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10224362-DS-18 | 10,224,362 | 20,664,466 | DS | 18 | 2157-12-17 00:00:00 | 2157-12-18 20:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
diltiazem / ether
Attending: ___.
Major Surgical or Invasive Procedure:
Thoracostomy insertion ___ with removal on ___
attach
Pertinent Results:
Admission Labs
-----------------
___ 07:12AM BLOOD WBC-8.4 RBC-3.91* Hgb-11.7* Hct-37.2*
MCV-95 MCH-29.9 MCHC-31.5* RDW-15.0 RDWSD-51.4* Plt ___
___ 10:03PM BLOOD ___ PTT-36.9* ___
___ 12:53AM BLOOD Glucose-226* UreaN-11 Creat-1.0 Na-134*
K-4.3 Cl-95* HCO3-27 AnGap-12
___ 08:06AM BLOOD ALT-12 AST-20 AlkPhos-151* TotBili-0.8
___ 12:53AM BLOOD proBNP-1525*
___ 10:03PM BLOOD cTropnT-<0.01
___ 12:53AM BLOOD Calcium-9.1 Phos-3.3 Mg-2.0
___ 01:08PM PLEURAL TNC-1875* ___ Polys-38*
Lymphs-40* Monos-0 Eos-2* Baso-1* Macro-19* Other-0
___ 01:08PM PLEURAL TotProt-6.6 Glucose-10 LD(LDH)-4130
Cholest-145 proBNP-1650
Discharge Labs
___ 06:12AM BLOOD WBC-6.1 RBC-3.99* Hgb-12.0* Hct-38.3*
MCV-96 MCH-30.1 MCHC-31.3* RDW-14.9 RDWSD-52.7* Plt ___
___ 06:12AM BLOOD ___ PTT-35.6 ___
___ 06:12AM BLOOD Plt ___
___ 06:12AM BLOOD Glucose-90 UreaN-15 Creat-1.0 Na-141
K-5.4 Cl-96 HCO3-34* AnGap-11
___ 06:12AM BLOOD ALT-17 AST-21 AlkPhos-143* TotBili-0.6
___ 06:12AM BLOOD Albumin-3.6 Calcium-9.7 Phos-4.1 Mg-2.0
___ 1:08 pm PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Pleural fluid, left:
POSITIVE FOR MALIGNANT CELLS.
- Metastatic lung adenocarcinoma.
- Immunohistochemical stains show the tumor cells to be positive
for TTF-1 and to show weak-focal
positivity for Napsin-A.
Note: The tumor cells in this specimen are morphologically
similar to those present in the prior left
lower lobe wedge resection ___, reviewed). The prepared
cell block has low tumor
cellularity.
Imaging
-------------
CTA Chest ___
1. No pulmonary emboli.
2.Progressive, loculated, large left pleural effusion, for which
thoracentesis may provide more definitive assessment with
regards
to etiology, with resultant atelectasis of the entire LLL and
posterior lingula.
3.Stable postoperative changes in the superior LLL.
4. Progressive inferior thickening of the linear
scarring/atelectasis
in the RLL.
5. Mild lung emphysema.
6. Mild atherosclerosis, with stable 4.5 cm ascending aortic
aneurysm and stable stented 4 cm aneurysm of the proximal most
abdominal aorta.
7.Progressive, mild bilateral hilar lymphadenopathy.
Pathology: ___: Lung adenocarcinoma, TTF-1 and Napsin
positive, see synoptic report.
CXR ___
IMPRESSION:
Left pleural effusion has decreased in volume. There is
improved
atelectasis
in the left lower lobe. Cardiomediastinal silhouette is stable.
Small right
pleural effusions unchanged.
CXR ___
IMPRESSION:
1. Interval decrease in size of the left pleural effusion.
2. Associated compressive atelectasis of the left lower lobe.
3. No pneumothorax.
CXR ___
IMPRESSION:
In comparison with the study of ___, the left chest tube
remains in
place and there is little change in the degree of pleural
effusion with
compressive atelectasis at the base. No evidence of appreciable
pneumothorax.
Cardiomediastinal silhouette is stable. There has been
substantial
improvement in pulmonary vascular status with only relatively
mild vascular,
congestion at this time.
CXR ___
IMPRESSION:
No significant change in left-sided pigtail catheter.
Cardiomediastinal
silhouette is stable. There may be interval improvement in
aeration of the
left lung base with persistent small left pleural effusion with
compressive
atelectasis. Mild prominence of the pulmonary vasculature.
Left basilar and
retrocardiac atelectasis. Tortuous aorta. There are no
pneumothoraces.
Brief Hospital Course:
___ is a ___ year old male with a history of CHF,
COPD, A. fib, lung carcinoma (status post resection in ___,
AAA (is post stenting ___ transfer from outside hospital due
to worsening dyspnea on exertion over the last 5 weeks due to
acute on chronic CHF exacerbation and large exudative L pleural
effusion secondary to metastatic lung adenocarcinoma. His
dyspnea improved with IV diuresis and with drainage of left
sided pleural effusion via a thoracostomy tube and was
discharged on room air. He will follow up with interventional
pulmonology for consideration of insertion of a Pleurx catheter
as an outpatient. He will also need follow up with
hematology-oncology for further care.
TRANSITIONAL ISSUES:
==========================
Discharge Cr: 1.0
Discharge Weight: 118.48 kg (261.2 lbs)
Discharge Diuretic: Furosemide 20mg PO daily
[] Patient will need to follow-up with interventional
pulmonology for consideration of placement of a pleurx
outpatient.
[] Patient may benefit from further titration of his Lasix
dosing given he required repeated diuresis during this
hospitalization for concerns of volume overload and pulmonary
congestion.
[] Patient's supplemental potassium was stopped in the setting
of his climbing potassium levels while hospitalized. Please
recheck patient's labs and determine if he requires reinitiation
of this.
ACUTE ISSUES:
=============
#Lung adenocarcinoma s/p VATS with resection
#Exudative L pleural effusion ___ Stage 4 Lung Adenocarcinoma
Presented with hypoxia that was suspected to be secondary to a
large left pleural effusion. Interventional pulmonology placed a
chest tube on ___ with pleural studies significant for an
exudative effusion with cytology showing metastatic lung
adenocarcinoma. His gram satin and culture was negative for any
growth. His chest tube was pulled on ___ with a plan for
consideration of outpatient Pleurx insertion. Oncology was
contacted to help arrange follow-up with Thoracic Oncology.
#Acute on chronic diastolic CHF exacerbation (EF65-70% in
___
Presenting with progressive dyspnea with an elevated BNP and
crackles at the R base and large L pleural effusion, and thus
some aspect of hypoxia attributed to CHF exacerbation. He was
started on IV diuresis with Lasix and was was down 6 kg during
this admission with a discharge weight of 118.48 kg. He was
discharged on his home Lasix 20mg PO daily, with instructions to
follow-up with his cardiologist for further consideration of
dose adjustments.
#Leukocytosis
Had a bump in his WBC count to 12.5 on ___ but without any
infectious symptoms or spikes in fevers. His wbc count down
trended to normal levels without any intervention.
#COPD
His home Spiriva and Advair were held and transitioned to
duonebs while in house. His inhalers were restarted upon
discharge.
CHRONIC ISSUES:
===============
#AAA s/p PMEG ___ w/ CTA ___ showing stable sac size but
c/f type 1b vs type 2 endoleak
Follows with vascular surgery. Planned for surgery but postponed
given recent admissions
#OSA
Continued home CPAP with ___
#Atrial fibrillation
- AC: His home Rivaroxaban was held and was transitioned to a
heparin gtt pending his thoracostomy placement. His home
Rivaroxaban was restarted upon discharge.
- RC: continued verapamil 120mg XL daily and metoprolol 100mg XL
daily
#HLD
Continued home atorvastatin
#Chronic pain
Continued home buproprion and tramadol
CORE MEASURES
=============
#CODE: Full code
#CONTACT: ___ (wife) ___ or ___
Greater than ___ hour spent on care on day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tiotropium Bromide 1 CAP IH DAILY
2. Rivaroxaban 20 mg PO DAILY
3. Albuterol Inhaler 1 PUFF IH Q6H:PRN dyspnea
4. Atorvastatin 40 mg PO QPM
5. BuPROPion XL (Once Daily) 150 mg PO DAILY
6. TraMADol 50 mg PO BID:PRN Pain - Moderate
7. Verapamil SR 120 mg PO Q24H
8. Furosemide 20 mg PO DAILY
9. Potassium Chloride 20 mEq PO DAILY
10. Metoprolol Succinate XL 100 mg PO DAILY
11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
Discharge Medications:
1. Albuterol Inhaler 1 PUFF IH Q6H:PRN dyspnea
2. Atorvastatin 40 mg PO QPM
3. BuPROPion XL (Once Daily) 150 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
RX *fluticasone propion-salmeterol 250 mcg-50 mcg/dose 1 puff IH
once a day Disp #*1 Disk Refills:*0
5. Furosemide 20 mg PO DAILY
6. Metoprolol Succinate XL 100 mg PO DAILY
7. Rivaroxaban 20 mg PO DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
9. TraMADol 50 mg PO BID:PRN Pain - Moderate
10. Verapamil SR 120 mg PO Q24H
11. HELD- Potassium Chloride 20 mEq PO DAILY This medication
was held. Do not restart Potassium Chloride until you have
repeat blood work
12.Outpatient Lab Work
ICD-9 Code: ___.0
Contact Information: ___ Fax ___ Phone
___
Labs: Basic Metabolic Panel
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
=======
Malignant pleural effusion
SECONDARY
=========
Afib
HFpEF
COPD
HLD
HTN
OSA
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 taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
- You were admitted to the hospital for evaluation of your
shortness of breath
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
- While you were in the hospital we preformed a number of
imaging test which showed increased fluid in your lungs. We put
in a chest tube and drained the fluid off your lung. This fluid
showed you reoccurrence of your adenocarcinoma. We also gave you
medications to help you urinate some of the extra fluid out of
your body.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Please continue to take all your medications and follow up
with your doctors at your ___ appointments.
- Please have repeat blood work within the next week.
We wish you all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10224374-DS-14 | 10,224,374 | 28,232,517 | DS | 14 | 2171-07-14 00:00:00 | 2171-07-23 20:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending: ___.
Chief Complaint:
transfer for hyperkalemia, hyponatremia, fatigue
Major Surgical or Invasive Procedure:
Paracentesis
History of Present Illness:
Mr. ___ is a ___ with a history of alcoholic cirrhosis (on
diuretics), hyperlipidemia, and hypertension who is transferred
from ___ with hyperkalemia, hypotension to the ___ (fluid
responsive), and acute kidney injury.
.
He carries a diagnosis of alcoholic hepatitis diagnosed in ___
with refractory ascites that has been paracentesis-dependent
over the past 9 months (needed 4 paracenteses total). He
recently underwent a 10.5L tap about 5 days ago which was chased
with albumin. Since that time, he has had increasing general
fatigue, malaise, and weakness. He mentions cramping of the
hands and distal lower extremities. He has been severely
constipated as well, and has had poor PO intake due to a lack of
appetite. Per his GI doctor's note, his diuretic regimen has
been uptitrated due to the refractory ascites, and he referred
the patient into the ___ due to concerns that he was
over-diuresed. There, labs revealed K 6.1, na 118, cr 2.3, wbc
12, hct 55. His most recent creatinine was 0.9 one month ago. He
was given an unknown amount of normal saline and transferred to
___ for further evaluation. He had an appointment with
hepatology here within the week to establish care.
.
At ___, his initial vitals were 97.2 70 120/68 18 99%. He was
fully alert and oriented times three. Urgent hepatology consult
recommended paracentesis, albumin, and holding diuretics.
Another liter of NS was infused. Initial K was 6.1, down to 5.7
on recheck. EKG showing ?peaking of V2-V4. Na returned at 113.
Paracentesis was not consistent with SBP.
.
Upon arrival to the floor, initial vitals were: T 98.1 P84 BP
97/69 RR18 Sat100RA. He is tired but in NAD, and is mentating
normally. He denies ever having a liver biopsy. He never has had
renal disease in the past. Denies recent use of NSAIDs.
.
On ROS, he denies hematemesis, melena, hematochezia, weight
loss, nausea, vomiting, dysuria, hematuria, confusion, headache,
abdominal pain,chest pain, shortness of breath.
Past Medical History:
-likely alcoholic cirrhosis
-refractory ascites, diuretic dependent
-___ cyst
-gynecomastia
-Hypertension
-Migraines
-S/P hernia repair x ___
-S/p cholecystectomy
-Hyperlipidemia
-Aseptic necrosis of the hip s/p right hemiarthroplasty
-Alcoholic hepatitis ___
-Colon polyp
Social History:
___
Family History:
FAMILY HISTORY: Brother with alcoholism.
Physical Exam:
ADMISSION PHYISCAL:
VITALS: T98.1 P84 BP 97/69 RR18 Sat100RA
GENERAL: well appearing, thin male in NAD
HEENT: PERRL, EOMI
NECK: no carotid bruits, JVD
LUNGS: CTAB anteriorly and posteriorly
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: distended though soft, positive shifting dullness,
liver span 6cm, no organomegaly, no caput
EXTREMITIES: No c/c/e, +palmar erythema, no spiders
NEUROLOGIC: A+OX3 CN2-12 intact, strength ___ throughout,
sensation intact to soft touch bilaterally.
.
DISCHARGE PHYSICAL:
VS 98.3, 100/58, p77, R20, 98%RA
GEN: Alert. Cooperative. In no apparent distress. Appears
comfortable
HEENT/NECK: PERRLA. EOMI. Mucous membranes pink/moist. No
icterus or pallor.
CHEST: Clear to auscultation B/L. No wheezes or crackles. No
gynecomastia.
CV: S1, S2. Regular rate and rhythm. ___ systolic mumur best
heard at the apex that radiateds to the carotids. No
gallops/rubs appreciated. Pulses 2+ throughout. JVD ~3cm.
ABDOMEN: Distended but less than patient's baseline. + fluid
wave. Dullness to percussion at bulging flanks. Liver palpable
below costal margin. BS present. Soft. Nontender. No caput
medusae.
EXTREMITIES: No palmar erythema or contractures. No gross
deformities, clubbing, or cyanosis. No edema
NEURO: No asterixis. Alert and fully oriented. CNII-XII intact,
motor and sensory grossly normal
SKIN: No jaundice, no spider angiomas or telangeictasias. No
rashes, bruises or ulcerations.
Pertinent Results:
ADMISSION LABS/STUDIES:
___ 07:40PM BLOOD WBC-12.1* RBC-5.66 Hgb-17.6 Hct-51.3
MCV-91 MCH-31.1 MCHC-34.4 RDW-13.2 Plt ___
___ 07:40PM BLOOD Neuts-80.7* Lymphs-8.9* Monos-9.2 Eos-0.9
Baso-0.3
___ 07:43PM BLOOD Na-116* K-5.2*
___ 07:50PM BLOOD ___ PTT-32.4 ___
___ 07:50PM BLOOD Glucose-103* UreaN-70* Creat-2.3* Na-113*
K-5.7* Cl-83* HCO3-24 AnGap-12
___ 07:50PM BLOOD ALT-34 AST-25 AlkPhos-117 TotBili-0.5
___ 07:50PM BLOOD Lipase-128*
___ 07:50PM BLOOD Albumin-3.2* Calcium-8.3* Phos-5.3*
Mg-3.2* Iron-54
___ 07:50PM BLOOD calTIBC-259* Ferritn-680* TRF-199*
___ 07:50PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 07:50PM BLOOD HCV Ab-NEGATIVE
___ 07:52PM BLOOD Lactate-1.5
___ 09:38PM ASCITES WBC-214* RBC-185* Polys-3* Lymphs-21*
___ Mesothe-7* Macroph-69*
___ 09:38PM ASCITES Glucose-130 Creat-2.1
.
___ 9:38 pm PERITONEAL FLUID
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
.
___ 12:31AM URINE Hours-RANDOM UreaN-923 Creat-103 Na-LESS
THAN K-43 Cl-LESS THAN
___ 12:31AM URINE Osmolal-481
___ 12:31AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 12:31AM URINE Color-Yellow Appear-Clear Sp ___
.
ECG Study Date of ___ 7:24:10 ___
Sinus rhythm with slight P-R interval prolongation. Borderline
decreased limb lead QRS amplitude. Early anterior R wave
transition. Non-specific ST segment flattening throughout. No
previous tracing available for comparison.
.
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___
8:48 ___: There is moderate-to-large amount of mainly simple
ascites in all
four quadrants, most pronounced in the right lower quadrant.
There is liver cirrhosis with slightly increased echogenicity of
the liver. The portal vein is patent with normal hepatopetal
flow. The gallbladder has been surgically removed. The CBD is
normal measuring 4 mm. The spleen is enlarged measuring 15 cm
in length.
IMPRESSION:
1. Patent main portal vein with hepatopetal flow.
2. Moderate-to-large amount of mainly anechoic ascites with
small quantities of echogenic debris.
3. Findings consistent with cirrhosis.
4. Splenomegaly.
.
INTERVAL LABS/STUDIES:
___ 06:50AM BLOOD Glucose-83 UreaN-69* Creat-1.9* Na-119*
K-4.3 Cl-84* HCO3-23 AnGap-16
___ 03:20PM BLOOD Na-118* K-4.0 Cl-88*
___ 08:20PM BLOOD UreaN-57* Creat-1.6* Na-126* K-3.8 Cl-88*
___ 03:07AM BLOOD Glucose-83 UreaN-50* Creat-1.4* Na-126*
K-4.8 Cl-91* HCO3-25 AnGap-15
___ 08:02AM BLOOD UreaN-45* Creat-1.3* Na-127* K-4.0 Cl-90*
___ 06:50AM BLOOD Calcium-8.0* Phos-4.8* Mg-2.9*
.
DISCHARGE STUDIES:
___ 06:35AM BLOOD Glucose-79 UreaN-32* Creat-1.1 Na-133
K-4.4 Cl-97 HCO3-25 AnGap-15
___ 03:07AM BLOOD ALT-37 AST-32 LD(LDH)-96 AlkPhos-93
TotBili-1.4
___ 03:07AM BLOOD Lipase-179*
___ 06:50AM BLOOD WBC-7.4 RBC-4.52* Hgb-14.4# Hct-40.9#
MCV-90 MCH-31.8 MCHC-35.2* RDW-13.2 Plt ___
___ 03:07AM BLOOD Albumin-4.0 Calcium-8.6 Phos-3.6 Mg-2.6
Brief Hospital Course:
Mr. ___ is a ___ male with a history of alcoholic cirrhosis
and refractory ascites here with acute kidney injury,
hyponatremia, and hyperkalemia secondary to large volume
peritoneal tap/over diuresis.
ACTIVE PROBLEMS:
# HYPONATREMIA: The patient was admitted the medicine floor
followed by the Liver service. His diuretic medications were
held, and he was treated with albumin infusions over three days
as well as a less than 1L fluid restricted, high-protein diet.
His sodium improved, and his fatigue and tremors resolved. He
was stable by day of discharge with follow-up appointment with
the ___ Liver service.
# HYPERKALEMIA: The patient was treated with kayexalate, holding
of diuretics, and gradual correction of his other electrolyte
abnormalities and volume status. His hyperkalemia resolved and K
was stable by day of discharge.
# ACUTE KIDNEY INJURY: Likely prerenal due to decreased
effective circulating volume.
Treated by holding diuretics as well as holding
anti-hypertensives (to enhance renal perfusion) . His Cr was
down-trending during admission with the albumin infusions and
correction of his intravascular volume status, and was 1.1 on
discharge.
# ABDOMINAL PAIN: The likely source of his initial pain was
general distension from the ascites. The pain resolved during
his admission and there was no evidence of SBP on paracentesis.
CHRONIC ISSUES:
# ALCOHOLIC CIRRHOSIS, complicated by refractory ascites. The
patient was treated as above for his acute complications. He had
already scheduled an appointment with Dr. ___ to establish care
here. The patients diuretics were held on discharge until he
followed up as an outpatient.
# HYPERTENSION: The patient was initially hypotensive on outside
hospital presentation to the ER, likely secondary to a decreased
effective circulating volume from large volume paracentesis and
diuresis. His antihypertensives were held and his blood
pressure was stable during his stay here.
TRANSITIONAL ISSUES:
1)The patient was instructed to cease his diuretics and
anti-hypertensive medications on discharge pending follow up
evaluation.
Medications on Admission:
1. Verapamil SR 240 mg PO Q24H
2. Furosemide 40 mg PO DAILY
3. Spironolactone 100 mg PO DAILY
4. Amoxicillin ___ mg PO BEFORE DENTAL WORK
Discharge Medications:
1. Amoxicillin ___ mg PO BEFORE DENTAL WORK
2. <1000mL fluid restricted diet.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Hyponatremia, Hyperkalemia, Acute Kidney Injury,
Cirrhosis
Secondary: Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you at ___
___. You were admitted because your lab values
showed you had a very low sodium, a high potassium, and a high
creatinine. These were likely related to your recent abdominal
paracentesis/tap and your diuretic medications. We treated you
with albumin, which pulls water back into your blood vessels, as
well as a fluid restricted, Ensure-supplemented diet, which
helped the concentration of sodium to rise. By the day of your
discharge, your sodium, potassium, and creatinine were within
normal laboratory ranges. You should continue a 1000mL a day or
less, fluid restricted diet, and follow up with a liver
specialist and your PCP regarding to discuss further management.
.
Please note the following changes in your medications:
Please STOP your spironolactone until you discuss this diuretic
medication with your doctors.
___ STOP your furosemide until you discuss this diuretic
medication with your doctors.
___ STOP your verapamil because your blood pressure has been
normal or low during your stay here. You can discuss restarting
this medication at your next appointment.
Followup Instructions:
___
|
10224486-DS-17 | 10,224,486 | 28,029,898 | DS | 17 | 2135-06-30 00:00:00 | 2135-06-30 17:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
imbalance, syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ PMR on chronic steroid, COPD, h/o prostate ca, low BP,
h/o CVA (right hippocampus and right internal capsule) w/
residual balance problems and neuropathic pain at ___, now p/w
syncope.
History obtained from patient and family.
Family reports that pt has been more forgetful and has trouble
w/ balancing since his his CVA last year.
A few weeks ago, pt reports that he felt dizzy when he tried to
stand up from bed, and lost consciousness for a few second.
He saw PCP ___ ___, who attributed the episode to orthostasis.
On day of admission. Pt went to the restroom to urinate. He
felt dizzy in the bathroom. No CP, palpitation. He tried to
find a soft spot to land, but then lost consciousness. His wife
found him down no the floor for an unknown period of time. Pt
was not having seizure like movement or incontinence. He denies
tongue biting. He also denies BRBPR or melena.
EMS found the patient on the toilet looking ashen but
responsive. Patient vomited twice while in route. Patient states
he feels dizzy to the EMS, but denies other complaints. He
denies h/o DVT of PE. He denies hemoptysis. He has not had
decreased PO. No f/c, diarrhea/constipation. He has been
taking low dose prednisone for > ___ years for PMR. No recent new
or discontinuation of medications. He has had progressive ___
swelling, and was recommended by PCP to wear compression
stockings. He dnies orthopnea or DOE.
In the ED, initial vitals: 95.0 80 143/89 23 95% RA
- pt as Initially diaphoretic and somnolent but became more
awake and responded appropriate
- Labs notable for: WBC 12.2 w/ 6.4% Eos, trop < 0.01. normal
chem 10, normal UA, normal LFt
- CT head: No acute intracranial process. Hypodensity within the
right cerebellum is likely due to an old infarct, although new
since ___.
- Pt given: 1L NS bolus, and zofran x 1
On arrival to the floor, pt reports feeling dizzy right before
being transferred to the hospital bed. He had no additional
complaints.
Past Medical History:
PMR - on chronic low dose prednisone
COPD
Prostate cancer s/p radical prostatectomy, no radiation
hx UTI
low blood pressure
hard of hearing (currently only has one at the hospital with
him)
Social History:
___
Family History:
Brother passed away from prostate cancer. Another brother passed
away from bladder cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals- 98.2 76 128/60 23 95% RA
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
GU- no foley
Ext- trace b/l ___ edema w/o redness or tenderness. warm, well
perfused, 2+ pulses, no clubbing, cyanosis
Neuro- CNs2-12 intact, AAO3, motor function symmetrical
throughout. decreased sensation at L hand.
.
DISCHARGE PHYSICAL EXAM
Vitals- 98.3 124/62 71 18 96RA
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, occassional irregular beat (corresponding to PVC on
telemery), Normal S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
GU- no foley
Ext- trace b/l ___ edema w/o redness or tenderness. warm, well
perfused, 2+ pulses, no clubbing, cyanosis
neurological exam
Mental Status: Alert and oriented to person, place (___) and
the month and year. Able to relate history without much
difficulty. Attentive to conversation. Language is fluent and
appropriate with intact comprehension, repetition and naming of
both high and low frequency objects. Normal prosody. There were
no paraphasic errors. Speech was not dysarthric. Able to follow
both midline and appendicular commands. No neglect, left/right
confusion or finger agnosia. registers ___ words and recalls ___
at 5 min (no improvement with clues or list)
Cranial Nerves:
I: not tested
II: visual fields full to confrontation
III-IV-VI: pupils equally round, reactive to light. Normal
conjugated, extra-ocular eye movements in all directions of
gaze. When the patient sat up and became symptomatic he
developed right beating torsional nystagmus in primary gaze that
increased with right gaze and resolved with left gaze. this
nystagmus resolved with his symptoms.
V: Symmetric perception of LT in V1-3
VII: Face is symmetric at rest and with activation; symmetric
speed and excursion with smile. left sided pstosis at times
VIII: Hearing intact to finger rub bl (heading aids inplace)
IX-X: Palate elevates symmetrically
XI: Shoulder shrug and head rotation ___ bl
XII: No tongue deviation or fasciculations
Motor: Normal muscle bulk and tone throughout. No pronator drift
rebound
Strength:
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ 5 5
R ___ 5 5
Reflexes:
Bi Tri ___ Pat Ach
L ___ 2 1
R ___ 2 1
Toes are down going bilaterally.
Sensory: decreased sensation to pinprick, light touch, vibration
and temperature on the left. Proprioception decreased bl.
Coordination: Finger to nose and heel to shin are mildly less
acurate on the right. RAM is slower on the left but with regular
cadence.
Gait: Very unstable falling to the left. No truncal ataxia.
Pertinent Results:
___ LABS
___ 08:08AM BLOOD WBC-12.2* RBC-4.64 Hgb-14.2 Hct-41.1
MCV-89 MCH-30.6 MCHC-34.6 RDW-13.1 Plt ___
___ 08:08AM BLOOD ___ PTT-24.8* ___
___ 08:08AM BLOOD Glucose-171* UreaN-19 Creat-1.2 Na-141
K-4.0 Cl-105 HCO3-24 AnGap-16
___ 08:08AM BLOOD ALT-23 AST-26 AlkPhos-75 TotBili-0.4
___ 08:08AM BLOOD Lipase-43
___ 08:08AM BLOOD cTropnT-<0.01
___ 06:50PM BLOOD cTropnT-<0.01
___ 07:54PM BLOOD cTropnT-<0.01
___ 07:54PM BLOOD Calcium-9.2 Phos-2.2* Mg-2.0
___ 06:27AM BLOOD VitB12-478
___ 05:28AM BLOOD %HbA1c-5.9 eAG-123
___ 05:28AM BLOOD Triglyc-80 HDL-48 CHOL/HD-3.0 LDLcalc-81
___ 06:27AM BLOOD Cortsol-10.0
___ 08:08AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:22AM BLOOD Lactate-1.7
.
DISCHARGE LAB
___ 06:06AM BLOOD WBC-10.1 RBC-4.49* Hgb-14.0 Hct-39.1*
MCV-87 MCH-31.1 MCHC-35.7* RDW-12.9 Plt ___
___ 06:06AM BLOOD Glucose-88 UreaN-18 Creat-1.0 Na-138
K-3.7 Cl-103 HCO3-25 AnGap-14
___ 06:06AM BLOOD Calcium-8.7 Phos-2.9 Mg-1.9
.
IMAGING
# ___ CT HEAD W/O CONTRAST
There is no evidence of acute major vascular territory
infarction, hemorrhage, edema, or mass. Hypodense region in the
right cerebellum which is new since ___, likely
reflects an area of interval infarction. Bilateral
periventricular, subcortical and deep white matter hypodensities
are likely a sequela of chronic small vessel ischemic disease.
Prominent ventricles and sulci suggest the age-related volume
loss, grossly unchanged from prior. Basal cisterns are patent.
No osseous abnormalities seen. There is mucosal thickening
within the
anterior ethmoid air cells and left frontal sinus. Remainder of
the visualized paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The orbits are unremarkable.
The known anterior communicating artery aneurysm is better
visualized on the prior MRA dated ___.
No acute intracranial process. Interval development of right
cerebellar
infarct since ___.
# ___ MRI & MRA BRAIN AND MRA
Acute infarcts in the distribution of the right posterior
inferior cerebellar artery. No other infarcts are identified.
There is no evidence of acute or Chronic blood products. There
is no significant mass effect seen on the fourth ventricle.
There are moderate changes of small vessel disease in the
periventricular white matter and in the brainstem. No abnormal
enhancement is seen.
MRA of the neck demonstrates slight delayed acquisitions. The
proximal right vertebral artery is not visualized. This appears
to be slight extension of changes seen on the previous MRA
examination. The distal V2, V3 and V4 Segments of the right
vertebral artery are visualized on the postcontrast MRA.
Limited evaluation of both carotid arteries demonstrate no
evidence of
vascular occlusion or stenosis. The left vertebral artery
proximal portion is not well visualized on maximum intensity
projections but appears normal on the source images.
1. Acute right posterior inferior cerebellar artery infarct.
Small-vessel
disease and brain atrophy. No enhancing brain lesions.
2. MRA of the neck demonstrates nonvisualization of the proximal
portion of the right vertebral artery which could be due to
intrinsic disease. This appears to be further extension compared
to the previous MRA.
Brief Hospital Course:
___ w/ PMR on chronic steroid, COPD, h/o prostate ca, low BP,
p/w imbalance, syncope.
# Syncope - pt reports multiple episode of dizziness (no frank
vertigo) and "passing out." Unclear if patient ever truly loss
consciousness. Most likely related to his recent cerebellar
stroke. Pt was not orthostatic, recent TSH wnl, am cortisol
normal. CE negative x 3; serum tox/urine tox normal. TTE without
etiology. Telemetry notable for asymptomatic SVT that resolved
with vagal manuever x 1, otherwise unremarkable. patient was
discharged to rehab with ___ of ___ monitoring.
# R cerebellar stroke - likely occurred ___ weeks prior to
hospitalization, likely explains the episodes of dizziness. His
aspirin was switched to plavix 75mg daily. Atorvastatin was
increased to 80mg daily. Patient was discharge to rehab.
# Urinary retention - no signs of infection based on UA.
resolved without intervention.
# Eosinophilia - mild, absolute count 780. no signs of end organ
damange
# COPD - breathing well on room air. no wheezing, increased
sputum production. no signs of infection. continued on albuterol
inhaler prn
# PMR
- cont. home prednisone 2mg daily
# Hypothyroidism
- cont. home levothyroxine
# GERD
- cont. home omeprazole
TRANSITIONAL ISSUE
- ___ of hearts monitoring
- plavix 75mg daily, atorvastatin 80mg daily
- omeprazole temporarily held given interaction with plavix,
please consider to restart as appropriate
- please consider recheck eosinophil count in 6 month and
monitor for signs of end organ involvement.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
2. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES TID
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
4. PredniSONE 2 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO DAILY
7. Lisinopril 5 mg PO DAILY
8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation as
needed
9. Levothyroxine Sodium 25 mcg PO DAILY
10. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Atorvastatin 80 mg PO DAILY
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES TID
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
5. Levothyroxine Sodium 25 mcg PO DAILY
6. Lisinopril 5 mg PO DAILY
7. PredniSONE 2 mg PO DAILY
8. Clopidogrel 75 mg PO DAILY
9. ProAir HFA (albuterol sulfate) 90 mcg/actuation INHALATION AS
NEEDED
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis
Right cerebellar stroke (CVA)
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:
Dear Mr. ___,
It has been our pleasure caring for you here at ___. You were
admitted because you were having imbalance and falls at home.
Unfortunately, we found that you have had a stroke a few weeks
ago. We have added a medication called plavix, to help you
reducde the risk of future stroke. We are sending you home with
a heart monitoring device, so we can help track future episodes
of dizziness/passing out and make sure that it is not a problem
with your heart. Your care is being transitioned to a rehab to
help you with recovery.
We wish you all the best,
Your ___ care team
Followup Instructions:
___
|
10224486-DS-18 | 10,224,486 | 23,093,095 | DS | 18 | 2135-07-19 00:00:00 | 2135-07-20 17:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
headache, dizziness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ PMR on chronic steroid, COPD, h/o prostate ca, low BP,
h/o CVA (right hippocampus and right internal capsule in ___
w/ residual balance problems and neuropathic pain at LUE, acute
infarcts in the distribution of the right posterior inferior
cerebellar artery (___) who presents to the ED with
dizziness and headache. He states this morning at approximately
10 AM he was getting dressed for his PCP visit when he became
acutely dizzy, "felt like the world was spinning," and
lightheaded as though his contact out. Felt very unwell and had
to lay down. He was nauseous, and that he had pain behind his
right eye. Daughter found him on the bed, lying down down,
looking pale. Did not loose consciousness. Similar presentation
to his stroke (hospitalized at ___ ___. She
called EMS. States that he had been doing well since getting out
of rehab on ___. Needed a walker to walk since his balance
was still problematic. Had been wearing ___ of hearts monitor
since hospitalization. Denies any changes in medications. Denies
recent illnesses, chest pain, pain during urination, bowel
incontinence, trouble breathing, fevers, chills.
In the ED, initial vitals were: 97.7 80 146/76 16 96% 2L. Labs
significant for Cr 1.1, wbc 8.9(eos 6.9%), Hgb 13.9, Hct 39.9,
trop <0.01, Serum tox negative. UA hazy, large leuks, negative
nitrites, trace proteins, 14wbc, few bacteria. Code stroke was
called. CT head w/o contrast showed evolving right cerebellar
infarct without superimposed hemorrhage. Neurology evaluated pt
and did not feel this was an acute neurologic process. Pt had
been taking plavix since discharge. EP evaluated ___ of hearts
which did not show any arrythmias, but pt was not wearing
monitor this morning. Suggest outpatient cardiology appointment.
At points, pt was somnolent/sleepy in the ED. Per report,
orthostatic in the ED. Given 1L NS, 1gm Ceftriaxone. Prior to
transfer, vitals 98.3 89 126/95 16 94% RA.
On the floor, patient comfortable, lying in bed. With his
daughter and his wife. Able to tell me that an ambulance brought
him to the hospital today. He denies any complaints at this
time. Is not dizzy, having chest pain, headache, difficulty
breathing, urinary discomfort. Daughter says that his coloring
is much improved. Per daughter, since being discharged from the
hospital in ___, he had been doing well in rehab. He has
chronic residual left sided weakness and left arm and hand
numbness from his first stroke. His balance is still poor from
the second stroke, and cannot ambulate without walker. All
deficits are stable. During the last event, he had left eye
pain. This time his pain is in his right eye. Since being home
from rehab he has had difficulty concentrating on reading the
newspaper.
Of note, patient has a chronic penis clamp that he uses for
chronic urinary leakage. Prescribed by his urologist.
Past Medical History:
Stroke ___ and ___
PMR - on chronic low dose prednisone
COPD
Prostate cancer s/p radical prostatectomy, no radiation
hx UTI
low blood pressure
hard of hearing (currently only has one at the hospital with
him)
hypothyroidism
Social History:
___
Family History:
Brother passed away from prostate cancer. Another brother passed
away from bladder cancer.
Physical Exam:
=========================
ON ADMISSION:
=========================
Vitals: 97.9, 150/64, 80, 18, 95% RA
General: Alert, oriented x2 (person, place), comfortably lying
in bed, good coloring of face
HEENT: PERRL, EOMI, Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD, no thyromegaly
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Few end expiratory wheezes, upper airway sounds, no
ronchi or rales
Abdomen: large abdomen, Soft, non-tender, non-distended, bowel
sounds present, no organomegaly, no rebound or guarding
GU: penis clamp at mid shaft, distal penis edematous and
engorged
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities
right equal to left, decreased sensation in left palm and
digits, otherwise normal sensation, proprioception and
cerebellar function intact. Gait deferred.
==========================
ON DISCHARGE:
==========================
Vitals: 97.6, 124/57 (120-150s/60-80s), 60-70s, 18, 97% RA
General: Alert, oriented x2.5 (person, place, year- not date or
month), good coloring of face
HEENT: PERRL, EOMI, Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD, no thyromegaly
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: lungs clear diffusely, no ronchi or rales
Abdomen: large abdomen, Soft, non-tender, non-distended, bowel
sounds present, no organomegaly, no rebound or guarding
GU: penis clamp at mid shaft, distal penis edematous and
engorged
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, moving all extremities, able to sit up
on own.
Pertinent Results:
===================
ADMISSION LABS:
===================
___ 10:52AM WBC-8.9 RBC-4.56* HGB-13.8* HCT-39.9* MCV-87
MCH-30.2 MCHC-34.6 RDW-12.7
___ 10:52AM NEUTS-71.3* LYMPHS-13.9* MONOS-6.9 EOS-6.9*
BASOS-1.0
___ 10:52AM ___ PTT-29.7 ___
___ 10:30PM GLUCOSE-126* UREA N-15 CREAT-1.0 SODIUM-137
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-25 ANION GAP-12
___ 10:30PM CK-MB-1 cTropnT-<0.01
___ 10:52AM cTropnT-<0.01
___ 10:52AM ALT(SGPT)-23 AST(SGOT)-16 ALK PHOS-82 TOT
BILI-0.3
====================
DISCHARGE LABS:
====================
___ 05:43AM BLOOD WBC-9.0 RBC-4.23* Hgb-12.8* Hct-36.8*
MCV-87 MCH-30.3 MCHC-34.8 RDW-12.6 Plt ___
___ 05:36AM BLOOD Glucose-75 UreaN-14 Creat-1.0 Na-138
K-4.3 Cl-104 HCO3-24 AnGap-14
___ 10:52AM BLOOD ALT-23 AST-16 AlkPhos-82 TotBili-0.3
___ 05:36AM BLOOD Calcium-9.1 Phos-2.7 Mg-2.0
___ 05:43AM BLOOD CRP-7.8*
ESR pending
====================
STUDIES:
====================
CT head w/o contrast: FINDINGS: In the area of recent right
cerebellar infarcts, subtle hypodensity is noted consistent with
infarct evolution. There is no superimposed hemorrhage. Aside
from this, no acute findings are identified. Ventriculomegaly is
stable. White matter hypodensity is unchanged. Imaged sinuses
notable for mild mucosal thickening. Mastoid air cells and
middle ear cavities are well aerated.
IMPRESSION:
Evolving right cerebellar infarct without superimposed
hemorrhage.
Brief Hospital Course:
___ w/ PMR on chronic steroid, COPD, h/o prostate ca, low BP,
h/o CVA (right hippocampus and right internal capsule in ___
w/ residual balance problems and neuropathic pain at LUE, acute
infarcts in the distribution of the right posterior inferior
cerebellar artery (___) who presents to the ED with
dizziness and headache consistent with previous strokes.
# Dizziness
# Headaches:
# Recent acute cerbrovascular infarctions in right posterior
inferior cerebella artery with residual deficits.
Presenting symptoms were concerning as this was his presenting
symptoms during prior admission for stroke. Code stroke was
called in the ED. CT head showed evolving previous cerebellar
stroke, but no new infarcts. Neurology evaluated him and did not
feel his symptoms were consistent with a new stroke. They did
not feel the need for MRI brain. Some concern about orthostatics
in the ED, but resolved when working with physical therapy. ___
of Hearts showed no arrythmias. Troponins ruled patient out for
MI. Patient had one episode of nausea when he quickly changed
positions when lying in bed, otherwise asymptomatic. Given
history of PMR, discussed possibility of GCA given headaches.
However headaches resolved. CRP slightly elevated and ESR normal
so thought unlikely. Did not feel it was consistent with
clinical picture. Worked with physical therapy and ambulated
steadily with walker and up stairs. Discharged home with
outpatient ___. Neurology recommended following up with
outpatient neurologist. Continued on plavix 75mg daily,
atorvastatin 80mg daily.
# ?UTI: In the ED there was some concern about a urinary tract
infection. Given one dose of ceftriaxone. Urinalysis was
unconvincing and antibiotics stopped. Remained afebrile with
normal wbc.
CHRONIC ISSUES:
# Hypothyroidism: continue levothyroxine
# Hypertension: continue lisinopril 5mg daily
# PMR: continue prednisone 2mg daily
# COPD: Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath, wheezing
# Eyes:
- Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
- Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES TID
- Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
=====================
TRANSITIONAL ISSUES:
=====================
- no changes made to medications
- Per neurology, symptoms not consistent with new stroke
- Recommend general neurology follow up
- Recommend outpatient cardiology follow up for frequent PVCs
and to evaluate ___ of Hearts
- Consider follow up with rheumatologist
- Given 1 day of ceftriaxone for question of urinary tract
infection
- Not orthostatic when working with ___
- Should use rolling walker for ambulation
- Should continue plavix 75mg daily (no aspirin)
- FULL CODE
- Contact: ___ (daughter, HCP): ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES TID
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
5. Levothyroxine Sodium 25 mcg PO DAILY
6. Lisinopril 5 mg PO DAILY
7. PredniSONE 2 mg PO DAILY
8. Clopidogrel 75 mg PO DAILY
9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath, wheezing
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath, wheezing
2. Atorvastatin 80 mg PO QPM
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
4. Clopidogrel 75 mg PO DAILY
5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES TID
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Levothyroxine Sodium 25 mcg PO DAILY
8. Lisinopril 5 mg PO DAILY
9. PredniSONE 2 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Headaches
Dizziness
SECONDARY DIAGNOSIS:
Cerebral vascular accident
Urinary incontinence
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of ___ at ___.
___ came to the hospital for dizziness and headache. ___ were
concerned that this was another stroke. ___ had a CT of your
head that did not show any new strokes. ___ were evaluated by
the stroke team and they felt that this event was most likely
due from low blood pressure when standing, rather than a stroke.
Your symptoms resolved. ___ worked with physical therapy and
they felt that ___ were safe to go home with outpatient ___.
There was also some concern about a urinary tract infection, but
your lab results were not consistent with one. ___ had 1 day of
antibiotics and then they were stopped.
It is very important that ___ follow up with your primary care
doctor, ___, and your cardiologist.
When ___ go from lying down to standing, make sure to move
slowly. Sit for a minute before going into a complete stand.
We wish ___ the best of health,
Your medical team at ___
Followup Instructions:
___
|
10224486-DS-19 | 10,224,486 | 26,143,533 | DS | 19 | 2135-08-08 00:00:00 | 2135-08-14 13:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Code Stroke
sudden onset dizziness and nausea
Major Surgical or Invasive Procedure:
Cardiac Loop Monitor implanted prior to discharge
History of Present Illness:
___ RHM h/o at least 2 posterior circulation strokes
presenting with sudden onset dizziness and nausea.
His first stroke was in ___ presented with left hand
sensory changes, dexterity loss, and increased gait
unsteadiness.
He was found to have evidence of a likely migrating thrombus
causing right thalamic, hippocampal, and capsular ischemia with
an occlusion of right P2. He was started on ASA at that time.
First recent encounter with neurology was on ___ (see
___ of that date); pt complained of several weeks of
non-vertiginous dizziness. CT head was done and patient
identified with ___ cerebellar stroke (h/o PCA stroke). ASA
was switched to Plavix.
Recently seen in the ED on ___ for similar light-headedness;
code stroke was called given similarity to prior symptoms. NIHSS
was 1 for LOC. On full exam pt had mild naming difficulty, weak
left IP. He was admitted to medicine (discharged ___ for
dizziness thought to be orthostatic (head was imaged with CT;
last MRI done on ___ at time of stroke).
Woke today in ___; tells me no new med issues since recent
discharge and no med changes since that time. At 7:30am, felt
dizzy (sounds like combination dysequilibrium and light-headed),
nauseated after he had already been standing for a few minutes.
He staggered back to the couch; difficulty walking on the way.
Mild improvement of sxs with sitting. Wife called ambulance and
he was brought into ED.
ED team's NIHSS was 0; mildly HTN to SBP 150s with ___ 120s. My
NIHSS was 3 for orientation (said ___, corrected to ___,
naming
(couldn't name cactus), and RUE > RLE ataxia (slight; c/w old R
___ stroke).
ROS: Positive for nausea and dizziness as above (persists in
sitting position) and a very mild bifrontal headache. Denies
neck
pain, back pain, focal weakness or numbness. Denies
receptive/productive speech deficits and dysphagia. No visual
complaints (absent or double). General ROS neg for F/C/sweats,
CP, SOB, abd pain, C/D, rash.
Past Medical History:
- Infarct in the right hippocampus, thalamus, and internal
capsule, with thrombus in the PCA. Diagnosed ___ residual
left side sensory changes, memory loss and gait imbalance.
Started on ASA.
- Cerebellar infarct, ___ territory ___ - presented with
"light-headedness"; no cerebellar complaints per se. ASA changed
to Plavix.
- COPD
- prostate cancer
- hypothyroidism
- HLD
- Polymyalgia rheumatica
- adrenal insufficiency
- glaucoma
- macular drusen
- ACOM aneurysm
Social History:
___
Family History:
Family History per recent note:
"Brother passed away from prostate cancer. Another brother
passed
away from bladder cancer."
Physical Exam:
Admission Physical Examination
0 97.5 66 162/80 14 94% 2L Nasal Cannula
General: Elderly man NAD NT ND
HEENT: NC/AT; + Hearing aides
Neck: No obvious bruits
Cardiac: Regular rate, no extra sounds
Pulm: Clear
Abdomen: Soft nl sounds
Extrem: Thin
Neurologic
- Mental status: A&Ox3 (initially said ___ thus the score
on the NIHSS but corrected within seconds to ___. Fluent with
intact naming save for cactus ("that thing in the desert").
Repetition and comprehension are normal. There was no left/right
confusion. No neglect. Linear, prompt, and appropriate; holds
attention to exam well and gives a cogent history.
- Cranial nerves: PERRL, VFFTC without extinguishing. Eyes
orthotropic, EOMI without obvious nystagmus. Face symmetric to
pin. Symmetric activation. Hearing aides in b/l but audition
equal with them. Tongue, palate, shrug symmetric.
- Motor: Full strength save for 4+ EHLs. Toes down. Tone
increased in legs. No drift.
- Sensory: Intact to hallux proprioception and finger to nose
with eyes closed. Pin is symmetric throughout. Deferred Romberg.
- Reflexes: Mildly brisk throughout
- Cerebellar: Mild ataxia FNF on the right (past points,
minimal
tremor). LUE normal FNF and heel/shin relatively symmetric and
smooth.
- Gait: Deferred
Discharge Exam
Unchanged from above
Pertinent Results:
___ 08:42AM BLOOD WBC-8.2 RBC-4.44* Hgb-13.4* Hct-37.9*
MCV-86 MCH-30.1 MCHC-35.2* RDW-12.9 Plt ___
___ 06:15AM BLOOD Neuts-59.1 ___ Monos-7.8
Eos-10.2* Baso-0.8
___ 08:42AM BLOOD ___ PTT-26.3 ___
___ 05:33PM BLOOD Glucose-84 UreaN-13 Creat-1.0 Na-141
K-4.2 Cl-104 HCO3-26 AnGap-15
___ 05:33PM BLOOD CK-MB-1 cTropnT-<0.01
___ 06:15AM BLOOD CK-MB-1 cTropnT-<0.01
___ 05:33PM BLOOD Calcium-8.8 Phos-3.3 Mg-1.9
___ 06:15AM BLOOD Calcium-9.0 Phos-2.7 Mg-2.3 Cholest-128
___ 06:15AM BLOOD Triglyc-90 HDL-38 CHOL/HD-3.4 LDLcalc-72
___ 08:49AM BLOOD Glucose-141* Na-138 K-3.7 Cl-105
calHCO3-24
___ 11:37AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-NEG
Head CT: There is no evidence of acute hemorrhage, edema, mass
effect, or acute infarction. Hypodensities seen in the right
cerebellum are compatible with known evolving chronic infarcts.
Chronic small vessel ischemic disease
with parenchymal atrophy. Mucosal thickening in the ethmoid
sinus. No acute bony abnormalities.
Head CTA: Again seen is a 4 mm aneurysm at the anterior
communicating artery.
There is irregularity of the right PCA likely due to
atherosclerotic disease.
The intracranial arteries are otherwise patent without evidence
of stenosis or occlusion.
Neck CTA: The proximal right vertebral artery to the mid V2
segment is not visualized and becomes recannulized at the distal
V2 segment, similar in extent to prior MRA from ___. The
left vertebral artery contains
atherosclerotic calcifications in the V2 segment without
significant flow limiting stenosis. Mild atherosclerotic
calcifications are seen at the carotid
bulb but the carotid arteries are otherwise patent without
stenosis, occlusion, or dissection.
Mildly enlarged mediastinal and hilar lymph nodes are not
present
measuring up to 10 mm. A 5 mm nodule in the right upper lobe.
Correlate clinically and with dedicated CT imaging.
___ MRI
1. No evidence of acute infarction, hemorrhage, or mass effect.
2. Chronic infarctions in the right greater than left
cerebellar hemispheres.
3. T2/FLAIR signal hyperintensity in the periventricular,
subcortical, and deep white matter which is nonspecific but
likely on the basis of chronic small vessel ischemic disease.
4. A 4mm anterior communicating artery aneurysm, unchanged.
Right vertebral artery not well seen, better assessed on the
prior MR
angiogram and recent CT angiogram studies.
___ CT Head
Right cerebellar infarction continues to evolve with increased
hypodensity. There is no intracranial hemorrhage. No new mass
effect or acute territorial infarction. Prominent ventricles and
sulci are compatible with age-related volume
loss.Periventricular white matter hypodensities are consistent
with chronic small vessel ischemic disease. The basal cisterns
appear patent and there is preservation of gray-white matter
differentiation. No fracture is identified. The visualized
paranasal sinuses, mastoid air cells, and middle ear cavities
are clear.
IMPRESSION:
No intracranial hemorrhage. Continued evolution of right
cerebellar
infarction.
Brief Hospital Course:
___ RHM h/o posterior circulation stroke x2, HLD, AI who
presented with dizziness and nausea similar to presentation of
prior strokes as well as hospitalizations where no new strokes
were detected. DDx included new strokes, recrudescence, and
orthostasis. MRI showed no evidence of acute infarction,
hemorrhage, or mass effect. But, the patient continued to have
dizzy spells. He also had a fall with head strike (no LOC) after
using the restroom. Previously he wore ___ of Hearts monitor
with no evidence of arrythmia. But, with persistent
lightheadedness and the fall, we continued to be concerned about
arrythmia. ___ cardiology was consulted who placed a
implanted cardiac monitor prior to discharge. We continued him
on his previous medications including atorvastatin 80mg and
plavix 75mg. We also ordered tilt table testing in order to
assess for autonomic nervous system dysfunction as a cause of
his symptoms. We instructed him to purchase a blood pressure
cuff and to keep a log of his blood pressures. He was instructed
to bring this log to his next appointment. Because he is an
___ patient, we instructed him to arrange follow up with his
primary care physician in the next ___s the
Neurology clinic at ___ in ___ months. ___ cardiology
informed us that they would call the patient with a follow up
appointment shortly after discharge. He was discharged home in
stable condition.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath, wheezing
2. Atorvastatin 80 mg PO QPM
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
4. Clopidogrel 75 mg PO DAILY
5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES TID
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Levothyroxine Sodium 25 mcg PO DAILY
8. Lisinopril 5 mg PO DAILY
9. PredniSONE 2 mg PO DAILY
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath, wheezing
2. Atorvastatin 80 mg PO QPM
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
4. Clopidogrel 75 mg PO DAILY
5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES TID
6. Levothyroxine Sodium 25 mcg PO DAILY
7. PredniSONE 2 mg PO DAILY
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Lisinopril 5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Presyncope
History of multiple strokes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
You were hospitalized due to symptoms of nausea, lightheadedness
and dizziness. MRI performed during this hospitalization showed
no evidence of acute infarction, hemorrhage, or mass effect.
Although we do not believe you had a stroke, we are very
concerned about your risk factors for future strokes including
hypertension, high cholesterol, and an possibly an irregular
heart rate. We would like you to continue your previous blood
pressure medications, atorvastatin 80mg, and plavix 75mg daily
to prevent future strokes. We consulted cardiology who placed an
implanted cardiac monitor to keep record of your heart rate to
determine if there is a cardiac cause of your dizziness and
strokes. We also put an order in for you to have tilt table
testing in order to assess your autonomic nervous system. This
test will give us information on how your body registers
position and blood pressure. Please purchase a blood pressure
cuff at your nearest pharmacy and start measuring your blood
pressure daily. Keep a log of your blood pressures and bring
them to every appointment. We also recommend a heart healthy
diet (low fat, low salt), daily exercise, and stress reduction
techniques. Please follow up with your primary care physician in
the next ___ weeks. We would also like you to follow up in
Neurology clinic at Atrius in ___ months. Atrius cardiology will
call you with a follow up appointment. You will also be called
to make an appointment for Tilt Table testing (autonomic
testing).
Followup Instructions:
___
|
10224486-DS-20 | 10,224,486 | 20,204,009 | DS | 20 | 2135-09-02 00:00:00 | 2135-09-02 11:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Lightheaded Vertiginous
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is an ___ year-old right handed man with history of 2
prior stroke,first one in ___ with decreased left hand
sensation,dexterity, and increased gait unsteadiness,(R PCA
stroke ) and the second on ___ with subacute onset of
"dizziness" with episodes of syncope and pre-syncope, and right
posterior inferior cerebellar artery infarct, presented to the
hospital this time with inability to ambulate, slurred speech
and
somnolence.
After the second stroke the patient was discharged to rehab and
after he was done with acute rehab he went home, since that time
he presented to ED with episodes of vertigo and difficulty with
his gait.
His most recent admission was 20 days ago, when the work up did
not show any new infarction.
Per his wife the patient was suppose to use walker but he does
not like it and does not use it.
Last night when the patient and his wife went out he told his
wife that he did not feel well, and felt dizzy( light headed and
vertiginous)
They went home and this morning he woke up with dizziness which
he described it as room spinning sensation as well as light
headedness when he changed his position from sitting to
standing.
For the first time after his strokes his speech was slurred and
he could not walk even with walker.
They decided to come to ED, therefor they called ___ and he was
transferred here by EMS.
He denied any fever, but has been mildly depressed with
hypersomnia, he spent most of his time in bed.
Per his wife his memory is also affected, although he never got
lost, but he often forgets to use his walker, he still works
twice a week with home ___.
After the second stroke his ASA was changed to Plavix.
Past Medical History:
- Infarct in the right hippocampus, thalamus, and internal
capsule, with thrombus in the PCA. Diagnosed ___ residual
left side sensory changes, memory loss and gait imbalance.
Started on ASA.
- Cerebellar infarct, ___ territory ___ - presented with
"light-headedness"; no cerebellar complaints per se. ASA changed
to Plavix.
- COPD
- prostate cancer
- hypothyroidism
- HLD
- Polymyalgia rheumatica
- adrenal insufficiency
- glaucoma
- macular drusen
- ACOM aneurysm
Social History:
___
Family History:
Family History per recent note:
"Brother passed away from prostate cancer. Another brother
passed
away from bladder cancer."
Physical Exam:
In exam:
0 77 162/79 16 94% RA
General: Elderly man, tired, NAD NT ND
HEENT: NC/AT; + Hearing aides
Neck: No obvious bruits
Cardiac: Regular rate, no extra sounds
Pulm: Clear with decreased breathing sounds bibasilar.
Abdomen: Soft nl sounds
Extrem: Thin, peripheral pulses intact
Neurologic
- Mental status: awake, mildly sleepy, closed his eyes multiple
times during the interview, Ox3
Fluent with intact naming for HFO, but could not name index
finger. Repetition and comprehension are normal. There was no
left/right confusion. No neglect.
Attentive to ___ Backward.
- Cranial nerves: Pupils are asymmetric( different from prior
exam), left is 2.3mm, right is 3.5 mm both reactive to light,
difference is more obvious in dark room.
Has ___ beats of right dirrection nystagmus in his left gaze(
new from the past admission).
Face sensation symmetric to light touch. Facial muscles are
symmetric.
Hearing aides in b/l but audition
equal with them.
Tongue, palate, shrug symmetric.
- Motor:
Has left pronator drift on the left side, Full strength except
for weakness in left FE and bilateral EHLs. Toes down. Tone
increased in legs.
- Reflexes: Mildly brisk throughout
- Sensory: Dcreased to pin on the right side.
- Cerebellar: Mild ataxia FNF bilaterally, inacurrate HKS
bilaterally.
- Gait: tilted to the left and right in upright position, able
to stand with help ___ tilted toward left, has wide base staps
and eventually leaned backward on the bed.
DISCHARGE EXAM:
Dizziness improved. Alert, oriented. intact comprehension and
expression. No focal weakness. Left sided dysmetria persists.
Pertinent Results:
___ 12:45PM BLOOD WBC-9.4 RBC-4.83 Hgb-14.3 Hct-42.2 MCV-88
MCH-29.7 MCHC-33.9 RDW-13.8 Plt ___
___ 09:10AM BLOOD WBC-7.9 RBC-4.61 Hgb-13.9* Hct-40.3
MCV-87 MCH-30.2 MCHC-34.6 RDW-13.7 Plt ___
___ 09:10AM BLOOD Neuts-63.9 ___ Monos-7.7 Eos-7.3*
Baso-0.6
___ 12:45PM BLOOD Plt ___
___ 09:10AM BLOOD Plt ___
___ 09:10AM BLOOD Plt ___
___ 09:10AM BLOOD ___ PTT-25.9 ___
___ 12:45PM BLOOD Glucose-103* UreaN-15 Creat-1.1 Na-139
K-4.8 Cl-107 HCO3-28 AnGap-9
___ 09:10AM BLOOD Glucose-121* UreaN-12 Creat-1.0 Na-141
K-3.6 Cl-109* HCO3-24 AnGap-12
___ 12:04AM BLOOD CK(CPK)-75
___ 09:10AM BLOOD ALT-16 AST-22 AlkPhos-77 TotBili-0.7
___ 12:45PM BLOOD CK-MB-2 cTropnT-<0.01
___ 12:04AM BLOOD CK-MB-2 cTropnT-<0.01
___ 09:10AM BLOOD cTropnT-<0.01
___ 12:45PM BLOOD Calcium-9.3 Phos-3.1 Mg-2.0
___ 09:10AM BLOOD Albumin-3.5 Calcium-9.7 Phos-3.3 Mg-1.7
___ 12:04AM BLOOD VitB12-522
___ 12:04AM BLOOD TSH-1.7
___ 12:04AM BLOOD CRP-1.2
___ 09:10AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:15PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 05:25PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ CT HEAD - No evidence of hemorrhage or infarction.
___ CTA read pending but only area of right distal vertebral
artery hypoplasia with reconstitution noted
Brief Hospital Course:
___ M with PMHx of multiple posterior circulation strokes, HLD,
and polymyalgia rheumatica on low-dose prednisone, who
re-presented to the hospital with complaints of lightheadedness
accompanied by difficulty with ambulation. He has been
repeatedly evaluated for similar complaints before, last
discharged on ___, with placement of Reveal device and plan for
autonomics evaluation outpt. However, this time, pt had
dysarthria in ED (new symptom), and on our exam he had much more
truncal ataxia than previously documented.
# Stroke:
Given recent Reveal, pt can't have MRI but repeat HCT did show
new L SCA embolic-appearing stroke. Atorvastatin continued as
well as Plavix at home dosing. Contacted patient's cardiologist
and PCP and conveyed recommendation that although not a
clear-cut stroke cause has been identified, given that this was
the third stroke in 5 months in different vascular territories
and while on 2 different antiplatelets, an embolic source is
very likely and therefore anticoagulation is recommended,
provided that the patient's living arrangements allow for it. We
did not make the decision unilaterally given that patient will
not be following with us and some discussion/ consideration is
necessary before the definitive decision is made.
# Cardiovascular:
The reveal was interrogated which showed runs of asymptomatic
SVT and some button pushes with PACs & PVCs but no AFib. Recent
TTE shows nl EF, nl atrial size, no ASD/PFO. Repeat CTA
head/neck showed hypoplastic right vertebral artery with
reconstitution proximally.
# Rheumatologic
For polymalgia rheumatica, we continued prednisone 2mg daily.
Labs for CRP = 1.2, ESR = 2 indicated good effect.
# Placement:
He was evaluated by physical therapy who recommended
rehabilitation.
# Transitions of care:
He was discharged with autonomic testing arranged as an
outpatient. He was instructed to follow up with his PCP,
___, and a neurologist at at___.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 72 ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (x) No [reason
() non-smoker - (x) unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Sob
2. Atorvastatin 80 mg PO QPM
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
4. Clopidogrel 75 mg PO DAILY
5. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
6. Levothyroxine Sodium 25 mcg PO DAILY
7. PredniSONE 2 mg PO DAILY
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Lisinopril 5 mg PO DAILY
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Sob
2. Atorvastatin 80 mg PO QPM
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
4. Clopidogrel 75 mg PO DAILY
5. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
6. Levothyroxine Sodium 25 mcg PO DAILY
7. PredniSONE 2 mg PO DAILY
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Lisinopril 5 mg PO DAILY
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
3. Clopidogrel 75 mg PO DAILY
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
5. Levothyroxine Sodium 25 mcg PO DAILY
6. PredniSONE 2 mg PO DAILY
7. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Sob
8. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
9. Lisinopril 5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Cerebellar Stroke
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 hospitalized due to symptoms of slurred speech and gait
problems 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:
Previous strokes
Hypertension
Hyperlipidemia
Please take your medications as prescribed.
Please followup with Neurology and your primary care physician.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10224753-DS-21 | 10,224,753 | 29,671,345 | DS | 21 | 2176-03-16 00:00:00 | 2176-03-16 17:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / Chicken Derived
Attending: ___.
Chief Complaint:
abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ with a history of sickle cell anemia
complicated by pulmonary hypertension (on oxygen at home) and
splenic infarction who presents with severe abdominal pain, and
concern for sickle cell crisis. The patient reports that her
symptoms began with initiation of a colonoscopy prep one day
prior to admission. She completed the MiraLax and magnesium
citrate without issue, however after 2 glasses of Suprep, she
began passing large amounts of non-bloody diarrhea per rectum.
She then began to vomit profusely and repeatedly, roughly every
___ minutes, initially stomach contents, then bile; the emesis
was non-bloody. Shortly thereafter, she experienced the onset of
acute abdominal pain, beginning in the left upper quadrant and
extending diffusely to the lower abdomen. Due to persistent
nausea, vomiting, and abdominal pain the patient presented to
the ___ Emergency Department where she was given
anti-emetics and dilaudid; a CXR and labs were reportedly normal
and after improvement in her symptoms, she was discharged home.
On the day of admission, the patient woke with recurrent nausea,
vomiting, and abdominal pain. She presented for her colonoscopy
and was sent to the ___ Emergency Department. She denied any
chest pain, bone pain, headache, dizziness, lightheadedness,
changes in vision, focal weakness, or shortness of breath above
her baseline. She denied any blood in her diarrhea or vomit. She
denied any pain aside from abdominal pain. Ms. ___ denies
any recent illnesses, fevers, chills, or nausea/vomiting before
her bowel prep.
In the ED, initial vitals: T 98.3 HR 56 BP 133/71 RR 22 O2
95% 2L
- Exam notable for: normal mental status
- Labs notable for: lactate 2.2, H/H 9.5/26.5, reticulocyte
count 3.8, negative UA with specific gravity >1.050
- Imaging notable for:
--CT Abdomen/Pelvis: No acute intra-abdominal process. Changes
consistent with sickle cell anemia: the spleen is shrunken and
calcified, consistent with auto-infarction in the setting of
known sickle cell disease. H-shaped lumbar vertebral bodies are
identified, in keeping with the history of sickle cell disease.
AVN of the bilateral femoral heads, more extensive on the right,
without loss of the normal contour of the femoral heads, is
noted and likely due to sickle cell disease. Other than
calcified soft tissue granulomas, the abdominal and pelvic wall
is within normal limits.
-- CXR: There is moderate cardiomegaly. The left hilar contour
is prominent, consistent with known pulmonary hypertension.
There is right basilar atelectasis. No focal consolidation or
pneumothorax.
- Pt given: dilaudid 2mg IV, metoclopramide 10mg IV, 1000 ml NS,
- Vitals prior to transfer: T 98.9 HR 87 BP 91/57 RR 12 O2
96% NC
On arrival to the floor, Ms. ___ reports moderate abdominal
pain, resolution of her nausea, and chills.
ROS:
No fevers, night sweats, or weight changes. No changes in vision
or hearing, no changes in balance. No cough. No chest pain or
palpitations. No constipation. No dysuria or hematuria. No
hematochezia, no melena. No numbness or weakness, no focal
deficits.
Past Medical History:
sickle cell anemia
infarcted spleen
pulmonary hypertension (baseline abnormal EKG)
obstructive sleep apnea
GERD
avascular necrosis of femoral head/neck
endometriosis
migraine headache
chest pain
abdominal pain (LLQ)
colonic adenoma
pulmonary embolism (diagnosed w/multiple emboli in ___, per
patient resolved by ___
adjustment disorder
hypothyroidism
hypercholesterolemia
prolonged QT interval
chronic anticoagulation use
Social History:
___
Family History:
Extensive history of breast cancer; mother ___ in ___, 2
aunts diagnosed before 70. Otherwise negative.
Physical Exam:
ADMISSION
Vitals- T 98.0 HR 77 BP 101/63 RR 20 O2 98% RA
General- Alert, oriented, no acute distress, shivering
intermittently
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, possible S4.
Abdomen- soft, Non-distended. Tender to moderate palpation; no
rebound tenderness, guarding, or tenderness to percussion.
Hypoactive bowel sounds.
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE
Vitals: 98.8 92/49-120/70 90 18 98% on 2L
General- Alert, oriented, lying down in bed
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, JVP evelated to earlobe, no LAD
Lungs- CTAB, decreased lung sounds at R lung base. Dullness to
percussion over R lung base. Work of breathing stable from
___.
CV- regular rhythm, tachycardic, slight S4 best heard at left
sternal border, loud P2.
Abdomen- soft, distended in epigastrium, tender in epigastrium,
LUQ and bilateral lower quadrants with rebound tenderness, no
organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, pitting edema bilaterally
Neuro- motor function grossly normal
Pertinent Results:
CT Abdomen/Pelvis: No acute intra-abdominal process. Changes
consistent with sickle cell anemia: the spleen is shrunken and
calcified, consistent with auto-infarction in the setting of
known sickle cell disease. H-shaped lumbar vertebral bodies are
identified, in keeping with the history of sickle cell disease.
AVN of the bilateral femoral heads, more extensive on the right,
without loss of the normal contour of the femoral heads, is
noted and likely due to sickle cell disease. Other than
calcified soft tissue granulomas, the abdominal and pelvic wall
is within normal limits.
CXR: There is moderate cardiomegaly. The left hilar contour is
prominent, consistent with known pulmonary hypertension. There
is right basilar atelectasis. No focal consolidation or
pneumothorax.
Labs on Admission:
------------------
___ 12:27PM WBC-7.0 RBC-2.73* HGB-9.5* HCT-26.5* MCV-97
MCH-34.8* MCHC-35.8 RDW-21.3* RDWSD-67.4*
___ 12:27PM PLT SMR-NORMAL PLT COUNT-288
___ 12:27PM NEUTS-87.3* LYMPHS-6.7* MONOS-5.2 EOS-0.0*
BASOS-0.1 IM ___ AbsNeut-6.08 AbsLymp-0.47* AbsMono-0.36
AbsEos-0.00* AbsBaso-0.01
___ 12:27PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-3+
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-2+
TARGET-3+ TEARDROP-2+ FRAGMENT-2+
___ 12:27PM RET AUT-3.8* ABS RET-0.10
___ 12:27PM GLUCOSE-123* UREA N-11 CREAT-1.1 SODIUM-143
POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-25 ANION GAP-15
___ 12:31PM LACTATE-2.2*
___ 12:27PM ALT(SGPT)-17 AST(SGOT)-24 ALK PHOS-62 TOT
BILI-1.3
___ 12:27PM LIPASE-27
___ 12:27PM cTropnT-<0.01
___ 12:27PM ALBUMIN-4.1
Labs on Discharge:
--------------------
___ 06:33AM BLOOD WBC-6.2 RBC-2.33* Hgb-8.3* Hct-22.5*
MCV-97 MCH-35.6* MCHC-36.9 RDW-21.6* RDWSD-69.3* Plt ___
___ 06:33AM BLOOD Glucose-83 UreaN-8 Creat-0.8 Na-139 K-3.6
Cl-105 HCO3-25 AnGap-13
___ 06:33AM BLOOD Calcium-8.3* Phos-3.8 Mg-1.7
Brief Hospital Course:
This is a ___ year old female with past medical history of sickle
cell anemia, chronic respiratory failure / pulmonary HTN on home
O2, chronic pulmonary embolism on coumadin, admitted ___
with acute sickle cell pain crisis in setting of
dehydration from colonoscopy prep, course complicated by
constipation, acute pain crisis resolving with supportive
therapy, able to be discharged home on home medications.
# Sickle Cell Anemia / Acute Sickle Cell Pain Crisis / Nausea -
patient presenting with vomiting, abdominal pain in setting of
colonsocopy bowel prep; symptoms similar to prior sickle cell
crises. A CT abdomen did not show acute processes and showed
only changes characteristic of sickle cell anemia. CXR without
signs of acute chest syndrome. Additional workup for infection
negative including urine and blood. Ms. ___ was treated with
dilaudid 0.25-0.75mg IV Q4h for pain, ativan for nausea (given
history of prolonged Qtc), and aggressive volume resuscitation
with normal saline. Bloodwork was notable for an elevated uric
acid, total bilirubin, LDH, and reitculocyte count, consistent
with sickle cell crisis. These labs trended downward over the
course of Ms. ___ hospitalization. The patient was
maintained on her home medications for sickle cell anemia
including hydroxyurea 1000mg daily and folic acid 1mg daily. She
was successfully transitioned to PO pain meds.
# Constipation - course notable for constipation in setting of
above; felt to be from dehydration due to preceeding diarrhea as
well as opiate effect; her symptoms resolved with a bowel
movement.
# Chronic PULMONARY EMBOLISM: Patient has history of multiple
simultaneous pulmonary embolisms diagnosed in ___. Per
patient's report, resolved by imaging in ___. On chronic
anticoagulation. She had been off coumadin in anticipation of
colonoscopy, and was being bridged with lovenox. On admission,
her INR was 1.3. She was restarted on her home warfarin and
bridged with lovenox. By the time of discharge, her INR was 1.5,
so she was discharged on a lovenox bridge.
#PULMONARY HYPERTENSION: The patient had a long-standing history
of pulmonary hypertension, with likely contribution from her
sickle cell anemia, pulmonary emboli, and obstructive sleep
apnea. The patient remained on her home doses of Bosentan and
treprostinil, and stable from the perspective of her pulmonary
hypertension throughout her hospitalization. At the time of
discharge, her weight was 82.6 (dry weight is 81.6).
#GERD: Continued home lansoprazole.
#HYPOTHYROIDISM: Continued home levothyroxine.
***TRANSITIONAL ISSUES:***
- INR subtherapeutic during this admission, requiring lovenox
bridge being continued at time of discharge, please recheck INR
at follow-up visit (INR at discharge was 1.5) to determine if
lovenox can be stopped
- Can consider discussing with GI re: future elective admission
in future for colonoscopy preparation under medical supervision
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Polyethylene Glycol 17 g PO DAILY:PRN constipation
2. Warfarin 7.5 mg PO 5X/WEEK (___)
3. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
4. Furosemide 20 mg PO EVERY OTHER DAY
5. Hydroxyurea 1000 mg PO DAILY
6. Enoxaparin Sodium 80 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
7. Levothyroxine Sodium 50 mcg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Morphine Sulfate ___ 30 mg PO TID
10. Morphine Sulfate ___ 15 mg PO TID
11. Zolpidem Tartrate 10 mg PO QHS:PRN insomia
12. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
13. Vitamin D ___ UNIT PO DAILY
14. treprostinil 1.74 mg/2.9 mL (0.6 mg/mL) inhalation QID
15. bosentan 125 mg oral BID
16. T.E.D. Knee Length-M-Long (comp stocking, knee,long,small)
medium on legs DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Hydroxyurea 1000 mg PO DAILY
3. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Warfarin 7.5 mg PO 5X/WEEK (___)
6. treprostinil 1.74 mg/2.9 mL (0.6 mg/mL) inhalation QID
7. Vitamin D ___ UNIT PO DAILY
8. Zolpidem Tartrate 10 mg PO QHS:PRN insomia
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Morphine Sulfate ___ 30 mg PO TID
11. Morphine Sulfate ___ 15 mg PO TID
12. Furosemide 20 mg PO EVERY OTHER DAY
13. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
14. bosentan 125 mg oral BID
15. T.E.D. Knee Length-M-Long (comp stocking, knee,long,small) 0
2 ON LEGS DAILY
16. Enoxaparin Sodium 80 mg SC BID
Start: Today - ___, First Dose: Next Routine Administration
Time
Discharge Disposition:
Home
Discharge Diagnosis:
sickle cell crisis
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 ___
for a sickle cell crisis. You were closely monitored and treated
with oxygen, intravenous fluids, pain medications and
anti-nausea medications. You recovered well and the team
believes that you are in stable condition to be discharged to
home.
Please take all of your medications as prescribed and keep all
appointments with your medical providers. It was a pleasure
taking part in your care and we wish you the best of health
going forward.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10224976-DS-26 | 10,224,976 | 28,714,752 | DS | 26 | 2164-01-31 00:00:00 | 2164-02-13 17:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old male who presented to the ED after
having fevers at home and discussion with his ___ clinic.
He has a history significant for stage III osteosarcoma on chemo
(last received ___.
He spoke to the Oncology fellow on call and noted taht two days
ago he felt warm and took his temperature which was 99.9, and
after taking acetaminophen, his temp increased to 100.4. A
similar episode recurred last night with temperatures of 99-100.
He has been without symptoms throughout these episodes, notably
without SOB, CP, nausea or vomiting, no abdominal pain, no
urinary symptoms or bowel symptoms. He has been compliant with
his antibiotics (levofloxacin) at home. He does have
resolving mucositis from his chemotherapy, and notes that while
his BMs are not diarrhea, they have been loose ("like mud")
occurring once a day or every other day.
He had a planned admission tomorrow (___) after his
appointment with Dr. ___ additional chemotherapy. After
discussion with the Oncology fellow, Mr. ___ agreed to come
to the ED for work-up and admission.
In the ED:
Initial vital signs were 97.8 108 120/70 20 97%.
Transfer vitals: 97.5 94 ___ 100% RA
Given: Cefepime, gabapentin, and morphine SR
Access: Right chest POC #20 1 inch needle accessed in ED
Fluids: None
Labs: Notable for increase in all lines on CBC. Chem 7 WNL.
Lactate 1.0.
Studies: CXR - No definite acute cardiopulmonary process.
Persistent small bilateral effusions with fluid within the right
major fissure.
Review of Systems:
(+) Per HPI
(-) Denies blurry vision. Denies headache, sinus tenderness,
rhinorrhea or congestion. Denies chest tightness, palpitations.
Denies cough, shortness of breath, or wheezes. Denies nausea,
vomiting, diarrhea, constipation, abdominal pain, melena,
hematemesis, hematochezia. Denies dysuria. Denies arthralgias or
myalgias. Denies rashes. All other systems negative.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- ___: pain developed in right hip which he initially
thought was due to overcompensation from past left ACL tears and
which progressed to severe around ___ ___nd
___ with activity.
- ___: collapsed due to pain in snowstorm. X-ray and MRI
showed aggressive lesion of proximal right inner trochanteric
area and femur.
- ___: acetabular mass biopsy as osteosarcoma with
chondroblastic differentiation and right femur lesion c/w
enchondroma
- ___: admitted for Cycle 1 doxorubicin cisplatin,
afterwards with neutrapenia and diarrhea. Treated empirically
for
cdiff.
- ___: given methotrexate1200mg/m2 with leukovorin
rescue
- ___: admitted for Cisplatin 50mg/m2 (used adult
protocol dose as opposed to pediatric dose due to renal
insufficiency) and doxorubicin 37.5mg/m2 D1 and 2. ___ given
neulasta though still developed significant neutropenia.
-___: admitted for ___ cycle of
cisplatin/adriamycin.
- ___: Admitted with shortness of breath secondary to
malignant effusion. Underwent pleurodesis, as well as adjuvant
chemotherapy with etopaside and ifosfamide ___.
Experienced side effects of ifosfomide including confusion,
asterixis, ___, hypokalemia, hypomagnesemia, and
hypophosphatemia. He received neulasta ___. Also complicated by
neutropenic fever, culture negative, b-glucan and galactomannan
negative. Treated with vanc/cefepime/voriconazole and discharged
on levofloxacin x4 days when he defervesced and his ANC was
>1000.
PAST MEDICAL HISTORY:
- torn left ACL repair ___ and ___, further tear ___
- cervical radiculopathy
- esophageal stricture s/p dilation
Social History:
___
Family History:
Father had MI at age ___
Maternal grandmother with lung cancer. No other family history
of malignancy.
Physical Exam:
ADMISSION:
Vitals: T:99.1 BP: 114/70 HR: 112 RR: 20 02 sat: 100% on RA
GENERAL: NAD, awake and alert
HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva, patent
nares, MMM, good dentition, multiple healing oral ulcers, no
erythema or exudate
Lymph: no cervical LAD
CARDIAC: Tachycardic, regular rhythm, nl S1 S2, no MRG, trace
pedal edema, flat JVP
Respiratory: CTA, good inspiratory effort, right base with some
soft crackles no rales or wheezes, no accessory muscle use
GI: +BS, soft, non-tender, non-distended, no rebound or
guarding, no HSM
MSK: warm and well-perfused, no cyanosis, clubbing
PULSES: 2+ DP pulses bilaterally
NEURO: sensation grossly normal, gait deferred, no gross deficit
DERM: well healing right hip scar, no erythema or induration. No
erythema surrounding his port. Stage II decubitus ulcer present
on admission.
DISCHARGE:
Vitals: T 98.2 (Tm 98.7), BP 114/68, HR 108 RR 20 02 sat 95% on
RA
GENERAL: NAD, alert and oriented, appropriate
HEENT: AT/NC, EOMI, anicteric sclera, MMM, no mucositis
NECK: supple, no LAD
CARDIAC: Regular rhythm, nl S1 S2, no MRG
Respiratory: CTA, no rales or wheezes.
GI: +BS, soft, non-tender, non-distended, no rebound or guarding
MSK: warm and well-perfused, no cyanosis, clubbing, edema
NEURO: alert and oriented, CN ___ grossly intact, no asterixis,
R leg strength not tested due to pain, L leg with ___ strength
DERM: well healing right hip scar, no erythema or induration. No
erythema surrounding his port. Well healing scab from chest
tube.
Pertinent Results:
ADMISSION LABS:
===========
___ 04:30PM BLOOD WBC-7.7# RBC-3.66*# Hgb-10.4*# Hct-29.9*#
MCV-82 MCH-28.3 MCHC-34.6 RDW-14.3 Plt ___
___ 04:30PM BLOOD Neuts-79.1* Lymphs-11.5* Monos-8.9
Eos-0.1 Baso-0.4
___ 04:30PM BLOOD Glucose-109* UreaN-6 Creat-0.8 Na-137
K-4.1 Cl-102 HCO3-25 AnGap-14
___ 06:15AM BLOOD Calcium-7.9* Phos-3.3# Mg-1.3*
___ 04:30PM BLOOD ALT-54* AST-46* AlkPhos-84 TotBili-0.4
DISCHARGE LABS:
===========
___ 05:44AM BLOOD WBC-1.8*# RBC-2.68* Hgb-7.8* Hct-21.9*
MCV-82 MCH-29.1 MCHC-35.5* RDW-14.1 Plt ___
___ 05:44AM BLOOD Neuts-82.7* Lymphs-14.2* Monos-1.8*
Eos-0.5 Baso-0.8
___ 05:44AM BLOOD Plt ___
___ 05:44AM BLOOD Glucose-113* UreaN-12 Creat-0.9 Na-135
K-3.8 Cl-105 HCO3-21* AnGap-13
___ 05:44AM BLOOD ALT-29 AST-14 AlkPhos-68 TotBili-0.4
___ 05:44AM BLOOD Calcium-7.9* Phos-2.0* Mg-1.8
IMAGING:
===========
CXR ___:
IMPRESSION:
No definite acute cardiopulmonary process. Persistent small
bilateral
effusions with fluid within the right major fissure.
KUB ___:
IMPRESSION:
1. Nonspecific bowel gas pattern without evidence of
obstruction or ileus.
2. Large amount of stool seen throughout the colon and rectum.
CXR ___:
Cardiac size is top normal. Loculated small-to-moderate right
pleural
effusion is unchanged. New opacities in the left lower lobe are
worrisome for pneumonia. Left effusion is small. Multiple left
lung nodules are better seen in prior CT. Right Port-A-Cath is
in standard position.
Brief Hospital Course:
___ with stage III osteosarcoma of the right acetabulum s/p
adjuvant chemotherapy with ifosfamide and etopaside. Surgical
resection of the primary tumor ___. He presented with fever,
then had mild hypothermia, however no localizing symptoms for
infection. Also started cycle 2 of adjuvant chemotherapy,
complicated by neurotoxicity.
ACTIVE ISSUES:
=============
# Fever: At home patient recorded temp of 100.4 the last two
days prior to admission. His recent admission was complicated by
neutropenic fever treated with vanc, cefepime, vori, and
ultimately levofloxacin once his counts recovered. No obvious
source was identified and cultures were negative. This admission
he remained hemodynamically stable and did not have particular
localizing symptoms, so after one dose cefepime in ED
antibiotics were not continued. CXR was unremarkable on
admission. He had a mild transaminitis that improved. Blood and
urine cultures no growth. Spiked to 101.2 on ___, pt was
asymptomatic, CXR showed LLL opacities. Has since been afebrile
overnight. No localizing sx, pt felt sweaty but otherwise fine.
Repeated blood cultures from peripheral and port. Possible
source would be pt's port, however port does not have erythema.
It is likely that fever is related to tumor burden. Pt not
neutropenic, decision was made for no abx unless his clinical
picture changes. Urine and blood cultures (port and peripheral)
with no growth.
# Hypothermia, mild: His temperature was persistently low on
___ (PO 94.5, rectal 97) and he was having some cold sweats.
Improved after a few hours with temperature consistently 98,
other VS otherwise stable. Repeat blood cultures showed no
growth, TSH and free T4 were within normal limits. Orthostatics
checked to evaluate for peripheral autonomic dysregulation, and
pt not orthostatic by VS. Unclear etiology, possible autonomic
dysregulation as side effect of chemotherapy.
# Neurotoxicity: Pt was noted to be slow to respond, worsening
confusion, and whole body asterixis/myoclonus. Started ___ ___
and worsened overnight. Ifosfomide infusion was discontinued
___ at 0330 (45% through infusion) as Ifosfamide has documented
side effect of CNS toxicity or encephalopathy (12% to 15%), and
pt experienced mild CNS side effects during first cycle with
ifosfamide. Thiamine started ___ ___ to reverse CNS sx effects.
Continued fluid hydration to help clear CNS toxicity. Pt's
mental status and myoclonus slowly improved and was at baseline
by time of discharge.
# Osteosarcoma: Stage III osteosarcoma s/p 4 cycles of
neoadjuvant chemotherpy followed by surgical resection of the
primary tumor at ___ by Dr ___ on ___. Pt received
adjuvant chemotherapy with etopaside and ifosfamide ___.
Cycle 2 adjuvant chemo with etopaside and ifosfamide started
___, planned ___ose reduce by 15% given previous
CNS side effects and renal toxicity. See above # Neurotoxicity.
Discontinued ifosfamide as above. Continued etopaside through
last dose ___. Issue with getting Neulasta so neupogen started
in house. Plan is to rescan him during the week of ___ and
tentatively admit for high dose MTX during the week of ___
# Constipation: Chronic and likely related to opiates. Continued
home bowel regimen with colace, senna, miralax, bisocodyl. Had
BM on ___ after lactulose.
CHRONIC ISSUES:
===============
# HTN: History of HTN on amlodipine. Initially held given
borderline pressures, then continued to hold amlodipine to
closely monitor BPs given neurotoxicity.
# Hip pain: Chronic right sided hip pain. Continued current home
regimen with MS contin, oxycodone PRN, gabapentin, and tylenol.
# Tachycardia: Sinus tachycardia, HR normally in 100s-110s.
Likely ___ pro-inflammatory state.
# Anxiety: Stable. Continued ativan 0.5mg prn anxiety.
TRANSITIONAL ISSUES:
================
- Plan is to rescan him during the week of ___ and tentatively
admit for high dose MTX during the week of ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H
2. Amlodipine 10 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 200 mg PO TID
5. Iron Polysaccharides Complex ___ mg PO DAILY
6. Morphine SR (MS ___ 45 mg PO Q8H
7. Multivitamins 1 TAB PO DAILY
8. Senna 2 TAB PO DAILY
9. Bisacodyl 10 mg PO DAILY constipation
10. Polyethylene Glycol 17 g PO DAILY constipation
11. Nystatin Oral Suspension 5 mL PO QID mucositis
12. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN mouth
sores
13. Neutra-Phos 4 PKT PO DAILY
14. Potassium Chloride 40 mEq PO DAILY
15. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Discharge Medications:
1. Filgrastim 480 mcg SC Q24H Duration: 5 Days
RX *filgrastim [Neupogen] 480 mcg/0.8 mL 480 mcg SC daily Disp
#*5 Syringe Refills:*0
2. Acetaminophen 650 mg PO Q6H
3. Bisacodyl 10 mg PO DAILY constipation
4. Docusate Sodium 100 mg PO BID
5. Gabapentin 200 mg PO TID
6. Iron Polysaccharides Complex ___ mg PO DAILY
7. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN mouth
sores
8. Morphine SR (MS ___ 45 mg PO Q8H
9. Multivitamins 1 TAB PO DAILY
10. Neutra-Phos 4 PKT PO DAILY
11. Nystatin Oral Suspension 5 mL PO QID mucositis
12. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
13. Polyethylene Glycol 17 g PO DAILY constipation
14. Potassium Chloride 40 mEq PO DAILY
15. Senna 2 TAB PO DAILY
16. Amlodipine 10 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
primary: osteosarcoma
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:
It was a pleasure caring for you at ___
___. You came to the hospital with a fever, and to
receive your scheduled chemotherapy. You unfortunately had side
effects from the chemotherapy, including tremor, confusion, and
sleepiness. The ifosfamide was stopped early, after about 40%
of the total dose. You were continued on the etoposide for the
full 5-day course. You were treated with thiamine and IV fluids
to help clear the effects of the ifosfamide. After several days
were were almost back to your normal awareness and had no
remaining tremor.
During your admission you had a day of low temperatures (oral
94, rectal 97) with shaking chills. We did not determine the
cause of these low temperatures, as there was no sign of
infection on imaging or cultures. You later had a single
low-grade fever without a clear source of infection.
On the day of discharge you were given the ___ of 5 daily
filgrastim shots. You should continue these shots at home for
the next 4 days to help your immune system recover from the
chemotherapy.
Once you are home you will likely become neutropenic, meaning
your immune system is less able to fight infection. Please use
a regimen of stool softeners and laxatives to ensure you have at
least 1 bowel movement a day, as you are at risk for infection
from your gut. Please also monitor your temperature and call
the ___ clinic if you have any temperature > 100.3 or
shaking chills.
Followup Instructions:
___
|
10225055-DS-6 | 10,225,055 | 23,223,406 | DS | 6 | 2127-10-05 00:00:00 | 2127-10-05 13:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / Lipitor
Attending: ___
Chief Complaint:
decrease level of consciousness
Major Surgical or Invasive Procedure:
intubation ___
extubated ___
History of Present Illness:
___ year old female with COPD on home O2, history of brain
aneurysm, chronic back pain, TIA, presents from home with
unresponsiveness.
Patient has a history of COPD and is on home O2. She also has
chronic back pain and was recently prescribed gabapentin one
weeks ago. Family noted patient had one week of increased
lethargy. Denied fevers, chills, myalgias, or chest pain.
Patient had intermittent coughing including day before episode
of unresponsiveness but this is not far from her baseline.
Overnight last night, she texted a friend that she had throat
tightness, lip swelling, and hives/rash feeling like she had an
allergic reaction. That morning her daughter who she lives with
heard a thump. She then found her unresponsive, foaming at the
mouth and beet red. EMS was called and found the patient
unresponsive. They initiated CPR for 1 min despite patient
opening her eyes, due to gurgling noises. No shocks, no
epinephrine given. They bagged her as she was note breathing. Of
note, no stridor or wheezing documented. She was taken to
___. She was empirically given
epinephrine, Benadryl and solumedrol empirically for possible
anaphylaxis. She had soft pressures SBP's in the 90's and tachy
to the 130's on presentation. Started on peripheral levophed for
hypotension and then intubated. CT head and neck done was
unremarkable. Patient was reportedly 'opening eyes' to commands
at OSH.
Transferred to ___ for further management. In out ED she was
intubated and sedated.
In ED initial VS: 105 148/88 22 100% intubated
Exam:
Bilateral breath sounds, no intraoral lesions seen, pupils
reactive, belly breathing concern for retaining with COPD
Labs significant for: WBC 15.8, VBG: ___
Patient was given:
Imaging notable for: CXR with ET tube 2 cm from carina,
bilateral interstitial thickening greater at the bases with some
mediastinal congestion. No clear consolidations.
Consults: None
On arrival to the MICU, Intubated and sedated. It was revealed
that patient had taken black seed oil containing thymoquinone
for the first time.
Past Medical History:
COPD on home O2
Depression
Anxiety
Fall Bilat ankle fractures
Chronic back pain
History ICA aneurysm
S/p Parathyroidectomy
TIA
Social History:
___
Family History:
Non-contributory to her current presentation
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: Reviewed in Metavision
GENERAL: Intubated and sedated.
HEENT: Swollen lips and tongue.
NECK: supple, JVP not elevated, no LAD
LUNGS: CTAb, some rhonchi but no wheezes
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Blanching red rash noted on chest neck. No hives
NEURO: Following basic commands. PERRLA
DISCHARGE PHYSICAL EXAM:
CN: PERRL 3->2mm, limite upward gaze, downward gaze and
aBduction
on the right sclera to L, L inferior field deficit, L neglect
and
L homonymous hemianopsia, seems mild as able to finger count in
all quadrants. subtle L NLFF w/ intact volitional activation.
Sensorimotor: Normal bulk, increased tone in LEs.
RUE: ___ delt, tri, bi
LUE: ___ delt, ___ bic, ___ tri
LLE: Ileo ___, Left foot drop.
Sensation: intact bilaterally without extinction on upper
extremities
Pertinent Results:
LABS:
=====
___ 09:54PM CK-MB-2 cTropnT-<0.01
___ 09:54PM C3-127 C4-31
___ 05:24PM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 05:24PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD*
___ 05:24PM URINE RBC-8* WBC-15* BACTERIA-NONE YEAST-NONE
EPI-<1
___ 05:24PM URINE MUCOUS-OCC*
___ 05:06PM ___ TEMP-38.1 PO2-48* PCO2-36 PH-7.44
TOTAL CO2-25 BASE XS-0
___ 05:06PM LACTATE-2.2*
___ 02:23PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 01:23PM ___ TEMP-37.2 PO2-42* PCO2-62* PH-7.26*
TOTAL CO2-29 BASE XS-0 INTUBATED-INTUBATED
___ 01:23PM LACTATE-2.7*
___ 01:11PM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 01:11PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM*
___ 01:11PM URINE RBC-18* WBC-5 BACTERIA-FEW* YEAST-NONE
EPI-0
___ 01:11PM URINE AMORPH-RARE*
___ 01:11PM URINE MUCOUS-FEW*
___ 01:10PM GLUCOSE-138* UREA N-16 CREAT-0.8 SODIUM-146
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-24 ANION GAP-16
___ 01:10PM ALT(SGPT)-21 AST(SGOT)-32 LD(LDH)-434*
CK(CPK)-179 ALK PHOS-64 TOT BILI-0.7
___ 01:10PM CK-MB-3 cTropnT-<0.01
___ 01:10PM ALBUMIN-3.8 CALCIUM-8.5 PHOSPHATE-3.5
MAGNESIUM-1.8
___ 01:10PM TSH-0.75
___ 01:10PM WBC-17.6* RBC-4.17 HGB-12.7 HCT-40.2 MCV-96
MCH-30.5 MCHC-31.6* RDW-12.5 RDWSD-44.0
___ 01:10PM NEUTS-92.0* LYMPHS-2.8* MONOS-4.3* EOS-0.1*
BASOS-0.1 IM ___ AbsNeut-16.20* AbsLymp-0.50* AbsMono-0.75
AbsEos-0.01* AbsBaso-0.02
___ 01:10PM ___ PTT-24.9* ___
___ 01:10PM ___ 11:02AM ___ PO2-46* PCO2-72* PH-7.18* TOTAL
CO2-28 BASE XS--3
___ 11:02AM LACTATE-2.5*
___ 11:02AM O2 SAT-73
___ 10:50AM GLUCOSE-162* UREA N-16 CREAT-0.9 SODIUM-145
POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-23 ANION GAP-16
___ 10:50AM estGFR-Using this
___ 10:50AM ALT(SGPT)-24 AST(SGOT)-41* ALK PHOS-67 TOT
BILI-0.3
___ 10:50AM ALBUMIN-3.9 CALCIUM-8.3* PHOSPHATE-4.3
MAGNESIUM-2.1
___ 10:50AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 10:50AM URINE HOURS-RANDOM
___ 10:50AM URINE bnzodzpn-POS* barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-POS* mthdone-NEG
___ 10:50AM WBC-15.2* RBC-4.36 HGB-13.3 HCT-42.7 MCV-98
MCH-30.5 MCHC-31.1* RDW-12.6 RDWSD-45.2
___ 10:50AM NEUTS-84.3* LYMPHS-6.5* MONOS-8.1 EOS-0.1*
BASOS-0.1 IM ___ AbsNeut-12.77* AbsLymp-0.99*
AbsMono-1.23* AbsEos-0.02* AbsBaso-0.01
___ 10:50AM PLT COUNT-197
___ 10:50AM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 10:50AM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-100*
GLUCOSE-TR* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 10:50AM URINE RBC-6* WBC-5 BACTERIA-FEW* YEAST-NONE
EPI-3 TRANS EPI-1
___ 10:50AM URINE HYALINE-5*
___ 10:50AM URINE AMORPH-RARE*
___ 10:50AM URINE MUCOUS-FEW*
MICROBIOLOGY:
__________________________________________________________
___ 4:58 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Preliminary): NO GROWTH.
__________________________________________________________
___ 5:24 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 5:01 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 1:10 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 10:50 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 10:50 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
IMAGING:
=========
CXR ___:
IMPRESSION:
Standard positioning of the enteric and endotracheal tubes. No
focal
consolidation to suggest pneumonia.
MRI ___:
IMPRESSION:
1. Late acute versus early subacute infarcts involving the right
occipital and
high right posterior frontal lobes, better characterized on
subsequent MRI
examination.
2. No convincing evidence for acute intracranial hemorrhage.
3. Status post placement of a right cavernous and paraclinoid
ICA vascular
stent, which appears patent within the limitations of CT.
Adjacent
peripherally calcific structure which likely represents
patient's known
aneurysm without visualized contrast opacification within its
lumen.
4. Multifocal atherosclerotic disease throughout the
intracranial and cervical
vasculature, without high-grade stenosis, occlusion, or definite
aneurysm.
5. Technically limited and essentially nondiagnostic CT
perfusion examination.
EEG:
IMPRESSION: This telemetry captured no pushbutton activations.
It showed a
widespread ___ Hz activity with a very broad distribution,
usually appearing
over all areas similarly. This was interrupted by bursts of
generalized
slowing or bursts of suppression in all areas. Together, these
findings
indicate a widespread encephalopathy. The most common causes are
medications,
metabolic disturbances, and infection. There was intermittent
focal slowing
over the right hemisphere, suggesting subcortical dysfunction in
this region
and consistent with patient's known infarct. There were
occasional sharp wave
discharges in the right frontal region, occasionally occurring
in brief, 6
second runs of rhythmic activity at about 1.7 Hz. These runs
suggest an
increased risk for focal epileptogenesis, but they were not long
or sustained
enough to indicate ongoing seizures. There were no definite
electrographic
seizures in the recording.
MRI Brain ___:
IMPRESSION:
Acute infarcts in the distribution of right middle cerebral
artery extending
to the watershed distributions. Petechial hemorrhage in the
right frontal
lobe.
DISCHARGE LABS:
===============
___ 07:20AM BLOOD WBC-12.9* RBC-4.70 Hgb-14.3 Hct-44.2
MCV-94 MCH-30.4 MCHC-32.4 RDW-12.4 RDWSD-42.9 Plt ___
___ 07:20AM BLOOD Glucose-103* UreaN-39* Creat-1.1 Na-144
K-3.6 Cl-98 HCO___ AnGap-19*
Brief Hospital Course:
___ year old female with COPD on home O2, history of R ophthalmic
artery aneurysm s/p stent, history of prior TIA , chronic back
pain, presents from home with unresponsiveness, and angioedema,
given epi, methylpred, Benadryl and intubated, later found to
have a new left sided weakness diagnosed as an acute stroke.
Thought was that she may have had an allergic reaction which led
to unwitnessed hypotension and collapse, which led to acute
ischemic stroke in watershed distribution.
# Episode of hypotension:
# Unresponsiveness:
Unclear etiology. Possible respiratory unresponsiveness ___
angioedema vs anaphylaxis. Patient with h/o hives to NSAIDS and
unclear if supplement provided by friend (Black seed) included
NSAIDs not on label but OTC medications prone to undocumented
additives. Patient was intubated at the outside hospital and
transferred to ___ for further managment. She was treated with
epinephrine, glucocorticoid and anti-histamines for anaphylaxis.
Patient's angioedema improved within 24hours. F/u with an
allergy specialist is recommended.
# right hemispheric cerebral infarction in watershed
distribution:
On first night of hospitalization, while sedation had been
weaned off slightly, she
was found to have new left-sided weakness. CT/CTA head revealed
multiple hypodensities in the R parietal, temporal and occipital
lobes. An MRI of the brain exhibited ischemic lesions in
watershed distribution. A TTE was without evidence for ASD/PFO
and did not reveal intracardiac masses thrombi or valvular
pathology. Cardiac monitoring did not reveal atrial fibrillation
or flutter. Patient was ASA 325mg loaded. She was continued on
ASA 81mg daily and Neurosurgery team came to evaluate her as
well. Patient's pravastatin was continued. HbA1C 5.2, LDL 88 and
TSH 0.68. Thought was that she may have had an anaphylactic
shock which led to hypotension and acute ischemic stroke in
watershed distribution. Her exam was notable for a CN III palsy
and a visual field deficit. Outpatient follow-up with a
neuro-ophthalmologist is recommended. We arranged for follow-up
with Dr. ___ in Neurology ___. Ms. ___ was discharged
to a rehabilitation facility.
# hypercarbic respiratory Failure: Known COPD, but not a chronic
retainer per Dr. ___ ___ pulmonologist). Prescribed O2
at all times, but patient often does not wear her oxygen during
the day. Intial gas in ED with mixed respiratory and metabolic
acidosis on vent. Unclear trigger, though in light of the other
signs and symptoms likely due to anaphylaxis. She completed
Azithromycin x 5 days. Patient was extubated without
difficulties after two days, and her treatment was continued.
# H/O right ophthalmic artery aneurysm: Right ophthalmic artery
aneurysm s/p stenting and coil with Dr. ___. On exam the
patient was noted to have right CN III palsy. Imaging was
reviewed by Neurosurgery and Neurology and it was thought that
it might be due to thrombosis of her aneurysm. F/u with a
neuro-ophthalmologist is recommended.
Transitional Issues
===================
[] outpatient f/u with neuro-ophthalmologist
[] f/u with an allergy specialist is recommended
[] f/u with primary care physician ___ 14 days of discharge.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day
2? () Yes - () No
4. LDL documented? (x) Yes (LDL = 88 ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) () Yes - (x) No [if LDL
>70, reason not given: patient preferred to stay on pravastatin
20
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
]
6. Smoking cessation counseling given? (x) Yes - () No [reason
() non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FLUoxetine 40 mg PO DAILY
2. Pravastatin 20 mg PO QPM
3. TraZODone 150 mg PO QHS:PRN insomnia
4. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain -
Moderate
5. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
6. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation
DAILY
7. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
2. Lidocaine 5% Patch 1 PTCH TD QAM PRN pain
3. Aspirin 81 mg PO DAILY
4. FLUoxetine 40 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
6. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation
DAILY
7. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain -
Moderate
8. Pravastatin 20 mg PO QPM
9. TraZODone 150 mg PO QHS:PRN insomnia
10. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
anaphylactic shock
right cerebral hemispheric infarction in watershed distribution
right CN III palsy
musculoskeletal chest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized with signs and symptoms of a severe
allergic reaction. You were diagnosed with an ACUTE ISCHEMIC
STROKE, a condition where you brain is not adequately supplied
with oxygen. We believe that a low blood pressure and/or low
oxygen concentrations in your blood from your severe allergic
reaction were the cause of your stroke.
The brain is the part of your body that controls and directs all
the other parts of your body, so damage to the brain from being
deprived of its blood supply can result in a variety of
symptoms. Stroke can have many different causes, so we assessed
you for medical conditions that might raise your risk of having
stroke. In order to prevent future strokes, we plan to modify
those risk factors. Your risk factors are:
1) hypercholesterolemia
You were continued on pravastatin and aspirin and started on
clopidogrel. Please take your other medications as prescribed.
Please follow up with Neurology as listed below. Please follow
up with your primary care physician ___ 14 days of discharge.
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:
___
|
10225233-DS-8 | 10,225,233 | 24,759,243 | DS | 8 | 2134-03-06 00:00:00 | 2134-03-06 13:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
venom-honey bee / bee pollen / bee pollen / bee pollen /
venom-honey bee / hornet venom
Attending: ___.
Chief Complaint:
Left Hip Fracture
Major Surgical or Invasive Procedure:
Left hip hardware removal and placement of long DHS
History of Present Illness:
___ female history of hypertension, hyperlipidemia, left hip
fracture status post DHS ___ years ago) who presents with the
above fracture status post mechanical trip and fall. The
patient
was ambulating while at home when she tripped over her dog's
leash and fell directly onto her left side. She was unable to
ambulate afterwards. No head strike or loss of consciousness.
She was able to scoot herself across the floor and call ___ for
an ambulance. She was evaluated in outside hospital, placed
into
a posterior slab splint and sent to be I for further evaluation.
She denies any numbness or tingling. She is currently in
minimal
pain and is very comfortable with a posterior slab splint in
place. With respect to her previous injury, she reports that
when she was roughly ___ years old, she sustained a left hip
fracture that was treated with a DHS and has been asymptomatic
since then. She denies any antecedent hip, groin or thigh pain.
Past Medical History:
Hypertension, hyperlipidemia
Social History:
___
Family History:
Non-contributory
Physical Exam:
Exam:
Vitals:
Temp: 99.8 (Tm 99.8), BP: 134/74 (103-134/57-74), HR: 91
(83-95),
RR: 18, O2 sat: 97% (94-98), O2 delivery: Ra
General: NAD
LLE:
dressing to left hip c/d/i
Fires ___, FHL, TA, GSC
SILT s/s/t/sp/dp
WWP
Pertinent Results:
See OMR
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left hip fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for left hip removal of hardware and revision to long
DHS, 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
touch down weightbearing in the left lower extremity, and will
be discharged on enoxaparin for DVT prophylaxis. The patient
will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Medications on Admission:
.
1. Losartan Potassium 50 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
hold for loose stools
3. Enoxaparin Sodium 40 mg SC QHS
RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*28 Syringe
Refills:*0
4. Omeprazole 20 mg PO DAILY
5. Simvastatin 40 mg PO QPM
6. Losartan Potassium 50 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Left hip fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Touch down weightbearing on left lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Please take all medications as prescribed by your
physicians at discharge.
3) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take enoxaparin 40mg injection daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
Physical Therapy:
Touch down weight bearing, left lower extremity
Treatments Frequency:
Any staples or superficial sutures you have are to remain in
place for at least 2 weeks postoperatively. Incision may be
left open to air unless actively draining. If draining, you may
apply a gauze dressing secured with paper tape. You may shower
and allow water to run over the wound, but please refrain from
bathing for at least 4 weeks postoperatively.
Call your surgeon's office with any questions.
Followup Instructions:
___
|
10225498-DS-4 | 10,225,498 | 28,667,941 | DS | 4 | 2176-09-30 00:00:00 | 2176-10-22 11:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / morphine /
Ativan
Attending: ___.
Chief Complaint:
Abdominal pain, nausea, vomiting.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. ___ is a ___ w/ a hx of Crohn's, radiation proctitis, and
chronic abdominal pain who presents w/ 5 days of abdominal pain,
nausea, and vomitting that she reports is consistent with
previous crohn's flares. At baseline, Ms. ___ has chronic
abdominal pain and has a colostomy bag that she received in ___. She was in her usual state of health on 5 days PTA when
she developed general malaise. She reported increased abdominal
distention and pain in the right and left lower quadrants. The
pain was localized to her lower abdomen and was a constant pain
that radiated to her lower back on the left. Her abdominal pain
changed in character to a ___ stabbing pain 1 day PTA. Around
this time, she also reports nausea and vomitting and not being
able to keep any food down. The vomitting began as stomach
remnants, was non-bloody without coffee grounds, and became
bilious 1day PTA. Also she reports subjective fevers that began
as 99.8F 4 days PTA, 100 on ___ days PTA, and 101.6 on 1 day
PTA. She also reports bright red blood in the colostomy bag and
that she had to change the bag ___ times daily which is
increased from her usual 1 change/day.
She denies recent changes in medication, diet, activity, sick
contacts. She reports that the only food that she can keep down
is mozarella sticks and raspberry ginger ale.
She went to ___ for better control of her
Crohns flare. She reports being given Zofran, Dilaudid,
Solumedrol, and Benedryl, which gave her better control of her
pain. She reports that she was transfered to ___ at the
request of her PCP.
In the ED, initial vital signs were Pain 8 98.4 90 129/84 18
97%. Patient was given Ciprofloxain 400mg IV, Metronidazole
500mg IV, Ondanzetron 4mg IV, Dilaudid 1mg IV 3x,
Diphenyhydramine 25mg IV due to reported itching with Dilaudid.
Her labs were concerning for leukocytosis of 16.0 with 91.3% PMN
and postive ketones in urine. She was admitted to medicine for
further workup of her abdominal pain.
On the floor, her vitals were 98.4. HR: 96. BP: 112/68. O2: 99%
ra. RR: ___. She reports abdominal pain, nausea, and
dizziness. She reports bilious vomitting 3x in the morning.
Review of sytems:
(+) fever, dizziness, nausea, vomitting, bilateral headache at
temples, abdominal pain, bright red blood in colostomy,
(-) fever, chills, night sweats, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- Crohn's: diagnosed in ___ complicated by 3 small bowel
resections. Pt had temporary colostomy since ___. Flares on
average every 6 months with most recent flare in ___
- Gallstones: s/p cholecystectomy in ___, stent placement in
common bile duct in ___
- Nephrolitiasis: frequent w/ last epidose in ___
- Chronic abdominal pain: managed by ___ pain management clinic
- Left clear cell ovarian cancer: diagnosed at age ___, treated
with aggressively radiation and peritoneal chemotherapy
- Radiation proctitis: diagnosed ___ years ago, treated with argon
coagulation
- Pulmonary embolism: from clot on a central port in ___.
Treated with Fondaparinaux
- Fibromyalgia
- Panic attacks: managed with Alprazolam in periods of increased
stress
- ADHD
- Right knee arthroscopic surgery: after fall during
cheerleading
Social History:
___
Family History:
- Crohn's : Father, son
- ___ cancer: Father, paternal grandfather
- ___ cancer: Maternal aunt
- Breast cancer: Mother
- Brain tumor unspecified: Paternal grandmother
Physical Exam:
ON ADMISSION:
VITALS- 98.8 120/70 87 20 97%RA
GENERAL- Alert, oriented X3, in discomfort due to abdominal pain
HEAD- Normocephalic and atraumatic
EYES- Visual acuity grossly normal, conjuctiva clear, sclera
anicteric, PERRLA 3>2mm, EOMI
EARS- Hearing intact to finger rub
NOSE- Nasal mucosa pink, septum midline, no sinus tenderness
MOUTH/THROAT- MMM, oropharynx clear, good dentition
NECK- supple, no thyroid nodules or thyromegaly, no LAD. Carotid
pulses brisk, no JVD. Internal jugular line without erythema and
swelling.
THORAX- Resonant to percussion, clear to auscultation
bilaterally with scattered rhonchi. No wheezes or rales
CV- RRR, normal S1 + S2, no murmurs, rubs, gallops
ABDOMEN- soft, non-distended, with normoactive bowel sounds
present. Diffuse tenderness expecially on lower quadrants. No
rebound tenderness or CVA tenderness. Organomegaly couldnt be
assessed due to pain
MS- No evidence of swelling or deformity. Good ROM present
SKIN- No rashes, ulcers, lesions
EXT- warm, well perfused, 2+ pulses in DP, no clubbing, cyanosis
or edema
NEURO- CNs2-12 intact, motor function ___ in upper and lower
extremities, sensation grossly normal bilaterally
.
ON DISCHARGE:
VS: T 98.6 Tm 99.0 BP 116/71 (116-123/70-84) HR 101 (86-101) R
20 97-100%RA
GENERAL- Alert, oriented x3, visibly sad and occasionally crying
but not writhing or in acute distress from pain
HEENT: sclera anicteric, PERRLA 3>2mm, EOMI, MMM, OP clear
THORAX- clear to auscultation bilaterally. No wheezes, rales, or
rhonchi
CV- RRR, normal S1 + S2, no murmurs, rubs, gallops, no JVD
ABDOMEN- Soft, non-distended w/ normoactive bowel sounds.
Diffuse tenderness in lower quadrants. Unable to asses
organomegaly due to patient insistence
MS- No evidence of swelling or deformity. Good ROM present
EXT- WWP, 2+ pulses in DP, no clubbing, cyanosis or edema
SKIN- No rashes, ulcers, lesions
NEURO- CNs2-12 grossly intact
Pertinent Results:
LABS ON ADMISSION:
___ 02:25AM BLOOD WBC-16.0* RBC-3.93* Hgb-11.5* Hct-35.0*
MCV-89 MCH-29.4 MCHC-33.0 RDW-15.2 Plt ___
___ 02:25AM BLOOD Neuts-91.3* Lymphs-7.2* Monos-0.5*
Eos-0.7 Baso-0.3
___ 02:25AM BLOOD ESR-4
___ 02:25AM BLOOD Glucose-90 UreaN-13 Creat-0.6 Na-138
K-3.4 Cl-106 HCO3-25 AnGap-10
___ 02:25AM BLOOD ALT-13 AST-15 AlkPhos-70 TotBili-0.3
___ 02:25AM BLOOD Lipase-29
___ 02:25AM BLOOD Albumin-4.0
___ 06:40AM BLOOD Mg-1.6
___ 02:25AM BLOOD CRP-0.8
___ 02:36AM BLOOD Lactate-0.8
___ 02:36AM BLOOD ___
.
LABS ON DISCHARGE:
___ 06:40AM BLOOD WBC-8.1 RBC-3.58* Hgb-10.3* Hct-32.1*
MCV-90 MCH-28.9 MCHC-32.2 RDW-15.4 Plt ___
___ 06:40AM BLOOD Glucose-111* UreaN-11 Creat-0.7 Na-140
K-3.4 Cl-105 HCO3-27 AnGap-11
.
IMAGING & STUDIES:
___ ED CXR: The heart size is within normal limits. There
are slightly low lung volumes. There are no pneumothoraces. No
catheters are seen which is consistent with the right IJ central
venous line removal. Bony structures are intact.
.
MICRO:
___ ED BLOOD CX X 2: NGTD (FINAL)
Brief Hospital Course:
This is the brief hospital course for a ___ year-old female (new
to ___ with a self-reported past medical history significant
for Crohns disease, ovarian cancer, and radiation proctitis who
presented to ___ this admission with a 7-day history of
nausea, vomiting, and abdominal pain.
.
The patient was admitted on ___ (HD1) and discharged ___
(HD2). The following medical issues were active during this
hospitalization:
# Abdominal pain: The differential for her GI symptoms was
initially broad. For Ms. ___, the symptoms were especially
concerning for an active crohns flare primarily because she
reported this spectrum of symptoms to be consistent with past
episodes or flares. She did have a leukocytosis with a
predominance of PMNs on admission, but her ESR and CRP were
unremarkable and she had received IV steroids at an OSH prior to
transfer to ___. Also concerning, an infectious colitis, was
on the differential, however, she did not fit this presentation
with respect to time of onset, recent medication use, food
intake, or other risk factors. She did not report any rectal
secretions making radiation proctitis less likely, although she
had had this in the past on numerous occasions. Colostomy bag
was still draining at her baseline consistency/rate/appearance
ruling out obstruction. Also, we were less concerned about
ischemia because her lactate was within the normal limits. Most
likely, her symptoms and appearance as well as data gathered
from labs, micro, and imaging were consistent with an
exacerbation of her chronic abdominal pain.
.
A stool culture was ordered, but the patient refused both rectal
exams to test for heme as well as collection of this sample by
nursing and herself. She was placed on bowel rest upon arrival
and given IV fluids for hydration. Zofran and Dronabinol were
given for nausea. Eventually, the patient was transitioned from
the pain medications started in the ED to her home regimen.
There was some delay in this transition as ___ medical records
were difficult to attain and the first 3 physician numbers
attained from the patient were not accurate. Additionally, her
prior GI doctor at ___ terminated his medical relationship with
the patient due to its "lack of therapeutic value." Her home
Mesalamine was continued. No antibiotic therapy was continued as
there was no evidence of active infection on exam, imaging, or
labs. Her white count resolved on the following day indicating
likely demarginalization from the day prior's steroid dose. She
was able to tolerate an oral diet with candy and soda at her
bedside throughout her stay. On preparation for discharge, she
reported that her out-patient narcotics were completely empty
and she wanted a refill, but couldn't see her pain doctor until
___.
.
The patient's physical exam, micro data, and labs were all
reassuring that she was not experiencing a Crohn's disease
flare. She was afebrile throughout the admission, and with
stable vital signs. Nursing and patient reports revealed no
episodes of bloody stools or vomiting of any kind during her
stay. She not been seen by her GI doctor since before her last
Crohns flare months ago and she was instructed to see her GI
doctor as soon as possible for a check-up. She also had missed
numerous Pain Management appointments, and had run out of pain
medication on the day of presentation to ___. She was strongly
urged to see her pain doctor in person as their narcotic
contract and treatment plan required urgent clarification. She
was given a 3 day supply of her home oxycodone and oxycontin to
get her through the weekend and to her pain doctor on ___.
There were no changes to her medications.
.
On HD2, also day of discharge (DOD), the patient reported
constant abdominal pain and inadequate pain management
overnight. She denied fevers, chills, sweats, joint pain, bright
red blood in colostomy bag, and hematemesis. She did not have
excessive stool output in colostomy bag, but reported increased
gas. Of note, overnight, ___ hospital records were finally
attained and GI doctor's termination of patient relationship was
noted with other documents illustrating a poor compliance on the
patient's behalf with medications as well as appointments.
.
# Panic attacks: pt reported increased anxiety due to her
perceived flare this admission and wanted her home Xanax. She
reports having a panic attack in OSH where she felt numbness on
her fingers while her internal jugular line was being placed.
There were no neurological deficits on exam.
- continued home ALPRAZolam 0.5 mg PO/NG BID:PRN anxiety, no new
script given
- social work consulted
.
# History of ovarian cancer: pt reported hx of stage 3 clear
cell ovarian cancer of the left s/p left salpingoophorectomy
when she was ___. She was treated with radiation and chemotherapy
that was complicated by radiation proctitis. She does not report
recurrence of the cancer. No records were able to be obtained
regarding the patient's ovarian cancer. She states that it
initially occurred overseas on a military base and then at
___. For future follow-up records and history
should be clarified with oncologist.
- defer to out-patient oncology follow up
.
# ADHD: pt reports hx of ADHD that is controlled with home
Adderall.
- Adderall XR *NF* (amphetamine-dextroamphetamine) 20 mg Oral
daily continued from home
.
* Patient Taking the following as well *
- Docusate Sodium 100 mg PO/NG BID
- Ferrous Gluconate 325 mg PO DAILY
- FoLIC Acid 1 mg PO/NG DAILY
- Vitamin D 50,000 UNIT PO/NG 1X/WEEK (FR)
.
# Access: Patient had a right internal jugular central line on
arrival from the OSH. Since she required neither steroids,
antibiotics, nor fluids, this line was removed on arrival. CXR
showed no abnormalities post-pull.
.
# Emergency Contact: ___ (boyfriend) ___.
Was at bedside on arrival, then left.
Medications on Admission:
- Alprazolam 0.5 mg Oral Tablet tid prn anxiety
- Amphetamine-Dextroamphetamine 30 mg Oral Tablet TAKE 1 TABLET
bid
- Oxycodone 30 mg Oral Tablet every 4 to 6 hrs
- OXYCONTIN 20 mg Oral Tablet Extended Release 12 hr bid
- Mesalamine (ASACOL) 400 mg Oral Tablet, (E.C.) 800mg tid
- Dronabinol 15mg TID prn loss of appetite
- Phernergan (Promethazine) 25mg qd prn
- Ferrous Gluconate 324 mg (36 mg iron) Oral Tablet AS DIRECTED
- DOCUSATE SODIUM (COLACE ORAL) 100 mg po bid
Discharge Medications:
1. Vitamin D 50,000 UNIT PO 1X/WEEK (FR)
2. Oxycodone SR (OxyconTIN) 20 mg PO Q12H
hold for sedation or rr < 10.
RX *oxycodone 20 mg 1 Tablet(s) by mouth every twelve (12) hours
Disp #*3 Tablet Refills:*0
3. OxycoDONE (Immediate Release) 30 mg PO Q6H:PRN pain
hold for sedation or rr < 10.
RX *oxycodone 30 mg 30 Tablet(s) by mouth every six (6) hours
Disp #*6 Tablet Refills:*0
4. Mesalamine ___ 800 mg PO TID
5. FoLIC Acid 1 mg PO DAILY
6. Ferrous Gluconate 325 mg PO DAILY
7. Dronabinol ___ mg PO BID nausea
8. Docusate Sodium 100 mg PO BID
9. ALPRAZolam 0.5 mg PO BID:PRN anxiety
10. Adderall XR *NF* (amphetamine-dextroamphetamine) 30 mg Oral
BID
11. Promethazine 25 mg PO Q6H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Chronic abdominal pain
Secondary:
Crohns disease
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 abdominal discomfort, nausea and
vomiting. Your physical exam and labs were reassuring that you
were not having a Crohn's disease flare. You were afebrile
throughout this admission with stable vital signs and no
episodes of bloody stools or vomiting. Please drink plenty of
fluids as it is easy to become dehydrated in the summertime.
You have not been seen by your GI doctor since before your last
Crohn's disease flare. Please call to make an appointment for
within ___ weeks of discharge.
Since you missed your Pain Management appointment, we have given
you a small supply of pain medication. Please do not drive,
operate machinery, or take other sedating medications while on
these narcotic pain medications.
We did not make any changes to your medications.
Followup Instructions:
___
|
10225567-DS-6 | 10,225,567 | 20,746,341 | DS | 6 | 2156-03-16 00:00:00 | 2156-03-16 21:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
Mesenteric angiogram, colonoscopy
History of Present Illness:
The patient is a ___ year old male, history of diabetes,
recurrent LGIB, constipation who presents with BRBPR.
Patient reports that approximately 11 days ago he had first
episode of bright red blood per rectum. He presented to ___
___ where he was admitted for approximately a week. During
that admission he had colonoscopy that did not show evidence of
active bleed. He was transfused PRBCs. Discharged home 5 days
ago. Noticed new bleeding last night, re-presented to ___ today. Initially plan for admission, however, patient
requested AMA discharge for evaluation at ___. Reports one
episode of bright red blood per rectum at ___ prior to
arrival. Mild left lower quadrant abdominal pain occasionally.
No anticoagulation. Denies fever, chills, chest pain, shortness
of breath, nausea, vomiting, change in bladder function, change
in vision or hearing, bruising, adenopathy, new rash or lesion.
In the ED:
- Initial vitals: T 97.8 HR 78 BP 134/48 RR 18 SpO2 100% RA
- Exam notable for: Soft, Nondistended, mild left lower quadrant
abdominal discomfort to palpation. Rectal: Gross bright red
blood.
- Labs notable for: Hgb of 8.2, BUN 25, creatinine 1.6, INR
1.1, pH of 7.31, CO2 50
- Imaging notable for: Active arterial bleeding in the
descending colon.
2. Bilateral nonobstructing renal calculi.
- Pt given: IV pantoprazole 40mg, IV lorazepam 25mg, PO
citalopram 20mg, PO losartan 100mg, SC insulin 4 units, LR; 1u
pRBCs
GI recommended IV PPI BID, T&C 3U, diet of clears in case of
colonoscopy, CTA A/P in case of brisk bleeding. At 730 AM on
___ he had a large episode of hematochezia. He received 1 unit
of PRBCS and CTA Abd/pelvis showed findings compatible with
active arterial bleeding in the descending colon. ___ was
consulted and he was to undergo ___ embolization, however the
mesenteric angiogram was negative for lower GI bleed.
Vitals prior to transfer: T 97.9 HR 63 BP 137/71 RR 18 SpO2 97%
RA
Upon arrival to the floor, the patient has no active complaints.
REVIEW OF SYSTEMS:
General: no weight loss, fevers, sweats.
Eyes: no vision changes.
ENT: no odynophagia, dysphagia, neck stiffness.
Cardiac: no chest pain, palpitations, orthopnea.
Resp: no shortness of breath or cough.
GI: no nausea, vomiting, diarrhea.
GU: no dysuria, frequency, urgency.
Neuro: no unilateral weakness, numbness, headache.
MSK: no myalgia or arthralgia.
Heme: no bleeding or easy bruising.
Lymph: no swollen lymph nodes.
Integumentary: no new skin rashes or lesions.
Psych: no mood changes
Past Medical History:
Type 2 diabetes
Renal calculi
Chronic kidney disease stage 3
Hypertension
Benign prostatic hyperplasia
Social History:
___
Family History:
Hypertension
Hyperlipidemia
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: T 97.9 HR 63 BP 137/71 RR 18 SpO2 97% RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, ___ systolic murmur
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, Nondistended, mild left lower quadrant abdominal
discomfort to palpation.
Rectal: gross bright red blood
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally.
DISCHARGE PHYSICAL EXAM:
========================
Vitals: 24 HR Data (last updated ___ @ 008)
Temp: 98 (Tm 98.0), BP: 104/61 (104-152/61-75), HR: 68
(64-73), RR: 17 (___), O2 sat: 96% (95-99), O2 delivery: RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, ___ 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: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally.
Pertinent Results:
ADMISSION LABS
==============
___ 05:25PM NEUTS-59.2 ___ MONOS-9.0 EOS-2.2
BASOS-0.7 IM ___ AbsNeut-3.54 AbsLymp-1.71 AbsMono-0.54
AbsEos-0.13 AbsBaso-0.04
___ 05:25PM WBC-6.0 RBC-2.63* HGB-8.2* HCT-27.5* MCV-105*
MCH-31.2 MCHC-29.8* RDW-15.8* RDWSD-59.5*
___ 05:25PM ALBUMIN-4.0
___ 05:25PM LIPASE-48
___ 05:25PM ALT(SGPT)-32 AST(SGOT)-39 ALK PHOS-101 TOT
BILI-0.2
___ 05:25PM GLUCOSE-326* UREA N-25* CREAT-1.6* SODIUM-137
POTASSIUM-4.7 CHLORIDE-101 TOTAL CO2-16* ANION GAP-20*
___ 06:38PM ___ PTT-28.8 ___
___ 07:56PM ___ PO2-20* PCO2-50* PH-7.31* TOTAL
CO2-26 BASE XS--2
INTERVAL LABS
=============
___ 06:10AM BLOOD WBC-6.0 RBC-2.24* Hgb-6.8* Hct-22.2*
MCV-99* MCH-30.4 MCHC-30.6* RDW-15.8* RDWSD-56.5* Plt ___
___ 08:00AM BLOOD WBC-5.7 RBC-2.38* Hgb-7.3* Hct-23.0*
MCV-97 MCH-30.7 MCHC-31.7* RDW-15.9* RDWSD-55.1* Plt ___
___ 06:40AM BLOOD WBC-6.0 RBC-2.27* Hgb-6.9* Hct-22.3*
MCV-98 MCH-30.4 MCHC-30.9* RDW-15.9* RDWSD-56.3* Plt ___
___ 06:27AM BLOOD WBC-5.0 RBC-2.59* Hgb-7.7* Hct-24.9*
MCV-96 MCH-29.7 MCHC-30.9* RDW-17.7* RDWSD-61.2* Plt ___
___ 08:00AM BLOOD Glucose-176* UreaN-27* Creat-1.5* Na-140
K-4.9 Cl-104 HCO3-23 AnGap-13
___ 06:40AM BLOOD Glucose-163* UreaN-25* Creat-1.5* Na-139
K-4.6 Cl-103 HCO3-24 AnGap-12
___ 08:00AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.7
___ 06:40AM BLOOD Calcium-8.6 Phos-3.2 Mg-1.8
DISCHARGE LABS
===============
___ 06:10AM BLOOD WBC-5.6 RBC-2.69* Hgb-7.9* Hct-26.1*
MCV-97 MCH-29.4 MCHC-30.3* RDW-17.3* RDWSD-60.9* Plt ___
___ 06:10AM BLOOD Glucose-169* UreaN-19 Creat-1.5* Na-143
K-4.7 Cl-103 HCO3-24 AnGap-16
___ 06:10AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.1
IMAGING
=======
___ CTA AP
1. Findings compatible with active arterial bleeding in the
descending colon.
2. Bilateral nonobstructing renal calculi.
___ MESENTERIC ARTERIOGRAM
Negative mesenteric angiogram for lower GI bleed.
___ TRANSTHORACIC ECHO
Mild symmetric left ventricular hypertrophy with normal cavity
size and regional/global biventricular systolic function.
Quantitative biplane left
ventricular ejection fraction is 62 % (normal 54-73%). Mild
aortic stenosis. Mild aortic regurgitation.
STUDIES/PROCEDURES
==================
___ COLONOSCOPY
Colonoscopy report: Severe diverticulosis of the left colon. Old
blood seen throughout colon, predominantly in the descending
colon. Within the limitations of this exam, no fresh bleeding
was seen. Internal hemorrhoids. Source of prior hemorrhage
likely resolved diverticular bleeding.
Brief Hospital Course:
TRANSITIONAL ISSUES:
====================
[ ]The GI team recommended a follow-up outpatient colonoscopy in
___ year after discharge, to be arranged by the patient's PCP.
Since colonoscopy screening is not recommended for patients ___
years old, the patient can choose to undergo this colonoscopy in
___ year if it is within his goals of care.
[ ]The patient's LGIB is likely due to diverticular bleed. It is
important for the patient to maintain a ___ diet and
continue with his bowel regimen to reduce risk of constipation.
[ ]His home losartan was held in setting of LGIB. The patient
should follow up with his PCP prior to restarting losartan.
[ ]The patient's TTE showed normal EF with mild aortic stenosis
and mild aortic regurgitation. This can be followed up by his
PCP and monitored outpatient with TTEs every ___ years.
ACUTE/ACTIVE PROBLEMS:
======================
#. Lower GIB
Presented with BPBPR and was found to have gross bright red
blood in the rectal vault on exam. Had an episode of large
volume hematochezia in the ED and received 1u pRBC. Hgb bumped
appropriately to 7.5 from 6.8. CT angio abd/pelv showed findings
compatible with active arterial bleeding in the descending
colon. ___ was consulted and patient was taken for an ___
embolization; however, the mesenteric angiogram was negative for
lower GI bleed so embolization was not performed. His H/H were
monitored with CBCs twice daily, with transfusion threshold for
Hgb <7. His losartan was held in the setting of bleeding. He had
no further episodes of bleeding but Hgb on ___ was 6.9 so he
received a ___ pack of RBCs. During his admission, the patient
was not symptomatic, denying chest pain, shortness of breath or
extertional dyspnea, lightheadedness, abdominal pain. GI
performed a colonoscopy on ___, which did not visualize active
bleeding. Colonoscopy visualized L-sided diverticulosis, which
is likely the etiology of the patient's presenting complaint.
Recommended outpatient colonoscopy in ___ year with PCP and
___ diet. On discharge, patient remains asymptomatic and
Hgb is 7.9, Hct 26.1.
#. Systolic murmur
Physical exam was notable for a ___ systolic murmur, most
prominent in left-upper sternal border. Neither the patient nor
the patient's son were aware of the murmur. The patient denied
symptoms of chest pain or palpitations, exertional dyspnea,
lightheadedness, presyncope/syncope. Outside records were not
available. TTE was performed and showed normal EF and mild
aortic stenosis, mild aortic regurgitation. This can be followed
outpatient with echos every ___ years.
#. Elevated creatinine
Creatinine on admission was 1.6. Patient's baseline creatinine
was unknown; one discharge summary from ___ from ___
mentioned that the patient has a history CKD stage 3 and his
creatinine on ___ was 1.3. During this admission, he did not
have symptoms of dysuria, hematuria, oliguria, or polyuria.
Patient's PCP confirmed that patient does have CKD and baseline
creatinine is 1.5. On discharge, the patient's creatinine is
1.5.
CHRONIC/STABLE PROBLEMS:
========================
#. Type 2 diabetes
-Home glipizide and metformin were held.
-Placed on insulin sliding scale during admission.
#. HTN
-Home losartan held in setting of LGIB
#. HLD
-Continued Pravastatin 40mg daily
#. Depression
-Continued citalopram 40mg daily
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Citalopram 40 mg PO DAILY
2. GlipiZIDE XL 10 mg PO DAILY
3. Losartan Potassium 100 mg PO DAILY
4. Pravastatin 40 mg PO QPM
5. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
Discharge Medications:
1. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 dose by
mouth once a day Disp #*30 Gram Refills:*0
2. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Citalopram 40 mg PO DAILY
4. GlipiZIDE XL 2.5 mg PO BID
5. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
6. Pravastatin 40 mg PO QPM
7. HELD- Losartan Potassium 100 mg PO DAILY This medication was
held. Do not restart Losartan Potassium until you've talked to
your doctor.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: diverticular bleed, mild aortic stenosis,
mild aortic regurgitation
Secondary diagnosis: type 2 diabetes, renal calculi, chronic
kidney disease stage 3, hypertension, benign prostatic
hyperplasia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You came to the hospital because you had bloody bowel
movements.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- Your blood counts were monitored closely.
- You received 2 blood transfusions to help keep your blood
counts normal.
- You received an angiogram, which did not find a source of
active bleeding.
- You received a colonoscopy, which did not find a source of
active bleeding but found multiple diverticulosis, which leads
us to suspect that your bleeding was due to a diverticular
bleed.
- You received a heart ultrasound (transthoracic echo), which
showed some mild valvular changes in your heart that can be
monitored by your PCP.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
- Please continue to take all of your medications as directed
- Please follow up with all the appointments scheduled with
your doctor
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
10225619-DS-6 | 10,225,619 | 21,697,329 | DS | 6 | 2129-06-05 00:00:00 | 2129-06-06 14:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cipro
Attending: ___
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with recent PMH of myocarditis/pericarditis who
was recently discharged ___ s/p V-fib arrest and hypoxic
respiratory failure with intubation who is presenting for "heart
fluttering." Tonight he was watching TV and he felt 8
consecutive palpitations. He normally has ___ PVCs, but this is
abnormal from him. The PVCs resolved, but he became nervous and
felt his heart rate accelerate, became diaphoretic and nervous.
He denies outright chest pain, SOB, F/C/N/V. He is followed by
his cardiologist Dr. ___. He continues to take metoprol and
lisinopril as directed. His metoprolol was uptitrated to
controlled PVCs. Cardiology has had discussions with him
regarding ICD placement, but the patient has been reluctant to
pursue this thus far.
In the ED, initial vitals were 99.0 80 131/87 16 100% ra. Labs
were within normal limits and troponin was negative. CXR showed
no pleural or pericardial effusion. Heart size WNL. EKG showed
NSR, normal axis, normal intervals. T-wave inversion in inferior
and lateral leads, unchanged from previous EKG on ___. No ST
segment changes. He was admitted to cardiology for overnight
monitoring on tele. He took his metoprolol dose shortly prior to
transfer. Vitals prior to transfer were 98.3 70 101/49 17 98%
RA.
On arrival to the floor, the patient is in no acute distress.
Reports noticing the occasional PVC, but has not noticed any
further runs of fluttering heartbeats as earlier today. He
denies any chest pain, dyspnea, lightheadedness, nausea,
vomiting. Denies any recent URI, fevers, chills, cough,
abdominal pain, diarrhea, dysuria, lower extremity swelling.
On review of systems, He denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, syncope or presyncope.
Past Medical History:
-Perimyocarditis in ___ and ___, d/c on ___ after VT/VF
arrest with hypoxemic and hypercapnic respiratory failure
requiring MICU stay, ___ showed resolution, preserved
systolic function (EF 55%)
Social History:
___
Family History:
Mother reports having PVCs and palpitations
Physical Exam:
PHYSICAL EXAMINATION:
VS: 98.6, 98/60, 62, 18, 98% RA
GENERAL: well appearing male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no JVD.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. 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+
DISCHARGE EXAM: no change
Pertinent Results:
ADMISSION LABS
___ 12:30AM BLOOD WBC-7.6 RBC-5.18 Hgb-15.3 Hct-45.1 MCV-87
MCH-29.6 MCHC-33.9 RDW-13.4 Plt ___
___ 12:30AM BLOOD Glucose-105* UreaN-21* Creat-1.1 Na-142
K-3.7 Cl-103 HCO3-29 AnGap-14
___ 12:30AM BLOOD Calcium-9.7 Phos-3.9 Mg-2.0
DISCHARGE LABS
___ 05:55AM BLOOD WBC-4.8 RBC-5.47 Hgb-16.4 Hct-48.2 MCV-88
MCH-30.0 MCHC-34.1 RDW-13.4 Plt ___
___ 05:55AM BLOOD Glucose-89 UreaN-17 Creat-1.1 Na-139
K-4.6 Cl-102 HCO3-32 AnGap-10
___ 05:55AM BLOOD Calcium-9.7 Phos-4.0 Mg-2.0
TELEMETRY
0730 ___ - 8 beat run of monomorphic VT
STUDIES
___ EKG:
Sinus rhythm. Compared to the previous tracing of ___ the T
wave
abnormalities are less prominent in the context of increase in
rate with
sinus arrhythmia. Otherwise, no diagnostic interim change.
TRACING #2
Read by: ___
___ Axes
Rate PR QRS QT/QTc P QRS T
70 134 86 404/421 69 2 -6
___ CHEST X-RAY
IMPRESSION: No acute cardiothoracic process.
