRN Pain - Moderate
4. Diazepam 5 mg PO QHS:PRN insomnia
5. amLODIPine 5 mg PO DAILY
6. Gabapentin 300 mg PO QID
7. Lisinopril 40 mg PO DAILY
8. Anastrozole 1 mg PO DAILY
9. clotrimazole-betamethasone ___ % topical DAILY:PRN rash
10. Atenolol 100 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
3. Heparin 5000 UNIT SC BID
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
5. amLODIPine 5 mg PO DAILY
6. Anastrozole 1 mg PO DAILY
7. Atenolol 100 mg PO DAILY
8. Atorvastatin 20 mg PO QPM
9. clotrimazole-betamethasone ___ % topical DAILY:PRN rash
10. Diazepam 5 mg PO QHS:PRN insomnia
11. Gabapentin 300 mg PO QID
12. Lisinopril 40 mg PO DAILY
13. MetFORMIN (Glucophage) 500 mg PO BID
14. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
lumbar stenosis
lumbar spondylosis
lumbar scoliosis
acute anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Lumbar Decompression With Fusion:
You have undergone the following operation: Lumbar Decompression
With Fusion
Follow-up Appointments
After you are discharged from the hospital and settled at home
or rehab, please make sure you have two appointments:
1.2 week post-operative wound check visit after surgery
2.a post-operative visit with your surgeon for ___ weeks after
surgery.
You can reach the office at ___ and ask to speak
with your surgeons surgical coordinator/staff to schedule or
confirm your appointments
Wound Care
If not already done in the hospital, remove the incision
dressing on day 2 after surgery.
You may shower day 3 after surgery. Starting on this ___ day,
you should gently cleanse the incision and surrounding area
daily with mild soap and water, patting it dry when you are
finished.
Some swelling and bruising around the incision is normal. Your
muscles have been cut, separated and sewn back together as part
of your surgical procedure. You will leave the hospital with
back discomfort from the surgical incision. As you become more
active and the incision and muscles continue to heal, the
swelling and pain will decrease.
Have someone look at the incision daily for 2 weeks. Call the
surgeons office if you notice any of the following:
___ redness along the length of the incision
___ swelling of the area around your incision
___ from the incision
___ of your extremities greater than before surgery
___ of bowel or bladder control
___ of severe headache
___ swelling or calf tenderness
___ above 101.5
Do not soak or immerse your incision in water for 1 month. For
example, no tub baths, swimming pools or jacuzzi.
Activity Guidelines
You MAY be given a RIGID BRACE that you will wear whenever
sitting up, standing, or walking. You will wear it for ___
weeks after surgery. See the last page of these instructions for
details on wearing the brace.
Avoid strenuous activity, bending, pushing or holding your
breath. For example, do not vacuum, wash the car, do large
loads of laundry, or walk the dog until your follow-up visit
with your surgeon.
Avoid heavy lifting. Do not lift anything over ___ pounds for
the first few weeks that you are home from the hospital.
Increase your activities a little each day. Walking is good
exercise. Plan rest periods and try to avoid hills if possible.
Remember, exercise should not increase your back pain or cause
leg pain.
Reaching: When you have to reach things on or near the floor,
always squat (bending the knees), rather than bending over at
the waist.
Lying down: when lying on your back, you may find that a pillow
under the knees is more comfortable. When on your side, a
pillow between the knees will help keep your back straight.
Sitting: should be limited to 40-60 minutes at a time for the
first week. Slowly increase the amount of sitting time,
remembering that it should not increase your back pain.
Stairs: use stairs only once or twice a day for the first week,
or as directed by the surgeon. Climb steps one at a time,
placing both feet on the step before moving to the next one.
Driving: you should not drive for ___ weeks after surgery. You
should discuss driving with your surgeon /nurse practitioner
/physician ___. You may ride in a car for short distances.
When in the car, avoid sitting in one position for too long.
If you must take long car rides, do not ride for more than 60
minutes without taking a break to stretch (walk for several
minutes and change position.).
Sexual activity: you may resume sexual activity ___ weeks after
surgery (avoiding pain or stress on the back).
Reduction in symptoms: patients who have experienced back and
radiating leg pain for a short window of time before surgery
should anticipate a significant decrease in pre-operative
symptoms. If the pain has been present for a longer period
(months to years), the pre-operative symptoms will recover on a
more gradual basis week by week. It is not practical to expect
immediate relief of symptoms. Routinely, pain will gradually
improve on a weekly basis, weakness on a monthly basis, and
numbness in a range of 6 months to ___ year.
Physical Therapy
Outpatient Physical Therapy (if appropriate) will not begin
until after your post-operative visit with your surgeon. A
prescription is needed for formal outpatient therapy.
You may be given simple stretching exercises or a prescription
for formal outpatient physical therapy, based on what your needs
are after surgery.
Medications
You will be given prescriptions for pain medications and stool
softeners upon discharge from the hospital.
Pain medications should be taken as prescribed by your surgeon
or nurse practitioner/ physician ___. You are allowed to
gradually reduce the number of pills you take when the pain
begins to subside.
If you are taking more than the recommended dose, please
contact the office to discuss this with a practitioner ___
medication may need to be increased or changed).
Constipation: Pain medications (narcotics) may cause
constipation. It is important to be aware of your bowel habits
so you ___ develop severe constipation that cannot be treated
with simple, over the counter laxatives.
Most prescription pain medications cannot be called into the
pharmacy for renewal. The following are 2 options you may
explore to obtain a renewal of your narcotic medications:
1.Call the office ___ days before your prescription runs out and
speak with office staff about mailing a prescription to your
home/pharmacy. (Prescriptions will not be sent by Fed Ex/UPS)
2.Call the office 24 hours in advance and speak with our office
staff about coming into the office to pick up a prescription.
If you continue to require medications, you may be referred to
a pain management specialist or your medical doctor for ongoing
management of your pain medications
Avoid NSAIDS for ___ weeks post-operative. These medications
include, but are not limited to the following:
1.Non-steroidal Anti-inflammatory drugs: Advil, Aleve, Cataflam,
Clinoril, Diclofenac, Dolobid, Feldene, Ibuprofen, Indocin,
Medipren, Motrin, Nalfon, Naprosyn, Nuprin, Relafen, Rufen,
Tolectin, Toradol, Trilisate, Voltarin
Blood Clots in the Leg
1.It is not uncommon for patients who recently had surgery to
develop blood clots in leg veins.
Symptoms include low-grade fever, and/or redness, swelling,
tenderness, and/or an
aching/cramping pain in your calf.
You should call your doctor immediately if you have these
symptoms.
To prevent blood clots in legs, try walking and/ or pumping
ankles several times during the day.
If the blood clot breaks free from the leg vein, it can travel
to the lungs and cause severe breathing difficulty and/or chest
pain. If you experience this, call ___ immediately.
Questions
Any questions may be directed to your surgeon or physician
___.
1.During normal business hours (8:30am- 5:00pm), you can call
the office directly at ___. Turn around time for a
phone call is 24 hours. After normal business hours, you can
call the on-call service and we will get back to you the next
business day.
If you are calling with an urgent medical issue, please tell
the coordinator that it is an urgent issue and needs to be
discussed in less than 24 hours (i.e. pain unrelieved with
medications, wound breakdown/infection, or new neurological
symptoms).
Lumbar Corset or (TLSO) Brace Guidelines
You MAY have been given a rigid brace that you will wear for
___ weeks after surgery.
You should put on your brace as you have been instructed by the
orthotist (brace maker). Instructions will be reviewed in the
hospital by the nursing staff and Physical Therapist.
It is a good idea to start practicing with your brace before
surgery (putting it on/taking it off, sitting, standing,
walking, and climbing steps with the brace) so you can assist
with your post-operative care in the hospital.
Keep the name and phone number of the person who fitted and
dispensed your brace close by in case you need to have the brace
checked and/or adjusted.
You should always have a barrier between your surgical incision
and the brace. For example, you may want to put on a light
t-shirt and then the brace before getting dressed for the day.
During periods of rest, take off the brace and expose the
incision to the air by lying on your side for a few hours. This
will reduce the chance of your wound breaking down.
1.The brace must be worn at all times with the following 3
exceptions: 1.Lying flat in bed during a rest period or at
night to sleep.
2.Getting out of bed at night to go to the bathroom, returning
to bed immediately when you are finished.
3.Showering. You may wish to use a shower chair to help prevent
bending/twisting while bathing. You should have someone help
wash your back and legs.
Physical Therapy:
Activity: ad lib with TLSO brace
Treatments Frequency:
eval wound daily
pt/ot eval
Followup Instructions:
___
|
10193875-DS-17 | 10,193,875 | 20,281,843 | DS | 17 | 2165-08-24 00:00:00 | 2165-08-24 19:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Propoxyphene
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This patient is a ___ year old male with a history of CAD s/p RCA
Inferior STEMI ___, lateral OM STEMI ___, recent mLAD stent at
___ a few weeks ago, ___ EF 35-40%, hypertension,
hyperlipidemia, congenital deafness and alcohol abuse who
presents complaining of body pain and chest pain in the setting
of intoxication. He was brought in by ambulance for evaluation
of chest pain and "full body pain" for a couple days.
.
According to him he has had left sided chest pain for the last 3
days. The pain is both dull and sharp and is constant. It does
not radiate into his arms or jaw. It is associated with
shortness of breath and nausea and he reports one episode of
nonbloody vomiting earlier today. No diarrhea. He has some
abdominal pain at baseline which he says is unchanged. Other
pain at this time includes both knees and both wrists, all of
which have been hurting more for the past ___ days. Neither of
these pains are new for him.
.
He reports drinking two pints of vodka on the day of admission
with his last drink at 4pm yesterday afternoon. He has not taken
any of his meds including his cardiac meds for more than 1 week,
which he says is because he ran out. He didn't know where to get
refills.
.
In the ED his initial vital signs were 98.3 104 138/83 20
94%/ra. An EKG was without ischemic changes. Initials labs were
notable for a serum EtOH level of 88. Serum tox was negative for
aspirin, acetamenophen, benzos, barbituates or tricyclics. A
chest x-ray (my read) was notable only for hyperexpanded lungs
consistent with COPD and showed no signs of focal infiltrate. He
was given a 325mg aspirin and admitted to the floor for chest
pain and alcohol withdrawal. He was admitted for chest pain,
noncompliance with meds, and alcohol withdrawal.
.
On arrival on the floor he appears mildly intoxicated but in no
acute distress. He is reporting ___ chest pain which has been
going on for days. He also is reporting mild shortness of breath
also going on for days.
.
He reports having had 2 major cardiac interventions, 1 several
years ago (___) here at ___ and one within the last few months
at ___. He is supposed to be on ___. He was last admitted to
___ on ___ for chest pain at which time he was 1 month
out from having a stent placed in his LAD. He had a cardiac
catheterization at the time which showed chronic non-obstructive
changes and no intervention was warranted. He was started on
isosorbide mononitrate 30mg daily for his angina symtoms and set
up to follow up with cardiology. The plan was for an outpatient
echo and stress test, with the thought being that if a stress
test showed any reversible disease in RCA distribution they
might consider future intervention of his chronically occluded
RCA at some point.
.
REVIEW OF SYSTEMS:
+ per HPI +chronic cough, +shortness of breath, +chest pain,
+chronic abdominal pain, +nausea, +vomiting,
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, diarrhea, constipation,
BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
PAST MEDICAL HISTORY:
CAD s/p multiple STEMIs and stents
COPD
Osteonecrosis of R knee and chronic pain
Congenial deafness
HTN
sCHF (EF 30%)
.
Cath History:
-Inferior ST elevation myocardial infarction at the age of ___
and on ___ when he presented with the inferior MI, he was
found to have occlusion of the mid right coronary artery that
was treated with balloon angioplasty.
-He may have had another PTCA in ___.
-On ___, in the setting of a lateral STEMI, he was found
to have an occluded second obtuse marginal branch that was
treated with bare metal stenting.
-___ when again he presented with chest pain. The right
coronary artery was chronically occluded. The LAD had diffuse
40% stenosis in the mid portion. The first diagonal, which was a
small vessel, had a 60% stenosis. The circumflex had a 50%
stenosis in its mid portion, but the obtuse marginal branch,
which was stented, was
remained patent.
- cardiac evaluation included an echocardiogram on ___,
which showed an ejection fraction of 35-40% with inferior
hypokinesis and some akinesis in the inferior wall as well.
-At ___ had a mLAD stent recently a few weeks ago (no further
records available at this time)
.
PSYCHIATRIC HISTORY:
Dx: depression and schizophrenia by history, although his
description of psychosis is not diagnostic (intermittent AH and
visual illusions, becoming suspicious when others walk behind
him, and episodes of severe anger).
Hosp: multiple psychiatric, dual diagnosis, and detox
admissions, most recently detoxed in ___ and admitted in
___ at ___.
Med trials: states that he has been stable on risperidone and
celexa
SA/SIB: reports SA by cutting wrists in ___ and that he was
severely depressed at this time
Psychiatrist/therapist: none
Social History:
___
Family History:
EtOH and CAD in multiple family members
Physical ___:
ADMISSION EXAM:
VS: 97.0 94 16 139/97 96 ra
GENERAL - Alert, interactive, mildly intoxicated, NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD, no carotid bruits
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - faint rhonchi throughout, no wheeze, otherwise clear,
resp unlabored, no accessory muscle use
ABDOMEN - NABS, soft, very mild diffuse tenderness, ND, no
masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, deaf but reads lips, CNs II-XII grossly
intact, muscle strength ___ throughout, sensation grossly intact
throughout, DTRs 2+ and symmetric, cerebellar exam intact, gait
not tested
Pertinent Results:
ADMISSION LABS:
___ 09:58PM BLOOD WBC-4.7 RBC-4.14* Hgb-14.0 Hct-38.8*
MCV-94 MCH-33.8* MCHC-36.1* RDW-13.2 Plt ___
___ 09:58PM BLOOD Neuts-63.7 ___ Monos-7.3 Eos-5.6*
Baso-1.4
___ 09:58PM BLOOD ___ PTT-31.2 ___
___ 09:58PM BLOOD Glucose-90 UreaN-14 Creat-0.7 Na-141
K-3.7 Cl-104 HCO3-26 AnGap-15
___ 09:58PM BLOOD cTropnT-<0.01
___ 09:58PM BLOOD ASA-NEG Ethanol-88* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
OTHER PERTINENT LABS:
___ 09:58PM BLOOD cTropnT-<0.01
___ 07:07AM BLOOD CK-MB-5 cTropnT-<0.01
___ 02:45PM BLOOD CK-MB-4 cTropnT-<0.01
___ 02:45PM BLOOD Lipase-21
___ 07:07AM BLOOD ALT-51* AST-60* CK(CPK)-132 AlkPhos-72
TotBili-0.8
___ 02:39PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
DISCHARGE LABS:
IMAGING:
CXR ___: Hyperinflation without acute cardiopulmonary
process.
Brief Hospital Course:
___ year old gentleman with a history of severe CAD s/p recent
stent placement and EtOH abuse who presented with left sided
chest pain in the setting of having stopped his cardiac
medications, with chest pain likely musculoskeletal in etiology
and perhaps related to gastritis, and with course c/b EtOH
withdrawal and pancytopenia.
.
# Chest Pain: Was concerning for ACS given noncompliance with
cardiac meds (including ___ in the setting of a recent
stent. However, no EKG changes concerning for ischemia, and
troponin negative x3. ___ have been anginal pain, but not
representing plaque rupture or occlusion. Differential also
included GERD, PUD, costochondritis, or pain secondary to fall.
CXR did not show any acute process. Patient was restarted on
cardiac regimen of ___, aspirin, BB, statin, and lisinopril.
Given reproducible nature of pain on exam, he was given tylenol
and tramadol for pain.
.
# Epigastric pain: Likely secondary to GERD or gastritis in
setting of EtOH abuse. Patient initially restarted on PPI,
though later transitioned to ranitidine in setting of developing
pancytopenia. Lipase was WNL. Transaminases only mildly
elevated.
.
# EtOH Abuse: Patient reported drinking ___ pints of liquor
daily. Has history of withdrawal, seizures, and DTs. Patient
began to demonstrate withdrawal symptoms the morning following
admission. Was monitored per ___ protocol, and received
diazepam as needed for withdrawal symptoms. Was given MVI,
thiamine, folic acid. SW consulted.
.
# HTN: BPs were generally well-controlled. Continued prior
regimen of atenolol, lisinopril and Imdur.
.
# Pancytopenia: Most likely secondary to EtOH abuse. Stopped
PPI and switched to H2 blocker, held heparin. Could consider
RUQ ultrasound in outpatient setting to evaluate for potential
cirrhosis/splenomegaly. Advised outpatient providers that ___
is also a possible offender. He will have CBC checked on ___ to
monitor.
.
# Pulsatile abdominal aorta: Was not felt again besides at
initial admission. Given smoking, he should be eligible for
screening ultrasound at the age of ___.
.
# Depression: Inadequately managed in that he has no outpatient
provider and does not have any medications covered as an
outpatient. He seems poorly connected to the resources
available. Did not endorse active SI.
Social work consulted for placement/depression/resources.
.
# Arthritis/Pain: Continued tylenol and tramadol. Held ibuprofen
given concern for gastritis and known coronary disease.
.
TRANSITIONAL ISSUES:
-Patient's code status was full code this admission.
-CBC will need to be checked and followed-up by PCP ___ ___ to
ensure stability. She was contacted.
Medications on Admission:
Previous Medication List (patient only on aspirin at time of
admission):
albuterol 90 mcg 2 puffs q6H prn
atenolol 50mg daily
atorvastatin 40mg daily
clopidogrel 75mg daily
aspirin 81mg daily
nitroglycerin 0.4 mg SL prn chest pain
isosorbide mononitrate 30mg ER daily
fluticasone-salmeterol 250-50 BID
ibuprofen 600mg TID prn
lisinopril 5mg daily
ondansetron 4mg PO TID prn nausea
pantoprazole 40mg ER daily
risperidone 0.25mg PO QHS
tramadol 50mg QID prn w/600mg ibuprofen
zolpidem 10mg QHS prn
cetirizine 10mg daily
Nicotine patch 14mg
multivitamin
Discharge Medications:
1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
Disp:*1 cartridge* Refills:*0*
2. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
call Dr. ___ you need to use this medication.
Disp:*10 Tablet, Sublingual(s)* Refills:*0*
6. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
7. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
Disp:*1 Disk with Device(s)* Refills:*2*
8. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. risperidone 0.25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
10. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
11. cetirizine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H
(every 8 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
15. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
17. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day as
needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
18. Outpatient Lab Work
CBC on ___,
phone ___
fax ___
19. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) patch
Transdermal once a day for 5 weeks: START 21mmg nicotine patch
for 5 weeks then, 14 mg patch for 2 weeks then 7 mg patch for 2
weeks. Do not smoke while using the patch.
.
Disp:*35 patches* Refills:*0*
20. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) patch
Transdermal once a day for 14 days: START 21mmg nicotine patch
for 5 weeks then, 14 mg patch for 2 weeks then 7 mg patch for 2
weeks. Do not smoke while using the patch.
.
Disp:*14 patches* Refills:*0*
21. nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) patches
Transdermal once a day for 14 days: START 21mmg nicotine patch
for 5 weeks then, 14 mg patch for 2 weeks then 7 mg patch for 2
weeks. Do not smoke while using the patch.
.
Disp:*14 patches* Refills:*0*
22. Outpatient Lab Work
CBC lab check ___. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
24. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
25. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
26. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once
a day as needed for constipation.
Disp:*30 packets* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Atypical chest pain
Gastritis
Alcohol withdrawal
Secondary Diagnoses:
Pancytopenia
Depression
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with chest pain. Tests showed
you did not have a heart attack. We think you pain may have
been caused by gastritis, which is irritation of the stomach.
This pain can be exacerbated by alcohol use.
While you were here you showed signs of withdrawal from alcohol.
We strongly advise you to stop drinking, and have arranged for
you to go to ___.
It is very important that you continue taking all of your
cardiac medications. Not taking them significantly increases
your risk of having a heart attack.
We made the following changes to your medications:
STOPPED ibuprofen
STOPPED pantoprazole
STARTED ranitidine
STARTED folic acid
STARTED thiamine
STARTED nicotine patch
START 21mmg nicotine patch for 5 weeks then, 14 mg patch for 2
weeks then 7 mg patch for 2 weeks. Do not smoke while using the
patch.
CONGRATULATIONS ON QUITTING SMOKING!
Please continue to take other medications as you have been
doing.
You need your bloodwork checked to monitor your platelets on
___ at Dr. ___.
Followup Instructions:
___
|
10193946-DS-9 | 10,193,946 | 22,870,970 | DS | 9 | 2119-02-13 00:00:00 | 2119-02-13 13:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
adhesive tape
Attending: ___.
Chief Complaint:
Right shoulder dislocation
Major Surgical or Invasive Procedure:
Closed reduction of right shoulder
History of Present Illness:
___ is a ___ year-old female with history of
osteoporosis and hypothyroidism who presents to the ED as
transfer from ___ for management of persistent right
shoulder dislocation. Patient slipped and fell, impacting her
right elbow. She had immediate pain and felt her shoulder pop.
She was evaluated at ___ and diagnosed with a dislocated
right shoulder. She underwent reduction attempts twice under
Ketamine sedation, which were unsuccessful. An elbow laceration
was repaired prior to transfer. On arrival she reports
previously having some tingling in her right fingers, but it is
now resolved. She denies shaving any numbness and denies pain in
any other location. She denies history of shoulder dislocation
Past Medical History:
Osteoporosis
Hypothyroidism
HTN
Social History:
___
Family History:
N/C
Physical Exam:
AVS wnl
In sling
Wiggling fingers
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 shoulder dislocation and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for closed reduction of right
shoulder, 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'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
non weight bearing in the right upper extremity in sling at all
times, and will not require additional DVT prophylaxis. The
patient will follow up with Orthopedic Sports Clinic this week.
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:
Levothyroxine
Atenolol
HCTZ
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
Discharge Disposition:
Home
Discharge Diagnosis:
R shoulder dislocation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. 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:
- Non weight bearing of right upper extremity in sling at all
times
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
Continue all home medications unless specifically instructed to
stop by your surgeon.
ANTICOAGULATION:
- You do not require any additional anticoagulation upon
discharge, please ambulate as usual to help prevent blood clots.
Sling Care:
- Sling must be left on until follow up appointment unless
otherwise instructed.
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
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Followup Instructions:
___
|
10194132-DS-18 | 10,194,132 | 20,336,899 | DS | 18 | 2189-09-15 00:00:00 | 2189-09-17 08:02:00 |
Name: ___. ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Pain on bilateral ___ s/p fall with head strike
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ former ___ w/ CKD, spinal stenosis, and multiple
recent issues including myopericarditis earlier this year
treated successfully with corticosteroids, and more recently has
had increasing bilateral flank pain, presented to the ED
following a mechanical fall with head strike last night. Has
been on percocet and tramadol for back pain, last evening felt
imbalanced, ___ syncope, fell from a chair onto L hip and
occiput, ___ LOC, has had increasing L hip pain since, as well as
new midline low back pain. He went to his PCP's office, where he
got plain films of L hip and knee, which were negative for acute
fracture, and was sent to ED for further eval. Regarding his
recent back pain, he had an MR ___ on ___ (not yet read
in ___ records but per PCP ___ "extensive edema and swelling
of the left psoas muscle from L2 to L4 with lesser degree on the
right psoas muscle. There is also some associated posterior
paraspinal edema, more on the left than right side." His
atorvastatin was stopped last week, and CPK was within normal
limits, but ESR was 40. Given concern for myositis, he was
referred for rheumatology and ID for a muscle biopsy next week.
In the ED, initial vitals: 97.6 86 187/95 16 98% RA. Exam
notable for lumbar midline tenderness, L hip tenderness,
occipital abrasion. Stool was guaiac negative. Labs notable
for WBC 7.7, Hgb 10.9 (baseline Hct 30), BUN/Cr 44/2.8 (baseline
Cr ___, HCO3 36 but lytes otherwise WNL, and INR 3.8. UA w/
300 protein and few bacteria. CT abdomen/pelvis was performed
which showed ___ evidence of bleeding. CT head showed a L
frontal lobe hemorrhagic mass with surrounding edema. CT neck
showed ___ fracture but did show an incidental 2.1 cm
heterogenous thyroid nodule. Trauma surgery evaluated and felt
___ evaluation was needed. Neurosurgery evaluated and
recommended reversal of his INR with FFP and Vitamin K to
achieve INR equal to or less than 1.5, and repeating head CT in
8 hours to assess stability vs. MRI. He received 1L NS, 2u FFP,
10 mg Vitamin K, morphine and zofran. Repeat CT scan 8 hours
later showed stability of the hemorrhagic mass. His PCP called
in and requested admission for pain management, so the ___
was admitted to medicine. VS prior to transfer were: 98 78
166/74 16 98% NC.
Currently, 98.8 167/76 84 18 94ra
ROS:
___ fevers, chills, night sweats, or weight changes. ___ changes
in vision or hearing, ___ changes in balance. ___ cough, ___
shortness of breath, ___ dyspnea on exertion. ___ chest pain or
palpitations. ___ nausea or vomiting. ___ diarrhea or
constipation. ___ dysuria or hematuria. ___ hematochezia, ___
melena. ___ numbness or weakness, ___ focal deficits.
Past Medical History:
-Atrial fibrillation (paroxysmal, on warfarin)
-CKD stage 3 (GFR ___, baseline Cr _3.1_)
-Myopericarditis in ___? earlier this year, treated with
steroids
-Hypertension
-Pseudogout
-Erectile dysfunction
-Spinal stenosis
-Obesity
-Impaired glucose tolerance, Last HBA1C <6
-Benign prostatic hyperplasia
-Gout
Social History:
___
Family History:
Not contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS:98.8 167/76 84 18 94ra
GENERAL: Alert, oriented, ___ acute distress
HEENT: An abrasion at the back of his head with some dry blood.
Sclerae anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, ___ LAD
RESP: CTAB ___ wheezes, rales, rhonchi
CV: RRR, Nl S1, S2, ___ MRG
ABD: Soft, NT/ND bowel sounds present, ___ rebound tenderness or
guarding, ___ organomegaly
GU: ___ foley
MSK: Upper extremity and LRE with full range of motion. intact
sensation, reflexes (1+), neurovascularly intact.
Left ___: diminished ROM both passive and acitive, limited with
pain.(flexion, extensition, internal and eternal
rotation).Neurovascularly intact.
SPINE- Midline ttp lower spine ___
EXT: Warm, well perfused, 2+ pulses, ___ clubbing, cyanosis or
edema
NEURO: ao x3 ___ intact, finger to nose intact, negative
babinski.
GAIT: Stable standing, a few steps with walker.
SKIN: ___ excoriations or rash.
DISCHARGE PHYSICAL EXAM:
========================
VS: 98.4 ___ ___ 18 94ra
GENERAL: Alert, oriented, ___ acute distress
HEENT: An abrasion at the back of his head with some dry blood.
Sclerae anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, ___ LAD
RESP: CTAB ___ wheezes, rales, rhonchi
CV: RRR, Nl S1, S2, ___ MRG
ABD: Soft, NT/ND bowel sounds present, ___ rebound tenderness or
guarding, ___ organomegaly
GU: ___ foley
MSK: Upper extremity and LRE with full range of motion. intact
sensation, reflexes (1+), neurovascularly intact.
Left ___: diminished ROM both passive and acitive, limited with
pain.(flexion, extensition, internal and eternal rotation).
Neurovascularly intact.
SPINE- Midline ttp lower spine ___
EXT: Warm, well perfused, 2+ pulses, ___ clubbing, cyanosis or 1+
edema on LLE up to ankle.
NEURO: ao x3 ___ intact, finger to nose intact, negative
babinski.
GAIT: Stable standing, a few steps with walker.
SKIN: ___ excoriations or rash.
Pertinent Results:
ADMISSION LABS:
===============
___ 10:00PM BLOOD ___
___ Plt ___
___ 10:00PM BLOOD ___
___
___ 10:00PM BLOOD ___ ___
___ 10:00PM BLOOD ___
___
___ 10:00PM BLOOD ___
___ 10:00PM BLOOD ___
PERTINENT IMAGING:
==================
C SPINE CT ___:
IMPRESSION:
1. ___ acute fracture or traumatic malalignment.
2. 2.1 cm heterogeneous nodule in the right lobe of thyroid
gland. Recommend nonemergent thyroid ultrasound for further
evaluation, if this has not already been performed.
Imaging CT HEAD W/O CONTRAST ___
IMPRESSION:
Centered within left frontal lobe there is a hemorrhagic mass
with surrounding edema. ___ material seen extending
into would appears to be the ___ space adjacent to this
mass. MRI is more sensitive for evaluation of intracranial mass
lesions.
Imaging CT ABD & PELVIS W/O CON ___
IMPRESSION:
1. ___ evidence of retroperitoneal or intraperitoneal hematoma.
2. Bilateral renal atrophy, and multiple renal cysts.
3. Diverticulosis without evidence of diverticulitis.
4. Small amount of fluid in the subcutaneous fat in the region
of the lower back, which is a nonspecific finding. Recommend
correlation with physical
Imaging MRI & MRA BRAIN ___
IMPRESSION:
1. ___ significant interval change in left frontal lobe
intraparenchymal
hematoma with small amount of surrounding vasogenic edema.
Intravenous
contrast was not administered. This limits evaluation for the
presence of
underlying mass which cannot be entirely excluded. Followup MRI
examination with contrast to evaluate for underlying mass lesion
is recommended.
2. MRA images degraded by motion artifact. ___ definite
evidence of aneurysm, vascular malformation, or stenosis.
Imaging CT HEAD W/O CONTRAST ___
IMPRESSION:
___ significant interval change in size or appearance of the left
frontal lobe hemorrhagic mass with surrounding edema, with
___ material seen extending into what appears to be the
___ space adjacent to this lesion. ___ new foci of
hemorrhage identified.
PERTINENT MICRO:
================
___ 8:40 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: ___ GROWTH.
___ BLOOD CULTURE Blood Culture, ___
___ BLOOD CULTURE Blood Culture, ___
DISCHARGE LABS:
===============
___ 05:40AM BLOOD ___
___ Plt ___
___ 06:00AM BLOOD ___
___
___ 05:40AM BLOOD Plt ___
___ 05:40AM BLOOD ___
___
___:45AM BLOOD ___ LD(LDH)-267* ___
___
___ 05:40AM BLOOD ___
___ 05:45AM BLOOD ___
Brief Hospital Course:
___ former ___ w/ CKD, Afib (On coumadin- stopped 4
days prior to presentation), spinal stenosis, myopericarditis,
and more recently has had increasing bilateral flank pain,
presented to the ED following a mechanical fall with head strike
and increased Lower Extremity pain.
ACTIVE ISSUES:
==============
# L frontal lobe intraparenchymal hemorrhage with possible mass:
The ___ fell from a chair the night before presentation.
Reports that the fall was in the context of feeling "woozy"
after taking his pain medications (percocet and tramadol for
back pain) and he slipped and fell from a chair and landed on
occiput and left hip. He had ___ LOC, ___ syncope. Plain films of
L hip and knee which were negative for acute fracture, and was
sent to ED for further evaluation. CT scan showed L frontal lobe
intraparenchymal hemorrhage and could not rule out possible
mass. He remained without neurological deficits during his
hospital stay and repeat CT and non contrast MRI showed ___
changes, but were unfortunately insufficient to completely
exclude a mass given motion artifact and lack of IV contrast.
Neurosurgery recommended follow up with neurosurgery and repeat
MRI with contrast 4 weeks after discharge to more definitively
assess this questionable mass.
# L Hip pain s/p fall:
The fall happened in the context of ongoing bilateral hip pain.
___ had ___ fracture on xray. Outpatient work up for chronic
hip pain included an MRI showing edema and swelling of the psoas
muscles L>R, normal CK, elevated ESR (40). Given PCP's concern
for myositis, rheumatology was consulted. Rheumatology felt
that myositis was unlikely given normal CK and lack of diffuse
involvement of muscles with pain and weakness. The edema in the
psoas muscle was attributed to bleeding in the muscle in the
context of an supratherapeutic INR and minor trauma. The ___
was treated with Tylenol with codiene and his pain was
___. Tramadol was stopped due to concern that it
could lower seizure threshold, given intracranial bleed. The
___ was discharged home with physical therapy.
# Supratherapeutic INR:
___ on coumadin for paroxysmal Afib and had stopped taking
it 4 days prior to presentation due to INR 5.5. At presentation
INR was 3.8, so in the context of his intracranial bleed he was
reversed with 10 mg PO Vitamin K and 2u FFP, after which his INR
came down to 1.6. His warfarin was stopped at discharge due to
ICH.
CHRONIC ISSUES:
===============
# Myopericarditis:
___ had a diagnosis of Myopericarditis in ___ about 5
months before presentation. He was on a steroid taper and we
continued with the taper per rheumatology recommendations.
# Atrial fibrillation (paroxysmal, on coumadin):
We continued home carvediol and stopped coumadin.
# CKD stage 3 (GFR ___:
His creatinine ranged from 2.8 to 3.0 which was within his
baseline range.
# Hypertension:
Continued Home meds Hydralzine, torsemide.
# Pseudogout and gout:
Continued home allopurinol
TRANSITIONAL ISSUES:
====================
- The ___ intracranial hemorrhage is currently an absolute
contraindication to anticoagulation. His warfarin was
discontinued on this hospital stay.
- It was not clear whether or not there was an intracranial mass
in the area of hemorrhage seen on CT and MRI (without contrast).
Neurosurgery recommended a repeat MRI w/ gadolinium; however,
the ___ was not comfortable with this given that his GFR was
<30. This should be revisited as an outpatient, as the ___
will need an MRI for more definitive visualization of the area
of concern
- ___ will ___ with neurosurgery in 4 weeks
- ___ tramadol was discontinued due to risk of lowering
seizure threshhold. His pain was adequately controlled with
tylenol alone; he did not require oxycodone during this hosptial
stay.
- Per rheumatology, a muscle biopsy is not indicated. ___
pending Aldolase to rule out myositis (already very unlikely
given normal CK)
- Given ___ evidence of myositis, the ___ can likely restart
his lipitor and amiodarone - decision deferred to outpatient PCP
- ___ somewhat anxious regarding getting an MRI- consider
___ ativan for anxiolysis in the future if MRI clinically
indicated
- a 2.1 cm heterogeneous nodule in the right lobe of thyroid
gland was seen incidentally on chest CT. Radiology recommended
a nonemergent thyroid ultrasound for further evaluation, if this
has not already been performed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. PredniSONE 2 mg PO DAILY
Tapered dose - DOWN
3. HydrALAzine 25 mg PO DAILY
4. Warfarin 6.25 mg PO DAILY
5. Carvedilol 6.25 mg PO BID
6. Torsemide 20 mg PO DAILY
7. Viagra (sildenafil) 100 mg oral DAILY
8. Terazosin 10 mg PO QHS
9. Allopurinol ___ mg PO DAILY
10. TraMADOL (Ultram) 50 mg PO QID
Discharge Medications:
1. Carvedilol 12.5 mg PO BID
2. HydrALAzine 25 mg PO BID
3. Terazosin 10 mg PO QHS
4. Acetaminophen w/Codeine ___ TAB PO Q4H:PRN pain not relieved
by tylenol
do not exceed 3g acetaminophen per day
RX ___ 300 ___ mg 1 tablet(s) by mouth
every four (4) hours Disp #*30 Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
6. Senna 17.2 mg PO HS
RX *sennosides 8.6 mg 1 tablet by mouth at bedtime Disp #*30
Tablet Refills:*0
7. Allopurinol ___ mg PO DAILY
8. PredniSONE 10 mg PO DAILY
Tapered dose - DOWN
9. Torsemide 20 mg PO QAM
10. Cialis (tadalafil) 5 mg oral QHS
11. Torsemide 10 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: left frontal lobe intraparenchymal bleed,
supratherapeutic INR, deconditioning
Secondary: Atrial fibrillation, chronic kidney disease,
myopericarditis, gout, pseudogout, erectile dysfunction,
obeisty, benign prostatic hyperplasia
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 Dr. ___,
___ was our pleasure caring for you at ___
___. You were admitted to the hospital after you fell
and hit your head, as well as your left Hip and knee. A CT scan
of your head showed an intraparenchymal bleed in the left
frontal lobe. This most likely happened because your coumadin
levels were too high. You received vitamin K and to reverse
your elevated INR, and the bleeding stabilized. Our
neurosurgeons evaluated you and did not think that you needed
surgery.
However, because of the bleeding, it was not possible to exclude
a mass in this area. We attempted to further characterize the
mass with a brain MRI, but the evaluation was limited by motion
artifact and lack of contrast. You will ___ with the
neurosurgeons in clinic in 4 weeks to have repeat imaging
performed (CT or MRI - you can discuss this with the
neurosurgeons) to definitely address whether or not there is an
underlying mass in the area of the bleed. Because you had
bleeding in the brain, you should NOT resume taking warfarin
until further discussing the risks and benefits with your
primary care physician.
Finally, because you were being evaluated for hip pain as an
outpatient and your primary care physician was concerned about
myositis, our rheumatologists evaluated you. They felt that the
edema seen in your psoas muscle on MRI was most likely a small
bleed in the muscle given your supratherapeutic INR. They did
NOT think that myositis was likely contributing to your pain,
and they did not think you needed a muscle biopsy. We think
that you will benefit from physical therapy to improve your
strength and decreased doses of pain medications, which can be
potentially sedating and contribute to falls. When you were
feeling better, we discharged you home.
Thank you for allowing us to participate in your care.
Followup Instructions:
___
|
10194314-DS-11 | 10,194,314 | 29,997,991 | DS | 11 | 2130-04-02 00:00:00 | 2130-04-02 16:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right facial droop and dysarthria
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Ms. ___ is a ___ year old left handed female with past
medical
history of HTN, HL, Arthritis p/f ___ after being found by
relatives with dysarthria, right facial droop, and word finding
difficulty. At 0930 this morning, the patient was noted to be
in
her normal state of health with no deficits, but was found to
have right facial droop at 1130hrs by family. Pt initially taken
to ___, but transferred to ___ for further intervention.
Upon arrival to ___, code stroke called and patient was
evaluated with NIHSS scale = 5, notable for facial droop on
right, dysarthria, word finding difficulties. CTA/P was
obtained
showing no embolus or obstruction of vessels, and perfusion
noted
no penumbra. An EKG was obtained for the patient which showed
atrial fibrillation with RVR. The patient has no history of
this.
Because the time of evaluation exceeded 3 hours and there was no
evidence of vascular occlusion present no tPA or angiographic
intervention was initiated.
Past Medical History:
- Arthritis
- HTN
- HL
- GERD
- R Rotator Cuff surgery ___
- R Knee replacement ___
Social History:
___
Family History:
no history of strokes of cardiac disease
Physical Exam:
Vitals: T 98.1, HR 99-121, BP 162/87, Sat 100% RA
General: Awake, alert, responds to commands, dysarthric .
HEENT: R facial droop
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: tachycardic, irregular
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to self, difficult to assess
other answers ___ dysarthria. Unable to relate history.
Attentive, follows commands. Language impaired unable to
repeat.
No evidence of neglect. No gaze preference.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades. No gaze
preference.
V: Facial sensation intact to light touch.
VII: Right facial droop, blunted right nasolabial fold.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate not assessed.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 3 3 3 3 1
Plantar response was equivocal bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF.
-Gait: Not assessed
Pertinent Results:
___ 11:38PM ___ PTT-72.7* ___
___ 06:03PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 06:03PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 05:30PM GLUCOSE-98 UREA N-20 CREAT-0.9 SODIUM-145
POTASSIUM-3.4 CHLORIDE-109* TOTAL CO2-23 ANION GAP-16
___ 05:30PM ALT(SGPT)-14 AST(SGOT)-22 LD(LDH)-194 ALK
PHOS-72 TOT BILI-0.3
___ 05:30PM cTropnT-<0.01
___ 05:30PM ALBUMIN-3.9 CALCIUM-8.7 PHOSPHATE-3.1
MAGNESIUM-1.9 CHOLEST-174
___ 05:30PM %HbA1c-5.7 eAG-117
___ 05:30PM TRIGLYCER-71 HDL CHOL-55 CHOL/HDL-3.2
LDL(CALC)-105
___ 05:30PM TSH-1.1
___ 05:30PM CRP-4.4
___ 05:30PM WBC-6.9 RBC-4.10* HGB-13.4 HCT-39.2 MCV-96
MCH-32.8* MCHC-34.3 RDW-13.2
___ 05:30PM PLT COUNT-239
___ 05:30PM ___ PTT-29.4 ___
___ 05:30PM SED RATE-17
___ 03:05PM GLUCOSE-93 NA+-144 K+-3.9 CL--102 TCO2-27
___ 02:35PM CREAT-1.1
___ 02:35PM UREA N-25*
CTP: Area of increased MTT and decreased blood flow and blood
volume in the left frontal lobe in the MCA territory
representing an area of
ischemia/infarction.
CTA: Decreased visualization of the left MCA branches distally;
subtle dense focus in the left Sylvian fissure on NECT- se 2, im
11- ?
thrombus/calcification. Fenestration in Basilar artery.
MRI:(preliminary)There is restricted diffusion in the
distribution of the superior
of the left MCA involving the insula extending into the left
frontal lobe superiorly. There is no evidence of hemorrhage. The
FLAIR images
demonstrate mildly increased signal in the corresponding
regions. There are also scattered foci of increased signal in
the subcortical white matter bilaterally.
There is no mass lesion or hemorrhage. Normal flow voids are
present in the major intracranial vessels. Visualized paranasal
sinuses, mastoids, and orbital contents are unremarkable.
Echocardiogram: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%). 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) are mildly thickened but
aortic stenosis is not present. There are filamentous strands on
the right coronary aortic leaflet consistent with Lambl's
excresences (normal variant). No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
There is mild-moderate pulmonary artery systolic hypertension.
There is an anterior space which most likely represents a
prominent fat pad.
Brief Hospital Course:
This is a ___ year old left handed woman with past medical
history of HTN,
HL, Arthritis who presented from ___ after being found by
relatives with
dysarthria, right facial droop, and word finding difficulty. At
___ found to have NIHSS = 5, was determined to be outside of
tPA
window ~3.5-4hrs after last known asymptomatic period. Imaging
showed no apparent thrombus or obstruction on CT/CTA. Also noted
to be in Afib with RVR to 118 bpm.
Neuro: The patient was admitted the stroke service. She had an
MRI which showed acute ischemia in the left insular cortex which
is consistent with her persentation. She had an Echocardiogram
which showed no ASD, though it was a suboptimal study. Her
fasting LDL was 104 and glycohemoglobin was 5.7. She was
continued on her home dose of atorvastatin. We held
antihypertensives to allow for autoregulation. Her dysarthria
and word finding difficulty improved during the admission.
Cardiac: The patient presented with new afib in RVR. She was
started on a heparin drip for stroke prevention and the
coumadin. We held antihypertensives and her home atenolol.
Cardiac enzymes were negative x2. She has been switched to
lovenox for bridging.
FEN: The patient was seen by speech and swallow who cleared her
for thin liquids and soft solids.
1. Dysphagia screening before any PO intake? Yes
2. DVT Prophylaxis administered? Yes
3. Antithrombotic therapy administered by end of hospital day 2?
Yes
4. LDL documented? Yes (LDL =110 )
5. Intensive statin therapy administered? home dose(for LDL >
100)
6. Smoking cessation counseling given? non-smoker
7. Stroke education given? Yes
8. Assessment for rehabilitation? Yes
9. Discharged on statin therapy? Yes
10. Discharged on antithrombotic therapy? Yes Anticoagulation
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? Yes
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Atenolol 25 mg PO DAILY
2. Atorvastatin 10 mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. Atorvastatin 10 mg PO DAILY
3. Enoxaparin Sodium 80 mg SC Q12H
4. Warfarin 5 mg PO DAILY16
5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
left insular cortex infarct
Atrial fibrillation
Discharge Condition:
Mental Status: Alert and oriented to year, month and date within
2 days. Answered ___ but corrected. Naming and
Repetition is intact. mildly Dysarthric.
Cranial Nerves: mild R facial droop. EOMI. VFF. Other CN intact.
Motor: No pronator drift.
Left: Delt 5, Bic 5, Tri 5, FEx 5, IO 5, TA 5, ___ 4+
Right:Delt4+, Bic 5, Tri4+, FEx4+, IO4+, TA 5, ___ 4+
Reflexes: ___ Quad
Left: 3 2
Right: 3 3
Plantar response: equivocal
Coordination: FNF intact,
Discharge Instructions:
Dear Ms. ___,
You were admitted for a stroke . This was thought to be
secondary to your atrial fibrillation. You were started on
coumadin for stroke protection. Your stroke risk factors were
checked. You should continue to not smoke. Your cholesterol
was 104. You were continued on statin. You had a cardiac
echocardiogram which demonstrated no cardioembolic source,
though the study quality was not ideal and may need to be
repeated at some point. You were checked for blood glucose
control with a HgB A1c. The level was 5.7. You need to
continue your blood pressure control.
You should continue to eat a low fat healthy diet, and follow up
with your primary care physician and stroke ___ as
directed bleow.
It was a pleasure taking care of you.
Followup Instructions:
___
|
10194423-DS-4 | 10,194,423 | 25,670,259 | DS | 4 | 2126-12-14 00:00:00 | 2126-12-14 11:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Mrs. ___ is a ___ year-old patient who was transferred from
___ for further evaluation of a left frontal
subdural hematoma. Per outside medical records, the patient has
presented to their ED multiple times for alcoholism.
Per medical records, Mrs. ___ drank a bottle of scotch last
evening and sustained a fall. She has an elevated ethanol level
and was kept in ___ ED for detoxification. A non-contrast
head CT was completed showing the intracranial hematoma.
On evaluation in our ED, Mrs. ___ was falling asleep during
my
exam. Very little history could be obtained, as a result.
The patient endorses headaches, but no other symptoms. She
denied
any seizures, vision/hearing changes, arm or leg weakness,
facial
droop.
Past Medical History:
PMHx:
Per medical records, alcohol abuse, alcohol withdrawal,
hypokalemia, hypomagnesemia.
All:
NKA
Social History:
+ ETOH
Physical Exam:
O: T: 98.1 HR 114 BP 160/102 RR 18 O2 Sat 95% on room air
Gen: WD/WN, comfortable, NAD.
HEENT: PERRL.
Neuro:
Mental status: Lethargic. Falling asleep during exam.
Orientation: Oriented to person, place, and date.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Not tested.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation normal.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: No pronator drift. Poor effort on exam. Generally ___.
Sensation: Intact to light touch.
EXAM ON DISCHARGE:
AOx3, full motor, neuro intact
Pertinent Results:
Non-contrast head CT (outside hospital):
Left frontal subdural hematoma with maximum width 4mm. Cerebral
atrophy noted. No MLS.
Labs:
WBC 14.8, Hgb 16, Hct 46, plat 215
___ 10.4, PTT 27.3, INR 1
Na 136, K 4.4, Cl 91, HCO3 20, BUN 11, Cr 0.___
IMPRESSION:
No significant interval change of a 4 mm left frontoparietal
subdural
hematoma.
Brief Hospital Course:
Mrs. ___ was admitted to the neurosurgical ICU on ___ for
close monitoring of her left frontal SDH. She was started on a
CIWA protocol for ETOH withdrawal. She remained in stable
conditions over night.
On ___, she remained neurologically and hemodynamically intact.
She was transferred to the floor in stable conditions. She
continued to score on the CIWA scale.
On ___, the patient remained stable. She was started on her home
dose clonidine and other home meds. Physical therapy evaluated
the patient and found the patient safe for discharge home,
however the patient did not feel comfortable going home yet.
Will plan for discharge home tomorrow. Patient declined Social
Work. On ___ patient expressed readiness to go home and denied
any assistance with her ETOH abuse. Patient was discharged home.
Medications on Admission:
ClonazePAM 1 mg PO BID
Fluoxetine 40 mg PO DAILY
Gabapentin 100 mg PO BID
Tiotropium Bromide 1 CAP IH DAILY
Phosphorus 250 mg PO TID
Multiple vitamins
NALTREXONE
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. ClonazePAM 1 mg PO BID
3. Fluoxetine 40 mg PO DAILY
4. Gabapentin 100 mg PO BID
5. Phenytoin Sodium Extended 100 mg PO TID
For 7 days
RX *phenytoin sodium extended 100 mg 1 capsule(s) by mouth three
times a day Disp #*15 Capsule Refills:*0
6. Tiotropium Bromide 1 CAP IH DAILY
7. Phosphorus 250 mg PO TID
Discharge Disposition:
Home
Discharge Diagnosis:
Left Frontal SDH
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions
Brain Hemorrhage without Surgery
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.
We recommend that you refrain from drinking alcohol
especially in excessive amounts.
Medications
You may resume all Home Medications except for anything
that thins your blood.
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed for 7 days.
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
Followup Instructions:
___
|
10194602-DS-21 | 10,194,602 | 29,342,922 | DS | 21 | 2134-06-22 00:00:00 | 2134-06-22 14:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
codeine / aspirin
Attending: ___
Chief Complaint:
Acute Renal Failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ ___ gentleman with a history of iCMP (EF
35%, stable 3VD) and stage IIIb colonic adenocarcinoma with
microsatellite instability s/p C1 FOLFOX not tolerated ___
thrombocytopenia, s/p CK, s/p 3 cycles of palliative intent
pembrolizumab with progression of disease who was found to have
elevated creatinine prior to C4 of pembrolizumab.
Mr. ___ was in his usual state of health prior to presenting
to
clinic on ___. He continues having ___
pain which is fairly well controlled with prn oxycodone. He was
found to have Cr 3.9 leading to referral to ED and holding of
pembrolizumab.
ED initial vitals were 97.9 71 152/88 18 100% RA
Prior to transfer vitals were 97.6 61 105/62 19 100% RA
ED ___ significant for:
-CBC: WBC: 5.9. HGB: 10.3*. Plt Count: 89*. Neuts%: 65.2.
-Chemistry: Na: 134. K: 4.5. Cl: 100. CO2: 16*. BUN: 63*. Creat:
4.4*. Ca: 9.1. Mg: 1.8. PO4: 4.5.
-Coags: INR: 1.5*. PTT: 36.8*.
-LFTs: ALT: 37. AST: 34. Alk Phos: 93. Total Bili: 0.4.
-UA: RBC 4, WBC 1, rare mucous casts. Na 81
-CXR: no PNA
-Renal US: No hydronephrosis
ED management significant for:
-Medications: 1L NS in clinic, 2L NS in ED
On arrival to the floor, patient reports that he has been in his
usual state of health except for decreased po intake secondary
to slight nausea over past week. ___ fevers, chills. He
reports that he also normally he gets his medications pre
pacakaged by ___ pharmacy, but a week ago this stopped for
a few days and he was "eyeballing" his meds, and as a result
probably took more Lasix and metformin than he was supposed to.
He denies any change in his urinary habits however. He reports
not checking weights daily despite his history of CHF, and
reports a weight of ___ lbs. Weight (bed) 183 today.
Patient denies fevers/chills, night sweats, headache, vision
changes, dizziness/lightheadedness, weakness/numbnesss,
shortness
of breath, cough, hemoptysis, chest pain, palpitations,
abdominal
pain, nausea/vomiting, diarrhea, hematemesis,
hematochezia/melena, dysuria, hematuria, and new rashes.
Past Medical History:
PAST ONCOLOGIC HISTORY (Per OMR, reviewed):
-Presented to ___ with anemia
and was found to have a large, nearly obstructing mass in the
cecum. Biopsy confirmed invasive adenocarcinoma and the patient
was transferred to ___ for further management. CEA on ___
was 11.4 and on ___ was 7.9. CT torso showed no evidence of
metastatic disease.
-Taken to the OR on ___ where he underwent exploratory
laparotomy, extended right colectomy, debridement and
resection of abdominal wall and placement of fiducials.
Pathology
revealed poorly differentiated adenocarcinoma, consistent with
___ colonic adenocarcinoma. The tumor penetrated the
visceral peritoneum, consistent with T4 lesion. There were tumor
deposit(s) in the subserosa or ___ pericolic or
perirectal tissues without regional lymph node metastasis ___
lymph nodes), consistent with stage N1c. There was intramural
lymphovascular invasion and focal perineural invasion, but no
large vessel invasion. There was loss of nuclear expression of
MLH1 and PMS2; there was focal weak expression of MSH6 and
intact
expression of MSH2. Margins were negative, but the distance of
tumor from the radial margin was 58 mm.
-Given his T4a disease and concern for abdominal wall margin,
Mr.
___ has met with Dr. ___ Radiation ___ and
started stereotactic body radiation on ___. During his second
Cyberknife session, he developed dyspnea/orthopnea and was
transferred to the ED where he was treated for CHF exacerbation.
After diuresis and BP control, he felt better and signed out
AMA.
He did not show up to his follow up Cyberknife appointment, but
he returned a few weeks later and completed his Cyberknife
treatment on ___.
-He received C1D1 adjuvant FOLFOX on ___ but was unable to
have further chemotherapy due to ___ and cytopenias.
-CT torso on ___ showed interval increase size in a
peripherally enhancing necrotic mass within the right
anterolateral abdominal wall raising concern for tumor
recurrence, and new hepatic lesion concerning for metastasis.
-He started palliative pembrolizumab C1D1 on ___.
___: C2D1 pembrolizumab
___: C3D1 pembrolizumab
-___: CT torso:
1.Interval increase in size of the 1.5 cm segment 5 metastatic
liver lesion since ___, now measuring 2.2 x 2.2 x 2.8
cm. 2. Interval increase in size of the right anterolateral
abdominal wall 6.0 cm peripherally enhancing necrotic mass
since
___, now measuring 6.7 x 3.1 x 5.5 cm.
-___: pembrolizumab held due to ___
PAST MEDICAL HISTORY (Per OMR, reviewed):
- Coronary artery disease
- Ischemic cardiomyopathy, EF 35%
- History of left ventricular clot, previously on Apixaban
- Diabetes mellitus
- Hypertension
- Dyslipidemia
- Hepatitis C carrier
- Borderline personality disorder
- Anemia
- Fibromyalgia
- s/p Tonsillectomy
Social History:
___
Family History:
from WebOMR, confirmed with patient
Grandmother: lung cancer. Family history unclear
Physical Exam:
===ADMISSION PHYSICAL EXAM===
VS: 98.1 ___ 20 99 Ra
GENERAL: well appearingappearing gentleman
HEENT: Anicteric, PERLL, Mucous membranes wet, OP clear.
CARDIAC: Regular rate and rhythm, normal heart sounds, ___
systolic murmuer LUSB. No HJR, no JVP elevation, no peripheral
edema
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: non distended, slight firmness LLQ, surgical scar over
umbilicus, no tenderness
EXT: Warm, well perfused. No lower extremity edema. No erythema
or tenderness.
NEURO: A&Ox3, good attention and linear thought, CN ___
intact. Strength full throughout. Sensation to light touch
intact.
SKIN: No significant rashes.
===DISCHARGE PHYSICAL EXAM===
VS: 97.8PO 137 / 78 66 18 98 Ra
GENERAL: NAD
HEENT: Anicteric, MMM
CARDIAC: RRR nl S1S2 no m/r/g; no JVD
LUNG: CTAB
ABD: soft, nt/nd
EXT: Warm, well perfused.
NEURO: A&Ox3, no focal deficits
SKIN: No significant rashes.
Pertinent Results:
===ADMISSION LABS===
___ 10:05AM BLOOD ___
___ Plt ___
___ 01:44AM BLOOD ___
___ Im ___
___
___ 01:44AM BLOOD ___ ___
___ 01:44AM BLOOD ___ 10:05AM BLOOD ___
___
___ 10:05AM BLOOD ___
___ 01:44AM BLOOD ___
___ 01:44AM BLOOD ___
___ 01:10PM BLOOD ___
___ 10:05AM BLOOD ___
___
___ 01:44AM BLOOD ___
___ 10:05AM BLOOD ___
___ 01:10PM BLOOD ___
___ 01:58AM BLOOD ___
===MICRO===
___ URINE URINE ___ EMERGENCY WARD
===STUDIES===
___ Imaging RENAL U.S.
No evidence of renal vein thrombosis or hydronephrosis
___ Imaging RENAL U.S.
No hydronephrosis or definite stones.
___ Imaging CHEST (PA & LAT)
No pneumonia.
TTE (___):
LVEF 25%. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is severe regional left
ventricular systolic dysfunction with mid to distal septal,
anterior, lateral and apical akinesis. No masses or thrombi are
seen in the left ventricle. 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. Trivial mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
===DISCHARGE LABS===
___ 06:25AM BLOOD ___
___ Plt ___
___ 06:25AM BLOOD Plt ___
___ 06:25AM BLOOD ___
___
___ 06:25AM BLOOD ___
___ 08:48AM BLOOD HCV ___
Brief Hospital Course:
Mr. ___ is a ___ ___ gentleman with a history of iCMP (EF
35%, stable 3VD) and stage IIIb colonic adenocarcinoma with
microsatellite instability s/p C1 FOLFOX not tolerated ___
thrombocytopenia, s/p CK, s/p 3 cycles of palliative intent
pembrolizumab with progression of disease who was found to have
elevated creatinine prior to C4 of pembrolizumab.
#Acute on Chronic Kidney Injury
#Acute tubular necrosis: Baseline Creatinine ___. Creatinine
upon admission 4.4, which was presumed to be prerenal in setting
of poor PO and taking medications incorrectly (taking extra
Lasix, lisinopril, and metformin). Contrast nephropathy may have
contributed, as well, given staging CT on ___. Renal ultrasound
without evidence of obstruction or thrombus. Urine sediment with
hyaline and granular casts, but no evidence of a
glomerulonephritis (nephritis is a possible pembro toxicity).
Renal function improved with cautious IV fluids and holding
nephrotoxins. Renally cleared meds were held, including
apixaban, oxycodone, oral hypoglycemic.
Nephrology was consulted, who agreed with the above. At the time
of discharge creatinine was 2.0. It was felt that ___ was due to
patient surreptiously taking extra Lasix after his ___ caremark
stopped bubble packing his medications for a few days.
#Ischemic Cardiomyopathy
#Chronic Systolic Heart Failure. Patient with dyspnea/orthopnea
in past after ___ cyberknife session and was treated for HF
exacerbation in past. ___ be etiology of ___. ___ ECHO
showed Normal LV cavity size with EF 32%. TTE here with EF of
25%. Home Lasix and ACEi were held in setting of ___. Continued
home atorvastatin and coreg. Lasix and ___ were held at d/c to
be resumed after ___ if creatinine normalizes.
___ chronic pain: Localized to abdomen at this time.
oxycodone converted to hydromorphone equivalent
#Type II Diabetes Mellitus: Held metformin, repaglinide; Lispro
sliding scale while in house
#Advanced MSI Colonic Adenocarcinoma: Did not tolerate FOLFOX
given cytopenias. s/p CK. Has progressed on pembrolizumab, which
was held during hospitalization. Further plans per outpatient
oncology.
# Hx LV thrombus: Notes document that patient was on apixaban in
past for LV thrombus, but no recent documentation. On review of
___ records, it appears that patient was on
apixaban in past for LV thrombus in setting of reduced EF from
ischemic CM. He then had redemonstrated LV thrombus in ___
during ___ admission, and was restarted on apixaban,
and had ___ ECHO that showed persistent thrombus. While in
house Echo shoed no thrombus (but sensitivity of TTe for LV
thrombus ___ %). However, given patient's difficulty with
proper adherence to medications and reason for admission
(surreptious use of Lasix) decision was made to hold apixaban on
discharge, and follow up with his cardiologist Dr. ___
consideration of resuming anticoagulation. His PCP and
oncologist were made aware of decision to hold anticoagulation.
ECHO FINDINGS ___:
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is severe regional left
ventricular systolic dysfunction with mid to distal septal,
anterior, lateral and apical akinesis. No masses or thrombi are
seen in the left ventricle. 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. Trivial mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
# Anxiety: continued home sertraline, clonazepam
TRANSITIONAL ISSUES:
=====================
-Stopped home metformin after discussion with PCP - ___ hold
indefinitely due to labile creatinine
-Held home Lasix and Lisinopril due to ___ from Lasix overdose
above. Patient to have repeat creatinine and labs checked on
___ - if creatinine at baseline resume home Lasix and
Lisinopril (Creatinine 2.0 on discharge)
-Patient to follow up with cardiology regarding decision for
anticoagulation for LV thrombus. Anticoagulation held on
discharge given no LV thrombus seen on echo in house. (ECHO
results above)
-Patient to follow up with oncology on ___ for resumption
pembrolizumub
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain -
Moderate
2. ClonazePAM 1 mg PO BID
3. Sertraline 50 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Repaglinide 0.5 mg PO TIDAC
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Lisinopril 5 mg PO DAILY
8. Furosemide 40 mg PO DAILY
9. Apixaban 5 mg PO BID
10. Carvedilol 12.5 mg PO BID
11. Atorvastatin 40 mg PO QPM
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Carvedilol 12.5 mg PO BID
4. ClonazePAM 1 mg PO BID
5. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain -
Moderate
6. Repaglinide 0.5 mg PO TIDAC
7. Sertraline 50 mg PO DAILY
8. HELD- Apixaban 5 mg PO BID This medication was held. Do not
restart Apixaban until you see your doctor
9. HELD- Furosemide 40 mg PO DAILY This medication was held. Do
not restart Furosemide until you see your doctor this ___ to
recheck your kidney function
10. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do
not restart Lisinopril until you see your doctor this ___ to
recheck your kidney function
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
#Acute on Chronic Kidney Injury
#Acute tubular necrosis
Secondary Diagnoses:
#Ischemic Cardiomyopathy
#Chronic Systolic Heart Failure
___ chronic pain
#Type II Diabetes Mellitus
#Advanced MSI Colonic Adenocarcinoma
#Hx LV thrombus
#Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___
because you had abnormal labs. Your doctors were concerned about
your kidney function. While you were here, we found that your
kidneys were temporarily damaged. We think that this damage was
caused by some of your medications (when they were not packaged
like they usually are). We monitored your kidney function very
closely, and it improved while you were here.
It will be very important that you continue taking your
medications exactly as prescribed. It is also very important
that you weigh yourself everyday. Call your doctor if you weight
changes by more than a lb in a day or 3 lbs in a week. It is
also VERY important you stop your home furosemide and
Lisinopril.
It was a pleasure caring for you,
Your ___ Care Team
Followup Instructions:
___
|
10194756-DS-12 | 10,194,756 | 24,976,083 | DS | 12 | 2183-03-17 00:00:00 | 2183-03-17 17:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
alcoholic hepatitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ y.o. M with EtOH cirrhosis (Childs ___
Class B, MELD 21) c/b hepatic encephalopathy, Grade 1 varices,
along with EtOH use disorder, dementia ___ EtOH use, h/o
hepatitis C (achieved SVR in ___ however detectable VL
recently), depression, anxiety, HTN, HLD, T2DM, obesity who
presents from outpatient At___ GI clinic for mild alcoholic
hepatitis.
On ___, pt saw his outpatient GI (Dr ___ who
recommended admission for elevated labs. Per Dr ___:
patient has had more profound decline in overall clinical status
including encephalopathy and abrupt increase of LFTs since last
lab check in ___. His hepatitis C PCR was elevated at 15 at
his GI appointment as well.
His last labs in ___ is as follows:
Tbili: 2.7, Dbili: 1.1, ALT: 70, AST: 111, AP: 148
Patient denies nausea, vomiting, abdominal pain, weight gain,
SOB.
___ ED Course
================
- In the ED, initial vitals were: T:97.7 HR:94 BP:115/65 RR:18
94% RA
- Exam was notable for: bilateral scleral icterus, clear breath
sounds, nontender abdomen, and no asterixis
- Labs were notable for:
WBC:5.5, Hgb: 14.8, Hct:43.8 Plt: 126
Na: 133, K: 4.6, Cl: 93, bicarb: 28, BUN: 12, Cr: 0.7, Gluc: 110
Ca: 9.2, Mg: 1.4, P: 3.2
ALT: 63, AST: 214, AP: 139, Tbili: 6.4, Dbili: 2.5, Lipase: 46.
___: 14.0, PTT: 30.6, INR: 1.3
Serum tox, Urine tox negative. Blood and Urine culture from ___
pending.
- Studies were notable for: Echogenic liver with poor
penetration, suboptimally assessed, may represent steatosis,
though more advanced forms of liver disease not excluded on the
basis of this appearance. Reassuringly, no ascites and no
stigmata of HCC on RUQ-US. Patient had a normal CXR.
- The patient was given: IV Magnesium Sulfate (4 gm)and PO
Lactulose 30 mL.
- Hepatology was consulted who recommended admission to floor,
CIWA score, full ID work up including BCx and UCx, nutritional
consult, and SW consult. No recommendation to start steroid
given
a low DF score of 15.
___ Medicine Floor
====================
On arrival to the floor, patient was AOx 1 (thought he was in
___, year ___. He could not remember how he got to the
hospital, but states he was sent in by his PCP regarding
abnormal
labs. He currently states he is not in any pain and abdomen is
not distended compared to baseline. Denies any nausea, vomiting,
abd pain.
After discussing with his father, pt normally knows what day of
the week it is, but his mental status "varies." The father had
last seen pt ___ days ago and does not see him on a daily basis.
We spoke with his brother who was present during his outpt visit
today, who said pt normally does not know place or time and is
normally AOx1; however agrees with his father and says pt
sometimes has "better days where he knows where he is, what he's
doing"; he also notes pt lives alone, father is primary
caretaker
and they have been concerned pt is not taking his meds. Per his
father, pt does not have visiting nurse; previously had one, but
pt became "belligerent" and refuses to let them assist.
Last drink: On ___, pt had 4 full glasses of wine.
Since then, he strongly denies any further EtOH use; however,
his
brother states pt's last drink was ~2 days ago. He denies any
prior h/o ICU admissions for EtOH withdrawal or seizures. His
father states he is not aware of how much the pt drinks, as pt
does this discreetly; however, he continues to see that the pt's
house is littered with bottles of alcohol when he visits.
REVIEW OF SYSTEMS: Per HPI, otherwise, 10-point review of
systems
was within normal limits.
Past Medical History:
-EtOH cirrhosis c/b hepatic encephalopathy, Grade 1 varices
-EtOH use disorder
-Dementia ___ EtOH use
-h/o hepatitis C (achieved SVR in ___
-Hemachromatosis ___ carrier
-Depression, Anxiety
-HTN
-HLD
-T2DM, diet controlled
-Obesity
-Hypothyroidism
Social History:
___
Family History:
Mother - breast cancer
Father - CAD/PVD. No h/o MI
Sister - ___ artery stenosis. Possible stroke in late ___,
died at ___.
No family h/o liver disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
97.9F, 146/72, HR 84, RR 16, SpO2 98% RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: Pupils reactive to light. Sclera jaundiced. MMM.
NECK: No JVD.
CARDIAC: RRR, nml s1 s2, no mrg.
LUNGS: Diminished RLL breath sounds, otherwise CTA.
ABDOMEN: Soft, nd, nt.
EXTREMITIES: Warm, no ___.
SKIN: No rashes or lesions.
NEUROLOGIC: AOx1 (as above). No focal neurologic deficits. No
asterixis on exam.
DISCHARGE PHYSICAL EXAM:
========================
VS: 24 HR Data (last updated ___ @ 1645)
Temp: 98.3 (Tm 98.3), BP: 115/54 (115-125/54-81), HR: 88
(74-92), RR: 18 (___), O2 sat: 92% (92-96), O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: Pupils reactive to light. Sclera jaundiced. MMM.
NECK: No JVD.
CARDIAC: RRR, nml s1 s2, no mrg.
LUNGS: CTAB, no wheezes/rales/rhonchi
ABDOMEN: Soft, NTND
EXTREMITIES: Warm, no ___.
SKIN: Jaundiced. No rashes or lesions.
NEUROLOGIC: AOx3 (person, place, month/day of week/year). No
focal neurologic deficits. No asterixis on exam.
Pertinent Results:
ADMISSION LABS:
===============
___ 01:25PM BLOOD WBC-5.5 RBC-4.30* Hgb-14.8 Hct-43.8
MCV-102* MCH-34.4* MCHC-33.8 RDW-14.7 RDWSD-55.3* Plt ___
___ 01:25PM BLOOD Neuts-63.1 ___ Monos-13.2*
Eos-0.7* Baso-0.7 Im ___ AbsNeut-3.47 AbsLymp-1.20
AbsMono-0.73 AbsEos-0.04 AbsBaso-0.04
___ 01:25PM BLOOD Plt ___
___ 01:25PM BLOOD Glucose-110* UreaN-12 Creat-0.7 Na-133*
K-4.6 Cl-93* HCO3-28 AnGap-12
___ 01:25PM BLOOD ALT-63* AST-214* AlkPhos-139*
TotBili-6.4* DirBili-2.5* IndBili-3.9
___ 01:25PM BLOOD Lipase-46
___ 01:25PM BLOOD Albumin-3.4* Calcium-9.2 Phos-3.2 Mg-1.4*
___:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
DISCHARGE LABS:
===============
___ 06:25AM BLOOD WBC-4.6 RBC-3.98* Hgb-13.5* Hct-41.4
MCV-104* MCH-33.9* MCHC-32.6 RDW-14.6 RDWSD-56.8* Plt ___
___ 06:25AM BLOOD ___ PTT-31.4 ___
___ 06:25AM BLOOD Glucose-106* UreaN-17 Creat-0.9 Na-137
K-4.5 Cl-98 HCO3-26 AnGap-13
___ 06:25AM BLOOD ALT-46* AST-147* AlkPhos-160*
TotBili-5.4*
___ 06:25AM BLOOD Calcium-9.0 Phos-4.0 Mg-1.8
MICROBIOLOGY:
=============
__________________________________________________________
___ 5:06 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 1:13 pm URINE SOURCE: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
IMAGING:
========
RUQUS (___)
1. Echogenic liver with poor penetration, suboptimally
assessed, may
represent steatosis, though more advanced forms of liver disease
not excluded
on the basis of this appearance.
2. Cholelithiasis without evidence of cholecystitis.
3. Main portal vein patent with hepatopetal flow.
4. Mild splenomegaly.
2-view CXR (___)
No acute intrathoracic process. Elevated right hemidiaphragm.
Brief Hospital Course:
SUMMARY:
========
___ y.o. M with EtOH cirrhosis (___ Class B, MELD 21) c/b
hepatic encephalopathy, Grade 1 varices, along with EtOH use
disorder, dementia ___ EtOH use, h/o hepatitis C (achieved SVR
in ___, depression, anxiety, HTN, HLD, T2DM, obesity who
presents from outpatient ___ for mild alcoholic
hepatitis - managed conservatively which was resolving on
discharge.
TRANSITIONAL ISSUES:
====================
[] HCV VL <15 but detectable on ___ - please follow up and
treat as needed.
[] Will benefit from ongoing support in trying to remain
abstinent from alcohol;
[] He was sent home with a script for glucerna shakes given
concerns about poor overall nutritional intake. Please renew
prescription as appropriate.
[] Per the patient's brother, guardianship is pending. We had an
extensive discussion with the patient who demonstrated intact
basic safety understanding (e.g. what to do in case of a fire,
what to do in case of injury or new onset bleeding), such that
we felt he was safe to return home without 24 hour supervision
(family is very close by, but he lives alone).
ACUTE ISSUES:
=============
#Alcoholic hepatitis
Pt presented with abnormal labs with AST of 214 and ALT of 63 ___s elevated Tbili to 6.4 consistent with acute on chronic
alcoholic hepatitis. Less likely acute viral hepatitis as would
expect elevation of LFTs into 1000s. Utox and serum tox without
evidence of drug ingestions. RUQUS with no evidence of
obstruction or congestion. Seen by Hepatology in the ED who
recommended against steroids as MDF 15. Was managed
conservatively with LFTs downtrending to AST 147, ALT 46 and
Tbili 5.4.
#Alcohol use disorder
Per family's report pt with a history of heavy alcohol use with
last drink per patient on ___, but per family 2 days
prior to admission. He was monitored on CIWA with no evidence of
withdrawal. He reported being motivated to abstain from alcohol
on discharge home. SW evaluated patient to offer resources to
help support his sobriety but patient declined any social
supports or medications.
#Alcoholic cirrhosis (Childs Class B, MELD 21)
Hx of alcoholic cirrhosis c/b hepatic encephalopathy and grade I
varices.
-Volume: no evidence of volume overload during admission, not on
home diuretics
-Infection: no evidence of infection on admission
-Bleeding: last EGD ___ showed Grade I varices in lower third
of esophagus, no evidence of acute bleeding. continued home
nadolol
-Encephalopathy: continued on home lactulose TID and rifaximin
550mg BID
-Screening: Last EGD as above. RUQUS with no suspicious masses
on admission poor candidate due to recent active alcohol use,
currently not listed
# Alcohol-induced dementia: presented with acute-on-chronic
encephalopathy in setting of recent alcohol-use relapse and
acute alcoholic hepatitis. Mental status normalized during
hospitalization. He had intact basic safety awareness and was
oriented to person, place, and time on the day of discharge. He
is independent in ADLs, but is not independent with some IADLs,
which his father and siblings help him with.
[] Per the patient's brother, guardianship is pending. We had an
extensive discussion with the patient who demonstrated intact
basic safety understanding (e.g. what to do in case of a fire,
what to do in case of injury or new onset bleeding), such that
we felt he was safe to return home without 24 hour supervision
(family is very close by, but he lives alone).
#Hepatitis C
Genotype 2B. Previously in SVR s/p ribavirin and sofosbuvir but
PCR viral quant detectable at <15 on ___.
CHRONIC/STABLE ISSUES:
======================
#HTN
-Continued home Lisinopril 10 mg PO DAILY
#HLD
-Continued home Pravastatin 80 mg PO QPM
#Depression, Anxiety
-Continued home FLUoxetine 80 mg PO DAILY
#T2DM
Per Atrius records this is diet-controlled. Maintained on HISS
as needed.
# CODE: Full Code (discussed w/ patient)
# CONTACT: ___ (father) - ___, ___
(brother) - ___
.
.
.
.
Time in care: >30 minutes in discharge related activities on the
day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lactulose 15 mL PO TID hepatic encephalopathy
2. Lisinopril 10 mg PO DAILY
3. rifAXIMin 550 mg PO BID
4. FLUoxetine 80 mg PO DAILY
5. Nadolol 20 mg PO DAILY
6. Pravastatin 80 mg PO QPM
7. FoLIC Acid 1 mg PO DAILY
8. Thiamine 100 mg PO DAILY
9. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral DAILY
10. econazole 1 % topical BID
Discharge Medications:
1. Glucerna 1.5 Cal (nut.tx.gluc.intol,lac-free,soy) 1 bottle
oral TID W/MEALS
RX *nut.tx.gluc.intol,lac-free,soy [Glucerna 1.5 Cal] 1 bottle
by mouth three times daily with meals Refills:*0
2. Thiamine 500 mg PO TID Duration: 2 Days
Please then take 200mg daily for 5 days, then resume 100mg daily
subsequently
RX *thiamine HCl (vitamin B1) 250 mg ___ tablet(s) by mouth once
a day Disp #*10 Tablet Refills:*0
3. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral DAILY
4. econazole 1 % topical BID
5. FLUoxetine 80 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Lactulose 15 mL PO TID hepatic encephalopathy
8. Lisinopril 10 mg PO DAILY
9. Nadolol 20 mg PO DAILY
10. Pravastatin 80 mg PO QPM
11. rifAXIMin 550 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Alcoholic hepatitis
SECONDARY DIAGNOSES:
====================
Alcohol use disorder
Alcoholic cirrhosis
Hepatitis C
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
- You were admitted to the hospital from your liver doctor's
office for bloodwork showing evidence of worsening liver injury.
WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL?
- You were diagnosed with alcoholic hepatitis - which is
inflammation of your liver due to injury from drinking alcohol.
- You were monitored closely and your liver function tests
improved.
- You were seen by a nutritionist who recommends that you drink
___ Glucerna shakes with each meal for nutritional
supplementation - this will help you to get better faster
- You were seen by a social worker to offer you supports to
ensure that you abstain from alcohol use - you were not
interested in any additional medications or supports to help you
with this.
- You improved and were ready to go home. You should have close
follow-up with your liver doctor to make sure that you are
continuing to improve.
WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL?
- Continue to take all your medicines as prescribed below.
- Continue to abstain from alcohol to help ensure that your
liver injury does not worsen and continues to improve.
- If you have any fevers/chills, chest pain, trouble breathing,
abdominal pain, nausea/vomiting, blood in your vomit or bowel
movements, black or tarry stools, or any other symptoms that
concern you please seek medical care.
- Show up to your appointments as listed below.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10194804-DS-13 | 10,194,804 | 28,431,878 | DS | 13 | 2141-03-22 00:00:00 | 2141-03-23 19:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Erythromycin Base / Phenothiazines / codeine / Benadryl
Attending: ___.
Chief Complaint:
R-sided numbness and urinary problems
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
___ is a ___ LEFT-handed woman with past
medical history of recurrent neurologic events of unclear
etiology as well as significant anxiety and depression with
prior
suicide event, who presents today for evaluation of R lower
hemithorax and leg numbness of 1 week and urinary complaints.
She
noted this coming on fairly quickly but not suddenly, and
without
an apparent trigger. She has a band-like sensation around her
lower chest on R. She characterizes the bladder problem as a few
episodes inability to hold the urine with large-volume
incontinence. Although some of these occurred without warning,
at
other times she can sort of feel when her bladder is filling
"but
only on the left side", and she has also noticed difficulty
emptying her bladder. She had one small accident involving stool
but has also recently changed her diet and had some looser
stools. She has felt cold, and experienced chills over the last
week too. She does admit to a lot of stress currently due to law
school finals and a recent breakup. She recently re-established
care with a psychotherapist (Dr. ___ at ___.
The right-sided symptoms and bladder problems are new for the pt
but she has had transient neurological problems before. In ___,
she developed a period of a couple of weeks of great fatigue,
then blurred vision and decreased visual acuity, followed by
decreased sensation and strength in the entire left side of the
body (face, arm, leg). During this time, she had difficulty
attending school, and also lost about 50 lbs but is not sure
why.
The strength recovered gradually over a couple of years with the
help of OT & ___ but the numbness has persisted, and she
continues
to have episodes of L hand tremor. She also continues to have
problems with her peripheral vision. An MRI brain reportedly
showed "MS" but a spinal tap was "clear". She was later told by
another physician that she does not have MS but could have
chronic Lyme disease. She is not sure if she was ever tested for
Lyme. She recalls having target rashes a few times as a child
growing up in ___. She certainly has never been treated for
either CNS Lyme or multiple sclerosis. She was also told that
she
should see a psychiatrist to treat her problems but felt that
this was dismissing her physical complaints. She recently saw
Dr.
___ in neurology clinic for a first consultation.
Other neurological symptoms include at least monthly migraines
that are preceded by black lines in her vision, frequent
episodes
of vertigo, and L-sided sensorineural hearing loss and tinnitus
of long standing.
Nil else on neurological ROS.
On general ROS,
+ palpitations with anxiety
no fevers/rigors/night sweats but has had chills; endorses
recent
anorexia; no chest pain/dyspnea/exercise intolerance/cough; no
nausea/vomiting/diarrhea/abdominal pain/melena/hematochezia; no
dysuria/hematuria; no myalgias/arthralgias
Past Medical History:
- HTN
- Unclear neurologic diagnosis, as above
- Migraine w/aura
- L SN hearing loss
- GERD
- depression, with 2 psychiatric hospitalizations, 1 after a
suicide attempt with pills after miscarriage and in the middle
of a divorce
- anxiety
No PSH
She is G4P1 (1 miscarriage, 2 abortions)
Social History:
___
Family History:
Children: son healthy
___: sister died of complications of lupus
Parents: mom with migraines (and several of her relatives with
the same); father ___ (and several of his relatives
with the same)
Grandparents: MGM w/migraines; PGF w/RA
Also positive for heart disease, diabetes, depression
Physical Exam:
#####Admission Physical Exam#####
VS T:99.5 HR:65 BP:135/86 RR:16 SaO2:100%RA
General: NAD but tearful
- Head: NC/AT, no conjunctival injection or icterus, no
oropharyngeal lesions
- Fundoscopy: discs flat with crisp disc margins (no
papilledema), normal color. I cannot appreciate temporal pallor.
Spontaneous venous pulsations are present. Arteries & veins
normal without arteriolar narrowing or venous engorgement, no
crossing changes observed.
- Neck: Supple, no nuchal rigidity. No lymphadenopathy; thyroid
palpable
- Cardiovascular: carotids with normal volume & upstroke; RRR,
no
M/R/G
- Respiratory: Nonlabored, clear to auscultation with good air
movement bilaterally
- Abdomen: nondistended, normal bowel sounds, no
tenderness/rigidity/guarding
- Extremities: Warm, no cyanosis/clubbing/edema, palpable
radial/dorsalis pedis pulses. No synovitis of
elbows/wrists/fingers.
