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10205925-DS-17 | 10,205,925 | 24,483,928 | DS | 17 | 2189-03-28 00:00:00 | 2189-04-01 15:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ with PMH lumbar stenosis s/p 3 spine
surgeries at ___ for spinal stenosis, HTN, CAD, TIA, who
presents with acute worsening of his lower back pain. The pain
started this morning with sharp shooting pain in the lower back
that does not radiate down the legs. He had been admitted
___ with acute worsening of his pain and chronic lower
extremitiy weakness after a fall. He had an MRI at that time
that showed worsening multilevel degenerative changes, worse
than prior, with severe evidence of myelomalacia. He was seen by
ortho spine at that time, and since the findings were not felt
to be acute, it was not believed surgery would be a helpful
option. The primary team had discharged patient to rehab with
the intent for physical therapy as treatment of his symptoms.
However, he refused rehab placement and went directly home.
The patient's BLE weaknes, R>L, has been worsening over time and
has led to his frequent falls. He reports that at home he can no
longer walk. He is using a wheelchair to get around. He denies
loss of bowel or bladder control or new tingling or
numbness/weakness/pareshtesias. The pain in his back only exists
when he moves his back.
During his prior hospitalization, he also experienced hematuria
and urinary retention and was started on tamsulosin. He was
discharged to follow up with urology. During his urology visit,
it was presumed that his hematuria is likely related to
retention causing stretching of the bladder and prostate along
with straining with constipation. The patient declined further
imaging with cystocopy. He was discharged with a foley catheter
which was pulled at the urology appointment. He was instructed
to notify his PCP or go to the ED if he could not void following
the d/c of his foley. He reports no urinary retention or
hematuria at this time.
In the ED, initial vs were 98.3 HR: 120 BP: 180/110 Resp: 20
O(2)Sat: 95%RA. He had a spinal MRI with significant stenosis,
herniations and degenerative disease unchanged from prior. He
was given a dose of morphine 4mg IV, 3 doses of dilaudid 1mg IV,
and valium. He cannot recall if these improved his pain.
On arrival to the floor, patient reports was noted to be fairly
drowsy. A bit later, he was noted to be more awake but writhing
in pain any time he moved. He could not focus on answers to
question due to the pain. He voided with assistance into the
urinal approx 100cc.
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 ___.
-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 EXAM:
VS 98.9, 157/94, 110, 20, 94% on 2L
GEN Uncomfortable appearing elderly white male, A&Ox3
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, soft bibasilar rales
present, no ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP, 2+ pitting b/l ___ edema R>L, difficult to palpate ___
pulses due to edema
NEURO CN II-XII intact, exam limited due to back pain however it
is noted that he can move both upper extremities and can move
both toes on command. full sensation bilaterally.
SKIN no ulcers or lesions
DISCHARGE EXAM:
VS - 97.8, 99.1, 112/56, 91, 18, 95% on RA
GEN Uncomfortable appearing elderly white male, A&Ox3
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, soft bibasilar rales
present, no ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP, 2+ pitting b/l ___ edema R>L, difficult to palpate ___
pulses due to edema
NEURO CN II-XII intact, exam limited due to back pain however it
is noted that he can move both upper extremities and can move
both toes on command. full sensation bilaterally.
SKIN no ulcers or lesions
Pertinent Results:
ADMISSION LABS:
___ 12:50AM BLOOD WBC-9.2 RBC-3.91* Hgb-11.5* Hct-34.9*
MCV-89 MCH-29.5 MCHC-33.0 RDW-13.3 Plt ___
___ 12:50AM BLOOD Glucose-108* UreaN-20 Creat-1.3* Na-138
K-4.7 Cl-104 HCO3-22 AnGap-17
___ 06:15AM BLOOD Calcium-8.3* Phos-3.6 Mg-2.2
UA:
___ 12:47PM URINE Color-Yellow Appear-Clear Sp ___
___ 12:47PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-MOD
___ 12:47PM URINE RBC-3* WBC-9* Bacteri-NONE Yeast-NONE
Epi-0
___ 12:47PM URINE Mucous-RARE
___ 12:47PM URINE Hours-RANDOM UreaN-1006 Creat-152 Na-72
K-52 Cl-63
___ 12:47PM URINE Osmolal-645
DISCHARGE LABS:
___ 07:30AM BLOOD WBC-7.6 RBC-3.75* Hgb-11.1* Hct-33.7*
MCV-90 MCH-29.6 MCHC-32.9 RDW-13.6 Plt ___
___ 07:30AM BLOOD Glucose-135* UreaN-36* Creat-1.4* Na-138
K-4.7 Cl-104 HCO3-24 AnGap-15
___ 07:30AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.4
PERTINENT MICRO/PATH:
NONE
PERTINENT IMAGING:
MRI T/L SPINE:
The study is compared with the very recent non-enhanced MR
examinations of the lumbar spine dated ___, and cervicothoracic
spine, dated
___. There is no significant change since these recent
examinations.
Allowing for the limitations, above, as well as the moderate
thoracolumbar
S-scoliosis with rotatory component, levoconvex in the lumbar
spine, there is
no new vertebral compression or abnormality of alignment. There
is no
evidence of spinal epidural or subdural hematoma. There is
persistent focal
T2-hyperintensity associated with cord thinning at the T11-12
level, related
to severe multifactorial spinal canal narrowing and cord
compression, as
before. There is no new abnormality of cord signal through the
conus
medullaris. Following contrast administration, there is no new
pathologic
vertebral, paravertebral or epidural soft tissue,
leptomeningeal,
intramedullary or radicular focus of enhancement.
As thoroughly documented in the reports of the recent
examinations, there is
severe multilevel, multifactorial degenerative disease which, in
combination
with marked thickening and ossification of the ligamenta flava
and
superimposed on congenitally abnormal spinal canal geometry,
results in severe
canal stenosis with cord remodeling. This is most marked at:
The T6-T7 level where a prominent disc protrusion moderately
severely narrows
the ventral canal, indenting the spinal cord.
At T11-12, as above, a large disc-endplate spondylotic complex,
with marked
ligamentum flavum thickening, severely narrows the spinal canal,
compressing
the cord with resultant thinning and signal abnormality,
representing
established myelomalacia.
At L1-2, a disc-endplate spondylotic complex, eccentric to the
left, severely
narrows that subarticular zone and both neural foramina.
At L2-3, a prominent disc protrusion moderately narrows the
spinal canal.
Again demonstrated is the grade 1 degenerative anterolisthesis
of L4 on L5. At
both the L4-5 and L5-S1 level, disc-endplate spondylotic
complexes,
superimposed on the above factors severely narrow the spinal
canal with marked
central crowding of the traversing nerve roots and loss of the
normal
CSF-signal within the thecal sac. There is also severe neural
foraminal
narrowing at these levels, as before.
IMPRESSION: No acute abnormality and no change since the recent
studies of
___ and ___, highlighted by:
1. No evidence of thoracolumbar spinal epidural or subdural
hematoma.
2. Multilevel spinal cord compression with stable cord thinning
and signal
abnormality at the T11-12 level, representing established
myelomalacia.
3. Multilevel spinal canal and neural foraminal stenosis with
spinal cord
remodeling and exiting neural impingement, as documented
previously. There is
very severe lumbar spinal canal stenosis, particularly at the
L4-5 level.
4. No pathologic focus of enhancement.
Brief Hospital Course:
REASON FOR ADMISSION:
___ with PMH of severe lumbar spinal stenosis s/p 3 spine
surgeries and recently admitted for fall with worsening ___
weakness and back pain who now presents with uncontrolled back
pain on and off since d/c, acutely worsening this morning, and a
stable MR spine.
ACUTE ISSUES:
#Acute on chronic back pain: Pt with severe back pain initially
concerning for new cord compression. Urgent MR spine was
performed in ED which showed stable degenerative changes and
myelomalacia from his films during the last hospitalization. His
outpatient spine specialist, Dr. ___, was consulted during
this admission, who recommended starting a course of IV steroids
to reduce inflammation. (The patient cannot take NSAIDs due to
chronic kidney disease.) He received one day of IV steroids
followed by a 2 day course of oral prednisone. His pain has been
managed with low dose oxycodone, ativan, tylenol, and IV
dilaudid for breakthrough pain. Would continue low dose
oxycodone, ativan, and tylenol with goal to decrease doses, as
these can worsen patient's urinary retention. He was discharged
with plans for inpatient ___ and rehab, which he refused during
his last hospitalization.
#Urinary retention: Noted during previous hospitalization for
which foley cath was placed. He also developed hematuria, likely
secondary to traumatic foley. CT A/P was performed during last
admission, showing no concerning urologic findings. He did not
pass his outpatient voiding trial. He was seen by urology at
that time, who felt his retention was in part exacerbated by
severe constipation causing obstruction. We also feel that his
lumbar stenosis/myelomalacia may be contributing. A foley was
placed during this admission as well for urinary retention. He
was discharged with foley in place and will need to complete a
voiding trial in ten days or once oxycodone is no longer needed.
If fails this trial, will likely need foley replaced and would
need to contact outpatient urologist.
CHRONIC ISSUES:
# HTN/CAD s/p DES and BMS to RCA ___: Asymptomatic. Continued
home ASA, plavix, metoprolol, pravastatin, and losartan.
# CKD: Pt admitted with Cr slightly above baseline. Improved
with IV fluids and temporary stopping ___ and lasix. These were
restarted without complication.
# Diastolic CHF: Chronic, appears euvolemic on exam. Continue
home lasix ___ regimen.
# GERD: Continued home pantoprazole.
# Constipation: continued extensive outpatient bowel regimen and
uptitrated as needed for BM daily.
# Anemia: mild, at baseline. No signs of active bleeding or
hemolysis.
TRANSITIONAL ISSUES:
# Outpatient voiding trial; urology follow up.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Furosemide 20 mg PO 2X/WK (MO, TH)
hold for sbp <100
4. Gabapentin 300 mg PO Q 12H
hold for somnolence
5. Losartan Potassium 25 mg PO DAILY
hold for sbp <100
6. Metoprolol Tartrate 12.5 mg PO BID
hold for sbp <100 or hr <55
7. Multivitamins 1 TAB PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. Pravastatin 20 mg PO DAILY
10. Nitroglycerin SL 0.3 mg SL PRN chest pain
11. Acetaminophen ___ mg PO Q6H:PRN pain
12. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
13. Docusate Sodium 100 mg PO BID
hold for loose stools
14. Lactulose 30 mL PO Q6H:PRN constipation
15. Milk of Magnesia 30 mL PO Q6H:PRN constipation
16. Polyethylene Glycol 17 g PO DAILY:PRN constipation
17. Senna 1 TAB PO BID:PRN constipation
18. Tamsulosin 0.4 mg PO DAILY
19. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN pain
2. Bisacodyl 10 mg PO BID
3. Polyethylene Glycol 17 g PO BID constipation
4. Senna 2 TAB PO HS
5. Lidocaine 5% Patch 1 PTCH TD DAILY
6. Lorazepam 0.5 mg PO Q4H:PRN back pain
7. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone [Oxecta] 5 mg 0.5 (One half) tablet(s) by mouth q4
Disp #*10 Tablet Refills:*0
8. Aspirin 81 mg PO DAILY
9. Clopidogrel 75 mg PO DAILY
10. Docusate Sodium 100 mg PO BID
hold for loose stools
11. Furosemide 20 mg PO 2X/WK (MO, TH)
hold for sbp <100
12. Gabapentin 300 mg PO Q 12H
hold for somnolence
13. Lactulose 30 mL PO Q6H:PRN constipation
14. Losartan Potassium 25 mg PO DAILY
hold for sbp <100
15. Metoprolol Tartrate 12.5 mg PO BID
hold for sbp <100 or hr <55
16. Milk of Magnesia 30 mL PO Q6H:PRN constipation
17. Multivitamins 1 TAB PO DAILY
18. Nitroglycerin SL 0.3 mg SL PRN chest pain
19. Pantoprazole 40 mg PO Q24H
20. Pravastatin 20 mg PO DAILY
21. Tamsulosin 0.4 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Lumbar spinal stenosis
Secondary diagnosis:
Chronic kidney disease
Urinary retention
Hypertension
Chronic constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for control of your acutely worsening
back pain. You initially had an MRI of your spine, which showed
stable disease from your last hospitalization. The spine service
and neurology service were consulted. You were started on a
short course of steroids to reduce inflammation. You were also
given medications to treat your pain. Physical therapists worked
with you daily to try to improve your mobility. We now feel it
is safe for you to leave the hospital.
Also, during your stay, you were unable to fully empty your
bladder. A foley catheter was placed to help with voiding. You
will need to continue this for the next ten days or after
discontinuing your oxycodone. Afterwards you will need to have a
voiding trial to see if you are able to empty fully on your own.
We made the following changes to your medications:
START lidocaine patch
START lorazepam
INCREASE tylenol
INCREASE bisacodyl
INCREASE miralax
Followup Instructions:
___
|
10206108-DS-6 | 10,206,108 | 29,616,521 | DS | 6 | 2170-09-01 00:00:00 | 2170-09-01 08:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
assault, likely with knife and blunt object
Major Surgical or Invasive Procedure:
___ Repair of depressed skull fx with mesh
___ Knee I&D
___ suturing of facial and head lacerations
History of Present Illness:
___ assaulted, found on sidewalk by emergency personel with
multiple stab wounds to the face and head. Pt has poor
recollection of event: pt responded to a late night call for
auto work (has a 24hr auto service business) and was assaulted
upon arrival, + LOC, pt states he does not recall attack. Pt
complained of pain to head and R knee.
Past Medical History:
PMH: nephrolithiasis
PSH: lithotripsy
Medications: None
Allergies: None
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION: upon admission ___
HR: 94 BP: 158/124 Resp: 18 O(2)Sat: 100 Normal
Constitutional: Comfortable
HEENT: multiple lacerations to scalp/face/lips, Pupils
equal, round and reactive to light, Extraocular muscles
intact
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema, laceration to R
lateral lower leg and pretibial skin.
Skin: No rash, Warm and dry
Neuro: Speech fluent, MAE, strength/sensation intact
Psych: calm, , Normal mentation
___: No petechiae
Upon discharge: 97.7F, 76, 150/68, 18, 96% RA
Constitutional: Comfortable
HEENT: 3 right sided facial lacerations, sutured with good
closure, scalp lacs with staples, all C/D/I, Pupils equal, round
and reactive to light, Extraocular muscles intact
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema, R lower leg in
___
Skin: No rash, Warm and dry
Neuro: Speech fluent, MAE, strength/sensation intact
Psych: calm, , Normal mentation
___: No petechiae
Pertinent Results:
___ 12:45PM BLOOD Hct-22.3*
___ 05:45AM BLOOD WBC-9.9 RBC-2.70* Hgb-8.1* Hct-23.8*
MCV-88 MCH-29.9 MCHC-33.9 RDW-13.2 Plt ___
___ 05:15AM BLOOD WBC-9.1 RBC-2.81* Hgb-8.2* Hct-24.8*
MCV-88 MCH-29.3 MCHC-33.3 RDW-13.0 Plt ___
___ 01:41AM BLOOD WBC-12.1* RBC-4.32* Hgb-12.8* Hct-37.9*
MCV-88 MCH-29.7 MCHC-33.9 RDW-13.0 Plt ___
___ 01:47AM BLOOD Neuts-73* Bands-0 Lymphs-14* Monos-12*
Eos-0 Baso-0 Atyps-1* ___ Myelos-0
___ 05:45AM BLOOD Plt ___
___ 05:15AM BLOOD Plt ___
___ 01:47AM BLOOD ___ PTT-23.7* ___
___ 01:41AM BLOOD ___ 05:15AM BLOOD Glucose-118* UreaN-13 Creat-1.0 Na-139
K-4.0 Cl-101 HCO3-32 AnGap-10
___ 01:47AM BLOOD Glucose-149* UreaN-12 Creat-1.0 Na-139
K-3.9 Cl-105 HCO3-27 AnGap-11
___ 05:15AM BLOOD Calcium-8.3* Phos-1.6* Mg-2.1
___ 10:54AM BLOOD freeCa-1.05*
___: chest x-ray:
No acute intrathoracic process
___: c-spine x-ray:
1. No evidence of fracture or malalignment.
2. High-density fluid is partially imaged in the right maxillary
sinus.
Brief Hospital Course:
Mr. ___ was admitted to the Trauma ICU, and transferred to
the floor ___. Injuries and imaging as follows:
CXR: non acute
CT C-spine: negative for fracture
CT Head: depressed R frontal bone, R ZMC fx (non-displaced),
lateral maxillary fracture (non-displaced)
R Knee: med fem condyle fx
CT max/face: non-displaced ___ fracture with extension into
lateral maxilla
He was taken to the OR with neurosurgery on the morning of his
admission for repair of his depressed cranium. Please see
operative notes for details. Intraoperatively, orthopaedics was
consulted to assess the right medial femoral condyle fracture --
they debrided and irrigated the right knee and closed fixed the
distal femur fracture.
He was transferred back to the TSICU. Post-procedure CT Head
demonstrated post-op changes, resolution of the depressed skull
fracture. Pt continued to have benign neuro exam.
On the floor, pt's pain was well controlled on oral pain
medication. He tolerated a regular diet on soft foods, and was
WBAT, ROMAT on RLE, and was seen by ___ in house. Pt was seen by
OMFS, who evaluated his dental fractures and reviewed panorex
film. ___ was found to have 6 dental fractures, and will follow
up with a dentist upon discharge.
Day of discharge, pt was afebrile, comfortable, with pain well
controlled. His facial sutures were removed by plastic surgery.
He will f/u with his primary care doctor, ___,
orthopedic surgery, and plastic surgery after discharge. Plastic
surgery will follow his facial fractures and lacerations, which
___ and plastic surgery agree are non-operative.
Medications on Admission:
none
Discharge Medications:
1. chlorhexidine gluconate 0.12 % Mouthwash Sig: One (1) 30ML
Mucous membrane BID (2 times a day) for 2 weeks.
Disp:*28 1000ML(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. tramadol 50 mg Tablet Sig: ___ Tablets PO QID (4 times a
day).
Disp:*45 Tablet(s)* Refills:*1*
4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every ___
hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*2*
5. Dilaudid 2 mg Tablet Sig: ___ Tablets PO every ___ hours as
needed for severe pain: take only for very severe pain. Do not
drive or drink alcohol ever while taking this medicine.
Disp:*30 Tablet(s)* Refills:*0*
6. ibuprofen 200 mg Tablet Sig: ___ Tablets PO Q8H (every 8
hours) as needed for pain: Please take four tablets every 8
hours until ___. After ___, please take ___ tablets
every 8 hours as needed for pain .
Disp:*60 Tablet(s)* Refills:*1*
7. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day as
needed for constipation.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Assault:
Depressed fracture right frontal bone
Right zygomaticotemporal arch fracture
Right lateral wall of the maxillary sinus fracture
Minimally displaced fracture of medial femoral condyle
Multiple dental fractures
Multiple facial and scalp lacerations
Right knee laceration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
WBAT RLE
- ___ ___
- ___ brace unlocked to RLE
Discharge Instructions:
You were admitted to the ___ after having been reportedly
assaulted. You were found to have a skull fracture, a fracture
above your right knee, facial bone fractures, multiple
lacerations/stab wounds to your face, and a stab wound above
your right knee. Our neurosurgeons performed surgery in the
operating room to treat your skull fracture. Our plastic
surgeons repaired your lacerations, and our orthopedic surgeons
examined your knee. Our oral surgeons saw you for your broken
teeth and have recommeded mouth rinses and follow up with your
own dentist after discharge.
Please call your doctor or go to the emergency department if:
*You experience new chest pain, pressure, squeezing or
tightness.
*You develop new or worsening cough, shortness of breath, or
wheeze.
*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 an unusual discharge.
*Your pain is not improving within 12 hours or is not under
control within 24 hours.
*Your pain worsens or changes location.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*You develop any concerning symptoms.
General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 20
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please continue to
wear your leg brace over your right leg as directed. Please
also follow-up with your primary care physician.
Incision Care:
*Please call your surgeon or go to the emergency department if
you have increased pain, swelling, redness, or drainage from the
incision site.
*Avoid swimming and baths until cleared by your surgeon.
*You may shower and wash incisions with a mild soap and warm
water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Followup Instructions:
___
|
10206418-DS-22 | 10,206,418 | 27,759,864 | DS | 22 | 2195-06-21 00:00:00 | 2195-06-21 21:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right sided chest discomfort, shortness of breath, LLE edema
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with history of hypertension, hypothyroidism
and recent admission ___ to ___ for cholangitis secondary to
choledocolithiasis s/p multiple ERCPs with stone removal and
stent placement presenting from home with 2 days of right sided
chest discomfort, shortness of breath, and left lower extremity
edema.
Patient reports that the day prior to presentation she noticed
that her left lower leg was swollen. She states that he also
noticed that she developed progressive dyspnea on exertion that
she noticed when walking from the kitchen to the bedroom
yesterday. She states that when she became dyspneic, she noticed
a "knot" in her right lower rib cage that improved with rest.
She denies chest pain, diaphoresis, radiation of the rib cage
discomfort, nausea, vomiting, abdominal pain, fevers, or chills.
In the ED, initial vital signs were: 96.5 80 130/60 16 95% RA
- Exam was notable for: lungs clear, RUQ abdominal tenderness,
LLE edema
- Labs were notable for: WBC 14.3, H/H 9.1/27.9, plts 225, Na
136, BUN/Cr ___, ALT 42, AST 58, AP 176, total bili 0.5,
lipase 136, INR 1.2, lactate 1.9, troponin T 0.04 -> 0.05
- Imaging: LENIs demonstrated bilateral ___ DVTs, CTA Chest
demonstrated extensive bilateral PEs and extensive pneumobilia,
duct dilatation with stent, and multiple hepatic hypodensities.
- The patient was given: 1L NS and started on heparin gtt
- Consults: Cardiology was consulted in the ED and recommended
heparin gtt and admission to ___.
Vitals prior to transfer were: 98.7 71 121/53 18 99% Nasal
Cannula.
Upon arrival to the floor, patient denies chest pain, shortness
of breath, abdominal pain.
Past Medical History:
- Pulmonary emboli, bilateral submassive (___)
- DVT, bilateral (___)
- Choledocholithiasis c/b cholangitis s/p multiple ERCPs and CBD
stent
- Hypertension
- Hypothyrodism
- GERD
- Cataracts
- Hearing loss
- Insomnia
Social History:
___
Family History:
Both mother and father had MI. No family history of gallstones
to her knowledge.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 97.9 147/61 80 20 94% on 2L
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA.
NECK: Supple, JVP flat.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: Normal bowel sounds, soft, mildly tender to palpation
in lower quadrants bilaterally, non-distended, no organomegaly.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Without rash.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
DISCHARGE PHYSICAL EXAM:
VS: T 96.7(Ax)/98.1 | ___ | 115/52-139/51 | 18 | 97% 1L NC
General: Elderly woman, frail but NAD. A+O x3.
HEENT: PERRL. EOMI. MMM. Sclera anicteric
CV: +S1/S2. No murmurs
Lungs: CTAB. No crackles, wheezes, rhonchi.
Abdomen: Soft, nondistended. +BS. Minimal RUQ tenderness,
otherwise nontender.
Ext: WWP. ___ LLE edema. No RLE edema.
Neuro: CN2-12 intact. MAE equally.
Skin: No rashes or wounds.
Pertinent Results:
ADMISSION LABS:
___ 04:00PM BLOOD WBC-14.3* RBC-2.89* Hgb-9.1* Hct-27.9*
MCV-97 MCH-31.5 MCHC-32.6 RDW-13.2 RDWSD-46.1 Plt ___
___ 04:00PM BLOOD Neuts-81.8* Lymphs-9.6* Monos-7.2
Eos-0.1* Baso-0.3 Im ___ AbsNeut-11.69* AbsLymp-1.37
AbsMono-1.03* AbsEos-0.01* AbsBaso-0.05
___ 04:00PM BLOOD ___ PTT-25.5 ___
___ 04:00PM BLOOD Glucose-120* UreaN-27* Creat-1.3* Na-136
K-4.8 Cl-104 HCO3-23 AnGap-14
___ 04:00PM BLOOD ALT-42* AST-58* AlkPhos-176* TotBili-0.5
___ 04:00PM BLOOD Lipase-136*
___ 04:07PM BLOOD Lactate-1.9
KEY LABS:
___ 04:00PM BLOOD cTropnT-0.04*
___ 10:43PM BLOOD cTropnT-0.05*
___ 05:50AM BLOOD CK-MB-2 cTropnT-0.04*
___ 06:02PM BLOOD CK-MB-2 cTropnT-0.05*
___ 03:24AM BLOOD CK-MB-1 cTropnT-0.06*
DISCHARGE LABS:
___ 05:10AM BLOOD WBC-5.2 RBC-2.85* Hgb-8.7* Hct-27.9*
MCV-98 MCH-30.5 MCHC-31.2* RDW-14.1 RDWSD-50.5* Plt ___
___ 05:10AM BLOOD ___ PTT-53.1* ___
___ 05:10AM BLOOD Glucose-91 UreaN-12 Creat-1.0 Na-137
K-4.7 Cl-106 HCO3-24 AnGap-12
___ 05:10AM BLOOD Calcium-8.9 Phos-3.0 Mg-2.1
___ 05:10AM BLOOD ALT-17 AST-19 AlkPhos-96 TotBili-0.3
DirBili-0.1 IndBili-0.2
IMAGING/STUDIES:
___ BILATERAL ___ U/S:
1. Bilateral lower extremity acute deep venous thrombosis:
(i) Non-occlusive thrombus of the left common femoral vein and
complete
occlusive thrombus of the left superficial femoral, popliteal,
and calf veins.
(ii) Non-occlusive thrombus of the right posterior tibial vein,
and complete
occlusive thrombus of the right peroneal veins.
2. Moderate soft tissue edema in the left lower extremity.
___ CTA CHEST: IMPRESSION:
1. Extensive bilateral acute pulmonary emboli involving all of
the lobar arteries as well as multiple subsegmental and
segmental branches with evidence of right heart strain and
likely a right middle lobe pulmonary infarct.
2. Multiple hepatic hypodensities, particularly in right
hepatic lobe segment 5 with apparent rim enhancement that are
slightly larger since ___. Given the short interval
growth, abscess favored rather than a rapidly growing
metastasis.
3. Persistent but improved intrahepatic ductal dilatation after
the placement of a biliary stent with expected pneumobilia.
4. Mild dilation of the main pancreatic duct up to 5 mm with
tapering more distally, new or more conspicuous since the prior
exam, perhaps related to interval biliary stent placement.
5. Diverticulosis.
6. Bilateral renal cortical lesions are too small to
characterize on CT, statistically most likely cysts.
7. Mild left renal caliectasis without frank hydronephrosis.
8. Gallbladder fundal adenomyomatosis.
9. Known deep venous thrombosis in the lower extremities,
incompletely imaged and detailed on the ultrasound from the same
day.
___ ECHOCARDIOGRAM: The left atrium is normal in size. No
atrial septal defect is seen by 2D or color Doppler. The
estimated right atrial pressure is ___ mmHg. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). The estimated cardiac index is
normal (>=2.5L/min/m2). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). The right
ventricular cavity is mildly dilated with borderline normal free
wall function. There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload. 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. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is moderate pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of ___,
the right ventricle is dilated with signs of pressure/volume
overload, and the estimated pulmonary arterial pressure is
greater. Left ventricular systolic function is slightly less
vigorous.
___ Imaging LIVER OR GALLBLADDER US:
IMPRESSION: Two vague hypoechoic hepatic lesions in segment 4B/5
which likely corresponds to abnormalities identified on recent
abdominal CT. By imaging, these are more concerning for solid
hepatic lesions such as malignancy or metastatic disease,
however infection is still a possibility particularly given
history of cholangitis. Biopsy or attempted aspiration would be
technically difficult given imaging limitations and patient
immobility. Risk of procedure with intrahepatic biliary
dilatation should also be considered.
Brief Hospital Course:
___ female with history of hypertension, hypothyroidism,
and recent admission ___ for cholangitis secondary to
choledocholithiasis s/p multiple ERCPs with stone removal and
stent placement presenting with 2 days of RUQ abdominal
discomfort, shortness of breath, and left lower extremity edema,
found to be newly hypoxic with extensive DVTs/PEs without clear
evidence of hemodynamic instability.
=============
ACUTE ISSUES:
=============
# Submassive PE, DVTs: Newly hypoxic with extensive PEs without
hemodynamic instability. Potentially provoked in the setting of
recent hospitalization for severe sepsis that involved multiple
procedures. Not a candidate for NOACs based on eGFR and likely
GI bleeding. The patient was started on a heparin gtt as a
bridge to warfarin 1 mg daily. The patient's next INR should be
drawn ___.
# Hepatic hypodensities: Hypodensities with some rim
enhancement, concerning for hepatic abscess or infected biloma.
CBD stent in place but potentially only accessing right biliary
system with persistent (improved) biliary dilation; ERCP
evaluated and determined no intervention needed. No
leukocytosis, no fevers, or other signs of infection (but
questionable that patient could mount inflammatory response due
to advanced). ID initially recommended empiric coverage with
ceftriaxone and metronidazole, which she received for 2 days
before discontinuing given clinical stability and low suspicion
for infection. for further evaluation, obtained RUQ ultrasound
that demonstrated these liver lesions as solid-appearing and
concerning for malignancy. This was discussed at length with
both the patient and her son, who agreed that biopsy or any
invasive study would not be within her goals of care.
# Anemia, acute on chronic: Most likely upper GI source given
guaiac-positive dark tarry stools. Hgb improved to 9.1 on ___
from 7.3 on ___ after 1u pRBCs. Hemoglobin stable after that.
GI consulted for possible EGD but deferred as stable and
remained available in the event of subsequent drops in
hemoglobin, of which there were none. Started on pantoprazole
40mg BID, which was continued at discharge. This can be
continued after discharge for a duration up to the patient's
outpatient providers. Recommended to continue at least while on
anticoagulation.
# Troponinemia: Patient presented with modestly elevated
troponin in the setting of extensive PEs and EKG changes. Peak
Tpn=0.06, with CK-MB no greater than 2. ___ represent demand
ischemia and type II NSTEMI. However, troponin elevation is
difficult to interpret in the setting of patient's renal
dysfunction.
# ___ on CKD: Patient presented with Cr 1.3 from baseline 0.9,
most likely pre-renal. Worsening Cr to 1.4 on ___, which may
represent contrast injury from CTA on ___. Even at baseline,
patient's eGFR=20. Improved to 0.9 on ___.
# Transaminitis: Patient presents with hepatocellular pattern of
injury with only slightly elevated AP and stable total
bilirubin, which speaks against obstruction. Some AST may be
leak from myocyte necrosis in the setting of NSTEMI vs. growing
hepatic malignancy or abscess. Given clinical stability and
borderline normalization of LFTs, these were not trended
further.
# Hypertension: Only mildly hypertensive on presentation to
floor, then normotensive. Given concern for possible hemodynamic
compromise in the setting of PE, initially held antihypertensive
meds. Restarted slowly as pressures stabilized. Discharged on
Valsartan 80 mg daily. Atenolol was discontinued and was NOT
restarted at discharge given poor renal function and acceptable
blood pressures. Please note that atenolol should not be
restarted as it should not be given in CKD.
# Hypothyroidism: Continued home levothyroxine
# GERD: Continued home omeprazole
# Osteoporosis: Continued home calcitonin
# Recent cholangitis s/p ERCP: Pt will need repeat ERCP for
stent pull 4 weeks from prior discharge (approx. ___.
# CONTACT: ___
Relationship: Son
Phone number: ___
# CODE STATUS: DNR/DNI
=====================
TRANSITIONAL ISSUES:
=====================
[ ] Discharged on Warfarin 1 mg daily for goal ___ for
treatment of bilateral PE and DVTs.
[ ] Next INR check recommended ___ at rehab facility
[ ] Patient's PCP ___ follow her INR after discharge from rehab
[ ] Length will be ongoing as determined by her outpatient
providers
[ ] Atenolol discontinued in the setting of large PEs. Should
NOT be restarted due to her CKD.
[ ] Amlodipine discontinued (no longer needed to maintain BPs).
It may be restarted in the future if necessary.
[ ] Valsartan dosage was decreased to 80 mg daily from 160 mg
daily. It may be restarted in the future if necessary.
[ ] Started on pantoprazole 40mg BID due to guaiac-positive
stool with concern for ulcer or gastritis on anticoagulation.
This can be continued after discharge for a duration up to the
patient's outpatient providers. Recommended to continue at least
while on anticoagulation.
[ ] Patient has liver masses hypodense on imaging: malignancy
vs. abscess. Would not like to undergo biopsy. If becomes
febrile or hypotensive, low threshold to consider sepsis and
transfer to hospital for further management.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Atenolol 100 mg PO DAILY
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Valsartan 160 mg PO DAILY
6. Calcitonin Salmon 200 UNIT NAS DAILY
Discharge Medications:
1. Valsartan 80 mg PO DAILY
2. Calcitonin Salmon 200 UNIT NAS DAILY
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Warfarin 1 mg PO DAILY16
5. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSES:
- Bilateral pulmonary emboli, submassive
- Bilateral deep venous thrombi
SECONDARY DIAGNOSES:
- Hepatic malignancy vs. abscesses vs. infected bilomas
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It has been a pleasure to care for you here at ___.
You were admitted with shortness of breath and chest pain. You
were found to have blood clots in your lungs and legs. You were
started on a blood thinner medication called heparin and then
transitioned to an oral blood thinner called warfarin.
You will continue taking warfarin for ___ months after your are
discharged. You will need to get blood tests ___ times per week
to make sure the dose of this medication is correct.
In addition, there was evidence of a lesion in your liver.
Initially, this was thought to be infection for which you were
briefly on antibiotics; however, imaging suggests that this this
lesion may be cancer. Since you have been feeling quite well
without fever or new pain, the medical team felt you do not need
antibiotics. We discussed the possibility of a biopsy for the
liver lesions, but you decided that this was not within your
goals and desires.
You will be discharged to a rehabilitation facility, where you
will continue to receive medication for the blood clots. At the
facility, staff will work with you to help get you stronger.
Thank you for letting us participate in your care,
Your ___ Care team
Followup Instructions:
___
|
10206502-DS-12 | 10,206,502 | 24,665,446 | DS | 12 | 2128-11-12 00:00:00 | 2128-11-12 19:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Food Impaction
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
___ year old male patient with a history which includes severe
ischemic cardiomyopathy, status post CABG in ___, history of
lung disease due to asbestosis, history of conduction system
disease, status post pacemaker implantation and subsequent
upgrade to a biventricular ICD, history of recurrent ventricular
tachycardia due to an inferior wall scar with appropriate shocks
approximately once a year, history of AAA repair in ___, status
post partial gastrectomy for duodenal adenocarcinoma ___ years
ago who presented to the ED with with food impaction.
Per GI consult note:
He has a longstanding history of dysphagia to solids and
liquids. Last EGD in ___ showed mild gastritis, but normal
efferent and afferent limbs. He has not undergone other work-up
of this dysphagia and just tries to avoid steak. He is not on a
dysphagia diet.
Yesterday, around 10am, he ate cereal, a banana, and several
small donuts for breakfast. Around 5pm, he attempted to eat a
roast beef sandwich, but could not swallow it. He has since not
been able to swallow liquids or solids. He is not tolerating his
secretions. He does not have associated abdominal pain, nausea,
vomiting, or GI bleeding. He notes that he has had episodes of
dysphagia in the past, but usually transient and resolving after
30 minutes or so. He was given water to sip in ED and could not
keep it down. He has had some chest pressure while in the ED but
was HD stable. Labs were significant for INR of 3.3 on check in
the ED.
Patient was transffered to the OR for EGD. He recieved 3U FFP by
anesthesia to do EGD which revealed "significant esophagitis
with significant edema and macerated mucosa in the distal
esophagus and GE junction, likely site of recently passed
impacted food bolus.
Food bolus that likely spontaneously passed from distal
esophagus prior to the procedure was seen upon entry into the
stomach.
Otherwise normal EGD to jejunum"
Patient was extubated in the PACU but became progressively more
hypoxic and required reintubation thought to be due to Volume
overload and sedation in setting of FFP. He was given 5mg IV
lasix in the PACU.
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:
1. Coronary artery disease status post coronary artery
bypass graft in ___ and ___
2. Left ventricular aneurysm.
3. Congestive heart failure with ejection fraction less than
20% from the echocardiogram in ___. He had a
biventricular implantable cardioverter-defibrillator placed
in ___.
4. s/p IMI
5. AAA - repaired in ___
6. Chronic obstructive pulmonary disease.
7. Hypertension.
8. Hyperlipidemia status post appendectomy in ___.
9. BPH
10. DM2
Social History:
___
Family History:
Significant for father dying of lung cancer and mother dying of
myocardial infarction at age ___.
Physical Exam:
Admission Physical Exam:
97.9 HR 70 V paced, BP ___ systolic/50s diastolic sat 100%
Vitals: satting 100% on spontaneous breathing trial
GENERAL: Alert, intubated but nodding appropriatley to question
HEENT: Sclera anicteric,
NECK: supple, JVP not elevated
LUNGS: lungs clear anteriorly
CV: Regular rate and rhythm, well healed CABG scar
ABD: soft, non-tender, non-distended, well healed midline scar
EXT: Warm, well perfused, 2+ pulses, no edema
Discharge Physical Exam:
Vitals: 98.2 93-116/60s-70s ___ 93-100% RA 190 out
over 8 hours, 3250/340 over 24 hours
General: well-appearing elderly man, no acute distress
HEENT: PERRL, EOMI, oropharynx clear, dry mucous membranes
CV: r/r/r, II/VI systolic murmur heard throughout precordium,
JVP 10 cm H20
Lungs: bibasilar crackles, no wheeze
Abdomen: soft, nontender, normoactive bowel sounds
GU: no foley in place
Ext: cool arms, cool legs, no c/c/e
Neuro: AAOx3, moving all extremities
Skin: multiple ecchymotic lesions of the arms
Pertinent Results:
ADMISSION LABS:
====================================
___ 07:00PM ___ PTT-58.2* ___
___ 07:00PM ___ PTT-58.2* ___
___ 04:40PM GLUCOSE-136* UREA N-21* CREAT-1.0 SODIUM-141
POTASSIUM-5.0 CHLORIDE-103 TOTAL CO2-26 ANION GAP-17
___ 04:40PM estGFR-Using this
___ 04:40PM cTropnT-<0.01
___ 04:40PM WBC-12.2* RBC-4.48* HGB-13.9 HCT-43.0 MCV-96
MCH-31.0 MCHC-32.3 RDW-13.6 RDWSD-48.2*
___ 04:40PM NEUTS-81.0* LYMPHS-12.2* MONOS-6.0 EOS-0.1*
BASOS-0.4 IM ___ AbsNeut-9.84* AbsLymp-1.48 AbsMono-0.73
AbsEos-0.01* AbsBaso-0.05
___ 04:40PM PLT COUNT-203
___ 04:40PM ___ PTT-81.4* ___
PROCEDURES/IMAGING:
==================================
EGD ___
Impression: Severe esophagitis with significant edema,
friability, and macerated mucosa in distal esophagus and GE
junction, likely site of recently passed impacted food bolus.
Endoscope was able to traverse the GE junction with some
resistance.
Severe gastritis. Anatomy consistent with previous distal
gastrectomy and billroth II reconstruction. Anastomotic sites
appeared normal, without ulceration and were easily traversed.
Food bolus that likely spontaneously passed from distal
esophagus prior to the procedure was seen upon entry into the
stomach.
Otherwise normal EGD to jejunum
Recommendations: Likely recently passed food bolus prior to
start of procedure. Recommend repeat endoscopy in 8 weeks to
re-evaluate severely edematous, narrowed and ulcerated GE
junction.
NPO tonight, advance to clears in the morning.
PO PPI BID x 8 weeks, QD thereafter
Additional notes: The attending was present for the entire
procedure. The patient's home medication list is appended to
this report. FINAL DIAGNOSES are listed in the impression
section above. Estimated blood loss = zero. No specimens were
taken for pathology
CXR ___: Pulmonary fibrosis, similar in overall pattern to
prior exam. Calcified pleural plaque. Pacemaker in place.
CXR ___: FINDINGS: COMPARED TO THE MOST RECENT PRIOR FILM, I
DOUBT SIGNIFICANT INTERVAL CHANGE.
CXR ___:
Extensive interstitial markings again seen in both lungs, most
pronounced at the bases. The medial left hemidiaphragm is
slightly less distinct than on the prior film, raising the
question of more confluent opacification in this area.
Otherwise, I doubt significant interval change
___: IMPRESSION: As compared to the previous radiograph, the
extent of a right pleural effusion
has minimally increased. The lung volumes continue to be low
and reticular
opacities are seen at both lung bases. Mild fluid overload is
present.
Unchanged appearance of the cardiac silhouette.
DISCHARGE LABS:
=================================
___ 09:22AM BLOOD ___
___ 07:50AM BLOOD Glucose-104* UreaN-17 Creat-0.8 Na-140
K-4.1 Cl-107 HCO3-21* AnGap-16
___ 07:50AM BLOOD Calcium-8.1* Phos-2.8 Mg-1.9
___ 07:50AM BLOOD Digoxin-2.1*
Brief Hospital Course:
Mr. ___ is a ___ yo man with h/o ischemic CMP (EF ___ in
___ s/p BiV ICD, CAD s/p CABG, asbestosis, and AAA repair in
___ who presented with food impaction in the ED. He had an EGD
that showed severe esophagitis/gastritis, a narrowed ulcerated
GE junction, macerated mucosa, and a food bolus that has passed
in to the stomach. His stay was complicated by hypoxia and
oliguria. He was admitted to the MICU for hypoxia and intubated.
He had an aspiration event on extubation however did not develop
clinical signs and symptoms of pneumonia. He tolerated clears
and then full liquids during his stay. Patient should continue
with a full liquid diet until the end of this week (1 week
total) and then advance diet as tolerated, as per GI recs. He
will have a repeat endoscopy in 8 weeks with out patient GI
follow up. He also had oliguria throughout his stay with
___ of urine output despite aggressive fluid
resusitation, with intermittent trials of diuresis. Cr was
stable at 0.8-1.0 throughout stay. His urine out put increased
to around 40-50 cc/hr with fluids and lasix however decreased to
around 20 cc/hour soon after fluid boluses/IV lasix. Urine out
put was monitored with a foley and bladder scans showed no
urinary retention. Patient has a history of atrial fibrillation
on warfarin - INR on discharge was 3.9.
TRANSITIONAL ISSUES:
======================================
- follow up with cardiology ___ for INR check and coumadin
re-dosing
- follow up with primary care provider on ___
- oliguria: patient likely has low urine out put at baseline,
encourage PO in take
- omeprazole 40mg twice daily for 8 weeks then 40mg once daily
thereafter indefinately, repeat EGD in 8 weeks to evaluate
narrowed GE junction with subsequent out patient GI follow up
-may need follow up with Pulm concerning honey combing
bilaterally seen on imaging concerning for pulmonary fibrosis
- ___ need repeat Echo to evaluate ___, most recent Echo in
system is from ___ and shows EF of ___
- Digoxin was stopped during admission due to concern for
digoxin toxicity (patient has a past history of this and is on
amiodarone as well), follow up with cardiology as an out patient
Please see below for a more detailed problem based summary.
=
=
=
=
================================================================
#Hypoxemia: Patient experienced hypoxic respiratory failure
after intubation in the MICU: Thought to possibly be due to
volume overload from FFP, although may have been related to
suspected underlying ILD. He recieved 5mg IV lasix and was
grossly incontinent of urine. On initial evaluation patient did
well on ___ pressure support, and SBT. The patient was extubated
successfuly. He was hydrated with PO and IVF to ensure UOP
>30mL/h. The patient continued to have appropriate oxygen
saturation during the day and was called out from MICU to the
floor. On the floor patient had 1 episode of desaturation to 90%
on RA after recieving 2.5L of fluid over 24 hours for
oliguria/hypovolemia. This resolved after 5mg IV lasix and
patient was saturating well on RA on discharge.
#Impacted food bolus: evidence of passing on EGD. Patient had
severe esophagitis and may have dysmotility disorder. The
patient was able to tolerate thin liquids well in the PACU. On
the floor the patient tolerated a full liquid diet well. GI
recommends repeat endoscopy in 8 weeks to re-evaluate severely
edematous, narrowed and ulcerated GE junction. They also
recommended omeprazole 40mg BID for 8 weeks and then 40mg once
daily indefinitely thereafter as well as continued out patient
GI follow up after EGD.
#Oliguria: He also had oliguria throughout his stay with
___ of urine output despite aggressive fluid
resusitation, with intermittent trials of diuresis. Cr was
stable at 0.8-1.0 throughout stay. His urine out put increased
to around 40-50 cc/hr with fluids and lasix however decreased to
around 20 cc/hour soon after fluid boluses/IV lasix. Urine out
put was monitored with a foley and bladder scans showed no
urinary retention. Problem was reviewed with PCP prior to
discharge; agreed that further attempts to target higher urine
output - in setting of good renal function -was likely to
prolong hospitlaization without significant benefit. Foley was
d/ced, and patient was discharged with plans to f/u this issue
with his primary care physician.
#Afib on coumadin: rate and rhythem controlled with amiodarone,
metoprolol and anticoagulated with coumadin. Digoxin was
discontinue during this admission due to concern for digoxin
toxicity, as patient is on amiodarone and has a past history of
digoxin toxicity. INR was slightly supratheraputic on admission
and he recieved 3 units FFP. Patient was continued on amiodarone
and metoprolol on the floor. He was re-started on 2mg warfarin
___ on the floor which was increased to 4mg warfarin given
___ and ___. Patient's INR on discharge was 3.9. His
warfarin dose was held the day of discharge and he was
instructed to follow up with out patient Cardiology the day
after discharge (appointment scheduled) to check an INR and
re-dose his warfarin. The patient also has a primary care out
patient appointment scheduled ___.
#CAD: The patient was continued on ASA, patient discharged on
home statin. Unclear if patient is actually taking statin or
not.
#Ischemic cardiomyopathy s/p placement of biventricular ICD:
Thought to be acutely overloaded in PACU related to volujme
recieved of FFP. Received 5mg IV lasix and was incontinent of
urine. Currently oxygenation appears improved though pressures
were soft. Home lisinopril was held during admission as patient
had SBPs in ___ on the floors as well. He may need a repeat
Echo to evaluate cardiac function as his last Echo was in ___
and showed an EF of ___.
# Leukocytosis: Downtrended to within normal limits during
admission. Leukocytosis was likely stress response from being
re-intubated/extubated ___. Infectious work up was negative.
We considered aspiration pneumonia however patient did not have
sputum production, cough, or fever or chills. His CXR showed
some questionable aspiration pneumonitis that should resolve
without intervention.
Patient was medically stable for discharge on ___ with
followup as scheduled.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Digoxin 0.125 mg PO DAILY
2. Amiodarone 100 mg PO DAILY
3. Metoprolol Succinate XL 12.5 mg PO DAILY
4. Lisinopril 2.5 mg PO DAILY
5. Lovastatin 40 mg oral QPM
6. Omeprazole 20 mg PO BID
7. Warfarin 4 mg PO 2X/WEEK (___)
8. Warfarin 2 mg PO 5X/WEEK (___)
9. Aspirin 81 mg PO DAILY
10. Cyanocobalamin 50 mcg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Amiodarone 100 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Cyanocobalamin 50 mcg PO DAILY
4. Metoprolol Succinate XL 12.5 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*90
Capsule Refills:*3
7. Lisinopril 2.5 mg PO DAILY
8. Lovastatin 40 mg ORAL QPM
Discharge Disposition:
Home With Service
Facility:
___
___:
Primary diagnoses:
Impacted food bolus
Hypoxia
Oliguria
Secondary diagnoses:
Honeycombing in lungs bilaterally
sCHF with EF ___ in ___
Atrial fibrillation
CAD
Ischemic cardiomyopathy s/p placement of biventricular ICD
Discharge Condition:
EGD ___:
Impression:
- Severe esophagitis with significant edema, friability, and
macerated mucosa in distal esophagus and GE junction, likely
site of recently passed impacted food bolus. Endoscope was able
to traverse the GE junction with some resistance.
- Severe gastritis. Anatomy consistent with previous distal
gastrectomy and billroth II reconstruction. Anastomotic sites
appeared normal, without ulceration and were easily traversed.
- Food bolus that likely spontaneously passed from distal
esophagus prior to the procedure was seen upon entry into the
stomach.
- Otherwise normal EGD to jejunum
- Recommendations: Likely recently passed food bolus prior to
start of procedure. Recommend repeat endoscopy in 8 weeks to
re-evaluate severely edematous, narrowed and ulcerated GE
junction.
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you. You were admitted to the
hospital for food impaction. You had an EGD that showed
ulcerations, severe inflammation of your esophagus and stomach,
narrowing at the junction between your esophagus and stomach,
and a food bolus that was likely lodged in your esophagus but
had passed in to the stomach at the time of the EGD. Please
continue your full liquid diet until the end of the week and
then advance your diet as tolerated.
Please take omeprazole twice daily for the next 8 weeks and
then once daily thereafter.
Please follow up with GI for a repeat EGD in 8 weeks, and please
follow up with them afterwards in out patient clinic. Your stay
was complicated by low oxygen saturations, low urine output, and
a high level of your blood thinner. Your blood thinner was
discontinued upon discharge.
It is very important that you follow up with your Cardiologist
___ ___ concerning your INR and coumadin
dosing. They should call you.
Please also follow up with your primary care provider in ___ few
days (appointment below) concerning the issues above. Please
weigh yourself every morning and call MD if weight goes up more
than 3 lbs.
We wish you all the ___.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10206590-DS-19 | 10,206,590 | 26,927,205 | DS | 19 | 2155-05-10 00:00:00 | 2155-05-12 08:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
"hair dye"
Attending: ___.
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
Intubation ___ (___) - ___
Lumbar Puncture ___
History of Present Illness:
the patient is a ___ y/o woman with a PMH significant for CKD,
membranous nephropathy, HTN, HLD, chronic pleural effusions,
depression, and sciatica who presented to ___ after being found
unresponsive found to have seizures of unclear etiology.
She was found unresponsive by her family and was brought to ___
where she was hypoxic to the ___, CXR demonstrated concern for
pneumonia, head CT was unremarkable. She was subsequently
intubated, started on a propofol drip, and transferred to ___
for intensive care after she was witnessed to have tonic clonic
activity concerning for seizures. Of note, patient is typically
A&Ox4 and independent, with no hx of seizure activity. Per her
son, patient did have ___ weeks of mild URI symptoms that the
family attributed to allergies.
In the ___ ED, initial vitals were Tmax 102.8, HR 96, BP
148/84, RR 22 100% RA. Her exam was notable for rhonchi in lungs
bilaterally, miotic pupils, and +Babinski. Labs were notable for
WBC 16.4, Cr 2.1, Lactate 3.4, Urine: Urine Protein>600, Glucose
300, Ketone 10. LP with 1 WBC and 5 RBCs. Repeat CXR showed
bilateral atelectasis, CT head w/o contrast showed no acute
abnormalities. Patient was started on a IV fentanyl citrate
drip, IV propofol drip, vanc/CTX x1, and IV Tylenol for fever.
She was admitted to the MICU for further evaluation and
management.
Past Medical History:
CKD
COPD
Bronchiectasis
Emphysema
Membranous nephropathy
HTN (not on anti hypertensives)
HLD
Chronic pleural effusions
Depression
Sciatica
Osteoporosis
Vitamin D deficiency.
Social History:
___
Family History:
Noncontributory to presenting complaint
Physical Exam:
ADMISSION PHYSICAL EXAM
=========================
GEN: Frail older woman lying in bed, intubated and sedated
EYES: Pupils small and minimally reactive. Gaze conjugate
CV: RRR, no murmurs, rubs, or gallops
RESP: Decreased breath sounds at the bases bilaterally, no
wheezing or ronchi
GI: Soft, non-distended. BS hypoactive
EXT: Cool and clammy, 1+ edema in BLEs
NEURO: Sedated, withdraws to painful stimuli
DISCHARGE PHYSICAL EXAM
=========================
General: Lying in bed, comfortable, interactive
HEENT: PERRL/EOMI, anicteric, MMM
Neck: No cervical lymphadenopathy; RIJ incision site c/d/i
Lungs: CTAB, no wheezes, rales, rhonchi
CV: RRR, normal S1/S2; no murmurs, rubs, gallops
GI: Soft, non-tender, non-distended; no masses; Dobhoff tube in
place
Ext: Warm, no rashes. Full range of motion, R PICC in place
Neuro: A&Ox3, CN II-XII in tact, strength weak but symmetric in
upper and lower extremities, sensation in tact
Pertinent Results:
Admission Labs:
===============
___ 04:38PM BLOOD WBC-16.4* RBC-3.88* Hgb-12.0 Hct-38.9
MCV-100* MCH-30.9 MCHC-30.8* RDW-16.6* RDWSD-60.6* Plt ___
___ 07:45PM BLOOD ___ PTT-67.8* ___
___ 04:38PM BLOOD Glucose-144* UreaN-21* Creat-2.1* Na-148*
K-4.2 Cl-114* HCO3-16* AnGap-18
___ 10:36PM BLOOD ALT-8 AST-12 LD(LDH)-282* AlkPhos-87
TotBili-<0.2
___ 10:36PM BLOOD Albumin-1.9* Calcium-7.8* Phos-5.3*
Mg-2.3 Iron-12*
___ 10:41PM BLOOD Type-ART pO2-122* pCO2-35 pH-7.40
calTCO2-22 Base XS--1
Discharge Labs:
===============
___ 07:00AM BLOOD WBC-12.1* RBC-2.68* Hgb-8.2* Hct-27.6*
MCV-103* MCH-30.6 MCHC-29.7* RDW-17.5* RDWSD-61.9* Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD Glucose-107* UreaN-42* Creat-1.9* Na-147
K-4.6 Cl-115* HCO3-22 AnGap-10
Studies:
========
___ CT
No acute intracranial abnormality.
___ CXR
The endotracheal tube terminates 3.7 cm above the carina. A
right internal
jugular central venous catheter terminates in lower superior
vena cava. The enteric tube terminates in the body of the
stomach.
There are small bilateral pleural effusions (right greater than
left). There
is no focal consolidation, pneumothorax or pulmonary edema. The
cardiomediastinal silhouette is within normal limits. No acute
osseous abnormalities are identified
___ MRI
1. No evidence of mass, hemorrhage or recent infarction.
2. Patchy abnormal signal within the bihemispheric cortices
without associated
diffusion abnormalities may be related to the seizure activity.
3. Chronic microvascular angiopathy changes.
___ CT CHEST/ABDOMEN/PELVIS
1. No evidence of malignancy in the abdomen or pelvis given the
limitations of an unenhanced scan.
2. Uncomplicated cholelithiasis.
3. Nonobstructing punctate left renal calculi.
4. Colonic diverticulosis without evidence of diverticulitis.
5. Please refer to the separately dictated CT chest report from
the same date for a description of thoracic findings.
___ MRI HEAD
1. No evidence of acute infarction or intracranial hemorrhage.
2. Moderate parenchymal volume loss and severe chronic small
vessel ischemic disease.
3. No definite evidence of mesial temporal sclerosis. No gray
matter heterotopia, focal cortical dysplasia or focal lobar
encephalomalacia.
Brief Hospital Course:
Ms. ___ is a ___ woman with a past medical history
significant for CKD, membranous nephropathy, COPD, HTN, HLD,
chronic pleural effusions, depression, and sciatica who
presented as a transfer after being found unresponsive and
hypoxic, with subsequent tonic-clonic activity concerning for
seizure of unknown etiology.
Brief Hospital Course by Problem
==========================
#Seizures: Patient remained intubated in the setting of her
seizures and was admitted to the MICU. She was started on
lacosamide 75mg BID, levetiracetam 250mg BID, and fosphenytoin
50mg Q8H. She continued to have generalized bursts of period
discharges on EEG that gradually improved during her MICU
course. She was eventually extubated on ___ following
resolution of abnormal EEG findings and improved neurologic
exam, and transferred to the floor. On ___, patient was taken
off fosphenytoin. On ___, her lacosamide dose was decreased to
37.5mg BID. She was followed by neurology throughout the course
of her hospitalization.
The etiology of her new onset seizures is unclear. She reports
having URI symptoms and a diffuse pruritic rash in the days
leading up to her hospitalization. MRI head demonstrated no
evidence of mass, hemorrhage or recent infarction. CT
head/chest/abdomen/pelvis were unremarkable. Blood cultures and
urine cultures were negative. RPR, Legionella, Enterovirus, VZB,
CMV, EBV, and HSV PCR were negative. Of note, patient received
several doses of IV acyclovir for possible HSV encephalitis
during her MICU course, as well as one dose of
vancomycin/ceftriaxone for possible bacterial meningitis.
Paraneoplastic and autoimmune panels were sent, and are pending.
She will follow up with neurology as an outpatient for further
management of her anti-epileptic medications.
#Acute hypoxemic respiratory failure / fever / leukocytosis:
Patient was hypoxic to the ___ on initial presentation,
requiring intubation. She later developed a transient fever and
leukocytosis, which resolved. This is likely secondary to
aspiration in the setting of her seizure, as well as volume
overload in the setting of her bilateral chronic pleural
effusions due to CKD (takes 80mg torsemide daily). On ___,
patient was able to be extubated. She was restarted on her home
torsemide on ___ after she demonstrated evidence of tachypnea
and had progression of her pleural effusions on CXR. At the time
of discharge, she was saturating well on room air and
non-tachypneic.
#Dysphagia: Upon extubation, patient failed her speech and
swallow evaluation, likely due to global weakness from MICU
course as well as recent intubation. She was made NPO, and a
Dobhoff tube was placed for tube feeds. A right PICC line was
placed. On ___, patient was advanced to purees/nectars. She
will be discharged with her Dobhoff tube and R PICC line, and
her diet will be further managed at rehab.
___ on CKD, membranous nephropathy: Patient has CKD, baseline
~1.5-1.9 (per Atrius records). Patient was admitted with a Cr
2.2, likely pre-renal in etiology due to dehydration and poor PO
intake. Following appropriate fluid resuscitation and
improvement in nutritional supplementation, patient's Cr
improved throughout her hospitalization. At time of discharge,
her Cr was 1.9.
#Normocytic anemia: Patient was found to have slowly downtending
Hgb and +guaic test during MICU course, requiring 1u pRBCs on
___. Her hemolysis labs were unremarkable. On discharge, her
H/H was 8.2/27.6.
#Lactic acidosis: On admission, lactate was 3.4, repeat lactate
was 0.8. Lactic acidosis occurred likely in the setting of her
seizure.
#Hypertension: Patient was hypertensive up to the SBPs 170s-200s
several days during her hospitalization; she was asymptomatic
throughout her hospital course. She us usually normotensive at
baseline (per Atrius records), on aspirin. This hypertension was
likely secondary to her chronic sciatic pain, as well as to
potential volume overload in the setting of withholding her home
torsemide. Following resumption of her torsemide, her SBPs
trended down to the 140s. She will follow up with her PCP as an
outpatient for this issue.
#Sciatica: Patient has low back pain secondary to sciatica at
baseline. Her pain was adequately managed on her home tylenol
regimen. On ___, she was restarted on her home gabapentin. Her
nortriptyline was held throughout her hospitalization.
#Hyperlipidemia: Patient was continued on home atorvastatin.
Transitional Issues:
====================
[] follow daily weights. Her discharge weight is 53.4 kg. If
this goes up or down by more than 3 lbs consider adjusting
discharge torsemide 80 mg, consider decreasing if her Cr
increases
[] follow a BMP in 3 days to ensure stable with re-initiation of
home diuretic
[] please follow up on her hypertension found on this hospital
admission
[] please follow up on anti-epileptic drug regimen for new onset
seizures
Code: full
HCP: ___ ___
Medications on Admission:
1. Alendronate Sodium 70 mg PO QMON
2. Nortriptyline 10 mg PO QHS
3. Gabapentin 300 mg PO QHS
4. Torsemide 80 mg PO DAILY
5. Senna 8.6 mg PO BID:PRN Constipation - First Line
6. Docusate Sodium 100 mg PO BID
7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 20 mg PO QPM
10. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. LACOSamide 37.5 mg PO BID
2. LevETIRAcetam 250 mg PO Q12H
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. Alendronate Sodium 70 mg PO QMON
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 20 mg PO QPM
7. Docusate Sodium 100 mg PO BID
8. Gabapentin 300 mg PO QHS
9. Nortriptyline 10 mg PO QHS
10. Senna 8.6 mg PO BID:PRN Constipation - First Line
11. Torsemide 80 mg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
- Seizure
- Acute Hypoxemic Respiratory Failure
Secondary Diagnosis
- ___ on CKD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital because you were found to be
unresponsive and having trouble breathing
WHAT HAPPENED TO ME IN THE HOSPITAL?
- In the hospital, you were found to be having seizures.
Because of this you needed a tube in your throat to help you
breathe.
- You were started on anti-seizure medications and began to
improve
- We tried to figure out the source of the seizures, but all of
the studies we performed were normal.
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:
___
|
10206973-DS-3 | 10,206,973 | 23,072,356 | DS | 3 | 2160-05-30 00:00:00 | 2160-05-30 06:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Erythromycin Base / Percocet / Ibuprofen / Shellfish Derived /
Synthroid / Cyclobenzaprine
Attending: ___.
Chief Complaint:
R olecranon fracture
Major Surgical or Invasive Procedure:
Right olecranon open reduction and internal fixation
History of Present Illness:
___ w/ R olecranon fracture. Patient was running outside to get
out of the rain when she slipped and fell. Since that time,
significant pain and swelling of the R elbow. Denies numbness /
tingling or weakness.
Past Medical History:
Hypothyroidism, HTN
Social History:
___
Family History:
NC
Physical Exam:
Exam on admission:
Vitals: 98.7 96 169/94 18 100%
Gen: NAD
Heart: RRR
Lungs: CTABL
Ab: soft NT/ND
Right upper extremity:
Skin intact, swelling and tenderness over the R elbow
Soft, non-tender arm and forearm
AROM/PROM of elbow limited by pain.
Full AROM/PROM on the wrist, and digits
+EPL/FPL/DIO (index) fire
+SILT axillary/radial/median/ulnar nerve distributions
+Radial pulse
Exam on discharge:
AFVSS
NAD, A+Ox3
RUE:
In postoperative splint, c/d/i
Compartments soft and compressible
No pain with passive motion of fingers
SILT over M/R/U distributions
Motor intact EPL, FPL, intrinsics
WWP fingers
Pertinent Results:
___ 04:40AM BLOOD WBC-10.3 RBC-4.16* Hgb-12.3 Hct-38.2
MCV-92 MCH-29.6 MCHC-32.2 RDW-13.2 Plt ___
___ 01:35PM BLOOD Neuts-79.7* Lymphs-16.2* Monos-3.4
Eos-0.5 Baso-0.2
___ 04:40AM BLOOD Plt ___
___ 04:40AM BLOOD ___ PTT-31.2 ___
___ 04:40AM BLOOD Glucose-81 UreaN-12 Creat-0.8 Na-140
K-3.8 Cl-102 HCO3-26 AnGap-16
___ 04:40AM BLOOD ___
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 olecranon fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction and internal
fixation, which the patient tolerated well (for full details
please see the separately dictated operative report). The
patient was taken from the OR to the PACU in stable condition
and after recovery from anesthesia was transferred to the floor.
The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home 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 nonweightbearing in the right
upper extremity, and will be discharged on aspirin and early
mobilization 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. Lorazepam 0.5 mg PO TID:PRN anxiety
2. Levothyroxine Sodium 125 mcg PO DAILY
3. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4-6H coughing/wheezing
4. Atenolol 25 mg PO DAILY
5. Calcitriol 0.25 mcg PO 5X/WEEK (___)
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN pain
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. Levothyroxine Sodium 125 mcg PO DAILY
3. Calcitriol 0.25 mcg PO 5X/WEEK (___)
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Lorazepam 0.5 mg PO TID:PRN anxiety
6. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*50 Tablet Refills:*0
7. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*50 Tablet Refills:*0
8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4-6H coughing/wheezing
9. Hydrocodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
RX *hydrocodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth
every four (4) hours Disp #*80 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right olecranon fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
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 aspirin 325mg daily for 2 weeks and mobilize
frequently
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
ACTIVITY AND WEIGHT BEARING:
- Nonweightbearing in the right arm
- Splint to remain in place until follow up in 2 weeks
Followup Instructions:
___
|
10207354-DS-20 | 10,207,354 | 24,602,624 | DS | 20 | 2186-04-06 00:00:00 | 2186-04-09 16:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever, Confusion
Major Surgical or Invasive Procedure:
___ Placement
History of Present Illness:
In brief, Mr. ___ was recently admitted to the hospital with
a fall and with hyponatremia. He was discharged home and
presented to the hospital on ___ with fever, weakness and AMS.
He was found to have a purulent IV site and was diagnosed with
MSSA bacteremia. Also had MSSA UTI. ID was consulted. Please
read below regarding the patient's antibiotic course. A CT
abdomen was performed as part of his workup and showed acute
pancreatitis. Patient was started on fluids for management of
his pancreatitis. He also had melena with downtrending H/H and
received 2U pRBC during his hospital stay. EGD was performed on
___ and showed mild esophagitis, portal hypertensive
gastropathy, and mild gastritis. No biopsies were taken as
patient was recently on apixaban. Patient remained confused
during his hospital stay. The etiology of his encephalopathy was
attributed to sepsis, pancreatitis, prolonged hospitalization,
and possibly cephalosporin use. Head imaging showed evidence of
dural thickening, possibly ___ leptomeningeal disease. ID did
not think he had acute bacterial meningitis. LP was recommended
but is currently postponed due to recent aspirin and apixiban
use. Patient remained on cefazolin monotherapy. Patient's renal
function also worsened on ___ with an increase in his
creatinine to 2.3-2.8 from a baseline of around 1.0-1.6. Renal
was consulted and attributed his renal failure to ATN
(precipitant unclear) as urine microscopy revealed muddy brown
casts. AIN was on the differential as he was started on new
medications (cephalosporins and PPI). Cardiology was also
consulted to help manage congestive heart failure and possible
cardiorenal syndrome. There was concern that the bacteremia may
have worsened his mitral valve and recommended TEE as well as
aggressive diuresis (which renal agreed with). He received Lasix
100 mg IV without good UOP (only about 200-300 cc UOP). It was
recommended that he receive Lasix with metolazone if no
improvement. Patient was ultimately transferred to the ___
service for management of his diuresis and for TEE.
On arrival to the floor, patient denied any shortness of breath
or pain. Per wife, his confusion is improved and he is closer to
baseline.
Past Medical History:
- Coronary artery disease: s/p BMS to proximal ramus (___)
- Mitral regurgitation: moderate-severe with MVP/partial flail
(___)
- Aortic regurgitation: Moderate (TTE ___
- Heart failure: Diastolic. (EF 55% ___
- Hypertension
- Dyslipidemia
- Permanent atrial fibrillation - CHADS2=3 (age, CHF, HTN).
- Pulmonary artery HTN - (PASP of 47+ RA, TTE ___.
- Invasive breast cancer T2N3 ER+, HER-2/neu -, s/p left
mastectomy on tamoxifen (___)
- Chronic kidney disease, stage III: Baseline cr 1.6
- Obstructive sleep apnea, on CPAP
Social History:
___
Family History:
- Father: Died at age ___ from MI, stroke
- Mother: Died at age ___ from bowel cancer
- Siblings: Brother with bowel cancer, sister died at ___
- Children: Son, daughter, 5 grandchildren are healthy
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION EXAM:
==============
General: NAD
VITAL SIGNS: T 100.9 BP 114/56 HR 107 RR 20 O2 96%RA
HEENT: MMM, no OP lesions
CV: RR, NL S1S2
PULM: CTAB
ABD: Soft, NTND, no masses or hepatosplenomegaly.
LIMBS: No edema, clubbing, tremors, or asterixis.
NEURO: Alert and oriented, no focal deficits.
DISCHARGE EXAM:
==============
VS: 98.2 ___ 16 96% RA
Weight: 62kg
GENERAL: AAOX3, pleasant, laying flat in bed
HEENT: Atraumatic, sclera anicteric.
NECK: Supple, No JVD.
CARDIAC: RRR, normal S1, S2. ___ holosystolic murmur at apex
with radiation to axilla.
LUNG: CTAB
ABDOMEN: soft, nondistended, nontender to palpation.
EXTREMITIES: Warm and well perfused. Hands without edema. Trace
pedal edema.
GU: no foley.
PULSES: 2+ DP pulses bilaterally
NEURO: CN grossly II-XII intact
SKIN: No rash
Pertinent Results:
ADMISSION LABS:
=============
___ 01:30PM BLOOD WBC-3.1* RBC-3.52* Hgb-8.4* Hct-27.4*
MCV-78* MCH-23.9* MCHC-30.7* RDW-22.4* RDWSD-60.5* Plt Ct-98*
___ 01:30PM BLOOD Neuts-94* Bands-1 Lymphs-4* Monos-1*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-2.95 AbsLymp-0.12*
AbsMono-0.03* AbsEos-0.00* AbsBaso-0.00*
___ 01:30PM BLOOD Hypochr-2+ Anisocy-3+ Poiklo-3+
Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-1+ Schisto-1+
Burr-2+ Tear Dr-1+ Fragmen-OCCASIONAL
___ 01:30PM BLOOD ___ PTT-38.2* ___
___ 01:30PM BLOOD Glucose-138* UreaN-41* Creat-1.6* Na-134
K-3.5 Cl-97 HCO3-23 AnGap-18
___ 01:30PM BLOOD ALT-23 AST-39 AlkPhos-89 TotBili-2.7*
DirBili-1.8* IndBili-0.9
___ 01:30PM BLOOD Albumin-2.9* Calcium-9.8 Phos-3.4 Mg-2.0
UricAcd-7.4*
___ 01:43PM BLOOD Lactate-3.3*
DISCHARGE AND PERTINENT LABS:
===========================
___ 06:10AM BLOOD IgM-58
___ 01:00PM BLOOD IgG-929 IgA-250
___ 05:05PM BLOOD Triglyc-266*
___ 01:00PM BLOOD proBNP-7789*
___ 07:15PM BLOOD CK-MB-2 cTropnT-0.06*
___ 06:15AM BLOOD cTropnT-0.05*
___ 01:00PM BLOOD GGT-31
___ 07:15PM BLOOD Lipase-1379*
___ 06:15AM BLOOD Lipase-507*
___ 06:23AM BLOOD WBC-2.7* RBC-2.69* Hgb-7.6* Hct-23.6*
MCV-88 MCH-28.3 MCHC-32.2 RDW-20.9* RDWSD-66.3* Plt ___
___ 06:23AM BLOOD ___ PTT-42.3* ___
___ 04:40AM BLOOD Ret Aut-3.6* Abs Ret-0.11*
___ 06:23AM BLOOD Glucose-86 UreaN-35* Creat-1.6* Na-131*
K-3.3 Cl-100 HCO3-22 AnGap-12
___ 04:40AM BLOOD LD(LDH)-214 TotBili-0.8 DirBili-0.4*
IndBili-0.4
___ 12:00AM BLOOD Lipase-112*
___ 07:20AM BLOOD ___
___ 06:23AM BLOOD Calcium-9.6 Phos-3.1 Mg-1.6
___ 05:00PM BLOOD calTIBC-286 VitB12-417 Folate-10.6
Ferritn-157 TRF-220
___ 05:05PM BLOOD Triglyc-266*
___ 01:00PM BLOOD IgG-929 IgA-250
___ 05:28AM BLOOD Lactate-1.7
IMAGING AND REPORTS:
===================
___ RUQ US:
Mildly distended gallbladder. No other findings to suggest
acute
cholecystitis. No evidence of intra or extrahepatic biliary
ductal
dilatation.
___ CT ABODMEN AND PELVIS:
1. Findings compatible with acute pancreatitis involving the
uncinate process head and proximal body as described in detail
above. Lack of intravenous contrast limits evaluation of extent
of parenchymal necrosis, or any associated vascular thrombosis.
No large peripancreatic fluid collections noted.
2. There are foci of discrete calcification within the
pancreatic parenchyma suggestive of prior episodes of
pancreatitis. The main duct however is not dilated.
3. There are bilateral moderate pleural effusions and a small
amount of free fluid in the pelvis. Bibasilar read lack station
atelectasis related to the pleural effusions is also seen.
4. Extensive osseous metastatic disease is unchanged compared to
___ with no pathologic fracture noted.
___ CT CHEST:
New borderline enlargement right peripectoral lymph node,
contralateral to
left mastectomy. No evidence of local tumor recurrence.
Moderate cardiomegaly, occluding biatrial enlargement, company
by probable
pulmonary arterial hypertension.
Mild bibasilar pulmonary consolidation most likely relaxation
atelectasis. New small layering nonhemorrhagic pleural
effusions. No evidence of pleural malignancy, despite extensive
skeletal metastasis involving all the bones of the chest cage.
No pathologic fractures.
___ ECHO:
The left atrium is elongated. The right atrium is markedly
dilated. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF = 70%). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). The right ventricular free wall is
hypertrophied. The right ventricular cavity is dilated with
depressed free wall contractility. The aortic valve leaflets (3)
are mildly thickened. There is no aortic valve stenosis.
Moderate (2+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is moderate/severe
bileaflet mitral valve prolapse. There is severe mitral annular
calcification. Severe (4+) mitral regurgitation is seen. The
left ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. The tricuspid
valve leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. Significant pulmonic regurgitation
is seen. There is no pericardial effusion.
If clinically indicated, a transesophageal echocardiographic
examination is recommended.
No definite vegetations seen. However, best excluded by
transesophageal echocardiography.
Compared with the prior study (images reviewed) of ___ the
findings are similar.
___ PORTABLE ABDOMEN:
There are air-filled borderline dilated loops of large bowel,
measuring a
maximum of 6.1 cm in the transverse colon. There are air-filled
and
abnormally dilated loops of small bowel measuring maximum of 3.1
cm. There is retained oral contrast in the cecum and ascending
colon These findings are most compatible with generalized ileus.
Limited without upright or lateral decubitus views, but there
is no gross free intraperitoneal air.
IMPRESSION:
1. Dilated loops of small and large bowel most compatible with
a generalized ileus.
___ MRCP
IMPRESSION:
1. Exam limited by motion artifact.
2. Normal gallbladder. No gallstones or ductal stones. No
intra or
extrahepatic bile duct dilation.
3. Normal MR signal characteristics of the liver, without focal
lesion.
4. Stranding and edema about the pancreas, compatible with known
history of
pancreatitis, without pancreatic duct dilation or fluid
collections. No focal
lesions detected.
5. Tiny cystic lesions within the pancreatic tail may reflect
mildly dilated
side branches versus tiny side branch IPMN.
RECOMMENDATION(S): 12 month followup MRCP following resolution
of acute
symptoms, for reassessment of the pancreatic tail cystic
lesions.
___ Head CT
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass.
There is
prominence of the ventricles and sulci suggestive of
involutional changes.
Periventricular and subcortical white matter hypodensities are
noted, likely
the sequelae of chronic small vessel ischemic disease. There is
preservation
of gray-white matter differentiation. The basal cisterns remain
patent.
There is no evidence of fracture. The visualized portion of the
paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
The visualized
portion of the orbits are unremarkable.
IMPRESSION:
No evidence of hemorrhage, infarction or mass.
___ Head MRI w and wo contrast
IMPRESSION:
1. Study is moderately degraded by motion.
2. New dural enhancement and signal intensity abnormalities
without as
described. Differential considerations include meningioma
metastatic disease,
or procedure related changes. Recommend correlation with
history of lumbar
puncture.
3. Limited visualization of patient's known skullbase and
cervical spine
blastic metastatic lesions.
4. No evidence of acute infarct.
___ Renal US
IMPRESSION:
No evidence of hydronephrosis or obstruction.
___ RUQ US Doppler
FINDINGS:
The liver isdemonstrates normal, homogeneous echotexture.. No
intrahepatic
biliary ductal dilation is seen. The common bile duct is normal
in caliber
and measures3 mm. The gallbladder is contracted. The patient
was not NPO..
No gallbladder wall thickening or pericholecystic fluid is seen.
The pancreas is obscured by overlying bowel gas. The spleen is
normal in
size, measuring 11.4 cm in length. Limited imaging of the
bilateral kidneys
demonstrates no hydronephrosis. No ascites is seen.
There are bilateral pleural effusions.
Liver Doppler:
The main portal vein and right and left portal vein branches are
patent with
appropriate directional flow. Main portal vein velocity was
26.5
centimeters/second. The left, middle, and right hepatic veins
are patent.
The main hepatic artery is patent with brisk upstroke.
IMPRESSION:
Patent hepatic vasculature.
___ Echocardiogram transesophageal
Conclusions
No spontaneous echo contrast is seen 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. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the aortic arch and the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened. No masses or vegetations are seen on the aortic
valve. No aortic valve abscess is seen. Moderate (2+) aortic
regurgitation is seen. The aortic regurgitation jet is
eccentric, directed toward the anterior mitral leaflet. There is
moderate/severe bileaflet mitral valve prolapse. There is
partial mitral leaflet flail of the A2 scallop of the anterior
mitral leaflet. There is a large (1.9x 0.4 cm) elongated mass on
the mitral valve attached to the partial flail A2 segment which
likely represents chordal elements/pap muscle and superimposed
vegetation. No mitral valve abscess is seen. An eccentric,
posteriorly directed jet of severe (4+) mitral regurgitation is
seen. There is no abscess of the tricuspid valve. No
vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion.
IMPRESSION: Mitral valve prolapse with partial flail of the
anterior mitral leaflet with superimposed vegetation and severe
eccentric mitral regurgitation. Moderate aortic regurgitation.
No other valvular vegetation or abscess seen.
___ CT Abd Pelvis w/o contrast
IMPRESSION:
1. No evidence of retroperitoneal hematoma.
2. Diffuse osseous metastatic disease appears grossly unchanged.
3. Findings consistent with chronic pancreatitis including
multiple
parenchymal calcifications, but no evidence for acute
inflammatory changes.
4. Bilateral pleural effusions, moderate, increased in size.
5. Bilateral renal lesions, not fully characterized on a
noncontrast CT, not
significantly changed.
___ Right groin US
IMPRESSION:
3.6 cm predominantly fat containing right inguinal hernia,
corresponding to
the swelling at the groin. This is better seen on the recent
CT, which
demonstrated a small amount of fluid versus a non-enlarged lymph
node within
the hernia sac.
MICROBIOLOGY
===========
___ 1:10 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Reported to and read back by ___, ___ @
00:09 (___).
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
___ 3:20 pm URINE ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
STAPH AUREUS COAG +. >100,000 ORGANISMS/ML..
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
NITROFURANTOIN-------- <=16 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
___ 2:55 pm BLOOD CULTURE #2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 2:53 pm CSF;SPINAL FLUID
Source: LP TUBE#3 AND SHARED WITH CYTOLOGY.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
Reported to and read back by ___. ___
___ @ 2:50
AM.
GRAM NEGATIVE ROD(S). RARE GROWTH .
SPECIMEN BEING REPLANTED ___. REPLANT: NO GROWTH
AT 48H.
GRAM NEGATIVE ROD IS LIKELY CONTAMINANT.
FUNGAL CULTURE (Final ___: NO FUNGUS ISOLATED.
Enterovirus Culture (Final ___: No Enterovirus
isolated.
Brief Hospital Course:
___ y/o male with a past medical history of hairy cell leukemia
s/p rituxan, breast cancer (ER/PR+, HER2 neg) s/p left
mastectomy in ___ and adjuvant tamoxifen, then switched to
fulvestrant in ___ for metastatic progression by tumor
markers and on PET-CT (bone and lymph nodes), CAD s/p BMS (to
proximal ramus ___, MR with MVP, dCHF (EF 55%), HTN, AF, CKD
stage III who initially presented to ___ on ___ with fevers
and weakness and was found to have MSSA bacteremia and
pancreatitis course complicated by ATN, slow GI bleed.
Oncology service course ___
============================
Hyperbilirubinemia: Unclear etiology Isolated Direct bilirubin,
with mild transaminase elevation. Normal alk phos and ggt. RUQ
U/S done in ED unremarkable. MRCP completed, shows only known
acute pancreatitis. Held atorvastatin which was restarted after
resolution of hyperbilirubinemia and transfer to the cardiac
service.
GI bleed: Patient with 3 total episodes of melena associated
with Hgb drop. Transfused 1 unit. Received EGD which did not
show clear source of bleed but did show evidence of portal HTN
gastropathy without clear cause. Initially started on IV PPI
then transitioned to oral omeprazole BID.
Pancreatitis: Stranding on CT, elevated lipase although
clinically asymptomatic. EBV Negative and CMV viral load
negative. Etiology unclear as patient does not drink and no
evidence of gall stones. Patient was made NPO initially and
hydrated with gentle IVF, his diuretics were held initially.
Eventually his diet was advanced as tolerated and once he began
to gain weight his home diuretics were restarted. By time of
transfer to cardiology service, symptoms resolved.
Altered Mental Status: Concern for metastatic involvement of
dura vs Toxic metabolic encephalopathy multifactorial from
cephalosporin, infection, pancreatitis, and hospitalization.
Attempted keeping circadian rhythm intact, minimize tethers,
encourage family at bedside.
Hypercalcemia: Likely secondary to malignancy. Normalized with
Calcitonin.
Heart Failure/Cardiology Service Course ___ -
=======================================
#Acute on chronic sCHF exacerbation: 20lb weight gain, grossly
volume overloaded and anasarcic at time of transfer to heart
failure service. Started on Lasix gtt at 20/hr without good
urinary output, likely in the setting of ATN. Diuril 500mg IV x1
daily added with good urine output as his renal function started
to improve. We continued diuril several days for diuresis until
patient's creatinine began to improve. Patient eventually given
PO metolazone in addition to lasix drip. He was transitioned and
discharged on torsemide 80mg PO regimen for diuresis. Patient
was also started on hydralazine, and imdur. Eplerenone was
restarted. Patient was not started on ACE inhibitor given
worsening kidney function and given that his LVEF is preserved.
However, consider starting as outpatient if remains
hypertensive. Discharge weight was: 62kg
# Atrial fibrillation: Mr. ___ was rate controlled with
metoprolol. We held his apixiban due to renal failure. He was
briefly started on hep gtt but that was complicated by worsening
anemia and the heparin gtt was discontinued. He was continued on
subcutaneous heparin BID until 7 days after GI bleed, at which
time he was restarted on hep get and bridged to warfarin with a
goal INR of ___. Patient was very sensitive to warfarin during
hospitalization and was discharged on an alternating 1 to 1.5mg
dose.
#Mitral Regurgitation: patient with severe mitral regurgitation
with possible vegetation vs a flail leaflet seen on TEE. Will
need to be evaluated after completion of antibiotic course per
above by cardiac surgery and structural heart team for possible
mitral clip.
#GI Bleed: Patient denied any melanotic or bloody stools. Had
negative stool guaiac towards the last quarter of his hospital
course. His hemoglobin remained steady. Omeprazole was
continued.
___ on CKD/ATN: Patient has a Creatinine that peaked at 4.4, in
the setting of ATN most likely from vancomycin toxicity. Renal
was consulted and spun the urine at which time muddy brown casts
were visualized. While he was volume overloaded, there was no
indication for HD. We continued to diurese him and his Cr
continued improving with good urine output. His Cr at discharge
was 1.6. He is scheduled to follow up with nephrology as an
outpatient.
#MSSA Bacteremia/Endocarditis: Patients family reports he had a
purulent IV site several days after recent hospital discharge in
early ___ and this is a likely source for Staph aureus
bacteremia. Urine culture and blood culture positive for MSSA
that was sensitive to cefazolin. He was started on Vanc and
subsequently transitioned to cefazolin. We consulted the
infectious disease team, who recommended follow-up with a TEE to
evaluate for possible endocarditis. The TEE was performed and
showed a possible mitral valve vegetation versus a flail
leaflet. The cefazolin course will be 6 weeks for presumed
endocarditis and will complete on ___. After the
course, patient needs repeat blood culture and possibly a repeat
TEE which will be decided upon after completion of antibiotics.
#Encephalopathy: Etiology unclear but attributed to delirium
from prolonged hospitalization vs. sepsis. On the cardiology
service, his mental status continued to improve and he was AAOX3
after some diuresis and continued treatment of sepsis. He change
in mental status was felt to be due to sepsis or hypoxia due to
fluid overload. Patient had a head CT with findings of
leptomeningeal enhancement. A lumbar puncture was performed and
was negative for malignant cells and infection. Most likely
cause of the CT findings was a spontaneous CSF leak.
# Anemia: Source unclear, s/p 4U pRBC during hospitalization.
Most likely from leukemia in combination w/ ckd, anemia of
chronic disease. Initially there was suspicion of GI bleed but
EGD was negative and stool guiac negative. Hb was stable to
improving by time of discharge.
#Hematuria - patient occasionally reports gross hematuria with
stable H/H. Possibly from prolonged foley use. Urine culture was
negative. Urine was sent for cytology to evaluate for
malignancy. Patient needs to follow up with urology as an
outpatient and needs a CT urogram if his kidney function allows.
Otherwise further imaging is needed.
# Pancytopenia - most likely due to hairy cell leukemia. Patient
was not neutropenic during hospitalization. Received partial
rituximab dose. Counts were stable to improving by discharge.
# Hairy cell leukemia, Breast cancer: Receive fulvestrant for
breast cancer on ___. Received rituxan on ___ but had to be
stopped prematurely given infusion reaction with hypertension,
tachycardia, flushing, chills. Heme/onc held off treating
patient in-house given reaction and the low initial dose at
which the reaction occurred. Will follow up with his outpatient
oncologists for further evaluation and treatment.
# Moderate pulmonary hypertension seen on TTE when patient was
grossly hypervolemic. Most likely from hypervolemia. Consider
repeating TTE if there is further concern as an outpatient.
# Hyponatremia: Likely secondary to CHF vs SIADH in setting of
chronic disease. Na remained stable in the low 130s on a 1.5L
fluid restriction which he should continue as outpatient.
#Pain in ___ MTP of Left foot: Possibly gout vs musculoskeletal
pain. Was not erythematous and warm most likely due to patient's
low WBC and inability to mount large inflammatory response. Was
not treated given that patient cannot take NSAIDs, prednisone
(with possible endocarditis), or colchicine. Pain resolved after
a couple days and exam remained unremarkable.
#Right groin inguinal hernia: On ultrasound: 3.6 cm
predominantly fat containing right inguinal hernia,
corresponding to the swelling at the groin. This is better seen
on the recent CT, which demonstrated a small amount of fluid
versus a non-enlarged lymph node within the hernia sac. Surgery
evaluated hernia and recommended that it be monitored. On their
assessment a 1cm lymph node was visible within the hernia.
Should be followed up by outpatient oncologist.
Brief Summary of other issues
-- He had encephalopathy that improved with resolving infection
and diuresis. Head CT showed leptomeningeal enhancement but
lumbar puncture was negative for malignant cytology or
infection. Most likely cause of the enhancement was a
spontaneous CSF leak.
-- Patient had R first MTP pain possibly due to gout, untreated
due to risk for ___ and pancytopenia however the pain resolved
after a couple days.
-- Patient received fulvestrant for breast cancer and an attempt
was made to administer rituximab. However, he developed an
infusion reaction and rituximab had to be stopped.
-- A right inguinal hernia was noticed during the
hospitalization and evaluated by an ultrasound and seen on prior
CT. Surgery evaluated hernia and recommended that it be
monitored. On their assessment a 1cm lymph node was visible
within the hernia. Should be followed up by outpatient
oncologist.
-- Patient developed some gross hematuria and urine cytology was
sent which is pending. His Hb was stable. This should be
followed up with urology and CT urogram as an outpatient.
-- Patient had mild hyponatremia most likely from heart failure
and ADH secretion, however, was stable in the low 130s with a
1.5L daily fluid restriction which should be followed as
outpatient.
TRANSITIONAL ISSUES:
==================
[] patient needs blood cultures after completion of antibiotic
course - will be decided by infectious disease
[] consider repeat TEE after antibiotic course
[] patient needs to be re-evaluated again by cardiac surgery
after antibiotic course completion for potential surgical mitral
valve repair given mitral regurgitation - appointment scheduled
[] patient will need to follow up with the structural heart team
for possible mitral valve clip
[] started on warfarin for afib and set up with ___
___ clinic. Will need monitoring with INR goal ___
[] may need CT urogram as outpatient and follow up with urology
for gross hematuria
[] follow up CBC and anemia which is most likely from hairy cell
and anemia of chronic disease
[] patient has a right groin inguinal hernia with a 1cm lymph
node. Should be monitored as outpatient given history of
malignancy.
[] ensure patient following 1.5L fluid restriction
New Medications include: imdur, warfarin, hydralazine, warfarin,
omeprazole
Discharge weight: 62kg
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 2.5 mg PO BID
2. Atorvastatin 80 mg PO QPM
3. Metoprolol Succinate XL 12.5 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Eplerenone 12.5 mg PO DAILY
6. Potassium Chloride 20 mEq PO DAILY
7. sodium bicarb-sodium chloride 700-2,300 mg nasal DAILY
8. Sodium Chloride Nasal ___ SPRY NU QID
9. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
10. torsemide 40 mg oral DAILY
Discharge Medications:
1. Eplerenone 12.5 mg PO DAILY
RX *eplerenone 25 mg 0.5 (One half) tablet(s) by mouth once a
day Disp #*15 Tablet Refills:*0
2. Potassium Chloride 20 mEq PO BID
Hold for K >
RX *potassium chloride 20 mEq 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
3. Sodium Chloride Nasal ___ SPRY NU QID
4. Torsemide 80 mg PO DAILY
RX *torsemide 20 mg 4 tablet(s) by mouth once a day Disp #*120
Tablet Refills:*0
5. Metoprolol Succinate XL 12.5 mg PO DAILY
RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth
once a day Disp #*15 Tablet Refills:*0
6. HydrALAzine 40 mg PO TID
RX *hydralazine 10 mg 4 tablet(s) by mouth three times a day
Disp #*360 Tablet Refills:*0
7. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
RX *isosorbide mononitrate 30 mg 3 tablet(s) by mouth once a day
Disp #*90 Tablet Refills:*0
8. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
9. Warfarin 1.5 mg PO 4X/WEEK (___)
RX *warfarin 1 mg 1.5 tablet(s) by mouth Every ___,
___ Disp #*30 Tablet Refills:*0
10. Warfarin 1 mg PO 3X/WEEK (___)
RX *warfarin 1 mg 1 tablet(s) by mouth Every ___,
and ___ Disp #*30 Tablet Refills:*0
11. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
12. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth qpm Disp #*30 Tablet
Refills:*0
13. sodium bicarb-sodium chloride 700-2,300 mg nasal DAILY
14. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
15. Outpatient Lab Work
___: please check INR every other day at home and call the
result to:
Name: ___
Location: ___ ASSOCIATES
Address: ___, ___
Phone: ___
Discharge Disposition:
Home with Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
===============
MSSA Bacteremia
Pancreatitis
Acute on Chronic Diastolic Congestive Heart Failure
Acute Tubular Necrosis
Secondary Diagnoses
=================
Mitral Valve Insufficiency
Atrial Fibrillation
Hairy Cell Leukemia
Hematuria
Breast Cancer
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 bloodstream infection as well as
pancreatitis. During your stay, you developed fluid overload and
kidney injury requiring transfer to the cardiology service to
get rid off excess fluid. The fluid was removed with IV
medications and you improved. Your kidney function continued to
improve as well while you were inpatient. Our infectious disease
service saw you and recommended IV antibiotics for a total of 6
weeks which completed on ___.
We also stopped apixaban and started warfarin instead for your
atrial fibrillation. You will have close monitoring of your
blood work to make sure that the medication effect is the
correct amount.
While in the hospital you received treatment for your breast
cancer. You also received a dose of rituximab for the hairy cell
leukemia but you had a bad reaction to it. You will follow up
with the oncologists as an outpatient.
We also found an inguinal hernia that was evaluated by surgery
that can be monitored. There was also a lymph node within the
hernia that should be monitored by your oncologist.
If there are any questions or concerns, please call ___
and ask for Dr. ___ or Dr. ___ to be
paged to assist you.
Wishing you the best of health,
Your ___ Cardiology Team
Followup Instructions:
___
|
10207476-DS-41 | 10,207,476 | 28,276,158 | DS | 41 | 2180-03-26 00:00:00 | 2180-03-26 20:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Vancomycin / ___ Containing / Meropenem / Ceftriaxone
/ Ciprofloxacin / Flagyl / Levaquin / Aztreonam / moxifloxacin /
Bactrim / adhesive tape
Attending: ___
Chief Complaint:
Diastolic heart murmur heard at follow up
Major Surgical or Invasive Procedure:
___ trans esophageal echocardiogram under general anesthesia
History of Present Illness:
Patient is a ___ with history of CAD s/p inferior MI ___ s/p
DES to RCA and CABG (LIMA/LAD), HFrEF (LVEF 35%), paroxysmal AF
on xeralto, mild MR, aortic pseudoaneurysm s/p EVAR, and AML s/p
alloHSCT in ___ c/b GVHD (pulmonary) on prednisone who presents
with a new diastolic murmur.
Patient was evaluated by her PCP ___ and a new diastolic murmur
was appreciated on auscultation. Patient says that she has had
improving SOB related to GVHD (steroid dose increased over past
several weeks as below), though still endorsing exertional SOB
and bilateral ankle swelling that improves overnight after
sleeping. No chest pain or palpitations. No fevers. No
lightheadedness/dizziness. A discussion was had with patient's
outpatient cardiologist (Dr. ___ and oncologist (Dr. ___
who recommended transfer to ___ and admission to the
cardiology
service for urgent TTE to evaluate patient's pseudoaneurysm.
Of note, patient was last admitted to ___ ___
after presenting with fatigue and concern for bradycardia.
ECG/telemetry was notable for NSR with VPBs, patient was
evaluated by cardiology. She was set up with ___ monitor at
time of discharge.
Patient was evaluated in the CDAC ___ for three weeks of
gradually progressive exertional dyspnea iso prednisone taper.
Cause of her symptoms was unclear, no clinical evidence of heart
failure, ECG without any new rhythm disturbance or signs of
missed ACS. Recommendation to ___ with pulmonology to
evaluate for worsening pulmonary GVHD iso prednisone
downtitration. Prednisone was subsequently increased to 20mg qd
by her pulmonologist, patient noted improvement in her symptoms
by ___ (next visit ___.
Patient last saw her oncologist ___, periodic exacerbations
of restrictive airway disease noted (?GVHD). VQ scan was
obtained as well as CT chest. The former showed low likelihood
of PE. The latter did not show any evidence of GVHD or PNA,
size
of excluded pseudoaneurysm was unchanged since prior study
performed ___ (slowly increased though since ___. PFTs
were also obtained and demonstrated moderately severe
obstructive
ventilator defect with a mild to moderate gas exchange defect
(no
significant change in FVC, FEV1 and DLCO since ___.
As for the history of her descending aortic pseudoaneurysm
(patient follows with Dr. ___, she is s/p EVAR with a
Cook Alpha Device ___. She was last seen in vascular
surgery clinic ___. MRA had shown slight increase in
diameter with a type 3 endoleak, no real concern at the time
(thought to be largely stable). Plan to follow with repeat
study
in six months (contrast allergy, needs MR or noncontrast CT).
Patient was also noted to have a small AAA, to be followed with
imaging of the torso upon ___.
Past Medical History:
- AML diagnosed ___ on routine bloodwork showing pancytopenia;
bone marrow biopsy showed myelodysplasia without cytogenetic
abnormalities
- Repeat bone marrow biopsy showed acute erythroleukemia
- Admitted ___ for induction 7+3 with cytarabine and
idarubicin, day 14 marrow showed no blasts
- ___ allogeneic transplantation from an HLA matched sibling
donor with pentostatin/TBI in ___ c/b mild GVHD
- ___ course complicated by STEMI ___ with DES to
RCA ___ and CABG (___) ___
- Complicated by GVHD of the skin and lungs
PAST MEDICAL HISTORY:
- CAD s/p STEMI ___ with DES to RCA ___ and CABG (___)
___
- Afib on Xarelto
- Diverticulitis, hx of perforated diverticulum ___ course
complicated by multiple abdominal abscesses; sigmoidostomy with
___ pouch and colostomy; reversed ___
- CHF with EF ___
- Hypertension
- Hypercholesterolemia
- GERD
- Type II Diabetes Mellitus
- Diverticulosis
- Occasional Bronchospasm
- History of SVC clot ___ PORT (s/p course of lovenox)
- History of C.Diff ___ & ___
- VRE
- Shingles
- Asthma
- Basal Cell Carcinoma s/p electrodessication and curettage on
___
- s/p tonsillectomy at the age of ___
- D&C for question of some polyps back in ___
- Hospitalization for pneumonia ___ - ___
- Adrenal Insufficiency
Social History:
___
Family History:
Mother: CVA.
Father: ___ cancer.
Sister: HTN, ___.
Physical Exam:
Admission:
VS: 97.5 139/56 65 18 94 RA
GENERAL: NAD, pleasant in conversation.
HEENT: Anicteric sclera.
NECK: No JVP elevation.
CV: RRR, S1/S2, ___ systolic murmur heard throughout the
precordium (loudest at LSB), no appreciable diastolic murmur on
auscultation, no gallops or rubs.
PULM: CTAB, coarse inspiratory breath sounds at the bases.
GI: NABS, abdomen soft, nondistended, nontender in all
quadrants,
no rebound/guarding, no hepatosplenomegaly.
EXTREMITIES: Trace edema in the feet bilaterally.
PULSES: 2+ radial pulses bilaterally.
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric.
DERM: Warm and well perfused, no excoriations or lesions, no
rashes.
Discharge:
VS: 97.7, ___, HR ___, RR 18, 02 sat 98% RA
General: Pleasant woman sitting up in bed in NAD
Neuro: alert and oriented without focal ___, speech
clear and coherent
Cardiac: regular rate and rhythm, ___ systolic murmur heard best
LSB, no JVD
Lungs: CTA bilat, breathing regiular and unlabored
Abd: soft NT/ND
Extremities: warm and well perfused without edema
Skin: fragile thin skin with scattered ecchymotic areas BUE,
periorbital ecchymosis, mid lip ecchymosis and left check
echymosis
Pertinent Results:
Admission:
___ 09:29PM BLOOD ___
___ Plt ___
___ 09:29PM BLOOD ___ ___
___ 09:29PM BLOOD ___
___
___ 09:29PM BLOOD ___ cTropnT-<0.01 ___
___ 09:29PM BLOOD CK(CPK)-69
Discharge:
___ 08:14AM BLOOD ___
___ Plt ___
___ 08:14AM BLOOD ___ ___
___ 08:14AM BLOOD ___
___
___ Transthoracic echocardiogram:
CONCLUSION:
The left atrial volume index is mildly increased. The right
atrium is mildly enlarged. There is no evidence for an atrial
septal defect by 2D/color Doppler. The estimated right atrial
pressure is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with a normal cavity size. There is mild regional
left ventricular systolic dysfunction with akinesis of the
inferoseptum, inferior, and inferolateral walls (see schematic)
and preserved/normal contractility of the remaining segments. No
thrombus or mass is seen in the left ventricle. Quantitative
biplane left ventricular ejection fraction is 42 %. There is no
resting left ventricular outflow tract gradient. No ventricular
septal defect is seen. Normal right ventricular cavity size with
mild global free wall hypokinesis.
The aortic sinus diameter is normal for gender with normal
ascending aorta diameter for gender. The aortic arch diameter is
normal. There is a significant flow acceleration in the proximal
descending thoracic aorta,
consistent with stenosis in the descending aorta. (peak gradient
25mmHg /mean gradient 18mmHg ). A possible type A/ascending
aortic dissection is seen. The aortic valve leaflets (3) are
mildly thickened. A
moderate (0.6 x 0.2 cm) echodensity is seen on the aortic side
of the aortic valve most c/w a Lambl's excrescence (cannot
exclude a vegetation if clinically suggested). 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 an eccentric, inferolateral directed jet of mild to
moderate [___] mitral regurgitation. The tricuspid valve
leaflets appear structurally normal. There is mild [1+]
tricuspid regurgitation. The pulmonary artery systolic pressure
could not be estimated. There is no pericardial effusion.
IMPRESSION: Possible Type A aortic dissection. Moderate sized
mass attached to the coaptation point of the aortic valve
leaflets most consistent with a Lambl's excrescence. Mild
symmetric left ventricular hypertrophy with normal cavity size
and mild regional systolic dysfunction c/w CAD in an RCA
distribution. Mild to moderate mitral regurgitation. Mild aortic
regurgitation. Mild tricuspid regurgitation. Acceleration of
flow in the descending aorta consistent with stenosis.
___ Trans esophageal Echo:
Left Ventricle - Ejection Fraction: 45% >= 55%
Findings
Limited TEE exam to rule out Ascending aortic dissection. Exam
done with Dr. ___.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
AORTIC VALVE: No AS. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
___ VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Written informed consent was obtained from the
patient. The patient was under general anesthesia throughout the
procedure. The patient appears to be in sinus rhythm. Results
were personally reviewed with the MD caring for the patient.
Conclusions
Right ventricular chamber size and free wall motion are normal.
There is no aortic valve stenosis. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. There is no pericardial effusion.
Dr. ___ was notified in person of the results.
The descending thoracic aorta is seen and not does not show any
dissection. Distal ascending aorta and proximal arch not
visualized.
Brief Hospital Course:
Patient is a ___ with history of CAD s/p
inferior MI ___ s/p DES to RCA and CABG (LIMA/LAD), HFrEF
(LVEF 35%), paroxysmal AF on xeralto, mild MR, aortic aneurysm
s/p EVAR, and AML s/p alloHSCT in ___ c/b GVHD (pulmonary) on
prednisone who presents with concern for a new diastolic murmur.
ACUTE ISSUES:
# New diastolic murmur
# History of aortic pseudoaneurysm - Initial echo ___ with
concern for ascending aortic dissection, type A. Unable to do CT
with contrast d/t anaphylaxis allergy to contrast. TEE done
under general anesthesia with plan for cardiac surgery if
positive for dissection. TEE was reportedly negative for
dissection per
___.
-Continue to treat HTN (currently well controlled) with
Metoprolol
-F/U with outpt vasc surgery per prior as scheduled
Resolved:
# Hyperglycemia, glucosuria
# Type II Diabetes Mellitus - Patient hyperglycemic to 400s in
ED
with significant glucosuria. NEG ketones. VBG not concerning
for significant acidemia. She received 10U regular insulin with
improvement in FSBG to 191. Probable worsening of hyperglycemia
iso uptitrated prednisone over the past several weeks. Better
today but PO intake limited.
- F/U with PCP
- ___ home metformin, repaglinide and resume on dc
# Hyperkalemia - Mildly elevated K in the ED without any ECG
changes,
- K today 4.8
# Hyponatremia - Only iso hyperglycemia, corrected is 136.
-Na 143
# Elevated anion gap metabolic acidosis - No concern for HHS/DKA
as above.
- Resolved
CHRONIC ISSUES:
===============
# Coronary artery disease s/p PCI/CABG
- Continue home aspirin, statin; Metoprolol
# Chronic heart failure with reduced EF slightly improved EF on
___ echo
- Preload: patient is not currently on any diuretics
- NHBK: Continue Metoprolol
- Afterload: no issues with blood pressure at present
# Paroxysmal atrial fibrillation
- Rate control: Continue metoprolol
- AC: Continue rivaroxaban, dose reduced to 15mg as per pharmacy
initially due to reduced cre clearance on admit. Now back to
baseline ok to resume 20mg per ___
# ___ Myeloproliferative Disorder
# AML s/p Allogeneic Stem Cell Transplant complicated by GVHD
(pulmonary)
- Continue home prednisone 20mg qd, consider initiation of PCP
ppx
- ___ home hydroxyurea
- Continue home acyclovir, azithromycin ppx
- Continue home albuterol, fluticasone/salmeterol, montelukast
(umeclidinium ___
# Leukocytosis
# Thrombocytosis - Chronic, at recent baseline. Patient with
known myeloproliferative disorder, on prednisone.
- f/u with PCP/Onc
# Hypothyroidism
- Continue home levothyroxine
# Anxiety
- Continue home lorazepam prn (BID from q4h)
# GERD
- Omeprazole for home esomeprazole
- Continue home famotidine/calcium carbonate prn
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of
breath/wheezing
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Azithromycin 250 mg PO 3X/WEEK (___)
6. Calcium Carbonate 1500 mg PO DAILY:PRN heartburn
7. Cyanocobalamin 500 mcg PO DAILY
8. Famotidine 20 mg PO BID:PRN dyspepsia
9. ___ Diskus (500/50) 1 INH IH BID
10. Hydroxyurea 500 mg PO 3X/WEEK (___)
11. Levothyroxine Sodium 25 mcg PO DAILY
12. LORazepam 0.25 mg PO Q4H:PRN
nausea/vomiting/anxiety/insomnia
13. Metoprolol Tartrate 25 mg PO DAILY:PRN palpitations
14. Montelukast 10 mg PO DAILY
15. PredniSONE 20 mg PO DAILY
16. Rivaroxaban 20 mg PO DINNER
17. Vitamin D ___ UNIT PO DAILY
18. esomeprazole magnesium 20 mg oral BID
19. MetFORMIN (Glucophage) 500 mg PO BID
20. Metoprolol Succinate XL 50 mg PO DAILY
21. umeclidinium 62.5 mcg/actuation inhalation DAILY
22. Repaglinide 0.5 mg PO TIDAC
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of
breath/wheezing
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Azithromycin 250 mg PO 3X/WEEK (___)
6. Calcium Carbonate 1500 mg PO DAILY:PRN heartburn
7. Cyanocobalamin 500 mcg PO DAILY
8. esomeprazole magnesium 20 mg oral BID
9. Famotidine 20 mg PO BID:PRN dyspepsia
10. ___ Diskus (500/50) 1 INH IH BID
11. Hydroxyurea 500 mg PO 3X/WEEK (___)
12. Levothyroxine Sodium 25 mcg PO DAILY
13. LORazepam 0.25 mg PO Q4H:PRN
nausea/vomiting/anxiety/insomnia
14. MetFORMIN (Glucophage) 500 mg PO BID
15. Metoprolol Succinate XL 50 mg PO DAILY
16. Metoprolol Tartrate 25 mg PO DAILY:PRN palpitations
17. Montelukast 10 mg PO DAILY
18. PredniSONE 20 mg PO DAILY
19. Repaglinide 0.5 mg PO TIDAC
20. Rivaroxaban 20 mg PO DINNER
21. umeclidinium 62.5 mcg/actuation inhalation DAILY
22. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Heart murmur
aortic pseudoaneurysm s/p EVAR
Chronic heart failure with reduced EF
paroxysmal atrial fibrillation
coronary artery disease
Hyperglycemia
Discharge Condition:
___ events: Admitted from f/u at PCPs with question of a new
diastolic murmur
Subjective: Denies CP, back pain, abd pain, remains DOE but much
improved on increased prednisone
___ data:
VS:Temp: 97.7, ___ HR ___, RR 18, 02 sat 98% RA
Fluid Balance: I&O not documented
Tele: ___, SR with occasional PVCs
LABS: WBC 12.4, HGB 10.3, Hct 35.4, PLTS 428, BUN 15, Creat 1.1,
Na 143, K+ 4.8, CL 104, HC03 28
Physical Examination:
General: Pleasant woman sitting up in bed in NAD
Neuro: alert and oriented without focal ___, speech
clear and coherent
Cardiac: regular rate and rhythm, ___ systolic murmur heard best
LSB, no JVD
Lungs: CTA bilat, breathing regiular and unlabored
Abd: soft NT/ND
Extremities: warm and well perfused without edema
Skin: fragile thin skin with scattered ecchymotic areas BUE.
Periorbital, lip and left check ecchymosis
Current medications reviewed [x]
Labs/micro/radiology reviewed, pertinent below [x]
Assessment: Patient is a ___ with history of CAD s/p
inferior MI ___ s/p DES to RCA and CABG (LIMA/LAD), HFrEF
(LVEF 35%), paroxysmal AF on xeralto, mild MR, aortic aneurysm
s/p EVAR, and AML s/p alloHSCT in ___ c/b GVHD (pulmonary) on
prednisone who presents with concern for a new diastolic murmur.
ACUTE ISSUES:
# New diastolic murmur
# History of aortic pseudoaneurysm - Initial echo this am with
concern for ascending aortic dissection, type 1. Unable to do CT
with contrast d/t anaphylaxis allergy to contrast. ___ done
under
general anesthesia with plan for cardiac surgery if positive for
dissection. ___ was reportedly negative for dissection per
___.
-Continue to treat HTN (currently well controlled) with
Metoprolol
Facial ecchymosis: bruising noted where eyes were taped, ETT was
placed and tied/taped. Patient bruises easily due to Rivaroxaban
and Prednisone leaves her skin fragile. Patient states tape
frequently causes irritation and skin tears.
Ecchymosis will resolve without intervention.
-Tape added as allergy/adverse effect, plan to use gentle cloth
tape with all procedures
Resolved:
# Hyperglycemia, glucosuria
# Type II Diabetes Mellitus - Patient hyperglycemic to 400s in
ED
with significant glucosuria. NEG ketones. VBG not concerning
for significant acidemia. She received 10U regular insulin with
improvement in FSBG to 191. Probable worsening of hyperglycemia
iso uptitrated prednisone over the past several weeks.
- F/U with PCP
- ___ metformin, repaglinide
# Hyperkalemia - Mildly elevated K in the ED without any ECG
changes,
- K today 4.8
# Hyponatremia - Resolved: Only iso hyperglycemia, corrected is
136.
-Na 143 today
# Elevated anion gap metabolic acidosis - No concern for HHS/DKA
as above.
- Resolved
CHRONIC ISSUES:
===============
# Coronary artery disease s/p PCI/CABG
- Continue home aspirin, statin; Metoprolol
# Chronic heart failure with reduced EF slightly improved EF on
___ echo
- Preload: patient is not currently on any diuretics
- NHBK: Continue Metoprolol
- Afterload: no issues with blood pressure at present
# Paroxysmal atrial fibrillation
- Rate control: Continue metoprolol
- AC: Continue rivaroxaban, dose reduced to 15mg as per pharmacy
# ___ Myeloproliferative Disorder
# AML s/p Allogeneic Stem Cell Transplant complicated by GVHD
(pulmonary)
- Continue home prednisone 20mg qd, consider initiation of PCP
ppx
- ___ home hydroxyurea
- Continue home acyclovir, azithromycin ppx
- Continue home albuterol, fluticasone/salmeterol, montelukast
(umeclidinium ___
# Leukocytosis
# Thrombocytosis - Chronic, at recent baseline. Patient with
known myeloproliferative disorder, on prednisone.
- f/u with PCP/Onc as scheduled
# Hypothyroidism
- Continue home levothyroxine
# Anxiety
- Continue home lorazepam prn (BID from q4h)
# GERD
- Omeprazole for home esomeprazole
- Continue home famotidine/calcium carbonate prn
# PROPHYLAXIS:
- DVT prophylaxis with: Rivaroxaban
- Pain management with: Tylenol
- Bowel regimen with: Senna PRN
# Emergency contact:
# Family/HCP updated? yes, pt's husband at the bedside and
questions were answered to their apparent satisfaction
Dispo: Discharge home without services
Anticipate:
[x d/c home
[] d/c home with services
[] d/c to rehab/LTC
*** Above plan reviewed and discussed with Dr. ___
___ Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because your primary care doctor thought he
identified a new heart murmur and we were concerned that there
was a problem with the blood flow around your heart called an
aortic dissection.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- We preformed an echocardiogram which was inconclusive
- We therefore did a trans esophageal echocardiogram under
general anesthesia that did not show a dissection.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Take all of your medications as prescribed without changes.
- Follow up with your doctors including ___ your primary
care appointment to be seen within 10 days. You will ___
with Dr. ___ as scheduled. If you have any symptoms between
now and that appointment that are concerning, please call the
___ Cardiology Call Center at ___.
It was a pleasure participating in your care. We wish you the
best!
-Your ___ Care Team
Followup Instructions:
___
|
10207476-DS-42 | 10,207,476 | 28,884,246 | DS | 42 | 2181-05-22 00:00:00 | 2181-05-22 19:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Vancomycin / Iodine-Iodine Containing / Meropenem / Ceftriaxone
/ Ciprofloxacin / Flagyl / Levaquin / Aztreonam / moxifloxacin /
Bactrim / adhesive tape
Attending: ___
Major Surgical or Invasive Procedure:
NONE
attach
Pertinent Results:
DISCHARGE EXAM:
===============
24 HR Data (last updated ___ @ 351)
Temp: 97.6 (Tm 98.0), BP: 121/65 (104-142/58-79), HR: 61
(61-170), RR: 16 (___), O2 sat: 97% (94-97), O2 delivery: Ra
With ambulation:
HRs to ___
SpO2 95-97% RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round and reactive
CV: RRR, nl S1, S2, II/VI holosystolic murmur, no JVD.
RESP: bronchial BS RUL
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Lower ext warm without edema
SKIN: No rashes
NEURO: AOx3, CN II-XII intact, ___ strength all ext, sensation
grossly intact to light touch, gait not tested
PSYCH: pleasant, appropriate affect
ADMISSION LABS:
================
___ 04:31PM BLOOD WBC-10.8* RBC-2.90* Hgb-11.9 Hct-36.6
MCV-126* MCH-41.0* MCHC-32.5 RDW-17.5* RDWSD-82.8* Plt ___
___ 04:31PM BLOOD Neuts-56.3 ___ Monos-9.9 Eos-0.4*
Baso-0.2 NRBC-2.5* Im ___ AbsNeut-6.10 AbsLymp-3.38
AbsMono-1.07* AbsEos-0.04 AbsBaso-0.02
___ 04:31PM BLOOD Glucose-144* UreaN-25* Creat-1.4* Na-137
K-4.3 Cl-100 HCO3-22 AnGap-15
___ 04:46PM BLOOD ___ pO2-32* pCO2-38 pH-7.40
calTCO2-24 Base XS--1
___ 04:46PM BLOOD Lactate-3.2*
___ 12:12AM BLOOD Lactate-3.3*
___ 03:01AM BLOOD Lactate-1.6
OTHER:
======
Trop 0.01 -> <0.01, CK-MB 3->2
INR ___
Fibrinogen 261
LDH 258, Hapto 206
Ferritin 93, TIBC 256, Iron 89
B12 790, Folate 5
Retic 2.2%
TSH 2.1
Lact 3.2 --> 1.6
DISCHARGE LABS:
===============
___ 09:20AM BLOOD WBC-5.2 RBC-2.70* Hgb-11.1* Hct-34.2
MCV-127* MCH-41.1* MCHC-32.5 RDW-17.6* RDWSD-83.7* Plt ___
___ 09:20AM BLOOD Glucose-99 UreaN-26* Creat-1.2* Na-139
K-4.4 Cl-102 HCO3-23 AnGap-14
___ 09:20AM BLOOD Calcium-9.4 Phos-3.7 Mg-1.6
MICRO:
===========
Strep Ag: neg
Legionella Ag: neg
UA: negative
Sputum (___): contaminated
Flu A/B (___): negative
Resp viral (___): Ag negative, Cx pending
BCx (___): pending x 1
BCx (___): pending x 1
IMAGING:
========
EKG (___):
NSR at 69 bpm, borderline LAD, PR 122, QRS 102, QTC 477, Q in
II/III/AVF, T wave flattening lateral leads, TWI V1-V3
EKG ___ at 11:37):
Afib at 110 bpm, LAD, QRS 94, QTC 473, STE resolved in II,
___ ST depressions less prominent but TWI deeper
V2-V3
compared to earlier EKG
EKG ___ at 10:25):
Afib at 158 bpm, LAD, QRS 94, QTC 496, sub-MM STE II, ST
depressions I, AVL, V2-V6 (STE and ___ depressions
more prominent compared to ___
CXR (___):
There is consolidation in the right upper lobe, which appears
slightly improved compared to prior CT. No new consolidation is
identified. There is pleural effusion or pneumothorax. There is
an aortic arch stent. The cardiomediastinal silhouette is stable
in appearance. No acute osseous abnormalities are identified.
Compression deformities in the lower thoracic and upper lumbar
spine, some of which have been treated with kyphoplasty, are
unchanged.
R ___ (___):
No evidence of deep venous thrombosis in the visualized right
lower extremity veins.
CT torso w/o cont (___):
1. Right upper lobe pneumonia.
2. Status post aortic arch stenting with stable size of
excluded
aneurysm.
3. Stable size of an abdominal aortic aneurysm.
4. Vertebroplasty changes at the thoracolumbar junction with
newly evident compression fracture at T11 which appears subacute
to chronic.
5. Additional nonemergent findings as above.
Brief Hospital Course:
___ with history of CAD s/p inferior MI ___ s/p DES to RCA
and
CABG (LIMA/LAD), HFrEF (LVEF 42% ___, paroxysmal AF on
Xarelto, mild MR, asthma, thoracic aortic pseudoaneurysm s/p
EVAR, and AML s/p alloHSCT in ___ c/b pulmonary GVHD and JAK2+
myeloproliferative d/o (on hydrea) p/w sepsis secondary to RUL
PNA, with course c/b atrial fibrillation with RVR.
# Sepsis from RUL community acquired PNA:
# Chronic adrenal insufficiency:
# Dyspnea on exertion:
# AML s/p Allogeneic Stem Cell Transplant complicated by
pulmonary GVHD:
# Asthma:
Admitted to the FICU for fever and hypotension, c/w sepsis.
Likely source RUL PNA seen on CT torso (which also showed stable
aortic arch and abdominal aortic aneurysms, see below). Flu A/B
and resp viral panel negative. BCx NGTD. Received IVFs with
resolution of hypotension and clearance of lactic acidosis;
never
required pressors. Initially treated with Linezolid/Zosyn and
then Unasyn/Azithromcyin (given allergies), transitioned to
Augmentin/doxycycline to complete a 7d course through ___.
Given her chronic steroid use (for GVHD), received stress dose
hydrocortisone on ___, transitioned to double her home
prednisone (20mg in place of 9mg) on ___ and then back to her
home prednisone 9mg on ___. Given mild, persistent DOE, CXR
repeated ___ showing an improving RUL infiltrate without
pulmonary edema. She was seen by pulmonary, who did not believe
her pulmonary GVHD to be a significant contributor and
recommended continuing her home prednisone dose. Low suspicion
for asthma exacerbation in the absence of wheezing; home Advair
and montelukast were continued and home Incruse was held in
hospital and resumed on discharge. Cardiac etiology also thought
unlikely as below. Her mild, persistent dyspnea on exertion at
the time of discharge was attributed to resolving PNA and
deconditioning. Given her reassuring vital signs, she was
discharged home with close outpatient ___ (PCP ___ ___,
pulmonary
on ___, and cardiology on ___.
# Paroxysmal atrial fibrillation:
Hx of pAF for which she is maintained on metoprolol and Xarelto
and followed by outpatient cardiology. Presented in NSR. Given
hypotension, home Metoprolol was initially held. On ___,
triggered for afib w/RVR, likely secondary to resolving sepsis.
EKG showed anterolateral ST depressions, likely rate-related
strain, with low suspicion for ACS in absence of chest pain and
with negative troponins x 2. TSH WNL. Rates were controlled with
resumption of home Metoprolol, and she converted back to NSR
prior to discharge. Seen by cardiology, who recommended
continuation of her home Toprol 50mg daily. Home Xarelto 20mg
daily was continued throughout her hospitalization. ___ with her
outpatient cardiologist (Dr. ___ scheduled for ___.
# CAD s/p inferior MI:
# Chronic HFrEF (LVEF 42% ___:
# Mild MR:
CAD s/p inferior MI ___ s/p DES to RCA and CABG (LIMA/LAD)
with borderline chronic HFrEF (42% ___ followed by
cardiology. Developed Afib w/RVR ___epressions on EKG, likely rate-related strain with low
suspicion
for ACS per cardiology given absence of chest pain and negative
cardiac biomarkers. Repeat EKG after conversion to NSR showed
resolution of inferior ST depressions but persistent pre-cordial
TWI, likely memory T-waves and less concerning for ___ per
cardiology. Home ASA and lipitor were continued and home
Metoprolol was resumed as above. No e/o volume overload, and
weight on discharge 129 lbs, consistent with her dry weight.
Home
lisinopril held for borderline ___, as below. ___ with her
outpatient cardiologist (Dr. ___ scheduled for ___.
# HTN:
Presented with hypotension, which resolved as above. Home
Metoprolol initially held, resumed prior to discharge given
recurrent afib. Home lisinopril was held in hospital and on
discharge, to be resume by outpatient providers.
# ___:
Cr 1.4 on admission from baseline 0.8-1.1. Improved with IVFs to
1.0 on ___. Cr borderline elevated to 1.2 on the day of
discharge, without evidence of volume overload. Home lisinopril
was held this admission and on discharge. She was encouraged to
hydrate and will ___ with her PCP ___ ___, at which time a BMP
should be repeated and lisinopril resumed if appropriate.
# Type II DM:
In setting of chronic steroid use. Last documented A1C 8.7
___. Home metformin was held in hospital and on discharge
given borderline Cr elevation as above. Would recommend repeat
BMP at PCP ___ on ___ with resumption of metformin at that time
if renal function stable.
# AML s/p Allogeneic Stem Cell Transplant complicated by
pulmonary GVHD.
# JAK2-Positive Myeloproliferative Disorder:
Followed by Dr. ___. As above, mild dyspnea on exertion
attributed to resolving PNA. Low suspicion per pulmonary for
flare of pulmonary GVHD. Home Hydrea 1g BID was continued along
with ppx acyclovir. Home azithromycin ppx was held while
treating
with doxycycline; patient instructed to resume on ___ after
completion of doxycycline course.
# Recurrent vertebral fxs s/p kyphoplasty:
CT chest this admission showed a subacute to chronic compression
fx at T11, for which she has been managed conservatively and
follows with the pain service as an outpatient. Neurologic exam
was intact and she was pain free this admission. She will ___
with the pain clinic as previously scheduled on ___.
# History of aortic pseudoaneurysm:
# Thoracic aortic aneurysm s/p endovascular repair:
Thoracic aortic aneurysm s/p stent graft in ___. Imaging this
admission showed aortic arch stenting with stable size of
excluded aneurysm and stable size of AAA. Vascular surgery
consulted given presenting hypotension but were not concerned
for
ruptured aneurysm given imaging. She will ___ with her
outpatient
vascular surgeon (Dr. ___ on ___.
# Macrocytic anemia:
# Thrombocytopenia:
Hgb 11.9 on admission, nadired at 9.2 and improved to 11.1 at
discharge. Plt nadired at 136 and improved to 185 at discharge.
Likely secondary to sepsis and home Hydrea, with no e/o bleeding
or hemolysis. B12/folate WNL, and no e/o iron deficiency. Home
Hydrea was continued. She will ___ with hematologist Dr. ___
on ___.
# Hypothyroidism:
TSH WNL. Home levothyroxine continued.
# Anxiety:
Home lorazepam held in hospital, resumed on discharge.
# GERD
Continued home Dexlansoprazole.
# Contacts/HCP/Surrogate and Communication: Husband -___
# Code Status/Advance Care Planning: FULL (confirmed)
** TRANSITIONAL **
[ ] ___ BCx, pending at discharge
[ ] repeat BMP at PCP ___ on ___ Cr 1.2 at discharge (consider
resumption of home lisinopril and metformin at that time if
appropriate)
[ ] assess dyspnea on exertion at outpatient ___ attributed to
resolving PNA and deconditioning at discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath
3. Atorvastatin 40 mg PO QPM
4. Azithromycin 250 mg PO 3X/WEEK (___)
5. Dexilant (dexlansoprazole) 60 mg oral daily
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. Hydroxyurea 1000 mg PO DAILY
8. Levothyroxine Sodium 25 mcg PO DAILY
9. Lisinopril 2.5 mg PO BID
10. LORazepam 0.25 mg PO Q4H:PRN anxiety
11. MetFORMIN XR (Glucophage XR) 500 mg PO BID
12. Metoprolol Succinate XL 50 mg PO DAILY
13. Montelukast 10 mg PO DAILY
14. PredniSONE 9 mg PO DAILY
15. Repaglinide 0.5 mg PO BIDWM
16. Rivaroxaban 20 mg PO DAILY
17. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation
daily
18. Aspirin 81 mg PO DAILY
19. Vitamin D 1000 UNIT PO DAILY
20. Cyanocobalamin 500 mcg PO DAILY
21. Famotidine 20 mg PO BID:PRN dyspepsia
22. Metoprolol Tartrate 25 mg PO DAILY:PRN symptomatic
palpitations
23. loteprednol etabonate 0.38 % ophthalmic (eye) DAILY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1
tablet(s) by mouth twice a day Disp #*5 Tablet Refills:*0
2. Doxycycline Hyclate 100 mg PO BID
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day
Disp #*5 Tablet Refills:*0
3. Acyclovir 400 mg PO Q12H
4. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Cyanocobalamin 500 mcg PO DAILY
8. Dexilant (dexlansoprazole) 60 mg oral daily
9. Famotidine 20 mg PO BID:PRN dyspepsia
10. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
11. Hydroxyurea 1000 mg PO DAILY
12. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation
inhalation daily
13. Levothyroxine Sodium 25 mcg PO DAILY
14. LORazepam 0.25 mg PO Q4H:PRN anxiety
15. loteprednol etabonate 0.38 % ophthalmic (eye) DAILY
16. Metoprolol Succinate XL 50 mg PO DAILY
17. Metoprolol Tartrate 25 mg PO DAILY:PRN symptomatic
palpitations
18. Montelukast 10 mg PO DAILY
19. PredniSONE 9 mg PO DAILY
20. Repaglinide 0.5 mg PO BIDWM
21. Rivaroxaban 20 mg PO DAILY
22. Vitamin D 1000 UNIT PO DAILY
23. HELD- Azithromycin 250 mg PO 3X/WEEK (___) This
medication was held. Do not restart Azithromycin until ___
24. HELD- Lisinopril 2.5 mg PO BID This medication was held. Do
not restart Lisinopril until instructed by our outpatient
doctors
25. HELD- MetFORMIN XR (Glucophage XR) 500 mg PO BID This
medication was held. Do not restart MetFORMIN XR (Glucophage XR)
until instructed by our outpatient doctors
___:
Home
Discharge Diagnosis:
Sepsis
Community-acquired pneumonia
Atrial fibrillation with RVR
Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was our pleasure to care for you at ___.
You came to the hospital because you were feeling unwell.
WHAT HAPPENED?
- You were found to have a pneumonia
- We gave you antibiotics and fluids to help you feel better
- You received additional steroids and then placed back on your
home prednisone
- You have an episode of atrial fibrillation, which resolved by
the time of discharge
WHAT SHOULD YOU DO AT HOME?
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs in 1 day or 5 lbs in 1 week
- Please continue Augmentin and doxycycline through ___
- Do NOT take azithromycin while on doxycycline; you can resume
this medication on ___
- Do NOT take lisinopril or metformin until instructed by your
outpatient doctors
___ the best!
Sincerely,
Your care team at ___
Followup Instructions:
___
|
10207476-DS-43 | 10,207,476 | 28,601,579 | DS | 43 | 2181-07-15 00:00:00 | 2181-07-15 16:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Vancomycin / Iodine-Iodine Containing / Meropenem / Ceftriaxone
/ Ciprofloxacin / Flagyl / Levaquin / Aztreonam / moxifloxacin /
Bactrim / adhesive tape
Attending: ___.
Major Surgical or Invasive Procedure:
none
attach
Pertinent Results:
ADMISSION LABS
===============
___ 02:20PM WBC-3.9* RBC-2.86* HGB-12.5 HCT-37.6 MCV-132*
MCH-43.7* MCHC-33.2 RDW-19.3* RDWSD-95.3*
___ 02:20PM NEUTS-62 ___ MONOS-10 EOS-0* BASOS-0
NUC RBCS-14.7* AbsNeut-2.42 AbsLymp-1.09* AbsMono-0.39
AbsEos-0.00* AbsBaso-0.00*
___ 02:20PM POIKILOCY-2+* OVALOCYT-1+* SCHISTOCY-1+*
ECHINO-1+* TEARDROP-1+* HOW-JOL-1+* RBCM-SLIDE REVI
___ 02:20PM ___ PTT-24.3* ___
___ 02:20PM CORTISOL-4.0
___ 02:20PM ALBUMIN-3.7 CALCIUM-8.4 PHOSPHATE-1.6*
MAGNESIUM-1.7
___ 02:20PM cTropnT-0.02*
___ 02:20PM LIPASE-25
___ 02:20PM ALT(SGPT)-18 AST(SGOT)-19 ALK PHOS-47 TOT
BILI-0.4
___ 02:20PM GLUCOSE-113* UREA N-11 CREAT-1.1 SODIUM-136
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-21* ANION GAP-14
___ 02:27PM LACTATE-1.6
___ 05:48PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR* BILIRUBIN-NEG UROBILNGN-NORMAL PH-6.0
LEUK-NEG
___ 05:48PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 07:00PM OTHER BODY FLUID FluAPCR-NEG FluBPCR-NEG
___ 07:54PM cTropnT-0.02*
PERTINENT LABS
================
___ 10:40AM BLOOD Ret Aut-2.4* Abs Ret-0.06
___ 07:40AM BLOOD ___ 10:40AM BLOOD ___ 10:40AM BLOOD Albumin-3.1* Iron-104
___ 10:40AM BLOOD calTIBC-216* VitB12-1612* Folate-8
___ Ferritn-154* TRF-166*
___ 07:55AM BLOOD TSH-5.3*
___ 07:40AM BLOOD Free T4-1.2
___ 12:03AM BLOOD Lactate-3.4*
DISCHARGE LABS
================
___ 07:25AM BLOOD WBC-3.5* RBC-2.13* Hgb-9.2* Hct-29.0*
MCV-136* MCH-43.2* MCHC-31.7* RDW-19.4* RDWSD-96.4* Plt Ct-81*
___ 07:25AM BLOOD Neuts-65 ___ Monos-9 Eos-2 Baso-0
NRBC-11.2* AbsNeut-2.28 AbsLymp-0.84* AbsMono-0.32 AbsEos-0.07
AbsBaso-0.00*
___ 07:25AM BLOOD Anisocy-1+* Poiklo-1+* Macrocy-3+*
Polychr-1+* Ovalocy-1+* Schisto-1+* How-Jol-1+* Acantho-1+* RBC
Mor-SLIDE REVI
___ 07:25AM BLOOD Plt Smr-LOW* Plt Ct-81*
___ 07:25AM BLOOD ___ PTT-26.3 ___
___ 07:25AM BLOOD Glucose-115* UreaN-14 Creat-1.0 Na-139
K-4.2 Cl-102 HCO3-21* AnGap-16
___ 07:25AM BLOOD Calcium-7.7* Phos-2.8 Mg-1.8
MICROBIOLOGY
=============
___ 2:20 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 5:48 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 6:39 pm
BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:29 am Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
PERTINENT IMAGING
=================
___ CHEST XRAY: Lungs are hyperinflated. No focal
consolidation. No pleural effusion or pneumothorax.
Cardiomediastinal silhouette is within normal limits. Stent
material in the aortic arch is noted. Coronary artery stents
are also noted. Multiple lower thoracic vertebral compression
deformities some containing cement are unchanged.
___ CT CHEST: 1. New ground-glass opacifications in the
right upper lobe concerning for infection.
2. Scattered pulmonary nodules measure up to 4 mm, follow-up is
recommended per the ___ criteria (no CT follow-up is
recommended in a low-risk patient, and an optional CT follow-up
in 12 months is recommended in a high-risk patient).