___ TTE:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal for the patient's body size. Overall left ventricular
systolic function is normal (LVEF 60%). Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. There is mild bileaflet mitral
valve prolapse. Trivial mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of ___, the left ventricular ejection fraction is now
normal.
Brief Hospital Course:
ASSESSMENT AND PLAN: ___ M with two episodes of perimyocarditis,
most recently in early ___ with VT/VF arrest and
respiratory failure requiring intubation and MICU stay, with
improvement in EF, ventricular ectopy since, presenting after
experiencing a fluttering heartbeat reminiscent of Vtach for 8
beats at home, 6 beat run of monomoprhic NSVT on tele ___.
# NSVT: Had 6 beat run of NSVT on ___ on tele, asymptomatic,
while sleeping. No palpitations, chest pain, dyspnea, while
ambulating around floor. No clinical evidence of
perimyocarditis (no chest pain, fevers, negative cardiac
enzymes, ___ echo showed normal LV function). He has been
uptitrated on metoprolol reduce incidence of ventricular ectopy.
Has discussed ICD placement but decided against it for now.
-Appreciate EP recs: increase metoprolol to 50mg bid
-Arrange for home cardiac monitor
-Outpatient exercise stress test
-Follow-up with Dr. ___.
# PUMP: Last Echo (___) showed normalisation of EF.
-continued lisinopril.
#CODE: Full
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Lisinopril 2.5 mg PO DAILY
hold for sbp<90
2. Metoprolol Succinate XL 50 mg PO DAILY
hold for sbp<90, hr<50
Discharge Medications:
1. Lisinopril 2.5 mg PO DAILY
hold for sbp<90
2. Metoprolol Tartrate 50 mg PO BID
hold for sbp < 90, hr < 55
RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Non-sustained ventricular tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you during your hospitalization for
palpitations. We kept you on the monitor and you had one 6 beat
run of ventricular tachycardia while you were sleeping.
Electrophysiology specialists saw you and recommended changing
your metoprolol to twice daily dosing to provide better
protection throughout the day. You will receive a cardiac
monitor within a week have follow-up with Dr. ___ as an
outpatient, see appointment below.
Followup Instructions:
___
|
10225620-DS-8 | 10,225,620 | 27,738,516 | DS | 8 | 2167-11-28 00:00:00 | 2167-11-28 13:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Shellfish Derived / Lithium / Lactose / Milk
Attending: ___.
Chief Complaint:
Weakness and confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH schizophrenia, multinodular goiter, hypothyroid, and
chronic LLE DVT on Coumadin who presents with weakness.
She was noted by her nurse at her assisted living facility to be
possible more confused and less verbal; at baseline, she is
virtually nonverbal. She has not had any pain, but has developed
a recent cough. Per EMS, she was hypoxic at 90% on RA and had
low-grade fever.
In the ED, initial VS 100.9 (Tmax 101.6), 99, 160/80, 16, 92% on
RA. Exam was notable for a tender and erythematous LLE> The
patient was unable to provide any verbal history but in the ED,
was able to nod yes or no appropriately to questions. Initial
labs showed wnl Chem 7, WBC 18.3, Hgb/Hct 14.9/44.3, Plt 167,
INR 2.3. Lactate was initially 4.1 but improved to 2.5 following
2L NS. UA was negative. LENIs showed no acute DVT of the LLE but
showed stable non-occlusive thrombus in the proximal L common
femoral vein stable from prior. CXR was wnl. The patient
received vancomycin and cefepime x 1 prior to transfer to the
floor.
Upon arrival to the floor, the patient was appearing well.
Review of systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria
Past Medical History:
Deep Vein Thrombosis (on coumadin)
Depression
Schizophrenia
Osteoarthritis
Asthma
HTN
Hypothyroidism
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 99.1 128/58 89 22 97%RA
GENERAL: AAOx3, NAD< flat affect, gives one word responses
HEENT: Normocephalic, atraumatic, PERRL, EOMI, sclera anicteric
NECK: No cervical lymphadenopathy
CARDIAC: RRR, no murmurs/rubs/gallops
LUNGS: CTAB with appropriate breath sounds appreciated in all
fields. No wheezes, ronchi or rales
BACK: skin has no visible lesions. No spinous process tenderness
ABDOMEN: Obese. Normal bowel sounds, non-distended, non-tender
to deep palpation in all 4 quadrants. Tympanic to percussion, no
organomegally.
EXTREMITIES: LLE significant for area of warm erythematous patch
extending from ankle up to knee. Area marked with skin marker.
LLE warmer than RLE. Skin on LLE is intact, no obvious ulcers,
excoriations or skin break down. Non-purulent appearing. No
edema, clubbing or cyanosis appreciated in any of the 4
extremities.
NEUROLOGIC: CN2-12 intact. Strength - RUE ___, LUE ___, RLE ___,
LLE ___, weak hand grip. Gait unable to assess, cannot walk
without assistance.
DISCHARGE PHYSICAL EXAM:
Vitals- 98.7PO 125/58 71 18 97%RA
GENERAL: NAD, AAOx3, smiling
HEENT: Normocephalic, atraumatic. Sclera anicteric.
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
LUNGS: Clear to auscultation anteriorly
ABDOMEN: Obese, nontender, non-distended, no rebound, no
guarding.
EXTREMITIES: Erythematous area on LLE not progressed beyond
margins from ___, erythema subjectively improved; L foot
swollen as compared to R foot. Skin on LLE is intact, no obvious
ulcers, excoriations or skin break down. Non-purulent appearing.
No edema, clubbing, or cyanosis appreciated in any of the 4
extremities.
NEUROLOGIC: A&Ox3. Previous: strength RUE ___, LUE ___, RLE ___,
LLE ___, weak hand grip.
Pertinent Results:
ADMISSION LABS
===============
___ 01:16PM BLOOD WBC-18.3*# RBC-4.55 Hgb-14.9 Hct-44.3
MCV-97 MCH-32.7* MCHC-33.6 RDW-12.7 RDWSD-45.7 Plt ___
___ 01:16PM BLOOD Neuts-82* Bands-4 Lymphs-3* Monos-11
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-15.74*
AbsLymp-0.55* AbsMono-2.01* AbsEos-0.00* AbsBaso-0.00*
___ 01:16PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 01:16PM BLOOD ___ PTT-32.7 ___
___ 01:16PM BLOOD Glucose-109* UreaN-22* Creat-1.1 Na-137
K-5.3* Cl-99 HCO3-23 AnGap-20
___ 01:16PM BLOOD ALT-20 AST-47* AlkPhos-38 TotBili-1.0
___ 01:16PM BLOOD Albumin-4.2
___ 01:16PM BLOOD TSH-21*
___ 07:10AM BLOOD T4-6.6 T3-53* Free T4-1.6
___ 01:35PM BLOOD Lactate-4.1*
___ 04:54PM BLOOD Lactate-2.5*
IMAGING STUDIES
===============
___ CXR: No acute intrathoracic abnormality
___ LENIS:
1. No evidence of acute deep venous thrombosis in the left lower
extremity
veins.
2. Tiny partial/non-occlusive thrombus at the proximal left
common femoral
vein appears chronic and in the same location of prior deep
venous thrombosis
in ___ and ___.
3. No right lower extremity deep venous thrombosis.
___ CXR:
There is a new left-sided PICC line. The tip is difficult to
preciselylocate that it is either in the distal SVC or
cavoatrial junction andtherefore is in a good position for use.
There continues to be denseconsolidation/volume loss in the
retrocardiac region. There is also patchyareas of volume loss in
the right lower lobe. There is no pneumothorax.
MICRO:
=======
___ 3:29 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 4:40 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
DISCHARGE LABS
================
___ 08:05AM BLOOD WBC-8.3 RBC-3.45* Hgb-11.1* Hct-33.6*
MCV-97 MCH-32.2* MCHC-33.0 RDW-13.3 RDWSD-47.6* Plt ___
___ 08:05AM BLOOD Plt ___
___ 08:05AM BLOOD Glucose-84 UreaN-14 Creat-0.8 Na-141
K-3.6 Cl-104 HCO3-25 AnGap-16
___ 07:15AM BLOOD Ret Aut-0.9 Abs Ret-0.03
___ 08:05AM BLOOD Calcium-8.3* Phos-4.0 Mg-1.8
___ 07:15AM BLOOD LD(LDH)-149 TotBili-0.5
___ 07:15AM BLOOD calTIBC-181* Hapto-379* Ferritn-372*
TRF-139*
Brief Hospital Course:
___ PMHx schizophrenia, hypothyroidism, and chronic LLE DVT on
coumadin who presented with LLE erysipelas.
#LLE ERYSIPELAS WITH SEPSIS. The patient presented from ___
___ to the ___ ED on ___. Upon presentation she was
noted to have an area of erythema on her LLE extending from her
ankle to her knee. Her admission labs were significant for WBC
18.3 and lactate 4.1. Lower extremity non-invasive studies were
performed which showed a non-occlusive chronic DVT in the LLE
and no acute DVT in the LLE or RLE. Blood and urine cultures
were obtained on admission and showed no growth by discharge.
She was started on empiric vancomycin for a presumed LLE
cellulitis and given 1L NS. Her lactate came down with IV NS,
her WBC trended down, her LLE erythema began to improve, and the
patient said she was feeling better. However, on ___ the
erythema looked significantly worse, but the erythema did not
surpass the margins marked on admission. Ceftriaxone was added
for better Strep coverage. On ___ there still was not much
improvement in the erythema, so ID was consulted. ID felt that
her exam was more consistent with an erysipelas as the area of
erythema was raised and the borders could be palpated. The
infection was most likely due to a Strep infection, and she was
improving on vanc and ceftriaxone so she was continued on both
antibiotics. It was felt that her infection was slower to
improve because it was erysipelas as opposed to cellulitis, and
because she most likely has impaired venous drainage from her
chronic LLE DVT and multiple L knee surgeries. On discharge her
WBC count was down to 9.5 and the erythema was improving. She
was discharged to a rehab on vanc and cefepime to be taken until
___ unless otherwise instructed by ID at her follow-up
appointment on ___.
#TOXIC METABOLIC ENCEPHALOPATHY/ALTERED MENTAL STATUS. Upon
admission the patient was reported to be less verbal than her
baseline. She was also responding with one word answers and had
a flat affect. This was thought to be due to her infection vs
inadequate thyroid supplementation vs Depakote toxicity. Her
thyroid supplementation was worked up (See below) and not felt
to be the cause of her encephalitis. Her FreeT4 was within
normal limits, and the encephalitis resolved without making any
changes to her Levothyroxine dose. Her Depakote level came back
low, so that was not the cause of her encephalitis. Her
encephalitis improved throughout the admission. She became more
interactive, was speaking in full sentences, and was fully
oriented. This suggests that the encephalitis was most likely a
result of her infection. Since admission she has been more
interactive, smiling and speaking in full sentences.
#HYPOTHYROID. On admission the patient had altered mental status
and was reported by a care provider at ___ to be less
verbal than her baseline. Thyroid studies were done to make sure
that she was receiving an adequate dose of Levothyroxine.
Thyroid studies revealed TSH 21 (high), T3 53 (low), and FreeT4
1.6 (normal). An email was sent to her outpatient
endocrinologist, Dr. ___ her and requesting if
any changes should be made to her Levothyroxine dose. No changes
were made as an inpatient, and she will followup with Dr.
___ as an outpatient.
#CHRONIC LLE DVT. On admission, the patient was continued on her
home dose of Coumadin 5mg daily. Her INR came back
supratherapeutic (3.3) after a few days of taking antibiotics
(vancomycin and ceftriaxone) so her Coumadin was held. Once her
INR was back in therapeutic range (2.0 on ___, her Coumadin was
restarted at 2.5mg daily, half her home dose. Her INR was being
monitored daily. On discharge her INR was 1.9.
#ANEMIA. The patient had slowly downtrending hemoglobin during
her hospitalization. Iron studies were performed which showed
low iron, high ferritin and low TIBC which consistent with
anemia of chronic disease. Her haptoglobin was high, indicating
that she is not hemolysing. No signs of active bleed and patient
HD stable. Continue to monitor as an out-patient and consider
iron supplementation. Discharge HgB 11.1.
#SCHIZOPHRENIA. She was continued on her home Bupropion,
Trazodone, Risperidone, Tramadol, and Depakote.
#ASTHMA. She was continued on her home Spiriva, and given
albuterol nebs PRN shortness of breath, coughing, and wheezing.
#HTN. Her home lisinopril was intially held as she was
hypotensive with SBP in the 100s-110s on admission. This was
likely a result of sepsis. Once her SBP stablized she was
restarted on her home lisinopril.
Transitional Issues:
======================
-On ceftriaxone and vancomycin for erysipelas with planned end
date ___ unless otherwise instructed by infectious disease
-Follow-up with infectious disease on ___ at 9:30am
-Held home warfarin from ___ given supratherapeutic INR.
Restarted at half home dose (2.5mg) on ___ because INR 2.0.
INR on discharge 1.9. Please check INR on ___ and adjust
warfarin dosing accordingly.
-Na 146 on discharge. Encouraged increased PO intake which she
tolerated well. Re-check labs within 2days of discharge
-Patient anemic with HgB 11.1 on discharge. Iron studies c/w
anemia of chronic disease. Check CBC within 1 week of discharge
to ensure stable. Consider iron supplementation. Last
colonoscopy in ___ only notable for diverticulosis.
-Daily ___ as tolerated and ACE-wrap to LLE to encourage venous
return
-TSH high at 21 on admission with normal T4. Emailed out-patient
Endocrinologist to make her aware. Will need close follow-up,
but no adjustment made to synthroid at this time given normal T4
level
-Ensure patient is taking synthroid on an empty stomach
-Code: Full
-Contact: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 150 mcg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Lisinopril 5 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Tiotropium Bromide 1 CAP IH DAILY
6. TraZODone 25 mg PO QHS
7. Divalproex (DELayed Release) 500 mg PO QHS
8. RisperiDONE 0.5 mg PO QHS
9. BuPROPion (Sustained Release) 150 mg PO BID
10. Vitamin D 400 UNIT PO BID
11. TraMADol 50 mg PO TID
12. Acetaminophen 650 mg PO DAILY
13. Warfarin 5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN fever or pain
2. BuPROPion (Sustained Release) 150 mg PO BID
3. Divalproex (DELayed Release) 500 mg PO QHS
4. FoLIC Acid 1 mg PO DAILY
5. Levothyroxine Sodium 150 mcg PO QAM hypothyroid
6. Lisinopril 5 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. RisperiDONE 0.5 mg PO QHS
9. Tiotropium Bromide 1 CAP IH DAILY
10. TraMADol 50 mg PO TID
11. Vitamin D 400 UNIT PO BID
12. Warfarin 2.5 mg PO DAILY16
13. CefTRIAXone 1 gm IV Q24H cellulitis Duration: 14 Doses
14. Docusate Sodium 100 mg PO BID
15. Senna 8.6 mg PO BID:PRN constipation
16. Vancomycin 1500 mg IV Q 12H cellulitis Duration: 14 Days
17. TraZODone 25 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Erysipelas
Secondary: Chronic left lower extremity deep venous thrombosis,
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 during your stay at ___
___. You were admitted for the fevers, chills
and worsening left leg pain and redness. Your symptoms were
caused by an infection in your leg called erysipelas. You were
placed on IV antibiotics which you will continue until ___
unless otherwise instructed by the infectious disease team. You
will follow-up in infectious disease clinic on ___ at
9:30pm for further management of your infection. Please call
your doctor or return to the hospital if you develop fevers,
chills, worsening left leg swelling or redness, or confusion.
We wish you all the best!
Your ___ Team
Followup Instructions:
___
|
10225793-DS-11 | 10,225,793 | 29,175,595 | DS | 11 | 2128-07-27 00:00:00 | 2128-08-10 22:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / IV Dye, Iodine Containing Contrast Media / aspirin
/ metronidazole
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with HCV cirrhosis complicated by HE and
ascites, chronic abdominal pain, and recent admission for new
right sided colitis brought in by her daughter for disorganized
speech, auditory hallucinations, and anxiety for 3 days. Though
she does have some confusion at baseline, her daughter reports
that she has never seen the patient this severe before. The
voices are telling her to repeat herself and she is not making
sense. She denies SI/HI and any substance use. She states she
has been compliant with her lactulose, but her daughter reports
otherwise. She continues to have her chronic abdominal pain,
which she has had for decades, but denies vomiting, fever,
chills, chest pain, sob, palpitations. Her last BM was this
morning. She has been "racing" for the past three days and has
been unable to sleep. She reports increased anxiety and
depression, and felt as if she was "about to freak out". She
reports not acting like her normal self. Daughter reports that
patient has been seeking to spend time with and talk with all of
her children because voices in her head are telling her to do
so.
She was previously hospitalized here just a few weeks ago
(___) with acute on chronic abdominal pain, fever, and
altered
mental status with radiographic evidence of right-sided colitis.
She was treated with ceftriaxone and flagyl until HOD 2 when
they
were discontinued, with subsequent improvement in her abdominal
pain. Colonoscopy showed normal mucosa throughout the TI and
colon. Biopsies were taken and additional polyp was biopsied,
showing normal colonic mucosa without colitis and fragments of
an adenoma. However, given concern for IBD, the patient was
started on mesalamine prior to discharge. Her altered mental
status was felt to be secondary to hepatic encephalopathy,
although she continued to report compliance. She was treated
with rifaximin and lactulose, with negative infectious work-up,
and mental status improved by discharge.
Of note, she was on triple therapy for her chronic hepatitis C
with excellent virologic response. She unfortunately developed
severe anemia and colitis requiring admission. Her therapy was
stopped and her virus relapsed. Given an elevated MELD at the
time of her last discharge, plan was to initiate the transplant
evaluation at her last outpatient appointment.
In the ED, initial vitals were 98.6 97 186/68 18 100% on rA. She
repeated "liver acceptance, liver acceptance, liver acceptance.
need to slow down" throughout the ED assessment. She was
initially very anxious and agitated, yelling at times,
whispering at others. Shortly after arriving she got 1mg PO
Ativan and has been calm and was agreeable thereafter. EKG sinus
at 82. CXR without acute process. RUQ u/s with patent veins. ED
resident reported that they did not see good pocket for
paracentesis on u/s. She was placed on a 1:1 sitter for racing
thoughts and auditory hallucinations. Most recent vitals prior
to transfer: 82 172/78 14 98% on RA.
ROS: +cough, denies diarrhea, negative unless noted above.
Past Medical History:
# HCV cirrhosis
-- genotype 1b, s/p 10 months ribavirin (failed)
-- decompensated by ascites and encephalopathy
# h/o ___ esophagus
# hypertension
# depression
Past Surgical History:
-s/p right ankle fracture and broken leg repair
-s/p cholecystectomy in ___
-s/p abdominoplasty: ___ (per ___ notes, ___ per
patient)
Social History:
___
Family History:
No history of liver disease. Addiction to alcohol and drugs
runs in her family, with both parents and four other siblings
affected.
Mother - CVA
Dad - CVA
3 brothers were murdered
___ are healthy.
Physical Exam:
ADMISSION EXAM
VS: 97.9 140/74 68 18 99% on RA 102kg
General: overweight female tearful, anxious
HEENT: sclera anicteric, PERRL, EOMI, MMM without lesions
Neck: supple, no JVD
CV: RRR, no m/r/g, + spiders
Lungs: CTAB, no w/r/c
Abdomen: +BS, soft, ND, subjective tenderness over epigastrium,
no appreciable ascites
GU: no foley
Ext: wwp, 2+ bilateral ___ edema to the knees, DP 2+ bilaterally
Neuro: A&OX3, CN ___ intact, symmetric strength, mild
asterixis, able to ___ backwards, unable to ___ backwards
Skin: no rashes
DISCHARGE EXAM:
T 97.9, BP 113/80, HR 60, RR 18, POx 98%RA
General: overweight female, pleasant and in NAD
HEENT: sclera anicteric, PERRL, EOMI
Neck: supple, no JVD
CV: S1, S2 regular with systolic ejection murmur
Lungs: CTAB
Abdomen: +BS, soft, ND, nontender, no appreciable ascites
Ext: wwp, 2+ bilateral ___ edema to the knees, DP 2+ bilaterally
Neuro: A&OX3, CN ___ intact, no asterixis, mental status intact
Skin: + spiders, no rashes
Pertinent Results:
ADMISSION
___ 12:45PM BLOOD WBC-2.2* RBC-3.18* Hgb-11.1* Hct-35.6*
MCV-112* MCH-35.0* MCHC-31.3 RDW-16.0* Plt Ct-62*
___ 12:45PM BLOOD Neuts-82* Bands-0 Lymphs-9* Monos-7 Eos-2
Baso-0 ___ Myelos-0
___ 12:45PM BLOOD Plt Smr-VERY LOW Plt Ct-62*
___ 12:45PM BLOOD Glucose-90 UreaN-11 Creat-0.9 Na-132*
K-7.3* Cl-103 HCO3-23 AnGap-13
___ 12:45PM BLOOD ALT-60* AST-170* AlkPhos-99 TotBili-3.5*
___ 12:45PM BLOOD Albumin-3.4*
___ 12:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:18PM BLOOD Na-136 K-4.6 Cl-105
___ 07:49PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 07:49PM URINE Color-Yellow Appear-Clear Sp ___
DISCHARGE
___ 05:30AM BLOOD WBC-2.6* RBC-2.70* Hgb-9.9* Hct-30.1*
MCV-111* MCH-36.5* MCHC-32.8 RDW-16.6* Plt Ct-51*
___ 05:30AM BLOOD ___ PTT-37.5* ___
___ 05:30AM BLOOD Glucose-77 UreaN-10 Creat-0.8 Na-137
K-3.5 Cl-107 HCO3-24 AnGap-10
___ 05:30AM BLOOD ALT-41* AST-69* AlkPhos-85 TotBili-2.9*
IMAGING:
RUQ ULTRASOUND: FINDINGS: The liver has a nodular liver contour,
compatible with cirrhosis. No definite focal liver lesions are
identified. The main, right and left hepatic veins are patent.
The main portal vein is also patent. The anterior and posterior
right portal veins are patent. Limited views of the right
kidney and pancreas are unremarkable. There is no ascites.
IMPRESSION: Patent hepatic and portal veins. No ascites.
Brief Hospital Course:
___ year old female with decompensated HCV cirrhosis complicated
by encephalopathy and ascites and chronic abdominal pain,
brought in by her daughter for disorganized speech, auditory
hallucinations, and anxiety for 3 days
# Altered mental status (Delirium): Resolved overnight. Given
her recent admission, liver failure, and particularly the
insomnia and that she's never had psych symptoms like these
before, our highest suspicion was that this is was mild hepatic
encephalopathy, with secondary possibility of an early
adjustment-type episode on underlying depression and anxiety
about her diagnosis. Patient also having severe incomnia. Other
toxic metabolic workup has been negative (including infectious).
Time course too short for mania. Patient no longer symptomatic,
and no SI/HI. Treated with lactulose/rifaximin for
encephalopathy. After discussion with patient and attending,
Ambien was chosen as sleep aid as only an occasional, prn
medication if she truly cannot sleep by 1 or 2 AM. Continued
fluoxetine. She was back at baseline by discharge after close
monitoring.
CHRONIC ISSUES
# HCV cirrhosis: Previously c/b ascites, encephalopathy. EGD
without varices. Now with bilateral ___ edema. Currently
decompensated. MELD 17. Continued lasix/spironolactone,
lactulose and rifaximin.
# Right sided colitis: biopsies without evidence of colitis, CT
findings only. Per Dr. ___ knows this patient, she
had done well whenever mesalamine has been started, and has
colitis type symptoms when it is stoppped, so continued it.
# Chronic abdominal pain: Treated with prn tylenol, less than 2
grams max per day
# h/o ___ esophagus: continued home PPI
# Hypertension: continued home atenolol
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO DAILY
2. Fluoxetine 60 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Lactulose 15 mL PO TID
5. Ondansetron 4 mg PO Q8H:PRN nausea
6. Pantoprazole 40 mg PO Q24H
7. Rifaximin 550 mg PO BID
8. Spironolactone 50 mg PO DAILY
9. Loperamide 2 mg PO TID:PRN Diarrhea
10. Mesalamine 500 mg PO TID
Discharge Medications:
1. Atenolol 50 mg PO DAILY
2. Fluoxetine 60 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Lactulose 30 mL PO TID
titrate to ___ bowel movements a day
5. Mesalamine 500 mg PO TID
6. Pantoprazole 40 mg PO Q24H
7. Rifaximin 550 mg PO BID
8. Spironolactone 50 mg PO DAILY
9. Acetaminophen 650 mg PO Q8H pain
10. Ondansetron 4 mg PO Q8H:PRN nausea
11. Loperamide 2 mg PO TID:PRN Diarrhea
ONLY USE THIS IF YOU ARE HAVING MORE THAN 5 BOWEL MOVEMENTS
DAILY.
12. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
DO NOT DRIVE OR OPERATE MACHINERY WHILE ON THIS.
RX *zolpidem 5 mg ___ tablet(s) by mouth at bedtime Disp #*5
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
hepatic encephalopathy
insomnia
SECONDARY:
hepatitis C cirrhosis
depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted due to confusion, which possibly represented
"hepatic encephalopathy," or confusion due to liver disease.
Your exam and vital signs were reassuring, and a medical workup
showed that you do not have an infection. You slept well
overnight and are much more oriented so you are being discharged
home.
We increased your Lactulose dose to prevent confusion; you
should increase or decrease the frequency of the medication to
ensure that you have ___ bowel movements daily. Please do not
take Loperamide unless you are having >5 bowel movements in a
day.
In addition, we are giving you a small supply of Ambien
(Zolpidem) to be used in the case of severe insomnia. You can
try ___ tab and if that doesn't work you can take the other ___
tab.
Followup Instructions:
___
|
10225793-DS-12 | 10,225,793 | 22,896,892 | DS | 12 | 2128-08-30 00:00:00 | 2128-08-30 18:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / IV Dye, Iodine Containing Contrast Media / aspirin
/ metronidazole
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of Hep C,
cirrhosis and recent admission in ___ for hepatic encephalopathy
who presents for evaluation following a fall. Patient states she
was in her usual state of health until ___ days prior to
admission when she started feeling gradually more "shakey and
weak" than usual. She reports that she was compliant with
rifaximin and lactulose and was having ___ bowel movements/day,
sat down to have a bowel movement on the day of admission, and
when she stood up she fell backwards in the bathroom, hit her
head on the wall or floor behind her. She does not recall
feeling dizzy or pre-syncopal before falling, does not recall
tripping on anything, does not think she lost consciousness. She
says she was able to stand up immediately following the fall and
called her daughter who came and drove her to the ___ ED.
In the ED, initial vs were: 99.8 92 144/65 24 100% RA. Labs were
remarkable for K of 5.3 and ammonia level of 60. Patient was
given oxycodone in addition to her home medications rifaximin,
lasix, protonix, and mesalamine. CT non-con of head and CT neck
were normal. CT abd/pelvis demonstrated no fracture with small
volume ascites and evidence of cirrhosis.
On the floor, vs were: T: 98 BP: 120/50 P: 66 R: 18 O2: 100% RA.
Patient says she is feeling sleepier than usual, and has some
mild cramping abdominal pain, worst in the epigstrium, which she
says is similar to her chronic abdominal pain but has been worse
since her fall. She appears to be a fair historian and is able
to recall the event leading up to her admission, though she is a
little vague on some details.
Of note, she was recently admitted ___ and discharged ___ for
disorganized speech, auditory hallucinations and anxiety that
improved with lactulose/rifaximin. Infectious work up at that
time was negative and symptoms were attributed to hepatic
encephalopathy and poor sleep.
Past Medical History:
Hep C Cirrhosis
-- genotype 1b, s/p 10 months ribavirin (failed)
-- decompensated by ascites and encephalopathy
Colitis with negative biopsies which has responded to mesalamine
in the past
Hypertension
___ esophagus
Past Surgical History:
-s/p right ankle fracture and broken leg repair
-s/p cholecystectomy in ___
-s/p abdominoplasty: ___ (per ___ notes, ___ per
patient)
Social History:
___
Family History:
No history of liver disease. FMH of drug/etoh addiction (parents
and sibblings; Mom and dad with CVA, 3 brothers murdered, all
her children healthy.
Physical Exam:
ADSMISSION PHYSICAL EXAM:
Vitals: T: 98 BP: 120/50 P: 66 R: 18 O2: 100% RA
General: Obese woman in no acute distress; appears lethargic but
cooperative and interactive
HEENT: NCAT, no bruises or ecchymoses, EOMI, PERRLA, sclerae
mildly icteric, OP clear with dentures in place, MMM
Neck: obese, supple, JVP at 7cm
CV: RRR, ___ systolic murmur heard best at RUSB radiating to
carotids
Lungs: Fair air movement, no wheezes, rhonchi or rales, no
accessory muscle use
Abdomen: TTP throughout abdomen without rebound/guarding
GU: no foley
Ext: 2+ pitting edema in BLE to ankle only, DP pulses 2+
bilaterally, toes cool but well perfused
Neuro: A&OX3, able to ___ forward and backwards with some
difficulty, ___ forward but when going backward misses ___ and
___, very long pauses between some months; + asterixis; light
touch sensation intact and symmetric throughout BUE and BLE;
strength ___ throughout BUE and BLE
Skin: Dry with sun damaged areas, many spider angiomas over
chest, back, arms, and face; multiple tattoos
DISCHARGE EXAM:
Vitals: T97.8, BP 108-126/53-64, HR 56-68, RR 18, 97%
General: Obese woman in no acute distress; alert, oriented. Able
to do days of week backwards.
HEENT: NCAT, no bruises or ecchymoses, sclerae icteric, OP clear
with dentures in place, MMM, mild erythema in posterior OP
CV: RRR, ___ systolic murmur heard best at RUSB radiating to
carotids
Lungs: bibasilar rare crackles
Abdomen: +bowel sounds, No longer tender, non-distended, liver
8cm below coastal margin
Ext: 2+ pitting edema in BLE to ankle
Neuro: A&OX3, able to ___ forward and backward quickly, no
asterixis
Skin: Dry with sun damaged areas, many spider angiomas over
chest, back, arms, and face; multiple tattoos
Pertinent Results:
ADMISSION LABS:
====================
(all initial labs from hemolyzed specimen)
___ 08:05AM BLOOD WBC-7.8# RBC-3.10* Hgb-11.4* Hct-34.4*
MCV-111* MCH-36.9* MCHC-33.3 RDW-16.9* Plt Ct-72*
___ 08:05AM BLOOD Neuts-83.1* Lymphs-9.9* Monos-6.5 Eos-0.4
Baso-0.2
___ 08:05AM BLOOD Glucose-95 UreaN-12 Creat-0.8 Na-128*
K-8.8* Cl-103 HCO3-20* AnGap-14
___ 10:55AM BLOOD Glucose-85 UreaN-12 Creat-0.7 Na-133
K-5.3* Cl-106 HCO3-19* AnGap-13
___ 08:05AM BLOOD Lipase-89*
___ 08:05AM BLOOD cTropnT-<0.01
___ 08:05AM BLOOD Ammonia-60
___ 11:45AM URINE Color-Orange Appear-Hazy Sp ___
___ 11:45AM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-2* pH-6.0 Leuks-NEG
___ 11:45AM URINE RBC-6* WBC-1 Bacteri-NONE Yeast-NONE
Epi-5
MICRO:
=========================
___ Blood Culture, Routine-PENDING
___ Blood Culture, Routine-PENDING
IMAGING:
=========================
CT C-spine ___
There is no evidence of fracture or alignment abnormality.
There is a tiny anterior osteophyte at C3-4. There is no
prevertebral soft tissue swelling. The thyroid gland appears
normal. The lung apices are clear. Non-contrast examination of
the soft tissues of the neck are unremarkable. IMPRESSION:
Minimal degenerative disk disease. Otherwise normal study.
CT abd/pelvis ___
IMPRESSION:
1. Findings consistent with cirrhosis and chronic portal venous
hypertension.
2. In the setting of chronic fat stranding due to vascular
congestion, an acute inflammatory process such as pancreatitis
may be missed. Correlate with lipase.
3. No fracture is present.
*Small amount of ascities mentioned in findings section
CT Head ___
There is no evidence of hemorrhage, edema, mass, mass effect, or
infarction. The ventricles and sulci are minimally prominent,
consistent with mild atrophy. There is no fracture. The imaged
paranasal sinuses, mastoid air cells, and middle ear cavities
are clear.
US abdomen with doppler ___
IMPRESSION:
1. Patent portal vasculature, with appropriate directional flow.
2. Cirrhosis, without evidence of a focal liver lesion.
3. Unchanged splenomegaly.
DISCHARGE LABS:
=======================
___ 09:13AM BLOOD WBC-1.5* RBC-2.44* Hgb-8.9* Hct-27.7*
MCV-113* MCH-36.5* MCHC-32.2 RDW-16.0* Plt Ct-56*
___ 09:13AM BLOOD ___
___ 09:13AM BLOOD Glucose-154* UreaN-12 Creat-0.7 Na-137
K-4.1 Cl-109* HCO3-22 AnGap-10
___ 09:13AM BLOOD ALT-27 AST-52* AlkPhos-68 TotBili-2.4*
___ 09:13AM BLOOD Phos-3.0 Mg-1.7
___ 06:30AM BLOOD HBsAb-PND HAV Ab-PND
Brief Hospital Course:
___ woman with decompensated alcoholic and HCV cirrhosis who
presented with increased falls due to encephalopathy with viral
URI as possible trigger, trauma work up negative for acute
injury.
# Hepatic encephalopathy: Patient presented encephalopathic with
increased falls. She reported full medication compliance with
___ BM/day at home. Infectious work up was negative including
UA, CXR, and blood cultures, though she did complain of viral
URI symptoms (sore throat). CT abdomen showed trace ascites, so
when mental status did not initially clear with increased
lactulose she was started empirically on SBP treatment with
ceftriaxone and albumin. These were discontinued when US of her
abdomen with doppler the following day showed no free fluid. US
was also negative for portal vein thrombus. Encephalopathy
improved with increased lactulose and continued rifaxamin, and
patient was able to return home.
# Neutropenia: she is baseline pancytopenic, likely came in
volume contracted, all counts dropped after albumin. It is
possible that she had a mild URI causing drop in counts,
encephalopathy and sore throat. She was warned about needing to
seek immediate medical care if febrile >100.4F.
# Cirrhosis: MELD of 19 on admission. Cirrhosis due to alcohol
abuse and hepatitis C. Decompensated by history of
encephalopathy and ascites. No history of varices (EGD ___.
Is currently initiating transplant work up with outpatient
hepatologist Dr. ___. Was seen by transplant social
work while here as had outpatient appointment scheduled during
hospitalization. Continued spironolactone and furosemide, as
well as treatment for encephalopathy as above.
CHRONIC ISSUES
# Depression/insomnia: Outpatient notes mention that insomnia
has been refractory for basic interventions, they were
considering outpatient sleep clinic referral. Could be from
depression, anxiety disorder, or sleep-wake cycle reversal from
liver disease. Continued fluoxetine and minimized low dose
ambien use.
# Colitis: Focal proctitis seen on colonoscopy and biopsy in
___ without clear etiology, but abdominal pain seems to have
responded somewhat to mesalamine, so outpatient hepatologist has
kept her on this. Continued here.
# Hypertension: Continued Atenolol. No varices on ___ EGD so
no need for non-selective beta blocker.
# GERD: continued Pantoprazole, zofran for nausea as needed
TRANSITIONAL ISSUES:
- Code status: full; Daughter ___ is HCP ___
- Blood cultures pending at discharge
- Hepatitis serologies pending to evaluate for immunity to Hep A
and B
- Consider futher work up for insomnia as would be ideal for
patient to be off Ambien to reduce fall risk
- Neutropenic at time of discharge with ANC <1000
- Patient was changed from atenolol to propanolol
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO DAILY
2. Fluoxetine 60 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Lactulose 30 mL PO TID
titrate to ___ bowel movements a day
5. Mesalamine 500 mg PO TID
6. Pantoprazole 40 mg PO Q24H
7. Rifaximin 550 mg PO BID
8. Spironolactone 50 mg PO DAILY
9. Acetaminophen 650 mg PO Q8H pain
10. Ondansetron 4 mg PO Q8H:PRN nausea
11. Loperamide 2 mg PO TID:PRN Diarrhea
ONLY USE THIS IF YOU ARE HAVING MORE THAN 5 BOWEL MOVEMENTS
DAILY.
12. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
DO NOT DRIVE OR OPERATE MACHINERY WHILE ON THIS.
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H pain
2. Fluoxetine 60 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Lactulose 30 mL PO TID
5. Mesalamine 500 mg PO TID
6. Ondansetron 4 mg PO Q8H:PRN nausea
7. Pantoprazole 40 mg PO Q24H
8. Rifaximin 550 mg PO BID
9. Spironolactone 50 mg PO DAILY
10. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
11. Loperamide 2 mg PO TID:PRN Diarrhea
12. Propranolol 20 mg PO BID
Please discuss increasing or decreasing the dose with your MD
RX *propranolol 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: hepatic encephalopathy
Secondary: mechanical fall; neutropenia; viral URI; cirrhosis
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 hospitalization at
___. You were admitted after a fall at home. Imaging of your
head, spine, and abdomen did not show any injury. Your lactulose
was increased and your mental status improved. It is possible
your increased lethargy and confusion ("encephalopathy") were
triggered by a mild viral upper respiratory tract infection.
Your white blood cell count was low while you were here. White
blood cells help us to fight infections. You should avoid coming
into contact with anyone who has any symptoms of viral or
bacterial infection, and wash your hands frequently. Seek
medical attention IMMEDIATELY if you measure a fever at home of
greater than 100.4.
Your atenolol was changed to propranolol, which is a medication
which will help your liver and your heart.
Followup Instructions:
___
|
10225793-DS-13 | 10,225,793 | 20,836,918 | DS | 13 | 2128-09-12 00:00:00 | 2128-09-15 10:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / IV Dye, Iodine Containing Contrast Media / aspirin
/ metronidazole
Attending: ___
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ hx of HCV cirrhosis (genotype 1b, s/p 10 months ribavirin
which failed) c/b HE and ascites, w/ recent admissions for
hepatic encephalopathy p/w AMS x several days. Pt reports her
children sent her in because she was confused for the past
couple of days. She agrees that she was confused. She reports
having periumbilical abd pain earlier today, starting this AM,
which was sharp, ___ and has since resolved. She reports
similar past episodes of abd pain when she does not take her
lactulose properly. Per ED report, this abd pain is chronic per
her family. She denies dysuria, fevers/chills. She reports
little bit of a dry cough for a couple of days. Reports 2 BMs
today, no blood or melena. 3 BMs yesterday. She has been taking
her lactulose TID.
Pt admitted ___ue to HE. Infectious work up
was negative including UA, CXR, and blood cultures, though she
did complain of viral URI symptoms (sore throat). CT abdomen
showed trace ascites, so when mental status did not initially
clear with increased lactulose she was started empirically on
SBP treatment with ceftriaxone and albumin. These were
discontinued when US of her
abdomen with doppler the following day showed no free fluid.
Encephalopathy improved with increased lactulose and continued
rifaxamin.
In the ED, initial vitals were 97.4 61 148/65 20 100%. RUQ U/S
No acute pathology. CXR done. Labs norable for Hct 32.9, plt 81,
INR 1.6, WBC count 4, AST/ALT 74/37, T bili 2.5, AP 126, Lipase
121, BUN/Cr ___, Na 136, lactate 1.9. Pt NPO, IVF for
possible pancreatitis. Bl cx sent. Serum tox negative. Pt given
lactulose x2. Pt admitted to ___ for likely hepatic
encephalopathy.
On arrival to the floor, pt is without complaints. Reports
feeling less confused. Denies pain.
ROS: per HPI
Past Medical History:
Hep C Cirrhosis
-- genotype 1b, s/p 10 months ribavirin (failed)
-- decompensated by ascites and encephalopathy
Colitis with negative biopsies which has responded to mesalamine
in the past
Hypertension
___ esophagus
Past Surgical History:
-s/p right ankle fracture and broken leg repair
-s/p cholecystectomy in ___
-s/p abdominoplasty: ___ (per ___ notes, ___ per
patient)
Social History:
The patient lives by herself, a son was living with her until a
couple days ago, but has moved out as he has found his own
place. She is thinking about asking her daughter to move in with
her. She takes care of all of her own appointments and
medications, no additional home supports, she "doesn't like to
ask my kids for help". She is divorced, however reports that her
and her ex-husband are still friends. She has 3 sons and 4
daughters. The patient reports that she is able to carry out her
ADLs and IADLs. EtOH: Last drink in ___. Previous
heavy drinker ~4 bottles of wine a day for a number of years.
Has had previous periods of being sober as well, but had
relapsed due to stressors in marriage. Tob: former, quit > ___
years ago, previous 1ppd x about ___ years. Drugs: denies present
or former, denies IVDU, however ex-husband was an IV drug user
Family History:
No history of liver disease. FMH of drug/etoh addiction (parents
and sibblings; Mom and dad with CVA, 3 brothers murdered, all
her children healthy.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 97.6, 143/84, 63, 20, 100% RA
General: pleasant obese woman, lying in bed, in NAD
HEENT: no scleral icterus
Neck: supple
CV: RRR, no murmurs
Lungs: CTAB, breathing comfortably
Abdomen: soft, obese, mildly distended, +BS, mildly tender in
periumbilical region, no shifting dullness
GU: no foley
Ext: no ___ edema, 2+ DPs, warm and well perfused
Neuro: small amt of asterixis, A&Ox3, knows president, grossly
intact
DISCHARGE PHYSICAL EXAMINATION:
VS: 98.6 112/62 60 20 100/RA
I/O: 800/NR BM x5 (ON) 1800/450 BM x4
General: pleasant obese woman, lying in bed, in NAD
HEENT: no scleral icterus
Neck: supple
CV: RRR, no murmurs
Lungs: CTAB, breathing comfortably
Abdomen: soft, obese, nondistended, +BS, nontender, no shifting
dullness
GU: no foley
Ext: no ___ edema, 2+ DPs, warm and well perfused
Neuro: no asterixis, A&Ox3
Pertinent Results:
ADMISSION LABS
___ 08:50PM BLOOD WBC-4.0# RBC-2.92* Hgb-10.7* Hct-32.9*
MCV-113* MCH-36.7* MCHC-32.5 RDW-17.7* Plt Ct-81*
___ 08:50PM BLOOD ___ PTT-35.8 ___
___ 08:50PM BLOOD Glucose-95 UreaN-10 Creat-0.6 Na-136
K-3.8 Cl-108 HCO3-21* AnGap-11
___ 08:50PM BLOOD ALT-37 AST-74* AlkPhos-126* TotBili-2.5*
___ 08:50PM BLOOD Lipase-121*
___ 08:50PM BLOOD Albumin-3.4*
___ 08:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:58PM BLOOD Lactate-1.9
DISCHARGE LABS
___ 06:00AM BLOOD WBC-3.7* RBC-2.90* Hgb-10.9* Hct-32.9*
MCV-113* MCH-37.4* MCHC-33.1 RDW-17.1* Plt Ct-86*
___ 06:00AM BLOOD ___ PTT-50.5* ___
___ 06:00AM BLOOD Glucose-96 UreaN-13 Creat-0.7 Na-139
K-4.0 Cl-110* HCO3-21* AnGap-12
___ 06:00AM BLOOD ALT-42* AST-78* AlkPhos-102 TotBili-4.2*
___ 06:00AM BLOOD Calcium-9.6 Phos-4.0 Mg-1.9
___ 03:18AM URINE Color-Yellow Appear-Clear Sp ___
___ 03:18AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
LABS PENDING AT DISCHARGE
blood cultures ___
OTHER LABS
None
MICRO DATA
___ 3:18 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING
Chest xray ___
PA and lateral views of the chest provided demonstrate no focal
consolidation, effusion or pneumothorax. The cardiomediastinal
silhouette is normal. Bony structures are intact. No free air
below the right hemidiaphragm. Clips are noted in the right
upper quadrant.
RUQ u/s with doppler ___
The liver demonstrates coarsened and nodular appearance, in
keeping with known cirrhosis, with no focal lesion identified.
The patient is status post cholecystectomy with no evidence of
intrahepatic biliary ductal dilatation. The common bile duct
measures 8 mm, within expected limits after cholecystectomy, and
not significantly changed since the prior study when it measured
6 mm. There is no evidence of ascites. The spleen is enlarged,
and measures 16 cm. The main portal vein demonstrates normal
hepatopetal flow.
Brief Hospital Course:
___ w/ hx of HCV cirrhosis (genotype 1b, s/p 10 months ribavirin
which failed) c/b HE and ascites, w/ recent admissions for
hepatic encephalopathy p/w AMS x several days.
# HEPATIC ENCEPHALOPATHY: H/o multiple admissions for HE. This
episode triggered by lactulose noncompliance over the weekend
(she did not take any medications in the weekend preceding
presentation when she was camping with her children). Pt
otherwise without symptoms to suggest infection and RUQ u/s
negative acute thrombus. No blood in stool per history and Hct
improved from previous. She received high dose lactulose
administration (30ml Q2 hour) with improvement in her mental
status back to baseline and resolution of asterixis. She was
continued on rifaximin and repleted with potassium liberally.
# Colitis: Mesalamine was continued in house.
# HCV Cirrhosis: c/b ascites and HE. She was continued on home
dose of lasix/aldactone and propranolol. Although recent EGD was
negative for varices, she uses bblocker to reduce portal HTN
with known dx of GAVE.
# Depression: She was continued on home dose fluoxetine.
# GERD: Continued on home dose ppi.
#ACCESS: PIV's
PROPHYLAXIS:
-DVT ppx with Heparin SC
-Pain management with Tylenol
-Bowel regimen with Lactulose
#CODE: Full
#CONTACT: Patient, ___ (daughter)
==========================================================
Transitional issues:
- plan for routine lab check in 1 week faxed to outpatient
hepatologist Dr. ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H pain
2. Fluoxetine 60 mg PO DAILY
3. Furosemide 50 mg PO DAILY
4. Lactulose 30 mL PO TID
5. Mesalamine 500 mg PO TID
6. Ondansetron 4 mg PO Q8H:PRN nausea
7. Pantoprazole 40 mg PO Q24H
8. Rifaximin 550 mg PO BID
9. Spironolactone 50 mg PO DAILY
10. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
11. Propranolol 20 mg PO BID
Please discuss increasing or decreasing the dose with your MD
Discharge Medications:
1. Fluoxetine 60 mg PO DAILY
2. Furosemide 50 mg PO DAILY
3. Mesalamine 500 mg PO TID
4. Rifaximin 550 mg PO BID
5. Spironolactone 50 mg PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Propranolol 20 mg PO BID
8. Ondansetron 4 mg PO Q8H:PRN nausea
9. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
10. Lactulose 30 mL PO TID
RX *lactulose 20 gram/30 mL 30 ml by mouth three times daily
Disp #*1700 Milliliter Refills:*0
11. Outpatient Lab Work
Please have labs checked on ___: CBC, chemistry 7 panel, AST,
ALT, AP, total bilirubin, ___, PTT, INR. Fax results to Dr.
___ ___. ICD: 571
Discharge Disposition:
Home
Discharge Diagnosis:
Hepatic encephalopathy
EtOH/HCV cirrhosis (decompensated)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to take care of you at ___. You were
admitted with confusion in the setting of not taking your
lactulose over the weekend. It is important to avoid future
episodes of hepatic encephalopathy (confusion from your
cirrhosis) that you take the lactulose every day on a schedule
with a goal for 4 soft, large stools daily. If you do not reach
this goal please give yourself extra doses of the lactulose
until you reach the goal.
Please follow up with your doctors as noted below.
Followup Instructions:
___
|
10225793-DS-17 | 10,225,793 | 23,101,776 | DS | 17 | 2129-09-04 00:00:00 | 2129-09-04 18:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / IV Dye, Iodine Containing Contrast Media / aspirin
/ metronidazole
Attending: ___.
Chief Complaint:
UTI.
Constipation.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with Childs C (HCV) cirrhosis (previously treated with
telaprevir stopped based on side effects, not on transplant list
based on BMI>40), decompensated hepatic encephalopathy, and
chronic abdominal pain who presents with acute worsening of
abdominal pain.
Patient reports that she was in her usual state of health until
10 days prior to this admission when she experienced worsening
LUQ pain. She states that the pain was usually worse in the
evening, and not associated with food or position. She also
endorsed ongoing nausea without vomiting. 1 day prior to
admission, the patient reports that the abdominal pain became
worse in the epigastric area without any radiation. She rated
the pain as ___ and described it as "severe and sharp." After
5 hours of enduring this acutely worsened episode and noting a
fever to 100.3, she presented to the ___ ED.
Of note, the patient report strict adherance to her prescribed
lactulose regimen, but states that she has not had a bowel
movement for 2 days and feels "constipated." Additionally, she
denied chest pain, dyspnea, cough, sputum, headache, dysuria,
diarrhea. Does endorse low-grade left shoulder aching.
Per recent d/c summary on ___, ___ has chronic abdominal
pain and has been on 5-ASA without any endoscopic evidence of
colitis; however, she has been responding to this treatment. The
workup has been negative for any specific infection with no
evidence of C. difficile colitis." Pt asserts that this pain is
unlike her chronic abdominal pain, which is more diffuse and
achy.
In the ED initial vitals were: 98.3 58 141/57 18 100%. Labs were
notable for normal chemistries, AST 53 ALT 30 ALP 109, Tbili 2,
Alb 3, lipase 91. WBC 3.7 with 49% PMN, H/H 11.8/36.7, plts 60.
UA w WBC 16, neg nitrite. She underwent a CT which revealed no
acute intrabdominal process. Bedside U/S revealed no ascitic
fluid to drain. Patinet was administered 5mg IV morphine x2 for
pain.
Upon arrival to the floor, she stated that her acute abdominal
pain was resolved, but may have been masked by the pain
medication.
Past Medical History:
HCV cirrhosis-genotype 1b (s/p 10 mos of ribavirin (failed) and
telapravir (stopped ___ side effects)
Hepatic encephelopathy ___ cirrhosis
Ascities ___ cirrhosis
Depression
___ esophagus
HTN
Chronic abdominal pain with (-) bx - treated with mesalamine
R ankle/leg fx
CCY (___)
Abdominoplasty (___)
Social History:
___
Family History:
Parents/siblings: drug/ETOH addiction
Parents: CVA
Physical Exam:
ADMISSION PHYSICAL:
Vitals - 97.2 157/72 55 100%RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera
NECK: supple neck
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, tender to deep palp epigastrium, no
rebound/guarding
EXTREMITIES: moving all extremities well, no cyanosis, clubbing.
trace pedal edema bilaterally
NEURO: no asterixis
SKIN: warm and well perfused
DISCHARGE PHYSICAL:
Vitals: 97.3 112/64 59 12 98%RA
GENERAL: Obese women lying comfortably in bed, NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera
NECK: supple neck, no lymphadenopathy or thyromegaly
CARDIAC: ___ holosystolic murmur in ___ intercostal thoracic
space, RRR, normal S1/S2
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: soft, protuberant, +BS, mildly tender to deep palp
epigastrium, no rebound/guarding
EXTREMITIES: moving all extremities well, no cyanosis, clubbing.
trace pedal edema bilaterally
NEURO: CN2-12 normal and intact, sensory and motor function
grossly intact, no asterixis
SKIN: warm and well perfused
Pertinent Results:
ADMISSION LABS:
___ 07:45PM BLOOD WBC-3.7*# RBC-3.37* Hgb-11.8* Hct-36.7
MCV-109* MCH-34.9* MCHC-32.1 RDW-15.8* Plt Ct-60*
___ 07:45PM BLOOD Neuts-48.7* ___ Monos-6.2
Eos-6.2* Baso-0.3
___ 07:45PM BLOOD Plt Ct-60*
___ 07:45PM BLOOD Glucose-94 UreaN-10 Creat-0.7 Na-139
K-4.1 Cl-110* HCO3-24 AnGap-9
___ 07:45PM BLOOD ALT-30 AST-53* AlkPhos-109* TotBili-2.0*
___ 07:45PM BLOOD Lipase-91*
___ 07:45PM BLOOD Albumin-3.0*
DISCHARGE LABS:
___ 06:50AM BLOOD WBC-3.0* RBC-3.21* Hgb-11.1* Hct-35.2*
MCV-109* MCH-34.7* MCHC-31.7 RDW-15.6* Plt Ct-54*
___ 06:50AM BLOOD Neuts-41.9* ___ Monos-8.8
Eos-7.3* Baso-1.0
___ 06:50AM BLOOD ALT-29 AST-50* AlkPhos-100 TotBili-2.6*
ABDOMINAL CT W/O CONTRAST (___)
IMPRESSION:
1. Cirrhotic liver and splenomegaly. Ascites is resolved.
2. No acute intra-abdominal abnormality.
RUQ/DUPLEX DOPPLER ABDOMEN (___)
IMPRESSION:
1. Nodular hepatic architecture. No concerning liver lesion
identified.
2. Patent hepatic vasculature.
3. Splenomegaly
Brief Hospital Course:
___ with Childs C (HCV) cirrhosis (previously treated with
telaprevir stopped based on side effects, not on transplant list
based on BMI>40), decompensated hepatic encephalopathy, and
chronic abdominal pain who presents with acute worsening of
abdominal pain.
#Abdominal pain: Abdominal CT w/o contrast was negative for any
intraabdominal process. The CT revealed increased stool burden,
despite patient's reported compliance with lactulose regimen.
Patient's abdominal pain was most likely ___ constipation. RUQ
U/S revealed unchanged liver and spleen pathology. BCx revealed
NGTD. Restarted home PPI, rifaximin, and mesalamine. Increased
lactulose to 30ml Q2H. After multiple doses of lactulose, the
patient experienced several bowel movements and a return to her
baseline of chronic abdominal pain. Patient was discharged with
an increase in her home dosage of lactulose to 30ml TID PO to
achieve ___ bowel movements daily.
# UTI: UA equivocal with WBC (16) and bacteria (mod), with neg
nitrates and leukocyte esterase. No symptoms. UCx revealed mixed
flora (contamination). She received ciprofloxacin for 1 day,
then stopped w/ culture results.
# Fevers: Since arriving in the ED, the patient remained
afebrile.
# Leukopenia: During hospitalization, patient remained
leukopenic, which was consistent with her baseline labs from her
previous admissions. Likely ___ cirrhosis
#Thrombocytopenic: Platelets consistent with her baseline labs
from previous admissions, most likely ___ cirrhosis induced
splenic sequestration.
#Cirrhosis ___ hep C (and likely EtOH): Stable. Continued
nadolol, lactulose, rifaximin, Lasix, and Aldactone.
Transitional Issues:
- Assess adequacy of new lactulose regiment in achieving ___
bowel movements per day.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Ondansetron 4 mg PO Q8H:PRN nausea
2. Lactulose 15 mL PO TID
3. Mesalamine 500 mg PO TID
4. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
5. Nadolol 20 mg PO DAILY
6. Cholestyramine 4 gm PO HS
7. Furosemide 50 mg PO DAILY
8. Spironolactone 50 mg PO BID
9. Pantoprazole 40 mg PO Q24H
10. Rifaximin 550 mg PO BID
11. Fluoxetine 60 mg PO DAILY
Discharge Medications:
1. Cholestyramine 4 gm PO HS
2. Fluoxetine 60 mg PO DAILY
3. Furosemide 50 mg PO DAILY
4. Lactulose 30 mL PO TID
RX *lactulose 20 gram/30 mL 30 mL by mouth Three times daily
Refills:*0
5. Mesalamine 500 mg PO TID
6. Nadolol 20 mg PO DAILY
7. Pantoprazole 40 mg PO Q24H
8. Rifaximin 550 mg PO BID
9. Spironolactone 50 mg PO BID
10. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
11. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
Constipation.
UTI.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted to ___ for worsening of your chronic
abdominal pain. In the ED, you received pain medications. An
abdominal CT was then performed, which revealed a mildly
increased amount of stool. Based on your lack of bowel
movements, your lactulose regimen was increased. After more
frequent and higher doses of lactulose, you were observed to
have several bowel movements with resolution of your acute
abdominal pain.
Thank you for allowing ___ to participate in your care.
Followup Instructions:
___
|
10225793-DS-23 | 10,225,793 | 23,989,569 | DS | 23 | 2133-07-08 00:00:00 | 2133-07-08 16:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / IV Dye, Iodine Containing Contrast Media / aspirin
/ metronidazole
Attending: ___.
Chief Complaint:
Left-sided chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with HCV cirrhosis and Stage I ___ s/p
cyberknife radiation (completed ___ who presented with 3
weeks of progressive left sided chest pain.
The patient states that she noticed the sudden onset of left,
anterior chest pain 3 weeks ago. She states the pain is sharp
and
very deep. It is exacerbated with movement and deep breathing.
It is associated with dyspnea because she is unable to take a
full breath. It is not associated with fevers/chills, nausea,
vomiting, diarrhea or diaphoresis. Of
note, she had influenza 2 months prior.
She was seen by her PCP who sent her to an orthopedic surgeon
who
evaluated the patient and felt it was not MSK in etiology. She
had gone to the ___ ER for evaluation twice and was
sent home. She presents today because the pain has persisted for
too long but has remained constant in quality.
Of note, the patient was recently admitted at ___ from ___
for dysphagia possibly due to food impaction. The patient
underwent EGD that demonstrated a mildly narrowed GE junction
but
was otherwise unremarkable and discharged with outpatient follow
up in the ___ clinic.
Past Medical History:
HCV cirrhosis
-genotype 1b s/p Harvoni with sustained virologic response
(___) & previously 10 mos of ribavirin (failed) and
telapravir (stopped ___ side effects)
-Decompensated by hepatic encephalopathy, Ascites (diuretic
responsive)
-Portal hypertensive gastropathy on nadolol (but no varices)
Non-small cell lung cancer of left upper lobe (stage 1) s/p
cyberknife radiation completed (___)
Depression
___ esophagus
HTN
Chronic abdominal pain with (-) bx, treated with mesalamine
R ankle/leg fx
CCY (___)
Abdominoplasty (___)
Social History:
___
Family History:
Parents/siblings: drug/ETOH addiction
Parents: CVA
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 97.6 BP 136/83 HR 60 R 18 SpO2 99 RA
GEN: NAD, obese
HEENT: Sclerae slightly jaundiced, moist mucous membranes
___: RRR, no MRG. Pain reproducible on palpation of L anterior
chest
RESP: No increased WOB, no wheezing, rhonchi or crackles.
Distant
breath sounds.
ABD: NTND no HSM
EXT: Warm, no edema
NEURO: No asterixis. CN II-XII intact, able to ambulate to bed
DISCHARGE PHYSICAL EXAM:
Temp: 97.5 PO BP: 133/82 HR: 60 RR: 18 O2 sat: 94% O2 delivery:
Ra
GEN: NAD, obese
HEENT: Sclerae mildly jaundiced, moist mucous membranes. PERRL,
EOMI.
___: RRR, no MRG. Pain reproducible on palpation of L anterior
chest, under left arm, and on left scapula.
RESP: Distant breath sounds. No increased WOB. No wheezing,
rhonchi or crackles.
ABD: Soft, non-distended. Mild tenderness in RUQ and epigastric
region.
EXT: Warm, no edema
NEURO: No asterixis. CN II-XII intact, able to ambulate to bed
Pertinent Results:
ADMISSION LABS:
================
___ 06:10PM GLUCOSE-91 UREA N-10 CREAT-0.7 SODIUM-139
POTASSIUM-4.8 CHLORIDE-107 TOTAL CO2-23 ANION GAP-9*
___ 06:10PM ALT(SGPT)-20 AST(SGOT)-61* ALK PHOS-116* TOT
BILI-3.1*
___ 06:10PM LIPASE-74*
___ 06:10PM cTropnT-<0.01 proBNP-125
___ 06:10PM ALBUMIN-2.9*
___ 06:14PM LACTATE-1.3
___ 06:10PM WBC-3.0* RBC-2.77* HGB-10.5* HCT-30.4*
MCV-110* MCH-37.9* MCHC-34.5 RDW-16.2* RDWSD-65.1*
___ 06:10PM NEUTS-57.8 ___ MONOS-10.1 EOS-2.0
BASOS-0.3 IM ___ AbsNeut-1.71 AbsLymp-0.86* AbsMono-0.30
AbsEos-0.06 AbsBaso-0.01
___ 06:10PM PLT COUNT-78*
___ 06:10PM ___ PTT-32.5 ___
___ 06:10PM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 06:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-7.5
LEUK-SM*
___ 06:10PM URINE RBC-2 WBC-14* BACTERIA-FEW* YEAST-NONE
EPI-4
INTERIM LABS:
=============
___ 12:43AM BLOOD CK-MB-<1 cTropnT-<0.01
STUDIES:
=========
CXR ___: Fiducial marker in the left upper lobe with
adjacent scarring/atelectasis. Otherwise, no acute
cardiopulmonary abnormality.
CTA CHEST ___:
1. No evidence of pulmonary embolism or aortic abnormality.
2. New healing fracture of the left second rib anteriorly.
3. Stable post treatment changes within the left upper lobe.
4. Hepatic cirrhosis, partially imaged.
DISCHARGE LABS:
===============
___ 12:43AM BLOOD WBC-2.6* RBC-2.99* Hgb-11.3 Hct-32.6*
MCV-109* MCH-37.8* MCHC-34.7 RDW-16.1* RDWSD-65.2* Plt Ct-62*
___ 12:43AM BLOOD Glucose-130* UreaN-12 Creat-0.8 Na-141
K-4.2 Cl-108 HCO3-20* AnGap-13
___ 12:43AM BLOOD ALT-22 AST-52* CK(CPK)-67 AlkPhos-127*
TotBili-3.5*
___ 12:43AM BLOOD Calcium-8.8 Phos-2.8 Mg-2.0
Brief Hospital Course:
Ms. ___ is a ___ F with Stage I NSCLC s/p cyberknife
radiation completed in ___ and HCV cirrhosis who presented
with 3 weeks of left-sided chest pain.
=====================
ACTIVE ISSUES
=====================
#Chest pain:
Pt presented with progressive, pleuritic, left anterior chest
pain with radiation to L shoulder. The pain was reproducible on
exam with movement and palpation of the left anterior chest,
underarm, and left posterior chest wall. EKG and troponins
normal. CXR was negative. Due to initial concern for pulmonary
embolism, a CTA chest was ordered. No evidence of PE. However,
CTA chest revealed a new healing fracture of the left 2nd rib
that is likely the source of the pain. No trauma to explain the
fracture. It may also be secondary to the stereotactic
radiotherapy she received to that site in ___ ___ et al. ___
Cancer ___, 13:68). Fibrotic radiation pleuritis could also be
contributing to her symptoms. She was given a lidocaine patch
for pain as well as acetaminophen 500mg PO Q6H:PRN and morphine
7.5mg PO Q6H:PRN for pain refractory to acetaminophen. She was
discharged on a lidocaine patch and acetaminophen (up to 2g
daily). Also given incentive spirometry to prevent atelectasis
from splinting.
=====================
CHRONIC ISSUES
=====================
#Chronic HCV Cirrhosis:
Childs B, MELD-NA 15 on admission. Previously decompensated by
portal hypertension, portal gastropathy, hepatic encephalopathy
and ascites s/p Harvoni with SVR. LFTs near baseline. No ascites
on POC U/S or hepatic encephalopathy. No asterixis on exam.
Continued home lactulose TID and rifaximin 550mg BID. Nadolol,
spironolactone 100mg BID, and torsemide 40mg BID were initially
held due to concern for PE, but were restarted prior to
discharge.
#Stage I NSCLC:
LUL s/p cyberknife stereotactic body radiotherapy finished on
___. Not receiving active treatment. Stable post-treatment
changes in the left upper lobe seen on CTA chest. Radiation
changes may have contributed to fracture and pain.
#Chronic abdominal pain: Stable except for chest pain as above.
Continued home mesalamine, cholestyramine, and pantoprazole.
Home hydroxyzine and cyclobenzaprine were initially held due to
concern for over-sedation, but restarted prior to discharge.
#Depression: Stable. Continued home paroxetine.
Note: given initial concern for potentially life threatening
process such as PE, admission initially expected to require ___
days hospitalization. Once pain found to be due to rib fracture
patient was able to leave, so stay was shorter than initially
anticipated.
=====================
CORE MEASURES
=====================
#CODE: Full (presumed)
#CONTACT: Name of health care proxy: ___
Relationship: Daughter
Phone number: ___
=====================
TRANSITIONAL ISSUES
=====================
[ ] Please follow up the patient's pain control on Tylenol and
Lidocaine patch. If her pain is not adequately controlled by the
above regimen, please consider other pain control options (e.g.
local nerve block, short-term course of opioids).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
2. HydrOXYzine 25 mg PO Q6H:PRN pruritus
3. Lactulose 30 mL PO TID
4. PARoxetine 40 mg PO DAILY
5. Rifaximin 550 mg PO BID
6. Spironolactone 100 mg PO BID
7. Torsemide 40 mg PO BID
8. Cholestyramine 4 gm PO DAILY
9. Cyclobenzaprine 5 mg PO TID:PRN pain
10. Magnesium Oxide 400 mg PO TID
11. Mesalamine 500 mg PO BID
12. Nadolol 20 mg PO DAILY
13. Ondansetron 4 mg PO Q8H:PRN nausea
14. Pantoprazole 20 mg PO Q24H
15. vit A,C and E-dietary suppl#12 ___ mg oral
daily
Discharge Medications:
1. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidoderm] 5 % apply one patch to left chest at
site of pain every 12 hours Disp #*30 Patch Refills:*0
2. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
3. Cholestyramine 4 gm PO DAILY
4. Cyclobenzaprine 5 mg PO TID:PRN pain
5. HydrOXYzine 25 mg PO Q6H:PRN pruritus
6. Lactulose 30 mL PO TID
7. Magnesium Oxide 400 mg PO TID
8. Mesalamine 500 mg PO BID
9. Nadolol 20 mg PO DAILY
10. Ondansetron 4 mg PO Q8H:PRN nausea
11. Pantoprazole 20 mg PO Q24H
12. PARoxetine 40 mg PO DAILY
13. Rifaximin 550 mg PO BID
14. Spironolactone 100 mg PO BID
15. Torsemide 40 mg PO BID
16. vit A,C and E-dietary suppl#12 ___ mg oral
daily
Discharge Disposition:
Home
Discharge Diagnosis:
Left 2nd rib fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___.
Why you were in the hospital:
- You came to the hospital because you were experiencing chest
pain for several weeks.
What was done for you in the hospital:
- We obtained a CT scan of the chest that showed a fracture in
the left second rib. This fracture is likely causing your pain.
It's possible that you also have some pain from your radiation
at that site in the past.
- We saw no evidence of a blood clot in your lungs.
What you should do after you leave the hospital:
- Continue taking all home medications that you were taking
before.
- We gave you a prescription for a lidocaine patch. If you
cannot get it covered by insurance, you can try lidocaine gel,
which you can get over-the-counter. Take oral Tylenol as needed,
but no more than 2 grams daily (500mg every 6 hours).
- Use the breathing device we gave you to make sure you're
taking deep breaths. Taking full breaths is important to keep
your lungs inflated.
- Follow up with your primary care provider to discuss trying
another pain medication if your pain is not controlled on the
Tylenol and lidocaine.
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10225793-DS-25 | 10,225,793 | 27,868,882 | DS | 25 | 2133-08-25 00:00:00 | 2133-08-27 11:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / IV Dye, Iodine Containing Contrast Media / aspirin
/ metronidazole
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female with history
of HCV cirrhosis c/b portal hypertension with HE, small EV,
PHG,
and ascites s/p Harvoni with SVR who presenting with ___ and
hyponatremia noted on outpatient blood work-up during her
hepatology follow-up.
Since discharge from the hospital on ___ for hepatic
encephalopathy and HRS, patient has noticed increased fatigue,
lethargy and weakness. Patient report nausea without vomiting.
Denies any fevers, chills, chest pain, shortness of breath,
abdominal pain, or urinary symptoms. Patient does report
diarrhea
which has been ongoing due to her lactulose. She reports 2
BM/day. She reports compliance with her medications, denies
NSAID
use and good PO intake. Labs drawn at the ___ clinic on
___ showed a Na of 127 and Cr of 1.8. She was referred to the
ED
for further work-up as well consideration of transplant.
Of note, patient was recently admitted to the hospital with HE
and ___. Her ___ improved with HRS treatment. She was discharged
off of midodrine, octreotide. She was on significant amount of
torsemide 40 mg twice a day and Aldactone 100 mg twice a day.
She was discharged on just Aldactone 100 mg daily, torsemide 20
mg daily. She was also treated for E. coli UTI while inpatient.
In the ED initial vitals: 98.5 78 132/74 18 99% RA
- Exam notable for:
Abdomen soft, nontender, slightly distended. No tappable pocket
of ascites on ultrasound
Regular rate and rhythm no murmurs rubs or gallops
Clear to aspiration bilaterally
No asterixis
Slight jaundiced
- Labs notable for: WBC 3.2 (at baseline), plts 64 (at
baseline), H/H stable, Na 129, Cr 1.8
- Imaging notable for: CXR:
RUQ U/S:
- Consults: Hepatology
- Patient was given: 25 g albumin + oxycodone 2.5 mg
On arrival to the floor, patient endorses the story above.
Reports slight headache. No new complaints.
Past Medical History:
HCV cirrhosis
-genotype 1b s/p Harvoni with sustained virologic response
(___) & previously 10 mos of ribavirin (failed) and
telapravir (stopped ___ side effects)
-Decompensated by hepatic encephalopathy, Ascites (diuretic
responsive)
-Portal hypertensive gastropathy on nadolol (but no varices)
Non-small cell lung cancer of left upper lobe (stage 1) s/p
cyberknife radiation completed (___)
Depression
___ esophagus
HTN
Chronic abdominal pain with (-) bx, treated with mesalamine
R ankle/leg fx
CCY (___)
Abdominoplasty (___)
Social History:
___
Family History:
Parents/siblings: drug/ETOH addiction
Parents: CVA
Physical Exam:
ADMISSION EXAM:
VS: 98.1 128 / 83 L Lying 79 20 100 Ra
GENERAL: NAD, pleasant and conversant, AAOx3
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: Supple
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: obese, soft, tender in the RLQ (chronic for her) no
rebound/guarding, no hepatosplenomegaly. POC ultrasound w/ no
e/o
ascites
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: moving all 4 extremities with purpose, mild asterixis
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM:
24 HR Data (last updated ___ @ 738)
Temp: 97.8 (Tm 98.0), BP: 126/68 (119-140/65-80), HR: 66
(66-95), RR: 18, O2 sat: 98% (96-99), O2 delivery: RA, Wt: 227.2
lb/103.06 kg
GENERAL: no apparent distress, lying comfortably in bed
HEENT: scleral icterus, oropharynx clear
NECK: supple, JVP flat, no cervical lymphadenopathy
HEART: RRR, S1/S2, III/VI systolic murmur
LUNGS: unlabored, CTAB
ABDOMEN: obese, soft, non-distended, chronic right upper
quadrant
tenderness
EXTREMITIES: warm, without edema, pulses symmetric and palpable
NEURO: subtle asterixis, non-focal
SKIN: no petechiae/purpura
Pertinent Results:
ADMISSION LABS:
___ 11:50AM URINE ___ BACTERIA-FEW*
YEAST-NONE ___ 11:50AM URINE BLOOD-TR* NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-6.0
LEUK-TR*
___ 11:50AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 11:55AM ___
___ 11:55AM PLT COUNT-95*
___ 11:55AM WBC-3.7* RBC-3.22* HGB-12.4 HCT-34.0 MCV-106*
MCH-38.5* MCHC-36.5 RDW-14.7 RDWSD-57.1*
___ 11:55AM ALBUMIN-4.2
___ 11:55AM ALT(SGPT)-26 AST(SGOT)-65* ALK PHOS-126* TOT
BILI-4.6*
___ 11:55AM estGFR-Using this
___ 11:55AM UREA N-29* CREAT-1.8*# SODIUM-127*
POTASSIUM-3.3* CHLORIDE-85* TOTAL CO2-25 ANION GAP-17
___ 02:20PM ___ PTT-30.8 ___
___ 02:20PM PLT COUNT-64*
___ 02:20PM NEUTS-63.7 ___ MONOS-12.6 EOS-1.2
BASOS-0.3 IM ___ AbsNeut-2.12 AbsLymp-0.73* AbsMono-0.42
AbsEos-0.04 AbsBaso-0.01
___ 02:20PM WBC-3.3* RBC-3.03* HGB-11.7 HCT-32.6*
MCV-108* MCH-38.6* MCHC-35.9 RDW-15.4 RDWSD-61.1*
___ 02:20PM ALBUMIN-3.7
___ 02:20PM LIPASE-105*
___ 02:20PM ALT(SGPT)-26 AST(SGOT)-83* ALK PHOS-102 TOT
BILI-4.2*
___ 02:20PM GLUCOSE-97 UREA N-33* CREAT-1.8* SODIUM-129*
POTASSIUM-4.2 CHLORIDE-91* TOTAL CO2-20* ANION GAP-18
___ 02:28PM NA+-129*
___ 02:28PM ___ COMMENTS-GREEN TOP
___ 03:10PM URINE RBC-2 WBC-4 BACTERIA-FEW* YEAST-NONE
EPI-5 TRANS EPI-<1
___ 03:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM*
___ 03:10PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 03:10PM URINE UHOLD-HOLD
___ 03:10PM URINE HOURS-RANDOM
___ 11:44PM SODIUM-131*
DISCHARGE LABS:
___ 06:07AM BLOOD WBC-1.2* RBC-2.19* Hgb-8.6* Hct-25.1*
MCV-115* MCH-39.3* MCHC-34.3 RDW-15.6* RDWSD-66.0* Plt Ct-39*
___ 06:07AM BLOOD Neuts-46.7 ___ Monos-18.6*
Eos-3.4 Baso-0.8 Im ___ AbsNeut-0.55* AbsLymp-0.35*
AbsMono-0.22 AbsEos-0.04 AbsBaso-0.01
___ 06:34AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-2+*
Macrocy-2+* Microcy-NORMAL Polychr-NORMAL Ovalocy-1+* Tear
Dr-1+*
___ 06:07AM BLOOD Plt Ct-39*
___ 06:07AM BLOOD ___ PTT-36.3 ___
___ 06:07AM BLOOD Glucose-81 UreaN-23* Creat-1.2* Na-138
K-4.2 Cl-104 HCO3-26 AnGap-8*
___ 06:07AM BLOOD ALT-18 AST-45* AlkPhos-73 TotBili-2.2*
___ 06:07AM BLOOD Albumin-3.4* Calcium-10.2 Phos-2.7 Mg-2.2
IMAGING:
___ RUQUS
IMPRESSION:
Coarsened nodular liver consistent with history of cirrhosis.
1.6 x 1.8 x 1.9 cm indeterminate hypoechoic lesion in the right
lobe of the
liver, not clearly seen on prior studies. Recommend liver MRI
for further
characterization.
Patent main portal vein.
RECOMMENDATION(S): Liver MRI for further characterization of
hypoechoic
lesion in the right lobe of the liver.
___ CXR
IMPRESSION: No acute intrathoracic process.
___ Renal US
IMPRESSION:
Slightly increased renal cortical echogenicity bilaterally
suggestive of
chronic medical renal disease. No hydronephrosis.
Brief Hospital Course:
___ female with HCV cirrhosis s/p ledipasvir-sofosbuvir
historically decompensated by ascites, esophageal varices, and
hepatic encephalopathy referred from ___ clinic for acute
kidney injury and hyponatremia, which have promptly resolved
with hydration.
#) Acute kidney injury, non-oliguric: creatinine 1.8 from normal
baseline. Probable pre-renal azotemia in the context of
intensified diuretic regimen and maintenance lactulose. Renal
insufficiency likewise improved with colloid and then
crystalloid, which is in keeping with pre-renal injury. Urine
sediment bland. No sonographic evidence of obstruction. Home
torsemide 20 mg and spironolactone 100 mg were held at
discharge.
#) HCV cirrhosis, Child B/MELD 29: s/p ledipasvir-sofosbuvir
with
sustained viral response. Historically decompensated by ascites,
esophageal varices, and hepatic encephalopathy, though no
concern for these at present. Home lactulose 30 ml TID and
rifaximin 550mg BID were continued with mindfulness of volume
status. MELD improved to 18 at discharge. Expedited transplant
evaluation deferred in this regard.
#) Pancytopenia: macryocytic anemia, thrombocytopenia, and
leukopenia all below baseline, which are presumably dilutional
in nature. Marrow hypoproliferative, though B12 previously
elevated. MDS remains plausible.
#) Hypovolemic hyponatremia: sodium 127 on arrival, which then
improved to 138 with fluid resuscitation.
CHRONIC/STABLE ISSUES:
#) ___: Cyberknife and stereotactic body radiotherapy
completed ___. In contact with radiation oncologist
regarding recurrence and implication for transplant.
#) Chronic abdominal pain: home mesalamine 500 mg BID and
cyclobenzaprine 5 mg TID PRN continued.
TRANSITIONAL ISSUES:
[ ]At discharge, weight = 102.8 kg; judiciously reintroduce home
torsemide and/or spironolactone when indicated.
[ ]At discharge, creatinine = 1.2; recommend repeat chem-10 in
one to two weeks.
[ ]For pancytopenia, recommend repeat CBC in one to two weeks
and hematology evaluation for consideration of bone marrow
biopsy.
[ ]Liaise with radiation oncologist regarding ___ recurrence
and implication for transplant.
[ ] 1.6 x 1.8 x 1.9 cm indeterminate hypoechoic lesion in the
right lobe of the
liver, not clearly seen on prior studies. Recommend liver MRI
for further
characterization.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
2. Cholestyramine 4 gm PO DAILY
3. HydrOXYzine 25 mg PO Q6H:PRN pruritus
4. Lactulose 30 mL PO TID
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. Magnesium Oxide 400 mg PO TID
7. Mesalamine 500 mg PO BID
8. PARoxetine 40 mg PO DAILY
9. Rifaximin 550 mg PO BID
10. Cyclobenzaprine 5 mg PO TID:PRN pain
11. Ondansetron 4 mg PO Q8H:PRN nausea
12. vit A,C and E-dietary suppl#12 ___ mg oral
daily
13. Torsemide 20 mg PO DAILY
14. Spironolactone 100 mg PO DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
2. Cholestyramine 4 gm PO DAILY
3. Cyclobenzaprine 5 mg PO TID:PRN pain
4. HydrOXYzine 25 mg PO Q6H:PRN pruritus
5. Lactulose 30 mL PO TID
6. Lidocaine 5% Patch 1 PTCH TD QAM
7. Magnesium Oxide 400 mg PO TID
8. Mesalamine 500 mg PO BID
9. Ondansetron 4 mg PO Q8H:PRN nausea
10. PARoxetine 40 mg PO DAILY
11. Rifaximin 550 mg PO BID
12. vit A,C and E-dietary suppl#12 ___ mg oral
daily
13. HELD- Spironolactone 100 mg PO DAILY This medication was
held. Do not restart Spironolactone until cleared by your liver
doctors.
14. HELD- Torsemide 20 mg PO DAILY This medication was held. Do
not restart Torsemide until cleared by your liver doctors.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
-Acute kidney injury
SECONDARY
-Hyponatremia
-HCV cirrhosis
-Pancytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were hospitalized for low blood sodium. Your
kidneys were also not functioning properly. We think this was
due to your water pills. Both improved with intravenous fluids.
WHAT SHOULD I DO WHEN I GO HOME?
-Please follow-up with your hepatologist, Dr. ___.
You have an appointment ___, but we would like you to see
him sooner. Please call tomorrow to schedule an appointment in
two weeks.
-Do not take your water pills (torsemide and spironolactone)
unless instructed otherwise by your hepatologist.
-Weigh yourself daily. Call your hepatologist if your weight
increases by three pounds in one day or five pounds in one week.
We wish you all the best.
Sincerely,
Your ___ care team
Followup Instructions:
___
|
10225793-DS-27 | 10,225,793 | 29,168,430 | DS | 27 | 2133-09-21 00:00:00 | 2133-09-21 22:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / IV Dye, Iodine Containing Contrast Media / aspirin
/ metronidazole
Attending: ___.
Chief Complaint:
Abdominal distension, confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ w hx of HCV and EtOH cirrhosis c/b portal
hypertension with HE, portal hypertensive gastropathy, and
ascites s/p Harvoni, ___ (diagnosed ___, s/p radiotherapy
___ with recent discharge for confusion at end ___
presenting with confusion. Last night, her son noticed that she
choked on some popcorn and thereafter, began acting in a
confused way intermittently. Patient states that she had some
nausea and mild regurgitation of food after eating at that time.
Examples of her bizarre behavior would include pouring water
into a strawberry container when asked to get water out of the
fridge. She states that she has been taking all of her
medications without skipping doses. No trauma or falls or focal
motor weakness or sensory deficits. No slurred speech or
headache. Patient denies SOB, chest pain. Some cough but denies
chills. No hemoptysis, bloody stools or urine. Has been stooling
regularly approximately 3 times per day.
Also endorses increased abdominal distention and weight gain of
approximately ___ pounds within the last ___ months.
Of note, the patient recently presented with altered mental
status, asterixis concerning for hepatic encephalopathy at the
end of ___. At the time she was reported to be taking her home
meds including lactulose and having regular bowel movements.
Her mental status improved with lactulose and rifaximin while
she was in house. Prior to that she was admitted for ___,
hyponatremia which resolved with hydration.
In the ED, initial VS were: T 96.9, HR 72, BP 155/69, RR 18, O2
sat 100% on RA
Exam notable for:
A&O*1. Repeats name. But thinks she is in ___ and thinks it
is ___.
No FND, EOMI. Very mild scleral icterus.
Able to ambulate.
Abdomen is distended and tender to palpation.
ECG: SR @ 68, nl axis, nl intervals, LVH by voltage criteria, no
ST/TW changes
Labs showed:
- VBG WNL
- Chem 7 hemolyzed: ___, whole blood K 4.4
- LFTs ALT 29, AST 121, AP 99, Tbili 2.4, Alb 3.3
- CBC 2.2/8.4/25.2/60
- Coags: ___ 16.2, PTT 29.6, INR 1.5
Imaging showed:
- RUQUS:
1. Cirrhotic morphology liver with splenomegaly and recanalized
umbilical vein. Patent hepatic vasculature.
2. Hypoechoic lesion in the right lobe of the liver measuring up
to 2.1 cm is indeterminate in etiology and grossly unchanged as
compared to abdominal ultrasound ___.
- CXR:
PA and lateral views of the chest provided.
Scarring with fiducial marker/clip is seen in the left upper
lobe. There is
no focal consolidation, effusion, or pneumothorax. The
cardiomediastinal
silhouette is normal.
Consults:
Hepatology recommended:
- Obtain RUQ US with Doppler
- Full infectious work up, panculture
- Diagnostic paracentesis if ascites present
- Full set of labs; optimize electrolytes; avoid sedatives
MERIT recommended:
-Infectious work-up w/ UA/UCx, CXR ___ acp, BCx
-RUQUS ___ ascites and no acute process
-Labs neg for HoNa
-Continue rifax/lactulose
Patient received: none
Transfer VS were: T 97.6 BP 119/71 HR 61 RR 18 O2 sat 99% Ra
On arrival to the floor, patient reports that she has been
feeling confused lately. Currently, she states that she is at
the ___ in ___, and that it is ___.
She stated that she knew this because she was previously asked
by the nurse. She notes mild tenderness to palpation in her
bilateral lower quadrants that has been present for some time.
Otherwise, she endorses the above story.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
HCV cirrhosis
-genotype 1b s/p Harvoni with sustained virologic response
(___) & previously 10 mos of ribavirin (failed) and
telapravir (stopped ___ side effects)
-Decompensated by hepatic encephalopathy, Ascites (diuretic
responsive)
-Portal hypertensive gastropathy on nadolol (but no varices)
Non-small cell lung cancer of left upper lobe (stage 1) s/p
cyberknife radiation completed (___)
Depression
___ esophagus
HTN
Chronic abdominal pain with (-) bx, treated with mesalamine
R ankle/leg fx
CCY (___)
Abdominoplasty (___)
Social History:
___
Family History:
Parents/siblings: drug/ETOH addiction
Parents: CVA
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
VS: T 97.6 BP 119/71 HR 61 RR 18 O2 sat 99% Ra
GENERAL: NAD, resting comfortably
HEENT: AT/NC, anicteric sclera, MMM, oropharynx clear without
exudate
NECK: supple, no LAD
CV: RRR, S1/S2, ___ systolic ejection murmur over LUSB no rubs
or gallops
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: normoactive bowel sounds, abdomen mildly distended but soft,
mild bilateral lower quadrant tenderness to palpation
EXTREMITIES: Trace lower extremity edema
PULSES: 2+ radial pulses bilaterally
NEURO: + asterixis, alert and oriented to person place and time,
moving upper and lower extremities antigravity
Skin: Telangiectasias noted over bilateral arms and lower
extremities, otherwise warm and well perfused, no excoriations
or lesions, no rashes
DISCHARGE PHYSICAL EXAM:
=========================
24 HR Data (last updated ___ @ 857)
Temp: 97.9 (Tm 98.6), BP: 138/79 (128-140/64-82), HR: 77
(62-79),
RR: 16 (___), O2 sat: 99% (97-100), O2 delivery: Ra, Wt: 239.4
lb/108.59 kg
General: Alert, oriented (person/place), no acute distress
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Normal sinus rhythm, +S1 + S2, SEM at LUSB, rubs, gallops
Abdomen: soft, tender to palpation of LLQ, non-distended, bowel
sounds present, no rebound tenderness or guarding
Ext: Warm, well perfused, 2+ pulses, no edema
Mental Status Exam:
Alert and Oriented to person, place
Memory: ___ words imprinted, ___ words recalled at 5 min, ___
with clue
Attention:
world backward : "dlorw"
Abstraction: What does it mean to put all your eggs in one
basket? - gave very literal interpretation, consistent with
prior
("exactly what it means, don't put eggs in one basket")
Neuro: UE strength ___ flexion/extension b/l, hand grip ___ b/l,
sensation intact throughout. minimal asterixis
Pertinent Results:
ADMISSION LABS:
=================
___ 05:49PM BLOOD WBC-2.2* RBC-2.19* Hgb-8.4* Hct-25.2*
MCV-115* MCH-38.4* MCHC-33.3 RDW-17.2* RDWSD-71.9* Plt Ct-60*
___ 05:49PM BLOOD Neuts-55.6 ___ Monos-11.0 Eos-3.2
Baso-0.5 AbsNeut-1.22* AbsLymp-0.65* AbsMono-0.24 AbsEos-0.07
AbsBaso-0.01
___ 05:49PM BLOOD ___ PTT-29.6 ___
___ 05:49PM BLOOD Glucose-80 UreaN-9 Creat-0.8 Na-142
K-6.4* Cl-112* HCO3-19* AnGap-11
___ 05:49PM BLOOD ALT-29 AST-121* AlkPhos-99 TotBili-2.4*
___ 05:49PM BLOOD Albumin-3.3*
___ 06:25PM BLOOD pO2-41* pCO2-38 pH-7.38 calTCO2-23 Base
XS--1 Comment-SOURCE NOT
___ 05:58PM BLOOD Lactate-1.5 K-4.4
INTERVAL LABS:
====================
___ 09:32AM BLOOD WBC-1.3* RBC-1.96* Hgb-7.6* Hct-22.8*
MCV-116* MCH-38.8* MCHC-33.3 RDW-17.2* RDWSD-72.3* Plt Ct-40*
___ 06:19AM BLOOD ___ PTT-35.4 ___
___ 06:44AM BLOOD ALT-17 AST-35 LD(LDH)-282* AlkPhos-101
TotBili-1.9*
___ 06:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 05:15AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 06:20AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
DISCHARGE LABS:
====================
___ 06:58AM BLOOD WBC-3.4* RBC-2.09* Hgb-8.3* Hct-23.9*
MCV-114* MCH-39.7* MCHC-34.7 RDW-16.6* RDWSD-68.6* Plt Ct-38*
___ 06:58AM BLOOD Plt Ct-38*
___ 06:58AM BLOOD ___ PTT-30.1 ___
___ 06:58AM BLOOD Glucose-197* UreaN-9 Creat-0.7 Na-139
K-4.1 Cl-108 HCO3-22 AnGap-9*
___ 06:58AM BLOOD ALT-20 AST-41* AlkPhos-122* TotBili-1.8*
___ 06:58AM BLOOD Calcium-9.2 Phos-1.7* Mg-1.9
MICROBIOLOGY:
=====================
Blood Culture, Routine (Final ___: NO GROWTH.
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
=======================
#LIVER/GALLBLADDER US
IMPRESSION:
1. Cirrhotic morphology liver with splenomegaly and recanalized
umbilical
vein. Patent hepatic vasculature.
2. Hypoechoic lesion in the right lobe of the liver measuring up
to 2.1 cm is
indeterminate in etiology and grossly unchanged as compared to
abdominal
ultrasound ___. Multiphasic CT or MRI is recommended
for further
characterization.
#Triphasic MRI Liver w/ and ___ con
IMPRESSION:
1. Markedly limited examination due to respiratory motion. A few
hypoenhancing
hepatic lesions measuring up to 10 mm seen on different
post-contrast phases,
are indeterminate. No definite OPTN l5 esions identified,
within the
limitations of this exam.
2. 16 mm T1 hyperintense lesion in segment VIII is indeterminate
and does not
meet OPTN 5 criteria, but may correspond to the prior
sonographic finding.
3. Worsening biliary dilation compared to two days prior of
unknown etiology.
No choledocolithiasis.
4. 6 mm cystic lesion in the pancreatic body may represent a
side branch IPMN
or sequela of chronic pancreatitis.
RECOMMENDATION(S): The patient would benefit from multiphasic
CT, as the two
prior MRI examinations have been limited by difficulty with
breathholding.
Please identify the specific allergic reaction to iodinated
contrast, as the
patient may be amenable to premedication in the event of
mild/moderate past
reactions.
#Pharm Stress Test
IMPRESSION: No anginal type symptoms or ST segment changes.
Nuclear
report sent separately.
#CARDIAC PERFUSION PHARM 2-DAY
IMPRESSION: 1. Enlarged left ventricular cavity size consistent
with
cardiomyopathy. 2. Normal myocardial perfusion with left
ventricular ejection fraction of 66%.
#CT ABD ___ C; CT PELVIS ___
FINAL READ PENDING
Brief Hospital Course:
PATIENT SUMMER FOR ADMISSION;
=============================
Ms. ___ is a is a ___ year old woman with a history of HCV and
EtOH cirrhosis c/b portal hypertension with HE, portal
hypertensive gastropathy, and ascites s/p Harvoni, ___
(diagnosed ___, s/p radiotherapy ___ and recent discharge
(___) for HE who presents with ___ days of altered mental
status likely ___ hepatic encephalopathy potentially in the
setting of underdosed lactulose. Her mini mental status exam
remained stable during admission.
ACTIVE ISSUES:
=================
#AMS:
Etiology likely hepatic encephalopathy given asterixis on
presentation and improvement of symptoms after starting
lactulose and rifaximin. Precipitant unclear. RUQ US ___
shows patent vasculature without evidence of ascites. Infectious
workup (CXR/UA/BCx) and serum+urine tox screens negative thus
far. Patient endorses compliance with home medications to ___
bowel movements per day. While admitted, she was titrated to
lactulose Q4H with improvement in her mental status. At the time
of discharge she was stable and instructed to continue taking
lactulose as necessary for ___ BM per day. Additionally her
mental status was tracked with mini mental status exams which
were stable, however should be evaluated with formal
neurocognitive testing. Additionally cyclobenzaprine was
discontinued on discharge given concern that it could be
contributing to confusion.
#Cirrhosis ___ HCV s/p ledipasvir-sofosbuvir w/ SVR. Child class
B9, MELD-Na 14 on admission, MELD-Na 14 on discharge. Previously
complicated by portal hypertension, portal gastropathy, hepatic
encephalopathy and ascites. LFTs near baseline throughout
admission. No ascites on RUQ U/S. No evidence of active
infection or bleeding. Regarding candidacy for future liver
transplant, pharmacologic stress test with no anginal type
symptoms or ST segment changes. Cardiac perfusion study pending
at discharge.
#Hypoechoic liver lesion:
RUQ US notable for 2.1 cm hypoechoic lesion in the right lobe of
the liver that was stable compared to prior imaging. Patient
underwent triphasic MRI x2 which was unable to fully
characterize lesion given patient inability to breath-hold
during contrast portion of study. Triphasic CT remarkable for
extensive right mid abdomen varices, final read pending at time
of discharge.
#Pancytopenia: Stable and chronic, likely secondary to
cirrhosis. Patient with Hgb 7.5-8.5 during admission without
evidence of hemodynamic changes or instability. There was no
overt signs of bleeding.
CHRONIC ISSUES:
===============
# NSCLC: Diagnosed ___ and s/p LUL Cyberknife and stereotactic
body radiotherapy finished on ___. Not receiving active
treatment. Being followed by Dr. ___/ Rad-Onc.
# Depression: Continued paroxetine 40 mg PO DAILY
# Chronic abdominal pain: Continued home mesalamine +
cholestyramine
# ___ esophagus: Continued pantoprazole
# Back pain: continued lidocaine 5% Patch 1 PTCH TD QAM
# Leg cramps: Holding home cyclobenzaprine due to confusion as
above
# Itching: Continue HydrOXYzine 25 mg PO Q6H:PRN itching
Transitional Issues:
=======================
[] Pending labs at discharge:
___ 18:31 BLOOD CULTURE Blood Culture, Routine
___ 18:30 BLOOD CULTURE Blood Culture, Routine
[] Follow up results of liver lesion seen on CT to be discussed
with patient at outpatient follow up visit on ___ in the Liver
Center.
[] P Mibi study pending at time of discharge, to be followed by
PCP and ___.
[] Consider stopping paroxetine given weight gain side effect,
can be discussed at next PCP ___.
[] ___ consider referral for formal Neurocognitive evaluation
given frequency of confusion episodes
[] Cyclobenzaprine was held on throughout admission and on
discharge given deliriogenic properties.
[] Patient counseled extensively regarding regular use of
lactulose, goal 3 bowel movements daily.
[] Follow up ___ blood cultures, no growth at discharge
Medication Changes:
-New Medications: None
-Stopped/Held Medications: Cyclobenzaprine
-Changed Medications: None
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cholestyramine 4 gm PO DAILY
2. HydrOXYzine 25 mg PO Q6H:PRN itching
3. Lidocaine 5% Patch 1 PTCH TD QAM
4. Mesalamine 500 mg PO BID
5. Ondansetron 4 mg PO Q8H:PRN nausea
6. Pantoprazole 20 mg PO Q24H
7. PARoxetine 40 mg PO DAILY
8. Rifaximin 550 mg PO BID
9. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
10. Magnesium Oxide 400 mg PO TID
11. vit A,C and E-dietary suppl#12 ___ mg oral
daily
12. Cyclobenzaprine 5 mg PO TID:PRN muscle cramps
13. Lactulose 30 mL PO Q4H
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
2. Cholestyramine 4 gm PO DAILY
3. HydrOXYzine 25 mg PO Q6H:PRN itching
4. Lactulose 30 mL PO Q4H
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. Magnesium Oxide 400 mg PO TID
7. Mesalamine 500 mg PO BID
8. Ondansetron 4 mg PO Q8H:PRN nausea
9. Pantoprazole 20 mg PO Q24H
10. PARoxetine 40 mg PO DAILY
11. Rifaximin 550 mg PO BID
12. vit A,C and E-dietary suppl#12 ___ mg oral
daily
13. HELD- Cyclobenzaprine 5 mg PO TID:PRN muscle cramps This
medication was held. Do not restart Cyclobenzaprine until
instructed to do so by PCP
___:
Home
Discharge Diagnosis:
Primary Diagnosis:
=====================
Hepatic Encephalopathy
Cirrhosis
Hypoechoic liver lesion
Secondary Diagnosis:
=====================
Pancytopenia
Chronic Back Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- You and your son noticed that you were confused and forgetful
at home for the last few days.
What did you receive in the hospital?
- We started you on scheduled doses of rifaximin + lactulose,
and saw improvement in your thought process.
- You had an MRI and CT scan of your liver to help characterize
a finding on your liver. The specific findings will be discussed
with you at your follow up appointment with Dr. ___.
- We did tests of your heart to help Dr. ___
evaluate you as a candidate for liver transplant.
- Because your the sodium in your body was high, you received
fluids for treatment, and it returned to normal.
What should you do once you leave the hospital?
- Please continue to take your rifaximin and lactulose as
directed. You should have a goal of 3 bowel movements each day.
- Attend all scheduled follow up appointments.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10225793-DS-32 | 10,225,793 | 25,564,623 | DS | 32 | 2134-04-09 00:00:00 | 2134-04-09 19:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / IV Dye, Iodine Containing Contrast Media / aspirin
/ metronidazole / eggplant
Attending: ___
Chief Complaint:
Weight gain, abdominal pain, shortness of breath
Major Surgical or Invasive Procedure:
Diagnostic paracentesis (___)
History of Present Illness:
___ year old woman with HCV/EtOH cirrhosis c/b ascites, edema and
refractory HE s/p ___ of a large IMV shunt due to
worsening hepatic encephalopathy on ___ with ___, in
addition to stage I NSCLC in complete remission s/p CyberKnife
stereotactic body radiotherapy (___), who was referred from
___ clinic for nearly 1 week of worsening dyspnea, ___
edema, abdominal distention, and 40 lb. weight gain. However, it
appears that she has been experiencing fluid retention since her
procedure in ___. (patient's weight is 236.99 lbs on
___ and 250 pounds on ___ and 264.2 on admission).
Patient also mentions that she is not urinating as she used to
despite being compliant with her medications. She reported
doubling spironolactone dose but remained on 20 mg PO lasix
daily without improvement in symptoms. She has been eating her
___ cooking and they order takeout once weekly;
she does not know how much salt she eats. No fevers, melena,
hematemesis, diarrhea, confusion. She is currently undergoing a
transplant workup but is not yet listed.
In the ED
- Initial vitals: AF HR 63 BP 107/81, RR 18 and SpO2 100% on RA
(BP ranged from 100s-150s/70-80s)
- Exam notable for: Mild sclera icterus, firm abdominal
distension with diffuse tenderness to palpation, non-peritoneal
abdomen, rales in the upper lung fields
- Labs notable for: pancytopenia at baseline and below
transfusion threshold, INR 1.3-1.4, normal chemistry, borderline
elevated AST 55, ALK 125 and TB 2.7 (predominantly indirect),
Albumin 3.2, Lipase of 85, negative troponin and normal proBNP.
She underwent diagnostic paracentesis and cell count was not
suggestive of SBP (TNC 154, PMNs 3%). UA was obtained and is
contaminated and flu swab was negative.
- Imaging notable for:
1. ___ CXR PA/LA: Similar appearance of small left pleural
effusion. Fiducial marker with associated linear
atelectasis/scarring in the left upper lobe. No new focal
consolidation to suggest pneumonia.
2. ___ RUQ US:
- Very limited study due to bowel gas and body habitus. Within
these limitations, the liver appears cirrhotic without obvious
intrahepatic biliary dilation or gross mass.
- Main portal vein and right portal vein are not visualized.
Left portal vein is patent and has hepatopetal flow. If there
is continued clinical concern for portal venous thrombosis, a
contrast enhanced CT or MR of the abdomen is recommended.
- Consults: GI - have not seen patient yet
- Patient was given:
1. Acetaminophen: 1,000 mg IV x1 + 500 mg PO x1
2. Morphine sulfate 2 mg IV x3 (last dose at 14:00 on ___
3. Oxycodone 5 mg PO x1
4. Rifaxamin 500 mg x2 (last dose at 10AM on ___
5. Lasix 40 mg IV x2 (last dose at 9 AM on ___
6. Spironolactone 50 mg PO x1
7. Pantoprazole 20 mg PO x1
8. Paroxetine 40 mg PO x1
9. Magnesium oxide 400 mg PO x1
10. Cepacol throat lozenge
11. Emtricitabine-Tenofovir alafen 200mg-25mg (Descovy) 1 tab x1
12. Raltegravir 400 mg PO x1
13. Hydroxyzine 50 mg PO x1
- ED Course: as noted above, pt was admitted with dyspnea and
volume overload. She was diuresed with IV Lasix 40 mg x2 and
given her home spironolactone. Diagnostic paracentesis was
performed and cell count was not concerning for SBP; thus she
was not started on antibiotics. Therapeutic paracentesis was not
performed. Additionally, she was given a total of ___ MME/24
hrs (2 mg IV morphine x2 + 5 mg PO oxycodone)
- Additionally, the patient was accidentally exposed to ?foreign
blood (bloody gauze in her ice chips though probably her own
gauze). Per ID, she was started on HIV post-exposure prophylaxis
for 28 days; she will also require PCP or ID follow up in 2
weeks for repeat testing.
Upon arrival to the floor, patient confirms history above. She
endorses diffuse pain and asks for oxycodone.
REVIEW OF SYSTEMS: Positive per HPI, remaining 10 point ROS
reviewed and negative.
Past Medical History:
1. Hepatitis C.
2. Cirrhosis (HCV, possibly ETOH)
3. Lung cancer (NSCLC)
4. ___ esophagus.
5. Depression.
6. Hypertension.
7. Obesity.
8. Status post abdominoplasty as well as cholecystectomy.
9. Unspecified colitis
Social History:
___
Family History:
- Mother (deceased at ___) - acute MI, emphysema
- Father (deceased) - stroke
- No FH cancers
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: Temp: 97.9 PO BP: 165/100 L Lying HR: 69 RR: 22 O2 sat: 99%
O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___
GENERAL: NAD
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, ejection systolic murmur best heard over the
right second intercostal space. No radiation to the carotids.
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Distended abdomen with shifting dullness, diffuse
tenderness esp. in the epigastric area. Caput Medusa
EXTREMITIES: +2 pitting edema bilaterally up to the knee levels
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
VS: 98.2 ___ 18 100
GEN: Well-appearing, comfortable.
HEENT: Mild scleral icterus.
CV: RRR, S1S2 nl, II/VI crescendo/decrescendo systolic murmur
heard best at the upper sternal border without radiation to
carotids.
RESP: Normal work of breathing. Minimal chest expansion visible
on deep inspiration. Resonant to percussion and clear to
auscultation at the base and apex of lungs bilaterally.
ABD: Obese. BS+, Soft, Slightly distended, Discomfort without
tenderness to palpation in all four quadrants. No guarding or
rebound.
EXT: trace edema of her bilateral lower extremities, markedly
improved from prior
NEURO: AAOx3, no asterixis
Pertinent Results:
ADMISSION LABS:
WBC-3.3* Hgb-9.6* Hct-29.8* MCV-108* Plt Ct-76*
Neuts-53.5 Lymphs-31.4
Glucose-110* UreaN-12 Creat-0.9 Na-140 K-6.5* Cl-109* HCO3-22
AnGap-9*
Calcium-9.2 Phos-3.4 Mg-2.0
ALT-32 AST-125* AlkPhos-111* TotBili-2.9* DirBili-0.5*
IndBili-2.4 Albumin-3.2*
___ PTT-32.7 ___
Lipase-85*
cTropnT-<0.01 proBNP-105
RELEVENT LABS:
___
calTIBC-187* Ferritn-39 TRF-144* Iron-36
AFP-3.3
DISCHARGE LABS:
WBC-1.3* Hgb-7.2* Hct-22.6* MCV-109* Plt Ct-33*
Neuts-42.9 Lymphs-37.9
Glucose-92 UreaN-12 Creat-0.8 Na-142 K-4.2 Cl-106 HCO3-28
AnGap-8* Mg-2.0
ALT-17 AST-33 AlkPhos-74 TotBili-2.0* Albumin-3.8
___ PTT-41.6* ___
MICROBIOLOGY:
HBsAg-NEG HBsAb-NEG HBcAb-POS*
HIV Ab-NEG
HCV Ab-POS*
HBV VL-NOT DETECT HCV VL-NOT DETECT
IMAGING:
___ CXR PA/LA: Similar appearance of small left pleural
effusion. Fiducial marker with associated linear
atelectasis/scarring in the left upper lobe. No new focal
consolidation to suggest pneumonia.
___ RUQ US:
- Very limited study due to bowel gas and body habitus. Within
these limitations, the liver appears cirrhotic without obvious
intrahepatic biliary dilation or gross mass.
- Main portal vein and right portal vein are not visualized.
Left portal vein is patent and has hepatopetal flow. If there
is continued clinical concern for portal venous thrombosis, a
contrast enhanced CT or MR of the abdomen is recommended.
___ ___ GUIDED PARACENTESIS: Small ascitic fluid pocket seen
in the right upper quadrant is insufficient for paracentesis.
This was discussed with the primary team.
___ CT A/P WITH AND WITHOUT CONTRAST:
1. Cirrhotic liver with signs of portal venous hypertension.
2. Small left pleural effusion.
3. No hepatic lesion meeting OPTN 5 criteria.
Brief Hospital Course:
SUMMARY:
___ is a ___ with HCV/ETOH cirrhosis decompensated by
volume overload and refractory HE s/p ___ by ___ in
___, in addition to stage I NSCLC in complete
remission, who presented from ___ clinic with at least 1
week of abdominal distension, lower extremity edema, dyspnea,
decreased urinary output and weight gain, likely secondary to
increased portal pressure/blood from the above procedure in
addition to disease progression.
ACTIVE ISSUES:
# Volume overload:
Presented with dyspnea, ___ edema, increased abdominal distension
and 15 lb weight gain since discharge in ___. Her dyspnea
was secondary to her enlarged abdomen and she was never hypoxic
during her hospitalization. Her volume overload is likely due to
increased portal pressure/blood flow following her ___ guided
procedure (___). Her discharge weight in ___
was 250 lbs; on admission she weighs 265 lbs. She was ecaluated
by ___ who did not think she needed TIPS or alternate procedure.
She was diuresed with 40-60 mg IV Lasix twice daily (w/ albumin
BID) and her home dose of Spironolactone was increased. She was
discharged on a new dose of Furosemide 60 mg PO once daily (up
from 20 mg) and Spironolactone 100 mg once daily (up from 50
mg); her discharge weight was 113 kg and she had no lower
extremity edema on exam.
# HCV/ETOH cirrhosis (MELD 14, Childs B):
[for details on history of diagnosis, please see note from
___ titled Hepatitis C by ___
___]
Pt is s/p closure of splenorenal shunt by ___ ___
(___) for refractory HE; also has history of ascites but
has not required paracentesis in the past. She started
undergoing transplant evaluation in ___ though was
denied for in ___ due to inability to complete the
evaluation on time in addition to her BMI 44. Unfortunately, her
BMI remains elevated and thus she still does not qualify for
transplant:
1. Volume: overloaded on presentation though did not require
therapeutic paracentesis. Discharged on Furosemide 60 mg daily
and Spironolactone 100 mg daily.
2. Infection: no history of SBP and diagnostic paracentesis on
admission has 3% PMNs with a negative gram stain. HBV and HCV
viral load were negative as well; she has been vaccinated
against hepatitis A
3. Blood: EGD ___ without varicies, though did note portal
gastropathy. Continues on propranolol (? portal HTN) and is due
for repeat EGD ___. Pt is also coagulopathic, with INR 1.7
and Plt 33 by discharge.
4. Encephalopathy: history of HE now s/p shunt closure. Her home
lactulose was increased from 15 mL TID to 30 mL QID while in
house.
5. Screening: vaccinated against flu (___), pneumovax
administration not documented; immune to ___. Her hepB status
is
unclear (positive core in ___, s/p 1x vaccine, positive core
on admission, negative viral load). Recent RUQ U/S without
concerning findings and AFP within normal limits
6. Other: decreased home dose of Hydroxyzine from 50 mg q6 PRN
to 25 mg q6 PRN for pruritus.
# Pancytopenia with neutropenia and lymphopenia: pt was
pancytopenic on admission, likely due to her progressive liver
disease. Her counts continued to drop throughout her stay.
Etiology of this progressive decline is unclear, though possibly
due to high dose diuretic as this has been known to cause bone
marrow suppression. She did not have any evidence of active
bleeding or infection.
# Iron deficiency anemia: given decline in hemoglobin and
complaints of leg cramps, serum iron studies were ordered. Her
ferritin was low at 39 (most recently 165 in ___. She was
given 2 doses of IV iron (___) and discharged on oral iron
to be taken every other day per new guidelines.
CHRONIC ISSUES:
# Leg cramps: continued home magnesium and ordered her for two
iron transfusions as her iron deficiency may be exacerbated her
symptoms.
# History of ___ esophagus: increased dose of pantoprazole
from 20 mg once daily to 40 mg once daily.
# Depression: continued home Paroxetine 40 mg once daily.
# History of NSCLC: Clinically without evidence of lung cancer
as recently as ___. History of a stage I non-small cell
lung cancer of left upper lobe status post CyberKnife
stereotactic body radiotherapy completing on ___. Of
note, pt was due for repeat chest CT ___ this was obtained
during her admission and was without suspicious findings.
TRANSITIONAL ISSUES:
Code status: Full, presumed
Contact: ___ - ___
Admission weight: 120 kg
Discharge weight: 113 kg
Discharge creatinine: 0.8
Discharge CBC: WBC 1.3, Hb 7.2, Plt 33
Discharge INR: 1.7
# Volume overload:
- Please follow up patient's weight and creatinine to ensure
appropriate dosing of oral diuretics
# Cirrhosis:
- Please follow up total bilirubin, as this was elevated to 2.0
at discharge
- Please follow up patient's INR and platelets, as she became
progressively coagulopathic during admission
- Please consider vaccination with pneumovax, as this has not
been documented in OMR
- To complete the transplant work up, pt needs:
[] Mammogram
[] ABG
[] Pap results
[] Weight loss (BMI < 40)
# Pancytopenia with neutropenia/lymphopenia:
- Please repeat CBC with diff at outpatient follow up and
consider further work up if indicated
# Iron deficiency anemia:
- Please repeat iron studies in the next ___ months
(___). If patient's iron stores are not replete, she
may require IV iron transfusions
- Pt may require outpatient work up for etiology of iron
deficiency though may be due to slow oozing from portal
gastropathy (s/p EGD and colonoscopy ___
# Other: please repeat HIV Ab in 3 months (___) as pt c/w
coming in contact with foreign body in ED
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Rifaximin 550 mg PO BID
2. Furosemide 20 mg PO DAILY
3. Spironolactone 50 mg PO DAILY
4. Propranolol 20 mg PO BID
5. Pantoprazole 20 mg PO Q24H
6. PARoxetine 40 mg PO DAILY
7. Magnesium Oxide 500 mg PO BID
8. HydrOXYzine 50 mg PO Q6H:PRN itch
9. Ondansetron 4 mg PO Q6H:PRN Nausea/Vomiting - First Line
10. Cholestyramine Light (cholestyramine-aspartame) 4 gram oral
DAILY:PRN itch
11. Lactulose 15 mL PO ___ DAILY
12. Meclizine 25 mg PO TID:PRN dizziness
Discharge Medications:
1. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
Every other day at lunch. Disp #*30 Tablet Refills:*3
2. Furosemide 60 mg PO DAILY
RX *furosemide 20 mg 3 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
3. HydrOXYzine 25 mg PO Q6H:PRN itch
4. Lactulose 30 mL PO QID
5. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
6. Spironolactone 100 mg PO DAILY
RX *spironolactone 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
7. Cholestyramine Light (cholestyramine-aspartame) 4 gram oral
DAILY:PRN itch
8. Magnesium Oxide 500 mg PO BID
9. PARoxetine 40 mg PO DAILY
10. Propranolol 20 mg PO BID
11. Rifaximin 550 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
- HCV/ETOH cirrhosis, decompensated by volume overload
SECONDRAY:
- Pancytopenia with neutropenia
- Iron deficiency anemia
- Leg cramps
- History of ___ esophagus
- Depression
- History of ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to ___ because you were had several weeks of
significant weight gain, swelling and shortness of breath.
What happened in the hospital?
- You were given IV diuretics to remove the fluid from your
body.
- You had several imaging studies to evaluate the procedure you
had back in ___. You did not need to have another
procedure.
- You were given IV iron because your iron levels were low which
is causing you to have anemia, or decreased red blood cells.
When you go home:
- Please weigh yourself immediately when you go home and record
this number. This will be your new "dry weight."
- Then, continue to weigh yourself every morning, after you
urinate. If your weight increases by ___ pounds in 2 days, or by
5+ pounds in a week, please call your liver doctor, as you may
need to increase your dose of diuretic (Furosemide/Lasix)
- We have made some changes to your medication list, so please
take them as prescribed (list attached).
- Please go to your follow up appointments (see below)
- If you develop worsening symptoms, such as increased leg
swelling, abdominal distension, shortness of breath, fever,
abnormal bleeding/bruising, or confusion, please call your
doctor or return to the emergency room.
It was a pleasure taking part in your care. We wish you all the
best with your health.
Sincerely,
The team at ___
Followup Instructions:
___
|
10225793-DS-33 | 10,225,793 | 25,350,529 | DS | 33 | 2134-05-31 00:00:00 | 2134-05-31 17:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / IV Dye, Iodine Containing Contrast Media / aspirin
/ metronidazole / eggplant
Attending: ___
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old woman with HCV/EtOH cirrhosis c/b ascites, edema and
refractory HE s/p ___ of a large IMV-L iliac vein shunt
due to
worsening hepatic encephalopathy on ___ with ___, in
addition to stage I NSCLC in complete remission s/p CyberKnife
stereotactic body radiotherapy (___) who presents with
altered
mental status. Patient reports that she had several nights of
insomnia, and slept all day yesterday (___) and did not take
her
lactulose. She reports last BM on ___. This morning, she noted
she had a more difficult time putting together sentences. In the
afternoon, her son noted she seemed more confused than usual,
which precipitated her presentation to the ED. She had some
upper
abdominal pain and distention which she notes usually accompany
her encephalopathic episodes. Reported time course of the past
few days may be unreliable to a degree given encephalopathy. She
has not had an encephalopathic episode since prior to her
___.
She denies any focal numbness, weakness, slurred speech, falls.
No recent head strike. Denies bloody stools or bloody vomiting.
No fever, chills, new cough, dysuria, ___ swelling.
In the ED
- Initial vitals: AF HR 62 BP 160/71, RR 18 and SpO2 100% on RA
- Exam notable for: No acute distress, abdomen soft, distended
and mildly tender diffusely, stools were guaiac negative, A&Ox2
to person and place, no asterixis
- Labs notable for: White blood cell count of 3.0, hemoglobin
11.4 with an MCV of 112, platelet count of 62. Total bilirubin
2.9, AST 72, ALT 29, alk phos 120. Lipase 78. Basic metabolic
panel overall unremarkable, with a creatinine of 0.7. INR 1.5.
Lactate 1.7. Urinalysis unremarkable however with 7 epis.
- Imaging notable for:
1. CXR PA/LA: No new focal consolidation to suggest pneumonia.
2. RUQ US:
1. Cirrhotic liver with a small amount of ascites and mild
splenomegaly.
2. Patent main portal vein and left portal vein with hepatopetal
flow. The right portal vein could not visualized.
- Consults: Hepatology recommended broad infectious workup,
diagnostic paracentesis, right upper quadrant ultrasound to
evaluate for portal vein thrombosis and q2-hour lactulose.
- Patient was given:
Tylenol ___ mg
Lactulose 30 mL
Spironolactone 100 mg
Propranolol 10 mg
Paroextine 40 mg
Furosemide 40 mg
Pantoprazole 20mg
- ED Course: Bedside ultrasound was performed and there was no
pocket on ultrasound amenable to bedside.
Upon arrival to the floor, patient reported above history and
noted abdominal pain.
REVIEW OF SYSTEMS: Positive per HPI, remaining 10 point ROS
reviewed and negative.
Past Medical History:
1. Hepatitis C.
2. Cirrhosis (HCV, possibly ETOH),
3. Lung cancer (NSCLC Stage I, s/p CyberKnife stereotactic body
radiotherapy ___
4. ___ esophagus
5. Depression.
6. Hypertension
7. Obesity
8. S/p abdominoplasty and cholecystectomy
9. Unspecified colitis, on Mesalamine intermittently, last ___
in ___ normal
Social History:
___
Family History:
- Mother (deceased at ___) - acute MI, emphysema
- Father (deceased at ___) - stroke
- 8 siblings:
- brother died of GI bleed ___ hepatitis
- sister died of overdose
- two other siblings murdered
- other four siblings alive and healthy
- No FH cancers
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
===============================
sat: 99% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___
GENERAL: NAD
HEENT: EOMI, mildly icteric sclera, pink conjunctiva, MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, ejection systolic murmur best heard over the
right second intercostal space. No radiation to the carotids.
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Distended abdomen. Normal bowel sounds. Tender to
palpation in the upper quadrants.
EXTREMITIES: No pitting edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox2 (person/place), bilateral hand tremor, no asterixis
SKIN: warm and well perfused, no excoriations or lesions, no
rashes, spider angiomas on chest
DISCHARGE PHYSICAL EXAMINATION:
===============================
VS:
24 HR Data (last updated ___ @ 817)
Temp: 97.9 (Tm 98.1), BP: 123/67 (123-141/67-81), HR: 56
(56-62), RR: 18, O2 sat: 96% (95-99), O2 delivery: Ra, Wt: 237.4
lb/107.68 kg
GENERAL: NAD
HEART: RRR, S1/S2, ejection systolic murmur best heard over the
right second intercostal space. No radiation to the carotids.
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Soft, ND. Normal bowel sounds. Mildly TTP in epigastric
region.
EXTREMITIES: No pitting edema
NEURO: A&Ox3. No asterixis.
Pertinent Results:
ADMISSION LABS:
===============
___ 02:10PM WBC-3.0* RBC-3.15* HGB-11.4 HCT-35.3 MCV-112*
MCH-36.2* MCHC-32.3 RDW-17.8* RDWSD-74.9*
___ 02:10PM NEUTS-52.9 ___ MONOS-15.2* EOS-3.0
BASOS-0.3 IM ___ AbsNeut-1.57* AbsLymp-0.84* AbsMono-0.45
AbsEos-0.09 AbsBaso-0.01
___ 01:35PM ___ PTT-33.8 ___
___ 02:10PM LIPASE-78*
___ 02:10PM ALT(SGPT)-29 AST(SGOT)-72* ALK PHOS-120* TOT
BILI-2.9*
___ 02:10PM GLUCOSE-73 UREA N-18 CREAT-0.7 SODIUM-141
POTASSIUM-4.7 CHLORIDE-110* TOTAL CO2-22 ANION GAP-9*
___ 02:21PM LACTATE-1.7
___ 03:15PM URINE URIC ACID-MANY*
___ 03:15PM URINE RBC-9* WBC-2 BACTERIA-NONE YEAST-NONE
EPI-7
___ 03:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.5
LEUK-NEG
___ 03:15PM URINE COLOR-Yellow APPEAR-Hazy* SP ___
REPORTS:
========
___ ABD US
IMPRESSION:
1. Cirrhotic liver with a small amount of ascites and mild
splenomegaly.
2. Patent main portal vein and left portal vein with hepatopetal
flow. The right portal vein could not visualized.
___ CXR
IMPRESSION:
No acute intrathoracic process. Fiducial again noted in the
left upper lobe.
___
IMPRESSION:
1. A 2 cm arterially enhancing lesion with washout in segment 8
of the liver
meets OPTN 5b criteria for HCC.
2. Iliac to IMV and IMV to SMV/portal vein collaterals persists,
not
significant changed compared to the prior study.
3. Mild perihepatic ascites and moderate pelvic free fluid.
4. 7 mm pancreatic hypodensity, likely side branch IPMN.
Recommend MRCP for
further evaluation.
RECOMMENDATION(S): MRCP
DISCHARGE LABS:
===============
___ 05:39AM BLOOD WBC-2.3* RBC-2.72* Hgb-9.9* Hct-30.1*
MCV-111* MCH-36.4* MCHC-32.9 RDW-17.2* RDWSD-70.9* Plt Ct-43*
___ 05:39AM BLOOD Glucose-83 UreaN-18 Creat-0.9 Na-143
K-4.5 Cl-105 HCO3-28 AnGap-10
___ 05:39AM BLOOD Plt Ct-43*
___ 05:39AM BLOOD ALT-26 AST-42* AlkPhos-93 TotBili-1.4
___ 05:39AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.7
Brief Hospital Course:
SUMMARY:
====================
___ year old woman with HCV/EtOH cirrhosis c/b ascites, edema and
refractory HE s/p ___ of a large IMV shunt due to
worsening hepatic encephalopathy on ___ with ___, who
presents with hepatic encephalopathy likely triggered by
medication non-adherence also with possible contribution from
persistent iliac to IMV collaterals. She was evaluated by
interventional radiology and further embolization was deferred
for further trial of medical therapy due to concern for
worsening portal hypertensive gastropathy and/or PVT. Hospital
course also notable for incidentally noted 2cm hepatic lesion
meeting radiographic criteria for ___ for which she will receive
outpatient treatment.
TRANSITIONAL ISSUES:
====================
Discharge weight: 237.4lbs
Discharge Cr: 0.9
[] Patient has history of IMV-iliac vein shunt (s/p ___
in ___ for refractory HE. She underwent CTAP on ___
notable for persistent collaterals to IMV unchanged from prior
scan in ___. She was discussed at multidisciplinary
conference with hepatology and ___ present and decision was made
to hold off on further embolization pending 2 week trial of
medical therapy as with repeat BRTO patient would be at
increased risk for exacerbation of portal hypertensive
gastropathy and portal venous thrombosis potentially requiring
concurrent TIPS placement. Please ___ patient's symptoms
and ensure ___ ___ as needed.
[] Patient had CTAP which incidentally noted 2cm enhancing
lesion meeting OPTN 5b criteria for HCC. She will require
outpatient treatment for this.
[] CTAP also incidentally noted 7mm pancreatic hypodensity
concerning for IPMN for which MRCP recommended for further
evaluation.
[] Patient's home lactulose was increased to QID as while in
house she was noted to have less than 3 bowel movements with TID
dosing. Please ___ number of BMs on this regimen.
[] Patient's home meclizine was held at discharge due to concern
that this could contribute to her encephalopathy.
ACUTE ISSUES:
=============
#Encephalopathy:
#Hx of IMV-Iliac vein shunt s/p ___ for refractory HE:
She presented to the hospital after being brought in by family
due to concern for increasing confusion and on initial exam
appeared to be mildly encephalopathic with word finding
difficulty. She reported good med compliance in general but did
report sleeping all day the day prior to admission and missing
her medications. Her family was at home with her when this
happened but did not wake her up to give her her medications.
She did not have any localizing infectious symptoms or evidence
of bleeding while inpatient, and infectious studies were all
negative at the time of discharge. RUQUS/abdominal ultrasound
showed patent portal vein and no tappable pocket. Her symptoms
improved initially with lactulose q2 hours and it was
subsequently titrated down as needed for goal ___ BMs per day.
She was continued on her home rifaximin. Patient has history of
IMV-iliac vein shunt (s/p ___ in ___ for refractory
HE. She underwent CTAP on ___ to evaluate for
recurrent/worsening shunt; CT was notable for persistent
collaterals to IMV unchanged from prior scan in ___. She was
discussed at multidisciplinary conference with hepatology and ___
present and ultimately decision was made to hold off on further
embolization for now as with portosystemic gradient of 23 mmHg
after BRTO of IMV shunt in ___, patient would be at
increased risk for exacerbation of portal hypertensive
gastropathy and portal venous thrombosis potentially requiring
concurrent TIPS placement to mitigate these risks. At the time
of discharge, plan was for patient to trial medical therapy for
another 2 weeks. She was given the contact information for Dr.
___ and ___ contact him as needed to discuss
BRTO/TIPS. Her outpatient hepatologist ___ was also
informed of this plan. At the time of discharge patient was
having ___ BMs per day and was fully oriented, though still
reported feeling some residual difficulty with wordfinding
compared to her baseline.
#HCC:
CTAP obtained during admission for evaluation of portosystemic
shunt was notable for 2cm enhancing lesion meeting OPTN 5b
criteria for HCC, as well as 7mm pancreatic hypodensity c/f IPMN
for which MRCP recommended for further eval. Per chart review,
the lesion now consistent with HCC was present but previously
smaller and did not meet OPTN 5b criteria in ___. She was
seen by ___ during this admission for discussion around possible
repeat embolization as above; her outpatient hepatologist Dr.
___ will arrange ___ with them for this as well as
outpatient treatment for her HCC.
# Hx Cirrhosis:
(MELD = 10, Childs B): secondary to HCV/ETOH, s/p closure of
IMV-L iliac shunt (___) for refractory HE; also has
history of ascites. She started undergoing transplant evaluation
in ___ but was denied for transplant in ___ due
to inability to complete the evaluation on time and BMI 44.
During this admission she received treatment for hepatic
encephalopathy as above. In terms of volume status, she appeared
euvolemic throughout this admission and was continued on her
home diuretics and 2g Na restriction. Weight at time of
discharge was 237.4lbs. In terms of infectious, broad infectious
workup as above was negative. She had mild ascites noted on
abdominal US and CTAP, however bedside ultrasound was without
tappable pocket. In terms of her history of varices/portal
gastropathy, her home propranolol 10mg BID was continued. See
above for new diagnosis of HCC during this admission.
#Abdominal pain
Unclear etiology. Patient reports a history of chronic abdominal
pain that is worsened iso HE episodes. ___ be component of
abdominal distention and discomfort contributing to pain. From
prior admissions, appears pain improves as HE clears. Her
abdominal pain remained stable and similar to her chronic pain
in nature throughout this admission. For pain control she
received oxycodone 2.5-5mg PRN which was subsequently weaned,
acetaminophen, lidocaine patches and hot compresses.
#Itching:
Continued home hydroxyzine qhs. Resumed cholestyramine (which
patient is prescribed as an outpatient but was not taking at
home).
CHRONIC ISSUES:
============================
# NSCLC:
Clinically without evidence of lung cancer as recently as
___. History of a stage I non-small cell lung cancer of
left upper lobe status post CyberKnife stereotactic body
radiotherapy completed on ___.
# Pancytopenia:
At baseline, likely secondary to cirrhosis. Her subcutaneous
heparin was held for platelets <50k. There was no evidence of
active bleeding during this admission.
# Depression:
Continued home Paroxetine 40 mg PO daily.
# History of ___ esophagus:
Home Pantoprazole switched to omeprazole while in house.
# History of ETOH abuse
# History of cocaine, BZD and heroin abuse:
Limited unnecessary BZDs and opiates in patient and provided
only when medically indicated.
#Viral Hepatitis
Hep C s/p cure; Hep B cAb positive, viral load negative.
CORE MEASURES:
==============
# CODE: Presumed FULL
# CONTACT: ___, daughter - ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. HydrOXYzine 25 mg PO ___ TABLETS QHS PRN itch
2. Lactulose 30 mL PO TID
3. Magnesium Oxide 500 mg PO BID
4. Pantoprazole 20 mg PO DAILY
5. PARoxetine 40 mg PO DAILY
6. Rifaximin 550 mg PO BID
7. Spironolactone 100 mg PO DAILY
8. Furosemide 40 mg PO DAILY
9. Propranolol 10 mg PO BID
10. Ondansetron 4 mg PO BID:PRN Nausea/Vomiting - First Line
11. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
12. Meclizine 25 mg PO Q6H:PRN vertigo
13. vitamins A,C,E-zinc-copper ___ unit-mg-unit oral
DAILY
Discharge Medications:
1. Cholestyramine 4 gm PO DAILY itching
RX *cholestyramine (with sugar) 4 gram 1 packet(s) by mouth once
a day Disp #*30 Packet Refills:*0
2. Lactulose 30 mL PO QID
RX *lactulose 20 gram/30 mL 20 g by mouth four times a day Disp
#*2 Bottle Refills:*20
3. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
4. Furosemide 40 mg PO DAILY
5. HydrOXYzine 25 mg PO ___ TABLETS QHS PRN itch
6. Magnesium Oxide 500 mg PO BID
7. Ondansetron 4 mg PO BID:PRN Nausea/Vomiting - First Line
8. Pantoprazole 20 mg PO DAILY
9. PARoxetine 40 mg PO DAILY
10. Propranolol 10 mg PO BID
11. Rifaximin 550 mg PO BID
12. Spironolactone 100 mg PO DAILY
13. vitamins A,C,E-zinc-copper ___ unit-mg-unit oral
DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: hepatic encephalopathy
Secondary diagnosis: HCV/EtOH Cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___.
Why did you come to the hospital?
- Your family noticed that you were more confused at home.
What did you receive in the hospital?
- You were found to have hepatic encephalopathy which caused you
to become more confused. This was likely due to a combination of
things, including missing your medications the day you came to
the hospital, and also due to an abnormal connection of blood
vessels in your belly. You had a procedure in the past to help
fix this. You were seen by the ___ doctors who did the last
procedure; however they decided to hold off on another procedure
for now given the risks. You were given their contact
information and should call them in 2 weeks if you feel your
confusion is not better.
- You underwent a CAT scan to figure out why you developed
encephalopathy. This CAT scan also showed that you have a spot
in your liver which now we can say for sure is liver cancer
(also called hepatocellular carcinoma). You will ___ with
your outpatient doctors for further treatment of this.
What should you do once you leave the hospital?
-It is very important that you have at least 3 bowel movements a
day to prevent confusion. Your lactulose dose was increased
during this hospitalization to help with this. If you are having
less than this, please take an extra dose of lactulose and call
your doctor's office to let them know.
-Please call the ___ doctors (___) in two weeks if
you feel your confusion is not better even when having at least
3 bowel movements a day.
-Please take your medications as prescribed and ___ with
your outpatient doctors as ___.
-Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
10225793-DS-39 | 10,225,793 | 21,795,896 | DS | 39 | 2134-10-01 00:00:00 | 2134-10-02 06:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / IV Dye, Iodine Containing Contrast Media / aspirin
/ metronidazole / eggplant
Attending: ___.
Chief Complaint:
Nausea vomiting abdominal distention
Major Surgical or Invasive Procedure:
Therapeutic paracentesis on ___ taking of 1.2 L. Ascitic
fluid negative for SBP.
History of Present Illness:
CHIEF COMPLAINT: abdominal pain and distension
HISTORY OF PRESENTING ILLNESS:
___ year old woman with a history of HCV/EtOH cirrhosis
complicated ___ s/p microwave ablation of segment 8 on ___,
ascites, SBP on cipro ppx, and refractory encephalopathy status
post BRTO of large IMV shunt (___), embolization of
portosystemic shunt and TIPS (___), TIPS reduction (___)
and known TIPS occlusion, presenting with abdominal pain,
distension and weight gain.
Pt first noticed symptoms beginning ___. She reports
constipation and had a small "not satisfying" bowel movement on
___ but has not had another since; she is also not passing
gas. She states that her belly has gotten bigger and that there
is fluid in it. She has gained 8 lbs over the course of this
time. Her PO intake has decreased and she has mild nausea as
well.
The patient was recently admitted ___ for a planned
microwave
ablation to a ___ lesion. On that admission she was monitored
after an uncomplicated procedure with ablation to segment 8 HCC,
she had some constipation that was treated with miralax, and had
a mild increase in her abdominal pain from baseline. She also
had
a RUQ ultrasound which demonstrated her known Occluded TIPS
without ascites or other findings. She was continued on her home
diuretics and discharged on ___.
In the ED initial vitals:
Temp 98.0 HR 91 BP 137/105 RR 20 02 100% RA
- Exam notable for:
Abd: Soft, normoactive bowel sounds, moderately distended.
Tender
to palpation over epigastrium, LUQ.
Ext: Warm and well perfused. No pitting edema or cyanosis.
- Labs notable for:
CBC: WBC 3.5 Hgb 12.6 PLt 63
BMP: Na 134 Cl 96 HC03 23 BUN 11 Cr. 1.1
LFTS: AST 93 ALT 34 Alk Phos 152 T bili 4.2
___: 16.8 PTT: 33.6 INR: 1.5
Lactate 2.6
Trop <0.01
UA + for 33 WBC but 11 epithelial cells
- Imaging notable for:
RUQ US: ___
1. TIPS in place with occlusion of the mid and distal portions.
2. Unchanged hepatopetal flow of the left hepatic vein.
3. Moderate ascites, unchanged from ___ and unchanged
splenomegaly.
CT A/P with PO contrast: ___
1. No bowel obstruction.
2. Cirrhotic liver with moderate ascites. TIPS is better
assessed on same day ultrasound.
3. Post ablation cavity in segment VII/VIII is better
characterized on prior MRI.
- Consults: Hepatology was consulted who recommended admission
to
Liver service after an abdominal CT, diagnostic paracentesis and
urine and blood cultures
- Patient was given:
- Hydromorphone .25mg x2
- zofran 4mg
Upon arrival to the floor, pt is feeling a bit better after
receiving pain meds. She does not understand why she is gaining
so much weight as she is taking her Lasix and spironolactone and
has been urinating well. She is quite constipated despite taking
lactulose and miralax. She wonders if her lactulose isn't
working
as well because her most recent prescription is orange and she
is
used to the clear kind. She has not been using opioids but does
use zofran intermittently. Her PO intake has been poor. Finally,
she notes increasing dyspnea on exertion over the course of a
few
days. She denies chest pain/pressure, palpitations. Also denie
fevers, chills, dysuria, abnormal bleeding or confusion.
Past Medical History:
Past Medical History:
1. Hepatitis C s/p interferon treatment with SVR
2. Cirrhosis (HCV, possibly ETOH), complicated by:
-- HCC
-- ascites
-- refractory hepatic encephalopathy s/p BRTO of large IMV shunt
___, embolization of portosystemic shunt and TIPS ___
3. Lung cancer in remission (___ Stage I, s/p CyberKnife
stereotactic body
radiotherapy ___
4. ___ esophagus
5. Depression
6. Hypertension
7. Obesity
8. S/p abdominoplasty and cholecystectomy
9. Unspecified colitis, on mesalamine in the past
Social History:
___
Family History:
Mother died aged ___ with an acute MI, and also had a history of
emphysema. Father died aged ___ secondary to a stroke. Brother
died secondary to GI bleed secondary to "hepatitis". Sister died
of overdose. Two other siblings murdered.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 24 HR Data (last updated ___ @ 2342)
(Tm 97.8), BP: 137/82 (___), HR: 75 (75-78), RR: 18, O2
sat: 98%, O2 delivery: Ra, Wt: 236.33 lb/107.2 kg
GENERAL: lying comfortably in bed, alert and interactive
HEENT: dry lips, sclera anicteric
HEART: distant heart sounds, regular rate and rhythm, no murmurs
LUNGS: breathing comfortably, clear but decreased breath sounds
throughout
ABDOMEN: moderately distended and tender in the LUQ, no rebound
or guarding
EXTREMITIES: no edema
NEURO: AOx3, no asterixis
Discharge physical exam
GEN: resting comfortably in bed, NAD, AAOx3,
pleasant, conversational
HEENT: moist mucosa, slightly icteric sclera
NECK: No JVD
CV: RR, S1+S2, systolic murmur best appreciated at RUSB
RESP: clear to auscultation
ABD: normoactive bowel sounds, splenomegaly appreciated on
percussion, mild pain with deep palpation in RUQ and LUQ, no
rebound or guarding, minimal fluid wave appreciated
EXT: WWP, no edema
NEURO: CN II-XII grossly intact, MAE
Pertinent Results:
Admission labs:
___ 02:31PM BLOOD WBC-3.5* RBC-3.39* Hgb-12.6 Hct-37.5
MCV-111* MCH-37.2* MCHC-33.6 RDW-19.0* RDWSD-78.4* Plt Ct-63*
___ 03:12PM BLOOD ___ PTT-33.6 ___
___ 02:31PM BLOOD ALT-34 AST-93* CK(CPK)-77 AlkPhos-152*
TotBili-4.2* DirBili-0.8* IndBili-3.4
___ 02:35PM BLOOD Lactate-2.6*
Imaging:
Liver ultrasound ___
IMPRESSION:
1. TIPS in place with occlusion of the mid and distal portions.
2. Unchanged hepatopetal flow of the left hepatic vein.
3. Moderate ascites, unchanged from ___ and unchanged
splenomegaly
CT abdomen pelvis ___
IMPRESSION:
1. No bowel obstruction.
2. Cirrhotic liver with moderate ascites. TIPS is better
assessed on same day
ultrasound.