- Back: no tenderness to percussion of spine or CV angles
- Rectal: intact anal wink and good rectal tone. Brown stool and
no masses in vault
- Skin was without rash, induration or neurocutaneous stigmata.
Intact hair, nails and nail folds.
Neurologic Examination:
Mental Status:
Awake, alert
- Appearance: Good grooming and hygiene.
- Behavior: generally interactive and cooperative with good eye
contact
- Attention: Recalls a coherent history and converses
appropriately. No neglect to visual or sensory double
stimulation. Concentration maintained when recalling months
backwards.
- Orientation: Oriented to self, location, date and
circumstances
- Mood/Affect: tearful, restricted in the dysthymic range
- Speech: no dysarthria; normal prosody; normal volume, rate,
turn taking, and duration of utterances
- Language: Fluent speech and good comprehension. No
paraphasias.
Follows two-step commands, midline and appendicular and crossing
the midline. High- and low-frequency naming intact. Intact
repetition.
- Thought Process: Logical and goal directed. No loosening of
associations. No apparent disorganization.
- Memory: Easily registers ___ objects and recalls ___ at 2
minutes, improving to ___ with cueing
- Praxis: No ideomotor apraxia or neglect w/o bodypart-as-object
or spacing errors.
Cranial Nerves:
[II] Pupils: equal in size and briskly reactive to light. No
RAPD.
Visual fields testing demonstrates "tunnel vision" - peripheral
vision loss that does not improve with distance from examiner
[III, IV, VI] The eyes are well aligned. EOM intact w/o
pathologic nystagmus. Horizontal and vertical saccades accurate
and symmetric, with no evidence of INO.
[V] V1-V3 with symmetrical sensation to light touch. Pterygoids
contract normally.
[VII] No facial asymmetry at rest and with voluntary activation.
[VIII] L decreased hearing
- Head thrust maneuver w/o corrective saccade.
[IX, X] Palate elevates in the midline.
[XI] Neck rotation normal and symmetric. Shoulder shrug strong.
[XII] Tongue shows no atrophy, emerges in midline and moves
easily.
Motor:
No pronation or drift. No tremor, asterixis or other abnormal
movements.
Bulk: normal
Tone: normal
Strength: full in all extremities, proximally & distally, in
flexors & extensors, although there is give-way in the R IP,
quad, hamstring.
Sensory:
Intact proprioception at hallux on L, completely unable to tell
on R.
Mid-thoracic sensory level in front & back on R, with decreased
sensation in entire R leg apart from sole
Cortical sensation: No extinction to double simultaneous
stimulation. Graphesthesia intact.
Reflexes
[Bic] [Tri] [___] [Pat] [Ach]
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response flexor bilaterally. Appears to have decreased
abdominal reflexes on R (and on L, pt endorses feeling a pull in
her abdominal muscles).
Coordination: No rebound. No dysmetria on finger-to-nose and
heel-knee-shin testing. Forearm orbiting symmetric.
Gait& station: falls backwards on Romberg testing but is much
steadier when distracted. Able to ambulate with hesitant steps
#####Discharge Exam####
MS: AOx3, appropriate. Anxious
CN: Intact
Motor: Full strength.
Sensation: Decreased sensation to pinprick on whole torso to
approximately level of T4 (breasts). R>L sensory loss. Also
reports decreased pinprick on R ___.
Reflexes: 2 and symmetric b/l
Gait: Stable. Narrow based, normal strides.
Pertinent Results:
___ 01:55PM BLOOD WBC-9.0 RBC-4.96 Hgb-14.8 Hct-45.7 MCV-92
MCH-29.9 MCHC-32.4 RDW-13.8 Plt ___
___ 01:55PM BLOOD Neuts-75.1* Lymphs-17.4* Monos-5.3
Eos-2.1 Baso-0.1
___ 01:55PM BLOOD Glucose-96 UreaN-12 Creat-0.7 Na-140
K-4.4 Cl-104 HCO3-27 AnGap-13
___ 01:55PM BLOOD cTropnT-<0.01
___ 01:55PM BLOOD Calcium-10.0 Phos-3.1 Mg-2.0
___ 01:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 01:55PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 01:55PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
MRI Brain/C-Spine/T-Spine ___: IMPRESSION:
1. Multiple foci of white matter FLAIR hyperintense signal of
the subcortical and periventricular as well as pontine white
matter in a distribution
compatible with demyelinating process such as multiple
sclerosis. There are no intracranial enhancing lesions to
suggest active demyelinating plaque,
assessment somewhat limited due to significant pulsation
artifacts.
No evidence of acute infarct.
2. T2 hyperintense mildly enhancing foci at the left aspect of
the cervical cord at C6-7 ___s of the anterior thoracic
cord at T10-11, suggesting active demyelinating process.
Additional T2 nonenhancing hyperintense lesion at the C3 level.
3. Multilevel mild cervical spondylosis as described above with
foraminal
narrowing at C4-5, C5-6 levels.
Brief Hospital Course:
# R sided numbness and urinary complaints
- Ms. ___ was admitted to neurology. Metabolic, infectious and
toxic evaluation did not reveal any significant abnormalities.
Her neurologic exam showed sensory changes in the right trunk
and leg, but there was also functional overlay on admission.
She underwent Brain and C-spine MRI which revealed evidence of
lesions suggestive of a demyelinating disease, including 2
active, enhancing lesions at c6-7 and t10-11. Her sensory
changes are more likely to be explained by the T10-11 lesion,
although not completely. Overall, her findings are suggestive of
an acute flare of a new Multiple Sclerosis diagnosis. She
underwent Lumbar puncture in ___ (after unsuccessful attempt on
floor), which revealed mild WBC elevation of 6 and 10, but was
otherwise benign.
She was felt to have likely Multiple sclerosis and was started
on high dose steroids: Methylprednisone 1g x5 days. Though she
continued to have sensory symptoms, she was otherwise doing
well, ambulatory and felt to be safe for discharge.
Outpatient appointment arranged with Dr. ___ outpatient
MS management. Notably, on the day of discharge, ___ CSF
cultures was growing a single colony of gram positive Cocci.
This was felt to be a contaminant as neither her clinical
picture, symptoms or other objective labs support an infectious
meningeal process. However, Ms. ___ was informed of this
Positive CSF culture prior to discharge and was counseled by the
provider for concerning symptoms including headache, confusion
or neck stiffness.
# Psychiatry
- Ms. ___ has an extensive history of anxiety and depression.
While in the hospital, she demonstrated this significantly and
was very stressed about the entire hospitalization. She
endorsed poor social support. Given clinical concern, she
briefly had a 1:1 sitter, though she never endorsed SI.
However, this was discontinued after being evaluated by
psychiatry. She was started on Citalopram 20mg PO QD during
this admission. Her outpatient PCP ___ was
contacted and agreed to manage her Citalopram. She agreed to
continue to see her psychotherapist on an outpt basis.
Medications on Admission:
1. Ibuprofen 600 mg PO Q8H:PRN pain
2. eletriptan HBr 20 mg oral as needed for Migraine
Discharge Medications:
1. Ibuprofen 600 mg PO Q8H:PRN pain
2. eletriptan HBr 20 mg oral Daily Migraine
Please take this medication at the dosage prescribed by your
doctor and only as they direct.
3. Outpatient Physical Therapy
Please evaluate and treat any gait instability.
4. Citalopram 20 mg PO DAILY
RX *citalopram 20 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*2
ICD-9 Multiple Sclerosis: 340
Discharge Disposition:
Home
Discharge Diagnosis:
1) Demyelinating Disease- New Diagnosis of Multiple Sclerosis
2) MS flare with sensory symptoms.
Discharge Condition:
Mental Status: Clear, coherent, sad affect.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were hospitalized with 1 week of right sided sensory change
and urinary incontinence. While in the hospital, you were on
the neurology service. To further clarify your symptoms, you
underwent an MRI of the Brain and the upper spine which revealed
evidence of "Demyelinating disease", most likely multiple
sclerosis. Based on the MRI image, there was evidence of an
"acute flare" causing your symptoms as well as evidence of
older, more chronic lesions.
You then underwent a Lumbar Puncture (spinal tap) for evaluation
of the protein in your spinal fluid. This labwork was still
pending at the time of your discharge.
You received 5 days of IV steroids to help speed the resolution
of your symptoms. You were doing well and felt to be safe for
discharge home. However, it will be critical for you to
follow-up with Dr. ___ (a multiple sclerosis specialist) for
future treatment and management of your disease and symptoms.
Before leaving the hospital, your doctor's told you about a
likely contaminant in your spinal fluid. One of two of your
bacterial spinal fluid cultures was growing one colony of
bacteria. This is not consistent with your symptoms and your
doctors ___ not think you have a bacterial infection.
However, please monitor for neck stiffness, severe unusual
headache and confusion. If these symptoms occur, please call
your doctor or go to the emergency room.
Followup Instructions:
___
|
10194974-DS-5 | 10,194,974 | 28,046,822 | DS | 5 | 2201-04-24 00:00:00 | 2201-05-18 13:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Amoxicillin
Attending: ___.
Chief Complaint:
Fall down stairs
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ Critical is a ___ male who presents to ___
on ___ with a mild TBI. Pt was found down at the bottom of
a flight of stairs by neighbors. On EMS arrival he was
unresponsive but became combative in route to the hospital.
Neighbors reported that the patient appeared "intoxicated"
earlier in the day. On arrival to the ED he continued to be
combative, moving all extremities purposefully with good
strength, vocalizing but not following commands (GCS 8). He was
intubated for airway protection and to obtain imaging,
paralytics given at 13:45. CT head showed multiple facial
fractures, Bilat temporal contusions and right temporal bone fx.
Pt unable to contribute to hx. Sedation (Propofol and fentanyl)
held for exam at 14:45.
Past Medical History:
Bipolar disorder, opiate use disorder (on Suboxone maintenance),
alcohol use disorder, sedative/hypnotic use disorder
Social History:
___
Family History:
Father - bipolar disorder, alcoholism
Sister - ?suicide attempt
Physical Exam:
Admission Physical Exam:
HR: 100 BP: 135/78 Resp: 24 O(2)Sat: 86% on a nonrebreather
Low
Constitutional: He has a GCS of 8; he is in a c-collar
HEENT: Toes are 2 mm and sluggishly reactive. He has
bilateral large periorbital edema somas
Some blood in his nose
Chest: Clear to auscultation
Cardiovascular: Normal first and second heart sounds
Abdominal: No mass. No distention
GU/Flank: Right buttock abrasion otherwise the spine was
negative
Extr/Back: No obvious long bone findings
Skin: Warm and dry
Neuro: He seems to move to painful stimuli all 4 extremities
but this exam is limited
Psych: GCS of 8
Discharge Physical Exam:
VS: T: 98.3 PO BP: 146/92 HR: 101 RR: 18 O2: 95% Ra
GEN: A+Ox3, NAD
CV: RRR
PULM: No respiratory distress, breathing comfortably on room air
EXT: wwp
Pertinent Results:
IMAGING:
___: CXR:
OG tube terminates at the GE junction. Please note, the OG tube
is coiled in the pharynx as seen on CT of the cervical spine.
Repositioning is advised. ET tube positioned appropriately.
___: CT Head:
1. Hemorrhagic contusion with subarachnoid and small subdural
hemorrhage in the right inferior temporal lobe without
significant mass-effect.
2. Hemorrhagic contusion with adjacent subarachnoid hemorrhage
in the left inferior temporal lobe.
3. Multiple fractures, specifically involving the right
squamous temporal
bone, right frontal bone extending to the right orbital roof,
bilateral
sphenoid greater wing fractures and bilateral lamina papyracea
fractures
described in further detail on concurrently performed CT of the
facial bones.
___: CT Torso:
1. No acute sequelae of trauma.
2. Lower lung posterior opacities likely atelectasis and
sequelae of
aspiration.
3. OG tube terminates the GE junction and is coiled in the
pharynx as seen on concurrently performed CT cervical spine.
___: CT c-spine:
1. Orogastric tube coiled in the pharynx, recommend
repositioning.
2. No fracture or malalignment in the cervical spine.
___: CT Sinus/Mandible/Maxillofacial:
1. Multiple fractures as described above including: Right
frontal and
squamous temporal bone, bilateral greater wing of sphenoid,
bilateral
maxillary sinus, left lateral pterygoid plate, bilateral lamina
papyracea,
right nasal bone.
2. Bilateral extraconal orbital hematoma and gas with small
volume left
intraconal hematoma.
3. Bilateral orbital proptosis and significant preseptal
hematoma and soft tissue swelling.
4. OG tube coiled in the pharynx.
___: CT Head:
1. Small bilateral acute subdural hematomas: 1.0 cm hyperdense
extra-axial
collection in the right vertex with small amount of 2 mm
subdural hematoma
seen layering in the right parietal convexity, which is
increased in
prominence since the earlier same day exam. New left subdural
hematoma 0.6 cm
in width along the left convexity with more conspicuous 2-3 mm
subdural
component seen layering along the left parietal convexity as
compared to the
prior study.
2. Stable right hemorrhagic contusion with subarachnoid
hemorrhage and a 3 mm
subdural hemorrhage along the right temporal convexity
3. Left hemorrhagic contusion with adjacent subarachnoid
hemorrhage in the
left inferior temporal lobe appears slightly increased in size
since prior
exam.
4. Possible very subtle small amount of intraventricular
hemorrhage in the
bilateral posterior horns.
5. Unchanged appearance of multiple facial fractures including
right frontal,
squamous temporal, bilateral greater wing of the sphenoid,
bilateral maxillary
sinus, lateral left pterygoid plate, bilateral lamina papyracea,
and right
nasal bone which are better described on same day CT
maxillofacial study.
___: CT Head:
1. Multiple areas of subarachnoid, intraparenchymal, subdural
hemorrhage, and
intra-ventricular hemorrhage are not appreciably changed
compared to prior
exam performed 11 hours prior. No significant midline shift of
structures.
2. No evidence of infarction.
3. Extensive facial fractures, as detailed on prior CT
maxillofacial exam
performed ___.
___: Temporal Bone CT:
1. Right parietal, squamous temporal bone fractures.
2. Left spheno-temporal buttress fracture.
3. No fracture of petrous, mastoid segments or optic capsule.
4. Intracranial hemorrhage, similar.
5. Mild opacification left mastoid air cells, no adjacent
fracture.
___: CT Head:
1. Stable interval exam with multifocal sites of
intraparenchymal, subdural,
intraventricular and subarachnoid hemorrhage. No evidence of
interval large
territorial infarction. No midline shift.
2. Known extensive facial fractures are better evaluated on the
CT
maxillofacial dated ___
___: CT Head:
1. Stable intracranial hemorrhage.
2. No midline shift or herniation. No evidence of new
hemorrhage.
3. Extensive fractures, similar.
___: CXR:
No previous images. Cardiac silhouette is within normal limits
and there is
no vascular congestion, pleural effusion, or acute focal
pneumonia.
LABS:
___ 07:39PM ___ PO2-41* PCO2-50* PH-7.33* TOTAL
CO2-28 BASE XS-0
___ 07:39PM LACTATE-2.6*
___ 07:39PM freeCa-1.16
___ 07:33PM GLUCOSE-167* UREA N-10 CREAT-0.6 SODIUM-139
POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-22 ANION GAP-14
___ 07:33PM CALCIUM-8.2* PHOSPHATE-2.8 MAGNESIUM-1.6
___ 07:33PM WBC-10.4* RBC-3.79* HGB-11.3* HCT-34.4*
MCV-91 MCH-29.8 MCHC-32.8 RDW-13.7 RDWSD-44.9
___ 07:33PM NEUTS-78.8* LYMPHS-10.8* MONOS-6.6 EOS-3.3
BASOS-0.2 IM ___ AbsNeut-8.17* AbsLymp-1.12* AbsMono-0.68
AbsEos-0.34 AbsBaso-0.02
___ 07:33PM ___ PTT-27.0 ___
___ 07:33PM PLT COUNT-205
___ 02:42PM URINE bnzodzpn-POS* barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 02:42PM TYPE-ART RATES-/18 TIDAL VOL-480 PEEP-5
O2-100 PO2-450* PCO2-47* PH-7.38 TOTAL CO2-29 BASE XS-2
AADO2-210 REQ O2-44 INTUBATED-INTUBATED
___ 02:42PM LACTATE-2.0
___ 02:42PM O2 SAT-96
___ 02:42PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:42PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 01:45PM GLUCOSE-197* UREA N-11 CREAT-0.6 SODIUM-137
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-24 ANION GAP-10
___ 01:45PM ALT(SGPT)-15 AST(SGOT)-31 ALK PHOS-110 TOT
BILI-0.3
___ 01:45PM LIPASE-11
___ 01:45PM ALBUMIN-3.8
___ 01:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 01:45PM WBC-7.5 RBC-3.91* HGB-11.6* HCT-35.8* MCV-92
MCH-29.7 MCHC-32.4 RDW-13.5 RDWSD-45.3
___ 01:45PM NEUTS-51.3 ___ MONOS-8.0 EOS-6.0
BASOS-0.4 IM ___ AbsNeut-3.84 AbsLymp-2.55 AbsMono-0.60
AbsEos-0.45 AbsBaso-0.03
___ 01:45PM ___ PTT-23.7* ___
___ 01:45PM PLT COUNT-172
Brief Hospital Course:
Mr. ___ is a ___ y/o male who presented to the ___
on ___ with a mild TBI after he was found down at the
bottom of a flight of stairs by neighbors. On EMS arrival he was
unresponsive but became combative in route to the hospital. GCS
was 8 at the time of arrival. He was intubated for airway
protection. CT head showed multiple facial fractures, bilateral
temporal contusions and a right temporal bone fracture. He was
transferred to ___ for ventilator management and frequent
neurochecks.
Neurosurgery recommended a 7 day course of keppra and a repeat
head CT. He was ultimately diagnosed with a mild traumatic
brain injury and was enrolled in the TBI pathway.
Plastic Surgery evaluated the patient's facial fractures and
recommended ENT consult for evaluation of temporal bone
fracture. Plastic Surgery recommended sinus precautions. ENT
recommended a temporal bone CT and agreed with sinus precautions
x 1 week.
While in the ICU, mental status waxed and waned and he
experienced episodes of agitation. He was started on hypertonic
saline, and a left IJ CVL was placed (which was later removed
when it was no longer needed). Psychiatry was consulted for
assistance with psychopharmacology and made adjustments to his
home medications. He received prn IV Haldol for moderate
agitation in addition to Seroquel.
Ophthalmology saw the patient to complete a dilated fundus exam
which was unremarkable.
The patient had a doboff placed and was started on tube feeds
with Vital at 10cc. He was started on a multivitamin, thiamine,
and folate.
The patient was extubated in AM on ___. A Foley was placed
in the afternoon as patient was retaining urine and thought to
not tolerate multiple intermittent straight caths. Difficult
foley placement (x5 attempts); eventual success with a coude tip
catheter.
The patient was then transferred to the surgical floor for
further care. The patient's mental status improved and he was
cleared for a regular diet. The dobhoff was removed. He
continued to have periods of agitation where he wanted to leave
the hospital. He eloped and was brought back by nursing and
security. He had a veil bed and sitter. The primary medical
team continued to coordinate care with Psychiatry, case
management and social work to arrange for a safe discharge plan
for home. Discharge medications were filled at the bedside and
plan was for a case manager to meet with the patient at home
once he was discharged.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Buprenorphine-Naloxone Film (8mg-2mg) 1 FILM SL DAILY
2. Gabapentin 800 mg PO TID
3. QUEtiapine Fumarate 400 mg PO QHS
4. QUEtiapine Fumarate 50 mg PO BID:PRN anxiety
5. Atorvastatin 80 mg PO QPM
6. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6)
hours Disp #*56 Tablet Refills:*0
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
swish and spit
RX *chlorhexidine gluconate 0.12 % administer 15 mL for oral
intake twice a day Disp #*210 Milliliter Refills:*0
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*0
5. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals [Multi-Vitamin HP/Minerals] 1
tab-cap by mouth once a day Disp #*14 Capsule Refills:*0
6. Nicotine Patch 21 mg/day TD DAILY
RX *nicotine 21 mg/24 hour Apply patch to area of upper arm once
a day Disp #*14 Patch Refills:*0
7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
8. Ramelteon 8 mg PO QHS insomnia
RX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth at bedtime
Disp #*14 Tablet Refills:*0
9. Senna 8.6 mg PO BID:PRN constipation
10. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a
day Disp #*14 Tablet Refills:*0
11. Gabapentin 600 mg PO TID
RX *gabapentin 600 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*42 Tablet Refills:*0
12. QUEtiapine Fumarate 50 mg PO BID agitation
RX *quetiapine 50 mg 1 tablet(s) by mouth twice a day Disp #*28
Tablet Refills:*0
13. QUEtiapine Fumarate 300 mg PO QHS
RX *quetiapine 300 mg 1 tablet(s) by mouth at bedtime Disp #*14
Tablet Refills:*0
14. QUEtiapine Fumarate 50 mg PO BID
15. Atorvastatin 80 mg PO QPM
16. Buprenorphine-Naloxone Film (8mg-2mg) 1 FILM SL DAILY
Consider prescribing naloxone at discharge
17. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
-Right zygomatic process, right frontal bone with extension
through the orbital roof, posterolateral wall of the bilateral
orbits, bilateral lamina papyracea, and right temporal bone
-Traumatic brain injury: Bilateral temporal contusion
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital after a fall downstairs. You
sustained a traumatic brain injury, a skull fracture as well as
multiple facial fractures. You initially received medical care
in the Intensive Care Unit and were then transferred to the
surgical floor once stable. The Neurosurgery service evaluated
your traumatic brain injury and recommended a 7 day course of a
medication, called keppra (Levetiracetam), to prevent seizures,
and you have completed this medication course. The ___
clinic will contact you at home to arrange for an outpatient
follow-up appointment.
The Plastic Surgery service will monitor your facial fractures.
You are now ready to be discharged home to continue your care.
Please note the following discharge instructions:
Return to the Emergency Department or see your own doctor right
away if any problems develop, including the following:
Persistent nausea or vomiting.
Increasing confusion, drowsiness or any change in alertness.
Loss of memory.
Dizziness or fainting.
Trouble walking or staggering.
Worsening of headache or headache feels different.
Trouble speaking or slurred speech.
Convulsions or seizures. These are twitching or jerking
movements of the eyes, arms, legs or body.
A change in the size of one pupil (black part of your eye) as
compared to the other eye.
Weakness or numbness of an arm or leg.
Stiff neck or fever.
Blurry vision, double vision or other problems with your
eyesight.
Bleeding or clear liquid drainage from your ears or nose.
Very sleepy (more than expected) or hard to wake up.
Unusual sounds in the ear.
Any new or increased symptoms
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
10195252-DS-18 | 10,195,252 | 26,056,423 | DS | 18 | 2110-11-26 00:00:00 | 2110-11-26 17:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache, nausea, vomiting and diplopia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a significant FH suggestive of an undefined inherited
coagulopathy and a past medical history significant for a right
DVT and extensive bilateral PEs dx ___ who after significant
negative thrombophilia workup (save a mildly elevated
anti-cardiolipin Ab IgG) was advisd to take life-long warfarin
and self-discontinued this after a few months, hypertension on
no therapy afetr having self-stopped medication, alcohol abuse,
hyperlipidemia no longer taking a statin and poorly controlled
T2DM on no medications who presents with 2 days of headache,
diplopia on standing and nausea and vomiting with CT showing
possible cerebral venous sinus thrombosis and transferred to
___ for further managment.
He has no baseline deficits and is completely independent. His
health has been well lately, but he describes personal stressors
lately, including the fact that he is unemployed (but later
reports that he manages his own business), he has had to see his
younger brother go to a nursing home for a stroke, and his
mother
also sustained a stroke. He was admitted to ___ for five days
approximately ___ years ago when he developed symptoms of right
lower extremity swelling. He reports that at the time, he would
work several hours straight at a desk and was largely immobile.
He was diagnosed with a DVT and was placed on a heparin drip and
transitioned to coumadin. He had numerous blood tests at the
___,
and he was instructed to take coumadin for "life". He ultimately
discontinued this medication few months later due to "stresses".
He also notes, "do you know that it is a rat poison?" He has not
seen a doctor in over ___ years.
His symptoms started at about 4pm on ___. He was lying
down
and taking a nap. When he got up, he experienced symptoms of
nausea and proceeded to vomit several times. This was nonbloody
and nonbilious. His vomitting led to a headache, which he
describes as a diffusely localized throbbing pain that
ultimately
never went away. He also complains of diplopia when he would
stand up and that would get better when he laid back down, but
cannot tell me whether it was horizontal or vertical diplopia.
He
also experienced dizziness, which he describes as a sensation of
spinning. He finally presented to an ED on ___ ___ as his
headache was not improving. He was concerned that he may have
had
a stroke. At this OSH, routine laboratory analysis showed an
elevated blood glucose (341), elevated creatinine (1.2) but no
leukocytosis or anemia. A CT scan at the OSH showed a question
of
right transverse sinus thrombosis without any associated
hemorrhage, and thus was transferred to the ___ ED for further
evaluation.
Review of systems is positive for some palpitations that he has
been experiencing over the past several months. They can occur
at
any time of the day. He also has been experiencing occasional
pangs of left arm numbness over the past ___ months. There have
been no changes in his gait, dysarthria, dysphagia, blurry
vision, asymmetric numbness, weakness or shooting electrical
pains. On general review of systems, the pt denies recent fever
or chills. 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.
Addendum with additional information:
Of note, over the past few months patient has noted episodes of
left arm numbness lasting seconds. He rarely checks ___ at
home.
He proceeded to an MRV which showed extensive dural sinus
thrombosis including superior sagittal, right transverse,
straight and sigmoid sinuses with possibly some clot in the
right IJV. There was no evidence of infarct or
edema/hydrocephalus. Patient had a repeat thrombophilia screen
drawn and patient was then started on IV heparin with a goal PTT
of 60-80. Hematology were consulted and felt that our and
previous ___ workup were sufficient.
Hematology added information:
Testing in ___ and ___ showed that he does not have
Factor V Leiden (by ___ resistance assay), has normal Protein C
and S and Antithrombin III activity, and was negative for lupus
anticoagulant. ___ testing also showed that he is negative for
the G20210A prothrombin gene mutation. ___ testing also
showed
elevated ACA IgG (17.2, normal range ___, but normal IgM.
This
was not retested on ___ for unclear reasons.
Past Medical History:
- Right unprovoked DVT ___ and complicated by multiple
bilateral PEs (acute pulmonary embolism of the with central
filling defects of the right interlobar and bilateral lobar as
well as multiple bilateral segmental pulmonary arteries with
enlarged pulmonary artery caliber suggestive of pulmonary
arterial hypertension) and advised to take warfarin lifelong
although self-discontinued this (thrombophilia workup at ___
negative at ___ save mildly elevated ACA IgG). He had possibly
residual DVT with non-occlusive thrombus in superficial femoral
vein thrombosis on CT in ___
- HTN no longer taking lisinopril
- Poorly controlled DM II not taking medications with
retinopathy previously and proteinuria previously on metformin
and stopped this several years ago. Most recent HbA1c 12.7
___.
- Hypercholesterolemia and stopped his statin
Social History:
___
Family History:
1 twin died at birth unclear cause. 2 full siblings - Brother
had a severe stroke age ___ and is currently in a nursing home.
Sister had a PE age roughly ___ and is otherwise well.
2 half siblings brother died of ? cancer and sister well.
Father died of heart disease age ___ no clots. Mother had a
stroke age ___.
Cousin age ___ who had a DVT.
Unclear re paternal aunts/uncles and maternal aunts/uncle only 1
alive and has DM no clots.
Has 4 children who are well.
Physical Exam:
Physical Exam:
Vitals: See attached.
General: Awake, cooperative, pleasant, NAD. ___ accent, but
understands/speaks ___ well.
HEENT: NC/AT, no conjunctival icterus noted, MMM, no lesions
noted in
oropharynx. Tympanic membranes clear. Very prominent temporal
vessels suggesting possible collaterals.
Neck: Supple, no masses or lymphadenopathy
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted. No carotid bruits.
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities: warm and 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. Pt. was able to register 3 objects and recall ___ at 5
minutes. The pt. had good knowledge of current events.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1mm and brisk. Visual acuity is ___ OS/OD
III, IV and VI: EOM are intact and full, no nystagmus
V: Facial sensation intact to light touch.
VII: Diminished activation of the right NLF when asked to smile
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 IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
proprioception throughout.
DTRs:
___ just present.
Plantar response mute
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Not assessed.
.
.
Discharge examination:
Appears fatigued and complains of headache. Prominent temporal
vessels suggesting possible collaterals. Normal fields and fundi
with reasonably crisp disc margins. No CN deficits. Full power
throughout and plantars mute bilaterally.
Pertinent Results:
Laboratory investigations:
Admission labs:
___ 11:10AM BLOOD WBC-6.6 RBC-4.98 Hgb-14.9 Hct-44.0 MCV-88
MCH-29.9 MCHC-33.9 RDW-12.3 Plt ___
___ 04:50AM BLOOD ___ PTT-28.0 ___
___ 11:10AM BLOOD Glucose-321* UreaN-13 Creat-1.0 Na-135
K-3.7 Cl-96 HCO3-27 AnGap-16
___ 11:10AM BLOOD TotProt-6.8 Albumin-4.1 Globuln-2.7
Calcium-8.6 Phos-2.3* Mg-2.2 Cholest-211*
.
Thrombophilia screening:
___ 04:50AM BLOOD Lupus-NEG
___ 04:50AM BLOOD ProtCFn-125* ProtSFn-84
___ 11:10AM BLOOD PEP-NO SPECIFIC ABNORMALITIES SEEN
IgG-1408 IgA-263 IgM-78
___ 03:12AM URINE U-PEP-MULTIPLE PROTEIN BANDS SEEN, WITH
ALBUMIN PREDOMINATING BASED ON IFE (SEE SEPARATE
REPORT),NEGATIVE FOR ___ PROTEIN; IFE-NO MONOCLONAL
BANDS
___ 04:50AM BLOOD b2micro-2.4*
___ 11:10AM BLOOD BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA,
IGM, IGG)-Negative
___ 11:10AM BLOOD ___ 04:50AM BLOOD ACA IgG-10.3 ACA IgM-7.4
.
Other pertinent labs:
___ 11:10AM BLOOD TSH-0.31
___ 11:10AM BLOOD TotProt-6.8 Albumin-4.1 Globuln-2.7
Calcium-8.6 Phos-2.3* Mg-2.2 Cholest-211*
___ 11:10AM BLOOD Triglyc-70 HDL-99 CHOL/HD-2.1 LDLcalc-98
LDLmeas-109
___ 11:10AM BLOOD %HbA1c-12.7* eAG-318*
___ 11:10AM BLOOD ALT-20 AST-13 LD(LDH)-193 AlkPhos-50
TotBili-0.3
.
Discharge labs:
___ 05:50AM BLOOD WBC-4.5 RBC-4.88 Hgb-14.3 Hct-42.2 MCV-87
MCH-29.4 MCHC-33.9 RDW-12.3 Plt ___
___ 05:50AM BLOOD ___ PTT-64.3* ___
___ 05:50AM BLOOD Glucose-212* UreaN-9 Creat-0.9 Na-137
K-3.6 Cl-100 HCO3-31 AnGap-10
___ 05:50AM BLOOD Albumin-3.6 Calcium-8.3* Phos-3.6 Mg-2.1
___ 05:50AM BLOOD ALT-19 AST-19 AlkPhos-45 TotBili-0.5
.
.
Urine:
___ 03:12AM URINE Color-Straw Appear-Clear Sp ___
___ 03:12AM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-1000 Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 03:12AM URINE RBC-1 WBC-<1 Bacteri-FEW Yeast-NONE Epi-0
___ 03:12AM URINE CastHy-8*
___ 03:12AM URINE Mucous-RARE
___ 03:12AM URINE Hours-RANDOM
___ 03:12AM URINE Hours-RANDOM Creat-45 Na-100 K-31 Cl-114
TotProt-89 Prot/Cr-2.0*
___ 12:45PM URINE Hours-RANDOM Creat-46 Na-75 K-17 Cl-79
___ 12:45PM URINE Osmolal-354
.
.
Radiology:
MR HEAD & MRV HEAD W/O CONTRAST Study Date of ___ 2:12 AM
FINDINGS:
MRI HEAD: There is no acute intracranial hemorrhage, infarction,
edema, mass,
or mass effect seen. There is loss of flow void in the superior
sagittal
sinus and the visualized right internal jugular vein. Multiple
scattered
T2/FLAIR hyperintensities are seen in bilateral periventricular
and
subcortical white matter which are nonspecific. Note is made of
a prominent
right superior ophthalmic vein. There are no diffusion
abnormalities. There
is abnormal susceptibility seen in the expected location of the
straight
sinus, superior sagittal sinus and the right transverse and
sigmoid sinuses.
Thrombus within the sinuses appears isointense on T1, and iso to
hyperintense
on T2 weighted images with central portions of the thrombus
showing abnormal
susceptibility. Major intracranial arterial flow voids are
preserved.
Visualized orbits, paranasal sinuses, and mastoid air cells are
unremarkable.
Note made of prominent adenoids.
MRV HEAD: There is loss of flow signal in the superior sagittal
sinus,straight sinus, right transverse sinus, right sigmoid
sinus, and
visualized right internal jugular vein. There is preserved flow
signal in the
internal cerebral veins, vein of ___, left transverse and
sigmoid sinuses.
IMPRESSION: 1. Extensive venous sinus thrombosis involving the
superior
sagittal, straight sinus, right transverse, right sigmoid, and
visualized
right internal jugular vein. Based on the MR imaging
characteristics, the
thrombus appears to be acute/early subacute.
2. No acute intracranial infarction or hemorrhage is detected.
3. Note made of prominent adenoids. Please correlate with
clinical findings.
.
CT HEAD W/O CONTRAST Study Date of ___ 3:06 ___
FINDINGS: Relative ___ of the superior sagittal,
straight, right transverse, and right sigmoid sinuses is
compatible with known thrombus. There is mild diffuse cerebral
edema with obscuration of the gray-white matter junction and
sulcal effacement, stable to slightly increased from prior
examination. There is no acute hemorrhage or vascular
territorial infarct. Remote left putaminal lacune is noted.
Midline structures are preserved.
Paranasal sinuses are well aerated. The mastoid air cells and
middle ear
cavities are clear. Orbits and intraconal structures are
symmetric.
IMPRESSION: Venous sinus thrombosis, with mild diffuse cerebral
edema, and no evidence of hemorrhage.
.
CT HEAD W/O CONTRAST Study Date of ___ 8:45 AM
FINDINGS: Again seen is relative ___ of the
superior sagittal,
straight, right transverse, and right sigmoid sinus compatible
with known
venous sinus thrombosis. There is no evidence of hemorrhage,
edema, mass,
mass effect, or vascular territorial infarction. Ventricles and
sulci are
normal in size and configuration. Left putamen lacunar infarct
is again
noted. The visualized paranasal sinuses and mastoid air cells
are well
aerated.
IMPRESSION: No change in known venous sinus thrombosis. No
evidence of large territorial infarction or hemorrhage. Follow
up with MRI/MRV as indicated.
.
.
Cardiology:
ECG Study Date of ___ 9:28:26 AM
Sinus rhythm. Left atrial enlargement. Left ventricular
hypertrophy.
No previous tracing available for comparison.
Read by: ___
Intervals Axes
Rate PR QRS QT/QTc P QRS T
93 148 88 348/405 65 34 17
.
.
Neurophysiology:
EEG STUDY DATE ___
Preliminary report
No evidence of seizure activity and no epileptiform discharges.
Frontal intermittent rhythmic delta activity (FIRDA) present
with at times bursts of generalised slowing consistent with
patient's history of venous sinus thrombosis. Background mildly
slow but reaches 9Hz alpha.
Brief Hospital Course:
___ with a significant FH suggestive of an undefined inherited
coagulopathy and a past medical history significant for a right
DVT and extensive bilateral PEs dx ___ who after significant
negative thrombophilia workup (save a mildly elevated
anti-cardiolipin Ab IgG) was advised to take life-long warfarin
and self-discontinued this after a few months, hypertension on
no therapy after having self-stopped medication, alcohol abuse,
hyperlipidemia no longer taking a statin and poorly controlled
T2DM on no medications who presented with 2 days of headache,
diplopia on standing and nausea and vomiting with CT showing
possible cerebral venous sinus thrombosis and transferred to
___ for further management on ___. Patient was found to
have an extensive right cerebral venous sinus thrombosis
extending down to the right IJV. Patient was started on IV
heparin and bridged to warfarin. Hematology recommended lifelong
warfarin. BP and diabetes were very poorly controlled and
required considerable insulin sliding scale and
anti-hypertensive uptitration. Patient complained of increased
lethargy at the end of his stay latterly attributed to poor
sleep in hospital which improved. EEG showed FIRDA and no
epileptiform discharges and repeat CT-head scan was stable.
Patient was deemed appropriate for discharge to rehab on
___. He has neurology, PCP and hematology ___. PCP
was updated and will refer for ___ ___.
.
.
# Neurology:
Patient has a significant FH for possible heritable
thrombophilia and had previous DVT and extensive bilateral PEs
diagnosed at ___ in ___. Patient presented with 2 days of
headache, diplopia on standing and nausea and vomiting with CT
showing possible cerebral venous sinus thrombosis and
transferred to ___ for further management on ___.
Examination on admission was unremarkable other than prominent
scalp vessels which were likely collaterals.
MRI/MRV showed no edema but extensive right venous sinus
thrombosis involving the superior sagittal, straight sinus,
right transverse, right sigmoid, and visualized right internal
jugular vein.
Hematology were consulted and felt that his thrombosis was
subacute in keeping with imaging findings and recommended
lifelong anticoagulation. Repeat thrombophilia screening was
done (previously had extensive hypercoagulable workup at ___
and all results were negative. Patient was started on IV heparin
and warfarin and given previous issues with non-compliance was
kept in hospital to await therapeutic INR.
BP was very poorly controlled and he initially required frequent
IV anti-hypertensives and latterly was controlled on three
agents. ___ were consulted regarding his diabetes which was
also very poorly controlled with HbA1c 12.7% and his HISS was
uptitrated in house. Given considerable drinking history, he was
started on a CIWA scale though he never ended up having signs of
alcohol withdrawal.
Patient had a chronic headache in house requiring narcotic
analgesia and developed slight left lip numbness with repeat CT
head showing mild diffuse cerebral edema and no hemorrhage.
Patient complained of increased lethargy and stable headache and
repeat CT on ___ revealed on this occasion no edema or
hemorrhage and no in his known venous sinus thrombosis. EEG
showed no evidence of seizure activity and no epileptiform
discharges with mildly slow background but reached 9Hz alpha in
addition to frontal intermittent rhythmic delta activity (FIRDA)
with at times bursts of generalised slowing consistent with
patient's history of venous sinus thrombosis. His lethargy
improved and examination continued to be unremarkable.
He was eventually therapeutic regarding his warfarin and after
___ review was felt to benefit from rehab. His headache improved
and was requiring minimal oxycodone PRN. He was therefore
transferred to rehab on ___. He has neurology, PCP and
hematology ___. PCP was updated and will refer for ___
___ ___.
.
# Hematology:
Hematology were consulted and recommended lifelong
anticoagulation.
Previous evaluation at ___ revealed testing in ___ and
___ which showed no evidence of Factor V Leiden (by ___
resistance assay not by mutation analysis). He had a normal
Protein C and S and Antithrombin III activity, and was negative
for lupus anticoagulant. ___ testing showed elevated ACA IgG
(17.2, normal range ___, but normal IgM. This was not retested
on ___ for unclear reasons. In ___ he was also found to be
negative for the ___ prothrombin gene mutation.
On this admission, hypercoagulability labs were sent and were
all normal including normal Protein C/S profiles save elevated
Protein C function, beta 2 glycloprotein negative, lupus
anticoagulant negative, SPEP/UPEP with no monoclonal band and
IG's normal. Anticardiolipin Ab negative. Factor V Leiden
mutation (only functional assay done at ___ in ___ and
homocysteine levels can be considered as an outpatient.
He was continued on IV heparin and this was stopped on ___
after his INR had been therapeutic for 48 hours. INR on
discharge was 3.0 and warfarin was decreased to 5mg and INR will
need to be regularly checked at rehab. has hematology ___.
.
# Cardiology:
Patient had very difficult to control BP and initially required
considerable uptitration of oral medications in addition to
frequent IV hydralazine, IV metoprolol and IV labetalol for SBP
180s-190s. Patient was eventually stabilised on lisinopril 40mg
qd, labetalol 200mg tid and amlodipine 10mg qd with SBPs in
140s-150s. He will require further anti-hypertensive titration
as an outpatient.
.
# Endocrinology:
Patient has had very poorly controlled type 2 DM with very high
HbA1c values at ___ which seemed at times to correlate with his
drinking. He and was previously on metformin although this was
self-discontinued. HbA1c was 12.7% on admission and blood
glucose values were very poorly controlled. ___ were
consulted and his HISS was uptitrated in house. He was given
diabetic and insulin injection teaching. He was discharged to
rehab on an insulin sliding scale and Lantus 36 units at night.
PCP ___ refer to ___ ___ as an
outpatient.
Medications on Admission:
Nil. as he had stopped medications years ago.
.
Was previously on warfarin, metformin 1g bid, lisinopril 20mg
daily (previosuly 40mg and reduced due to concern of hypotension
causing light-headedness) and a statin (Atorvastatin 10mg daily)
and these were stopped this after a couple of months not
informed to do so by a physician.
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for headache, T>38.3.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day) as needed for constipation.
4. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours)
as needed for Pain.
Disp:*20 Tablet(s)* Refills:*0*
8. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for neck pain/headache.
9. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
___.
10. insulin regular human 100 unit/mL Solution Sig: as per
sliding scale Injection per sliding scale.
11. Lantus 100 unit/mL Solution Sig: ___ (36) UNITS
Subcutaneous at bedtime.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Extensive right venous sinus thrombosis in a patient with a
___ hereditary hypercoagulable state of as yet unclear cause
(thrombophilia screen has thus far proved negative)
Difficult to control hypertension
Type 2 Diabetes requiring insulin
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance
Neurologic:
A+Ox3. Prominent temporal vessels suggesting possible
collaterals. Normal fields and fundi. No CN deficits. Full power
throughout and plantars mute bilaterally.
Discharge Instructions:
It was a pleasure taking care of you during your stay at the
___ ___ ___. You presented with
headache, nausea and vomiting and were found to have a large
clot in the veins supplying your head on the right side. Given
this, you were started on an intravenous blood thinner called
heparin in addition to an oral blood thinner called warfarin.
You had persistent headache which required narcotic analgesia
and latterly improved. You had no abnormal examination findings
and imaging of the brain with repeated CT head scans was stable.
You were kept in hospital until your warfarin level (INR) was
sufficiently high when the heparin was stopped. We consulted
hematology who recommended lifelong warfarin given your previous
clots on your lung in addition to the potentially
life-threatening clotting of your head veins. You must take this
medication every day for the rest of your life. We have
organised hematology ___ as below which you should attend.
.
Your blood pressure was also very high and required three
different medications to control it. You were therefore
discharged on amlodipine, lisinopril and labetalol. Your PCP
___ follow your blood pressure and you may need further changes
to your medications.
.
Your diabetes was also poorly controlled for which we consulted
the ___ diabetes specialists. You were started on insulin and
your blood glucose readings improved with treatment. You were
therefore discharged on an insulin sliding scale to rehab and
you received diabetes education. Your PCP ___ arrange diabetes
___ for you with the ___ specialists.
You were discharged once your warfarin level (INR) was at the
right level and you were demeed appropriate for rehab. You have
neurology and PCP ___ as below in addition to hematology
___. You must see your PCP ___ on discharge.
.
Medication changes:
We STARTED warfarin 5mg daily - your warfarin levels should be
checked at rehab and by your PCP on discharge
___ STARTED Lantus (insulin glargine) 36 units at night and an
insulin sliding scale for your diabetes per the ___ Diabetes
specialists
We STARTED cyclobenzaprine 10mg three times daily as needed for
your headache
We STARTED amlodipine 10mg daily for your blood pressure
We STARTED lisinopril 40mg daily for your blood pressure
We STARTED labetalol 200mg three times daily for your blood
pressure
We STARTED tylenol and oxycodone as needed for your headaches
and this should be tapered when they settle down
Followup Instructions:
___
|
10195870-DS-11 | 10,195,870 | 29,349,814 | DS | 11 | 2188-06-12 00:00:00 | 2188-06-12 13:32:00 |
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:
None
History of Present Illness:
___ s/p whipple on ___ now w/ abdominal pain, nausea/vomiting.
The patient states that she has had worsening abdominal pain
since returning home as well as occasional nausea. She has not
had any fevers or chills. She has been tolerating small amounts
of POs, but has been eating fairly fatty foods. She
has still been having normal bowel movements, last today,
without diarrhea or steatorrhea.
Past Medical History:
PMHx: none
PSH: Pancreatic mass resection (___) at ___
___ in ___, ___
Social History:
___
Family History:
Mother - gastritis
Father - HTN
No family history of cancer or any pancreatic disorder
Physical Exam:
Vitals: 91.6 88 102/66 16 100RA
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, Moderately tender throughout, no guarding/rebound.
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 05:55AM BLOOD WBC-17.8* RBC-4.23 Hgb-11.5* Hct-35.3*
MCV-83 MCH-27.1 MCHC-32.5 RDW-14.1 Plt ___
___ 07:05AM BLOOD WBC-13.0* RBC-3.55* Hgb-9.6* Hct-29.7*
MCV-84 MCH-27.1 MCHC-32.5 RDW-14.0 Plt ___
___ 05:55AM BLOOD Glucose-115* UreaN-8 Creat-0.5 Na-137
K-4.4 Cl-96 HCO3-29 AnGap-16
___ 07:05AM BLOOD Glucose-96 UreaN-7 Creat-0.5 Na-137 K-4.3
Cl-101 HCO3-27 AnGap-13
___ 05:55AM BLOOD ALT-37 AST-21 AlkPhos-155* TotBili-0.3
___ 09:00AM ASCITES Amylase-21
___ ABD CT:
IMPRESSION:
1. Findings concerning for early or partial small bowel
obstructon. A
distended loop of small bowel has a thickened wall and contains
fecalized
material with a transition point located just deep to surgical
staples to the right of midline in the mid abdomen. Some
contrast has passed into the distal collapsed loops suggesting
perhaps a partial obstruction at this time. The wall thickening
may be reactive or inflammatory, however, ischemia is not
excluded.
2. A superior mesenteric contributory vein adjacent to surgical
clips
demonstrates an eccentric area of hypoattenuation which may
represent
nonoclussive thrombus vs postop changes with narrowing.
3. The stomach is distended proximal to the gastrojejunostomy
site however
contrast is passing into the distal decompressed jejunum.
4. Intra-abdominal and pelvic free fluid that is more than
expected
post-operatively. Possible areas of peritoneal enhancement.
Correlation with the possibility of peritonitis is recommended.
Brief Hospital Course:
The patient s/p ___ on ___ was admitted to the HPB
Surgical Service for observation secondary to abdominal pain.
The patient underwent abdominal CT scan which was concerning for
partial bowel obstruction. Patient's drain amylase was 21 on
admission. The patient was made NPO with IV fluids, she was
started on clears and transferred to the floor for observation.
On HD # 2, patient's diet was advanced to regular and was well
tolerated. The patient's education about post Whipple diet was
reinforced. JP drain was removed as output and amylase level was
low. The patient was discharged home in stable condition.
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 received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*100 Tablet Refills:*0
3. Acetaminophen 1000 mg PO Q8H pain
4. Metoclopramide 10 mg PO QIDACHS
RX *metoclopramide HCl 10 mg 1 by mouth QACHS Disp #*56 Tablet
Refills:*0
5. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*5
Discharge Medications:
1. Pantoprazole 40 mg PO Q24H
2. Docusate Sodium 100 mg PO BID
3. Acetaminophen ___ mg PO Q6H:PRN pain
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
5. Senna 1 TAB PO BID
6. Metoclopramide 10 mg PO QIDACHS
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain s/p Whipple procedure on ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
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, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
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 steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Followup Instructions:
___
|
10195979-DS-8 | 10,195,979 | 22,570,972 | DS | 8 | 2144-11-18 00:00:00 | 2144-11-21 01:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Iodinated Contrast Media - IV Dye / E-Z-HD Barium / frozen
plasma
Attending: ___
Chief Complaint:
abdominal pain, fever
Major Surgical or Invasive Procedure:
___: Pigtail drain into hepatic bed
History of Present Illness:
This patient is a ___ year old male who complains of ABD
PAIN. ___ yo male with liver laceration and tib fib fracture
after MVC> Developed portal venous thrombus. Discharged from
hospital approximately 10 days ago with an abdominal drain
still ___ place. Patient reports new RUQ pain and fevers over
the last ___s darker and occasionally bloody
discharge from drain. No new back pain. No dysuria. No CP,
SOB.
Timing: Intermittent
Quality: Crampy
Severity: Moderate
Duration: Days
Location: RUQ
Associated Signs/Symptoms: fever
Past Medical History:
None
Social History:
___
Family History:
Non-contributory
Physical Exam:
Physical Exam: physical examination upon admission
Vitals: 99.4, 119, 128/77, 18, 98RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: tachycardic, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, well healed midline laparotomy scar, nondistended,
right sided tenderness to palpation more severe around drain
site, drain ___ place with some yellow/green drainage from around
drain, no rebound or guarding, normoactive bowel sounds, no
palpable masses
Ext: RLE ___ brace, wounds healing well, c/d/i, no erythema or
induration
Pertinent Results:
LABORATORY:
Admission
12.2 > 9.6/30.8< 624
135 95 10
-------------< 125
4.4 32 0.6
ALT-26 AST-22 AlkPhos-338* TotBili-0.3
Discharge
9.6 > 9.2/ 28.2 < 611
135 96 6
------------< 103
4.2 29 0.5
ALT-16 AST-16 LD(LDH)-137 AlkPhos-250* TotBili-0.2 DirBili-0.1
IndBili-0.1
IMAGING:
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
___: CT abdomen and pelvis:
No evidence of acute process on this non-contrast CT.
Decreasing size of the hepatic collections
___: chest x-ray:
No acute intrathoracic process.
___: US of lower ext:
No evidence of DVT ___ the left or right lower extremity.
Nonvisualization of the right calf veins due to overlying cast.
___: liver/gallbladder US:
1. The main and left portal veins are patent, however the right
portal vein is not visualized secondary to poor acoustic window.
2. Changes from known laceration/contusion involving the right
lobe of the
liver
PROCEDURES:
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
___: liver aspiration:
Technically successful ultrasound-guided drainage of hepatic
surgical bed
collection with culture sent. No immediate post-procedural
complications.
MICROBIOLOGY:
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
Time Taken Not Noted ___ Date/Time: ___ 3:05 pm
ABSCESS Site: LIVER
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
Reported to and read back by ___ (___) ___
@1700.
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Preliminary):
GRAM POSITIVE COCCUS(COCCI). MODERATE GROWTH.
ANAEROBIC CULTURE (Preliminary):
Time Taken Not Noted ___ Date/Time: ___ 3:05 pm
ABSCESS Site: LIVER
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
Reported to and read back by ___ (___) ___
@1700.
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Preliminary):
STREPTOCOCCUS ANGINOSUS (___) GROUP. MODERATE
GROWTH.
Susceptibility testing requested by ___ ___.
YEAST. SPARSE GROWTH.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
Brief Hospital Course:
The patient was re-admitted to the hospital with abdominal pain
and fever. He had been discharged 10 days ago with a drain ___
the hepatic bed. ___ addition to his abdominal pain, he reported
an increase ___ the drain output. Upon admission, he was made
NPO, given intravenous fluids and underwent imaging. Cat scan
images showed no acute process and a decrease ___ size of the
hepatic collections. No acute pulmonary process was reported on
the chest x-ray. Ultrasound of the lower extremities were done
which showed no DVT's. Because of his history of portal vein
thrombosis, the patient was started on a heparin drip with
monitoring of his PTT. The patient underwent serial abdominal
examinations and his white blood cell count was closely
monitored. He continued to have fevers and was scheduled for a
second drain placement. During an infusion of fresh frozen
plasma, the patient was noted to have hives on his upper
extremities. The infusion was discontinued and reaction
protocol was undertaken. On HD #4, the patient was taken to
Interventional radiology where he underwent placement of a
pigtail catheter into the hepatic bed. Cultures were sent which
showed gm + cocci (streptococcus angiosis and yeast). The
patient was started on a 2 week course of augmentin and
fluconazole. The initial drain was inched out over ___ days and
was removed on HD #5. The patient resumed his coumadin on HD #5,
receiving 2.5 mg. A bridging regimen of lovenox was started on
HD #6 and the heparin drip was discontinued. Because of the
patient's diminished appetite, nutrition services were consulted
and provided recommendations for nutritional supplements. The
social worker met with the patient and family and provided
emotional support. A family meeting was scheduled to answer
questions about the ___ hospital course and to address
discharge plans. The patient was discharged on HD # 7 ___ stable
condition. Appointments for follow-up were made with the acute
care service, and plastic surgery.
Medications on Admission:
1. gabapentin 300mg QD
2. dilaudid ___ PO Q4-6hrs prn
3. ativan 2mg PO prn
4. coumadin (daily dosing)
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Docusate Sodium 100 mg PO BID
5. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
6. Senna 1 TAB PO BID
7. Warfarin 2.5 mg PO DAILY16
please monitor INR daily
8. Enoxaparin Sodium 60 mg SC BID Start: ___, First Dose:
Next Routine Administration Time
9. Fluconazole 400 mg PO Q24H
10. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
fever
abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were readmitted to the hospital with right upper quadrant
pain and fever. You underwent a cat scan of the abdomen and you
were found to have a decrease ___ the size of the liver
collection. You had a ___ drain placed around the liver
collection. Your white blood cell count has decreased and your
abdominal pain has decrease. You are now preparing for
discharge home with the following instructions:
You will be discharged with the abdominal drain:
Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid ___ the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes ___ character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself ___
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation
___ addition to the above instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep ___ fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change ___ your symptoms, or any new symptoms that
concern you
Followup Instructions:
___
|
10196085-DS-16 | 10,196,085 | 21,559,477 | DS | 16 | 2169-10-27 00:00:00 | 2169-10-27 13:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tylenol / lisinopril / Penicillins / furosemide
Attending: ___.
Chief Complaint:
Anemia
Major Surgical or Invasive Procedure:
None
Past Medical History:
HTN
HLD
Positive PPD treated with Isoniazid in ___
Diet controlled diabetes
Social History:
___
Family History:
No known family history of cancer
Pertinent Results:
___ 04:46PM BLOOD WBC-3.6* RBC-2.30* Hgb-3.9* Hct-14.8*
MCV-64* MCH-17.0* MCHC-26.4* RDW-33.0* RDWSD-75.3* Plt ___
___ 12:50AM BLOOD WBC-4.9 RBC-3.1* Hgb-5.8* Hct-21.2*
MCV-69* MCH-19.5* MCHC-28.3* RDW-34.4* RDWSD-83.0* Plt ___
___ 08:54AM BLOOD WBC-5.9 RBC-3.32* Hgb-6.4* Hct-23.3*
MCV-70* MCH-19.3* MCHC-27.5* RDW-33.6* RDWSD-84.2* Plt ___
___ 07:00AM BLOOD WBC-7.2 RBC-3.28* Hgb-6.3* Hct-22.8*
MCV-69.5* MCH-19.2* MCHC-27.6* RDW-33.6* RDWSD-82.5* Plt ___
___ 10:55PM BLOOD WBC-9.9 RBC-4.42 Hgb-9.1* Hct-32.0*
MCV-72* MCH-20.6* MCHC-28.4* RDW-UNABLE TO RDWSD-UNABLE TO Plt
___
___ 07:20AM BLOOD WBC-4.9 RBC-3.91 Hgb-8.9* Hct-30.7*
MCV-79* MCH-22.8* MCHC-29.0* RDW-37.8* RDWSD-116.5* Plt Ct-61*
___ 06:12PM BLOOD ___ PTT-24.9* ___
___ 08:44AM BLOOD D-Dimer-2047*
___ 07:33AM BLOOD ___ 07:00AM BLOOD ___ 07:33AM BLOOD Ret Aut-4.4* Abs Ret-0.17*
___ 04:46PM BLOOD Glucose-130* UreaN-8 Creat-0.7 Na-144
K-4.1 Cl-108 HCO3-24 AnGap-12
___ 04:46PM BLOOD ALT-25 AST-38 AlkPhos-93 TotBili-0.5
___ 04:46PM BLOOD proBNP-3557*
___ 04:46PM BLOOD Albumin-2.7* Iron-20*
___ 04:46PM BLOOD calTIBC-341 ___ Ferritn-4.0* TRF-262
___ 06:19PM BLOOD Lactate-2.6*
___ 12:50AM BLOOD Lactate-2.1*
___ 06:08AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
Malaria Antigen Test (Final ___: Negative for Plasmodium
antigen.
___ 06:51AM BLOOD WBC-7.0 RBC-4.53 Hgb-10.7* Hct-37.2
MCV-82 MCH-23.6* MCHC-28.8* RDW-UNABLE TO RDWSD-UNABLE TO Plt
___
___ 06:51AM BLOOD Neuts-70.7 ___ Monos-6.8 Eos-1.3
Baso-0.4 NRBC-0.3* Im ___ AbsNeut-4.92 AbsLymp-1.42
AbsMono-0.47 AbsEos-0.09 AbsBaso-0.03
___ 06:51AM BLOOD Plt ___
___ 08:13AM BLOOD Glucose-86 UreaN-23* Creat-0.8 Na-143
K-4.4 Cl-93* HCO3-36* AnGap-14
___ 06:51AM BLOOD TSH-1.6
___ 06:51AM BLOOD HIV Ab-NEG
___ Babesia DNR PCR not detected
CXR ___:
FINDINGS: There bibasilar opacity silhouetting the
hemidiaphragms. Cardiac silhouette appears enlarged compared to
prior. Superiorly, lungs are clear. No acute
osseous abnormalities.
IMPRESSION: Bilateral pleural effusions. Enlarged cardiac
silhouette with configuration raising the possibility of a
pericardial effusion.
Echocardiogram ___:
The left atrial volume index is SEVERELY increased. There is
normal left ventricular wall thickness with a normal cavity
size. There is SEVERE global left ventricular hypokinesis. The
visually estimated left ventricular ejection fraction is 25%.
There is no resting left ventricular outflow tract gradient. The
right ventricular free wall is hypertrophied. Mildly dilated
right ventricular cavity with SEVERE global free wall
hypokinesis. Intrinsic right ventricular systolic function is
likely lower due to the severity of tricuspid regurgitation.
There is abnormal interventricular septal motion c/w right
ventricular pressure and volume overload. 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) are mildly thickened.
There is no aortic valve stenosis. There is mild [1+] aortic
regurgitation. The mitral valve leaflets are mildly thickened
with no mitral valve prolapse. There is mild to moderate [___]
mitral regurgitation. The tricuspid valve leaflets are mildly
thickened. There is moderate
to severe [3+] tricuspid regurgitation. There is moderate to
severe pulmonary artery systolic hypertension. In the setting of
at least moderate to severe tricuspid regurgitation, the
pulmonary artery systolic pressure may be UNDERestimated. There
is no pericardial effusion. A left pleural effusion is present.
CXR ___:
IMPRESSION:
Compared to chest radiograph ___.
Severe enlargement of cardiac silhouette has not improved.
Small bilateral
pleural effusions are stable or decreased. No pneumothorax.
New, mild
interstitial edema is likely. Consolidation in the left lower
lobe and perihilar right upper lobe are new. Both suggest
pneumonia although a component of atelectasis is typically seen
at the lung base.
Brief Hospital Course:
Ms. ___ is a ___ yo ___ speaking lady (speaks
___ with HTN and HLD who presented with increased lower
extremity edema and dyspnea who was found to be severely anemic
and with acute decompensated heart faiulre. Initially history
was limited by the patient's refusal to answer questions. In
the ED, vitals were HR 100, BP 142/70, RR16, O2Sat 91% RA. Labs
were sent which showed severe anemia with Hb 3.9, Hct 14.8, Iron
20, Ferritin of 4.0. She also had an elevated BNP at 3557, Alb
2.7. A CXR showed bilateral pleural effusions and enlarged
heart. She was given 2 units of pRBCs and admitted to medicine.
#Iron deficiency anemia:
Given her hemodynamic stability, her anemia was thought to have
been chronic in nature. She reponded well to blood transfusion
and had no evidence of active
bleeding. She was given IV iron daily for 4 doses. Her
hemoglobin was stable and improved to 10.7 by the time of
discharge. Her PCP was contacted who confirmed she had a
negative colonoscopy in ___ and that she had no known history
of anemia, though her last recorded CBC was in ___. During her
hospital course, discussion about needing a colonoscopy was
initiated (with the patient and her niece), but the decision was
made to complete this as an outpatient. The patient expressed
hesitation about getting the colonoscopy despite counseling.
Hematology was consulted to rule-out other etiologies. They
agreed that her presentation was consistent with severe iron
deficiency and thalassemia trait. She had negative malaria
antigen and negative babesia PCR. She should have a repeat CBC
checked in 1 weeks time and weekly thereafter. She should
follow-up with Gastroenterology. If no one calls the patient
with an appointment, please call our GI office to schedule.
#Thrombocytopenia:
While hospitalized, the patient had a platelet drop from 235
down to 61 (at the lowest, occurred over days). She had
received no heparin products and had no signs of hemolysis or
infection. Hematology was concerned for possible drug-induced
ITP since she had been receiving Lasix as a new drug since
admission. Lasix was changed to Torsemide. With this change,
her thrombocytopenia improved. Lasix has been listed as an
allergy for the patient and she should not take this in the
future.
#Systolic congestive heart faiulre, Tricuspid regurgitation/mild
mitral regurgitation:
Echo showed LVEF 25% with severe hypokinesis, mildly dilated RV,
moderate-severe pulmonary HTN. Echo also showed significant
tricuspid and mitral regurgitation and pulmonary artery HTN
(which is likely secondary to left heart disease). CXR on ___
showed consolidation in the left lower lobe and perihilar right
upper lobe, though she had been afebrile with respiratory
complaints . No history of lung disease per PCP's records,
besides history of TB that was treated in ___. She briefly was
on supplemental O2 early in her hospital course but this
resolved with diuresis with Lasix. Cardiology was consulted.
An HIV and TSH were sent (negative) and testing for nutritional
deficiency (including carnitine) was pending at discharge. She
is discharged on metoprolol succinate 12.5 mg daily and
torsemide daily. She will need outpatient cardiology to be set
up on discharge.
#HTN: She was discharged on Amlodipine 5mg daily and Metoprolol
XL 12.5 daily.
She completed documentation designating her niece ___ as a
healthcare proxy.
Medications on Admission:
Amlodipine 5mg daily
Metoprolol tartrate 50mg daily
Vitamin D
Discharge Medications:
1. Ferrous Sulfate 325 mg PO DAILY
2. Metoprolol Succinate XL 12.5 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Simvastatin 10 mg PO QPM
5. Torsemide 40 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Iron deficiency anemia
Thrombocytopenia
Tricuspid regurgitation
Mitral regurgitation
Heart failure with reduced ejection fraction
Pulmonary artery HTN
Hypokalemia
Elevated INR
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with shortness of breath and lower extremity
swelling. You were found to have low blood counts (called
anemia). You were given a blood transfusion which improved your
blood counts. You were also seen by our Hematologists (anemia
specialists). We suspect that you have a source of slow
bleeding in your bowels. While your blood counts had improved
at the time of discharge, we do strongly recommend that you
follow-up with a Gastroenterologist (or stomach doctor) for
further management.
While you were here you were also found to have low platelet
levels which we believe was a side-effect to the medication
furosemide. Please do not take furosemide in the future.
Finally, we believe that the low blood counts caused you to go
into congestive heart failure. You were seen by our
Cardiologists. They recommend you start a new medication called
metoprolol and that you see them in follow-up in the clinic.
Please see Gastroenterology and Cardiology in follow-up. If you
do not hear from these offices in 2 business days, please call
to schedule the appointment.
Please have a CBC checked in 1 week.
Followup Instructions:
___
|
10196241-DS-8 | 10,196,241 | 29,251,950 | DS | 8 | 2132-04-06 00:00:00 | 2132-04-07 15:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Per admitting fellow: Patient is a ___ yo female known case of
lap gastric bypass 3 weeks post op at ___ (operated by Dr.
___, presenting to the hospital refereed from the PMD for
worsening left leg swelling, shortness of breath, and back pain
of 2 days duration. She reports that her symptoms have started
two days ago with increasing edema of her chronically edematous
LLE. The patient tried to elevate the LLE initially. Then with
increasing shortness of breath and some pleuritic back pain, the
patient was evaluated by her PMD. She was transferred to ___
for further workup of her symptoms. She denies any fever
chills, cough or syncope. She reports being on a liquid diet
and tolerating well. She is taking her Roxicet PRN about once
daily. She is not constipated and is passing regular urine. She
was seen in post operative follow up at ___ this week.
Past Medical History:
Past Medical History:
Morbid obesity, HTN, back pain, OA LLE.
Past Surgical History:
lap Roux en Y bypass ___ at ___ by Dr. ___ Roux 100cm,
21mm EEA GJ retrocolic), Lt TKR
Social History:
___
Family History:
DVT and PE in cousin and DVT in aunt. CAD, HTN, DM2, ESRD,
hypothyroidism
Physical Exam:
On admission:
Vitals: Pain ___ T 97.7 HR 72 BP 122/71 RR 16 Sat 100% 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, mildly tender in the LLQ, no rebound or
guarding, normoactive bowel sounds, no palpable masses
Ext: LLE edema, LLE warmer and well perfused bilaterally.
On discharge:
VSS
Neuro: Alert and oriented x 3
Cardiac: RRR
Lungs: CTA B
Abd: Soft, nondistended, nontender, no rebound
tenderness/guarding
Ext: 1+ left lower extremity edema, no edema of right lower
extremity
Pertinent Results:
___ 07:40AM BLOOD WBC-3.8* RBC-4.15* Hgb-10.3* Hct-32.5*
MCV-78* MCH-24.8* MCHC-31.7 RDW-17.0* Plt ___ Plt ___
Glucose-93 UreaN-13 Creat-0.8 Na-139 K-4.1 Cl-105 HCO3-21*
AnGap-17 Calcium-9.1 Phos-4.5 Mg-1.8 ___ PTT-79.2*
___
___ 08:23PM BLOOD K-4.7
IMAGING:
CTA CHEST W&W/O C&RECONS, NON-CORONARY:
IMPRESSION:
Bilateral pulmonary emboli as described above without evidence
of significant right heart strain or pulmonary infarct.
CT ABD & PELVIS W/O CONTRAST:
IMPRESSION:
1. No acute intra-abdominal or pelvic process. No evidence of
anastomotic leak.
2. Moderate amount of retained fluid in the excluded stomach
remnant, without evidence of duodenal dilation. No enteric
contrast in the excluded stomach.
3. Enlarged, bulky uterus likely due to fibroids versus
adenomyosis.
Brief Hospital Course:
Ms. ___ presented to the Emergency Department on ___ with shortness or breath, left leg swelling and back pain
at the direction of her primary care provider. Upon arrival, a
Chest CTA was performed and indicative of bilateral pulmonary
emboli without significant right heart strain. Additionally, an
Abd/ Pelvic CT was performed and consistent with 'no acute
intra-abdominal or pelvic process' and 'no evidence of
anastomotic leak'. A heparin gtt was initiated and the patient
was transferred to the general surgical floor for ongoing
observation and management.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed with oral Roxicet prn.
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. She did not
require supplemental oxygen therapy during her hospitalization.
GI/GU/FEN: The patient's diet was advanced to a Bariatric Stage
4 diet on HD1, which was well tolerated. Patient's intake and
output were closely monitored. JP output remained
serosanguinous throughout admission; the drain was removed prior
to discharge.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: Given confirmation of PE on CTA, a heparin gtt was
initiated and titrated prn to maintain PTT levels of 60-80.
Additionally, po warfarin was initiated on HD1. The patient's
INR became therapeutic at 2.1 on HD6 and the heparin gtt was
discontinued.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a stage 4
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. She will follow-up with her
Bariatric Surgeon at ___ and also with the ___
___ clinic for management of warfarin dosing.
Medications on Admission:
1. Metoprolol Tartrate 12.5 mg PO BID
2. Ranitidine 150 mg PO BID
3. Ursodiol 300 mg PO BID
Discharge Medications:
1. Metoprolol Tartrate 12.5 mg PO BID
2. Ranitidine 150 mg PO BID
3. Ursodiol 300 mg PO BID
4. Warfarin 5 mg PO DAILY
Please crush
RX *warfarin 5 mg 1.5 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pulmonary Embolism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You presented to the hospital with shortness of breath and leg
swelling. A CT scan was revealing for blood clots in your lung.
You were treated with intravenous and oral blood thinners.
Your INR is now within the therapeutic range and you are
preparing for discharge to home with the following instructions:
Coumadin Discharge Instructions:
Guidelines for Medication Use
Follow the fact sheet that came with your medication. It tells
you when and how to take your medication. Ask for a sheet if you
didnt get one.
Do not take Coumadin during pregnancy because it can cause birth
defects. Talk to your doctor about the risks of taking Coumadin
while pregnant.
Take Coumadin at the same time each day.
If you miss ___ dose, take it as soon as you rememberunless its
almost time for your next dose. In that case, skip the dose you
missed. ___ take a double dose.
Keep appointments for blood (protime/INR) tests as often as
directed.
___ take any other medications without checking with your
doctor first. This includes over-the-counter medications and any
herbal remedies.
Other Precautions
Tell all your healthcare providers that you take Coumadin. Its
also a good idea to carry a medical identification card or wear
a medical ID bracelet.
Use a soft toothbrush and an electric razor.
___ go barefoot. ___ trim corns or calluses yourself.
Keep Your Diet Steady
Keep your diet pretty much the same each day. Thats because
many foods contain vitamin K. Vitamin K helps your blood clot.
So eating foods that contain vitamin K can affect the way
Coumadin works. You ___ need to avoid foods that have vitamin
K. But you do need to keep the amount of them you eat steady
(about the same day to day). If you change your diet for any
reason, such as due to illness or to lose weight, be sure to
tell your doctor.
Examples of foods high in vitamin K are asparagus, avocado,
broccoli, and cabbage. Oils, such as soybean, canola, and olive
oils are also high in vitamin K.
Alcohol affects how your body uses Coumadin. Talk to your doctor
about whether you should avoid alcohol while youre using
Coumadin.
Herbal teas that contain sweet clover, sweet ___, or tonka
beans can interact with Coumadin. Keep the amount of herbal tea
you use steady.
Possible Side Effects
Tell your doctor if you have any of these side effects, but
___ stop taking the medication until your doctor tells you to.
___ side effects include the following:
More gas (flatulence) than usual
Bloating
Diarrhea
Nausea
Vomiting
Hair loss
Decreased appetite
Weight loss
When to ___ Your Doctor
___ your doctor immediately if you have any of the following:
Trouble breathing
Swollen lips, tongue, throat, or face
Followup Instructions:
___
|
10196336-DS-16 | 10,196,336 | 20,770,222 | DS | 16 | 2188-05-03 00:00:00 | 2188-05-05 06:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nausea/Vomiting, PineSol Ingestion, ___
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ year old M with history of heroin abuse (last use approx 24
hours ago) Hep C who presented for accidental ingestion of
___. Per patient, drank approx 2 tbsp of ___ that his
wife had in a cup on the table for cleaning. Denies SI/ideations
of self-harm. He had episode of pink emesis without frank blood,
and no abdominal pain.
He has a history of Hep C, not on any treatment, which he states
was diagnosed last year. He also complains of diffuse muscle
aches and pains, with elevated CK on admission to hospital at
466.
Admission labs remarkable for a Cr of 3.7 (baseline approx
0.7-0.9), with anion gap of 23, which has since improved to 1.6
with a gap of 17.
Patient feels "on edge" this morning, which he is attributing to
withdrawal; he states that he has never fully gone through
withdrawal before because he will continuously use or inhale
heroin. Denies chest pain, nausea/vomiting, shortness of breath,
abd pain, nausea/vomiting, or diarrhea/constipation.
Past Medical History:
Positive PPD in ___, which was rechecked in ___ and
subsequently negative (never treated).
Peptic ulcer disease.
Hepatitis C diagnosed ___ ___ per patient report
Social History:
___
Family History:
Denies family history of psychiatric illness or chemical
dependence
Physical Exam:
===============
ADMISSION EXAM:
===============
VS - 97.9, 124/72, 57, 18, 99% on room air
General: Anxious gentleman, standing next to hospital bed,
continuously stretching muscles
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: distant heart sounds, bradycardic, normal S1 + S2, no
murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Very thin, well healed horizontal abdomianl scar at
umbilicus, soft, non-distended, minimally tender to palpation
RUQ without rigidity or guarding, no hepatosplenomegaly, normal
bowel sounds present, no fluid wave
GU: No foley, no CVA tenderness
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema; no calf swelling, tenderness, erythema or induration
Skin: No rashes or lesions, hyperpigmentation consistent with
sunexposure on back and chest
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
===============
DISCHARGE EXAM:
===============
VS - 98.1, 124/86, 65, 18, 100% on room air
General: Anxious-appearing gentleman, laying in hospital bed
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: distant heart sounds, bradycardic, normal S1 + S2, no
murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Very thin, well healed horizontal abdominal scar at
umbilicus, soft, non-distended, minimally tender to palpation
RUQ without rigidity or guarding, no hepatosplenomegaly, normal
bowel sounds present, no fluid wave
GU: No foley, no CVA tenderness
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema; no calf swelling, tenderness, erythema or induration
Skin: No rashes or lesions, hyperpigmentation consistent with
sunexposure on back and chest
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
Pertinent Results:
===============
ADMISSION LABS:
===============
___ 01:50PM PLT COUNT-224
___ 01:50PM NEUTS-75.0* LYMPHS-12.6* MONOS-10.5 EOS-0.6*
BASOS-0.8 IM ___ AbsNeut-7.66* AbsLymp-1.29 AbsMono-1.07*
AbsEos-0.06 AbsBaso-0.08
___ 01:50PM WBC-10.2* RBC-4.62 HGB-14.6 HCT-44.0 MCV-95
MCH-31.6 MCHC-33.2 RDW-13.3 RDWSD-46.5*
___ 01:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 01:50PM RHEU FACT-11
___ 01:50PM OSMOLAL-300
___ 01:50PM ALBUMIN-4.8
___ 01:50PM ALT(SGPT)-48* AST(SGOT)-51* CK(CPK)-466* ALK
PHOS-58 TOT BILI-0.5
___ 01:50PM estGFR-Using this
___ 01:50PM GLUCOSE-127* UREA N-51* CREAT-3.7* SODIUM-141
POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-24 ANION GAP-23*
___ 06:06PM LACTATE-1.0
___ 06:06PM ___ COMMENTS-GREEN TOP
___ 06:09PM ___ PO2-46* PCO2-47* PH-7.40 TOTAL
CO2-30 BASE XS-2
==================
PERTINENT RESULTS:
==================
___ 01:50PM BLOOD Glucose-127* UreaN-51* Creat-3.7* Na-141
K-4.1 Cl-98 HCO3-24 AnGap-23*
___ 08:01AM BLOOD Glucose-95 UreaN-44* Creat-1.6*# Na-136
K-3.5 Cl-98 HCO3-25 AnGap-17
___ 01:50PM BLOOD ALT-48* AST-51* CK(CPK)-466* AlkPhos-58
TotBili-0.5
___ 08:01AM BLOOD ALT-34 AST-44* LD(LDH)-436* CK(CPK)-272
AlkPhos-46 TotBili-0.6
___ 01:50PM BLOOD Osmolal-300
___ 08:01AM BLOOD Osmolal-289
___ 08:01AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE
___ 08:01AM BLOOD CRP-0.5
___ 01:50PM BLOOD RheuFac-11
___ 08:01AM BLOOD C3-93 C4-13
___ 01:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 01:50PM BLOOD HoldBLu-HOLD
___ 06:09PM BLOOD ___ pO2-46* pCO2-47* pH-7.40
calTCO2-30 Base XS-2
___ 06:06PM BLOOD Lactate-1.0
___ 12:14AM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 12:14AM URINE Color-Yellow Appear-Clear Sp ___
___ 12:14AM URINE RBC-5* WBC-4 Bacteri-NONE Yeast-NONE
Epi-<1
___ 12:14AM URINE Hours-RANDOM UreaN-1225 Creat-243 Na-41
K-65 Cl-LESS THAN TotProt-31 Phos-123.3 Prot/Cr-0.1
___ 12:14AM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-POS amphetm-NEG oxycodn-NEG mthdone-NEG
___ 8:01 am IMMUNOLOGY
**FINAL REPORT ___
HCV VIRAL LOAD (Final ___:
8,850,000 IU/mL.
Performed using Cobas Ampliprep / Cobas Taqman HCV v2.0
Test.
Linear range of quantification: 1.50E+01 IU/mL - 1.00E+08
IU/mL.
Limit of detection: 1.50E+01 IU/mL.
___ 12:14 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Renal Ultrasound (___): IMPRESSION:
No evidence of hydronephrosis.
===============
DISCHARGE LABS:
===============
___ 08:00AM BLOOD WBC-5.0 RBC-4.07* Hgb-13.1* Hct-39.3*
MCV-97 MCH-32.2* MCHC-33.3 RDW-13.4 RDWSD-47.4* Plt ___
___ 08:01AM BLOOD WBC-6.2 RBC-4.45* Hgb-14.1 Hct-44.9
MCV-101* MCH-31.7 MCHC-31.4* RDW-13.7 RDWSD-50.4* Plt ___
___ 08:00AM BLOOD Plt ___
___ 08:00AM BLOOD ___ PTT-27.5 ___
___ 08:01AM BLOOD Plt ___
___ 08:01AM BLOOD ___ PTT-25.8 ___
___ 08:00AM BLOOD Glucose-87 UreaN-28* Creat-1.0 Na-140
K-3.8 Cl-105 HCO3-26 AnGap-13
___ 03:28PM BLOOD Glucose-96 UreaN-40* Creat-1.6* Na-138
K-4.5 Cl-102 HCO3-26 AnGap-15
___ 08:00AM BLOOD ALT-33 AST-38 LD(LDH)-333* AlkPhos-45
TotBili-0.5
___ 08:01AM BLOOD ALT-34 AST-44* LD(LDH)-436* CK(CPK)-272
AlkPhos-46 TotBili-0.6
Brief Hospital Course:
Mr. ___ is a ___ year old gentleman with history of hepatitis C
who presents with accidental PineSol ingestion and was
subsequently found to have acute renal failure, which improved
to the patient's approximate baseline with fluids.
ACTIVE ISSUES:
===============
# Acute renal failure
# Anion gap acidosis:
The patient presented for accidental PineSol ingestion, but
admission labs were remarkable for a serum creatinine of 3.7 and
FENa of 0.44% with a mild gap acidosis. Urinalysis was
unremarkable and sediment analysis was nondiagnostic. Creatinine
downtrended with IV fluids, likely in response to volume
depletion in the setting of poor fluid intake combined with mild
starvation ketoacidosis from poor PO intake. Cr returned to
normal at 1.0 at time of discharge.
# Toxic Ingestion:
The patient initially presented to the Emergency Department for
an accidental PineSol ingestion; per the patient, he had
accidentally drank approximately 2 tablespoons of cleaner that
his wife had poured into a cup on a table to use for cleaning,
thinking it was tea. He denied any suicidal ideations or
thoughts of self-harm with assessment by psychiatry during
hospitalization. Admission labs were remarkable for an elevated
anion gap of 23 that normalized with fluids but thought to be a
separate process as discussed above. A toxicology consult was
called, but the amount of toxin the patient ingested and the
timing of the observed laboratory abnormalities were not
consistent with damage due to acute toxin ingestion so no
further intervention was warranted.
# Polysubstance Abuse:
The patient endorsed a history of both heroin and cocaine abuse,
using both substances multiple times per week. Urine toxicology
screen was positive for both substances on admission. He was
placed on ___ protocol with lorazepam, methocarbamol,
loperamide, and Vistaril as needed. A social work consult was
placed in order to help the patient transition to a ___
clinic for further management of opiate abuse, in an effort to
maintain and promote sobriety.
# Depression:
The psychiatry consult liaison service was consulted; the
patient expressed no suicidal or homicidal ideations. He denied
ingesting PineSol in an effort to harm himself. Recommended
continued follow-up on an outpatient basis.
CHRONIC ISSUES:
==============
# Hepatitis C:
The patient has a history of chronic hepatitis C, diagnosed in
___. Hepatitis C viral load was 8,850,000 IU/mL. The patient
will follow-up with his new primary care physician for further
evaluation and treatment.