3. Stable size of the excluded aortic arch aneurysm.
4. Cholelithiasis.
Brief Hospital Course:
PATIENT SUMMARY STATEMENT FOR ADMISSION
=========================================
Ms. ___ is a ___ female with AML s/p alloSCT in
___ complicated by pulmonary GVHD, secondary JAK2+
myeloproliferative disease/essential thrombocytosis on hydrea,
thoracic aneurysm s/p stent graft ___, asthma, paroxysmal atrial
fibrillation on Xarelto, MI s/p CABG, adrenal insufficiency on
prednisone, DMII, HFrEF (LVEF 42% ___, and vertebral
fractures s/p kyphoplasty. She presented with weakness, fever,
and worsening shortness of breath . Admitted for likely PNA vs.
worsening GVHD.
TRANSITIONAL ISSUES
====================
Discharge weight: 57.52 kg - 126.8 lbs
Discharge Cr: 1.0
Discharge Hgb: 9.2
Discharge ANC: 2.28
Discharge platelets: 81
[ ] Follow-up with Dr. ___ ___ - will arrange sooner
follow-up with NP
[ ] Follow-up cell counts to consider need for repeat bone
marrow biopsy
[ ] Consider restarting hydroxyurea, which was held while
inpatient in the setting of pancytopenia
[ ] Consider restarting lisinopril which was held while
inpatient due to soft blood pressure
[ ] Recheck thyroid function tests given finding of slightly
high TSH with normal free T4
ACUTE MEDICAL ISSUES ADDRESSED
=================================
# Fever / SOB
# Pneumonia
# ? Worsening Pulmonary GVHD
Patient presented with fever, weakness, worsening shortness of
breath and cough. Unclear etiology given CXR, UA, and flu swab
negative. She had documented fever to 101.4 in the ED. Her RVP
was negative but CT chest reported possible pneumonia.
Additional concern for worsening GVHD in setting of recent
decreased dose of prednisone. Patient received full course of
antibiotic for pneumonia (piperacillin/tazobactam). Additionally
steroid dosing was increased temporarily in the setting of
worsening SOB, fevers and known secondary adrenal insufficiency.
Throughot admission shortness of breath and cough improved
significantly and therefore we restarted steroid taper.
# Secondary adrenal insufficiency
Given patient's history of secondary adrenal insufficiency and
fever as above with need for 3L NS for normalization of lactate
in setting of recent decreased prednisone dose, we tripled the
patient's prednisone dose to 30 mg daily. Prior to discharge we
restarted steroid taper which was tolerated with no new
symptoms.
#Pancytopenia
Pt with worsening pancytopenia on presentation which was
different from her baseline. Plan was for bone marrow biopsy on
___ but counts remained stable and uptrended slightly
throughout admission. Bone marrow biopsy was deferred but as a
transitional issue patient needs to follow blood cell count
trends to determine the need for repeat bone marrow biopsy.
# JAK2-Positive Myeloproliferative Disorder
# AML s/p Allogeneic Stem Cell Transplant complicated by
Pulmonary GVHD
Patient admitted with pancytopenia as above and therefore
hydroxyurea was held. Prednisone dose was also increased as
detailed above. She was continue on her home acyclovir, Advair,
Montelukast.
CHRONIC ISSUES PERTINENT TO ADMISSION
=======================================
# CAD s/p CABG
# Chronic HFrEF (LVEF 42% ___
# Mild MR
- Patient continued on home ASA, Lipitor, metoprolol, and
lisinopril
# DMII: In setting of chronic steroid use.
- Held home metformin and managed with ISS while inpatient
# Paroxysmal Atrial Fibrillation
- Patient continued on home metoprolol and rivaroxaban
- One dose of rivaroxaban was held in anticipation of bone
marrow biopsy but was restarted soon after decision to defer.
# Hypothyroidism
___ checked and found to be slightly high with normal free T4
- Patient continued on home levothyroxine
# Anxiety
- Patient continued on home Ativan PRN
# GERD
- Patient continued on home dexlansoprazole as non-formulary
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Cyanocobalamin 500 mcg PO DAILY
4. Famotidine 20 mg PO BID:PRN dyspepsia
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. Hydroxyurea 1000 mg PO DAILY
7. Levothyroxine Sodium 25 mcg PO DAILY
8. PredniSONE 10 mg PO DAILY
9. Rivaroxaban 20 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of
breath/wheezing
12. LORazepam 0.25 mg PO Q4H:PRN
nausea/vomiting/anxiety/insomnia
13. Metoprolol Succinate XL 50 mg PO DAILY
14. Metoprolol Tartrate 25 mg PO DAILY:PRN symptomatic
palpitations
15. Montelukast 10 mg PO DAILY
16. Acyclovir 400 mg PO Q12H
17. Azithromycin 250 mg PO 3X/WEEK (___)
18. Lisinopril 2.5 mg PO BID
19. MetFORMIN XR (Glucophage XR) 500 mg PO BID
20. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation IH DAILY
21. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit PO DAILY
22. Dexilant (dexlansoprazole) 60 mg PO DAILY
23. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic (eye)
BID
24. Lotemax (loteprednol etabonate) 0.5 % ophthalmic (eye) DAILY
Discharge Medications:
1. PredniSONE 10 mg PO DAILY
Start this dose on ___
2. Ramelteon 8 mg PO QPM:PRN insomnia
RX *ramelteon 8 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*2
3. PredniSONE 20 mg PO DAILY Duration: 3 Doses
4. Rivaroxaban 15 mg PO DINNER
5. Acyclovir 400 mg PO Q12H
6. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of
breath/wheezing
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 40 mg PO QPM
9. Azithromycin 250 mg PO 3X/WEEK (___)
10. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit PO DAILY
11. Cyanocobalamin 500 mcg PO DAILY
12. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic (eye)
BID
13. Dexilant (dexlansoprazole) 60 mg PO DAILY
14. Famotidine 20 mg PO BID:PRN dyspepsia
15. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
16. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation IH DAILY
17. Levothyroxine Sodium 25 mcg PO DAILY
18. LORazepam 0.25 mg PO Q4H:PRN
nausea/vomiting/anxiety/insomnia
19. Lotemax (loteprednol etabonate) 0.5 % ophthalmic (eye)
DAILY
20. MetFORMIN XR (Glucophage XR) 500 mg PO BID
21. Metoprolol Succinate XL 50 mg PO DAILY
22. Metoprolol Tartrate 25 mg PO DAILY:PRN symptomatic
palpitations
23. Montelukast 10 mg PO DAILY
24. Vitamin D 1000 UNIT PO DAILY
25. HELD- Hydroxyurea 1000 mg PO DAILY This medication was
held. Do not restart Hydroxyurea until Dr. ___ you to
do so
26. HELD- Lisinopril 2.5 mg PO BID This medication was held. Do
not restart Lisinopril until your PCP tells you to do so
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
- Community acquired pneumonia
- Possible rosined graft versus host disease
SECONDARY DIAGNOSES
====================
- Acute myelogenous leukemia status post allogeneic stem cell
transplant and myeloproliferative disorder
- Secondary adrenal insufficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a privilege taking care of you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted because you were having fevers and increased
shortness of breath and cough
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We investigated the different possible causes for your fever.
- We believe the fever and shortness of breath were most likely
caused by a pneumonia that initially was a viral infection and
could have been superinfected by a bacteria.
- Also as you had history of pulmonary graft versus host
disease, we increased your prednisone temporarily to cover the
possibility of GVHD flare.
- Initially your blood counts were dropping and this initially
made us consider that you could need a bone marrow biopsy.
However, your blood counts recovered while getting the treatment
for pneumonia and biopsy was not necessary.
- You successfully finished the antibiotic course for the
pneumonia
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:
___
|
10207925-DS-16 | 10,207,925 | 21,126,849 | DS | 16 | 2173-06-22 00:00:00 | 2173-06-23 14:15:00 |
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:
___ Exploratory laparotomy, lysis of adhesions
History of Present Illness:
HISTORY OF PRESENT ILLNESS: ___ with 48 hours of abdominal pain
and 36 hours of vomiting. Reportedly the patient was in her
usual state of health until earlier this week when she had the
onset of severe diffuse abdominal pain. This was accompanied by
copious vomiting which has been initially non-bilious, but this
evening has become slightly brownish in character. She denies
green emesis. She states that she had a small volume of stool
one day prior to admission but has had no stool for the past 24
hours prior to admission and did not feel like she is passing
gas. She denies fevers. She denies syncope. She denies sick
contacts.
Past Medical History:
Past Medical History: Arthritis, asymptomatic gallstones,
hypertension, low back pain, hyperparathyroidism,
hypothyroidism, osteoporosis, spinal stenosis.
Past Surgical History:
1. Parathyroidectomy
2. Cataract surgery.
3. Hip replacement and revision in ___ and ___
right knee replacement in ___.
Past OB History: Three pregnancies, total three vaginal
deliveries. Birth weight of largest baby delivered vaginally 8
pounds. No forceps or vacuum-assisted vaginal delivery.
Past GYN History: Menopause at age ___.
Social History:
___
Family History:
Father, brain tumor. Sister has some kind of cancer, unknown to
the patient.
Physical Exam:
PHYSICAL EXAMINATION
Temp: 98.4 HR: 90 BP: 155/89 Resp: 18 O(2)Sat: 100 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nondistended, positive bilateral lower
quadrant tenderness, left lower quadrant greater than right
lower quadrant. No peritoneal findings.
GU/Flank: No costovertebral angle tenderness
Skin: Warm and dry
Neuro: Speech fluent
Psych: Normal mood
Pertinent Results:
___ 05:40AM BLOOD Hct-33.2*
___ 05:44AM BLOOD WBC-5.5 RBC-3.26* Hgb-10.3* Hct-30.9*
MCV-95 MCH-31.6 MCHC-33.2 RDW-13.8 Plt ___
___ 05:44AM BLOOD Plt ___
___ 05:40AM BLOOD Glucose-100 UreaN-8 Creat-0.9 Na-136
K-4.5 Cl-99 HCO3-26 AnGap-16
___ 05:44AM BLOOD Glucose-111* UreaN-11 Creat-1.0 Na-134
K-4.0 Cl-99 HCO3-27 AnGap-12
___ 08:35PM BLOOD ALT-14 AST-24 AlkPhos-69 TotBili-0.6
___ 05:40AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.0
___ 11:03AM BLOOD Lactate-0.9
___: EKG:
Sinus rhythm with delayed A-V conduction. Complete left
bundle-branch block.
Repolarization ST-T wave changes. Compared to the previous
tracing of ___ the rate is faster.
___: cat scan of abdomen and pelvis:
IMPRESSION:
1. Hign grade small bowel obstruction with transition point in
the right lower abdomen, likely in the proximal ileum. Small
amount of free fluid surrounds dilated loops of bowel and there
is mild mesenteric edmea. Some bowel loops appear to have
decreased mucosal enhancement, concerning for early ischemia,
though the vascular supply appears normal. No pneumatosis or
portal venous gas at this time.
2. Multiple colonic diverticulosis without associated
inflammatory changes.
3. Cholelithiasis without acute cholecystitis.
___: chest x-ray:
FINDINGS: Nasogastric tube extends to the mid to lower portion
of the body of the stomach. There is enlargement of the cardiac
silhouette without definite vascular congestion or pneumonia.
___: EKG:
Sinus rhythm. The P-R interval is prolonged. Left bundle-branch
block.
Compared to the previous tracing of ___ there is no
significant change.
Brief Hospital Course:
___ year old female admitted to the acute care service with
abdominal pain. Upon admission, she was made NPO, given
intravenous fluids, and underwent imaging. She was also noted to
have a mild elevation in the white blood cell count. A cat scan
showed a small bowel obstruction with a transition point likely
in the right lower abdomen. The patient was placed on bowel rest
and a ___ tube was placed for bowel decompression.
Despite these measures, the patient continued to have abdominal
pain and was taken to the operating room on HD # 3 where she
underwent an exploratory laparotomy and lysis of adhesions. An
epidural catheter was placed for pain management in the holding
area. Intra-operative findings included copious amount of
hemorrhagic ascites in the abdomen as well as dilated bowel in
its mid portion, as well as an area in the bowel which was
ischemic. The operative course was stable with a 50cc blood
loss. The patient was extubated after the procedure and
monitored in the recovery room.
The post-operative course was stable. The ___ tube was
removed by the patient on the operative day. The patient's
surgical pain was controlled with the epidural catheter. The
patient was started on sips after return of bowel function and
gradually advanced to a regular diet. Initially the patient
experinced bouts of nausea which were controlled with zofran.
Her vital signs remained stable and electrolytes were monitored
and repleted. On POD #3, the patient was reported to have mild
erythema around the mid-abdomen and was started on a week course
of kefzol. Over 48 hours, the intensity of the erythema
decreased. The epidural catheter was removed on POD # 3 and the
patient was transitioned to oral analgesia. In preparation for
discharge, the patient was evaluated by physical therapy.
Because of the patient's deconditioning, recommendations were
made for discharge to rehabilitation facility. The patient was
discharged on POD #6 with stable vital signs and a normalized
white blood cell count. Instructions for follow-up with the
acute care service were formalized.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amitriptyline 10 mg PO HS
2. Amlodipine 5 mg PO DAILY
3. Carvedilol 12.5 mg PO QAM
4. Carvedilol 25 mg PO HS
5. Hydrochlorothiazide 25 mg PO DAILY
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Lisinopril 10 mg PO HS
8. Pantoprazole 40 mg PO QAM
9. Cyanocobalamin 1000 mcg PO DAILY
10. Ferrous Sulfate 325 mg PO DAILY
11. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv
with min-lycopene-lutein;<br>mv-min-folic acid-lutein) Oral
daily
12. Citracal Regular *NF* (calcium citrate-vitamin D3) 250-200
mg-unit Oral daily
Discharge Medications:
1. Amitriptyline 10 mg PO HS
2. Amlodipine 5 mg PO DAILY
3. Carvedilol 12.5 mg PO QAM
4. Carvedilol 25 mg PO HS
5. Hydrochlorothiazide 25 mg PO DAILY
6. Acetaminophen 325-650 mg PO Q6H:PRN pain
7. Bisacodyl 10 mg PR HS:PRN constipation
8. Cephalexin 500 mg PO Q6H Duration: 8 Days
last dose ___
9. Docusate Sodium 100 mg PO BID
10. Heparin 5000 UNIT SC TID
11. Senna 1 TAB PO BID
12. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
13. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv
with min-lycopene-lutein;<br>mv-min-folic acid-lutein) 0 tablet
ORAL DAILY
14. Citracal Regular *NF* (calcium citrate-vitamin D3) 250-200
mg-unit Oral daily
15. Cyanocobalamin 1000 mcg PO DAILY
16. Ferrous Sulfate 325 mg PO DAILY
17. Levothyroxine Sodium 75 mcg PO DAILY
18. Lisinopril 10 mg PO DAILY
19. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent (speaks ___, limited
___
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with abdominal pain and
vomitting. A cat scan was done which showed a small bowel
obstruction. You were placed on bowel rest and a ___
tube was placed. Because your bowel was slow to recover, you
were taken to the operating room for an exploratory laparotomy
and release of adhesions. You are slowly recovering from your
surgery and preparing for discharge to a rehabilitation facility
where you can regain your strength and mobility.
Followup Instructions:
___
|
10208053-DS-15 | 10,208,053 | 24,398,147 | DS | 15 | 2135-01-13 00:00:00 | 2135-01-13 20:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
Pacemaker placement (___)
Direct current cardioversion (___)
History of Present Illness:
___ male h/o HTN, HLD, DMII, CKD (baseline Cr 1.3),
severe AS s/p bioprosthetic valve AVR presenting to the
emergency department with weakness, syncope yesterday. He
reports yesterday he felt that it was going to pass out and then
had a syncopal episode striking his head. Today he continues to
feel weak and unwell. He noted that his heart rate was slow at
home. Denies any chest pain, shortness of breath, abdominal
pain. No fevers or chills.
In the ED, initial vitals BP:183/54 HR: 36, RR: 14, O2Sat: 98,
O2Flow: 2 lnc. Nl WBC, Chem 7 normal with exception of his Cr is
1.7 (unknown baseline). BNP 1586. CXR No definite acute
cardiopulmonary process. Head CT no acute intracranial process.
EKG showed bradycardia to ___ with type I second degree heart
block.
Past Medical History:
- Severe Aortic Stenosis s/p bioprosthetic valve
- Hypertension
- Hyperlipidemia
- Diabetes mellitus Type II
- GERD
- Obesity
- Renal Insufficieny (baseline Cr 1.3)
- small scrotal hernia
- allergic rhinitis
- atrial fibrillation
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Upon Admission:
=========================================
VS: T= 98.0 BP=174/110 .HR=35. RR=18. O2 sat=98%RA
GENERAL: Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 7 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Upon Discharge: Exam remained unchanged except for HR increased
70. Sinus rhythm paced
===========================
Pertinent Results:
___ 12:40PM BLOOD WBC-7.5 RBC-4.99 Hgb-15.3 Hct-45.5 MCV-91
MCH-30.7 MCHC-33.6 RDW-13.7 Plt ___
___ 05:40AM BLOOD Glucose-150* UreaN-31* Creat-1.7* Na-140
K-4.4 Cl-104 HCO3-25 AnGap-15
___ 12:40PM ___ PTT-28.7 ___
___ 12:40PM cTropnT-<0.01
___ 12:40PM proBNP-1586*
___ Head CT without contrast:No acute intracranial process.
Mild age-related atrophy.
___ CXR: No pneumothorax. Pacemaker leads in satisfactory
position.
Brief Hospital Course:
___ male h/o HTN, HLD, DMII, CKD (baseline Cr 1.3),
severe AS s/p bioprosthetic valve AVR.
Active Issues
=======================
#Syncope: The differential for syncope includes vasovagal event,
orthostasis, arrhythmias, aortic stenosis. Most likely diagnosis
is bradycardia given EKG shown third degree heart block with HR
___. Upon arrival to floor, EKG appeared to be 3rd degree heart
block. Unlikely to be aortic stenosis causing syncope given his
recent syncopal event given that he is s/p prosthetic AVR.
Metoprolol was held and his third degree heart block did not
improve. Cardiac electrophysiology was consulted and he received
a dual chamber pacemaker on ___. Prior to the procedure, he
was found to be in atrial flutter and had direct current
cardioversionx2 and then placed on propafenone ___ po BID. He
tolerated the procedure well without complications. CXR on the
day after pacemaker implantation confirmed proper pacemaker lead
placement. The day after pacemaker was placed, it was
interrogated and determined to be functioning properly. He
received a total of 3 days of keflex.
.
#A.fib (not on coumadin): Patient had history of a.fib that was
transient in the setting of AVR. He was on coumadin for
approximately 6 weeks s/p AVR as per patient. He was rate
controlled with metoprolol, which was discontinued upon
discharge (see above). Patient had an episode of atrial flutter
prior to pacemaker placement. He received direct current
cardioversionx2 which returned him to sinus rhythm. He was also
placed on propafenone ___ po bid.
.
Inactive Issues
================================
#Hypertension: Upon arrival to the floor, the patient was
hypertensive to SBPs 170/65 and bradycardic to ___.
#Severe aortic stenosis s/p bioprosthetic AVR
#DM: he was maintained on an insulin sliding scale during
admission.
.
Transitional Issues:
================================
-brief episode of atrial flutter may require further management
for arrhythmia
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Metoprolol Succinate XL 50 mg PO DAILY
hold SBP<100 HR<50
2. Simvastatin 20 mg PO DAILY
3. GlipiZIDE 2.5 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Furosemide 20 mg PO DAILY:PRN lower extremity swelling
6. FoLIC Acid 1 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Fexofenadine 180 mg PO DAILY
Discharge Medications:
1. Simvastatin 20 mg PO DAILY
2. Propafenone HCl 225 mg PO BID
RX *propafenone ___ mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
3. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. FoLIC Acid 1 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Cephalexin 500 mg PO Q8H Duration: 2 Days
RX *cephalexin 500 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*7 Tablet Refills:*0
7. GlipiZIDE 2.5 mg PO DAILY
8. Furosemide 20 mg PO DAILY:PRN lower extremity swelling
9. Fexofenadine 180 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Third degree heart block
Atrial flutter
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 taking care of you here at ___
___.
You came in because you had an episode of syncope and hit your
head. Your head cat-scan showed nothing abnormal. While in ED,
you were found to have a very slow irregular heart rate called
heart block. You had a pacemaker placed on ___. You were
found to have a very fast irregular heart rate called atrial
flutter. Before you had the pacemaker placed you received direct
current cardioversion, which made you have a normal heart rate.
On ___, your device was examined and was shown to be
functioning properly. A CXR that day confirmed that the leads
were properly placed. You were started on antibiotic called
cefazolin. You will need this for a total of 3 days (stop on
___.
The following changes were made to your medications:
-STOP Metoprolol
-START cefazolin (Keflex) 500mg three times a day for a total of
2 more days (stop on ___
-START Propafenone ___ mg twice daily, Dr. ___ will discuss
if you will need this medication for the long term.
Followup Instructions:
___
|
10208178-DS-10 | 10,208,178 | 26,400,939 | DS | 10 | 2145-05-13 00:00:00 | 2145-05-13 19:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / latex / nitrofurantoin
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH significant for ?MI, Afib on coumadin, HTN, s/p
PPM who presents with acute onset chest pain, which started
while patient was sitting up in bed. The pain was located under
her right breast, and was described as dull, rated ___. The
pain spontaneously resolved in a "few minutes". Patient denies
associated shortness of breath or diaphoresis. She does report
some nausea. Patient denies any fever, chills, vomiting, or new
cough (she has a cough at baseline), orpthopnea, PND, abdominal
pain, and pain with urination. Patient received 2 baby aspirin
at ___ and EMS was called. En route, EMS gave the
patient sublingual nitro x 2.
In the ED, initial vitals were: 97.8 BP173/99 P64 RR18 97% on
RA. Troponins were negative x 2. EKG was difficult to interpret
as she is paced. Of note there is artifact secondary to bladder
stimulator. CXR significant for retrocardiac opacity, concerning
for consolidation vs pleural fluid. Patient was started on a
heparin drip prior to being transported to the floor.
On arrival to the floor, patient reports feeling well. She
denied any chest pain or SOB. Of note, patient was recently seen
at ___ for cough. Pulmonary work up was done,
however we do not have records. Patient does not report having a
recent stress test.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies shortness of breath. Denies palpitations.
Denies diarrhea, constipation or abdominal pain. No dysuria.
Denies arthralgias or myalgias. Ten point review of systems is
otherwise negative.
Past Medical History:
? Silent MI- diagnosed over ___ years ago, no history of CABG or
PCI.
Atrial fibrillation on coumadin
Hypertension
s/p PPM
Hypothyroidism
Arthritis
Bipolar, depressive
___
Anxiety
Glaucoma
Constipation
Incontinence
Insomnia
Venous thrombosis
S/p bladder stimulator placement
Social History:
___
Family History:
Non-contributory.
Physical Exam:
ON ADMISSION
VS: T98.4 BP144/71 P63 RR18 96RA
General: Sitting in bed, appears comfortable. Pleasant. No acute
distress.
HEENT: Moist mucous membranes.
Neck: Supple, no JVD.
CV: Regular rate and rhythm. Normal S1, S2. No S3, S4 or
murmurs.
Lungs: Course breath sounds with bibasilar crackles. No wheezes.
Abdomen: +BS, soft, nondistended, nontender to palpation.
Ext: Warm and well perfused. Pulses 2+. No peripheral edema.
Neuro: CN II-XII grossly intact. Tremor noted in jaw and
fingertips. moving all extremities grossly.
ON DISCHARGE
VS: T98.0 BP160/72 P62 RR20 91RA
General: Laying in bed, appears comfortable, pleasant, no acute
distress.
HEENT: Moist mucous membranes.
Neck: Supple, no JVD.
CV: Regular rate and rhythm. Split S1? Normal S2. No S3, S4. ___
systolic murmur loudest at apex.
Lungs: Clear to auscultation bilaterally. No wheezes or
crackles.
Abdomen: +BS, soft, nondistended, nontender to palpation.
Ext: Warm and well perfused. Pulses 2+. No peripheral edema.
Neuro: CN II-XII grossly intact. Tremor noted in jaw and
fingertips. moving all extremities grossly.
Pertinent Results:
ON ADMISSION
___ 02:28PM BLOOD WBC-9.8 RBC-3.61* Hgb-10.3* Hct-34.4*
MCV-95 MCH-28.4 MCHC-29.8* RDW-15.8* Plt ___
___ 02:28PM BLOOD Neuts-79.2* Lymphs-12.6* Monos-5.9
Eos-2.0 Baso-0.3
___ 02:28PM BLOOD ___ PTT-28.3 ___
___ 02:28PM BLOOD Glucose-84 UreaN-11 Creat-0.5 Na-139
K-4.2 Cl-100 HCO3-29 AnGap-14
___ 02:28PM BLOOD cTropnT-<0.01
___ 02:28PM BLOOD Calcium-9.2 Phos-3.8 Mg-2.0
ON DISCHARGE
___ 06:05AM BLOOD WBC-6.7 RBC-3.30* Hgb-9.5* Hct-31.5*
MCV-96 MCH-28.9 MCHC-30.2* RDW-15.9* Plt ___
___ 06:05AM BLOOD ___ PTT-31.6 ___
___ 06:05AM BLOOD Glucose-73 UreaN-10 Creat-0.5 Na-139
K-3.8 Cl-103 HCO3-29 AnGap-11
___ 06:05AM BLOOD CK-MB-3 cTropnT-<0.01
___ 06:05AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.8
STUDIES
CXR (___)
1. Left base/retrocardiac opacity, which may represent
consolidation as well as a small left pleural effusion.
2. Mild pulmonary edema
ECHO (___)
The left atrium is moderately dilated. The estimated right
atrial pressure is at least 15 mmHg. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). There is mild (non-obstructive) focal hypertrophy of
the basal septum. 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. There
is a nonmobile echodensity noted in the arch (>4 mm), which is
most consistent with atheroma. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Mild (1+)
aortic regurgitation is seen. Mild (1+) mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular size
and function, without obvious regional wall motion abnormalities
seen within the technical limitations of the exam. Mild aortic
and mitral regurgitation. Pacemaker wire noted in the right
heart. Mild pulmonary artery systolic hypertension.
CXR PA/LAT (___)
As compared to the previous radiograph, the lung volumes have
increased, likely reflecting improved ventilation. There is
unchanged
moderate cardiomegaly, but the pre-existing signs of fluid
overload have
completely resolved. No pleural effusions. Minimal atelectasis
at the left lung bases. No pneumonia. Unchanged pacemaker
position, unchanged position of the bilateral shoulder
replacement.
Brief Hospital Course:
___ with PMH significant for Afib, HTN, ? history of MI who
presents with acute onset right-sided chest pain.
# Chest pain:
Resolved upon arrival to ___. Patient remained asymptomatic
and hemodynamically stable during hospitalization. DDx included
musculoskeletal pain secondary to coughing, pneumonia, angina,
and acute coronary syndrome. ACS less likely given negative
troponins x 3. Her EKG was difficult to interpret as she is
paced at baseline. Patient was scheduled for a stress test,
however she was unwilling to change her DNR/DNI code status for
the study. As the risk of a cardiac event is less likely, this
was not further pursued. Patient was medically managed. We
continued propranolol and triamterine-HCTZ. She was started on
pravastatin 40mg daily. Aspirin is not indicated as she is on
coumadin for atrial fibrillation and she had not had any recent
stents.
# Hypertension: Currently hypertensive. Baseline unknown. She
was continued on propranolol and triamterine-HCTZ.
# Atrial fibrillation:
Patient is rate controlled with propranolol. CHADS2VASC 4. She
is antocoagulated with warfarin.
# ___: Appears to be stable. Continued
carbidopa/levodopoa.
# Hypothyroidism: Continued levothyroxine.
# Arthritis: Pain controlled with tylenol and lidoderm patch.
TRANSITIONAL ISSUES:
* Stress test unable to be completed as patient did not want to
change her code status (DNR/DNI) during the study.
* Patient started on pravastatin 40mg daily.
* Consider titrating antihypertensives.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Milk of Magnesia 30 mL PO QHS: PRN constipation
2. Multivitamins 1 TAB PO DAILY
3. Mytab Gas (simethicone) 80 mg oral BID
4. Nitroglycerin SL 0.4 mg SL PRN chest pain
5. Polyethylene Glycol 17 g PO BID
6. Senna 2 TAB PO HS
7. Tiotropium Bromide 1 CAP IH DAILY
8. Travatan Z (travoprost) 0.004 % ophthalmic daily
9. TraZODone 100 mg PO HS
10. Enema Disposable (sodium phosphates) ___ gram/118 mL rectal
PRN constipation
11. Acetaminophen 325 mg PO Q4H:PRN pain
12. Mapap Arthritis Pain (acetaminophen) 650 mg oral BID
13. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
14. Antacid Anti-Gas (alum-mag
hydroxide-simeth;<br>calcium-simethicone) 400mg-400mg-40mg/5mL
oral Q4H:PRN GI upset
15. Bisacodyl ___AILY:PRN constipation
16. BuPROPion 100 mg PO DAILY
17. Carbidopa-Levodopa CR (50-200) 1 TAB PO HS
18. Carbidopa-Levodopa (___) 1 TAB PO TID
19. ___ (docusate sodium) 100 mg oral daily
20. Levothyroxine Sodium 50 mcg PO DAILY
21. LOPERamide 2 mg PO QID:PRN diarrhea
22. Lorazepam 0.5 mg PO DAILY
23. Lorazepam 0.5 mg PO DAILY:PRN anxiety
24. Ranitidine 150 mg PO BID
25. Artificial Tears 2 DROP BOTH EYES Q6H:PRN dryness/itchiness
26. menthol 5 mg mucous membrane PRN sore throat
27. Guaifenesin 10 mL PO Q4H:PRN cough
28. melatonin 3 mg oral HS
29. Lidocaine 5% Patch 1 PTCH TD QAM
30. Lactulose 15 mL PO EVERY OTHER DAY AT HS
31. Duloxetine 20 mg PO DAILY
32. Ondansetron 8 mg PO Q8H:PRN nausea
33. Omeprazole 20 mg PO DAILY
34. Warfarin 3 mg PO DAILY16
35. Propranolol LA 80 mg PO DAILY
36. Triamterene-Hydrochlorothiazide (37.5/25) 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 325 mg PO Q4H:PRN pain
2. Artificial Tears 2 DROP BOTH EYES Q6H:PRN dryness/itchiness
3. Bisacodyl ___AILY:PRN constipation
4. BuPROPion 100 mg PO DAILY
5. Carbidopa-Levodopa (___) 1 TAB PO TID
6. Carbidopa-Levodopa CR (50-200) 1 TAB PO HS
7. Duloxetine 20 mg PO DAILY
8. Guaifenesin 10 mL PO Q4H:PRN cough
9. Lactulose 15 mL PO EVERY OTHER DAY AT HS
10. Levothyroxine Sodium 50 mcg PO DAILY
11. Lidocaine 5% Patch 1 PTCH TD QAM
12. Milk of Magnesia 30 mL PO QHS: PRN constipation
13. Multivitamins 1 TAB PO DAILY
14. Omeprazole 20 mg PO DAILY
15. Ondansetron 8 mg PO Q8H:PRN nausea
16. Polyethylene Glycol 17 g PO BID
17. Propranolol LA 80 mg PO DAILY
18. Ranitidine 150 mg PO BID
19. Tiotropium Bromide 1 CAP IH DAILY
20. TraZODone 100 mg PO HS
21. Triamterene-Hydrochlorothiazide (37.5/25) 1 CAP PO DAILY
22. Warfarin 3 mg PO DAILY16
23. Pravastatin 40 mg PO DAILY
24. Antacid Anti-Gas (alum-mag
hydroxide-simeth;<br>calcium-simethicone) 400mg-400mg-40mg/5mL
oral Q4H:PRN GI upset
25. ___ (docusate sodium) 100 mg oral daily
26. Enema Disposable (sodium phosphates) ___ gram/118 mL rectal
PRN constipation
27. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
28. LOPERamide 2 mg PO QID:PRN diarrhea
29. Lorazepam 0.5 mg PO DAILY
30. Lorazepam 0.5 mg PO DAILY:PRN anxiety
31. Mapap Arthritis Pain (acetaminophen) 650 mg oral BID
32. melatonin 3 mg oral HS
33. menthol 5 mg mucous membrane PRN sore throat
34. Mytab Gas (simethicone) 80 mg oral BID
35. Nitroglycerin SL 0.4 mg SL PRN chest pain
36. Senna 2 TAB PO HS
37. Travatan Z (travoprost) 0.004 % ophthalmic daily
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSIS:
Chest pain
SECONDARY DIAGNOSIS:
Atrial fibrillation
Hypertension
___ disease
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___. As you recall, you were admitted because of
chest pain. Testing did not show a heart attack. We believe the
chest pain may be musculoskeletal as you have been coughing. We
are glad you are feeling better.
Followup Instructions:
___
|
10208372-DS-13 | 10,208,372 | 26,278,747 | DS | 13 | 2165-03-22 00:00:00 | 2165-03-23 16:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ yo man with metastatic lung cancer, who
presents with hemoptysis x 1 day
He was in his USOH until mid-morning of admission, when he
coughed up a 2-3 cm bright red blood clot. He had approximately
3
more episodes over the course of the morning. Each subsequent
episode produced smaller and smaller blood clots. In addition,
he
noted some increased dyspnea at rest and wheezing, which was
minimally relieved by home albuterol inhaler.
He endorses intermittent left chest "constriction" or pressure
over the last month that seemed more constant today. It is not
pleuritic. He denies any increased ___ edema, calf tenderness,
fevers/chills, palpitations.
In the ED: T 99.1 | 66 | 164/80 | 100% RA. A CTA was performed
which showed unchanged large left hilar mass that encases left
mainstem bronchus and obstructs left main PA. CBC was unchanged
from baseline. In the ED, he had a couple more episodes of
hemoptysis, which was pink or small amount of blood mixed in
with
regular sputum.
Past Medical History:
Mr. ___ endorses a history of seasonal
allergies, reflux, high blood pressure and Paget's disease of
bone primarily involving his right hip. This was diagnosed in
___ range. No bleeding or clotting disorders.
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VITALS:
T 97.5 F | 191/80 | 63 | 96% RA
General: Well appearing Caucasian man, sitting up at edge of
bed,
pleasant and conversant
Neuro:
Cranial nerves: PERRL, EOMI, Facial sensation equal bilaterally,
resists eye opening ___, hearing intact to finger rub b/l,
palate
elevates symmetrically, tongue midline, shoulder shrug ___
Motor:
___ deltoid, bicep, tricep, handgrip bilaterally
___ hip flexion, knee extension/flexion, plantar and
dorsiflexion
Sensation intact to light touch over UE and ___
Alert and oriented to person, place, time
HEENT: Oropharynx clear. No supraclaviacular or cervical
adenopathy
Cardiovascular: regular, bradycardic, no murmurs
Chest/Pulmonary: Clear to auscultation over the right lung
fields.
Decreased breath sounds at left base. Dull to percussion.
Whistling inspiratory breath sounds at the left mid lung field.
Clear breath sounds in left upper lung field.
Abdomen: Soft, nontender, nondistended, normoactive bowel sounds
Extr/MSK: No peripheral edema, no calf tenderness on exam
Skin: No rashes
Access: PIV
DISCHARGE PHYSICAL EXAM ===
VITALS: 99, 176 / 76, 58, 18 99% ra
General: Well appearing Caucasian man, sitting up at edge of
bed,
pleasant and conversant
Neuro:
Cranial nerves: PERRL, EOMI, Facial sensation equal bilaterally,
resists eye opening ___, hearing intact to finger rub b/l,
palate
elevates symmetrically, tongue midline, shoulder shrug ___
Motor:
___ deltoid, bicep, tricep, handgrip bilaterally
___ hip flexion, knee extension/flexion, plantar and
dorsiflexion
Sensation intact to light touch over UE and ___
Alert and oriented to person, place, time
HEENT: Oropharynx clear. No supraclaviacular or cervical
adenopathy
Cardiovascular: regular, bradycardic, no murmurs
Chest/Pulmonary: Clear to auscultation over the right lung
fields.
Decreased breath sounds at left base. Dull to percussion.
Whistling inspiratory breath sounds at the left mid lung field.
Clear breath sounds in left upper lung field.
Abdomen: Soft, nontender, nondistended, normoactive bowel sounds
Extr/MSK: No peripheral edema, no calf tenderness on exam
Skin: No rashes
Access: PIV
Pertinent Results:
ADMISSION LABS:
================
___ 03:15PM BLOOD WBC-7.4 RBC-3.48* Hgb-10.3* Hct-31.7*
MCV-91 MCH-29.6 MCHC-32.5 RDW-15.1 RDWSD-48.7* Plt ___
___ 03:15PM BLOOD Neuts-58.5 ___ Monos-12.8 Eos-2.0
Baso-0.3 Im ___ AbsNeut-4.34 AbsLymp-1.92 AbsMono-0.95*
AbsEos-0.15 AbsBaso-0.02
___ 03:15PM BLOOD ___ PTT-27.5 ___
___ 03:15PM BLOOD Glucose-93 UreaN-15 Creat-1.0 Na-142
K-4.3 Cl-104 HCO3-25 AnGap-13
STUDEIS:
==========
CTA CHEST ___
IMPRESSION:
1. Left hilar mass as well as multiple left lung nodules are
unchanged to
minimally increased in size compared to prior. Mass continues
to obstruct the main left pulmonary artery, encase and narrow
the left mainstem bronchus, and occlude left upper lobe bronchi
as seen on most recent prior on ___.
2. Assessment of the left segmental and subsegmental pulmonary
arteries system is limited due to the occlusion of the main left
pulmonary artery.
3. No right-sided pulmonary embolus.
4. Moderate left pleural effusion has increased in size compared
to prior.
___ CXR
IMPRESSION:
No significant interval change noting a left hilar mass with
secondary
left-sided volume loss and pleural effusion.
DISCHARGE LABS:
================
___ 08:50AM BLOOD WBC-6.6 RBC-3.33* Hgb-9.6* Hct-30.1*
MCV-90 MCH-28.8 MCHC-31.9* RDW-14.9 RDWSD-47.9* Plt ___
___ 08:50AM BLOOD Neuts-63.5 ___ Monos-11.0 Eos-2.6
Baso-0.0 Im ___ AbsNeut-4.17 AbsLymp-1.47 AbsMono-0.72
AbsEos-0.17 AbsBaso-0.00*
___ 08:50AM BLOOD Plt ___
___ 08:50AM BLOOD Glucose-119* UreaN-14 Creat-1.1 Na-144
K-3.8 Cl-103 HCO3-25 AnGap-16
Brief Hospital Course:
PATIENT SUMMARY
___ yo man with metastatic lung cancer, who presents with small
volume hemoptysis x 1 day in the setting of a large left hilar
mass encasing mainstem bronchus.
ACUTE ISSUE
# Hemoptysis
Patient presented with one day of hemoptysis, in setting of
known lung cancer w large L hilar mass encasing his L main
bronchus. He has never had this symptom before. CTA chest w/o
evidence of pulmonary embolism, massive hemoptysis, or other
concerning findings such as tumor invasion into an area that
could trigger major bleed. Hemoglobin low but stable, at
patient's baseline around 10. Hemoptysis resolved without any
intervention, likely related to small amount of bleeding from
tumor. Patient was advised to discontinue his baby aspirin. No
further changes were made as he remained hemodynamically stable
on room air and asymptomatic, and he was discharged.
CHRONIC ISSUE
# Hypertension: Noted to have elevated blood pressures to 180s
systolic at times. No HA, vision changes, chest pain, worsening
of baseline SOB. No evidence of end-organ damage on labs.
Maintained on his home enalapril, will be transitional issue.
TRANSITIONAL ISSUES
[] As above, SBP noted to be elevated at times. Please consider
titrating blood pressure medication if this is noted outpatient.
[] ASA for primary prevention was discontinued as risks
(bleeding) outweighing benefits at this point. Readdress in the
future if appropriate for patient to restart.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enalapril Maleate 20 mg PO DAILY
2. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath,
wheezing
3. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
4. Dexamethasone 2 mg PO DAILY ON DAY 2 AND 3 AFTER CHEMOTHERAPY
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Omeprazole 40 mg PO DAILY
8. Ranitidine 150 mg PO QHS:PRN heartburn
9. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
10. Aspirin 81 mg PO DAILY
11. Cetirizine 10 mg PO DAILY
12. Calcium Carbonate 500 mg PO QID:PRN heartburn
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath,
wheezing
3. Calcium Carbonate 500 mg PO QID:PRN heartburn
4. Cetirizine 10 mg PO DAILY
5. Dexamethasone 2 mg PO DAILY ON DAY 2 AND 3 AFTER
CHEMOTHERAPY
6. Enalapril Maleate 20 mg PO DAILY
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
10. Omeprazole 40 mg PO DAILY
11. Ranitidine 150 mg PO QHS:PRN heartburn
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
- Hemoptysis
- Metastatic lung cancer with L hilar mass encasing L main
bronchus
- Dyspnea
SECONDARY DIAGNOSES
- Hypertension
- Pleural effusions
- Chronic anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
WHY DID YOU COME TO THE HOSPITAL?
- You were coughing up blood.
WHAT HAPPENED TO YOU DURING YOUR HOSPITAL STAY?
- We did a scan to check your lungs for anything dangerous that
might be causing the bleeding, such as a blood clot in your
lungs or changes in your lung tumor. We did not find any of
these things.
- Since your bloody cough stopped, and your vital signs and
labs were stable, we felt it was safe to discharge you home.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
1) Please take your medications as below.
2) Attend all of your follow-up appointments as scheduled.
We wish you the best in your recovery and it was a pleasure to
care for you.
Followup Instructions:
___
|
10208372-DS-14 | 10,208,372 | 25,738,748 | DS | 14 | 2166-06-14 00:00:00 | 2166-06-14 11:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
short of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ man with metastatic lung
adenocarcinoma to brain and bone s/p 4 cycles of palliative
carboplatin and pemetrexed and 28 cycles of pemetrexed
maintenance with progression followed by second line
___ initiated in ___ now on pem/pembro
maintenance (last given ___.
___ presented for neuro oncology appointment today when he
was
found to be very dyspneic. Labs revealed hgb 6.6, plt 43k, WBC
3.3. Given these abnormalities, his oncologist was concerned
for
immune mediated cellular destruction vs. bleeding and referred
___ to the ___ ED with the following recommendations:
- repeat CBC, LDH, haptoglobin, liver function testing with
bilirubin fractionation, Coombs testing, and peripheral smear
- FOBT - would transfuse 1u PRBCs (type and screen completed
earlier today in outpatient clinic
- If hemolysis present, would suspect immune mediated toxicity,
would admit and initiate steroid therapy.
On arrival to the ED, initial vitals were
Temp 97.7 HR 85 BP 142/69 RR 20 O2 sat 100% RA.
Exam was unremarkable.
Labs in ED notable for hemoglobin 6.6, platelets 43. Haptoglobin
was 279. Cr 1.4. Lactate 3.6 which then normalized to 0.9 after
1L IVF. Liver panel was within normal limits. Blood cultures
were
sent.
With respect to imaging, he had RLE ultrasound that did not show
DVT.
He was given one unit packed red blood cells and admitted to the
oncology service for further workup ans management.
Prior to transfer, vitals were Temp 97.8 HR 66 BP 171/84 RR
16.
On arrival to the floor, patient reports that over the last
several weeks, he has noticed increasing dyspnea on exertion.
While the patient notes a long-standing history of shortness of
breath, he has noticed a precipitous decrease in his exercise
capacity. He was formally able to walk up a flight of stairs
without shortness of breath but he now feels winded performing
his activities of daily living. This shortness of breath is not
associated with any chest pain, lightheadedness, dizziness or
palpitations. His dyspnea has been so severe that he spends
most
of his day on the couch. He notes no orthopnea, sleeps on one
pillow, or paroxysmal nocturnal dyspnea.
Additionally, the patient notes new lower extremity edema. While
he has always had some edema, he notes that this lower extremity
edema is worse than prior. He is somewhat unclear on the exact
timeframe but says it is in the past week or so that he is
really
noticed his lower extremity edema. He notes that it is worse on
the right than on the left.
Patient denies fevers/chills, night sweats, headache, vision
changes, dizziness/lightheadedness, weakness/numbnesss, cough,
hemoptysis, chest pain, palpitations, abdominal
pain, nausea/vomiting, diarrhea, hematemesis,
hematochezia/melena, dysuria, hematuria, and new rashes.
Past Medical History:
Mr. ___ endorses a history of seasonal
allergies, reflux, high blood pressure and Paget's disease of
bone primarily involving his right hip. This was diagnosed in
___ range. No bleeding or clotting disorders.
Social History:
___
Family History:
Non-contributory
Physical Exam:
GEN: NAD
EYES: Anicteric
HENT: oral mucosa moist
CV: RRR, no murmurs, no JVD
RESP: non-labored breathing on room air, good air entry
bilaterally, no crackles, no wheezes
GI: soft, non-tender, non-distended, normal bowel sounds
GU: no suprapubic tenderness
EXT: bilateral ___ with trace pitting edema up to mid calf
MSK: ___ motor strength throughout
SKIN: no jaundice
NEURO: Alert, oriented x4
PSYCH: calm
Pertinent Results:
___ 05:48AM BLOOD WBC-4.8 RBC-2.63* Hgb-8.1* Hct-24.3*
MCV-92 MCH-30.8 MCHC-33.3 RDW-16.3* RDWSD-52.5* Plt Ct-41*
___ 06:20AM BLOOD WBC-4.3 RBC-2.67* Hgb-8.1* Hct-24.2*
MCV-91 MCH-30.3 MCHC-33.5 RDW-15.9* RDWSD-51.3* Plt Ct-37*
Brief Hospital Course:
___ with metastatic lung adenocarcinoma to brain and bone on
chemo, presented with dyspnea on exertion, found with Hgb 6.6,
PLT 34. He was admitted for dyspnea secondary to symptomatic
anemia. Etiology unclear. No signs of bleeding. No elevated bili
or schistocytes, hemolysis unlikely. Consider bone marrow
suppression given pancytopenia, but patient with normal
reticulocyte count, not consistent with bone marrow suppression.
Coombs negative. Hematology consulted, do not think chemo would
typically cause new pancytopenia. S/p 2U pRBC, Hgb improved
appropriately and stabilized. Dyspnea improved after blood
transfusions.
TTE unremarkable. CXR with left pleural effusion. Consider
malignant effusion, given
history of lung cancer. No signs of infection. Unlikely to be
cause of dyspnea, since dyspnea improved with improvement in
Hgb. The patient preferred to defer diagnostic thoracentesis at
this time.
The patient was stable upon discharge. The patient was advised
to follow up with his ___ physician ___ ___ for
pancytopenia and left pleural effusion. Risks and benefits were
discussed, the patient verbalized understanding and agreed to
plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
3. Enalapril Maleate 20 mg PO DAILY
4. azelastine 0.15 % (205.5 mcg) nasal BID
5. GuaiFENesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. amLODIPine 5 mg PO DAILY
8. Atorvastatin 40 mg PO DAILY
9. Naproxen 500 mg PO Q12H
10. Omeprazole 40 mg PO BID
11. Aspirin 81 mg PO DAILY
12. Cetirizine 10 mg PO DAILY
13. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheeze
14. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheeze
3. amLODIPine 5 mg PO DAILY
4. Atorvastatin 40 mg PO DAILY
5. azelastine 0.15 % (205.5 mcg) nasal BID
6. Cetirizine 10 mg PO DAILY
7. Enalapril Maleate 20 mg PO DAILY
8. Fluticasone Propionate NASAL 2 SPRY NU DAILY
9. FoLIC Acid 1 mg PO DAILY
10. GuaiFENesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
11. Omeprazole 40 mg PO BID
12. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
Discharge Disposition:
Home
Discharge Diagnosis:
Pancytopenia
Left pleural effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Reason for hospitalizations: low blood level
Treatments in hospital: 2 units blood transfusion
Instruction for after discharge from hospital:
1) Follow up with Dr. ___ on ___
(appointment scheduled).
Followup Instructions:
___
|
10208781-DS-4 | 10,208,781 | 22,847,710 | DS | 4 | 2142-11-14 00:00:00 | 2142-11-14 13:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Codeine
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo F, restrained driver in ___. Sustained L rib Fx ___, and
grade III kidney laceration. GCS 15 on arrival. Denies LOC,
self-extricated. Was seen at OSH, transferred to ___ for
management of polytrauma. Presents with ___ sharp, LUQ pain
Past Medical History:
PMH: hepatitis C, depression, anxiety, breast ca, osteoporosis
PSH: hysterectomy, back surgery, hand surgery, shoulder surgery
Social History:
___
Family History:
non-con
Physical Exam:
Admission Physical Exam
General: No acute distress, GCS 15
HEENT: PERRL
Cardiovascular: RRR, no r/m/g
Respiratory / Chest: Expansion symmetric, CTA bil, (Sternum:
Stable ), Deep inspiration limited by pain.
Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present
LUE: 2+ pulse, warm, no edeuma. small skin lacerations and
bruising over left shoulder
RUE: 2+ pulse, warm, no edeuma.
Skin: no skin changes abdomen, back.
Neurologic: (Awake / Alert / Oriented: x 3), Moves all
extremities
Discharge Exam:
T: 98.6; HR: 74; BP: 100/62; RR; 20; ___ 93RA
HEENT: NC/AT, PERRL
CV: RRR, no m,r,g
Rest: CTA
Abd; Soft, NT/ND
ext, 2+ pulses b/l, no edema
Pertinent Results:
___ 01:45AM BLOOD WBC-9.7 RBC-3.92* Hgb-13.1 Hct-38.4
MCV-98 MCH-33.3* MCHC-34.1 RDW-12.2 Plt ___
___ 06:01AM BLOOD Hct-38.3
___:10AM BLOOD Hct-39.4
___ 05:38PM BLOOD Hct-34.9*
___ 04:50AM BLOOD Hct-37.8
___ 05:00PM BLOOD Hct-34.0*
___ 04:50AM BLOOD WBC-6.9 RBC-3.82* Hgb-12.8 Hct-36.2
MCV-95 MCH-33.5* MCHC-35.3* RDW-12.4 Plt ___
___ 11:23PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 11:23PM URINE RBC-2 WBC-18* Bacteri-NONE Yeast-NONE
Epi-0
Brief Hospital Course:
Ms ___ was admitted from the ED to the trauma ICU, where she
was observed for 12 hours. Her C-collar was removed after being
cleared clinically. Pain control was performed with Dilaudid.
She was hemodynamically stable. Urine output remained adequate
with no gross hematuria. She was seen by the urologic surgery
team who recommended serial hematocrits, bedrest, and no further
imaging unless she had gross hematuria or dropping hematocrit.
After her 6am and 10am hematocrits were stable at 38, and
urology had no operative recommendations, she was transferred to
the floor for further observation.
On the floor, she continued to have hematocrits checked which
were all stable. 48 hours after her injury she was able to get
out of bed and was ambulating well at discharge. She stated
that she had been diagnosed with a urinary tract infection the
day prior to admission, and was started on bactrim, this will be
continued for 3 more days on admission, as her UA while in the
hospital had wbcs present.
Medications on Admission:
Vicodin 7.5/325 prn, Bactrim DS" (started ___ for UTI), prozac
40', diazepam 10prn, Chantix 1", omeprazole 20', requip 4'
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
2. ropinirole 1 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
3. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours)
as needed for Pain.
Disp:*30 Tablet(s)* Refills:*0*
4. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
5. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
6. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
7. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Grade 3 Kidney Laceration
Left rib fractures ___, 12
Urinary Tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the ___ surgery service for a motor vehicle
accident, kidney laceration, rib fractures. You are doing well
and are ready for discharge. Please continue to use your
incentive spirometer 10 times per hour while awake, and monitor
your urine for signs of blood. If you have blood in your urine
call the ___ clinic immediately. You also have a urinary tract
infection, you should take bactrim for 2 more days
Please call your doctor or go to the emergency department if:
*You experience new chest pain, pressure, squeezing or
tightness.
*You develop new or worsening cough, shortness of breath, or
wheeze.
*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 an unusual discharge.
*Your pain is not improving within 12 hours or is not under
control within 24 hours.
*Your pain worsens or changes location.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*You develop any concerning symptoms.
General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day. You may start
taking motrin tomorrow (___)
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 20
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician.
Followup Instructions:
___
|
10208867-DS-21 | 10,208,867 | 22,470,664 | DS | 21 | 2150-02-21 00:00:00 | 2150-08-09 18:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / adhesive tape / penicillin G / Cephalosporins
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
laparoscopic cholecystectomy
History of Present Illness:
HPI: ___ reports 2 weeks of intermittent band-like tightening
across her upper abdomen and acute-onset sharp and constant
right
upper quadrant abdominal pain for the last 8.5 hours with
associated nausea but no vomiting, fevers or chills. She
reports
relief of pain only after receiving morphine in ED.
Past Medical History:
OBHx:
G1P1
Primary LTCS after failed VAVD
PMH: Denies
PSH: Breast Bx
Social History:
___
Family History:
noncontributory
Physical Exam:
PHYSICAL EXAMINATION: upon admission: ___
Temp: 98.8 HR: 58 BP: 128/75 Resp: 15 O(2)Sat: 100 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, Nondistended, right upper quadrant
tenderness to palpation
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash
Neuro: Speech fluent
Psych: Normal mood
Pertinent Results:
___ 02:15AM BLOOD WBC-6.6 RBC-4.45 Hgb-12.8 Hct-40.3 MCV-91
MCH-28.8 MCHC-31.8 RDW-13.1 Plt ___
___ 02:15AM BLOOD Neuts-78.1* Lymphs-16.9* Monos-3.2
Eos-1.4 Baso-0.4
___ 02:15AM BLOOD Plt ___
___ 02:15AM BLOOD Glucose-109* UreaN-17 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-25 AnGap-13
___ 02:15AM BLOOD ALT-19 AST-21 AlkPhos-64 TotBili-0.3
___ 02:15AM BLOOD Lipase-30
___ 02:15AM BLOOD Albumin-4.2
___: liver/gallbladder ultrasound:
IMPRESSION: Cholelithiasis with impacted 9 mm gallbladder neck
stone. There is mild focal tenderness on examination. The
gallbladder is not distended, and there is no wall thickening,
however, early acute cholecystitis is a possibility given the
history and findings.
Brief Hospital Course:
The patient was admitted to the acute care service with right
upper quadrant pain. Upon admission, she was made NPO, given
intravenous fluids, and underwent imaging of the abdomen. On
ultrasound, she was reported to have gallstones with an immobile
9-mm gallbladder neck stone. On HD #1, she was taken to the
operating room for a laparoscopic cholecystectomy. Her
operative course was stable with minimal blood loss. She was
extubated after the procedure and monitored in the recovery
room.
She was has been started on a regular diet. Her vital signs have
been stable and she has been afebrile. She has been voiding
without difficulty.
She is preparing for discharge home with follow-up with Dr.
___.
Medications on Admission:
MVI
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for pain.
2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for loose stool.
4. tramadol 50 mg Tablet Sig: One (1) Tablet PO four times a
day.
Disp:*25 Tablet(s)* Refills:*0*
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. Multiple Vitamins Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
___ were admitted to the hospital with right upper quadrant
pain. ___ underwent an ultrasound of your abdomen and ___ were
found to have gallstones. ___ were taken to the operating room
and ___ had your gallbladder removed. ___ are recovering from
your surgery. Your vital signs are stable and ___ are preparing
for discharge home with the following instructions:
Please call your doctor or return to the emergency room if ___
have any of the following:
* ___ experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If ___ are vomiting and cannot keep in fluids or your
medications.
* ___ 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.
* ___ see blood or dark/black material when ___ vomit or have a
bowel movement.
* ___ have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern ___.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items ___ pounds for 6 weeks. ___ may
resume moderate exercise at your discretion, no abdominal
exercises.
Wound Care:
___ may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips ___ days after surgery.
Please call the doctor if ___ have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
___
|
10208884-DS-17 | 10,208,884 | 29,568,450 | DS | 17 | 2137-05-28 00:00:00 | 2137-05-28 20:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Tetanus Vaccines & Toxoid / fentanyl / morphine / NSAIDS
(Non-Steroidal Anti-Inflammatory Drug) / methotrexate
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
L hip hemiarthroplasty ___
Bone Marrow Biopsy ___
History of Present Illness:
___ PMHx for Crohn's disease on triple therapy (
Methotrexate, Prednisone, Remicade), AAA repair transferred from
___ for unwitnessed fall. Per patient, she has
been
seen a doctor for dizziness. No etiologies were found. Patient
was walking and simply felt his legs giving out. HE states that
he fell on his left side, with no LOC and GCS of 15. Patient
complained of significant pain. Patient on admission to OSH was
found to be pancytopenic. This was not known prior to this
hospital course.
Patient currently appears extremely nervous and anxious. He
states that he had poor experiences during his previous hospital
stays.
Past Medical History:
Crohn's disease (on remicade)
Rheumatoid arthritis (on prednisone & methotrexate)
Anticoagulated with warfarin for hx DVT/PE
CAD/MI (s/p PCI)
PVD
Hiatal hernia
AAA repair
PVD
___: Pancytopenia thought to be secondary to drug effect ?
methotrexate versus immunosuppression versus Vitamin B12
deficiency.
___: Left Hip Fracture s/p repair by ortho.
Social History:
___
Family History:
No history of bone marrow suppression.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals: Stable
General: AAOx3, anxious
HEENT: Pupils equal and reactive, no facial lesions
Cardiac: Normal S1, S2
Respiratory: Breathing comfortably on room air
Abdomen: Soft, non-tender, no rebound or guarding
Extremity:
Left hip pain, right hip WNL. Nonhealing ulcer on left shin
DISCHARGE PHYSICAL EXAM
=======================
Vital Signs: T 98.7 HR 89 BP 135/84 RR 16 99% RA
General: alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM
Lungs: clear to auscultation bilaterally
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
Ext: Warm, well perfused, L pedal edema, tenderness to palpation
over dorsal surface and most pronounced over MTP joint, +
allodynia, mild erythema
Skin: Multiple ecchymoses over chest and upper extremities.
Petechiae on ___ b/l. 2 cm shallow venous ulcer on L ___, dressed.
L hip: staples in place, c/d/i, mildly TTP. no visible hematoma.
Pertinent Results:
ADMISSION LABS
==============
___ 04:45AM BLOOD WBC-1.1* RBC-2.15* Hgb-6.9* Hct-21.0*
MCV-98 MCH-32.1* MCHC-32.9 RDW-19.0* RDWSD-67.8* Plt Ct-26*
___ 04:45AM BLOOD Neuts-12* Bands-0 Lymphs-81* Monos-5
Eos-2 Baso-0 ___ Myelos-0 AbsNeut-0.13*
AbsLymp-0.89* AbsMono-0.06* AbsEos-0.02* AbsBaso-0.00*
___ 04:45AM BLOOD ___ PTT-33.4 ___
___ 04:45AM BLOOD Glucose-118* UreaN-27* Creat-1.4* Na-133
K-4.2 Cl-102 HCO3-20* AnGap-15
___ 04:45AM BLOOD Albumin-2.7* Calcium-7.7* Phos-2.0*
Mg-1.6
DISCHARGE LABS
==============
___ 05:40AM BLOOD WBC-8.0 RBC-2.53* Hgb-7.6* Hct-23.8*
MCV-94 MCH-30.0 MCHC-31.9* RDW-17.2* RDWSD-56.4* Plt ___
___ 05:40AM BLOOD Neuts-72* Bands-0 Lymphs-7* Monos-14*
Eos-4 Baso-0 ___ Metas-1* Myelos-2* AbsNeut-5.76
AbsLymp-0.56* AbsMono-1.12* AbsEos-0.32 AbsBaso-0.00*
___ 05:40AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
___ 05:40AM BLOOD Plt Smr-NORMAL Plt ___
___ 05:40AM BLOOD Glucose-101* UreaN-7 Creat-0.7 Na-138
K-3.9 Cl-106 HCO3-26 AnGap-10
___ 05:40AM BLOOD Calcium-7.5* Phos-2.5* Mg-1.7
CBC TREND
=========
___ 04:45AM BLOOD WBC-1.1* RBC-2.15* Hgb-6.9* Hct-21.0*
MCV-98 MCH-32.1* MCHC-32.9 RDW-19.0* RDWSD-67.8* Plt Ct-26*
___ 11:24AM BLOOD WBC-1.1* RBC-2.19* Hgb-7.0* Hct-21.5*
MCV-98 MCH-32.0 MCHC-32.6 RDW-19.3* RDWSD-68.7* Plt Ct-57*
___ 01:30PM BLOOD Hct-22.7*
___ 07:22PM BLOOD WBC-0.8* RBC-2.31* Hgb-7.4* Hct-22.1*
MCV-96 MCH-32.0 MCHC-33.5 RDW-19.6* RDWSD-66.7* Plt Ct-47*
___ 06:40AM BLOOD WBC-0.9* RBC-2.29* Hgb-7.2* Hct-22.2*
MCV-97 MCH-31.4 MCHC-32.4 RDW-19.9* RDWSD-68.6* Plt Ct-36*
___ 07:50PM BLOOD WBC-0.5* RBC-2.47* Hgb-7.8* Hct-23.4*
MCV-95 MCH-31.6 MCHC-33.3 RDW-19.7* RDWSD-66.3* Plt Ct-26*
___ 06:50AM BLOOD WBC-0.5* RBC-2.05* Hgb-6.4* Hct-19.7*
MCV-96 MCH-31.2 MCHC-32.5 RDW-19.3* RDWSD-67.3* Plt Ct-17*
___ 05:10PM BLOOD WBC-0.6* RBC-2.49* Hgb-7.8* Hct-23.2*
MCV-93 MCH-31.3 MCHC-33.6 RDW-17.8* RDWSD-58.1* Plt Ct-14*
___ 11:38PM BLOOD WBC-0.7* RBC-2.33* Hgb-7.2* Hct-21.6*
MCV-93 MCH-30.9 MCHC-33.3 RDW-18.4* RDWSD-59.3* Plt Ct-12*
___ 05:00AM BLOOD WBC-0.5* RBC-2.02* Hgb-6.4* Hct-18.8*
MCV-93 MCH-31.7 MCHC-34.0 RDW-18.4* RDWSD-60.6* Plt Ct-9*
___ 03:12PM BLOOD WBC-0.5* RBC-2.38* Hgb-7.4* Hct-22.1*
MCV-93 MCH-31.1 MCHC-33.5 RDW-17.5* RDWSD-56.2* Plt Ct-35*
___ 11:25PM BLOOD WBC-0.6* RBC-2.42* Hgb-7.5* Hct-22.2*
MCV-92 MCH-31.0 MCHC-33.8 RDW-17.1* RDWSD-55.3* Plt Ct-31*
___ 04:05AM BLOOD WBC-0.7* RBC-2.47* Hgb-7.6* Hct-22.6*
MCV-92 MCH-30.8 MCHC-33.6 RDW-16.7* RDWSD-53.5* Plt Ct-27*
___ 05:56AM BLOOD WBC-0.5* RBC-2.18* Hgb-6.9* Hct-20.3*
MCV-93 MCH-31.7 MCHC-34.0 RDW-16.9* RDWSD-54.4* Plt Ct-38*
___ 03:00PM BLOOD WBC-0.6* RBC-2.29* Hgb-7.0* Hct-20.8*
MCV-91 MCH-30.6 MCHC-33.7 RDW-16.5* RDWSD-53.0* Plt Ct-34*
___ 11:25PM BLOOD WBC-0.8* RBC-2.10* Hgb-6.4* Hct-19.3*
MCV-92 MCH-30.5 MCHC-33.2 RDW-16.6* RDWSD-53.8* Plt Ct-29*
___ 05:20AM BLOOD WBC-0.9* RBC-2.36* Hgb-7.2* Hct-21.3*
MCV-90 MCH-30.5 MCHC-33.8 RDW-16.6* RDWSD-51.9* Plt Ct-22*
___ 07:51PM BLOOD WBC-1.1* RBC-2.52* Hgb-7.6* Hct-22.7*
MCV-90 MCH-30.2 MCHC-33.5 RDW-17.2* RDWSD-55.1* Plt Ct-18*
___ 02:26AM BLOOD WBC-1.0* RBC-2.19* Hgb-6.7* Hct-19.8*
MCV-90 MCH-30.6 MCHC-33.8 RDW-16.8* RDWSD-52.9* Plt Ct-17*
___ 09:30AM BLOOD WBC-1.1* RBC-2.43* Hgb-7.4* Hct-22.3*
MCV-92 MCH-30.5 MCHC-33.2 RDW-16.5* RDWSD-53.4* Plt Ct-14*
___ 09:45PM BLOOD WBC-1.5* RBC-2.52* Hgb-7.8* Hct-23.3*
MCV-93 MCH-31.0 MCHC-33.5 RDW-16.7* RDWSD-53.9* Plt Ct-14*
___ 05:30AM BLOOD WBC-1.8* RBC-2.46* Hgb-7.4* Hct-22.8*
MCV-93 MCH-30.1 MCHC-32.5 RDW-16.7* RDWSD-54.1* Plt Ct-12*
___ 08:42PM BLOOD WBC-2.2* RBC-2.51* Hgb-7.6* Hct-23.3*
MCV-93 MCH-30.3 MCHC-32.6 RDW-16.4* RDWSD-54.1* Plt Ct-23*#
___ 02:56PM BLOOD WBC-3.7*# RBC-2.81* Hgb-8.6* Hct-26.8*
MCV-95 MCH-30.6 MCHC-32.1 RDW-16.7* RDWSD-56.9* Plt Ct-57*#
___ 06:40AM BLOOD WBC-4.5 RBC-2.42* Hgb-7.4* Hct-22.9*
MCV-95 MCH-30.6 MCHC-32.3 RDW-16.9* RDWSD-56.5* Plt Ct-97*#
___ 04:14PM BLOOD Hgb-8.4* Hct-26.2*
___ 05:23AM BLOOD WBC-6.3 RBC-2.36* Hgb-7.1* Hct-22.3*
MCV-95 MCH-30.1 MCHC-31.8* RDW-17.0* RDWSD-57.2* Plt ___
___ 05:40AM BLOOD WBC-8.0 RBC-2.53* Hgb-7.6* Hct-23.8*
MCV-94 MCH-30.0 MCHC-31.9* RDW-17.2* RDWSD-56.4* Plt ___
PANCYTOPENIA WORKUP
===================
___ 02:44AM BLOOD HBsAb-NEGATIVE
___ 02:44AM BLOOD HCV Ab-NEGATIVE
___ 05:00AM BLOOD HBsAg-NEGATIVE HBcAb-NEGATIVE
VITAMIN B12
===========
___ 05:20AM BLOOD VitB12-118* Hapto-215* Ferritn-1081*
HIV
===
___ 02:44AM BLOOD HIV Ab-Negative
URINALYSIS
==========
___ 02:05AM URINE Color-DkAmb Appear-Hazy Sp ___
___ 02:05AM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR
___ 02:05AM URINE RBC->182* WBC-14* Bacteri-NONE Yeast-NONE
Epi-0]
FURTHER WORKUP OF PANCYTOPENIA
==============================
___ 04:45
PARVOVIRUS B19 ANTIBODIES (IGG & IGM)
Test Result Reference
Range/Units
PARVOVIRUS B19 ANTIBODY 6.20 H
(IGG)
Reference Range
<0.9 Negative
0.9-1.1 Equivocal
>1.1 Positive
IgG persists for years and provides life-long immunity.
To diagnose current infection, consider Parvovirus
B19 DNA, PCR.
Test Result Reference
Range/Units
PARVOVIRUS B19 ANTIBODY <0.9
(IGM)
Reference Range
<0.9 Negative
0.9-1.1 Equivocal
>1.1 Positive
___ 19:51
EBV PCR, QUANTITATIVE, WHOLE BLOOD
Test Result Reference
Range/Units
SOURCE Whole Blood
EBV DNA, QN PCR 1858 H <200 copies/mL
___ 14:56
SED RATE
Test Result Reference
Range/Units
SED RATE BY MODIFIED TNP mm/h
___
* Test not performed. *
* Quantity not sufficient. *
MICROBIOLOGY
============
___: BLOOD CULTURE: NO GROWTH.
___: BLOOD CULTURE: NO GROWTH.
___: MRSA SCREEN: NO MRSA ISOLATED.
___: URINE CULTURE: NO GROWTH.
___ 2:44 am Blood (CMV AB) Source: Venipuncture.
**FINAL REPORT ___
CMV IgG ANTIBODY (Final ___:
EQUIVOCAL FOR CMV IgG ANTIBODY BY EIA.
5 AU/ML.
___ 2:44 am Blood (EBV) Source: Venipuncture.
**FINAL REPORT ___
___ VIRUS VCA-IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS EBNA IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS VCA-IgM AB (Final ___:
NEGATIVE <1:10 BY IFA.
INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION.
In most populations, 90% of adults have been infected at
sometime
with EBV and will have measurable VCA IgG and EBNA
antibodies.
Antibodies to EBNA develop ___ weeks after primary
infection and
remain present for life. Presence of VCA IgM antibodies
indicates
recent primary infection.
___ 12:50 pm STOOL CONSISTENCY: FORMED Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
___ Reported to and read back by ___ AT
11:00 AM.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
___ 7:51 pm Immunology (CMV) Source: Venipuncture.
**FINAL REPORT ___
CMV Viral Load (Final ___:
CMV DNA not detected.
IMAGING
=======
___ ECG
Baseline artifact. Sinus rhythm with premature beats, possibly
sinus with
aberration versus ventricular premature beats. There appear to
be atrial
premature beats on the T waves in the early precordial leads. No
previous
tracing available for comparison.
Intervals Axes
Rate PR QRS QT QTc (___) P QRS T
95 ___ 484/532 0 0 30
___: CT Torso w/Contrast
IMPRESSION:
1. Acute left femoral subcapital fracture, with surrounding
adductor
intramuscular hematoma extending superiorly to involve the left
iliacus
muscle.
2. No evidence of trauma within the chest. No solid organ
injury within the abdomen or pelvis.
3. Right upper lobe ground glass opacity may represent infection
in the
appropriate clinical setting.
4. Acute ascending colitis.
5. Right nephrolithiasis, including a 1.3 cm stone in the right
renal pelvis.
Surrounding periureteral fat stranding raises the possibility of
underlying urinary tract infection.
6. Evidence of ventral wall mesh weakening.
7. Abnormal esophageal wall thickening with a 1.1 cm hyperdense
focus along the posterior wall distally, which can be further
evaluated by endoscopy.
8. Status post stenting of a descending thoracic aortic
aneurysm, with the
excluded sac measuring 6.4 cm.
9. Mild stenosis at the distal endovascular graft-femoral artery
anastomosis bilaterally.
___: CT Torso w/contrast
IMPRESSION:
1. Acute left femoral subcapital fracture, with surrounding
adductor
intramuscular hematoma extending superiorly to involve the left
iliacus
muscle.
2. No evidence of trauma within the chest. No solid organ
injury within the abdomen or pelvis.
3. Right upper lobe ground glass opacity may represent infection
in the
appropriate clinical setting.
4. Acute ascending colitis.
5. Right nephrolithiasis, including a 1.3 cm stone in the right
renal pelvis. Surrounding periureteral fat stranding raises the
possibility of underlying urinary tract infection.
6. Evidence of ventral wall mesh weakening.
7. Abnormal esophageal wall thickening with a 1.1 cm hyperdense
focus along the posterior wall distally, which can be further
evaluated by endoscopy.
8. Status post stenting of a descending thoracic aortic
aneurysm, with the
excluded sac measuring 6.4 cm.
9. Mild stenosis at the distal endovascular graft-femoral artery
anastomosis bilaterally.
___: LLE X ray
FINDINGS:
Hip: There is an acute subcapital fracture of the right femoral
neck with
superior displacement, varus angulation and mild impaction of
the distal
fragment. The distal fracture fragment is superiorly displaced
by
approximately 1 cm relative to the femoral head component.
Knee: No acute fracture or dislocation. Medial and lateral
compartment
spaces appear preserved. No joint effusion is seen.
Left ankle: Limited images of the left ankle demonstrate no
evidence of
fracture.
IMPRESSION:
Acute right femoral subcapital fracture. No other fractures
identified.
___ ___
FINDINGS:
There are no abnormally dilated loops of large or small bowel.
Limited evaluation without upright or lateral decubitus films,
but there is no gross intraperitoneal free air seen. There are
2 stents overlying the lower thorax and right hemipelvis,
respectively, which are compatible with patient's known history
of descending thoracic aortic aneurysm stent and right common
iliac artery stent. There are corkscrew like metallic densities
overlying the abdomen and compatible with patient's known
history of ventral hernia repair. There is a clip overlying the
left mid abdomen. A left total hip arthroplasty is incompletely
visualized.
IMPRESSION:
1. No evidence of small bowel or large bowel dilatation.
___ L hip X ray
FINDINGS:
Left hip hemiarthroplasty. Mild background hip joint
degenerative change
bilaterally. There is vascular calcification. There is an
apparent vascular stent in the right hemipelvis. Density in the
soft tissues of the medial right thigh unchanged from prior.
Apparent prior mesh hernia repair in the lower abdomen right
flank. Degenerative changes lower lumbar spine partly seen.
Soft tissue gas and staples along the left hip surgical site.
Small corticated bone fragment is seen along the native left
femoral neck, measuring 2.7 cm in length.
IMPRESSION:
Satisfactory appearance of left total hip arthroplasty.
Small bone fragment along the native left medial femoral neck is
noted.
___ ___:
FINDINGS:
There is normal compressibility, flow, and augmentation of the
bilateral
common femoral, femoral, and popliteal veins. Normal color flow
is
demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral
veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
Soft tissue thickening is seen overlying the left calf.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
Pathology
===========
___ Left Femoral Head: Consistent with fracture.
___: Peripheral Blood Smear
Peripheral Blood Smear: The smear is adequate for evaluation .
Erythrocytes are markedly decreased, normochromic and normocytic
and have slight anisopoikilocytosis including elliptocytes,
ovalocytes, echinocytes. The white blood cell count is markedly
decreased The majority of eosinophils are hypersegmented.
Platelet count appears markedly decreased. Occasional large
platelets are seen. A 100 cell differential shows 1%
neutrophils, 1% bands, 89% lymphocytes, 4%monocytes,
4%eosinophils, 1% basophil.
___ Bone marrow core/aspirate: insufficient for analysis.
___ Cytogenetics: Normal male karyotype.
___ Bone marrow immunophenotyping:
Impression:
Cell marker analysis demonstrates the presence of 4.9% CD34(+)
blasts with a myeloid phenotype; since blast percentage is best
assessed by morphology, correlation with the marrow
histopathologic findings (see separate pathology report
___ is recommended.
Additionally, cell marker analysis demonstrates a T-cell
dominant lymphoid profile with no definite monotypic B-cell
population identified. The exact significance of the minor
subset of double negative T-cells (CD4-, Cd8-) is uncertain;
expanded double negative T-cells can be seen in a variety of
clinical conditions including certain infections, autoimmune
conditions, autoimmune lymphoproliferative syndrome etc.
Correlation with clinical and cytogenetic findings is
recommended. Flow cytometry immunophgenpyting may not detect all
abnormal populations due to topography, sampling or artifact of
sample preparation.
___ FISH: negative MDS panel.
___: Bone marrow/core results
HYPOCELLULAR BONE MARROW WITH EVIDENCE OF STROMAL DAMAGE,
REDUCED,
LEFT-SHIFTED MYELOPOIESIS, NEARLY ABSENT ERYTHROPOIESIS, AND
DYSPLASTIC/ATYPICAL MEGAKARYOCYTES. SEE NOTE.
Note: The findings are highly suggestive of myeloid injury due
to patient's current
medications, which include methotrexate, Remicade and
prednisone. Please correlate with
cytogenetics and other clinical and laboratory studies.
Immunohistochemistry is pending.
___: Bone marrow Immunophenotyping:
Immunophenotypic findings show the presence of 6.0% myeloblasts
in this bone marrow sample. Blast counts are best assessed by
morphologic counts, so correlation with morphologic findings
(see separate marrow report) is recommended.
Definitive diagnostic immunophenotypic features of involvement
by lymphoma are not seen in specimen. However, there is an
expanded subpopulation of double negative T-cells; expanded
double negative T-cells can be seen in a variety of clinical
conditions, including certain viral infections, autoimmune
disorders and autoimmune lymphoproliferative syndrome.
Correlation with clinical, morphologic (see separate pathology
report ___ and cytogenetic findings is recommended.
Brief Hospital Course:
Mr. ___ is a ___ gentleman with history of Crohn's
disease and RA (on methotrexate, Remicade as well as occasional
prednisone), CAD, PVD (s/p stent), AAA repair, and
anticoagulated with warfarin for hx of DVT/PE who is presented
after fall with hip fracture, now s/p fixation by ortho, found
to have pancytopenia.
#Pancytopenia: Patient found to have WBC 1.0 with ANC of 60,
platelets 31. Counts continued to downtrend during admission,
with nadir of WBC 0.5 (ANC 7) and platelets 17. Patient also
anemic on presentation, with Hb 8.1, unknown baseline. Patient
placed on neutropenic precautions and diet, and home
immunosuppressive therapies held. He required several
transfusions of PRBC's and received two bags of platelets over
the course of admission. Differential for pancytopenia included
infection (particularly viral), primary bone marrow process,
malignancy, toxin, or medication effect. Patient on several
immunosuppressive therapies, for crohn's (remicade)/RA
(methotrexate) which were also considered as possible causes.
Patient underwent bone marrow biopsy (dry tap on ___,
successful repeat biopsy on ___, the results of which were
pending at the time of discharge. Viral panel revealed elevated
EBV viral load, but was otherwise unremarkable. Patient found to
be B12 deficient, so he was repleted with daily SC B12.
Patient's counts spontaneously began to improve on ___. Counts
continued to increase over the next several days and ___ on
discharge was 8.0 with normal differential and platelets 297.
Patient still anemic on discharge with Hb 7.6. Per heme/onc, the
cause of patient's pancytopenia was multifactorial, including
medication effect of methotrexate, B12 deficiency and possibly
elevated EBV VL. Patient to follow up with heme/onc as
outpatient.
#Colitis: Patient has history of crohn's, but reported good
control on remicade with no recent flares. There was evidence of
ascending colitis by CT on admission. Patient denied fevers,
abdominal pain, nausea, vomiting or bloody stools. He did report
baseline occasional diarrhea. Given ANC 60, there was concern
for typhlitis, but since he was asymptomatic, it was felt to be
less likely. Patient initially started on Vanc/Cefepime/Flagyl.
On HOD#2 he had episode of melena and then developed watery
diarrhea. He was found to have c diff and was transitioned from
Vanc/Cefepime/Flagyl to PO Vanc and Flagyl. Melena resolved on
HOD#4 and patient's H/H subsequently remained stable. Diarrhea
improved on antibiotic regimen and he was discharged on 14 day
course of PO Vanc/Flagyl with outpatient GI follow up.
#Melena/Guaiac positive stool: patient had several episodes of
guaiac positive stool on HOD#3 and 4, with subsequent drop in
H/H requiring transfusion. Patient considered to be at high risk
of bleeding out from GI tract given thrombocytopenia. Team was
also concerned about bleeding into leg, given known hematoma and
recent surgery. Patient was given PO Vitamin K to reverse INR,
all anticoagulation was held and patient was started on
Pantoprazole 40mg IV BID. Hemoglobin was trended every 8 hours
until stabilized. Melena resolved by HOD #4 and H/H remained
stable. Thrombocytopenia subsequently resolved. He was
transitioned to PO Pantoprazole and discharged with close GI
follow up.
#Syncope: patient reported several episodes of syncope and
pre-syncope in the weeks leading up to admission. He endorsed
dizziness with standing and walking. Likely secondary to anemia,
but orthostasis secondary to volume depletion was also be
considered. Patient's EKG showed no evidence of arrhythmia and
patient denied palpitation. Patient did not report history of
seizures and blood glucose was within normal limits throughout
admission. Patient was monitored on telemetry with no events.
Patient experienced no further episodes of syncope during
admission. He will follow up with PCP.
#Hip fracture w/hematoma s/p fixation: CT A/P at OSH significant
for fracture of L hip with hematoma. He was transferred to ___
for management of L hip fracture and admitted to ___ for his
pancytopenia. The patient was subsequently transferred to the
floor where he was hemodynamically stable. Orthopedic surgery
was consulted for the left hip fracture and on hospital day 2 he
taken to the operating room for left hip hemiarthroplasty. There
were no adverse events in the operating room. Patient was
extubated, taken to the PACU until stable, then transferred to
the ward for observation. The patient had no acute issues
postoperatively and was monitored for 24 hours. The medicine
team was consulted for the management of his acute medical
issues. He was transferred to the medicine team on HOD#3. He
initially experienced a significant amount of pain on the floor,
requiring dilaudid PCA. His pain subsequently improved and he
was transitioned to home dose Oxyocodone and dilaudid PRN for
breakthrough. Anticoagulation was initially held in setting of
thrombocytopenia, but patient started on home dose Warfarin with
Enoxaparin bridge on ___ in setting of rebounding counts. INR
was 1.8 at time of discharge, so he was continued on Enoxaparin
until therapeutic on Warfarin at rehab. Patient was able to work
with physical therapy and recovered from his surgery well. He
was discharged to rehab with close orthopedic follow up.
#Thrush: patient had evidence of thrush on exam, secondary to
leukopenia. He was initially treated with nystatin mouthwash,
but was started on PO Fluconazole out of concern for
esophagitis. His thrush gradually improved over course of
admission and patient able to tolerate PO. Fluconazole was
discontinued prior to discharge. He was continued on nystatin
swish and swallow.
#Crohn's: Patient reported history of Crohn's disease, treated
with Remicade as outpatient. He was also on Methotrexate and PRN
Prednisone for rheumatoid arthritis. Patient's
immunosuppressants held in setting of pancytopenia. Per
heme/onc, methotrexate is likely cause of pancytopenia and
should not be re-started. Patient to follow up with PCP and GI
to discuss treatment options going forward.
#RA: Patient reported history of RA and complained of diffuse
joint pain during admission. He was continued on home Oxycodone,
but immunosuppressants held as above. Patient's counts recovered
prior to discharge and home Prednisone was resumed. Patient
instructed not to resume methotrexate as above. He will follow
up with PCP to discuss alternate treatment options for RA.
#History of DVT/PE: Patient has history of DVT/PE and was
considered to be very high risk for clotting, particularly in
setting of recent hip surgery. Unfortunately, he was
thrombocytopenic on transfer, so home warfarin was discontinued.
On ___ he was found to have ___ swelling and pain, concerning
for DVT. ___ were negative. He was restarted on home Warfarin
with Enoxaparin bridge on ___, in the setting of improving
counts. INR on discharge was 1.8 and he was discharged with
instructions to continue Enoxaparin until therapeutic on
Warfarin with goal INR ___.
#Gout: On ___ patient developed pain in bilateral toe MTP
joints. Patient reported history of gout and both the quality of
pain and location were consistent with this diagnosis. Patient
not febrile, with no edema or erythema to suggest septic joint.
Bilateral nature of pain also not consistent with septic joint.
Patient started on allopurinol ___ daily and received 0.6mg
Cochicine, with improvement in his pain.
#CAD/PVD: patient not on statin. Home Metoprolol and Furosemide
held out of concern for GI bleed. Resumed upon discharge.
TRANSITIONAL ISSUES
===================
# Pancytopenia was thought to be secondary to methotrexate.
Methotrexate should be listed as an allergy.
# Patient's blood pressure was well controlled off of amlodipine
and labetalol during hospitalization. Please obtain blood
pressures daily. When blood pressure becomes elevated please
resume amlodipine and labetalol as needed.
# Please follow up CBC with differential within one week
following discharge from the hospital.
# Please continue Lovenox with Coumadin until INR is therapeutic
between ___. Please check INR daily starting on ___. When
INR is therapeutic between ___, please discontinue lovenox.
# Please continue Vancomycin 500 mg Q6H and Metronidazole 500 mg
IV Q8H with end date ___.
# Patient will require referral to Urology given evidence of
hematuria on numerous urinalysis.
# INCIDENTALOMA THAT NEEDS FOLLOW UP WITH GASTROENTEROLOGY: CT
TORSO OBTAINED DURING HOSPITALIZATION: ABNORMAL ESOPHAGEAL WALL
THICKENING WITH A 1.1 CM HYPERDENSE FOCUS ALONG THE POSTERIOR
WALL DISTALLY, WHICH NEEDS FURTHER EVALUATION WITH ENDOSCOPY.
# CT TORSO: Right upper lobe ground glass opacity will require
repeat imaging as an outpatient.
# Please follow up final evaluation of the bone marrow biopsy.
# Vitamin B12 Supplementation: Vitamin B12 was noted to be low
during hospitalization. Continue B12 1000 mcg SC daily with end
date ___. Then start Vitamin B12 1000 mcg SC WEEKLY x 4
weeks. Then start Vitamin B12 1000 mcg SC MONTHLY ONGOING. His
Vitamin B12 should be evaluated to assess improvement of the
Vitamin B12 level.
# Please call Orthopedics clinic at ___ to discuss when
to have the left hip staples removed.
# Code Status: DNR/OK to intubate
# Contact Information: wife ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO BID heartburn
2. Furosemide 20 mg PO DAILY
3. Labetalol 200 mg PO BID
4. Celecoxib 200 mg ORAL DAILY:PRN Arthritis
5. PredniSONE ___ mg PO DAILY:PRN arthritis
6. Methotrexate 20 mg PO 1X/WEEK (FR)
___ MD to order daily dose PO DAILY16
8. Multivitamins 1 TAB PO DAILY
9. OxycoDONE (Immediate Release) 20 mg PO TID
10. Amlodipine 5 mg PO DAILY
11. Potassium Chloride 10 mEq PO DAILY
12. Ferrous Sulfate 325 mg PO BID
13. Infliximab 475 mg IV Q8WEEKS
14. Metoprolol Tartrate 25 mg PO DAILY
Discharge Medications:
1. Ferrous Sulfate 325 mg PO BID
2. OxycoDONE (Immediate Release) 20 mg PO TID
3. PredniSONE 10 mg PO DAILY:PRN joint pain
4. Warfarin 1 mg PO DAILY16
5. Atorvastatin 10 mg PO QPM
6. Cyanocobalamin 1000 mcg IM/SC DAILY Duration: 6 Doses
7. Docusate Sodium 100 mg PO BID
8. Enoxaparin Sodium 40 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
9. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
10. Nystatin Oral Suspension 5 mL PO QID:PRN pain
11. Vancomycin Oral Liquid ___ mg PO Q6H
12. Senna 8.6 mg PO BID:PRN constipation
13. Omeprazole 20 mg PO BID heartburn
14. Furosemide 20 mg PO DAILY
15. Multivitamins 1 TAB PO DAILY
16. Metoprolol Tartrate 25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
==================
Pancytopenia
Left femoral neck fracture
Clostridium difficile colitis
Secondary Diagnosis
====================
Crohn's Disease
Rheumatoid Arthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___. You were admitted after a hip fracture. You
underwent surgery to repair your hip fracture and you did well.
You were also found to have very low blood counts. You received
transfusions of red blood cells and platelets, and underwent a
procedure to obtain a sample of your bone marrow. You were found
to have very low vitamin B12 levels, so we started you on B12
supplementation.
The results of your bone marrow test were not back at the time
of discharge, but you will have a follow up appointment with the
blood doctors to discuss these results. The blood specialists
believe that your low blood counts were due to your methotrexate
and vitamin B12 deficiency. You should not take Methotrexate in
the future.
During this hospitalization you were also found to have an
infection called C diff colitis, which caused you to have
diarrhea. We started you on antibiotics and you did well. You
should continue antibiotics until ___. Please also follow
up with your Gastroenterologist (see appointments below).
Additionally, you underwent a CT scan of your chest and abdomen.
The CT scan did show a lesion within the esophagus. This will
need to be followed up by your Gastroenterologist with an upper
endoscopy. It is very important that you follow up with your
Gastroenterologist to have this assessed.
You also need a repeat image of your chest to assess a opacity
that was noted of your lung. Please follow up with your primary
care physician to discuss this follow up.
You will continue recovery from your hip surgery at rehab and
follow up with orthopedic surgery as an outpatient.
We wish you all the best in your recovery!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10208917-DS-13 | 10,208,917 | 29,555,885 | DS | 13 | 2183-04-20 00:00:00 | 2183-04-21 21:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Witnessed seizure
Major Surgical or Invasive Procedure:
___: Intubation and mechanical ventilation.
History of Present Illness:
Mr. ___ is a ___ year old gentleman with a history of
alcoholism, traumatic brain injury, frequent EtOH withdrawal
seizures, ? epilepsy who is presenting after he was witnessed to
be having a seizure outside the ___ earlier
today.
EMS was called and he was brought to the ED. Not felt to be
seizing when arrived in ED and no clear seizure events since. He
was intubated for airway protection and started on fentanyl and
midazolam. Slight eye deviation to right appreciated on initial
exam. A head CT was relatively unchanged from prior. He was
started him on CTX for a possible UTI. BPs fine, afebrile. Vent
Settings at time of transfer AC 550 x 14 PEEP 5. 2x PIVs for
access. On arrival to the MICU he was intubated and sedated.
Per report, the patient has a long history of alcoholism,
drinking up to 1 pint of vodka every day. He was seen in the ED
the day prior to admission (___) after being found intoxicated
on the ground. At that time he was found to have an blood
alcohol level of 383. Approximately three weeks prior to this
(on ___ he was admitted to ___ for a seizure in the setting
of alcohol withdrawal. During that admission he was intubated
and extubated without complication. He expressed some interest
in going to detox however then eloped on ___ prior to any
arrangements being made. He did not have any prescriptions when
he eloped. An attempt was made to contact his sister to locate
him however she was not aware of his whereabouts.
Past Medical History:
1) EtOh abuse, hx of DTs with seizures, previously intubated
2) Essential tremor
3) Epilepsy
4) Incarceration in ___ for ___ years
5) TBI after being hit in head with 2x4 and subsequent seizure
d/o
6) HL not on meds
7) HTN not on meds
Social History:
___
Family History:
Father died at age ___ from alcoholic complications; mother died
at age ___ from alcoholic complications.
Physical Exam:
ADMISSION PHYSICAL EXAM (___):
Vitals: hr 82 bp 142/94 sat 100% on FiO2 40 550 x 14 PEEP 5
General: Somnolent/heavily sedated/unresponsive
HEENT: pupils constricted but equal and sluggishly reactive to
light, MMM, intubated
Lungs: intubated but clear anteriorly
CV: RR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: Warm, well perfused, palpable distal pulses, thick
unclipped toenails, no clubbing, cyanosis or edema.
DISCHARGE PHYSICAL EXAM (___):
PHYSICAL EXAM:
VS - Tm 99.1F, Tc 98.5, BP 100-120/57-75, HR 60-96, R 18, 95-98%
O2-sat % RA.
GENERAL - disheveled, NAD, uncomfortable, in C-collar
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII intact, muscle strength ___
throughout, sensation intact in all extremities. Gait deferred.
Pertinent Results:
ADMISSION LABS:
___ 07:48PM BLOOD WBC-3.6*# RBC-4.32* Hgb-13.2* Hct-41.7
MCV-97 MCH-30.5 MCHC-31.6 RDW-14.9 Plt ___
___ 07:48PM BLOOD Neuts-76.1* Lymphs-15.4* Monos-6.3
Eos-1.1 Baso-1.2
___ 07:48PM BLOOD Glucose-90 UreaN-4* Creat-0.9 Na-143
K-3.8 Cl-104 HCO3-19* AnGap-24*
___ 04:44AM BLOOD Calcium-8.3* Phos-1.9* Mg-1.7
___ 07:59PM BLOOD Type-ART Rates-14/ Tidal V-550 PEEP-5
FiO2-100 pO2-457* pCO2-35 pH-7.37 calTCO2-21 Base XS--3
AADO2-220 REQ O2-45 -ASSIST/CON Intubat-INTUBATED
___ 07:45PM URINE Color-Yellow Appear-Clear Sp ___
___ 07:45PM URINE Blood-SM Nitrite-POS Protein-30
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-2* pH-6.0 Leuks-SM
___ 07:45PM URINE RBC-6* WBC-51* Bacteri-MOD Yeast-NONE
Epi-0 TransE-<1 RenalEp-<1
DISCHARGE LABS:
___ 07:00AM BLOOD WBC-4.6 RBC-4.62 Hgb-14.7 Hct-44.4 MCV-96
MCH-31.8 MCHC-33.1 RDW-14.4 Plt ___
___ 04:44AM BLOOD Neuts-80.5* Lymphs-12.1* Monos-5.9
Eos-1.1 Baso-0.3
___ 07:00AM BLOOD Glucose-98 UreaN-6 Creat-0.7 Na-138 K-4.4
Cl-103 HCO3-24 AnGap-15
___ 07:00AM BLOOD Calcium-9.0 Phos-2.7 Mg-1.9
MICRO:
___ UCxr:
URINE CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000
ORGANISMS/ML..
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
NITROFURANTOIN-------- <=16 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=0.5 S
IMAGING:
___ C-spine MRI
IMPRESSION:
1. There is no evidence of cervical malalignment, the signal
intensity
throughout the cervical spinal cord is normal with no evidence
of focal or diffuse lesions.
2. Multilevel disc degenerative changes, more significant at
C4/C5, C5/C6 and C6/C7 levels.
___ CXR
IMPRESSION: Right lower lobe opacity consistent with pneumonia.
___ CT C-Spine w/o Contrast
No evidence of fracture or dislocation.
___ CT Head w/o Contrast
No evidence of acute process. Stable encephalomalacia in the
left frontal lobe.
___ CXR
Endotracheal tube tip projects approximately 5.5 cm above the
carina. Esophageal catheter tip projects over left upper
quadrant, likely within the stomach. Right costophrenic angle
incompletely imaged.
Brief Hospital Course:
___ homeless gentleman with an extensive history of alcoholism
and TBI with seizure d/o who has had multiple ED visits and
admissions for ETOH toxicity/seizures who was admitted after a
generalized seizure likely ___ to alcohol withdrawal
# Alcohol Withdrawal/Abuse: Patient has an extensive history of
alcoholism with multiple admission for alcohol intoxication and
presumed withrawal seizures. Per patient, he drinks 1 quart of
vodka per day since he was a teenager. Patient was maintained on
a CIWA scale while inpatient and did not have significant
symptoms except diaphoresis, he did not receive any diazepam for
over 48 hours prior to discharge. He was treated with thiamine,
folate and multivitamins. He was seen by social work and
provided with detox information and housing resources. He was
evaluated by psych due to concern of capacity/insight/underlying
undiagnosed pychiatric disorder. He was assessed to have
capacity/insight but just makes poor decisions. He was offered a
stay at the ___ which he declined. Patient expresses
a wish to return to ___ as soon as possible and was discharged
to a shelter with information on how to access outpatient
alcohol abstinence programs.
# Seizures: Patient's seizure prior to admission was most likely
due to ETOH withdrawal based on history. He also has a history
of TBI with resulting seizure disorder which likely contributes
as well. He has not taken his prescribed Keppra in ___ years.
Patient did not demonstrate seizure activity throughout
admission. He was restarted on Keppra and discharged with a
prescription.
# C-spine tenderness: Patient has baseline C-spine tenderness
after he was struck by a car in ___. He displayed worsening
posterior midline neck pain after his witnessed seizure. He was
maintained in a C-collar throughout admission. C-spine CT and
MRI were negative for acute processes, only degenerative
changes. He was evaluated by neurosurgery who recommended a
C-collar for 4 weeks and follow-up with the spine clinic. We
provided him with the number for the Spine Clinic and he was
discharged with a ___ J collar.
# UTI: Patient's UA was suggestive of a UTI with 51 WBCs,
moderate bacteria, nitrite positive, small leuk. Patient also
had a Foley catheter placed at admission. It was unclear if he
was symptomatic. Urcine culture grew out >100,000 Coag negative
Staph which was pan sensitive. He was treated for a complicated
UTI with IV ceftriaxone for 4 days and discharged on DS Bactrim
until ___ for a total of a 7day course.
# Code status: Patient was FULL CODE throughout admission.
# Transitional issues:
-Discharged in ___ J collar with phone number for spine clinic
to follow-up in 4 weeks
-Discharged with prescription for Keppra and asked to make an
appointment with a PCP, he was given the phone number for ___ as
well as the ___ Primary Care Clinic.
-He was given information on local outpatient alcohol abuse
programs which he expressed some interest in attending
Medications on Admission:
1) Keppra 1000mg PO BID (not taking)
2) Thiamine 100mg PO daily (not taking)
3) Folate 1mg PO daily (not taking)
4) Multivitamin 1 tab PO daily (not taking)
Discharge Medications:
1. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*2
2. LeVETiracetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth Twice daily Disp
#*60 Tablet Refills:*0
3. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*2
4. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*2
5. Sulfameth/Trimethoprim DS 1 TAB PO BID
Please take last dose on ___.
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth Twice daily Disp #*6 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Seizure, likely secondary to alcohol withdrawal
Alcohol detoxification
Secondary diagnosis:
Acute on chronic cervical spine pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Hi Mr. ___,
You were admitted to the hospital on ___, because you
suffered a seizure from alcohol withdrawal. You were initially
in the intensive care unit and intubated for protection of your
airway. You were extubated the next day and transferred to the
medicine floor to manage your alcohol withdrawal symptoms. You
did not demonstrate any seizure activity and you did not display
any significant symptoms of withdrawal. You were placed in a
neck collar due to concern for neck injury. While you have
chronic neck pain and your CT and MRI scans were negative for
any damage to your spinal cord, you will need to keep the collar
on for the next 4 weeks. You will need to see a specialist in
the spine clinic at that time.
You were also seen by social work who provided with information
of alcohol abstinence programs and housing resources. You were
also restarted on Keppra to control your seizures. You should
continue this medication and it will be important to avoid
alcohol.
You also had a urinary tract infection which we treated with
antibiotics. Please take Bactrim twice daily until ___.
You have expressed wishes to return to ___ as soon as
possible. We offered you a short stay at the ___, but
you declined.
Followup Instructions:
___
|
10209056-DS-13 | 10,209,056 | 22,246,020 | DS | 13 | 2132-09-07 00:00:00 | 2132-09-22 22:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
quinine / NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___
Chief Complaint:
Flank pain, hyponatremia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with history of type 2 diabetes mellitus,
hyperlipidemia, chronic cough, and chronic back pain who
presents with worsening left flank/back pain x4 days. The pain
is on the left upper flank in a horizontal band-like
distribution, without radiation. It is sharp, "stabbing from the
skin to the inside" with a severity of ___. It is worse with
deep inspiration and general movement but not exacerbated by
coughing. He has no history of trauma/injury. He first noticed
some mild pain on ___ while watching TV, which worsened
throughout the night until it was very severe. He saw his PCP ___
___ and was given cyclobenzaprine without relief. The pain
continued to worsen, so he presented to the ED. He has never had
this pain before; it is separate and different from his usual
chronic back pain. No recent history of severe coughing. He was
on a recent 10 day course of prednisone but no long-term steroid
use. He drinks ___ gallons of water per day to relieve symptoms
related to chronic cough.
In the ED, initial VS were 10 97.4 95 153/95 20 100% RA. Labs
were notable for Na 125, which downtrended to 122 following
administration of IVF 1000 mL NS. Additionally, he was found to
have Cr 1.3, Hgb 13.3, and Wbc 8.8. UA was notable for 1000
glucose with no blood, ___, or nitrite. CTU showed no renal
stone, pyelonephritis, or other acute intra-abdominal or pelvic
process to explain patient's pain. Patient received IVF 1000 mL
NS (started 100 mL/hr) and a total of 12 mg IV Morphine Sulfate.
Transfer VS were 8.0 90 147/99 18 100% RA
On arrival to the floor, patient reports continued ___ pain. No
fevers, chills, sweats. No dysuria, hematuria. No abdominal
pain, nausea/vomiting/diarrhea. No chest pain or shortness of
breath, his chronic cough is improved compared to when it first
developed but otherwise stable.
REVIEW OF SYSTEMS:
per HPI
Past Medical History:
PAST MEDICAL AND SURGICAL HISTORY:
Hyperlipidemia
Disc disorder of cervical region
Disc disorder of lumbar region
Allergic rhinitis
Gout of big toe
Insomnia
Overweight
Vitamin D deficiency
T2DM (type 2 diabetes mellitus)
Colonic adenoma
Cervical facet joint syndrome
Eczema of both hands
OSA (obstructive sleep apnea)
Social History:
___
Family History:
Brother Alive; ___ at age ___ CAD/PVD - Early
Father ___ at age ___ Hyperlipidemia
Maternal Grandfather ___ at age ___ Stroke
Maternal Grandmother ___
Mother Alive Arthritis; Diabetes - Type II
Paternal Grandfather ___
___ Grandmother ___
Sister Alive
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97.8 128/89 79 18 99%RA
GENERAL: NAD, lying in bed, fatigued yet easily engages in
conversation
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, voice hoarse
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: diminished breath sounds and crackles appreciated in LLL,
no wheezes, rales, rhonchi, breathing comfortably without use of
accessory muscles, resonant to percussion
ABDOMEN: slightly distended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema. Pulses DP/Radial 2+
bilaterally
SKIN: No evidence of ulcers, rash, or lesions on back, chest, or
limbs.
MSK: TTP amd hyperalgesia to light touch over superior left
flank in a dermatomal distribution from T8-9. No vesicular
lesions or erythema. No edema or hematoma.
NEURO: CN II-XII intact. ___ strength and normal sensation in
lower extremities bilaterally.
DISCHARGE PHYSICAL EXAM:
VS - 97.9 119/85 76 18 98%RA
GENERAL: NAD, lying in bed woken up from sleep, alert and
happily engages in conversation
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, voice hoarse
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles, resonant to percussion
ABDOMEN: slightly distended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema. Pulses DP/Radial 2+
bilaterally
SKIN: No evidence of ulcers, rash, or lesions on back, chest, or
limbs.
MSK: less TTP over superior left flank in a dermatomal
distribution from T7-9. No vesicular lesions, erythema, or
hematoma.
NEURO: CN II-XII intact. ___ strength and normal sensation
throughout
Pertinent Results:
ADMISSION LABS:
===============
___ 05:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
___ 05:15PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:15PM URINE UHOLD-HOLD
___ 05:15PM URINE OSMOLAL-418
___ 05:15PM URINE HOURS-RANDOM CREAT-94 SODIUM-52
___ 06:20PM PLT COUNT-220
___ 06:20PM NEUTS-74.9* LYMPHS-18.5* MONOS-5.8 EOS-0.5*
BASOS-0.1 IM ___ AbsNeut-6.59* AbsLymp-1.63 AbsMono-0.51
AbsEos-0.04 AbsBaso-0.01
___ 06:20PM WBC-8.8 RBC-4.29* HGB-13.3* HCT-39.3* MCV-92
MCH-31.0 MCHC-33.8 RDW-12.2 RDWSD-40.4
___ 06:20PM estGFR-Using this
___ 06:20PM GLUCOSE-222* UREA N-10 CREAT-1.3* SODIUM-125*
POTASSIUM-4.3 CHLORIDE-85* TOTAL CO2-28 ANION GAP-16
___ 10:30PM OSMOLAL-266*
___ 10:30PM GLUCOSE-199* UREA N-9 CREAT-1.2 SODIUM-122*
POTASSIUM-4.5 CHLORIDE-86* TOTAL CO2-21* ANION GAP-20
___ 04:12AM CALCIUM-9.4 PHOSPHATE-4.6* MAGNESIUM-1.7
___ 04:12AM GLUCOSE-175* UREA N-9 CREAT-1.1 SODIUM-128*
POTASSIUM-4.3 CHLORIDE-92* TOTAL CO2-26 ANION GAP-14
___ 04:57AM PLT COUNT-226
___ 04:57AM WBC-7.8 RBC-4.05* HGB-12.2* HCT-37.2* MCV-92
MCH-30.1 MCHC-32.8 RDW-11.9 RDWSD-40.5
___ 04:57AM CORTISOL-4.0
___ 04:57AM CALCIUM-9.6 PHOSPHATE-4.7* MAGNESIUM-1.7
___ 04:57AM GLUCOSE-169* UREA N-9 CREAT-1.1 SODIUM-129*
POTASSIUM-4.1 CHLORIDE-92* TOTAL CO2-26 ANION GAP-15
___ 12:45PM GLUCOSE-202* UREA N-9 CREAT-1.2 SODIUM-129*
POTASSIUM-4.6 CHLORIDE-92* TOTAL CO2-29 ANION GAP-13
___ 08:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-150 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 08:25PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:25PM URINE U-PEP-NO PROTEIN
___ 08:25PM URINE HOURS-RANDOM TOT PROT-7
DISCHARGE/PERTINENT LABS:
=========================
___ 04:29AM BLOOD WBC-6.8 RBC-4.32* Hgb-13.3* Hct-40.6
MCV-94 MCH-30.8 MCHC-32.8 RDW-12.0 RDWSD-41.6 Plt ___
___ 04:29AM BLOOD Glucose-216* UreaN-11 Creat-1.2 Na-130*
K-4.3 Cl-93* HCO3-26 AnGap-15
___ 04:29AM BLOOD Calcium-9.3 Phos-4.9* Mg-2.0
___ 09:40AM BLOOD D-Dimer-288
___ 10:50AM BLOOD Free T4-1.3
___ 10:50AM BLOOD Cortsol-30.1*
___ 09:40AM BLOOD PEP-NO SPECIFIC ABNORMALITIES SEEN;
INTERPRETED BY ___, MD, PHD
___ 09:40 ACTH - FROZEN
Test Result Reference
Range/Units
ACTH, PLASMA 16 ___ pg/mL
MICROBIOLOGY:
=============
URINE CULTURE (Final ___: NO GROWTH.
URINE CULTURE (Final ___: NO GROWTH.
IMAGING:
========
CTU (ABD/PEL) W/CONTRAST ___ 8:09 ___: No urolithiasis,
pyelonephritis, or other acute intra-abdominal or pelvic process
to explain the patient's pain.
CHEST (PA & ___ 9:40 AM): Low lung volumes with
minimal bibasilar atelectasis.
CT CHEST W/O CONTRAST ___ 4:20 ___: No CT findings
explaining the clinical condition of the patient. Mild
distention of the gallbladder containing contrast (vicarious
excretion of contrast).
Brief Hospital Course:
Mr. ___ is a ___ male with history of type 2
diabetes mellitus, hyperlipidemia, chronic cough, and chronic
back pain who presented with worsening left flank/back pain for
four days prior to presentation, also found to have
hyponatremia.
ACTIVE ISSUES:
# Flank/back pain:
Localized pain in a dermatomal pattern at the level of T12 on
the left. Pleuritic and exacerbated by movement and pressure.
CTU negative for kidney stones and any intra-abdominal or bone
abnormalities. D-dimer was negative, and chest CT was negative
for lung parenchymal or vertebral/bony abnormalities. The main
differential diagnoses included muscle strain, preherpetic
neuralgia, or neuropathic pain related to known spinal disease.
He was without neurologic deficits throughout admission.
Patient's pain improved while in the hospital, and he was eager
for discharge with close outpatient follow-up; he was discharged
on a short course of oxycodone with instructions to return if
pain worsens significantly or a rash develops.
# Hyponatremia:
Serum sodium of 125 on admission. After correction for
hyperglycemia was 127. Patient euvolemic and urine lytes were
notable for elevated urine osmolality and elevated urine sodium
consistent with SIADH. TSH was normal. Initial AM cortisol was
low, but repeated AM cortisol, ACTH, as well as ACTH stimulation
test were normal. SIADH likely related to pain. The corrected
sodium improved from 125 on admission to 131 on discharge with
fluid restriction. Renal was consulted and recommended 2L fluid
restriction, ensure TID to increase solute intake and increase
water excretion. Patient to follow-up with nephrology as an
outpatient.
# Constipation:
Likely due to opiates and decreased activity. Patient started on
Senna, Colace, Miralax, and Bisacodyl.
CHRONIC ISSUES:
# Chronic cough: Omeprazole, Flonase, and Advair were continued.
# Insomnia: Amitriptyline and zolpidem were continued.
# Gout: Allopurinol was continued.
# Hyperlipidemia: Atorvastatin was continued.
# Diabetes mellitus: Metformin was held in favor of insulin
sliding scale and resumed at discharge.
TRANSITIONAL ISSUES:
====================
# Monitor for resolution of back pain, and consider additional
evaluation, including additional imaging, if pain persists or
worsens.
# Monitor for occurrence of shingles rash in the area of the
pain, and treat as needed.
# Patient was discharged on 2 L fluid restriction and high
solutes diet (Ensure TID).
# Check sodium within week after discharge, and consider
stopping 2 L fluid restriction if sodium normalizes. If
hyponatremia persists/worsens, consider additional evaluation;
referral to outpatient nephrology is advised.
# Would suggest rechecking CBC with differential within 1 week
post-discharge, given mild anemia to 37.2-39.3 that had
improved to 40.6-41.2 by discharge, without dedicated
intervention and left shift.
# Follow up on pending SPEP.
# Patient complained of constipation, for which he was
discharged on senna, Colace, and miralax; he was advised to
discuss further with his primary care physician if constipation
persists or nausea, vomiting, or abdominal pain develops.
# Although a diagnosis of chronic kidney injury is noted in his
discharge worksheet, on further review, eGFR remained within
normal limits throughout his admission, hence he is not felt to
have acute or chronic kidney injury.
# CODE STATUS: Full (confirmed)
# EMERGENCY CONTACT: ___ (___) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Zolpidem Tartrate 5 mg PO QHS insomnia
3. Omeprazole 20 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Atorvastatin 40 mg PO QPM
6. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
7. Amitriptyline 50 mg PO QHS
8. Fluticasone Propionate NASAL 2 SPRY NU DAILY
9. Chlorpheniramine Maleate 12 mg PO BID
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY
RX *bisacodyl 5 mg ___ tablet(s) by mouth Daily Disp #*60 Tablet
Refills:*0
2. Ensure (food supplemt, lactose-reduced) 8 ounces oral TID
RX *food supplemt, lactose-reduced [Ensure] 237 Milliliter by
mouth three times a day Refills:*0
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth Daily
Disp #*30 Packet Refills:*0
5. Senna 8.6 mg PO BID constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
6. Allopurinol ___ mg PO DAILY
7. Amitriptyline 50 mg PO QHS
8. Atorvastatin 40 mg PO QPM
9. Chlorpheniramine Maleate 12 mg PO BID
10. Fluticasone Propionate NASAL 2 SPRY NU DAILY
11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
12. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Zolpidem Tartrate 5 mg PO QHS insomnia
15.Outpatient Lab Work
Please draw blood for:
CBC, Na, K, Cl, HCO3, BUN, Cr, Glucose.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Flank pain
Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you here at ___. You came to
the hospital because you were experiencing left-sided flank
pain. You were also found to have a low level of sodium.
What happened to you during your hospital stay?
- You had several imaging to evaluate for the cause of your
flank pain. CT scan of the abdomen did not show any kidney
stones and no bone abnormalities. CT scan of the chest did not
show any abnormalities in the lung to explain your symptoms.
- The cause of your flank pain remained unclear, we suspect that
it is related to either a muscle strain or early shingles.
- We treated you with pain medications including lidocaine
patch, Tylenol, and oxycodone with improvement in your pain.
- You also underwent a lot of blood testing to evaluate for the
cause of low sodium level; blood hormones were overall within
normal limits. We suspect that the low sodium is related to a
combination of recent prednisone and excessive intake of water.
What should you do when you go home?
- Continue taking pain medications, and try to gradually
decrease the frequency of oxycodone with plan to stop taking
medications within a few days.
- Monitor for occurrence of rash in the area of pain, if this
happens, you should call your PCP to be evaluated for shingles.
- Limit water intake to 2 L per day until you see your PCP.
- You should also drink Ensure (high solutes drink) three times
a day because this will help with your low sodium.
- You should have your blood checked next week and follow up
with your PCP as scheduled.
- You should continue taking senna, colace, and miralax for your
constipation. If you don't have a bowel movements, have nausea,
or vomiting, please call your PCP.
Thank you for allowing us to be part of your care.
Your ___ team
Followup Instructions:
___
|
10209431-DS-21 | 10,209,431 | 22,784,629 | DS | 21 | 2153-10-01 00:00:00 | 2153-10-01 17:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___ cardiac catheterization
___:
Urgent coronary artery bypass graft x5: Left internal mammary
artery to left anterior descending artery, saphenous vein grafts
to diagonal and posterior descending arteries, and saphenous
vein sequential graft to obtuse marginal and ramus arteries.
History of Present Illness:
This is a ___ year old male with no significant PMHx p/w chest
pain. Patient reports that he has been experiencing exertional
chest pain and dyspnea that has been getting progressively worse
over the past several weeks. He reports that he first
experienced these symptoms in ___ but until a couple of
weeks ago, the pain and SOB were very infrequent and always
associated with exertion. Now, his CP and SOB come on more
frequently with walking only a few feet. He presented to urgent
care on ___ with chest pain, he had an EKG which showed ST
depressions in leads I, avl, and V3-V6 while having chest pain,
Q waves in leads II, III. At urgent care, he received 325 mg
Aspirin and Nitroglycerin SL x1 with relief of pain. ST
depressions resolved when chest pain free. He was transferred at
___ ED.
In the ED,
- Initial vitals: 97.4 82 162/84 16 97%
- Labs significant for:
Na 136, K 4.3, Cl 99, HCO3 28, BUN 18 Cr 1.0
Trop <0.1, BNP 676
- CXR: No evidence of acute cardiopulmonary disease.
- Transfer vitals: 98.2 68 148/78 16 100% RA
On arrival to the floor, the patient experienced ___ chest pain
while walking to the restroom. EKG again showed ST depressions
in leads I, aVL, V2-V6. He received a SL nitro which relieved
his pain. EKG showed some improvement with the SL nitro but
still had some depression. He notes some ankle swelling for the
past several days for which he took Furosemide which he had from
a prescription years ago.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, palpitations, syncope or
presyncope.
Past Medical History:
None- no primary care evaluation for past ___ years
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission PE:
Pulse:63 Resp:20 O2 sat:95% RA
B/P ___
Height:6'2" Weight:296lbs/134.27kg
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [] bowel sounds
+[]
Extremities: Warm [x], well-perfused [] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:1+ Left:1+
DP Right:1+ Left:1+
___ Right:1+ Left:1+
Radial Right:1+ Left:1+
Carotid Bruit Right:- Left:-
Discharge PE:
Pulse:66 Resp:26 O2 sat:95% on 2L NC
B/P ___ Tmax 99.5F, current 98.1F
Height:6'2" Weight:140.7kg
General:NAD, Obese
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs with decreased bases bilaterally [x]
Sternum: stable, healing well, no erythema or drainage
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [] Edema: 1+ BLE [x]
Left leg vein harvest incision: healing well, no erythema or
drainage
Neuro: Grossly intact [x]
Pulses:
DP Right:1+ Left:1+
___ Right:1+ Left:1+
Radial Right:1+ Left:1+
Pertinent Results:
STUDIES:
___ Cardiac Catheterization
LMCA diffusely diseased with 80-90% stenosis. LAD has 95% ostial
stenosis with good distal and diagonal targets. The circumflex
is co-dominant and has 90% proximal stenosis with good distal
___ target. RCA has 9% calcified stenosis, diffuse proximal
and ___ stenosis. Right PDA has high take-off and 80%
stenosis after the origin.
IMPRESSION: Severe left main and 3 vessel CAD
___ Echocardiogram
No atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity is moderately dilated. Overall left
ventricular systolic function is mildly to moderately depressed
(LVEF= ? 40 %) secondary to akinesis of the basal-mid inferior
and inferolateral walls. The remaining segments were not well
visualized in apical views. 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 aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse.
Physiologic mitral regurgitation is seen (within normal limits).
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with moderate cavity dilatation and ?
mild-moderate regional systolic dysfunction.
___ TEE (preliminary):
Conclusions
Prebypass
No atrial septal defect is seen by 2D or color Doppler. There is
an inferobasal left ventricular aneurysm. Overall left
ventricular systolic function is mildly depressed (LVEF= 40 %).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the aortic arch. The descending
thoracic aorta is mildly dilated. There are complex (>4mm)
atheroma in the descending thoracic aorta. There are complex
(>4mm) atheroma in the abdominal aorta. No thoracic aortic
dissection is seen. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. Trace aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. Mild to moderate (___)
mitral regurgitation is seen. There is no pericardial effusion.
Dr. ___ was notified in person of the results in the OR
during the procedure.
Postbypass
The patient separated from bypass on a phenylephrine infusion.
The cardiac output is estimated as 4.9 by TEE.
There are no new wall motion abnormalities. There is no change
in AI. The MR is now mild. The aorta shows no sign of injury or
dissection.
RV Function is normal. LVEF is now 45%.
Portable CXR ___:
IMPRESSION: The right IJ central line has the distal lead tip
at the cavoatrial junction. The left basilar chest tube has
been removed. There is again seen markedly low lung volumes
with atelectasis at the lung bases. No definite consolidation
or pneumothoraces are identified.
LABS:
___ 05:00AM BLOOD WBC-9.6 RBC-3.44* Hgb-9.9* Hct-28.7*
MCV-83 MCH-28.8 MCHC-34.5 RDW-14.4 Plt ___
___ 03:02AM BLOOD WBC-13.6* RBC-3.75* Hgb-10.7* Hct-31.7*
MCV-85 MCH-28.5 MCHC-33.7 RDW-14.4 Plt ___
___ 04:31PM BLOOD WBC-8.1 RBC-5.27 Hgb-14.8 Hct-43.1 MCV-82
MCH-28.1 MCHC-34.4 RDW-13.9 Plt ___
___ 03:02AM BLOOD ___ PTT-26.7 ___
___ 05:00AM BLOOD Glucose-104* UreaN-32* Creat-1.1 Na-135
K-4.5 Cl-96 HCO3-31 AnGap-13
___ 09:10PM BLOOD UreaN-32* Creat-1.2 Na-134 K-4.2 Cl-95*
___ 03:02AM BLOOD Glucose-97 UreaN-29* Creat-1.3* Na-130*
K-4.9 Cl-97 HCO3-26 AnGap-12
___ 04:31PM BLOOD Glucose-102* UreaN-18 Creat-1.0 Na-136
K-4.3 Cl-99 HCO3-28 AnGap-13
___ 12:30PM BLOOD ALT-52* AST-43* AlkPhos-66 TotBili-0.8
___ 12:50AM BLOOD CK-MB-11* MB Indx-2.9 cTropnT-<0.01
___ 12:30PM BLOOD %HbA1c-5.9 eAG-123
___ 03:02AM BLOOD Triglyc-218* HDL-33 CHOL/HD-7.0
LDLcalc-154*
Brief Hospital Course:
Mr. ___ was admitted to the ___ service under Dr.
___ on ___ for worsening exertional chest pain. His
urgent care EKG from that same day showed ST depressions in
leads I, avL, and V3-V6 with Q waves in Leads II, III. His
troponins remained negative, but his cardiac catheterization
showed multivessel disease.
He was brought to the Operating Room on ___ where the
patient underwent urgent coronary artery bypass graft x5: Left
internal mammary artery to left anterior descending artery,
saphenous vein grafts to diagonal and posterior descending
arteries, and saphenous vein sequential graft to obtuse marginal
and ramus arteries. Overall the patient tolerated the procedure
well and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. He did have
brief postoperative atrial fibrillation and was started on
amiodarone, but coumadin was not added since he returned quickly
to sinus rhythm. He had a peak creatinine bump to 1.4, but has
since returned to his normal preoperative level. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD 4, the patient was ambulating freely, the
wound was healing and pain was controlled with oral analgesics.
He is being started on lisinopril for his cardiomyopathy. He is
also being discharged on a statin with mildly elevated LFTs and
will need to have these repeated as an outpatient with further
work up if they remain elevated. The patient was discharged to
___ in ___ in good condition with
appropriate follow up instructions
Medications on Admission:
This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain/fever
do not take more than 4000mg/day please
2. Amiodarone 400 mg PO BID
___ BID through ___, then 400mg daily x 7 days, then 200mg
daily
3. Aspirin EC 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Docusate Sodium 100 mg PO BID
6. Metoprolol Tartrate 50 mg PO TID
7. Potassium Chloride 20 mEq PO BID Duration: 14 Days
8. Furosemide 40 mg PO BID Duration: 14 Days
9. Lisinopril 5 mg PO DAILY
10. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth
every six (6) hours Disp #*60 Tablet Refills:*0
11. Milk of Magnesia 30 ml PO DAILY
hold for loose stools
Discharge Disposition:
Extended Care
Facility:
___
for Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
Primary:
Coronary Artery Disease
s/p Urgent coronary artery bypass graft x5: Left internal
mammary artery to left anterior descending artery,saphenous vein
grafts to diagonal and posterior descending arteries, and
saphenous vein sequential graft to obtuse marginal and ramus
arteries.
Brief postoperative atrial fibrillation
Unstable angina
Ischemic cardiomyopathy
Secondary:
Past Medical History:
cervical spine injury with fall ___ years ago, now resolved,
migraines, PNA in ___
Past Surgical History
back surgery for herniated lumbar disks "many years ago"
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Left leg vein harvest incision - healing well, no erythema or
drainage
Edema -1+ bilaterally
Discharge Instructions:
You were admitted to the hospital with chest pain with exertion
that had been worsening. You had EKG that were concerning for
blockages in your heart. You underwent a cardiac catheterization
that showed severe blockages in many arteries. You underwent
bypass surgery.
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
10209608-DS-10 | 10,209,608 | 24,841,722 | DS | 10 | 2135-01-21 00:00:00 | 2135-01-21 19:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
Transfer for DKA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with a history of type 1
diabetes with one prior episode of DKA who presented as a
transfer from ___ for treatment of DKA.
He was in his usual state of health until yesterday, when he
went
out for his daughter's birthday. He states that he ate a large
dinner and he had several glasses of wine. He awoke at 130 this
morning with abdominal pain, nausea and vomiting. He states he
is
vomited approximately 10 times since then. He does report a dark
brown coffee-ground color to the vomit. He has no prior history
of GI bleeding, and no history of cirrhosis. He takes no
anticoagulation. He denies any melena or hematochezia. He was
given 80 mg of Protonix prior to transport from ___. He was
also started on insulin drip with fluids for the DKA. EKG at
___ was concerning for ST elevation in aVR; cardiology was
curb-sided at ___, and suggested that he may need a
catheterization once these immediate issues are resolved,
although did not feel that this was urgent iso his DKA.
Past Medical History:
HTN
HLD
DMI
Depression
Anxiety
Chronic Pain (R Ankle)
Insomnia
PERIPHERAL NEUROPATHY
CHRONIC KIDNEY DISEASE
DIABETIC RETINOPATHY
PERIPHERAL VASCULAR DISEASE
ERECTILE DYSFUNCTION
B12 DEFICIENCY ANEMIA
INFECTIOUS ENDOCARDITIS
MSSA, vegetation on aortic valve
Social History:
___
Family History:
Alcoholism, DM
Physical Exam:
ADMISSION EXAM:
==================
VS: ___ 101HR 138/110 12RR 97%
General- NAD
HEENT- PERRL, EOMI, normal oropharynx
Lungs- Non-labored breathing, CTAB
CV- RRR, no murmurs, normal S1, S2
Abd- Soft, nontender, mildy distended vs obese, no guarding,
rebound or masses
Msk- No spine tenderness, moving all 4 extremities, no edema
Neuro-A&O x3, CN ___ intact, normal strength and sensation in
all extremities, normal speech
Skin- No rash
Psych- Normal affect, Slight depression on questioning regarding
outlook and desire for further medical care
DISCHARGE EXAM:
================
Vitals: ___, 178 / 81, 81, 18, 97% RA
General: Alert older man in NAD
HEENT: +Lower lip contusion, improving; anicteric scleare
Lungs: CTAB - no wheezes, rhonchi, or crackles
CV: RRR, no m/r/g
GI: +BS, S, NT, ND
Ext: Warm, no BLE edema
Neuro: Alert, oriented, no facial asymmetry, ___ BUE/BLE
strength
Pertinent Results:
ADMISSION LABS:
================
___ 01:10PM BLOOD WBC-16.0* RBC-3.88* Hgb-11.4* Hct-36.1*
MCV-93 MCH-29.4 MCHC-31.6* RDW-12.1 RDWSD-41.1 Plt ___
___ 01:10PM BLOOD Neuts-89.6* Lymphs-3.3* Monos-6.4
Eos-0.0* Baso-0.3 Im ___ AbsNeut-14.34* AbsLymp-0.52*
AbsMono-1.03* AbsEos-0.00* AbsBaso-0.04
___ 01:15PM BLOOD ___ PTT-24.6* ___
___ 01:10PM BLOOD Glucose-469* UreaN-52* Creat-3.5*# Na-136
K-5.6* Cl-89* HCO3-12* AnGap-35*
___ 01:10PM BLOOD ALT-26 AST-32 CK(CPK)-52 AlkPhos-105
TotBili-0.4
___ 01:10PM BLOOD Lipase-11
___ 01:10PM BLOOD CK-MB-5 cTropnT-<0.01
___ 04:09PM BLOOD CK-MB-10 MB Indx-13.3* cTropnT-0.05*
___ 09:00PM BLOOD CK-MB-25* cTropnT-0.22*
___ 01:10PM BLOOD Albumin-4.0 Calcium-9.6 Mg-1.6
Cholest-152
___ 03:58PM BLOOD %HbA1c-8.8* eAG-206*
___ 01:10PM BLOOD Triglyc-114 HDL-43 CHOL/HD-3.5 LDLcalc-86
___ 01:10PM BLOOD Beta-OH-6.8*
___ 01:20PM BLOOD ___ pO2-39* pCO2-43 pH-7.17*
calTCO2-17* Base XS--13 Intubat-NOT INTUBA
___ 04:23PM BLOOD ___ pO2-49* pCO2-41 pH-7.21*
calTCO2-17* Base XS--11 Comment-GREEN TOP
___ 08:50PM URINE Color-Yellow Appear-Clear Sp ___
___ 08:50PM URINE Blood-TR* Nitrite-NEG Protein-30*
Glucose-300* Ketone-10* Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 08:50PM URINE RBC-<1 WBC-0 Bacteri-NONE Yeast-NONE
Epi-0
___ 08:50PM URINE CastHy-58*
PERTINENT INTERVAL LABS:
======================
___ 03:57AM BLOOD CK-MB-21* MB Indx-13.6* cTropnT-0.38*
___ 07:56AM BLOOD CK-MB-26* cTropnT-0.53*
___ 01:24PM BLOOD CK-MB-23* MB Indx-14.1* cTropnT-0.46*
___ 08:42AM BLOOD ___ pO2-37* pCO2-45 pH-7.30*
calTCO2-23 Base XS--4
___ 11:19AM BLOOD ___ pO2-47* pCO2-44 pH-7.33*
calTCO2-24 Base XS--2
MICROBIOLOGY:
===============
___ BCx: No growth to date (preliminary)
___ BCx: No growth to date (preliminary)
IMAGING
========
___ CXR IMPRESSION: No evidence of acute cardiopulmonary
disease.
___ TTE:
The left atrial volume index is normal. There is normal left
ventricular wall thickness with a normal cavity size. There is
suboptimal image quality to assess regional left ventricular
function. The visually estimated left ventricular ejection
fraction is 65%. There is no resting left ventricular outflow
tract gradient. Normal right ventricular cavity size with normal
free wall motion. The aortic sinus diameter is normal for gender
with a normal ascending aorta diameter for gender. The aortic
arch diameter is normal with a normal descending aorta diameter.
The aortic valve leaflets (3) appear structurally normal. 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 trivial mitral regurgitation.
The pulmonic valve leaflets are normal. 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: Poor image quality. No gross wall motion
abnormalities (cannot exclude with certainty).
DISCHARGE LABS:
================
___ 07:00AM BLOOD WBC-5.5 RBC-3.52* Hgb-10.3* Hct-32.3*
MCV-92 MCH-29.3 MCHC-31.9* RDW-12.0 RDWSD-40.5 Plt ___
___ 07:00AM BLOOD Glucose-154* UreaN-21* Creat-1.4* Na-142
K-4.3 Cl-104 HCO3-24 AnGap-14
___ 07:00AM BLOOD ALT-13 AST-18 LD(LDH)-190 AlkPhos-96
TotBili-0.5
___ 07:00AM BLOOD Albumin-3.5 Calcium-8.8 Phos-2.9 Mg-1.7
Brief Hospital Course:
Mr. ___ is a ___ man with a history of type 1
diabetes with one prior episode of DKA who presented to
___ with abdominal pain, nausea, and vomiting;
subsequently transferred to ___ for treatment of DKA with c/f
UGIB and type II ___ now off insulin drip and transferred to
the medical floor - however patient was adamant to go home
without obtaining a cardiac stress test or adequate blood
pressure control. He was able to verbalize the risks and
benefits, and was ultimately discharged home with services.
TRANSITIONAL ISSUES
=====================
[] Obtain repeat labs at next PCP follow up: CBC, BMP
[] Follow up FSBGs; adjust insulin regimen PRN
[] Follow up with outpatient Endocrinologist for further
management of insulin. Of note, ___ was concerned about Mr.
___ ability to manage his insulin pump. As such, he was
discharged on subcutaneous insulin: Glargine 20U qAM and qPM,
Humalog 5U TIDAC, and a Humalog sliding scale.
[] Recommend Cardiology follow up for consideration of pMIBI. Of
note, Mr. ___ declined to get a pMIBI as recommended by
cardiology while inpatient, instead deferring to get as an
outpatient.
[] Follow up gastroparesis. Consider GI evaluation for motility
agents.
[] Follow up HTN, adjust antihypertensive regimens PRN
[] Recommend monitoring of EtOH misuse. Consider outpatient
treatment options.
[] Recommend Psychiatry referral for depression and anxiety
ACUTE ISSUES
===============
# T1DM
# DKA
Patient has longstanding T1DM with one prior episode of DKA
(which occurred after SuperBowl). Most likely trigger for his
DKA was binge eating and drinking, as well as insulin pump
cartridge not being replaced. At home, has insulin pump and does
not take long acting insulin. In the ICU, he was started on an
Insulin gtt with subsequent closure of his anion gap. As such,
his Insulin drip was stopped and he was transitioned to SC
Insulin as per ___ recommendations: Glargine 20U qAM and QHS;
Humalog 5U TIDWM; with Humalog ISS 150/50/2/2. Ultimately,
___ was concerned about his ability to use his insulin pump
and advised that he not be restarted on it - and instead be
transitioned to SC insulin. Ultimately, he was discharged on the
above SC Insulin regimen. He is to follow up with his Atrius
Endocrinologist for further management and consideration of
restarting his insulin pump. Recommend close outpatient follow
up as well as diabetes education (particularly in regards to
carbohydrate counting as well as insulin pump management).
# ___, likely Type II
Initially had ST elevations in aVR, after which he had rising
troponins 0.05 ->
0.38. Ultimately felt to be secondary to increased demand in the
setting of underlying CAD. He received a full dose aspirin.
Heparin gtt was started empirically x3 days (___). His
home atenolol was otherwise transitioned to Carvedilol 18.75mg
BID; and he was continued on atorvastatin. TTE demonstrated no
WMA and EF 65%. ___ Cardiology was consulted, who recommended
a pMIBI however the patient declined to have this as an
inpatient - instead prefers to have as an outpatient.
# ___ on CKD
Baseline ~1.5-1.8, increased to 3.5 on admission. Likely
pre-renal in context of DKA. FeNA 0.8%. Improved after IVF
administration and resolution of DKA. His discharge Creatinine
was 1.4.
# Coffee-Ground Emesis
# Gastroparesis
# Normocytic Anemia
Patient has report of 1 episode of coffee-ground emesis at home
in setting of DKA. Stool guaiac neg. Initially was felt to
possibly represent a ___ tear; however he remained
hemodynamically stable and with a stable anemia during his
hospitalization. Additionally, stool guaiac was negative. He was
started on a BID PPI x72 hours (___) empirically.
Hypothesize that his coffee-ground emesis instead may have been
emesis of gastric contents in the setting of known
gastroparesis.