3. Post ablation cavity in segment VII/VIII is better
characterized on prior
MRI.
Micro: None relevant
Discharge labs:
___ 05:42AM BLOOD WBC-1.6* RBC-2.45* Hgb-9.4* Hct-27.4*
MCV-112* MCH-38.4* MCHC-34.3 RDW-17.8* RDWSD-73.7* Plt Ct-38*
___ 05:42AM BLOOD ___ PTT-35.2 ___
___ 05:42AM BLOOD Glucose-81 UreaN-10 Creat-1.0 Na-135
K-4.1 Cl-102 HCO3-25 AnGap-8*
___ 05:42AM BLOOD ALT-20 AST-43* AlkPhos-107* TotBili-2.2*
Brief Hospital Course:
___ year old female with a history of HCV/EtOH cirrhosis
complicated HCC, ascites, and refractory encephalopathy status
post BRTO of large IMV shunt (___), embolization of
portosystemic shunt and TIPS (___), and TIPS reduction
(___), NSCLC in remission (s/p CyberKnife radiotherapy
(___), ___ esophagus, depression and HTN, presenting
with N/V abdominal pain and increased abdominal distension.
RUQ US showed TIPS in place with occlusion of the mid and distal
portions unchanged from prior with moderate ascites. We then did
a therapeutic paracentesis draining 1.2 L and gave 100 g of
albumin. Additionally gave lactulose to help with constipation.
Abdominal pain slowly resolved after paracentesis and bowel
movements.
Pt had evidence ___ with creatinine jumping from baseline of
0.9-1.2 so initially held her home diuretic medications. ___ was
prerenal and once creatinine normalized we restarted home
diuretic medications.
=======================
TRANSITIONAL ISSUES:
=======================
___
- Follow up: Please check electrolytes and adjust diuretics as
needed
- Tests required after discharge: Check electrolytes at PCP
___ on ___
- Incidental findings: None
OTHER ISSUES:
- Hemoglobin prior to discharge: 9.4
- Cr at discharge: 1.0
- Antibiotic course at discharge: None
# CONTACT:
___ ___
# CODE: Assumed full code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
2. Furosemide 40 mg PO DAILY
3. HydrOXYzine 50 mg PO DAILY:PRN itching, sleep
4. Lactulose 45 mL PO QID
5. Magnesium Oxide 400 mg PO BID
6. Pantoprazole 40 mg PO Q24H
7. PARoxetine 40 mg PO DAILY
8. rifAXIMin 550 mg PO BID
9. Spironolactone 100 mg PO DAILY
10. Ciprofloxacin HCl 500 mg PO DAILY
11. Simethicone 120 mg PO QID bloating
12. Ondansetron 4 mg PO BID:PRN Nausea/Vomiting - First Line
13. vit A-vit C-vit E-zinc-copper ___ unit-mg-unit
oral DAILY
14. Meclizine 12.5 mg PO BID:PRN vertigo
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 capsule(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) [Vitamin B-1] 100 mg one tablet(s)
by mouth once a day Disp #*30 Tablet Refills:*0
4. Vitamin D 1000 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 2,000 unit one capsule(s) by
mouth every other day Disp #*30 Tablet Refills:*0
5. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
6. Ciprofloxacin HCl 500 mg PO DAILY
7. Furosemide 40 mg PO DAILY
8. HydrOXYzine 50 mg PO DAILY:PRN itching, sleep
9. Lactulose 45 mL PO QID
10. Magnesium Oxide 400 mg PO BID
11. Meclizine 12.5 mg PO BID:PRN vertigo
12. Ondansetron 4 mg PO BID:PRN Nausea/Vomiting - First Line
13. Pantoprazole 40 mg PO Q24H
14. PARoxetine 40 mg PO DAILY
15. rifAXIMin 550 mg PO BID
16. Simethicone 120 mg PO QID bloating
17. Spironolactone 100 mg PO DAILY
18. vit A-vit C-vit E-zinc-copper ___ unit-mg-unit
oral DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Abdominal distention secondary to constipation and buildup of
ascites
Discharge Condition:
Mental status at baseline A/O x3. Abdominal distention improved
since admission with return to baseline weight.
Discharge Instructions:
Dear ___,
___ was a pleasure caring for you during your admission to ___!
Below you will find information regarding your stay.
WHY WAS I ADMITTED TO THE HOSPITAL?
-You were admitted to the hospital for increasing abdominal
pain and distention.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
-We got an imaging study of your liver which was unchanged from
prior studies. Additionally, we also drained some 1.2 L of
fluid of your stomach. Lastly, we gave some medications to help
with your constipation.
WHAT SHOULD I DO WHEN I GO HOME?
-Please stick to a low salt diet and monitor your fluid intake
-Take your medications as prescribed
-Keep your follow up appointments with your primary care
doctor, transplant social worker and liver doctor
___ you for letting us be a part of your care!
Your ___ Care Team
Followup Instructions:
___
|
10225793-DS-41 | 10,225,793 | 23,126,553 | DS | 41 | 2134-11-06 00:00:00 | 2134-11-06 17:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / IV Dye, Iodine Containing Contrast Media / aspirin
/ metronidazole / eggplant
Attending: ___.
Chief Complaint:
abdominal pain, fever
Major Surgical or Invasive Procedure:
Diagnostic Paracentesis ___
Therapeutic Paracentesis ___
History of Present Illness:
___ year old woman with HCV/EtOH cirrhosis c/b ascites,
refractory
encephalopathy s/p BRTO and TIPS, prior SBP, and OPTN5B lesion
in
liver segment VIII coming in with abdominal distension,
decreased
appetite, headache and fever.
She reports that her distention started last ___ but got
much worse on ___ and has been progressively getting worse.
She also reports abdomen pain mostly across the top of her
stomach. She states that she has been adherent to her diuretics
and has been urinating a lot. She drinks about 3.2L of water per
day. She does not use salt at all when cooking. Because of the
worsening distension her appetite has been poor and she cannot
eat in the morning due to nausea and vomiting. She generally
won't eat anything until 1pm and has only been able to take down
vegetable juice, protein rinks and pickle juice (only a
tablespoon or two per day). On ___ night she had a fever to
___ associated with chills. She reports ___ headache that
feels similar to her prior migraines that has not been improving
with APAP. She states that in the past fioricet has helped her.
Denies any recent intake of alcohol or drugs. She denies any leg
swelling. She also endorses SOB with exertion that gets worse
when her abdomen is distended. She was advised by PCP to be seen
today.
On arrival to the floor, she endorses the above. Her headache
improved a little with fioricet but is requesting something else
for pain. She currently denies any other symptoms.
Past Medical History:
Past Medical History:
1. Hepatitis C s/p interferon treatment with SVR
2. Cirrhosis (HCV, possibly ETOH), complicated by:
-- HCC
-- ascites
-- refractory hepatic encephalopathy s/p BRTO of large IMV shunt
___, embolization of portosystemic shunt and TIPS ___
3. Lung cancer in remission (___ Stage I, s/p CyberKnife
stereotactic body
radiotherapy ___
4. ___ esophagus
5. Depression
6. Hypertension
7. Obesity
8. S/p abdominoplasty and cholecystectomy
9. Unspecified colitis, on mesalamine in the past
Social History:
___
Family History:
Mother died aged ___ with an acute MI, and also had a history of
emphysema. Father died aged ___ secondary to a stroke. Brother
died secondary to GI bleed secondary to "hepatitis". Sister died
of overdose. Two other siblings murdered.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 98.1F, 123 / 73, HR84, RR 18, 100% RA
GENERAL: NAD, laying flat in no respiratory distress
HEENT: AT/NC, EOMI, PERRL, icteric sclera, pink conjunctiva, MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: distended but not tense, tender to palpation diffusely
but worse in the epigastric region associated with rebound
tenderness, ecchmyosis on abdomen
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose, CN II-XII
intact, no meningismus, bilateral tremor in both hands but no
asterixis
DISCHARGE PHYSICAL EXAM
=======================
VS: T 98.0, BP 113/72, HR 76, RR 18, O2 97% on RA
GENERAL: well-appearing female in NAD, lying flat in no
respiratory distress
HEENT: AT/NC, EOMI, icteric sclera, pink conjunctiva, MMM
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: soft, less distended, nontender to palpation in all
four quadrants, no rebound/guarding ecchmyosis on abdomen
EXTREMITIES: 1+ edema b/l. no cyanosis, clubbing
SKIN: eccymoses diffusely throughout
NEURO: A&Ox3, moving all 4 extremities with purpose, bilateral
tremor in both hands but no asterixis
Pertinent Results:
ADMISSION LABS
==============
___ 03:57PM BLOOD WBC-6.5 RBC-2.64* Hgb-10.1* Hct-30.9*
MCV-117* MCH-38.3* MCHC-32.7 RDW-19.2* RDWSD-82.8* Plt Ct-49*
___ 03:57PM BLOOD Neuts-76.9* Lymphs-9.8* Monos-12.3
Eos-0.3* Baso-0.2 Im ___ AbsNeut-5.03 AbsLymp-0.64*
AbsMono-0.80 AbsEos-0.02* AbsBaso-0.01
___ 03:57PM BLOOD ___ PTT-30.1 ___
___ 03:57PM BLOOD Glucose-98 UreaN-15 Creat-1.1 Na-133*
K-5.2 Cl-99 HCO3-20* AnGap-14
___ 03:57PM BLOOD ALT-25 AST-70* AlkPhos-114* TotBili-6.3*
___ 03:57PM BLOOD Albumin-4.0 Calcium-9.4 Phos-2.3* Mg-2.1
___ 03:57PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-7*
Tricycl-NEG
___ 04:01PM BLOOD Lactate-2.3*
___ 11:34PM BLOOD Lactate-1.6
PERTINENT LABS
==============
___ 05:15AM BLOOD Ret Aut-4.4* Abs Ret-0.09
___ 05:15AM BLOOD ALT-14 AST-29 LD(LDH)-217 AlkPhos-71
TotBili-2.7* DirBili-0.9* IndBili-1.8
___ 05:15AM BLOOD Hapto-<10*
MICRO
=====
___ 06:15PM ASCITES TNC-1039* RBC-504* Polys-60* Lymphs-0
Monos-4* Mesothe-7* Macroph-29*
___ 06:15PM ASCITES TotPro-0.7 Glucose-106
___ 6:15 pm PERITONEAL FLUID PERITONEAL.
GRAM STAIN (Final ___:
3+ ___ 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, if
applicable.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
___ 03:36PM URINE RBC-1 WBC-8* Bacteri-FEW* Yeast-NONE
Epi-6 ___ BCx NGTD
IMAGING
=======
___ RUQUS
1. Moderately limited study due to overlying bowel gas and poor
sonographic penetration.
2. No flow is seen within the TIPS and flow is reversed in the
left portal
vein, similar in appearance to prior ultrasound from ___ and
consistent with occlusion of the TIPS.
3. Cirrhotic liver with large volume ascites.
DISCHARGE LABS
==============
___ 05:37AM BLOOD WBC-1.5* RBC-2.04* Hgb-7.9* Hct-23.8*
MCV-117* MCH-38.7* MCHC-33.2 RDW-18.5* RDWSD-78.6* Plt Ct-42*
___ 05:37AM BLOOD ___ PTT-35.4 ___
___ 05:37AM BLOOD Glucose-72 UreaN-8 Creat-0.8 Na-140 K-4.5
Cl-105 HCO3-22 AnGap-13
___ 05:37AM BLOOD ALT-14 AST-35 AlkPhos-68 TotBili-2.7*
___ 05:37AM BLOOD Albumin-4.2 Calcium-9.6 Phos-2.7 Mg-2.0
Brief Hospital Course:
SUMMARY
=======
Ms. ___ is a ___ year old woman with HCV/EtOH cirrhosis c/b
ascites, hepatic encephalopathy s/p BRTO and TIPS, prior SBP on
cipro ppx, and HCC s/p ablation, who presented with abdominal
distension and fever found to have SBP treated with 5 days of
ceftriaxone with plan for Bactrim ppx, also c/b migraine
headaches.
ACTIVE ISSUES
=============
#SBP
#DECOMPENSATED ETOH CIRRHOSIS
MELD 25, Child C on admission. Presenting with worsening
abdominal distension and fever, found to have SBP. Imaging does
show a proximal occlusion of her TIPS though this is not new.
Patient has history of SBP on cipro ppx as outpatient, which she
has been compliant with. Treated with SBP protocol with albumin
x2 doses and a full 5 day course of Ceftriaxone 2 g IV q24hrs
(___). Started Bactrim DS daily for SBP ppx as patient
failed cipro ppx. Held diuretics during admission iso infection,
restarted on discharge. Continued home PPI, lactulose,
rifaximin, and nutritional supplementation during admission.
#Headache/migraine
Reported headache on presentation with similar symptoms to prior
migraines. No meningismus and neurologic exam is non-focal. Had
been receiving fioricet, now likely re-presenting with rebound
headaches. Should follow-up with PCP outpatient regarding
migraine headaches.
#Pancytopenia
Patient currently pancytopenic with history of intermittently
becoming pancytopenic. Likely occurs in setting of active
infection as well as liver disease. Bactrim ppx was started day
prior to discharge to ensure tolerance given bone marrow
suppression side effects, tolerated well with no change in cell
counts. Please recheck CBC at ___ visit on ___.
Can consider outpatient Hematology consultation.
CHRONIC ISSUES
==============
#Depression
Patient continued on home PARoxetine 40 mg PO DAILY.
#Insomnia
Patient continued on home HydrOXYzine PRN for sleep
TRANSITIONAL ISSUES:
[] Discharge WBC: 1.5
[] Discharge HGB: 7.9
[] Discharge PLT: 42
[] Discharge INR: 1.9
[] Discharge Tbili: 2.7
[] Please recheck labs at ___ visit on ___: CBC,
Chem-10, and LFTs.
[] Please consider outpatient workup for headaches. Likely
rebound headaches given fioricet use. Consider preventive
migraine treatment, though should avoid NSAIDs given
thrombocytopenia.
[] Patient with pancytopenia during admission likely in setting
of acute infection and liver disease. Has intermittently
recovered numbers in the past. Could consider outpatient
Hematology consultation if remains persistently low.
[] Had SBP while on cipro ppx; switched to Bactrim ppx prior to
discharge. Should ensure bone marrow suppression does not occur.
[] Should discuss outpatient therapeutic paracentesis schedule
with patient to ensure that they are at the appropriate time
interval to prevent re-admissions.
# CODE: Presumed FULL
# CONTACT: ___, daughter/HCP, ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
2. Ciprofloxacin HCl 500 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Lactulose 30 mL PO TID
5. Magnesium Oxide 400 mg PO BID
6. Multivitamins 1 TAB PO DAILY
7. Pantoprazole 40 mg PO Q24H
8. PARoxetine 40 mg PO DAILY
9. rifAXIMin 550 mg PO BID
10. Vitamin D 1000 UNIT PO DAILY
11. Thiamine 100 mg PO DAILY
12. Simethicone 120 mg PO QID:PRN bloating
13. Ondansetron 4 mg PO BID:PRN Nausea/Vomiting - First Line
14. Meclizine 12.5 mg PO BID:PRN vertigo
15. HydrOXYzine 50 mg PO DAILY:PRN itching, sleep
16. Furosemide 40 mg PO DAILY
17. Spironolactone 100 mg PO DAILY
18. vit A-vit C-vit E-zinc-copper ___ unit-mg-unit
oral DAILY
Discharge Medications:
1. Sulfameth/Trimethoprim DS 1 TAB PO/NG DAILY
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth once a day Disp #*30 Tablet Refills:*0
2. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
3. FoLIC Acid 1 mg PO DAILY
4. Furosemide 40 mg PO DAILY
5. HydrOXYzine 50 mg PO DAILY:PRN itching, sleep
6. Lactulose 30 mL PO TID
7. Magnesium Oxide 400 mg PO BID
8. Meclizine 12.5 mg PO BID:PRN vertigo
9. Multivitamins 1 TAB PO DAILY
10. Ondansetron 4 mg PO BID:PRN Nausea/Vomiting - First Line
11. Pantoprazole 40 mg PO Q24H
12. PARoxetine 40 mg PO DAILY
13. rifAXIMin 550 mg PO BID
14. Simethicone 120 mg PO QID:PRN bloating
15. Spironolactone 100 mg PO DAILY
16. Thiamine 100 mg PO DAILY
17. vit A-vit C-vit E-zinc-copper ___ unit-mg-unit
oral DAILY
18. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
Spontaneous Bacterial Peritonitis
Ascites
SECONDARY DIAGNOSES
Alcoholic/Hepatitis C Cirrhosis
Migraine Headaches
Pancytopenia
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 because you had abdominal pain
and fever.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You had fluid removed from your abdomen. This fluid showed an
infection.
- You received antibiotics for the infection.
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Keep your follow up appointments with your doctors
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight changes by more
than 3 pounds
- Please stick to a low salt diet and monitor your fluid intake
- If you experience any of the danger signs listed below please
call your primary care doctor or come to the emergency
department immediately.
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team
Followup Instructions:
___
|
10225793-DS-45 | 10,225,793 | 22,812,527 | DS | 45 | 2135-01-24 00:00:00 | 2135-01-25 16:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / IV Dye, Iodine Containing Contrast Media / aspirin
/ metronidazole / eggplant
Attending: ___.
Chief Complaint:
nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
PARACENTESIS
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
==============================
___ is a ___ year old female with history of HCV/ETOH
cirrhosis c/b refractory ascites, HE s/p BRTO and TIPS
(occluded), SBP on bactrim ppx, HCC s/p RFA, and ___
esophagus who is presenting with nausea, abdominal pain, and
inability to tolerate PO. Patient states that for the past ___
days she has had nausea and dry heaves that have prevented her
from eating, drinking, and taking her medications. She took her
temperature at home using a temporal thermometer and had
temperatures ranging from 99-104 at home. She also has had
increasing abdominal pain during this time. At baseline, she has
chronic diffuse abdominal pain and this has worsened to a sharp
diffuse pain over the past few days. She presented for her
weekly
paracentesis today where 7.5 liters were removed and she
received
albumin resuscitation. It was recommended that she present to
the
ED after her paracentesis due to her increasing abdominal pain,
nausea, and inability to tolerate PO.
In the ED initial vitals: T 97.3 HR 93 BP 146/50 RR 16 SpO2 100%
RA
- Exam notable for:
Constitutional: Mildly uncomfortable
HEENT: Sclera icterus. Oropharyx without mucosal lesions
Resp: CTABL
CV: RRR, no murmur
Abd: Diffuse mild ttp and distension. Left dressing in place
from
paracentesis.
- Labs notable for:
H/H 7.8/25.1
Chem7: Na 133 K 4.9 HCO3 17 BUN 23 Cr 1.5
LFTs: ALT 23 AST 41 ALP 116 Tbili 3.2 Dbili 1.0
Coags: INR 1.9
Para fluid studies negative for SBP
- Imaging notable for:
RUQUS - occluded TIPS, possible minimal flow in proximal aspect.
Patent main portal vein. Cirrhotic liver w/sequela of portal
hypertension (recanalized paraumbilical vein, mild splenomegaly
and small volume ascites).
L ___ - no DVT
CXR - no acute abnormality
- Consults:
Hepatology - recommend holding diuretics iso ___, RUQUS with
dopplers, low threshold for empiric abx, admit to ET under
___
- Patient was given:
IV Morphine Sulfate 4 mg
IV Ondansetron 4 mg
IV Morphine Sulfate 2 mg
On arrival to the floor, patient endorses diffuse abdominal pain
that is improved after administration of morphine in the ED. She
endorses subjective fevers and chills, dry cough, and nausea.
Denies chest pain, shortness of breath, vomiting, diarrhea,
dysuria, melena or BRBPR. She states that she has been having
___
BMs daily with lactulose. Of note, she has had multiple
hospitalizations for similar presentations, detailed below in
___.
Past Medical History:
Past Medical History:
1. Hepatitis C s/p interferon treatment with SVR
2. Cirrhosis (HCV, possibly ETOH), complicated by:
-- HCC
-- ascites
-- refractory hepatic encephalopathy s/p BRTO of large IMV shunt
___, embolization of portosystemic shunt and TIPS ___
3. Lung cancer in remission (___ Stage I, s/p CyberKnife
stereotactic body
radiotherapy ___
4. ___ esophagus
5. Depression
6. Hypertension
7. Obesity
8. S/p abdominoplasty and cholecystectomy
9. Unspecified colitis, on mesalamine in the past
Social History:
___
Family History:
Mother died aged ___ with an acute MI, and also had a history of
emphysema. Father died aged ___ secondary to a stroke. Brother
died secondary to GI bleed secondary to "hepatitis". Sister died
of overdose. Two other siblings murdered.
Physical Exam:
ADMISSION PHYSICAL EXAM
=========================
VS: ___ 0052 Temp: 97.8 PO BP: 137/75 HR: 87 RR: 18 O2 sat:
100% O2 delivery: Ra
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, ___ systolic murmur heard best at apex
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: distended, diffusely TTP, no rebound or guarding, LLQ
para site with dressing d/c/I +fluid wave
EXTREMITIES: trace pitting ___ edema bilaterally
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose, mild
asterixis, able to perform DOYB
SKIN: warm and well perfused, multiple ecchymoses on bilateral
upper extremities
DISCHARGE PHYSICAL EXAM
=========================
24 HR Data (last updated ___ @ 1144)
Temp: 98.4 (Tm 98.4), BP: 149/71 (132-149/63-82), HR: 91
(80-93), RR: 16 (___), O2 sat: 99% (94-100), O2 delivery: RA,
Wt: 207.5 lb/94.12 kg
GENERAL: NAD, lying in bed
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, ___ systolic murmur heard best at apex
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: distended, diffuse, mild, TTP, no rebound or guarding,
LLQ para site with dressing d/c/I +fluid wave
EXTREMITIES: trace pitting ___ edema bilaterally
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose, mild
asterixis, able to perform DOYB
SKIN: warm and well perfused, multiple ecchymoses on bilateral
upper extremities
Pertinent Results:
ADMISSION LABS:
=================
___ 05:36PM BLOOD WBC-2.3* RBC-2.09* Hgb-7.8* Hct-25.1*
MCV-120* MCH-37.3* MCHC-31.1* RDW-18.5* RDWSD-81.8* Plt Ct-45*
___ 05:36PM BLOOD Neuts-62.8 Lymphs-18.4* Monos-17.1*
Eos-0.9* Baso-0.4 Im ___ AbsNeut-1.43* AbsLymp-0.42*
AbsMono-0.39 AbsEos-0.02* AbsBaso-0.01
___ 06:02PM BLOOD ___ PTT-35.2 ___
___ 05:36PM BLOOD Glucose-106* UreaN-23* Creat-1.5* Na-133*
K-4.9 Cl-101 HCO3-17* AnGap-15
___ 05:36PM BLOOD ALT-23 AST-41* AlkPhos-116* TotBili-3.2*
DirBili-1.0* IndBili-2.2
___ 05:36PM BLOOD Albumin-4.7 Calcium-10.1 Phos-3.1 Mg-2.4
DISCHARGE LABS:
=================
___ 06:55AM BLOOD WBC-1.7* RBC-2.04* Hgb-7.6* Hct-22.6*
MCV-111* MCH-37.3* MCHC-33.6 RDW-20.9* RDWSD-83.1* Plt Ct-40*
___ 04:30AM BLOOD Neuts-53.8 ___ Monos-18.6*
Eos-3.2 Baso-0.5 AbsNeut-1.01* AbsLymp-0.44* AbsMono-0.35
AbsEos-0.06 AbsBaso-0.01
___ 06:55AM BLOOD ___ PTT-39.4* ___
___ 06:55AM BLOOD Glucose-71 UreaN-15 Creat-1.0 Na-136
K-5.2 Cl-105 HCO3-21* AnGap-10
___ 06:55AM BLOOD ALT-14 AST-34 AlkPhos-79 TotBili-4.2*
___ 06:55AM BLOOD Albumin-4.4 Calcium-9.6 Phos-2.4* Mg-2.2
PERTINENT IMAGING:
===================
RUQUS
IMPRESSION:
Limited study due to patient body habitus and overlying bowel
gas. Within
these confines:
1. No substantial change in occlusion of the TIPS, with possible
minimal flow
within the proximal aspect. Patent main portal vein.
2. Cirrhotic liver, with sequela of portal hypertension,
including a
recanalized paraumbilical vein, mild splenomegaly, and small
volume ascites.
Brief Hospital Course:
BRIEF HOSPITAL SUMMARY:
==========================
Ms. ___ is a ___ year old female with history of HCV/ETOH
cirrhosis complicated by refractory ascites, HE s/p BRTO and
TIPS (occluded), SBP on bactrim ppx, HCC s/p RFA, and ___
esophagus, chronic abdominal pain who is presenting with
abdominal pain, reported fever at home, nausea, and inability to
tolerate PO. She had a LVP on ___ with 7.5L fluid removal and
was administered albumin. She quickly reported recurrent
abdominal distention and underwent second LVP on ___ with 4L
fluid removal. She will likely need twice weekly abdominal
paracentesis as it was thought her abdominal pain was due to
rapid ascites re-accumulation. She is currently not listed for
transplant due to ongoing social issues/lack of support at home.
She had ___ as well that was thought to be pre-renal in etiology
that improved with albumin.
TRANSITIONAL ISSUES:
=====================
NEW/CHANGED/STOPPED MEDICATIONS:
- Held home spironolactone 150mg daily given hyperkaelmia
- Started vitamin K 5mg PO daily challenge x 3 days (end date
___
DISCHARGE WEIGHT: 94.12kg 207.5lbs
DISCHARGE DIURETIC: Lasix 20mg daily
DISCHARGE CR: 1.0
[ ] Patient will need to be arranged for twice weekly
paracentesis, instead of weekly
[ ] At hepatology follow-up will need to be re-arranged for MRI
Liver W&WO contrast for HCC screening given she missed this
while she was inpatient
[ ] Continue to encourage low sodium diet
[ ] Can consider palliative care as an outpatient given not a
transplant candidate and worsening refractory ascites
ACTIVE ISSUES
=============
# Abdominal pain - History of HCV/EtOH cirrhosis complicated by
refractory ascites requiring weekly LVP presenting with
worsening abdominal pain. She underwent LVP on ___ with 7.5L
fluid removal without evidence of SBP and was administered
albumin. She quickly reported recurrent abdominal distention and
underwent second LVP on ___ with 4L fluid removal. She will
likely need twice weekly abdominal paracentesis as it was
thought her abdominal pain was due to rapid ascites
re-accumulation and also non-adherence to low sodium diet.
Remainder of infectious work-up was negative. RUQUS showed no
substantial change in occlusion of TIPS which is chronic and
with patent main portal vein. Nutrition was consulted for low
sodium diet education. She was treated with tylenol and PO
tramadol:PRN for pain. She is currently not listed for
transplant due to ongoing social issues/lack of support at home.
# ___ - Baseline Cr 0.8-1, presented with Cr 1.5. Cr improved
with albumin challenge and albumin s/p LVP and down-trended
prior to discharge. Her home spironolactone was discontinued on
discharge given borderline hyperkalemia. Her diuretic regimen
was restarted at furosemide 20mg qdaily as above.
# HCV/ETOH cirrhosis - HCV/ETOH cirrhosis complicated by
refractory ascites, HE s/p BRTO and TIPS (occluded), SBP on
bactrim ppx. MELD 24. Not currently on the transplant list due
to lack of social support, although these conversations are
ongoing given her poor quality of life and multiple
readmissions.
- Volume: Will require twice weekly ___ paracenteses, holding
home spironolactone and continuing home lasix 20mg daily
- Infection: History of SBP, on Bactrim ppx
- Bleeding: History of varices s/p BRTO ___ and TIPS
___. Last EGD was ___ which was negative for varices.
- Hepatic encephalopathy: History in past, no current evidence
on this admission, though has not been having BMs at goal, on
lactulose 30mL TID and rifaximin 550mg BID
- Screening: ___ s/p RFA. Had MRI scheduled on ___ that will
need to be re-arranged given she was inpatient
CHRONIC ISSUES
==============
# Pancytopenia - Stable, chronic in setting of cirrhosis.
# Depression - Continued on home PARoxetine 40 mg PO DAILY.
# Vertigo - On home Meclizine 12.5 mg PO BID:PRN vertigo
# ___ esophagus - Continued on home Pantoprazole 40 mg PO
Q24H
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
2. FoLIC Acid 1 mg PO DAILY
3. HydrOXYzine 50 mg PO DAILY:PRN itching, sleep
4. Lactulose 30 mL PO TID
5. Meclizine 12.5 mg PO BID:PRN vertigo
6. Ondansetron 4 mg PO BID:PRN Nausea/Vomiting - First Line
7. Pantoprazole 40 mg PO Q24H
8. PARoxetine 40 mg PO DAILY
9. rifAXIMin 550 mg PO BID
10. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
11. Thiamine 100 mg PO DAILY
12. Zinc Sulfate 220 mg PO DAILY
13. Furosemide 60 mg PO DAILY
14. Magnesium Oxide 400 mg PO BID
15. PreserVision AREDS (vitamins A,C,E-zinc-copper)
___ unit-mg-unit oral DAILY
16. Spironolactone 150 mg PO DAILY
17. Gabapentin 100 mg PO BID
Discharge Medications:
1. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
3. FoLIC Acid 1 mg PO DAILY
4. Gabapentin 100 mg PO BID
5. HydrOXYzine 50 mg PO DAILY:PRN itching, sleep
6. Lactulose 30 mL PO TID
7. Magnesium Oxide 400 mg PO BID
8. Meclizine 12.5 mg PO BID:PRN vertigo
9. Ondansetron 4 mg PO BID:PRN Nausea/Vomiting - First Line
10. Pantoprazole 40 mg PO Q24H
11. PARoxetine 40 mg PO DAILY
12. PreserVision AREDS (vitamins A,C,E-zinc-copper)
___ unit-mg-unit oral DAILY
13. rifAXIMin 550 mg PO BID
14. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
15. Thiamine 100 mg PO DAILY
16. Zinc Sulfate 220 mg PO DAILY
17. HELD- Spironolactone 150 mg PO DAILY This medication was
held. Do not restart Spironolactone until as directed by your
hepatologist
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
=====================
Acute on chronic abdominal pain
SECONDARY DIAGNOSIS:
====================
HCV/EtOH cirrhosis
___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___ ,
It was a privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
- You were admitted to the hospital he complains of nausea
vomiting and abdominal pain
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
-You had a paracentesis that did not show any evidence of SBP
-You abdominal pain was treated with tylenol and tramadol
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- You will be arranged for twice weekly paracentesis
- Please continue to take all your medications and follow up
with your doctors at your ___ appointments.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
- Please continue to adhere to a low salt diet
We wish you all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10225793-DS-6 | 10,225,793 | 27,095,914 | DS | 6 | 2127-09-10 00:00:00 | 2127-09-10 15:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / IV Dye, Iodine Containing Contrast Media / aspirin
Attending: ___
Chief Complaint:
Abdominal pain
Confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old male with history of HCV and etOH
cirrhosis, previously on interferon/ribavirin but discontinued
due to toxicity, presented to the ED complaining of two weeks of
transverse low back pain, pain up the flank, and RUQ pain. She
described some SOB without cough or wheeze, subjective fevers,
and nausea. She denied vomiting, diarrhea, sick contacts. She
also denied any urinary complaints including dysuria, frequency,
or hematuria. There was no urinary or bowel incontinence,
weakness or numbness in the legs. Some family members endorsed
some mild confusion. She was on lactulose and rifaximin at home,
but reported that she had ran out of medication recently, and
went without lactulose for 4 days.
Her pain in the lower back was described as sharp, ___, with no
modifiers that she could think of. It was not relieved by home
oxycodone. Her flank pain was described as a cramping sensation.
Finally, her RUQ tenderness was similarly ___ with no
modifiers.
In the ED, she was afebrile with stable vital signs. A CXR was
performed for the SOB which noted a normal heart size with mild
interstitial edema only. A CT-urogram did not demonstrate and
hydronephrosis or nephrolithiasis.
Past Medical History:
1.) Hepatitis C infection: first first diagnosied ___ years ago.
Unsure how this was contracted. Husband was an IV drug user
with confirmed hepatitis C and patient has tattoo history.
Patient also has a Blood transfusion history in ___, but none
prior to this. Received interferon with ribavirin x 10 months ___
years go, but reportedly failed. Unclear what type of failure
this was. Genotype 1b. No known history of varices, with last
normal EGD on ___. No ascites. Has had elevated ammonia in
the past, treated with prior history of HE. Was previously
followed by Dr. ___ in ___ with liver ultrasounds
every 6 months and EGD's annually. Patient was seen in liver
clinic in ___, when she was noted to have positive ___,
positive smooth muscle antibody, AFP 11.1 and IgG ___.
2.) ___ disease (normal egd/path ___: past clinic
notes describe chronic nausea, vomiting and abdominal pain
secondary to gastritis
3.) Hypertension
4.) Depression: stopped her own meds 3 weeks ago; no current or
5.) abdominoplasty: ___ (per ___ notes, ___ per
patient)
6.) broken leg repair: right ankle fracture long ago
7.) Cholecystectomy: long time ago
8.) liver biopsy ___ years ago (cirrhosis)
Social History:
___
Family History:
No history of liver disease. Addiction to alcohol and drugs
runs in her family, with both parents and four other siblings
affected.
Physical Exam:
Physical exam on admission:
VS - Temp 97.9 F, BP 160/80, HR 61, R 20, O2-sat 98 % RA
GENERAL - obese female NAS
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - mildly TTP RUQ, epigastrum, bs nl, no
masses/organomegaly
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&OxBI, self, ___
Physical exam on discharge:
VS: T98.1 BP 110s-130s/50s-60s P60s-70s R18 96%RA 3BMs
Gen: NAD, female appearing of stated age
HEENT: NCAT, mild scleral icterus, MMM
Neck: supple, no LAD, trachea midline
Pulm: breath sounds in all lung fields, though decreased air
movement most likely secondary to reduced effort. No crackles,
wheezes, or rhonchi noted.
Abd: Large, non-distended abdomen, soft without peritoneal signs
or rebound. RUQ tenderness to superficial and deep palpation.
Flank pain not reproducible by palpation. No CVAT.
Extrem: 1+ ___ edema, non-pitting
MSK: paraspinal tenderness to deep palpation, improved
Neuro: no asterixis today, able to perform days of wk forwards
and backwards today
Pertinent Results:
Lab results on admission:
___ 07:30PM BLOOD WBC-2.8* RBC-3.47* Hgb-12.5 Hct-37.1
MCV-107* MCH-36.0* MCHC-33.7 RDW-15.1 Plt Ct-71*
___ 07:30PM BLOOD Neuts-57.2 ___ Monos-8.5 Eos-3.1
Baso-0.5
___ 07:30PM BLOOD ___ PTT-36.4 ___
___ 07:30PM BLOOD Glucose-108* UreaN-8 Creat-0.7 Na-139
K-3.6 Cl-109* HCO3-24 AnGap-10
___ 07:30PM BLOOD ALT-35 AST-67* AlkPhos-97 TotBili-1.5
___ 07:30PM BLOOD Lipase-65*
___ 07:30PM BLOOD proBNP-110
___ 07:30PM BLOOD Albumin-3.4*
Lab results on discharge:
___ 05:25AM BLOOD WBC-2.7* RBC-3.40* Hgb-12.2 Hct-36.6
MCV-108* MCH-35.9* MCHC-33.4 RDW-15.2 Plt Ct-65*
___ 05:25AM BLOOD ___
___ 05:50AM BLOOD Glucose-90 UreaN-9 Creat-0.8 Na-137 K-3.5
Cl-103 HCO3-29 AnGap-9
___ 05:25AM BLOOD ALT-31 AST-58* AlkPhos-94 TotBili-1.3
___ 05:25AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.0
___ 07:10AM BLOOD TSH-2.0
___ 09:55PM URINE Color-Yellow Appear-Clear Sp ___
___ 09:55PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-SM
___ 09:55PM URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-1
CT Abd (___): No evidence of nephrolithiasis. Mild sigmoid
diverticulosis without diverticulitis. Cirrhosis with
splenomegaly. No ___ noted.
CXR (___): Normal heart size with mild interstitial edema. No
bone lesions.
RUQ U/S (___): Cirrhotic liver without focal lesions. Patent
portal veins. Splenomegaly.
Micro:
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
The patient is a ___ year old female with history of HCV/EtOH
cirrhosis, s/p failed Ribavirin/interferon tx ___ toxicity, who
presented with lower back, flank, and RUQ pain and confusion.
Acute issues:
# Back/Flank/RUQ Pain: Reported two weeks of lower back and
flank pain with no modifiable features. Was initially concerned
for musculoskeletal back pain, nephrolithiasis, biliary stone,
pancreatitis, pneumonia, and zoster. Patient denied any recent
heavy lifting or bending, but did report a lot of housework
recently. She denied urinary symptoms (dysuria, hematuria,
frequency), CVAT and CTU was negative for stone. There was no
vesicular rash in dermatomal distribution, nor was there
exquisite pain on light tough. Patient's lipase was mildly
elevated, but she had no other clinical signs of pancreatitis
including vomiting. There were no clinical signs of pneumonia
(cough, fever) and CXR was negative. A RUQ ultrasound was
performed and no biliary stones were identified. Imaging of her
spine showed no osteous lesions or fractures. Her Back pain
seemed most consistent with musculoskeletal pain given worsening
with palpation and paraspinal lower back distribution. Given
that all RUQ studies had remained negative, pain was likely
secondary to discomfort from hepatitis. The patient was started
on a trial of Flexeril 5mg BID and lidocaine patch to lower
back. Back pain seemed to improve on this therapy. After
discussion with Dr. ___ was thought that the RUQ pain was
most consistent with the chronic pain of hepatitis given no
acute sources for the pain were identified. The patient was
continued on her home pain control along and the patient was
monitored for signs and symptoms of infection.
# Confusion: Mildly confused on admission, difficulty with
attention-related tasks, had only mild asterixis. Reported
missing doses of lactulose during which her family reports
increased the confusion. It was thought this was hepatic
encephalopathy. She was continued on home lactulose and
rifaximin, and any sedating medications were held. Her mental
status improved significantly with lactulose administration and
achieving ___ bowel movements per day. She was also started on
MiraLax as well to help with moving her bowels.
# SOB: Patient reports increased SOB for past two weeks, started
with pain. CXR was un revealing, no fevers while she was
inpatient, and there was no cough or sputum production. On exam,
there was no wheezing, crackles, or dullness. The SOB was
thought to be secondary to abdominal pain. With improvement of
her pain during the course of the hospitalization, the SOB
resolved as her pain became better controlled.
Chronic Issues:
# Cirrhosis: The patient had a history of EtOH and HCV
cirrhosis. She attempted Ribavirin/interferon treatment, but had
toxic side effects in ___ which included severe colitis.
After this episode, she was taken off the protocol.
# Hypertension: The patient has chronic HTN, treated with
atenolol. This was continued during her stay.
# Depression/anxiety: The patient had been chronically treated
for depression, and on home dose bupropion and fluoxetine. This
was continued throughout the stay.
Transitional Issues:
1. Pt has a follow up appointment w/ both her PCP and
gastroenterologist following this discharge
2. there are no pending microbiology studies at time of
discharge
Medications on Admission:
- atenolol 50 mg PO daily
- bupropion HCl 200 mg PO daily
- fluoxetine 60 mg PO daily
- furosemide 20 mg PO daily
- lactulose 15 mL by mouth three times daily
- oxycodone 5 mg PO q6 prn pain
- pantoprazole 40 mg PO daily
- potassium chloride 20 mEq PO daily
- rifaximin 550 mg PO bid
Discharge Medications:
1. Atenolol 50 mg PO DAILY
2. BuPROPion 200 mg PO DAILY
3. Fluoxetine 60 mg PO DAILY
4. Lactulose 15 mL PO TID
please take enough lactulose in order to achieve ___ bowel
movements per day
5. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
6. Pantoprazole 40 mg PO Q24H
7. Potassium Chloride 20 mEq PO DAILY
8. Rifaximin 550 mg PO BID
9. Furosemide 60 mg PO DAILY
hold for sbp < 90
RX *furosemide 20 mg 3 Tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
10. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 packet by mouth daily
Disp #*30 Packet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Hepatitis C cirrhosis
Hepatic encephalopathy
Muscle strain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted to the hospital with lower back, side, and
abdominal pain on your right side. Your family members also
thought you might be more confused than usual. In the hospital,
we did several tests including a CT scan of your abdomen, chest
xray, and ultrasound. We did not find any kidney stones,
gallstones, infections, pneumonia, liver tumors ___
fractures that could be causing the pain you are experiencing.
Your back pain was most likely just muscle strain and your belly
pain was related to your liver disease. You should continue to
exercise daily in order to help your back pain. You may need
physical therapy in the future which your primary care physician
can help you arrange. Finally, we believe your initial confusion
was because of the buildup of toxins in your blood caused by
your liver disease. We treated this with lactulose and rifaximin
which you should continue to take while at home to prevent
confusion. Please take enough lactulose in order to achieve ___
bowel movements per day.
The following changes have been made to your medications:
INCREASE Furosemide to 60mg daily
START Miralax daily to help you have ___ soft bowel movements
daily
Followup Instructions:
___
|
10225793-DS-8 | 10,225,793 | 23,052,044 | DS | 8 | 2127-11-30 00:00:00 | 2127-12-05 16:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / IV Dye, Iodine Containing Contrast Media / aspirin
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Cerebral angiogram
History of Present Illness:
___ yr old female pt with hx of liver cirrhosis and hepatitis
C, who presented today with worsening headaches since this
morning, she has hx of migraines, but she stated that this
headache is different, is very severe and throbbing thoughout
her
head associated with nausea, but no vomiting, she denied any
weakness or seizures. she was evaluated by neurology who
requested brain MRI that showed questionable brain aneurysm
Past Medical History:
1.) Hepatitis C infection: first first diagnosied ___ years ago.
Unsure how this was contracted. Husband was an IV drug user
with confirmed hepatitis C and patient has tattoo history.
Patient also has a Blood transfusion history in ___, but none
prior to this. Received interferon with ribavirin x 10 months ___
years go, but reportedly failed. Unclear what type of failure
this was. Genotype 1b. No known history of varices, with last
normal EGD on ___. No ascites. Has had elevated ammonia in
the past, treated with prior history of HE. Was previously
followed by Dr. ___ in ___ with liver ultrasounds
every 6 months and EGD's annually. Patient was seen in liver
clinic in ___, when she was noted to have positive ___,
positive smooth muscle antibody, AFP 11.1 and IgG ___.
2.) ___ disease (normal egd/path ___: past clinic
notes describe chronic nausea, vomiting and abdominal pain
secondary to gastritis
3.) Hypertension
4.) Depression: stopped her own meds 3 weeks ago; no current or
5.) abdominoplasty: ___ (per ___ notes, ___ per
patient)
6.) broken leg repair: right ankle fracture long ago
7.) Cholecystectomy: long time ago
8.) liver biopsy ___ years ago (cirrhosis)
Social History:
___
Family History:
No history of liver disease. Addiction to alcohol and drugs
runs in her family, with both parents and four other siblings
affected.
Pertinent Results:
___ CT head: There is no intracranial hemorrhage, edema, or
mass effect. The gray-white matter differentiation is
preserved. Ventricles and sulci demonstrate mild atrophic
change. The visualized paranasal sinuses and mastoid air cells
are clear.
___ Liver Us:The liver demonstrates coarsened echotexture,
but no focal lesion or intrahepatic biliary dilatation. Trace
amounts of perihepatic ascites are present. The portal vein is
patent with directionally appropriate flow. Views of the
pancreatic head and body are normal, but the pancreatic tail is
obscured by overlying bowel gas.
The CBD measures 5 mm in caliber.
___ MRA head and neck: No acute infarct, mass effect, or
hydrocephalus on brain MRI. MRA of the head demonstrates no
vascular occlusion, stenosis, or an aneurysm greater than 3 mm
in size. Although the preliminary report was provided of
aneurysms on the MRA, no distinct aneurysms are seen. MRA of
the neck is limited by delayed acquisitions and contrast within
the veins of the neck. No vascular occlusion seen, but
evaluation for stenosis could not be performed.
___ Cerebral angiogram:
Evaluation is limited by motion.
Preliminary ReportEvaluation is also limited due to tortuosity
of the vessels and the left Preliminary Reportvertebral artery
could not be fully catheterized. Hence, the catheter was
Preliminary Reportplaced at the origin of the left vertebral
artery and hand injections were
Preliminary Reportperformed. No 3D injection of the left
vertebral artery could be performed.
Preliminary ReportLimited evaluation of the left vertebral
artery demonstrates no definite
Preliminary Reportaneurysm or vascular malformation. The right
vertebral artery could not be Preliminary Reportcatheterized due
to severe tortuosity and patient motion.However, a CT
Preliminary Reportangiogram is recommended to exclude subtle
abnormality.
Preliminary ReportEvaluation of the right common carotid artery
and left common carotid artery Preliminary Reportdemonstrates no
definite evidence of aneurysm in the intracranial circulation.
Preliminary ReportHowever, the study is limited by motion.
Ammonia
___ 03:57 79*
Brief Hospital Course:
Ms. ___ was evaluated in the emergency room in consultation
and was subsequently admitted to the Neurosurgery service for
workup of her severe headache.
The morning after her admission, the patient was evaluated and
found to be somewhat lethargic, with speech delay and expressive
aphasia. She was transferred to the intensive care unit for
closer monitoring.
She underwent a cerebral angiogram after being pre medicated for
her contrast allergy. Cerebral angiogram was negative for an
underlying aneurysm.
Her amonia level returned slightly elevated, she was seen by her
Gastroeneterologist,given several doses of lactulose and
discharged home with follow up instructions.
Medications on Admission:
Medications - Prescription
ATENOLOL - atenolol 50 mg tablet
1 Tablet(s) by mouth daily
BUPROPION HCL - (Prescribed by Other Provider) - bupropion HCl
100 mg tablet
2 Tablet(s) by mouth daily
FLUOXETINE - fluoxetine 20 mg capsule
3 Capsule(s) by mouth daily
FUROSEMIDE - furosemide 20 mg tablet
1 Tablet(s) by mouth once a day
LACTULOSE - lactulose 10 gram/15 mL Oral Soln
15 mL by mouth three times daily Titrate to ___ stools daily.
Hold if more tahn 4 stools a day.
ONDANSETRON HCL - ondansetron HCl 4 mg tablet
1 tablet(s) by mouth tid prn
OXYCODONE - oxycodone 5 mg tablet
1 Tablet(s) by mouth q 6 hours prn for pain
PANTOPRAZOLE - pantoprazole 40 mg tablet,delayed release
1 Tablet(s) by mouth once a day
POTASSIUM CHLORIDE [KLOR-CON M20] - Klor-Con M20 20 mEq
tablet,extended release
1 Tablet(s) by mouth once a day
RIFAXIMIN [XIFAXAN] - Xifaxan 550 mg tablet
550 mg Tablet(s) by mouth twice a day
Discharge Medications:
1. Atenolol 50 mg PO DAILY
2. BuPROPion 200 mg PO BID
3. Fluoxetine 60 mg PO DAILY
4. Furosemide 20 mg PO DAILY
5. Lactulose 30 mL PO TID
Titrate to ___ BMs daily. ___ MD if change in mental status.
RX *lactulose 10 gram/15 mL 30 grams by mouth three times a day
Disp #*300 Fluid Ounce Refills:*1
6. Pantoprazole 40 mg PO Q24H
7. Rifaximin 550 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Hepatic encephalopathy
Hep C
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with Embolization and/or Stent placement
Dr. ___
___ 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
What to report to office:
Changes in vision (loss of vision, blurring, double vision,
half vision)
Slurring of speech or difficulty finding correct words to use
Severe headache or worsening headache not controlled by pain
medication
A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
Trouble swallowing, breathing, or talking
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call ___ for transfer to closest
Emergency Room!
Followup Instructions:
___
|
10225882-DS-4 | 10,225,882 | 24,656,116 | DS | 4 | 2178-01-16 00:00:00 | 2178-01-19 17:11:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
-Thoracentesis
-Paracentesis
-Pleurex Catheter Placement.
History of Present Illness:
The patient is a ___ year old male with PMHx HTN and recently
diagnosed follicular lymphoma who presents with dyspnea.
The patient has been undergoing workup of lymphoma since ___
when he developed night sweats and weight loss. He started
noting increase in abdominal girth in ___, which progressed to
include DOE as well. Imaging showed ascites, pleural effusion,
and diffuse LAD. On ___, he had a paracentesis with 3L
removed. He was admitted to ___ on ___ for expedited
workup given his symptoms. During that admission, he underwent
a lymph node biopsy w/ Dr. ___ on ___, and on ___ had
ultrasound-guided paracentesis done of 2300 mL and a
thoracentesis was done of 1200 mL. He was seen by Dr. ___
___ Oncology with plans for follow up visit next week to discuss
the results of the biopsies. He was sent home on lasix 20mg
daily which he has been taking. Since his discharge though, he
has felt increasingly unwell, with fatigue, worsening shortness
of breath, and increased abdominal girth since then as well. He
has had persistent leg edema as well, left greater than right -
an ultrasound during his last admission was negative for DVT.
He initially presented to ___ where CXR showed large pleural
effusion. He was initially hypotensive which improved after
1LNS, then he was transferred to ___ for further workup.
In the ED, initial VS were: 97.3 100 117/67 24 99%. Labs showed
leukocytosis to 13, Cr of 1.3, lactate of 2.6. ABG showed
7.41/40/343/26. He was given 1 additional liter NS,
ceftriaxone/azithromycin as pneuomnia could not be excluded,
nebs, and was placed on CPAP which gave him marked improvement
in his respiratory status. On transfer, vitals were systolic
105, RR 24, O2 100% on NIVVP, 86.
On arrival to the MICU, patient's VS.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies shortness of breath, cough, dyspnea or
wheezing. Denies chest pain, chest pressure, palpitations.
Denies constipation, abdominal pain, diarrhea, dark or bloody
stools. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
1. Hypertension.
2. Depression.
3. Migraine.
4. Bladder dysfunction.
5. Laminectomy
6. Arthroscopy
7. Sinus reconstruction
8. Varicocele
Social History:
___
Family History:
NC
- Father: ___ cancer
- Sister: ___ cancer
- No history of lymphoma or immune disorders
Physical Exam:
Admission Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Discharge Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Left lung reduced air entry to mid-chest. Left pleurex
catheter in place. right lung clear to air entry with reduced
air entry at the lung base.
Abdomen: distended, no leakage at paracentesis sites, bowel
sounds present, no organomegaly, no tenderness to palpation, no
rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis.
Mild edema bilaterally, left worse than right.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Pertinent Results:
Admission Labs:
___ 02:40AM BLOOD WBC-13.4* RBC-4.70 Hgb-13.3* Hct-42.6
MCV-91 MCH-28.3 MCHC-31.2 RDW-16.2* Plt ___
___ 02:40AM BLOOD Neuts-72.8* ___ Monos-6.7 Eos-1.0
Baso-0.7
___ 02:40AM BLOOD ___ PTT-26.9 ___
___ 02:40AM BLOOD Glucose-97 UreaN-23* Creat-1.3* Na-136
K-4.3 Cl-100 HCO3-22 AnGap-18
___ 02:40AM BLOOD ALT-12 AST-31 LD(LDH)-244 AlkPhos-73
TotBili-0.5
___ 02:40AM BLOOD Lipase-35
___ 02:40AM BLOOD Albumin-3.5 Calcium-8.8 Phos-3.2 Mg-2.1
UricAcd-6.3
___ 03:01AM BLOOD Lactate-2.6*
___ 05:18AM BLOOD Type-ART Temp-36.7 PEEP-5 FiO2-100
pO2-343* pCO2-40 pH-7.41 calTCO2-26 Base XS-1 AADO2-336 REQ
O2-61 Intubat-NOT INTUBA
Interim Labs:
___ 02:40AM BLOOD Triglyc-274*
___ 02:40AM BLOOD HBsAb-PND
___ 02:40AM BLOOD b2micro-PND
Ascites:
___ 01:59PM ASCITES ___ RBC-4000* Polys-3*
Lymphs-95* Monos-2*
___ 01:59PM ASCITES TotPro-2.8 Glucose-91 Creat-1.1
LD(LDH)-108 Albumin-2.2 Triglyc-379
___ 01:59PM OTHER BODY FLUID IPT-PND
___ 04:48PM BONE MARROW ___
Discharge Labs:
___ 06:10AM BLOOD WBC-8.0 RBC-4.22* Hgb-12.0* Hct-37.6*
MCV-89 MCH-28.5 MCHC-32.0 RDW-16.8* Plt ___
___ 06:06AM BLOOD Neuts-74.6* Lymphs-14.7* Monos-6.4
Eos-3.4 Baso-0.9
___ 06:10AM BLOOD Plt ___
___ 06:10AM BLOOD ___ PTT-30.0 ___
___ 06:10AM BLOOD ___
___ 06:10AM BLOOD
___ 06:10AM BLOOD Glucose-98 UreaN-18 Creat-1.0 Na-138
K-4.4 Cl-104 HCO3-27 AnGap-11
___ 06:10AM BLOOD ALT-11 AST-18 LD(___)-137 AlkPhos-49
TotBili-0.2
___ 06:10AM BLOOD Calcium-8.7 Phos-4.4 Mg-2.1 UricAcd-5.5
___ 03:00PM PLEURAL WBC-5040* RBC-9900* Polys-7* Lymphs-81*
Monos-4* Meso-5* Macro-3*
___ 04:45PM PLEURAL WBC-4075* ___ Polys-4*
Lymphs-84* ___ Macro-12*
___ 03:00PM PLEURAL Glucose-126 Creat-1.1 LD(LDH)-122
Triglyc-75
___ 04:45PM PLEURAL TotProt-2.9 Glucose-144 LD(___)-93
Albumin-2.3 Cholest-53 Triglyc-62
___ 03:44PM ASCITES WBC-83___* RBC-3167* Polys-6* Lymphs-85*
Monos-2* Mesothe-1* Macroph-3* Other-3*
___ 09:06AM ASCITES WBC-6125* ___ Polys-4* Lymphs-4*
___ Mesothe-1* Macroph-1* Other-90*
___ 01:59PM ASCITES ___ RBC-4000* Polys-3*
Lymphs-95* Monos-2*
___ 03:44PM ASCITES TotPro-2.4 Glucose-107 LD(LDH)-99
Albumin-1.9
___ 09:06AM ASCITES TotPro-2.5 Glucose-163 Creat-1.1
LD(___)-84 Amylase-29 TotBili-0.2 Albumin-2.1
___ 01:59PM ASCITES TotPro-2.8 Glucose-91 Creat-1.1
LD(LDH)-108 Albumin-2.2 Triglyc-379
___ 01:59PM OTHER BODY FLUID CD23-DONE CD45-DONE
___ CD10-DONE CD19-DONE CD20-DONE Lamba-DONE
CD5-DONE
___ 01:59PM OTHER BODY FLUID CD3-DONE
___ 01:59PM OTHER BODY FLUID IPT-DONE
___ 04:48PM BONE MARROW ___
Microbiology:
___ 1:59 pm PERITONEAL FLUID
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary):
ANAEROBIC CULTURE (Preliminary):
HBV Viral Load (Final ___:
HBV DNA not detected.
Blood and urine cultures pending
.
___ 3:44 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Imaging:
___ TTE:
Conclusions
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). The estimated cardiac
index is high (>4.0L/min/m2). Right ventricular chamber size and
free wall motion are normal. 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 no mitral valve prolapse. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Mild
pulmonary artery hypertension. Dilated ascending aorta. No
pericardial effusion. Bilateral pleural effusions.
___ LENIs:
IMPRESSION: No evidence of DVT in the right or left leg.
Enlarged lymph
nodes in the inguinal regions bilaterally.
___ CXR:
IMPRESSION:
1. Stable large left pleural effusion and small right pleural
effusion.
2. Atelectasis at the left base
___ Bone Marrow Biopsy
SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY:
DIAGNOSIS:
Hypercellular bone marrow with extensive involvement by
follicular lymphoma
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear:
The smear is adequate for evaluation. Red blood cells are
normochromic and normocytic with anisopoikilocytosis including
frequent burr cells, occasional elliptocytes, and macrocytes are
seen. Rare nuclear RBC's are seen. The white blood cell count
appears normal. A subset of lymphocytes are atypical and
display a cleaved nuclear morphology. Platelet count appears
normal and giant forms are not seen. Differential shows 74%
neutrophils, 8% monocytes, 17% lymphocytes, 1% eosinophils.
Aspirate Smear:
The aspirate material is suboptimal for evaluation due to
paucity of spicules. M:E ratio is 2:1. Erythroid precursors
are normal in number and exhibit dyspoietic forms with
irregular nuclear contours, asymmetric nuclear budding. Myeloid
precursors appear normal in number and show normal maturation.
Occasional abnormal nuclear lobation and pseudo Pelger Huët
forms are seen. Megakaryocytes are present in normal; abnormal
forms are seen including several hypolobated forms,
micromegakaryocytes, forms with disjointed nuclei. Small
cleaved lymphocytes are seen; no large lymphoid cells are seen.
A 500 cell differential shows: 1% Blasts, 2% Promyelocytes,
6% Myelocytes, 5% Metamyelocytes, 30% Bands/Neutrophils, 1%
Plasma cells, 35% Lymphocytes, 20% Erythroid.
Clot Section and Biopsy Slides:
The core biopsy material is adequate for evaluation. It
consists of a 0.9 cm core biopsy, trabecular marrow with a
cellularity of over 90%. Approximately 70% of marrow
cellularity is comprised of atypical lymphocytes with scant
cytoplasm and irregularly shaped nuclei; focal areas (<10%) of
larger cells (centroblasts) with more open chromatin and
nucleoli are seen. In the remaining cellularity, M:E ratio
estimate is normal. Erythroid precursors exhibit overall
normoblastic maturation. Myeloid precursors have complete
maturation to neutrophilic stage. Megakaryocytes are present
and are loosely clustered focally.
ADDITIONAL STUDIES:
Flow cytometry: See separate report - shows involvement by
Follicular lymphoma.
___ Peritoneal fluid cytology
Peritoneal fluid:
ATYPICAL.
Numerous monomorphic small atypical lymphocytes.
___ Peritoneal Fluid flow Cytometry
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: ___, FMC-7,
Kappa, Lambda, and CD antigens 3, 5, 10, 19, 20, 23, 45.
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize blast/lymphocyte yield.
Lymphoid cells comprise 83% of total analyzed events.
B cells comprise 66% of lymphoid gated events and have a slight
Kappa predominance (Kappa gain). They co-express pan B-cell
markers CD19, 20, along with CD10, FMC-7. They do not express
any other characteristic antigens including CD5, CD23.
T cells comprise 28% of lymphoid gated events and express mature
lineage antigens (CD3, CD5).
INTERPRETATION
Immunophenotypic findings consistent with involvement by
follicular lymphoma. Correlation with clinical findings and
morphology (see ___ is recommended.
___ Pleural fluid cytology
Pleural fluid:
Numerous lymphoid cells. Please also see corresponding
flow cytometry report (___).
Mesothelial cells and macrophages are also present.
___ Cytogenetics
KARYOTYPE:
nuc ish(MYCx2)[100],(IGH@,BCL2)x4(IGH@ con BCL2x3)[78/100]
Culture of this peritoneal fluid did not yield metaphase
cells for analysis, therefore the chromosome analysis could
not be performed.
FISH analyses of interphase nuclei with the IGH@/BCL2 and
MYC probes were interpreted as ABNORMAL for the IGH@/BLC2
probes, consistent with rearrangement of these loci with an
additional fusion signal seen. The MYC probe hybridization
was interpreted as normal. Please see below for details of
the FISH analyses.
FISH DETAILS:
FISH evaluation for an IGH@-BCL2 rearrangement was
performed on nuclei with the LSI IGH@/BCL2 Dual Color,
Dual Fusion Translocation Probe ___ Molecular) for
IGH@ at 14q32 and BCL2 at 18q21 and is interpreted as
ABNORMAL. Rearrangement was observed in 78/100 nuclei,
which exceeds the normal range (up to 1%) established for
these probes in the Cytogenetics Laboratory at ___. An
additional fusion signal was seen in all abormal cells.
IGH@-BCL-2 rearrangement is a typical cytogenetic
aberration in a subset B-cell lineage non-Hodgkin's
lymphoma of follicular center cell origin.
FISH evaluation for a MYC rearrangement was performed on
nuclei with the LSI MYC Dual Color Break Apart
Rearrangement Probe ___ Molecular) at 8q24 and is
interpreted as NORMAL. No rearrangement was observed in
100/100 nuclei, which is within the normal range
established for this probe in the Cytogenetics Laboratory
at ___. Up to 4% of cells in normal samples can show
apparent MYC rearrangement using this probe set. A normal
MYC FISH finding can result from absence of a MYC
rearrangement, from an atypical MYC rearrangement, or from
an insufficient number of neoplastic cells in the
specimen.
These FISH tests were developed and their performance
determined by the ___ Cytogenetics Laboratory as
required by the ___ ___ regulations. They have not been
cleared or approved by the ___. Food and Drug
Administration. The FDA has determined that such clearance
or approval is not necessary. These tests are used for
clinical purposes.
This study was necessary for the analysis
of this specimen.
This study was necessary for the analysis
of this specimen.
This study was necessary for the analysis
of this specimen.
This study was necessary for the analysis
of this specimen.
___ Immunophenotyping
FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: ___, FMC-7,
Kappa, Lambda, and CD antigens 3,5,10,19,20,23,45.
RESULTS
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield.
Lymphoid cells comprise 1% of total analyzed events.
B cells are scant in number precluding evaluation of clonality.
Within the monocytoid cell / large cell gate, there is a small
population of CD10 positive events, which shows dim CD20 gain
(an artifact cannot be excluded). These events do not express
CD19. In addition, they do not have light chain (bright)
expression.
T cells comprise 80% of lymphoid gated events,and express mature
lineage antigens CD3,CD5).
INTERPRETATION:
Diagnostic immunophenotypic features of involvement by B cell
lymphoma are not seen in specimen. Correlation with clinical
findings is recommended. Flow cytometry immunophenotyping may
not detect all lymphomas due to topography, sampling or
artifacts of sample preparation.
___ Paracentesis
Uneventful diagnostic and therapeutic paracentesis with removal
of 4 liters of milky ascitic fluid.
___ CXR
In comparison with study of ___, there has been placement of a
left Pleurx catheter with removal of substantial amount of
pleural fluid. No definite pneumothorax. Atelectatic changes
persist at the bases and there is mild blunting of the right
costophrenic angle.
Brief Hospital Course:
___ y/o male with new diagnosis of follicular lymphoma who p/w
dyspnea, found to have recurrent large pleural effusion.
.
ACTIVE ISSUES:
.
# Respiratory distress - The likely cause of his respiratory
distress is the large left pleural effusion, which is likely due
to lymphoma. He also had significant ascites causing increased
diaphragmatic pressure. Paracentesis successfully removed 2L of
fluid and relieved his breathing, although he remained on oxygen
support. Thoracentesis was performed on ___ with about 1.2L of
fluid removal; no antibiotics were initiated. One Light's
criteria was met but was borderline (Pleural fluid protein /
Serum protein >0.5), likely c/w exudate ___ lymphoma. Given the
rapid reaccumulation of fluid from malignant etiology (confirmed
by flow cytometry of pleural fluid), the patient needed more
definitive therapy either via initiation of treatment for
lymphoma or eradication of pleural space. He subsequently
received treatment with bendamustine and rituximab as below, but
continued to reaccumulate pleural effusions requiring recurrent
thoracentesis. We eventually decided to place a left-sided
pleurx catheter to allow frequent drainage of his malignant
pleural effusions.
.
# Lymphoma - Paracentesis from ___ showed cells c/w
follicular lymphoma, his lymph node biopsy was also c/w
follicular lymphoma. CT torso from ___ showed substantial
lymphadenopathy throughout the abdomen. He was initiated on
dexamethasone ___ for a planned 4 day course. Tumor lysis labs
were followed and the patient was provided aggressive hydration.
Allopurinol was also provided to avoid hyperuricemia. Provided
acyclovir to prevent HSV reactivation, particularly given
history of post-herpetic neuralgia in legs. Bone marrow biopsy
performed ___ was consistent with follicular lymhpoma. The
patient was transferred to the Oncology service with the
intention of initiating chemotherapy, and started on
bendamustine as well as rituximab. On first receiving
rituximab, he developed a bas reaction, with tachycardia,
hypertension and rigors. Infusion was stopped. The patient was
temporarily transferred to the intensive care unit to receive
rituximab via a 24 hour desensitization protocol. During the
desensitization, he had a mild episode of tightness in his chest
with no decrease on O2 saturation. He improved with nebilizers
and was able to be transferred back to floor immediately after
the infusion. He did however, continue to rapidly reaccumulate
both pleural effusions and ascites, with multiple thoracenteses
and paracenteses, and eventual placement of a pleurx catheter as
above. He will followup with Dr. ___ Dr. ___
further care as an outpatient.
# Ascites: Malignant ascites consistent with follicular
lymphoma. He underwent three diagnostic and therapeutic
paracenteses during his hospital stay, the first two on the
floor and the third with ___ and removal of 4L ascitic
fluid. He will need to followup for furtehr therapeutic
paracenteses.
# Lower extremity edema (L>R) - ultrasound of the LLE (BID
___ showed no DVT. On exam he has L>R lymphadenopathy. CT
showed massive abdominal and pelvic lymphadenopathy that likely
caused venous compression leading to asymmetric edema. Repeat
RLE USS also showed no evidence of DVT. His inguinal
lymphadenopathy and lower extremity edema had improved somewhat
following chemotherapy.
.
#Paroxysmal AVT - Patient had multiple episodes of SVT to the
170s during his time in the FICU. He complained only of
palpitations and remained hemodynamically stable. He broke
spontaneously and did not require vagal maneuvers or
pharmacologic agents. The patient had experienced these
episodes at home as well, however they had become more frequent
since his admission to ___ and initiation of chemo. He was
started on a low dose of metoprolol 12.5mg bid in an attempt to
suppress these episodes.
.
# Hypertension - Patient was hypotensive on initial presentation
to ___ which improved with fluids. He was normotensive on
transfer to ___.
.
Transitional Issues:
- He ___ require close outpatient followup with Drs ___
___ for ongoing management of his follicular lymphoma.
He will also need to followup with interventional pulmonology
for management of his pleurx catheter and recurrent pleural
effusions. Dr. ___ will also arrange for recurrent
therapeutic paracenteses as needed.
Medications on Admission:
Allopurinol ___ mg daily
Diovan daily
Lipitor 20 mg daily
Lasix 20mg daily
ProAir as needed
multivitamin
magnesium
B12
fish oil
Discharge Medications:
1. allopurinol ___ mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*0*
2. Lipitor 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*90 Tablet(s)* Refills:*0*
3. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. ProAir HFA 90 mcg/actuation HFA Aerosol Inhaler Sig: One (1)
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
Disp:*qs * Refills:*0*
5. multivitamin Capsule Sig: One (1) Capsule PO once a day.
6. Fish Oil 300 mg Capsule Oral
7. cyanocobalamin (vitamin B-12) Oral
8. escitalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
9. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) for 30 days.
Disp:*qs Tablet(s)* Refills:*0*
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
12. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
13. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Disp:*14 Tablet, Rapid Dissolve(s)* Refills:*0*
14. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: 1.5 Tablet Extended Release 24 hrs PO once a day.
Disp:*45 Tablet Extended Release 24 hr(s)* Refills:*2*
15. oxycodone 5 mg Capsule Sig: ___ Capsules PO every ___ hours
as needed for pain: do not take if drowsy. Do not drive or
operate heavy machinery while taking this medication.
Disp:*10 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Follicular Lymphoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted with shortness of
breath and abdominal distension from fluid accumulating in your
abdomen and lungs due to follicular lymphoma. We performed
multiple taps to drain the fluid from your lungs and abdomen,
and placed a catheter in your left chest to allow frequent
drainage of the pleural effusions. Analysis of the fluid was
consistent with follicular lymphoma, and no other malignant or
infectious process was identified.
While you were here, we also treated you with bendamustine and
rituximab. You initially developed a reaction to rituximab, but
subsequently underwent uneventful desensitization in the ICU.
Please followup with Drs. ___ following
discharge, for ongoing management of your follicular lymphoma.
During your hospitalization, you had a number of episodes of a
fast heart rate. We started you on medication (metoprolol) to
slow down your heart. Please continue taking this medication
following discharge.
We made the following changes to your medications:
STOPPED
-Valsartan
STARTED
-Escitalopram for anxiety
-Acyclovir and Bactrim to prevent infections
-Metoprolol for blood pressure and heart rate
-Senna and Sodium Docusate to help move your bowels
-Ondansetron for nausea
Please continue taking your other medications as usual.
Followup Instructions:
___
|
10225882-DS-5 | 10,225,882 | 28,998,553 | DS | 5 | 2178-01-24 00:00:00 | 2178-01-24 16:58:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: ___ yo M with a recently diagnosed low grade, stage IV
follicular lymphoma with large abdominal mass causing lymphatic
obstruction and chylothorax, now C1D13 R-Bendamustine with
decrease in palpable LAD but recurrent ascites/pleural effusion
requiring pleurex pigtail catheter placement now presenting with
increasing dyspnea, abdominal distention over the last ___
hours.
He was seen in clinic on ___ and c/o pain at pleurex catheter
site. He was evaluated by thoracics and advised not to use the
catheter over the weekend. Last drainage of 800cc last ___.
He has not had fever, chills.
In ER: (Triage Vitals: 97.8 83 126/80 18 97% RA) Meds Given: IV
hydromorphone, Radiology Studies: CXR.
Past Medical History:
Oncological History:
- ___ Developed NS
- ___ Developed abdominal swelling
- ___ Developed DOE, worsening abdominal swelling
- ___ CT torso showed diffuse lymphadenopathy, bilateral
pleural effusions, ascites, nodal disease
- diagnosed w/ stage IV (bone marrow involvement), low grade
follicular lymphoma with massive abdominal LAD causing lymphatic
obstruction with chylous accumulation in the abdomen and pleural
space.
Other PMH:
1. Hypertension.
2. Depression.
3. Migraine.
4. Bladder dysfunction.
5. Laminectomy
6. Arthroscopy
7. Sinus reconstruction
8. Varicocele
Social History:
___
Family History:
- Father: ___ cancer
- Sister: ___ cancer
- No history of lymphoma or immune disorders
Physical Exam:
VS 97.3 114/72 72 20 96%RA
GEN: AAOx3, NAD
HEENT: PERRLA, EOMI, MMM, no thrush, no OP erythema or lesions
NECK: supple, no LAD, no JVD
___: RRR, no m/r/g
LUNGS: reg resp rate, breathing unlabored, no accessory muscle
use, decreased bs at bilateral bases, L>R; no overlying crackles
or wheeze
ABD: soft, distended, full flanks, NT, NABS
ext: 2+ pulses, no c/c/e
Skin: no rashes
neuro: CN ___ intact, strength and sensation intact
Pertinent Results:
___ 05:40AM BLOOD WBC-5.7 RBC-4.04* Hgb-11.6* Hct-36.6*
MCV-91 MCH-28.7 MCHC-31.6 RDW-17.7* Plt ___
___ 05:40AM BLOOD Glucose-75 UreaN-9 Creat-0.9 Na-141 K-4.2
Cl-107 HCO3-27 AnGap-11
___ 05:40AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.3
___ CTA of the Chest
1. No evidence of pulmonary embolism.
2. Bilateral pleural effusions, both moderate to large in size
with a Pleurx catheter within the left-sided effusion.
3. Extensive conglomerates of lymphadenopathy involving the
retroperitoneal space as well as the base of the mesentery
extending down to the iliacs. Additional lymphadenopathy within
bilateral inguinal and pelvic regions.
Brief Hospital Course:
___ yo M with a recently diagnosed low grade, stage IV follicular
lymphoma with large abdominal mass causing lymphatic obstruction
and chylothorax, recurrent ascites/pleural effusion requiring
pleurex pigtail catheter placement now presenting with
increasing dyspnea.
# Follicular Lymphoma
Treated with second dose of rituxan on ___, requiring FICU
transfer for desensitization given his reaction to the chemo on
previous admission. He tolerated the chemotherapy well and was
discharged home with plan to have next cycle of bendamustine as
an outpatient.
# Dyspnea
CXR shows enlarged pleural effusions, particularly on the left
side. Pleurex catheter was drained 1L on admission with
improvement in dyspnea. Patient remained comfortable throughout
hospitalization. He was discharged with plan to have pleurex
drained as an outpatient.
Medications on Admission:
acyclovir 400mg tid
albuterol MDI
allopurinol ___ mg daily
atorvastatin 20mg qhs
Vit B12
escitalopram 20mg daily
furosemide 20mg daily
metoprolol XL 37.5 mg daily
TMP-SMX SS daily
MVI
Omega-3
ondansetron prn
oxycodone ___ mg q 6 hours prn
senna
Discharge Medications:
1. allopurinol ___ mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. ProAir HFA 90 mcg/actuation HFA Aerosol Inhaler Sig: One (1)
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Fish Oil 300 mg Capsule Sig: One (1) Capsule PO once a day.
7. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet
PO DAILY (Daily).
8. escitalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
12. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: 1.5 Tablet Extended Release 24 hrs PO once a day.
14. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4
hours) as needed for pain.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Lymphoma
Pleural effusions
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted to the hospital to receive your next dose of
Rituxan, which you tolerated well in our ICU. You also had some
chest pain and trouble breathing which is likely related to your
fluid in your lungs. Your catheter was also drained.
No medication changes.
Followup Instructions:
___
|
10225882-DS-6 | 10,225,882 | 26,131,392 | DS | 6 | 2178-09-03 00:00:00 | 2178-09-04 11:28:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain/fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ y/o male with h/o stage IV follicular lymphoma
with large abdominal mass causing recurrent ascites/pleural
effusion requiring pleurex pigtail catheter placement who
presented with chest pain and low grade fever. Patient had
pleurax cath placed on ___ by IP. He states that he
generally has "aches and pains", while yesterday everything felt
out of "whack". He had increased pain radiating down left side
of neck, pain in left chest when taking a deep breath and also
felt as if the catheter was coming out the top of left lung when
taking a deep breath. Overnight pt was up with ? reflux, which
pt was putting down to overindulgence during ___. Today pt
drained plreural cath and noted to have clots which he has not
experienced before, pt also noted to have temp 100.3. He notes
that he has chills and nightsweats which he attributed to his
lymphoma.
In the ED, initial VS were: 98.9 87 156/94 18 96%RA. Patient was
given a dose of levofloxacin due to concern for pneumonia. IP
was contacted but did not see the patient. They felt that the
pluerex was unlikely to be causing his symptoms. He had a CT
which showed minnimally increased small to moderate sized left
pleural effusion and adjacent atelectasis with left pleural
catheter in similar position.
On arrival to the floor, the patient was comfortable and in NAD.
Patient states that he has chronic pain and that his body
typically feels as if it had a bad sunburn.
REVIEW OF SYSTEMS:
(+) see HPI
(-) headache, vision changes, rhinorrhea, congestion, sore
throat, shortness of breath, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
- HTN
- Depression
- Migraine
- Bladder dysfunction
- Stage IV follicular lymphoma with large abdominal mass causing
lymphatic obstruction and chylothorax and ascites
Continued pleural effusions requiring pigtail ___ and
intermittent drainage.
- ___ C1 R-bendamusitine
- ___ Additional dose of rituximab
- ___ C2 R-bendamustine
- ___ C3 R-Bendamustine
- ___ C4 R-bendamustine
- ___ C5 R-bendamustine
- ___ C6 R-bendamustine
PSX:
- Laminectomy
- arthroscopy
- sinus reconstruction
Social History:
___
Family History:
mother ___, father alive at ___,
bladder cancer, sister with ___ meningitis, unknown type of
cancer
Physical Exam:
On admission:
VS - Temp F98.5, BP 131/79, HR 75, 98 O2-sat % RA
GENERAL - patient appeared comfortable and in NAD
HEENT - MMM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS - decreased breath sounds at the left lung base, no
wheezes or rhonchi appreciated, pleurex catheter site appeared
c/d/i
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/some diffuse tenderness to palpation/ND, no
masses or HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Pertinent Results:
On admission:
___ 05:30PM BLOOD WBC-10.8# RBC-4.98 Hgb-15.0 Hct-44.3
MCV-89 MCH-30.2 MCHC-33.9 RDW-12.9 Plt ___
___ 05:30PM BLOOD Neuts-83.9* Lymphs-5.1* Monos-8.0 Eos-2.7
Baso-0.4
___ 06:00AM BLOOD ___ PTT-32.7 ___
___ 05:30PM BLOOD Glucose-91 UreaN-14 Creat-1.2 Na-139
K-4.3 Cl-106 HCO3-20* AnGap-17
___ 05:30PM BLOOD cTropnT-<0.01
___ 06:00AM BLOOD Calcium-9.5 Phos-3.6 Mg-2.1
___ 05:38PM BLOOD Lactate-1.3
CXR ___:
Small left pleural effusion with overlying atelectasis. Patchy
left base
retrocardiac opacity may relate to a combination of pleural
effusion and
atelectasis, but underlying consolidation is not excluded.
CTA ___:
Brief Hospital Course:
Mr. ___ is a ___ y/o male with h/o stage IV follicular lymphoma
with large abdominal mass causing recurrent ascites/pleural
effusion requiring pleurex pigtail catheter placement who
presented with chest pain and low grade fever.
# Chest Pain: Concern for pneumonia given low grade fever
however not evident on CT scan. Patient denies having worsening
cough and WBC count is within normal limits. He appears to be
having symptoms related to the pleurex catheter however IP did
not feel that his symptoms were consistent. As far as other
etiologies for chest pain two sets of cardiac enzymes were
negative. CT scan did not show evidence of PE. Antibiotics were
held as patient was not febrile. IP evaluated patient and
recommended having pleurex set to continues suction. Pleural
fluid was sent for analysis and gram stain showed polymicrobial
infection and he was started on empiric
vancomycin/cefepime/flagyl. Culture grew out 2 colonies of strep
viridans sensitive to penicillin and he was transitioned to
Augementin. He was given oxycodone for pain control. He will
complete a 3 week course of antibiotics as an outpatient and
follow up with IP.
# Fever: Patient had a fever of 100.3 at home but has been
afebrile since admission. With chest pain, concern for pneumonia
therefore given a dose of levofloxacin in the ED however as
described above not evident on CT scan. Antibiotis were
initially held but started after IP drained R lung effusion and
culture was notable for strep viridans. He did not have a fever
during admission.
# Stage IV Follicular Cancer: Patient appears to be doing well
from this standpoint and is followed by Dr. ___ as an
outpatient. He is not receving any active treatment.
# Baldder Dysfunction: stable on current regimen. Continued home
oxybutynin.
Transitions of Care:
1.Pt will follow up with IP for further management of pleurex
catheter and antibiotic course.
2.He declined home services.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Metoprolol Succinate XL 37.5 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Escitalopram Oxalate 20 mg PO DAILY
4. oxybutynin chloride *NF* 5 mg Oral daily
5. Fish Oil (Omega 3) 300 mg PO DAILY
6. Docusate Sodium 100 mg PO BID:PRN Constipation
7. Senna 1 TAB PO BID:PRN Constipation
8. Multivitamins 1 TAB PO DAILY
9. Acyclovir 400 mg PO Q8H
10. Loratadine *NF* 10 mg Oral daily
11. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB/wheezing
12. Cyanocobalamin 50 mcg PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
2. Atorvastatin 20 mg PO DAILY
3. Cyanocobalamin 50 mcg PO DAILY
4. Docusate Sodium 100 mg PO BID:PRN Constipation
5. Escitalopram Oxalate 20 mg PO DAILY
6. Metoprolol Succinate XL 37.5 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Senna 1 TAB PO BID:PRN Constipation
9. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB/wheezing
10. Fish Oil (Omega 3) 300 mg PO DAILY
11. Loratadine *NF* 10 mg Oral daily
12. oxybutynin chloride *NF* 5 mg Oral daily
13. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth q12hrs Disp #*30 Tablet Refills:*0
14. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Empyema
Secondary Diagnosis:
Stage IV follicular lymphoma
Migraine Headaches
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you in the hospital. You were
admitted with chest pain. Blood tests and your EKG were
reassuring that the pain was not from the heart. A CAT scan of
your chest showed that you did not have a blood clot or
pneumonia in your lungs. You were evaluated by our
Interventional Pulmonary team who sampled fluid from your lungs
which showed a bacterial infection. You were started on
antibiotics and additional fluid was removed from your lungs.
Wishing you the best!
Followup Instructions:
___
|
10225882-DS-9 | 10,225,882 | 22,962,298 | DS | 9 | 2182-10-23 00:00:00 | 2182-10-23 17:17:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with stage IV follicular lymphoma w/ large abd mass c/b
lymphatic obstruction, chylothorax s/p C6 ___ ___
years
ago), recent worsening LAD now on monoclonal antibody therapy
(C3D1 - clinical trial ___, last dose ___ who presents
with fever.
Mr ___ began on ___ ___ two weeks ago and had his third round
on ___. Felt well afterward but on the night of ___,
developed fever to 102.4 with intermittent shaking chills. At
baseline, has night sweats.
Denies: new vision changes, neck pain/stiffness, mouth pain,
shortness of breath, coughing, abdominal pain, diarrhea,
constipation, concerning skin rashes, port pain/redness/drainage
Confirms: burning on urination but has been going on for years
now. Nocturia approximately 4 awakenings a night. Headdache
around the temples, mild, beginning yesterday. He recently had a
port placed on ___.
Past Medical History:
___ yo man with a diagnosis of low grade, stage IV follicular
lymphoma with large abdominal mass causing lymphatic
obstruction and chylothorax and ascites. Was initially managed
with a cycle of ___ with clincial improvement and
resolution of all palpable LAD. Continued pleural effusions
requiring pigtail ___ and intermittent drainage.
- ___ C1 R-bendamusitine
- ___ Additional dose of rituximab
- ___ C2 ___
- ___ C3 ___
- ___ C4 ___
- ___ C5 ___
- ___ C6 ___
___ ___
- ___ C1D1
- ___ C2D1
- ___ C3D1
PAST MEDICAL HISTORY:
PMH:
- HTN
- Depression
- Migraine
- Bladder dysfunction
PSX:
- Laminectomy
- arthroscopy
- sinus reconstruction
Social History:
___
Family History:
mother ___, father alive at ___, bladder cancer,
sister with ___ meningitis, unknown type of cancer
Physical Exam:
Admission Exam:
===============
VITAL SIGNS: 100.4-> 101.1, 161 / 89 93 18 96 Ra
General: NAD
HEENT: MMM, no OP lesions, PERRL, EOMI
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
GI: BS+, soft, NT to palpation, mild distention
LIMBS: No edema, clubbing, tremors
SKIN: No rashes or skin breakdown. PORT in right upper chest
without e/o surrounding erythema. dressing is c/d/i
NEURO: Oriented x3. Cranial nerves II-XII are within normal
limits excluding visual acuity which was not assesed; strength
is ___ of the proximal and distal upper and
lower extremities
Discharge Exam:
===============
VS: 97.8 134 / 84 85 16 98 Ra
GEN: nontoxic appearance, alert and answers questions
appropriately
HEENT: Sclera anicteric, MMM, oropharynx clear
Cards: RRR, nl S1/S2, no MRG
Pulm: CTAB, no wheezes/rales/rhonchi
Abd: Soft, NTND, normoactive bowel sounds
Skin: PORT site right upper chest with dried blood, no erythema
noted
Neuro: moving all extremities purposefully against gravity
Pertinent Results:
Admission Labs:
===============
___ 03:50PM BLOOD WBC-12.0* RBC-4.65 Hgb-13.8 Hct-41.9
MCV-90 MCH-29.7 MCHC-32.9 RDW-14.1 RDWSD-46.3 Plt ___
___ 03:50PM BLOOD Neuts-86.8* Lymphs-3.3* Monos-7.2 Eos-1.7
Baso-0.2 Im ___ AbsNeut-10.42* AbsLymp-0.40* AbsMono-0.87*
AbsEos-0.21 AbsBaso-0.02
___ 04:27AM BLOOD ___ PTT-28.8 ___
___ 03:50PM BLOOD Glucose-114* UreaN-23* Creat-1.3* Na-141
K-3.7 Cl-103 HCO3-27 AnGap-15
___ 03:50PM BLOOD ALT-20 AST-16 AlkPhos-61 TotBili-0.4
___ 03:50PM BLOOD LD(LDH)-189
___ 03:50PM BLOOD Albumin-3.8 Calcium-9.0
___ 03:50PM BLOOD Phos-3.4 Mg-2.2 UricAcd-3.7
___ 03:50PM BLOOD CRP-53.2*
Interim Labs:
=============
___ 02:17PM BLOOD CRP-118.7*
___ 09:06PM BLOOD CRP-134.3*
___ 11:42AM BLOOD CRP-121.6*
___ 06:30PM BLOOD CRP-111.0*
___ 12:00AM BLOOD CRP-94.1*
___ 09:24AM BLOOD CRP-73.4*
___ 04:43AM BLOOD Lactate-1.3
Discharge Labs:
===============
___ 12:00AM BLOOD Glucose-129* UreaN-14 Creat-1.1 Na-143
K-4.3 Cl-103 HCO3-27 AnGap-17
___ 12:00AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.3
___ 12:00AM BLOOD WBC-7.3 RBC-4.49* Hgb-13.3* Hct-40.1
MCV-89 MCH-29.6 MCHC-33.2 RDW-13.6 RDWSD-44.5 Plt ___
Microbiology:
=============
___ Urine Culture: negative
___ Blood Cultures: pending at time of discharge
___ MRSA Screen: pending at time of discharge
Studies:
========
___ CXR: Bibasilar opacities may represent atelectasis.
However, superimposed pneumonia cannot be excluded in the
appropriate clinical setting, particularly in the right lung.
___ CXR: In comparison with the study of ___, the
tip of the Port-A-Cath is in the mid SVC. No evidence of
kinking. Little change in the appearance of the heart and lungs.
Brief Hospital Course:
Brief Summary:
==============
___ with stage IV follicular lymphoma w/ large abd mass c/b
lymphatic obstruction, chylothorax s/p C6 ___ ___
years ago), recent worsening LAD now on bispecific monoclonal
antibody therapy (C3D1 - clinical trial ___, last dose
___ who presented with fever. He was placed on broad
spectrum antibiotics Vancomycin and Ceftazadime for 48 hours. He
remained afebrile. Culture results were negative. CRP was
trended given concern for developing cytokine storm and peaked
at 130 before downtrending. Antibiotics were discontinued and he
was monitored clinically for 24 hours, without additional fever.
He had a headache during his hospitalization, which is baseline
for him. Presenting fever may have be infusion related. He was
discharged to home with close BMT follow up on ___.
Transitional Issues:
====================
[ ] Has oncology appointment on ___
[ ] MRSA and blood cultures pending at time of discharge
[ ] Follow up on headache/migraine symptoms. Takes Excedrin PRN
for them.
Acute Issues:
=============
# Fever
# Leukocytosis:
Ddx inclusive of infection v. infusion related fever given h/o
fevers/rigors after previous doses of bispecific antibody v.
fever associated with lymphoma. No infectious symptoms on ROS
but PNA could not excluded given his CXR revealing bibasilar
opacities. Was placed on vancomycin and ceftazidime for 48 hours
and was discontinued subsequently. U/A, urine culture, blood
cultures were either unremarkable or no growth to date. MRSA
screen was pending upon discharge. Fever, therefore, was likely
secondary an ADE from the bispecific antibody infusion.
Work up for cytokine storm was done as mentioned below.
# PORT site evaluation. CXR without e/o malpositioning. IV team
evaluated, able to flush with proper blood return.
# CRP Elevation: Peaked at 134 during hospitalization. Initial
concern for cytokine storm that was causing his fevers. During
hospitalization, CRP downtrended with last CRP draw at 73.4.
Chronic Issues:
===============
# Migraines: history of migraines which he takes Excedrin and
oxycodone for. Had a headache on admission and throughout
hospitalization. Took indomethacin on day of discharge with
adequate relief.
# COPD/OSA: continued home regimen of CPAP without changes.
# HTN: continued home regimen of metoprolol succinate 37.5 daily
without changes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Gabapentin 900 mg PO TID
3. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
4. Metoprolol Succinate XL 37.5 mg PO DAILY
5. Cyanocobalamin 50 mcg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Fish Oil (Omega 3) 1000 mg PO DAILY
8. Senna 8.6 mg PO BID:PRN constipation
9. Vitamin D 1000 UNIT PO DAILY
10. Calcitrate (calcium citrate) unknown oral DAILY
11. Excedrin Migraine (aspirin-acetaminophen-caffeine) unknown
oral unknown
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
2. Allopurinol ___ mg PO DAILY
3. Calcitrate (calcium citrate) unknown oral DAILY
4. Cyanocobalamin 50 mcg PO DAILY
5. Excedrin Migraine (aspirin-acetaminophen-caffeine) unknown
oral Frequency is Unknown
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. Gabapentin 900 mg PO TID
8. Metoprolol Succinate XL 37.5 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 2 tablet(s) by mouth every six (6) hours Disp
#*24 Tablet Refills:*0
11. Senna 8.6 mg PO BID:PRN constipation
12. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Fever
Secondary Diagnosis
Follicular Lymphoma
Obstructive Sleep Apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your hospitalization
at ___. Briefly, you were hospitalized with a fever after your
infusion of clinical trial medication. You were kept on
antibiotics for 48 hours. Culture results did not show any
source of infection. Antibiotics were stopped and you remained
well. You were discharged to home with close follow up with your
outpatient oncologists. It's possible that your fever was
related to the infusion of the clinical trial drug itself.
Please return to the hospital if you start having troubles
breathing or high fevers.
We wish you the best,
Your ___ Treatment Team
Followup Instructions:
___
|
10226496-DS-8 | 10,226,496 | 26,162,745 | DS | 8 | 2172-01-06 00:00:00 | 2172-01-06 17:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dysphagia, odynophagia
Major Surgical or Invasive Procedure:
EGD on ___
History of Present Illness:
___ with large cell lung cancer presents as transfer from ___ with chest pain and dysphagia. Pt was diagnosed several
months ago and on chemo and radiation, known RUL and significant
mediastinal burden. Reports progressively worsening dysphagia
and odynophagia. Feels like food gets stuck in chest. Able to
drink in sips. Denies SOB changed from baseline. Denies fevers,
chills, vomiting, abdominal pain, dysuria, diarrhea. At ___,
EKG and troponin wnl, CXR stable from prior, and they spoke with
pt's oncologist (Dr. ___ who agreed with transfer for
urgent GI work-up, and potential stent placement.
In ___ GI consulted. Pt given 1Lns.
ROS: +as above, otherwise reviewed and negative
Past Medical History:
large cell lung cancer
- on chemo and radiation
HLD
Social History:
___
Family History:
no malignancy
Physical Exam:
Physical Exam on Admission:
Vitals: T:98.3 BP:139/78 P:20 R:18 O2:99%ra
PAIN: 2
General: nad
EYES: anicteric
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd
Ext: no e/c/c
Skin: no rash
Neuro: alert, follows commands
=
=
=
=
=
=
=
================================================================
Physical Exam on Discharge:
VS: T 98.2 BP 110s-130s/60s-70s, P ___, RR ___, O2 99% RA
Gen: Cachectic appearing gentleman, pleasant, in NAD.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL. No
palpable cervical lymphadenopathy.
CV: tachycardic, normal S1/S2, no m/r/g. Flat JVP.
P: CTAB throughout
Abd: Soft, +BS, NT/ND. No palpable masses.
Skin/Ext: Warm, reticulated, non-blanching patch in L AC, not
tender or fluctuant. Non-tender. 2+ pulses, no edema.
Erythematous patch in back, stable.
Neuro: AAOx3, CNII-XII intact, ___ strength upper/lower
extremities, grossly normal sensation.
Pertinent Results:
Labs On Admission:
___ 07:00AM BLOOD WBC-5.4 RBC-3.91* Hgb-10.8* Hct-34.3*
MCV-88 MCH-27.6 MCHC-31.5* RDW-13.9 RDWSD-44.0 Plt ___
___ 07:00AM BLOOD ___ PTT-27.2 ___
___ 07:00AM BLOOD Glucose-95 UreaN-12 Creat-0.6 Na-135
K-4.0 Cl-103 HCO3-24 AnGap-12
___ 07:00AM BLOOD Albumin-3.3* Calcium-8.1* Phos-3.0 Mg-1.8
================================================================
Labs on Discharge:
___ 06:30AM BLOOD WBC-1.3* RBC-3.67* Hgb-10.4* Hct-31.0*
MCV-85 MCH-28.3 MCHC-33.5 RDW-13.2 RDWSD-40.7 Plt ___
___ 06:30AM BLOOD Plt ___
___ 06:30AM BLOOD Glucose-166* UreaN-9 Creat-0.6 Na-135
K-3.5 Cl-101 HCO3-26 AnGap-12
___ 06:30AM BLOOD ALT-14 AST-15 AlkPhos-66 TotBili-0.3
___ 06:30AM BLOOD Calcium-8.9 Phos-2.0* Mg-1.8
================================================================
Clinical Imaging:
___ CXR:
2 views of the chest compared with ___ chest radiograph
and chest CT. COPD with medial posterior left upper lobe mass
and
left perihilar scarring are stable. No superimposed acute
parenchymal
consolidation, volume loss, pleural process or failure.
Mediastinal contours stable.
Conclusion: COPD and left upper lobe mass and scarring, stable.
No acute abnormality or change from ___.
___ CT Chest;
1. 2 cm spiculated superior segment left lung mass unchanged.
2. Increasing extensive bulky subcarinal adenopathy enveloping
the esophagus with adenopathy around the left hilum and anterior
mediastinum
ENDOSCOPIC STUDIES:
EGD ___:
Diffuse candidiasis was found in the entire esophagus.
A large area of extrinsic compression was found in the
middle third of the esophagus. The scope was withdrawn. Dilation
was performed with ___ dilator with mild resistance at 32
Fr.
There was severe extra and thick compression at the mid
esophagus, presumably from patient's known tumor and adenopathy.
No intrinsic esophageal mass seen. The exam was otherwise
without
abnormality. The entire examined stomach was normal. The
examined duodenum wasnormal.
CXR Conclusion: COPD and left upper lobe mass and scarring,
stable. No acute abnormality or change from ___
Brief Hospital Course:
Mr. ___ is a ___ y/o M w/ large cell undifferentiated lung cancer
w/neuroendocrine features, stage IIIB, with bulky adenopathy and
previous compression of his esophagus, s/p chemo and radiation
therapy (last cycle ___ who presented with worsening
dyaphagia and odynophagia x 1 week.
#Dysphagia/Large cell lung cancer: He has presented previously
with dysphagia and now re-presents with worsening dysphagia and
odynophagia over the last week, c/b decreased PO intake.
Previously, his bulky adenopathy was noted to be compressing the
esophagus. We obtained a GI consultation who performed an EGD
and assessed the degree of the compression, and thought that the
patient did not need to be stented. The passage of the scope
sufficiently dilated the esophagus. We started him on a liquid
diet which he tolerated well. Nutrition was consulted and
recommended adding ensure plus supplementation three times a
day. We discussed with Dr. ___ (Outpatient oncologist)
who recommended outpatient oncology follow-up upon discharge
within 1 week, which we have set up. At that time, they will
determine optimal management for his bulky adenopathy and
consider palliative treatment.
#Left Forearm Rash/Diffuse Rash: Mr. ___ had developed a
non-blanching, retiform erythematous patch overlying his
vasculature on the L forearm . After discussion with Dr.
___ learned that he had developed this previous in
___ after cisplatin/taxol, and recently received another dose
last week. We treated him with atarax and sarna which alleviated
his symptoms well. Dermatology was consulted and agreed with the
management. He was see Dr. ___ 1 week, at which time
the rash will be examined again. He also had a more diffuse
popular rash over his back and arms, which was pruritic, and
should be trended at his next appointment. The etiology was
unclear, but it was improving at the time of discharge.
#Fever/Tachycardia: During this hospitalization, Mr. ___
developed one episode of T 100.7, was feeling chills at the
time. We worked him up with a CXR which was negative, and a UA
was negative. At the time of discharge, his blood cultures had
been NGTD. Please follow-up on final blood cultures results.
#Pain Control: Well-controlled. We continued him on oxycodone
___ Q4H PRN.
#GERD: We continued home pantoprazole.
#Hyperlipidemia: We continued home atorvastatin.
Transitional Issues:
1. Please follow-up regarding his dysphagia and ensure he is
tolerating the liquid diet well/nutritionally adequate.
2. Please coordinate with Dr. ___ treatment
approaches for Mr. ___ at this time for the bulky adenopathy/lung
cancer.
3. Please follow-up regarding this superficial thrombophlebitis
on L forearm and ensure it resolves, as well as popular rash
over back and right arm.
4. At the time of discharge, his pain was well-controlled,
please assess and ensure he has proper pain control due to
severe tumor burden.
5. Please follow-up on final blood cultures results. At the time
of discharge, it was NGTD.
Code Status: Full Code (Confirmed)
Contact information: Son ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. Docusate Sodium 100 mg PO DAILY
3. Pantoprazole 40 mg PO Q24H
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB/wheeze
5. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO Q6H:PRN severe
pain
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB/wheeze
2. Docusate Sodium 100 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO Q6H:PRN severe
pain
5. Pantoprazole 40 mg PO Q24H
6. HydrOXYzine 25 mg PO Q6H:PRN Itch
RX *hydroxyzine HCl 25 mg 1 Tab by mouth every six (6) hours
Disp #*12 Tablet Refills:*0
7. Sarna Lotion 1 Appl TP BID:PRN itch
Discharge Disposition:
Home
Discharge Diagnosis:
Large cell lung cancer
Esophageal compression
Superficial thrombophlebitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
You were admitted because you were having difficulty swallowing.
This was because some of the cancerous lymph nodes were pushing
up on your esophagus, causing you to have difficulty and painful
swallowing. Due to your difficulty swallowing, we switched you
over to a liquid diet. In addition, we obtained a
gastroenterology consultation, who evaluated you and performed
an endoscopy. During the procedure and by passing the scope
through your throat, it opened up the esophagus and they did not
need to stent it. You were continued on your liquid diet
afterward and tolerated it well.
During this hospital course, you also developed a rash on your
left forearm. After speaking with you and your son, we learned
that you had developed this before when you received
cisplatin/taxol treatment. Since you last received this a week
ago, we believe it was related to the medication and treated you
with hydroxyzine, a medication that helps you with the itch, as
well as sarna lotion. We discussed this with Dr. ___
agreed. Additionally, we obtained a dermatology consultation,
and they evaluated your arm and also agreed with the plan.
It was a pleasure to care for you during this hospitalization.
Good luck!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10226756-DS-14 | 10,226,756 | 24,245,396 | DS | 14 | 2136-09-16 00:00:00 | 2136-09-16 17:55:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
All allergies / adverse drug reactions previously recorded have
been deleted
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___ ex lap, mesh excision, Exploratory laparotomy with left
inguinal hernia
History of Present Illness:
HPI: Pt with multiple prior left inguinal hernia repairs woke up
from
sleep at midnight with excruciating sharp pain in his lower abd.
The
pain is intermittent, recurring every ___ mins with a duration
of
~2mins each time. Pt hasn't had a BM in 4 days and in the days
prior his stools were smaller in volume. The pt also complains
of
abd distention, nausea, and vomitx1 in the ED. Note that last
week the
pt introduced raisins into his diet and had 2 episodes diarrhea
prior
to his decreased in BMs. Note the pt also notes decreased UOP
today.
When he did urinate his urine was dark yellow-brown.
Past Medical History:
Gout
kidney stones
HTN
BNPH - last PSA believes with Dr. ___ on ___
sinusitis
Surgery: Per patient, left inguinal hernia repair in the
distant past followed by laparoscopic left inguinal hernia
(done by by Dr. ___, who is out of town)several years ago.
Social History:
___
Family History:
No prostate, renal, or bladder cancer
Physical Exam:
___: Physical examination upon discharge:
VS: 98.9 HR 107 BP 163/97 18 100RA
General: NAD
Heart: RRR, no m/r/g
Lungs: CTAB
Abd: hyperactive bowel sounds, distended, tympanitic, firm,
tender to palpation in lower abd in the midline and the RLQ
Pelv: hernia visualized in L inguinal region
Ext: wwp, no c/c/e
Pertinent Results:
___ 05:17AM BLOOD WBC-10.3# RBC-4.44* Hgb-14.1 Hct-42.3
MCV-95 MCH-31.7 MCHC-33.3 RDW-13.2 Plt ___
___ 04:59AM BLOOD WBC-5.1 RBC-4.22* Hgb-13.3* Hct-39.4*
MCV-94 MCH-31.6 MCHC-33.8 RDW-13.2 Plt ___
___ 07:35PM BLOOD WBC-9.6# RBC-5.23 Hgb-16.4# Hct-48.6#
MCV-93 MCH-31.3 MCHC-33.7 RDW-13.4 Plt ___
___ 05:17AM BLOOD Plt ___
___ 05:17AM BLOOD Glucose-92 UreaN-17 Creat-1.5* Na-140
K-4.5 Cl-103 HCO3-25 AnGap-17
___ 04:59AM BLOOD Glucose-76 UreaN-13 Creat-1.4* Na-141
K-4.7 Cl-107 HCO3-27 AnGap-12
___ 05:17AM BLOOD Calcium-8.1* Phos-4.4# Mg-1.9
___ 05:04AM BLOOD Calcium-8.0* Phos-3.5 Mg-2.0
___ 05:26AM BLOOD Lactate-1.1
___: X-ray of the abdomen:
IMPRESSION: Abundant stool in the right colon with areas of
dilated colon with relative paucity of gas in the distal
descending colon/sigmoid, underlying large bowel obstruction may
be present. CT pending.
___: EKG:
Sinus rhythm with a ventricular premature beat. Since the
previous tracing of ___ ventricular premature beat is new
___: cat scan of abdomen and pelvis:
IMPRESSION:
1. Left inguinal hernia with incarcerated sigmoid colon,
resulting in early high-grade closed loop obstruction.
2. Benign prostatic hypertrophy with bladder outlet
obstruction.
___: chest x-ray:
IMPRESSION: Normal chest findings identified on single AP chest
views.
Brief Hospital Course:
The patient was admitted to the acute care service with
abdominal pain. Upon admission, he was made NPO, given
intravenous fluids, and underwent imaging. On cat scan of the
abdomen he was reported to have a left inguinal hernia with an
incarcerated sigmoid colon, resulting in a early high-grade
closed loop obstruction. The hernia was reduced in the emergency
room with immediate relief of pain. He was then observed for
the possible evolution of an acute abdomen which he did not
develope. Because of the severity of the recurrence, he was then
taken to the operating room for an exploratory laparotomy,
excision of the prior mesh (which was adherent to the sigmoid
colon and the iliac artery, and repair of the left inguinal
hernia repair by a retroperitoneal route. His post-operative
recovery was swift. He developed some wound erythema that was
treated with Kefzol afer a CT revealed no fluid collections.
Medications on Admission:
allopurinol ___ daily
dutasteride .5mg daily
HCTZ 25mg daily
losartan 100 mg daily
OTC vitamins
Discharge Medications:
1. dutasteride *NF* 0.5 mg Oral Daily Reason for Ordering: Wish
to maintain preadmission medication while hospitalized, as there
is no acceptable substitute drug product available on formulary.
2. dutasteride *NF* 0.5 mg Oral Daily Reason for Ordering: Wish
to maintain preadmission medication while hospitalized, as there
is no acceptable substitute drug product available on formulary.
3. dutasteride *NF* 0.5 mg Oral Daily Reason for Ordering: Wish
to maintain preadmission medication while hospitalized, as there
is no acceptable substitute drug product available on formulary.
4. Hydrochlorothiazide 25 mg PO DAILY
5. Losartan Potassium 100 mg PO DAILY
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
7. Tamsulosin 0.4 mg PO HS
8. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
recurrent left inguinal hernia
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 lower abdominal pain.
You were found to have a left inguinal heria. You were taken to
the operating room for hernia repair. You are recovery nicely
from the surgery and you are preparing for discharge home with
the following instructions:
Followup Instructions:
___
|
10226847-DS-18 | 10,226,847 | 26,562,792 | DS | 18 | 2182-01-27 00:00:00 | 2182-01-27 14:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
acute appendicitis
Major Surgical or Invasive Procedure:
laparoscopic appendectomy ___
History of Present Illness:
___ w/ hx htn presents w/ gradual onset of dull, generalized
abdominal pain around 1630 the day prior. The pain become
sharper and more intense in the RLQ as the night went on. The
patient endorses some dry heaves, but no emesis. He also
endorses some chills and anorexia. The patient came to the ED
because his pain was unremitting. The patient denies fevers.
In the ED, the patient is afebrile and VSS. He is TTP in the
RLQ, has a WBC 18.2 and a CT scan showing appendicitis.
Past Medical History:
PMH: htn
PSH: denies
Social History:
___
Family History:
noncontributory
Physical Exam:
On Admission:
98.8 65 122/65 18 100RA
Gen: NAD
CV: RRR
R: CTAB
Abd: s/obese/TTP RLQ, +psoas sign
Ext: no edema
On Discharge:
98.6 81 127/73 18 98RA
NAD, A&O
RRR
No resp distress
Abd soft, appropriately tender, mildly disteded, dressings c/d/i
Ext wwpx4, no edema
Pertinent Results:
___ 12:10AM BLOOD WBC-18.2* RBC-5.17 Hgb-14.9 Hct-42.3
MCV-82 MCH-28.7 MCHC-35.1* RDW-12.0 Plt ___
___ 12:10AM BLOOD Glucose-122* UreaN-17 Creat-0.9 Na-132*
K-4.2 Cl-101 HCO3-21* AnGap-14
___ 12:10AM BLOOD ALT-55* AST-24 AlkPhos-48 TotBili-0.8
CT A/P ___
Appendicolith within a fluid filled 13 mm hyperenhancing
appendix with
surrounding fat stranding consistent with appendecitis. No
drainable fluid
collections or large intraabdominal free air.
Brief Hospital Course:
Patient was admitted to the ACS service on ___ with acute
appendicitis. Hhe was kept NPO and was taken to the OR for a
laparoscopic appendectomy which he tolerated without issue. For
full details please see the operative report. Post op his diet
was advanced and his pain was controlled with PO pain meds. He
was able to void and to ambulate independently. He was
discharged to home with plans to follow up in the ___ clinic in
one week with 5 days of cipro/flagyl.
Medications on Admission:
lisinopril 10'
Discharge Medications:
1. Ciprofloxacin HCl 750 mg PO Q12H
RX *ciprofloxacin 750 mg 1 tablet(s) by mouth twice a day Disp
#*10 Tablet Refills:*0
2. Lisinopril 10 mg PO DAILY
3. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every 8 hours Disp
#*15 Tablet Refills:*0
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*30 Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*28 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home with the following instructions:
Please follow up at the appointment in clinic listed below. We
also generally recommend that patients follow up with their
primary care provider after having surgery. We have scheduled an
appointment for you listed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for ___ weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" a couple weeks. You might want
to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You could have a poor appetite for a couple days. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressings you have small plastic bandages
called steristrips. 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.
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
___
|
10227155-DS-12 | 10,227,155 | 25,753,333 | DS | 12 | 2145-10-11 00:00:00 | 2145-10-12 15:52:00 |
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:
EGD ___
attach
Pertinent Results:
ADMISSION LABS
==============
___ 01:27AM BLOOD WBC-7.2 RBC-3.72* Hgb-10.9* Hct-34.9*
MCV-94 MCH-29.3 MCHC-31.2* RDW-14.2 RDWSD-48.0* Plt ___
___ 01:27AM BLOOD Neuts-86.6* Lymphs-9.6* Monos-3.4*
Eos-0.0* Baso-0.1 Im ___ AbsNeut-6.20* AbsLymp-0.69*
AbsMono-0.24 AbsEos-0.00* AbsBaso-0.01
___ 01:50PM BLOOD ___ PTT-28.9 ___
___ 01:27AM BLOOD Glucose-525* UreaN-89* Creat-15.0* Na-137
K-6.4* Cl-89* HCO3-21* AnGap-27*
___ 01:50PM BLOOD Calcium-9.7 Phos-5.5* Mg-2.1
___ 03:09AM BLOOD ___ pO2-109* pCO2-48* pH-7.36
calTCO2-28 Base XS-0 Comment-GREEN TOP
IMAGING
=======
CXR ___
Mild pulmonary vascular congestion. No edema.
MICRO
=====
___ 1:30 pm BLOOD CULTURE Source: Line-R fem line 2 OF
2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
STUDIES
=======
EGD ___
- Grade C esophagitis in the mid and distal esophagus
- A small, non-bleeding ___ tear was noted in the
distal esophagus
- A brief view of the stomach body was notable for normal mucosa
without any blood
- Due to the large esophageal clot, a full endoscopic view of
the stomach fundus, antrum or duodenum was not obtained.
DISCHARGE LABS
==============
___ 07:42AM BLOOD WBC-5.7 RBC-2.67* Hgb-8.0* Hct-25.0*
MCV-94 MCH-30.0 MCHC-32.0 RDW-14.4 RDWSD-47.3* Plt ___
___ 07:42AM BLOOD Glucose-134* UreaN-27* Creat-6.5*# Na-139
K-4.4 Cl-97 HCO3-27 AnGap-15
___ 07:42AM BLOOD Calcium-8.5 Phos-4.9* Mg-2.0
Brief Hospital Course:
TRANSITIONAL ISSUES
===================
[ ] Discharge HGB 8.0
[ ] Please complete repeat labs in 1 week by ___ to
follow-up his anemia.
[ ] Patient left AMA before receiving repeat endoscopy to
evaluate suspected ___ tear. Therefore, would greatly
benefit from repeat endoscopy within the next week to ensure
healing. We did not feel comfortable restarted his apixaban
without this re-evaluation. His CHADs2VASc is ___ so we felt it
was reasonable to hold apixaban on discharge, but he will need
to be restarted on this medication when repeat EGD shows
healing.
[ ] Patient likely with ___ tear in setting of
nausea/vomiting due to gastroparesis flare and missed HD
session. Patient should continue PPI as well as prn reglan for
nausea and to help with motility. Patient reports that he has
infrequent gastroparesis flares (yearly) but would benefit from
outpatient gastroparesis management.
BRIEF HOSPITAL COURSE
======================
Mr ___ is a ___ man with history of IDDM, ESRD on
HD (MWF), CAD s/p CABG in ___, Afib w/ RVR history of
gastroparesis on reglan, presented with nausea/vomiting,
initially admitted to ICU in setting of respiratory distress
after missing dialysis, then re-admitted to ICU in setting of
hematemesis found to have possible ___ tear on EGD.
Patient was treated with IV PPI and standing Zofran. Apixaban
was held during this time in setting of bleeding. Course was
also complicated by Afib with RVR resolved with addition of
standing metoprolol. Patient left AMA right as he was been
called for repeat EGD to assess healing of his ___
tear. Patient became belligerent and hostile to medical staff.
He is fully aware that his apixaban is being held until he has a
repeat EGD and therefore has a risk of stroke, and he is willing
to take this risk. Hemoglobin has been stable with no further
bleeding on discharge.
ACUTE ISSUES
===============
#Discharged AMA
Patient left AMA right as he was been called for repeat EGD to
assess healing of his ___ tear. Patient became
belligerent and hostile to medical staff. He is fully aware that
his apixaban is being held until he has a repeat EGD and
therefore has a risk of stroke, and he is willing to take this
risk. Hemoglobin has been stable with no further bleeding on
discharge.
# Acute upper GI bleed
Patient developed hematemesis after multiple episodes of emesis.
EGD on ___ showed esophagitis and a clot with possible
___ tear. Patient was kept on IV PPI, standing Zofran
until nausea resolved and stable. Apixaban was held in the
setting of active bleeding. Patient has been hemodynamically
stable with stable hemoglobin. No further nausea/vomiting or
melena. Patient left AMA right as he was been called for repeat
EGD to assess healing of his ___ tear. Patient became
belligerent and hostile to medical staff. He is fully aware that
his apixaban is being held until he has a repeat EGD and
therefore has a risk of stroke, and he is willing to take this
risk. Hemoglobin has been stable with no further bleeding on
discharge.
# Nausea and Vomiting
# Gastroparesis
Patient presented with nausea/vomiting likely in the setting of
known gastroparesis as well as uremia from missed HD session.
Patient was on standing anti-emetics given ___ tear.
Zofran and reglan were made prn. He has been tolerating oral
intake with no N/v. Mild epigastric pain with belching.
# Paroxysmal Afib/flutter
Discharged ___ from ___ on metop, apixaban, amiodarone
but recently switched to carvedilol. His fill history however
does not reflect this, and it appears he has not filled these
meds which his story collaborates. On ___, patient had elevated
HRs in 150s with 2:1 block requiring IV metop with conversion to
NSR. Standing metoprolol tartrate 6.25mg QID was added with
patient continuing in NSR until left AMA. As above, holding
apixaban in setting of bleeding. Unable to get repeat EGD before
left and medical team not comfortable sending him on apixaban
without visualizing his esophagus.
# HTN
Had held home amlodipine, losartan iso GI bleed. Started
metoprolol as above. Restarted home amlodipine as blood
pressures have tolerated.
#Likely OSA
Concern for apneic periods during sleep throughout admission.
Would benefit from outpatient sleep study.
CHRONIC ISSUES
===============
# ESRD
Continued HD per renal
# IDDM
Continued insulin 50 units glargine daily, sliding scale
# HLD
Continued atorvastatin
#CODE STATUS: FULL
>30 min spent on discharge planning including face to face time.
Pt was deemed to have capacity at time of AMA and understood the
risks of leaving prematurely.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Glargine 50 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
5. Pantoprazole 40 mg PO Q24H
6. Losartan Potassium 25 mg PO DAILY
7. TraMADol 50 mg PO BID:PRN Pain - Moderate
8. Gabapentin 100 mg PO TID
9. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
10. Apixaban 2.5 mg PO BID
11. sevelamer CARBONATE 800 mg PO TID W/MEALS
12. CARVedilol 12.5 mg PO BID
Discharge Medications:
1. Glargine 55 Units Dinner
Humalog 8 Units Breakfast
Humalog 8 Units Lunch
Humalog 8 Units Dinner
2. amLODIPine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. CARVedilol 12.5 mg PO BID
6. Gabapentin 100 mg PO TID
7. Losartan Potassium 25 mg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. sevelamer CARBONATE 800 mg PO TID W/MEALS
10. TraMADol 50 mg PO BID:PRN Pain - Moderate
11. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
Acute Gastrointestinal Bleed
SECONDARY DIAGNOSES
===================
Gastroparesis
Atrial Fibrillation with RVR
ESRD on HD
Hypoxemic respiratory failure, Resolved
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 privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were nauseous and vomiting.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You received dialysis
- You were in the Intensive Care Unit for special monitoring and
care of your breathing
- You developed bloody vomit and a scope was placed down through
your mouth which showed bleeding coming from your feeding tube
- You were given medications to help your nausea and to prevent
further bleeding
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Please continue to take all of your medications and follow-up
with your appointments as listed below.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10227830-DS-10 | 10,227,830 | 27,908,511 | DS | 10 | 2143-04-01 00:00:00 | 2143-04-01 21:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Cystoscopy with stent placement in left ureter
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of dementia
who presented to the ED with diffuse abdominal pain, nausea,
vomiting and fever (Tmax 102). Her symptoms began yesterday with
N/V, abd pain, generalized weakness (described difficulty with
walking), and was subjectively hot to the touch. Earlier today
starting 2 hrs prior to presentation had cognitive decline per
the family compared to her baseline. She has dementia, and is at
baseline AOx1-2.
She first presented to ___ where she was noted to have a WBC
23.7, Cr 1.2, lactate 3.3, and UA with 500 leuk esterase, neg
nitrites, 2+ bact, 150 Ubld, and no epi cells. Blood and urine
cultures were obtained as was a CT abdomen which was notable for
a sizable L renal cyst possible UPJ obstruction. She was given
Tylenol, Zofran, and 750mg Levaquin and transferred to ___ for
possible ___ intervention.
Past Medical History:
- Memory impairment consistent with Alzheimer's type dementia,
status post neuropsychological testing ___.
- Hypertension.
- Hypercholesterolemia.
- Umbilical hernia.
- Glucose intolerance.
- Removal of basal cell carcinoma.
- Cholecystectomy ___.
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: T:99.6 BP:140/68 HR:74 RR:18 O2Sat:98% RA
General: elderly woman, asleep but arousable, in NAD
HEENT: Sclera anicteric
Neck: supple
Lungs: crackles at bases, otherwise decreased cooperation with
exam but no wheezing heard
CV: rrr, no murmurs
Abdomen: soft, non-distended, bowel sounds present, tenderness
present in LUQ with no guarding. No CVA tenderness
Ext: Warm, well perfused, no clubbing, cyanosis or edema.
Endorsed calf pain with palpation bilaterally
Skin: warm and dry
Neuro: arousable, interactive with exam, oriented to self and
___, cannot recall recent events.
DISCHARGE PHYSICAL EXAM:
========================
Vitals: T 98.5, BP 147/84, HR 76, RR 18, O2Sat 97%RA
UOP: 1700cc on ___ (0.9 cc/kg/hr); 500cc since midnight
General: elderly woman, sitting comfortably in chair, no visible
distress
Lungs: Bibasilar crackles, otherwise clear to auscultation
CV: RRR, no m/g/r.
ABD: soft, non-distended. Intermittent tenderness in epigastric
region and left abdomen/flank; less pronounced in back.
Normoactive BS.
Ext: warm, well perfused, 2+ DP pulses
Pertinent Results:
LAB DATA:
============
On Admission:
___ 06:46PM LACTATE-1.3
___ 06:40PM URINE HOURS-RANDOM
___ 06:40PM URINE UHOLD-HOLD
___ 06:40PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 06:40PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-LG
___ 06:40PM URINE RBC-62* WBC->182* BACTERIA-FEW
YEAST-NONE EPI-0
___ 06:30PM GLUCOSE-116* UREA N-24* CREAT-1.2* SODIUM-135
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-23 ANION GAP-15
___ 06:30PM estGFR-Using this
___ 06:30PM WBC-19.6*# RBC-4.15* HGB-12.8 HCT-37.9 MCV-91
MCH-30.9 MCHC-33.8 RDW-13.0
___ 06:30PM NEUTS-85* BANDS-3 LYMPHS-6* MONOS-6 EOS-0
BASOS-0 ___ MYELOS-0
___ 06:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL ACANTHOCY-OCCASIONAL
___ 06:30PM PLT SMR-NORMAL PLT COUNT-202
On Discharge:
___ 06:15AM BLOOD WBC-14.8* RBC-3.60* Hgb-11.3* Hct-33.1*
MCV-92 MCH-31.4 MCHC-34.2 RDW-13.4 Plt ___
___ 06:15AM BLOOD Glucose-92 UreaN-22* Creat-1.1 Na-137
K-3.6 Cl-108 HCO3-24 AnGap-9
___ 06:15AM BLOOD Calcium-8.0* Phos-1.5* Mg-1.9
IMAGING/STUDIES:
=================
KUB ___:
1. No evidence of obstruction or intraperitoneal free air.
2. Residual contrast material in the bilateral collecting
systems from prior IV contrast administration, with
dilation of the left renal collecting system, as seen on
prior CT.
___-abd/pelvis:
LEFT BASILAR PLEURAL FLUID AND PARENCHYMAL DISEASE. THE
PARENCHYMAL DISEASE COULD REPRESENT ATELECTASIS. ABNORMAL LEFT
KIDNEY WITH LARGE CYSTIC STRUCTURES. THIS COULD BE A LARGE LEFT
UPJ OBSTRUCTION, PARAPELVIC CYST AND/OR OBSTRUCTING LEFT UPPER
POLE MOIETY. THE LEFT KIDNEY IS CONSIDERABLY DEFORMED BY THIS
PROCESS. MRI MAY BE USEFUL FOR FURTHER EVALUATION. SMALL AMOUNT
OF GAS IN THE BLADDER AND ENHANCEMENT OF ITS MUCOSA WHICH COULD
INDICATE AN INFLAMMATORY PROCESS. HYPERTROPHIC CHANGES IN THE
SPINE. STATUS POST CHOLECYSTECTOMY. VENTRAL HERNIA
___ CXR ___: NO EVIDENCE FOR PNEUMONIA.
___ RETROGRADE UROGRAPHY:
A total of 9 intraoperative fluoroscopic spot views were
acquired, without a radiologist present. Contrast material was
injected into the left collecting system, demonstrating marked
deformity of the left renal pelvis and calices secondary to
compression by large parapelvic cysts. A nephroureteral stent
was placed and appears in satisfactory position. For additional
details, please see the operative report in the ___
medical record.
The study and the report were reviewed by the staff radiologist.
MICROBIOLOGY DATA:
==================
___ Blood cultures: pending (no growth to date)
___ Blood cultures: pending (no growth to date)
___ Urine cultures: No growth
___ Blood cultures: pending (no growth to date)
___ Blood cultures: pending (no growth to date)
___ Urine cultures: No growth
___ Urine cultures from intraoperative specimen:
___ 12:24 pm URINE Site: CYSTOSCOPY LEFT PELVIC.
**FINAL REPORT ___
URINE CULTURE (Final ___:
PROTEUS MIRABILIS. 1,000-10,000 CFU/ML.
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ microbiology data:
___ ___ Blood culture: No growth to date
___ ___ Blood culture: No growth to date
___ Urine Cultures: proteus mirabilis >100,000 org/ml
--Sensitive to all antibiotics tested except Nitrofurantoin.
Brief Hospital Course:
Ms. ___ is a ___ year-old woman with dementia who presented
with abdominal pain, fever, leukocytosis, and pyuria consistent
with pyelonephritis. On imaging was found to have abnormal renal
anatomy and obstruction. She is status-post left ureteral stent
placement on ___ complicated by septic shock ___,
recovering appropriately after fluid resuscitation and IV
antiobiotic therapy.
ACTIVE ISSUES:
==============
# Pyelonephritis: Presented with abdominal pain, elevated WBC,
fever, and UA concerning for pyelonephritis. CT abdomen showed
possible obstruction of kidney, likley from complicated cysts.
Creatinine was mildly elevated to 1.2 from baseline of 1.
Urology placed ureteral stent on ___. Patient went into
septic shock the following night likely from bacteria seeding
after the procedure but has recoved well. Urine cultures from
___ at initial presentation as well as urine cultures ___
taken intra-operatively grew proteus mirabilis. Patient has been
afebrile for 72 hours at the time of discharge. She was
transitioned to ciprofloxacin to complete a total of 14 days of
antibiotic therapy (___). Her WBC has been downtrending
slowly and she continues to have some residual abdominal pain
particularly with movement. Her foley continues to be in place
to ensure decompression of the bladder to prevent reflux and
contamination of the kidney past the stent. Once she has
completed her antibiotics, would recommend discussing foley
removal with her urologist and removal of foley.
#Septic Shock: Patient developed septic shock on night of ___
after her left ureter was stented. She became febrile and
hypotensive to 60/40, not responsive to fluids. She was
resuscitated with 5 liters of saline overnight and her
antibiotics were broadened to cefepime and vancomycin. Systolic
blood pressure remained in the ___ for around 12 hours.
Family meeting was held, patient was made comfort measures only.
Patient was neither transferred to intensive care nor given
pressors, as per family's wishes. Comfort measures only was
reversed the following morning after she improved clinically
following fluid rescusiation and broad spectrum antibiotics. She
had an acute kidney injury with low urine output as a
complication of her septic shock which has been recovering. She
has been mentating at her baseline throughout.
# Acute Kidney Injury: Likely was acute tubular necrosis in the
setting of prolonged hypotension. Creatinine has improved to 1.1
from 1.8. She was diuresed with 10mg IV lasix once for volume
overload noted on exam and her volume status has improved. Her
urine output has recovered and she is no longer oliguric.
# Abdominal Pain: Most likely due to pyelonephritis and L kidney
/ ureter stent placement. Patient continues to endorse abdominal
pain, particularly in LLQ and left flank, that is exacerbated by
movement. This pain is consistent with her pain at presentation
and is most likely localized to her left flank as opposed to her
back as a result of her abnormal renal anatomy. Her pain is
controlled with Tylenol and should resolve over time as
inflammation from her infection resolves over time.
INACTIVE ISSUES:
===============
# Dementia, Alzheimer's: Lives in the locked dementia unit at
___. Per outpatient notes she has had increasing
memory loss and is unable to provide a history or make her own
medical decisions at baseline. She was continued on Donepezil
throughout the hospital stay.
# Hypertension: Her home dose of lisinopril has been withheld
since her hemodynamic status became tenuous. It was restarted
upon discharge.
# Depression/Anxiety: She was continued on her home dose of
Escitalopram
# Hypercholesterolemia: She was continued on her home dose of
simvastatin
# Health Maintenance: She was continued on her home dose of ASA
81, B12, calcium/vitamin D, vitamins
TRANSITION ISSUES:
==================
- CODE STATUS: DNR/DNI
- Health Care Proxys: Son (___) ___ and daughter ___
___
- If she becomes febrile again, would recommend CT abdomen to
investigate for further obstruction or abscess given her
complicated renal anatomy
- she is discharged with a foley to prevent urine backflow
re-infecting her kidney. Once she completes 2 weeks of
antibiotics, recommend touching base with her urologist ___
___ ___) to discuss foley removal
- she will need to follow up with ___ in ___ clinic
in ___ weeks.
- She will likely need stent exchange/removal in ~3 months
- please check a chem10 panel tomorrow ___ he had
electrolytes repleted prior to discharge from ___.
- She will restart her ACEi at discharge - recommend a chem7
check in 3 days (___) to monitor potassium and creatinine
- Patient was discharged on Ciprofloxacin HCl 500 mg PO Q12H to
complete 2 week course of antibiotics. Last Day ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Docusate Sodium 100 mg PO DAILY
3. Simvastatin 20 mg PO DAILY
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Cranberry-Probiotics-Vitamin C (cranberry conc-C-bacillus
coag) 450-30-50 mg-mg-million oral daily
6. Donepezil 5 mg PO DAILY
7. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral BID
8. Aspirin 81 mg PO DAILY
9. Escitalopram Oxalate 5 mg PO DAILY
10. Cyanocobalamin 1000 mcg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Cyanocobalamin 1000 mcg PO DAILY
3. Docusate Sodium 100 mg PO DAILY
4. Donepezil 5 mg PO DAILY
5. Escitalopram Oxalate 5 mg PO DAILY
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Simvastatin 20 mg PO DAILY
8. Acetaminophen 650 mg PO Q6H:PRN pain
9. Ciprofloxacin HCl 500 mg PO Q12H Duration: 10 Days
Last Day ___
10. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral BID
11. Cranberry-Probiotics-Vitamin C (cranberry conc-C-bacillus
coag) 450-30-50 mg-mg-million oral daily
12. Lisinopril 10 mg PO DAILY
13. Ondansetron 4 mg IV Q4H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
pyelonephritis
septic shock
urinary tract obstruction
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure meeting you during your recent hospitalization
at ___. You had a severe urinary tract infection and were
found to have an obstruction in your ureter. The urologists
placed a stent to relieve the obstruction. Your infection was
very severe and caused low blood pressure but with antibiotics
you improved drastically. You have what appear to be cysts on
your left kidney. You continue to have some residual pain in
your abdomen which is expected considering the severity of your
kidney infection. Let your doctor know if your pain gets worse
or does not improve over the next couple weeks. Please follow up
with Dr. ___ urology; he will decide if and when your
stent is exchanged.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10227968-DS-9 | 10,227,968 | 22,473,802 | DS | 9 | 2178-06-20 00:00:00 | 2178-06-22 15:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o man with PMHx significant for CAD s/p CABG (___), AS s/p
tissue AVR (___), BPH, PAF not on coumadin, DMII c/b neuropathy
and charcot foot with multiple hospital admissions for
mechanical falls c/b fractures (ribs, pelvis, sacrum) presenting
with CP. The patient is a very poor historian and thinks he is
admitted because he was in a car accident (which he was not).
Per family, he has been complianing of worsening chest pain
across his lower chest over the course of the past week. The
pain is not exertional, is sharp in quality and is worse with
movement and palpation. His daughter thinks he may have fallen
recently at rehab. She notes that he urinates frequently due to
his BPH, and his falls often occur when he is trying to walk to
the bathroom. Family has also noted worsening abdominal and BLE
edema for the past 2 days. Currently, he denies CP/N/V,
lightheadedness or palpitations. He endorses SOB and orthopnea,
does not know if he has ever had PND. Family states that his
baseline mental status waxes and wanes and that he has been
increasingly confused over the past several months.
.
In the ED, VS were:
T 97.7 HR 112 BP 124/79 RR 18 O2 Sat 96% 2L NC
Labs were notable for BNP 22139, Trop 0.05, CKMB 3 and CK 41.
CTPA was performed and was negative for PE or PNA. He was given
ASA 325, Vicodin and 20mg IV Lasix. EKG was notable for IV
conduction delay, L axis, poor R wave progression and early
repolatization. He had a sudden episode of R sided CP @ 04:30 -
EKG had some ST depressions in precordial leads, which were
slightly deeper when compared to prior. For this he was given
Vicodin and the pt promptly fell back asleep. He was admitted to
___ for CHF exacerbation.
.
On the floor, initial VS were:
T 96 BP 121/76 HR 66 RR 20 O2 Sat 99% RA Wt 76 kg
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia
2. CARDIAC HISTORY:
-CABG: ___
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
BPH
Multiple Mechanical Falls
Multiple Fractures (pelvis, sacrum, ribs)
HLD
DMII
Charcot Foot
Diabetic Neuropaty
Social History:
___
Family History:
Father: MI ~___
Physical Exam:
Admission Exam:
VS: T 96 BP 121/76 HR 66 RR 20 O2 Sat 99% RA Wt 76 kg
GENERAL: Elderly man in NAD, slightly obtunded but easily
arousable, appropriate.
HEENT: NCAT. EOMI. MMM.
NECK: Supple with JVP 15cm above the RA
CARDIAC: RRR, loud P2, II/VI systolic murmur best heard at the
xiphoid, no rubs or gallops
PULM: Faint crackles in dependent lung fields, no increased WOB,
no wheezes. Severe pain with movement of the torso, reproducible
with palpation.
ABDOMEN: Soft, non tender, mildly distended. NABS. No bruits.
EXTREMITIES: 2+ pitting edema of the BLEs to the shin. Multiple
superficial abrasions consistent w trauma.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ ___ 2+
Left: Carotid 2+ DP 2+ ___ 2+
NEURO: A/O to person only. CN II-XII intact. Non focal.
.
Discahrge Exam:
VS: T ___ BP 102-121/62-76 HR ___ RR 20 O2 Sat 100% RA
GENERAL: Elderly man in NAD, alert, appropriate
HEENT: NCAT. EOMI. MMM.
NECK: Supple with JVP 8cm above the RA
CARDIAC: RRR, loud P2, II/VI systolic murmur best heard at the
xiphoid, no rubs or gallops
PULM: Faint crackles in dependent lung fields, no increased WOB,
no wheezes.
ABDOMEN: Soft, non tender, mildly distended. NABS. No bruits.
EXTREMITIES: 2+ pitting edema of the BLEs to the shin. Multiple
superficial abrasions consistent w trauma.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ ___ 2+
Left: Carotid 2+ DP 2+ ___ 2+
NEURO: A/O to person only. CN II-XII intact. Non focal.
Pertinent Results:
Admission Labs:
___ 03:00AM BLOOD WBC-6.3 RBC-3.70* Hgb-10.8* Hct-34.0*
MCV-92 MCH-29.1 MCHC-31.7 RDW-16.4* Plt ___
___ 03:00AM BLOOD Neuts-80.6* Lymphs-14.5* Monos-3.9
Eos-0.8 Baso-0.2
___ 03:00AM BLOOD ___ PTT-33.1 ___
___ 03:00AM BLOOD Glucose-196* UreaN-49* Creat-1.1 Na-136
K-4.5 Cl-93* HCO3-33* AnGap-15
___ 03:00AM BLOOD CK-MB-3 ___
___ 03:00AM BLOOD cTropnT-0.05*
___ 09:15AM BLOOD CK-MB-2 cTropnT-0.04*
___ 07:25AM BLOOD CK-MB-2 cTropnT-0.05*
___ 09:15AM BLOOD Calcium-10.3 Phos-3.5 Mg-1.6
___ 03:57AM BLOOD D-Dimer-441
.
Discharge Labs:
___ 07:25AM BLOOD WBC-6.0 RBC-3.55* Hgb-10.4* Hct-33.1*
MCV-93 MCH-29.3 MCHC-31.4 RDW-16.6* Plt ___
___ 07:25AM BLOOD Glucose-84 UreaN-51* Creat-1.2 Na-141
K-3.9 Cl-95* HCO3-36* AnGap-14
.
Studies:
CT Chest (___):
CT CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST: The thyroid
gland is
homogeneous without focal nodule. No supraclavicular, axillary,
mediastinal, or hilar lymphadenopathy is identified. The heart
is moderately enlarged however there is no pericardial effusion.
The patient is status post CABG and the native coronary
vasculature is densely calcified. The thoracic aorta
demonstrates moderate atherosclerotic calcification, though is
non-aneurysmal. Post-contrast images do not opacify the thoracic
aorta limiting evaluation for acute dissection. However no large
dissection or intramural hematoma is identified. There is no
pulmonary embolism to subsegmental levels.
The tracheobronchial tree is patent to subsegmental levels,
though with mild bronchiectasis in the right lower lobe.
Subsegmental atelectasis is
identified within the right lung base. Otherwise there is no
focal pulmonary nodule, mass, or pleural effusion.
The imaged upper abdominal viscera show a moderate amount of
ascites with
indeterminate attenuation values ranging from ___ though
likely simple
fluid. The imaged liver, spleen, and stomach appear within
normal limits.
The adrenal glands are not seen. Dense atherosclerotic vascular
calcifications are noted.
OSSEOUS STRUCTURES: Multiple subacute bilateral rib fractures
are noted. No bone destructive lesion is apparent.
IMPRESSION:
1. Limited evaluation for aortic dissection given the lack of
opacification of the thoracic aorta. No large dissection or
intramural hematoma.
2. No pulmonary embolism.
3. Moderate cardiomegaly, no pericardial effusion.
4. Subsegmental atelectasis in the lung bases, no focal
consolidation or
pleural effusion.
5. Moderate ascites within the abdomen.
6. Multiple subacute bilateral rib fractures. No pneumothorax.
.
CXR (___):
AP AND LATERAL CHEST RADIOGRAPHS, FOUR IMAGES: Lung volumes are
low. Minimal linear opacities at the bases correspond with
dependent atelectasis seen on concurrent chest CT. There is no
pneumothorax, confluent consolidation or pleural effusion.