# Tobacco Abuse:
The patient was maintained on a nicotine patch while in-house
TRANSITIONAL ISSUES:
=====================
- Needs to regularly establish care with a primary care
physician, appointment arranged
- Continue Hepatitis C monitoring on an outpatient basis
- Recommend intensive outpatient detoxification program for
heroin and cocaine addiction with referral for ___ clinic,
which patient reported had been a barrier before
- Ensure adequate hydration and PO intake given acute kidney
injury that resolved with fluids
- Recommend outpatient psychiatry referral
- Encourage smoking cessation
# Code Status: Full Code
# CONTACT: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Naproxen 500 mg PO Q12H
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Acute Kidney Injury
Toxic Ingestion
Secondary Diagnosis:
Heroin Abuse
Cocaine Abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Intermittently Alert and interactive vs
sleepy and lethargic.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a plasure taking care of you at ___
___. You were admitted for an accidental ingestion of
PineSol. Additionally, your kidneys were injured from inadequate
fluid intake. You were given IV fluids and your kidney function
improved.
Avoiding further heroin and cocaine use is essential for your
health. You can injure your kidneys and other vital organs, such
as your brain and your heart with continued drug use.
Please avoid NSAID use (aspirin, ibuprofen, naproxen, etc.) due
to your kidney injury, you can use Tylenol if needed for pain
(do not exceed maximum dose of 3 grams per day).
Please attend all of your follow-up appointments as scheduled.
If you need to change an appointment, please attempt to make a
new appointment as close to your originally scheduled
appointment, in order to ensure safe follow-up.
We wish you the best in health,
Your Care Team at ___
Followup Instructions:
___
|
10196360-DS-14 | 10,196,360 | 26,789,435 | DS | 14 | 2118-01-13 00:00:00 | 2118-01-13 15:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / clonidine / Hydralazine /
phenytoin / amlodipine
Attending: ___.
Chief Complaint:
DOE, dry cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with a history of DM Type II, CKD since ___,
afib/flutter on coumadin, HTN, subarachnoid hemorrhage, and
aortic valve replacement x 2 here with DOE and dry cough.
Patient noted symptoms over the past two weeks. Seem to occur
when starting from a resting position (ie exiting car or when he
first walks up). Sxs are inconsistent as he has been able to do
his usual mile-long walk with his wife though he thinks he might
be going more slowly lately and avoiding stairs. Also noted new
onset bothersome dry cough over same period of time, seems worse
with lying flat. Notes orthopnea, PND, and 5lbs weight gain over
this time. No edema, abdominal distention, chest pain/pressure,
pleuritic CP, fevers, chills, nausea. Did recently travel to ___
___ in ___. Warfarin has been held recently due to EGD
yesterday.
In the ED, initial vitals were 0 98.0 56 185/64 22 99% RA Labs
notable for trop x 1 negative, creatinine 1.5 (recent bl), bnp
559, Hct 30.5, INR 1.0. CXR with Mild edema and cardiomegaly.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, myalgias, rash,
hemoptysis, black stools or red stools. 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
palpitations, syncope or presyncope.
Past Medical History:
Hypertension, essential
HISTORY AORTIC VALVE REPLACEMENT TWICE ___ for bicuspid
valve disease, bioprosthetic valve
SUBARACHNOID Hemorrhage
Gallstone pancreatitis requiring partial pancreatectomy leading
to DM and pancreatic insufficiency
HYPERCHOLESTEROLEMIA
ANEMIA, Fe def
Obesity
DM (diabetes mellitus), type 2, uncontrolled, with renal
complications, last a1c 10.3 ___
Atrial flutter/fibrillation on coumadin s/p ablation
CKD (chronic kidney disease) x ___ year, undergoing outpt workup
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission:
VS: 98.7 124/64 76 18 100%RA 66.1kg
General: well-appearing, pleasant, NAD
HEENT: dry MM
Neck: JVP at 12
CV: RRR, ___ systolic murmur at RUSB not radiating to carotids,
no ___ or rubs
Lungs: frequent coughing with deep inspiration, no crackles,
decreased breath sounds, dullness or egophony
Abdomen: soft, obese, normal BS, no HSM, not tender
Ext: 2+ DP and ___, no edema
Discharge
VS: 97.7 ___ 53-58 18 97% RA
90.3K (93.4 on admission)
1500/3100 (-1600) -275cc this morning
Telemetry- No overnight events; Avg HR 50-60s
GENERAL: AA OX3 NAD, breathing comfortably
HEENT: NCAT. PERRLA, EOMI, MMM. Sclera anicteric, no
conjunctival pallor. OP clear, trachea midline, no thyromegaly
or cervical LAD.
NECK: Supple, with JVP of 10 cm without evidence of HJR.
Carotids benign bilaterally.
CARDIAC: S1/S2 without MGR. PMI non-enlarged, non-displaced. No
parasternal or subxiphoid heaves, precordial thrills, or
palpable pulsations in the 3LICS.
LUNGS: Lungs CTAPB without WRR. Resp unlabored, no accessory
muscle use.
ABDOMEN: Soft, NT, ND. BS + X4, No HSM or tenderness. Abd aorta
not enlarged by palpation. No abdominal bruits.
EXTREMITIES: No CCE or edema. No femoral bruits. L femoral
access site unremarkable.
SKIN: No concerning lesions.
Pertinent Results:
___ 06:00AM BLOOD WBC-4.9 RBC-3.40* Hgb-9.7* Hct-29.2*
MCV-86 MCH-28.5 MCHC-33.3 RDW-12.9 Plt ___
___ 07:10PM BLOOD WBC-4.4 RBC-3.48* Hgb-9.9* Hct-30.5*
MCV-87 MCH-28.5 MCHC-32.6 RDW-12.9 Plt ___
___ 06:00AM BLOOD ___ PTT-30.0 ___
___ 06:00AM BLOOD Glucose-236* UreaN-27* Creat-1.7* Na-140
K-3.8 Cl-97 HCO3-31 AnGap-16
___ 07:10PM BLOOD Glucose-145* UreaN-21* Creat-1.5* Na-141
K-4.0 Cl-103 HCO3-27 AnGap-15
___ 06:00AM BLOOD CK-MB-2 cTropnT-<0.01
___ 01:37AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:10PM BLOOD cTropnT-<0.01
___ 07:10PM BLOOD proBNP-559*
Renal U/S: FINDINGS: The right kidney measures 11.9 cm and the
left kidney measures 10.5cm. There is no hydronephrosis,
nephrolithiasis, or focal renal lesions bilaterally.
IMPRESSION: No ultrasonographic abnormalities of the kidneys
identified.
Chest X-ray: IMPRESSION: Mild edema and cardiomegaly.
Brief Hospital Course:
This is a ___ man with a h/o afib on coumadin, AVRX2 with
bioprosthetic valve, HTN, HL,DM here with SOB concerning for
new-onset acute heart failure.
#Heart Failure: given pt report of weight gain, congestion on
CXR, heart failure was thought the likeliest diagnosis., however
pro-BNP level is indeterminate at 559, though this could be
falsely low due to his obesity. Pulmonary infection was possible
though he does not have other infectious s/s, no fever, chills,
night sweats, leukocytosis.
After diuresing 2L and a weight loss of 4 pounds, patient was
symptomatically much improved. An echocardiogram was not
obtained due to the weekend coverage and should be obtained as
an outpatietn. He did not exhibit any fevers, rashes, other
symptoms that would point to endocarditis. He did have a
systolic and diastolic murmur that seem to be old per old
records.
He was discharged on a 20mg dose of PO lasix. His chlorthalidone
was discontinued so as to not double up on diuretics. His
lisinopril was continued as was his carvedilol.
# CKD: Stable creatinine elevation ~1.5 noted since ___,
peaking in the 2.3 range in early ___. Likely related to DM
but being worked up by ___ as outpatient. Renal U/S was
negative.
- outpatient follow-up
#DM: Good control in-house. Cont outpatient regimen.
# AFib/Aflutter: Maintained sinus rhythm throughout his
hospitalization. INR subtherapeutic today as warfarin was held
for outpatient EGD yesterday. Continued carvedilol and coumadin
# Pancreatic insufficiency: s/p partial pancreatectomy after
gallstone pancreatitis
- consider restarting creon as outpt
Transitional Issues:
-follow up volume status
-obtain echo
-renal u/s was negative
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Chlorthalidone 25 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. Omeprazole 20 mg PO BID
4. Warfarin 5 mg PO DAILY16
5. Terazosin 5 mg PO HS
6. Simvastatin 20 mg PO DAILY
7. Carvedilol 25 mg PO BID
8. Aspirin 81 mg PO DAILY
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Glargine 40 Units Bedtime
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Carvedilol 25 mg PO BID
3. Glargine 40 Units Bedtime
4. Lisinopril 40 mg PO DAILY
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Omeprazole 20 mg PO BID
7. Simvastatin 20 mg PO DAILY
8. Terazosin 5 mg PO HS
9. Warfarin 5 mg PO DAILY16
10. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute systolic heart failure
secondary: chronic kidney disease
Hypertension
Aortic valve replacement
Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you had shortness of
breath. We think this is because you have too much fluid in your
body as a result of your heart pumping too softly. We got rid of
your fluid with a medicine called Lasix.
We will continue to give you lasix as well as your lisinopril.
We will discontinue the chlorthalidone.
You will need to follow up soon with your cardiologist in order
to obtain another echocardiogram, or ultrasound of your heart.
Also, be sure to take your blood pressure medicines and keep
your pressure under control.
Limit the amount of sodium you consume to less than 2grams. If
you gain more than 3 pounds, please call your doctor. You
currently weigh 90.3 Kg (199 lbs)
Followup Instructions:
___
|
10196360-DS-15 | 10,196,360 | 25,427,434 | DS | 15 | 2121-03-21 00:00:00 | 2121-03-22 22:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / clonidine / Hydralazine /
phenytoin / amlodipine / trimethoprim / lisinopril / losartan /
spironolactone
Attending: ___.
Chief Complaint:
___, Dyspnea on exertion
Major Surgical or Invasive Procedure:
Transesophageal Echocardiogram and Cardioversion
History of Present Illness:
___ year old man with a history of AS s/p two prior valve
replacements, diabetes, CKD, dCHF, atrial flutter s/p ablation
in ___ and atrial fibrillation who is admitted for ___. Pt
developed atrial fibrillation on ___ and subsequently underwent
cardioversion. He developed atrial fibrillation again and was
planned for a repeat cardioversion on ___. Pt had preop labs
drawn on ___, which showed Cr 3.0 (previously 1.9). He was
referred to the ED for further evaluation. Pt notes that he has
not noticed any changes to the quality or quantity of his urine.
No hematuria. Otherwise, his weight has been stable (dry weight
~200lb). He was recently started on dronedarone. Otherwise, no
changes to his diuretic regimen. No increased thirst. Pt denies
CP. He notes some DOE. No ___ swelling, although he has noticed
mild abdominal distension over the past week, which he gets when
he is volume overloaded.
In the ED, initial vitals: 97.7; 70; 125/54; 16; 100% RA
Labs notable for:
Cr 3.2 (1.9 on ___
H/H: 11.4/33.6 (near baseline)
Platelets 118
UA with 1000 glucose
- No imaging was performed
- Patient given: 1L NS
- Vitals prior to transfer:
97.2; 68; 101/47; 16; 98% RA
On arrival to the floor, pt reports feeling well.
Past Medical History:
Hypertension, essential
HISTORY AORTIC VALVE REPLACEMENT TWICE ___ for bicuspid
valve disease, bioprosthetic valve
SUBARACHNOID Hemorrhage
Gallstone pancreatitis requiring partial pancreatectomy leading
to DM and pancreatic insufficiency
HYPERCHOLESTEROLEMIA
ANEMIA, Fe def
Obesity
DM (diabetes mellitus), type 2, uncontrolled, with renal
complications, last a1c 10.3 ___
Atrial flutter/fibrillation on coumadin s/p ablation
CKD (chronic kidney disease) x ___ year, undergoing outpt workup
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION:
Vitals: 98.4; 103/62; 61; 17; 95 ra
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, JVP
could not be fully appreciated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Irregularly irregular. III/VI systolic murmur. III/VI
diastolic murmur.
Abdomen: soft, non-tender, moderately-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly. No
CVA tenderness.
Ext: Warm, well perfused, no cyanosis. Trace pitting edema in ___
Skin: Without rashes or lesions
Neuro: A&Ox3. Grossly intact.
DISCHARGE:
GENERAL: NAD
NECK: Supple with JVP ~9
CARDIAC: Irregular rhythm, normal S1, S2. Systolic and diastolic
murmurs best heard at the left sternal border
LUNGS: Resp were unlabored. Bibasilar crackles.
ABDOMEN: Soft, markedly distended, no tenderness.
EXTREMITIES: Trace pitting edema around ankles. Warm and well
perfused.
Pertinent Results:
ADMISSION:
___ 12:45AM BLOOD WBC-5.8 RBC-3.72* Hgb-11.4* Hct-33.6*
MCV-90 MCH-30.6 MCHC-33.9 RDW-16.2* RDWSD-53.2* Plt ___
___ 12:45AM BLOOD Neuts-67.9 Lymphs-17.2* Monos-8.9 Eos-5.5
Baso-0.2 Im ___ AbsNeut-3.96 AbsLymp-1.00* AbsMono-0.52
AbsEos-0.32 AbsBaso-0.01
___ 12:45AM BLOOD ___ PTT-41.8* ___
___ 12:45AM BLOOD Glucose-276* UreaN-94* Creat-3.2*# Na-135
K-3.7 Cl-96 HCO3-25 AnGap-18
___ 12:45AM BLOOD proBNP-1503*
___ 09:20AM BLOOD Calcium-8.9 Phos-4.4 Mg-2.5
DISCHARGE:
___ 05:58AM BLOOD WBC-5.4 RBC-3.72* Hgb-11.2* Hct-34.5*
MCV-93 MCH-30.1 MCHC-32.5 RDW-16.6* RDWSD-56.2* Plt ___
___ 05:58AM BLOOD ___ PTT-40.3* ___
___ 05:58AM BLOOD Glucose-167* UreaN-75* Creat-2.5* Na-139
K-3.6 Cl-102 HCO3-22 AnGap-19
___ 05:58AM BLOOD Calcium-9.3 Phos-3.8 Mg-2.4
___ Renal US:
Sub-centimeter simple renal cyst in the right upper pole.
Otherwise normal renal ultrasound. No hydronephrosis.
___ CXR:
Mediastinal wires are seen. There is marked cardiomegaly which
is stable. There is mild prominence of the pulmonary
interstitial markings without overt pulmonary edema. No focal
consolidation or pneumothoraces are seen
___ TTE:
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with inferior wall hypokinesis.
The remaining segments contract normally (LVEF = 50 %). The
estimated cardiac index is normal (>=2.5L/min/m2). The right
ventricular cavity is moderately dilated with borderline normal
free wall function. [Intrinsic right ventricular systolic
function is likely more depressed given the severity of
tricuspid regurgitation.] The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(?#) appear structurally normal with good leaflet excursion.
Moderate (2+) aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. Moderate (2+) mitral
regurgitation is seen. There is also diastolic mitral
regurgitation. Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with mild regional systolic dysfunction
suggestive of CAD. Moderate pulmonary artery systolic
hypertension. Moderate aortic regurgitation. Moderate mitral
regurgitation. Right ventricular cavity dilation with low normal
free wall motion.
___ TEE:
Mild spontaneous echo contrast is present in the left atrial
appendage. No thrombus is seen in the left atrial appendage. No
atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). The ascending, transverse and
descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque to 35 cm from the incisors. The aortic
valve leaflets are mildly thickened (?#). Moderate to severe
(___) aortic regurgitation is seen. The aortic regurgitation
jet is eccentric, directed toward the anterior mitral leaflet.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
There is no pericardial effusion.
IMPRESSION: No intracardiac thrombus seen.
Brief Hospital Course:
___ year old man with a history of aortic stenosis s/p two prior
valve replacements, diabetes, CKD, diastolic CHF, atrial flutter
s/p ablation in ___ and atrial fibrillation who was admitted
for ___. His ___ was thought to be due to volume congestion
and/or dronaderone use. The patient was diuresed with
improvement in creatinine. He had transesophageal echocardiogram
with cardioversion on ___ which successfully restored sinus
rhythm. He was discharged on dronaderone for rhythm control and
his diltiazem was stopped. He should follow-up with cardiology
and for outpatient creatinine/chemistries for ___ and ___
failure.
Acute Kidney Injury on Chronic Kidney Disease:
The patient presented with creatinine 3.2. Baseline appears to
be ~1.7-1.9. There was concern for congestion due to acute heart
failure exacerbation versus toxicity from dronaderone. The
patient was diuresed with IV Lasix toward euvolemia with
improvement in creatinine to 2.5. He was discharged on
dronaderone. He should have follow-up creatinine to ensure
resolution of ___. If the patient has persistent or worsening
___, would recommend further diuresis or re-assessment of
dronaderone as appropriate. Of note, allopurinol dose was
decreased due to decreased creatinine clearance.
#Atrial Fibrillation:
CHADS2 = 3. The patient was initially supratherapeutic and
warfarin was decreased until the patient was in the therapeutic
range. He was initially continued on diltiazem and dronaderone
was held on admission. The patient had TEE with cardioversion on
___ which successfully restored sinus rhythm. His diltiazem
was stopped, and he was continued on dronaderone at discharge.
He should continue on warfarin and should follow-up for INR. He
should follow-up with cardiology.
#Acute exacerbation of diastolic heart failure:
Admitted with dyspnea on walking. He was found to be fluid
overloaded and diuresed with IV Lasix. At the time of discharge,
his dyspnea had resolved. He was discharged on his prior home
dose of Bumetanide 4mg BID. He was continued on home eplerenone
and carvedilol. Home diltiazem was stopped as above. He should
follow-up with repeat BNP and with cardiology in the outpatient
setting.
#Diabetes:
The patient was continued on home regimen and a sliding scale.
His blood glucose control in the hospital was suboptimal and he
should follow-up for possible outpatient adjustment of his
diabetic regimen.
#Hyperlipidemia
-Continued home atorvastatin
#Gout:
Decreased allopurinol dose to 150mg daily in the setting of
decreased creatinine clearance.
TRANSITIONAL:
- Please repeat chemistry and BNP at next visit to ensure
improvement ___ and ___ failure
- Please check INR at next visit; supratherapeutic in house in
setting of atypical diet
- If the patient has persistent or worsening ___, would
recommend further diuresis or re-assessment of dronaderone as
appropriate
- Follow-up with cardiology for ___ and ___ failure
- Patient restarted on dronaderone s/p cardioversion for atrial
fibrillation, now in sinus rhythm
- Home diltiazem was stopped
- Allopurinol decreased from 300 mg to 150 mg in setting of
decreased Cr clearance
- Patient should follow-up for possible adjustment of diabetic
medication regimen as glucose control was suboptimal during
hospitalization
# CONTACT: ___ (wife) ___
# CODE STATUS: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO QPM
2. Carvedilol 25 mg PO BID
3. Diltiazem Extended-Release 180 mg PO DAILY
4. Dronedarone 400 mg PO BID
5. Warfarin 2.5 mg PO 3X/WEEK (___)
6. Warfarin 3.75 mg PO 4X/WEEK (___)
7. Creon 12 1 CAP PO TID W/MEALS
8. Atorvastatin 20 mg PO QPM
9. Glargine 18 Units Breakfast
Glargine 15 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
10. Bumetanide 4 mg PO BID
11. Eplerenone 12.5 mg PO QAM
12. Omeprazole 20 mg PO BID
13. Influenza Vaccine Quadrivalent 0.5 mL IM NOW X1
Start: ___, First Dose: Next Routine Administration Time
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Bumetanide 4 mg PO BID
4. Carvedilol 25 mg PO BID
5. Creon 12 1 CAP PO TID W/MEALS
6. Dronedarone 400 mg PO BID
7. Eplerenone 12.5 mg PO QAM
8. Glargine 18 Units Breakfast
Glargine 15 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
9. Omeprazole 20 mg PO BID
10. Warfarin 3.75 mg PO 4X/WEEK (___)
11. Warfarin 2.5 mg PO 3X/WEEK (___)
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Acute exacerbation of diastolic heart failure
Atrial Fibrillation status-post cardioverson
Acute Kidney Injury
Secondary:
Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted to ___ because you had some shortness of
breath and evidence of kidney injury on labs. While you were
here, we gave you medicine to help get extra fluid out of your
body. We also did an electrical "cardioversion" of your heart to
switch in back from atrial fibrillation into a normal rhythm.
This was successful. When you leave, please remember to take all
of your medications as directed. If you feel shortness of
breath, chest pain, or any other concerning symptoms, please
call your doctor or report to the emergency department
immediately. Please weigh yourself every morning, call MD if
weight goes up more than 3 lbs.
Thank you for allowing us to care for you here,
Your ___ Care Team
Followup Instructions:
___
|
10196360-DS-17 | 10,196,360 | 22,054,493 | DS | 17 | 2121-08-30 00:00:00 | 2121-08-30 15:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / clonidine / Hydralazine /
phenytoin / amlodipine / trimethoprim / lisinopril / losartan /
spironolactone / protamine
Attending: ___.
Chief Complaint:
lightheadedness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with a PMHx of HFrEF and recent TAVR
who presents for lightheadedness. He notes that he was in his
USH until this afternoon when he developed lightheadedness and
dizziness. He reports it lasted on the order of minutes, and
when he went outside to sit down and wait for the ambulance the
sensation dissipated. He denies CP, SOB, abd pain, cough, LOC,
or syncope with this. He notes since discharge continuing on his
current medication regimen, including clopidogrel, as his
warfarin has not been therapeutic.
In the ED, initial vitals were:
98.2 113 120/81 18 100% RA
- Exam notable for:
Lungs clear to auscultation
Systolic murmur
No abdominal tenderness
No peripheral edema
- Labs notable for:
SCr 1.9, urine with glc 1000
- Imaging was notable for:
none completed
- Patient was given:
___ 21:27 IV Adenosine 6 mg
___ 21:33 IV Adenosine 6 mg
___ 22:00 IV Verapamil 10 mg
Past Medical History:
Aortic valve replacement, ___ for bicuspid valve disease,
bioprosthetic valve; TAVR ___
___
Gallstone pancreatitis requiring partial pancreatectomy leading
to DM and pancreatic insufficiency
HYPERCHOLESTEROLEMIA
Iron deficiency anemia
Obesity
DM (diabetes mellitus), type 2, uncontrolled
Atrial flutter/fibrillation on coumadin s/p ablation
CKD (chronic kidney disease)
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
Vital Signs: 98.2 119/82 113 20 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP not elevated. no LAD
CV: Tachycardic and irrgeular. Normal S1+S2, ___ systolic
ejection murmur throughout precordium
Lungs: Minimal crackles in RLL, otherwise CTAB
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE PHYSICAL EXAM:
========================
Tele: regular rhythm, ventricular tachycardia, RBBB.
Is/Os: ___ (100/750)
Weight: 89.3 kg (89.0)
PHYSICAL EXAMINATION:
VS: T 98.5 BP 95/67 (90-110/60-70) HR 121 (110-120s) O2Sat 98%
RA
General: pleasant man, lying comfortably in bed, alert and
awake, speaking in full sentences, in NAD
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI
Neck: Supple, JVP to midneck
CV: Tachycardic, irregular rhythm. Normal S1+S2, ___ systolic
ejection murmur throughout precordium
Lungs: Decreased breath sounds on right, no crackles, wheezes,
or rhonchi.
Abdomen: +BS, soft, NTND, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
=================
___ 08:30PM BLOOD WBC-6.5 RBC-3.99* Hgb-12.5* Hct-37.0*
MCV-93 MCH-31.3 MCHC-33.8 RDW-14.8 RDWSD-50.4* Plt ___
___ 08:30PM BLOOD Neuts-70.0 Lymphs-14.9* Monos-8.3 Eos-5.7
Baso-0.5 Im ___ AbsNeut-4.56 AbsLymp-0.97* AbsMono-0.54
AbsEos-0.37 AbsBaso-0.03
___ 08:30PM BLOOD Glucose-353* UreaN-52* Creat-1.9* Na-135
K-3.8 Cl-96 HCO3-23 AnGap-20
___ 08:30PM BLOOD CK(CPK)-57
___ 08:30PM BLOOD CK-MB-4
___ 08:30PM BLOOD cTropnT-<0.01
___ 08:55PM URINE Color-Straw Appear-Clear Sp ___
___ 08:55PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
NOTABLE LABS:
=============
___ 03:29AM BLOOD ___ PTT-21.7* ___
___ 05:45AM BLOOD ___ PTT-33.5 ___
___ 05:30AM BLOOD ___
___ 08:30PM BLOOD CK-MB-4
___ 08:30PM BLOOD cTropnT-<0.01
___ 03:29AM BLOOD CK-MB-4 cTropnT-0.02*
DISCHARGE LABS:
================
___ 05:30AM BLOOD ___
___ 05:30AM BLOOD Glucose-191* UreaN-50* Creat-2.0* Na-138
K-3.4 Cl-98 HCO3-25 AnGap-18
___ 05:30AM BLOOD Calcium-9.2 Phos-3.4 Mg-2.0
IMAGING:
=========
___ Imaging CHEST (PORTABLE AP)
Compared to chest radiographs since ___ most recently ___.
Severe cardiomegaly is chronic. Mild pulmonary vascular
congestion is also long-standing. There is no pulmonary edema
or focal pulmonary abnormality although the very large cardiac
silhouette obscures the lower lungs. Lateral view would be very
helpful for their assessment. No appreciable pleural effusion.
No pneumothorax.
Brief Hospital Course:
Mr. ___ is a ___ year old man with h/o HFrEF (EF 40-45% on
___, atrial flutter/fibrillation (s/p ablation and multiple
cardioversions, on Coumadin), T2DM (s/p pancreatectomy), s/p
recent TAVR on ___ who presented with lightheadedness, found
to have tachycardia.
#Supraventricular Tachycardia
#Atrial flutter
Pt p/w lightheadedness with EKGs demonstrating regular wide
complex tachycardia with RBBB morphology. He received adenosine
in the ED with subsequent tracings compatible with atypical
flutter. His troponins peaked at 0.02 but his CK-MB remained
flat, likely ___ demand ischemia in setting of sustained
tachycardia. During admission, patient remained tachycardic in
the 100-120s range although without symptoms. His metoprolol
succinate was fractionated and uptitrated to a total dose of
200mg daily with continued tachycardia. EP was consulted, who
recommended adding digoxin 0.125mg every other day. During the
admission, he remained asymptomatic and was discharged with
close EP cardiology follow up.
#Chronic HFrEF
Patient with EF 40-45% on last TEE. Appeared euvolemic on exam.
His bumex was continued on his home dose. During the admission,
he reported feeling fluid overloaded and his Bumex was increased
from 3mg qAM and 2mg qPM to 3mg BID for 1 day (___) with
plans to resume home dose of 3mg qAM and 2mg qPM on ___. His
eplerenone was also held in the context of uptitrating his
metoprolol.
#s/p TAVR
Patient underwent successful TAVR on ___, on ASA with
Plavix bridge to Coumadin. Upon admission his INR was
subtherapeutic at 1.6. His home dose of Coumadin was increased
to 4mg daily. The Plavix was discontinued when his INR became
therapeutic.
#GERD
Patient on omeprazole at home. His omeprazole was held and he
was started on pantoprazole given concurrent Plavix use. He was
then restarted on home omeprazole after Plavix was discontinued
(as above).
TRANSITIONAL ISSUES:
====================
#Medication changes:
- increased metoprolol succinate to 100mg BID
- started digoxin 0.125mg every other day (first dose ___
- held eplerenone
- increased warfarin to 4mg daily
- discontinued Plavix
- started potassium 20mg PO daily
- increased bumex ___ dose to 3mg for ___. To resume 2mg qPM
on ___
[] Digoxin level to be drawn ___. Please follow up level.
[] Patient reported feeling fluid overloaded with increase in
weight. Bumex ___ dose on ___ increased to 3mg. Will then
resume home dose of 3mg qAM and 2mg qPM. Please f/u fluid status
and weights and adjust bumex dose as needed. Also please check
creatinine and potassium on ___ for medication adjustments.
[] Patient's warfarin increased to 4mg daily for subtherapeutic
INR. INR on discharge 2.3. Also started on digoxin. Please check
INR on weekly basis until warfarin dose stabilized.
[] Patient's eplerenone held while uptitrating metoprolol.
During admission, SBP ___. Please consider restarting
eplerenone once pressures can tolerate.
# CODE: full (confirmed)
# CONTACT/HCP: ___ (wife) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Bumetanide 2 mg PO QPM
4. Creon 12 1 CAP PO TID W/MEALS
5. Eplerenone 25 mg PO QAM
6. Metoprolol Succinate XL 25 mg PO BID
7. Omeprazole 20 mg PO BID
8. Aspirin 81 mg PO DAILY
9. Clopidogrel 75 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Warfarin 3.75 mg PO 4X/WEEK (___)
12. Warfarin 2.5 mg PO 3X/WEEK (___)
13. Glargine 18 Units Breakfast
Glargine 15 Units Bedtime
14. Bumetanide 3 mg PO QAM
Discharge Medications:
1. Digoxin 0.125 mg PO EVERY OTHER DAY
RX *digoxin 125 mcg 1 tablet(s) by mouth every other day Disp
#*15 Tablet Refills:*0
2. Potassium Chloride 20 mEq PO DAILY
RX *potassium chloride 20 mEq 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
3. Bumetanide 3 mg PO QAM
4. Bumetanide 3 mg PO QPM
Please take 3mg on ___. On ___ resume taking 2mg qPM
RX *bumetanide 1 mg 3 tablet(s) by mouth qPM Disp #*90 Tablet
Refills:*0
5. Glargine 18 Units Breakfast
Glargine 15 Units Bedtime
6. Metoprolol Succinate XL 100 mg PO BID
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
7. Warfarin 4 mg PO DAILY16
RX *warfarin [Coumadin] 2 mg 2 tablet(s) by mouth daily16 Disp
#*60 Tablet Refills:*0
8. Allopurinol ___ mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Atorvastatin 20 mg PO QPM
11. Creon 12 1 CAP PO TID W/MEALS
12. Omeprazole 20 mg PO BID
13. Vitamin D 1000 UNIT PO DAILY
14. HELD- Eplerenone 25 mg PO QAM This medication was held. Do
not restart Eplerenone until instructed by your doctor
15.Outpatient Lab Work
Draw Chem 7 and digoxin level
Fax results to Dr. ___
___ number: ___
ICD code: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
====================
Supraventricular Tachycardia
Chronic heart failure with reduced ejection fraction
SECONDARY DIAGNOSES:
====================
Type 2 diabetes mellitus
GERD
Chronic kidney disease
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were recently admitted to ___
___.
Why I was here?
- You came in with lightheadedness and found to have a fast
heart rate.
- You were also found to have a low INR.
What happened while I was here?
- Your metoprolol dose was increased and you were started on a
new medication, digoxin.
- Your warfarin was increased to help get your INR level up.
When it became greater than 2.0, your Plavix was discontinued.
- Your Bumex was increased to 3mg morning and night.
What I should do when I go home?
- Continue to take all of your medications as prescribed.
- Follow up with Dr. ___ in clinic.
- Get your labs drawn on ___
- Weigh yourself every morning, call your doctor if your weight
goes up by more than 3 lbs.
Thank you for allowing us to care for you,
Your ___ Care Team
Followup Instructions:
___
|
10196368-DS-17 | 10,196,368 | 20,365,916 | DS | 17 | 2188-03-20 00:00:00 | 2188-03-21 07:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Amoxicillin / Flagyl / Latex / Percocet / ___
___ (Lotion Moisturizer) / Bactrim
Attending: ___.
Chief Complaint:
Fevers, chills
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ yo M with hx of Crohn's disease, BPH, MICU stays in
___ for GI bleeding c/b E.coli urosepsis, and more recent
admission for UTI discharged ___ who presents with fevers,
chills, and hypotension. The pt has a chronic indwelling foley
due to a failed voiding trial after his admission in ___. The
catheter has intermittently obstructed with clots and developed
leaks. He was recently admitted on ___ for UTI and hypotension.
As he has a hx of S. aureus UTI resistant to cipro, the pt
received IV gentamycin and CTX. He was then transitioned to PO
bactrim but was switched to vanc/cefepime after he developed
delirium and fevers. He was transitioned to a 14-day course of
keflex ___ mg PO Q6H. Blood and urine cultures during that
admission were negative. On ___, he was discharged on keflex
___ mg PO TID x 10 days.
The following day the pt developed severe lower abdominal pain
and decreased urinary output. He was seen in the ED early
yesterday morning where his foley was exchanged with relief of
his symptoms. He was also started on bactrim DS BID out of
concern for ongoing UTI. Per his wife, after discharge from the
ED he had worsening confusion at home, elevated from his
baseline. He developed fevers and chills, prompting his wife to
bring him to ___ yesterday afternoon.
In the ___, VS were T 102.8 HR 130 BP 88/49 RR 26. WBC
4 w/ 81% Neuts, lactate 4. He was given 2L NS, 650 tylenol, and
1 g CTX IV. UA was dirty, and urine cultures were drawn. He was
brought to the BI for further management.
In the BI ED, VS T 100.8 HR 118 BP 85/40 RR 18 O2Sat 97%. Pt
noted to have dry mucous membranes and was ___ on exam. Labs
were notable for WBC 3.9 w/ 93% Neut, Hct 31.7, Plt 70 (similar
to baseline). Cr 1.2 (baseline 0.8) and lactate 2.4. UA with LG
leuks, neg nitrites, WBC >182, and FEW bacteria. He was given 5L
of IV NS. Central line was placed.
On arrival to the MICU, VS T 99.2 HR 105 BP 104/56 RR 20 O2Sat
95% 4L NC. Pt endorsed fevers, chills, and chronically mild
cough at home but denied recurrence of lower abdominal pain,
abdominal distention, N/V, bloody stools, changes in bowel
habits, or SOB. He did not appear in acute distress and was
lying comfortably in bed.
Past Medical History:
- Crohn's disease s/p procto-colectomy with ileostomy ___ ___ Dr. ___.
- Melanoma left forearm, ___
- s/p right elbow surgery
- BPH
- DJD
- s/p Right knee replacement
- HTN
- Alcohol Dependence
- Alcoholic Cirrhosis
- UGIB
- DM2
- Aortic stenosis (mild on echo ___ with valve area
1.2-1.9cm2)
- C2 fracture ___
- Hyperlipidemia
- Depression
Social History:
___
Family History:
Biological Mother ___ - STROKE
Biological Father ___ at age ___.
Son - ___ disorder
Son - melanoma
Physical ___:
VS T 99.2 HR 105 BP 104/56 RR 20 O2Sat 95% 4L NC
GENERAL - ___ yo M comfortably lying in bed, appropriate and in
NAD
HEENT - PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no cervical lymphadenopathy, no JVD (though
difficult to assess due to habitus)
LUNGS - Bibasilar crackles, resp unlabored, no accessory muscle
use
HEART - Sinus tach, ___ SEM over RSB
ABDOMEN - NABS, soft/NT, somewhat distended (his baseline), no
rebound/guarding, ostomy site clean
EXTREMITIES - warm extremities, 2+ peripheral pulses (radials,
DPs), wearing pneumoboots
NEURO - awake, ___, CNs II-XII grossly intact, no asterixis
Pertinent Results:
___ 08:15PM BLOOD WBC-3.9* RBC-3.63* Hgb-10.2* Hct-31.7*
MCV-87 MCH-28.0 MCHC-32.1 RDW-16.0* Plt Ct-70*
___ 03:53AM BLOOD WBC-4.4 RBC-2.93* Hgb-8.3* Hct-25.6*
MCV-88 MCH-28.4 MCHC-32.5 RDW-16.0* Plt Ct-61*
___ 06:45AM BLOOD WBC-5.2 RBC-3.21* Hgb-8.9* Hct-27.8*
MCV-87 MCH-27.7 MCHC-32.0 RDW-15.8* Plt Ct-80*
___ 08:15PM BLOOD Plt Smr-VERY LOW Plt Ct-70*
___ 03:53AM BLOOD ___ PTT-39.6* ___
___ 06:45AM BLOOD Plt Ct-80*
___ 08:15PM BLOOD Glucose-115* UreaN-20 Creat-1.2 Na-141
K-4.4 Cl-108 HCO3-22 AnGap-15
___ 03:53AM BLOOD Glucose-126* UreaN-20 Creat-1.0 Na-139
K-4.6 Cl-111* HCO3-21* AnGap-12
___:45AM BLOOD Glucose-102* UreaN-14 Creat-0.8 Na-140
K-3.8 Cl-106 HCO3-29 AnGap-9
___ 03:53AM BLOOD proBNP-997*
___ 03:53AM BLOOD ALT-24 AST-62* LD(LDH)-140 AlkPhos-120
TotBili-1.8*
___ 06:45AM BLOOD ALT-17 AST-41* LD(LDH)-141 AlkPhos-124
TotBili-0.9
___ 08:42AM BLOOD Albumin-2.4* Calcium-10.7* Phos-3.4
Mg-1.6
___ 12:08PM BLOOD PTH-32
___ 08:42AM BLOOD 25VitD-27*
___ 03:20PM BLOOD PEP-NO SPECIFI IgG-1310 IgA-728* IgM-88
IFE-NO MONOCLO
.
CT ABDOMEN:
CONCLUSION:
1. New hepatic hypodensities, two in the left lobe, possibly
representing
cysts but new compared to ___ and heterogeneous serpiginous
hypodensity
posteriorly in the right lobe, possibly sequela from the
patient's recent
episodes of sepsis but for which magnetic resonance imaging is
recommended for further evaluation. Note that this occurs on a
background of mild cirrhotic change, splenomegaly and trace
ascites.
2. Status post ileostomy with no evidence of obstruction or
abdominal mass. Mild mesenteric stranding.
3. Stable prostate enlargement with thickened bladder wall and
indwelling Foley.
4. Atherosclerosis including coronary artery disease and
mild-to-moderate cardiomegaly.
5. Contour and trabecular irregularity in the posterior right
iliac wing not changed compared to ___.
6. A 4- to 5-mm pancreatic hypodensity, question IPMN. This
can be assessed with MRI when the patient's liver abnormality is
evaluated.
.
___ CXR:
There are low lung volumes. Nevertheless, there is substantial
enlargement of the cardiac silhouette with evidence of pulmonary
vascular congestion. Retrocardiac opacification is consistent
with volume loss in the lower lobes. Blunting of the
costophrenic angle on that side is consistent with a small
effusion.
.
___:
No evidence of left lower extremity deep venous thrombosis. The
calf veins were not well evaluated.
.
Prostate transurethral resection of prostate:
Stromal and glandular hyperplasia.
MRCP
IMPRESSION:
1. Segment 4A 1.9 cm hypervascular lesion with washout
consistent with HCC.
2. Segments ___ T2 hypointense branch like lesions most likely
represent
focal thrombophlebitis.
3. Persistent cirrhosis, splenomegaly, small varices.
4. Multiple cystic lesions throughout the pancreatic
parenchyma, the largest
in the uncinate process containing an enhancing mural nodule,
with slightly
dilated main duct, consistent multiple side branch IPMN's.
Brief Hospital Course:
___ man w/PMHx including alcoholic cirrhosis, recurrent UTIs
associated
w/obstructive BPH and chronic Foley, admitted w/sepsis from
another UTI also found to have asymptomatic hypercalcemia.
.
#Sepsis / urinary tract infection: Patient presented with SIRS
and fluid responsive hypotension with urinary source risk factor
of indwelling foley and abnormal urinalysis. The urine culture
grew yeast (recent treatment with cefelexin and bactrim). Blood
cultures were no growth. He was started on broad spectrum
antibiotics but then given clinical improvement without culture
data was transitioned to ceftriaxone. He was ordered for
fluconazole for the yeast and appears to have received 2 doses.
Pt was treated with antibiotics for 14 days of therapy.
.
#Bladder outlet obstruction / BPH: Urology was consulted and the
patient underwent inpatient TURP on ___. He tolerated the
procedure well. Post-operative CBI was weaned and voiding trial
was successful with multiple PVR's of zero.
.
#Hypercalcemia: The patient was noted to have an elevated
calcium. The PTH was normal. SPEP and UPEP were normal. Vitamin
D was slightly low, pt is taking a MVI. pTHrP was 13. CT abdomen
and pelvis showed new hepatic hypodensities and a pancreatic
hypodensity. An MRI was obtained to further characterize this,
which showed a new liver nodule concerning for HCC.
.
#Etoh cirrhosis: He has a history of compensated disease without
obvious ascites, encephalopathy, or upper variceal bleeding
(has known ___ bleeding). Hepatology was consulted
pre-operatively. He was continued on rifaxamin. The nadolol and
diuretics were held. There was mild evidence of encephalopathy
post-operatively and lactulose was started on ___.
.
#Hepatic hypodensity / pancreatic hypodensity: MRI abdomen a new
liver nodule concerning for HCC. This was discussed with the
patient and his wife. The patient will be discussed at Liver
tumor board on ___ and he will follow up with hepatology to
discuss next steps.
# Anemia: Attributed to anemia of chronic disease. Hct
stabilized at 27. Pt continued to have mild hematuria following
TURP. Will need to follow up hematocrit as an outpatient.
.
CHRONIC ISSUES:
#Chronic orthostatic hypotension: He was continued on midodrine.
In the past he has had to stop furosemide, spironolactone, and
nadolol and tamsulosin because of this.
.
#Crohn's: s/p procto-colectomy w/ileostomy ___
#History of GI bleed: continued on pantoprazole
#Hyperlipidemia: pravastatin
#Mild AS:
#Diabetes: diet controlled as outpatient
#Depression: sertraline
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. traZODONE 50 mg PO HS:PRN insomnia
2. Sertraline 50 mg PO DAILY
3. Pravastatin 10 mg PO DAILY
4. Pantoprazole 40 mg PO Q24H
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze
7. FoLIC Acid 1 mg PO DAILY
8. Rifaximin 550 mg PO BID
Please call Dr. ___ about "prior authorization" with
your insurance
9. Miconazole Powder 2% 1 Appl TP TID:PRN fungal infection
10. Midodrine 10 mg PO TID
11. Cephalexin 500 mg PO Q6H
12. Sulfameth/Trimethoprim DS 1 TAB PO BID
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Miconazole Powder 2% 1 Appl TP TID:PRN fungal infection
3. Midodrine 10 mg PO TID
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Pravastatin 10 mg PO DAILY
7. Rifaximin 550 mg PO BID
8. Sertraline 50 mg PO DAILY
9. TraZODone 50 mg PO HS:PRN insomnia
10. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze
11. Lactulose 30 mL PO TID
RX *lactulose 20 gram/30 mL 30 mL by mouth three times a day
Disp #*1000 Milliliter Refills:*0
12. Cefpodoxime Proxetil 400 mg PO Q12H
RX *cefpodoxime 200 mg 2 tablet(s) by mouth every twelve (12)
hours Disp #*6 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Urinary tract infection
bladder outlet obstruction
cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with a urinary tract infection. You were
treated with antibiotics and your symptoms improved. You
underwent a TURP to treat your bladder outlet obstruction due to
an enlarged prostate. You tolerated the procedure well and were
able to urinate normally on discharge. You will need to continue
antibiotics post discharge for three more days.
You were found to have a high calcium level. You will need to
follow up with an endocrinologist after discharge for ongoing
evaluation.
Followup Instructions:
___
|
10196692-DS-5 | 10,196,692 | 24,402,467 | DS | 5 | 2117-09-04 00:00:00 | 2117-09-04 14:43:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fall, head strike, SDH, head laceration
Major Surgical or Invasive Procedure:
scalp laceration repair with skin staples (___)
History of Present Illness:
Ms. ___ is a ___ yo woman with a PMH of Arthritis and Gout who
presents as an OSH transfer from ___ ___ with fall and
subdural hematoma. She reports that she rolled out of bed this
morning; unclear if she experienced loss of consciousness. At
the OSH, she was found to have a 7 cm scalp laceration; CT head
demonstrated 5 mm SDH. CT neck was negative. She endorsed
headache without vision changes numbness, tingling, weakness,
chest pain, or abdominal pain.
She notes increasing falls over the past few years. Patient
moved to assisted living facility for more frequent falls. Notes
about 4 falls a year. Notes falls are not mechanical or related
to vertigo. Denies chest pain, no history of palpitations or
seizure. Was encouraged to use walker, which she has been using.
Patient notes she always gets short of breath with walking. Saw
a pulmonologist in ___, Dr ___. Endorses slight
headache.
In the ED, initial vitals were: T 97.2F BP 153/95 mmHg P 96 RR
18 O2 96% RA
Exam notable for: A&O, 8 cm laceration to top of head w/ staples
in place, hematoma, no active bleeding. Neurologically intact.
RRR, CTAB, abdominal soft, moving all extremities with normal
range of motion. No pain.
Labs showed
CHEMISTRIES:
140 / 100 / 29
---------------< 72
5.2 / 19 / 0.9
Trop-T: <0.01
proBNP: 84
CBC:
13.2
8.8 >----< 192
39.5
DIFF:
N:66.4 L:18.5 M:11.1 E:1.9 Bas:0.7 ___: 1.4 Absneut: 5.84
Abslymp: 1.63 Absmono: 0.98 Abseos: 0.17 Absbaso: 0.06
COAGS:
___: 10.4 PTT: 22.6 INR: 1.0
UA: few bacteria, small leuks, trace blood, neg nitrites, 5 ___
Imaging showed: CT head with unchanged R cerebral convexity
subacute subdural hematoma without significant mass effect or
shift of normally midline structures. No new intracranial
hemorrhage as well as left frontal soft tissue swelling and
laceration towards the vertex without underlying fracture. CXR
was normal.
Received PO Metoprolol Tartrate 25 mg and IV Metoprolol Tartrate
5 mg for SVT to 170s.
Transfer VS were 98 93 159/104 13 96% Nasal Cannula
Neurosurgery, ___, and CM were consulted.
Decision was made to admit to medicine for further management
pending placement at rehab.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. denies sinus tenderness, rhinorrhea or congestion. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denies arthralgias or myalgias.
Past Medical History:
Rheumatoid Arthritis
HTN
Chronic shoulder pain
Social History:
___
Family History:
Mother with balance issues, father had a stomach ulcer, brother
with high blood pressure.
Physical Exam:
ADMISSION PHYSICAL EXAM:
============================
Vital Signs: 98.2 PO 128 / 84 L Lying 97 19 99 4L
General: Alert, oriented, no acute distress
HEENT: Head with large laceration over left frontal scalp. 8
staples in place. Crusted blood. Sclerae anicteric, MMM,
oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no
LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation,
DISCHARGE PHYSICAL EXAM:
============================
Vital Signs: 97.5 PO 149 / 90 L Lying ___
General: Alert, oriented, no acute distress, well appearing
HEENT: Head with large laceration over left frontal scalp. 8
staples in place. Crusted blood. Sclerae anicteric, MMM,
oropharynx clear, EOMI, PERRL, neck supple, JVP not elevated, no
LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Faint bibasilar rales that clear with coughing.
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,
Pertinent Results:
ADMISSION LABS:
==============================
___ 10:20AM BLOOD WBC-8.8 RBC-4.00 Hgb-13.2 Hct-39.5
MCV-99* MCH-33.0* MCHC-33.4 RDW-13.6 RDWSD-48.4* Plt ___
___ 10:20AM BLOOD Neuts-66.4 Lymphs-18.5* Monos-11.1
Eos-1.9 Baso-0.7 Im ___ AbsNeut-5.84 AbsLymp-1.63
AbsMono-0.98* AbsEos-0.17 AbsBaso-0.06
___ 10:20AM BLOOD ___ PTT-22.6* ___
___ 10:20AM BLOOD Glucose-72 UreaN-29* Creat-0.9 Na-140
K-5.2* Cl-100 HCO3-19* AnGap-26*
___ 10:20AM BLOOD proBNP-84
___ 10:20AM BLOOD cTropnT-<0.01
___ 07:26AM BLOOD Calcium-9.2 Phos-4.4 Mg-2.3
___ 10:20AM BLOOD VitB12-600
___ 10:20AM BLOOD TSH-0.94
___ 10:20AM URINE Color-Straw Appear-Clear Sp ___
___ 10:20AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
___ 10:20AM URINE RBC-<1 WBC-5 Bacteri-FEW Yeast-NONE
Epi-<1 TransE-<1
MICROBIOLOGY:
==============================
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING & STUDIES:
==============================
+ CT Head: Unchanged right cerebral convexity subacute subdural
hematoma without significant mass effect or shift of normally
midline structures. No new intracranial hemorrhage. Left frontal
soft tissue swelling and laceration towards the vertex without
underlying fracture.
+ CXR ___: Essentially normal chest for age.
+ ECG: SVT to 168 on most recent EKG, also sinus tach to 114 on
previous
DISCHARGE LABS:
==============================
___ 05:00AM BLOOD WBC-5.8 RBC-3.72* Hgb-12.4 Hct-37.8
MCV-102* MCH-33.3* MCHC-32.8 RDW-13.4 RDWSD-50.4* Plt ___
___ 05:00AM BLOOD Glucose-103* UreaN-22* Creat-1.0 Na-143
K-3.9 Cl-105 HCO3-26 AnGap-16
___ 07:20AM BLOOD ALT-15 AST-20 LD(LDH)-279* AlkPhos-51
TotBili-0.6
Brief Hospital Course:
Ms. ___ is a very pleasant ___ y/o woman with a history
rheumatoid arthritis and gout who presented originally to ___
___ with fall from bed c/b traumatic subdural hematoma and
scalp laceration. Hospital course notable for mild hypoxemia,
tachycardia and orthostasis, which have improved. Patient was
seen by physical therapy who felt that patient would benefit
from rehabilitation prior to returning home.
# S/p fall: Patient had fall with headstrike after rolling out
of bed while asleep. Low suspicion for cardiac etiology given
mechanical nature to fall and headstrike, however history of
recurrent falls (though without LOC) without clearly mechanical
component is concerning for cardiac etiology. However, she was
seen by physical therapy who noted gait instability,
deconditioning and physical therapy needs. She was also found to
be mildly orthostatic in the hospital which may have predisposed
to previous falls, though likely did not contribute to current
fall from bed. She was monitored on telemetry with no evidence
of arrhythmia but did have sinus tachycardia up to 130s with
ambulation, though this improved with encouraging PO intake and
IV fluids. She is being discharged to rehab to prevent
deconditioning and work on balance and gait training.
# Scalp laceration: Secondary to hitting head on dresser while
falling. Patient presented to ___ with head lac,
where skin staples were placed on ___. She will staples removed
on ___.
# Subacute Traumatic Subdural Hematoma: Patient was found to
have traumatic subdural hematoma (7mm) Repeat NCHCT showed
stable subacute SDH without mass effect or midline shift. Exam
showed no focal neurological deficits. Neurosurgery evaluated
patient and felt that no acute neurosurgical intervention was
needed and that she should be scheduled for 1 month follow-up
with repeat NCHCT.
# Narrow complex, regular supraventricular tachycardia: Patient
found to have HR in 170s upon presentation in the ED, though not
captured by EKG. Unclear if sudden onset or gradual to determine
if sinus tach, AT vs AVNRT. She was hemodynamically stable with
this heart rate and HR normalized with IV Lopressor and home
metroprolol dose. She was continued on metoprolol tartrate 25mg
BID without further arrhythmia. She was monitored on telemetry
and was noted to have HR that increased to 130s at time with
ambulation though primarily resting in ___ and 110s with
ambulation. EKG showed sinus rhythm without strain pattern.
Wells score for 1.5 points, indicating ___ risk group: 1.3%
chance of PE in an ED population. Given improvement with IVF and
metoprolol, and low Well's score, CTA was deferred.
[ ] if patient has true syncopal episode, reasonable to setup
long-term event monitor.
[ ] if worsening tachycardia or hypoxia, reasonable to pursue
CTA.
CHRONIC ISSUES:
=========================
# HTN: continued metoprolol BID
# GERD: continued omeprazole
# Rheumatoid Arthritis: continue home regimen.
TRANSITIONAL ISSUES:
=========================
# CODE: Full
# CONTACT: ___ (proxy) ___ / ___ (caretaker)
___
[ ] Patient should not drive until re-evaluation by OT.
[ ] Head staples placed on ___, remove on ___.
[ ] Patient will need to followup with neurosurgery for
re-evaluation and repeat non-contrast head CT.
[ ] if patient has true syncopal episode, reasonable to setup
long term event monitor.
[ ] if worsening tachycardia or hypoxia, reasonable to pursue
CTA.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Metoprolol Tartrate 25 mg PO BID
2. Methotrexate 2.5 mg PO 1X/WEEK (MO)
3. Multivitamins 1 TAB PO DAILY
4. Omeprazole 20 mg PO DAILY
5. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
6. Aspirin 81 mg PO Q6H:PRN pain
7. Actemra (tocilizumab) 162 mg/0.9 mL subcutaneous 1X/WEEK
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
3. Senna 17.2 mg PO HS
4. TraZODone 25 mg PO QHS:PRN insomnia
5. Actemra (tocilizumab) 162 mg/0.9 mL subcutaneous 1X/WEEK
6. Methotrexate 2.5 mg PO 1X/WEEK (MO)
7. Metoprolol Tartrate 25 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 20 mg PO DAILY
10. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
11. HELD- Aspirin 81 mg PO Q6H:PRN pain This medication was
held. Do not restart Aspirin until you see your neurosurgeon
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSIS
=============================
# S/p fall with headstrike and laceration
# Stable Subacute SDH
# Narrow complex, Regular supraventricular tachycardia
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 meeting you and taking care of you. You were
admitted to ___ after a fall from rolling out of bed. You hit
your head and had a large cut on your head and suffered a small
bleed in your head. You had a staples placed to control the
bleeding and help the cut heal, these will need to be removed on
___. You had imaging of your head which showed that the
intra-cranial bleed (subdural hematoma) was stable in size and
that you did not need surgery but will need to followup with the
neurosurgeons in one month where you will need another CT scan
of your head. We recommend that you not drive until you have
seen the neurosurgeons and an occupational therapist to discuss
resuming driving.
We wish you the best,
Your ___ team
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.
-No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
***Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
-You may use Acetaminophen (Tylenol) for minor discomfort
What You ___ Experience:
- You may have difficulty paying attention, concentrating, and
remembering new information.
- Emotional and/or behavioral difficulties are common.
- Feeling more tired, restlessness, irritability, and mood
swings are also common.
- Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
- Headache is one of the most common symptom after a brain
bleed.
- Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
- Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
- There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
Followup Instructions:
___
|
10196757-DS-7 | 10,196,757 | 29,070,483 | DS | 7 | 2153-02-03 00:00:00 | 2153-02-03 22:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Zocor / Ciprofloxacin / Quinolones / Statins-Hmg-Coa Reductase
Inhibitors / Niacin
Attending: ___.
Chief Complaint:
Several months of low back pain with acute worsening
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI:
Mr. ___ is a pleasant ___ gentleman with a history of
chronic back pain (and h/o prior lumbar fusion),
nephrolithiasis,
CAD, AF (on coumadin), and hypertension who presented to the ED
today due to acute worsening of his back pain last night. He
states that he woke up in the middle of the night with
excruciating lower back pain. The pain was located where he
typically has had pain in the past, but this particular event
was
much more severe than his usual pain. For the past several
months
his lower back has been bothering him. He says he has had some
outpatient workup for the pain, but is unable to describe
exactly
what has been done and what he has been told in terms of
diagnosis. He has had two separate CABG surgeries in the past,
no
peripheral vascular surgeries or workup. He denies any leg pain,
leg numbness, leg weakness, cramping, or any other signs or
symptoms of claudication. He denies any chest pain or shortness
of breath. He denies any abdominal pain, emesis, or diarrhea.
He first presented overnight at an OSH (I believe ___, where a CTA torso was performed as part of his
workup.
Per the OSH read, the imaging was only significant for "90%
occlusion of the SMA", which prompted transfer to ___. Given
this reported finding, Vascular Surgery was called for
consultation.
Past Medical History:
Past Medical History:
Atrial fibrillation (on Coumadin)
Diabetes
GERD
Hypertension
Hyperlipidemia (does not tolerate statin therapy)
H/o prostate cancer s/p radiation
Pancytopenia
Chronic back pain
GI bleed ___ while on Plavix
Nephrolithiasis
Chronic back pain
Osteoarthritis
CAD s/p CABG x2
________________________________________________________________
Past Surgical History:
Lumbar disc fusion 1970s
Multiple lithotripsies
Bilateral knee replacements
CABG #1 ___ RIMA-RCA and SVG-OM
CABG #2 ___ LIMA-LAD, SVG-OM, and SVG-OM-PDA
Multiple percutaneous coronary interventions
Social History:
___
Family History:
Father passed away from CAD at age ___, uncle with CAD age ___.
Mother with CVA in her ___. No other cardiac history. No
arrhythmia, cardiomyopathies, or sudden cardiac death.
Physical Exam:
Discharge Physical Exam:
Gen: Awake, alert, NAD
HEENT: Sclerae anicteric, mucous membranes moist, oropharynx is
clear.
NECK: Trachea is midline, thyroid unremarkable, no palpable
cervical lymphadenopathy, no visible JVD.
CV: Regular rate, irregular rhythm, well-healed prior CABG
incision.
PULM/CHEST: Clear to auscultation bilaterally, respirations are
unlabored on room air.
ABD: Soft, nondistended, nontender, no rebound or guarding,
nontympanitic, no palpable masses, no hernias.
Ext: No lower extremity edema, distal extremities feel warm and
appear well-perfused. No skin breakdown or ulcerations.
Pulses: R P/P/P/D; L P/P/P/D
Pertinent Results:
Discharge labs
___ 07:30AM BLOOD WBC-2.5* RBC-3.75* Hgb-12.7* Hct-38.0*
MCV-101* MCH-33.9* MCHC-33.4 RDW-14.6 RDWSD-54.7* Plt Ct-99*
___ 07:30AM BLOOD ___ PTT-32.4 ___
___ 07:30AM BLOOD Glucose-139* UreaN-16 Creat-0.8 Na-139
K-3.7 Cl-104 HCO3-25 AnGap-14
___ 07:30AM BLOOD Calcium-9.0 Phos-2.7 Mg-1.9
___ CTA Abd Pelvis
IMPRESSION:
1. Similar appearance of prevertebral hypodense with mass effect
on the
posterior aspect of the suprarenal abdominal aorta at the level
of the
diaphragmatic hiatus, near the origins of the celiac axis and
superior
mesenteric artery, which causes extrinsic compression and severe
narrowing of the abdominal aorta. There is severe narrowing or
occlusion of the celiac artery origin.
2. Diverticulosis without evidence of diverticulitis.
3. Nodular appearance of the liver concerning for cirrhosis.
Recommend
correlation with clinical history and liver function tests.
___ MRA Abd
IMPRESSION:
The abdominal aorta at the level of the celiac axis is
extrinsically narrowed
by approximately 75% by a 2.1 x 1.5 cm cystic lesion, favored to
represent
focally dilated lymphatics. There is no evidence of aortic
dissection or
intraluminal thrombus. The constellation of of findings is
favored to
represent background chronic degenerative disc disease/
osteophyte formation
which has caught disruption of retroperitoneal lymphatics with
subsequent
formation of granulation tissue, and cystic structure
representing focally
dilated lymphatic channel exerting mass effect and narrowing the
abdominal
aorta. Alternatively the cystic lesion could represent
hemorrhagic material,
representative of a "discal cyst". Confirmatory assessment may
be obtained
via percutaneous sampling of this cystic structure, however
consultation with
intervention radiology is recommended if this is sought after.
___ MRI L spine
IMPRESSION:
1. Large prominent anterior osteophytes at L1-L2 with a lesion
just anterior
to the osteophytes which exerts mass effect on the aorta causing
luminal
narrowing. The lesion is favored to be extruded disc material
which extends
inferiorly up to the level of L3 vertebrae as described above.
The
prevertebral fluid is likely inflammatory response to the disc
protrusion.
However, consider the possibility of superimposed infection,
although there is
no evidence of diskitis or osteomyelitis.
2. Diffusely low T1/T2 marrow signal involving the visualized
lower thoracic
and lumbar vertebrae, nonspecific, either secondary to
myeloproliferative or
infiltrative disorder. Clinical correlation is recommended.
3. Diffuse fatty marrow involving the sacrum, probably secondary
to prior
radiation therapy.
4. Multilevel multifactorial degenerative disease of the lumbar
spine, worst
at L5-S1 with moderate bilateral neural foramen narrowing.
5. Please refer to separate dictation of MRA of the abdomen for
evaluation of
aortic patency.
Brief Hospital Course:
Mr ___ presented to the ___ ED on ___ for acutely
worsening lower back pain. He underwent multiple imaging tests
to evaluate the origin of his pain and was found to have a
cystic lesion at the level of his celiac axis of unclear
etiology. He was observed, and his pain improved with PO pain
medication. He was discharged on ___ after consultation
between the vascular surgery and spine surgery service, who both
felt that he was safe to follow up as an outpatient for further
evaluation and management. He was discharge with follow up
appointments scheduled, with instructions to restart all of his
home medications, and in good condition with minimal pain and
tolerating a diet. He will follow up with vascular surgery,
spine surgery, and his PCP.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ___ (warfarin) 4 mg oral 4X/WEEK
2. ___ (warfarin) 3 mg oral 3X/WEEK
3. Allopurinol ___ mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. MetFORMIN (Glucophage) 500 mg PO QHS
6. Isosorbide Dinitrate 30 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. NIFEdipine CR 30 mg PO DAILY
9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
10. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
11. Duloxetine 20 mg PO DAILY
12. Propranolol 30 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID
5. Duloxetine 20 mg PO DAILY
6. Isosorbide Dinitrate 30 mg PO DAILY
7. Propranolol 30 mg PO DAILY
8. Jantoven (warfarin) 4 mg oral 4X/WEEK
9. Jantoven (warfarin) 3 mg oral 3X/WEEK
10. MetFORMIN (Glucophage) 500 mg PO QHS
11. NIFEdipine CR 30 mg PO DAILY
12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
Discharge Disposition:
Home
Discharge Diagnosis:
Aortic lesion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted to ___ for
evaluation of your lumbar discs by the spine and vascular
surgeons. You were also medically optimized prior to surgery.
Your aortic lesion was evaluated, and you will follow up as an
outpatient to discuss further surgical management. You are ready
to go home.
Please restart your Coumadin at your previous dosage.
Followup Instructions:
___
|
10196817-DS-19 | 10,196,817 | 23,322,665 | DS | 19 | 2144-02-19 00:00:00 | 2144-02-19 08:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo male with a history of melanoma being treated with
nivolumab and ipilimumab who is admitted with diarrhea. The
patient states the diarrhea started about 2 weeks ago but got
significantly worse over the last 3 days. He called his primary
oncology office who had him start taking Imodium and then
lomotil
which he was taking every six hours and still having almost
constant diarrhea. He also has been taking simethicone for the
bloating and cramping he has been having. He denies any fevers,
nausea, shortness of breath, dysuria, or rash. Of note he did
have a rash which was thought to be related to ipilimumab and he
was put on prednisone with resolution. He is currently on a
prednisone taper.
Given the large amount of diarrhea he went to his local ED where
he was given solumedrol for possible ipilimumab colitis per his
primary oncologist. Stool studies were also done and he was then
transferred.
REVIEW OF SYSTEMS:
- All reviewed and negative except as noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
- Patient notes that his twin brother ___ first pointed out a
black mole on his back one year prior to presentation. Over the
past summer it started growing so he sought dermatologic care
with Dr. ___, ___. He had a biopsy
on
___. Biopsy showed malignant melanoma at least 2.75 mm
deep, nodular type, ulcerated, 6 mitoses/mm2, positive margins,
no PNI or LVI. Patient was referred to ___ clinic
for further management. He had a wide local excision and
sentinel
lymph node biopsy on ___. This unfortunately showed
residual melanoma to a depth of 9.___s some
microsatellites. One lymph node completely replaced with tumor
and second was with micro-metastases, pT4bN3MX, stage IIIc.
Patient went on to have a completion lymphadenectomy on
___. PET/CT showed one small area of uptake in the liver
with no discrete lesion. MRI abdomen did show a small lesion,
which would be very difficult to reach for biopsy. This was
followed and unfortunately eventually found to be consistent
with
melanoma. Lesion was treated with CyberKnife, but shortly
thereafter follow-up imaging found new subcutaneous nodules in
right back and axilla, lung nodules, and bone involvement.
- Patient was initiated on ___ protocol ___, "Nivolumab
plus
Ipilimumab plus Sargramostim versus Nivolumab plus Ipilimumab in
Patients with Unresectable Stage III/IV Melanoma." C1D1 was
___. He developed diffuse rash and shortness of breath
around ___, and is now on steroid taper. Cycle 2 is being
held pending conclusion of steroid taper.
PAST MEDICAL HISTORY:
- Hyperlipidemia
- Pre-diabetes
- CAD with MI and PCI in ___
- Gout
- Inguinal hernia
Social History:
___
Family History:
Father with ___ and ___ but no melanoma.
Physical Exam:
Discharge Exam
General: NAD
HEENT: MMM, no OP lesions
CV: RR, NL S1S2
PULM: CTAB
ABD: Soft, nontender, non-dstended, NABS
LIMBS: No edema, clubbing, tremors, or asterixis
SKIN: No rashes or skin breakdown
NEURO: Alert and oriented, no focal deficits.
Pertinent Results:
ADMISSION LABS
==============
WBC: 3.5*. RBC: 4.49*. HGB: 12.5*. HCT: 38.4*. MCV: 86. RDW:
14.1. Plt Count: 145*.
Neuts%: 85.9*. Lymphs: 9.2*. MONOS: 4.3*. Eos: 0.0*. BASOS: 0.3.
Na: 137. K: 5.0 (Hemolysis falsely elevates this test). Cl: 105.
CO2: 21*. BUN: 22*. Creat: 1.2. Ca: 9.2. Mg: 2.1. PO4: 4.2.
Alb: 3.9. AST: 30 (Hemolysis falsely elevates this test). ALT:
33. Alk Phos: 121. Total Bili: 0.8. Alb: 3.9.
IMAGING:
========
CT Abdomen: Preliminary Read:
1. No evidence of colitis or intra-abdominal infection.
2. Increased size of left lobe hepatic hypodensity and new 10 mm
right lower lobe pulmonary nodule are concerning for progressive
metastatic disease.
3. Stable osseous metastasis since ___ without evidence of
pathologic fracture.
Brief Hospital Course:
___ man w/PMHx metastatic melanoma s/p excision, XRT, nivolumab
and ipilimumab (C1D1 ___, presenting with autoimmune
colitis ___ ipilimumab.
# Melanoma
# Ipilumamb induced diarrhea, in the setting of metastatic
melanoma, also on nivolumab.
OSH C. diff negative. Patient was initially treated with IV
methylprednisone with significant improvement of his diarrhea.
He was transitioned from IV methylprednisone to prednisone 100
mg daily, which will be tapered as an outpatient. Because of
anticipated prolonged course of prednisone, he was placed on PPI
and Bactrim ppx. He was continued on his home
diphnoxylate-atropine and loperamide. Of note, CT imaging at
admission showed some metastatic lesions which will require
further follow-up.
# ___. Cr previously elevated to 1.3 from normal baseline, but
this resolved. Likely in setting of decreased PO intake and
significant GI losses recently as described above.
# Mild leukopenia and thrombocytopenia. Stable. Likely related
to recent monoclonal antibodies.
# Blurry vision. S/p exam w/Ophthalmology on ___ which was
unremarkable. Unclear etiology but no evidence that it is
concerning. If recurrent, he may need further outpatient workup.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. ClonazePAM 0.5 mg PO QHS:PRN Insomnia
4. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
5. LORazepam 0.5 mg PO Q4H:PRN Anxiety
6. PredniSONE 40 mg PO DAILY
Tapered dose - DOWN
7. Rosuvastatin Calcium 40 mg PO QPM
8. Aspirin 81 mg PO DAILY
9. LOPERamide 2 mg PO QID:PRN Diarrhea
10. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN Diarrhea
11. Simethicone 40-80 mg PO QID:PRN Flatulence/Bloating
Discharge Medications:
1. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
2. PredniSONE 100 mg PO DAILY
Decrease dose by 20 mg every four days.
Tapered dose - DOWN
RX *prednisone [Deltasone] 20 mg 100 mg by mouth daily Disp #*60
Tablet Refills:*0
3. Allopurinol ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atenolol 25 mg PO DAILY
6. ClonazePAM 0.5 mg PO QHS:PRN Insomnia
7. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN Diarrhea
8. LOPERamide 2 mg PO QID:PRN Diarrhea
9. LORazepam 0.5 mg PO Q4H:PRN Anxiety
10. Rosuvastatin Calcium 40 mg PO QPM
11. Simethicone 40-80 mg PO QID:PRN Flatulence/Bloating
Discharge Disposition:
Home
Discharge Diagnosis:
autoimmune colitis secondary to ipilimumab
acute renal failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted with diarrhea from one of the medications you
were given to treat your melanoma. The diarrhea was treated
with steroids, and you improved. You also noted some blurry
vision and were evaluated by the ophthalmologist who felt that
your eye exam was normal.
Please follow-up with your outpatient providers as instructed
below.
Thank you for allowing us to participate in your care. All best
wishes for your recovery.
Sincerely,
Your ___ medical team
Followup Instructions:
___
|
10196817-DS-20 | 10,196,817 | 27,093,784 | DS | 20 | 2144-07-06 00:00:00 | 2144-07-06 18:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
leg pain, weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with h/o metastatic melanoma on nivolumab
and s/p XRT to back mass and iliac met who presents with
worsening lower extremity pain and weakness.
Patient reports he has had pain in his legs since ___. It
is bilateral, but worse on the right than on the left. The pain
is mostly in his thighs and his hips. The pain radiates down his
legs bilaterally, though notably worse on the right. He denies
any numbness or tingling on either side or in his feet. He
denies any diarrhea or constipation. He denies any back pain. He
has felt increasingly weak, mostly due to the pain. He has been
taking ibuprofen as well as oxycodone for the pain, but neither
have been controlling the pain well. He is having a particularly
difficult time with sleeping at night given the pain. He denies
any fevers or chills. He presented to clinic today with these
symptoms and given his history of metastatic melanoma, was
referred to the ED.
In the ED, initial vitals were stable. A code cord was called.
MRI of the C-, T-, and L- spine did not show any cord
compression or evidence of malignant disease in the spine. There
was moderate multilevel degenerative changes, most pronounced at
L3-4 level with severe canal narrowing without evidence of cord
or caudal equina compression. Neurosurgery was consulted and did
not recommend any surgical intervention. Patient was given IV
morphine 4mg, 1mg IV dilaudid x 4, 1 tab Percocet x 2, oxycodone
10mg, 650mg Tylenol, and his home medications. He was then
admitted for pain control.
On the floor, patient reports that his pain is stable. The
dilaudid has worked the best for his pain control. Besides his
thighs, he is also complaining of pain in his knees,
particularly the left knee, which seems swollen to him. He also
believes his ankles have been a little swollen and painful.
ROS: positive per HPI, otherwise negative
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
- Patient notes that his twin brother ___ first pointed out a
black mole on his back one year prior to presentation. Over the
past ___ it started growing so he sought dermatologic care
with Dr. ___, ___. He had a biopsy
on
___. Biopsy showed malignant melanoma at least 2.75 mm
deep, nodular type, ulcerated, 6 mitoses/mm2, positive margins,
no PNI or LVI. Patient was referred to ___ clinic
for further management. He had a wide local excision and
sentinel
lymph node biopsy on ___. This unfortunately showed
residual melanoma to a depth of 9.___s some
microsatellites. One lymph node completely replaced with tumor
and second was with micro-metastases, pT4bN3MX, stage IIIc.
Patient went on to have a completion lymphadenectomy on
___. PET/CT showed one small area of uptake in the liver
with no discrete lesion. MRI abdomen did show a small lesion,
which would be very difficult to reach for biopsy. This was
followed and unfortunately eventually found to be consistent
with
melanoma. Lesion was treated with CyberKnife, but shortly
thereafter follow-up imaging found new subcutaneous nodules in
right back and axilla, lung nodules, and bone involvement.
- Patient was initiated on ___ protocol ___, "Nivolumab
plus
Ipilimumab plus Sargramostim versus Nivolumab plus Ipilimumab in
Patients with Unresectable Stage III/IV Melanoma." C1D1 was
___. He developed diffuse rash and shortness of breath
around ___, and completed a steroid taper. Now on
nivolomab monotherapy.
PAST MEDICAL HISTORY:
- Hyperlipidemia
- Pre-diabetes
- CAD with MI and PCI in ___
- Gout
- Inguinal hernia
Social History:
___
Family History:
Father with ___ and ___ but no melanoma.
Physical Exam:
Admission exam:
vitals: 98.2 PO 121/71 70 18 93% RA
General: well appearing elderly man, no acute distress
HEENT: PERRL, EOMI, oropharynx is clear
CV: r/r/r, no m/r/g
Resp: CTA bilaterally
Abd: soft, nontender, nondistended
Msk: there are large nodules over the left sacral area, right
scapula, right axilla that correspond to metastatic deposits
Neuro: alert and oriented, CN II-XII intact, strength is ___
bilateral hip flexion and extension, mostly limited by pain
Pertinent Results:
Admission labs:
___ 01:35PM BLOOD WBC-4.0 RBC-3.93* Hgb-10.2* Hct-33.0*
MCV-84 MCH-26.0 MCHC-30.9* RDW-13.7 RDWSD-42.4 Plt ___
___ 01:35PM BLOOD Neuts-76.5* Lymphs-6.3* Monos-12.9
Eos-2.5 Baso-0.5 Im ___ AbsNeut-3.03 AbsLymp-0.25*
AbsMono-0.51 AbsEos-0.10 AbsBaso-0.02
___ 01:35PM BLOOD Glucose-108* UreaN-13 Creat-0.7 Na-134
K-4.6 Cl-100 HCO3-25 AnGap-14
___ 01:22PM BLOOD Lactate-1.2
Imaging:
___ MRI C/T/L spine
IMPRESSION:
1. No evidence of spinal cord compression or cord signal
abnormality.
2. Significant multilevel degenerative changes are seen along
the spine, most notably in the lumbosacral spine, with
multifocal spinal canal stenosis, as described in detail above.
3. Multiple well-circumscribed, heterogeneous and predominantly
cystic
enhancing lesions are incompletely visualized abutting the right
psoas, left flank and left ilium, likely representing metastatic
lesions. These lesions were better seen on prior CT abdomen
pelvis from ___.
4. 1.6 cm right renal cyst.
IMPRESSION:
No previous images. The bony structures and joint spaces are
within normal
limits except for a small superior patellar spur. There is a
moderate joint
effusion.
Of incidental note is extensive vascular calcification in the
trifurcation
vessels.
DC LABS:
___ 07:20AM BLOOD WBC-3.6* RBC-3.69* Hgb-9.6* Hct-30.9*
MCV-84 MCH-26.0 MCHC-31.1* RDW-13.8 RDWSD-42.1 Plt ___
___ 08:06AM BLOOD Glucose-123* UreaN-15 Creat-0.8 Na-139
K-3.9 Cl-100 HCO3-27 AnGap-16
Brief Hospital Course:
Mr. ___ is a ___ man with h/o metastatic melanoma on nivolumab
and s/p XRT to back mass and iliac met who presents with
worsening lower extremity pain and weakness consistent with
cancer pain and radiculopathy from spinal stenosis and DJD
# lumbosacral radiculopathy
# degenerative disc disease
# acute on chronic cancer pain
Patient p/w worsening bilateral lower extremity pain and
weakness, concerning for cord compression but MRI was
reassuring. There was severe canal narrowing that may be
contributing to his symptoms. It was unclear if nivolumab was
contributing to worsening arthritis (this was a consideration at
his last oncology visit). Likely this pain was related to his
cancer and spine related disease. Palliative care was consulted
and he was initiated on Oxycontin 10mg BID with Oxycodone ___
q4 prn, Tylenol 1g TID, Ibuprofen, and consideration for
gabapentin 100mg qHS. Outpatient ___ was recommended.
# knee pain
# arthritis NOS
Bilateral knee pain, but L > R with palpable effusion noted on
exam. Per prior oncology notes, could be related to nivolumab.
Xray negative and good ROM. Recommended continued follow up.
Of note, recent ___ was negative for DVT.
# metastatic melanoma
Patient missed infusion of nivolumab given his admission. Will
be scheduled for next week.
# gout: continued allopurinol
# htn: continued home atenolol
# depression: continued home citalopram
# hld: continued home rosuvastatin
Code status: confirmed full code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atenolol 25 mg PO DAILY
4. ClonazePAM 0.5 mg PO QHS:PRN Insomnia
5. Rosuvastatin Calcium 20 mg PO QPM
6. Citalopram 20 mg PO DAILY
7. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Mild
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day
Disp #*180 Tablet Refills:*0
2. Gabapentin 100 mg PO QHS
RX *gabapentin 100 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
3. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
cancer related pain
RX *oxycodone [OxyContin] 10 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth once a day Disp #*90 Packet Refills:*0
5. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
6. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
7. Allopurinol ___ mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Atenolol 25 mg PO DAILY
10. Citalopram 20 mg PO DAILY
11. ClonazePAM 0.5 mg PO QHS:PRN Insomnia
12. Ibuprofen 800 mg PO TID
13. Rosuvastatin Calcium 20 mg PO QPM
14.Rolling Walker
dx: metastatic melanoma, cancer pain
prognosis: good
length of need: 13 months
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Radiculopathy/DJD spine
Acute on chronic cancer pain
Melanoma with metastasis to bone
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with increased leg pain and weakness. MRI of
the spine was re-assuring but did show arthritis. Palliative
care and ___ evaluated you and recommend continued ___ and follow
up with them. We have started new pain medication for you.
Please follow up closely with your oncologists for ongoing care
Followup Instructions:
___
|
10197135-DS-10 | 10,197,135 | 27,859,404 | DS | 10 | 2169-04-02 00:00:00 | 2169-04-02 17:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
escitalopram / venlafaxine
Attending: ___
Chief Complaint:
worsening LFTs, N/V
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with anxiety and confusion over the past several months
presenting with acutely elevated LFTs.
1 week ago began feeling poorly with nausea, HA, 1x vomiting.
Saw
PCP on ___ and LFTs in the 1000s. Repeated ___ AM and in
the 4000s. Had a liver MRI which didn't show any abnormalities.
No US or other testing. No history of liver disease. He has lost
about 10lbs in the past week or two.
Now actually feeling better; less pale, no nausea, no abdominal
pain. Still w/ minimal appetite. No travel. No raw seafood. No
herbals/supplements aside from wheat grass (purium brandname).
Has been taking wheat grass for about a month now. Two beers or
two shots a day for years.
Also has had confusion over the past several months. No clear
etiology. Reports negative CT Head. Neurocognitive testing
abnormal but reported it may be "due to anxiety." By confusion,
he means that he does not understand things fast. He also tends
to forget things more often.
In the ED,
- Initial vitals were: 97.8 86 139/97 16 98% RA
- Exam was notable for: GI: Soft, nontender, nondistended. No
hepatosplenomegaly. NEURO: AOx3. Moving all extremities
appropriately. No asterixis.
- Labs were notable for:
CBC wnl
Serum tox negative in particular negative EtOH and acetaminophen
CK 96
BMP wnl with Cr 1.1
ALT 2913 AST 1624 LDH 621 AP 123 Tbili 0.8 Alb 4
___ 14.3 PTT 27.6 INR 1.3
- Studies were notable for:
US doppler: patent hepatic vasculature, echogenic liver
consistent with steatosis, most advanced liver disease cannot be
excluded. No evidence of Budd-Chiari
- Hepatology consulted: acute hepatitis, no encephalopathy and
so
will admit to medicine, send off INR, CPK, LDH, HAV, HBV, HCV,
CMV, HSV, HEV, ___, AMA, ___, ceruloplasmin, tox screen, abd US
doppler. Per hepatology no NAC.
- Patient was given: nothing
On arrival to the floor, he states he is feeling much better, no
nausea or vomiting. Confirms not having any abdominal pain.
Past Medical History:
- Anxiety
Social History:
___
Family History:
- Negative for liver disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: reviewed in omr
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: supple
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing. .