# Hypertension
Noted to be quite hypertensive during his hospitalization. His
home Atenolol was transitioned to Carvedilol 25mg BID for
increased BP effect. He was otherwise started on Amlodipine 5mg
daily. He intermittently received PO Hydralazine for SBP >180.
Prior to discharge, he was restarted on his home Lisinopril 20mg
daily (initially held due to ___. Given the patient opted to be
discharged prior to adequate blood pressure control, he is
follow up with his PCP for close monitoring and further
titration of his medications.
# Hyponatremia
Noted to have hyponatremia to 126 after ~ 5L IVF, including D5,
in the beginning of his hospitalization. Likely due to excess
free water. He remained asymptomatic, and this normalized
without intervention.
CHRONIC ISSUES
===============
# Alcohol Abuse Hx
Patient now with decreased EtOH consumption, with reports of ___
drinks per week with occasional binge. LFTs were wnl, however he
continued to have a thrombocytopenia ~110s. Given his reported
binge drinking, he was started on Thiamine 100mg daily. Social
work was additionally consulted. He did not endorse symptoms of
withdrawal during his hospitalization. He should continue to
have discussions as an outpatient about his EtOH misuse.
# Chronic Pain
Has history of R Ankle pain secondary to diabetic neuropathy and
traumatic injury. Continued home Percocet 5 q6hr PRN severe
pain.
# Depression
# Anxiety
Has history of depression/anxiety surrounding medical care over
last ___ years. Made light of wanting to be DNR/DNI, but defers
decision to wife who maintained full code. He was continued on
home Sertraline and Lorazepam. Social work was consulted for
coping. Recommend outpatient Psychiatry follow up.
# Insomnia
Continued home Trazodone 100mg QHS
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Atenolol 50 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. LORazepam 0.5 mg PO Q8H:PRN Anxiety
4. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain -
Moderate
5. Sertraline 50 mg PO TID
6. Omeprazole 20 mg PO DAILY
7. TraZODone 100 mg PO QHS
8. Furosemide 20 mg PO DAILY
9. Lisinopril 20 mg PO DAILY
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. CARVedilol 25 mg PO BID
RX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
4. Glargine 20 Units Breakfast
Glargine 20 Units Dinner
Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 5 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
5. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
6. Atorvastatin 80 mg PO QPM
7. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
8. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
9. LORazepam 0.5 mg PO Q8H:PRN Anxiety
10. Omeprazole 20 mg PO DAILY
11. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain
- Moderate
12. Sertraline 50 mg PO TID
13. TraZODone 100 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Diabetic ketoacidosis
Secondary:
Type II ___ on CKD
Coffee-ground emesis
Gastroparesis
Anemia
Hypertension
Hyponatremia
History of EtOH abuse
Chronic pain
Depression
Anxiety
Insomnia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- Your blood sugars were too high and you developed "DKA"
- You became dehydrated and your kidneys were hurt as well as
your heart
WHAT HAPPENED TO ME IN THE HOSPITAL?
- The ___ team was consulted to help with your insulin
- The Cardiology team was consulted, and recommended that you
have a stress test called a "pharmacologic MIBI". You declined
to have this while in the hospital - but said you were open to
having it as an outpatient.
- You were eager to leave the hospital without doing the cardiac
stress test and without getting your blood pressure under
control. Ultimately, you understood the risks and benefits of
not staying in the hospital, and you decided to leave.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please take subcutaneous insulin as instructed below. We do
NOT advise that you restart your insulin pump until you discuss
further with Dr. ___.
- Continue to take all your medicines and keep your
appointments.
- Please monitor your blood sugars closely. Call Dr. ___
___ if you have blood sugar readings greater than 400 x2
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10209685-DS-10 | 10,209,685 | 20,705,174 | DS | 10 | 2123-11-23 00:00:00 | 2123-11-24 12:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
lisinopril / phenylephrine
Attending: ___
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
HPI: ___ RHF h/o pAF/flutter, moderate aortic stenosis, and 3
miscarriages now p/w sudden onset and now resolved vertigo.
She woke up at about 6:30 this morning feeling well. She took
her
losartan, metoprolol, and aspirin. While at rest (? walking), at
about 8:30am, she had sudden onset room-spinning vertigo. She
could not walk without holding onto anything. Laying down did
not
help; no clear change eyes open/closed. BP was around 150/90.
About 45 minutes into the vertigo, she developed nausea with
emesis x3 (she did have a few "amost involuntarY" bowel
movements
as well). The vertigo resolved around the time she arrived to
the
ED, about an hour and a half.
On arrival to the ED, VS were 0 97.9 76 144/78 18 98% RA. The ED
examination was unremarkable. EKG was non-ischemic. Basic
chemistries, CBC were normal, CXR clear. CT did show some
periventricular leukomalacia but no territorial strokes. CTA did
not show dissection or significant vessel stenosis.
Pt also notes that over the past week or so, BPs have
occasionally been higher than normal (SBP 160s from normal
120s).
She has had constant right arm ache (right shoulder down to
elbow) over the past month (she was worried this represented
atypical angina - but may have had a MSK injury in ___
throwing
boxes and this is now worsened by movement); otherwise she has
been well. About 3 weeks ago, she had a cough which lingered
until a few days ago.
ROS: Positive for right arm ache; feels kind of "weird" which is
difficult to describe otherwise. Denies HA/neck pain/back pain.
No incontinence. Denies word-finding or articulation
difficulties. Feels her comprehension is normal. Vision without
sudden changes, amaurosis. Hearing normally less on left for
years. Swallowing normal. Full strong throughout without any
numbness/tingling. Denies F/C/sweats, chest pain, cough
(resolved
3 d ago), abdominal pain, N/V/C/D, myalgia, arthralgia, rash.
Past Medical History:
- Atrial fib/flutter; patient did not want to go on coumadin
because her boyfriend had a lot of bruising and GI bleeding
- Moderate aortic stenosis; dx ___ years ago
- Hypertension
- Left breast DCIS ___ tx with lumpectomy and XRT; followed
annual mammograms
- Hypothyroid since ___
- Diverticulosis
- Arthritis
- b/l knee replacements
- recent transient left foot pain radiating up the leg a few
weeks ago
- hearing loss over past ___ years
- 1 stillborn in ___, 3 miscarriages
- cataracts s/p surgery (bilateral)
Social History:
___
Family History:
- Mother died in her ___ from CHF (also CAD, PVD, valve
replacement)
- Father died age ___, lung ca
- 2 brothers died in their ___ (both with DM1 - 1 with stroke
and
1 with MI)
- ___ brother died at age ___ with a AAA rupture
- 3 Sisters, 1 with some cardiac disease and another
- 1 sister had a stillborn child
Physical Exam:
0 68 134/57 20 98% RA
Gen: NAD NT ND
HEENT: No ptosis
Neck: Limited ROM (no pain), referred cardiac murmur in carotids
but no vertebral bruits
Card: + murmur, regular at the moment
Pulm: CTAB no r/r/w
Abd: Soft NT ND
Extrem: Thin, arthritic, hairless
Neurologic
- MS: A&Ox3 (says ___. Registers and recalls ___. Normal
naming, fluency, prosody, repetition, command following. Days of
week in reverse done normally. Knows name of president. No
neglect.
- CN: PERRL slightly irregular but 2.5 ->1.5 ___. VFFTC without
extinguishing. Slight exotropia. Coarse pursuit with saccadic
intrusions. EOMI; inconsistent diplopia on left and up gaze. No
clear difference to pin (? less R V1). Slightly faint in L ear.
- Motor: 4+ pattern in RUE; LUE strong save 4+ IOs. The legs
are
slightly increased in tone and are strong save 4+ IPs and
EHLs/EDBs/FDBs. Strong withdrawal b/l and left toe slightly up
already but no obvious Babinski.
- Sensory: Finger to nose with eyes closed is normal. Intact to
large hallux deviations. Does not extinguish to double.
Sensitive
to pin throughout. Does not fall with Romberg.
- Reflexes: Brisk throughout save absent knees (surgical)
- Cerebellar: FNF without tremor or dysmetria. Mirroring is
normal. No checked reflexes. Heel/shin symmetric and with mild
clumsiness. No truncal ataxia.
- Gait: Moderate base, kyphotic, normal arm swing, turns well.
Able to heel walk better than toe walk. Poor tandem but can make
it a couple of steps.
Pertinent Results:
___ 11:42AM cTropnT-<0.01
- CXR ___ (prelim): Cardiac silhouette size is normal.
Mediastinal and hilar contours are unremarkable. Pulmonary
vasculature is normal. Lungs are essentially clear except for
minimal atelectasis in the lower lobes. No focal consolidation,
pleural effusion or pneumothorax is present. Moderate
degenerative changes with anterior osteophyte formation seen in
the lower thoracic spine.
- NON-CONTRAST CT HEAD: No acute vascular territory infarction
or
intracranial hemorrhage. Chronic changes including atrophy and
probable small vessel ischemic changes.
- CTA HEAD/NECK: No evidence of arterial dissection, stenosis or
aneurysm >3mm in the great vessels of the head/neck. 10 x 8mm
left thyroid nodule, which could be further evaluated with
thyroid ultrasound on a non-urgent basis if clinically
warranted.
Brief Hospital Course:
Ms. ___ was admitted to the Stroke Neurology service and
monitored. She had no further episodes of dizziness during the
admission. MRI did not reveal any acute stroke, but did show
extensive chronic small vessel disease.
Stroke workup was significant for:
Ms. ___ was started on apixiban and discharged home with close
follow-up with her PCP. She will also see a Stroke Neurologist
in the future.
.
TRANSITIONAL ISSUES FOR OUTPATIENT PROVIDERS
- TIA: Now on apixaban. Please follow up lipids. Please order
TTE and arrange for ___ neurology follow up.
- Endocrine: 10 x 8mm left thyroid nodule noted incidentally on
CTA head/neck.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 50 mcg PO DAILY
2. Losartan Potassium 50 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Ascorbic Acid ___ mg PO DAILY
5. coenzyme Q10 10 mg oral DAILY
6. lutein 10 mg oral DAILY
7. Multivitamins 1 TAB PO DAILY
8. Vitamin B Complex 1 DROP PO DAILY
9. Vitamin D ___ UNIT PO DAILY
10. Aspirin 81 mg PO DAILY
11. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Levothyroxine Sodium 50 mcg PO DAILY
3. Losartan Potassium 50 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Vitamin B Complex 1 CAP PO DAILY
6. Vitamin D ___ UNIT PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. coenzyme Q10 10 mg oral DAILY
9. lutein 10 mg oral DAILY
10. turmeric (bulk) 95 % miscellaneous DAILY
11. Apixaban 5 mg PO BID
this REPLACES aspirin; do not take both.
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth every 12 hours
Disp #*60 Tablet Refills:*3
12. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Transient Ischemic Attack
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital after an episode of dizziness
that was the result of a "TIA" or transient ischemic attack.
This means that a clot blocked off the blood flow to part of
your brain (the ischemia attack part) but that the clot was
broken up before it could kill those brain cells (the
"transient" part). This was likely a clot from your heart that
traveled to your brain.
Though the event did not leave any permanent damage to your
brain, you are at risk for further strokes given your history of
atrial flutter/fibrillation, aortic stenosis and miscarriages.
We started you on apixiban 5mg (1 pill) two times per day to
help prevent strokes in the futures. You no longer will need to
take aspirin.
We wish you the best as you go forward. Please do not hesitate
to contact us with any questions or concerns. We have notified
Dr. ___ what happened and we have asked her to order
an echocardiogram and to refer you to an Atrius neurologist for
follow-up care.
Your medications have changed as follows:
- START apixaban 5mg (1 pill) every 12 hours / two times per day
- STOP aspirin (it is replaced by apixaban)
- CONTINUE the rest of your home medications without change
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10209685-DS-12 | 10,209,685 | 20,456,737 | DS | 12 | 2128-04-19 00:00:00 | 2128-04-19 19:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / phenylephrine
Attending: ___.
Major Surgical or Invasive Procedure:
___: Electrical cardioversion
attach
Pertinent Results:
ADMISSION LABS:
===============
___ 09:01AM WBC-5.8 RBC-4.16 HGB-12.0 HCT-38.3 MCV-92
MCH-28.8 MCHC-31.3* RDW-14.0 RDWSD-46.7*
___ 09:01AM GLUCOSE-95 UREA N-28* CREAT-0.8 SODIUM-145
POTASSIUM-5.0 CHLORIDE-111* TOTAL CO2-16* ANION GAP-18
___ 09:01AM CALCIUM-10.0 PHOSPHATE-3.2 MAGNESIUM-2.0
___ 09:01AM ___ PTT-37.6* ___
___ 09:01AM cTropnT-<0.01
___ 09:27AM LACTATE-1.2
___ 09:01AM TSH-1.8
___ 09:01AM FREE T4-1.5
PERTINENT INTERVAL LABS:
========================
None
MICRO:
======
None
STUDIES:
========
___: CXR
No overt pulmonary edema. Cardiomegaly.
DISCHARGE LABS:
===============
___ 05:38AM BLOOD WBC-5.8 RBC-3.42* Hgb-10.0* Hct-31.5*
MCV-92 MCH-29.2 MCHC-31.7* RDW-14.0 RDWSD-46.6* Plt ___
___ 05:38AM BLOOD Glucose-88 UreaN-25* Creat-0.8 Na-141
K-4.6 Cl-111* HCO3-21* AnGap-9*
___ 05:38AM BLOOD Calcium-9.3 Phos-2.7 Mg-2.0
Brief Hospital Course:
PATIENT SUMMARY:
================
___ year old woman w/PMH severe AS s/p ___ ___, pAF/aflutter
on ___, HTN, DJD s/p bilateral TKR, hypothyroidism
who presented with palpitations and chest heaviness, found to be
in atrial flutter, now s/p successful cardioversion with
restoration of sinus rhythm. Her home metoprolol was increased
and she felt improved and was discharged with PCP follow up.
# CORONARIES: LAD 30% ostial stenosis, normal left main, RCA,
and
LCx
# PUMP: EF 66%
# RHYTHM: sinus
TRANSITIONAL ISSUES:
====================
DISCHARGE WEIGHT: 88.8 kg (195.77)
[ ] Metoprolol: Pt's metoprolol XL was increased from 75mg to
100mg for better rate control of her afib/flutter. Given history
of dizziness with increased doses, follow up on her symptoms and
ensure she is not getting dizzy with increased dosing.
[ ] ASA 81mg: Pt was previously on ASA 81mg in the setting of
her ___, but hadn't been taking it in recent years. Given her
history of ___, and mild coronary disease, she would
benefit from chronic aspirin use. She was started on this while
admitted. Please continue the conversation about ASA use and
consider keeping patient on this long-term given her
history/risk factors.
ACUTE ISSUES:
=============
# Atrial flutter/atrial fibrillation
She presented in atrial flutter with rates in 140-150s with
associated palpitations, chest heaviness, and nausea. Attempted
conversion with vagal maneuvers, metoprolol, and adenosine
without success, so she was successfully electrically
cardioverted with restoration of sinus rhythm. Her symptoms
improved and she admitted for monitoring overnight
post-cardioversion. She was stable the day after cardioversion
and was discharged on an increased dose of metoprolol XL and PCP
follow up.
- AC: Continued home ___ 20mg daily
- RC: INCREASED home metoprolol succinate to 100mg daily
# HFpEF (EF 66%)
Her exam on admission was slightly hypervolemic with mildly
elevated JVP and lower extremity edema, likely secondary to her
tachyarrhythmia. Per the patient, her EDW is around 193lbs and
her weight was 195lbs on admission. She reports subacute
increase in ___ swelling, which she manages with Lasix 20mg
daily, but otherwise reports no other symptoms consistent with
CHF exacerbation. She was felt to be stable given reassuring
exam and subacute onset and was discharged on her home dose of
Lasix with close PCP follow up to monitor volume exam.
- Continued home Lasix 20mg daily
# AS s/p ___
Stable. No symptoms.
- STARTED ASA 81mg daily
CHRONIC ISSUES:
===============
# HTN: Continued losartan 50mg BID
# Hypothyroidism: Continued levothyroxine 50mcg daily
# Neuropathy: Continued gabapentin 100mg QHS
# Nutrition: Continued vit C, vit B12, MVI, vit D
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO DAILY
2. Metoprolol Succinate XL 75 mg PO DAILY
3. Losartan Potassium 50 mg PO BID
4. ___ 20 mg PO DAILY
5. Gabapentin 100 mg PO QHS
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Ascorbic Acid ___ mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Cyanocobalamin 500 mcg PO DAILY
11. Acetaminophen w/Codeine ___ TAB PO Q6H:PRN Pain - Mild
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Metoprolol Succinate XL 100 mg PO DAILY
3. Ascorbic Acid ___ mg PO DAILY
4. Cyanocobalamin 500 mcg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Gabapentin 100 mg PO QHS
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Losartan Potassium 50 mg PO BID
9. Multivitamins 1 TAB PO DAILY
10. ___ 20 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Atrial flutter
SECONDARY DIAGNOSIS:
====================
Atrial fibrillation
HFpEF
AS s/p ___
HTN
Hypothyroidism
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. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because your heart rate was very fast
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You came into the hospital feeling poorly from a very fast
heart rate called atrial flutter. We tried to treat you with
medications to normalize your heart rhythm, but when that didn't
work, we shocked your heart back into normal rhythm.
- We monitored you overnight after the procedure to make sure
your heart rhythm stayed normal. You had occasional bouts of
atrial fibrillation with faster heart rates, but this can be
controlled with medication at home.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
appointments listed below.
Thank you for allowing us to be involved in your care, we wish
you all the best!
- Your ___ Healthcare Team
Followup Instructions:
___
|
10210153-DS-16 | 10,210,153 | 29,401,675 | DS | 16 | 2202-01-05 00:00:00 | 2202-01-05 20:30:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
unknown antibiotic given after knee surgery
Attending: ___.
Chief Complaint:
Generalized weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a Farsi-speaking ___ yo. RHM with complex PMH
including R thalamic CVA, multifactorial gait d/o (w/spondylotic
myelopathy, peripheral neuropathy, extrapyramidal symptoms),
extensive cervical spondylosis, 2 small&stable meningiomas, AFib
on warfarin, untreated rectal CA, DVT, PE, CAD, HL, OSA,
depression/adjustment d/o, presenting now from PCP's office,
where he came with complaints of weakness and pains, then was
found to be dizzy and to be suddenly unable to sit up from exam
table, becoming tearful. Pt recently spent several months in
___, where he presented to the ED once with "dizziness" and was
assessed to be anxious and depressed, and was discharged with
alprazolam, with the recommendation to start an antidepressant
as
outpatient. Upon his return, he saw his PCP ___ ___, who
recommended discontinuing alprazolam. Since then, pt has been
"angry" at home, also dysphoric, insomniac, and "perseverating
on
life decisions". Pt returned to see his PCP yesterday, where he
was found to be tangential and describing generalized pain
(mostly in legs), unsteadiness, requesting pain med refill. When
PCP tried to examine pt on exam table, pt suddenly became unable
to sit up as this was making him "dizzy" and pt became
tremulous,
then laid back down and became tearful. As PCP was unable to
fully examine pt, he transferred him to the ED for further
evaluation. Here, pt had orthostatins (lying to sitting), which
were negative.
On neurologic ROS, endorses headache/lightheadedness. Also
endorses pain in his knees bilaterally and severe pain in his
feet, and occasional muscle jerks in his legs.
No confusion/syncope/seizures/difficulty with producing or
comprehending speech/amnesia/concentration problems; no loss of
vision/blurred vision/amaurosis/diplopia/vertigo, tinnitus,
hearing difficulty, dysarthria, or dysphagia. No loss of
sensation/numbness/tingling. No difficulty with gait/balance
problems/falls.
On general ROS, no fevers/chills/rigors/night
sweats/anorexia/weight loss. No chest
pain/palpitations/dyspnea/exercise intolerance/cough. No
nausea/vomiting/diarrhea/abdominal pain. Endorses chronic
constipation. Endorses chronic urinary frequency and urgency.
Past Medical History:
- R thalamic CVA
- Seen by Dr. ___ in neurology clinic for multifactorial
gait d/o (w/spondylotic myelopathy, peripheral neuropathy,
extrapyramidal symptoms)
- extensive cervical spondylosis
- 2 small&stable meningiomas, followed here by Dr. ___
- AFib on warfarin
- untreated rectal CA
-DVT, chronic PE (negative hypercoagulable w/u)
- CAD
- HL
- AAA
- GERD
- BPH
- Osteoarthritis
- S/p bilateral knee surgeries
- S/p hernia repair
- moderately severe OSA
- evaluated here by psych for depression/adjustment d/o,
narcissistic personality d/o
Social History:
___
Family History:
Mother died at ___ yo. from natural causes
Father died at ___ yo. from PNA
2 sisters healthy
brother w/prostate CA
3 children, 1 son w/MI
Physical Exam:
ADMISSION PHYSICAL EXAM:
Time Temp HR BP RR Pox
18:18 98 70 139/59 18 96% ra
General: NAD, lying in bed comfortably but becomes distressed
when manipulating pt's legs or trying to sit up.
- Head: NC/AT, no conjunctival pallor or icterus, no
oropharyngeal lesions. + Arcus senilis. + Diagonal earlobe
creases.
- Neck: Lateral limitation of neck motion but no meningismus.
No lymphadenopathy or thyromegaly.
- Cardiovascular: No carotid or subclavian bruits; carotids with
normal volume & upstroke; jugular veins nondistended, RRR
w/prominent S2, no M/R/G
- Respiratory: Nonlabored, clear to auscultaton with good air
movement bilaterally
- Abdomen: nondistended, normal bowel sounds, no
tenderness/rigidity/guarding, no hepatosplenomegaly to palpation
and percussion
- Extremities: Warm, no cyanosis/clubbing/edema, palpable
radial/dorsalis pedis pulses. No synovitis of
elbows/wrists/fingers.
- Skin: Vitiligo, erythematous feet
Neurologic Examination:
Mental Status: Awake, alert, oriented x 3. Recalls a coherent
history. Per son, no problems with speech or orientation. Masked
facies. Positive glabellar tap and palmomental reflex. Unable to
perform Luria hand sequence.
Cranial Nerves: [II] PERRL 3->2 brisk. VF full to number finger
motion, including DSS. Funduscopy shows crisp disc margins, no
papilledema. [III, IV, VI] EOM intact including upgaze, no
nystagmus or saccadic intrusions. [V] V1-V3 with symmetrical
sensation to cold. Pterygoids contract normally. [VII] No facial
asymmetry. [VIII] Hearing grossly intact. [IX, X] Palate
elevation symmetric. [XI] SCM/Trapezius strength ___
bilaterally.
[XII] Tongue midline and moves facilely.
Motor: Some atrophy of small muscles of hand. Increased tone in
legs. No pronation or drift. No asterixis. Resting tremor of
left
wrist and fingers, also postural tremor in that hand.
Cogwheeling
elicited in left wrist with facilitation.
[ Direct Confrontational Strength Testing ]
Arm
Deltoids [C5] [R 5] [L 5]
Biceps [C5] [R 5] [L 5]
Triceps [C6/7] [R 5] [L 5]
Extensor Carpi Radialis [C6] [R 5] [L 5]
Finger Extensors [C7] [R 5] [L 5]
Finger Flexors [C8] [R 5] [L 5]
Leg - testing very limited by pain, give-way weakness
Iliopsoas [L1/2] [R 3] [L 2]
Quadriceps [L3/4] [R 5] [L 5]
Hamstrings [L5/S1] [R 5-] [L untestable]
Tibialis Anterior [L4] probably full bilaterally
Gastrocnemius [S1] [R 5] [L 5]
Extensor Hallucis Longus [L5] [R 4] [L 4]
Sensory: Did not tolerate pinprick exam. Cold sensation
decreased
on left hemibody, also decreased further in feet to level of
ankles bilaterally. Intact proprioception in toes. Positive
Tinel's at tarsal tunnel bilaterally.
Reflexes
[Bic] [Tri] [___] [Quad] [Ankle]
L ___ 0 0
R ___ 0 0
Plantar response extensor on left, did not tolerate on right.
Coordination: No dysmetria on finger-to-nose and toe-to-finger
testing. No dysdiadochokinesia.
Gait: Pt unable to sit up.
DISCHARGE PHYSICAL EXAM:
Pertinent Results:
LABS ON ADMISSION:
WBC-3.9* RBC-4.73 Hgb-14.4 Hct-43.6 MCV-92 MCH-30.5 MCHC-33.1
RDW-14.0 Plt ___
Neuts-57.3 ___ Monos-6.8 Eos-4.2* Baso-0.8
___ PTT-47.4* ___
Glucose-98 UreaN-27* Creat-1.3* Na-141 K-4.3 Cl-103 HCO3-30
AnGap-12
Calcium-8.9 Phos-2.5* Mg-2.0
Urinalysis: Color-Straw Appear-Clear Sp ___ Blood-NEG
Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG
Urobiln-NEG pH-6.5 Leuks-NEG
NCHCT (___): There is no acute intracranial hemorrhage, edema,
mass effect or major vascular territorial infarct. Prominent
ventricles and sulci are
unchanged, compatible with mild global age-related volume loss.
The basal
cisterns are preserved. There is no shift of normally midline
structures.
Gray-white matter differentiation is preserved.
Hypoattenuation in the right thalamus is encephalomalacia from
prior hemorrhage seen on MRI ___. Mild hypoattenuation
in the subcortical and periventricular white matter is likely
sequelae of chronic microvascular ischemic disease. Calcified
extra-axial masses in the right frontal (2:14) and left
occipital regions (2:16) are unchanged, compatible with
meningiomas. No osseous abnormality is identified. The
visualized paranasal sinuses, mastoid air cells, and middle ear
cavities are clear.
IMPRESSION: No acute intracranial process.
PELVIS X-RAY (___): A single frontal supine view of the pelvis
was obtained. There is no fracture or dislocation. No pubic
symphysis or sacroiliac joint diastasis. The sacral arcs appear
intact. Mesh from prior hernia repair mesh is noted in the right
inguinal region. The visualized bowel gas pattern is
non-obstructive. Vascular calcification noted at the level of
the iliac arteries.
IMPRESSION: No fracture or dislocation on this single view.
CXR (___): Findings suggest severe chronic pulmonary
hypretension with
possible early cardiac decompensation. No pneumonia.
MRI C-SPINE (___): Extensive cervical spinal degenerative
change, including moderate spinal canal narrowing with
deformation of the spinal cord from C4 through C7. Overall,
when accounting for differences in technique, findings are
minimally changed since ___.
Brief Hospital Course:
# NEURO: Patient was admitted to the General Neurology service
for workup of his generalized weakness and dizziness. He has
known multifactorial gait disorder due to cervical myelopathy
and peripheral neuropathy, and his neurologic exam was largely
unchanged from baseline on admission. Ultimately his complaints
of general weakness and dizziness were most likely mediated more
by chronic pain and depression than an acute neurological event
or new medical illness, especially since pain and lack of
cooperation hamper exam. Considered worsening cervical
myelopathy, but repeat C-spine MRI was mostly unchanged. Other
treatable aspects of his presentation included depression, so
during hospitalization he was empirically started on duloxetine
to treat both his mood and likely somatic side effects of
depression. In addition, as he had mild Parkinsonism on exam
(cogwheeling and pill-rolling tremor of left hand) a trial of
Levodopa 1mg TID was initiated. These symptoms will be followed
up and Levodopa further uptitrated if helpful as an outpatient
by his neurologist Dr. ___. Patient was followed by physical
therapy throughout hospitalization, who recommended discharge to
rehab or home with 24-hour care and home ___. After discussion
with patient and his family, it was decided to discharge him
home with close follow up and home ___.
# HEME: Patient has h/o multiple DVTs and PEs, on Coumadin
therapy at home. During hospitalization his INR trended up so
Coumadin was held on HD ___. INR on discharge was 3.3. Will be
followed up by ___ clinic and adjusted as
needed.
==============================
TRANSITIONS OF CARE:
- INR trending up during hospitalization so Coumadin HELD on
___. Needs INR rechecked by ___ on ___
and adjusted for goal INR ___.
- Pt started on Sinemet for Parkinsonism during hospitalization.
Response will be followed up by Dr. ___ in ___ Clinic on
___ and uptitrated if effective.
Medications on Admission:
ACETAMINOPHEN-CODEINE - acetaminophen-codeine 300 mg-30 mg
tablet. 1 Tablet(s) by mouth twice a day as needed for pain
FINASTERIDE - finasteride 5 mg tablet. 1 Tablet(s) by mouth once
a day
GABAPENTIN - gabapentin 100 mg capsule. 2 Capsule(s) by mouth at
bedtime
METOPROLOL SUCCINATE - metoprolol succinate ER 25 mg
tablet,extended release 24 hr. 1 Tablet(s) by mouth once a day
SIMVASTATIN - simvastatin 20 mg tablet. 1 Tablet(s) by mouth at
bedtime
TRIAMCINOLONE ACETONIDE - triamcinolone acetonide 0.1 % Topical
Cream. apply to affected areas twice a day for 1 week
WARFARIN - warfarin 3 mg tablet. 1 to 2 Tablet(s) by mouth once
a
day as directed to maintain INR Issue 4 months supply for
extended travel
WARFARIN - warfarin 2 mg tablet. 2 to 4 Tablet(s) by mouth daily
as directed by health care associates ___ clinic
Medications - OTC
OMEPRAZOLE MAGNESIUM [PRILOSEC OTC] - Prilosec OTC 20 mg
tablet,delayed release. 1 Tablet(s) by mouth once a day
Discharge Medications:
1. Finasteride 5 mg PO DAILY
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Simvastatin 20 mg PO DAILY
4. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID
5. Acetaminophen w/Codeine 1 TAB PO BID:PRN pain
6. Gabapentin 200 mg PO HS
7. Duloxetine 30 mg PO DAILY
RX *duloxetine [Cymbalta] 30 mg 1 capsule(s) by mouth daily Disp
#*30 Capsule Refills:*2
8. Carbidopa-Levodopa (___) 1 TAB PO TID Duration: 2 Weeks
RX *carbidopa-levodopa 25 mg-100 mg 1 tablet(s) by mouth three
times a day Disp #*90 Tablet Refills:*2
9. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Multifactorial gait disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital for generalized weakness and
malaise. You have known longstanding problems with walking and
balance. In the hospital we looked for causes of worsening gait
(such as worsening spinal stenosis). Our workup was reassuring.
We believe your balance problems are due to chronic
deconditioning as well as your known spinal stenosis and
peripheral neuropathy. You will need physical therapy as an
outpatient. We also started a trial of Sinemet
(Levodopa-Carbidopa) to help with your tremor, which we will
continue until you are seen by Dr. ___. We also started
Cymbalta (Duloxetine), an anti-depressant medication which can
also be helpful for treating chronic aches and pains.
.
In the hospital your Coumadin levels were high, so we held your
Coumadin. You will need to follow up with ___ clinic
TOMORROW to have your INR rechecked and your Coumadin re-dosed.
.
Please attend the outpatient appointment listed below with
Neurology (Dr. ___ to follow up on your hospitalization.
.
We made the following changes to your medications:
1. STARTED duloxetine (Cymbalta) 30mg by mouth daily - for
depression
2. STARTED carbidopa-levodopa (Sinemet) ___ one tab by mouth
three times daily -- for tremor
3. HELD warfarin (due to supratherapeutic INR)
-- You should have your INR rechecked TOMORROW and followed up
by the ___ for advice on how to adjust
your warfarin dosing.
Followup Instructions:
___
|
10210328-DS-12 | 10,210,328 | 25,464,052 | DS | 12 | 2190-11-21 00:00:00 | 2190-11-24 11:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
shrimp
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old ___ female transferred to ___ from
___ for increasing abdominal pain and possible
dilated CBD.
She has a known history of HCV (genotype 1) associated cirrhosis
complicated by ___ with 2 HCC lesions,s/p RFA, most recently to
segment V in ___.
Her cirrhosis has been also complicated by grade I-II varices.
She was initially admitted to ___ for abdominal pain and was
found to have a dilated CBD, prompting transfer to ___.
Repeat US in our ED revealed pericholecystic fluid and
gallbladder wall thickening. She was transferred to the
medical floor for further evaluation.
I spoke to her this evening via a ___ interpreter.
Ms ___ had no active complaints. She appeared confused. She
was able to tell me the year, name of the city, and her name,
however could not give me details regarding her disease process.
She denied fevers, chills, abdominal pain, nausea, vomiting.
She endorsed diarrhea.
Past Medical History:
Genotype 1A Hep C cirrhosis
HCC status post RFA to a sub 2 cm
lesion in segment VII and status post RFA to a second lesion in
segment V
Social History:
___
Family History:
(per OMR)
Father had hepatitis C and mother suffered from hypertension. No
history of cancer.
Physical Exam:
Admission Exam:
VS: temp 100.5, 127/58, 104, 16, 96% RA
Gen: Asian female, sitting up in bed, confused
Neuro: + asterixis
Cardiac: Nl s1/s2 RRR no m/r/g
Pulm: clear bilaterally
Abd: soft, nontender throughout
Ext: warm and well perfused
Discharge Exam:
Vital Signs: 97.7 92/56 71 16 98%RA
Pain ___
GEN: Alert, NAD
HEENT: NC/AT, scleral icterus
CV: RRR, no m/r/g
PULM: CTA B
GI: S/ND, BS present, no tenderness to palpation, no r/g
NEURO: Non-focal, oriented x 3, no asterixis or tremor noted
Pertinent Results:
Admission Labs:
___ 12:30PM BLOOD WBC-2.3* RBC-3.04* Hgb-9.9* Hct-29.1*
MCV-96 MCH-32.6* MCHC-34.0 RDW-13.8 RDWSD-47.7* Plt Ct-45*
___ 12:30PM BLOOD Neuts-85.0* Lymphs-9.4* Monos-5.2
Eos-0.0* Baso-0.4 Im ___ AbsNeut-1.98 AbsLymp-0.22*
AbsMono-0.12* AbsEos-0.00* AbsBaso-0.01
___ 02:02PM BLOOD ___ PTT-35.1 ___
___ 12:30PM BLOOD Glucose-151* UreaN-21* Creat-0.7 Na-134
K-4.2 Cl-102 HCO3-25 AnGap-11
___ 12:30PM BLOOD ALT-35 AST-88* AlkPhos-92 TotBili-7.8*
DirBili-3.5* IndBili-4.3
___ 12:30PM BLOOD Lipase-60
___ 12:30PM BLOOD Albumin-3.2* Calcium-8.6 Phos-3.0 Mg-1.9
___ 04:33PM BLOOD Lactate-2.5*
Discharge Labs:
___ 06:10AM BLOOD WBC-1.7* RBC-2.73* Hgb-8.7* Hct-26.6*
MCV-97 MCH-31.9 MCHC-32.7 RDW-14.0 RDWSD-49.7* Plt Ct-49*
___ 06:10AM BLOOD Glucose-80 UreaN-18 Creat-0.7 Na-134
K-4.4 Cl-106 HCO3-26 AnGap-6*
___ 06:10AM BLOOD ALT-22 AST-43* AlkPhos-81 TotBili-5.4*
___ 06:10AM BLOOD Calcium-8.0* Phos-2.7 Mg-2.5
___ 01:18PM URINE Color-LtAmb Appear-Cloudy Sp ___
___ 01:18PM URINE Blood-SM Nitrite-POS Protein-TR
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-8* pH-7.0 Leuks-NEG
___ 01:18PM URINE RBC-3* WBC-6* Bacteri-MOD Yeast-NONE
Epi-2
BCX x 2 with NGTD
RUQ U/S - IMPRESSION:
Cholelithiasis. Gallbladder wall thickening and pericholecystic
fluid which could be related to underlying liver disease similar
to recent MRI but to be correlated clinically. No intra or
extrahepatic biliary duct dilation.
MRCP - IMPRESSION:
1. Post RFA status of segment 7 and segment 4B/ 5, without
evidence of residual tumor. No lesions meeting OPTN Class 5 for
HCC in the current study.
2. Cirrhosis and confluent fibrosis, with sequelae of portal
hypertension including splenomegaly with Gamma Gandy bodies,
extensive esophageal and gastric varices, and recanalized
umbilical vein.
3. Cholelithiasis without cholecystitis.
4. Mild interval decrease in the size of the moderate right non
hemorrhagic pleural effusion.
5. No evidence of biliary obstruction.
Brief Hospital Course:
___ y/o F with PMHx of HCV cirrhosis c/b HCC s/p RFA, who was
transferred from OSH with abdominal pain and OSH imaging c/f CBD
dilation. Repeat U/S here showing GB wall thickening and
pericholecystic fluid without biliary ductal dilatation. MRCP
did not show acute process. Hepatology evaluated; they felt that
patient's initial presentation was likely related to passed
biliary stone.
# Abdominal Pain / Jaundice / Hyperbilirubinemia: Initially
concerning for possible cholangitis given suggestion of CBD
dilation on OSH imaging. However, repeat imaging here without
evidence of biliary dilatation. Hepatology service evaluated.
They felt that presentation likely representative of passed
gallstone. LFT's continue to improve, and patient remained
pain-free. She was treated with a 10-day course of cipro/flagyl
per GI recs for possible biliary infection on presentation.
# Fever: Ddx includes biliary/GI source vs. UTI (positive UA on
presentataion; however, UCx was not sent). Treated with
cipro/flagyl as above, which would cover either. No further
fevers, Bcx negative.
# HCV Cirrhosis: Presentation was initially concerning for
possible decompensated liver disease, including encephalopathy,
asterixis on presentation. Improved with lactulose. Patient was
altert and oriented x 3 at discharge, she was discharged back on
her home rifaximin.
# Thrombocytopenia / Anemia / Leukopenia: Likely related to
liver disease, near pt's baseline. Counts were stable at the
time of discharge.
# Depression: On citalopram / quetiapine. Psych followed given
reports of SI in the ED. She was reassessed by psych on the day
of discharge and felt to be stable for discharge. She was
instructed to follow up with her oupatient psychiatrist.
# Medication Reconciliation: Pt gets meds from multiple
pharmacies and was unable to list her medications for me, making
medication reconcilitation difficult. At discharge, she was
instructed to resume her home medications as she was taking them
prior to admission, with the addition of cipro/flagyl to
complete planned 10 day course.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. QUEtiapine Fumarate 25 mg PO QHS
2. Lorazepam 0.5 mg PO Q8H:PRN anxiety
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Furosemide 40 mg PO DAILY
5. Spironolactone 100 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Rifaximin 550 mg PO TID
8. Citalopram 10 mg PO DAILY
9. Vitamin D ___ UNIT PO EVERY 2 WEEKS (___)
Discharge Medications:
1. Citalopram 10 mg PO DAILY
2. Fluticasone Propionate NASAL 1 SPRY NU DAILY
3. Furosemide 40 mg PO DAILY
4. Lorazepam 0.5 mg PO Q8H:PRN anxiety
5. Multivitamins 1 TAB PO DAILY
6. QUEtiapine Fumarate 25 mg PO QHS
7. Rifaximin 550 mg PO TID
8. Spironolactone 100 mg PO DAILY
9. Vitamin D ___ UNIT PO EVERY 2 WEEKS (___)
10. Ciprofloxacin HCl 500 mg PO Q12H
Please continue for 4 more days (last day ___.
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*8 Tablet Refills:*0
11. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
Please continue for 4 more days (last day ___.
RX *metronidazole 500 mg 1 tablet(s) by mouth every 8 hours Disp
#*12 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Presumed Passed Gallstone
HCV Cirrhosis
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 abdominal pain and worsening
of your liver function tests. It seems that this was likely
related to a gallstone that you passed on your own. Your labs
are now getting better. You were also treated with antibiotics
for a fever. You should continue these antibiotics for a total 7
day course (last day ___.
Followup Instructions:
___
|
10210832-DS-20 | 10,210,832 | 26,289,690 | DS | 20 | 2157-05-30 00:00:00 | 2157-05-30 14:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache, Blurred vision, Eyelid drooping
Major Surgical or Invasive Procedure:
___: excision of the right posterior ramus mandibular
cystic lesion.
History of Present Illness:
___ yo M previously healthy developed HAs 1.5 mos ago and 2
weeks ago developed double vision when looking to the right. He
noticed around that time that his right eyelid was drooping as
well. The HA initially resolved in 2 weeks but now has returned
with a feeling of pressure in the right eye. He endorses
sensory
change in V1 that he describes as feeling "hotter". Denies
active drainage from nose but did have a cold with rhinorrhea
that appears to have resolved. Denies changes in hearing.
Denies
other weakness, numbness, tingling, nausea, vomiting.
Past Medical History:
None
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
O: T: 98.0 HR:54 BP:122/58 RR:16 Sat:100% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Normocephalic, atraumatic, Eyes injected bilaterally
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Right 5mm-4mm, left 3mm-2mm. Visual fields are full to
confrontation.
III, IV, VI: Pupils as above. Right eye unable to abduct past
midline, +nystagmus in left lateral gaze bilaterally;
+ right ptosis
V, VII: Facial strength symmetric, Right V1 decreased sensation
VIII: Hearing intact/symmetric to finger rub Bilaterally
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Coordination: normal on finger-nose-finger, rapid alternating
movements
______________________
PHYSICAL EXAM AT DISCHARGE:
*****
Pertinent Results:
___: MRI/A BRAIN
1. Large lobulated mass within the right cavernous sinus mass
and the right sphenoid sinus, with erosion into the right aspect
of the sella and erosion of the right clivus. The mass
demonstrates multiple small blood vessels. While the CTA from
one day earlier demonstrated a large blood vessel with same
density as other arteries within the mass, the present MRA does
not demonstrate any arterial flow within the mass.
2. Expansile aggressive lesion in the right mandible, which is
only partially included on the present MRI and the preceding CT,
and is therefore not optimally assessed.
3. Diagnostic considerations for the right cavernous sinus/right
sphenoid sinus mass include atypical aggressive hemangioma
(although the large blood vessel with arterial density on the
preceding CTA new would be unusual even for an atypical
hemangioma). Diagnostic considerations for both above-described
lesions include Langerhans cell histiocytosis and sarcoma.
Metastatic disease is less likely but may also be considered in
an appropriate
clinical setting.
4. The right cavernous internal carotid artery is displaced
anterolaterally by the right cavernous sinus/sphenoid mass
without narrowing.
___: CTA HEAD
1. Lobulated, densely vascular mass is centered in the right
cavernous sinus
and appears partially cystic, with extension into the right
sphenoid sinus and
erosion of the right clivus and sella. Differential diagnosis
is broad and
includes Langerhan's cell histiocytosis, sarcoma, and less
likely atypical
hemangioma or atypical mucocele.
2. Expansile, lytic lesion in the right mandible with central
enhancing
component could also be explained by ___'s cell
histiocytosis or
sarcoma.
3. Numerous enhancing blood vessels and possible pseudoaneurysms
within the
right cavernous sinus mass are demonstrated on the CTA, and
although the right
internal carotid artery is slightly anterolaterally displaced,
there is no
evidence of internal carotid artery stenosis or discrete feeding
vessel.
4. No CTA sequelae of carotid-cavernous fistula.
___: CT neck w/ con
Unchanged appearance of highly vascular erosive mass centered in
the right
cavernous sinus and a lytic expansile mass centered in the right
mandible. No
evidence of inferior extension into the soft tissues of the
neck. No
pathologic cervical lymphadenopathy is identified.
___ Panorex
The previously identified expansile lesion in the right mandible
is not well seen on this examination and is better characterized
on prior imaging.
Brief Hospital Course:
Mr. ___ was admitted to ___ on ___ for further workup
of a large lobulated mass within the right cavernous sinus mass
and the right sphenoid sinus, with erosion into the right aspect
of the sella and erosion of the right clivus. A second lesion
was also noted in the right mandible. CTA confirmed that the
lesion was highly vascular, and cerebral angiography with
embolization was planned prior to operative intervention.
Oncology was consulted for further evaluation. ENT was
consulted for workup and surgical assistance, with initial plan
for endoscopic endonasal biopsy of the nasopharyngeal mass.
After extensive discussion, decision was made to defer
endoscopic approach for tissue sampling, and move forward with
biopsy of the right mandibular lesion to aid in diagnosis. OMFS
was consulted for assistance, and the patient proceeded to the
OR on ___ for excision of the right posterior ramus
mandibular
cystic lesion.
Due to sella involvement and displacement of the pituitary, a
full hormone panel was ordered and Endocrinology was consulted,
with recommendation for stress dose steroids in the
___ period due to low cortisol levels. No additional
hormone dysfunction was identified on initial evaluation.
The patient remained hemodynamically stable throughout admission
with a stable neurologic exam. He continued to experience
diplopia due to his known right cranial nerve III & VI palsies.
He remained fully ambulatory and was discharged on ___ in
stable condition with close neurosurgery follow-up pending final
pathology. He will be seen in clinic with Dr. ___ ___ for
embolization and possible tumor resection/biopsy.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
Duration: 7 Days
RX *chlorhexidine gluconate 0.12 % rinse mouth twice a day
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right sinus/skull base/sella lesion, Right mandible lesion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neuro: VFF to finger counting, R ptosis, R eye unable to abduct
and can only partially adduct, some restriction in upward gaze
Discharge Instructions:
Dear Mr. ___,
You were transferred to us after one of your scans showed a soft
tissue mass in your brain and your jaw. The Oromaxillofacial
surgeons (___) took a biopsy of the mass in your jaw, and the
results from that are still pending. Please be sure to follow up
with the ___ surgeons when they have scheduled you. We would
like to see you back in clinic next ___ to go
over further plans for workup, which includes a cerebral
angiogram/embolization. You will receive more details at that
time.
It was a pleasure taking care of you in the hospital, and we
wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10210916-DS-15 | 10,210,916 | 26,080,000 | DS | 15 | 2113-11-01 00:00:00 | 2113-11-01 19:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Loss of consciousness, concern for seizure.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
HPI: Mr. ___ is a jolly ___ man with ETOH use,
cirrhosis, HTN, and HLD who presents after an episode of loss of
consciousness.
He was in a pub this afternoon around 1pm reading a book. He
needed to have a bowel movement so got up out of the bar stool
but felt lightheaded so sat back down. A couple friends came
over
to chat with him about the book. He felt like he was having a
hard time carrying on the conversation for about 1 min. Also
felt
faint and very lightheaded and lost consciousness. Denies any
odd
smells or tastes, no de ___ or epigastric rising sensation
prior to losing consciousness. Friends held him up on the
barstool. EMS was called as was his wife. They arrived about
8min
later, but he was still being held up in his seat. His arms were
shaking as well, right seemed to be more than left. He was
slumped forward with drool coming out of the left side of his
mouth. Friends report that he lost all color in his face. Had
bowel incontinence but no urinary incontinence, no tongue
biting.
EMTs put him in a stretcher, and he started moving and looking
around a little confused immediately afterwards. By the time he
got into the ambulance (and was lying flat), he was laughing and
joking with the EMTs and was able to recite his wife's phone
number to them.
This has never happened before. He takes a lot of blood pressure
medications but only took valsartan 160mg and amlodipine 5mg
that
morning. Took metoprolol XL 25mg yesterday (tapered over the
last
several months down from 200mg XL qd). Amlodipine was also
tapered from 10mg. He was coming off BP medications because he
lost 20 pounds over the last 8 months. He ate an almond
croissant
in the morning and coffee, did not drink additional water. Only
took a few sips of beer at the pub.
Typically drinks 2 large bottles of wine per day. Last drink was
yesterday (today only had a few sips).
Past Medical History:
GERD, HTN, HLD, EtOH use, cirrhosis, transaminitis,
appendectomy, hernia repair, 2 ACL repairs
Social History:
___
Family History:
No family history of seizures.
Physical Exam:
Discharge Physical Exam:
Vitals:
Temp: 98.2-98.7F
HR: ___
BP: ___
RR: ___
O2 sats: 95% on room air.
Left handed.
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: tachycardic
Pulmonary: breathing comfortably on RA
Abdomen: Soft, NT, ND
Extremities: Warm, no edema
Neck: Difficulty turning neck all the way to either side, some
limited range of motion with neck.
Neurologic Examination:
- Mental status: Awake, alert, oriented to self, ___, date.
Able to relate history without difficulty. Attentive. Speech is
fluent with full
sentences, intact repetition, and intact verbal comprehension.
Naming intact. No paraphasias. No dysarthria. Normal prosody.
No apraxia. No evidence of hemineglect. No left-right confusion.
Able to follow both midline and appendicular commands.
- Cranial Nerves: Pupils: 3-->2 mm, briskly reactive equally.
VF full to number counting.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Tongue midline.
- Motor: Normal bulk and tone. No drift. Low amplitude high
frequency tremor in bilateral upper extremities. No asterixis.
[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1]
L 4 5 4 5 5 4 5 5 5 5
R 4 5 4 5 5 4 5 5 5 5
Toe flexors and extensors bilaterally weak.
Reflexes: Toes downgoing bilaterally.
- Sensory: No deficits to light touch bilaterally
- Coordination: + action tremor, and sometimes misses examiner's
finger, but no clear dysmetria.
- Gait: normal gait.
Admission Physical Exam:
Vitals: T: 97.7F HR: 92 BP: 144/70 RR: 18 SaO2: 98% RA
General: tremulous but in excellent spirits
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: tachycardic
Pulmonary: breathing comfortably on RA
Abdomen: Soft, NT, ND
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented to self, ___, date.
Able to relate history without difficulty. Attentive, able to
name ___ backward without difficulty. Speech is fluent with full
sentences, intact repetition, and intact verbal comprehension.
Naming intact. No paraphasias. No dysarthria. Normal prosody.
No
apraxia. No evidence of hemineglect. No left-right confusion.
Able to follow both midline and appendicular commands.
- Cranial Nerves: PERRL 3->2 brisk. VF full to number counting.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No drift. Low amplitude high
frequency tremor in bilateral upper extremities. No asterixis.
[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1]
L 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 3+ 2+ 3+ 3+ 2
R 3+ 2+ 3+ 3+ 2
Plantar response flexor bilaterally
- Sensory: No deficits to light touch bilaterally
- Coordination: No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait: deferred
Pertinent Results:
___ 02:13PM BLOOD WBC-4.7 RBC-3.28* Hgb-10.5* Hct-31.1*
MCV-95 MCH-32.0 MCHC-33.8 RDW-13.0 RDWSD-44.8 Plt ___
___ 02:13PM BLOOD Neuts-48.0 ___ Monos-11.5 Eos-5.5
Baso-1.5* Im ___ AbsNeut-2.26 AbsLymp-1.57 AbsMono-0.54
AbsEos-0.26 AbsBaso-0.07
___ 05:30AM BLOOD Glucose-103* UreaN-15 Creat-0.9 Na-137
K-4.3 Cl-101 HCO3-24 AnGap-16
___ 10:10PM BLOOD ALT-66* AST-75* AlkPhos-70 TotBili-0.8
___ 10:10PM BLOOD cTropnT-<0.01
___ 10:10PM BLOOD Albumin-4.4 Calcium-8.8 Mg-1.6
___ 02:13PM ETHANOL-88*
Echocardiogram ___:
Normal biventricular systolic function. No cause of syncope
identified.
MRI Brain ___:
1. No evidence of a seizure focus on non-contrast MRI. No
evidence for acute intracranial abnormalities.
2. Severe, symmetric bilateral hippocampal volume loss.
Brief Hospital Course:
Mr. ___ is a ___ year old gentleman with a history of
alcoholism who presented with one episode of loss of
consciousness that included some shaking movements, witnessed by
a friend.
Mr. ___ had only eaten an "almond croissant" that day, and
felt that he may have been dehydrated. He drank alcohol the
night before, but had not had much other hydration in that day.
He walked to a pub near his house, and felt slightly shaky on
his way walking over to the pub, but he sat down and ordered a
beer with his friend. In having a conversation with his friend,
Mr. ___ turned pale, diaphoretic, and then collapsed onto the
table. His friend held him up and supported him, at which point
Mr. ___ had convulsions of his upper extremities.
EMS was called, and Mr. ___ "came to" when he was laid down
on the stretcher. Until that time, his friends maintained him
in a seated position.
Mr. ___ recalls that he had to have a bowel movement before
the loss of consciousness, and that when he was on the
stretcher, he had to have a bowel movement so badly that he went
right there on the stretcher, and felt embarrassed. He does,
indeed remember having a bowel movement.
This history that Mr. ___ provided was suspicious for
syncope, and convulsive syncope. The fact that he turned pale,
and diaphoretic, prior to the event of shaking suggests that
syncope was the cause of the convulsions, and not an epileptic
seizure. While Mr. ___ alcoholism is a risk factor for
seizures, this event does not seem consistent with a seizure.
In the ED, Mr. ___ alcohol level was 0.088. Mr. ___
reported that his blood pressure in the ambulance was 90/50.
While inpatient, he had normal blood pressures, if not elevated
(in the 140s).
Routine EEG was performed while in the hospital, and was read
preliminarily as normal, with the final read pending.
He had a brain MRI, which was overall negative, besides having
significant evidence of hippocampal atrophy.
On history, Mr. ___ complained of some neck pain. On physical
exam, his pattern of mild weakness, unnoticed by him or his
wife, is consistent with a cervical spondylosis, and some lumbar
root disease. This can be addressed in the outpatient setting by
his primary providers.
The differential diagnosis of Mr. ___ syncope includes
vasovagal/hypotension, a sensitive carotid sinus, or an
arrhythmia.
Mr. ___ had recently started taking baclofen, as his only
recent medication change prior to this event. We are suspicious
that the baclofen may have precipitated a drop in blood
pressure, that could have led to the syncope. We recommended
that Mr. ___ not take the baclofen anymore, until he follows
up with his primary doctor who prescribed this medication,
intended to be used to curb his alcohol "appetite," as Mr.
___ described its purpose.
He did not feel any palpitations leading up to this event.
We prescribed a 30-day heart monitor upon discharge, to evaluate
for any arrhythmias that could be intermittent.
We made no other changes to Mr. ___ medications, besides
recommending that he stop the baclofen.
Mr. ___ and his wife agreed with plans for discharge and
follow-up.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Valsartan 160 mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Baclofen 10 mg PO TID
4. Vitamin B Complex 1 CAP PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Pravastatin 40 mg PO QPM
7. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*11
2. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*11
3. amLODIPine 5 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Pravastatin 40 mg PO QPM
6. Valsartan 160 mg PO DAILY
7. Vitamin B Complex 1 CAP PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Syncope
Cervical spondylosis
Lumbar stenosis
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 neurology unit at ___ because there
was concern that you had a seizure versus a syncopal (fainting)
episode. The episode you describe sounds most suspicious for
syncope, where not enough blood/oxygen gets to your brain, and
you "pass out." The pieces of the story that are most suspicious
of syncope are that you turned pale and were sweating. Some
people, when they faint, can have "convulsions," but these are
not seizures. Because you had witnessed convulsions, however, we
wanted to observe you to make sure you did not have any
seizures.
You had an EEG, which was overall normal (though the final
interpretation is still pending). You had a brain MRI, which did
not show any sign of stroke or other cause of a possible
seizure. You were monitored on a heart monitor here, which was
normal, and should go home with a heart monitor, to watch for
any arrhythmia that could have provoked the syncopal episode.
Your fainting episode was most likely prolonged because you were
being held up; in the future, if you faint, you should be lying
flat to allow you to regain consciousness as quickly as
possible.
We are concerned that the new medication, baclofen, could have
caused your blood pressure to drop, and therefore, caused you to
faint. We recommend stopping that medication until you visit the
doctor that prescribed it.
The pain in your neck is not related to the fainting episode.
You likely have arthritis in your spine/neck, which can cause
this pain. The arthritis in your spine (cervical spondylosis,
lumbar stenosis) is causing a very mild amount of weakness from
pinched nerves and nerve irritation/inflammation).
Besides recommending to not use the baclofen anymore, there were
no other changes to your medications.
Followup Instructions:
___
|
10211120-DS-18 | 10,211,120 | 21,230,206 | DS | 18 | 2129-08-30 00:00:00 | 2129-08-30 16:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Amoxicillin
Attending: ___.
Chief Complaint:
Headache, visual changes
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ woman with a history of depression/anxiety who
presents with new onset headache associated with visual changes.
Her symptoms began 10 days ago with a holocephalic throbbing
headache, exhaustion, and vision changes (described further
below). She had some nausea associated with the headache for the
first few days but no vomiting. The headache was ___ in
severity
and associated with photo- and phonophobia. Her pain improved
with lying down in a dark, quiet environment and seemed to
improve with sleeping. There was no association with positional
changes, she thinks it may be worse with valsalva, but it has
not
woken her from sleep. After her headache had persisted for 2
days
she saw her PCP who prescribed ___ ___. She has been taking
this once about every other day without much relief. She has not
tried any other medications for the headache. She has had
occasional rare headaches in the past but nothing like this. Her
mother and her sister have a history of migraines but she has
never had a migraine before. She has never had headaches
associated with her menstrual cycle in the past but does note
that her current headache did coincide with the onset of her
period.
Around the same time her headache began she also began to
experience vision changes including seeing trails behind moving
objects. She reports a similar episode ___ year ago when she was
on
abilify which resolved when she stopped the medication. However
this time the trails persisted, and she also developed
blurry or "cloudy/hazy" vision and difficulty focusing,
particularly in her peripheral vision. She also reports pain
behind her eyes. ___ days ago she began seeing black lines and
dots in her peripheral vision which would appear randomly and
last for a few seconds at a time. Around this time she also
began
to experience extended darkened vision after blinking.
In addition, she also reports bilateral high pitched tinnitus,
also starting 10 days ago. It is most noticeable in quiet
environments but has been there constantly. There is no
pulsatile
component. Also 3 days ago a friend noticed that her pupils were
more dilated than normal even in bright lights.
Over the last ___ days she has begun to feel unsteady on her
feet, losing her balance and stumbling, particularly feels "off"
when in the elevator. Has not had any falls. Last night she
developed a tingling sensation in her left fingers as well as
numbness from her L shoudler down and felt that her L arm was
weak. A few hours later she developed tingling in her toes b/l.
She has also noticed over the last 12 hours distortion of her
vision in R eye, and dim vision in her L eye. Additionally she
has noticed some short term memory problems over the last 12
hours, including misplacing her cell phone and forgetting recent
conversations. Due to these symptoms she presented to the ED
this
morning, where she was evaluated by ophthalmology and was told
that her exam was normal. She was discharged from the ED as she
already had an appointment scheduled this afternoon with Dr.
___.
On neurologic review of systems, the patient denied any changes
in speech or swallowing. Does report lightheadedness but no
vertigo. She reports occasional unintentional jerking movements
associated with chills. No bowel or bladder incontinence or
retention. Gait was unsteady as above. Reports history of head
trauma when very young (unknown LOC).
She does report some recent stress, as she was hospitalized for
depression ___ year ago this month and has been thinking about
this
recently. Her depression is much improved now and she denies any
other significant stressors in work or home life currently.
On general review of systems, the patient reports frequent
chills. No fevers. No night sweats or recent weight loss or
gain.
Denied cough, shortness of breath. Denied chest pain or
tightness, palpitations. +Nausea at onset of HA (no vomiting),
none currently. Denied diarrhea, constipation or abdominal pain.
No recent change in bowel or bladder habits. No dysuria. Denied
arthralgias or myalgias. Denied rash.
Past Medical History:
Depression/anxiety - hospitalized for depression ___ year ago
Past Surgical History:
Dermoid cyst removed from eyebrow
Social History:
___
Family History:
Mother ___ y/o has migraines, thyroid disease, skin cancer,
breast
mass. Also has a hx of blood clot in her leg after a varicose
vein removal.
Father has high cholesterol.
Sister has migraines, thyroid disease, and PTSD.
Several cousins with history of miscarriages early in pregnancy.
Physical Exam:
T 97.8 BP 115/75 HR 85 RR 16 O2% 98% RA
General: Awake, cooperative, NAD.
Head and Neck: no cranial abnormalities, no scleral icterus
noted, mmm, no lesions noted in oropharynx.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs clear to auscultation bilaterally
Cardiac: regular rate and rhythm, normal s1/s2. No murmurs,
rubs,
or gallops appreciated.
Abdomen: soft, non-tender, normoactive bowel sounds, no masses
or
organomegaly noted.
Extremities: no edema
Skin: no rashes or lesions noted
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt. was able to name both high and low
frequency objects. Able to read without difficulty. Speech was
not dysarthric. The pt. had good knowledge of current events.
There was no evidence of apraxia or neglect, calculations
intact.
Registered ___ and recalled ___ at 5 minutes.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 6 to 5mm b/l. Visual fields full on bedside testing
with red pin. Funduscopic exam revealed no papilledema,
exudates,
or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and sternocleidomastoid
bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No rigidity. No adventitious movements, such as
tremors, noted. No asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch throughout. Reports patchy
decreased pinprick over L medial foot. Reports slightly
decreased
cold sensation over lateral L hand. Pinprick and cold are
otherwise intact throughout. Proprioception is intact at the
great toes b/l. Vibratory sense is ___ at R and ___ at L great
toe.
-Deep tendon reflexes:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
Pertinent Results:
___ 07:50AM PLT COUNT-266
___ 07:50AM NEUTS-55.2 ___ MONOS-3.7 EOS-1.9
BASOS-0.9
___ 07:50AM WBC-5.5 RBC-4.47 HGB-13.7 HCT-38.8 MCV-87
MCH-30.7 MCHC-35.4* RDW-12.4
___ 07:50AM CALCIUM-9.4 PHOSPHATE-3.6 MAGNESIUM-2.1
___ 07:50AM estGFR-Using this
___ 07:50AM GLUCOSE-97 UREA N-9 CREAT-0.6 SODIUM-141
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-27 ANION GAP-13
___ 09:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 09:30AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 09:30AM URINE GR HOLD-HOLD
___ 09:30AM URINE UCG-NEGATIVE
Brief Hospital Course:
___ woman with a hx of depression/anxiety presenting
with
severe HA x 10 days associated with nausea, photo-/phonophobia,
and a myriad of visual changes along with transient LUE sensory
changes. She has no prior history of migraines but given her
family history, the association with her menstrual cycle and
recent stressors, and associated symptoms, new onset migraine is
a potential etiology. However the duration of the headache and
atypical visual symptoms, along with her family history of blood
clots and miscarriages as well as her current contraceptive use,
place her at risk of a venous sinus thrombosis. We will admit
her
to the general neurology service for further work-up including
an
MRI/MRV and management of her pain.
______________
Hospital Course on ___
Neurology:
Ms. ___ was admitted to the neurology service under Dr.
___. An MRI and MRV were performed upon admission to rule out
an intracranial process causing her symptoms. This imaging did
not reveal any abnormalities. Also, as her headache did not have
symptoms consistent with increased intracranial pressure and her
eye exam did not reveal any abnormalities, the possibility of an
underlying condition like pseudotumor seemed unlikely. With
normal imaging, we continued migraine treatment with
Toradol/compazine. She had a significant component of tension
headache with a bandlike pressure sensation and significant
muscle contracture pain in her neck and shoulders. For this
flexeril was also tried with the explanation that some visual
changes may worsen with this medication. An LP was performed on
___ to rule out an underlying infectious process or IIH.
Opening pressure was 14, protein and glucose were normal, cell
counts were normal, and gram stain was negative. Her headache
gradually improved with a combination of toradol, compazine, and
flexeril. She continued to have some visual complaints that were
difficult to explain. We discussed that headaches can be
multifactorial and that treatment of prolonged headache is
likely to involve more than just medications.
Cardio/Pulm:
No acute issues
ID:
No signs of acute infection. No antibiotics were initiated
FENGI:
PO as tolerated. IVF were given as adjunct headache treatment
Dispo:
Pt was discharged home on *** in good condition. She will follow
up with Dr. ___ in clinic.
Medications on Admission:
Sumatriptan 50mg prn for migraines
Nuvaring
Desvenlafaxine 100mg XR Q24hrs
Multivitamin
Vitamin D
Fish oil
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain, fever.
2. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea, headache.
Disp:*20 Tablet(s)* Refills:*0*
3. Pristiq 100 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO Daily ().
4. cyclobenzaprine 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times
a day) as needed for muscle contracture headache.
Disp:*20 Tablet(s)* Refills:*0*
5. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for headache.
6. sumatriptan succinate 50 mg Tablet Sig: One (1) Tablet PO
twice a day as needed for migraine headache.
Discharge Disposition:
Home
Discharge Diagnosis:
Migraine Headache
Tension Headache
Visual changes
Depression
Anxiety
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 ___ on
___ for evaluation of your persistent headache and
visual changes. An MRI/MRV of your head to look for any
structural abnormalities or blood clots was normal. You also had
a lumbar puncture which showed normal spinal fluid pressure and
normal cell counts, ruling out an infectious cause. After ruling
out other potential etiologies, we treated you with medications
to help with migraine as well as tension headaches. These
included Toradol, Compazine, and Flexeril. We also discussed
other therapies for headaches including acupuncture, therapy,
massage.
.
We made the following changes to your medications:
Started Compazine 10mg every 6 hours as needed for
headache/nausea
Started Flexeril 5 mg every 8 hours as needed for muscle spasm
related headache.
******
If you experience any of the below listed danger signs, please
call your doctor or go to the nearest Emergency Department.
It was a pleasure taking care of you during your hospital stay.
Followup Instructions:
___
|
10211404-DS-11 | 10,211,404 | 20,311,499 | DS | 11 | 2131-06-21 00:00:00 | 2131-06-21 15:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Syncope/Fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ who presents s/p fall. Per EMS report, patient had been
running in and out of mother's apartment and then was found face
down in living room. Patient reports that she took a sip of wine
-> glass an a half of wine and an amoxicillin tablet. She then
woke up in a pool of blood outside. She then went back into the
living room and ended up on the floor. She confirms that she
lost consciousness. She at first denied any street drugs but
when I asked her about her about the positive cocaine tox screen
she reported that she smoked MJ on ___ it tased funny so
that may have cocaine in it. She denies IVDU. She drinks 1.5
glasses of wine per day. In the ED the patient stated that she
was dizzy before she fell. Here on the floor she does not report
cp, n/v/d/shortness of breath, LH or dizziness, fever or chills
prior to the fall. Per EMS, family reports patient having
history of substance abuse. Her son notes that in the last month
she has been more altered, which he believes is due to increased
use of alcohol. Complaining of left sided face pain, denies neck
and back pain. She denies weight loss. She does not want anyone
in her family to know about the positive drug screen since "some
of them are judgemental".
.
In ER: (Triage Vitals:8 |96.9 |63 |181/80 |16 |100% RA )
Given: nONE
Radiology Studies:CT head, neck/sinus
consults called: OMFS
Past Medical History:
- Vertigo, hearing loss
- s/p thoracotomy
- invasive ductal carcinoma, left breast, diagnosed by biopsy at
___ ___
- ruptured rt typannic membrane s/p surgery here ___,
ENT)
Social History:
___
Family History:
Her mother is alive at age ___ in good health. She does not
report any other family medical history.
Physical Exam:
Vitals: T 99.1 P 53 BP 151/91 RR 16 SaO2 99% on RA
GEN: Middle aged female who looks uncomfortable.
HEENT: L sided jaw swelling. + lip swelling with excoriations
present
She is unable to open her mouth secondary to pain
NECK: supple
CV: s1s2 early peaking SEM at LLSB and LUSB without radiation to
the carotids
RESP: b/l ae no w/c/r
L thoracic wall tenderness to palpation
ABD: +bs, soft, NT, ND, no guarding or rebound
back:
EXTR:no c/c/e 2+pulses
DERM: no rash apart from excoriations on lip
NEURO: L sided lip droop secondary to fracture
PSYCH: calm, cooperative
Pertinent Results:
___ 02:10AM URINE HOURS-RANDOM
___ 02:10AM URINE UHOLD-HOLD
___ 02:10AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-POS amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 02:10AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 02:10AM URINE RBC-<1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-2
___ 02:10AM URINE MUCOUS-RARE
___ 08:30PM GLUCOSE-97 UREA N-14 CREAT-1.0 SODIUM-139
POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-22 ANION GAP-15
___ 08:30PM estGFR-Using this
___ 08:30PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
___ 08:30PM WBC-10.4* RBC-5.82* HGB-13.7 HCT-43.7 MCV-75*
MCH-23.5* MCHC-31.4* RDW-18.0* RDWSD-43.5
___ 08:30PM NEUTS-71.8* LYMPHS-16.1* MONOS-10.0 EOS-0.9*
BASOS-0.5 IM ___ AbsNeut-7.47* AbsLymp-1.67 AbsMono-1.04*
AbsEos-0.09 AbsBaso-0.05
___ 08:30PM PLT COUNT-200
===============================
ADMISSION SINUS CT
1. Fracture of the left mandibular condyle involving the head
and neck with
angulation of the largest fracture fragment which is anteriorly
dislocated
with respect to the glenoid. No other mandibular or facial
fracture.
2. Paranasal sinus disease, as described above.
Updated wetread discussed by Dr. ___ with Dr. ___
on the
___ ___ at 10:04 ___, 5 minutes after discovery of
the findings.
ETT MIBI
IMPRESSION:
1. Probably normal myocardial perfusion at the level of exercise
achieved.
Inferior wall defect most consistent with attenuation.
2. Normal left ventricular cavity size and systolic function.
IMPRESSION: Atypical symptoms with symptomatic drop in systolic
blood
pressure in late exercise. No ischemic EKG changes. Average
functional
capacity. Blunted heart rate response. Nuclear report sent
separately.
ECHO
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Symmetric LVH with normal global and regional
biventricular systolic function.
DC LABS:
___ 07:35AM BLOOD WBC-5.7 RBC-5.01 Hgb-11.8 Hct-37.5
MCV-75* MCH-23.6* MCHC-31.5* RDW-16.3* RDWSD-43.5 Plt ___
___ 07:14AM BLOOD Glucose-102* UreaN-14 Creat-0.8 Na-137
K-4.4 Cl-107 HCO3-22 AnGap-12
___ 07:22AM BLOOD cTropnT-<0.01
___ 07:14AM BLOOD TSH-3.7
Brief Hospital Course:
The patient is a ___ year old female with recent diagnosis of
breast cancer who presents s/p fall with mandibular fracture in
the setting of ETOH use and tox screen positive for cocaine.
SYNCOPE with fall and MANDIBULAR FRACTURE
SINUS BRADYCARDIA:
Etiology of possible syncope unclear. Seen by OMFS who
recommended full liquid diet for ___ weeks, and who said they
would call her to arrange follow up. Pt. would not comply with
full liquids, pureed diet was requested and allowed. Her tongue
was lacerated as well, but ___ said no specific intervention
was indicated. She remained bradycardic during her
hospitalization, but never was other than sinus rhythm, and
orthostatics were negative. There was no evidence of myocardial
ischemia. Echocardiogram showed LVH only. ETT-MIBI was also
unremarkable for ischemia. It was suggested that her fall may
have been related to vertigo from her rupture TM, vs substances,
vs orthostasis. She was discharged to continue supportive care,
pain control, and will follow up with trauma/OMFS surgery for
ongoing care. She will also follow up with cardiology regarding
her sinus bradycardia. It should be noted that telemetry x5
days did not identify any other concerning events.
PRIMARY HTN:
Likely essential hypertension with LVH, with very high BP here,
in part likely due to toradol. Improved with amlodipine and
lisinopril. These were continued on discharge. FOllow up chem
7 testing was recommended on follow up to monitor electrolytes.
OTITIS MEDIA/RUPTURED TM
Ruptured rt tympanic membrane - a recurrent issue. Seen by ENT
who recommended drops, dry ear precautions, and outpatient
follow up with Dr. ___.
Positive cocaine metabolites: pt denied using cocaine. States
she used marijuana, and thinks this was 'laced' with cocaine.
SW consulted, and saw pt while hospitalized.
INVASIVE DUCTAL CARCINOMA, LEFT BREAST:
diagnosed by biopsy at ___
___. Pt being followed by Dr. ___ continue.
Medications on Admission:
She does not take any meds at home.
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Ciprofloxacin 0.3% Ophth Soln 4 DROP BOTH EARS BID
RX *ciprofloxacin-dexamethasone [Ciprodex] 0.3 %-0.1 % 5 drops
AD twice a day Disp ___ Milliliter Milliliter Refills:*0
3. Lisinopril 10 mg PO DAILY
have your blood test (kidney function and potassium level) in
one - two weeks with your primary MD
RX *lisinopril 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Senna 8.6 mg PO BID c
take while taking oxycodone
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
5. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
avoid with alcohol or while driving
RX *oxycodone 10 mg 1 tablet(s) by mouth four times a day Disp
#*28 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Syncope with mandibular fracture
Hypertension
Bradycardia
LVH
Breast Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted after passing out, falling, and fracturing
your jaw. The cause of your "syncope" is not entirely clear,
but possibly related to low blood pressure or dizziness from
your ear infection. For your jaw fracture, we recommend a soft
diet and pain control. We recommend follow up with the trauma
surgery team in the next few weeks. We also recommend follow up
with Dr. ___ ENT, as well with a cardiologist to follow
up.
Please confirm your insurance and contact these providers for
ongoing care.
Followup Instructions:
___
|
10212287-DS-5 | 10,212,287 | 21,417,519 | DS | 5 | 2188-09-30 00:00:00 | 2188-09-30 10:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
C6 inferior articular process fracture dislocation
Major Surgical or Invasive Procedure:
C6 laminectomy and C5-T1 PSIF (Dr. ___, ___.
History of Present Illness:
___ male presents with the above fracture s/p diving
into a pool and hitting his head. Patient dove into pool hit his
head. Immediately had head/neck pain and pain that shoots down
left arm into pointer finger. No LOC, no n/v/AMS. Pain in his
lateral left neck that radiates down his left arm to pointer
finger. Feels weak in that arm. No ___ symptoms, weakness,
parethesias, urinary/bowel sx. Patient denies numbness,
tingling, weakness, saddle anesthesia, loss of bowel or bladder
function. Only location of numbness is left pointer finger and
posterior aspect of hand.
Past Medical History:
Denies
Social History:
___
Family History:
Non-pertinent
Physical Exam:
Last 24h: No acute events overnight
PE:
VS ___ 2336 Temp: 99.9 PO BP: 154/95 L Sitting HR: 78 RR:
18
O2 sat: 100% O2 delivery: Ra
NAD, A&Ox4
nl resp effort
RRR
dressing c/d/I
drain output: 15 cc
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 SILT SILT SILT
L SILT SILT SILT 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 4* 5 5 5
*Improving since surgery
___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___
R 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5
Pertinent Results:
___ 06:41AM BLOOD WBC-12.9* RBC-4.66 Hgb-13.9 Hct-39.3*
MCV-84 MCH-29.8 MCHC-35.4 RDW-13.0 RDWSD-40.1 Plt ___
___ 06:40AM BLOOD WBC-7.1 RBC-4.89 Hgb-14.7 Hct-42.0 MCV-86
MCH-30.1 MCHC-35.0 RDW-13.1 RDWSD-41.1 Plt ___
___ 08:33AM BLOOD WBC-10.3* RBC-5.11 Hgb-15.4 Hct-42.9
MCV-84 MCH-30.1 MCHC-35.9 RDW-13.1 RDWSD-40.0 Plt ___
___ 08:33AM BLOOD Neuts-73.8* ___ Monos-6.1
Eos-0.0* Baso-0.3 Im ___ AbsNeut-7.61* AbsLymp-2.01
AbsMono-0.63 AbsEos-0.00* AbsBaso-0.03
___ 06:41AM BLOOD Plt ___
___ 06:40AM BLOOD Plt ___
___ 08:33AM BLOOD Plt ___
___ 08:33AM BLOOD ___ PTT-30.9 ___
___ 06:41AM BLOOD Glucose-105* UreaN-9 Creat-1.1 Na-144
K-3.9 Cl-104 HCO3-23 AnGap-17
___ 06:40AM BLOOD Glucose-68* UreaN-13 Creat-1.2 Na-142
K-5.1 Cl-105 HCO3-24 AnGap-13
___ 08:33AM BLOOD UreaN-10
___ 06:41AM BLOOD Calcium-9.4 Phos-5.0* Mg-1.7
___ 08:33AM BLOOD ASA-NEG Ethanol-87* Acetmnp-NEG
Tricycl-NEG
___ 08:42AM BLOOD Glucose-90 Lactate-2.4* Creat-0.9 Na-147
K-5.8* Cl-109* calHCO___-21
Brief Hospital Course:
Patient was admitted to the ___ ___ Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery
was without complication and the patient was transferred to the
PACU in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a IV and PO pain medications. Diet was
advanced as tolerated. The patient was transitioned to oral
pain medication when tolerating PO diet. Foley was removed
postoperatively without issue. Physical therapy was consulted
for mobilization OOB to ambulate. Hospital course was otherwise
unremarkable. On the day of discharge the patient was afebrile
with stable vital signs, comfortable on oral pain control and
tolerating a regular diet.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
may take over the counter
2. Diazepam 5 mg PO Q12H:PRN spasms
may cause drowsiness
RX *diazepam 5 mg 1 tablet by mouth every twelve (12) hours Disp
#*14 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
please take while taking narcotic pain medications
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*14 Tablet Refills:*0
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
please do not operate heavy machinery, drink alcohol or drive
RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4)
hours Disp #*50 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
C6 left inferior facet fx-dislocation with C7 radiculopathy and
weakness
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Posterior Cervical Fusion
You have undergone the following operation: Posterior Cervical
Decompression and Fusion
Immediately after the operation:
Activity:You should not lift anything greater
than 10 lbs for 2 weeks.You will be more comfortable if you do
not sit in a car or chair for more than~45 minutes without
getting up and walking around.
Rehabilitation/ Physical ___ times a
day you should go for a walk for ___ minutes as part of your
recovery.You can walk as much as you can tolerate.Limit any kind
of lifting.
Cervical Collar / Neck Brace:You need to wear
the brace at all times until your follow-up appointment which
should be in 2 weeks.You may remove the collar to take a
shower.Limit your motion of your neck while the collar is
off.Place the collar back on your neck immediately after the
shower.
Wound Care:Remove the dressing in 2 days.If the
incision is draining cover it with a new sterile dressing.If it
is dry then you can leave the incision open to the air.Once the
incision is completely dry (usually ___ days after the
operation) you may take a shower.Do not soak the incision in a
bath or pool.If the incision starts draining at anytime after
surgery,do not get the incision wet.Call the office at that
time.If you have an incision on your hip please follow the same
instructions in terms of wound care.
You should resume taking your normal home
medications
You have also been given Additional Medications
to control your pain.Please allow 72 hours for refill of
narcotic prescriptions, so please plan ahead.You can either have
them mailed to your home or pick them up at the clinic located
on ___.We are not allowed to call in narcotic
prescriptions (oxycontin,oxycodone,percocet) to the pharmacy.In
addition,we are only allowed to write for pain medications for
90 days from the date of surgery.
Follow up:
Please Call the office and make an appointment
for 2 weeks after the day of your operation if this has not been
done already.
Please call the office if you have a fever>101.5 degrees
Fahrenheit,drainage from your wound,or have any questions.
Followup Instructions:
___
|
10212492-DS-18 | 10,212,492 | 28,756,051 | DS | 18 | 2125-02-11 00:00:00 | 2125-02-11 15:15:00 |
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 arm pain
Major Surgical or Invasive Procedure:
Open reduction and internal fixation of left both bone forearm
fracture
History of Present Illness:
___ yof R-handed, s/p MVC, low speed, restrained driver, car vs.
phone pole, mis-estimated a turn and wheel hit curb. No
preceding cardiac or neuro sx. C/o L forearm pain only. Obvious
L forearm deformity.
Past Medical History:
None
Social History:
___
Family History:
Non contributory
Physical Exam:
Admission Exam
PE:
NAD, AOx3
BUE skin clean and intact
Signif tenderness, deformity, and ecchymosis over distal dorsum
of forearm w/obvious instability of fractures
Arms and forearms are soft
Moderate pain with passive motion
R M U SITLT
EPL FPL EIP EDC FDP FDI intact
2+ radial pulses
Contralateral extremity examined with good range of motion,
SILT, motors intact and no pain or edema
LABS: Notable for K 3.2 INR 1.0 hct 45.5
Pertinent Results:
___ 02:00PM GLUCOSE-147* UREA N-22* CREAT-1.0 SODIUM-138
POTASSIUM-3.2* CHLORIDE-99 TOTAL CO2-24 ANION GAP-18
___ 02:00PM estGFR-Using this
___ 02:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 02:00PM WBC-7.6 RBC-4.83 HGB-14.2 HCT-45.5 MCV-94
MCH-29.3 MCHC-31.1 RDW-13.0
___ 02:00PM NEUTS-62.4 ___ MONOS-5.2 EOS-0.9
BASOS-1.0
___ 02:00PM PLT COUNT-296
___ 02:00PM ___ PTT-28.3 ___
Brief Hospital Course:
The patient was admitted to the Orthopaedic Trauma Service for
repair of a left both bone forearm fracture. The patient was
taken to the OR and underwent an uncomplicated repair. The
patient tolerated the procedure without complications and was
transferred to the PACU in stable condition. Please see
operative report for details. Post operatively pain was
controlled with a PCA with a transition to PO pain meds once
tolerating POs. The patient tolerated diet advancement without
difficulty and made steady progress with ___.
Weight bearing status: Non Weight Bearing in long arm splint.
The patient received ___ antibiotics. The incision
was clean, dry, and intact without evidence of erythema or
drainage; and the extremity was NVI distally throughout. The
patient was discharged in stable condition with written
instructions concerning precautionary instructions and the
appropriate follow-up care.
All questions were answered prior to discharge and the patient
expressed readiness for discharge.
Medications on Admission:
Sertraline
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours)
as needed for pain: Do not drink alcohol or drive while on this
medication. .
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Left both bone forearm fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
******SIGNS OF INFECTION**********
Please return to the emergency department or notify MD if you
should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101.5, chills,
redness or drainage at the incision site; chest pain, shortness
of breath or any other concerns.
-Wound Care: You can get the wound wet/take a shower starting
from 3 days post-op. 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 continued to be non-draining.
******WEIGHT-BEARING*******
Non Weight Bearing in long arm splint
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on ___.
*****ANTICOAGULATION******
- No systemic anticoagulation needed. Please keep active. Walk
as tolerated.
Followup Instructions:
___
|
10213059-DS-20 | 10,213,059 | 29,029,082 | DS | 20 | 2154-07-27 00:00:00 | 2154-07-30 19:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Naproxen / Penicillins / Codeine
Attending: ___.
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of IVDU, HBV, HCV, afib on xarelto, chronic
pain, hypothyroidism, CHF, CAD who presents with altered mental
status.
Upon interviewing the patient, he is lethargic but will awake
to loud voice but does not want to give history. States he is
tired and would like to go to sleep. Rest of history is taken
from medical records.
He apparently was feeling weak at home. Stated that his doctors
have ___ trying to get him to come into the hospital for a
while. Unclear how he got to the hospital.
In the ED, initial vitals were: 99.5 120 105/68 26 93% RA
- Labs notable for WBC 10.1
- Imaging: CT head and neck without acute fracture/bleed.
CXR showing mild pulmonary edema. Right Foot Xray showing
possible calcaneal osteomyelitis.
Podiatry was consulted and recommended IV antibiotics and
admission.
Patient was given: Vanc/cefepime
On the floor, he able to tell me that he is having pain in his
foot and stomach. He refuses to tell me more than that.
Past Medical History:
HCV, genotype 2
Cirrhosis
Small esophageal varicies
Bipolar depression
Anxiety
h/o endocarditis ___ years ago
h/o pulmonary embolus ___ years ago
s/p cervical discectomy
polysubstance abuse (last use one year per pt)
cervical radiculopathy s/p MVA in ___
ADHD
Hypothyoidism
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION EXAM:
Vital Signs: 98.2 98 / 61 Lying 116 20 94 RA
General: Lethargic, arouses to loud voice. Will not answer
orientation questions.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple
CV: irregular rhythm, normal S1 + S2, no murmurs, rubs, gallops
Lungs: fine crackles at bases
Abdomen: Soft, tender in LLQ.
GU: No foley
Ext: Venous stasis dermatitis bilaterally. evidence of
mid-tarsal amputation on left. Heel covered in clean bandage.
Neuro: Unable to participate. MS as above.
DISCHARGE EXAM:
Vitals: 97.8
PO 115 / 57
R Sitting 88 20 94 RA
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - sclerae anicteric
HEART - irregularly irregular, nl S1-S2, no MRG
LUNGS - clear to auscultation bilaterally
ABDOMEN - soft, non-tender to palpation
EXTREMITIES - L foot s/p TMA amputation. Left heel ulcer with
suture. Ulcer on back of left leg, no drainage. Pitting edema on
dependent areas of thigh & sacrum (improved from ___. Left
anterolateral thigh with scattered erythematous papules.
NEURO - awake, A&Ox3
Pertinent Results:
ADMISSION LABS:
___ 12:05PM BLOOD WBC-10.1* RBC-4.08* Hgb-10.4*# Hct-33.6*
MCV-82# MCH-25.5*# MCHC-31.0* RDW-19.7* RDWSD-58.8* Plt ___
___ 06:51PM BLOOD ___ PTT-35.5 ___
___ 12:05PM BLOOD Glucose-70 UreaN-8 Creat-0.6 Na-137 K-3.8
Cl-99 HCO3-27 AnGap-15
___ 12:05PM BLOOD ALT-16 AST-17 AlkPhos-74 TotBili-0.9
___ 12:05PM BLOOD Lipase-17
___ 06:29AM BLOOD proBNP-3240*
___ 06:29AM BLOOD Calcium-8.0* Phos-2.8 Mg-1.8
___ 06:27AM BLOOD %HbA1c-4.9 eAG-94
___ 06:29AM BLOOD TSH-13*
___ 06:29AM BLOOD Free T4-0.8*
___ 06:29AM BLOOD CRP-65.9* AFP-1.1
___ 06:08PM BLOOD ___ pO2-55* pCO2-47* pH-7.41
calTCO2-31* Base XS-3 Intubat-NOT INTUBA
___ 06:08PM BLOOD Lactate-1.4
___ 06:08PM BLOOD O2 Sat-85
___ 05:59AM URINE Color-Yellow Appear-Hazy Sp ___
___ 05:59AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-8* pH-6.0 Leuks-TR
___ 05:59AM URINE RBC-4* WBC-6* Bacteri-FEW Yeast-NONE
Epi-3
___ 05:59AM URINE bnzodzp-POS* barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-POS*
DISCHARGE LABS:
___ 09:00AM BLOOD WBC-6.2 RBC-3.80* Hgb-9.6* Hct-32.3*
MCV-85 MCH-25.3* MCHC-29.7* RDW-20.3* RDWSD-62.5* Plt ___
___ 06:37AM BLOOD Glucose-111* UreaN-18 Creat-0.8 Na-139
K-4.4 Cl-97 HCO3-31 AnGap-15
MICROBIOLOGY:
___ BLOOD CULTURES X2: NEGATIVE
___ URINE CULTURE: NEGATIVE
___ 2:20 pm SWAB Source: Left posterior ___.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
in this
culture.
STAPH AUREUS COAG +. SPARSE GROWTH.
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 .
SENSITIVITIES: MIC expressed in
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
___ C DIFFICILE: NEGATIVE
___ 6:05 pm FLUID,OTHER PSOAS MUSCLE FLUID
ASPIRATION.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
STUDIES:
___ XR BILATERAL FEET: FINDINGS:
AP and lateral views of both feet provided.
Right foot: There has been prior resection of the head and neck
of the
proximal phalanx of the great toe. Also noted is resection of
the terminal phalanx of the second ray. No definite fracture
dislocation or signs of osteomyelitis.
Left foot: There has been prior transmetatarsal amputation of
the left foot. The bones appear demineralized diffusely and
there is diffuse soft tissue swelling most pronounced at the
distal stump. No soft tissue gas or radiopaque foreign body.
There is lack of cortical detail at the level of the calcaneal
base which is concerning for osteomyelitis. Absence of prior
studies limits assessment.
IMPRESSION:
Findings, as detailed above, raise concern for osteomyelitis at
the base of the left calcaneus.
___ CXR: IMPRESSION: Cardiomegaly, hilar congestion and
mild interstitial edema.
___ CT HEAD: IMPRESSION: No acute intracranial process.
Motion artifact limits evaluation.
___ CT C-SPINE: 1. No evidence of fracture or traumatic
malalignment.
2. Moderate to severe degenerative changes are seen throughout
the cervical spine, most pronounced at the C3-C4 vertebral
level.
___ RESTING ABI: IMPRESSION:
No evidence of significant arterial insufficiency to the lower
extremities at rest.
___ RUQUS:
1. Cirrhotic liver morphology, without evidence of focal lesion,
or ascites. The portal vein is patent.
2. Splenomegaly.
3. Mildly distended gallbladder with wall thickening but no
edema. There is also scant pericholecystic fluid. These
findings are nonspecific but could be related to underlying
liver disease.
4. 6 mm cystic structure within the neck of the pancreas, as
described above, which could be a dilated side branch or a
cystic lesion and can be further evaluated with MRCP.
5. Mildly dilated extrahepatic segment of the CBD up to 1.1 cm
with no
obstruction identified. No intrahepatic biliary dilatation.
___ TTE: Conclusions
The left atrium is mildly dilated. The right atrium is markedly
dilated. There is mild symmetric left ventricular hypertrophy
with normal cavity size and regional/global systolic function
(LVEF>55%). The right ventricular cavity is markedly dilated
with mild global free wall hypokinesis. There is abnormal
diastolic septal motion/position consistent with right
ventricular volume overload. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. Severe [4+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
[In the setting of at least moderate to severe tricuspid
regurgitation, the estimated pulmonary artery systolic pressure
may be underestimated due to a very high right atrial pressure.]
There is no pericardial effusion.
IMPRESSION: Markedly dilated right ventricle with mild global
systolic dysfunction. Severe functional tricuspid regurgitation.
At least moderate pulmonary hypertension.
___ MRI PELVIS WITHOUT CONTRAST: 1. Limited exam as patient
could not tolerate the entire study, including
omission of contrast-enhanced evaluation.
2. Soft tissue edema at the posterior lower gluteal region could
reflect
cellulitis in this clinical setting. Edema of the adjacent
gluteal
musculature which is more marked on the right could reflect
myositis, and
early pyomyositis is not excluded. No large fluid collection is
demonstrated, however evaluation for microabscess formation is
limits on noncontrast exam.
3. The sacrum and coccyx do not demonstrate evidence of
osteomyelitis.
4. There is a right sided retroperitoneal ovoid area of signal
abnormality
which is partly T1 hyperintense, suggestive of a retroperitoneal
hematoma,
possibly nonacute.
5. Soft tissue edema in the scrotum, incompletely evaluated,
recommend
clinical evaluation.
Recommendation: Consider further evaluation with
contrast-enhanced CT which may better depict the retroperitoneal
lesion in addition to excluding small rim enhancing foci of
microabscess formation the right gluteal region.
___ CT PELVIS W CONTRAST: 1. Markedly limited exam due to
streak artifact from patient's bilateral hip prostheses.
2. Right psoas muscle fluid collection measuring 3.6 cm. This
is consistent with a hematoma. Superinfection of this fluid
collection cannot be completely excluded in the appropriate
clinical setting.
3. Small subcutaneous fluid collection in the right buttock.
This may be
related to subcutaneous injection.
4. No drainable fluid collection in the gluteus muscles on the
right
___ ___ PROCEDURE: CT-guided aspiration of a right psoas
collection, no fluid could be aspirated. This finding is
consistent with hematoma. Sample was sent for microbiology
evaluation.
Brief Hospital Course:
___ with history of IVDU, HBV, HCV s/p Ribavirin/interferon in
___ in SVR, afib with atrial clot on xarelto (although not
taking), chronic pain on methadone prescribed by PCP,
___, CHF on lasix, CAD who presents with altered
mental status thought to be secondary to polypharmacy/infection.
He was found to have a coccygeal ulcer with possible
superimposed infection for which he was treated with 14 days
antibiotics. He was also volume overloaded (ECHO showed moderate
pulmonary HTN and 4+ TR) and was diuresed.
#Discharge planning: He continued to refuse the only rehab that
accepted him. If he cannot get a nicer rehab, then he would like
to go home. Intermittently expressed that he "wanted to die." He
had no intent/plan and has been evaluated by psychiatry this
hospitalization who did not think this was active suicidality.
He displayed capacity to make the decision to go home, despite
the high risk that he may need to be rehospitalized or even die
given his weakness and lack of resources.
#Altered mental status: Per report, pt becomes so drowsy that he
sometimes wakes up in his own stool at home and unable to clean
himself. We decreased his methadone to 10 mg Q6h and he was more
alert. He continued to complain of pain and we slowly uptitrated
methadone to his home dosing with continued alertness.
#Coccygeal ulcer: We did treat him with IV Vanc, Flagyl, Ceftaz
for infected ___ ulcer that improved. He has a deep coccyx ulcer
that while does not appears infected, has a low chance of proper
healing given his inability to properly care for himself.
Psychiatry was consulted for capacity assessment and he was
deemed to have capacity. We permed an MRI of his pelvis which
was negative for osteo.
#BLE posterior calf ulcers c/b cellulitis: Most likely from
venous stasis. Finished course of IV antibiotics. ABI without
significant arterial blockage. Nutrition recommended Vitamin C,
Zinc, and MV. Wound care per wound care RN.
#Heart failure with preserved EF: An ECHO here showed 4+TR,
moderate pulmonary HTN, and RV dilation and together with his
CXR suggested he was volume up; therefore, he was given IV
lasix. Discharged on 40 mg PO Lasix. Recommend continuing this
at least until edema resolves.
#Diarrhea: ___ have been antibiotic-associated. C. diff was
negative. Stool consistency improving with psyllium on
discharge.
#Left anterior thigh Rash: Possible antibiotic rash given PCN
allergy and that he received ceftazidime. Prescribed
triamcinolone cream.
CHRONIC ISSUES:
#Chronic Pain: Confirmed with ___ ___ @ 12:22
that patient was filling Rx for methadone 20 mg Q6H (max 80 mg
daily). Methadone uptitrated to this dose as above.
#Anxiety/Depression: Continue wellbutrin/clonopin to help
prevent withdrawal. He expresed passive SI, but denied having a
plan or intent.
#Cirrhosis - From chronic Hep C infection, treated in ___ with
Ribavirin and Interferon but then lost to followup. Per OMR, did
have small varices; however, no EGD on file here. No other
complications of cirrhosis known. RUQ here showing cirrhosis
without PVT, ascites. AFP WNL. Overall, appears compensated.
Needs EGD.
#Hypothyroidism: Elevated TSH and low free T4 on admission labs.
Levothyroxine increased from 100 mcg to 125 mcg daily.
#COPD: Continued advair/albuterol.
#Neuropathy: Continued gabapentin.
#Gout: Continued allopurinol.
#Atrial fibrillation: Continued metoprolol; No AC due to past
falls. Patient self-discontinued xarelto. Aware of risk of
stroke.
Transitional issues
[] Heart failure: Discharge weight 254 pounds. Continue 40 mg PO
Lasix daily with goal weight 245 (pending normal renal
function). Would consider lowering Lasix to 20 mg or 10 mg daily
once at goal weight. Check chem-7 on ___ at next follow-up
appointment.
[] MRPC to evaluate 6-mm cystic structure within the neck of the
pancreas and dilated ducts
[] Hepatology follow-up & screening EGD
[] TFT in ___ weeks as his TSH was elevated with low T4 and we
increased Synthroid from 100 to 125 (increased dose on ___
[] Consider Cognitive Testing, as psych felt there was some
element of impairment.
[] ECHO showing Markedly dilated right ventricle with mild
global systolic dysfunction. Severe functional tricuspid
regurgitation 4+. At least moderate pulmonary hypertension.
Consider PHTN workup outpt.
[] Ensure resolution of left thigh rash
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Metoprolol Succinate XL 100 mg PO DAILY
3. Methadone 20 mg PO Q6H
4. Furosemide 10 mg PO DAILY
5. ClonazePAM 1 mg PO TID
6. BuPROPion 150 mg PO QAM
7. Allopurinol ___ mg PO DAILY
8. Atorvastatin 10 mg PO QPM
9. Levothyroxine Sodium 100 mcg PO DAILY
10. Gabapentin 400 mg PO QID
11. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
12. FoLIC Acid 1 mg PO DAILY
13. Aspirin 81 mg PO DAILY
14. Docusate Sodium 100 mg PO TID
15. Thiamine 100 mg PO DAILY
16. BuPROPion 75 mg PO QPM
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY Duration: 10 Days
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID:PRN
mouth rinsing
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/dose 1
puffs INH twice a day Disp #*60 Disk Refills:*0
4. Multivitamins 1 TAB PO DAILY
5. Zinc Sulfate 220 mg PO DAILY Duration: 10 Days
6. Furosemide 40 mg PO DAILY
7. Gabapentin 400 mg PO TID
8. Levothyroxine Sodium 125 mcg PO DAILY
9. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
10. Allopurinol ___ mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. Atorvastatin 10 mg PO QPM
13. BuPROPion 150 mg PO QAM
14. BuPROPion 75 mg PO QPM
15. ClonazePAM 1 mg PO TID
16. Docusate Sodium 100 mg PO TID
hold for loose stools
17. FoLIC Acid 1 mg PO DAILY
18. Methadone 20 mg PO Q6H
RX *methadone 10 mg 2 tabs by mouth Q6H PRN Disp #*12 Tablet
Refills:*0
19. Metoprolol Succinate XL 100 mg PO DAILY
20. Omeprazole 20 mg PO DAILY
21. Thiamine 100 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
- BLE posterior calf ulcers c/b cellulitis
- Toxic-metabolic encephalopathy
- Chronic left heel ulcer c/b osteomyelitis
- Incidental finding: 6-mm cystic structure within the neck of
the pancreas which can be further evaluated with MRCP
Secondary:
- Chronic systolic heart failure
- Paroxysmal atrial fibrillation
- COPD
- ETOH/Hepatitis C cirrhosis
- H/O pulmonary embolism
- Bipolar disorder
- Chronic pain on methadone therapy
- Chronic venous stasis dermatitis
- ETOH abuse, continuous
- Prior IVDU
- Chronic non-compliance
- Prior left TMA
- Hypothyroidism
- Gout
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 came here for altered mental status which we believe is due
to too many sedating medications (methadone for example) as well
as infection. While you were here, we discovered that your legs
wounds were likely infected and we treated you with IV
antibiotics. You had an MRI of your pelvis which did not show
any deeper infection.
We wish you the best,
Your ___ team.
Followup Instructions:
___
|
10213059-DS-21 | 10,213,059 | 29,330,929 | DS | 21 | 2154-08-29 00:00:00 | 2154-08-29 17:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Naproxen / Penicillins / Codeine
Attending: ___.
Chief Complaint:
Fall, AMS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of IVDU, HBV, HCV s/p Ribavirin/interferon in
___ in SVR, afib with past atrial clot on xarelto (although not
taking), chronic pain on methadone prescribed by PCP,
___, and CAD who presents with L ankle pain
after a fall from his wheelchair at rehab yesterday. Patient
states that his wheelchair broke and he slid to the floor, he
denies any headstrike or LOC. He is experiencing acute on
chronic L foot pain after the fall. Of note, he endorses
chronic, poorly healing ulcers of the lower extremities
bilaterally. Patient was recently discharged from ___ ___
after an admission for AMS in the setting of medication over
sedation (he was also treated with vanc/flagyl/ceftaz for
infected ___ ulcer, diuresed in setting of ___.
In the ED, initial vital signs were: 98.1 95 135/95 18 96% RA
- Exam notable for: Patient lethargic and hard to respond,
erythematous/swollen bilateral lower extremities
- Labs were notable for
CBC: 5.3,9.6/32.3,105
BMP: 137,5.0,99,28,18,.8
Lactate: 1.3
Urine: NEG blood/nitrite/protein/glucose/bilirubin, small leuks,
1 RBC, 4WBCs, few bacteria
- Studies performed include
L ankle X-ray
FINDINGS:
The osseous structures are diffusely demineralized. Patient is
status post transmetatarsal amputation. No acute fracture or
dislocation is present. No cortical destruction is seen.
Assessment of the ankle mortise is slightly limited due to the
lack of a dedicated mortise view. Mild degenerative changes are
noted involving the midfoot. Flattening of the base of the
calcaneus likely reflects interval debridement, with adjacent
heterotopic calcification within the plantar soft tissues.
There is diffuse soft tissue swelling without subcutaneous gas.
Pes planus deformity is again noted.
IMPRESSION:
No acute fracture or dislocation.
CXR
FINDINGS:
Interval removal of the left PICC line. There is again marked
enlargement of the cardiac silhouette. Minimal left basilar
atelectasis. There is mild pulmonary vascular congestion
without overt pulmonary edema. No large pleural effusion or
pneumothorax is identified. Chronic appearing left rib
fractures.
IMPRESSION:
Pulmonary vascular congestion without overt pulmonary edema.
Marked
enlargement of the cardiac silhouette.
- Patient was given 0.4 mg narcan administered, cognition
improved
- Vitals on transfer: 97.7, 108/77, 84, 18, 95 RA
Upon arrival to the floor, the patient recounts the story as
above. He is AOx3, denies any fevers/chills. He still
complains of pain in his L ankle, asking for pain medications.
Past Medical History:
HCV, genotype 2
Cirrhosis
Small esophageal varicies
Bipolar depression
Anxiety
h/o endocarditis ___ years ago
h/o pulmonary embolus ___ years ago
s/p cervical discectomy
polysubstance abuse (last use one year per pt)
cervical radiculopathy s/p MVA in ___
ADHD
Hypothyoidism
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION
=========
Vitals- 97.7, 108/77, 84, 18, 95 Ra
GENERAL: AOx3, NAD
HEENT: Pupils equal, round, and reactive bilaterally,
extraocular muscles intact. No conjunctival pallor or
injection, sclera anicteric and without injection. Dry mucous
membranes. Oropharynx is clear.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate, +soft systolic murmur, no
rubs/gallops. No JVD.
LUNGS: Bibasilar inspiratory crackles, otherwise CTABL.
ABDOMEN: Normal bowels sounds, non distended, non-tender to
deep palpation in all four quadrants.
EXTREMITIES/SKIN: Chronic venous stasis changes bilateral ___,
skin erythematous and warm to touch. Slightly swollen. s/p L
TMA. Skin breakdown over L calcaneus. 3cmx6cm ulcer on
posterior L calf, non-tender, erythematous and edematous
granulation tissue.
NEUROLOGIC: CN2-12 intact. ___ strength througout. Normal
sensation. +Intention tremor.
DISCHARGE
=========
97.7, 109/62, 95, 18, 92 RA
GENERAL: AOx3, NAD
HEENT: Pupils equal, round, and reactive bilaterally,
extraocular muscles intact. No conjunctival pallor or
injection, sclera anicteric and without injection. Dry mucous
membranes. Oropharynx is clear.
NECK: No cervical/submandibular/supraclavicular lymphadenopathy.
CARDIAC: Regular rhythm, normal rate, +soft systolic murmur, no
rubs/gallops. No JVD.
LUNGS: b/l inspiratory basilar crackles
ABDOMEN: Normoactive bowels sounds, non distended, mild TTP to
deep palpation in RUQ. No organomegaly.
EXTREMITIES/SKIN: Chronic venous stasis changes bilateral ___,
skin erythematous and warm to touch. Slightly swollen. s/p L
TMA. Legs wrapped with kerlix b/l. Scattered sub-millimeter
papules over thighs, also R elbow, no surrounding erythema, no
discharge.
NEUROLOGIC: Grossly intact. +Intention tremor.
Pertinent Results:
ADMISSION LABS
==============
___ 03:05PM BLOOD WBC-5.3 RBC-3.85* Hgb-9.6* Hct-32.3*
MCV-84 MCH-24.9* MCHC-29.7* RDW-20.0* RDWSD-61.1* Plt ___
___ 03:05PM BLOOD Neuts-62.6 Lymphs-15.2* Monos-16.5*
Eos-4.2 Baso-1.1* Im ___ AbsNeut-3.31# AbsLymp-0.80*
AbsMono-0.87* AbsEos-0.22 AbsBaso-0.06
___ 03:05PM BLOOD Plt ___
___ 03:05PM BLOOD Glucose-70 UreaN-18 Creat-0.8 Na-137
K-5.0 Cl-99 HCO3-28 AnGap-15
___ 03:26PM BLOOD Lactate-1.3
___ 02:50PM URINE Color-Yellow Appear-Clear Sp ___
___ 02:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-SM
___ 02:50PM URINE RBC-1 WBC-4 Bacteri-FEW Yeast-NONE Epi-<1
___ 02:50PM URINE Mucous-RARE
PERTINENT LABS
==============
___ 10:35AM BLOOD TSH-8.8*
___ 10:35AM BLOOD ___
MICRO
=====
___ 2:50 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 2:45 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 3:05 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 12:36 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
___ 4:45 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**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.
STUDIES/IMAGING
===============
DX ANKLE & FOOT ___
FINDINGS:
The osseous structures are diffusely demineralized. Patient is
status post transmetatarsal amputation. No acute fracture or
dislocation is present. No cortical destruction is seen.
Assessment of the ankle mortise is slightly limited due to the
lack of a dedicated mortise view. Mild degenerative changes are
noted involving the midfoot. Flattening of the base of the
calcaneus likely reflects interval debridement, with adjacent
heterotopic calcification within the plantar soft tissues.
There is diffuse soft tissue swelling without subcutaneous gas.
Pes planus deformity is again noted.
IMPRESSION:
No acute fracture or dislocation.
CXR ___
FINDINGS:
Interval removal of the left PICC line. There is again marked
enlargement of the cardiac silhouette. Minimal left basilar
atelectasis. There is mild pulmonary vascular congestion
without overt pulmonary edema. No large pleural effusion or
pneumothorax is identified. Chronic appearing left rib
fractures.
IMPRESSION:
Pulmonary vascular congestion without overt pulmonary edema.
Marked
enlargement of the cardiac silhouette.
ECG ___
Baseline artifact. Atrial fibrillation with a controlled
ventricular response. Right bundle-branch block. No major change
from the previous tracing. Repeat tracing of better clinical
quality suggested.
DISCHARGE LABS
==============
NONE
Brief Hospital Course:
___ with history of IVDU, HBV, HCV s/p Ribavirin/interferon in
___, afib with past atrial clot on xarelto (although not
taking), chronic pain on methadone prescribed by PCP,
___, and CAD who presented with L ankle pain
after a fall from his wheelchair at rehab.
# Altered mental status/lethargy - Most likely in setting of
sedating medications, s/p narcan with improvement of mental
status in the ED. Of note, patient additionally had recent
hospitalization also for medication over-sedation, pain/anxiety
regimen clearly required downtitration. Patient had been taking
methadone 20mg q6h and Clonazepam up to 5mg daily at home.
Patient's primary care physician (___) agreed
with plan to taper methadone/clonazepam, he will participate in
outpatient taper. Consulted CPS AM ___, they too were in
agreement with this plan, also recommended increasing Gabapentin
to 600mg QID (started ___. Outpatient taper of
methadone/clonazepam will ultimately be determined by Dr. ___.
While inpatient, methadone was decreased first to 15mg q6h and
then to 15mg TID and 10mg daily (plan for 5mg total decrease per
week, last decrease ___, clonazepam was decreased first to
1mg TID and then to .75mg BID and 1mg daily (plan for 0.25mg
total decrease per week, last decrease ___.
# L ankle pain - s/p traumatic fall, x-ray NEG for acute
fracture on admission. An infectious process seemed less likely
given that he was afebrile and without leukocytosis, no clinical
indication for abx.
# Chronic Venous Stasis - Patient did not appear to have any
progressing cellulitis at this time, though there were multiple
areas of skin breakdown, he is at high risk of infection. L calf
ulcer in particular was concerning for edematous venous stasis
ulcer vs. SCC.
Wound consult was placed, compression bandages with kerlix,
wound care recommendations left in OMR.
# Skin lesions - Patient complained of pruritic, erythematous
lesions over the thighs and arms. Possibilities include
infectious etiology vs. self-inflicted wounds in the setting of
itching. The lesions were not consistent with scabies. Patient
was treated with topical hydrocortisone.
# Heart failure with preserved EF - TTE ___ showed 4+TR,
moderate pulmonary HTN, and RV dilation, patient discharged on
40 mg PO Lasix after prior admission. CXR on this admission
without any increased signs of volume overload, patient did
though complain of increased SOB when lying flat. Continued
Lasix 40mg qd gave additional IV 40mg ___ with good urine
output.
# Atrial fibrillation - CHA2DS2-VASc 4. Patient was continued on
metoprolol for rate control. He has been treated with xarelto in
past, no current AC due to past falls. HRs to 130-140s
transiently ___. There should be some discussion of role
for AC as outpatient.
#Anxiety/Depression - Passive SI during last admission, none
currently.
- Continued wellbutrin/clonopin (decreasing as above)
# Cirrhosis - In setting of past EtOH abuse and chronic Hep C
infection (treated in ___ with Ribavirin and Interferon,
subsequently lost to follow-up). Per OMR, did have small
varices; however, no EGD on file here.
- Patient will require EGD to assess for varices
# Hypothyroidism
- Continued Levothyroxine 125 mcg daily
#COPD
- Continued advair/albuterol
- Duonebs PRN
# Neuropathy/chronic pain - Consulted CPS ___.
- Increased Gabapentin as above, continued methadone as above
#Gout
- Continued allopurinol
TRANSITIONAL ISSUES
===================
- Patient was started on Methadone/Clonazepam taper. Discharge
regimen is Methadone 15mg TID ___, 0600, 1800), Methadone 10mg
qd (1200) with recommendation to decrease by a total of 5mg per
week until off. Discharge regimen is Clonazepam 0.75mg BID ___
and 1600) and 1mg qd (0000) with recommendation to decrease by a
total of 0.25 mg per week until off.
- Patient was started on loperamide/diphenoxylate-atropine for
diarrhea, Cdiff NEG/final stool cultures pending at time of d/c
- Patient is not on anticoagulation for afib, CHA2DS2-VASc 4,
should have further discussion as outpatient
- Patient has serious chronic venous stasis ulcers, L posterior
calf lesion is particularly concerning
- In setting of cirrhosis, patient will require EGD to assess
for varices
- Discharge weight: 106.8 kg (235.45 lb)
====================
#CODE STATUS: DNR/DNI
#Contact: None on file
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. BuPROPion 150 mg PO QAM
5. BuPROPion 75 mg PO QPM
6. ClonazePAM 1 mg PO TID
7. Gabapentin 400 mg PO TID
8. Levothyroxine Sodium 125 mcg PO DAILY
9. Metoprolol Succinate XL 100 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Thiamine 100 mg PO DAILY
12. Ascorbic Acid ___ mg PO DAILY
13. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
14. Multivitamins 1 TAB PO DAILY
15. Zinc Sulfate 220 mg PO DAILY
16. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
17. Docusate Sodium 100 mg PO TID
18. FoLIC Acid 1 mg PO DAILY
19. Furosemide 40 mg PO DAILY
20. Methadone 20 mg PO Q6H
21. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID:PRN
mouth rinsing
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Moderate
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth three times a day Disp #*60 Tablet Refills:*0
2. Diphenoxylate-Atropine 1 TAB PO Q6H
RX *diphenoxylate-atropine 2.5 mg-0.025 mg 1 tablet(s) by mouth
every six (6) hours Disp #*120 Tablet Refills:*0
3. LOPERamide 2 mg PO QID diarrhea
RX *loperamide [Anti-Diarrhea] 2 mg 1 tablet by mouth four times
a day Disp #*120 Tablet Refills:*0
4. Miconazole Powder 2% 1 Appl TP BID
RX *miconazole nitrate [Anti-Fungal] 2 % Apply to groin twice a
day Disp #*71 Gram Gram Refills:*0
5. ClonazePAM .75 mg PO BID
RX *clonazepam 0.25 mg 3 tablet(s) by mouth twice a day Disp
#*18 Tablet Refills:*0
6. ClonazePAM 1 mg PO DAILY
Please take at 0000
RX *clonazepam 1 mg 1 tablet(s) by mouth daily Disp #*3 Tablet
Refills:*0
7. Gabapentin 600 mg PO QID
RX *gabapentin 600 mg 1 tablet(s) by mouth four times a day Disp
#*120 Tablet Refills:*0
8. Methadone 10 mg PO DAILY
Please take at 1200
RX *methadone 10 mg 1 tablet by mouth daily Disp #*3 Tablet
Refills:*0
9. Methadone 15 mg PO TID
Please take at 0600, 1800, 0000
RX *methadone 5 mg 3 tablets by mouth three times a day Disp
#*27 Tablet Refills:*0
10. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
RX *albuterol sulfate [ProAir HFA] 90 mcg 2 puff IH every six
(6) hours Disp #*1 Inhaler Refills:*0
11. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
12. Ascorbic Acid ___ mg PO DAILY
RX *ascorbic acid (vitamin C) 500 mg 1 capsule(s) by mouth daily
Disp #*30 Capsule Refills:*0
13. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
14. Atorvastatin 10 mg PO QPM
RX *atorvastatin 10 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
15. BuPROPion 150 mg PO QAM
RX *bupropion HCl 75 mg 2 tablet(s) by mouth qam Disp #*30
Tablet Refills:*0
16. BuPROPion 75 mg PO QPM
RX *bupropion HCl 75 mg 1 tablet(s) by mouth qpm Disp #*30
Tablet Refills:*0
17. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID:PRN
mouth rinsing
RX *chlorhexidine gluconate 0.12 % Oral rinse twice a day Disp
___ Milliliter Milliliter Refills:*0
18. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/dose
250-50 mcg IH twice a day Disp #*1 Disk Refills:*0
19. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
20. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
21. Levothyroxine Sodium 125 mcg PO DAILY
RX *levothyroxine 125 mcg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
22. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
23. Multivitamins 1 TAB PO DAILY
RX *multivitamin [Daily Multi-Vitamin] 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
24. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 (One) capsule(s) by mouth once a day Disp
#*30 Capsule Refills:*0
25. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
==================
L Ankle Pain
Diarrhea
Toxic metabolic encephalopathy
Secondary Diagnosis
===================
Atrial fibrillation
Congestive Heart failure with preserved EF
Chronic Venous Stasis Ulcers
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
you sustained a fall. You appeared quite sleepy in the
emergency department and so you received a dose of Narcan in
order to reverse any over-sedating effects of Methadone. Upon
transfer to general medicine, it was decided that your doses of
Methadone and Clonazepam were too high given your history of
falls. A slow dose reduction was initiated, to be completed by
your primary care doctor, ___. You have been given
prescriptions to last through ___, at which
point you will follow-up with Dr. ___.
Since you were having diarrhea, studies were sent to check for
any infections. All these tests returned NEGATIVE. You were
then started on two medications (Loperamide,
Diphenoxylate-Atropine) to decrease the number of daily bowel
movements. You should continue to take these medications as
directed by your primary care doctor.
It was a pleasure taking care of you!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10213338-DS-37 | 10,213,338 | 26,849,416 | DS | 37 | 2161-12-21 00:00:00 | 2162-01-28 17:47:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Biaxin / Vancomycin / Haldol / Heparin Agents / Flagyl / Sulfite
Attending: ___.
Chief Complaint:
painful joint
Major Surgical or Invasive Procedure:
Arthrocentesis
History of Present Illness:
This is a ___ year old lady with a history of SLE, ESRD on HD who
presented to the emergency department with 1 week duration of
shoulder pain.
She reports she was in her usoh until 1 week ago when she
developed sudden onset pain that is achy and constant in nature.
The pain occasionally radiates up to her neck and localizes to
the anterior lateral shoulder over the rotator cuff. She denies
trauma, recent falls or injury to her shoulder. She reports
recent temperatures in the low ___.
.
Of note she was evaluated for left shoulder pain last fall and
received several cortisone shots from her rheumatologist with
significant improvement in her pain. She also has a history of
right knee pain and swelling and has had avascular necrosis
noted on multiple imaging studies of both her knees. Knee
replacement has been discussed in the past but thus far deferred
by the patient. She was seen in clinic yesterday with her
primary care physician who according to the patient raised
concern that her present left sided shoulder pain was AVN. She
was admitted in ___ for polyarthralgia which was felt to be
secondary to a lupus flare.
In the ED, initial VS were: 99.2 91 155/67 18 100%. Exam was
significant for right shoulder effusion with ___ pain on
passive and active rotation of her arm. Orthopaedics was
consulted and recommended rheumatology for joint tapping. An
attempted bedside tap by rheumatology was performed without
success. The patient subsequently underwent right shoulder
tapping by ___. Joint fluid demonstrated ___ wbc and was
negative for crystals concerning for septic joint. She was
started on vancomycin with plan for re-evaluation for possible
joint washout. She received 5mg x 3 IV morphine for pain
management. She was given vancomycin for treatment of likely
septic joint and 4mg iv zofran for nausea. Labs were significant
for ESR 46, CRP 82.7, creatinine 0.6 and WBC 3.4. Vitals on
transfer were: 99.2 91 155/67 18 100%.
On arrival to the floor, initial vitals were 98.5 130/58 77 18
96RA. She reported significant improvement in her symptoms of
shoulder pain since joint tap.
Review of systems:
(+) Per HPI
(-) Denies chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denied cough, shortness of
breath. Denied chest pain or tightness, palpitations. Denied
nausea, vomiting. No recent change in bowel or bladder habits.
No dysuria.
Past Medical History:
- SLE: Followed by Dr. ___ manifestation =
arthralgia in hips and knees
- ESRD: Secondary to lupus nephritis, s/p failed transplant w/
subsequent nephrectomy, HD on ___.
- Cardiomyopathy - EF 60-65% (___). Severe diastolic
dysfunction.
- H/o chest pain: H/o cardiomyopathy with nl cath in ___, nl
P-MIBI in ___. Evaluated by Dr. ___ in ___ and diagnosed
with atypical CP likely GI (epiploic appendagitis).
- Chronic abdominal pain: S/p cholecystectomy in ___,
pancreatitis ___ pancreatic divisum, partial SBO in ___,
epiploic appendagitis in ___
- Hypertension: On beta blocker, ACE I, CCB.
- H/o dyslipidemia: ___ lipid panel wnl.
- Thrombocytopenia: H/o HIT with positive PF4 in ___ but neg on
follow-up, h/o TTP in ___.
- Anemia: On epoetin at HD, h/o autoimmune hemolytic anemia,
positive anti-E Ab against RBC, thalassemia trait based on
microcytic indices and peripheral smear review by Dr. ___.
- Bronchiolitis obliterans-organizing pneumonia
- H/o recurrent rectal abscesses first noted ___, recurrent
in ___ and a drain was left in, ___: ultrasound negative,
CT ___ no rectal abscess; drained by Dr. ___ in
___ who felt this was resolved when he saw her in ___
- DCIS and atypical ductal hyperplasia ___ s/p lumpectomy.
- Osteoporosis
- H/o avascular necrosis of left knee
- H/o adrenal crisis in ___.
- H/o seizure disorder.
- H/o uterine fibroid in ___, s/p hysterectomy for excessive
bleeding.
- Raynaud's phenomenon
Social History:
___
Family History:
Mother died of lupus in her ___ (died of an MI).
Brother with EtOH abuse.
Unaware of any other medical problems in father or siblings.
Physical Exam:
Pjhysical Exam on Day of Admission:
Vitals: 98.5 130/58 77 18 96RA.
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, nml S2/S2, ___ holosystolic murmur at LUSB, no rubs
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
MSK: tenderness to palpation of anterior shoulder without
obvious deformity or assymetry when compared to opposite
shoulder, pain with active and passive movement of right
shoulder, unable to abduct shoulder without assistance of left
hand. No erythema or warmth overlying joint.
Labs:
Physical Exam on Day of Discharge:
VS: Tm 100.6, Tc 99.1, HR 84, BP 133/68, RR 15, O2Sat ___
Gen: in dialysis, awake, alert, oriented x3
HEENT: sclera anicteric, mucous membrane moist
Neck: supple
CV: + systolic and diastolic murmurs
Resp: CTAB anteriorly, no w/c/r
Abd: soft, NT, ND, BS+
Extremities: warm, dry, 2+ DP b/l, no edema
MSK: right shoulder with minimal effusion, not tender to
palpation, not particularly warmer than the left shoulder,
active ROM of the right shoulder without discomfort
Access: left arm AVF in use
Pertinent Results:
___ 05:15PM BLOOD WBC-4.9 RBC-3.76* Hgb-10.8* Hct-33.2*
MCV-88 MCH-28.7 MCHC-32.6 RDW-18.2* Plt ___
___ 06:41AM BLOOD WBC-4.0 RBC-3.26* Hgb-9.2* Hct-28.7*
MCV-88 MCH-28.2 MCHC-32.1 RDW-18.4* Plt ___
___ 05:15PM BLOOD Neuts-65.7 ___ Monos-11.3*
Eos-2.7 Baso-0.4
___ 11:40AM BLOOD Neuts-52.6 ___ Monos-14.0*
Eos-3.4 Baso-1.0
___ 05:15PM BLOOD ESR-53*
___ 11:40AM BLOOD ESR-56*
___ 05:15PM BLOOD UreaN-30* Creat-6.3*# Na-143 K-4.0 Cl-94*
HCO3-38* AnGap-15
___ 06:41AM BLOOD Glucose-87 UreaN-44* Creat-10.4*# Na-131*
K-4.6 Cl-92* HCO3-29 AnGap-15
___ 05:15PM BLOOD ALT-169* AST-83* AlkPhos-352* TotBili-0.4
___ 06:55AM BLOOD Calcium-9.7 Phos-5.5*# Mg-2.3
___ 06:41AM BLOOD Calcium-9.4 Phos-5.2* Mg-2.3
___ 05:15PM BLOOD CRP-90.2*
___ 11:40AM BLOOD CRP-82.7*
___ 08:00AM BLOOD dsDNA-NEGATIVE
___ 08:00AM BLOOD C3-138 C4-52*
___ 06:39AM BLOOD Vanco-19.1
___ 07:32AM BLOOD Vanco-22.7*
.
Blood Culture x 4 negative growth to date
.
Gram Stain and fluid culture no growth to date
.
Shoulder Xray ___
IMPRESSION: No evidence of acute fracture or dislocation. Subtle
linear
sclerosis along the superomedial humeral head, similar to left
shoulder
radiographs of ___ which on the prior study noted consistent
with known bone infarcts. Early avascular necrosis is not
excluded. Consider correlation with MRI.
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
This is a ___ year old lady with a history of SLE, ESRD on HD who
presented to the emergency department with 1 week duration of
shoulder pain with joint fluid analysis concerning for septic
joint. She was started on vancomycin with significant
improvement in pain and discharged on total 2 week course of
vancomycin to be given with dialysis.
# RIGHT SHOULDER PAIN: Etiology of shoulder pain most concerning
of septic joint. Initial joint fluid with 81,000 WBC and culture
negative. Avascular necrosis of joints especially in patients on
HD and on chronic immunosuppression is known to pre-dispose
patients to septic arthritis. No crystals seen on joint fluid
analysis. Appreciate rheumatology or orthopaedics involvement in
care of this patient. Fluid culture however did not grow
bacteria. Ultimately given analysis of fluid chemistry,
presence of fever and significant improvement with antibiotics -
decision was made to continue antibiotic therapy for total 14
days with vancomycin to be given with HD.
# ESRD on HD: Etiology of renal failure secondary to lupus
nephritis. History of failed transplant. She was continued on
sevelamer and nephrocaps and sensipar. HD was continued while
she was an inpatient.
# SLE: History of lupus complicated by lupus nephritis and ESRD.
Lupus improved with initiation of HD. Most recent flare in ___ with presentation of polyarthralgia managed with
systemic steroids taper. Followed by rheumatology here at ___.
Other focal presenting shoulder pain, she is at baseline
arthralgia state. Complement, C3, C4, CH50 and anti-dsDNA were
sent on admission and were pending at time of discharge.
Rheumatology was consulted on admission.
# ANEMIA: History of anemia of chronic disease. Managed on
epogen shots in the outpatient setting. Presenting with baseline
hct.
# THROMBOCYTOPENIA: At baseline. Historically felt to be
secondary to lupus.
# HTN: BP well controlled. She was continued on lisinopril and
nifedipine.
# DIASTOLIC CHF: EF >55%, with severe diastolic dysfunction on
most recent echo in ___. Euvolemic on exam. She was continued
on aspirin, ace-inh and betablocker.
TRANSITIONAL ISSUES:
- pending labs: complement c3, c4, ch50, anti-dsDNA, blood
culture
- follow-up: PCP, ___
Medications on Admission:
B COMPLEX-VITAMIN C-FOLIC ACID [NEPHROCAPS] - 1 mg Capsule - one
Capsule(s) by mouth daily
CLOBETASOL 0.05 % Ointment - twice a day
DOXERCALCIFEROL [HECTOROL] - given at dialysis
EPOETIN ALFA [EPOGEN] - given at dialysis
HYDROMORPHONE - 2 mg Tablet - ___ Tablet(s) by mouth every 6
hours as needed as needed for pain
LISINOPRIL - 40 mg Tablet - 2 Tablet(s) by mouth DAILY (Daily)
METOPROLOL TARTRATE - 50 mg Tablet - 2 Tablet(s) by mouth three
times daily
NIFEDIPINE - 90 mg Tablet Extended Release - one Tablet(s) by
mouth daily.
RENUELA - 800mg 3tabs with meals
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D] - 1,000 unit Capsule -
1 Capsule(s) by mouth once a day
DOCUSATE SODIUM [COLACE] - 100 mg Capsule - 1 Capsule(s) by
mouth
twice a day
POLYETHYLENE GLYCOL 3350 [MIRALAX] - 17 gram Powder in Packet -
1 packet by mouth once a day
TYLENOL PRN
Discharge Medications:
1. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. clobetasol 0.05 % Cream Sig: One (1) Appl Topical BID (2
times a day).
3. hydromorphone 2 mg Tablet Sig: ___ Tablets PO every ___ hours
as needed for pain.
4. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
6. nifedipine 90 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO DAILY (Daily).
7. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
10. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
11. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
12. Vancomycin 1000 mg IV HD PROTOCOL Sliding Scale
13. vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
with hemodialysis for 10 days: day 1 = ___
day 14 = ___.
Disp:*qS * Refills:*0*
14. fluconazole 150 mg Tablet Sig: One (1) Tablet PO once a day
for 1 days.
Disp:*1 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Septic Arthritis
2. End Stage Renal Disease, Lupus
3. Yeast infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for a swollen and painful joint. Analysis of
the fluid was concerning for an infected joint (septic
arthritis). You were started on an antibiotic, vancomycin and
were significantly improved. Please continue this antibiotic
for total of two weeks at dialysis.
.
It was a pleasure taking care of you.
The following medication changes were made:
1. START vancomycin with hemodialysis for a total of 2 weeks.
2. START fluconazole 150 mg, 1 tab, by mouth, once only for your
yeast infection.
.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
.
You should be sure to follow up with your doctors as ___
below.
Followup Instructions:
___
|
10213338-DS-38 | 10,213,338 | 25,467,944 | DS | 38 | 2163-04-11 00:00:00 | 2163-04-13 18:43:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Biaxin / Vancomycin / Haldol / Heparin Agents / Flagyl / Sulfite
Attending: ___.
Chief Complaint:
fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH SLE, ESRD ___ lupus nephritis) on HD (T, TH, ___
who presents with fevers. She had a fistula revision with
transplant surgery, Dr. ___ ___. Preoperatively, she received
600 mg linezolid, given her h/o VRE and MRSA. After going home
after her surgery, she reported feeling fatigued, had one
episode of vomiting and had fever. She went to her dialysis
session yesterday where she was noted to be febrile to 100.3.
Fistula site looked clean without erythema or drainage. Blood
cultures were drawn and after removing 2L of fluid patient was
sent to ED. Of note patient was also taking keflex at home. She
has been on keflex for a groin folliculitis, that is now
improving.
.
She also had some constipation (last BM 2 days ago) and right
sided abdominal pain which is chronic for her but no nausea and
no persistnet vomiting. She had a dry cough, but that is now
improving. She has chronic myalgias from her lupus, but none
new. No sick contacts or sore throat. She has felt more SOB over
the past couple of weeks, walking only a block before having to
rest. She denies chest pressure, chest pain, pleuritic pain. She
had occasional palpitations, but none currently.
Initial VS in the ED: T 101.7 90 144/65 16 100% 4L.
Labs notable for lactate 2.2, trop 0.15, WBC 6.9, AST/ALT
120/180, AP 398, tbili 0.6. Blood cultures were sent (pt does
not make urine). She was also given a dose of vancomycin
(unclear what her allergy is for which she is listed).
Past Medical History:
- SLE: Followed by Dr. ___ manifestation =
arthralgia in hips and knees
- ESRD: Secondary to lupus nephritis, s/p failed transplant w/
subsequent nephrectomy, HD on ___.
- Cardiomyopathy - EF 60-65% (___). Severe diastolic
dysfunction.
- H/o chest pain: H/o cardiomyopathy with nl cath in ___, nl
P-MIBI in ___. Evaluated by Dr. ___ in ___ and diagnosed
with atypical CP likely GI (epiploic appendagitis).
- Chronic abdominal pain: S/p cholecystectomy in ___,
pancreatitis ___ pancreatic divisum, partial SBO in ___,
epiploic appendagitis in ___
- Hypertension: On beta blocker, ACE I, CCB.
- H/o dyslipidemia: ___ lipid panel wnl.
- Thrombocytopenia: H/o HIT with positive PF4 in ___ but neg on
follow-up, h/o TTP in ___.
- Anemia: On epoetin at HD, h/o autoimmune hemolytic anemia,
positive anti-E Ab against RBC, thalassemia trait based on
microcytic indices and peripheral smear review by Dr. ___.
- Bronchiolitis obliterans-organizing pneumonia
- H/o recurrent rectal abscesses first noted ___, recurrent
in ___ and a drain was left in, ___: ultrasound negative,
CT ___ no rectal abscess; drained by Dr. ___ in
___ who felt this was resolved when he saw her in ___
- DCIS and atypical ductal hyperplasia ___ s/p lumpectomy.
- Osteoporosis
- H/o avascular necrosis of left knee
- H/o adrenal crisis in ___.
- H/o seizure disorder.
- H/o uterine fibroid in ___, s/p hysterectomy for excessive
bleeding.
- Raynaud's phenomenon
- hip & thigh pain, likely sciatica, being evaluated by ortho
- folliculitis
PSH:
-L brachiobasilic AV fistula (___)
-lap cholecystectomy/CBD exploration (___)
-multiple R lumpectomies/re-excisions (___)
-total vaginal ___ caldoplasty (___)
-living donor renal transplant (___), transplant nephrectomy
(___)
- R THR (___)
-multiple AVF revisions last on ___
Social History:
___
Family History:
Mother died of lupus in her ___ (died of an MI).
Brother with EtOH abuse.
Unaware of any other medical problems in father or siblings.
Physical Exam:
Admission Physical Exam:
Vitals: T: 98.4 BP: 124/58 P: 83 R: 18 O2: 98%RA
General: pleasant female, thin, sitting up in bed, NAD
HEENT: NCAT, PERRL, MMM, OP Clear
Neck: supple, soft, no LAD, no JVD
CV: RRR, nl S1 S2, ___ systolic murmur heard throughout
Lungs: CTAB without wheezes or crackles, no use of accessory
muscles
Abdomen: +BS, well-healed R lower quadrant scar, soft,
non-distended, slight TTP in RUQ, neg ___, mild TTP in RLQ,
which patient reports is her chronic pain there, no rebound or
guarding
GU: normal appearing external genitalia, no erythema or evidence
of folliculitis
Ext: warm, dry, no edema, back without spinal process
tenderness, slight right sided paraspinal mm tenderness, no
erythema or warmth at Right hip
Neuro: oriented x3, CN2-12 intact, strength grossly intact,
normal gait
Skin: L AVF appears c/d/i without erythema, + thrill, no warmth
or fluctuance
.