Mediastinal and hilar contours are within normal limits. The
cardiac silhouette is moderately enlarged. A prosthetic aortic
valve is noted. Median sternotomy wires appear grossly intact.
IMPRESSION:
1. Mild bibasilar atelectasis
2. Moderate cardiomegaly
.
Rib Series (___):
Radiographs are insensitive to evaluate for rib
fractures. Multiple right-sided and left-sided anterolateral rib
fractures
are seen; likely ___ on the right and ___ on the left. Please
see CTA of the chest for further details from earlier the same
day.
Brief Hospital Course:
Primary Reason for Admission: ___ y/o man with PMHx significant
for CAD s/p CABG (___), AS s/p tissue AVR (___), BPH, DMII c/b
neuropathy and charcot foot with multiple hospital admissions
for mechanical falls c/b fractures (ribs, pelvis, sacrum)
presenting with MSK chest pain.
.
Active Problems:
.
# Chest Pain: Pt's pain was positional, reporducible with
palpation and not associted with exertion. Troponins were
slightly elevated 0.04-0.05, though CKBM was normal (see
results). Given recent h/o falls, suspicion was for rib
fractures. CT chest confirmed multiple subacute rib fractures
and the patient's pain was treated with Toradol, Tylenol,
Lidocaine patch and Oxycodone. Given his multiple fractures,
Social Work was consulted due to conern for elder abuse. After a
lengthy discussion with the patient, it was determined there was
no elder abuse involved in the patient's injuries and that his
fractures were due to falls. PE was ruled out with CTPA.
Troponin leak was felt to be ___ demand in the setting of mild
fluid overload given BLE edema, orthopnea and elevated JVP.
.
TRANSITIONAL ISSES: The patient should not return to the
emergency room for chest pain that is reporducible with
palpation, pain that is positional or pain that readily responds
to Oxycodone.
.
# Frequent Falls: Pt has been hospitalized multiple times
recently with falls, mechanical in nature. He has severe
diabetic peripheral neuropathy and Charcot foot, which makes him
very unsteady on his feet. Falls often occur when the patient is
attmepting to stand to use the bathroom. Given his considerable
diuretic requirement and BPH, the patient urinates frequently.
As such, he should be placed on a q2h urination schedule and
should be prompted with urainte every 2 hours by RN or other
qualified person at ___. He will require assistance with
ambulation and should also be on bed/chair alarms.
.
# Pain Control: Pt has considerable pain from his multiple rib
fractures. For this, he should take standing Tylenol 1g TID as
well as Oxycodone prn as prescribed. He should also have a
Lidocaine Patch applied daily to painful areas of his chest.
Furthermore, given his pain is positional and assocaited with
movement, he should be pre-medicated with appropriate analgesics
before bed/chair transfers or other physical activity.
.
# CHF: Pt has known CHF, though no records in ___ system. He
had previously been followed by a Cardiologist in ___ care
will now be transferred to Dr. ___. On HD#1, pt was given
80mg IV Lasix with excellent response (-2L). On HD two the
patient was no longer orthopnic and he was restarted on Bumex,
which was increased to 3mg po bid. At the time of discharge, he
was comfortable on RA and his BLE edema was improved. He will
see Dr. ___ in Cardiology clinic on ___ for ongoing
management of his CHF.
.
# BLE Ulcers: Wound care as follows:
Pressure ulcer care per guidelines:
Turn and reposition off back q 2 hours and prn
Limit sit time to 1 hour at a time using a pressure
redistribution cushion
For coccyx: Cleanse wound with wound cleanser then pat dry then
place Mepilex border 6x6 change every 3 days
For ___: Cleanse wound with wound cleanser then pat dry apply
aloe vesta to dry intact tissues cover wound with Adaptic -
nonadherent dressing followed by dry gauze and/or ABD pad wrap
with Kerlix change daily
.
Chronic Problems:
.
# CAD:
- Cont Metoprolol
- Cont Simvastatin
- Cont ASA 81
.
# BPH:
- Cont finasteride
- Cont tamsulosin
.
# DMII:
- Cont Glyburide and ISS as directed
.
# Hypothyroidism:
- Cont levothyroxine
.
# MDD:
- Cont sertraline
.
# GERD:
- Cont omeprazole
.
Transitional Issues: Pt was discharged back to ___ of ___
___. Social work felt there was NO component of elder abuse in
the patient's rib fractures. Q2 hour urination schedule,
assistance with ambulation and bed/chair alarms should be
employed to reduce this patient's fall risk and risk for
readmission. He should not return to the hosptial for chest pain
that is reporducible with palpation, pain that is positional or
pain that readily responds to Oxycodone. He will follow up with
Dr. ___ his CHF and CAD.
Medications on Admission:
aspirin 81 mg daily
colace 100 mg bid
finasteride 5 mg daily
glyburide 5 mg daily
lactobacillus 1 tab tid prior to meals
levothyroxine 50 mcg daily
lorazepam 0.5 mg tablet qhs
metoprolol SUCCinate 25 mg qam, 12.5 mg qpm
multivitamin daily
omeprazole 20 mg qhs
senna 2 tabs BID
sertraline 50 mg daily
tamsulosin 0.4 mg daily
vitamin d3 1000 units daily
Tylenol ___ mg q6h prn pain/fever
bumex 2 mg PO BID at 6am and 2pm
novolog sliding scale
sorbital 15 mg PO q tues and ___
Sorbital 15 mg PO daily prn constipation
Lovenox 30 mg SC daily
Bisacody 10 mg daily prn constipation
fleet enema prn
milk of magnesia 30 mg daily prn constipation
ambien 5 mg qhs insomnia
ativan 0.5 mg q8h prn anxiety
vicodin ___ PO bid
vicodin ___ q4h prn breakthrough pain
simvastatin 40 mg qhs
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO QAM (once a day (in the
morning)).
7. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
0.5 Tablet Extended Release 24 hr PO HS (at bedtime).
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
12. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
14. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. bumetanide 2 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
16. sorbitol 70 % Solution Sig: One (1) Miscellaneous DAILY
(Daily) as needed for constipation.
17. glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
18. lactobacillus acidophilus 100 million cell Capsule Sig: One
(1) Capsule PO three times a day: prior to meals.
19. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED): sliding scale as directed.
20. Lovenox 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous once
a day.
21. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
22. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for chest pain: apply to rib fractures as needed for
chest pain.
23. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for severe pain.
24. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Rib Fractures
Secondary Diagnosis:
CHF Exacerbation
Dementia
CAD
___
MDD
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 caring for you at the ___
___. You were admitted for chest pain and fluid
overload. Your chest pain is from rib fractures. For your fluid
overload, we gave you IV diuretics and increaed your home Bumex
dose. You are now safe to return home.
Please note the following changes to your mediacitons:
INCREASED Bumex to 3mg by mouth twice a day
STARTED Tylenol 1g by mouth three times a day
STARTED Lidocaine Patch to rib fractures daily for pain
STARTED Oxycodone 2.5mg by mouth as needed for pain
Thank you for allowing us to participate in your care.
Followup Instructions:
___
|
10228499-DS-17 | 10,228,499 | 28,180,590 | DS | 17 | 2183-06-30 00:00:00 | 2183-07-01 15:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
leg pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo male with sickle cell disease (SC trait), Type 2 DM
presents with progressive right thigh and left ankle pain,
consistent with prior pain crises. Patient has been trying to
hydrate over the past few days, but symptoms have progressed.
He presented to ___ today, and was triaged to the ED for further
evaluation.
In the ED:
VS: 97.9 78 128/78 18 100% RA
received IVF, morphine, Dilaudid, and admitted for further
evaluation.
Upon arrival to the floor, patient noted improved right knee
pain. No back pain, although the right hip pain does radiate
down to foot at times. Pain best described as stabbing. Right
knee pain worse with movement, worse with weight-bearing.
Denies recent trauma at work. No fevers or chills at home.
Pain typical of past sickle cell pain crises.
12 point ROS notable for lack of chest pain, fever, cough,
dyspnea, abdominal pain, and dysuria. No bowel/bladder
incontinence, no lower extremity weakness or numbness. All
other ROS negative.
Past Medical History:
- Hemoglobin SC disease
- Diabetes mellitus diagnosed in ___.
- History of positive PPD, which was not treated based on
patient preference.
- History of laser treatment to the eyes secondary to sickle
cell retinopathy.
- "Enlarged heart" diagnosed on the chest x-ray.
- Pterygium in the both eyes.
- Screening colonoscopy in ___. An adenomatous polyp was
found.
- History of sciatica which was treated conservatively.
- Necrosis in the right distal femur based on MRI ___.
Social History:
___
Family History:
The patient's children have sickle cell trait.
The patient's brother died in ___ from hypertension
complications.
Physical Exam:
Admission Physical Exam:
VS: 98.7 135/78 HR 7 RR 18 98% RA
General: pleasant, well-appearing, no distress
HEENT: anicteric sclerae, clear oropharynx
Neck: no cervical or clavicular lymphadenopathy
CV: RRR, normal S1, S2, no murmurs
Pulm: lungs clear to auscultation bilaterally
Abd: soft, non-tender, (+) splenomegaly
Skin: no rash
Ext: 2+ radial and DP pulses, no edema. right knee with (+)
crepitus, pain over medial joint line. ___ test negative.
Straight leg raise test negative. No hip pain with full ROM.
No lumbar back pain.
Neuro: strength ___ in RLE hip flexion, limited due to pain in
right knee. DTRs 1+ throughout, CNs and sensation grossly
intact
Psych: pleasant, appropriate
Discharge Physical Exam:
Vital Signs: AFVSS
GEN: Alert, NAD
HEENT: NC/AT
CV: RRR, no m/r/g
PULM: CTA B
GI: S/NT/ND, BS present, splenomegaly
EXT:
R Knee -> TTP on the inferomedial aspect of the joint, FROM, no
deformities
___ strength in both ___
Pertinent Results:
Admission Labs:
___ 04:35PM BLOOD WBC-5.1 RBC-4.57* Hgb-11.9* Hct-34.9*
MCV-76* MCH-26.0* MCHC-34.0 RDW-17.9* Plt Ct-68*
___ 04:35PM BLOOD Neuts-52 Bands-0 ___ Monos-3 Eos-1
Baso-0 Atyps-4* ___ Myelos-0
___ 04:35PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-3+ Polychr-NORMAL Target-1+
___ 04:35PM BLOOD Glucose-102* UreaN-11 Creat-0.8 Na-139
K-3.8 Cl-104 HCO3-24 AnGap-15
___ 04:35PM BLOOD ALT-14 AST-20 AlkPhos-55 TotBili-1.1
___ 04:35PM BLOOD Lipase-36
___ 04:35PM BLOOD Albumin-4.6
___ 10:46AM BLOOD %HbA1c-4.8 eAG-91
___ 10:46AM BLOOD LDLmeas-60
___ 05:47PM BLOOD Lactate-1.1
Discharge Labs:
___ 07:15AM BLOOD WBC-2.8* RBC-3.60* Hgb-9.6* Hct-27.4*
MCV-76* MCH-26.6* MCHC-35.1* RDW-17.6* Plt Ct-55*
___ 07:12AM BLOOD Glucose-105* UreaN-7 Creat-0.8 Na-142
K-4.3 Cl-108 HCO3-27 AnGap-11
___ 07:12AM BLOOD Calcium-8.7 Phos-2.6* Mg-1.8
___ 03:20PM URINE Color-Straw Appear-Clear Sp ___
___ 03:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
Blood Cx PENDING X 2
CXR - IMPRESSION: No acute cardiopulmonary process.
Right Knee Films - IMPRESSION:
Mild to moderate tricompartmental osteoarthritis, somewhat
progressed as compared to ___.
Brief Hospital Course:
___ y/o M with PMHx of hemoglobin SC disease, DM, who presents
with RLE pain for the past 4 days, typical of prior sickle cell
crises.
# RLE Pain: Pt reported that his symptoms were consistent with
prior sickle cell crises. While patients with hemoglobin SC are
less likely to have pain crises, it is still possible.
Considering x-ray findings, there may also have been a component
of osteoarthritis contributing. Given stable knee exam, low
suspicion for ligamentous tear. Pt was treated conservatively
with IVFs, O2, narcotics. Pain improved, and he was discharged
home.
# Leukopenia: Of note, on the day of discharge, the patient was
noted to have a leukopenia (WBC 2.8) of unclear etiology. Diff
was added on, and the patient was not neutropenic. While the
patient has had low WBC's in the past, this was lower than he
has previously been. He was instructed to f/u with his PCP this
week for repeat CBC. He was also instructed to return to the ED
if he has any fevers.
# Hemoglobin SC Disease: As above, presentation concerning for
pain crisis as above. Hct ranged ___ throughout admission.
# Thrombocytopenia: Likely ___ hemoglobin SC disease and splenic
sequestration. Plts at baseline. No e/o bleeding.
# DM2, controlled, without complications: On metformin.
TRANSITIONAL ISSUES:
- Pt presented with RLE pain typical of prior pain flares.
Resolved with conservative management (IVFs, O2, narcotics). Of
note, R knee films did show OA, which could also be
contributing.
- Labs on d/c notable for leukopenia (2.8), which is new. Diff
did not show neutropenia. Pt will need to follow-up with PCP in
the next few days for repeat CBC.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 500 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Ferrous Sulfate 325 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. MetFORMIN (Glucophage) 500 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Hemoglobin SC 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:
You presented to the hospital with pain in your right leg, which
was consistent with your prior sickle cell pain flares. Your
symptoms improved with conservative management, and you are now
being discharged home.
You can use over-the-counter tylenol for any pain you have at
home.
As we discussed, on the day of discharge, one of your blood
numbers (your "white blood cell count") was low. You should
follow up with your PCP to recheck this. It is VERY important
that you talk with your PCP or come back to the emergency room
if you develop any fevers.
It was a pleasure taking part in your medical care.
Followup Instructions:
___
|
10228499-DS-18 | 10,228,499 | 27,935,730 | DS | 18 | 2186-08-05 00:00:00 | 2186-08-05 15:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
neck/back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ with the history below who presented to
___ ED today from clinic for neck/back pain and dizziness.
___ male patient with ___ adult onset diabetes mellitus,
positive PPD, splenomegaly and thrombocytopenia, thought likely
secondary to sickle cell disease who presents with neck/back
pain.
The patient presented today to clinic with 1 week history of
neck/back pain. Patient reports that going back a week he woke
up with neck pain, thinking he had slept on it wrong. Up until
two days ago the pain was intermittent. 2 days ago it became
constant. The pain starts at the base of the skull posteriorly
and radiates down along his spine to the mid back. The pain is
exacerbated by rotation of neck. It is not particularly TTP. The
patient has never had these symptoms or pains prior. No fever,
no chills, no rash, no photophobia, no blurred or double vision.
No bowel or bladder incontinence, able to ambulate without
support.
The patient also reported lightheadedness/dizziness in this
context. However, upon further clarification, it appears that he
experiences these brief episodes of lightheadedness often and
they go back decades. He denies any vertigo, but sometimes he
will feel lightheaded when he gets up to walk. He reports that
as he walks it resolves spontaneously. He has not been evaluated
for this as far as he can remember. There is no associated
hearing issues. He never gets lightheaded at rest. He has never
lost consciousness.
Past Medical History:
- Hemoglobin SC disease
- Diabetes mellitus diagnosed in ___.
- History of positive PPD, which was not treated based on
patient preference.
- History of laser treatment to the eyes secondary to sickle
cell retinopathy.
- "Enlarged heart" diagnosed on the chest x-ray.
- Pterygium in the both eyes.
- Screening colonoscopy in ___. An adenomatous polyp was
found.
- History of sciatica which was treated conservatively.
- Necrosis in the right distal femur based on MRI ___.
Social History:
___
Family History:
The patient's children have sickle cell trait.
The patient's brother died in ___ from hypertension
complications.
Physical Exam:
Admission exam:
Afebrile and vital signs stable (reviewed in bedside record)
General Appearance: pleasant, comfortable, no acute distress
Eyes: PERLL, EOMI, no conjuctival injection, anicteric
ENT: no sinus tenderness, MMM, oropharynx without exudate or
lesions, no supraclavicular or cervical lymphadenopathy, no JVD.
Mild TTP at posterior skull base. No TTP along spine or
paraspinal region.
Respiratory: CTA b/l with good air movement throughout
Cardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops
Gastrointestinal: nd, +b/s, soft, nt, no masses or HSM
Extremities: no cyanosis, clubbing or edema
Skin: warm, no rashes/no jaundice/no skin ulcerations noted
Neurological: Alert, oriented to self, time, date, reason for
hospitalization. Cn II-XII intact. ___ strength throughout.
No sensory deficits to light touch appreciated. Psychiatric:
pleasant, appropriate affect. No nystagmus.
GU: no catheter in place
Discharge exam:
vitals: 98.0 PO 132/77 87 18 99 RA
General: well appearing elderly man, no acute distress
HEENT: PERRL, EOMI, oropharynx is clear, neck is supple, there
is some pain with ROM with rotation, rotation is limited at
about 70 degrees on the left and right
CV: r/r/r, no murmurs
Resp: CTA bilaterally
GI: soft, nontender, nondistended
Ext: wwp, no edema
Msk: no TTP along the cervical, lumbar, or thoracic spine, no
paraspinal muscle tenderness
Neuro: CN II-XII intact, moving all extremities, sensation
intact
Pertinent Results:
Laboratory studies:
___ 04:20PM URINE HOURS-RANDOM
___ 04:20PM URINE UHOLD-HOLD
___ 04:20PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 03:12PM LACTATE-1.9
___ 12:40PM GLUCOSE-296* UREA N-12 CREAT-0.8 SODIUM-138
POTASSIUM-5.1 CHLORIDE-100 TOTAL CO2-25 ANION GAP-18
___ 12:40PM estGFR-Using this
___ 12:40PM WBC-4.6 RBC-4.59* HGB-11.7* HCT-34.0* MCV-74*
MCH-25.5* MCHC-34.4 RDW-16.8* RDWSD-44.5
___ 12:40PM NEUTS-43.2 ___ MONOS-4.5* EOS-1.5
BASOS-0.4 IM ___ AbsNeut-2.00 AbsLymp-2.32 AbsMono-0.21
AbsEos-0.07 AbsBaso-0.02
___ 12:40PM ___ PTT-30.2 ___
___ 12:40PM PLT COUNT-66*
___ 12:40PM RET AUT-3.7* ABS RET-0.17*
Imaging:
MRI C- T- and L-spine
IMPRESSION:
1. No evidence of cord compression or abnormal enhancement to
suggest
infectious process.
2. Multilevel degenerative changes of the cervical and lumbar
spine, as
detailed above.
Brief Hospital Course:
Mr. ___ is a ___ man with h/o sickle cell disease c/b
splenomegaly and thrombocytopenia and diabetes mellitus who p/w
neck/back pain, likely due to radiculopathy.
# Neck/back pain
# cervical radiculopathy
# degenerative disc disease
MRI C-, T-, and L-spine reassuring for any acute spinal
pathology but showing multi-level degenerative disc disease.
Symptoms are most consistent with cervical radiculopathy given
numbness and tingling at the fingers and toes. ___ have
musculoskeletal component given muscular pain at the base of the
head. Not likely related to sickle cell disease given stable h/h
and lack of hemolysis on labs (see below). Patient was given a
soft collar to use as needed and at night. He was referred to
outpatient ___, and started on Tylenol and tramadol as needed for
pain. At discharge, pain was well controlled and patient
ambulated independently.
# Lightheadedness
Chronic in nature and thus unlikely to be related to presenting
symptoms. Appears to orthostatic, though orthostatic vitals were
negative. Patient encouraged to maintain hydration.
# SCD
Labs on admission were not consistent with hemolysis with stable
h/h, normal LDH, normal tbili, and stable reticulocyte count.
Home folic acid was continued.
# DM: Patient requested refill of his metformin, which was done.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. MetFORMIN (Glucophage) 500 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO TID
RX *acetaminophen 325 mg 2 tablet(s) by mouth TID:prn Disp #*30
Tablet Refills:*0
2. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
RX *tramadol 50 mg ___ tablet(s) by mouth q4h:prn Disp #*10
Tablet Refills:*0
3. FoLIC Acid 1 mg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Cervical radiculopathy
Degenerative disc disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure caring for you during your stay at ___
___ ___. You were admitted for pain in your
neck and back. You had an MRI which showed degenerative disease.
We believe your pain is related to arthritis and not your sickle
cell disease. You should continue to do physical therapy as an
outpatient. You should use Tylenol as needed for the pain.
Please wear your soft collar at night and during the day as
needed to help with the pain.
Take care,
Your ___ Team
Followup Instructions:
___
|
10228499-DS-19 | 10,228,499 | 26,251,808 | DS | 19 | 2189-05-09 00:00:00 | 2189-05-13 21:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
body pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ male with history of sickle
cell disease with alpha thalassemia who presented from clinic to
the ED with 3 days of body aches, headache, pain in his lower
back and legs c/f sickle cell pain crisis.
Pt presented to his PCP ___ 1 week of whole body aches that
worsened over the last 2 days. Specially, pain is worse over his
bilateral knees, legs and back. His left hip/leg is the most
painful and feels a bit stiff. Symptoms are similar to prior
pain
crises which he gets every ___ years. He has been taking
naproxen
at home; does not use opiates (though was recently prescribed
acetaminophen with codeine).
In the ED:
- Initial vital signs: 97.7 83 154/89 14 97% RA
- Exam unremarkable.
- Labs were notable for: plt 66 (at baseline), hb 11 (at
baseline), wbc 3.5 (normal diff)
- Studies performed include: CXR, unremarkable
- Patient was given: 4 mg IV morphine, 6U insulin, 1,000 mg
acetaminophen PO x2
- Consults: merit
Vitals on transfer: 97.9 85 117/65 18 98% RA
Upon arrival to the floor, patient feels much better. He can
actually move his left leg with full range of motion and says
the
pain is nearly gone. He has no other complaints including fever,
poor appetite or abdominal symptoms. He denies shortness of
breath or cough. He is urinating normally.
REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise
negative.
Past Medical History:
- Hemoglobin SC disease
- Diabetes mellitus diagnosed in ___.
- History of positive PPD, which was not treated based on
patient preference.
- History of laser treatment to the eyes secondary to sickle
cell retinopathy.
- "Enlarged heart" diagnosed on the chest x-ray.
- Pterygium in the both eyes.
- Screening colonoscopy in ___. An adenomatous polyp was
found.
- History of sciatica which was treated conservatively.
- Necrosis in the right distal femur based on MRI ___.
Social History:
___
Family History:
The patient's children have sickle cell trait.
The patient's brother died in ___ from hypertension
complications.
Physical Exam:
ADMISSION EXAM
VITALS: 24 HR Data (last updated ___ @ 2332)
Temp: 97.9 (Tm 97.9), BP: 117/65 (117-146/65-66), HR: 85
(85-89), RR: 18, O2 sat: 98% (96-98), O2 delivery: Ra, Wt: 149.6
lb/67.86 kg
GENERAL: Alert and interactive. In no acute distress.
HEENT: dry lips, Sclera anicteric and without injection.
CARDIAC: borderline tachycardia, regular rhythm and no murmurs
RESP: Clear to auscultation bilaterally.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
MSK: No spinous process tenderness. No CVA tenderness.
EXT: no edema. normal ROM. mild tenderness over palpation of
left
hip. Pulses DP/Radial 2+ bilaterally.
NEUROLOGIC: AOx3.
PSYCH: appropriate mood and affect
DISCHARGE EXAM
VITALS: ___ 1129 Temp: 97.9 PO BP: 129/65 L Lying HR: 91
RR:
18 O2 sat: 99% O2 delivery: Ra FSBG: 393
GENERAL: Alert and interactive. In no acute distress.
CARDIAC: borderline tachycardia, regular rhythm and no murmurs
RESP: Clear to auscultation bilaterally.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
Pertinent Results:
ADMISSION LABS
___ 10:45AM BLOOD WBC-3.5* RBC-4.22* Hgb-11.0* Hct-31.9*
MCV-76* MCH-26.1 MCHC-34.5 RDW-16.7* RDWSD-44.9 Plt Ct-66*
___ 10:45AM BLOOD Neuts-48.3 ___ Monos-6.2 Eos-2.8
Baso-0.6 Im ___ AbsNeut-1.71 AbsLymp-1.48 AbsMono-0.22
AbsEos-0.10 AbsBaso-0.02
___ 07:43AM BLOOD ___ PTT-28.9 ___
___ 10:45AM BLOOD Ret Aut-3.0* Abs Ret-0.12*
___ 10:45AM BLOOD Glucose-156* UreaN-11 Creat-0.9 Na-141
K-4.0 Cl-105 HCO3-25 AnGap-11
___ 07:43AM BLOOD ALT-8 AST-14 LD(LDH)-179 AlkPhos-60
TotBili-1.0
___ 07:43AM BLOOD Calcium-9.4 Phos-3.5 Mg-1.6
___ 07:43AM BLOOD Hapto-<10*
___ 10:57AM BLOOD Lactate-1.2
DISCHARGE LABS
___ 07:43AM BLOOD WBC-3.0* RBC-3.78* Hgb-10.0* Hct-28.5*
MCV-75* MCH-26.5 MCHC-35.1 RDW-16.6* RDWSD-44.8 Plt Ct-56*
___ 07:43AM BLOOD Glucose-199* UreaN-12 Creat-0.9 Na-144
K-4.1 Cl-107 HCO3-23 AnGap-14
MICROBIOLOGY
___ 11:48 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING/STUDIES
CXR ___:
IMPRESSION:
No acute cardiopulmonary abnormality.
Brief Hospital Course:
___ is a ___ male with history of Hemoglobin SC with alpha
thalassemia who presented from clinic to the ED with 3 days of
body aches, headache, pain in his lower back and legs consistent
with hemoglobin SC pain crisis. He was treated with IV fluids
and Tylenol with improvement in his symptoms prior to discharge.
His Hb remained stable not requiring any blood product
transfusions.
TRANSITIONAL ISSUES
===================
[ ] NEW/CHANGED MEDS
- None
[ ] Measure CBC and hemolysis labs at PCP ___ in 1 week
[ ] Will refer back to Dr. ___ for ongoing
management of his hemoglobin SC
ACUTE ISSUES
=================
# Hemoglobin SC pain crisis - History of Hb SC disease and alpha
thalassemia trait followed previously by Dr. ___ in hematology
last seen in ___. Patient was referred to the ED with bilateral
hip and R knee pain concerning for Hemoglobin SC crisis. His
symptoms rapidly improved with 1L IVF and Tylenol. He did not
require any opioid pain meds. His hemoglobin was 10 within his
baseline. His haptoglobin was <10 he is likely having low grade
hemolysis. He did not require any PRBC transfusions. CXR was
normal showing no signs of acute chest syndrome. He was advised
to continue to maintain adequate PO intake, can take Tylenol PRN
for pain. Given his anemia, pain crisis, and ongoing
thrombocytopenia, he was arranged for ___ with Dr. ___.
He will continue with folic acid supplementation. Will make
transitional issue for PCP to ___ CBC and hemolysis labs
at ___.
# Pancytopenia - On admission, his WBC 3.5 with normal diff, Hb
11 and plt 66, both of which are at baseline. He has known
splenomegaly as well which is likely the etiology of his known
thrombocytopenia as per last evaluation by his Hematologist.
CHRONIC ISSUES:
===============
# DMII - His home metformin, glyburide were held during
admission and placed on SSI. His home oral agents were resumed
at discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN XR (Glucophage XR) 1500 mg PO DAILY
2. Naproxen 500 mg PO BID:PRN Pain - Moderate
3. GlipiZIDE XL 10 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. FoLIC Acid 1 mg PO DAILY
3. GlipiZIDE XL 10 mg PO DAILY
4. MetFORMIN XR (Glucophage XR) 1500 mg PO DAILY
5. Naproxen 500 mg PO BID:PRN Pain - Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
- Hemoglobin SC pain crisis
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 initially came to the hospital because of worsening hip and
knee pain that was thought to be a sickle pain crisis. You were
given IV fluids and Tylenol which helped improve your symptoms.
Please ___ with your PCP and also Dr. ___. Continue to
take all of your medications as prescribed.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10228633-DS-13 | 10,228,633 | 26,805,687 | DS | 13 | 2139-07-01 00:00:00 | 2139-07-03 00:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
Malaise, weakness
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
___ with history of AFib (on coumadin), CHF (class III), CKD
(stage 3), and HTN referred to the ED by his PCP ___ having
3 days of malaise, weakness, fatigue, fever to 102, and
dehydration. PCP also is concerned about his worsening renal
dysfunction. Pt's daughter states he has not been able to get up
from off the couch ___ three days due to weakness. She believes
he could have had a fever for the last few days but only got it
checked at his appointment this AM. Patient denies dyspnea. No
cough.
___ the ED, initial vitals were T 102 HR 110 BP 105/60 RR 32 O2
95% on RA. UA was significant for RBC, few bacteria, and
hyaline casts. On collection, urine was dark/clear/foul
smelling. Labs notable for K+ of 3.2, BUN of 56, Cr of 2,
glucose of 212, Hct of 35.5, WBC of 7.3, and INR of 2.9. CXR
showed L upper and mid lung consolidation and small left pleural
effusion. 1 liter of fluids given, 2nd bag hung, 500cc bolus
given due to BP 75/23. Foley and central line were placed.
Ceftriaxone (1g) and azithromycin (500mg) given.
On arrival to the MICU, vitals 100.6 115 (afib) 131/51 19 97%
RA, CVP 13. IJ placed.
At baseline, patient is active. A week ago he was cleaning his
yard without difficulty. Reports 18lb weight loss over 4 months.
Past Medical History:
1. Atrial fibrillation (on Coumadin)
2. Hypertension, essential
3. CHF NYHA class III (symptoms with mildly strenuous
activities)
4. CKD (chronic kidney disease) stage 3, GFR ___ ml/min
5. TAA
6. Pseudophakia, macular degeneration
7. Endophthalmitis
8. Gout
9. Testicular hypofunction
10. Gynecomastia
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION EXAM:
.
100.6 115 (afib) 131/51 19 97% RA, CVP 13.
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, bounding, no LAD
Lungs- Coarse crackles on L; R lung clear
CV- JVD, irregular rate, irregular rhythm. Murmur at LLSB; apex.
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
.
DISCHARGE EXAM:
97.6 100 91/43 18 99% on 3L
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, bounding, no LAD
Lungs- Coarse crackles on L; R lung clear
CV- Tachycardic, irregular rhythm. Murmur at LLSB and apex.
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION:
___ 01:22PM NEUTS-94.2* LYMPHS-2.1* MONOS-3.5 EOS-0.2
BASOS-0
___ 01:22PM GLUCOSE-212* UREA N-56* CREAT-2.0* SODIUM-135
POTASSIUM-3.2* CHLORIDE-96 TOTAL CO2-24 ANION GAP-18
___ 01:26PM LACTATE-1.7
___ 05:49PM LACTATE-2.2*
___ 11:55PM LACTATE-1.8
___ 01:53PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.0
LEUK-NEG
___ 01:53PM URINE RBC-4* WBC-0 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 08:06PM TYPE-CENTRAL VE TEMP-38.1 PO2-31* PCO2-38
PH-7.41 TOTAL CO2-25 BASE XS--1 INTUBATED-NOT INTUBA
.
CXR ___ opacity within the left upper and mid
lung field peripherally is concerning for pneumonia. Small left
pleural effusion. Followup radiographs after treatment are
recommended to ensure resolution of this finding.
.
DISCHARGE:
.
___ 03:03AM BLOOD WBC-5.1 RBC-3.53* Hgb-10.5* Hct-31.6*
MCV-89 MCH-29.9 MCHC-33.4 RDW-14.4 Plt ___
___ 03:03AM BLOOD Plt ___
___ 03:03AM BLOOD Glucose-143* UreaN-80* Creat-2.1* Na-138
K-3.4 Cl-102 HCO3-23 AnGap-16
___ 03:03AM BLOOD Calcium-9.4 Phos-5.3* Mg-2.4
___ 03:30AM BLOOD Type-CENTRAL VE Temp-36.7 O2 Flow-4
pO2-38* pCO2-39 pH-7.37 calTCO2-23 Base XS--2 Comment-NASAL ___
___ 03:30AM BLOOD Lactate-1.4
___ 2:55 pm SPUTUM Source: Expectorated.
.
SPUTUM CX:
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
___ 7:50 pm BLOOD CULTURE Source: Line-right TLC.
Blood Culture, Routine (Pending):
.
URINE CULTURE (Final ___: NO GROWTH.
.
CXR ___: Slight interval increase ___ the left lung
opacification.
.
ECHO: The left ventricular cavity is moderately dilated. The
left ventricular ejection fraction is severely reduced (LVEF =
20 %), primarily due to mechanical dyssynchrony with a typical
left bundle branch block-type activation sequence. The right
ventricular free wall thickness is normal. (___) aortic
regurgitation, moderate (2+) mitral regurgitation, significant
pulmonic regurgitation is seen. The end-diastolic pulmonic
regurgitation velocity is increased suggesting pulmonary artery
diastolic hypertension. Impression: reduced left ventricular
ejection fraction; marked intraventricular dyssynchrony;
consider cardiac resynchronization therapy if clinically
indicated
Brief Hospital Course:
___ M with hx of AFib, CHF, CKD, and HTN who presented with fever
and 3 days of malaise.
.
ACUTE ISSUES:
.
# PNEUMONIA: On admission, CXR was concerning for loculated
effusion, hemorrhagic effusion, pneumococcal pneumonia, and
possible mass. Fever, neutrophil predominance, and left mid- and
upper-lung consolidation made pneumonia very likely, and he was
treated for community acquired pneumonia. Received one dose of
ceftriaxone and azithromycin on day of admission (___) and was
transitioned to ceftriaxone and levofloxacin with first dose
___ for broader coverage against possible resistant organisms.
Narrowed to levofloxacin on ___ given sputum ___ showed GPC ___
pairs. Sputum culture revealed repiratory flora. Patient
developed hemoptysis during admission, hemodynamically stable.
Hemoptysis may be secondary to pneumococcal pneumonia or another
underlying pathology, such as malignancy. Patient remains
without dyspnea, cough, or leukocytosis on discharge. On ___,
he was transitioned to levofloxacin PO 750 Q48hr for a total of
3 doses as part of discharge planning. He received 1st dose of
PO on ___. Thus, he is to get one of ___ and last dose on
___. It is recommended to repeat CXR ___ 6 weeks and if lung
findings are persistent, to perform a CT-chest to r/o mass given
history of 15-lbs weight loss ___ the past 4 months.
.
# HYPOTENSION: Initial BP ___ ED 101/83. On lisinopril and lasix
at home. Episode of hypotension ___ ED (75/23) responded to
fluid bolus. Given SIRS and known infectious source, concern
was for sepsis. Lactate peaked at 2.2 and subsequently returned
to normal. CvO2 of 54 suggested possible contribution of
cardiogenic shock, especially given his class III CHF. CvO2
since risen to 75; echo demonstrates EF = 20%. ___ MICU, patient
maintained SBP 100s-110s during day with transient drops to
___ overnight, requiring fluid bolus on night of ___. On
___, lasix resumed with maintenance of normotension.
Lisinopril held throughout. On discharge SBP ___.
.
Afib: Pt on metoprolol and coumadin at home. On presentation to
the ED, pt ___ Afib to 110; however, given setting of
hypotension, metoprolol was held. Upon MICU arrival, he was
tachycardic to 120-150. He was given multiple metoprolol IV 5mg
to control his rate. He responded well. With his BP becoming
more stable, he was started on metoprolol 25mg TID, changed from
home dose BID. His coumadin was held at times due to
supratherapeutic INR 4.8 but was resumed once INR became
therapeautic. Given setting of hemoptysis, risk vs. benefit
ratio must be reassessed.
.
# ACUTE-ON-CHRONIC SYSTOLIC HEART FAILURE EXACERBATION: History
of Class III systolic CHF. Idiopathic per ___ cardiologist
note. EF: 29% by ___ ___ 35%, by ___ (___). At home on
lasix 80mg BID daily, lisinopril 20mg daily, and metoprolol 50mg
daily. Per cardiology notes, patient is clinically stable.
Last BNP: 497 (___). Denies orthopnea or PND. Received 2.5L
fluid ___ ED. New echo shows EF = 20%. Restarted on home
metoprolol and lasix. Upon return to stable BP, lasix at home
dose was started on ___.
.
# HYPOKALEMIA: 3.2 on admission, repleted. On hospital day 3, K+
of 3.4, repleted again. Likely medication effect (lasix) vs.
poor recent PO intake. Recovered upon discharge.
.
CHRONIC ISSUES:
# CHRONIC KIDNEY DISEASE: Stage III CKD. Per Atrius notes,
baseline Cr 1.7. BUN, Cr 56, 2.0 on admission, like prerenal
etiology given ratio: dehydration (poor PO intake x3 days) vs.
poor perfusion secondary to CHF exacerbation. BUN, Cr rose to
80, 2.1 during admission ___ setting of diuresis. Creatinine
returned to baseline of 1.6 upon dicharge. However, lisinopril
was held throughout given low BP.
.
# ANEMIA: Baseline Hct = 41-44. Hct since admission: 35.5->33.9
->30.3->31.6. No hematemesis or melena. Hemorrhagic effusion
vs. myelosuppression (given drop ___ platelets) ___ setting of
possible malignancy. Upon discharge, all blood counts improved.
Hct remained stable.
.
# THROMBOCYTOPENIA: Baseline platelet count 120s. Since
admission, 122->90. As noted above, concern for
myelosuppression given anemia and possibility of malignancy.
Improved upon discharge.
.
# GOUT: acute episodes managed most recently with prednisone
___ NSAIDs and colchicine use minimized due to renal
impairment.
.
TRANSITIONAL ISSUES:
.
# LUNG CONSOLIDATION: Given pneumonia, smoking history, recent
unintentional weight loss, and hemoptysis, concern for lung
malignancy. CXR should be repeated ___ 6 weeks, and pending
resolution of pneumonia but persistence of L lung opacification,
outpatient chest CT may be warranted.
# Pneumonia treatment: levofloxacin 750 mg PO Q48hr: one dose on
___ and last dose on ___.
# AFib on coumadin ___ the setting of hemoptysis: Given setting
of hemoptysis and INR 2.9 on discharge, coumadin was held on day
of discharge. F/u with PCP is warranted to assess risk vs.
benefit ratio of anticoagulation ___ the setting of hemoptysis
and ABX treatment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 4 mg PO DAILY16
2. Lisinopril 20 mg PO DAILY
3. Metoprolol Tartrate 25 mg PO BID
4. Furosemide 80 mg IV BID
Discharge Medications:
1. Levofloxacin 750 mg PO Q48H Duration: 2 Doses
Please dose ___ AM on ___ and ___ to complete treatment for
pnumonia
2. Furosemide 80 mg PO BID
3. Metoprolol Tartrate 25 mg PO Q 8H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
# Pneumonia, community aquired
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr ___,
It was a pleasure taking care of you at the ___
___. You were admitted for a pneumonia,
which was treated with antibiotics. Your blood pressure was
initially low, but improved as we treated your infection. You
are being discharged to a rehabilitation facility to regain your
strenght after being ___ the hospital.
Followup Instructions:
___
|
10228726-DS-9 | 10,228,726 | 29,855,923 | DS | 9 | 2165-06-19 00:00:00 | 2165-06-29 15:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Latex / Erythromycin Base / Indomethacin / Omalizumab /
Iodine-Iodine Containing / Meperidine
Attending: ___
Chief Complaint:
Asthma, Anisicoria
Major Surgical or Invasive Procedure:
Lumbar puncture in emergency room ___
History of Present Illness:
___ woman with multiple medical problems significant for
asthma, NIDDM, anxiety, depression, and HTN who presents after
two weeks of asthma exacerbation despite around the clock
duonebs on prednisone x6 days. Her symptoms began 10 days ago
when she started feeling chest tightness wheezing, and coughing
fits consistent with prior episodes of asthma, which gradually
worsened throughout the day. She began treating herself with
nebulizers and was seen at the office and sent to the ED for
tachycardia. She was treated with more nebulizations and started
on a prednisone taper, and was given IVF. She felt improved from
___ until this morning. She has had a worsening headache
throughout all of this, and complains of right sided "delay."
.
Her HA has been worse for the last three days and this morning
her husband noted that her right pupil was dilated after neb
treatment at ___ office. She was then sent to our ED for
concern for stroke.
.
In the ED: Labs were concerning for lactate of 8.4 which
improved to 3.3 with 4L IVF. Also tachycardic to 130s, improving
to ___ with IVF. Her labs were otherwise unremarkable. An LP was
done which was negative for infection or bleed. CXR - no acute
process. Head CT, no acute process. MRI/MRA done, not read.
Neuro consulted-> recommended LP, MRI/MRA and admit to medicine
with consult.
Vitals on transfer: 97.8,99,136/74,14,97%ra
.
Currently, fatigued, but comfortable and appropriate.
.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, vision changes, rhinorrhea,
congestion, sore throat, abdominal pain, vomiting, diarrhea,
constipation, dysuria, hematuria.
Past Medical History:
SUICIDE THREAT OR ATTEMPT, UNSPEC
DM (diabetes mellitus), type 2, uncontrolled
HISTORY HYSTERECTOMY INCLUDING CERVIX
CHEST PAIN, UNSPEC
COLONIC ADENOMA
COLONIC POLYP
DIVERTICULOSIS
CONSTIPATION - CHRONIC
FATTY LIVER
ARTHRALGIA, UNSPEC SITE
CYSTITIS - INTERSTITIAL
PALPITATIONS
ALLERGY, UNSPEC
ESOPHAGEAL REFLUX
HYPERTENSION - ESSENTIAL, BENIGN
DEPRESSIVE DISORDER
THYROID NODULE
OBESITY, UNSPEC
HYPERLIPIDEMIA
ANXIETY STATES
ASTHMA
Social History:
___
Family History:
Noncontributory
Physical Exam:
VS - Temp 97.7F, BP 136/69, HR 73, R , O2-sat % RA
Pulsus: 2
GENERAL - Fatigued looking middle aged woman, comfortable,
appropriate, NAD
HEENT - NC/AT, right pupil 5mm reactive, left pupil 4mm
reactive, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat - cough, no wheeze good air movement, resp
unlabored, no accessory muscle use
HEART - PMI, normal rate RR, I/VI SEM at upper sternal border,
nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ with the exception of her right foot 4+ with dorsal flexors,
sensation grossly intact throughout, hyper-reflexive left
patella, DTRs 2+ elsewise and symmetric
Pertinent Results:
Labs on Admission:
___ 04:16PM BLOOD WBC-10.0 RBC-4.26 Hgb-12.1 Hct-36.7
MCV-86 MCH-28.4 MCHC-33.0 RDW-12.9 Plt ___
___ 04:16PM BLOOD Neuts-89.7* Lymphs-8.7* Monos-0.9*
Eos-0.6 Baso-0.2
___ 04:16PM BLOOD ___ PTT-18.8* ___
___ 04:16PM BLOOD ___ 05:10PM BLOOD ESR-15
___ 04:16PM BLOOD Glucose-325* UreaN-21* Creat-1.0 Na-137
K-6.0* Cl-99 HCO3-18* AnGap-26*
___ 04:16PM BLOOD ALT-58* AST-39 LD(LDH)-335* AlkPhos-66
TotBili-0.2
___ 05:10PM BLOOD ALT-57* AST-27 CK(CPK)-21* AlkPhos-66
TotBili-0.2
___ 05:10PM BLOOD Lipase-24
___ 05:10PM BLOOD CK-MB-1 cTropnT-<0.01
___ 04:16PM BLOOD Calcium-9.8 Phos-3.6 Mg-1.9
___ 05:10PM BLOOD CRP-3.5
___ 04:16PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:17PM BLOOD Glucose-327* Lactate-8.4* K-8.4*
___ 05:30PM URINE Color-Straw Appear-Clear Sp ___
___ 05:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 05:30PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
___ 10:20PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* Polys-87
___ ___ 10:20PM CEREBROSPINAL FLUID (CSF) TotProt-23
Glucose-140 LD(LDH)-19
___ 10:20PM CEREBROSPINAL FLUID (CSF) Albumin-0
Labs on Discharge:
___ 05:25AM BLOOD WBC-9.6 RBC-3.73* Hgb-10.6* Hct-31.8*
MCV-85 MCH-28.5 MCHC-33.4 RDW-12.9 Plt ___
___ 05:30AM BLOOD Glucose-57* UreaN-17 Creat-0.7 Na-141
K-3.9 Cl-104 HCO3-26 AnGap-15
___ 05:30AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.2
___ 05:44AM BLOOD Lactate-1.5
Microbiology
___ 10:20 pm CSF;SPINAL FLUID #3.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
Imaging:
___ ___: No acute intracranial process.
.
CXR ___: No acute cardiopulmonary process.
.
MRI/MRA Brain ___: Unremarkable MRI and MRA of the brain.
Brief Hospital Course:
___ yo F with asthma exacerbation, who presents with symptoms
concerning for stroke, asthma exacerbation and elevated lactate.
.
.
# Asthma/Reactive airways: The patient was treated with
prednisone, nebulizers and cough suppressants, and her symptoms
improved. She was never hypoxic and her symptoms seemed chiefly
related to cough, supporting more of an allergic/reactive
airways etiology. CXR was not suggestive of an underlying
infectious etiology. She was discharged with a plan for a
prednisone taper, and a recommendation to be seen in pulmonary
clinic.
.
# Diabetes Mellitus: The patients oral hypoglycemic medications
were initially held on admission. With prednisone
administration, the patient had a significant increase in her
glucose to the 400s. She was then restarted on her home orals,
and told to increase home lantus to 10, as well as increase her
mealtime sliding scale. Patient was discharged with close PCP
follow up to help her manage sugars during her prednisone taper.
.
# Anisicoria: Patient presented with a headache and reportedly
nonreactive right pupil that was concerning for head bleed
versus stroke. Her symptoms had resolved on arrival to the ED;
she was seen by neurology who did not find any persistent
neurologic deficits. NCHCT and MRI/MRA of brain were
unremarkable and showed no bleed or evidence of infarction.
Patient also had an LP that was not suggestive of meningitis or
other infectious process. A possible explanation may be that
the patient somehow introduced nebulizer solution (such as
ipratropium) into one eye, causing her unilateral symptoms.
.
.
# Lactic acidosis: The patient had a significant elevation of
lactate on admission, which rapidly resolved with administration
of IVF. She had no evidence of end organ dysfunction or
infection. Her lactic acidosis was most likely an effect of
albuterol overuse.
.
# Hypertension: The patient's blood pressure was elevated during
the course of her hospitalization, but this was in the setting
of respiratory distress. She was instructed to follow-up with
her PCP regarding further management of her hypertension.
.
# Headache: Patient complained of headache that improved over
the course of her hospitalization. This was worsened with
valsalva and was felt to be most likely a post-LP headache. She
was treated with caffeine and low dose oxycodone, with
improvement in symptoms.
.
# Insomnia/anxiety: Patient was continued on home lorazapam, but
at a decreased dose. Her anxiety improved significantly as her
breathing improved.
Medications on Admission:
Albuterol sulfate prn
Advair 500-50 BID
Lantus 10
Novolog SSI
Prednisone 60mg daily (pred taper now increased)
cyclobenzaprine 10mg TID prn back spasm
Irbesartan 150mg daily
Darifenacin 7.5mg daily
nystatin powder
Fish Oil 1000mg daily
Epipen prn anaphylaxis
Fluticasone 50mcg spray Nasal daily
Aspirin 81mg daily
multivitamin 1 tab daily
Discharge Medications:
1. prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day for
6 days: Take 40 mg daily for three days, then 20 mg daily for
three days and then stop.
Disp:*9 Tablet(s)* Refills:*0*
2. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) for 1 weeks.
Disp:*30 Capsule(s)* Refills:*0*
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
5. Advair Diskus 500-50 mcg/dose Disk with Device Sig: One (1)
Inhalation twice a day.
6. insulin glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous once a day.
7. Novolog 100 unit/mL Solution Sig: ASDIR Subcutaneous four
times a day: ___ need to increase sliding scale while on
prednisone.
8. codeine-guaifenesin ___ mg/5 mL Syrup Sig: ___ MLs PO Q6H
(every 6 hours) as needed for cough.
Disp:*30 ML(s)* Refills:*0*
9. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for anxiety.
10. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
12. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for muscle spasms.
14. irbesartan 150 mg Tablet Sig: One (1) Tablet PO daily ().
15. darifenacin 7.5 mg Tablet Extended Release 24 hr Sig: One
(1) Tablet Extended Release 24 hr PO once a day.
16. glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
17. metformin 1,000 mg Tablet Sig: One (1) Tablet PO once a day.
18. omega-3 fatty acids Capsule Sig: One (1) Capsule PO
DAILY (Daily).
19. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
20. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Nasal once a day.
21. multivitamin Capsule Sig: One (1) Capsule PO once a day.
22. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO QID (4
times a day) as needed for itching.
23. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for pain for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Asthma excacerbation/Reactive airways disease
Lactic Acidosis
anisocoria
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital for an asthma exacerbation.
You had an elevation in your lactate, which we think was related
to dehydration in conjunction with use of albuterol. You also
had a dilated right eye, which resolved on its own. We did
imaging of your brain and consulted neurology, and it does not
appear that you had a stroke or any other abnormality of the
brain.
.
We made the following changes to your medications:
Take prednisone 40 mg for three days, 20 mg for three days and
then stop
Start tessalon perles three times daily as needed for cough
Start robitussin with codeine as needed for cough
Start Singulair daily
You will likely need to increase your insulin while taking
prednisone
You may restart metformin today
Followup Instructions:
___
|
10229025-DS-17 | 10,229,025 | 23,454,742 | DS | 17 | 2136-09-01 00:00:00 | 2136-09-01 20:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
Atrial Flutter
Major Surgical or Invasive Procedure:
TEE and cardioversion
History of Present Illness:
___ PMH sigificant for HTN, HLD, DM who initially presented to
his PCP with mild sinusitis symptoms, found to be in atrial
flutter. The patient said that he works as a ___ at
___ and a few of his coworkers have been having intermittent
viral like illnesses. He has had intermittent URI symptoms with
sinus congestion for over 1 months, but over the last few days
it has intensified with increasing pressure and nasal discharge.
He said that the mucus is green with associated sore throat.
No cough, chest pain, palpitations, nausea, vomiting,
diaphoresis. He went to his PCP for evaluation of sinusitis and
was found to be tachycardic and EKG with atrial flutter. He was
sent to the ___ for further evaluation and management.
He denies that his legs are swollen, no dyspnea on exertion, no
chest pain. He endorses palpitations, known to him to be PVCs
from prior workup.
The patient's vital signs when initially in the ___, T:98.5 HR:61
BP: 50/100 HR:20 O2Sat:97% ra. The patient CBC was within normal
limits without any significant predominance on the differential.
Chem 7 was unremarkable. EKG obtained showed atrial flutter with
2:1 and 3:1. good BP. CXR was unremarkable. As per documentation
within the ___ dash, a physician in the ___ spoke with Dr. ___
___ adviced that the patient be admitted for anticoagulation
with heparin to be bridged to coumadin. It is noted within the
___ that the patient is guaiac negative. In the ___, the patient
was administered metoprolol XR 200mg, heparin, asa 325,
quinapril 20mg, warfarin 10mg, lansoprazole 30mg, amlodipine
10mg and doxycycline 100mg x1. Vital signs prior to transfer
98.1 HR:115 BP:153/95 RR:16 O2 Sat:98%.
Upon arrival to the floor, the patient appeared well.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
-CABG: NONE
-PERCUTANEOUS CORONARY INTERVENTIONS: NONE
-PACING/ICD: NONE
3. OTHER PAST MEDICAL HISTORY:
DJD
Peptic Ulcer Diseasse in ___
Hernia Age ___
Palpitations
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION EXAM:
VS: T=98.0 BP=122/62 HR=120 RR=12 O2 sat= 98% RA
GENERAL: WDWN man in NAD. Oriented x3. Mood, affect appropriate.
HEENT: EOMI. Conjunctiva were pink, no pallor or cyanosis of the
oral mucosa.
NECK: Supple with JVP not elevated
CARDIAC: tachycardic, normal S1, S2. No m/r/g. No thrills,
lifts. No S3 or S4.
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: multiple tattoos
PULSES:
Right: radial 2+ DP 2+ ___ 2+
Left: radial 2+ DP 2+ ___ 2+
Neuro: CNII-XII intact, strenght and sensation intact.
.
DISCHARGE EXAM:
VS: 98.4, 149/101, 96, 18, 96%RA
GENERAL: WDWN man in NAD. Oriented x3. Mood, affect appropriate.
HEENT: EOMI. Conjunctiva were pink, no pallor or cyanosis of the
oral mucosa.
NECK: Supple with JVP not elevated
CARDIAC: tachycardic, normal S1, S2. No m/r/g. No thrills,
lifts. No S3 or S4.
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: multiple tattoos
PULSES:
Right: radial 2+ DP 2+ ___ 2+
Left: radial 2+ DP 2+ ___ 2+
Neuro: CNII-XII intact, strenght and sensation intact.
Pertinent Results:
CBC:
___ 12:07PM BLOOD WBC-8.6 RBC-5.14 Hgb-15.8 Hct-47.6 MCV-93
MCH-30.7 MCHC-33.2 RDW-12.7 Plt ___
___ 06:05AM BLOOD WBC-6.6 RBC-4.88 Hgb-14.9 Hct-44.5 MCV-91
MCH-30.6 MCHC-33.6 RDW-12.6 Plt ___
COAGS:
___ 12:07PM BLOOD ___ PTT-42.4* ___
___ 06:05AM BLOOD ___ PTT-150* ___
CHEM-10
___ 12:07PM BLOOD Glucose-506* UreaN-20 Creat-1.1 Na-133
K-5.0 Cl-94* HCO3-29 AnGap-15
___ 06:05AM BLOOD Glucose-137* UreaN-17 Creat-0.7 Na-140
K-3.3 Cl-102 HCO3-30 AnGap-11
___ 06:05AM BLOOD Calcium-9.5 Phos-3.9 Mg-2.1
___ 06:05AM BLOOD Calcium-8.8 Phos-4.3 Mg-1.9
A1c:
___ 06:05AM BLOOD %HbA1c-12.2* eAG-303*
IMAGING:
___ ECHO:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF 65%). The right ventricular
free wall thickness is normal. Right ventricular chamber size is
normal. with borderline normal free wall function. There are
focal calcifications in the aortic arch. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is no pericardial effusion.
___ CXR:
FINDINGS: PA and lateral views of the chest demonstrate no
focal consolidations worrisome for pneumonia. There are no
pleural surfaces abnormalities such as effusion. Cardiac size
is stable. No pneumothorax or pulmonary edema. Old rib
fractures noted on the left.
___ EKG:
Atrial flutter with rapid ventricular response. Diffuse
non-specific ST-T wave changes. No previous tracing available
for comparison.
Brief Hospital Course:
ASSESSMENT AND PLAN: ___ yo man with history of HTN, HLD, DMII
(unknown last A1c) presents from his PCP office in atrial
flutter.
# RHYTHM: The patient presented with new onset atrial flutter
found incidentally while in his primary care clinic for
sinusitis. He was admitted and monitored on telemetry. He was
seen by EP and plan for cardioversion, but it was delayed due to
uncontrolled serum glucose. He was started on a heparin drip
and we treated his diabetes as below. He was continued on his
metoprolol succinate 200mg PO Daily, ASA 81mg pO daily. He was
also started on coumadin for a CHADS score of 2. He was
successfully cardioverted on ___. He tolerated the procedure
well and was discharged home with a lovenox bridge. Dr. ___
will follow his INR while Dr. ___ is away and then Dr. ___
will manage his coumadin thereafter.
# HTN: Was normotensive throughout most of the hospitalization.
Continued his home medications as listed.
- Amlodipine 10 mg PO DAILY
- Metoprolol Succinate XL 200 mg PO DAILY
- Quinapril 20 mg PO DAILY
# Sinusitis: Given chronicity concern for bacterial
superinfection. Treated with doxycycline and his symptoms
greatly improved at the time of discharge. He will complete a
10 day course to finish on ___.
# Depression: It seems that the patient continues to be
depressed from the loss of his wife ___ years ago. While I only
spent a little time with him, he does not seem to have overcome
his grief. I suspect that part of his lack of engagement in his
medical care is secondary to this depression. While in house we
continued his medications.
- BuPROPion (Sustained Release) 300 mg PO QAM
- Citalopram 20 mg PO DAILY
# HLD: Continued Atorvastatin 40 mg PO DAILY
# DMII: The patient's A1c was 12.2. The patient claims he takes
his insulin, but he was receiving doses of insulin that was well
below his home dose and his sugars were well controlled in the
160s. When he refused the insulin it would rise to the 300s.
His actos was held and we continued him on lantus as well as an
insulin sliding scale. It may be that he does not follow a good
diet at home and needs the increased doses of insulin, while in
house he was on a diabetic diet. He was discharged on his home
insulin regiment and plan to follow up with his endocrinologist
on ___.
# Peptic Ulcer Diseasse in ___: COntinued Lansoprazole while
inpatient.
Transitional Issues:
- Will need close follow up to evaluate whether or not he needs
an ablation
- Continued management of his diabetes
- Further evaluation and treatment of depression
- He needs better personal engagement in his care.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pioglitazone 30 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
Hold for SBP<100
3. Lansoprazole Oral Disintegrating Tab 15 mg PO DAILY
4. Amlodipine 10 mg PO DAILY
5. BuPROPion (Sustained Release) 300 mg PO QAM
6. Citalopram 20 mg PO DAILY
7. Metoprolol Succinate XL 200 mg PO DAILY
Hold for HR<50, SBP< 95
8. Quinapril 20 mg PO DAILY
Hold for SBP<100
9. Aspirin 81 mg PO DAILY
10. Glargine 90 Units Bedtime
Insulin SC Sliding Scale using HUM InsulinMax Dose Override
Reason: home dose
11. Multivitamins 1 TAB PO DAILY
12. Chondroitin Sulfate *NF* (chondroitin sulf A sod
(bulk);<br>chondroitin sulfate A) 250 mg Oral Daily
Discharge Medications:
1. Enoxaparin Sodium 80 mg SC BID
RX *enoxaparin 80 mg/0.8 mL 80 mg INJ twice a day Disp #*14
Syringe Refills:*0
2. Warfarin 5 mg PO DAILY16
RX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
3. Amlodipine 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO DAILY
6. BuPROPion (Sustained Release) 150 mg PO BID
7. Citalopram 20 mg PO DAILY
8. Glargine 90 Units Bedtime
Insulin SC Sliding Scale using HUM InsulinMax Dose Override
Reason: home dose
9. Lansoprazole Oral Disintegrating Tab 15 mg PO DAILY
10. Metoprolol Succinate XL 200 mg PO DAILY
11. Quinapril 20 mg PO DAILY
12. Doxycycline Hyclate 100 mg PO Q12H Duration: 7 Days
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day
Disp #*14 Capsule Refills:*0
13. Chondroitin Sulfate *NF* (chondroitin sulf A sod
(bulk);<br>chondroitin sulfate A) 250 mg Oral Daily
14. Multivitamins 1 TAB PO DAILY
15. Pioglitazone 30 mg PO DAILY
16. Outpatient Lab Work
Please have your ___ drawn on ___ prior to your
clinic appointment. Have the results called in or faxed to Dr.
___. Thanks.
Dr. ___: ___
Fax: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Atrial Flutter
Secondary Diagnosis:
Diabetes
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you while you were admitted to
___ for your abnormal heart
rhythm. You were seen by our electrophysiologists who felt that
converting your heart to sinus rhythm would be the best
treatment for you. You had an ultrasound of the heart to make
sure there was no clot in your heart and then you were
electrocardioverted back to sinus rhythm. You tolerated the
procedure well and are now ready for discharge. It is important
that you take the lovenox until your coumadin is in therapeutic
range. The goal is to have your INR in the ___ range. You
should have your INR checked on ___.
Followup Instructions:
___
|
10229029-DS-3 | 10,229,029 | 26,299,524 | DS | 3 | 2172-01-27 00:00:00 | 2172-01-27 11:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Bactrim DS / lisinopril / azithromycin
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with ___ afib, copd, htn, presents sp mechincal fall at home,
complaining of left hip pain as well as right groin pain.
Patient was notably seen in our ED in ___ after a
similar mechanical fall, sustaining left inferior and superior
pubic rami fractures as well as small acetabular fracture.
Patient was seen by orthopaedics at that time, with
recommendations for 50% weight bearing, and was cleared by ___ to
return home from the ED. She has followed up in ___
___ with interval healing of these fracture patterns and
improvement overall in her functional status. She states tat
today she tripped while walking from her porch, landing on her
left side. She had immediate worsening of her left hip pain as
well as a new pain in her right groin. Denies lower extremity
weakness, distal parasthesia or anesthesia.
Past Medical History:
ARTHRITIS
ASTHMA
BACK PAIN
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
ESOPHAGITIS
EXERTIONAL DYSPNEA
HEALTH MAINTENANCE
HERNIORRHAPHY
HYPERCALCEMIA
HYPERTENSION
IRON DEFICIENCY ANEMIA
LEFT BUNDLE BRANCH BLOCK
MITRAL REGURGITATION/AORTIC STENOSIS
OSTEOPOROSIS
PHARMACY
RECTAL BLEEDING
RENAL INSUFFICIENCY
THRUSH
UPPER RESPIRATORY INFECTION
UTI
VENTRAL HERNIA
CHEMICAL GASTRITIS
CHRONIC KIDNEY DISEASE
ATRIAL FIBRILLATION
ATRIAL FIBRILLATION
MYOCARDIAL INFARCTION -NSTEMI ___, Cath ___
obstructive coronary disease, EF 50% stress Mibi
Social History:
___
Family History:
NC
Physical Exam:
In general, the patient is a well appearing ___ lying in
stretcher
Vitals: T 97.2dF HR 82 BP 152/90 RR 16 SpO2 100%
Pelvis stable to AP and lateral compression, with tenderness to
palpation over the left hip.
Right lower extremity:
Skin intact
Soft, non-tender thigh and leg
Full, painless AROM/PROM of knee, and ankle. Slight discomfort
with external rotation and abduction of the right hip
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
Left lower extremity:
Skin intact
Soft, non-tender thigh and leg
Full, painless AROM/PROM of knee, and ankle. There is slight
discomfort with left hip flexion and abduction
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
Pertinent Results:
___ 11:40PM ___ PTT-29.5 ___
___ 11:40PM PLT COUNT-205
___ 11:40PM NEUTS-80.9* LYMPHS-13.8* MONOS-4.1 EOS-1.0
BASOS-0.3
___ 11:40PM WBC-15.4*# RBC-3.54* HGB-11.7* HCT-34.0*
MCV-96 MCH-33.0* MCHC-34.3 RDW-13.3
___ 11:40PM GLUCOSE-108* UREA N-26* CREAT-1.3* SODIUM-139
POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-22 ANION GAP-20
___ 12:40AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 12:40AM URINE UHOLD-HOLD
___ 11:30AM WBC-14.7* RBC-3.08* HGB-10.1* HCT-30.0*
MCV-97 MCH-32.7* MCHC-33.6 RDW-12.9
___ 08:15PM HCT-25.6*
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have nonoperative pelvic fracture and was admitted to the
orthopedic surgery service for monitoring and mobillization.
The patients home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The patient's hematocrit
23.9 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 WBAT in the bilateral lower
extremities, and will be discharged on her home medications
(rivaroxaban [Xarelto]) 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:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Amiodarone 200 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Calcium Carbonate 1000 mg PO HS
5. Docusate Sodium 100 mg PO BID
6. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
7. Furosemide 20 mg PO DAILY
8. Gabapentin 300 mg PO HS
9. Omeprazole 20 mg PO DAILY
10. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4-6H Disp #*30
Tablet Refills:*0
11. Rivaroxaban 15 mg PO DINNER
12. Senna 17.2 mg PO HS
13. Tiotropium Bromide 1 CAP IH DAILY
14. Valsartan 40 mg PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Amiodarone 200 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Calcium Carbonate 1000 mg PO HS
5. Docusate Sodium 100 mg PO BID
6. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
7. Furosemide 20 mg PO DAILY
8. Gabapentin 300 mg PO HS
9. Omeprazole 20 mg PO DAILY
10. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4-6H Disp #*30
Tablet Refills:*0
11. Rivaroxaban 15 mg PO DINNER
12. Senna 17.2 mg PO HS
13. Tiotropium Bromide 1 CAP IH DAILY
14. Valsartan 40 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
for Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
Pelvic fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Continue your home rivaroxaban
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated BLEs
Physical Therapy:
WBAT
Treatments Frequency:
none
Followup Instructions:
___
|
10229029-DS-4 | 10,229,029 | 23,524,248 | DS | 4 | 2174-10-31 00:00:00 | 2174-10-31 12:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim DS / lisinopril / azithromycin / Sulfa (Sulfonamide
Antibiotics)
Attending: ___.
Chief Complaint:
falls
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo woman with h/o Afib on rivaroxaban s/p AVJ ablation and
VVI pacemaker ___, multiple mechanical falls c/b acetabular
fracture, who presents after two unwitnessed falls at home.
Patient reports multiple falls over the past several years,
which she says are always due to tripping or her legs just
"giving out", never syncopal. She has had a hip fracture in the
past but feels that she recovered well. She continues to do some
of the exercises she was taught by ___.
She was feeling well overall when she fell about 1 week ago and
hit her left face and left knee. She says that she was rounding
a corner in her house and tripped and fell. Per daughter she has
had balance issues for several years. She developed significant
bruising on her face and knee but was still able to walk with a
walker at home. She then had a fall yesterday which she also
reports was due to tripping. She endorses some lightheadedness
during these time periods but is unclear about whether she felt
lightheaded prior to falling. She denies chest pain,
palpitations, but her daughter says that she has been
complaining of ongoing shortness of breath since having her
pacemaker in and loss of energy. Denies ___, fevers/chills.
She also came in today because she has been having some word
finding difficulties, saying the wrong word and having to
correct herself, which is new since today.
-In the ED, initial VS were 36.3 72 103/66 18 100% RA .
-Exam notable for left mandible bruising, left maxilla tender
with bruising, left eye conjunctival hemorrhage, III/VI systolic
murmur, crackles at lung bases, swollen left knee with bruising
-Labs showed Cr 1.6 (baseline 1.3), WBC 11.7 (N 76.8%), Hgb 8.9
(baseline 12.9), INR 2.3, BNP 3446, trop <0.01
-EKG was paced
-CT head wnl
-CXR without consolidation but low lung volumes
-Non-contrast CT torso found no internal bleeding
-Received NS @ 125 ml/hr
-Transfer VS were 99.4 70 107/63 18 100% RA
On arrival to the floor, patient feels well. Some mild pain in
left knee at rest in bed. No chest pain or palpitations. No SOB,
orthopnea, or PND.
Past Medical History:
Cardiac/Pulmonary:
- ATRIAL FIBRILLATION s/p cardioversion x4, AVJ ablation and
pacemaker
- NSTEMI ___, Cath ___ with no obstructive coronary
disease
- LEFT BUNDLE BRANCH BLOCK
- Systolic Dysfunction (EF 45-50% ___
- Aortic Stenosis (valve area 0.8 ___
- MITRAL REGURGITATION
- Tricuspid Regurgitation
- HYPERTENSION
- Asthma / CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Orthopedic:
- Multiple Falls
- ACETABULAR FRACTURE
- chest ___
- OSTEOPOROSIS
- ARTHRITIS
- BACK PAIN
Other:
- CHRONIC KIDNEY DISEASE
- IRON DEFICIENCY ANEMIA
- RECTAL BLEEDING
- CHEMICAL GASTRITIS
- ESOPHAGITIS
- CYSTOCELE, bladder suspension ___
- HYPERCALCEMIA
- THRUSH
- incisional hernia at appendectomy scar
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
===============================
VS: 99.4 70 107/63 18 100% RA
GENERAL: Elderly, pleasant and talkative, no distress
FACE: Large hematoma over left maxilla. Large ecchymosis over
left mandible and neck.
EYES: PERRL, EOMI, L conjunctival hemorrhage, no icterus
NECK: Normal ROM. JVP not elevated.
CV: RRR, ___ systolic mid-peaking murmur. 2+ DP pulses.
PULM: non-labored, bibasilar crackles
ABD: soft, NTND
GU: no suprapubic tenderness
RIGHT WRIST: Edema and ecchymosis over ulnar head.
LLE: Large hematoma extending from gluteus/posterior down to
knee. Knee markedly swollen and bruised, diffusely tender to
palpation.
Skin: bruising along skin on left medial thigh, over knee, calf
NEURO: A&Ox3, normal attention and memory. Speech with
intermittent paraphasias, no dysarthria. CN ___ intact.
Strength, coordination, and gait testing deferred due to
injuries.
Pertinent Results:
ADMISSION LABS
==========================
___ 01:33PM BLOOD WBC-11.7*# RBC-3.03*# Hgb-8.9*#
Hct-28.5*# MCV-94 MCH-29.4 MCHC-31.2* RDW-14.3 RDWSD-48.7* Plt
___
___ 01:33PM BLOOD Neuts-76.8* Lymphs-13.5* Monos-7.7
Eos-0.9* Baso-0.2 Im ___ AbsNeut-9.02*# AbsLymp-1.58
AbsMono-0.90* AbsEos-0.10 AbsBaso-0.02
___ 01:33PM BLOOD ___ PTT-31.2 ___
___ 01:33PM BLOOD Glucose-94 UreaN-45* Creat-1.6* Na-136
K-4.9 Cl-100 HCO3-21* AnGap-20
___ 01:33PM BLOOD ALT-10 AST-32 AlkPhos-61 TotBili-1.1
___ 01:33PM BLOOD proBNP-3446*
___ 01:33PM BLOOD cTropnT-<0.01
___ 07:00AM BLOOD cTropnT-<0.01
PERTINENT INTERVAL LABS
==========================
___ 01:33PM BLOOD Albumin-3.7
___ 01:33PM BLOOD VitB12-843
___ 07:00AM BLOOD %HbA1c-5.1 eAG-100
___ 01:33PM BLOOD TSH-3.8
DISCHARGE LABS
==========================
___ 05:45AM BLOOD WBC-7.6 RBC-2.56* Hgb-7.7* Hct-25.0*
MCV-98 MCH-30.1 MCHC-30.8* RDW-14.7 RDWSD-51.9* Plt ___
___ 05:50AM BLOOD ___ PTT-27.0 ___
___ 05:45AM BLOOD Glucose-89 UreaN-37* Creat-1.5* Na-141
K-4.1 Cl-107 HCO3-20* AnGap-18
IMAGING & STUDIES
==========================
___ ECG
V-paced
___ CT HEAD
1. No evidence of acute intracranial hemorrhage or fracture.
2. Mucosal thickening on the right maxillary sinus apparently
is new since the prior exam, otherwise no significant changes
are visualized.
___ CXR
In comparison with the study of ___, there are slightly
lower lung volumes. The cardiac silhouette remains within
normal limits with tortuosity of the aorta single lead pacer
extending to the apex of the right ventricle.
No evidence of vascular congestion or acute pneumonia.
Loss of height of a mid dorsal vertebra, unchanged from the
previous study.
___ CT CHEST/ABD/PELVIS W/O
IMPRESSION:
1. No evidence of free fluid or retroperitoneal bleed. No
evidence of acute intrathoracic or intraabdominal injury within
the limitation of an unenhanced scan.
2. Aneurysmal ascending aorta measuring up to 4.0 cm.
3. Calcifications within the pancreas likely secondary to
chronic
pancreatitis.
___ XR KNEE (AP, LAT & OBLIQUE)
IMPRESSION:
1. Prepatellar infrapatellar hematoma.
2. No evidence of fracture or dislocation.
3. Moderate-to-severe tricompartmental degenerative changes.
___ XR WRIST(3 + VIEWS) RIGHT
IMPRESSION:
1. 3 mm osseous fragment along the dorsal wrist of unknown
chronicity may be the sequela of trauma.
2. Calcific tendinosis of the radioulnar joint.
3. Moderate to severe degenerative changes of the triscaphe
joint.
Brief Hospital Course:
___ with h/o mechanical falls c/b hip fracture, afib s/p AVJ
ablation and pacemaker on rivaroxaban, p/w unwitnessed falls,
large RLE hematoma, and paraphasias concerning for TIA/stroke.
========================
ACTIVE ISSUES
========================
# UNWITNESSED FALLS:
Likely mechanical. No arrhythmias on ECG or telemetry. Recent
TTE with severe AS that may have contributed (see below).
Paraphasias concerning for TIA/CVA but CT head negative and no
other deficits to suggest contribution to falls. Patient noted
she has had forming words before due to dry mouth and her
tongue/cheeks/lips sticking, and personally felt that this was
the issue this time that people were concerned about. No
evidence for infection, ACS, PE, seizure. She was evaluated and
treated by ___ and discharged to rehab.
# PARAPHASIAS:
CT head negative, but small TIA possible. MRI was not possible
due to pacemaker. Treated empirically with aspirin and high-dose
statin. Resolved by HD3. Patient noted she has had forming words
before due to dry mouth and her tongue/cheeks/lips sticking, and
personally felt that this was the issue this time that people
were concerned about.
# ACUTE BLOOD LOSS ANEMIA:
Only clear site identified was LLE hematoma. CT torso negative
for internal bleeding. Guaiacs negative. Hb stabilized and
patient remained HDS. Rivaroxaban was initially held, later
restarted.
# LEFT KNEE TRAUMA:
Evaluated by Ortho who had low suspicion for hemarthrosis. She
was treated with ___ and outpatient Ortho follow-up was arranged.
Started draining blood through blister the day before discharge
and was started on prophylactic PO Keflex/Doxycycline to prevent
infection, to be continued for a 7 day course.
# RIGHT WRIST FRACTURE:
No nerve or vascular injury. Evaluated by Ortho and OT. Treated
with removable splint. Outpatient f/u arranged.
# ATRIAL FIBRILLATION:
S/P cardioversion x4, AVJ ablation, with pacemaker. CHADS2Vasc
at least 5, possibly 7 if paraphasias represent new TIA/CVA.
V-paced with no arrhythmia on telemetry or ECG. Rivaroxaban was
initially held due to concern for bleeding and then restarted.
# AORTIC STENOSIS:
Recent TTE with severely stenotic valve area (0.8) but gradient
only 27. Discussed with Cardiology who felt very low suspicion
for contribution to falls.
# SYSTOLIC HEART FAILURE, CHRONIC:
Recent TTE with mildly depressed EF (45-50%), severe AS by valve
area (0.8, though gradient only 27), ___ MR, 3+ TR. Septal
hypokinesis c/w abnormal conduction. No evidence for
exacerbation. Home furosemide, metoprolol, and lisinopril were
continued.
============================
CHRONIC ISSUES
============================
# H/O NSTEMI:
No evidence for acute ischemia. Cath ___ with no obstructive
CAD. Home aspirin was continued. Atorvastatin was increased to
80mg given concern for TIA/CVA.
# ASTHMA/COPD
No wheezing or exacerbation. Home tiotropium was continued, with
albuterol available prn.
#GERD
Home PPI continued.
TRANSITIONAL ISSUES:
==============================
DISCHARGE WEIGHT: 62.9 kg
________________________________________
TO DO:
[ ] Follow up weights and volume status. Discharged home on
decreased Lasix dose given soft BPs
[ ] Follow up QOD CBCs for the next week to ensure stabilization
of H/H
[ ] Consider decreasing dose of gabapentin, as it was wondering
during at admission if this contributed to her fall- only taking
abs at home
[ ] Physical therapy
[ ] Re-start Xarelto 15 mg DAILY on ___ as long as H/H is
stable/improving
>> check kidneys before restarting
[ ] L knee wound care
________________________________________
FYI:
o DECREASED Lasix to 20 mg (was on 40 mg at home)
o HOLDING Xarelto given tenuous H/H
o STARTED atorvastatin given concern for stroke
________________________________________
ANTIBIOTICS:
o Keflex/Doxy ___ - ___
________________________________________
PROCEDURES:
o None
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. Lisinopril 5 mg PO DAILY
3. Gabapentin 400 mg PO TID:PRN neuropathy
4. Tiotropium Bromide 1 CAP IH DAILY
5. Metoprolol Succinate XL 100 mg PO DAILY
6. Rivaroxaban 15 mg PO DINNER
7. Ferrous Sulfate 325 mg PO DAILY
8. Furosemide 40 mg PO DAILY
9. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
10. Omeprazole 20 mg PO DAILY
11. Aspirin EC 81 mg PO EVERY OTHER DAY
12. Loratadine 10 mg PO DAILY
13. Vitamin B Complex 1 CAP PO DAILY
14. Ascorbic Acid ___ mg PO DAILY
15. Cal-Citrate (calcium citrate-vitamin D2) 250-100 mg-unit
oral Unknown
16. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN
17. Vitamin E 400 UNIT PO DAILY
18. Gabapentin 400 mg PO QHS
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Cephalexin 250 mg PO Q8H
RX *cephalexin 250 mg 1 capsule(s) by mouth every eight (8)
hours Disp #*14 Capsule Refills:*0
3. Doxycycline Hyclate 100 mg PO Q12H
Please take this with food and avoid sunlight exposure while
taking this medication.
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth every
twelve (12) hours Disp #*9 Capsule Refills:*0
4. Vitamin D 800 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth
once a day Disp #*60 Tablet Refills:*0
5. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. Gabapentin 400 mg PO BID:PRN neuropathy
DO NOT GIVE EVENING DOSE IN ADDITIONAL TO USUAL 400 mg QHS DOSE
RX *gabapentin 400 mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
7. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
8. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN
9. Ascorbic Acid ___ mg PO DAILY
10. Aspirin EC 81 mg PO EVERY OTHER DAY
11. Cal-Citrate (calcium citrate-vitamin D2) 250-100 mg-unit
oral Unknown
12. Ferrous Sulfate 325 mg PO DAILY
13. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
14. Gabapentin 400 mg PO QHS
RX *gabapentin 400 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
15. Lisinopril 5 mg PO DAILY
16. Loratadine 10 mg PO DAILY
17. Metoprolol Succinate XL 100 mg PO DAILY
18. Omeprazole 20 mg PO DAILY
19. Tiotropium Bromide 1 CAP IH DAILY
20. Vitamin B Complex 1 CAP PO DAILY
21. Vitamin E 400 UNIT PO DAILY
22. HELD- Rivaroxaban 15 mg PO DINNER This medication was held.
Do not restart Rivaroxaban until sure that CBC is stable
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
=========================
- Mechanical fall
- Left lower extremity hematoma
- Acute blood loss anemia
- Right wrist fracture
SECONDARY DIAGNOSES
========================
- Chronic atrial fibrillation status post ablation and
ventricular pacemaker placement
- Long-term anticoagulation
- Aortic stenosis
- Chronic systolic heart failure
- Asthma
- Chronic obstructive pulmonary disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___.
Why you were admitted: you had a couple falls and some injuries
What we did while you were here:
- We did X-rays, CT scans, and blood tests to make sure that
there was no other cause of your fall. Everything looked ok and
we think this was from unsteadiness on your feet.
- We started antibiotics since your left knee was oozing and we
wanted to prevent infection
Instructions for when you leave the hospital:
- Continue taking all of your new medications as listed below
- Follow up with the doctor appointments listed below
- Weigh yourself every morning. Call your doctor if your weight
goes up more than 3 pounds.
We wish you a speedy recovery!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10229195-DS-7 | 10,229,195 | 26,545,861 | DS | 7 | 2173-12-04 00:00:00 | 2173-12-05 09:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
amoxicillin
Attending: ___.
Chief Complaint:
RLQ pain
Major Surgical or Invasive Procedure:
___: Laparoscopic appendectomy
History of Present Illness:
___ no sig PMH w/w 4 days RLQ pain. Pt endorses anorexia, w/o
N/V. Denies constipation/diarrhea. Denies hematemesis, bloating,
cramping, melena, BRBPR. His ROS was otherwise negative
Past Medical History:
Past Medical History:
HTN
Past Surgical History: Wisdom teeth removal
Social History:
___
Family History:
Hypertension
Physical Exam:
Admission Physical Exam:
Vitals: 98.6 97 128/79 16 98% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: Clear to auscultation b/l
ABD: Soft, nondistended, TTP RLQ with +tenderness/guarding at
McBurney's point.
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
VS: T: 99.4, HR: 88 BP: 122/78 RR: 12 O2: 95% RA
GEN: NAD, AOx3
HEENT: atraumatic, normocephalic, MMM, EOMI
CV: RRR
PULM: CTAB
ABD: soft, non-distended, appropriately tender to palpation,
incisions clean and dry without erythema or drainage; covered
with steri-strips, gauze and tegaderm
EXT: WWP, no edema b/l
Pertinent Results:
IMAGING:
___: CT Abdomen/Pelvis:
1. Acute appendicitis without evidence of drainable fluid
collections or
extraluminal gas.
2. 1 cm left medial iliac cystic bone lesion likely benign in
nature.
LABS:
___ 12:30PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 11:35AM GLUCOSE-104* UREA N-17 CREAT-0.9 SODIUM-139
POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-27 ANION GAP-18
___ 11:35AM ALT(SGPT)-23 AST(SGOT)-23 ALK PHOS-56 TOT
BILI-0.5
___ 11:35AM ALBUMIN-4.8
___ 11:35AM WBC-5.9 RBC-4.96 HGB-14.9 HCT-45.2 MCV-91
MCH-30.0 MCHC-33.0 RDW-12.5 RDWSD-41.2
___ 11:35AM NEUTS-64.8 ___ MONOS-7.6 EOS-1.7
BASOS-1.0 IM ___ AbsNeut-3.82 AbsLymp-1.46 AbsMono-0.45
AbsEos-0.10 AbsBaso-0.06
___ 11:35AM PLT COUNT-224
Brief Hospital Course:
The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal/pelvic CT revealed acute uncomplicated
appendicitis. The patient underwent laparoscopic appendectomy,
which went well without complication (reader referred to the
Operative Note for details). The patient remained
hemodynamically stable in the PACU, IVF were discontinued once
the patient had sufficient PO intake. He received PO
acetaminophen and oxycodone for pain control.
Diet was progressively advanced as tolerated to a regular diet
with good tolerability. Post-operatively, the patient had
urinary retention and was bladder scanned for approximately 400
ccs. A foley catheter was reinserted with about 500ccs out, and
the patient was written for Flomax. The catheter was later
removed on POD #1, and the patient voided without issue. During
this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amlodipine-benazepril 2.5-10 mg oral DAILY
2. Cetirizine 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
PACU ONLY
2. Docusate Sodium 100 mg PO BID
please hold for loose stool
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN BREAKTHROUGH
PAIN
RX *oxycodone 5 mg 1 tablet(s) by mouth every four hours Disp
#*15 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
5. amlodipine-benazepril 2.5-10 mg oral DAILY
6. Cetirizine 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ with
acute appendicitis (inflammation of the appendix). You were
taken to the operating room and underwent laparoscopic removal
of your appendix. This procedure went well. You are now
tolerating a regular diet and your pain is better controlled.
You are now ready to be discharged from the hospital to continue
your recovery. Please note the following discharge
instructions:
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
10229264-DS-13 | 10,229,264 | 25,809,401 | DS | 13 | 2175-04-30 00:00:00 | 2175-04-30 16:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old woman with reported history of
HIV, epilepsy, ?brain cancer, psychotic illness, polysubstance
abuse, who presents with prolonged seizure.
History is obtained from OSH report. She was sitting on stairs
at home with family, fell forward and hit her head, then had
generalized convulsions. EMS called and witnessed movements x5
mins, gave Ativan 2mg which resolved the convulsions. She was
described as postictal and unresponsive, taken to ___
who gave 1gm keppra, 2mg Ativan unclear reasons, 1gm phenytoin
all reportedly for poor responsiveness and GCS of 3, without
mention of any recurrent convulsive activity. She was intubated
for unresponsiveness and labored breathing, and subsequently
transferred to ___. Prior to intubation she was hypertensive
up to SBP 210's, and after receiving 5mg of labetalol and
intubated, this dropped to 90-100s. A ___ report showed right
occipital encephalomalacia. Chemistry was unremarkable, LFTs
mildly elevated with AST 62, ALT 34. UA was negative. According
to nursing report, she is a daily alcohol drinker and stopped
intake 2 days ago; however an MD report from the OSH states her
last drink was ___ years ago. Serum EtOH was negative, but urine
opiates were positive. Unfortunately family could not be
contacted for corollary information.
On review of OMR there is a record with her name and DOB with
notes dating from ___ of multiple psychiatric admissions to
___ for depression and psychosis. It is mentioned on discharge
summary that she was taking phenytoin 200/300mg BID for
unspecified seizure disorder, and has history of multiple head
injuries from an abusive partner. HIV was mentioned and her last
CD4 count in ___ was 162; she was not taking HAART at the time.
PCP at that time listed at ___ center.
Past Medical History:
HIV
?Brain cancer vs other chronic lesion ? toxoplasmosis?- resected
at ___ ___?
Seizure disorder
COPD
Opioid dependence
HCV with possible hepatic encephalopathy
Meningoencephalitis due to toxoplasmosis
Traumatic head injury in setting of domestic abuse
Former polysubstance abuse with cocaine, klonopin, and alcohol-
prior to stroke and brain mass resection ___ years ago.
Depression
adhesive shoulder capsulitis
Social History:
___
Family History:
Unable to obtain.
Physical Exam:
ADMISSION PHYSICAL EXAMINTION:
General: intubated, opens eyes briefly to voice
HEENT: normocephalic, sclera noninjected, mucous membranes moist
Neck: supple
CV: RRR, no m/r/g
Lungs: CTAB
Abdomen: distended but soft, +BS, nontender
GU: Foley in place
Ext: warm, well perfused; RUE contracted in flexion posture
Skin: no rashes or edema
Neuro (off Propofol x15 mins):
MS- opens eyes to verbal stimuli, regards examiner but does not
track, does not follow any commands (in setting of language
barrier). Localizes briskly to noxious stimuli.
CN- R pupil 2->1.5mm, L pupil 3->2mm, both briskly reactive,
+VORs. +corneal reflexes b/l, subtle R facial weakness. Strong
cough and gag reflexes.
Sensory/Motor- severe spasticity on R, with RUE withdrawing in
plane of bed to noxious stimuli, and RLE withdrawing somewhat
antigravity. LUE + LLE full strength, purposeful movements.
Coordination- not tested.
DTRs- 2+ R, 2 L. R toes upgoing, L mute.
DISCHARGE PHYSICAL EXAMINATION:
Pertinent Results:
___ 04:35AM BLOOD WBC-9.7 RBC-5.87* Hgb-11.2 Hct-36.8
MCV-63* MCH-19.1* MCHC-30.4* RDW-19.2* RDWSD-37.2 Plt ___
___ 04:35AM BLOOD Neuts-32.5* Lymphs-59.2* Monos-5.8
Eos-1.6 Baso-0.6 Im ___ AbsNeut-3.29 AbsLymp-6.00*
AbsMono-0.59 AbsEos-0.16 AbsBaso-0.06
___ 04:35AM BLOOD Hypochr-NORMAL Anisocy-1+* Poiklo-1+*
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+* Tear
Dr-1+*
___ 04:35AM BLOOD Plt Smr-NORMAL Plt ___
___ 10:19AM BLOOD WBC-8.0 Lymph-32 Abs ___ CD3%-48
Abs CD3-1216 CD4%-9 Abs CD4-232* CD8%-38 Abs CD8-962*
CD4/CD8-0.24*
___ 03:00PM BLOOD K-4.6
___ 04:35AM BLOOD Glucose-90 UreaN-11 Creat-0.6 Na-144
K-3.0* Cl-100 HCO3-29 AnGap-15
___ 04:35AM BLOOD ALT-57* AST-69*
___ 10:19AM BLOOD ALT-27 AST-38 LD(LDH)-272* CK(CPK)-278*
AlkPhos-133* TotBili-0.4
___ 04:35AM BLOOD Calcium-8.8 Phos-4.8* Mg-2.3
___ 02:35AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:51AM BLOOD HIV1 VL-NOT DETECT
___ 11:08AM BLOOD freeCa-1.07*
___ 10:13AM CEREBROSPINAL FLUID (CSF) TNC-4 RBC-0 Polys-30
___ Macroph-17
___ 10:13AM CEREBROSPINAL FLUID (CSF) TotProt-23 Glucose-64
___ 10:13AM CEREBROSPINAL FLUID (CSF) ___ VIRUS (JCV) DNA
QUANTITATIVE PCR-PND
___ 07:06PM CEREBROSPINAL FLUID (CSF) ___ VIRUS
DNA, PCR-Test
___ 10:13AM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-Test Name
___ 10:13AM CEREBROSPINAL FLUID (CSF) CSF HOLD-Test
IMAGING
1. Restricted diffusion in the right hippocampus is nonspecific
and may be
related to ischemia due to decreased perfusion (stroke) or
increased demand (seizure activity). The seizure history and the
only mildly low ADC value may favor seizure activity.
2. T2 and FLAIR hyperintense area in the left frontoparietal
corona radiata and centrum semiovale without associated
restricted diffusion or postcontrast enhancement is nonspecific
but may represent an area of demyelination secondary to PML,
although with slightly atypical appearance. This lesion was
present on retrospect on prior CTs.
3. Please note that the postcontrast MP-RAGE images are severely
motion
degraded.
Right shoulder XRAY:
No acute fracture dislocation. Minimal glenohumeral and AC
osteoarthritis.
Brief Hospital Course:
Ms. ___ is a ___ woman with a history of HIV, stroke,
and epilepsy who was admitted for management of a prolonged
convulsive seizure requiring intubation. Etiology for her
seizure was in the setting of non-adherence to keppra. She was
extubated within one day without complications. Her EEG showed
right posterior quadrant focal slowing with epileptiform
discharges in the right parietal and right temporal regions,
suggesting that her seizure likely originates from this region.
No electrographic seizures were detected. Her hospital course
was complicated by a transient fever (<24hrs) that
self-resolved. Infectious work-up, including lumbar puncture,
blood cultures, HIV viral load, EBV PCR, and HSV PCR was
negative. Her CD4 count was 232, CD4/CD8 ratio was 0.24. We
resumed her home dose of 1000 mg keppra twice a day and she had
no further seizures.
During her admission, she complained of right shoulder stiffness
and pain (paretic from her prior stroke). XRAY of her shoulder
was negative for subluxation. She was stable for discharge to
home with ___ care from her husband and daughter and with home
___. Her exam on discharge was at her baseline prior to her
hospital admission, with right upper and lower extremity
paresis. We provided counseling and education on medication
compliance during her stay and confirmed that all of her
medications are delivered to her home pre-packaged.
#Seizures:
Patient was not taking her home keppra 1000 mg BID and this is
what is thought to have caused her seizure. Patient on CVEEG
with persistent focal slowing in the right posterior quadrant,
with interictal epileptiform discharges in the right parietal
and right temporal regions independently. Background slowing
consistent with a mild encephalopathy. She was treated with
keppra, at her home dose. MRI with signs of previous
toxoplasmosis in right occipital region, as well as small area
of restricted diffusion in the right temporal lobe likely
reflecting recent seizure. Per review of prior hospital records,
history of toxoplasmosis, but no malignancy. LP was within
normal limits. HSV PCR pending.
#Acute respiratory failure requiring intubation:
Patient was intubated after becoming somnolent with concern for
maintaining airway after receiving lorazepam 2mg. Patient
extubated ___ hours later and was weaned to room air.
#HIV/AIDS
Patient was restarted on home anti retroviral medication. Her
CD4 count this admission was 232. Per prior records, her CD4
count in ___ was reportedly 8.
Transitional Issues:
- Follow-up with PCP ___ ___ weeks
- continue home ___ for right hemiparesis
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
2. amLODIPine 2.5 mg PO DAILY
3. cyproheptadine 4 mg oral DAILY
4. Descovy (emtricitabine-tenofovir alafen) 200-25 mg oral DAILY
5. FoLIC Acid 1 mg PO DAILY
6. LevETIRAcetam 1000 mg PO BID
7. Reglan (metoCLOPramide) 10 mg oral QHS
8. Nicotine Patch 14 mg TD DAILY
9. Multivitamins 1 TAB PO DAILY
10. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath,
wheezing
11. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
12. Dolutegravir 50 mg PO DAILY
13. Sertraline 100 mg qday
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath,
wheezing
2. amLODIPine 2.5 mg PO DAILY
3. cyproheptadine 4 mg oral DAILY
4. Descovy (emtricitabine-tenofovir alafen) 200-25 mg oral
DAILY
5. Dolutegravir 50 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. LevETIRAcetam 1000 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. Nicotine Patch 14 mg TD DAILY
10. Reglan (metoCLOPramide) 10 mg oral QHS
11. Sertraline 100 mg PO DAILY
12. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
13. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
seizure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Supportive Ambulation with Straight Cane.
Discharge Instructions:
Dear ___,
___ were admitted to the hospital because ___ had a seizure and
suffered a head injury. Your seizure was because ___ missed two
doses of your anti-seizure medication (LEVETIRACTAM). It is very
important that ___ continue to take your seizure medication
EVERY SINGLE MORNING AND EVERY SINGLE EVENING. If ___ miss ___
dose of your medication, ___ are at risk of suffering from
another seizure.
When ___ had a seizure this time, we were concerned that ___ may
be going into episodes of multiple frequent seizures (PROLONGED
CONVULSIVE SEIZURES). For this reason, ___ were first admitted
to the INTENSIVE CARE UNIT because we were worried that ___ may
not be able to breathe by yourself. We placed a tube in your
lungs to help your breathing for one day while we gave ___ high
doses of seizure medication.
___ had no further problems after we started your seizure
medication. ___ were stable on your home seizure medication and
did not have any additional seizures while on this dose.
We sent for several lab tests during your hospital stay, which
showed that all of your HIV medications are working very well to
keep the virus level low.
It is VERY IMPORTANT that ___ TAKE ALL OF YOUR MEDICATIONS AS
DIRECTED. PLEASE NEVER MISS ___ MEDICATION DOSE.
We made no medication changes on your hospital admission.
Follow up with your Primary Care Physician ___
___ within ___ weeks.
Thank ___ for allowing us to participate in your care.
___ Neurology
Followup Instructions:
___
|
10229302-DS-19 | 10,229,302 | 26,194,242 | DS | 19 | 2132-09-20 00:00:00 | 2132-09-23 07:24:00 |
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, Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with a past medical history
of dementia, hyperlipidemia, diabetes, hypertension, and
multiple syncopal episodes who presented as a transfer from an
outside hospital for sudden loss of consciousness. Code stroke
activated in the ED for a question of unilateral weakness prior
to arrival.
Per EMS report and outside hospital records, patient was found
to be in his usual state of health helping his family bring
groceries into the house, when he reportedly froze in place, had
a blank look on his face taking 2 steps backward and proceeded
to fall, hitting his head on the curb. Per family, they feel as
he tripped on the entrance step. He did not have any abnormal
movements of the arms and legs. However on initial EMS
assessment, he was reported to have possibly decreased movement
of the right side of his body. He was given Narcan given the
unresponsiveness, which led to multiple episodes of emesis. He
was quickly intubated given low GCS.
On arrival to the outside hospital, he had elevated blood
pressure to 230/110 with a decreased respiratory rate of 4,
normal fingersticks, and tachycardia up to 110.
Of note, there is a report of a similar presentation in
___ to an outside hospital for syncope and facial droop,
which was reported to be very similar to the episode today with
the exception of the facial droop. He apparently underwent an
MRI of the brain which was normal, as well as an echocardiogram
which was reportedly normal as well. There was no reported
sequelae after this event.
Past Medical History:
Dementia, BPH, hyperlipidemia, diabetes, high blood pressure
Social History:
___
Family History:
3 brothers with diabetes, 2 of them with Alzheimer's
Physical Exam:
ADMISSION EXAM
===============
T 96.0 HR 44 BP 141/61 Intubated
CMV VT 500/ RR 16/ FiO2 30%/ PEEP +5 (post-abg)
General: GCS E1 V1 M3
HEENT: Multiple superficial wounds on the back of his head, no
oropharyngeal lesions
___: RRR
Pulmonary: Intubated, good air movement, LCTA bilaterally
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema. 1 cm Laceration to L ___ digit over
the middle phalanx
DISCHARGE EXAM
===============
Vitals: 99.2 168/73 74 28 99 35%tm
General: NAD, laying back in bed with face mask
HEENT: AT/NC, EOMI, with face mask and NGT, no JVD, neck supple
Cardiac: RRR, s1+s2 normal, grade III/VI systolic murmur
appreciated at RUSB
Pulm: Upper airway secretions, rhonchi present diffusely, no
frank wheezing present
Abd: +BS, non-distended, non-tender
Ext: Pulses present, no edema
Neuro: Unable to assess
Pertinent Results:
ADMISSION LABS
================
___ 05:27PM WBC-10.8* RBC-3.45* HGB-11.3* HCT-33.8*
MCV-98 MCH-32.8* MCHC-33.4 RDW-12.2 RDWSD-43.8
___ 05:27PM PLT COUNT-192
___ 05:27PM ___ PTT-25.1 ___
___ 05:27PM ___ 05:27PM LIPASE-23
___ 05:27PM CK(CPK)-203
___ 05:27PM CK-MB-5 cTropnT-0.01
___ 05:35PM GLUCOSE-198* LACTATE-1.6 NA+-133 K+-5.1
CL--105
___ 01:50AM BLOOD Glucose-152* UreaN-21* Creat-1.5* Na-138
K-5.4* Cl-103 HCO3-21* AnGap-14
IMAGING/STUDIES
================
___ CXR
AP portable upright view of the chest. There has been interval
placement of an OG tube which extends into the left upper
abdomen. The endotracheal tube remains low lying within the
trachea positioned approximately 12 mm above the carina.
Recommend slight retraction for more optimal positioning. Lung
volumes are low. There is bibasilar atelectasis again noted.
Lungs otherwise clear.
___ CT Head and Neck
1. No evidence of infarction or hemorrhage.
2. Dense carotid calcifications, with a 70% stenosis of the
right carotid
artery and 50% stenosis of the left carotid artery by NASCET
criteria.
___ EEG
This is an abnormal continuous ICU EEG monitoring study because
of a low-voltage slow background consistent with a severe
encephalopathy,
nonspecific with regard to etiology. There are no pushbutton
activations,
epileptiform discharges or electrographic seizures.
___
MRI Head w/ and w/o con
1. No acute intracranial abnormality.
2. Extensive white matter chronic small vessel ischemic disease.
3. Generalized parenchymal volume loss, likely age related.
___
MR ___ w/o con
1. Linear fluid signal tracking underneath the anterior inferior
border of the C4 vertebral body and extending prevertebral most
likely relates to the patient's extensive degenerative changes
rather than trauma.
2. Mild multilevel degenerative changes of the cervical ___
most significant at C3-C4 where there is slight indentation of
the ventral cord without evidence of abnormal cord signal.
3. Findings compatible with diffuse idiopathic skeletal
hyperostosis (DISH).
4. Incidental note of evidence of an aberrant right subclavian
artery.
___ NCHCT:
Motion limited exam without evidence for acute intracranial
abnormalities.
___ CXR:
In comparison with the study of ___, there is increased
opacification
in the right mid and upper zones, worrisome for developing
aspiration/pneumonia. Otherwise little change.
MICROBIOLOGY
=============
___ Blood, urine cultures negative
___ Sputum respiratory culture negative
___ MRSA screen negative
___ Urine Cx: Negative
___: Blood Cx x2: PND
DISCHARGE LABS
===============
___ 08:55AM BLOOD WBC-13.9* RBC-3.14* Hgb-10.1* Hct-31.6*
MCV-101* MCH-32.2* MCHC-32.0 RDW-12.6 RDWSD-46.8* Plt ___
___ 08:55AM BLOOD Plt ___
___ 03:15PM BLOOD Glucose-PND UreaN-PND Creat-PND Na-PND
K-PND Cl-PND HCO3-PND
___ 03:15PM BLOOD Calcium-PND Phos-PND Mg-PND
Brief Hospital Course:
___ with a background history ___ Body dementia, HLD, DM,
HTN, carotid artery stenosis and multiple syncopal episodes, who
originally presented to the ED after a self limited episode of
syncope, followed by unilateral weakness concerning for stroke
and requiring intubation for airway protection, now status post
extubation and normal brain imaging, and second MICU admission
for respiratory distress.
ACUTE ISSUES:
# Hypertensive emergency:
# Acute on Chronic Heart failure with diastolic dysfunction
(LVEF 65-75%):
Pt with a background history of severe HTN at home. Blood
pressure readings have also elevated since admission, requiring
uptitration and changes to home medications. Patient transferred
back to MICU ___ for tachypnea and concern for hypoxic
respiratory failure. Required 10L O2 by facemask, however it is
unclear what his previous O2 requirement was. CXR demonstrated
evidence of vascular congestion without consolidation. Most
likely pulmonary congestion in setting of HFpEF and severe HTN.
Recent TTE showed preserved global biventricular systolic
function. Treated with serial furosemide while clinically
overloaded until lab evidence of intravascular dryness.
Originally treated with labetalol until adequately titrated,
then converted to Metoprolol Tartrate 5 mg IV Q6H, and
amlodipine 10mg daily. Held losartan given worsening ___.
# Malnutrition:
Given both dysphagia and dysphonia is being evaluated by speech
and swallow while receiving tube feeds to maintain nutrition
status. He was determined to not be eligible for tolerating PO
given oscillating LOA, orally defensive and lingering pulmonary
secretions with difficulty of clearance. Risk for aspiration of
such secretions if orally re-challenged. He had NGT after
intubation and he self-pulled this and aspirated. Planned for
transfer to ___ given family presence and request to have
patient nearby. Continued on oral care Q4h, and aspiration
precautions.
# Concern for VAP
Patient spiked a fever to ___ with increased secretions on
___. No evidence of obvious focal consolidation on serial
CXRs, albeit difficult to interpret in setting of extensive
pulmonary edema. Finished cefepime prior for total 7 days (D1 =
___. Worsening agitation/sedation prompted CXR
which demonstrated worsening opacities in R lung field
consistent w/ PNA vs aspiration pneumonitis the day after he
pulled his NGT. Therefore restarted cefepime given worsening CXR
status on ___ ___ day course until ___. Was placed on
respiratory consult, with prompt chest ___, and trended CBC
daily.
# Acute kidney injury on chronic kidney disease
#Hypernatremia
Creatinine has been progressively increasing since admission,
with a peak at 2.5. Apparent baseline of 1.5. MICU felt may be
pre-renal in nature given poor PO intake and diuresis, however
may be component of cardio-renal given vascular congestion on
CXR and worsening renal function without overly aggressive
diuresis since admission. Worth noting patient also with
contrast load on ___. Further observation favored a
pre-renal cause with both total body and intravascular volume
depletion. He was originally resuscitated with maintanence
quantities of D5W on the floor to correct some hypernatremia,
however transitioned to ___ continuous to replete
intra-vascular for ___ and ___ water for hypernatremia.
Continued holding losartan in setting of ___.
# Altered mental status/Encephalopathy
# Dementia
Patient with syncopal episode after carrying groceries and
tripping on stairs, per family report. Episode described as
patient "freezing" in place, blank stare and eyes rolling back
following by a fall with head trauma. Per EMS report, patient
was found unresponsive and received Narcan and had multiple
episodes of emesis. Patient was intubated on ___ for a GCS of
4 and airway protection, and extubated on ___. Previous
episode of similar syncope in ___ was thought to be
secondary to autonomic dysfunction. Differential diagnosis also
includes arrhythmias, TIA given potential unilateral weakness
noted, and vasovagal given carotid artery stenosis. Patient was
bradycardiac on presentation with no obvious arrhythmias, but
will need further evaluation. CT head and CTA head/neck with no
evidence of hemorrhage or main vessel occlusion. No evidence of
seizures on EEG and negative cardiac work up. Most likely
etiology is autonomic dysfunction in setting ___ Body
dementia. ___ have had a reaction to lorazepam w/ excessive
somnolence and inability to arouse/interact. Would consider
seroquel 25mg PO if agitate, albeit not ideal in ___
dementia.
CHRONIC/STABLE ISSUES:
# Hyperlipidemia: Continued with Atorvastatin 20mg daily
# Depression: Continued Escitalopram 5mg PO daily
# Type 2 diabetes mellitus: Continued ISS
# Laceration ___ left finger: Likely secondary to fall.
Currently bandaged and in splint.
TRANSITIONAL ISSUES:
-PNA: Will complete 7 day course of HAP on ___. His MRSA was
negative so no need for vancomycin. Consider adding anaerobic
coverage if continues to spike fever (for aspiration pneumonia).
-Nutrition: He pulled his NGT on ___ while acutely agitated.
He was too delirious and his high aspiration risk to place a
dobhoff. Continue reassessing swallowing function and need for
dobhoff pending ___ conversations.
-AMS: Somnolent on discharge, but mumbles to sternal rub. No
focal neuro deficits, but difficult to assess. Likely secondary
to hypoxemia from aspiration in the setting of severe ___ body
dementia.
-Hypernatremia: Sodium was 150 upon discharge (slowly rising
over a few days). Likely hypovolemic due to poor PO and
diuresis. Started on ___ at 100 mL/hr. Please check sodium
on admission to monitor.
-Labs: Creatinine on discharge is 1.9 (downtrending) and hgb is
10.1 (stable) with wbc 13.9 (stable elevation).
#CODE STATUS: Full (confirmed). Please continue to discuss code
status with HCP.
#CONTACT: ___, wife/HCP, ___
___, daughter/HCP, ___
___, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tamsulosin 0.4 mg PO QHS
2. Atorvastatin 10 mg PO QPM
3. Losartan Potassium 50 mg PO QAM
4. Metoprolol Succinate XL 25 mg PO DAILY
5. amLODIPine 5 mg PO DAILY
6. Glargine 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Aspirin 81 mg PO DAILY
8. Escitalopram Oxalate 5 mg PO QHS
9. QUEtiapine Fumarate 25 mg PO QHS
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. CefePIME 1 g IV Q12H
3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
4. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
5. Docusate Sodium 100 mg PO BID
6. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
7. Glucose Gel 15 g PO PRN hypoglycemia protocol
8. GuaiFENesin 5 mL PO Q6H
9. Heparin 5000 UNIT SC BID
10. Metoprolol Tartrate 5 mg IV Q6H
11. Senna 8.6 mg PO BID Constipation - First Line
12. Sodium Chloride 0.9% Flush ___ mL IV Q8H and PRN, line
flush
13. Sodium Chloride 0.9% Flush ___ mL IV Q8H and PRN, line
flush
14. amLODIPine 10 mg PO DAILY
15. Atorvastatin 20 mg PO QPM
16. Escitalopram Oxalate 5 mg PO DAILY
17. Glargine 32 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
18. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until cleared by other hosptial
19. HELD- Losartan Potassium 50 mg PO QAM This medication was
held. Do not restart Losartan Potassium until cleared by other
hosptial
20. HELD- Metoprolol Succinate XL 25 mg PO DAILY This
medication was held. Do not restart Metoprolol Succinate XL
until cleared by other hosptial
21. HELD- QUEtiapine Fumarate 25 mg PO QHS This medication was
held. Do not restart QUEtiapine Fumarate until cleared by other
hosptial
22. HELD- Tamsulosin 0.4 mg PO QHS This medication was held. Do
not restart Tamsulosin until cleared by other hosptial
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY:
Hypertensive emergency
Congestive heart failure
Hypoxic respiratory Failure
Ventilator associated pneumonia
Acute kidney injury
Altered mental status
Malnutrition
SECODNARY:
___ body dementia
Chronic kidney disease
Hyperlipidemia
Diabetes Mellitus type II
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
Why was I in the hospital?
- You were hospitalized because you lost your balance and
tripped, followed by weakness which was concerning from a
potential stroke.
What was done while I was in the hospital?
- You were found to have very high blood pressure, which could
have caused fluid to back up into your lungs making it difficult
to breathe. This is more likely since pictures of your heart
showed valves which did not completely block flow from going in
the wrong direction.
- You were intubated and started on mechanical ventilation in
the intensive care unit to protect your airway.
- Pictures were taken that showed that you did not have new
changes in your brain which would have been concerning for a
stroke. Signs of wear and tear were shown in your spinal at the
level of your neck.
- Other pictures later demonstrated signs of an infection in
your lungs. This may have been from materials passing down the
wrong tube instead of into your stomach or from infectious
bacteria gaining access to your lungs from the ventilator tube.
- You were started on medications to target the infection in
your lungs and to keep your blood pressure controlled, in
addition to help clear fluid from your lungs.
- You were treated with oxygen and clearance of your lung
secretions.
- You were transferred to a hospital near your home for better
family access.
Best wishes,
Your ___ team
Followup Instructions:
___
|
10229306-DS-17 | 10,229,306 | 20,999,639 | DS | 17 | 2123-04-08 00:00:00 | 2123-04-13 21:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Triptans-5-HT1 Antimigraine
Agents / gadolinium contrast medium / haloperidol / risperidone
Attending: ___
Chief Complaint:
Right Flank pain
SI
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman
with a history of nephrolithiasis who presents for evaluation
for
suicidal statements.
Per the patient's parents, she was trying to overdose with
amitriptyline. Patient reports that she was told by her
psychiatrist that she could take "more than one amitriptyline."
She took 3 tablets total because she couldn't sleep. On exam
(both in ED and on the floor), she denies feeling suicidal. Also
denies auditory or visual hallucinations.
Patient reports a relapsing and remitting course of UTI symptoms
including R flank pain and suprapubic pain over several weeks.
She reports have received extensive antibiotic therapy for this
infection, including IV antibiotics X 4 days (? CTX) at ___, several days of oral antibiotics (? keflex) that she
could not tolerate due to nausea and another ___ days of IV
antibiotics during a readmission at ___. Per patient, last abx
were one week ago. On discharge from her second admission at ___
one week prior she felt better but her symptoms have since
returned. This includes those stated above as well as nausea
without vomiting and chills; denies fevers. Of note, in the
midst
of this course, she did present to the ___ ED twice with flank
pain and was seen by urology here on ___. A urine culture
from her ___ ED visit grew enterococcus resistant to
vancomycin
and ampicillin.
Past Medical History:
Nephrolithiasis
Anxiety
Ureteroscopy
Generalized Anxiety Disorder
Social History:
___
Family History:
Noncontributory
Physical Exam:
Admission Physical Exam
=======================
VS: 98.3 PO 126/95 ___ 99% on RA
GENERAL: well-appearing young woman in NAD, lying in bed
HEENT: AT/NC, EOMI, PERRL, anicteric sclera
NECK: supple
HEART: RRR, S1/S2, no murmurs
LUNGS: CTAB anteriorly
ABDOMEN: nondistended, mild suprapubic tenderness but otherwise
non-tender to palpation, + R flank pain
EXTREMITIES: no edema
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no rashes
Discharge Physical Exam:
========================
___ 0712 Temp: 98.2 PO BP: 107/62 HR: 79 RR: 18 O2 sat: 97%
O2 delivery: Ra
GENERAL: well-appearing young woman, walking the hall
HEENT: anicteric sclera, no chemosis
ABDOMEN: soft, non-distended, mild LLQ tenderness but otherwise
non-tender to palpation, no rebound or guarding, mild left CVA
tenderness
EXTREMITIES: no ___ edema
NEURO: A&Ox3, no focal deficits
SKIN: warm and well perfused, no rashes
Pertinent Results:
Admission Labs:
===============
___ 03:13PM BLOOD WBC-10.9* RBC-4.75 Hgb-13.1 Hct-39.3
MCV-83 MCH-27.6 MCHC-33.3 RDW-12.8 RDWSD-38.5 Plt ___
___ 03:13PM BLOOD Glucose-75 UreaN-14 Creat-0.8 Na-142
K-4.4 Cl-105 HCO3-22 AnGap-15
___ 05:02AM BLOOD Calcium-8.5 Phos-3.5 Mg-1.9
Microbiology:
============
MICROBIOLOGY DATA:
___ 6:58 am URINE
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA, CONSISTENT WITH FECAL CONTAMINATION.
___ 2:45 am URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. 10,000-100,000 CFU/mL.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 64 I
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ =>32 R
PARTNERS URINE CULTURES
___ ___ Culture-Partners- Mixed urogenital gram positve and
gram negative
___ Urine Culture- Partners- ___ mixed bacteria
___ URINE CULTURE -Partners- >100,000 CFU/ml ENTEROCOCCUS
FAECALIS
Susceptibility
Enterococcus faecalis
Ampicillin<=2 Susceptible
Ciprofloxacin<=1 Susceptible
Daptomycin1 Susceptible
Erythromycin>4 Resistant
Gentamicin SynergySusceptible
Levofloxacin<=1 Susceptible
Linezolid>4 Resistant
Nitrofurantoin<=32 Susceptible
Penicillin G2 Susceptible
Rifampin<=1 Susceptible
Streptomycin SynergySusceptible
Tetracycline>8 Resistant
Vancomycin1 Susceptible
Imaging:
========
Bilateral Renal U/S ___: "Bilateral nonobstructing
nephrolithiasis. A 2.1 cm subcapsular fluid collection in the
lower pole of the right kidney was not seen on any prior renal
ultrasounds and could, in the appropriate clinical setting,
reflect developing abscess. Alternative differential
considerations include a small subcapsular hematoma. Recommend
correlation with urinalysis, physical examination, and history
of
recent trauma."
Right Renal U/S ___:
1. Subcapsular region of hypoechogenicity in the right kidney
which is
difficult to visualize but appears unchanged compared to the
prior ultrasound
of ___. It is difficult to discern whether this
represents a
fluid collection or possible scar. If desired MRI could be
performed for
further evaluation.
2. Small nonobstructing stone seen bilaterally in the kidneys.
No
hydronephrosis.
Discharge Labs:
===============
___ 05:29AM BLOOD WBC-7.5 RBC-4.22 Hgb-11.3 Hct-34.8 MCV-83
MCH-26.8 MCHC-32.5 RDW-12.8 RDWSD-38.4 Plt ___
___ 05:29AM BLOOD Plt ___
___ 05:29AM BLOOD Glucose-96 UreaN-13 Creat-0.6 Na-140
K-4.5 Cl-106 HCO3-24 AnGap-10
___ 05:29AM BLOOD Calcium-8.5 Phos-2.8 Mg-1.8
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a history of emotional
reactivity concerning for borderline personality disorder, past
trauma, somatic symptom disorder and hundreds of OSH ED visits
over the last ___ years, and nephrolithiasis s/p b/l ureteral
stents who presents with suicidal ideation and UTI, admitted to
medicine for diagnosis and treatment before transfer to
psychiatry.
ACTIVE ISSUES:
======================
#Uncomplicated cystitis
#Hx of MDR complicated UTIs
#concern for R renal Subcapsular fluid collection
Pt with long history of urinary tract symptoms, presenting with
urinary frequency and hesitancy. Has had many ED visits and
hospitalizations for symptoms. Most recently, she was admitted
to ___ (___) late ___, received
ampicillin for UA with >100k Amp susceptible Entercoccus,
discharged ___ on amoxicillin for 14d course. Seen again at ___
and ___ ___ with flank pain/nausea, ___ at ___ for nausea
preventing her from taking amoxicillin. Seen at ___
___, switched to Cephalexin, admitted to ___ at ___
unable to tolerate oral antibiotics, but supposedly completed
10d course of therapy. She was discharged off of antibiotics.
___ she again when to ED at ___ but was dissatisfied with the
care and left. Of note, she had a urine culture ___ at ___
with Enterococcus resistant to vancomycin and ampicillin. During
this presentation, renal u/s in the ED ___ showed 2.1 cm
subcapsular fluid collection in the lower pole of the right
kidney not seen on prior imaging, concerning for abscess. She
was empirically started on cefepime/daptomycin and ID was
consulted. In conversation with radiology about further imaging,
an MRI was deferred due to contrast allergy. Repeat renal u/s
___ suggested that the area may be a scar vs fluid collection
but was overall stable. Based on this information, lack of
leukocytosis, Urine cx x2 not revealing for microorganism, no
change in presenting symptoms with antbiotics, lack of fever,
and refusal of all further medical treatment including
antibiotics, she completed 5d course for uncomplicated
cystitis(Cefepime/dapto ___, transitioned to linezolid
___.
#Borderline Personality disorder:
#Somatic Symptoms Disorder:
#Suicidal Ideation:
Patient's psychiatry history includes generalized anxiety
disorder, self-reported unspecified eating disorder (in
remission), cluster B traits, somatic symptom disorder and
history of trauma. Patient presented to ED after calling 911
because her parents were not letting her take her medications.
She reportedly took additional amitriptyline in a suicide
attempt which was thwarted by her family (father was able to get
the pill bottle away from her and she only took a few pills).
Initially she asked to be taken to the hospital for psychiatric
hospitalization because she wanted to die. Psychiatry assessed
the patient in ED and recommended ___ and 1:1 sitter.
Psychiatry continued to follow the patient, recommending
inpatient psychiatric management of her strong emotional
reactivity and frequent conflicts with her parents that are
often managed by emergency personnel. She was re-evaluated on
___ at which time a partial hospitalization program was
recommend given improvement in her symptoms, resolution of SI,
and ability to engage in some safety planning with her mother.
She was discharged with an intake appointment at ___ on the
morning of ___. She was discharged to continue home
medications with the exception of amitriptyline, without any new
prescriptions at discharge.
#Insomnia:
Patient has had long history of Insomnia, most recently taking
amitriptyline. This was held on admission and she was treated
with Seroquel QHS. She was discharged without prescriptions with
the understanding that she would have close follow-up the
following day at which point this could be reassessed.
Chronic Issues:
===============
#Chronic right Flank Pain:
#Nephrolithiasis s/p lithotripsy and utereteroscopy/stent
Patient reported right flank pain on presentation. She has a
history of b/l non obstructing stones s/p lithotripsy in the
past and ureteroscopy/stent placement ___ at ___ which were
subsequently removed. Renal ultrasounds did not show obstructing
stones. A repeat UA on ___ was benign. Her pain was adequately
controlled with Tylenol ___ Q6H,as well as ibuprofen 400mg
Q8H PRN. She has f/u with her outpatient nephrologist and
urologist. She was previously recommended to undergo metabolic
workup for stones.
#Bladder fullness
#? Psychogenic urinary retention
Patient reported that she experienced bladder fullness and
difficulty voiding. Initially her PVR was consistently ___,
however on ___ she was noted to be retaining >800 cc urine and
declined straight catheterization until being given Ativan,
after which she voided on her own. Per her father, this has
happened numerous times and she ultimately always voids on her
own. Psychogenic component was suspected given sudden onset in
concert with family meeting confirming she would have inpatient
psychiatric treatment that day, refusing other medical care, and
sudden resolution. She was offered a referral to uro-gynecology
but declined.
TRANSITIONAL ISSUES
======================
-intake appointment at ___ partial hospitalization program
___ at 8:15 am
-Please reassess patient sensation of bladder retention.
-Patient has history of recurrent renal calculi, previously
recommended to undergo metabolic workup for kidney stones.
-holding home amitriptyline and not discharged with inpatient
Seroquel; melatonin may be appropriate in the future
-s/p 5d antibiotic course for uncomplicated UTI
(cefepime/daptomycin ___, linezolid ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Escitalopram Oxalate 10 mg PO DAILY
2. Gabapentin 1200 mg PO QHS
3. LORazepam 1 mg PO Q12H:PRN insomnia, anxiety
4. Amitriptyline 25 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times daily
Disp #*12 Tablet Refills:*0
2. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
RX *ibuprofen [Advil] 200 mg 2 tablet(s) by mouth three times
daily Disp #*6 Tablet Refills:*0
3. Escitalopram Oxalate 10 mg PO DAILY
4. Gabapentin 1200 mg PO QHS
5. Gabapentin 400 mg PO BID:PRN headache
6. ___ (21) (norethindrone ac-eth estradiol) ___ mg-mcg
oral DAILY
7. LORazepam 1 mg PO Q12H:PRN insomnia, anxiety
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
complicated UTI
Suicidal Ideation
Secondary Diagnosis
Anxiety/Depression
Insomnia
Right sided flank pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___ ,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- You came to the hospital because you were not feeling well
and were found to have a UTI.
- Psychiatry evaluated you and recommended you stay in the
hospital for further evaluation. They felt you were doing better
and able to return home with intensive outpatient psychiatric
care arranged.
What did you receive in the hospital?
- We treated your UTI.
- You got new medicine for sleep.
What should you do once you leave the hospital?
- Please see below for your appointments.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10229306-DS-18 | 10,229,306 | 24,190,836 | DS | 18 | 2124-02-11 00:00:00 | 2124-02-11 18:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Triptans-5-HT1 Antimigraine
Agents / gadolinium contrast medium / haloperidol / risperidone
/ Cipro
Attending: ___
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with history of multiple
concussions, anxiety, and migraines who presents for evaluation
of 1 month history of left eye blurry vision and refractory
headache. History provided by patient and review of records.
Ms. ___ has had multiple evaluations by neurologists,
including seeing 3 within our system - Drs. ___ and
___. Primarily she is followed by Dr. ___. Her
neurologic
history dates back to ___ when she was ___ years old. She was
bending over to pick up something on the floor when she hit her
head on the bottom of the desk. She did not lose consciousness.
She was symptomatic until ___, when she suffered a second
concussion. At this time, she was doing laundry and taking
clothes out of the machine, when someone opened the door for a
machine above her, struck her in the head. She fell to the
ground
and lost consiousness. Afterward she began having headaches.
Her baseline headaches, which she has had since the concussion
in
___, are characterized by a "pressure" pain, located between
the
eyes, lasting for a few hours at a time, occurring multiple
times
per week, but not particularly debilitating. Headaches are
associated with intermittent diplopia, occurring when she is
reading primarily; her neurologist Dr. ___ has attributed
this to convergence spasm. She has nausea, intermittently
associated with vomiting. She also has mild dizziness with her
headaches, which she has difficulty describing further. She has
trialed vestibular ___ without improvement. Her pain had been
well
controlled on gabapentin 1200mg TID. Headaches are exacerbated
by
concentrating, reading, and doing school work.
She has had a few more concussions. Her most recent concussion
was 7 months ago. After this concussion she initially had a more
severe headache from baseline, but this returned back to normal
over the summer. She attributes this to the fact that she was
out
of school for the summer (she is a student at ___)
and
therefore was not strained to trigger headaches with school
work.
She began having more severe headaches as well as new left eye
blurry vision ___ weeks ago. She woke up one morning with "the
worst headache of my life" and she has had the headache
persistently since. The headache is similar in character to her
baseline headaches, with the exception that 1) it is more pain
than baseline, quite debilitating (described as "hammering in my
head"); 2) more prominent photophobia; 3) now associated with
left eye blurry vision. Regarding the blurry vision, she
describes it as a sensation of blurriness as well as "everything
having a shadow over it." This is present out of the entire
field
of the left eye only. When she covers her left eye, vision out
of
the right eye is normal. When she covers her right eye, vision
out of this left eye is blurry. No loss of vision. She denies
seeing any overt positive visual phenomena such as lightning
bolts or floaters, but does note that "a few times I've seen
some
spots, just for a few seconds." It is exacerbated with reading
and looking at near objects, relative to far objects (but still
present when looking in distance).
After developing these symptoms she tried taking ibuprofen,
tylenol and benadryl at home without relief. She initially came
to ___ where symptoms were transiently relieved
after getting a dose of decadron, magnesium, IVF, toradol and
benadryl. She reports "dilaudid helped it more than anything
else" and helped pain get more manageable, but was never truly
pain free.
Her most prominent symptom since that time has been the blurry
vision of the left eye. She notes vision appears "more dull" out
of that eye and difficulty appreciating colors. She has some
pain
with moving the left eye.
10 days ago, on ___ for further workup of these new symptoms
she had an MRI head without contrast. She could not get it with
contrast due to having an allergy to gadolinium, which she
describes as "some problems breathing but not anaphalaxis." MRI
revealed "FLAIR hyperintensity in the posterior aspect of the
left optic nerve near the apex with questionable high signal on
diffusion." Due to question of optic neuritis, Dr. ___ her to Dr. ___. Dr. ___ pt on ___, who
felt that presentation overall was not c/w optic neuritis, more
likely migrainous, and that the FLAIR changes may have been
artifact. Nonethless, contrast enhanced MRI was planned in the
outpatient setting.
This morning, pt reports that the pain and blurry vision was so
severe that she was unable to function. She was unable to read
at
all which was a change from before, where she had some periods
where she could do simpler school work. As a result she
contacted
Dr. ___ advised that she go to ED and be considered for
admission to neurology for further evaluation.
Of note, per discussion with Dr. ___ concern for pain
seeking behavior has emerged. She has multiple medication
allergies which has limited treatment options.
On neuro ROS, the pt reports headache, blurry vision as above.
Significant neck pain.
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 reports nausea and several
episodes of vomiting within last day.
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:
Nephrolithiasis
Anxiety
Ureteroscopy
Generalized Anxiety Disorder
Social History:
___
Family History:
Positive for ___ disease, and mother with
peripheral neuropathy. No family history of headaches.
Physical Exam:
Admission Physical Exam:
Vitals: T 97.9F, HR 86, BP 115/69, RR 16, O2 99% RA
General: Awake, overweight, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx. +muscle tension of trapezius and cervical neck
muscles to palpation.
Neck: Supple, no nuchal rigidity
Pulmonary: breathing non labored on room air
Cardiac: warm and well perfused
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities: No cyanosis, clubbing or edema bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake, alert, oriented to self, place, time and
situation. Able to relate history without difficulty. Attentive
to examiner. 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 6 to 5mm and brisk; ?more sluggish reaction on left.
Unable to do pupillary exam in dark given pt was in a bright,
busy ED hallway where I could not turn off lights. No RAPD.
Visual acuity ___ OD, ___ OS even despite correcting for
refractive error. Reports red desaturation of left eye. VFF to
confrontation. Fundoscopic exam performed, revealed crisp disc
margins with no papilledema, exudates, or hemorrhages; I could
visualize venous pulsations.
III, IV, VI: mild R esotropia at rest. EOMI without nystagmus
when able to give good effort. Initially she seemed to have
bilateral abduction difficulty but this was overcome with good
effort. 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
R 5 ___ 5 ___ 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, 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 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. Difficulty walking in tandem. Romberg absent.
Discharge Physical Exam:
Vitals: Temp: 98.6 PO BP: 137/72 HR: 83 RR: 18 O2
sat: 97% O2 delivery: Ra
General: Awake, overweight, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple, no nuchal rigidity
Pulmonary: breathing non labored on room air
Cardiac: warm and well perfused
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities: No cyanosis, clubbing or edema bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake, alert, oriented to self, place, time and
situation. Able to relate history without difficulty. Attentive
to examiner. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Speech was not dysarthric. Able to
follow both midline and appendicular commands. The pt had good
knowledge of current events.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 7mm and minimally reactive to light.
III, IV, VI: When patient asked to look to the R, both pupils
look to the R. When patient asked to look to the L, neither
pupil
moves. After covering the L pupil, the R pupil moves to the R
and
L on command. After covering the R pupil, the L pupil does not
move when asked to look to the L.
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
R 5 ___ 5 ___ 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, 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 flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
-Gait: Deferred
Pertinent Results:
ADMISSION LABS
---------------
___ 03:29PM BLOOD WBC-14.4* RBC-4.76 Hgb-12.6 Hct-38.7
MCV-81* MCH-26.5 MCHC-32.6 RDW-13.8 RDWSD-40.7 Plt ___
___ 03:29PM BLOOD Neuts-64.7 ___ Monos-5.8 Eos-1.6
Baso-0.5 Im ___ AbsNeut-9.32* AbsLymp-3.91* AbsMono-0.83*
AbsEos-0.23 AbsBaso-0.07
___ 03:29PM BLOOD Glucose-69* UreaN-12 Creat-0.9 Na-141
K-4.6 Cl-106 HCO3-23 AnGap-12
___ 03:29PM BLOOD Calcium-9.1 Phos-2.5* Mg-1.8
___ 03:29PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
DISCHARGE LABS
----------------
___ 06:25AM BLOOD Glucose-202* UreaN-11 Creat-0.7 Na-140
K-4.8 Cl-107 HCO3-22 AnGap-11
MRI BRAIN AND ORBIT W AND WO CONTRAST
1. Nonspecific scattered and nonenhancing subcortical punctate
FLAIR
hyperintensities in the posterior bilateral frontal lobes which
could
represent migraine related white matter changes. Alternatively,
these white
matter lesions could represent at an autoimmune/inflammatory
process.
Distribution pattern of the white matter lesions does not
suggest an
underlying demyelinating condition.
2. Unremarkable MRI of the orbits.
CXR
No acute cardiopulmonary process.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with history of
anxiety, migraines, borderline personality disorder, somatic
symptom disorder, hx of hospitalizations for suicidal attempt,
who presented for evaluation of 1 month history of left eye
blurry
vision and refractory headache.
Persistent Headache
==================
Upon arrival to ED, pt received a one-time regimen of Decadron,
Magnesium, IVF, Toradol and Benadryl. She was admitted to
General Neurology service and started on regimen of standing
Decadron 2mg IV q6, Benadryl 25mg PO prn, and Toradol 15mg IV q6
prn. She was otherwise continued on her home pain medications.
These medications were continued until discharge.
L eye blurriness
================
While inpatient, patient was evaluated by Ophthalmology who
found no concerning pathology involving her eye/orbit. She
underwent MRI Head/Orbits which was unremarkable.
Transitional Issues:
-Patient will complete a Decadron taper and receive
Benadryl/Magnesium prn for her headaches
-Patient will follow up with her Pain Management Specialist Dr.
___ in near future
Medications on Admission:
clonazepam 2 mg at bedtime
gabapentin 1200 mg tid
___ birth control pills
Seroquel 200 mg at bedtime
Zoloft 100 mg p.o. at bedtime
zolpidem ER 6.25 mg at bedtime
Discharge Medications:
1. Cyclobenzaprine 10 mg PO TID:PRN headache
2. Dexamethasone 2 mg PO Q8H
Please take per discharge instructions
Tapered dose - DOWN
RX *dexamethasone 2 mg 1 tablet(s) by mouth Every 12 hours Disp
#*7 Tablet Refills:*0
3. DiphenhydrAMINE 25 mg PO Q6H:PRN Headache
RX *diphenhydramine HCl 25 mg 1 tablet(s) by mouth Every 6 hours
Disp #*30 Tablet Refills:*0
4. Gabapentin 1200 mg PO TID
5. ___ (21) (norethindrone ac-eth estradiol) 1 TAB ORAL
DAILY
6. Magnesium Oxide 400 mg PO DAILY:PRN Headache
RX *magnesium oxide 400 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
7. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth Daily Disp #*15
Tablet Refills:*0
8. QUEtiapine Fumarate 200 mg PO QHS
9. Sertraline 100 mg PO DAILY
10. Zolpidem Tartrate 5 mg PO QHS
11. ClonazePAM 2 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Refractory Headache
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 Neurology Service at ___
___ due to persistent headache and new
onset blurry vision in left eye. Upon admission, you were
provided analgesics and steroids to treat your headache. You
were evaluated with an MRI of your Brain and Orbits which was
negative for any acute intracranial process. You were evaluated
by Ophthalmology who did not find any eye pathology. At this
time you will be discharged with continued treatment for your
headache and planned follow up with your Pain Management
specialist. Please take as follows for headache:
-Dexamethasone 2mg by mouth ever 8 hours for 2 days,
then Dexamethasone 2mg by mouth every 12 hours for 2 days,
then Dexamethasone 1mg by mouth every 12 hours for 2 days,
then Dexamethasone 1mg by mouth daily for 2 days,
then off
-Benadryl 25mg by mouth every 8 hours as needed
-Magnesium 400mg daily as needed
-Please follow up with your Pain Management physician, ___.
___, as scheduled on ___
It was a pleasure taking care of you,
___ Neurology Team
Followup Instructions:
___
|
10229306-DS-19 | 10,229,306 | 21,424,660 | DS | 19 | 2124-12-09 00:00:00 | 2124-12-09 20:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Triptans-5-HT1 Antimigraine
Agents / gadolinium contrast medium / haloperidol / risperidone
/ Cipro / prochlorperazine / Reglan
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Lumbar Puncture
Lumbar drain placement
History of Present Illness:
Ms. ___ is a ___ right-handed woman with history
notable for prior TBI c/b convergence spasm and post-traumatic
headaches, anxiety, insomnia, somatoform disorder, and
intractable migraines s/p botulinum toxin injections and
occipital nerve blocks presenting for evaluation of headache and
visual disturbance.
Ms. ___ reports gradual onset of a bifrontal, "throbbing" and
"stabbing" headache four days prior to presentation, associated
with mild photo- and phonophobia and nausea. Her headache
worsened the following morning, becoming more prominent with
head movement, and she later began to notice "spots" of light in
her right eye. As her symptoms progressed into the following
day, she visited her outpatient neurologist, Dr. ___
she received occipital nerve blocks for her neck pain and
related headaches. However, Ms. ___ reports considerable
worsening of her symptoms following this procedure, prompting
her to contact her neurologist this morning, who recommended
topical ice packs at the site of her injections, which provided
modest relief. Her headaches and right eye visual disturbance
nevertheless continued to progress, to the point that while on a
tour for her new position at ___ today, finding her headache
intolerable, she attempted to sit and rest and accidentally
fell; she was noted to have some tremulousness thereafter,
prompting presentation to the ED. At time of evaluation, she
noted loss of vision in the right eye, prompting code stroke
activation for further evaluation. Ms. ___ notes that the
character of her current headaches is comparable to her prior
migraines, though considerably worsened in severity, and adds
that the headaches are non-positional without transient visual
obscurations; she does report a period of prolonged, mild left
ear tinnitus last night that has since resolved.
Notably, Ms. ___ has been noted to have visual disturbance
associated with her headaches in the past, at one point
resulting in referral to Dr. ___ in ___ for
consideration of optic neuritis; her then left-sided ocular
symptoms and examination findings were noted to be more
consistent with a migrainous than inflammatory process, and she
ultimately underwent inpatient contrast-enhanced MRI (due to her
documented allergy and headache symptoms) which revealed
non-specific white matter hyperintensities but no ocular
findings.
On review of systems, aside from the above, Ms. ___ denies
recent vertigo, speech disturbance, diplopia, dysarthria,
dysphagia, focal weakness, paresthesiae, bowel or bladder
incontinence, gait disturbance, fevers, chills, cough, dyspnea,
chest discomfort, abdominal pain, changes in bowel or bladder
habits, or rash.
Past Medical History:
Nephrolithiasis
Migraine
Ureteroscopy
Generalized Anxiety Disorder
Morbid Obesity
Social History:
___
Family History:
Positive for ___ disease, and mother with
peripheral neuropathy. No family history of headaches.
Physical Exam:
At admission:
General: Mildly uncomfortable, noting severe headache
HEENT: NCAT, neck supple
___: Warm, well-perfused
Pulmonary: No tachypnea or increased WOB
Abdomen: Soft, ND
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented to time and place. Able
to relate history without difficulty. Speech is fluent with
intact verbal comprehension. No dysarthria. No apparent
hemineglect. Able to follow both midline and appendicular
commands.
- Cranial Nerves: PERRL (7 to 4 mm ___. Cylindrical visual field
constriction OS, inconsistent finger counting within central
field OD (though, on Dr. ___ several minutes
thereafter, acuity was noted only as light perception) though
with ostensibly full fields with hand movement and absence of
reported asymmetry on hand comparison. ?spontaneous venous
pulsations OD on fundoscopy. Esodeviation OD albeit without
corrective saccades on cover-uncover or alternate cover tests.
EOM largely intact aside from inconsistent, distractible,
conjugate limitation of right gaze with normal saccades. V1-V3
without deficits to light touch bilaterally. No facial movement
asymmetry. Hearing intact to conversation. Palate elevation
symmetric. Trapezius strength ___ bilaterally. Tongue midline.