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: Warm. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. No asterixis. No
dysdiadochokinesia. Unable to follow commands well (ie. when
asked to place ___ digit on his noise and demonstrating, he
would
use his ___ digit, then his ___ digit, and eventually his ___
digit)
DISCHARGE PHYSICAL EXAM:
========================
Well-appearing middle-aged male sitting comfortably in bed,
non-jaundiced, alert and conversant, abdomen soft, nontender,
nondistended
Pertinent Results:
Admission Labs
================
___ 11:42PM BLOOD WBC-5.5 RBC-4.70 Hgb-15.2 Hct-44.6 MCV-95
MCH-32.3* MCHC-34.1 RDW-13.5 RDWSD-46.1 Plt ___
___ 11:42PM BLOOD Neuts-55.8 ___ Monos-9.3 Eos-4.0
Baso-0.7 Im ___ AbsNeut-3.07 AbsLymp-1.62 AbsMono-0.51
AbsEos-0.22 AbsBaso-0.04
___ 11:42PM BLOOD Plt ___
___ 02:00AM BLOOD ___ PTT-27.6 ___
___ 11:42PM BLOOD ALT-2913* AST-1624* LD(LDH)-621*
CK(CPK)-96 AlkPhos-123 TotBili-0.8
___ 11:42PM BLOOD Albumin-4.0
___ 07:25AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.9
___ 11:42PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
Microbiology
------------
None
Imaging
-----------
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___
2:31 AM
IMPRESSION:
1. Patent hepatic vasculature with appropriate direction of
flow.
2. No sonographic findings specific to Budd-Chiari.
3. Normal spleen.
DUPLEX DOPP ABD/PEL Study Date of ___ 2:31 AM
IMPRESSION:
1. Patent hepatic vasculature with appropriate direction of
flow.
2. No sonographic findings specific to Budd-Chiari.
3. Normal spleen.
DISCHARGE LABS:
---------------
___ 06:15AM BLOOD WBC-6.5 RBC-4.73 Hgb-15.1 Hct-44.9 MCV-95
MCH-31.9 MCHC-33.6 RDW-13.9 RDWSD-47.7* Plt ___
___ 06:15AM BLOOD Glucose-101* UreaN-7 Creat-1.2 Na-141
K-4.9 Cl-103 HCO3-26 AnGap-12
___ 06:15AM BLOOD ALT-1548* AST-317* LD(LDH)-191 AlkPhos-94
TotBili-0.8
___ 04:02PM BLOOD IgG-994 IgA-387 IgM-155
___ 11:42PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 11:42PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG
IgM HAV-NEG
___ 11:42PM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 11:42PM BLOOD ___
___ 04:02PM BLOOD CMV VL-NOT DETECT
___ 04:02PM BLOOD HBV VL-NOT DETECT HCV VL-NOT DETECT
___ 04:02PM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD-Neg
___ 04:02PM BLOOD HERPES SIMPLEX VIRUS, TYPE 1 & 2 DNA,
QUANTITATIVE REAL TIME PCR-Neg
___ 01:20PM BLOOD CERULOPLASMIN-WNL
Brief Hospital Course:
___ M w/ anxiety and confusion over the past several months
presenting with acutely elevated LFTs to the thousands. There
was no evidence of synthetic dysfunction or hepatic
encephalopathy. Liver enzymes trended down spontaneously,
etiology as yet unclear. Will have outpatient hepatology and
neuropsych followup.
Acute Issues
=============
#Acute liver injury: No evidence of acute liver failure on
admission, given INR <1.5 and no hepatic encephalopathy. Likely
drug induced injury from previous exposure to escitalopram vs.
venlafaxine. Extensive infectious workup including
HAV/HBV/HCV/EBV/CMV/HSV was negative as were autoimmune
hepatitis serologies and ceruloplamin levels were WNL. Nothing
in history to suggest ischemic insult. US doppler revealed no
evidence of PVT or Budd Chiari. Per ___ paperwork, on ___: AST
___, ALT 1372. On ___: AST 4502, ALT 3537, Tbili 1.3.
Radiographic w/u w/ MRI abdomen on ___: no intrahepatic or
extrahepatic biliary dilatation, no clear radiographic evidence
of cirrhosis but some steatosis seen in right lobe. Patient
endorsed taking wheatgrass supplement, but per brief review,
this is not associated with ___. Tox screen was negative. LFTs
trended down. Patient will be seen in ___ clinic
the week of discharge.
#Anxiety
On escitalopram at home, held iso acute liver injury
Chronic Issues
===============
#Sub-acute cognitive decline
Mainly consisting of difficulties w/ memory and executive
function per history. MRI ___ without anatomic explanation. Has
reportedly had a neuropsych evaluation although we do not have
access to this. Provided patient with the number to schedule an
assessment with ___ neuropsychology should he choose to do so.
Also encouraged f/u with his PCP ___ 3 weeks of discharge.
TRANSITIONAL ISSUES:
====================
[] f/u w/ ___ Hepatology
[] repeat LFTs at hepatology appointment
[] Determine when safe to resume home escitalopram for anxiety
[] Remind him to schedule an appointment with neuropsychology
for further workup of subacute cognitive decline
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Escitalopram Oxalate 20 mg PO DAILY
2. Ibuprofen Dose is Unknown PO Frequency is Unknown
3. Acetaminophen Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Lidocaine 5% Patch 1 PTCH TD QAM knee pain
RX *lidocaine [Lidocaine Pain Relief] 4 % Apply to painful area
of knee QAM Disp #*10 Patch Refills:*0
2. HELD- Acetaminophen Dose is Unknown PO Frequency is Unknown
This medication was held. Do not restart Acetaminophen until
cleared by your liver doctor
3. HELD- Escitalopram Oxalate 20 mg PO DAILY This medication
was held. Do not restart Escitalopram Oxalate until instructed
by your liver doctor
4. HELD- Ibuprofen Dose is Unknown PO Frequency is Unknown
This medication was held. Do not restart Ibuprofen until
instructed by your liver doctor
Discharge Disposition:
Home
Discharge Diagnosis:
Acute liver injury of unclear etiology
Subacute mild cognitive impairment
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for an injury to your liver
What was done for me while I was in the hospital?
-We ordered a variety of tests to identify what caused your
liver injury
-It is still not entirely clear, and several tests are still
pending
-Your liver tests started improving nicely on their own.
What should I do when I leave the hospital?
-Please take all of your medications as prescribed and keep your
appointments, listed below
-Avoid any medications not prescribed by your doctor ___
supplements, Tylenol, ibuprofen, etc.) until specifically
instructed by your new liver doctor ___ you ___ see in clinic
this week)
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10197669-DS-14 | 10,197,669 | 29,663,549 | DS | 14 | 2170-04-20 00:00:00 | 2170-04-22 10:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Dilaudid
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
___: Cystoscopy, urethral dilation, foley placement
History of Present Illness:
Mr. ___ is a ___ male who complains of fall, T-spine
fracture, transferred for trauma evaluation. Patient presented
to OSH after fall off
of a ladder approximately 20ft while trying to cut tree
branches. Fell onto his heels then his back. Abrasions from the
fall. No head trauma, no LOC. No CP, SOB, abdominal pain. No
paresthesias, no weakness, no incontinence. Timing: Sudden Onset
Past Medical History:
PMHx
Non Hodgkin lymphoma
Hypertension
Hyperlipidemia
Anxiety
atrophic R kidney
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
Temp: 97.7 HR: 60 BP: 118/48 Resp: 18 O(2)Sat: 97 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Extraocular muscles intact
Oropharynx within normal limits
Chest: Clear to auscultation, no chest wall tenderness
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended
GU/Flank: pain to lower lumbar area
Extr/Back: + pulses, FROM, no deformity
Skin: No rash, Warm and dry
Neuro: Speech fluent, GCS 15, full strength, nl sensation LT
Psych: Normal mood, Normal mentation
___: No petechiae
Discharge Physical Exam:
VS:WNl please see the flowsheets
GEN: NAD, AOx3
HEENT: NCAT, EOMI, PERRLA
CV: RRR
PULM: No respiratory distress
ABD: Soft, NT, ND, no rebound or guarding
GU: Foley in place
EXT: No CCE, pulses full
Pertinent Results:
IMAGING:
___: CT Torso:
1. Acute 2 column burst fracture of the L3 vertebral body.
There is 3 mm of bony retropulsion into the central canal with
severe canal narrowing at that level.
2. There are additional fractures of the anterior osteophyte of
the L2
vertebral body as well as a probable transverse fracture through
the L2
vertebral body with mild height loss, but no retropulsion. There
is also a
fracture of the anterior inferior osteophyte at L1 and mild
irregularity of the superior endplate of L4 with slight height
loss also suggestive of acute fracture. Widening of the anterior
disc spaces at L2-3 and L3-4 is concerning for ligamentous
injury.
3. Blood products tracking along the bilateral psoas muscles and
the
retroperitoneum is related to the acute vertebral fractures.
4. Atrophic right kidney.
___: CT c-spine:
1. No evidence of fracture or traumatic subluxation.
2. Multilevel moderate degenerative change as described above.
___: CXR:
Compared to prior chest radiographs none more recent than
___.
Lung volumes are very low but lungs are clear. Heart is normal
size.
Mediastinal silhouette is a normal postoperative appearance
given low lung
volumes. Central lymph node calcifications may be present. No
pleural
abnormality.
___: US RENAL ARTERY DOPPLER LEFT:
1. Moderate left hydronephrosis, increased compared to prior
exam.
2. Pre void bladder volume of 352 cc. Postvoid residual was not
calculated as patient was unable to void.. Consider repeat
examination after voiding to assess for resolution of
hydronephrosis.
3. Severely atrophic right kidney is not well visualized.
___: Portable Abdomen x-ray:
1. Distended stomach with normal bowel-gas pattern.
2. No evidence of free intraperitoneal air.
3. Compression deformity of the L3 vertebral body is better
visualized on CT abdomen performed ___.
___: CXR:
Compared to chest radiographs since ___, most recent ___.
Nasogastric drainage tube ends just below the gastroesophageal
junction with lead to be advanced at least 10 cm to move all the
side ports into the stomach.
Lungs are very low in volume but clear. Heart size is normal.
Cardiomediastinal and hilar silhouettes and pleural surfaces are
unremarkable.
___: MR L-spine:
1. There is increased retropulsion of the posterior cortex of
the L3 burst
compression fracture since most recent CT torso. Increased STIR
signal within interspinous ligaments without evidence of a
through and through tear. No signal abnormality was noted in
bilateral facet joints.
2. There is severe spinal canal narrowing with compression of
the cauda equina nerve roots at the level of the L3 burst
fracture and at L3-L4.
3. The acute fracture through the anterior inferior endplate of
the L2
vertebral bodies better seen on prior CT.
___: CT L spine:
1. Burst compression fracture of L3 with 50% reduction in height
and
retropulsion into the spinal canal causing mild spinal canal
narrowing.
2. Anterior endplate fracture of L2.
3. Multilevel degenerative changes.
___ Scrotal US:
1. No suspicious intra testicular mass.
2. Small bilateral hydroceles are noted.
Labs:
___ 07:00PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 07:00PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-30*
GLUCOSE-TR* KETONE-TR* BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 07:00PM URINE RBC-1 WBC-1 BACTERIA-FEW* YEAST-NONE
EPI-0
___ 07:00PM URINE GRANULAR-1*
___ 07:00PM URINE MUCOUS-RARE*
___ 04:22PM LACTATE-2.6*
___ 04:04PM GLUCOSE-103* UREA N-26* CREAT-2.1* SODIUM-139
POTASSIUM-5.3* CHLORIDE-104 TOTAL CO2-18* ANION GAP-17*
___ 04:04PM CK(CPK)-162
___ 04:04PM CK-MB-4 cTropnT-<0.01
___ 04:04PM WBC-17.1*# RBC-3.93* HGB-13.2* HCT-38.8*
MCV-99* MCH-33.6* MCHC-34.0 RDW-11.9 RDWSD-43.2
___ 04:04PM NEUTS-88.4* LYMPHS-4.0* MONOS-6.9 EOS-0.1*
BASOS-0.2 IM ___ AbsNeut-15.09* AbsLymp-0.69* AbsMono-1.17*
AbsEos-0.01* AbsBaso-0.03
___ 04:04PM PLT COUNT-163
___ 04:04PM ___ PTT-28.1 ___
Brief Hospital Course:
Mr. ___ is a ___ y/o male with hx of right renal atrophy after
XRT for lymphoma, who was transferred from OSH with a L3
compression fracture after fall. At ___, the patient had a CT
torso which revealed additional fractures of L1/L2 osteophyte, a
L2 body fracture and L4 endplace fracture, with question of
L2-L4 ligamentous injury. A small retroperitoneal bleed was
seen on imaging, most likely related to the acute vertebral
fractures. A small amount of blood was seen on the patient's
UA. A renal artery US was ordered to assess for renal injury and
the US demonstrated moderate left hydronephrosis.
Neurosurgery was consulted and no urgent or emergent
neurosurgical intervention was warranted. They recommended an
MRI L spine to assess for ligamentous injury, Q4H neuro checks,
an LSO brace and maintaining strict logroll precautions until
the patient was fitted with the LSO. CT c-spine was negative and
the c-collar was cleared. MRI was done which revealed lumbar
stenosis due to epidural lipomatosis. CT L spine was repeated
which was stable. It was recommended that the patient wear the
LSO brace at all times when out of bed and should logroll into
brace, and f/u w/ Dr. ___ in 4 weeks with AP/Lat
xrays. Physical Therapy was consulted and worked with the
patient and ultimately recommended discharge to rehab.
On HD2, the patient c/o abdominal pain and showed a distended
stomach with normal bowel-gas pattern. A NGT was placed with
some maroon output so a PPI was started. The patient was made
NPO and received IVF for hydration. The patient had urinary
retention and prior straight catheterization was successful, but
traumatic. A foley catheter was attempted by the primary team
but was unsuccessful, so Urology was consulted. Urology
performed a cystoscopy, urethral dilation, and foley placement
and recommended leaving the foley in place for ___ days given
cystoscopy with dilation.
On HD4, the patient's NGT was removed and his diet was gradually
advanced to a regular diet which the patient tolerated. Pain
was controlled with oxycodone and acetaminophen. He remained
stable from a cardiovascular and pulmonary standpoint; vital
signs were routinely monitored. The patient's blood counts were
closely watched for signs of bleeding, of which there were none.
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.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, foley catheter was draining clear yellow urine, and
pain was well controlled. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan, and he was
discharged to rehab in stable condition.
Medications on Admission:
SIMVASTATIN 20 MG TABLET
90 Days Supply ___ ___ ___,
___ ___
LOSARTAN POTASSIUM 100 MG TAB
90 Days Supply ___ ___ ___,
___ ___
WELCHOL 625 MG TABLET
90 Days Supply ___ ___ ___,
___ ___ ___ [___]
First: ___
Last: ___ MG TABLET
90 Days Supply ___ ___ ___,
___ ___ citalopram [Celexa]
First: ___
Last: ___
Geriatric Alert
AMLODIPINE BESYLATE 5 MG TAB
90 Days Supply ___ ___ ___,
___ ___
LOSARTAN POTASSIUM 50 MG TAB
90 Days Supply ___ ___ ___,
___ ___
DIPHENOXYLATE-ATROP 2.5-0.025
90 Days Supply ___ ___ ___,
___ ___
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
please hold for loose stool
3. Heparin 5000 UNIT SC BID
4. Lidocaine 5% Patch 1 PTCH TD QAM LBP
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
please wean off this medication as tolerated
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY
please hold for loose stool
7. Senna 8.6 mg PO HS
please hold for loose stool
8. Tamsulosin 0.4 mg PO QHS
9. amLODIPine 5 mg PO DAILY
10. Aspirin 81 mg PO EVERY OTHER DAY
11. Citalopram 40 mg PO DAILY
12. colesevelam 625 mg oral BID
13. Losartan Potassium 50 mg PO BID
14. Omeprazole 20 mg PO DAILY
15. Ranitidine 75 mg PO BID
16. Simvastatin 20 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
L3 body 2 column burst fracture
L2 vertebral body fx
L1, L2 osteophyte fractures
L4 superior endplate fracture
Lumbar stenosis due to epidural lipomatosis
Secondary Diagnosis:
Urinary retention
Proximal urethral stricture
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 ___ after
a fall and were found to have fractures of your spine with a
small associated bleed into your abdominal cavity. Your spine
injuries were assessed by the Neurosurgery team and no surgical
intervention was warranted. It was recommended that you wear a
LSO brace while out of bed and you will have a follow-up in the
___ clinic for repeat imaging to assess your spine.
While in the hospital, you had difficulty voiding and the
Urology service placed a foley catheter. You should follow-up
with your outpatient Urologist, Dr. ___ a voiding trial.
While in the hospital, you had abdominal pain and distention, so
a nasogastric tube (NGT) was placed to help rest your bowels.
When you had return of bowel function, the NGT was removed and
your diet was gradually advanced. You are now tolerating a
regular diet and your pain is better controlled.
You have worked with Physical Therapy and it is recommended that
you be discharged to rehab to regain your strength. You are now
medically ready to be discharged from the hospital. Please
follow the discharge instructions below to ensure a safe
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.
Foley Catheter:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
continue foley for ___ days given cystoscopy with dilation
Followup Instructions:
___
|
10197716-DS-2 | 10,197,716 | 20,135,166 | DS | 2 | 2168-07-02 00:00:00 | 2168-07-02 16:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Constipation, urinary retention
Major Surgical or Invasive Procedure:
Foley catheter insertion
History of Present Illness:
This is a ___ woman with a pmhx. significant for
recently diagnosed stage IIIA squamous cell lung cancer,
undergoing chemoratidation with cisplatin/etoposide who is
admitted with constipation for ___ days and urinary
incontinence.
Ms. ___ was diagnosed with stage IIIa NSCLC in ___
after presenting to ___'s office with non-productive cough for a
few weeks. At OSH she was found to have a right paratracheal
density, and a subsequent CT scan demonstrated wide-spread
malignancy of the right hemithorax. On ___, Ms ___
underwent bronchoscopy by IP, which showed a completely occluded
right main stem bronchus with infiltration of the distal trachea
on the right. Right main stem tumor debridement was performed
with cryo and electrocautery, and post-debridement, the RML and
RLL bronchus were completely patent. PET was negative for
disease outside of right hemithorax and brain MRI was without
malignant foci. Ms. ___ finished CDDP/Etoposide C1D4 on
___, and has been tolerating the regimen well aside from nausea
and fluid retention.
In the ED, initial vitals were: 98.8 52 ___ 100%. Patient
received 1 Fleet's enema with minimal watery stool output.
According to nursing notes, buttocks was very red and
excoriated, and barrier cream was applied. Patient complained
of urinary retention; urinalysis was negative for infection.
Patient admitted to OMED for further evaluation of constipation
and symptom management. Vitals on admission were: 97.7 106
118/68 18 97%. On the floor patient says that she has been
"leaking" stool all day. Feels better, but thinks she may still
need to pass more stool.
ROS: Patient denies fevers, chills, chest pain, worsening
shortness of breath, vomiting, pain in her calves, or dysuria.
She endorses urinary frequency and an inability to pass urine on
day of admission. Has had nausea but no vomiting.
Past Medical History:
--L Breast cancer, Stage I, ER-, s/p L lumpectomy and XRT in
___. She was previously followed by Dr ___ recently
by Dr ___ at ___.
--Hypertension
--Osteoporosis
--Anal fissure
--Lichen sclerosis
--Hearing loss
Social History:
___
Family History:
The patient's father died from ___ Cancer at the age of ___.
No other known family history of malignancies.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.0, 118/82, 93, 20, 96% on RA
GENERAL: Well appearing, slightly uncomfortable, no acute
distress
CHEST: Decreased breath sounds throughout both lung fields,
rhonchi on right, cough and some wheezing with talking
CARDIAC: Slightly tachycardic, no murmurs, rubs, or gallops
ABDOMEN: Hyperactive bowel sounds, soft, non-tender,
non-distended
EXTREMITIES: No edema bilaterally
NEURO: A&Ox3, ambulating around emergency department without
difficulty
DISCHARGE PHYSICAL EXAM:
Vitals - 97.4 124/72 P87 R20 985ra
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
MMM, NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB, no w/r/r
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, strength ___ in all 4 ext, sensation
grossly intact
Pertinent Results:
ADMISSION:
___ 07:25PM URINE HOURS-RANDOM
___ 07:25PM URINE GR HOLD-HOLD
___ 07:25PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 07:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-70 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 07:25PM URINE RBC-1 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 07:25PM URINE MUCOUS-RARE
___ 11:50AM UREA N-23* CREAT-0.8 SODIUM-133 POTASSIUM-3.9
CHLORIDE-93* TOTAL CO2-29 ANION GAP-15
___ 11:50AM estGFR-Using this
___ 11:50AM ALT(SGPT)-21 AST(SGOT)-20 ALK PHOS-91 TOT
BILI-0.6
___ 11:50AM CALCIUM-9.2 MAGNESIUM-2.2
___ 11:50AM WBC-12.0* RBC-4.36 HGB-12.5 HCT-37.1 MCV-85
MCH-28.7 MCHC-33.8 RDW-12.7
___ 11:50AM PLT COUNT-340
___ 11:50AM ___ ___
DISCHARGE:
___ 07:10AM BLOOD WBC-2.0* RBC-3.59* Hgb-10.2* Hct-30.2*
MCV-84 MCH-28.4 MCHC-33.8 RDW-12.8 Plt ___
___ 07:10AM BLOOD Neuts-64.7 ___ Monos-5.0 Eos-2.1
Baso-0.1
___ 07:10AM BLOOD ___ ___
___ 07:10AM BLOOD Glucose-94 UreaN-21* Creat-0.6 Na-139
K-4.0 Cl-104 HCO3-29 AnGap-10
___ 07:10AM BLOOD Calcium-8.0* Phos-2.5* Mg-1.6
___ Abdominal Xray:
IMPRESSION: Nonspecific bowel gas pattern with borderline
dilated large bowel to 6.2 cm with multiple air-fluid levels.
___ Ultrasound LEFT UPPER EXTREMITY: Grayscale and Doppler
sonograms of left internal jugular, subclavian, axillary, and
brachial veins were performed. There is normal compressibility
and flow throughout. Complete thrombosis of the entire course
of the cephalic vein is seen. Loss of respiratory variation
throughout the entire left upper extremity venous system is
likely due to compression of the left brachiocephalic vein as it
drains into the ___.
IMPRESSION: Left cephalic vein thrombophlebitis. No DVT in the
left upper extremity.
Brief Hospital Course:
___ woman with stage IIIa NSCLC in first cycle of
etoposide/cisplatin who was admitted with severe constipation
and acute urinary retention.
# Constipation - Resolved with treatment with lactulose. No pain
on defecation. Possibly secondary to multiple days of high dose
ondansetron in setting of insufficient home bowel regimen.
Patient experienced loose stools afterwards, but were forming by
day of discharge. Patient advised to continue colace and senna
at home with high fiber diet.
# Urinary Retention: Resolved, and complicated by low renal
urine production/fluid retention, which was managed with
furosemide. Unclear etiology, but possibly secondary to
medication side effect vs mass effect fromn constipation.
# Left upper extremity edema, new for patient. Ultrasound showed
loss of respiratory variation throughout the entire left upper
extremity venous system is suggesting compression of the left
brachiocephalic vein. Also showed cephalic vein thrombus but no
DVT. Another possibility is that this is secondary to lymphedema
in setting of past lymph node resection.
# Volume overload - With mild edema, weight gain, and poor urine
output. Patient treated with furosemide 20mg IV to increase
urine output with good response.
# Stage IIIA NSCLC: Patient missed cycle 1 day #8 of
chemotherapy (was scheduled for cisplatin due to constipation
and urinary retention but it was given here on ___. Patient
also received her scheduled radiation treatments.
TRANSITIONAL ISSUES:
1) Monitoring of left upper extremity swelling
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Multivitamins 1 TAB PO DAILY
2. Vitamin D 800 UNIT PO DAILY
3. Calcium Carbonate 500 mg PO QID
4. Aspirin 81 mg PO DAILY
5. Hydrocortisone (Rectal) 2.5% Cream ___ID
6. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP TID:PRN Rash
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Shortness of
breath
9. Prochlorperazine 10 mg PO Q6H:PRN Nausea
10. DiphenhydrAMINE ___ mg PO HS:PRN Insomnia
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. Hydrocortisone (Rectal) 2.5% Cream ___ID
4. Multivitamins 1 TAB PO DAILY
5. Pantoprazole 20 mg PO Q24H
6. Docusate Sodium 200 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
7. Senna 2 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*30 Tablet Refills:*0
8. Calcium Carbonate 500 mg PO QID
9. Prochlorperazine 10 mg PO Q6H:PRN Nausea
10. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP TID:PRN Rash
11. Vitamin D 800 UNIT PO DAILY
12. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Shortness of
breath
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Constipation
Urinary Retention
Non Small Cell Lung Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you here at ___. You were
admitted to the hospital with constipation and urinary
retention. Both of these issues may be medication related. By
the time of discharge, both of these problems had resolved. You
will follow-up with Dr. ___ as listed below.
Please continue all your medications as you have been
instructed.
Followup Instructions:
___
|
10197716-DS-3 | 10,197,716 | 23,656,886 | DS | 3 | 2169-03-26 00:00:00 | 2169-03-26 13:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
SOB, fatigue
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with h/o metastatic NSCLC s/p 4 cycles of cis/etoposide with
XRT complicated by radiation pneumonitis, s/p CyperKnife to the
brain metastases and now on C1D13 of taxotere who presents with
worsening dyspnea, cough and fatigue. The cough has been "wet"
but with minimal sputum production, present for 2 days and a
change from her baseline rare cough. She hasn't had fevers. She
also reports decreased appetite, fatigue/low energy, difficulty
walking, swelling of arms and legs, pain all over her body (none
right now). SHe notes diarrhea after taxotere, but more recently
has had constipation for several days without relief from
colace, senna, miralax. She has had nausea as well. She believes
many of her current sx are secondary to taxotere or subsequent
neulasta.
In the ER, she was originally tachycardic to 170, which
reportedly improved w/ Valsalva to HR in 120s. This was sinus
tachycardia. She had a CTA to r/o PE, which showed Markedly
worsening metastatic disease in the lungs bilaterally, right
greater than left, mediastinum, liver, and likely spleen.
Occluded right upper lobe bronchus and severely attenuated right
upper lobe pulmonary artery. In the ER she was given vancomycin,
levofloxacin, and clindamycin for possible post obstructive PNA.
Review of sytems:
(+) Per HPI
(-) 10 point ROS otherwise negative
Past Medical History:
DIAGNOSIS: Squamous Cell Carcinoma of the Lung, Stage IIIA, now
metastatic
ONCOLOGIC HISTORY: per OMR
Ms ___ is a ___ year old female with remote history of smoking
and Stage I ER- Breast Cancer, s/p lumpectomy and XRT in ___,
who presented to her PCP ___ ___ with few weeks of
non-productive cough. She was initially prescribed a course of
azithromycin and antitussives, however her cough persisted and
was later assosiated with dyspnea and wheezing. On ___, the
patient had a chest x-ray at ___, which was notable for
a R paratracheal density. She was also given oral steroids,
floventand albuterol inhalers. The aforementioned xray finding
wasfurther evaluated with a chest CT on ___, which
demonstrated wide spread malignancy in the R hemithorax. There
was a R paratracheal mass, 3.5 cm x 2.7 cm, invading the R upper
mediastinum, associated with bulky mediastinal LAD (2 cm node at
the level of the upper trachea, 2.2 x 3.4 cm at the level of the
lower trachea, R hilar LAD approaching 2.5 cm in diameter with
protrusion into the R main bronchus toward the carina). The RUL
bronchus appeared completely obstructed. In addition, a small
4mm RLL nodule was identified. On ___, Ms ___ underwent
bronchoscopy by Dr ___ showed a completely occluded
right main stem bronchus fungating lesion with infiltration of
the distal trachea on the right. R main stem tumor debridement
was performed with the use of cryo and electrocautery. Post
debridement, the RML and RLL bronchus were completely patent.
Level 7, 4L and 4R LNs were sampled with EBUS-TBNA. Pathology
from the main lesion confirmed moderately to poorly
differentiated Squamous cell carcinoma. The tumor was
positive for CK7, CK5/6, p63 and negative for TTF-1, CK20,
GCDFP,mammoglobin, S-100. Cytology from the level 4R LN was
positive for malignant cells. Cytology from level 4L and 7 LNs
was non-diagnostic (level 4L - few atypical epithelial cells,
level 7- blood only). On ___, the patient underwent PET/CT
which redemonstrated a partially necrotic, highly FDG-avid 31mm
x 27mm RUL lesion, with associated FDG-avid mediastinal and
R-hilar bulky adenopathy. Notably, there was no L hilar LAD or
evidence of extrathoracic spread. To complete staging, the
patient also underwent brain MRI which was negative for CNS
metastatic involvement. Thus, the patient was diagnosed with
Stage IIIA NSCLC.
-___ C1D1 Cisplatin/Etoposide with concurrent XRT
-___ C2D1 Cisplatin/Etoposide with concurrent XRT
-___ - completed XRT
-___ - C3D1 Cisplatin/Etoposide
-___ - C4D1 Cisplatin/Etoposide
-___: CTA done in the setting of worsening SOB, showed
"Cavitation and fluid within the pulmonary parenchyma of the
right lung apex may represent necrotizing radiation
pneumonitis."
No PE. Given Lasix and levofloxacin with no improvement.
-___: Began steroid course for radiation pneumonitis
-___: L inguinal hernia diagnosed
-___: CT showed "multiple hypodense liver lesions suspicious
for metastatic disease." Hernia surgery deferred.
-___: PET showed "Overall, increasing local disease and
increasing widespread metastatic disease to the bones, lungs,
mediastinal, lymph nodes and liver." MRI brain showed "New
enhancing lesions in both frontal lobes suggestive of brain
metastases since the previous MRI of ___: Liver biopsy, path c/w metastatic poorly differentiated
lung adenocarcinoma
-___: Underwent CyberKnife to the brain lesions
-___: CTA showed markedly worsening metastatic disease in the
lungs bilaterally, right greater than left, mediastinum, liver,
and likely spleen.
OTHER PAST MEDICAL HISTORY:
- L Breast cancer, Stage I, ER-, s/p L lumpectomy and XRT in
___.
- Hypertension
- Osteoporosis
- Anal fissure
- Lichen sclerosis
- Hearing loss
Social History:
___
Family History:
Father died from ___ Cancer at the age of ___
Physical Exam:
ADMISSION PHYSICAL:
Vitals: T 98.2 HR 120 RR 22 BP 110/70 Ox 98% on 2LNC
GEN: Alert, oriented to name, place and situation. Fatigued
appearing but comfortable, no acute signs of distress.
HEENT: NCAT, Pupils equal and reactive, sclerae non-icteric, o/p
clear, MMM.
Neck: Supple
CV: Tachycardic
RESP: Decreased BS b/l
ABD: Soft, non-tender, non-distended, + bowel sounds.
EXTR: +lower leg edema b/l
DERM: No active rash.
PSYCH: Appropriate and calm.
DISCHARGE PHYSICAL:
Vitals: 97.4 ___ 110 20 100% on 2L
GEN: alert & oriented x3, fatigued-appearing, but NAD
HEENT: MMM, pupils equal and reactive, clear OP, no ___
___: Supple, no ___, no thyromegaly
Cardiac: Tachycardic w/few ectopic beats
Chest: Diffuse rhonchi and wheezes b/l
ABD: Soft, non-tender, non-distended, + bowel sounds.
EXT: WWP, no edema
Pertinent Results:
ADMISSION LABS:
===============
___ 11:30PM BLOOD WBC-36.8* RBC-3.05* Hgb-8.8* Hct-25.9*
MCV-85 MCH-28.8 MCHC-34.0 RDW-16.6* Plt ___
___ 11:30PM BLOOD Neuts-87* Bands-6* Lymphs-3* Monos-3
Eos-0 Baso-0 ___ Metas-1* Myelos-0
___ 11:30PM BLOOD Glucose-122* UreaN-24* Creat-0.8 Na-138
K-3.8 Cl-100 HCO3-27 AnGap-15
SIGNIFICANT STUDIES:
====================
___ CTA Chest: IMPRESSION: Markedly worsening metastatic disease
in the lungs bilaterally, right greater than left, mediastinum,
liver, and likely spleen. Occluded right upper lobe bronchus
with collapse of the right upper lobe and severely attenuated
right upper lobe pulmonary artery.
DISCHARGE LABS:
===============
___ 06:45AM BLOOD WBC-26.6* RBC-2.84* Hgb-8.0* Hct-24.8*
MCV-87 MCH-28.2 MCHC-32.3 RDW-16.2* Plt ___
___ 06:45AM BLOOD Neuts-93.3* Lymphs-3.8* Monos-2.5 Eos-0.3
Baso-0.1
___ 06:45AM BLOOD Plt ___
___ 07:53AM BLOOD Glucose-101* UreaN-25* Creat-1.2* Na-140
K-4.0 Cl-105 HCO3-27 AnGap-12
___ 07:53AM BLOOD Calcium-8.7 Phos-4.3 Mg-1.8
Brief Hospital Course:
Mrs. ___ is a ___ y/o female with a h/o metastatic NSCLC s/p 4
cycles of cis/etoposide with XRT complicated by radiation
pneumonitis, s/p CyperKnife to the brain metastases and now on
C1D13 of taxotere who presented with worsening dyspnea, cough
and fatigue and was found to have progression of her NSCLC.
# NSCLC: The patient was initially diagnosed with stage IIIA
squamous cell CA of the lung in ___. She completed 4
cycles of cis/etoposide with XRT. Her course was complicated by
radiation pneumonitis. Unfortunately, her imaging within 4
months of completing treatment showed disease progression with
evidence of mets to the brain and liver. She underwent
CyberKnife to the brain lesions and C1 of
taxotere. Given multiple side effects of chemotherapy and
worsening of disease seen on CT on admission palliative care was
consulted. After long disucssion with the patient and family
they decided to transition goals of care to symptomatic and
comfort treatment and she was discharged home with hospice.
# Dyspnea/cough: CTA showed no evidence of PE, but rather
worsening malignant disease in lungs bilaterally. Given new
productive cough there was concern for a post-obstructive PNA,
though she hasn't had fevers and WBC elevation likely ___
neulasta. In the ED she recieved vancomycin, levaquin, and
clindamycin. On the floor the patient was continued on levaquin.
Additionally the patients cough was treated with lidocaine nebs,
Guaifenesin-CODEINE, benzonatate, oxycodone, and morphine. The
patient felt that the morphine significantly helped the patients
shortness of breath and cough.
# Tachycardia: HR to 170s in ER but improved with vagal
maneuvers. The patient was tachycardic to 100s-120s throughout
course. No PE on CTA. Likely related to underlying pulmonary
process as above.
# Pain control: with tylenol + ibuprofen alternating and
oxycodone
Transitional Issue:
-Consider addition of: Lidocaine 2% 2 mL nebulizers QID:PRN
cough. Can nebulize 3ml so patient can inhale for cough. patient
should not eat 45mins after inhalation. Was tried in hospital
and with some help. Patient had not used for about a day on
discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen w/Codeine ___ TAB PO Q4H:PRN pain
2. Lorazepam 0.5 mg PO Q4H:PRN anxiety
3. Citracal + D (calcium phosphate-vitamin D3) 250 mg calcium-
250 unit Oral daily
4. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*30 Tablet Refills:*0
2. Acetaminophen 1000 mg PO BID
3. Benzonatate 100 mg PO TID cough
RX *benzonatate 100 mg one capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
4. Calcium Carbonate 500 mg PO DAILY
RX *calcium carbonate 500 mg calcium (1,250 mg) one tablet(s) by
mouth daily Disp #*30 Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg one tablet(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
6. Ibuprofen 600 mg PO BID
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram 17 g by mouth
daily Disp #*30 Each Refills:*0
8. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg one tab by mouth twice a day Disp
#*60 Tablet Refills:*0
9. Lorazepam 0.5-1 mg PO Q4H:PRN anxiety
RX *lorazepam 0.5 mg ___ tabs by mouth every 4 hours Disp #*30
Tablet Refills:*0
10. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H cough
RX *codeine-guaifenesin 100 mg-10 mg/5 mL ___ ml by mouth Q 6
hours Disp ___ Milliliter Refills:*0
11. Citracal + D (calcium phosphate-vitamin D3) 250 mg calcium-
250 unit Oral daily
12. Multivitamins 1 TAB PO DAILY
13. Morphine Sulfate (Concentrated Oral Soln) ___ mg PO Q1H:PRN
cough, respiratory distress, pain
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) ___ mg by mouth
every 1 hour Disp ___ Milliliter Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Metastatic NSCLC
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 to take care of you at the ___
___. You were admitted for management of
your shortness of breath and high heart rate. Your increased
shortness of breath and cough were found to be the reuslt of
progression of your underlying lung disease. Your increased
heart rate was corrected in the Emergency Room with vagal
maneuvers, and has not required further intervention. You had
extensive discussions with your primary Oncologist and our
Palliative Care Team, and will be going home with hospice
services to ensure your comfort and care. Thank you for allowing
us to participate in your care this hospitalization.
Followup Instructions:
___
|
10197727-DS-7 | 10,197,727 | 22,818,424 | DS | 7 | 2158-05-27 00:00:00 | 2158-05-27 06:56:00 |
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 acetabular fracture, left ankle fracture, type B aortic
dissection, splenic laceration
Major Surgical or Invasive Procedure:
ORIF R acetabular fx, Left SI joint, Left ankle
TEVAR
History of Present Illness:
___ s/p high speed MVC, intoxicated driver vs parked car.
Needle decompression performed at scene, combative on
presentation and intubated for airway protection. CXR notable
for
widened mediastinum, chest tube placed in ED. CT C/A/P notable
for Type B aortic dissection, R acetabulum fracture and R native
hip dislocation. Orthopaedics consulted for further evaluation.
Patient with persistent hypotension in ED s/p massive
resusciation. Plan for repeat CT scan aborted given hypotension,
proceeded directly to TSICU. Intubated and sedated at the time
of
ortho eval, unable to assess neurological status of the right
lower extremity.
Past Medical History:
Asthma
Social History:
___
Family History:
NC
Physical Exam:
Temp: 98.2 PO BP: 124/74 HR: 86 RR: 20 O2 sat: 96%
O2 delivery: Ra
P/E: Well appearing, NAD
GEN: AOx3, WN, in NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR
PULM: unlabored breathing with symmetric chest rise, no
respiratory distress
EXT:
Right lower extremity:
-SILT s/s/sp/dp/t nerves reports improving numbness of the
extremity although still present
-Fires ___, FHL, TA, ___
-Toes wwp
Left lower extremity:
Aircast boot at bedside. Dressings c/d/i. Toes are warm and
well-perfused. Wiggles toes, SILT s/sp/sp/dp/t distributions
Pertinent Results:
See OMR
Brief Hospital Course:
Patient is a ___ year old male that presented to the emergency
department on ___ s/p a high speed MVC as ? intoxicated driver
vs. parked car. Prior to arrival, a chest needle decompression
was performed at the scene. He was combative on presentation and
intubated for airway protection. CXR was notable for widened
mediastinum, thus a chest tube was placed in the ED. CT C/A/P
was notable for Type B aortic dissection, R acetabulum fracture
and R native hip dislocation. Patient also had persistent
hypotension in the ED s/p massive resuscitation with 7 u PRBC's,
2 u FFP and 1 U Platelets. He was therefore admitted to the
TSICU and started on esmolol for
HR/BP control. His R acetabular fracture was placed in traction
by ortho with his LLE splinted.
He was then taken to the operating room by vascular surgery and
underwent endovascular thoracic pseudo-aneurysm repair on
___ which he tolerated well. (Please see operative report
for details of this procedure). His chest tube was placed to
waterseal and MRI of his spine was obtained per ortho request.
TF was then started post operatively and patient tolerated this
well. On ___ the patient eas extubated and spine recommended a
hard cervical collar and TLSO brace. A PICC line placed and MAC
was discontinued. He was started on aspirin and his esmolol drip
needed to be restarted for poorly controlled BPs.
On ___ he was advanced to a regular diet and his medications
were transitioned to oral (SBP goal was liberalized to <150 per
vascular). He did however require a dose of IV labetalol and
hydralazine for breakthrough HTN. Later, his cervical collar was
removed after discussion with spine surgery and APS was
consulted for continued pain control. He was then transferred
from the ICU to floor on ___.
Once on the inpatient floor, his pain remained well controlled
with consistent use of PCA. He did complain of an isolated
episode of chest pain that day. He described a sensation of food
being stuck, but a precautionary EKG was obtained and this was
normal. Following that episode, his pain resolved and reported
normal swallow function. On ___ he was made NPO after midnight
for surgery with orthopedics on ___ and his forehead sutures
were removed.
On ___ he was taken to the operating room with orthopedics and
his care was transferred to orthopedics post-operatively. He was
taken to the OR on ___ for ORIF R acetabular fx, Left SI
joint, Left ankle. 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 patient was incidentally found to have a
6mm pulmonary nodule and a subsegmental PE. He was lovenox
bridged to coumadin for a 3 month anticoagulation plan. 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
touchdown weight bearing in bilateral lower extremities, and
will be discharged on a lovenox bridge to coumadin for DVT
prophylaxis. The patient will follow up with Dr. ___
vascular surgery 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:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Aspirin 81 mg PO DAILY
3. Bisacodyl ___AILY:PRN Constipation - Second Line
4. Calcium Carbonate 500 mg PO QID:PRN heartburn
5. Diazepam 5 mg PO Q8H:PRN muscle spasm
RX *diazepam 5 mg 1 tablet by mouth every eight (8) hours Disp
#*9 Tablet Refills:*0
6. DiphenhydrAMINE 25 mg PO Q6H:PRN rash
7. Docusate Sodium 100 mg PO BID
8. Enoxaparin Sodium 130 mg SC Q12H
9. FoLIC Acid 1 mg PO DAILY
10. Gabapentin 400 mg PO BID
11. Gabapentin 600 mg PO QHS
12. Ibuprofen 600 mg PO Q8H
13. Ipratropium-Albuterol Neb 1 NEB NEB Q4H
14. Lactulose 30 mL PO DAILY
15. Lidocaine 5% Patch 2 PTCH TD QAM
16. Lisinopril 10 mg PO DAILY
17. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - Second
Line
Reason for PRN duplicate override: Alternating agents for
similar severity
18. Multivitamins W/minerals 1 TAB PO DAILY
19. Ondansetron 4 mg IV Q8H:PRN Nausea/Vomiting - First Line
20. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every three (3) hours
Disp #*50 Tablet Refills:*0
21. OxyCODONE SR (OxyCONTIN) 20 mg PO Q12H
RX *oxycodone 5 mg 1 tablet(s) by mouth every twelve (12) hours
Disp #*6 Tablet Refills:*0
22. Polyethylene Glycol 17 g PO BID
23. Ramelteon 8 mg PO QPM:PRN insomnia
Should be given 30 minutes before bedtime
24. Senna 8.6 mg PO BID
25. Thiamine 100 mg PO DAILY
26. ___ MD to order daily dose PO DAILY16
27. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right acetabular fracture, right hip dislocation, left ankle
fracture, type B aortic dissection, pneumothorax, splenic
laceration
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:
INSTRUCTIONS AFTER ORTHOPAEDIC AND VASCULAR SURGERY:
- You were in the hospital for multiple injuries and surgeries.
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:
-Touchdown weightbearing in bilateral lower extremities, left
lower extremity in an Aircast boot.
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Take Ibuprofen 600 every 8 hours around the clock
3) Take OxyContin twice a day
4) Add oxycodone as needed for increased pain. Aim to wean off
this medication over the next few weeks. 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.
5) Do not stop the Tylenol and ibuprofen until you are off of
the narcotic medication.
6) 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.
7) 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.
8) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
9) Please take all medications as prescribed by your physicians
at discharge.
10) Continue all home medications unless specifically instructed
to stop by your surgeon.
ANTICOAGULATION:
- Please take warfarin daily for 3 months. Please follow-up
with your primary care physician for management of your
subsegmental pulmonary embolism found during this
hospitalization.
WOUND CARE:
- You may shower.
- 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.
TREATMENT/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 after POD3. 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.
Call your surgeon's office with any questions.
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 greater than 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 less than 30 DAYS OF REHAB
Physical Therapy:
Activity: Activity: Activity as tolerated
Right lower extremity: Touchdown weight bearing
Left lower extremity: Touchdown weight bearing in aircast boot
when out of bed
TDWB BLE; posterior hip precautions RLE
TLSO when oob for comfort, OK to decline, no twisting, bending,
lifting
Treatments Frequency:
Wound care:
Site: Incision
Type: Surgical
Dressing: Gauze - dry
Comment: To be changed as needed. Overwrap any dressing
bleedthrough with gauze and paper tape
Followup Instructions:
___
|
10197826-DS-2 | 10,197,826 | 21,433,640 | DS | 2 | 2165-07-31 00:00:00 | 2165-07-31 13:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
worsening back pain and weakness
Major Surgical or Invasive Procedure:
T11-L1 Lami/Fusion with T11-L2 Interbody spacer on ___ with
Dr. ___.
History of Present Illness:
___ male with worsening back pain and weakness in the
setting of lumbar stenosis and T11-T12 severe spinal
stenosis/disc herniation on the left side a/w weakess and
urinary incontinence.
Past Medical History:
PAST MEDICAL HISTORY: Hepatitis C, Benign prostatic hypertrophy,
GERD, Sleep apnea
MEDICATIONS:Neurontin 400mg TID, Flomax 0.4mg daily, oxycodone
5mg every 6 hours as needed, Motrin 800mg as needed
ALLERGIES: None
SURGICAL HISTORY: Appendectomy, L4-L5 herniated disc ___,
L4-L5
surgery ___, Spinal stenosis ___, Right foot tendon transfer
___
Social History:
The patient does not work. He smokes cigars and a pipe. He quit
smoking cigarettes ___ years ago. He is single. Hx of narcotic
abuse X ___ years ago.
Physical Exam:
Sensory:
UE
C5 C6 C7 C8 T1
(lat arm) (thumb) (mid fing) (sm finger) (med arm)
R SILT SILT SILT SILT SILT
L SILT SILT SILT SILT SILT
___
L2 L3 L4 L5 S1 S2
(Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh)
R SILT SILT SILT ___ ___ ___
L SILT SILT SILT ___ ___ ___
Motor:
UE Dlt(C5) Bic(C6) WE(C6) Tri(C7) WF(C7) FF(C8)FinAbd(T1)
R 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5
Motor:
___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___
R* 5 5 5 1 0 3 3
L** 5 5 5 3 3 3 3
*RLE foot drop is chronic
**LLE strength is improving
Pertinent Results:
___ 11:15AM BLOOD WBC-8.2 RBC-3.65* Hgb-11.5* Hct-33.9*
MCV-93 MCH-31.5 MCHC-33.9 RDW-12.7 RDWSD-43.2 Plt ___
___ 03:40AM BLOOD WBC-9.3 RBC-3.88* Hgb-12.1* Hct-35.6*
MCV-92 MCH-31.2 MCHC-34.0 RDW-12.6 RDWSD-42.2 Plt ___
___ 03:10PM BLOOD WBC-6.0 RBC-4.34* Hgb-13.2* Hct-39.8*
MCV-92 MCH-30.4 MCHC-33.2 RDW-12.3 RDWSD-41.5 Plt ___
___ 03:10PM BLOOD Neuts-57.5 ___ Monos-8.4 Eos-2.5
Baso-0.5 Im ___ AbsNeut-3.44 AbsLymp-1.83 AbsMono-0.50
AbsEos-0.15 AbsBaso-0.03
___ 11:15AM BLOOD Plt ___
___ 03:40AM BLOOD Plt ___
___ 03:10PM BLOOD Plt ___
___ 03:10PM BLOOD ___ PTT-30.8 ___
___ 11:15AM BLOOD Glucose-108* UreaN-18 Creat-0.8 Na-146
K-3.6 Cl-111* HCO3-25 AnGap-10
___ 03:40AM BLOOD Glucose-120* UreaN-11 Creat-0.9 Na-145
K-4.1 Cl-112* HCO3-23 AnGap-10
___ 03:10PM BLOOD Glucose-86 UreaN-15 Creat-0.7 Na-139
K-4.0 Cl-107 HCO3-23 AnGap-9*
___ 11:15AM BLOOD Calcium-8.3* Phos-1.5* Mg-1.7
___ 03:40AM BLOOD Calcium-8.5 Phos-2.7 Mg-1.7
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.
POD#1 Mr. ___ developed an episode of b/l hand numbness and
difficulty holding a cup. MRI c-spine was completed which did
show that he had cervical stenosis. He remains NVI in UE's and
baseline exam is stable in ___. He will eventually need
surgical treatment for this once he is well healed from this
surgery. He will see Dr. ___ follow up.
Physical therapy and Occupational therapy were consulted for
mobilization OOB to ambulate and ADL's.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:
Flomax
Gabapentin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Cyclobenzaprine 10 mg PO TID:PRN pain/spasm
may cause drowsiness
3. Docusate Sodium 100 mg PO BID
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
wean as able
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
5. Gabapentin 400 mg PO TID
6. Tamsulosin 0.4 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. T11-12 disc herniation.
2. T11-L1 spinal stenosis.
3. Thoracic myelopathy
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 or stand
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.
Diet: Eat a normal healthy diet.You may have
some constipation after surgery.You have been given medication
to help with this issue.
Brace:You may have been given a brace.If you
have been given a brace,this brace is to be worn when you are
walking.You may take it off when sitting in a chair or while
lying in bed.
Wound Care: Keep the incision covered with a
dry dressing until your follow up appointment. ___ be changed
daily if needed. If the incision starts draining at anytime
after surgery, do not get the incision wet.Cover it with a
sterile dressing.Call the office.
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 or fax narcotic
prescriptions(oxycontin,oxycodone,percocet) to your 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 may at
that time start physical therapy
We will then see you at 6 weeks from the day of
the operation and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
1)Weight bearing as tolerated.2)Gait,balance training.3)No
lifting >10 lbs.4)No significant bending/twisting.
Treatments Frequency:
Please keep the incision covered with a dry dressing on until
your follow up appointment. ___ be changed daily if needed. 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.
Followup Instructions:
___
|
10198377-DS-13 | 10,198,377 | 29,256,780 | DS | 13 | 2152-05-03 00:00:00 | 2152-05-03 14:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
___ dual chamber pacemaker placement ___
History of Present Illness:
___ h/o syncope, valvular heart disease (bicuspid aortic valve,
dilated aortic root), and atrial flutter s/p unsuccessful
ablation in ___ presents to ED with recurrent pre-syncope.
Describes sensation of impending doom and heart stopping, and
sustained several presyncopal episodes then a fall that scraped
his elbow and knee during which he believes he lost
consciousness temporarily. Reports recent congestion last week
that has resolved with antihistamines, but otherwise denies any
recent fevers, chills, night sweats, chest pain, dyspnea,
palpitations, N/V, or urinary/bowel irregularities.
In the ED, initial vitals were 98.2 77 ___ 100%. EKG
showed RBBB with LAFB, 75 bpm, with no significant ST changes.
Rhythm strips demonstrated up to 7 second asystolic pauses noted
with non-conducting P waves, though did not have syncope. EP
was consulted and recommended emergent permanent pacemaker
placement for high-grade heart block. Labs were unremarkable,
including trop neg x1. He was given atenolol 25mg and diazepam
5mg. Transfer vitals were 97.9 78 116/73 18 99%.
On the floor, pt was comfortable, somewhat sore but otherwise no
complaints.
Past Medical History:
1. CARDIAC RISK FACTORS: (-) Diabetes, (-) Dyslipidemia, (-)
Hypertension
2. CARDIAC HISTORY:
- CABG: N/A
- PERCUTANEOUS CORONARY INTERVENTIONS: N/A
- PACING/ICD: N/A
3. OTHER PAST MEDICAL HISTORY:
syncope previously thought to be secondary to orthostasis
valvular heart disease (bicuspid aortic valve, dilated aortic
root)
atrial flutter s/p unsuccessful ablation in ___
Social History:
___
Family History:
Father is ___ and has diabetes and atrial fibrillation. Mother
is ___ and has spinal stenosis and lives in a nursing home. He
has one healthy brother. No children. No family history of
stroke, hypertension, dyslipidemia, early coronary artery
disease or sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.7, ___, 64-73, 95% RA, 185 lb
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: supple, no JVD
CV: regular rhythm, no m/r/g, pacer site c/d/i
Lungs: CTAB, no w/r/r
Abdomen: soft, NT/ND, BS+
Ext: WWP, no c/c/e, 2+ distal pulses bilaterally
Neuro: moving all extremities grossly
DISCHARGE PHYSICAL EXAM:
VS: 98.2, 95-107/68-72, 63-68, 95-100%, 600/825
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: supple, no JVD
CV: regular rhythm, no m/r/g, pacer site c/d/i
Lungs: CTAB, no w/r/r
Abdomen: soft, NT/ND, BS+
Ext: WWP, no c/c/e, 2+ distal pulses bilaterally
Neuro: moving all extremities grossly
Pertinent Results:
ADMISSION LABS:
___ 01:20PM BLOOD WBC-6.6 RBC-5.11 Hgb-15.3 Hct-42.8 MCV-84
MCH-29.9 MCHC-35.7* RDW-13.6 Plt ___
___ 01:20PM BLOOD Glucose-112* UreaN-22* Creat-0.9 Na-140
K-4.2 Cl-102 HCO3-25 AnGap-17
___ 01:20PM BLOOD cTropnT-<0.01
___ 01:56PM BLOOD Glucose-100 Na-139 K-3.9 Cl-100
calHCO3-25
___ 01:56PM BLOOD Hgb-15.3 calcHCT-46
DISCHARGE LABS:
___ 07:35AM BLOOD WBC-7.8 RBC-5.28 Hgb-15.8 Hct-44.5 MCV-84
MCH-29.9 MCHC-35.4* RDW-13.4 Plt ___
___ 07:35AM BLOOD Glucose-98 UreaN-18 Creat-0.9 Na-142
K-4.1 Cl-106 HCO3-27 AnGap-13
___ 07:35AM BLOOD ___ PTT-27.6 ___
___ 07:35AM BLOOD Calcium-9.1 Phos-3.3 Mg-2.2
CXR ___: **PRELIM**
No previous images. Dual-channel pacer device inserted
through the left subclavian vein has leads extending to
the right atrium and apex of the right ventricle. No
evidence of pneumothorax. No acute focal pneumonia,
vascular congestion, or pleural effusion.
Brief Hospital Course:
___ h/o syncope, valvular heart disease (bicuspid aortic valve,
dilated aortic root), and atrial flutter s/p unsuccessful
ablation in 1990s presents to ED with recurrent pre-syncope,
found to have high-grade heart block.
# High-grade heart block: found to have up to 7 second asystolic
pauses noted with non-conducting P waves. He emergently
underwent PPM placement ___ dual chamber pacemaker)
___. Post-PPM interrogation showed normally functioning
pacemaker ___. His CXR showed leads in place. He received
3 doses of vancomycin and was discharged with clinda for 2 more
days (unclear penicillin allergy so keflex was avoided). Pain
control with acetaminophen was sufficient. He was continued on
aspirin and atenolol. Lyme serology was drawn and will need
follow-up.
TRANSITIONAL ISSUES:
# CODE: full confirmed
# EMERGENCY CONTACT: partner ___ ___
# Follow up at ___ in 7 days and Device Clinic in 10 days
# Lyme serology was drawn and will need follow-up
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO QHS
hold for HR<55, SBP<95
2. Meclizine 25 mg PO TID:PRN dizziness
3. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 50 mg PO QHS
3. Meclizine 25 mg PO TID:PRN dizziness
4. Clindamycin 300 mg PO Q6H Duration: 2 Days
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every six (6)
hours Disp #*8 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
high-degree heart block, now status post permanent pacemaker
placement
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 to participate in your care at ___. You
were admitted after you had a ___ dual chamber pacemaker
placed for high-degree heart block that was likely responsible
for your symptoms. Your heart did well overnight and your
pacemaker was functioning well the following morning. Please
follow-up at ___ and with Device Clinic next week.
Followup Instructions:
___
|
10198600-DS-12 | 10,198,600 | 29,856,792 | DS | 12 | 2126-09-17 00:00:00 | 2126-09-17 12:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / duloxetine
Attending: ___.
Chief Complaint:
Lightheaded
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female admitted from ___ after transferred from PCP
office with slow A. fib in the low ___, as well as hypotension
with blood pressure ___ in office. Patient endorsed
lightheadedness since the night prior, denied syncope. Symptoms
continued into the next morning (on the day of admission). She
recently increased her lasix dose over the last 2 months from
once daily to twice daily due to increase in ___ edema, her PCP
decreased her ___ from 80mg to 40mg last week due to low
BP.
Past Medical History:
1. CARDIAC RISK FACTORS: (-) Diabetes, (+) Dyslipidemia, (+)
Hypertension
2. CARDIAC HISTORY:
-CABG: None.
-PERCUTANEOUS CORONARY INTERVENTIONS: None.
-PACING/ICD: None.
3. OTHER PAST MEDICAL HISTORY:
- Aortic insufficiency, mitral valve regurgitation
- Hypertension
- Hyperlipidemia
- polymyositis
- sciatica
- osteoarthritis
- GERD
- s/p R shoulder replacement
- h/o diverticulitis
- h/o C.diff x 2 (in the context of diverticulitis)
Social History:
___
Family History:
Father had MI in ___. Sister has HLD, HTN. No family history of
early MI, arrhythmia, cardiomyopathies, or sudden cardiac death;
otherwise non-contributory.
Physical Exam:
Admission Physical Exam: ___
VS: HR 63, BP 122/59, RR 16, O2 100% RA
Gen: Alert, no acute distress
Neuro: Oriented x 3, moving all extremities, speech clear, mood
and affect appropriate
CV: Regular rate/rhythm, +murmur
Chest: Lungs clear bilaterally, breathing non-labored
ABD: Soft, non-tender, +BS
Extr: BLE warm/well-perfused with no ___ edema, ___ pulses
Skin: Warm, dry, intact
Discharge Physical Exam: ___
VS: T 98.2, HR ___, BP 111/54, 119/46, 121/65, RR 18,
93-95% RA
Gen: Alert, no acute distress
Neuro: Oriented x 3, moving all extremities, speech clear, mood
and affect appropriate
CV: Regular rate/rhythm, +murmur
Chest: Lungs clear bilaterally, breathing non-labored
ABD: Soft, non-tender, +BS
Extr: BLE warm/well-perfused with no ___ edema, ___ pulses
Skin: Warm, dry, intact
Pertinent Results:
ECHO ___ at 4:30 ___ - Full report in OMR
LVEF = 65%
No aortic stenosis, Mild (1+) aortic regurgitation.
Moderate (2+) mitral regurgitation.
Moderate [2+] tricuspid regurgitation.
Moderate pulmonary artery systolic hypertension.
No pericardial effusion.
No major change compared with prior (___)
___ 12:23PM BLOOD cTropnT-<0.01
___ 12:32PM BLOOD Lactate-1.7
CBC
___ 12:23PM BLOOD WBC-11.6* RBC-4.21 Hgb-11.4 Hct-35.2
MCV-84 MCH-27.1 MCHC-32.4 RDW-15.4 RDWSD-46.2 Plt ___
___ 08:55AM BLOOD WBC-8.6 RBC-4.57 Hgb-12.1 Hct-38.1 MCV-83
MCH-26.5 MCHC-31.8* RDW-15.3 RDWSD-46.5* Plt ___
COAG
___ 12:23PM BLOOD ___ PTT-24.9* ___
CHEM
___ 12:23PM BLOOD Glucose-96 UreaN-28* Creat-1.0 Na-131*
K-5.0 Cl-94* HCO3-24 AnGap-18
___ 08:55AM BLOOD Glucose-84 UreaN-14 Creat-0.7 Na-138
K-3.7 Cl-99 HCO3-29 AnGap-14
___ 12:23PM BLOOD Calcium-8.2* Phos-4.3 Mg-2.0
___ 08:55AM BLOOD Mg-2.0
Brief Hospital Course:
Mrs. ___ was transferred directly to the Emergency Department
from cardiologist office. She was given 0.5mg Atropine in the ___
with improvement in heart rate from 45 to 60. She had gradual
improvement in symptoms and her heart rate and blood pressure
remained stable overnight. Her evening Verapamil was given at a
decreased dose of 120mg and she was given a dose of 240mg
Verapamil in the morning which is also a decrease from her usual
AM dose. She is to continue on this decreased dose upon
discharge. Her Atenolol was stopped. In the morning she reported
feeling significantly better and has not had any recurrent
symptoms of lightheadedness, she denies any chest pain,
shortness of breath or palpitations. She was given ___ of
Hearts monitor and has a follow up appointment scheduled with
Dr. ___. Renal function improved with hydration, and may have
increased the effect of atenolol. All discharge planning
including medication changes and follow up were discussed with
the patient and her husband, and they both verbalize
understanding and agreement with the plan of care.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
2. Valsartan 40 mg PO DAILY
3. Gabapentin 300 mg PO BID
4. Zolpidem Tartrate 5 mg PO QHS:PRN sleep
5. Atenolol 12.5 mg PO DAILY
6. Verapamil SR 180 mg PO BID
7. Atorvastatin 10 mg PO QPM
8. Furosemide 20 mg PO DAILY
9. HYDROcodone-acetaminophen ___ mg oral Q4H:PRN
10. TraMADol 50 mg PO BID:PRN Pain - Moderate
11. meloxicam 15 mg oral DAILY
12. Potassium Chloride 10 mEq PO DAILY
13. Aspirin 81 mg PO DAILY
14. TraZODone 50 mg PO QHS:PRN sleep
15. Amitriptyline 25 mg PO QHS
16. Gabapentin 600 mg PO QHS
Discharge Medications:
1. Verapamil SR 120 mg PO QPM
2. Verapamil SR 240 mg PO QAM
3. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
4. Amitriptyline 25 mg PO QHS
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 10 mg PO QPM
7. Furosemide 20 mg PO DAILY
8. Gabapentin 600 mg PO QHS
9. Gabapentin 300 mg PO BID
take Gabapentin as you were prior to admission
10. HYDROcodone-acetaminophen ___ mg oral Q4H:PRN
11. meloxicam 15 mg oral DAILY
12. Potassium Chloride 10 mEq PO DAILY
13. TraMADol 50 mg PO BID:PRN Pain - Moderate
14. TraZODone 50 mg PO QHS:PRN sleep
15. Valsartan 40 mg PO DAILY
16. Zolpidem Tartrate 5 mg PO QHS:PRN sleep
Discharge Disposition:
Home
Discharge Diagnosis:
Bradycardia
Hypotension
Discharge Condition:
___ with approximately one day of lightheadedness, fatigue,
sent from PCP office to ___ on ___ with hypotension and
bradycardia, given atropine in ___ with improvement, admitted to
EP service for further evaluation and treatment.
Subjective: Reports feeling better this morning compared to
yesterday, got up to commode and denies having any
lightheadedness today. Denies CP/SOB.
Objective:
Reviewed VS and pertinent labs.
Weight: 50.4 kg
Tele: SR ___, no alarms
Physical Exam:
VS: T 98.2, HR ___, BP 111/54, 119/46, 121/65, RR 18,
93-95% RA
Gen: Alert, no acute distress
Neuro: Oriented x 3, moving all extremities, speech clear, mood
and affect appropriate
CV: Regular rate/rhythm, +murmur
Chest: Lungs clear bilaterally, breathing non-labored
ABD: Soft, non-tender, +BS
Extr: BLE warm/well-perfused with no ___ edema, ___ pulses
Skin: Warm, dry, intact
Diagnostic testing:
ECHO ___ at 4:30 ___ - Full report in OMR
LVEF = 65%
No aortic stenosis, Mild (1+) aortic regurgitation.
Moderate (2+) mitral regurgitation.
Moderate [2+] tricuspid regurgitation.
Moderate pulmonary artery systolic hypertension.
No pericardial effusion.
No major change compared with prior (___)
Assessment/Plan: #Hypotension/Bradycardia: Improved, BP and HR
stable overnight
- Electrolytes WNL, repeat today
- Holding Atenolol
- Decreased dose of Verapamil given last night
#Valvular heart disease: 1+ AI, ___ MR, 2+TR
- Continue daily lasix with close monitoring of I/O, fluid
balance, and renal function, daily weights
#Hypertension/Hyperlipidemia: chronic, admitted for hypotension,
blood pressures overnight 111/54, 119/46, 121/65 with HR ___
- Reduced dose verapamil given last night, plan to change home
doses
- HOLDING BB for now
- Continue Atorvastatin
# Dispo: Home with husband, ___ monitor
___, NP ___
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted from the Emergency Department after being sent
by your doctor for symptoms of lightheadedness with low blood
pressure and low heart rate.
Your heart rate and blood pressure remained stable overnight and
your symptoms have improved, therefore Dr. ___ has cleared you
to be discharged home with ___ of Hearts monitor to follow up
with him as an outpatient. The appointment with Dr. ___ has
been scheduled for ___ at 3:00PM.
MEDICATION CHANGES:
1. Your Atenolol was stopped, please do not resume unless
directed by your doctor ___ Dr. ___.
2. Your Verapamil dose was changed to 240mg in the morning, and
120mg in the evening. A new prescription for the changed doses
has been sent to your ___ pharmacy electronically. (___)
It has been a pleasure to have participated in your care. If you
have any questions related to recovery from your procedure or
are
experiencing any symptoms that are concerning to you, please
call
your cardiologist or the ___ Heartline at ___ to
speak with a cardiologist or cardiac nurse practitioner.
Followup Instructions:
___
|
10198664-DS-19 | 10,198,664 | 26,752,143 | DS | 19 | 2151-12-16 00:00:00 | 2151-12-16 20:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
Omental tissue biopsy
attach
Pertinent Results:
Admission labs:
CBC WBC 10.4, H/H of 12.0/3.1, Plt 232
BMP WNL
LFTS: ALT 39, AST 42, Alk Phos 276, t. bili 0.7.
RUQ ultrasound (___)
Heterogeneous hepatic parenchyma with indeterminate hepatic
masses
KUB (___)
Large amount of stool throughout the colon.
No overly dilated segments of bowel to suggest obstruction and
no
free intraperitoneal air detected.
CT Abdomen (___)
Report not available for review, though pt reports possible
splenic vein thrombosis.
CT abdomen from ___-- ___ read by our radiologists:
FINDINGS:
The lung bases appear clear. There is no pericardial or pleural
effusion.
The heart size is normal.
There are numerous (greater than 25) ill-defined hypoenhancing
hepatic lesions
involving all hepatic segments, the majority subcentimeter in
size, with the
largest lesion measuring up to 2.2 cm, most compatible with
metastases (series
2, image 23, 17, 28). There is no intra or extrahepatic bile
duct dilation.
The gallbladder is decompressed, and appears normal. No
radiopaque ductal
stones are seen.
There is a 4.5 x 5.2 cm pancreatic body mass which extends
anteriorly to
contact the lesser curvature of the stomach, with obscure a shin
of the
intervening fat plane (series 2, image 22, 25). There is mild
upstream
pancreatic duct dilation with tail atrophy (series 2, image 24).
The mass
obliterates the splenic vein. There is also encasement of
splenic artery
(series 2, image 24). The mass also contacts the portal splenic
confluence
(series 42,224 image 34), without attenuation of the main portal
vein. The
SMV appears patent. The SMA is separate from the lesion. There
is encasement
of the proximal common hepatic artery (series 2, image 25).
Adjacent adenopathy is present, including a 1.4 cm gastrohepatic
node (series
2, image 24) and multiple enlarged porta hepatis nodes (series
2, image 27,
24). In addition, there are multiple mesenteric and omental
nodules
throughout the abdomen (series 2, image 28, 31, 33, 35, 42), the
largest
measuring 2.3 x 1.8 cm along the left abdomen (series 2, image
35).
The spleen size is within normal limits. There are no focal
splenic lesions.
The adrenal glands are normal in size and shape.
The kidneys are normal in size and enhance symmetrically,
without
hydronephrosis.
The stomach and intra-abdominal and intrapelvic loops of small
and large bowel
are normal in caliber. No focal gastrointestinal lesion is
detected.
There is extensive colonic diverticulosis.
The bladder is mildly distended, and appears normal. The uterus
is
retroverted, and normal in size. A partially calcified fundal
fibroid is
incidentally noted (series ___, image 44).
No concerning adnexal lesions are detected.
There are moderate atherosclerotic calcifications throughout the
abdominal
aorta and iliac branches, without dissection or flow-limiting
stenosis. No
aneurysm is detected.
The there are no osseous lesions concerning for malignancy or
infection.
There is extensive lumbar spondylosis, without
spondylolisthesis.
IMPRESSION:
1. 4.5 x 5.2 cm pancreatic body mass with numerous (greater than
25) hepatic
lesions, porta hepatis and peripancreatic adenopathy, a numerous
mesenteric
and omental nodules. The constellation of findings favor
metastatic
pancreatic adenocarcinoma.
2. The pancreatic mass obliterates the splenic vein, with
encasement of the
splenic artery, proximal common hepatic artery, and splenic
artery. The mass
contacts the main portal vein, without significant attenuation.
3. Extensive colonic diverticulosis.
4. Fibroid uterus.
CT head:
IMPRESSION:
1. No evidence of mass, hemorrhage or infarction.
2. Paranasal sinus inflammatory changes.
CT chest:
IMPRESSION:
1. Although better appreciated on the prior CT abdomen pelvis,
re-demonstrated
is a pancreatic body mass with innumerable hepatic lesions,
peripancreatic
adenopathy and mesenteric and omental nodules.
2. A 6 mm nodule in the left lung base for which attention on
follow-up
imaging is recommended..
3. Millimetric perifissural nodules bilaterally are nonspecific,
but may
represent intrapulmonary lymph nodes.
4. Innumerable bilateral peripheral micro nodules are also
nonspecific, but
may be infectious versus inflammatory in etiology.
US guided biopsy:
IMPRESSION:
Technically successful ultrasound-guided left omental biopsy
with small
postprocedural hematoma.
Discharge exam:
GENERAL: Alert, awake. lying in bed this AM in no apparent
distress
EYES: Anicteric, PERRL
ENT: Ears and nose unremarkable. Oropharynx without visible
lesion, MMM
CV: S1 S2 normal, regular rate. no m/r/g. No JVD.
RESP: No increased wob, lung fields clear to auscultation
bilaterally
GI: Abdomen soft, ND. +BS. +TTP diffusely- worst in Left
abdominal side.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI, speech fluent, moves all limbs, sensation to light touch
grossly intact throughout
PSYCH: pleasant, appropriate affect
Discharge labs:
___ 07:15AM BLOOD WBC-8.0 RBC-3.21* Hgb-9.8* Hct-30.8*
MCV-96 MCH-30.5 MCHC-31.8* RDW-12.3 RDWSD-43.2 Plt ___
___ 07:15AM BLOOD Glucose-104* UreaN-9 Creat-0.6 Na-139
K-4.5 Cl-99 HCO3-26 AnGap-14
___ 08:33PM BLOOD CA ___ -PND
Brief Hospital Course:
SUMMARY/ASSESSMENT: ___ female who presents with
abdominal pain, transferred from urgent care after imaging
showed pancreatic mass and innumerable hepatic masses concerning
for metastatic cancer up unknown primary, underwent omental
biopsy on ___/w metastatic cancer, most
likely pancreatic in origin given imaging findings
ACUTE/ACTIVE PROBLEMS:
# Malignancy of unknown primary:
Imaging significant for multiple hepatic masses, pancreatic mass
(4.5x3.5 cm). Additionally, noted to have one visualized left
lower lobe pulmonary nodule on abdominal imaging which may or
may not be related to abdominal masses. CT head negative for
acute intracranial pathology. On admission, CEA found to be
elevated, and CA ___ was sent but pending at time of discharge.
CT chest with contrast did not show any further metastasis but
did re-confirm presence of LLL pulmonary nodule that may or may
not be metastatic lesion. Pt underwent ___ guided biopsy of L
omentum on ___. Preliminary pathology on ___ c/w metastatic
adenocarcinoma. Most likely pancreatic in origin given imaging
findings, but final pathology pending at time of discharge.
Oncology met with pt to discuss next steps regarding follow up
in clinic with pancreatic oncology specialist and to answer
preliminary questions. Pain was controlled with oxycodone ___
mg q6h prn as well as Maalox and Zofran prn. Pt was discharged
with one week supply of oxycodone as well as bowel medications
and Maalox for management of indigestion.
# Post procedure hematoma
Seen on US by ___ post procedurally. Hgb drop of 1.6 since
procedure. Had pain immediately after and with shoulder pain
that may have been ?referred from hematoma. Pain improved day
after biopsy. CBC should be rechecked at follow up given slight
down trend on day of discharge.
# ?Splenic vein thrombus:
Patient reported being told that she had "splenic vein thrombus"
on CT imaging at OSH, however, official report and in discussion
with radiology here- splenic vein is fully occluded and not
visualized in CT imaging. Given occlusion and malignancy,
patient at high risk for splenic vein thrombus, however,
anticoagulation not recommended at this time given lack of true
thrombus.
CHRONIC/STABLE PROBLEMS:
# ADD:
Continue Amphetamine-Dextroamphetamine XR 60 mg PO DAILY
# Depression:
Continue FLUoxetine 80 mg PO DAILY
Continue TraZODone 50-100 mg PO QHS prn insomnia
Continue Rexulti (brexpiprazole) 0.5 mg oral DAILY
Obtain routine EKG for QTc monitoring
# Gastritis:
Continue omeprazole 10 mg PO DAILY
Transitional issues:
======================
[ ] Follow up final pathology. Oncology to set patient up with
follow up in clinic with pancreatic oncology specialist
[ ] Pt discharged with oxycodone 10 mg q6h prn for 1 week
supply (28 pills) as well as docusate/senna/miralax for bowel
regimen.
[ ] Please monitor patient's indigestion and adjust regimen as
needed. Pt discharged with instructions to continue home PPI and
start Maalox prn as this provided her best symptom control
inpatient
[ ] Consider reimaging or doppler US to investigate potential
splenic v thrombus
>30 minutes of time spent on patient care and discharge care
coordination
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amphetamine-Dextroamphetamine XR 60 mg PO DAILY
2. FLUoxetine 80 mg PO DAILY
3. TraZODone 50 mg PO QHS:PRN insomnia
4. Rexulti (brexpiprazole) 0.5 mg oral DAILY
5. Omeprazole 10 mg PO DAILY
6. Acyclovir 200 mg PO Q12H
Discharge Medications:
1. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
indegestion
RX *alum-mag hydroxide-simeth 200 mg-200 mg-20 mg/5 mL 10 ml by
mouth every eight (8) hours Disp #*2 Package Refills:*0
2. Docusate Sodium 100 mg PO BID:PRN Constipation - Second Line
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth every
twelve (12) hours Disp #*60 Capsule Refills:*0
3. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 10 mg ___ tablet(s) by mouth every six (6) hours
Disp #*28 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO BID:PRN Constipation - Third
Line
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 dose by
mouth twice a day Refills:*0
5. Senna 8.6 mg PO BID:PRN Constipation - First Line
RX *sennosides [Senna Laxative] 8.6 mg 1 tablet by mouth twice a
day Disp #*60 Tablet Refills:*0
6. Acyclovir 200 mg PO Q12H
7. Amphetamine-Dextroamphetamine XR 60 mg PO DAILY
8. FLUoxetine 80 mg PO DAILY
9. Omeprazole 10 mg PO DAILY
10. Rexulti (brexpiprazole) 0.5 mg oral DAILY
11. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain ___ malignancy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms ___,
You came into the hospital with abdominal pain and indigestion.
When you got to the hospital, we did a CT scan of your abdomen
which showed a mass near your pancreas and concerning changes in
your liver. We did a biopsy that unfortunately showed
preliminary findings consistent with cancer. Given your imaging
findings, this likely represents metastatic pancreatic cancer.
We had the oncology team meet with you to answer your questions
regarding next steps. They will set you up to meet with a
pancreatic specialist in their clinic.
We encourage you to keep note of all the questions that you come
up with in the coming days so that you can bring them up at your
clinic appointment. We encourage you to return to your normal
level of activity and diet as tolerated. We are sending you home
with medications to help control your abdominal pain and
indigestion. Please note that when taking the oxycodone, it is
important to also take medications to help you move your bowels
and to prevent constipation.
Medications:
Followup Instructions:
___
|
10198913-DS-10 | 10,198,913 | 22,853,423 | DS | 10 | 2171-05-30 00:00:00 | 2171-05-30 13:55:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Aspirin
Attending: ___.
Chief Complaint:
Incomprehensible speech and right facial weakness
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ yo RHW with h/o DM, HTN, HL, breast CA, TIAs presents with
incomprehensible speech and right sided weakness as Code Stroke.
The history is provided by patient's sister with whom she lives.
The patient was at her baseline this morning, walking with her
walker, talking and laughing. She ate breakfast without trouble.
She was normal at 11:30am, but shortly after her sister noticed
something wrong with her speech. There was a repair man fixing
their dishwasher, and the patient kept saying "that man." She
seemed to have trouble finding words, then her speech became
completely impossible to understand. It is unclear if she was
even using real words. It was also slurred. Her mouth looked
"twisted" toward the left side. Her right arm looked limp. She
was seated at the time. Her sister called PCP's office, and by
their recommendation called EMS. On arrival to ED, NIHSS ">14"
with decreased R hand grip, R neglect and gaze deviation, and
global aphasia. She was taken immediately to CT scanner, but we
had severe difficulty obtaining scan because patient became
extremely agitated, frightened, and kept trying to squirm off
table, tachycardic to 150s, SBP 200. She received Ativan 1 mg in
2 divided doses, and CT scan was obtained, as well as CTA.
During this time, Dr. ___ was present and having discussion
weighing risks and benefits of tPA with sister. Given the
patient's baseline dementia, her age and the time since last
normal, it was decided that her risk outweighed benefit and
sister agreed. After CT/CTA, examination seemed mildly improved,
in particular with regards to right side strength. HR remained
in 100s, and she received IVF bolus. SBP improved to 160-180s.
ROS: unable to obtain from patient, per her sister there was no
recent complaints of headache, vertigo, numbness, tingling. No
fever, chills, cough, shortness of breath, chest pain or
tightness, vomiting, diarrhea, abdominal pain.
Past Medical History:
-DM c/b retinopathy
-HTN
-HL
-legally blind
-hearing loss
-TIAs, sister reports no clinical presentation of TIA but doctor
told her about them
-dementia
-hip replacement ___
-breast CA ___ s/p chemo and XRT
-HL
Social History:
___
Family History:
Son died of MI at age ___
Physical Exam:
Vitals: T 99.2 HR 98 BP 188/80 RR 20 02 100%/RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, eyes open spontaneously, attending to the
left side and cannot look to the right. Intermittently trembling
all over. Making some repetitive sounds that are not words or
neologisms. Not following any commands. Unable to state name.
Cannot assess for dysarthria.
-Cranial Nerves:
I: Olfaction not tested.
PERRL 3 to 2mm and brisk. Decreased blink to threat on R. Eyes
intermittently looking to L or midline, but cannot cross to L
side with command, sound or VOR. R facial weakness.
-Motor: Increased tone with active resistance throughout c/w
gegenhalten. Trembling intermittently diffusely throughout body,
which sister says is baseline. Spontaneous, purposeful and
antigravity movements with bilateral
UEs. Spontaneous movements in ___ L>R. Withdraws to noxious
(nailbed pressure) symmetrically in UEs, but asymmetrically in
LEs with R side less withdrawal not fully antigravity.
-Sensory: intact pain sensation throughout
-DTRs: difficult to elicit due to poor relaxation and movement,
withdraws to Babinski bilaterally.
-Coordination and Gait unable to assess
** Discharge Summary: Patient awake, alert, and oriented to
self, gives birth year as current year. Poor attention requires
redirection but answers appropriately.
Pertinent Results:
___ 08:09PM GLUCOSE-371* UREA N-12 CREAT-0.7 SODIUM-138
POTASSIUM-3.5 CHLORIDE-98 TOTAL CO2-25 ANION GAP-19
___ 04:15PM URINE HOURS-RANDOM
___ 02:32PM ___ PTT-35.6 ___
___ 02:32PM PLT COUNT-380
___ 02:32PM PLT COUNT-380
___ 02:32PM ___ PTT-35.6 ___
___ 02:32PM WBC-4.5 RBC-3.83* HGB-11.8* HCT-35.7* MCV-93
MCH-30.8 MCHC-33.0 RDW-13.4
___ 02:32PM TSH-2.7
___ 02:32PM UREA N-16
___ 02:36PM estGFR-Using this
___ 02:36PM CREAT-0.6
___ 02:40PM GLUCOSE-266* NA+-140 K+-3.7 CL--99 TCO2-28
___ 04:15PM URINE RBC-3* WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 04:15PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
___ 04:15PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:15PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 04:15PM URINE HOURS-RANDOM
___ 05:59PM LACTATE-1.6
___ 05:59PM TYPE-ART PO2-140* PCO2-41 PH-7.46* TOTAL
CO2-30 BASE XS-5
___ - ECHO: The left atrium is normal in size. No
thrombus/mass is seen in the body of the left atrium. No atrial
septal defect or patent foramen ovale is seen by 2D, color
Doppler or saline contrast with maneuvers. The estimated right
atrial pressure is ___ mmHg. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. 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. Trivial mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
___ - MRI IMPRESSION:
1. A small curvilinear focus of acute infarction in the right
frontal lobe
subcortical white matter, without surrounding edema or mass
effect.