Discharge Physical Exam:
Vitals: T max 99.1 Tx 98.4 83 136/67 94%RA
General: pleasant female, thin, sitting up in bed
HEENT: MMM, OP Clear
Neck: supple, soft, no LAD, no JVD
CV: RRR, nl S1 S2, ___ systolic murmur heard throughout
Lungs: CTAB without wheezes or crackles, no use of accessory
muscles
Abdomen: +BS, well-healed R lower quadrant scar, soft,
non-distended, tenderness to palpation in the RUQ, mild TTP in
RLQ, no rebound or guarding
Ext: warm, dry, no edema, back without spinal process
tenderness, no erythema or warmth at Right hip
Neuro: oriented x3, CN2-12 intact, strength grossly intact,
normal gait
Skin: L AVF appears c/d/i without erythema, + thrill, no warmth
or fluctuance
Pertinent Results:
Pertinent Labs:
___ 03:40PM BLOOD WBC-6.9 RBC-3.23* Hgb-9.1* Hct-28.4*
MCV-88 MCH-28.2 MCHC-32.1 RDW-20.2* Plt ___
___ 03:40PM BLOOD Neuts-77.1* Lymphs-13.1* Monos-8.0
Eos-1.6 Baso-0.3
___ 03:40PM BLOOD ___ PTT-33.0 ___
___ 03:40PM BLOOD Glucose-82 UreaN-17 Creat-3.7*# Na-140
K-4.0 Cl-95* HCO3-34* AnGap-15
___ 03:40PM BLOOD ALT-180* AST-121* CK(CPK)-54 AlkPhos-396*
TotBili-0.6
___ 06:20AM BLOOD ALT-148* AST-90* CK(CPK)-52 AlkPhos-397*
TotBili-1.4
___ 03:40PM BLOOD Lipase-48
___ 03:40PM BLOOD CK-MB-1
___ 03:40PM BLOOD cTropnT-0.15*
___ 06:20AM BLOOD CK-MB-2 cTropnT-0.14*
___ 03:40PM BLOOD Albumin-4.2
___ 06:20AM BLOOD Calcium-9.9 Phos-4.7* Mg-2.2
___ 03:40PM BLOOD Lactate-2.2*
___ 03:40PM BLOOD CRP-44.4*
___ 03:40PM BLOOD ESR-87*
.
___ 3:30 pm BLOOD CULTURE VENIPUNCTURE.
Blood Culture, Routine (Pending):
Brief Hospital Course:
___ with PMH SLE, ESRD ___ lupus nephritis on HD (T, TH, ___
who presentsed with fevers.
.
# Fevers: Patient had revision of her AV fistula on ___ and
subsequently developed fevers to 101 and felt unwell with nausea
and vomiting at home. The following morning, she had a fever in
dialysis as well so was sent to he ED for further evaluation.
Blood cultures were drawn at dialysis as well as in the ED which
were negative to date. Her fevers were thought to be secondary
to a viral illness given recent cough or transient bacteremia
from her recent fistula procedure. She did not have any
localizing signs or symptoms of infection. She received one dose
of IV vancomycin in the ED. She was subsequently monitored for
48 hours off antibiotics and did not have any further fevers.
She continued her Keflex she had been taking for folliculitis
which was improving per her report and by exam. She felt at her
baseline on the day of discharge. She will follow up with PCP
for further care.
.
# Shortness of breath: Patient reported shortness of breath with
exertion in the past few months which has worsened in the past
few weeks. CXR did not show any pneumonia or signs of CHF. EKG
was unchanged from prior and her CK-MB was normal. She was
ordered for exercise stress test by Dr. ___ to evaluate for
cardiac etiology. Her last nuclear stress test in ___ did not
show any signs of cardiac ischemia. No signs of arrythmia
during this admission. Patient was recommended to follow up with
her cardiologist Dr. ___ further evaluation.
.
# Transaminitis: Patient has history on/off transaminitis. DDX
included recent antibiotics, vs lupus flare vs viral illness.
Patient also has RUQ tenderness which she reports is chronic.
RUQ ultrasound showed 1cm extrahepatic dilation which was
previously seen on ___ ultrasound but not ___. She may
benefit from outpatient MRCP to further evaluate for her
extrahepatic biliary dilatation although since it was present in
the past and her LFTs were downtrending, we did not feel an
inpatient workup was necessary.
Chronic issues:
# ESRD on HD: Continue Nephrocaps, sevelamer
# SLE: Complicated by lupus nephritis, now ESRD (as above),
Raynauds, and Avascular necrosis. She follows with Dr.
___. Not currently on any active treatment, last seen in
___.
# HTN: BP well controlled during this admission. continue
lisinopril, metoprolol, nifedipine
.
Transitional Issues:
- Final results of blood culture pending at the time of
discharge.
- Patient will follow up with PCP ___ discharge.
- Patient was asked to schedule for exercise stress test ordered
by Dr. ___. She was also asked to make an appointment with
her cardiologist for further evaluation of her exertional
shortness of breath
- Patient had RUQ ultrasound during this admission to evaluate
for transaminitis which showed 1cm biliary ductal dilatation
which had been previously seen on one prior ultrasound study in
___. Radiology recommended MRCP which could be performed as
outpatient for further evaluation. Patient was encouraged to
follow up with her gastroenterologist.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Nephrocaps 1 CAP PO DAILY
2. Cephalexin 250 mg PO Q24H
to complete course
3. Doxercalciferol 4 mcg IV WITH HD
4. Epoetin Alfa ___ unit SC WEEKLY HD
5. HYDROmorphone (Dilaudid) 2 mg PO Q4-6HR pain
6. Levofloxacin 250 mg PO Q24H
started on ___, not still taking
7. Lisinopril 40 mg PO BID
8. Metoprolol Tartrate 100 mg PO TID
9. NIFEdipine CR 90 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. sevelamer CARBONATE 2400 mg PO TID W/MEALS
12. ValACYclovir 500 mg PO Q12H:PRN rash
13. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
14. Acetaminophen 1000 mg PO DAILY:PRN pain
15. Ascorbic Acid ___ mg PO DAILY
16. Vitamin D 1000 UNIT PO DAILY
17. Docusate Sodium 100 mg PO BID:PRN constipation
18. Vitamin E 400 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO DAILY:PRN pain
2. Ascorbic Acid ___ mg PO DAILY
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Lisinopril 40 mg PO BID
5. Metoprolol Tartrate 100 mg PO TID
6. Nephrocaps 1 CAP PO DAILY
7. NIFEdipine CR 90 mg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. sevelamer CARBONATE 2400 mg PO TID W/MEALS
10. Vitamin D 1000 UNIT PO DAILY
11. Vitamin E 400 UNIT PO DAILY
12. Epoetin Alfa ___ unit SC WEEKLY HD
13. Doxercalciferol 4 mcg IV WITH HD
14. Cephalexin 250 mg PO Q24H
15. ValACYclovir 500 mg PO Q12H:PRN rash
16. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
17. HYDROmorphone (Dilaudid) 2 mg PO Q4-6HR pain
Discharge Disposition:
Home
Discharge Diagnosis:
1. Fever
Secondary Diagnosis:
2. Transaminitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___, it was a pleasure taking care of you during
your hospitalization at ___. You were admitted because you
had fevers following revision of your AV fistula. You were
monitored for more than 24 hours without any further fevers and
you did not show any signs of infection. Please follow up with
your PCP for further care (see below). Please continue your
regular schedule for hemodialysis.
During this admission you also reported shortness of breath with
exertion in the past few weeks. You have been ordered for
excercise stress test by Dr. ___. Please call the number
provided to you by Dr. ___ to schedule this test. Please
also schedule an appointment with your cardiologist for
evalaution of your shortness of breath.
Finally please also schedule an appointment with your
gastroenterologist for further evalauation and management of
your abdominal pain.
Followup Instructions:
___
|
10213338-DS-40 | 10,213,338 | 21,676,158 | DS | 40 | 2163-06-12 00:00:00 | 2163-06-13 14:59:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Biaxin / Vancomycin / Haldol / Heparin Agents / Flagyl / Sulfite
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms ___ is a ___ year old woman with PMHx significant for ESRD
on HD (___) with last HD on the day of admission, HTN,
cardiomyopathy with dCHF, who presents with fever, chills and
cough. She reports the onset of the symtptoms at the begining of
the week. She reports a high tempurature of 100.1. She has been
coughing up white sputum. No other symtpoms.
In the ED, initial vs were: 99.6 87 155/73 16 96% RA . Labs were
remarkable for white count of 4.1 and a CXR consistent with
evolving RLL PNA. Patient was given cefepime and levofoxicin.
Vitals on Transfer: 98.7 81 142/61 18 98%
On the floor patient reports that she is doing well and was
wonderting if she would be able to go home today as she has a
funeral at 1700 on ___.
Review of sytems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. 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:
- SLE: Followed by Dr. ___ manifestation =
arthralgia in hips and knees
- ESRD: Secondary to lupus nephritis, s/p failed transplant w/
subsequent nephrectomy, HD on ___.
- Cardiomyopathy - EF 60-65% (___). Severe diastolic
dysfunction.
- H/o chest pain: H/o cardiomyopathy with nl cath in ___, nl
P-MIBI in ___. Evaluated by Dr. ___ in ___ and diagnosed
with atypical CP likely GI (epiploic appendagitis).
- Chronic abdominal pain: S/p cholecystectomy in ___,
pancreatitis ___ pancreatic divisum, partial SBO in ___,
epiploic appendagitis in ___
- Hypertension: On beta blocker, ACE I, CCB.
- H/o dyslipidemia: ___ lipid panel wnl.
- Thrombocytopenia: H/o HIT with positive PF4 in ___ but neg on
follow-up, h/o TTP in ___.
- Anemia: On epoetin at HD, h/o autoimmune hemolytic anemia,
positive anti-E Ab against RBC, thalassemia trait based on
microcytic indices and peripheral smear review by Dr. ___.
- Bronchiolitis obliterans-organizing pneumonia
- H/o recurrent rectal abscesses first noted ___, recurrent
in ___ and a drain was left in, ___: ultrasound negative,
CT ___ no rectal abscess; drained by Dr. ___ in
___ who felt this was resolved when he saw her in ___
- DCIS and atypical ductal hyperplasia ___ s/p lumpectomy.
- Osteoporosis
- H/o avascular necrosis of left knee
- H/o adrenal crisis in ___.
- H/o seizure disorder.
- H/o uterine fibroid in ___, s/p hysterectomy for excessive
bleeding.
- Raynaud's phenomenon
- hip & thigh pain, likely sciatica, being evaluated by ortho
- folliculitis
.
PSH:
-L brachiobasilic AV fistula (___)
-lap cholecystectomy/CBD exploration (___)
-multiple R lumpectomies/re-excisions (___)
-total vaginal ___ caldoplasty (___)
-living donor renal transplant (___), transplant
___
-R THR (___)
-multiple AVF revisions last on ___
Social History:
___
Family History:
Mother died of lupus in her ___ (died of an MI).
Brother with EtOH abuse.
Unaware of any other medical problems in father or siblings.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.4, 154/68, 84, 20, 96%RA
General: NAD, laying in bed, ___
___: MMM, EOMI, PERRLA
Neck: Supple, no LAD
Lungs: ___ at right base
CV: RRR, no murmer or rubs
Abdomen: +BS, soft, NT/ND
Ext: No lower extermity pitting edema
Skin: Warm and dry
Neuro: CN ___ grossly intact
DISCHARGE PHYSICAL EXAM:
Vitals: T 98.4, HR 84, BP 154/68, RR 20, SpO2 96% on RA
General: Awake, alert, oriented, no acute distress
___: MMM, sclera anicteric, oropharynx clear
Lungs: Bibasilar crackles; no wheezes; moving air well with no
increased work of breathing
CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic
murmur
Abdomen: soft, tender in RUQ, non-distended, bowel sounds
present, no hepatosplenomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema; AVF on left side with bruit
Pertinent Results:
ADMISSION LABS:
___ 01:25AM BLOOD WBC-4.1 RBC-2.92* Hgb-8.4* Hct-27.1*
MCV-93 MCH-28.6 MCHC-30.9* RDW-21.0* Plt ___
___ 01:25AM BLOOD Neuts-71* Bands-0 ___ Monos-8 Eos-2
Baso-0 ___ Myelos-0
___ 01:25AM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+
Pencil-OCCASIONAL Tear ___
___ 01:25AM BLOOD Glucose-100 UreaN-27* Creat-4.5*# Na-138
K-5.2* Cl-95* HCO3-29 AnGap-19
DISCHARGE LABS:
___ 06:15AM BLOOD WBC-3.3* RBC-2.83* Hgb-8.1* Hct-26.4*
MCV-93 MCH-28.6 MCHC-30.6* RDW-21.1* Plt ___
___ 06:15AM BLOOD Glucose-83 UreaN-30* Creat-5.2* Na-139
K-3.8 Cl-96 HCO3-31 AnGap-16
Brief Hospital Course:
Ms. ___ is a ___ yo lady with a PMH significant for SLE and
ESRD on HD who was admitted for shortness of breath that has
been present for the past several months and worse for the past
four days, accompanied by low grade fevers.
# Dyspnea: The cause of this patient's dyspnea is unclear. CXR
on admission ___ showed mild RLL consolidation. Given recent
hsopitalization as well as multiple risk factors, patient was
started on treatment for HCAP initially with levofloxacin,
cefepime, and vancomycin. Given the minimal changes on CXR, her
lack of elevated WBC, normal saturations on RA, and history of
prolonged dyspnea, pneumonia was considered less likely,
especially MRSA, and the patient was narrowed to levofloxacin.
Other possible causes of her dyspnea include pulmonary edema vs.
pulmonary embolism vs. CAD vs. CHF/cardiomyopathy vs.
cryptogenic organizing pneumonia. Unfortunately, the patient
left AMA before furtehr work-up could be pursued. She was
discharged with a 7-day course of levofloxacin and
recommendations for outpatient follow-up. It will likely be
useful to obatin CT chest, PFTs, stress test, and echo for
furtehr evaluation. The patient's case was discussed with her
outpatient physicians including Dr. ___, Dr. ___
(___), Dr. ___.
# ESRD on HD: ESRD due to SLE. On HD ___ for ___.
Maintained on home meds while inpatient.
# SLE: Complicated by lupus nephritis, now ESRD (as above),
Raynauds, and Avascular necrosis. She follows with Dr.
___. Not currently on any active treatment.
# HTN: BP currently normotensive. Continued home lisinopril,
metoprolol, and nifedipine .
TRANSITIONAL ISSUES:
# persistent dyspnea - further evaluation may include chest CT,
PFTs, stress test, and echo
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 80 mg PO DAILY
Hold for SBP<100
2. Metoprolol Tartrate 100 mg PO TID
Hold for HR<60
3. Nephrocaps 1 CAP PO DAILY
4. NIFEdipine CR 90 mg PO DAILY
Please hold for SBP<100
5. sevelamer CARBONATE 2400 mg PO TID W/MEALS
6. Aspirin 81 mg PO DAILY
7. Docusate Sodium 100 mg PO BID:PRN constipation
8. Doxercalciferol 4 mcg IV WITH HD
9. Epoetin Alfa ___ unit SC WEEKLY HD
10. Vitamin D 1000 UNIT PO DAILY
11. Vitamin E 400 UNIT PO DAILY
12. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
13. HYDROmorphone (Dilaudid) 2 mg PO Q4-6H:PRN pain
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. HYDROmorphone (Dilaudid) 2 mg PO Q4-6H:PRN pain
4. Lisinopril 80 mg PO DAILY
5. Metoprolol Tartrate 100 mg PO TID
6. Nephrocaps 1 CAP PO DAILY
7. NIFEdipine CR 90 mg PO DAILY
8. sevelamer CARBONATE 2400 mg PO TID W/MEALS
9. Vitamin D 1000 UNIT PO DAILY
10. Levofloxacin 500 mg PO Q48H Duration: 3 Doses
RX *levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth every 48
hours Disp #*3 Tablet Refills:*0
11. Doxercalciferol 4 mcg IV WITH HD
12. Epoetin Alfa ___ unit SC WEEKLY HD
13. Vitamin E 400 UNIT PO DAILY
14. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
pneumonia
dyspnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was ___ taking care of you at ___. You were admitted
___ for shortness of breath and low grade fevers. You were
started on antibiotics for possible pneumonia. We recommended
you stay for further evaluation but you left against medical
advice. Please return is your symptoms worsen.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10213338-DS-41 | 10,213,338 | 28,630,596 | DS | 41 | 2163-06-26 00:00:00 | 2163-06-26 21:53:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Biaxin / Vancomycin / Haldol / Heparin Agents / Flagyl / Sulfite
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
R lung thoracentesis
EEG
CT Abdomen
CT Chest
Brain MRI
History of Present Illness:
Ms. ___ is a ___ with a history significant for systemic
lupus erythematosis (c/b lupus nephritis, ESRD s/p right renal
transplant, rejection and removal now on HD ___, TTP/HUS
in ___ and ___ s/p plasmapharesis in ___, ?chronic
ITP,cardiomyopathy with diastolic heart failure, BOOP who
presents with recurrent shortness of breath and fevers.
Per the pt, she began having low grade fevers back at the end of
___. She was admitted twice in ___ on ___ just after
her left upper arm HD fistula was revised. At that time her
fever (100.3 F) was attributed to transient bacteremia from
fistula revision vs. viral illness and she was discharged.
Unfortunately, she was noted to have slurred speech in dialysis
a few days later and was admitted with a fever (101.4F) again
with unclear source. During both admissions she had complained
of SOB that had been ongoing for several months. Her work-up for
this revealed interval worsening of her known mitral and
triscuspid valve regurgitation from previous TTE in ___.
In follow-up from this admission she was seen by GI (who on her
admission had noted liver hemosiderosis on MRCP, considered
cardiac hemosiderosis for her SOB, no clear source for fever)
and ID (who considered prosthetic joint infection). Around this
time she was noted to have "Well circumscribed, raised, 2-cm
violaceous lesions on both thighs that are slightly tender",
which were concerning for septic emboli. One of these lesions
was biopsied, and the pathology on ___ was consistent with
systemic vasculitis vs septic vasculitis. Importantly, at no
point did any blood cultures grow organisms. However, she
continued to have fever, noted to be 100.6F on ___. Ms.
___ says that she called her rheumatologist, Dr. ___,
to say that she thought she might be having a lupus flare and
requested steroids. There is a note in OMR from Dr. ___
___ that he prescribed prednisone. Ms. ___ says that she
never took the steroids as she started to feel better. Of note,
these symptoms that she had been experiencing were not
consistent with her typical lupus flare, which primarily
consists of knee arthralgias. Anti ds-DNA was negative, C3 was
normal at 138 and C4 was slightly elevated to 51 on ___.
Ms. ___ subsequently presented to the ___ ED on ___ for
acute worsening of her dyspnea on exertion that had been going
on for several months. At this time she also had a cough, and
had continued low grade fevers. CXR at that time noted a RLL
consolidation in the lung that was new. She was started on
levofloxacin for presumed CAP, and actually left against medical
advice to go the funeral of her nephew. She was discharged with
a prescription for a course of levofloxacin, which she says she
took.
She presents this admission with a cough that is occasionally
productive of blood tinged sputum. She reports that she became
acutely short of breath on day of admission when walking up a
flight of stairs. She denies any CP. She notes that she has
palpitations daily that are unrelated to the dyspnea and occur
at rest and with exertion. She denies any calf pain or lower
extremity edema, but does have foot cramps. She thinks that
dyspnea is related to dialysis and notes that whenever they do
not take off enough fluid her dyspnea worsens. On ROS she also
notes RUQ abdominal pain that has been present for 6+ years,
without any associated n/v/d.
In the ER, initial vitals were 99 109 166/74 20 100% 4L. Labs
notable for Trop 0.13, CK-MB 2, BNP 65151 D-dimer 424. CXR with
mild increased vascular congestion, no pleural effusions.
On the floor, vs were: 99.7, 186/75, 168/74, 109, 18, 95% RA.
Patient currently feeling well.
Review of systems:
(+) Per HPI
(-) Denies recent weight loss or gain. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies nausea, vomiting,
diarrhea, constipation. No dysuria. Denies arthralgias or
myalgias. Ten point review of systems is otherwise negative.
Past Medical History:
- SLE: Followed by Dr. ___ manifestation =
arthralgia in hips and knees
- ESRD: Secondary to lupus nephritis, s/p failed transplant w/
subsequent nephrectomy, HD on ___.
- Skin biopsy ___ with pathology suggestive of vasculitis
- Cardiomyopathy - EF 60-65% (___). Severe diastolic
dysfunction.
- H/o chest pain: H/o cardiomyopathy with nl cath in ___, nl
P-MIBI in ___. Evaluated by Dr. ___ in ___ and diagnosed
with atypical CP likely GI (epiploic appendagitis).
- Chronic abdominal pain: S/p cholecystectomy in ___,
pancreatitis ___ pancreatic divisum, partial SBO in ___,
epiploic appendagitis in ___
- Hypertension: On beta blocker, ACE I, CCB.
- H/o dyslipidemia: ___ lipid panel wnl.
- Thrombocytopenia: H/o HIT with positive PF4 in ___ but neg on
follow-up, h/o TTP in ___.
- Anemia: On epoetin at HD, h/o autoimmune hemolytic anemia,
positive anti-E Ab against RBC, thalassemia trait based on
microcytic indices and peripheral smear review by Dr. ___.
- Bronchiolitis obliterans-organizing pneumonia
- H/o recurrent rectal abscesses first noted ___, recurrent
in ___ and a drain was left in, ___: ultrasound negative,
CT ___ no rectal abscess; drained by Dr. ___ in
___ who felt this was resolved when he saw her in ___
- DCIS and atypical ductal hyperplasia ___ s/p lumpectomy.
- Osteoporosis
- H/o avascular necrosis of left knee
- H/o adrenal crisis in ___.
- H/o seizure disorder.
- H/o uterine fibroid in ___, s/p hysterectomy for excessive
bleeding.
- Raynaud's phenomenon
- hip & thigh pain, likely sciatica, being evaluated by ortho
- folliculitis
.
PSH:
-L brachiobasilic AV fistula (___)
-lap cholecystectomy/CBD exploration (___)
-multiple R lumpectomies/re-excisions (___)
-total vaginal ___ caldoplasty (___)
-living donor renal transplant (___), transplant
___
-R THR (___)
-multiple AVF revisions last on ___
Social History:
___
Family History:
Mother died of lupus in her ___ (died of an MI).
Brother with EtOH abuse.
Unaware of any other medical problems in father or siblings.
Physical Exam:
ADMISSION PHYSICAL:
Vitals: 99.7, 186/75, 168/74, 109, 18, 95% RA
General: alert, NAD
HEENT: MMM, PERRLA, EOMI
Neck: no LAD, JVP not elevated
Lungs: fine crackles without wheezing, normal air movement
CV: tachycardic, regular, IV/VI holosytolic murmur heard
throughout precordium loudest at apex, radiating to axill and
back
Abdomen: soft, tender RUQ, no rebound or guarding, +BS
Ext: WWP, no CCE
Skin: no rashe
Neuro: CN II-XII intact, oriented x3
DISCHARGE PHYSICAL:
Vitals: T 98 HR 78 BP 126/66 R 14
Gen: confortable, lying in bed
Neck: JVP not elevated
Resp: bibasilar crackles, improved air movement bilaterally
CV: RRR, III/VI murmur at ___
Abd: +BS, TTP in RUQ, mild guarding, no rebound
Ext: no clubbing, cyanosis, or edema
Neuro: A&Ox2, motor and sensation grossly intact
Pertinent Results:
ADMISSION LABS:
___ 06:20PM WBC-6.7# RBC-3.12* HGB-9.3* HCT-28.7* MCV-92
MCH-29.7 MCHC-32.3 RDW-20.8*
___ 06:20PM NEUTS-74* BANDS-1 ___ MONOS-1* EOS-2
BASOS-1 ATYPS-2* ___ MYELOS-0
___ 06:20PM CALCIUM-10.5* PHOSPHATE-2.8 MAGNESIUM-2.3
___ 06:20PM cTropnT-0.13*
___ 06:20PM CK-MB-2 ___
___ 06:20PM GLUCOSE-93 UREA N-42* CREAT-6.3*# SODIUM-139
POTASSIUM-4.2 CHLORIDE-93* TOTAL CO2-28 ANION GAP-22*
___ 06:32PM LACTATE-2.0
___ 07:11PM D-DIMER-424
___ 06:27AM BLOOD WBC-11.1*# RBC-2.93* Hgb-8.4* Hct-26.4*
MCV-90 MCH-28.7 MCHC-31.8 RDW-21.0* Plt ___
___ 06:25AM BLOOD Hypochr-3+ Anisocy-3+ Poiklo-1+
Macrocy-2+ Microcy-1+ Polychr-1+ Ovalocy-1+ Target-OCCASIONAL
Tear Dr-OCCASIONAL
___ 03:30PM BLOOD ESR-58*
___ 05:50AM BLOOD CRP-27.4*
___ 06:27AM BLOOD ALT-22 AST-18 LD(LDH)-199 AlkPhos-252*
TotBili-0.4
___ 05:42AM BLOOD TSH-9.1*
___ 05:42AM BLOOD Free T4-1.6
___ 07:30AM BLOOD calTIBC-207 Ferritn-2134* TRF-159*
___ 03:30PM BLOOD dsDNA-NEGATIVE
___ 05:50AM BLOOD C3-165 C4-49*
___ 06:40AM BLOOD PEP-NO SPECIFI
___ 06:40AM BLOOD ANTI-GBM-Test
Pleural Fluid (___) : Negative for malignant cells
___ 09:03AM PLEURAL ___ RBC-1075* Polys-56* Lymphs-9*
___ Meso-1* Macro-32* Other-2*
___ 09:03AM PLEURAL TotProt-3.1 Glucose-111 LD(___)-115
Albumin-2.1 ___ Misc-PROBNP = 1
DISCHARGE LABS:
___ 06:25AM BLOOD WBC-6.5 RBC-2.90* Hgb-8.1* Hct-25.7*
MCV-88 MCH-27.9 MCHC-31.5 RDW-20.8* Plt ___
___ 06:25AM BLOOD Glucose-91 UreaN-43* Creat-7.6*# Na-136
K-4.3 Cl-94* HCO3-28 AnGap-18
___ 07:30AM BLOOD ALT-15 AST-21 LD(LDH)-197 AlkPhos-230*
TotBili-0.4
___ 06:25AM BLOOD Calcium-9.8 Phos-4.1 Mg-2.3
___ 07:30AM BLOOD Triglyc-71 HDL-41 CHOL/HD-2.4 LDLcalc-43
EKG: Sinus tachycardia. Non-specific lateral ST-T wave
abnormalities. No major change from the previous tracing except
for a faster sinus rate.
MICRO:
All blood, sputum, and pleural cultures were negative.
IMAGING:
CXR (___):
IMPRESSION:
1. Increased opacity in the right lung base concerning for
right lower lobe pneumonia.
2. Small right pleural effusion and potential mild pulmonary
edema.
3. Stable cardiomegaly and prominence of the main pulmonary
artery.
CXR (___):
IMPRESSION:
1. New focal consolidation overlying the right lower lobe
concerning for pneumonia.
2. Stable cardiomegaly with cephalization of the vessels and
hilar fullness, without evidence of pulmonary edema.
MR ___ w/o Contrast (___):
IMPRESSION:
No acute intracranial abnormality. Stable white matter changes
likely related to chronic microvascular ischemic disease. Stable
mall focal area of FLAIR hyperintensity in the left frontal
lobe, likely related to an old infarct and/or small vessel
ischemia.
CTA CHEST W/AND W/O CONTRAST (___)
IMPRESSION:
1. No findings of pulmonary embolism or aortic dissection.
2. Bilateral pleural effusions right side greater than left
with bibasilar atelectasis. Tiny pericardial effusion.
3. Stable splenic hypodensity may represent a cyst or
hemangioma.
4. Diffuse sclerosis of the bones most consistent with renal
osteodystrophy, similar to the prior study.
CT Abdomen/Pelvis w/contrast (___)
IMPRESSION:
1. No acute intra-abdominal or intrapelvic process.
Specifically, no CBD stricture, intrahepatic bile duct dilation,
or acute liver process detected.
2. Diffuse mesenteric stranding, in combination with
subcutaneous edema, likely third spacing. No focal
intra-abdominal fluid collections are seen.
3. Post-surgical changes within the right lower quadrant,
reflecting prior renal transplant site. A focus of soft tissue
along the right pelvic side wall appears slightly more prominent
since ___, likely post-surgical in etiology.
4. Extensive paraaortic lymphadenopathy, in keeping with known
history of SLE.
5. Atrophic native kidneys with cystic changes related to
chronic dialysis.
6. Post-cholecystectomy.
7. Avascular necrosis of the left femoral ___. Right total hip
arthroplasty.
8. Small fat containing left inguinal hernia.
9. This protocol was not optimized specifically to evaluate for
hemosiderosis, as no precontrast scan was obtained.
CXR (___)
IMPRESSION: No evidence of pneumothorax. No effusion is seen.
EEG (___)
Mildly abnormal study due to brief runs of polymorphic delta
coming from the right posterior quadrant. There were no
associated sharps or spikes. There were no electrographic
seizures seen during the routine. These findings can be
associated with focal cerebritis or a focal infectious process.
Please correlate clinically.
CT-Guided Lymph Node Biopsy (___):
FINDINGS: Enlarged lymph nodes. The target left para-aortic
lymph node measures 2.4 cm transverse dimension.
IMPRESSION: CT guided left retroperitoneal lymph node biopsy.
Pathology pending
Brief Hospital Course:
___ w/ ESRD on HD, HTN, cardiomyopathy with dCHF, SLE, BOOP,
DCIS s/p lumpectomy, seizure d/o (___), R renal transplant and
removal, who presented w/ recurrent SOB and blood-tinged sputum.
#HCAP: Recently discharged ___ for DOE (started Levoflox for
RLL infiltrate), but left AMA to attend nephew's funeral.
Returned ___. On ___, she was febrile and started Vanc/Cef for
HCAP based on physical exam and CXR findings of persistent RLL
infiltrate. She was broadened to Vanc/Zosyn for anaerobic
coverage on ___ for continued fevers. CT chest ___
demonstrated a R-sided effusion, which was tapped and found to
be non-complicated exudative effusion. She completed an 8-day
course of antibiotics and her cough and blood-tinged sputum had
resolved by discharge.
#Dyspnea: Patient admitted with symptoms of SOB on exertion with
elevated BNP with differential diagnosis including fluid
overload, PNA, SLE vasculitis, PE (normal d-dimer). Most likely
etiology was fluid overload, but evaluation difficult with new
HCAP. She had a negative ANCA, negative Anti-GBM, normal SPEP,
and a CT without evidence of vasculitis. It is likely that her
dyspnea was a combination of fluid overload and PNA
concominantly.
#AMS: Upon readmission on ___, she was noted to be acutely
encephalopathic, with word finding difficulties and extreme
emotional lability. She was transferred to the MICU, where she
returned to baseline MS (___) and received brain MRI per neuro
recs (no acute stroke, but chronic microvascular disease). She
had sick euthyroid (TSH 9.1 but normal T4 1.6) and sedating meds
were held (i.e. Zolpidem). EEG from ___ (after patient returned
to baseline) was abnormal suggestive of a focal cerebritis or
focal infectious process, but neuro felt this was nonspecific
and could be related to her prior stroke. The most likely
etiology of her AMS was hyperactive delirium secondary to toxic
metabolic encephalopathy (possibly due to HCAP, however, the
inciting factor is unclear), however seizure is also possible.
Neurology recommends 24 hour EEG should another such episode
occur. She was discharge ___, relating appropriately.
#FUO: Of note, Ms. ___ has been having low grade fevers since
___ with no clear etiology. She was admitted twice previously,
and was seen by GI (who on her admission had noted liver
hemosiderosis on MRCP, considered cardiac hemosiderosis for her
SOB, no clear source for fever) and ID (who considered
prosthetic joint infection). A skin biopsy on ___ prior to
this admission revealed a leukocytoclastic vasculitis. Although
Dr. ___ steroids for presumed lupus flare with
vasculitis, she never took prednisone, and the lesions resolved
on their own. In this admission, she continued to be febrile to
as high as 103 while on Vanc/Zosyn, for several days, which
prompted us to consult hematology and perform a CT
Abdomen/Pelvis, which revealed extensive para-aortic LAD that
had increased in size from a prior CT in ___. She received
CT-guided LN biopsy on ___. Results were pending at the time of
discharge.
#Abdominal pain: She also has chronic abdominal pain (RLQ),
which had been ongoing for ___bdomen/pelvis
revealed what appear to be post-surgical changes in the RLQ,
without anything else to explain her pain.
CHRONIC ISSUES:
#ESRD: Ms. ___ also received HD while she was in the hospital
and we continued here on her home CKD medications (Nephrocaps,
Epoetin, Sevelamer. Her elevated Alk Phos is most likely ___
renal osteodystrophy.
#SLE: Followed by Dr. ___. ANCA neg, anti-dsDNA negative,
ESR 58, CRP 27.4, C3 165, C4 49, negative HFE. Of note, her
ferritin was ___.
#Shoulder pain, bilaterally: Ms. ___ has a history of
avascular necrosis, torn rotator cuffs, and osteoclastic
activity in her shoulders bilaterally. She was treated with low
doses of IV Dilaudid and PO Oxycodone.
#Thrombocytopenia: H/o HIT with positive PF4 in ___ but neg on
follow-up, h/o TTP in ___.
- Stable on this admission
#Normocytic Anemia: On epoetin at HD, h/o autoimmune hemolytic
anemia, positive anti-E Ab against RBC, thalassemia trait based
on microcytic indices and peripheral smear review (teardrops) by
Dr. ___.
-Stable on this admission
#Hypertension: We continued home antihypertensives (Lisinopril
80 mg daily, Metoprolol 100 mg TID and Nifedipine CR 90 mg
daily)
TRANSITIONAL ISSUES:
[] Please make sure to follow up on pathology results of LN
biopsy
[] Consider further work-up for patient's FUO, which may be due
to underlying malignancy, as she is at an increased risk for
Lymphoma given her diagnosis of SLE and previous
immunosuppresive therapies (for failed R kidney transplant)
[] Pt needs stress echo and PFTs as outpatient (which are
scheduled)
[] Med changes: Re-started patient on Aspirin 81 for cardiac
protection. Decreased dose of Hydromorphone to 1 mg q8h PRN to
avoid sedation/confusion. Discontinued Zolpidem as it appeared
to precipitate an episode of delirium/confusion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. HYDROmorphone (Dilaudid) 2 mg PO Q4-6H:PRN pain
4. Lisinopril 80 mg PO DAILY
5. Metoprolol Tartrate 100 mg PO TID
6. Nephrocaps 1 CAP PO DAILY
7. NIFEdipine CR 90 mg PO DAILY
8. sevelamer CARBONATE 2400 mg PO TID W/MEALS
9. Vitamin D 1000 UNIT PO DAILY
10. Levofloxacin 500 mg PO Q48H
11. Doxercalciferol 4 mcg IV WITH HD
12. Epoetin Alfa ___ unit SC WEEKLY HD
13. Vitamin E 400 UNIT PO DAILY
14. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
15. Acetaminophen 1000 mg PO DAILY PRN pain
16. Polyethylene Glycol 17 g PO DAILY:PRN constipation
17. Clindamycin 600 mg PO ___ MINUTES PRIOR TO DENTAL
PROCEDURE
Discharge Medications:
1. Docusate Sodium 100 mg PO BID:PRN constipation
2. Lisinopril 80 mg PO DAILY
3. Metoprolol Tartrate 100 mg PO TID
4. Nephrocaps 1 CAP PO DAILY
5. NIFEdipine CR 90 mg PO DAILY
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. sevelamer CARBONATE 2400 mg PO TID W/MEALS
8. Vitamin D 1000 UNIT PO DAILY
9. Vitamin E 400 UNIT PO DAILY
10. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth
daily Disp #*30 Tablet Refills:*3
11. Doxercalciferol 4 mcg IV WITH HD
12. Epoetin Alfa ___ unit SC WEEKLY HD
13. Acetaminophen 1000 mg PO DAILY PRN pain
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day
Disp #*180 Tablet Refills:*0
14. HYDROmorphone (Dilaudid) 1 mg PO Q8H:PRN pain
RX *hydromorphone 2 mg 0.5 (One half) tablet(s) by mouth every
eight (8) hours Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Health Care Associated Pneumonia
Fever of Unknown Origin
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
It was a pleasure taking care of you while you were here at
___. You were admitted with shortness of breath. On your first
day here, you were confused and we sent you to the ICU because
we were concerned. You became less confused and an MRI of your
brain demonstrated that you did not have a stroke.
You were found to have pneumonia and you were treated with
antibiotics (Vancomycin and Zosyn). You were also found to have
fluid in your lungs and the pulmonary doctors came and performed
a procedure where they drained the fluid from your right lung.
Given your persistent fevers, we performed a lymph node biopsy
through your back. The results will take a few weeks to come
back.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10213338-DS-42 | 10,213,338 | 23,340,206 | DS | 42 | 2163-07-08 00:00:00 | 2163-07-08 12:26:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Biaxin / Vancomycin / Haldol / Heparin Agents / Flagyl / Sulfite
Attending: ___.
Chief Complaint:
TB rule out
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
___ yo female with a history significant for SLE(c/b lupus
nephritis, ESRD s/p right renal transplant, rejection and
removal now on HD ___, TTP/HUS
in ___ and ___ s/p plasmapharesis in ___, ?chronic
ITP,cardiomyopathy with diastolic heart failure, BOOP who
presents after recent admission for fever of unknown origin
(___) for rule out of tuberculosis. Please see the
Discharge Summary from that admission for more details.
The patient has had multiple systemic symptoms since ___.
She endorses chronic cough that over the last few months has
been occasionally productive of blood. Had had intermittent
fevers and night sweats. She also notes skin lesions that are
similar to what occur during SLE flares. These lesions have
increased over the past month. Biopsy in ___ of skin lesions
showed focal fibrinoid necrosis of mid-dermal vessels consistent
with vasculitis and mild perivascularlymphocytic inflammation.
Given her persistant fevers, a lymph node biopsy was performed
during her most recent admission that focally necrotizing
granulomatous inflammation with negative AFB stains. Denies
exposure to TB although has traveled to ___.
Given her cough and multiple lung infections, and the patient's
need for regular hemodialysis, she was admitted to rule out TB
while continuing her HD.
In the ED, initial VS were 100.3 77 127/71 16 99% RA. On arrival
to the floor, patient reports severe bilateral shoulder and left
knee joint pains (where she normally gets joint pain) as well as
shaking chills.
REVIEW OF SYSTEMS:
Per HPI
All other 10-system review negative in detail.
Past Medical History:
- SLE: Followed by Dr. ___ manifestation =
arthralgia in hips and knees
- ESRD: Secondary to lupus nephritis, s/p failed transplant w/
subsequent nephrectomy, HD on ___.
- Skin biopsy ___ with pathology suggestive of vasculitis
- Cardiomyopathy - EF 60-65% (___). Severe diastolic
dysfunction.
- H/o chest pain: H/o cardiomyopathy with nl cath in ___, nl
P-MIBI in ___. Evaluated by Dr. ___ in ___ and diagnosed
with atypical CP likely GI (epiploic appendagitis).
- Chronic abdominal pain: S/p cholecystectomy in ___,
pancreatitis ___ pancreatic divisum, partial SBO in ___,
epiploic appendagitis in ___
- Hypertension: On beta blocker, ACE I, CCB.
- H/o dyslipidemia: ___ lipid panel wnl.
- Thrombocytopenia: H/o HIT with positive PF4 in ___ but neg on
follow-up, h/o TTP in ___.
- Anemia: On epoetin at HD, h/o autoimmune hemolytic anemia,
positive anti-E Ab against RBC, thalassemia trait based on
microcytic indices and peripheral smear review by Dr. ___.
- Bronchiolitis obliterans-organizing pneumonia
- H/o recurrent rectal abscesses first noted ___, recurrent
in ___ and a drain was left in, ___: ultrasound negative,
CT ___ no rectal abscess; drained by Dr. ___ in
___ who felt this was resolved when he saw her in ___
- DCIS and atypical ductal hyperplasia ___ s/p lumpectomy.
- Osteoporosis
- H/o avascular necrosis of left knee
- H/o adrenal crisis in ___.
- H/o seizure disorder.
- H/o uterine fibroid in ___, s/p hysterectomy for excessive
bleeding.
- Raynaud's phenomenon
- hip & thigh pain, likely sciatica, being evaluated by ortho
- folliculitis
.
PSH:
-L brachiobasilic AV fistula (___)
-lap cholecystectomy/CBD exploration (___)
-multiple R lumpectomies/re-excisions (___)
-total vaginal ___ caldoplasty (___)
-living donor renal transplant (___), transplant
___
-R THR (___)
-multiple AVF revisions last on ___
Social History:
___
Family History:
Mother died of lupus in her ___ (died of an MI).
Brother with EtOH abuse.
Unaware of any other medical problems in father or siblings.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS:99.3 145/63 79 18 100/RA
General: Thin ___ in NAD. Bundled in two blankets to the neck.
Pleasant and conversant
HEENT: NCAT, EOMI, Dry mucous membranes
Neck: Supple, no LAD
Lungs: Bibasilar crackles, otherwise clear
CV: Regular rate and rhythm. III/VI systolic murmur
Abd: Soft, non distended. Tender to palpation in RUQ (baseline).
Normoactive bowel sounds
Ext: Warm, well perfused. Fistula in right arm
Skin: Multiple 1-2 cm hyperpigmented patches b/l lower
extremities
Neuro: A&Ox3, CNII-XII grossly intact.
.
DISCHARGE PHYSICAL EXAM:
VS: 98.8 118/61 86 16 96/RA
General: Thin ___ in NAD. Bundled in two blankets to the neck,
getting dialysis. Pleasant and conversant
HEENT: NCAT, EOMI, Dry mucous membranes
Neck: Supple, no LAD
Lungs: Bibasilar crackles, otherwise clear
CV: Regular rate and rhythm. III/VI systolic murmur
Abd: Soft, non distended. Tender to palpation in RUQ (baseline).
Normoactive bowel sounds. No rebound or guarding
Ext: Warm, well perfused. Fistula in left arm. Left knee with
effusion but not tenderness
Skin: Multiple 1-6 cm hyperpigmented patches b/l lower
extremities
Neuro: A&Ox3, CNII-XII grossly intact.
Pertinent Results:
ADMISSION LABS:
___ 05:10PM GLUCOSE-87 UREA N-52* CREAT-8.3* SODIUM-141
POTASSIUM-4.4 CHLORIDE-96 TOTAL CO2-31 ANION GAP-18
___ 05:10PM CALCIUM-9.8 PHOSPHATE-3.4 MAGNESIUM-2.4
___ 05:10PM WBC-7.1 RBC-2.82* HGB-7.6* HCT-25.3* MCV-90
MCH-26.8* MCHC-29.9* RDW-21.1*
___ 05:10PM PLT COUNT-155
___ 05:00PM GLUCOSE-87 UREA N-52* CREAT-8.4* SODIUM-140
POTASSIUM-4.4 CHLORIDE-96 TOTAL CO2-32 ANION GAP-16
___ 05:00PM ALT(SGPT)-15 AST(SGOT)-21 LD(LDH)-201 ALK
PHOS-198* TOT BILI-0.4
___ 05:00PM CALCIUM-9.9 PHOSPHATE-3.4 MAGNESIUM-2.4
___ 05:00PM dsDNA-NEGATIVE
___ 05:00PM CRP-57.0*
___ 05:00PM C3-127 C4-43*
___ 05:00PM WBC-7.2 RBC-2.80* HGB-7.6* HCT-24.9* MCV-89
MCH-27.1 MCHC-30.4* RDW-21.3*
___ 05:00PM PLT COUNT-156
___ 05:00PM ___ PTT-36.0 ___
___ 05:00PM SED RATE-83*
___ 02:40PM HBsAg-NEGATIVE HBs Ab-NEGATIVE
___ 02:40PM HIV Ab-NEGATIVE
___ 02:40PM HCV Ab-NEGATIVE
MICROBIOLOGY:
___ 8:23 am SPUTUM Source: Induced.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
___ 2:01 pm SPUTUM Source: Induced.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
___ 10:57 pm SPUTUM Source: Expectorated.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Pending):
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ BLOOD CULTURE Blood Culture, Routine-PENDING
Brief Hospital Course:
___ with complicated PMH including SLE(c/b lupus nephritis, ESRD
s/p right renal transplant, rejection and removal now on HD
___, intermittent fevers and cough productive of blood
presenting after lymph node biopsy showed focally necrotizing
granulomatous inflammation with negative AFB stains. Admitted to
rule out TB while continuing to receive HD, now with AFB sputum
negative x3.
#) Possible Tb: Pt admitted with concern for TB infection given
recent fevers and h/o chronic cough and placed on respiratory
isolation in a negative pressure room. TB ruled out with
negative AFB on concentrated sputum smears x 3. Sputum
microbiology results as well as this discharge summary were
faxed to HD center at ___ prior to discharge. AFB
cultures and quantiferon gold pending at time of discharge.
#) Granulomatous inflammatory lymph node: Infectious vs
rheumatological etiologies. TB ruled out as above, other
infectious work up including blood cultures and CXR negative.
Rheumatologic cause possible given h/o SLE, however
granulomatous inflammation not typical for SLE. Pt will require
continued followup with rheumatology and infectious disease
after discharge.
#) Fevers: Pt recently admitted for fever of unknown origin s/p
lymph node biopsy on prior admission as above. Pt was
intermittently febrile throughout this admission without
localizing infectious symptoms, other vital signs within normal
limits. Blood cultures, CXR unrevealing. Ruled out for TB as
above.
#) Constipation: Increased bowel regimen.
#) SLE: Rheumatology consulted, felt that current presentation
was not consistent with SLE flare. Did not initiate steroids
given concern for occult infection. Will need close outpatient
rheum followup.
#) ESRD secondary to Lupus nephritis: On HD. Continued
hemodialysis according to ___ schedule during admission.
#) Skin rash: Pt with multiple hyperpigmented lesions on lower
extremities. Per the patient, these lesions occur with her
lupus. Biopsy in ___ showed vasculitis. Given that more
lesions are appearing, should also consider cutaneous
manifestations of TB. Would consider derm c/s for rebiopsy of
lesions as outpatient.
#) RUQ pain: Per patient, this is chronic ___ years) with
unclear etiology. Continued PO hydromorphone for pain control.
#) Depressed mood: Social work consulted. Referral given for
therapist on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID:PRN constipation
2. Lisinopril 80 mg PO DAILY
3. Metoprolol Tartrate 100 mg PO TID
4. Nephrocaps 1 CAP PO DAILY
5. NIFEdipine CR 90 mg PO DAILY
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. sevelamer CARBONATE 2400 mg PO TID W/MEALS
8. Vitamin D 1000 UNIT PO DAILY
9. Vitamin E 400 UNIT PO DAILY
10. Aspirin 81 mg PO DAILY
11. Doxercalciferol 4 mcg IV WITH HD
12. Epoetin Alfa ___ units SC WEELY HD
13. Acetaminophen 1000 mg PO Q8H:PRN pain
14. HYDROmorphone (Dilaudid) 1 mg PO Q8H:PRN pain
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 200 mg PO BID constipation
4. HYDROmorphone (Dilaudid) 1 mg PO Q8H:PRN pain
5. Lisinopril 80 mg PO DAILY
6. Metoprolol Tartrate 100 mg PO TID
7. Nephrocaps 1 CAP PO DAILY
8. NIFEdipine CR 90 mg PO DAILY
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. sevelamer CARBONATE 2400 mg PO TID W/MEALS
11. Vitamin D 1000 UNIT PO DAILY
12. Vitamin E 400 UNIT PO DAILY
13. Doxercalciferol 4 mcg IV WITH HD
14. Epoetin Alfa ___ units SC ___ HD
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Fevers of unknown origin
SECONDARY DIAGNOSIS:
- SLE
- ESRD on HD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was our pleasure taking care of you during your admission to
___. You were admitted on ___ after having an abnormal
lymph node biopsy and there was concern that you might have
tuberculosis (TB).
You had to have dialysis as an inpatient while we were testing
you for TB. You had 3 different samples of your sputum tested
and were found to not be positive for TB.
You continued to have intermittent fevers. This could be
occurring for multiple reasons and you will need to outpatient
follow up for further evaluation.
Again, it was our pleasure taking care of you. We wish you the
best of luck!
Followup Instructions:
___
|
10213338-DS-48 | 10,213,338 | 20,880,022 | DS | 48 | 2165-05-04 00:00:00 | 2165-05-05 15:30:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Biaxin / Vancomycin / Haldol / Heparin Agents / Flagyl / Sulfite
/ Sulfa (Sulfonamide Antibiotics) / CellCept
Attending: ___.
Chief Complaint:
Fever, Tachycardia
Major Surgical or Invasive Procedure:
Fistulogram ___
History of Present Illness:
___ woman with ESRD on HD (TTS) due to lupus nephritis, failed
kidney transplant (on azathioprine), HTN, HFpEF, atypical chest
pain, chronic abdominal pain, recurrent rectal abscess, h/o TB,
TTP, HIT, DCIS, adrenal crisis, also known VRE and MRSA carrier
presenting with left foot lesion and concern for osteomyelitis.
Patient reports that she had relative sudden onset of pain the
left foot about 2 months ago, which she describes as stabbing
and radiating up her leg, ___ addition to her chronic back,
abdomen, head, and shoulder pain, which are all stable.
On ___ podiatry removed the left ___ toenail and pus was
expressed, growing CONS, at that time Dr. ___ he was
able to probe to bone. ESR was 29 and CRP was 1.4. There is a
transplant surgery note from ___ stating that there was some
concern for infected scabs over her fistula, for which she was
given vancomycin and ancef.
She reports than when she was given vancomycin at HD she
developed red "welts" on her thighs, that were painful and now
have started to resolve and left dark circles on her skin. She
went for HD today and was referred to the ED.
___ the ED, initial vitals were: 99.8 117 111/67 18 99%;, she was
noted to have a black necrotic area over the left big toe and
___ toe
- Labs were significant for lactate 2.0, K 4.8, WBC 4.9, Hgb
10.5, Plt 104. Blood cultures were sent.
- Plain film of the left foot revealed "Slight progression of
erosion and lysis" of the ___ and ___ distal phalanx; CXR showed
no acute process
- The patient was given acetaminophen, zosyn, 500cc IVF,
hydrocortisone 100mg, morphine 5mg IV, azathioprine 50mg PO,
labetalol 200mg PO
- Podiatry came to see patient and removed the ___ toe nail and
expressed about 1cc of purulent material which showed 1+ GPCs ___
pairs and clusters
- Vascular was also called for consult, they are discussing the
role of CTA but no formal recommendations yet.
Vitals prior to transfer were: 98.2 98 112/58 16 98% RA
Upon arrival to the floor, patient complains of spasming pain
between her shoulders which she says is not new. Her foot pain
is stable, decreased since having the nerve block
Social History:
___
Family History:
Mother died of lupus ___ her ___ (died of an MI).
Brother with EtOH abuse.
Unaware of any other medical problems ___ father or siblings.
Physical Exam:
====================
ADMISSION EXAM
====================
Vitals: 99.2F, BP 120/54, HR 107, RR 18, 95% RA
General: Alert, oriented, ___ mild distress due to shoulder pain
HEENT: Sclera anicteric, EOMI, MM dry, oropharynx clear, no
thrush appreciated
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur
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: feet are warm; Left foot is dressed , c/d/i, not disturbed.
no edema; left DP and ___ pulses dopplered by podiatry
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation
Skin: multiple 1cm hyperpigmented annular lesions on the left
thigh; punctate (1-2mm) hypopigmented clusters on dorsum of left
wrist
====================
DISCHARGE EXAM
====================
Vitals: 99.1 90-100s 110s-150s/50-60s 18 100% on RA
General: Pleasant thin ___ woman ___ no distress
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur
Lungs: Clear to auscultation bilaterally
Abdomen: RLQ well-healed scar, soft, nontender, nondistended.
GU: No foley
Ext: feet are warm; left foot dressing c/d/i
Skin: multiple 1cm hyperpigmented annular lesions on the left
thigh and wrists bilaterally, with overlying scale. Fistula ___
left arm has overlying scabbing. +thrill. Chin w/bandage.
Pertinent Results:
=============
ADMISSION LABS
=============
___ 12:45PM BLOOD WBC-5.9# RBC-3.30* Hgb-10.5* Hct-32.0*
MCV-97 MCH-31.7 MCHC-32.7 RDW-17.1* Plt ___
___ 12:45PM BLOOD Neuts-75* Bands-0 Lymphs-13* Monos-8
Eos-2 Baso-0 Atyps-2* ___ Myelos-0
___ 12:45PM BLOOD Glucose-113* UreaN-20 Creat-3.6*# Na-137
K-4.8 Cl-92* HCO3-31 AnGap-19
___ 06:05AM BLOOD Calcium-10.2 Phos-5.2*# Mg-2.5
___ 06:05AM BLOOD Cortsol-31.7*
___ 06:05AM BLOOD CRP-GREATER THAN ASSAY
___ SED RATE- 120
=============
MICROBIOLOGY
=============
___ 4:42 pm SWAB Source: Left ___ toe.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
WOUND CULTURE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT
PRESENT ___
this culture..
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
Blood cultures negative x 3.
Direct Antigen Test for Herpes Simplex Virus Types 1 & 2 (Final
___:
Reported to and read back by ___ ON
___,
10:46AM.
POSITIVE FOR HERPES SIMPLEX TYPE 1 (HSV1).
Viral antigen identified by immunofluorescence.
=============
IMAGING
=============
LEFT FOOT XR ___: IMPRESSION:
1. Slight progression of erosion and lysis of the tuft of the
fifth distal phalanx since the prior exam, concerning for
osteomyelitis.
2. Slight progression of erosive change at the tuft of the
first distal
phalanx, concerning for osteomyelitis.
CXR ___: IMPRESSION:
1. Multi chamber cardiomegaly, unchanged.
2. No focal infiltrate to suggest pneumonia identified.
3. Mild upper zone redistribution, without overt CHF.
4. Rounded densities ___ the right lower zone are thought to
represent a nipple
shadow and artifact due to overlapping ribs. Consider repeat
frontal
radiograph with nipple markers to confirm this.
5. Suspected osteonecrosis left humeral head.
Fistulogram ___: FINDINGS:
1. Fistulagram demonstrating moderate stenoses at the basilic,
brachial, and axillary veins. Patent AV fistula arterial
anastomosis / inflow without stenosis.
2. No flow-limiting stenoses on post angioplasty venogram.
US AORTA ___: IMPRESSION:
Extensive atherosclerotic plaque ___ the aorta however no
aneurysm visualized.
=============
DISCHARGE LABS
=============
___ 06:21AM BLOOD WBC-5.5 RBC-2.30* Hgb-7.4* Hct-21.2*
MCV-92 MCH-32.2* MCHC-35.0 RDW-16.6* Plt Ct-90*
___ 06:21AM BLOOD Glucose-88 UreaN-60* Creat-7.6*# Na-134
K-5.1 Cl-91* HCO3-29 AnGap-19
___ 06:21AM BLOOD Calcium-9.4 Phos-5.8* Mg-2.3
___ 06:19AM BLOOD dsDNA-NEGATIVE
___ 06:19AM BLOOD CRP-GREATER TH
___ 06:19AM BLOOD C3-164 C4-48*
___ 07:43AM BLOOD cTropnT-0.16*
___ 04:50PM BLOOD CK-MB-2 cTropnT-0.19*
___ 12:11AM BLOOD CK-MB-3 cTropnT-0.25*
___ 06:19AM BLOOD cTropnT-0.37*
___ 04:38PM BLOOD cTropnT-0.60*
Brief Hospital Course:
___ woman with lupus (on azathioprine), ESRD on HD (TTS) due to
lupus nephritis, failed kidney transplant, HTN, HFpEF, known VRE
and MRSA carrier presenting with left foot osteomyelitis. Pt has
___ and ___ digit wounds with highly elevated CRP (greater than
assay), able to probe to bone, with changes on X-ray, all of
which is highly suspicious for osteomylitis. She clinically
appeared well. She was followed by ID, podiatry, and vascular
during her hospitalization. Podiatry deferred surgical
intervention due to concern for poor wound healing. Vascular
planned for nonurgent revascularization of LLE with angiogram
planned for ___. As a result, bone biopsy was not obtained,
and she was started on empiric treatment for osteomyelitis.
There was initial concern for vancomycin allergy, but pt was
able to tolerate this ___ the hospital without difficulty. She
will be discharged on vancomycin and ceftazidime dosed w/ HD for
planned 6 wk course. While ___ the hospital, she underwent
fistulogram and angioplasty of three stenosed areas, with
improvement after the procedure. Of note, her hospital course
was c/b outbreak of HSV on chin, treated with 5 day course of
acyclovir. She also acute on chronic anemia; this should be
trended as outpatient and consideration given to EPO with HD.
Also of note during her hospitalization, she had knee pain,
rash, hair loss, and fever suggestive of possible lupus flare.
Serum markers were negative, and pt was evaluated by
rheumatology who felt her presentation was not consistent with a
flare. She will have close follow-up with rheumatology.
Of note, pt had episode of chest pain during dialysis on ___.
There were no changes on EKG, but troponin increased from 0.16
to 0.37, with flat CKMB. She had no further episodes of chest
pain, so this was attributed to demand ___ setting of tachycardia
and hypertension during HD. Vascular surgery requested troponin
as pre-operative testing for angiogram, so one was drawn prior
to discharge, and was elevated at 0.6. Of note, pt did not have
any symptoms of chest pain or anginal equivalents at the time,
this was drawn purely for pre-operative purposes. As suspicion
for myocardial ischemia is extremely low, she was discharged.
====================
ACUTE ISSUES
====================
#Left foot ___ and ___ digit ulcers, c/f osteomyelitis: Pt has
___ and ___ digit wounds with highly elevated CRP (greater than
assay), able to probe to bone, with changes on X-ray, all of
which is highly suspicious for osteomylitis. She clinically
appears well. Per ID recs, she was on daptomycin and ceftazidime
dosed w/ HD. ___ discussion with podiatry, they did not plan to
perform intervention due to concern for poor wound healing.
Vascular did not plan to urgently revascularize her LLE. Though
it would be ideal to obtain bone biopsy, unfortunately it was
unable to be obtained, so we decided to treat empirically for a
planned 6 week course. Initial plan from ID was for
daptomycin/ceftazidime, but her ___ facility cannot give
daptomycin. Pt had reported allergy to vancomycin, but this did
not sound c/w true allergy. She tolerated vancomycin with
pretreatment. She was discharged on vancomycin/ceftaz TIW w/ HD
with plan for planned 6 wk course (___). Pt to f/u
with Podiatry ___ ___ days. F/u with Vascular with plan for
angiogram ___ 1 wk.
#orolabial HSV: Pt has grouped vesicles on chin, with DFA + for
HSV1. Given immunosuppression, she was treated with Acyclovir
200 mg PO/NG Q12H for planned 5 day course (___)
# Lupus: Pt had joint pain, hair loss, skin lesions,
anemia/thrombocytopenia (though no evidence of hemolysis) which
was suspicious for lupus flare. However, she was evaluated by
rheumatology who did not find her symptoms consistent with a
flare, as most are chronic. Additinally, lab testing showed
stable C3/C4 and negative dsDNA. CRP was greater than assay, but
this was ___ setting of osteomyelitis so was not helpful. She was
continued on azathioprine and prednisone.
#Chest pain/troponin elevation: Now resolved. Pt had chest pain
prior to HD on ___, which quickly resolved. EKG did not show
any changes, and pt was able to tolerate HD. Initial trop 0.16
which is consistent with her baseline, but which trended up to
0.37. Her CK-MB is flat. She has had no further episodes of
chest pain. The troponin elevation could be due to demand from
tachycardia ___ setting of pain, etc, but seems unlikely to
represent a true NSTEMI given the lack of EKG changes, flat MB,
and low level troponin elevation. Vascular surgery requested
troponin as pre-operative testing for angiogram, so one was
drawn prior to discharge, and was elevated at 0.6. Of note, pt
did not have any symptoms of chest pain or anginal equivalents
at the time, this was drawn purely for pre-operative purposes.
As suspicion for myocardial ischemia is extremely low, she was
discharged.
#Normocytic Anemia: Pt with chronic anemia, but Hb has been
downtrending since admission from 10 to 7.4 today. No clinical
evidence of bleeding and hemolysis labs are normal. This is
likely multifactorial due to poor production ___ setting of ESRD
and myelosuppression from infection.
# Fistula stenosis s/p angioplasty: Pt had stenoses of her left
axillary, brachial, and basilic veins on fistulogram. Stenoses
improved after intervention.
#Left knee pain: pt was recently admitted to orthopedics service
at ___ on ___ for left knee pain. Tap was performed which
showed 19,560 WBC (81% neutrophils), negative gram stain and
culture, negative for crystals. Imaging showed findings c/w
progression of OA. As a result, OA is the most likely etiology,
though inflammation from lupus is possible though less likely.
Her pain was controlled.
====================
CHRONIC ISSUES
====================
# ESRD: due to lupus nephritis, gets HD ___ via fistula ___
LUE. Anuric.
- appreciate renal recs
- sevelamer, nephrocaps
# Hypertension: Initially had been hypotensive but now
hypertensive. Initially, lisinopril was held, but was restarted
prior to discharge.
# Chronic pain: Continued lidopatch, acetaminophen, dilaudid
====================
TRANSITIONAL ISSUES
====================
-Continue with acyclovir for total 5 day course ___ -
___ for treatment of HSV outbreak.
-Pt will be discharged on Vancomycin/Ceftazidime to be given
after hemodialysis for a total 6 week course (___).
Please pre-treat with tylenol ___ po x 1 and benadryl 25mg po
x1 30 mins prior to giving vancomycin.
-Check weekly CBC/diff, ESR, CRP, LFTs for monitoring of
antibiotics
-f/u ___ ___ clinic
-podiatry f/u scheduled with Dr. ___ EPO with HD given chronic anemia
-f/u with Rheumatology
-plan for LLE angiogram on ___ - time of procedure
not yet determined
# CODE STATUS: Full, would not want prolonged measures
# CONTACT: ___ (friend/hcp) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO DAILY:PRN headache/pain
2. Docusate Sodium 100 mg PO BID constipation
3. Labetalol 100 mg PO BID
4. Lidocaine 5% Patch 1 PTCH TD QAM
5. Lisinopril 80 mg PO DAILY
6. Nephrocaps 1 CAP PO DAILY
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. sevelamer CARBONATE 2400 mg PO TID W/MEALS
9. Azathioprine 50 mg PO DAILY
10. Epoetin Alfa 11,000 UNIT IV THREE TIMES A WEEK WITH HD
11. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation 2
puffs IH Q6H PRN cough
12. HYDROmorphone (Dilaudid) 2 mg PO Q8H:PRN pain
13. DiphenhydrAMINE 25 mg PO QHS:PRN insomnia
14. Unisom (doxylamine) (doxylamine succinate) 25 mg oral
QHS:PRN insomnia
15. PredniSONE 5 mg PO DAILY
Discharge Medications:
1. Azathioprine 50 mg PO DAILY
2. Docusate Sodium 100 mg PO BID constipation
3. Labetalol 100 mg PO BID
4. Lidocaine 5% Patch 1 PTCH TD QAM
5. Lisinopril 80 mg PO DAILY
6. Nephrocaps 1 CAP PO DAILY
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. PredniSONE 5 mg PO DAILY
9. sevelamer CARBONATE 2400 mg PO TID W/MEALS
10. Epoetin Alfa 11,000 UNIT IV THREE TIMES A WEEK WITH HD
11. Unisom (doxylamine) (doxylamine succinate) 25 mg oral
QHS:PRN insomnia
12. ProAir HFA (albuterol sulfate) 90 mcg/actuation INHALATION 2
PUFFS IH Q6H PRN cough
13. CefTAZidime 1 g IV POST HD (___)
Plan for 6 week course (___).
14. Acetaminophen 1000 mg PO DAILY:PRN headache/pain
15. HYDROmorphone (Dilaudid) 2 mg PO Q8H:PRN pain
16. Acyclovir 200 mg PO Q12H
course ___.
RX *acyclovir 200 mg 1 capsule(s) by mouth every twelve (12)
hours Disp #*5 Capsule Refills:*0
17. Calcitriol 0.75 mcg PO 3X/WEEK (___)
RX *calcitriol 0.25 mcg 3 capsule(s) by mouth qHD Disp #*36
Capsule Refills:*0
18. Vancomycin 750 mg IV HD PROTOCOL
Plan for 6 week course (___).
19. Acetaminophen 650 mg PO 3X/WEEK (___) Duration: 1 Dose
Please give ___ minutes prior to giving vancomycin
20. DiphenhydrAMINE 25 mg PO 3X/WEEK (___)
Please give ___ min prior to vancomycin
21. Outpatient Lab Work
ICD-9: 730 Osteomyelitis
Check weekly CBC/diff, ESR, CRP, LFTs.
Please send results to: ___ CLINIC - FAX: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
-osteomyelitis
SECONDARY DIAGNOSIS:
-peripheral vascular disease
-SLE
-end stage renal disease secondary to lupus nephritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was our pleasure to care for you during your recent
hospitalization at ___. You
were hospitalized due to a bone infection (called osteomyelitis)
___ your left first and fifth toes. We treated you with
antibiotics, and you were evaluated by the podiatry and vascular
surgery teams.
You should continue on the antibiotics (vancomycin and
ceftazidime, dosed with hemodialysis) for at least 6 weeks.
While you were here, you had an outbreak of herpes on your chin.
You should continue to take the acyclovir for a total of 5 days.
The last day will be ___.
You will be called about a time for the angiogram next ___
(___).
We wish you all the best!
-Your ___ Team
Followup Instructions:
___
|
10213338-DS-53 | 10,213,338 | 28,193,598 | DS | 53 | 2165-09-26 00:00:00 | 2165-09-27 14:44:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Biaxin / Vancomycin / Haldol / Heparin Agents / Flagyl / Sulfite
/ Sulfa (Sulfonamide Antibiotics) / CellCept / aspirin
Attending: ___.
Chief Complaint:
L toe abscess
Major Surgical or Invasive Procedure:
1. Ultrasound-guided access to the right common femoral
artery and placement of a ___ sheath.
2. Selective catheterization of the left popliteal artery,
___ order vessel.
3. Left lower extremity angiogram.
4. Balloon angioplasty of the left peroneal artery stenosis
with a 2 mm x 20 mm apex balloon.
5. Balloon angioplasty of a popliteal artery stenosis with
a 3 mm x 40 mm Amphirion balloon.
History of Present Illness:
PCP: Dr. ___.
CC: L ___ abscess
HPI: ___ woman with ESRD on HD (TTS) due to lupus nephritis,
failed
kidney transplant (on azathioprine), HTN, HFpEF, atypical chest
pain, chronic abdominal pain, recurrent rectal abscess, h/o TB,
TTP, HIT, DCIS, adrenal crisis, also known VRE and MRSA carrier,
h/o osteo s/p L great hallux amputation and 5 hallux amputation
in ___ seen in ___ clinic this AM and noted to have
abscess to hallux amp site that was I&D'ed cultures sent. She
began having pain at the site of the L great hallux amputation 3
days ago. Abscess was drained and culture was taken. She was
referred for admission for IV antibiotics. per podiatry will
likely require revision of amp site during this admission
no fevers/chills. She reports banging her foot against her
computer desk 2 days ago. ___ pain in foot after IV dialudid. +
R upper quadrant pain x ___ which improves with eating food
and ice. No nausea or vomiting. No diarrhea. + bloating. She
thinks that the bloating may be because she needs HD today.
In ER: (Triage Vitals:5 98.8 79 163/69 16 100% RA )
Meds Given: ___ 21:24 IV Ampicillin-Sulbactam 3 g
___
___ 21:27 IV HYDROmorphone (Dilaudid) .5 mg ___
___ 23:07 IV Vancomycin 1000 mg ___
REVIEW OF SYSTEMS:
CONSTITUTIONAL: [X] All normal
HEENT: [X] All normal
RESPIRATORY: [X] All normal
CARDIAC: [X] All normal
GI: As per HPI
GU: [X] All normal
SKIN: [+] chronic rash x ___ years of unknown etiology
MUSCULOSKELETAL: [+] Per HPI
NEURO: [X] All normal
ENDOCRINE: [X] All normal
HEME/LYMPH: [+] easy bleeding
PSYCH: [X] All normal
All other systems negative except as noted above
Past Medical History:
PAST MEDICAL HISTORY:
- Presumed Miliary TB: concerning liver/spleen/kidney lesions on
CT, AFT smear neg x3 and MTB direct amplification neg, started
on RIPE
- SLE: Followed by Dr. ___ manifestation =
arthralgia in hips and knees
- ESRD: Secondary to lupus nephritis, s/p failed transplant w/
subsequent nephrectomy, HD on ___.
- Skin biopsy ___ with pathology suggestive of vasculitis
- Cardiomyopathy - EF 60-65% (___). Severe diastolic
dysfunction.
- H/o chest pain: H/o cardiomyopathy with nl cath in ___, nl
P-MIBI in ___. Evaluated by Dr. ___ in ___ and diagnosed
with atypical CP likely GI (2- Chronic abdominal pain: S/p
cholecystectomy in ___,
pancreatitis ___ pancreatic divisum, partial SBO in ___,
epiploic appendagitis in ___
- Hypertension: On beta blocker, ACE I, CCB.
- H/o dyslipidemia: ___ lipid panel wnl.
- Thrombocytopenia: H/o HIT with positive PF4 in ___ but neg on
follow-up, h/o TTP in ___.
- Anemia: On epoetin at HD, h/o autoimmune hemolytic anemia,
positive anti-E Ab against RBC, thalassemia trait based on
microcytic indices and peripheral smear review by Dr. ___.
- Bronchiolitis obliterans-organizing pneumonia
- H/o recurrent rectal abscesses first noted ___, recurrent
in ___ and a drain was left in, ___: ultrasound negative,
CT ___ no rectal abscess; drained by Dr. ___ in
___ who felt this was resolved when he saw her in ___
- DCIS and atypical ductal hyperplasia ___ s/p lumpectomy.
- Osteoporosis
- H/o avascular necrosis of left knee bil humeral head.
- H/o adrenal crisis in ___.
- H/o seizure disorder.
- H/o uterine fibroid in ___, s/p hysterectomy for excessive
bleeding.
- Raynaud's phenomenon
- hip & thigh pain, likely sciatica, being evaluated by ortho
- folliculitis
Social History:
___
Family History:
Mother died of lupus in her ___ (died of an MI).
Brother with EtOH abuse.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T 97.9 P 77 BP 159/65 RR SaO2 100% on RA
GEN: Very pleasant, NAD, comfortable appearing
HEENT: ncat anicteric MMM
NECK: supple
CV: s1s2 rr no m/r/g
RESP: b/l ae no w/c/r
ABD: +bs, soft, RUQ tenderness, ? + hepatomegaly
EXTR:faint 1+ DPP pulse of the L foot
L great toe amputation surgical site with macerated skin
present, slightly malodorous, tender to the touch, no pus
expressed
L upper extremity fistula with palpable thrill and audible bruit
DERM: multiple macular hyperpigmented lesions
NEURO: face symmetric speech fluent
PSYCH: calm, cooperative
DISCHARGE PHYSICAL EXAM
VS - 98.0 (98.8), 127/52, 62, 20, 98% on RA
General: NAD, pleasant
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, III/VI systolic murmur loudest at
LL sternal border
Lungs: Crackles at the bases, decreased with several deep
respirations but still present, no wheezes, rales, rhonchi
Abdomen: Liver extends 2 finger breadths below costal margin.
TTP in RUQ, epigastrium. No tenderness over rest of abdomen.
Non-distended, no rebound, no fluid wave
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis or edema; left
foot in dressing, clean and dry. Stitches over L first toe, no
signs of erythema, pus or drainage. exquisitely tender to light
palpation. Scattered are of hyperpigmentation noted on BUE and
BLE. LUE AVF with palpable thrill.
Neuro: CNII-XII intact, moving all extremities, speech fluent,
gait deferred.
Pertinent Results:
ADMISSION LABS
==============
___ 06:12PM LACTATE-2.5*
___ 05:55PM GLUCOSE-105* UREA N-95* CREAT-10.4*#
SODIUM-139 POTASSIUM-6.0* CHLORIDE-91* TOTAL CO2-25 ANION
GAP-29*
___ 05:55PM estGFR-Using this
___ 05:55PM WBC-4.4 RBC-3.75*# HGB-11.4# HCT-36.7# MCV-98
MCH-30.4 MCHC-31.1* RDW-21.2* RDWSD-75.0*
___ 05:55PM NEUTS-70.6 LYMPHS-12.4* MONOS-12.2 EOS-2.3
BASOS-0.5 NUC RBCS-0.7* IM ___ AbsNeut-3.14# AbsLymp-0.55*
AbsMono-0.54 AbsEos-0.10 AbsBaso-0.02
___ 05:55PM PLT COUNT-126*#
PERTINENT LABS
==============
___ 06:30AM BLOOD ALT-22 AST-28 AlkPhos-281* TotBili-0.4
___ 06:30AM BLOOD Lipase-62*
___ 06:30AM BLOOD CRP-4.0
___ 06:12PM BLOOD Lactate-2.5*
SED RATE BY MODIFIED 17 < OR = 30 mm/h
___
DISCHARGE LABS
==============
___ 06:45AM BLOOD WBC-3.9* RBC-3.25* Hgb-9.4* Hct-30.8*
MCV-95 MCH-28.9 MCHC-30.5* RDW-20.2* RDWSD-71.3* Plt ___
___ 08:00AM BLOOD ___ PTT-34.6 ___
___ 06:45AM BLOOD Glucose-108* UreaN-81* Creat-11.1*#
Na-132* K-5.4* Cl-88* HCO3-24 AnGap-25*
___ 06:45AM BLOOD Calcium-9.4 Phos-6.2* Mg-2.4
IMAGING
=======
L foot X ray:
Status post amputations of the first distal phalanx and fifth
toe at the level of the base of the proximal phalanx without
definite cortical destruction to suggest osteomyelitis. Soft
tissue swelling and probable subcutaneous gas is noted in the
region of the amputation sites.
RECOMMENDATION(S): Please note that MRI would be a more
sensitive examination to detect for the presence of
osteomyelitis.
MICROBIOLOGY
============
No growth in cultures x4
No growth in pharynx or hallux tissue
No growth in wound swab
Brief Hospital Course:
___ woman with ESRD on HD (TTS) due to lupus nephritis, failed
kidney transplant, HTN, diastolic CHF, chronic abdominal pain,
recurrent rectal abscess, TTP, HIT, DCIS, adrenal crisis, also
known VRE and MRSA carrier who presented with an infected L
hallux amputation site and concern for osteomyelitis. She
underwent amputation revision ___, with no evidence of osteo
in either resected bone or residual margin. While in the
hospital she was treated with vancomycin and unasyn with plan to
continue vancomycin per HD protocol as an outpatient. Given
surgical margins which were negative osteo, patient will be
discharged on two weeks of vancomycin for soft tissue surgical
site infection. While inpatient, she continued to receive
dialysis ___. Vascular surgery was consulted for evaluation
of her peripheral vascular disease and she underwent angiogram
___ with stenting x2.
Due to recent left hallux infection and revision amputation,
transplant surgery will wait to place interpositional AV graft
until patient finishes outpatient antibiotic treatment.
# ACUTE OSTEOMYELITIS: s/p left partial hallux and fifth toe
amputation in ___ for ostemyelitis. Tissue culture with
coag negative staph at that time. Patient was treated with
course of IV abx. Patient was seen on ___ by podiatry for
follow up and there was concern for reccurent infection of left
hallux due to purulence on exam. She was admitted to medicine
and started on vanc/unasyn. Prelim wound culture from ___
negative. Patient underwent revision of partial hallux
amputation on ___ by podiatry. Treated initially with
vanc/unasyn. Examination of surgical specimen was negative for
osteo, and there was no growth in any tissue, swab, or blood
cultures. She was transitioned vanc with dialysis for 14 days
(start: ___, last day after dialysis ___.
# ESRD: Secondary to lupus nephritis. Patient continued on HD
T, THurs, ___ through LUE AVF. Per transplant surgery, patient
will need revision of graft outpatient after antibiotics are
completed.
# PVD. Vascular surgery consulted for concern of non-healing
surgical wounds. Non-invasive arterial studies showing
aorto-bi-iliac & distal b/l tibial disease. Angiogram ___ was
conducted, with angioplasty x2; patient will continue on
atorvastatin 40mg, ASA 81 for life and Plavix for 30 days.
# RUQ pain: Patient with known hepatomegaly of many years with
multiple hypodensities. Unclear etiology at this time. RUQ U/S
within normal limits and with patent portal flow. ALT/AST
continue to be within normal limits.
# Pancytopenia: stable. Seen by heme/onc in ___. Thought to
be secondary to SLE / SLE meds with anemia ___ CKD and chronic
infections.
# Chronic HSV Infection: Given immunosupression and ID recs in
___, patient should be on acyclovir 200mg q12h. Patient had
been taking it PRN but this was changed to standing this
admission.
# Systemic Lupus Erythematosus: continued 5mg of prednisone,
plaquenil and azathioprine
# Hypertension: Continued home doses of lisinopril and
labetalol.
# HFpEF: Patient continued to be euvolemic and asymptomatic on
admission. Volume was managed in HD.
TRANSITIONAL ISSUES
-Plan for 2 weeks of vancomycin in HD: vancomycin will be dosed
per HD protocol; plan for 2 week total course through ___
(last dose should be given ___ following dialysis).
-Patient will follow up with vascular surgery regarding her
non-healing surgical site and peripheral vascular disease
-Patient will follow up with transplant surgery after completion
of antibiotics for placement of interpositional AV graft or
"jump graft".
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Labetalol 100 mg PO BID
2. Lisinopril 80 mg PO DAILY
3. PredniSONE 5 mg PO DAILY
4. Hydroxychloroquine Sulfate 200 mg PO DAILY
5. sevelamer CARBONATE 3200 mg PO TID W/MEALS
6. Docusate Sodium 100 mg PO BID
7. Nephrocaps 1 CAP PO DAILY
8. HYDROmorphone (Dilaudid) 1 mg PO Q6H:PRN pain
9. Acetaminophen 1000 mg PO ONCE
10. Acyclovir 200 mg PO Q12H PRN outbreaks
Discharge Medications:
1. Vancomycin 1000 mg IV HD PROTOCOL
For outpatient HD. Duration 2 weeks with option for longer
pending podiatry appointment in 2 weeks.
RX *vancomycin 1 gram Per HD protocol mg IV with hemodialysis
Disp #*4 Vial Refills:*0
2. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily in the evening
Disp #*30 Tablet Refills:*0
3. sevelamer CARBONATE 3200 mg PO TID W/MEALS
4. PredniSONE 5 mg PO DAILY
5. Nephrocaps 1 CAP PO DAILY
6. Lisinopril 80 mg PO DAILY
7. Labetalol 100 mg PO BID
8. Hydroxychloroquine Sulfate 200 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily
as needed Disp #*30 Packet Refills:*0
11. Azathioprine 50 mg PO DAILY
12. Acyclovir 200 mg PO Q12H
13. Acetaminophen 650 mg PO Q8H pain/fever
RX *acetaminophen 325 mg 2 tablet(s) by mouth every 8 hours Disp
#*60 Tablet Refills:*0
14. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
15. Calcitriol 0.75 mcg PO WITH HEMODIALYSIS
RX *calcitriol 0.25 mcg 3 capsule(s) by mouth with dialysis Disp
#*30 Capsule Refills:*0
16. Clopidogrel 75 mg PO DAILY
You should take a total of 30 days.
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
17. Unisom Sleepgels (diphenhydrAMINE HCl) 50 mg oral DAILY:PRN
sleep
18. HYDROmorphone (Dilaudid) 2 mg PO Q3H:PRN pain
RX *hydromorphone 2 mg 1 tablet(s) by mouth every 3 hours as
needed Disp #*24 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Left First Toe Abscess
End Stage Renal Disease
Peripheral Vascular Disease
Right Upper Quadrant Pain
SECONDARY DIAGNOSES:
Pancytopenia
Systemic Lupus Erythematosus
Hypertension
Chronic Diastolic Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
You were admitted to ___ for concern of infection in your left
great toe. You had a revision of your previous surgery and were
treated with antibiotics. You also had an angiogram procedure.
You also received dialysis while you were here. Physical therapy
evaluated you and recommended continuing physical therapy at
home.
Moving forward, you will continue to be treated with antibiotics
at dialysis. Your antibiotics may be adjusted per the
recommendation of your podiatrists. Please continue to take all
medications as prescribed and attend all scheduled follow up
appointments. Do not hesitate to seek medical attention if you
feel fever/chills, nausea/vomiting, or concerning changes in
your operated toe such as discoloration, worsening pain, or
drainage.
Wishing you the best of health,
Your ___ team
Followup Instructions:
___
|
10213338-DS-55 | 10,213,338 | 24,846,149 | DS | 55 | 2166-01-07 00:00:00 | 2166-01-14 20:45:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Biaxin / Vancomycin / Haldol / Heparin Agents / Flagyl / Sulfite
/ Sulfa (Sulfonamide Antibiotics) / CellCept / aspirin
Attending: ___
Chief Complaint:
Chest pain, SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female with history of lupus, peripheral vascular
disease s/p toe amputations, ESRD on HD TThS, and atypical chest
pain who presents with chest pain and shortness of breath for
the last week. Pt reports first noticing the pain 4 days PTA on
her way into dialysis. Her discomfort is primarily that of
shortness of breath. It happens with exertion. The chest pain is
left sided pain without radiation. It is worse with lying flat
and better with sitting up. Denies jaw, arm, or back pain. It is
not pleuritis. It has been noted at HD and is improved with SL
Nitroglycerin. Throughout the week the pain has gotten
progressively worse. On the day prior to admission she has a
temporary HD catheter removed (placed during revisions of AV
fistula). On day of admission Ms. ___ completed a session,
but the chest pain worsened even more at rest prompting her to
come to the ED. Of note, patient recently stopped Imuran in the
setting of not having clinical improvement while on it. She
denies orthopnea or PND. Denies sick contacts. Denies recent
viral illness.
On arrival to the ED, she had an ECG done that showed STD
laterally in the setting of LVH. Bedside ECHO with no effusion,
Trop 0.35 (renal failure- baseline), MB 8 (baseline ___,
lactate 3.9 i/s/o ESRD, recheck at 2.1. Her cardiac markers were
at baseline. BNP actually lowest it has been with our assay.
Cards fellow evaluated in the ED and said that this picture is
not c/w ACS.
Patient was given:
SL Nitroglycerin SL .4 mg, PO Aspirin 324 mg, IV DRIP
Nitroglycerin, Started .14 mcg/kg/min and subsequently stopped.
PO Aluminum-Magnesium Hydrox.-Simethicone 30 mL, PO Donnatal 10
mL, PO Lidocaine Viscous 2% 10 mL.
On Transfer Vitals were: 98.2 78 126/70 15 100% RA
On arrival to the floor: Pt reports that she feels improved
since presentation. She does not have any chest pain or SOB
currently.
Past Medical History:
PAST MEDICAL HISTORY:
- Presumed Miliary TB: concerning liver/spleen/kidney lesions on
CT, AFT smear neg x3 and MTB direct amplification neg, started
on RIPE
- SLE: Followed by Dr. ___ manifestation =
arthralgia in hips and knees
- ESRD: Secondary to lupus nephritis, s/p failed transplant w/
subsequent nephrectomy, HD on ___.
- Skin biopsy ___ with pathology suggestive of vasculitis
- Cardiomyopathy - EF 60-65% (___). Severe diastolic
dysfunction.
- H/o chest pain: H/o cardiomyopathy with nl cath in ___, nl
P-MIBI in ___. Evaluated by Dr. ___ in ___ and diagnosed
with atypical CP likely GI (2- Chronic abdominal pain: S/p
cholecystectomy in ___,
pancreatitis ___ pancreatic divisum, partial SBO in ___,
epiploic appendagitis in ___
- Hypertension: On beta blocker, ACE I, CCB.
- H/o dyslipidemia: ___ lipid panel wnl.
- Thrombocytopenia: H/o HIT with positive PF4 in ___ but neg on
follow-up, h/o TTP in ___.
- Anemia: On epoetin at HD, h/o autoimmune hemolytic anemia,
positive anti-E Ab against RBC, thalassemia trait based on
microcytic indices and peripheral smear review by Dr. ___.
- Bronchiolitis obliterans-organizing pneumonia
- H/o recurrent rectal abscesses first noted ___, recurrent
in ___ and a drain was left in, ___: ultrasound negative,
CT ___ no rectal abscess; drained by Dr. ___ in
___ who felt this was resolved when he saw her in ___
- DCIS and atypical ductal hyperplasia ___ s/p lumpectomy.
- Osteoporosis
- H/o avascular necrosis of left knee bil humeral head.
- H/o adrenal crisis in ___.
- H/o seizure disorder.
- H/o uterine fibroid in ___, s/p hysterectomy for excessive
bleeding.
- Raynaud's phenomenon
- hip & thigh pain, likely sciatica, being evaluated by ortho
- folliculitis
Social History:
___
Family History:
Mother died in her ___, had SYSTEMIC LUPUS ERYTHEMATOSUS, END
STAGE RENAL DISEASE, CORONARY ARTERY DISEASE
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T=98.7 BP= 154/81 HR= 74 RR= 18 O2 sat= 100RA
GENERAL: Thin appearing woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 7 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. ___ systolic murmur best heard at the
apex with radiation to axilla. No thrills, lifts. No S3 or S4.
No friction rub.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits. bandage overlying
right foot at site of amputation is c/d
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses are diminished but symmetric.
DISCHARGE PHYSICAL EXAM
VS: T=98.5 BP= 158/88 HR= 78 RR= 18 O2 sat= 100RA
GENERAL: Thin appearing woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa..
NECK: Supple with JVP of 7 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. ___ systolic murmur best heard at the
apex with radiation to axilla. No thrills, lifts. No S3 or S4.
No friction rub.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits. bandage overlying
right foot at site of amputation is c/d
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses are diminished but symmetric.
Pertinent Results:
ADMISSION LABS:
---------------
___ 12:15PM BLOOD WBC-4.5 RBC-3.73* Hgb-10.4* Hct-33.4*
MCV-90 MCH-27.9 MCHC-31.1* RDW-20.0* RDWSD-63.6* Plt ___
___ 12:15PM BLOOD Neuts-61 Bands-0 ___ Monos-14*
Eos-4 Baso-0 Atyps-2* ___ Myelos-0 NRBC-1* AbsNeut-2.75
AbsLymp-0.95* AbsMono-0.63 AbsEos-0.18 AbsBaso-0.00*
___ 12:15PM BLOOD Glucose-69* UreaN-21* Creat-3.9*# Na-141
K-3.6 Cl-95* HCO3-27 AnGap-23*
PERTINENT LABS:
---------------
___ 12:15PM BLOOD CK-MB-8 ___
___ 12:15PM BLOOD cTropnT-0.35*
___ 05:00PM BLOOD cTropnT-0.43*
___ 06:10AM BLOOD cTropnT-0.43*
___ 12:15PM BLOOD Albumin-4.6 Calcium-9.6 Phos-1.9*# Mg-2.1
___ 05:00PM BLOOD dsDNA-NEGATIVE
___ 05:00PM BLOOD CRP-3.9
___ 05:00PM BLOOD C3-130 C4-44*
___ 12:30PM BLOOD Lactate-3.9*
___ 06:43PM BLOOD Lactate-2.1*
DISCHARGE LABS:
---------------
___ 06:10AM BLOOD WBC-3.3* RBC-3.53* Hgb-10.1* Hct-32.5*
MCV-92 MCH-28.6 MCHC-31.1* RDW-19.9* RDWSD-65.4* Plt ___
___ 06:10AM BLOOD Glucose-91 UreaN-43* Creat-6.6*# Na-140
K-5.6* Cl-96 HCO3-30 AnGap-20
___ 04:33PM BLOOD Na-137 K-4.6
STUDIES:
---------
___ CXR
FINDINGS:
Single upright view of the chest provided.
There is no focal consolidation, effusion, or pneumothorax.
Streaky left
lower lobe atelectasis is similar to prior. Moderate
cardiomegaly is similar to prior. Imaged osseous structures are
intact. No free air below the right hemidiaphragm is seen.
Aortic arch calcification appears similar to prior.
IMPRESSION:
No acute intrathoracic process.
Brief Hospital Course:
___ year old female with history of lupus, peripheral vascular
disease s/p toe amputations, ESRD on HD TThS, and atypical chest
pain who presents with chest pain and shortness of breath for
the last week.
# Chest pain: Pt reports first noticing the pain 4 days PTA on
her way into dialysis. Her discomfort is primarily that of
shortness of breath. It happens with exertion. The chest pain is
left sided pain without radiation. It has been noted at HD and
is improved with SL Nitroglycerin. Throughout the week the pain
has gotten progressively worse, though improved after dialysis
sessions. On arrival to the ED, she had an ECG done that showed
STD laterally in the setting of LVH. Bedside ECHO with no
effusion, Trop 0.35 (renal failure- baseline), MB 8 (baseline
___, lactate 3.9 i/s/o ESRD, recheck at 2.1. Her cardiac
markers were at baseline. BNP actually lowest it has been with
our assay. Cards fellow evaluated in the ED and said that this
picture is not c/w ACS. Her symptoms quickly improved with
nitroglycerin and GI cocktail. She was asymptomatic on floor.
Because of her clinical stability but exertional pain history
and high risk of CAD it was decided to pursue an outpatient work
up for CAD/angina. She was referred to an outpatient
cardiologist and will undergo a stress TTE.
Chronic:
# ESRD: Secondary to lupus nephritis. HD T, THurs, ___ through
LUE AVF.
# Pancytopenia/anemia: Improved since last admission. Thought to
be secondary to SLE / SLE meds with anemia ___ CKD and chronic
infections.
# Chronic HSV Infection: Pt did not take acyclovir as she was
not symptomatic
# Systemic Lupus Erythematosus: continued 5mg of prednisone,
plaquenil
# Hypertension: Continued home doses of lisinopril and
labetalol.
Transitional issues:
--------------------
- C3, C4, ESR and DsDNA pending at time of discharge as part of
lupus flair workup.
- Pt was started on Imdur as anti anginal, please uptitrate as
necessary
- Pt was ordered for outpatient pharmacological stress echo
- Pt will follow up with cardiology. Referred to Dr. ___.
Code: Full
Contact: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 10 mg PO DAILY
2. Acetaminophen 650 mg PO Q6H:PRN pain/fever
3. Lisinopril 80 mg PO DAILY
4. Hydroxychloroquine Sulfate 200 mg PO DAILY
5. Lidocaine 5% Patch 1 PTCH TD QAM Pain
6. ammonium lactate 12 % topical BID
7. Labetalol 100 mg PO BID
8. Docusate Sodium 100 mg PO BID
9. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
10. doxylamine succinate 25 mg oral QHS
11. Clindamycin 600 mg PO Frequency is Unknown
12. Acyclovir 200 mg PO Q12H
13. HYDROmorphone (Dilaudid) 2 mg PO Q8H:PRN Severe bone pain
14. sevelamer CARBONATE 2400 mg PO TID W/MEALS
15. Pantoprazole 40 mg PO Q24H
16. Collagenase Ointment 1 Appl TP DAILY
17. Nephrocaps 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain/fever
2. Acyclovir 200 mg PO Q12H
3. Collagenase Ointment 1 Appl TP DAILY
4. Docusate Sodium 100 mg PO BID
5. HYDROmorphone (Dilaudid) 2 mg PO Q8H:PRN Severe bone pain
6. Hydroxychloroquine Sulfate 200 mg PO DAILY
7. Labetalol 100 mg PO BID
8. Lidocaine 5% Patch 1 PTCH TD QAM Pain
9. Lisinopril 80 mg PO DAILY
10. Nephrocaps 1 CAP PO DAILY
11. Pantoprazole 40 mg PO Q24H
12. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
13. PredniSONE 10 mg PO DAILY
14. sevelamer CARBONATE 2400 mg PO TID W/MEALS
15. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
16. ammonium lactate 12 % topical BID
17. Clindamycin 600 mg PO BEFORE DENTAL PROCEDURES
18. doxylamine succinate 25 mg oral QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Chest pain syndrome
Secondary diagnosis:
End Stage Renal Disease on hemodialysis
Systemic lupus erythematosus
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 Ms. ___,
You were admitted to ___ for chest pain. Your chest pain
improved with minimal intervention. We monitored your labs and
believe that you are safe to go home. However, we still have not
figured out why you had chest pain. We are worried that it might
be your heart. Because of this we ordered a stress test, which
can help to tell us if your heart is causing your symptoms. We
also will call you with an appointment to follow up with a
cardiologist.
Thank you for allowing us to be part of your care.
Sincerely,
Your ___ team
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10213338-DS-56 | 10,213,338 | 22,160,556 | DS | 56 | 2166-02-23 00:00:00 | 2166-02-23 14:06:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Biaxin / Vancomycin / Haldol / Heparin Agents / Flagyl / Sulfite
/ Sulfa (Sulfonamide Antibiotics) / CellCept / aspirin
Attending: ___.
Chief Complaint:
Episode of VTach on telemetry
Major Surgical or Invasive Procedure:
___: DES to LAD and Diagonal. ___ years Plavix, lifelong 81
mg aspirin
___: Extended right colectomy with temporary abdominal
closure.
___: Washout and LOA, End ileal-to-side transverse
colostomy, double-layer, hand-sewn with Closure of fascia with
16 x 8 cm biologic mesh with primary closure of skin over the
biologic mesh.
___: Exploratory laparotomy with resection of
ileotransverse anastomosis and ileostomy and primary fascia
closure with flaps.
History of Present Illness:
___ with a complicated past medical history including SLE, ESRD
___ lupus nephritis s/p failed transplant) with HD, raynauds
vasculiits (on skin biopsy), cardiomyopathy with clean cath
___, and P-MIBI in ___, Chronic abdominal pain s/p
cholecystectomy in ___, pancreatitis ___ pancreatic divisum,
HTN, dyslipidemia, thrombocytopenia, severe PVD and L toe
amputation who presents with recurrent chest pain.
Patient noted having small amount of chest pain this morning,
and during dialysis it significantly worsened. She describes it
a sharp, shooting chest pain, ___, that radiates to her back.
Denies radiation to her arm or neck, no claudication with
chewing or changes in vision. Denies nausea/vomiting or diuresis
associated. She does note that her chest pain is worse with
palpation (though describes this as a different pain) and that
deep breaths exacerbate her current chest pain. The pain is
worse now when lying down, and slightly improved leaning
forward. Of note, patient was able to complete her dialysis. She
was given x1 sublingual nitro with some benefit, but was not
given follow up doses and was instructed to come to the ED.
The patient was most recently admitted to ___ service for
evaluation of atypical chest pain, was started on IMDUR 60 and
discharged with plan for stress test next week. Unfortunately
the patent was unable to fill though was unable to fill
prescription before jhaving to return
In the ED, initial vitals were Pain 5, T 99.6, pulse 132, BP
96/66, R 16 and 100%RA. Physical exam was notable for Left
sternal border systolic murmur, chest pain with palpation, and
RUQ abdominal pain. While on telemetry the patient was noted to
have new onset a-fib and episode of Ventricular Tachycardia
confirmed by EP. Vtach and afib ultimately self resolved. CTA
chest showed no evidence of PE, or aortic dissection, but was
notable for mild thickening of the mid and distal esophageal
wall appears to been present on prior study and may relate to
gastritis. She was given full dose aspirin 324, GI cocktail
with some benefit, dialudid, 1L NS, and 40meq PO potassium
before being sent to the CCU.
On arrival to the CCU patient reported still having chest pain,
and received 0.5mg of dilaudid with good effect.
Denied any fevers, chills, nausea/vomiting, shortness of breath,
diarrhea, does endorse constipation (last BM ___, hard, small),
dysuria, or new rashes.
Past Medical History:
- Presumed Miliary TB: concerning liver/spleen/kidney lesions on
CT, AFT smear neg x3 and MTB direct amplification neg, started
on RIPE
- SLE: Followed by Dr. ___ manifestation =
arthralgia in hips and knees
- ESRD: Secondary to lupus nephritis, s/p failed transplant w/
subsequent nephrectomy, HD on ___.
- Skin biopsy ___ with pathology suggestive of vasculitis
- Cardiomyopathy - EF 60-65% (___). Severe diastolic
dysfunction.
- H/o chest pain: H/o cardiomyopathy with nl cath in ___, nl
P-MIBI in ___. Evaluated by Dr. ___ in ___ and diagnosed
with atypical CP likely GI (2- Chronic abdominal pain: S/p
cholecystectomy in ___, pancreatitis ___ pancreatic divisum,
partial SBO in ___, epiploic appendagitis in ___
- Hypertension: On beta blocker, ACE I, CCB.
- H/o dyslipidemia: ___ lipid panel wnl.
- Thrombocytopenia: H/o HIT with positive PF4 in ___ but neg on
follow-up, h/o TTP in ___.
- Anemia: On epoetin at HD, h/o autoimmune hemolytic anemia,
positive anti-E Ab against RBC, thalassemia trait based on
microcytic indices and peripheral smear review by Dr. ___.
- Bronchiolitis obliterans-organizing pneumonia
- H/o recurrent rectal abscesses first noted ___, recurrent
in ___ and a drain was left in, ___: ultrasound negative,
CT ___ no rectal abscess; drained by Dr. ___ in
___ who felt this was resolved when he saw her in ___
- DCIS and atypical ductal hyperplasia ___ s/p lumpectomy.
- Osteoporosis
- H/o avascular necrosis of left knee bil humeral head.
- H/o adrenal crisis in ___.
- H/o seizure disorder.
- H/o uterine fibroid in ___, s/p hysterectomy for excessive
bleeding.
- Raynaud's phenomenon
- hip & thigh pain, likely sciatica, being evaluated by ortho
- folliculitis
Social History:
___
Family History:
Mother died of lupus in her ___ (died of an MI).
Brother with EtOH abuse.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 98.4 84 117/61(75) 15 98% RA
General: NAD, pleasant
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, III/VI systolic murmur loudest at
LL sternal border; TTP at left sternal border
Lungs: Crackles at the bases, decreased with several deep
respirations but still present, no wheezes, rales, rhonchi
Abdomen: Liver extends 2 finger breadths below costal margin.
TTP in RUQ, epigastrium. No tenderness over rest of abdomen.
Non-distended, no rebound, no fluid wave
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis or edema; left
foot in dressing, clean and dry. no signs of erythema, pus or
drainage, tender to palpation.
Neuro: CNII-XII intact, moving all extremities, speech fluent,
gait deferred.
DISCHARGE PHYSICAL EXAMINATION:
VS 98.8 HR ___ 139/73-149/78 RR 18 O2 100%RA WT:
A&O
wound vac in place
no edema
Left AVF +bruit/thrill
Pertinent Results:
LABORATORY STUDIES ON ADMISSION
===============================================
___ 04:30PM BLOOD WBC-4.1 RBC-3.53* Hgb-10.1* Hct-31.5*
MCV-89 MCH-28.6 MCHC-32.1 RDW-19.9* RDWSD-64.2* Plt Ct-95*
___ 04:30PM BLOOD Neuts-72.4* Lymphs-15.8* Monos-9.1
Eos-2.0 Baso-0.2 Im ___ AbsNeut-2.94 AbsLymp-0.64*
AbsMono-0.37 AbsEos-0.08 AbsBaso-0.01
___ 04:30PM BLOOD ___ PTT-31.0 ___
___ 04:30PM BLOOD Glucose-120* UreaN-28* Creat-4.7*# Na-142
K-3.3 Cl-96 HCO3-33* AnGap-16
___ 04:30PM BLOOD ALT-37 AST-47* CK(CPK)-90 AlkPhos-354*
TotBili-0.3
___ 04:30PM BLOOD Lipase-67*
___ 04:30PM BLOOD CK-MB-4 ___
___ 04:30PM BLOOD cTropnT-0.64*
___ 04:30PM BLOOD Calcium-8.8 Phos-2.5*# Mg-2.1
___ 04:36PM BLOOD K-3.3
OTHER PERTINENT LABORATORY STUDIES
===============================================
DISCHARGE LABORATORY STUDIES
===============================================
MICROBIOLOGY
===============================================
___ 12:14 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
IMAGING/REPORTS
===============================================
___ CTA CHEST
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Bronchial mucoid impaction in the left lower lobe with
associated
subsegmental atelectasis.
3. Mild thickening of the mid and distal esophageal wall appears
to been
present on prior study and may relate to esophagitis.
4. Tiny pleural effusions.
5. Persistent sclerosis of the imaged left humeral head may
reflect AVN.
6. Mild cardiomegaly.
___ TTE
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. Overall left ventricular
systolic function is mildly depressed (LVEF= 45 %). [Intrinsic
left ventricular systolic function is likely more depressed
given the severity of valvular regurgitation.] Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are mildly
thickened (?#). There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. There is mild functional mitral stenosis (mean
gradient 5mmHg) due to mitral annular calcification. An
eccentric, posteriorly directed jet of severe (4+) mitral
regurgitation is seen. Moderate to severe [3+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. [In the setting of at least moderate to severe
tricuspid regurgitation, the estimated pulmonary artery systolic
pressure may be underestimated due to a very high right atrial
pressure.] There is a trivial/physiologic pericardial effusion.
IMPRESSION: Mildly depressed left ventricular systolic
function. Increased left ventricular filling pressure. Severe
mitral regurgitation. Moderate to severe tricuspid
regurgitation. Severe pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of ___,
the left ventricular systolic function is worse. The severity of
mitral and tricuspid regurgitation has increased. The pulmonary
artery sytolic pressure is higher (previously 42 mmHg).
___ KUB
Multiple dilated loops of small bowel measuring up to 4.2 cm,
with fecalized bowel loops in the left lower quadrant. These
findings can be seen in the setting of small bowel obstruction.
If there is clinical concern, CT can be obtained for further
evaluation.
___ CT ABD&PELVIS
1. New extensive portal venous gas and other findings are highly
concerning for bowel necrosis involving the cecum and ascending
colon. In the setting of extensive atherosclerotic disease, an
ischemic cause is considered most likely. However longstanding
immunosuppression could contribute to an infectious etiology
such as typhlitis, given cecal and right colonic distribution.
2. Bilateral atrophic kidneys and mild retroperitoneal
lymphadenopathy are
unchanged compared to the prior study.
3. Diffuse osseous sclerosis is unchanged, reflecting the
sequelae of renal osteodystrophy.
Brief Hospital Course:
___ with a complicated past medical history including SLE, ESRD
___ lupus nephritis s/p failed transplant) with HD, raynauds
vasculiits (on skin biopsy), colectomy and colostomy (___), CAD
(s/p stenting of the LAD and diag with DES) cardiomyopathy,
Chronic abdominal pain s/p cholecystectomy in ___, pancreatitis
___ pancreatic divisum, HTN, dyslipidemia, thrombocytopenia,
severe PVD and non-healing L toe amputation who presented
initially with recurrent chest pain and underwent PCI stenting
of the LAD and diag on ___ for 70% stenosis in the Mid LAD
and 95% stenosis in the ___ Diagonal. Circumflex had 80%
stenosis and RCA had serial 60% mid lesions. She returned to the
CCU post cath.
Following stenting on ___, the patient was started on Plavix
and Aspirin without bleeding. While being titrated for
anti-hypertensives (labetolol) and afterload reduction
medications (Isordil, lisinopril), the patient began to complain
of increasing abdominal discomfort on the evening of ___. A CT
abd/pelvis the morning of ___ revealed extensive portal
venous gas concerning for bowel necrosis of cecum and ascending
colon. Surgery was consulted, and Dr. ___ performed an
extended right colectomy with temporary abdominal closure
leaving the abdomen open overnight. On ___, she was taken
back to the OR by Dr. ___ for extensive lysis of
adhesions, resection of 6cm of terminal ileum, anastamosis of
her ileum to her transverse colon, and placement of a biologic
mesh to facilitate closure and prevent compartment syndrome.
Postop, she went to the SICU where she was extubated on ___.
During her stay in the SICU the patient initially required
levophed, then nicardipine gtt for subsequent hypertension. The
patient was continued on Aspirin 81mg, Plavix, and low dose
Warfarin for a DVT ppx (goal INR 1.5-2) given history of HIT.
The patient was previously on argatroban, but there was
difficulty maintaining therapeutic dosing and she was
transitioned to Warfarin.
On ___, while at regularly scheduled HD (___), the
patient was noted to have wide complex tachycardia up to the
140s. Prior to this event, the patient's brother visited and
upset her (he was crying and per patient intoxicated). The
patient became anxious and had increased palpitations with chest
pressure. The arrhythmia was initially thought to be Afib with
aberrancy. Vagal maneuvers were attempted and VT was noted,
Amiodarone was given IVP then drip. K+, Mg and Calcium
repletion were given. Troponin was 0.71 (down trending). The
patient had been in sustained VT for 2 hours before arrival to
the CCU, when it finally broke.
Of note, the patient had an episode of afib and sustained VT on
telemetry in the ED on admission that was very similar in
appearance to this episode of VT. That episode self resolved.
Unclear etiology of V tach. Patient was started on amiodarone on
___ with loading dose and plan for 200 mg BID x 1 month. She
underwent HD subsequently without any v tach or symptoms. She
was also continued on aspirin and plavix. Coumadin was
discontinued, as risks outweighed benefits of having patient on
triple therapy for anticoagulation. Amiodarone was decreased to
200mg daily on ___. A f/u with Cardiologist Dr. ___ was
scheduled for ___.
On ___, patient had significantly increased pain in RLQ with
guarding, and incisional site was oozing serosanguinous fluid.
KUB was unremarkable but CT abdomen/pelvis showed a leaking
anastomosis. She was taken back to the OR for the third time on
___ for exploratory laparotomy with resection of ileotransverse
anastomosis, ileostomy and primary fascia closure with flaps for
anastomotic leak. Surgeon was Dr. ___. EBL was 500cc. 2L
IVF, 500 albumin and 3u PRBC were infused.
She was extubated on POD1. Flatus was noted in the ostomy. Diet
was advanced to clears on pod 2 as she had stool output. NGT was
discontinued. Pressors were stopped and she underwent HD.
Cycled troponins peaked at 0.85. Cardiology recommended
discontinuation of trending troponins given lack of clear
significance and/or clinical correlation.
POD3 she was transferred out of the SICU with home medications
and stool softeners resumed. On POD5 she was noted to have
significant wound erythema, with indication of wound breakdown.
Staples were removed from ___ wound region and packed
with dry gauze. Murky brown-tinged discharge was coming from the
wound. On POD6, all inferior staples on the wound were removed
(leaving 4 staples at superior part of incision). The wound was
opened and packed with dry gauze. Some skin sloughing was noted
around wound with small skin tears. Duoderm was placed on
healthy tissue around wound.
On POD6-7 wound appeared to have cleaner base with minimal
drainage, was changed q shift with WTD dressing. Ostomy/wound
care consult was obtained and recommendation was to apply
melgisorb/ xeroform over tears, and this dressing was changed
daily.
Daily dressing changes and ostomy care continued as well as HD
on ___ schedule. She persistently complained
of nausea (with one single episode of vomiting) and thus
underwent CT AP on ___ showed no evidence of active bowel leak.
Multiple rim enhancing fluid collections in the abdomen and
pelvis were seen consistent with abscesses. Antibiotics, IV
Linezolid and Ceftriaxone were continued from ___, and she
has remained afebrile. JP was removed on pod 13.
A feeding tube was placed on ___. After about a week of
improved nutrition, the wound base started to show improved
healing and the surrounding skin was much less friable. The wet
to dry dressings were continued until ___ when it was
determined that the surrounding skin was improved enough to
place the wound vac (white then black sponge). Melgisorb was
placed to the right side of the wound where skin appeared
necrotic (wet)and a tegaderm was placed on it and then VAC
dressing placed over it with suction set at 125 mmHg.
On ___, an EGD was performed for persistent c/o nausea. A 10mm
clean based ulcer was noted in the cardia and a polyp in the
pylorus. Angioectasias was seen in the duodenun. NGT was
repositioned at the end of the procedure as it had curled in her
mouth during the procedure. Placement was confirmed with a CXR.
Otherwise normal EGD to third part of the duodenum.
Recommendations included BID PPI x 8 weeks. Repeat EGD in 8
weeks to assess for ulcer healing. H. pylori stool Ag was sent,
but test cancelled as stool was too watery. An H. plylori
antibody was sent on ___.
Palliative Care was consulted for coping support, exploration of
goals of
care as she was overwhelmed with new ostomy. A volunteer with an
ostomy met with her. After this visit, she seemed more hopeful
that she could live with an ostomy.
Hemodialysis was continued 3 times/week via the left arm AVF.
___ Schedule was planned. She was dialyzed
on ___ then on ___ to get her on ___ schedule.
On the evening of ___, she complained of abdominal pain and
nausea. A KUB was done to evaluate noting paucity of small bowel
gas with contrast in the descending, sigmoid colon and the
rectum. No pneumoperitoneum was seen. Abdominal pain resolved.
Nausea persisted intermittently on ___ after HD. Zofran was
given.
CHRONIC ISSUES:
================
# SLE: Long standing history of SLE with known complications
including vasculitis and lupus nephritis. Most recent ds DNA
negative and CRP ___ <10. Was on immunosuppression daily that
was discontinued for wound healing.
- Azathioprine 50mg Qdaily-on hold
- Hydroxychloroquine 200mg PO daily-resumed ___
- Prednisone 5mg daily-resumed
# ESRD: ___ lupus nephritis, anuric and goes to dialysis 3 times
per week (___), most recent ___
- Continue sevelamer 2400 TID with meals
- Dialysis ___
# PVD/recent amputation: Documented PVD on previous lower
extremity catheterizations and recent arterial dopplers.
Difficulty healing L great toe amputation.
- Wound care recs for toe
- Continue to monitor
- Continue atorvastatin
TRANSITIONAL ISSUES
====================
# CODE: Full code
# CONTACT: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain/fever
2. Acyclovir 200 mg PO Q12H
3. Collagenase Ointment 1 Appl TP DAILY
4. Docusate Sodium 100 mg PO BID
5. HYDROmorphone (Dilaudid) 2 mg PO Q8H:PRN Severe bone pain
6. Hydroxychloroquine Sulfate 200 mg PO DAILY
7. Labetalol 100 mg PO BID
8. Lidocaine 5% Patch 1 PTCH TD QAM Pain
9. Lisinopril 80 mg PO DAILY
10. Nephrocaps 1 CAP PO DAILY
11. Pantoprazole 40 mg PO Q24H
12. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
13. PredniSONE 5 mg PO DAILY
14. sevelamer CARBONATE 2400 mg PO TID W/MEALS
15. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
16. ammonium lactate 12 % topical BID
17. Clindamycin 600 mg PO BEFORE DENTAL PROCEDURES
18. doxylamine succinate 25 mg oral QHS
19. Azathioprine 50 mg PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO Q24H prophylactic
2. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
3. Hydroxychloroquine Sulfate 200 mg PO DAILY
4. Labetalol 100 mg PO BID
5. Nephrocaps 1 CAP PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. PredniSONE 5 mg PO DAILY
8. Aspirin 81 mg PO DAILY
Lifelong aspirin for drug eluting stents
9. Atorvastatin 80 mg PO QPM
10. Calcitriol 0.25 mcg PO 3X/WEEK (___)
11. Clopidogrel 75 mg PO DAILY
recommended ___ years duration
12. Simethicone 40-80 mg PO QID:PRN gas pain
13. Clindamycin 600 mg PO BEFORE DENTAL PROCEDURES
15. Acetaminophen 325-650 mg PO Q6H:PRN pain
16. Amiodarone 200 mg PO DAILY
17. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
18. Dronabinol 2.5 mg PO BID
19. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
20. Glucose Gel 15 g PO PRN hypoglycemia protocol
21. LORazepam 0.5 mg IV Q8H:PRN Anxiety
22. Sucralfate 1 gm PO TID
slurry not to be given within 2 hours of hydroxychloroquine
23. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eye
24. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
ESRD (Lupus nephritis)
ACS
Mesenteric ischemia
Necrotic right colon
Anastomotic leak
Abdominal wound break down
Malnutrition
Afib
Vtach
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (___
or cane).
Discharge Instructions:
You will be transferring to ___ Rehab
Call Dr. ___ office at ___ if you develop
fever, worsening abdominal pain, nausea, vomiting, abdominal
bloating, redness, discharge or drainage from abdominal wound,
wound edge has increased necrotic tissue, malfunction of AVF or
any concerns.
Followup Instructions:
___
|
10213338-DS-58 | 10,213,338 | 28,130,637 | DS | 58 | 2166-07-04 00:00:00 | 2166-07-04 17:36:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Biaxin / Vancomycin / Haldol / Heparin Agents / Flagyl / Sulfite
/ Sulfa (Sulfonamide Antibiotics) / CellCept / aspirin
Attending: ___
Chief Complaint:
L knee and shoulder pain and swelling
Major Surgical or Invasive Procedure:
___ - Left knee I&D and anterior synovectomy
___ - Left shoulder I&D and anterior synovectomy
___ - esophageal gastroduodenoscopy with clip placement
___ - esophageal gastroduodenoscopy with failed clip placement
History of Present Illness:
___ year old woman with a complicated past medical history
including CVID,SLE, ESRD ___ lupus nephritis s/p failed
transplant) with HD TTS, raynauds vasculiits (on skin biopsy),
cardiomyopathy with clean cath ___, and P-MIBI in ___, Chronic
abdominal pain s/p cholecystectomy in ___, pancreatitis ___
pancreatic divisum, HTN, dyslipidemia, PVD, and colectomy with
end-ileostomy ___ ischemic bowel who presents with 3 days of
atraumatic L shoulder and L knee pain similar to prior lupus
flares. She reports that she has had similar swelling of her
shoulder and knee and has had steroid injections by ortho in the
past. She reports that she was limping on her L knee in the
morning of ___ but was unable to walk by the end of the day.
The patient reports that she has felt warm over the last few
days with no true fevers/chills. She has a dry cough at
baseline. No n/v/d
In the ED, initial vitals were: 98.9 (TMAX 101.1) 82 130/57 16
100% RA
Exam notable for: L shoulder and L knee swelling and reduced
ROM
Labs notable for: H/H 6.6/21.5, WBC 5.0 (N77.6), creat 4.8 (on
HD)
Imaging notable for: CXR: Streaky bibasilar opacities suggest
atelectasis however infection should be considered in the
appropriate setting. Pulmonary vascular engorgement without
frank edema.
Patient was given: Prednisone 5 mg, clopidogrel 75 mg, dilaudid
4 mg, hydroxychloroquine sulfate 200 mg, asa 81 mg, amiodarone
200 mg, acetaminophen 650 mg
The ED spoke to ortho about this patient but did not officially
consult. Ortho recommended tapping the knee when on the floor.
Vitals prior to transfer: 99.9 84 110/52 16 98% RA
On the floor, the patient reports that she still has
significant left knee and L shoulder pain, as well as pain in
all small digits of b/l hands. She denies any ongoing
fevers/chills, abdominal pain, diarrhea, chest pain, shortness
of breath, although she has been feeling weaker than usual
lately. Otherwise ROS as above
Past Medical History:
- Presumed Miliary TB: concerning liver/spleen/kidney lesions on
CT, AFT smear neg x3 and MTB direct amplification neg, started
on RIPE
- SLE: Followed by Dr. ___ manifestation =
arthralgia in hips and knees
- ESRD: Secondary to lupus nephritis, s/p failed transplant w/
subsequent nephrectomy, HD on ___.
- Skin biopsy ___ with pathology suggestive of vasculitis
- Cardiomyopathy - EF 60-65% (___). Severe diastolic
dysfunction.
- H/o chest pain: H/o cardiomyopathy with nl cath in ___, nl
P-MIBI in ___. Evaluated by Dr. ___ in ___ and diagnosed
with atypical CP likely GI (2- Chronic abdominal pain: S/p
cholecystectomy in ___, pancreatitis ___ pancreatic divisum,
partial SBO in ___, epiploic appendagitis in ___
- Hypertension: On beta blocker, ACE I, CCB.
- H/o dyslipidemia: ___ lipid panel wnl.
- Thrombocytopenia: H/o HIT with positive PF4 in ___ but neg on
follow-up, h/o TTP in ___.
- Anemia: On epoetin at HD, h/o autoimmune hemolytic anemia,
positive anti-E Ab against RBC, thalassemia trait based on
microcytic indices and peripheral smear review by Dr. ___.
- Bronchiolitis obliterans-organizing pneumonia
- H/o recurrent rectal abscesses first noted ___, recurrent
in ___ and a drain was left in, ___: ultrasound negative,
CT ___ no rectal abscess; drained by Dr. ___ in
___ who felt this was resolved when he saw her in ___
- DCIS and atypical ductal hyperplasia ___ s/p lumpectomy.
- Osteoporosis
- H/o avascular necrosis of left knee bil humeral head.
- H/o adrenal crisis in ___.
- H/o seizure disorder.
- H/o uterine fibroid in ___, s/p hysterectomy for excessive
bleeding.
- Raynaud's phenomenon
- hip & thigh pain, likely sciatica, being evaluated by ortho
- folliculitis
Social History:
___
Family History:
Mother died of lupus in her ___ (died of an MI).
Brother with EtOH abuse.
Physical Exam:
MEDICAL FLOOR ADMISSION EXAM
Vitals: 99.3 | 85 | 114/59 | 18 | 100%RA
General: alert, oriented, no acute distress
HEENT: sclera anicteric, MMM
Neck: supple
Lungs: CTAB, no wheezes, rales, ronchi
CV: regular rate and rhythm, normal S1 + S2, III/VI systolic
murmur at RUSB
Abdomen: soft, non-tender, non-distended, midline surgical scar
below the umbilicus, ostomy in place in RLQ with yellow/brown
stool in bag
GU: no foley
Ext: warm, well perfused, ecchymoses noted over knees b/l; L
knee with large, moderately tender swelling with ___ degree
passive ROM; subpatellar bursitis also noted: L shoulder swollen
mildly swollen anteriorly with reduced ROM, TTP laterally over
deltoid/humeral head area.
Skin: no rashes noted
Neuro: CNs2-12 grossly intact, motor function grossly normal
with limited ROM in L shoulder and knee
DISCHARGE EXAM
-----------------
Vitals:
98.0-98.8 108-122/50-67 ___ ___ 98-100% RA
GENERAL:
HEENT: MMM, oropharynx w/thrush, PERRL
CARDIAC: ___. Normal S1, S2. ___ systolic murmur loudest at the
base.
LUNGS: CTAB
ABDOMEN: soft, non-tender, BS+. Ostomy with semiformed brown
output.
EXT: Upper extremity fistula intact, no ___ edema bilaterally. R
foot warm, well perfused, no edema, but unable to palpate
pulses; distal L foot slightly cooler than R, digits 1 and 5
amputated, slightly increased swelling from prior. Bilateral
heel echymoses. L knee extremely tender to palpation, appearing
more swollen than prior, no exudates.
SKIN: Diffuse dark patches throughout extremities
NEURO: Motor function grossly normal
Pertinent Results:
ADMISSION LABS:
==================
___ 08:05PM BLOOD WBC-5.0 RBC-2.28* Hgb-6.6* Hct-21.5*
MCV-94 MCH-28.9 MCHC-30.7* RDW-20.5* RDWSD-69.0* Plt ___
___ 08:05PM BLOOD Neuts-77.6* Lymphs-12.4* Monos-8.4
Eos-0.8* Baso-0.0 NRBC-0.8* Im ___ AbsNeut-3.86
AbsLymp-0.62* AbsMono-0.42 AbsEos-0.04 AbsBaso-0.00*
___ 08:05PM BLOOD Glucose-78 UreaN-30* Creat-4.8*# Na-139
K-4.0 Cl-94* HCO3-31 AnGap-18
___ 06:10AM BLOOD CRP-176.3*
___ 06:10AM BLOOD IgG-412* IgA-138 IgM-<5*
___ 06:10AM BLOOD C3-145 C4-52*
___ 05:10PM JOINT FLUID ___ Polys-81*
___ Macro-19
___ 06:00AM BLOOD Glucose-97 UreaN-69* Creat-7.6*# Na-130*
K-5.4* Cl-90* HCO3-26 AnGap-19
___ 11:18AM BLOOD K-5.3*
___ 03:46AM BLOOD Glucose-229* UreaN-83* Creat-8.6* Na-128*
K-7.2* Cl-86* HCO3-18* AnGap-31*
___ 06:26AM BLOOD ALT-155* AST-309* AlkPhos-268*
TotBili-6.0*
___ 03:46AM BLOOD CK-MB-2 cTropnT-0.20*
___ 10:51AM BLOOD CK-MB-5 cTropnT-0.23*
___ 05:47PM BLOOD CK-MB-4 cTropnT-0.23*
IMAGING:
==================
___ L knee XR
1. Worsening lucency and fragmentation of the lateral femoral
condyle and
small suprapatellar effusion is worrisome for septic joint and
osteomyelitis
until proven otherwise.
2. Worsening bony sclerosis of the medial and lateral femoral
condyles and
patella likely reflects bone infarcts in the setting of lupus.
___ L shoulder XR
Mixed areas of sclerosis and lucency in the left femoral head
similar to ___ in part reflect areas of known osteonecrosis.
However, an erosion cannot be excluded and in this patient with
renal failure, amyloid arthropathy could have a similar
appearance. A follow-up MRI could be considered to evaluate for
possible erosive changes.
___ ARTERIAL DUPLEX U/S LEFT LEG
No flow seen within the anterior tibial, posterior tibial and
dorsalis pedis arteries.
Low flow within the peroneal artery.
Monophasic waveforms within the mid and distal SFA and popliteal
artery.
MICROBIOLOGY:
==================
___ 10:26 am JOINT FLUID Source: shoulder.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
Reported to and read back by ___ ___ ___
12:15PM.
STAPHYLOCOCCUS ___. SPARSE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS ___
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.5 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 1 S
___ 5:30 pm JOINT FLUID LEFT KNEE JOINT FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
Reported to and read back by ___ ___ ___
13:15.
STAPHYLOCOCCUS ___. RARE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
DISCHARGE LABS:
==================
___ 06:25AM BLOOD WBC-16.5* RBC-2.82* Hgb-8.2* Hct-26.5*
MCV-94 MCH-29.1 MCHC-30.9* RDW-17.9* RDWSD-59.3* Plt ___
___ 06:25AM BLOOD Glucose-87 UreaN-69* Creat-5.2*# Na-131*
K-4.5 Cl-88* HCO3-24 AnGap-24*
___ 06:25AM BLOOD Calcium-9.1 Phos-3.4 Mg-1.8
Brief Hospital Course:
Ms. ___ is a ___ woman with a PMH notable for SLE,
ESRD on HD, CAD s/p DES to LAD and D1, and history of
ventricular tachycardia presented with septic arthritis of the L
knee and L shoulder, course complicated by anemia ___ GIB from
gastric polyp and bradycardia.
# L knee and left shoulder Septic Arthritis: Presented with
septic left knee and shoulder growing Staph Lugdenesis,
sensitive to nafcillin/cefazolin. She underwent washout of both
joints with orthopedics. Bacteremia was suspected given multiple
sources with same organism, but blood cultures negative. TTE and
TEE negative for endocarditis. She had repeat tap of left knee
on ___ due to worsening pain and fever but culture remained
negative. She will continue on dilaudid for pain control and
cefazolin until ___ with ID follow up.
# Anemia ___ GIB: Patient with h/o gastric polyp s/p banding on
___. In setting of worsening anemia EGD on ___ found two
bleeding polyps in the pylorus that were clipped. Repeat EGD
demonstrated that the clips had slipped off the bleeding sites
which were not unsalvageable. ___ were consulted but due to the
high vascularity of the region, an ___ procedure would not be
definitive treatment. The only definitive treatment would be
surgery, but she was not a good surgical candidate. In
discussion with ardiology it was decided to hold Plavix (washout
ended ___. She continued to have downtrending H/H at time of
discharge and will require close monitoring and likely ongoing
transfusions of pRBCs.
# Left foot/calf pain: Patient with cool and painful left distal
foot with ulceration over heel/toes. Arterial study notable for
decreased peroneal flow, some popliteal flow, but no flow in
___, post ___, dorsalis pedis. It is previously known that
she perfuses her L foot with her peroneal artery only.
Angiography was deferred given c/f GIB but should be considered
as outpatient.
# Hyperkalemia: Patient with transient hyperkalemia to 7 in
setting of CKD, and resultant bradycardia requiring brief CCU
stay. Transfusion reaction and hemolysis was considered. The
blood bank does not feel that a the patient experienced a
hemolytic transfusion reaction, and the patient received 1U PRBC
immediately prior to transfer from CCU -> medicine on ___.
Resolved uneventfully prior to discharge.
CHRONIC ISSUES:
===============
# SLE:
Multiple admissions for AMS, thought to be possibly lupus flare
and steroid dose increased in ___. Ig and complement levels
stable since last labs: IgG 412, IgA 138, IgM <5. C3 145, C4 52.
___ positive 1:40 with speckled pattern, dsDNA negative.
Received IVIG here. Also home prednisoe and hydroxycholoroquine
were continued.
# ESRD on HD:
Continued HD on usual TTS schedule, as well as home nephrocaps
and Sevelamer
# CAD: Has multi-vessel disease. s/p DES in ___ to LAD and
D1. Given bleeding, discussed regimen with Dr. ___
cardiologist). Decision made to stop Plavix in setting of GIB.
ASA continued for now.
# CVID: Stably low IgG and IgM levels. Received 20g (400mg/kg)
on ___ (___ brand, which she had received in ___ without
problems per report) without adverse reaction.
# History of HIT: Avoid all heparin products.
# GERD: Pantoprazole 40 mg PO Q12H.
TRANSITIONAL ISSUES:
-Patient discharged on course of cefazolin (end date ___
with ID follow up
-Please check CBC weekly and transfuse pRBCs as needed for Hgb <
7
-Patient with severe PAD of left leg; angiography deferred given
GIB. Consider angiography if GIB stabilizes.
-Please monitor for melena or bright red blood per rectum
-Monitor fevers, pain/swelling of left knee and left shoulder
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO DAILY:PRN pain
2. Acyclovir 200 mg PO Q12H
3. Amiodarone 200 mg PO DAILY
4. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry eye
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Calcitriol 0.25 mcg PO 3X/WEEK (___)
8. Clindamycin 1% Solution 1 Appl TP BID:PRN rash
9. Clopidogrel 75 mg PO DAILY
10. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN pain
11. Hydroxychloroquine Sulfate 200 mg PO DAILY
12. Nephrocaps 1 CAP PO DAILY
13. PredniSONE 5 mg PO DAILY
14. sevelamer CARBONATE 800 mg PO TID W/MEALS
15. Simethicone 40-80 mg PO QID:PRN gas pain
16. Benzonatate 100 mg PO TID:PRN cough
17. LOPERamide 2 mg PO QID:PRN watery stool
18. Clindamycin 600 mg PO BEFORE DENTAL PROCEDURES
19. Pantoprazole 40 mg PO Q12H
20. LORazepam 0.5 mg PO Q8H:PRN anxiety
21. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
22. ammonium lactate 12 % topical rub into skin all over body
BID - pt now uses PRN
Discharge Medications:
1. Caphosol 30 mL ORAL QID:PRN dry mouth
2. CeFAZolin 2 g IV POST HD (MO,WE)
3. CeFAZolin 3 g IV POST HD (FR)
4. DiphenhydrAMINE 25 mg PO QHS:PRN itching or sleep
5. Ferrous Sulfate 325 mg PO DAILY
6. Metoprolol Tartrate 12.5 mg PO Q6H
7. Sarna Lotion 1 Appl TP DAILY:PRN dry skin
8. Vitamin D ___ UNIT PO 1X/WEEK (FR)
9. Acetaminophen 325-650 mg PO Q6H
10. Acyclovir 200 mg PO Q12H
11. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
four (4) hours Disp #*20 Tablet Refills:*0
12. Amiodarone 200 mg PO DAILY
13. ammonium lactate 12 % topical rub into skin all over body
BID - pt now uses PRN
14. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eye
15. Aspirin 81 mg PO DAILY
16. Atorvastatin 40 mg PO QPM
17. Benzonatate 100 mg PO TID:PRN cough
18. Calcitriol 0.25 mcg PO 3X/WEEK (___)
19. Clindamycin 1% Solution 1 Appl TP BID:PRN rash
20. Clindamycin 600 mg PO BEFORE DENTAL PROCEDURES
21. Hydroxychloroquine Sulfate 200 mg PO DAILY
22. LOPERamide 2 mg PO QID:PRN watery stool
23. LORazepam 0.5 mg PO Q8H:PRN anxiety
24. Nephrocaps 1 CAP PO DAILY
25. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
26. Pantoprazole 40 mg PO Q12H
27. PredniSONE 5 mg PO DAILY
28. sevelamer CARBONATE 800 mg PO TID W/MEALS
29. Simethicone 40-80 mg PO QID:PRN gas pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Septic arthritis (Staphylococcus lug___) of left shoulder
and left knee
- Anemia from a GI bleed
SECONDARY DIAGNOSIS:
- Lupus
- End stage renal disease on hemodialysis
- Common variable immunodeficiency
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. ___-
___ was a pleasure taking care of you at ___. You originally
came to the emergency room because of increasing pain and
swelling in your left knee and shoulder.
While you were here, the radiologists took samples of fluid from
both joints and they grew a bacteria called Staphylococcus
Lugdunesis. The orthopedic surgeons took you to the operating
room on ___ and ___ to clean out your knee and shoulder
respectively. The bacteria was found to be sensitive to an
antibiotic called cefazolin and you will be treated with it for
six weeks.
Over the course of your time in the hospital, but in particular
after returning to the main part, you had continued bleeding
from two blood vessels in your stomach. It could not be
adequately controlled despite endoscopic procedures. The final
plan formulated from multiple multidisciplinary discussions was
to discontinue your Plavix to control the bleeding.
Things to keep in mind when you leave:
- Call your primary doctor if you have more swelling and pain in
your joints.
- Call your doctor if you cough up blood or notice blood in your
stool or dark, tarry stool
- Continue your scheduled follow-up with your infectious disease
doctor to determine additional steps in your antibiotic
treatment
Thank you for letting us participate in your care.
-Your ___ team
Followup Instructions:
___
|
10213765-DS-4 | 10,213,765 | 28,522,861 | DS | 4 | 2113-04-13 00:00:00 | 2113-04-13 17:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
___: Open reduction, internal fixation anterior pelvic
ring and posterior pelvic ring injury with 7.3 mm screws
History of Present Illness:
This patient is a ___ year old male brought in by medics
light from the scene after a reported 30 foot fall through
skyline all performing snow maintenance building roof.
Extrication time was approximately 40 minutes from the
building. The patient was brought in with concern for pelvis
injury. He is wearing a cervical collar, awake, alert, and
oriented x3. Positive LOC according to bystanders. Patient
is ___ only. He complains of abdominal pain and
mild shortness of breath. Vital signs are normal on arrival.
Has received 100 mcg of fentanyl prior to arrival. He denies
significant headache, vision changes, nausea, vomiting. He
states he has no medical history, allergies, medications, or
surgical history.