- Motor: No pronator drift. No tremor on initial examination,
though distractible tremor noted in follow-up examination by Dr.
___. Subtle give-way weakness in LUE, but on best effort,
[Delt][Bic][Tri][ECR][FEx][IP][Quad][Ham][TA]
L 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 1+ 1+ 1+ 1+ 1+
R 1+ 1+ 1+ 1+ 1+
- Sensory: No deficits to light touch bilaterally. No extinction
to DSS.
- Coordination: No dysmetria with FNF or HKS testing
bilaterally.
- Gait: Deferred.
Exam at discharge:
24 HR Data (last updated ___ @ 420)
Temp: 98.1 (Tm 98.9), BP: 121/77 (97-121/69-77), HR: 91
(90-97), RR: 18 (___), O2 sat: 98% (97-100), O2 delivery: RA
General: young, obese woman lying in bed. appears uncomfortable.
HEENT: NC/AT, no scleral icterus noted, MMM,
Neck: Supple
CV: RRR
Lungs: CTA bilaterally
Abdomen: obese, soft, NT/ND
Ext: No ___ edema.
Skin: no rashes or lesions noted.
Neuro: alert, interactive, oriented x3, fluent, EOMI including
upgaze, VFF appear full to confrontation, PERRL 7-3mm bilat,
face
symm, no pronator drift, all with full strength and range of
motion.
sensation intact throughout to light touch, reflexes equal
throughout.
Fundoscopic exam bilateral papillae. Visual exam stable as per
neuro-ophtho.
Pertinent Results:
___ 06:30AM BLOOD WBC-11.5* RBC-4.80 Hgb-11.1* Hct-37.5
MCV-78* MCH-23.1* MCHC-29.6* RDW-15.1 RDWSD-42.4 Plt ___
___ 03:28PM BLOOD Neuts-69.3 ___ Monos-5.4 Eos-1.5
Baso-0.6 Im ___ AbsNeut-9.55* AbsLymp-3.11 AbsMono-0.74
AbsEos-0.21 AbsBaso-0.08
___ 06:30AM BLOOD Plt ___
___ 06:30AM BLOOD Glucose-114* UreaN-13 Creat-0.9 Na-139
K-4.5 Cl-108 HCO3-19* AnGap-12
___ 06:10AM BLOOD ALT-39 AST-34 AlkPhos-110*
___ 03:28PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 06:30AM BLOOD Calcium-9.5 Phos-3.6 Mg-2.2
___ 03:46PM BLOOD Glucose-81 Creat-0.7 Na-136 K-4.3 Cl-109*
calHCO3-22
___ 06:30AM BLOOD WBC-11.5* RBC-4.54 Hgb-10.6* Hct-34.4
MCV-76* MCH-23.3* MCHC-30.8* RDW-15.4 RDWSD-41.5 Plt ___
___ 03:28PM BLOOD WBC-13.8* RBC-5.13 Hgb-11.7 Hct-38.8
MCV-76* MCH-22.8* MCHC-30.2* RDW-15.2 RDWSD-41.1 Plt ___
___ 06:30AM BLOOD Neuts-57.7 ___ Monos-6.8 Eos-5.2
Baso-0.7 Im ___ AbsNeut-6.60* AbsLymp-3.23 AbsMono-0.78
AbsEos-0.60* AbsBaso-0.08
___ 06:55AM BLOOD ___ PTT-32.6 ___
___ 06:30AM BLOOD Glucose-97 UreaN-17 Creat-0.9 Na-138
K-3.5 Cl-109* HCO3-18* AnGap-11
___ 06:10AM BLOOD Glucose-100 UreaN-13 Creat-0.7 Na-142
K-4.4 Cl-108 HCO3-22 AnGap-12
___ 07:05AM BLOOD ALT-20 AST-12
___ 06:30AM BLOOD Calcium-8.4 Phos-2.3* Mg-2.3
___ 06:55AM BLOOD %HbA1c-5.4 eAG-108
___ 12:10AM BLOOD HCG-<5
___ 03:28PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 06:40AM BLOOD ___ pO2-83* pCO2-36 pH-7.32*
calTCO2-19* Base XS--6 Comment-GREEN TOP
___ 03:59PM BLOOD freeCa-1.24
___ 11:53AM BLOOD BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA,
IGM, IGG)-PND
___ 03:57PM URINE pH-8 Hours-24 Volume-1225 Calcium-13.5
Uric Ac-20.7
___ 03:57PM URINE 24Ca++-165
___ 10:35PM URINE bnzodzp-POS* barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 03:57PM URINE OXALATE-PND
___ 03:57PM URINE CITRATE-PND
___ 10:49AM CEREBROSPINAL FLUID (CSF) TotProt-46*
Glucose-74
___ 10:49AM CEREBROSPINAL FLUID (CSF) TNC-4 RBC-3 Polys-0
___ Macroph-52
___ 4:50 pm CSF;SPINAL FLUID Source: LP 3.
**FINAL REPORT ___
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, if
applicable.
FLUID CULTURE (Final ___: NO GROWTH.
___ 10:35 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 12:44 pm THROAT FOR STREP
**FINAL REPORT ___
R/O Beta Strep Group A (Final ___:
NO BETA STREPTOCOCCUS GROUP A FOUND.
------ Reports:
ECG - normal sinus.
___ HEAD W&W/O C & RECOIMPRESSION:
1. No acute intracranial abnormality.
2. Patent circle of ___ without evidence of
stenosis,occlusion,or aneurysm.
3. Patent bilateral cervical carotid and vertebral arteries
without evidence
of stenosis, occlusion, or dissection.
4. The dural venous sinuses are patent. There is short-segment
focal stenosis
at the junctions of the transverse and sigmoid sinuses
bilaterally, which can
be associated with idiopathic intracranial hypertension.
5. Redemonstration of partially empty sella.
___ PUNCTURE (W/ FLU
IMPRESSION:
1. Lumbar puncture at L3-L4 without complication.
2. Opening pressure: >50 cm H2O.
3. 34 ml of CSF was removed, 24 ml of which were sent to the lab
in 4 vials
for requested analysis.
4. Closing pressure: 16 cm H2O.
___ HEAD W/O CONTRAST
IMPRESSION:
1. No acute intracranial abnormality, specifically no evidence
of an acute stroke, intracranial mass or hemorrhage.
2. Mild empty sella, often seen in the setting of idiopathic
intracranial hypertension. However, this finding by itself may
represent a benign finding.
3. Additionally, subtle concavity at the posterior globe seen on
FLAIR
sequence is also nonspecific, and may represent one of signs of
idiopathic intracranial hypertension, therefore recommend
clinical correlation for papilledema.
4. Although not optimized for such evaluation, visualized optic
chiasm is grossly unremarkable.
___ (PORTABLE AP)
IMPRESSION: Lungs are low volume with moderate pulmonary
vascular congestion. Cardiomediastinal silhouette is stable.
There are no pleural effusions. No pneumothorax
___ PUNCTURE (W/ FLU
IMPRESSION: 1. Lumbar puncture at L3-L4 without complication.
2. Opening pressure: 40 cm H2O.
3. Closing pressure: 14 cm H2O.
Brief Hospital Course:
Ms. ___ is a ___ right-handed woman with history
notable for prior TBI c/b convergence spasm and post-traumatic
headaches, anxiety, insomnia, somatoform disorder, and
intractable migraines s/p botulinum toxin injections and
occipital nerve blocks presenting for evaluation of headache and
visual disturbance.
She was noted to have new papilledema since her prior documented
evaluation last
___, with associated splinter hemorrhages, raising concerns
for intracranial hypertension as the etiology of her headaches.
CTA/CTV reassuringly did not reveal evidence of venous sinus
thrombosis. She underwent ___ guided LP which revealed an opening
pressure of >50. 34 cc of CSF was drained and closed with a
pressure of 16. Neuro ophthalmology was consulted and Dr.
___ her in his office soon after admission.
Visual acuity testing revealed her best corrected distance to be
___ in each eye. Funduscopy revealed Frisen 2 (possibly trace
Frisen 3) papilledema ___ with extensive peripapillary RNFL heme
OS>OD. Automated perimetry revealed mild inferior loss and blind
spot enlargement OD>OS. LP revealed OP > 50 with normal
constituents.
She was started on oral Topamax initially given the relative
contraindication for acetazolamide with the history of
nephrolithiasis. She noted some improvement in headache and
visual changes after initial LP but her symptoms gradually
worsened over the next ___ hours. Acetazolamide was added and
serial visual field testing was done which showed some worsening
in visual fields which is likely a sign of increased
intracranial pressures. Topamax and acetazolamide doses were
increased to optimize therapy and neurosurgery consulted for
lumbar drain placement. She was transferred to Neuro ICU for
closer monitoring.
In the NeuroICU, only about 1cc of fluid drained from the lumbar
drain. Neurosurgery was notified and they tried to adjust the
drain, but the drain was deemed non-functional. Visual fields
remained unchanged during this period. Lumbar drain was removed
and patient was called back out to the floor.
On the floor, note was made of acidemia and hypochloremia on
acetazolamide, which was discontinued in consultation with
Nephrology, who recommended addition of potassium citrate for
prevention of kidney stones. Topiramate was uptitrated in lieu
of acetazolamide, and visual fields were noted to be stable off
acetazolamide. A short course of added baclofen was added for
cervicalgia contributing to the headaches, and recommendation
was made for bariatric surgery on follow-up.
TRANSITIONAL ISSUES
1. Check basic chemistry profile in one week to evaluate for
hyperkalemia.
2. Avoid future use of retinoic acid products, consider
switching to non-estrogen based contraceptive strategies.
3. Outpatient follow-up with nephrology, neuro-ophthalmology,
urology, and bariatric surgery as above.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Mirtazapine 15 mg PO QHS
2. ClonazePAM 2 mg PO QHS:PRN insomnia
3. Tiagabine 8 mg PO QHS
4. Baclofen 10 mg PO QHS
5. Norethindrone-Estradiol 1 TAB PO DAILY
6. QUEtiapine Fumarate 300 mg PO QHS
7. Sertraline 100 mg PO DAILY
8. Gabapentin 800 mg PO TID
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Moderate
2. ClonazePAM 2 mg PO QHS
3. Cyclobenzaprine 5 mg PO TID:PRN neck spasm Duration: 1 Week
RX *cyclobenzaprine 5 mg 1 tablet(s) by mouth three times a day
Disp #*21 Tablet Refills:*0
4. Gabapentin 800 mg PO TID
5. Ibuprofen 600 mg PO Q8H:PRN Pain - Severe
6. Mirtazapine 15 mg PO QHS
7. Potassium Citrate 20 mEq PO TID
RX *potassium citrate 10 mEq (1,080 mg) 2 tablet(s) by mouth
three times a day Disp #*180 Tablet Refills:*0
8. QUEtiapine Fumarate 300 mg PO QHS
9. Sertraline 100 mg PO DAILY
10. Topiramate (Topamax) 200 mg PO BID
RX *topiramate 200 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Idiopathic intracranial hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted for evaluation and management of intractable
headache associated with vision disturbance. Your eye exam
showed swollen optic discs which was concerning for elevated
pressures around the brain. You underwent CT scan of the head
with contrast which did not show any abnormalities. You then
underwent a procedure called Lumbar puncture (LP) where a needle
was inserted in your lower back and spinal fluid was removed.
We were able to measure the CSF pressure (pressure inside the
head) through this procedure and noted that it was elevated.
This confirmed the diagnosis of idiopathic intracranial
hypertension (IIH).
You were admitted to the hospital and started on medication
called topiramate and acetazolamide. You were also seen by
neuro-ophthalmology (Dr. ___ and your visual fields were
tested. You were noted to have some decrease in vision and with
repeated testing it was noted to be getting slightly worse. You
underwent lumbar drain placement to help drain the CSF fluid
gradually, but the lumbar drain was not successful. Your vision
remained stable. You had a subsequent LP in the setting on
consistent headaches and lack vision loss since initial
improvement no admission, with no relief of headaches or further
improvement in visual symptoms. Your Acetazolamide was
discontinued in the setting of lack of clinical benefit with
academia and hypo-chloremia, and your topiramate dose was
increased instead. Your visual fields remained stable, and
discussion about weight loss and life style modifications to
help permanently treat your IIH. You met with a nutritionist
during her hospitalization to review dietary techniques. We are
also arranging for you to meet with the bariatric surgeon for
long-term weight loss plans. We also provided you with a short
course of a muscle relaxant for your headaches.
Patient instructions:
You should avoid retinoic acid products, which are commonly
found in acne creams.
He should speak to your primary provider about
___ birth controls.
You should aim to lose 5% of your current body weight.
You should follow up with nephrology.
You should follow up with your urologist at ___, Dr. ___
___ - ___ ___ Urologist.
Follow-up with the bariatric surgery team.
Please drink greater than 2.5L of fluid daily.
Follow-up with your primary care provider.
Check basic chemistry profile in one week to assure that
potassium level isn't elevated.
Start taking Kcitrate 20 mEQ three times a day.
Start Topamax 200 mg twice a day.
Take Flexeril 5 mg up to 3 times a day as needed for neck spasms
for the next ___ weeks.
It is okay to continue taking your Tiagabine as previously
prescribed.
=====================
Patient education material adapted from UPTODATE:
What is idiopathic intracranial hypertension?
Idiopathic intracranial hypertension is a condition that causes
pressure inside the skull. It is also called "pseudotumor
cerebri."
Idiopathic intracranial hypertension causes headaches and vision
loss.
What causes idiopathic intracranial hypertension?
Doctors ___ not know the cause. But idiopathic intracranial
hypertension is more common in women and obese people.
Certain medicines seem to make some people more likely to get
idiopathic intracranial hypertension. These medicines include
tetracycline, high doses of vitamin A, and growth hormone.
What are the symptoms of idiopathic intracranial hypertension?
The symptoms include:
- Bad headaches Some people say the worst pain is right behind
the eyes.
- Short periods of vision loss This can happen in 1 or both
eyes. It usually lasts a few seconds and might happen once in a
while or several times a day.
- Dimming of vision
- Trouble seeing things at the edge of your line of sight
- Double vision
- Seeing flashing lights
- Noises inside your head The noise might sound like rushing
water or wind. It often pulses in time with your heartbeat and
can come and go.
In rare cases, people with idiopathic intracranial hypertension
lose their vision forever.
Will I need tests?
Yes. Tests can include:
Eye exam An eye doctor ___ use special tools to look for
swelling at the back of your eye, near the optic nerve (figure
1). Most patients with idiopathic intracranial hypertension have
swelling of the optic nerve. The optic nerve connects the eye to
the brain.
Visual field test This test checks how well you can see things
that are at the edges of your line of sight. The test will be
repeated from time to time to check your optic nerves.
MRI or CT scan These are imaging tests that take pictures of
the inside of your brain. Your doctor can use them to check if a
tumor or other problem is causing your symptoms.
Lumbar puncture (sometimes called a "spinal tap") During this
procedure, a doctor puts ___ needle into your lower back to
measure the fluid pressure inside your skull.
How is idiopathic intracranial hypertension treated?
Treatments include:
**** Weight loss If you are overweight, your doctor ___
recommend a diet or weight loss program. If you are very
overweight and cannot lose weight by dieting, your doctor might
recommend medicines or weight-loss surgery. (please see hand-out
printed for you.)
Medicines Your doctor might prescribe medicines that help
lower the amount of spinal fluid your body makes. Spinal fluid
is the fluid that surrounds the brain and spinal cord. He or she
might also recommend medicines used to prevent and treat
headaches.
Thank you for the opportunity to partake in your care,
The ___ neurology team.
Followup Instructions:
___
|
10229306-DS-20 | 10,229,306 | 22,045,848 | DS | 20 | 2125-02-26 00:00:00 | 2125-02-26 18:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Triptans-5-HT1 Antimigraine
Agents / gadolinium contrast medium / haloperidol / risperidone
/ Cipro / prochlorperazine / Reglan / sumatriptan / promethazine
Attending: ___.
Chief Complaint:
headache, syncope
Major Surgical or Invasive Procedure:
Angiogram on ___
History of Present Illness:
The patient is a ___ year old with ___ diagnosed in ___ who presents with intractable headaches, nausea and
inability to PO as well as 2 episodes of syncope in the last 24
hours.
She had increasing headaches with pulsatile tinnitus around
___. She had gained about 50lbs. She presented to the ED in
___ for worsening vision OD>OS (blurry, no obvious field
loss). Papilledema was noted in each eye. It is unclear what
true
acuities were given issues with bedside testing. ___/CTV showed
patent venous sinus. LP under fluoroscopy revealed an opening
pressure > 50cmH20 with 1 WBC, 0 RBC, protein 16, glucose 59.
Her
headache improved with this and Topiramate but gradually
increased. Acetazolamide was added up to 1.5 mg bid but she had
acidemia. Topimax was at 200 mg bid. She had subsequent LPs for
elevated pressures in ___ and ___, all with elevated
pressures (OP 42 at ___ ___.
She now reports worsening of her headaches over the last week.
Last ___ her head starting feeling like a balloon again. It
was worse when laying down and did not change when walking
around. She started taking diclofenac, acetaminophen and
tizanidine last week which she said did not help her headache.
Last ___ she developed intermittent nausea and vomiting. On
___ she was having pulsatile tinnitus and fuzzy edges of
her
vision. She went to ___ on ___ with LP with OP 39. This
helped her headache for about 24 hours and then it returned -
same as before. It was not worse with walking or sitting up.
She then saw Dr. ___ in ___ clinic on ___. He
noted the following exam: Her visual acuity was: OD: ___ NI
PH
OS: ___. here were unreliable fields. There was stable Frisen
1
papilledema. She was reluctant to undergo VPS; there was
discussion of weight loss surgery. He continued topiramate at
200
mg bid and recommended f/u in 1 week.
Yesterday she was feeling nauseous and had episodes of vomiting
at times. She ended up passing out for unclear period of time.
She was brought to the ED and had CTH which was stable. She was
given Benadryl and Ativan and discharged home. She has not been
able to eat or drink much since being home given her nausea and
intractable headache. Today she tried to go to work but had
ongoing lightheadedness at times. She had an episode when
standing up where she thought she would pass out so she sat down
in the chair and felt better but still had a syncopal episode.
She says her sbp was ___ and her BG was 53 because she has not
been able to eat much.
Past Medical History:
- Traumatic brain injury
- Anxiety
- Insomnia
- Somatoform disorder
- Intractable migraine
- Nephrolithiasis s/p lithotripsy (calcium oxalate, calcium
phosphate)
- Myopic
- Conversion spasm in the setting of traumatic brain injury
Social History:
___
Family History:
Positive for ___ disease, and mother with
peripheral neuropathy. No family history of headaches.
Physical Exam:
Neurologic:
-Mental Status: Alert, oriented. Attentive to exam and can
provide linear history. Language is fluent without dysarthria.
No
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 5->4 and brisk. EOMI without nystagmus.
bilateral subtle temporal arcuate field deficits, OD ___ -1->
___, OS ___ -1-> ___, mild papilledema bilaterally.
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 Gastroc
L 5 ___ ___ 5 -* -* 5 5
R 5 ___ ___ 5 5 5 5 5
*not tested given leg in a brace
-Sensory: No deficits to light touch, pinprick, proprioception
throughout. No extinction to DSS.
-DTRs:
Bi ___ Pat Ach
L 2 2 - 2
R 2 2 - 2
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF
-Gait: Has brace on left leg given an injury and stress
fracture,
walks with crutches
Discharge Physical Exam:
Neurologic:
-Mental Status: Alert, oriented. Attentive to exam and can
provide linear history. Language is fluent without dysarthria.
No
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 8->4 and brisk. EOMI without nystagmus.
VFF are full to confrontational testing. Mild papilledema
bilaterally.
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 Gastroc
L 5 ___ ___ 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5
*not tested given leg in a brace
-Sensory: No deficits to light touch throughout. No extinction
to DSS.
-DTRs:
Bi ___ Pat Ach
L 2 2 - 2
R 2 2 - 2
Plantar response was flexor bilaterally.
-Coordination: No dysmetria on FNF
-Gait: able to ambulate with left leg brace and crutch
Pertinent Results:
___ 01:40PM BLOOD WBC-9.5 RBC-4.75 Hgb-10.7* Hct-37.0
MCV-78* MCH-22.5* MCHC-28.9* RDW-15.5 RDWSD-43.4 Plt ___
___ 04:23AM BLOOD ___ PTT-31.0 ___
___ 04:23AM BLOOD Plt ___
___ 04:23AM BLOOD Glucose-118* UreaN-16 Creat-0.9 Na-140
K-4.3 Cl-107 HCO3-23 AnGap-10
___ 04:23AM BLOOD Calcium-9.1 Phos-4.7* Mg-2.2
___ 12:01AM BLOOD Cortsol-0.5* Testost-31 SHBG-71
calcFT-3.4
___ 12:01AM BLOOD Estradl-83
___ 01:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
Brief Hospital Course:
___ is a ___ year old woman with history of obesity
and IIH diagnosed in ___ with intractable headaches, who
presented to ___ after a syncopal event in the setting of not
drinking any fluid for 48 hours.
She was monitored in the emergency department with stable blood
pressures and blood sugars. She reported a severe headache which
was worse compared to her normal IIH headache. She was evaluated
by ophthalmology who noted no visual field deficits, normal
visual acuity, and no change in her papilledema which has been
stable since ___. She was admitted to neurology for further
management of her headache. She was seen by neurosurgery who
discussed consideration of stenting for IIH which is a
relatively new therapeutic intervention. She underwent angiogram
on ___ which revealed no areas amenable to stenting. She was
therefore not deemed a potential surgical candidate for
stenting. She remained a possible candidate for VP shunt,
however as this is not emergent neurosurgery recommended
outpatient follow-up for consideration of shunt placement. We
sent some hormonal laboratory tests in preparation for possible
surgical intervention at the request of Dr. ___. In
discussion with Dr. ___ recommended no lumbar puncture
while inpatient as the amount of CSF drained should only provide
relief for a few hours to at most 1 day, and patient has had
complications of lumbar puncture with low pressure headaches.
Therefore, the risks were thought to outweigh the benefits.
Similarly, lumbar drain was not thought to be a good option as
patient has had issues with lumbar drain placement in the past,
and it puts her at risk for infection. As she has had no vision
loss, these procedures are not thought to be urgent in nature.
While on the neurology service patient was continued on her home
oral medications. To assist with pain control, we attempted an
IV dose of acetaminophen, however this did not improve her
headache. She was also given a dose of Ativan and IV Benadryl in
the emergency department, but these also did not improve her
headache. She tried an increased dose of tizanidine, which did
not help her headache, though on discharge requested this
medication to be filled at the higher dose. We recommend that
she only take this at night as needed, and not to take more than
1 tab at a time while at home as it can cause low blood
pressure. She did not want to try other muscle relaxants as they
have not helped in the past. She tried IV magnesium but this was
not effective. She requested tramadol, but we discussed with her
that we would not recommend opioid pain medications for
treatment of headaches, as it is unlikely to be of help and will
only cause long-term problems for her. Notably, while she
complained of severe pain, she always was resting comfortably in
bed on evaluation. She was tolerating p.o. intake well, with no
nausea or vomiting. Her blood pressures were within normal
limits. We discussed with ___ that there was no reason that
she needs to stay in the hospital as it would be unlikely that
we would be able to treat her headache medically. We discussed
that she will need long-term solutions for her headache,
including lifestyle intervention with diet and weight loss.
While she waits for gastric surgery consideration, she should
start pursuing diet and exercise on her own. We referred her to
the ___ where they have lifestyle coaches who can
help with these goals. We offered referral to the ___
medicine center, but she did not want referral at this time. At
the time of discharge, she had stable vision with continued
headache. We discussed our plans with her family at length who
were in agreement with plan of care.
Prior to leaving the hospital, ___ and ___ mother got into
an argument. ___ was verbally antagonizing her mother, and
her mother asks that we put her on a "psychiatric hold".
___ mother left the room, and I was able to speak to
___ alone. ___ had a plan for leaving the hospital, she
said that she needed to be away from her mother for the evening
and she was planning on going to a hotel for the night, and was
taken over to get there. She tells me that she has enough money
to do so because she works. She requested a letter to excuse
her from work for the days that she missed. ___ does feel
safe at home, there is no concern of physical abuse, though
___ says that she and her parents yelled each other very
frequently. ___ has not had thoughts of hurting herself or
anyone else. She understands her care plan, and though she is
unhappy that she continues to be in pain, she does want to leave
the hospital today. As she was in agreement with our
recommendations and there was no concern for her safety, she was
discharged home.
Transitional issues
Follow-up with neuro-ophthalmology
Follow-up in ___ clinic for consideration of shunt
Follow-up with Dr. ___ headache
___ home medications without change
Avoid over-the-counter pain medications more than 1 to 2
days/week
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 0.5 mg PO QID
2. ClonazePAM 1 mg PO QHS
3. Diclofenac Sodium ___ 50 mg PO BID
4. Gabapentin 800 mg PO TID
5. Mirtazapine 22.5 mg PO QHS
6. Potassium Citrate 30 mEq PO BID
7. Sertraline 100 mg PO DAILY
8. suvorexant 30 mg oral QHS
9. Tiagabine 8 mg PO QHS
10. Tizanidine 4 mg PO BID
11. Tizanidine 2 mg PO QHS
12. Topiramate (Topamax) 200 mg PO BID
13. DULoxetine ___ 40 mg PO DAILY
Discharge Medications:
1. ClonazePAM 0.5 mg PO QID
2. ClonazePAM 1 mg PO QHS
3. Diclofenac Sodium ___ 50 mg PO BID
4. DULoxetine ___ 40 mg PO DAILY
5. Gabapentin 800 mg PO TID
6. Mirtazapine 22.5 mg PO QHS
7. Potassium Citrate 30 mEq PO BID
8. Sertraline 100 mg PO DAILY
9. suvorexant 30 mg oral QHS
10. Tiagabine 8 mg PO QHS
11. Tizanidine 2 mg PO QHS
12. Tizanidine 4 mg PO BID
13. Topiramate (Topamax) 200 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
___
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 because you were not eating or
drinking because you were nauseous, which caused your blood
pressure to be low. While you were in the hospital, you
continued to have a headache. We evaluated you for a possible
surgical intervention with an angiogram on ___. However, you
were not deemed to be a surgical candidate. You would be a
candidate for a shunt, but this is not an emergency so
neurosurgery recommended you follow up as an outpatient to
consider this procedure.
We continued your home pain medications. We tried IV Tylenol
once, but this did not improve your headache. We discussed that
we would not recommend opioid pain medications for the treatment
of headache, as this class of medications makes pain worse.
We discussed that we will not be able to fix your headache with
medications right now. We can work together to address your
headache over the long term with lifestyle intervention
including meditation, dietary changes, exercise, and social
supports. Weight loss surgery can be helpful, but we urge you to
begin this process now, as it can take many months to undergo
this procedure, and even a small amount of weight loss will help
your headaches.
We discussed other causes of headache which could be
contributing to your headache from ___. Such possibilities
include medication overuse (taking Tylenol or NSAIDs more than 2
days per week), and muscle spasm.
We recommend that you continue to follow up with Dr. ___
___ Dr. ___, as well as with neurosurgery to discuss shunt
placement if you decide this is the right choice for you.
It was a pleasure taking care of you, and we wish you the very
best.
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10229579-DS-3 | 10,229,579 | 27,352,491 | DS | 3 | 2189-11-16 00:00:00 | 2189-11-18 12:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
erythromycin / Penicillins / Lexapro / Levaquin / ciprofloxacin
/ doxycycline
Attending: ___.
Chief Complaint:
abdominal and fevers
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ G1P1 with a h/o drug
induced lupus, depression, and menorrhagia ___ to fibroids and
endometrial polyps who is 2 days s/p a ___
transferred from ___ w/ abdominal pain, n/v, and fevers,
OB/GYN was consulted for evaluation of post-operative
complications.
On ___, she underwent an operative hysteroscopy w/ submucosal
myoma resection and D&C for menorrhagia, submucosal fibroids,
and
endometrial polyps. Over 50% of the fibroid was protruding into
the uterine cavity. The procedure was uncomplicated.
The patient reported overall feeling well after the procedure
until yesterday on ___ when she developed nausea, 2
episodes
of small volume (1 cup full), non-bilious emesis, dizziness, and
fevers with a T-max of 101.4. She reported that the episodes of
emesis were small volume approximately 1 cupful. Her last
emesis
was noon on ___. Given these symptoms, the patient called
her primary surgeon and was instructed to present to the
emergency room at ___ for further evaluation.
Exam at ___ notable for fever of 100.5, tachycardia with a
heart rate of 118, BP 121/76, RR 18, satting 100% on room air.
Abdomen was noted to be tender. Pelvic exam deferred. PUS was
performed at ___, which has been unread.
Labs performed were notable for a white count of 6.9 with no
bandemia and a slight left shift of 74. She had a normal
lactate
of 1.1. Her labs were only notable for a mild hypokalemia of
3.4.
At ___, she was treated w/ the following: Flagyl ___,
Toradol ___, morphine and ___, and ceftriaxone at 2238.
Given the patients pain and fever, there was concern for
postprocedural endometritis. The patient was transferred to
___
for further management.
Upon arrival to the ED, the patient reports feeling the same.
She denies any further episodes of emesis. She reports some
mild
to moderate lower abdominal pelvic pain. She denies any heavy
vaginal bleeding. She reports only spotting after the surgery.
She denies any unusual vaginal discharge. She denies any
urinary
or bowel symptoms such as constipation or diarrhea.
ROS: 10 point review of systems is otherwise negative except as
mentioned above
PMH:
- anxiety/depression
- Lupus SLE vs drug-induced
- GERD
- sickle cell trait
- migraine HA
- asthma, exercise induced
- SVT
- Anemia
PSH:
- ___ hsc mmy, D&C
- eye surgery
OBHx: G1P1
GYNHx: h/o fibroids, denies h/o STIs, abnormal pap smears
- LMP ___
- no contraception
- sexually active w/ female partner
- no h/o STIs
- last STI screening per pt report ___, declines further
testing
SH: denies T/D/E
MEDS:
- Effexor 37.5
- iron 325
- meloxicam 7.5mg
Allergies (Last Verified ___ by ___:
*Penicillins
ciprofloxacin
doxycycline
erythromycin
Levaquin
Lexapro
Physical Exam:
General: NAD, comfortable
CV: RRR, no m/r/g
Lungs: normal work of breathing, CTAB
Abdomen: soft, non-distended, minimal fundal tenderness with
deep
palpation. no rebound or guarding.
Extremities: no edema, no TTP, pneumoboots in place bilaterally
Pertinent Results:
___ 11:15AM GLUCOSE-81 UREA N-6 CREAT-0.6 SODIUM-139
POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-21* ANION GAP-15
___ 11:15AM CALCIUM-8.0* PHOSPHATE-2.0* MAGNESIUM-1.5*
___ 11:15AM NEUTS-51.3 ___ MONOS-12.9 EOS-6.7
BASOS-0.8 IM ___ AbsNeut-2.59 AbsLymp-1.41 AbsMono-0.65
AbsEos-0.34 AbsBaso-0.04
___ 11:15AM PLT COUNT-184
___ 06:20AM URINE HOURS-RANDOM
___ 06:20AM URINE UCG-NEG
___ 06:20AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 06:20AM URINE BLOOD-TR* NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-80* BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-TR*
___ 06:20AM URINE RBC-3* WBC-9* BACTERIA-FEW* YEAST-NONE
EPI-2
___ 06:20AM URINE MUCOUS-FEW*
___ 06:00AM WBC-6.4 RBC-3.26* HGB-7.3* HCT-24.7* MCV-76*
MCH-22.4* MCHC-29.6* RDW-15.9* RDWSD-43.7
___ 06:00AM PLT COUNT-158
___ 03:56AM GLUCOSE-85 UREA N-7 CREAT-0.7 SODIUM-138
POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-20* ANION GAP-13
___ 03:56AM estGFR-Using this
___ 03:56AM WBC-6.6 RBC-3.50* HGB-7.6* HCT-25.9* MCV-74*
MCH-21.7* MCHC-29.3* RDW-16.0* RDWSD-42.6
___ 03:56AM NEUTS-56.1 ___ MONOS-9.6 EOS-5.5
BASOS-0.6 IM ___ AbsNeut-3.67 AbsLymp-1.83 AbsMono-0.63
AbsEos-0.36 AbsBaso-0.04
___ 03:56AM PLT COUNT-173
___ 03:56AM ___ PTT-24.9* ___
Brief Hospital Course:
*) Postprocedural endometritis
- ___ hsc mmy & D&C, uncomplicated
- Tmax (home) 101.4 w/ abd pain, nausea (resolving), and 2
episodes of small volume emesis
- bimanual exam notable for fundal tenderness
- continue IV gent/clinda x 72hrs (___)
- pain: Tylenol, ibuprofen | Zofran prn nausea
- ADAT
- Final CT Abd/Pelvis ___: no e/o bowel injury. No air or
fluid. Heterogeneity of endo cavity. Fibroid uterus.
- transition to PO clindamycin ___ AM
*) h/o drug induced lupus: multiple antibiotic drug allergies,
s/p plaquenil, holding meloxicam in the setting of ibuprofen
administration
*) depression: continue Effexor 37.5mg
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
Do not take more than 4000mg in 24 hours.
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours.
Disp #*50 Tablet Refills:*0
2. Clindamycin 600 mg PO Q8H
RX *clindamycin HCl 300 mg 2 capsule(s) by mouth every 8 hours.
Disp #*72 Capsule Refills:*0
3. Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate
Take with food.
RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours. Disp
#*50 Tablet Refills:*0
4. Venlafaxine XR 37.5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
post-operative endometritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the gynecology service for management of
your post-operative endometritis. You have recovered well and
the team believes you are ready to be discharged home. Please
call Dr. ___ office with any questions or concerns. Please
follow the instructions below.
Endometritis: Infection of your uterus.
* Take your antibiotics as prescribed. Please complete the full
course of antibiotic.
* You may eat a regular diet.
* You may walk up and down stairs
**** It is important to call your doctor if you develop any
abdominal pain, fever, chills, abnormal vaginal discharge. ****
Call your doctor for:
* fever > 100.4F
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
10229726-DS-5 | 10,229,726 | 20,431,767 | DS | 5 | 2128-08-22 00:00:00 | 2128-08-22 20:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins
Attending: ___
Chief Complaint:
ALS, risk for respiratory decompensation
Major Surgical or Invasive Procedure:
Tunneled line
History of Present Illness:
___ is a pleasant ___ year-old right-handed man with HTN
and
recent neurology admission (___) for ALS confirmed
on
EMG/NCS, acetycholine receptor (binding and modulating) Ab
positive myasthenia now on Cellcept and Mestinon, and thymoma
with plan for future resection who is followed by Dr. ___
presents with worsening bulbar symptoms for five days with
further decline over the last two days.
Please see below for details of neurologic history and recent
admission to Neurology General service. Following discharge home
on ___, the patient felt that his dysphagia and
dysarthria
were 95% of baseline and felt that IVIG had been greatly
beneficial. He continued to have a sensation of throat closure
when lying flat and has been lying on his side; he was able to
sleep this way without difficulties.
He was seen by Dr. ___ on ___. As an outpatient, his
Cellcept was increased from 500mg BID to ___ BID following
discharge (not due to worsening symptoms, per patient); he
experienced nausea, so the dose was decreased to 750mg BID. He
was also started on Mestinon (currently on 30mg BID). He was
seen
by thoracic surgery on ___ and a plan was made to pursue
thymectomy within ___ weeks (operative date not yet confirmed).
Beginning on ___ and worsening on ___ and
again
on ___, he began to experience fatigue with chewing,
had
dysarthria with prolonged talking, and required two swallow
attempts before food would go down his esophagus. He denies
choking or gagging on his food. Because of the fatigue with
chewing, it took him an hour to eat a meal on ___ evening. He
notes that his tongue gets tired, and he is unable to move the
food around in his mouth. He feels these symptoms are similar in
severity to those that prompted his first admission. Symptoms
are
worse at the end of the day. He feels his hand weakness and leg
weakness are unchanged since discharge; he has been taking short
walks. Also, since 1:00 ___ today, he has noticed an increase in
twitching in his arms and legs bilaterally. He denies diplopia
or
facial droop. His dyspnea at rest is unchanged; he does have
some
mild dyspnea after walking up a flight of stairs which has
worsened over the same period. He was told by Dr. ___
the
phone to double his Mestinon dose this morning to 60mg, and he
felt better after this. Dr. ___ him to come to the ED
for admission for plasmapheresis.
Per the discharge summary dated ___, he presented with
"approximately ___ years of progressively worsening weakness as
well as ~4 weeks of "throat closure" sensation while lying
supine, 2 weeks of dysphagia (solids), and 1 week of dysarthria
that worsened at the end of the day or after prolonged speaking.
He underwent EMG/NCS which was consistent with motor neuron
disease (amyotrophic lateral sclerosis). His exam was also
notable for fatigable weakness, and he was subsequently found to
be acetylcholine receptor antibody positive which is consistent
with myasthenia. He underwent extensive work up which revealed
thymoma. Overall working diagnosis is that these two rare
diseases could be the result of a paraneoplastic process rather
than occurring independently although the paraneoplastic panel
is pending.
"He had CT torso, MRI chest,
thyroid US, and testicular US which only revealed anterior
mediastinal mass and slightly enlarged prostate. He also
underwent extensive laboratory evaluation for inflammatory,
infectious, and malignant processes. They were notable for
positive acetylcholine receptor antibody. Pending tests include
___ Syndrome panel, paraneoplastic panel from serum
and CSF, SPEP, and UPEP. His NIFs/VCs were trended and remained
in the normal range. PSA was normal. Skin evaluation did not
reveal any lesions at this time.
"He underwent biopsy of mediastinal mass with ___, and it
revealed
a thymoma. Thoracic surgery evaluated patient and will follow up
with him to schedule thymectomy.
"Because of his symptoms, we decided to initiate 5 days of IVIG
which he tolerated well. On day of discharge, in consultation
with Dr. ___ initiated ___ 500mg BID. He was seen by
___, and they recommended outpatient ___. OT did not feel he had
any OT needs.
"Patient experiences significant respiratory distress while
lying
supine. As a result, he underwent repeat supine PFTs which did
show diaphragm weakness. Sleep medicine was consulted and agreed
with trial of BiPAP, but the patient did not tolerate this
despite different setting trials. We reviewed the risks of not
using BiPAP, and the patient was willing to accept those risks.
He may benefit from a sleep study as an outpatient. He was
counseled to use a pillow at night that can be placed behind him
while he sleeps on his side, and the patient trialed this in the
hospital.
"Patient notices difficulty with chewing
and swallowing. He had multiple bedside swallow evaluations, and
he was initially started on soft solids and thin liquids; they
ultimately felt that he was safe to continue to take regular
solids and thin liquids by mouth.
"Troponin from
0.03 to 0.05 then to 0.04 of unclear significance. He had echo
that was unremarkable and pharmacologic stress test that was
negative. Cardiology recommended starting atorvastatin as an
outpatient." They ultimately did not feel that aspirin was
indicated.
On neuro ROS, he denies headache, loss of vision, blurred
vision,
diplopia, lightheadedness, vertigo, tinnitus or hearing
difficulty. Denies difficulties comprehending
speech. Denies focal numbness or parasthesiae. No bowel or
bladder incontinence or retention.
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:
- ALS diagnosed ___ based on EMG/NCS
- Myasthenia
- Thymoma confirmed on biopsy (not yet resected)
- HTN
Social History:
___
Family History:
- Father: CAD.
Physical Exam:
ADMISSION PHYSICAL EXAM:
97.4F 84 136/82 17 100%RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, full ROM
Pulmonary: breathing comfortably on RA, counts to 30 on
exhalation
Cardiac: warm and well-perfused
Abdomen: ND
Extremities: no cyanosis/clubbing/edema
Skin: no rashes or lesions noted.
MS: Alert, oriented x 3. Able to relate history
without difficulty. Language is fluent with intact
comprehension. Normal prosody. There were no paraphasic errors.
Speech was dysarthric, most pronounced with lingual sounds. No
dyarthria noted. Able to follow both midline and appendicular
commands.
CN: Pupils 4-->2, VFF, EOMI, 2 beats of horizontal nystagmus on
rightward gaze, 1 beat on leftward gaze. No ptosis, including
with sustained upgaze. No diplopia. Negative Cogan's lid twitch.
Facial sensation V1-3 intact. No bifacial weakness. Hearing
grossly intact. No dysarthria noted. Palate/uvula/tongue
midline.
Trapezius ___.
Motor: Atrophy of thenar and hypothenar eminences bilaterally,
___ atrophy bilaterally. Right TA atrophy. Tone normal.
Fasciculations in hypothenar eminence on left. No tongue
fasciculations. Neck flexion ___, Extension ___. Full strength
in
b/l
deltoids, biceps, triceps, ECR (on the right has a
baseline Dupuytren's contracture where FEx have limited range of
motion but ultimately 4+/5 and symmetric, ___ on left). Right
deltoid ___ after 30 pumps. IOs 4+ right, 4 left.
R IP ___, L 4+/5. Quads right ___, left ___. R Hamstring
___ and L ___. R TA ___, R ___ ___, L TA 4+/5, L ___
4+/5. left ___ ___, right ___ 4+/5. R toe extensors 2, toe
flexores 4-. L toe extensors 4+, flexors 4+.
Sensory: LT symmetric in all four extremities. Sensation
decreased to temperature in RLE distal to mid calf, medial
sensory loss>lateral. Also PP loss circumferentially near
malleoli 20% of normal with preserved sensation distally and
proximally.
Reflexes:
-DTRs: R triceps brisk, L biceps brisk, otherwise 2 except 1 at
left Achilles, absent at right Achilles. L toe equivocal, R
downgoing.
Coordination: No dysmetria on FNF and HKS.
Gait: steppage gait with lifting of RLE
===========================================
DISCHARGE PHYSICAL EXAM:
General: awake, cooperative, NAD
HEENT: NC/AT, no scleral icterus noted, MMM
Pulmonary: breathing comfortably, no tachypnea or increased
WOB;
able to count to 48 in one breath
Cardiac: skin warm, well-perfused
Abdomen: soft, ND
Extremities: symmetric, no edema
Neurologic:
-Mental Status: Alert, oriented x3. His language is fluent with
intact comprehension. He is able to follow both midline and
appendicular commands.
-Cranial Nerves: 4->2 mm b/l No ptosis. EOMI. Face is symmetric
at rest and with activation, intact to light touch. Examiner is
able to overcome his eye closure, cheek puff and mouth closure.
Hearing intact to finger rub. ___ strength in SCM and trapezii
bilaterally.
-Motor: Head flexion and extension full.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ 5 4+ 4 5 5 5- 5 3 5
R 5 ___ 5 4+ 4 5 5 1 5 2 5
no asterixis
Fatiguability on repeated deltoid testing.
-Sensory: Intact to light touch throughout. Pinprick: intact in
arms proximally and distally. Becomes less sharp at mid calf on
L leg. Intact on R leg. some hyperesthesia on R foot. No sensory
level over back.
proprioception: intact to large amplitude movements at the toes
bilaterally
-DTRs: ___.
-Coordination: no rebound. FNF intact, no dysmetria.
finger tapping intact.
Pertinent Results:
ADMISSION LABS:
___ 05:17PM BLOOD WBC-5.4 RBC-3.90* Hgb-12.5* Hct-36.9*
MCV-95 MCH-32.1* MCHC-33.9 RDW-14.5 RDWSD-49.9* Plt ___
___ 05:17PM BLOOD Neuts-42.9 ___ Monos-7.3 Eos-0.0*
Baso-0.0 Im ___ AbsNeut-2.30# AbsLymp-2.65 AbsMono-0.39
AbsEos-0.00* AbsBaso-0.00*
___ 06:28AM BLOOD ___ PTT-28.3 ___
___ 05:17PM BLOOD Glucose-85 UreaN-13 Creat-0.9 Na-136
K-4.4 Cl-98 HCO3-25 AnGap-13
___ 05:17PM BLOOD ALT-40 AST-36 AlkPhos-127 TotBili-0.6
___ 05:17PM BLOOD cTropnT-0.03*
___ 11:11PM BLOOD CK-MB-24* cTropnT-0.05*
___ 06:28AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.2
IMAGING:
CXR ___:
Successful placement of a 23cm tip-to-cuff length tunneled
pheresis catheter. The tip of the catheter terminates in the
right atrium. The catheter is ready for use.
DISCHARGE LABS:
___ 04:27AM BLOOD WBC-4.8 RBC-3.30* Hgb-10.8* Hct-32.2*
MCV-98 MCH-32.7* MCHC-33.5 RDW-14.7 RDWSD-52.7* Plt ___
___ 04:27AM BLOOD ___ PTT-32.1 ___
___ 04:27AM BLOOD Glucose-88 UreaN-11 Creat-0.7 Na-140
K-4.1 Cl-106 HCO3-24 AnGap-10
___ 05:17PM BLOOD ALT-40 AST-36 AlkPhos-127 TotBili-0.6
___ 04:27AM BLOOD Calcium-8.4 Phos-4.0 Mg-2.0
Brief Hospital Course:
Mr. ___ is a ___ year old right-handed man with past medical
history notable for amyotrophic lateral sclerosis, AChR
antibody-positive myasthenia ___, thymoma, and HTN admitted
with five days of fatigable chewing and dysarthria, most
consistent with flare of myasthenia ___. His exam was notable
for mild fatiguable deltoid weakness, no ptosis, no diplopia or
cranial nerve abnormalities. The dysarthria resolved by the time
of discharge. A tunneled line was placed and he received 1 dose
of PLEX on ___. Afterwards, he experience mild hypotension and
nausea and which self resolved. Given stability of symptoms, he
was planned for receiving the rest of his PLEX sessions as an
outpatient, next ___. Cellcept was increased to 1000mg BID and
Lisinopril was held while getting PLEX. All other home meds were
unchanged.
Transitional issues:
- hold Lisinopril while getting PLEX
- increase Cellcept to 1000mg BID
- next PLEX session ___
- follow-up with Dr. ___ as outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Mycophenolate Mofetil 750 mg PO BID
2. Gabapentin 300 mg PO QHS
3. Lisinopril 20 mg PO DAILY
4. Pyridostigmine Bromide 30 mg PO BID
Discharge Medications:
1. Mycophenolate Mofetil 1000 mg PO BID
RX *mycophenolate mofetil 500 mg 2 tablet(s) by mouth twice a
day Disp #*120 Tablet Refills:*1
2. Gabapentin 300 mg PO QHS
3. Pyridostigmine Bromide 30 mg PO BID
4. HELD- Lisinopril 20 mg PO DAILY This medication was held. Do
not restart Lisinopril until you talk with your PCP.
Discharge Disposition:
Home
Discharge Diagnosis:
Myasthenia ___ (MG) flare
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 ___ with difficulty chewing and slurred
speech concerning for myasthenia ___ flare. Your Cellcept was
increased to 1000mg twice a day. You had a tunneled line placed
to initiate PLEX (plasma exchange). You had your first session
on ___ and will continue PLEX as an outpatient, with 2nd dose
planned for tomorrow. You will complete 5 sessions as an
outpatient. Because you had nausea and low blood pressure
following your first session, you will be monitored after the
sessions to ensure you tolerate it well.
Please continue your home medications as you have been taking
them, except for Lisinopril which we are holding until you are
done with PLEX to prevent further lowering your blood pressure.
Follow-up with Dr. ___ in clinic. We will arrange for an
appointment. If you do not hear about an appointment in the next
week, please call her office at ___.
It was a pleasure taking care of you,
Your ___ Neurologists
Followup Instructions:
___
|
10229778-DS-26 | 10,229,778 | 22,140,720 | DS | 26 | 2130-03-29 00:00:00 | 2130-03-29 18:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
none
attach
Pertinent Results:
Admission Labs:
===============
___ 11:20AM BLOOD WBC-15.1* RBC-4.87 Hgb-13.9 Hct-43.1
MCV-89 MCH-28.5 MCHC-32.3 RDW-15.1 RDWSD-49.1* Plt ___
___ 11:20AM BLOOD Neuts-90.2* Lymphs-2.0* Monos-6.7
Eos-0.1* Baso-0.3 Im ___ AbsNeut-13.65* AbsLymp-0.31*
AbsMono-1.02* AbsEos-0.01* AbsBaso-0.04
___ 11:20AM BLOOD ___ PTT-36.0 ___
___ 11:20AM BLOOD Glucose-100 UreaN-28* Creat-1.1 Na-140
K-4.9 Cl-101 HCO3-27 AnGap-12
___ 11:20AM BLOOD cTropnT-0.01
___ 11:37AM BLOOD Lactate-1.4
Imaging:
========
1. Similar appearance of a small left pleural effusion since
___. No
evidence of focal consolidations.
2. Since ___, there is a changed positioning of a left chest
wall pacemaker device, with 1 of the leads seemingly
malpositioned at its attachment to the generator device.
Discharge Labs:
===============
___ 08:43AM BLOOD WBC-7.3 RBC-4.79 Hgb-13.7 Hct-43.1 MCV-90
MCH-28.6 MCHC-31.8* RDW-15.2 RDWSD-50.4* Plt ___
___ 08:43AM BLOOD ___
___ 08:43AM BLOOD Glucose-98 UreaN-25* Creat-1.1 Na-143
K-4.4 Cl-104 HCO3-26 AnGap-13
Brief Hospital Course:
Mr. ___ is a ___ male with the past medical
history of CHF, CAD s/p bypass, Afib, s/p pacemaker, recurrent
cellulitis now presenting with worsening RLE
redness and swelling. He was initially brought in due to
concerns for hypotension at home although he was normotensive
here.
ACUTE/ACTIVE PROBLEMS:
# Cellulitis:
Pt has history of recurrent leg infections. He presented with
right lower extremity erythema and warmth as well leukocytosis
to 15. He received a dose of IV vancomycin in the ED as well as
cefazolin and was treated with cefazolin on the floor. His
cellulitis was not purulent.
He was discharged on PO Keflex TID (renally dosed) to complete
an additional 7 day course.
# Hypotension
# Presyncope
Reportedly had SBP in ___ for one reading at home. Patient
reports being asymptomatic, though his son notes he appeared
fatigued (though did not lose consciousness). This apparently
resolved without intervention and he was normotensive in the ED
and on the floor.
Patient's son notes he has a history of vasovagal episodes so
may have been consistent with this.
His pacemaker was interrogated in the ED with no evidence of any
arrhythmias. Troponin was negative.
He had RLE edema in the setting of cellulitis. DVT felt to be
very unlikely given he is already on warfarin and is
consistently in therapeutic range.
Home antihypertensives were initially held but resumed prior to
discharge. He was ambulating without any symptoms of orthostasis
and felt back to baseline.
CHRONIC/STABLE PROBLEMS:
# CHF: echo in ___ w/ mild reduced EF: held Lasix and
metoprolol initially given reported hypotension at home. Resumed
prior to discharge.
#CAD s/p bypass: continued ASA, atorvastatin
# Afib s/p PPM: continued home warfarin
# Hx bacteremia: reportedly on amoxicillin ppx for ___ yrs for
history of enterococcus bacteremia. Held while receiving
vancomycin in the ED, resumed prior to discharge
> 30 minutes spent on discharge coordination and planning
Transitional Issues:
====================
- discharged on 7 days of Keflex to treat cellulitis
- consider TTE for further evaluation of presyncope
- consider duplex US of RLE if edema does not resolve with
treatment of infection
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Warfarin 2.5 mg PO DAILY16
3. Atorvastatin 80 mg PO QPM
4. Amoxicillin 500 mg PO Q12H
5. Tamsulosin 0.4 mg PO QHS
6. Furosemide 20 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Medications:
1. Cephalexin 500 mg PO Q8H
RX *cephalexin 500 mg 1 capsule(s) by mouth every eight (8)
hours Disp #*21 Tablet Refills:*0
2. Amoxicillin 500 mg PO Q12H
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Furosemide 20 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Tamsulosin 0.4 mg PO QHS
8. Warfarin 2.5 mg PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Cellulitis
Pre-syncope
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came in after your blood pressure was low at home. Your
blood pressure quickly improved on its own. You may have had
another vasovagal episode. The cardiologists checked your
pacemaker and did not find any signs of an abnormal heart
rhythm.
We also found that you had cellulitis. We treated you with IV
antibiotics and your infection improved. It will be important to
continue taking oral antibiotics after leaving the hospital.
Please call your primary doctor's office on ___ to schedule
follow up. It will be very important to see someone to check
your blood pressure and to make sure that the infection and
swelling in your leg have resolved.
It was a pleasure taking care of you, and we are happy that
you're feeling better!
Followup Instructions:
___
|
10230495-DS-17 | 10,230,495 | 22,223,144 | DS | 17 | 2179-07-03 00:00:00 | 2179-07-03 17:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Percocet / morphine
Attending: ___.
Chief Complaint:
Left knee prosthetic joint infection
Major Surgical or Invasive Procedure:
L TKA I&D and liner exchange ___, ___
History of Present Illness:
___ with PMH of L TKA ___ years ago, ___, does not remember
surgeon), DM on insulin, A fib on Eliquis, ESRD with plan for HD
line placement who presents with acute onset L knee pain. At
midnight, she woke up from sleep with severe L knee pain. She
was
unable to walk but took some Tylenol with no relief. At 5am, she
called ___ and was taken to OSH where an infectious work up
revealed leukocytosis and a warm, tender L knee with pain on
PROM.
She denies any fevers, chills, nausea or vomiting. She has had
some HA but no URI symptoms, chest pain, dyspnea, back pain, and
abdominal pain. She states her feet have been red for some time
but is using "ointment" that't not helping.
Past Medical History:
DM
Afib on Eliquis
Social History:
___
Family History:
N/C
Physical Exam:
Left Lower Extremity:
Ace wrap clean and dry.
Motor intact to ankle plantarflexion/dorsiflexion, ___.
Sensation intact to light touch in SP/DP/T distributions.
Palpable pedal pulses. Foot warm and well-perfused.
Pertinent Results:
___ 03:20PM BLOOD WBC-10.0 RBC-3.05* Hgb-9.5* Hct-29.7*
MCV-97 MCH-31.1 MCHC-32.0 RDW-15.2 RDWSD-54.0* Plt ___
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left knee prosthetic joint infection and was admitted
to the orthopedic surgery service. The patient was taken to the
operating room on ___ for L TKA I&D and liner exchange,
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 was seen by the infectious disease team, who recommended
a six-week course of ceftriaxone. She had a PICC line placed for
long-term antibiotic administration. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the left lower extremity, and
will be discharged on her home Eliquis for DVT prophylaxis. The
patient will follow up with her primary orthopedic surgeon at
___ per routine. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
Medications on Admission:
Insulin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. CefTRIAXone 2 gm IV Q24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 g once a day
Disp #*39 Intravenous Bag Refills:*0
3. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
4. Docusate Sodium 100 mg PO BID
5. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
6. Glucose Gel 15 g PO PRN hypoglycemia protocol
7. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Give 2 mg for
mild pain, 4 mg for moderate pain, or 6 mg for severe pain.
RX *hydromorphone [Dilaudid] 2 mg 1 to 3 tablet(s) by mouth
every four (4) hours Disp #*30 Tablet Refills:*0
8. Insulin SC
Sliding Scale
Fingerstick QACHS, HS
Insulin SC Sliding Scale using HUM Insulin
9. Miconazole 2% Cream 1 Appl TP BID Toe fungal infection
10. Apixaban 2.5 mg PO BID
11. Bumetanide 0.5 mg PO DAILY
12. Metoprolol Succinate XL 25 mg PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Senna 17.2 mg PO HS
15. Spironolactone 25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Left knee prosthetic joint 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:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated of the left lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add dilaudid ___ mg PO every four hours as needed for
increased pain. Aim to wean off this medication in 1 week or
sooner. This is an example on how to wean down:
Take 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take your home Eliquis, 2.5 mg twice daily.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
INFECTIOUS DISEASE DISCHARGE INSTRUCTIONS
ID OPAT Program Intake Note - Order Recommendations
OPAT Diagnosis: GBS L knee prosthetic joint infection and BSI
OPAT Antimicrobial Regimen and Projected Duration:
Agent & Dose: Ceftriaxone 2g q24h
Start Date: ___
Projected End Date: ___
LAB MONITORING RECOMMENDATIONS: NOTE: For lab work to be drawn
after discharge, a specific standing order for Outpatient Lab
Work is required to be placed in the Discharge Worksheet -
Post-Discharge Orders. Please place an order for Outpatient Labs
based on the MEDICATION SPECIFIC GUIDELINE listed below:
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
NAFCILLIN,CEFTRIAXONE,MEROPENEM,ERTAPEMEN: WEEKLY: CBC with
differential, BUN, Cr, AST, ALT, Total Bili, ALK PHOS, CRP
FOLLOW UP APPOINTMENTS: TBD
All questions regarding outpatient parenteral antibiotics after
discharge should be directed to the ___ R.N.s at
___ or to the on-call ID fellow when the clinic is
closed.
PLEASE NOTIFY THE ID SERVICE OF ANY QUESTIONS REGARDING THESE
RECOMMENDATIONS OR WITH ANY MEDICATION CHANGES THAT OCCUR AFTER
THE DATE/TIME OF THIS OPAT INTAKE NOTE.
Physical Therapy:
WBAT LLE. Evaluate and treat.
Treatments Frequency:
Dry gauze dressing changes as needed.
Followup Instructions:
___
|
10230495-DS-18 | 10,230,495 | 20,781,435 | DS | 18 | 2179-08-20 00:00:00 | 2179-08-20 10:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Percocet / morphine
Attending: ___.
Chief Complaint:
ft prosthetic knee septic arthritis and left shoulder septic
arthritis
Major Surgical or Invasive Procedure:
___: left knee arthroplasty explant with placement of an
antibiotic spacer and left knee and left shoulder irrigation and
debridement
History of Present Illness:
___ w DM, afib on eliquis, CKD, L TKA in ___ c/b PJI s/p
I&D, liner exchange ___ - ___ presenting to the ED
with fever, L knee pain c/f persistent PJI. She was seen in Dr.
___ yesterday, who expressed concern for
persistent
infection, but she returned to rehab with increasing pain and
inability to ambulate. She developed a temp to 100.5 this AM,
so
she presented to the ED.
In the ED, WBC 7, CRP 260.
She denies nausea, vomiting, diarrhea. Denies recent trauma.
She has been on CTX with ID followup, and she states that her
pain slightly improved after her initial I&D but then quickly
returned.
Past Medical History:
DM
Afib on Eliquis
Social History:
___
Family History:
N/C
Pertinent Results:
___ 04:52AM BLOOD WBC-8.6 RBC-2.80* Hgb-8.0* Hct-25.2*
MCV-90 MCH-28.6 MCHC-31.7* RDW-16.1* RDWSD-53.1* Plt ___
___ 05:35AM BLOOD WBC-8.2 RBC-2.70* Hgb-7.6* Hct-24.2*
MCV-90 MCH-28.1 MCHC-31.4* RDW-16.1* RDWSD-53.0* Plt ___
___ 04:55AM BLOOD WBC-8.8 RBC-2.75* Hgb-7.8* Hct-24.2*
MCV-88 MCH-28.4 MCHC-32.2 RDW-16.2* RDWSD-52.3* Plt ___
___ 05:50PM BLOOD WBC-9.3 RBC-3.06* Hgb-8.5* Hct-27.0*
MCV-88 MCH-27.8 MCHC-31.5* RDW-15.9* RDWSD-51.1* Plt ___
___ 05:18AM BLOOD WBC-12.0* RBC-2.27* Hgb-6.4* Hct-20.4*
MCV-90 MCH-28.2 MCHC-31.4* RDW-15.9* RDWSD-52.7* Plt ___
___ 06:35AM BLOOD WBC-7.4 RBC-2.92* Hgb-8.3* Hct-26.5*
MCV-91 MCH-28.4 MCHC-31.3* RDW-15.5 RDWSD-51.3* Plt ___
___ 05:00AM BLOOD WBC-7.6 RBC-2.84* Hgb-8.4* Hct-26.0*
MCV-92 MCH-29.6 MCHC-32.3 RDW-15.6* RDWSD-51.9* Plt ___
___ 06:10AM BLOOD WBC-7.6 RBC-2.88* Hgb-8.4* Hct-26.8*
MCV-93 MCH-29.2 MCHC-31.3* RDW-15.5 RDWSD-52.9* Plt ___
___ 05:35AM BLOOD Neuts-68.9 Lymphs-18.5* Monos-9.1 Eos-1.8
Baso-0.4 Im ___ AbsNeut-5.61 AbsLymp-1.51 AbsMono-0.74
AbsEos-0.15 AbsBaso-0.03
___:50PM BLOOD Neuts-75.6* Lymphs-15.0* Monos-8.1
Eos-0.3* Baso-0.2 Im ___ AbsNeut-7.05* AbsLymp-1.40
AbsMono-0.76 AbsEos-0.03* AbsBaso-0.02
___ 02:05PM BLOOD Neuts-64.1 ___ Monos-11.9
Eos-0.5* Baso-0.4 Im ___ AbsNeut-4.72 AbsLymp-1.65
AbsMono-0.88* AbsEos-0.04 AbsBaso-0.03
___ 06:35AM BLOOD ___ PTT-29.4 ___
___ 05:00AM BLOOD ___ PTT-30.2 ___
___ 02:05PM BLOOD ___ PTT-31.9 ___
___ 04:52AM BLOOD Glucose-173* UreaN-24* Creat-1.0 Na-135
K-4.9 Cl-99 HCO3-23 AnGap-13
___ 05:35AM BLOOD Glucose-169* UreaN-29* Creat-1.3* Na-134*
K-4.4 Cl-100 HCO3-22 AnGap-12
___ 02:51PM BLOOD UreaN-31* Creat-1.6*
___ 05:50PM BLOOD UreaN-32* Creat-1.9*
___ 05:18AM BLOOD Glucose-214* UreaN-29* Creat-1.6* Na-134*
K-4.5 Cl-100 HCO3-21* AnGap-13
___ 06:35AM BLOOD Glucose-178* UreaN-22* Creat-1.3* Na-135
K-4.2 Cl-96 HCO3-21* AnGap-18
___ 05:00AM BLOOD Glucose-205* UreaN-20 Creat-1.3* Na-134*
K-4.1 Cl-95* HCO3-23 AnGap-16
___ 06:10AM BLOOD Glucose-199* UreaN-17 Creat-1.0 Na-135
K-4.5 Cl-98 HCO3-22 AnGap-15
___ 02:05PM BLOOD Glucose-234* UreaN-21* Creat-1.1 Na-137
K-4.9 Cl-100 HCO3-20* AnGap-17
___ 05:35AM BLOOD ALT-<5 AST-15
___ 05:50PM BLOOD ALT-5 AST-19 LD(LDH)-149 AlkPhos-276*
TotBili-0.3
___ 04:52AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.8
___ 05:35AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.2
___ 05:50PM BLOOD Albumin-2.4* Mg-1.5*
___ 05:18AM BLOOD Calcium-7.6* Phos-4.1 Mg-1.4*
___ 02:05PM BLOOD Calcium-9.0 Phos-2.5* Mg-1.5*
___ 05:35AM BLOOD CRP->300*
___ 02:05PM BLOOD CRP-260.1*
___ 04:52AM BLOOD IgG-1217
___ 05:50PM BLOOD IgG-1177
___ 05:50PM BLOOD Vanco-9.7*
___ 05:35AM BLOOD EDTA ___
___ 02:13PM BLOOD Lactate-1.7
___ 03:20PM JOINT FLUID ___ RBC-875 Polys-96*
___ Macro-2
___ 03:20PM JOINT FLUID Crystal-NONE
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left prosthetic knee septic arthritis and left
shoulder septic arthritis and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for left knee arthroplasty explant with placement of an
antibiotic spacer and left knee and left shoulder irrigation and
debridement, which the patient tolerated well. For full details
of the procedure please see the separately dictated operative
report. The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient's home medications
were continued throughout this hospitalization. The patient
worked with ___ who determined that discharge to rehab was
appropriate.
The ___ hospital course was notable for the following:
The patient's creatinine increased to 1.6 on ___ from 1.3 on
the previous day. The creatinine was rechecked in the evening of
___ and it had increased to 1.9. It trended downward to 1.6
on ___ and to 1.3 on ___. Her diuretics were held. Her
creatinine on ___ was 1.0.
The patient was unable to void after multiple attempts at
removing the Foley catheter. The Foley catheter was replaced in
the evening of ___ and will be kept in place for 5 days.
The infectious disease team was consulted and their final
recommendation was to discontinue Vancomycin and to continue
ceftriaxone for 6 weeks.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the left upper extremity in sling
for comfort and partial-weight bearing in the left lower
extremity. Knee immobilizer at all times when out of bed, and
will be discharged on 1 week of subcutaneous heparin 5000u BID
postoperatively (through ___, and then will resume her home
dose of Eliquis. 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.
Ms. ___ was discharged to rehab in stable condition.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 12.5 mg PO BID
2. Bumetanide 0.5 mg PO DAILY
3. CefTRIAXone 2 gm IV Q24H
4. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
3. Heparin 5000 UNIT SC BID
Continue through ___, then resume home dose Eliquis 2.5mg
twice daily
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
5. Senna 8.6 mg PO BID:PRN Constipation - First Line
6. Bumetanide 0.5 mg PO DAILY
7. CefTRIAXone 2 gm IV Q24H
Start date: ___
Tentative stop date: ___
8. Metoprolol Tartrate 12.5 mg PO BID
9. Omeprazole 20 mg PO DAILY
10. HELD- Apixaban 2.5 mg PO BID This medication was held. Do
not restart Apixaban until ___ (resume after SC Heparin BID
course completed)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
a left prosthetic knee septic arthritis and left shoulder septic
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:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as Colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please call your surgeon's office to schedule or confirm your
follow-up appointment.
7. SWELLING: Ice the operative joint 20 minutes at a time,
especially after activity or physical therapy. Do not place ice
directly on the skin. You may wrap the knee with an ace bandage
for added compression.
8. ANTICOAGULATION: Please continue your SUBCUTANEOUS HEPARIN
5000 units twice daily for 1 week postoperatively (through
___, then resume home dose Eliquis.
9. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower after surgery while wearing your aquacel
dressing, but no tub baths, swimming, or submerging your
incision until after your first checkup and cleared by your
surgeon. After the aquacel dressing is removed 7 days after your
surgery, you may leave the wound open to air. Check the wound
regularly for signs of infection such as redness or thick yellow
drainage and promptly notify your surgeon of any such findings
immediately.
10. ___ (once at home): Home ___, Aquacel removal POD#7, and
wound checks. If there are suture tags on either end of the
incision left, please cut the suture tags flush with the skin on
both sides on POD#7, when the aquacel is removed.
11. ACTIVITY: Partial weightbearing left lower extremity, knee
immobilizer at all times when out of bed. Weightbearing as
tolerated left upper extremity in sling for comfort, range of
motion as tolerated left upper extremity. No strenuous exercise
or heavy lifting until follow up appointment.
12. PICC CARE: Per protocol
13. WEEKLY LABS: draw on ___ and send result to ID RNs
at: ___ R.N.s at ___.
- CBC/DIFF
- CHEM 7
- LFTS
- ESR/CRP
**All questions regarding outpatient parenteral antibiotics
should be directed to the ___ R.N.s at
___ or to the on-call ID fellow when the clinic is
closed.
Physical Therapy:
WBAT LUE in sling for comfort
PWB LLE in knee immobilizer at all times when out of bed
Treatments Frequency:
remove aquacel POD#7 after surgery
apply dry sterile dressing daily if needed after aquacel
dressing is removed
wound checks daily after aquacel removed
Followup Instructions:
___
|
10231309-DS-16 | 10,231,309 | 21,775,791 | DS | 16 | 2137-11-28 00:00:00 | 2137-12-02 10:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
bronchoscopy ___
History of Present Illness:
___ is a ___ year old college student whose only medical
history is PCOS who presented to the emergency room on ___
with chest pain. She had an elevated d-dimer and a CTA chest was
notable for bilateral ground glass and enlarged, but
morphologically normal, axillary lymph nodes. She was discharged
to home with azithromycin, and followed up with her PCP ___
who ordered an x ray after noting decreased lung sounds on
physical exam, ultimately due to a large pleural effusion for
which she was sent to the ED. She is now s/p chest tube
placement and 1 dose of Levaquin and sent to the medical floor
for further management.
Per patient, she had been having mostly nocturnal right-sided
chest "tightness" that was worse with coughing and deep
inspiration, and ultimately responded to eating less acidic
food. The episode that caused her to present to the ED on
___ was characteristically different - on the left side and
more intense, which caused her to go to the ED. She denies any
fevers or chills, but notes her appetite is poor.
Patient notes since late ___ she has had a nagging dry cough
without any shortness of breath, hemoptysis, fever, or chills.
She states that this cough stopped for a short time before she
developed the chest pain that caused her to come into the ED.
She does note some night sweats, but states that "its hot out"
and ensures they are not drenching. She has lost 12 pounds
intentionally over the last few months by going to the gym. She
states that her quantiferon was ordered when she applied for
employment at ___ on ___ (where she still
works per ___ and never needed treatment for latent TB because
her CXR was normal. She denies any runny nose, sore throat,
muscle aches.
There is no family history of autoimmune disease,
lymphoproliferative disease, cancer. She denies any joint
swellings, mouth ulcers, hair loss, rashes. No new sexual
contacts, travel.
REVIEW OF SYSTEMS: per HPI.
In the ED, initial vitals: 101.7, HR 140, BP 138/80, RR 25,
97%NC
- Labs notable for:
WBC: WBC 8.7, Hgb 12.1, Hct 37.7, Plt 284
Lytes:
137 / 98 / 6
--------------- 123
4.0 \ 22 \ 0.8
- Imaging notable for:
Low lung volumes. Left basilar chest tube in place with small
bilateral pleural effusions. No definite pneumothorax.
Retrocardiac opacity may reflect atelectasis but infection is
not excluded correct clinical setting.
- Pt given:
___ 15:13 PO Acetaminophen 1000 mg
___ 15:13 IV Ondansetron 4 mg
___ 15:56 IVF NS
___ 15:56 IV Levofloxacin 750 mg ___
___ 19:37 IV Fentanyl Citrate 50 mcg
- Vitals prior to transfer: T 99.6, HR 115, BP 136/78, RR 16,
99%Nasal Cannula
On the floor, patient is in pain from the chest tube and says
she is not short of breath.
Review of systems:
(+) Per HPI
(-) 10 Point review of systems otherwise negative
Past Medical History:
-PCOS
Social History:
___
Family History:
no family history of rheumatologic disorders, cancer,
lymphoproliferative disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
Vital Signs: 102.5, HR 120, BP 144/92, RR 36, 100% 2l
General: Tearful, at times tachypnic with notable cough,
becoming less tachypnic throughout interview and exam
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: regular tachycardia, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: speech fluent
DISCHARGE PHYSICAL EXAM:
=========================
Vital Signs: 98.2 BP 108/70 HR 81 RR 18 96% on 1L
General: NAD. Appears stated age. Lying comfortably in bed.
HEENT: NC/AT, Sclerae anicteric
CV: RRR with normal S1 + S2. No murmurs, rubs, or gallops.
Lungs: Normal respiratory effort. Decreased breath sounds over
left lung base, otherwise no wheezes, rales or rhonchi.
Abdomen: Soft, non-tender, non-distended. Normoactive BS.
Ext: No edema or erythema.
Skin: Warm and dry.
Neuro: A&Ox3. ___ strength, normal sensation in bilateral lower
extremities.
Psych: Normal mood and affect.
Pertinent Results:
ADMISSION LABS:
===============
___ 03:18PM BLOOD WBC-8.7 RBC-4.40 Hgb-12.1 Hct-37.7 MCV-86
MCH-27.5 MCHC-32.1 RDW-13.0 RDWSD-40.5 Plt ___
___ 03:18PM BLOOD Neuts-84.6* Lymphs-7.3* Monos-6.7
Eos-0.0* Baso-0.2 Im ___ AbsNeut-7.34* AbsLymp-0.63*
AbsMono-0.58 AbsEos-0.00* AbsBaso-0.02
___:43AM BLOOD ___ PTT-26.6 ___
___ 07:43AM BLOOD ___
___ 10:45PM BLOOD Ret Aut-1.2 Abs Ret-0.05
___ 03:18PM BLOOD Glucose-123* UreaN-6 Creat-0.8 Na-137
K-4.0 Cl-98 HCO3-22 AnGap-21*
___ 10:45PM BLOOD ALT-31 AST-41* LD(___)-371* AlkPhos-66
TotBili-0.4
___ 10:45PM BLOOD TotProt-8.0 Albumin-3.9 Globuln-4.1*
Calcium-8.5 Phos-2.5* Mg-1.8 UricAcd-3.3
___ 10:45PM BLOOD Hapto-412*
___ 10:45PM BLOOD CRP-94.0*
___ 10:45PM BLOOD HIV Ab-Negative
___ 10:54PM BLOOD ___ pO2-76* pCO2-36 pH-7.41
calTCO2-24 Base XS-0
___ 10:54PM BLOOD Lactate-1.5
___ 03:56PM URINE Color-Straw Appear-Hazy Sp ___
___ 03:56PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 03:56PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-2
___ 07:40PM PLEURAL TNC-1060* ___ Polys-44*
Lymphs-33* Monos-0 Plasma-1* Macro-22* Other-0
___ 07:40PM PLEURAL TotProt-5.8 Glucose-52 LD(LDH)-1844
Cholest-89 ___ Misc-BODY FLUID
___ 05:18AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 11:54PM OTHER BODY FLUID ADENOSINE DEAMINASE, FLUID-PND
PERTINENT MICROBIOLOGY/PATHOLOGY:
=================================
___ Pleural pathology:
1. Pleural adhesions, left: Necrotizing granulomatous pleuritis
with organizing fibrinopurulent
exudate, see note.
2. Parietal pleura, left: Necrotizing granulomatous pleuritis
with organizing fibrinopurulent exudate, see note.
Note: Infectious stains are performed on both samples. Multiple
AFB and ___ stains reveal rare acid-fast bacilli in both
samples. GMS and Gram's stains are negative.
___ Bone Biopsy:
ANAEROBIC CULTURE (Final ___:
Reported to and read back by ___ ___
2:23PM.
PROPIONIBACTERIUM ACNES. RARE GROWTH.
___ Abscess:
ACID FAST CULTURE (Preliminary):
AFB GROWN IN CULTURE; ADDITIONAL INFORMATION TO FOLLOW.
___ BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
___ Pleural fluid:
ACID FAST CULTURE (Preliminary):
AFB GROWN IN CULTURE; ADDITIONAL INFORMATION TO FOLLOW.
___ BAL:
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
~7000 CFU/mL Commensal Respiratory Flora.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
MTB Direct Amplification (Final ___:
M. TUBERCULOSIS DNA NOT DETECTED BY NAAT:
DISCHARGE LABS:
================
___ 07:37AM BLOOD WBC-7.5 RBC-3.90 Hgb-10.7* Hct-33.4*
MCV-86 MCH-27.4 MCHC-32.0 RDW-14.6 RDWSD-44.4 Plt ___
___ 07:37AM BLOOD Glucose-89 UreaN-8 Creat-0.6 Na-136 K-4.3
Cl-100 HCO3-24 AnGap-16
___ 07:37AM BLOOD ALT-23 AST-21 AlkPhos-60 TotBili-0.3
IMAGING:
=========
CTA Chest with Contrast ___
IMPRESSION:
1. Mildly limited examination due to respiratory motion
artifact. Within these limitations, no evidence of pulmonary
embolism or aortic abnormality.
2. Scattered ground-glass and nodular opacities throughout the
lungs bilaterally, which are nonspecific, but are likely
infectious or inflammatory in nature. No focal consolidations.
3. Small left pleural effusions.
CXR ___
Low lung volumes. Left basilar chest tube in place with small
bilateral pleural effusions. No definite pneumothorax.
Retrocardiac opacity may reflect atelectasis but infection is
not excluded correct clinical setting.
___ CT Chest non con
Small dependent residual left pleural effusion may be isolated
from new left pleural drainage catheter.
Extensive left lung consolidation makes it difficult to
distinguish atelectasis from pneumonia, but the relative absence
of consolidation on ___ plaque prior to the pleural drainage
suggests that the pleural effusion preceded the lung findings,
which are largely atelectasis.
Lytic lesions, two lower most thoracic vertebrae, with
narrowing, but less than complete obliteration of the
intervening disc space, accompanied by thickening of the
paraspinal soft tissue most likely due to chronic infection,
such as tuberculosis, with secondary tuberculous empyema.
___ CTA Chest and Abdomen:
1. Multifocal pneumonia with partially loculated left pleural
effusion and small left hydropneumothorax, difficult to exclude
empyema. If further chest tube placement is attempted, consider
targeted placement within the loculated components.
2. Small simple appearing right pleural effusion.
3. No evidence of pulmonary embolism.
4. Large abscess within the right paraspinal muscle, already
drained at the time of this dictation.
5. Findings concerning for discitis-osteomyelitis centered at
T11-12 adjacent perivertebral fluid collection concerning for
abscess. Close follow-up is advised. Consider MRI to assess
further and to evaluate for epidural extension.
___ CXR:
Comparison to ___. The extensive parenchymal opacity
on the left has minimally increased in extent and severity. The
extent of the left pleural effusion is not substantially
changed. On the right, a small pleural effusion is visualized.
Moderate cardiomegaly. No pneumothorax.
___ MRI Thoracic and Lumbar Spine:
1. T11-T12 discitis and osteomyelitis with abnormal bone marrow
signal of T10 vertebral body and syndesmophytes extending from
T9 through T12 levels.
2. Right T11-T12 neural foramina soft tissue enhancement which
may compress the right T11 exiting nerve root.
3. The paraspinal enhancement has decreased compared to the
prior CT.
4. While discitis osteomyelitis from other bacterial sources
remains in
consideration, anterior signal changes involving T9-T10
vertebral bodies and along the syndesmophytes is suspicious for
TB spondylo arthritis.
5. No evidence of epidural abscess, spinal canal stenosis, or
cord compression.
6. Inflammatory changes with a right posterior paraspinal
intramuscular abscess at T11-L3 levels difficult to compare to
prior CT for interval changes.
7. Anterior paraspinal inflammatory changes with redemonstration
of loculated left-sided pleural effusion with consolidation,
likely related to multifocal
pneumonia. Please refer to recent CTA chest dated ___
for additional details.
Brief Hospital Course:
Ms. ___ is a ___ y/o female with a hx of PCOS who
presented with chest pain and fever.
#Exudative Effusion
#T11-T12 Lytic Bone Lesions
#Tuberculosis:
Patient presented with chest pain, non-productive cough, and
dyspnea. Imaging showed a left-sided pleural effusion and lytic
lesions in T11-T12. She was initially treated with CTX,
azithromycin, vancomycin, and flagyl without improvement.
Infectious work-up including blood/urine cultures, sputum
samples, bronchoscopy with BAL (___), and pleural fluid
analysis negative, including both culture and AFB. Pleural fluid
did reveal an exudative process with an elevated adenosine
deaminase concerning for possible TB. She also had a positive
quantiferon gold in the past; however, all AFBs done during the
hospitalization remained negative (prior to discharge) so TB was
not definitive at this time. A left-sided chest tube was placed
___ and eventually removed ___. She was continued on
broad-spectrum antibiotics until metronidazole and vancomycin
were discontinued on ___ and ceftriaxone on ___. Subsequently,
the patient became septic appearing (febrile, tachycardic,
tachypnic, worsening O2 requirement), so she was placed back on
vancomycin and ceftazidime on ___. Despite broad spectrum
antibiotics, she remained febrile and with an O2 requirement.
Spinal biopsy was done ___bdomen at that time showed a
10.1 cm right paraspinal fluid collection. A drain was placed in
the collection on ___ and remained until ___ when an MRI spine
showed the collection had resolved. CTA was also done on ___
due to worsening hypoxia - it was negative for PE but showed a
persistent loculated left-sided pleural effusion. MRI ___ was
also negative for any invasion in the epidural space. Around
this same time, a preliminary read of MTB DAT was negative,
making TB less likely. However, given the persistent oxygen
requirement and fevers despite several days of antibiotics and
source control, the patient was taken off all antibiotics on
___ with plans to start empiric tuberculosis treatment. That
same day, pleural biopsy pathology from ___ returned with
granulomas and rare AFB. On ___, she began rifampin, isoniazid,
pyrazinamide, and ethambutol and remained on this regimen until
discharge. Of note, on the day of discharge (___), bone biopsy
returned with rare growth of p. acnes. ID felt this did not
correlate with the clinical picture and decided to hold
treatment with the assumption that tuberculosis was the
pathologic organism. Several days following discharge, micro
returned with AFB growth in both the paraspinal fluid collection
and pleural fluid.
No other medications were changed during this hospitalization
TRANSITIONAL ISSUES:
====================
[ ] Patient needs to continue rifampin, isoniazid, pyrazinamide,
and ethambutol. Also given vitamin B6 to be taken while on
isoniazid.
[ ] Needs to see ophthalmology as an outpatient given medication
regimen.
[ ] Will be followed by the health department. Will be under
daily, direct observation of medication administration.
[ ] Will need monitoring of LFTs and for any clinical
improvement - will be closely followed by ID at ___ for this.
[ ] Contact isolation at home for the first two weeks of
treatment, per the dept of health.
# Contact: Mom ___ ___
# Code Status: full
Medications on Admission:
None
Discharge Medications:
1. Ethambutol HCl 1600 mg PO DAILY
RX *ethambutol 400 mg 4 tablet(s) by mouth Once a day Disp #*120
Tablet Refills:*0
2. Isoniazid ___ mg PO DAILY
RX *isoniazid ___ mg One tablet(s) by mouth Once a day Disp #*30
Tablet Refills:*0
3. Lidocaine 5% Patch 1 PTCH TD QPM
4. Pyrazinamide ___ mg PO DAILY
RX *pyrazinamide 500 mg 4 tablet(s) by mouth Once a day Disp
#*12 Tablet Refills:*0
5. Pyrazinamide ___ mg PO DAILY
RX *pyrazinamide 500 mg 4 tablet(s) by mouth Once a day Disp
#*100 Tablet Refills:*0
6. Pyridoxine 50 mg PO DAILY
RX *pyridoxine (vitamin B6) 50 mg One tablet(s) by mouth Once a
day Disp #*30 Tablet Refills:*0
7. Rifampin 600 mg PO Q24H
RX *rifampin 300 mg 2 capsule(s) by mouth Once a day Disp #*60
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Extrapulmonary tuberculosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
Why you were admitted to the hospital:
- You were admitted for fever and chest pain
What we did while you were here:
- We performed a variety of tests that showed you had an
infection in/around your lung, in a couple bones in your spine,
and in the muscle around your spine.
- You were treated with antibiotics for several days (without
getting better), while we were waiting for all of the tests to
return.
- You also had a drain placed around your lung and in the fluid
collection in your back muscles. You also had a biopsy of the
bone in your back to help diagnose the disease.
- In the end, most of our tests indicate that you have
tuberculosis - you were started on four medications (rifampin,
isoniazide, pyrazinamide, and ethambutol) to treat this
infection.
What you need to do once you return home:
- It is important that you continue taking the four medications
(rifampin, isoniazide, pyrazinamide, and ethambutol) as
prescribed every day. You will also need to take a vitamin,
vitamin B6, to protect your nerves while you are taking the TB
meds.
- You also need to follow-up with the health department as they
instruct you.
- Finally, you will need to follow-up with your primary care
doctor, an eye doctor, and the infectious disease doctors to
ensure ___ are continuing to get better. See below for
information on these appointments.
It was a pleasure taking care of you.
Sincerely,
___ Care Team
Followup Instructions:
___
|
10231763-DS-12 | 10,231,763 | 27,792,466 | DS | 12 | 2188-01-06 00:00:00 | 2188-01-06 16:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
shellfish derived
Attending: ___
Chief Complaint:
Pleuritic chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year-old man with a history of GERD, here with PEs.
He was admitted to ___ on ___, where he was started on
lovenox and then bridged to Xarelto; he was discharged home on
___ and was doing ok until the middle of the week,
when he started to feel shart L-sided chest pain (pleuritic)
especially at night. Each jolt of pain would only last seconds
or minutes (up to 2min). He had no known fevers, but did feel
chills. He denies frank dyspnea or cough. He has not had any
hemoptysis. His ROS is otherwise negative.
He presented to ___, where CXR showed LLL consolidation, which
turned out to be consistent with a pulmonary infarct on CTA. He
was transferred to ___ for further management; MASCOT consult
did not feel advanced therapies were needed.
In the ED, his VS were T 100.2, HR 84, BP 120/82, RR 18, satting
94% on R. He was given azithromycin, CTZ and was started on
heparin gtt.
Past Medical History:
GERD
PE
Social History:
___
Family History:
No FHx of clotting/bleeding disorders; no cancers; no premature
CAD.
Physical Exam:
T 98.2, BP 156/82, HR 68, RR 18, satting 97% on 2L NC and then
95% on RA without any desaturations with ambulation
General Appearance: pleasant, comfortable, no acute distress
Eyes: PERLL, EOMI, no conjuctival injection, anicteric
ENT: MMM, no JVD, no carotid bruits, no thyromegaly or palpable
thyroid nodules
Respiratory: Subtly dull over L base, otherwise no
crackles/wheezes.
Cardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops
Gastrointestinal: nd, +b/s, soft, nt, no masses or HSM
Extremities: no cyanosis, clubbing or edema; no palpable cords.
Skin: warm, no rashes/no jaundice/no skin ulcerations noted
Neurological: Alert, oriented to self, time, date, reason for
hospitalization. Cn II-XII grossly intact.
Psychiatric: pleasant, appropriate affect
GU: no catheter in place
Pertinent Results:
Admission labs:
___ 08:40PM BLOOD WBC-8.9 RBC-4.35* Hgb-12.0* Hct-36.4*
MCV-84 MCH-27.6 MCHC-33.0 RDW-13.2 RDWSD-40.6 Plt ___
___ 08:40PM BLOOD Neuts-62.7 Lymphs-18.9* Monos-12.2
Eos-4.7 Baso-0.8 Im ___ AbsNeut-5.58 AbsLymp-1.68
AbsMono-1.09* AbsEos-0.42 AbsBaso-0.07
___ 08:40PM BLOOD ___ PTT-32.9 ___
___ 08:40PM BLOOD Glucose-103* UreaN-15 Creat-1.1 Na-137
K-4.2 Cl-99 HCO3-26 AnGap-16
___ 08:40PM BLOOD cTropnT-<0.01 proBNP-47
___ 02:00AM BLOOD cTropnT-<0.01
___ 08:40PM BLOOD Calcium-8.9 Phos-3.4 Mg-2.1
___ 08:52PM BLOOD Lactate-0.8
Imaging:
___ Bilateral ___ (prelim):
IMPRESSION: No evidence of deep venous thrombosis in the right
or left lower extremity veins.
___ Imaging:
___ TTE:
IMPRESSION: BORDERLINE-ABNORMAL ECHOCARDIOGRAM.
Normal left ventricular size and systolic function. Estimated
ejection fraction of 60% to 65%. No apparent regional wall
motion abnormalities. Mildly impaired left ventricular
relaxation.
Normal right ventricular size and systolic function. No
___ sign to suggest massive or submassive pulmonary
embolism.
Mildly thickened aortic valve leaflets but no aortic stenosis.
Mild aortic regurgitation.
Trace mitral regurgitation. Normal left atrial size and normal
left atrial pressure.
Trace-to-mild tricuspid regurgitation. Trace pulmonic
insufficiency.
No pulmonary hypertension.
___ CTA:
IMPRESSION: There are left-sided pulmonary emboli again noted
extending from the distal main pulmonary artery into the left
lower lobe sub- segmental pulmonary arteries. The amount of
emboli appear similar to slightly decreased especially within
lower lobe pulmonary arteries. There is more focal density
abutting the chest wall within the left lower lobe, laterally
with air bronchograms and uncertain if this may represent a
region of developing pulmonary infarction.
There has been an increase in the left-sided pleural effusion
and an
apparent overlying atelectasis.
There has been development of a small pulmonary embolism within
a pulmonary artery within the superior segment of the right
lower lobe.
There is no aortic dissection.
Hiatal hernia.
Brief Hospital Course:
Mr. ___ is a ___ yo man with h/o GERD and recently diagnosed
unproked PE who presents with left sided pleuritic chest pain,
found to have possible pulmonary infarct.
# unprovoked PE
# pleuritic chest pain likely ___ pulmonary infarct
Patient originally diagnosed with extensive PE from distal main
left pulmonary artery into lobar, segmental, and subsegmental
branches of the LLL at ___ on ___. He was discharged
on rivaroxaban, which he reported taking correctly twice a day
with meals. He presented again to ___ with pleuritic
chest pain and repeat CTA showed evidence of possible left
pulmonary infarct and small associated pleural effusion, which
are likely the cause of his symptoms. Effusion not felt to be
hemorrhagic per imaging. He was initially transferred to ___
for evaluation of advanced therapies. MASCOT consulted; given
his overall clinical stability (normal BP, HR, and oxygenation)
and lack of right heart strain (as evidenced by normal troponin,
BNP, and lack of radiographic evidnce), no further interventions
were thought to be necessary. After a discussion regarding
risks/benefits of rivaroxaban vs Coumadin, patient elected to
continue rivaroxaban. As there was no evidence of
anticoagulation failure, rivaroxaban was thus continued.
Patient's pain improved at discharge.
45 minutes were spent on discharge care planning and
coordination, > 50% of which was spent discussing diagnosis with
patient and his family.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Rivaroxaban 20 mg PO DAILY
Discharge Medications:
1. Rivaroxaban 15 mg PO BID
2. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
acute pulmonary embolus
pulmonary infarct
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure caring for you during your stay at ___
___. You were admitted out of concern for
your pulmonary embolus causing lung infarction. This was likely
the cause of your pain. We do not believe that you need any
intervention on your blood clot and that you should be able to
continue taking Xeralto as you were. Be sure to take it with
food to ensure adequate absorption. Your echocardiogram (an
ultrasound of your heart) at ___ was normal.
Please see your primary care physician ___ ___ weeks of
discharge to ensure that you are doing well.
Take care,
Your ___ Team
Followup Instructions:
___
|
10232033-DS-14 | 10,232,033 | 27,943,983 | DS | 14 | 2151-06-24 00:00:00 | 2151-06-24 15:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / merepenum / Penicillins / Demerol
Attending: ___.
Chief Complaint:
fainting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o female with a history of recurrent
syncope, multiple cardiac arrest, s/p pacemaker placement at ___
(___), who presents following recurrent syncopal episodes,
concern for cardiac arrest.
The patient reports a history of recurrent syncopal episodes
since a cholecystectomy in ___ that was complicated by vagal
nerve injury. She describes pre-syncopal symptoms, including
lightheadedness, dizziness, nausea, and altered senses that
occur
prior to her passing out. She notes that they typically happen
following extreme pain or persistent vomiting. Do not occur with
urination. She has had ~2 episodes within the last year.
Mr. ___ notes that she had a left molar extraction a week
ago for a cavity and broken crown. A few days later on ___, she
then developed worsening jaw pain near the extraction site, for
which she was started on clindamycin. She presented to her
dentist today for further evaluation. The dentist anesthetized
the area and was waiting to further evaluate the patient when
she
had a syncopal episode. A carotid pulse was not felt and CPR was
started with ROSC achieved within 30 seconds. Soon after, she
had
another syncopal episode and again received a few compressions
resulting in ROSC. She describes having similar pre-syncopal
symptoms prior to these events. Denies seizure activity, tongue
biting, incontinence, chest pain, shortness of breath or
palpitations.
She was taken to ___ on ___; however, left there
AMA as she disagreed with her care. She began driving to ___,
when her symptoms returned. She pulled over at the fire station,
had another syncopal episode (no chest compressions done) and
then was transported to ___. There, her vitals were
stable. CBC and BMP were normal. EKG was without ischemia and
CXR
without acute processes. Decision made to transfer here for
pacemaker evaluation and ENT evaluation of the dental site per
her outpatient dental provider's request.
Of note, the patient was admitted to ___ for similar
symptoms in ___. TTE at that time was unremarkable. cvEEG done
during one of the episodes showed no significant changes, no
epileptiform activity. Etiology was felt to be likely
pseudoseizure, vs less likely seizure or cardiac in nature. She
was also noted to be orthostatic but remained asymptomatic from
this standpoint. Psychiatry was consulted and she declined
medication changes or new psychiatry providers.
In the ED:
- Initial vital signs were notable for: Temp 97.9F BP 144/91 HR
64 RR 16 99% on RA
- Exam notable for: Alert, tearful, extraction site left upper
jaw without erythema, signs of infection. CTAB. RRR. Severe TTP
along sternum. A&Ox3.
- Labs were notable for:
BMP: Na 140, K 4.5, Cl 104, CO2 24, BUN/Cr ___, BG 99, AG 12
CBC: WBC 6.9, H/H 14.___, plt 173
Trop-T <0.01, lactate 0.9
UCG negative
- Studies performed include:
AP CXR: No acute cardiopulmonary process. Please note this study
is not sensitive/nondiagnostic for the detection of sternal
fracture, particularly in the absence of a lateral view.
- Patient was given: IV morphine 4mg x2, 1L LR, po pantoprazole,
IV clindamycin
- Consults: EP - no events noted on brief interrogation. Plan
for
admission, telemetry and EP consult in the morning.
Vitals on transfer: Temp 97.8F BP 118/107 HR 60 RR 16 96% on RA
Upon arrival to the floor, the patient reports persistent pain
over her left face/jaw. She feels like the pain is moving into
her sinus, left ear and into her neck. She also has noticed
redness over the check. No fever, chills, headache, vision
changes, drainage, or other focal symptoms. She denies chest
pain, shortness of breath, palpitations, nausea or vomiting.
Past Medical History:
- Anxiety: on pharmacologic treatment
- Hysterectomy and L salpingo-oophrectomy: ___. Per patient
report, prophylaxis for ovarian cancer, but R ovary intact. Also
had rectocele and cystocele
- Laparoscopic cholecystectomy ___: history of pain, and bile
leakage.
- Tonsillectomy
- Sinus surgery: following broken nose
Social History:
___
Family History:
Father passed of sudden MI at age ___, Mother with hx of ovarian
cancer.
Physical Exam:
ADMISSION PHYSICAL
==================
VITALS: Temp 97.4F BP 109/74 HR 63 RR 17 98% on RA
GENERAL: WDWN female in NAD. Lying comfortably in bed.
HEENT: NCAT. PERRL, Sclera anicteric and without injection. MMM.
Oropharynx clear. Dental extraction site clean, without drainage
or erythema. TTP over site as well as diffusely over her left
upper/lower mandible. Erythema over her chin and left lower
face.
CARDIAC: RRR with normal S1 and S2. No m/r/g.
RESP: Normal respiratory effort. CTAB without wheezes, rales or
rhonchi.
ABDOMEN: Soft, NT/ND. Normoactive BS. No guarding or masses.
MSK: Warm, well perfused. No ___ edema or erythema.
SKIN: Warm, dry. No rashes.
NEUROLOGIC: Alert and interactive. CN2-12 grossly intact. Moves
all extremities.
PSYCH: appropriate mood and affect
DISCHARGE PHYSICAL
==================
___ 0434 Temp: 97.8 PO BP: 109/71 HR: 66 RR: 17 O2 sat: 94%
O2 delivery: Ra
GENERAL: Well appearing, in no acute distress, c/o diminishing
left jaw/cheek pain.
HEENT: NCAT. PERRL, Sclera anicteric and without injection. MMM.
Oropharynx clear. Dental extraction site clean, without drainage
or erythema. TTP over site as well as diffusely over her left
upper/lower mandible. No longer erythematous over her chin and
left lower face. Dentition is generally intact. Extraction site
#15 (upper left ___ molar) healing well with no sign of
ulceration or infection, no sinus perforation is noted.
CARDIAC: RRR with normal S1 and S2. No m/r/g.
RESP: CTAB, Breathing is non labored
ABDOMEN: Soft, NT/ND. Normoactive BS. No guarding or masses.
MSK: Warm, well perfused. No ___ edema or erythema.
SKIN: Warm, dry. No rashes.
NEUROLOGIC: Alert and interactive. No focal deficits.
Pertinent Results:
ADMISSION LABS
==============
___ 10:25PM BLOOD WBC-6.9 RBC-4.25 Hgb-14.7 Hct-42.0
MCV-99* MCH-34.6* MCHC-35.0 RDW-11.8 RDWSD-42.6 Plt ___
___ 10:25PM BLOOD ___ PTT-33.2 ___
___ 10:22PM BLOOD Glucose-99 UreaN-9 Creat-0.8 Na-140 K-4.5
Cl-104 HCO3-24 AnGap-12
___ 10:22PM BLOOD cTropnT-<0.01
___ 07:00AM BLOOD Calcium-8.7 Phos-4.8* Mg-2.2
___ 10:39PM BLOOD Lactate-0.9
IMAGING AND STUDIES
===================
___ CXR PORTABLE
Dual lead left-sided pacemaker is seen with leads extending to
the expected positions of the right atrium right ventricle. No
focal consolidation, pleural effusion, or evidence of
pneumothorax is seen. Cardiac silhouette size is borderline,
likely accentuated by AP technique. Mediastinal contoursare
unremarkable.
IMPRESSION:
No acute cardiopulmonary process. Please note this study is not
sensitive/nondiagnostic for the detection of sternal fracture,
particularly in the absence of a lateral view.
___ CHEST (PA LAT)
Left-sided pacemaker leads projecting over the right atrium and
right
ventricle.
Lungs are well expanded. No focal areas of consolidation or
parenchymal
abnormalities. Cardiomediastinal silhouette is normal. No
pleural effusion or pneumothorax.
IMPRESSION:
No acute cardiopulmonary findings.
___ CT Sinus:
1. No acute fracture.
2. At the site of the patient's left upper molar extraction,
there is air in the socket but no residual tooth fragments.
___ PANOREX (TEETH XR)
Reviewed by ___ and by dentistry. Extraction site of #15 does
not
appear to have any residual root fragments. No bony pathology or
caries detected on adjacent teeth.
DISCHARGE LABS
==============
___ 06:05AM BLOOD WBC-6.2 RBC-3.89* Hgb-13.4 Hct-38.9
MCV-100* MCH-34.4* MCHC-34.4 RDW-11.5 RDWSD-41.4 Plt ___
___ 06:05AM BLOOD Plt ___
___ 06:05AM BLOOD Glucose-122* UreaN-14 Creat-0.9 Na-146
K-4.6 Cl-107 HCO3-25 AnGap-14
___ 06:05AM BLOOD Calcium-8.9 Phos-4.7* Mg-2.2
MICROBIOLOGY
============
___ Blood Culture, Routine-PENDING
Brief Hospital Course:
TI:
[] Continue clindamycin x7 day course (___)
[] F/u with outpatient dental
[] Strongly advised pt not to drive anymore given recurrent
syncopal episodes.
ASSESSMENT AND PLAN:
====================
Ms. ___ is a ___ y/o female with a history of recurrent
syncope, multiple cardiac arrests s/p pacemaker placement at ___
(___), who presented with left jaw pain and recurrent syncopal
episodes.
ACUTE ISSUES:
=============
#Recurrent Vasovagal Syncope
Ms. ___ has a history of recurrent syncope. She presented
to the hospital this admission with left jaw pain and multiple
episodes of syncope. She notes that her syncopal episodes are
classically triggered by pain. Her description of pre-syncopal
symptoms following a severe painful stimuli is most consistent
with a vasovagal event, particularly as these events have only
started occurring since partial severance of her vagal nerve
during the cholecystectomy. Cardiac etiology was ultimately
thought to be less likely. EP was consulted for pacemaker/EKG
review which did not show any arrhythmia. She was monitored on
tele without events noted. Orthostatics were normal. Last TTE
done at ___ did not show concern for structural heart disease
and cardiac exam was without murmurs. She improved with rest
and pain control without any further syncopal episodes seen.
She was instructed not to drive.
# S/p dental extraction
# Concern for dental infection
The patient underwent left molar extraction on ___ due to
cavity complicated by infection, and is now on PO clindamycin.
At admission, she was still reporting significant pain in her
left jaw and left maxillary area. CT Sinus showed air in the
socket but no residual tooth fragments. Dental Panorex showed no
concern for communication of the extraction site with the
sinuses. She was discharged on PO Clindamycin 300 mg qid, and
will continue her course for a total of 1 more day. Her pain was
treated with Acetaminophen 1000mg TID standing, Oxycodone 5mg
q4h prn, IV morphine 4mg q6h prn for breakthrough pain, Zofran
prn for nausea. She was discharged on a regimen of acetaminophen
1000 3 times daily standing. She did not want to take any
opioid medications at home and feels confident that she can
control her pain well on acetaminophen.
#Chest contusion ___ chest compressions
Ms. ___ experienced significant chest pain following
outpatient CPR. Chest X-Ray showed no evidence of rib fractures.
Pain was managed pain aggressively given prior syncopal episodes
following painful stimuli. She was treated with lidocaine
patches, and medications as above. Her pain improved during her
stay.
CHRONIC ISSUES:
===============
#Anxiety: Patient continued home Xanax.
#GERD/GI distress: Patient continued her home pantoprazole, and
also received Tums as needed.
CODE STATUS: Full (presumed)
CONTACT: ___ (husband) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
2. ALPRAZolam 1 mg PO TID:PRN anxiety
3. Pantoprazole 40 mg PO Q12H
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*21 Tablet Refills:*0
2. Clindamycin 300 mg PO QID
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth four times a
day Disp #*6 Capsule Refills:*0
3. ALPRAZolam 1 mg PO TID:PRN anxiety
4. Pantoprazole 40 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
Vasovagal syncope
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
-You were admitted to the hospital because of fainting
WHAT HAPPENED IN THE HOSPITAL?
==============================
-During the hospital you were continued on antibiotics, seen by
our electrophysiologists who looked at your pacemaker and found
no issues, and were also seen by our dentistry and oral surgeon
teams who ordered a scan of your head that did not find any
acute abnormalities requiring surgery.
-An x-ray of your teeth was also performed and no acute
abnormalities were found
-We also treated you for your pain while you are here to keep
your comfortable
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Please continue to take all of your medications as directed
- Please follow up with all the appointments scheduled with your
doctor and your dentist
___ you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
10232271-DS-25 | 10,232,271 | 27,173,906 | DS | 25 | 2135-07-14 00:00:00 | 2135-07-14 17:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
levofloxacin / ciprofloxacin
Attending: ___.
Chief Complaint:
Tachycardia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
I have read the Medicine Nightfloat note and agree with transfer
of care to the CCU. In brief, this patient is a ___ with past
history of tachy-bradycardia s/p PPM, seizure disorder,
intracranial anerusym s/p multiple interventions, recently
hospitalized from ___ for presumed pneumonia (although
without radiographic evidence), who presented for fatigue,
increased lower extremity swelling, and shortness of breath over
the past several days. Patient presented ___ with new onset L
sided chest and abdomen pain, eventually diagnosed with PNA
though there was no radiographic evidence. She was treated with
levaquin for CAP. Symptoms initially improved, however she
proceeded to develop DOE and ___ edema over the subsequent 2
weeks.
Since admission, she has been diuresed with 40 IV Lasix with
significant symptomatic improvement.
Tonight, she triggered for tachycardia to 150s. Received 10mg IV
dilt x 3, subsequently SBPs dropped to ___. Pt was placed in
___ with improvement in BP to ___. She also
received 2L IVF. She was asymptomatic throughout, with no
light-headedness or palpitations. Tachycardia reviewed on tele
was felt to be atrial tachycardia. She was loaded with PO
digoxin (as unable to load IV digoxin on the floor). She was
also briefly started on a heparin gtt due to concern for new AF.
MDs wished to give metoprolol for further HR control, however
the floor RNs refused to give it due to the patient's labile
BPs. Ultimately, the decision was made to transfer to the CCU
where the RNs are more comfortable managing tachyarrhythmias.
On arrival to the CCU, she has no complaints. She says she feels
much better than she did when she came in. She denies
light-headedness/dizziness, chest pain, shortness of breath,
palpitations.
Past Medical History:
1. CARDIAC RISK FACTORS
None
2. CARDIAC HISTORY
- Coronaries: History of NSTEMI, thought to be demand. No
ischemic evaluation performed.
- ___ TTE with EF 50%. Clinically with CHF. TTE this
admission not yet done.
- Rhythm: Tachy/brady syndrome s/p PPM
3. OTHER PAST MEDICAL HISTORY
- Left parietotemporal AVM s/p cyberknife ___
- Seizure disorder secondary to AVM
- R ICA aneurysm s/p pipeline ___, L paraophthalmic ICA
neurysm, and possible R vertebral aneurysm
- L ICA aneurysm s/p pipeline ___
- Hypothyroidism
- Schizophrenia
- Bilateral lower extremity edema
- Cholecystectomy
- Cognitive impairment
- Anemia
- Thrombocytopenia
- Tachy-brady syndrome s/p PPM placement in ___
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
Admission physical exam:
General: No acute distress.
HEENT: PERRL, EOMI. MMM.
Neck: No JVP elevation.
Cardiac: Tachycardic. S1, S2. No MRG.
Lungs: Diminished at the bases, otherwise clear.
Abdomen: Soft, NT/ND. +BS.
Extremities: trace ___ edema
Skin: No significant rashes or erythema.
Discharge physical exam:
VS: 98.6, 90-115/70, 81, ___ RA
General: well-appearing, sitting in chair, NAD. Answers
questions slowly.
Neck: no JVP
Lungs: bilateral lower lobe crackles, no accessory muscle use or
labored breathing
CV: RRR, S1+S2, no M/R/G
Abdomen: non-distended, soft, non-tender, +BS
Ext: WWP, no edema
Neuro: oriented to self, ___
Pertinent Results:
ADMISSION LABS
=============
___ 12:40PM BLOOD WBC-7.5 RBC-3.05* Hgb-10.3* Hct-31.2*
MCV-102* MCH-33.8* MCHC-33.0 RDW-14.2 RDWSD-53.5* Plt ___
___ 12:40PM BLOOD Neuts-59.5 ___ Monos-14.4*
Eos-0.3* Baso-0.3 Im ___ AbsNeut-4.47# AbsLymp-1.88
AbsMono-1.08* AbsEos-0.02* AbsBaso-0.02
___ 12:40PM BLOOD ___ PTT-25.9 ___
___ 12:40PM BLOOD Glucose-67* UreaN-14 Creat-0.8 Na-137
K-4.8 Cl-98 HCO3-28 AnGap-16
___ 12:40PM BLOOD ALT-7 AST-21 LD(LDH)-331* AlkPhos-48
TotBili-0.3
___ 12:40PM BLOOD proBNP-1600*
___ 12:40PM BLOOD cTropnT-<0.01
___ 07:00AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 12:40PM BLOOD Albumin-3.2* Calcium-8.3* Phos-3.7 Mg-2.0
___ 12:40PM BLOOD Folate->20
___ 12:40PM BLOOD TSH-1.1
___ 07:00AM BLOOD 25VitD-44
___ 12:40PM BLOOD Valproa-90
___ 01:01PM BLOOD Lactate-1.8
___ 01:40PM URINE Color-Yellow Appear-Clear Sp ___
___ 01:40PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-6.5 Leuks-NEG
IMAGING/STUDIES
==============
___ (PA & LAT)
No pneumonia or edema. Unchanged cardiomegaly. Unchanged
position of left upper chest wall pacemaker and pacer wires.
___
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen.
Trivial mitral regurgitation is seen. The pulmonary artery
systolic pressure could not be determined. There is a small
pericardial effusion.
IMPRESSION: Low-normal left ventricular systolic function
secondary to intraventricular dyssynchrony. Small
circumferential pericardial effusion.
Compared with the prior study (images reviewed) of ___,
pericardial effusion is new. Biventricular systolic function is
similar.
___ (PORTABLE AP)
In comparison with the study ___, there are lower lung
volumes.
Continued enlargement the cardiac silhouette with dual channel
pacer with
leads in the right atrium and right ventricle. Minimal if any
vascular
congestion.
There is increased opacification at the left base obscuring the
hemidiaphragm,
consistent with volume loss in left lower lobe and small pleural
effusion.
MICRO
=====
___ Blood Cx: No growth
___ Urine Cx: No growth
___ Blood cx: No growth
___ Urine Cx: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES),
CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.
___ MRSA screen: No MRSA isolated
DISCHARGE LABS
=============
___ 06:30AM BLOOD WBC-7.2 RBC-2.52* Hgb-8.4* Hct-25.0*
MCV-99* MCH-33.3* MCHC-33.6 RDW-13.9 RDWSD-50.5* Plt ___
___ 06:30AM BLOOD Glucose-93 UreaN-12 Creat-0.5 Na-132*
K-4.9 Cl-93* HCO3-28 AnGap-16
___ 06:30AM BLOOD Calcium-8.4 Phos-4.1 Mg-2.1
Brief Hospital Course:
Ms. ___ is a ___ year old woman with past history of seizure
disorder, cerebral AVM, ICA aneurysm s/p pipeline embolization,
SSS s/p PPM placement, admitted for worsening fatigue and lower
extremity edema, i/s/o recent ICU stay for PNA and perhaps
increased AF burden on pacemaker interrogation s/p brief CCU
stay for difficult to control AF with rapid ventricular rate.
#A FIB, PAROXYSMAL:
#s/p PPM for TACHY-BRADY SYNDROME/SSS:
Recently with increased burden of AF on PPM interrogation. For
the majority of her admission, she was clinically and
hemodynamically stable in A-paced rhythm. Not anticoagulated
i/s/o prior CVA's and recent interventions. Had several episodes
of a fib with RVR this admission, managed initially with IV and
PO metoprolol (pt developed hypotension when given IV diltiazem
for RVR) and eventually with amiodarone. Pt was given one dose
of amiodarone 150mg IV but became hypotensive during this. It
was noted that she was hypotensive in a-paced rhythm at 60, but
normotensive in a-fib to 110-140, so baseline pacer rate
increased to 80 temporarily in setting of pneumonia (see below).
It was decided to start sotalol. She had continued runs of RVR
to 160 on sotalol 80mg BID but this improved on 120mg BID. She
is asymptomatic when in RVR and maintains her BPs. Recommend
___ of ___ monitor as outpatient to evaluate for sustained
runs of RVR. Not anticoagulated as she is on dual antiplatelet
therapy for her cerebral pipeline embolization.
#PNEUMONIA: pt with worsening hypoxia on ___ despite
improving diueresis and CXR with new left retrocardiac
consolidation. He was started on vanco/cefepime (___) with
subsequent resolution of hypoxia. She was de-escalated to
cefpodoxime to complete a 7 day course of antibiotics.
#Acute diastolic heart failure exacerbation:
Likely decompensated due to increased a-fib burden. Presented
with worsening fatigue i/s/o possible CHF exacerbation. No
previous CHF diagnosis; TTE this admission without significant
findings. Would suspect that there is some baseline diastolic
dysfunction and increased AF burden recently, in addition to
myocardial dysfunction stemming from recent ICU stay for
pneumonia/septic shock. Diuresed with IV Lasix until pt appeared
euvolemic. Restarted home furosemide 20mg daily.
#HYPONATREMIA: patient with hyponatremia, mild without clear
etiology. Developed as patient was diuresed - likely the result
of diuresis. Has improved since stopping IV diuresis. TSH and AM
cortisol this admission were WNL, making thyroid or adrenal
etiology quite unlikely. Placed on 1500mL fluid restriction
while admitted. Discharge Na 132.
#Left Parietotemporal AVM s/p cyberknife:
#Right ICA anerusym s/p pipeline, left paraotphamlic ICA
anerusym, and right vertebral anerusym: Continued aspirin 325
mg, Plavix 75 mg daily.
#Seizure Disorder: Continued divalproex ___ mg QAM, 1000 mg QPM.
#Schizophrenia: Continued home risperidone 1mg QAM, 2 mg QPM.
#Vitamin D Deficiency: Continued home vitamin D.
#Macrocytic Anemia: Iron studies consistent with anemia of
chronic disease. Stool guaiac negative. Hgb slowly downtrended
from 10 to 8.4 on discharge without evidence of bleed.
#Hypothyroid: TSH 1.1 this admission. Continued home
levothyroxine.
TRANSITIONAL ISSUES
===================
[] Discharge weight: 70.4 kg
[] Initiated sotalol, 120mg BID discharge dose. Recommend ___
of Hearts for monitoring of recurrent RVR. *Note she is
asymptomatic with HR 160. ___ QTc 421.
[] Recommend initiation of anticoagulation after completion of
clopidogrel course for pipeline embolization
[] Pacer lower limit increased to 80 in setting of hypotension
and pneumonia. Can reduce limit back to 60 at next visit.
#CODE: Full code
#CONTACT: ___, sister, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Divalproex (EXTended Release) 750 mg PO QAM
4. Divalproex (EXTended Release) 1000 mg PO QPM
5. Furosemide 20 mg PO DAILY
6. Levothyroxine Sodium 150 mcg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. PARoxetine 20 mg PO DAILY
9. RisperiDONE 1 mg PO QAM
10. RisperiDONE 2 mg PO QPM
11. Vitamin D 1000 UNIT PO DAILY
12. Calcium Carbonate 500 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Sotalol 120 mg PO BID
4. Calcium Carbonate 500 mg PO DAILY
5. Divalproex (EXTended Release) 750 mg PO QAM
6. Divalproex (EXTended Release) 1000 mg PO QPM
7. Furosemide 20 mg PO DAILY
8. Levothyroxine Sodium 150 mcg PO DAILY
9. PARoxetine 20 mg PO DAILY
10. RisperiDONE 1 mg PO QAM
11. RisperiDONE 2 mg PO QPM
12. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Atrial fibrillation with RVR
Pneumonia
Secondary diagnosis:
Sick sinus syndrome s/p pacemaker placement
Hyponatremia
History of AVMs
Seizure disorder
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
You came to the hospital because of fatigue and leg swelling
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You were given a diuretic/water pill (called furosemide AKA
Lasix) through the IV to get rid of excess fluid.
- You had frequent episodes of a fast, abnormal heart rhythm
call atrial fibrillation. We started you on a new medicine
called sotalol for this and your rates improved.
- You were found to have a pneumonia. We treated you with
antibiotics for this.
WHAT WILL HAPPEN WHEN YOU LEAVE THE HOSPITAL?
- Continue to take all of your medicines as prescribed.
- Weigh yourself every morning, after you wake up and urinate.
If your weight goes up by more than 3 lbs, please call your
cardiologist, Dr ___ (___), for further guidance.
- Your cardiologist may want to have you on a cardiac event
monitor, and if so his office will arrange this and contact you.
We wish you the best!
Sincerely,
Your ___ care team
Followup Instructions:
___
|
10232271-DS-26 | 10,232,271 | 26,683,554 | DS | 26 | 2135-08-02 00:00:00 | 2135-08-02 18:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
levofloxacin / ciprofloxacin
Attending: ___
Chief Complaint:
Dyspnea, fatigue
Major Surgical or Invasive Procedure:
L Pigtail placement ___ removal ___
History of Present Illness:
Ms. ___ is a ___ year old woman with a past medical history of
tachy-brady syndrome and SSS s/p PPM, IC aneurysm, and multiple
recent hospitalizations for PNA presenting with 3 days of
increasing fatigue, cough, labored breathing, anorexia and "not
being herself" per sister.
The patient was having increased fatigue and was falling asleep
at home. She was having shorntess of breath and tachypnea at
home. She developed cough that is mildly productive one day
prior to admission. She has a decreased appetite. She developed
loose stools lasting >1 wk following her most recent discharge
from the hospital. This has resolved within the past 3 days. Her
PCP is working her up for C. diff. She has a PCP appointment of
___ and held off seeing a doctor with ___ plan to be evaluated at
this scheduled appointment.
She was found to be hypotensive at her PCP's office and her PCP
sent her for urgent cardiology evaluation at her ___
cardiologist's office. He interrogated the pacer that showed
atrially paced and pacemaker interrogation did not demonstrate
any significant A. fib burden since discharge from ___
___. His cardiologist determined that arrhythmia is
not a contributor to her current presentation.
Of note, the patient was recently hospitalized from ___
for presumed pneumonia and ___ with increased burden of AF
on PPM interrogation. For the majority of her admission, she was
clinically and hemodynamically stable in A-paced rhythm. Not
anticoagulated i/s/o prior CVA's and recent interventions. Had
several episodes of a fib with RVR that admission, managed
initially with IV and PO metoprolol (pt developed hypotension
when given IV diltiazem for RVR) and eventually with amiodarone.
Pt was given one dose of amiodarone 150mg IV but became
hypotensive during this. It was noted that she was hypotensive
in a-paced rhythm at 60, but normotensive in a-fib to 110-140,
so baseline pacer rate increased to 80 temporarily in setting of
pneumonia (see below). It was decided to start sotalol. She had
continued runs of RVR to 160 on sotalol 80mg BID but this
improved on 120mg BID. She was asymptomatic when in RVR and
maintained her BPs. Not anticoagulated as she is on dual
antiplatelet therapy for her cerebral pipeline embolization.
She also saw her PCP who ordered ___ CXR notable for bilateral
pleural effusions, L>R. Denies fever, chills, chest pain,
nausea/vomiting, new onset edema.
Pertinent ED course:
Initial vitals:
97.5 80 94/63 18 100% RA
Labs:
WBC 13.4
Na 128
Lactate 1.8
IMAGING:
CXR ___:
New moderate left and trace right layering pleural effusions. No
additional change.
CT chest: Moderate left and small right pleural effusions
substantial atelectasis in the left lower lobe, Prominent
mediastinal lymph nodes, Small to moderate pericardial effusion,
Dilated left pulmonary artery may suggest pulmonary
hypertension, No pulmonary embolism or aortic abnormality.
Patient was given:
___ 21:41 IVF NS
___ 21:41 IV CefePIME 2 g
___ 23:36 IV Vancomycin
Upon arrival to the floor, the patient is sleeping. She awakes
to voice and answers yes or no questions.
REVIEW OF SYSTEMS:
Unable to perform full ROS as patient is sleeping and
intermittently awakens and answers few questions.
Past Medical History:
1. CARDIAC RISK FACTORS
None
2. CARDIAC HISTORY
- Coronaries: History of NSTEMI, thought to be demand. No
ischemic evaluation performed.
- ___ TTE with EF 50%. Clinically with CHF. TTE this
admission not yet done.
- Rhythm: Tachy/brady syndrome s/p PPM
3. OTHER PAST MEDICAL HISTORY
- Left parietotemporal AVM s/p cyberknife ___
- Seizure disorder secondary to AVM
- R ICA aneurysm s/p pipeline ___, L paraophthalmic ICA
neurysm, and possible R vertebral aneurysm
- L ICA aneurysm s/p pipeline ___
- Hypothyroidism
- Schizophrenia
- Bilateral lower extremity edema
- Cholecystectomy
- Cognitive impairment
- Anemia
- Thrombocytopenia
- Tachy-brady syndrome s/p PPM placement in ___
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
==============================
ADMISSION PHYSICAL EXAM:
==============================
VITALS: 98.3 121/83 81 20 94 Ra
WEIGHT: 68.6kg, last discharge weight 70.4kg
GEN: No distress. Pale, Lethargic with coughing spells.
HEENT: Normocephalic and atraumatic. Oropharynx is clear and
moist. No oropharyngeal exudate. Conjunctivae and EOM are
normal. Pupils are equal, round, and reactive to light. Right
eye exhibits no discharge. Left eye exhibits no discharge. No
scleral icterus.
Neck: No JVD present. No tracheal deviation present. No
thyromegaly present.
Cardiovascular: Irregular rhythm. No murmurs rubs gallops.
Pulmonary/Chest: Effort normal. No respiratory distress. She has
no wheezes. She has no rales. She exhibits no tenderness.
Diminished breath sounds over the left base.
Abdominal: She exhibits no distension and no mass. There is no
tenderness. There is no rebound and no guarding.
Musculoskeletal: She exhibits 1+ bilateral leg edema
Neurological: Arousable to voice. Moves all four extremities
Skin: No rash noted. She is not diaphoretic. No erythema. No
pallor
==============================
DISCHARGE PHYSICAL EXAM:
==============================
VS: 97.8 103/68 79 18 98 Ra
GEN: Seated in chair at bedside, eating breakfast.
HEENT: Moist mucous membranes
Cardiovascular: Regular rhythm. No murmurs rubs gallops.
Pulmonary/Chest: Faint bibasilar crackles, otherwise CTAB
Abdominal: SNTND no R/G.
Musculoskeletal: Trace edema, nonpitting.
Neurological: Alert, resting tremor. Moves all four extremities
Skin: No rash noted.
Pertinent Results:
=======================
ADMISSION LABS
=======================
___ 06:30PM BLOOD WBC-13.4*# RBC-3.09* Hgb-9.9* Hct-30.6*
MCV-99* MCH-32.0 MCHC-32.4 RDW-14.4 RDWSD-52.6* Plt ___
___ 06:30PM BLOOD Neuts-75.2* Lymphs-10.6* Monos-12.5
Eos-1.1 Baso-0.1 Im ___ AbsNeut-10.05*# AbsLymp-1.42
AbsMono-1.67* AbsEos-0.15 AbsBaso-0.02
___ 01:25PM BLOOD ___ PTT-26.2 ___
___ 06:30PM BLOOD Glucose-93 UreaN-13 Creat-0.7 Na-128*
K-5.9* Cl-91* HCO3-23 AnGap-20
___ 06:04AM BLOOD ALT-7 AST-9 AlkPhos-57 TotBili-0.2
___ 06:04AM BLOOD Albumin-2.2* Calcium-7.2* Phos-3.9 Mg-2.0
___ 07:12PM BLOOD Lactate-1.8 K-4.5
=======================
PERTINENT RESULTS
=======================
___ 05:08PM PLEURAL TNC-701* ___ Polys-11*
Lymphs-12* ___ Meso-7* Macro-67* Other-3*
___ 05:08PM PLEURAL TotProt-3.3 Glucose-118 Creat-0.5
LD(LDH)-112 Amylase-27 Albumin-1.9 Cholest-61
=======================
MICROBIOLOGY
=======================
__________________________________________________________
___ 6:31 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool. **FINAL REPORT ___
C. difficile DNA amplification assay (Final ___: Negative
__________________________________________________________
___ 5:08 pm PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
__________________________________________________________
___ 10:55 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
__________________________________________________________
___ 10:25 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
__________________________________________________________
___ 9:20 pm BLOOD CULTURE 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 6:35 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
====================
CYTOLOGY:
====================
Pleural fluid ___: NEGATIVE FOR MALIGNANT CELLS.
Reactive mesothelial cells, lymphocytes, and histiocytes.
====================
IMAGING:
====================
CT CHEST ___. Moderate left and small right pleural effusions substantial
atelectasis in the left lower lobe and possible aspiration.
2. Small to moderate pericardial effusion.
3. Findings suggest pulmonary hypertension.
4. No subsegmental pulmonary embolism or aortic abnormality.
===
Videoswallow ___
FINDINGS:
Laryngeal penetration is seen with solids without gross
aspiration.
Barium passes freely through the oropharynx and esophagus
without evidence of obstruction.
IMPRESSION:
Penetration with solids. No gross aspiration.
===
CXR ___
FINDINGS:
There is streaky density at the left base consistent with
subsegmental
atelectasis as before. The left costophrenic sulcus is not
blunted consistent with a small effusion. A left pleural
drainage catheter remains in place. The heart and mediastinal
structures are unchanged. A cardiac pacemaker is present as on
the earlier study.
IMPRESSION: Interval increase in small left effusion. No other
significant change.
===
CXR ___:
IMPRESSION: Compared to chest radiographs ___ through ___.
Small pleural effusions and mild bibasilar atelectasis are still
present.
Upper lungs clear. Mild cardiomegaly has worsened, but there is
no dema. No pneumothorax. Transvenous right atrial right
ventricular pacer leads in standard placements. No radio-opaque
pleural drainage tube is visible.
===
TTE ___
Normal left ventricular cavity size and global systolic
function. Normal right ventricular cavity size and free wall
motion. . There is a very small (<0.7cm) circumferential
pericardial effusion without echocardiographic signs of
tamponade. IMPRESSION: Very smalll circumferential pericardial
effusion wthout echographic signs of tamponade. Compared with
the prior study (images reviewed) of ___, effusion is
smaller.
===
CXR ___
IMPRESSION:
Compared to chest radiographs ___ through ___.
Small bilateral pleural effusions unchanged. Mild to moderate
left lower lobe atelectasis stable. Upper lungs clear. Heart
size top-normal. No
pneumothorax. Transvenous right atrial right ventricular pacer
leads
continuous from the left pectoral generator.
=======================
DISCHARGE LABS
=======================
___ 06:10AM BLOOD Glucose-90 UreaN-8 Creat-0.6 Na-132*
K-4.7 Cl-94* HCO3-26 AnGap-12
___ 06:10AM BLOOD Calcium-8.0* Phos-3.7 Mg-2.0
___ 07:14AM BLOOD Lactate-1.8
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a past medical history of
SSS s/p PPM, IC aneurysm, and recent hospitalization for PNA
presenting with 3 days of increasing fatigue, cough, labored
breathing, anorexia found to be hypotensive at her outpatient
provider admitted ___, found to have new left pleural
effusion.
==================
ACUTE ISSUES
==================
# Left pleural effusion: The patient underwent chest tube
placement on ___ pleural fluid analysis was equivocal for
exudative effusion (see pleural fluid analysis in OMR/DC
summary). Given 3% "others" there was initial concern for
possible malignancy, however, cytology was negative. Ultimately,
it was felt that her confusion was due to a parapneumonic
effusion in the setting of recent PNA. She was initially treated
with broad-spectrum antibiotics which were narrowed to Unasyn.
Prior to discharge she was transitioned to Augmentin. She will
complete a total 14 day course; this was chosen given a desire
for an extended course above HAP coverage although not felt to
warrant 4 week treatment course for complicated pleural
effusion. End date for Augmentin is ___. Her chest tube was
removed on ___ with no significant reaccumulation of fluid.
While admitted she did have a speech and swallow evaluation
which did not show any aspiration.
# Encephalopathy:
# Sepsis: The patient had hypotension at her outpatient
providers' office that improved with fluids. Recent treatment
for pneumonia during admission in late ___ with vancomycin and
cefepime that was transitioned to cefpodoxime. She was
empirically started on vancomycin and cefepime in the ED for
empiric HAP treatment, then transitioned to Vancomycin/Unasyn,
and then to just Unasyn (MRSA swab negative) with plan for 14
day course with Augmentin as above. Speech and swallow evaluated
patient at bedside and w/video swallow and determined no
aspiration. Notably UA w/o UTI; stool without C. Diff.
# Hypotension:
# Hyponatremia:
# Elevated lactate: The patient has baseline blood pressures in
the systolic ___. After resolution of sepsis as above, the
patient had an episode of worsened hypotension to the systolic
___ and elevated lactate that improved with intravenous fluids.
An echocardiogram was obtained that showed only a very small
pericardial effusion without evidence of tamponade. The patient
appeared clinically hypovolemic, and in addition to IVF her home
Lasix was held; this should be resumed on ___. Her sodium on
day of discharge was 132 (trending up from 130 on day prior); a
BMP should be checked on ___.
# Loose stools: Patient developed loose stools, possibly related
to antibiotic use as above. C. diff was sent and was negative.
# Paroxysmal atrial fibrillation: Patient is s/p PPM for
tachy-brady syndrome/SSS and with recent admission for increased
atrial fibrillation burden during which she was initiated on
sotalol. Pacemaker interrogated by her outpatient cardiologist
prior to admission who found to increase in atrial fibrillation
burden. She remained hemodynamically stable in A-paced rhythm
throughout admission, with occasional short bursts of
nonsustained atrial fibrillation w/RVR.
# Chronic diastolic CHF: She was thought to have diastolic
dysfunction in setting of persistent afib. The patient was
hypovolemic on exam, and Lasix was held as noted above.
Discharge weight: 67.8 kg.
# Pericardial effusion: Noted to be small on prior TTE. On ___,
she was found to have SBP in mid ___, asymptomatic; however, she
had stat TTE to rule out tamponade given prior pericardial
effusion. This showed very minimal effusion with no
echocardiographic findings of tamponade.
# Macrocytic Anemia: Previous workup unremarkable, likely
thyroid related. Hb 9.9 on admission and remained stable.
==================
CHRONIC ISSUES
==================
# Left Parietotemporal AVM s/p cyberkinfe
# Right ICA anerusym s/p pipeline embolization device, left
paraotphamlic ICA aneurysm, and right vertebral anerusym. She
was continued aspirin 325 mg (cannot hold); home Plavix 75 mg
daily was initially held ___ for chest tube then resumed after
chest tube removal.
# Seizure Disorder:
- continued divalproex ___ mg QAM
- continued divalproex ___ mg QPM
# Schizophrenia
- continued risperidone 1mg QAM
- continued risperidone 2 mg QPM
# Vitamin D Deficiency:
- continued vitamin D
# Hypothyroid: TSH wnl this admission
- continued home levothyroxine
=========================
TRANSITIONAL ISSUES
=========================
- Discharge weight: 67.8 kg
- Please ensure adequate oral intake, particularly given ongoing
loose stools
- Lasix held at discharge; to be resumed on ___
- Please check ___ at next cardiology appointment (scheduled for
___. Na on day of discharge was 132 (up from 130 on day
prior).
- Follow-up with ___ clinic in ___ weeks
- Continue Augmentin until ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 500 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Divalproex (EXTended Release) 750 mg PO QAM
4. Divalproex (EXTended Release) 1000 mg PO QPM
5. Levothyroxine Sodium 150 mcg PO DAILY
6. PARoxetine 20 mg PO DAILY
7. RisperiDONE 1 mg PO QAM
8. RisperiDONE 2 mg PO QPM
9. Vitamin D 1000 UNIT PO DAILY
10. Sotalol 120 mg PO BID
11. Furosemide 20 mg PO DAILY
12. Aspirin 325 mg PO DAILY
Discharge Medications:
1. 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 #*11 Tablet Refills:*0
2. Aspirin 325 mg PO DAILY
3. Calcium Carbonate 500 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Divalproex (EXTended Release) 750 mg PO QAM
6. Divalproex (EXTended Release) 1000 mg PO QPM
7. Levothyroxine Sodium 150 mcg PO DAILY
8. PARoxetine 20 mg PO DAILY
9. RisperiDONE 1 mg PO QAM
10. RisperiDONE 2 mg PO QPM
11. Sotalol 120 mg PO BID
12. Vitamin D 1000 UNIT PO DAILY
13. HELD- Furosemide 20 mg PO DAILY This medication was held.
Do not restart Furosemide until ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Parapneumonic Pleural Effusion
Toxic Metabolic Encephalopathy
Heart Failure Preserved Ejection Fraction
Secondary Diagnosis:
Atrial Fibrillation
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
Why was I admitted to the hospital?
-You were admitted with low blood pressure, cough and difficulty
breathing. You were found to have a fluid collection in your
left lung which was likely causing your symptoms.
What did we do for you in the hospital?
-You were treated with antibiotics and a tube was placed to
drain the fluid in your lung.
-Tests run on the fluid showed that it was most likely caused by
infection
-You were seen by our speech and swallow team, who found that
food and liquid do not go into your lungs when you eat.
What should I do at home?
-You should continue taking antibiotics for a total of 14
days(last day ___
-You should follow up with your primary care physician.
-You should continue taking all of your medications as
prescribed.
We wish you all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10232271-DS-28 | 10,232,271 | 25,061,299 | DS | 28 | 2135-11-19 00:00:00 | 2135-11-19 19:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
levofloxacin / ciprofloxacin
Attending: ___.
Chief Complaint:
Decreased speech output, staring spell, ? aphasia, ? weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of cognitive
impairment, schizophrenia, and multiple aneurysms s/p Pipeline
embolization of the right ICA on ___ and a second
embolization ___ and most recent pipeline embolization of
right ICA aneurysm on ___ who presents as a code stroke for
expressive aphasia.
Briefly patient was in her usual state of health until circa
7:10pm. When she was trick a treating she suddenly became less
responsive and would have a blank stare on her face. She was
also noted to have trouble getting her words out and when she
would say something it would not make sense. There was
reportedly no focal weakness and they did not notice any other
focal deficit. No gaze deviation or head deviation or any kind
of
body shaking, no urinary incontinence or tongue biting.
EMS was called and she was brought to ___ for further evaluation. Here a code stroke was
called. She had an NIHSS of 3 forward finding difficulty, mild
dysarthria and 1 mistake in LOC questions. According to the
family who was at bedside she was already improving but still
not
at her baseline. At baseline she is developmentally delayed
depends on her family for all her ADL's. Is at baseline slow
when she talks but the family said she is slower than usual. CT
head was obtained which did not show any acute process. CTA
head
and neck was obtained which showed patent vessels. TPA was not
given.
Of note patient had similar episode in ___. At the time she
presented with disorientation, inattention, language
deficits, mild bilateral leg weakness and urinary incontinence,
concerning for seizure. She underwent EEG which showed slowing
but no seizures. She was then again admitted earlier this year
with episode of language difficulties concerning for seizure vs
TIA. She again underwent EEG which showed slowing but no
seizures
as well as TIA work up.
Past Medical History:
1. CARDIAC RISK FACTORS
None
2. CARDIAC HISTORY
- Coronaries: History of NSTEMI, thought to be demand. No
ischemic evaluation performed.
- ___ TTE with EF 50%. Clinically with CHF. TTE this
admission not yet done.
- Rhythm: Tachy/brady syndrome s/p PPM
3. OTHER PAST MEDICAL HISTORY
- Left parietotemporal AVM s/p cyberknife ___
- Seizure disorder secondary to AVM
- R ICA aneurysm s/p pipeline ___, L paraophthalmic ICA
neurysm, and possible R vertebral aneurysm
- L ICA aneurysm s/p pipeline ___
- Hypothyroidism
- Schizophrenia
- Bilateral lower extremity edema
- Cholecystectomy
- Cognitive impairment
- Anemia
- Thrombocytopenia
- Tachy-brady syndrome s/p PPM placement in ___
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
Physical Exam:
- General: Awake, cooperative, NAD.
- HEENT: NC/AT
- Neck: Supple
- Pulmonary: no increased WOB
- Cardiac: well perfused
- Abdomen: soft, nontender, nondistended
- Extremities: no edema, pulses palpated
- Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x person and place. Able to
name
___ forward would not backwards. language was slow with word
finding difficulty, she appeared to have intact comprehension
but
made some parapahsic mistakes with repetition normal prosody.
There were paraphasic errors. Patient had difficulty naming
objects. Unable to read but did not have glasses . speech was
mildly dysarthric. Able to follow simple commands There was no
evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus.
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.
She had a mild right upper extremity resting tremor as well as a
head tremor
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
-DTRs: 2+ throughout
Plantar response flexor bilaterally.
-Sensory: No deficits to light touch, pinprick throughout. No
extinction to DSS.
-Coordination: No intention tremor. No dysmetria on FNF
bilaterally.