2. Extensive cerebral changes as described above, most of which
were seen on the prior study of ___. Faint foci, in the
pons. Given the similar in appearance to the prior study, these
are likely nonspecific in appearance and may relate to small
vessel ischemic changes.
___ - CT HEAD IMPRESSION: No acute intracranial
hemorrhage or mass effect.
___ - CTA NECK W & W/O CON & RECON IMPRESSION:
1. No acute intracranial abnormality.
2. No evidence of flow-limiting stenosis, dissection, cerebral
aneurysm
larger than 2 mm, or other vascular abnormality.
3. Multinodular goiter; correlate clinically.
Brief Hospital Course:
This is a ___ year old woman with multiple vascular risk factors
presenting with aphasia, right facial weakness and agitation.
# NEURO:
The patient was initially admitted to the neurology floor but
upon arrival was observed to have tonic/clonic movements of all
extremities with an episode of vomiting and guaiac + stool. She
was transfer to the ICU overnight. Repeat CT head at that time
was stable. The patient was placed on EEG which revealed no
seizure acitivity. She was also started on Keppra at that time.
MRI was performed the following day and shows a tiny acute
infarct in the right frontal lobe.
# CV:
The patient was seen to have blood pressures which fluctuated
into the 200s systolic for which Hydralazine was employed with
good effect. Her heart rate was noted to be transiently elevated
over day ___ for which bolus fluids were given to good effect.
Her home anti-hypertensive, Nifedipine CR, was restarted for
ongoing control.
The patient's stroke risk factors where checked. Her A1c was
7.9%, LDL was 132. Echocardiogram showed no thrombus, PFO and EF
was preserved. The patient was continued on her home plavix dose
and a statin was added.
# ENDO:
The patients sugars were seen to be elevated over the course of
her admission for which sliding scale insulin was employed.
Metformin was also restarted once kidney function was seen to be
within normal limits. Her other oral hypoglycemic was restarted
on discharge.
# TRANSITIONS OF CARE
- Social Work was consulted for concerns of safety in the
patient's current living environment. They will continue their
screen and complete their evaluation during the ___
rehabilitation stay
- Keppra will be maintained as outpatient therapy for the
concern of seizure activity
- Continue following A1c% which was elevated on admission,
consider altering for better control if persistently elevated.
- Please continue on Regular Diabetic/Consistent Carbohydrate
with Consistency Ground (dysphagia) and Nectar prethickened
liquids
- Meds whole with water as tolerated
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clopidogrel 75 mg PO DAILY
2. MetFORMIN (Glucophage) 1000 mg PO BID
3. Nateglinide 60 mg PO TIDAC
4. NIFEdipine CR 30 mg PO DAILY
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
2. MetFORMIN (Glucophage) 1000 mg PO BID
3. NIFEdipine CR 30 mg PO DAILY
4. Nateglinide 60 mg PO TIDAC
5. Atorvastatin 20 mg PO DAILY
6. LeVETiracetam 750 mg PO BID
7. Senna 1 TAB PO BID:PRN constipation
8. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Cerebral embolism with infarcts
Seizures
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were evaluated at ___
because of a sudden onset of difficulty speaking and right
facial droop. You subsequently had some whole body shaking that
was suspicious for seizure. You had an MRI which showed multiple
small strokes.
We evaluated your stroke risk factors including:
- Hemoglobin A1C elevated at 7.9% indicating control of your
Diabetes was not good.
- LDL cholesterol was elevated at 132 which was also an
indication for intervention.
- Echocardiogram which was normal.
Your home dose of Plavix was continued along to prevent stroke,
and diabetes was controlled with Insulin and Metformin, the
latter of which will be continued as an outpatient. We started
Atorvastatin to better control your cholesterol. Because of the
jerking activity which was witnessed, and the leg shaking
reported by your family members, we started an anti-convulsant
medication, Keppra, which will also be continued as an
outpatient.
Our social workers, physical therapists, and occupational
therapists evaluated you to determine the safest, and most
___ facility for your ongoing care given our findings of
stroke and seizure disorder. We determined that discharge to a
skilled nursing facility was most appropriate for your
convalesence.
Followup Instructions:
___
|
10199438-DS-9 | 10,199,438 | 20,643,500 | DS | 9 | 2170-06-23 00:00:00 | 2170-06-23 16:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Keflex
Attending: ___.
Chief Complaint:
left leg swelling with pus drainage
Major Surgical or Invasive Procedure:
___ LLE thigh washout,vac chng,closure ___ thigh/knee
___ LLE thigh exp, SFA ligation, stentgraft explant
___ metatarsal head resection, L foot debridement.
___ Evacuation of left thigh infection. Removal of infected
SFA and stent graft.
History of Present Illness:
Mr. ___ is a ___ who presents to the ED due to concern for
swelling, redness, and drainage from his left popliteal area. He
has an extensive history of vascular intervention in the LLE,
including L CFA & EIA endarterectomy, SFA stenting, & popliteal
endarterectomy in ___ followed by thrombolysis for acute
occlusion of the left SFA/popliteal/TP in ___, and
later re-occlusion associated with continued LLE rest pain and
wound s/p CFA to ___ bypass with in situ GSV on ___. He then
had multiple interventions including PTA of the bypass and
distal ___, above knee vein graft to distal ___ jump graft, and
most recently PTA of L ___ bypass on ___.
Today, he called the on call fellow with concerns of swelling
and redness of the knee as well as drainage per report from his
wife. He was instructed to go to the emergency department for
evaluation, and presented to ___ where he was noted to have
purulence from a wound in the knee. He thus was transferred to
___ for further care.
Upon evaluation, Mr ___ notes one episode of fevers and
chills a week ago. He denies nausea, vomiting, shortness of
breath, or chest pain. The redness and swelling began in the
last few days and was associated with increased pain. The
drainage was first noted this morning. He has no complaints
regarding his RLE.
Past Medical History:
Past Medical History:
-PAD
-HTN
Past Surgical History:
-L CFA, EIA endarterectomy, stenting of SFA, above and below
knee popliteal endarterectomy (___)
-Thrombolysis of left SFA, popliteal, TP trunk (___)
-Diagnostic RLE angio (___)
-Left CFA to ___ bypass with in situ GSV (___)
-LLE angio, angioplasty ___ BP and distal ___ (___)
-L foot sesamoidectomy and debridement (___)
-L AK vein graft-dist ___ bypass jump graft w/ R ceph vein
(___)
-RLE angiogram (___)
-Right SFA to posterior tibial artery bypass using nrGSV
(___)
-PTA of L ___ bypass (___)
Social History:
___
Family History:
PAD in mother including vascular bypass
Physical Exam:
DISCHARGE PHYSICAL EXAM:
========================
- pain well controlled, decreasing opiate requirement
- increasing ambulation
Objective
Vitals:
Temp: 98.4, BP: 138/76, HR: 79 RR: 16 O2 sat: 98%, O2
delivery: Ra
Gen: NAD, AxOx3
Card: RRR, no m/r/g
Pulm: no respiratory distress, minimal diffuse dry crackles
throughout, no W or rhales
Abd: Soft, non-tender, non-distended, normal bs.
Wounds: L proximal and distal leg dressing c/d/i, would vac
holding suction with minimal serous drainage
Ext: LLE edema, warm well-perfused RLE without edema
Mid leg wound, clean, pink granulation tissue.
Left foot with dressing intact.
Neuro: moving all extremities spontaneously, soft touch intact
Pulses: R:
Pertinent Results:
___ 03:50AM BLOOD WBC-3.6* RBC-2.59* Hgb-7.3* Hct-23.2*
MCV-90 MCH-28.2 MCHC-31.5* RDW-15.9* RDWSD-50.8* Plt ___
___ 03:27AM BLOOD Glucose-109* UreaN-6 Creat-0.7 Na-143
K-4.3 Cl-104 HCO3-29 AnGap-10
Brief Hospital Course:
Mr. ___ is a ___ HTN, HLD, significant PAD (on ASA 81,
Plavix) who presented to the ED at ___ on ___ with swelling,
redness, and drainage from his left popliteal area. He has an
extensive history of vascular intervention in the LLE, including
L CFA & EIA endarterectomy, SFA stenting, & popliteal
endarterectomy in ___ followed by thrombolysis for acute
occlusion of the left SFA/popliteal/TP in ___, and
later re-occlusion associated with continued LLE rest pain and
wound s/p CFA to ___ bypass with in situ GSV on ___. He then
had multiple interventions including PTA of the bypass and
distal ___, above knee vein graft to distal ___ jump graft, and
most recently PTA of L ___ bypass on ___. On the day
of presentation, he called the on call fellow with concerns of
swelling and redness of the knee as well as drainage per report
from his wife. He was instructed to go to the emergency
department for evaluation, and presented to ___ where he was
noted to have purulence from a wound in the knee. He thus was
transferred to ___ for further care.
He was taken to the ___ on ___ for I&D of complex left thigh
abscess, excision of infected superficial femoral artery and
infected stent graft, and repair of distal superficial femoral
artery and above-knee popliteal artery. He was also noted to
have a full-thickness ulcerations to the plantar medial aspect
of the first metatarsal head, and was taken to the OR on ___
with podiatry for debridement and ___ metatarsal head resection
and ___ lengthening. He was then taken back on ___ by vascular
surgery for left thigh wound exploration, removal of infected
stent graft w/ ligation of left SFA, and vac change. APS was
consulted on ___ for persistent severe postoperative pain
limiting his LLE extension at the knee and recommendation was
made to change to gaba 300mg BID and 600mg QHS. He was also
evaluated by OPAT management of his infection and recommendation
made to for 2gr rocephin iv for ___. He saw plastic
surgery and they recommend to follow as out patient.
His pain is controlled and he is stable for discharged.
He will be followed
by Podiaty, OPAT and vascular surgery. When will refer to
plastic surgery if indicated.
He underwent the procedures below:
___ LLE thigh washout,vac chng,closure ___ thigh/knee
___ LLE thigh exp, SFA ligation, stentgraft explant
___ metatarsal head resection, L foot debridement.
___ A PICC was placed
___ Evacuation of left thigh infection. Removal of infected
SFA and stent graft.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Aspirin 81 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. lisinopril-hydrochlorothiazide ___ mg oral DAILY
5. Gabapentin 600 mg PO DAILY
6. Gabapentin 300 mg PO QPM
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. CefTRIAXone 2 gm IV Q24H graft infection
last dose ___
3. Docusate Sodium 100 mg PO BID
4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
RX *oxycodone 5 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*15 Tablet Refills:*0
5. Tamsulosin 0.4 mg PO QHS
6. Atorvastatin 80 mg PO QPM
7. Gabapentin 300 mg PO QAM
8. Aspirin 81 mg PO DAILY
9. Clopidogrel 75 mg PO DAILY
10. Gabapentin 600 mg PO DAILY
11. lisinopril-hydrochlorothiazide ___ mg oral DAILY
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
-Peripheral Arterial disease.
-Infected left thigh wound/infected superficial femoral artery
and superficial femoral artery stent graft.
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 at ___
___. You were admitted to the hospital after
multiple surgical procedure were performed on your left leg.
These procedures were done to control the infection on your
leg. You tolerated the procedure well and are now ready to be
discharged from the hospital. Please follow the
recommendations below to ensure a speedy and uneventful
recovery.
Vascular Leg Surgery Discharge Instructions
What to except:
It is normal feel tired for ___ weeks after your surgery
It is normal to have leg swelling. Keep your leg elevated as
much as possible. This will decrease the swelling.
Your leg will feel tired and sore. This usually passes
within a few weeks.
You have two areas on your leg with sutures and an open wound
around your knee. The open incision will be being managed with
the wound VAC. The ___ will take care of this for you. Visiting
Nurse ___. Members of your health care team will discuss
this with you before you go home.
Medications:
Before you leave the hospital, you will be given a list of all
the medicine you should take at home. If a medication that you
normally take is not on the list or a medication that you do not
take is on the list please discuss it with the team!
It is very important that you take Aspirin every day! You
should never stop this medication before checking with your
surgeon
Pain Management:
It is normal to feel some discomfort/pain following surgery.
This pain is often described as soreness.
You may take Tylenol (acetaminophen ) as needed for pain.
You will also receive a prescription for stronger pain medicine,
if the Tylenol doesnt work, take prescription medicine.
Narcotic pain medication can be very constipating, please also
take a stool softner such as Colace. If constipation becomes a
problem, your pharmacist can suggest additional over the counter
medications.
Your pain medicine will work better if you take it before your
pain gets to severe.
Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
Activity:
Do not drive until your surgeon says it is okay. In general,
driving is not allowed until
-the staples or sutures in your leg have been taken out.
-your leg feels strong
-you have stopped taking pain medication and feel you could
respond in an emergency
Walking is good because it helps your muscles get stronger and
improves blood flow. Start with short walks. If you can, go a
little further each time, letting comfort be your guide.
Try not to go up and downstairs too much in the first weeks.
Use stairs only once or twice a day until your incision is fully
healed and you are back to your usual strength.
Avoid things that may constrict blood flow or put pressure on
your incision, such as tight shoes, socks or knee highs.
Do not take a tub bath or swim until your staples are removed
and your wound is healed.
When you sit, keep your leg elevated to reduce swelling.
If swelling in your leg is getting worse, lie down with your
leg up on a pillows. If your swelling continues, please call
your surgeon. You may be instructed to use special elastic
bandages or stockings.
Try not to sit in the same position for a long while. For
example, ___ go on a long car ride.
You may go outside. But avoid traveling long distances until
you see your surgeon at your next visit.
You may resume sexual activity after your incisions are well
healed.
Your incision
Your incision may be slightly red around the stitches. Do
not let the shower spray right on the incision, Let the soapy
water run over the incision, then rinse. Gently pat the area
dry. Do not scrub the incision, Do not apply ointment or
lotions to the incision. Because of the wound vac, you may need
to coordinate the time of shower on the day of visit by the ___.
You do not need to cover the incision if there is no drainage,
If there is a small amount of drainage, put a small sterile
gauze or Bandaid over the incison.
It is normal to feel a firm ridge along the incision, This
will go away as your wound heals.
Diet and Bowels
It is normal to have a decreased appetite. Your appetite will
return over time. Follow a well-balanced, health healthy diet,
without too much salt and fat.
Prescription pain medicine might make you constipated. If
needed, you may take a stool softener (such as Colace) or gentle
laxative (ask your pharmacist for recommendations).
Drinking more fluid may also help.
If you go 48 hours without a bowel movement, or having pain
moving your bowels, call your primary care physician.
Followup Instructions:
___
|
10199636-DS-16 | 10,199,636 | 25,494,735 | DS | 16 | 2197-06-30 00:00:00 | 2197-07-01 13:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Darvocet-N 50 / Xylocaine / Marcaine / Novocain / Lisinopril /
Diovan / Green Dye / Yellow Dye / blue,yellow, and red dyes /
lidocaine
Attending: ___.
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old woman with PNH of DM2, HTN, HLD
who presents with dull left flank and lower back pain radiating
to the left abdomen and left groin region. The pain started on
___ around 7am and had sudden onset. By 12pm the
patient was unable to move and needed help to walk because of
the pain. She also felt nauseous and dry heaved several times
but did not vomit.
She has had similar symptoms in the past when she started a new
insulin and those symptoms were relieved with acetominophen. In
this case, acteominophen did not control the pain. The patient
denies dysuria, hematuria, change urinary frequency or urgency,
fever, chills, diarrhea, constipation. No new weakness, fatigue
or myalgia.
In the ED, initial vitals were: T: 98.4 HR: 75 BP: 158/99 R: 16
O2sat:100%RA. The patient was given tramadol and morphine
sulfate and held for observation in the ED overnight. The
patient says she had continued pain while in observation and
felt nauseous and unable to eat or drink. The pain remained at
___ during the day on ___ and the patient was unable to
tolerate PO intake so she was sent to the floor.
On the floor initial vitals are: T: 98.6 HR: 80 BP: 144/83 RR:
18 O2sat: 98 RA ___. The patient reports being in a
constant ___ pain which is worse when she moves. She feels best
when lying flat. She has diminished appetite and feels nauseous.
She has not eaten since coming to the hospital but has had ice
chips.
Past Medical History:
- Degenerative disk disease
- Type 2 diabetes mellitus
- Hypertension
- Hyperlipidemia
- Osteoarthritis
- Obstructive sleep apnea
- GERD
- Hypothyroidism s/p radioactive iodine treatment for Graves
disease in ___
- Fractured pelvis after getting hit by car in ___
Social History:
___
Family History:
n/c
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: 98.7; 144/83; 80; 18; 98/RA
General: Alert, oriented, lying comfortably in bed
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-distended, bowel sounds present, diffusely
tender to light palpation, worse on left side, no rebound or
guarding. CVA tenderness on L side.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII grossly intact, moving all extremities
DISCHARGE PHYSICAL EXAM
Vitals: T:98.2 (98.2-98.4) HR:58 (58-64) BP:131/65
(122-132/60-65) RR:20 (___) O2sat:100%RA ___
General: Alert, sitting up on side of bed, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, no LAD, no JVD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes or crackles
Abdomen: Scar below umbilicus at midline; tender to palpation on
left side; soft, non-distended, bowel sounds present
Back: Tender to palpation on left side
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AOx3. Sensation to light touch diminished in left lower
extremity. Range of motion on hip flexion, internal and external
rotation limited by patient discomfort. ambulatory
Pertinent Results:
=================
ADMISSION LABS
=================
___ 03:50PM BLOOD WBC-6.8 RBC-4.97 Hgb-14.3 Hct-42.5 MCV-85
MCH-28.7 MCHC-33.6 RDW-14.4 Plt ___
___ 03:50PM BLOOD Neuts-71.1* ___ Monos-4.0 Eos-0.5
Baso-0.5
___ 03:50PM BLOOD Glucose-226* UreaN-11 Creat-0.8 Na-134
K-3.6 Cl-96 HCO3-23 AnGap-19
___ 03:50PM BLOOD ALT-34 AST-27 AlkPhos-111* TotBili-0.4
___ 03:50PM BLOOD Lipase-29
___ 03:50PM BLOOD cTropnT-<0.01
___ 03:50PM BLOOD Albumin-4.8
___ 05:40AM BLOOD Calcium-9.7 Phos-3.9 Mg-1.7
=================
MICROBIOLOGY
=================
___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA (
>= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL
CONTAMINATION.
=================
IMAGING
=================
1. ECG ___: Sinus rhythm. There appears to be minimal ST
segment depressions in leads III and aVF with T wave inversions
in those leads as well as leads V2-V4. These changes are
worrisome for an acute myocardial ischemia. Compared to the
previous tracing of ___ these changes are more prominent.
Clinical correlation is suggested
2. CTU (ABD/PEL) W/&W/O CONTRAST ___:
Urinary: Mild left hydronephrosis, no evidence of
nephrolithiasis, no renal atrophy.
Hepatobiliary: Fatty liver
Gastrointestinal: diverticulosis without diverticulitis
Other: Small fat containing umbilical hernia.
Lower chest, pancreas, spleen, adrenals, retroperitoneal,
vascular systems grossly normal
3. BILAT HIPS (AP,LAT & AP) ___:
1. No acute fracture or dislocation. Old healed right inferior
pubic ramus fracture.
2. Mild bilateral hip joint degenerative changes.
4. MR ___ SPINE W/O CONTRAST ___:
IMPRESSION:
1. Degenerative lumbar spondylosis including and facet
arthropathy and disc protrusions with multilevel neural
foraminal and spinal canal stenoses, as described, slightly
increased at the L4-L5 level compared to ___.
No labs on discharge
Brief Hospital Course:
___ is a ___ year old woman with PMH of DM2, HTN and
HLD who presented with left sided flank and back pain radiating
to the abdomen, groin and thigh. Her CT scan along with her labs
rule out an acute abdominal process. The etiology of her pain is
likely musculoskeletal, and her lumbar spine MRI demonstrated
stenosis and DJD.
====================
Acute issues
====================
# Back and flank pain
Her clinical presentation, the CT scan and her admission labs
ruled out acute abdomen. Her symptoms of being unable to stand
or move her left leg suggested a musculoskeletal etiology
arising from her hip or back, with a superimposed abdominal
pain, possibly from a passed stone. Her pain improved with
tylenol and tramadol with the affected area shrinking to include
only the left flank with radiation to the groin and leg.
Abdominal pain largely resolved.
Regarding other possible causes: Urinary tract obstuction likely
contributed to her initial presentation, as described in the
"hydronephrosis" section below. Abdominal aorta was normal on
CT, ruling out aortic dissection. Troponin was not elevated and
patient had no signs of chest pain or dyspnea, making MI
unlikely. The pancreas was normal on CT and lipase was not
elevated, making pancreatitis unlikely. No dilation or
obstruction was seen in the small and large bowel making both
physical obstruction and a neurogenic obstruction unlikely.
There were no signs of edema or fat stranding and the patient
had no fevers, diarrhea or elevated WBC count, which might
suggest a mesenteric lymphadenitis or gastritis. No signs of rib
fracture, abdominal or retroperitoneal abscess were seen on CT.
No signs of blastic or lytic lesions were visualized in the
bones on CT. Lumbar spine MRI was obtained, which showed spinal
stenosis and DJD.
The patient went 4 days without a bowel movement, so
constipation likely contributed to her discomfort, although it
likely did not cause her pain.
Patient was given morphine in the ED and transitioned to PO
tylenol and tramadol. She was dischared upon ability to tolerate
PO meds. Senna and docusate were used to relieve constipation.
Ondansetron was givne for nausea. Fluids were given as patient
could not initially tolerate PO. ___ evaluated the patient and
agreed that the etiology of pain was likely musculoskeletal low
back vs. hip.
# Hydronephrosis
The only diagnostic abnormality on the patient's workup was mild
left sided hydronephrosis which could be consistent with a
previous obstruction. She had a clear urinalysis and a negative
urine culture as well as normal blood WBC count, so she is
unlikely to have a urinary tract infection. If she had passed a
stone or had other form of transient obstruction, her pain would
have resolved. Repeat UA showed no signs of hematuria making
this an unlikely cause of her continued pain.
====================
Chronic issues
====================
# Diabetes: The patient's most recent HbA1c on file was 8.8 in
___. Home lantus was adjusted while patient could not
tolerate PO, and she was placed on SSI. Home metformin and
glimepiride were held.
# Heart disease: Patient has hypertension and coronary artery
disease. Continued home amlodipine, losartan,
hydrochlorothiazide, metoprolol, atorvastatin.
# GERD: Continued home lansoprazole
# Hypothyroidism: Continued home levothyroxine
====================
Transitional issues
====================
- Continue chronic pain management. Started on gabapentin 100mg
TID during this admission with alleviation in symptoms. Can
uptitrate as needed.
- Patient to continue outpatient ___.
- patient counseled to use discharge medications for pain
relief, and not to use previously prescribed opiates (as she did
not require any during last few days of hospitalization). also
counseled that in general she should avoid driving if taking
opiates for pain control
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amaryl (glimepiride) 2 mg Oral BID
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 10 mg PO DAILY
5. Losartan Potassium 100 mg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Metoprolol Succinate XL 25 mg PO DAILY
8. lansoprazole 30 mg Oral daily
9. Levothyroxine Sodium 112 mcg PO DAILY
10. levemir 30 Units Bedtime
11. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. lansoprazole 30 mg Oral daily
6. Levothyroxine Sodium 112 mcg PO DAILY
7. Losartan Potassium 100 mg PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
9. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
10. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth Q8H PRN Disp #*30
Tablet Refills:*0
11. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
12. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth q8h prn Disp #*30
Tablet Refills:*0
13. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth bid prn Disp
#*60 Capsule Refills:*0
14. Amaryl (glimepiride) 4 mg ORAL DAILY
15. Calcium 500 With D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral 1 tablet daily
16. Famotidine 20 mg PO DAILY
17. Ferrous Sulfate 325 mg PO DAILY
18. MetFORMIN (Glucophage) 1000 mg PO BID
19. Multivitamins 1 TAB PO DAILY
20. Outpatient Physical Therapy
21. Gabapentin 100 mg PO TID
RX *gabapentin 100 mg one capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
22. levemir 30 Units Bedtime
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Back pain
Degenerative disc disease
Secondary diagnoses:
Hydronephrosis
Diabetes
GERD
HTN
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized at ___ from ___ -
___
because you had pain in your abdomen and back on the left side.
We were able to determine that this pain was not due to
infection, inflammation of your organs, or obstruction of your
intestines or kidneys. We do not believe that there are any
emergency issues you have at this time.
No new medications were started during this admission and no
changes were made to your existing medications.
You have follow up scheduled with your primary care doctor
listed below.
We wish you all the best!
-Your ___ Team
Followup Instructions:
___
|
10199879-DS-17 | 10,199,879 | 22,636,062 | DS | 17 | 2110-06-01 00:00:00 | 2110-06-02 15:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
chest pain, dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with obesity, sleep apnea and prior tobacco use who now
presents with chest & radiating L arm discomfort x1 day, in the
setting of an abnormal stress test and DOE for the past month.
She says that at her prior baseline she could walk 3 miles per
day without difficulty, but that for the past month or so she
gets very winded even with walking down a hallway and has to
take
a break. In this context she was referred to a cardiologist, who
had her undergo an exercise EKG about a week ago which was
notable for inducible ischemic changes in an inferior
distribution (just SOB but no chest/arm discomfort during the
stress test). She had PFTs at the time which were normal.
___
she underwent a repeat exercise stress test, this time with EKG
and TTE. The EKG showed similar inferior wall ischemic changes,
she became dyspneic but not with chest/arm discomfort, and TTE
did not show any definitive inducible wall motion abnormalities
but image quality was poor such that inferior wall was not well
visualized.
She went home after the stress echo and later that evening, at
rest/out of the blue, she began experiencing a mid-sternal
"chest
tightness" with pain radiating to the left upper arm. Not
accompanied by SOB. Lasted for hours on end, nothing seemed to
make it better or worse, and she did not sleep well as a result.
She came to the ED around mid-day, and ___ when she was
given
ASA and nitroglycerin in the afternoon, she reports that both
meds helped (they were given at different times) in reducing her
pain, which at this point is all but gone entirely. ROS positive
for feeling sweaty along with the chest discomfort, but without
nausea.
Past Medical History:
1. CARDIAC RISK FACTORS
- Age
- Smoking history
- Obesity
2. CARDIAC HISTORY
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
- OSA
Social History:
___
Family History:
there is no premature coronary disease or sudden cardiac in
early age.
Physical Exam:
ADMISSION PE:
24 HR Data (last updated ___ @ 2302)
Temp: 98.4 (Tm 98.4), BP: 121/77, HR: 66, RR: 18, O2 sat:
96%, O2 delivery: Ra
Otherwise notable for pleasant obese woman alert and conversant,
NAD, ambulating independently. JVP 5cm, lungs CTAB, heart
regular
without MRG, abd soft/NT/ND, legs warm without edema
==================
DISCHARGE PE:
VS: tmax 97.8, BP 101-129/55-80, HR 60's, RR 18, 97%RA
Tele: SR prolonged PR and PVCs, 60's
unchanged by PE done on admission. Pleasant woman alert and
conversant, NAD, ambulating independently. JVP 5cm, lungs CTAB,
heart regular without MRG, abd soft/NT/ND, legs warm without
edema
Pertinent Results:
___ 01:24PM BLOOD WBC-6.2 RBC-5.17 Hgb-14.7 Hct-46.0*
MCV-89 MCH-28.4 MCHC-32.0 RDW-13.9 RDWSD-45.0 Plt ___
___ 01:24PM BLOOD Neuts-61.1 ___ Monos-7.9 Eos-0.0*
Baso-0.6 Im ___ AbsNeut-3.80 AbsLymp-1.87 AbsMono-0.49
AbsEos-0.00* AbsBaso-0.04
___ 05:55AM BLOOD ___ PTT-30.0 ___
___ 01:24PM BLOOD Glucose-92 UreaN-19 Creat-1.0 Na-139
K-5.4 Cl-102 HCO3-26 AnGap-11
___ 04:37PM BLOOD cTropnT-<0.01
___ 01:24PM BLOOD cTropnT-<0.01
Stress test: ___ at BID-N
CONCLUSION: Average functional exercise capacity for age and
gender. Ischemic ECG changes with no symptoms to achieved
treadmill stress. Suboptimal visualization of the basal
inferolateral walls to interpret but otherwise no 2D
echocardiographic evidence of inducible ischemia to
achieved workload of all other segments. No Doppler evidence for
a change in left ventricular filling pressure with exercise.
Normal resting blood pressure with a normal blood pressure and a
normal heart rate response to achieved workload. Unable to
assess baseline PASP. Stress PASP normal. If high clinical
concern for ischemia of basal inferolateral walls could repeat
with contrast.
UNILAT LOWER EXT VEINS LEFT: ___
IMPRESSION:
No evidence of deep venous thrombosis in the left lower
extremity veins.
CHEST XRAY: ___
IMPRESSION:
No acute cardiopulmonary process.
Brief Hospital Course:
___ with OSA, obesity and 35-pack-year smoking history who
presents with 24 hours of chest/L arm pain following an abnormal
exercise stress test, in the absence of cardiac biomarker
elevation, concerning for unstable angina.
CORONARIES: unknown
PUMP: EF 60-65%
RHYTHM: sinus
# Unstable angina: Received ASA 324mg and SL nitro 0.4mg in the
ED, resolving her
chest discomfort. Plan was to admit for cardiac cath. She was
NPO all day on ___ with no CP however due to urgent cases, her
case was deferred. After discussion with attending, Dr. ___,
___ ___ year fellow, Dr. ___ was made with patient and
family that she would go home and electively come back on
___ for the procedure
- start metoprolol 25 mg night, nitro SL PRN, atorvastatin 80mg
every night, and ASA 81mg daily
-planned cath on ___
-___ with Dr. ___ discharge
# Depression
-Continue home escitalopram
# OSA
-Does not use CPAP (has yet to be fitted for one at home)
# Dispo: DC home with family with outpatient cath on ___
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Escitalopram Oxalate 10 mg PO QAM
2. Vitamin D3 (cholecalciferol (vitamin D3)) 3000 units oral QAM
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Metoprolol Succinate XL 25 mg PO QPM
4. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
5. Escitalopram Oxalate 10 mg PO QAM
6. Vitamin D3 (cholecalciferol (vitamin D3)) 3000 units oral
QAM
Discharge Disposition:
Home
Discharge Diagnosis:
chest pain
sleep apnea
emphysema
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 ___
___.
WHY WAS I IN THE HOSPITAL?
==========================
- You presented to hospital due to chest pain and shortness of
breath. Based on EKG and labs results, you did not have a heart
attack however the stress test imaging warranted a cardiac cath.
We planned to have you go for the procedure today however due to
scheduling it was feasible. You wanted to go home and come back
electively early next week for the procedure. You were offered
the option to stay however I understand you want to go home.
Please take it easy at home. No working out or any strenuous. If
you have chest pain, try nitroglycerin. Nitroglycerin is a
medication that can be used as needed for chest pain. If you
develop chest pain, place 1 tablet under the tongue and allow it
to dissolve. If after 5 minutes you are still having chest pain,
you can repeat this every 5 minutes for UP TO 3 doses. If chest
pain persists after 3 doses, call ___. You should always lie
down if you need to take this medication, because it can cause a
drop in your blood pressure which can lead to lightheadedness or
possibly cause someone to pass out if blood pressure drops too
low. Even if your chest pain resolves, you should contact your
cardiologist to inform them of your symptoms.
WHAT SHOULD I DO WHEN I GO HOME?
================================
Continue your current medications with the following changes:
- START aspirin 81 mg for presumed coronary artery disease. This
keep the platelets from sticking to vessel wall and causing a
heart attack.
- START atorvastatin (Lipitor) 80 mg every night (best absorbed
when taken in the evening), this medication not only reduces
cholesterol, but has been shown to help decrease risk of heart
attack in the future for people who have coronary artery (heart)
disease.
- START metoprolol succinate 25 mg every night. This medication
belongs to a class of medications known as Beta Blockers. Beta
blockers slow the heart down and can lower blood pressure. They
help reduce the amount of work the heart has to do, and can help
to reduce risk of future heart attack.
- START nitroglycerin as needed. See blurb above.
Written drug information has been provided to you.
The cardiac cath scheduling nurses should call you at home to
discuss the date and time of the procedure and will go over pre
procedure instruction and what medications to take or hold the
night before and morning of your procedure.
If you were given any prescriptions on discharge, any future
refills will need to be authorized by your outpatient providers,
primary care or cardiologist.
It was a pleasure participating in your care.
If you have any urgent questions that are related to your
recovery from your hospitalization or are experiencing any
symptoms that are concerning to you and you think you may need
to return to the hospital, please call the ___ HeartLine at
___ to speak to a cardiologist or cardiac nurse
practitioner.
-Your ___ Care Team
Followup Instructions:
___
|
10199945-DS-11 | 10,199,945 | 25,949,698 | DS | 11 | 2173-07-19 00:00:00 | 2173-07-19 11:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: PODIATRY
Allergies:
Compazine / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) /
topiramate
Attending: ___.
Chief Complaint:
R foot infection
Major Surgical or Invasive Procedure:
___ for R ___ toe partial amp
History of Present Illness:
Ms. ___ is a ___ with history of DM c/b neuropathy and ___
ulcerations, multiple recent hospitalizations for pneumonia with
c/f aspiration (had recent swallow study w/o evidence of
aspiration however), multiple psych disorders (currently on a
stable regimen), hx of vertical gastric banding (has not been
seen regarding this recently). She presents to the ___ ED,
after referral from her podiatrist at ___, for further workup
of a right foot infection. She has had a right second toe ulcer
for several months. She has been treated with wound care and
oral abx in the past. Last week she had a debridement of a
superficial abscess of the R ___ toe. She has been on Keflex,
Bactrim, and most recently clindamycin for treatment of
infections in the right ___ toe. The toe worsened over the
course of the last few days. She reports increased pain in the
toe despite being neuropathic at baseline. She denies any recent
n/v/f/c/cp/sob. She has had a prior amputation on the Left foot
___ an infection
Past Medical History:
THYROID NODULE
HYPOTHYROIDISM, UNSPEC
BULIMIA (NONORGANIC ORIGIN)
MYOCARDIAL INFARCT, UNSPEC SITE & CARE
SPONDYLOSIS - LUMBOSACRAL
ANEMIA - IRON DEFIC, UNSPEC
COLONIC ADENOMA
RESTLESS LEGS SYNDROME
HEADACHE
DISC DISPLACEMENT - LUMBAR
ESOPHAGEAL REFLUX
DUB (Dysfunctional Uterine Bleeding)
Vitreous floaters
Cortical cataract
Hypercholesteremia
OSA on CPAP
Morbid obesity
Osteoarthritis, knee: Bilateral
Trochanteric bursitis; Right
Neuropathy
Lichen sclerosus
Osteoarthritis, hand
Borderline personality disorder
Bipolar disorder, unspecified
Impingement syndrome of left shoulder
Social History:
___
Family History:
father - CAD; mother - colon cancer
Physical Exam:
Admission Physical:
VITALS: 98.0 76 145/82 16 100% RA
GEN: NAD, Aox3, pleasant
RESP: CTA
CV: RRR, extremities well perfused
ABD: Soft, NT, ND
___ FOCUSED EXAM: Dp/Pt pulses palpable, cap refill less than 3
sec to the digits. moderate edema to the Right forefoot and ___
digit. Ulceration to the dorsal distal aspect of the ___ toe
with dry eschar. no fluctuance noted. erythema to the ___ toe.
pain on palpation of the ___ toe. light touch sensation
diminished to the feet b/l. No pain with active ROM of the L and
R ankle and ___ MPJ b/l. mild pain with ROM of the R ___ toe.
Discharge Physical:
AVSS
GEN: NAD, Aox3, pleasant
RESP: CTA
CV: RRR, extremities well perfused
ABD: Soft, NT, ND
___ FOCUSED EXAM: Dp/Pt pulses palpable, cap refill less than 3
sec to the digits. Surgical dressing is clean dry and intact.
Pertinent Results:
___ 10:08PM BLOOD WBC-11.4* RBC-3.99 Hgb-11.5 Hct-36.8
MCV-92 MCH-28.8 MCHC-31.3* RDW-14.4 RDWSD-48.4* Plt ___
___ 10:08PM BLOOD Neuts-70.2 Lymphs-18.0* Monos-6.3 Eos-4.6
Baso-0.5 Im ___ AbsNeut-8.01*# AbsLymp-2.05 AbsMono-0.72
AbsEos-0.53 AbsBaso-0.06
___ 10:08PM BLOOD Plt ___
___ 10:08PM BLOOD Glucose-95 UreaN-14 Creat-0.8 Na-137
K-4.1 Cl-95* HCO3-30 AnGap-16
___ 06:20AM BLOOD Calcium-9.1 Phos-4.5 Mg-2.0
___ 10:08PM BLOOD CRP-6.9*
___ 10:28PM BLOOD Lactate-1.4
IMAGING:
Right Foot Xrays: ___ FINDINGS: There appears to be
lateral subluxation, if not complete dislocation, of the second
proximal phalanx with respect to the metatarsal head. There is
no
cortical erosion involving this phalanx to suggest
osteomyelitis. However, there is a small cortical erosion of the
third metatarsal head without priors for comparison. No evidence
of fracture. Mild hallux valgus metatarsus varus deformity.
Degenerative changes are seen particularly at the first
interphalangeal joint and at the intertarsal joints. There is a
small plantar calcaneal spur. No soft tissue calcification or
radio-opaque foreign body is detected.
IMPRESSION: 1. Lateral subluxation, if not complete dislocation,
of the second proximal phalanx with respect to the metatarsal
head. No evidence of osteomyelitis involving this phalanx. 2.
Small cortical erosion involving the third metatarsal head, of
indeterminate chronicity and etiology. 3. Degenerative changes
involving the first interphalangeal joint and intertarsal
joints.
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the podiatric surgery team. The patient was found
to have R foot infection and was admitted to the podiatric
surgery service. The patient was taken to the operating room on
___ for R ___ digit partial amputation, 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
PWB in the right lower extremity to her heel. 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:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild
2. ARIPiprazole 30 mg PO QHS
3. Baclofen 20 mg PO QHS
4. BuPROPion XL (Once Daily) 300 mg PO DAILY
5. ClonazePAM 1 mg PO QHS
6. Cyclobenzaprine 10 mg PO TID:PRN spasm
7. DULoxetine 120 mg PO QHS
8. Ferrous Sulfate 47.5 mg PO DAILY
9. Gabapentin 1200 mg PO AT 5PM
10. Gabapentin 300 mg PO AT BREAKFAST AND LUNCH
11. Hydrochlorothiazide 25 mg PO DAILY
12. HydrOXYzine 40 mg PO QPM:PRN insomnia
13. LamoTRIgine 300 mg PO DAILY
14. Levothyroxine Sodium 125 mcg PO DAILY
15. Methylphenidate SR 20 mg PO QAM
16. Multivitamins 1 TAB PO DAILY
17. Pantoprazole 40 mg PO Q24H
18. rOPINIRole 3 mg PO ONCE IN EVENING AS NEEDED
19. Venlafaxine XR 150 mg PO DAILY
20. ZIPRASidone Hydrochloride 80 mg PO BID
21. Levofloxacin 750 mg PO Q24H
22. Betamethasone Valerate 0.1% Ointment 1 Appl TP TID
23. Clobetasol Propionate 0.05% Ointment 1 Appl TP ___
24. Clotrimazole Cream 1 Appl TP BID
25. Cyclobenzaprine 5 mg PO TID:PRN spasm
26. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
27. MetFORMIN XR (Glucophage XR) ___ mg PO DAILY
28. Prometrium (proGESTerone micronized) 200 mg oral DAILY
29. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
30. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*20 Tablet Refills:*0
2. Clindamycin 300 mg PO Q8H
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every eight (8)
hours Disp #*30 Capsule Refills:*0
3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*30 Tablet Refills:*0
4. QUEtiapine Fumarate 25 mg PO QHS
5. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
7. albuterol sulfate 90 mcg inhalation Q4H:PRN shortness of
breath
8. ARIPiprazole 30 mg PO QHS
9. Baclofen 20 mg PO QHS
10. Betamethasone Valerate 0.1% Ointment 1 Appl TP TID
11. BuPROPion XL (Once Daily) 300 mg PO DAILY
12. Clobetasol Propionate 0.05% Ointment 1 Appl TP ___
13. ClonazePAM 1 mg PO QHS
14. Clotrimazole Cream 1 Appl TP BID
15. Cyclobenzaprine 5 mg PO TID:PRN spasm
16. Cyclobenzaprine 10 mg PO TID:PRN spasm
17. DULoxetine 120 mg PO QHS
18. Ferrous Sulfate 47.5 mg PO DAILY
19. Gabapentin 300 mg PO LUNCH
20. Gabapentin 1200 mg PO QPM
21. Gabapentin 300 mg PO BREAKFAST
22. Hydrochlorothiazide 25 mg PO DAILY
23. HydrOXYzine 25 mg PO QHS:PRN insomnia
24. lamoTRIgine 300 mg oral DAILY
25. Levothyroxine Sodium 125 mcg PO DAILY
26. MetFORMIN XR (Glucophage XR) ___ mg PO DAILY
Do Not Crush
27. Methylphenidate SR 20 mg PO QAM
28. Multivitamins 1 TAB PO DAILY
29. Pantoprazole 40 mg PO Q24H
30. Pravastatin 80 mg PO DAILY
31. Prometrium (proGESTerone micronized) 200 mg oral DAILY
32. rOPINIRole 3 mg oral QPM
33. Venlafaxine XR 150 mg PO DAILY
34. ZIPRASidone Hydrochloride 80 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
R foot infection
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 at ___. You were admitted
to the Podiatric Surgery service for your right foot infection.
You were given IV antibiotics while here. You are being
discharged home with the following instructions:
ACTIVITY:
There are restrictions on activity. Please remain non weight
bearing to your R foot until your follow up appointment. You
should keep this site elevated when ever possible (above the
level of the heart!)
No driving until cleared by your Surgeon.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your leg wound(s).
New pain, numbness or discoloration of your foot or toes.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
Exercise:
Limit strenuous activity for 6 weeks.
No heavy lifting greater than 20 pounds for the next ___ days.
Try to keep leg elevated when able.
BATHING/SHOWERING:
You may shower immediately upon coming home, but you must keep
your dressing CLEAN, DRY and INTACT. You can use a shower bag
taped around your ankle/leg or hang your foot/leg outside of the
bathtub.
Avoid taking a tub bath, swimming, or soaking in a hot tub for 4
weeks after surgery or until cleared by your physician.
MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
DIET:
There are no special restrictions on your diet postoperatively.
Poor appetite is not unusual for several weeks and small,
frequent meals may be preferred.
FOLLOW-UP APPOINTMENT:
Be sure to keep your medical appointments.
If a follow up appointment was not made prior to your discharge,
please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are ___
through ___.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE.
Followup Instructions:
___
|
10199945-DS-9 | 10,199,945 | 23,358,585 | DS | 9 | 2172-01-06 00:00:00 | 2172-01-10 17:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Compazine / NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___
Chief Complaint:
E cellulitis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female with bipolar, prediabetes recently started on
metformin, HTN, and h/o osteomyelitis of her right ___ toe
treated with a prolonged course of oxacillin presenting with LLE
cellulitis.
Pt reports that she has had a corn on her left second toe for
which she saw a podiatrist a week ago. Per pt, the podiatrist
shaved the corn. She states that on ___, she noticed that
the toe was more red and painful. She subsequently developed
erythema and pain on her left lower leg and presented to her
___ podiatrist on ___ who per ___ notes debrided what was
now an ulcer on her left ___ toe. Of note, the podiatrist did
not see purulence, and could not probe deeply. The podiatrist
also noted the ascending erythema and referred pt to the ___
ED for evaluation.
In the ED, initial vitals were: 98.5 89 190/101 22 100% on RA
- Labs were significant for WBC 10.1 with 75% PMNs, na 141,
BUN/Cr ___
- X-ray of left second toe did not evidence of bony lysis, but
did show soft tissue swelling and irregularity along the second
digit.
- The patient was given Percocet
Vitals prior to transfer were: 98 80 170/88 18 99% on RA
Upon arrival to the floor, pt reports LLE pain.
REVIEW OF SYSTEMS:
(+) Per HPI
Past Medical History:
THYROID NODULE
HYPOTHYROIDISM, UNSPEC
BULIMIA (NONORGANIC ORIGIN)
MYOCARDIAL INFARCT, UNSPEC SITE & CARE
SPONDYLOSIS - LUMBOSACRAL
ANEMIA - IRON DEFIC, UNSPEC
COLONIC ADENOMA
RESTLESS LEGS SYNDROME
HEADACHE
DISC DISPLACEMENT - LUMBAR
ESOPHAGEAL REFLUX
DUB (Dysfunctional Uterine Bleeding)
Vitreous floaters
Cortical cataract
Hypercholesteremia
OSA on CPAP
Morbid obesity
Osteoarthritis, knee: Bilateral
Trochanteric bursitis; Right
Neuropathy
Lichen sclerosus
Osteoarthritis, hand
Borderline personality disorder
Bipolar disorder, unspecified
Impingement syndrome of left shoulder
Social History:
___
Family History:
father - CAD; mother - colon cancer
Physical Exam:
PHYSICAL EXAM on admission:
Vitals: 98.9 144/63 74 18 99% on RA, Wt 141.3kg
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM
Neck: Supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Obese, Soft, non-tender, non-distended, bowel sounds
present, no organomegaly, no rebound or guarding
GU: No foley
Ext: Left ___ toe with pigmented ulcer that is superficial with
surrounding erythema TTP; distal left shin with tender erythema
Neuro: Grossly intact.
PHYSICAL EXAM on discharge:
VS: 98.8 ___ 20 96%RA
Curr: 97.4 127/55 76 20 98%RA
Gen: well apearing, NAD
HEENT: MMM, OP clear
Neck: Supple without lymphadenopathy
Pulm: Generally CTA
Cor: RRR (+)S1/S2 no m/r/g
Abd: Soft, obese, non-tender
Extrem: Warm, well-perfused, no significant edema
Skin: Erythema on anterior shin dissipated. Continued tenderness
with marked improvement. L toe ulcerated with clean granulation
tissue
Neuro: AOx3, CN II-XII grossly intact, motor function grossly
intact
Pertinent Results:
Labs on admission
------------------
___ 04:08PM BLOOD WBC-10.1 RBC-4.26 Hgb-12.2 Hct-36.8
MCV-87# MCH-28.6 MCHC-33.1 RDW-14.1 Plt ___
___ 04:08PM BLOOD Plt ___
___ 04:08PM BLOOD Glucose-109* UreaN-13 Creat-0.7 Na-141
K-3.6 Cl-102 HCO3-28 AnGap-15
___ 06:27AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.1
___ 06:27AM BLOOD VitB12-442
___ 06:27AM BLOOD CRP-21.0*
___ 06:27 Sed Rate 14
___ Imaging TOE(S), 2+ VIEW LEFT
IMPRESSION:
No evidence of bony lysis. Soft tissue swelling and
irregularity along the second digit.
___ BLOOD CULTURE Blood Culture,
Routine-PENDING
Blood Culture, Routine (Final ___: NO GROWTH.
Labs on discharge
------------------
___ 06:02AM BLOOD WBC-7.0 RBC-4.18* Hgb-12.1 Hct-36.9
MCV-88 MCH-29.0 MCHC-32.9 RDW-14.4 Plt ___
___ 06:02AM BLOOD Glucose-101* UreaN-11 Creat-0.7 Na-142
K-4.2 Cl-102 HCO3-30 AnGap-14
___ 06:02AM BLOOD Calcium-9.3 Phos-4.4 Mg-2.0
___ 06:27AM BLOOD VitB12-442
___ 06:27AM BLOOD CRP-21.0*
Brief Hospital Course:
Ms. ___ is a ___ year old patient with PMH of osteomyelitis of
her right foot after hammer toe surgery (___), multiple
psychiatric comorbidities, and hypertension who was admitted for
cellulitis to her L lower extemity due to ulceration to ___
digit.
BRIEF HOSPITAL COURSE
=======================
ACTIVE ISSUES
---------------
# LOWER EXTREMITY CELLULITIS: Exam and x-rays reassuring that
there is no underlying osteomyelitis. Exam on admission
concerning for marked erythema and tenderness of the L ___ toe
with tracking to anterior shin, no purlence. Due to concern for
developing purulence, podiatry assessed patient and L ___ toe
ulceration debrided at bedside. No purulence noted on their
exam, rather wet-fibro-granular base. Due to clinical
improvement with IV antibiotics and low suspicion for
osteomyelitis, patient changed to oral antibiotics
(Bactrim/Augmentin). Recommend continuing to tend wound with wet
to dry dressing changes daily with saline. Once discharged, pt
should f/u with OSH podiatrist, Dr. ___, in 1 week for
monitoring.
CHRONIC ISSUES
------------------
#Neuropathy: Patient found to have reduced vibratory sensation
on outpatient podiatry exams. Attributed to diabetes, though
last A1c testing earlier this year with well-controlled average
blood glucoses. Exam in affected lower extremity is difficult to
interpret given tenderness in setting of infection. If
neuropathy is indeed present, evaluation for other causes of
neuropathy is likely indicated. Vitamin B12 levels WNL. Consider
outpatient Neurology evaluation
#Pre-diabetes: Patient reportedly with pre-diabetes, last A1c
was 5.9% in ___. Continued on home dose metformin.
#Psychiatric comorbidities: Patient with history of bipolar
disorder vs. depression with psychosis, borderline personality
disorder, and impulse control disorder currently on several
medications. At baseline without symptoms. Patient continued on
home aripiprazole, bupropion, gabapentin, lamotrigine,
methylphenidate, and venlafaxine
#Hyperlipidemia: Patient continued on home dose aspirin,
pravastatin
#Hypothyroidism: Patient continued on home dose levothyroxine
#GERD: Patient continued on pantoprazole
#OSA: Patient continued on home CPAP settings.
#RLS: Patient continued on ropinarole
#Morbid obesity s/p distant bariatric surgery: noted. No
complications noted
TRANSITIONAL ISSUES
[] Podiatry: Please follow up L toe ulceration and assess
improvement with oral antibiotics
[] Continue antibiotics for 7 days (to end ___
[] Consider outpatient Neurology evaluation for neuropathy
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ropinirole 3 mg PO QPM
2. Gabapentin 300 mg PO QAM
3. Gabapentin 1200 mg PO QHS
4. Methylphenidate SR 20 mg PO QAM
5. clindamycin phosphate 1 % topical BID
6. econazole 1 % topical BID
7. Fluocinolone Acetonide 0.01% Solution 1 Appl TP ASDIR
8. ARIPiprazole 20 mg PO QHS
9. Ibuprofen 600 mg PO Q8H:PRN Pain
10. Prometrium (proGESTerone micronized) 200 mg oral DAILY
11. BuPROPion (Sustained Release) 300 mg PO QAM
12. LaMOTrigine 300 mg PO QHS
13. Venlafaxine XR 300 mg PO DAILY
14. urea 40 % topical QHS
15. ClonazePAM 0.5 mg PO QHS
16. Nystatin-Triamcinolone Cream 1 Appl TP BID
17. Aspirin 81 mg PO DAILY
18. Docusate Sodium 100 mg PO BID
19. Senna 8.6 mg PO BID:PRN Constipation
20. Pravastatin 40 mg PO QPM
21. Levothyroxine Sodium 125 mcg PO DAILY
22. Pantoprazole 40 mg PO Q12H
23. Vitamin D ___ UNIT PO DAILY
24. Betamethasone Valerate 0.1% Ointment 1 Appl TP BID
25. Lidocaine 5% Ointment 1 Appl TP Q4H:PRN Pain
26. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
Discharge Medications:
1. ARIPiprazole 20 mg PO QHS
2. Aspirin 81 mg PO DAILY
3. BuPROPion (Sustained Release) 300 mg PO QAM
4. ClonazePAM 0.5 mg PO QHS
5. Docusate Sodium 100 mg PO BID
6. Gabapentin 300 mg PO QAM
7. Gabapentin 1200 mg PO QHS
8. Ibuprofen 600 mg PO Q8H:PRN Pain
9. LaMOTrigine 300 mg PO QHS
10. Levothyroxine Sodium 125 mcg PO DAILY
11. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
Do Not Crush
12. Methylphenidate SR 20 mg PO QAM
13. Pantoprazole 40 mg PO Q12H
14. Pravastatin 40 mg PO QPM
15. Ropinirole 3 mg PO QPM
16. Senna 8.6 mg PO BID:PRN Constipation
17. Venlafaxine XR 300 mg PO DAILY
18. Vitamin D ___ UNIT PO DAILY
19. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*14 Tablet Refills:*0
20. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth Q6H:PRN Disp #*30 Tablet
Refills:*0
21. Sulfameth/Trimethoprim DS 2 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*14 Tablet Refills:*0
22. Betamethasone Valerate 0.1% Ointment 1 Appl TP BID
23. clindamycin phosphate 1 % topical BID
24. econazole 1 % topical BID
25. Fluocinolone Acetonide 0.01% Solution 1 Appl TP ASDIR
26. Lidocaine 5% Ointment 1 Appl TP Q4H:PRN Pain
27. Nystatin-Triamcinolone Cream 1 Appl TP BID
28. Prometrium (proGESTerone micronized) 200 mg oral DAILY
29. urea 40 % topical QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
------------------
L TOE 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 with an ulcerated left toe and tender skin
rash. You were evaluated by our podiatrists and felt NOT to have
a bone infection (osteomyelitis). You were treated with IV
antibiotics, but due to your good clinical progression, this was
changed to oral antibiotics.
Please follow up with your podiatrist Dr. ___ in one week
to monitor the rash and left toe.
It was a pleasure taking care of you at ___.
Sincerely,
Your Team at ___
Followup Instructions:
___
|
10200169-DS-20 | 10,200,169 | 29,874,747 | DS | 20 | 2175-07-09 00:00:00 | 2175-07-09 13:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left leg pain
Major Surgical or Invasive Procedure:
Left periprosthetic femur fracture ORIF
History of Present Illness:
Patient is a ___ HTN HLD, mechanical fall this AM making his
bed, no headstrike no LOC. This was an isolated injury. He was
taken to ___ and transfered here for further
management. He has a history of prior bilateral total hip
arthroplastys done at ___ by Dr. ___ in the 1980s. He
did not have any trouble with these hips prior to the fall.
Past Medical History:
HTN
HLD
Social History:
___
Family History:
NC
Physical Exam:
Vitals:AVSS in ED
Patient is in NAD, AOx3
Right lower extremity:
Superficial knee abrasion
Soft, non-tender thigh and leg
Full, painless AROM/PROM of hip, knee, and ankle
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
Left lower extremity:
Skin intact
Pain over the high with deformity
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
Pertinent Results:
___ 01:10PM GLUCOSE-138* UREA N-20 CREAT-1.0 SODIUM-134
POTASSIUM-3.4 CHLORIDE-99 TOTAL CO2-28 ANION GAP-10
___ 01:10PM estGFR-Using this
___ 01:10PM WBC-12.6* RBC-4.59* HGB-14.7 HCT-44.1 MCV-96
MCH-32.0 MCHC-33.3 RDW-12.1
___ 01:10PM NEUTS-85.2* LYMPHS-8.7* MONOS-5.4 EOS-0.3
BASOS-0.3
___ 01:10PM PLT COUNT-162
___ 01:10PM ___ PTT-29.9 ___
___ 01:00PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 01:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 01:00PM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-0
___ 01:00PM URINE MUCOUS-RARE
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 left periprosthetic femur fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for left periprosthetic femur fracture
ORIF, 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.
Musculoskeletal: Prior to operation, patient was NWB LLE.
After procedure, patient's weight-bearing status was
transitioned to ___ LLE. Throughout the hospitalization,
patient worked with physical therapy who determined that
discharge to a rehabilitation facility was appropriate.
Neuro: Post-operatively, patient's pain was controlled by IV
pain medication and was subsequently transitioned to oxycodone
with good effect and adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Hematology: The patient's hematocrits were monitored and the
patient did not require transfusion of blood products.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: A po diet was tolerated well. Patient was also started
on a bowel regimen to encourage bowel movement. Intake and
output were closely monitored.
ID: The patient received perioperative antibiotics. The
patient's temperature was closely watched for signs of
infection.
Prophylaxis: The patient received enoxaparin during this stay,
and was encouraged to get up and ambulate as early as possible.
At the time of discharge on ___, POD #2, the patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. The incision was clean, dry, and intact
without evidence of erythema or drainage; the extremity was NVI
distally throughout. The patient was given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 2 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 100 mg PO DAILY
2. Simvastatin 10 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Metoprolol Tartrate 25 mg PO Q6H
3. Simvastatin 10 mg PO DAILY
4. Acetaminophen 650 mg PO TID
5. Docusate Sodium 100 mg PO BID
6. Enoxaparin Sodium 40 mg SC QPM Duration: 2 Weeks
Start: Today - ___, First Dose: Next Routine Administration
Time
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
8. Senna 8.6 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left periprosthetic femur 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:
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 40mg 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:
- Touch down weight bearing left lower extremity.
Physical Therapy:
- TDWB LLE
Treatments Frequency:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
Followup Instructions:
___
|
10200169-DS-21 | 10,200,169 | 20,991,076 | DS | 21 | 2175-07-15 00:00:00 | 2175-07-15 18:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
EKG changes, wound bleeding
Major Surgical or Invasive Procedure:
None this hospitalization.
History of Present Illness:
___ with PMHX HTN, HLD on ___ s/p left periprosthetic femur
fracture ORIF, which the patient tolerated well sent to
___ and now returns with bloody drainage from his
wound site and ST depressions on EKG while at rehab. Pt unsure
when bleeding started but says when doctors changed ___ was
bleeding yesterday. Pt on Lovenox and ASA. Pt denies CP, SOB,
dizziness, syncope, back pain, abdominal pain, HA, N/V. No leg
pain unless trying to move it.
In the ED, initial vs were 98.3 100 103/62 12 96% RA.
Labs were remarkable for HCT 26.2 (from 44.1 prior to surgery),
Troponins 0.11, Na 132, Neutrophils 83, INR 1.1. Lovenox was
held and pt was transfused 1 unit packed RBC. Incision intact,
no need for urgent surgical intervention. Admitted to medicine
for anemia and possible demand ischemia. Vitals on transfer were
98.8, 84, 113/60, 18, 97%RA.
On the floor, vs were: T 98.0 P 85 BP 128/62 R 20 O2 sat 95% RA.
Pt was lying comfortably in bed, denying any chest pain, SOB,
leg pain, any discomfort.
Review of sytems:
(+) 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. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias. Ten
point review of systems is otherwise negative.
Past Medical History:
-HTN
-HLD
-left periprosthetic femur fracture ORIF (___)
-bilateral total hip arthroplastys (1980s)
-kidney stone surgical removal (___)
-tonsillectomy (long time ago)
Social History:
___
Family History:
Father with stroke. Mother with stomach cancer. Sister with
cancer (pt doesn't know what kind). Daughter with kidney
transplant and pacemaker. No known family history of blood
clots.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 98.0 BP: 128/62 P: 85 R: 20 O2: 95%RA
General: Alert, oriented, no acute distress. Lying comfortably
in bed.
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. ___ systolic murmur
radiating to carotids.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Bleeding from left leg, bandaged now.
Skin: No rashes
Neuro: alert, grossly intact
DISCHARGE PHYSICAL EXAM:
Vitals: 97.7 108/60 63 18 95% RA
General: Alert, oriented, no acute distress. Lying comfortably
in bed.
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. ___ systolic murmur
radiating to carotids.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. Left
leg with staples in place c/d/i, no oozing or bleeding.
Abrasions on lateral leg covered in xeroform but without active
oozing/bleeding. Less LLE swelling.
Skin: No rashes
Neuro: Alert, grossly intact
Pertinent Results:
ADMISSION LABS:
___ 04:26PM BLOOD WBC-10.7 RBC-2.69* Hgb-8.7* Hct-26.2*
MCV-97 MCH-32.2* MCHC-33.1 RDW-12.7 Plt ___
___ 04:26PM BLOOD Neuts-83.0* Lymphs-9.1* Monos-7.3 Eos-0.6
Baso-0.1
___ 04:26PM BLOOD ___ PTT-28.8 ___
___ 04:26PM BLOOD Glucose-166* UreaN-27* Creat-1.1 Na-132*
K-3.8 Cl-98 HCO3-29 AnGap-9
___ 12:36AM BLOOD CK(CPK)-694*
___ 04:26PM BLOOD cTropnT-0.11*
___ 06:00AM BLOOD Albumin-2.8* Calcium-8.1* Phos-2.5*
Mg-1.9
INTERVAL LABS:
___ 10:15AM BLOOD cTropnT-0.09*
DISCHARGE LABS:
___ 05:30AM BLOOD WBC-7.8 RBC-3.37* Hgb-11.2* Hct-33.3*
MCV-99* MCH-33.0* MCHC-33.5 RDW-13.1 Plt ___
___ 05:30AM BLOOD Glucose-134* UreaN-25* Creat-1.0 Na-137
K-4.1 Cl-103 HCO3-26 AnGap-12
___ 05:30AM BLOOD Calcium-8.6 Phos-2.9 Mg-1.7
MICRO:
None
IMAGING:
TTE ___
The left atrium is elongated. The left atrial volume is mildly
increased. The right atrium is moderately dilated. The estimated
right atrial pressure is ___ mmHg. There is mild symmetric left
ventricular hypertrophy. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic valve leaflets are
mildly thickened (?#). There is mild aortic valve stenosis
(valve area 1.2-1.9cm2). Moderate (2+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global/regional biventricular function. Biatrial
enlargement. Mild aortic stesnosis, with calculated ___ 1.6 cm2
and moderate aortic insufficiency. Mild mitral regurgitation.
Mild pulmonary artery systolic hypertension. No significant
pericardial effusion. Mildly dilated ascending aorta.
UNILAT LOWER EXTREMITY VEINS LEFT ___
IMPRESSION: No evidence of deep vein thrombosis. Calf veins not
visualized.
Brief Hospital Course:
___ with PMHX HTN, HLD on ___ s/p left periprosthetic femur
fracture ORIF, which the patient tolerated well returns from
rehab with bloody drainage from his wound site and ST
depressions on EKG with hospital course complicated by concern
for LLE DVT.
ACTIVE MEDICAL ISSUES:
# ST depression: Patient found to have ST depressions on EKG at
rehab as well as elevated troponin on admission. Given bloody
drainage from wound site and significant hematocrit drop, EKG
changes were most likely due to anemia and cardiac demand
ischemia. Initially the differential also included acute
coronary syndrome and pulmonary embolism; however these were
less likely given that the patient had no chest pain, no
shortness of breath, no signs of DVT, and that he was
anticoagulated with prophylactic Lovenox. In addition, lower
extremity non-invasive test showed no evidence of DVT. Patient
receieved 4 units PRBCs in total, and hematocrit improved to
32-33 and remained stable. Troponins downtrending. Currently
without chest pain. Aspirin and Lovenox were continued. His EKG
changes improved and by discharge showed no signs of ST
elevations or depressions.
# Wound site drainage: Patient had recent bloody drainage from
wound site. He was evaluated by Orthopedics who did not see a
need for further intervention. Site was bandaged. Pt received a
total of 4 units PRBCs. By discharge wound site was no longer
actively bleeding and showed no signs of compartment syndrome.
# Left lower extremity swelling: Patient presented with LLE
swelling, giving rise to concern for DVT. LENIs were performed
and were negative, and swelling decreased.
# Anemia: Pt had Hct drop from 44.1 prior to surgery to 26.2.
Given drainage from wound site, this was likely the etiology. He
received 4 units PRBC and hematocrit stabilized >30. He was
restarted on lovenox for DVT prophylaxis on ___.
# Hyponatremia: Na was 132 on presentation, most likely
secondary to hypovolemia. Received PRBC. Normalized at time of
discharge.
CHRONIC MEDICAL ISSUES:
# HTN: Stable. Patient was continued home metoprolol.
# HL: Patient previously on low dose simvastatin. Given elevated
troponin in the setting of anemia, patient likely had coronary
artery disease. Patient was started on Atorvastatin 80mg daily.
Transitional Issues:
- Please continue to monitor his wound for bleeding and check
hematocrit and EKGs if concern for more active bleeding.
- Please re-check hematocrit on ___, goal is to be above 30 and
stable.
- Patient started on atrovastatin 80mg daily for concern of CAD
given elevated troponin. Please monitor LFTs and cholesterol.
- Please continue Lovenox for a 2 week course (Day 1 to be given
evening of ___ and to finish ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Metoprolol Tartrate 25 mg PO Q6H
3. Simvastatin 10 mg PO DAILY
4. Acetaminophen 650 mg PO TID
5. Docusate Sodium 100 mg PO BID
6. Enoxaparin Sodium 40 mg SC QPM
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
8. Senna 8.6 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Metoprolol Tartrate 25 mg PO Q6H
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
6. Senna 8.6 mg PO BID
7. Atorvastatin 80 mg PO DAILY
8. Calcium Carbonate 500 mg PO TID
9. Vitamin D 800 UNIT PO DAILY
10. Enoxaparin Sodium 40 mg SC QPM Duration: 2 Weeks
Start: Today - ___, First Dose: Next Routine Administration
Time
2 week course (Day 1 to be given evening of ___ and to
finish ___.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Anemia
Secondary Diagnosis: Left Femur Fracture s/p ORIF, Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to the hospital
because you were having bleeding from you surgical site and had
changes on your EKG. You were transfused red blood cells and
your bleeding improved.
All the best,
Your ___ Team
Followup Instructions:
___
|
10200479-DS-7 | 10,200,479 | 25,650,421 | DS | 7 | 2126-12-17 00:00:00 | 2126-12-17 17:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Bright red bleeding per rectum
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ with h/o HTN, HLD, arthritis, PUD who presents
with BRBPR and associated abdominal pain. Patient reports his
abdominal pain presented the ___ night (___) after he awoke
to have a bowel movement. He describes the pain as sharp and
unbearable and localized to lower abdominal quadrants, unlike
any abdomianl pain he has ever had before. The pain subsided and
he proceeded back to bed without observing his stool.
The following ___ (___) the patient presented to work where he
had a sudden onset of abdominal pain and BRBPR--he reports loose
brown stool generously intermixed with bright red blood. Again
his abdominal pain was localized to his lower abdominal
quadrants. Diaphoresis followed. He reports he had x3 more
episodes of BRBPR before calling ___ and being instructed to go
to the ___ for further evaluation and workup.
He notes a history of ongoing diarrhea for the past ___ years.
This developed gradually over weeks to months. This diarrhea
occurs mid week, and not on the weekends. Usually has ___ loose
bowel movements on the days he has diarrhea. He has been
diagnosed with irritable bowel syndrome. He takes Immodium for
these symptoms, which is effective. He does not drink coffee. he
works as a ___ denies expsoure to
chemicals or metals at his workplace. He is a former smoker
(3ppd ___, quit ___. No ETOH (quit ___ years ago) or drug
use.
Patient denied any fevers/chills and reports no similar symptoms
in past. His states his weight has been stable over the past ___
years, however it flucuates during the week. He says he loses
~10lbs during the weekdays, which he regains during the weekend.
He notes that because of ongoing nausea and diarrhea, he has had
been eating poorly for ___ years. No acute changes in his
appetite or diarrhea over the last few days; he denies feeling
dehydrated or dizzy. Additionally denies palpitations,
headaches, changes in vision or hearing, new numbness,
paresthesias, dysuria.
He has had a colonoscopy in ___ that noted 2 polyps and
diverticulosis of the left and right colon and an EGD that
demonstrated antrum ulcer and deep antrum erosions. Repeat EGD
in ___ revealed that his antrum ulcer had healed.
In the ED initial vitals were: 98.6 56 138/83 96%. An EKG
demonstrated afib with RVR. At times his heart rates were
recorded in the low 100's. Labs were significant for WBC 12.3.
Lactate 1.6. Patient was given pantoprazole 80mg IV x1 and
morphine IV x1 for abdominal pain and IVF. CXR unremarkable. CT
imaging demonstrated wall thickening and fat stranding
surrounding the descending colon suggesting colitis. Vitals
prior to transfer were: 98.4 55 121/79 16 98% RA.
Upon arrival to the floor, patient's abdominal pain improved
with morphine. Overnight, He had a 30cc bloody BM (bright blood
interlaced with some stool and clots). He remained in afib w/
RVR. Currently, the patient deports his abdmoninal pain is
appropriately controlled. He continues to be in afib with RVR.
He denies chest pain and chest pressure.
Past Medical History:
Hypertension
Hyperlipidemia
Arthritis
Peptic ulcer disease
Lumbar disc displacment
Carpal tunnel syndrome
Restless leg syndrome
Irritable bowel syndrome
Benign prostatic hypertrophy
Diverticulosis
Colonic adenoma
Appendicitis s/p appendectomy (___)
Inguinal hernia s/p repair (___)
Social History:
___
Family History:
Mother: ___
Father: ___, alzheimers
Physical Exam:
============================
PHYSICAL EXAM ON ADMISSION:
============================
PHYSICAL EXAM:
VITALS: T:98.6 BP:132/71 HR:101 irregular RR:18 02 sat:100RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: irregularly irregular, S1/S2, no murmurs, gallops, or
rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, tenderness throughout lower abdomen
most prominent in mid lower abdomen, no rebound or guarding
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
============================
PHYSICAL EXAM ON DISCHARGE:
============================
Vitals: Tm 97.6, Tc 97.0, BP ___, P ___ reg, R 18,
SpO2 96% RA
General: NAD, A&O, sitting comfortably in bed
HEENT: PERRLA, EOMI, sclera anicteric, MMM, OP clear w/o exudate
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes/rales/ronchi
CV: RRR, nml s1s2, no m/r/g
Abdomen: Soft, ND, mild TTP lower abd quadrants, no rebound
tenderness or guarding, no organomegaly
GU: no foley
Back: 3cm x 3cm mobile soft tissue nodule on the left upper
back, midthoracic spinal hyperaesthesia.
Ext: WWP, 2+ pulses, no c/c/e, mild diffuse muscular atrophy,
pneumoboots in place
Neuro: CNII-XII intact, full strength throughout, SILT
throughout
Pertinent Results:
=============================
LABS ON ADMISSION: (___)
=============================
BLOOD WBC-12.3* RBC-4.41* Hgb-14.3 Hct-43.5 MCV-99* MCH-32.3*
MCHC-32.8 RDW-12.6 Plt ___
BLOOD Neuts-73.9* ___ Monos-5.8 Eos-1.5 Baso-0.2
BLOOD ___ PTT-30.8 ___
BLOOD Plt ___
BLOOD Glucose-100 UreaN-10 Creat-0.9 Na-140 K-3.8 Cl-103 HCO3-27
AnGap-14
BLOOD Lactate-1.6
=============================
PERTINENT LABS:
=============================
___ 07:03AM BLOOD WBC-11.3* RBC-4.52* Hgb-14.6 Hct-44.0
MCV-97 MCH-32.3* MCHC-33.2 RDW-12.4 Plt ___
___ 07:23AM BLOOD WBC-6.8 RBC-3.83* Hgb-12.7* Hct-37.8*
MCV-99* MCH-33.1* MCHC-33.5 RDW-12.2 Plt ___
___ 07:03AM BLOOD TSH-0.73
=============================
LABS ON DISCHARGE:
=============================
___ 06:10AM BLOOD WBC-7.1 RBC-3.67* Hgb-12.1* Hct-35.3*
MCV-96 MCH-32.9* MCHC-34.2 RDW-12.3 Plt ___
___ 06:10AM BLOOD Glucose-111* UreaN-13 Creat-0.9 Na-142
K-3.9 Cl-109* HCO3-26 AnGap-11
===================
IMAGING:
===================
ECHO (___): The left atrium and right atrium are normal in
cavity size. No left atrial mass/thrombus seen (best excluded by
transesophageal echocardiography). Left ventricular wall
thicknesses and cavity size are normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). The estimated
cardiac index is normal (>=2.5L/min/m2). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are elongated. There is
no mitral valve prolapse. The estimated pulmonary artery
systolic pressure is normal. There is an anterior space which
most likely represents a prominent fat pad.
CT ABDOMEN (___):
- Colitis involving a long segment of descending colon, possibly
related to ischemia given the location, but infectious and
inflammatory etiologies are also possible.
- Patent intra-abdominal and pelvic vasculature. No evidence of
vascular occlusion. However, moderate calcified atherosclerotic
disease of the abdominal aorta
CXR (___): No acute cardiopulmonary abnormality.
EKG (___): Coarse A fib with RVR, ventricular rate 115 bpm,
no significant ST/T wave changes.
COLONOSCOPY ___, @ OSH): Diverticulosis in the left and
right colon. Two 3 mm polyps at 40 cm snared Polyp retrieved.
Biopsies obtained. Internal hemorrhoids.
Brief Hospital Course:
Mr. ___ is ___ with h/o PUD and IBS who presented with BRBPR
and abdominal pain, found to have colitis on CT scan and A Fib
with RVR on EKG.
===============
ACTIVE ISSUES:
===============
# Colitis w/ BRBPR: Patient had x1 additional episode of BRBPR
before his bleeding spontanously resolved. His H/H remained
stable during his hospitalization. He did not require blood
products. IV morphine was used to control pain and he was placed
on bowel rest w/IVF. CT scan demonstrated colitis involving a
long segment of descending colon just distal to the splenic
flexure. Location of colitis suggested ischemic etiology,
possibly embolic and related to underlying Afib w/ RVR that was
discovered on presentation. An ECHO, performed on ___, showed
no evidence of a thrombus or valvular pathology. Stool studies
were negative making infectious colitis less likely. Patient had
no further bleeding during this admission. His diet was
advanced which he tolerated well and his abdominal pain
resolved. He had a bowel movement that was guaiac negative on
___ prior to discharge.
# Atrial Fibrillation: Patient was discovered to be in Afib w/
RVR on presentation (new per pt). He denied chest pain, SOB,
dizziness. Unclear if acute (reactive in setting of colitis) vs
paroxysmal (primary Afib which caused the colitis through
thromboembolism). An ECHO, performed on ___, showed no evidence
of a thrombus or valvular pathology. There was concern for
thromboembolic origin of BRBPR. His rates were controlled by
initiating Metoprolol and he was monitored closely on telemetry.
Given a CHA2DS2-VASc score of 3 (+age, +HTN, +atherosclerotic
aorta), patient was started on Rivaroxaban on ___. His TSH was
within normal limits. Patient spontaneously converted to NSR on
night prior to discharge.
================
CHRONIC ISSUES:
================
# Chronic Pain: Patient has h/o of severe arthritis and lumbar
disc displacment that cause him significant pain. He initially
received IV morphine for his abdominal pain which adequately
controlled his baseline arthritic pain. His home pain
medications (Gabapentin, Cyclobenzaprine, Diazepam prn) were
resumed upon being able to tolerate a regular diet.
# Hypertension: His Lisinopril was held for most of his
hospitalization given low normal BPs. He was discharged with
instructions to no longer take it.
# Hyperlipidemia: Continued home statin.
=====================
TRANSITIONAL ISSUES:
=====================
- Started on Rivaroxaban 20 mg PO ___ on ___ for atrial
fibrillation.
- Started on Metoprolol Succinate XL 25 mg PO DAILY on ___ for
atrial fibrillation.
- Discharged with instruction to not take home Lisinopril until
PCP follow up given lower blood pressures this admission.
- Patient will likely need follow up with cardiology to discuss
further management of patient's new diagnosis of atrial
fibrillation.
- Patient was seen by SW this admission for concern of
significant stressors secondary to his work situation. They felt
that patient might benefit from SW or Psych referral as
outpatient for ongoing depression and stress management.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
2. Gabapentin 900 mg PO HS
3. Simvastatin 10 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. Diazepam 5 mg PO Q8H:PRN back pain
6. Cyclobenzaprine 10 mg PO HS
7. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Rivaroxaban 20 mg PO DINNER
Daily with the evening meal.
RX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth qpm Disp
#*30 Tablet Refills:*3
2. Cyclobenzaprine 10 mg PO HS
3. Diazepam 5 mg PO Q8H:PRN back pain
4. Gabapentin 900 mg PO HS
5. Omeprazole 20 mg PO DAILY
6. Simvastatin 10 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY Atrial Fibrillation
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*3
8. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Colitis
Atril fribrillation with rapid ventricular rate
SECONDARY DIAGNOSES:
Hypertension
Hyperlipidemia
Arthritis
Lumbar disc displacment
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was pleasure caring for you during your hospitalization. In
summary, you presented to the hospital for bleeding from your
rectum and abdominal pain. In the Emergency Department, you were
given IV fluids for dehydration, morphine for your pain. You had
a CT scan of your abdomen which showed inflammation of your the
left side of your colon called "colitis". An EKG showed an
irregular heart rhythm called atrial fibrillation and
occasionally your heart rate was very fast.
You were transferred to the Medicine Floor you were closely
monitored. In order to evaluate your heart, you underwent an
ECHO which showed normal heart anatomy with no evidence of a
clot. Your heart rate slowed down after you were given plenty of
IV fluids. You were started on a medication called Metoprolol
for your irregular heart rhythm to make sure your heart rate did
not go too fast. Your pain was controlled with morphine. Your
abdominal pain imrpoved and your bleeding stopped. Your diet was
slowly advanced. Given this new abnormal heart rhythm, we
discussed your risk of stroke from blood clots that can form
when the heart doesn't contract normally from the fibrillation.
We recommended that you start on blood thinners and see a
Cardiologist. You were started on a medication called
Rivaroxaban ("Xarelto") that is a pill you will take once daily.
The night before you left the hospital, your heart went back
into it's normal rhythm called "normal sinus rhythm."
Your high cholesterol, high blood pressure and chronic pain were
treated with your home medications, with the exception of
lisinopril which you did not receive due to concern that it
could drop your blood pressure too low.
We do recommend that you keep your appointment with your GI
doctor for further work up.
We wish you the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10200495-DS-18 | 10,200,495 | 26,686,178 | DS | 18 | 2125-05-25 00:00:00 | 2125-05-25 19:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Lightheadedness, transferred from OSH for hygroma on head CT
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ gentleman with h/o EtOH abuse, HTN, AFib
not on Warfarin, CAD, and right face/arm weakness due to prior
trauma who presented to ___ for lightheadedness and
was transferred here due to abnormal head CT.
He is a ___ veteran. At his baseline, he has neuropathy and
some patchy areas of numbness on his right leg, both arms, and
right face from war injuries. He walks with a cane sometimes for
instability. Has a history of heavy EtOH use with multiple quit
attempts in the past. Denies EtOH w/d seizures or DTs, but says
that others have told him that he has siezed in the past. He was
in his usual state of health until the day of presentation; he
did not have any breakfast and he went to his favorite bar for a
drink and some food. He drank one beer, and stood up to walk
towards his friends. He felt flushed and lightheaded, as if he
was going to pass out but he never lost consciousness. No fall,
no head strike. Friends at the bar were concerned so an
ambulance was called. He went to ___ and had normal
labs but a CT scan showing right sided hygroma w/o shift which
was new since ___, so he was transferred here for
Neurosurgical evaluation.
In the ED, initial VS were: T97.4, HR 90, BP 110/70, RR 16, POx
99%RA. Labs were notable for WBC 5.2 (62% neut, 4% bands, 4%
atypicals), Hct 35.9 (unknown baseline). EKG suggested prior
inferior infarct but no acute ischemic changes. On telemetry, he
was noted to go into Afib w/ RVR up to HR 140 but
hemodynamically stable, and this resolved with Metoprolol 5mg
IV; he was then given his home dose of Metoprolol PO. Also
received ASA 81mg and 250cc normal saline. Neurosurgery felt
that as this is a hygroma, intervention is not needed but they
will consult on the floor. He was admitted to Medicine for
pre-syncope, especially given his cardiac history.
On the floor, he says he feels much better than he did earlier.
He is hungry. Does not want to stand up because he feels this
will make him lightheaded. He denies drinking more than 1 drink
today; also denies EtOH withdrawal seizures or DTs (though he
says that people have seen him sieze before). He denies any
chest pain, palpitations, shortness of breath. No headache or
neck pain. No change in vision, no new weakness or slurred
speech.
REVIEW OF SYSTEMS:
Pertinent for right eye crusting on ___ with mild blurry
vision at that time. Also, numbness as noted above. 5 pound
unintentional weight loss over the past year.
Denies fever, chills, night sweats, headache, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
HTN
Afib not on Warfarin (CHADS2=1)
CAD
-s/p NSTEMI ___
-PCI (Lmain, OM2, diag1)
AICD ___ for primary prevention
Amiodarone-related hypothyroidism
peripheral neuropathy
gunshot wounds from ___ with residual right mouth / shoulder
/ leg motor deficits
s/p appendectomy
s/p abdominal and right thigh surgery for gunshots
left knee surgery with metal pin in place
Social History:
___
Family History:
Brother died of an MI at ___.