Past Medical History:
none
Family History:
noncontributory
Physical Exam:
PHYSICAL EXAMINATION
O(2)Sat: 99 Normal
Constitutional: Mildly uncomfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Nondistended, mildly diffusely tender without
guarding. No bruising or flank pain
Extr/Back: No cyanosis, clubbing or edema, no obvious
deformity. Pelvis appears stable
Skin: Warm and dry
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
___: No petechiae
PE on discharge:
VS: 98.3, 79, 110/40, 18, 98%ra
Gen: A&O x3, NAD
Chest: LS ctab
CV: HRR, normal s1/s2
Abd: soft, NT/ND. left pelvic and left hip staples
Ext: no edema
Pertinent Results:
___ 06:20AM BLOOD WBC-4.0 RBC-3.13* Hgb-9.9* Hct-27.5*
MCV-88 MCH-31.7 MCHC-36.1* RDW-13.1 Plt ___
___ 07:55PM BLOOD Hct-27.3*
___ 01:00PM BLOOD Hct-26.9*
___ 06:05AM BLOOD WBC-4.3 RBC-2.97* Hgb-9.3* Hct-26.0*
MCV-88 MCH-31.4 MCHC-35.8* RDW-12.8 Plt ___
___ 12:13AM BLOOD Hct-27.7*
___ 07:28PM BLOOD Hct-30.4*
IMAGING:
CT C-SPINE
1. No evidence of fracture or dislocation.
CT HEAD
No evidence of acute intracranial abnormality.
CT CHEST; CT ABD & PELVIS
1. Moderate right pneumothorax and pneumomediastinum. Multiple
right lung
contusions.
2. Grade 2 liver injury. Small amount of perihepatic hemorrhage
tracking
inferiorly into the pelvis.
3. Possible tiny contusion in the superior aspect of the spleen.
4. Nondisplaced right seventh rib fracture. Fractures of the
superior inferior left pubic rami. Fractures of the left sacral
ale and left ischial tuberosity.
WRIST XRAY
No fracture or dislocation. Carpal rows appear intact. No
radiopaque foreign body. Soft tissues unremarkable.
CXR ___
As compared to the previous image, there is no substantial
change in dimension of the right apical pneumothorax. The
patient shows no evidence of tension. The pre described subtle
right lower lung parenchymal opacity has completely resolved, a
small atelectasis in the infra hilar right lung regions
persists. Unremarkable left lung. Normal size of the cardiac
silhouette. No pneumonia or pleural effusions.
Brief Hospital Course:
The patient is a healthy ___ male who by report fell 30
feet through a sky light with GCS 15. He was brought to the
emergency department by med flight was concern for pelvic or hip
fracture. He complains of abdominal pain. Fast exam is negative.
CT demonstrates pneumothorax and right 7th rib fracture, lung
contusions. Imaging also reveal the patient has a left
compression pelvic fracture, and Orthopedic Surgery was
consulted. The patient was currently stable with a patent
airway and pain well controlled. Head CT and cervical spine CT
negative. CT abdomen demonstrates grade 2 liver laceration and
small splenic injury. Patient was admitted to ___ for further
management of injuries and serial hematocrits.
HD2 the patient was taken to the operating room with Orthopedics
for open reduction, internal fixation anterior pelvic ring and
posterior pelvic ring injury with 7.3 mm screws. The patient
tolerated the procedure well and remained hemodynamically
stable. On POD1 the patient was transferred to the floor.
Hematocrits remained stable. Pain was well controlled. Diet was
progressively advanced as tolerated to a regular diet with good
tolerability. The patient voided without problem. During this
hospitalization, the patient worked with Physical Therapy and
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 with crutches, voiding without assistance, and
pain was well controlled. He was cleared by Physical Therapy
for home with outpatient ___. The patient was discharged home
without services. The patient and his family received discharge
teaching, including lovenox teaching with the use of an
interpreter, and follow-up instructions with understanding
verbalized and agreement with the discharge plan. He had
follow-up scheduled with the ___ clinic and with Orthopedics.
..
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
4. Outpatient Physical Therapy
Medical Dx / ICD9: 959.9/trauma 850.9/Concussion
Activity Orders: L ___: TDWBING, R ___: WBAT
Goals: Gait training
5. Enoxaparin Sodium 40 mg SC QHS
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg sc once a day Disp #*14
Syringe Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1: Fall from 30 feet
2: Grade 2 liver laceration, small splenic injury
3: Anterior and posterior pelvic ring fracture, left-sided
4: moderate left-sided pneumothorax with pulmonary contusion
5: Right 7th rib 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:
You were admitted to ___ after falling 30 feet through a
skylight. You sustained multiple injuries, including a liver
laceration, pelvic fracture, and rib fracture. You were taken to
the operating room and had your pelvis fixed by the Orthopedic
team. You have worked with Physical Therapy and Occupational
Therapy, and you are cleared for discharge home to continue your
recovery. Please note the following discharge instructions:
Liver/ Spleen lacerations:
*AVOID contact sports and/or any activity that may cause injury
to your abdominal area for the next ___ weeks.
*If you suddenly become dizzy, lightheaded, feeling as if you
are going to pass out go to the nearest Emergency Room as this
could be a sign that you are having internal bleeding from your
liver or spleen injury.
*AVOID any blood thinners such as Motrin, Naprosyn, Indocin,
Aspirin, Coumadin or Plavix for at least ___ days unless
otherwise instructed by the MD/NP/PA.
Rib Fractures:
* Your injury caused one rib 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).
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
Followup Instructions:
___
|
10213803-DS-10 | 10,213,803 | 26,255,243 | DS | 10 | 2192-10-06 00:00:00 | 2192-10-06 15:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hypoxemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo M w/ AML s/p allotransplant in ___, currently in
remission, who presented with syncope. Pt has been having URI
symptoms for the last week including nonproductive cough and
nasal congestion. He was seen in the clinic on ___ and
given azithromycin. He took 500mg that day, and in the evening,
in the setting of standing from sitting, he felt dizzy and
lightheaded, but did not fall. He became concerned and phoned
the nurse practitioner ___ Dr. ___ morning. He was
switched to Levoquin, and by ___ his cough had become
productive as he was able to get more mucous out.
However, yesterday evening, he went from sitting in the recliner
to standing when he went to refill his ice container and in a
few minutes, felt light headed and fell backwards, hitting his
head on a cabinet. He did not feel diaphoretic or nauseous
beforehand. He believes he lost consciousness but for < 1 minute
as his wife came immediately downstairs. He had no tongue
biting, but did lose control of his urine and felt a little
confused after he came to. He was taken to ___,
where CT head and C-spine were performed and negative for acute
process. CXR, however, showed evidence of a RLL pneumonia. Per
report, his pressures were in the ___ and he was started on
vanc/zosyn. He was going to be placed in the ICU there, but due
to lack of beds, he was transfered to ___.
He otherwise feels well and denies any fevers/chills, nausea,
vomiting, abd pain, cp/sob or diarrhea. He has no dyspnea upon
lying flat and has had no leg swelling.
On arrival to the MICU, pt is accompanied by his sister and
wife. He has no current complaints.
Past Medical History:
1. AML, status post reduced-intensity sibling allogeneic stem
cell transplant ___, last chemo ___
2. CAD with 3 vessel disease: not a candidate for CABG
- s/p BMS x 3 to LAD ___
- s/p NSTEMI ___
3. CHF (congestive heart failure) with EF of 35% on last ECHO in
___
4. Hx c. diff colitis
5. Hx pulmonary aspergillus infection
Past oncologic history (per OMR):
Presented in ___ with pancytopenia - Bone marrow biopsy
consistent with AML and started induction chemotherapy with 7+3.
Post-induction, had a decline in his ejection fraction. Cardiac
catheterization, which showed a 3v CAD and he had 3 stents
placed to the LAD. He was again readmitted in ___ for a
septic episode and found to have a NSTEMI from demand ischemia
in the setting of hypertension. He developed atrial
fibrillation with RVR and converted back to sinus rhythm with
amiodarone, and since been on metoprolol since that time for
rate control. He is followed by pulmonary, ID, cardiology and
hematology. He has a history of aspergillus infection in the
lingula and was kept on voriconazole for this.
He underwent a matched sibling allogeneic stem cell
transplant on ___ with fludarabine and busulfan as his
conditioning regimen. Post-transplant he has done very well
overall with an excellent performance status. Around day +___,
he was noted to have new LLL opacities per chest CT which
appeared to progress over subsequent scans. He underwent 2
bronchoscopies and a lung biopsy which were non-diagnostic for
infection. He completed a prednisone taper in ___ and had
subsequent near resolution of the opacities per subsequent CT.
However, a new 1-2 cm peripheral pulmonary nodule was noted in
the L posterior lung field. Repeat chest CT on ___ showed
resolution of the pulmonary nodule, although there was again
noted new nodules and ground glass opacities within the LLL. He
has remained asymptomatic from a respiratory standpoint
throughout with good pulmonary function on serial PFTs.
Social History:
___
Family History:
Brother - AML s/p transplant here at ___ in ___. Father -
history of "multiple small heart attacks," died in his ___.
Physical Exam:
Admission exam:
VS: 98.9 69 91/57 17 94%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: supple, no LAD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Decreased breath sounds at the bases, poor airway
movement. Minimal rhonchi diffusely.
Abdomen: Soft, NT, ND, bowel sounds present, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred
Discharge exam:
98.1 114/70 76 18 96% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no LAD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Decreased breath sounds at the bases, poor airway
movement. Minimal rhonchi diffusely.
Abdomen: Soft, NT, ND, bowel sounds present, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred
Pertinent Results:
Admission labs:
___ 05:35AM BLOOD WBC-7.5 RBC-4.15* Hgb-12.7* Hct-39.8*
MCV-96 MCH-30.5 MCHC-31.9 RDW-17.9* Plt ___
___ 05:35AM BLOOD Neuts-39* Bands-6* ___ Monos-13*
Eos-0 Baso-1 Atyps-7* ___ Myelos-0 NRBC-1*
___ 05:35AM BLOOD ___ PTT-40.2* ___
___ 05:35AM BLOOD Glucose-142* UreaN-35* Creat-1.3* Na-135
K-4.2 Cl-108 HCO3-21* AnGap-10
___ 05:35AM BLOOD CK-MB-4 cTropnT-<0.01
___ 05:35AM BLOOD Albumin-2.9* Calcium-7.4* Phos-4.3 Mg-2.0
___ 05:45AM BLOOD Lactate-1.2
Discharge labs:
___ 04:45AM BLOOD WBC-11.8* RBC-3.99* Hgb-12.1* Hct-37.5*
MCV-94 MCH-30.4 MCHC-32.3 RDW-18.6* Plt ___
___ 04:45AM BLOOD Neuts-29* Bands-1 Lymphs-47* Monos-10
Eos-8* Baso-0 Atyps-2* Metas-3* Myelos-0 NRBC-1*
___ 04:45AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-1+ Ovalocy-1+ Target-1+ Schisto-1+
Tear Dr-1+
___ 04:45AM BLOOD Glucose-101* UreaN-13 Creat-0.7 Na-138
K-5.0 Cl-107 HCO3-26 AnGap-10
___ 04:45AM BLOOD ALT-36 AST-50* LD(LDH)-249 AlkPhos-41
TotBili-0.3
___ 04:45AM BLOOD Albumin-3.1* Calcium-8.1* Phos-2.7 Mg-2.2
CXR ___
FINDINGS: Since the prior exam, the lung volumes are lower,
with a new
opacity at the right base with associated elevation of the right
hemidiaphragm. No other consolidation is identified. There is
no pulmonary edema, pleural effusion or pneumothorax. The
cardiomediastinal silhouette is normal. IMPRESSION: Right
basilar opacity, most consistent with a new pneumonia.
Blood Cx NGTD
Brief Hospital Course:
___ w/ AML (normal Karyotype) s/p MRD Allo SCT (___), CAD
s/p BMS x 3 (___), sCHF (EF 35%) who presents with syncope,
found to have pneumonia.
ACUTE
# Pneumonia/Hypoxia - Pt presented with RLL infiltrate in the
setting of 4L O2 requirement and syncopal episode. Pt was
afebrile, without leukocytosis, and did not endorse any cough
leading up to presentation however. He had been treated with
azithro and then levaquin prior to presentation to OSH on ___
where his initial presentation was for syncope. He was
transferred here for further management. He was started on
vanc, cefepime and initially presented to the ___ floor.
However, his SBPs were in the ___. He was transferred to the
___ where he was bolused 500cc NS x 2 with improvement noted in
his BPs. He was transferred to the floor and his O2 was rapidly
weened. He was ambulating without difficulty and breathing
easily on RA. After clinical improvement, a PICC line was
placed and the pt was transitioned to CTX for a planned total
abx course of 8 days (last day ___.
# Hypotension/Syncope - Pt with baseline SBP 100-110s while on
metoprolol and lisinopril. On presentation, endorsed feeling
"cruddy" several days PTA and had been on abx as above. Pt
endorsed symptomatic orthostasis x 2 days PTA. On the day of
admission, pt stated that he arose from his chair, felt
lightheaded, attempted to get to the refridgerator for a glass
of water, but he passed out, and hit his head on the kitchen
table. SBPs were in the ___ initially. CT head at OSH was
negative. In the ICU here, pt was orthostatic by BP
measurement. This resolved with IVF. Cre was elevated as well
c/w mild hypovolemia. Metoprolol and lisinopril were held
initially and restarted at half dose prior to d/c (metoprolol
succ 50 daily and lisinopril 2.5 daily). SBPs were in the 120s
on discharge. Pt was encouraged to maintain adequate hydration
though he did not endorse any particular hx of poor PO intake or
volume loss prior to presentation. Of note, regarding syncopal
episode, pt gave no hx c/w seizure like episode or cardiac
arrhythmia. There was a clear prodrome that proceeded the
event. EKG was neg for arrhythmia or ischemia.
# ___: Pt's creatinine up to 1.3 from baseline 0.9 - 1.0. Likely
secondary to pre-renal etiology given symptoms of dizziness and
light-headedness upon standing as well as orthostatic change.
Further supported by specific gravity of > 1.030 on urinalysis
at ___. Resolved with IV hydration and holding
of ACEI. Lisinopril was restarted at lower dose prior to d/c.
.
CHRONIC
# AML - not on current active treatment, but followed by Dr.
___.
.
# ___ - Pt not on any diuretic therapy at home and his CHF
seems to be compensated. EF 35%. Continued on home metop and
ACEI at lower dose.
.
# CAD s/p NSTEMI with 3 BMS - Continued home ASA. Metoprolol
and ACEI as above.
.
TRANSITIONAL
# pull PICC on ___ visit with Dr. ___ abx course
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. Metoprolol Succinate XL 100 mg PO DAILY
3. Simvastatin 20 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Levofloxacin 500 mg PO Q24H
6. Aspirin 81 mg PO DAILY
7. Vitamin D 50,000 UNIT PO ONCE PER MONTH
Discharge Medications:
1. CeftriaXONE 1 gm IV Q24H
last day ___
RX *ceftriaxone 1 gram 1 g IV q24hrs Disp #*3 Gram Refills:*0
2. Aspirin 81 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Simvastatin 20 mg PO DAILY
5. Vitamin D 50,000 UNIT PO ONCE PER MONTH
6. Lisinopril 2.5 mg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pneumonia
Syncope
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
It was a pleasure caring for you during your recent admission to
___. You were admitted with pneumonia and a fainting episode.
You were started on IV antibiotics. Ultimately, a PICC line
was placed. You will need to complete an 8 day course of
antibiotics, with the last day being ___. We also reduced
your lisinopril and metoprolol dose.
Followup Instructions:
___
|
10214395-DS-9 | 10,214,395 | 29,443,407 | DS | 9 | 2179-11-29 00:00:00 | 2179-11-29 13:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Keflex / Sulfa (Sulfonamide Antibiotics) / Penicillins / Keflex
/ codeine / ciprofloxacin
Attending: ___
Chief Complaint:
Small bowel obstruction
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx dwarfism and dementia transferred from ___ for
SBO. Vomiting this morning. RLQ and LLQ abdominal pain. Has
known ventral abdominal hernias, loss of domain and report of
multiple ventral hernia repairs with mesh performed at ___
___ by Dr. ___.
At the time of consultation, pt AFVSS, tender to palpation in
bilateral lower quadrants without frank peritoneal signs, WBC
11, lactate 1.6, review of CTAP with air and stool in distal
colon with relative discrepancy in small bowel caliber without
distinct transition point on preliminary review. Note made of
multiple small-bowel containing complex ventral hernias.
Past Medical History:
PMH: dwarfism, dementia, CVA, epilepsy, OA, HTN, FTT,
hydrocephalus s/p VPS, arthritis, urinary incontinence,
constipation, GERD, depression
PSH: open CCY, cesaerean x3, TAH, VP shunt, mult VHR
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission Physical Exam:
VS: T 98.6, HR 100, BP 179/90, RR 16, SaO2 99%rm air
GEN: habitus consistent with achondroplastic dwarfism
HEENT: EOMI, MMM
CV: tachycardic
PULM: CTAB
BACK: No CVAT
ABD: soft, distended - most prominently in bilateral lower
quadrants, incisional scars notable for midline laparotomy,
right
subcostal, 3cm R transverse incision consistent with VP shunt,
TTP with voluntary guarding bilateral lower quadrants without
evidence of rebound. Pronounced abdominal veins.
PELVIS: deferred
EXT: warm, well perfused
Discharge Physical Exam:
VS: 98.5 79 137/78 18 96%
General: habitus consistent with achondroplastic dwarfism
CV: Regular rate and rhythm, no murmurs, distant heart sounds
PULM: clear bilaterally
Abdomen: soft non distended, non tender, midline scar well
healed, right subcostal scar
Extremities: warm and well perfused
Pertinent Results:
___ 03:38AM LACTATE-1.6
___ 03:18AM GLUCOSE-73 UREA N-16 CREAT-0.6 SODIUM-141
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-20* ANION GAP-20
___ 03:18AM WBC-11.5* RBC-4.87 HGB-13.8 HCT-43.9 MCV-90
MCH-28.3 MCHC-31.4* RDW-14.6 RDWSD-48.0*
___ 03:18AM NEUTS-69.9 ___ MONOS-6.8 EOS-2.1
BASOS-0.4 IM ___ AbsNeut-8.00* AbsLymp-2.35 AbsMono-0.78
AbsEos-0.24 AbsBaso-0.05
___ 03:18AM PLT COUNT-348
Imaging:
CTAP ___ (___) - [prelim review]
no free air/fluid. dilated loops of small bowel, no distinct
transition point. multiple bowel containing ventral hernias. air
and stool in colon/rectum.
Brief Hospital Course:
Ms. ___ is a ___ year-old female with a history of multiple
ventral hernia repairs and VP shunt who presented to ___ on
___ from an OSH with concern for SBO on CT. On clinic exam,
the patient was not acutely toxic. She was admitted to the
Acute Care Surgery team for further medical management.
On HD2, the Plastic Surgery team was consulted regarding
consideration of repair of the patient's ventral hernia. They
will be involved in her operation which will be scheduled as an
outpatient. The Neurosurgery team was also consulted to
determine benefits verses risk of ventral hernia repair with her
current VP shunt. They recommend discussing with her primary
Neurosurgeon for full discussion on risks, operative planning,
surgical prophylaxis, and follow-up for VPS. This plan was
discussed with the patient's house manager.
The remainder of the ___ hospital course is summarized by
systems below:
Neuro: The patient was alert and oriented throughout
hospitalization; pain was controlled on oral pain medicine and
her pain resolved upon return of bowel function.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: On HD3, the patient had return of bowel function and
the diet was advanced sequentially to a Regular diet, which was
well tolerated. Patient's intake and output were closely
monitored.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and
venodyne 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,
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:
APAP 325, ASA 81, Atorvastatin 20, Bisacodyl 10, Colace 100,
Cymbalta 60, Diltiazem CD 240, Fleet Enema, Metamucil 0.52, MOM
400/5, Naprosyn 375, ___ ___, Omeprazole 20, KCL ER 10,
Pramipexole 0.125, Prochlorperazine 10, Rivastigmine 1.5, Senna
8.6, Vitamin D 1000
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Diltiazem Extended-Release 240 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Duloxetine 60 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Potassium Chloride 10 mEq PO QID
9. Pramipexole 0.125 mg PO DAILY
10. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Small bowel obstruction with multiple small-bowel containing
complex ventral hernias
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 presented to the ___ on
___ and were found to have a small bowel obstruction. You
were admitted to the Acute Care Surgery team for further medical
care. You conservatively treated and were restricted from
eating to promote bowel rest and you were started on IV fluids.
Your small bowel obstruction self-resolved and you are now
tolerating a regular diet. You are now medically cleared to be
discharged home to continue your recovery.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. 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:
___
|
10214881-DS-11 | 10,214,881 | 20,147,582 | DS | 11 | 2129-04-30 00:00:00 | 2129-05-05 14:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
first-time witnessed seizure
Major Surgical or Invasive Procedure:
___ frontal lobe stereostaic brain biopsy
History of Present Illness:
Ms. ___ is a ___ woman with no significant PMHx
who presented to ___ as a transfer from an OSH following first
time witnessed seizure and CT finding of R frontal hypodensity
concerning for malignancy.
The day prior to presentation, the patient was doing well. She
attended a family ___ and was her happy normal self. The
evening prior to presentation, she reports onset of a bifrontal
headache, squeezing in nature, without other symptoms. This is
unusual for her, but she took ibuprofen with symptomatic relief.
She went to bed.
The next point in history is when her friend (with whom she
shares a room), was woken by her "screaming" at 3am. She looked
over her and saw her convulsing (per history appears consistent
with generalized convulsion). Her eyes were "roving" and
upwards, not clearly deviated and she was unresponsive. Her
pillow was covered with saliva. Her witnessed convulsion lasted
per reports between ___ minutes. EMS was called. Following
spontaneous termination of the seizure, family reports she was
confused and altered for approximately the next half hour.
Initially she was taken to ___, where a CT
revealed a 4cm R frontal hypodensity concerning for mass. She
was subsequently transferred to ___ for further management
after receiving 250mg of Keppra.
Past Medical History:
uncomplicated child birth ___ years ago
Social History:
___
Family History:
No family history of stroke, seizure, neurologic disease.
Parents a;ive and well. No family history of malignancy.
Physical Exam:
Physical Exam (Admission ___
Vitals:
T= 98.3F, BP= 112/66 , HR= 99 , RR= 18, SaO2= 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: (with aid of ___ translator) Alert, oriented
x 3. Able to relate history without difficulty. Language is
fluent with intact repetition and comprehension. Normal
prosody.
Pt. was able to name both high and low frequency objects from
NIHSS. Speech was not dysarthric. Able to follow both midline
and appendicular commands. Difficulty with ___ backwards
(missed
___ and ___, but was giggling). ___ backwards w/o
difficulty. Pt. was able to register 3 objects and recall ___
at
5 minutes. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: (in dim room) PERRL 6 to 3mm w/ hippus, both directly and
consentually; brisk bilaterally. VFF to confrontation.
Funduscopic exam revealed no papilledema, exudates, or
hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch in all distributions
VII: No facial droop, facial musculature symmetric and ___
strength in upper and lower distributions, bilaterally
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline, deviates side to side w/o
difficulty.
-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
R ___ ___ ___ 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2+ 2 1
R 2 2 2 2 1
- Plantar response was mute bilaterally (very ticklish, required
multiple attempts).
-Sensory: No deficits to light touch, cold sensation,
proprioception throughout. No extinction to DSS.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
Physical Exam (Discharge)
Awake, alert, language fluent. vision full to finger-counting,
PERRL, EOM intact, no nystagmus. Muscle strength ___ in all 4
extremities, no drift. Intact to touch on face and all
extremities.
Pertinent Results:
___ CHEST (PA & LAT)
Low lung volumes which accentuate the bronchovascular markings,
but no
definite focal consolidation seen.
___ MR HEAD W & W/O CONTRAST
Non-enhancing T2 hyperintense cortically-based mass in the right
middle
frontal gyrus without surrounding edema, most consistent with
low-grade
neoplasm such as astrocytoma or dysembryoplastic neuroepithelial
tumor (DNET). Oligodendroglioma is less likely.
___ MR ___
No significant interval change in T2/FLAIR hyperintense lesion
in the right frontal lobe. An cell perfusion images reveal no
increased perfusion in this region. On spectroscopy, there
elevated choline peaks consistent with neoplasm.
___ CT Abd/Pelvis
1. No abdominopelvic malignancy detected.
2. Low lying IUD with tip within the cervix.
3. Please see separate same day CT chest dictation for dedicated
thoracic
findings.
___ CT Chest
No evidence of intrathoracic malignancy.
___ CT Stereotaxis for biopsy
Right frontal hypodensity consistent with known mass seen on the
prior MRI.
___ Brain biopsy pathology: pending
___ CT Head
Expected postsurgical changes at the right frontal craniotomy
site without hemorrhage.
Brief Hospital Course:
Ms. ___ is a ___ woman with no
significant PMH, who presented to ___ as a transfer from an
OSH following first time witnessed seizure and CT finding of R
frontal hypodensity concerning for malignancy. Her MRI showed T2
hypertense cortically-based mass in the R middle frontal gyrus,
without surrounding edema. This suggested low-grade neoplasm,
DNET, or oligodendroglioma.
The patient got a chest, abdomen and pelvis CT to rule out
metastasis, and these scans were negative for malignancy. MR
___ showed an elevated choline peak concerning for
glioma.
On ___, the patient was brought to the OR for a right sided
stereotactic brain biopsy. Her intraoperative course was
uneventful, please refer to the post operative note. The patient
was extubated in the OR and brought to the PACU for close
monitoring.
She remained neurologically intact throughout admission,
including post-biopsy. Her pathology is pending. She was
discharged on dexamethasone to control swelling, and keppra to
prevent further seizures. She will be followed up in Brain Tumor
Clinic for the final pathology results and treatment plan.
Medications on Admission:
Ibuprofen prn headache/pain. very infrequently.
Discharge Medications:
1. LeVETiracetam 750 mg PO Q12H
RX *levetiracetam [Keppra] 750 mg 1 tablet(s) by mouth twice
daily Disp #*60 Tablet Refills:*11
2. Ibuprofen 400 mg PO Q8H:PRN pain
3. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily as needed Disp #*60 Capsule Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice daily as
needed Disp #*60 Capsule Refills:*0
5. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every 6
hours as needed Disp #*30 Tablet Refills:*0
6. Dexamethasone 2 mg PO Q12H
RX *dexamethasone 2 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
7. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Generalized tonic clonic seizure, secondary to mass lesion
R frontal lobe brain lesion, s/p biopsy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to the hospital after having a first-time
seizure. Your CT and MRI scans of your brain showed a mass
lesion in your right frontal lobe. You had a biopsy of this
lesion, and the final pathology is pending.
You were evaluated by Neuro-Oncology in the hospital and will
follow up with them in clinic for your final diagnosis and
treatment plan. It is very important to attend all of your
clinic appointments.
You are discharged on Keppra, a medication to prevent seizures,
and dexamethasone to prevent swelling due to the tumor. You will
have pain medication for your post-op pain and medication to
treat constipation (which can be caused by the pain medication).
It was a pleasure taking care of you during this admission.
Discharge Instructions
Brain Tumor
Surgery
You underwent a biopsy. A sample of tissue from the lesion in
your brain was sent to pathology for testing.
Frozen preliminary was: Inconclusive
Please keep your incision dry until your sutures/staples are
removed.
You may shower at this time but keep your incision dry.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
***Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
***You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
What You ___ Experience:
You may experience headaches and incisional pain.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Feeling more tired or restlessness is 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.
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:
___
|
10215159-DS-21 | 10,215,159 | 24,039,782 | DS | 21 | 2128-01-15 00:00:00 | 2128-01-15 16:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Shellfish / lisinopril / Neosporin / Sulfa(Sulfonamide
Antibiotics) / Ativan / morphine / Statins-Hmg-Coa Reductase
Inhibitors / Benadryl / Codeine / alendronate sodium /
fenofibrate / Fosamax / lorazepam / Niaspan Extended-Release /
Pneumovax 23 / glyburide / lactose
Attending: ___.
Chief Complaint:
Intraparenchymal Hemorrhage
Major Surgical or Invasive Procedure:
___ R craniotomy for ___ evacuation
History of Present Illness:
___ F on ASA 81mg and Plavix 75mg hx CAD s/p drug eluting
cardiac stents
x3 in ___, DM, HTN, COPD who presents from OSH with large
right intraparenchymal hemorrhage with intraventricular
hemorrhage. Pt was found by her sister altered, confused, only
saying "yes" or "no", last seen well yesterday. 911 was called
and pt taken to OSH where she was reportedly
AOx1. She was intubated for CT and reportedly suffered a
generalized seizure upon intubation. She was given ativan and
loaded with phenytoin. CT head revealed large ICH. She was
given DDAVP and transferred to ___ for further evaluation.
Past Medical History:
Chronic obstructive pulmonary disease
HTN
Osteoporosis, treated with yearly Reclast
Spinal stenosis
DJD
Diabetes mellitus with recent HgA1c 6.4%
CAD s/p 3 DES (___)
PSH:
Hysterectomy
colon cancer resection
ankle surgery
Social History:
___
Family History:
Father: lung cancer, Mother: stroke
Physical ___:
Exam on Admission
O: BP: 144 /70 HR: 80 R 18 O2Sats 100%
Gen: intubated, sedation on hold
HEENT: normocephalic, atraumatic
Neck: cervical collar in place
Extrem: Warm and well-perfused. multiple bruises, prominent
right
knee ecchymosis with edema
Neuro:
Mental status: GCS 6
No Eye opening
Non verbal/Intubated
Withdrawal bilateral uppers right greater than left
minimal withdrawal bilateral lowers
Pupils brisk ___, right slightly irregular
Absent Corneals
+ gag, + cough
EXAM ON DISCHARGE
Vitals- Tm 99.5 BP126-153/45-58 HR80-88 RR18 SaO294%RA
General- Elderly woman w/ large bulging mass from site of
craniotomy. Intermittently alert and opens eyes, tracks
intermittently. NAD.
HEENT- Sclera anicteric, pupils anesicoric, MMM, oropharynx
clear
Neck- supple, JVP not elevated
Lungs- Clear on anterior lung fields.
Back: Erythematous and dry rash on back with more moist and
erythematous area on sacrum and gluteal cleft
CV- Regular rate and rhythm
Abdomen- soft, non-tender, non-distended, bowel sounds present.
PEG dressing c/d/i.
GU- Foley draining amber yellow urine
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- Awake and alert, intermittent tracking and wiggles toes
by command intermittently (occasionally even answering questions
with toe movement), unable to answer questions
Pertinent Results:
IMAGING
___ CT C-spine
1. No acute fracture or subluxation. Degenerative changes are
most pronounced at the C6-C7 level with endplate sclerosis
irregularity and disc space narrowing.
2. Foci of air within the left supracavicular region with soft
tissue
induration may relate to attempted central line placement.
Correlation with history of such.
___ ___
Large right frontal intraparenchymal hemorrhage with
intraventricular
extension involving the right lateral ventricle, occipital horn
of the left lateral ventricle, third ventricle as well as
extending into the fourth ventricle. Prominent ventricles are
noted concerning for evolving hydrocephalus. Mass effect with
effacement of the frontal horn of the right lateral ventricle,
sulcal effacement, an approximate 0.8 cm leftward shift of
normally midline structures.
Trace likely subdural hemorrhage layers along the falx
anteriorly.
___ CTA head
1. Two mm aneurysm of the right cavernous internal carotid
artery.
2. Patent Circle of ___.
3. Unchanged, large right frontal intraparenchymal hematoma with
intraventricular extension, local mass effect, and 9 mm of right
to left midline shift. No new hemorrhage.
___ NCHCT
1. Status post right craniotomy with small underlying
extra-axial collection of air and blood.
2. Status post evacuation of right frontal parenchymal hematoma
with small amount of blood and foci of air in the surgical bed.
3. Stable small amount of subarachnoid and subdural hemorrhage
along the
anterior falx bilaterally. Small amount of subarachnoid
hemorrhage along
bilateral convexities is more conspicuous compared to
approximately 6 hr
earlier.
4. Unchanged blood throughout the right lateral ventricle, third
ventricle and fourth ventricle, as well as in the occipital horn
of the left lateral ventricle. Stable ventricular size,
age-appropriate. In the absence of more remote studies for
comparison, it is not known whether any subtle obstructive
hydrocephalus may be present.
___ CT HEAD W/OUT CONTRAST
1. Stable size of ventricles.
2. Status post evacuation of right frontal hematoma with
expected evolution
since prior study. No evidence of new hemorrhage.
___ PORTABLE CHEST-XRAY
NG tube tip is in the stomach. Heart size and mediastinum are
unchanged but the res interval development of increased left
pleural effusion as well as left basal consolidation, concerning
for aspiration. Mild vascular congestion is present but overall
unchanged.
___ ECHO
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
normal (LVEF>55%). Diastolic function could not be assessed. The
number of aortic valve leaflets cannot be determined. The aortic
valve is not well seen. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are not
well seen. Trivial mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is an
anterior space which most likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Within limitations of
study, there appears to be normal global left ventricular
systolic function. The right ventricle is not well visualized.
Pulmonary artery pressures and diastolic parameters are
indeterminate.
___ CT HEAD W/O CONTRAST
1. Mild increase in ventricular size since prior study.
Attention to
follow-up is recommended.
2. Stable intraventricular hemorrhage with expected evolution
since prior
study. No evidence of new hemorrhage or extension of
pre-existing image.
___ - Non-contrast Head CT:
1. Stable intraparenchymal and intraventricular hemorrhage as
described.
2. Evolving postoperative changes related to patient's right
frontal
craniotomy and subdural hematoma evacuation.
3. Grossly stable approximately 3 mm right to left midline
shift.
4. Please note MRI of the brain is more sensitive for the
detection of acute infarct.
___ CTA HESD W/ W/O CONTRAST
1. There is apparent increased size of subcutaneous fluid
overlying the right frontal craniotomy, although this may be
secondary to patient positioning. Given a possible defect
within the dura underneath the right frontal craniotomy site,
the findings could represent CSF leak if the subcutaneous
collection continues to grow in size.
2. Apparent increase in size of the extra-axial fluid along the
right lateral convexity concerning for a CSF hygroma, although
this may be secondary to differences in patient positioning.
2. Similar post-surgical findings including intraventricular
hemorrhage and mild leftward 3 mm shift.
3. No new intracranial hemorrhage.
CT head W/O Contrast ___
IMPRESSION:
1. Increased hypodense subdural collection overlying the right
cerebral
hemisphere without acute blood products. Increased effacement
of the right frontal and parietal sulci and new effacement of
the ventricles. Slightly increased leftward shift of midline
structures.
2. Stable hypodensity at the site of prior right frontal
hematoma evacuation without evidence for new blood products.
CHEST (PORTABLE AP) Study Date of ___ 4:31 ___
IMPRESSION:
Lungs well expanded and clear. Small left pleural effusion
probably present, unchanged. Normal cardiomediastinal
silhouette. Feeding tube ends in the upper stomach. Right PIC
line ends in the low SVC. No pneumothorax
___ Video swallow
Pt presents with moderate oropharyngeal dysphagia characterized
by delayed swallow initiation and pharyngeal weakness. These
deficits result in consistent penetration of thin and
nectar-thick liquids (thin > nectar). Most penetrated material
is
stripped from the laryngeal vestibule at the height of the
swallow; however, some remains and places pt at risk for trace
aspiration of residue.
___ CT HEAD W/O CONTRAST
1. Hypodense subdural fluid collection overlying the right
cerebral hemisphere
is significantly reduced in size from the prior examination.
Soft tissue
swelling and fluid collection overlying the right scalp is
similar-appearing
to slightly improved.
2. Hypodensity at the site of prior right frontal hematoma
evacuation is
slightly increased from the prior examination, expected
evolution.
3. No new hemorrhage or acute infarction.
___ CT HEAD W/O CONTRAST
IMPRESSION:
1. Subcutaneous fluid collection and soft tissue swelling
overlying the scout adjacent to the craniotomy site is increased
from the prior examination and now measures 2 cm at its
greatest diameter.
2. Hypodense subdural fluid collection and hypodensity involving
the right frontal lobe are stable from the prior examination.
3. No new hemorrhage or acute infarction. No evidence of
herniation or
midline shift.
___ CT HEAD W/O CONTRAST
IMPRESSION:
1. Right frontal craniotomy changes with slight interval
decrease in size of the overlying subcutaneous scalp fluid
collection.
2. Stable appearance of the evacuation cavity in the right
frontal lobe with stable small amount of residual hemorrhage
layering in the occipital horns.
No new intracranial hemorrhage.
3. Stable prominence of the ventricles.
___ CT HEAD W/O CONTRAST
1. Slightly enlarged hypodense subcutaneous fluid collection
overlying the
right craniotomy site, measuring 8.5 x 2.0 cm, previously 7.5 x
1.4 cm.
2. No acute intracranial abnormalities. No new large territorial
infarcts or hemorrhage.
3. Stable appearance of postsurgical changes, including axial
fluid
collection.
LABS
___ 06:10PM BLOOD WBC-13.9* RBC-4.45 Hgb-11.7 Hct-36.7
MCV-83 MCH-26.3 MCHC-31.9* RDW-14.4 RDWSD-42.4 Plt ___
___ 06:10PM BLOOD Neuts-85.2* Lymphs-6.4* Monos-5.6
Eos-0.4* Baso-0.5 Im ___ AbsNeut-11.82* AbsLymp-0.89*
AbsMono-0.78 AbsEos-0.05 AbsBaso-0.07
___ 06:10PM BLOOD ___ PTT-25.5 ___
___ 06:10PM BLOOD Glucose-175* UreaN-19 Creat-0.8 Na-139
K-5.0 Cl-102 HCO3-23 AnGap-19
___ 06:00PM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 06:00PM URINE RBC-15* WBC-133* Bacteri-FEW Yeast-NONE
Epi-0
___ 06:00PM URINE RBC-15* WBC-133* Bacteri-FEW Yeast-NONE
Epi-0
___ 05:02AM BLOOD WBC-11.7* RBC-3.26* Hgb-8.3* Hct-27.9*
MCV-86 MCH-25.5* MCHC-29.7* RDW-15.9* RDWSD-48.5* Plt
___ 05:02AM BLOOD Neuts-71.8* Lymphs-12.1* Monos-6.1
Eos-9.1* Baso-0.3 Im ___ AbsNeut-8.39* AbsLymp-1.42
AbsMono-0.71 AbsEos-1.07* AbsBaso-0.04
___ 09:33AM URINE Blood-NEG Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-LG
___ 09:33AM URINE RBC-4* WBC-136* Bacteri-FEW Yeast-NONE
Epi-<1 TransE-1
___ 01:11PM BLOOD ALT-36 AST-33 LD(LDH)-196 AlkPhos-64
TotBili-0.2
___ 02:45PM BLOOD STRONGYLOIDES ANTIBODY,IGG-Test
___ 09:28AM BLOOD WBC-9.0 RBC-2.94* Hgb-7.5* Hct-25.6*
MCV-87 MCH-25.5* MCHC-29.3* RDW-16.4* RDWSD-50.4* Plt ___
___ 09:28AM BLOOD Neuts-71 Bands-0 Lymphs-10* Monos-5
Eos-11* Baso-1 ___ Metas-2* Myelos-0 NRBC-1* AbsNeut-6.39*
AbsLymp-0.90* AbsMono-0.45 AbsEos-0.99* AbsBaso-0.09*
___ 09:28AM BLOOD ___ PTT-28.7 ___
___ 09:28AM BLOOD Glucose-134* UreaN-14 Creat-0.5 Na-137
K-3.8 Cl-103 HCO3-23 AnGap-15
___ URINE CULTURE
KLEBSIELLA PNEUMONIAE |
AMIKACIN-------------- <=2 S
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- R
___ URINE CULTURE
ESCHERICHIA COLI |
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
HOSPITAL COURSE
___, Ms. ___ was admitted from the emergency room. She
underwent a CTA which was negative for any vascular
abnormalities with the exception of a 2mm R ICA aneusyms. The
patientw as transfused platelets for recent aspirin use and went
to the operating room urgently for a right craniotomy for clot
evacation. Her post operative scan showed good evacuation of the
clot and stable ventricle size, so no intraventricular drain was
placed.
___, the patient was following commands appropriate for
extubation.
___, during morning rounds patient not opening her eyes but
follows commands on RUE and bilateral lower extremities. Around
1000, nursing noted patient not following commands, patient
assessed was more lethargic but continues to wiggle bilateral
lower extremities. Requested patient to have an ABG due to
significant respiratory co-morbities and CT Head that was
stable.
___, patient continues to be neurologically stable. On morning
rounds, patient is tachypnic however maintaining her
oxygenation, patient tachycardic with rates 95-105. Her chest
x-ray was concerning for more pulmonary congestion with possible
aspiration. Patient was given 20mg lasix with good urinary
output however did not effect her respiratory status. Patient is
pending an echocardiogram to assess her current cardiac function
given her signfificant cardiac/respiratory history.
___, patient was noted to not be following commands as briskly
as prior. Patient neurologically exam is non-verbal, RUE will
localize with constant noxious stimulus, RLE wiggle
toes/withdrawal to noxious; LLE triple flexion only, and weak
extension of LUE. Patient underwent a NCHCT that was stable with
mild increase in ventricles. Per report, patient had SVT around
0400 that resolved with 5mg Metoprolol. Patient continues to be
tachypneic with rates in mid-___ maintain her oxygenation.
Critical care team to continue to monitor her closely for the
need for re-intubation.
On ___ her exam remained stably poor and she was satting well
with nasal cannula in the setting of tachypnea to the low 30's.
On ___, the patient's right upper extremity was noted to be
more active. It was determined she would be transferred to the
step down unit.
On ___, the patient was noted to have a bump in her WBC count,
from 13 to 16.7. A urinalysis was ordered and was noted to be
positive for leuks and she was started on Ceftriaxone. The foley
catheter was discontinued. A non-contrast head CT was performed
and noted to be stable; given the results of this CT, Aspirin
and Plavix were started. ACS was consulted for placement of a
PEG tube. She was started on standing nebulizers. Overnight, she
was triggered for O2 saturation levels which were dropping into
the low ___. She received 20mg of Lasix and underwent a repeat
chest x-ray which was poor quality. She continued with
persistent tachycardia and tachypnea. She received a second dose
of Lasix 20mg as well as morphine and her symptoms improved.
Given this event, it was determined she would be transferred to
the ICU for close monitoring.
On ___, the patient was noted to have a WBC count of 19.1, up
from 16. A chest x-ray was performed and concerning for PNA.
On ___, the patient was noted to have an enlarging right pupil
diameter size at 0200AM. She received Mannitol 25g IV x1 STAT.
She underwent a STAT non-contrast head CT which was negative for
hemorrhage or herniation. She was evaluated by the ICU team who
did not feel intubation was necessary.
On ___, the patient remained neurologically stable on
examination. The patient remains on Zosyn and Vancomycin. EEG
monitoring showed....
On ___, the patient continues to be neurologically stable.
Patient is more frequently following commands on RUE/RLE; eyes
open spontaneously. Patient is being treated for PNA with
Zosyn/Vancomycin. Patient's sodium is trending up, increased
free water flushes; will continue to monitor closely.
On ___ the patients eyes were open spontaneoulsy, the patient
was sitting in a reclines. The patient was localizing with her
bilateral upper extremities, right greater than left, and the
the patient wiggled her toes on command. Medicine was consulted
for recurrent fevers while on antibiotics, and they suggested an
ID consult. ID reccomended to continue current antibiotic
regimen as white blood cells had decreased & to monitor the
patients incision and fluid collection in her head as a possible
source of infection.
On ___, ID recommending RUQ U/S for transaminitis. Patient
became anisocoric with R>L by 3mm. CT head performed and showed
worsening external hydrocephalus with MLS. Discussed with
___. No head wrapping. Pt added to OR for ___ for possible
VPS insertion. ASA and Plavix held. Made NPO, IVF at midnight.
___: CT head stable to improved MLS; persistent external
collection; Exam improved although per family is more confused
compared to ___ held TF during day while following exam,
began moving left side purposefully;
On ___, may restart TF- no shunt today. more bright on exam.
pupils asymmetry pronounced but stable, vanc level 23- held pm
vanco dose will repeat vanco level, UA from ___ and ___ ++
yeast-ID stated change foley no need to treat with
ABT/antifungals , WBC improved at 10.
On ___ the patient was alert and oriented to person and place
as well as year of birth. The patient would wiggle her toes to
command to her bilateral lower extremities and would give a
"thumbs up" to her right upper extremity and was spontaneously
moving her left upper extremity. A repeat NCHCT was done and
showed an increased size of subdural collection with left
midline shift. The patient was scheduled for the OR on ___
for a left frontal VP shunt. The patients vancomycin trough was
14.8 and her Vancomycin was restarted. The patient began having
loose stools and a culture for CDIFF was sent. The patient was
cleared by speech and swallow for a nectar thick/ ground diet.
On ___ the patient remained stable. Her neurologic exam was
unchanged and she was oriented to herself, location and her
year of birth. The patient was re-evaluated by speech & swallow
and was made NPO as she did not pass her swallow evaluation. A
video study was ordered for ___. Her stool culture was
negative for C-diff.
On ___ the patient remained stable. The patient underwent a
video swallow per speech and swallow and the reccomendations
included a puree/nectar thick liquid diet although still
reccomend PEG placement. ACS was consulted. The patients
electrolytes were repleated. Surgical consent was obtained for
the VP shunt placement from patients sister ___. Nutrition
recommended that the patient be given a diabetic diet (glucerna
tube feeds with glucerna shakes), banana flakes and calorie
counts.
___, patient remains neurologically intact. A repeat CT scan
Head was done and showed a significant decrease in subdural
collection; OR was cancelled for VP shunt. In light of this, ACS
was re-consulted for PEG placement, a KUB was ordered per
request of team. Patient leukocyotsis is persistent however is
13, ordered for change of foley and UA/urine culture.
On ___ she was awaiting a PEG placement and was otherwise
stable.
On ___ her PEG was placed without difficulty and her neurologic
exam was stable
On ___ her tube feeds were started and rehab planning was
begun. She was also more awake and able to state both her name
and that she was at ___.
On ___ the patient was retsrted on her home aspirin and plavix.
The patients diet was changed from NPO as she was seen and
evaluated by speech and swallow and they had recommended nectar
thick liquids and pureed solids and the patients electrolytes
were repleated. Rehab planning continued. On exam the patients
eyes were open spontaneously although the patient would not
respond to orientation questions. She would track with her eyes,
and continued with mild anisocoria. The patient was moving her
uppers antigravity, and would wiggle her toes to command.
On ___ the patient remained neurologically stable. She was
alert and sitting up in a chair with eyes open spontaneously.
She would wave "hello" with her right hand as well as show her
right thumb, and two fingers on the right hand. The patient was
following simple commands, and wiggling her toes to command. Her
staples were removed from the right side of her head and the
incision was clean dry and intact without signs and symptoms of
infection.
On ___, the patient continued to do well out of restraints. She
was sitting up in her chair. Her neurological exam remained
stable. Currently await insurance authorization for disposition
planning. She was felt to
___ Patient was transferred to medicine service after having
suspected aspiration event. She is being treated with IV
vancomycin, CefePIME, MetRONIDAZOLE (FLagyl) 500 mg IV Q8H. Last
day will be ___,
___ Patient was found to have C-diff. She was started on PO
vancomycin to be continued until ___.
___ Patient was found to have multi-drug resistant klebsiella
colonization of foley. Foley was changed but treatment was not
felt to be warranted.
SUMMARY:
___ year old female with CAD s/p stentingx3 (___), HTN, COPD,
stage 1 colon cancer, and DMII admitted on ___ with large
right frontal IPH with IVH and MLS s/p right craniotomy
evacuation. Unfortunately she was left with significant physical
impairments and is non-verbal. Subsequently she had an
aspiration event and was treated with antibiotics (see below for
course). She has C-diff and is being treated with PO vancomycin
(see below). She has a non-infectious rash on her back and
buttocks due to heat and moisture, but she has had some
eosinophilia which should be monitored in the event it is
medication related (eosinophilia was noted on ___ AM even
before starting antibiotics that day). To prevent skin breakdown
she has a chronic foley which was colonized with pan-resistant
klebsiella, at this time she is asymptomatic so treatment was
not warranted but foley was replaced ___. Foley can
eventually be removed when skin around buttocks heals. Her
chronic DM has been controlled with diet and ISS if need for
elevated finger sticks; COPD was treated with home nebulizers.
She was continued on ASA 81mg, Plavix, metoprolol tartrate and
pravastatin for her CAD s/p DES (___). At discharge she is
medically and neurologically stable though limited as described
in the exam.
TRANSITIONAL ISSUES:
#Antibiotics for aspiration PNA: IV Vancomycin, cefepime and
flagyl (___)
#C-Diff: PO vancomycin (Concurrent w/ IV vancomycin) w/ last day
of PO vanc on ___
#Keprra 500 BID to be continued for 3 months after surgery (last
day ___
#Goal SBP <160
#Consider SLP for swallowing as she was taking purees and
thickened liquids
#Remove foley when buttocks skin heals
#For macerated skin around sacrum and buttocks keep dry, barrier
cream, and preventative measures as needed
#Monitor Eosinophilia
#Subcutaneous CSF leak overlying R frontal bone (8.5 x 2.0 cm)
overlying the site of craniotomy is stable and does not need to
be evacuated per neurosurgery
Medications on Admission:
Asa 81mg, Plaviix 75mg, METFORMIN 1000MG BID, LOSARTAN 100MG
daily,
PRAVASTATIN SODIUM 10 MG Daily, SERTRALINE HCL 100 MG Daily,
METOPROLOL SUCC ER 50 MG TAB DAily, FLUTICASONE PROP 50 MCG
SPRAY
USE 1 SPRAY IN EACH NOSTRIL ONCE A DAY, SPIRIVA 18 MCG
CP-HANDIHALER
INHALE 1 CAPSULE ONCE A DAY, PROAIR HFA 90 MCG INHALER 2 PUFFS
EVERY 4 HOURS AS NEEDED
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Losartan Potassium 50 mg PO DAILY
5. Sertraline 100 mg PO DAILY
6. Budesonide 0.5 mg/2 mL INHALATION BID
7. CefePIME 2 g IV Q8H
8. Fluticasone Propionate NASAL 2 SPRY NU DAILY
9. HydrALAzine ___ mg IV Q6H:PRN SBP>160
10. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
11. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
12. LeVETiracetam Oral Solution 500 mg PO BID
13. Metoprolol Tartrate 50 mg PO Q6H
14. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
Stop on ___. Miconazole Powder 2% 1 Appl TP BID
16. Modafinil 400 mg PO DAILY
17. Ondansetron 4 mg IV Q8H:PRN nausea
18. Pravastatin 10 mg PO QPM
19. Vancomycin 1000 mg IV Q 12H
20. Vancomycin Oral Liquid ___ mg PO Q6H
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary:
- Right frontal IPH with bilateral intraventricular extension
- Post-operative right frontal extracranial CSF collection
- Aspiration pneumonia
- C. difficile colitis
- Asymptomatic catheter-associated bacteruria (MDR Klebsiella)
Secondary:
- CAD s/p RCA PCI with overlapping ___ ___
- Diabetes mellitus type II
- Hypertension
- COPD
- Stage I colon cancer s/p laparoscopic right colectomy ___
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear ___ were admitted to ___ on ___ after having a bleed in
your brain. ___ underwent a surgery called a craniotomy to
remove the blood from your brain. Surgery made the following
recommendations:
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
___ have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that ___ take this medication consistently and on
time.
___ may use Acetaminophen (Tylenol) for minor discomfort if
___ are not otherwise restricted from taking this medication.
Some weeks after receiving your surgery ___ vomited and some of
the vomit got into your lungs. ___ were treated with
antibiotics. Subsequently ___ started to have liquid diarrhea
and were found to have an infection called C-diff diarrhea. ___
are being treated with antibiotics for this. Please take all of
your medications as directed and attend all of your follow up
appointment.
Take care and be well. Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10215416-DS-19 | 10,215,416 | 27,534,252 | DS | 19 | 2170-05-21 00:00:00 | 2170-07-20 22:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
vomitting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hospitalized w four days of mailaise, intermittent
palpitations and one day of emesis. She has been in her usual
state of health without recent hospitalization or antibiotics
and began feeling unwell. She then noted racing heart sensation
present at rest, more notable at night, without chest pain or
shortness of breath but with some anxiety. Resolved on its own
but recurred. Decreased appetite developed early in the week
and then she developed multiple episodes of vomiting today,
inability to keep food/fluids down and one watery diarrhea this
AM. She came to ED where she had sinus tach 140s, normotension,
lack of fever, lactemia 5 and hypokalemia, hypoMG. Lactate
improved with fluids and she also received PO K 40, Mg 2gm IV
and several doses of valium for elevated CIWA.
She consumes ___ glasses of wine most nights with dinner. She
tried a glass of wine today but that made her stomach worse.
She has never had withdrawal or personal problems related to
drinking.
ROS: she also noted swelling of her L ankle this AM and then
some bruises over her toes, she denies any trauma or injuries.
no cough, +mid back pain, no headache, neck stiffness,
confusion, abdominal pain, dysura, +urinary frequency, no focal
joit pains, +anxiety
Past Medical History:
s/p breast surgery
Social History:
___
Family History:
not pertinent to current management
Physical Exam:
98.2 150/94 pulse 105-114, 18 99ra
aox3, calm and attentive
clear lungs
regular pulse
soft abdomen
no audible cardiac rub or extra heart sounds
no asymmetry of ankles or feet
tiny bruise on ___ toe on L foot
Pertinent Results:
___ 03:30PM BLOOD WBC-13.1*# RBC-4.40 Hgb-14.7 Hct-42.7
MCV-97 MCH-33.4* MCHC-34.4 RDW-12.8 RDWSD-46.1 Plt ___
___ 03:30PM BLOOD Neuts-79.6* Lymphs-11.9* Monos-7.1
Eos-0.1* Baso-0.9 Im ___ AbsNeut-10.43* AbsLymp-1.56
AbsMono-0.93* AbsEos-0.01* AbsBaso-0.12*
___ 03:30PM BLOOD Glucose-118* UreaN-6 Creat-0.8 Na-136
K-3.0* Cl-92* HCO3-18* AnGap-29*
___ 03:30PM BLOOD Calcium-11.6* Phos-3.9 Mg-1.4*
___ 03:30PM BLOOD D-Dimer-254
___ 07:51PM BLOOD Lactate-2.3*
___ 03:44PM BLOOD Lactate-5.0*
EKG: personally reviewed sinus tachycardia 130s, no STE,
___ 08:00AM BLOOD WBC-8.9 RBC-3.61* Hgb-12.1 Hct-36.7
MCV-102* MCH-33.5* MCHC-33.0 RDW-13.1 RDWSD-49.1* Plt ___
___ 08:00AM BLOOD Glucose-106* UreaN-6 Creat-0.7 Na-137
K-3.9 Cl-104 HCO3-21* AnGap-16
___ 08:00AM BLOOD ALT-53* AST-56* AlkPhos-34* TotBili-1.5
___ 07:51PM BLOOD Lactate-2.3*
Brief Hospital Course:
___ with suspected acute gastroenteritis causing electrolyte
disturbance and acidosis as well as tachycardia.
#Gastroenteritis: Symptoms resolved in hospital, norovirus
negative.
#Tachycardia: resolved with hydration
#Alcohol use: She did not score on CIWA
# Abnormal LFTs: Advised her to f/u with PCP
___ on ___:
The Preadmission Medication list is accurate and complete.
1. Norethindrone-Estradiol 1 TAB PO DAILY
Discharge Medications:
1. Norethindrone-Estradiol 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
1. Viral gastroenteritis
2. Tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with vomiting and diarrhea consistent with a
viral gastroenteritis. You have improved greatly with fluids.
Please continue to follow a bland diet at home, and avoid dairy
for the next few days. Thus far, we have not found bacteria in
your urine, so we are stopping antibiotics for a urinary tract
infection. Also, your blood pressures were slightly elevated in
the hospital - please discuss this with Dr ___. You also had
very slight elevation in liver function tests which you can also
discuss with her.
Followup Instructions:
___
|
10215709-DS-10 | 10,215,709 | 25,035,026 | DS | 10 | 2156-07-04 00:00:00 | 2156-07-04 09:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Cefaclor / orange food dye
Attending: ___.
Chief Complaint:
atypical headache
Major Surgical or Invasive Procedure:
___: Diagnostic Cerebral Angiogram
___: Cerebral angiogram with coiling of Left ICA aneurysm
History of Present Illness:
___ year old right-handed female with h/o migraines who woke up
this morning feeling nauseas and lightheaded. She then
developed a head which she described as a heavy felling and then
developed flushing. She continue to feel "apprehensive" and
"unwell" throughout the morning. She had her colleague take her
blood pressure which was slightly elevated compared to her
baseline. She reported that her headache progressed and she
called her PCP and was evaluated later on the day. She reports
her BP was elevated and was sent to ED to evaluated for
aneurysmal bleed and transferred to ___ is she had an SAH.
Previously, pt had a Brain MRI and an incomplete angiogram in
___ which was essentially negative. She had a repeat
MRI/A today at ___ which showed a 6mm
left ICA aneurysm and 2mm A2 aneurysm.
Past Medical History:
migraines, hypercholesterolemia, MVP
Social History:
___
Family History:
paternal grandfather died of aneurysmal bleed at age ___
Physical Exam:
O: T: 98.1 70 133/86 18 97%
Gen: WD/WN, comfortable, NAD.
HEENT: head short cut, atraumatic, eyes clear, fundi normal, no
a/v nicking, no papilledema nose patent, throat clear Pupils:
___ EOMs - intact
Neck: Supple, no thyromegaly, trachea midline
Lungs: CTA bilaterally, resonant
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: ___ objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 2+ -----------
Left 2+ -----------
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Handedness Right
PHYSICAL EXAM UPON DISCHARGE:
AOx3, ___ with full motor. Groin soft/ + pulses
Pertinent Results:
___ angiogram
ReportIMPRESSION: Ms. ___ underwent cerebral
angiography, which revealed a 4 mm-sized left superior
hypophyseal artery aneurysm pointing medially and inferiorly
into the cavernous sinus. The patient tolerated the procedure
well and there were no immediate complications.
___ CXR
FINDINGS: PA and lateral chest views were obtained with patient
in upright
position. The heart size is normal. No configurational
abnormalities
identified. Thoracic aorta unremarkable. No mediastinal
abnormalities are
seen. The pulmonary vasculature is normal. No signs of acute or
chronic
parenchymal infiltrates are present, and the lateral and
posterior pleural
sinuses are free. No evidence of pneumothorax in the apical area
on the
frontal view. Skeletal structures of the thorax grossly within
normal limits.
IMPRESSION: Normal chest findings on preoperative examination.
Brief Hospital Course:
___ woman admitted to the neurosurgery service with incidental
finding of a cerebral aneurysm and atypical headache. On ___
she underwent a diagnostic cerebral angiogram which confirmed a
4mm left ICA aneurysm. She did well post procedure. The results
were discussed with her and she elected to undergo coiling asap
therefore it was scheduled for ___.
She underwent the coiling procedure under ___ anesthesia and
recovered well. She was monitored in the ICU overnight without
any difficulty. She was discharged home on ___ on ASA 325mg
daily for 30 days.
Medications on Admission:
Simvastatin 5 mg QD (not taking recently); Fioricet PRN
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: ___
Tablets PO every six (6) hours as needed for headache.
Disp:*60 Tablet(s)* Refills:*0*
3. diazepam 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day)
as needed for headache.
Disp:*20 Tablet(s)* Refills:*0*
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 30 days.
Disp:*30 Tablet(s)* Refills:*0*
5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
LEFT INTERNAL CAROTID ARTERY ANEURYSM
HEADACHE
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after your workup for headache
revealed and incidental finding of cerebral aneurysm. You
underwent a diagnostic cerebral angiogram and then a Cerebral
angiogram with coiling of your aneurysm. You tolerated this
procedure well. You were recovered in the ICU overnight and
discharged on ___.
Angiogram with Embolization and/or Stent placement
Medications:
Take Aspirin 325mg (enteric coated) once daily for one month
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
When you go home, you may walk and go up and down stairs.
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
After 1 week, you may resume sexual activity.
After 1 week, gradually increase your activities and distance
walked as you can tolerate.
No driving until you are no longer taking pain medications
Followup Instructions:
___
|
10216074-DS-16 | 10,216,074 | 20,697,613 | DS | 16 | 2179-10-05 00:00:00 | 2179-10-05 13:10:00 |
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 elbow deformity and left hip pain and s/p fall
Major Surgical or Invasive Procedure:
___ L elbow I&D, exfix. L ___ ___
History of Present Illness:
Pt without significant past medical history and no L distal
radius fracture and concommittant L elbow open dislocation as
well as a L acetabular fx after a fall ___ feet from a ladder.
Past Medical History:
no pertinent past medical history
Social History:
___
Family History:
unknown
Pertinent Results:
___ 06:00AM BLOOD WBC-17.1* RBC-3.33* Hgb-10.4* Hct-31.9*
MCV-96 MCH-31.2 MCHC-32.6 RDW-12.0 RDWSD-41.9 Plt ___
___ 02:30PM BLOOD WBC-13.6* RBC-2.70* Hgb-8.4* Hct-26.7*
MCV-99* MCH-31.1 MCHC-31.5* RDW-12.1 RDWSD-43.6 Plt Ct-85*
___ 06:40AM BLOOD WBC-14.2* RBC-2.63* Hgb-8.2* Hct-25.4*
MCV-97 MCH-31.2 MCHC-32.3 RDW-12.0 RDWSD-42.0 Plt Ct-78*
___ 09:00AM BLOOD WBC-12.2* RBC-2.56* Hgb-8.0* Hct-24.1*
MCV-94 MCH-31.3 MCHC-33.2 RDW-11.9 RDWSD-40.7 Plt ___
___ 09:00AM BLOOD ___ PTT-24.9* ___
___ 09:00AM BLOOD Glucose-101* UreaN-20 Creat-0.6 Na-141
K-3.6 Cl-106 HCO3-26 AnGap-13
___ 02:45PM BLOOD Glucose-130* Lactate-1.9 Na-141 K-4.0
Cl-106 calHCO3-25
Brief Hospital Course:
Hospitalization Summary
The patient presented to the emergency department after a fall
from a ladder and was evaluated by the orthopedic surgery team
for pain and deformity in the left arm. The patient was found to
have left distal radius fracture and left elbow dislocation and
was admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for open reduction
internal fixation of left distal radius and
irrigation/debridement and open reduction internal fixation of
left elbow fracture dislocation, 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 was
noted to have waxing and waning consciousness while on the floor
and was evaluated for causes of delerium including UA/UCx, TSH,
LFTs, was given thiamine, and a NCHCT was performed to evaluate.
The appropriate interventions were performed. The patient was
moved to a suite with a window, was given frequent reorientation
and pain medication was provided appropriately. On POD 2 the
patient's platelets were noted to drop from initial 200s to ___.
Lovenox was stopped and patient was switched to fondaparinux. A
hematology consult was requested to evaluate the possibility of
HIT. After HIT was ruled out, the patient was restarted on
lovenox. He developed some significant constipation in house
which resolved with methylnaltrexone x1 and an aggressive bowel
regimen. 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
nonweight bearing in the left upper extremity and touchdown
weight bearing in the left 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 Q4H
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Calcium Carbonate 500 mg PO TID
4. Docusate Sodium 200 mg PO BID
5. Enoxaparin Sodium 40 mg SC QPM Duration: 4 Weeks
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 MG SC QPM Disp #*28 Syringe
Refills:*0
6. Lactulose ___ mL PO TID constipation
7. Multivitamins 1 TAB PO DAILY
8. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*50 Tablet Refills:*0
9. Pantoprazole 40 mg PO Q24H
10. Polyethylene Glycol 17 g PO DAILY
11. Senna 17.2 mg PO BID
12. Tamsulosin 0.4 mg PO DAILY
13. Thiamine 100 mg PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
left acetabular fracture, left distal radius fracture, open
elbow fracture dislocation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for repair of your left distal radius
and washout of your open left elbow fracture dislocation by
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 in your left upper 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 fondaparinux 2.5 daily x4 weeks
WOUND CARE:
- you have an external fixator device in place at your left
upper extremity.
- Pin site care should be performed daily including wrapping the
pins with xeroform strips and gauze. Be careful not to wrap too
tightly which can cause skin necrosis.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
-the splint that is in place should stay there until you are
seen in clinic at follow up.
Physical Therapy:
Activity: Activity: Activity as tolerated Activity: Ambulate
twice daily if patient able
Left lower extremity: Touchdown weight bearing
Left upper extremity: Non weight bearing
Encourage turn, cough and deep breathe q2h when awake<br>LUE
___ use platform crutch
Treatments Frequency:
Pt with hinged external fixator at elbow. Perform daily pisite
care with placement of xeroform and loosely wrapped gauze around
pins. keep in splint until f/u. staples will be removed at
initial 2 week follow up visit.
Followup Instructions:
___
|
10216097-DS-12 | 10,216,097 | 23,709,960 | DS | 12 | 2189-07-17 00:00:00 | 2189-07-17 15:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril / metoprolol
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Thoracentesis (___)
Paracentesis (___)
Right Heart Catheterization (___)
___ CT-guided Lymph Node Biopsy (___)
Right/Left Heart Catheterization (___)
Myocardial Biopsy (___)
History of Present Illness:
___ year-old man with a PMH significant for AFib (on coumadin),
CAD, sCHF (LVEF 47% per echo ___ who presents with dyspnea.
The patient reports that over the past ___ months that he has
had progressive SOB with ___ edema and increasing abdominal
girth. He reports that he is strict with his 2g diet, but then
will report eating the chicken wrap multiple times at
___. He lives in a duplex and reports that he is no
longer able to walk up the one flight of stairs necessary to
reach the second level. Despite all of this progressive SOB, he
denies any PND or orthopnea. Patient is followed at ___
Cardiology, most recently seen ___ by NP ___ for
progressively worsening dyspnea on exertion, fatigue, and
abdominal girth despite an increase in Torsemide dose from 40
BID to 60 BID. Today, patient reports similar symptoms despite
yet another increase in Torsemide to 60mg BID. He was going to
come to the ER last week as the weather prevented him from
traveling. He has recently increased his dose of torsemide to 60
mg BID. He reports that his currently weight is ~10 lb above his
comfortable dry weight of 197 lbs. He is otherwise notably
negative for chest pain, PND, orthopnea, fever/chills, abdominal
pain, N/V/D.
In the ED intial vitals were 98.2 73 113/36 28 92%. Labs notable
for Chem-7 with BUN/Cr 42/1.6 (within baseline) otherwise wnl,
CBC with mild thrombocytopenia to Plt 134 otherwise wnl, proBNP
3025, lactate 1.1, coags with INR 3.2. CXR showed The patient
was administered aspirin 243mg, and 80 IV lasix. The patient is
now admitted to ___ service for diuresis. Vitals on transfer:
97.8 81 106/66 20 92% RA.
ROS: On review of systems, 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 recent fevers, chills or rigors.
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,
paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope
or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes
- HLD
2. CARDIAC HISTORY:
- Atrial fibrillation on anticoagulation
- CABG:
- PERCUTANEOUS CORONARY INTERVENTIONS:
- PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
- CKD (chronic kidney disease) stage 3, GFR ___ ml/min
- CAD (coronary artery disease)
- Prostate cancer
- Erectile dysfunction
- Insomnia
- Hx embolic stroke
- Mediastinal adenopathy
- Pleural effusion, right
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission Physical Exam:
VS: 98.1 122/76 81 18 94%RA
GENERAL: NAD. Oriented x3. Able to speak in full sentences, but
does take deep breath in betwee
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP up to angle of mandible, very prominent
EJ.
CARDIAC:RR, normal S1, S2. No m/r/g. Unable to appreciate any
S3,S3
LUNGS: No accessory muscle use, Decreased breath sounds on R no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. Protuberant abdomen with shifting dullness,
EXTREMITIES: + Venous stasis changes b/l. 2+ edema up to thighs
Discharge Physical Exam:
VS: 98.0 101-117/57-62 ___ 20 92-99/RA
I+O 24H: 1150/1675
I+O 8H: --/400
Weight: 79.9kg (80.0) (80.5) (80.3) (80.3kg) (80.1kg)
Telemetry: Rate controlled afib
GENERAL: WDWN M in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM
NECK: Supple with JVP ___
CARDIAC: irregular nl S1/S2. No m/r/g. No t/l. No S3 or S4.
LUNGS: CTAB, no w/r/r
ABDOMEN: Soft, NT. Moderately distended with positive fluid
wave. Liver edge ~3cm below costal margin.
EXTREMITIES: No c/c/e. Dry No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: 2+ ___ b/l
Pertinent Results:
Admission Labs:
=====================================
___ 06:07PM ___ PTT-42.1* ___
___ 05:59PM LACTATE-1.1
___ 05:49PM GLUCOSE-97 UREA N-42* CREAT-1.6* SODIUM-139
POTASSIUM-3.9 CHLORIDE-97 TOTAL CO2-27 ANION GAP-19
___ 05:49PM estGFR-Using this
___ 05:49PM ALT(SGPT)-22 AST(SGOT)-31 ALK PHOS-259* TOT
BILI-0.9
___ 05:49PM CK-MB-8 cTropnT-0.05* proBNP-3025*
___ 05:49PM URINE HOURS-RANDOM
___ 05:49PM URINE HOURS-RANDOM
___ 05:49PM URINE HOURS-RANDOM
___ 05:49PM URINE UHOLD-HOLD
___ 05:49PM URINE UHOLD-HOLD
___ 05:49PM URINE UHOLD-HOLD
___ 05:49PM URINE GR HOLD-HOLD
___ 05:49PM WBC-8.5 RBC-4.66 HGB-13.5* HCT-41.0 MCV-88
MCH-29.0 MCHC-33.0 RDW-16.9*
___ 05:49PM NEUTS-69.2 ___ MONOS-7.9 EOS-2.4
BASOS-0.2
___ 05:49PM PLT COUNT-134*
Pertinent Labs:
=====================================
___ 05:20AM BLOOD PEP-NO SPECIFI FreeKap-78.3*
FreeLam-67.7* Fr K/L-1.16 IgG-1527 IgA-685* IgM-83 IFE-NO
MONOCLO
___ 03:45PM BLOOD AFP-2.3
___ 03:45PM BLOOD HCG-LESS THAN
___ 04:31AM BLOOD calTIBC-510* ___ Ferritn-171
TRF-392*
___ 05:49PM BLOOD CK-MB-8 cTropnT-0.05* proBNP-3025*
___ 07:15AM BLOOD CK-MB-6 cTropnT-0.05*
___ 02:21PM BLOOD proBNP-DONE
___ 05:20AM BLOOD proBNP-5650*
___ 01:35PM BLOOD proBNP-5984*
___ 01:51AM BLOOD CK-MB-4 cTropnT-0.07*
___ 05:25AM BLOOD CK-MB-4 cTropnT-0.06*
___ 04:31AM BLOOD Ret Aut-3.9*
___ 10:36PM URINE U-PEP-NEGATIVE F
___ 02:21PM PLEURAL WBC-4* RBC-219* Polys-19* Lymphs-46*
Monos-11* Meso-7* Macro-17*
___ 02:21PM PLEURAL TotProt-3.9 Glucose-125 LD(___)-99
Albumin-2.1 ___ Misc-PRO BNP =
___ 08:11AM PLEURAL WBC-3150* Hct,Fl-19.0* Polys-74*
Lymphs-17* Monos-0 Eos-7* Macro-2*
___ 08:11AM PLEURAL TotProt-5.4 Glucose-80 LD(LDH)-247
Amylase-64 Albumin-2.6
___ 01:02PM ASCITES WBC-725* RBC-1575* Polys-23* Lymphs-45*
Monos-1* Mesothe-10* Macroph-21*
___ 01:02PM ASCITES Albumin-2.5
___ 08:33AM OTHER BODY FLUID CD45-DONE Kappa-DONE CD10-DONE
CD19-DONE CD20-DONE Lamba-DONE CD5-DONE
___ 08:33AM OTHER BODY FLUID IPT-DONE
Microbiology:
=====================================
___ 2:21 pm PLEURAL FLUID
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 1:02 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 8:11 am PLEURAL FLUID
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
Time Taken Not Noted Log-In Date/Time: ___ 2:06 pm
TISSUE Site: CHEST BLOOD CLOT RIGHT CHEST.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 11:12 am STOOL CONSISTENCY: LOOSE Source:
Stool.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
___ 1:50 pm URINE Source: ___.
URINE CULTURE (Final ___: NO GROWTH.
___ 7:05 am BLOOD CULTURE #1.
Blood Culture, Routine (Final ___: NO GROWTH.
___ 5:20 am BLOOD CULTURE
Blood Culture, Routine (Final ___: NO GROWTH.
___ 12:21 am MRSA SCREEN Source: Nasal swab.
MRSA SCREEN (Final ___: No MRSA isolated.
Studies:
=====================================
___ CHEST (PA & LAT): Right mid to lower lung opacity
concerning for right middle and lower lobe pneumonia with
associated right pleural effusion. Recommend followup to
resolution.
ATRIUS STUDIES:
Last CXR ___: There is moderate size right pleural effusion
similar to prior study of ___.
Echo ___: LVEF 47%, ischemic cardiomyopathy, markedly dilated
left and right atria Atrius ECG ___: Atrial fibrillation.
Left axis deviation. Right bundle branch block. Possible old
anterior MI. Nonspecific ST and T wave changes. Abnormal ECG
When compared with ECG of ___ 12:33, there are no
significant changes
Right Upper Quadrant Ultrasound ___
There is a large volume of ascites, and the portal vein is
patent with pulsatile flow, suggestive of right heart failure.
No focal liver abnormalities. Moderate splenomegaly.
CXR ___: Interval increase in large right pleural effusion
with leftwards shift of mediastinum. No left pleural effusion.
No evidence of pulmonary edema. Limited evaluation of the heart
due to overlying abnormality.
CXR ___: In comparison with the earlier study of this date,
the anterior chest tube has been removed. No evidence of
pneumothorax. Increasing opacification at the right base is
consistent with effusion and atelectasis, though in the
appropriate clinical setting superimposed pneumonia would have
to be considered. Substantial enlargement of the cardiac
silhouette process.
CHEST (PORTABLE AP)Study Date of ___ 1:57 ___
IMPRESSION: In comparison with the earlier study of this date,
the anterior chest tube has been removed. No evidence of
pneumothorax. Increasing opacification at the right base is
consistent with effusion and atelectasis, though in the
appropriate clinical setting superimposed pneumonia would have
to be considered. Substantial enlargement of the cardiac
silhouette process.
CHEST (PORTABLE AP)Study Date of ___ 7:51 AM
IMPRESSION:
Slight interval improvement in opacities at right base.
CHEST (PORTABLE AP)Study Date of ___ 12:24 ___
FINDINGS:
The right-sided chest tube is been removed. There is a tiny
right apical
pneumothorax and possible tiny loculated pneumothorax at the
base of the right lung. Otherwise, I doubt significant interval
change. Minimal blunting of the right costophrenic angle is
again noted.
IMMUNOPHENOTYPING-FNA RT SUPRACLAVICULAR LN (Procedure Date
___
INTERPRETATION
Non-specific T cell dominant lymphoid profile; B cells do not
express aberrant markers CD5 and CD10, but clonality can not be
assessed due to the presence of cytophilic antibody (nonspecific
staining pattern). Flow cytometry immunophenotyping may not
detect all abnormal populations due topography, sampling or
artifacts of sample preparation.
CHEST (PORTABLE AP)Study Date of ___ 7:12 AM
IMPRESSION:
1. Right lung base drain remains in place. Minimal , if any,
residual
pneumothorax.
2. Upper zone redistribution bibasilar atelectasis slightly
increased. No
overt CHF.
3. Ovoid opacity right mid lung -- question artifact due to
overlying scapula. Attention to this area on followup films is
requested.
CHEST (PORTABLE AP)Study Date of ___ 11:20 AM
IMPRESSION:
INTERVAL REMOVAL OF DRAIN. SUSPECT SMALL RIGHT APICAL
PNEUMOTHORAX.
ECGStudy Date of ___ 1:26:26 ___
Atrial fibrillatio with a controlled ventricular response.
Diffuse low
voltage. Right bundle-branch block. Left anterior fascicular
block. Compared to the previous tracing of ___ no diagnostic
interim change.
IntervalsAxes
RatePRQRSQT/QTcPQRST
70 ___
CARDIAC CATH REPORT (___):
IMPRESSIONS:
- Normal coronary arteries
- Elevated left and right heart filling pressures, but no
equalization between left and right heart chambers or other
hemodynamic features to suggest restriction or constriction.
CHEST (PORTABLE AP)Study Date of ___ 12:42 AM
IMPRESSION:
As compared to ___, a small right apical pneumothorax
is similar to prior study. Hazy increased opacity with oblique
orientation A in the right mid lung probably represents
loculated pleural fluid. New patchy right retrocardiac opacity
could reflect atelectasis, aspiration, and less likely
developing pneumonia. Short-term followup radiographs may be
helpful in this regard.
PORTABLE ABDOMENStudy Date of ___ 10:46 AM
FINDINGS: There is air in non-distended loops of small and large
bowel, without an obstructive pattern. No free intra-abdominal
air is identified.
CHEST (PORTABLE AP)Study Date of ___ 10:10 ___
IMPRESSION:
In comparison with the study of ___, there again is
substantial
enlargement of the cardiac silhouette with apparent loculated
pleural fluid in the right mid zone. Mild elevation of pulmonary
venous pressure is again seen. Asymmetric opacification at the
right base raises the possibility of atelectasis, aspiration, or
even pneumonia. Prominence of interstitial markings is
consistent with some elevation of pulmonary venous pressure.
CHEST (PORTABLE AP)Study Date of ___ 8:03 AM
IMPRESSION:
In comparison with the study of ___, there is little change.
Again there is substantial enlargement of the cardiac silhouette
with some elevation of pulmonary venous pressure in prominence
of the mediastinum. Probable loculated pleural fluid is again
seen in the right mid zone.
CT CHEST W/O CONTRASTStudy Date of ___ 2:43 ___
IMPRESSION:
1. 7.6 cm intrinsically hyperdense, heterogeneously lobulated
anterior
mediastinal mass is new since the prior outside CT of the chest
from ___. Possibilities include lymphoma given extensive
supraclavicular and mediastinal lymphadenopathy, as well as
thymic neoplasm such as thymic
carcinoma, or germ-cell tumor.
2. Moderate nonhemorrhagic pericardial effusion, with no CT
evidence of
tamponade physiology.
3. Nonhemorrhagic multiloculated right pleural effusion and
hydropneumothorax is moderate in volume. Posteromedial right
pleural nodularity versus small loculated pleural effusion,
difficult to assess given the lack of IV contrast.
4. Trace left pleural effusion.
5. Mild to moderate centrilobular emphysema.
6. Small volume perihepatic and perisplenic ascites.
Portable TTE (Complete) Done ___ at 11:59:22 AM FINAL
The left atrium is dilated. The right atrium is moderately
dilated. The estimated right atrial pressure is at least 15
mmHg. Left ventricular wall thicknesses are normal. The left
ventricular cavity is mildly dilated. Overall left ventricular
systolic function is low normal (LVEF 50%) secondary to severe
hypokinesis of the interventricular septum. The right
ventricular free wall thickness is normal. The right ventricular
cavity is markedly dilated with moderate global free wall
hypokinesis. The aortic valve leaflets (3) are mildly thickened.
There is mild aortic valve stenosis (valve area = 1.7 cm2). Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild to moderate (___) mitral regurgitation
is seen. There is moderate pulmonary artery systolic
hypertension. There is a moderate to large sized pericardial
effusion. The effusion appears circumferential. There are no
echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of ___,
the pericardial effusion is larger, but no signs of cardiac
tamponade.
FDG TUMOR IMAGING (PET-CT)Study Date of ___
IMPRESSION:
1. Anterior mediastinal lobulated mass of peripheral low level
FDG
avidity about central hyperdense region of no activity, possibly
reflective of hemorrhage or proteinaceous material. This is
associated with a large FDG avid right lower paratracheal node
and non FDG avid pericardial effusion. Differential includes
lymphoma, malignancy of thymic origin, and germ cell tumor.
2. Right clavicular 2.6 x 1.0 cm node demonstrates low level FDG
avidity, but would be amenable to biopsy.
3. Loculated right pleural effusions with hydropneumothorax as
well as foci of air within the pleural space and tracts of FDG
avidity within the right chest wall, thought sequela of recent
intervention. Clinical correlation is advised.
4. Nodularity along the inferior and posterior aspect of the
right pleura
demonstrates low level FDG avidity. Though
inflammatory/infectious etiologies remain on the differential,
metastasis cannot be excluded.
5. Focus of increased FDG avidity within the sigmoid colon,
possibly
physiologic, but for which correlation with
sigmoidoscopy/colonoscopy may be helpful, if clinically
indicated.
CHEST (PORTABLE AP)Study Date of ___ 7:09 AM
IMPRESSION:
In comparison with the study of ___, there is little overall
change. Again there is substantial enlargement of the cardiac
silhouette with relatively mild elevation in pulmonary venous
pressure, raising the possibility of cardiomyopathy or
pericardial effusion. Opacification in the right mid lung is
again consistent with loculated pleural effusion. If the
condition of the patient permits, a lateral view would allow
better definition of the pleural collection.
MRI MEDIASTINUM/LUNG W/O CONTRASTStudy Date of ___ 1:00
___
IMPRESSION:
1. Anterior mediastinal mass is most consistent with a hematoma.
Areas of
small focal nodularity or vascularity cannot be assessed without
IV contrast but no obvious solid mass lesion is seen. If follow
up is desired, IV contrast would be needed to provide additional
information but the hematoma itself and related mass effect
could be followed up using chest radiographs.
2. Left lower lobe consolidation may represent pneumonia or
aspiration, new from ___. Stable right pleural
effusion and pericardial effusion.
3. Mediastinal lymphadenopathy is unchanged from ___.
The patient underwent biopsy of the right supraclavicular lymph
node on ___.
4. Enlarged main pulmonary artery suggests underlying pulmonary
arterial
hypertension.
FINE NEEDLE ASPIRATION (___):
*** UNABLE TO ACCESS REPORT ON OMR AS OF ___ ***
ECGStudy Date of ___ 12:49:20 AM
Possible idioventricular rhythm versus atrial fibrillation with
a slow and
regularized ventricular response rate. Left axis deviation.
Right
bundle-branch block. Low voltage QRS complex. Compared to the
previous
tracing of ___ the ventricular response rate is slower and
regularized.
The QRS morphology is comparable to the prior reading of atrial
fibrillation suggesting atrial fibrillation with a regularized
ventricular reponse rate.
No P waves are identified. Clinical correlation is suggested.
IntervalsAxes
RatePRQRSQT/QTcPQRST
___ ___
BX SUPERFISCAL CER,AXL OR INGStudy Date of ___ 7:57 AM
IMPRESSION:
Technically successful fine needle aspiration of the enlarged
right
supraclavicular lymph node. No periprocedural complications.
Cytology is
pending.
Tissue: MYOCARDIUM, BIOPSY (___):
*** UNABLE TO ACCESS REPORT ON OMR AS OF ___ ***
CARDIAC CATH REPORT (___):
IMPRESSIONS:
- Elevation of right and left heart pressures as above with no
evidence of constriction
- Moderately severe pulmonary artery hypertension
- Low cardiac index
- RV biopsy specimens sent to Pathology
CHEST PORT. LINE PLACEMENTStudy Date of ___ 7:37 ___
IMPRESSION:
As compared to the previous radiograph, the patient has received
a Swan-Ganz catheter, inserted over the right internal jugular
vein. The course of the catheter is unremarkable, the tip of the
catheter projects over the proximal parts of the right pulmonary
artery. No pneumothorax or other complication. The loculated
right pleural effusion has minimally increased in size. Moderate
cardiomegaly persists. No pulmonary edema.
CHEST (PORTABLE AP)Study Date of ___ 7:30 AM
IMPRESSION:
In comparison with the study of ___, there is little
overall change. The
tip of the Swan-Ganz catheter again extends into the right
pulmonary artery
beyond the mediastinal border. Loculated pleural effusion within
the major
fissure on the right is essentially unchanged. Moderate
enlargement of the
cardiac silhouette is again seen with mild indistinctness of
pulmonary vessels
suggesting some elevated pulmonary venous pressure. Blunting of
the right
costophrenic angle is again noted.
CHEST (PORTABLE AP)Study Date of ___ 2:22 ___
IMPRESSION:
In comparison with the earlier study of this date, the PA
catheter is been
pulled back to a good position within the mediastinal portion of
the right
pulmonary artery. Otherwise little change.
Portable TTE (Complete) Done ___ at 11:47:12 AM FINAL
The estimated right atrial pressure is at least 15 mmHg. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is mildly depressed (LVEF= 45 %) secondary to akinesis
of the anterior septum and hypokinesis of the anterior free wall
and apex. The mitral valve leaflets are mildly thickened. Mild
(1+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is a large pericardial
effusion. There are no echocardiographic signs of tamponade. No
right atrial or right ventricular diastolic collapse is seen.
Compared with the prior study (images reviewed) of ___, the
findings are similar.
ECGStudy Date of ___ 8:14:46 AM
Baseline artifact. Probable atrial fibrillation with borderline
rapid
response. Marked left axis deviation. Right bundle-branch block.
Possible
septal myocardial infarction. Compared to the previous tracing
of ___
the rate is now faster. QRS morphology is similar. Then, it was
slow and
regular suggesting idioventricular rhythm. Clinical correlation
is suggested.
IntervalsAxes
RatePRQRSQT/QTcPQRST
98 ___
CHEST (PORTABLE AP)Study Date of ___ 2:32 ___
IMPRESSION:
In comparison with the study of ___, there is little
overall change.
Continued substantial enlargement of the cardiac silhouette with
mild
elevation of pulmonary venous pressure and pseudo tumor of
pleural fluid in the major fissure on the right. ___
catheter remains in good position.
*** FOR BIOPSY AND CARDIAC CATHETERIZATION REPORTS, PLEASE SEE
WEBOMR ***
DISCHARGE LABS:
==================================================
___ 12:01AM BLOOD Hgb-8.2* Hct-26.1*
___ 10:50AM BLOOD Hgb-8.0* Hct-25.5*
___ 05:17AM BLOOD WBC-9.6 RBC-2.89* Hgb-8.0* Hct-25.4*
MCV-88 MCH-27.8 MCHC-31.7 RDW-17.1* Plt ___
___ 05:17AM BLOOD Plt ___
___ 05:17AM BLOOD ___ PTT-36.5 ___
___ 05:17AM BLOOD Glucose-102* UreaN-73* Creat-2.2* Na-132*
K-4.4 Cl-90* HCO3-28 AnGap-18
___ 05:17AM BLOOD Calcium-9.0 Phos-4.8* Mg-2.8*
Brief Hospital Course:
PATIENT
Mr ___ is a ___ year-old man with a past medical
history significant for an uncharacterized chronic
cardiomyopathy with sCHF, AFib, CAD, who presented to ___ with
dyspnea, found to have heart failure and indicentally diagnosed
with a mediastinal mass/lymphadenopathy concerning for
malignancy.
ACTIVE ISSUES:
# Acute-on-chronic CHF: Patient presented with worsening dyspnea
and abdominal distension in the setting of increasing diuretic
doses. He was found to have an elevated BNP and clinically
appeared very volume overloaded. He was diuresed with lasix
boluses and a drip. His home carvedilol and diovan were held in
the setting of borderline blood pressures due to diuresis but
carvedilol was restarted on ___ and he was also started on
spironolactone. LHC on ___ demonstrated clean coronaries without
any significant obstruction. RHC on ___ showed elevated PCWP of
27 despite patient appearing euvolemic. Diruesis was resumed for
several days but halted on ___ when patient developed ___. BNP
at that time was 5984 and patient weight was 78.3kg. As his
volume status was unclear and he had difficulty with further
diuresis, he was transferred to the CCU on ___ for tailored
therapy after undergoing a myocardial biopsy (eventually showed
chronic ischemic changes) and receiving a ___-Ganz catheter in
the Cath Lab. In the CCU, the patient was started on a lasix gtt
(initially at 10/hr, later increased to 15/hr) and for low BPs
was supported with concurrent dopamine gtt. Lasix gtt, dopamine
gtt, and Swan were weaned off by ___, as patient was
transitioned to PO torsemide. At this point, the patient was
down approximately 8 kg from admission weight (86.5 kg -> 78
kg), no longer complained of dyspnea, had no swelling in his
legs, and had less abdominal distension than before. On ___, IJ
line was discontinued and, patient was restarted on carvedilol.
Carvedilol eventually changed back to metoprolol given concerns
of hypotension. Mr ___ returned to the hospital floors where
he was continued on oral diuretics and his volume status
remained even. Weight on discharge was 80.5kg.
# Anterior Mediastinal Mass: A chest CT which was obtained for
ongoing hemoptysis demonstrated a previously unknown 7.6cm
anterior mediastinal mass not seen on chest CT 9 months prior. A
follow-up PET/CT was suggestive of a hematoma without FDG
avidity in mass, but it was noted that there was uptake in
adjacent lymph nodes. Patient underwent a planned excision
biopsy, but instead an FNA of the FDG-avid clavicular node which
was non-diagnostic. It was unclear wheter the observed FDG
avidiy was a primary malgiancy or reactive secondary to a
primary hematoma. After discussion with Atrius Heme/Onc and
Radiology, decision was made not to pursue biopsy of anterior
mediastinal mass itself due to radiographic appearance
suggestive of hematoma. Instead, IP was consulted for
transbronchial biopsy of right paratracheal lymph node. However,
this procedure was defered to the outpatient setting given the
difficulty scheduling. Patient discharged with intent for
outpatient biopsy by thoracic surgery and ___ week interval
follow-up imaing.
# Pericardial effusion: A large circumferential effusion as seen
on patient's transthoracic echocardiogram on ___ (2.6 cm) and
___ (2.7 cm). There was no evidence of tamponade physiology.
Malignancy could not be excluded as a cause, especially given
above workup. Given stability of effusion, decision was made not
to perform a pericardiocentesis during this hospitalization and
will require regular interval follow-up.
# Anemia: Hgb on admission in ___ range, but from ___,
had largely been in ___ range. No evidence of hemolysis based on
labs. Iron studies on ___ reveal low iron, elevated TIBC, and
normal ferritin - possibly indicative of mixed picture (such as
iron deficiency anemia + anemia of chronic disease). ___ is a
reasonable cause given patient's several sources of blood loss -
initially from hemothorax, and later on from epistaxis. Anemia
of chronic disease also possible given mediastinal LAD
suggestive of an inflammatory or malignant process.
# Right pleural effusion/hemothorax: Patient was noted to have a
right pleural effusion on presentation which was only minimally
worse than seen on prior x-ray in ___. He was diuresed as above
and on ___, interventional pulmonary placed a chest tube and
approximately 3L transudatative fluid was drained. Chest tube
was discontinued on ___, however, on ___ patient developed a
new oxygen requirement. On repeat imaging, pleural effusion had
reaccumulated. This was in the setting of a supratherapeutic PTT
on heparin drip the day prior and patient had a drop in
hematocrit. He was taken to the OR by thoracic surgery who
drained 3.5L dark red blood and clot and placed 3 chest tubes.
Patient tolerated the procedure well and chest tubes were
discontinued on ___. Patient continued to have mild
hemoptysis and pain around the chest tube site for several days.
Treated with lidocaine patch and expectorants. A CT chest was
performed to evaluate and did not identify a cause for the
hemoptysis, but did identify the anterior mediastinal mass
detailed above. Hemoptysis and localized pain gradually resolved
and were not present several days prior and through discahrge.
# Ascites: A large amount of ascites was demonstraed on a RUQ
ultrasound at admission. Patient underwent an ___ guided
paracentesis on ___ with lab values suggestive of a
transudative cardiac acites. Patient underwent diuresis as
detailed above and acites clinically improved. However,
patient's abdomen remained distended throughout his hospital
course. Before discharge, bed-side ultrasonography demonstrated
an absence of acites or any other significant fluid collections.
No further paracentesis was pursued.
# Hyponatremia: On ___, patient was noted to be hyponatremic to
129, repeat 130, down from prior two days. A TSH and am cortisol
were normal and urine electrolytes were consistent wiht a
pre-renal etiology. This was likely due to hypervolemic
hyponatremia and sodium improved with diuresis. With
stabilization on a daily oral diuretic, Mr ___ sodium
stabilized in the low 130s, which was thought to be his new
baseline.
# Epistaxis: in the CCU, patient had several episodes of
epistaxis, likely in setting of blowing his nose and being on
heparin gtt. ENT cauterized one spot on left, but saw diffuse
mucosal bleeding (could not cauterize both left and right at
same time bc of risk for septal burn). Recommended afrin and
pressure, and bleeding resolved for several days. Bleeding
restarted on ___, resistant to afrin and pressure. ENT
evaluated and packed, but bleeding persisted. Subsequently
underwent silver nitrate cauterization and repeat packing.
Discharged on cephalexin with intent for outpatient ENT
follow-up and removal.
CHRONIC ISSUES:
# Atrial Fibrillation: Patient's warfarin was initially held
given his multiple invasive procedures. He was maintained on a
heparin drip which was stopped as needed for scheduled
interventions and in the setting of patient's hemothorax. Was
rate controlled with carvedilol and later metoprolol. Did not
have any significant runs of RVR. Prior to patient's discharge
home, he was transitioned to enoxaparin with intent to continue
as an outpatient until his biopsy. (Planned to resume warfarin
therafter.)
# Hyperlipidemia: Continued on home simvastatin.
# CKD: Basseline creatinie of 1.6, had several ___ during
hospitalization (likely diuresis ATN/AIN related as detailed
above)
# History of CVA: Continued on home simvastatin and
anticoagulation as detailed above. Aspirin was held given his
multiple invasice procedures. He was bridged with heparin while
warfarin was held for the majority of his hospitalization.
Aspirin was held at time of discharge given impending biopsy
with intent to resule after completion.
# Insomnia: Continued on home lorazepam.
# Gout: Continued on home allopurinol.
TRANSITIONAL ISSUES:
# Patient requires paratracheal lymph node sampling based on FDG
avidity. Currently scheduled for an appointment with thoracic
surgery on ___ to plan for biopsy.
# Patient will be discharged on lovenox bridge until his
thoracic surgical biopsy. ___ resume warfarin afterwards at
discretion of PCP. Please resume INR monitoring as previous once
warfarin is re-initiated
# Patient with packed bilateral narces with 10cm merocels s/p
silver nitrate cautery. Started on 5d cephalexin and scheduled
for removal by ENT Dr ___ on ___.
# Patient with anterior mediastinal mass identified while
inpatient. Requires follow-up MRI in ___ weeks time per
Hematology/Oncology
# Please consider restarting aspirin as an outpatient after
biopsy is performed (indication is CVA, not CAD - patient with
clean coronaries)
# Patient with wide QRS in the setting of LBBB, and significant
heart failure symptoms despite an EF of 45%, may benefit from
CRT in the future.
# Patient with occasional short runs of NSVT (longest 20
seconds) while hospitalized. ___ benefit from an EP study and
possible ICD in the future.
# Patient started on metoprolol succinate for HFdEF
# Patient started on famotidine for GERD symptoms
# Patient with a large, non-hemodynamically compomising
pericardial effusion without evidence of tamponade physiology.
Please follow with serial imaging and intervene as needed.
# Patient discharged with home services and home ___
# Code: Full (confirmed with patient)
# Contact: ___ (Cousin/HCP) ___
# ___ Weight: 80.5kg
Medications on Admission:
1. Lorazepam 1 mg PO QHS:PRN insomnia
2. Carvedilol 3.125 mg PO BID
3. Torsemide 60 mg PO BID
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Allopurinol ___ mg PO DAILY
6. Vitamin D ___ UNIT PO DAILY
7. Simvastatin 20 mg PO QPM
8. Valsartan 20 mg PO DAILY
9. Warfarin 3 mg PO 2X/WEEK (MO,FR)
10. Warfarin 5 mg PO 5X/WEEK (___)
11. Aspirin 81 mg PO DAILY
12. B Complete (vitamin B complex) unknown oral unknown
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. Lorazepam 1 mg PO QHS:PRN insomnia
4. Simvastatin 20 mg PO QPM
5. Vitamin D ___ UNIT PO DAILY
6. Acetaminophen 650 mg PO Q6H:PRN Pain
7. Famotidine 20 mg PO Q24H
RX *famotidine 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
8. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
9. Enoxaparin Sodium 80 mg SC BID
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 80 mg/0.8 mL 80 mg inj twice a day Disp #*60
Syringe Refills:*0
10. Torsemide 60 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSES:
Systolic Congestive Heart Failure
Right Pleural Effusion
Anterior Mediastinal Mass
SECONDARY DIAGNOSES:
Atrial Fibrillation
Chronic Kidney Disease
Hemothorax
Acute Kidney Injury
Ascites
Hypertension
Hyponatremia
Hyperlipidemia
Leukocytosis
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 during your
hospitalization at ___. You were admitted to the hospital
because you were having worsening shortness of breath and
abdominal distension. You were found to have worsening of your
heart function and an excess of fluid in your lungs as well as
in your abdomen. We treated you with medications to remove the
excess fluid from your body. We also sampled fluid from your
belly and your lungs, the testing of which implicated your heart
as the cause of the fluid build up.
You twice underwent a procedure called a catheterization, where
the arteries of your heart were examined and the pressure inside
the heart were measured. This demonstrated that your arteries
were not blocked, however, the pressures in your heart were very
high and that your heart was not pumping very well. We also took
a small biopsy of your heart muslce which showed that there was
some scarring from a lack of blood flow.
We also had the interventional pulmonary team drain the
collection of fluid around your right lung which helped you
breathe better. Unfortunately, you bled into this area and you
required extra tubes put in place to help drain this blood. The
bleeding eventually stopped and the tubes were removed without
issue.
You spent some time in the intensive care unit so we could have
consistent pressure readings to help us remove excess fluid from
your body as best we could. We eventually found an oral diuretic
(torsemide) which could keep you from having too much fluid in
your body.
In the process of diagnosing these problems, we found that you
had a large mass in the front part of your chest. It is unclear
exactly what this is at the time - it could be a large mass of
blood or it could be something more concerning like a cancer.
You were seen by our oncologists who recommended that you have a
biopsy of this mass and the surrounding lymph nodes. This will
be performed after you leave the hospital.
Please take all medications as prescribed and keep all scheduled
appointments. Should you have a recurrence of the same symptoms
that originally brought you to the hospital, experience any of
the warning signs listed below, or have any other symptoms that
concerns you, please seek medical attention. Additionally,
please limit your salt intake and weigh yourself daily. If your
weight increases by more than 3 pounds in 1 day, or if it
increases by more than 5 pounds in 3 days, please call your
physician.
It was a pleasure taking care of you. Best of luck to you in
your future health.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10216153-DS-11 | 10,216,153 | 29,755,610 | DS | 11 | 2161-07-20 00:00:00 | 2161-07-20 17:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Vicodin / Percocet / Hayfever / Xeloda
Attending: ___.
Chief Complaint:
Shortness of breath, chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w metastatic mucinous breast cancer complicated by ___
pleural
effusions and three-times weekly thoracentesis presents with
SOB.
She had a thoracentesis today that did not alleviate symptoms.
Also notes tightness in chest.
In the ED, BP on the lower side (though this is chronic for
patient) in the ___ and s/p 500cc bolus of fluid. Troponin
negative. CXR with worsening pleural effusions and mild
interstitial edema.
On arrival to the floor, pt satting well on 2L (similar to home
O2), states that they drained 900cc fluid from her pleurex on
___. States always has "racing heart." No N/V/cough/fevers or
chills. Had multiple BM's on ___ but none since
___
given reduced PO intake.
Past Medical History:
Mucinous breast cancer s/p right mastectomy in ___ for invasive
ductal CA
Multiple plastic surgeries for breast reconstruction
Distant right lumpectomy for benign mass
Multiple hip surgeries for congenital hip dysplasia
Social History:
___
Family History:
Father had colon ___ in his ___ and that her brother had a polyp,
but she is not sure what kind. Her mother passed away at age ___
of ___ dementia and uterine cancer.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
===========================
General: cachectic
VITAL SIGNS: VSS
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: tachycardic, NL S1S2 no S3S4 MRG
PULM: Reduced BS bilaterally midway through lung field
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
NEURO: 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;
reflexes are 2+ of the biceps, triceps, patellar, and Achilles
tendons, toes are down bilaterally; gait is normal, ___ is
non pathologic, coordination is intact.
PHYSICAL EXAM ON DISCHARGE:
===========================
GEN: cachectic, emaciated.
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: tachycardic, NL S1S2 no S3S4 MRG
PULM: Reduced breath sounds bilaterally in lower lung fields
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
LIMBS: 2+ edema in b/l ___. No clubbing, tremors, or asterixis;
SKIN: No rashes or skin breakdown
NEURO: 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;
reflexes are 2+ of the biceps, triceps, patellar, and Achilles
tendons, toes are down bilaterally; gait is normal, ___ is
non pathologic, coordination is intact.
Pertinent Results:
LAB RESULTS ON ADMISSION:
=========================
___ 11:00PM BLOOD WBC-1.2* RBC-3.36* Hgb-8.7* Hct-27.2*
MCV-81* MCH-25.9* MCHC-32.0 RDW-17.1* RDWSD-49.6* Plt ___
___ 11:00PM BLOOD Neuts-23* Bands-0 ___ Monos-25*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-0.28*
AbsLymp-0.62* AbsMono-0.30 AbsEos-0.00* AbsBaso-0.00*
___ 11:00PM BLOOD ___ PTT-24.0* ___
___ 11:00PM BLOOD Glucose-125* UreaN-14 Creat-0.5 Na-132*
K-4.1 Cl-95* HCO3-26 AnGap-15
___ 11:00PM BLOOD cTropnT-<0.01
___ 11:13PM BLOOD ___ pO2-21* pCO2-45 pH-7.42
calTCO2-30 Base XS-2
___ 11:13PM BLOOD Lactate-1.5
___ 11:13PM BLOOD O2 Sat-40
LAB RESULTS ON DISCHARGE:
=========================
IMAGING:
========
CXR ___
-------------
1. Metastatic masses and mediastinal lymphadenopathy are
unchanged and better seen on prior CT chest from ___.
2. Hypoinflated lungs with interval decrease in pleural
effusions compared to prior exam in ___, with small
residual effusions present bilaterally.
3. Bilateral PleurX drains are in stable position.
CTA ___
--------------
1. No evidence of pulmonary embolism to the segmental level.
2. Massive hypervascular lymphadenopathy seen throughout the
mediastinum, in the hilar regions and in the lower neck. This
appears stable in size compared to the prior exam.
3. Enhancing soft tissue mass extending from the region of the
right
cardiophrenic angle through into the chest wall with destruction
of the
adjacent sternum, similar to the prior exam.
4. Bilateral pleural effusions with pleural catheters in place.
5. Findings of diffuse osseous metastatic disease.
6. Mild increase in size of hypervascular lesion at the liver
dome. Numerous new smaller peripherally enhancing liver lesions
are likely reflective of progressive hepatic metastatic disease.
Brief Hospital Course:
Ms. ___ is a lovely ___ year old lady with history of
metastatic mucinous breast cancer c/b bilateral pleural
effusions s/p pleurex placement requiring three times weekly
thoracentesis who was admitted for two days of acute on chronic
dyspnea, chest tightness, and lower extremity edema.
# Dyspnea: Pt has chronic dyspnea, CP symptoms for which she has
been evaluated. Patient improves w/ scheduled pleurex drainage
3x weekly, but lately has been becoming increasingly SOB on the
days w/o drainage. s/p ACS r/o. CT chest w/ no e/o PE, slight
increase in tumor burden. On exam, has known chest wall mass,
but not causing any discomfort. Continued pleurex drains on MWF
as previously scheduled, and also added PO Lasix 20mg QD given
she reported significant improvement in symptoms when used in
house.
# Lower Extremity Edema: Chronic, 3+ pitting edema. Patient does
not otherwise appear volume overloaded. Recent TTE as outpatient
___ notable for RVSP of 36 mmHg and redemonstrates known small
pericardial effusion; normal LV systolic function, borderline
dilated RV with normal systolic function. Evaluation for
nephrotic syndrome negative. Her albumin is low at 2.8, which
could certainly contribute. As patient complained of pain and
distension, difficulty ambulating with such edema, we opted to
trial gentle diuresis with IV furosemide ___, which improved
her symptoms. Therefore, she was started on Lasix 20mg PO QD.
On discharge, weight is 46.2kg and Cr is 0.5. Patient feels much
improved on new Lasix 20mg, with less ___ pain and improved
ambulation with her walker.
# Metastatic Breast Cancer: Patient is s/p 2 cycles of eribulin.
Per review of records, her ___ fell from a pretreatment
level of 577 to 531 after one dose. We note that on her CTA
obtained this admission, there appears to be mild increase in
size of hypervascular lesion at the liver dome and numerous new
smaller peripherally enhancing liver lesions. However, this is a
comparison to her scan in ___, which was prior to starting
eribulin. She started another cycle of eribulin on ___ prior
to d/c and will follow up with Dr. ___ to discuss any further
treatments. Outpatient plans at time of discharge to repeat
another dose or eribulin on ___.
#GOC: ___ discussion had with medical team, patient, and
patient's best friend ___. Ultimately patient decided to
change code status to DNR/DNI and complete MOLST form. However,
she would like to continue treatments per Dr. ___
___, and set up plans for home hospice if/when her
cancer markers stop responding to therapy. Patient will be
discharged home on hospice, however will continue chemotherapy
with Dr. ___ now. She is not afraid of dying. Her most
important goals at this time are to set up financial security
for her daughter ___ (has CP and patient is primary provider
with help of community services) and to be able to die at home.
# Hypothryoidism: Continued home levothyroxine
# Constipation: Continued home bowel regimen
TRANSITIONAL ISSUES:
====================
METASTATIC BREAST CANCER
[ ] Will continue MWF pleurex drainage w/ nurse services at home
[ ] Added Lasix 20 mg QD to help better manage pleural effusions
and ___ edema
[ ] Clinic appointment for chemo on ___.
[ ] Patient signed MOLST for during this admission and is now
DNI/DNR.
GOC
[ ] home hospice with ___, but will continue
chemotherapy as well for now given no side effects.
# Code: DNR/DNI
# Contact: ___ (friend) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
2. Prochlorperazine 10 mg PO Q6H:PRN nausea
3. Docusate Sodium 100 mg PO BID
4. Senna 8.6 mg PO BID:PRN constipation
5. Zolpidem Tartrate 5 mg PO QHS
6. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate
7. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL 30 mg
PO QPM
8. Levothyroxine Sodium 75 mcg PO DAILY
9. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Furosemide 20 mg PO DAILY
2. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety/nausea/vomiting
3. Polyethylene Glycol 17 g PO DAILY:PRN constipation
4. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
5. docusate sodium 100 mg ORAL BID
6. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate
RX *hydromorphone 2 mg 1 tablet(s) by mouth Q2H Disp #*20 Tablet
Refills:*0
7. Levothyroxine Sodium 75 mcg PO DAILY
8. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL 30 mg
PO QPM
9. Prochlorperazine 10 mg PO Q6H:PRN nausea
10. Senna 8.6 mg PO BID:PRN constipation
11. Vitamin D ___ UNIT PO DAILY
12. Zolpidem Tartrate 5 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
==================
Metastatic mucinous breast cancer
Bilateral pleural effusions
Bilateral lower extremity edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___!
You first came to us because of shortness of breath, chest pain,
and lower extremity swelling.
While you were here, we did a CT scan of your chest to make sure
that there was no clot in your lungs- and indeed there was not.
However, this re-demonstrated that the cancer is invading your R
chest wall, which is the cause of your symptoms. We continued to
drain the fluid in your lungs and added Lasix to help remove
fluid in hopes of making you feel better.
During your hospitalization, we had a talk with you regarding
your goals for the rest of your care. You ultimately decided it
was best for you to continue the chemotherapy as Dr. ___
___, but with a plan to enter hospice care in order to
maximize your comfort if you do not have a good response to the
chemo. You have a follow up appointment in Dr. ___ office on
___.
Thank you for allowing us to participate in your care!
Please take care, we wish you the best.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10216556-DS-21 | 10,216,556 | 23,888,667 | DS | 21 | 2131-06-27 00:00:00 | 2131-06-28 14:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril / eggs / penicillin G
Attending: ___.
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
Central Venous Line placement - ___, removal ___
Intubated on admission to ICU ___
EGD ___
Paracentesis ___
History of Present Illness:
Patient is a ___ ___ speaking M with a PMH of developmental
delay, dementia, CKD on HD, CAD s/p CABG, tubulovillious adenoma
s/p R hemicolectomy and recent admit to ___ from
___ with LGIB and c. diff infection who presents with
altered mental status from his dialysis center. Patient was
recently transferred from acute care rehab back to his group
home approximately 1 week ago. In speaking with the staff from
his group home, he has been less responsive and more confused
since coming back from rehab. He has been asking when he can go
home though he was already home. He has also had increased
stool incontinence and has had to start wearing a diaper. He had
diarrhea that began 3 days ago, described as watery, non-bloody.
He has also had a dry cough. He is typically able to say his
name at baseline and can communicate his needs but is not always
oriented to place/ time. He has had poor po intake over the last
2 days and has looked 'pale.' He presented to his dialysis
center today and was transferred to ___ for concern of altered
mental status.
On arrival to the ED, his initial VS were: 94.7 80 126/59 18
100% RA. He as intermittently following commands but not
tracking and not answering questions. He was not handling his
secretions and was intubated for airway protection. He had a CT
head that was normal. CT chest showed atelectasis. CT abdomen
showed cirrhosis. Labs were significant for WBC 1.6, HCT 28,
platelets 25 ___ ___. He was given vanco/ zosyn/ flagyl. He was
initially on propofol for sedation which was switched to fent
(50/hr) / midazolam (1mg/hr) as he became hypotensive on
propofol. He also received 800 cc IVF. VS prior to transfer
were: P 70, 96/51, 98% on vent (CMV TV 550, rate 12, PEEP 12,
F1O2 40%).
Review of systems:
(+) Per HPI, otherwise unable to obtain
Past Medical History:
-LGIB admitted ___ to ___ for anastamotic
friability and melena, BRBPR, given PRBCs, platelets, FFP; no
scope ___ thrombocytopenia
-Hx of c. diff treated with flagyl in ___
-CKD ___ on HD
-CAD s/p CABG in ___
-DMII diet controlled
-CHF (unknown EF)
-Tubulovillious adenoma s/p right hemi-colectomy in ___
-severe persistent thrombocytopenia
-Splenomegaly
-GERD
-Dementia
-Obesity
-Developmental Delay
Social History:
___
Family History:
Unknown.
Physical Exam:
On Admission:
General: obtunded, intubated
HEENT: Sclera anicteric, MMM, oropharynx clear, not tracking,
pupils 2 mm, sluggish, small amt serosanginous output from OG
tube
Neck: supple, unable to assess JVD, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally over anterior chest
Abdomen: soft, non-tender, mild distention, bowel sounds
present, liver and spleen enlarged, no rebound or guarding
GU: foley in place
Ext: AV graft in place in RUE, 2+ pitting edema
Neuro: obtunded, not following commands
Physical Exam On Discharge:
Vitals 98 - 110/54 - 82 - 20 - 96%
General- Alert, no acute distress, lying on his back at
dialysis, pleasant, smiling
HEENT- Sclera anicteric, MM moist, oropharynx clear
Neck- supple
Lungs- CTA bilaterally, no wheezes, rales, ronchi
CV- RR, normal S1 + S2, systolic murmur, rubs, gallops
Abdomen- soft, non-tender, very obese with multiple midline
scars, distended, bowel sounds present, no rebound tenderness or
guarding, no gross hepatomegaly and no splenomegaly, no shifting
dullness, no fluid wave
GU- diaper
Ext- no edema.
Neuro- not examined today
Pertinent Results:
On Admission:
___ 11:30AM BLOOD WBC-1.6* RBC-2.55*# Hgb-9.4* Hct-28.8*
MCV-113*# MCH-36.9*# MCHC-32.8 RDW-17.8* Plt Ct-25*
___ 11:30AM BLOOD Neuts-75.2* Lymphs-13.3* Monos-10.6
Eos-0.5 Baso-0.3
___ 11:30AM BLOOD ___ PTT-33.9 ___
___ 11:30AM BLOOD Glucose-139* UreaN-48* Creat-8.3*# Na-136
K-3.5 Cl-104 HCO3-22 AnGap-14
___ 11:30AM BLOOD ALT-46* AST-96* CK(CPK)-961* AlkPhos-114
TotBili-0.5
___ 11:30AM BLOOD Albumin-2.7* Calcium-8.8 Phos-3.4 Mg-1.7
___ 03:43AM BLOOD calTIBC-200* Ferritn-220 TRF-154*
___ 03:43AM BLOOD Ammonia-124*
___ 10:30PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HAV-NEGATIVE
___ 06:00PM BLOOD AMA-NEGATIVE
___ 06:00PM BLOOD ___
___ 06:00PM BLOOD AFP-<1.0
___ 06:00PM BLOOD IgG-3005*
___ 11:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 10:30PM BLOOD HCV Ab-NEGATIVE
___ 11:33AM BLOOD ___ Tidal V-500 PEEP-5 FiO2-100
pO2-431* pCO2-39 pH-7.36 calTCO2-23 Base XS--2 AADO2-243 REQ
O2-48 -ASSIST/CON Intubat-INTUBATED
___ 11:31AM BLOOD Lactate-2.8*
Test Result Reference
Range/Units
CERULOPLASMIN 21 ___ mg/dL
___ 06:15AM BLOOD HIV Ab-NEGATIVE
On Discharge:
___ 06:19AM BLOOD WBC-2.7* RBC-2.40* Hgb-8.5* Hct-27.0*
MCV-113* MCH-35.5* MCHC-31.6 RDW-18.6* Plt Ct-23*
___ 06:19AM BLOOD Glucose-150* UreaN-28* Creat-7.9*#
Na-131* K-4.6 Cl-100 HCO3-29 AnGap-7*
___ 06:15AM BLOOD ALT-19 AST-33 AlkPhos-84 TotBili-0.5
___ 06:19AM BLOOD Calcium-9.2 Phos-3.9 Mg-2.0
Imaging:
CT abd/pelvis ___ - IMPRESSION: 1. No acute thoracic,
abdominal or pelvic process within the limitations of a
noncontrast examination. 2. Nodular liver, large ascites and
massive splenomegaly compatible with cirrhosis. 3. 9 mm
intermediate density cystic lesion in the right renal upper pole
which is likely a proteinaceous or hemorrhagic cyst. This can
be further characterized by ultrasound. 4. Fat containing
ventral hernia. 5. Possible gallstones or sludge.
Liver US ___ - IMPRESSION: 1. Heterogeneous echogenicity
with coarse echotexture and nodular contour, compatible with
cirrhosis. No suspicious hepatic lesions are identifie.
Moderate abdominal ascites. 2. Cholelithiasis without
sonographic evidence of acute cholecystitis. 3. Patent portal
vein with normal hepatopetal flow.
EGD ___ -
Findings:
Esophagus:No definite varices. One nodule at 30 cm with small
submucosal hematoma that could represent NG tube trauma left
undisturbed and another small less than 5mm erosion at 35 cm.
Mild irregular GE junction at 40 cm.
Stomach:Mild portal hypertension gastropathy in the body and
fundus and proeminent folds in the antrum suggestive of portal
hypertension.
Duodenum:Normal duodenum with yellow bile seen. Proeminent
Brunner glands in the duodenum
Impression:No signs of upper GI bleeg. No definite varices. One
nodule ~1 cm at 30 cm with small submucosal hematoma that could
represent NG tube trauma left undisturbed now but will require
biopsy if present after one month.
Otherwise normal EGD to second part of the duodenum
Recommendations:Protonix 20 mg BID for 4 weeks
Continue to monitor CBC, if continue to drop/shift down will
need a colonoscopy
Repeat EDG in ___ weeks for now for biopsies of the esophageal
nodule if persistent.
CXR ___ - IMPRESSION: 1. Right internal jugular central
line is unchanged in position. A nasogastric tube is seen
coursing to the level of the distal esophagus with the tip not
identified due to underpenetration. There is a stable small
right apical pneumothorax. In the interim, however, there has
been interval appearance of bilateral perihilar and airspace
process most likely representing moderate pulmonary edema.
There are layering bilateral effusions. The heart remains
enlarged status post median sternotomy for CABG and mitral valve
replacement.
URINE STUDIES
=============
___ 03:43AM URINE Color-Yellow Appear-Clear Sp ___
___ 03:43AM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-5.0 Leuks-NEG
___ 03:43AM URINE ___ WBC-0 Bacteri-FEW Yeast-NONE
Epi-0
ASCITIC FLUID
=============
___ 10:46AM ASCITES WBC-135* RBC-1050* Polys-2* Lymphs-13*
___ Mesothe-4* Macroph-81*
___ 10:46AM ASCITES TotPro-1.2 Albumin-LESS THAN
MICROBIOLOGY
============
___ PERITONEAL FLUID GRAM STAIN-FINAL;
FLUID CULTURE-FINAL;
ANAEROBIC CULTURE-FINAL
___ SPUTUM GRAM STAIN-FINAL;
RESPIRATORY CULTURE-FINAL
___
Blood Culture, Routine-FINAL
___ Blood Culture, Routine-FINAL
___ URINE Legionella Urinary Antigen -FINAL
___ URINE CULTURE-FINAL
___ SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-FINAL
___ STOOL C. difficile DNA amplification assay-FINAL
{POSITIVE FOR CLOSTRIDIUM DIFFICILE}
___ MRSA SCREEN-FINAL
___ Blood Culture, FINAL
Norovirus, EIA (Stool)
Norovirus Antigen POSITIVE
Brief Hospital Course:
BRIEF HOSPITAL COURSE
=====================
Mr. ___ is a ___ year-old male with PMH of developmental delay,
dementia, CKD on HD who presented with altered mental status. He
was found to have cirrhosis (new diagnosis on this admission,
EGD without varices, but showed portal gastropathy and a
nodule). Central line placed, complicated by a stable
pneumothorax (eventually removed). Also found to have norovirus
and clostridium dificile infections, completed a 14 day course
of PO vancomcyin for recurrent c. diff. He improved and was
discharged back to his group home ___ home) with
___ and ___.
ACTIVE ISSUES
=============
#. Altered mental status - The patient presented to ___ from
his outpatient dialysis center due to altered mental status. In
the ED he was intermittently following commands and not
answering questions. Unable to handle his respiratory secretions
and intubated for airway protection. A CT abdomen showed
cirrhosis and ascites. He was given vanc/zosyn/flagyl and
admitted to the ICU. In the ICU, the patient was having diarrhea
and tested positive for C. Diff and norovirus (see below). He
was started on rifaximin and lactulose. Ascites tapped and was
negative for SBP, however given that he had been started on
ceftriaxone prior to the tap this was continued for a 5 day
course. The patient's mental status improved. He was extubated
on ___ and was mentating closer to his baseline afterwards.
Overall, his initial altered mental status was thought to be
most likely to hepatic encephalopathy (new diagnosis of
cirrhosis on this admission), as well as significant
contribution by these multiple infections.
- His legal guardian did feel that he was not at his former
baseline (prior to multiple hospitalizations in
___ for colectomy and other medical problems).
Overall, he would most benefit from the normalcy and routine at
his group home, as opposed to rehab facility. Please also see
discussion of developmental delay below.
- Follow up with hepatology as below.
#. Diarrhea (Positive for Norovirus, C. Diff) - The patient was
having frequent loose stools on admission. C. Diff and norovirus
testing sent and both returned positive. He does have a history
of C. diff ___, at ___). Given critical
illness, he was started on oral vancomycin and IV metronidazole.
The patient's diarrhea improved and he was transitioned to oral
vancomycin alone on ___. This should be continued for 14 days
per guidelines, as this was the first recurrence of c.
difficile. He was treated symptomatically for norovirus and
maintained on GI contact precautions.
- Treated for c. diff until ___. Of note, c. diff toxin may
not clear immediately even with treatment, so low yield to check
in the near future.
- Some of his diarrhea was persistent in house; some of this may
have been due to lactose intolerance (on lactaid as an
outpatient).
#. Cirrhosis - The patient was found to have cirrhosis and new
ascites on CT abdomen done on admission. Seen by hepatology and
work-up of cirrhosis initiated. Negative to date. Also had
ascites tapped as above w/o evidence of SBP. The patient
underwent EGD due to guaiac (+) output from the NGT which showed
portal gastropathy and a nodule in the esophagus of unclear
origin (possibly trauma from NG tube placement, see below). The
patient was managed with lactulose and rifaximin.
- He should have hepatology ___ as an outpatient
(arranged).
- Use care with hepatotoxic agents, no more than 2 grams of
acetaminophen daily.
# Portal gastropathy: In the ICU, he was noted to have blood in
his OG tube. He underwent EGD, which did not show evidence of
varices. He did have portal gastropathy. He also had evidence
of a small nodule, which was attributed to NG tube trauma and
left undisturbed. However, this should be followed up (if nodule
persists at 4 weeks, it should be biopsied). He was started on
high dose pantoprazole BID, and should continue for four weeks
only.
- Pantoprazole should be stopped ___ in order to decrease
risk for recurrent c. difficile infection.
#. Thrombocytopenia - Most likely related to cirrhosis, also
appears to have bone marrow suppression. He received 3 units of
platelets during his hospital stay. Also recieved DDAVP prior to
procedures. Please see discussion of cirrhosis and
pancytopenia. His recent baseline was in the ___ in ___ and
___. This was trended during his time on the
general medical floor and he did not require further
transfusion.
#. Pneumothorax- The patient developed a small pneumothorax
presumably during central line insertion. This was followed with
serial CXRs and did not expand. CXR on ___ showed stable
pneumothorax (after removal of central line).
- Please get a ___ chest PA and lateral at primary care
doctor ___ appointment.
# Episode of bleeding at dialysis. On ___ he was noted to be
bleeding from fistula after dialysis. Pressure was held for
several minutes by nursing staff. No evidence of thrombosis in
the fistula and bleeding stopped. This was discussed with the
___ team, and he will be contacted by ___ fistula
access nurse after discharge in order to assess the patency of
his fistula. This should be coordinated with his outpatient
dialysis unit.
#. Pancytopenia - Chronic anemia slightly below baseline here.
Could be related to oozing from portal gastropathy, chronic
kidney disease, or myelosuppression. Could also be other
hematologic component (given macrocytosis, could consider
myelofibrosis vs MDS). He received 1x PRBCs with good response
in the ICU. Per his group home, he was evaluated by a
hematologist at ___.
- Needs hematology ___ with prior hematologist, or can
consider referral from primary care doctor.
# Asymptomatic hypotension: He was noted to have low blood
pressures (often in the ___ during the day, down to high ___
overnight) while asymptomatic. He was worked up extensively for
infection, but did not have any evidence of this, no evidence of
sepsis picture either. He remained stable during admission;
excessive IV hydration was avoided given his dialysis
requirement.
CHRONIC ISSUES
==============
#. ESRD on HD - Continued on hemodialysis MWF in-house,
(initially with IV vancomycin which was stopped ___. Please
see below regarding bleeding fistula. He should continue on MWF
dialysis at his unit in ___.
# CAD s/p CABG in ___: Currently does not appear to be on any
medication for this. His medications were reconciled with group
home records.
- Consider daily baby aspirin.
# DM type 2, diet controlled: He was maintained on a humalog
insulin sliding scale while in house. He had minimal need for
this, and was discharged with instructions to maintain a
diabetic diet.
# CHF (unknown EF): Currently does not appear to be on any
medication for this. His volume status is maintained with
dialysis three times per week.
# Tubulovillous adenoma s/p right hemi-colectomy in ___:
Per his group home, he had some difficulty with lower GI
bleeding after the surgery. He did not have evidence of this
during this admission. He should follow up with his surgeon.
# GERD: Omeprazole was switched to pantoprazole for a short
course. Recommend discontinuing pantoprazole as soon as possible
to decrease possibility of recurrent c. diff infection. H2
blockers such as ranitidine can also increase the risk of c.
difficile, so please consider this prior to prescribing
medication for reflux disease.
# Dementia / developmental delay: Please see discussion of
altered mental status above. Mr. ___ lives at a group home and
there, he is very friendly, interactive, and lively at his group
home. He continued to be friendly and interactive during his
hospitalization, but did appear subdued at times and reported
feeling sad, because he wanted to return to his group home.
- Major medical decisions were made in conjunction with his
legal guardian (including HIV consent).
TRANSITIONAL ISSUES
===================
- Code status: Full code, confirmed with ___
(HCP/guardian).
- Emergency contact: ___, HCP/Guardian,
___, ___. Niece, ___.
- His group home is ___ (via ___
___). Fax is ___. ___ RN at the group home is Ms.
___ (___) ___ and ___.
- Studies pending at discharge: None.
- Needs follow up EGD ___ weeks after discharge for submucosal
hematoma on EGD during this admission. If hematoma is persistent
in 1 month, it requires biopsy (left undisturbed during EGD).
- Please discontinue/down-titrate pantoprazole as soon as
possible (___) to decrease risk of recurrent c. diff
infection.
- Continue to monitor HCT, if continues to decrease, he may need
a colonoscopy.
- Needs follow up with hematology regarding pancytopenia.
- Needs speech and swallow re-evaluation WITH dentures in in
order to advance his diet (we could not locate his dentures in
his hospital room, these could be at his outpatient dialysis
center, if they are not there, he unfortunately needs new
dentures).
- If he shows e/o bleeding, please check stat CBC (has history
of low platelets, though not at transfusion threshold currently,
without bleeding) as well as coags. He may benefit from a
platelet transfusion or DDAVP.
- Needs follow up CXR (PA and lateral) to evaluate small stable
pneumothorax at primary care follow-uu appointment.
- Consider baby aspirin daily for primary prevention.
- A copy of this discharge summary was faxed to Dr. ___ at
___ and to Mr. ___ group home at ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Nephrocaps 1 CAP PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Docusate Sodium 200 mg PO DAILY
5. Simvastatin 20 mg PO DAILY
6. Renagel *NF* 800 mg Other TID
7. Lactaid *NF* (lactase) 3,000 unit Oral TID with meals
8. Risperidone 2 mg PO HS
9. zinc oxide *NF* ___ % Topical BID
10. Guaifenesin 10 mL PO Q6H:PRN cough
11. Acetaminophen 650 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Nephrocaps 1 CAP PO DAILY
3. Lactulose 15 mL PO BID confusion
Please HOLD if more than ___ BMs per day.
RX *lactulose 10 gram/15 mL 15 mL by mouth twice daily Disp
#*473 Milliliter Refills:*0
4. Rifaximin 550 mg PO BID
RX *rifaximin [___] 550 mg one tablet(s) by mouth twice
daily Disp #*30 Tablet Refills:*0
5. Ferrous Sulfate 325 mg PO DAILY
6. Guaifenesin 10 mL PO Q6H:PRN cough
7. Lactaid *NF* (lactase) 3,000 unit Oral TID with meals
8. Renagel *NF* 800 mg Other TID
9. Simvastatin 20 mg PO DAILY
10. Pantoprazole 40 mg PO Q12H Duration: 1 Months
STOP after ___ to avoid increased risk of c. diff.
RX *pantoprazole 40 mg one tablet(s) by mouth every 12 horus
Disp #*32 Tablet Refills:*0
11. Outpatient Lab Work
Please check HCT and platelet count ___ and fax results to
Dr. ___ at ___. ICD-9 Code 287.5:
Thrombocytopenia.
12. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg one tablet(s) by mouth every 8 hours Disp
#*30 Tablet Refills:*0
13. Sarna Lotion 1 Appl TP DAILY:PRN puritis
RX *camphor-menthol [Sarna Anti-Itch] 0.5 %-0.5 % one
application twice daily Disp #*1 Bottle Refills:*0
14. zinc oxide *NF* ___ % Topical BID
15. ProMod Protein *NF* (protein supplement) 2 oz Oral twice
daily, breakfast and dinner
total = 120ml/4oz daily.
Discharge Disposition:
Home with Service
Facility:
___
Discharge Diagnosis:
Primary: C. difficile infection
Encephalopathy
Cirrhosis
Norovirus
Pneumothorax
Portal hypertensive gastropathy
Pancytopenia
Secondary: ESRD on dialysis
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 part in your care at ___
___. You were admitted for confusion noted
at your outpatient dialysis center. While here, you were
intubated because you weren't breathing well. You had a central
line placed for IV fluids and antibiotics, which was complicated
by a small pneumothorax. You were also found to have c. diff and
norovirus, both are infections of the gut which can cause
diarrhea. You were started on oral antibiotics for your c. diff
infection. Finally, you were also found to have cirrhosis. You
should follow up with a hepatologist (liver doctor) after
discharge. You should follow up with your primary care doctor,
we made the appointment for you below.
Followup Instructions:
___
|
10216740-DS-20 | 10,216,740 | 23,135,539 | DS | 20 | 2167-06-10 00:00:00 | 2167-06-10 16:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PLASTIC
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / Sulfa
(Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
___ small finger increasing pain, redness, swelling and
purulent discharge from the pin sites
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ LHD with ___ hand infection 3 weeks s/p complex repair of
a table saw injury. On ___ he was taken emergently to
the OR by Dr. ___ for ___ hand wound exploration with
___ small finger proximal phalanx fracture ORIF (plate,
cerclage wire, two pins) and tendon, nerve and microvascular
repair (see op note for details). He was discharged on postop
day 2 ___ a dorsal blocking splint and did well postoperatively
from a pain control and rehab standpoint until ___, when he
developed increasing pain, redness, swelling and purulent
discharge from the pin sites. He presented to the ED and Hand
Surgery was consulted for evaluation. Denies fever or chills.
Past Medical History:
Hyperlipidemia, Anxiety, Nephrotic Kidney disease
Social History:
___
Family History:
Noncontributory
Physical Exam:
Vitals: 98.2, 75, 145/84, 18, 98% RA
Gen: NAD, A&Ox3, pleasant and conversational, wife at bedside
___ upper extremity:
- dorsal blocking orthoplast splint removed for further
evalauation
- pin sites with small amount of expressable purulence and
surounding warmth and erythema but no obvious drainable
collection
- small area of dehiscence with serous drainage along ulnar
border of small finger at level of proximal phalanx fracture
site; otherwise, repaired laceration/incision over volar aspect
of metacarpal heads is well approximated and healing well.
- warmth and edema extends proximally to the level of the
proximal third of the forearm
- no pain with passive range of motion of the wrist, MP, or IP
joints
- good capillary refill ___ the ulnar and radial aspects of the
distal pulp of all digits including his small finger
- normal finger cascade with ability to place and hold his small
finger with active flexion indicating firing of both FDS and
FDP.
- small finger remains insensate ___ the ulnar digital nerve
distribution of the small finger, otherwise sensation is intact
to light touch on the radial aspect of the small finger and on
the ulnar and radial aspects of digits 1, 2, 3, and 4.
Pertinent Results:
___ 06:04PM LACTATE-0.9
___ 05:45PM GLUCOSE-89 UREA N-14 CREAT-1.5* SODIUM-139
POTASSIUM-5.0 CHLORIDE-104 TOTAL CO2-26 ANION GAP-14
___ 05:45PM estGFR-Using this
___ 05:45PM WBC-7.6 RBC-4.64 HGB-13.1* HCT-39.6* MCV-85
MCH-28.2 MCHC-33.1 RDW-13.4
___ 05:45PM NEUTS-76.7* LYMPHS-16.3* MONOS-5.1 EOS-1.4
BASOS-0.6
___ 05:45PM PLT COUNT-242
___ 07:12AM BLOOD WBC-7.4 RBC-4.66 Hgb-13.3* Hct-40.4
MCV-87 MCH-28.6 MCHC-33.0 RDW-13.5 Plt ___
___ 07:12AM BLOOD Glucose-111* UreaN-14 Creat-1.5* Na-141
K-4.4 Cl-104 HCO3-26 AnGap-15
___ 05:35AM BLOOD WBC-5.2 RBC-4.28* Hgb-11.9* Hct-37.1*
MCV-87 MCH-27.9 MCHC-32.2 RDW-13.6 Plt ___
___ 05:35AM BLOOD Neuts-52.7 ___ Monos-6.6 Eos-2.0
Baso-0.9
.
MICROBIOLOGY:
___ 7:48 pm SWAB Source: R ___ finger.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
WOUND CULTURE (Preliminary):
STAPH AUREUS COAG +. MODERATE GROWTH.