-Gait: Deferred
Pertinent Results:
___ 05:00AM BLOOD WBC-5.5 RBC-3.51* Hgb-10.8* Hct-32.2*
MCV-92 MCH-30.8 MCHC-33.5 RDW-18.7* RDWSD-62.0* Plt Ct-79*
___ 06:25AM BLOOD WBC-5.2 RBC-3.38* Hgb-10.4* Hct-30.9*
MCV-91 MCH-30.8 MCHC-33.7 RDW-18.6* RDWSD-62.8* Plt Ct-75*
___ 05:00AM BLOOD Plt Ct-79*
___ 05:00AM BLOOD Glucose-95 UreaN-27* Creat-0.8 Na-135
K-4.1 Cl-93* HCO3-32 AnGap-10
___ 06:25AM BLOOD Glucose-90 UreaN-17 Creat-0.7 Na-137
K-4.0 Cl-95* HCO3-34* AnGap-8*
___ 06:25AM BLOOD ALT-8 AST-10 AlkPhos-52
___ 05:00AM BLOOD Calcium-8.2* Phos-4.0 Mg-1.9
___ 06:25AM BLOOD %HbA1c-5.5 eAG-111
___ 06:25AM BLOOD Triglyc-80 HDL-56 CHOL/HD-2.4 LDLcalc-62
___ 06:25AM BLOOD TSH-0.80
___ 06:25AM BLOOD Valproa-111*
___ 08:09PM BLOOD Valproa-89
___ 08:09PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
IAMGING:
Final Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old woman with aphasia, weakness r/o
stroke// r/o stroke
TECHNIQUE: Sagittal and axial T1 weighted imaging were
performed. After
administration of Gadavist intravenous contrast, axial imaging
was performed
with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE
imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: Outside facility brain MRI of ___
CTA head and neck of ___
CTA head and neck from ___
FINDINGS:
T2/FLAIR hyperintensity in the left temporoparietal region may
represent
posttreatment changes, or venous hypertension, similar to
slightly increased
in comparison with ___ (12:10). Nodular and linear
focus of
enhancement along the adjacent posterior temporal lobe cortex
could be related
to post radiation changes or sequela venous ischemia (101:46).
There is no
evidence of an arteriovenous malformation. The there is a
developmental
venous anomaly in the posterior left temporal lobe extending
from the
ventricular surface of the atrium draining within the
superficial system
eventually into the left vein ___ a in the distal left
transverse sinus.
Caliber of the DVA is smaller today compared with ___, likely
from interval
therapy. No evidence of cavernoma.
Subependymal gray matter heterotopia is again noted along the
frontal horn and
body of the right lateral ventricle (12:13). Adjacent area of
cortical
thickening involving anterior margin of the right insula is most
consistent
with subcortical gray matter heterotopia, with flattening of the
adjacent
cortical surface suggestive of pulmonary ___ a, stable.
A focus of susceptibility artifact in the right temporal lobe
could reflect a
prior small hemorrhage (13:11). There is no evidence of acute
infarction,
acute hemorrhage, or mass effect.
There are no additional foci of abnormal enhancement on
postcontrast images.
Bilateral ICA pipeline stents are better assessed on CTA
performed on ___. The dural venous sinuses are patent on MP-RAGE
images. There
is atrophy or postsurgical change of the right parotid gland.
Mucous retention cysts are present in the right maxillary sinus.
There is
mild mucosal thickening of the anterior ethmoid air cells.
There is partial
opacification of the bilateral mastoid air cells. The orbits
are
unremarkable.
IMPRESSION:
1. No evidence of acute infarction or hemorrhage.
2. Edema in the left posterior temporal lobe is likely related
to post
radiation changes, or sequela from venous hypertension/ischemia.
3. Focal nodular enhancement along the temporal lobe cortex in
the region of
radiation therapy could be related to posttreatment changes or
subacute
infarct. Recommend follow-up imaging to resolution.
4. Subependymal gray matter heterotopia right frontal lobe, and
adjacent
cortical malformation development including subcortical gray
matter
heterotopia.
FINDINGS:
CONTINUOUS EEG: The background activity shows posterior and
centrally
predominant 7.5-8.0 Hz alpha activity with suitable central beta
activity.
Intermittent slowing is noted over both lateral temporal regions
with a left
temporal predominance. Paroxysmal interictal epileptic activity
is also noted
bitemporally with a definite right-sided predominance. There
were also a few
isolated left frontal and central discharges seen predominantly
on the Spike
detection algorithm. There continued to be occasional periods of
paroxysmal
generalized delta compatible with frontal intermittent rhythmic
delta (FIRDA)
SLEEP: The patient progresses from wakefulness to stage N2, then
slow wave
sleep.
PUSHBUTTON ACTIVATIONS: There are no pushbutton activations.
SPIKE DETECTION PROGRAMS: There are numerous automated spike
detections,
predominantly for electrode and movement artifact but also for
the paroxysmal
interictal epileptic discharges over the right lateral temporal
region and the
relatively rare discharges seen in the left temporal and the
isolated
discharges seen in the left frontal region.
SEIZURE DETECTION PROGRAMS: There are [several automated seizure
detections,
predominantly for electrode and movement artifact. There are no
electrographic seizures.
QUANTITATIVE EEG: Trend analysis is performed with Persyst Magic
Marker
software. Panels include automated seizure detection, rhythmic
run detection
and display, color spectral density array, absolute and relative
asymmetry
indices, asymmetry spectrogram, amplitude integrated EEG, burst
suppression
ratio, envelope trend, and alpha delta ratios. Segments showing
abnormal
trends are reviewed, and show diffuse slowing.
CARDIAC MONITOR: Shows a generally regular rhythm with an
average rate of 60
bpm and what appears to be a paced cardiac rhythm.
IMPRESSION: This is an abnormal video-EEG monitoring session
because of
multifocal bilateral independent and generalized slowing
compatible with
multifocal cortical subcortical structural pathology. There are
also
multifocal independent interictal discharges showing more
frequent discharges
over the right lateral temporal region. Compared to the prior
day's
recording, there is no significant change.
FINDINGS:
CONTINUOUS EEG: The background activity shows posterior and
centrally
predominant 7.5-8.0 Hz alpha activity with suitable central beta
activity.
Intermittent slowing is noted over both lateral temporal regions
with a left
temporal predominance. Paroxysmal interictal epileptic activity
is also noted
bitemporally with a definite right-sided predominance. There
were also a few
isolated left frontal and central discharges seen predominantly
on the Spike
detection algorithm. There continued to be occasional periods of
paroxysmal
generalized delta compatible with frontal intermittent rhythmic
delta (FIRDA)
SLEEP: The patient progresses from wakefulness to stage N2, then
slow wave
sleep.
PUSHBUTTON ACTIVATIONS: There are no pushbutton activations.
SPIKE DETECTION PROGRAMS: There are numerous automated spike
detections,
predominantly for electrode and movement artifact but also for
the paroxysmal
interictal epileptic discharges over the right lateral temporal
region and the
relatively rare discharges seen in the left temporal and the
isolated
discharges seen in the left frontal region.
SEIZURE DETECTION PROGRAMS: There are [several automated seizure
detections,
predominantly for electrode and movement artifact. There are no
electrographic seizures.
QUANTITATIVE EEG: Trend analysis is performed with Persyst Magic
Marker
software. Panels include automated seizure detection, rhythmic
run detection
and display, color spectral density array, absolute and relative
asymmetry
indices, asymmetry spectrogram, amplitude integrated EEG, burst
suppression
ratio, envelope trend, and alpha delta ratios. Segments showing
abnormal
trends are reviewed, and show diffuse slowing.
CARDIAC MONITOR: Shows a generally regular rhythm with an
average rate of 60
bpm and what appears to be a paced cardiac rhythm.
IMPRESSION: This is an abnormal video-EEG monitoring session
because of
multifocal bilateral independent and generalized slowing
compatible with
multifocal cortical subcortical structural pathology. There are
also
multifocal independent interictal discharges showing more
frequent discharges
over the right lateral temporal region. Compared to the prior
day's
recording, there is no significant change.
INDICATION: History: ___ with New defecits, s/p right ICA embo
3 days ago.//
Bleed? Aneurysm clot? CVA?.
TECHNIQUE: Contiguous MDCT axial images were obtained through
the brain
without contrast material. Subsequently, helically acquired
rapid axial
imaging was performed from the aortic arch through the brain
during the
infusion of 70 mL of Omnipaque350 intravenous contrast material.
Three-dimensional angiographic volume rendered, curved
reformatted and
segmented images were generated on a dedicated workstation. This
report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy
(Head) DLP =
903.1 mGy-cm.
2) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 65.3 mGy
(Head) DLP =
32.7 mGy-cm.
3) Spiral Acquisition 4.6 s, 36.5 cm; CTDIvol = 30.9 mGy
(Head) DLP =
1,130.2 mGy-cm.
Total DLP (Head) = 2,066 mGy-cm.
COMPARISON: ___ MR head without contrast.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is mild global parenchymal volume loss. There is no large
infarct,
acute intracranial hemorrhage, or mass effect. There
low-attenuation with the
left temporal and parietal lobes related to the left temporal
parietal AVM,
similar to the prior study. There is periventricular nodular
gray matter
heterotopia around the frontal horn and body of the right
lateral ventricle,
much better appreciated on MRI. The orbits are unremarkable.
There is a mucous retention cyst within the right maxillary
sinus. The
paranasal sinuses, middle ear cavities, mastoid air cells are
otherwise clear.
CTA HEAD:
The large draining vein into left transverse sinus is consistent
with the
known left temporoparietal arterial venous malformation, similar
to the prior
study.
There is flow diverting stent mediated embolization of bilateral
ICA
aneurysms. The right para ophthalmic aneurysm measures 6 mm in
long axis and
3 mm in short axis dimension (series 3, image 224), similar to
the ___ CTA. No residual flow or recanalization of the other ICA
aneurysms. In
stent stenosis cannot be assessed, however there is normal
peripheral runoff.
No new aneurysm is identified.
The vessels of the circle of ___ and their principal
intracranial branches
otherwise appear normal without stenosis or occlusion. The
dural venous
sinuses are patent.
CTA NECK:
There is mild extracranial atherosclerosis. There is a 2 mm
focal outpouching
within the distal right ICA (series 3, image 170) with
appearance of a small
pseudoaneurysm, unchanged prior studies.
The carotid and vertebral arteries and their major branches
otherwise appear
normal with no evidence of stenosis or occlusion. There is no
evidence of
internal carotid stenosis by NASCET criteria.
OTHER:
There is a right subclavian approach central venous catheter.
The left
pulmonary artery is enlarged, suggestive of underlying pulmonary
arterial
hypertension. The lung apices are clear.
No enlarged cervical lymph nodes are identified. There is a 2
cm nodule
within the right lobe of the thyroid.
There is a sclerotic lesion within the right scapula underlying
the glenoid
(series 3, image 65), likely an enchondroma and unchanged from
the ___
chest CT.
Incomplete fusion of the posterior C1 arch is noted. Grade 1
retrolisthesis
of C3 on C4 is likely secondary to facet arthropathy.
IMPRESSION:
1. The flow diverting stent mediated embolization of multiple
internal carotid
artery aneurysms, with residual filling of the 6 x 3 mm right
para ophthalmic
aneurysm, similar to the ___ CTA head neck. In
stent stenosis
cannot be assessed, however there is normal peripheral runoff.
No new
aneurysm is identified.
2. Left temporal parietal AVM, similar in appearance to ___.
3. Mild extracranial atherosclerosis, without ICA stenosis by
NASCET criteria.
There is a 2 mm distal right ICA pseudoaneurysm unchanged from
prior studies.
4. Findings consistent with pulmonary arterial hypertension.
Brief Hospital Course:
This is a ___ year old woman with a history of cognitive
impairment, seizures, schizophrenia, and multiple aneurysms s/p
Pipeline embolization of the right ICA on ___ and a second
embolization ___ and most recent pipeline embolization of
right ICA aneurysm on ___ who presented as a code stroke from
an outside hospital for expressive aphasia and a staring spell.
CT imaging was negative for acute intracranial hemorrhage. MRI
brain with and without contrast was negative for acute infarct.
Continuous video EEG did not show epileptiform activity. Her
clinical exam improved to her neurological baseline within 24
hours. Based on her exam and the history of her transient
episode of unresponsiveness, with a slow return to baseline, we
think her event is most likely consistent with seizures.
We added an additional seizure medication to her anti-epileptic
regimen: Lamictal.
EEG: multifocal independent interictal discharges showing more
frequent discharges over the right lateral temporal region
MRI: No acute infarct
Transitional Issues:
- continue to uptitrate lamictal slowly as follows:
LAMICTAL TITRATION:
week 1: Take 25 mg every other day
week 2: Take 25 mg every other day
week 3: Take 25 mg daily
week 4: Take 25 mg daily
week 5: Take 25 mg AM, 25 mg ___
week 6: Take 50 mg AM, 25 mg ___
week 7: Take 50 mg AM, 50 mg ___
week 8: Take 75 mg AM, 50 mg ___
week 9: Take 75 mg AM, 75 mg ___
week 10: Take 100mg AM, 75 mg ___
week 11: Take 100mg AM, 100 mg ___
- we also dispensed rescue Ativan sublingual 0.5-1 mg PRN any
seizure > 5 minutes
Transitional Issues:
- follow-up with Dr. ___ on ___ at 9:15 AM
regarding further management of lamictal titration and AED
regimen
- follow-up with PCP for thrombocytopenia
- monitor for rash ___ Syndrome while on lamictal)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain
2. Aspirin 325 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Divalproex (EXTended Release) 750 mg PO QAM
5. Divalproex (EXTended Release) 1000 mg PO QPM
6. Levothyroxine Sodium 150 mcg PO DAILY
7. PARoxetine 20 mg PO DAILY
8. RisperiDONE 1 mg PO QAM
9. RisperiDONE 2 mg PO QPM
10. Spironolactone 25 mg PO DAILY
11. Sotalol 120 mg PO Q12H
12. Fluticasone Propionate NASAL 2 SPRY NU DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. Furosemide 40 mg PO BID
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain
2. LamoTRIgine 25 mg PO AS DIRECTED
Titrate as directed
RX *lamotrigine 25 mg 1 tablet(s) by mouth every other day Disp
#*7 Tablet Refills:*0
3. LORazepam 0.5-1 mg SL PRN Seizure > 5 minutes
RX *lorazepam 1 mg 0.5 (One half) tablet(s) SL PRN Disp #*30
Tablet Refills:*0
4. Aspirin 325 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Divalproex (EXTended Release) 750 mg PO QAM
7. Divalproex (EXTended Release) 1000 mg PO QPM
8. Fluticasone Propionate NASAL 2 SPRY NU DAILY
9. Furosemide 40 mg PO BID
10. Levothyroxine Sodium 150 mcg PO DAILY
11. PARoxetine 20 mg PO DAILY
12. RisperiDONE 1 mg PO QAM
13. RisperiDONE 2 mg PO QPM
14. Sotalol 120 mg PO Q12H
15. Spironolactone 25 mg PO DAILY
16. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure
Discharge Condition:
Mental Status: Confused - sometimes.
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear ___,
___ were admitted to the hospital for workup of an episode of
unresponsiveness and a staring spell that was accompanied by
slow speech, followed by a gradual return to your normal self.
The hospital that ___ initially presented to was concerned that
___ may be having a stroke and transferred ___ to ___ for
further workup, as ___ recently had your aneurysm embolization
performed at ___.
At ___, we were concerned that your episode was related to a
seizure. We imaged your brain and found no evidence of stroke.
We also evaluated your brain activity through EEG. Your EEG read
showed areas in your brain that are susceptible to producing
seizures.
In conjunction with your neurologist, we started ___ a new
seizure medication - lamictal. Please take this medication on a
titration schedule as described with ongoing follow-up with your
neurologist.
NEW MEDICATIONS ON THIS ADMISSION:
LAMICTAL:
week 1: Take 25 mg every other day
week 2: Take 25 mg every other day
week 3: Take 25 mg daily
week 4: Take 25 mg daily
week 5: Take 25 mg AM, 25 mg ___
week 6: Take 50 mg AM, 25 mg ___
week 7: Take 50 mg AM, 50 mg ___
week 8: Take 75 mg AM, 50 mg ___
week 9: Take 75 mg AM, 75 mg ___
week 10: Take 100mg AM, 75 mg ___
week 11: Take 100mg AM, 100 mg ___
ATIVAN: Put this medicine under your tongue for any seizure
lasting longer than 5 minutes.
We made no further changes on this admission.
Of note, we noticed that your platelet count, a blood product
that helps clotting, has been decreasing. It was stable on this
admission but it is lower than what it was a few months ago.
Please follow-up with your PCP regarding your platelet count.
Please also be cautious of any side effects that ___ may develop
while on lamictal, such as skin rashes. If ___ notice a skin
rash, please call your Neurologist or PCP ___.
Follow-up with your outpatient neurologist within ___ weeks and
with your PCP ___ ___ weeks.
Thank ___ for allowing us to participate in your care.
___ Neurology
Followup Instructions:
___
|
10232286-DS-7 | 10,232,286 | 20,559,188 | DS | 7 | 2143-11-13 00:00:00 | 2143-11-15 13:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Oxycodone
Attending: ___
Chief Complaint:
found down
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH alcoholism, GERD, prostate cancer s/p XRT and
brachytherapy who was brought in to the ED by ambulance after
being found down. Per his sister, she went to his apartment and
found him down in a puddle of his own stool. He was unresponsive
so she called ___ and he was brought to the ED by EMS.
In the ED he was found to be tachycardic, hypotensive ___,
with leukocytosis (WBC 16.2), hyponatremia (119), elevated
transaminases, coagulopathy, and hyperbilirubinemia. He had a
RUQUS done which showed an echogenic liver and gallbladder
sludge without stones or gallbladder wall thickening. He also
had a CXR which showed no acute process or consolidation. A head
CT was also done, with read pending on transfer to the ICU.
In the ED he was given 1L NS but his BP did not respond so he
was given another 1L NS, given Zosyn & Vanco 1g, and started on
levo 0.12, increased to 0.18 mcg/kg/min.
On arrival to the MICU, patient is oriented to self and year,
but not date or place. He does not remember what happened prior
to him coming to the hospital. He denies any pain but reports
feeling uncomfortable overall. He denies any recent fevers,
chills, cough, blood in stool or vomit. He states that he has
had previous alcohol withdrawals that gave him the shakes but
responds inconsistently when asked how much he has been drinking
recently.
Past Medical History:
Alcoholic hepatitis
Allergic rhinitis
Cerival spondylosis
Colonic polyps (colonoscopy ___ with hyperplastic
polypectomy)
Depression
Gastritis (last EGD ___
GERD
HTN
Peptic ulcer disease
Prostate cancer (s/p XRT and brachytherapy ___
Macroscopic hematuria
Social History:
___
Family History:
noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: HR: 112, BP: 117/79, RR 16, O2 sat 97% RA
GENERAL: alert, oriented to self and ___ only, no acute
distress, jaundiced
HEENT: Sclera icteric, PERRL, MMM, oropharynx clear
NECK: supple. no neck stiffness
LUNGS: Clear to auscultation bilaterally, faint expiratory
wheeze diffusely, no rales or rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, mildly distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, palpable distal pulses with 4+ pitting
edema to mid-thigh. Erythema over RLE without wounds, lesions or
warmth with TTP over erythema. +asterixis, shaky
SKIN: erythema over RLE per above, no other rashes or lesions
NEURO: strength symmetric ___ in upper and lower extremities
bilaterally, sensation grossly intact, AAOx1-2, +asterixis. Gait
deferred. CN II-XII grossly intact
DISCHARGE PHYSICAL EXAM:
=========================
Resting comfortably with RR 20
Pertinent Results:
LABS ON ADMISSION:
==================
___ 04:09PM WBC-16.2*# RBC-2.42*# HGB-9.0*# HCT-25.4*#
MCV-105*# MCH-37.2*# MCHC-35.4 RDW-18.2* RDWSD-69.4*
___ 04:09PM NEUTS-89* BANDS-0 LYMPHS-7* MONOS-2* EOS-0
BASOS-0 ___ METAS-1* MYELOS-1* AbsNeut-14.42* AbsLymp-1.13*
AbsMono-0.32 AbsEos-0.00* AbsBaso-0.00*
___ 04:09PM HYPOCHROM-OCCASIONAL ANISOCYT-OCCASIONAL
POIKILOCY-1+ MACROCYT-OCCASIONAL MICROCYT-NORMAL
POLYCHROM-OCCASIONAL TARGET-1+ BURR-OCCASIONAL
___ 04:09PM PLT SMR-NORMAL PLT COUNT-155
___ 04:09PM ___ PTT-36.2 ___
___ 04:09PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 04:09PM ALT(SGPT)-114* AST(SGOT)-261* CK(CPK)-351*
ALK PHOS-92 TOT BILI-15.5* DIR BILI-8.6* INDIR BIL-6.9
___ 04:09PM LIPASE-289*
___ 04:09PM ALBUMIN-2.4* CALCIUM-8.2* PHOSPHATE-4.1
MAGNESIUM-1.8
___ 04:09PM GLUCOSE-139* UREA N-60* CREAT-3.9*#
SODIUM-119* POTASSIUM-5.5* CHLORIDE-88* TOTAL CO2-14* ANION
GAP-23*
___ 04:22PM ___ PO2-30* PCO2-32* PH-7.39 TOTAL
CO2-20* BASE XS--5
___ 04:22PM LACTATE-5.7*
___ 07:39PM LACTATE-3.4*
___ 11:34PM LACTATE-2.8*
___ 06:35PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 06:35PM URINE COLOR-DARK AMBER APPEAR-Cloudy SP
___
___ 06:35PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-TR KETONE-NEG BILIRUBIN-LG UROBILNGN-4* PH-5.5 LEUK-SM
___ 06:35PM URINE RBC->182* WBC-80* BACTERIA-FEW
YEAST-NONE EPI-1
___ 06:35PM URINE GRANULAR-3* HYALINE-3*
MICRO:
======
___ BCx - NGTD
___ UCx -URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
ENTEROCOCCUS SP.. 10,000-100,000 CFU/mL. PREDOMINATING
ORGANISM.
INTERPRET RESULTS WITH CAUTION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
Stool- c.diff negative
Blood culture fungal- negative
___ Urine culture- Yeast
STUDIES:
=========
___ LIVER OR GALLBLADDER US
1. Echogenic liver consistent with steatosis. Other forms of
liver disease and more advanced liver disease including
steatohepatitis or significant hepatic fibrosis/cirrhosis cannot
be excluded on this study.
2. Gallbladder sludge without stones or gallbladder wall
thickening.
___ CHEST (PORTABLE AP)
No definite acute cardiopulmonary process.
EKG: Low voltage, poor quality but appears to be sinus tach with
no evidence of ischemia.
Most Recent labs: (labs not drawn once pt became CMO)
=========================================================
___ 05:23AM BLOOD WBC-13.0* RBC-2.59* Hgb-8.9* Hct-27.7*
MCV-107* MCH-34.4* MCHC-32.1 RDW-21.7* RDWSD-84.5* Plt Ct-92*
___ 05:43AM BLOOD Neuts-83.2* Lymphs-9.7* Monos-4.9*
Eos-0.6* Baso-0.1 NRBC-0.3* Im ___ AbsNeut-13.53*
AbsLymp-1.58 AbsMono-0.79 AbsEos-0.09 AbsBaso-0.02
___ 06:05AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
___ 05:23AM BLOOD Plt Ct-92*
___ 05:23AM BLOOD ___ PTT-52.7* ___
___ 05:23AM BLOOD Glucose-138* UreaN-57* Creat-1.9* Na-143
K-3.8 Cl-112* HCO3-16* AnGap-19
___ 05:23AM BLOOD ALT-49* AST-124* LD(LDH)-278* AlkPhos-86
TotBili-24.6*
___ 05:23AM BLOOD Albumin-2.5* Calcium-8.8 Phos-3.9 Mg-2.0
___ 12:55PM BLOOD ___ 04:00AM BLOOD HBsAg-Negative HBsAb-Positive
HBcAb-Negative HAV Ab-Negative IgM HBc-Negative IgM HAV-Negative
___ 12:55PM BLOOD TSH-2.5
___ 12:41PM BLOOD AMA-NEGATIVE
___ 04:00AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 04:00AM BLOOD IgG-1097 IgA-597* IgM-217
___ 04:00AM BLOOD HCV Ab-Negative
___ 04:00AM BLOOD HCV VL-NOT DETECT
Brief Hospital Course:
___ man with alcohol use disorder and prostate ca s/p
XRT/brachytherapy, initially admitted to the MICU with septic
shock and encephalopathy. After stabilized, patient was
transferred to the liver-renal service where he was given on
going supportive care as well as IV antibiotics. Despite
lactulose, nutritional optimization, and broad spectrum
antibiotics, his cognitive status continued to decline. Given
his already poor prognosis compounded with his worsening mental
status, decision was made to transition to comfort care. Patient
will be discharged with hospice care. His sister has been
heavily involved in the decision making.
#Toxic Metabolic Encephalopathy:
Multiple possible causes including hepatic encephalopathy,
hyponatremia, infection, seizure. CT head without e/o
intracranial hemorrhage. No evidence on exam of focal neurologic
deficit, and no evidence of seizure activity. He was started on
lactulose q2hr for hepatic encephalopathy given significant
asterixis on initial exam. He was also treated empirically with
antibiotics for presumed infection with Vancomycin and Zosyn.
Urine cultures returned growing enterococcus sensitive to
vancomycin. Chest x ray also returned concerning for HAP.
Despite treatment of his infections and lactulose, his mental
status never returned to his baseline which per sister was very
compromised to begin with. Mental decline attributed to alcohol
dementia in the setting of decompensated cirrhosis with hepatic
encephalopathy.
#Transaminitis:
#Hyperbilirubinemia:
#Coagulopathy:
#Alcoholic hepatitis
Has never been formally diagnosed with cirrhosis and has not
seen a hepatologist as an outpatient; however, given his history
of EtOH abuse and echogenic liver on RUQUS his transaminitis,
coagulopathy, and hyponatremia are all likely due to
decompensated cirrhosis. Hep serologies/automimmune work-up
unrevealing.
#EtOH abuse: Unclear how much patient drinks, though per his
sister it has been increasing and he has previously been in
alcohol rehab at least twice. He was treated in the MICU with
phenobarb for concern of EtOH withdrawal, and was also treated
with high dose thiamine as well as folate and MVI
CHRONIC ISSUES:
==============
# Hypertension: reportedly on lisinopril 30 mg at home, though
does not appear to have filled since ___. Held in setting of
hypotension.
# h/o Prostate Cancer s/p XRT: sees Urology at CHA. Followed
with them ___ and had cystoscopy for hematuria, recurrent
UTIs with no e/o cancer recurrence, but missed f/u appointment
___. Held Flomax in setting of hypotension. Continued home
finasteride
# Communication: ___ (sister) ___, cell
___
# Code: DNR/DNI, CMO
Transitional issues:
======================
# For dyspnea, he should receive ___ mg of 4mg/ml liquid
dilaudid q6H PRN, to be titrated as needed
# Discharged with Hospice/comfort measures only
# Family Contact: ___
Relationship: Sister
Phone number: ___
Cell phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. Tamsulosin 0.4 mg PO QHS
3. TraMADol 50 mg PO TID:PRN Pain - Moderate
4. Omeprazole 40 mg PO DAILY
5. Lisinopril 30 mg PO DAILY
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN dyspnea
2. budesonide 0.5 mg INHALATION Q8H
3. Haloperidol 0.5-2 mg IV Q4H:PRN delirium
4. HYDROmorphone (Dilaudid) 0.25-0.5 mg IV Q15MIN:PRN Pain or
respiratory distress
5. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN wheeze
6. Nicotine Patch 14 mg TD DAILY
7. Scopolamine Patch 1 PTCH TD Q72H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
=================
Septic shock with pneumonia
Hepatic encephalopathy
Alcoholic hepatitis
Alcohol dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic and not arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear ___,
It was a pleasure caring for your brother here at ___.
As you know, ___ had a long hospital course complicated by
infection and encephalopathy. Despite all our efforts, his
mental status did not improve and continued to decline. Since it
was determined that his mental status is not going to return to
his baseline, you had ongoing discussions with the team about
his goals of care and wishes. After several discussions with the
team and his family, you determined it would be best to focus on
his comfort rather than continue with aggressive medical
interventions. Since then, we've ensured he's remained
comfortable with no pain or shortness of breath.
We are so sorry for your loss and wishing you and your family
all the best.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10232455-DS-21 | 10,232,455 | 26,467,493 | DS | 21 | 2160-02-11 00:00:00 | 2160-02-17 00:02:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Compazine / Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
EKOs
History of Present Illness:
___ no significant medical Hx p/w ___ progressive DOE. About ___
ago, pt given unknown abx and flonase sprayfor cough and SOB.
Cough resolved and SOB mostly improved after abx. Then pt went
to ___ for 1wk and while there, noticed mild DOE but thought
it was ___ humidity. Pt returned from ___ 2 or 3d ago with
significant progression of DOE yesterday. Pt says it progressed
over the course of the day until she was short of breath with
long seated conversations. She also endorses onset of leg
"tingling" yesterday. She has had discomfort in her legs with
stairs but denies any swelling. Pt went to PCP, did EKG that
showed inferolat T wave changes from ___ and pt was
referred to ED.
In the ED, initial vitals were:
Pain 0 98.6 95 134/78 20 99% RA
Pt had contrast allergy in ___. Given pre-tx protocol prior to
CTA of Solumedrol IV 40mg (1st dose 4hr prior to CT, 2nd dose
just before CT), Benadryl IV 50mg (give dose 1hr prior to CT).
CTA confirmed PE occluding most of R pulm artery and mild L pulm
artery. Pt admitted to medicine and in ER was started on weight
based heparin with bolus dose.
Vitals prior to transfer were: Pain 0 98 111 117/85 29 95% Nasal
Cannula
Upon arrival to the floor, pt denies dizziness, HA, CP, abdom
pain; does still feel slightly SOB. Has no notable prior medical
Hx. No recent Rx changes; no prior h/o PE or blood clots; per
OMR and pt, last Pap Smear/gyn up to date ___ last
___ neg; last Colon Screen: Normal ___ colonoscopy.
Past Medical History:
Submassive PE
Social History:
___
Family History:
Denies h/o CA or blood clots or bleeding issues in parents; no
siblings
Physical Exam:
ADMISSION PHYSICAL EXAM:
===============================
Vitals: 97.6 ___ 22 100% 3L NC
General: Alert, oriented, no acute distress but labored
breathing
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated but external jugular waveforms
visible with respiration above clavicles
CV: Regular rate and rhythm, normal S1 + S2, ?faint S3 LLS
border, no murmurs
Lungs: Clear to auscultation bilaterally, no wheezes
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: No foley
Ext: Warm, well perfused, no edema, no swelling/erythema of
calves or ___ sign
DISCHARGE PHYSICAL EXAM:
===============================
VS: 97.5, 126/73, 57, 16, 100% on RA
Weight: 54.4kg
Gen: Comfortable on room air, NAD. Pleasant, elderly woman.
HEENT:anicteric sclera, EOMs intact
NECK: No JVD; neck supple.
CV: RRR, no MRGs. Normal S1/S2, +S3
PULM: CTA b/l; no wheezes, rhonchi, or rales.
ABD: Soft, non-tender, nondistended. NABS.
EXT: Warm, well-perfused. 2+ DP pulses b/l. 1+ pitting edema.
SKIN: No lesions.
NEURO: A&Ox3.
Pertinent Results:
ADMISSION LABS:
========================
___ 12:30PM BLOOD WBC-6.6 RBC-4.74 Hgb-13.7 Hct-41.8 MCV-88
MCH-28.9 MCHC-32.8 RDW-14.3 RDWSD-46.3 Plt ___
___ 11:10PM BLOOD ___ PTT-31.1 ___
___ 12:30PM BLOOD Glucose-111* UreaN-15 Creat-0.9 Na-139
K-4.7 Cl-104 HCO3-22 AnGap-18
___ 12:30PM BLOOD proBNP-7233*
___ 12:30PM BLOOD cTropnT-<0.01
___ 09:35PM BLOOD cTropnT-<0.01
___ 12:30PM BLOOD D-Dimer-2840*
STUDIES:
=============
+ CXR (___): No acute cardiopulmonary process. No
interval change.
+ CTA (___): Massive right-sided pulmonary embolus with a
near occlusive thrombus in the right lower lobar and segmental
pulmonary arteries, right middle lobar pulmonary artery, and
right upper lobar and segmental pulmonary arteries. Less
thrombus burden on the left with nonobstructive thrombus in the
left upper segmental pulmonary arteries and the left lower
segmental pulmonary arteries, mostly in the posterior basal
segmental pulmonary artery. RV enlargement with flattening of
the interventricular septum suggestive of right heart strain.
The main and right pulmonary arteries are normal in caliber.
+ EKG (___): Sinus, rate ~100, RBBB, with inferolateral
T-wave changes.
+ TTE (___): EF 55%, TR gradient *116 mm Hg. Severely
dilated, hypokinetic right ventricle with moderate to severe
tricuspid regurgitation and severe pulmonary artery systolic
hypertension. Findings concerning for primary pulmonary process
(e.g. acute on chronic pulmonary embolus, severe COPD, etc.).
Clinical correlation is suggested.
+ BILAT LOWER EXT VEINS (___)
FINDINGS:
There is normal compressibility, flow, and augmentation of the
bilateral common femoral, femoral, and popliteal veins. Normal
color flow is demonstrated in the tibial and peroneal veins.
Duplicated popliteal veins seen bilaterally. There is normal
respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst. IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity veins.
DISCHARGE LABS:
========================
___ 06:30AM BLOOD WBC-4.6 RBC-4.61 Hgb-13.4 Hct-41.4 MCV-90
MCH-29.1 MCHC-32.4 RDW-14.6 RDWSD-47.3* Plt ___
___ 06:30AM BLOOD ___ PTT-32.9 ___
___ 06:30AM BLOOD Glucose-93 UreaN-10 Creat-0.8 Na-139
K-4.8 Cl-101 HCO3-26 AnGap-17
___ 06:30AM BLOOD Calcium-9.8 Phos-4.3 Mg-2.1
Brief Hospital Course:
Ms. ___ is a previously healthy ___ female who
presented with subacute dyspnea ___ weeks), found to have
submassive pulmonary embolus.
# CORONARIES: No history of cardiac cath.
# PUMP: LVEF 55%, severely dilated, hypokinetic RV with mod to
severe TR
# RHYTHM: NSR, tachycardic, with RBBB
============
ACUTE ISSUES
============
# Submassive pulmonary embolism:
Likely provoked in the setting of air travel to ___ one
week prior, especially given no other PMH, no smoking history,
recent surgery, or history of coagulopathy in the family. Cancer
screening is up to date (colonoscopy in ___ with single 3 mm
polyp, next in ___, mammogram in ___, Pap smear in ___.
Patient presented with S1Q3T3 EKG, D-dimer on admission
2840, proBNP: 7233, Trop negative x 2. CTA-PE showed large
submassive PE and TTE revealed RV dysfunction, ___ revealed
no DVT. MASCOT consulted and based on RV dysfunction,
recommended EKOS, so patient transferred to CCU. Patient
underwent EKOS, with 24 hour TPA infusion on ___. Started on
heparin gtt post EKOS. On ___, EKOS and venous sheath pulled
without complication. Patient transitioned from heparin to
Lovenox. Discharged on Rivaroxaban on ___. Patient has close
follow up with Dr. ___, at which time she will have repeat
echo.
# Primary prevention.
- Discontinued ASA 81mg daily
Transitional Issues
=====================
#Patient presented w/submassive PE, presumed to be in setting of
travel. Cancer w/u UTD, but patient should follow closely with
PCP.
#Patient discharged on rivaroxaban (15 mg BID x 2 weeks and 20
mg daily thereafter). Please monitor patient closely for
compliance, bleeding complications.
#Patient to follow up with Dr. ___ one week. Should
have repeat echo at that time.
# Discharge weight: 54.4kg
# Code: Full
# Contact/HCP: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Systane (peg 400-propylene glycol) 0.4-0.3 % ophthalmic PRN
dry eyes
3. Fluticasone Propionate NASAL 1 SPRY NU BID
Discharge Medications:
1. Fluticasone Propionate NASAL 1 SPRY NU BID
RX *fluticasone 50 mcg/actuation 1 spry IN twice a day Disp #*1
Bottle Refills:*0
2. Systane (peg 400-propylene glycol) 0.4-0.3 % ophthalmic PRN
dry eyes
3. Rivaroxaban 15 mg PO BID Duration: 14 Days
RX *rivaroxaban [___] 15 mg 1 tablet(s) by mouth twice a day
Disp #*28 Tablet Refills:*0
4. Rivaroxaban 20 mg PO DAILY
you will start this dosage after finishing your 2 weeks of 15mg
twice a day
RX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth daily Disp
#*14 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Submassive pulmonary embolism.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted because of difficulty
breathing and found to have a pulmonary embolism (clot in your
long). You were given medications to thin your blood and
underwent a procedure to break up the clot, and your breathing
improved. You should begin taking Rivaroxaban daily on ___ to
thin your blood and prevent future clots. You should also follow
up with Dr. ___ one week. You will have a repeat echo
at this time.
It was wonderful to meet you and we wish you all the best in
your recovery.
Sincerely,
Your Medical Team
Followup Instructions:
___
|
10232602-DS-22 | 10,232,602 | 28,587,641 | DS | 22 | 2189-07-24 00:00:00 | 2189-07-25 09:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Latex / Nitroimidazole Derivatives / Bactrim / codeine
Attending: ___.
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
Bronchoscopy ___
History of Present Illness:
___ from ___ (moved here ___ years ago, has not been
back) with complicated history including periods of homelessness
who is admitted after being discharged 2 days prior from
___ after being treated for pneumonia and presumed
parapneumonic effusion.
Her ___ course discharge summary is unavailable at this
time. Her presentation there started when she developed a
bilateral stabbing chest pain that made it difficult to take a
full breath. She did not notice subjective fever or chills, but
did have a cough. She has been having night sweats for years,
which she relates to having amenorrhea since ___. Reportedly at
___ she has a CT and TTE which together revealed large
bilateral effusions and no cardiac dysfunction. She had a R
thoracentesis that removed 1L, and received CTX, azithro and was
ultimately discharged on levofloxacin. She states she did not
feel fully better at discharge, and had follow-up with her PCP
on the day of presentation. Given tachypnea, hypoxia in clinic
she was sent to the ED for further evaluation.
In the ED, initial vital signs were: 99.7 108 114/78 22 91% RA
- Exam was notable for: diminished lung sounds bilaterally
- Labs were notable for: WBC elevated to 16.8 with 8.1% eos,
trop < 0.01, BNP 141, coags WNL, lactate 2.0, BUN/Cr ___
- pleural fluid studies: pH 7.34, protein 4.6, glucose 110, LDH
914, Cr 0.7, amylase 26, cholest and ___ PND, 7200 WBC with 55%
eos, ,
- Imaging:
- The patient was given: 1g vancomycin, 2g cefepime, IV
dilaudid 0.5 mg x 2, dilaudid 1 mg IV x 2
- Consults: interventional pulmonology, who placed a left chest
tube
Vitals prior to transfer were: 103 120/76 18 95% Nasal Cannula
Upon arrival to the floor, she endorses the above story. No
travel outside of ___ in the last ___ years with the
exception of trying to go to ___ with her family, but the
trip was cut short because of a burst appendix. Denies weight
loss, endorses weight gain. Denies symptoms of dysphagia,
odynophagia, reflux. She has been having diarrhea with recent
antibiotics. She also endorses significant bleach exposure as
she uses it to clean twice a day.
REVIEW OF SYSTEMS: Per HPI. Denies headache, visual changes,
pharyngitis, rhinorrhea, nasal congestion, cough, fevers,
chills, sweats, weight loss, dyspnea, chest pain, abdominal
pain, nausea, vomiting, diarrhea, constipation, hematochezia,
dysuria, rash, paresthesias, and weakness.
Past Medical History:
nephrolithiasis s/p lithotripsy
pyelonephritis
seizure d/o
bipolar d/o
CIN II
IBS and crohn's
anorexia nervosa
asthma
LSC appendectomy (ruptured per pt)
LEEP
Multiple D&Cs for TABs/SABs
PSYCHIATRIC HISTORY
-axis I diagnoses: mood disorder NOS v. major depression
-axis II diagnoses: personality disorder NOS; r/o borderline
personality
disorder. trauma history
-problem list (per prior behavioral health provider at ___:
impulsivity,
depressed/irritable mood, mood lability, disorganized and
chaotic interpersonal
relationships, ___ involvement
-prior notes also mention eating disordered behavior which does
not fit a clear
diagnostic category
-med regimen on transfer of care ___: benzodiazepines,
mirtazapine,
quetiapine; previously on valproex (for mood stabilization)
Social History:
___
Family History:
Grandfather -- lung cancer
Grandmother -- breast cancer
Physical Exam:
**Patient discharged against medical advice**
ADMISSION PHYSICAL EXAM:
VITALS: 98.5 120/83 106 20 93% 5L
GENERAL: in distress from chest tube pain
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear.
NECK: Supple, no LAD,JVP flat.
CARDIAC: tachy, regular, no rub or gallop
PULMONARY: decreased breath sounds half way up lungs on left,
___ of the way up on right, no other adventitious sounds. L
chest tube draining serosanguinous fluid
ABDOMEN: Normal bowel sounds, soft, non-tender,no organomegaly.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Without rash. Numerous tattoss
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
DISCHARGE PHYSICAL EXAM:
VITALS: 99.2 110s-130s/70s-90s ___ 94-100% RA
GENERAL: NAD
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP erythematous.
NECK: Supple, no LAD,JVP flat.
CARDIAC: tachy, regular, no rub or gallop
PULMONARY: crackles at right lung base, otherwise CTA
ABDOMEN: Normal bowel sounds, soft, non-tender,no organomegaly.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Without rash. Numerous tattoos
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
Pertinent Results:
ADMISSION LABS:
===============
___ 03:23PM BLOOD WBC-16.8* RBC-3.95 Hgb-11.2 Hct-34.7
MCV-88 MCH-28.4 MCHC-32.3 RDW-13.6 RDWSD-43.7 Plt ___
___ 03:23PM BLOOD Neuts-70.3 Lymphs-15.2* Monos-4.8*
Eos-8.1* Baso-0.5 Im ___ AbsNeut-11.81* AbsLymp-2.55
AbsMono-0.81* AbsEos-1.37* AbsBaso-0.09*
___ 03:23PM BLOOD ___ PTT-26.0 ___
___ 03:23PM BLOOD Plt ___
___ 03:23PM BLOOD Glucose-154* UreaN-8 Creat-0.8 Na-141
K-4.4 Cl-105 HCO3-26 AnGap-14
___ 03:23PM BLOOD ALT-17 AST-30 LD(LDH)-577* AlkPhos-57
TotBili-0.2
___ 03:23PM BLOOD proBNP-141
___ 03:23PM BLOOD cTropnT-<0.01
___ 03:23PM BLOOD Lipase-13
___ 03:23PM BLOOD TotProt-6.8 Albumin-3.6 Globuln-3.2
URINE STUDIES:
==============
___ 06:57PM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 06:57PM URINE Hours-RANDOM
MICRO:
======
___ Blood cultures negative to date
___ 5:57 pm PLEURAL FLUID PLUERAL FLUID.
GRAM STAIN (Final ___:
4+ (>10 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 (Preliminary): NO GROWTH.
___ 1:33 pm PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final ___:
3+ ___ 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 (Preliminary): NO GROWTH.
___ 6:37 pm SPUTUM Source: Induced.
GRAM STAIN (Final ___:
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
___ 4:17 pm SPUTUM Source: Induced.
GRAM STAIN (Final ___:
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
MTB Direct Amplification (Preliminary):
Sent to State Lab for further testing ___.
___ 4:49 am SPUTUM Source: Induced.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
___ 4:39 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
OTHER IMPORTANT LABS:
=====================
___ 06:55AM BLOOD TSH-1.6
___ 02:35PM BLOOD Cortsol-PND
___ 08:30AM BLOOD Cortsol-17.9
___ 06:34AM BLOOD Cortsol-1.1*
___ 08:20AM BLOOD ANCA-NEGATIVE B
___ 06:55AM BLOOD ___
___ 06:55AM BLOOD RheuFac-<10 CRP-25.1*
___ 10:50AM BLOOD HIV Ab-Negative
___ 06:55AM BLOOD SED RATE-Test
___ 06:55AM BLOOD IGE-PND
___ 06:55AM BLOOD CYCLIC CITRULLINATED PEPTIDE (CCP)
ANTIBODY, IGG-Test
___ 06:55AM BLOOD ASPERGILLUS ANTIBODY-PND
___ 10:50AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-Test
___ 10:50AM BLOOD COCCIDIOIDES ANTIBODIES TO TP AND F
ANTIGENS, ID-PND
___ 10:50AM BLOOD B-GLUCAN-Test
___ 08:20AM BLOOD STRONGYLOIDES ANTIBODY,IGG-PND
___ 08:20AM BLOOD ECHINOCOCCUS ANTIBODY (IGG)-PND
DISCHARGE LABS:
===============
___ 08:30AM BLOOD WBC-9.9 RBC-4.25 Hgb-11.6 Hct-36.8 MCV-87
MCH-27.3 MCHC-31.5* RDW-13.4 RDWSD-41.8 Plt ___
___ 08:30AM BLOOD Neuts-59.8 ___ Monos-5.0 Eos-6.0
Baso-0.9 Im ___ AbsNeut-5.93 AbsLymp-2.62 AbsMono-0.50
AbsEos-0.60* AbsBaso-0.09*
___ 08:30AM BLOOD Plt ___
___ 08:30AM BLOOD Glucose-88 UreaN-12 Creat-0.8 Na-142
K-4.2 Cl-107 HCO3-25 AnGap-14
___ 08:30AM BLOOD Calcium-9.2 Phos-5.1* Mg-2.0
___ 08:30AM BLOOD Cortsol-17.9
Brief Hospital Course:
**Patient was discharged against medical advice**
___ with history of IBS, recent admission to ___
treated for community acquired pneumonia with associated
effusion, presents with hypoxia, found to have bilateral
exudative eosinophilic pleural effusions and peripheral
eosinophilia of unclear etiology.
# Hypoxia secondary to eosinophilic exudative pleural effusion
and peripheral eosinophilia: Unclear etiology. Most likely
secondary to allergy of some sort, possibly to depakote or
nitrofurantoin. Given history of asthma, however, we considered
___ or ABPA however ANCA and galactomannan were
negative. Patient had extensive infectious (bacterial, fungal,
parasitic) and rheumatologic work up as an in patient, as well
as bronchoscopy ___ with BAL. Beta-glucan was indeterminate,
___ were negative. Strongyloides, Echinoccocus, IgE,
aspergillus antibody, adenosine deaminase from pleural fluid,
quantiferon gold and BAL microbiology data was pending on
discharge. Patient was ruled out for active TB with AFB sputum
negative X 3. She had bilateral chest tubes placed during
admission by Interventional Pulmonology that were removed prior
to discharge. Possible causes of eosinophilia were thought to be
drug reaction (to macrobid or valproic acid), adrenal
insufficiency (AM cortisol 1), however he normal cortisol
stimulation test rules out the latter. Allergy most likely.
# Mood disorder NOS/Borderline personality disorder:
Patient had worsening mood lability/agitation, which was
attributed to holding her valproic acid as this was thought to
be a possible medication culprit causing eosinophilia and
therefore was not re-started. Psychiatry was consulted and
recommended out patient follow up with psychiatry as patient was
leaving against medical advice. She was continued on her home
psychiatric medication regimen.
# Diarrhea: In setting of IBS, however increased amount of
watery bowel movements from baseline. No abdominal
pain/fever/chills/N/V. C.diff was negative. Patient was
continued on her home IBS medication regimen.
# H/o asthma: Continued on home Albuterol and Advair inhalers.
# Chronic pain: Was continued on home gabapentin.
TRANSITIONAL ISSUES:
===================
- patient left against medical advice
- needs TTE to evaluate for pericarditis/myocarditis, if patient
has cardiovascular involvement and infectious work up negative
will need to be started on steroids
- follow up pending ___, IgE, aspergillus IgG, adenosine
deaminase pleural fluid, beta glucan, strongyloides,
echinococcus, BAL results
- valproic acid discontinued upon admission and discharge as was
thought to be possible culprit of eosinophilia
- psychiatry follow up for ongoing treatment psychiatric
diagnosis and medication regimen off depakote
- quantiferon gold pending on discharge
- Pulmonary and IP follow up as above
- follow up CXR to evaluate pleural effusions
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
2. Benzonatate 100 mg PO TID:PRN cough
3. ClonazePAM 1 mg PO TID
4. Diphenoxylate-Atropine 1 TAB PO Q8H:PRN diarrhea
5. eletriptan HBr 40 mg oral prn migraine
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. Gabapentin 300 mg PO QAM
8. Gabapentin 300 mg PO QHS
9. Hyoscyamine 0.125 mg PO TID:PRN cramps
10. Lidocaine 5% Patch 1 PTCH TD QPM
11. Mirtazapine 30 mg PO QHS
12. QUEtiapine Fumarate 400 mg PO QHS
13. Rifaximin 200 mg PO TID
14. Sucralfate 1 gm PO BID
15. Donnatal Dose is Unknown PO Frequency is Unknown
16. DICYCLOMine 20 mg PO TID
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
2. Benzonatate 100 mg PO TID:PRN cough
3. DICYCLOMine 20 mg PO TID
4. Diphenoxylate-Atropine 1 TAB PO Q8H:PRN diarrhea
5. Gabapentin 300 mg PO QAM
6. Gabapentin 300 mg PO QHS
7. Hyoscyamine 0.125 mg PO TID:PRN cramps
8. Lidocaine 5% Patch 1 PTCH TD QPM
9. Mirtazapine 30 mg PO QHS
10. Rifaximin 200 mg PO TID
11. Sucralfate 1 gm PO BID
12. eletriptan HBr 40 mg oral prn migraine
13. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
14. ClonazePAM 1 mg PO TID
15. QUEtiapine Fumarate 400 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Hypoxemic respiratory failure
Bilateral Exudative eosinophilic pleural effusions
SECONDARY DIAGNOSES:
Asthma
IBS
Mood disorder NOS
Borderline personality disorder
Chronic pain
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 because of shortness and
breath and a new oxygen requirement. The cause of your symptoms
is unclear - a majority of your diagnostic work up was pending
on discharge and you decided to leave against medical advice.
Please continue to take all your medications and follow up with
your primary care physician and psychiatrist as an out patient.
Your Depakote is being held at discharge and you will need to
discuss this with your psychiatrist. You will also need an
echocardiogram as outpatient. If your strongyloides testing
returns positive, you will need to be treated for the infection.
If it is negative, you will need to be started on steroids.
It was a pleasure taking care of you.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10232685-DS-17 | 10,232,685 | 28,505,936 | DS | 17 | 2152-10-13 00:00:00 | 2152-10-13 20:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abnormal Ct, Abscess, Transfer
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMHx of BPH, HLD and recent
admission for diverticular bleeding who presents as transfer
from
___ for ENT evaluation of R parapharyngeal abscess.
Patient notes 3 days of gradually worsening, constant right
lower
throat pain which is worsened by swallowing, associated with
episodes of drooling at night which is new for him. He was
unable
to tolerate swallowing his pills this AM, and has had decreased
PO intake for solids and liquids; perhaps only had 2 cups of
coffee in the last three days. He notes increased secretions and
voice change (huskier/hoarse). He denies any fevers or chills.
No
trismus. No difficulty breathing or chest pain. He does note
that he has +R ear pain and that his hearing aids have had some
increased drainage.
Past Medical History:
Diverticulitis
Diverticular bleeding
Polypectomy in ___
Hypercholesterolemia
BPH
Cervical disc disease
Social History:
___
Family History:
Non-contributory.
Physical Exam:
ADMISSION PHYSICAL:
VS: 98.9 PO 116 / 55 R Lying 76 18 94 2LNC
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM. Uvula is midline, no trismus. There is no elevation of
mucosa under tongue. +moderate amount of cerumen, removed.
Tympanic membranes are without erythema or bulging.
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Crackles at right base, breathing comfortably without use
of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema , capillary refill
>2s
PULSES: 2+ DP pulses bilaterally
NEURO: ___, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL:
GENERAL: NAD
HEENT: AT/NC, EOMI, no trismus, uvula is midline, PERRL,
anicteric sclera, neck supple
HEART: RRR, S1+S2 normal, no m/g/r apprciated
LUNGS: Mild bi-basilar crackles w/ RLL>LLL
ABDOMEN: +BS, non-tender, non-distended
EXTREMITIES: Pulses present, no cyanosis, clubbing, or edema
NEURO: ___, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
___ 06:20PM GLUCOSE-98 UREA N-13 CREAT-0.9 SODIUM-141
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-24 ANION GAP-13
___ 06:20PM WBC-7.1 RBC-3.09* HGB-9.5* HCT-28.6* MCV-93
MCH-30.7 MCHC-33.2 RDW-14.2 RDWSD-47.5*
___ 06:20PM NEUTS-63.5 ___ MONOS-10.6 EOS-1.5
BASOS-0.3 IM ___ AbsNeut-4.53 AbsLymp-1.70 AbsMono-0.76
AbsEos-0.11 AbsBaso-0.02
___ 06:20PM PLT COUNT-266
___ 06:20PM ___ PTT-25.5 ___
DISCHARGE LABS:
___ 05:32AM BLOOD WBC-11.1*# RBC-2.87* Hgb-8.6* Hct-26.7*
MCV-93 MCH-30.0 MCHC-32.2 RDW-14.1 RDWSD-47.4* Plt ___
___ 05:32AM BLOOD Plt ___
___ 05:32AM BLOOD Glucose-97 UreaN-18 Creat-1.1 Na-144
K-4.4 Cl-109* HCO3-23 AnGap-12
___ 05:32AM BLOOD Calcium-8.3* Phos-3.7 Mg-1.9
IMAGING:
___ CXR:
Fatty opacities at the bilateral lung bases representing either
atelectasis or
infection in the appropriate clinical context.
Brief Hospital Course:
Mr. ___ is a ___ year old gentleman with PMHx of BPH, HLD and
recent LGIB who presents as transfer from ___ for R
parapharyngeal abscess, course complicated by hypoxia and
possible aspiration pneumonia.
ACUTE ISSUES:
# R parapharyngeal abscess: Visualized on CT neck. Patient
without trismus, and is able to swallow secretions. On original
FOE, patient with lateral pharyngeal wall and secretions on the
right side, but airway reported to be widely patent. No evidence
of otitis media. Patient without history of immunocompromise,
hence started amp/sulbactam for oral/rhinogenic/otogenic source.
Continued through ___, when he is planned for discharge with a
transition to oral Augmentin for a 2 week course.
# Hypoxia
# Concern for pneumonia: Patient developed desaturation while in
the ED, CXR was obtained and revealed RLL > LLL opacities. Given
distribution and clinical history, likely compatible with an
aspiration pneumonia. No evidence of airway compromise. Although
not necessary to treat in this case, he is concurrently covered
with antibiotics as above.
CHRONIC ISSUES:
# Normocytic Anemia
# History of diverticular bleeding: Hgb on admit 9.5, on last
discharge 10.8 (acute blood loss anemia from diverticular
source,
baseline in ___ is 14), no evidence of recent bleeding.
Although Hb experienced a drop, he received significant IVF and
is prone to a dilution effect.
# HLD: Continued home simvastatin 20 mg PO qPM upon tolerating
PO
# BPH: Continued home tamsulosin 0.4 mg PO qHS + dutasteride
0.5mg daily
TRANSITIONAL ISSUES:
-Follow-up: ENT and PCP
-___ medications: Augmentin (14d to finish on ___
-Last hgb was 8.6 and cr was 1.1. Please recheck cbc at her next
PCP appointment
-___ status: Full (presumed)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tamsulosin 0.4 mg PO QHS
2. Simvastatin 20 mg PO QPM
3. dutasteride 0.5 mg oral DAILY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet by mouth
every 12 hours Disp #*28 Tablet Refills:*0
2. dutasteride 0.5 mg oral DAILY
3. Simvastatin 20 mg PO QPM
4. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
===================
Para-pharyngeal abscess
Aspiration pneumonia
Secondary diagnosis:
====================
Benign Prostatic hypertrophy
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
Why was I in the hospital?
- You were hospitalized because you had an infection in the
back/lower part of your mouth and throat causing a collection to
form.
- You were also noted to have an infection in your lungs which
may have been caused from the collection and issues with
swallowing.
What was done while I was in the hospital?
- Pictures were taken that showed your lung infection, and a
camera was used to visualize your infection collection and to
ensure your airway remained open.
- You were started on medications to treat this infection. You
were also transitioned to an oral version of such antibiotics.
What should I do when I go home?
- It is very important that you take your medications as
prescribed.
- Please go to your scheduled appointment with your primary
doctor.
- If you have worsening fevers, trouble breathing or trouble
talking or swallowing, please tell your primary doctor or go to
the emergency room.
Best wishes,
Your ___ team
Followup Instructions:
___
|
10232836-DS-20 | 10,232,836 | 25,600,305 | DS | 20 | 2126-02-21 00:00:00 | 2126-02-22 15:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PODIATRY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
bilateral foot wounds/infection
Major Surgical or Invasive Procedure:
___: Bilateral foot debridement
History of Present Illness:
___ with history of DM, HTN, HLD who is being admitted
pre-operatively prior to surgical debridement on ___. Patient
is well known to Dr. ___, previously underwent left
foot 1t metatarsal osteotomy on ___ and L ___ met head
resection with abx spacer placement on ___. He is also
followed by Dr. ___ PVD, and underwent LLE angiogram
which revealed AT occluded with 2 vessel run off into the foot,
with ___ feeding the plantar vessels and reconstituted into short
segement DP. The patient's ulcerations were noted to be
worsening over the past few weeks and he subsequently developed
redness and drainage. Patient denies f/c/n/v/sob/cp.
Past Medical History:
DM, HTN, Hyperlipididemia
Social History:
___
Family History:
Noncontributory
Physical Exam:
Physical Exam upon admission
VSS
GEN: NAD, pleasant, A&Ox3
CV: RRR
Lungs: CTAB, no respiratory distress
Abdomen: Soft, NT, ND
___: Nonpalpable DP, ___ pulses. Biphasic DP and ___ pulses b/l on
doppler ultrasound. Ulcer plantar aspect left foot+ fibrous base
with probe to bone. + surrounding erythema and edema,
serosanguinous drainage. No lymphangiitis, purulence,fluctuance.
Ulcer plantar aspect right foot, with + fibrous base, with
undermining present at distal aspect. Minimal surrounding
erythema and edema. No purulence, lymphangiitis.
MMT + ___ bilaterally.
Physical Exam upon Discharge
VSS
GEN: NAD, pleasant, A&Ox3
CV: RRR
Lungs: CTAB, no respiratory distress
Abdomen: Soft, NT, ND
___: C/D/I dressing to b/l feet. Cap refill <3 seconds to all
digits. Patient able to flex and extend all digits and b/l
ankles.
Pertinent Results:
LAB RESULTS UPON ADMISSION:
___ 06:19PM LACTATE-2.9*
___ 06:14PM GLUCOSE-68* UREA N-24* CREAT-0.9 SODIUM-138
POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-23 ANION GAP-19
___ 06:14PM estGFR-Using this
___ 06:14PM WBC-12.3*# RBC-4.64 HGB-11.9* HCT-37.7*
MCV-81* MCH-25.6* MCHC-31.6* RDW-15.2 RDWSD-44.2
___ 06:14PM NEUTS-61.6 ___ MONOS-8.3 EOS-1.9
BASOS-0.2 IM ___ AbsNeut-7.60* AbsLymp-3.39 AbsMono-1.02*
AbsEos-0.23 AbsBaso-0.03
___ 06:14PM PLT COUNT-275
PERTINENT LAB RESULTS:
___ 08:10AM BLOOD WBC-8.4 RBC-4.65 Hgb-11.9* Hct-38.3*
MCV-82 MCH-25.6* MCHC-31.1* RDW-15.5 RDWSD-45.8 Plt ___
___ 08:10AM BLOOD Glucose-150* UreaN-17 Creat-1.0 Na-138
K-4.9 Cl-98 HCO3-30 AnGap-15
___ 08:10AM BLOOD Calcium-9.7 Phos-3.9 Mg-1.9
___ 06:00AM BLOOD CRP-33.8*
___ 09:45AM BLOOD Vanco-15.0
___ 09:08PM BLOOD Vanco-16.0
___ 11:01PM BLOOD Vanco-23.0*
___ 02:50PM BLOOD Vanco-21.4*
IMAGING:
Chest Xray (___): PA and lateral views of the chest
provided. Lung volumes are low. Allowing for this, there is no
focal consolidation, effusion, or pneumothorax. The
cardiomediastinal silhouette is normal. Imaged osseous
structures are intact. No free air below the right
hemidiaphragm is seen. IMPRESSION: No acute intrathoracic
process.
Foot Xray (___): AP, lateral and oblique views of the left
foot provided. Prior amputation at the second and fifth ray
noted. There has been interval development of a air-filled soft
tissue ulcer at the plantar aspect of the great toe. The
previously noted antibiotic cement at the first MTP joint is no
longer seen, question interval removal. The bone at the first
MTP appears well corticated though given proximity to the
underlying ulceration, a component of osteomyelitis is
impossible to exclude. Small heel spurs noted. There is
collapse of the midfoot. Diffuse soft tissue swelling without
tracking of soft tissue gas. Again seen is a linear metallic
foreign body within the heel measuring 10 mm unchanged.
CHEST X-RAY (___):
New right PICC line ends ___ the right atrium, approximately 2 cm
below the
estimated location of the superior cavoatrial junction. Lung
volumes are
quite low exaggerating heart size probably top. Mediastinal
veins are
probably engorged, but the lungs are grossly clear and there is
no appreciable pleural effusion. No pneumothorax.
ART EXT (REST ONLY) (___):
Normal appearing arterial flow to the level of the ankle. There
is some
suggestion of distal tibial disease based on reduced forefoot
PVRs. The great toe pressures are reduced out of proportion to
the PVR which may be consistent with very distal disease, distal
embolization or vasospasm. Clinical correlation recommended
PATHOLOGY:
1. Bone, metatarsal, left ___, debridement:
- Fragments of hyalinized fibrous tissue with few embedded bone
fragments; no significant inflammatory infiltrate is identified.
2. Bone, metatarsal, right ___, debridement:
- Fragments of hyalinized fibrous tissue with few embedded bone
fragments; no significant inflammatory infiltrate is identified.
MICROBIOLOGY:
Blood Culture ___: Negative
___ 7:03 pm SWAB Source: Left foot.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
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, THEY ARE NOT PRESENT
___ this
culture.
ANAEROBIC CULTURE (Final ___:
BACTEROIDES FRAGILIS GROUP. MODERATE GROWTH.
BETA LACTAMASE POSITIVE.
___ 1:55 pm TISSUE RIGHT ___ MERATARSAL .
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
WORK UP PER ___ ___.
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
___ this
culture.
ENTEROCOCCUS SP.. SPARSE GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). RARE GROWTH.
PASTEURELLA SPECIES. RARE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
PENICILLIN G---------- 2 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 1:54 pm TISSUE LEFT ___ METATARSAL.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
SMEAR REVIEWED; RESULTS CONFIRMED.
TISSUE (Final ___:
WORK UP PER ___ ___ .
PROTEUS MIRABILIS. SPARSE GROWTH.
ENTEROCOCCUS SP.. QUANTITATION NOT AVAILABLE.
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
___ this
culture.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).
QUANTITATION NOT AVAILABLE.
PROTEUS MIRABILIS. SPARSE GROWTH. SECOND MORPHOLOGY.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
| ENTEROCOCCUS SP.
| | PROTEUS
MIRABILIS
| | |
AMPICILLIN------------ <=2 S <=2 S <=2 S
AMPICILLIN/SULBACTAM-- <=2 S <=2 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PENICILLIN G---------- 2 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final ___:
UNABLE TO R/O PATHOGENS DUE TO OVERGROWTH OF SWARMING
PROTEUS SPP..
Brief Hospital Course:
The patient was admitted to the podiatric surgery service from
clinic on ___ for a bilateral foot infection. On
admission, he was started on broad spectrum antibiotics. He was
take to the OR on ___ for bilateral foot debridement
with VAC placement. Pt was evaluated by anesthesia and taken to
the operating room. There were no adverse events ___ the
operating room; please see the operative note for details.
Afterwards, pt was taken to the PACU ___ stable condition, then
transferred to the ward for observation.
Post-operatively, the patient remained afebrile with stable
vital signs; pain was well controlled oral pain medication on a
PRN basis. The patient remained stable from both a
cardiovascular and pulmonary standpoint. He was placed on
vancomycin, ciprofloxacin, and flagyl while hospitalized. He was
evaluated by the infectious disease team who recommended that
the patient remain ___ the hospital until microbiology was
finalized to identify proper antibiotics as well as course of
antibiotics. Infectious disease ultimately recommended placing
the patient on 6 weeks of IV vancomycin, PO ciprofloxacin, and
PO flagyl. He had a PICC line placed on ___ which was found
to be ___ proper position following re-positioning by the ___
nurse. His intake and output were closely monitored and noted to
be adequate. The patient received subcutaneous heparin
throughout admission; early and frequent ambulation were
strongly encouraged while remaining PWB to his b/l heels and
avoiding weight to his forefoot. He was evaluated by physical
therapy who deemed him safe to return home with his current
weightbearing status.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating PWB to his heels, voiding without assistance,
and pain was well controlled. The patient was discharged home
with services. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
1. Atorvastatin 40 mg PO QPM
2. Ibuprofen 800 mg PO Q8H:PRN pain
3. Lisinopril 40 mg PO DAILY
4. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
5. 70/30 80 Units Breakfast
70/30 80 Units Dinner
6. Amlodipine 2.5 mg PO DAILY
7. Hydrochlorothiazide 50 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Amlodipine 2.5 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Hydrochlorothiazide 50 mg PO DAILY
4. 70/30 80 Units Breakfast
70/30 80 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
5. Lisinopril 40 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
8. Vancomycin 1500 mg IV Q 12H
RX *vancomycin 1 gram 1500 mg IV twice a day Disp #*72 Vial
Refills:*0
RX *vancomycin 500 mg 1500 mg IV twice a day Disp #*72 Vial
Refills:*0
9. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*36 Tablet Refills:*2
10. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*36 Tablet Refills:*1
11. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
12. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth q 4 hours Disp #*20
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Bilateral foot ulcerations
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane). Partial weightbearing to both heels. Avoid weight to
front of foot.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
to the Podiatric Surgery service after your right foot surgery.
You were given IV antibiotics while here. You are being
discharged home with the following instructions:
ACTIVITY:
There are restrictions on activity. Please remain weight bearing
as tolerated to right and left heel ___ surgical shoes until your
follow up appointment. You should keep this site elevated when
ever possible (above the level of the heart!)
No driving until cleared by your Surgeon.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness ___ or drainage from your leg wound(s).
New pain, numbness or discoloration of your foot or toes.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
Exercise:
Limit strenuous activity for 6 weeks.
No heavy lifting greater than 20 pounds for the next ___ days.
Try to keep leg elevated when able.
BATHING/SHOWERING:
You may shower immediately upon coming home, but you must keep
your dressing CLEAN, DRY and INTACT. You can use a shower bag
taped around your ankle/leg or hang your foot/leg outside of the
bathtub.
You will have wound VACs applied to your feet by home nursing
once you are discharged. These will need to be changed every 3
days.
Avoid taking a tub bath, swimming, or soaking ___ a hot tub for 4
weeks after surgery or until cleared by your physician.
MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods ___ your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
DIET:
There are no special restrictions on your diet postoperatively.
Poor appetite is not unusual for several weeks and small,
frequent meals may be preferred.
FOLLOW-UP APPOINTMENT:
Be sure to keep your medical appointments.
If a follow up appointment was not made prior to your discharge,
please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are ___
through ___.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE.
Followup Instructions:
___
|
10233019-DS-12 | 10,233,019 | 21,785,718 | DS | 12 | 2132-04-10 00:00:00 | 2132-04-10 11:54:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left native hip dislocation with associated acetabulum fracture,
left thumb proximal phalanx fracture IP joint subluxation
Major Surgical or Invasive Procedure:
Left acetabulum open reduction internal fixation
History of Present Illness:
24 ___ speaking male, otherwise healthy presents as a
transfer from OSH status post motorcycle collision versus porch,
unhelmeted but denies head strike/LOC, with imaging notable for
a
left native hip dislocation with acetabular fracture. Patient
was transferred to ___ for further management. Patient
interviewed with assistance from phone interpreter. Reports
exquisite left thigh pain. Denies numbness or tingling. Denies
pain in other extremities or joints aside from the left thumb.
Past Medical History:
none
Social History:
___
Family History:
noncontributory
Physical Exam:
Left lower extremity exam
-dressing c/d/I
-fires ___
-silt s/s/sp/dp/t nerve distributions
-foot WWP
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left native hip dislocation associated acetabular
fracture and was closed reduced under sedation in the ED with a
femoral traction pin placed. He also had a left thumb proximal
phalanx fracture with IP joint subluxation and was splinted. He
was subsequently admitted to the orthopedic surgery service. The
patient was taken to the operating room on ___ for left
acetabulum surgical fixation, which the patient tolerated well.
For full details of the procedure please see the separately
dictated operative report. The patient was taken from the OR to
the PACU in stable condition and after satisfactory recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to home with home ___ was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
touchdown weightbearing in the left lower extremity with
posterior hip precautions, and will be discharged on Lovenox for
DVT prophylaxis. The patient will follow up with Dr. ___
___ routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC QPM
RX *enoxaparin 40 mg/0.4 mL ___t bedtime Disp #*28
Syringe Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain
don't drink or drive while taking
RX *oxycodone 5 mg 1=2 tablet(s) by mouth q4h prn Disp #*60
Tablet Refills:*0
5. Senna 8.6 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
L native hip dl, acetab fx, left thumb proximal phalanx fracture
w/ associated IP joint subluxation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Discharge Instructions:
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 weightbearing left lower extremity with posterior hip
precautions
-Non weightbearing left upper extremity in the splint
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone Lovenox as needed for increased pain. Aim to
wean off this medication in 1 week or sooner. This is an
example on how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- If you have a splint in place, splint must be left on until
follow up appointment unless otherwise instructed. Do NOT get
splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
You will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please call the hand clinic to follow-up with Dr. ___ in 1
week. Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills.
Physical Therapy:
Touchdown weightbearing left lower extremity with posterior hip
precautions
non weightbearing left upper extremity in the splint
Treatments Frequency:
Staples to be removed at 2 week postop appointment in clinic
Followup Instructions:
___
|
10233088-DS-20 | 10,233,088 | 25,615,049 | DS | 20 | 2159-09-22 00:00:00 | 2159-09-23 05:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cefaclor / morphine / Tegaderm / Dilaudid
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Bronchoscopy/BAL ___
History of Present Illness:
Ms. ___ is a ___ year old female with a pmh significant for
renal cell carcinoma currently on drug trial, who has had
malaise, myalgias, and fatigue since ___. She has had
persistent symptoms which has never completely resolved. She
developed fevers over the past few nights with the highest being
102.8. In addition to her fevers she has had productive green
sputum.
In addition she has had shortness of breath with minimal
exertion and difficulty breathing overnight while trying to
sleep. She has been awakening with drenching sweats, and chills.
It takes her 5 hours to get up the energy to shower. She has not
had any CP, abdominal pain, nausea, vomiting, diarrhea.
In ED/Clinic, initial vitals were: 100.8 116 98/61 18 96% 2L
Labs were significant for a WBC of 22, platelets of 510, normal
chemistry and LFTs. Patient was given levofloxacin. Patient
underwent CT chest and CXR which both demonstrated pneumonia.
Final vitals prior to transfer were 99.2 82 112/66 16 98% RA.
Access - PIV
IVF - 1L NS
Review of Systems:
(+) Per HPI
(-) Denies headache. Denies chest pain or tightness,
palpitations, lower extremity edema. Denies nausea, vomiting,
diarrhea, constipation, abdominal pain, melena, hematemesis,
hematochezia. Denies dysuria, stool or urine incontinence.
Denies rashes or skin breakdown. No numbness/tingling in
extremities. All other systems negative.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- ___: CT urogram shows renal cell carcinoma, suspicious for
metastasis, and a small 1 cm nodule at the posterior pole of the
right kidney.
- ___: MRI abdomen again demonstrates suspicious for
metastasis.
- ___: Pathology shows Clear cell renal cell carcinoma.
- ___: Initial evaluation by Dr. ___ medical
oncology at ___, offered treatment as part of a clinical trial
comparing sunitinib and cabozantinib for first-line therapy in
metastatic renal cell carcinoma.
- ___: Second opinion regarding systemic therapy at ___.
- ___ and ___: Cycle 1 of high-dose
IL-2.
- ___: Surveillance CT torso shows new hepatic metastases
and increasing size of right adrenal and renal metastases.
- ___: Begins enrollment in clinical trial ___ lymphoma treated with MOPP and ABV chemotherapy
and chest radiotherapy under the guidance of Dr. ___ at
___
- ___: relapsed Hodgkin lymphoma. Receives a short course of
chemotherapy (precise agents unknown).
- ___: Undergoes autologous hematopoietic stem cell
transplantation in ___ under the guidance of Dr. ___.
- ___: Followed in the ___ clinic at ___ by
___, N.P
PAST MEDICAL HISTORY:
Hypertension
Social History:
___
Family History:
Mother had ___ lymphoma. Maternal grandfather had renal
cell carcinoma in his ___. Maternal uncle had ___
lymphoma. Another maternal uncle had melanoma. Maternal aunt had
renal cell carcinoma in her late ___. Paternal uncle had
prostate cancer and pancreatic cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T: 98.4 BP: 100/60 HR: 118 RR: 32 02 sat: 94% on 2L NC
GENERAL: NAD
HEENT: mildly dry MM
CARDIAC: tachycardic, regular rhythm
LUNG: decreased breath sounds at the bases bilaterally, no
wheeze,
GI: Soft NT/ND
EXTREMITIES: No edema
PULSES: 2+ radial
NEURO: Oriented and appropriate
SKIN: no rash on limited exam
DISCHARGE PHYSICAL EXAM
Vitals: T98.6 BP130/82 RR18 97%2L NC 93%RA
GENERAL: well appearing female in NAD, lying flat on her bed
comfortable.
HEENT: mildly dry MM and mild mucositis
CARDIAC: RRR, no MRG appreciated
LUNG: decreased breath sounds in left lung base, crackles RLL.
Otherwise clear throuhgout. No wheezing
GI: Soft NT/ND
EXTREMITIES: No edema
PULSES: 2+ radial
NEURO: Oriented and appropriate
SKIN: no rash on limited exam
Pertinent Results:
ADMISSION LABS
___ 02:10PM BLOOD WBC-22.0* RBC-5.03 Hgb-13.3 Hct-41.7
MCV-83 MCH-26.5* MCHC-32.0 RDW-13.5 Plt ___
___ 02:10PM BLOOD Neuts-87.5* Lymphs-7.3* Monos-4.4 Eos-0.4
Baso-0.3
___ 02:10PM BLOOD Plt ___
___ 02:10PM BLOOD UreaN-20 Creat-1.1 Na-136 K-4.2 Cl-99
HCO3-26 AnGap-15
___ 02:10PM BLOOD ALT-29 AST-26 AlkPhos-125* TotBili-0.4
___ 02:10PM BLOOD Calcium-9.8 Phos-2.8 Mg-1.8
___ 02:10PM BLOOD TSH-0.96
___ 02:10PM BLOOD Free T4-1.2
___ 08:40AM BLOOD Cortsol-38.1*
___ 06:29PM BLOOD Lactate-1.4
URINE
___ 11:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 11:00PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
___ 11:00PM URINE RBC-0 WBC-13* Bacteri-FEW Yeast-NONE
Epi-<1 TransE-<1
___ 11:00PM URINE CastHy-4*
MICROBIOLOGY
___ blood cx X 2 pending
___ Urine culture negative
___ 9:39 pm 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 ___:
No respiratory viruses isolated.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
___ Legionella Urinary antigen negative
___ BAL
___ 12:33 pm BRONCHOALVEOLAR LAVAGE BROCHIAL LAVAGE.
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___: NO GROWTH, <1000
CFU/ml.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
___ 12:33 pm Rapid Respiratory Viral Screen & Culture
BROCHIAL LAVAGE.
**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..
Respiratory Viral Antigen Screen (Final ___:
Greater than 400 polymorphonuclear leukocytes;.
Specimen inadequate for detecting respiratory viral
infection by DFA
testing.
___ 12:32 pm BRONCHIAL WASHINGS BROCHICAL WASH.
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___: NO GROWTH, <1000
CFU/ml.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
___ Stool C diff negative
PERTINENT IMAGING
___ CXR PA& LAT
Multifocal pneumonia at the right and left lung base, worse
compared with prior exam with new involvement of the right lower
lung.
___ CT chest w/contrast
1. Interval development of multiple areas of dense
consolidation involving
bilateral lower lobes and the right middle lobe, concerning for
multifocal
pneumonia.
2. Stable mediastinal and hilar lymphadenopathy.
3. Increased size of hepatic and adrenal metastases.
___ Bronch/BAL
The airways were inspected. In both the right and left lungs
there was significant airway edema and thick, white/yellow,
purulent secretions. A bronchial washing of 15 ccs was taken
from the right mainstem bronchus. Then a 60cc of NS was
instilled in the Right Lower lobe was taken. There was total
return of 20ccs of purulent thick fluid. This was sent for
culture. A brief airway evaluation was performed with no
endobronchial leasions.
___ CXR PA&LAT
Increased bibasilar opacities consistent with worsening
multifocal pneumonia.
DISCHARGE LABS
___ 10:10AM BLOOD WBC-12.4* RBC-4.62 Hgb-12.0 Hct-38.5
MCV-83 MCH-25.9* MCHC-31.1 RDW-13.9 Plt ___
___ 10:10AM BLOOD Neuts-81.5* Lymphs-13.2* Monos-3.6
Eos-1.2 Baso-0.5
___ 10:10AM BLOOD Plt ___
___ 10:10AM BLOOD Glucose-97 UreaN-11 Creat-0.8 Na-140
K-3.9 Cl-105 HCO3-27 AnGap-12
___ 02:10PM BLOOD ALT-29 AST-26 AlkPhos-125* TotBili-0.4
___ 10:10AM BLOOD Calcium-9.1 Phos-3.5 Mg-1.8
Brief Hospital Course:
Ms ___ is a ___ with metastatic RCC that progressed despite
high dose IL-2, now on a phase 1 clinical trial of ipilimumab
(anti CTLA4) and nivolumab (anti PD-1) presenting with 2 weeks
of fevers and cough.
#. Sepsis secondary to pneumonia: Multifocal pneumonia on chest.
On presentation, patient was quite ill with fevers and
hypotension but improved with fluids/antibiotics
(vanc/cefipeme/levofloxacin). There was concern that patient may
have been presenting with a hyperresponse to a viral infection
or autoimmune pneumonitis due to clinical trial drugs rather
than an infection. Bronch/BAL, however, indicated neutrophils
only with extensive pustulence. This was more suggestive of
infectious process causing patient's symptoms so steroids were
NOT started. Vanc/cefipeme were discontinued 5 days after admit
since cultures remained negative (___). She is to complete a 10
day course of levofloxacin (last dose ___. Patient was unable
to be completely weaned off of O2, thought to be secondary to
the severity of her pneumonia. On discharge, patient was
saturation 87% on RA. She was discharged home with O2 and
saturations should be titrated >88% by ___.
#. Renal cell carcinoma: metastatic, on enrolled in a drug trial
of ipilimumab (anti CTLA4) and nivolumab (anti PD-1)
#. Hypertension: She has had low BPs over the past few months
and had not been taking her atenolol. Atenolol was held on
discharge.
#. Depression: recent depression/anxiety. Patient had been seen
by psychiatry prior to admit who had started patient on
escitalopram at 5mg daily and recommended uptitrating to 10mg
daily. Patient was discharged on latter dose.
TRANSITIONAL ISSUES
# complete a 10 day course of levofloxacin (last dose ___
# Atenolol has been held due to soft blood pressures prior to
admission. During admission atenolol continued to be held and
patient was eutensive. ___ consider restarting as outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Zolpidem Tartrate 5 mg PO HS
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
3. Cetirizine 10 mg oral daily
4. Atenolol 50 mg PO DAILY
5. Escitalopram Oxalate 5 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
2. Escitalopram Oxalate 10 mg PO DAILY
3. Zolpidem Tartrate 5 mg PO HS
4. Benzonatate 200 mg PO TID:PRN cough
RX *benzonatate 200 mg 1 capsule(s) by mouth three times daily
Disp #*28 Capsule Refills:*0
5. Levofloxacin 750 mg PO DAILY Duration: 4 Days
Last dose ___
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*4
Tablet Refills:*0
6. Guaifenesin ER 1200 mg PO Q12H:PRN cough
RX *guaifenesin [Adult Tussin Chest Congestion] 100 mg/5 mL 5 mL
by mouth qdaily Disp #*1 Bottle Refills:*0
7. Cetirizine 10 mg oral daily
8. Home Oxygen
___ via NC continuous pulse dose for portability. Dx Pneumonia.
RA O2 sat 87% at rest. ___ needs portability
___ for ___ and MD ___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: community acquired pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you here at ___. You were
found to have a pneumonia for which you were started on
antibiotics. Initially, there was concern that you may be having
a drug reaction from the new drug trial but we believe this is
less likely. You improved on antibiotics and should continue
this with last dose ___. We wish you all the best.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10233088-DS-22 | 10,233,088 | 26,257,040 | DS | 22 | 2161-07-23 00:00:00 | 2161-07-24 14:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cefaclor / morphine / Tegaderm / Dilaudid /
Gadolinium-Containing Contrast Media
Attending: ___
Chief Complaint:
Left Main Bronchus Obstruction
Major Surgical or Invasive Procedure:
Placement of L main bronchus stent on ___
Placement of L chest tube on ___ removal on ___.
History of Present Illness:
Ms. ___ is a ___ yo lady with a history of Hodgkin lymphoma s/p
BMT in ___, metastatic renal cell Ca (to brain, leptomeningeal)
s/p multiple lines of treatment now on axitinib (tyrosine-kinase
inhibitor) who presents with acute worsening of shortness of
breath found to have LMB obstruction and left lung collapse.
She reports that she was well until a few weeks ago when she
developed wheezing. She was otherwise asymptomatic at the time.
This past week she noted some SOB and this weekend went on a
trip out of town where she noted her breathing worsened. She
drove home from ___ on ___ and noted some L upper
shoulder pain. Around 4AM on the day of presentation she woke
up with acute worsening of her SOB And left upper back/shoulder
pain. She otherwise has had no recent hemoptysis, no cough, no
fevers.
Notably about one month ago she had a viral illness and had
hemoptysis (she reports small amounts but her husband thinks it
was a few napkins full). The hemoptysis resolved on its own but
she sought evaluation at an OSH emergency room where, per the
patient, a CT of the chest was done at that time and did not
show any evidence of pulmonary metastases.
She initially presented to ___ and was found to be
hypoxemic (unclear how much) and responded to NC (was briefly on
NIPPV). She was given vanc/aztreonam and sent to ___.
CT read at OSH: no PE, obstruction of the left mainstem bronchus
at the site of the previously seen endobronchial lesion which
has significantly increased in size. There is diffuse multifocal
left upper and left lower lobe airspace consolidation suggestive
of post obstructive pneumonia. Given the history of renal cell
carcinoma most likely etiology is a metastasis to the left
mainstem bronchus. There is associated mediastinal and right
hilar lymphadenopathy. Hyperdense material in region of superior
pericardial recess could be related to hyperdense pericardial
fluid or metastatic infiltration of pericardium.
On presentation to the ___ ___ she is afebrile and satting in
the low ___ on 5L NC. She was briefly placed on NRB for comfort.
On transfer to the MICU, vitals were: 98.5 115 115/77 18 100%
Nasal Cannula. On arrival to the MICU, she was resting
comfortably. No acute distress on 4L NC.
Past Medical History:
PAST ONCOLOGIC HISTORY PER OMR:
___ Hodgkin lymphoma with extensive chest LAD
MOPP and ABV chemotherapy
XRT to chest by Dr. ___ at ___
___ Relapsed Hodgkin lymphoma
Induction chemotherapy
___ Auto BMT by Dr. ___
___ Hematuria
___ Small blood clots in urine
___ CT chest at ___ showed mediastinal, hilar LAD, left
renal
mass
___ CT urogram shows a large left renal tumor
___ MRI abdomen shows left renal tumor
___ Undergoes laparoscopic left radical nephrectomy
Pathology: clear cell renal cell carcinoma
___ C1 HD IL-2
___ DFCI ___ with ___ Plus Sunitinib or Pazolpanib
for RCC
___ C1D1 DFCI ___ - ___ pneumonia requiring hospitalization
Completed SRS to cerebellar lesion via cyber knife
Started pazopanib
Now on axinitib
PAST MEDICAL HISTORY:
- Likely metastatic renal cell carcinoma, as above
- Hodgkin lymphoma s/p SCT
- Hypertension
Social History:
___
Family History:
Mother had ___ lymphoma. Maternal grandfather had renal
cell carcinoma in his ___. Maternal uncle had ___
lymphoma. Another maternal uncle had melanoma. Maternal aunt had
renal cell carcinoma in her late ___. Paternal uncle had
prostate cancer and pancreatic cancer. Diabetes prevalent on
paternal side of family
Physical Exam:
Admission PHYSICAL EXAM:
=
================================================================
Vitals: T: 98.9 BP: 144/93 P: 121 R: 26 O2: 95%4LNC
General Appearance: NAD, resting comfortably. Whispering.
HEENT: MMM, O/P clear, sclera anicteric
Neck: trachea midline, no stridor, supple.
Chest: Diminished BS throughout L lung with bronchial breath
sounds. Right side CTA.
Cardiovascular: reg rate, nl S1/S2, no MRG
Abdomen: soft, NT/ND, NABS, no HSM
Extremities: no CCE
Neurological: A&O x3, no motor or sensory deficits grossly.
Psychiatric: normal mood, no depression/anxiety
Skin: No rash, skin eruptions, or erythema
Discharge PHYSICAL EXAM:
=
================================================================
Vitals: T 99.1-98.8 BP 123/83-150/82 HR 57-66 O2 95-97% RA,
sats to 90% with ambulation
General Appearance: NAD
HEENT: MMM, O/P clear, voice moderately hoarse
Neck: trachea midline, no stridor, supple.
Chest: Clean bandage overlying left chest where chest tube had
been placed, Inspiratory/expiratory wheezes, however much
improved relative to date of transfer from the MICU.
Cardiovascular: reg rate, nl S1/S2, no MRG
Abdomen: soft, NT/ND, NABS, no HSM
Extremities: no CCE
Neurological: A&O x3, no motor or sensory deficits grossly.
Psychiatric: normal mood, no depression/anxiety
Skin: erythema of right arm, tenderness improved upon discharge
Pertinent Results:
Admission Labs
=======================================
___ 03:15PM BLOOD WBC-9.7 RBC-6.98*# Hgb-16.4*# Hct-53.7*#
MCV-77*# MCH-23.5*# MCHC-30.5* RDW-18.2* RDWSD-43.7 Plt ___
___ 03:15PM BLOOD Neuts-79.4* Lymphs-12.9* Monos-6.6
Eos-0.2* Baso-0.5 Im ___ AbsNeut-7.67*# AbsLymp-1.25
AbsMono-0.64 AbsEos-0.02* AbsBaso-0.05
___ 03:15PM BLOOD Plt ___
___ 03:15PM BLOOD Glucose-118* UreaN-28* Creat-1.1 Na-138
K-5.5* Cl-102 HCO3-22 AnGap-20
___ 02:25AM BLOOD ALT-13 AST-19 LD(LDH)-229 AlkPhos-88
TotBili-0.6
___ 02:25AM BLOOD Calcium-9.1 Phos-4.1 Mg-1.7
ICU Discharge Labs
======================================
___ 02:34AM BLOOD WBC-10.2* RBC-5.39* Hgb-12.4 Hct-41.3
MCV-77* MCH-23.0* MCHC-30.0* RDW-16.7* RDWSD-45.3 Plt ___
___ 02:34AM BLOOD Plt ___
___ 02:34AM BLOOD Glucose-116* UreaN-13 Creat-0.9 Na-140
K-4.4 Cl-105 HCO3-26 AnGap-13
___ 02:34AM BLOOD Calcium-9.0 Phos-2.7 Mg-1.8
Discharge Labs
======================================
___ 06:18AM BLOOD WBC-7.2 RBC-5.69* Hgb-12.9 Hct-42.9
MCV-75* MCH-22.7* MCHC-30.1* RDW-17.6* RDWSD-44.2 Plt ___
___ 06:18AM BLOOD Plt ___
___ 06:18AM BLOOD Glucose-109* UreaN-19 Creat-0.9 Na-142
K-4.4 Cl-102 HCO3-31 AnGap-13
___ 06:18AM BLOOD Calcium-9.8 Phos-3.9 Mg-1.6
IMAGING:
================
EKG ___: Baseline artifact. Sinus rhythm at upper limits of
normal rate. Possible inferior wall myocardial infarction of
indeterminate age. Late R wave progression. Compared to the
previous tracing of ___ rates are similar. Axis is now more
leftward. Precordial S wave is more prominent and persist into
lead V6. There more leftward axis is associated with more
apparent Q waves in leads III and aVF. Clinical correlation is
suggested.
CT Chest without contrast ___:
1. Patient is post left mainstem bronchial stenting and
endobronchial tumor
debulking. The stent is patent and appropriately placed without
complications.
2. Continued consolidations in the left lower lobe, concerning
for
post-obstructive pneumonia.
3. Right lower lobe consolidation is new since ___.
Differential considerations include aspiration, pneumonia, and
disease spread.
4. New mediastinal and hilar lymphadenopathy and left perihilar
obstructive
mass since ___
CXR AP ___:
1. Near complete opacification of the left lung, likely due to
new atelectasis of the left lung from known obstructing left
mainstem bronchial mass.
CXR AP ___: n comparison with the earlier study of this date,
there has been placement of a left mainstem bronchus shunt with
substantial Re aeration of the left hemithorax. Persistent
opacification at the left base most likely represents
atelectasis. In the appropriate clinical setting, superimposed
pneumonia would be difficult to exclude.
There are mild atelectatic changes at the right base. The
pulmonary vessels are indistinct and mildly engorged, consistent
with some elevation of pulmonary venous pressure.
CXR AP ___: Interval placement of a left pigtail catheter. The
patient now shows a 5 mm post interventional left apical
pneumothorax without evidence of tension. Mild increase in
extent and severity of the pre-existing left lower lung opacity.
CXR AP ___: Comparison to ___. Interval removal of
the left chest tube. The millimetric left pneumothorax is
unchanged. No evidence of tension. Unchanged appearance of the
right lung.
CXR PA/Lat ___:
1. Since ___, left basilar atelectasis is improved, a
moderate right
pleural effusion is slightly increased, and small right apical
pneumothorax
persists.
2. Pleural and parenchymal opacities in the right apex are also
improved since ___.
CXR PA/Lat ___: In comparison to the prior radiograph of 1 day
earlier, a small right pleural effusion has resolved, right
upper lobe postobstructive atelectasis and consolidation have
partially cleared, and platelike atelectasis in the left lower
lobe has slightly improved. Other findings including
intrathoracic lymphadenopathy and the right chest wall mass are
not appreciably changed.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with RCC with known brain mets,
hodgkins lymphoma s/p BMT in ___, who presented to the ___ with
SOB and chest pressure who was found to have L lung collapse
secondary to a L hilar mass compressing the L main stem bronchus
and subsequently underwent airway stent placement, chest tube
drainage of pleural effusion, complicated by pneumothorax, and
treatment for a post-obstructive pneumonia.
MICU Course:
=============
The patient was transferred from an OSH ___ where she was
diagnosed with a collapsed L left and admitted to the MICU for
her increased O2 requirement of 5L NRM. On the morning of
hospital day 2 she was brought to the interventional procedure
room for diagnostic and interventional bronchoscopy.
Bronchoscopy revealed collapse of the left main stem bronchus.
A stent was placed with success and airflow was restored to the
left lung. Pre-procedure imaging suggested a left hilar mass to
be responsible for the airway obstruction, so biopsies were
taken for pathological analysis. The patient recovered from the
procedure without complication. Post-procedure Chest Ct
suggested L pleural effusion and L lower lobe consolidations.
For this, she was started on vancomycin and meropenem for
suspected post-obstructive pneumonia. On hospital day three, a
left chest tube was placed to drain the pleural effusion. The
pleural fluid analysis suggested an exudative effusion but was
not an empyema. The chest tube was removed on hospital day four
and the patient was transferred to the general medical floor
when her O2 requirement improved to 2L NC.
FLOOR Course:
===================
#L Lung Collapse: Likely secondary to compression of left
mainstem bronchus from endobronchial tumor. She underwent airway
stent placement in the L main stem bronchus on ___ and required
MICU stay for stabilization and observation. L hilar mass was
biopsied during this procedure; the pathology results are
pending currently but are concerning for pulmonary metastasis
from ___. Prior to discharge, patient was satting well on room
air with ambulatory O2 sat over 90%.
#Left lower lobe pneumonia: Noted on CT scan with significant
consolidation concerning for post-obstructive pneumonia. She was
initially treated broadly with vancomycin and meropenum. The
patient was transitioned to augmentin for a 10 day course
starting on ___, finishing on ___.
#Bilateral Pleural effusions: Patient with L>R pleural effusions
on admission. Pigtail catheter placed ___ on left with pleural
fluid suggested exudative effusion likely a result of pneumonia
and the L hilar mass. Pigtail removed on ___ with minimal
reaccumulation on serial CXR. Right sided effusion resolved on
repeat CXR ___.
#Pneumothorax: the patient developed a small left apical PTX as
a result of the chest tube placement. This resolved prior to
discharge. She was also noted to have a small right apical PTX
on CXR which was not hemodynamically significant and was
resolved on day of discharge.
#RCC: the patient's axinitib was continued during her recovery
as directed by the Heme/Onc service.
#Superficial thrombophlebitis: Patient had infiltrated IV on
right forearm with erythema and mild edema/tenderness. The IV
was removed and symptoms improved prior to discharge with warm
compresses.
#Hypertension: Lisinopril initially held due to critical
illness. This was restarted prior to discharge.
#Depression: Escitalopram continued throughout admission.
TRANSITIONAL ISSUES:
======================
[ ]Patient will need to follow-up in 6 weeks in ___ clinic with
repeat CT scan at that time (scheduled for ___
[ ]Patient to continue mucinex DM BID and flutter valve 3x/day
for ten days. Did not qualify for home O2 (O2 sat 90%
ambulation) but was instructed to not overexert herself while
completing antibiotic course. SaO2 at rest was 95-97% RA.
[ ]Discharged on 10 day course of augmentin ending ___
[ ]Please follow-up pleural fluid cultures and pathology from
___
[ ]Please follow-up pathology on lung mass from biopsy ___
# CODE STATUS: FULL
# CONTACT: Name of health care proxy: ___
Relationship: Husband
Phone number: ___
Cell phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. axitinib 5 mg oral BID
3. Zolpidem Tartrate 10 mg PO QHS
4. Escitalopram Oxalate 10 mg PO DAILY
Discharge Medications:
1. axitinib 5 mg oral BID
2. Escitalopram Oxalate 10 mg PO DAILY
3. Zolpidem Tartrate 10 mg PO QHS
4. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
RX *albuterol sulfate [ProAir HFA] 90 mcg ___ puffs inhaled
every six (6) hours Disp #*1 Inhaler Refills:*0
5. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 10 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*15 Tablet Refills:*0
6. Guaifenesin ER 600 mg PO Q12H
RX *guaiFENesin 1 tablet by mouth twice a day Disp #*20 Tablet
Refills:*0
7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing
RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 3 mL
inhaled every six (6) hours Disp #*30 Ampule Refills:*0
8. Lisinopril 20 mg PO DAILY
9. Nebulizer machine
Please provide nebulizer machine
Discharge Disposition:
Home
Discharge Diagnosis:
Left lung collapse due to airway compression by a mass in the
chest.
Left Pleural effusion s/p drainage
Left lower lobe Post-obstructive Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
You were admitted to ___ for severe shortness
of breath and chest pain. You were found to have a collapsed
lung due to masses in your chest which required placement of a
stent to keep the airway in your chest open to aerate your left
lung. Biopsies were taken of the mass and are currently pending.
You were found to have a pneumonia which was likely due to the
mass collapsing the airway. You should continue to take
augmentin (an antibiotic) for a total of 10 days, finishing on
___.
Additionally, you developed fluid around your lungs which also
made it more difficult for you to breath. A chest tube was
place to remove the fluid to make it easier for you to breath.
The tube came out and there is nothing else you need to do for
this. Cultures and pathology of the fluid are currently pending.
You were started on several new medications for your shortness
of breath and pneumonia. Please continue to take all of your
medications as prescribed. Additionally, please continue to use
your flutter valve three times per day for the next ten days.
Please do not overexert yourself as your oxygen saturations were
borderline when you were active.
Please continue to apply warm compresses to your right arm. The
swelling and pain should resolve. If pain becomes unresponsive
to oral pain medication (tylenol), please seek medical
attention.
Please follow-up with your oncologist as noted below. You will
also need to follow-up with interventional pulmonology in 6
weeks for a repeat CT scan.
It was a pleasure taking care of you!
Your ___ Care Team
Followup Instructions:
___
|
10233088-DS-23 | 10,233,088 | 22,900,482 | DS | 23 | 2161-09-22 00:00:00 | 2161-09-22 21:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cefaclor / morphine / Tegaderm / Dilaudid /
Gadolinium-Containing Contrast Media
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
___: Flexible/Rigid bronchoscopy, stent revision, APC/Cryo,
Left mainstem silicone stent placement
___: Bedside fiber optic endosocopy/laryngoscopy
History of Present Illness:
Ms. ___ is a ___ woman with PMHx of Hodgkin lymphoma
s/p BMT in ___, metastatic renal cell carcinoma (to brain s/p
cyberknife) and leptomeningeal disease, resistant to multiple
lines of therapy, currently on axitinib, who is presenting with
shortness of breath.
Of note, she was recently admitted to ___ for acute worsening
of shortness of breath found to have LMB obstruction and left
lung collapse s/p flexible + rigid bronchoscopy, tumor
destruction and excision and LMS stent placement. During this
hospitalization, she was also found to have a left sided pleural
effusion that required chest tube drainage, cytology was
negative for malignancy.
She is now presenting with acute worsening shortness of breath
and was found to have and increase in size of the left sided
lung mass with new obstruction of the left mainstem bronchus
with resultant atelectasis of the left lower lobe.
In the ED, initial VS were 97.3 109 145/95 18 98% Nasal Cannula.
-Exam notable for tachypnea.
-Labs showed:
- Na 138 K 4.3 Cl 96 CO2 26 BUN 17 Cr 0.9 Ca 9.6 P 3.1
- ALT 12 AST 22 AP 78 LDH 252 Tbili 0.4 Alb 4.1
- TSH 5.6 Free T4 1.3
- WBC 8.7 Hgb 16 Hct 53 Plt 329
- N:72.8 L:16.9 M:8.4 E:1.3 Bas:0.5
Imaging showed:
- CTA Chest: 1. No evidence of pulmonary embolism or aortic
abnormality. 2. Increase in size of the sub- carinal nodal
metastatic conglomerate causing new obstruction of the left
mainstem bronchus. Resultant atelectasis of the left lower lobe
and opacities in the lingula could reflect atelectasis or
postobstructive pneumonia.
3. Progression of disease with increase in size of multiple
pulmonary nodules, lymphadenopathy, upper abdominal metastases
and right chest wall metastasis.
-She received: IVF 1000 mL NS, IV Levofloxacin 750 mg, PO/NG
Citalopram 10 mg, PO MetRONIDAZOLE
- IP was consulted with plan for add-on case for
Rigid/Flex/Stent revision/Electrocautery on ___.
Decision was made to admit to medicine for further management.
- Transfer VS were
98.4 110 149/83 24 92% RA
On arrival to the floor, patient reports chest pain radiating to
the left shoulder, similar to that experienced last time she had
a bronchus obstruction. Also complains of nausea.
Past Medical History:
PAST ONCOLOGIC HISTORY PER OMR:
___ Hodgkin lymphoma with extensive chest LAD
MOPP and ABV chemotherapy
XRT to chest by Dr. ___ at ___
___ Relapsed Hodgkin lymphoma
Induction chemotherapy
___ Auto BMT by Dr. ___
___ Hematuria
___ Small blood clots in urine
___ CT chest at ___ showed mediastinal, hilar LAD, left
renal
mass
___ CT urogram shows a large left renal tumor
___ MRI abdomen shows left renal tumor
___ Undergoes laparoscopic left radical nephrectomy
Pathology: clear cell renal cell carcinoma
___ C1 HD IL-2
___ DFCI ___ with ___ Plus Sunitinib or
Pazolpanib
for RCC
___ C1D1 DFCI ___
___ - ___ pneumonia requiring hospitalization
Completed SRS to cerebellar lesion via cyber knife
Started pazopanib
Now on axinitib
PAST MEDICAL HISTORY:
- Likely metastatic renal cell carcinoma, as above
- Hodgkin lymphoma s/p SCT
- Hypertension
Social History:
___
Family History:
Mother had ___ lymphoma. Maternal grandfather had renal
cell carcinoma in his ___. Maternal uncle had ___
lymphoma. Another maternal uncle had melanoma. Maternal aunt had
renal cell carcinoma in her late ___. Paternal uncle had
prostate cancer and pancreatic cancer. Diabetes prevalent on
paternal side of family
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
ADMISSION PHYSICAL EXAM:
VS - 99.1 144/92 112 20 93RA
GENERAL: NAD
HEENT: Ill appearing woman in NAD, hoarse voice. AT/NC, EOMI,
PERRL, anicteric sclera, pink conjunctiva, MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: Tachycardic RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Markedly decreased breath sounds over left lung fields. No
wheezes.
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
========================
VS: Tc/Tm 97.9/AF | HR 99 | BP 107/68-117/77 | RR 22 | 02 95% RA
General: Sleeping, but easily arousable. NAD. Looking more
comfortable. Hoarse, soft voice but improved phonation compared
to prior.
HEENT: No scleral icterus. PERRL, EOMI. MMM.
Neck: No JVD, no LAD.
CV: RRR, S1/S2. No M/R/G.
Lungs: Scant rhonchi and bronchial breath sounds very
significantly improved from prior. Decreased breath sounds at
left base.
Abdomen: Soft, nontender, nondistended. Hernia left abdomen,
mildly tender.
Ext: Warm and well perfused. 2+ DP pulses. No edema.
Pertinent Results:
ADMISSION LABS:
==============
___ 03:06PM BLOOD WBC-8.7 RBC-7.31* Hgb-16.0* Hct-53.0*
MCV-73* MCH-21.9* MCHC-30.2* RDW-23.2* RDWSD-54.0* Plt ___
___ 03:06PM BLOOD Neuts-72.8* Lymphs-16.9* Monos-8.4
Eos-1.3 Baso-0.5 Im ___ AbsNeut-6.32* AbsLymp-1.47
AbsMono-0.73 AbsEos-0.11 AbsBaso-0.04
___ 03:06PM BLOOD UreaN-17 Creat-0.9 Na-138 K-4.3 Cl-96
HCO3-26 AnGap-20
___ 03:06PM BLOOD ALT-12 AST-22 LD(LDH)-252* AlkPhos-78
TotBili-0.4
___ 03:06PM BLOOD Albumin-4.1 Calcium-9.6 Phos-3.1
KEY LABS:
=========
___ 04:59AM BLOOD ___
___ 03:06PM BLOOD TSH-5.6*
___ 03:06PM BLOOD Free T4-1.3
DISCHARGE LABS:
===============
___ 07:00AM BLOOD WBC-7.3 RBC-5.90* Hgb-12.5 Hct-42.9
MCV-73* MCH-21.2* MCHC-29.1* RDW-23.2* RDWSD-56.7* Plt ___
___ 07:00AM BLOOD Glucose-81 UreaN-19 Creat-0.8 Na-143
K-4.5 Cl-101 HCO3-32 AnGap-15
___ 07:00AM BLOOD Calcium-9.4 Phos-3.8 Mg-2.0
MICROBIOLOGY:
=============
___ 10:00 pm BLOOD CULTURE X2: NO GROWTH.
___ 5:30 pm BRONCHOALVEOLAR LAVAGE
LEFT LOWER LOBE PNEUMONIA.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___: NO GROWTH, <1000
CFU/ml.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
KEY IMAGING:
===========
___ CTA CHEST IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Increase in size of the sub- carinal nodal metastatic
conglomerate causing new obstruction of the left mainstem
bronchus. Resultant atelectasis of the left lower lobe and
opacities in the lingula could reflect atelectasis or
postobstructive pneumonia.
3. Progression of disease with increase in size of multiple
pulmonary nodules, lymphadenopathy, upper abdominal metastases
and right chest wall metastasis.
___ CHEST XR:
Status post left tracheal stenting. Increased elevation of the
left hemidiaphragm. Moderate mediastinal widening that should
be closely monitoring. Moderate left basal and paramediastinal
atelectasis. No visible pleural effusion. No pneumothorax.
Stable appearance of the right lung. Known right-sided rib
destruction.
___ CHEST XR: Bronchial stent is barely visible on the
radiograph. The stent appears to be in stable position.
Minimal increase in extent of for pre-existing left pleural
effusion and left basilar atelectasis, on the basis of left
diaphragmatic elevation.
On the right, there is a large bony destruction at the level of
the seventh rib, with a substantial soft tissue component.
Moderate cardiomegaly persists.
___ VIDEO OROPHARYNGEAL SWALLOW: Barium passes freely through
the oropharynx and esophagus without evidence of obstruction.
There was no gross aspiration or penetration. Asymmetry of the
vocal cords is noted.
IMPRESSION: Normal oropharyngeal swallowing videofluoroscopy.
Brief Hospital Course:
Ms. ___ is a ___ woman with past medical history of
Hodgkin lymphoma s/p BMT in ___ and metastatic renal cell
carcinoma (to brain s/p cyberknife and leptomeninges, resistant
to multiple lines of therapy) currently on nivolumab plus
axitinib, who presented with progressive shortness of breath and
found to have new obstruction of her left mainstem bronchus
despite a previous stenting. Required brief MICU stay for acute
hypoxic respiratory failure after IP bronchoscopy and stent
revision on ___, but returned to medical floor with significant
improvement in her respiratory status.
===============
ACTIVE ISSUES:
===============
# Endobronchial obstruction secondary to metastatic RCC:
Initially presented with worsening airway obstruction and
dyspnea in the setting of progression of existing pulmonary
metastatic disease. On ___, interventional pulmonology performed
flexible+rigid bronchoscopy, which demonstrated 100% obstruction
of the left mainstem bronchus, 80% obstruction of RUL, and 20%
RBI obstruction. Cryodebridement and APC was performed to remove
obstructing tumor from right and left airways. Old stent
removed. A silicone stent (12x40-mm) was placed in left mainstem
bronchus. Procedure was complicated by acute hypoxic respiratory
failure which occur in the PACU and required a brief MICU stay
(see below for details). After this procedure, continued
levofloxacin and metronidazole for possible post-obstructive
pneumonia, prednisone 40 mg daily (5-day burst), nebulized
bronchodilators, and aggressive pulmonary toilet with Mucomyst
and flutter valve. Patient's oxygen requirement decreased back
to baseline (room air) and airway remained stable.
# Hypoxic respiratory distress: Developed worsening tachypnea
with increasing O2 requirement post-procedure while in PACU,
thought to be secondary to mucous plugging or post-operative
inflammation. Also consider anaphylaxis or anaphylactoid
reaction after receiving a dose of Unasyn (documented Cefaclor
allergy). She received furosemide 10 mg IV in the PACU,
methylprednisone IV, and nebulizers and was transferred to the
ICU for monitoring overnight. In the ICU, she remained stable on
4L NC and was downtitrated to 2L NC. She was treated with
levofloxacin and flagyl for possible post-obstructive pneumonia.
She was treated with prednisone 40mg daily with a plan to
complete a five day course.
# C. difficile: Patient admitted with known diagnosis of C.
difficile on oral metronidazole. Briefly transitioned to oral
vancomycin solution, but restarted metronidazole prior to
discharge. Plan for total 14-day course of metronidazole (to be
continued 4 days after finishing levofloxacin). Diagnosed by
primary oncologist on ___ after presenting with diarrhea;
however, patient had no diarrhea while inpatient.
# Left vocal fold paralysis: Patient was already followed by ENT
as outpatient due to left vocal fold paralysis, likely due to
tumor impingement on the recurrent laryngeal nerve. During
hospitalization, there was some concern that patient's left
vocal fold paralysis could compromise patient's cough and
potentially allow aspiration. ENT was consulted and did bedside
fiberoptic evaluation which confirmed paralysis of left vocal
fold. Speech and swallow evaluation was ordered with
oropharyngeal videofluoroscopic swallowing study, which was
essentially normal but did show "trace pharyngeal dysphagia
characterized by mild swallow delay and rare, shallow
penetration of thin liquids." Recommendation for diet is regular
solids with thin liquids. Patient to follow up with Dr. ___
in ENT as an outpatient.
Of note, patient complained of esophageal pain with swallowing
during speech and swallow study. This may be related to tumor
impingement on/infiltration of esophagus commented in her
___ CTA chest study. Further monitoring is recommended.
================
CHRONIC ISSUES:
================
# High hemoglobin/Erythrocytosis: Likely secondary to
paraneoplastic EPO production from clear cell RCC. Hemoglobin
within normal limits during this hospitalization; no need for
therapeutic phlebotomy during hospitalization.
# RCC with intrapulmonary, bony, and leptomeningeal mets:
Patient has undergone multiple lines of treatment, including
cyberkinfe to brain mets in ___ and ___, pazopanib-intolerant
due to diarrhea, with PD on axitinib, transitioned to nivolumab
plus axitinib. Axitinib therapy complicated by diarrhea per
hem/onc fellow and was held during this admission and not
restarted at discharge; this medication will be managed by the
patient's primary hem/onc providers. Patient did have
significant chest wall and left shoulder pain, likely due to
metastatic disease in those areas. This pain was managed with
oxycodone ___ mg PO q.4H p.r.n. for pain. Note that patient has
not tolerated IV morphine or hydromorphone well in the past.
# Hypertension: Continued Lisinopril
# Depression: Continued Escitalopram
CODE: Full confirmed
EMERGENCY CONTACT HCP: ___
Relationship: Husband
Phone number: ___
====================
TRANSITIONAL ISSUES:
====================
[ ] Patient's axitinib was stopped during hospital stay and upon
discharge due to concern for potentially worsening of pulmonary
symptoms. Please discuss whether to restart as an outpatient.
[ ] Patient discharged on LEVOFLOXACIN 750mg PO daily for
planned 10-day course (last day= ___
[ ] Patient discharged on METRONIDAZOLE 500mg PO Q.8H for
planned 14-day course (last day= ___
[ ] Discharged on PREDNISONE 40mg daily to be taken through ___
to finish 5-day burst
[ ] Discharged with Albuterol nebulizer solution, Saline
nebulizer solution, and Mucomyst nebulizer solution to be used
as directed for wheezing, shortness of breath, and chest
tightness due to secretions after stenting procedure.
[ ] Consider OP Speech follow-up for laryngeal
videostroboscopy/voice therapy prior to or following ENT's plan
for potential vocal fold injection.
[ ] Patient's BAL acid fast culture and fungal culture were
pending at time of discharge.
Medications on Admission:
1. axitinib 5 mg oral BID
2. Escitalopram Oxalate 10 mg PO DAILY
3. Zolpidem Tartrate 10 mg PO QHS
4. Guaifenesin ER 600 mg PO Q12H
5. Lisinopril 20 mg PO DAILY
6. MetroNIDAZOLE 500 mg PO TID
7. LOPERamide 2 mg PO QID:PRN diarrhea
8. LORazepam 1 mg PO Q8H:PRN anxiety
9. Methylprednisolone 32 mg PO ONCE:PRN contrast
10. DiphenhydrAMINE 50 mg PO ONCE:PRN contrast
Discharge Medications:
1. Escitalopram Oxalate 10 mg PO DAILY
2. Guaifenesin ER 600 mg PO Q12H
3. Lisinopril 20 mg PO DAILY
4. LORazepam 1 mg PO Q8H:PRN anxiety
5. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*25 Tablet Refills:*0
6. Zolpidem Tartrate 10 mg PO QHS
7. LOPERamide 2 mg PO QID:PRN diarrhea
8. Levofloxacin 750 mg PO DAILY
Take through ___.
RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*4
Tablet Refills:*0
9. PredniSONE 40 mg PO DAILY
Take through ___.
RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*2
Tablet Refills:*0
10. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
___ cause sedation. Do take before driving.
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
11. Acetylcysteine 20% ___ mL NEB Q4H
RX *acetylcysteine 200 mg/mL (20 %) ___ mL nebulized every four
(4) hours Disp #*30 Vial Refills:*0
12. Albuterol 0.083% Neb Soln ___ NEB IH Q2H:PRN sob, wheezing
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 3 mL neb every six
(6) hours Disp #*30 Vial Refills:*0
13. Sodium Chloride 3% Inhalation Soln 15 mL NEB Q4H
RX *sodium chloride 3 % 15 mL nebulized every four (4) hours
Disp #*60 Vial Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Airway obstruction due to metastatic renal cell carcinoma
- Post-obstructive pneumonia
SECONDARY DIAGNOSES:
- Vocal fold paralysis
- C. difficile infection, mild
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 worsening shortness of breath. This was
due to tumor blocking off your airways. Interventional
pulmonology was able to do a procedure to remove this
obstruction. A new stent was placed in your left lung.
When you go home, it is important to keep taking your
antibiotics as directed. You should also keep using your green
flutter valve several times a day indefinitely.
We have stopped your axitinib because it may contribute to your
shortness of breath. You are scheduled to follow up with your
oncology doctors on ___. They will decide the further plan
with axitinib.
Thank you for letting us participate in your care,
Your ___ team
Followup Instructions:
___
|
10233142-DS-7 | 10,233,142 | 20,640,463 | DS | 7 | 2180-10-08 00:00:00 | 2180-10-08 19:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Major Surgical or Invasive Procedure:
Coronary angiogram
PCI w/ DES placed in mid-RCA
attach
Pertinent Results:
ADMISSION LABS
==============
___ 12:30PM BLOOD WBC-9.9 RBC-5.64 Hgb-16.6 Hct-47.1 MCV-84
MCH-29.4 MCHC-35.2 RDW-12.0 RDWSD-36.4 Plt ___
___ 12:30PM BLOOD Neuts-69.1 ___ Monos-9.0 Eos-0.9*
Baso-0.4 Im ___ AbsNeut-6.85* AbsLymp-2.02 AbsMono-0.89*
AbsEos-0.09 AbsBaso-0.04
___ 12:30PM BLOOD Glucose-102* UreaN-12 Creat-0.9 Na-139
K-4.9 Cl-104 HCO3-22 AnGap-13
PERTINENT LABS
==============
CARDIAC:
___ 12:30PM BLOOD cTropnT-0.11*
___ 04:47PM BLOOD CK-MB-26* cTropnT-0.23*
___ 06:50AM BLOOD cTropnT-0.45*
___ 02:45PM BLOOD CK-MB-10 MB Indx-5.0 cTropnT-0.30*
___ 02:45PM BLOOD CK(CPK)-202
OTHER:
___ 07:29AM BLOOD %HbA1c-5.5 eAG-111
PERTINENT RESULTS
=================
___ Cardiac cath
95% stenosis of RCA, 80% stenosis of RPDA
Findings
Single vessel coronary artery disease.
Successful PTCA/stent of the mid RCA using drug-eluting stent.
Recommendations
ASA 81mg per day indefinitely.
Prasugrel 10mg QD for minimum 12 months.
Secondary prevention of CAD and further management as per
primary cardiology team.
___ TTE
LVEF 50-55%
IMPRESSION: Moderate left ventricular hypertrophy with normal
cavity size and mild regional systolic dysfunction c/w CAD in a
PDA distribution. Mild right ventricular cavity dilation with
focal hypokinesis of the basal and mid right ventricular free
wall. No valvular pathology or pathologic flow identified.
Indeterminate pulmonary artery systolic pressure. Mild thoracic
aortic enlargement.
DISCHARGE LABS
==============
___ 07:00AM BLOOD WBC-8.5 RBC-5.42 Hgb-15.8 Hct-47.2 MCV-87
MCH-29.2 MCHC-33.5 RDW-12.3 RDWSD-38.9 Plt ___
___ 07:00AM BLOOD Glucose-106* UreaN-12 Creat-0.9 Na-141
K-4.4 Cl-103 HCO3-24 AnGap-14
___ 07:00AM BLOOD Calcium-10.7* Phos-3.0 Mg-2.3
Brief Hospital Course:
=====================
TRANSITIONAL ISSUES
=====================
[] New NSTEMI discharged on aspirin, prasugrel, atorvastatin,
metoprolol, lisinopril
[] Should be on ASA 81 indefinitely, prasugrel 10 QD for at
least 12 months
[] Uptitrate metoprolol and lisinopril as tolerated
[] Recommend lipid panel in 1 month to assess adequacy of high
intensity statin therapy, consider adding ezetimibe or PCSK-9
inhibitor if with continued dyslipidemia
[] A1c 5.5% on ___
=====================
ASSESSMENT AND PLAN:
=====================
CORONARIES: 95% RCA s/p stent; 80% RPDA, 50% RV; 40% diag
PUMP: Unknown
RHYTHM: NSR
___ w/ hx of dyslipidemia who presented with chest pain in the
setting of an NSTEMI, s/p coronary angio w/ DES to RCA for 95%
occlusion of mid-RCA. Angiogram also notable for right PDA 80%
occlusion. TTE demonstrated normal LVEF (50-55%), moderate LVH,
mild regional systolic dysfunction in PDA distribution c/w CAD.
His hospital course was uncomplicated. He was discharged on
aspirin, prasugrel, atorvastatin, metoprolol, lisinopril.
===============
ACTIVE ISSUES:
===============
#NSTEMI s/p PCI with DES to RCA
#CAD
Presented w/ chest pain, found to have NSTEMI. Went to cath lab,
angiogram revealed 95% occlusion of mid-RCA and right PDA 80%
occlusion. DES placed in mid-RCA. Patient without any
significant family history or smoking history. TC 262, LDL 153,
HDL 59, triglycerides 247, A1c 5.5%. Post-PCI TTE w/ normal
LVEF, systolic dysfunction in PDA distribution c/w CAD. We
medically optimized him for his CAD/NSTEMI, HLD, and HTN as
follows:
-ASA 81mg and prasugrel 10mg daily for stent thrombosis
prevention
-Home atorvastatin 80mg daily for HLD. We debated adding Zetia
or PCSK-9 inhibitor, but deferred this to outpatient providers.
-Metoprolol 12.5mg q6h consolidated to 50 mg XL daily on
discharge. Recommend uptitrating as HR tolerates.
-Start lisinopril 5. His BPs were soft so we did not uptitrate
further, consider uptitrating as BPs tolerate.
#HTN
Management per above
#HLD
Management per above
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth once daily at night
Disp #*30 Tablet Refills:*0
3. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
5. Prasugrel 10 mg PO DAILY
RX *prasugrel 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
NSTEMI
HLD
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted to the hospital because you had a heart
attack, which happens when the blood supply to your heart gets
blocked
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You underwent a procedure that showed that one of your
arteries that supplies blood to your heart was almost closed
off. We opened it during the procedure with a metal tube called
a stent, which stays in the artery.
- We started you on a lot of medicines to help prevent a heart
attack from happening in the future and prevent your stent from
clotting and giving you another heart attack
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
appointments listed below.
- It is very important to take your aspirin and prasugrel every
day.
- These two medicines keep the stent in the artery open and help
reduce your risk of having a future heart attack.
- If you stop these medications or miss ___ dose, you risk causing
a blood clot forming in your heart stents and having another
heart attack
- Please do not stop taking either medication without taking to
your heart doctor.
- You are also on other new medications to help your heart,
including metoprolol and lisinopril. These medicines help to
reduce your blood pressure and keep your heart healthier after
the heart attack. Please take these as directed.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
10233152-DS-12 | 10,233,152 | 23,962,140 | DS | 12 | 2138-12-31 00:00:00 | 2138-12-31 14:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Macrobid
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a PMH of asthma, OA, HTN, hx of breast CA s/p
lumpectomy and radiation who presents with 3 weeks of shortness
of breath and abdominal pain after OSH imaging showed several
pulmonary emboli and multiple masses. Had CTPA done at Urgent
care which showed PE and liver masses, sent to ___ ED
where CT abd/pelvis was done and it showed large right
suprarenal
mass, liver lesions, ?diverticulitis. Head CT showed chronic
lacunar infarcts.
#SOB: has had SOB for years attributed to asthma. For the past
week has had severe SOB that is progressing and associated with
a
cough. gets very winded walking.
#Abdominal pain and distention for a few weeks now that is worse
with eating. has not lost weight. no nausea or vomiting. no
diarrhea.
#Headache: intermittent moderate to severe headache x1 week.
#left hip pain: chronic issue. has been attributed to OA. has
been much worse recently.
CT imaging shows from OSH:
-several PEs
-large right suprarenal mass with invasion into the liver and
central necrosis
-at least 5 hepatic lesions concerning for metastasis
-2 round pulmonary nodules in the lingula in the right middle
lobe 2.2 cm suspicious for metastasis
-concern for diverticulitis with perforation
-chronic appearing lacunar infarct
In ED at ___: T 98.1, HR 71, BP 144/86, 97% on 2L
Labs: BMP WNL, ALT 29, AST 20, Alk phos 155, T bili 0.9. WBC
11.8
(WBC was 15 at OSH). UA 9 WBC, neg nit, sml ___, no bacteria.
urine and blood cultures sent.
Meds: cefepime, flagyl, heparin, morphine, Ativan
Consults: surgery- no concern for diverticulitis- no indication
for surgery.
Past Medical History:
Asthma
HTN
Breast CA s/p lumpectomy and radiation
GERD
Osteoarthritis
Social History:
___
Family History:
No family history of cancer.
Physical Exam:
Admission Physical Exam:
========================
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: diffuse expiratory wheezing.
GI: Abdomen soft, non-distended, non-tender to palpation. no CVA
tenderness
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Discharge Physical Exam:
========================
VS WNL
Note Date: ___ Time: 1754
Note Type: Progress note
Note Title: HMED Progress Note
Electronically signed by ___, MD on ___ at 6:03
pm Affiliation: ___
CC: ___ of breath
Past 24H Events:
- NAE overnight.
- S/p Liver Bx ___. Patient understands that biopsy results
will
not come back until days after discharge
- Discussed pros/cons of lovenox vs DOAC. She wants to be taught
how to administer lovenox self-injections and if liver Bx
results
neg for malignancy, will transition to a DOAC at that time.
- Cough improved with guaifenisin
EXAM
___ 0828 Temp: 98.4 PO BP: 126/87 HR: 92 RR: 18 O2 sat: 93%
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, no murmur, no S3, no S4. No JVD.
RESP: CTAB
GI: Abdomen soft, non-distended, non-tender to palpation. no CVA
tenderness, mild fullness in epigastrum
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: anxious, but insightful
Pertinent Results:
Admission Labs:
===============
___ 02:45AM BLOOD WBC-11.8* RBC-4.18 Hgb-11.9 Hct-37.5
MCV-90 MCH-28.5 MCHC-31.7* RDW-15.5 RDWSD-51.1* Plt ___
___ 02:45AM BLOOD Neuts-91* Lymphs-3* Monos-2* Eos-0*
___ Metas-2* Myelos-2* AbsNeut-10.74* AbsLymp-0.35*
AbsMono-0.24 AbsEos-0.00* AbsBaso-0.00*
___ 02:45AM BLOOD ___ PTT-28.5 ___
___ 02:45AM BLOOD UreaN-9 Creat-0.6 Na-135 K-4.2 Cl-101
HCO3-22 AnGap-12
___ 02:45AM BLOOD ALT-29 AST-20 AlkPhos-155* TotBili-0.9
___ 02:45AM BLOOD proBNP-496*
___ 02:45AM BLOOD cTropnT-<0.01
___ 02:45AM BLOOD Albumin-3.4* Calcium-9.0 Phos-3.8
___ 05:32AM BLOOD CEA-2.6 AFP-3.8
___ 02:59AM BLOOD Lactate-1.4
Imaging:
========
___ guided liver Bx
Uncomplicated 18-gauge targeted liver biopsy x 5, with specimen
sent to pathology. Given that initial passages mostly revealed
necrotic material, subsequent passages targeted the very
peripheral portion of the lesion.
CT Head OSH
No acute intracranial abnormalities are identified. No focal
areas of brain edema seen.
CT Chest w/ and w/o IV contrast OSH
The heart is normal in size. Aorta is normal in caliber.
Minimal atherosclerotic change. No filling defects are found
among pulmonary arterial branches.
There is no pleural or pericardial effusion. No lymphadenopathy
is identified in the chest.
Abdomen is reported separately.
Bones appear demineralized. There are no suspicious bone
lesions. Smooth suspicious nodule in the right upper lobe
(9:135
close) measures 7 mm in diameter. Small calcified granuloma at
the left lung base. Very small subpleural nodule
of soft tissue density in the left lower lobe (9:282), which is
more in keeping with high probability of a benign nodule.
CT A/P with contrast OSH
1. Large mass in the right upper quadrant most suggestive of
adrenal cortical carcinoma including tumor thrombus in the
inferior vena cava, direct invasion of the liver, separate liver
metastases, and pulmonary metastasis.
2. Findings consistent with acute diverticulitis. Small
localized focus of free air; not distant free air. Dense fat
stranding suggesting very early phlegmonous change but no
significant well-defined fluid collection at this time.
Discharge Labs:
===============
WBC: 10.9 <-- 11.8 <-- 9.9 <-- 13.6
Chem: WNL
Estradiol 49
CEA 2.6
AFP 3.9
CA ___: 24
Total free plasma metanephrines: 96 (<=205)
Aldosterone: 3 (WNL)
DHEA: 279
Testosterone: 100
SHBG: 33
AM Cortisol: 18.8
proBNP: 496
UCx: Negative
BCx: NGTD
Pending labs:
==============
Androstenedione: PND
17-Hydroxyprogestereone: PND
ACTH: PND
Plasma Metanephrines: PND
Renin: PND
Brief Hospital Course:
___ with a PMH of asthma, HTN, OA, breast CA s/p lumpectomy and
radiation who presented with 3 weeks of shortness of breath and
abdominal pain and was found to have new pulmonary emboli and a
large suprarenal mass invading the liver, with
concern for liver and pulmonary metastasis.
ACUTE/ACTIVE PROBLEMS:
# Subsegmental Pulmonary Emboli
# Acute Hypoxic Respiratory failure
Prsented with one week of worsening SOB and cough. Found to have
LLL subsegmental PEs. Likely triggered by new malignancy. There
were no signs of R heart strain on EKG and troponin was
negative. She was started on a heparin drip but then
transitioned to Lovenox ___ SubQ QD (1.5mg/kg) given high
concern for a malignant suprarenal mass.
[] PCP follow up on ___ to determine whether lovenox should be
continued (namely if Liver bx reveals malignancy) vs DOAC such
as Apixiban (if liver biopsy does not reveal malignancy)
# Suprarenal mass invading liver
# Pulmonary nodules
# Multiple liver lesions
Found to have large R suprarenal mass invading the liver, with
multiple liver lesions and pulmonary nodules concerning for
metastasis. She underwent ___ guided biopsy on ___ which path
pending. Given concern for adrenal cortical carcinoma (based
___ on imaging), serologic studies were sent off (see
transitional issues below).
[] PCP to follow up liver biopsy results to determine need for
Oncology referral
# Asthma:
Presented with diffuse wheezing on admission which quickly
resolved. Continued home flovent and Montelukast with nebulizer
treatments as needed
# Concern for diverticulitis with perforation
Outside read of CT Abd/Pelvis concerning for diverticulitis with
perforation however surgery. She was seen by surgery in the ED,
who felt that there was no clinical concern for diverticulitis.
She was started on CTX and flagyl. Second opinion read and CT
Abd/Pelvis showed localized diverticulitis for which she was
discharged on cipro/metronidazole to end a 7 day course on ___.
# Leukocytosis
WBC 15 on admission. No fever. No clear localizing
signs/symptoms
of infection. Could be diverticulitis (however not per surgery),
UTI (mild pyuria), or necrotic tumor. Narrowed Abx to
Cipro/Flagyl given neg UCx, BCx NGTD and diverticulitis on CT
A/P which she will complete a 7 day course on ___
# Lacunar infarcts on imaging
CT head was obtained at OSH due to headache and showed chronic
appearing lacunar
infarcts in the right basal ganglia. Second opinion read of CT
at ___ commented on "prominent perivascular spaces seen in the
right inferior basal ganglia region" but did not clearly
identify any prior infarcts, though the prominent perivascular
spaces could be a sign of chronic small vessel disease. Patient
did not want to start atorvastatin or aspirin at this time due
to feeling overwhelmed.
#Constipation, likely ___ intraabdominal malignancy. LBM ___
- C/w Senna/ BID
CHRONIC/STABLE PROBLEMS:
# HTN: takes losartan and metoprolol at home. Initially held,
then restarted prior to discharge
# GERD: continued home omeprazole.
# Insomnia: continued home trazodone
Transitional issues
[] PCP to follow up the following pended labs
Androstenedione: PND
17-Hydroxyprogestereone: PND
ACTH: PND
Plasma Metanephrines: PND
Renin: PND
[] PCP to follow up on the pathology of the liver biopsy
performed ___
[] If liver biopsy reveals malignancy, reorder and continue
lovenox (only prescribed enough until PCP appointment on ___
due to out of pocket ___. If liver biopsy does not reveal
malignancy, can transition to Apixiban for treatment of PE
[] Continue with Cipro/Metronidazole to end on ___ for acute
diverticulitis
[] Rediscuss initiation of Atorva 40mg and ASA 81mg PO QD for
secondary stroke prophylaxis given evidence of chronic lacunar
infarct on CT Head.
Greater than 40 mins were spend in discharge planning and
coordination of care.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 50 mg PO DAILY
2. Metoprolol Tartrate 25 mg PO BID
3. TraZODone 50 mg PO QHS:PRN insomnia
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Albuterol Inhaler 1 PUFF IH Q4H:PRN sob
6. Montelukast 10 mg PO DAILY
7. Omeprazole 40 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO BID Duration: 5 Days
Last dose ___
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*11 Tablet Refills:*0
2. Enoxaparin Sodium 100 mg SC DAILY
RX *enoxaparin 100 mg/mL 100 mg SubQ once a day Disp #*30
Syringe Refills:*0
3. GuaiFENesin-Dextromethorphan 5 mL PO Q6H:PRN cough
RX *dextromethorphan-guaifenesin [Robafen DM Cough] 100 mg-10
mg/5 mL 10 mg by mouth every six (6) hours Refills:*0
4. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three
times a day Disp #*16 Tablet Refills:*0
5. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
6. Albuterol Inhaler 1 PUFF IH Q4H:PRN sob
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Losartan Potassium 50 mg PO DAILY
9. Metoprolol Tartrate 25 mg PO BID
10. Montelukast 10 mg PO DAILY
11. Omeprazole 40 mg PO DAILY
12. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Acute pulmonary embolism
RUQ mass
Diverticulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were transferred from ___ after you were found to
have blood clots in your lung and an abdominal mass. You were
started on a blood thinner to treat the blood clots known as
lovenox. You also had a biopsy of the mass in your abdomen which
your Primary Care Doctor ___ follow up the results of. Based on
the results of this biopsy, your Primary Care Doctor ___ help
determine whether you need to see an Oncologist (cancer doctor)
and whether you need to continue on Lovenox. Lastly, you will
continue on two antibiotics (Ciprofloxacin/Metronidazole) to end
on ___ to treat your diverticulitis.
It was a pleasure taking care of you.
Your ___ Team
Followup Instructions:
___
|
10233255-DS-14 | 10,233,255 | 24,939,253 | DS | 14 | 2173-11-29 00:00:00 | 2173-12-02 08:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
headache, nausea, vomiting, lethargy
Major Surgical or Invasive Procedure:
Superficial skin biopsy of back lesion on ___ -> pathology
consistent with ___
History of Present Illness:
The patient is an ___ year-old man with a history of melanoma,
HLD, and DM who presents to ___ with headache,
altered mental status, and vomiting and was found to have
multiple intracranial masses with right IPH on NCHCT. He was
transfered to ___ ED where Neurology is being consulted. History
is obtained primarily from his son who does not know all the
intricacies of his medical history.
Per his son, as the patient is quite lethargic, the patient has
not been himself all week. He was confused and forgetting
things which is very unsual for him. But there was no clear
change until the morning of ___ when he awoke with a severe
headache. He was lethargic and confused the entire day. His son
notes that he did not take his meds or check his FSG which he
does automatically every day. At dinner time, he started
vomiting continuously until he started vomiting a small amount
of blood. His family called EMS and he was taken to ___ by
ambulance.
At ___, initial vitals were stable. The ___ showed
multiple hemorrhagic lesions with vasogenic edema. He was
treated with Zofran 4mg and Solumedrol 10mg IV prior to transfer
here.
On neurologic review of systems, the patient denies current
headache, weakness, or difficulty breathing. He cannot
participate in a full ROS given his mental status.
Past Medical History:
- Malignant Melanoma s/p resection on right cheek ___, 1.42mm
___ ___, sentinel lymph node biopsy resection (path negative
on 3 lymph nodes)
- Squamous Cell Carcinoma
- Irregular heart rhythm, previously on coumadin, which was
stopped ___ years ago for unclear reasons
- HLD
- DM
- Right knee surgery
- Left eye blindness since the ___ after a nail went into his
orbit. Subsequent surgery on his left eye and lid has left him
with a left eyelid that rarely opens.
Social History:
___
Family History:
Multiple family members with cancer including the patients
brother who had throat cancer.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
Vitals: 96.5 62 125/67 16 100% 1L nasal Cannula
General: sleeping in bed, multiple erythematous scaling skin
lesions on face, NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Extremities: Warm, no edema, multiple skin lesions that are
Neurologic Examination:
- Mental Status - sleeping, arousable to voice. Oriented to
person, place, ___. He recalls that he is
in the hospital because of a bleed in his brain. He requires a
few reminders to stay awake. Able to recite months of year
backwards. Speech is fluent with full sentences, intact
repetition, and intact verbal comprehension. Content of speech
demonstrates intact naming (high and low frequency) and no
paraphasias. Normal prosody. No dysarthria. No apraxia. No
evidence of hemineglect. No left-right agnosia.
- Cranial Nerves - Pupil 3->2 brisk on right eye. Left eyeball
is sclerotic with no ___ or pupil. VF full to number counting
on right eye. EOMI, no nystagmus. V1-V3 without deficits to
light touch bilaterally. Left eyelid opens only slightly
(baseline). Otherwise no facial asymmetry. Hearing intact to
finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength
___ bilaterally. Tongue midline.
- Motor - Normal bulk and tone. No drift. No tremor or
asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
- Sensory - No deficits to light touch, pin, or proprioception
bilaterally.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 0 0
R 2 2 2 0 0
Plantar response ? ___ on right, clearly ___ on left.
====================================================
DISCHARGE NEUROLOGICAL PHYSICAL EXAM:
Mental status: Alert, oriented x3 (fully). Speech fluent
however at times hesitant before starting a sentence. Followed
all commands. Excellent recollection of details of his medical
history.
CN: unchanged from above (please note left eye is chronic
finding)
Motor: Full strength throughout, unchanged.
DTRS: bilateral ___ toes
Gait: Negative rhomberg. Gait steady, narrow base. Did not
require assistance or cane.