Father had an MI at ___.
Nobody with stroke.
Physical Exam:
Admission exam:
VS - Temp ___, BP 113/84, HR 75, R 16, O2-sat 100% RA
ORTHOSTATICS - unable to perform as patient becomes symptomatic
when standing (lightheaded)
___ - Thin gentleman appearing older than his stated age;
Alert, interactive, NAD
HEENT - PERRL, EOMI except slight right eye upgaze palsy,
sclerae anicteric, dry MM, very poor dentition
NECK - Supple, no thyromegaly, no JVD, no carotid bruits
HEART - PMI non-displaced, currently heart is regular with
S1-S2, no MRG
LUNGS - prolonged exp phase; no wheezing or rhonchi
ABDOMEN - midline scar; (+)bowel sounds, no tenderness
EXTREMITIES - thin, 2+ DP pulses, no edema; right shoulder with
deformity and muscle wasting
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3; upon standing patient is very unsteady
with broad-based stance; right mouth droop with tongue deviating
to right (baseline); right deltoid and trapezius weakness;
otherwise ___ leg strength; cerebellar tasks more inaccurate on
left; proprioceptive deficit of toes bilaterally; gait deferred
due to instability
Discharge exam - unchanged from above
Pertinent Results:
Admission labs:
___ 06:30PM BLOOD WBC-5.2 RBC-3.69* Hgb-12.6* Hct-35.9*
MCV-97 MCH-34.2* MCHC-35.3* RDW-14.7 Plt ___
___ 06:30PM BLOOD Neuts-62 Bands-4 ___ Monos-3 Eos-2
Baso-1 Atyps-4* ___ Myelos-0
___ 06:30PM BLOOD ___ PTT-26.8 ___
___ 06:30PM BLOOD Glucose-104* UreaN-16 Creat-1.1 Na-134
K-3.9 Cl-95* HCO3-28 AnGap-15
___ 07:20AM BLOOD ALT-45* AST-56* AlkPhos-148* TotBili-0.6
___ 06:30PM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:30PM BLOOD CK(CPK)-28*
___ 07:20AM BLOOD Albumin-3.7 Calcium-8.7 Phos-1.8* Mg-1.5*
___ 07:20AM BLOOD ___ 06:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Discharge labs:
___ 08:25AM BLOOD WBC-4.2 RBC-3.08* Hgb-10.4* Hct-30.6*
MCV-100* MCH-33.7* MCHC-33.9 RDW-15.4 Plt ___
___ 08:25AM BLOOD Glucose-105* UreaN-14 Creat-1.1 Na-134
K-3.7 Cl-101 HCO3-25 AnGap-12
Imaging:
-CT head ___, from OSH): Note of right frontal hygroma with
no midline shift.
-CXR (___): No previous images. Cardiac silhouette is within
normal limits,and the lungs are free of acute pneumonia, and
there is no vascular
congestion. Single-channel pacer defibrillator device extends to
the apex of the right ventricle. Of incidental note are multiple
metallic shrapnel fragments as well as several old healed
fractures.
Brief Hospital Course:
___ with EtOH abuse, HTN, AFib not on Warfarin, CAD, and right
face/arm weakness at baseline who was transferred to ___ for
presyncope and an incidental finding of a hygroma at OSH
#Presyncope: Cause was thought to be orthostasis from volume
depletion, he was very lightheaded upon standing upon arrival to
___ and was volume resuscitated with IV fluids. His
lightheadedness had resolved by the time of discharge. Alcohol
intoxication may have also been a factor, although he reports
having just one drink at the bar that night, his alcohol level
was undetectable upon arrival to ___ and the rest of his serum
tox screen was negative. Unlikely to be from incidentally noted
hygroma, as discussed below. We also considered arrhythmias,
especially tachycardia or bradycardia from his Afib. There was
no evidence of hemodynamically significant arrhythmia on
telemetry and his HR remained well controlled in Afib and
intermittently in NSR. Of note, he was admitted to the ___
recently after his ICD fired to terminate AFib with RVR at a
rate of 180.
#Hygroma: Right frontal hygroma found on OSH CT head prior to
this admission, which prompted transfer for neurosurgical
evaluation. Neurosurgery was consulted and felt that there was
no intervention necessary and that this was not the cause of his
presenting symptoms.
#Gait instability: Patient reports multiple recent falls at home
and appeared very unsteady on his feet at admission. He walked
with a broad based gait and poor coordination. He has known
neuropathy in his legs, B12 was checked as a potential cause for
his neuropathy and level was normal. He was seen by physical
therapy who recommended rehab.
#AMS: On the third day of admission, Mr. ___ was noticeably
more agitated and disoriented, thinking he was in a church
basement. This was thought to be partly due to alcohol
withdrawal, he improved by the next day and was A&Ox3 with a
calm demeanor. He was placed on diazepam via CIWA scale this
admission, as below.
#EtOH abuse: Alcohol intake remains unclear, patient reports ___
drinks per day on average. He was placed on a diazepam CIWA
scale and was scoring in the ___ on the third day of admission,
mostly for agitation and tremor. His symptoms improved and was
no longer requiring diazepam at discharge. He was also started
on thiamine/folate/MVI. After his mental status improved by day
4, he was more cooperative and stated he was glad to be in the
hospital because "it keeps me away from alcohol."
#AFib (CHADS2=1): As above, his heart rate remained well
controlled. He was not anticoagulated prior to admission,
likely because of his high fall risk. He was continued on his
dome doses of metoprolol, aspirin and amiodarone.
#HTN: He remained normotensive this admission. Continued on
home dose of metoprolol, lisinopril held at admission but
restarted prior to discharge.
#CAD: No chest pain or SOB this admission. Continued on ASA,
Plavix, metoprolol. Lisinopril held as above for orthostatic
hypotension.
#Hypothyroidism: Continued on home dose of levothyroxine. This
may be related to amiodarone use, he is followed by a PCP and
electrophysiology at the ___.
#Anemia: Hct at baseline according to ___ records in CPRS.
#Code status this admission: FULL CODE
#Transitional issues:
-Will be transferred to rehab given gait instability and high
fall risk
-Started on MVI/thiamine/folate given unclear amount of alcohol
use
-Consider further workup of hygroma if has further neurological
symptoms
Medications on Admission:
Aspirin 81 mg daily
Clopidogrel 75 mg daily
Metoprolol succinate 100 mg daily
Lisinopril 2.5 mg daily
Amiodarone 200 mg daily
Rosuvastatin 10mg daily
Synthroid 50mcg daily
Omeprazole 20mg EC daily
Albuterol sulfate
Cyanocobalamin (vitamin B-12) daily
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
4. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
5. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every ___ hours as needed for shortness
of breath or wheezing.
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. cyanocobalamin (vitamin B-12) 250 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Volume depletion
Alcohol withdrawal
Secondary diagnoses:
Atrial fibrillation
Coronary artery disease
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. ___,
It was a pleasure taking care of you during your admission to
___ for lightheadedness and the finding of a hygroma in your
brain. You were found to be dehydrated and were given IV fluids
and your lightheadedness improved. There were no arrhythmias
noted on your heart monitoring.
The following changes were made to your medications:
START multivitamin 1 tab by mouth daily
START thiamine 100mg by mouth daily
START folate 1mg by mouth daily
Followup Instructions:
___
|
10200741-DS-21 | 10,200,741 | 23,153,671 | DS | 21 | 2153-03-08 00:00:00 | 2153-03-08 14:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
face weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ woman with a history of ADD who
presents with 1.5 weeks of left dental pain, subjective fevers,
2
days of right facial weakness and abnormal taste.
She first developed pain in one of her left maxillary molars
___ from back) last ___. Over the subsequent week the
pain worsened. She once measured a temperature ___ F, and on
other nights this week noted night sweats. She went to the
health
clinic at ___ 2 days ago and was given a
prescription
for Augmentin to treat sinusitis. She does also complain of
left-sided congestion, but says her tooth pain was her primary
complaint and focused very clearly on a single tooth.
That evening she noticed right-sided facial weakness, and has
since had ever-increasing difficulty drinking fluids due to this
weakness. She endorses abnormal taste, but denies any changes in
her hearing including hyperacusis. She still complains of
worsening tooth pain as well as night sweats. She also complains
of left frontal headache.
She does not have any history of cold sores. She denies any
photo/phonophobia, neck stiffness, confusion, or malaise.
ROS:
+ Right facial weakness
+ Left frontal headache
+ Left dental pain
+ Night sweats
- No recent loss of vision, blurred vision, diplopia,
dysarthria,
lightheadedness, vertigo, tinnitus, or hearing difficulty.
Past Medical History:
ADHD
Social History:
___
Family History:
Father with rheumatoid arthritis.
Physical Exam:
Admission physical exam
-Vitals: T:96.0 BP:116/90 HR:99 RR:16 SaO2:98%
-General: Awake, cooperative, NAD.
-HEENT: NC/AT. No scleral icterus noted. MMM. No lesions noted
in
oropharynx.
-Neck: Supple. No nuchal rigidity.
-Cardiac: Well perfused.
-Pulmonary: Breathing comfortably on room air.
-Abdomen: Soft, NT/ND.
-Extremities: No cyanosis, clubbing, or edema bilaterally.
-Skin: No rashes or other lesions noted.
NEUROLOGIC EXAM:
-Mental Status: Alert, oriented x 3. Able to relate detailed
history without difficulty. Attentive. Language is fluent. There
are no paraphasic errors. Able to read without difficulty. Able
to follow both midline and appendicular commands.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 5 to 3mm and brisk. VFF to confrontation and no
extinction.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation decreased on left (V1-V2>V3) to light touch
and pin-prick ~75% of normal (moving from R->L, abnormal
sensation begins approximately 2cm to the left of midline).
VII: Right upper and lower facial weakness -- decreased brow
activation, slowed blink, weak eye closure, and facial droop.
Taste impaired to saccharine solution on right side of tongue.
No
stylomastoid foramen tenderness.
VIII: Hearing grossly intact to speech. No hyperacusis.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline and equal strength bilaterally.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5
-Sensory: No deficits to light touch or pinprick throughout
(except left face as above).
-Coordination: No intention tremor. No dysmetria on FNF.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing.
Discharge physical exam
-General: Awake, cooperative, NAD.
-HEENT: NC/AT. No scleral icterus noted. MMM.
-Neck: Supple. No nuchal rigidity.
-Cardiac: Well perfused.
-Pulmonary: Breathing comfortably on room air.
-Abdomen: Soft, NT/ND.
-Extremities: No cyanosis, clubbing, or edema bilaterally.
-Skin: No rashes or other lesions noted.
NEUROLOGIC EXAM:
-Mental Status: Alert. Able to relate detailed
history without difficulty. Attentive. Language is fluent. There
are no paraphasic errors. Able
to follow both midline and appendicular commands.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 5 to 3mm and brisk. VFF to confrontation
III, IV, VI: EOMI without nystagmus.
V: Facial sensation decreased on left (V1-V2>V3) to light touch
and pin-prick ~75% of normal
VII: Right upper and lower facial weakness -- weak eye closure,
and facial droop.
VIII: Hearing grossly intact to speech. No hyperacusis.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline and equal strength bilaterally.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5
-Sensory: No deficits to light touch or pinprick throughout
(except left face as above).
-Coordination: No intention tremor. No dysmetria on FNF.
-Gait: Walks independently
Pertinent Results:
Labs
___ 12:53PM BLOOD WBC-8.0 RBC-4.21 Hgb-11.0* Hct-35.6
MCV-85 MCH-26.1 MCHC-30.9* RDW-13.2 RDWSD-40.2 Plt ___
___ 12:53PM BLOOD CRP-106.8*
MRI brain
1. Findings compatible with sinusitis in an ostiomeatal unit
pattern involving
the left maxillary sinus, anterior left ethmoid air cells, and
left frontal
sinus. Correlate for acuity.
2. No definite cranial nerve abnormality. Specifically,
bilateral symmetric
enhancement of the facial nerves, particularly within the
tympanic segments,
is likely normal given its bilaterally and is of unlikely
clinical
significance.
CT sinus
1. Near complete opacification of the left maxillary sinus, as
well as partial
opacification of the left-sided ethmoid air cells, and mild
mucosal thickening
in the left frontal sinus, findings concerning for acute
sinusitis given the
clinical context.
2. No evidence of facial abscess or periodontal disease.
Brief Hospital Course:
___ is a ___ woman with a history of ADD who
presented with 1.5 weeks of left dental pain, night sweats, left
frontal headache, 2 days of right facial weakness and abnormal
taste. Her exam is notable for right ___ nerve palsy with
abnormal taste and upper and lower facial weakness; as well as
mild sensory deficit on the left side of her face. She underwent
MRI brain w/wo contrast and with thin cuts which was normal.
The etiology of her symptoms is thought to be due to Bells
Palsy. Regarding her left mild sensory deficits, this is likely
due to acute left sided sinusitis causing some abnormal
sensation. At this time we do not think she has multiple cranial
neuropathy. We will treat the bells palsy with prednisone. We
will also continue her augmentin for the sinusitis. We did
discuss with the patient and her mother, that should she have
new focal neurological deficits or worsening infectious symptoms
she would need to come back to the ED. Otherwise she will follow
up with neurology in the next few days, as well as with her
dentist.
=============================
Transitional issues:
-Follow up neurology
-Follow up with dentist
-complete 7 days of prednisone 60mg daily (until ___
-complete a 10 day course (until ___
Medications on Admission:
n/a
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 8 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab-cap by mouth
every twelve (12) hours Disp #*15 Tablet Refills:*0
2. PredniSONE 60 mg PO DAILY
RX *prednisone 20 mg 3 tablet(s) by mouth once a day Disp #*18
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right facial nerve palsy
Sinusitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___
___ were admitted to ___ for right sided facial weakness due
to a condition called Bell's palsy, which is a condition in
which the muscles on one side of your face become weak or
paralyzed. It is usually caused by some kind of compression to
the seventh cranial nerve, such as inflammation. This is also
called the facial nerve. Bells palsy can happen to anyone. It
usually resolves within weeks to months, if it is mild such as
in your case. Your MRI brain did not show any cranial nerve
abnormality but did show evidence of sinusitis. We are treating
your sinusitis with augmentin. For your bell's palsy we will
start ___ on steroids which ___ should take for 7 days.
Please follow up with Neurology and your dentist and primary
care physician as listed below.
If ___ 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 or double vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
___
- 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
- Worsening of your infectious symptoms such as fevers
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10200966-DS-21 | 10,200,966 | 28,178,166 | DS | 21 | 2161-04-05 00:00:00 | 2161-04-06 08:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
___ with history of AAA repair ___, complicated by CKD IV,
currently undergoing evaluation for renal transplant, who
initially presented to ___ with dyspnea and fatigue,
five days after a 2 day course of copious black tarry stools.
Also endorsed lightheadedness but denied chest pain.
On arrival at ___ there was concern that this melena could
be explained by an aortoenteric fistula and represent a
complication of her prior surgery. OSH labs notable for Hct 15
(Hct was 33 on ___ and Cr 4.8. Trop I there elevated to 6.24
with ? new lateral ST depressions. She was transfused 2 units
PRBCs and sent to ___ ED.
On arrival at the ___ ED, initial vitals 97.7 58 134/70 16 94%
RA. Patient appeared pale and tired, VSS. No abdominal
tenderness tenderness. Initial labs 12.3/5.8/17.9/262,
chemistries Na 126, K 3.8, Cl 91, HCO3 17, BUN 120, Cr 4.8. AST
53, lactate 1.2, CK 111, MB 8, Trop 0.47. UA negative. Vascular
was consulted, and given concern for aorto-enteric fistula, he
had CTA which was negative for fistula but suggestive of upper
GIB. GI was also consulted with plan to likely scope in am.
Renal transplant consulted with plan to initiate HD in the
morning if necessary.
He received an additional unit of blood prior to transfer.
Access: peripherals, two ___ and an 18.
On arrival to the MICU, intial vitals were stable. Patient had
no complaints.
Review of systems:
A complete ROS was negative except as noted in HPI.
Past Medical History:
PMH: HTN, HLD, PVD, PAD, tachycardia
induced myopathy, afib/flutter s/p ablation, COPD, AAA, RAS,
OSA, hypothyroidism, B renal cysts
PSH: inguinal hernia repair as a child
Social History:
___
Family History:
Father had hypertension and died of cardiac
disease. Mother had thyroid cancer. Two sister have
hypertension.
No history of kidney disease in the family.
Physical Exam:
ADMISSION EXAM:
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
DISCHARGE EXAM:
VS: ****
UOP:*****
gen: pt in NAD
HEENT: NC/AT, sclera anicteric, conjunctiva noninjected, PER,
MMMs
CV: slow, regular, systolic murmur at base
Pulm: trace bibasilar crackles L>R, slightly improved
Abd: S mild distension, BS+
Extr: wwp ___ edema L>R, grossly unchanged
Neuro: alert and interactive; grossly intact
Skin: no lesions noted on limited exam
Psych: normal range of affect
Pertinent Results:
================
ADMISSION LABS
================
___ 11:54PM BLOOD WBC-12.3* RBC-1.91*# Hgb-5.8*# Hct-17.9*#
MCV-94 MCH-30.4 MCHC-32.4 RDW-17.0* RDWSD-52.5* Plt ___
___ 11:54PM BLOOD Neuts-82.8* Lymphs-7.3* Monos-8.6
Eos-0.4* Baso-0.2 NRBC-0.2* Im ___ AbsNeut-10.17*
AbsLymp-0.90* AbsMono-1.05* AbsEos-0.05 AbsBaso-0.03
___ 11:54PM BLOOD ___ PTT-27.7 ___
___ 11:54PM BLOOD Plt ___
___ 11:54PM BLOOD Glucose-95 UreaN-120* Creat-4.8* Na-126*
K-3.8 Cl-91* HCO3-17* AnGap-22*
___ 11:54PM BLOOD ALT-30 AST-53* CK(CPK)-111 AlkPhos-73
TotBili-0.8
___ 11:54PM BLOOD Albumin-3.7 Calcium-8.5 Phos-5.8* Mg-2.0
___ 12:06AM BLOOD Lactate-1.2
___ 12:50AM URINE Color-Straw Appear-Clear Sp ___
___ 12:50AM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-0
___ 12:17PM URINE Hours-RANDOM Creat-85 Na-<20
=================
KEY INTERIM LABS
=================
troponin trended up to max 1.69 but CK and CK-MB mained normal
creatinie trended up to maximum of 7.4 and BUN 123
Phosphate trended to maximum 9.4
================
DISCHARGE LABS
================
___ 06:25AM BLOOD WBC-7.7 RBC-2.61* Hgb-7.6* Hct-23.4*
MCV-90 MCH-29.1 MCHC-32.5 RDW-15.7* RDWSD-50.4* Plt ___
___ 06:25AM BLOOD Glucose-104* UreaN-110* Creat-6.5*
Na-130* K-4.0 Cl-91* HCO3-21* AnGap-22*
___ 06:25AM BLOOD Calcium-9.1 Phos-8.1* Mg-2.6
=====================
IMAGING & STUDIES
=====================
EGD ___:
Normal mucosa in the esophagus
Irregular Z-line
Ulcer in the first part of the duodenum
Erythema in the antrum, stomach body and fundus compatible with
gastritis (biopsy)
Medium hiatal hernia
Small non-bleeding angioectasia in jejunum.
Otherwise normal EGD to jejunum
CTA ABD/PELVIS ___: 1. Dense contrast, matching arterial
blood pool, is seen within the proximal
jejunum. Although this area does not appear to spread out/pool
on the delayed phase, given the density of contrast on the
arterial phase, it remains concerning for upper GI bleed. This
area is located approximately 3.8 cm from the aorta. There is
no evidence of ectopic gas adjacent to or within the aorta, or
periaortic soft tissue thickening/stranding, making aortoenteric
fistula less likely.
2. Small bilateral simple pleural effusions, moderate amount of
simple
intra-abdominal ascites, and diffuse anasarca are consistent
with volume
overload status.
3. Gallbladder wall thickening is felt to be secondary to third
spacing in the setting of ascites.
4. Diverticulosis.
CXR ___: Cardiomegaly is substantial. A appears to be
slightly worse than back on ___.
There is no appreciable pulmonary edema. Mild vascular
congestion is present. No definitive pleural fluid demonstrated
on this PA radiograph examination. There is no pneumothorax.
EGD ___:
IMPRESSION: Marked biatrial enlargement. Mild symmetric left
ventricular hypertrophy with moderately dilated cavity and mild
regional systolic dysfunction c/w CAD (mid LAD). Markedly
dilated right ventricle with depresed systolic function. At
least moderate mitral regurgitation.
Compared with the TTE from ___ (images reviewed) of
___ the regional dysfunction is new.
============
MICROBIOLOGY
============
Urine culture ___ - No growth
Pathology from EGD biopsy
A. Stomach: Fundal mucosa with mild chronic inflammation; H.
pylori stains are negative (control
satisfactory); PAS stains non-contributory; iron stains positive
for particulate material in the lamina
propria;changes consistent with "iron pill" gastropathy.
Brief Hospital Course:
___ year old man w/ stage IV-V CKD w/ transplant work-up in
progress, hx/o severe PVD/AAA s/p endarterectomy and bypass
surgery in ___, CAD, diastolic CHF, and aflutter s/p ablation,
COPD, and OSA, who presented with melena, now s/p EGD w/
duodenal ulcer that is suspected source of bleeding. Course c/b
worsening renal function after contrast exposure and volume
overload, as well as wide complex tachycrdia (VT vs SVT w/
aberrancy)
# UGIB: Patient presented with melena, jejunum extravasation on
CTA, and anemia consistent with UGIB. No clear precipitant (no
NSAID or steroid use). Vascular surgery evaluated patient and
ruled out aortoenteric fistula based on CTA. Patient was
transfused 3u pRBC in the ICU and kept on BID IV PPI. GI was
consulted and performed a EGD/enteroscopy on ___, which showed
duodenal ulcer that appearaed to be already healing, as well as
small AVM in jejunum. Ulcer felt to be cause of bleed. S/p 3
units transfusion, stable hgb on PPI. He was discharged with
high dose PPI (pantoprazole 40 mg po bid for six weeks) to
promote ulcer healing. NO H pylori detected in sample obtained
during EGD
___ on CKD:
- presumed ___ contrast exposure, creatinine steadily worsened
to mid-7 range by ___
but down trended to 6.5 by time of discharge
- bicarb uptitrated due to acidosis and he was discharged on
sodium bicarbonate 1300 mg po bid.
- he was discharged on renvela (sevelamer) for elevated
phosphorus levels
- patient also took home aranesp while in house (according to
his normal schedule)
- he was counseled on renal diet (low potassium, low phosphorus)
and should have chemistries checked by PCP within ___ week of
discharge.
#CHF, CAD:
- troponin elevated and rose up to 1.69, but CK-MB and CK
normal, suggesting CHF/renal failure and not acute event
- TTE showing worsened EF w/ ?new focal wall motion abnormality,
cardiology consulted
- low suspicion for active ACS or event during this admission -
they felt that he had a type II NSTEMI and did not want to
perform cardiac catheterization given ___
- restarted ASA ___ after clearing w/ GI
- increased simvastatin to 20 mg
- Patient with significant volume overload secondary to
resuscitation in setting of GI bleed and his kidney injury. He
was discharged on torsemide 30 mg a day, and is expected to lose
1 lb a day. He denied orthopnea or PND.
#Wide complex tachycardia:
- ___ overnight, VT vs SVT/aberrancy
- ___, appeared more c/w aberrancy
- Patient will f/u with an outpatient cardiologist at ___
___ (Dr ___ I will send him this discharge summary
as patient needs to be considered for rhythm monitoring for
episodes of this wide complex tachycardia as well as his sick
sinus syndrome (HR in the 40-60s) this hospitalization and he
was asymptomatic.
#Hyponatremia - appears to be hypervolemic hyponatremia,
improved with diuresis
Na at 130 on day of discharge.
#Afib/flutter, bradycardia:
- slow VR
- no anticoagulation currently - would address in outpatient
setting although likely no anticoagulation in near future given
GIB
#HTN:
- held amlodipine in setting of bleed
- BP started to rise to 150s/80s by the time of discharge.
- outpatient providers can consider alternate to amlodipine as
there is an increased risk of rhabdomyolysis with use of
simvastatin and amlodipine.
#Hypothyroidism:
- cont home levothyroxine
TRANSITIONAL ISSUES:
(1) in future may address issue of anticoagulation given
fib/flutter but would not consider in near future given bleed
(2) further inquiry into atorvastatin cost, as it is now generic
and would be preferable to simvastatin
(3) consider outpatient cardiac rhythm monitoring given wide
complex tachycardia of unclear significance - if further events
c/f VT could consider device
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Calcitriol 0.25 mcg PO DAILY
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Torsemide 20 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. coenzyme Q10 100 mg oral daily
7. Fish Oil (Omega 3) Dose is Unknown PO Frequency is Unknown
8. Simvastatin 10 mg PO QPM
9. Multivitamins 1 TAB PO DAILY
10. Aranesp (in polysorbate) (darbepoetin alfa in polysorbat)
100 mcg/0.5 mL injection monthly
Discharge Disposition:
Home
Discharge Diagnosis:
Gastrointestinal hemorrhage due to duodenal ucler
Acute on chronic renal failure due to contrast nephropathy
Congestive heart failure
Wide complex tachycardia
Sick sinus syndrome
Discharge Condition:
Hemodynamically stable, improving renal function, near baseline
cognitive and functional status
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted due to a severe gastrointestinal bleed due to
an ulcer in your duodenum, the part of your intestine that the
stomach drains into. You developed a severe anemia due to the
blood loss requiring blood transfusions. The ulcer is being
treated with an acid reducing medication called pantoprazole,
which should help it heal. However if you notice red or
black/tarry stool or you have worsening fatigue, paleness, or
lightheadedness you should be evaluated immediately in case
there is more bleeding.
Most likely because of the contrast that you received to
evaluate the bleeding, your kidney function worsened, but is now
improving. Be SURE TO AVOID MEDICATIONS SUCH AS IBUPROFEN OR
NAPROXYN. These can worsen your kidney function. Also, please
follow a diet low in potassium and phosphorus (I have given you
a handout)
Please take the medicine synthroid on an empty stomach, ___ hour
before you eat. Please take the medicine renvela (2 tablets)
with each meal to keep your phosphorus levels low. I have also
started sodium bicarbonate, as you also need this for your
kidneys.
Try to space out your medicines -
I recommend that you take the synthroid first thing in the
morning, ___ hour before meals. Take your sodium bicarbonate,
renvela (sevelamer), omeprazole and torsemide with breakfast.
Take the aspirin, amlodipine, nephrocaps, sevelamer with lunch.
At dinner, take the sevelamer. Before you go to bed, take the
simvastatin. Use lactulose when you need it for constipation.
I have sent your prescriptions to your pharmacy (___ in
___ but am giving you paper copies just in case there is a
problem. I have sent prescriptions for nephrocaps, lactulose,
sevelamer, pantoprazole, nicotine patches and sodium
bicarbonate. You should have refills on your torsemide
prescription.
Followup Instructions:
___
|
10201059-DS-17 | 10,201,059 | 24,815,491 | DS | 17 | 2135-09-09 00:00:00 | 2135-09-09 16:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L hip pain
Major Surgical or Invasive Procedure:
L hip hemiarthroplasty
History of Present Illness:
___ year old female with chief complaint of fall ___ days ago onto
left side. History is provided with assistance of ___
interpreter. Patient reports that she slipped after she became
dizzy while walking quickly around her house about 10 days ago.
She has had severe pain with bearing weight on the Left leg; she
has been slowly ambulating with minimal amount of weight on the
left hip since then, but mostly has been bed bound. She states
that she thought it would get better with rest so she did not
seek care until today. She initially presented to the ___,
was found to have left femoral neck fracture with angulation.
Patient denies any other pains. No numbness or tingling. Patient
reports pain in her left groin with movement.
Past Medical History:
HTN, Osteoporosis
Social History:
Lives with her two daughters. ___ EtOH, smoking, or drug use.
Physical Exam:
Exam on Discharge
NAD, A&Ox3
RLE
Incision well approximated. Fires
___. SITLT s/s/dp/sp/tibial
distributions. 1+ DP pulse, wwp distally.
Pertinent Results:
___ 07:46PM WBC-6.6 RBC-4.40 HGB-12.9 HCT-40.4 MCV-92
MCH-29.3 MCHC-31.9* RDW-12.7 RDWSD-42.6
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have L hip fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for L hip hemiarthroplasty, 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
weight bearing as tolerated in the 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 500 mg PO 5X/DAY
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 30 mg SC QHS
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 30 mg/0.3 mL 1 syringe SC every evening Disp #*14
Syringe Refills:*0
5. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four to six hours
Disp #*42 Tablet Refills:*0
6. Senna 17.2 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
L 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:
- weight bearing as tolerated left lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and 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
Physical Therapy:
- weight bearing as tolerated, left lower extremity
- ROMAT left lower extremity
Treatments Frequency:
- dressing to come off on POD5 (___)
- after dressing comes off, then incision may be left open
Followup Instructions:
___
|
10201558-DS-7 | 10,201,558 | 29,441,570 | DS | 7 | 2168-09-15 00:00:00 | 2168-09-15 15:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
right facial sensory change
Major Surgical or Invasive Procedure:
None
History of Present Illness:
(history is obtained through interpretation from her daughter
who
is present during this exam)
The pt is a ___ year-old right-handed woman who presents with 12
hrs of progressive of right sided facial sensory change,
dysarthria and right fingertip numbness on a background of HTN,
DM, HL.
She was in her usual state health until yesterday afternoon when
she first noticed a sensation of tightening in her right eye
(without pain) which progressed to involve the lower portion of
her right face, lip. She endorses a sensation of feeling as it
is
was swollen and and heavy and eventually a dense numbness
(novacaine-type). Her friends noted that she had a speech change
that was subtle and which the patient herself endorses (although
at first this is denied by her daughter). She also was told by
her friends that she had an asymmetry in her face and her
daughter agrees that her face looks different. However, she
attempted to sleep it off last night and did not come to the ED.
This morning she woke up and felt that her right fingertips felt
different, tingly (most pronounced in the index) with a
subjective sense of weakness. She decided to come to the ED
given
the progression of her symptoms.
Since this morning her condition has not changed. She has never
had such symptoms beforehand. In the days prior to onset, she
was
not feeling ill in any way. She has no recent infections or
medication changes.
She denies weakness, numbness, tingling in upper or lower
extremities. She denies changes in gait, vertigo, difficulty
swallowing, visual changes, diplopia, headache.
On neuro ROS, the pt denies difficulties producing or
comprehending speech. 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:
-DIABETES TYPE II
-HYPERTENSION
-HYPERLIPIDEMIA
-GASTROESOPHAGEAL REFLUX
-HYPOTHYROIDISM s/p hemithyroidectomy for goiter
-VARICOSE VEINS
-"EDTA-INDUCED THROMBOCYTOPENIA"
-LEFT TOTAL KNEE REPLACEMENT
Social History:
___
Family History:
No known neurological disorders, early strokes, seizures,
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.4 48 140/82 20 97%
General: ___ yo woman awake, laying down in the bed ,
cooperative,
NAD. Apparent drooping of the Left side of the face along with
ptosis. Decreased blinking frequency in the left side was
notable. Forehead wrinkling symmetric in both side.
HEENT: weakness in left side of face up to eye.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
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.
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
(per report of her daughter) Pt. was able to name both high and
low frequency objects. Speech was slightly dysarthric (per
daughter, most notable with labial sounds). Able to follow both
midline and appendicular commands.The pt. had good knowledge of
current events. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 5 mm --> 4mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus, dysconjugate gaze or
reported diplopia. Normal saccades.
V: Facial sensation was impaired to pinprick and cold
temperature
in the right side in all distributions of V, but intact to light
touch. Decreased sensation to light touch of tongue on the right
anterior portion.
VII: facial droop on the left. forehead wrinkling appreciated
both side symetrically, decreased spontaneous blinking on the
left, decreased strength in orbicularis oculi.
VIII: Hearing decreased in the right to finger-rub compared to
the left side
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue strength wnl bilaterally.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception except in the left side of the
face. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. No dysmetria on FNF
bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
DISCHARGE PHYSICAL EXAM:
Gen: NAD, AAOx3
HEENT: nc/at, mucosa moist and pink, oropharynx clear without
exudate or erythema
CV: rrr, no m/r/g
Pulm: CTAB
Abd: BS+, soft, NT, ND
MSK: no c/c/e
Neuro: EOMI, PERRLA, mild left sided ptosis with easily broken
shutting of left eyelid (right strength wnl), bilateral eyes
able to close fully, flattening of left side of forehead,
sensation to light touch intact throughout face though is
diminished on right - 80/100 on right but 100/100 on left,
finger rub well heard bilaterally, palatal elevation wnl, left
sided NLF with asymmetric smile with downward droop of left
___ border, shoulder shrug wnl, SCM strenght ___
bilaterally. Sensation to taste (jellied applejuice) diminished
on right but wnl on left.
Strength ___ at bilateral deltoids, triceps, biceps, ECR, IO,
IP, quads, hams, TA, gastrocs, ___. Sensation to light touch and
vibration intact throughout. Reflexes wnl.
Pertinent Results:
ADMISSION LABS:
___ 11:30AM BLOOD WBC-7.1 RBC-4.37 Hgb-13.4 Hct-38.9 MCV-89
MCH-30.7 MCHC-34.4 RDW-12.3 Plt Ct-UNABLE TO
___ 11:30AM BLOOD Neuts-62 Bands-0 ___ Monos-3 Eos-3
Baso-0 ___ Myelos-0
___ 11:30AM BLOOD ___ PTT-31.5 ___
___ 11:30AM BLOOD Glucose-91 UreaN-16 Creat-0.5 Na-137
K-4.1 Cl-102 HCO3-25 AnGap-14
___ 05:50AM BLOOD ALT-141* AST-123* LD(LDH)-184 AlkPhos-85
TotBili-0.6
___ 11:30AM BLOOD Calcium-9.9 Phos-3.6 Mg-2.1
___ 05:50AM BLOOD %HbA1c-6.1* eAG-128*
___ 05:50AM BLOOD Triglyc-241* HDL-38 CHOL/HD-5.3
LDLcalc-116
___ 11:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-5*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
CT HEAD ___:
FINDINGS:
There is no evidence of acute intracranial hemorrhage, edema,
mass effect, or infarction. The ventricles and sulci are normal
in size and configuration for age. The basal cisterns appear
patent, and there is preservation of gray-white matter
differentiation.
No fractures are identified. The visualized paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The
globes are unremarkable.
IMPRESSION:
No acute intracranial pathology.
CTA HEAD/NECK ___:
IMPRESSION:
1. Major intracranial and cervical vessels patent, without
evidence of
aneurysm, arteriovenous malformation, dissection or occlusion.
2. Appearance of medialization of the right vocal cord, with
asymmetric
prominent of the right pyriform sinus. The findings could be
seen in right
vocal paralysis. Recommend clinical correlations.
3. Status post left hemithyroidectomy.
MRI HEAD ___: PRELIMINARY REPORT
FINDINGS: The ventricles, sulci, and subarachnoid spaces are
normal in size and configuration. There is no evidence of acute
infarct or hemorrhage. There is no focal signal abnormality in
the brain. There is no abnormal intra or extra-axial fluid
collection, no shift of normally midline structures, and no mass
lesion or mass effect.
There are normal major intracranial vascular flow voids. There
is minimal
ethmoid and maxillary sinnus mucosal thickening. Otherwise, the
visualized paranasal sinuses, mastoids, and orbits are
unremarkable.
IMPRESSION:
No acute intracranial abnormality. No evidence of infarct,
hemorrhage, or
mass.
Brief Hospital Course:
Ms. ___ was admitted to the ___ Neurology stroke service on
___ after presenting with left sided facial weakness and
right sided facial numbness that developed since ___. Her
admission exam is documented above. Her active hospital issues,
by system, are as follows:
1) Neuro - Presented with signs of acute stroke vs left-sided
Bell's palsy. CT, CTA head/neck, and MRI brain negative for
acute infarct or hemorrhage. Patient with LMN signs by HD1
(flattening of left forehead, delayed left sided eye blink,
ongoing left sided facial droop). Able to close left eye.
Clinically diagnosed with Bell's palsy. Etiology unclear; Lyme
serology pending at time of discharge. Discharged home with
prescriptions for prednisone and valacyclovir. Neurology
follow-up scheduled with Dr. ___ on ___.
2) CV: History of HTN, resumed home meds on discharge. BP
well-controlled while hospitalized.
3) Endo: New dx of pre-diabetes. HbA1c 6.1 on admission labs. As
below, communicated with PCP regarding ___ monitoring now that
steroids are being started.
TRANSITIONAL ISSUES:
- Lyme titers pending at time of discharge, should be followed
up and appropriately treated if necessary at next PCP or
neurology appointment.
- Has recently been diagnosed with pre-diabetes, diet
controlled. Discharged with prescription for prednisone 80mg
daily for one week. Instructed to follow-up with PCP regarding
blood glucose control.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO DAILY
Hold for sBP <90, HR <60
2. Hydrochlorothiazide 25 mg PO DAILY
Hold for sBP <90, HR <60
3. Levothyroxine Sodium 175 mcg PO DAILY
4. Metoclopramide 10 mg PO HS:PRN indigestion
5. Pantoprazole 40 mg PO Q24H
6. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. PredniSONE 80 mg PO DAILY Duration: 7 Doses
RX *prednisone 20 mg 4 tablet(s) by mouth daily Disp #*28 Tablet
Refills:*0
3. ValACYclovir 1000 mg PO Q8H Duration: 7 Days
RX *valacyclovir 1,000 mg 1 tablet(s) by mouth q8hrs Disp #*21
Tablet Refills:*0
4. Atenolol 50 mg PO DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
6. Levothyroxine Sodium 175 mcg PO DAILY
7. Metoclopramide 10 mg PO HS:PRN indigestion
8. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
- Bell's palsy
SECONDARY:
- hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
Thank you for choosing ___ for your medical care. You were
admitted for concerns of left-sided facial weakness and right
sided numbness. Your symptoms were initially concerning for a
stroke, and you underwent CTA and MR imaging. Fortunately, your
studies were negative. You did not have a stroke. Instead, you
have a condition called Bell's palsy - caused by poor
functioning of the facial nerve.
You should plan to take new medications, called valacyclovir and
prednisone, for one week. Prednisone may cause high blood
sugars. You should get in contact with your primary care
physician to arrange for a blood sugar check. You should also
follow-up with the neurology department as indicated below.
It was a pleasure participating in your care.
Followup Instructions:
___
|
10201591-DS-18 | 10,201,591 | 29,917,330 | DS | 18 | 2154-05-31 00:00:00 | 2154-06-01 09:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ pmh below presents with CC of a constellation of symptoms,
primarily chest and abdominal pain. Chest pain was yesterday,
becoming abdominal pain today located primarily in the upper
epigastrium and radiating through the belly and to the chest. No
n/v/d. She had a temp of 100.1 at triage, but otherwise no
fevers per pt. At 6am, a nurse who is a relative noted L leg
weakness and a L eye droop which has since improved. Last normal
was when pt went to sleep yesterday evening. ___ has had a dry
cough for 2 weeks. She has had several weeks of worsening b/l
leg edema, has not been on lasix recently, was on it previously.
On the floor, vs were: 98.5 141/87 64 20 96RA
Past Medical History:
PAST MEDICAL HISTORY:
-systolic and diastolic heart failure
-breast cancer s/p mastectomy ___ years ago
-HTN
-right hip replacement
-bilateral knee replacement
-chronic pedal edema
-bilateral cataract implants in ___ and ___
-hx of DVT
-atrial fibrillation
-syncope
-chronic renal failure
-hypokalemia
Social History:
___
Family History:
brother with DM, stroke
daugther with stroke
Physical Exam:
PHYSICAL EXAM:
Vitals: 98.5 141/87 64 20 96RA
Wt: 85kg
General: AOx2 (person, place)
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP difficult to appreciate ___ body habitus
Lungs: mild crackles at bases bilaterally, decreased breath
sounds at bases
CV: irreg, nl rate, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Back: No TTP over C,T,L spine
Ext: Warm, well perfused, no clubbing, cyanosis; 3+ pitting
edema to sacrum
Neuro: equal strength bl at level of ankle, no facial droop
PHYSICAL EXAM:
Vitals:98.7 142/90 62 20 96RA
Wt: 74kg
General: elderly woman in no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP difficult to appreciate ___ body habitus
Lungs: minimally reduced breath sounds at bases bilaterally.
Improved inspiratory crackles. No wheezes. No accessory muscle
use, no tripoding.
CV: irreg, nl rate, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Back: No TTP over C,T,L spine
Ext: Warm, well perfused, no clubbing, cyanosis; 2+ pitting
edema to sacrum
Neuro: A&O x name, location. Grossly normal sensation. Difficult
assess strength, but ___ distally in feet.
Pertinent Results:
ADMISSION LABS:
___ 09:15AM BLOOD WBC-7.0# RBC-3.13* Hgb-11.3* Hct-36.3
MCV-116* MCH-36.2* MCHC-31.2 RDW-17.7* Plt ___
___ 09:15AM BLOOD ___ PTT-58.8* ___
___ 09:15AM BLOOD Glucose-126* UreaN-19 Creat-0.9 Na-141
K-3.3 Cl-105 HCO3-25 AnGap-14
___ 09:15AM BLOOD Albumin-3.4* Calcium-8.7 Phos-2.8 Mg-1.9
___ 09:15AM BLOOD ASA-NEG Acetmnp-NEG
___ 09:20AM BLOOD Lactate-1.9
DISCHARGE LABS:
___ 07:20AM BLOOD WBC-3.0* RBC-2.90* Hgb-10.4* Hct-32.9*
MCV-114* MCH-36.0* MCHC-31.7 RDW-17.0* Plt ___
___ 03:30PM BLOOD Glucose-123* UreaN-19 Creat-0.9 Na-145
K-3.4 Cl-105 HCO3-28 AnGap-15
___ 07:20AM BLOOD Calcium-8.1* Phos-3.7 Mg-2.3
IMAGING:
CT HEAD:
FINDINGS:
There is no hemorrhage, edema, mass effect or acute large
territory infarct.
Prominent ventricles and sulci compatible with age-related
involutional
change. The basal cisterns appear patent and there is
preservation of
gray-white matter differentiation. No acute fracture is
identified. Old
fixation hardware is seen along the left maxillary bone. A
mucous retention
cyst is visualized left maxillary sinus as well as left frontal
sinus. The
mastoid air cells and middle ear cavities are clear. The globes
are
unremarkable.
IMPRESSION:
No acute intracranial process.
CT ABDOMEN PELVIS/CTA CHEST
IMPRESSION:
1. No acute thoracic, abdominal or pelvic process.
2. Multiple findings suggestive of congestive heart failure
including
cardiomegaly, bilateral pleural effusions, and there is third
spacing of fluid
in the mesentery and soft tissues.
3. Multiple vertebral body compression fractures with the L3
fracture new
since prior exam on ___. Severe bilateral
glenohumeral joint
degenerative changes with associated effusion sequestering in
the subscapular
space.
4. 7 mm hypodensity in the pancreatic body. MRCP recommended.
5. Cholelithiasis.
6. Multinodular enlarged thyroid appearing roughly stable from
___.
MRI SPINE:
IMPRESSION:
1. Compression deformities as above, most strikingly involving
the L1
vertebral body where there is mild retropulsion of the superior
aspect of that
vertebral body. However, this does not result in severe spinal
canal stenosis
at this (or any other fractured) level.
2. Degenerative changes as catalog above, including moderately
severe spinal
canal narrowing at L4-L5.
3. Extensive lobulated T2 hyperintensity surrounding the
glenohumeral joints
bilaterally, appearing septated in areas. This is incompletely
evaluated
though likely represents large joint effusions or adjacent
bursal fluid
collections.
MRCP:
IMPRESSION:
1. 1.2-cm cystic pancreatic lesion in the pancreatic body, most
likely
representing a side branch ___. Envisioning the patient's age
and size of
the lesion a followup MRI exam in one year is recommended to
ensure stability.
2. Cholecystolithiasis with a focal area of fundal
adenomyomatosis.
3. Moderate-sized right-sided pleural effusion.
4. Right upper pole renal cysts.
L SPINE PLAIN FILM
FINDINGS: No previous images. There is a compression fracture
of L1 with
associated fracture at T12 and extensive bridging osteophytes,
suggesting that
this represents an old injury. An apparent acute compression
fracture is seen
at L3. There may be slight anterolisthesis at the L3-4 level.
There is marked narrowing at L4-5 and L5-S1, consistent with
substantial
degenerative changes.
Brief Hospital Course:
Ms. ___ is a ___ year old female with systolic and diastolic
CHF, HTN, Afib, CKD, hx of DVT, hx of syncope presenting with
dyspnea, chest pain, incidental finding of numerous compression
fractures and possible ___.
# CHF: Pt initially presented which chest pain (actually mid
epigastric pain)so CT scan performed and patient noted to have
pulmonary edema, pleural effusions. Also grossly volume
overloaded on exam. Had not been receiving lasix. Decision
made to diurese patient aggressively with goal ___ negative per
day. She was given Lasix IV 40mg daily with good output. She
was transitioned to PO lasix 40mg daily and had 2 incontinent
voids afterwards. Pt no longer with dyspnea. Pt has known
systolic and diastolic CHF w/ last echo ___ showing EF 55-60%.
Pt has bilateral R > L pleural effusions on CT from ___
which is decreased on her subsequent MRI, cardiomegaly,
prominent ___ edema. Patient has had significant improvement with
diuresis with complete resolution of dyspnea and improvement in
weight (down ~11kg).
-cont furosemide 40mg po daily
-repeat lytes as an outpatient
# Compression fractures: found on imaging while in ED.
Evaluated by spine while in the ED who recommended evaluation
with MRI C, T, L spine. No pain on exam, no change in strength
bl at level of ankle. Difficult to lift legs given prominent ___
edema. MRI showed retropulsion (mild) at L1, compression
fractures at L3, and degenerative changes at L4/L5. Seen by
ortho who recommend brace when out of bed.
-continue brace for compression fx per orthopedics
-f/u with ortho in 2 weeks
#Incidental Finding of suspected Intraductal Papillary Mucinous
Neoplasm on pancreas: reports intermittent upper abdominal pain
but no weight loss, no change in stools, no abnormal LFTs. Small
mass was found incidentally on CT chest. MRCP shows ___ lesion,
recommend ___ year follow up for interval increase.
-f/u as outpatient, consider annual MRI
# Intermittent lower chest and upper abdominal pain: likely
etiologies include GERD or abdominal gas. Lipase normal.
Negative troponins, no concerning changes on ECG. Very short in
duration. Could be referred pain from thoracic compression
fractures but Pt does not seem to be moving when she experiences
the pain.
-no acute intervention performed
# Leukopenia/Thrombocytopenia: unclear etiology, WBCs have
trended from 7.0k -> 4.3k, -> 3.1k -> 2.9k->3.5->3.0->2.9. No
evidence of systemic infection aside from intermittent brief
abdominal pain. No diarrhea, no dysuria, no cough, no fevers. No
obvious medication effects; no new medications. Plts stable in
100K since ___. No evidence of bleeding.
-follow up as outpatient and see if trend continues
#HTN: continued metoprolol, patient hypertensive to 170s when
not on lasix. Sent out on PO furosemide and should have
outpatient PCP consider further ___. Likely
exacerbated by fludricortisone.
#Atrial Fibrillation and h/o DVT: continued warfarin while
inpatient, will have INR rechecked on ___ and should be
followed by ___ ___ clinic.
#Syncope: positive tilt table test owing to possible autonomic
dysreflexia. On fludricortisone 0.1mg BID. No acute changes
were made.
TRANSITIONAL ISSUES:
-Should make an appointment with orthopedic surgery in 2 weeks
-Should have PCP follow up ___ lesion and whether utility in
further work up at this time
-Should have PCP ___ BP medications
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 2.5 mg PO ___
2. Warfarin 5 mg PO ___
3. Metoprolol Tartrate 25 mg PO BID
4. FoLIC Acid 1 mg PO DAILY
5. Klor-Con 10 *NF* (potassium chloride) 10 mEq Oral qd
6. Fludrocortisone Acetate 0.1 mg PO BID
Discharge Medications:
1. ___ Bed
The patient has a medical condition requiring positioning of the
body not feasible by an ordinary bed to alleviate pain.
Diagnosis: Congestive Heart Failure, Osteoporosis, Lumbar
compression fracture
2. Medical Equipment
Please provide a three in one commode. The patient is confined
to a single room.
Diagnosis/ICD-9: Congestive Heart Failure, Osteoporosis, Lumbar
compression fracture
3. Medical Equipment
Please provide one shower chair.
Diagnosis/ICD-9:
Congestive Heart Failure: 428.0, Osteoporosis: 733.0, Lumbar
compression fracture: 805.4
4. Fludrocortisone Acetate 0.1 mg PO BID
5. FoLIC Acid 1 mg PO DAILY
6. Metoprolol Tartrate 25 mg PO BID
7. Warfarin 3 mg PO ___
RX *warfarin 1 mg 3 tablet(s) by mouth daily on ___,
___ Disp #*90 Tablet Refills:*0
8. Warfarin 5 mg PO ___
9. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
10. Klor-Con 10 *NF* (potassium chloride) 10 mEq Oral qd
Discharge Disposition:
Home With Service
Facility:
___
___:
Heart failure
compression fracture
intraductal papillary mucinous neoplasm
hypertension
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for shortness of breath and chest
pain. While you were here, you were found to have too much
fluid, including it being in your chest, lungs, and legs. We
gave you lasix for this and you lost a significant amount of
water weight. You should continue to take Lasix daily, and
follow up with your primary care doctor about this medication.
You should have your blood drawn on ___ to check your
electrolytes.
You also were found to have compression fractures of your spine,
and orthopedic surgery saw you. They recommend you wear a brace
anytime you are out of bed. You should see them in follow up in
the next few weeks.
You were also found to have a small mass in your pancreas. An
MRI was performed which recommended that you have a repeat in ___
year. Please talk with your primary care doctor about this
lesion, called ___ (Intraductal Papillary Mucinous Neoplasm).
There is no urgent need to do anything about this.
You were also found to have high blood pressure your last two
days here when you did not receive lasix. Your fludricortisone
may be making your blood pressure high. You should speak with
your PCP regarding the need for more blood pressure medications.
Followup Instructions:
___
|
10201643-DS-19 | 10,201,643 | 28,004,948 | DS | 19 | 2197-05-13 00:00:00 | 2197-05-13 12:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending: ___.
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None this hospitalization.
History of Present Illness:
CAD s/p DES ___, ICD placement for prior EF of 30% with syncope
but more recent EF 45%, ischemic stroke on Plavix monotherapy,
T2a prostate cancer s/p XRT and hormonal therapy, CKD, and a
recent diagnosis of stage IV adenocarcinoma of the lung presents
with shortness of breath. He last saw onc ___ at which point he
was doing well, it was reaffirmed due to significant
comomrbidity and age, chemotherapy was not recommended.
He has a history of prior thoracentesis for pleural effusions,
He presented to ___ clinic on ___ where he had a
thoracentesis to remove ___ cc of fluid, ultimately determined
to be malignant adenocarcinoma of the lung. He came to ___ clinic
again on ___ where the decision was made to pursue TPC
placement for a malignant pleural effusion. He presented to the
OR on ___ after holding his Plavix for 5 days in preparation
for the procedure. However, bedside US on the day of the
procedure showed minimal fluid and the decision was made to
abort the procedure and RTC in 1 month. He saw IP ___ at which
point he was not symptomatic and there was no increase in fluid,
no intervention pursued at this time.
Interviewed today in conjunction with dtr ___ and ___ at
bedside. He states that he has had leg swelling worsening
bilaterally over the past few weeks (always has left leg
swelling to some degree, but both legs more swollen). Over the
past 5 days, he has felt worsening dyspnea consistent with
previously
when he had prior thoracentesis. Has had dry nonproductive
cough. No fevers, no chest pain, notes decreased urine output
but no dysuria or burning with urination or difficulty
initiating stream. No diarrhea though has occasional liquidy
stool (1 small episode per day), no nausea/vomiting. Not able to
lie flat.
ED COURSE: T 97.9 HR 66 135/87 16 96% RA. Hgb 8, WBC 5.5,
plts 165, BNP 3K, LFTs WNL, INR 1.2. CXR with small pleural
effusions though increased from prior, loculated left pleural
effusion again noted w/ pleural opacity in left mid lower lung.
No signs of edema/pneumonia.
On arrival to the floor he states he feels a bit better than
before but still somewhat dyspneic, but speaking in full
sentences, and fairly comfortable. All other 10 point ROS neg.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Stage IV lung CA, with malignant pleural effusion. Never
received cancer directed treatment.
Past Medical History:
- CAD, s/p BMS to RCA in ___, and s/p prior inferior MI around
___
- Ischemic cardiomyopathy, with reduced EF (as low as 35%,
currently 45%)
- Prostate cancer, intermediate risk. s/p XRT and one year
hormonal therapy per notes
- History of CVA ___, with slurred speech and leg weakness
without much residual deficit, requiring rehab stay at that time
- s/p ICD (reduced EF and syncope)
- Chronic kidney disease, stage IV
- Hypertension
- Hyperlipidemia
- Osteoporosis
- Glaucoma
- Gout
- Skin cancers (nonmelanoma)
- Colon polyps
- Compression fracture of T12
Social History:
___
Family History:
No known pulmonary disease.
Physical Exam:
========================
Admission Physical Exam:
========================
VITAL SIGNS: 97.6 122/60 81 22 97% RA
General: Mild-mod dyspnea, but appears comfortable, using some
accessory muscles at times
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly. Left eye with slight facial
droop, difficult to see full ___ at rest, per pt baseline
after prior stroke.
CV: RR, NL S1S2 no S3S4 MRG.
PULM: No crackles but wheezing throughout on auscultation all
lung fields.
GI: BS+, soft, NTND, no masses or hepatosplenomegaly.
LIMBS: 2+ pitting edema bilaterally.
SKIN: No rashes a few scattered small scabs over left
foreleg/ankle healing well.
NEURO: Oriented x3. Cranial nerves II-XII are within normal
limits excluding visual acuity which was not assessed, no
nystagmus; strength is ___ of the proximal and distal upper and
lower extremities; pt has slightly less strehgnth in RUE.
========================
Discharge Physical Exam:
========================
VITAL SIGNS: Temp 97.6, BP 110/40, HR 84, RR 18, O2 sat 96% RA.
General: Pleasant. Improved dyspnea, appears comfortable sitting
up on the side of bed.
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy. Left eye with slight facial droop,
difficult to see full ___ at rest, per pt baseline after
prior stroke. + Strabismus.
CV: RR, NL S1S2 no S3S4 MRG.
PULM: Mild wheezing in all lung fields. Decreased breath sounds
left lung halfway up. Fair air movement with short inspiratory
phase.
GI: BS+, soft, NTND, no masses or hepatosplenomegaly.
LIMBS: 3+ pitting edema left leg, 2+ edema right leg.
SKIN: No rashes a few scattered small scabs over left
foreleg/ankle healing well. Hyperkeratotic papules over left ear
and scalp.
NEURO: Oriented x3. Cranial nerves II-XII are within normal
limits excluding visual acuity which was not assessed, no
nystagmus; strength is ___ of the proximal and distal upper and
lower extremities; pt has slightly less strength in RUE.
Pertinent Results:
IMAGING:
========
___ DUP EXTEXT BIL (MAP
Deep vein thrombosis in one of the left peroneal (calf) veins.
___ (PA & LAT)
AP upright and lateral views of the chest provided. AICD again
seen with leads positioned in the region of the right atrium and
right ventricle. Pleural effusions are noted, small, though
increased from prior. A loculated left pleural effusion is
again noted with pleural based opacity noted along the lateral
margin of the left mid to lower lung. A spiculated nodule is
noted in the left infrahilar region. Cardiomediastinal contour
is unchanged. No convincing signs of edema or pneumonia. The
bony structures are intact.
ADMISSION LABS:
===============
___ 05:44PM BLOOD WBC-5.5 RBC-2.66* Hgb-8.0* Hct-26.7*
MCV-100* MCH-30.1 MCHC-30.0* RDW-15.6* RDWSD-57.9* Plt ___
___ 05:44PM BLOOD Neuts-75.9* Lymphs-9.9* Monos-10.1
Eos-3.2 Baso-0.4 Im ___ AbsNeut-4.20 AbsLymp-0.55*
AbsMono-0.56 AbsEos-0.18 AbsBaso-0.02
___ 05:55PM BLOOD ___ PTT-30.2 ___
___ 05:44PM BLOOD Glucose-111* UreaN-67* Creat-2.1* Na-148*
K-4.5 Cl-110* HCO3-25 AnGap-18
___ 05:44PM BLOOD proBNP-3097*
___ 05:44PM BLOOD Albumin-3.3* Calcium-8.6 Phos-3.8 Mg-1.9
___ 05:44PM BLOOD VitB12-1664* Ferritn-101
DISCHARGE LABS:
===============
___ 07:51AM BLOOD WBC-4.5 RBC-2.74* Hgb-8.0* Hct-26.5*
MCV-97 MCH-29.2 MCHC-30.2* RDW-15.6* RDWSD-54.7* Plt ___
___ 07:51AM BLOOD ___
___ 07:51AM BLOOD Glucose-91 UreaN-63* Creat-2.2* Na-140
K-4.0 Cl-105 HCO3-26 AnGap-13
___ 07:51AM BLOOD Calcium-8.2* Phos-3.9 Mg-1.7
Brief Hospital Course:
PRINCIPLE REASON FOR ADMISSION:
___ year old man with CAD s/p DES ___, ICD placement for prior
EF of 30% with syncope but more recent EF 45%, ischemic stroke
on Plavix monotherapy, T2a prostate cancer s/p XRT and hormonal
therapy, CKD, and a recent diagnosis of stage IV adenocarcinoma
of the lung (not receiving treatment) presents with shortness of
breath.
# Shortness of breath
# Cough
# Pulmonary Embolus
# Malignant pleural effusion: Given DVT on ___, dyspnea likely
caused by acute PE leading to reactive airways. We deferred CTA
given poor renal function. He was started on a heparin drip and
transitioned to coumadin due to his poor kidney function,
precluding lovenox. He as also given round the clock albuterol
nebulizers and started on long-acting anticholinergic Spiriva.
Shortness of breath and cough also likely compounded by
malignant pleural effusions, progressive cancer, and possibly
some pulmonary edema. IP deferred thoracentesis and diuresis was
held much of admission due to mild hypernatremia, poor kidney
function, and normal room air O2 sats. He was discharged on
Coumadin with therapeutic INR with ___ and will be monitored by
___.
# Hypernatremia: Unclear etiology. Patient denied thirst and
seemed to have appropriate access to free water. Deferred IV
free water given edema. Improved at time of discharge.
# Anemia: Macrocytic, likely due to malignancy/inflammatory
block. B12 and ferritin normal.
# CKD: Creatinine 2.2, at baseline.
# H/O CAD: Cont home carvedilol, 80mg daily atorva, Plavix.
# H/o Ischemic stroke: Cont home Plavix.
# HTN: Normotensive during stay, cont home hydral, HCTZ.
====================
Transitional Issues:
====================
- Please follow-up pending blood cultures from ___.
- Please continue to monitor INR and ensure patient follow-up
with ___ clinic.
- Please ensure follow-up with Oncology and Palliative Care.
- Code Status: DNR/DNI
- Contact: ___ (daughter/HCP) ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. HydrALAzine 25 mg PO Q12H
5. Carvedilol 25 mg PO BID
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of
breath/wheezing
RX *albuterol sulfate [ProAir HFA] 90 mcg Take ___ puffs IH
every 6 hours Disp #*1 Inhaler Refills:*2
2. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg Take 1
cap IH daily. Disp #*30 Capsule Refills:*2
3. Warfarin 1 mg PO DAILY16
RX *warfarin 1 mg Take 1 tablet by mouth daily. Disp #*30 Tablet
Refills:*1
4. Atorvastatin 80 mg PO QPM
5. Carvedilol 25 mg PO BID
6. Clopidogrel 75 mg PO DAILY
7. HydrALAzine 25 mg PO Q12H
8. Hydrochlorothiazide 25 mg PO DAILY
9.Outpatient Lab Work
Please draw INR on ___.
Diagnosis: DVT (ICD-10 I82.40)
Please call or fax results to ___ clinic. Phone:
___, Fax: ___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- DVT/PE
- Chronic Kidney Disease
- Metastatic Lung Adenocarcinoma
- Malignant Pleural Effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted with increasing leg weakness
and shortness of breath. An ultrasound of your legs showed a new
blood clot and you were started on a blood thinning medication
called Coumadin (also known as warfarin). We suspect you may
also have a blood clot in your lungs causing some of your
respiratory symptoms. You were also very wheezy, so we started
you on new inhaler medications. You will need to follow up with
Dr. ___ as scheduled, and the ___ clinic nurses will be
in touch with you frequently to help monitor and adjust your
coumadin levels.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10201891-DS-14 | 10,201,891 | 24,862,430 | DS | 14 | 2162-01-12 00:00:00 | 2162-01-12 13:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
headaches, confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yr old male pt, right handed, with hx of HTN, who
presented with worsening frontal headaches for the past month,
he
also presented with confusion for couple of days, he stated that
the headaches is getting worse over the past month, also per
wife
she noted some intermittent confusion. He was taken to OSH where
a head CT showed a left frontal mass with surrounding edema.
No ASA, plavix or coumadin intake
Past Medical History:
HTN
Social History:
___
Family History:
NC
Physical Exam:
On Admission:
AVSS
awake, alert, oriented x3
follows commands throughout
PERRL, EOMI, FSTM
no drift
MAE x ___
sensation intact to light touch
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
On Discharge:
A&Ox3
PERRL
EOMs intact
Face symmetrical
tongue midline
No pronator drift
Motor: ___ throughout
Pertinent Results:
MR HEAD W & W/O CONTRAST ___ 5:45 A
1. Aggressive, hypercellular rim-enhancing mass in the inferior
medial left frontal lobe, with significant mass effect including
left subfalcine
herniation, compression of the right inferior frontal lobe
(cannot exclude
invasion), displacement and likely narrowing of the A2 segments
of the
anterior cerebral arteries, and medial displacement of the left
uncus without midbrain compression. The appearance of the mass
is most suggestive of glioblastoma. A metastasis is less
likely. Lymphoma is unlikely, given the heterogeneity of the
lesion, unless the patient is immunocompromised.
2. 2-mm displacement of the right cerebellar tonsil below the
foramen magnum, which may be related to either congenital
tonsillar ectopia or sequela of increased intracranial pressure.
Brief Hospital Course:
___ y/o M with headaches presents with new L frontal lesion.
Patient was admitted to the neurosurgery service for further
evaluation and workup. He was given 10mg decadron in ED and
started on 4mg Q6H. He was also given dilantin and pain
medication. On ___, MRI head was done which showed L
parasagittal lesion with significant vasogenic edema. On
examination, patient was neurologically intact. He remained on
decadron and surgery was discussed. Patient was discharged home
in stable condition to return for elective surgery next week.
Medications on Admission:
Lisinopril, lopressor, Nexium
Discharge Medications:
1. Dexamethasone 4 mg PO Q6H
RX *dexamethasone 4 mg 1 tablet(s) by mouth every six (6) hours
Disp #*90 Tablet Refills:*1
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*90 Capsule Refills:*1
3. Lisinopril 30 mg PO DAILY
4. Metoprolol Tartrate 25 mg PO BID
5. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet,delayed release (___) by
mouth Q24H Disp #*90 Tablet Refills:*1
6. LeVETiracetam 500 mg PO BID
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a
day Disp #*90 Tablet Refills:*1
7. Acetaminophen w/Codeine ___ TAB PO Q6H:PRN pain
RX *acetaminophen-codeine [Tylenol-Codeine #3] 300 mg-30 mg ___
tablet(s) by mouth every six (6) hours Disp #*60 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
L parasagital lesion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Your were diagnosed with a L parasagital brain lesion on this
admission. You will return on ___ for surgery.
Please take you pain medication as prescribed
Increase your intake of fluids and fiber, as narcotic
pain medicine can cause constipation. We generally recommend
taking an over the counter stool softener, such as Docusate
(Colace) while taking narcotic pain medication.
Do not take any anti-inflammatory medicines such as Motrin,
Aspirin, Advil, and Ibuprofen etc.
**You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
We do not recommend that you drive while taking pain
medication.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
Followup Instructions:
___
|
10202010-DS-7 | 10,202,010 | 25,676,260 | DS | 7 | 2134-08-29 00:00:00 | 2134-09-01 11:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
sudden onset L visual field cut, c/f stroke
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo M with a paternal and personal history of
DVT/PE, heavy smoking history, and HTN and DM which resolved
following gastric bypass ___, who presents with L visual field
cut, L sensory symptoms, and L sided weakness which began
suddenly at 1 ___ today. He was at work when he noticed that he
had a diffuse headache and then could not see well on the L.
This
was followed by speech slurring and L arm/leg weakness/numbness.
He was driven to the ED by a friend and code stroke was
activated
at 14:00.
NIHSS 10 on arrival notable for L inferior quadrantanopia, L
facial droop, arm/leg drift, L diminished sensation, L ataxia,
mild dysarthria, and mild naming deficits. He was alert and
conversant throughout. Mr. ___ also endorses significant
diplopia with L gaze and diffuse headache. CT/CTA showed no
evidence of bleed, subacute stroke, or large vessel cutoff. BP
on
arrival was 150/105 and was subsequently 160s/90s. tPA bolus was
administered at 2:31 ___. His naming subsequently improved but
the
rest of his deficits remained.
On neuro ROS, the pt denies lightheadedness, vertigo, tinnitus
or
hearing difficulty. Denies difficulties comprehending speech.
No
bowel or bladder incontinence or retention. Denies difficulty
with gait. Otherwise positive as in HPI.
On general review of systems, the pt denies recent fever or
chills. No night sweats. Used to weigh 500 lbs prior to his
gastric bypass surgery in ___ and now weighs 185 lbs. 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:
___ - DVT/PE, PNA requiring trach that was subsequently removed
___ - gastric bypass, HTN and IDDM previously but subsequently
resolved
Social History:
___
Family History:
Dad and grandfather on paternal side with multiple DVT/PE. No
known history of MI/strokes.
Physical Exam:
# Admission Physical Exam #
Physical Exam:
Vitals: T: P: R: 16 BP: SaO2:
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM
Neck: Supple
Pulmonary: Regular respirations
Cardiac: RRR
Abdomen: soft
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to spell WORLD backward
without difficulty. Language is fluent with intact repetition
and
comprehension. Normal prosody. There were no paraphasic errors.
Pt had some difficulty with naming, but corrected himself over
___ seconds (called glove "hand", called feather "leaf", had
difficulty with hammock). Able to read without difficulty. Able
to follow both midline and appendicular commands. The pt had
good
knowledge of current events. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. L inferior quandrantanopia.
III, IV, VI: No skew deviation with cover uncover, but L eye
with
exotropia and diplopia with L gaze, diminished L eye raising
with
looking up.
V: Facial sensation diminished to light touch but not
temperature/pinprick on L V2/V3.
VII: L full facial droop (LMN). Ma/Pa pronunciation impaired.
VIII: Hearing intact to tuning fork bilaterally.
IX, X: Palate elevates symmetrically, but Ka and Ga
pronunciation
impaired.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes to the left with difficulty moving the
tongue to the R to push against R cheek (c/f L tongue weakness).
___ impaired.
-Motor: Normal bulk, tone throughout. L pronator drift. No
asterixis noted.
Delt Bic Tri WrE IP Quad Ham TA Gastroc
L 4 4+ ___ 4+ 5 4+ 5
R 5 ___ 5 ___ 5
-Sensory: Deficits to light touch throughout L side. No clear
deficit to cold/pinprick sensation. 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: Significant intention tremor with FNF on L.
Dysmetria with HKS on L (seemed out of proportion to weakness).
Poor rhythm with finger tapping and RAM on L.
-Gait: deferred
# Discharge Exam #
MS: Awake, alert. Slightly dysarthric (lingual sounds only).
Voice is raspy, he believes it is worse than his baseline.
CN:
EOMI. Face symmetric. Sensation intact. No clear VF cut. L
tongue deviation. Cannot move to the right. Palate
midline.
Motor: L pronator drift and subtle left deltoid weakness, Rest
of muscles ___.
Coord: No clear asymmetry in FNF.
Pertinent Results:
___ 02:08PM BLOOD WBC-8.1 RBC-4.73 Hgb-13.1* Hct-40.1
MCV-85 MCH-27.7 MCHC-32.7 RDW-14.5 RDWSD-44.5 Plt ___
___ 07:22AM BLOOD WBC-8.9 RBC-4.40* Hgb-12.0* Hct-38.0*
MCV-86 MCH-27.3 MCHC-31.6* RDW-14.6 RDWSD-45.8 Plt ___
___ 05:22AM BLOOD Neuts-79.3* Lymphs-11.2* Monos-8.6
Eos-0.3* Baso-0.2 Im ___ AbsNeut-7.43* AbsLymp-1.05*
AbsMono-0.81* AbsEos-0.03* AbsBaso-0.02
___ 05:22AM BLOOD ___ PTT-31.3 ___
___ 07:22AM BLOOD Glucose-91 UreaN-12 Creat-0.9 Na-139
K-4.0 Cl-99 HCO3-27 AnGap-17
___ 02:08PM BLOOD ALT-21 AST-46* AlkPhos-87 TotBili-0.1
___ 05:22AM BLOOD ALT-332* AST-471* LD(LDH)-385* CK(CPK)-69
AlkPhos-142* TotBili-0.3
___ 03:14PM BLOOD ALT-254* AST-218* LD(___)-365*
AlkPhos-135* Amylase-55 TotBili-0.2
___ 07:22AM BLOOD ALT-199* AST-125* AlkPhos-156*
TotBili-0.2
___ 02:08PM BLOOD Lipase-50
___ 05:22AM BLOOD GGT-109*
___ 03:14PM BLOOD Lipase-49
___ 02:08PM BLOOD cTropnT-<0.01
___ 05:22AM BLOOD CK-MB-1 cTropnT-<0.01
___ 02:08PM BLOOD Albumin-4.6
___ 05:22AM BLOOD TotProt-6.4 Albumin-4.0 Globuln-2.4
Cholest-178
___ 03:14PM BLOOD Cholest-188
___ 05:22AM BLOOD Triglyc-203* HDL-48 CHOL/HD-3.7
LDLcalc-89
___ 03:14PM BLOOD Triglyc-183* HDL-52 CHOL/HD-3.6
LDLcalc-99
___ 05:22AM BLOOD TSH-2.9
___ 03:14PM BLOOD IgM HBc-Negative IgM HAV-Negative
___ 05:22AM BLOOD CRP-2.3
___ 02:08PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:14PM BLOOD HCV Ab-Negative
___ 02:11PM BLOOD Glucose-93 Na-140 K-5.1 Cl-106 calHCO3-21
Imaging:
CTA Head and Neck:
1. Unremarkable head and neck CTA noting mild atherosclerosis.
2. No acute intracranial abnormality.
CT Head:
No acute intracranial abnormality. Specifically, no hemorrhage.
MRI Head wo contrast:
1. No acute intracranial abnormality.
2. Paranasal sinus disease as described above.
CT Head:
1. There is no evidence of acute intracranial process or
hemorrhage
2. Mild paranasal sinus disease as described above
Liver US:
1. 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.
2. Minimal intrahepatic biliary dilatation is likely related to
post
cholecystectomy state.
Echo:
The left atrium is elongated. No thrombus/mass is seen in the
body of the left atrium. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) 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 appears
structurally normal with trivial mitral regurgitation. No mass
or vegetation is seen on the mitral valve. There is mild
pulmonary artery systolic hypertension. No vegetation/mass is
seen on the pulmonic valve. There is no pericardial effusion.
Brief Hospital Course:
Patient received tPA in the ED and was subsequently taken to the
ICU for post-tPA monitoring. He subsequently did wel. MRI done
following the event was without evidence of infarct.
Echocardiogram was without cardiac source. It is unclear whether
his event was an MRI negative stroke (most c/w small left
medullary infarct) vs. a non-organic cause as some of the
symptoms/ exam findings were not consistent and did not
correlate to a specific stroke syndrome vs. embellishment of
underlying deficits. He was discharged on aspirin.
# Transaminitis
- Patient was found to have an incidental transaminitis
elevation in the setting of RUQ tenderness. He underwent
evaluation, and was found on Liver US was notable for steatosis.
LFTs were downtrending on day of discharge.
#Transitional Issues:
- Outpatient Workup for Transaminitis.
- Stroke Neurology Followup
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*1
2. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN headache
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg 1 tablet(s)
by mouth q8 hr Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
MRI Negative Stroke
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 resulting from an ACUTE
ISCHEMIC STROKE, a condition where a blood vessel providing
oxygen and nutrients to the brain is blocked by a clot. The
brain is the part of your body that controls and directs all the
other parts of your body, so damage to the brain from being
deprived of its blood supply can result in a variety of
symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- Prior smoking history
- Prior DVT
We are changing your medications as follows:
ASA 81 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:
___
|
10202035-DS-7 | 10,202,035 | 23,128,703 | DS | 7 | 2197-12-31 00:00:00 | 2197-12-31 12:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Amoxicillin / benzocaine / codeine / lidocaine / nitrofurantoin
/ Penicillins / Sulfa (Sulfonamide Antibiotics) / oxycodone
Attending: ___.
Chief Complaint:
Left hip pain
Major Surgical or Invasive Procedure:
Left Hip short TFN
History of Present Illness:
___ w/ hx angina, GERD, transferred from ___ w/ a left
intertroch hip fracture. Patient claims that she was geting out
of her daughters car when a scarf blew to the ground, she went
to
pick it up and lost her balance chasing after it when the wind
blew it again and fell. Denies HS/LOC. Trauma w/u including head
CT at ___ (-) except for left intertroch hip fx. Transferred
to ___ for further care. Denies paresthesias. Denies f/c.
Past Medical History:
HTN
CAD s/p mid LAD stent placement (unclear when)
Renal cell carcinoma s/p left nephrectomy
GERD
Social History:
___
Family History:
Mother: died in her ___ of cancer (unknown)
Father: died of MI in his late ___
Brother: longtime smoker, died of lung ca
Children: healthy
Physical Exam:
On admission:
AFVSS
NAD, oriented x3, slightly confused at times but appropriately
answers all questions.
LLE: Leg shortened and externally rotated. Skin intact. Mild
swelling of thigh/hip.
Knee/ankle non ttp, no pain with ROM
___
SILT ___
WWP, +2 DP
Moves all other extremeties/joints w/o pain.
On discharge:
___
NAD, A+Ox3
LLE:
Dressings c/d/i
___
___ ___
WWP, +2 DP
Pertinent Results:
___ 05:35AM BLOOD WBC-4.3 RBC-2.65* Hgb-8.3* Hct-22.6*
MCV-85 MCH-31.3 MCHC-36.6* RDW-14.8 Plt ___
___ 07:45PM BLOOD Neuts-89.0* Lymphs-5.4* Monos-4.9 Eos-0.5
Baso-0.2
___ 05:35AM BLOOD Plt ___
___ 07:45PM BLOOD ___ PTT-26.3 ___
___ 06:00AM BLOOD Glucose-97 UreaN-14 Creat-0.8 Na-134
K-4.3 Cl-98 HCO3-26 AnGap-14
___ 06:00AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.8
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 left intertrochanteric femur fracture and was admitted
to the orthopedic surgery service. The patient was taken to the
operating room on ___ for left hip TFN, 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 rehab 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 weight bearing as tolerated in the
left lower extremity, and 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:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Calcium+D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200
unit oral daily
5. Famotidine 20 mg PO DAILY
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Acetaminophen 650 mg PO Q6H
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*50 Tablet Refills:*0
6. Enoxaparin Sodium 30 mg SC DAILY Duration: 2 Weeks
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 30 mg/0.3 mL 30 mg SC once a day Disp #*14
Syringe Refills:*0
7. Senna 17.2 mg PO HS
8. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*50 Tablet Refills:*0
9. Calcium+D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200
unit oral daily
10. Famotidine 20 mg PO DAILY
11. Multivitamins W/minerals 1 TAB PO DAILY
12. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left intertrochanteric femur 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:
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 30mg daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated in the left leg
Physical Therapy:
WBAT LLE
ROMAT
Treatments Frequency:
Dressings may be changed as needed for drainage. No dressings
needed if wound is clean and dry.
Staples will be removed in ___ weeks at Ortho trauma follow up
appointment in clinic.
Followup Instructions:
___
|
10202394-DS-15 | 10,202,394 | 29,488,607 | DS | 15 | 2199-02-19 00:00:00 | 2199-02-19 18:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
metoprolol / Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
painless jaundice
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
___ yo M with PMH significant for Prostate Ca Dx ___ s/p XRT and
lupron, HTN, poorly-defined SVT (holter ___ and known
pancreatic lesion found in ___ now presenting with 3 weeks of
jaundice.
Back in ___ increasing issues with falls on background of
weightloss. Had admission in ___ without obvious finding for
falls although was seen by cardiology in outpt and had holter
with multiple short episodes of atrial tach. Due to weight loss,
PCP obtained CT torso which found a pancreatic lesion concerning
for malignancy. At that time patient and wife did not want to
pursue finding further and per PCP were not interested in
intervention.
More recently patient reported to have painless jaundice with
increasing fatigue leading to today's ER presentation. In the
ED, initial vitals were: T98., HR58, BP 161/55, RR 18, Sat 98%.
Per ER team, discussed with PCP (Dr. ___: wife called PCP
2 days ago to report pt being "very yellow" but reported yellow
hue for 3 weeks. Did have Abd CT in ___ here with findings
suspicious for a pancreatic lesion (likely malignant). Pt did
not want anything invasive at that time. Per PCP needs ___ for
jaundice although is not a surgical candidate. Per ER team, ERCP
was contacted athough did not see in the ER. VS on transfer:
On the floor,
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. 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:
?SVT- not clearly documented with similar episode in ___
Prostate cancer - diagnosed ___ years ago treated with radiation
HL
HTN
Pancreatic Lesion (likely IPMN, no work up)
Social History:
___
Family History:
Noncontributory.
Physical Exam:
Admission Exam:
General: nad
Lungs: clear
CV: rrr no r/g
Abdomen: bowel sounds present, soft, nt/nd
Ext: no e/c/c
Skin: no rash
Neuro: alert, follows commands
Discharge Exam:
97.1 117/60 63 18 99% RA
___ pain
Icteric sclerae
MMM, no OP lesions
rr, nl rate, soft murmur
Lungs CTAB
soft, nontender, nondistended
Ext: wwp, no edema
Skin: jaundice, diffuse rash chest, stomach, arms, back
Neuro: alert, oriented, follows commands, no confusion
Pertinent Results:
___ 01:55PM BLOOD WBC-5.1 RBC-4.12* Hgb-11.5* Hct-37.4*
MCV-91# MCH-28.0 MCHC-30.9*# RDW-16.1* Plt ___
___ 01:55PM BLOOD ___ PTT-38.4* ___
___ 01:55PM BLOOD Glucose-151* UreaN-14 Creat-0.8 Na-140
K-3.8 Cl-100 HCO3-27 AnGap-17
___ 01:55PM BLOOD ALT-78* AST-110* AlkPhos-396*
TotBili-12.3*
___ 07:15AM BLOOD ALT-53* AST-73* AlkPhos-313* TotBili-9.5*
___ 08:10AM BLOOD CA ___ -Test
CTAP: 1. Marked increased in size of a complex cystic mass
within the uncinate process with further dilation of the main
pancreatic duct and side branches from ___. The
findings are in keeping with a mixed IPMN. No definite evidence
for metastatic disease. 2. New, moderate intrahepatic biliary
ductal dilation and further dilation of
the common bile duct and gallbladder. Common bile duct stent in
situ,
however, patency is not assessed but can be correlated with
bilirubin levels. 3. Slight increase in nonspecific mediastinal
lymphadenopathy.
4. Volume overload as evidenced by anasarca, trace bilateral
pleural
effusions and a small amount of ascites. 5. Heavy aortic
valvular calcifications, enough to be hemodynamically
significant.
ERCP: Distended opening of the major papilla with thick mucus
probably due to IPMN of the pancreas suggestive of malignant
transformation. Limited pancreaticogram of the head region
showing a stricture of that area. Successful cannulation of the
biliary duct with a sphincterotome. Cholangiogram showing mild
dilation of the right and left hepatic ducts. The CHD and CBD
measured 8-10mm. The distal CBD showed a 2cm long stricture
probably due to the mass of the head of the pancreas. Balloon
sweeps showed debris and a large amount of mucus. Successful
sphincterotomy, cytology brushings and biopsies of the distal
CBD stricture. Successful placement of a 5cm by ___
double-pigtail biliary stent.