Sensitivity testing performed by Sensititre.
SENSITIVE TO TETRACYCLINE MIC <=2 MCG/ML.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=2 S
LEVOFLOXACIN----------<=0.25 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
.
IMAGING:
Radiology Report HAND (AP, LAT & OBLIQUE) ___ Study Date of
___ 5:49 ___
FINDINGS: The patient is status post ORIF of a fifth proximal
phalangeal
fracture. Two fixation plates, screws, a cerclage wire, and two
wires,
similar ___ appearance as compared to the prior study given
differences ___
patient positioning. The patient's fingers are relatively
flexed and the
mid-to-distal fifth digit is not optimally evaluated; however,
no new fracture is identified. Suggestion of associated soft
tissue swelling is again seen.
.
IMPRESSION: Status post ORIF of the fifth digit proximal
phalanx comminuted fracture, similar ___ appearance compared to
the prior study.
Brief Hospital Course:
The patient was admitted to the plastic surgery service on
___ for observation and treatment of ___ small finger pin
infection. An Ulnar nerve block was obtained following infusion
of 15cc of 1% lidocaine with epinephrine. A culture swab was
used to sample the already-expressed purulence from the
ulnar-most pin site. The two dorsally-located pin sites were
then each extended ___ turn by small 0.5 cm superficial incisions
to explore and attempt to express additional pus, however no
drainable purulent collections were identified. Given the
delicate nature of the neurovascular repair performed on
___, further exploration was not pursued. The patient
was placed ___ an ulnar gutter splint and his ___ hand
elevated.
.
Neuro: The patient received oxycodone and tylenol, as needed,
with adequate pain relief noted.
.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
.
GI/GU: The patient was given IV fluids as needed when NPO. His
diet was advanced when appropriate, which was tolerated well. He
was also started on a bowel regimen to encourage bowel movement.
Intake and output were closely monitored.
.
ID: A swab culture was taken of pus expressed from pin site and
sent for workup. Upon admission, the patient was started on IV
vancomycin and unasyn with good effect and improvement of signs
of infection noted over several days. On hospital day 3, swab
culture showed MSSA, and IV antibiotics were discontinued ___
favor of PO Augmentin. The patient's temperature was closely
watched for signs of infection.
.
At the time of discharge on Hospital day #3, the patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled.
Medications on Admission:
Diovan, Fluoxetine, Simvastatin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet
extended release(s) by mouth every eight (8) hours Disp #*40
Tablet Refills:*0
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
Please complete entire course
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*20 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*40 Capsule Refills:*0
4. Fexofenadine 60 mg PO BID:PRN allergy symptoms
5. Fluoxetine 20 mg PO DAILY
6. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
Only take for severe pain, not controlled by tylenol
RX *oxycodone 5 mg ___ capsule(s) by mouth every four (4) hours
Disp #*35 Tablet Refills:*0
7. Simvastatin 40 mg PO DAILY
8. Valsartan 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
___ finger pin-site infection
Discharge Condition:
Patient is ___ stable condition with normal mentation and normal
ambulation.
Discharge Instructions:
You were seen for your ___ finger pinsite infection. You were
treated with antibiotics including vancomycin and unasyn and
then changed to augmentin. Your hand was placed ___ a splint and
elevated.
.
Continue to keep your ___ hand ___ a splint and elevated. Do
not soak your hand and keep it dry. You should apply a clean,
dry dressing daily.
.
Do not exercise or bear weight on your ___ hand.
.
You may resume your regular diet.
.
Medications:
1. Resume your regular medications unless instructed otherwise
and take any new meds as ordered. Pleae complete the entire
course of the prescribed antibiotics.
2. You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging. Do not take more
than 3g of tylenol ___ a day.
3. Take prescription pain medications for pain not relieved by
tylenol.
4. Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high ___ fiber.
Followup Instructions:
___
|
10217041-DS-13 | 10,217,041 | 21,082,885 | DS | 13 | 2150-05-14 00:00:00 | 2150-05-14 13:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Bactrim / Demerol / Percocet
Attending: ___.
Chief Complaint:
Ex-fix pin site pain/infection
Major Surgical or Invasive Procedure:
___ Removal of pelvic exfix
History of Present Illness:
The patient is a pleasant female who was
involved in a motor vehicle accident in ___ where she was
struck by a vehicle, suffering a severe pelvic fracture. She
was taken to ___ where an external fixator
was placed as was an SI screw by Dr. ___. She has had
the external fixator on now for almost 4 weeks and has had
some increased drainage from the right pin site. Given the
concerns for infection, a decision was made to proceed with
removal of the ex fix and assessed the pelvis for stability.
Past Medical History:
PMH:
- mild asthma, exercise induced
- eczema
- cervical and lumbar herniated discs (treated with injections
and stable, no h/o spine surgery)
- intermittent reflux (PRN zantac)
- migraines
- h/o community acquired PNA
- herpes simplex involving eye (maintenance acyclovir)
PSH:
- appendectomy
- pelvis ORIF on ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
AFVSS
Gen: A&Ox3, No actue distress
Pelvis: Pin site dressings c/d/i
Pertinent Results:
___ 01:15AM BLOOD CRP-38.9*
___ 01:15AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.0
___ 06:00AM BLOOD Calcium-8.4 Phos-4.0 Mg-2.0
___ 01:15AM BLOOD Glucose-104* UreaN-6 Creat-0.5 Na-137
K-4.0 Cl-103 HCO3-30 AnGap-8
___ 06:00AM BLOOD Glucose-92 UreaN-6 Creat-0.5 Na-137 K-3.7
Cl-103 HCO3-30 AnGap-8
___ 01:15AM BLOOD ESR-65*
___ 01:15AM BLOOD ___ PTT-46.0* ___
___ 01:15AM BLOOD Plt ___
___ 01:00PM BLOOD ___ PTT-44.9* ___
___ 06:00AM BLOOD ___
___ 06:00AM BLOOD Plt ___
___ 01:15AM BLOOD Neuts-78.3* Lymphs-14.9* Monos-4.7
Eos-1.7 Baso-0.4
___ 01:15AM BLOOD WBC-9.2 RBC-3.36* Hgb-10.1* Hct-30.7*
MCV-92 MCH-30.1 MCHC-32.9 RDW-15.3 Plt ___
___ 06:00AM BLOOD WBC-7.2 RBC-3.00* Hgb-9.4* Hct-27.8*
MCV-93 MCH-31.3 MCHC-33.7 RDW-15.1 Plt ___
Brief Hospital Course:
The patient presented as a direct admit to the orthopedic
surgery service after experiencing some fevers, chills, and
noting some increasing drainage from her right ex-fix pin site
while at ___ for rehab. The patient was taken to the
operating room on ___ for removal of pelvic ex-fix, 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
progressed to a regular diet and oral medications by POD#1. The
patient was given perioperative antibiotics and anticoagulation
per routine. The patients home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to home with services was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is weight bearing as tolerated in the
right lower extremity, and touch down weight bearing in the left
lower extremity. 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:
Per OMR
1.acyclovir
acyclovir 400 mg tablet
1 Tablet(s) by mouth twice a day ___
2.albuterol sulfate [ProAir HFA]
ProAir HFA 90 mcg/actuation Aerosol Inhaler
2 (Two) puffs(s) orally four times a day as needed
3.ammonium lactate
ammonium lactate 12 % Topical Cream
apply feet once a day ___
4.desonide
desonide 0.05 % Topical Cream
apply to eczema twice a day ___
5.epinephrine [EpiPen]
EpiPen 0.3 mg/0.3 mL (1:1,000) injection,auto-injector
use epi pen in allergic crisis as needed ___
6.fluticasone [Flonase]
Flonase 50 mcg/actuation Nasal Spray
2 (Two) in each nostril once a day ___
7.fluticasone [Flovent HFA]
Flovent HFA 220 mcg/actuation Aerosol Inhaler
___ puffs inhaled twice a day rinse after use ___
8.ibuprofen
ibuprofen 800 mg tablet
one Tablet(s) by mouth tid for 4 days then prn ___
9.montelukast [Singulair]
Singulair 10 mg tablet
1 Tablet(s) by mouth daily ___
10.ranitidine HCl
ranitidine 150 mg tablet
1 Tablet(s) by mouth twice a day ___.tacrolimus [Protopic]
Protopic 0.03 % Topical Ointment
apply to affected area daily ___
12.tizanidine
tizanidine 4 mg tablet
1 Tablet(s) by mouth up to tid; take no more than 3 doses in 24
hours; do not use while taking acyclovir ___
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN migraine
3. Acyclovir 400 mg PO Q12H
4. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
RX *bisacodyl [Laxative] 5 mg 2 tablet(s) by mouth Daily as
needed for constipation Disp #*28 Tablet Refills:*0
5. Calcium Carbonate 500 mg PO TID W/MEALS
6. Citalopram 30 mg PO DAILY
7. Desonide 0.05% Cream 1 Appl TP BID
8. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth Twice
daily as needed for constipation Disp #*28 Capsule Refills:*0
9. Fluticasone Propionate 110mcg 2 PUFF IH BID
10. Gabapentin 400 mg PO TID
RX *gabapentin 400 mg 1 capsule(s) by mouth Three times daily
for pain control Disp #*45 Capsule Refills:*0
11. Iron Polysaccharides Complex ___ mg PO BID
12. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth Every 4 to 6 hours
as needed for pain control Disp #*90 Tablet Refills:*0
13. Milk of Magnesia 30 ml PO BID:PRN Constipation
14. OxyCODONE SR (OxyconTIN) 10 mg PO QHS
RX *oxycodone 10 mg 1 tablet(s) by mouth Daily each evening for
pain control Disp #*20 Tablet Refills:*0
15. Polyethylene Glycol 17 g PO DAILY
16. Senna 2 TAB PO HS
RX *sennosides [senna] 8.6 mg 2 tabs by mouth Daily as needed
for constipation Disp #*28 Capsule Refills:*0
17. Tizanidine ___ mg PO TID:PRN spasms
RX *tizanidine 2 mg ___ capsule(s) by mouth Up to three times
daily as needed for spasms Disp #*40 Tablet Refills:*0
18. Doxycycline Hyclate 100 mg PO Q12H Duration: 10 Days
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth Twice daily
for ___isp #*20 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pelvic ex-fix pin site infection
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
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.
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Daily dressing changes and ex pin site wound care by ___
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated right lower extremity, Touch down
weight bearing left lower extremity
Physical Therapy:
Weight bearing as tolerated right lower extremity
Touch down weight bearing left lower extremity
Treatments Frequency:
Daily ex pin site wound drssing changes and cleaning
Followup Instructions:
___
|
10217041-DS-14 | 10,217,041 | 24,067,749 | DS | 14 | 2150-06-14 00:00:00 | 2150-06-15 20:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Bactrim / Demerol / Percocet
Attending: ___.
Chief Complaint:
pelvic pain/expanding hematoma
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ s/p car vs pedestrian accident in ___ in ___. She
had an open pelvic fracture with a bladder perforation and
vaginal lacerations. She was treated with an SI screw and
external fixation. Course complicated by pelvic hematoma, UTI,
and superficial RLE DVT found on routine screening and she was
placed on coumadin. She was sent to ___ on ___. On
___ there appeared to be increased drainage coming from the pin
site and she was admitted to ___ for removal external hardware
and antibiotics. CX data showed MRSA. She underwent on ___
removal of pelvic hardware except SI screw. She has been
followed
by ortho and noted to have a stable L perineal hematoma.
Over the past few days she has been a bit more active on
crutches
at home. She noted some increased discomfort last night, and
then at
5AM noted sudden increase in pain to ___ and feeling the
swelling increase to the perirectal area. She and her husband
called an ambulance and she was taken to ___. There, VSS
and labs were OSH labs: WBC 9, hct 33.9, plts 222, INR 1.9. She
was transferred to ___.
Past Medical History:
PMH:
- mild asthma, exercise induced
- eczema
- cervical and lumbar herniated discs (treated with injections
and stable, no h/o spine surgery)
- intermittent reflux (PRN zantac)
- migraines
- h/o community acquired PNA
- herpes simplex involving eye (maintenance acyclovir)
PSH:
- appendectomy
- pelvis ORIF on ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
On Admission
PE: 98.3 76 120/67 16 97% RA
Abdomen: soft, flat, NT
External anatomy: labial swelling noted on L at 5 o'clock.
Approximately 7 x 4 cm. No overlying erythema suggestive of
cellulitis. exquisitely TTP. On digital examination, swelling
approximately 5cm up L vaginal sidewall, just distal to palpable
vaginal sutures.
Ext: NE, NT
On day of discharge
PE NAD
CTAB
RRR
abd s nt, nd
GU: 8cm perineal hematoma, no e/o infection
ext: NE, NT
Pertinent Results:
___ 09:30PM WBC-7.2 RBC-3.66* HGB-10.6* HCT-32.7* MCV-93
MCH-29.1 MCHC-31.3 RDW-13.3
___ 09:30PM PLT COUNT-203
___ 09:30PM ___ PTT-35.1 ___
___ 04:55PM WBC-7.7 RBC-3.85* HGB-11.3* HCT-34.8* MCV-90
MCH-29.3 MCHC-32.5 RDW-13.2
___ 04:55PM NEUTS-71.2* LYMPHS-17.1* MONOS-6.2 EOS-5.3*
BASOS-0.4
___ 04:55PM PLT COUNT-233
___ 04:55PM ___ PTT-39.5* ___
___ 03:14PM HGB-12.3 calcHCT-37
___ 11:57AM LACTATE-0.8
___ 11:50AM GLUCOSE-91 UREA N-8 CREAT-0.6 SODIUM-142
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-28 ANION GAP-14
___ 11:50AM estGFR-Using this
___ 11:50AM WBC-9.1 RBC-3.99*# HGB-11.7* HCT-36.5# MCV-91
MCH-29.3 MCHC-32.0 RDW-13.1
___ 11:50AM NEUTS-77.2* LYMPHS-14.1* MONOS-5.1 EOS-3.0
BASOS-0.5
___ 11:50AM PLT COUNT-231
___ 11:50AM ___ PTT-44.8* ___
Brief Hospital Course:
Mrs. ___ is a ___ who was being anticoagulated for a DVT s/p
severe pelvic fracture 2 mos ago admitted with left labial
hematoma and initially active extravasation from branch of L
internal pudendal artery. This then stabilized after reversal of
anti-coagulation, followed by expectant management with serial
exams and hematocrits performed.
Her anticoagulation, initial INR 2.0, was reveresed with vitamin
K and FFP. Of note pt received one unit of FFP without issue but
on initiation of her second unit had an allergic reaction with
eye swelling requiring benadryl and an albuerol neb for
resolution. By hospital day 2 her INR was 1.2, hematocrit
stabilized, and the hematoma stabilized at 8cm. With expectant
management and ice packs to area, pain in labia significantly
decreased. On discharge day, pain was well controlled on po
medications and the patient was able to tolerate ADLs and void
without foley catheter.
During her admission the gyn-oncology service was consulted
regarding possibility of evacuation of the clot for symptomatic
relief. This was thought to be unexceptable risk of infection
and thus expectant management was continued. Given that active
bleeding in area had clinically stopped, ___ intervention was not
thought to be necessary.
Orthopedics was also consulted who recommended discontinuation
of her anti-coaguation at this time.
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*2
2. Gabapentin 600 mg PO QAM
RX *gabapentin 600 mg 1 tablet(s) by mouth daily Disp #*40
Capsule Refills:*0
3. OxycoDONE (Immediate Release) 10 mg PO Q8H:PRN pain
RX *oxycodone 10 mg 1 tablet(s) by mouth no more frequently than
every 8 hours Disp #*45 Tablet Refills:*0
4. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H
RX *oxycodone [OxyContin] 30 mg 1 tablet extended release 12
hr(s) by mouth every 12 hours Disp #*30 Tablet Refills:*0
5. Lactulose 30 mL PO DAILY PRN constipation
RX *lactulose 10 gram/15 mL 30 ml by mouth daily Disp #*1 Bottle
Refills:*3
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
left perineal hematoma
s/p pelvic fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mrs. ___,
___ was a pleasure caring for you here at ___. You were
admitted for a hematoma in your pelvis which was expanding while
you were on anti-coagulation. Once your anti-coagulation was
stopped, your bleeding stopped and you hematoma has not grown in
size. Your pain is controlled with oral medication and you are
urinating, eating a regular diet and ambulating. Thus you were
felt to be safe to go home.
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Take a stool softener such as colace while taking narcotics to
prevent constipation
* Do not combine narcotic and sedative medications or alcohol
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs
* No strenuous activity until your post-op appointment
* No heavy lifting of objects >10lbs for 6 weeks.
* You may eat a regular diet
* No strenuous activity until cleared by your doctor
___ your doctor for:
* fever > 100.4
* worsening pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
*shortness of breath, chest pain, dizziness/lightheadedness
To reach medical records to get the records from this
hospitalization sent to your doctor at home, ___ ___.
Followup Instructions:
___
|
10217517-DS-18 | 10,217,517 | 23,637,976 | DS | 18 | 2130-03-23 00:00:00 | 2130-03-24 07:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
___ who by report from ___, had an epidose of back pain
that radiated down left arm, nausea. On arrival to ___ the
patient could recall if or when she had this back pain. She
sould not describe the timing, character, or if she has ever had
previous episodes. She denied chest/back pain or nausea on
arrival.
Past Medical History:
Hypercalcemia
Anemia
HTN
DM on metformin
Hyperparathyroidism
silent MI, ___ LHC -> no coronary disease but takotsubo
cardiomyopathy
Social History:
___
Family History:
Physical Exam:
98.4 84 139/76 18 98 RA
Gen: Well appearing, in no acute distress
Neuro: A &O x3 but forgetful at times
Pulm: CTAB
Cardiac: RRR
GI: Soft, NT to palp, ND
Extremities: Distal pulses intact bilaterally. No open areas or
ulcerations.
Neuro: CN II-XII intact b/l
Pertinent Results:
___ 03:06AM BLOOD WBC-10.4* RBC-3.65* Hgb-10.5* Hct-32.0*
MCV-88 MCH-28.8 MCHC-32.8 RDW-13.9 RDWSD-44.4 Plt ___
___ 05:45AM BLOOD WBC-9.9 RBC-4.10 Hgb-11.7 Hct-36.0 MCV-88
MCH-28.5 MCHC-32.5 RDW-13.8 RDWSD-44.2 Plt ___
___ 05:45AM BLOOD Neuts-66.2 ___ Monos-9.4 Eos-1.7
Baso-0.5 Im ___ AbsNeut-6.73* AbsLymp-2.20 AbsMono-0.95*
AbsEos-0.17 AbsBaso-0.05
___ 03:06AM BLOOD Plt ___
___ 05:45AM BLOOD Plt ___
___ 05:45AM BLOOD ___ PTT-28.5 ___
___ 05:45AM BLOOD ___
___ 03:06AM BLOOD Glucose-131* UreaN-25* Creat-1.0 Na-133
K-4.3 Cl-101 HCO3-21* AnGap-15
___ 05:45AM BLOOD Glucose-185* UreaN-21* Creat-0.9 Na-133
K-4.6 Cl-94* HCO3-25 AnGap-19
___ 05:45AM BLOOD Glucose-185* UreaN-21* Creat-0.9 Na-133
K-4.6 Cl-94* HCO3-25 AnGap-19
___ 05:45AM BLOOD estGFR-Using this
___ 12:37PM BLOOD ALT-11 AST-20 LD(LDH)-212 CK(CPK)-89
AlkPhos-99 TotBili-0.2
___ 05:45AM BLOOD Lipase-164*
___ 03:06AM BLOOD Calcium-8.2* Phos-3.8 Mg-1.8
___ 12:37PM BLOOD Albumin-3.9
___ 05:45AM BLOOD Calcium-9.6 Phos-3.6 Mg-1.9
___ 05:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:45AM BLOOD LtGrnHD-HOLD
___ 03:06AM BLOOD WBC-10.4* RBC-3.65* Hgb-10.5* Hct-32.0*
MCV-88 MCH-28.8 MCHC-32.8 RDW-13.9 RDWSD-44.4 Plt ___
___ 03:06AM BLOOD Plt ___
___ 03:06AM BLOOD Glucose-131* UreaN-25* Creat-1.0 Na-133
K-4.3 Cl-101 HCO3-21* AnGap-15
___ 03:06AM BLOOD Calcium-8.2* Phos-3.8 Mg-1.8
___ EKG - Sinus rhythm with borderline first degree A-V
conduction delay. Possible inferior myocardial infarction, age
indeterminate. Consider anteroseptal myocardial infarction, age
indeterminate. Compared to tracing #1 no significant change.
___ 12:37PM BLOOD CK-MB-5 cTropnT-<0.01
___ 05:45AM BLOOD cTropnT-<0.01
___ CXR FINDINGS: The thoracic aorta is tortuous.
Otherwise, the cardiomediastinal silhouettes are within normal
limits. The bilateral hila are unremarkable. There are low lung
volumes. There may be mild atelectasis at the lung bases.
There is no focal lung consolidation. There is no evidence of
pulmonary vascular congestion. There is no pneumothorax or
pleural effusion. A hiatus hernia is noted.
IMPRESSION: No acute cardiopulmonary process. Hiatus hernia.
Brief Hospital Course:
Ms. ___ is a ___ year old female with a PMH of HTN and DMII who
presented to with back pain which had subsequently resolved by
the time she was evaluated by our service. She underwent CTA at
OSH which demonstrated a penetrating aortic ulceration just
below the level of the celiac artery. Unfortunately her anatomy
was unfavorable for endovascular repair and she voiced strong
opposition to surgical repair which we agreed with given her age
and comorbidities making her a high risk surgical patient.
Cardiac enzymes were negative. She continued to deny abdominal,
chest or back discomfort through the remainder of her hospital
stay.
Her blood pressure was closely monitored and she required PRN
doses of IV hydrazine. Ultimately she required titration of her
home antihypertensive regimen. At the time of discharge her BP
is 120's-130's/70's. The importance of blood pressure control
was reviewed with the pt and family. The patient was seen and
evaluated by ___ who felt d/c to home with intermittent
supervision to be appropriate. She is ambulating independently
with a walker, tolerating a diet, voiding and moving her bowels
without issue. Her son and daughter plan to physically check on
her daily and she is d/c home with ___ services and ___ home
safety eval. BP monitoring 2x/daily. The pt is declining
followup with vascular surgery and the family is aware and
agreeable. One week followup has been arranged with PCP in the
setting of adjustment of antihypertensive regimen.
Medications on Admission:
1. Lisinopril /Hydrochlorothiazide 20mg/12.5 mg PO DAILY
2. MetFORMIN (Glucophage) 500 mg PO BID
3. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Lisinopril /Hydrochlorothiazide 20mg/12.5 mg PO DAILY
3. MetFORMIN (Glucophage) 500 mg PO BID
4. Metoprolol Succinate XL 75 mg PO DAILY
5. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Penetrating aortic ulceration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you here at ___
___. You were admitted to our hospital for
back pain which since resolved and were have to have an aortic
ulceration. The risks and benefits of surgical intervention were
reviewed with you and your family, which you ultimately did not
pursue. Your blood pressure medications have been adjusted
during your stay. Please follow the recommendations below to
ensure a speedy and uneventful recovery.
MEDICATIONS:
Take Aspirin 81mg (enteric coated) once daily
Please see medication list - your blood pressure medications
have been adjusted. Your goal BP in 130/80. Please take your BP
twice daily and report high and/or low blood pressure to your
PCP.
WHAT TO EXPECT AT HOME:
Drink plenty of fluids and eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
ACTIVITIES:
When you go home, you may walk and go up and down stairs as
long as you feel steady.
You may shower.
* You were not driving prior to hospital admission.
Followup Instructions:
___
|
10217776-DS-13 | 10,217,776 | 20,416,140 | DS | 13 | 2153-05-19 00:00:00 | 2153-05-19 16:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Statins-Hmg-Coa Reductase Inhibitors / ampicillin
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
ERCP/sphincterotomy (___)
cholecystectomy (___)
History of Present Illness:
Ms. ___ is an ___ female past medical history
hypertension hyperlipidemia and CKD transfer from ___ with
abdominal pain, common bile duct dilatation, cholelithiasis and
pancreatitis. Patient reports ___ began having intermittent
right upper quadrant pain after meals and associated nausea,
anorexia. Pain became progressive and this morning after
breakfast and it was persistent so she went to the ED at ___
___. Labs there were remarkable for elevated lipase,
LFTs and right upper quadrant ultrasound showing
choledocholithiasis with dilation of the common and pancreatic
ducts.
She does not report fevers or chills. She does not report
emesis. She had nausea yesterday. She has lost 10 lbs over the
past year because of a loss of appetite and the food does not
taste good since her husband died a year ago. She does not
report dark urine but she occasionally has light colored stools.
She reports developing "irritable bowel syndrome" such that she
needs to take benefiber or else she will not be able to have a
bowel movement. She does not have constiipation but has small
soft brown stools that are difficult for her to pass. The
benefiber helps with this. She has never had a colonoscopy. She
does not report neuro symptoms, slurred speech and chest pain.
She reports that her legs don't feel strong enough to hold her
up than they used to. She does not report night sweats.
Past Medical History:
chronic kidney disease (baseline Cr 3.2-3.7)
carotid stenosis s/p CEA (___)
primary hyperthyroidism
parathyroid adenoma
TIA
hypertension
hyperlipidemia
renal artery stenosis
multifocal atrial tachycardia
cataracts
gout
hearing loss
s/p tonsillectomy (___)
s/p tubal ligation (___)
s/p hysterectomy (___)
s/p cataract surgery (___)
Social History:
___
Family History:
She has no known family history of
hepatobiliary disease.
Physical Exam:
ADMISSION EXAM
=================================
EXAM ___ Temp: 98.3 PO BP: 177/71 R Lying HR: 68 RR:
18
O2 sat: 98% O2 delivery: Ra
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, systolic murmur.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended diffuse mildly tender to
palpation. No HSM
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,
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM
=================================
VITALS: Temp: 98.0 PO BP: 162/66 R Lying HR: 73 RR: 18 O2 sat:
95% O2 delivery: Ra
GENERAL: Elderly, well appearing woman in no acute distress.
Comfortable.
NEURO: AAOx3. Moving all four extremities with purpose.
HEENT: NCAT. EOMI. MMM.
CARDIOVASCULAR: Regular rate & rhythm. III/VI systolic murmur
over the RUSB.
PULMONARY: Fine crackles at the right base. Breathing
comfortably
on room air.
ABDOMEN: Laparoscopic incision sites x3 are clean and without
drainage. Otherwise soft, non-tender, non-distended.
EXTREMITIES: Warm, well perfused, non-edematous.
SKIN: No significant rashes.
Pertinent Results:
ADMISSION LABS
=================================
___ 10:20PM BLOOD WBC-4.7 RBC-2.77* Hgb-8.8* Hct-28.4*
MCV-103* MCH-31.8 MCHC-31.0* RDW-14.3 RDWSD-53.7* Plt ___
___ 10:20PM BLOOD Neuts-69.6 Lymphs-13.5* Monos-11.4
Eos-4.5 Baso-0.4 Im ___ AbsNeut-3.24 AbsLymp-0.63*
AbsMono-0.53 AbsEos-0.21 AbsBaso-0.02
___ 10:20PM BLOOD ___ PTT-26.1 ___
___ 10:20PM BLOOD Glucose-93 UreaN-62* Creat-3.7* Na-141
K-5.3 Cl-109* HCO3-17* AnGap-15
___ 10:20PM BLOOD ALT-1528* AST-936* AlkPhos-326*
TotBili-2.3*
___ 10:20PM BLOOD Lipase-1235*
___ 10:20PM BLOOD Albumin-3.9
___ 10:30PM BLOOD Lactate-0.8
PERTINENT INTERVAL LABS
=================================
___ 07:21AM BLOOD WBC-6.4 RBC-2.63* Hgb-8.4* Hct-27.9*
MCV-106* MCH-31.9 MCHC-30.1* RDW-15.2 RDWSD-57.8* Plt ___
___ 06:26AM BLOOD Glucose-90 UreaN-41* Creat-3.5* Na-140
K-5.0 Cl-112* HCO3-18* AnGap-10
___ 07:21AM BLOOD ALT-129* AST-160* AlkPhos-274*
TotBili-0.5
___ 07:10AM BLOOD Lipase-12
___ 07:10AM BLOOD TotProt-5.1* Calcium-10.2 Phos-4.5 Mg-1.6
Iron-51
___ 07:10AM BLOOD calTIBC-208* Ferritn-384* TRF-160*
___ 07:00AM BLOOD ___ Folate->20
___ 06:26AM BLOOD Calcium-10.7* Phos-4.0 Mg-2.3
___ 03:54AM BLOOD PTH-579*
___ 07:10AM BLOOD TSH-2.9
___ 07:10AM BLOOD 25VitD-37
___ 07:10AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 07:21AM BLOOD HIV Ab-NEG
___ 07:10AM BLOOD HCV Ab-NEG
DISCHARGE LABS
=================================
___ 06:26AM BLOOD Glucose-90 UreaN-41* Creat-3.5* Na-140
K-5.0 Cl-112* HCO3-18* AnGap-10
PERTINENT STUDIES
=================================
OUTSIDE HOSPITAL CT ABDOMEN
Multiple gall stones in gall bladder. Marked biliary ductal
dilatation. No definite pancreatic mass. Calcifications are
present within the pancreas.
RENAL US (___)
Echogenic atrophic kidneys consistent with medical renal
disease. There is no hydronephrosis. No renal stones or
suspicious solid masses are visualized. Small simple cysts are
noted bilaterally.
Brief Hospital Course:
___ with history of CKD, primary hyperparathyroidism, carotid
stenosis, TIA, HTN/HLD among other issues who was transferred
here for acute gallstone pancreatitis now s/p ERCP with
sphincterotomy and cholecystectomy. Hospital course was notable
for ___ and hypercalcemia in setting of known CKD and primary
hyperthyroidism. She was discharged home with ___ with plan for
close outpatient follow up of these known chronic conditions
# GALLSTONE PANCREATITIS
Initially presented to an outside facility with severe
epigastric pain. Initial workup was notable for elevated lipase,
LFTs, and RUQ US showing choledocholithiasis with dilation of
common bile and pancreatic ducts. She was transferred to ___
for ERCP and sphincterotomy on ___ with extraction of a 1.2 cm
ampullary stone originating in the pancreatic duct. She
subsequently underwent cholecystectomy on ___ without
complication. Post-operatively developed urinary retention
requiring intermittent straight catheterization which
spontaneously resolved in <24 hours. She otherwise recovered
without issue and was discharged home with physical therapy. She
will follow up with general surgery approximately 2 weeks
post-discharge.
# CHRONIC KIDNEY DISEASE
Hospital course notable for rise in Cr to peak of 3.7. Patient
has a known history of CKD with creatinine baseline fluctuating
between 3.2-3.7 per recent outpatient records. Renal ultrasound
was suggestive of chronic disease without hydronephrosis or
other acute issue.
# PRIMARY HYPERTHYROIDISM
Labs with incidentally noted hypercalcemia ranging from
10.7-11.4, with profoundly elevated PTH >500. Findings
suggestive of primary hyperparathyroidism which was confirmed on
PCP ___. The patient also has a history of parathyroid
adenoma for which she was previously referred to an
endocrinologist. She was advised to follow up with her PCP for
further discussion of primary hyperthyroidism and possible
referral back to endocrinologist. Of note, outside hospital CT
abdomen showed evidence of nephrolithiasis, however no stones
were visualized on in-house renal US.
# ANEMIA
Macrocytic, below baseline of ~9.5 in ___. No significant
EtOH use. B12 and folate levels normal. Possibly some dilution
and acute loss following OR. Macrocytosis possibly from elevated
PTH and allopurinol. Improving at time of discharge.
# THROMBOCYTOPENIA
With nadir of 102. Labs from ___ normal. Likely due to acute
illness and ___ bleeding. Improved to 146 and
up-trending at time of discharge.
TRANSITIONAL ISSUES
=================================
[ ] Repeat CBC/chemistry at time of PCP follow up to ensure
renal function remains stable and anemia improving.
[ ] Recommend referral back to endocrinologist for symptomatic
primary hyperparathyroidism. CT abdomen at outside hospital with
evidence of nephrolithiasis (though later not visualized on
dedicated renal US at ___.
[ ] Incidentally noted systolic murmur over RUSB as well as
right carotid bruit. Consider TTE + carotid ultrasound if not
already evaluated. (Notably with history of TIA s/p left CEA).
#CODE STATUS: full (confirmed)
#CONTACT: ___ (daughter: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. CARVedilol 12.5 mg PO BID
4. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Allopurinol ___ mg PO DAILY
4. CARVedilol 12.5 mg PO BID
5. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
# GALLSTONE PANCREATITIS
SECONDARY DIAGNOSES:
# ACUTE ON CHRONIC KIDNEY DISEASE
# PRIMARY HYPERTHYROIDISM
# ANEMIA
# THROMBOCYTOPENIA
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. ___,
It was a pleasure taking care of you at ___.
Why you were in the hospital:
- gallstone pancreatitis
- abnormal kidney function
What was done for you in the hospital:
- We performed an ERCP and cholecystectomy (gallbladder removal)
to treat your pancreatitis
- We monitored and treated your abnormal kidney function
What you should do after you leave the hospital:
- Please take your medications as detailed in the discharge
papers. If you have questions about which medications to take,
please contact your regular doctor to discuss.
- Please go to your follow up appointments as scheduled in the
discharge papers. Most of them already have a specific date &
time set. If there is no specific time specified, and you do not
hear from their office in ___ business days, please contact the
office to schedule an appointment.
- Please monitor for worsening symptoms. If you do not feel like
you are getting better or have any other concerns, please call
your doctor to discuss or return to the emergency room.
We wish you the best!
Sincerely,
Your ___ Care Team
SURGICAL INSTRUCTIONS
========================================
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
Followup Instructions:
___
|
10217918-DS-7 | 10,217,918 | 21,084,833 | DS | 7 | 2183-08-30 00:00:00 | 2183-08-30 12:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Ceclor
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___ Laparoscopic cholecystectomy
History of Present Illness:
___ year old male who complains of RUQ
PAIN. He had an episode of right upper quadrant pain one
week ago when he was admitted to the hospital for 2 days. He
apparently per his report had a CT scan which showed
gallstones, an ultrasound which showed no gallstones, a
barium swallow which was normal. He then developed acute
onset of right quadrant pain at noon today, which has since
resolved. He had a lot of alcohol to drink last night. He
denies nausea vomiting fevers or chills
Past Medical History:
PSH: R ankle surgery for fracture
Social History:
___
Family History:
Noncontributory
Physical Exam:
Upon presentation:
Temp: 98.6 HR: 92 BP: 141/87 Resp: 28 O(2)Sat: 100 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, mildly tender RUQ, no g/r
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: Warm and dry
Neuro: Speech fluent
Psych: Normal mentation
___: No petechiae
Pertinent Results:
___ 01:48PM GLUCOSE-101* UREA N-16 CREAT-1.1 SODIUM-143
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-24 ANION GAP-18
___ 01:48PM ALT(SGPT)-88* AST(SGOT)-119* ALK PHOS-65 TOT
BILI-1.0
___ 01:48PM LIPASE-28
___ 01:48PM ASA-NEG ETHANOL-31* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 01:48PM WBC-5.5 RBC-5.16 HGB-15.9 HCT-45.9 MCV-89
MCH-30.7 MCHC-34.6 RDW-11.8
___ 01:48PM NEUTS-72.3* ___ MONOS-4.6 EOS-1.5
BASOS-0.5
Galbladder ultrasound:
IMPRESSION: Gallbladder sludge and stones without biliary
dilatation. No
secondary findings to suggest acute cholecystitis.
MRCP:
IMPRESSION:
1. Gallstones and sludge within the gallbladder with associated
mild
gallbladder wall edema and pericholecystic fluid. Overall,
findings are
consistent with acute or subacute cholecystitis. No biliary
abnormality or
evidence of biliary stone.
Brief Hospital Course:
He was admitted to the Acute Care surgery team and underwent
gallbladder ultrasound showing gallbladder sludge and stones
without biliary dilatation. No secondary findings to suggest
acute cholecystitis. He also underwent an MRCP which showed
gallstones and sludge within the gallbladder with associated
mild
gallbladder wall edema and pericholecystic fluid. Overall,
findings were
consistent with acute or subacute cholecystitis. No biliary
abnormality or
evidence of biliary stone. He was then consented and taken to
the operating room for laparoscopic cholecystectomy. There were
no complications. Postoperatively he did well. His diet was
advanced and his pain controlled on oral narcotics.
He is being discharged to home and will follow up as instructed
in the Acute Care Surgery Clinic.
Medications on Admission:
Denies
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: ___ Tablets PO every ___ hours as
needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
2. Tylenol ___ mg Tablet Sig: Two (2) Tablet PO every ___ hours
as needed for pain.
3. Advil 200 mg Tablet Sig: Three (3) Tablet PO every six (6)
hours as needed for pain.
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
5. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) ML's
PO once a day as needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
Acute cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with an inflammed gallbladder
requiring an operation to remove it. Your postoperative course
has progressed so that now you are being discharged to home.
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items ___ pounds for 6 weeks. You may
resume moderate exercise at your discretion, no abdominal
exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips ___ days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
___
|
10217984-DS-13 | 10,217,984 | 20,225,069 | DS | 13 | 2132-12-06 00:00:00 | 2132-12-08 18:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Confusion and Memory Problems
Major Surgical or Invasive Procedure:
Lumbar Puncture
History of Present Illness:
Ms. ___ is a ___ yo woman with a history of cerebral
aneurysm
s/p clipping who presented with several weeks of confusion and
memory problems.
On initial history taking, the patient volunteers that she has
been forgetful and that other people have to fill her in on what
has happens during the day. She thinks she has been confused for
days, but her religious sister corrects her and says weeks.
She is accompanied to the ED by 2 of the nuns she lives with
(the
patient herself is a nun). They provide the following history.
The week after ___, the patient was not herself, was
confused,
wasn't sure where she was or where her room was. The patient
said
that things were foggy but she would have moments when she felt
more clear. For example, she can't remember where the dishes go,
where the light switch is, where the paper towels are. She
volunteers at the food pantry once per week but forgot to go
last
week. She has been forgetting prayers and mass, which occur
daily. Her gait has changed, and she is bent over and walking
very fast, almost running, which is unusual for her. On ___
she visited her brother but later that day did not remember that
she had gone. She did not remember shopping with her sister
shortly after she went. Her symptoms have been steady since
onset.
No concern for abuse or violence. The only stressor would have
been her friends gone for the week after ___.
At baseline, the patient is very helpful, keeps busy around the
house. She is sharp and independent. She has some awareness that
everything is not right. She is now very worried all of the
time.
She had an aneurysm clip approximately ___ years ago, on the R
side. She was diagnosed after developing a severe headache,
found
down after several days. From this, she has a chronic
anisocoria,
with R side larger. She had TIAs one year ago but fully
recovered
from these.
On neurologic review of systems, the patient denies headache,
lightheadedness.
Denies difficulty with producing or comprehending speech.
Denies loss of vision, blurred vision, diplopia, vertigo,
tinnitus, dysarthria, or dysphagia.
Denies muscle weakness.
Denies loss of sensation.
Denies bowel or bladder incontinence or retention.
On general review of systems, the patient denies fevers, rigors,
night sweats, or noticeable weight loss.
Denies chest pain, palpitations, dyspnea, or cough.
Denies nausea, vomiting, diarrhea, constipation, or abdominal
pain. Denies dysuria or hematuria. Denies myalgias,
arthralgias, or rash.
Past Medical History:
R aneurysm s/p clipping ___ years ago (___)
HTN
Heart murmur
?Afib
?hole in heart
Chronic hearing loss with hearing aids
Social History:
___
Family History:
Father - deceased of aneurysm in ___.
Physical Exam:
- Mental Status -
Awake, alert, oriented to name, hospital, ___, ___. Thinks
the month is ___ but corrects to ___ after being
reminded
that it's ___. Thinks the year is ___. When asked her age,
she says that she thinks she's older than ___ but not yet ___. She
states her religion is Catholic. Attention to examiner easily
attained and maintained. Concentration maintained when recalling
days backwards, and initially makes a mistake on months
backwards
but self corrects. Structure of speech demonstrates fluency with
full sentences, intact repetition, and intact verbal
comprehension. When asked what she would do if she saw smoke
coming out from under the door, she said "get out of the house
as
fast as possible." When asked why, she said "because I think
there might be a fire." She acurately described with L side of
the cookie jar card, stating that the boy was trying to get
cookies to give to his sister but was falling off the stool.
However, she was unable to state what the mother was doing and
that water was running out of the sink; she stated that the
woman
was looking out the window. Content of speech demonstrates
intact
naming (high and low frequency) and no paraphasias. Normal
prosody. No dysarthria. Verbal registration and recall ___
with category cueing but cannot recall the other two words even
with choices. + ideomotor apraxia. No evidence of hemineglect.
No
left-right agnosia. No grasp, no glabellar.
- Cranial Nerves -
I. not tested
II. R 4.5 mm and fixed, L 2mm and reactive. On fundoscopic exam,
R optic disc margin was sharp, L could not be seen. VFF.
III, IV, VI. R eye with limited abduction, upgaze, and downgaze.
L eye with full movements. No nystagmus.
V. facial sensation was intact
VII. face was symmetric with full strength of facial muscles
VIII. hearing was intact to finger rub bilaterally.
IX, X. symmetric palate elevation.
XI. SCM and trapezius were of normal strength and volume.
XII. tongue protrudes in midline
- Motor -
Muscle bulk and tone were normal. No pronation, no drift. No
tremor or asterixis.
Delt Bic Tri ECR IO IP Quad Ham TA Gas ___
L 5 5 ___ 5 5 5 5 5 5
R 5 5 ___ 5 5 5 5 5 5
**she had mild UMN pattern weakness in UEs on attending's exam
- Sensation -
Intact to light touch, temperature, pinprick, vibration, and
proprioception throughout.
- DTRs -
___ response flexor bilaterally.
- Cerebellar -
Mild R dysmetria on FNF, Mild L ataxia on HKS.
- Gait -
Normal initiation. Narrow base. Cautious, but not ataxic and
does
not list to either side. Negative Romberg.
________________________
Discharge Exam:
Awake, alert, oriented to name and place but cannot consistently
state the name of the hospital. States that she is frustrated
that she cannot go back to her home. She is worried about the
cost of rehab. She has poor eye contact. She has a flat
affect. Structure of speech demonstrates fluency with full
sentences, intact repetition, and intact verbal comprehension.
Normal
prosody. No dysarthria. Knows to call ___ if there is an
emergency but does not endorse that she would because she doesnt
think she has a problem.
- Cranial Nerves -
II. R 4.5 mm and fixed, L 2mm and reactive. VFF.
III, IV, VI. R eye with limited abduction, upgaze, and downgaze.
L eye with full movements. No nystagmus.
V. facial sensation was intact
VII. face was symmetric with full strength of facial muscles
VIII. hearing was intact to finger rub bilaterally.
IX, X. symmetric palate elevation.
XI. SCM and trapezius were of normal strength and volume.
XII. tongue protrudes in midline
- Motor -
Muscle bulk and tone were normal. No pronation, no drift. No
tremor or asterixis.
Delt Bic Tri ECR IO IP Quad Ham TA Gas ___
L 5 5 ___ 5 5 5 5 5 5
R 5 5 ___ 5 5 5 5 5 5
- Sensation -
Intact to light touch, temperature, pinprick, vibration, and
proprioception throughout.
- DTRs -
___ response flexor bilaterally.
- Cerebellar -
Mild R dysmetria on FNF, Mild L ataxia on HKS.
- Gait -
Normal initiation. Narrow base.
Pertinent Results:
CT Head w/o Contrast ___: IMPRESSION:
1. Streak artifact from right perimesencephalic cistern aneurysm
clip limits examination.
2. Postsurgical changes related to prior right frontotemporal
craniotomy and aneurysm clipping as described.
3. Right anterior temporal lobe encephalomalacia.
4. No acute intracranial pathology.
5. Atrophy, probable small vessel ischemic changes, and
atherosclerotic
vascular disease as described.
6. Please note MRI of the brain is more sensitive for the
detection of acute infarct.
CXR ___: IMPRESSION:
1. Hyperinflated lungs, with no evidence of pneumonia.
2. Moderate cardiomegaly with no evidence of heart failure.
EEG ___: IMPRESSION: This is an abnormal video EEG
monitoring session because of (1)
near-continuous theta slowing in the right hemisphere, more
notably over the
temporal region and which can be sharply contoured which is
likely due to her
prior known lesion. (2) Mild-moderate background slowing is
indicative of a
non-specific mild-moderate encephalopathy. (3) A breach artifact
is present on
the right, likely due to her known past surgery. No definite
epileptiform
discharges or electrographic seizures are seen during this
recording.
CT Abdomen W/ Contrast ___: IMPRESSION:
1. Diffuse aortic atherosclerotic calcification. Aneurysmal
dilation of right and left common iliac arteries, with fusiform
dilation on the right and both fusiform and saccular aneurysmal
dilation on the left.
2. No evidence of malignancy in the abdomen or pelvis.
3. Splenic calcifications consistent with granulomas. Bilateral
renal
hypodensities including a right lower pole cyst and additional
hypodensities too small to characterize.
4. 1 cm left ovarian cyst appears homogeneous and according to
current
departmental guidelines, does not require specific imaging
followup.
5. Please refer to separately dictated chest CT report of same
date for
detailed evaluation of thoracic findings.
CT Chest w/ Contrast ___: IMPRESSION:
No evidence of intrathoracic malignancy. No acute intrathoracic
process
identified.
Echocardiogram ___: IMPRESSION: Mild aortic regurgitation
with normal valve morphology. Mild symmetric left ventricular
hypertrophy with preserved regional and hyperdynamic global
biventricular systolic function. Dilated thoracic aorta. These
findings are c/w hypertensive heart.
___ 05:15AM BLOOD WBC-7.5 RBC-4.23 Hgb-13.1 Hct-37.8 MCV-90
MCH-31.1 MCHC-34.7 RDW-13.7 Plt ___
___ 05:50AM BLOOD Neuts-68.6 ___ Monos-10.1 Eos-2.0
Baso-0.5
___ 05:15AM BLOOD Plt ___
___ 09:45AM BLOOD ___ PTT-24.6* ___
___ 01:25PM BLOOD Lupus-NEG
___ 05:15AM BLOOD Glucose-91 UreaN-15 Creat-0.7 Na-136
K-3.9 Cl-101 HCO3-27 AnGap-12
___ 09:00PM BLOOD ALT-22 AST-25 AlkPhos-96 TotBili-0.2
___ 09:00PM BLOOD Lipase-41
___ 09:45AM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:15AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.1
___ 02:57AM BLOOD VitB12-980* Folate-8.7
___ 08:10AM BLOOD %HbA1c-5.3 eAG-105
___ 08:10AM BLOOD Triglyc-74 HDL-91 CHOL/HD-2.0 LDLcalc-80
___ 02:57AM BLOOD TSH-2.7
___ 02:57AM BLOOD T4-5.5 T3-117
___ 08:10AM BLOOD 25VitD-25*
___ 01:25PM BLOOD ANCA-NEGATIVE
___ 12:45PM BLOOD Anti-Tg-174* Thyrogl-UNABLE TO
antiTPO-126*
___ 07:25AM BLOOD IgA-190
___ 08:10AM BLOOD b2micro-2.3*
___ 02:57AM BLOOD HIV Ab-NEGATIVE
___ 06:30AM BLOOD Phenyto-16.7
___ 09:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:57AM BLOOD HCV Ab-NEGATIVE
Brief Hospital Course:
Ms. ___ is a ___ yo woman with epilepsy and prior R PCOMM
aneursym s/p clipping ___ week acute decompensation with memory
problems. Based on elevated anti TPO antibodies and a thryoid
ultrasound conistent with thyroiditis, it is believed that she
has ___'s Encephalopathy.
# ___'s Encephalopathy- She underwent Lumbar Puncture in
the ED. NCHCT revealed known sequelae of prior R Pcomm
aneurysm, bleed and clipping. MRI was unable to be done due to
known Aneurysm Clip. LP was done x2, with benign reults.
Early in her hospital course, in the setting of severe
agitation, she was started on seroquel PRN. Her Anti-TPO and
anti-Thyroglobulin levels were significantly elevated. In the
clinical setting of her subacute cognitive decline, she was
diagnosed with ___'s Encephalopathy. High Dose steroids
(Solumedrol 1g/qd) was started and she finished a ___nd was started on Prednisone 60mg wiyh a planned outpatient
taper. She did not initially improve after the 5 days of
solumedrol and thus IVIG was started. However, approximately
___ days after starting IVIG, she became less confused, less
agitated and was improving. However, it is difficult to discern
if the improvement was a lag in the steroid response or due to
the IVIG.
# Thyroiditis
Due to her anti-TPO and anti-thyroglobulin antibodies she
underwent a thyroid ultrasound which demonstrated evidence of
thyroiditis. Her TSH and FT4 were normal. Endocrinology was
consulted. Due to a expected long taper of high dose steroids,
Endocrine recommended that a bone mineral density test be done.
The test showed that she has osteoporosis. At this time, it was
recommended that she not start on bisphosphanates yet. She was
started on Vitamin D and Calcium supplementation. She will
follow up with outpatient Endocrine on ___. It was also
discussed that in the setting of long term steroids, adrenal
insufficiency will be a concern and she might need stress dose
steroids when sick.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Phenytoin Infatab 100 mg PO DAILY
2. Phenytoin Infatab 200 mg PO QHS
3. Lisinopril 2.5 mg PO DAILY
4. Fluvirin ___ (flu vaccine ts ___ ___ yr+)) 45 mcg
(15 mcg x 3)/0.5 mL injection As Directed
5. Aspirin 81 mg PO DAILY
6. Cyanocobalamin 100 mcg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Cyanocobalamin 100 mcg PO DAILY
3. Lisinopril 2.5 mg PO DAILY
4. Phenytoin Infatab 100 mg PO DAILY
5. Phenytoin Infatab 200 mg PO QHS
6. Apixaban 5 mg PO BID
7. Calcium Carbonate Suspension 1250 mg PO BID
5 mL (1 tsp) = 1250 mg Calcium Carbonate = 500 mg of Elemental
Calcium
8. Famotidine 20 mg PO Q12H
9. Metoprolol Tartrate 12.5 mg PO Q6H
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. QUEtiapine Fumarate 25 mg PO BID
13. PredniSONE 60 mg PO DAILY
Start 50mg daily on ___ until your Neurology appointment.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
___'s Encephalopathy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were hospitalized at ___ following a ___ week cognitive
decline (worsening memory and confusion). You were admitted to
the Neurology Inpatient Service. While in the hospital you
underwent imaging evaluation (CT Scan), blood work, and
evaluation of your spinal fluid (via lumbar puncture). Your
doctors ___ in antibodies associated with a
condition called ___'s Encephalopathy. You were started
on steroids for this. Initially, you had 5 days of IV steroids.
Now you are taking steroids by mouth. Also, you had 5 days of
IVIG.
Followup Instructions:
___
|
10218060-DS-20 | 10,218,060 | 25,033,900 | DS | 20 | 2139-04-30 00:00:00 | 2139-05-01 08:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
gentamicin
Attending: ___.
Chief Complaint:
Weakness, altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ w/ h/o IPF, pulmonary MAC, aspergillosis,
LLL mass likely adenoCA, CAD s/p CABG, who presented to the
___ ED with lethargy and failure to thrive with three to four
days with very little PO intake. Patient was found by his son
who noted a HR 150's and SBP ___. He was admitted to the floor
but required an MICU stay for SVT. He was transferred back to
the floor after resolution of SVT.
Pt recently hospitalized from ___ to ___ of this year for
failure to thrive. His work up included LENIs which did not show
any DVT, B12/TSH wnl, and infectious workup was otherwise
negative. He was continued on voriconazole for aspergillosis and
recurrent MAC was thought to be unlikely.
Past Medical History:
PAST MEDICAL HISTORY:
1. Idiopathic pulmonary fibrosis
2. Bronchiectasis
3. Cavitary pulmonary Mycobacterium avium infection, on triple
antibiotics for ___ years and on rifampin and azithromycin for
___ year, stopped as of ___ of this year
4. Right upper lobe aspergilloma, on voriconazole since ___
5. Left lower lobe slowly growing groundglass opacity, most
likely
lepidic predominant adenocarcinoma
6. Allergic rhinitis and postnasal drip
7. Anxiety disorder with panic attacks
8. CAD, status post CABG
9 Diabetes
10. Osteoporosis
11. Aspiration
12. Sedation and tardive kinesia
13. History of hyponatremia, likely SIADH
14. AS/AI
15. Pulmonary hypertension
Social History:
___
Family History:
Patient's father had coronary artery disease. Mother died of
liver disease. No lung disease.
Physical Exam:
ADMISSION EXAM:
===============
VITALS: 133 113/85 95 25 95% 3L
GENERAL: Alert, oriented to person, place and year/month, no
acute distress, appears diaphoretic
HEENT: Sclera anicteric, mouth appears very dry
NECK: supple, JVP elevated 5 cm above clavicle
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Tachycardic, RRR, S1 and S2 heard, no m/r/g
ABD: soft, non-tender, non-distended,quiet bowel sounds, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, 2+ pitting
edema of the legs, 1+ halfway up through the thighs
SKIN: No rashes
NEURO: CN2-12 intact, Strength ___ in UE and ___ in ___
DISCHARGE EXAM:
===============
T 97.9 BP 154/68 HR 72 RR 18 O2 92% on 2L
GENERAL: Resting comfortably in bed, NAD, alert and responding
appropriately
HEENT: NC/AT, sclera anincteric, EOMI, dry, cracked lips, MMM
without erythema or exudates, no oropharyngeal lesions noted
Neck: Supple, no LAD, no JVD
CV: RRR. Grade III/VI systolic murmur with clear S2 and
radiation
to carotids
RESP: Course crackles throughout lung field more prominent in
bases
GI: Soft, non-tender, active bowel sounds, non-distended, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ DP, 1+ pitting edema extending to
shins ___, notable clubbing of all extremities
NEURO: Oriented x3
Pertinent Results:
Admission Labs
==============
___ 07:30PM BLOOD WBC-8.6 RBC-4.40* Hgb-11.9* Hct-40.1
MCV-91 MCH-27.0 MCHC-29.7* RDW-16.2* RDWSD-54.1* Plt ___
___ 07:30PM BLOOD Neuts-75.1* Lymphs-13.9* Monos-9.0
Eos-0.8* Baso-0.6 Im ___ AbsNeut-6.46* AbsLymp-1.19*
AbsMono-0.77 AbsEos-0.07 AbsBaso-0.05
___ 07:30PM BLOOD Plt ___
___ 07:30PM BLOOD Glucose-175* UreaN-37* Creat-1.2 Na-148*
K-5.1 Cl-108 HCO3-33* AnGap-12
___ 05:54AM BLOOD Albumin-2.7* Calcium-8.1* Phos-2.9 Mg-2.0
Other Labs
=============
___ 05:54AM BLOOD TSH-0.41
___ 07:35PM BLOOD Lactate-1.0
___ 05:54AM BLOOD CK-MB-6 cTropnT-0.35* proBNP-2551*
___ 09:41AM BLOOD CK-MB-6 cTropnT-0.34*
___ 01:00PM BLOOD CK-MB-5 cTropnT-0.31*
Discharge labs:
===============
___ 08:10AM BLOOD WBC-6.6 RBC-4.24* Hgb-11.5* Hct-37.6*
MCV-89 MCH-27.1 MCHC-30.6* RDW-15.9* RDWSD-51.7* Plt ___
___ 08:10AM BLOOD Plt ___
___ 08:10AM BLOOD Glucose-165* UreaN-14 Creat-0.7 Na-141
K-4.9 Cl-100 HCO3-32 AnGap-9
___ 08:10AM BLOOD Calcium-8.4 Phos-1.9* Mg-1.8
Imaging
=======
CXR ___
FINDINGS:
In comparison with the prior study from ___,
re-demonstrated is
extensive fibrotic chronic lung disease with diffuse prominence
of the
interstitial markings. Findings are stable to possibly
minimally increased on the left, and underlying infection or
pulmonary edema is not excluded. No pleural effusion is seen.
The cardiac and mediastinal silhouettes are stable.
IMPRESSION:
Re-demonstrated, extensive, diffuse chronic interstitial lung
disease with
possible subtle increase in opacity, particularly on the left,
underlying
pulmonary edema or infection are difficult to exclude.
CARDIOVASCULAR ECHO ___
The left atrial volume index is moderately increased. There is
mild symmetric left ventricular hypertrophy with normal cavity
size. There is mild global left ventricular hypokinesis with
relative sparing of the lateral wall, and relatively greater
hypokinesis of the inferior wall (LVEF = 45 %). Doppler
parameters are most consistent with Grade III/IV (severe) left
ventricular diastolic dysfunction. Right ventricular chamber
size is normal with mild global free wall hypokinesis. There is
mild aortic valve stenosis. Mild (1+) central aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The tricuspid valve leaflets are mildly thickened. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
mildly depressed global biventricular systolic function.
Suggestion of elevated LV filling pressure and restrictive
filling. Mild aortic stenosis and regurgitation. Mild mitral
regurgitation.
CT HEAD W/OUT CON ___:
IMPRESSION:
1. No evidence of acute intracranial hemorrhage, midline shift,
mass effect, or acute large vascular territory infarct.
2. Dense atherosclerotic disease in the carotid siphons,
unchanged from prior exams.
CT CHEST W/OUT CON ___:
IMPRESSION:
No evidence of new infection since ___ following involution of
previous
Aspergillus abscess, right upper lobe. Probable congestive
heart failure,
explaining generalized increase in peribronchial radiodensity of
the right
lung and new pleural effusions, and new increase diameter, main
pulmonary
artery.
VIDEO OROPHAYNGEAL SWALLOW ___:
IMPRESSION:
Mild oropharyngeal dysphagia with no aspiration. Penetration
with thin/nectar thick liquids.
Microbiology
============
___ Blood Cx: Pending
___ Urine Cx: Negative
___ Blood Cx: Pending
Brief Hospital Course:
___ year old gentleman with hx of IPF, pulmonary MAC and
aspergillosis, LLL mass, CAD s/p CABG who presented with
lethargy, s/p MICU course for SVT now resolved, and transferred
to the floor.
#Failure to thrive/Lethargy:
Per family history, subacute decline, without clear source, with
multiple prior infections. Ddx is broad includes LLL mass
concerning for malignancy, infection, malnutrition,
polypharmacy, depression, and developing ___. Etiology
is likely multifactorial. Recent neurology visit w/ Dr. ___
___ that pt showed bradykinesia, shuffling gait, and mild
rigidity, but that these findings were confounded by
voriconazole, which can increase lethargy and decrease clearance
of mirtazapine. Pt was referred to ___ specialist. There
is also a concern that the patient aspirates with eating. Recent
psych notes suggest that outpatient psychiatrist, Dr. ___, was
weaning ___ oxazepam and mirtazapine and even considering
admission to ___ Geriatric. Neurology was consulted and
recommended MRI head and c-spine without contrast that can be
done on outpatient basis to assess for cervical spondylosis.
Psych was consulted to help make recommendations regarding
multiple sedating psych medications on panel. They recommended
discontinuing the patient's home oxazepam. ___ and OT were
consulted. Speech and Swallow did videoswallow and found that
the patient was not aspirating. They recommended a soft diet
with thin liquids. Nutrition was consulted and recommended
starting tube feeds, if within the ___. A family meeting was
held and pt decided he did not want to start tube feeds. Per
discussion, he will start fortified protein shakes, such as
Ensure Vanilla.
#SVT:
Patient transferred to MICU early ___ due to tachycardia
unresponsive to IV metopx2 with EKG c/f SVT. SVT resolved during
initial abdominal exam in the MICU, without further
intervention. Noted to have troponin rise with initial Trop of
0.35 but Trops and CKMB have began downtrending and EKG without
ischemic changes, and no chest pain. Metoprolol was uptitrated
to 12.5 q6h.
#Hypernatremia:
Most likely related to insensible losses and poor PO intake. Per
family, patient had his swallowing evaluated several months ago
and was told he was aspirating. Since then he has had poor PO
intake. Na rapidly corrected in the MICU (150->145 in 8 hours).
Patient received fluids to correct his hypernatremia and
presumed dehydration. Upon discharge, his Na was 141.
#Hyperkalemia:
K of 3.4 on ___. Given 60 mg KCl. Repeat K at 5.6. EKG was done
which showed PR interval slightly prolonged compared to prior.
No peaked T waves. QRS widened, but no change from prior exam.
Repeat K at 4.9 at discharge.
#Acute on chronic diastolic heart failure with pleural
effusions:
Patient has lower extremity edema, hx of CAD, proBNP of 2551 and
was recently started on home O2. Denies dyspnea on exertion
though has been wheelchair bound and less active. Non contrast
chest CT found no evidence of new infection and pulmonary edema
___ CHF was deemed more probable explanation of generalized
increase in opacity noted on CXR. Patient was given one dose of
IV Lasix. After that, he had an episode of hypotension, so no
further diuresis was given. He appeared euvolemic at time of
discharge.
#Diarrhea:
Patient had intermittent episodes of diarrhea while in the
hospital. No fever, leukocytosis, abdominal pain, or blood bowel
movements. Low concern for infection, but family requested that
the patient get tested for C. difficile as an outpatient.
CHRONIC/STABLE PROBLEMS:
#Bronchiectasis
#Idiopathic Pulmonary Fibrosis
Managed by Dr. ___. Patient was continued on home
pirfenidone and ipratropium-albuterol neb
#Cavitary Pulmonary MAC:
Pt was on triple antibiotics for ___ years and on rifampin and
azithromycin for ___ year. This was stopped as of ___ this year.
He is followed by ID. Abx stopped because of negative sputum
AFB.
#Right upper lobe aspergilloma: Pt has been on voriconazole
since ___. Voriconazole levels were drawn and were
0.6mcg/mL on discharge. Galactamannan negative on discharge.
#Left lower lobe slowly growing groundglass opacity, most likely
lepidic predominant adenocarcinoma. Per family, pt does not want
a biopsy.
#DM2: Continued home insulin with Humalog in place of novolog
#Hypothyroidism: Continued home Levothyrozine
#GERD: Continud home Ranitidine
#HLD: Continued home Rosuvastatin
#HTN: Patient was being given Metoprolol Tartrate 12.5 mg PO/NG
Q6H, losartan and furosemide were held in setting of
hypotension. BP was 129/57 at discharge.
#CAD: Continued home aspirin, statin, metop
#Anxiety/Depression: Continued home mirtazapine. Patient's home
oxazepam was discontinued per psychiatry recommendations.
======================
TRANSITIONAL ISSUES
======================
[] MRI head and c-spine without contrast can be done on
outpatient basis to assess for cervical spondylosis
[] Losartan and furosemide held in setting of ___, and also in
setting of hypotension. Please continue to monitor blood
pressure and volume status and re-start as an outpatient as
needed.
[] Metoprolol uptitrated from 25 XL daily to 50 XL daily.
Continue to monitor heart rate and adjust as needed.
[] Follow-up with PCP, ___, cardiology.
[] Continue to follow with neurology and ___ specialist
referral as previously discussed as outpatient.
[] Follow-up blood glucose and continue to manage diabetes as
outpatient.
[] Consider C-diff and stool cultures as outpatient if
continuing to report diarrhea.
[] Follow-up blood cultures pending at time of discharge (no
growth to date).
[] Oxazepam was discontinued without any signs of withdrawal.
[] Please continue to manage voriconazole. Email was sent to
Drs. ___ regarding the following - Level on this
admission: 0.6mcg/mL on discharge. Galactamannan sent and
negative.
# Code status: full code (presumed) with ongoing discussions
# Contact: ___ (Son and HCP), ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Levothyroxine Sodium 100 mcg PO 5X/WEEK (___)
3. Levothyroxine Sodium 200 mcg PO 2X/WEEK (___)
4. Losartan Potassium 50 mg PO BID
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Mirtazapine 30 mg PO QHS
7. Oxazepam 5 mg PO TID
8. pirfenidone 801 mg oral TID
9. Ranitidine 150 mg PO BID
10. Rosuvastatin Calcium 5 mg PO QPM
11. Voriconazole 200 mg PO Q12H
12. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
13. ipratropium bromide 0.03 % nasal QID:PRN
14. Furosemide 10 mg PO DAILY:PRN leg swelling
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth every night Disp
#*30 Tablet Refills:*0
2. Metoprolol Succinate XL 50 mg PO DAILY
3. NovoLOG (insulin aspart) 60 units subcutaneous QAM
4. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
5. Aspirin 81 mg PO DAILY
6. ipratropium bromide 0.03 % nasal QID:PRN
7. Levothyroxine Sodium 100 mcg PO 5X/WEEK (___)
8. Levothyroxine Sodium 200 mcg PO 2X/WEEK (___)
9. Mirtazapine 30 mg PO QHS
10. NovoLOG (insulin aspart) 20 subcutaneous QPM
11. pirfenidone 801 mg oral TID
12. Ranitidine 150 mg PO BID
13. Voriconazole 200 mg PO Q12H
14. HELD- Furosemide 10 mg PO DAILY:PRN leg swelling This
medication was held. Do not restart Furosemide until evaluated
by your PCP
15. HELD- Losartan Potassium 50 mg PO BID This medication was
held. Do not restart Losartan Potassium until evaluated by PCP
___:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
- Failure to thrive
SECONDARY DIAGNOSIS
===================
- Hypernatremia
- Hyperkalemia
- SVT
- Acute on chronic diastolic heart failure
Discharge Condition:
Patient is alert and oriented, but altered. Uses a wheelchair.
Discharge Instructions:
Mr. ___,
WHY WERE YOU IN THE HOSPITAL?
- You came in because you were weak and tired.
- Your son found that you had a high heart rate and low blood
pressure.
WHAT WAS DONE FOR YOU WHILE YOU WERE HERE?
- Your heart rate returned to normal.
- We had psychiatry make some changes to your medications.
- We hydrated you with fluids.
- We had speech evaluate your ability to swallow and recommend a
diet for you.
WHAT SHOULD YOU DO WHEN YOU GO HOME?
- You should stop taking your oxazepam. Your other medications
have changed, see below.
- You should continue eating foods that are soft and drink thin
liquids, including protein shakes.
- You should follow-up with your primary care physician,
___, and cardiologist (appointment information below).
It was a pleasure taking care of you at ___!
Sincerely,
Your Care Team
Followup Instructions:
___
|
10218168-DS-18 | 10,218,168 | 28,349,018 | DS | 18 | 2139-06-29 00:00:00 | 2139-06-30 20:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Penicillins
Attending: ___
Chief Complaint:
Cellulitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ w/Hx of DVT on Coumadin, Stage 3 CKD, HTN,
HLD, IBS, EIN, and cholelithiasis, and recurrent ___ cellulitis
who presents with worsening RLE pain, redness, and swelling in
the setting of PO Abx
Pt was treated with a course of Cipro and Clindamycin and
stopped when her symptoms became worse. She re-visited her PCP
___ ___ who recommended restarting the ABX. She endorses
chills but denies any fevers, no CP/SOB, no cough/cold/flu
symptoms. Pt has morbid obesity and stasis dermatitis. Per PCP,
pt called today to state that she is going to the ED. Declined
to be re-evaluated at ___ she is supposed to apply topical
steroid to leg and antifungal cream or powder to feet. She has
difficulty putting on compression stockings due to her body
habitus. She has a known anterior wall abdominal hernia that has
caused intermittent abdominal pain. No N/V. She has noticed
increased diarrhea with the ABX as well as some blood in the
stool. Denies any dysuria.
In the ED, initial vitals were: T96.1 67 133/54 22 100% RA
- Exam notable for: +BS, soft, large 7cm x 7cm protrusion along
the midline abdominal wall consistent with known hernia
RLE erythematous to the mid shin, circumferential, warm and
tender to palpation, 2+ pitting edema, no underlying fluctuance
LLE with chronic venous stasis changes, non erythematous, 2+
pitting edema, Guaiac negative stool
- Labs notable for: WBC 10.6, Hb 12.4, Cr 1.1, Lac 2.2, INR 2.0
- Imaging was notable for: Rt ___ w/limited exam without
definite signs of right leg DVT.
Patient was given: IV Vanc, IV Benadryl, IV Famotidine
Upon arrival to the floor, patient reports blood/black stools
occasionally since starting PO Abx on ___, most recently last
week. Endorsing diarrhea in same frame. No abd pain, +hernia,
n/v/c, cp, sob, +doe/orthopnea though is chronic issue. occ
vertigo/dizziness. no new numbness/weakness/tingling, vision
changes. Has been worse since ___, when was only on Rt ___, and
now b/l and increased distribution.
Daughter reports c/f inability to walk and take care of herself
at home on her own. Mild forgetfulness.
Past Medical History:
HTN
anxiety
obesity
hyperlipidemia
DVT (dx ___
IBS
Ckd STAGE 3
Cellulitis
Palmar and plantar keratoderma.
Iron deficiency anemia
History of fibroids and heavy menses.
Degenerative joint disease
EIN
Social History:
___
Family History:
Positive for diabetes mellitus in mother and father. Positive
for hypertension.
Physical Exam:
ADMISSION PHYSICAL EXAM:
==============================
VITAL SIGNS: 98.1 141 / 67 L Lying 67 20 100 Ra
GENERAL: NAD, pleasant
HEENT: PERRL, EOMI, NCAT, no OP lesions
NECK: unable to assess JVP
CARDIAC: RRR, s1/s2, no mgr
LUNGS: decreased bibasilar breath sounds R>L
ABDOMEN: soft, mild ttp at hernia (chronic), no rebound/guarding
EXTREMITIES: ___ ___ edema, erythema to midshin (w/bilateral
lesions), no fluctuance, ttp, warm
NEUROLOGIC: sensation/motor grossly normal
DISCHARGE PHYSICAL EXAM:
==========================
VITALS: 98.3 BP 105-125/62-75 HR ___ RR18 98RA
GENERAL: Alert, oriented, in no acute distress, lying down
HEENT: PERRL, MMM, oropharynx clear
NECK: Supple, unable to assess JVP
RESP: crackles at bases on anterior exam, symmetric air entry,
unchanged
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
ABD: +BS, soft, no tenderness to palpable chronic mid wall
hernia
EXT: warm, well perfused, chronic venostasis changes, both lower
legs wrapped, improved edema, no fluctuance, no crepitus, no
ulcers
Pertinent Results:
ADMISSION LABS:
================
___ 03:00PM BLOOD WBC-10.6* RBC-4.16 Hgb-12.4 Hct-39.4
MCV-95 MCH-29.8 MCHC-31.5* RDW-14.7 RDWSD-51.7* Plt ___
___ 05:24PM BLOOD ___ PTT-36.6* ___
___ 03:00PM BLOOD Glucose-96 UreaN-13 Creat-1.1 Na-140
K-3.7 Cl-101 HCO3-22 AnGap-21*
___ 07:00AM BLOOD Calcium-9.4 Phos-3.6 Mg-2.1
PERTINENT LABS:
=================
___ 06:43AM BLOOD calTIBC-380 Ferritn-81 TRF-292
___ 03:14PM BLOOD Lactate-2.2*
___ 07:09AM BLOOD Lactate-1.2
DISCHARGE LABS:
==================
___ 06:21AM BLOOD WBC-7.8 RBC-3.84* Hgb-11.5 Hct-36.3
MCV-95 MCH-29.9 MCHC-31.7* RDW-14.6 RDWSD-50.4* Plt ___
___ 06:21AM BLOOD Glucose-93 UreaN-19 Creat-1.2* Na-139
K-3.6 Cl-99 HCO3-22 AnGap-22*
___ 06:21AM BLOOD Calcium-9.3 Phos-3.5 Mg-2.2
MICRO:
==========
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___. ___ ___
09:00AM.
Surveillance blood cultures from ___ and ___- No growth to
date
IMAGING:
==========
___ CXR:
There is mild central pulmonary vascular engorgement without
overt pulmonary edema. No focal consolidation or pleural
effusion is seen. There is no evidence of pneumothorax. The
cardiac silhouette is mildly enlarged. Mediastinal contours are
unremarkable.
___ Lower Extremity US
Limited evaluation due to large body habitus. There are
symmetric waveforms comparing right and left common femoral vein
with appropriate response to Valsalva maneuver. There is
compressibility, blood flow and response to augmentation within
the right common femoral, superficial femoral, popliteal veins.
Calf veins could not be assessed. No ___ cyst is seen.
IMPRESSION:Limited exam without definite signs of right leg DVT.
___ 06:21AM BLOOD WBC-7.8 RBC-3.84* Hgb-11.5 Hct-36.3
MCV-95 MCH-29.9 MCHC-31.7* RDW-14.6 RDWSD-50.4* Plt ___
Brief Hospital Course:
Ms ___ is a ___ w/Hx of DVT on Coumadin, CKD, HTN,
Endometrial Intraepithelial Neoplasia (EIN), prior cellulitis
who presents with worsening RLE pain, redness, and swelling in
the setting of being on PO antibiotics.
#Cellulitis
#Chronic Venous stasis: Patient has prior history of cellulitis,
with known stasis dermatitis. Her admission exam was not
concerning for a significant infection, no purulence. She was
previously treated with clindamycin and ciprofloxacin for a
course of about 2 weeks, and reported her symptoms were getting
worse. She also has baseline tinea and skin breakdown for which
she takes fluocinide, ketoconazole and
nystatin. Her skin breakdown likely source of infection entry.
She received 2 doses of IV vancomycin initially, developed signs
of red man's reaction resolved with Benadryl, and was
transitioned to clindamycin PO with good effect, dose 300 mg q6
per renal dosing, with plan to end course on ___. Her exam
improved with antibiotics, but more so with wrapping her legs
with ace bandages and elevating her legs. She remained afebrile
and hemodynamically stable. Given limited ambulation and need
for optimization, physical therapy evaluation suggested
discharge to ___. She completed her antibiotic course during
her hospitalization.
#CONS blood culture: ___ bottles, contaminant, surveillance
cultures no growth to date, remained afebrile without any need
for further antibiotics.
#Anemia/Hematochezia: Ms. ___ had reported intermittent
blood/black stools, in patient stool guaiac neg. No known
colonoscopy in past. She has a history of iron deficiency anemia
in outpatient notes, iron studies here with normal ferritin and
iron level. Vaginal bleeding may be a source, and thus will need
outpatient followup for EIN. She had no evidence of clinical
bleeding, with stable CBC.
#Diastolic HF: last EF >55% in ___, no current symptoms of
exacerbation, she is on room air and otherwise without
respiratory or cardiac complaints.
#Endometrial Intraepithelial Neoplasia (EIN): given concern for
bleeding, and concern for progressive endometrial dysplasia,
inpatient gynecology evaluated her. Patient declined GYN
evaluation on ___. She has a Mirena IUD. Plan for outpatient
followup.
#Disposition:
Ms. ___ had been medically stable for discharge since ___
___. She had a bed offer from ___ on ___ and
despite discussing her going to rehab every day with her, she
became quite upset at the idea of going to rehab and refused to
go. We reached out to her daughter, ___, at her request,
and discussed this with ___. ___ expressed her
strong preference that her mother not leave until the next day,
even though we had explained that ___ has been medically
stable for discharge and is not requiring inpatient level of
care. Our medical team, nursing team and supervisor, and case
manager all spoke with ___ and ___ on separate occasions
and together, however the patient and ___ continued to
feel quite upset and angry with the decision of her medical
stability.
Upon assessment the morning of discharge, the patient apologized
for her behavior yesterday and said she was ready and happy to
go to rehab once a bed was available. Her PCP was agreeable to
discharge plan. Around noontime, the patient was noted to be
visibly upset and quite anxious again, after speaking with her
daughter ___. She reported to the staff that she was
going home. The inpatient team went in several times to speak
with the patient regarding her sudden decision. Unfortunately,
she continued to get quite upset, and asked us to leave every
time we came in, and started calling the police. Our CM spoke
with her at length, recommending rehab (bed available at ___
___), however patient firmly decided to go home with services.
Discharge paperwork was completed and a chair car was arranged
for Ms. ___.
CHRONIC ISSUES
==============
#Hx of DVT: INR 2.0 on admission. Dosed daily for warfarin, 7.5
mg was her dose most recently given antibiotics. She received
7.5 mg for the first 3 days of hospitalization, then resumed on
her 5 mg home dose daily. INR target ___.
#CKD: known CKD stage 3, Atrius creatinine seems to be ___.
#HTN: continue home Triamterene/HCTZ
#Anxiety: uses lorazepam as needed
TRANSITIONAL ISSUES:
=====================
-Discharge Hgb: 11.5
-Discharge INR 2.5, dosing warfarin 5 mg daily (given 7.5 mg
initially given she was on antibiotics, now on 5 mg daily
dosing). Please monitor INR and adjust accordingly.
-Discharge Creatinine 1.2
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
2. Clindamycin 450 mg PO Q8H
3. Ciprofloxacin HCl 500 mg PO Q12H
4. Fluocinonide 0.05% Cream 1 Appl TP BID apply to legs
5. Multivitamins 1 TAB PO DAILY
6. Warfarin 5 mg PO DAILY16
7. Ketoconazole 2% 1 Appl TP BID
8. nystatin 100,000 unit/gram topical BID
9. Docusate Sodium 100 mg PO BID
10. LORazepam 1 mg PO Q6H:PRN anxiety
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. TraMADol 25 mg PO BID
3. TraMADol 25 mg PO Q6H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
4. Docusate Sodium 100 mg PO BID
5. Fluocinonide 0.05% Cream 1 Appl TP BID apply to legs
6. Ketoconazole 2% 1 Appl TP BID
7. LORazepam 1 mg PO Q6H:PRN anxiety
8. Multivitamins 1 TAB PO DAILY
9. nystatin 100,000 unit/gram topical BID
10. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
11. Warfarin 5 mg PO DAILY16
Discharge Disposition:
Home with Service
Facility:
___
Discharge Diagnosis:
Primary:
-Cellulitis
-Chronic Venostasis Changes
Secondary:
-Diastolic Heart Failure
-History of DVT on coumadin
-Endometrial Intraepithelial Neoplasia (EIN)
-Chronic Kidney Disease
-Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ On ___ with concern for
cellulitis. You had a mild infection which we treated with
clindamycin. Your cellulitis will likely be slow to completely
resolve given your venous stasis which requires regular bandages
and compression to help with your blood flow. You were assessed
by our physical and occupational therapists who recommended
discharge to rehab. You finished your antibiotic course before
discharge. You have decided to go home instead of rehab as we
had recommended.
We recommend continuing to walk as much as you can, elevating
your legs and having your legs wrapped.
Best wishes
Your ___ care team
Followup Instructions:
___
|
10218242-DS-16 | 10,218,242 | 26,440,379 | DS | 16 | 2153-01-06 00:00:00 | 2153-01-07 19:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
none
attach
Pertinent Results:
ADMISSION/SIGNIFICANT LABS:
=======================
___ 06:16AM BLOOD WBC-8.4 RBC-4.54* Hgb-14.3 Hct-43.4
MCV-96 MCH-31.5 MCHC-32.9 RDW-14.0 RDWSD-49.4* Plt ___
___ 06:16AM BLOOD Neuts-77.1* Lymphs-13.5* Monos-7.7
Eos-1.0 Baso-0.2 Im ___ AbsNeut-6.44* AbsLymp-1.13*
AbsMono-0.64 AbsEos-0.08 AbsBaso-0.02
___ 06:16AM BLOOD ALT-148* AST-213* AlkPhos-120
TotBili-5.3*
___ 07:10AM BLOOD ALT-142* AST-141* AlkPhos-148*
TotBili-4.5* DirBili-3.0* IndBili-1.5
___ 06:45AM BLOOD Lactate-1.6
MICRO:
=====
None
IMAGING/OTHER STUDIES:
====================
MRCP ___. Subcentimeter focal filling defect along the distal CBD, may
represent
small choledocholithiasis. Prominent CBD measuring up to 1 cm.
Mildly
prominent central hepatic ducts with minimal periportal edema.
2. Hepatic steatosis. Patent hepatic vasculature.
3. Other findings as detailed above.
LABS ON DISCHARGE:
=================
___ 07:10AM BLOOD WBC-6.2 RBC-4.88 Hgb-15.5 Hct-47.2 MCV-97
MCH-31.8 MCHC-32.8 RDW-13.8 RDWSD-49.5* Plt ___
___ 07:10AM BLOOD Glucose-124* UreaN-15 Creat-1.0 Na-141
K-4.1 Cl-107 HCO3-21* AnGap-13
Brief Hospital Course:
Mr. ___ is a ___ male with the past medical history of
CAD, HTN, HLP, presents with abdominal pain and obstructive
jaundice
# Obstructive Jaundice, dilated CBD:
# Abdominal pain:
Patient presented initially to outside hospital with abdominal
pain where labs were notable for direct hyperbilirubinemia and
US showed dilated CBD. Patient transferred for ERCP evaluation.
MRCP was obtained, but patient chose to leave AMA prior to the
results. His pain had fully resolved but labs with persistent
hyperbilirubinemia (slightly downtrending, tbili 4.5 <- 5.3).
Following discharge, MRCP report resulted demonstrating
"subcentimeter focal filling defect along the distal CBD, may
represent small choledocholithiasis." At the time of this
discharge summary's completion, review of the OMR indicates that
the ERCP team has reached out to the patient to discuss these
results and coordinate arrangement of outpatient ERCP.
CHRONIC/STABLE PROBLEMS:
# HTN: Continued amlodipine and atenolol.
# CAD: Resumed home ASA on discharge; recommend decreasing to
81mg if there is no clear indication for full dose.
# HLP: Continued Crestor and fenofibrate
# COPD: Not on any current therapies. Initiation at discretion
of PCP.
TRANSITIONAL ISSUES:
==================
[] Patient is recommended to undergo ERCP for further evaluation
and potential treatment of his obstructive jaundice.
[] Consider decreasing ASA dosage to 81mg unless there is a
strong indication for higher dose.
> 30 mins spent coordinating discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Fenofibrate 145 mg PO DAILY
3. Rosuvastatin Calcium 5 mg PO QPM
4. Atenolol 50 mg PO DAILY
5. Aspirin 325 mg PO DAILY
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Fenofibrate 145 mg PO DAILY
5. Rosuvastatin Calcium 5 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
# obstructive jaundice:
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 care for you at the ___
___. You were transferred to our hospital for further
workup of blockage of your bile duct. At this time we are not
certain of what has caused this and additional results are
pending. It is very likely that you will need a procedure called
ERCP to help relieve the blockage and possibly take biopsies. It
is possible that the blockage was due to a gallstone, but in
some cases cancer can lead to this issue as well.
It was our recommendation that you stay for further evaluation,
but you decided to leave against our medical advice to stay. In
choosing to leave, you acknowledged the risks that your pain
could recur, a life-threatening infection could develop, and
that this could possibly delay the diagnosis of a cancer. You
understood these risks and opted to leave and follow up with
your primary care doctor. We respect your autonomy to make these
decisions.
Please coordinate a follow up appointment with your PCP
immediately to further discuss the results of your pending
imaging and what to do next. If you develop any danger signs
listed below, then please go to the emergency room immediately.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10218444-DS-14 | 10,218,444 | 20,818,668 | DS | 14 | 2157-04-20 00:00:00 | 2157-04-20 22:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
silver
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Exploratory laparotomy, lysis of adhesion,
enteroenterostomy
History of Present Illness:
___ w hx pelvic squamous cell CA s/p partial mass resection,
RSO, sigmoid colostomy (___) s/p chemoXRT now w abdominal
pain x 2 days, nausea, vomiting. Completed chemoXRT in fall.
PET/CT ___ read as no evidence of disease. In usual state of
health until ___. Pain sudden onset. Diffuse epigastric.
___ severity. Constant w intermittent increased intensity.
Decreased gas and stool in ostomy. +Nausea/vomiting. Minimal po
intake. To
ED for further evaluation. Surgery consult obtained.
On surgery eval, patient reports pain improved w IV analgesics.
+Nausea. Denies fever, chills, chest pain, shortness of breath,
dysuria, blood in stool.
Past Medical History:
PMH: Menorrhagia, status post hysteroscopy, polypectomy and
endometrial ablation, HLD, Osteoporosis.
PSH: Ex lap, RSO, debulking pelvic tumor, (___)
Social History:
___
Family History:
Father had heart problems and died from sudden death at the age
of ___. Brother died at the age of ___ from a myocardial
infarction. Per OMR, maternal aunt with stomach cancer, maternal
aunt with breast cancer and two cousins with
breast cancer, younger sister with type 2 diabetes.
Physical Exam:
Admission Physical Exam:
VS: 97.4 107 117/83 18 100% RA
GEN: WD, WN in NAD
HEENT: NCAT, anicteric
CV: RRR
PULM: non-labored, no respiratory distress
ABD: soft, NT, +distended, well healed lower midline incision,
LLQ excoriation ___ XRT w non-adherent dressing, LLQ colostomy
pink w no air in bag
PELVIS: deferred
EXT: WWP, no CCE
NEURO: A&Ox3, no focal neurologic deficits
Discharge Physical Exam:
VS: T: 98.6, HR: 90, BP: 107/66, RR: 18, O2: 98% RA
General: A+Ox3, NAD
CV: RRR, no M/G/R
PULM: CTA b/l
ABD: colostomy with liquid brown stool and flatus in bag.
Midline surgical abdominal incision with staples OTA, skin
well-approximated, no s/s infection
Extremities: no edema
Pertinent Results:
___ 05:37AM LACTATE-1.4
___ 05:01AM ___ PTT-34.7 ___
___ 03:50AM GLUCOSE-120* UREA N-17 CREAT-0.8 SODIUM-136
POTASSIUM-3.6 CHLORIDE-95* TOTAL CO2-26 ANION GAP-19
___ 03:50AM ALT(SGPT)-12 AST(SGOT)-21 ALK PHOS-77 TOT
BILI-0.3
___ 03:50AM LIPASE-17
___ 03:50AM ALBUMIN-4.3
___ 03:50AM WBC-7.4# RBC-4.78# HGB-14.6# HCT-43.4#
MCV-91# MCH-30.5 MCHC-33.6 RDW-11.9 RDWSD-39.5
___ 03:50AM NEUTS-89.5* LYMPHS-5.0* MONOS-4.7* EOS-0.0*
BASOS-0.1 IM ___ AbsNeut-6.65*# AbsLymp-0.37* AbsMono-0.35
AbsEos-0.00* AbsBaso-0.01
___ 03:50AM PLT COUNT-326
Imaging:
___: Cytology (peritoneal fluid) Pathology:
PERITONEAL FLUID:
NEGATIVE FOR MALIGNANT CELLS.
Reactive mesothelial cells, macrophages, lymphocytes, and
neutrophils.
Note: Immunostains for p63 and p16 (weak cytoplasmic staining in
rare cells only) are negative.
___: CT ABD&PEL:
1. Closed loop small-bowel obstruction with 2 sites of
transition in the upper mid pelvis with mild ascites. No
specific evidence of ischemia or
perforation. Surgical consultation is recommended.
2. Retained fluid and mild wall thickening of the rectal stump
is similar to prior FDG PET and may reflect postradiation
change.
3. Multiple chronic findings including small hypodensities in
the liver,
pancreas and left kidney are unchanged. Also, pelvic venous
congestion and 3.3 cm uterine fibroid.
Brief Hospital Course:
Ms. ___ is a ___ year-old female w/hx pelvic squamous cell
CA s/p partial mass resection, sigmoid colostomy (___) s/p
chemoXRT who presented to the ED on ___ with abdominal pain
and decreased output from her ostomy. CT abd&pelvis was
concerning for a small bowel obstruction with transition point.
The patient was admitted to the Acute Care Surgery service for
further medical care.
Given findings, the patient was taken to the operating room for
an exploratory laparotomy, lysis of adhesions and
enterotenterostomy. There were no adverse events in the
operating room; please see the operative note for details. Pt
was extubated, taken to the PACU until stable, then transferred
to the ward for observation.
The remainder of the ___ hospital course is summarized by
systems below:
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with IV pain
medication and then transitioned to oral acetaminophen and
oxycodone once tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO with a
___ tube in place for decompression. On POD3, the NGT
was removed as there was low gastric residual. She was kept NPO
with IVF until she started to have flatus in her ostomy bag. On
POD5, the patient was started on a clears diet which was
well-tolerated. On POD6, the diet was advanced sequentially to
a Regular diet, which was well tolerated. Patient's intake and
output were closely monitored.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient's established home ___ services were
contacted to restart her home care after discharge. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
do NOT drink alcohol or drive while taking this medication
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every four
(4) hours Disp #*30 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
please hold for loose stool
4. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Closed loop small-bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You presented to the ___ on
___ with abdominal pain and were found to have a small
bowel obstruction. You were admitted to the Acute Care Surgery
team and underwent an exploratory laparotomy, lysis of adhesions
and repair of your small bowel. You tolerated this procedure
well and were transferred to the surgical floor to await return
of bowel function and to achieve pain control.
You are now tolerating a regular diet, your ostomy is
functioning, and your pain is better controlled. You are now
medically cleared to be discharged home to continue your
recovery. Your abdominal incision staples will be removed at
your follow-up appointment in the Acute Care Surgery clinic.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*Your staples will be removed at your follow-up appointment.
Monitoring Ostomy output/ Prevention of Dehydration:
*Keep well hydrated.
*Replace fluid loss from ostomy daily.
*Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
*Try to maintain ostomy output between 1000mL to 1500mL per day.
*If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with
each episode of loose stool. Do not exceed 16mg/24 hours.
Followup Instructions:
___
|
10218965-DS-15 | 10,218,965 | 29,855,994 | DS | 15 | 2132-11-29 00:00:00 | 2132-11-29 11:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Novocain / mold / morphine
Attending: ___.
Chief Complaint:
right wrist pain, cat bite
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo right handed female patient with hx of
depression, anxiety, GERD who presents as a transfer from ___ for cat bite and right upper extremity cellulitis.
Patient reports being bitten by her mother's cat on ___
afternoon. Noticed erythema, pain, tenderness, and warmth over
the site. Tried ice, elevation, hydrogen peroxide soak,
ibuprofen, without significant benefit. Given worsening of
symptoms, went into ___ for further eval.
At ___, patient received Tdap vaccine, dilaudid for
pain control, IV unasyn, IV vancomycin prior to transfer. Two
sets of blood cultures were collected, which are NGTD at this
time. At ___ ___, Plastics/Hand was consulted, who requested
hand/forearm X-ray, which revealed no foreign body or soft
tissue
gas, but showed degenerative changes in the hand joints. soft
tissue ultrasound did not show a drainable fluid collection or
retained foreign body. Sent off cultures from purulence
expressed
from puncture site on the wrist. Recommended volar splint,
strict
elevation in skyhook, H2O2 soak, IV unasyn and Vanc, and
observation overnight. She was given the aforementioned ABx,
dilaudid, oxycodone, ranitidine in the ___ along with her home
meds (clonazepam, omeprazole, citalopram). She was not febrile,
and no leukocytosis present.
Of note, ROS is otherwise negative for chest pain, shortness of
breath, abdominal pain, n/v. Does note few day history of dry
cough, 1 day history of rhinorrhea, no sputum production, known
fever at home, sore throat, or known sick contacts.
Past Medical History:
anxiety
Past Surgical History:
Tonsillectomy and adenoidectomy, appendectomy, hysterectomy,
right RCR, left knee repair x2, T11-S1 Lumbar Fusion ___,
Social History:
___
Family History:
noncontributory
Physical Exam:
V: 97.8, 57, 120/67, 18, 97% on RA
Gen: WDWN female patient in no acute distress
HEENT: NCAT
Eyes: EOMI, MMM
Neck: supple, no JVD
CV: RRR no m/r/g
Lungs: CTAB
Abdomen: +BS, soft, NT, ND
Extremities/skin: no lower extremity edema. Over the right
medial
wrist area: significant improvement of increased warmth,
erythema
in terms of distribution as well as severity. receded compared
to
marking. mild tenderness, 3 puncture sites. minimal drainage.
some tracking of erythema proximally to right forearm area.
Neuro: A&Ox3, nonfocal
Psych: appropriate mood and affect
Pertinent Results:
___ 07:08AM BLOOD WBC-2.9* RBC-3.63* Hgb-10.8* Hct-34.0
MCV-94 MCH-29.8 MCHC-31.8* RDW-12.8 RDWSD-44.4 Plt ___
___ 07:08AM BLOOD Glucose-87 UreaN-11 Creat-0.7 Na-143
K-4.5 Cl-104 HCO3-28 AnGap-11
___ 7:00 pm SWAB Source: Right Volar wrist puncture
wound.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Preliminary):
GRAM NEGATIVE ROD(S). RARE GROWTH.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
Blood cultures no growth to date
Brief Hospital Course:
___ yo F pt with hx of anxiety, depression, GERD, low back pain
who presents after a cat bite as a transfer from ___
___ with findings concerning for cellulitis on the right
wrist/forearm.
# Cat bite
# Right arm cellulitis
- significant cellulitis on presentation with evidence of
lymphangitic spread. Patient exhibited clinical improvement
after multiple doses of IV vancomycin and unasyn. Not septic on
presentation. no leukocytosis or fever here (but temp of 100.2
at ___. plastics/hand surgery was consulted and recommended
elevation of arm, ice packs, volar splint (provided). ultrasound
and X-ray of the area was unremarkable for drainable
abscess/fluid collection or foreign body. Patient had some
spontaneous discharge at the puncture site, which was sent for
microbiology, currently growing rare gram negative rods,
suspected to be pasturella. Patient received Tdap vaccine in the
___ prior to transfer. Patient was transitioned to PO
augmentin and Bactrim to complete a 7 day course of antibiotics.
She was provided 4 tablets of oxycodone on discharge for pain
control
# URI symptoms: patient reported 3 day history of URI symptoms
prior to presentation, consistent with viral upper respiratory
infection. Her lungs were clear, did not have productive cough
or hypoxia. She was treated symptomatically with cepacol
lozenges and benzonatate.
# Constipation: patient was given bowel regimen during admission
and on discharge.
# anxiety/depression: continued home celexa, clonazepam
# GERD: continued home omeprazole and ranitidine
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 40 mg PO DAILY
2. Ranitidine 150 mg PO QHS
3. Citalopram 40 mg PO DAILY
4. ClonazePAM 0.5 mg PO BID
5. Fluticasone Propionate NASAL 1 SPRY NU BID
6. TraZODone 200 mg PO QHS:PRN insomnia
7. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 5 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth two times a day Disp #*10 Tablet Refills:*0
2. Benzonatate 100 mg PO TID:PRN cough Duration: 7 Days
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
as needed Disp #*15 Capsule Refills:*0
3. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain - Severe
Duration: 2 Days
RX *oxycodone 5 mg 1 tablet(s) by mouth twice a day as needed
Disp #*4 Tablet Refills:*0
4. Senna 17.2 mg PO BID:PRN constipation Duration: 5 Days
RX *sennosides 8.6 mg 2 tablet(s) by mouth twice a day as needed
Disp #*10 Tablet Refills:*0
5. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 5 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*10 Tablet Refills:*0
6. Citalopram 40 mg PO DAILY
7. ClonazePAM 0.5 mg PO BID
8. Fluticasone Propionate NASAL 1 SPRY NU BID
9. Omeprazole 40 mg PO DAILY
10. Ranitidine 150 mg PO QHS
11. TraZODone 200 mg PO QHS:PRN insomnia
12. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Cellulitis
Cat bite
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted after cellulitis (skin/soft tissue infection)
following a cat bite. You were treated with IV antibiotics, and
sent home on oral antibiotics.
Followup Instructions:
___
|
10219100-DS-6 | 10,219,100 | 24,462,171 | DS | 6 | 2167-04-13 00:00:00 | 2167-04-13 21:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Vicodin / Iodinated Contrast Media - IV Dye
Attending: ___
Chief Complaint:
Light-headedness
Major Surgical or Invasive Procedure:
Pacemaker placement (___)
History of Present Illness:
Mr. ___ is a ___ year old gentleman with PMH HTN, HLD,
idiopathic angioedema, pulmonary nodules (granulomatous), NIDDM,
and prostate cancer who presented with lightheadedness, was
found
to have new CHB, had pacemaker urgently placed and now admitted
to ___ for monitoring overnight.
He has a long-standing history of palpitations followed by Dr.
___. Per EP consultation, on the night before his
presentation, he was woken with chest discomfort and then felt
lightheaded. He was able to drive to ___ but felt too
lightheaded to stay there. He has an Apple watch and was noted
to
have heart rate in the ___ during episodes of lightheadedness.
However, there were other times he had no symptoms that he was
also in the heart rates of 30. He went to BI-N and was
transferred to ___ for further evaluation.
He reported taking multiple nutritional supplements
("Immu-health", "Delphinol", "Hoxsey" and "SGS-Brocco"). He
denied tick exposure, rashes, chronic cough, eye inflammation,
arthralgias or oral ulcers, syncope, ___ edema, dyspnea, or
bleeding issues.
In the ED initial vitals were: 96.9 40 134/77 18 97% RA
EKG: CHB with ventricular rate of 37bpm
Labs/studies notable for:
CBC: 8.6 > 14.6/43.8 < 191
INR 1, PTT 27.5
Chem: 139/4.9; 99/24; ___ < 165
TnT <0.01, BNP 90
TSH 2.3
Lactate 3.3, VBG 7.38/44
UA 1000 glucose, Tr Ketones, 8 WBC, Few Bact
Patient was given: Nothing
EP was consulted in the ED: "The patient has symptomatic
bradycardia with evidence of hypoperfusion (elevated lactate)
and
we recommended urgent placmenet of PPM. All risks and benefits
were discussed with the patient, who was in agreement with the
procedure."
On the floor, post-procedurally, patient is feeling well and
endorses the above history.
Past Medical History:
-cluster headaches
-GERD
-atypical chest pain: cardiac stress test ___ negative
-Prostate cancer- observed
Social History:
___
Family History:
Both of his parents are elderly. Father is ___, has had coronary
artery bypass surgery and valve replacements. Mother is ___ and
has had GERD. He has a ___ and ___ siblings,
both healthy and alive and well.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
============================
VS: 160 / 86 R Lying 79 18 97 RA
GENERAL: Well developed, well nourished gentleman in NAD.
Oriented x3. Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. EOMI.
Conjunctiva pink. No pallor or cyanosis of the oral mucosa.
Somewhat dry MM.
NECK: Supple. JVP not elevated at 90 degrees.
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops.
LUNGS: No chest wall deformities or tenderness. L chest wall PPM
dressing in place. Respiration is unlabored with no accessory
muscle use. No crackles, wheezes or rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAM
======================
GENERAL: WDWN adult man in NAD
HEENT: NCAT, sclerae anicteric
NECK: Supple, JVP not elevated
CARDIAC: RRR, normal S1/S2, no m/r/g
LUNGS: CTAB, no increased work of breathing. L chest wall PPM
dressing in place, clean.
ABDOMEN: Soft, non-tender, non-distended, normoactive BS
EXTREMITIES: Warm, pulses 2+ bilaterally, no edema
Pertinent Results:
ADMISSION LABS
==============
___ 09:48AM BLOOD WBC-8.6 RBC-4.71 Hgb-14.6 Hct-43.8 MCV-93
MCH-31.0 MCHC-33.3 RDW-13.2 RDWSD-45.0 Plt ___
___ 09:48AM BLOOD Neuts-71.0 Lymphs-18.9* Monos-9.0
Eos-0.5* Baso-0.2 Im ___ AbsNeut-6.07 AbsLymp-1.62
AbsMono-0.77 AbsEos-0.04 AbsBaso-0.02
___ 09:48AM BLOOD ___ PTT-27.5 ___
___ 09:48AM BLOOD Plt ___
___ 09:48AM BLOOD Glucose-165* UreaN-22* Creat-1.0 Na-139
K-4.9 Cl-99 HCO3-24 AnGap-16
___ 09:48AM BLOOD proBNP-90
___ 09:48AM BLOOD cTropnT-<0.01
___ 09:48AM BLOOD TotProt-7.2 Calcium-10.0 Phos-3.8 Mg-2.1
Iron-113
___ 09:48AM BLOOD calTIBC-393 Ferritn-171 TRF-302
___ 09:48AM BLOOD TSH-2.3
___ 10:01AM BLOOD ___ pO2-24* pCO2-44 pH-7.38
calTCO2-27 Base XS--1 Intubat-NOT INTUBA
___ 10:01AM BLOOD Lactate-3.3*
DISCHARGE LABS
==============
___ 06:59AM BLOOD WBC-6.6 RBC-4.39* Hgb-13.9 Hct-40.6
MCV-93 MCH-31.7 MCHC-34.2 RDW-13.0 RDWSD-44.1 Plt ___
___ 06:59AM BLOOD Plt ___
___ 06:59AM BLOOD ___ PTT-25.5 ___
___ 06:59AM BLOOD Glucose-166* UreaN-16 Creat-0.8 Na-138
K-4.3 Cl-100 HCO3-25 AnGap-13
___ 01:15PM BLOOD HBsAg-NEG
___ 01:15PM BLOOD HIV Ab-NEG
___ 01:15PM BLOOD HCV Ab-NEG
___ 09:15AM BLOOD Lactate-2.6*
IMAGING
========
TTE (___)
CONCLUSION:
The left atrium is mildly dilated. The right atrium is mildly
enlarged. There is mild symmetric left ventricular hypertrophy
with a normal cavity size. There is normal regional and global
left ventricular systolic function. Quantitative biplane left
ventricular ejection fraction is 72 %. There is no resting left
ventricular outflow tract gradient. Normal right ventricular
cavity size with normal free wall motion. The aortic sinus
diameter is normal for gender with normal ascending aorta
diameter for gender. The aortic arch diameter is
normal. The aortic valve leaflets (3) 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 mild [1+] mitral
regurgitation. There is diastolic mitral regurgitation due to
complete heart block. 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: Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global biventricular systolic
function. Mild diastolic mitral regurgitation in the setting of
complete heart block.
CHEST X RAY (___)
FINDINGS:
A left chest wall pacemaker has been placed in the interim. The
leads end
within the right atrium and right ventricle. The
cardiomediastinal silhouette
remains prominent. There is no pulmonary edema. There is no
parenchymal
consolidation or pleural effusion. No pneumothorax.
IMPRESSION:
1. Left chest wall pacemaker with leads in the right atrium and
right
ventricle.
2. Cardiomegaly. No pulmonary edema. No pneumothorax.
MICROBIOLOGY
============
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
Brief Hospital Course:
Mr. ___ is a ___ year old gentleman with PMH HTN, HLD,
idiopathic angioedema, pulmonary nodules (granulomatous), NIDDM,
and prostate cancer who presented with lightheadedness, was
found to have new CHB, had pacemaker urgently placed.
CORONARIES: no hx CAD
PUMP: ___: ___ dilated. RA mildly enlarged. Mild
cLVH. EF 72%. nl RV. 1+MR. ___ MR due to CHB.
A-sensed V-paced
#Complete heart block s/p PPM
Unclear trigger, infectious workup pending per EP. There was
also some evidence of conduction system disease in ___ (LAFB),
at a relatively young age, which raises concern for secondary
causes, notably sarcoid given granulomas on CT chest, vs
infection. None of his herbal supplements are known to
precipitate CHB. Had urgent PPM placement due to symptomatic and
elevated lactate to 3.3. Pt was kept overnight for monitoring
and there were no further complications.
- followup infectious and inflammatory workup with Lyme, ACE,
SPEP/UPEP, iron studies
- pt will need a cardiac CT PET to investigate for possible
cardiac sarcoid given GGO and pulmonary nodules found in CT
- repeat EKG at follow up
- Device clinic follow up after discharge
# HTN: Not on a hypertensive, BP 150-160s/80s while in house,
consider adding medication.
# HLD: Continue atorvastatin 20 mg daily
# DM: ISS while in house.
- Aspirin 81 mg PO DAILY
- Farxiga (dapagliflozin) 5 mg oral DAILY
# Pulmonary Nodules: "CT with ground-glass lesion in the right
upper lobe could be an early at no carcinoma spectrum
malignancy. Many smaller nodular ground-glass opacities
throughout the right lung are more likely inflammatory."
Recommended outpatient CT for followup.
# GERD:
- Esomeprazole 40 mg Other BID
# Cluster Headaches
- ZOLMitriptan 5 mg oral PRN
Transitional issues:
[] ___ follow up, reschedule appointment
[] Cardiac CT PET scan needed to evaluate for cardiac sarcoid,
still needs to be ordered
[] Follow up with Device Clinic and Dr. ___
[] Follow up lyme antibodies, ACE level, UPEP
Date of Implant: ___
Indication: Complete heart block
Device brand/name: MDT
Model Number: Azure XT ___ MRI ___
A lead brand/model/implant date: ___ ___ CapSureFix®
Novus
BBL ___
RV lead brand/model/implant date: ___ CapSureFix®
Novus BBL ___
# LANGUAGE: ___
# CODE STATUS: Full code (p)
# CONTACT: ___ ___ (c); ___ (h, first
call at night)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Esomeprazole 40 mg Other BID
3. Atorvastatin 20 mg PO DAILY
4. Farxiga (dapagliflozin) 5 mg oral DAILY
5. ZOLMitriptan 5 mg oral PRN
6. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Esomeprazole 40 mg Other BID
4. Farxiga (dapagliflozin) 5 mg oral DAILY
5. Multivitamins 1 TAB PO DAILY
6. ZOLMitriptan 5 mg oral PRN
Discharge Disposition:
Home
Discharge Diagnosis:
Complete heart block
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you here at ___.
You were admitted because you had an episode of lightheadedness.
An EKG was done to detect your heart rhythm and it was found
that you were in complete heart block. This means that the atria
and the ventricles of your heart were not beating in synchronoy
which is dangerous. You were immediately taken for pacemaker
placement. You tolerated the procedure well and your heart
rhythm is doing much better now.
We sent off several blood tests to figure out why your heart
went into an abnormal rhythm in the first place. The results are
pending and will need to be followed up by your cardiologist.
Please follow up with Dr. ___ as well as the Device Clinic
within 1 week so your new pacemaker can be monitored.
You will need a CT- PET scan of your heart to investigate
further why your heart went into an abnormal rhythm.
We are happy to see you feeling better and wish you the best of
luck.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10219419-DS-7 | 10,219,419 | 25,680,789 | DS | 7 | 2164-11-10 00:00:00 | 2164-11-12 16:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nausea and Vomiting
Major Surgical or Invasive Procedure:
___: Diagnostic laparoscopy, liver and portal lymph
node biopsy.
___: Exploratory laparotomy, portal and hepatic artery
lymph node biopsies, intraoperative ultrasound,
gastrojejunostomy and placement of fiducial markers
History of Present Illness:
___ with recently diagnosed Klatskin's tumor s/p R ant, R
post, L PTBDs on recent admission ___ currently scheduled
for explorative laparoscopy vs possible hepatic lobectomy vs
extrahepatic CBD resection for ___ presents with nausea and
vomiting x2 days.
Patient was initially diagnosed with Klatskin's tumor when he
presented to ___ ___ with 2 months of painless jaundice. CT
showed marked intrahepatic and extrahepatic biliary duct
dilatation, prominent pancreatic duct and question of 1.3 cm
ampullary mass. Attempted ERCP at the time showed a partial
gastric outlet obsruction from infiltrating pyloric channel mass
which was passed through however aborted due to inability to see
the ampulla. The biopsy from the pre-pyloric region showed
pre-pyloric/pyloric mucosa with ulcer, hemorrhage, acute and
chronic inflammation. He subsequently underwent bilateral
interal
to external PTBDs (___) with the left side showing
complete obstruction at the hilum with inability fo pass the
stricture, ductal bushings were non diagnostic and patient was
transferred to ___ on ___. During that hospital stay,
patient underwent a repeat EGD ___ which showed a pre-pyloric
ulceration with pyloric thickening, biopsy showing chronic
inflammation, + H.pylori (rx 2wks triple abx). CT chest on
___
did not show any evidence of metastasis. He underwent multiple
attempts to cross the Left system during his cholangiograms
which
were unsuccessful, though CBD brushings were able to be taken
which were negative, and cholangiogram showing a complete
occlusion of the left biliary system at the hilus and though
limited, no evidence of an ampullary mass. MRCP ___ showed
likely a type IV Klatskin tumor at the hepatic hilum (3.9x2.1cm)
without distal intrahepatic or nodal mets with likely thrombus
of
L hepatic vein, peripheral left portal venous branches with
attenuation of the central left portal vein, patent main portal
vein, and again, no evidence of an ampullary mass. Pt eventually
underwent a R anterior (___), R posterior PTBD (___) and
exchange
of L PTBD (___) on ___ with non-target core liver biopsy of
the right hepatic lobe was also done which showed ductular
proliferation, no steatosis or malignancy. Patient was
discharged
home w/services on ___ on a regular diet with all 3 biliary
drains capped with plans of a exp laparoscopy vs possible
hepatic
lobectomy vs extrahepatic CBD resection for ___. His labs at
time of discharge were WBC 7.5, Cre 0.6, ALT 34 AST 41 ALP 422,
Tbili 3.3 (latest Tbili 2.3 on ___.
Patient reports he has been feeling well since discharge until 2
days ago, had acute onset of intractable hiccups, small volume
emesis x 2 then a large bilious emesis this morning. He also
reports bloating however without any abdominal pain, change in
bowel habits. Currently continues to have hiccups, reports no
pain, no nausea, is passing flatus. He finished his H.Pylori
therapy abx on ___. He denies any fevers or chills.
ROS:
(+) per HPI
(-) chills, night sweats, unexplained fatigue/malaise/lethargy,
trouble with sleep, rashes, bleeding, easy bruising,
headache, dizziness, vertigo, syncope, weakness, paresthesias,
hematemesis, cramping, melena, BRBPR, dysphagia, chest pain,
shortness of breath, cough, edema, urinary frequency, urgency
Past Medical History:
PMH:HTN, HLD
PSH:none
Social History:
___
Family History:
Non-contributory
Physical Exam:
98.7 94 119/67 16 100% RA
GEN: A&O, NAD
HEENT: mild scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, distended, nontender, R anterior and posterior PTBDs
capped, tinge of bile around the anterior drain insertion site,
no erythema or induration. L PTBD capped, no erythema or
induration
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
Labs on Admisison: ___
WBC-6.4 RBC-3.69* Hgb-11.0* Hct-33.0* MCV-89 MCH-29.8 MCHC-33.3
RDW-13.8 RDWSD-45.0 Plt ___ PTT-27.3 ___
Glucose-125* UreaN-10 Creat-0.7 Na-136 K-3.4 Cl-97 HCO3-21*
AnGap-21*
ALT-17 AST-25 AlkPhos-199* TotBili-1.9* Albumin-2.6*
Calcium-8.3* Phos-3.0 Mg-1.7
Lipase-39 Lactate-1.6
___ TSH-1.9
.
Labs at discharge: ___
WBC-3.9* RBC-3.20* Hgb-8.7* Hct-27.4* MCV-86 MCH-27.2 MCHC-31.8*
RDW-14.6 RDWSD-45.2 Plt ___
Glucose-115* UreaN-5* Creat-0.5 Na-132* K-3.7 Cl-98 HCO3-25
AnGap-13
ALT-7 AST-16 AlkPhos-125 TotBili-0.6
Calcium-7.8* Phos-2.3* Mg-1.6
.
Brief Hospital Course:
___ with cirrhosis and Klatskin's tumor with previously placed
Right Anterior/posterior and Left PTBDs (___) also s/p
diagnostic laparoscopy, with biopsy of liver nodules and
periportal LN (neg) who now presents with nausea and vomiting at
home.
On admission, a CT of the abdomen and pelvis was obtained
showing marked gastric distention with apparent high-grade
obstruction at the gastric outlet. The PTBDs which remained
capped were in position and the liver still has persistent
intrahepatic biliary ductal dilation as on prior, most notable
in the left lobe.
An NG tube was placed. He received IV fluids for bolus.
He was taken to the OR as planned on ___ ___ on ___ for planned diagnostic laparoscopy, and liver and portal
lymph node biopsy. At the time of surgery the
liver was grossly nodular despite several weeks of adequate
biliary decompression. Per Dr ___ operative report, given
the operative findings combined with concern for more advanced
fibrosis on pre-op biopsy, it was determined the patient would
not be a candidate for resection of the left lobe with curative
intent. The goal changed to attempting to obtain tissue for
pathologic diagnosis and confirmation of malignancy. After
discussion with Dr ___, it was decided the mass
appeared to be mostly intrahepatic and not reachable
laparoscopically for biopsy so several nodules over segment IVB
were taken for biopsy. Also of note there was no evidence of
external compression to cause the gastric outlet obstruction. He
tolerated the procedure without complication. The PTBDs were
left capped.
In the immediate post op period, on his post op check the
patient was found to be tachycardic, and EKG revealed AFib with
RVR. He initially received IV metoprolol. Cardiac enzymes were
cycled and negative. He converted after about one hour.
Cardiology was consulted, and recommended PO atenolol and also
outpatient follow up.
He was monitored on telemetry and did not appear to have any
recurrence.
Also immediately post op the patient was noted to have SBPs in
the 90___. The epidural was stopped, and he was placed on a PCA
as well as receiving IV fluid boluses.
On ___ the patient underwent EGD with notable findings of
stenosis of the pylorus with biopsy taken and dilation of the
stenosis to 12 mm. This was an otherwise normal EGD to third
part of the duodenum.
He underwent capping trial, and the NG tube was removed. He was
started on clears and the IV fluid was stopped. Blood pressures
have improved and there has been no recurrence of the AFib on
his PO atenolol.
On HD 8 he again went for planned attempt at angioplasty of the
stricture. Rep aet EGD shows a benign intrinsic 8 mm stricture
that was 1 cm long in the pylorus. The scope traversed the
lesion and the diameter was increased to 12 ___.
Patient was kept on a liquid diet during this post op period
since the time of the initial surgery on ___. He was having no
complain or nausea/vomiting or pain.
Following the second EGD he did have some bradycardia which
responded to lowering the home atenolol to 50 mg daily. He was
asymptomatic.
He was tolerating a regular diet 3 days following the most
recent dilatation, however shortly after starting the regular
diet he was having complaint of ___ abdominal pain, and was
having increasing distension.
Given these worsening symptoms, Dr ___ an
operative solution of gastrojejunostomy, with another attempt at
biopsy, as all recent pathology taken at time of surgery is
again non-diagnostic.
Patient was kept on clears and on ___ he was once again taken
to the OR with Dr ___ for ___ laparotomy, portal
and hepatic artery lymph node biopsies, intraoperative
ultrasound, gastrojejunostomy and placement of fiducial markers.
He tolerated this procedure without complication. He was again
tried on an epidural that needed to be split. He was receiving
IVF and Albumin for SBPs in the 90___. He was also noted to have
low urine output overnight following this surgery, but once
fully resuscitated he was having adequate outputs. The NGT was
in place with only about 400 cc overnight.
On POD 4 following the gastrojej, he had a successful clamp
trial with minimal outputs and the NG tube was removed. He was
mildly distended and was not reporting flatus. He was started
slowly on sips.
He had a low grade temp to 100.4. Blood and urine cultures were
sent. The urine showed only a contaminated specimen. The blood
cultures are negative to date, but pending at time of discharge.
The abdominal distention was mildly improved, and his diet was
advanced to clears. Had no nausea and vomiting. By POD 8 from
the gastrojej he was having flatus, and the diet was increased
to as tolerated. He was also taking supplements.
Abdominal incision from the gastrojej had erythema surrounding
the suture line, and some mild drainage. The area that was
draining was open and packed. He received IV Kefzol while
hospitalized and was discharged to home on oral Keflex. The
erythema was improving and he did not have fevers.
He was discharged to home with ___. He had return of bowel
function and was tolerating a diet. The three PTBDs remained
capped. Short term follow up with Dr ___ has been planned.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 75 mg PO DAILY
2. Captopril 100 mg PO BID
3. Acetaminophen 650 mg PO Q8H:PRN pain
4. Docusate Sodium 100 mg PO BID
5. Milk of Magnesia 30 mL PO DAILY:PRN constipation
6. Pantoprazole 40 mg PO Q12H
7. Senna 8.6 mg PO BID
8. Sucralfate 1 gm PO QID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Atenolol 50 mg PO DAILY
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Do not drive after taking this medication. Do not mix with
alcohol.
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*90 Tablet Refills:*0
4. Senna 8.6 mg PO BID
5. Milk of Magnesia 30 mL PO DAILY:PRN constipation
6. Docusate Sodium 100 mg PO BID
7. Pantoprazole 40 mg PO Q12H
8. Sucralfate 1 gm PO QID
9. Cephalexin 250 mg PO Q6H Duration: 4 Days
Please finish entire course even if symptoms improve.
RX *cephalexin 250 mg 1 tablet(s) by mouth Every 6 hours Disp
#*16 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Biliary obstruction and gastric outlet obstruction
Atrial fibrillation
Incisional infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Please call Dr. ___ office at ___ for fever
of 101 or greater , chills, nausea, vomiting, diarrhea,
constipation, increased abdominal pain, pain not controlled by
your pain medication, swelling of the abdomen or ankles,
yellowing of the skin or eyes, inability to tolerate food,
fluids or medications, the drain insertion site has redness,
drainage or bleeding, or any other concerning symptoms.
You will have a visiting nurse come to help you take care of
your wound every day. The site will need to be dressed, please
keep the dressing dry and clean.
You are being given an antibiotic for your skin infection,
please finish the whole prescription.
Followup Instructions:
___
|
10219457-DS-21 | 10,219,457 | 22,278,453 | DS | 21 | 2186-04-01 00:00:00 | 2186-04-01 02:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
___: Open repair of ruptured abdominal aortic aneurysm
History of Present Illness:
___ who was walking through a parking lot when she began to feel
"unwell" with shortness of breath and abdominal pain radiating
to her back. Upon arrival to ___ she was noted to be
hypotensive with a SBP in the ___ and was continuing to complain
of back pain. She was too unstable to go to CT scan, so she was
transfused 1 unit of PRBC and a cordis was placed and then
transferred to ___ for treatment. The endovascular team was
mobilized and upon arrival the patient with alert and oriented
with a SBP of 100. She was complaining of back pain. An
emergent CT was obtained that showed a contained rupture of an
AAA. She was taken immediately to room 18 from the CT scanner.
Past Medical History:
AAA, otherwise unknown.
Social History:
___
Family History:
Unknown
Physical Exam:
On initial evaluation in ___ ED
SBP 100, HR 110s
Gen: alert and oriented, answering questions
HEENT: PERLA, anicteric
Chest: tachycardiac, lungs clear
Abd: tender and distended
Pulses: palpable left femoral, faintly palpable right femoral,
dopplerable left ___, nondopplerable right ___
Pertinent Results:
CTA abdomen/pelvis ___:
Ruptured abdominal aortic aneurysm extending from the level of
the renal arteries (two left renal arteries, one right) to
approximately 8 mm proximal to the aortic bifurcation. The iliac
arteries are not involved. Active extravasation is seen from the
anterolateral wall. Extensive retroperitoneal hemorrhage.
Brief Hospital Course:
On ___, the patient was brought emergently to the
endovascular suite for open AAA repair. Please refer to the
operative note for details. Post-operatively, she was
transferred to the CVICU where she promptly lost her pulse and
coded. Her dismal prognosis was discussed with the family, and
they decided upon withdrawal of care. Thus, the patient expired
in the early morning of ___.
Medications on Admission:
Unknown
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Ruptured abdominal aortic aneurysm.
Discharge Condition:
Expired.
Discharge Instructions:
She who has gone, so we but cherish her memory.
Followup Instructions:
___
|
10220107-DS-14 | 10,220,107 | 27,514,460 | DS | 14 | 2203-07-30 00:00:00 | 2203-07-30 14:45:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Difficulty seeing R-side of things
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is an ___ year-old R-handed man with PMHx of recent
cardiac
bypass surgery on ___ who presents with difficulty seeing the
right side of objects and was found to have a L PCA territory
infarction on CT scan. The patient reports that he felt well
yesterday (___) when he went to a doctor's appointment in the
afternoon. He went home and in the evening (he isn't sure of
the
time as he didn't look at the clock) he started to feel a little
bit "spacey". He didn't feel like watching the football game
which was "unusual" for him. He went to bed around 9:30pm. He
got up sometime in the early morning (again he didn't look at a
clock) and was seeing some "weird stuff", like that the room was
larger than it was and that there were chairs there that he knew
couldn't be where they were. He noticed at this time that his L
arm was numb, so he looked down at it and had no trouble seeing
it, but when he looked at his R arm and shoulder he couldn't see
it. He got up to use the restroom and his L arm sensation
improved but he still couldn't see his R arm. He made his way
to
the bathroom but found it "difficult" to get there given that
his
vision was "strange". He then was able to get to the bathroom
and back and went back to sleep. He woke up at 10am and told
his
wife about his "dream" and when he was talking to her he said "I
can't see you" and pointed to his R eye. The patient's wife
called the pt's PCP who told him to immediately come to the ED.
In the ED the patient received a NCHCT that showed a L PCA
territory subacute infarction. He was admitted to the stroke
service for further workup.
On neuro ROS, the pt reports difficulty seeing the R side of
objects, but denies headache, loss of vision, diplopia,
dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash
Past Medical History:
Prostate cancer
Hyperlipidemia
Hypertension
Gout
s/p Bilateral inguinal hernia repair
s/p Proctectomy
s/p Angioplasty ___ years ago
S/p CABG : ___
Social History:
___
Family History:
Premature coronary artery disease- non contributory
Physical Exam:
Vitals: T: 98.2; P:70; R: 18; BP:132/86; SaO2: 96% on RA
General: Awake, cooperative, tearful when unable to complete a
task but otherwise NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
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, healing midline
sternotomy scar
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.
Neurological Exam:
-Mental Status: Alert, oriented x 2 (knew the year, month and
got
the date wrong by 2 days but knew the ___. Able to relate
history without difficulty. Attentive, able to name ___
backward
slowly but without difficulty. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Patient was able to name glove of the ___
but had to explain what the purpose of cactus, chair, feather,
hammock and key were. He kept saying "I know what it is, I just
can't get the word" and would accurately describe what they each
did. When reading would spell the letters out and then say the
word. He was unable to accurately see/process some of the
letters and would often get the words wrong ie. thanke instead
of
thanks. Speech was not dysarthric. Able to follow both midline
and appendicular commands. Pt. was able to register 3 objects
and
recall ___ at 3 minutes, and no more even with cues. 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. Pt reported that he could see a
pin in all visual quadrants, but he was slower to respond in the
RUQ on testing. When asked he reported that he could only make
out the eye on the examiner's L side (his R field of vision) if
he concentrated hard, but that the examiner's R eye was easily
apparent. Funduscopic exam revealed no papilledema, exudates, or
hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. Subtle R pronator drift.
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: Decreased vibratory sensation at the L big toe,
otherwise 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 3 1
R 2 2 2 3 1
Plantar response was mute bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem for 2 steps. Needed someone to
walk next to him to tell him where he was going, but was very
steady and didn't need assistance to stay up. Romberg with
slight
sway.
Pertinent Results:
___ 05:25AM BLOOD WBC-5.1 RBC-3.39* Hgb-9.8* Hct-29.9*
MCV-88 MCH-28.8 MCHC-32.7 RDW-14.0 Plt ___
___ 06:09AM BLOOD WBC-5.4 RBC-3.48* Hgb-10.0* Hct-30.6*
MCV-88 MCH-28.7 MCHC-32.7 RDW-13.9 Plt ___
___ 12:45PM BLOOD WBC-6.3 RBC-3.59* Hgb-10.3* Hct-31.5*
MCV-88 MCH-28.7 MCHC-32.7 RDW-13.6 Plt ___
___ 07:35AM BLOOD WBC-7.3 RBC-3.32* Hgb-9.7* Hct-29.1*
MCV-88 MCH-29.1 MCHC-33.3 RDW-13.5 Plt ___
___ 11:35AM BLOOD WBC-7.2 RBC-3.61* Hgb-10.3* Hct-32.0*
MCV-89 MCH-28.7 MCHC-32.4 RDW-13.8 Plt ___
___ 11:35AM BLOOD Neuts-74.9* Lymphs-16.3* Monos-4.9
Eos-3.5 Baso-0.4
___ 12:45PM BLOOD Neuts-71.5* Lymphs-17.5* Monos-7.8
Eos-2.7 Baso-0.5
___ 05:25AM BLOOD ___ PTT-34.9 ___
___ 05:25PM BLOOD ___
___ 06:09AM BLOOD ___ PTT-65.1* ___
___ 05:47AM BLOOD ___ PTT-81.4* ___
___ 11:35AM BLOOD ___ PTT-35.1 ___
___ 05:25AM BLOOD Glucose-98 UreaN-25* Creat-1.5* Na-140
K-4.6 Cl-104 HCO3-23 AnGap-18
___ 05:25PM BLOOD Glucose-94 UreaN-26* Creat-1.3* Na-139
K-4.6 Cl-103 HCO3-21* AnGap-20
___ 06:09AM BLOOD Glucose-99 UreaN-27* Creat-1.3* Na-140
K-4.5 Cl-104 HCO3-24 AnGap-17
___ 05:47AM BLOOD Glucose-106* UreaN-32* Creat-1.6* Na-137
K-4.5 Cl-102 HCO3-26 AnGap-14
___ 12:45PM BLOOD Glucose-114* UreaN-25* Creat-1.5* Na-139
K-4.6 Cl-102 HCO3-24 AnGap-18
___ 07:35AM BLOOD Glucose-88 UreaN-15 Creat-1.2 Na-138
K-4.3 Cl-101 HCO3-23 AnGap-18
___ 11:35AM BLOOD Glucose-101* UreaN-22* Creat-1.3* Na-140
K-4.3 Cl-104 HCO3-23 AnGap-17
___ 07:35AM BLOOD ALT-15 AST-21 CK(CPK)-41* AlkPhos-69
TotBili-0.5
___ 07:35AM BLOOD CK-MB-2 cTropnT-0.02*
___ 11:35AM BLOOD cTropnT-0.03*
___ 05:25AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.1
___ 06:09AM BLOOD Calcium-8.7 Phos-4.0 Mg-2.0
___ 05:47AM BLOOD Calcium-9.0 Phos-4.1 Mg-2.3
___ 07:35AM BLOOD %HbA1c-5.9 eAG-123
___ 07:35AM BLOOD Triglyc-140 HDL-29 CHOL/HD-4.1 LDLcalc-63
___ 11:35AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 11:47AM BLOOD Lactate-1.3
___ 11:35PM URINE Color-Yellow Appear-Clear Sp ___
___ 06:00PM URINE Color-Straw Appear-Clear Sp ___
___ 11:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 06:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 11:35PM URINE Hours-RANDOM Creat-161 Na-158 K-46 Cl-120
___ 06:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
ECHO:
The left atrium is elongated. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thicknesses and
cavity size are normal. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is low normal (LVEF 50%). No
masses or thrombi are seen in the left ventricle. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is borderline pulmonary artery systolic hypertension.
There is a very small circumferential pericardial effusion
without echocardiographic signs of tamponade.
IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity size with low normal global systolic function. Borderline
pulmonary artery systolic hypertension. No definite cardiac
source of embolism identified.
MRI
CONCLUSION: Findings consistent with left posterior cerebral
artery
infarction. No evidence of hemorrhage.
Brief Hospital Course:
Mr ___ is an ___ year-old R-handed man with PMHx of recent
cardiac bypass surgery on ___ who presents with difficulty
seeing the right side of objects and was found to have a L PCA
territory infarction on CT scan. His exam was notable for
difficulty with naming, difficulty with reading and difficulty
with vision on the R side of his visual field
He was admitted to the neurology stroke service for further
workup of his stroke where he went into an atrial fibrillation
with RVR. This was the likely etiology of his embolic stroke.
The new onset of AFib might be related to his recent cardiac
bypass surgery. Thus, for secondary stroke prevention, he was
started on coumadin and bridged with IV Heparin drip. Given
the interaction of amiodarone and coumadin his INR went to 1.9
in 3 days. He was discharged at this level and instructed to
have an INR drawn in 2 days to monitor his coumadin.
Additionally his stroke risk factors were checked and he was
found to have an LDL of 63 and HbA1c of 5.9 which did not
require any further inervention. He was evaluated by ___ and OT
who recommended outpatient follow up. He also passed a bedside
swallow evaluation.
# CARDIOVASCULAR:
- After discussion with cardiac surgery he was continued on
metoprolol at low dosing (6.25mg BID). Echo demonstrated a
normal left ventricular cavity size with low normal global
systolic function. Borderline pulmonary artery systolic
hypertension but no definite cardiac source of embolism was
identified. For his afib with RVR he went back into sinus
rhythm on Amiodarone 400 q 8 hours for 3 days, then 400 q12 for
1 week, then 400 daily for a week then 200 daily for a week till
the patient is seen by his cardiologist.
# ___:
Creatine went to 1.6 but responded to hydration to 1.3 the next
day making a prerenal etiology most likely.
Medications on Admission:
- tylenol ___ Q4H PRN
- ascorbic acid ___ QD
- ASA 81mg QD
- calcium carbonate 500mg QID PRN
- docusate 100mg BID
- glucosamine-MSM 1 tab QD
- metoprolol 6.25mg BID
- percocet ___ tabs Q4H PRN (pt reports he hasn't been taking
this lately)
- metamucil 1 packet QD
- sarna lotion QID PRN
- simvastatin 40mg QD
- vitamin D 400 units QD
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain, fever
2. Ascorbic Acid ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Calcium Carbonate 500 mg PO QID:PRN indigestion
5. Metoprolol Tartrate 12.5 mg PO BID
6. Sarna Lotion 1 Appl TP QID:PRN itching
7. Simvastatin 40 mg PO DAILY
8. Vitamin D 400 UNIT PO DAILY
9. Warfarin 2.5 mg PO DAILY16
RX *warfarin [Coumadin] 2.5 mg ___ tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
10. Amiodarone 400 mg PO BID Duration: 2 Days
400 q12 for 2 days, then 400 daily for a 7 days. then 200 daily
until the patient is seen by a cardiologist.
RX *amiodarone 200 mg 2 tablet(s) by mouth twice daily Disp #*30
Tablet Refills:*0
11. Outpatient Lab Work
Reason Atrial Fibrillation and Stroke.
Labs: Na,K,Cl, HCO3,BUN,Cr, ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Stroke (left posterior cerebral artery)
Acute Kidney Injury (pre-renal related to dehyration)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You presented on ___ with difficulty seeing the right side of
objects. On imaging you were found to have a stroke (left
posterior cerebral artery occlusion.) The cause of this was
likely your heart arrythmia, (atrial fibrillation) Which you
have started on Amiodarone an antiarrythmic. and was found to
have a L PCA
As for your coumadin (blood thinner to prevent further strokes),
a nurse ___ come on ___ to draw your blood. Your goal INR
is 2 - 3. Your INR at discharge was 1.9
For the Arrythmia your Amiodarone was started at 400 mg twice a
day for a week and then 400 mg daily for a week and then 200 mg
daily for a week till you follow up with your cardiologist.
You will be followed by CTSurgery and Cardiology.
Please followup 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 ___
- 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 ___
- sudden drooping of one side of the ___
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of
___
- sudden blurring or doubling of ___
- sudden onset of vertigo (sensation of your environment
spinning around ___
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization.
Remember on a blood thinner take care of your body. if striking
your head please come to the hospital immediately. if Heart
starts racing also come back to the hospital.
Followup Instructions:
___
|
10220107-DS-16 | 10,220,107 | 27,122,498 | DS | 16 | 2205-01-26 00:00:00 | 2205-01-26 20:12:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
adhesive tape
Attending: ___
Chief Complaint:
Presyncope
Major Surgical or Invasive Procedure:
ERCP with epinephrine injection
History of Present Illness:
Mr. ___ is an ___ w/hx of stroke, afib on lovenox with, CAD
s/p CABG, prostate cancer, pancreatic ca, HTN, s/p ERCP stent
placement on ___ presenting with presyncope.