Pertinent Results:
ADMISSION LABS:
___ 09:25AM BLOOD WBC-7.4 RBC-4.59* Hgb-14.6 Hct-44.9
MCV-98 MCH-31.7 MCHC-32.4 RDW-12.2 Plt ___
___ 09:25AM BLOOD Glucose-301* UreaN-24* Creat-1.0 Na-137
K-4.7 Cl-102 HCO3-25 AnGap-15
___ 09:25AM BLOOD Calcium-9.1 Phos-2.6* Mg-1.9
DISCHARGE LABS:
___ 05:15AM BLOOD WBC-8.7 RBC-3.92* Hgb-13.1* Hct-37.5*
MCV-96 MCH-33.4* MCHC-34.9 RDW-12.0 Plt Ct-98*
___ 05:15AM BLOOD Glucose-231* UreaN-25* Creat-0.8 Na-133
K-4.2 Cl-101 HCO3-23 AnGap-13
___ 05:15AM BLOOD Calcium-8.8 Phos-2.4* Mg-2.0
URINE:
___ 01:18AM URINE Color-Straw Appear-Clear Sp ___
___ 01:18AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 01:18AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1 TransE-<1
==================
IMAGING:
CT CHEST ___:
Multiple pulmonary nodules are suspicious for pulmonary
metastases in this patient with history of melanoma.
Wedge-shaped opacity in left lower lobe could be due to
pulmonary hemorrhage or pulmonary infarct. Centrally enhancing
rounded lesion proximal to ground-glass opacity may reflect a
pulmonary metastasis encasing a pulmonary vessel and obstructing
a subsegmental airway. An inflammatory process mimicking a
metastasis is also possible, and direct correlation to the
outside CT scans would be helpful in this regard as well as
followup imaging. Cardiomegaly, coronary artery calcifications,
and possible pulmonary arterial hypertension.
CT ABD/PELVIS ___:
Enhancing 1.4 cm left renal mass, which may represent a
metastasis or
primary renal cell carcinoma. Otherwise no evidence of
metastatic disease in the abdomen or pelvis. Cholelithiasis.
Findings at the lung bases concerning for metastatic disease.
MR HEAD ___:
Multiple foci of intrinsic T1 hyperintensity with associated
hemorrhage in
FLAIR hyperintensity throughout the bilateral cerebral
hemispheres, with
largest focus at the right frontal lobe, as described above.
There is no
definite evidence of abnormal enhancement associated with these
lesions
although evaluation is limited in the setting of extensive
intrinsic T1
hyperintensity. Findings are most consistent with patient's
history of
metastatic disease secondary to melanoma.
==================
PATHOLOGY ___:
Skin, back, disc shave (1A-1D):
- Squamous cell carcinoma, invasive, well to moderately
differentiated,
extending to the deep specimen margin.
==================
Brief Hospital Course:
Mr. ___ is a ___ year-old man with a history of melanoma
(stage ___, HLD, and DM who presented to ___
___ (___) with headache, altered mental status, and
vomiting and was found to have multiple intracranial hemorrhagic
masses. He was given Decadron 10mg IV and transferred to ___ for
further care.
#NEUROLOGY (intracranial metastatic lesions, likely melanoma)
Here, initial examination was notable for lethargy, inattention,
left ___ toe, and chronic left eye scleral changes with
eyelid ptosis after trauma. His alertness improved drastically
over 12 hours as solumedrol was continued. No new focal
neurological deficits.
MRI of his brain confirmed intracranial hemorrhagic lesions some
of which were enhancing. Radiologically, these lesions were
most consistent with metastatic melanoma. Neurosurgery was
consulted, but there was no intracranial lesion amenable to
biopsy. For further evaluation of malignancy, CT torso w/
contrast showed a 1.4cm renal enhancing lesion and possible
pulmonary lesions. Neurooncology evaluated the patient and
recommend that the patient's prior melanoma slides needed to be
reviewed prior to treatment course was intiated, especially
given his non focal exam. The renal lesion was too small to
biopsy. Radiation oncology recommended whole brain radiation
either after tissue biospy obtained or per family preference.
Patient and family felt comfortable for this to be arranged on
an outpatient basis.
# DERMATOLOGY: (squamous cell carcinoma and history of malignant
melanoma)
Dermatology was consulted given multiple skin lesions, the most
concerning of which was ___ sized pink crateriform nodule
with scant scale and telangiectasia under dermoscopy". This was
excised and pathology showed this was found to be invasive
squamous cell carcinoma. His outpatient dermatologist Dr.
___ at ___ was contacted regarding his prior history of
melanoma. Per records, the patient had a lesion on his right
cheeck resected in ___ that was characterized as stage ___,
___, depth 1.42cm. ___ surgery later done to take out
further margins. Sentinel node biopsy x3 done which was
negative at that time. These pathology slides were obtained
from ___ and were brought to our derm path lab for reading on
___.
# ENDOCRINE: (diabetes mellitis)
He has a history of diabetes managed on oral agents. He was
hyperglycemic to 200-300 while inpatient given high dose
steroids and was managed on sliding scale insulin. He was
discharged on his home oral agents (which were stopped during
the admission). His PCP was contacted given that he might need
to be started on insulin if his sugars were poorly controlled at
home. The patient and family were instructed to call the PCP if
sugars were persistently above 250.
# CHRONIC ISSUES:
- BPH: continued his home finasteride and tamsulosis
- HTN: continued his home antihypertensives
- HLD: continued his home statin
# TRANSITIONAL ISSUES:
-His son ___ lives at home (along with the
wife) with the patient and can be reached at ___.
-He is instructed to call Neurology resident on-call if there
are new neurological symtpoms.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 20 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. potassium citrate 10 mEq oral BID
4. Lisinopril 5 mg PO DAILY
5. MetFORMIN XR (Glucophage XR) 750 mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
8. imiquimod 5 % topical 2x weekly
9. Tamsulosin 0.4 mg PO HS
10. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE DAILY
11. GlipiZIDE 5 mg PO DAILY
Discharge Medications:
1. Finasteride 5 mg PO DAILY
2. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE DAILY
3. Simvastatin 20 mg PO DAILY
4. Tamsulosin 0.4 mg PO HS
5. GlipiZIDE 5 mg PO DAILY
6. imiquimod 5 % topical 2x weekly
7. Lisinopril 5 mg PO DAILY
8. MetFORMIN XR (Glucophage XR) 750 mg PO DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
10. potassium citrate 10 mEq ORAL BID
11. Acetaminophen 1000 mg PO Q8H:PRN headache
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*180 Tablet Refills:*1
12. LeVETiracetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
13. PredniSONE 60 mg PO DAILY
RX *prednisone 20 mg 3 tablet(s) by mouth QAM Disp #*90 Tablet
Refills:*0
14. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*30 Tablet Refills:*1
15. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule,delayed ___ by
mouth QAM Disp #*30 Capsule Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic intracranial masses
Squamous cell carcinoma
Probable metastatic melanoma
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 while you were admitted to
___. You were admitted with headaches, nausea, vomiting, and
lethargy. We performed a number of images of your brain and
torso and have found that you have multiple masses in your brain
that are most likely cancerous. We have also found a mass
within one of your kidneys that is likely cancerous. The
primary cancer is most likely melanoma, but we cannot exclude
renal cancer. We have involved a number of consulting teams to
determine a treatment course. Your treatment course will be
determined after your dermatology slides are reviewed by our
dermatology - pathology department. You will be seen by Dr.
___ neurooncologist, on ___ to determine follow-up.
You will also be follow by the radiation oncologists and they
will contact you with an appointment.
We have started you on a number of medications:
1) Keppra (levetiracetam) 1000mg twice a day to prevent seizures
2) Prednisone 60mg daily to minimize swelling in the brain
3) Omeprazole 20mg daily to prevent GI discomfort
4) Zofran (ondansetron) 4mg every 8 hours as needed for nausea
Please call your dermatologist, Dr. ___, to arrange closer
follow-up for removal of the lesion on your back.
When you return home, you will likely continue to have headaches
and you can treat these with tylenol. Please refrain from
taking Aspirin or ibuprofen.
When you return home, if you have sudden worsening headache, or
nausea vomiting, please seek medical attention. You can call
___ and ask for the neurology resident on-call if there
are questions that you may have.
Followup Instructions:
___
|
10233650-DS-22 | 10,233,650 | 29,070,767 | DS | 22 | 2128-09-27 00:00:00 | 2128-09-27 10:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Peristomal pain
Major Surgical or Invasive Procedure:
None this admission
___ - laprascopic TAC, end ileostomy
History of Present Illness:
Mr. ___ is a ___ with a history of autoimmune sclerosing
pancreatitis with recent diagnosis of ulcerative colitis who
presents with worsening abdominal pain and hematochezia.
Past Medical History:
-Auto-immune sclerosing pancreatitis: dx in ___. He was
seen by Dr. ___ of the multi-disciplinary
pancreas center in ___. Various flares of acute
pancreatitis that have responded well to steroids. ERCPs w/
stent placement (___) and stent removals (___). Steroids
for autoimmune sclerosing pancreatitis was stopped 3 days prior
to last admission (___).
Social History:
___
Family History:
-He notes no family history of Crohn's, UC, or other GI
disorders. He also notes no autoimmune disorders in family.
-Brother: testicular cancer at ___
-Father: HTN
-Grandfather: prostate cancer, grandmother with NHL lymphoma
Physical Exam:
AAO NAD
reg rate
cta
abd soft, nt, mildly ttp around ostomy, no purulence, stoma pink
and patent, easily digitized
no peripheral edema
Pertinent Results:
___ 06:05AM BLOOD WBC-8.5 RBC-2.81* Hgb-7.5* Hct-24.4*
MCV-87 MCH-26.7 MCHC-30.7* RDW-14.2 RDWSD-45.1 Plt ___
___ 06:05AM BLOOD Glucose-109* UreaN-6 Creat-0.7 Na-139
K-4.4 Cl-107 HCO___ AnGap-14
Brief Hospital Course:
Mr. ___ presented to the ED at ___ on ___ with
worsening abdominal pain and hematochezia. On exam, a q-tip
easily passed next to ostomy to level of fascia
circumferentially, murky fluid return - no purulence, stoma pink
and patent, easily digitized. A CT was done to look for a
potential fluid collection which showed post surgical changes w/
no large fluid collection concerning for abscess or e/o of a
leak at the rectal pouch. He was admitted for antibiotics and
monitoring. He remained afebrile w/ improved abdominal pain and
no further episodes of hematochezia. He was found to be positive
for Cdiff on ___ and started on PO Vanc and IV/Flagyl to be
continued for a total of 14d.
Neuro: Pain was well controlled on oxycodone and tylenol
CV: Vital signs were routinely monitored during the patient's
length of stay.
Pulm: The patient was encouraged to ambulate, sit and get out
of bed, use the incentive spirometer, and had oxygen saturation
levels monitored as indicated.
GI: The patient was advanced to and tolerated a regular diet at
time of discharge. The ostomy output was closely monitored
during his stay and he was found to be +Cdiff on ___.
GU: Urine output was monitored as indicated. At time of
discharge, the patient was voiding without difficulty.
ID: The patient's vital signs were monitored for signs of
infection and fever. The patient was started on and continued on
antibiotics as indicated. His most recent regimen was IV flagyl
and PO vanc for +Cdiff on ___. He will be d/c on PO vanc for a
total of 14d.
Heme: The patient had blood levels checked during the hospital
course to monitor for signs of bleeding and infection. The
patient had vital signs, including heart rate and blood
pressure, monitored throughout the hospital stay.
On ___, the patient was discharged to home. At discharge, he
was tolerating a regular diet, passing flatus, stooling,
voiding, and ambulating independently. He will follow-up in the
clinic in ___ weeks. This information was communicated to the
patient directly prior to discharge.
Social Issues Causing a Delay in Discharge:
[x] No social factors contributing in delay of discharge.
Medications on Admission:
1. Calcium Carbonate 500 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
5. LOPERamide 4 mg PO TID
Titrate as necessary (take more wafers if your ostomy output
continues to be too high)
RX *loperamide 2 mg 2 tablets by mouth three times a day Disp
#*30 Tablet Refills:*3
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*15 Tablet Refills:*0
7. Psyllium Wafer 2 WAF PO BID
Titrate as necessary (take more wafers if your ostomy output
continues to be too high)
RX *psyllium [Metamucil] 1.7 g 2 wafer(s) by mouth twice a day
Disp #*30 Wafer Refills:*3
9. PredniSONE 20 mg PO DAILY Duration: 2 Days
take 20mg a day on ___ and ___
RX *prednisone 10 mg 2 tablet(s) by mouth every day Disp #*4
Tablet Refills:*0 ( to taper to 10 tomorrow)
11. Docusate Sodium 100 mg PO BID
take while taking narcotics (oxycodone)
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
2. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
3. Omeprazole 20 mg PO DAILY
Home Medications:
1. Calcium Carbonate 500 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
5. LOPERamide 4 mg PO TID
Titrate as necessary (take more wafers if your ostomy output
continues to be too high)
RX *loperamide 2 mg 2 tablets by mouth three times a day Disp
#*30 Tablet Refills:*3
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*15 Tablet Refills:*0
7. Psyllium Wafer 2 WAF PO BID
Titrate as necessary (take more wafers if your ostomy output
continues to be too high)
RX *psyllium [Metamucil] 1.7 g 2 wafer(s) by mouth twice a day
Disp #*30 Wafer Refills:*3
9. PredniSONE 20 mg PO DAILY Duration: 2 Days
take 20mg a day on ___ and ___
RX *prednisone 10 mg 2 tablet(s) by mouth every day Disp #*4
Tablet Refills:*0 ( to taper to 10 tomorrow)
11. Docusate Sodium 100 mg PO BID
take while taking narcotics (oxycodone)
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Elevated WBC, peristomal pain
Discharge Condition:
Stable
Discharge Instructions:
___ should continue your antibiotics as prescribed and continue
your stoma care as instructed. Monitor for fevers, chills, night
sweats, increasing erythema or purulent drainage.
The most common complication from an ileostomy placement is
dehydration. The output from the stoma is stool from the small
intestine and the water content is very high. The stool is no
longer passing through the large intestine which is where the
water from the stool is reabsorbed into the body and the stool
becomes formed. ___ must measure your ileostomy output for the
next few weeks. The output from the stoma should not be more
than 1200cc or less than 500cc. If ___ find that your output has
become too much or too little, please call the office for
advice. The office nurse or nurse practitioner can recommend
medications to increase or slow the ileostomy output. Keep
yourself well hydrated, if ___ notice your ileostomy output
increasing, take in more electrolyte drink such as Gatorade.
Please monitor yourself for signs and symptoms of dehydration
including: dizziness (especially upon standing), weakness, dry
mouth, headache, or fatigue. If ___ notice these symptoms please
call the office or return to the emergency room for evaluation
if these symptoms are severe. ___ may eat a regular diet with
your new ileostomy. However it is a good idea to avoid fatty or
spicy foods and follow diet suggestions made to ___ by the
ostomy nurses.
___ monitor the appearance of the ostomy and stoma and care
for it as instructed by the wound/ostomy nurses. ___ 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.
Followup Instructions:
___
|
10234345-DS-21 | 10,234,345 | 23,043,929 | DS | 21 | 2174-07-18 00:00:00 | 2174-07-29 22:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Near syncope, fall with head strike
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ y/o M w/ hx of COPD and h/w of prostate
CA s/p prostatectomy p/w intermittent lightheadness for last
month and was transferred from ___ s/p fall for stable,
non-operative small subarachnoid bleeding and neurosurgery
evaluation.
Mr. ___ reports first noticing the lightheadedness about
1 month ago. Every day he has to walk about ___ flights of
stairs to his room, and about 1 month ago he began noticing that
he felt "woozy" at the top of the stairs. He would feel light
headed, with "fogginess" of his vision, and feeling of
imbalance. He states that he would feel immediately better upon
sitting down during these episodes. He denies syncope. He denies
that this happens at rest. He denies associated chest pain,
palpitations. He reports shortness of breath after 1 flight of
stairs that is stable from prior. He reports two prior falls
i/s/o this lightheadedness, denies any LOC, did not seek medical
attention, no headstrikes on these episodes.
Over the course of this month, he denies medication changes, and
reports good PO intake, no cough elevated from baseline, no
sputum production elevated from baseline. He denies PND, no
orthopnea, reports ___ edema in R leg from recent sprained ankle,
but no increase in swelling, no bilateral swelling. He is a
life-long smoker. He denies hx of cardiac disease. Over the last
___ years, patient has also noted progressive pain in distal
quads on exertion, improving with rest. He begins to note this
after climbing about 1 flight of stairs.
During one of these episodes on ___, patient fell backwards
and hit his head on kitchen counter. He denies LOC. He was able
to get up and call EMS. He was brought in to ___ and on
___ was found to have tiny punctate SAH hemorrhages. He was
subsequently transferred to Neurosurgery here at ___ for
further management. He was observed overnight, neurologically
intact throughout his stay with an improving repeat NCHCT.
Medicine was consulted for syncopal work-up, and on exam he was
noted to have sats that fell from 96-98% to 65% with associated
lightheadedness. He was then transferred to medicine for further
syncopal work-up.
Currently, he is feeling well and asymptomatic while lying in
bed. He denies any pain.
ROS:
No fevers, chills, night sweats, or weight changes. No changes
in vision or hearing. No cough, no shortness of breath. No chest
pain or palpitations. No nausea or vomiting. No diarrhea or
constipation. No dysuria or hematuria. No hematochezia, no
melena. No numbness or weakness, no focal deficits.
Past Medical History:
COPD
Prostate Ca s/p prostatectomy
Depression
Social History:
___
Family History:
Denies family history of heart disease, DM. Father died of
cancer, unclear what kind.
Physical Exam:
ADMISSION PHYSICAL EXAM
===============================
T:98.2 HR:72 BP:148/68 RR:20 Sat:99% ra
Gen: WD/WN, comfortable, NAD.
HEENT: laceration to occiput, repaired in ED
Neck: Supple. No neck pain to palpation or motion
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3
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: decreased bulk and normal tone bilaterally. No abnormal
movements, tremors. Strength full power ___ throughout. No
pronator drift
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements
DISCHARGE PHYSICAL EXAM
================================
Vitals: 97.9 152/66 (111-154/60-76) 59 (59-67) 18 100% RA
General: alert, oriented, no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: clear to auscultation bilaterally, mild inspiratory
rhonchi throughout lung fields, no crackles
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
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
NOTABLE LABS
==============================
___ 05:42AM BLOOD WBC-8.8 RBC-3.83* Hgb-11.9* Hct-36.8*
MCV-96 MCH
31.0 MCHC-32.3 RDW-14.0 Plt ___
___ 05:42AM BLOOD Neuts-68.8 ___ Monos-6.9 Eos-4.1*
Baso-0.2
___ 05:42AM BLOOD Plt ___
___ 06:45PM BLOOD ___ PTT-33.8 ___
___ 05:42AM BLOOD Glucose-103* UreaN-15 Creat-0.6 Na-137
K-4.7 Cl
102 HCO3-25 AnGap-15
___ 05:42AM BLOOD LD(LDH)-164 TotBili-0.8
___ 05:42AM BLOOD Calcium-9.3 Phos-3.6 Mg-2.2 Iron-51
___ 05:42AM BLOOD calTIBC-217* VitB12-692 Ferritn-627*
TRF-167*
NOTABLE IMAGING
=============================
CT HEAD W/O CONTRAST ___
1. Small amount of right subarachnoid hemorrhage has decreased.
No new
hemorrhage.
2. Small right parietal subgaleal hematoma without evidence for
a fracture.
3. Fluid in the right maxillary sinus, similar to 1 day earlier.
Please
correlate clinically whether the patient may have symptoms of
acute sinusitis.
ECHO ___:
FINDINGS: The left atrium and right atrium are normal in cavity
size. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). There
is mild (non-obstructive) focal hypertrophy of the basal septum.
Right ventricular chamber size and free wall motion are normal.
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 leaflets are
mildly thickened. There is no mitral valve prolapse. There is no
systolic anterior motion of the mitral valve leaflets. Mild (1+)
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Normal regional and global biventricular systolic
function. Mild mitral regurgitation.
Stress test, Nuclear, Pharmacological ___:
FINDINGS: The image quality is adequate. Left ventricular cavity
size is normal. Rest and stress perfusion images reveal a small
region of fixed decreased activity at the inferoapical region in
the presence of soft tissue attenuation. Gated images reveal
normal wall motion. The calculated left ventricular ejection
fraction is 69%.
IMPRESSION: Fixed decreased activity at the inferoapical region,
which is probably normal in the presence of soft tissue
attenuation. EF 69% (stress).
Brief Hospital Course:
BRIEF SUMMARY STATEMENT: ___ y/o M with a history of ___
transferred from ___ with a sub arachnoid hemorrhage
for neurosurgical management after a mechanical fall and head
strike in the setting of about 1 month of lightheadedness and
near syncope on exertion. Mr. ___ SAH was determined
to be non-operative and he was followed until deemed to be
neurologically stable and with serial head CT demonstrating
improvement of the SAH. He was then transferred to medicine for
further evaluation of his near-syncopal episodes. ECHO was
negative for structural, outflow obstruction. Pharmacological
nuclear stress test was unremarkable with EF of 69%. Patient was
noted to have desats into the high ___ on ambulation with
lightheadedness, despite negative cardiac work-up. Pulmonology
was curbsided and recommended outpatient pulmonology follow-up
and chest CT imaging as these symptoms may be attributable to
his COPD. Patient was attempted to be discharge on home O2 and
COPD regimen however place of living does not allow for O2 and
he can not currently afford his inhaler medications. He is to
see his PCP who should arrange pulmonology follow-up.
ACTIVE ISSUES
===================================
# Sub-arachnoid hemorrhage: Mr. ___ was neurologically
stable throughout his admission. His SAH was determined to be
non-operative by neurosurgery and he was followed until deemed
to be neurologically stable and with serial head CT
demonstrating improvement of the SAH. He was then transferred to
medicine for further evaluation of his near-syncopal episodes.
On discharge he was neurologically intact with staples in place
in the occiput from his initial laceration.
#Near-syncope: Mr. ___ complained of about 1 month of
lightheadedness, near syncopy on exertion that led to his most
recent fall. He has a history of COPD, not on home O2, and no
cardiac history. He denies any chest pain associated with the
episodes or changes in his baseline dyspnea on exertion over the
last month. While hospitalized, he was in normal sinus rhythm
without ischemic changes on EKG and no arrhythmias noted on
telemetry. ECHO was negative for structural abnormalities or
outflow obstruction. Given the reproducibility on exertion of
these symptoms, we were concerned Mr. ___ was
experiencing an anginal-equivalent, however pharmacological
nuclear stress test was unremarkable with no reversible defects
and an LVEF of 69%. Mr. ___ had no syncopal events
during this admission. We are uncertain of the etiology of his
symptoms although it may be related to his significant hypoxia
on exertion.
#Hypoxemia: Mr. ___ did not experience respiratory
distress during this admission but was noted to have ambulatory
oxygen desaturations into the high ___ as well as some
lightheadedness which resolved with rest. This may be related to
his COPD. As such, pt. was recommended to see pulmonology as an
outpatient. We attempted to discharge the pt. home with O2.
Unfortunately, his current place of living does not allow for
home O2. As such, the pt. refused this service.
#COPD: Patient does not take home COPD medications and is not on
home oxygen therapy and is an active smoker. He was started on
daily Fluticasone Propionate inhaler treatment on admission. He
reports he does not intend to quit smoking at this time. He was
discharged on home controller medications for his COPD, which he
has been on in the past and a recommendation for home oxygen
therapy, though his current housing situation does not allow
home oxygen therapy.
INACTIVE ISSUES
================================
#Depression: Patient was stable on his home citalopram.
TRANSITIONAL ISSUES
=============================
# Neurosurgery followup: Pt. has appointment and non-contrast
head CT appointment made with Dr ___ in approximately
4 weeks.
# Outpatient pulmonary follow-up: Patient needs outpatient
pulmonary follow up for further assessment/management of COPD
and outpatient Chest CT for further characterization of
COPD/lung disease that may be contributing to his pre-syncopal
symptoms.
# Hypoxia: Frequently de'sating into the low ___ with activity.
Pt. was recommended to be discharged on home O2. His current
facility does not allow oxygen. Pt's symptoms and life
expectancy would benefit if he quits smoking and is started on
home O2. ___ facility to look into this policy. Will also look
into veterans benefits as pt. was in the ___.
# Staples: Scalp staples require removal in ___ days following
placement which was on ___.
# Aspirin: Verified with neurosurgery on discharge, that aspirin
81mg daily safe to resume.
# Ankle-Brachial Indices as Outpatient: Patient complained of
chronic worsening bilateral pain in distal quadricep region on
exertion over the last ___ years. Given the patient's age and
extensive smoking history, we recommend he be evaluated for
peripheral vascular disease with Ankle Brachial Index testing.
# Anemia: Patient was noted to be anemic with Hct of 36.8. B12
normal. Iron studies were consistent with anemia of chronic
disease.
# CODE STATUS: Full Code
# CONTACT: ___ (___) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Pravastatin 10 mg PO DAILY
3. Citalopram 10 mg PO DAILY
4. Oxybutynin 5 mg PO BID
5. cod liver oil 1,250-135 unit oral daily
6. Centrum Silver
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein) 1
tab oral daily
7. FoLIC Acid 1 mg PO DAILY
8. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Citalopram 10 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Oxybutynin 5 mg PO BID
4. Pravastatin 10 mg PO DAILY
5. Thiamine 100 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Centrum Silver
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein) 1
tab oral daily
8. cod liver oil 1,250-135 unit oral daily
9. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 CAP IH
Daily Disp #*30 Capsule Refills:*3
10. Fluticasone Propionate 110mcg 2 PUFF IH BID
RX *fluticasone [Flovent Diskus] 100 mcg 2 Puffs IH twice a day
Disp #*3 Disk Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
===========================
Sub-arachnoid hemorrhage
Hypoxia
Secondary Diagnosis
===========================
Chronic obstructive pulmonary disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking part in your care at the ___. You
were transferred to ___ from ___ for
neurosurgical evaluation after you were found to have a small
amount of bleeding around your brain called a sub arachnoid
hemorrhage. The neurosurgeons decided not to operate and
repeated imaging of your head which showed improvement of your
bleed.
Once the neurosurgeons made sure your head bleed was under
control, you were transferred to the medical service for further
work up of your episodes of light-headedness and instability
after walking up stairs for the last month. We did not find any
structural problems with your heart on ultrasound. We also did
not find any problems in the blood circulation in your heart.
We currently do not know the cause of your lightheadedness,
though we think it could be related to your existing lung
condition as we noted that your oxygen saturation dropped on
exertion. We recommend pulmonology follow-up with imaging
(non-contrast lung CT) as an outpatient for further
investigation.
We wish you a speedy recovery!
Your ___ Care Team
Followup Instructions:
___
|
10234573-DS-10 | 10,234,573 | 21,592,870 | DS | 10 | 2147-06-12 00:00:00 | 2147-06-12 12:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
none
attach
Pertinent Results:
IMPORTANT LABS:
===============
___ 10:40PM BLOOD WBC-8.6 RBC-2.56* Hgb-8.3* Hct-26.3*
MCV-103* MCH-32.4* MCHC-31.6* RDW-15.2 RDWSD-57.9* Plt Ct-76*
___ 05:53PM BLOOD WBC-5.4 RBC-2.25* Hgb-7.3* Hct-23.2*
MCV-103* MCH-32.4* MCHC-31.5* RDW-15.0 RDWSD-57.3* Plt Ct-62*
___ 05:30AM BLOOD WBC-4.8 RBC-2.19* Hgb-7.1* Hct-22.9*
MCV-105* MCH-32.4* MCHC-31.0* RDW-15.5 RDWSD-59.1* Plt Ct-49*
___ 10:40PM BLOOD Neuts-81.1* Lymphs-12.6* Monos-5.6
Eos-0.0* Baso-0.1 Im ___ AbsNeut-7.00* AbsLymp-1.09*
AbsMono-0.48 AbsEos-0.00* AbsBaso-0.01
___ 01:50PM BLOOD Neuts-63.9 ___ Monos-13.2*
Eos-0.4* Baso-0.4 Im ___ AbsNeut-3.29 AbsLymp-1.12*
AbsMono-0.68 AbsEos-0.02* AbsBaso-0.02
___ 05:01AM BLOOD Neuts-52.8 ___ Monos-12.5
Eos-0.7* Baso-0.3 Im ___ AbsNeut-3.02 AbsLymp-1.92
AbsMono-0.72 AbsEos-0.04 AbsBaso-0.02
___ 10:40PM BLOOD ___ PTT-35.4 ___
___ 10:40PM BLOOD Plt Ct-76*
___ 05:01AM BLOOD ___ PTT-33.0 ___
___ 05:30AM BLOOD ___ PTT-35.8 ___
___ 01:50PM BLOOD ___
___ 05:01AM BLOOD ___
___ 10:40PM BLOOD Glucose-148* UreaN-19 Creat-1.0 Na-131*
K-3.9 Cl-94* HCO3-22 AnGap-15
___ 01:50PM BLOOD Glucose-101* UreaN-17 Creat-0.9 Na-130*
K-3.8 Cl-95* HCO3-23 AnGap-12
___ 05:30AM BLOOD Glucose-90 UreaN-14 Creat-1.0 Na-139
K-4.3 Cl-103 HCO3-26 AnGap-10
___ 10:40PM BLOOD ALT-55* AST-48* AlkPhos-673* TotBili-1.0
___ 01:50PM BLOOD ALT-39 AST-28 LD(LDH)-101 AlkPhos-520*
TotBili-0.5
___ 05:30AM BLOOD ALT-26 AST-27 AlkPhos-552* TotBili-0.3
___ 10:40PM BLOOD cTropnT-<0.01
___ 10:40PM BLOOD Lipase-13
___ 10:40PM BLOOD Albumin-3.3* Calcium-8.9 Phos-2.3*
Mg-1.4*
___ 01:50PM BLOOD Albumin-3.1* Calcium-8.6 Phos-2.5* Mg-1.8
___ 05:30AM BLOOD Calcium-9.1 Phos-4.5 Mg-2.0
___ 10:57PM BLOOD Lactate-2.0
MICROBIO:
=========
___ 2:00 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 10:40 pm BLOOD CULTURE FRTOM PORT LINE.
Blood Culture, Routine (Pending): No growth to date.
___ 11:42 pm FLUID,OTHER Source: biliary fluid.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
FLUID CULTURE (Preliminary):
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
___ this
culture.
ANAEROBIC CULTURE (Preliminary): RESULTS PENDING.
IMAGING:
==========
CXR ___:
No acute cardiopulmonary abnormality.
CT abd/pelv ___:
1. Redemonstration of a segment 8 hepatic lesion with similar
degree of
upstream biliary dilatation compared to ___. There
is unchanged
hyperenhancement surrounding the bile ducts ___ segments 4 and 5,
consistent
with cholangitis. Additional hepatic masses are stable.
2. Interval placement of a percutaneous abdominal drain, with
interval
resolution of the fluid collection anterior to the left hepatic
lobe.
3. A percutaneous cholecystostomy drain remains ___ place within
the
gallbladder. No new or enlarging fluid collection is
identified.
4. 1.5 cm cystic structure ___ the left adnexa with an adjacent
subcentimeter
calcification may represent a dermoid. Recommend non-urgent
pelvic
ultrasound.
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
======================
___ PMH of Metastatic Cholangiocarcinoma (on
gemcitabine/cisplatin), Recent Cholecystitis (c/b pericholic
fluid collection s/p percutaneous drain placement), presented to
ED with fever, admitted to oncology for further workup/treatment
TRANSITIONAL ISSUES:
====================
[] Continue ciprofloxacin and Flagyl to complete 7 day course -
will complete on ___.
ACTIVE ISSUES:
==============
#Fever
Unclear source No obvious source of fevers on CT or by symptoms.
She recently had an admission for fever and was found to have
pericholecystic abscess s/p drain placement ___ntibiotics (discharged on augementin). She was treated
empirically on admission with vancomycin, ceftriaxone, and
metronidazole. She was continued on these broad-spectrum
antibiotic to 48 hours and narrowed to ciprofloxacin and Flagyl.
Perihepatic abscess drain had 0 drainage but she was inpatient
and was pulled by interventional radiology on ___ without
incident. No clear source of infection was identified and so she
was treated for presumed cholangitis. She did not have any
subsequent fever while on antibiotics. She will continue her
ciprofloxacin and Flagyl until ___.
# Stage IV Intrahepatic Cholangiocarcinoma
Currently on Gemcitabine/Cisplatin, due for chemotherapy on the
day of admission which was held ___ the setting of acute
infection. She will follow-up with Dr. ___ to resume
chemotherapy on discharge.
# Anemia ___ Malignancy
#Iron deficiency anemia
No iron supplementation while acutely infected. Anemia also
likely related to recent chemotherapy. Did not require
transfusions while inpatient
# Thrombocytopenia: Likely due to chemotherapy.Did not require
transfusions while inpatient
# Depression: Continue home escitalopram
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Bisacodyl ___ mg PO DAILY:PRN Constipation - Second Line
3. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
4. Escitalopram Oxalate 20 mg PO DAILY
5. LORazepam 0.5 mg PO Q6H:PRN nausea/vomiting/anxiety/insomnia
6. MethylPHENIDATE (Ritalin) 5 mg PO DAILY
7. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
8. Multivitamins W/minerals Chewable 1 TAB PO DAILY
9. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
10. Prochlorperazine ___ mg PO Q6H:PRN Nausea/Vomiting - Second
Line
11. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO BID Duration: 9 Doses
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*9 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*14 Tablet Refills:*0
3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
4. Bisacodyl ___ mg PO DAILY:PRN Constipation - Second Line
5. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
6. Escitalopram Oxalate 20 mg PO DAILY
7. LORazepam 0.5 mg PO Q6H:PRN nausea/vomiting/anxiety/insomnia
8. MethylPHENIDATE (Ritalin) 5 mg PO DAILY
9. Multivitamins W/minerals Chewable 1 TAB PO DAILY
10. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
12. Prochlorperazine ___ mg PO Q6H:PRN Nausea/Vomiting -
Second Line
13. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Disposition:
Home
Discharge Diagnosis:
Fever
Cholangitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I ___ THE HOSPITAL?
- You were admitted for fevers/chills
WHAT HAPPENED TO ME ___ THE HOSPITAL?
-___ the hospital we got some blood tests and imaging of your
abdomen to look for the cause of your fevers. There was no clear
cause of your fevers, but given your recent infection we treated
you with antibiotics. With antibiotics your fever improved and
we discharged you home on antibiotics.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Your antibiotics will finish on ___
- Please call Dr ___ tomorrow to schedule an
appointment for next week
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10235340-DS-6 | 10,235,340 | 21,675,365 | DS | 6 | 2126-07-20 00:00:00 | 2126-07-20 20:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right buttock pain
Major Surgical or Invasive Procedure:
___ ___ Embombolization
History of Present Illness:
This patient is a ___ year old male who complains of R BUTTOCK
PAIN. Report is from patient and his mother who is also a
___. He had a skiing accident 3 days ago where he fell
injuring his right buttocks on a rock. He was
seen in an outside hospital ER - and apparently had a "seizure".
Apparently while sitting in a wheelchair, he became lightheaded
and diaphoretic and had 20 seconds of shaking. His workup at
that time included a head CT which
per report was normal and a pelvic x-ray. He was seen by a
surgeon who told him he had a gluteal hematoma. He was
discharged home was taking ibuprofen but last night developed
worsening right gluteal pain extending into his right popliteal
area.
Past Medical History:
Discectomy, asthma
Social History:
___
Family History:
Mother and sister both have prolonged bleeding time and tend to
bleed easily
Physical Exam:
Physical Exam upon admission:
Temp: 98.1 HR: 115 BP: 139/71 Resp: 20 O(2)Sat: 100 Normal
Constitutional: Uncomfortable
HEENT: Normocephalic, atraumatic
Chest: Clear to auscultation
Cardiovascular: Tachycardic, regular, 2+ DP pulses
bilaterally
Abdominal: Soft, Nontender, Nondistended
GU/Flank: No costovertebral angle tenderness
Extr/Back: Tense right gluteal hematoma, rigth lreg FROM
Skin: Warm and dry
Neuro: Speech fluent
Psych: Normal mentation
___: No petechiae
Physical Examination upon discharge:
VS: 98.4, 70, 135/52, 98/RA
Gen: NAD, lying in bed.
Heent: EOMI, MMM.
Cardiac: Normal S1, S2. RRR
Pulm: Lungs CTAB. No W/R/R/
Abd: Soft/nontender/nodistended.
Ext: + pedal pulses. No CCE. L groin no hematoma.
Neuro: AAOx4, normal mentation.
Pertinent Results:
___ 05:49AM BLOOD WBC-9.7 RBC-3.60* Hgb-11.0* Hct-32.6*
MCV-91 MCH-30.7 MCHC-33.9 RDW-13.3 Plt ___
___ 08:45AM BLOOD WBC-10.4 RBC-4.08* Hgb-12.5* Hct-37.4*
MCV-92 MCH-30.7 MCHC-33.5 RDW-13.0 Plt ___
___ 08:45AM BLOOD Neuts-62.2 ___ Monos-5.5 Eos-6.4*
Baso-0.7
___ 08:45AM BLOOD Glucose-98 UreaN-20 Creat-0.9 Na-137
K-4.4 Cl-100 HCO3-27 AnGap-14
___ CTA PELVIS W&W/O C & RE
IMPRESSION:
1. Small focus of active extravasation in the right gluteus
maximus muscle, likely originating from a branch of the inferior
gluteal artery.
2. Hematoma involving the right gluteal musculature and right
piriformis.
3. No evidence of fracture.
___ ILIAC
IMPRESSION: Technically difficult embolization of a
pseudoaneurysm versus
Preliminary Reportlocalized extravasation from the right
inferior gluteal artery.
Brief Hospital Course:
This patient was admitted to ___ for right buttock pain. He
was admitted to the Acute Care service after Cat Scan imaging
revealed that he had extravasation of his gluteal artery. on
___, he was taken to interventional radiology for
embolization and coiling of his gluteal artery. The patient
tolerated the procedure well. He did receive intraenous
hydration after his ___ procedure to clear the contrast that was
given. On the day of discharge, the patient's hematrocrit was
stable at 32.6. His left groin did not show evidence of bleeding
or hematoma. He was tolerating a regular diet. He was off bed
rest and ambulating around his room independently. The patient
was experiencing pain upon ambulating which he described as
intense and coming on suddenly, so a hematatocrit to rule out
bleeding, and it was 33.7. The patient was given an oral pain
regimen and was made aware that he may experience pain around
his R buttock hematoma for a few more days. The patient's vital
signs were stable and he was afebrile. He was given instructions
to follow up at his scheduled appointments in the ___ and
with his PCP ___ 2 weeks from discharge.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q4H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Right inferior gluteal artery extravasation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the ___ after having experienced injury
to your right gluteal artery. While you were here, you were
taken to interventional radiology for embolization and coiling
of your bleed. On the day of discharge, your hematocrit was
stable and your pain was well controlled. You will followup with
your PCP as well as ___ in ___ weeks.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing, tightness
or dizziness.
*New or worsening cough, shortness of breath, or wheeze.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
10235783-DS-7 | 10,235,783 | 29,844,433 | DS | 7 | 2118-03-07 00:00:00 | 2118-03-07 16:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
adhesive tape
Attending: ___.
Chief Complaint:
LLE pain and ischemia
Major Surgical or Invasive Procedure:
Left above knee amputation
History of Present Illness:
___ year-old male who is s/p axillary bifemoral bypass graft w/
known occlusion of the right limb who was recently discharged to
rehab, who presents with dysphagia and hypotension - vascular
surgery is consulted for worsening
mottling of the RLE. The patient initially presented with
dysphagia - CT neck demonstrated laryngeal soft-tissue
thickening w/ concern for airway compromise. Chest x-ray was
concerning for aspiration pneumonia. ENT was consulted and the
patient was admitted to the MICU for further management.
In regards to his leg, the patient reports that he has had
worsening bilaterally lower extremity pain. He does not notice a
difference between the right and the leg.
Past Medical History:
PMH: DM, HTN, Remote hx. of gout
PSH: R Pop-AT bypass, R ___ toe partial amputation, Hernia x2,
___ external iliac stent and Left femoral/profunda
endarterectomy and left Fem-BK Pop bypass with PTFE,
___, unable to lyse clot, ___ of L
Fem-BK pop bypass with R cephalic vein graft, ___ toe
amp, open, ___ TMA
Social History:
___
Family History:
NC
Physical Exam:
DISCHARGE EXAM:
VS: 98.9 72 110/65 18 97% RA
Gen: AO x3, NAD
Lungs: CTAB
Heart: RRR,no JVD
Abdomen: Abd soft NT, ND
Ext: wounds well healing, no erythema or exudate, warm to touch,
Pulses R: P/D-graft/D/D L: D/AKA
Pertinent Results:
___ 06:55AM BLOOD WBC-11.2* RBC-2.48* Hgb-7.8* Hct-24.3*
MCV-98 MCH-31.5 MCHC-32.1 RDW-15.9* RDWSD-58.2* Plt ___
___ 06:55AM BLOOD Glucose-85 UreaN-12 Creat-0.8 Na-134
K-4.0 Cl-96 HCO3-25 AnGap-17
Brief Hospital Course:
Mr. ___ was admitted to ___ on ___ after another
episode of acute limb ischemia and onset of pain. He was
immediately placed on a heparin drip anticoagulation and had CTA
performed. Due to his extensive history of multiple angiographs,
bypasses, and angioplasties, the decision was made to perform an
AKA. Patient was amenable to plan and consent was obtained.
On ___ he underwent Left above knee amputation. Please refer
to dictated operative report for full details. He tolerated the
procedure well and after an uneventful PACU stay was transferred
to the floor on a diet, Foley in place, pain control with PCA.
On POD #1 he was transitioned to an oral pain medication regimen
and his home meds were restarted. His IV fluids were
discontinued on POD #2.
On POD #4, the patient presented abdominal distention and was
not passing flatus. KUB showed ileus, but also a 10 cm cecum. CT
abdomen and pelvis showed no evidence of cecal volvulus and
dilated small bowel loops measuring up to 4.2 cm without a
discrete transition point, consistent with ileus. He also
developed acute kidney injury with Cr 2.4 and FeNa 0.2%. He was
made NPO with IVF, an NGT and Foley was placed. On POD #6, he
had return of bowel function, his NGT was removed and his diet
was advanced. His renal injury resolved (Cr 1.1).
By day of discharge, POD #8, Mr. ___ was tolerating a
regular diet, voiding without assistance, and pain was
controlled. He expressed his willingness to be discharged to
Rehabilitation and appropriate discharge instructions were
provided.
INCIDENTAL FINDINGS:
- Adrenal adenomas noted on CT abdomen ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Aspirin 81 mg PO DAILY
4. Lisinopril 20 mg PO BID
5. Gabapentin 300 mg PO DAILY
6. Clopidogrel 75 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
9. Senna 8.6 mg PO BID:PRN Constipation
Discharge Medications:
1. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth Every ___ hours Disp
#*30 Tablet Refills:*0
2. Acetaminophen 1000 mg PO Q8H
3. amLODIPine 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 20 mg PO QPM
6. Clopidogrel 75 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Gabapentin 300 mg PO TID
9. Lisinopril 20 mg PO BID
10. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left lower limb ischemia
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:
It was a pleasure taking care of you at ___
___. During your hospitalization, you had surgery to
remove unhealthy tissue on your lower extremity. You tolerated
the procedure well and are now ready to be discharged from the
hospital. Please follow the recommendations below to ensure a
speedy and uneventful recovery.
LOWER EXTREMITY AMPUTATION
DISCHARGE INSTRUCTIONS
ACTIVITY
You should keep your amputation site elevated and straight
whenever possible. This will prevent swelling of the stump.
It is very important that you put no weight or pressure on
your stump with activity or at rest to allow the wound to heal
properly.
You may use the opposite foot for transfers and pivots, if
applicable. It will take time to learn to use a walker and
learn to transfer into and out of a wheelchair.
MEDICATION
Before you leave the hospital, you will be given a list of all
the medicine you should take at home. If a medication that you
normally take is not on the list or a medication that you do not
take is on the list please discuss it with the team!
You will likely be prescribed narcotic pain medication on
discharge which can be very constipating. If you take narcotics,
please also take a stool softener such as Colace. If
constipation becomes a problem, your pharmacist can suggest an
additional over the counter laxative.
You should take Tylenol ___ every 6 hours, as needed for
pain. If this is not enough, take your prescription narcotic
pain medication. You should require less pain medication each
day. Do not take more than a daily total of 3000mg of Tylenol.
Tylenol is used as an ingredient in some other over-the-counter
and prescription medications. Be aware of how much Tylenol you
are taking in a day.
BATHING/SHOWERING:
You may shower when you feel strong enough but no tub baths or
pools until you have permission from your surgeon and the
incision is fully healed.
After your shower, gently dry the incision well. Do not rub
the area.
WOUND CARE:
Please keep the wound clean and dry. It is very important that
there is no pressure on the stump. If there is no drainage, you
may leave the incision open to air.
Your staples/sutures will remain in for at least 4 weeks. At
your followup appointment, we will see if the incision has
healed enough to remove the staples.
Before you can be fitted for prosthesis (a man-made limb to
replace the limb that was removed) your incision needs to be
fully healed.
CALL THE OFFICE FOR: ___
Opening, bleeding or drainage or odor from your stump incision
Redness, swelling or warmth in your stump.
Fever greater than 101 degrees, chills, or worsening
incisional/stump pain
NO OTHER PROVIDER, EXCEPT YOUR VASCULAR SURGEON, SHOULD
DETERMINE IF YOUR STAPLES ARE READY TO BE REMOVED FROM YOUR
STUMP!
IF THERE ARE ANY QUESTIONS, THE PROVIDER SHOULD CALL THE
VASCULAR SURGERY OFFICE AT ___ TO DISCUSS. THE
STAPLES WILL BE REMOVED IN THE OFFICE AT YOUR FOLLOWUP
APPOINTMENT WHEN IT IS DETERMINED BY THE VASCULAR SURGEON THAT
THE WOUND HAS SUFFICIENTLY HEALED.
Followup Instructions:
___
|
10235789-DS-11 | 10,235,789 | 26,541,935 | DS | 11 | 2140-04-15 00:00:00 | 2140-04-15 16:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ y/o M with history of dementia, NPH, and
seizures presents s/p witnessed fall at ___ by CNA.
Patient is nonverbal at baseline so history is obtained from
records.
Per report, the CNA stated that she was giving the patient
assistance with ADLs when he fell from the edge of his bed and
hit his head. There was no loss of consciousness, but he did
sustain a laceration on his L forehead. They presented to
___ where his head laceration was sutured and a
head CT was performed which showed an acute on chronic SDH.
Patient was transferred to ___ for further evaluation. He was
evaluated by neurosurgery and it was determined that no surgical
intervention was warranted.
He was admitted to the neurosurgical floor and on ___ triggered
for desaturation to the ___ temporarily requiring 100% face mask
(now on 3L NC). CXR at the time showed diffuse opacifications
in L lung field (aspiration vs. PNA vs atelectasis). Pt was
started on levofloxacin IV Bedside swallow evaluation was
conducted and it was recommended that patient remain NPO until
goals of care are discussed.
Past Medical History:
Dementia, constipation, BPH, arthritis, psoriasis, depression,
aspiration pneumonia, esophageal reflux, seizures, NPH, GI
bleed,
appendectomy, tonsillectomy
Social History:
___
Family History:
___
Physical Exam:
ADMISSION:
==========
Vitals- 98.4, 78, 128/88, 18, 94% 3LNC
General- minimally responsive, opens eyes to voice, nonverbal
HEENT- Sclera anicteric, MMM
Neck- supple
Lungs- diffuse rhonchi throughout with copious secretions
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE:
==========
Vitals- 98.3, 97.8, 58-86, 110-151/66-87, 18, 96%2LNC
General- minimally responsive, opens eyes to voice, nonverbal
HEENT- Sclera anicteric, MMM
Neck- supple
Lungs- diffuse rhonchi throughout with secretions improved from
yesterday
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION:
==========
___ 05:19PM COMMENTS-GREEN TOP
___ 05:19PM LACTATE-2.6*
___ 02:08PM LACTATE-3.3*
___ 02:00PM GLUCOSE-118* UREA N-11 CREAT-0.9 SODIUM-139
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-26 ANION GAP-16
___ 02:00PM estGFR-Using this
___ 02:00PM URINE HOURS-RANDOM
___ 02:00PM URINE HOURS-RANDOM
___ 02:00PM URINE UHOLD-HOLD
___ 02:00PM URINE GR HOLD-HOLD
___ 02:00PM WBC-10.2 RBC-4.98 HGB-15.2 HCT-47.5 MCV-95
MCH-30.5 MCHC-32.1 RDW-13.1
___ 02:00PM NEUTS-84.2* LYMPHS-9.5* MONOS-4.7 EOS-0.5
BASOS-1.1
___ 02:00PM PLT COUNT-368
___ 02:00PM ___ PTT-33.7 ___
___ 02:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
DISCHARGE:
==========
___ 07:45AM BLOOD WBC-6.3 RBC-4.10* Hgb-12.7* Hct-38.2*
MCV-93 MCH-31.1 MCHC-33.3 RDW-12.8 Plt ___
___ 07:45AM BLOOD Glucose-109* UreaN-8 Creat-0.8 Na-141
K-3.5 Cl-106 HCO3-27 AnGap-12
___ 07:45AM BLOOD Calcium-8.5 Phos-2.5* Mg-2.1
IMAGING:
========
___ CT C-SPINE
IMPRESSION:
1. No acute fracture or malalignment.
2. Subdural hematoma along the posterior falx and left
tentorium. Low
density subdural collections overlying the temporal lobes.
3. Right right temporal subarachnoid hemorrhage, similar to
prior.
4. Dependent debris in the trachea with findings suggestive
aspiration right upper lobe.
___ CXR:
IMPRESSION: AP chest compared to ___, 2:34 p.m.:
New opacification at the lung bases is probably atelectasis,
left more severe than right. Upper lungs grossly clear. No
pneumothorax or pleural effusion. Heart size is normal.
___ CXR:
FINDINGS: As compared to the previous radiograph, no relevant
change is seen. Left-sided lung parenchymal opacity with air
bronchograms, suggestive of asymmetric pulmonary edema or
aspiration. The atelectasis in the retrocardiac lung regions is
slightly more severe than on the previous image. Unchanged
appearance of the cardiac silhouette. Unchanged right lung.
Brief Hospital Course:
Mr. ___ is a ___ y/o M with history of dementia, NPH, and
seizures presents s/p witnessed fall at ___ by CNA
resulting in SDH, not an operative candidate. Course complicated
by aspiration event, now being transferred to medicine for
___/Palliative care consult.
# Subdural hemorrhage: Per neurosurgery not an operative
candidate. Neurological status was monitored and remained
stable.
# Aspiration: Patient at high aspiration risk likely ___ altered
neurological function after SDH. Requires frequent deep
suctioning. He was started on IV levofloxacin and was kept
strict NPO. He was started on a scopolamine patch on ___ to
reduce secretions. Goals of care discussions were had with wife
and his poor prognosis was conveyed. He was made DNR/DNI and
wife wishes to transition to hospice. Speech and swallow
re-evaluated the patient on the day of discharge and determined
that strict NPO was the safest diet. A thorough discussion was
had with his wife about the possibility of comfort feeding
acknowledging the risk of aspiration. We will leave this to the
wife's discretion. We also will leave medication transitions to
the discretion of hospice in terms of transitioning to gel,
sublingual or topical anti-epileptics, pain medications etc.
# Leukocytosis: WBC elevated following aspiration event, likely
aspiration pneumonitis vs. pneumonia. Trended down with time.
TRANSITIONAL ISSUES:
-transition to hospice at ___
-foley will need to be discontinued at hospice, was placed at
outside hospital
-medications that require PO administration will need to be
crushed in applesauce if patient is receiving comfort feedings
or given via an alternative route per hospice practice
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 325 mg PO Q6H:PRN pain
2. Bisacodyl 10 mg PR HS:PRN constipation
3. Docusate Sodium (Liquid) 100 mg PO BID
4. LaMOTrigine Dose is Unknown PO Frequency is Unknown
5. Omeprazole 20 mg PO DAILY
6. senna 8.8 mg/5 mL oral daily
Discharge Medications:
1. Scopolamine Patch 1 PTCH TD ONCE Duration: 72 Hours
2. Bisacodyl 10 mg PR HS:PRN constipation
3. Acetaminophen 325 mg PO Q6H:PRN pain
4. Docusate Sodium (Liquid) 100 mg PO BID
5. LaMOTrigine 25 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. senna 8.8 mg/5 mL oral daily
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary diagnosis: Subdural hemorrhage
Secondary diagnoses: Dementia, constipation, BPH, arthritis,
psoriasis, depression, aspiration pneumonia, esophageal reflux,
seizures, NPH, GI bleed, appendectomy, tonsillectomy
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your hospitalization
at ___. You were admitted after a fall and had bleeding in
your head. You had trouble managing your secretions and our
concern was that you were breathing in secretions. You were
started on a medication to dry up the secretions. You were given
antibiotics and were discharged back to ___' home.
Followup Instructions:
___
|
10235983-DS-8 | 10,235,983 | 27,440,850 | DS | 8 | 2146-02-21 00:00:00 | 2146-02-21 20:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
shellfish derived
Attending: ___.
Chief Complaint:
abscess in neck
Major Surgical or Invasive Procedure:
Bedside drainage (needle) of left neck abscess ___
History of Present Illness:
Ms. ___ is a ___ female with active IVDU, chronic
Hepatitis C (untreated) presenting as a transfer from
___
for ENT evaluation of neck abscess following cocaine injection.
She injected cocaine into her neck on ___ and subsequently
developed pain, redness, and swelling at the injection site. She
initially went to ___ on ___ with plan for transfer to
___ but the patient left AMA. She then returned to
___ the next day with worsening pain with some radiation
into her arm. She was given doxycycline/cefazolin and
subsequently transferred for ENT evaluation.
Upon arrival to the ___, patient afebrile with stable vitals
and no concern for airway compromise. Endorsing ___ pain. Labs
notable for no leukocytosis and mild anemia. No new imaging
given
CT neck at ___, which demonstrated a masslike abnormality
at
the left supraclavicular region containing a more discrete
nodular area measuring 1.4 x 1.2 x 0.7 cm which is suspicious
for
a small abscess. ENT consulted with plan for surgical drainage.
Patient given Vancomycin but developed some itching. She was
given Benadryl with plan to resume at half rate. VSS on
transfer.
Upon arrival to the floor, patient is very pleasant and recounts
the above history. She reports feeling subjectively febrile the
night of injection but otherwise hasn't had any fevers or
chills.
Denies HA, shortness of breath, abdominal pain. She does endorse
exertional fatigue and diffuse body aches, which she attributes
to withdrawing from her ___. She denies difficulty
speaking,
swallowing, or breathing. Overall, she feels that the lump in
her
neck is smaller than it was initially.
In regards to her past psychiatric history, she states that she
has been diagnosed with BPD that is depression predominant. She
has not had any mania episodes in several years and denies
current racing thoughts or insomnia. She denies any SI or
thoughts of self harm and states that she was intoxicated when
attempting to inject cocain in her neck, trying to get high and
could not find a better vein.
Past Medical History:
IVDU (cocaine, last ___ heroin last ___
hx of EtOH abuse
History of HCV (untreated)
PTSD
Bipolar Disorder
Social History:
___
Family History:
Reviewed and found to be not relevant to this illness/reason for
hospitalization.
Physical Exam:
ADMISSION EXAM:
___ Temp: 97.9 PO BP: 105/62 HR: 78 RR: 18 O2 sat: 97%
O2 delivery: RA
GENERAL: very pleasant, somewhat impulsive young lady in NAD.
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate.
Neck: At the proximal left clavicle there is a 4cm nodular firm
lesion without significant warmth, erythema, or purulence. Not
particularly tender to the touch.
CV: regular rate with no murmur appreciated, no S3, no S4. No
JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored. No stridor or accessory
muscle use.
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. 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. No concerning tenderness
with palpation along the vertebrates.
SKIN: Scattered healing pustular skin lesions, some with
excoriations on the forearms bilaterally. No obvious splinter
hemorrhages ___ lesions.
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout.
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM:
Vitals: T 99.2 BP 137/90 HR 100 RR 18 O2 sat 98% on room air
GENERAL: initially very pleasant, somewhat impulsive young lady
in NAD. Later when interviewed was anxious, crying, upset
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate.
Neck: Left neck base covered with pressure dressing
CV: regular rate with no murmur appreciated, no S3, no S4. No
JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored. No stridor or accessory
muscle use.
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. 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. No concerning tenderness
with palpation along the vertebrates.
SKIN: Scattered healing pustular skin lesions, some with
excoriations on the forearms bilaterally. No obvious splinter
hemorrhages ___ lesions.
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI, speech fluent, moves all limbs, sensation to light touch
grossly intact throughout.
PSYCH: pleasant, appropriate affect, impaired judgement and
insight
Pertinent Results:
LABS:
___ 11:43AM BLOOD WBC-4.6 RBC-1.96* Hgb-5.5* Hct-19.1*
MCV-97 MCH-28.1 MCHC-28.8* RDW-16.3* RDWSD-57.3* Plt ___
___ 11:43AM BLOOD Neuts-61.5 ___ Monos-8.9 Eos-0.9*
Baso-0.4 Im ___ AbsNeut-2.83 AbsLymp-1.27 AbsMono-0.41
AbsEos-0.04 AbsBaso-0.02
___ 11:43AM BLOOD Glucose-72 UreaN-13 Creat-0.7 Na-155*
K-3.6 Cl-114* HCO3-17* AnGap-24*
___ 05:28AM BLOOD HIV Ab-NEG
___ 05:28AM BLOOD Mg-2.2
___ 05:28AM BLOOD ___ PTT-32.3 ___
IMAGING:
___ CT Neck w/ Contrast:
1. 2.0 cm abscess in the left supraclavicular region, involving
the lateral
sternocleidomastoid muscle. Additional 0.5 cm abscess within
the right
sternocleidomastoid muscle.
2. Numerous prominent bilateral level 2 and 3 lymph nodes are
likely
reactive.
___ Chest X-ray:
Final Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with shortness of breath, neck
abscess// rule
out septic emboli, any other lung process
IMPRESSION:
No previous images. Cardiac silhouette is within normal limits
and there is
no vascular congestion, pleural effusion, or acute focal
pneumonia.
MICRO:
___ Blood cultures x2 NGTD (pending)
Brief Hospital Course:
In brief, Ms. ___ is a ___ female with history of
polysubstance abuse (tobacco, IVDU, heavy ETOH use), bipolar
disorder and chronic hepatitis C who was admitted as transfer
from ___ for neck abscess iso IV drug use relapse into
neck, which was drained at bedside by ENT and she was given
antibiotics. Initially started on empiric IV vancomycin. Blood
cultures negative to date at time of discharge. Unfortunately no
sample sent from initial drainage of abscess at bedside. There
had been plan to re-send culture later that day by ENT, however
patient left prior to this happening therefore there is no data
from abscess to go off of. She was discharged with empiric
course of oral Bactrim (1 tab DS BID) to complete over next ___
days, and she was provided instructions for local wound care and
pressure dressing.
She will need close outpatient ___ with her PCP, ___
provider, and counselor/therapist.
She was provided prescriptions for nicotine replacement products
to help with smoking cessation.
Patient ultimately left against medical advice after multiple
discussions. She expressed understanding of risks of doing so.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Buprenorphine-Naloxone Tablet (8mg-2mg) 2 TAB SL DAILY
Discharge Medications:
1. Nicotine Patch 21 mg/day TD DAILY
RX *nicotine 21 mg/24 hour 1 patch transdermal once a day Disp
#*30 Patch Refills:*1
2. Nicotine Polacrilex 2 mg PO Q1H:PRN nicotine craving
RX *nicotine (polacrilex) 2 mg use one gum every one hour Disp
#*30 Gum Refills:*1
3. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 10 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*20 Tablet Refills:*0
4. Buprenorphine-Naloxone Tablet (8mg-2mg) 2 TAB SL DAILY
Please take ___ dose on ___, resume usual home dose on 79.
Discharge Disposition:
Home
Discharge Diagnosis:
Neck abscess
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 an infected collection on
your neck. This was drained and you were given antibiotics.
Instructions for care of your neck:
1. Please cover in thick/folded piece of gauze and cover tightly
with tape. Change daily or if oozing. Continue this for 7 days.
2. Please take the ENTIRE COURSE OF PRESCRIBED ANTIBITOICS.
3. If you have increased pain, redness, drainage, trouble
swallowing or breathing, or fevers/chills, IMMEDIATELY CALL ___
TO TAKE YOU TO CLOSEST EMERGENCY ROOM
4. ___ - may take ___ dose today, resume your usual full
home dose on ___
Followup Instructions:
___
|
10236009-DS-10 | 10,236,009 | 24,567,058 | DS | 10 | 2136-05-14 00:00:00 | 2136-05-14 17:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
shellfish derived / peanut / lisinopril
Attending: ___.
Chief Complaint:
Abdominal Pain, nausea, vomiting
Major Surgical or Invasive Procedure:
___ Line Placement ___, removed ___
History of Present Illness:
This is a ___ gentleman with past medical history of
insulin-dependent type 1 diabetes who usually gets his care at
___ who presented to the ___ ED with a 4-day history of
generalized abdominal pain, nausea, vomiting. Patient reports
that he ran out of his insulin approximately 7 days ago and was
unable to obtain refills. Subsequently, he started developing
polydipsia, polyuria, dysuria, and progressively worsening
crampy
abdominal pain. He describes the pain as nonradiating but is
associated with nausea and intermittent nonbloody, nonbilious
emesis. Denies fevers, chills, chest pain, palpitations,
neurologic symptoms. Denies any new medications, history of
gallbladder disease.
Patient is not sure of other medical problems, although takes
furosemide and metoprolol for his heart. Reports taking 15U
lantus every morning, does not take mealtime boluses or sliding
scale. Checks his FSBG approximately 2x/week. Unable to remember
name of his PCP.
In the ED,
Initial Vitals:
97.4, ___, 19, 100% RA
Exam:
General: uncomfortable, in pain, able to answer questions
Abd: soft, non distended, tender throughout abdomen, no rebound
or guarding
Labs:
12.5 > 13.8/43.3 < ___ AGap=44
------------<630
5.0 2 1.6
ALT: 60 AP: 110 Tbili: 0.8 Alb: 4.3
AST: 65 Lip: 742
Beta-OH:12.6
VBGs
___
Lactate:3.7
Interventions:
2L NS
Insulin drip at 6 units/hour
IV Zofran 4 mg
IV hydromorphone 0.5 mg
IV Thiamine or placebo Study Med 200 mg
VS Prior to Transfer:
97.7, ___, 20, 98% RA
Past Medical History:
Diabetes mellitus type 1
Hyperlipidemia
H/o HFrEF
Hypertension
Social History:
___
Family History:
Sister - DM
Mother - HTN
Maternal Aunts - HTN
Physical ___:
ADMISSION PHYSICAL EXAM
=======================
VS: 98, 167/108, 108, 18, 100% RA
GEN: appears much older than stated age
HEENT: poor dentition, dry MM
CV: tachycardic, no M/R/G
RESP: CTAB
GI: soft, ND, TTP diffusely without rebound or guarding
EXT: dry, no ___ edema
NEURO: AAOx3, no gross focal deficits
PSYCH: flat affect
DISCHARGE PHYSICAL EXAM
=======================
24 HR Data (last updated ___ @ 614)
Temp: 97.5 (Tm 98.4), BP: 112/80 (112-166/80-101), HR: 95
(75-97), RR: 18 (___), O2 sat: 99% (99-100), O2 delivery: Ra
GENERAL: Alert, interactive, NAD.
HEENT: NC/AT. PERRLA. Sclera anicteric w/o injection. MMM.
Oropharynx clear.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: NR, RR. Normal S1 + S2. No m/r/g.
LUNGS: CTAB bilaterally, no wheezes, rales, or rhonchi. Normal
WOB on RA.
ABDOMEN: Soft, non-distended, non-tender. +BS.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash or bruising.
NEUROLOGIC: A&Ox3. Strength grossly normal throughout.
Pertinent Results:
ADMISSION LABS
==============
___ 09:35PM BLOOD WBC-12.5* RBC-4.28* Hgb-13.8 Hct-43.3
MCV-101* MCH-32.2* MCHC-31.9* RDW-12.9 RDWSD-47.8* Plt ___
___ 09:35PM BLOOD Neuts-81.7* Lymphs-10.0* Monos-6.9
Eos-0.1* Baso-0.7 Im ___ AbsNeut-10.23* AbsLymp-1.25
AbsMono-0.86* AbsEos-0.01* AbsBaso-0.09*
___ 12:34AM BLOOD ___
___ 09:35PM BLOOD Glucose-630* UreaN-26* Creat-1.6* Na-133*
K-5.0 Cl-87* HCO3-2* AnGap-44*
___ 09:35PM BLOOD ALT-60* AST-65* AlkPhos-110 TotBili-0.8
___ 09:35PM BLOOD Lipase-742*
___ 09:55AM BLOOD CK-MB-12* MB Indx-11.9* cTropnT-<0.01
___ 09:35PM BLOOD Albumin-4.3
___ 09:35PM BLOOD Beta-OH-12.6*
___ 09:43PM BLOOD ___ pO2-144* pCO2-10* pH-7.17*
calTCO2-4* Base XS--22 Intubat-NOT INTUBA
___ 09:43PM BLOOD Lactate-3.7*
DISCHARGE LABS
==============
___ 06:09AM BLOOD WBC-10.4* RBC-3.16* Hgb-10.3* Hct-30.5*
MCV-97 MCH-32.6* MCHC-33.8 RDW-13.2 RDWSD-46.7* Plt ___
___ 06:09AM BLOOD ___ PTT-30.3 ___
___ 06:09AM BLOOD Glucose-151* UreaN-15 Creat-0.7 Na-138
K-4.5 Cl-103 HCO3-23 AnGap-12
___ 06:09AM BLOOD ALT-78* AST-91* LD(LDH)-213 AlkPhos-122
TotBili-0.7
___ 06:09AM BLOOD Calcium-9.0 Phos-3.9 Mg-1.9
OTHER KEY LABS
==============
___ 04:59AM BLOOD ___ 09:55AM BLOOD CK(CPK)-101
___ 09:55AM BLOOD CK-MB-12* MB Indx-11.9* cTropnT-<0.01
___ 04:20PM BLOOD CK-MB-14* cTropnT-<0.01
___ 05:12AM BLOOD VitB12-1435* Folate-10
___ 05:32AM BLOOD %HbA1c-13.4* eAG-338*
___ 12:20AM BLOOD Triglyc-486*
___ 09:55AM BLOOD Ethanol-NEG
___ 05:32AM BLOOD ASA-NEG Acetmnp-NEG Tricycl-NEG
MICRO
=====
___ 12:05 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
BLOOD CULTURES ___ - No Growth
STUDIES
=======
CXR ___
No comparison. Moderate scoliosis with subsequent asymmetry of
the ribcage. The lung volumes are normal. Normal size of the
cardiac silhouette. Normal hilar and mediastinal contours. No
pneumonia, no pulmonary edema, no pleural effusions, no
pneumothorax.
Abdomen US ___
Echogenic liver consistent with steatosis. Other forms of liver
disease and more advanced liver disease including
steatohepatitis or significant hepatic fibrosis/cirrhosis cannot
be excluded on this study.
ECG ___:
Normal sinus rhythm
ST & T wave abnormality, consider inferior ischemia
ST & T wave abnormality, consider anterolateral ischemia
Prolonged QT interval
Abnormal ECG
ECG ___:
ectopic atrial rhythm
Incomplete left bundle branch block
ST & T wave abnormality, consider inferior ischemia
ST & T wave abnormality, consider anterolateral ischemia
Prolonged QT interval
Abnormal ECG
When compared with ECG of ___ 09:27,
Ectopic atrial rhythm has replaced Sinus rhythm
TTE ___
The left atrial volume index is normal. The estimated right
atrial pressure is ___ mmHg. There is mild symmetric left
ventricular hypertrophy with a normal cavity size. There is
normal regional and global left ventricular systolic function.
Left ventricular cardiac index is normal (>2.5 L/min/m2). There
is no resting left ventricular outflow tract gradient. Tissue
Doppler suggests a normal left ventricular filling pressure
(PCWP less than 12mmHg). Normal right ventricular cavity size
with normal free wall motion. Tricuspid annular plane systolic
excursion (TAPSE) is normal. The aortic sinus diameter is normal
for gender with normal ascending aorta diameter for gender. The
aortic arch diameter is normal with a normal descending aorta
diameter. There is no evidence for an aortic arch coarctation.
The aortic valve leaflets (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 mild [1+] 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: Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/ global biventricular systolic
function. Mild mitral regurgitation. Normal pulmonary artery
systolic pressure.
___ ECG:
Normal sinus rhythm
T wave abnormality, consider inferolateral ischemia versus
repolarization change in the setting of LVH
Abnormal ECG
When compared with ECG of ___ 16:18,
Sinus rhythm has replaced Ectopic atrial rhythm
QT has shortened
Brief Hospital Course:
Mr. ___ is a ___ M w/ hx of HLD, past alcohol use disorder,
past pancreatitis, poorly controlled insulin-dependent T1DM who
presented w/ abdominal pain, nausea, and nonbloody-nonbilious
emesis found to be in DKA I/s/o not taking his insulin for 7
days, requiring admission to medical ICU. Course was also
complicated by elevated lipase and epigastric pain concerning
for acute pancreatitis, abnormal ECG and elevated CK-MB
concerning for possible type II NSTEMI. He was managed with
aggressive fluid repletion, insulin drip, and analgesics with
resolution of DKA, then ultimately transferred to the floor for
further titration of insulin regimen prior to discharge. Patient
was noted to have significant insulin requirement requiring
escalation of insulin dosing, but had FSBG stable mostly in
150s-200s at time of discharge. Discharged with plan for very
close follow-up.
TRANSITIONAL ISSUES:
==================
[] Normocytic anemia of unclear etiology. Repeat CBC once fully
recovered from acute illness, consider iron labs.
[] RUQUS showing hepatic steatosis. Consider fibroscan and
repeat LFTs/platelets/coags given concern for liver disease in
patient w significant EtOH history.
[] Developed abnormal ECG w/ T-wave inversions and ST segment
changes, slightly elevated CK-MB initially concerning for type
II NSTEMI though likely just related to severe metabolic
derangements. Repeat ECG outpatient and can consider stress
test.
[] Will need close monitoring, frequent education re: insulin
dosing and adherence.
ACUTE/ACTIVE ISSUES:
====================
# Insulin-dependent T1DM w/ poor control (A1C 13.4%)
# DKA
Patient is an insulin-dependent type 1 diabetic who ran out of
medications approximately 7 days prior to arrival and then
developed diffuse abdominal pain, nausea, and emesis found to
be in DKA. At baseline he reported only checking his FSBG
2x/week and taking only his long-acting insulin, but was not
using mealtime boluses or sliding scale. He was placed on
insulin drip and managed in the ICU with resolution of anion gap
after several days, then transferred to the medical floor for
further care. ___ was consulted for insulin
management and patient required uptitration of insulin doses,
ultimately discharged with FSBG in 150s-200s. He also met with a
diabetes nurse educator and social worker and by the time of
discharge expressed good understanding of his diabetes
management.
# Elevated lipase, epigastric pain
Patient has history of acute pancreatitis related to EtOH use,
however reports significant reduction in drinking for past
month. Lipase 700s on admission w/ epigastric pain,
triglycerides mildly elevated to 400s. Abdominal U/S did not
detect abnormalities of pancreas. Unclear if this was true acute
pancreatitis as pain and lipase could be explained by DKA alone,
vs. DKA leading to acute pancreatitis which can occur in ___
of cases. Regardless, patient was treated as acute pancreatitis
in ICU w/ aggressive fluid repletion and pain management. He had
good resolution of abdominal pain and was able to tolerate a
full diet by the time he was transferred to the medical floor
with pain managed on Tylenol.
# Abnormal ECG w/ elevated CK-MB of uncertain significance
ECG on ___ showed diffuse T-wave inversions and ST
abnormalities, new from prior ECG at ___. CK-MB was elevated to
14, however trops were negative and patient denied CP or SOB.
Per cards curbside there was concern for Type 2 NSTEMI so
patient was put on ASA 81, atorva 80, heparin gtt for 48 hours,
home metop fractionated to 6.25mg q6h. TTE normal without wall
motion abnormalities and normal EF. Given that patient had
multiple metabolic derangements I/s/o severe DKA and CK-MB is a
nonspecific cardiac marker this was ultimately thought unlikely
to be NSTEMI so atorva was decreased to 20mg. Repeat ECG
improved though still w/ T inversions, difficult to interpret
I/s/o recovery from severe illness. Started on losartan 50mg
daily for cardiac prevention and statin dose reduced to 20mg
daily.
CHRONIC/STABLE ISSUES:
======================
# Thrombocytopenia
Platelets initially wnl in 200s, subsequently downtrended to low
100s, resolved to high 100s by discharge. Patient has steatosis
but no evidence of cirrhosis on RUQUS, however concerned for
liver function given history of significant EtOH abuse. No
evidence of bleeding.
# Normocytic anemia
Initial Hb 13.8 but subsequently downtrended to nadir of 10.1.
Likely partially ___ dilution following aggressive IVF repletion
in ICU, or could also be mixed microcytic/macrocytic though
folate normal and B12 >normal. No melena or other evidence of
gross GI bleeding.
# Hepatic steatosis
Noted on RUQUS. Also has mildly elevated LFTs and INR uptrending
throughout admission. This is difficult to interpret given acute
illness, but concerned for risk of underlying liver disease
especially given extensive EtOH history.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Furosemide 40 mg PO DAILY
3. Omeprazole 40 mg PO DAILY
4. Glargine 15 Units Breakfast
5. Losartan Potassium 100 mg PO DAILY
6. Naltrexone 50 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Atorvastatin 20 mg PO QPM
RX *atorvastatin 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. FreeStyle Lancets (lancets) 28 gauge miscellaneous QID
Duration: 1 Month
Please provide with 100 lancets
Test BG 4 times daily
4. FreeStyle Lite Meter (blood-glucose meter) 1 glucometer
miscellaneous ONCE
Test BG 4 time daily
5. FreeStyle Lite Strips (blood sugar diagnostic)
miscellaneous QID Duration: 1 Month
Test BG 4 times daily
Please provide with 100 strips
6. Glucagon Emergency Kit (human) (glucagon (human
recombinant)) 1 mg injection PRN
1 for emergency use
RX *glucagon (human recombinant) [Glucagon Emergency Kit
(human)] 1 mg 1 mg PRN Disp #*1 Vial Refills:*0
7. Insulin Syringe (insulin syringe-needle U-100) 0.5 mL 29
gauge x ___ miscellaneous QID
use to inject insulin 4
times daily
Please provide with 100
8. Ketone Urine Test (acetone (urine) test) miscellaneous
PRN
RX *acetone (urine) test [Ketone Urine Test] PRN Disp #*100
Strip Refills:*0
9. Glargine 40 Units Breakfast
Humalog 15 Units Breakfast
Humalog 15 Units Lunch
Humalog 15 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *blood sugar diagnostic [FreeStyle Test] Test BG 4 time
daily Test BG 4 time daily Disp #*100 Strip Refills:*0
RX *insulin glargine [Lantus U-100 Insulin] 100 unit/mL AS DIR
40 Units before BKFT Disp #*2 Vial Refills:*0
RX *blood-glucose meter [FreeStyle System Kit] Test BG 4 time
daily Test BG 4 time daily Disp #*1 Kit Refills:*0
RX *insulin lispro [Humalog U-100 Insulin] 100 unit/mL AS DIR
Upto 11 Units QID per sliding scale 15 Units before LNCH;Units
QID per sliding scale 15 Units before DINR;Units QID per sliding
scale Disp #*2 Vial Refills:*0
RX *lancets [FreeStyle Lancets] 28 gauge Test BG 4 times daily
Disp #*100 Each Refills:*0
RX *insulin syringe-needle U-100 31 gauge X ___ use to inject
insulin 4 times daily Disp #*100 Syringe Refills:*0
10. Losartan Potassium 50 mg PO DAILY
RX *losartan 50 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Naltrexone 50 mg PO DAILY
13. Omeprazole 40 mg PO DAILY
14. HELD- Furosemide 40 mg PO DAILY This medication was held.
Do not restart Furosemide until told to by your primary care
doctor
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
Diabetic ketoacidosis
Acute pancreatitis
Abnormal ECG w/ elevated CK-MB of uncertain significance
Type 1 diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
- You came to the hospital because you were having abdominal
pain and nausea. You were experiencing diabetic ketoacidosis
caused by not taking insulin. You were also found to have
inflammation in your pancreas called pancreatitis.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
- You received insulin to lower your blood sugar. You also got
pain medication to help with your abdominal pain. You were in
the intensive care unit for several days.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Please continue to take all your medications and follow up
with your doctors at your ___ appointments.
- It is VERY important that you check your blood sugar four
times per day (breakfast, lunch, dinner, and before bed), and
take all of your insulin:
- 40 Units of Lantus (long-acting insulin) every morning
- 15 Units of Humalog (short-acting insulin) with every meal
- If your blood sugar is >400 at lunch time, take an
additional 10 units of Lantus
- Insulin sliding scale every time you check your blood
sugar: Give an ADDITIONAL 3 units of Humalog for blood sugar
between 200-240; 5 units for sugar 240-280; 7 units for sugar
280-320; 9 units for sugar 320-360; 11 units for sugar 360-400;
13 units for sugar >400
- Please return to the hospital if your abdominal pain gets much
worse or you experience more nausea, vomiting, or confusion.
We wish you all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10236309-DS-18 | 10,236,309 | 28,802,658 | DS | 18 | 2166-11-17 00:00:00 | 2166-11-19 13:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Malaise, SOB, myalgia, chest pressure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ yoM with PMH of CAD s/p CABG, biventricular
pacer, COPD on 2L at home (at night), CKD, asbestosis with known
pleural plaques, AAA s/p repair who presented to the ED with a 4
day history of myalgia, SOB, and dull chest pain. He was in his
usual state of health until ___ day, when he started to
feel tired and achy all over. Per daughter, he began to sleep a
lot and lost his appetite. He states that his cough worsened as
well. He described the cough as productive of white phlegm,
about a tablespoon a day. He says that he was around "a lot of
people" during ___ and might have sat across from someone
who had a cold. Denies nausea, vomiting, diarrhea.
His daughter, ___, states that they went to a ___
clinic on either ___ or ___, where patient was started on
erythromycin. They tried to call his PCP at the ___, but his
previous PCP retired and his new PCP was on vacation.
Patient states that over the past several weeks, he has been
trying to lose weight by eating healthier food. He lives with
his daughter ___, who is his caretaker. A few months ago,
he presented to ___ with dark stools. An EGD was
done, which reportedly showed no bleeding. Per patient's
daughter, they did not do a colonoscopy because of his age and
other medical issues. Neither the patient nor his daughter
remembers whether he got the flu vaccine this year, as he
receives his primary care at the ___.
In the ED, he received 1x dose of azithromycin 500mg iv and
ceftriaxone 1g iv. He also received 500cc of NS bolus. CXR
showed a retrocardiac opacity that may be either atelectasis or
pneumonia.
Labs were notable for Hgb of 9.9, Cr 1.4, and proBNP of 4507.
Upon arrival to the floor, the patient was breathing comfortably
on 2L NC. He states that his appetite has improved since
arriving in the ED. He also thinks that his cough is improving
and his throat is not as sore anymore. He states that at home,
he only uses his oxygen at night. However, he sometimes gets SOB
and light-headed during the day, and this is his baseline.
Past Medical History:
CARDIAC HISTORY
-CAD s/p CABG in ___ SVG -> R-PDA, SVG -> OM1 with skip to D1,
SVG to LAD known to be occluded
- Moderate-Severe AS
- Infarct related cardiomyopathy s/p BiV ICD
- Nonsustained VT
OTHER PAST MEDICAL HISTORY
- Diabetes
- Hypertension
- Dyslipidemia
- Abdominal aortic aneurysm s/p repair
- Asbestos exposure w/ pleural plaques known
- Gout
- GERD
- CKD Stage III
- Bilateral corneal transplant
- Umbilical hernia repair
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
Admission Physical exam:
General: elderly man sitting up, NAD
HEENT: ATNC
CV: harsh systolic murmur with radiation to clavicles
Resp: faint wheezing bilaterally, breathing comfortably on 2L NC
GI: +BS, nontender
Extr: Trace edema bilaterally
Neuro: Alert, oriented, able to answer all questions
appropriately
Pertinent Results:
ADMISSION LABS:
============
___ 02:35PM BLOOD WBC-7.8# RBC-3.20* Hgb-9.9* Hct-32.3*
MCV-101* MCH-30.9 MCHC-30.7* RDW-15.9* RDWSD-58.4* Plt ___
___ 02:35PM BLOOD Neuts-73.3* Lymphs-14.4* Monos-7.6
Eos-4.1 Baso-0.3 Im ___ AbsNeut-5.72# AbsLymp-1.12*
AbsMono-0.59 AbsEos-0.32 AbsBaso-0.02
___ 02:35PM BLOOD Glucose-104* UreaN-51* Creat-1.4* Na-145
K-4.1 Cl-102 HCO3-30 AnGap-13
___ 02:35PM BLOOD CK(CPK)-34*
___ 02:35PM BLOOD CK-MB-2 proBNP-4507*
___ 02:35PM BLOOD cTropnT-<0.01
___ 06:41AM BLOOD Calcium-8.6 Phos-3.1 Mg-1.9
___ 06:41AM BLOOD VitB12-789
___ 02:39PM BLOOD Lactate-1.0
___ 06:41AM BLOOD ___ PTT-26.4 ___
DISCHARGE LABS:
============
___ 06:10AM BLOOD WBC-6.7 RBC-3.21* Hgb-9.6* Hct-31.2*
MCV-97 MCH-29.9 MCHC-30.8* RDW-15.3 RDWSD-54.4* Plt ___
___ 06:10AM BLOOD Glucose-108* UreaN-55* Creat-1.6* Na-145
K-4.3 Cl-106 HCO3-29 AnGap-10
___ 06:10AM BLOOD Calcium-9.4 Phos-3.9 Mg-2.0
MICRO:
=====
___ GRAM STAIN, CULTURE: CONTAMINATED
___ Culture, Routine-PENDING
IMAGES:
=======
CXR ___
1. Interval increased retrocardiac opacity could be left lower
lobe focal pneumonia in the appropriate clinical situation
versus atelectasis.
2. Increased peribronchial wall thickening can be seen with
small airways disease and chronic inflammation.
3. Extensive bilateral pleural plaques.
4. Cardiomegaly without edema or pleural effusion. No evidence
of pneumothorax.
Brief Hospital Course:
Mr ___ is a ___ yoM with PMH of CAD s/p CABG, biventricular
pacer, COPD on 2L at home, CKD, asbestosis with known pleural
plaques, AAA s/p repair who presented to the ED with a 4 day
history of myalgia, SOB, and cough.
ACUTE ISSUES:
=============
#Malaise, cough, loss of appetite
#Presumed pneumonia
#COPD exacerbation
Presented with 4 day history of myalgia, SOB, and cough.
Symptoms consistent with viral URI vs COPD exacerbation, however
CXR had possible retrocardiac opacity LLL, so he was started on
CTX/azithro in the ED ___, continued for 2 days, and
transitioned to levaquin for 3 days to complete a 5d course (End
___, renal clearance decreased so held dose ___. Had no fevers
or leukocytosis to suggest bacterial pneumonia however given
multiple risk factors seemed reasonable to treat. Was still
complaining of frequent cough, especially with supine
positioning, and occasional wheezing, so started prednisone
burst (___) for total 3 days for possible COPD exacerbation
and started feeling much better. Pt was satting well on room air
with ambulation by day of discharge. ___ was consulted,
recommended home with ___.
#HFpEF
#CAD s/p CABG
#Moderate-Severe AS
Pt proBNP elevated to 4507 in the ED; however, was similar to
his previous values and there was no evidence of pulmonary edema
on CXR. Most recent echo ___, w moderate-severe AS and a
left ventricular systolic function that was low normal (LVEF
55%). Troponin negative in the ED, no elevation of CKMB.
Appeared hypovolemic on initial exam and received 500 cc IVF.
Initially held home lasix for dehydration and ?___ but restarted
after starting steroids, however lost weight and Cr increased to
1.6 so discharged on 40 mg lasix instead of 60mg until PCP
___ Discharge weight 221 lbs. Continued home Asa 81,
atorvastatin. He is due for a repeat TTE and may need a surgical
vs TAVR workup given his angina if his AS has progressed.
#Leg pain/fatigue
#Stable Angina
Not complaining of angina in hospital but has complained of leg
pain/fatigue which often coincides with angina. Likely has PVD
with claudication, as an outpatient his carvedilol was being
uptitrated rather than starting a nitrate, would continue to
uptitrate if BP can tolerate vs starting nitrate outpatient.
Please consider noninvasive ___ vascular studies as an
outpatient, and consider increasing Atorvastatin to 80 mg.
Cardiology followup was requested on discharge.
#CKD
Initially thought Cr b/l 1.0-1.1 based on prior data, but was
stable at Cr 1.4 with normal electrolytes so perhaps this is
his baseline. Started to increase on day of discharge to 1.6
possibly i/s/o restarting lasix. Renally dosed medications.
CHRONIC ISSUES:
================
#HTN: Held home lisinopril in the setting of infection and
normotension, held on discharge for rising Cr and normotension.
#Gout: Continued home Allopurinol but dose reduced 150 mg daily
for renal dosing.
#HLD: Continued home atorvastatin.
#Asbestosis: Chronic lung disease on 2L home O2 QHS and nasal
sprays, see above re: O2 management
#Anemia: Hgb 9.9, similar to Hgb in ___.
#Dry eyes, recent corneal transplant
-continue home Latanoprost and Prednisolone eye drops
-continue home hypertonic saline ointment
TRANSITIONAL ISSUES:
===============
[ ] discharged on reduced dose of lasix 40 mg daily until PCP
___ (from 60 mg daily), please ___ weight and Cr.
- Discharge weight 221 lbs.
- Discharge Cr 1.6 (baseline 1.4)
[ ] Lisinopril held on discharge, please ___ BP and Cr at PCP
___
[ ] Decreased allopurinol to 150 mg daily for renal dosing
[ ] Completed 5d course of abx for CAP (ctx/azithro -> levaquin)
and 3 day burst of Prednisone 40 mg for COPD exacerbation
[ ] c/o leg fatigue/pain with walking coinciding with angina,
please consider vascular studies as outpatient and uptitration
of beta blocker vs nitrate
[ ] He is due for a repeat TTE for his aortic stenosis.
[ ] Discharged with ___ for home ___
#Code: Full, presumed
#Emergency contact: ___ (daughter) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
3. Allopurinol ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Carvedilol 6.25 mg PO BID
7. Furosemide 60 mg PO DAILY
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Lisinopril 10 mg PO DAILY
10. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES QHS
11. Benzonatate 100 mg PO TID
12. Ipratropium Bromide MDI 1 PUFF IH TID
13. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH BID
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 0.5 (One half) tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
2. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
3. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Benzonatate 100 mg PO TID
8. Carvedilol 6.25 mg PO BID
9. Ipratropium Bromide MDI 1 PUFF IH TID
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
11. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES QHS
12. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH BID
13. HELD- Lisinopril 10 mg PO DAILY This medication was held.
Do not restart Lisinopril until speaking with your primary care
doctor and having your kidney function tested
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Pneumonia
COPD exacerbation
Claudication
Aortic Stenosis
Secondary:
CKD
Chronic diastolic HF
CAD
Angina
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 came to the hospital because you were not feeling well.
You had a chest x-ray that may have showed pneumonia, though
this was hard to tell because of your plaques.
You finished a course of treatment for pneumonia with
antibiotics and started to feel a lot better.
You also got treatment for COPD exacerbation with steroids,
which really helped you.
When you go home, please work with a physical therapist.
Please talk to your cardiologist and primary care doctor about
the pain and fatigue in your legs because this may require
further testing and treatment.
Your lasix (water pill) amount was decreased. Please weigh
yourself every morning, call MD if weight goes up more than 3
lbs in one day or 5 lbs in one week.
It was a pleasure caring for you and we wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10236309-DS-21 | 10,236,309 | 23,054,150 | DS | 21 | 2167-11-21 00:00:00 | 2167-11-21 19:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Presyncope, fall
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Mr. ___ is a ___ year old M w/ HFpEF (recovered EF 20% -->
59%), severe AS, CAD s/p CABG, AAA (8x6.3, not operable), HTN,
HLD recently hospitalized for decompensated HF and TAVR
evaluation (ultimately assessed not to be candidate), now
presenting with pre-syncope, fall, and coccyx fracture.
Patient was recently hospitalized at ___ from ___ to ___
for decompensated HF, underwent TAVR evaluation. Ultimately
assessed not to be candidate for TAVR due to AAA (8x6cm) with
prohibitive operative risk. Diuresed and discharged home with
plan for palliative care follow-up and evaluation for possible
home hospice. At that hospitalization, he was started on
ranolazine, and his torsemide was decreased from 20 mg twice
daily to 30 mg daily.
The history was obtained from the patient and his daughter, who
was at the bedside.
The patient has had dizziness since ___ hours after returning
home
from the hospital. He reports that it is all the time, not just
with changes in position. Patient's daughter states that she
thinks it was from the ranolazine, which was newly started on
the
last hospitalization. Given his dizziness, she called the CDAC,
as well as his outpatient cardiology office. No one returned
her
call. She kept giving him the ranolazine because she did not
know if she should stop it without first hearing from a
cardiologist. The patient states that he was walking from the
kitchen to the dining room, when he felt dizzy, and fell to his
right hand side. He reports he struck his head, but he does not
know on what. He reports pain on the side of his chest, which
was not present prior to the fall. The pain is worse with deep
inspiration. Pain is also worse with arm movement and with
pressure.
Denies LOC, denies palpitations. Reports pain in his head as
well
after head strike.
He also reports nausea and vomiting that has been ongoing since
he is returned home from the hospital. He has a decreased
appetite. He is constipated. His last bowel movement movement
was 2 weeks prior to admission. His shortness of breath, which
is chronic, is worse since returning home. He reports his
weight
on hospital discharge was 211. On the morning prior to
admission, it was 210 pounds. He is compliant with his
medications.
In the ED:
Initial vitals: 95.6 80 108/64 16 97% 2L NC
Labs notable for hemoglobin 8.4, creatinine 1.9, troponin less
than 0.01, lactate 1.1, UA negative.
CT Head
No acute intracranial process or calvarial fracture.
CT C spine
1. No acute fracture. Old nonunited dens fracture.
2. Mild anterolisthesis of C4 over C5 is of indeterminate age,
possiblydegenerative. If clinical concern for ligamentous
injury,
MRI is moresensitive.
3. Severe multilevel degenerative changes of the cervical spine.
4. Please see separate report performed on the same day for
detailedevaluation of the chest including moderate right pleural
effusion.
CT Torso
1. There is a mildly displaced fracture at the sacral-coccygeal
junction. Otherwise, no evidence of acute intrathoracic or
intraabdominal injury within the limitation of an unenhanced
scan.
2. Postsurgical changes following aorto-bi-iliac stenting of an
infrarenal abdominal aortic aneurysm, measuring up to 8.1 cm
the,
unchanged since ___.
3. Moderate to severe cardiomegaly with bilateral dependent
nonhemorrhagic pleural effusions, moderate on the right and
small
on the left.
Patient was given IV Zofran, IV Tylenol, IV morphine.
Cardiology was consulted in the emergency department, and
recommended admission to ___.
Past Medical History:
CARDIAC HISTORY
-CAD s/p CABG in ___ SVG -> R-PDA, SVG -> OM1 with skip to D1,
SVG to LAD known to be occluded
- HFrEF s/p BiV ICD
- Moderate-Severe AS
- AFib with RVR
- Nonsustained VT
OTHER PAST MEDICAL HISTORY
- Diabetes
- Hypertension
- Dyslipidemia
- Abdominal aortic aneurysm s/p repair
- Asbestos exposure w/ pleural plaques known
- Gout
- GERD
- CKD Stage III
- Bilateral corneal transplant
- Umbilical hernia repair
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
GENERAL: Well developed, well nourished Caucasian male. in NAD.
Oriented x3.
HEENT: Sclerae anicteric, MMM.
CARDIAC: Regular rate and rhythm. Normal S1, S2. There is a
III/VI mid-peaking murmur best auscultated at the RUSB,
without radiation to the carotids or axilla.
LUNGS: CTAB
CHEST: TTP over right and left lateral chest, no ecchymosis
noted
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. There is 2+ pitting edema from
the mid-shin down, with 1+ to trace higher up to the posterior
thigh.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAM:
GENERAL: Well developed, well nourished Caucasian male. in NAD.
Oriented x3.
HEENT: Sclerae anicteric, MMM.
CARDIAC: Regular rate and rhythm. Normal S1, S2. There is a
III/VI mid-peaking murmur best auscultated at the RUSB,
without radiation to the carotids or axilla.
LUNGS: CTAB
CHEST: TTP over right and left lateral chest, no ecchymosis
noted
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. There is 1+ pitting edema up
to
mid-shin bilaterally.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
ADMISSION LABS
==============
___ 12:50PM BLOOD WBC-5.0 RBC-2.69* Hgb-8.4* Hct-27.6*
MCV-103* MCH-31.2 MCHC-30.4* RDW-17.5* RDWSD-65.7* Plt ___
___ 12:50PM BLOOD Glucose-108* UreaN-53* Creat-1.9* Na-136
K-4.4 Cl-91* HCO3-31 AnGap-14
___ 06:40AM BLOOD Calcium-9.0 Phos-4.5 Mg-2.2
DISCHARGE LABS
==============
___ 06:17AM BLOOD WBC-7.3 RBC-2.64* Hgb-8.1* Hct-27.5*
MCV-104* MCH-30.7 MCHC-29.5* RDW-17.4* RDWSD-66.9* Plt ___
___ 06:17AM BLOOD Glucose-100 UreaN-59* Creat-2.2* Na-137
K-4.8 Cl-91* HCO3-35* AnGap-11
___ 06:17AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.2
PERTINENT STUDIES
=================
___ CT Spine w/o Contrast
IMPRESSION
1. No acute fracture. Old nonunited dens fracture.
2. Mild anterolisthesis of C4 over C5 is of indeterminate age,
possibly
degenerative. If clinical concern for ligamentous injury, MRI
is more
sensitive.
3. Severe multilevel degenerative changes of the cervical spine.
4. Please see separate report performed on the same day for
detailed
evaluation of the chest including moderate right pleural
effusion.
___ CT Head w/o Contrast
IMPRESSION:
1. No acute intracranial process.
___ CT Torso w/o Contrast
IMPRESSION:
1. Buckling of the cortex at the sacrococcygeal junction
consistent with acute fracture.
2. Simple appearing trace perihepatic fluid.
3. Moderate to severe cardiomegaly with bilateral dependent
nonhemorrhagic
pleural effusions, moderate on the right and small on the left.
4. Postsurgical changes following aorto-bi-iliac stenting of an
infrarenal
abdominal aortic aneurysm, measuring up to 8.1 cm, similar
compared to since ___.
Brief Hospital Course:
Outpatient Providers: Mr. ___ is a ___ year old M w/ HFrEF
(recovered EF 20% --> 59%), severe AS, CAD s/p CABG, AAA (8x6.3,
not operable), HTN, HLD recently hospitalized for decompensated
HF and TAVR evaluation (ultimately assessed not to be
candidate), now presenting with pre-syncope, fall, and coccyx
fracture.
TRANSITIONAL ISSUES
===================
[ ] Patient and family would like to transition him to hospice,
but are not yet set up with a hospice company. Please follow-up
with them to help facilitate this transition. His code status is
now DNR/DNI.
[ ] Patient and family were offered the choice to deactivate the
defibrillator part of his ICD. They opted to not pursue this
while inpatient. Please continue to reevaluate the utility in
deactivating patient's defibrillator.
[ ] As patient transitions to more comfort measures, please
evaluate which medications are more in line with his goals.
[ ] Patient's dose of torsemide was increased to 40mg daily.
Please evaluate if this continues to be an appropriate dose for
him.
ACUTE ISSUES
============
#Presyncope
Thought likely ___ ranolazine vs influenza like illness vs his
known AS. Reassuringly, his orthostatics were negative. His
ranolazine was held, and patient was treated symptomatically for
his viral like symptoms. Plan to transition to hospice care
given his AS was pursued as discussed below. His dizziness at
time of discharge was improved.
# Nausea, Vomiting, Viral-like symptoms
Presenting with symptoms concerning for possible URI vs viral
gastroenteritis. Reassuringly, white count remained normal, and
no recent fevers or chills. Influenza was negative, but viral
panel was still pending at time of discharge. There was also
concern his symptoms could be secondary to his poor cardiac
function. He was given Zofran PRN with mild improvement in his
symptoms, started on a significant bowel regiment for severe
constipation, and was treated symptomatically for his other
symptoms.
# Coccyx fracture:
Mildly displaced on imaging, but opted to be managed
conservatively, given that patient is a poor surgical candidate.
Received analgesia with Tylenol and oxycodone PRN.
#Chest Pain:
Likely musculoskeletal in setting of fall. Reproducible on
palpation. No evidence of rib fractures on CT scan. Trop upon
arrival negative, EKGs have been stable, no c/f ACS. Received
Tylenol and oxycodone PRN for pain.
# ADHF
# HFrEF w/recovered EF
Patient previously with HFrEF (EF 20%), later recovered to 41%,
now 59%. Previous discharge weight was 211, while weight on
admission 216, however on exam patient did not appear markedly
volume overloaded, nor had change to his baseline oxygen
requirement. Slowly uptitrated torsemide to 40mg to help a
little more with volume control, and continued home metoprolol.
# Goals of Care
Patient initially stated that he "doesn't want to think about"
his goals of care. His daughter stated that palliative care was
consulted on last admission, but that she told them to go away,
because they made the patient "worked up." On ___, long
discussion with family and patient, again attempting to
readdress GOC. Given the severity of patient's symptoms, again
recommended patient begin to explore hospice care, to which they
were more amenable. Patient and family opted to pursue hospice
care at home, and transitioned patient to DNR/DNI. Discussed
with all members of family that it may be within their goals of
care to consider deactivating the patient's defibrillator,
however they stated they felt overwhelmed already with the
transition to hospice and wished to defer this decision till
later. Prior to discharge, family was unhappy with services and
equipment provided by ___ hospice company, and thus fired
the company. Instead, after extensive discussion with both case
management, physician team, and family/patient, the decision was
made that patient would still be discharged home, but with ___
services. His ___ services would help transition him to a
different hospice company.
# Severe AS
TTE ___ notable for peak gradient 52 (mean 30), with a
calculated valve area of 0.7 cm^2. Gradient and peak flow felt
to be possibly underestimated iso MR. ___ for TAVR but
assessed not to be candidate based on limited life expectancy
___ AAA) and uncertain functional/symptomatic benefit.
# AAA
S/p endovascular repair in ___. During recent hospitalization,
found to be enlarged to largest axial dimension 8.0 x 6.3 on
non-contrast CT (CTA deferred given renal function). Evaluated
by vascular surgery and felt to have prohibitive operative risk,
with ~50% risk of rupture in next 6 months.
# Dyspnea
# Asbestosis
# Restrictive lung disease
# Chronic hypoxemic/hypercarbic respiratory failure
# Respiratory acidosis with compensatory metabolic alkalosis
Patient's dyspnea is likely multifactorial. He has decompensated
heart failure with severe AS and complicated coronary artery
disease as well as severe restrictive lung disease. He was
previously using 2L NC only at night, but is now requiring
continuous 2L. His respiratory status at time of discharge has
improved with diuresis and is currently stable. He was continued
on home albuterol and ___ equivalent, salmeterol.
================
CHRONIC ISSUES:
================
# CAD s/p CABG
Continued home ASA 81 mg, atorvastatin 40 mg PO daily
# A fib
Continue home amiodarone. Not on a/c due to prior GI bleeds
# CKD
At baseline during hospitalization
# Anemia
Chronic anemia, decreased during recent hospitalization with
work-up showing low retics (0.08), normal B12, LDH, haptoglobin.
Prior GI bleeds in the setting of AC, but no recent bleeds.
Stable today compared to prior.
# Reported history of diabetes:
Prior notes indicate that the patient has diabetes - but he has
never filled a prescription for any diabetic medications, and
his A1c back in ___ was 5.1%. Most recent A1C 5.2
# Gout
Continued home allopurinol
# Thrombocytopenia
Chronic, stable on admission compared to prior.
# CODE: DNR/DNI(confirmed)
# CONTACT: HCP: ___ (___)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild/Fever
2. Amiodarone 200 mg PO QAM
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QPM
6. Metoprolol Succinate XL 12.5 mg PO QAM
7. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES QAM
8. Vitamin D 1000 UNIT PO QPM
9. Multivitamins W/minerals 1 TAB PO DAILY
10. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN
11. carboxymethylcellulose sodium 0.5 % ophthalmic (eye)
DAILY:PRN
12. Cyanocobalamin 1000 mcg PO DAILY
13. ipratropium bromide 42 mcg (0.06 %) nasal TID
14. olodaterol 2.5 mcg/actuation inhalation QAM
15. sodium chloride 5 % ophthalmic (eye) QPM
16. Sodium Chloride Nasal ___ SPRY NU DAILY:PRN congestion
17. Torsemide 30 mg PO DAILY
18. Ranolazine ER 500 mg PO BID
19. Allopurinol ___ mg PO QAM
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*20 Tablet Refills:*0
2. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
RX *ondansetron 4 mg 1 tablet(s) by mouth Q8Hrs PRN Disp #*12
Tablet Refills:*0
3. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth Q6HRs PRN
Disp #*10 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth daily Disp #*10 Packet Refills:*0
5. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*20 Tablet Refills:*0
6. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
7. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild/Fever
8. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN
9. Allopurinol ___ mg PO QAM
10. Amiodarone 200 mg PO QAM
11. Aspirin 81 mg PO DAILY
12. Atorvastatin 40 mg PO QPM
13. carboxymethylcellulose sodium 0.5 % ophthalmic (eye)
DAILY:PRN
14. Cyanocobalamin 1000 mcg PO DAILY
15. ipratropium bromide 42 mcg (0.06 %) nasal TID
16. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QPM
17. Metoprolol Succinate XL 12.5 mg PO QAM
18. Multivitamins W/minerals 1 TAB PO DAILY
19. olodaterol 2.5 mcg/actuation inhalation QAM
20. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES QAM
21. Sodium Chloride Nasal ___ SPRY NU DAILY:PRN congestion
22. sodium chloride 5 % ophthalmic (eye) QPM
23. Vitamin D 1000 UNIT PO QPM
24.Durable Medical Equipment
ICD-9 CODE: 39___.0
Medical Bed
Duration: ___ months
Prognosis: Fair
25.Durable Medical Equipment
ICD-9 CODE: 396.0
Medical Recliner
Duration: ___ months
Prognosis: Fair
26.Durable Medical Equipment
ICD-9 CODE: 396.0
Medical Commode
Duration: ___ months
Prognosis: Fair
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
=======
Presyncope
Viral-like illness
Coccyx fracture
Chest Pain
HFrEF w/recovered EF
GOC
SECONDARY
=========
Severe Aortic Stenosis
Abdominal Aortic Aneurysm
Restrictive 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).
***IT IS MEDICALLY NECESSARY FOR PATIENT TO HAVE AMBULANCE
TRANSPORT HIM HOME***
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you had a fall at
home.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- While in the hospital we evaluated you for possible causes for
your fall. We think it may have been related to your
medications, as well as likely a viral infection.
- We also changed some of your heart medications to hopefully
help your symptoms.
WHAT SHOULD I DO WHEN I GO HOME?
- We would encourage you to discuss hospice services further
with your ___ service.
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10236654-DS-10 | 10,236,654 | 28,218,959 | DS | 10 | 2184-01-18 00:00:00 | 2184-01-18 18:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
shrimp
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Drain placement
History of Present Illness:
Patient is a ___ male who is s/p RALP with extended bilateral
pelvic lymph node dissection on ___ for high risk prostate
cancer. He had an unremarkable post-operative course but
complained of ongoing abdominal "fullness" since the time of his
surgery. Over the last several days he has been experiencing
fevers up to 101 at home and worsening RLQ abdominal pain. This
prompted an evaluation including CT abdomen/pelvis demonstrating
a lymphocele in the right pelvis measuring up to 9cm. He was
recommended to present to the ER for further evaluation.
Aside from pain and chills he is otherwise feeling well. No
nausea/vomiting/diarrhea. Tolerating po intake.
Past Medical History:
Liver disease
Hypogonadism
GERD
Social History:
___
Family History:
Father - died of esophageal cancer at age ___.
Maternal aunt - breast cancer in her ___.
Denies other family history of malignancy. He has 4 siblings.
Physical Exam:
GEN -- NAD
Abd -- SNT
Drain in place and draining serous yellow fluid
Urine -- No foley catheter at this time
Pertinent Results:
___ 06:29AM BLOOD WBC-6.9 RBC-3.16* Hgb-9.2* Hct-27.7*
MCV-88 MCH-29.1 MCHC-33.2 RDW-12.4 RDWSD-39.7 Plt ___
___ 08:11PM BLOOD WBC-10.7* RBC-3.77* Hgb-10.9* Hct-33.2*
MCV-88 MCH-28.9 MCHC-32.8 RDW-12.6 RDWSD-40.3 Plt ___
___ 08:11PM BLOOD Neuts-77.6* Lymphs-9.3* Monos-10.4
Eos-2.0 Baso-0.3 Im ___ AbsNeut-8.32* AbsLymp-0.99*
AbsMono-1.11* AbsEos-0.21 AbsBaso-0.03
___ 12:34PM BLOOD Neuts-74.2* Lymphs-12.8* Monos-9.5
Eos-2.9 Baso-0.4 Im ___ AbsNeut-5.95 AbsLymp-1.03*
AbsMono-0.76 AbsEos-0.23 AbsBaso-0.03
Brief Hospital Course:
Mr. ___ was admitted from the ED to the Urology service with
a known lymphocele with possible infection. ___ was consulted for
drain placement. On HD#1, a pigtail drain was placed without
complication. He also was continued on IV Vancomycin and
Cefepime for broad coverage. The gram stain from specimen taken
at the time of drainage demonstrated gram + cocci. The culture
was pending at the time of discharge. On HD#2, he remained
afebrile, was tolerating a regular diet, and his pain was
well-controlled. At that time, it was felt that he was stable
for discharge as he had been afebrile for > 24 hours. He was
transitioned to Bactrim at the time of DC and will be continued
for 14 days. The patient was instructed to record the drain out
put daily and ___ services were also coordinated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Sulfameth/Trimethoprim DS 1 TAB PO/NG BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth every 12 hours Disp #*28 Tablet Refills:*0
2. Multivitamins 1 TAB PO DAILY
3. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Lymphocele
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
- Please measure drain output daily and record. Bring the drain
output record to your next appointment. Drain will likely be
removed when the output is < 30 cc per day.
-ALWAYS follow-up with your referring provider ___ your PCP
to discuss and review your post-operative course and
medications. Any NEW medications should also be reviewed with
your pharmacist.
-You may take ibuprofen and tylenol together for pain control.
-The maximum dose of Tylenol (ACETAMINOPHEN) is 3- 4 grams (from
ALL sources) PER DAY.
-Ibuprofen should always be taken with food. If you develop
stomach pain or note black stool, stop the Ibuprofen. Ibuprofen
works best when taken around the clock.
-For your safety and the safety of others; PLEASE DO NOT drive,
operate dangerous machinery, or consume alcohol while taking
narcotic pain medications.
-Do not drive or drink alcohol while taking narcotics and do not
operate dangerous machinery
-You may be given prescriptions for a stool softener ___ a
gentle laxative. These are over-the-counter medications that
may be health care spending account reimbursable.
-Colace (docusate sodium) may have been prescribed to avoid
post-surgical constipation or constipation related to use of
narcotic pain medications. Discontinue if loose stool or
diarrhea develops. Colace is a stool-softener, NOT a laxative.
-Senokot (or any gentle laxative) may have been prescribed to
further minimize your risk of constipation.
-___ medical attention for fevers (temp>101.5), worsening pain,
drainage or excessive
bleeding from incision, chest pain or shortness of breath.
-resume regular home diet and remember to drink plenty of fluids
to keep hydrated and to minimize risk of constipation. For the
first few days at home, you should eat SMALL PORTIONS. Avoid
high fat, bulky or fried foods.
-___ medical attention for fevers (temp>101.5), worsening pain,
drainage or excessive
bleeding from incision, chest pain or shortness of breath.
Followup Instructions:
___
|
10236661-DS-5 | 10,236,661 | 21,445,622 | DS | 5 | 2186-02-13 00:00:00 | 2186-02-14 19:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Captopril / Hydralazine / metoprolol / Nortriptyline /
omeprazole
Attending: ___.
Chief Complaint:
diarrhea, abdominal pain
Major Surgical or Invasive Procedure:
Endoscopic ultrasound (EUS) - ___
History of Present Illness:
___ y/o female w/ history of atrial fibrillation, anticoaguluated
on Xarelto (last Coumadin dose two weeks ago), ?CHF, SSS s/p
pacemaker, stomach resection for "scarring" presenting with
three months of diarrhea, acute bleeding yesterday and abdominal
pain yesterday.
Patient was in rehab for one month after being evaluated for
chest pain, discharged one week ago. Bleeding yesterday was
noticed by daughter, ___. Abdominal pain is described as
"feeling like something's falling" and pain is worse with
coughing.
In the ED, initial vitals were:
98, HR 71, 117/77, RR 16, 100%RA
- Exam notable for:
raw anal area
abdominal pain
- Labs notable for:
Lactate 2.3
___
ALT 24
AST 41
AP 143
Lipase 64
Alb 3.3
Tbili 0.7
7.1>11.3/36.5<241
INR 2.0
UA: Large leukocytes
Blood trace, Nitrite negative, Protein 30, Glucose negative,
Ketones negative, RBC 9, WBC 18, EPI 10
- Imaging was notable for:
___ CT ABDOMEN/PELVIS
1. Severe intra and extrahepatic biliary dilatation without a
definite
obstructing lesion identified on this examination. Gallbladder
is distended with fluid without evidence of acute cholecystitis.
There is also main pancreatic ductal dilatation. MRCP or ERCP
should be considered.
2. Long segment of sigmoid colon demonstrating circumferential
thickening and adjacent fat stranding, which likely represents
infectious or inflammatory colitis. No evidence of ischemia.
Diverticulosis, however the fat stranding
is not focal to any single diverticula.
3. Severe degenerative changes within the lumbar spine with
severe endplate irregularity at well L1-2 and L3-4, which may be
degenerative, however there are no priors for comparisons.
- Patient was given:
___ 17:22 IV Morphine Sulfate 4 mg
___ 17:22 IV Ondansetron 4 mg
___ 18:09 IVF NS Started 250 mL/hr
Upon arrival to the floor, patient reports that diarrhea has
been ongoing for about 3 months. Has up to 6 bowel movements a
___. It is described watery and loose. Described as brown.
Became dark brown after taking iron pills. Her daughter noticed
some bright red blood on tissue that had fallen down. Patient
says she has a history of diarrhea. She would have a month of
diarrhea and then it would go away. Thinks the diarrhea has been
going on for about 6 months off and on. Came to the hospital
because of the blood. No lightheadedness or dizziness. No more
bloody bowel movements today. Patient reports that ED confirmed
that she had blood in the stool.
Takes ibuprofen (2 tablets) mostly every morning. Has been
taking it for headaches since the fall of this past year. Has
not used Tylenol for headaches.
Has associated abdominal pain below the umbilicus. Explained as
sharp. Seems like something "dropped" inside abdomen. Comes and
goes and not particularly before a bowel movement.
Stopped Coumadin a month ago and is now on Xarelto.
No medication changes since discharge as per patient.
Past Medical History:
HTN
Complex partial seizures
Restless Leg syndrome
3 surgical procedures on rt shoulder, right hip replacement x
2, left ankle fusion
Migraine headache
atrial fibrillation
SSS with pacemaker
Cholelithiasis
Duodenal ulcer
Lower GI bleed
B/L knee replacement surgery
Depression
Social History:
___
Family History:
Mother - varicose veins
Father - MI at age ___
Children - healthy
Physical Exam:
ADMISSION EXAM:
===================
VITAL SIGNS: 98.2 PO 121 / 80 85 18 94 RA
GENERAL: elderly female, no acute distress
HEENT: NCAT, PERRLA, EOMI
NECK: supple, no cervical LAD
CARDIAC: S1/S2, RRR, no murmurs, rubs or gallops
LUNGS: CTA b/l
ABDOMEN: Vertical scar from previous operation. Mid epigastric
mass felt under scar, non tender to palpation. Large oblong mass
protruding from right abdomen, bullotable. Non tender to
palpation. No overlying erythema noted. Prominent veins
overlying area. Tenderness to palpation over suprapubic/lower
mid gastric area.
EXTREMITIES: no cyanosis, bruising or edema
NEUROLOGIC: A&O x 3.
DISCHARGE EXAM:
=======================
VITAL SIGNS: 98.1 PO 147 / 94 72 18 97 RA
GENERAL: elderly female, no acute distress
HEENT: NCAT, PERRLA, EOMI
NECK: supple, no cervical LAD
CARDIAC: irregularly irregular, no murmurs, rubs or gallops
LUNGS: CTAB
ABDOMEN: Vertical scar from previous operation. Mid epigastric
mass felt under scar, non tender to palpation.
EXTREMITIES: no cyanosis, bruising or edema
NEUROLOGIC: A&O x 3. Moving all extremities.
Pertinent Results:
ADMISSION LABS:
========================
___ 03:00PM BLOOD WBC-7.1 RBC-3.82* Hgb-11.3 Hct-36.5
MCV-96 MCH-29.6 MCHC-31.0* RDW-17.0* RDWSD-59.5* Plt ___
___ 03:00PM BLOOD Neuts-69.9 Lymphs-15.2* Monos-10.6
Eos-3.4 Baso-0.6 Im ___ AbsNeut-4.96 AbsLymp-1.08*
AbsMono-0.75 AbsEos-0.24 AbsBaso-0.04
___ 03:00PM BLOOD ___ PTT-36.7* ___
___ 03:00PM BLOOD Glucose-82 UreaN-10 Creat-0.6 Na-136
K-5.0 Cl-104 HCO3-18* AnGap-19
___ 03:00PM BLOOD ALT-24 AST-41* AlkPhos-143* TotBili-0.7
___ 03:00PM BLOOD Lipase-64*
___ 03:00PM BLOOD Albumin-3.3* Calcium-8.9 Phos-3.4 Mg-2.0
___ 03:52PM BLOOD Lactate-2.3*
___ 07:00PM URINE Color-Yellow Appear-Hazy Sp ___
___ 07:00PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 07:00PM URINE RBC-9* WBC-18* Bacteri-FEW Yeast-NONE
Epi-10 TransE-<1
DISCHARGE LABS:
===========================
___ 08:10AM BLOOD WBC-6.0 RBC-3.50* Hgb-10.2* Hct-31.9*
MCV-91 MCH-29.1 MCHC-32.0 RDW-16.6* RDWSD-54.8* Plt ___
___ 08:10AM BLOOD ___ PTT-36.8* ___
___ 08:10AM BLOOD Glucose-92 UreaN-9 Creat-0.7 Na-139 K-3.7
Cl-103 HCO3-25 AnGap-15
___ 08:10AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.9
IMAGING/STUDIES
================
CT Abdomen/Pelvis with Contrast (___):
IMPRESSION:
1. Severe intra and extrahepatic biliary dilatation without a
definite
obstructing lesion identified on this examination. Gallbladder
is distended. No gallbladder wall thickening or pericholecystic
fluid is seen, but ensuing acute cholecystitis is not excluded.
There is also main pancreatic ductal dilatation. MRCP or ERCP
should be considered to evaluate for an obstruction lesion.
Ampullary stenosis is a consideration.
2. Long segment of sigmoid colon demonstrating circumferential
thickening and possible subtle adjacent fat stranding, which may
be due to infectious or inflammatory colitis. Diverticulosis,
however the fat stranding is not focal to any single
diverticula.
3. Severe degenerative changes within the lumbar spine with
severe endplate irregularity at well L1-2 and L3-4, most likely
degenerative, however there are no priors for comparisons. '
Endoscopic Ultrasound/EGD (___):
The bile duct was imaged at the level of the porta-hepatis, head
of the pancreas and ampulla. The maximum diameter of the bile
duct was 18 mm. The bile duct was markedly dilated but otherwise
normal in appearance. The dilation extended to the level of the
ampulla. No intrinsic stones or sludge were noted.
The ampulla was located at the rim of a large diverticulum -
otherwise normal. (biopsy)
Otherwise normal upper eus to third part of the duodenum
Previous partial gastrectomy with Billroth 1 gastroenterostomy
of the stomach body (biopsy)
Diverticulum in the area of the papilla
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
Ms. ___ is an ___ y/o woman with history of HTN, CHF (LVEF
unknown), atrial fibrillation on warfarin, SSS s/p PPM who
presented for diarrhea and abdominal pain, and was found to have
C. diff.
Ms. ___ is an ___ y/o woman with history of HTN, CHF (LVEF
unknown), atrial fibrillation on warfarin, SSS s/p PPM who
presented for diarrhea and abdominal pain, and was found to have
C. diff.
#C. diff: Patient finished a course of clindamycin in early
___ for pneumonia and thought she was experiencing more
diarrhea than usual. During her rehab stay, patient was
diagnosed with C.diff and treated with a 10 ___ course of
antibiotics. Repeat C.diff studies were sent during this
hospitalization and returned positive. The patient was started
on treatment with PO vanocmycin. She should continue vancomycin
until seen by a GI doctor ___ 1 = ___. Because she already
failed a full course of c diff treatment, she may warrant
treatment for longer than the usual two weeks. Exact course to
be determined by GI.
#BRBPR: Patient noticed specks of bright red blood after
diarrhea on ___ with some lower abdominal pain. Patient had no
further drops in H/H noted and was hemodynamically stable. CT
scan showed colitis. Presumed secondary to c. diff infection. No
intervention deemed appropriate given very minor nature of
bleeding.
#Intra and extrahepatic biliary dilatation: The patient was
found to have severe intra and extrahepatic biliary dilatation,
with main pancreatic duct dilation and dilation of gallbladder
without evidence of infection without a definite obstructing
lesion on CT scan. Gallbladder, even though distended and filled
with fluid, appears to be draining adequately given no rise in
alk phos or total bilirubin. Patient's pacemaker was
incompatible with MCRP so patient had an endoscopic ultrasound
___ which showed ductal dilatation, but no obstructing stones
or mass that might cause the ductal dilatation. Biopsies were
taken and were pending at time of discharge.
#Chronic Diastolic Heart Failure: Patient with mild symmetric
left ventricular hypertrophy w preserved systolic function and
ECHO showing LVEF 55%. Previous CTA showed mild evidence of pulm
edema and proBNP was 2393- stable from last admission. Her
stress test did not show any abnormality. Patient's diuretic was
held in the setting of diarrhea. This should be restarted as the
diarrhea resolves.
#Atrial Fibrillation: Patient with atrial fibrillation, V paced
with ICD, INR 2.0 on admission. CHADS2VASC 3 (age, dCHF, HTN).
Patient's xarelto was held prior to Endoscopic U/S and resumed
on ___. Atenolol 25 mg daily was continued for rate control.
# CAD risk: Continued atorvastatin 40 mg and BP control with
amlodipine/atenolol
# Hypertension: continued amlodipine/atenolol.
# Seizure Disorder: continued home keppra
# Depression: continued home venlafaxine
# Restless leg syndrome: continued home pramipexole
TRANSITIONAL ISSUES
====================
- We are holding patient's Lasix because of her diarrhea. She
appears euvolemic at discharge. PCP may resume ___ as diarrhea
resolves if appropriate.
- The patient may have refractory c. diff, and she should
continue taking vancomycin until seen by a GI doctor. 12 days of
Vancomycin prescribed at discharge. At PCP follow up, please
prescribe additional Vancomycin to cover her until she sees GI
on ___.
# CONTACT: ___ (daughter) ___ ___ (son)
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN sob, wheezing
3. Omeprazole 20 mg PO DAILY
4. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
5. amLODIPine 2.5 mg PO DAILY
6. Atenolol 25 mg PO DAILY
7. Calcium Carbonate 1250 mg PO DAILY
8. Ferrous Sulfate 325 mg PO DAILY
9. Furosemide 20 mg PO DAILY
10. Gabapentin 300 mg PO QHS
11. LevETIRAcetam 500 mg PO BID
12. Lidocaine 5% Patch 1 PTCH TD QAM
13. Magnesium Oxide 250 mg PO QHS
14. Multivitamins 1 TAB PO DAILY
15. Potassium Chloride 40 mEq PO DAILY
16. Pramipexole 2 mg PO QHS
17. TraZODone 25 mg PO QHS:PRN insomnia
18. Venlafaxine 37.5 mg PO DAILY
19. Rivaroxaban 20 mg PO DAILY
Discharge Medications:
1. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin [Vancocin] 125 mg 1 capsule(s) by mouth every six
(6) hours Disp #*56 Capsule Refills:*0
2. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
3. amLODIPine 2.5 mg PO DAILY
4. Atenolol 25 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Calcium Carbonate 1250 mg PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. Gabapentin 300 mg PO QHS
9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN sob, wheezing
10. LevETIRAcetam 500 mg PO BID
11. Lidocaine 5% Patch 1 PTCH TD QAM
12. Multivitamins 1 TAB PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Pramipexole 2 mg PO QHS
15. Rivaroxaban 20 mg PO DAILY
16. TraZODone 25 mg PO QHS:PRN insomnia
17. Venlafaxine 37.5 mg PO DAILY
18. HELD- Furosemide 20 mg PO DAILY This medication was held.
Do not restart Furosemide until you are told by your primary
care doctor
19. HELD- Magnesium Oxide 250 mg PO QHS This medication was
held. Do not restart Magnesium Oxide until you follow up with
your PCP.
20. HELD- Potassium Chloride 40 mEq PO DAILY This medication
was held. Do not restart Potassium Chloride until you are told
to do so by your primary care doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- C. diff infection
Secondary Diagnosis:
- hepatobiliary ductal dilatation
- Chronic diastolic heart failure
- A-fib
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized at ___.
Why were you in the hospital?
=============================
- You were admitted because you were having diarrhea and blood
in your stool.
What did we do for you?
=======================
- We monitored your blood count to make sure it remained stable.
The blood in your diarrhea resolved. We think it was from
inflammation of your intestines.
- You had an ultrasound to look for stones/masses that may be
causing your symptoms. The ultrasound was normal.
- We started you on antibiotics for a infection in your
intestines (C. diff infection).
What do you need to do?
=======================
- It is important that you continue taking antibiotics
(Vancomycin) for your infection. You should take the Vancomycin
4 times per ___ until you see a GI doctor. We initially told you
to stop taking the Vancomycin after two weeks, but we think that
you should continue taking it until you see a GI doctor.
- Please follow up with your primary care doctor ___
information below.)
It was a pleasure taking care of you. We wish you the best!
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
10236661-DS-8 | 10,236,661 | 24,788,945 | DS | 8 | 2186-09-10 00:00:00 | 2186-09-10 15:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Captopril / Hydralazine / metoprolol / Nortriptyline /
omeprazole
Attending: ___.
Chief Complaint:
Dysphagia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: ___ yo woman with a history of HFpEF, AFib on Rivaroxaban,
SSS s/p pacemaker, C. diff colitis, HTN, recent hip fracture and
subsequent rehab stay, presenting with substernal chest pain for
6 days and pain that occurs with swallowing. Patient reported
that the pain started ___ ( approximately one week prior to
admission) after eating and swallowing with a sensation of
choking. She felt as though food was stuck. The pain initially
worsened, and then subsequently improved, with only mild or
minimal pain over the next 3 days. On ___ evening, the
patient reported worsening pain which has gotten more severe for
the last 2 days. She reports associated shortness of breath on
exertion, nausea, no vomiting. She otherwise denies fevers,
chills, diaphoresis, abdominal pain, diarrhea, dysuria, lower
extremity edema.
In the ED, initial VS were 98 87 103 20 95% RA.
Exam with crackles in the bases bilaterally, with now
Labs notable for CBC 10.4, H/H 12.3/39.1, Plt 336. BMP WNL. LFTS
WNL with mildly alk phos of 161. proBNP elevated at 1137.
She received IV keppra, 2 mg morphine, x 2, cyclobenzaprine 5
mg,
atenolol 25 mg.
UA with 131 epithelial cells, with trace blood, and 120 WBC,
negative nitrites
CXR with slight increase in opacity over the posterior, inferior
lung on the lateral view, which could be atelectasis or
underlying consolidation.
Per ED report, she subsequently underwent a p.o. challenge and
was able to drink lots of water. The patient felt severe
burning
pain and felt as though the fluid was stuck. She was
subsequently admitted for dysphasia workup and possible
dehydration given decreased PO intake.
Upon arrival to the floor, the patient tells the story as above.
She reports that she has had continuous substernal pain which
she
describes as both "sharp" as well as a fiery" pain which is
clearly associated with attempting to eat or drink. She reports
she was able to tolerate some liquids, but almost no food. She
reports she has not really tolerated any food in the last few
days apart from few crackers. She reports a feeling of
"helplessness" he is very concerned about her inability to eat
or
drink. She otherwise denies fevers, chills, cough, diarrhea,
blood in stools, dysuria. She is recently undergoing treatment
for chronic and recurrent C. difficile colitis, which per OMR
review, her vancomycin scheduled to end today, the day of
admission. She denies any recent diarrhea. She has never had
any difficulty with swallowing like this before, although she
does have a prior history of gastrectomy. She reports some
ulcers in her mouth over the past week which have since
resolved.
During my interview, she attempts to drink some water. He
instantly has worsening recurrence of her substernal chest pain
and she stops drinking fluid. There is no difficulty breathing
or other signs of aspiration.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
PAST MEDICAL/SURGICAL HISTORY:
- Recent CDiff Colitis, on Vancomycin and undergoing workup for
possible fecal transplant
- HTN
- Atrial fibrillation
- SSS with pacemaker
- Cholelithiasis
- Duodenal ulcer
- Lower GI bleed
- Complex partial seizures
- Restless Leg syndrome
- Migraine headache
- Depression
Surgeries:
- 3 surgical procedures on rt shoulder, right hip replacement x
2, left ankle fusion
- B/L knee replacement surgery
Social History:
___
Family History:
Father - MI at age ___
Brothers - MI
Physical ___:
ADMISSION EXAM:
VITALS: 98.8 PO 150 / 97L Lying 78 20 97 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
Mucous membranes dry with no clear mucosal lesions
CV: Heart irregular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally
GI: Abdomen soft, non-distended, non-tender 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: Review in OMR
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
Mucous membranes dry with no clear mucosal lesions
CV: Heart irregular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally
GI: Abdomen soft, non-distended, non-tender to palpation
MSK: Mild pain with ROM at right hip.
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS
--------------
___ 11:30AM BLOOD WBC:10.4*# RBC:4.43 Hgb:12.3 Hct:39.1
MCV:88 MCH:27.8 MCHC:31.5* RDW:15.3 RDWSD:49.3* Plt Ct:336#
___ 11:30AM BLOOD Neuts:78.0* Lymphs:11.8* Monos:8.2
Eos:1.1
Baso:0.4 Im ___ AbsNeut:8.14* AbsLymp:1.23 AbsMono:0.86*
AbsEos:0.11 AbsBaso:0.04
___ 11:30AM BLOOD Glucose:97 UreaN:11 Creat:0.5 Na:140
K:5.0
Cl:101 HCO3:24 AnGap:15
___:30AM BLOOD ALT:7 AST:20 AlkPhos:161* TotBili:0.4
___ 11:30AM BLOOD Lipase:32
___ 03:59PM BLOOD cTropnT:<0.01
___ 11:30AM BLOOD cTropnT:<0.01
___ 11:30AM BLOOD Albumin:3.6 Calcium:8.9 Phos:2.8 Mg:2.2
IMAGING
-------
CXR ___
Mild basilar atelectasis. Slight increase in opacity over the
posterior, inferior lung on the lateral view, which could relate
to atelectasis, but underlying consolidation is not excluded..
Prior EGD ___
Excavated Lesions A single diverticulum with large opening was
found in the area of the papilla. The ampulla was normal. No
mucin or mass lesions were noted.
Impression: Previous partial gastrectomy with Billroth 1
gastroenterostomy of the stomach body (biopsy)
Diverticulum in the area of the papilla
Otherwise normal EGD to third part of the duodenum
Prior EUS ___
Impression: Diverticulum in the area of the papilla
EUS. Pancreas parenchyma was homogenous, with a normal "salt and
pepper" appearance
Pancreas duct: The pancreas duct was dilated and measured 8 mm
in
maximum diameter in the head of the pancreas and 4 mm in maximum
diameter in the body of the pancreas. The duct was tortuous. The
dilation extended to the level of the ampulla. No mass lesions
or
stones were noted.
The bile duct: The maximum diameter of the bile duct was 18 mm.
The bile duct was markedly dilated but otherwise normal in
appearance. The dilation extended to the level of the ampulla.
No
intrinsic stones or sludge were noted.
The ampulla was located at the rim of a large diverticulum -
otherwise normal. (biopsy)
Otherwise normal upper eus to third part of the duodenum
Recommendations: CBD and PD dilation to the level of the ampulla
were noted - no pathology was noted at the level of the ampulla.
Dilation may be related to post-surgery and large diverticulum.
Consider following patient clinically and with repeat LFTs.
Further assessment indicated in patient develops biliary /
pancreas symptoms or abnormal labs.
CT head w/o contrast ___
IMPRESSION:
1. No evidence of large territorial infarction or intracranial
hemorrhage. Chronic microangiopathy and global atrophy.
Barium esophagram ___:
Mild narrowing at the GE junction. There was holdup of barium
tablet at the GE junction for more than 15 minutes.
EEG:
IMPRESSION: Normal extended routine EEG in wakefulness. There
were no focal abnormalities or epileptiform features.
EGD ___:
Small hiatal hernia
Grade D esophagitis in the mid and lower esophagus (biopsy,
biopsy)
(biopsy)
Previous of the stomach
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
___ yo woman with a history of HFpEF, atrial fibrillation on
rivaroxaban, SSS s/p pacemaker, C. difficile colitis,
hypertension, recent hip fracture and subsequent rehab stay,
presenting with substernal chest pain for six days and pain that
occurs with swallowing also presenting with delirium while
hospitalized.
Gastroenterology was consulted on admission. Barium esophagram
was ordered, however patient was unable to tolerate standing for
the exam. Given her mild epigastric pain and dysphagia for
several days which improved with PPI, likely gastritis and mild
acid reflux contributing to her inability to tolerate PO intake.
She began eating normal diet within one day of hospitalization.
ACUTE/ACTIVE PROBLEMS:
#Dysphagia: Patient reporting significant ongoing dysphagia to
both solids and liquids for a week prior to admission. She has
no prior history of this. She does have a prior partial
gastrectomy as well as a prior EGD showing diverticulum. She
had been tolerating liquids, but now having nausea with solids.
EGD with evidence of esophagitis, possibly due to alendronate or
viral causes, biopsy pending. Barium swallow with some slowing
of barium at GE junction. She is on PO PPI. Nutrition is
following. Biopsy of esophagus currently pending.
# History of recurrent C .difficile: Per outpatient record
review in ___, she had a low grade fever on ___
associated with loose stools. C Diff PCR came back positive on
___ and she was started back on PO Vanco 250 mg TID on ___.
She is planning to see Dr. ___ at ___ ___ who
agreed with the treatment plan and pt was scheduled to see him
in the office for possible endoscopic
fecal transplantation due to her multiple recurrences. Her 2
week taper was planned to end on ___. Discussed with GI,
given resolution of diarrhea, she will not have fecal transplant
and vancomycin was discontinued. She was continued on her home
cholestyramine.
# Encephalopathy: given persecutory delusions and change in
mental status and underlying history, ordered head CT with no
acute abnormalities noted. She is intermittently delusional,
but overall oriented x 3. Neurology was consulted and
recommended EEG, which was overall unremarkable. Given
inability to take PO, venlafaxine was being held, which could
have contributed. Overall, mental status has been better.
# Atrial fibrillation: on home rivaroxaban and atenolol. Both
medications were held when she was not taking in PO, but
restarted.
# Prior history of complex partial seizure: Keppra continued and
changed to PO (was on IV on admission) given history of
seizures, which was discussed with neurology.
# Recent hip fracture s/p placement: patient treated with
acetaminophen, gabapentin, and lidocaine patch.
# Hypertension: patient was continued on her home amlodipine and
atenolol
# Depression: patient was continued on her home venlafaxine and
mirtazapine.
# HLD: statin was continued.
# Restless leg syndrome/insomnia: home gabapentin increased to
300mg TID and pramipexole were given.
# Functional status: ambulates with walker, per patient's
daughter, she has been having difficulty ambulating with walker
and was in rehab prior for similar reason. Patient's daughter
has been concern regarding risk of her mother falling.
Currently,
patient has been staying with her son. She was evaluated by ___.
Daughter set up support structure for her to be able to go home.
She was discharged home with daughter and services.
TRANSITIONS OF CARE
--------------------
- ___ restarting Alendronate
# Contacts/HCP/Surrogate and Communication: daughter ___
___
# Code Status/ACP: DNR/DNI confirmed with patient; per Atrius
records, patient has a MOLST form.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Rivaroxaban 20 mg PO DAILY
2. LevETIRAcetam 500 mg PO BID
3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
4. Mirtazapine 7.5 mg PO QHS
5. Gabapentin 200 mg PO QHS
6. Cyclobenzaprine 5 mg PO TID:PRN spasm
7. amLODIPine 10 mg PO DAILY
8. Alendronate Sodium 70 mg PO 1X/WEEK (___)
9. Ferrous Sulfate 325 mg PO DAILY
10. Cholestyramine 4 gm PO DAILY
11. Atorvastatin 40 mg PO QPM
12. TraZODone 25 mg PO QHS:PRN insomnia
13. Collagenase Ointment 1 Appl TP DAILY
14. Vancocin (vancomycin) 250 mg oral Q8H
15. Venlafaxine 37.5 mg PO BID
16. Calcium Carbonate 500 mg PO DAILY
17. Pramipexole 2 mg PO QHS
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. Atenolol 25 mg PO DAILY
RX *atenolol 25 mg 1 tablet(s) by mouth once a day Disp #*30
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 #*60 Capsule Refills:*0
4. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
5. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*45 Capsule Refills:*0
6. amLODIPine 10 mg PO DAILY
7. Atorvastatin 40 mg PO QPM
8. Calcium Carbonate 500 mg PO DAILY
9. Cholestyramine 4 gm PO DAILY
10. Collagenase Ointment 1 Appl TP DAILY
11. Cyclobenzaprine 5 mg PO TID:PRN spasm
12. Ferrous Sulfate 325 mg PO DAILY
13. LevETIRAcetam 500 mg PO BID
14. Mirtazapine 7.5 mg PO QHS
15. Pramipexole 2 mg PO QHS
16. Rivaroxaban 20 mg PO DAILY
17. TraZODone 25 mg PO QHS:PRN insomnia
18. Venlafaxine 37.5 mg PO BID
19. HELD- Alendronate Sodium 70 mg PO 1X/WEEK (___) This
medication was held. Do not restart Alendronate Sodium until
discuss with your PCP.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Dysphagia
Gastritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of your during your stay. You were
hospitalized for difficulty in tolerating oral intake. You has
esophagitis (inflammation of your esophagus) and were continued
on acid reflux medications. You are now taking all of your oral
medications Your diarrhea resolved and you do not have C.
difficile infection currently.