Bile duct brushings/biopsy: pending
Brief Hospital Course:
___ with history of prostate cancer and pancreatic lesion (known
since ___ concerning foro IPMN with work up deferred by
patient who presents with 1 month of painless jaundice and
fatigue.
# Painless Jaundice:
# Pancreatic lesion concerning for malignancy:
# Transaminitis:
He had a cystic pancreatic lesion. He underwent ERCP and had
pigtail catheter placed with copious mucinous exudate. The main
concern is for IPMN with malignant transformation. He had a CTA
torso (with pre-medication) which showed evidence of this mass.
Pancreatic surgery saw the patient and recommended close follow
up in ___ clinic to discuss findings (biopsy
results, ___ and determine plan. The biopsy results are
pending. The patient and family are aware that this is likely
cancerous. He will need repeat ERCP (to be scheduled by ERCP
doctors) for reevaluation and stent exchange in ___ weeks. His
diet was advanced he he felt slightly improved from recent days.
Of note, his atorvastatin was held.
# Rash:
He developed a rash consistent with drug rash, likely secondary
to allergy to contrast. This occured previously with contrast
administration and he was treated with prednisone without
benefit. We will attempt symptomatic control with sarna lotion.
Further treatment may be necessary at rehab. No evidence of
hemodynamic or respiratory compromise.
# Malnutrition, protein and calorie:
The etiology may be sercondary to biliary duct obstruction or
malignancy. We have been supporting his nutrition with ensure
plus. This should continue at rehab. He will be seen by a
nutritionist on ___. If his appetite is not improving he may
need an appetite stimulating medication or gtube depending on
goals of care.
# Presyncope:
He had an episodes of vasovagal presyncope while attempting to
have a bowel movement. This is likely secondary to straining and
increased vagal tone. No further episodes of this.
# Hypertension, benign:
His blood pressure was stable (120/60) at time of discharge. He
was not orthostatic. His valsartan was discontinued.
# Anemia:
Mild. Stable. Trend as outpatient. Likely secondary to nutrition
and suppression from chronic illness.
# Full Code
# CONTACT: Wife and HCP - ___ ___ / cell#
___
Transitional issues:
# Follow up on ___ for findings of biopsy and to discuss
plan
# Nutritional support
# Rehab (discharge to rehab for ___
# PCP follow up after discharged from rehab
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 10 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Valsartan 160 mg PO DAILY
Discharge Medications:
1. Senna 8.6 mg PO BID:PRN constipation
2. Polyethylene Glycol 17 g PO DAILY:PRN
3. Aspirin 81 mg PO DAILY
Restart this medication on ___. Ferrous Sulfate 325 mg PO DAILY
5. Sarna Lotion 1 Appl TP QID:PRN pruritis
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
- Painless jaundice - due to complex cystic mucinous pancreas
lesion concerning for IPMN with malignant transformation (bx
pending)
- HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with jaundice. You had a known pancreatic mass
for which you deferred evaluation in ___. An ERCP was
done showing bile duct obstruction and copious mucinous exudate
concerning for a pancreatic cystic neoplasm with malignant
transformation. A biliary stent was placed, and it will need to
be exchanged again in 2 months. Cytology and pathology specimens
were submitted and are pending. A CT scan was done and you were
evaluated by the surgical team.
Please attend all of your follow up appointments especially the
___ appointment. At this appointment they will evaluate you
for different treatment options for your pancreatic lesion.
Followup Instructions:
___
|
10202778-DS-24 | 10,202,778 | 21,365,589 | DS | 24 | 2184-01-20 00:00:00 | 2184-01-20 13:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Augmentin / ASA/NSAIDS
Attending: ___.
Chief Complaint:
cellulitis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o male with history poorly controlled DM, ESRD on HD, PVD,
b/l charcot's foot s/p right below knee guillotine with
completion BKA on ___ and ___ respectively secondary to
complications from charcot fracture and infection presents from
clinic with drainage and erythema from stump concerning for
cellulitis. Patient has been doing well since discharge. He was
at rehab and has been home recently with ___ services. He denies
any fevers, chills, drainage, or erythema until today at clinic
when the stump drained some. His health has otherwise been
stable. He did not go to dialysis today. He is upset that he was
waiting for so long prior to admission. He has not been keeping
stump elevated. He has been eating well and passing regular
bowel movements.
His review of symptoms is otherwise negative for weakness,
numbness, nausea, vomiting, jaundice, chest pain, shortness of
breath, bloody bowel movements, dysuria, hematuria (patient
occasionally makes small amount of urine).
Past Medical History:
PMH: ESRD on HD, DM2 uncontrolled, charcot, HTN, HLD, PVD, OSA,
gout, obesity, CKD, b/l Charcot
PSH:
___ completion right BKA
___ right below knee guillotine
___ RIGHT FOOT ___ DIGIT DEBRIDEMENT/ AMPUTATION
___ SPLIT THICKNESS SKIN GRAFT RECONSTRUCTION TO LEFT FOOT
___ Left Plantar Debridement with VAC
___ Ulcer Excison Exostectomy; Rotational Flap Midfoot
___ Ulcer Excison Exostectomy; Rotational Flap Midfoot
___ cuboid extostectomy left foot; excision of ulcer and
closure left foot
___ cuboid extostectomy left foot; excision of ulcer and
closure left foot
appendectomy (pediatric), CCY (___)
Social History:
___
Family History:
N/C
Physical Exam:
Temp: 98.1 HR 67 BP" 107/50 RR: 18 92% RA
Gen: sitting in wheel chair no distress alert interactive
HEENT: atraumatic, non icteric
CV: regular rate, no murmurs, rubs, gallops, brachiocephalic
fistula with palpable thrill on right
RESP: clear to auscultation bilaterally
Abd: obese, soft, non tender
Ext: right BKA stump with erythema although decreased from
admission, tenderness at lateral edge, some fluidity to
palpation posteriorly
Left foot: well healed incisions from multiple foot surgeries
Pertinent Results:
___ 06:23AM BLOOD WBC-10.2 RBC-3.66* Hgb-10.8* Hct-33.7*
MCV-92 MCH-29.5 MCHC-32.0 RDW-16.5* Plt ___
___ 11:35AM BLOOD WBC-9.6 RBC-3.87* Hgb-11.4* Hct-35.8*
MCV-92 MCH-29.5 MCHC-32.0 RDW-16.5* Plt ___
___ 06:01PM BLOOD WBC-9.9 RBC-4.14*# Hgb-12.3*# Hct-38.3*#
MCV-92 MCH-29.7 MCHC-32.1 RDW-16.3* Plt ___
___ 06:23AM BLOOD Glucose-138* UreaN-54* Creat-7.3*# Na-141
K-4.5 Cl-97 HCO3-31 AnGap-18
___ 06:40AM BLOOD Glucose-171* UreaN-39* Creat-5.6*# Na-139
K-4.2 Cl-95* HCO3-29 AnGap-19
___ 11:35AM BLOOD Glucose-369* UreaN-64* Creat-7.9*# Na-140
K-4.7 Cl-97 HCO3-25 AnGap-23*
___ 06:23AM BLOOD Calcium-9.9 Phos-6.4* Mg-2.3
___ 06:40AM BLOOD Calcium-9.3 Phos-5.9* Mg-2.2
___ 11:35AM BLOOD Calcium-9.4 Phos-6.0* Mg-2.2
___ 06:23AM BLOOD Vanco-13.3
CT right lower extremity w/o contrast
FINDINGS:
The patient is status post below-the-knee amputation. Extensive
vascular
calcifications are present throughout the imaged extremity. The
distal aspect
of the tibial stump appears regular. The fibular stump has a
somewhat
irregular distal aspect, but probably within normal limits given
the surgery.
Within the muscle flap, deep to the superficial fascia there is
a collection
of hypodense material within minimal intervening areas of
hyperdense material
spanning 9.3 x 3.9 x 4.5 cm. Surrounding this collection of
fluid as well as
extending superiorly to above the knee is extensive soft tissue
edema.
A small knee joint effusion is noted. Tricompartmental
degenerative changes of
the knee are present without any evidence of acute fracture.
IMPRESSION:
1. Large collection of fluid that appears to be within the
muscular flap, deep
to the superficial fascia. Infection cannot be ruled out,
although other
considerations could include postoperative seroma/ hematoma.
Extensive soft
tissue edema extends superiorly from the stump and collection to
above the
knee
Brief Hospital Course:
The patient was admitted on ___ for cellulitis of the BKA
stump after he was seen in clinic. He was started on IV
antibiotics and treated conservatively. His hospital course by
system is described below.
Neuro: The patient did not develop any substantial pain during
this admission. He was given tylenol PRN for pain.
CV: The patient was started on his home beta blocker upon
admission. He remained hemodynamically stable and was without
acute cardiovascular issue during this hospitalization.
Resp: There were no acute respiratory issues during this
hospitalization.
GI: The patient was started on a renal diet upon admission.
Given concern that he may require incision, drainage or
rexploration he was made NPO on the night of HD#1 and again
HD#3. When there was no operatiion pursued he was again placed
on his renal diet.
Renal: The patient is a usual ___ dialysis
patient, however, due to him being admitted following clinic on
HD#1 (a ___ he was unable to get his dialysis that day.
Consequently he had dialysis on HD#2 and again and HD#4 to bring
him back to his usual ___ schedule. He was
started on his home nephrocaps and phosphate binders.
Endo: Initially when it was uncertain whether the patient was
going to require surgery his basal insulin dose was reduced. His
glucose control was poor in the hospital. On HD#4 when it was
decided that no operation would be pursued this hospitalization
his insulin dosing was returned to his home dosage.
ID: The patient was initially started on IV vancomyocin and
cefepime given his adverse reactions to cipro and amoxicillin.
He remained afebrile without an elevated white count throughout
the hospitalization. The appearance of the cellulitis on the BKA
stump slowly improved. A Ct scan revealed a fluid collection in
the distal aspect of the BKA however it was decided against
drainage or revision. It was deemed more prudent to treat
conservatively with antibiotics and observe since the patient
remained stable rather than pursue a revision. On HD#4 he was
switched to PO levaquin.
Heme: The patient was put on heparin DVT prophylaxis while in
the hospital.
Transitional issues.
1) antibiotics: We would like the patient to complete a 14 days
course of antibiotics. This would mean dialysis dosing of
vancomyocin for the patient until ___. Additionally he should
continue his course of levaquin until then as well.
2) The patient has been doing well from a mobility standpoint
but he did have one mishap while transfering and thus we have
recommended he continue his home ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Allopurinol ___ mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Nephrocaps 1 CAP PO DAILY
4. Gabapentin 200 mg PO QHD
5. Cyclobenzaprine 10 mg PO TID:PRN spasm
6. Glargine 50 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Calcium Acetate ___ mg PO TID W/MEALS
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Calcium Acetate ___ mg PO TID W/MEALS
3. Gabapentin 200 mg PO QHD
4. Glargine 50 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Nephrocaps 1 CAP PO DAILY
7. Levofloxacin 250 mg PO Q48H
RX *levofloxacin [Levaquin] 250 mg 1 tablet(s) by mouth every
other day Disp #*5 Tablet Refills:*0
8. Cyclobenzaprine 10 mg PO TID:PRN spasm
9. Vancomycin IV Sliding Scale
Start: Tomorrow - ___, First Dose: First Routine
Administration Time
please adminster vancomyocin at dialysis by levels until ___
RX *vancomycin 1 gram ___ mg IV at dialysis ___ Disp #*5
Vial Refills:*0
10. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ capsule(s) by mouth every 4 hours Disp
#*20 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Cellulitis
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:
You were admitted to the hospital after your amputation stump
developed cellulitis. You were treated with IV antibiotics and
the cellulitis improved. A CT scan was done of the stump that
showed a fluid collection, however, it was felt that given your
stability on antibiotics further surgeries on the stump would
not be helpful at this time. Thus you were discharged with plans
to continue the antibiotics for a total of two weeks and follow
up in cilinc in 1 week for rexamination of the stump.
1) please continue to take the levofloxacin every other day
until ___. please also get vancomyocin adminstered at
dialysis until ___.
2) please resume all your home medications
3) please monitor yourself closely for signs of infection,
fever, drainage from the stump or increasing redness or
tenderness
Followup Instructions:
___
|
10203235-DS-16 | 10,203,235 | 24,203,891 | DS | 16 | 2130-04-25 00:00:00 | 2130-04-26 13:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
Chest Pain, Jaw Pain, Dyspnea
Major Surgical or Invasive Procedure:
None this hospitalization.
History of Present Illness:
___ hx CAD s/p CABG, NSTEMI in ___, multiple PCIs mostly
recently with DES x2 to LCx and POBA of OM1, DM2, HLD, CKD Stage
III, presents for L-sided CP wrapping to the back.
Patient reports that she has chronic shortness of breath with
exertion and L-sided chest pain wrapping around the back that is
typically relieved with a single SL NTG. Last night, however,
her CP came at rest, and was only partially relieved by a SL
NTG; then she suffered severe shortness of breath while in bed.
She took 2 more SL NTG while summoning EMS; en route she was
given an additional 2 SL NTG, and then another 2 in the ED. She
has had no orthopnea, PND, ___ edema, cough, congestion, fevers,
chills, n/v, abdominal pain, change in bowel or urinary habits.
In the ED initial vitals were 99.6 79 177/92 22 100% NC. EKG
showed NSR 74bpm, nl axis, QTc 464, submillimeter STD
I/aVL/V5/V6 more prominent but seen previously in ___. CXR
showed moderate pulmonary edema. Labs notable for WBC 10.7, H/H
10.1/32.4, Bicarb 21, BUN/Cr 41/1.9, Gluc 215, Trop 0.06 with
CK-MB 7, proBNP 1573. INR 1.2. Patient was given SL NTG 0.4mg.
Vitals on transfer: 70 160/69 20 99% RA.
On the floor, patient is comfortable, chest pain free and
without shortness of breath, and is able to contribute to the
history as above and below.
Past Medical History:
- CAD s/p CABG (LIMA/LAD, SVG/OM1, SVG/D1, SVG/PDA), BMS to
SVG/OM1 and DES to mLAD in ___ DES to ___, ___ DES to
LCx, NSTEMI treated with BMS to SVG to PDA (___), Echo
(___): EF 55% with elevated PCWP and trace MR, no AS/AI
- DMII c/b Retinopathy, Nephropathy, CAD
- Hypertension
- HLD with LDL of 98 and HDL of 33 in ___ -> on rosuvastatin
40mg daily currently
- CKD stage III likely diabetic nephropathy, last Cr 1.6 in
___.
- Iron Deficiency Anemia
- Joint Pains
Social History:
___
Family History:
Mother with diabetes and heart failure. Father with diabetes.
Son with sarcoid.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T=98.2 BP=178/77 HR=69 RR=18 O2 sat=95%RA
GENERAL: WDWN F 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, unable to appreciate JVP
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: Obese, soft, NTND. No tenderness.
EXTREMITIES: No c/c/e.
NEURO: Face symmetric, moving all four extremities normally.
DISCHARGE PHYSICAL EXAM:
VS: 98.7 ___ 96-99%RA
GENERAL: WDWN in NAD, no distress.
HEENT: NCAT, MMM
NECK: Supple, JVP 7
CARDIAC: RRR with loud S2. No murmurs/rubs/gallops.
LUNGS: Clear to auscultation, no crackles bilaterally
ABDOMEN: Obese, soft, NTND. No tenderness.
EXTREMITIES: No c/c/e.
NEURO: Face symmetric, moving all four extremities normally.
Pertinent Results:
ADMISSION LABS
___ 07:10AM BLOOD WBC-9.0 RBC-3.49* Hgb-9.7* Hct-30.7*
MCV-88 MCH-27.8 MCHC-31.6* RDW-13.1 RDWSD-41.5 Plt ___
___ 07:10AM BLOOD ___ PTT-28.5 ___
___ 07:10AM BLOOD Glucose-126* UreaN-39* Creat-1.7* Na-138
K-4.6 Cl-105 HCO3-25 AnGap-13
PERTINENT LABS
___ 01:01AM BLOOD CK-MB-7 cTropnT-0.06* proBNP-1573*
___ 07:10AM BLOOD CK-MB-12* cTropnT-0.17*
___ 01:45PM BLOOD CK-MB-12* MB Indx-4.8 cTropnT-0.25*
___ 08:50PM BLOOD CK-MB-8 cTropnT-0.18*
DISCHARGE LABS
___ 07:06AM BLOOD WBC-8.5 RBC-3.65* Hgb-10.1* Hct-31.9*
MCV-87 MCH-27.7 MCHC-31.7* RDW-13.2 RDWSD-41.5 Plt ___
___ 07:20AM BLOOD ___ PTT-60.2* ___
___ 07:20AM BLOOD Glucose-142* UreaN-39* Creat-1.7* Na-136
K-4.0 Cl-98 HCO3-26 AnGap-16
___ 07:20AM BLOOD Calcium-9.0 Phos-4.1 Mg-2.0
STUDIES
ECG: Sinus bradycardia. Q-T interval prolongation. Diffuse ST-T
wave changes present may be due to ischemia. Clinical
correlation is suggested. Compared to the previous tracing of
___ the ST-T wave changes appear less pronounced. Otherwise,
findings are similar.
CXR ___: Moderate pulmonary edema.
Echocardiogram ___:
The left atrium and right atrium are normal in cavity size.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). The estimated cardiac
index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests
an increased left ventricular filling pressure (PCWP>18mmHg).
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) are mildly thickened
but aortic stenosis is not present. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. Increased
PCWP.
Brief Hospital Course:
___ hx CAD s/p CABG, NSTEMI in ___, multiple PCIs mostly
recently with DES x2 to LCx and POBA of OM1, DM2, HLD, CKD Stage
III, presents with angina and CHF exacerbation.
# NSTEMI/CAD: Patient presented approximately 1 month after most
recent stenting. She reported pain had resolved for about 1 week
and subsequently recurred intermittently. Endorsed 100%
adherence to ASA/plavix. CP was anginal equivalent. Remained CP
free in house. Cardiac enzymes were trended and peaked at
troponin 0.25, CK-MB 12. EKG was largely unchanged from prior
and echocardiogram unremarkable. She was treated with heparin
gtt for 48 hours total. Medical management with ASA, plavix,
metoprolol, rosuvastatin, valsartan continued in house. Given
hypertension imdur and hydral added as below.
#Acute on chronic diastolic CHF exacerbation: Pulmonary edema on
CXR on admission. She was diuresed with IV Lasix boluses and
discharged on usual Lasix 20 mg PO daily. TTE did not show new
abnormalities.
#Hypertension: In house patient with elevated blood pressures to
systolic 170s. She was started on hydralazine and imdur with
good improvement.
# DM2: Home NPH continued with Humalog sliding scale.
# Anemia: Home ferrous sulfate continued.
# Sinus Congestion/Asthma: Home Flonase, albuterol continued.
# GERD: Home PPI continued
# CODE: confirmed Full
TRANSITIONAL ISSUES:
- Patient started on Imdur 30mg daily due to recurrent
exertional chest pain. She tolerated this dose well without
issues of headache. If patient continues to have anginal chest
pain would recommend increasing trialing increase in Imdur to
60mg daily or increasing dose of Ranolazine to 1000mg twice
daily. If patient is unable to tolerate Imdur than would
recommend increasing dose of Ranolazine to 1000mg twice daily.
- Patient started on Hydralazine 25mg TID for hypertension.
Continue to monitor blood pressure and adjust as needed.
- Please refer for outpatient cardiac rehab.
- Please consider outpatient nutrition referral.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Valsartan 320 mg PO DAILY
2. Metoprolol Tartrate 100 mg PO BID
3. Ranolazine ER 500 mg PO BID
4. Fluticasone Propionate NASAL 2 SPRY NU BID:PRN congestion
5. Rosuvastatin Calcium 40 mg PO QPM
6. NPH 64 Units Breakfast
NPH 32 Units Bedtime
Insulin SC Sliding Scale using Novolog Insulin
7. Ferrous Sulfate 325 mg PO DAILY
8. Furosemide 20 mg PO DAILY
9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
10. Fluticasone Propionate 110mcg 2 PUFF IH BID:PRN SOB
11. Clopidogrel 75 mg PO DAILY
12. Omeprazole 20 mg PO DAILY
13. Aspirin 81 mg PO DAILY
14. albuterol sulfate 90 mcg/actuation inhalation Q4-6H:PRN SOB
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Fluticasone Propionate NASAL 2 SPRY NU BID:PRN congestion
4. NPH 64 Units Breakfast
NPH 32 Units Bedtime
5. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
6. Omeprazole 20 mg PO DAILY
7. Ranolazine ER 500 mg PO BID
8. Rosuvastatin Calcium 40 mg PO QPM
9. Valsartan 320 mg PO DAILY
10. albuterol sulfate 90 mcg/actuation inhalation Q4-6H:PRN SOB
11. Fluticasone Propionate 110mcg 2 PUFF IH BID:PRN SOB
12. Ferrous Sulfate 325 mg PO DAILY
13. Furosemide 20 mg PO DAILY
14. Metoprolol Tartrate 100 mg PO BID
15. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg Take 1 tablet by mouth daily.
Disp #*30 Tablet Refills:*0
16. HydrALAzine 25 mg PO Q8H
RX *hydralazine 25 mg Take 1 tablet by mouth three times per
day. Disp #*90 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
NSTEMI
Coronary artery disease
Secondary
Acute on chronic diastolic CHF exacerbation
Hypertension
Type 2 diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to the hospital
because you were having chest pain and were found to have an
elevation of your heart enzymes. Your EKG looked the same as
before. Because of concern that you might have a small blockage
in one of your arteries you were started on a heparin drip to
thin your blood. You underwent an echocardiogram to look at the
function of your heart which showed your heart function is good.
Your medications were also adjusted. You were started on a
medication called Imdur to help prevent further episodes of
chest pain. If you are unable to continue taking this medication
due to side effects (due to headache), please call your
Cardiologist to make other medication adjustments. You were also
started on a blood pressure medication called hydralazine that
is to be taken three times per day.
Please follow up at your scheduled appointments.
All the best,
Your ___ Team
Followup Instructions:
___
|
10203235-DS-17 | 10,203,235 | 27,901,592 | DS | 17 | 2130-06-03 00:00:00 | 2130-06-03 17:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
___ Cardiac catheterization
History of Present Illness:
___ yo F w/ h/o CAD s/p CABG in ___, NSTEMI in ___, multiple
PCIs mostly recently with DES x2 to LCx and POBA of OM1 in
___, DM2, HLD, CKD Stage III, presents d/t dyspnea and ECG
changes.
The patient and her family state that for the past ___ days she
has been more short of breath with exertion and has had more
lower extremity edema than usual. She has been taking all her
medications usually. On ___ she laid down to go to sleep and
developed her usual left-sided chest pain with dyspnea. Usually
her pain resolved with nitroglycerin at this time she had to
take 3 nitroglycerin's without relief. She went to ___
___, where ECG was concerning for changes --> STD in V4-6
with mild STE in aVR. She was started on BiPAP there and given
80IV Lasix with 1.5L UOP, also nitro paste placed. Trop negative
x1 at that time. Pt transferred here given her cardiology is
here. Denies current dyspnea, CP, HA, additional complaints.
In the ED, initial VS were: 97 76 164/83 21 100% Nasal Cannula
ED ECG: STD V4-5 <1 mm, STE in aVR similar to prior here, less
significant elevation/depression as at OSH initially.
CXR IMPRESSION: Mild to moderate pulmonary edema improved
relative to examination dated ___
On arrival to the floor, patient reports that she is feeling
much better. Denies chest pain, palpitations. Does endorse
shortness of breath and cough that is worse with lying down.
Over the last few days has been feeling short of breath with
ambulating less than one block. Usually has stable chest pain on
the left lower chest radiating to her back one exertion that has
been relieved with nitro SL. See HPI above for current episode
of chest pain which was similar in quality and not relieved by
SL nitro which prompted seeking care. She also had associated
palpitations.
Past Medical History:
- CAD s/p CABG (LIMA/LAD, SVG/OM1, SVG/D1, SVG/PDA), BMS to
SVG/OM1 and DES to mLAD in ___ DES to ___, ___ DES to
LCx, NSTEMI treated with BMS to SVG to PDA (___), Echo
(___): EF 55% with elevated PCWP and trace MR, no AS/AI
- DMII c/b Retinopathy, Nephropathy, CAD
- Hypertension
- HLD with LDL of 98 and HDL of 33 in ___ -> on rosuvastatin
40mg daily currently
- CKD stage III likely diabetic nephropathy, last Cr 1.6 in
___.
- Iron Deficiency Anemia
- Joint Pains
Social History:
___
Family History:
Mother with diabetes and heart failure. Father with diabetes.
Son with sarcoid.
Physical Exam:
ADMISSION PHYSICAL EXAM
=====================
VS: 98.0 70 142/70 20 95%RA
GENERAL: NAD, obese lady, pleasant and cooperative
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: normal respiratory effort. No wheezes, rales, rhonchi.
Mild bibasilar crackles.
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: no cyanosis, clubbing. 1+ pedal edema.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
======================
Vitals: 97.5 64 ___ 20 99% on ra
I/O= ___, 350/400(24hrs)
Weight: 86.9 -> 86.9
Telemetry: Paced. Some PVCs. No alarms
GENERAL: NAD, obese lady, pleasant and cooperative
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: normal respiratory effort. No wheezes, rales, rhonchi.
Mild bibasilar crackles.
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: no cyanosis, clubbing. 1+ pedal edema.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
=============
___ 03:44AM BLOOD WBC-10.5* RBC-3.69* Hgb-10.1* Hct-32.2*
MCV-87 MCH-27.4 MCHC-31.4* RDW-13.5 RDWSD-42.3 Plt ___
___ 03:44AM BLOOD Neuts-76.5* Lymphs-15.6* Monos-5.9
Eos-1.0 Baso-0.5 Im ___ AbsNeut-8.06* AbsLymp-1.64
AbsMono-0.62 AbsEos-0.10 AbsBaso-0.05
___ 03:44AM BLOOD ___ PTT-30.1 ___
___ 03:44AM BLOOD Glucose-205* UreaN-41* Creat-2.3* Na-136
K-4.6 Cl-100 HCO3-22 AnGap-19
___ 03:44AM BLOOD CK(CPK)-487*
___ 03:44AM BLOOD CK-MB-24* MB Indx-4.9 cTropnT-0.30*
proBNP-1677*
___ 03:44AM BLOOD Calcium-9.6 Phos-2.9 Mg-1.8
DISCHARGE AND PERTINENT LABS
==========================
___ 05:50AM BLOOD WBC-8.2 RBC-3.93 Hgb-10.5* Hct-33.8*
MCV-86 MCH-26.7 MCHC-31.1* RDW-13.6 RDWSD-42.7 Plt ___
___ 05:50AM BLOOD ___ PTT-27.0 ___
___ 05:50AM BLOOD Glucose-139* UreaN-50* Creat-1.9* Na-137
K-4.0 Cl-98 HCO3-28 AnGap-15
___ 11:30AM BLOOD CK-MB-34* MB Indx-6.8* cTropnT-0.93*
___ 07:15PM BLOOD CK-MB-22* MB Indx-5.9 cTropnT-0.68*
___ 05:50AM BLOOD Calcium-9.3 Phos-4.3 Mg-2.5
IMAGING
=======
___ CXR PA&L
FINDINGS:
PA and lateral chest radiographs were provided. Median
sternotomy wires
appear intact. Surgical clips project over the left mediastinal
border.
Comparison is made to radiographs dated ___. Mild
cardiomegaly
is stable. Bilateral pulmonary opacities are present though
improved relative
to prior study consistent with pulmonary edema. Blunting of
bilateral
costophrenic angles likely reflect small pleural effusions. No
evidence of
pneumothorax.
IMPRESSION:
Mild to moderate pulmonary edema improved relative to
examination dated ___.
___ Cardiac cath
1. Unchanged Cx stents.
2. Branch vessel disease and likely collateral insufficiency in
setting of episodic hypertension as cause of NSTEMI.
3. Normal LV filling pressures.
4. Systemic hypertension.
5. Failed cannulation of LCA via right radial artery.
___ ECG
Baseline artifact. Sinus rhythm. Left atrial abnormality. ST
segment
depression in leads I, aVL and V3-V6 potentially consistent with
myocardial
ischemia. Clinical correlation is suggested. Compared to the
previous tracing
of ___ the findings are similar.
MICROBIOLOGY
============
None
Brief Hospital Course:
#Chest Pain/NSTEMI/CAD/HTN/Hyperlipidemia.
Ms. ___ was transferred from ___ for cardiac
care after she experienced chest pain at rest on day of
admission and had a few days worsening shortness of breath. She
had troponin elevation peak at 0.93 with CKMB 34 at ___. She
was started on heparin drip, and continued on plavix, aspirin,
metoprolol, ___, and high dose statin. Her ECG was notable for
some ST depressions in V4-V5. She underwent right radial cardiac
catheterization which showed unchanged Cx stents, and branch
vessel disease, with normal LV filling pressures. No stent was
placed. Patient was discharged on home meds including:
clopidogrel, aspirin, metoprolol, simvastatin, and valsartan.
#Acute on chronic diastolic CHF exacerbation :(LVEF >55%):
Patient appeared clinically hypervolemic on exam with pedal
edema and lung crackles with an elevated pBNP of 1677. She was
diuresed at ___ and at ___ with IV lasix and was
discharged with 40mg PO Lasix which is an increase from 20mg
that she was taking prior to admission at home. Her fluid status
should be followed up closely.
___ on CKD: Has stage 3 CKD, Cr 1.9 on ___. On admission 2.1
most likely from CHF exacerbation. Improved with diuresis to
near baseline of 1.9 on day of discharge.
#Anemia: Has stable anemia with Hb ~ 10. Was continued on home
iron supplementation. Should be followed as outpatient.
#Insulin dependent diabetes mellitus: continued on home insulin
regimen.
TRANSITIONAL ISSUES
=================
DISCHARGE WEIGHT: 86.9kg
DISCHARGE CR: 1.9
LASIX DOSE: 40mg PO daily
[] recheck renal panel to ensure creatinine is stable in 1 week
[] monitor blood pressure and titrate antihypertensives as
needed to improve BP control
[] reassess patient volume status and adjust home furosemide as
needed
[] monitor CBC for stability/improvement of anemia
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Fluticasone Propionate NASAL 2 SPRY NU BID:PRN congestion
4. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
5. Omeprazole 20 mg PO DAILY
6. Ranolazine ER 500 mg PO BID
7. Rosuvastatin Calcium 40 mg PO QPM
8. Valsartan 160 mg PO DAILY
9. albuterol sulfate 90 mcg/actuation inhalation Q4-6H:PRN SOB
10. Fluticasone Propionate 110mcg 2 PUFF IH BID:PRN SOB
11. Ferrous Sulfate 325 mg PO DAILY
12. Furosemide 20 mg PO DAILY
13. Metoprolol Tartrate 100 mg PO BID
14. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
15. HydrALAzine 25 mg PO Q8H
16. NPH 64 Units Breakfast
NPH 34 Units Bedtime
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Fluticasone Propionate 110mcg 2 PUFF IH BID:PRN SOB
5. Fluticasone Propionate NASAL 2 SPRY NU BID:PRN congestion
6. HydrALAzine 25 mg PO Q8H
7. NPH 64 Units Breakfast
NPH 34 Units Bedtime
8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
9. Metoprolol Tartrate 100 mg PO BID
10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
11. Omeprazole 20 mg PO DAILY
12. Rosuvastatin Calcium 40 mg PO QPM
13. Valsartan 160 mg PO DAILY
14. albuterol sulfate 90 mcg/actuation inhalation Q4-6H:PRN SOB
15. Ranolazine ER 500 mg PO BID
16. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
==============
NSTEMI
Secondary Diagnosis
================
Diastolic Congestive Heart Failure, acute on chronic
exacerbation
___ on CKD
Insulin Dependent Diabetes Mellitus
Hypertension
Hyperlipidemia
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 ___ after you
experience chest pain. You underwent a heart catheterization
which showed stable stents and no new lesions. No new stents
were placed. You are to continue taking all of your medications
that you were taking prior to coming to the hospital. We will
increase your Lasix dose to Lasix 40mg daily.
We found that you had some extra fluid on your body and gave you
lasix to get rid of the excess fluid. It is important to weigh
yourself daily and notify your doctor if you gain more than 3
lbs in a day.
We also found that your kidneys were working slightly worse but
this was most likely having too much fluid on your body. Their
function improved back to their baseline.
We wish you the best of health,
Your ___ Care Team
Followup Instructions:
___
|
10203235-DS-19 | 10,203,235 | 27,652,177 | DS | 19 | 2130-08-17 00:00:00 | 2130-08-19 09:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Chest Pain, Dyspnea
Major Surgical or Invasive Procedure:
Left heart catheterization with placement of 4 DES in the
RCA(overlapping 2.5 x 33, 2.5 x 38, 3.0 x 38 and 3.0 x 23 Xience
___ and balloon angioplasty of the PDA.
History of Present Illness:
The patient is a ___ y/o woman with past medical history of CAD
(s/p CABG in ___, NSTEMI in ___ and ___, multiple PCIs mostly
recently with DES x2 to LCx and POBA of OM1 in ___, and most
recent NSTEMI in ___, managed medically as it was attributed
to HTN), diastolic CHF, DM2, HLD, CKD Stage III who presents
with sudden onset retrosternal and L arm pain while walking
around home late last night. She describes sharp pain that
started in her arm and then moved across the left side of her
chest. The pain coincided with an acute episode of SOB. She took
3 SL nitroglycerin, which did not relieve the pain and then
proceeded to call Lifeline. She received O2 and a full dose
aspirin in the ambulance. On arrival to the ED, she had RA SpO2
in the mid ___, improved to mid-90s on NRB. She denies recent
infectious symptoms. However, she notes progressive swelling,
SOB, and short episodes of chest and arm pain over the past few
weeks. The pain prior to admission was non-remitting and similar
to previous MI. It resolved on arrival, dyspnea ongoing.
In the ED initial vitals were: T= 98.4 HR=77 BP=146/124 RR=30
SpO2=100%NRB
EKG ___ @ 8:22: Sinus, rate 62. QTc 451/455. T wave
inversions in 1, 2, avL, V2 - V6.
Labs/studies notable for: ___ troponin elevated to 0.19
(baseline <0.01). Creatinine 2.2, BUN 49, UA +leuk/-nitr
Patient was given:
- Home medications, including Valsartan, Metoprolol Tartrate,
Omeprazole, Isosorbide Mononitrate, Clopidigrel, Amlodipine,
Albuterol Inhaler, Fluticasone Propionate
- Furosemide 20mg IV
- Nitroglycerin drip 0.35-3.5 mcg/kg/min IV DRIP TITRATE TO SBP
< 130
- Nitroglycerin SL 0.4 mg SL ONCE
- Heparin IV per Weight-Based Dosing Guidelines Initial Bolus:
4000 units IVP Initial Infusion Rate: 1050 units/hr
- CeftriaXONE 1 g IV ONCE
Vitals on transfer: T=97.9, HR=67, BP=155/64, RR=16, SpO2=97%RA
On the floor, the patient denies chest pain and SOB. She
observes that the swelling in her legs has decreased since the
administration of Furosemide in the ED. She affirms that she has
been urinating frequently.
Past Medical History:
- CAD s/p CABG (LIMA/LAD, SVG/OM1, SVG/D1, SVG/PDA), BMS to
SVG/OM1 and DES to mLAD in ___ DES to ___, ___ DES to
LCx, NSTEMI treated with BMS to SVG to PDA (___), Echo
(___): EF 55% with elevated PCWP and trace MR, no AS/AI
- DMII c/b Retinopathy, Nephropathy, CAD
- Hypertension
- HLD with LDL of 98 and HDL of 33 in ___ -> on rosuvastatin
40mg daily currently
- CKD stage III likely diabetic nephropathy, last Cr 1.6 in
___.
- Iron Deficiency Anemia
- Joint Pains
Social History:
___
Family History:
Mother with diabetes and heart failure. Father with diabetes.
Son with sarcoid.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T=97.9, HR=67, BP=155/64, RR=16, SpO2=97%RA
GENERAL: Middle-aged woman sitting comfortably in NAD. Oriented
x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with no discernible JVP.
CARDIAC: RR, normal S1/S2. Soft systolic murmur. No rubs or
gallops. No thrills, lifts.
LUNGS: Decreased breath sounds throughout, crackles at both
bases, no wheezes or rhonchi.
ABDOMEN: Soft, obese, NTND. No HSM.
EXTREMITIES: 1+ bilateral ___ edema, WWP.
SKIN: No stasis dermatitis, ulcers, or scars.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAM:
VS: T= 98.2F, HR= 65 (65-90), BP= 144/58 (131-175/55-71), RR=18,
SpO2=100%RA
Weight= 85.7 (from 84.5)
I/O= 1742/2550 (net negative -808)
GENERAL: Middle-aged woman sitting comfortably in NAD. Oriented
x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. MMM.
NECK: Supple with no discernible JVP.
CARDIAC: RR, normal S1/S2. Soft systolic murmur. No rubs or
gallops. No thrills, lifts.
LUNGS: CTAB. No crackles, wheezes, or rhonchi.
ABDOMEN: Soft, obese, NTND. No HSM.
EXTREMITIES: Minimal bilateral ___ edema, WWP.
SKIN: No stasis dermatitis, ulcers, or scars.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
ADMISSION LABS:
___ 01:55AM BLOOD WBC-12.1* RBC-3.58* Hgb-9.6* Hct-31.5*
MCV-88 MCH-26.8 MCHC-30.5* RDW-14.5 RDWSD-46.7* Plt ___
___ 01:55AM BLOOD Neuts-73.5* Lymphs-17.3* Monos-5.9
Eos-2.3 Baso-0.4 Im ___ AbsNeut-8.92*# AbsLymp-2.10
AbsMono-0.72 AbsEos-0.28 AbsBaso-0.05
___ 01:55AM BLOOD ___ PTT-29.5 ___
___ 01:55AM BLOOD Glucose-245* UreaN-49* Creat-2.2* Na-135
K-4.6 Cl-104 HCO3-22 AnGap-14
___ 01:55AM BLOOD ALT-12 AST-22 CK(CPK)-173 AlkPhos-84
TotBili-0.2 DirBili-0.1 IndBili-0.1
___ 01:55AM BLOOD cTropnT-<0.01
___ 08:22AM BLOOD cTropnT-0.19*
___ 02:20PM BLOOD cTropnT-0.34*
___ 01:55AM BLOOD Albumin-4.0 Calcium-9.4 Phos-3.8 Mg-2.0
DISCHARGE LABS:
___ 07:50AM BLOOD WBC-9.6 RBC-3.25* Hgb-8.7* Hct-28.3*
MCV-87 MCH-26.8 MCHC-30.7* RDW-14.6 RDWSD-46.0 Plt ___
___ 07:50AM BLOOD ___ PTT-27.2 ___
___ 07:50AM BLOOD Plt ___
___ 07:50AM BLOOD Glucose-165* UreaN-40* Creat-1.7* Na-136
K-4.3 Cl-101 HCO3-26 AnGap-13
___ 06:55AM BLOOD CK-MB-8 cTropnT-0.21*
___ 12:37AM BLOOD cTropnT-0.35*
___ 07:50AM BLOOD Calcium-9.1 Phos-4.0 Mg-1.9
___ NEGATIVE URINE CULTURE
___ Conclusions
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. There is mild regional left
ventricular systolic dysfunction with hypokinesis of the basal
inferior and inferoseptal walls (best seen on Optison images).
The remaining segments contract normally (LVEF = 55%). Doppler
parameters are indeterminate for left ventricular diastolic
function. 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. There is no mitral valve prolapse. There
is physiologic mitral regurgitation. The estimated pulmonary
artery systolic pressure is normal. There is an anterior space
which most likely represents a prominent fat pad. Compared with
the prior study (images reviewed) of ___, regional left
ventricular systolic dysfunction is new and is suggestive of
CAD. Other findings are similar.
STRESS TEST: ___ Exercise Nuclear:
-Exercise portion: ST segment depression in the setting of
baseline abnormalities in the absence of anginal type symptoms.
Nuclear report sent separately.
-Nuclear portion: Mild-to-moderate partially reversible defect
in anterior and apical wall as well as inferior wall. 2. Normal
wall motion. 3. Normal ejection fraction.
CXR ___
1. Moderate pulmonary edema. No pleural effusions.
2. Mild cardiomegaly.
EKG ___ @ 8:22: Sinus, rate 62. QTc 451/455. T wave
inversions in 1, 2, avL, V2 - V6.
L HEART CATHETERIZATION ___
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. There
is mild regional left ventricular systolic dysfunction with
focal basal inferior hypokinesis. The remaining segments
contract normally (LVEF = 50%). Tissue Doppler imaging suggests
an increased left ventricular filling pressure (PCWP>18mmHg).
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) are mildly thickened
but aortic stenosis is not present. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Elevated LVEDP.
Brief Hospital Course:
BRIEF SUMMARY
==============
___ y/o woman with past medical history of CAD (s/p CABG in ___,
NSTEMI in ___ and ___, multiple PCIs mostly recently with DES
x2 to LCx and POBA of OM1 in ___, and most recently NSTEMI
in ___ managed medically as it was attributed to HTN),
diastolic CHF, DM2, HLD, CKD Stage III who presents with sudden
onset retrosternal and L chest pressure/pain, dyspnea, found to
have NSTEMI and CHF exacerbation.
ACTIVE ISSUES
===============
# NSTEMI: The patient presented with chest pain that started in
her left arm and spread to her neck and L chest. She took 3 SL
nitroglycerin at home, which did not relieve her symptoms and
then proceeded to call Lifeline. Labs revealed elevated
troponins to 0.19 (baseline <0.01, peak 0.34 on the day of
admission) and EKG with sinus rhythm and T wave inversions in 1,
2, avL, V2 - V6, diagnostic of NSTEMI. She was started on
heparin gtt and nitroglycerin gtt at a low rate, which was
weaned on hospital day 2 with no recurrent chest pain. In
addition, the patient was continued on her home medications with
the exception of Metoprolol Tartrate, which was decreased to
25mg PO Q6H (increased back to 100mg BID on discharge) and
Amlodipine, which was discontinued. After consulting with Dr.
___ received a left heart catheterization on ___
that revealed extensive RCA occlusion. Four DES were placed
overlapping 2.5 x 33, 2.5 x 38, 3.0 x 38 and 3.0 x 23 Xience
___. She also had balloon angioplasty of the PDA. Heparin
gtt was discontinued after cath. She was continued on home
metoprolol, Aspirin 81 mg daily, Clopidogrel 75 mg daily,
Ranolazine ER 500 mg BID, Rosuvastatin 40mg daily, Valsartan 160
mg daily. Imdur ER 30mg BID was held until the day of discharge.
# Acute on chronic systolic CHF exacerbation: Patient reported
persistent dyspnea in addition to chest pain, highly suggestive
of both CHF exacerbation and NSTEMI given her extensive history
of heart failure and CAD. She also noted progressive swelling in
her legs over the past several days with a CXR showing pulmonary
edema. On arrival to the ED, she had SpO2 in the mid ___ on RA,
which improved to mid-90s on NRB. She received a bolus of IV
Lasix and shortly thereafter transitioned to RA with 98% SpO2.
The patient was given 20mg IV Lasix daily for diuresis and
discharged with her home dose of 20mg PO with instructions to
take an additional pill if her weight increases. She patient
remained asymptomatic with no difficulty breathing for the
remainder of hospitalization. Discharge weight: 85.7 kg.
# Hypertension: Patient was continued on home medications of
valsartan 160 mg daily, Imdur 30 mg BID, and metoprolol 100 mg
BID as above at discharge. Home amlodipine was held during
hospitalization and on discharge. Consideration of increasing
valsartan to 320 mg was discussed but not performed as it might
decrease her pill burden in the future should she need further
antihypertensive agents.
# Leukocytosis: Resolved over the course of admission to ___
count of 9.6. Patient admitted with WBC count of 12.1. UA with
positive leukocytes, negative nitrites. No urinary symptoms.
Given ceftriaxone 1g IV in the ED. Negative urine culture. No
consolidation on CXR. No fever. Patient remained HD stable.
# Chronic kidney disease: Patient has a baseline creatinine of
1.7 - 2.0. Elevated to 2.2 on admission, then decreased to 1.7
with diuresis.
CHRONIC ISSUES
=============
# Anemia: Low H/H throughout admission. Anemia of chronic
disease likely contributing to persistent anemia given patient's
chronic cardiac issues. Patient was continued on Ferrous Sulfate
325 mg PO DAILY. Iron, LDH, ferritin, TIBC studies returned
within normal limits.
# Diabetes: Continued home NPH (64 units qAM, 28 units qPM).
HISS.
# GERD: Continued Omeprazole 20 mg PO DAILY.
TRANSITIONAL ISSUES
===================
New Medications: None
Discontinued Medications: Amlodipine
- Careful monitoring of blood pressure, patient may need
uptitration of blood pressure regimen as above. Consider
increasing losartan to 320 mg daily if needed.
- Discharge weight: 85.7 kg. Patient instructed to take an extra
dose of 20 mg Lasix (for a total dose of 40 mg) if her weight
increases by ___ pounds.
- Follow up patient's anemia (Hgb 8.7 on discharge), normal iron
studies
- Recommend referral to cardiac rehabilitation as an outpatient
(note: patient has concerns about copay)
# CODE: Full code, confirmed.
# CONTACT: ___ (HCP) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Ranolazine ER 500 mg PO BID
5. Metoprolol Tartrate 100 mg PO BID
6. Omeprazole 20 mg PO DAILY
7. Rosuvastatin Calcium 40 mg PO QPM
8. Valsartan 160 mg PO DAILY
9. Isosorbide Mononitrate (Extended Release) 30 mg PO BID
10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
11. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN wheeze, dyspnea
12. Flovent HFA (fluticasone) 44 mcg/actuation inhalation
BID:PRN with colds
13. Fluticasone Propionate NASAL 2 SPRY NU BID
14. Amlodipine 5 mg PO DAILY
15. Furosemide 20 mg PO DAILY
16. NPH 64 Units Breakfast
NPH 28 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
17. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. NPH 64 Units Breakfast
NPH 28 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Omeprazole 20 mg PO DAILY
6. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN wheeze, dyspnea
7. Ranolazine ER 500 mg PO BID
8. Rosuvastatin Calcium 40 mg PO QPM
9. Valsartan 160 mg PO DAILY
10. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
11. Flovent HFA (fluticasone) 44 mcg/actuation inhalation
BID:PRN with colds
12. Fluticasone Propionate NASAL 2 SPRY NU BID
13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
14. Isosorbide Mononitrate (Extended Release) 30 mg PO BID
15. Furosemide 20 mg PO BID
16. Metoprolol Tartrate 100 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Non-ST Elevation Myocardial Infarction (NSTEMI), Acute
on chronic diastolic CHF
Secondary: Coronary Artery Disease, Hypertension, Dyslipidemia,
Diabetes Mellitus Type 2, Chronic Kidney Disease, Iron
Deficiency Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came to the hospital on ___ with left-sided chest pain
and shortness of breath. In the emergency room, you received
medications to improve your breathing. Testing showed damage to
your heart (a heart attack), which may have been caused by fluid
overload from your congestive heart failure. During your
hospitalization, you received four stents to open blockage of
the right coronary artery as well as a balloon angioplasty of
the posterior descending artery. You were discharged on the same
home medications you were taking prior to admission with the
exception of amlodipine, which was discontinued. Currently, you
are prescribed 20mg Lasix per day (1 pill). Please weigh
yourself everyday and, if your weight increases by ___ or
more, take an additional Lasix pill (2 pills, 40mg total) that
morning. You have follow up appointments scheduled with your
primary care physician and cardiologist, listed below. Thank you
for the opportunity to participate in your care.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10203235-DS-21 | 10,203,235 | 28,960,005 | DS | 21 | 2133-10-07 00:00:00 | 2133-10-08 14:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Imdur / gabapentin
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Coronary angiogram with IVUS-guided stent deployment in the RCA
for ostial in-stent restenosis ___
History of Present Illness:
___ with CAD s/p CABG (LIMA-LAD, SVG-OM1, SVG-D1, SVG-PDA) ___
with subsequent PCI of 2 SVGs but all SVGs now known occluded,
subsequent DES to ostial LMCA, mid LAD, LCX/OM, RCA/RPPL and
PTCA of RPDA (most recently ___, type 2 diabetes mellitus with
CKD, presenting with chest pain.
Patient's CAD is managed at the ___. Her last coronary
angiogram was performed was ___ in the setting of Type 1
NSTEMI. This showed patent LMCA, LAD proximal 50% prior to a
total occlusion; CX proximal 50% and 60% stenoses, mid 50%
stenosis; RPDA proximal 70% and 90% stenosis and mid-distal 90%
stenosis; RPL 70% in-stent restenosis; patent LIMA-LAD. She
underwent staged PCI 3 days later with deployment of a 2x18 mm
DES in the distal RCA (trapping/crushing a stripped stent
against the vessel wall) with balloon angioplasty of the RPDA.
She was last seen in cardiology clinic ___ when she reported
an overall improvement in her anginal symptoms, taking
nitroglycerin tabs ___ times a week for shortness of breath.
She then developed chest pain starting around ___ on ___,
radiating to the left arm and axilla. She took nitroglycerin
with some improvement, but called EMS as the pain was
persistent. EMS EKG demonstrated aVR ST elevations with diffuse
ST depressions. She was given ASA 325 mg and 2 additional tabs
of SL nitroglycerin. She had taken her AM dose of clopidogrel
___. She was transported to the ___ ED for further
evaluation.
In the ED initial vitals were: T 97.7F, HR 107, BP 172/82, RR
21, SaO2 97% on RA. EKG showed a mild increase in ST elevation
of aVR, new diffuse ST depressions. Patient appeared
uncomfortable but otherwise benign general exam and
cardiopulmonary exam. Labs/studies notable for: WBC 9.7, Hgb
9.4, Plt 225, INR 1.3, Na 134, K 4.7, Cl 96, HCO3 23, BUN 62, Cr
2.1, Glucose 497 Alb 4.1, TBili 0.2, AST 17, ALT 14, AP 84,
Lipase 58, TnT <0.01. VBG: pH 7.38, pCO2 40: Na 132, K 4, Cl
104, Lactate 1.8, Hgb 9.7, Glucose 450. Cardiology was consulted
who felt her presentation was consistent with NSTEMI and
recommended IV heparin with EKG monitoring. Given her
hypertension to SBP's >170's, aggressive hypertension treatment
was also recommended. Patient was given Nitroglyerin and Heparin
infusions, regular insulin 10 units sc. Vitals on transfer: T
97.8F, HR 102, BP 168/74, RR 17, ___ 99% on RA, pain ___.
After arrival to the cardiology ward, patient noted her pain was
decreased compared with at presentation, but still present. To
clarify, she ate dinner at 7:40 ___ on ___ and developed chest
pain while sitting at 8:00 ___. SL nitroglycerin helped but the
pain persisted so she came to the ED. She denied nausea,
vomiting, changes to her baseline shortness of breath,
orthopnea, constipation, diarrhea, or increased lower extremity
edema. She was also concerned as her FSBG were in the 400's
throughout the day despite normal insulin administration and
dietary intake.
REVIEW OF SYSTEMS: 10 point ROS as above, otherwise negative
Past Medical History:
- CAD s/p CABG (LIMA-LAD, SVG-OM1, SVG-D1, SVG-PDA; all SVGs now
occluded) ___ BMS to SVG-OM1 and 2.5x13 mm Cypher DES to
mid LAD, documentation of occlusion of SVG-D1 ___
unsuccessful PCI of stenosed SVG-OM, 3.5x13 mm Cypher DES to
ostial LMCA ___ NSTEMI treated with 2 BMS to SVG-PDA,
documentation of occlusion of SVG-OM ___ three 2.25x14
mm Resolute DES to LCx/OM (and documentation of occlusion of
SVG-RPDA) ___ NSTEMI ___ with stable CAD (unable to
cannulate LMCA via right radial approach); 2.5x33, 2.5x38, 3x38
and 3x23 mm Xience ___ DES in RCA and RPL with PTCA of RPDA
___ 2x18 mm Onyx DES to distal RCA (trapping/crushing a
stripped 2x15 mm Onyx) & PTCA of RPDA ___
- Hypertension
- Hyperlipidemia with LDL of 98 and HDL of 33 in ___ -> on
rosuvastatin 40 mg daily currently
- Type 2 diabetes mellitus complicated by retinopathy,
nephropathy, CAD
- CKD stage 4 likely diabetic nephropathy
- Iron Deficiency Anemia
- Joint Pain
Social History:
___
Family History:
Mother with diabetes and heart failure. Father with diabetes.
Son with sarcoid.
Physical Exam:
At admission
GENERAL: Older appearing black woman sitting in NAD, pleasant
24 HR Data (last updated ___ @ 340) Temp: 97.5 (Tm 97.5),
BP: 137/52 (137-186/52-86), HR: 103 (103-104), RR: 22, O2 sat:
95%, O2 delivery: RA
Wt: 197.53 lb/89.6 kg
HEENT: PERRL, non-erythematous oropharynx
NECK: No cervical lymphadenopathy in anterior or posterior
chains
CV: RRR; no murmurs, rubs or gallops
PULM: CTAB--without wheezes, crackles or rhonchi
ABD: obese, non-tender, + BS
EXT: Nonpitting edema of right ankle
NEURO: AAOx3
At discharge
General: Lying in bed comfortably, answering questions
appropriately
Vitals: 24 HR Data (last updated ___ @ 527) Temp: 98.2 (Tm
98.2), BP: 119/54 (82-171/40-79), HR: 75 (64-99), RR: 20
(___), O2 sat: 95% (91-100), O2 delivery: 2L (2L-20),
Wt: 195.99 lb/88.9 kg (89.5)
Fluid Balance -181
HEENT: No JVD
Lungs: CTAB--no wheezes, crackles, rhonchi
CV: RRR; no rub, murmurs or gallop.
Abdomen: Soft, no rigidity, non-tender, bowel sounds present.
Ext: Warm. Trace edema. No clubbing or cyanosis
Pertinent Results:
___ 12:28AM BLOOD WBC-9.7 RBC-3.56* Hgb-9.4* Hct-30.5*
MCV-86 MCH-26.4 MCHC-30.8* RDW-14.4 RDWSD-44.9 Plt ___
___ 12:28AM BLOOD Neuts-58.8 ___ Monos-7.0 Eos-1.5
Baso-0.2 Im ___ AbsNeut-5.70 AbsLymp-3.11 AbsMono-0.68
AbsEos-0.15 AbsBaso-0.02
___ 12:28AM BLOOD ___ PTT-25.0 ___
___ 12:28AM BLOOD Glucose-497* UreaN-62* Creat-2.1* Na-134*
K-4.7 Cl-96 HCO3-23 AnGap-15
___ 12:28AM BLOOD ALT-14 AST-17 AlkPhos-84 TotBili-0.2
___ 12:28AM BLOOD Albumin-4.1
___ 12:40AM BLOOD ___ pO2-56* pCO2-40 pH-7.38
calTCO2-25 Base XS-0
___ 12:40AM BLOOD Glucose-450* Lactate-1.8 Creat-2.0*
Na-132* K-4.0 Cl-104
___ 12:40AM BLOOD Hgb-9.7* calcHCT-29 O2 Sat-85
___ 12:28AM BLOOD cTropnT-<0.01
___ 06:30AM BLOOD CK-MB-21* cTropnT-0.20*
___ 02:30PM BLOOD CK-MB-31* cTropnT-0.68*
___ 12:00AM BLOOD CK-MB-21* cTropnT-0.71*
___ 07:40AM BLOOD CK-MB-13*
___ 07:37AM BLOOD CK-MB-7
ECG ___ 00:29:29
Sinus tachycardia. Repol abnrm suggests ischemia, diffuse leads.
Compared to previous ECG ___, diffuse ST abnormality is much
worse and suggests diffuse ischemia.
ECG ___ 20:56:17
Normal sinus rhythm. Extensive anterolateral and inferior
ST-depressions. Consider ischemic syndrome
CXR ___
Lung volumes are low with bronchovascular crowding. Retrocardiac
opacities likely represent atelectasis. There may be mild
pulmonary vascular congestion without frank edema. No
pneumothorax or large pleural effusions. The cardiomediastinal
silhouette is accentuated by low lung volumes, but remains
mildly enlarged. Atherosclerotic calcifications are noted in the
aortic knob. Median sternotomy wires are redemonstrated.
IMPRESSION: 1. Hypoinflated lungs with pulmonary vascular
congestion. 2. Retrocardiac opacities likely represent
atelectasis.
Echocardiogam ___:
The left atrial volume index is normal. The estimated right
atrial pressure is ___ mmHg. There is normal left ventricular
wall thickness with a normal cavity size. There is mild regional
left ventricular systolic dysfunction with focal basal inferior
hypokinesis (see schematic) and preserved/normal contractility
of the remaining segments. Quantitative biplane left ventricular
ejection fraction is 59% (normal 54-73%). Left ventricular
cardiac index is normal (>2.5 L/min/m2). There is no resting
left ventricular outflow tract gradient. Tissue Doppler suggests
an increased left ventricular filling pressure (PCWP greater
than 18 mmHg). Normal right ventricular cavity size with normal
free wall motion. Tricuspid annular plane systolic excursion
(TAPSE) is normal. The aortic sinus diameter is normal for
gender with normal ascending aorta diameter for gender. The
aortic arch diameter is normal with a normal descending aorta
diameter. There is no evidence for an aortic arch coarctation.
The aortic valve leaflets (?#) are mildly thickened. There is no
aortic valve stenosis. There is no aortic regurgitation. The
mitral valve leaflets appear structurally normal with no mitral
valve prolapse. There is moderate mitral annular calcification.
There is trivial mitral regurgitation. Due to acoustic
shadowing, the severity of mitral regurgitation could be
UNDERestimated. The pulmonic valve leaflets are not well seen.
The tricuspid valve leaflets appear structurally normal. There
is physiologic tricuspid regurgitation. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity size with mild regional systolic dysfunction most
consistent with single vessel coronary artery disease (PDA
distribution).No valvular pathology or pathologic flow
identified. Normal pulmonary artery systolic pressure. Compared
with the prior TTE (images reviewed) of ___, the findings
are similar
Coronary Angiogram - ___:
The coronary circulation is right dominant.
LM: The Left Main, arising from the left cusp, is a large
caliber vessel. This vessel bifurcates into the Left Anterior
Descending and Left Circumflex systems.
LAD: The Left Anterior Descending artery, which arises from the
LM, is a large caliber vessel. There is a stent in the ostium
and proximal segment. There is a 100% in-stent restenosis in the
proximal segment. The Diagonal, arising from the proximal
segment, is a medium caliber vessel.
Cx: The Circumflex artery, which arises from the LM, is a large
caliber vessel. There is a 40% stenosis in the proximal segment.
The ___ Obtuse Marginal, arising from the proximal segment, is a
medium caliber vessel. The ___ Obtuse Marginal, arising from the
mid segment, is a medium caliber vessel.
RCA: The Right Coronary Artery, arising from the right cusp, is
a large caliber vessel. There is a stent in the ostium and
proximal segment. There is a 95% in-stent restenosis in the
ostium. There is a stent in the proximal and mid segments. There
is a stent in the mid and distal segments. There is a stent in
the distal segment. The Right Posterior Descending Artery,
arising from the distal segment, is a medium caliber vessel. The
Right Posterolateral Artery, arising from the distal segment, is
a medium caliber vessel.
Bypass Grafts:
LIMA: A medium caliber arterial LIMA graft connects to the mid
segment of the LAD. This graft is patent.
Interventional details: Patient has been on chronic DAPT. PCI
was performed on therapeutic UFH. A 6 ___ JR4 guide provided
adequate support. Crossed with a Sion Blue wire into the distal
PLV. Predilated with a 2.5 mm balloon to deliver IVUS. IVUS
demonstrated neointimal hyperplasia and maybe slight
geographical miss, with a 3.75-4.0 diameter. We then pre-dilated
with a 3.0x12mm NC balloon. We then deployed a 3.5 mm x 12 mm
DES (Onyx). The stent was post dilated again with a 4.0 NC
balloon, including at the overalap. Final angiography revealed
normal flow, no dissection and 0% residual stenosis.
Findings: Severe ostial RCA ISR. S/p IVUS-guide PCI (Onyx DES
3.5x12mm, post-dilated to 4.0)
DISCHARGE LABS:
___ 07:37AM BLOOD WBC-6.8 RBC-3.14* Hgb-8.2* Hct-27.3*
MCV-87 MCH-26.1 MCHC-30.0* RDW-14.7 RDWSD-46.6* Plt ___
___ 07:37AM BLOOD ___ PTT-24.4* ___
___ 07:37AM BLOOD Glucose-305* UreaN-33* Creat-1.7* Na-137
K-5.2 Cl-103 HCO3-23 AnGap-11
___ 07:37AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.8
Brief Hospital Course:
Ms. ___ is a ___ with CAD s/p CABG (LIMA-LAD, SVG-OM1,
SVG-D1, SVG-PDA) ___ with subsequent occlusions of all SVGs;
S/P multiple DES to mid LAD (___), ostial LMCA (___), LCx/OM
(___), RCA/RPL ___ and ___ and type 2 diabetes mellitus
presenting with chest pain and admitted for an NSTEMI. On
arrival, EKG demonstrated new diffuse ST depression. She was
placed on heparin and nitroglycerin infusions. Patient was
continued on home metoprolol 100 mg total daily, isosorbide
dinitrate 10 mg TID, aspirin 81 mg daily, clopidogrel 75 mg and
ranolazine. Patient received additional clopidogrel 300 mg
re-load on hospital day 2. Patient's valsartan and furosemide
were held in preparation for contrast angiography given CKD. She
was hypertensive on arrival which was thought secondary to pain
as it resolved with initiation of nitroglycerin drip. Peak CK-MB
31, peak troponin-T 0.71. Echocardiographic LVEF 59% with focal
basal inferior hypokinesis (unchanged from ___. She
underwent coronary angiography which showed 95% in-stent
restenosis of the ostial RCA and 100% in-stent restenosis of the
LAD with LIMA-LAD graft patent. IVUS-guided re-stenting of the
ostial RCA was performed. Post-PCI course was complicated by
transient chest pain requiring reinitiation of nitrolycerin
infusion. Pain resolved without additional intervention. Given
no ST elevations on EKG (but persistent ST depressions) and
resolution of pain without additional intervention, low concern
for stent thrombosis. Patient was monitored for 24 hours post
PCI and remained stable. She was discharged without chest pain
with plan for follow up in clinic. Patient was reinitiated on
valsartan and furosemide with metoprolol tartrate transitioned
to metoprolol succinate prior to discharge. Given presentation
with NSTEMI and now 2 layers of drug-eluting stents in the
ostium of the RCA, prolonged and preferably lifelong dual
anti-platelet therapy was recommended.
Other active medical issues:
# Hypertension: Patient with history of hypertension on
valsartan, furosemide, metoprolol. Elevated pressures on
presentation thought to be in the setting of NSTEMI/Chest pain.
In line with this, patient's pressures improved with
nitroglycerin infusion. Patient's valsartan and furosemide were
held during early course of hospitalization as above but
reinitiated prior to discharge.
# Type 2 diabetes mellitus with hyperglycemia and hypoglycemia:
Patient with difficult to manage diabetes mellitus with known
labile blood sugars. During her hospitalization, she
demonstrated sudden increase in FSBG, non-responsive to
home standing U-500 and sliding scale Humalog. Patient was
without any infectious signs or symptoms and reported no dietary
indiscretion. Therefore, ongoing hyperglycemia thought likely
due to ongoing NSTEMI event. In attempting to control sugars,
patient did have episode of hypoglycemia. Therefore, ___ was
consulted and provided recommendations for U-500 dosing while
inpatient. Patient was discharged on home dosing with
recommendation for close outpatient glucose monitoring and
follow up.
CHRONIC MANAGEMENT:
# Hyperlipidemia: Patient continued on rosuvastatin.
# GERD: Patient's PPI switched from omeprazole to pantoprazole
to avoid FDA warning about interaction of omeprazole with
clopidogrel. Patient discharged on this medication.
# CKD, stage ___: Patient's creatinine fluctuates between 1.7 to
mid 2's per OMR and ___ records. Currently is at baseline.
Valsartan and furosemide held prior to catheterization in
anticipation of contrast without elevation in Cr. These
medications were resumed prior to discharge.
# ? COPD: Patient on albuterol and Flovent for unclear reason.
Uses it for assistance with shortness of breath.
TRANSITIONAL ISSUES:
[] Patient is now recommended for lifelong dual antiplatelet
therapy given concentric layers of drug-eluting stent. This
should be continued in the outpatient setting.
[] Patient's sugars very challenging to control. Discharged on
home regimen given that NSTEMI and NPO status likely impacting
glucose control inpatient. Patient should monitor blood sugars
closely outpatient with outpatient provider ___.
[] Patient with medications suggestive of COPD diagnosis.
However, patient unaware of any diagnosis. This should be
evaluated further in outpatient setting.
[] Patient seen by ___ who deemed her excellent candidate for
cardiac rehabilitation. Benefits of outpatient cardiac
rehabilitation reviewed with patient. Patient last did this at
time of CABG and was interested in enrolling again now at
___. The patient was provided with referral
information and a prescription for outpatient cardiac
rehabilitation.
MEDICATION CHANGES:
[] Patient's metoprolol tartrate was converted to metoprolol
succinate
[] Patient's omeprazole was converted to pantoprazole given FDA
warning about interaction between omeprazole and clopidogrel
CORE MEASURES:
# CODE STATUS: Full (presumed)
# CONTACT: ___ (son): ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN cough
2. Aspirin 81 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Ezetimibe 10 mg PO DAILY
5. Furosemide 40 mg PO DAILY
6. Metoprolol Tartrate 50 mg PO BID
7. Omeprazole 20 mg oral DAILY
8. Ranexa (ranolazine) 500 mg oral BID
9. Rosuvastatin Calcium 40 mg PO QPM
10. Valsartan 160 mg PO BID
11. Isosorbide Mononitrate (Extended Release) 30 mg PO BID
12. Flovent HFA (fluticasone) 44 mcg/actuation inhalation BID
13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN Chest pain
14. Ferrous Sulfate 325 mg PO DAILY
15. U-500 Conc 70 Units Breakfast
U-500 Conc 60 Units Lunch
U-500 Conc 50 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Metoprolol Succinate XL 100 mg PO DAILY
2. Pantoprazole 40 mg PO Q24H
3. U-500 Conc 70 Units Breakfast
U-500 Conc 60 Units Lunch
U-500 Conc 50 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN cough
5. Aspirin 81 mg PO DAILY
6. Clopidogrel 75 mg PO DAILY
7. Ezetimibe 10 mg PO DAILY
8. Ferrous Sulfate 325 mg PO DAILY
9. Flovent HFA (fluticasone) 44 mcg/actuation inhalation BID
10. Furosemide 40 mg PO DAILY
11. Isosorbide Mononitrate (Extended Release) 30 mg PO BID
12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN Chest pain
13. Ranexa (ranolazine) 500 mg oral BID
14. Rosuvastatin Calcium 40 mg PO QPM
15. Valsartan 160 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
-Non-ST segment Elevation Myocardial Infarction
-Native and bypass graft coronary artery disease with chronic
total occlusions
-Restenosis of prior drug-eluting stent in the right coronary
artery and left anterior descending arteries
-Hypertension
-Hyperlipidemia
-Type 2 Diabetes mellitus with
-Hypoglycemia
-Chronic Kidney Disease, Stage 4
-Gastroesophageal reflux disease
-Possible reactive airway disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
WHY DID YOU COME TO THE HOSPITAL?
- You came to the hospital because you were experiencing chest
pain.
WHAT HAPPENED IN THE HOSPITAL?
- We gave you medication to help treat your chest pain
- We performed a percutaneous intervention (PCI) (a procedure
when we look for any blockages in the vessels in your heart and
treat them). We saw a blockage in the right coronary artery (one
of the main blood vessels that provides blood to your heart) and
we opened the vessel with a stent.
- We monitored you after the procedure. You had some chest pain
right after the procedure, but this resolved.
- We felt you were safe to go home with close follow up with
your outpatient providers.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Weigh yourself every morning, seek medical attention if your
weight goes up more than 2 lbs in 1 day or 3 lbs in 1 week.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
It was a pleasure participating in your care. We wish you the
best!
-Your ___ Care Team
Followup Instructions:
___
|
10203383-DS-23 | 10,203,383 | 21,087,991 | DS | 23 | 2139-07-01 00:00:00 | 2139-07-01 18:34:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever, cough
Major Surgical or Invasive Procedure:
Bone Marrow Bx ___
History of Present Illness:
___ y.o F with low grade follicular lymphoma with malignant
pleural effusion, presenting from ___ clinic with fever and
persistent cough. Note she has h/o follicular lymphoma
previously
treated with RCVP and bendamustine/Rituxan
now maintained on Rituxan c/b neutropenia, hepatitis B on
entecavir, hypothyroidism who was admitted on ___ for
productive cough and SOB x 1 month, found to have large R sided
pleural effusion on CXR s/p Chest tube, diagnosed with recurrent
lymphoma with malignant effusion, discharged ___.
The patient reports that over the last few days her husband had
"the flu" although he was not tested for the flu. She endorses a
cough which was unchanged since her prior admission. She denies
myalagias or neck pain or neck stiffness. She endorses back pain
in the middle of her spine. She denies history of spinal
injections.
She denies chest pain, abdominal pain, dysuria, diarrhea.
Repeat CXR today showed decrease in right sided pleural
effusion,
no obvious consolidations.
Note she was discharged after hospitalization ___ for
malignant pleural effusion/recurrent lymphoma. She had cough and
dyspnea on presentation, chest tube placed but loculation was
present, CT removed ultimately after pt had improvement of cough
and dyspnea. Recurrent lymphoma was demonstrated on pleural
fluid
analysis. Note hosp course c/b BRBPR with constipation, this was
felt to be related to external hemorrhoids and CBC stable. She
was seen in f/u by Dr. ___ on ___ and started on zydelig with
first dose ___.
ED COURSE:
T 99.7 HR 81 BP 93/55 RR 22 99% RA. Prior to transfer Tmax was
101.1 down to 99.7 before transfer. BP before transfer 103/64 HR
76 RR 21 99% RA. Her resp viral screen was Flu A positive.
Otherwise labs pertinent for neutropenia (___ 620) plts 166, Hct
27.6, lactate 2.0, Chem largely unremarkable, coags WNL. She was
given cefepime and vanc, last doses ___ at 5:30 pm pm. Also got
Tamiflu last dose ___ po at 8 AM. Resp viral testing
cancelled.
On arrival to the floor, using a telephone Mandarine
interpreter,
pt notes that she has not felt improved. She feels that the
cough
hasn't changed but her appetite is slightly better. Her back
pain
is resolved. No SOB/CP.
REVIEW OF SYSTEMS:
12 ROS negative except for what is mentioned above in HPI
Past Medical History:
Oncologic History:
Follicular Lymphoma - diagnosed ___
R-CVP followed by maintenance Rituximab - good response
___ - disease progression - grade I/III follicular
lymphoma with a follicular pattern in 100% of the node. Received
4 cycles of B/R followed by maintenance Rituximab, last dose
___: pleural fluid/tissue c/2 follicular lymphoma
Treatment History:
R-CVP ___
Maintenance Rituxan: ___ - ___ (8 doses)
C1 Bendamustine ___ (Rituxan held d/t leukocytosis)
C1 complicated by admission for Fever & Neutropenia.
C2 Bendamustine/Rituxan ___
C3 Bendamustine/Rituxan ___
C4 Bendamustine/Rituxan ___
Maintenance Rituxan
C1 Rituxan ___
C2 Rituxan ___
C3 Rituxan ___
C4 Rituxan ___
Past Medical History:
Hypothyroidism
Micropapillary Thyroid Cancer
Vitamin D Deficiency
Thalassemia Trait
External and Internal Hemorrhoids
Hepatitis B, on entecavir
Positive PPD
PSH:
Total thyroidectomy (___)
Latent TB infection: completed 9 months of INH therapy for this
(started ___ as well).
Social History:
___
Family History:
Father with stomach cancer. No h/o leukemia or lymphoma. Mother
may have had DM.
Physical Exam:
Admission PE:
VITAL SIGNS: 105/57 87 18 96% RA
General: NAD
HEENT: MMM, + shoddy CVL adenopathy, neck supple, OP
erythematous but no exudates or lesions
CV: RR, NL S1S2 no S3S4 MRG
PULM: + crackles b/l lower bases good air entry b/l,
incessantly
coughing intermittently productive sputum
GI: BS+, soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
NEURO: Grossly wnl
Discharge PE:
VS: Tc: 98 100/57 72 18 99% RA
GEN: NAD, resting comfortably in bed
HEENT: NCAT, Pupils equal and reactive, sclerae anicteric, OP
clear, MMM.
Neck: Supple, no JVD.
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
RESP: mild diminished breath sounds on right, stable
ABD: Soft, non-tender, non-distended, + bowel sounds.
EXTR: No lower leg edema, no clubbing or cyanosis
DERM: No active rash.
Neuro: grossly intct
PSYCH: Appropriate and calm.
Pertinent Results:
ADMISSION LABS
___ 06:00PM BLOOD WBC-5.3 RBC-5.00 Hgb-9.2* Hct-29.4*
MCV-59* MCH-18.4* MCHC-31.3* RDW-19.5* RDWSD-37.9 Plt ___
___ 06:00PM BLOOD Neuts-8* Bands-0 Lymphs-79* Monos-2*
Eos-0 Baso-0 Atyps-11* ___ Myelos-0 AbsNeut-0.42*
AbsLymp-4.77* AbsMono-0.11* AbsEos-0.00* AbsBaso-0.00*
___ 05:35AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-1+ Target-1+
Schisto-OCCASIONAL Tear Dr-1+
___ 06:00PM BLOOD Glucose-169* UreaN-16 Creat-0.6 Na-136
K-3.8 Cl-100 HCO3-23 AnGap-17
___ 06:00PM BLOOD ALT-19 AST-40 AlkPhos-53 TotBili-0.3
___ 06:00PM BLOOD Albumin-4.2 Calcium-8.4 Phos-3.8 Mg-2.1
PERTINENT LABS
___ 06:21PM OTHER BODY FLUID FluAPCR-POSITIVE *
FluBPCR-NEGATIVE
___ 06:35AM BLOOD IgG-<40*
___ 07:10AM BLOOD IgG-490*
___ 07:26AM BLOOD IgG-825
___ 08:40PM URINE Color-Yellow Appear-Clear Sp ___
___ 08:40PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 08:40PM URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-<1
CBC:
___ 06:00PM BLOOD Neuts-8* Bands-0 Lymphs-79* Monos-2*
Eos-0 Baso-0 Atyps-11* ___ Myelos-0 AbsNeut-0.42*
AbsLymp-4.77* AbsMono-0.11* AbsEos-0.00* AbsBaso-0.00*
___ 07:40AM BLOOD Neuts-15* Bands-1 Lymphs-78* Monos-6
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-0.58* AbsLymp-2.81
AbsMono-0.22 AbsEos-0.00* AbsBaso-0.00*
___ 06:35AM BLOOD AbsNeut-0.38*
___ 09:15AM BLOOD Neuts-1* Bands-0 Lymphs-90* Monos-2*
Eos-0 Baso-0 Atyps-7* ___ Myelos-0 AbsNeut-0.03*
AbsLymp-2.81 AbsMono-0.06* AbsEos-0.00* AbsBaso-0.00*
___ 07:10AM BLOOD AbsNeut-0.00*
___ 07:05AM BLOOD Neuts-0 Bands-0 Lymphs-96* Monos-4* Eos-0
Baso-0 ___ Myelos-0 AbsNeut-0.00* AbsLymp-2.11
AbsMono-0.09* AbsEos-0.00* AbsBaso-0.00*
___ 07:00AM BLOOD AbsNeut-0.00*
___ 07:26AM BLOOD Neuts-0 Bands-0 Lymphs-97* Monos-1* Eos-0
Baso-0 Atyps-2* ___ Myelos-0 AbsNeut-0.00* AbsLymp-1.98
AbsMono-0.02* AbsEos-0.00* AbsBaso-0.00*
___ 12:43PM BLOOD Neuts-0 Bands-0 Lymphs-91* Monos-3* Eos-0
Baso-0 Atyps-6* ___ Myelos-0 AbsNeut-0.00* AbsLymp-1.75
AbsMono-0.05* AbsEos-0.00* AbsBaso-0.00*
___ 06:45AM BLOOD Neuts-0 Bands-0 Lymphs-98* Monos-0 Eos-0
Baso-0 Atyps-2* ___ Myelos-0 AbsNeut-0.00* AbsLymp-1.80
AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*
___ 04:50PM BLOOD Neuts-0 Bands-0 Lymphs-84* Monos-6 Eos-0
Baso-0 Atyps-10* ___ Myelos-0 AbsNeut-0.00* AbsLymp-2.54
AbsMono-0.16* AbsEos-0.00* AbsBaso-0.00*
___ 09:15AM BLOOD Neuts-5* Bands-0 Lymphs-95* Monos-0 Eos-0
Baso-0 ___ Myelos-0 AbsNeut-0.12* AbsLymp-2.19
AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*
___ 06:05AM BLOOD Neuts-24* Bands-8* Lymphs-61* Monos-6
Eos-0 Baso-0 ___ Myelos-1* AbsNeut-1.09*
AbsLymp-2.07 AbsMono-0.20 AbsEos-0.00* AbsBaso-0.00*
___ 06:10AM BLOOD Neuts-40 Bands-1 ___ Monos-7 Eos-0
Baso-0 ___ Myelos-1* NRBC-3* AbsNeut-4.31
AbsLymp-5.36* AbsMono-0.74 AbsEos-0.00* AbsBaso-0.00*
DISCHARGE LABS
___ 06:10AM BLOOD WBC-10.5*# RBC-4.39 Hgb-7.9* Hct-25.7*
MCV-59* MCH-18.0* MCHC-30.7* RDW-19.7* RDWSD-37.9 Plt ___
___ 06:10AM BLOOD Neuts-40 Bands-1 ___ Monos-7 Eos-0
Baso-0 ___ Myelos-1* NRBC-3* AbsNeut-4.31
AbsLymp-5.36* AbsMono-0.74 AbsEos-0.00* AbsBaso-0.00*
___ 06:10AM BLOOD Glucose-107* UreaN-14 Creat-0.6 Na-139
K-3.7 Cl-106 HCO3-22 AnGap-15
___ 06:05AM BLOOD ALT-12 AST-16 AlkPhos-55 TotBili-0.3
___ 06:10AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.0
IMAGING:
CXR ___
Small right pleural effusion has decreased since ___.
Fullness in the right lower paratracheal station has also
decreased suggesting improvement in mediastinal adenopathy.
Fissural thickening or atelectasis adjacent to the right major
fissure persists, but atelectasis elsewhere in the lower lobe
has
improved. Left lung is grossly clear. Mild cardiac enlargement
is
unchanged, but pulmonary vasculature is normal and there is no
edema.
MICROBIOLOGY
___ 06:21PM OTHER BODY FLUID FluAPCR-POSITIVE *
FluBPCR-NEGATIVE
Brief Hospital Course:
___ w/ recurrent follicular lymphoma and malignant effusion who
is admitted to for febrile neutropenia found to have influenza A
#Fever with severe neutropenia: Patient has history of
follicular lymphoma and had recently started treatment with
idelalisib. She was found to be neutropenic in clinic, developed
a fever and was admitted. Upon admission patient was started on
cefepime. Work up revealed Flu A positive. Bacterial cultures
negative, CXR negative. UA negative. Pt was started on Tamiflu
on ___ and neupogen. Patient had an ANC of 0 from ___ to ___
when the patient's counts began to rise. Afebrile since ___.
ANC at time of discharge 1090. Underlying etiology was thought
to be due to idelalisib in addition to underlying viral
infection.
#Influenza A: - Continue Tamiflu until ___ for 28 day course
(___)
#Follicular Lymphoma: Initial worsening pancytopenia (see above)
due to idelalisib and influenza. Patient was treated as above.
CMV and Hep B viral load negative. Patient was given IVIG on
___ for low immunoglobulins. Allopurinol was held in
setting of normal uric acid. Bone marrow bx was performed on
___, results pending at time of discharge.
#Pleural Effusion: Clinically stable.