Pt recently admitted to ___ with painless jaundice, found to
have ___ cm obstructive mass (pancreatic ca) requiring stent
procedure. No complications with procedure, discharged ___.
Denies BM since ___ with exception of small BM this AM,
"dark brown" denies n/v/d/hematochezia/melena.. Asx since
discharge until DOA. This AM ~___, pt felt "clammy and
diaphoretic after Lovenox injection while standing. Felt weak,
lightheaded and "off" --abated somewhat with sitting. Denies
fall, LOC, SOB, cp, tachycardia, abdominal pain, visual aura,
fever, chills. His wife encouraged him to go to ED. At ___
___, initial vitals were 125/64 63 20 98 100%RA, no
orthostasis. EKG NSR, LAD, FDAVB, no signs of ischemia or
arryhtmia. Stool on exam was maroon colored, highly guaic
positive. Due to recent discharge, transferred to ___.
In the ___ ED, initial vs were: 98.6 66 106/61 (baseline 130s
per Atrius) 16 94% RA @ 14:16
Labs were remarkable for:
Hct drop from 32.6 on discharge to 26.1 on admission.
Elevated BUN
Hyperglycemia
LFTs c/w cholestasis, good synthetic fxn of the liver (INR
1.2); interval worsening transaminitis from discharge
Hypophosphatemia
Borderline high lactate
U/A dipstick bland
No intervention was given in the the ED. The patient was then
admitted to the medical service for further management.
Past Medical History:
Pancreatic cancer
Prostate cancer
Hyperlipidemia
Hypertension
Gout
s/p Bilateral inguinal hernia repair
s/p Prostatectomy
s/p Angioplasty ___ years ago
S/p CABG : ___
Social History:
___
Family History:
FAMILY HISTORY: Mother with lung cancer. Sister with breast
cancer around ___. Father with stroke.
Physical Exam:
>>>ADMISSION PHYSICAL EXAM<<<
Vitals: 97 120/68 66 20 100 RA
General: very pleasant, younger appearing than chronological
age. NAD.
HEENT: Sclera anicteric, no lingual icterus, MMM, oropharynx
clear, Uvula deviated slightly to the right
Neck: supple, JVP not elevated, no LAD
Lungs: +sternotomy scar. Clear to auscultation bilaterally, no
wheezes, rales, rhonchi
CV: Regular rate and rhythm, no murmurs, rubs, or galllops
Abdomen: ___ scar, soft, non-tender, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pedal pulses, no clubbing, cyanosis
or edema
Skin: Tanned/yellow, skin; 2 lipomas, long standing without
change, 2x3cm left lateral shoulder, 5x7cm left upper back.
Neuro: ___, ___ strength throughout all extremities, no
cranial nerve deficitis. AAOx3. ___ recall ___ recall with
prompting), some mild short term memory loss, trouble finding
words
Rectal: deferred due to multiple prior examinations. Per ___
ED note, no stool palpated on rectal exam, wall guiaic positive.
From OSH, stool was noted to be maroon and very occult positive.
Per colonoscopy ___ pt has internal hemorrhoids.
>>>DISCHARGE PHYSICAL EXAM<<<
Vitals: 97 120/68 66 20 100 RA
General: very pleasant, younger appearing than chronological
age. NAD.
HEENT: Sclera anicteric, no lingual icterus, MMM, oropharynx
clear, Uvula deviated slightly to the right
Neck: supple, JVP not elevated, no LAD
Lungs: +sternotomy scar. Clear to auscultation bilaterally, no
wheezes, rales, rhonchi
CV: Regular rate and rhythm, no murmurs, rubs, or galllops
Abdomen: ___ scar, soft, non-tender, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pedal pulses, no clubbing, cyanosis
or edema
Skin: Non-jaundiced; 2 lipomas, long standing without change,
2x3cm left lateral shoulder, 5x7cm left upper back.
Neuro: ___, ___ strength throughout all extremities, no
cranial nerve deficitis. AAOx3. ___ recall ___ recall with
prompting), some mild short term memory loss, trouble finding
words
Pertinent Results:
>>> ADMISSION LABS <<<
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
___ 14:58 3.3* 2.77* 8.1* 26.1* 94 29.4 31.3 14.6 210
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
___ 14:58 58.1 32.2 6.4 2.8 0.5
BASIC COAGULATION ___, PTT, PLT, INR) ___ PTT Plt Ct ___
___ 14:58 210
___ 14:58 12.9* 49.4* 1.2*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 14:58 185*1 38* 1.0 139 4.2 ___
ENZYMES & BILIRUBIN ___ 14:58
ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili
425* 244* 295* 1.4
OTHER ENZYMES & BILIRUBINS Lipase
___ 14:58 18
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
___ 14:58 3.6 8.9 2.4* 2.0
Blood Gas Lactate ___ 15:08 2.1*
>>> NO IMAGING STUDIES THIS HOSPITALIZATION <<<
>>> INTERVENTIONS <<<
ERCP: The esophagus was normal with no stigmata of recent
bleeding.
The stomach was normal with no stigmata of recent bleeding seen.
Fresh red blood was noted in the duodenal bulb.
A large blood clot was noted in the second portion of the
duodenum covering the previously placed metallic biliary stent.
The stent was patent and actively draining bile.
Active oozing of blood at the sphincterotomy site, s/p 7 cc of
___ epinephrine was injected at the sphincterotomy site with
good hemostasis.
The site was observed for 5 min with no evidence of active
bleeding. No further intervention was required.
>>>> DISCHARGE LABS <<<<
Brief Hospital Course:
Mr. ___ is an ___ c/ PMHx of stroke, A. fib, CAD S/P CABG,
HTN, prostate cancer, newly diagnosed pancreatic cancer S/P ERCP
+ stent who presented to ___ with presyncope, found to have a
GIB at the site of his sphincterotomy; now S/P ERCP with
epinephrine injection.
ACTIVE ISSUES
# GIB: patient presented with pre syncopal episode. His symptoms
were secondary to hypovolemia due to GI bleed, thought to be due
to post-sphincterotomy bleed. Lovenox was held, the patient
received 2 u pRBC to and the ERCP team consulted. At that time,
they recommended close monitoring of H/H and if worsened, would
require endoscopic intervention (at this time HCT was 26). After
receiving the 2 units of pRBCs, his HCT continued to trend down
to a nadir of 20.3 and he had two large melanotic BMs, at which
point the ERCP team brought him for endoscopy, where the source
of bleeding at the sphincterotomy was identified and hemostasis
achieved.
After ERCP, he was given 1 additional unit of blood and has
since remained hemodynamically stable, no longer had any
melanotic stools, without any physical or laboratory signs of
blood loss.
# Anemia: see above
# Hypercoagulabilty: Lovenox was stopped upon arrival due to
GIB. The patient is at high risk for clots, given intermittent
A. fib and pancreatic cancer, however, with recent GIB, he is
also high risk for bleeding. Lovenox was held during the
hospitalization, but the patient is discharged with instructions
to resume Lovenox anticoagulation at home, 5 days post-ERCP.
# Pancreatic cancer: S/P ERCP with metal stent placement.
Cytology brushing came back as atypical. Sent for CT chest with
contrast for staging purposes that revealed a thorax without any
evidence of metastases. Will meet with ___ oncology/surgery team
on ___.
# Sinus bradycardia: the patient has been in NSR or sinus
bradycardia during this hospitalization. His HR had fallen to
the high 30's (sinus bradycardia) overnight but he remained
asymptomatic.
CHRONIC ISSUES
#Hypertension: holding beta-blockers due to bradycardia
#Chronic lipoma: stable
#Anxiety associated with depression: not currently on medication
#Prostate cancer: noted
#Hyperlipidemia: not currently on medication due to liver damage
#Gout: stable
#CAD--silent MI s/p CABG ___
TRANSITIONAL ISSUES
[ ] Multidisciplinary pancreatic cancer meeting on ___
[ ] Restart beta-blocker if HR permits
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 500 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Vitamin D 400 UNIT PO DAILY
4. Ascorbic Acid ___ mg PO DAILY
5. Fish Oil (Omega 3) 1000 mg PO DAILY
6. Glucosamine-Chond-MSM Complex ___
___ 0 unknown ORAL DAILY
7. Metoprolol Tartrate 12.5 mg PO BID
8. Enoxaparin Sodium 80 mg SC BID
Start: ___, First Dose: Next Routine Administration Time
9. Simvastatin 40 mg PO DAILY
10. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Calcium Carbonate 500 mg PO DAILY
3. Enoxaparin Sodium 80 mg SC BID Anticoagulation
Start: Future Date - ___, First Dose: First Routine
Administration Time
Start this medication on ___
RX *enoxaparin [Lovenox] 80 mg/0.8 mL 80 mg sc twice daily Disp
#*60 Syringe Refills:*0
4. Fish Oil (Omega 3) 1000 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Simvastatin 40 mg PO DAILY
7. Vitamin D 400 UNIT PO DAILY
8. Glucosamine-Chond-MSM Complex ___
___ 1 unknown ORAL DAILY
9. Artificial Tears ___ DROP BOTH EYES PRN Itchy eyes
RX *dextran 70-hypromellose [Artificial Tears] ___ drops twice
a day Disp #*1 Bottle Refills:*0
10. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Presyncope
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at the ___
___. You were admitted for low blood pressure that
was caused by bleeding from your procedure (ERCP). You had
another procedure to stop the bleeding, which was successful.
We held your lovenox due to the bleeding. Please restart taking
this medication on ___. This is a injection medication to
prevent any clots from forming. At this point, do NOT take your
daily aspirin. Dr. ___ will check your blood counts next
week to ensure there is no further bleeding.
We also held your metoprolol because your heart rate is now
slower. You will follow up with Dr. ___ week and he will
let you know if you can restart the medication.
Please also follow up with your primary care doctor to discuss
when to restart aspirin and your blood pressure medications.
You may continue eating a normal diet, as you can tolerate -
without any restrictions. It is expected to have small amount of
black stools for the next 2 days.
If you continue to have black stools, diarrhea (black or bloody)
or bloody stools, or if you feel lightheaded or are concerned
with worsening of your condition, please call your doctor right
away.
Followup Instructions:
___
|
10220150-DS-8 | 10,220,150 | 21,122,220 | DS | 8 | 2131-04-30 00:00:00 | 2131-05-13 10:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
___
Attending: ___.
Chief Complaint:
R facial and arm paresthesia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ y/o woman w/ factor V Leiden (on
rivaroxaban), SLE, hypothyroidism, and h/o renal failure; she
presented for new-onset R-face and RUE paresthesia/numbness.
No known inciting factors. No missed medication doses.
She was noted to have R-facial and RUE decreased sensation to
pinprick and vibration. Neurologic exam o/w normal.
Admitted to Neurology due to concern for stroke causing
unilateral sensory changes.
Past Medical History:
factor V Leiden (on rivaroxaban);
SLE;
hypothyroidism;
h/o renal failure
Social History:
___
Family History:
unremarkable
Physical Exam:
General: Awake, cooperative, anxious appearing.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented, attentive. Language is fluent
with intact repetition and comprehension. Normal prosody. There
were no paraphasic errors. Pt. was able to name both high and
low
frequency objects. Can describe stroke card in good detail. Able
to read without difficulty. Speech was
not dysarthric. Able to follow both midline and appendicular
commands. There was no evidence of apraxia or neglect. When
trying to remember the names of her medications, she bursts out
into tears.
CN
I: not tested
II,III: VFF to confrontation, pupils 4mm->2mm bilaterally
III,IV,VI: EOMI, no ptosis. No nystagmus
V: sensation intact V1-V3 to LT
VII: Facial strength intact/symmetrical, symm forehead wrinkling
VIII: hears finger rub bilaterally
IX,X: palate elevates symmetrically, uvula midline
XI: SCM/trapezeii ___ bilaterally
XII: tongue protrudes midline with full excursions bilaterally,
no dysarthria
Motor: Normal bulk and tone, no rigidity; no asterixis or
myoclonus. No pronator drift.
Delt Bi Tri WE FE Grip IO
C5 C6 C7 C6 C7 C8/T1 T1
L 5 ___ 5 5 5
R 5 ___ 5 5 5
IP Quad ___ PF
L2 L3 L4-S1 L4 L5 S1/S2
L 5 5 5 ___
R 5 5 5 ___
Reflex: No clonus
Bi Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L ___ 2 ___ Flexor
R ___ 2 ___ Flexor
-Sensory: No deficits to light touch. No extinction to DSS.
Decreased pinprick in the right face 80% compared to 100% on the
left. Splits the midline with vibration on the face. Decreased
pinprick in the right arm distal to the elbow, 75% compared to
100% on the left. Pinprick above the elbow symmetric. Pinprick
in
the leg symmetric bilaterally. JPS intact bilaterally. Vibration
>10 seconds at the great toes bilaterally.
-Coordination: No intention tremor, dysdiadochokinesia noted. No
dysmetria on FNF or HKS bilaterally.
Gait: stable.
Pertinent Results:
___ 06:30AM BLOOD WBC-5.4 RBC-4.22 Hgb-12.6 Hct-39.3 MCV-93
MCH-29.9 MCHC-32.1 RDW-12.5 RDWSD-42.9 Plt ___
___ 10:18AM BLOOD ___ PTT-29.0 ___
___ 06:30AM BLOOD Glucose-84 UreaN-12 Creat-1.6* Na-144
K-4.0 Cl-107 HCO3-24 AnGap-13
___ 10:18AM BLOOD ALT-17 AST-24 AlkPhos-86 TotBili-0.5
___ 06:30AM BLOOD Triglyc-41 HDL-51 CHOL/HD-3.0 LDLcalc-96
___ 10:18AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
Brief Hospital Course:
Ms. ___ is a ___ y/o woman w/ factor V Leiden (on
rivaroxaban), SLE, hypothyroidism, and h/o renal failure; she
presented for new-onset R-face and RUE paresthesia/numbness.
No known inciting factors. No missed medication doses.
She was noted to have R-facial and RUE decreased sensation to
pinprick and vibration. Neurologic exam o/w normal.
Admitted to Neurology due to concern for stroke causing
unilateral sensory changes.
Pt had no acute events inpt. Did note moderate headache that
started shortly after admission.
MRI brain negative for stroke.
She was discharged in stable condition to f/up w/ primary care.
Medications on Admission:
1. Hydroxychloroquine Sulfate 200 mg PO BID
2. Levothyroxine Sodium 150 mcg PO DAILY
3. Omeprazole 20 mg PO BID
4. Rivaroxaban 20 mg PO DAILY
Discharge Medications:
1. Hydroxychloroquine Sulfate 200 mg PO BID
2. Levothyroxine Sodium 150 mcg PO DAILY
3. Omeprazole 20 mg PO BID
4. Rivaroxaban 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
focal paresthesias
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted for evaluation of sensory changes in the
right-side of your face and right forearm.
MRI did not show any evidence of stroke.
You should follow-up with your primary care physician at the
earliest available appointment. If he or she deems it necessary,
follow-up with Neurology.
It was a pleasure taking care of you.
- Your ___ Neurology team
Followup Instructions:
___
|
10220335-DS-6 | 10,220,335 | 21,739,872 | DS | 6 | 2143-11-03 00:00:00 | 2143-11-03 13:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right lower quadrant abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: The patient is a ___ who presented with RLQ pain beginning
the AM of ___. The pain was constant and exacerbated with
movement, alleviated by lying still. She had no nausea,
vomiting,
fevers, or diarrhea. She has had no prior episodes.
Past Medical History:
none
Social History:
___
Family History:
nc
Physical Exam:
PE: upon admission: ___:
VS: 99.0 107 123/76 18 100%RA
Gen: NAD
CV: RRR S1 S2
Lungs: CTA B/L
Abd: soft, ND, acutely TTP in RLQ with mild guarding
Physical examination upon discharge: ___:
Vital signs: t=98.6, bp=98/58, hr=74, rr=16, room air oxygen
saturation 98%
General: NAD, resting comfortably
CV: ns2, s2, -s3, -s4
LUNGS: Clear ant. and posterior
ABDOMEN: soft, non-tender, no guarding
EXT: + dp bil., no calf tenderness bil., ext. warm, + dp bil
MENTATION: alert and oriented x 3 (husband conversing to her in
___
Pertinent Results:
___ 06:13AM BLOOD WBC-9.0 RBC-4.14* Hgb-12.0 Hct-35.8*
MCV-87 MCH-29.1 MCHC-33.6 RDW-12.1 Plt ___
___ 06:36AM BLOOD WBC-8.3 RBC-4.40 Hgb-12.5 Hct-37.7 MCV-86
MCH-28.4 MCHC-33.2 RDW-12.1 Plt ___
___ 04:00PM BLOOD WBC-7.9# RBC-4.76# Hgb-13.7# Hct-40.9#
MCV-86 MCH-28.8 MCHC-33.6 RDW-11.9 Plt ___
___ 04:00PM BLOOD Neuts-76.1* ___ Monos-3.2 Eos-0.2
Baso-0.3
___ 06:13AM BLOOD Plt ___
___ 10:30AM BLOOD ___ PTT-32.1 ___
___ 06:13AM BLOOD Glucose-62* UreaN-10 Creat-0.6 Na-138
K-4.1 Cl-105 HCO3-21* AnGap-16
___ 04:00PM BLOOD Glucose-101* UreaN-6 Creat-0.6 Na-142
K-3.5 Cl-107 HCO3-27 AnGap-12
___ 06:13AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.9
___: abdominal/pelvis doppler:
IMPRESSION:
1. No findings suggestive of ovarian torsion.
2. Prominent free fluid.
3. Blind-ending dilated tubular structure measuring up to 8 mm
in diameter in right lower quadrant at the site of pain which
did not compress with pressure, may represent dilated appendix.
Please correlate clinically with evidence of acute appendicitis;
CT could be considered for confirmation.
___: pelvic US:
IMPRESSION:
1. No findings suggestive of ovarian torsion.
2. Prominent free fluid.
3. Blind-ending dilated tubular structure measuring up to 8 mm
in diameter in right lower quadrant at the site of pain which
did not compress with pressure, may represent dilated appendix.
Please correlate clinically with evidence of acute appendicitis;
CT could be considered for confirmation.
___: cat scan of abdomen and pelvis:
IMPRESSION:
1. Hyperenhancing and slightly thickened tip of the appendix
could represent
early "tip appendicitis" or, alternatively, reflect "passive"
inflammation
related to the process centered in the right colon (#2, below).
2. Focal segmental pneumatosis of the mid-ascending colon, of
uncertain
significance. There is no significant mural thickening in this
well-opacified
and -distended segment. There is also no mesenteric or portal
venous gas.
There is relatively mild thickening of the lateral conal fascia
and parietal
peritoneum in this region.
3. Moderate amount of slightly complex but non-hemorrhagic
pelvic free fluid may relate to either of the two processes,
above.
COMMENT: These findings may be related to focal segmental
ischemia, as has been reported with drugs of abuse, particularly
cocaine. Other diagnostic considerations, including typhilitis,
are unlikely in the absence of history of immunocompromise
and/pr the use of corticosteroids or chemotherapeutic agents.
This appearance is atypical for "benign" idiopathic pneumatosis
cystoides intestinalis. Though the patient demographics are
appropriate for the entity of right colonic diverticulitis, the
absence of colonic thickening and adjacent fat-stranding, as
well as the lack of a "culprit" diverticulum would be most
unusual.
Brief Hospital Course:
The patient was admitted to the acute care service with right
lower quadrant abdominal pain. Upon admission, she was made
NPO, given intravenous fluids, and underwent imaging. On cat
scan, she was found to have a hyperenhancing and slightly
thickened tip of the appendix suggestive of early "tip
appendicitis" or "passive" inflammation related to the process
centered in the right colon Focal segmental pneumatosis of
the mid-ascending colon was also visualized. She was started on
intravenous ciprofloxacin and flagyl and placed on bowel rest.
Her white blood cell count was closely monitored.
On HD #3, she was noted to have a decrease in the abdominal pain
and was started on a regular diet. Her antibiotics have been
converted to an oral route and she is planning for discharge
home with a 2 week course of ciprofloxacin and flagly. The GI
service was notified about an outpatient colonoscopy to evaluate
for diverticulosis in ___ weeks, followed by a visit to the
acute care clinic.
Medications on Admission:
OCP
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 14 Days
RX *Cipro 500 mg 1 tablet(s) by mouth every twelve (12) hours
Disp #*28 Tablet Refills:*0
2. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 14 Days
RX *Flagyl 500 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*42 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
early appendicititis
Discharge Condition:
Mental Status: Clear and coherent (speaks ___
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with right lower quadrant
pain. You were placed on bowel rest and started on intravenous
antibiotics. Your abdominal pain is slowly resolving and you
are preparing for discharge home with the following
instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications, except your birth
control pills. Use a back-up method of contraception and
discuss resuming them when you see your primary care MD.
Followup Instructions:
___
|
10220448-DS-20 | 10,220,448 | 25,347,810 | DS | 20 | 2132-03-15 00:00:00 | 2132-03-16 22:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Dysuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___ man w/ non-insulin dependent type 2 diabetes,
HTN, hyperlipidemia, and COPD who is currently being worked up
by urology for urinary retention that started at the end of
___ and is referred to the ED from urgent care clinic after
they were unable to straight cath him for urinary retention. He
lives at home with wife and granddaughter. He was unable to void
while at adult day care on the day of admission and was sent to
___ via EMS. He endorses abdominal pain that resolved with
cath and inability to urinate since this morning, however he had
only been urinating a little bit over the last ___ days. He
endorses dysuria X ___nd was note dto have green
purulent appearing fluid at the tip of his penis in the ___
clinic. Previous urology visit with plan for outpatient
cystoscopy, repeat UA, trial of Flomax and constipation meds. He
has been taking these medications. He denies N/V/D, fevers,
chest pain, SOB or other symptoms.
Notably, he presented to ___ ED on ___ w/ acute urinary
retention. He had been constipated (which resolved after
addition of prune juice) but there was no other obvious inciting
factor. A Foley catheter was placed in the ED yielding 800 mL
urine and he was scheduled for urology follow up. At urology
follow up ~1.5 weeks later, he was noted to have paraphimosis
and marked preputial edema - paraphimosis was reduced with
gentle traction and pressure.
In the ED, initial vitals were: 98.3 85 ___ RA
- Exam notable for: Enlarged, but non-tender prostate. Guaiac
negative. RRR. NTND abd. ___ draining cloudy urine with
sediment. No blood or clots. No c/c/e. 600 cc urine output
- Labs notable for: WBC 3.4, Hgb 11.2 both are at recent
baseline. Na 119, repeat 118 on whole blood. Serum osm 247,
urine osm 137
- Patient was given: 1L NS bolus, 1g CTX
Vitals on transfer: 97 84 125/68 14 99% RA
Upon arrival to the floor, patient reports that he is feeling
ok, denies any CP, SOB, abd pain, n/v/d. He endorses that he has
lost weight over the last few weeks, but cannot say how much. He
says he hasn't been eating very much, ___ lack of appetite and
is def eating less now than he was ___ months ago. He might have
a little soup for lunch and might have some rice for dinner. he
lives with his daughter (who is currently on vacation) so he is
living with a different daughter, per his son. ___ any melena
or new cough. Endorses a chronic cough for years, unchanged.
Nonproductive, not coughed up any blood. Has been drinking
enough water and does not feel thirsty. No fevers/chills at
home.
Past Medical History:
Asthma/COPD
DM
HTN
HLD
Inguinal hernia
Social History:
___
Family History:
noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS - 98.4 | 100/59 | 85 | 18 | 94%RA
GENERAL - No acute distress, lying in bed.
HEENT - Mucus membranes moist. Sclera anicteric. Oropharynx
clear.
NECK - Supple, JVP not appreciated.
CARDIAC - Regular rate and rhythm, no murmurs, rubs, and
gallops.
LUNGS - Clear to auscultation bilaterally.
ABDOMEN - Soft, non-tender, non-distended.
GU: No phimosis. Pus visible coming from meatus on exam.
EXTREMITIES - No edema, cyanosis, or erythema.
BACK - No CVA tenderness.
DRE - Prostate enlarged but not focally tender.
NEUROLOGIC - Per children, alert and oriented. Follows commands.
Face symmetric, tongue midline.
DISCHARGE PHYSICAL EXAM:
VITALS - 97.9 | 140-150/86 | 81 | 20 | 94%RA
GENERAL - No acute distress, lying in bed.
HEENT - Mucus membranes moist. Sclera anicteric. Oropharynx
clear.
NECK - Supple, JVP not appreciated.
CARDIAC - Regular rate and rhythm, no murmurs, rubs, and
gallops.
LUNGS - Clear to auscultation bilaterally.
ABDOMEN - Soft, non-tender, non-distended.
GU: Some paraphimosis --> reduced
EXTREMITIES - No edema, cyanosis, or erythema.
BACK - No CVA tenderness.
NEUROLOGIC - Per children, alert and oriented. Follows commands.
Face symmetric, tongue midline.
Pertinent Results:
ADMISSION LABS:
___ 09:04PM NA+-125*
___ 08:20PM GLUCOSE-105* UREA N-11 CREAT-0.8 SODIUM-125*
POTASSIUM-4.2 CHLORIDE-87* TOTAL CO2-25 ANION GAP-17
___ 08:20PM ALT(SGPT)-12 AST(SGOT)-18 LD(LDH)-159 ALK
PHOS-98 TOT BILI-0.6
___ 08:20PM CALCIUM-9.3 PHOSPHATE-3.2 MAGNESIUM-1.3*
___ 08:20PM OSMOLAL-263*
___ 03:37PM NA+-118*
___ 03:20PM URINE HOURS-RANDOM UREA N-92 CREAT-11
SODIUM-42 POTASSIUM-5 CHLORIDE-31
___ 03:20PM URINE OSMOLAL-135
___ 01:20PM GLUCOSE-110* UREA N-13 CREAT-1.0 SODIUM-119*
POTASSIUM-3.9 CHLORIDE-81* TOTAL CO2-23 ANION GAP-19
___ 01:20PM estGFR-Using this
___ 01:20PM OSMOLAL-247*
___ 01:20PM URINE HOURS-RANDOM
___ 01:20PM URINE UHOLD-HOLD
___ 01:20PM WBC-3.4* RBC-3.96* HGB-11.2* HCT-32.5*
MCV-82# MCH-28.3 MCHC-34.5# RDW-11.7 RDWSD-34.6*
___ 01:20PM NEUTS-56.7 ___ MONOS-18.5* EOS-1.2
BASOS-0.3 IM ___ AbsNeut-1.90 AbsLymp-0.77* AbsMono-0.62
AbsEos-0.04 AbsBaso-0.01
___ 01:20PM PLT COUNT-228
___ 01:20PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 01:20PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-LG
___ 01:20PM URINE RBC-37* WBC->182* BACTERIA-MANY
YEAST-NONE EPI-0
___ 01:20PM URINE WBCCLUMP-MOD
MICROBIOLOGY:
URINE CULTURE (Final ___:
CITROBACTER FREUNDII COMPLEX. >100,000 CFU/mL.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER FREUNDII COMPLEX
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
PATHOLOGY: None
IMAGING:
Renal ultrasound:
IMPRESSION:
No hydronephrosis.
DISCHARGE LABS:
___ 06:48AM BLOOD WBC-3.5* RBC-3.53* Hgb-10.1* Hct-30.6*
MCV-87 MCH-28.6 MCHC-33.0 RDW-11.9 RDWSD-37.9 Plt ___
___ 06:48AM BLOOD Glucose-97 UreaN-5* Creat-0.9 Na-132*
K-4.6 Cl-94* HCO3-24 AnGap-19
___ 06:48AM BLOOD Calcium-9.1 Phos-3.0 Mg-1.5*
Brief Hospital Course:
SUMMARY: ___ with a history of non-insulin dependent DM2, HTN,
HLD, COPD, and urinary retention presenting with urinary
retention, hyponatremia, and UTI.
ACTIVE ISSUES:
#Urinary retention: A foley was placed. No hydronephrosis was
seen on renal ultrasound. Urology was consulted and advised to
keep the foley until follow-up.
#Complicated UTI: The patient was started on ceftriaxone for a
seven-day course for complicated UTI, which was then narrowed to
Bactrim. Cultures came back showing pan-sensitive Citrobacter.
Bactrim was discontinued after 5 days given low concern for
infection and concern that med could be contributing to
hyponatremia.
#Hyponatremia: Initially had a sodium of 118 on admission.
Thought to be due to a combination of decreased solute intake
and hydrochlorothiazide use. Improved 8 mEq within the first 24
hours with normal saline, then up to 132. Sodium then decreased
to 129 and urine lytes were repeated, this time showing high
urine osms and urine sodium. An overlying SIADH etiology was
considered, and with fluid restriction, sodium rose to 132. Pt
was discharged on a fluid restriction; please follow Na as an
outpatient and consider liberalizing fluid intake if stable, if
any evidence of persistent SIADH would evaluate for other
etiologies of SIADH.
CHRONIC ISSUES:
# HTN: continued losartan and metoprolol tartrate. Pt was
mildly hypertensive prior to discharge and pts PCP was notified
of likely need to uptitrate antihypertensives in the setting of
recent discontinuation of HCTZ.
# NIDDM: ISS
# COPD: continued tiotropium, albuterol PRN SOB
New Medications:
None
Discontinued Medications:
HCTZ
TRANSITONAL ISSUES:
-The patient is being discharged with a Foley for urology
follow-up on ___.
-f/u with PCP ___ 1 week
-f/u sodium at next PCP appointment to ensure improvement (132
at discharge)
-Consider further workup for SIADH. Patient notably has
extensive smoking history and may benefit from low-dose CT scan.
-f/u blood pressure and consider adding additional agents if
elevated (i.e. CCB)
-Avoid HCTZ in the setting of recent hyponatremia
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 100 mg PO DAILY
2. Tiotropium Bromide 1 CAP IH DAILY
3. Metoprolol Tartrate 50 mg PO DAILY
4. MetFORMIN (Glucophage) 250 mg PO QHS
5. Polyethylene Glycol 17 g PO DAILY
6. Senna 8.6 mg PO BID
7. Simvastatin 40 mg PO QPM
8. Aspirin 81 mg PO DAILY
9. Tamsulosin 0.4 mg PO QHS
10. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
11. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
3. Aspirin 81 mg PO DAILY
4. Losartan Potassium 100 mg PO DAILY
5. MetFORMIN (Glucophage) 250 mg PO QHS
6. Metoprolol Tartrate 50 mg PO DAILY
7. Polyethylene Glycol 17 g PO DAILY
8. Senna 8.6 mg PO BID
9. Simvastatin 40 mg PO QPM
10. Tamsulosin 0.4 mg PO QHS
11. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS: URINARY RETENTION, COMPLICATED URINARY TRACT
INFECTION, HYPONATREMIA
SECONDARY DIAGNOSES: HYPERTENSION, DIABETES MELLITUS, 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. ___,
You were seen for retention of urine, infection of the urinary
tract, and low sodium. You were given a foley catheter,
antibiotics, and fluids to treat these conditions.
When you leave the hospital, you should try and eat a balanced,
full diet to prevent electrolyte abnormalities. You should only
drink 1.5 liters per day, including any water, tea, juice, or
other liquids you drink. You should follow up with the urology
doctors to take ___ of your foley catheter.
It was our pleasure to care for you. We wish you the very best!
Your team at ___
Followup Instructions:
___
|
10220895-DS-3 | 10,220,895 | 29,386,357 | DS | 3 | 2154-08-16 00:00:00 | 2154-08-16 17:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Clindamycin / Zocor / Azithromycin / Lisinopril
Attending: ___.
Chief Complaint:
dizziness, blurry vision, confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is very poor historian, history obtained from record.
___ F w/hx of memory loss and confusion (? dementia), alcohol use
and depression p/w episode of dizziness, blurry vision, and
confusion at 1PM when health aid visited. Pt thinks she woke up
at 11AM and with symptoms but is unsure, however states she was
in normal health last night. Sx resolved ~2PM today but now c/o
minor headache. Denies paralysis, numbness, aphasia. Denies
F/C/N/V change bowel/bladder habits. Denies chest
pain/SOB/cough.
Documented memory disorder, frequent falls and concussions by
gerontology doc. Past MRI ___: Cortical atrophy and chronic
small vessel ischemic disease. Pt lives by herself, but has
"assitant" come to the house from ___ daily for medications.
Initial vitals in ED:
0 97.5 83 145/83 18 100% RA
On exam:
Aox2 (not year) Neuro: ___ grossly intact. Strength full bilat
U and L. No numbness/parasthesias
Imaging: CT HEAD NC No acute intracranial abnormality. Age
related volume loss and chronic small vessel ischemic disease.
Labs unremarkable. Seen by neurology who felt this was not TIA.
Patient admitted for TIA workup.
Vitals prior to transfer were:
Today 21:19 0 97.7 84 142/82 18 99% RA
On the floor no complaints
Past Medical History:
Depression
Alcohol Use
Dementia
HYPERTENSION, Hyperlipemia
MACULAR DEGENERATION
ORIF RIGHT LEG FRACTURE
RIB FRACTURE
STREPTOCOCCAL PHARYNGITIS
TINNITUS
TONSILLECTOMY
PAST SURGICAL HISTORY: Significant for an ectopic pregnancy,
lysis of abdominal adhesions, a right leg fracture, after
falling on the ice, which was kept in place with rods and
screws and a left leg fracture with multiple contusions from a
motor vehicle accident in ___.
Social History:
___
Family History:
per OMR: Significant for her father who had an addiction issue.
Her mother died of dementia and COPD at age ___. Her father and
grandmother had mental illness and her grandfather
died of stomach cancer.
Physical Exam:
=============================
ADMISSION PHYSICAL EXAM:
=============================
VS:97.7 84 142/82 18 99% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, 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: 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
.
.
=============================
DISCHARGE PHYSICAL EXAM:
=============================
VS 98.7 110/70 ___
GENERAL: ___ lying comfortably in bed, in no acute distress.
HEENT: AT/NC, anicteric sclera, pink conjunctiva, moist mucous
membranes, 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: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact. Oriented to her name, hospital,
month/day (not year). Could state the days of the week
backwards.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
=============================
LABS:
=============================
___ 05:43PM BLOOD WBC-9.8# RBC-4.52 Hgb-15.6 Hct-46.2
MCV-102* MCH-34.5* MCHC-33.7 RDW-12.2 Plt ___
___ 05:43PM BLOOD Neuts-82.8* Lymphs-11.8* Monos-4.5
Eos-0.4 Baso-0.4
___ 05:43PM BLOOD Glucose-118* UreaN-18 Creat-0.8 Na-138
K-3.8 Cl-98 HCO3-30 AnGap-14
___ 05:43PM BLOOD TSH-0.89
.
.
=============================
URINE:
=============================
___ 05:43PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:43PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR
___ 05:43PM URINE RBC-15* WBC-2 Bacteri-FEW Yeast-NONE
Epi-1
___ 05:43PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG
.
.
=============================
IMAGING:
=============================
CT HEAD W/O CONTRAST ___
FINDINGS: There is no evidence of hemorrhage, edema, mass
effect, or large vascular territory infarction. The ventricles
and sulci are prominent, consistent with age-related volume
loss. The basal cisterns are patent. Periventricular confluent
white matter hypodensities are consistent with chronic small
vessel ischemic disease. Overall, these findings are similar to
the prior MRI from ___.
No fracture is identified. There are severe degenerative
changes in the left temporo-mandibular joint. The visualized
paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. The soft tissues are unremarkable.
.
IMPRESSION: No acute intracranial abnormality. Unchanged
age-related volume loss and chronic small vessel ischemic
disease.
Brief Hospital Course:
PRIMARY REASON FOR ADMISSION:
===================================
Ms. ___ is a ___ with a history of depression, dementia,
alcohol use who presents with a 3 hour episode of
dizziness/confusion/blurry vision now resolved.
.
ACTIVE ISSUE:
===================================
#Dizziness, blurry vision, history of falls: The patient was
admitted after having reportedly telling her ___ that she was
dizzy and had blurry vision. She was brought to the ED where
Neurology was consulted for concern of TIA. CT was without
evidence of acute abnormality. Neurology felt that her exam was
notable for significantly impaired memory and somewhat impaired
attention, distal neuropathy with diminished vibration, diffuse
hyperreflexia and a wide-based gait. It seemed that overall she
has a multifcatorial gait disorder, with cervical spondylosis
and neuropathy contributing at least somewhat. She should see
her Neurologist and MRI of the neck as an outpatient. She may
also benefit from wearing a soft cervical collar at night.
.
.
CHRONIC ISSUES:
===================================
#Depression: The patient had been seen as an outpatient and
previously diagnosed with acute grief reaction superimposed on
dysthymic disorder, chronic insomnia, chronic alchohol abuse,
and ongoing cognitive decline. She was continued on her home
venlafaxine.
.
#Alcohol dependency: Per review of OMR, the patient reported
drinking wine and vodka in the evenings to help with sleep. She
had no signs of withdrawal during this admission. per clinic
notes: Because of her inability to sleep, she has been drinking
wine as
.
#Hypercholesterolemia: Her statin was continued.
.
#HTN: She was normotensive during the admission, maintained on
her home medications.
.
#Insomnia: She was continued on her home quetiapine at
nighttime. Given her history of falls, she may benefit from an
alternative medication.
.
.
TRANSITIONAL ISSUES:
- Given her dementia and other comorbidities, she may benefit
from more services (such as 24 hour care)
- She should wear a soft cervical collar at night.
- She is currently on quetiapine qhs, but given her history of
falls she may benefit from a different nightime medication.
- She may benefit from outpatient MRI neck for futher evaluation
of her cervical disease
- HCP: ___ (daughter): ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 30 mg PO DAILY
2. Hydrochlorothiazide 12.5 mg PO DAILY
3. Losartan Potassium 25 mg PO BID
4. QUEtiapine Fumarate 50 mg PO QHS
5. Venlafaxine XR 225 mg PO DAILY
Discharge Medications:
1. Atorvastatin 30 mg PO DAILY
2. Hydrochlorothiazide 12.5 mg PO DAILY
3. Losartan Potassium 25 mg PO BID
4. QUEtiapine Fumarate 50 mg PO QHS
5. Venlafaxine XR 225 mg PO DAILY
6. Please wear soft cervical collar at night. ICD 9 721.1
CERVICAL SPONDYLOSIS WITH MYELOPATHY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
- Lightheadedness
- Blurry vision
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was our pleasure participating in your care here at ___.
You were admitted on ___ after having dizziness, blurry
vision and a headache. You were seen by the Neurology team who
felt that this was fortunately not related to a mini-stroke.
Given that you continued to do well here and did not have any
further symptoms, you will be discharged home.
You were seen by Neurology. They would like you to wear a
cervical soft collar every night.
If you feel dizzy or confused, please let your nurse or doctors
___. Please avoid drinking alcohol while you are taking your
medications as this can make you more at risk of having falls.
Again, it was our pleasure taking care of you.
We wish you the best,
-- Your ___ Primary Team
Followup Instructions:
___
|
10221179-DS-11 | 10,221,179 | 21,815,961 | DS | 11 | 2119-10-11 00:00:00 | 2119-10-11 14:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
C2 type III Dens fracture
Major Surgical or Invasive Procedure:
C1-C2 laminectomy, posterior fusion
History of Present Illness:
___ is an ___ male who presents with
complaint of neck pain and found to have a C2 fracture. He
reports that on ___ he was shoveling snow outside of his
house. When he was done shoveling the snow he noted his neck was
sore. Neck pain has progressively worsened since, which caused
him to present to the ED for evaluation. CT C-spine showed an
acute odontoid fracture with anterior displacement of the
proximal fracture fragment. He denies numbness, tingling, or
weakness in his arms/legs.
Past Medical History:
PMH: arthritis, HLD, colonic volvulus, OSA w/ CPAP, carpal
tunnel
PSH: bunionectomy
Social History:
___
Family History:
Grandparent with colon cancer
Physical Exam:
ON ADMISSION:
-------------
: T: 97.5 BP: 115/88 HR: 74 R 18 O2Sats 97% RA
Gen: WD/WN, comfortable, NAD.
Neck: Paraspinal tenderness to palpation
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
T D B T WE WF IP Q H AT ___ G
R 5 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch
Reflexes: B T Br Pa Ac
Right 1 0 0 1 0
Left 1 0 0 1 0
-------------
ON DISCHARGE:
-------------
Pertinent Results:
Please see OMR for pertinent results.
Brief Hospital Course:
#Type III dens fracture
Patient was admitted to the neurosurgical service with a plan
for conservative management in a cervical collar. Given his
degree of kyphosis and difficulty fitting the collar, he elected
to undergo operative management of his fracture. He was taken to
the OR on ___ for C1-2 laminectomy and posterior fusion. The
procedure was uncomplicated, but he remained intubated post-op
due to facial swelling post-op and slow awakening and was
transferred to the ICU for further monitoring. On the morning of
POD#1, he was successfully extubated. He was stable on
supplemental O2 via NC. He was able to transfer to the floor on
POD#2. He was subsequently stable on RA with CPAP overnight. He
worked with ___ who determined that discharge to rehab was
appropriate on POD4.
#Asymmetric BP
Patient was noted to have asymmetric blood pressure measurements
(R>L by 60 points). he underwent a CT of the chest, which
revealed a high-grade stenosis and calcification at the origin
of the left subclavian artery, without evidence of dissection or
aneurysm. Cardiology was consulted for pre-operative clearance
and requested a nuclear perfusion scan given severely calcified
coronaries on the CTA. Patient was scheduled to have stress test
on ___, but was unable to have due to drinking coffee that
morning. Pharmacologic stress test was deferred pre-op given
Cardiology feeling there was low risk for MI intra-op. This was
discussed with patient and his son who agreed that they did not
want to delay surgery to have stress test. He did not have any
post-operative blood pressure issues.
#Multiple Solid Pulmonary Nodules
Patient was found to have an incidental finding of multiple
pulmonary nodules on CTA chest. Plan was made for outpatient
follow up with PCP and ongoing surveillance of nodules.
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
will follow up with the surgeon 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.
I provided an opioid prescription with a notation that it can be
filled at a lower amount. I discussed with the patient regarding
the quantity of the opioid prescribed and the option to fill the
prescription in a lesser quantity. I also discussed the risks
associated with the opioid prescribed. Prior to prescribing the
opioid, I utilized the ___ Prescription
Awareness Tool) to review the patient's previous prescriptions.
Medications on Admission:
Aspirin 325mg QD, Citalopram 40mg QD, Simvastatin 20mg QD
Discharge Medications:
1. Acetaminophen (Liquid) 325-650 mg PO Q6H:PRN Pain -
Mild/Fever
Reason for PRN duplicate override: Alternating agents for
similar severity
2. Acetaminophen-Caff-Butalbital 2 TAB PO Q4H:PRN Headache
3. Bisacodyl ___AILY:PRN Constipation - Second Line
4. Calcium Carbonate 500 mg PO QID:PRN heartburn
5. Docusate Sodium 100 mg PO BID
6. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain -
Moderate
Only take as needed.
RX *oxycodone 5 mg 2.5 mg by mouth q6hr prn Disp #*30 Tablet
Refills:*0
7. Senna 17.2 mg PO HS
8. Rosuvastatin Calcium 40 mg PO QPM
9. Citalopram 40 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Type III Dens fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid - cane.
Discharge Instructions:
Discharge Instructions
Spinal Fusion
Surgery
Your incision is closed with staples or sutures. You will need
suture/staple removal.
Do not apply any lotions or creams to the site.
Please keep your incision dry until removal of your
sutures/staples.
Please avoid swimming for two weeks after suture/staple
removal.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
You must wear your brace at all times when out of bed. You may
apply your brace sitting at the edge of the bed.
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. ___ 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.
Do NOT smoke. Smoking can affect your healing and fusion.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc
until cleared by your
neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
New weakness or changes in sensation in your arms or legs.
Followup Instructions:
___
|
10221318-DS-10 | 10,221,318 | 20,086,643 | DS | 10 | 2169-12-02 00:00:00 | 2169-12-03 17:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ibuprofen
Attending: ___.
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms ___ is a ___ year old otherwise healthy woman who had
recent hosptialization ___ for headache, d/c'd ___, who
represents with headache.
She was admitted on ___ here for three days of ___
headache with fever to Tmax 103, after lumbar puncture at ___
___ showed tube #1: WBC: 24, RBC: 137,000. LP tube #4: WBC 28,
RBC: 103,000, glucose 62, protein 128, cloudy. She was initially
treated empirically for meningitis with
vancomycin/ceftriaxone/acyclovir but these were discontinued
after cultures and HSV testing returned negative. She has no
prior history of headache.
She was discharged to home with diagnosis of headache in the
setting of viral syndrome. Headache at discharge was ___.
However, within a few hours after discharge, she reports return
of headache to ___, with associated light sensitivity and
nausea/vomiting. Headache was throbbing, involving full head. No
associated visual changes or neurologic changes. She had not
taken anything since discharge.
Initial VS in ED were, 96.3 86 165/104 16 100% RA. Received
Fioricet, reglan in the ED.
On the floor, patient patient reports headache is almost fully
resolved, now ___, with resolution of nausea and light
sensitvity.
Past Medical History:
- diabetes during pregnancy
- s/p ___
Social History:
___
Family History:
Father passed away from MI and ___. Mom with diabetes.
Physical Exam:
ADMISSION AND DISCHARGE EXAM:
VS- 98.7 137/73 97 20 96% RA
GENERAL: NAD, pleasant overweight woman
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, MMM, dentures,
supple neck, some trapezius muscle tenderness, 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: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN ___ intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
LABS:
====
___ 09:05PM BLOOD ___
___ Plt ___
___ 09:05PM BLOOD ___
___
___ 09:05PM BLOOD ___ ___
___ 09:05PM BLOOD ___
___
___ 09:05PM BLOOD ___
___ 09:05PM BLOOD ___
___
IMAGING:
========
___ CTA head & neck: 1. Unremarkable unenhanced head CT without
evidence of infarct or hemorrhage. 2. CTA head and neck
demonstrates hypoplastic right vertebral artery with a poorly
visualized V4 segment, which may relate to a combination of
hypoplasia and atherosclerotic disease. There is no aneurysm.
MICROBIOLOGY:
=============
___ Blood cultures (from previous admission) - NGTD
Brief Hospital Course:
Ms ___ is a ___ year old healthy woman who presents with
recurrent left sided heache after recent admission for fever,
headache, with bloody LP, unremarkable imaging and neg HSV PCR.
# Headache: RESOLVED at time of admission. Likely ___
headache. Patient now afebrile and AOx3 with no focal deficits
on exam, with unremakrable infectious work up and neurologic
imaging thus far, making infectious etiology or vascular event
less concerning. Neurology saw patient in ED, and ___ exam
and normal CTA, felt this was likely migraine vs ___.
Patient has no history of prior migraines. Per neruology
recommendation patient discharged on verapamil 40mg TID to
prevent further headaches, with follow up with PCP in ___.
# Tobacco Use: counseled patient on smoking cessation.
TRANSITIONAL ISSUES:
====================
- Started on verapmail 40mg TID for migraine ppx, to follow up
with PCP
- CODE: FULL
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN headache
2. Verapamil 40 mg PO Q8H
RX *verapamil 40 mg 1 tablet(s) by mouth q8hrs Disp #*42 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
# PRIMARY:
- Headache ___ puncture vs migraine)
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. You were admitted for
headache. You were seen by the neurologists and had head imaging
which was normal. You likely had a headache related to your
spinal tap. You can take tylenol as needed for headache. We
started you on verapamil as migraine propylaxis.
Followup Instructions:
___
|
10221321-DS-24 | 10,221,321 | 20,843,630 | DS | 24 | 2124-04-21 00:00:00 | 2124-04-27 10:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Prednisone
Attending: ___.
Chief Complaint:
RA flare
Major Surgical or Invasive Procedure:
Dental extraction
History of Present Illness:
___ F with h/o polyarticular RA and Sjogren's who presents with
RA flare, multiple dental abscesses, and tongue ulcers. Pt
reports this flare began a few weeks ago. She is on prednisone
10mg BID chronically and has not increased her dose with this
flare. Has not been taking her prescribed Orencia due to the
dental abscesses. She endorses total body pain everywhere and
has many swollen joints, including the MCP, PIP, and DIP joints.
She has had a rash on her arms b/l for the last several days,
which she says is typical of her RA flares. She also endorses a
14lb weight gain with worsening ___ edema over the last 10 days.
States she has multiple broken and infected teeth due to
Sjogren's which are causing irritation/ulceration of her tongue.
Has required multiple extractions in the past.
In ED pt given Augmentin, Lasix 40mg IV, methadone 20mg ,
prednisone 10mg and oxycodone 90mg
ROS: 2 weeks of lower back pain radiating down L leg, numbness
in feet b/l for ___ weeks
Past Medical History:
anxiety
fibromyalgia
anemia
Polyarticular RA
Sjogren's syndrome
Asthma
SVT
Hypothyroidism (hashimotos)
T2DM
Obesity
Social History:
___
Family History:
no RA
Physical Exam:
Vitals: T:98.5 BP:146/78 P:90 R:18 O2:98%ra
wt: 141kg
PAIN: 10
General: nad
HEENT: anicteric, mult broken and missing teeth, tongue with
mult ulcerations
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd + ventral hernia
reducible
Ext: knee high TEDs ___, pitting edema ___ to knees
Skin: rash on BLUE
Neuro: alert, follows commands
Pertinent Results:
___ 05:25PM WBC-8.4 RBC-4.00 HGB-8.8* HCT-31.0* MCV-78*
MCH-22.0* MCHC-28.4* RDW-18.6* RDWSD-51.3*
___ 05:25PM NEUTS-69.6 ___ MONOS-4.0* EOS-2.1
BASOS-0.7 IM ___ AbsNeut-5.84 AbsLymp-1.92 AbsMono-0.34
AbsEos-0.18 AbsBaso-0.06
___ 05:25PM PLT COUNT-373
___ 05:25PM GLUCOSE-141* UREA N-8 CREAT-0.5 SODIUM-139
POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-26 ANION GAP-19
___ 08:56PM URINE RBC-1 WBC-8* BACTERIA-FEW YEAST-NONE
EPI-1
___ 08:56PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-SM
___ 07:48AM BLOOD WBC-7.7 RBC-4.05 Hgb-9.3* Hct-31.7*
MCV-78* MCH-23.0* MCHC-29.3* RDW-18.9* RDWSD-53.2* Plt ___
___ 07:48AM BLOOD ALT-112* AST-122* AlkPhos-117*
TotBili-0.2
___ 07:48AM BLOOD Mg-1.9 Iron-21*
___ 07:48AM BLOOD calTIBC-511* Ferritn-28 TRF-393*
Right Knee Xray
Loosening of tibial component of total knee arthroplasty.
Brief Hospital Course:
ASSESSMENT AND PLAN: ___ w/polyarticular RA and Sjogren's who
presents with RA flare, extensive dental caries and chipped
teeth causing oral ulcers.
RA Flare: likely triggered by dental infection and inability to
take Orencia; she was maintained on home dose of prednisone and
opiates, with instructions to f/u with dermatology on discharge.
Extensive Dental Caries: Felt to be secondary to Sjogren's
syndrome and excessive dry mouth. She was seen by dental
service who advised full extraction and all teeth removed. ___
service evaluated her and took her to the OR for complete
extraction.
Pain control: Patient on very high doses of opiates which were
continued in house; arrangements for a PCA had been made after
release from PACU, but patient felt that dose of IV dilaudid was
inadequate to meet her needs, and remained on oral oxycodone,
and experienced significant pain. Discussed with patient that
if she requires further surgeries that the pain service should
be consulted while in house to help establish PCA guidelines.
She was given a limited number of oxycodone pills to take with
her ongoing regimen to help manage the increased RA pain and
oral pain as a result of her surgery
___ Edema: long standing, due to prednisone use; she took one
dose of lasix in the hospital and it caused significant leg
cramping so she refused additional doses.
DM: Treated with sliding scale insulin while hospitalized.
Anxiety, asthma, hypothyroidism: Continued home medications
Knee Pain: Patient complained of increasing right knee pain;
XRAY shows loosening of tibial component of knee arthroplasty;
discussed with orthopedics service but patient insisted on
discharge home before any evaluation could be done by them. She
walks very little (only go get to toilet) and is wheelchair
bound. She is aware of this finding and insisted on setting up
outpatient f/u on her own.
Iron deficiency Anemia: Patient does not have menstrual periods
and denies melena. She does have a history of hemorrhoidal
bleeds, however. I discussed need for outpatient f/u including
testing for celiac disease (esp given her autoimmune history)
and stool guiaiac with endoscopy and colonoscopy. She will
discuss with her outpatient providers.
Adrenal suppression: Patient has suppression of the HPA axis
given long term steroid use; she was given stress dose steroids
(Iv hydrocortisone) around the time of the surgery and she will
continue with twice her home dose of prednisone for 3 days.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Orencia (abatacept) 125 mg/mL subcutaneous 1X/WEEK
2. Albuterol Inhaler 1 PUFF IH BID:PRN wheeze
3. ALPRAZolam 1 mg PO TID:PRN anxiety
4. Amitriptyline 75-125 mg PO QHS
5. Cyanocobalamin 1000 mcg IM/SC 4X/WEEK (MO)
6. Cyclobenzaprine 10 mg PO QID:PRN muscle spasm
7. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
8. Fentanyl Patch 75 mcg/h TD Q72H
9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
10. Furosemide 40 mg PO DAILY:PRN ___ edema
11. Hydrocortisone Acetate Suppository ___ID
12. Levothyroxine Sodium 300 mcg PO DAILY
13. MetFORMIN (Glucophage) 500 mg PO BID
14. Methadone 20 mg PO TID
15. Metoprolol Succinate XL 100 mg PO QHS
16. PredniSONE 10 mg PO BID
17. Tizanidine ___ mg PO Q8H:PRN muscle spasm
18. OxycoDONE (Immediate Release) 60-90 mg PO Q4H:PRN
breakthrough pain
Discharge Disposition:
Home
Discharge Diagnosis:
1. Dental caries, s/p extraction
2. Rheumatoid Arthritis
3. Knee replacement
4. Chronic pain
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 because of severely diseased
teeth that had to be removed. Your pain level has dramatically
increased secondary to this pain. I am prescribing some extra
pills of oxycodone to help you control this pain. You should
also take a higher dose of prednisone for the next few days and
then taper as needed. I would also recommend that you take
augmentin for the next five days as well. As discussed, you
have anemia, and this is probably related to your hemorrhoidal
bleeding since you have had a normal endoscopy and colonoscopy
within the past ___ years. There is a concern that part of your
knee replacement is loose. Please followup with Dr ___ as
soon as you are able to do so.
Followup Instructions:
___
|
10221321-DS-27 | 10,221,321 | 23,085,302 | DS | 27 | 2127-10-21 00:00:00 | 2127-10-21 22:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ketamine
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with PMHx of AS ___ bicuspid AV, vulvar squamous cell
carcinoma (diagnosed ___, s/p partial right posterior radical
vulvectomy, wide local excision of left vulva, radiation
complicated by necrosis), chronic hypercarbia likely ___ obesity
hypoventilation (on home Trilogy Ventilator), polyarticular
erosive severe RA w/ significant disability on chronic steroids
complicated by ___ disease, HTN, hypothyroidism, chronic
pain, & anxiety, who presents with 3 days of dyspnea, reported
15-pound weight gain, and lower extremity
edema.
In the ED,
Ms. ___ is s ___ w/ AS ___ bicuspid AV (on TTE,
valve
area 1.3 cm^2, mean gradient 32 mmHg), vulvar squamous cell
carcinoma (diagnosed ___, s/p partial right posterior radical
vulvectomy + wide local excision of left vulva ___ +
radiation complicated by radiation necrosis), chronic
hypercarbia
likely ___ obesity hypoventilation (on home Trilogy Ventilator),
polyarticular erosive severe RA w/ significant disability on
chronic steroids complicated by ___ disease, HTN,
hypothyroidism, chronic pain, & anxiety, who presents with 3
days
of dyspnea, reported 15-pound weight gain, and lower extremity
edema.
In the ED,
- Initial Vitals:
T97.9 HR96 BP153/107 RR35 O260s% 3L NC
CT Chest: diffuse bilateral nodular. opacities, no PE
- Interventions:
___ 17:00 IH Ipratropium-Albuterol Neb
___ 17:27 IV MethylPREDNISolone Sodium Succ 80 mg
___ 17:27 PO Aspirin 324 mg
___ 17:27 IV Furosemide 80 mg
___ 19:00 IV CefTRIAXone 1 gm ___ Stopped (1h
___
___ 21:02 PO/NG OxyCODONE (Immediate Release) 30 mg
___ 21:40 IV Azithromycin 500 mg
___ 23:47 IH Ipratropium-Albuterol Neb 1
Upon arrival to the floor, she states that she has not not felt
back to her normal self since discharge. She states that over
the past week, she has in particular felt quite fatigued,
dyspneic, and has experienced in nearly 15 pound weight gain.
On admission, she weighs 235, up from 222 on discharge ___. She
states she has had no dietary indiscretion and has been taking
her diuretics, though she is not totally clear whether she is
taking her furosemide or not, as she states that she thinks that
the furosemide loses effects after couple days, at which point
she will substitute this with torsemide. Is not clear to me if
she is actually taking her diuretic. She is continued on
steroids for rheumatoid arthritis, and is not been able to lower
past 40 mg without an increase in respiratory symptoms.
Past Medical History:
PMH:
Rheumatoid arthritis
Fibromyalgia
Sjogren's disease
Hashimotos hypothyroidism
Chronic steroid use: Cushings, steroid induced DM, osteoporosis
MSK: Chronic pain syndrome, lumbar spinal stenosis and
spondylolisthesis, sciatica, DJD, compression fracture T9
(___)
Pituitary microadenoma
Polyneuropathy
Chronic strep pneumonia pulmonary colonization
Rectal prolapse
Internal hemorrhoids
Neutrophylic dermatosis
Anxiety
Chronic fatigue syndrome
PSH:
Left shoulder total replacement
Cholecystectomy
hernia repair
Extraction of all teeth
Bilateral TKR
L4-S1 microdiscectomy (___)
Social History:
___
Family History:
family history of early cardiac disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
Vitals reviewed.
GENERAL: Ill-appearing, hunched over in bed, kyphotic.
HEAD: Left eye ecchymotic, conjunctiva clear, EOMI, pupils
reactive, sclera anicteric, oral mucosa w/o lesions.
NECK: Supple, no LAD, no thyromegaly. JVP to mid-neck.
CARDIAC: Precordium is quiet, PMI displaced to left, RRR, S1 w/
harsh systolic murmur best heard @ RUSB w/ S2.
RESPIRATORY: Speaking in full sentences, coarse throughout.
ABDOMEN: Unremarkable inspection, soft, NT, +BS. No palpable
organomegaly.
EXTREMITIES: Warm, pitting edema to knees bilaterally.
DISCHARGE PHYSICAL EXAM:
======================
Temp: 98. BP: 127/79 L Lying HR: 80 RR: 18 O2 sat: 94% O2
delivery: 4L NC
GENERAL: Sitting in bed, NAD
EYES: Anicteric, pupils equally round
ENT: MMM, cushingoid appearance
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear though dec BS throughout, no wheezes, severe
kyphosis.
GI: Obese, non-distended, and NTTP.
Bowel sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: no edema noted. moves all extremities with severe chronic
degenerative changes from RA in bilateral hands/wrists.
SKIN: Chronic stasis changes
NEURO: Alert, oriented, face symmetric
Pertinent Results:
ADMISSION LABS:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
___ 05:15PM BLOOD WBC-6.3 RBC-3.78* Hgb-10.1* Hct-35.0
MCV-93 MCH-26.7 MCHC-28.9* RDW-19.7* RDWSD-64.9* Plt ___
___ 05:15PM BLOOD Neuts-91.1* Lymphs-4.1* Monos-2.4*
Eos-0.0* Baso-0.2 NRBC-1.0* Im ___ AbsNeut-5.74
AbsLymp-0.26* AbsMono-0.15* AbsEos-0.00* AbsBaso-0.01
___ 05:15PM BLOOD ___ PTT-23.2* ___
___ 05:15PM BLOOD Glucose-141* UreaN-17 Creat-0.5 Na-140
K-4.3 Cl-90* HCO3-40* AnGap-10
___ 05:15PM BLOOD proBNP-46
___ 05:15PM BLOOD cTropnT-<0.01
___ 05:15PM BLOOD Calcium-8.6 Phos-3.5 Mg-2.0 Iron-36
___ 05:15PM BLOOD calTIBC-355 Ferritn-98 TRF-273
___ 05:14PM BLOOD ___ pO2-57* pCO2-77* pH-7.36
calTCO2-45* Base XS-13
___ 05:14PM BLOOD Lactate-1.7
DISCHARGE LABS:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
MICROBIOLOGY:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
___ BLOOD CULTURE no growth
___ URINE CULTURE
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ SPUTUM CULTURE <10 PMNs and >10 epithelial cells/100X
field.
___ MRSA SCREEN negative
IMAGING:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
___ CHEST (PORTABLE AP)
Moderate pulmonary edema, worse in the interval. Patchy
opacities in the
lungs bilaterally could reflect atelectasis, though infection is
not excluded and continued follow-up imaging after diuresis is
suggested.
___ CTA CHEST
1. Extensive diffuse nodular opacities concerning for multifocal
pneumonia.
Given history of malignancy, repeat chest CT in 3 months
recommended.
2. No evidence of pulmonary embolism although the subsegmental
arteries are not well assessed.
3. Moderate coronary calcification in, notable for age.
4. Chronic appearing multiple rib, sternal, and vertebral body
fractures
without evidence of acute fracture.
5. Mild splenomegaly.
___ CT CHEST W/O CONTRAST
Traumatic improvement of the prior bilateral extensive
coalescent
centrilobular nodules is very mild diffuse ground-glass
opacities remaining now, making these findings more suggestive
of a resolving infectious process.
Multiple sputum cultures were obtained and showed only oral
flora, unable to run PJP screen
Beta Glucan Elevated
Histo Ag negative
Blasto Ag negative
Aspergillus Ag negative
Cocci pending at discharge
Brief Hospital Course:
___ with PMHX of Erosive RA on chronic steroids, vulvar squamous
cell Ca s/p resection and XRT c/b radiation necrosis, Moderate
Aortic Stenosis ___ bicuspid valve, chronic hypercarbia likely
___ obesity hypoventilation (home trilogy), HTN, hypothyroidism,
chronic pain on high dose opiates, and anxiety who was admitted
with hypoxic and hypercarbic resp failure likely secondary to
acute on chronic CHF with atypical PNA.
# Acute hypoxemic hypercarbic respiratory failure
# Multifocal pneumonia
# Acute on chronic Diastolic CHF
# PJP, presumed
The patient has chronic hypercarbia ___ body habitus requiring
nocturnal Trilogy and presented with acute worsening of her
respiratory status thought to be secondary to PNA and Acute on
Chronic diastolic CHF exacerbation. She required HFNC and BiPAP
initially while in the ICU to maintain sat >90%. CXR showed
pulmonary edema and bilateral patchy opacities. Given high O2
requirement and cancer hx, CTA was performed and showed
extensive diffuse nodular opacities concerning for multifocal
pneumonia, without PE. Clean sputum culture was not able to be
obtained. Pt was diuresed and treated with an empiric course of
Abx for HAP. Pt was started on empiric treatment for PJP PNA
given elevated LDH and beta gluten though confirmatory sputum
was unable to be obtained. Pt underwent a repeat CT that showed
dramatic improvement in opacities suggestive of resolving
infectious process. Pulmonary was consulted after transition to
medicine as pt was not tolerating high dose Bactrim well.
Bronchoscopy was felt to be high risk and decision was made to
complete the course of treatment for possible PJP with
Atovaquone 750mg BID x 21 days. Pt was still requiring ___ NC
at rest despite dramatic improvement in exam and imaging.
Suspect that pt has some degree of baseline hypoxia as she was
diuresed below her prior dry weight. Pt was discharged home
with continuous O2 and plan for pulmonary follow up for repeat
imaging, oxygen requirement reassessment and f/u PFTs. Pt was
given instructions to resume Bactrim ppx dosing once the 21 day
course of therapy for PJP is complete.
# Acute on chronic diastolic heart failure exacerbation
Patient initially presented with edema and weight gain, with
pulmonary edema on imaging. Pt was aggressively diuresed down
to a new dry weight of 206lb with normal creatinine. Pt was
transitioned back to torsemide 40mg daily to maintain euvolemia.
# Normocytic anemia
Chronic, remained at baseline Hb (~10). Iron studies were sent,
normal iron and ferritin but slightly low Tsat suggestive of
possible iron deficiency anemia.
# Chronic pain with high dose opiate requirements and high risk
home regimen. Pt was continued on methadone 20mg BID and 10mg
ohs with oxycodone 90mg q4hr prn with gabapentin, and APAP. She
did not require ANY dilaudid throughout the admission and admits
to not using it at home despite having recently filled a
prescription for 720 pills of dilaudid. Pt was strongly
encouraged to dispose of the dilaudid and use only the regimen
prescribed by her PCP with goal to wean down in the future. Pt
was given a prescription for narcan at the time of discharge.
# Vulvar squamous cell carcinoma - Initial concern for
metastatic lesions to lung, but repeat Chest CT much improved,
suspect lung findings are infectious/edema. Repeat chest CT in
6 wks and outpt follow up with Rad/Onc.
# Hypertension
Continued amlodipine 10mg daily.
# Rheumatoid arthritis:
Severe erosive seropositive RA, followed by ___. Continued on
chronic prednisone of 40mg daily.
# Hypothyroidism:
Continued home levothyroxine.
# Anxiety
Continued home alprazolam BID PRN
TRANSITIONAL ISSUES:
==================================================
[ ] iron deficiency anemia, recommend followup with PCP
[ ] high dose opiate regimen, providers have agreed to defer all
pain regimen prescriptions to PCP ___. Pt was NOT given
any prescriptions for opiates at discharge
[ ] Pulm follow up for repeat imaging, PFTs and assess
hypoxemia.
> 30min spent on clinical care on the day of discharge including
time spent on patient education, coordination of followup and
transition of care.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Naloxone Nasal Spray 4 mg IH ONCE as needed for opiate
overdose
2. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
3. Alendronate Sodium 70 mg PO QSAT
4. ALPRAZolam 1 mg PO QHS
5. amLODIPine 10 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. Furosemide 80 mg PO DAILY
8. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN BREAKTHROUGH PAIN
9. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN wheezing
10. Levothyroxine Sodium 250 mcg PO DAILY
11. lidocaine HCl 3 % topical Q1H:PRN
12. Methadone 20 mg PO BID
13. Methadone 10 mg PO QHS
14. Metoprolol Succinate XL 100 mg PO QHS
15. Omeprazole 40 mg PO BID
16. OxyCODONE (Immediate Release) 90 mg PO Q4H:PRN Pain -
Moderate
17. Polyethylene Glycol 17 g PO DAILY:PRN constipation
18. PredniSONE 40 mg PO DAILY
19. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
20. Vitamin D ___ UNIT PO 1X/WEEK (SA)
21. Gabapentin 900 mg PO TID
22. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
23. Naproxen 500 mg PO Q12H:PRN Pain - Moderate
24. Cyclobenzaprine 10 mg PO TID:PRN muscle cramps with diuresis
Discharge Medications:
1. Atovaquone Suspension 750 mg PO BID
Last day of therapy is ___
RX *atovaquone 750 mg/5 mL 750 mg by mouth twice a day Disp #*28
Milliliter Refills:*0
2. Torsemide 40 mg PO DAILY
3. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
5. Alendronate Sodium 70 mg PO QSAT
6. ALPRAZolam 1 mg PO QHS
7. amLODIPine 10 mg PO DAILY
8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
9. Gabapentin 900 mg PO TID
10. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN wheezing
11. Levothyroxine Sodium 250 mcg PO DAILY
12. Methadone 20 mg PO BID
13. Methadone 10 mg PO QHS
14. Metoprolol Succinate XL 100 mg PO QHS
15. Naloxone Nasal Spray 4 mg IH ONCE as needed for opiate
overdose
RX *naloxone [Narcan] 4 mg/actuation 1 spray intranasal as
needed Disp #*1 Spray Refills:*0
16. Naproxen 500 mg PO Q12H:PRN Pain - Moderate
17. Omeprazole 40 mg PO BID
18. OxyCODONE (Immediate Release) 90 mg PO Q4H:PRN Pain -
Moderate
19. Polyethylene Glycol 17 g PO DAILY:PRN constipation
20. PredniSONE 40 mg PO DAILY
21. Vitamin D ___ UNIT PO 1X/WEEK (SA)
22. HELD- Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
This medication was held. Do not restart Sulfameth/Trimethoprim
DS until Atovaquone course is complete. Plan to restart after
___ Oxygen
Continuous oxygen ___ NC O2
Dx: Hypoxia at rest < 88% on RA
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hypoxic and hypercarbic resp failure
Atypical Pneumonia, possible PCP
___ on chronic diastolic CHF
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed to chair or wheelchair.
Discharge Instructions:
You were admitted with weight gain, low oxygen levels and
concern for an atypical pneumonia. You have been managed with
aggressive fluid removal and should continue taking Torsemide
40mg daily to prevent re-accumulation of fluid. You have
completed treatment for bacterial pneumonia. You are still
being treated for an typical pneumonia called PCP with
___ 750mg BID. You were seen by our pulmonary
specialists and you will need to follow up with them as shown
below. You will need to continue taking the Atovaquone for 14
days to complete a ___fter the course is complete,
you should resume taking Bactrim once daily for prevention of
this infection.
We discussed your pain regimen and we strongly recommend that
you dispose of the dilaudid tabs that were recently filled as
you have not needed them at all in the hospital. We have
provided you with a new prescription for narcan given the
increased risk of overdose on your current pain regimen. We
encourage you to speak with Dr. ___ weaning down your
chronic opiate regimen (oxycodone/methadone) as you continue to
recover from this admission.
You should continue wearing ___ NC oxygen at all times until
you are seen in follow up with pulmonary at ___.
Best wishes from your team at ___
Followup Instructions:
___
|
10221321-DS-28 | 10,221,321 | 29,419,926 | DS | 28 | 2127-12-24 00:00:00 | 2127-12-25 15:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ketamine
Attending: ___.
Chief Complaint:
DOE, worsening hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with hx of aortic stenosis ___ bicuspid AV (on TTE,
valve area 1.3 cm^2, mean gradient 32 mmHg), vulvar squamous
cell
carcinoma (diagnosed ___, s/p partial right posterior radical
vulvectomy + wide local excision of left vulva ___ +
radiation complicated by radiation necrosis), chronic
hypercarbia
likely ___ obesity hypoventilation (on home Trilogy Ventilator),
polyarticular erosive severe RA w/ significant disability on
chronic steroids complicated by ___ disease, HTN,
hypothyroidism, chronic pain, and anxiety with multiple recent
hospitalizations for acute on chronic hypoxia, presenting with
recurrent hypoxia.
Pt was hospitalized at ___ ___ for acute respiratory
failure, initially to the ICU for BiPAP. She was treated for
both
COPD exacerbation as well as acute diastolic heart failure.
Discharge weight at that hospitalization was 220 lbs.
She was rehospitalized at ___ ___ again for
respiratory complaints in the setting of weight gain and ___
edema, with wt 222->235 lbs. During that hospitalization, mixed
hypoxemic/hypercarbic respiratory failure was attributed to
multifocal pneumonia and acute on chronic diastolic heart
failure. She required ICU stay for HFNC and BiPAP; CTA was
negative for PE, and did reveal pulmonary edema and diffuse
nodular opacities concerning for pneumonia. Decision was made to
treat empirically for PJP pneumonia given radiographic findings,
elevated LDH and beta glucan in the setting of chronic high dose
steroids. She did not tolerate high dose Bactrim, and decision
was made to complete course of treatment for possible PJP
infection with atovaquone 750 mg PO BID x21 days. She was
advised
to resume ppx dose Bactrim upon completion of atovaquone. She
was
discharged on ___ NC, with apparent "dramatic improvement in
exam and imaging." Aggressive diuresis resulted in new dry
weight
of 206 lbs, with stable Cr. She was transitioned to torsemide 40
mg PO daily at discharge.
She reports progressive dyspnea and hypoxia over the past week,
and presented to the ED for further evaluation.
In the ___ ED, pt was hypoxic with mild resp distress. Labs
were notable for
WBC 9.1, Hb 9.2, Plt 304
BUN 15, Cr 0.6
Lactate 2.2
VBG ___
INR 1.0
BNP 60
Imaging:
CXR - mild pulmonary edema
L shoulder xrays - no acute findings (old periprosthetic humerus
frx)
Received:
Duonebs
Bactrim DS 1 tab
Gabapentin 900 mg PO
Alprazolam 1 mg
On arrival to the floor, pt reports that, after discharge in
___, she was supposed to taper rapidly off of prednisone. She
reports that she has been continuously on prednisone for ___
years, and has never been able to taper successfully. Previously
prednisone had been for her RA; recent hospitalizations reflect
the first time she has taken prednisone for breathing. Within 1
week of her discharge, at prednisone 35 mg, her dyspnea
progressed; under guidance from her PCP, she increased dose back
to 60 mg PO daily. Around the time of increased prednisone, she
noted increased fluid retention, with progressive dyspnea. She
was able to maintain SaO2 on ___ supplemental O2, and began a
more gradual prednisone taper, and had ___ hour stretches of
tolerating RA. Prednisone got as low as 20 mg, but she noted
more
fluid retention, and switched from torsemide to lasix. She
continued prednisone taper down to 15 mg, but dyspnea and
hypoxia
progressed. She recalls that approximately ___ days ago, she
increased lasix to 160 mg PO TID prn, taking ___ and ___ daily
doses if initial doses produced inadequate diuresis. She was
taking a maximum of 160 mg PO three times daily. With this dose,
she lost 7 lbs in the week prior to presentation. Despite
diuresis, she continued to have hypoxia and edema, which
prompted
evaluation in the ___ ED. She notes that she did start taking
bactrim ppx 2 days prior to presentation, which she believes
correlated with some improvement in dyspnea. Last weight was 224
lbs. She denies chest pain, F/C, headaches, sore throat,
abdominal pain, diarrhea, constipation, dysuria, hematuria,
melena, hematochezia. She endorses cough productive of opaque
yellow sputum and rhinorrhea, which is chronic; she attributes
rhinorrhea to seasonal allergies.
ROS: 10 point review of system reviewed and negative except as
otherwise described in HPI
Past Medical History:
PMH:
Rheumatoid arthritis
Fibromyalgia
Sjogren's disease
Hashimotos hypothyroidism
Chronic steroid use: Cushings, steroid induced DM, osteoporosis
MSK: Chronic pain syndrome, lumbar spinal stenosis and
spondylolisthesis, sciatica, DJD, compression fracture T9
(___)
Pituitary microadenoma
Polyneuropathy
Chronic strep pneumonia pulmonary colonization
Rectal prolapse
Internal hemorrhoids
Neutrophylic dermatosis
Anxiety
Chronic fatigue syndrome
PSH:
Left shoulder total replacement
Cholecystectomy
hernia repair
Extraction of all teeth
Bilateral TKR
L4-S1 microdiscectomy (___)
Social History:
___
Family History:
family history of early cardiac disease
Physical Exam:
Admission Exam:
VS: 98.1 PO 165 / 114 74 20 98 5L NC
GEN: obese female sitting up in bed, intermittently interrupting
sentences, alert and interactive, comfortable, no acute
distress,
Cushingoid
HEENT: PERRL, anicteric, conjunctiva pink, oropharynx without
lesion or exudate, moist mucus membranes, ears without lesions
or
apparent trauma, facial telangectasias
LYMPH: no anterior/posterior cervical, supraclavicular
adenopathy
CARDIOVASCULAR: Regular rate and rhythm with ___ systolic murmur
at RUSB
LUNGS: diffusely diminished breath sounds, diffuse end
expiratory
wheeze, coarse breath sounds throughout L lung fields
GI: obese, soft, nontender, without rebounding or guarding,
nondistended with normal active bowel sounds, no hepatomegaly
appreciated
EXTREMITIES: 2+ bilateral ___ pitting edema, venous stasis
changes, dressing in place over LLE skin tear. Diffuse RA
changes, immobilized LUE in setting of humeral fracture
GU: no foley, site of vulvectomy with wide excision with central
necrosis, scant drainage, TTP, clean site
SKIN: chronic skin thinning, ecchymoses consistent with chronic
steroid use
NEURO: Alert and interactive, cranial nerves II-XII grossly
intact, strength and sensation grossly intact
PSYCH: normal mood and affect
DISCHARGE EXAM:
98.5 124 / 82 93 20 94 4LNC
GEN: cushingoid female in NAD, no resp distress at rest
HEENT: MMM
CV: RRR
RESP: moving air well bilaterally, minimal exp wheezes
crackles
ABD: soft, NT, ND, NABS
GU: no foley
EXTR: no residual edema in BLE (much improved)
NEURO: alert, appropriate oriented
DERM: hemorrhagic blister over distal left shin, skin tear over
proximal left skin and erythema over RLE shin.
LUE with diffuse bruising around upper arm
MSK: severe degenerative changes from RA
Pertinent Results:
___ 05:39PM BLOOD WBC-9.1 RBC-3.59* Hgb-9.2* Hct-32.3*
MCV-90 MCH-25.6* MCHC-28.5* RDW-17.0* RDWSD-55.1* Plt ___
___ 06:40AM BLOOD WBC-11.4* RBC-3.60* Hgb-9.1* Hct-31.8*
MCV-88 MCH-25.3* MCHC-28.6* RDW-15.8* RDWSD-51.1* Plt ___
___ 05:39PM BLOOD Glucose-160* UreaN-15 Creat-0.6 Na-141
K-4.6 Cl-92* HCO3-38* AnGap-11
___ 08:39AM BLOOD Glucose-100 UreaN-12 Creat-0.5 Na-138
K-3.6 Cl-90* HCO3-38* AnGap-10
___ 06:40AM BLOOD Glucose-97 UreaN-14 Creat-0.5 Na-140
K-3.4* Cl-89* HCO3-40* AnGap-11
___ 05:39PM BLOOD ALT-15 AST-11 AlkPhos-125* TotBili-<0.2
___ 05:39PM BLOOD Lipase-12
___ 05:39PM BLOOD cTropnT-<0.01
___ 05:50PM BLOOD ___ pO2-42* pCO2-72* pH-7.37
calTCO2-43* Base XS-12
Left arm films:
No significant change in the right shoulder. New callus along
fracture site of the proximal left humerus, but otherwise no
significant change.
Portable CXR
Finding suggests mild pulmonary edema.
Chest CT
1. Interval increase in size and number of bilateral pleural
based nodular
opacities measuring up to 1.9 cm in the right middle lobe, which
are
concerning for metastatic disease given patient's history of
malignancy.
Recommend PET-CT for further evaluation.
2. Peribronchiolar nodular opacities in the left lower lobe are
likely
inflammatory versus infectious in etiology.
3. Mild splenomegaly.
RECOMMENDATION(S): PET-CT
Brief Hospital Course:
___ with hx of aortic stenosis ___ bicuspid AV, vulvar squamous
cell carcinoma, chronic hypercarbia with home trilogy, erosive
severe RA on chronic steroids, chronic pain on opiates, and
anxiety who p/w acute on chronic hypoxia likely ___
acute on chronic diastolic heart failure.
# Acute on chronic mixed hypercarbic & hypoxemic respiratory
failure"
# Acute on chronic diastolic heart failure:
# Obesity hypoventilation syndrome:
Pt presented with significant volume overload (weight 226lbs),
BLE pitting edema and high O2 requirements. She was
aggressively diuresis with IV Lasix and returned to dry weight
of 207lbs without any evidence of kidney injury. After pt had
reached relative dry weight and was doing much better but was
still experiencing DOE, requiring between ___ of NC O2. ___
was consulted and pt underwent a CHest CT that showed enlarged
peripheral based nodules, follow up PET was recommended. We
reached out to her Rad Onc, Gyn Onc, Rheum and Pulm teams to
ensure everyone was aware of the findings. It remains unclear
if these are rheumatoid nodules or if they are due to metastatic
spread of vulvar malignancy. Dr ___ has ordered a PET scan
that pt will have completed in the next ___ weeks. ___ has
recommended additional work up including PFTs, repeat TTE with
bubble and sleep study to better understand her ongoing O2
requirements as well as optimize her trilogy. Her ___ was
discontinued as it was felt to be unnecessary and ___ had
suggested ongoing diuresis but pt was really eager to return
home. She will continue Lasix 80mg BID with plan to take
Metolazone for ___ of weight gain. She is already taking
potassium repletion at home that corresponds with her Lasix
regimen and agrees to notify her PCP if she is taking metolazone
as she will need close follow up of her labs. Pt was discharged
with plan for close PCP and pulm follow up for additional work
up and will be getting PET scheduled in the next ___ weeks for
follow up of these nodules.
# Rheumatoid arthritis: Severe erosive seropositive RA, followed
by Dr. ___. Pt was continued on prednisone and was
started on a slow wean to be continued as an outpt. Pt was
taking Prednisone 50mg daily with TMP-SMZ ppx, PPI and Vit D.
# Hypothyroidism: continued home levothyroxine
# Acute on chronic pain: Pt has chronic pain managed by a high
dose opiate regimen prescribed by her PCP. No changes made in
house, pt was continued on methadone TID (20mg/20mg/10mg) and
oxycodone 90 mg PO Q4H PRN with additional breakthrough once
daily. NSAIDs were held during diuresis and pt was treated with
Tylenol ATC.
# Hypertension: amlodipine 10mg daily
# Anxiety: continued home alprazolam QID PRN
# Vulvar squamous cell carcinoma: Pt was continued on her pain
regimen, no acute changes were made
Transition Issues:
- PET scan for better evaluate pulm nodules, ordered by Dr. ___
(___)
- Pulm follow up for PFTs, sleep study and TTE with bubble
- PCP follow up with repeat BMP next week and weight check
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
2. ALPRAZolam 1 mg PO QID:PRN anxiety
3. amLODIPine 10 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. Gabapentin 900 mg PO TID
6. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN wheezing
7. Levothyroxine Sodium 250 mcg PO DAILY
8. Methadone 20 mg PO BID
9. Methadone 10 mg PO QHS
10. Metoprolol Succinate XL 100 mg PO QHS
11. Omeprazole 40 mg PO DAILY
12. OxyCODONE (Immediate Release) 90-150 mg PO Q4H:PRN Pain -
Severe
13. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
14. Alendronate Sodium 70 mg PO QWED
15. Naloxone Nasal Spray 4 mg IH ONCE as needed for opiate
overdose
16. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
17. Polyethylene Glycol 17 g PO DAILY:PRN constipation
18. PredniSONE 60 mg PO DAILY
19. Vitamin D ___ UNIT PO 1X/WEEK (WE)
20. Naproxen 220 mg PO BID:PRN Pain - Moderate
21. Furosemide 160 mg PO TID:PRN fluid retention
Discharge Medications:
1. MetOLazone 5 mg PO DAILY:PRN weight gain > ___
Please notify ___ MD if you are taking, will need f/u labs.
RX *metolazone 5 mg one tablet(s) by mouth daily as needed Disp
#*20 Tablet Refills:*0
2. Furosemide 80 mg PO BID
3. PredniSONE 50 mg PO DAILY
4. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
6. Alendronate Sodium 70 mg PO QWED
7. ALPRAZolam 1 mg PO QID:PRN anxiety
8. amLODIPine 10 mg PO DAILY
9. Gabapentin 900 mg PO TID
10. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN wheezing
11. Levothyroxine Sodium 250 mcg PO DAILY
12. Methadone 20 mg PO BID
Consider prescribing naloxone at discharge
13. Methadone 10 mg PO QHS
Consider prescribing naloxone at discharge
14. Metoprolol Succinate XL 100 mg PO QHS
15. Naloxone Nasal Spray 4 mg IH ONCE as needed for opiate
overdose
16. Omeprazole 40 mg PO DAILY
17. OxyCODONE (Immediate Release) 90-150 mg PO Q4H:PRN Pain -
Severe
18. Polyethylene Glycol 17 g PO DAILY:PRN constipation
19. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
20. Vitamin D ___ UNIT PO 1X/WEEK (WE)
21. HELD- Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
This medication was held. Do not restart Fluticasone-Salmeterol
Diskus (500/50) until you are seen by pulmonary
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on chronic hypoxic and hypercarbic resp failure
Acute on chronic diastolic CHF
Enlarging pulm nodules, unclear if due to RA or spread of
malignancy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(wheelchair).
Discharge Instructions:
You were admitted with worsening shortness of breath and found
to have acute on chronic hypoxia. You have been treated with
aggressive diuresis and are back to your dry weight of 207lbs.
You underwent a Chest CT that was notable for multiple pleural
based nodules that appears more prominent than the last chest
CT. As we discussed, it is important for you to get the follow
up PET scan to help guide next steps. We have not made any
changes to your Lasix regimen but have provided a prescription
for Metolazone 5mg to be taken with Lasix if your weight
increases by ___. Please notify Dr. ___ you are taking
Metolazone because it can really deplete your potassium stores.
You will need to get follow up labs to monitor renal function if
you are taking this medication. Please keep all the follow up
appointments as scheduled below. It is important that you
continue to weigh yourself every morning, call MD if weight goes
up more than 3 lbs.
Best wishes from your team at ___
Followup Instructions:
___
|
10221634-DS-4 | 10,221,634 | 27,654,198 | DS | 4 | 2164-02-14 00:00:00 | 2164-02-14 15:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Generalized Clonic Seizure
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
Mr. ___ arrived as "EU CRITICAL, ___ is a ___
year old right handed male with history of Class I Meningioma
complicated by a generalized clonic seizure ___ status post
resection, and C5-C7 Laminectomy status post fusion in ___MS from work as a ___ where he
was witnessed to have a generalized clonic seizure complicated
by impact
to the left forehead status post intubation. Per EMS record and
family report (who was informed of events by police), the
patient was in normal state of health until he suddenly fell to
the ground and began to have convulsions throughout his body.
The duration of this is unknown, and per EMS, the patient was
unresponsive after the event. Intubation was attempted in
transport but was unable to be achieved. Upon arrival at ___,
the patient was successfully intubated upon ABG findings of
severe acidosis (pH 7.1, HCO3 - 9). Of note, the patient had an
almost exactly similar event in ___ at the same place at
work at which time his meningioma was identified. Non-contrast
Head CT imaging demonstrated no acute process, identifying the
left frontal cortex status post resection. In the ED the
patient was loaded with Keppra, started on continuous
EEG monitoring, and admitted to Neurology.
The patient was transferred from the ED after stabilization to
the NICU for further management, where repeat ABG showed
resolution of his acidosis. Of note, his responsiveness
significantly improved and after EEG evaluation revealed no
epileptiform activity, the patient was successfully extubated.
Past Medical History:
- Grade I Meningioma found in ___ after patient's only other
generalized clonic seizure, s/p resection (by ___ at ___ -
was d/c'ed on Keppra for 6 months and then was tapered off.
- C5-C7 Laminectomy for b/l arm pain and weakness in ___ at
___.
- Hernia repairs x 3
- Gout, no recent flares
Social History:
___
Family History:
His mother died at age ___ from diabetes. His
father died at age ___ from accidental drowning. He has 2
sisters
and 3 brothers; a sister and another brother have diabetes. He
has a son and a daughter and they are both healthy.
Physical Exam:
Examination upon extubation in NICU:
Vitals: 97.8F, 88, ___, 131/96-170/82, 100% RA
General: Awake, cooperative, sleepy.
HEENT: Bruises over left anterolateral aspect of forehead
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to person, place, and time.
Able
to relate history without difficulty. Attentive, language is
fluent with intact repetition and comprehension. Normal
prosody.
There were no paraphasic errors. Pt. was able to name both high
and low frequency objects. Able to read without difficulty.
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 without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted. Motor limited by pain
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 4+ ___ ___ 5 4 4 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 1 1 2 1
R 2 1 1 2 1
Plantar response was equivocal bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Did not ambulate as on seizure/fall precaution
DISCHARGE PHYSICAL EXAM:
Healing laceration on L forhead. Shoulder pain improved, full
ROM, strength full, no point tenderness over shoulder joint or
rotator cuff muscules.
Neuro: CN II-XII wnl, strength ___, reflexes ___, sensation
intact to cold and vibration
Pertinent Results:
___ 04:49AM BLOOD WBC-5.7# RBC-4.29* Hgb-12.9*# Hct-38.6*#
MCV-90# MCH-30.1 MCHC-33.4 RDW-13.7 Plt ___
___ 10:10AM BLOOD WBC-12.9* RBC-5.55 Hgb-16.8 Hct-54.5*
MCV-98 MCH-30.3 MCHC-30.9* RDW-13.5 Plt ___
___ 04:49AM BLOOD Glucose-102* UreaN-10 Creat-0.9 Na-141
K-3.6 Cl-111* HCO3-24 AnGap-10
___ 10:10AM BLOOD Glucose-222* UreaN-18 Creat-1.3* Na-145
K-4.5 Cl-101 HCO3-9* AnGap-40*
___ 04:49AM BLOOD Calcium-7.4* Phos-2.8 Mg-2.1
___ 10:10AM BLOOD Albumin-5.3*
___ 02:38PM BLOOD Type-ART pO2-231* pCO2-41 pH-7.33*
calTCO2-23 Base XS--4
___ 11:04AM BLOOD Lactate-7.4*
___ 02:38PM BLOOD Lactate-1.9
___ 10:___-SPINE W/O CONTRAST
IMPRESSION: No evidence of fracture or alignment abnormality.
___ 10:15 AM
CT HEAD W/O CONTRAST
IMPRESSION:
1) No acute intracranial process.
2) Status post meningioma removal with resultant encelophmalacia
in the left Preliminary Reportfrontal region.
___ 10:___HEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST
IMPRESSION: No evidence of acute intra-abdominal or
intra-thoracic traumatic process.
___ 10:24 AM
CT SINUS/MANDIBLE/MAXILLOFACIA
IMPRESSION: No evidence of fracture. Opacification of the
para-nasal sinuses, consistent with recent intubation.
___ 11:06 AM
KNEE (AP, LAT & OBLIQUE) LEFT
IMPRESSION: No evidence of fracture or dislocation.
CT L shoulder: No fracture of the humeral head or glenoid.
Brief Hospital Course:
Neuro:
The patient presents via EMS from work as a ___
where he was witnessed to have a generalized clonic seizure c/b
impact to the left forehead s/p intubation. The duration was
unknown, and the patient was unresponsive after the event.
Intubation was attempted in transport but was unable to be
achieved. Upon arrival at ___, the patient was successfully
intubated upon ABG findings of severe acidosis (pH 7.1, HCO3 -
9). Of note, the patient had an almost exactly similar event in
___ at the same place at work at which time his meningioma
was identified. ___ demonstrated no acute process,
identifying the left frontal cortex s/p resection. In the ED
the patient was loaded with Keppra, started on continuous EEG
monitoring, and admitted to Neurology.
The patient was transferred from the ED after stabilization to
the NICU for further management, where repeat ABG showed
resolution of his acidosis. Of note, his responsiveness
significantly improved and after EEG evaluation revealed no
epileptiform activity, the patient was successfully extubated.
On examination after extubation the patient had no focal
deficits, although his exam was complicated by pain in the left
shoulder and thigh where he impacted upon falling after the
onset of his seizure. He also complained of swelling on the
left eye which made his lid feel heavier, although no visual
deficit was noted.
On the morning after admission, the patient reported feeling
better and was looking forward to eating. He again noted no
deficits, and the exam was unchanged from the previous night.
Per the EEG fellow, the study of Mr. ___ continuous
monitoring revealed no epileptiform activity. He was loaded on
Keppra with 1800 mg IV, and was continued on Keppra 1000 mg BID
(to be continued indefinently after discharge). The patient had
some injuries with his fall and GTC. A L shoulder fracture was
suspected and ortho was called, but CT L shoulder showed no
evidence of fracture. The patient was discharged on Keppra with
follow up with his neuro oncologist. He was re-educated about
seizure precautions including no driving x 6 months after a
seizure, no climbing ladders, no swimming or baths, no operating
standing machinery. He was educated to limit alcohol intake to a
maximum of 2 drinks per day and avoid flashing lights to avoid
other seizure triggers.
Cardiopulmonary:
The patient was slightly tachycardic on admission which resolved
into the evening, and his blood pressure was allowed to
autoregulate.
Renal:
Initial ABG / Metabolic panel results showed a severe acidosis
likely secondary to lactate buildup s/p the ictal event. Upon
arrival to the NICU, an ABG was obtained which shows significant
resolution of his metabolic acidosis. Renal function otherwise
was not compromised as evidenced by the metabolic panel.
GI:
The patient was prophylaxed against reflux with an H2 Blocker.
Prophylaxis:
Over his ICU course, the patient was maintained on SC heparin
and pneumoboots
for DVT prophylaxis.
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. Smoking cessation counseling given? () Yes - (x) No (Reason
(x) non-smoker - () unable to participate)
Transitional Issues:
--Follow up with neuro oncologist
--Continue Keppra indefinently
Medications on Admission:
No Outpatient medications.
Discharge Medications:
1. Keppra 1000mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
- Generalized Tonic Clonic Seizure
- New onset focal epilepsy, left frontal (partial epilepsy with
impairment of consciousness.
- Respiratory compromise requiring ventilatory support
- History of benign brain tumor, meningioma, left frontal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___. You were admitted to the hospital after having a
seizure at work. You were initially intubated, but extubated
soon and you remained stable. You were started back on your
previous dose of Keppra (1000 mg twice a day), to be continued
indefinently to prevent future seizures.
It is improtant that you do not drive after a seizure for 6
months. Stay away from any activity that could be dangerous if
you were to have another seizure, including climbing on ladders,
heights, swimming, bathing in a bathtub, mowing the lawn or
operating other heavy machinery. Limit alcoholic drinks to a
maximum of two per day, and avoid any flashing lights/strobe
lights as these may precipitate seizures.
It is important that you continue to take all your medications
as prescribed and keep your follow up appointmens.
Followup Instructions:
___
|
10221634-DS-5 | 10,221,634 | 25,519,779 | DS | 5 | 2164-11-17 00:00:00 | 2164-11-17 18:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
Mr. ___ is a ___ right-handed man with a history
of meningioma s/p resection in ___ and resultant
seizure disorder who presents after a generalized tonic clonic
seizure at work this morning. EMS was called, and he reportedly
had an additional seizure en route to the ED. Details/duration
of these events are currently somewhat unclear. Upon arrival to
___ he was initially minimally responsive but moving all
extremities
spontaneously. He subsequently had another seizure and was
intubated for airway protection. He was loaded with 1g
fosphenytoin IV and started on propofol for sedation.
.
His current antiepileptic regimen includes levetiracetam 1500mg
BID and lamotrigine 150mg BID. His family deny any missed doses.
He was last seen in neurology clinic on ___, at which point he
was doing well and had a normal neurologic exam. His last
seizure was on ___. His most recent levels from ___
include Keppra 22.6 and Lamictal 5.6. His Keppra was increased
from 1000mg BID to ___ BID at this time. Repeat levels were
planned to be
drawn at his next visit in ___. He is also scheduled to have a
repeat MRI in ___.
.
Per prior records, he was started on Keppra at the time of his
first seizure in ___. He was continued on this for 6
months post-operatively until ___, at which point he
elected to discontinue it as he did not like the way it made him
feel. He did well until ___, at which point he presented
with two generalized tonic clonic seizures and was intubated and
admitted to the neuro ICU. He was restarted on keppra 1000mg BID
during this admission. He subsequently saw Dr. ___ in follow up
in ___, at which point he continued to complain of severe
fatigue on Keppra. He therefore began a transition to Lamictal,
but during this again developed breakthrough seizures. His
Keppra
was increased back to 1000mg BID and he was also continued on
Lamictal 150mg BID.
.
ROS currently unable to be obtained from patient, but per family
he has had no recent illnesses, fever/chills, or infectious
symptoms at home. He has been complaining of headaches, but
these seem to have been an ongoing issue since his meningioma
resection.
Past Medical History:
1. L frontal grade I meningioma - diagnosed ___ when he
presented with a generalized tonic-clonic seizure. S/p resection
by Dr. ___ ___. Has been subsequently followed by Dr.
___ in ___ clinic.
2. Seizure disorder as above
3. C5-7 laminectomy and fusion at ___ in ___
4. Hernia repairs
5. Gout
Social History:
___
Family History:
(per OMR): His mother died at age ___ from diabetes. His father
died at age ___ from accidental drowning. He has 2 sisters and 3
brothers; a sister and another brother have diabetes. He has a
son and a daughter and they are both healthy.
Physical Exam:
========================
ADMISSION PHYSICAL EXAM:
========================
Vitals: 98.4 79 136/83 30 100%
General: Intubated and sedated, intermittent spontaneous
movements of all extremities but no evidence of continued
seizure activity
HEENT: dried blood over face, no scleral icterus noted, MMM
Neck: in hard cervical collar
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: Intubated and sedated on propofol. No response
to voice, moves all extremities to stimulation.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1mm and brisk. No blink to threat. Fundi unable
to be visualized.
III, IV, VI: Gaze midline and conjugate. Unable to perform
oculocephalics due to hard C collar.
V: Weak corneals present b/l
VII: Face appears symmetric with ETT
VIII: Unable to assess
IX, X: +Gag
XI: Unable to assess
XII: Unable to assess
-Motor: Normal bulk, slightly decreased tone throughout. Moving
all extremities spontaneously but not purposefully. Withdraws
briskly to noxious stimulation throughout.
-Sensory: Withdraws to noxious stimulation throughout
-DTRs: ___ throughout. Plantar response was extensor
bilaterally.
-Coordination/gait: Unable to assess
Pertinent Results:
ADMISSION LABS:
- WBC-10.9 RBC-5.51 Hgb-16.4 Hct-53.7* MCV-97 MCH-29.8
MCHC-30.6* RDW-12.9 Plt ___
- ___ PTT-27.7 ___
- ___
- UreaN-18 Creat-1.3* Glucose-211* Lactate-17.2* Na-146* K-3.9
Cl-105 calHCO3-11*
- ALT-24 AST-19 AlkPhos-79 TotBili-0.4 Lipase-90* Albumin-5.5*
- CK-MB-2 cTropnT-<0.01
- Phenyto-<0.6*
- ABG: pO2-172* pCO2-51* pH-6.96* calTCO2-12* Base XS--21
- Serum tox: ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
- UTox: bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG
amphetm-NEG mthdone-NEG
- UA: Color-Yellow Appear-Hazy Sp ___ Blood-MOD
Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG
Urobiln-NEG pH-5.0 Leuks-NEG
RBC-15* WBC-1 Bacteri-NONE Yeast-NONE Epi-<1 CastHy-1*
Mucous-RARE
DISCHARGE LABS:
- WBC-5.1 RBC-4.33* Hgb-13.1* Hct-38.6* MCV-89 MCH-30.2
MCHC-33.9 RDW-13.7 Plt ___
- ___ PTT-30.2 ___
- Glucose-107* UreaN-9 Creat-0.9 Na-142 K-3.9 Cl-107 HCO3-27
AnGap-12
- Calcium-8.3* Phos-2.4* Mg-2.0
- Phenyto-15.4
EEG (___): This is an abnormal continuous EEG recording due
to fronto-central predominant mixed theta and alpha with
superimposed beta bacground acitivity, which is indicative of
encephalopathy likely associated with sedative medication. There
are no clear epileptiform discharges or seizures recorded. There
is a left sided breach rhythm and left frontal-central slowing,
probably related to previous surgery
___ (___):
1. No evidence of acute hemorrhage or infarction.
2. Status post left frontal lobe lesion resection with residual
hypodensity compatible with post-operative changes.
CT C-SPINE WO CONTRAST (___): No acute fracture or
subluxation. Status post C5 through C7 anterior fusion without
evidence of hardware complications. Mild degenerative changes
throughout the cervical spine.
AP UPRIGHT CXR (___):
1. ET tube at the level of the lower medial clavicles, slightly
high.
Clinical correlation requested.
2. Bibasilar opacities.
3. Unusual opacity overlying left medial scapula, possibly
artifact versus nonaggressive lucent lesion. Consider further
evaluation with dedicated shoulder radiographs.
Brief Hospital Course:
Mr. ___ is a ___ RH M with h/o grade I meningioma s/p
resection (___) and resultant seizure disorder who p/w GTC
at work and two more seizures en route to ED. In the ED he was
intubated, loaded with 1g fosphenytoin, and started on propfol
for sedation. He has been maintained on Keppra and Lamictal and
had been
seizure free since ___.
# NEURO: Patient was admitted to the Neuro ICU for monitoring
after intubation in the ED. Continuous EEG showed encephalopathy
and breach artifact but no seizures. Toxic-metabolic and
infectious workup for etiology of his breakthrough seizures were
unremarkable. ___ showed post-operative changes, no hemorrhage
or new lesions. For treatment of his seizures, he was loaded
with PHT 1g IV in ED (per above), then standing therapy with PHT
1g TID after this, goal level ___. Home Keppra and Lamictal
were continued. Patient was extubated without complication on HD
#2 and transferred to the floor. After another 24 hours of
observation on EEG, he was discharged home. Keppra and Lamictal
levels from ___ are pending on discharge. He will need
phenytoin + Lamictal levels rechecked on ___ and faxed to
his neurologist Dr. ___. ___ consider tapering back to 2 AED
regimen as outpatient if he remains seizure free.
====================
TRANSITIONS OF CARE:
- Studies pending on discharge: Keppra + Lamotrigine levels from
___
- Needs phenytoin + lamotrigine levels checked on ___ and
faxed to Dr. ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LeVETiracetam 1500 mg PO BID
2. LaMOTrigine 150 mg PO BID
3. Thiamine Dose is Unknown PO DAILY
Discharge Medications:
1. LaMOTrigine 150 mg PO BID
2. LeVETiracetam 1500 mg PO BID
3. Thiamine 100 mg PO DAILY
Home dose is unknown.
4. Phenytoin Sodium Extended 100 mg PO TID
RX *phenytoin sodium extended [Dilantin Extended] 100 mg 1
capsule(s) by mouth three times a day Disp #*90 Capsule
Refills:*3
5. Outpatient Lab Work
Please check phenytoin (Dilantin) and lamotrigine (Lamictal)
levels on morning of ___ (BEFORE patient has taken AM
doses of these medications) and fax results to ___ MD ___
___.
Discharge Disposition:
Home
Discharge Diagnosis:
ACUTE ISSUES:
1. Breakthrough partial complex seizure with secondary
generalization
CHRONIC ISSUES:
1. Localization-related epilepsy ___ meningioma resection)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neuro exam = nonfocal.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital after having a generalized
tonic-clonic seizure at home. You were intubated for airway
protection and extubated the following day. A new seizure
medication (phenytoin, or Dilantin) was started for seizure
prevention. Your outpatient neurologist (Dr. ___ may decide to
stop one of your seizure medications in the future if
appropriate.
.
Please call Dr. ___ (telephone ___ to
schedule a follow-up appointment within the next TWO WEEKS.
.
You will need to have your labs (phenytoin and lamictal blood
levels) checked this coming ___. Please come to
the lab FIRST THING in the morning and have the blood test
BEFORE you take your morning doses of medications. Results will
be faxed to Dr. ___.
.
We made the following changes to your medications:
1. STARTED phenytoin sodium extended 100mg by mouth three times
daily
Please CONTINUE taking your other medications (including Keppra
and Lamictal) as you were prior to hospitalization.
Followup Instructions:
___
|
10221634-DS-6 | 10,221,634 | 28,007,793 | DS | 6 | 2166-01-19 00:00:00 | 2166-01-27 21:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year-old right-handed man history
of
a left frontal Grade I meningioma s/p resection in ___
and resultant seizure disorder with frequent breakthrough
seizures presents with a witnessed breakthrough GTC.
The patient went to bed last night around 10PM and woke up
around
5AM to take his AM medications as he usually does (lamictal
200mg
and keppra 1500mg). At 9AM he called his wife and seemed to be
in his normal state of health. He went back to bed and slept in
until about 1PM, at which time he woke up and went to the
bathroom to take a shower and then take his scheduled TID keppra
dose. His seizure actually occurred as he had his medications
in
hand. His son who lives with him was in the other room and
heard
a loud prolonged groan followed by a thud. He found his father
unresponsive on the ground in the bathroom with his head wedged
near the door. Over the course of the next ___ minutes he had
upper extremity stiffening followed by convulsions associated
with urinary incontinence. His son who is an EMT witnessed the
entire event and positioned him on his side. The patient did
vomit and the son suspects he may have aspirated.
Mr. ___ remained post-ictal on EMS arrival but
convulsions
had stopped. He had a normal fingerstick in the field. He
gradually returned to baseline mental status over the course of
___ minutes en route to ___. On arrival he was
intermittently
desatting to 70's on room air and was triggered for hypoxia
around 1400. During that trigger event, he was noted to have
twitching in the RUE>RLE lasting about 1 minute. He was given
2mg ativan and convulsions subsided. Hypoxia initially improved
with NRB, transitioned to 2L NC with stable O2 sats >95%.
Lungs,
however, sounded roncherous and there was concern for aspiration
on CXR. Labs showed normal CBC and chemistry, but lactate was 5.
There was not a clear trigger to his event. He had been feeling
well recently, and went golfing on ___ with friends. His
wife suggests that he may have been dehydrated and may have been
sleeping poorly. Of note his typical breakthrough seizure
frequency has been about once per 3 months (last in ___. He
was last admitted to ___ Neurology in ___ with a
cluster
of 3 generalized tonic clonic seizures and was intubated for
airway protection on arrival. He was loaded with fosphenytoin
but
continuous EEG only showed no seizures, and only diffuse
encephalopathy which improved in 24 hours. Toxic-metabolic and
infectious workup for etiology of his breakthrough seizures were
unremarkable. He has been follow as outpatient by Dr. ___
who have uptitrated lamictal to 200mg BID and keppra to 1500mg
TID. Vimpat 100mg BID was reportedly added (as per OMR notes
from ___, and ___, but the patient does not
have the medication with him and does not recall Vimpat as one
of
his home meds. Last documented keppra level 16.3, last lamictal
level 4.8 was in ___.
On neuro ROS today, he endorses mild headache. No loss of
vision,
blurred vision, diplopia, dysarthria, dysphagia,
lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
1. L frontal grade I meningioma - diagnosed ___ when he
presented with a generalized tonic-clonic seizure. S/p resection
by Dr. ___ ___. Has been subsequently followed by Dr.
___ in ___ clinic.
2. Seizure disorder as above
3. C5-7 laminectomy and fusion at ___ in ___
4. Hernia repairs
5. Gout
Social History:
___
Family History:
(per OMR): His mother died at age ___ from diabetes. His father
died at age ___ from accidental drowning. He has 2 sisters and 3
brothers; a sister and another brother have diabetes. He has a
son and a daughter and they are both healthy.
Physical Exam:
ADMISSION EXAM
Vitals: T:98 HR-83 BP-105/69 24 93% Nasal Cannula
General: somnolent, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs roncherous bilaterally with transmitted upper
airway sounds
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 self, ___, year, not OBAMA.
Able to relate history without difficulty. Somnolent in the
setting of ativan, but able to name ___ backward with prompting.
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors. Pt was able to
name both high and low frequency objects. Able to read without
difficulty. Speech was not dysarthric. Able to follow both
midline and appendicular commands. There was no evidence of
neglect.
-Cranial Nerves:
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No 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 3 2 3 2 1
R 3 2 3 2 1
Plantar response was flexor bilaterally.
-Coordination: Significant bilateral intention and postural
tremors, no dysdiadochokinesia noted. Slowness but no dysmetria
on FNF or HKS bilaterally.
-Gait: Patient somnolent, unable to test gait
DISCHARGE EXAM
Unchanged from admission.
Pertinent Results:
___ 03:00PM LACTATE-5.2*
___ 02:45PM GLUCOSE-164* UREA N-19 CREAT-1.2 SODIUM-144
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-24 ANION GAP-19
___ 02:45PM estGFR-Using this
___ 02:45PM ALT(SGPT)-18 AST(SGOT)-19 ALK PHOS-63 TOT
BILI-0.4
___ 02:45PM ALBUMIN-4.7
___ 02:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 02:45PM WBC-5.9 RBC-5.14 HGB-15.7 HCT-48.0 MCV-93
MCH-30.5 MCHC-32.7 RDW-12.6
___ 02:45PM NEUTS-69.7 ___ MONOS-5.2 EOS-2.0
BASOS-0.8
___ 02:45PM PLT COUNT-207
___ 02:45PM ___ PTT-27.0 ___
EEG monitoring
CONTINUOUS EEG: The background activity shows a low amplitude
symmetric 10.0
Hz alpha rhythm admixed with occasional lower voltage and faster
frequencies
anteriorly. The amplitude is slightly higher on the left frontal
leads
compared to the right.
SPIKE DETECTION PROGRAMS: There were no entries in this file.
SEIZURE DETECTION PROGRAMS: There were four automated seizure
detections for
chewing or movement/muscle artifact. There were no
electrographic seizures.
PUSHBUTTON ACTIVATIONS: There were no pushbutton activations.
SLEEP: Progressed from sleep into wakefulness.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: This continuous video EEG monitoring captured no
electrographic
seizures. Automated and routine sampling demonstrated the
presence of a
breach rhythm over the left frontal region. Faster beta activity
would be
consistent with medication effect. No epileptic activity was
identified.
Brief Hospital Course:
Mr. ___ was admitted to the neurology service after
having several witnessed breakthrough seizures.
He was monitored on continuous EEG, which showed no further
seizures. He was continued on his home AEDs initially, and his
lamictal was uptitrated (there had been an outpatient plan to
add Vimpat, however patient had not been taking this medication,
and we decided to max out his current agents instead). His
Keppra was also increased, and changed to the XR formulation
___ --> 1500 TID).
He was discharged home with a plan to continue uptitrating
Lamictal as follows:
Lamictal 225mg twice daily x 1 week
Lamictal 250mg twice daily x 1 week
Lamictal 275mg twice daily x 1 week
Lamictal 300mg twice daily ongoing
He was found to have an aspiration pneumonia as a result of his
seizure and was started on a course of augmentin for a total 7
day course.
OUTSTANDING ISSUES
[ ] Continue augmenting for 5 more days
[ ] Uptitrate Lamictal as above
[ ] New dose of Keppra as above
[ ] Has epilepsy clinic follow up scheduled.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LaMOTrigine 200 mg PO BID
2. LeVETiracetam 1500 mg PO BID
3. LeVETiracetam 1000 mg PO NOON
4. LACOSamide 100 mg PO BID
5. Sertraline 100 mg PO DAILY
6. TraZODone 50 mg PO HS
7. Lorazepam 0.5 mg PO ONCE:PRN seizure
Discharge Medications:
1. LaMOTrigine 225 mg PO BID
RX *lamotrigine [Lamictal] 200 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*0
RX *lamotrigine [Lamictal] 25 mg ___ tablet(s) by mouth twice a
day Disp #*90 Tablet Refills:*0
2. LeVETiracetam 1500 mg PO TID
RX *levetiracetam [Keppra XR] 750 mg 2 tablet(s) by mouth three
times a day Disp #*180 Tablet Refills:*0
3. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*10 Tablet Refills:*0
4. Lorazepam 0.5 mg PO ONCE:PRN seizure
5. Sertraline 100 mg PO DAILY
6. TraZODone 50 mg PO HS
Discharge Disposition:
Home
Discharge Diagnosis:
Epilepsy
Aspiration pneumonia
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 epilepsy service at ___ for
breakthrough seizures. You were found to have a resulting
aspiration pneumonia and were started on antibiotics. For your
seizures, we increased the dose of your lamictal. We plan to
continue to increase it as an outpatient, slowly, as follows:
Lamictal 225mg twice daily x 1 week
Lamictal 250mg twice daily x 1 week
Lamictal 275mg twice daily x 1 week
Lamictal 300mg twice daily ongoing
Once you reach this dose, you should continue taking Lamictal
300mg twice daily until you have follow up in epilepsy clinic as
listed below.
We also increased your Keppra to 1500mg three times per day, and
changed it to the XR formulation.
It was a pleasure taking care of you during this hospital stay.
Followup Instructions:
___
|
10221648-DS-7 | 10,221,648 | 20,191,073 | DS | 7 | 2189-10-07 00:00:00 | 2189-10-17 14:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
___ Complaint:
Nausea and vomiting.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. ___ is a ___ year old woman who presents with nausea,
vomiting and fatigue x 1 day.
___: Patient fell at home in ___ last week after she
"turned too fast". She did not lose consciousness, but was in
significant pain. According to her dauther, she has a history of
an unsteady gait. She was hospitalized at ___ in
___ and found to have superficial left facial trauma, and bruised
ribs. She reportedly had a head CT at that time that showed no
intracranial hemorrhage. She reportedly had X-rays that ruled
out rib fracture. She was diagnosed with a UTI on that admission
and started on macrobid ___ mg BID. She denied having dysuria at
that time, but endorsed urinary frequency that has since
resolved. She was discharged on ___ and her son-in-law drove
her to ___ that day.
___: She has been staying in a hotel in ___ with
her daughter. For the first few days after discharge her
daughter reports she was anxious and agitated, but cognition was
intact. She reports mild sundowning. Over the week the patient
adjusted well, became less agitated and had more energy. Patient
had occipital headache on ___ but it resolved with tylenol.
___: Patient reports that in the evening she "did not feel like
herself." She felt she was quiet, fatigued and had little
energy. Her daughter reported she seemed fine. She ate pizza
that night, and felt nauseous afterwards.
___, 0500: Patient woke up and was nauseous. She vomited
twice. Small amounts of clear liquid. Non-bloody, non-bilious.
Afterwards her daughter reported she was lethargic, and sleepy
so her daughter called EMS, who took her to the hospital.
In the ED, initial vs were T 98.9(at 16:15) HR 98 BP 127/59 RR
21 O299%. In the ED she received 4 mg zofran IV, and IVF which
resolved her nausea. Later in the ED she became hypotensive with
SBP down to ___ she was asymptomatic and had no mental status
changes. She was given a 500 cc bolus and her vitals stabilized.
She was started on levofloxacin for concern of pneumonia. She
got 2 Ls total in the ED.
Transfer VS T 98.8, HR 94, BP 97/46, RR 20, O2 Sat 97%
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
palpitations, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, dysuria, hematuria, weakness,
difficulty speaking, edema.
Past Medical History:
- Hypertension
- Hyperlipidemia
- CAD s/p CABG ___ years ago
- Basal cell carcinoma s/p MOHs procedure
- s/p cholecystectomy
- Ectopic pregnancy
- s/p hip replacement ___ years ago
- Interstitial lung disease (followed by a Pulmonologist in ___)
Social History:
___
Family History:
Father - died of stroke
Mother - died at age ___ for unknown reason
Physical Exam:
ADMISSION PHYSICAL EXAM
VS T 97.4 BP 110/63 HR 100 RR 18 O2 98% on 3L
GEN: Thin, Alert, oriented, no acute distress
HEENT: Resolving ecchymosis around left eye. MMM, post-surgical
changes in eyes bilaterally (right pupil larger than left and
oval shaped). Pupils reactive to light. EOMI with no double
vision, pain or nystagmus, sclera anicteric, OP clear
NECK: supple, flat neck veins - no JVD, lymphadenopathy on left
side of her neck, no thyromegaly, no tenderness
PULM Good aeration, fine inspiratory bibasilar crackles slightly
louder on the right, rest of lungs CTAB, no rubs, rhonchi, or
wheezes
CV: RRR, normal S1/S2, ___ systolic murmur heard best at right
upper sternal border, no rubs or gallops. Midline scar over
sternum from CABG
ABD: soft, non-tender to palpation, non-distended, normoactive
bowel sounds, no hepatomegaly or splenomegaly, no paplable
masses. Scar under right costal margin from CCY, and midline
scar under umbilicus from ectopic pregnancy
EXT: ecchymosis and scabs over shins bilaterally, venous stasis
changes. Extremities are cold to palpation.
Pulses:
R L
___ 0 0
TP 0 1+
NEURO:
Mental status:
- Alert and oriented x 3
- Attention intact, can spell WORLD backwards and forwards, and
say ___ backwards
- Recall intact: ___ words at 5 min and remembred last one with
categorical cue
- Language intact: can repeat "no ifs ands or buts about it"
- Fund of knowledge: knows ___ and defeated Republican
candidate
CNs2-12 intact. Pupils reactive to light, right pupil larger
than left and irregular shape. Post-surgical changes from
cataract surgery.
___ strength in delts, bis, tris, Fex, Fflex, IP, ham, quad, TA,
gastroc bilaterally
Sensation grossly intact throughout
SKIN: resolving ecchymosis around left eye. Venous stasis
changes, chronic bruises and scabs over shins bilaterally.
.
DISCHARGE PHYSICAL EXAM:
VS T 97.6 Tmax 98.9 BP 110/59 HR 74 RR 18 O2 95% on RA
GEN: Thin, Alert, oriented, no acute distress
HEENT: Resolving ecchymosis around left eye. MMM, post-surgical
changes in eyes bilaterally (right pupil larger than left and
oval shaped). Pupils reactive to light, sclera anicteric, OP
clear
NECK: supple, flat neck veins - no JVD, lymphadenopathy on left
side of her neck, no thyromegaly, no tenderness
PULM Good aeration, lungs CTAB, no rubs, rhonchi, crackles, or
wheezes. No evidence of increased work of breathing
CV: RRR. Normal S1, loud S2 heard louder at right upper sternal
border. ___ systolic murmur heard best at right upper sternal
border, no rubs or gallops. Midline scar over sternum.
ABD: soft, non-tender to palpation, non-distended, normoactive
bowel sounds, no hepatomegaly or splenomegaly, no paplable
masses. Scar under right costal margin from CCY, and midline
scar under umbilicus from ectopic pregnancy
EXT: ecchymosis and scabs over shins bilaterally, venous stasis
changes. Extremities are cold to palpation.
NEURO:
Mental status- alert and oriented, no confusion
Motor grossly intact
SKIN: resolving ecchymosis around left eye. Venous stasis
changes, chronic bruises and scabs over shins bilaterally.
Pertinent Results:
ADMISSION LABS
___ 11:45AM BLOOD WBC-16.1* RBC-5.05 Hgb-15.3 Hct-47.3
MCV-94 MCH-30.2 MCHC-32.2 RDW-14.7 Plt ___
___ 11:45AM BLOOD Neuts-90.3* Lymphs-5.5* Monos-2.5 Eos-1.3
Baso-0.4
___ 11:45AM BLOOD Glucose-132* UreaN-25* Creat-0.7 Na-141
K-4.3 Cl-104 HCO3-22 AnGap-19
___ 11:45AM BLOOD ALT-34 AST-57* AlkPhos-184* TotBili-0.6
___ 11:45AM BLOOD Lipase-23
___ 11:45AM BLOOD Albumin-4.1
.
OTHER PERTINENT LABS
___ 11:45AM BLOOD cTropnT-0.01
___ 07:41AM BLOOD cTropnT-0.04*
___ 01:10PM BLOOD cTropnT-0.04* proBNP-7959*
___ 04:35PM BLOOD Lactate-2.6*
___ 08:43AM BLOOD Lactate-1.2
.
DISCHARGE LABS
___ 06:20AM BLOOD WBC-9.6 RBC-4.31 Hgb-12.9 Hct-40.8 MCV-95
MCH-29.9 MCHC-31.6 RDW-14.9 Plt ___
___ 06:20AM BLOOD Glucose-82 UreaN-23* Creat-0.6 Na-141
K-4.5 Cl-106 HCO3-24 AnGap-16
___ 06:20AM BLOOD ALT-30 AST-39 AlkPhos-146* TotBili-0.3
___ 06:20AM BLOOD Calcium-8.6 Phos-2.4* Mg-1.8
.
IMAGING:
CXR ___
IMPRESSION: No acute cardiopulmonary process.
.
CT HEAD NON-CONTRAST ___
IMPRESSION:
1. No acute intracranial abnormality.
2. Age-related volume loss and chronic small vessel ischemic
disease.
.
EKG ___
Sinus rhythm. A-V nodal conduction delay. Left atrial
enlargement. Left
anterior fascicular block. Left ventricular hypertrophy with
associated
repolarization abnormalities. No previous tracing available for
comparison.
___
___
.
MICROBIOLOGY
___ Blood Culture, Routine-FINAL
___ Blood Culture, Routine-FINAL
.
URINE STUDIES
___ 12:40PM URINE Color-Yellow Appear-Clear Sp ___
___ 12:40PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 12:40PM URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-3
___ 02:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 02:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
Brief Hospital Course:
>> BRIEF HOSPITAL COURSE.
Ms. ___ is a pleasant ___ year old lady who presented with
1 day of nausea and vomiting. She was found in the emergency
department to be asymptomatically hypotensive to the ___
systolic. Upon admission the patient's nausea and vomiting
resolved, and her hemodynamics stabilized with volume
administration. She had some instances of hypoxia to 88%
saturation during ambulation during admission. However, this
resolved to mid-90s oxygen saturation by discharge (see
discussion below).
.
>> ACTIVE ISSUES:
# Nausea and vomiting
She had 2 episodes of nausea and NB-NB vomiting the morning of
admission. This resolved quickly. She tolerated food well while
admitted. Given the quick onset and short duration of her nausea
and vomiting the most likely cause was a short viral
gastroenteritis, or a mild food-borne illness. Given her age and
history of CAD, the possibility of atypical acute coronary
syndrome was considered. However, an EKG was unchanged from
previous studies and had no evidence of ischemia or infarction.
Additionally her troponins were stable and reassuring. Based on
exam and laboratory studies the patient did not have a bacterial
or inflammatory cause of her GI symptoms, and they resolved
spontaneously.
.
# Fluid-responsive Hypotension
The patient was asymptomatically hypotensive to the ___ systolic
while in the emergency department and was tachycardic. She was
given 2 liters of fluid at that time and her hemodynamics
stabilized. During the rest of her admission her blood pressure
remained stable. Her hypotension was likely d/t hypovolemia
given recent poor PO intake and vomiting. There was initial
concern for a possibility of infectious etiology, but the
patient was afebrile during her stay, had no specific symptoms
of infection, and her initial high WBC was likely due to
hemoconcentration. Blood cultures were drawn and were pending on
discharge.
.
# Hypoxia
She initially desaturated to 88% with ambulation. The patient
did not complain of SOB, and had no cough. On physical exam she
had bibasilar crackles on day one of admission that resolved
likely due to volume overload (received 2L in ED) and a history
of pulmonary hypertension and interstitial lung disease. She
likely self-diuresed during her stay which helped her hypoxia
resolve. Additionally, the patient has a history of pulmonary
hypertension and interstitial lung disease for which she is
followed by a pulmonologist in ___. She was prescribed steroid
inhalers one month ago and finds them helpful. Her PCP reported
that the level of oxygen saturation in the hospital has been her
baseline for 2 months. She was given her home inhalers during
admission. By discharge, the patient was saturating well on room
air and O2 sat was 95% with ambulation. Her home medications
should be continued and she should continue to follow up with
her PCP and pulmonologist.
.
# Urinary incontinence
The patient complains of incomplete bladder emptying, and has
had multiple episodes of urinary incontinence while in the
hospital. This is chronic and per her family has recently
started wearing adult underwear. Her symptoms are most
descriptive of overflow incontinence. Post-void residual bladder
scan had 193 ml. Differential could include detrusor
underactivity (aging, low estrogen state). Her PCP is aware of
her incontinence and following it.
.
# Fall
The patient fell 2 weeks ago and was hospitalized for a week. It
was ruled to be a mechanical fall on that admission, and not a
syncopal episode. In light of her recent hospital admission a
___ syncope work up was not warranted on this visit. The patient
and her family both report that she is unsteady on her feet. She
was evaluated by physical therapy who provided education, and
recommended a walker and home ___.
.
# Pneumonia
There was some concern of pneumonia initially, and the patient
received two doses of levofloxacin. However, the patient's chest
x-ray was clear and she had no fever, SOB, or cough making
pneumonia extremely unlikely. As such her anti-biotics were
discontinued.
.
>> INACTIVE ISSUES:
# CAD
Patient has CAD with a history of CABG ___ years ago. She denied
any chest pain but her complaint of nausea and vomiting was
potentially concerning for atypical ACS. She had an EKG which
was unchanged from previous and serial troponins were flat. She
was continued on her home dose of aspirin and metoprolol and had
no issues on this admission.
.
# Hypertension
History of hypertension treated with enalapril and metoprolol.
Enalapril was held after last hospital admission. Metoprolol was
continued on this hospital admission and she was normotensive
after rehydration.
.
# Hyperlipidemia
Stable on this admission, and patient was continued on home
statin.
.
>> TRANSITIONAL ISSUES:
- Code status: DNR/DNI.
- Emergency contact: ___ (daughter, health care
proxy) ___
- PCP is ___ ___
- Studies pending at discharge: Blood cultures x2 from ___
(of note, both are now final w/ no growth).
- Continued investigation / management of urinary incontinence
and pulmonary hypertension.
- A copy of this discharge summary was faxed to Dr. ___
at ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lidocaine 5% Patch 1 PTCH TD DAILY Back pain
2. Metoprolol Tartrate 50 mg PO BID
3. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
4. Simvastatin 20 mg PO DAILY
5. Acetaminophen 325 mg PO Q6H:PRN Pain
6. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 325 mg PO Q6H:PRN Pain
2. Aspirin 81 mg PO DAILY
3. Metoprolol Tartrate 50 mg PO BID
4. Simvastatin 20 mg PO DAILY
5. Lidocaine 5% Patch 1 PTCH TD DAILY Back pain
6. Outpatient Physical Therapy
Please dispense a rolling walker for ongoing physical therapy.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Nausea, vomiting
Pneumonia
Interstitial lung disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ because of nausea and vomiting. You
were thought to have a mild pneumonia on admission, but with
continued observation, we determined that you did not have
pneumonia. We treated you for your nausea and vomiting.
While you were here, some changes were made to your medications.
Please STOP macrobid (antibiotic), as you no longer have a UTI.
Followup Instructions:
___
|
10221767-DS-6 | 10,221,767 | 21,843,161 | DS | 6 | 2146-09-25 00:00:00 | 2146-09-25 12:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right leg pain
Major Surgical or Invasive Procedure:
Right patella ORIF
History of Present Illness:
___ s/p fall onto knee when tripped. No head injury. No LOC.
Denies other pains or injuries. Initially seen in ___? and
transferred as patient did not want to be admitted elsewhere and
wanted to be closer to home. She did not clear ___ at ER in
___. Transferred for further evaluation and potential
surgery.
Past Medical History:
Reports otherwise healthy, had gallbladder removed. No isssues
with anesthesia. No bleeding or clotting disorders.
Social History:
___
Family History:
noncontributory
Physical Exam:
AVSS
NAD, A&Ox3
RLE: Dressing clean and dry. In ___. Fires FHL, ___, TA,
GCS. SILT ___ n distributions. 1+ DP pulse, wwp
distally.
Pertinent Results:
___ 04:30AM BLOOD WBC-8.7 RBC-3.53* Hgb-11.2 Hct-32.9*
MCV-93 MCH-31.7 MCHC-34.0 RDW-12.4 RDWSD-42.5 Plt ___
___ 05:20AM BLOOD WBC-7.3 RBC-3.67* Hgb-11.4 Hct-34.1
MCV-93 MCH-31.1 MCHC-33.4 RDW-12.9 RDWSD-43.8 Plt ___
___ 12:20AM BLOOD WBC-8.9 RBC-3.40* Hgb-10.8* Hct-32.0*
MCV-94 MCH-31.8 MCHC-33.8 RDW-12.6 RDWSD-43.2 Plt ___
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right patella fracture and right tibial plateau fracture
and was admitted to the orthopedic surgery service. The patient
was taken to the operating room on ___ for right patella
ORIF, 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
touchdown weight bearing in the right lower extremity in a
___ locked in extension, 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 1000 mg PO Q8H
RX *acetaminophen 325 mg 2 capsule(s) by mouth every 6 hours
Disp #*120 Capsule Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
3. Enoxaparin Sodium 40 mg SC QPM
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 40 mg/0.4 mL 1 syringe subcutaneous daily Disp
#*28 Syringe Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*55 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right patella fracture, right minimally displaced tibial plateau
fracture
Discharge Condition:
AVSS
NAD, A&Ox3
RLE: Dressing clean and dry. In ___. Fires FHL, ___, TA,
GCS. SILT ___ n distributions. 1+ DP pulse, wwp
distally.
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:
- touchdown weight bearing right lower extremity in ___
brace locked in extension
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 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
Touchdown weight bearing right lower extremity in ___ locked
in extension
Treatments Frequency:
Dry sterile dressing changes as needed
Followup Instructions:
___
|
10221833-DS-15 | 10,221,833 | 25,958,424 | DS | 15 | 2116-11-01 00:00:00 | 2116-11-07 12:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
___ with history of metastatic alveolar soft parts sarcoma with
mets to lung (S/p resection in ___ and new diagnosed brain
mets s/p one treatment of Cyberknife who presents with headache.
Had Cyberknife on ___. Had HA afterwards which was expected.
___ and ___ HA improved. This AM had worsening headache
that would not respond to Tylenol or oxycodone. He then
presented
to the ED for evaluation where he underwent a CT scan revealing
worsening edema with 6mm shift. He was given Zofran and decadron
8mg and admitted to the floor. On arrival to the floor he
reports
that his HA is markedly better though still rates it at ___.
Denies nausea or vomiting
REVIEW OF SYSTEMS: 10 point ROS was completed and otherwise
negative.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
___ presented with a sore mass in
the left posterior buttock. Ultrasound ___ showed a 7 x
5.2
x 4.8 cm heterogeneous hypoechoic vascular solid mass. MRI
performed ___ confirmed the finding of a heterogeneous
mass, and biopsy ___ showed high-grade sarcoma consistent
with alveolar soft parts sarcoma. PET CT ___ showed the
left gluteal mass as well as multiple bilateral pulmonary
nodules; the largest measuring 15 mm which were non-FDG avid.
Mr. ___ underwent wide resection of the left buttock soft
tissue sarcoma ___ ___s left upper lobe and left
lower lobe wedge resection by VATS. Metastases were found in
___
nodules, the largest measuring 2 cm. The left buttock tumor
measured 8 cm.
CT scan ___ demonstrated three right sided pulmonary nodules,
one of which was increasing in size. PFTS (FEV1 94%/ DLCO 132%)
demonstrated adequate reserve for him to undergo further
resection. He underwent a VAST RUL wedge and RLL wedge resection
on ___. His intreoperative course went without any
complications.
He was admitted to ___ on ___ after presenting with new
headache, found to have multiple brain metastases. MRI evidence
of a 1.9 cm lesion in the right frontal
lobe, left frontal likely extra-axial 1.6 cm lesion, left
parieto-occipital 6 mm area (potentially confluence of venous
structures versus extra-axial lesion) and 3 mm left cerebellar
hemisphere enhancing lesion. He was treated with CK to all of
these areas, completing ___.
Social History:
___
Family History:
The patient's grandfather had a cancer. He does not know the
details. His mother has diabetes ___.