Hepatitis B: continue entecavir
Hypothyroidism: continue home meds
#idelalisib held
#Patient discharged on Tamiflu x4 total weeks. (Last day ___
# please f/u bone marrow bx
#Uric Acid 4.8 at time of discharge, please recheck and consider
restarting allopurinol
# CODE: Confirmed Full
# EMERGENCY CONTACT: ___ DAUGHTER WAY
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Entecavir 0.5 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Levothyroxine Sodium 150 mcg PO DAILY
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. Vitamin D 1000 UNIT PO DAILY
6. Allopurinol ___ mg PO DAILY
7. Bisacodyl 10 mg PO DAILY:PRN constipation
8. DiphenhydrAMINE 25 mg PO QHS insomnia
9. Docusate Sodium 100 mg PO BID:PRN constipation
10. Senna 8.6 mg PO BID:PRN constipation
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY:PRN constipation
2. DiphenhydrAMINE 25 mg PO QHS insomnia
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Entecavir 0.5 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Levothyroxine Sodium 150 mcg PO DAILY
7. Ondansetron 8 mg PO Q8H:PRN nausea
8. Senna 8.6 mg PO BID:PRN constipation
9. Vitamin D 1000 UNIT PO DAILY
10. OSELTAMivir 75 mg PO Q12H
RX *oseltamivir [Tamiflu] 75 mg 1 capsule(s) by mouth every
twelve (12) hours Disp #*26 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Influenza
Neutropenic fever
Grade IV neutropenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were admitted with fevers, cough and muscle aches. ___ were
found to have influenza along with a very low white blood cell
count. ___ were given Tamiflu to treat the flu, your lymphoma
medication idelalisib was held and ___ were given Neupogen to
help increase your white blood cell count. Your fevers, cough
and muscle aches resolved and your white blood cell count slowly
improved.
Followup Instructions:
___
|
10203383-DS-24 | 10,203,383 | 25,683,106 | DS | 24 | 2141-03-13 00:00:00 | 2141-03-13 17:22:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
febrile neutropenia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
PER ED NOTE:
___ with lymphoma on chemo who is presenting with fever. She
started having body pains progressively worsening over the past
month and urinary tract infection diagnosed by her pcp and
treated with oral antibiotics started yesterday. She noticed a
fever this morning, but was feeling unwell yesterday and may
have
had a fever then. She endorses increased urinary frequency,
diarrhea, nausea, vomiting and dysuria. She denies cough,
shortness of breath, abdominal pain.
Review of Systems: As above
ED Course:
Vitals: T101.0 HR96 BP110/77 RR20 100% RA
Febrile to 101.0, ANC 0.15, Urine with 28WBC, no nitrites.
Started on vanc and cefepime. UCx and BCx sent, CXR with no
focal
consolidation.
Exam in ED notable for: Ulceration on the lower lip, dry mucous
membranes without any other oral lesions appreciated. No CVVA
tenderness.
WBC 2.3, ANC 0.15
Hgb: 10.2
plt: 349
FluAPCR: Negative
FluBPCR: Negative
Urine with 28WBC, no nitrites
Lactate:1.9
On the floor, the patient complains of being very cold. She has
some sensation of being unable to completely empty her bladder,
as well as dysuria. She reports the fever started this morning,
and she vomited before coming to the ED. She is denying
abdominal
pain, chest pain, shortness of breath, or cough. She
additionally
complains of ___ knee and finger joint pain, which is worse than
at her recent rheumatologist appointment.
Interview conducted through phone interpreter as in-person
interpreter was not available.
Past Medical History:
PAST MEDICAL/SURGICAL HISTORY:
- relapsed follicular lymphoma
- 0.7 cm (T1) micropapillary thyroid cancer s/p resection ___,
with resulting hypothyroidism
- seronegative symmetrical synovitis with pitting edema
- beta thal trait
- vitamin D deficiency
- External and Internal Hemorrhoids, s/p banding
- positive PPD
\PAST ONCOLOGIC HISTORY:
Oncologic History:
--Follicular Lymphoma - diagnosed ___: R-CVP followed by
maintenance Rituximab - good response
--___ - disease progression - grade I/III follicular
lymphoma with a follicular pattern in 100% of the node. Received
4 cycles of B/R followed by maintenance Rituximab, last dose
___: pleural fluid/tissue c/2 follicular lymphoma,
started on idelalisib on ___
Treatment History:
R-CVP ___
Maintenance Rituxan: ___ - ___ (8 doses)
C1 Bendamustine ___ (Rituxan held d/t leukocytosis)
C1 complicated by admission for Fever & Neutropenia.
C2 Bendamustine/Rituxan ___
C3 Bendamustine/Rituxan ___
C4 Bendamustine/Rituxan ___
Maintenance Rituxan
C1 Rituxan ___
C2 Rituxan ___
C3 Rituxan ___
C4 Rituxan ___
-Idelalisib started ___ but held ___ in setting of
neutropenia/influenza.
-Restarted idelalisib on ___ after resolution of influenza
and recovery of counts.
Social History:
___
Family History:
Father with stomach cancer. No h/o leukemia or lymphoma. Mother
may have had DM.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 100.3 BP 107 / 60 HR83 RR18 98% Ra
Gen: shivering and under many blankets
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
LYMPH: No cervical, supraclavicular, axillary, or inguinal LAD
CV: Normocardic, regular. Normal S1,S2. No MRG.
LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND.
EXT: WWP. No ___ edema.
SKIN: No rashes/lesions, petechiae/purpura ecchymoses.
NEURO: A&Ox3.
LINES: PIV
DISCHARGE PHYSICAL EXAM
Vitals: 97.9 102/68 81 18 96 RA
Tmax 98.8
Gen: laying in bed, smiling to entrance
HEENT: No conjunctival pallor. No icterus. MMM. Lower lip with
0.3 cm red unroofed blister, smaller than yesterday
LYMPH: No cervical, supraclavicular, axillary, or inguinal LAD
CV: Normocardic, regular. Normal S1,S2. No MRG.
LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND.
EXT: WWP. No ___ edema.
SKIN: No rashes/lesions, petechiae/purpura ecchymoses.
NEURO: A&Ox3.
LINES: PIV
Pertinent Results:
ADMISSION LABS
___ 07:50AM BLOOD WBC-2.3*# RBC-5.68* Hgb-10.2* Hct-32.8*
MCV-58* MCH-18.0* MCHC-31.1* RDW-15.2 RDWSD-28.8* Plt ___
___ 07:50AM BLOOD Neuts-6.7* Lymphs-76.1* Monos-16.4*
Eos-0.4* Baso-0.4 Im ___ AbsNeut-0.15* AbsLymp-1.72
AbsMono-0.37 AbsEos-0.01* AbsBaso-0.01
___ 07:50AM BLOOD ___ PTT-29.1 ___
___ 07:50AM BLOOD Glucose-142* UreaN-9 Creat-1.0 Na-141
K-3.9 Cl-101 HCO3-23 AnGap-17
___ 07:50AM BLOOD Albumin-4.1 Calcium-9.2 Phos-2.8 Mg-1.7
RELEVANT IMAGING
CHEST (PA & LAT) Study Date of ___ 6:59 AM
FINDINGS:
PA and lateral views of the chest provided.Lungs are well
aerated. No focal consolidations. Right basilar atelectasis
and scarring is noted.
Cardiomediastinal and hilar silhouettes are stable. No
pulmonary edema. No pleural effusions. No pneumothorax.
IMPRESSION:
No focal consolidation.
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 6:12 ___
IMPRESSION:
1. No acute process within the abdomen or pelvis.
2. No abdominal or pelvic lymphadenopathy.
3. Mesenteric soft tissue haziness has significantly improved
compared to ___.
4. Please see separate report performed on the same day for
detailed
evaluation of the chest.
CT CHEST W/CONTRAST Study Date of ___ 6:13 ___
IMPRESSION:
1. Perifissural opacity in the right middle lobe is most likely
atelectasis. No focal consolidation to suggest pneumonia.
2. No lymphadenopathy.
3. Please see separate report performed on the same day for
detailed
evaluation of the abdomen pelvis.
COMPLETE GU U.S. (BLADDER & RENAL) Study Date of ___ 3:59
___
FINDINGS:
The right kidney measures 10.4 cm. The left kidney measures 10.1
cm. There is no hydronephrosis, stones, or masses bilaterally.
Normal cortical echogenicity and corticomedullary
differentiation are seen bilaterally.
The bladder is normal in appearance.
Prevoid volume of the bladder is 359.8 cc.
Postvoid volume of the bladder is 12.4 cc.
IMPRESSION:
1. Normal kidney and bladder ultrasound.
2. post void residual of 12.4 cc.
DISCHARGE LABS:
___:20PM BLOOD WBC-15.4* RBC-5.76* Hgb-10.3* Hct-33.8*
MCV-59* MCH-17.9* MCHC-30.5* RDW-16.6* RDWSD-31.5* Plt ___
___ 01:20PM BLOOD Neuts-59 Bands-6* ___ Monos-1*
Eos-0 Baso-0 ___ Metas-8* Myelos-6* Promyel-1*
AbsNeut-10.01* AbsLymp-2.93 AbsMono-0.15* AbsEos-0.00*
AbsBaso-0.00*
___ 01:20PM BLOOD Hypochr-1+* Anisocy-2+* Poiklo-3+*
Macrocy-NORMAL Microcy-3+* Polychr-NORMAL Ovalocy-2+*
Schisto-1+* Tear Dr-1+* Bite-1+* Ellipto-2+*
___ 01:20PM BLOOD WBC-PND Lymph-PND Abs ___ CD3%-PND
Abs CD3-PND CD4%-PND Abs CD4-PND CD8%-PND Abs CD8-PND
CD4/CD8-PND
___ 06:10AM BLOOD Glucose-108* UreaN-14 Creat-0.7 Na-146
K-4.1 Cl-105 HCO3-23 AnGap-18
___ 06:05AM BLOOD ALT-14 AST-9 LD(LDH)-235 AlkPhos-44
TotBili-0.4
___ 06:10AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.6
___ 01:20PM BLOOD IgG-97* IgA-10* IgM-<5*
Brief Hospital Course:
This is a ___ year old woman with recurrent follicular stabilized
on idelalisib who presents with febrile neutropenia, with
suspected urinary source.
# Febrile Neutropenia
# Urinary tract infection
# possible HSV
Patient presented with fever and in the setting of severe
neutropenia on ___, complaining of urinary frequency and
sensation of being unable to completely empty her bladder,
although no dysuria. She was seen by her primary care doctor on
___ and prescribed nitrofurantoin for presumed urinary tract
infection. Blood cultures as well as urine cultures here were
negative. She received a bone marrow biopsy no cultures were
obtained at the time. UA here was notable for 28 WBC and 1 RBC.
Blood cultures and urine cultures here were negative. She had a
bone marrow biopsy on ___ with results pending at discharge.
Additionally she had CT imaging of the chest, abdomen, and
pelvis which did not reveal gross progression of disease. She
was initiated on cefepime for neutropenic fever with presumed
urinary source. Due to her complaint of urinary frequency she
had a complete GU ultrasound which revealed no structural
abnormality. Post-void residual is 12 mL. Patient also had a
lower lip ulcer, and was initiated on acyclovir 800 mg 3 times
daily. She was transitioned to ciprofloxacin on ___ remained
afebrile for 24 hours prior to discharge. She will be discharged
on ciprofloxacin for ___s prophylactic acyclovir.
# Recurrent follicular lymphoma
# Neutropenia
Neutropenia was presumed to be due to idelalisib (Zydelig),
which was held in the setting of acute infection. Patient
received G-CSF with appropriate recovering counts. She should
continue her idelalisib at home and dose reduction and scheduled
G-CSF should be considered if appropriate. She was continued on
her home Bactrim prophylaxis. Results of bone marrow biopsy are
pending at discharge.
# Remitting seronegative symmetrical synovitis with pitting
edema (RS3PE): Continued on home prednisone 10 mg daily.
# Hepatitis B: Continued on home entecavir
# Thyroid cancer, s/p resection with resulting hypothyroidism:
Continued levothyroxine.
TRANSITIONAL ISSUES
NEW medications
- Ciprofloxacin HCl 500 mg PO/NG Q12H
- Acyclovir 400 mg PO/NG Q8H
[] To consider dose reduction of idelalisib if indicated
[] To consider scheduled G-CSF if indicated
[] Patient will continue on ciprofloxacin until ___
[] Patient was discharged on acyclovir prophylaxis
[] Bone marrow biopsy results pending at discharge
[] IgA; IgG; IgM; CD$pending at discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Entecavir 0.5 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Levothyroxine Sodium 100 mcg PO DAILY
4. Naproxen 375 mg PO Q12H
5. PredniSONE 10 mg PO DAILY
6. Ranitidine 150 mg PO BID
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
RX *acyclovir 400 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*90 Tablet Refills:*0
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*14 Tablet Refills:*0
3. Entecavir 0.5 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Naproxen 375 mg PO Q12H
7. PredniSONE 10 mg PO DAILY
8. Ranitidine 150 mg PO BID
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Neutropenic Fever
Urinary tract infection
HSV
SECONDARY DIAGNOSES
Recurrent follicular lymphoma
Remitting seronegative symmetrical synovitis with pitting edema
Hepatitis B
Thyroid cancer, S/P resection
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___!
WHY WAS I ADMITTED TO THE HOSPITAL?
You were admitted to the hospital because you had a fever and
your white blood cell count was low, which makes it easy for you
to get an infection.
WHAT HAPPENED WHEN I WAS IN THE HOSPITAL?
We gave you antibiotics to treat an infection in your urine. You
also got a pill to help treat the sore on your lip, which is
caused by a virus. In addition, you got a shot which helps your
body make more white blood cells to help fight infection.
WHAT SHOULD I DO WHEN I LEAVE?
You should continue to take your medicines as prescribed. They
are listed below for you. You should follow up with Dr. ___.
You should continue to take your chemotherapy pill.
We wish you all the best!
Your ___ care team
Followup Instructions:
___
|
10203665-DS-16 | 10,203,665 | 21,525,249 | DS | 16 | 2165-08-18 00:00:00 | 2165-08-18 15:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin
Attending: ___.
Major Surgical or Invasive Procedure:
Bedside swallow evaluation
attach
Pertinent Results:
___ 04:30AM BLOOD WBC-13.2* RBC-4.52 Hgb-13.6 Hct-42.6
MCV-94 MCH-30.1 MCHC-31.9* RDW-13.2 RDWSD-45.3 Plt ___
___ 05:30AM BLOOD WBC-12.4* RBC-4.13 Hgb-12.5 Hct-37.8
MCV-92 MCH-30.3 MCHC-33.1 RDW-13.2 RDWSD-44.3 Plt ___
___ 04:30AM BLOOD Glucose-115* UreaN-16 Creat-1.0 Na-143
K-4.2 Cl-105 HCO3-23 AnGap-15
___ 04:38AM BLOOD Lactate-1.7
___ 05:20AM URINE Blood-MOD* Nitrite-POS* Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR*
___ 05:20AM URINE RBC-<1 WBC-3 Bacteri-FEW* Yeast-NONE
Epi-<1
Urine culture with >100K CFUs of E coli
Blood cultlures pending, NGTD
CXR ___
Right lung base airspace opacity can represent atelectasis
however pneumonia
cannot be excluded correct clinical setting. Small bilateral
pleural
effusions.
Brief Hospital Course:
___ y/o F with PMHx dementia, urinary
incontinence, osteopenia, spinal stenosis, allergic rhinitis,
who
presented with chief complaint of right flank pain. ED course
notable for fever, with imaging concerning for possible
RLL PNA and urine culture growing E coli.
# CAP
Highest on the differential would be PNA vs. UTI. Symptoms in
the
ED were attributed to PNA given imaging showing atelectasis vs.
PNA in the R lower lung fields. This could be related to chronic
aspiration, which is supported by her husband's report of
coughing at night when she is lying on her back. Of note,
however, she did have CVAT on exam in the ED, and her UA, while
only with few bacteria, did have + nitrites. Thus, UTI is also a
consideration. Nevertheless, she has been started on CTX/azithro
which would cover both etiologies. Other potential causes for
fever alone would include viral illness. Could also consider CNS
process given encephalopathy and lethargy; however, given lack
of
neck stiffness or clear photophobia on exam, with more likely
cause as above, this seems less likely.
- continue to monitor abdominal exam (pt denied any pain when I
evaluated her)
- continue CTX/azithro (___) to cover for possible UTI vs.
PNA. Discharged on cefpodoxime and azithromycin for 4 more days
- continued bowel regimen, as constipation could worsen the
patient's symptoms
# ADVANCED DEMENTIA: No active issues. Not currently on
medications. Per report, pt did not tolerate Namenda in the
past. Pt was put on delirium precautions on admission and her
meds were crushed as she tends to chew rather than swallow them
whole.
TRANSITIONAL ISSUES
[ ] Meds were crushed as she tends to chew rather than swallow
them whole. Seen by SLP who otherwise feel she can swallow
normally
[ ] Take cefpodoxime and azithromycin for 4 more days for
pneumonia and UTI
>30 min spent on discharge planning including face to face time
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Azithromycin 250 mg PO DAILY Duration: 5 Doses
2. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
Please crush prior to taking
3. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 5 Days
4. Polyethylene Glycol 17 g PO DAILY
5. Senna 8.6 mg PO BID:PRN Constipation - First Line
Please crush in ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Pneumonia
UTI
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with back pain and fevers. You
were found to have a pneumonia on your chest x ray as well as a
urinary tract infection. We treated this with antibiotics and
you improved. Please follow up with your primary care doctor.
Followup Instructions:
___
|
10203920-DS-15 | 10,203,920 | 26,408,767 | DS | 15 | 2171-03-22 00:00:00 | 2171-03-23 11:42:00 |
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, diarrhea, tachycardia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old M w/ history of BPH who presented to
the ED after feeling unwell yesterday afternoon after eating
breakfast. He vomited multiple times and had stool incontinence.
His grandson-in-law is an MD and recommended he go to the ED
after his father reported his pulse to be in the 130s.
In the ED, initial vitals were T101.0 HR 122 BP 98/48 RR 22 SPO2
97% RA. His exam was notable for tachycardia, decreased breath
sounds in LLL, mild bilateral edema. Labs notable for WBC 2.2
with neutrophilic predominance, Hgb 12.5, plts 129, bicarb 19
with AG 18, Cr 1.5/BUN 35 --> 38/1.8, lactate 3.2 --> 2.1, trops
0.03 --> 0.01. UA non-inflammatory. Imaging notable for CXR with
"Patchy bibasilar opacities could reflect atelectasis with
aspiration and infection not excluded in the correct setting."
He was given IV ceftriaxone and azithromycin and 500 cc NS in
addition to home finasteride.
Upon arrival to the floor, patient reports that he had a few
episodes of vomiting which came on after eating. His last meal
was ___ afternoon when he ate fish and then did not eat or
drink much on ___ when he came in to the emergency room. He
has not had any cough. He never coughs or chokes on his food. No
sick contacts. Nausea/vomiting is resolved. No diarrhea. Had
normal BM yesterday. No fevers, CP, SOB, rhinorrhea, sputum
production or cough.
ROS: Positive per HPI. Remaining 10 point ROS reviewed and
negative
Past Medical History:
Benign prostatic hyperplasia
Social History:
___
Family History:
Father with cardiac disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
PHYSICAL EXAM:
VITAL SIGNS: 98.1 PO 106 / 64 80 20 96 Ra
GENERAL: Well-appearing elderly male, appears younger than
stated
age, laying comfortably in bed
HEENT: NC/AT. PERRL. EOMI. MMM.
NECK: Supple
CARDIAC: RRR. Nl s1/s2 No m/r/g
LUNGS: CTAB. No w/r/r. No respiratory distress
ABDOMEN: Soft. Non-tender, non-distended. Normoactive bowel
sounds.
EXTREMITIES: No ___
NEUROLOGIC: AAOx3. CN II-XII intact. Sensation to LT intact x4
ext. Strength ___ x4 ext.
SKIN: Warm, well-perfused, no rashes
DISCHARGE PHYSICAL EXAM:
VITALS: T 97.2 | BP 110/50-60s | HR 60-70 | RR 18 | spO2 98% RA
GENERAL: Elderly man sitting in chair reading newspaper.
HEENT: Pupils equally round and reactive, oral mucosa moist and
without lesions, no cervical or supraclavicular lymphadenopathy.
CARDIAC: Regular rate, regular rhythm with occasional missed
beats, no murmurs appreciated.
LUNGS: Breathing comfortably on room air, clear bilaterally.
ABDOMEN: Soft, non-distended, non-tender, no masses or
hepatosplenomegaly appreciated.
EXTREMITIES: Warm and well perfused, no lower extremity edema.
NEUROLOGIC: Alert and oriented, CNII-XII grossly intact, walking
with assistance.
SKIN: No rashes noted on exam.
Pertinent Results:
===============
ADMISSION LABS
===============
___ 02:00PM BLOOD WBC-2.2* RBC-3.91* Hgb-12.5* Hct-37.3*
MCV-95 MCH-32.0 MCHC-33.5 RDW-13.3 RDWSD-46.6* Plt ___
___ 02:00PM BLOOD Neuts-93.4* Lymphs-4.9* Monos-0.9*
Eos-0.4* Baso-0.0 Im ___ AbsNeut-2.09 AbsLymp-0.11*
AbsMono-0.02* AbsEos-0.01* AbsBaso-0.00*
___ 02:00PM BLOOD Ret Aut-1.3 Abs Ret-0.05
___ 02:00PM BLOOD Glucose-139* UreaN-35* Creat-1.5* Na-143
K-4.0 Cl-106 HCO3-19* AnGap-18
___ 02:00PM BLOOD ALT-13 AST-25 CK(CPK)-114 AlkPhos-50
TotBili-0.5
___ 02:00PM BLOOD CK-MB-1 cTropnT-<0.01 ___ 02:00PM BLOOD Albumin-3.3* Calcium-7.8* Phos-2.0*
Mg-1.6
===============
PERTINENT LABS
===============
___ 05:46AM BLOOD Glucose-113* UreaN-38* Creat-1.8* Na-143
K-3.7 Cl-108 HCO3-17* AnGap-18
___ 08:00PM BLOOD cTropnT-0.03*
___ 10:47PM BLOOD CK-MB-1 cTropnT-0.01
___ 05:46AM BLOOD Iron-11*
___ 06:35AM BLOOD Calcium-8.0* Phos-2.6* Mg-2.0
___ 05:46AM BLOOD TSH-0.88
===============
DISCHARGE LABS
===============
___ 06:35AM BLOOD Glucose-102* UreaN-35* Creat-1.3* Na-147
K-3.9 Cl-110* HCO3-24 AnGap-13
==================
STUDIES/PATHOLOGY
==================
CXR ___: IMPRESSION: Patchy bibasilar opacities could reflect
atelectasis with aspiration and infection not excluded in the
correct setting.
============
MICROBIOLOGY
============
URINE CULTURE (Final ___: NO GROWTH.
Blood cultures ___: No growth to date
Brief Hospital Course:
SUMMARY: Mr. ___ is a ___ year old M with history of BPH
presenting with nausea and vomiting found to have likely viral
gastroenteritis and resulting dehydration, pancytopenia, and
type II NSTEMI.
# Gastroenteritis
# Nausea/vomiting
Patient presenting with fevers, tachycardia, N/V, and
leukopenia. Initial concern for PNA, so patient given 1x doses
of azithromycin and ceftriaxone, which were later stopped with
CXR not concerning for PNA and lack of respiratory symptoms.
Lipase and LFTs normal, not concerning for acute pancreatitis or
biliary process. He was given IV fluids for resuscitation. He
was tolerating PO intake and had resolution of his nausea and
vomiting on discharge.
# Pancytopenia
Patient with anemia one year ago, but presented with new
thrombocytopenia and leukopenia. ___ be in the setting of sepsis
+ volume resuscitation. No history or lab findings concerning
for acute malignant process. Absolute retic count is 0.05 and
iron low at 11, so likely iron deficiency, although MDS also on
differential diagnosis.
[] Repeat CBC w/ diff on ___, ___
[] Consider Hematology referral if pancytopenia persists
[] Consider iron supplementation
# ___
Cr up to 1.8 from last known baseline of 1.2. Likely ___ volume
loss from diarrhea. Improved to 1.3 after IVF resuscitation.
[] Repeat Chem 10 on ___, ___
# Type II NSTEMI
Patient with no CP but mild troponin leak to 0.03 that resolved.
EKG with
V1-V2 ST-segment elevations that were stable throughout course.
Q waves also noted.
[] Consider outpatient stress test, aspirin, and statin if in
line with goals of care
CHRONIC PROBLEMS:
------------------
# BPH
Continue homed tamsulosin + finasteride
# Vitamin D deficiency
Continued home vitamin D
# B12 deficiency
Continued home b12
TRANSITIONAL ISSUES:
--------------------
[] Repeat CBC w/ diff on ___, ___
[] Consider iron supplementation
[] Consider Hematology referral if pancytopenia persists
[] Consider outpatient stress test, aspirin, and statin if in
line with goals of care
ADVANCED CARE PLANNING:
# CODE: full (confirmed)
# CONTACT: HCP, ___
Relationship: son
Phone number: ___
Cell phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyanocobalamin 1000 mcg PO DAILY
2. Vitamin D ___ UNIT PO DAILY
3. Finasteride 5 mg PO DAILY
4. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Cyanocobalamin 1000 mcg PO DAILY
2. Finasteride 5 mg PO DAILY
3. Tamsulosin 0.4 mg PO QHS
4. Vitamin D ___ UNIT PO DAILY
5.Outpatient Lab Work
Labs: CBC w/ diff, Chem10
Date: ___
ICD-9 code: ___.0
Please fax results to ___ ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Acute gastroenteritis
Dehydration
Acute kidney injury on chronic kidney disease
SECONDARY DIAGNOSIS
Type II NSTEMI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because were having nausea and
vomiting.
You were given IV fluids because your labs showed you were
dehydrated. You were checked for any signs of infection in your
lungs, urine, and blood, which were negative. You were monitored
to make sure your symptoms had resolved and that you could
tolerate eating and drinking, which you did.
Please follow up with your primary care doctor within 7 days of
discharge. Please try to stay hydrated at home and call your
doctor if you symptoms come back. Please get labs drawn on
___.
We wish you all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10204466-DS-10 | 10,204,466 | 27,259,697 | DS | 10 | 2147-04-03 00:00:00 | 2147-04-03 17:41:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Pravachol / Niacin
Preparations
Attending: ___.
Chief Complaint:
Atrial Fibrillation
Major Surgical or Invasive Procedure:
___ Cardioversion
History of Present Illness:
___ y/o F PMH paroxysmal atrial fibrillation, h/o PE, HTN who
comes into the ED with 4 days of palpitations, sOB, and feeling
weak.
The patient reported that it is difficult for her to determine
exaclty how her atrial fibrillation felt during its onset, but
she reports that it typically presents with the feeling of a
fast, irregular heart that lasts approximately ___ days and
resolves on its own and she would intermittently take an add'l
50mg when she remembers it.
Over the past 4 days, the patient has noted increasing
palpitations and weakness which is consistent with her previous
episodes of atrial fibrillation. She did not take add'l
metoprolol. The difference between this episode and previous
episodes is that she felt lightheaded which she typically has
not. She believed that the rhythm would self terminate as it
had some many times before, but when it persisted without relief
for 4 days she went to ___ where she was found to be in afib
with rate in ___ and hypotenisve to 90/60, but repeat was
126/76. She did report some pain between her shoulder blades.
She denied any chest pain, SOB, DOE, orhopnea, PMD.
In the ED, initial vitals were 2 97.4 85 134/67 18 98%. Labs
were unremarkable with the exception of INR of 2.5. Troponin was
negative <0.01. EKG showed afib 65bpm. NA 1mm STD V3, <1mm STE
V4. c/w prior CXR showed potential RL base opacity. Atrius
cardiology was consulted who recommended admission to ___ for
potential cardioversion in am. HR:66 BP120/50 RR:14 99%
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK
FACTORS:(+)Diabetes,(+)Dyslipidemia,(+)Hypertension
h/o PE
OSTEOPENIA
CORONARY ARTERY DISEASE, UNSPEC VESSEL TYPE
HEADACHE - MIGRAINE, OCULAR
PULMONARY NODULES / LESIONS - MULT
LIVER MASS
Congenital anomaly of optic disc
Pseudophakia
Cataract
OHT (ocular hypertension)
Advanced directives, counseling/discussion
PAF (paroxysmal atrial fibrillation)
Atrial fibrillation
Social History:
___
Family History:
Mom and ___ with CAD unknown type, Father ___ CA, No family
history of early MI, arrhythmia, cardiomyopathies, or sudden
cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION EXAM:
====================
VS: T=97.6 BP=140/87 HR=56 RR=18 O2 sat=99%RA
General: Well-appearing, appears younger than her stated age
HEENT: Sclera anicteric, PERRL, EOMI
Neck: No appreciable JVP, No cervical LAD
CV: Irregular, Nl S1,S2 No appreciable MRG
Lungs: CTAB no wheezes, crackles, rhonchi
Abdomen: Soft, NABS, NT/ND
Ext: trace b/l ___ edema
Neuro: CNII-XII grossly intact, sensation grossly intact
Skin: No rashes, but few ecchymoses on legs
PULSES: 2+ DP
DISCHARGE EXAM:
=====================
SINUS RHYTHM IN ___
General: Well-appearing, appears younger than her stated age
HEENT: Sclera anicteric, PERRL, EOMI
Neck: No appreciable JVP, No cervical LAD
CV: regular, Nl S1,S2 No appreciable MRG
Lungs: CTAB no wheezes, crackles, rhonchi
Abdomen: Soft, NABS, NT/ND
Ext: trace b/l ___ edema
Neuro: CNII-XII grossly intact, sensation grossly intact
Skin: No rashes, but few ecchymoses on legs
PULSES: 2+ DP
Pertinent Results:
ADMISSION LABS:
=================
___ 01:30PM BLOOD WBC-8.1 RBC-4.84 Hgb-13.9 Hct-41.5 MCV-86
MCH-28.7 MCHC-33.5 RDW-13.4 Plt ___
___ 01:30PM BLOOD ___ PTT-41.9* ___
___ 01:30PM BLOOD Glucose-91 UreaN-33* Creat-1.1 Na-140
K-4.2 Cl-100 HCO3-27 AnGap-17
DISCHARGE LABS:
==================
___ 08:00AM BLOOD Glucose-96 UreaN-33* Creat-0.9 Na-143
K-3.8 Cl-103 HCO3-29 AnGap-15
___ 08:00AM BLOOD WBC-7.4 RBC-4.80 Hgb-13.7 Hct-42.2 MCV-88
MCH-28.5 MCHC-32.5 RDW-13.5 Plt ___
IMAGING:
============
___ CXR:Very subtle opacity in the right lung base, which
overlaps with the underlying rib and could represent
atelectasis, pneumonia is also possible in the right clinical
setting.
Brief Hospital Course:
___ y/o F PMH paroxysmal atrial fibrillation, h/o PE, HTN who
comes into the ED with 4 days of palpitations, sOB, and feeling
weak found to be in afib with RVR who was successfuly
cardioverted to sinus rhythm on ___.
ACTIVE ISSUES:
=================
# A.Fib: Last TSH checked ___ 3.21. Patient symptomatic with
lightheadedness which is a new associated symptom with her PAF
given that her typical symptom is palpitations. Currently rate
controlled with metoprolol and anticoagulated with coumadin
CHADS2=2 (cannot find record of TIA/CVA or it would be 4). She
was monitored on telemetry with her home metoprolol dosing and
her rates were in the ___ on telemetry. She was continued on
her digoxin. She underwent successful cardioversion to sinus
rhythm on ___ and should have EKG checked at next outpatient
procedure.
.
CHRONIC ISSUES:
=================
# HTN: Chlorthalidone given relative hypotension and restarted
upon discharge. Her irbesartan was substituted for losartan
given nonformulary and irbesartan was restarted on discharge.
.
# h/o PE: Continued on coumadin for anticoagulation.
TRANSITIONAL ISSUES:
======================
# EKG as outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. chlorthalidone *NF* 12.5 mg Oral daily
2. Digoxin 0.125 mg PO DAILY
3. Warfarin 3.75 mg PO DAILY16
4. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE HS
5. Metoprolol Succinate XL 150 mg PO DAILY
hold for SBP<100, HR<50
6. Metoprolol Tartrate 25 mg PO DAILY:PRN palpitation
7. Vitamin D 1000 UNIT PO DAILY
8. irbesartan *NF* 75 mg Oral daily
9. Nitroglycerin SL 0.3 mg SL PRN chest pain
10. Magnesium Oxide 400 mg PO DAILY
Discharge Medications:
1. Digoxin 0.125 mg PO DAILY
2. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE HS
3. Metoprolol Tartrate 25 mg PO DAILY:PRN palpitation
4. Nitroglycerin SL 0.3 mg SL PRN chest pain
5. Vitamin D 1000 UNIT PO DAILY
6. Warfarin 3.75 mg PO DAILY16
7. Chlorthalidone *NF* 12.5 mg ORAL DAILY
8. irbesartan *NF* 75 mg Oral daily
9. Magnesium Oxide 400 mg PO DAILY
10. Metoprolol Succinate XL 150 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:Atrial Fibrillation
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 here at ___
___.
You came to the hospital because you had an irregular heart rate
called atrial fibrillation which you have had previously. This
time the atrial fibrillation made you more lightheaded and
lasted longer than it previously had. You underwent
cardioversion to make your heart rate regular again that was
successful.
No changes were made to your medications.
Followup Instructions:
___
|
10204710-DS-13 | 10,204,710 | 21,766,133 | DS | 13 | 2152-04-11 00:00:00 | 2152-04-21 16:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Bicycle accident
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ presented to ___ after a bicycle accident. He had
a ___ minute loss of consciousness according to his wife, and he
believes that he passed out on his bike and then crashed. He was
complaining primarily of left collarbone pain on arrival. He had
scattered abrasions over all extremities and a laceration on his
head.
Past Medical History:
Primary Sclerosing Cholangitis
Osteopenia
Social History:
___
Family History:
Sister has ___, paternal grandmother had "liver problems."
Physical Exam:
Admission exam:
===========================
Pulse 107 BP: 144/81 GCS 15
Appearance: Lying in stretcher, NAD but appears to be in pain
with movement
Eyes: L eyebrow abrasion
ENT: L ear scant blood, abrasion over R lip
Neck: WNL
Resp: WNL
CV: WNL
Chest: WNL
GI: WNL
GU: WNL
Lymph: WNL
MSK: Tender to palpation L distal clavicle
Skin: Scattered abrasions
Discharge exam:
===========================
98.3 122 / 74 ___
Gen: NAD
HEENT: Sutured L eyebrow laceration, Right upper lip abrasion
Neck: Supple
CV: RRR, no murmur
Resp: CTAB, breathing comfortably on room air
Abd: Soft, nontender, nondistended
MSK: Tender to palpation over left Clavicle
Skin: Scattered abrasions
Pertinent Results:
___ 02:30PM BLOOD WBC-16.4* RBC-4.85 Hgb-13.6* Hct-40.1
MCV-83 MCH-28.0 MCHC-33.9 RDW-12.7 RDWSD-38.5 Plt ___
___ 02:30PM BLOOD ___ PTT-27.4 ___
___ 02:30PM BLOOD UreaN-19 Creat-1.2
___ 02:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:39PM BLOOD Glucose-82 Lactate-1.8 Na-140 K-4.7
Cl-105 calHCO3-21
Imaging:
CXR ___:
1. Superiorly displaced left midclavicular fracture.
2. Fractures of the left second through fifth ribs. No definite
pleural
effusion or pneumothorax.
3. Low lung volumes with bibasilar atelectasis.
CT C-spine ___. Nondisplaced fractures of the posterior left second and third
ribs.
2. No acute fracture or traumatic malalignment in the cervical
spine..
CT head ___. No acute intracranial process.
2. Left supraorbital scalp laceration. No underlying fracture.
CT chest ___. Comminuted, displaced fracture of the midportion of the left
clavicle.
2. Multiple nondisplaced left-sided rib fractures involving the
left second
through fifth ribs including segmental fractures of the left
second through
fourth ribs.
3. Focal intrahepatic biliary dilation in segment 4 of the liver
of unclear
etiology. Recommend further evaluation on a nonemergent basis
with MRCP if no
relevant prior imaging has been previously obtained.
Xray shoulder/clavicle ___. Superiorly displaced left mid clavicle fracture with
approximately 12 mm of
override between fracture fragments. No dislocation.
2. Nondisplaced left second posterior rib fracture and minimally
displaced
left third posterior rib fracture.
Brief Hospital Course:
Mr. ___ was admitted to the hospital on ___ for pain control
and observation with his multiple rib fractures and clavicle
fracture. His left eyebrow laceration was irrigated and sutured
in the emergency department. Orthopedics was consulted for his
clavicle fracture and recommended a trial of nonoperative
management for 14 days with follow up in the orthopedic trauma
clinic. He was placed in a sling and instructed in its use. He
was also evaluated by ___, who found that he was functioning
near his baseline. On ___, his pain was well controlled, he was
using his incentive spirometer, he was breathing comfortably on
room air, he was able to ambulate around the floor
independently, and he was discharged home with follow up
arranged with his primary care physician and the orthopedic
trauma clinic.
Medications on Admission:
None
Discharge Medications:
1. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left clavicle fracture
Left ___ ribs fractures
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 ___
following your bicycle accident. You are recovering well and are
now ready for discharge. Please follow the instructions below to
continue your recovery:
* Your injury caused four rib fractures and a clavicle fracture
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).
Followup Instructions:
___
|
10204908-DS-12 | 10,204,908 | 20,439,008 | DS | 12 | 2188-02-14 00:00:00 | 2188-02-14 14:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tetanus Vaccines & Toxoid
Attending: ___
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ history of non-resectable gall bladder adenocarcinoma who is
s/p exploratory laparotomy, primary repair or duodenal
perforation, subtotal cholecystectomy, and placement of wall
stents for obstruction four months ago presenting with several
days of worsening abdominal pain, chills, and lethargy. She
recently had an outpatient CT showing showing metastasis to the
omentum and multiple fluid collections in the liver concerning
for abscesses. Per review of the patient's notes, it appears
that she was recommended to present to the ED previously for
inpatient admission and IV antibiotics. However the patient
refused admission and she was convinced to at least take PO
antibiotics as an outpatient. As such, she was managed on
Augmentin but over the past several days she has developed
sweats, worsening pain, and fatigue despite her antibiotic use
which caused her to present to the ED today.
She denies diarrhea, nausea, vomiting, frank fevers, headache.
She states that she has continued taking PO without difficulty.
She endorsed pruritus but denied changes in her skin or eye
color. She has continued to have brown stools. She denied CP
and SOB.
In the ED she was noted to have WBC of 31 with 20% bands, fevers
to 101.6, tachypnea to 28, and tachycardia to 128. She had a
lactate of 6.5 and elevated LFTs. She was empirically started
on Vanc/Zosyn for a biliary source of infection and was given
3L. Her SBPs were in the ___ intially on arrival and improved
to the 120s with fluids while her HR were in the 120s and is now
in the ___. Her lactate improved to 2.1 and she was admitted to
the MICU.
Review of systems:
(+) Per HPI
Past Medical History:
* Metastatic, non-resectable gallbladder cancer per HPI. She
has refused chemotherapy and radiation that were recommended and
has sought non-allopathic treatment.
* ? GERD
* HTN
* S/p tonsillectomy and appendectomy
Social History:
___
Family History:
Three brothers deceased of unknown cause
Physical Exam:
EXAM ON ADMISSION:
============================
Vitals: T: 97.5 BP: 138/78 P: 80 R: 18 O2: 100% RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, dry MM, oropharynx clear
Neck- supple, JVP not elevated
Lungs- Clear to auscultation with decreased BS at the bases
CV- Tachycardic, regular, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- Soft, moderate RUQ tenderness, non-distended, bowel
sounds present, no rebound tenderness or guarding, liver
palpable below costal margin
GU- foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, strength full through upper and lower
extremities
EXAM ON DISCHARGE:
=============================
VITALS: RR 16
General: Alert, oriented, easily arousable to voice, less
diaphoretic than before
HEENT: OP clear
CV: RRR
Chest: adequate air entry/chest expansion, no respiratory
distress
Abd: Continues to be distended and TTP
Pertinent Results:
LABS ON ADMISSION:
================================
___ 06:40PM NEUTS-78* BANDS-20* LYMPHS-1* MONOS-1* EOS-0
BASOS-0 ___ MYELOS-0
___ 06:40PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL TARGET-OCCASIONAL
___ 06:40PM PLT SMR-NORMAL PLT COUNT-196
___ 06:40PM WBC-31.7*# RBC-3.77* HGB-10.5* HCT-33.5*
MCV-89 MCH-27.8 MCHC-31.2 RDW-16.4*
___ 06:40PM ALBUMIN-2.7*
___ 06:40PM LIPASE-21
___ 06:40PM ALT(SGPT)-154* AST(SGOT)-113* ALK PHOS-576*
TOT BILI-3.4*
___ 06:40PM GLUCOSE-145* UREA N-45* CREAT-1.6*
SODIUM-128* POTASSIUM-4.4 CHLORIDE-91* TOTAL CO2-19* ANION
GAP-22*
___ 06:53PM LACTATE-6.5*
___ 09:11PM URINE AMORPH-FEW
___ 09:11PM URINE HYALINE-12*
___ 09:11PM URINE RBC-1 WBC-3 BACTERIA-FEW YEAST-NONE
EPI-0
___ 09:11PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-2* PH-5.5
LEUK-NEG
___ 09:11PM URINE COLOR-AMBER APPEAR-Hazy SP ___
___ 10:37PM LACTATE-2.1*
PERTINENT LABS:
==================================
___ 07:05AM BLOOD ___ PTT-31.8 ___
___ 01:21AM BLOOD cTropnT-<0.01
___ 01:21AM BLOOD Hapto-331*
___ 01:51AM BLOOD Lactate-1.9
___ 01:21AM BLOOD ALT-227* AST-396* LD(LDH)-582*
AlkPhos-402* TotBili-2.4*
___ 01:45PM BLOOD WBC-22.8* RBC-3.07* Hgb-8.7* Hct-27.4*
MCV-89 MCH-28.4 MCHC-31.9 RDW-16.9* Plt ___
MICROBIOLOGY:
==================================
___ 6:45 pm BLOOD CULTURE #2 SOURCE: VENIPUNCTURE.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
FROM ___ ORGANISM #1.
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
ESCHERICHIA COLI.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
FROM ___ ORGANISM #2. SECOND MORPHOLOGY.
ENTEROBACTER CLOACAE COMPLEX.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
FROM ___ ORGANISM #3.
ENTEROCOCCUS FAECIUM.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___-___#4 ___.
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
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Anaerobic Bottle Gram Stain (Final ___: GRAM
NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
GRAM POSITIVE COCCI IN CHAINS.
Reported to and read back by ___ AT 11:14AM ON
___.
___ 6:40 pm BLOOD CULTURE #1 SOURCE: VENIPUNCTURE.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Cefepime sensitivity testing confirmed by ___.
ESCHERICHIA COLI. ___ MORPHOLOGY. FINAL SENSITIVITIES.
Cefepime sensitivity testing performed by ___.
ENTEROBACTER CLOACAE COMPLEX. FINAL SENSITIVITIES.
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.
Cefepime & Piperacillin/Tazobactam sensitivity testing
performed
by ___.
ENTEROCOCCUS FAECIUM. 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..
Daptomycin = 4.0 MCG/ML.
Daptomycin Sensitivity testing performed by Etest.
KLEBSIELLA PNEUMONIAE.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___-___
#2 ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| | ENTEROBACTER
CLOACAE COMPLE
| | |
ENTEROCOCCUS FAE
| | | |
AMIKACIN-------------- <=2 S <=2 S
AMPICILLIN------------ =>32 R =>32 R =>32 R
AMPICILLIN/SULBACTAM-- =>32 R =>32 R
CEFAZOLIN------------- =>64 R =>64 R
CEFEPIME-------------- 2 S I S
CEFTAZIDIME----------- 16 R 16 R =>64 R
CEFTRIAXONE----------- =>64 R =>64 R =>64 R
CIPROFLOXACIN---------<=0.25 S <=0.25 S <=0.25 S
DAPTOMYCIN------------ S
GENTAMICIN------------ =>16 R =>16 R <=1 S
LINEZOLID------------- 2 S
MEROPENEM-------------<=0.25 S <=0.25 S 1 S
PENICILLIN G---------- =>64 R
PIPERACILLIN/TAZO----- 8 S 8 S R
TOBRAMYCIN------------ =>16 R =>16 R <=1 S
TRIMETHOPRIM/SULFA---- <=1 S 4 R <=1 S
VANCOMYCIN------------ =>32 R
Anaerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___ (___) 6:35AM
___.
Aerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
GRAM POSITIVE COCCI IN CHAINS.
Reported to and read back by ___ AT 11:14AM ON
___.
IMAGING:
==================================
___ RUQ US:
HISTORY: Unresectable gallbladder adenocarcinoma, sepsis and
liver abscesses.
Worsening clinical status and rising lactate.
COMPARISON: Ultrasound ___, CT ___.
FINDINGS:
There is a large subcapsular fluid collection along segments 7
and 8 of the
right lobe measuring 14 cm SI x 10 cm AP x 8.4 cm TV. The
collection has
complex internal echoes dependently and more anechoic fluid
superiorly. The
three hypoechoic liver lesions have increased in size. In
segment 8 there is
a 3 x 3.2 x 3.4 cm lesion adjacent to the collection. There is
a large 8.4 x
8.4 x 7.2 cm hypoechoic lesion in the right lobe. More
superiorly in the
right lobe there is a 3.1 x 2.3 x 3.7 cm hypoechoic lesion. The
main, left,
and anterior right portal veins are patent. The left posterior
portal vein is
not visualized. CBD stent and pneumobilia are again seen.
IMPRESSION:
1. Large subcapsular area along segments 7 and 8,complex and
hence, probable
abscess.
2. Increasing size of 3 hyperechoic liver lesions.
___ CT ABD/PELVIS:
Final Report
HISTORY: Bile duct cancer. Evaluate for metastatic and local
disease.
TECHNIQUE: Axial helical MDCT images were obtained through the
abdomen and
pelvis before and after administration of Omnipaque intravenous
contrast and
oral contrast scanning in the early arterial phase, portal
venous phase and a
delayed phase. Multiplanar reformatted images in coronal and
sagittal axes
were generated.
DLP: 1241 mGy-cm
COMPARISON: CT abdomen pelvis dated ___
FINDINGS:
The bases of the lungs are clear. The visualized heart and
pericardium are
notable for coronary artery calcifications and a small
pericardial effusion
which is new from prior.
CT abdomen: There are 3 rim enhancing hypodense lesions within
the liver
containing fluid and air consistent with hepatic abscesses. One
in segment 7
measures 18 x 14 mm (3: 20), one in segment ___ measures 13 x 13
mm (3: 27),
and one in segment 8 measures 17 x 21 mm (3: 16). There is
surrounding
parenchymal hyperemia.
Pneumobilia is present with 2 biliary metal stents in place. The
previous
internal external drain has been removed. The degree of biliary
dilatation
has decreased compared to the prior study.
A hypoenhancing mass in the gallbladder fossa has increased in
size now
measuring at least 5.5 x 5.1 x 6.7 cm with 2 fiducials noted
within it. There
is unchanged loss of the fat plane between the tumor and the
duodenum, as well
as new loss of fat plane between the tumor and the hepatic
flexure of the
colon concerning for tumor invasion. No air is seen within the
tumor to
suggest fistula. The omental metastases anterior to the liver
have
significantly increased in size, the largest of which measuring
2.6 x 4 cm (3:
39) is new. Mesenteric nodules as well as nodularity along the
left pericolic
gutter are also concerning for metastases. There is a new small
amount of
ascites.
There is unchanged dilatation of the pancreatic duct up to 6 mm.
The pancreas
is otherwise unremarkable. There is stable thickening of the
left adrenal
gland. The spleen and right adrenal gland 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
diverticulosis without evidence of diverticulitis. The
intraabdominal
vasculature demonstrates moderate atherosclerotic calcification.
A fat
containing periumbilical hernia is again noted.
CT pelvis: There is a 2.7 x 2.9 x 0.9 cm mass that along the
anterior
superior aspect of the bladder concerning for a drop metastasis.
Ascites
tracks into the pelvis. The uterus and adnexa are unremarkable.
There is no
inguinal or pelvic wall lymphadenopathy.
Osseous structures: No lytic or sclerotic lesions suspicious
for malignancy
is present. Multilevel degenerative changes of the lower lumbar
and thoracic
spine are present.
IMPRESSION:
1. Three hepatic abscesses measuring up to 2.1 cm in segements
7 and 8.
2. Progression of disease with increase in size of mass in the
gallbladder
fossa which appears to be invading the duodenum and hepatic
flexure of the
colon, significant increase in the size and number of omental
metastases as
well as nodules in the mesentery, left pericolic gutter and a
drop metastasis
on the bladder.
3. Patent biliary stents in place with decrease in biliary
dilatation and
interim removal of internal external biliary drain.
4. Stable thickening of the left adrenal gland.
5. Small amount of ascites, new from prior study.
6. New small pericardial effusion.
Brief Hospital Course:
Ms. ___ is a ___ with a PMH of metastatic gallbladder
cancer s/p biliary stent placement, h/o duodenal perforation
related to her malignancy, and recent outpatient imaging
concerning for hepatic abscesses presenting with sepsis. She is
now being discharged to ___ for hospice care.
# Sepsis - On admission patient met all SIRS criteria and has a
suspected biliary/hepatic abscess source. She would be
stratified as severe sepsis given her lactate on admission and
she was responsive to fluids, with downtrending lactate s/p
fluid resuscitation. Initially, patient was started on broad
spectrum antibiotics with Vanc/Zosyn. After blood cultures grew
GNRs, Vancomycin was discontinued and GNR coverage was broadened
to Zosyn and Cipro. Patient had a RUQ U/S to assess known
hepatic abscesses and possibility of ___ guided drainage. RUQ
U/S showed three abscesses (largest 3cm) but too small to drain.
She continued to worsen despite broadening IV abx to IV
meropenem/Linezolid. Her liver abscesses continued to enlarge,
WBC continued to be high, lactate was rising, and she developed
a nonoperable large subcapsular liver hematoma. At this point,
given the lack of surgical or medical options to treat her
biliary obstruction, cancer, and liver abscesss, she was
converted to comfort measures only. This was done in conjunction
with her, her daughter (HCP ___, and her medical team.
# Abdominal pain - Once converting to CMO, she is being treated
with oxycodone liquid 20mg Q4H and oxycodone liquid ___
Q2H:prn pain.
# Acute kidney injury - Cr 1.6 from baseline of 0.6. Given her
overall presentation this is likely pre-renal in etiology and
improved with IV fluids. Once she was switched to CMO, her labs
were no longer trended.
Transitional Issues:
# Communication: ___ - Daughter and HCP, Phone:
___
# Code: DNR/DNI/Comfort measures only
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. HYDROmorphone (Dilaudid) 2 mg PO Q3H:PRN pain
2. Morphine SR (MS ___ 15 mg PO Q12H
3. Acetaminophen 650 mg PO Q4H:PRN pain, fever
4. Albuterol 0.083% Neb Soln 2 NEB IH Q4H:PRN sob
5. Ascorbic Acid ___ mg PO BID
6. Bisacodyl ___AILY:PRN constipation
7. magnesium hydroxide 400 mg (170 mg) oral daily:prn
constipation
8. Multivitamins W/minerals 1 TAB PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Fleet Enema ___AILY:PRN constipation
11. Zinc Sulfate 220 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Albuterol 0.083% Neb Soln 2 NEB IH Q4H:PRN sob
3. Docusate Sodium 100 mg PO BID
4. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB or wheeze
5. Lorazepam 0.5 mg PO Q4H:PRN anxiety or agitation
6. OLANZapine (Disintegrating Tablet) 2.5 mg PO TID:PRN
agitation
7. OxycoDONE (Concentrated Oral Soln) ___ mg PO Q2H:PRN pain
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Sarna Lotion 1 Appl TP QID:PRN dry skin, itch
10. Senna 1 TAB PO BID:PRN constipation
11. OxycoDONE (Concentrated Oral Soln) 20 mg PO Q4H
12. Bisacodyl ___AILY:PRN constipation
13. Fleet Enema ___AILY:PRN constipation
14. magnesium hydroxide 400 mg (170 mg) oral daily:prn
constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Liver abscesses
Sepsis
Cholangitis
SECONDARY DIAGNOSIS
Metastatic gallbladder cancer
Lactic acidosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because you had sepsis. This
was due to infections in your liver. This is related to the
blockage of your liver bile ducts by worsening gallbladder
cancer. At first, you were given very broad IV antibiotics.
However, your infection did not get better, your liver abscesses
continued to get worse, and you developed a large bleed inside
your liver, which was causing you a great deal of pain. Because
there is no treatment to cure your gallbladder cancer and you
did not want aggressive treatment, you were switched to comfort
measures only.
You are being discharged to ___, which is an inpatient
hospice care facility that will continue to provide comfort care
and pain medications.
Followup Instructions:
___
|
10205542-DS-21 | 10,205,542 | 23,664,114 | DS | 21 | 2193-05-26 00:00:00 | 2193-05-30 13:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Cipro / Prilosec / Lyrica / nifedipine
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F w/ history of multiple sclerosis, appendiceal
carcinoid (goblet cell carcinoid T3; diagnosed after lap appy
___ at ___, s/p right hemicolectomy/BSO (___ ___ "clean" lymph nodes, per patient report), thereafter
complicated by x2 SBO ___ & ___ managed nonop), followed
by lysis of adhesions in ___ ___. Patient
states that she woke up this morning around 7am with crampy
abdominal pain. She tried to use the commode and had a
pencil-thin stool without relief. The patient experienced x3
episodes of emesis since then. She denies any flatus for a
couple
days. She states that she recently vacationed in ___
where she did have an episode of emesis that proceeded her
feelings of anorexia. Feels that this is similar in presentation
to her prior SBOs. She denies any recent fevers, chills, chest
pain, or shortness of breath.
Past Medical History:
PMH: GERD, MS, h/o pyelonephritis, appendiceal carcinoma
PSH: lap CCY (___), spinal fusion C6-7, lap appy (___), R
hemicolectomy/BSO (___), LOA (___)
Social History:
___
Family History:
Maternal grandmother: stomach cancer; Mother: stroke in her
___; Father: healthy; ___: healthy
Physical Exam:
Admission Physical Exam:
Vitals: T 98.2, HR 74, BP 131/81, RR 18 100% RA
Gen: appears uncomfortable, nontoxic
CV: RRR
P: nonlabored breathing on room air
GI: soft, TTP in RLQ/periumbilical area and epigastric area; no
tap or shake tenderness; no peritoneal signs; no distention
appreciated
Ext: WWP, no CCE
Discharge VS:
98.1, 78, 101/60, 18, 95%ra
Gen: A&O x3, lying comfortably in NAD
CV: HRR
Pulm: LS ctab
Abd: soft, NT/ND
Ext: no edema
Pertinent Results:
___ 05:29AM BLOOD WBC-8.7 RBC-3.74* Hgb-11.4 Hct-36.2
MCV-97 MCH-30.5 MCHC-31.5* RDW-12.9 RDWSD-45.7 Plt ___
___ 01:20PM BLOOD WBC-10.4*# RBC-4.00 Hgb-12.5 Hct-38.1
MCV-95 MCH-31.3 MCHC-32.8 RDW-12.9 RDWSD-45.2 Plt ___
___ 05:29AM BLOOD Glucose-110* UreaN-5* Creat-0.7 Na-142
K-4.6 Cl-106 HCO3-28 AnGap-13
___ 01:20PM BLOOD Glucose-141* UreaN-6 Creat-0.8 Na-133
K-7.6* Cl-98 HCO3-21* AnGap-22*
___ 01:20PM BLOOD ALT-14 AST-44* AlkPhos-71 TotBili-0.2
___ 05:29AM BLOOD Calcium-8.9 Phos-4.2 Mg-2.2
Imaging:
___ - CT A/P:
Relative dilatation of several fluid-filled distal ileal loops
in
the right lower quadrant, leading up to the ileocolonic
anastomosis. Fluid and air are demonstrated within the large
bowel distal to the anastomosis. Findings may represent an
early or partial small bowel obstruction at the level of the
anastomosis.
Brief Hospital Course:
___ F w/ hx of multiple sclerosis, appendiceal carcinoid, right
hemicolectomy/BSO, and prior small bowel obstructions, who
presents with evidence of bowel obstruction on radiographic
imaging and physical exam. The patient was hemodynamically
stable. She was admitted for non-operative management. She was
placed on bowel rest, nasogastric tube decompression, IV fluid
resuscitation, and serial abdominal exams.
On HD2 the patient was endorsing bowel function and pain had
resolved. The nasogastric tube was removed and diet was
sequentially advanced as tolerated with good tolerability.
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 denied pain.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. She would reschedule her MRE study and
follow-up with her PCP and in the surgical clinic once the MRE
was completed.
..
Medications on Admission:
Wellbutrin XL 150 mg daily, Neurontin 300 mg TID,
Cymbalta 40mg daily; cyclobenzaprine 5 mg tablet oral
5mg/5mg/10mg daily,glatiramer [Copaxone] Copaxone 40 mg/mL
subcutaneous syringe 1 injection 3 times weekly, baclofen 10mg
qHS
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN Headache
2. Baclofen 10 mg PO QPM
3. BuPROPion XL (Once Daily) 150 mg PO DAILY
4. Copaxone (glatiramer) 40 mg/mL subcutaneous MWF
5. Cyclobenzaprine 5 mg PO BID
6. Cyclobenzaprine 10 mg PO DAILY
7. DULoxetine 40 mg PO DAILY
8. Gabapentin 900 mg PO TID
9. LORazepam 0.5-1 mg PO Q8H:PRN anxiety
Discharge Disposition:
Home
Discharge Diagnosis:
Partial 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 the hospital with a partial small bowel
obstruction. You had a nasogastric tube placed to help
decompress your bowels, were placed on bowel rest and received
IV fluids for hydration. You had return of bowel function, so
the tube in your nose was removed and you were started on a
regular diet which you are tolerating. You are now ready to be
discharged home to continue your recovery.
Please follow the discharge instructions below to ensure a safe
recovery at home:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
Followup Instructions:
___
|
10205544-DS-10 | 10,205,544 | 28,757,511 | DS | 10 | 2127-03-14 00:00:00 | 2127-03-14 15:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Motor Vehicle Collision
Major Surgical or Invasive Procedure:
ORIF right intra-articular distal radius fracture 2 or more
fragments with internal fixation.
History of Present Illness:
This patient is a ___ year old male s/p MVC. Patient restrained
driver high speed MVC with multiple significantly injured
passengers, requiring airlift from
scene. Positive airbag deployment. Does not fully recall
event,extricated by EMS. C/o pain in wrist, leg, and lower
abdomen.
Past Medical History:
-none-
Social History:
Pt works full time and is in school part-time for his MBA.
Physical Exam:
On Admission:
Constitutional: Comfortable, GCS 15, boarded and collared
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light
Ccollar in place, no TTP
Chest: Clear to auscultation, no CW TTP/crepitus
Cardiovascular: Regular Rate and Rhythm
Abdominal: Mild lower abd TTP
Rectal: Heme Negative
GU/Flank: no blood at meatus
Extr/Back: sig deformed R wrist, swollen R foot, pulses
intact throughout
Skin: 6cm curvilinear laceration distal aspect of R lateral
thigh
Neuro: Speech fluent, ___ intact
Psych: Normal mood
On Discharge:
General: Awake, alert and oriented to person place and time. No
acute distress.
Cardiovascular: Pulses intact, Regular rate and rhythm. No extra
heart sounds.
Pulmonary: Clear to auscultation
Abdomen: Soft, not tender, not distended
Extremities: Left lower extremity, casted, no erythema, digits
warm and wel perfused and sensate. Right lower extremity WNL.
Right upper extremity casted, dressings clean and dry.
Pertinent Results:
___ 03:35AM WBC-15.2* RBC-5.36 HGB-15.4 HCT-46.3 MCV-86
MCH-28.8 MCHC-33.3 RDW-12.5
Brief Hospital Course:
Mr. ___ was admitted to the hospital after a motor
vehicle collision. In the ED he received a trauma CXR, a CT of
his Head, a CT of his chest, a CT of his cervical spine, Lower
extremity plain films, Upper extremity plain films. This imaging
revealed revealed that his wrist was displaced completely
because of a distal radius fracture, and fractures involving the
base of the second, third, and
likely fourth metatarsals concerning for Lisfranc fracture
dislocation. The wrist was reduced surgically in the emergency
room. This provided an improvement in his median nerve symptoms
to the point in preop he had intact sensation. Given the
displacement and instability the patient was taken to the OR for
operative fixation, please see operative note for details. An
xray of his foot revealed a left foot metatarsal fracture, for
this he was fitted with an aircast. Post operatively, he was
transferred to the floor for observation. He did well and was
started on a clear liquid diet. He tolerated this well without
pain or nausea and was subsequently advanced to a regular diet.
On ___ the patient worked with occupational therapy and
physical therapy who cleared the patient for home with support.
On ___ the patient was afebrile, ambulating with his
crutches, and tolerating a regular diet. He was educated on his
post operative care and follow up and verbalized understanding
and agreement with this plan. On ___ Mr. ___ was
discharged home with ___ services.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4-6H Disp #*25 Tablet
Refills:*0
3. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [Natural Senna Laxative] 8.6 mg 1 tab by mouth
twice a day Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Right intra-articular distal radius fracture 2 or more
fragments.
Metatarsal base fracture (left ___ digits)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital after a MOTOR VEHICLE
COLLISION. You sustained trauma to multiple body parts. You
received a ORIF of your Right intra-articular distal radius
fracture with internal fixation of 2 or more fragments. You have
since done well and are ready to return home to continue your
recovery.
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers medications.
- 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.
WOUND CARE:
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Keep your right upper extremity splint on, clean, and dry at
all times until follow up.
ACTIVITY AND WEIGHT BEARING:
- Non-weight bearing right upper extremity with range of motion
of digits as tolerated
- Touch-down weight bearing left lower extremity.
- Keep your left lower extremity aircast boot on, clean and dry
at all times.
Followup Instructions:
___
|
10205925-DS-16 | 10,205,925 | 22,796,722 | DS | 16 | 2189-03-12 00:00:00 | 2189-03-12 18:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
back pain, fall, ?worsening of chronic lower extremity weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a ___ yo M who is s/p 3 spine surgeries at ___
for spinal stenosis who presents with worsening of baseline BLE
weakness after a fall from standing. He states evening prior to
presentation he was using his walker get to the bathroom when he
turned to sit on the toilet and fell to the ground. He was
unable to get up. When helped up by EMTs he was unable to walk
with his walker as usual. He has had baseline BLE weakness for
many years and patient notes right worse than left which is his
baseline and has had several surgeries on L spine that were
unsuccessful. He c/o low back pain on presentation and denies
any numbness, paresthesias, loss of bowel or bladder control.
In the ED, initial VS were: 97.6 95 150/90 16 96% RA. In the ED
he received gabapentin and metoprolol PO (home medications).
Labs were notable for BUN 26 Cr 1.4 (at baseline), INR 1.1,
normal WBC and plt, H/H of 12.4/38. Right knee XRAY did not show
fracture or dislocation. He had CT abd-pelvis without contrast
which showed per prelim read no acute intra-abdominal process
with degenerative spinal changes, spinal stenosis unchanged from
___. He also had MRI C-T-L spine which showed degenerative
changes, spinal canal stenosis, and at the level of T11-12,
there is a focal disk protrusion with a small annular tear which
severely narrows the spinal canal and impinges upon the spinal
cord which demonstrates mild edema. He was evaluated by
orthopedic team who recommended admission to Medicine for pain
control and ___ since the spine changes seen on imaging are
probably non-operative per ortho team. Per ortho exam, normal
rectal tone and no ___ anesthesia. Vitals prior transfer
to the floor were: 98.1 74 119/62 16 96%RA.
On arrival to the floor, patient denies back pain, CP, SOB,
palpitations.
REVIEW OF SYSTEMS:
(+) as in HPI
(-) fever, chills, night sweats, shortness of breath, chest
pain, abdominal pain, nausea, vomiting, diarrhea, constipation,
BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
___- admitted with Morganella GNR sepsis found to have
ampullary mass- bx twice wth negative pathology. The patient
declined further evaluation
- Inferior MI on ___. Treated with 2 DES and 1 BMS
to the RCA. He presented atypically with a feeling of gas and
wanting to burp.
Most recent stress ___
Moderate partially reversible defect in the inferior wall that
extends to the septum, new when compared to prior exam. Mild
septal hypokinesis.
EF of 48%.
-recent mechanical falls
-spinal stenosis
-hypercholesterolemia
-hypertension
-history of TIA (while on Vioxx) in ___
-chronic renal insufficiency (baseline Cr: 1.5-1.7)
-elevated CK (while on statin)
-cholecystecomy in ___
-appendectomy
-GERD
-Chronic urticaria
-Colon polyps seen in last colonoscopy ___.
Diverticulosis
-Hepatitis in 1950s.
-Multiple back surgeries with severe cervical spondylosis and
abnormal cervical medullary junction
Social History:
___
Family History:
There is no family history of premature coronary artery disease
or sudden death. No history of liver disease or other
hepatobiliary disease.
Physical Exam:
ADMISSION:
VS - 98.7 Temp F, BP 146/64, HR 72, R 12, O2-sat 96% RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - normal rate, irregular rhythm, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - warm, +1 pitting edema in ___ bilaterally up to
tibial tuberosity. no cyanosis. 2+ peripheral pulses (radials,
DPs)
LYMPH - no cervical LAD
SPINE - no midline or paraspinal tenderness
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ in upper extremities bilaterally, ___ in left lower
extremity, ___ in right lower extremity (per patient, it has
been like this for several years, not different from baseline).
Sensation better in the left lower extremity compared to right
lower extremity. No clonus. Toes upgoing bilaterally. DTRs 1+
and symmetric in both upper and lower extremities, gait exam
defered.
.
DISCHARGE:
VS - 98.1 148/70 76 18 96% RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - normal rate, irregular rhythm, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - warm, no cyanosis.
LYMPH - no cervical LAD
SPINE - no midline or paraspinal tenderness
GU - Foley in place
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ in upper extremities bilaterally, ___ hip flexion B/L, ___
knee extention, ___ knee flexion B/L, ___ dorsiflexion and
plantar flexion on L, 3+/5 dorisflexion and plantar flexion on R
(as per pt, it has been like this for several years, not
different from baseline). Sensation better in the left lower
extremity compared to right lower extremity. No clonus. Toes
upgoing bilaterally. could not actually ilicit patellar DTRs.
Pertinent Results:
___ 05:38AM BLOOD Hct-34.1*
___ 05:19AM BLOOD WBC-7.0 RBC-3.61* Hgb-10.7* Hct-33.3*
MCV-92 MCH-29.6 MCHC-32.1 RDW-13.2 Plt ___
___ 09:45AM BLOOD WBC-5.8 RBC-3.96* Hgb-11.7* Hct-36.7*
MCV-93 MCH-29.4 MCHC-31.8 RDW-13.3 Plt ___
___ 02:30PM BLOOD WBC-6.8 RBC-4.13* Hgb-12.4* Hct-38.0*
MCV-92 MCH-30.1 MCHC-32.7 RDW-13.2 Plt ___
___ 02:30PM BLOOD Neuts-71.9* Lymphs-17.1* Monos-6.5
Eos-4.2* Baso-0.3
___ 02:30PM BLOOD ___ PTT-40.7* ___
___ 05:19AM BLOOD Glucose-92 UreaN-28* Creat-1.4* Na-142
K-4.2 Cl-105 HCO3-23 AnGap-18
___ 09:45AM BLOOD Glucose-197* UreaN-24* Creat-1.5* Na-139
K-4.4 Cl-105 HCO3-25 AnGap-13
___ 02:30PM BLOOD Glucose-143* UreaN-26* Creat-1.4* Na-143
K-4.3 Cl-105 HCO3-25 AnGap-17
___ 05:19AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.3
___ 09:45AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.2
___ 11:58AM URINE Color-Yellow Appear-Clear Sp ___
___ 11:58AM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 11:58AM URINE RBC-150* WBC-1 Bacteri-NONE Yeast-NONE
Epi-0
___ 11:58AM URINE Mucous-RARE
.
___ urine Cx pending
.
___ EKG: Sinus rhythm with premature atrial complexes.
Delayed R wave transition. Non-specific ST segment changes in
the lateral and high lateral leads. Compared to the previous
tracing of ___ the ventricular rate is faster.
.
___ XRAY KNEE (AP, LAT & OBLIQUE) RIGHT: No acute fracture
or dislocation. Chondrocalcinosis. Extensive vascular
calcifications.
.
___ CT ABDOMEN:
1. No acute intra-abdominal process.
2. No acute fracture.
3. Severe degenerative changes of lower lumbar spine with
spinal canal stenosis, grossly similar to ___. Assessment of
nerve root involvement is limited and would be better assessed
by MRI.
.
___ MRI L-SPINE W/OUT CONTRAST:
HISTORY: ___ male, status post fall. Assess for cord
compression.
TECHNIQUE: Noncontrast multiplanar multisequence T1 and T2
weighted images were acquired through the lumbar spine.
Dedicated sagittal STIR images were also obtained per trauma
protocol.
COMPARISON: CT torso on ___.
FINDINGS: There are postsurgical changes in the posterior
paraspinous soft tissues. The conus medullaris terminates at
T12-L1. There is clumping of nerve roots, could represent
either post-surgical changes and/or sequela of prior
arachnoiditis.
There are moderate-to-severe multilevel degenerative changes.
There is significant loss of the disc spaces at L2-3 to L4-5.
In the prior CT torso in ___, there was vacuum gas at these
levels.
At T11-12, there is a large osteophyte or a calcified disc
protrusion. In combination with ligamentum flavum thickening,
there is significant spinal canal narrowing, resulting in cord
thinning and signal abnormality, compatible with chronic
myelomalacia. The osteophyte and the bony canal narrowing were
already evident in ___. There is severe bilateral neural
foraminal narrowing.
At T12-L1, there is no disc herniation. There is ligamentum
flavum thickening with facet arthropathy, resulting in mild
spinal canal narrowing. There is moderate-to-severe bilateral
neural foraminal narrowing.
At L1-L2, there is probable L1-2 left hemilaminectomy. There is
a left-eccentric disc protrusion, resulting in left lateral
recess narrowing. There is severe bilateral neural foraminal
narrowing.
At L2-3, there is a prominent disc protrusion. In combination
with facet arthropathy and ligamentum flavum thickening, there
is severe spinal canal stenosis. There is bilateral several
neural foraminal narrowing.
At L3-4, there is probable L3-4 right hemilaminectomy. There is
a prominent disc protrusion. In combination with facet
arthropathy and ligamentum flavum thickening, there is moderate
spinal canal stenosis. There is bilateral moderate-to-several
neural foraminal narrowing.
At L4-5, there is grade 1 anterolisthesis of L4 on L5. There is
a prominent disc protrusion. In combination with facet
arthropathy and ligamentum flavum thickening, there is severe
spinal canal stenosis. There is bilateral moderate-to-several
neural foraminal narrowing.
At L5-1, there is a prominent disc protrusion. In combination
with facet arthropathy and ligamentum flavum thickening, there
is moderate-to-severe spinal canal stenosis. There is bilateral
moderate neural foraminal narrowing.
There is no abnormal STIR hyperintense to suggest acute
fracture.
IMPRESSION:
1. Severe multilevel degenerative changes, already evident in
___, with multilevel severe spinal canal stenosis and severe
neural foraminal narrowing, as described above.
2. Appearance of chronic myelomalacia at T11-T12.
3. Clumping of the nerve roots, could represent post-surgical
changes or sequela of prior arachnoiditis.
4. No evidence of acute fracture or malalignment.
.
___ MRI C-SPINE AND T-SPINE:
HISTORY: ___ male, with lower extremity weakness.
Upgoing Babinski sign. Assess for cord compression.
TECHNIQUE: Noncontrast multiplanar multisequence T1 and T2
weighted images were acquired through the cervical, thoracic and
lumbar spine.
COMPARISON: Multiple prior studies with the latest MR lumbar
spine on ___ and MR cervical spine on ___.
FINDINGS: The image quality is mildly degraded by motion.
Within the confines of the study:
CERVICAL SPINE: There is overall no significant interval change
alignment in the cervical spine. There are grade 1 the
anterolisthesis of C5 on C6 as well as C7 on T1. There is no
loss of vertebral height. There is diffuse disc desiccation.
At the craniocervical junction, there is a large pannus,
measuring 1.5 cm in thickness and resulting in moderate
narrowing of the foramen magnum, similar to the ___ study.
At C2-C3, there is no disc herniation, spinal canal narrowing or
neural foraminal narrowing.
At C3-C4, there is a prominent disc bulge. In combination with
significant ligamentum flavum thickening, there is
moderate-to-severe spinal canal stenosis. However, there is no
significant cord deformity or cord signal abnormality. There is
moderate left neural foraminal narrowing but no significant
right neural foraminal narrowing.
At C4-C5, there is no disc herniation, spinal canal stenosis, or
neural foraminal narrowing.
At C5-C6, there is uncovering of the disc secondary to the grade
1 anterolisthesis. There is mild spinal canal narrowing,
improved from prior.
There is subtle cord signal abnormality with cord thinning,
reflecting minimal chronic myelomalacia. There is no
significant neural foraminal narrowing.
At C6-C7, there is a diffuse disc bulge. In combination with
ligamentum flavum thickening, there is mild spinal canal
stenosis. There is mild-to-moderate neural foraminal narrowing.
At C7-T1, there is uncovering of the disc from grade 1
anterolisthesis. In combination with ligamentum flavum
thickening, there is moderate spinal canal narrowing. There is
also mild-to-moderate bilateral neural foraminal narrowing.
THORACIC SPINE: The vertebral body height and disc height are
preserved. There is normal thoracic kyphosis.
A T1- and T2-hyperintense focus in the T4 vertebral body is
compatible with an intraosseous hemangioma.
At T6-T7, there is a prominent disc protrusion. In combination
with moderate focal ligamentum flavum thickening, there is
moderate-to-severe spinal canal narrowing.. When correlating
with the CT Torso in ___, the findings represent a partially
calcified ligamentum flavum hypertrophy, and largely unchanged .
At T7-T8 and T8-T9 and T9-T10, there are similar, but smaller
focal ligamentum flavum thickening.
At T11-T12, there is moderate loss of disc space and a large
posterior disc protrusion. In combination with significant
focal ligamentum flavum thickening, there is severe spinal canal
stenosis. Cord thinning with T2 hyperintense cord signal
represents chronic myelomalacia.
LUMBAR SPINE: Detailed description of multilevel severe lumbar
spinal canal stenosis and neural foraminal narrowing was already
given in the study 5 hours earlier. There are no significant
interval changes.
IMPRESSION:
1. No evidence of acute cervical and thoracic abnormality.
2. Multilevel degenerative changes. Large retro-odontoid
pannus, unchanged. T6-T7 and T11-T12 severe spinal canal
stenosis, secondary to combination of disc herniation and
ligamentum flavum thickening. Evidence of chronic myelomalacia
T11-12.
3. Please refer to the report of MR lumbar spine study
performed 5 hour earlier for detailed description of severe
multilevel lumbar spondylosis.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
___, HTN,HL, chronic low back pain, spinal stenosis s/p multiple
surgeries, presents with low back pain and worsening of
bilateral upper and lower extremity weakness after a fall from
standing.
# Spinal Stenosis with myelopathy causing weakness and pain:
Patient has had progressive weakness in upper and lower
extremities that has led to increased frequency of falls. MRI
showed multilevel degenerative changes, worse than on prior MRI,
with severe evidence of chronic myelomalacia. Findings did not
appear acute, and patient and orthopedist Dr. ___ that
surgery was not the preferable treatment. Based in part on
recommendation of physical therapy, we did not initially think
the patient was safe to be discharged home. We recommended
rehabilitation with intensive physical therapy to improve the
patient's strength, and case management found an ideal bed for
the patient at ___. However, the patient and his
family declined this rehab program, preferring instead to go
directly home. We explained our recommendations and concerns to
the patient and his family, and they understood these
recommendations and the reasons behind them. However, against
our medical advice, the patient declined the rehabilitation
program, and, instead, decided to receive physical therapy and
visiting nurse services at home.
# Hematuria / Urinary Retention: The patient had decreased urine
output on the first hospital day. Bladder scan showed 1L of
fluid in the bladder, and then after voiding, still >400cc urine
by bladder scan. The following morning the patient passed small
blood clots in his urine and PVR was ~50cc. Therefore, it was
thought that the urinary retention was due to hematuria with
blood clots. Tamsulosin was started. PVRs increased to the
400s again that night, so a Foley catheter was placed. Urine
was clear, and HCT was stable. No evidence of infection on U/A.
The patient will follow up with urology next week to have Foley
removed for voiding trial and for possible further investigation
of hematuria.
# HTN/CAD s/p DES and BMS to RCA ___: Asymptomatic. We
continued home ASA, plavix, metoprolol, pravastatin, and
losartan.
# Diastolic CHF: Chronic, stable. We continued home lasix per
home regimen ___.
# CKD: baseline Cr 1.5-1.7. Cr 1.4 on admission. Medications
were renally dosed (including gabapentin, which was decreased to
300 mg twice daily rather than 4 times daily.
# GERD: Continued home pantoprazole.
# Constipation: Patient had not had a BM in several days and
complained of severe constipation. We started the patient on an
aggressive bowel regimen, which resolved the constipation.
# Transitional Issues:
- Patient will follow up with urology for urinary retention and
hematuria.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Gabapentin 300 mg PO QID
3. Multivitamins 1 TAB PO DAILY
4. Nitroglycerin SL 0.3 mg SL PRN chest pain
5. Clopidogrel 75 mg PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Furosemide 20 mg PO 2X/WEEK (MO,TH)
___ and ___
8. Losartan Potassium 25 mg PO DAILY
9. Metoprolol Tartrate 12.5 mg PO BID
10. Pravastatin 40 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Furosemide 20 mg PO 2X/WEEK (MO,TH)
___ and ___
4. Gabapentin 300 mg PO Q12H
RX *gabapentin 300 mg 1 capsule(s) by mouth Q12 Disp #*60
Capsule Refills:*0
5. Losartan Potassium 25 mg PO DAILY
6. Metoprolol Tartrate 12.5 mg PO BID
7. Multivitamins 1 TAB PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. Pravastatin 40 mg PO DAILY
10. Nitroglycerin SL 0.3 mg SL PRN chest pain
11. Acetaminophen ___ mg PO Q6H:PRN pain
RX *acetaminophen 500 mg 2 tablet(s) by mouth Q6H PRN Disp #*180
Tablet Refills:*0
12. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily PRN Disp #*60
Tablet Refills:*0
13. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
14. Lactulose 30 mL PO Q6H:PRN constipation
RX *lactulose 10 gram/15 mL 30 mL by mouth Q6H PRN Disp #*1
Bottle Refills:*0
15. Milk of Magnesia 30 mL PO Q6H:PRN constipation
RX *magnesium hydroxide [Milk of Magnesia] 400 mg/5 mL 30 mL by
mouth Q6H PRN Disp #*1 Bottle Refills:*0
16. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram/dose 1 packet by mouth
daily PRN Disp #*30 Packet Refills:*0
17. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth BID PRN Disp
#*60 Tablet Refills:*0
18. Tamsulosin 0.4 mg PO DAILY
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
19. Bedside Commode
one 3-in-1 bedside commode for home use
20. Wheelchair
one 18-inch wheelchair with removable leg rests and foam cushion
21. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth Q4H PRN
Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home with Service
Facility:
___
Discharge Diagnosis:
Primary:
- spinal stenosis
- hematuria
- urinary retention
Secondary:
- coronary artery disease
- hypercholesterolemia
- hypertension
- chronic renal insufficiency (baseline Cr: 1.5-1.7)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane) under supervision of physical therapy; out of Bed with
assistance to chair or wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with weakness after a fall.
You were evaluated by physical therapy, who felt that you were
not safe to be discharged home. They recommended rehabilitation
prior to going home with intensive physical therapy to improve
your strength. Against our medical advice, you declined the
rehabilitation program. Instead, you will receive physical
therapy and visiting nurse services at home. Please follow the
instructions of physical therapy as to how to make your home a
safe place for you given your current abilities and limitations.
The orthopedic spine surgeon Dr. ___ you because your MRI
suggested that a disc was protruding into your spinal cord.
There were several other areas of disease in your spine.
Surgery is likely not an option, but you may follow up with Dr.
___ you would like to discuss this further. Otherwise,
please cancel the scheduled appointment with Dr. ___.
You had urinary retention (incomplete emptying of your bladder)
while you were here that was likely due to blockage from blood
clots in your urinary tract. There was no evidence of
infection. A Foley catheter was placed to allow drainage of the
urine from your bladder. Please follow up with urology as
instructed below. Urology will let you know if the catheter can
be removed and whether you require further testing to
investigate the cause of the blood in your urine. The visiting
nurse ___ help you take care of the Foley catheter.
Thank you for allowing us to take part in your care.
Followup Instructions:
___
|
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