Physical Exam:
VS: 98/\.2 140/84 104 20 95%ra
GENERAL: NAD
HEENT: NC/AT, EOMI, PERRL, MMM
CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4
LUNG: clear to auscultation, no wheezes or rhonchi
ABD: +BS, soft, NT/ND, no rebound or guarding
EXT: No lower extremity pitting edema
PULSES: 2+DP pulses bilaterally
NEURO: ___, EOMI, face symmetric, no nystagmus, no tongue
deviation, strength ___, sensation intact to light touch, gait
steady, performs tandem gait, no dysmetria w/ FTN or HTS
testing, visual ___ full to confrontation
SKIN: Warm and dry, without rashes
Pertinent Results:
ADMISSION LABS:
___ 12:10PM BLOOD WBC-12.9*# RBC-4.97 Hgb-14.9 Hct-43.3
MCV-87 MCH-30.0 MCHC-34.4 RDW-12.8 RDWSD-39.8 Plt ___
___ 12:10PM BLOOD Neuts-80.0* Lymphs-10.3* Monos-7.7
Eos-0.1* Baso-0.2 Im ___ AbsNeut-10.36*# AbsLymp-1.33
AbsMono-0.99* AbsEos-0.01* AbsBaso-0.02
___ 12:10PM BLOOD ___ PTT-28.1 ___
___ 12:10PM BLOOD Glucose-96 UreaN-17 Creat-0.9 Na-137
K-4.1 Cl-99 HCO3-28 AnGap-14
___ 12:10PM BLOOD Calcium-9.1 Phos-4.1 Mg-2.0
IMAGING:
CT head ___
FINDINGS:
There is no intra-axial or extra-axial hemorrhage. There is a
slightly
hyperdense mass again noted abutting the right lateral ventricle
in the deep
white matter of the right posterior frontal lobe measuring
approximately 2.0 x
2.0 cm with increasing surrounding edema again noted. There is
new 6 mm
leftward shift of midline structures. There is a 13 mm
hyperdense lesion
abutting the left frontal lobe with associated mild edema not
significantly
changed. Known small left cerebellar lesion is not clearly
visualized.
Basilar cisterns remain patent. Paranasal sinuses appear well
aerated as do
the mastoid air cells and middle ear cavities. The bony
calvarium is intact.
IMPRESSION:
Intracranial metastasis with increasing edema surrounding the
right posterior
frontal lesion with new 6 mm leftward shift of midline
structures. No
hemorrhage.
Brief Hospital Course:
___ is a ___ with history of metastatic alveolar soft parts
sarcoma s/p resection of primary gluteal lesion ___ with mets
to lung (S/p resection in ___ and ___. He was found to
have new brain metastases this past month, treated with
cyberknife which completed ___. He presents with headache.
#Cerebral edema - Pt presents w/ worsening headache. CT head
showed increased edema primarily surrounding R frontal lesion.
NO intracranial hemorrhage. This is likely secondary to effects
of cyberknife. His headache resolved after 8mg IV dex in ED.
He is continued on 8mg dex PO BID and will taper over the next
___ days as instructed by neuro-oncology and radiation-oncology.
He will have f/u brain MRI as scheduled in one month. Cont GI
ppx with PPI while on steroids. He will f/u with Dr ___ in
___ clinic next week.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dexamethasone 4 mg PO Q12H
2. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Omeprazole 20 mg PO DAILY
2. Dexamethasone 8 mg PO Q12H Duration: 4 Doses
Please start with 8mg twice daily and follow the taper
instructions
3. Dexamethasone 2 mg PO DAILY
follow taper instructions
RX *dexamethasone 2 mg 1 tablet(s) by mouth daily Disp #*20
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Headache
Cerebral edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___ - ___ was a pleasure caring for you during your stay
at ___. You were admitted with headache and found to have
some increased brain swelling surrounding the right frontal
lesion following cyberknife. This is a known side effect of
radiation.
The headache improved rapidly with higher dose steroids.
You will take 8mg Dex for three days starting today, take at 8am
and 4pm.
On ___ decrease to 4 mg Dex in the morning and 4 mg Dex in
the
evening.
On ___ decrease to 4 mg Dex in the morning and 2 mg Dex in
the
evening.
on ___ decrease to 4 mg Dex in the morning only.
on ___ take 2 mg Dex in the morning only for 3 days and then
STOP.
Last dose of Dex is morning of: ___.
Continue to take 20 mg Prilosec until you are off Dex.
Followup Instructions:
___
|
10221833-DS-16 | 10,221,833 | 26,528,151 | DS | 16 | 2116-11-19 00:00:00 | 2116-11-26 12:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Dilaudid
Attending: ___.
Chief Complaint:
HEADACHE
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a very pleasant ___ year old male with history of
metastatic alveolar soft parts sarcoma, initiated in L hip with
mets to lung (S/p resection in ___ and new diagnosed brain
mets s/p one treatment of Cyberknife ___ presenting c/o
headache, nausea and vomiting. He recently completed a Decadron
taper on ___. Patient states this feels just like
his last presentation with associated neck pain. Patient states
the pain was gradual onset around 4am and awoke him from sleep,
it did not respond to Tylenol and got worse during the day.
Eventually to ED at 1pm yesterday. Patient denies fevers/chills,
cough, abdominal pain, cp/sob, weakness, numbness, vision
changes. Also reports that his neck appears somewhat swollen and
has been stiff with a fluid filled nodule on the back of his
neck. Patient was instructed to come to ED upon calling Dr.
___.
Patient was recently discharged from ___ on ___ when he
had presented with headache. Head CT showed increased edema
primarily surrounding R frontal lesion. His headache at that
time resolved after 8mg IV dex in ED. He was continued on a
dexamethasone taper and was planned to have a f/u brain MRI in
one month.
REVIEW OF SYSTEMS: 10 point ROS was completed and otherwise
negative. showed increased edema primarily surrounding R
frontal lesion.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
___ presented with a sore mass in
the left posterior buttock. Ultrasound ___ showed a 7 x
5.2
x 4.8 cm heterogeneous hypoechoic vascular solid mass. MRI
performed ___ confirmed the finding of a heterogeneous
mass, and biopsy ___ showed high-grade sarcoma consistent
with alveolar soft parts sarcoma. PET CT ___ showed the
left gluteal mass as well as multiple bilateral pulmonary
nodules; the largest measuring 15 mm which were non-FDG avid.
Mr. ___ underwent wide resection of the left buttock soft
tissue sarcoma ___ ___s left upper lobe and left
lower lobe wedge resection by VATS. Metastases were found in
___
nodules, the largest measuring 2 cm. The left buttock tumor
measured 8 cm.
CT scan ___ demonstrated three right sided pulmonary nodules,
one of which was increasing in size. PFTS (FEV1 94%/ DLCO 132%)
demonstrated adequate reserve for him to undergo further
resection. He underwent a VAST RUL wedge and RLL wedge resection
on ___. His intreoperative course went without any
complications.
He was admitted to ___ on ___ after presenting with new
headache, found to have multiple brain metastases. MRI evidence
of a 1.9 cm lesion in the right frontal
lobe, left frontal likely extra-axial 1.6 cm lesion, left
parieto-occipital 6 mm area (potentially confluence of venous
structures versus extra-axial lesion) and 3 mm left cerebellar
hemisphere enhancing lesion. He was treated with CK to all of
these areas, completing ___.
Social History:
___
Family History:
The patient's grandfather had a cancer. He does not know the
details. His mother has diabetes ___.
Physical Exam:
ADMISSION EXAM:
VS: 98.4 89 114/64 16 96% RA
GENERAL: NAD
HEENT: NC/AT, EOMI, PERRL, MMM
CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4
LUNG: clear to auscultation, no wheezes or rhonchi
ABD: +BS, soft, NT/ND, no rebound or guarding
EXT: No lower extremity pitting edema
PULSES: 2+DP pulses bilaterally
NEURO: A&O x 3, CN II-XII intact, 2+ deep tendon reflexes, ___
motor strength upper and lower limbs.
SKIN: Warm and dry, without rashes
DISCHARGE EXAM:
VS: 98.6, 118/77, 73, 16, 97%RA
GEN: NAD sitting in bed working on computer
HEENT: PERRLA. EOMI, MMM.
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: CTAB no crackles or wheezes
Abd: BS+, soft, NT, no rebound/guarding, no HSM
Extremities: wwp, no edema.
Skin: no rashes or bruising
Neuro: AOx3, CNs II-XII intact. ___ strength in U/L extremities.
Pertinent Results:
LABS:
___ 03:00PM BLOOD WBC-7.7 RBC-4.60 Hgb-13.9 Hct-42.0 MCV-91
MCH-30.2 MCHC-33.1 RDW-13.8 RDWSD-46.1 Plt ___
___ 03:00PM BLOOD Neuts-74.9* Lymphs-14.6* Monos-8.4
Eos-0.9* Baso-0.3 Im ___ AbsNeut-5.73 AbsLymp-1.12*
AbsMono-0.64 AbsEos-0.07 AbsBaso-0.02
___ 03:00PM BLOOD Glucose-96 UreaN-22* Creat-0.9 Na-140
K-3.8 Cl-103 HCO3-28 AnGap-13
IMAGING:
___ CTHEAD:
1. Intracranial metastases with surrounding edema are re-
demonstrated. A
left frontal lobe hyperdense metastatic lesion shows minimally
increased
surrounding edema. A right frontal lobe lesion is
re-demonstrated and shows
minimally decreased surrounding edema.
2. No acute intracranial hemorrhage.
___ MRI HEAD:
1. Slight interval increase in size of the dural based left
frontal convexity
mass with increased surrounding edema and mild local sulcal
effacement and no
midline shift.
2. Stable size of the right parietal lesion with mild decreased
surrounding
edema.
3. Two stable small cerebellar lesions and small right frontal
leptomeningeal
lesion, as described above.
4. Stable 0.7 cm area of enhancement along the left parietal
convexity, which
may represent a dural based lesion versus confluence of vessels.
5. No new intracranial metastatic disease.
Brief Hospital Course:
Mr ___ is a ___ with history of metastatic alveolar soft
parts sarcoma with mets to lung (S/p resection in ___ and
new diagnosed brain mets s/p one treatment of Cyberknife ___
two sessions on single day who presents now with headache after
stopping dexamethasone taper on ___. He was found to have
minimally increased edema on CT in ED. He received an MRI which
showed known brain lesions. He was given decadron 6mg in ED and
then prescribed a slow taper. He continued his home PPI.
Transitional:
==========================
Patient has an MRI scheduled for ___, unsure if he should
keep this given inpatient MRI
Has additional follow up already scheduled with Dr. ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Dexamethasone 4 mg IV Q12H
2. Acetaminophen 500 mg PO Q6H:PRN pain
3. Lidocaine 5% Patch 1 PTCH TD Q12H:PRN pain
4. Lorazepam 0.5 mg PO ___ MIN PRIOR TO CYBERKNIFE TREATMENT
5. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Omeprazole 20 mg PO DAILY
3. Dexamethasone 4 mg PO DAILY
RX *dexamethasone 1 mg 4 tablet(s) by mouth daily Disp #*32
Tablet Refills:*0
4. Lidocaine 5% Patch 1 PTCH TD Q12H:PRN pain
5. Lorazepam 0.5 mg PO ___ MIN PRIOR TO CYBERKNIFE TREATMENT
Discharge Disposition:
Home
Discharge Diagnosis:
Headache
Metastatic Sarcoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ on ___ after you had weaned from
prednisone and had a headache which did not resolve with home
medications. You received a CT and MRI of your head which showed
the known lesions in your brain. We started you back on
prednisone with a long slow taper. Please attend all of your
follow up appointments and take all of your medication as
prescribed. It was a pleasure taking part in your care.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10222300-DS-5 | 10,222,300 | 21,667,741 | DS | 5 | 2163-03-24 00:00:00 | 2163-03-24 16:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI:
___ with h/o b/l nephrolithiasis s/p multiple endoscopic stone
procedures including L URS/lithos/ureteral dilatation, R
URS/lithos/PCNL most recently s/p R ESWL ___ ___
presents with ___ h/o fever as high as 101-102, lethargy,
chills. He first was seen in ___ Urgent Care where he was
prescribed cipro and a KUB and urine culture were obtained. KUB
revealed LEFT ureteral calculus ~6-7mm and he was asked to seek
evaluation.
In the ___ he was febrile to 100.9 with stable hemodynamics.
A lactate was 1.2, WBC 6.5, Cr 1.0. He endorses hematuria and
passing stone fragments since his procedure.
He was admitted in ___ with post-operative fever s/p
ureteroscopy and was managed conservatively with antibiotics and
observation. Of note, he has a prior history this year of staph
epidermiidis UTIs resistant to penicillins and fluoroquinolones.
Past Medical History:
PSH: ESWL/URS multiple, cataract surgery, eye lid surgery
PMH: HLD, macular degeneration, depression, HTN, nephrolithiasis
Social History:
SH:
no tob, ___ etoh/nt
Physical Exam:
NAD
no resp distress
abd soft ntnd, mild R CVAT, no L CVAT
Pertinent Results:
___ 08:05AM BLOOD WBC-5.3 RBC-3.77* Hgb-11.2* Hct-33.5*
MCV-89 MCH-29.8 MCHC-33.5 RDW-12.6 Plt ___
___ 04:23PM BLOOD WBC-6.5 RBC-4.24* Hgb-12.6* Hct-36.9*
MCV-87 MCH-29.8 MCHC-34.2 RDW-12.7 Plt ___
___ 04:23PM BLOOD Neuts-77.0* Lymphs-13.9* Monos-8.2
Eos-0.5 Baso-0.5
___ 08:05AM BLOOD Glucose-123* UreaN-15 Creat-0.8 Na-141
K-3.6 Cl-106 HCO3-29 AnGap-10
___ 04:23PM BLOOD Glucose-107* UreaN-18 Creat-1.0 Na-141
K-4.1 Cl-101 HCO3-29 AnGap-15
Brief Hospital Course:
The patient was admitted to Dr. ___ service from
the ED for overnight
observation, pain control, and IV fluids and IV antibiotics
(broadly covered with vanco/ceftriaxone given prior ___ urine
culture records). He was monitored for fever, nausea and
vomiting. He essentially was asymptomatic after admission and
passed a few stone fragments. He remained afebrile through HD2
and thus diet was advanced as tolerated. A CT revealed no clear
etiology for his fevers. On evening of HD2 he was ready for
discharge with pain well controlled with oral pain medications,
tolerating regular diet, ambulating without assistance, and
voiding without difficulty. He was counseled extensively
regarding indications that necessitate urgent evaluation
including F/C, dysuria. He will f/u with Dr. ___ in clinic.
Medications on Admission:
lorazepam 0.5 mg Tab
1 Tablet(s) by mouth at bedtime as needed for sleep, anxiety
___ ___ 18:48)
lisinopril 20 mg Tab
1 Tablet(s) by mouth daily pt adjusts dose according to his BP.
He usually takes none to half a pill daily
___ ___ 18:48)
simvastatin 80 mg Tab
Tablet(s) by mouth daily
___ ___ 18:48)
oxycodone 5 mg Tab
1 Tablet(s) by mouth q4-6h as needed for pain
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours).
2. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia, anxiety.
3. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain ___.
Disp:*40 Tablet(s)* Refills:*0*
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*0*
7. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
nephrolithiasis
Discharge Condition:
stable, afebrile x24h, voiding, pain controlled with PO pain
medications, ambulating, oriented.
Discharge Instructions:
-Tylenol should be your first line pain medication, a narcotic
pain medication has been prescribed for breakthrough pain >4.
Replace Tylenol with narcotic pain medication.
-Max daily Tylenol (acetaminophen) dose is 4 grams from ALL
sources, note that narcotic pain medication also contains
Tylenol
-Make sure you drink plenty of fluids to help keep yourself
hydrated and facilitate passage of stone fragments.
-You may shower and bathe normally.
-Do not drive or drink alcohol while taking narcotics or operate
dangerous machinery
Followup Instructions:
___
|
10222637-DS-2 | 10,222,637 | 25,339,739 | DS | 2 | 2184-01-26 00:00:00 | 2184-01-26 12:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ with known 5mm R ACA aneurysm
scheduled for clinic evaluation this week who presented to the
ED
at OSH with sudden-onset severe headache in the setting of
hypertension.
The patient has a history of HTN and checks her BP at home;
today
she noted her BP to be 200/100. She denies any
activity/straining
at the time of headache onset. During this hypertensive episode,
she developed headache and right leg weakness. She presented to
OSH where ___ was negative for hemorrhage. She underwent LP
which was obtained after 3 attempts; CSF was noted to be grossly
bloody with uptrending RBC count so she was transferred to ___
for further evaluation.
On evaluation in the ED, she describes a holocephalic, primarily
frontal headache with some intermittent sharp pain to the right
side of her neck. She denied nausea and vomiting. She received
IV fentanyl prior to transfer with relief. She has intermittent
visual blurriness which has not worsened since headache onset.
SBP on evaluation in the 120's.
Past Medical History:
HTN
intermittent blurry vision
hearing loss
Social History:
___
Family History:
Non-contributory
Physical Exam:
Upon Admission:
==============
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs Full
Neck: Supple.
Lungs: No respiratory distress
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2mm bilaterally.
Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
Upon Discharge:
==============
___ x 3. NAD.
PERRLA. CN II-XII intact.
LS clear
RRR
Abdomen soft, NTND.
___ BUE and BLE. No drift.
Pertinent Results:
Please see OMR for relevant findings.
Brief Hospital Course:
___ is a ___ year old female with a known aneurysm who
presents with complaints of WHOL. NCHCT was negative for
hemorrhage.
#Aneurysm
The patient was admitted to the NICU for close neurological
monitoring. She was started on Nimodipine. CTA head and neck
showed a stable known Right ACA aneurysm. Outside hospital LP
results showed no xanthochromia. Her outpatient
antihypertensives were restarted and she was discharged home on
___. She will follow up in the office with Dr. ___ in
___ weeks.
#Headache
The patient has a history of migraines. Neurology was consulted
for headache management. They recommended continued management
of her hypertension and an outpatient follow up with a brain
MRI.
Medications on Admission:
lisinopril 10 mg tablet oral
1 tablet(s) Once Daily
hydrochlorothiazide 12.5 mg capsule oral
1 capsule(s) Once Daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Headache
Aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions
Severe Headache in the setting of known Cerebral Aneurysm
You were admitted for work up of severe Headache in the setting
of known cerebral aneurysm. Head CT did no show any hemorrhage
and CTA showed a stable, unruptured Right ACA aneurysm. LP
results from the outside hospital were reviewed and did not show
any signs of subarachnoid hemorrhage suggestive of aneurysmal
rupture. Your high blood pressure was treated and you were seen
by Neurology for known Migraines.
Activity
As tolerated.
Medications
Resume your normal medications and begin new medications as
directed.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site or puncture site.
Fever greater than 101.5 degrees Fahrenheit
Constipation
Blood in your stool or urine
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
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:
___
|
10222662-DS-6 | 10,222,662 | 23,662,589 | DS | 6 | 2114-12-11 00:00:00 | 2114-12-11 17:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Ludwigs angina
Major Surgical or Invasive Procedure:
Laryngoscopy by ENT (___)
History of Present Illness:
Patient is a ___ with PMH Fragile X syndrome, chronic
hyponatremia, HL, seizures, left DVT (on warfarin) who
presentsas transfer from ___ ___ for concern for Ludwig's
angina.
Patient is a poor historian who presented without caremember
from his facility but per chart review, patient began drooling
and complaining of mouth pain and a sore throat yesterday
afternoon. Upon arrival to ___, a CT neck was performed
that demonstrated a small ~1 x 0.6 x 0.2 cm abscess in the
midline floor of mouth. He was given a dose of Clindamycin (PCN
allergey). Given no ENT/OMFS coverage pt was tx to BI ___ for
further care.
Past Medical History:
Fragile X syndrome
chronic hyponatremia
HL
seizures
left DVT
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
Constitutional / General appearance: Appears comfortable, Awake
and alert
HEENT: PERRL
Neurologic: Moves all limbs, Follows commands
Cardiovascular: Regular rate and rhythm
Respiratory: Good symmetric air entry throughout
GI / Abdomen: Soft, nontender
Extremities / MSK: Warm peripheries
DISCHARGE PHYSICAL EXAM:
======================
Temp: 98.2, BP: 144/77, HR: 96, RR: 18, O2 sat: 90% RA
GENERAL: NAD, lying comfortable in bed
HEENT: Submental region non-tender to palpation. Mild swelling.
No stridor.
NECK: No cervical or posterior lymphadenopathy
CV: Regular rate and rhythm. normal S1/S2. no m/r/g
PULM: Clear to auscultation. No increased effort of breathing.
+cough, pt has difficulty w/ expectoration d/t cognitive
baseline
ABD: +BS, soft, non-tender, non-distended
EXTR: No edema, clubbing, jaundice
NEURO: uses walker with slightly shuffling gait (at baseline per
care taker). alert & oriented, but significant cognitive
impairments
SKIN: Warm and dry
Pertinent Results:
ADMISSION LABS:
====================
___ 04:35AM ___ PTT-57.1* ___
___ 04:35AM PLT COUNT-149*
___ 04:35AM NEUTS-64.1 LYMPHS-18.2* MONOS-16.6* EOS-0.4*
BASOS-0.2 IM ___ AbsNeut-5.33 AbsLymp-1.51 AbsMono-1.38*
AbsEos-0.03* AbsBaso-0.02
___ 04:35AM WBC-8.3 RBC-4.51* HGB-12.5* HCT-38.1* MCV-85
MCH-27.7 MCHC-32.8 RDW-15.1 RDWSD-46.2
___ 04:35AM WBC-8.3 RBC-4.51* HGB-12.5* HCT-38.1* MCV-85
MCH-27.7 MCHC-32.8 RDW-15.1 RDWSD-46.2
___ 04:35AM estGFR-Using this
___ 04:58AM ___ COMMENTS-GREEN TOP
___ 04:35AM GLUCOSE-97 UREA N-7 CREAT-0.4* SODIUM-128*
POTASSIUM-4.6 CHLORIDE-93* TOTAL CO2-24 ANION GAP-11
DISCHARGE LABS:
===================
___ 06:13AM BLOOD WBC-9.0 RBC-4.75 Hgb-13.1* Hct-40.6
MCV-86 MCH-27.6 MCHC-32.3 RDW-15.5 RDWSD-48.6* Plt ___
___ 06:13AM BLOOD ___
___ 06:13AM BLOOD Glucose-80 UreaN-10 Creat-0.6 Na-132*
K-4.6 Cl-94* HCO3-24 AnGap-14
IMAGING:
===================
CT Neck w/ Contrast (___):
1. Dental amalgam streak artifact and patient positioning limits
study.
2. Multiloculated, rim enhancing lesion in the midline floor of
the mouth
again concerning for abscesses as described, grossly stable
compared to prior
exam.
3. Enlarged left supraclavicular lymph node measuring up to 1.8
cm, with
additional scattered subcentimeter nonspecific lymph nodes are
noted
throughout the neck bilaterally.
4. Minimal nonspecific thickening of the platysma and induration
of
submandibular soft tissues, grossly stable. While finding may
represent
artifacts, cellulitis is not excluded on the basis of this
examination.
5. Paranasal sinus disease, as described.
6. Question patchy left upper lobe lung opacities versus
artifact. If
clinically indicated, consider correlation with dedicated chest
imaging.
7. Left maxillary periodontal disease as described.
CXR (___):
Lungs are low in volume. Mild bronchial cuffing or bronchial
wall thickening
seen in the left lung. Although there is no focal
consolidation, subtle
alveolitis might be missed on conventional chest radiographs and
detectable
only on chest CT. Heart size normal. No evidence of central
adenopathy. No
pleural abnormality.
RECOMMENDATION(S): Consider chest CT for detection of subtle
lung infection.
Brief Hospital Course:
SICU Course (___):
Pt was monitored overnight for any respiratory distress. ENT
scoped pt in the afternoon ___ and there was minor cellulitis
with no airway compromise. Based on this they recommended
overnight observation on the floor and 10 day course of
clindamycin (due to documented penicillin allergy). Pt also
received 3 doses of dexamethasone. The patient's diet was
advanced and he was started on his home medications. Medicine
team was called to transfer the patient to the floor.
Medicine Course (___):
Patient was then transitioned to oral clindamycin for a 10-day
course. Repeat CT showed stable lesion on patient's midline
floor of the mouth. Due to patient's increased risk of
aspiration and several mild episodes of hypoxia requiring ___
L nasal cannula, SLP consulted & obtained chest x-ray that did
not show any areas of focal consolidation. SLP felt pt was an
aspiration risk therefore made new recommendations for patients
diet. Cough w/ transient hypoxia possibly due to aspiration, no
e.o PNA. Blood cultures remained negative throughout admission.
On the floor patient was also hyponatremic to 129. Patient does
have history of chronic hyponatremia (unknown baseline), but
felt that due to poor possible p.o. intake 500 cc bolus of
normal saline was warranted. Warfarin held on the admission due
to INR of 3.7 but was resumed on ___ (INR 2.6) at dose of
7.5mg. Subsequent INR on ___ at 3.3 therefore daily dose was
held. Instructed patient and ___ (from group home) to resume
warfarin 2.5mg on ___ with repeat labwork on ___ and close
___ with PCP for warfarin titration in the setting of
current antibiotic regimen.
TRANSITIONAL ISSUES:
=================================
[]
MEDICATIONS:
- New Meds: Guaifenesin, clindamycin (last dose on ___
- Stopped Meds: None
- Changed Meds: NO warfarin ___, resume warfarin 2.5mg
___, please obtain labwork to check INR on ___ and
___ with PCP in order to determine best dose moving
forward.
___
[ ]PCP: please check INR ___ and adjust warfarin dosing as
needed. pt was supratherapeutic on admission at 3.7 (___).
Downtrended to 2.6 on ___ therefore was given 7.5mg with
___ INR at 3.3. Discharged with recommendations to hold
dose on ___ and then take warfarin 2.5mg on ___.
[ ]PCP: pt should ___ to examine lungs (increased risk of
aspiration due to patient's baseline and superimposed swelling),
airway, and oropharynx after completing 10 day course of
antibiotics (___) or sooner if symptoms worsen.
[ ]PCP: please continue to follow patient's chronic
hyponatremia.
[ ]PCP: CXR during admission revealed "Mild bronchial cuffing or
bronchial wall thickening seen in the left lung. Although there
is no focal consolidation, subtle alveolitis might be missed on
conventional chest radiographs and detectable only on chest CT."
If pt continues to have cough, progression of cough, or SOB can
consider repeat chest imaging for evaluation of alveolitis due
to aspiration.
[ ]Dentist: pt presented w/ concern for ludwigs angina, but
found to have approx. 1cm submental abscess with pharyngitis &
supraglotitis. Please evaluate patient for caries and provide
appropriate management.
Discharge Na: 132
Discharge Hgb: 13.1
Discharge INR: 3.3
# CODE: FULL presumed
# CONTACT: ___ (___ from ___) ___
ACUTE/ACTIVE ISSUES:
====================
# Submental abscess: Initially concerned for Ludwig's angina
given pain and swelling over chin. No respiratory compromise
while monitored in ___ and SICU overnight. Scope with ENT showed
clear airway with unilateral edema, likely viral pharyngitis and
supraglottitis and started on clindamycin for 10 day course (PCN
allergy), already finished decadron x3 doses. Low concern for
Ludwig's angina given current infection location in submental
area without extension to submandibular space causing airway
compromise. Last day of antibiotics = ___.
- continue to ___ BCx
# Cough w/ hypoxia: Productive cough with transient episodes of
hypoxia requiring ___ NC. Pt is a group home resident with a
soft/thin liquid diet, concern for aspiration. CXR without focal
consolidations. SLP seen and agreed pt has higher than usual
aspiration risk, especially in setting of oropharyngeal
infeciton. Pt successfully completed ambulatory O2 test prior to
discharge on RA. PCP can consider CT chest if pt continues to be
symptomatic.
- SLP Recommendations:
1. Diet: puree solids, nectar-thick liquids
2. Medications: whole in puree
3. Safe Swallowing Strategies:
-Supervision: 1:1
-Liquids via: bolus-restricting cup (i.e. adult ___ cup or
coffee cup lid)
-REDUCE DISTRACTIONS
-SLOW INTAKE
-Small bites/sips
4. General Safety:
-HOB at 30 degrees at all times & fully upright for meals
-Feed only when alert and attentive
-Eat slowly and carefully
-Remain upright for ___ minutes after meals
5. Oral care TID
# L DVT: Supratherapeutic INR 3.7 on admission, warfarin dose
held. Downtrended to 2.6. Restarted warfarin at 7.5mg on ___
with assistance of pharmacy, with INR of 3.3 on discharge.
- holding warfarin on ___
- give warfarin 2.5mg on ___
- obtain labwork to check INR on ___ (fax results to PCP)
# Chronic hyponatremia: Na 128, asymptomatic. Gave 500cc NS
bolus d/t concern for poor PO intake & hypovolemia. Sodium did
not improve after this therefore possibly SIADH due to patient's
AEDs. Na 132 on discharge.
- PCP ___
CHRONIC/STABLE ISSUES:
======================
# Fragile X
- continue home clonazepam 0.5mg BID, clonazepam 1mg TID prn,
propanolol 120mg QD, quetiapine 200mg TID
# Seizures
- continue home divalproex ___ BID, OXcarbazepine 450mg BID
# Anemia: Hgb 13.1, asymptomatic
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. QUEtiapine Fumarate 200 mg PO TID
2. ClonazePAM 1 mg PO TID
3. ClonazePAM 0.5 mg PO BID
4. OXcarbazepine 450 mg PO BID
5. Propranolol LA 120 mg PO DAILY
6. Omeprazole 20 mg PO BID
7. Divalproex (DELayed Release) 1000 mg PO BID
8. Warfarin Dose is Unknown PO DAILY16
Discharge Medications:
1. Clindamycin 300 mg PO QID Duration: 10 Days
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth four times a
day Disp #*34 Capsule Refills:*0
2. Warfarin 2.5 mg PO DAILY16
please take 2.5mg ___ and ___ with labs on ___.
3. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
Gingivitis
5. ClonazePAM 1 mg PO TID
6. ClonazePAM 0.5 mg PO BID
7. Dextromethorphan Polistirex ___ mg PO Q12H:PRN Cough
8. Divalproex (DELayed Release) 1000 mg PO BID
9. LOPERamide 2 mg PO TID:PRN Diarrhea
10. Omeprazole 20 mg PO BID
11. OXcarbazepine 450 mg PO BID
12. Propranolol LA 120 mg PO DAILY
13. QUEtiapine Fumarate 200 mg PO TID
14.Outpatient Lab Work
please obtain ___, INR
please fax to ATTN: Dr. ___ ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
viral pharyngitis
supraglotitis
Secondary:
fragile x syndrome
history of left leg deep vein thrombosis on warfarin
chronic hyponatremia
aspiration risk
transient hypoxia
anemia
Discharge Condition:
Mental Status: oriented, but cognitively impaired at baseline
Level of Consciousness: Alert and interactive.
Activity Status: Requires assistance w/ all ADLs d/t cognitive
delay
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for swelling in your neck
What was done for me while I was in the hospital?
- We took pictures of your neck and looked inside your throat
- We gave you medications to treat the infection
- The ear nose and throat doctors ___ your ___ and
recommend the best antibiotics to treat it.
- We took pictures of your lungs to look for infection and
aspiration.
- We gave you IV fluids to help your electrolytes.
- A speech pathologist to evaluated you and recommended how you
should take your pills (one at a time, whole, & in puree. No
straws) and what sorts of foods you should be eating.
- We gave you oxygen to help with your breathing and made sure
you no longer needed it.
- We gave you medications to help with your cough.
- We gitrated your warfarin medication because your blood was
too thin.
What should I do when I leave the hospital?
- Take all of your medications as directed
- ___ with all of your doctors as directed
- ___ routine labwork to monitor your blood levels (INR)
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10222892-DS-21 | 10,222,892 | 28,301,831 | DS | 21 | 2171-01-06 00:00:00 | 2171-01-06 13:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
codeine
Attending: ___
Chief Complaint:
dysarthria, left sided facial droop
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is an ___ year old right-handed woman with no
significant
past medical history who presents as a transfer from ___ with concern for stroke.
She has been in ___ visiting her daughter since last week.
She
spent the day running errands with her daughter. While they were
together today at the hair salon, her daughter noticed that her
speech all of a sudden seemed "like she had gotten Novocaine".
This was at approximately 4:30pm. She had last spoken to her
daughter only a minute or two before, without any slurring. In
particular her daughter noticed that she seemed to be having
trouble with "B" and "P" sounds. She then looked at Ms. ___
face and noticed that the right sound of her mouth was drooping.
Ms. ___ herself did not think her speech sounded particularly
slurred. She did not want to go to the hospital initially
because
she did not think anything was wrong. They made their way home
from the hairdresser, and ate dinner. While eating dinner, she
did not have any choking or dysphagia, though did dribble some
water from the right side of her mouth. Throughout this time
there was no weakness, clumsiness, sensory change, vision
changes, confusion, or difficulty speaking.
After dinner, she presented to ___. There, initial
vitals were notable for Temp 97.5, heart rate 71, blood pressure
128/73. She was noted to have a right facial droop and slurred
speech. CT head showed no acute intracranial abnormalities.
Telestroke consultation was obtained and tPA was recommended.
However, Ms ___ declined this as she felt the risk was too
substantial to justify the potential benefits. During this time
there was no fluctuation in her symptoms, and no new symptoms.
She was then transferred to ___ for further care.
On arrival to ___, thinking back, Ms ___ realized that at
7am
when she was having her morning coffee, she also dribbled some
of
it from the right side of her mouth. However, she spoke to her
daughter at that time without any dysarthria or facial droop.
Review of Systems:
Neurologic review of systems is as above.
On general review of systems, the patient denies recent fever,
chills, night sweats, or recent weight changes. Denies cough,
shortness of breath, chest pain or tightness, palpitations.
Denies nausea, vomiting, diarrhea, constipation or abdominal
pain. Denies dysuria, or recent change in bowel or bladder
habits. Denies arthralgias, myalgias, or rash.
Past Medical History:
Cataracts, bilateral, s/p removal
No history of hypertension, hyperlipidemia, diabetes, abnormal
heart rhythm, heart disease, or palpitations.
Social History:
___
Family History:
No family of neurologic disease. Father died at ___ of lung
cancer. Mother died at ___ of congestive heart failure.
Physical Exam:
Physical Examination on admission:
Vitals: 98.2 92 149/78 16 95% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Awake and alert. Able to relate history without
difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Able to name both high and low frequency objects. Able to follow
both midline and appendicular commands. There was no evidence of
apraxia or neglect. Speech is mildly dysarthric, though
intelligible.
-Cranial Nerves:
II, III, IV, VI: Slight anisocoria with R pupil larger than
left
by 1mm, both equally reactive. No rAPD. EOMI without nystagmus.
Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch and pinprick.
VII: Slight flattening of the right nasolabial fold.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk and tone throughout. No pronator drift. No
adventitious movements, such as tremor or asterixis noted.
[Delt][Bic][Tri][ECR][FEx][IO][IP][Quad][Ham][TA][Gas]
L 5 5 5 5 5 5 5 5 5 5 5
R 5 5 4+ 5 5 5 5 5 5 5 5
-Sensory: There is a symmetric and circumferential decrease in
both pinprick/temperature as well as vibratory sense below the
lower shin, bilaterally. No extinction to DSS. Romberg absent.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Negative
Unterberger.
Physical Exam on discharge:
General unchanged, strength unchanged, sensation unchanged. Exam
notable for dysarthria, mild Left sided nasolabial fold
flattening, mild L sided pronator drift. Some intention tremor
on L hand.
Pertinent Results:
___ 05:55AM BLOOD WBC-6.5 RBC-4.37 Hgb-13.0 Hct-39.5 MCV-90
MCH-29.7 MCHC-32.9 RDW-13.2 RDWSD-43.4 Plt ___
___ 05:55AM BLOOD Glucose-89 UreaN-16 Creat-1.1 Na-143
K-3.9 Cl-107 HCO3-25 AnGap-11
___ 05:55AM BLOOD Calcium-9.7 Phos-3.8 Mg-1.9
___ 01:31AM BLOOD %HbA1c-5.6 eAG-114
___ 01:31AM BLOOD Triglyc-121 HDL-83 CHOL/HD-2.5
LDLcalc-100
___ 01:31AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 01:31AM BLOOD Cholest-207*
___ 02:50AM URINE Blood-SM* Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
Telemetry: Normal sinus rhythem
Imaging:
CT head and CTA head and neck: No acute large territorial
infarction. No evidence of intracranial hemorrhage. Chronic
infarctions of the bilateral basal ganglia. Small 1.3 cm right
posterior parietal extra-axial calcified masslike lesion may
represent a meningioma. No significant stenosis, mild
intracranial atherosclerosis.
MRI brain:
1. 2 focal acute infarcts in the left frontal lobe. 2. 17 x 9
mm low signal intensity extra-axial mass, overlying the right
parietal lobe, which likely represents a calcified meningioma.
TTE: IMPRESSION: Mild symmetric left ventricular hypertrophy
with normal cavity size and regional/global biventricular
systolic function. Mild aortic regurgitation with mildly
thickened leaflets.
Brief Hospital Course:
Ms. ___ is a ___ year old woman without significant vascular
risk factors, other than a history of tobacco use, who is
admitted to the Neurology stroke service with abrupt onset of
right facial droop and asymmetry and possible mild aphasia
secondary to an acute ischemic stroke in the left frontal lobe.
MRI showed two punctate areas of restricted diffusion in the
left frontal lobe. Her stroke was most likely secondary to
embolic event given distribution of infarcts having to focal
areas found in the left frontal lobe. She was found to have
hyperlipidemia, with LDL of 100. Hemoglobin A1c was 5.6%. Other
work-up included CTA head and neck, which found some mild
intracranial atherosclerotic disease. As well as MRI head, which
found to acute infarcts left frontal lobe. The distribution is
concerning for embolic event. Patient monitor on telemetry while
inpatient, with no signs atrial fibrillation. Patient to be
discharged with a ZIO patch to monitor for A. fib. Patient has
signs of chorionic lacunar infarcts on MRI consistent with
poorly controlled hypertension. Patient started on amlodipine
5mg daily for hypertension and should be titrated outpatient.
TTE with no clear contributing etiology, just "IMPRESSION: Mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global biventricular systolic function. Mild aortic
regurgitation with mildly thickened leaflets."
The only deficit on discharge was mild dysarthria, mild right
sided nasolabial fold flattening, mild R sided pronator drift.
Some intention tremor on L hand. She will be given a discharge
prescription for speech therapy as an outpatient.
============================================
Transitional issues:
[] Patient should take Aspirin 81mg AND Clopidogrel 75mg daily
for 3 weeks, then STOP Clopidogrel and take only Aspirin 81mg
daily (per POINT Trial).
[] Incidental 17 mm x 9 mm extra-axial mass at the right
anterior parietal vertex, likely a meningioma.
[] Treat hypertension as an outpatient. Started Amlodipine 5mg
daily during admission, for blood pressure 150-170/70-80.
[] Follow-up on ZIO Patch results for paroxysmal atrial
fibrillation.
============================================
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 = ) - () 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 ___, 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 in written
form? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - () 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. Vitamin E Dose is Unknown PO Frequency is Unknown
2. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*3
2. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Aspirin Regimen] 81 mg 1 tablet(s) by mouth
once a day Disp #*90 Tablet Refills:*3
3. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth once a day Disp #*90
Tablet Refills:*3
4. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
5. Vitamin E 1 UNIT PO AS PREVIOUSLY TAKING
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
7.Outpatient Speech/Swallowing Therapy
Evaluation and treatment.
Cerebral infarction, unspecified. ICD ___
Discharge Disposition:
Home
Discharge Diagnosis:
Acute ischemic stroke
Hypertension
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 acute onset right
facial droop and dysarthria (slurred speech) 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:
Age, history of smoking, likely high blood pressure
We are changing your medications as follows:
-Start taking 81 mg of aspirin daily.
-Start taking Plavix 75 mg a day for 3 weeks, then STOP.
-Start taking atorvastatin 40 mg a day.
- Start taking Amlodipine 5mg a day.
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10223157-DS-27 | 10,223,157 | 23,981,349 | DS | 27 | 2192-07-10 00:00:00 | 2192-07-12 22:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Foot Pain and Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ year old woman with past medical history
significant for atrial fibrillation on Coumadin, breast cancer
s/p L mastectomy/chemotherapy and cognitive impairment who
presents for evaluation of worsening lower extremity redness and
diarrhea for four days.
The patient reports pain in her feet L>R and tenderness of the
skin over her lower back. She also reports fatigue but denies
chest pain, shortness of breath or nausea and vomiting. She
endorses intermittent loose stools, also confirmed by her
family. Also per her family, she started to seem fatigued at
home over the past week and was less talkative and active that
usual. In addition, they report that over the past 36 hours they
noticed a change in her R foot, where it is usually mildly red
it had become purple with an overlying grayness of the toes.
In the ED, initial vital signs were: T 97.7 P 89 BP 104/55 RR 15
SaO2 98% on RA. Labs were notable for CBC 9.1 > 10.9/34.8 < 284.
Chem: 132 4.4 96 21 31 0.9 107. ___ 106.6/INR 10.2. Studies
performed included a CXR and plain films of the feet
bilaterally. Patient was given 5mg Vitamin K and started on
Vancomycin and Zosyn. Vitals at the time of transfer were 97.7
86 16 111/70 94%RA. Upon arrival to the floor, the patient was
in atrial fibrillation with a rate of 120-140. She continued to
deny any symptoms of this condition including chest pain,
dizziness, weakness, N/V and only reported ___ pain as above.
Review of Systems: Reports pain in her feet (L>R) and tenderness
of the skin over her lower back and buttocks. She denies
headache, dizziness, weakness, cough, chest pain, shortness of
breath, nausea, vomiting.
Past Medical History:
ATRIAL FIBRILLATION
MITRAL REGURGITATION (MODERATE ON TTE ___
HYPERTENSION
HYPERLIPIDEMIA
R PELVIC FRACTURE
CHRONIC VENOUS STASIS ULCERS
BREAST CANCER S/P L MASTECTOMY and CHEMOTHERAPY
COGNITIVE IMPAIRMENT
OSTEOPENIA
PSORIASIS
VENOUS STASIS ULCERS
CERVICAL SPONDYLOSIS
*S/P APPENDECTOMY
*S/P LUMBAR SPINE SURG FOR DISC DZ
*S/P TOTAL ABDOMINAL HYSTERECTOMY
*S/P VARICOSE VEIN STRIPPING
Social History:
___
Family History:
Per prior notes, her father died at the age of ___ and had
multiple TIAs. Mother died at age ___ of a surgical complication
and one brother died at age ___ of pancreatic cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: BP 96/56 HR 124 RR 22 SaO2 98%RA
General: no acute distress but appears mildly ill, lying in bed
HEENT: anicteric, EOMI, PERRL
CV: irregularly irregular, tachycardic, no murmurs appreciated
Lungs: decrease breath sounds at the bases (R>L), mild crackles
at the bases bilaterally, apices clear to auscultation
Abdomen: mild tenderness centrally to deep palpation
Ext: mild swelling, ulcer of the L lateral and medial malleolus
with exposed granulation tissue but without drainage,also with
violaceous skin changes, ulcerations and necrosis of anterior
aspect of ___ toes
Neuro: AA+O X 2 (self, place but stated year as ___,
also unable to recount recent history at home or medications, UE
strength ___ bilaterally
Skin: large erythematous area with multiple skin tears on lower
back and rectum
DISCHARGE PHYSICAL EXAM
Vitals: 98.7 ___ 22 98 on 1.5L
General: no acute distress, lying in bed
HEENT: anicteric, EOMI
CV: irregularly irregular, tachycardic, no murmurs appreciated
Lungs: mild crackles at the bases bilaterally
Abdomen: non-tender, non-distended, normal bowel sounds
Ext: ___ cellulitis tremendously improved, now with only mild
erythema on the ___ and ___ toes
Neuro: AA+O X 2, interactive
Pertinent Results:
ADMISSION LABS
___ 11:45PM WBC-9.1 RBC-3.71* HGB-10.9* HCT-34.8* MCV-94
MCH-29.4 MCHC-31.4 RDW-16.8*
___ 11:45PM NEUTS-79.6* LYMPHS-13.2* MONOS-5.8 EOS-1.0
BASOS-0.3
___ 11:45PM PLT COUNT-284
___ 11:45PM GLUCOSE-107* UREA N-31* CREAT-0.9 SODIUM-132*
POTASSIUM-4.4 CHLORIDE-96 TOTAL CO2-21* ANION GAP-19
___ 11:45PM ___
___ 11:45PM CALCIUM-9.1 PHOSPHATE-3.5 MAGNESIUM-1.7
___ 12:09AM ___ PTT-65.2* ___
IMAGING
ECHO
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. There is mild regional left ventricular
systolic dysfunction with septal hypokinesis.. Overall left
ventricular systolic function is normal (LVEF>55%). The right
ventricular cavity is moderately dilated with moderate global
free wall hypokinesis. The ascending aorta is mildly dilated.
The number of aortic valve leaflets cannot be determined. The
aortic valve leaflets are moderately thickened. There is mild
aortic valve stenosis (valve area 1.2-1.9cm2). No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No masses or vegetations are seen on the mitral
valve, but cannot be fully excluded due to suboptimal image
quality. An eccentric, anteriorly directed jet of moderate to
severe (3+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. The tricuspid valve leaflets fail
to fully coapt. Moderate to severe [3+] tricuspid regurgitation
is seen. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion. There is an
anterior space which most likely represents a prominent fat pad.
IMPRESSION: Mild symmetric LVH with septal hypokinesis. Dilated
and hypokinetic right ventricle. At least mild aortic stenosis
(gradients relatively low due to poor LV function). Moderate to
severe, anteriorly directed mitral regurgitation. Moderate to
severe tricuspid regurgitation with moderate pulmonary
hypertension. Compared with the prior study (images reviewed) of
___, biventricular function has significantly worsened,
particularly of the right ventricle. The degree of tricuspid
regurgitation and pulmonary hypertension have increased.
ABI ON ___
IMPRESSION: Moderate bilateral arterial insufficiency in the
superficial femoral and posterior tibial arteries bilaterally.
FOOT PLAIN FILM
IMPRESSION: Concern for osteomyelitis of the right distal ___
metatarsal although this appearance conceivably relates to old
healed fracture this bone
CXR ON ___
IMPRESSION: Moderate cardiomegaly is stable. Pulmonary edema is
mild and stable. Large bilateral pleural effusions with adjacent
atelectasis have increased on the right. There is no
pneumothorax .
CXR ON ___
IMPRESSION:
1. Right lower lobe pneumonia.
2. Worsening pulmonary edema, now moderate.
DISCHARGE LABS:
___ 07:47AM BLOOD WBC-6.6 RBC-3.81* Hgb-10.9* Hct-35.2*
MCV-92 MCH-28.6 MCHC-31.0 RDW-16.3* Plt ___
___ 07:47AM BLOOD Plt ___
___ 07:47AM BLOOD Glucose-89 UreaN-21* Creat-0.7 Na-140
K-4.4 Cl-100 HCO3-33* AnGap-11
___ 09:55AM BLOOD ALT-47* AST-36 LD(LDH)-221 AlkPhos-155*
TotBili-0.6
___ 11:45PM BLOOD ___
___ 07:47AM BLOOD Calcium-8.7 Phos-2.9 Mg-1.8
___ 09:55AM BLOOD TSH-4.5*
___ 01:07PM BLOOD Lactate-1.7
Brief Hospital Course:
Ms. ___ is an ___ year old woman with past medical history
significant for atrial fibrillation on Coumadin, breast cancer
s/p L mastectomy/chemotherapy and cognitive impairment who
presented with ___ cellulitis and a supratherapeutic INR, with a
course complicated by persistent atrial fibrillation with RVR
and volume overload due to heart failure.
#ATRIAL FIBRILLATION
Ms. ___ was admitted in atrial fibrillation (CHADS2 Score - 2
for Age>___, Hx of HTN) with a rate of 120-140 on admission and a
SBP of 90-100. She remained asymptomatic. This problem was being
managed at home with Coumadin and Metoprolol Succinate ER 100mg
BID. Rate control was not achieved with Metoprolol or Diltiazem.
The Cardiology team assessed the patient and recommended use of
Metoprolol and digoxin for rate control on ___. This
resulted in improvements in her rates and on discharge her rates
were 90-110.
#SUPRATHERAPEUTIC INR
Ms. ___ was admitted with a supratherapeutic INR to 10.2. The
cause of this INR elevation is unclear but may have been
secondary to antibiotic use, poor medication adherence or
hepatic congestion secondary to worsening heart failure. She
received 5mg of PO Vitamin K in the ED with decrease in INR to
9.0 and repeat 2.5mg PO subsequently. Attempted to restart
warfarin once INR was in the target range of ___ but INR
increase to the supratherapeutic level of 5.2 on her home dose.
Warfarin was again held and was not given at the time of
dishcarge. Plan to restart on ___ if INR between ___.
#BILATERAL VENOUS STASIS ___ CELLULITIS
Ms. ___ has a history of LLE venous stasis disease and now
presents with increasing ___ erythema and superficial
ulcerations and necrosis of anterior aspect of ___ toes.
This improved on Vancomycin. Podiatry also recommended against
biopsy as they did not believe osteomyelitis was present.
Arterial imaging demonstrated moderate bilateral arterial
insufficiency in the superficial femoral and posterior tibial
arteries. She was transitioned to PO doxycycline then to PO
Keflex for Cellulitis. Local wound care to ___ for venous stasis
was continued as was Aquacel Ag to medial malleolar ulcer and
Profore/Cobran compressive dressing with assistance from the
Wound Care service.
#PULMONARY EDEMA
Evidence of moderate but worsened pulmonary edema on exam and on
CXR. BNP also >14,000. Home dose of Lasix is 40mg PO daily. Once
Ms. ___ cellulitis had improved and she was afebrile,
diuresis was initiated with IV Lasix. An Echo on ___
showed severe MR and moderate to severe TR. She was continued on
gentle diuresis and discharged on her home Lasix dose of 40mg PO
daily.
#DIARRHEA
Ms. ___ had reported diarrhea in the days leading up to her
hospitalization but none at the time of admission. C. difficile
was negative. Loose stools were managed with Loperamide.
#ALTERED MENTAL STATUS
Ms. ___ was admitted with concern for fatigue, lethargy and
AMS by her family. An infectious etiology such as UTI in
combination with her AFib with RVR and known cellulitis were all
considered as a cuase of her AMS. UA returned with >182 WBCs but
UC X 1 contaminant, repeat UC without growth. CTX was started
but discontinued after 3 days given UC negative on ___. Her
AMS improved with treatment of her cellulitis, diuresis and rate
control.
TRANSITIONAL ISSUES:
#Ms. ___ will be discharged on no warfarin but **WILL NEED AN
INR CHECK ON ___. THEN MAY RESTART AT 1MG DAILY AS
APPROPRIATE FOR GOAL INR ___
#Ms. ___ will be discharged on a new dose of Metoprolol XL
150mg daily.
#Ms. ___ is being discharged on Digoxin.
#Ms. ___ will continue wound care for her LLE ulcers and ___
cellulitis that has now largely resolved.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 100 mg PO HS
2. Furosemide 40 mg PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. Ketoconazole 2% 1 Appl TP BID
5. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID
6. Warfarin ___ mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Cellulitis, Diastolic Heart Failure, Acute
Pulmonary Edema
Secondary Diagnosis: Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - with assistance.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
for an infection in your foot and a fast heart rate (atrial
fibrillation). You were treated with antibiotics and medications
to decrease your heart rate and remove fluid from your lungs.
You will follow-up with your Cardiologist and Wound Care Team
going forward.
Best wishes,
Your ___ Team
Followup Instructions:
___
|
10223157-DS-29 | 10,223,157 | 29,662,390 | DS | 29 | 2192-08-28 00:00:00 | 2192-08-28 13:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Abdominal pain, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F CHF, AF on Coumadin presented with 3 days of abdominal pain
and distention. Per reports her pain is mainly in the lower
abdomen and is crampy. She denies having this pain before.
Reports thinking she had a BM 2 days ago, but she is not
entirely sure. Per report, she had 3 episodes of non-bloody
emesis at her rehab facility before being brought to ___.
Denies fevers, chills, BRBPR, melena. Of note, she was recently
admitted to the medical service ___ for blood streaks in
her stool and an episode of transient hypotension. The bleeding
self resolved (she had received vitamin K at the time given her
coumadin use). On that admission she underwent a flexible
sigmoidoscopy which was limited by inadequate prep. Per report
they were able to explore 20 cm into the colon and did not find
any active source
of bleed. At 5 cm into the rectum they noted a benign appearing
polyp which was not biopsied. She was planned for interval full
colonoscopy after prep as an outpatient.
Past Medical History:
ATRIAL FIBRILLATION
MITRAL REGURGITATION (MODERATE ON TTE ___
HYPERTENSION
HYPERLIPIDEMIA
R PELVIC FRACTURE
CHRONIC VENOUS STASIS ULCERS
BREAST CANCER S/P L MASTECTOMY and CHEMOTHERAPY
COGNITIVE IMPAIRMENT
OSTEOPENIA
PSORIASIS
VENOUS STASIS ULCERS
CERVICAL SPONDYLOSIS
*S/P APPENDECTOMY
*S/P LUMBAR SPINE SURG FOR DISC DZ
*S/P TOTAL ABDOMINAL HYSTERECTOMY
*S/P VARICOSE VEIN STRIPPING
Social History:
___
Family History:
Per prior notes, her father died at the age of 85 and had
multiple TIAs. Mother died at age ___ of a surgical complication
and one brother died at age ___ of pancreatic cancer.
Physical Exam:
PE on Admission
VS: 98.6 108 128/74 16 97% RA
Gen: NAD, alert; poor historian (baseline dementia)
___: irreg
Pulm: no distress
Abd: Softly distended, TTP lower abdomen with voluntary
guarding.
No rebound. No peritonitis. Well healed lower midline incision
___:
Rectal: liquid stool in vault, no impacted stool palpated. no
gross blood, guaiac +
PE on discharge
Gen: NAD, AAOx3
___: irregular distant heart sounds
Pulm: no distress
Abd: soft, non tender to palpation. no guarding or rebound
___: LLE moving, warm
Pertinent Results:
___ 07:44AM BLOOD WBC-4.2 RBC-3.49* Hgb-10.2* Hct-31.8*
MCV-91 MCH-29.2 MCHC-32.1 RDW-17.7* Plt ___
___ 07:50AM BLOOD WBC-4.1 RBC-3.35* Hgb-9.6* Hct-31.1*
MCV-93 MCH-28.8 MCHC-31.0 RDW-17.3* Plt ___
___ 08:07AM BLOOD WBC-3.6* RBC-3.20* Hgb-9.3* Hct-30.2*
MCV-94 MCH-29.1 MCHC-30.9* RDW-17.5* Plt ___
___ 06:55AM BLOOD WBC-3.6* RBC-3.32* Hgb-10.0* Hct-30.6*
MCV-92 MCH-30.1 MCHC-32.6 RDW-17.7* Plt ___
___ 08:30AM BLOOD WBC-7.2 RBC-3.87* Hgb-11.2* Hct-35.3*
MCV-91 MCH-28.9 MCHC-31.6 RDW-17.8* Plt ___
___ 04:15PM BLOOD WBC-6.0# RBC-4.08* Hgb-12.2 Hct-37.1
MCV-91 MCH-29.9 MCHC-32.9 RDW-17.6* Plt ___
___ 07:44AM BLOOD ___ PTT-42.3* ___
___ 08:22AM BLOOD ___
___ 01:20PM BLOOD ___ PTT-45.3* ___
___ 07:44AM BLOOD Glucose-106* UreaN-2* Creat-0.5 Na-133
K-3.9 Cl-105 HCO3-20* AnGap-12
___ 08:22AM BLOOD Glucose-118* UreaN-2* Creat-0.5 Na-135
K-4.1 Cl-105 HCO3-21* AnGap-13
___ 07:50AM BLOOD Glucose-96 UreaN-4* Creat-0.5 Na-136
K-3.9 Cl-103 HCO3-24 AnGap-13
___ 08:07AM BLOOD Glucose-100 UreaN-7 Creat-0.5 Na-135
K-3.0* Cl-99 HCO3-27 AnGap-12
___ 07:50PM BLOOD Glucose-97 UreaN-8 Creat-0.5 Na-134 K-4.0
Cl-101 HCO3-24 AnGap-13
___ 07:44AM BLOOD Calcium-8.1* Phos-2.6* Mg-2.0
___ 07:50AM BLOOD Calcium-8.2* Phos-2.7 Mg-1.7
___ 08:07AM BLOOD Calcium-8.3* Phos-3.3 Mg-2.1
Imaging:
CT abd:
1. Bowel obstruction due to a thickened segment of sigmoid colon
worrisome for malignancy. ? fistula of sigmoid/rectum
2. Left lower lobe ___ opacities. Question infectious
process.
3. Right middle lobe traction bronchiectasis and partial
collapse. Question history ___ infection
4. Small right and trace left pleural effusion
5. Right common iliac aneurysm with partial mural thrombus
Full impression:
1. Markedly abnormal bowel in the deep pelvis with apparent
fistulous
communication, an extraluminal collection, multiple areas of
tethering and a segment of thickened sigmoid proximal to which
there is partially obstructed bowel. The differential includes
possible inflammatory bowel disease versus prior diverticulitis
and subsequent complications. A neoplasm cannot be ruled out.
2. Cystic structures in the pelvis which should be further
assesses on a
nonurgent basis
3. Right common iliac aneurysm with partial mural thrombus
4. Left lower lobe ___ opacities. Question infectious
process or
aspiration.
5. Right middle lobe partial collapse.
6. Small right and trace left pleural effusion
7. Aortic valve calcifications
MR ENTEROGRAPHY
___ narrowed and thickened segment of mid sigmoid is noted with
tethering of adjacent small bowel loops, fistularization to
rectum and adjacent 3 cm abscess. Degree of bowel obstruction
is relatively unchanged. Findings again remain concerning for
malignancy with perforation, although recent colonoscopy did not
identify a lesion. Alternatively, an inflammatory stricture,
potentially related to diverticulitis, is a consideration. Two
simple appearing pelvic cystic structures, suspicious for
bilateral ovarian cystic neoplasms.
Brief Hospital Course:
The patient was admitted to the Acute Care Surgical Service on
___ for evaluation and treatment of abdominal pain and
emesis. Admission abdominal/pelvic CT revealed large bowel
obstruction, in region of sigmoid, dilated large bowel, and
dilated small bowel. CT scan suggestive of fistula of rectum to
sigmoid, and small bowel loop adherent to thickened sigmoid,
with inflammatory changes surrounding the
sigmoid colon and surrounding mesentery. Scan reviewed with
radiology; differential included diverticular disease or
malignancy. The patient was made NPO, started on IV fluids, had
a nasogastric tube was placed for decompression, she was started
on IV antibiotics, and had a Foley catheter placed for urine
output monitoring. Her coumadin was not restarted. She did not
have an intrabdominal fluid collection that was amenable to ___
drainage. The patient began experiencing large amounts of watery
stool. For the first 3 days of her admission she was
hemodynamically stable but required IV fluid boluses for lower
urine output. Stool samples sent were negative for c. diff. She
had a right thigh venous stasis ulcer that was evaluate by the
wound nurse. It did not progress to skin breakdown or require
special dressing but patient was regularly turned. By HD4, a
flexiseal was necessary and was placed to control the stool. And
the patient was given an IV fluid bolus to make up for volume
loss and low urine output. The NGT was removed and the patient's
diet was advanced to clears. The patient was hemodynamically
stable. Flexiseal was removed on HD5 and patient's diarrhea
improved and ultimately resolved with loperamide and psyllium
wafer. The patient was restarted on warfarin 1mg on HD ___ and
continued to receive it until discharge she remained therapeutic
with an INR of 2.0 at discharge.
Her pain was well controlled and at discharge she did not need
narcotics for pain control. Her diet was progressively advanced
as tolerated to a regular diet at discharge. The patient voided
and used a diaper for her incontinence.
The underlying etiology of her disease has a differential
includes possible inflammatory bowel disease versus prior
diverticulitis and subsequent complications. A neoplasm cannot
be ruled out. She was also found to have an E. coli UTI and was
ultimately discharged with 5 days of ciprofloxacin to a rehab
facility. At discharge her stools had become less frequent and
she no longer had diarrhea. Her abdominal exam was beign and she
was tolerating a regular diet. She has appointments scheduled
for follow up with our service at which we will re-evaluate her
coumadin and decide if we will continue it prior to further GI
workup. She has an appointmet with a gastroenterologist to
re-evaluate a potential malignant underlying etiology of her
possible contained perforation/diverticultis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amoxicillin ___ mg PO ONCE PRN dental cleaning
2. Digoxin 0.125 mg PO DAILY
3. enoxaparin 60 mg/0.6 mL subcutaneous Q12H
4. Furosemide 40 mg PO DAILY
5. Metoprolol Succinate XL 75 mg PO DAILY
6. Nystatin Cream 1 Appl TP BID
7. ondansetron 4 mg oral Q8H:PRN nausea
8. Potassium Chloride 20 mEq PO DAILY
9. Warfarin ___ mg PO DAILY16
10. Acetaminophen 650 mg PO Q6H:PRN pain
11. Bisacodyl 10 mg PR QHS:PRN constipation
12. Vitamin D 1000 UNIT PO DAILY
13. LOPERamide 2 mg PO QID:PRN diarrhea
14. cadexomer iodine 0.9 % topical 1 application every other day
to L ankle ulcers
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Digoxin 0.125 mg PO DAILY
3. Metoprolol Succinate XL 75 mg PO DAILY
4. Amoxicillin ___ mg PO ONCE PRN dental cleaning
5. Bisacodyl 10 mg PR QHS:PRN constipation
6. cadexomer iodine 0.9 % topical 1 application every other day
to L ankle ulcers
7. Furosemide 40 mg PO DAILY
8. Nystatin Cream 1 Appl TP BID
9. ondansetron 4 mg oral Q8H:PRN nausea
10. Potassium Chloride 20 mEq PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Ciprofloxacin HCl 500 mg PO Q12H
13. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
14. Warfarin ___ mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
___
___ and ___-Acute ___)
Discharge Diagnosis:
Large Bowel Obstruction
Diverticular Disease
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:
Ms ___,
You were admitted to ___ with abdominal pain and vomiting and
were found on CT scan to have a partial large bowel obstruction
and diverticulitis. You were kept nothing by mouth with a
nasogastric tube in place to decompress your stomach, given IV
fluids and IV antibiotics. You were also having a large amount
of diarrhea, which was sent for cultures and did not gorw
anything infectious. You have been slowly recovering and your
lab work and vital signs have been stable. You are now
tolerating a regular diet and your diarrhea has resolved. You
are ready to be discharged back to your rehab to continue your
recovery. Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon
Followup Instructions:
___
|
10223157-DS-30 | 10,223,157 | 22,211,582 | DS | 30 | 2192-10-31 00:00:00 | 2192-10-31 11:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
___ resection of sigmoid colon with descending
end-colostomy and oversew of rectum with takedown of coloileal
fistula.
History of Present Illness:
___ admitted to the Acute Care Surgical Service on
___ for evaluation and treatment of abdominal pain and
emesis. Admission abdominal/pelvic CT revealed large bowel
obstruction, in region of sigmoid, dilated large bowel, and
dilated small bowel. CT scan suggestive of fistula of rectum to
sigmoid, and small bowel loop adherent to thickened sigmoid,
with inflammatory changes surrounding the sigmoid colon and
surrounding mesentery. Patient subsequently improved on
conservative management and was discharged to rehab with plan
for
outpatient colonoscopy to further investigate sigmoid mass.
She recovered well at rehab and was followed up in the GI and
ACS
clinics. ___ was performed per GI to investigate for
risks of perforation prior to colonoscopy. However, over the
past
week she began having symptoms of nausea, vomiting, abdominal
distension and anorexia. Abdominal pain is worse on the right
and
she claims she continues to have bowel movements although she
was
not passing any gas. She endorses vomiting food and clear liquid
a couple of times a day with no hematemesis or bilious output.
She continues to be doubly incontient and did not note any blood
in stool or in her urine. There was no fever, shakes, chills or
other constitutional symptoms. She was re-admitted to ___ on
___ for further evaluation.
Past Medical History:
ATRIAL FIBRILLATION
MITRAL REGURGITATION (MODERATE ON TTE ___
HYPERTENSION
HYPERLIPIDEMIA
R PELVIC FRACTURE
CHRONIC VENOUS STASIS ULCERS
BREAST CANCER S/P L MASTECTOMY and CHEMOTHERAPY
COGNITIVE IMPAIRMENT
OSTEOPENIA
PSORIASIS
VENOUS STASIS ULCERS
CERVICAL SPONDYLOSIS
*S/P APPENDECTOMY
*S/P LUMBAR SPINE SURG FOR DISC DZ
*S/P TOTAL ABDOMINAL HYSTERECTOMY
*S/P VARICOSE VEIN STRIPPING
Social History:
___
Family History:
Per prior notes, her father died at the age of ___ and had
multiple TIAs. Mother died at age ___ of a surgical complication
and one brother died at age ___ of pancreatic cancer.
Physical Exam:
NAD, A&O to self and place
rrr,
no respiratory distress
Soft, mild post op TTP, ostomy with stool output. Midline
incision without erythema. Staples in place
Drain site with sutures in place.
MAE
Pertinent Results:
CT A/P: ___:
1. Fluid filled, dilated small bowel and distended large bowel,
terminating in
a thickened sigmoid colon, consistent with large bowel
obstruction.
2. Small amount of perihepatic ascites.
3. Bilateral pleural effusions, left greater than right.
4. Unchanged left pelvic extraluminal soft tissue density with
tethering of
adjacent bowel loops and focal thickening, probably stricture,
involving the
sigmoid colon. Fluid collections and inflammatory changes have
generally
decreased. This appearance may be secondary to stricturing from
complicated
diverticular disease but malignancy is not excluded.
5. Unchanged bilateral adnexal fullness, probably associated
with sequelae of
inflammatory changes, which have decreased. However, evaluation
with pelvic
ultrasound is recommended.
CXR: ___:
Free intraperitoneal air below the right hemidiaphragm is likely
due to
provided history of recent abdominal surgery. Marked leftward
patient rotation
limits evaluation of cardiomediastinal contours. Moderate to
large left
pleural effusion is accompanied by adjacent left lower lobe
collapse. Right
lung is clear except for minor linear atelectasis of the right
lung base and a
small adjacent pleural effusion. Repeat nonrotated radiograph
would be helpful
for more complete assessment of the chest when the patient's
condition
permits.
ECHO: ___:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with hypokinesis
of the basal septum and inferior wall. The remaining segments
contract normally (LVEF = 40-45 %). There is considerable
beat-to-beat variability of the left ventricular ejection
fraction due to an irregular rhythm/premature beats. Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). The right ventricular cavity is mildly
dilated with mild global free wall hypokinesis. The ascending
aorta is mildly dilated. There are three aortic valve leaflets.
The aortic valve leaflets are moderately thickened. No masses or
vegetations are seen on the aortic valve. There is mild aortic
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. There is a small (0.2x0.4 cm) echobright mass on the
mitral valve, which appears attached to the posterior leaflet,
seen to enter the left atrium during systole (best seen in PLAX
images). This may represent calcification, healed vegetation,
papillary fibroelastoma, or atypical/thickened appearance of a
torn chord. Severe (4+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of ___,
the gradient across the aortic valve is slightly greater; other
findings including the small mass associated with the mitral
valve appear similar. The echobright characteristics of the mass
and similar size/appearance from ___ are atypical for active
endocarditis.
Brief Hospital Course:
Mrs. ___ was admitted from the ED on ___ with recurrence
of symptoms of LBO. She was evaluated by GI as well during the
time of admission. Her symptoms had slight improvement, but she
continued to have RLQ and the CT scan showed possible thickened
sigmoid colon. On ___ She was taken to the operating room for
an open ___ with end colostomy. She initially tolerated
the procedure well. However, during her PACU stay she continued
to have low urine output. She was given multiple boluses and
albumin which did little to improve this. She did have a low
blood pressure, but it was felt that she would do well on the
floor. Unfortunately when she was transferred to the floor her
BP decreased to the mid to high 70's systolic. She was again
transferred to the PACU, under the supervision of the TSICU. She
was continued on fluid resuscitation. On POD 2 her urine output
continued to slowly improve. On POD ___ she was given
intermittent boluses and by POD5 her urine output returned to
normal. During this time she had no electrolyte abnormalities.
On POD 5 her pelvic drain was d/ced and the wound was sutured
closed. She was tolerating PO without difficulty, she was able
to move from her bed to her chair with assistance, and she had
good colostomy output. At the time of discharge she was doing
well
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Digoxin 0.125 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Ondansetron 4 mg PO Q8H:PRN nausea
4. Ferrous Sulfate 325 mg PO DAILY
5. Acetaminophen 650 mg PO Q6H:PRN pain
6. Bisacodyl 10 mg PR QHS:PRN constipation
7. Vitamin D 1000 UNIT PO DAILY
8. Warfarin ___ mg PO DAILY16
Discharge Medications:
1. Vitamin D 1000 UNIT PO DAILY
2. Furosemide 40 mg PO DAILY
3. Heparin 5000 UNIT SC TID
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone 2 mg 1 tablet(s) by mouth every ___ hours Disp
#*60 Tablet Refills:*0
5. Pantoprazole 40 mg PO Q24H
6. Acetaminophen 650 mg PO Q6H:PRN pain
7. Bisacodyl 10 mg PR QHS:PRN constipation
8. Digoxin 0.125 mg PO DAILY
9. Warfarin ___ mg PO DAILY16
10. Ondansetron 4 mg PO Q8H:PRN nausea
11. Metoprolol Succinate XL 50 mg PO DAILY
12. Ferrous Sulfate 325 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
for Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
Diverticular phlegmon of left upper quadrant with fistulization
to mid small bowel and possibly bladder.
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
___ were admitted to the hospital after a sigmoid Colectomy for
surgical management of your large bowel obstruction. ___ have
recovered from this procedure well and ___ are now ready to
return home. Samples from your colon were taken and this tissue
has been sent to the pathology department for analysis. ___ will
receive these pathology results at your follow-up appointment.
If there is an urgent need for the surgeon to contact ___
regarding these results they will contact ___ before this time.
___ have tolerated a regular diet, passing gas and your pain is
controlled with pain medications by mouth. ___ may return home
to finish your recovery.
___ have a new colostomy. It is important to monitor the output
from this stoma. It is expected that the stool from this ostomy
will be solid and formed like regular stool. ___ should have ___
bowel movements daily. If ___ notice that ___ have not had any
stool from your stoma in ___ days, please call the office. ___
may take an over the counter stool softener such as Colace if
___ find that ___ are becoming constipated from narcotic pain
medications. Please watch the appearance of the stoma, it should
be beefy red/pink, if ___ notice that the stoma is turning
darker blue or purple, or dark red please call the office for
advice. The stoma (intestine that protrudes outside of your
abdomen) should be beefy red or pink, it may ooze small amounts
of blood at times when touched and this should subside with
time. The skin around the ostomy site should be kept clean and
intact. Monitor the skin around the stoma for bulging or signs
of infection listed above. Please care for the ostomy as ___
have been instructed by the wound/ostomy nurses. ___ will be
able to make an appointment with the ostomy nurse in the clinic
7 days after surgery. ___ will have a visiting nurse at home for
the next few weeks helping to monitor your ostomy until ___ are
comfortable caring for it on your own.
___ have a long vertical incision on your abdomen that is closed
with staples. This incision can be left open to air or covered
with a dry sterile gauze dressing if the staples become
irritated from clothing. The staples will stay in place until
your first post-operative visit at which time they can be
removed in the clinic, most likely by the office nurse. Please
monitor the incision for signs and symptoms of infection
including: increasing redness at the incision, opening of the
incision, increased pain at the incision line, draining of
white/green/yellow/foul smelling drainage, or if ___ develop a
fever. Please call the office if ___ develop these symptoms or
go to the emergency room if the symptoms are severe. ___ may
shower, let the warm water run over the incision line and pat
the area dry with a towel, do not rub.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise ___ may gradually increase your activity as
tolerated but clear heavy exercise ________.
___ will be prescribed a small amount of the pain medication.
Please take this medication exactly as prescribed. ___ may take
Tylenol as recommended for pain. Please do not take more than
4000mg of Tylenol daily. Do not drink alcohol while taking
narcotic pain medication or Tylenol. Please do not drive a car
while taking narcotic pain medication.
Thank ___ for allowing us to participate in your care! Our hope
is that ___ will have a quick return to your life and usual
activities. Good luck!
Followup Instructions:
___
|
10223662-DS-8 | 10,223,662 | 27,129,617 | DS | 8 | 2167-06-12 00:00:00 | 2167-06-12 20:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Transfer for percutaneous nephrostomy.
Major Surgical or Invasive Procedure:
PCN placement
PCN re-placement
___ placement
History of Present Illness:
Ms. ___ is a ___ diabetic,
morbidly obese female with purported recurrent urinary tract
infection, ESBL organism historically recovered from urine,
transferred from two hospitals for probable percutaneous
nephrostomy ___ the context of hydronephrosis and superimposed
pyelonephritis secondary to chronic ureteropelvic junction
obstruction. She is too tired to meaningfully participate ___
this
encounter at five this morning, and asked this writer to return
instead, so much of her history is obtained from limited outside
hospital records. Patient reportedly had recurrent UTI on the
order of seven or more months, receiving several lines of
unspecified antibiotics. While she cannot recall antibiotic
names, she confirms they were all by mouth, and was never
hospitalized for intravenous ones. She has a chronic indwelling
Foley catheter, which was recently placed by a family member.
She
was apparently ___ her usual state of health until a few days ago
when she developed severe suprapubic pain consistent with prior
urinary tract infections, prompting her to seek care at
___, where a suboptimal ultrasound
exam
was equivocal for right hydronephrosis, so proceeded with CT
abdomen/pelvis, which preliminary revealed a right renal
abscess,
prompting transfer to a tertiary care ___ urology
referral, but was later amended to pyelonephritis alone ___ the
setting of chronic UPJ obstruction. She received ceftriaxone,
then meropenem ___ the context of microbiology data on record
there, indicating an ESBL E. coli (resistant to third and
fourth-generation cephalosporins) was recovered from her urine
___
___ and ___. Urine cultures have also been
positive for pan-sensitive S. agalactiae and
ampicillin-susceptible Enterococcus spp. She evidently was first
transferred to ___, yet promptly routed here
instead. Unclear if she was even evaluated there. She is
afebrile
and hemodynamically stable on arrival here. CBC is notable for
leukocytosis to 16 with neutrophilic predominance, normocytic
anemia with hemoglobin at 8.8, and thrombocytosis to 479.
Creatinine is 1.2. Urinalysis consistent with microscopic
hematuria, pyuria with WBC clumping, and few bacteria. Lactate
is
within normal limits. She received a
Past Medical History:
-Recurrent urinary tract infection.
-Non-insulin dependent type II diabetes.
-Hypertension.
-Hyperlipidemia.
-Morbid obesity.
-Obstructive sleep apnea.
-Migraine disorder.
Social History:
___
Family History:
Non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM
VITALS: T 100.6, HR 92, BP 114/69, 22, RA.
GENERAL: Obese female ___ no apparent distress.
HEENT: Anicteric sclerae. Oropharynx clear.
NECK: No supraclavicular lymphadenopathy. JVP undetectable
within
the confines of habitus.
CV: Distant heart sounds. Regular rate and rhythm. S1/S2.
Auscultation of gallop or murmur limited by habitus.
PULM: Unlabored. Anterior lung sounds distant but clear.
ABDOMEN: Soft, non-tender throughout.
BACK: Declined.
GU: Foley draining opaque yellow urine.
EXT: Warm, well perfused, chronic venous stasis dermatitis.
NEURO: non-focal.
DISCHARGE PHYSICAL EXAM
VITALS: 24 HR Data (last updated ___ @ 1122)
Temp: 98.1 (Tm 98.1), BP: 109/69 (109-126/53-70), HR: 60
(60-70), RR: 20 (___), O2 sat: 99% (93-100), O2 delivery: Ra
GENERAL: Obese female ___ no apparent distress, wearing CPAP
HEENT: Anicteric sclerae
NECK: Supple
CV: Distant heart sounds. Regular rate and rhythm. S1/S2. III/VI
ejection murmur best heard near mid-sternum/LUSB
PULM: Unlabored. Anterior lung sounds distant but clear.
ABDOMEN: Soft, NTND, R anterior PCN site c/d/i, draining minimal
light yellow non-bloody output, BS+, no organomegaly.
GU: indwelling foley draining yellow urine
EXT: WWP, chronic venous stasis dermatitis ___ ___. RUE PICC c/d/i
NEURO: Alert, answers questions appropriately, moves all
extremities
Pertinent Results:
___ 05:47AM BLOOD WBC-11.4* RBC-2.99* Hgb-7.6* Hct-27.7*
MCV-93 MCH-25.4* MCHC-27.4* RDW-17.8* RDWSD-59.2* Plt ___
___ 06:18AM BLOOD WBC-11.5* RBC-3.15* Hgb-8.0* Hct-29.2*
MCV-93 MCH-25.4* MCHC-27.4* RDW-17.6* RDWSD-59.0* Plt ___
___ 08:10PM BLOOD WBC-16.0* RBC-3.46* Hgb-8.8* Hct-29.5*
MCV-85 MCH-25.4* MCHC-29.8* RDW-17.4* RDWSD-54.2* Plt ___
___ 08:10PM BLOOD Neuts-80.6* Lymphs-12.3* Monos-5.9
Eos-0.3* Baso-0.3 Im ___ AbsNeut-12.89* AbsLymp-1.96
AbsMono-0.95* AbsEos-0.04 AbsBaso-0.04
___ 04:09AM BLOOD ___ PTT-28.5 ___
___ 08:10PM BLOOD ___ PTT-27.8 ___
___ 05:47AM BLOOD Glucose-98 UreaN-21* Creat-1.1 Na-144
K-4.6 Cl-102 HCO3-33* AnGap-9*13
___ 10:35AM BLOOD Glucose-117* UreaN-18 Creat-1.3* Na-138
K-3.9 Cl-97 HCO3-27 AnGap-14
___ 08:10PM BLOOD Glucose-104* UreaN-17 Creat-1.2* Na-139
K-3.9 Cl-97 HCO3-26 AnGap-16
___ 04:09AM BLOOD ALT-5 AST-10 AlkPhos-110* TotBili-<0.2
___ 10:35AM BLOOD ALT-5 AST-8 AlkPhos-79 TotBili-0.4
___ 05:47AM BLOOD Calcium-8.7 Phos-4.0 Mg-1.7
___ 08:00AM BLOOD Calcium-8.2* Phos-2.9 Mg-2.2
___ 09:44AM BLOOD calTIBC-157* ___ Ferritn-987*
TRF-121*
___ 09:40AM BLOOD Vanco-24.5*
___ 10:18AM BLOOD Vanco-29.3*
___ 08:10PM BLOOD Lactate-1.3
IMAGING
=======
CT ABD & PELVIS W/O CONTRAST Study Date of ___ 1:29 ___
1. Severe right-sided hydroureteronephrosis with superimposed
pyelonephritis. No definite calculus or obstructive lesion
seen, although evaluation of tumor is limited on this
noncontrast exam.
2. Prominent abdominal lymph nodes likely reactive.
NEPHROSTOMY CATHETER Study Date of ___ 5:18 ___
Marked hydronephrosis of the right kidney. 300 + cc of purulent
material aspirated from the right renal collecting system and
sent for culture.
Satisfactory placement of a ___ F right PCN by ultrasound. A CT
is recommended to confirm proper positioning given visual
limitations due to body habitus.
IMPRESSION: Successful placement of an anterior approach 10
___ nephrostomy on the right.
CT ABDOMEN W/O CONTRAST Study Date of ___ 1:58 AM
Technically limited study. Interval placement of a right
percutaneous
nephrostomy. Pigtail is probably within a mid to upper calyx of
the right
kidney, with interval improvement the degree of dilatation of
the renal
pelvis. Persistent enlargement of the kidney, ___ keeping with
known
pyonephrosis (output from the nephrostomy tube is reportedly
purulent).
CT ABD & PELVIS W/O CONTRAST Study Date of ___ 11:53 AM
1. Re-demonstrated is an anterior approach percutaneous
nephrostomy tube
terminating within the right renal collecting system, unchanged
___ position compared to the CT from ___. Limited
assessment of the right kidney ___ the absence of intravenous
contrast. Persistent stranding of fat surrounding the right
kidney noted.
2. Subsegmental atelectasis is seen at bilateral lung bases.
3. Severely enlarged main pulmonary artery concerning for
underlying pulmonary hypertension. Recommend correlation with
echocardiogram Findings.
CHEST PORT. LINE PLACEMENT Study Date of ___ 9:50 AM
Right-sided PICC line terminates at the level of the mid SVC.
Heart size is normal. Hilar and mediastinal contours are normal
aside from mild pulmonary vascular congestion. There is mild
left basilar atelectasis. There is no pleural effusion or
pneumothorax. Visualized osseous structures are grossly
unremarkable.
IMPRESSION: Right-sided PICC line terminates within the mid
SVC.
NEPHROSTOMY CATHETER Study Date of ___ 4:55 ___
Preprocedure CT scan demonstrated existing nephrostomy tube was
retracted away from the right renal collecting system. Right
renal collecting system was dilated with market perinephric
stranding.
Intraprocedural CT scans demonstrated a small window ___ between
2 bowel loops.
Final images demonstrate catheter ___ appropriate position with
pigtail ___
right nephric collection with catheter adjacent to bowel loops
but not through them.
IMPRESSION: Successful CT-guided placement of an ___ 30 cm
pigtail catheter into the collection. Samples were sent for
microbiology evaluation.
MICROBIOLOGY:
___ 8:59 pm ABSCESS Source: right kidney.
**FINAL REPORT ___
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
Reported to and read back by ___ @ ___ ON ___ -
___.
FLUID CULTURE (Final ___:
BETA STREPTOCOCCUS GROUP B. SPARSE GROWTH.
LACTOBACILLUS SPECIES. MODERATE GROWTH.
Susceptibility testing requested by ___ ___
___.
NOT VIABLE FOR SENSITIVITIES.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
BETA STREPTOCOCCUS GROUP B
|
CEFTRIAXONE-----------<=0.12 S
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.12 S
PENICILLIN G---------- 0.12 S
VANCOMYCIN------------ 0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 7:20 pm ABSCESS Source: Kidney PCN RIGHT KIDNEY
ABSCESS.
**FINAL REPORT ___
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
___ diabetic, morbidly obese w/ recurrent UTI, ESBL from prior
___ cultures, transferred from ___ to ___ to
___ for hydronephrosis and superimposed pyelonephritis ___
chronic ureteropelvic junction obstruction, covered empirically
with Vanc/Meropenem-->Meropenem after PCN placement, cultures
growing beta strep (group B) lactobacillus and now s/p PCN
re-placement on ___.
ACTIVE ISSUES
==============
#Pyelonephritis #h/o ESBL: Secondary to chronic UPJ obstruction,
possibly congenital. Initially with marked and uptrending
leukocytosis that downtrended throughout admission. Underwent
source control w/ right percutaneous nephrostomy on ___ with
reportedly purulent output. PCN was later malpositioned, so
exchanged altogether on ___. Pt has h/o ESBL E. coli from
___ cultures from ___ and ___. ID was
consulted and per their recommendations patient was empirically
treated with Vancomycin and Meropenem. PCN culture here then
growing only group B Streptococcus and Lactobacillus. Pt was
switched to meropenem monotherapy based on previous culture data
and completed a 14-day course (end-date = ___.
Patient was admitted with Foley placed at ___,
discontinued briefly ___ favor of external female urine
collection system, but did not fit properly, so Foley was
replaced. She otherwise cannot toilet alone due to habitus and
is at risk for maceration and regional skin break down. As
mobility increases, would recommend removing the Foley catheter
altogether given that it adds further risk for infection.
#Renal insufficiency: Cr 1.2 seemingly at baseline per record of
Cr 1.5 ___ ___ and 1.0-1.3 ___ years prior. Likely has some CKD
at baseline. Probable component of chronic obstructive uropathy
currently, though unilateral, and right is markedly atrophied.
Creatinine was 1.1 at the time of discharge.
#Bilateral ___ pain: mostly ___ dorsal feet, likely neuropathic
based on h/o DM. Improved with gabapentin 100 TID
#Normocytic anemia. Hemoglobin ___ 8-range from 11 months prior.
Probable component of chronic inflammation. Thrombocytosis is ___
keeping with this inflammatory state and no known hemorrhage.
Iron studies suggested a component of iron deficiency anemia
with anemia of chronic disease iso elevated ferritin. Received
IV ferric gluconate 125mg x 3d. There was no evidence of GIB
during this admission. Recommend outpatient follow up to ensure
age appropriate screening is up to date.
#Elevated INR: INR 1.4-1.5, down to 1.3 AM of ___, no evidence
of hemorrhage, could be ___ the setting of infection. Received
7500 SC heparin TID when not getting procedures.
#Skincare, breakdown prevention: applied miconazole powder.
Ordered bariatric air mattress.
CHRONIC/STABLE PROBLEMS:
========================
#Non-insulin dependent type II diabetes: Held metformin.
Initially ordered for sliding scale insulin but not requiring
any based on fingerstick checks so discontinued. Continued
diabetic diet initially but switched to regular diet per patient
request.
#Hypertension: Held triamterene/HCTZ but resumed home metoprolol
#Hypothyroidism: Received home levothyroxine
#Obstructive sleep apnea: Continued nocturnal CPAP
TRANSITIONAL ISSUES:
===================
[] Patient will need ___ follow-up for routine PCN exchange as an
outpatient (i.e., three months). PCN may eventually be
internalized.
[] ___ need nephrectomy or renal artery embolization as
definitive UPJ management. Has urology follow-up on ___.
[] Continue to encourage weight loss and healthy dietary
choices.
[] Repleted with 3 days of IV ferric fluconate for iron
deficiency anemia combined with anemia of chronic disease.
Recommend outpatient followup to ensure age appropriate
screening is up to date.
[] Patient's pharmacy prescriptions indicate omeprazole 40mg
daily (2 tabs of 20mg). Patient reports taking only 1 tab a day
(omeprazole 20mg daily) at home.
[] Triamterene-HCTZ held during admission for normotension ___
its absence. Monitor blood pressure and resume when appropriate.
[] Home piroxicam held during admission and on discharge as
patient was not requiring.
[] Patient with ___ foley during admission (discontinued
briefly ___ favor of external female urine collection system, but
did not fit properly, so Foley was replaced), did not require
home tolterodine, home regimen as follows:
#CODE: Full (confirmed)
#CONTACT: ___, husband (___)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D 1000 UNIT PO BID
2. Clotrimazole Cream 1 Appl TP BID
3. Cyanocobalamin 1000 mcg PO BID
4. Levothyroxine Sodium 250 mcg PO DAILY
5. Loratadine 10 mg PO DAILY
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Metoprolol Tartrate 50 mg PO BID
8. nystatin 100,000 unit/gram topical BID
9. Omeprazole 20 mg PO DAILY
10. rizatriptan 5 mg oral DAILY:PRN
11. Tolterodine Dose is Unknown PO TID
12. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
13. Zolpidem Tartrate 10 mg PO QHS
14. Piroxicam 20 mg PO DAILY
Discharge Medications:
1. Clotrimazole Cream 1 Appl TP BID
2. Cyanocobalamin 1000 mcg PO BID
3. Levothyroxine Sodium 250 mcg PO DAILY
4. Loratadine 10 mg PO DAILY
5. MetFORMIN (Glucophage) 500 mg PO BID
6. Metoprolol Tartrate 50 mg PO BID
7. nystatin 100,000 unit/gram topical BID
8. Omeprazole 20 mg PO DAILY
9. rizatriptan 5 mg oral DAILY:PRN
10. Vitamin D 1000 UNIT PO BID
11. Zolpidem Tartrate 10 mg PO QHS
12. HELD- Piroxicam 20 mg PO DAILY This medication was held. Do
not restart Piroxicam until you discuss with your doctor
13. HELD- Tolterodine Dose is Unknown PO TID This medication
was held. Do not restart Tolterodine until you discuss with your
doctor
14. HELD- Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY This
medication was held. Do not restart Triamterene-HCTZ (37.5/25)
until instructed by your rehab or primary provider.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
=================
Pyelonephritis
SECONDARY DIAGNOSIS:
===================
Renal insufficiency
Bilateral ___ pain
Normocytic anemia
Elevated INR
Non-insulin dependent type II diabetes
Hypertension
Hypothyroidism
Obstructive sleep apnea
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 care for you at the ___
___.
Why did you come to the hospital?
=================================
- You had a kidney infection.
What did you receive ___ the hospital?
=====================================
- ___ placed a drain to relieve the obstruction ___ your right
kidney.
- ___ replaced the drain with a different one.
- You received IV antibiotics to treat the kidney infection
- A long IV was placed ___ your right arm so you could keep
receiving the antibiotics after discharge.
What should you do once you leave the hospital?
===============================================
- Please continue taking your medications as prescribed.
- Please attend any outpatient appointments you have upcoming.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10223996-DS-6 | 10,223,996 | 28,831,691 | DS | 6 | 2180-05-13 00:00:00 | 2180-05-14 07:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Meperidine / Zithromax / Darvon / hazelnut / nut - unspecified
Attending: ___.
Chief Complaint:
abd pain ,n/v
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w h/o CAD s/p DES, HTN, CLL, recurrent SBO (this is his ___
time: ___ & ___ s/p ex-lap & SBR ___ p/w abd pain & nausea
who
presents for abd pain and nausea. Reports pain started this
morning from right UQ to right mid quadrant to midline, same as
prior SBO. Denies vomiting but has been taking Zofran that he
has
at home for "emergencies". He was having abdominal distension
since this morning and cramps that came in waves. Because this
felt similar to the prior episode and discomfort, he presented
to
the ED. Denies fever, chest pain, cough, sob. Reports had a
small thin BM this am and no flatus since then. His last meal
was
this morning and had a glass of water at 12pm. Denies dysuria.
Past Medical History:
PMH: OSA+cpap, CAD, HTN, hyperlipidemia, recurrent SBO treated
conservatively
PSH:
ex-lap & SBR ___, L4-5 laminiectomy and discectomy ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, mildly distended, nontender, no rebound or guarding,
no palpable masses
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 11:52PM URINE HOURS-RANDOM
___ 11:52PM URINE UHOLD-HOLD
___ 11:52PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 11:52PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 11:52PM URINE RBC-2 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 11:52PM URINE MUCOUS-RARE*
___ 08:42PM ___ COMMENTS-GREEN TOP
___ 08:42PM LACTATE-2.5*
___ 07:35PM LACTATE-1.7
___ 07:30PM GLUCOSE-109* UREA N-34* CREAT-1.3* SODIUM-144
POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-20* ANION GAP-23*
___ 07:30PM GLUCOSE-105* UREA N-35* CREAT-1.4* SODIUM-143
POTASSIUM-GREATER TH CHLORIDE-102 TOTAL CO2-18* ANION GAP-23*
___ 07:30PM estGFR-Using this
___ 07:30PM estGFR-Using this
___ 07:30PM ALT(SGPT)-33 AST(SGOT)-29 ALK PHOS-50 TOT
BILI-0.6
___ 07:30PM ALT(SGPT)-16 AST(SGOT)-68* ALK PHOS-26* TOT
BILI-0.6
___ 07:30PM LIPASE-39
___ 07:30PM LIPASE-39
___ 07:30PM ALBUMIN-4.8 CALCIUM-10.7* PHOSPHATE-5.3*
MAGNESIUM-2.1
___ 07:30PM ALBUMIN-4.9 CALCIUM-10.9* PHOSPHATE-5.4*
MAGNESIUM-2.2
___ 07:30PM WBC-23.8* RBC-5.66 HGB-17.7* HCT-48.7 MCV-86
MCH-31.3 MCHC-36.3 RDW-13.7 RDWSD-42.4
___ 07:30PM WBC-22.3* RBC-5.64 HGB-17.4 HCT-49.6 MCV-88
MCH-30.9 MCHC-35.1 RDW-13.9 RDWSD-44.1
___ 07:30PM NEUTS-52 BANDS-0 ___ MONOS-5 EOS-0
BASOS-0 ATYPS-2* ___ MYELOS-0 AbsNeut-12.38* AbsLymp-10.23*
AbsMono-1.19* AbsEos-0.00* AbsBaso-0.00*
___ 07:30PM NEUTS-43.7 ___ MONOS-4.5* EOS-0.6*
BASOS-0.5 NUC RBCS-0.1* IM ___ AbsNeut-9.72* AbsLymp-11.19*
AbsMono-1.01* AbsEos-0.13 AbsBaso-0.11*
___ 07:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 07:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 07:30PM PLT SMR-LOW* PLT COUNT-125*
___ 07:30PM ___ PTT-26.5 ___
___ 07:30PM PLT SMR-LOW* PLT COUNT-114*
Brief Hospital Course:
___ w h/o CAD s/p DES, HTN, CLL, recurrent SBO s/p ex-lap & SBR
___ admitted with SBO. The patient presented with severe pain
and was placed on IV morphine. An NGT was placed. He also had
low urine output and was given IVF. Eventually his diet was
advanced to clears. He opened up and was started on his home
meds. Mr. ___ was discharged from the hospital in stable
condition on HD3 tolerating a regular diet. He was asked to
follow up in ___ clinic.
Medications on Admission:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Chlorthalidone 12.5 mg PO DAILY
4. Gabapentin 600 mg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. Metoprolol Tartrate 12.5 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Chlorthalidone 12.5 mg PO DAILY
4. Gabapentin 600 mg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. Metoprolol Tartrate 12.5 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for a small bowel obstruction.
You were given bowel rest and intravenous fluids and a
nasogastric tube was placed in your stomach to decompress your
bowels. Your obstruction has subsequently resolved after
conservative management. You have tolerated a regular diet, are
passing gas and your pain is controlled with pain medications by
mouth. You may return home to finish your recovery.
If you have any of the following symptoms please call the office
for advice or go to the emergency room if severe: increasing
abdominal distension, increasing abdominal pain, nausea,
vomiting, inability to tolerate food or liquids, prolonged loose
stool, or extended constipation.
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
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities.
Followup Instructions:
___
|
10224171-DS-16 | 10,224,171 | 28,866,833 | DS | 16 | 2189-08-11 00:00:00 | 2189-08-11 17:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / pollen
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
___ Bronchoscopy
History of Present Illness:
Mr. ___ is a very pleasant ___ gentleman with a
longstanding smoking history, CHF, with last documented EF of
35%, status post NSTEMI in ___ of this year and three-vessel
CABG, LIMA to LAD, SV to OM, SV to PDA, a 50-pack-year smoking
history, squamous cell lung cancer, status post right lower
lobectomy ___, A flutter status post cardioversion
post procedure, hypertension, and dyslipidemia, presents with
shortness of breath.
Mr. ___ had previously been doing reasonably well, was
continuing to smoke several cigarettes per day, treated with
Symbicort and Spiriva, until ___ of this year when he
developed acute shortness of breath and was found to be in acute
volume overload. He was intubated ___ through ___,
also in the setting of a right upper lobe and right middle lobe
pneumonia. He was found to have an NSTEMI in that setting with
a peak troponin of 1.8 and was transferred to the ___ for
bypass surgery as I described above.
After recovering from that and returning home, he had a followup
CT scan on ___, that showed new multiple mediastinal and
hilar lymph nodes and a new spiculated lung mass 2.5 x 2.7cm in
the superior segment of the right lower lobe, which had
increased in size significantly. Bronchoscopy by Dr. ___
did not show any endobronchial lesions and 11L, 4L and 7 were
all
negative and 4R had atypical epithelial cells with an FNA of the
right lower lobe that was positive for malignant cells. As a
result, he underwent mediastinoscopy initially with Dr. ___ on
___ with a specimen from 4R that was negative and two
different specimens from 7 that were also negative. He
therefore underwent right lower lobectomy on ___,
which went
reasonably well. He was discharged to ___.
Unfortunately, he was readmitted on ___ with worsening
shortness of breath for several nights and pleuritic chest pain
and cough as well as decreased appetite. He had initially left
the hospital on between 2 and 4 liters of oxygen, which had
increased during his stay at ___. CTA on admission did not
show any PE, but did show fluid collection in the right lower
lung space and some consolidation of the left upper lobe and
right and left lower lobes. He underwent thoracentesis with the
Interventional Pulmonary Service with evacuation 150 mL of
serous fluid that was negative for culture and cytology that
showed very few atypical cells. He was treated with empiric
vancomycin and cefepime, which was transitioned to Levaquin. He
was again
discharged to ___ for followup care.
Since he has been there, he has completed his course of
antibiotics. He was noted to be positive for VRE, for which he
received one day of linezolid on the ___, but this was not
continued. He completed his antibiotic course on the ___ and he
has had serial chest x-rays following the infiltrate in the
right lower lobe which has not demonstrated any change by their
description on ___ and ___.
Other changes in his medications have been to increase his Lasix
from 20 mg to 40 mg and his respiratory medications remained the
same.
While the patient was in rehab, this time around, he began to
experience worsening shortness of breath again. He was taken to
___ where he was found to be hypoxic (unclear how much
he was desatting). He had a CXR and CT with contrast there
(which reported new consolidation vs progression tumor). When
patient arrived to our ED, initial vitals: 102.8 138 99/39 38
97% NRB. Patient's WCC was 7 but lactate was up to 3.0. Patient
was not intubated. He was given 250 cc NS x2 boluses and one
dose of levaquin. Patient was sent to the floor with two
peripheral IVs.
Past Medical History:
Past Medical History: recent acute respiratory failure d/t
systolic CHF & RML/RUL PNA, acute NSTEMI, HTN, dyslipidemia,
CAD, remote smoker
Past Surgical History: CABG ___, cataract surgery,
tonsillectomy, bilat inguinal hernia repair (of note, pt denies
carotid surgery listed in OSH records)
___ right video-assisted thoracoscopy converted to right
thoracotomy and lower lobectomy and mediastinal lymph node
dissection.
Social History:
___
Family History:
Father died of colon cancer
Mother died of a PE during childbirth
Physical Exam:
ADMISSION EXAM:
GENERAL: Alert, oriented, cachectic, breathing with accessory
muscles
HEENT: Sclera anicteric, MM very dry, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally with decreased breath
sounds at right base, no wheezes, rales, rhonchi
CV: TAchycardic and regular, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE EXAM:
Vitals: Tm/Tc 98.5, HR 97, BP 102/64, SaO2 94-96% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: Breathing comfortably, decreased breath sounds at right
base, no rales, wheezes, or rhonchi
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: +BS, soft, nondistended, nontender, no rebound or
guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Improving erythematous macules over chest where EKG
stickers had been
Neuro: Mild left eyelid drooping, otherwise grossly intact
Pertinent Results:
ADMISSION LABS:
___ 06:50PM BLOOD WBC-7.1 RBC-4.93# Hgb-13.6*# Hct-43.6#
MCV-89 MCH-27.5 MCHC-31.1 RDW-16.3* Plt ___
___ 06:50PM BLOOD Neuts-89.8* Lymphs-6.1* Monos-2.2 Eos-1.6
Baso-0.3
___ 03:20AM BLOOD ___ PTT-28.3 ___
___ 06:50PM BLOOD Glucose-128* UreaN-16 Creat-0.8 Na-135
K-4.9 Cl-105 HCO3-20* AnGap-15
___ 06:50PM BLOOD ALT-48* AST-35 AlkPhos-61 TotBili-0.3
___ 03:20AM BLOOD Calcium-7.6* Phos-4.0# Mg-1.4*
___ 08:03PM BLOOD ___ pO2-69* pCO2-36 pH-7.38
calTCO2-22 Base XS--2
___ 06:56PM BLOOD Lactate-3.0*
___ 07:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 07:00PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 07:00PM URINE RBC-3* WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
DISCHARGE LABS:
___ 05:58AM BLOOD WBC-8.4 RBC-3.45* Hgb-9.4* Hct-29.2*
MCV-85 MCH-27.3 MCHC-32.2 RDW-16.1* Plt ___
___ 05:58AM BLOOD Glucose-104* UreaN-15 Creat-0.6 Na-137
K-3.8 Cl-102 HCO3-29 AnGap-10
MICRO:
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
URINE CULTURE (Final ___: NO GROWTH.
IMAGING:
CT Trachea ___: *Preliminary Read*
IMPRESSION:
1. Status post right lower lobe lobectomy for squamous cell
carcinoma. No evidence of local recurrence.
2. Assessment for tracheobronchomalacia is limited due poor
voluntary ability to cooperate with inspiratory and expiratory
respiration tasks. No excessive collapsibility is observed but
bronchoscopic assessment or repeat trachea CT when the patient
is able to better cooperate may be considered.
3. Multifocal ground-glass, consolidative, and nodular
opacities, similar to ___ but increased since ___. Findings are most compatible with a multifocal infectious
pneumonia or cryptogenic organizing pneumonia. However, given
nodular configuration of several of these opacities, close
followup imaging is recommended to assess for resolution after
therapy.
4. Tracheobronchomegaly without central airway obstruction.
Small secretions within the lower trachea and lower lobe
bronchi. Persistent right middle lobe collapse since ___, with narrowing of the right middle lobe bronchus similar
to preoperative studies.
5. Small loculated right pleural fluid with adjacent pleural
thickening,
suggesting a complex exudative effusion.
6. Mediastinal and hilar lymphadenopathy, minimally increased
since ___.
7. Large hiatal hernia with patulous esophagus containing
retained contrast and fluid distally, which may predispose the
patient to aspiration.
8. Distended gallbladder without wall thickening.
CT CHEST WITH CONTRAST OUTSIDE HOSPITAL REPORT ___:
Dense consolidation right lower lung uncertain etiology. Debris
in the right lower lobe bronchus serving the affected lung.
Tumor progression. Acute pna or post obstructive atelactasis.
Dilation of esophagus above hiatal hernia which has increased
since the prior study. Stable mediastinal adenopathy.
Unchanged emphysema.
___ Video oropharygneal swallow:
FINDINGS:
Barium passes freely through the oropharynx and esophagus
without evidence of obstruction. There was trace penetration
with thin liquid. There was pharyngeal residue.
IMPRESSION:
Trace penetration with thin liquid.
Please refer to the speech and swallow division note in OMR for
full details, assessment, and recommendations.
___ CXR:
There is new right-sided PICC line with tip at the cavoatrial
junction. There continues to be right lower lobe collapse. There
is hazy alveolar infiltrate on the right that slightly
increased. The right-sided effusion is also slightly increased.
There is a minimally displaced right postero lateral fifth rib
fracture that is displaced more than on prior studies. The
appearance of the left lung is unchanged.
___ CXR:
Right lower lobe collapse and small right pleural effusion
unchanged. Lungs otherwise grossly clear. Heart size normal. No
pneumothorax.
Brief Hospital Course:
Mr. ___ is a ___ gentleman with a longstanding smoking
history, CHF (last documented EF of 35%), s/p NSTEMI in ___
and three-vessel CABG, squamous cell lung cancer s/p right lower
lobectomy in ___, atrial flutter s/p cardioversion post
procedure, hypertension, and dyslipiedmia who transferred from
an outside hospital for dyspnea, hypoxia, and hypotension.
# HOSPITAL-ACQUIRED PNEUMONIA: Patient was hypoxic on admission
with outside hospital chest CT notable for new RML infiltrate
vs. possible tumor progression. He was started on vancomycin,
cefepime, and levofloxacin given concern for HCAP.
Sputum cultures grew GNRs. Given hypoxia and tachycardia,
biilateral LENIs were performed and were negative for DVT.
Levofloxacin was discontinued on hospital day 2 and patient
completed an 8-day course of cefepime and vancomycin. He was
quickly weaned to room air. Due to concern for post-obstructive
pneumonia and tumor progression, a bronchoscopy was performed.
It showed very thick non-purulent secretions but no evidence of
torsion or stenosis. Interventional pulmonary recommended
mucinex ___ mg bid, mucomyst nebulizers bid, and chest
___ valve qh8 (can be weaned to bid in ___ weeks).
# SEVERE SEPSIS: On arrival to ___, patient was hypotensive
to the ___ and tachycardic and labs were notable for a rising
lactate. He spent one day in the ICU, where he received IV
fluids and was started on antibiotics for HCAP. Vital signs and
lactate normalized and patient continued to clinically improve
on the floor.
# ASPIRATION: Given patient's report of dysphagia and concern
for aspiration, a video swallow evaluation was performed. It
revealed pharyhgeal residue (solids > liquids) and intermittent
trace-mild penetration with thin liquid but no frank aspiration.
His function improved with chin tuck during swallowing and
techniques to prevent aspiration were reviewed with patient.
# TACHYCARDIA: Patient's HR was persistently in 150s in the
MICU concerning for atrial fibrillation, but repeat EKG at
slower rate revealed sinus tachycardia vs. atrial tachycardia.
His metoprolol tartrate was restarted and slowly uptitrated to
achieve adequate rate control. He was discharged on metoprolol
xl 100 mg daily.
TRANSITIONAL ISSUES:
- Patient needs to complete an 8-day treatment course for HCAP
with vancomycin and cefepime (last day ___. He has PICC in
place.
- Interventional pulmonary recommended mucinex ___ mg bid,
mucomyst nebulizers bid, and chest ___ valve qh8 (can be
weaned to bid in ___ weeks).
- To prevent aspiration, patient was instructed to keep chin
tucked while swallowing, eat small meals and chew well before
swallowing, and follow solids with sips of water.
- Megestrol was increased from 40 mg to 400 mg daily as this is
the correct dose for appetite stimulation.
- Given low-normal blood pressure, furosemide was discontinued.
Metoprolol was changed from 50 mg bid to xl 100 mg daily.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Januvia (sitaGLIPtin) 50 mg oral BID
2. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
3. Aspirin 81 mg PO DAILY
4. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Simvastatin 40 mg PO DAILY
7. Pantoprazole 40 mg PO Q24H
8. Tamsulosin 0.4 mg PO HS
9. Tiotropium Bromide 1 CAP IH DAILY
10. Alendronate Sodium 70 mg PO QSAT
11. Furosemide 40 mg PO DAILY
12. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q4H PRN
shortness of breath
13. Metoprolol Tartrate 50 mg PO BID
14. TraZODone 50 mg PO HS
15. Megestrol Acetate 40 mg PO DAILY
16. Vitamin D 1000 UNIT PO DAILY
17. Calcium Carbonate 600 mg PO BID
18. Docusate Sodium 100 mg PO EVERY OTHER DAY
19. Loratadine 10 mg PO DAILY
20. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO EVERY OTHER DAY
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Loratadine 10 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Simvastatin 40 mg PO DAILY
8. Tamsulosin 0.4 mg PO HS
9. Tiotropium Bromide 1 CAP IH DAILY
10. TraZODone 50 mg PO HS
11. Vitamin D 1000 UNIT PO DAILY
12. Alendronate Sodium 70 mg PO QSAT
13. Januvia (sitaGLIPtin) 50 mg oral BID
14. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
15. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION BID
16. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q4H PRN
shortness of breath
17. Vancomycin 1000 mg IV Q 12H
18. CefePIME 2 g IV Q8H
19. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal irritation
20. Megestrol Acetate 400 mg PO DAILY
21. Calcium Carbonate 1500 mg PO BID
22. Guaifenesin ER 1200 mg PO Q12H
23. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
- ___ pneumonia
- Sepsis
Secondary diagnoses:
- Squamous cell lung cancer s/p right lower lobectomy
- Chronic obstructive pulmonary disease
- Systolic heart failure
- Coronary artery disease
- Gastroesophageal reflux disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___. You were admitted
with a low oxygen level and low blood pressure and found to have
a pneumonia. You were treated with anbitioics and given IV
fluids and your oxygen level and blood pressure improved. A
swallow study showed that you have some difficulty swallowing,
so please remember to tuck your chin while swallowing and take
small bites. A bronchoscopy showed thick secretions but no
evidence of obstruction. Please remember to use the flutter
valve.
Please continue to take your medications as prescribed and keep
your follow-up appointments.
-Your ___ Team
Followup Instructions:
___
|
10224335-DS-11 | 10,224,335 | 27,287,008 | DS | 11 | 2190-02-19 00:00:00 | 2190-02-19 16:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Bloody drainage from ___ drain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male status post pylorus-preserving Whipple
procedure on ___,
discharged home on ___. He had a small pancreatic leak
noted
prior to discharge, and was sent home with a JP drain ___ place.
The afternoon prior to presentation, his wife noted his drainage
changed from milky white to dark red/brown. There was no bright
red blood, spurting drainage, or increased amount of drainage.
He
is otherwise feeling well.
Past Medical History:
Coronary artery disease
History of MI, stent ___ place
Hypertension
Arthritis
Dyslipidemia
Gout
GERD
multiple knee operations
Adenocarcinoma of the duodenum
Social History:
___
Family History:
No family history of early MI, otherwise non-contributory.
Physical Exam:
On Admission:
Vitals: T 99.6, HR 77, BP 146/96, RR 16, O2 98% 2l
Gen: a&o x3, nad
CV: rrr, no murmur
Resp: cta bilat
Abd: soft, NT, ND, +BS; healing surgical incision; JP drain ___ R
abdomen without surrounding erythema, induration, or drainage;
dark red/brown fluid ___ bulb
Extr: warm, well-perfused, 2+ pulses
DRE: normal tone, no gross or occult blood
On Discharge:
VS: 97.9, 68, 154/90, 14, 96% RA
GEN: NAD
CV: RRR, no m/r/g
Lungs: CTAB
Abd: Soft , NT/ND. Subcostal incision with steri strips and
healing well. R JP drain to bulb suction with minimal milky
output. JP site with dry dressing and c/c/d.
Extr: Warm, no c/c/e
Neuro: AAO x 3
Pertinent Results:
___ 05:23AM BLOOD WBC-7.9 RBC-3.74* Hgb-9.5* Hct-30.2*
MCV-81* MCH-25.5* MCHC-31.5 RDW-18.9* Plt ___
___ 04:58AM BLOOD Glucose-151* UreaN-21* Creat-0.8 Na-135
K-4.3 Cl-101 HCO3-26 AnGap-12
___ 05:44AM BLOOD Glucose-122* UreaN-22* Creat-0.8 Na-136
K-4.4 Cl-103 HCO3-27 AnGap-10
___ 05:05AM BLOOD Glucose-128* UreaN-17 Creat-0.8 Na-136
K-4.2 Cl-102 HCO3-26 AnGap-12
___ 05:21AM BLOOD Glucose-127* UreaN-15 Creat-0.8 Na-135
K-4.1 Cl-101 HCO3-28 AnGap-10
___ poorly defined fluid/gas collection adjacent to the
pancreatojejunostomy raising concern for an anastamotic leak.
Early abscess cannot be excluded with this technique. Also,
slight interval increase ___ fluid around the pancreatic body and
tail. No definite pseudoaneurysm or evidence of active contrast
extravasation. Patent main portal vein, splenic vein, and SMV.
___ ABD CT:
IMPRESSION:
Slight interval decrease ___ size of ill-defined fluid collection
adjacent to site of pancreatico-jejunostomy and extending along
the inferior aspect of the pancreas. No defined abscess.
Small new ill-defined fluid collection along the inferomedial
aspect of the stomach without enhancing wall.
Contrast did not reflux up to the stump to assess for leak here.
Unchanged prominent mesenteric, porta hepatis and
retroperitoneal lymph nodes.
Small left pleural effusion.
MICRO:
___ 9:27 am PERITONEAL FLUID FROM JP DRAIN.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ Reported to and read back by ___. ___ (___)
AT 2:10
___.
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
FLUID CULTURE (Final ___:
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
Work-up of organism(s) listed below discontinued (excepted
screened
organisms) due to the presence of mixed bacterial flora
detected
after further incubation.
KLEBSIELLA PNEUMONIAE. HEAVY GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/tazobactam sensitivity testing available
on request.
HAEMOPHILUS SP. MODERATE GROWTH.
SENSITIVITIES: MIC expressed ___
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
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Final ___:
Mixed bacterial flora-culture screened for B. fragilis, C.
perfringens, and C. septicum.
CLOSTRIDIUM PERFRINGENS. SPARSE GROWTH.
BACTEROIDES FRAGILIS GROUP. HEAVY GROWTH.
BETA LACTAMASE POSITIVE.
Brief Hospital Course:
Patient s/p Whipple procedure on ___ was readmitted to HPB
Surgery Service with new bloody output from JP drain. The JP
drain was placed intraoperatively and was left ___ place after
discharge for known pancreaticojejunostomy leak. His initial CT
scan on admission showed a poorly defined gas/fluid collection
near the pancreaticojejunostomy. He was admitted and made NPO
with IVF and had his JP drain placed to wall suction. His
initial JP amylase was ___, however he felt and looked
remarkably well. PICC line was placed on HD # 2 and TPN was
started.
Neuro: The patient required minimal pain medications throughout
this admission.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. Cardiac
medications and Lasix was restarted after admission.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Early
ambulation and incentive spirrometry were encouraged throughout
hospitalization.
GI/GU/FEN: On admission, patient was made NPO with IV fluids.
His drain output was monitored closely and remained a yellow
cloudy fluid throughout his admission. He had a PICC line placed
and was started on TPN HD 2. His sugars were initially high on
TPN and he ultimately required 56 units of regular ___ a full bag
of TPN. He was continued on TPN through ___. The output
from the drain however dropped from 300-400/day down to less
than 10 on HD # 8 POD # 17 and remained this way until
discharge. The patient at this time appeared clinically well and
so he underwent a CT scan to re-evaluate the collection. ___
comparing the CT scan from ___ to ___ it appeared that the
collection was stable and that the drain was well placed. As he
appeared clinically well the JP drain was first placed to
gravity on HD 7, POD 17 and then back to JP bulb suction only on
HD 8, POD 18 and was only having scant output. He appeared so
well that a clear diet was started, which was tolerated well,
without abdominal pain or increase ___ drain output. He was then
discharged on regular diet without TPN. Electrolytes were
routinely followed, and repleted when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. On HD 2 (___) he
was started on Unasyn and was noted to have no leukocytosis. He
did become febrile to 100.4 on HD 3 ___ the setting of receiving
a unit of blood. He only received ___ unit of RBC defervesce and
than had an additional unit transfused without fever. He was
continued on Unasyn through ___, at which point he was
transitioned to Augmentin to be continued at least through
follow up appointment with Dr. ___. His cultures from the
peritoneal fluid collected on ___ grew out C. perfringens
and B. fragilis as well as pan sensitive K. Pneumonia and
Hemophilus. He was discharged on Augmentin.
Endocrine: The patient's blood sugar was monitored throughout
his stay. While on TPN his sugars were noted to be low 200s
initially and did require insulin regular at 56 units per TPN
bag administration. At 56 units his sugars were controlled ___
the low 100s. After discontinue of TPN, patient's blood sugar
returned within normal limits. Patient was discharged home with
glucometer to continue monitoring his blood glucose. Insulin
teaching was started prior discharge.
Hematology: The patient's complete blood count was examined
routinely. He did receive 1.5 units of RBCs for Hct of 25.6 on
HD 2 with appropriate bump ___ Hct. He required no further
transfusions.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
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:
allopurinol ___, amlodipine 5', atorvastatin 80', carvedilol
25'', lasix 20', lisiniopril 40', pantoprazole 40'', ASA 81'
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
5. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
9. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
10. One Touch Ultra System Kit Kit Sig: One (1) kit
Miscellaneous before breakfast, lunch and dinner.
Disp:*1 kit* Refills:*0*
11. lancets Misc Sig: One (1) lancet Miscellaneous before
breakfast, lunch and dinner.
Disp:*1 box* Refills:*2*
12. test strips Sig: One (1) strip before breakfast, lunch and
dinner.
Disp:*1 box* Refills:*2*
13. Alcohol Pads Pads, Medicated Sig: One (1) pad Topical
before breakfast, lunch and dinner.
Disp:*1 box* Refills:*2*
14. Humalog 100 unit/mL Cartridge Sig: ___ units Subcutaneous
before breakfast, lunch and dinner: please see sliding scale
provided upon discharge.
Disp:*1 cartridge* Refills:*2*
15. insulin needles (disposable) 30 X ___ Needle Sig: One (1)
needle Miscellaneous before breakfast, lunch and dinner.
Disp:*1 box* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pancreaticojejunostomy leak s/p Whipple procedure
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.
.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid ___ 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.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself ___
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10224335-DS-13 | 10,224,335 | 22,606,002 | DS | 13 | 2192-07-05 00:00:00 | 2192-07-06 18:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
confusion and bilateral vision loss
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ M w Stage IIIC duodenal adenocarcinoma
metastatic to liver/lung ___ Whipple and chemo, also with HTN,
HLD, CAD ___ stent, PE/DVT ___, prior ___ transferred from OSH
with new visual changes and confusion.
The history is difficult to ascertain from the patient directly
due to what appears to be a mild nonfluent aphasia. Per his
wife, he had been in his usual state of health until ___
when he woke up with a constant frontal headache that was
associated with constant blurry vision. The headache was
non-throbbing, not clearly positional and associated with
nausea.
He had no diplopia and vision was not worse in one eye or the
other. He had no associated weakness, numbness or sensory
change.
Initially the symptoms were mild and Mr. ___ was able to
carry
on with daily activities of driving and cooking at home. He went
for his scheduled chemotherapy on ___. When his symptoms
persisted throughout the day on ___ he scheduled an
optometry visit for ___ morning.
He woke up with the same headache and vision change on ___
and
went to his optometry appointment at 11AM. He had a dilated
exam
that was normal and was told that he needed a new prescription
and also that he may have early cataracts. No vascular
abnormality was noted. Over the course of the day, his wife
thinks his vision got worse. He appeared to be looking past her
and was staring out of a window when attempting to watch TV.
With respect to speech, she felt like he was able to maintain
conversations but he had some word-finding difficulty. By 5pm
she felt like his vision was much worse and he was confused,
having difficulty with household tasks and forgetting names of
familiar people. Because his vision seemed much worse, she gave
him an aspirin and called EMS. He was noted to be AAOx3 and with
full strength and was taken to ___.
At ___ , BP was 162/92, HR 64. He was sent for CT that
showed multiple right parietal embolic-type infarcts. Labs were
notable for a very elevated troponin of 1.27/CK 215 although he
reported no CP, SOB, n/v, fevers/chills. EKG was sinus and
documented as "nothing acute". Although concern was for
possible
NSTEMI, no heparin was started due to concern for the parietal
lobe hypodensities. He was transferred to ___ for further
evaluation. Repeat trops 1.3 and Cardiology and Neurology were
consulted.
On neuro ROS, the pt denies diplopia, dysarthria, dysphagia,
lightheadedness, vertigo, tinnitus or hearing difficulty. Denies
difficulties producing or comprehending speech. Denies focal
weakness, numbness, parasthesiae. No bowel or bladder
incontinence or retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
- HTN
- HLD
- duodenal cancer (dx ___ ___ pylorus sparing Whipple, on
chemotherapy. He is being maintained on the DeGramont regimen of
___ ___, Lucovorin and CI ___ ___
- Obesity
- COPD
- History of MI ___, stent in place. Cardiologist in Dr.
___. Troponin leak and cardiac
catheterization ___ at ___ which per report showed no
acute occlusion.
-Gout
-GERD
-RLE DVT ___ and bilateral pulmonary emboli
found incidentally on staging CT ___ for which he was on
anticoagulation
-multiple bilateral knee operations (no replacements)
ONCOLOGIC HISTORY:
- ___: during work-up for knee replacement, found to be
anemic and upper endoscopy by Dr. ___ at ___ that
showed a massive polyp complex in the duodenum and biopsies
showed a large adenoma with at least high-grade dysplasia if not
possible intramucosal carcinoma. Dr. ___ this
further by endoscopic ultrasound and the scope could not be
completely passed.
- ___: with Dr. ___ pylorus sparing Whipple.
Adenocarcinoma of the duodenum with invasion through the
muscularis propria into subserosal soft tissue (pT3);
lymphovascular invasion is present with ___ lymph nodes
positive. A small anastomotic leak was noted at discharge and
patient was readmitted with bloody output from the drain from
___ to
___ thought to be secondary to a pancreatic fistula leak.
- ___: RLE DVT and b/l pulmonary emboli found ___
- ___: started FOLFOX and ___ completed cycle ___
- ___: progression of liver/lung disease on CT imaging
with rising CA ___: cycle 1 day ___ FOLFIRI, C___
Social History:
___
Family History:
Biologic father's medical history unknown.
Mother died of 'liver cancer' at ___ years old.
Sister is healthy.
No other known history of cancer.
Physical Exam:
Physical Exam:
Vitals: 97.8 59 153/94 16 97%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: 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 self, month, hospital (slow to
name it). Able to name ___ backward slowly. He appears to have a
mild nonfluent aphasia and has difficulty telling his history
spontaneously, although there is intact repetition and
comprehension. There were no paraphasic errors. Unable to see
the NIHSS card. Speech was not dysarthric. Able to follow both
midline and appendicular commands. Pt was able to register 3
objects and recall ___ at 5 minutes. Poor vision limits
assessment of neglect.
-Cranial Nerves:
II: Vision is so poor that he can only tell if my flashlight is
on or not. He cannot count fingers, but can tell if it is
moving
only when presented in the left visual field.
RIGHT pupil is 5->4. LEFT Pupil is 3.5->2.5mm. On fundoscopic
exam was difficult to visualize optic disc margins.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was upgoing on the left, equivocal on the
right.
-Coordination: No intention tremor. poor vision limits FNF. He
does perform HKS bilaterally.
-Gait: Normal base and arm swing
Pertinent Results:
**********
Laboratory Data:
136 ___ AGap=16
4.4 22 1.0
CK: 175 MB: 8
TROP 1.3 --->1.3---> 1.25
7.5 / 12.7/ 100 / 110
N:76.6 L:17.6 M:2.6 E:2.5 Bas:0.7
OSH Labs: BUN/Cr ___, Na 139, AST/ALT 65/47, AP 162, CK 215,
CKMb 7.6, tropT 1.27, WBC 7.7, Hct 35.2, plt 121, UA neg
EKG:
sinus, 57, LAFB, TWI in III, TW flattening in aVF (prev TWI), J
point elevation in V2-V3, upright T in V1-V4 when previous TWI
on
last EKG ___
Non-Contrast CT of Head:
OSH CT head: mild frontal cortical atrophy. 11mm wedge shaped
area of hypoattenuation in the posterior R parietal, a second 2
cm area of low attenuaion in the posterior R pariental, areas of
low-attenuation in posterior R parietal lobe, also 1.3 cm
hypodensity in the posterior right frontal lobe likely edema.
Picture consistent with subacute or old posterior R parietal
infarcts.
MRI Brain
MRI BRAIN
There are multiple acute infarcts identified. A left posterior
cerebral artery
territory infarct as well as a right parietal occipital
posterior cerebral
artery infarct are identified. In addition, there are multiple
small infarcts
seen in both cerebral hemispheres in the parietal and frontal
lobes as well as
several foci of acute infarction within both cerebellar
hemispheres. Small
acute infarct is seen in the left thalamus. There is no midline
shift or
hydrocephalus. Mild changes of small vessel disease seen. No
abnormal
enhancement identified. No evidence of acute or chronic blood
products.
IMPRESSION:
Multiple acute infarcts are identified without blood products as
described
above. The larger infarcts are seen in both posterior cerebral
artery
territories.
CT TORSO
FINDINGS:
CHEST: Two new pulmonary nodules are seen in the right middle
lobe, measuring 12 x 7 mm (2:37) and 8 x 6 mm (2:40).
Innumerable sub 4 cm pulmonary nodules are again seen throughout
the lungs. Some of the nodules appear to be new from prior exam
while other previously seen nodules are less conspicuous on this
exam. A subpleural nodule measuring 13 x 6 mm (2:46) is seen in
the left lung base, unchanged from prior exam. The lungs are
otherwise clear. The airways are patent to the subsegmental
levels bilaterally. No pathologically enlarged axillary,
mediastinal, or hilar lymph nodes are identified. There is no
pleural effusion. The heart and pericardium are within normal
limits.
ABDOMEN: LIVER: Innumerable hypodense lesions are seen scattered
throughout the liver, new from prior exam and consistent with
increased metastatic disease. There is no biliary ductal
dilatation.
GALLBLADDER: The patient is status post cholecystectomy.
PANCREAS: The patient is status post Whipple. The remaining
pancreas enhances homogeneously and is unremarkable.
SPLEEN: The spleen demonstrates a focal hypodense lesion, which
could
represent metastasis or possibly an infarct.
ADRENALS: The adrenal glands are unremarkable bilaterally.
KIDNEYS: A hypodensity is seen in the left kidney too small to
characterize
likely representing a renal cyst. The kidneys are otherwise
unremarkable.
GI: The patient is status post Whipple. The remaining stomach,
remaining small bowel, and large bowel are normal in caliber and
unremarkable. The appendix is unremarkable.
RETROPERITONEUM: There is no retroperitoneal or mesenteric
lymphadenopathy.
VASCULAR: The abdominal aorta demonstrates atherosclerotic
calcifications but is otherwise normal in appearance.
PELVIS: There is colonic diverticulosis without diverticulitis.
The sigmoid colon and rectum are normal in appearance. The
distal ureters and bladder are normal. There is no pelvic or
inguinal lymphadenopathy. There is no free fluid in the pelvis.
BONES AND SOFT TISSUES: Sclerotic osseous lesions suspicious for
metastatic disease are seen in T12 and L2. The lesion in L2
demonstrates destruction of the cortex of the vertebral body
with large soft tissue component of the tumor, which measures
3.9 x 3.3 cm. A sclerotic lesion is seen in the sacrum adjacent
to the SI joint on the left.
IMPRESSION:
1. Two new pulmonary nodules in the right middle lobe, which may
represent
metastatic disease.
2. New innumerable hypodense lesions scattered throughout the
liver,
consistent with increased metastatic disease.
3. Splenic hypodense lesion, which could represent metastasis or
possibly
infarct.
4. Sclerotic osseous lesions in T12 and L2, consistent with
metastatic
disease. The L2 lesion demonstrates cortical destruction and a
large soft
tissue component.
The study and the report were reviewed by the staff radiologist.
ECHOCARDIOGRAM
The left atrium is mildly dilated. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. The estimated right atrial pressure is
___ mmHg. Left ventricular wall thicknesses and cavity size are
normal. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. There is moderate
global left ventricular hypokinesis (LVEF = 30 - 35 %). Right
ventricular chamber size is normal. with mild global free wall
hypokinesis. Tricuspid annular plane systolic excursion is
depressed (1.2 cm) consistent with right ventricular systolic
dysfunction. The aortic root/aortic arch is mildly dilated. The
ascending aorta is moderately dilated. The aortic valve leaflets
(3) are mildly thickened. There is no aortic valve stenosis.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate (___) mitral regurgitation is seen.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Moderately, globally depressed left ventricular
function with mild right ventricular free wall hypokinesis. Mild
aortic and mild to moderate mitral regurgitation. Grade I left
ventricular diastolic dysfunction. Moderate dilation of the
ascending aorta. No echocardiographic evidence of persistent
foramen ovale/atrial septal defect.
Brief Hospital Course:
NEUROLOGY RESIDENT PROGRESS NOTE
___ is a ___ M h/o duodenal cancer metastatic to liver
and lung ___ chemo, HTN, CAD ___ stent, PE/DVT ___, prior ___
transferred from OSH with decreased visual acuity and confusion
in the setting of a possible STEMI (troponins elevated to 1.3
although without chest pain or EKG changes). On arrival to
___ neurological exam was significant for near complete loss
of bilateral vision, inattention and nonfluent aphasia. Visual
acuity was so poor he could only recognize a bright light or
finger movement in the left visual field at a distance of ___
feet. He had preserved strength, sensation, and cerebellar
function. CT from OSH showed multiple parietal embolic-type
infarcts and MRI confirmed large-territory left PCA as well as
right MCA inferior division infarcts. He has a known history of
prior DVT/PE, and metastatic cancer suggestive of a
hypercoagulable baselin. In the setting of troponin elevation
there was suspicion was for cardioembolic etiology. The exam
findings and imaging were consistent with cortical vision loss
from embolic stroke.
We preformed an echocardiogram to look for PFO or cardiac
thrombus and found none, although he has significant hypokinesis
and poor ejection fraction in the setting of his prior MIs. To
assess his metastatic lesion burden, we sent him for a CT torso
which unfortunately revealed likely new mestastases in the lung,
liver, spleen and spine, presumably from his duodenal carcinoma.
We discussed the findings with the patient's Oncologist, Dr.
___, who agreed with our plan to start coumadin for
further embolic stroke prevention. We gave a 1-time dose of
warfarin 5mg on ___ and subsequent INR was elevated to 2.3,
increased from 1.2 at baseline. We discussed the case with
pharmacy, who felt that the rise was due to a
warfarin-allopurinol interaction and advised a low dose warfarin
1mg daily on discharge. We discussed the plan with the
patient's Oncologist, Dr. ___ who agreed to draw
INRs at his office on ___ and will adjust his dose
accordingly.
At time of discharge the patient's exam had improved
significantly. His vision is close to baseline though continues
to be blurry in both eyes. Visual acuity on the left is worse
than right but this is baseline. The patient's speech,
orientation and congition improved to baseline and there were
minimal neurological findings at discharge aside from the vision
findings. Dr. ___ help to coordinate INR management
as outpatient.
Neuro:
- MRI head w/wout contrast demonstrated new bilateral posterior
occipital infarcts.
- fasting lipid panel (LDL-56) and HBA1c (5.8%)
- Discontinued aspirin. Do not restart unless there is a clear
indication as outpatient
- Starting heparin 1mg daily. He had a 1-time dose of 5mg on
___ and that increased INR to 2.3 likely due to interaction
with allopurinol. INR goal is ___.
- Restart home blood pressure meds
- Continue atorvastatin 40mg daily
CV:
-Cardiac enzymes peaked at 1.3, trended down to 1.25 by third
set. EKG showed no persistent ST changes. Cardiology
assessment was that EKG showed J
point elevation in V2-V3, amd upright T in V1-V4 when there was
previous TWI on
last EKG ___
- Tele shows EF 30% with wall motion abnormalities but no PFO
- Telemetry captured no Afib
HEME/ONC:
- Multiple metastatic lesions in the liver, spleen, spine and
lung. (See CT abdomen)
- Discussed case with outpatient Onc Dr. ___. Agrees with
anticoagulation with warfarin low dose.
- Will follow up on ___ in clinic for INR check
Medications on Admission:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Amlodipine 5 mg PO DAILY
4. Allopurinol ___ mg PO QHS
5. Lisinopril 2.5 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO QHS
2. Atorvastatin 40 mg PO DAILY
3. Lisinopril 2.5 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Warfarin 1 mg PO DAILY16
RX *warfarin [Coumadin] 1 mg 1 tablet(s) by mouth daily Disp
#*10 Tablet Refills:*0
6. Amlodipine 5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
1. Primary Diagnosis: bilateral parietal occipital ischemic
strokes
2. Secondary Diagnosis: new lesions in the liver, lung, and
spine concerning for metastatic cancer lesions
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ on ___ with confusion and
loss of vision in both eyes. You were first taken to an outside
hospital where you had elevated cardiac enzymes and a CT was
done which showed multiple areas of suspected stroke. We
repeated imaging of your brain when you arrived at ___
and that confirmed at least 2 or 3 areas of stroke near the back
of your brain in a region called the occipital lobe. This is an
area that is involved in vision and may explain your symptoms.
Due to your history of cancer, we obtained a CT scan of your
chest and abdomen and that test revealed a number of areas of
concerning new lesions: Those areas include the lung, liver,
spleen and spine. We discussed your case with your Oncologist
Dr. ___ agreed that starting a blood thinning
medication would be indicated to prevent further strokes. We
started a medication called WARFARIN or COUMADIN to thin your
blood, at a low dose of 1mg DAILY. You will need to closely
monitor blood levels of this drug, at least ___ times per week
and Dr. ___ will help arrange this for you.
WE ARE STOPPING YOUR HOME ASPIRIN DOSE to prevent unnecessary
bleeding risk, please discuss with your PCP if there is any
reason to continue it.
Please follow up with Dr. ___ office ON ___ FOR THE
FIRST INR DRAW. He will see you in clinic on ___ and may
make changes to your dose. We will also plan to see you in
Stroke Clinic at ___.
PLEASE NOTE:
Your symptoms were caused by an ACUTE ISCHEMIC STROKE, a
condition where a blood vessel providing oxygen and nutrients to
the brain is blocked by a clot. 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: cancer, poor heart function
We are changing your medications as follows: ADDING WARFARIN 1mg
DAILY
Please take your other medications as prescribed.
Please followup 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
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization.
Followup Instructions:
___
|
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