You were also noted to be confused. Neurology evaluated you and
your EEG did not show seizure like activity. You were continued
on Keppra twice daily. We wish you best wishes in your recovery.
Best wishes,
Your ___ team
Followup Instructions:
___
|
10236661-DS-9 | 10,236,661 | 21,590,908 | DS | 9 | 2186-09-19 00:00:00 | 2186-09-21 18:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Captopril / Hydralazine / metoprolol / Nortriptyline /
omeprazole
Attending: ___.
Chief Complaint:
Watery Diarrhea
Major Surgical or Invasive Procedure:
___ Colonoscopy with fecal matter transplant
History of Present Illness:
Ms. ___ is an ___ yo woman with a history of HFpEF, atrial
fibrillation on rivaroxaban, SSS s/p pacemaker, C. difficile
colitis, hypertension, recent hip fracture and subsequent rehab
stay with recent admission ___ for substernal chest pain
and odynophagia felt to be gastritis/GERD. She underwent EGD
with biopsy showing inflammation in esophagus felt to be from
alendronate. She also has a history of recurrent c. diff (at
least 5 episodes). On her last admission per discussion with GI,
vancomcyin was discontinued and FMT was deferred as she was
asymptomatic. Her daughter reports that last night she had
recurrence of watery diarrhea, decreased PO intake, and
generalized weakness. No ___ fevers, chest pain, dyspnea,
vomiting.
Past Medical History:
PAST MEDICAL/SURGICAL HISTORY:
- Recent CDiff Colitis, on Vancomycin and undergoing workup for
possible fecal transplant
- HTN
- Atrial fibrillation
- SSS with pacemaker
- Cholelithiasis
- Duodenal ulcer
- Lower GI bleed
- Complex partial seizures
- Restless Leg syndrome
- Migraine headache
- Depression
Surgeries:
- 3 surgical procedures on rt shoulder, right hip replacement x
2, left ankle fusion
- B/L knee replacement surgery
Social History:
___
Family History:
Father - MI at age ___
Brothers - MI
Physical ___:
Admission Exam:
VITALS: 98.9 PO 130 / 69 R Lying 89 18 100 RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Irregular rate and rhythm, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, grossly normal sensation
Discharge Exam:
VITALS: 97.6 PO 127 / 80 L Lying 61 18 95 Ra
GENERAL: comfortable, lying in bed eating breakfast, AOx3
HEENT: PERRLA, EOMI, anicteric
CV: RRR, no r/m/g
RESP: CTAB
GI: soft, NTND, no hepatosplenomagaly
Ext: warm, well perfused, no ___ edema
NEURO: CNII-XII intact, moving all 4 extremities, intact
sensation
Pertinent Results:
Admission labs:
=================
___ 10:40PM BLOOD WBC-19.3*# RBC-3.94 Hgb-11.1* Hct-34.6
MCV-88 MCH-28.2 MCHC-32.1 RDW-16.5* RDWSD-53.1* Plt ___
___ 10:40PM BLOOD Neuts-82.1* Lymphs-8.7* Monos-8.0
Eos-0.4* Baso-0.4 Im ___ AbsNeut-15.86*# AbsLymp-1.68
AbsMono-1.54* AbsEos-0.08 AbsBaso-0.07
___ 10:40PM BLOOD Glucose-135* UreaN-15 Creat-0.9 Na-137
K-3.6 Cl-101 HCO3-21* AnGap-15
___ 10:40PM BLOOD ALT-67* AST-58* AlkPhos-574* TotBili-0.7
___ 10:40PM BLOOD Albumin-3.5 Calcium-8.1* Phos-2.7 Mg-1.8
Discharge Labs:
==================
___ 06:10AM BLOOD WBC-5.2 RBC-3.72* Hgb-10.3* Hct-32.6*
MCV-88 MCH-27.7 MCHC-31.6* RDW-16.9* RDWSD-53.5* Plt ___
___ 06:10AM BLOOD Plt ___
___ 06:10AM BLOOD Glucose-78 UreaN-3* Creat-0.5 Na-142
K-3.5 Cl-105 HCO3-25 AnGap-12
___ 06:10AM BLOOD Calcium-8.2* Phos-3.5 Mg-2.0
Imaging:
==================
___ CT ab/pelvis
1. Mucosal hyperenhancement and wall thickening of the distal
descending,
sigmoid and rectum, compatible with proctocolitis, likely
infectious/inflammatory given distribution. No drainable fluid
collections
2. New healing right inferior pubic ramus fracture with small
amount of likely
old organized hematoma.
3. Additional unchanged findings as above.
___ CXR:
No substantial interval change from the previous exam. Mild
bibasilar
atelectasis without definite radiographic evidence for
pneumonia.
___ pelvis xray
Subacute right inferior pubic ramus fracture. Suspicion for a
comminuted
nondisplaced fracture of the right greater trochanter, which may
extend to the level of the hardware.
Brief Hospital Course:
Ms. ___ is an ___ year-old woman with a history of HFpEF,
atrial fibrillation on rivaroxaban, SSS s/p pacemaker, C.
difficile colitis, hypertension, recent hip fracture and
subsequent rehab stay with recent admission ___ for
substernal chest pain and odynophagia found to be related to
esophagitis on EGS who presented to the hospital with diarrhea
and hypotension found to be c.diff positive. Hypotension
resolved with 3L fluids and diarrhea improved on PO vancomycin.
Also had e.coli treated with 3 days of ceftriaxone. Prior to
discharge, she underwent successful fecal transplant via
colonoscopy on ___.
# Recurrent C. difficile:
# Hypotension
Patient has ___ of multiple C Diff infections treated with PO
vancomycin. In the past, GI discussed fecal transplant with
patient but given resolution of diarrhea at that time, it was
not pursued and vancomycin was dc'ed after seeing Dr. ___.
Patient presented with recurrent watery diarrhea, decreased PO
intake and found to be c.diff positive. Symptoms improved on Po
vancomycin. She was seen by GI and underwent successful fecal
transplant via colonoscopy on ___.
#UTI- No dysuria but with an episode of incontinence on the
floor. Urine culture with pansensitive E.coli and treated with 3
days of ceftriaxone ___ repeat of incontinence.
# Hip fracture s/p placement of hardware:
# chronic R Pubic ramus fracture
Evaluated by ortho in ED who felt that R superior and inferior
pubic rami fractures were chronic and healing likely from
previous falls ___ months ago. She was continued on home
acetaminophen, gabapentin, and lidocaine patch. Seen by ___ and
cleared for home with services with 4 week follow up by ortho.
Chronic Issues:
==================
#Dysphagia:
Patient has ___ of significant ongoing dysphagia to both solids
and liquids w/ prior partial gastrectomy as well as a prior EGD
showing diverticulum. EGD on last admission showed evidence of
esophagitis, possibly due to alendronate w/ biopsy positive for
reactive esophagitis. Barium swallow also showed some slowing of
barium at GE junction. Symptoms have resolved on PPI without
dysphagia or choking sensation with eating. Continued to hold
off on alendronate.
# Atrial fibrillation:
- Continued 15 mg rivaroxaban daily
- Continued home atenolol
# History of persecutory delusions:
Patient has ___ persecutory delusions and AMS on last admission.
She was AO X3 and is stable this admission.
- Continued home venlafaxine
# Prior history of complex partial seizure: Continued on home
Keppra
# Hypertension- Home meds held initially for hypotension but
restarted atenolol and amlodipine by discharge with good BP
control
# Depression: Continued on home venlafaxine and mirtazapine.
# HLD: Continued on home statin
# Restless leg syndrome/insomnia: Continued on home gabapentin
and pramipexole
TRANSITIONAL ISSUES:
- New Meds: None
- Stopped/Held Meds: None
- Changed Meds: None
- Post-Discharge Follow-up Labs Needed: None
() F/u with ortho in 4 weeks for old/healing pubic ramus
fracture
() Patient should avoid antibiotics as able
# CODE: Full (presumed)
# CONTACT:
Name of health care proxy: ___
Relationship: Daughter
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Cholestyramine 4 gm PO DAILY
4. Mirtazapine 7.5 mg PO QHS
5. Pramipexole 2 mg PO QHS
6. Rivaroxaban 20 mg PO DAILY
7. TraZODone 25 mg PO QHS:PRN insomnia
8. Venlafaxine 37.5 mg PO BID
9. LevETIRAcetam 500 mg PO BID
10. Ferrous Sulfate 325 mg PO DAILY
11. Cyclobenzaprine 5 mg PO TID:PRN spasm
12. Collagenase Ointment 1 Appl TP DAILY
13. Calcium Carbonate 500 mg PO DAILY
14. Pantoprazole 40 mg PO Q12H
15. Docusate Sodium 100 mg PO BID
16. Atenolol 25 mg PO DAILY
17. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
18. Gabapentin 300 mg PO TID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. amLODIPine 10 mg PO DAILY
3. Atenolol 25 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Calcium Carbonate 500 mg PO DAILY
6. Cholestyramine 4 gm PO DAILY
7. Collagenase Ointment 1 Appl TP DAILY
8. Cyclobenzaprine 5 mg PO TID:PRN spasm
9. Docusate Sodium 100 mg PO BID
10. Ferrous Sulfate 325 mg PO DAILY
11. Gabapentin 300 mg PO TID
12. LevETIRAcetam 500 mg PO BID
13. Mirtazapine 7.5 mg PO QHS
14. Pantoprazole 40 mg PO Q12H
15. Pramipexole 2 mg PO QHS
16. Rivaroxaban 20 mg PO DAILY
17. TraZODone 25 mg PO QHS:PRN insomnia
18. Venlafaxine 37.5 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Clostridium Difficile colitis
Urinary tract infection
Secondary:
Pelvic ramus fracture
Dysphagia
atrial fibrillation
Dysphagia
Depression
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 caring for you at ___
___!
WHY WERE YOU ADMITTED?
- you had recurrence of diarrhea and your blood pressure dropped
very low
WHAT HAPPENED IN THE HOSPITAL?
- You were found to have diarrhea because of a bacteria called
clostridium difficile (c.diff) that you've been infected with
multiple times previously
- You were treated with vancomycin by mouth to treat the
infection
- You got fluids to help with your blood pressure
- You had a urinatry tract infection and treated with
antibiotics
- You had an old fracture of the pelvic bone and were seen by
orthopedic surgeons but did not need any treatment
- You had a fecal transplant to hopefully definitively treat
recurrent c.diff infections
WHAT SHOULD YOU DO AT HOME?
- Please report to the ER if you start having increase in
diarrhea and are unable to eat or feel lightheaded or dizzy
- Please follow up with your orthopedic surgeon as below in 4
weeks to re-evaluate the pelvic bone fracture
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team
Followup Instructions:
___
|
10237082-DS-15 | 10,237,082 | 29,406,226 | DS | 15 | 2180-10-28 00:00:00 | 2180-10-28 13:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Protonix
Attending: ___.
Chief Complaint:
Right upper quadrant pain
Major Surgical or Invasive Procedure:
___: US guided liver biopsy
History of Present Illness:
___ w/ PMH of L portal vein thrombosis in ___ from an episode
of diverticulitis, presents with RUQ pain, with imaging findings
concerning for malignancy.
Patient states that 2 days ago he had a couple episodes of
emesis. The next day he developed this sharp pain in his right
upper quadrant and right groin area. He describes the pain as a
constant, sharp pain. About 1 week ago he endorses diarrhea. He
states that in the past month he has had irregular bowel
movements and has been more constipated. Also states that the
past couple days he has been burping frequently the past week.
He states his urine has been darker the past 3 days, but denies
dysuria, urinary frequency, or urinary urgency. Patient states
he went to ___ where he had a CT scan and
was told he had a "liver lesion". He was told to follow-up
outpatient with his doctor. He presented to ___ for a second
opinion since he has been followed by hepatology here in the
past. He states that he spoke to Dr. ___ earlier in the day
who told him to come to the ED.
In the ED, initial VS were: 97.6 104 119/67 17 95% RA
Exam notable for:
Con: Well appearing, in no acute distress
HEENT: NCAT. no icterus. EOMI. No OP lesions, MMM.
Resp: Breathing comfortably on RA. No incr WOB, CTAB.
CV: RRR. Normal S1/S2.
Abd: tender in RUQ, firm in RUQ
MSK: bilateral lower extremities without edema.
Skin: No rash, Warm and dry, No petechiae
Neuro: AOx3, speech fluent, no obvious facial asymmetry, moves
all 4 ext to command.
Psych: Normal mentation
Labs showed:
AST: 172 ALT: 167 AP: 509 Tbili: 2.6 Alb: 3.5
Imaging showed:
CT Chest:
1. 3.1 cm spiculated mass in the superior segment of the left
lower lobe is highly suspicious for primary lung malignancy.
2. A 1.0 cm sclerotic focus in the T9 vertebral body is likely a
bone island, and would be unusual for an osseous metastasis from
lung carcinoma. If clinically warranted, may consider nuclear
medicine bone scan for further evaluation.
3. Hepatic masses better assessed on same-day ultrasound.
RUQ ultrasound:
Innumerable discrete hypoechoic lesions scattered throughout the
hepatic parenchyma, highly concerning for metastases.
Correlation with CT scan performed at outside hospital is not
available for comparison at this time though further
characterization of these lesions is suggested.
OSH hospital records:
CT abd:
1. There are numerous hepatic lesions highly suspicious for
metastatic disease. No extrahepatic mass lesion is seen as a
possible primary lesion. It is conceivable that there may be a
hepatoma primary with hepatic metastases.
2. There is slight pericholecystic stranding around the
gallbladder, although by CT no gross wall thickening, calcified
gallstones, or evidence of biliary dilation is detected. Limited
ultrasound may be helpful to further assess the gallbladder.
Consults:
Hepatology:
Pt with history of PVT who is presenting for ___ opinion as was
found to have multiple liver lesions c/f metastases at OSH. -
would recommend CT C/A/P to help evaluate for possible primary
malignancy/better identify liver lesions - would defer to ED in
terms of whether to admit, but if suspicion high for malignancy,
may be reasonable for expedited workup - if admitted, patient
should be admitted to Gen Med service whom can consult
hepatology if they need our assistance in management
Patient received:
___ 18:46 IVF NS 1000 mL
___ 21:27 IV Morphine Sulfate
___ 21:27 IVF NS ( 1000 mL ordered)
___ 21:27 PO/NG Lisinopril 10 mg
___ 21:27 PO/NG Metoprolol Tartrate 25 mg
___ 21:33 PO Aluminum-Magnesium Hydrox.-Simethicone 30 mL
On arrival to the floor, the patient states that his abdominal
pain improved with the morphine that received in the ED. He
reports that he smoked 2ppd for ___ years, but quit ___ years
ago. Denies weight loss. Denies night sweats. Has endorsed upper
GI symptoms over the last ___ months including trouble drinking
water, acid reflux, and what he thinks is post nasal drip. He
was
prescribed a Z-pak by his PCP for ___ nasal drip and increased
sputum production. No hemoptysis. He states that he wants
treatment for these masses. His daughter is coming to the
hospital in the AM, and he would like the medical team to
discuss He would prefer to discuss the CT results in the AM when
his
daughter is present. He is aware the liver lesions are
concerning for cancer.
Endorses his urine has been darker the past 3 days, but denies
dysuria, urinary frequency, or urinary urgency.
Past Medical History:
Left portal vein thrombosis in setting of diverticulitis
CAD
Kidney stones
Arthritis
Diverticulosis
Social History:
___
Family History:
Sister - liver cancer
Sister - small cell lung cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.0 PO 157 / 84 Sitting ___ RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: Tachycardic, S1/S2, no murmurs, gallops, or rubs
LUNGS: diminished breath sounds in RUL. No crackles appreciated.
ABDOMEN: obese, mildly distended, no TTP, +BS
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHSYICAL EXAM:
VS: 97.5 136 / 70 84 20 95% RA
I/O ___
GENERAL: Appears well, NAD. Sitting up comfortably in bed.
HEENT: MMM, oropharynx without erythema,
exudates or ulcers.
NECK: Supple
LUNGS: CTAB
HEART: Distant heart sounds, RRR with normal S1 and S2.
ABD: +BS, no tenderness, softly distended
EXT: WWP, no ___ edema or erythema.
SKIN: +pustular rash on buttock with hard nodule underneath
NEURO: AOx3, CNII-XII grossly intact. Moves all extremities.
ACCESS: PIV
Pertinent Results:
ADMISSION LABS:
===========================
___ 04:47PM WBC-9.0 RBC-5.07 HGB-15.7 HCT-48.0 MCV-95
MCH-31.0 MCHC-32.7 RDW-14.7 RDWSD-51.1*
___ 04:47PM NEUTS-76.5* LYMPHS-9.0* MONOS-12.9 EOS-0.3*
BASOS-0.9 IM ___ AbsNeut-6.84* AbsLymp-0.81* AbsMono-1.16*
AbsEos-0.03* AbsBaso-0.08
___ 04:47PM ALBUMIN-3.5 CALCIUM-9.1 PHOSPHATE-3.4
MAGNESIUM-2.4 URIC ACID-6.5
___ 04:47PM LIPASE-40
___ 04:47PM ALT(SGPT)-167* AST(SGOT)-172* ___
ALK PHOS-509* TOT BILI-2.6*
___ 04:47PM GLUCOSE-143* UREA N-17 CREAT-0.8 SODIUM-138
POTASSIUM-5.2* CHLORIDE-100 TOTAL CO2-25 ANION GAP-13
___ 04:51PM URINE COLOR-ORANGE* APPEAR-Hazy* SP
___
___ 04:51PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM* UROBILNGN-2* PH-6.0
LEUK-NEG
___ 04:51PM URINE RBC-8* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-2
___ 04:51PM URINE MUCOUS-RARE*
___ 05:00PM RET AUT-1.8 ABS RET-0.09
___ 08:40PM ___
IMAGING:
===========================
___ LIVER ULTRASOUND:
Innumerable discrete hypoechoic lesions scattered throughout the
hepatic
parenchyma, highly concerning for metastases. Correlation with
CT scan
performed at outside hospital is not available for comparison at
this time
though further characterization of these lesions is suggested.
___ CT CHEST W/O CONTRAST:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: There is a 1.3 cm
peripherally
calcified nodule in the left thyroid lobe (2:6). There is no
supraclavicular or axillary lymphadenopathy.
UPPER ABDOMEN: A small hiatal hernia is noted. Multiple
hypodense liver
lesions are better appreciated on same day ultrasound study.
MEDIASTINUM: There is no mediastinal mass or lymphadenopathy. A
small hiatal hernia is noted, otherwise the esophagus is
unremarkable.
HILA: There is no hilar mass or lymphadenopathy, within the
limitations of an unenhanced study.
HEART and PERICARDIUM: Heart size is normal. Coronary artery
calcifications are severe. An LAD stent is also noted. The
thoracic aorta is normal in caliber. Extensive atherosclerotic
calcification of the aortic arch and proximal head neck vessels
are noted. There is no pericardial effusion.
PLEURA: No pleural effusion or pneumothorax.
LUNG:
1. PARENCHYMA: There is a 3.1 x 2.6 x 1.9 cm mass with
spiculated margins in the superior segment of the left lower
lobe (4:93, 601:76). Mild
centrilobular and paraseptal upper lobe predominant
emphysematous changes are noted. Bibasilar atelectasis is
noted.
2. AIRWAYS: The airways are patent to the level of the
segmental bronchi
bilaterally.
3. VESSELS: Main pulmonary artery diameter is within normal
limits.
CHEST CAGE: A 1.0 cm sclerotic focus in the T9 vertebral body
(602:75) is
noted. There is no acute fracture.
___ CT NECK W/ CONTRAST:
IMPRESSION
1. Patulous, air-filled esophagus could be related to
dysmotility. If
clinically indicated, a dedicated fluoroscopic esophagram could
be obtained to better evaluate motility.
2. 1 cm calcified left thyroid nodule does not require
additional follow-up based on size.
3. Moderate atherosclerotic calcification of the carotid
arteries with minimal stenosis bilaterally.
RECOMMENDATION(S): Thyroid nodule. No follow up recommended.
Absent suspicious imaging features, unless there is additional
clinical
concern, ___ College of Radiology guidelines do not
recommend further
evaluation for incidental thyroid nodules less than 1.0 cm in
patients under age ___ or less than 1.5 cm in patients age ___ or
___.
Suspicious findings include: Abnormal lymph nodes (those
displaying enlargement, calcification, cystic components and/or
increased enhancement) or invasion of local tissues by the
thyroid nodule.
___, et al, "Managing Incidental Thyroid Nodules Detected on
Imaging: White Paper of the ACR Incidental Findings Committee".
J ___ ___ 12:143-150.
___ ESOPHAGRAM:
The esophagus was not dilated. There was no stricture within
the esophagus. The esophageal mucosa is not well assessed on
this single contrast study. Multiple tertiary esophageal
contractions were noted, with significant delay in passage of
barium from the esophagus into the stomach. The lower
esophageal sphincter opened and closed normally. A 13 mm barium
tablet was administered, which was held up proximal to the GE
junction for approximately 30 seconds before passing into the
stomach. There was no gastroesophageal reflux. There was no
hiatal hernia. No overt abnormality in the stomach or duodenum
on limited evaluation.
IMPRESSION: Esophageal dysmotility with multiple tertiary
esophageal contractions.
___ RIGHT UPPER EXTREMITY DOPPLER US:
No evidence of deep vein thrombosis in the right upper
extremity.
___ MRI HEAD W/ AND W/O CONTRAST:
1. Study is mildly degraded by motion.
2. Within limits of study, no definite evidence of intracranial
metastatic disease.
3. Probable mild chronic small vessel disease.
4. Right cerebellar chronic infarct.
5. Paranasal sinus disease , as described.
___ KUB:
IMPRESSION:
1. Nonobstructive pattern without abnormally dilated bowel
loops.
2. Right pleural effusion.
PATHOLOGY:
===========================
___ SURGICAL PATHOLOGY SPECIMEN, LIVER BIOPSY
PATHOLOGIC DIAGNOSIS:
Liver, targeted left lobe lesion, needle core biopsies:
- Metastatic poorly-differentiated neuroendocrine carcinoma.
MICROBIOLOGY:
===========================
___ URINE CULTURE:
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed fecal flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
SUMMARY:
==============================
___ w/ PMH of L portal vein thrombosis in ___ from an episode
of diverticulitis, presenting with RUQ pain and imaging findings
concerning for malignancy found to have poorly differentiated
small cell lung cancer with metastases to the liver.
#SMALL CELL LUNG CANCER WITH LIVER METASTASES
#ACUTE LIVER INJURY, MIXED HEPATOCELLULAR AND CHOLESTATIC
The patient presented with new RUQ pain with hepatomegaly,
admission RUQ ultrasound showing numerous discrete masses
throughout the liver parenchyma, highly concerning for
metastatic disease. Given his extensive smoking history, CT
chest was performed, revealing spiculated 3.1x2.6.1.9 cm mass in
the superior segment of the left lower lobe. The patient
underwent liver biopsy, which confirmed a diagnosis of
metastatic small cell cancer. MRI brain negative for metastases.
Initially there was concern for TLS given elevated LDH (___)
and increased uric acid to 6.8. He was started on allopurinol
and fluids. LFTs continued to increased with elevated Tbili and
INR but then plateaued worrisome for highly invasive and rapidly
progressive malignancy. He is now s/p 3 days (___) of
dose reduced carboplatin/etoposide given that etoposide is 100%
hepatically cleared. By discharge, the patient's LFTs had
drastically improved, indicating a good treatment response, and
CBC remained completely stable. Expect nadir ~ day 14 from
carboplatin (___). He will continue with chemotherapy every 3
weeks.
#DYSPHAGIA TO SOLIDS AND LIQUIDS
#REFLUX
On admission, the patient presented with difficulty swallowing
solid and liquids with increased burping and burning in his
throat. He felt like everything he ate got stuck at top of his
throat. CT abdomen was without any masses compressing on GE
Junction or stomach. CT of his neck was also negative for any
compressive masses but did show air in esophagus suggestive of
dysmotility. He was cleared by Speech and swallow for regular
diet. Barium study showed significant esophageal dysmotility
with multiple tertiary esophageal contractions. He was
ultimately diagnosed with esophageal spasm, and his symptoms
improved drastically with diltiazem (exchanged with metoprolol
for atrial fibrillation) as well as a PPI and simethicone. We
also reviewed behavioral and nutritional interventions to
decrease symptoms, which improved significantly by discharge.
Plan for gastroenterology follow up (coordinated through PCP).
#ATRIAL FIBRILLATION WITH RVR:
Found to be in a fib with RVR with rates in 130s prior to liver
biopsy. He was started on metoprolol and increased to 18.75
q6hr, with good control of heart rates and he converted to NSR.
His rate control was changed to diltiazem in hopes that this
would also help with esophageal dysmotility. He was not started
on anticoagulation given risk of bleeding from liver biopsy and
have not ruled out CNS lesions. His CHADS-VASC score is 2
therefore it was felt that risk of starting anticoagulation
outweighed the benefits at this time. Mr. ___ was in
agreement and was open to starting anticoagulation at a later
date.
#URINARY TRACT INFECTION:
Patient with increased urinary frequency/polyuria (___)
starting on ___. UA was negative, but UCx grew >100,000 e.coli
(note that prior UCx earlier in admission was negative, and that
this UCx had fecal contamination). Renal function normal. Urine
lytes were unremarkable and did not suggest DI. Treated with
Ceftriaxone 1gm IV q24 hr for three days (___) and
symptoms improved. Given that his urine was contaminated, he was
not discharged on ABX.
#FOLLICULITIS:
On ___, patient noted a painful rash on his right buttock
which he has had in the past. Exam consistent with folliculitis,
concerning for low grade skin and soft tissue infection. He was
initiated on mupirocin 2% ointment to be applied twice daily for
a 7 day course (___).
#WEIGHT LOSS:
Patient with significant weight loss during admission, from
188.5 pounds to 173.9 pounds. This was felt to be
multifactorial, due to increased urinary output (patient was
volume overloaded on admission), altered diet inpatient, and
malignancy. Given esophageal spasm and weight loss, nutrition
was consulted and recommended the following:
- Regular, low fat diet; small frequent meals
- Supplements: Ensure clear drinks with meals
CHRONIC ISSUES:
==============================
#CORONARY ARTERY DISEASE:
s/p stenting (unclear locations): Restarted home ASA, holding
atorvastatin iso acute liver injury.
#H/O PORTAL VEIN THROMBOSIS:
Patient states that he took warfarin for ___ year after diagnosis
of portal vein thrombosis, and has not taken any blood thinners
since then.
#HYPERTENSION
Held home Lisinopril to give more blood pressure room during
uptitration of Diltiazem (see above). Also stopped metoprolol in
exchange for Diltiazem. Patient's blood pressures were normal
throughout admission.
TRANSITIONAL ISSUES:
==============================
ADMISSION WEIGHT: 85.5 KG (188.5 POUNDS)
DISCHARGE WEIGHT: 78.8 KG (173.9 POUNDS)
ONCOLOGY
[] Consider initiating systemic anticoagulation for new a fib
and increased hypercoagulability iso malignancy, though now in
sinus rhythm.
[ ] F/U with thoracic oncology, nursing visit, count check, ___
[ ] Port placement on ___
[ ] FYI G6PD negative
[ ] FYI Brain MRI: got records from OSH, looks like it was just
a polyp that was bleeding and they clipped it.
PRIMARY CARE:
[ ] Please follow up patient's weight given weight loss on
admission
[ ] Please arrange for GI outpatient follow up for esophageal
spasm
[ ] Lisinopril held, consider restarting if clinically indicated
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
6. Atorvastatin 20 mg PO QPM
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Diltiazem Extended-Release 240 mg PO DAILY
RX *diltiazem HCl 240 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
3. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
RX *lansoprazole 30 mg 1 capsule(s) under the tongue daily, 30
minutes before breakfast Disp #*30 Capsule Refills:*0
4. Mupirocin Ointment 2% 1 Appl TP BID right butt cheek
Duration: 7 Days
Please apply to your right buttock two times daily
RX *mupirocin 2 % Apply to rash on buttock twice daily Disp #*22
Gram Gram Refills:*0
5. Ondansetron ODT 8 mg PO Q8H:PRN nausea
RX *ondansetron 8 mg 1 tablet(s) under the tongue every 8 hours
Disp #*30 Tablet Refills:*0
6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*30
Tablet Refills:*0
7. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 1 packet by mouth once
daily with 8 ounces of water. Refills:*0
8. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice daily.
Disp #*30 Tablet Refills:*0
9. Simethicone 125 mg PO QID:PRN gas
RX *simethicone 125 mg 1 tablet by mouth 4 times daily Disp
#*120 Capsule Refills:*0
10. Acetaminophen (Liquid) 500 mg PO Q6H:PRN Pain - Mild
Do not exceed 2grams per day
11. Aspirin 81 mg PO DAILY
12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
13. HELD- Atorvastatin 20 mg PO QPM This medication was held.
Do not restart Atorvastatin until your doctor tells you it's
safe to do so
14. HELD- Lisinopril 20 mg PO DAILY This medication was held.
Do not restart Lisinopril until your doctor tells you it's safe
to do so
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Small cell lung cancer with metastases to the liver
Diffuse Esophageal Spasm
Secondary Diagnosis:
Urinary tract infection
Folliculitis
Weight loss
Atrial Fibrillation with RVR
Coronary Artery Disease
H/O Portal Vein Thrombosis
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to participate in your care.
Why was I admitted to the hospital?
- You were admitted to the hospital because you had new pain in
your right upper stomach and were having trouble swallowing both
solids and liquids.
What happened while I was here?
- We performed imaging, which showed a concerning looking mass
in your lungs and multiple masses in your liver.
- The radiology doctors performed ___ of one of these liver
masses, which showed that you have small cell lung cancer which
has spread to your liver.
- You received chemotherapy for the cancer.
- You had some spasms of your esophagus which were likely
causing your difficulty swallowing and we treated you with a
medication called diltiazem and simethicone (gasX).
What should I do when I leave the hospital?
- You should make sure you keep your follow-up appointments and
take your medications as listed below; in particular you should
follow-up with gastroenterology about the trouble swallowing.
We wish you the best.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10237339-DS-13 | 10,237,339 | 26,503,114 | DS | 13 | 2116-08-24 00:00:00 | 2116-08-24 12:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Nausea, vomiting x1 week
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with hx of treated schistosomiasis in ___ presenting with
intermittent N/V x1 week, and orthostasis. Pt spent one month in
___ in ___, and returned to ___ again in ___.
Immediately upon return from the ___ trip, she was diagnosed
with and completed a course of praziquantel for schistosomiasis.
One week prior to presentation, on ___ she developed nausea,
with sensation of the world spinning, unable to get out of bed.
She had dry heaves, and awoke feeling much less dizzy, but with
persistent nausea. Through ___, she had anorexia, unable to
tolerate a full diet. She had school work due, and tried to push
through her symptoms, assuming she had a GI virus. On ___ and
___, she had a better appetite, although she did notice some
postprandial nausea that then resolved. On the day prior to
presentation, at noon, she went for a run. At dinner, she began
to feel queasy, then abruptly developed terrible nausea with
"tunnel vision," emesis of lunch and ?dinner from prior night.
Emesis persisted q15-30 minutes. She presented to ___ for further evaluation, with
persistent q15 minute emesis. They gave oral rehydration
therapy, then 2L IVF, but was persistently orthostatic, and was
transferred to ___ ED. Review of ___ records reveal that they
were unable to obtain orthostatics ___ emesis when sitting up.
She denies headaches, sore throat, rhinorrhea, chest pain, SOB.
She has abdominal tenderness from repeated emesis, but none
prior to onset of emesis. Denies dysuria, hematuria, melena,
hematochezia, diarrhea, constipation. She did have alternating
diarrhea/constipation with ___ colored stools when she was
diagnosed with schisto; she does not have these symptoms with
this episode.
In the ___ ED:
VS 98.4, 72, 117/78, 98% RA
Labs notable for WBC 7.2, Hb 13.8, Plt 176, Cr 0.7, UHCG
negative, UA negative, LFTs WNL, parasite smear negative
Received 2L IVF at ___ prior to
transfer
UCx sent
On arrival to the floor, she reports Ativan helped with the
nausea, and allowed her to sleep, and able to tolerate some
ginger ale. Zofran did not relieve her symptoms.
ROS: all else negative
Past Medical History:
Blateral foot surgery
Acne
Dysmenorrhea
Migraine headaches with aura
Lactose intolerance
Social History:
___
Family History:
Father died of a ruptured berry aneurysm of the
Circle of ___ at age ___, pt was age ___. Mother with migraine
headache.
Physical Exam:
ADMISSION EXAM:
VS 99.0 PO 109 / 67 R Lying 90 18 99 Ra. HR 82->11 from lying to
standing (my measurement), lightheadedness with standing
improved from prior, but persists
Gen: Pleasant, thin female appears stated age, NAD
HEENT: PERRL, EOMI, clear oropharynx, anicteric sclera
Neck: Supple, no cervical or supraclavicular adenopathy
CV: RRR, no m/r/g
Lungs: CTAB, no wheeze or rhonchi
Abd: soft, mild TTP at suprapubic region, no rebound or
guarding, normoactive bowel sounds, no hepatosplenomegaly
GU: No foley
Ext: WWP, no c/c/e
Neuro: alert, interactive, CN II-XII intact, strength ___ in UE
and ___ bilaterally, finger to nose intact on R, deferred on L
___ L antecubital PIV, stands up without assistance
Skin: No rash or lesions
DISCHARGE EXAM:
VS: 98.0PO 97 / 57 60 16 100 Ra
Gen: Pleasant, thin female appears stated age, NAD
HEENT: PERRL, EOMI, clear oropharynx, anicteric sclera
Neck: Supple, no cervical or supraclavicular adenopathy
CV: RRR, no m/r/g
Lungs: CTAB, no wheeze or rhonchi
Abd: soft, NT/ND, no rebound or guarding, normoactive bowel
sounds, no hepatosplenomegaly
GU: No foley
Ext: WWP, no c/c/e
Neuro: alert, interactive, CN II-XII intact, strength ___ in UE
and ___ bilaterally, finger to nose intact bilaterally, gait
testing deferred at current time
Skin: No rash or lesions
Pertinent Results:
ADMISSION LABS:
___ 12:30PM URINE HOURS-RANDOM
___ 12:30PM URINE UCG-NEGATIVE
___ 12:30PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 12:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
___ 12:30PM URINE RBC-4* WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 12:30PM URINE MUCOUS-RARE
___ 05:20AM GLUCOSE-91 UREA N-12 CREAT-0.7 SODIUM-138
POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-19* ANION GAP-17
___ 05:20AM estGFR-Using this
___ 05:20AM ALT(SGPT)-14 AST(SGOT)-22 ALK PHOS-74 TOT
BILI-0.6
___ 05:20AM LIPASE-31
___ 05:20AM ALBUMIN-3.9
___ 05:20AM WBC-7.2 RBC-4.67 HGB-13.8 HCT-41.5 MCV-89
MCH-29.6 MCHC-33.3 RDW-12.3 RDWSD-40.1
___ 05:20AM NEUTS-85.1* LYMPHS-6.4* MONOS-7.4 EOS-0.4*
BASOS-0.3 IM ___ AbsNeut-6.09 AbsLymp-0.46* AbsMono-0.53
AbsEos-0.03* AbsBaso-0.02
___ 05:20AM PLT COUNT-176
___ 05:20AM PARST SMR-NEGATIVE
DISCHARGE LABS:
___ 07:00AM BLOOD WBC-3.9* RBC-4.44 Hgb-13.4 Hct-39.4
MCV-89 MCH-30.2 MCHC-34.0 RDW-12.3 RDWSD-40.2 Plt ___
___ 07:00AM BLOOD Glucose-128* UreaN-5* Creat-1.0 Na-141
K-3.8 Cl-104 HCO3-23 AnGap-18
___ 07:00AM BLOOD ALT-12 AST-16 AlkPhos-61 TotBili-0.2
___ 07:00AM BLOOD Albumin-3.7 Calcium-9.0 Phos-4.3 Mg-1.9
CT head w/ and w/out contrast ___:
1. No evidence of acute intracranial hemorrhage, intracranial
mass or edema.
Please note MRI of the brain is more sensitive for the
evaluation of
encephalitis or intracranial masses.
2. Trace thickening of the ethmoid sinuses.
MRI/MRA brain ___:
1. Unremarkable noncontrast enhanced brain MRI.
2. Normal brain MRA without evidence of an aneurysm.
Brief Hospital Course:
___ with hx of treated schistosomiasis in ___ presenting with
intermittent N/V x1 week and Orthostasis refractory to IV
hydration.
# N/V: Pt presented with worsening episodic nausea that
progressed to intractable emesis the day prior to presentation.
She otherwise reported some occasional chills and dizziness but
denied any obvious associated abdominal pain. No clear
association with food or worse at any particular time of day.
Symptoms self-resolved on HD2. Unclear cause as symptoms
sounded possibly related to CNS/inner ear etiologies but neuro
exam was intact and no nystagmus was noted. CT head and MRI
brain were obtained to look for possible CNS infections/lesion
that could explain pt's dizziness and nausea and both of these
were negative. ID was also consulted given pt's recent travel
to ___ and dx of schistosomiasis for which she completed tx
but they did not feel that her symptoms were related to a
parasitic infection. Neutrophilia and mild thrombocytopenia
were noted on CBC but these were felt to be stress-related.
Rest of Chem7 and LFT's were wnl. As pt's symptoms had
resolved, she felt that that she wanted to go home. She was
counseled to return for further GI work-up and imaging if
symptoms recurred as the yield of pursuing this w/u in the
absence of symptoms was felt to be low.
# Orthostasis: Felt to be related to volume depletion as this
improved with aggressive IV fluids (6L on admission)
# Migraine headaches: pt c/o mild headache on admission which
improved with fluids and Tylenol. Not similar to prior
migraines.
Transitional:
============
[] Pt presented with n/v, the etiology of which is unclear but
symptoms have self-resolved. If they recur, consider CT a/p for
further w/u.
Billing: greater than 30 minutes spent on discharge counseling
and coordination of care.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Minocycline 100 mg PO Q24H
2. Minastrin ___ Fe (norethindrone-e.estradiol-iron) 1 mg-20
mcg(24) /75 mg (4) oral DAILY
3. Tretinoin 0.05% Cream 1 Appl TP QHS
Discharge Medications:
1. Minastrin ___ Fe (norethindrone-e.estradiol-iron) 1 mg-20
mcg(24) /75 mg (4) oral DAILY
2. Minocycline 100 mg PO Q24H
3. Tretinoin 0.05% Cream 1 Appl TP QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Nausea and vomiting due to unclear cause
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came in with nausea, dizziness, and dehydration. We gave
you a lot of fluids and your symptoms improved. We also did a
CT scan and MRI of your head to look for any lesions or
inflammation to explain your symptoms and these were negative.
At this point, the cause of your symptoms is unclear. It is
possible that it could have been caused by an unusual viral
infection which has now improved. If you symptoms of nausea and
vomiting recur and you are unable to tolerate any oral intake,
please come back to the Emergency Department for further
evaluation. It might be helpful to obtain a CT scan of your
abdomen if and when you are having symptoms.
It was a pleasure taking care of you at ___
___.
Followup Instructions:
___
|
10237425-DS-9 | 10,237,425 | 20,193,910 | DS | 9 | 2184-05-13 00:00:00 | 2184-05-13 20:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ prior history of CAD w/MI in ___ and ___ x ___ s/p excision
on ___ p/w hypotension and fevers.
Patient states that he been in his usual state of good health
and underwent local resection of BCC lesions to his left
shoulder and left lower back approximately 4 days prior
presentation. States that he felt well over the weekend, and gf
who had been caring for surgical sites did not note any
discharge, although had been tender. Yesterday began to develop
fever to 102 (forehead temp strip) and subjective chills. He
denies any nausea, vomiting, diarrhea, abdominal pain, cough,
chest pain, shortness of breath, headache. States that he took
acetaminophen which reduced his fever, however today while at
work he noted that his fingers became very white and he had
shaking rigors.
As such he presented to his ___ urgent care
providers, they're noted to be febrile to 103, in addition
hypotensive at 80/40. Received approximate 750 cc normal saline
as well as vancomycin prior to arrival. Had been planned for
direct admission, however given his hypotension he was referred
to the ED for stabilization. Blood cultures were obtained prior
to presentation, in addition has a reportedly negative chest
film.
Per OP note: T of 102.7 at ___. Is three days s/p basal cell
carcinoma excision on left shoulder and mid lower back and was
on keflex for that and this site apparently does not appear
infected. Urine dipstick negative, urine cx, blood cx pending,
CBC with normal WBC count, but Creatinine is 1.7 today, which is
up from normal baseline. Per Dr ___ not on
___. She has given him IVF in Urgent Care, and BP is
stable; HR has come down from 106 to 95 with fluids. CXR
negative. He has also received one gram of IV Vancomycin given
past history of presumed MRSA sepsis in ___ in setting of lower
exremity cellulitis (no positive cultures). He also had elevated
transaminases that admission attributed to a statin.
.
In the ED, initial VS were 99.4 83 96/51 16 95% RA. Received 1L
NS and pip-taz. Labs notable for Cr 1.3, lactate 2.1, AST/ALT
:71/102 Tbili: 1.7. RUQ US negative.
.
On arrival to the floor, patient denies pain or shortness of
breath.
.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
CAD s/p MI in ___
Hypertension
Hyperlipidemia
bcc s/p excision ___
MRSA cellulitis w/sepsis ___
Social History:
___
Family History:
Patient denies any family history of heart disease, diabetes, or
cancer. Has a mother who is ___ years ___.
Physical Exam:
ON ADMISSION
VS - Tc: 99.6 HR: 108/84 BP: 90 18% RA
General: comfortable
HEENT: NC, AT, opc, good dentition
Neck: JVP 6cm, no lymphadenopathy
CV: RRR, no M/R/G
Lungs: CTA-B
Abdomen: +bs, soft, nt,nd, no masses.
GU: deferred
Ext: 2+ peripheral pulses, cool extremities, pink
Neuro: AOX3, CNII-XII intact
Skin: erythema, mild tenderness left shoulder surgical site, mid
lower back, sutures in place. no drainage, no flocculence at
site.
seborrheic keratosis with mild surrounding erythema on mid
abdomen (s/p cryotherapy).
ON DISCHARGE:
Vitals: Tm:99.5, Tc98.9, BP122/72,P76, RR18, SPO2 96% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: Crackles at bases bilaterally
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, obese, non-tender to palpation. No
hepatosplenomegaly. No caput medusae, no spider angiomas.
Ext: Warm, well perfused, 2+ pulses, no edema.
Skin: Lt shoulder with 3cm laceration, surrounding erythema
markedly improved. No drainage on dressing. No fluctuance
palpated.
Neuro: CNII-XII grossly intact.
Pertinent Results:
ON ADMISSION:
___ 06:20PM BLOOD WBC-5.1 RBC-3.89* Hgb-12.0* Hct-32.5*
MCV-84 MCH-30.8 MCHC-36.9* RDW-13.4 Plt ___
___ 06:20PM BLOOD ___ PTT-31.4 ___
___ 06:20PM BLOOD Glucose-145* UreaN-28* Creat-1.3* Na-135
K-3.9 Cl-101 HCO3-24 AnGap-14
___ 06:20PM BLOOD ALT-71* AST-102* AlkPhos-69 TotBili-1.7*
___ 06:20PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
___ 06:20PM BLOOD HCV Ab-NEGATIVE
___ 06:38PM BLOOD Lactate-2.1*
ON DISCHARGE
___ 05:48AM BLOOD WBC-4.3 RBC-3.56* Hgb-11.0* Hct-30.0*
MCV-84 MCH-30.9 MCHC-36.6* RDW-13.6 Plt ___
___ 05:48AM BLOOD Glucose-116* UreaN-11 Creat-1.0 Na-137
K-3.5 Cl-105 HCO3-29 AnGap-7*
___ 05:48AM BLOOD ALT-57* AST-51* AlkPhos-74 TotBili-0.7
___ 05:48AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.1
___ 05:34AM BLOOD calTIBC-183 ___ Ferritn-1788*
TRF-141*
___ 05:34AM BLOOD PSA-10.2*
IMAGING:
CXR:
FINDINGS: In comparison with the study of ___,
cardiomediastinal
silhouette is stable. There is hyperexpansion of the lungs
raising the
possibility of chronic pulmonary disease, without definite acute
focal
pneumonia. Blunting of the costophrenic angles is again seen,
consistent with
pleural thickening or pleural effusion and some atelectatic
changes at the
bases.
RUQ U/S:
IMPRESSION:
1. No evidence of cholelithiasis or cholecystitis.
2. Gallbladder polyp measuring 0.9 cm. Recommend follow-up in
6 months to
document stability.
3. Echogenic liver consistent with fatty infiltration. More
advanced forms of
liver disease such as cirrhosis or hepatic fibrosis cannot be
excluded on this
study.
Brief Hospital Course:
___ Y/o man with hx Hypertension, hyperlipidemia presenting with
fevers, with elevated lactate to 2.1, hypotension on
presentation meeting criteria for severe sepsis.
#Fever: Cellulitis at recent skin surgery site of excision of
basal cell carcinoma:
I also think he may have had viral prodrome with high fever and
lab changes detailed below. Patient initially presented with ___
SIRS criteria (fever, tachycardia) with elevated lactic acid and
Cr. Sources of infection include cellulitis from recent ___
excision site on Lt shoulder vs transient bacteremia ___
procedure. Other etiologies to considered included PNA, UTI,
cholangitis given hyperbilirubinemia, gastroenteritis given
diarrhea, and viral infection. CXR and UA were negative for
infection. Cholangitis was thought to be less likely as patient
was not having any abdominal pain. Furthermore, RUQ U/S was
reassuring. Empirically started on vancomycin and zosyn. Zosyn
was later discontinued as it was thought cellulitis was the most
likely source. Patient's blood pressure responded to IVF
resuscitation. Patient discharged on Bactrim, he will be treated
for a full 10 day course (___).
# Transaminitis: Present since ___. RUQ US showing fatty liver,
although cannot rule out hepatic firbosis and cirrhosis. DDx
includes NAFL, cirrhosis, vs statin use. Hepatology serologies
were negative. Patient does not have signs of cirrhosis on
physical exam. ___ consider hepatology follow as an outpatient
for further workup.
# Hyperbilirubinemia: New onset, indirect > direct, indicating
hemolysis vs ___'s syndrome. Reticulocyte count,
haptoglobin, and peripheral smear inconsistent with hemolysis.
Peripheral smear showed no schistocytes, no spherocytes, some
Burr cells (? liver disease), and neutrophils. Patient's Tbili
trended down during hospitalization.
# Thrombocytopenia: Seems to be chronic, however trending down
now. New downtrend may be ___ infection, liver disease, vs
antibiotics. Platelets remained stable.
# Anemia: Iron studies consistent with anemia of chronic
disease. H/H were stable.
# ARF: Cr elevated to 1.7 at ___. Baseline is 1.0
in ___. Etiology likely pre-renal. Patient s/p 3L NS. Cr back
at baseline.
# HTN: Atenolol was help in setting of severe sepsis. Patient to
continue atenolol on discharge.
# Hypercholesterolemia: Atorvastatin held in setting of LFT
elevation. Re-started upon discharge.
# CAD s/p MI
- Continue aspirin.
# BCC x ___ s/p excision
- Daily dressing change
- Suture removal 2 weeks from procedure (___)
- Continue to f/u with Dr ___
___ ISSUES:
- Patient discharged with Bactrim, he will complete a full 10
day course of antibiotics.
- RUQ with fatty liver: NAFL vs ___ vs. cirrhosis. Consider
outpatient hepatology follow-up.
- RUQ U/S: Gallbladder polyp measuring 0.9 cm which will require
a six-month to one-year followup.
- Patient hepatitis A and B antibody negative. Will need
hepatitis B vaccine.
- PSA 10.2, patient denied any urinary symptoms.
- Patient complained of Lt hamstring strain ___ softball injury.
Would like ___ as an outpatient.
- Patient complained of trigger finger in his right ___ digit.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Aspirin 81 mg PO DAILY
5. Sulfameth/Trimethoprim DS 1 TAB PO BID
End date: ___
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*16 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Cellulitis
SECONDARY DIAGNOSIS:
Transaminitis
Thrombocytopenia
Normocytic anemia
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 came in because of fever and low blood
pressure. The source of your infection is likely the ___
excision site. We treated you with IV antibiotics, and we will
continue to treat you with oral antibiotics for a total of 10
days (___). We are glad to see your infection is
improving.
We hope your muscle strain improves. We will let your PCP know
that ___ would be beneficial. Please follow up with your PCP, the
appointment is listed below.
Followup Instructions:
___
|
10237861-DS-21 | 10,237,861 | 24,850,167 | DS | 21 | 2182-04-12 00:00:00 | 2182-04-12 16:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
vertigo with nausea/vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old right handed male with history of
hypertension, sleeve gastrectomy, lumbar surgeries and resultant
left leg sensory changes and weakness, chronic left arm weakness
from, former tobacco use and prior episode of vertigo of unclear
etiology who presents with acute onset dizziness.
Per ___ he has been in his usual state of health recently
without any fevers, chills, URI symptoms or GI illnesses. He has
chronic left sided weakness and sensory changes in his leg. He
says he saw a neurologist at ___ and ___ previously for these
symptoms which were attributed to spine disease. He has had left
leg weakness (mild, can walk unassisted) since a "lumbar" spine
surgery in ___. He has minimal sensation in his left leg below
the knee since that surgery. He also developed left arm weakness
(mild) about ___ years for which he was told was due to issues
in
his neck. He had an episode of vertigo about a year ago which
lasted for several weeks and then abruptly resolved. He
reportedly had an MRI at that time that showed no stroke.
He reports that he woke up around 4A as usual and was walking
fine, feeling normal and came into work. Around 7A he was
sitting
at his desk working at the computer when he had sudden onset
sensation of room spinning. He felt like his vision with "jerky"
but there was no double vision. He then felt nauseous and
vomited. He noticed when he was walking that he felt like he was
going to side to side and had to grab onto things. He decided to
sit back at his desk and the dizziness was improved but never
completely went away. He had no difficulty speaking, new
weakness
or numbness. He had no headache at that time. Then around 9A he
had acute worsening of the sensation again with vomiting. He
continued to have "jerky" vision and again had difficulty
walking
when he tried to get up. Given persistence of symptoms he
decided
to come to the emergency room. While in the ED he developed a
bifrontal throbbing headache with light and sound sensitivity
which was partially relieved by acetaminophen. He continued to
have persistent dizziness although partially improved if he
stayed completely still. He has had no hearing changes or
ringing
in the ear.
Of note, he does report prior history of migraines which were
biposterior, throbbing with light and sound sensitivity. He
never
had auras and has not had migraines in several years.
ROS:
On neurological review of systems, the ___ denies
confusion,
difficulties producing or comprehending speech, loss of vision,
dysarthria, dysphagia, tinnitus or hearing difficulty. Denies
NEW
focal weakness (chronic left sided weakness), no new numbness,
parasthesiae (chronic LLE sensory changes). No bowel or bladder
incontinence or retention.
On general review of systems, the ___ denies recent fever,
chills, night sweats, or recent weight changes (lost 80 lbs in
past ___ years due to sleeve gastrectomy). Denies cough, shortness
of breath, chest pain or tightness, palpitations. Denies
diarrhea, constipation or abdominal pain. Denies dysuria, or
recent change in bowel or bladder habits. Denies arthralgias,
myalgias, or rash.
Past Medical History:
sleeve gastrectomy ___
chronic back pain
lumbar surgery x4 in ___ with resultant LLE weakness and
numbness
chronic left arm weakness x ___ years (unclear ___, was told
due to spinal disease), has been stable
left knee replacement ___
hypertension - on one ___
denies HLD
prior episode of acute onset vertigo lasting several weeks,
negative MRI at ___ ___
Social History:
___
Family History:
mother with ?heart problems in her ___
Physical Exam:
ON PRESENTATION:
================
Vitals: T: 97 BP: 138/82 HR: 68 RR: 16 SaO2: 99%
General: Awake, cooperative
HEENT: NC/AT, no scleral icterus noted
Neck: Supple, No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: RRR
Abdomen: obese, soft
Extremities: No ___ edema, does have some hyperpigmentation of
ankles bl, minimal hair
Neurologic:
-Mental Status: Alert, oriented to self, date, place and
interval
events, can ___ backward, fluent language with intact
comprehension, able to read, name high and low, no dysarthria,
no
apraxia or neglect
-Cranial Nerves:
L pupil 2->1, R 3.5->2.5, full fields to count and wiggle, right
beating nystagmus on right gaze, left beating nystagmus on left
gaze, face sensation full to pin throughout, no facial
asymmetry,
negative head impulse, negative vertical skew, palate symmetric,
tongue midline and full excursions
-Motor: Normal bulk and tone throughout. No pronator drift. No
adventitious movements, such as tremor or asterixis noted.
[Delt][Bic][Tri][ECR][FEx][[IP][Quad][Ham][TA][Gas]
L 5* 5 4+ 5 5 4 5 4* 4+ 5
R 5 5 5 5 5 5 5 5 5 5
-Sensory: diminished pin left lower extremity below knee and
"absent" starting at ankle through foot; absent proprioception
at
left toe, present at ankle. Unable to tolerate Romberg (see
below).
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 2 1 1 - 0
R 2 1 1 2 0
Plantar response was mute on left and down on right
-Coordination: No intention tremor. Normal ___
bilaterally. Dysmetria on left finger nose finger and mirroring,
oddly there was no rebound.
-Gait: Able to sit at edge of bed without truncal ataxia. Stood
with broad base and immediately fell to left side. Tried to
steady with 2 person assist but could not walk.
AT DISCHARGE:
=============
Vitals:
24 HR Data (last updated ___ @ 937)
Temp: 98.4 (Tm 98.4), BP: 152/69 (___), HR: 76
(___), RR: 16 (___), O2 sat: 99% (___), O2 delivery: RA
General: Awake, cooperative
HEENT: NC/AT, no scleral icterus noted
Neck: Supple, No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: RRR
Abdomen: obese, soft
Extremities: No ___ edema
Neurologic:
-Mental Status: Alert, oriented to self, date, place and
interval events, fluent language with intact comprehension, able
to read, name high and low, no dysarthria, no apraxia or neglect
-Cranial Nerves:
L pupil 4->2, R 5->3, full fields to count and wiggle, EOMI
without nystagmus in all directions, face sensation full to pin
throughout, no facial asymmetry, negative HiNTS, negative
vertical skew, palate symmetric, tongue midline and full
excursions
-Motor: Normal bulk and tone throughout. No pronator drift. No
adventitious movements, such as tremor or asterixis noted.
[___]
L 4 4 4- 4 4+ 4 4 4- 4 4 4 3
R 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: diminished pin left lower extremity below knee and
"absent" starting at ankle through foot; absent proprioception
at left toe, present at ankle.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 2 1 1 - 0
R 2 1 1 2 0
Plantar response was mute on left and down on right
-Coordination: No intention tremor. Normal ___
bilaterally. No dysmetria on finger nose finger and mirroring.
Romberg normal.
-Gait: Able to sit at edge of bed without truncal ataxia. Walked
with steady, narrow based gait.
Pertinent Results:
___ 11:40AM BLOOD
___
___
___
___
___
___
___
___
___
Plt ___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
cTropnT-<0.01
___
___
___
___
___
___
___
___
___
___
___
___
___
DIAGNOSTICS:
===============
___
IMPRESSION:
1. No evidence for an acute infarction. No mass effect on
noncontrast MRI.
2. Mild left maxillary and ethmoid sinus disease.
___
IMPRESSION:
1. Dental amalgam and venous contrast pooling streak artifact
limits study.
2. No intracranial hemorrhage or acute territorial infarct.
Please note MRI of the brain is more sensitive for the detection
of acute infarct.
3. Multilevel degenerative changes in the cervical spine with up
to moderate spinal canal narrowing and question congenital short
pedicles. If clinically indicated, consider dedicated cervical
spine MRI for further evaluation.
4. Nonspecific lymph nodes as described, which may be reactive.
5. Paranasal sinus disease, as described.
6. Nonocclusive atherosclerotic plaque of circle of ___ as
described.
7. Otherwise, grossly patent circle of ___ without definite
evidence of
stenosis,occlusion,or aneurysm.
8. Streak artifact limits evaluation of bilateral vertebral
artery origins.
9. Nonocclusive atherosclerotic changes of cervical carotid
arteries as
described.
10. Otherwise, grossly patent bilateral cervical carotid and
vertebral
arteries without definite evidence of stenosis, occlusion, or
dissection.
Brief Hospital Course:
Mr. ___ is a ___ year old male former smoker with hypertension
and history of migraines who presented to the ED with acute
onset vertigo.
History and exam notble for persistent vertigo with
nausea/vomiting and oscillopsia, headache and gait instability,
anisocoria (right>left), direction changing nystagmus, no
corrective saccade on head impulse, left dysmetria on FnF and
mirroring and broad based stance with fall to left. Some mild
left hemiparesis and left leg numbness reportedly chronic. After
IV tylenol and IV fluids, almost all exam findings improved. Day
of discharge exam notable for R>L anisocoria, mild left
hemiparesis and left leg numbness.
Active Issues:
==============
#Vestibular migraine
___ reports history of migraines, primarily biposterior in
the past. He endorses similar episodes of vertigo and nausea in
past. History and exam most consistent with migraine, especially
with reported pounding bifrontal headache in the ED and symptoms
limited to vertigo, nystagmus, and some dysmetria/ataxia in the
absence of other lateral medullary symptoms (anisocoria
baseline). Lateral medullary stroke unlikely, given resolution
of symptoms with IV fluids and IV tylenol and given negative
MRI. Peripheral etiologies such as vestibular neuritis or
Meniere's also less likely given central pattern of nystagmus on
initial presentation. Started prochlorperazine for
migraine/nausea/vomiting, which caused the ___ anxiety
requiring lorazepam so was discontinued. Seen by physical
therapy twice while inpatient due to initial gait instability,
recommended d/c to home without services. At time of discharge,
___ feels well and is in agreement with this plan.
- No prophylactic migraine medication started at this time as
unclear frequency of migraines and ___ cannot confirm which
home medications he is on
- Abortive medications: Naproxen 500 mg BID as needed for severe
headache, do not use more than 3 days a week. Zofran 4 mg q8h
for migraine (nausea/ vomiting).
- ___ should keep a headache diary to better assess
frequency, duration, and triggers
- Sleep hygiene, ___ reports he only sleeps 4 hours a night
for past ___ years
Chronic Issues:
===============
#Hypertension
History of hypertension, unclear per ___ if on medication
though reportedly previously on lisinopril. Metoprolol last
filled in ___ with no refills. BPs in ___ systolic range
while inpatient.
Transitional Issues:
====================
[] Neurology
- Post hospital follow up and migraine management
- will take naproxen prn and ondansetron prn until care is
established with PCP and neurology
- no other prophylactic or abortive medication started at this
time as ___ with infrequent migraines
[] Primary Care
Unclear per ___ if on antihypertensive medication though
reportedly previously on lisinopril. Metoprolol last filled in
___ with no refills.
- ___ consider statin therapy with LDL 99
- Management of hypertension per PCP
- ___ with significant anxiety while in the hospital, would
monitor mood
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 1200 mg PO TID
2. TraMADol ___ mg PO Q6H:PRN Pain - Moderate
Discharge Medications:
1. Naproxen 500 mg PO Q12H:PRN headache/migraine
Do not use more than 3 times a week
RX *naproxen 500 mg 1 tablet(s) by mouth twice daily as need for
migraine Disp #*30 Tablet Refills:*3
2. Ondansetron 4 mg PO Q8H:PRN migraine with nausea/vomiting
RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours as
needed Disp #*21 Tablet Refills:*0
3. Gabapentin 1200 mg PO TID
4. TraMADol ___ mg PO Q6H:PRN Pain - Moderate
** ___ did not know his home antihypertensives, should
continue without change **
Discharge Disposition:
Home
Discharge Diagnosis:
Migraine
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of vertigo with severe
nausea and vomiting thought to be resulting from migraine, a
condition which can present as a headache or as other neurologic
symptoms which might mimic a stroke. However, in your situation
we believe migraine is the explanation for your symptoms as you
had a MRI of your brain did not show a stroke. You have also had
very similar episodes in the past.
You will need follow up with your PCP and ___ for your
migraines. We recommend seeing your PCP ___ 1 week. It would
be helpful to keep a journal of your symptoms and any triggers
(such as foods, weather, caffeine, sleep schedule) which may
have been related to your symptoms. This will help your
providers determine how to best help you control your headaches.
Please also bring a list of your current medications to your
appointments.
For headache abortion until you see your PCP or ___:
1) Naproxen 500mg twice daily as needed for headache/migraine.
Try not to take this medication more than 3 days a week as too
much medication for headache can cause your headache to worsen.
2) Ondansetron 4 mg every 8 hours as needed for nausea/vomiting
3) Recommend drinking 8 cups of water daily, 30 minutes of
physical activity 5 times a week, focus on sleep hygiene as poor
sleep can trigger migraines, limit screen time (tv, ipads,
phones) as this can trigger migraines
Please follow up with your primary care physician and ___
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:
___
|
10238321-DS-22 | 10,238,321 | 29,455,580 | DS | 22 | 2172-12-20 00:00:00 | 2173-02-22 18:40:00 |
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, emesis
Major Surgical or Invasive Procedure:
None during current admission.
History of Present Illness:
___ with slow transit constipation s/p laparoscopic diverting
loop ileostomy on ___ by Dr ___. She was discharged from
the hospital on ___. Since then, she reports having worsening
upper abdominal pain since ___. She started having nonbloody,
bilious emesis that afternoon and was unable to tolerate PO. She
says she was having ostomy output then and it decreased today.
However, she recorded 300 cc of ostomy output on ___, 300 cc
on ___, and 250 cc on ___. She reports that the ostomy is
still producing some gas. Small BM per rectum earlier today. No
fevers, chills, sweats, dysuria/hematuria, chest pain, dyspnea.
She went to ___, where she got a CT scan (without PO
contrast). The concern was for a bowel obstruction,
so she was transferred to ___ for further management.
Past Medical History:
Urinary incontinence
Anxiety/depression
Long history of IBS with constipation / Colonic inertia.
Thyroid nodule on supression therapy.
Brain lesions with tremors.
Gastroesophageal reflux vs functional dyspepsia.
Acne rosacea.
Past Surgical History:
Bladder sling ___ years ago) at the ___ for stress
urinary incontinence.
Social History:
___
Family History:
FH:
Mother's sister has ___ disease. No family history of
colon cancer or other cancers.
Physical Exam:
Comfortable, thin, NAD
CTA
RRR
Abd soft, non-distended, mild diffuse tenderness
Colostomy beefy red, with thick yellow output in ostomy bag
Ext wwp, no edema
Pertinent Results:
___ 10:40AM
8.9 < 16.2/46.7 < 561
___ 06:15AM
136 | 100 | 18
4.1 | 22 | 0.7
Calcium-9.6 Phos-3.9 Mg-2.2
Radiology Report CHEST (PA & LAT) Study Date of ___ 11:00
___
1. No focal consolidation.
2. Enteric tube terminating in the gastric body.
Radiology Report ABDOMEN (SUPINE & ERECT) Study Date of
___ 10:22 AM
Prominent, dilated loop of small bowel in the mid abdomen could
represent
ileus or obstruction. If clinically required, additional
characterization with cross sectional imaging may be considered.
Radiology Report ABDOMEN (SUPINE & ERECT) Study Date of
___ 9:34 AM
In comparison with the study of ___, there is a relative
paucity of gas within the bowel. This presents a nonspecific
pattern. However, if there is serious concern for dilated
fluid-filled small bowel, CT would be the next imaging
procedure.
Brief Hospital Course:
Mrs. ___ presented to the emergency department at ___ on
___ with abdominal pain and emesis following discharge
from an uncomplicated diverting loop ileostomy placement (Please
see consult note for further details). After a brief and
uneventful stay in the ED, the patient was transferred to the
floor for further management.
Neuro: Her pain was controlled initially with IV dilaudid. After
her ostomy was cannulated, her pain had largely resolved and she
did not require additional pain medication.
CV: No issues
Pulm: No issues
GI: She initially presented with high ostomy output, greater
than 3L/day, and more than her baseline level of nausea so
loperamide was added to her regimen and GI was consulted. Her
anti-emetic regimen was changed to a combination of zofran,
ativan, pantoprazole and a scopolamine patch per GI
recommendations. On ___, she began complaining of a
significant, sudden increase in her abdominal pain and
distension, so a KUB was obtained which showed a dilated loop of
bowel with air-fluid levels, with significantly decreased ostomy
output. Her ostomy was cannulated with a straight catheter on
___, and over the following day, her ostomy output was greater
than 2L with the patient reporting nearly complete relief of her
pain. The catheter was left in until ___, then it was removed.
Her ostomy output decreased again, to less than 500cc, but the
output was thicker, yellow and she continued to be asymptomatic.
On ___, however, her pain returned, and the ostomy was
recannulated. This time, her ostomy output did not increase and
her pain and nausea remained, so it was removed the same day.
Prior to discharge, she was transitioned back to her home nausea
regimen.
GU: No issues
ID: The patient's WBC was briefly elevated, to 13.0, but had
resolved to within normal limits by time of discharge.
Heme: No issues
On ___, the patient was discharged to home. At discharge,
she was tolerating a regular diet, voiding, ambulating
independently and her ostomy was functioning. She will follow-up
in the clinic in ___ weeks. This information was communicated to
the patient directly prior to discharge.
Post-Surgical Complications During Inpatient Admission:
[ ] Post-Operative Ileus resolving w/o NGT
[x] Post-Operative Ileus requiring management with NGT
[ ] UTI
[ ] Wound Infection
[ ] Anastomotic Leak
[ ] Staple Line Bleed
[ ] Congestive Heart failure
[ ] ARF
[ ] Acute Urinary retention, failure to void after Foley D/C'd
[ ] Acute Urinary Retention requiring discharge with Foley
Catheter
[ ] DVT
[ ] Pneumonia
[ ] Abscess
[ ] None
Social Issues Causing a Delay in Discharge:
[ ] Delay in organization of ___ services
[ ] Difficulty finding appropriate rehabilitation hospital
disposition.
[ ] Lack of insurance coverage for ___ services
[ ] Lack of insurance coverage for prescribed medications
[ ] Family not agreeable to discharge plan
[ ] Patient knowledge deficit related to ileostomy delaying
discharge
[x] No social factors contributing in delay of discharge
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Benztropine Mesylate 1 mg PO DAILY
2. Acidophilus (L.acidoph & ___
acidophilus) 175 mg oral Daily
3. QUEtiapine Fumarate 25 mg PO QHS
4. Lorazepam 1 mg PO Q4H:PRN anxiety
5. Propranolol 20 mg PO BID
6. linaclotide 290 mcg oral Daily
7. Simvastatin 5 mg PO QPM
8. Multivitamins 1 TAB PO DAILY
9. Sertraline 75 mg PO DAILY
10. TraZODone 100 mg PO QHS
11. Levothyroxine Sodium 25 mcg PO DAILY
12. Cyanocobalamin 50 mcg PO DAILY
13. Vitamin D Dose is Unknown PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 25 mcg PO DAILY
2. LOPERamide 2 mg PO TID
RX *loperamide [Lo-Peramide] 2 mg 1 tablet by mouth three times
a day Disp #*90 Tablet Refills:*1
3. Lorazepam 0.5 mg PO Q6H:PRN anxiety
do not take if sleepy or while taking other medications
RX *lorazepam [Ativan] 0.5 mg 1 tablet by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
4. Ondansetron 4 mg PO TID W/MEALS
RX *ondansetron 4 mg 1 tablet(s) by mouth three times a day with
meals Disp #*50 Tablet Refills:*0
5. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. Propranolol 20 mg PO/NG BID
7. QUEtiapine Fumarate 25 mg PO QHS
8. Sertraline 75 mg PO DAILY
9. Simvastatin 5 mg PO QPM
10. TraZODone 100 mg PO QHS:PRN insomnia
11. Acidophilus (L.acidoph &
___ acidophilus) 175 mg oral
Daily
12. Benztropine Mesylate 1 mg PO DAILY
13. Cyanocobalamin 50 mcg PO DAILY
14. linaclotide 290 mcg oral Daily
15. Multivitamins 1 TAB PO DAILY
16. Vitamin D 50,000 UNIT PO DAILY
17. Promethazine 25 mg PO Q6H:PRN nausea
RX *promethazine 12.5 mg ___ tablets by mouth every 6 hours Disp
#*90 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Abdominal pain and nausea after discharge from the hospital
status post colectomy and ileostomy placement.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
___ were admitted to the inpatient Colorectal Surgery Clinic
with nausea and vomiting most likely due to a combination of
post-operative ileus and swelling at your ostomy site combined
with chronic nausea that ___ frequently experience at baseline.
___ have been started on zofran, phenergan, and lorazepam to
help control your nausea. ___ may continue to take the zofran
prior to meals. Take the lorazepam as needed. Please do not
drink alcohol or take narcotic pain medications while taking
lorazepam. Do not restart benztropine mesylate as this may be
related to your symptoms.
___ have a new ileostomy. The most common complication from a
new ileostomy placement is dehydration. The output from the
stoma is stool from the small intestine and the water content is
normally very high. ___ should measure your ileostomy output for
the next few weeks. The output from the stoma should not be more
than 1200cc or less than 300cc. If ___ find that your output has
consistently become too much or too little, please call the
office. The office nurse or nurse practitioner can recommend
medications to increase or slow the ileostomy output. Keep
yourself well hydrated, if ___ notice your ileostomy output
increasing, take in more electrolyte drinks, such as Gatorade.
Please monitor yourself for signs and symptoms of dehydration
including: dizziness (especially upon standing), weakness, dry
mouth, headache, or fatigue. If ___ notice these symptoms please
call the office or return to the emergency room for evaluation
if these symptoms are severe. ___ may eat a regular diet with
your new ileostomy. However it is a good idea to avoid fatty or
spicy foods and follow diet suggestions made to ___ by the
ostomy nurses.
Please monitor the appearance of the ostomy and stoma and care
for it as instructed by the wound/ostomy nurses. ___ 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.
Thank ___ for allowing us to participate in your care. We look
forward to seeing ___ at your follow-up appointment in clinic.
Followup Instructions:
___
|
10239232-DS-9 | 10,239,232 | 24,290,941 | DS | 9 | 2187-06-23 00:00:00 | 2187-06-24 10:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Aspirin
Attending: ___
Chief Complaint:
Transient right ___ vision loss
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old man with past medical history
including right parieto-temporal embolic stroke (___), atrial
fibrillation c/b sick sinus syndrome, hypertension and
hyperlipidemia who presents to the ___ ED ___ as a code
stroke
for transient right ___ vision loss lasting 30 minutes.
Pt states he awoke in his usual state of health. He was getting
ready to go to church when, all of a sudden, he noted that his
vision in his right ___ was distorted and "people looked darker
and usual". He noted a "graying" of his vision but not complete
blindness. He states that symptoms were in his right ___ only;
however, he did not cover his left or right ___ to determine
this. This lasted about 30 minutes and had completely resolved
at
time of assessment.
Otherwise, pt denies any slurred speech, word finding
difficulties, weakness, numbness, or facial droop. He states
that, during his prior stroke, he has vision loss in bilateral
eyes and numbness on his left side; he has no residual deficits.
En route to the ED, pt noted a mild, dull bifrontal headache
that
resolved after 10 minutes. He also reported transient
palpitations in the ambulance but no chest pain, shortness of
breath, or lightheadedness.
On neurologic review of systems, the patient denies
lightheadedness or confusion. Denies difficulty with producing
or
comprehending speech. Denies blurred vision, diplopia, vertigo,
tinnitus, hearing difficulty, dysarthria, or dysphagia. Denies
focal muscle weakness, numbness, parasthesia. Denies loss of
sensation. Denies bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the patient denies fevers, rigors,
night sweats, or noticeable weight loss. Denies chest pain,
dyspnea, or cough. Denies nausea, vomiting, diarrhea,
constipation, or abdominal pain. No recent change in bowel or
bladder habits. Denies dysuria or hematuria. Denies myalgias,
arthralgias, or rash.
Past Medical History:
Embolic Stroke (___): Right parieto-temporal; inferior division
right MCA territory infarction with evidence of clot
fragmentation; presented with left sided numbness and no
residual
symptoms
Hypertension
Hyperlipidemia
Atrial fibrillation with sick sinus syndrome
Prostate cancer s/p prostatectomy
Hernia repair
Social History:
___
Family History:
Denies family history of stroke or MI. His mother had glaucoma,
blindness, deceased at age ___. Father died when he was a ___,
does not know cause of death.
Physical Exam:
=========================
ADMISSION PHYSICAL EXAM
=========================
Vitals: T: 97.9 HR: 61 BP: 135/78 RR: 18 SaO2: 100% RA
General: NAD, pleasant, comfortable
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: bradycardic, irregularily irregular
Pulmonary: CTAB
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Skin: No rashes or lesions
___ Stroke Scale - Total [0]
1a. Level of Consciousness - 0
1b. LOC Questions - 0
1c. LOC Commands - 0
2. Best Gaze - 0
3. Visual Fields - 0
4. Facial Palsy - 0
5a. Motor arm, left - 0
5b. Motor arm, right - 0
6a. Motor leg, left - 0
6b. Motor leg, right - 0
7. Limb Ataxia - 0
8. Sensory - 0
9. Language - 0
10. Dysarthria - 0
11. Extinction and Neglect - 0
Neurologic Examination:
- Mental Status - Awake, alert, oriented to person, placea nd
time. Attention to examiner easily maintained. Recalls a
coherent
history. Able to recite months of year backwards. Speech is
fluent with full sentences, intact repetition, and intact verbal
comprehension. Content of speech demonstrates intact naming
(high
and low frequency) and no paraphasias. Normal prosody. No
dysarthria. No evidence of hemineglect. No left-right agnosia.
- Cranial Nerves - PERRL 3->2 brisk. VF full to number counting.
EOMI, no nystagmus. Acuity ___ bilaterally but pt wears
glasses
and he does have them with him at the time of assessment. V1-V3
without deficits to light touch bilaterally. No facial movement
asymmetry. Hearing intact to finger rub bilaterally. Palate
elevation symmetric. SCM/Trapezius strength ___ bilaterally.
Tongue midline.
- Motor - Normal bulk and tone. No drift. No tremor or
asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
- Sensory - No deficits to light touch, pin, or proprioception
bilaterally.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response flexor bilaterally.
- Coordination - No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait - Normal initiation. Narrow base. Normal stride length
and
arm swing. Stable without sway. Negative Romberg.
==========================
DISCHARGE PHYSICAL EXAM
==========================
Unchanged from admission physical exam.
Pertinent Results:
=======
LABS
=======
___ 05:21AM BLOOD ___ PTT-39.9* ___
___ 05:21AM BLOOD WBC-5.4 RBC-4.38* Hgb-12.0* Hct-38.0*
MCV-87 MCH-27.4 MCHC-31.6 RDW-14.3 Plt ___
___ 05:21AM BLOOD Glucose-81 UreaN-17 Creat-1.1 Na-143
K-4.0 Cl-109* HCO3-26 AnGap-12
___ 05:21AM BLOOD CK-MB-3 cTropnT-<0.01
___ 11:30AM BLOOD cTropnT-<0.01
___ 05:21AM BLOOD %HbA1c-6.2* eAG-131*
___ 05:21AM BLOOD Triglyc-75 HDL-60 CHOL/HD-2.5 LDLcalc-73
___ 05:21AM BLOOD TSH-1.3
___ 11:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 01:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 01:20PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
___ 01:20PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:21AM BLOOD TSH-1.3
___ 05:21AM BLOOD Triglyc-75 HDL-60 CHOL/HD-2.5 LDLcalc-73
URINE CULTURE (Final ___: <10,000 organisms/ml.
============
IMAGING
============
NCHCT (___):
No acute intracranial hemorrhage or mass effect.
Prior right occipital lobe infarcts, better seen with interval
evolution.
Consider MRI if not contra-indicated if there is concern for
acute infarction
CXR (___):
1. Mild bibasilar atelectasis, worse on the left. A small
underlying
consolidation cannot be entirely excluded.
2. Central pulmonary vascular congestion, without overt edema.
Top-normal
heart size.
MRI/A BRAIN (___):
1. No intracranial hemorrhage, acute infarct, or evidence of a
mass lesion.
2. Scattered foci of T2/FLAIR hyperintensity throughout the
cerebral white
matter, unchanged from ___ and likely the sequelae of chronic
small vessel
ischemic disease.
3. Mild atherosclerotic irregularity of the intracranial
internal carotid
arteries but no stenosis of the intracranial carotid or
vertebrobasilar
systems.
ECHO (___):
The left atrium is mildly dilated. No left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. Mild mitral
regurgitation. Mild biatrial enlargement.
Compared with the prior study (images reviewed) of ___,
the echo findings are similar. The rhythm is now atrial
fibrillation.
CTA HEAD AND NECK (___), preliminary:
No acute hemorrhage or infarction. No acute arterial
abnormalities.
Brief Hospital Course:
Mr. ___ is a ___ year old man with past medical history
including right parieto-temporal embolic stroke (___), atrial
fibrillation on coumadin, hypertension and hyperlipidemia who
presented to the ___ ED ___ as a code stroke for transient
vision loss (unclear from history if this was right ___ only or
bilateral) lasting 30 minutes. NIHSS was 0. Neurologic
examination at time of presentation was normal, as symptoms had
resolved. General examination was notable for bradycardia to the
___ with ___ second pauses and systolic blood pressure in the
130s. INR was therapeutic at 2.7. NCHCT was unremarkable. Pt was
admitted to the neurology stroke service for further management
of possible TIA.
Differential of the etiology of the TIA included an embolus or
stenosis in PCA or ophthalmic artery territory. MRI showed no
acute stroke and CTA head and neck did not show any vascular
occlusion or significant stenosis. Echo did not show any
thrombus or clot. INR remained therapeutic during hospital stay
and pt was continued on home warfarin. At time of discharge,
etiology of TIA remained unclear. Pt was discharged on his home
statin for further stroke prevention and was continued on
warfarin. Additionally, although suspicion of an ocular process
was low as symptoms had resolved, an ophthalmology follow-up
appointment was scheduled for the day after discharge so pt
could have a thorough ___ exam.
Otherwise, hospital course was complicated by atrial
fibrillation and asymptomatic bradycardia. SBP was maintained at
greater >120 throughout hospital stay. Troponin was <0.01 and
EKG did not show TWI or ST changes. As pt did not have an
outpatient cardiologist, cardiology was consulted who
recommended outpatient follow-up within one month. There was no
urgent need for pacemaker as bradycardia was asymptomatic and
SBP was maintained. TIA was not thought to be resultant to
bradycardia as SBP was maintained. Pt was advised to arrange
cardiology follow-up at time of discharge. Pt was restarted on
his home lisinopril and HCTZ on hospital day 2.
Hospital course was also complicated by an pre-renal ___ with
creatinine elevation to 1.5 on presentation. Creatinine improved
with volume repletion and was 1.1 on day of discharge. Admission
CXR also showed a possible left sided consolidation versus
atelectasis; as pt was asymptomatic and remained afebrile
without leukocytosis, CXR findings were attributed to
atelectasis.
On day of discharge, pt was feeling well. A stroke follow-up
appointment was arranged.
=======================
TRANSITIONS OF CARE
=======================
- Mr. ___ experienced asymptomatic bradycardia during his
hospital stay to a HR in the ___, this was worse when he was
sleeping. Cardiology was consulted who recommended outpatient
referral and follow-up within 1 month.
- MRI did not show an acute stroke.
=
=
=
=
=
=
=
=
================================================================
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (X) Yes [performed
and documented by admitting resident] () No
2. DVT Prophylaxis administered by the end of hospital day 2?
(X) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
() Yes - (X) No
4. LDL documented (required for all patients)? (X) Yes (LDL =
73) - () No
5. Intensive statin therapy administered? (X) Yes - () No [if
LDL >= 100, reason not given: ____ ]
(intensive statin therapy = simvastatin 80mg, simvastatin
80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin
20mg or 40mg, for LDL >= 100)
6. Smoking cessation counseling given? () Yes - (X) No [if no,
reason: (X) non-smoker - () unable to participate]
7. Stroke education given (written form in the discharge
worksheet)? (X) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No [if no, reason not assessed: ____ ]
9. Discharged on statin therapy? (X) Yes - () No [if LDL >= 100
or on a statin prior to hospitalization, reason not discharged
on statin: ____ ]
10. Discharged on antithrombotic therapy? () Yes [Type: ()
Antiplatelet - () Anticoagulation] - (X) No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (X) Yes - () No [if no, reason not
discharge on anticoagulation: ____ ] - () N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tamsulosin 0.4 mg PO HS
2. Warfarin 2.5 mg PO 2X/WEEK (___)
3. Warfarin 5 mg PO 4X/WEEK (___)
4. Lisinopril 20 mg PO DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
6. Atorvastatin 40 mg PO DAILY
Discharge Medications:
1. Atorvastatin 40 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. Tamsulosin 0.4 mg PO HS
5. Warfarin 2.5 mg PO 2X/WEEK (___)
6. Warfarin 5 mg PO 4X/WEEK (___)
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Transient ischemic attack
Secondary diagnosis:
Right parieto-temporal embolic stroke (___)
Atrial fibrillation on coumadin
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of vision loss resulting
from an TRANSIENT ISCHEMIC ATTACK OR "MINI STROKE", a condition
in which a blood vessel providing oxygen and nutrients to the
brain is temporarily 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.
Mini strokes can have many different causes and place you at
increased risk for stroke, so we assessed you for medical
conditions that might raise your risk of having a mini stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
Atrial fibrillation
Hypertension
Hyperlipidemia
Please take your home other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below. You will need to ask your primary care
physician for cardiology referral as you were found to have a
slow heart rate in the hospital. Please follow-up with
ophthamology at the appointment listed below so that you can
have a thorough ___ examination.
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:
___
|
10239261-DS-14 | 10,239,261 | 23,606,489 | DS | 14 | 2144-11-24 00:00:00 | 2144-11-24 16:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
abdominal pain, nausea
Major Surgical or Invasive Procedure:
ERCP s/p stent and with brushing on ___
History of Present Illness:
PCP: ___ had been seeing a PCP in ___ but has
not seen in ___ years and now lives in ___.
CC: ___ pain, transfer from ___
HISTORY OF PRESENT ILLNESS: Mr. ___ is a ___ yo ___ male
with PMh htn, T2DM presented to ___ with ___ days of
nausea and RUQ abdominal pain with obstructive jaundice and ___.
States symptoms started ___ (3days ago) with chills and
nausea only without abdominal pain. On ___ developed RUQ
sharp, stabbing "biting" pain with chills that resolved. ___
had improvement without pain but developed chills, worsening
pain on ___ so came to the emergency department at ___
___.
CT a/p showed B renal cysts but no biliary ductal dilation, also
with h/o cholecystectomy. Pt had scleral icterus and obstructive
pattern LFT elevation with low grade fever.
Review of systems:
(+) abdominal pain, nausea
(-) Denies chest pain, SOA, dizziness, diarrhea, constipation,
rash, confusion, syncope
Past Medical History:
Essential Hypertension
T2DM
Cholecystectomy ___
3 prostate biopsies
Social History:
___
Family History:
Denies FH of CVA, MI, CAD, GI disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T:100.0, HR 78, BP 155/88, O2 sat 100% RA, RR 18
Gen: NAD, resting
Eyes: EOMI,scleral icterus
HENT: NCAT, trachea midline
CV: RRR, S1-S2, no m/r/r/g, no edema, 2+ ___ BLE
Lungs: CTA B, no w/r/r/c
GI: +BS, soft, NTTP, ND, no wince to palpation in RUQ
GU: No foley
MSK: ___ strength bilaterally, intact ROM
Neuro: Moving all extremities, no focal deficits, A+Ox3
Skin: No rash or ecchymosis
Psych: Congruent affect, good judgment
DISCHARGE PHYSICAL EXAM:
VITALS: 98.3PO 135 / 67 77 18 100 Ra
GENERAL: Alert and in no distress, laying in bed
CV: RRR, II/VI systolic murmur at apex radiating to sternal
border, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended. Denies any pain to palpation
this AM. Bowel sounds present. No HSM
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS:
___
Na 136, K hemolyzed, Cl 104, HCO3 21, Cr 1.9-->1.7, BUN 19, Gluc
74
ALT 270-->237, ALKP 383-->332, Tbili 4.5-->4.4, ALKb 3.4, AST
159-->175, Dbili 1.2, Lip 58
Hgb 11.6, Hct 35.2, MCV 79, Plt 260 WBC 11.9-->10.9
INR 1.1
UA neg
DISCHARGE LABS:
___ 05:37AM BLOOD WBC-13.0* RBC-3.26* Hgb-8.4* Hct-24.7*
MCV-76* MCH-25.8* MCHC-34.0 RDW-14.4 RDWSD-39.7 Plt ___
___ 05:37AM BLOOD Glucose-88 UreaN-18 Creat-1.9* Na-140
K-3.8 Cl-101 HCO3-24 AnGap-15
___ 05:37AM BLOOD ALT-45* AST-31 AlkPhos-352* TotBili-1.0
___ 05:37AM BLOOD Calcium-8.8 Mg-2.0
___ 05:33AM BLOOD CRP-80.9*
IMAGING:
=======
___ CT a/p
Conclusion:
1. Cholecystectomy. Mild likely reservoir effect related to ___uct dilatation. No dense choledocholithiasis or
intrahepatic
bile duct dilatation.
2. Simple renal cysts of the right kidney. Probable benign 2 cm
right
adrenal incidental adenoma.
3. Uncomplicated colon diverticulosis.
4. Prostate enlargement elevating the bladder neck. Associated
with
nonspecific moderate diffuse bladder wall thickening.
Fat-containing
abdominal wall hernias.
5. Mild fatty infiltration of the liver. Other incidental
findings as
listed above.
6. No bulky pancreas head region mass, no dense
choledocholithiasis
shown. If symptoms and lab findings persist, MRCP may be
considered
for definitive common duct calculus exclusion.
___ CXR
Conclusion: Normal chest. No active/acute chest disease.
___ EKG LVH QTc 420, TWI I,AVL, V1 with V4-V6 TWI with j
point elevation
___ MRCP:
1. Moderate intrahepatic and extrahepatic biliary duct
dilatation appears
secondary to a 1.6 cm smooth stricture of the distal common bile
duct with no
obstructing mass lesion or choledocholithiasis identified.
2. Mild cholangitis involving the common bile duct and dilated
intrahepatic
bile ducts within the hepatic dome as well as centrally.
3. Dilated subcentimeter side-branch within the pancreatic tail
may reflect
side branch IPMN, without main duct dilatation. No pancreatic
head mass.
4. Prominent periportal lymph nodes may be reactive.
5. Incompletely characterized nodular left adrenal thickening
with 1.5 cm
right adrenal nodule are statistically likely to represent small
bilateral
adenomas.
CT a/p w/Contrast ___:
1. Interval placement of a CBD stent with expected pneumobilia.
There is no
intrahepatic abscess.
2. Eccentric thickening of the right posterolateral bladder
wall, for which an
underlying bladder neoplasm should be excluded.
RECOMMENDATION(S): Further evaluation of the bladder findings
with ultrasound
is recommended.
Bladder US ___:
1. No bladder wall mass identified as suspected on CT.
2. Prostatomegaly.
Bilateral ___ ___:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
Renal US ___:
1. No hydronephrosis. Unremarkable ultrasound appearance of the
renal
parenchyma.
2. Enlarged prostate.
RUQ US with dopplers ___:
1. Patent portal vein by color Doppler.
2. CBD stent in place with expected pneumobilia.
MRCP ___:
1. Cholangitis associated with microabscesses within segment II,
V, VII and
VIII, which has progressed since the prior scan. There is no
associated large
drainable abscess.
2. Unchanged (compared to the MRI dated ___ central intra
and extrahepatic
biliary ductal dilation with a CBD stent in place with
pneumobilia.
3. Multiple small side branch IPMNs in the pancreatic body and
tail, the
largest measuring 0.3 cm, unchanged.
4. Stable incompletely characterized right adrenal nodule.
RECOMMENDATION(S): The right adrenal nodule can be
characterized by a non
urgent dedicated scan- either CT or MRI, once patient's acute
condition
settles.
MRCP ___:
1. Progressive cholangitis with increased conspicuity of
multiple previously
identified subcentimeter hepatic micro abscesses involving
segment II, V, VII,
VIII. No definite new collections. No drainable collection.
2. Stable moderate central intrahepatic biliary duct dilatation
with gradual
tapering, expected pneumobilia and a reported common bile duct
stent,
unchanged from ___.
3. Incompletely characterized 1.4 cm right adrenal nodule.
4. Persistent large porta hepatis lymph nodes, likely reactive.
PATHOLOGY:
=========
CBD brushings ___: benign appearing ductal epithelial cells
PROCEDURES:
==========
ERCP ___:
The scout film was normal and revealed post cholecystectomy
clips.
There was a diverticulum between D1 and D2. The ampulla
appeared endoscopically normal but was located just distal to
the diverticulum.
The CBD was succesfully cannulated using a clevercut
sphincterotome, preloaded with 0.025 inch guidewire. Contrast
was injected and there was brisk flow through the ducts.
Contrast extended to the entire biliary tree. Mild dilatation
of bile duct noted up to 11 mm.
The left and right hepatic ducts and all intrahepatic branches
were normal.
Cholangiogram revealed tapering at the most distal CBD at the
the level of the ampulla.
Sphincteroplasty was performed in setting of jaundice, tapeing
on CBD on cholangiogram and elevated bilirubin. This was done
using a 10mm CRE balloon. After balloon sphincteroplasty, the
major papilla was effectively dilated.
Brushings for cytology of the distal CBD/ampullarysegment of
the bile duct were performed.
There was excellent contrast and biliary drainage at the end of
the procedure.
Otherwise normal ercp to third part of the duodenum
ERCP ___:
The scout film was normal and revealed post cholecystectomy
clips.
There was a diverticulum between D1 and D2.
The ampulla was normal but was located just distal to the
diverticulum.
The CBD was succesfully cannulated using a sphincterotome.
Contrast was injected and there was brisk flow through the
ducts.
Contrast extended to the entire biliary tree. Mild dilatation
of bile duct noted up to 12 mm.
The left and right hepatic ducts and all intrahepatic branches
were normal.
Cholangiogram again revealed tapering at the most distal CBD at
the the level of the ampulla.
Balloon sweeps were performed with small amount of purulent
fluid drainage extracted from biliary system.
Subsequently a ___ x 5 cm double pigtail stent was deployed
across the ampulla.
There was excellent contrast and biliary drainage at the end of
the procedure.
Otherwise normal ercp to third part of the duodenum
Brief Hospital Course:
Date of Admission: ___
Date of Discharge: ___
Procedures ERCP
Consults GI/Infectious Disease
Mr. ___ is a ___ yo ___ male with PMH of HTN, T2DM
presented to ___ with ___ days of nausea and RUQ
abdominal pain with obstructive jaundice and ___.
#Cholangitis: At ___, patient had a CT that showed biliary
ductal dilation and he was transferred to ___ for further
workup (ERCP). Initially, patient was having low grade
temperatures to 100 and was started on Unasyn. An ERCP was done
on ___ which showed tapering of the CBD so an sphincteroplasty
with stent placement was done. After the procedure, patient
spiked a fever to 102 and his antibiotics were broadened to
Vanc/Pip-Tazo. On ___ he was febrile to 103 with no localizing
symptoms. An MRCP was done that showed cholangitis and patient
had a second ERCP on ___ with stent placement, this time with
pus draining. Patient continued to have high grade fevers
despite improvement in his transaminitis and elevated bilirubin.
Patient was worked up for other etiologies of fever including
c.diff-negative, ___ duplex-negative, and a repeat CT abd/pelvis
which had no significant findings. Ultimately, patient was
switched to Daptomycin/Zosyn on ___ and his fever dissipated;
?may have been having Vanc drug related fevers. No positive
blood cultures were found. After completing antibiotics, he
continued to have low grade fevers and an increasing
leukocytosis. MRCP on ___ was concerning for recurrent
cholangitis and patient was restarted on Daptomycin and Zosyn on
___. He has been afebrile since restart latest course of abx.
His latest MRCP on ___ showed progressive cholangitis and
persistent hepatic micro-abscesses. ___ was consulted for ?core
needle biopsy to evaluate for etiology of recurrent cholangitis
and microabscesses but they felt that it would be too difficult
to obtain a directed biopsy and that a non-directed biopsy would
be of limited utility. D/w ID and plan for pt to complete 4
weeks of IV abx (d/c'ed with ertapenem) and then obtain repeat
MRCP after completion of abx and consider ___ biopsy at that time
if disease appears to be worsening.
# ___: Patient also presented with ___ which was initially
resolving but there was e/o re-injury of the kidney with a bump
in his creatinine to 2.4. FeNA 2.8% suggesting drug related or
contrast related injury. Creatinine remained stable between
2.1-2.3. Renal U/S with no e/o of hydronephrosis or
'medical/renal' disease. Patient d/c with a creatinine of 1.9.
# HTN: Patient with hypertension (uncontrolled) and was started
on amlodipine 10 mg. BP improved with a trial of chlorthalidone
but stopped out of concern of further kidney injury. Plasma
metanephrines came back negative. Patient with an EKG with LVH
and likely related TWI, troponin negative and patient without
chest pain. Latest SBP's on amlodipine were in the 130's
systolic.
#Diarrhea Patient with loose bowel movements after starting
his second course of antibiotics. Stool sample negative for
c.diff and was thought to be antibiotic induced diarrhea that
self-resolved.
CHRONIC STABLE ISSUES
# Prediabetes Patient with a hemoglobin A1c of 5.8%
# Microcytic anemia: Patient with no evidence of bleeding during
this admission. He will need an outpatient GI work-up but his
anemia appears to be secondary to chronic disease, likely
subacute course of cholangitis and frequent blood draws while in
the hospital. Hemoglobin stable in the 9s.
TRANSITIONAL ISSUES:
New Medications
-Ertapenem
-Amlodipine 10 mg daily
-follow up with hepatology and infectious disease for repeat
MRCP after completion of 4 weeks of abx and ?___ guided liver
biopsy at that time
-follow up CBC as an outpatient to continue to work up anemia
-follow up creatinine as an outpatient at next primary care
visit
# ??? Adrenal adenomas: Incompletely characterized nodular left
adrenal thickening with 1.5 cm right adrenal nodule are
statistically likely to represent small bilateral adenomas;
consider adrenal CT or MR in ___ year for further evaluation.
Greater than 30 minutes spent on discharge counseling and
coordination of care
Medications on Admission:
No Medications
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose
Stop: ___
RX *ertapenem [Invanz] 1 gram 1 gm IV daily Disp #*18 Vial
Refills:*0
4. Simethicone 40-80 mg PO QID:PRN gas
RX *simethicone [Gas Relief] 80 mg ___ tabs by mouth every 6
hours Disp #*60 Tablet Refills:*0
5. Tamsulosin 0.4 mg PO BID
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth twice daily Disp
#*60 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis
- Cholangitis
- Leukocytosis
- Acute renal failure
- Essential hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
You were admitted due to nausea, vomiting and abdominal pain and
found to have a constriction in your biliary ducts. This was
stented by our GI team. Samples taken showed you did NOT have
cancer.
You were having fevers and placed on IV antibiotics. You
completed a 10 day course on antibiotics, however after stopping
antibiotics, we were still concerned about ongoing infection
because of a low grade fever and increase in your white blood
cells (cells that fight infection). We got the infectious
disease doctors involved in your case and found no other source
of infection
During your hospitalization, you also had injury to your
kidneys. We think this was because of Vancomycin, an antibiotic
you received and contrast from a catscan of your abdomen. Your
kidney function should recover but you should follow up with
your new primary care doctor and have your kidney function
monitored.
It was a pleasure being part of your care
Your ___ team
Followup Instructions:
___
|
10239292-DS-6 | 10,239,292 | 24,115,970 | DS | 6 | 2152-10-28 00:00:00 | 2152-11-06 15:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. ___ is a ___ female PMHx lupus with Class
II Nephritis presents for evaluation of nausea/vomiting.
Pt states that she was in her usual state of health until
several
weeks ago when she noted onset of a malar facial rash as well as
facial/periorbital swelling. This progressed until the past 1
week over which time pt has had nausea and anorexia associated
with intermittent non bloody non bilious emesis. Pt has also
noted having MULTIPLE episodes of non bloody non melanotic non
mucus containing watery diarrhea that has been associated with a
constant non radiating diffuse sharp abdominal pain that is
worsened with eating.
Pt does notes having gradual onset of anasarca over the past
several weeks that has been associated with shortness of breath.
At baseline, pt notes that she can walk long distances without
significant shortness of breath but now cannot walk as far.
Pt notes no recent travel or dietary changes. No
fevers/chills/chest pain/uti symptoms. No cardiac history.No
tick
bites.
Pt lives in ___ and has been evaluated for this by primary
care and extensive workup was undertaken as an outpatient and pt
was seen by a nephrologist and rheumatologist within the past
few
days and was diagnosed with lupus. A kidney biopsy was obtained
and showed class II nephritis. Pt was started on plaquenil and
prednisone and has been taking them for the past 2 days.
Over the past 1 week, pt has been seen at ___
approximately 2 times for evaluation of the abdominal
pain/diarrhea/nausea as noted above. CT scan of abdomen/pelvis
performed a few days ago showed ascites/mucosa enhancement of
mild distal colon-- concern for colitis; no evidence of
obstruction or perforation.. CXR with bilateral pleural
effusion.
Labs with preserved renal function and albumin in the upper 2s
to
low3s.
Pt was treated with cipro and flagyl empirically for colitis for
the past 2 days but represented to ___ today due to
difficulty tolerating po/abdominal pain so was transferred here
for rheumatology evaluation.
LMP 5 weeks ago. Pt does not feel that she could be pregnant.
A 10 pt review of systems was obtained and is negative except
per
HPI.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Systemic Lupus Erythematosus
Lupus Nephritis, class II
Migraines
Social History:
___
Family History:
Reviewed and found to be not relevant to this
illness/reason for hospitalization.
Father: alive ___ healthy
mother: alive ___ AVMs
Physical Exam:
ADMISSION EXAM:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. 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; + edema on
face/arms/legs
SKIN: + malar rash on face;
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS
--------------
___ 09:55PM BLOOD WBC-7.0 RBC-4.16 Hgb-12.1 Hct-35.5 MCV-85
MCH-29.1 MCHC-34.1 RDW-14.1 RDWSD-42.9 Plt ___
___ 09:55PM BLOOD Neuts-85.6* Lymphs-11.2* Monos-2.3*
Eos-0.0* Baso-0.0 Im ___ AbsNeut-5.97 AbsLymp-0.78*
AbsMono-0.16* AbsEos-0.00* AbsBaso-0.00*
___ 09:55PM BLOOD ___ PTT-23.6* ___
___ 09:55PM BLOOD Glucose-131* UreaN-6 Creat-0.4 Na-140
K-3.9 Cl-107 HCO3-23 AnGap-10
___ 09:55PM BLOOD ALT-8 AST-16 TotBili-0.3
___ 09:55PM BLOOD cTropnT-<0.01
___ 09:55PM BLOOD Albumin-3.1* Calcium-8.2* Phos-2.1*
Mg-1.9 Cholest-171
___ 09:55PM BLOOD Triglyc-152* HDL-35* CHOL/HD-4.9
LDLcalc-106
___ 09:55PM BLOOD TSH-0.67
___ 09:55PM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG HAV Ab-NEG
IgM HAV-PND
___ 09:55PM BLOOD C3-21* C4-<2*
___ 09:55PM BLOOD HIV Ab-NEG
___ 09:55PM BLOOD HCV Ab-NEG
IMAGING
-------
___ CT A/P:
1. Increasing mild right and severe left hydronephrosis with
mild
distension of the urinary bladder. Findings are likely
secondary
to obstructing stones at the UV junctions bilaterally.
2. Small abdominopelvic ascites which has slightly improved.
3. Small bilateral pleural effusions with adjacent compressive
atelectasis which have decreased in size.
4. Interval decrease in size of small extracapsular left renal
hematoma.
5. Stable bilateral periaortic, and intrapelvic lymphadenopathy
___ CTA head & neck:
FINDINGS:
Motion, venous contrast pooling,overlying hardware streak
artifactandpatient
body habitus limits study. Additionally, study is limited by
venous
contamination.
CT HEAD WITHOUT CONTRAST:
There is no evidence of infarction,hemorrhage,edema,ormass. The
ventricles
and sulci are preserved in size and configuration.
The visualized portion of the paranasal sinuses, mastoid air
cells,and middle
ear cavities are clear. The visualized portion of the orbits are
preserved.
CTA HEAD:
Question proximal basilar artery fenestration versus volume
averaging
artifact. The vessels of the circle of ___ and their
principal
intracranial branches appear preserved without stenosis,
occlusion, or
aneurysm formation greater than 3 mm. The dural venous sinuses
are patent.
CTA NECK:
Bilateral carotid and vertebral artery origins are patent.
There is no evidence of internal carotid stenosis by NASCET
criteria.
The carotidandvertebral arteries and their major branches appear
preserved
with no evidence of stenosis or occlusion.
OTHER:
Evaluation lungs is limited secondary to motion artifact. The
visualized
portion of the thyroid gland is preserved. Scattered
subcentimeter
nonspecific lymph nodes are noted throughout the neck
bilaterally, without
definite enlargement by CT size criteria.
IMPRESSION:
1. Limited study as described.
2. No acute intracranial abnormality. Please note MRI of the
brain is more
sensitive for the detection of acute infarct.
3. Patent circle of ___ without definite evidence of
stenosis,occlusion,or
aneurysm.
4. Patent bilateral cervical carotid and vertebral arteries
without definite
evidence of stenosis, occlusion, or dissection.
5. Additional findings as described above.
___ LUE duplex u/s
IMPRESSION:
1. No evidence of deep vein thrombosis in the left upper
extremity.
2. Occlusive thrombus within the cephalic vein.
___ Renal u/s
FINDINGS:
Mild right hydronephrosis. Multiple echogenic foci are seen
within the right
kidney, measuring up to 0.5 x 0.5 x 0.4 cm, likely representing
renal stones.
No discrete masses identified. Additionally, there is mild left
hydronephrosis. No left renal stones or discrete masses
identified. T normal
cortical echogenicity and corticomedullary differentiation are
seen
bilaterally.
Right kidney: 12.9 cm
Left kidney: 13.4 cm
The bladder is moderately well distended and normal in
appearance.
IMPRESSION:
Persistent mild bilateral hydronephrosis, slightly improved on
the left
compared to prior ultrasound dated ___.
Redemonstration of
multiple right renal stones.
=====================
DISCHARGE LABS:
___ 06:00AM BLOOD WBC-8.5 RBC-3.23* Hgb-9.9* Hct-28.5*
MCV-88 MCH-30.7 MCHC-34.7 RDW-13.1 RDWSD-40.5 Plt ___
___ 07:48AM BLOOD ___ PTT-25.2 ___
___ 06:00AM BLOOD Glucose-90 UreaN-15 Creat-0.7 Na-143
K-3.4* Cl-106 HCO3-26 AnGap-11
___ 07:30AM BLOOD ALT-19 AST-18 AlkPhos-38 TotBili-0.4
___ 06:00AM BLOOD Albumin-3.5 Calcium-8.8 Phos-2.5* Mg-1.7
___ 09:55PM BLOOD Triglyc-152* HDL-35* CHOL/HD-4.9
LDLcalc-106
___ 09:55PM BLOOD TSH-0.67
___ 09:55PM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG HAV Ab-NEG
IgM HAV-NEG
___ 09:55PM BLOOD ___ Titer-GREATER TH
dsDNA-POSITIVE*
___ 09:55PM BLOOD PEP-NO MONOCLO IgG-1455 IgA-276 IgM-176
IFE-NO MONOCLO
___ 07:30AM BLOOD C3-46* C4-3*
___ 09:55PM BLOOD HIV Ab-NEG
___ 07:55AM BLOOD tTG-IgA-15
___ 09:55PM BLOOD HCV Ab-NEG
Brief Hospital Course:
___ old female with recently diagnosed SLE, with class II
lupus nephritis presents for evaluation of anasarca, abdominal
pain, nausea and vomiting. Hospital course was complicated by
worsening lupus nephritis, severe hydronephrosis and ___, and
inability to tolerate po.
TRANSITIONAL ISSUES:
=====================
# Contacts/HCP/Surrogate and Communication: health care proxy:
___, Mother, ___
# Code Status/Advance Care Planning: Full
HOSPITAL COURSE BY PROBLEM:
==========================
# Acute kidney injury: due to b/l UVJ obstruction w/ b/l
hydroureteronephrosis
# Bilateral hydronephrosis: not yet resolved based on ___ renal
U/S
# Bilateral nephrolithiasis
Acute rise in Cr from 0.8 to 2.3 on ___ initially concerning
for prerenal injury v RPGN. However, imaging consistent with
severe hydronephrosis. Placement of foley catheter, IVF and
initiation of Tamsulosin helped improve Cr. Urology was
consulted for possible intervention for nephrolithiasis if Cr
did not improve, but fortunately it did with medical management
(flomax, IVF, and treatment of Lupus nephritis as above) and her
Cr returned to prior baseline and she was urinating without
difficulty and her abdominal pain had resolved. A repeat renal
u/s was performed on ___, per Urology recommendations, which
showed that the b/l hydronerphosis had *not* resolved, but given
that she was clinically better, no further interventions were
needed as inpatient. The Urology team advised outpatient
follow-up for repeat u/s in ___ weeks and consideration of
definitive stone management if needed.
# SLE/Nephritis
# Lupus nephritis:
Active sediment and proteinuria with Cr 0.4->1 on admission.
Given lack of rapid improvement with IVF, patient was treated
with pulse dose steroids 1g methylprednisolone x3d. Creatinine
improved to 0.8 after steroids, but then increased to 2.3 due to
hydronephrosis. Unlikely to have contribution from worsening
autoimmune disease given that she had no other signs of
deterioration and
urine sediment was less active than prior. After steroid pulse
she was switched to 30 iv BID methylprednisolone --> prednisone
40 mg daily with the addition of mycophenolate which was
titrated to 720 mg BID. On discharge, her insurance company
declined to pay for mycophenolate sodium (Myfortiq) but was OK
with paying for mycophenolate mofetil (CellCept), which was OK
with the Nephrology team, who advised using a dose of 1000 mg
BID. Was discharged on prednisone with plan for taper per
outpatient Rheumatologist.
[] Please initiate PJP ppx if will remain on high-dose
prednisone for prolonged period
# Positive beta-2-glycoprotein 1 IgA Ab
Testing performed on ___:
BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA, IGM, IGG)
Test Result Reference
Range/Units
B2 GLYCOPROTEIN I (IGG)AB <9 <=20 SGU
B2 GLYCOPROTEIN I (IGM)AB <9 <=20 SMU
B2 GLYCOPROTEIN I (IGA)AB 27 H <=20 ___
[] Please repeat BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA, IGM,
IGG) as appropriate as an outpatient to confirm persistent
elevation in Ab that could be consistent with anti-phospholipid
syndrome.
# Abdominal pain: initial concern for colitis
Patient presented with abdominal pain, nausea with vomiting and
diarrhea, with ___ with non-specific colonic
thickening c/w colitis. Etiology of abdominal pain unclear,
likely secondary to gut edema and possible vasculitis. CT second
read and mesenteric duplex without evidence of vasculitis or
other vascular process. GI was consulted but did not feel
endoscopy/colonoscopy was warranted given her improving clinical
course with symptomatic treatment. She received morphine and
then dilaudid for pain, which were tapered as her pain improved.
Stool studies were negative. GI team ultimately felt that the
majority of her presenting symptoms were likely consistent with
obstructive nephrolithiasis. She was not requiring any PRN pain
medication in the ___ days prior to discharge.
# Hypertension:
Normotensive on admission but then with pressures to the
160-170s, likely secondary to pulse dose steroids and pain. She
was started on amlodipine 5 mg daily, to good effect.
Amlodipine was changed to lisionpril 5 mg daily on discharge,
per nephrology recommendations.
# Left cephalic vein occlusive thrombus: superficial; no DVT on
LUE u/s. Patient had been refusing HSQ for many days, developed
a superficial thrombus at site of prior IV with distal LUE
edema. IV had been removed prior to u/s confirming presence of
superficial thrombus. We counseled usual conservative measures
(heat, elevation) and used the opportunity to reinforce the
importance of HSQ for VTE ppx, which she was subsequently
willing to receive.
# Blurry vision: during hospital stay she/her mother reported
blurry vision; story was vague and inconsistent across various
providers (hospitalist, neurologist, ophthalmologist), but
overall was concerning initially for a uveitis or some other
process related to her very active SLE.
-Ophtho consult: no major findings, ___ vision b/l, advised
Neuro c/s.
-Neuro consult: patient provided different history to Neuro team
than to myself or Ophtho team; no major concerning findings on
their exam; advised CTA head & neck
-CTA head & neck was not concerning for any abnormalities.
Neurology signed off.
-Her pupil & CN exam remained stable and normal throughout.
-She reported her vision was totally normal and at her baseline
for the 2 days prior to discharge.
Time in care: >45 minutes in discharge-related activities on the
day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 20 mg PO DAILY lupus
2. Hydroxychloroquine Sulfate 200 mg PO DAILY lupus
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*3
3. Mycophenolate Sodium ___ 720 mg PO BID
RX *mycophenolate sodium 360 mg 2 tablet(s) by mouth twice a day
Disp #*120 Tablet Refills:*3
4. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*3
5. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*20
Capsule Refills:*0
6. PredniSONE 40 mg PO DAILY
Take until at least ___, then prednisone should be tapered by
primary Rheumatologist.
RX *prednisone 20 mg 40 mg by mouth once a day Disp #*60 Tablet
Refills:*1
7. Hydroxychloroquine Sulfate 200 mg PO DAILY lupus
8.Outpatient Lab Work
Please check chem10.
Please send results to:
Name: ___
Location: ___
Address: ___
Phone: ___
Fax: ___
Discharge Disposition:
Home
Discharge Diagnosis:
# Acute kidney injury: due to b/l UVJ obstruction w/ b/l
hydroureteronephrosis; now resolved
# Bilateral hydronephrosis: not yet resolved based on ___ renal
U/S
# Bilateral nephrolithiasis
# Hypernatremia: in setting of resolving ___ w/
polyuria; resolved w/ hypotonic IVF
# Hypokalemia: in setting of resolving obstructive ___ w/
polyuria; improved w/ oral repletion
# SLE
# Lupus nephritis
# Hypertension: new this hospitalization
# Left cephalic vein occlusive thrombus (superficial; no DVT on
LUE u/s)
# Right ulnar nerve paresthesias: unclear etiology, resolving
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 ___.
Why did you come to the hospital?
- Because you were having abdominal pain with nausea and
diarrhea
What happened while you were in the hospital?
- We evaluated your belly and did not see any evidence of
infection in your gut.
- We were concerned about your kidneys suffering damage from the
lupus and thus treated you with steroids and a medication called
mycophenolate
- You had kidney stones which caused urine to back up and cause
both of your kidneys to malfunction. This improved with fluids,
placing a foley catheter and medication to help the stones pass.
What should you do after you leave the hospital?
- Please have your labs checked in the next ___ days with the
results sent to your Nephrologist. We have provided you with a
prescription for these labs that you should bring with you to
the outpatient laboratory.
- For your kidney stones and hydronephrosis: please arrange to
see a Urology doctor in clinic within the next ___ days. Our
Urology doctors are happy to see you in their clinic here
(office #: ___, or you can arrange to see a Urologist
closer to home in ___. At that appointment you should have
a repeat renal ultrasound and renal function labs checked (a
"chem 10") to ensure that these issues are resolving.
- For your lupus flare: please continue your current medications
and plan to see your Rheumatologist within the next ___ days to
be re-evaluated and to start tapering your dose of prednisone.
- For your kidney inflammation and high blood pressure as a
result of lupus: please continue your current medications and
plan to see your primary Nephrologist within the next 3 weeks to
be re-evaluated.
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10239405-DS-18 | 10,239,405 | 29,600,846 | DS | 18 | 2124-04-25 00:00:00 | 2124-05-15 21:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
codeine
Attending: ___
Chief Complaint:
Left hand weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ RH F w PMHx of COPD, tobacco use,
HLD, and malignancy who presents to ___ ED after acute onset
of
left hand weakness.
Ms. ___ states that she was in her usual state of health
upon waking around 04:30 this morning. At 6:30AM, she picked up
her small dog and brought him downstairs - she did not note any
hand weakness at that time. At 7:30, as she was making coffee
she
noticed weakness in her L hand after a napkin fell out of her
hand. She tried to pick it up again, but was unable to; she was
able to pick it up without difficulty using the right hand. A
short time later, she tried to pick up a teaspoon off the
counter
with her left hand, and was again unable to hold it in her
grasp.
She became concerned about a possible stroke and asked her
husband to drive her to the ED.
While in the ED, she believes that her symptoms have improved.
She is not able to hold a small plastic basin in her left hand
without dropping it. She is unable, however, to pick up a coin
off of a flat surface.
On ROS, she denies any recent illness or systemic symptoms. She
denies HA, blurry or double vision, hearing changes, dizziness
or
lightheadedness, numbness or tingling, weakness other than what
is described about. She has never had symptoms like this in the
past. She denies any recent trauma to the LUE. Denies any
history
of cardiac arrhythmias or heart fluttering / racing.
Past Medical History:
- COPD
- HLD
- stage I infiltrating ductal carcinoma of the right breast
- s/p lumpectomy and sentinel node bx ___
- s/p chemotherapy
- no evidence of recurrent disease
- left upper lobe lung adenoCa, left lower lobe carncinoma
- s/p excision ___
- s/p radiation therapy ___
- s/p hysterectomy
- osteoporosis
Social History:
___
Family History:
Sister with CVA in her early ___. No family history of seizure.
Physical Exam:
=====================
ADMISSION PHYSICAL EXAM
=======================
VS T98.2 HR95 BP139/86 RR16 Sat100%RA
GEN - thin, elderly F; anxious and tearful
HEENT - NC/AT, MMM
NECK - full ROM, no meningismus
CV - RRR
RESP - normal WOB
ABD - soft, NT, ND
EXTR - atraumatic, WWP
___ Stroke Scale - Total [1]
1a. Level of Consciousness - 0
1b. LOC Questions - 0
1c. LOC Commands - 0
2. Best Gaze - 0
3. Visual Fields - 0
4. Facial Palsy - 0
5a. Motor arm, left - 1
5b. Motor arm, right - 0
6a. Motor leg, left - 0
6b. Motor leg, right - 0
7. Limb Ataxia - 0
8. Sensory - 0
9. Language - 0
10. Dysarthria - 0
11. Extinction and Neglect - 0
NEUROLOGICAL EXAMINATION
MS - Awake, alert, oriented x3. Attention to examiner easily
attained and maintained. Concentration maintained when recalling
months backwards. Recalls a coherent history. Speech is fluent
with normal prosody and no paraphasias. Naming, comprehension,
reading, and repetition intact. No apraxia. No evidence of
hemineglect. No left-right agnosia.
CN - [II] PERRL 3->2 brisk. VF full to number counting. [III,
IV,
VI] EOMI, with fatiguable L beating nystagmus on L gaze. [V]
V1-V3 without deficits to light touch bilaterally. [VII] No
facial movement asymmetry with forced eyelid closure or
volitional smile. [VIII] Hearing intact to finger rub
bilaterally. [IX, X] Palate elevation symmetric. [XI]
SCM/Trapezius strength ___ bilaterally. [XII] Tongue midline
with
full ROM.
MOTOR - Normal bulk and tone. No pronation, but some downward
drift of the LUE. No tremor or asterixis.
=[Delt] [Bic] [Tri] [ECR] [FEx] [IO] [IP] [Quad] [Ham] [TA]
[Gas]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1]
L 4+ 5 5 5 5 5 5 5 4+ 5 5
R 5 5 5 4+ 4+ 4 5 5 4+ 5 5
*Able to grasp a small plastic basin with the left hand. Unable
to pick up a quarter off of a flat surface with the left hand.
SENSORY - No deficits to light touch and PP. Proprioception
intact at B/L great toes. No extinction to double simultaneous
tactile stimulation.
REFLEXES -
=[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 3 2
R 2 2 2 2 1
Plantar response flexor bilaterally.
Pectoral jerk present bilaterally.
COORD - No dysmetria with finger to nose. Mild clumsiness with
RAM using left hand, within expected range for known weakness.
GAIT - Normal initiation. Narrow base.
.
==========================
DISCHARGE PHYSICAL EXAM
==========================
VS 98.5F, 138/76 (89-145), HR 73, RR 18, 99% on RA
General - NAD
Mental status - Alert, oriented x3
Cranial nerves - EOMI, Pupils reactive to light s/p cataract
surgery with some irregularity of right pupil, Face symmetric,
Tongue midline
Motor - ___ bilateral, deltoid, bicep, tricep, IP, TA
bilaterally
Sensory - Light touch symmetric bilaterally
Coordination - No dysmetria on finger nose finger or mirroring.
Pertinent Results:
=====================
PERTINENT LABS
=====================
___ 09:46AM BLOOD WBC-9.4 RBC-4.60 Hgb-12.7 Hct-39.9 MCV-87
MCH-27.6 MCHC-31.8* RDW-13.9 RDWSD-44.3 Plt ___
___ 09:46AM BLOOD ___ PTT-28.7 ___
___ 05:03AM BLOOD Glucose-97 UreaN-18 Creat-0.8 Na-138
K-4.8 Cl-101 HCO3-27 AnGap-15
___ 09:46AM BLOOD Lipase-22
___ 05:03AM BLOOD Calcium-9.2 Phos-4.6* Mg-2.1 Cholest-201*
___ 11:55AM BLOOD %HbA1c-6.1* eAG-128*
___ 05:03AM BLOOD Triglyc-126 HDL-53 CHOL/HD-3.8
LDLcalc-123
___ 09:46AM BLOOD TSH-3.2
___ 09:49AM BLOOD Glucose-95 Na-140 K-4.3 Cl-101 calHCO3-28
___ 02:02PM URINE Color-Yellow Appear-Clear Sp ___
___ 02:02PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 02:02PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1 TransE-<1
.
====================
RESULTS
====================
EKG ___
Sinus rhythm. Left axis deviation. Minor T wave abnormalities.
Compared to the previous tracing of ___ lateral T wave
abnormalities are less pronounced.
.
CTA HEAD AND NECK ___
1. No acute intracranial abnormality without acute territorial
infarct,
hemorrhage, mass, or mass effect.
2. The patent head and neck vasculature without occlusion,
significant
stenosis, or aneurysm.
.
CHEST XRAY ___
No acute cardiopulmonary process.
.
MRI HEAD WITHOUT CONTRAST ___
Unremarkable brain MRI without acute abnormality. No evidence
of infarction.
.
___ ECHOCARDIOGRAM
IMPRESSION: Mild mitral regurgitation with normal valve
morphology. Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. No definite
structural cardiac source of embolism identified.
Brief Hospital Course:
___ with COPD, tobacco use, HLD, and malignancy who presents
with acute onset left hand weakness that resolved quickly during
admission consistent with transient ischemic attack.
.
Her MRI was negative for stroke and her CTA head and neck showed
no significant large vessel stenosis. As her history was
consistent with TIA involving a cortical hand which would likely
be embolic in etiology, her stroke risk factors were checked and
fasting lipid panel showed hyperlipidemia with cholesterol 201,
LDL of 123. Her atorvastatin was increased to 80mg QHS and she
was started on aspirin 81mg daily. Her HbA1C was borderline
elevated at 6.1% which will need to be followed by her primary
care provider. TSH was within normal limits at 3.2.
.
Echocardiogram showed mitral valve regurgitation and was
negative for PFO, ASD, or intracardiac clot. Her in hospital
telemetry did not show any atrial fibrillation. Given the
suspicion for embolic etiology of her TIA, she was set up with
___ monitoring for 2 weeks to be followed up by her
neurologist.
.
==========================
# TRANSITIONAL ISSUES #
==========================
- Aspirin 81mg daily started
- Increased to Atorvastatin 80mg daily
- Echo negative for intracardiac clot
- ___ of hearts for 2 weeks.
- Borderline elevated HbA1C.
.
.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - ___ bedside swallow by RN () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 123 ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - Atorva 80mg
() No [if LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 60 mg PO QPM
2. Vitamin D ___ UNIT PO Q2 WEEKS
3. Alendronate Sodium 70 mg PO DAILY
4. Spiriva with HandiHaler (tiotropium bromide) 18 mcg
inhalation DAILY
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
Discharge Medications:
1. Alendronate Sodium 70 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. Vitamin D ___ UNIT PO Q2 WEEKS
5. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Spiriva with HandiHaler (tiotropium bromide) 18 mcg
inhalation DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
1.) 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 for left hand weakness that we think was due
to a transient ischemic attack or mini-stroke. A transient
ischemic attack occurs when the blood flow to part of your brain
is blocked for a short period of time, then returns - causing
symptoms that last less than 24 hours.
You had brain imaging that was negative for stroke. The blood
vessels in your brain were also imaged and were open.
Your risk factors for stroke were checked and were as follows:
Your cholesterol was high so your Lipitor was increased to 80mg
QHS.
Your HbA1c was 6.1% which shows pre-diabetes. This will need to
be followed by your primary care provider.
Your thyroid function tests were normal.
Your echocardiogram of your heart did not show any clot that
could be responsible for your stroke.
You may need to be set up with a heart monitor for atrial
fibrillation as an outpatient called ___ of Hearts. Our
holter monitor department has been contacted and they will mail
you the monitor.
You will need to follow up with neurology and watch out for
symptoms 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:
___
|
10239721-DS-13 | 10,239,721 | 25,809,631 | DS | 13 | 2124-06-20 00:00:00 | 2124-06-21 17:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of Breath (SOB)
Major Surgical or Invasive Procedure:
___ line placement
History of Present Illness:
Ms. ___ is an ___ year-old female with history of afib (on
Coumadin), uncontrolled DM, PAD, CKD stage IV (baseline Cr
___ who presents with volume overload and elevated troponin.
Patient was discharged from ___ on ___ after she had been
admitted for management of ___ ulcer and hyponatremia. She
returned to ___ today w/ worsening leg pain and SOB. She
denied chest pain, palpitations, fevers, chills or cough.
At ___ she had a CXR showing pulmonary edema and ECG c/f
new Q waves in V1-2. She also had an elevated troponin of 0.16
and a proBNP of 11,115. Cardiology there was consulted and
recommended starting a heparin gtt and transferring to ___ for
further care. He also received a full strength aspirin, 20 mg IV
lasix, simvastatin 80 mg, and 4 mg IV morphine.
In the ED, initial VS were: 97.1 89 167/49 18 100% 2L NC
Labs showed:
-H/H 7.9/23.9, WBC 11.5, plt 401
-Na 125, bicarb 18, BUN 29, Cr 1.8
-Trop-T 0.16, CK 66, MB 3
-___ 16.1, PTT 45, INR 1.5
Imaging showed: CXR reportedly showing pulmonary edema at OSH.
No imaging in ___ ED.
Consults: Vascular
Vascular surgery has seen and evaluated this patient, and signed
off with recommendations for wound care: Wound care: "cleanse
wound daily with normal saline, pat dry, apply a nickel-thick
layer of santyl, cover with saline-moistened gauze, wrap with
kerlix. Please provide patient with a heel-offloading boot for
left leg while ambulating/working with ___
Patient received:
___ 00:14 IV Heparin Started 600 units/hr
___ 01:12 IV Furosemide 40 mg
Transfer VS were: 78 183/80 15 98% 2L NC
On arrival to the floor, patient endorses the story above.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
Hypertension, essential
Hypercholesterolemia
DM (diabetes mellitus), type 2, uncontrolled
Carotid bruit
Cerebral infarction
PAF (paroxysmal atrial fibrillation)
Anticoagulant long-term use
Dysphagia
Weight loss
Osteoarthrosis, wrist; R
Pseudophakia
Corneal subepithelial haze
Retinopathy
CKD stage IV
Hyperparathyroidism due to renal insufficiency
Onychomycosis
Anemia
Vitamin D deficiency
Peripheral arterial disease
Left leg pain
Social History:
___
Family History:
Mother with DM
Physical Exam:
============================
ADMISSION PHYSICAL EXAMINATION
============================
VS: 97.6 ___ 2L
GENERAL: NAD
HEENT: NCAT, MMM
NECK: JVP to angle of mandible at 60 degrees
CV: Irregularly irregular, normal rate. No m/r/g
PULM: Diminished bilaterally w/ bibasilar crackles
GI: Abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: L calf ulcer dressed. L dry heel ulcer w/o
drainage, no surrounding edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
============================================
DISCHARGE PHYSICAL EXAM:
====================================
Temp: 98.0 PO BP 157/73 HR 76 RR18 93 Ra fBG 142
GENERAL: Alert, sitting in bed, NAD
HEENT: Sclera anicteric, PERRLA, EOMI, MMM
CV: irregular rhythm, regular rate, normal S1 S2, no murmurs,
rubs, gallops
LUNGS: CTAB, no crackles or wheezes; diffuse upper airway sounds
ABD: Soft, non-distended, non-tender; BS+
EXT: Warm, no clubbing, cyanosis, no ___ edema
B/L upper extremities with 2+ pitting edema; UEs are non-tender
to palpation
MSK: muscle wasting present in all extremities; with bandages in
place over L leg
Neuro: Alert, AAOx3, responds appropriately to questions
Pertinent Results:
=============
ADMISSION LABS
=============
___ 12:10AM BLOOD WBC-11.5* RBC-2.97* Hgb-7.9* Hct-23.9*
MCV-81* MCH-26.6 MCHC-33.1 RDW-15.2 RDWSD-44.3 Plt ___
___ 12:10AM BLOOD Neuts-74.0* Lymphs-15.9* Monos-8.3
Eos-0.3* Baso-0.8 Im ___ AbsNeut-8.52* AbsLymp-1.83
AbsMono-0.96* AbsEos-0.04 AbsBaso-0.09*
___ 12:12AM BLOOD ___ PTT-45.0* ___
___ 12:10AM BLOOD Glucose-163* UreaN-29* Creat-1.8* Na-125*
K-3.8 Cl-91* HCO3-18* AnGap-16
___ 12:10AM BLOOD CK(CPK)-66
___ 12:10AM BLOOD CK-MB-3 ___
___ 12:10AM BLOOD cTropnT-0.16*
___ 07:44AM BLOOD CK-MB-3 cTropnT-0.19*
___ 07:44AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.0
___ 12:10AM BLOOD Osmolal-271*
___ 08:46PM BLOOD TSH-5.2*
___ 03:34AM BLOOD Cortsol-19.7
___ 12:20AM URINE Blood-MOD* Nitrite-NEG Protein-100*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG*
___ 12:20AM URINE RBC-160* WBC-50* Bacteri-FEW* Yeast-NONE
Epi-<1
==============
DISCHARGE LABS
=============
___ 05:55AM BLOOD WBC-9.2 RBC-2.99* Hgb-8.2* Hct-25.8*
MCV-86 MCH-27.4 MCHC-31.8* RDW-17.3* RDWSD-55.0* Plt ___
___ 04:11AM BLOOD ___
___ 05:55AM BLOOD Glucose-117* UreaN-48* Creat-1.9* Na-143
K-4.3 Cl-106 HCO3-20* AnGap-17
___ 05:55AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.4
============
MICROBIOLOGY
============
URINE CULTURE (Final ___: NO GROWTH.
URINE CULTURE (Final ___:
YEAST. 10,000-100,000 CFU/mL.
Blood Culture, Routine (Final ___: NO GROWTH.
Blood Culture, Routine (Final ___: NO GROWTH.
=======
IMAGING
=======
CXR - ___
HEART SIZE IS ENLARGED. MEDIASTINUM IS STABLE. RETROCARDIAC
CONSOLIDATION IS EXTENSIVE ASSOCIATED WITH BILATERAL PLEURAL
EFFUSION AND THAT IS CONCERNING FOR BIBASAL PNEUMONIA OR
ASPIRATION.
TTE - ___
The left atrial volume index is moderately increased. The right
atrium is moderately enlarged. There is no evidence for an
atrial septal defect by 2D/color Doppler. The estimated right
atrial pressure is >15mmHg. There is normal left ventricular
wall thickness with a normal cavity size. There is normal
regional left ventricular systolic function. Overall left
ventricular systolic function is hyperdynamic. The visually
estimated left ventricular ejection fraction is 75-100%. There
is no resting left ventricular outflow tract gradient. No
ventricular septal defect is seen. Tissue Doppler suggests an
increased left ventricular filling pressure (PCWP greater than
18mmHg). There is Grade II diastolic dysfunction. Normal right
ventricular cavity size with low normal free wall motion.
Intrinsic right ventricular systolic function is likely lower
due to the severity of tricuspid regurgitation. The aortic sinus
diameter is normal for gender with normal ascending aorta
diameter for gender. The aortic arch diameter is normal. The
aortic valve leaflets (3) appear structurally normal. There is
mild aortic valve stenosis. There is no aortic regurgitation.
The mitral valve leaflets are mildly thickened with no mitral
valve prolapse. There is mild to moderate [___] mitral
regurgitation. Due to acoustic shadowing, the severity of mitral
regurgitation could be UNDERestimated. The tricuspid valve
leaflets appear structurally normal. There is moderate to severe
[3+] tricuspid regurgitation. There is moderate to severe
pulmonary artery systolic hypertension. In the setting of at
least moderate to severe tricuspid regurgitation, the pulmonary
artery systolic pressure may be UNDERestimated. There is a
trivial pericardial effusion. Bilateral pleural effusions are
present.
IMPRESSION: Small hyperdynamic left ventricle. Top normal cavity
size, low normal systolic function of the right ventricle.
Moderate to severe tricuspid regurgitation with moderate to
severe pulmonary hypertension. At least mild to moderate mitral
regurgitation. Mild aortic stenosis. Bilateral pleural
effusions. Echocardiographic evidence for diastolic dysfunction
with elevated PCWP.
Compared with the prior TTE ___ , there is more tricuspid
regurgitation, pulmonary pressures are higher, bilateral pleural
effusions are present.
CXR - ___
There is pulmonary vascular congestion. The heart size is
enlarged however stable. Bilateral pleural effusions are
stable. There is retrocardiac atelectasis. Mild pulmonary
vascular congestion.
CXR - ___
In comparison with the study of ___, there is again
enlargement of the cardiac silhouette a with stable vascular
congestion and bilateral layering pleural effusions with
compressive atelectasis at the bases, more prominent on the
right.
RUE U/S ___:
IMPRESSION:
No evidence of deep vein thrombosis in the right upper
extremity.
Brief Hospital Course:
PATIENT SUMMARY:
===================
Ms. ___ is a ___ with history of atrial fibrillation (on
Coumadin), uncontrolled DM, PAD, CKD stage IV (baseline Cr
___, who presented with volume overload and elevated
troponin concerning for new diagnosis of heart failure. She has
had a prolonged and complicated hospital course, most notable
for hyponatremia thought to be ___ hypotonic, SIADH and
hypervolemia, as well as worsening heart and kidney failure.
#CORONARIES: unknown
#PUMP: EF 75-100%
#RHYTHM: Atrial fibrillation
ACUTE ISSUES:
=============
#New Heart Failure with preserved Ejection Fraction (___)
Patient presented with shortness of breath and found to be
volume overloaded with elevated BNP to 11115 on ___. CXR
from ___ showed bilateral pleural effusion and pulmonary
edema. TTE showed evidence for diastolic dysfunction with
elevated PCWP with small hyperdynamic left ventricle (EF between
75-100%). Moderate to severe tricuspid regurgitation with
moderate to severe pulmonary hypertension and mild to moderate
mitral regurgitation. Patient was diuresed with IV lasix. During
her hospital stay, she became hyponatremic requiring CCU
transfer (see below). She was started on Lasix gtt with good
response and improvement in dyspnea and sodium levels. She was
transitioned to oral Torsemide 10mg to optimize kidney as well
as cardiac function. Weight on discharge was 116.4lbs. Patient
was discharged on Carvedilol and Amlodipine.
#NSTEMI
Patient presented with elevated troponins to 0.19 and Q waves in
V1-V2 without chest pain. She was medically managed initially
with heparin gtt. Patient will be discharged on aspirin 81mg
daily and Pravastatin 80 mg.
#Hyponatremia
Presented with chronic hyponatremia. Na on admission was 125. Na
reached a nadir of 117 with altered mental status necessitating
CCU transfer. Hyponatremia was thought to be ___ acute
decompensated diastolic heart failure, with possible
contribution of SIADH because of pain. In the CCU, patient was
managed with lasix gtt and fluid restriction of 1 L daily with
subsequent improvement in sodium levels. Pain was managed with
gabapentin and lidocaine patch. Patient was transferred to the
MICU ___ for worsening hyponatremia and encephalopathy and
was fluid restricted and her clinical status improved. Following
this, her Na slowly trended upward over the next 9 days and
normalized to a discharge Na of 143.
#Hypertension
During her stay, blood pressure was difficult to control and
patient was taking maximum doses of several antihypertensive
agents. Use of additional agents (clonidine, carvedilol) limited
by side effects of bradycardia on these medications. She was
started on multiple anti-hypertensives in an attempt to control
her BPs, and was transiently on a nitroglycerin gtt due to
hypertensive emergency. She will be discharged on Hydralazine,
Carvedilol, Torsemide, Amlodipine. Of note, higher threshold for
BP allowed given the risk of stroke re-expression syndrome with
lower blood pressures.
___ on CKD
Baseline Cr 2.0-2.5. Cr initially 1.8 at time of presentation
and has uptrended to peak of 3.1 Worsening of kidney function
was thought to be due to cardiorenal syndrome and poor perfusion
of the kidneys. Lisinopril was held. Cr improved to on discharge
to 1.9.
#Left calf vascular ulcer
Patient had recent admission for ___ ulcers that was managed by
vascular surgery. Left calf ulcer measures around 15cm by 5cm
with central area of stage 3 ulcer with what looks like
yellowish granulation tissue with no signs of infection. Patient
was managed with doxycycline for total 14 day course (last day
___ and wound care. Pain was managed with gabapenbin and
tylenol. Per vascular surgery, patient is not a surgical
candidate for revascularization given her general condition and
the ulcer being superficial and pressure type, recommending
offloading pressure and applying santyl to wound. Patient was
discharged with wound care.
# Mixed, Multifactorial Anemia
Patient was anemic and required two transfusions throughout
hospitalization. Baseline Hgb ___, which is likely
multifactorial, with CKD and anemia of chronic disease
contributing. Discharge Hgb: 8.2
# Goals of Care
Complicated family dynamic with multiple discussions regarding
goals of care. On arrival to the MICU ___, son/HCP ___ (with
discussion with other family members) decided on DNR/DNI code
status. Has completed MOLST in chart. Palliative care was
consulted
and assisted with these discussions. Patient will be discharged
home with ___ services and possible bridge to hospice.
CHRONIC & RESOLVED ISSUES:
============================
#Atrial fibrillation: Rate control with Carvdilol and
anticoagulation with warfarin.
Discharge INR: 3.0.
#Type II DM: managed with Glargine and ISS.
#Pseudomonas bacterurea/colonization
UCx from ___ growing pseudomonas; patient appears asymptomatic
and has in-dwelling catheter. Catheter was exchanged and repeat
cultures
growing pseudomonas again. Urine sensitivities from ___ show
pseudomonas sensitive to: ciprofloxacin, gentamicin, meropenem,
tobramycin. Given patient's history of seizures and the risk of
lowering
seizure threshold with these antibiotics, as well as the fact
that the
patient had no clinical signs of a urinary tract infection and
this is
a common colonizer of the urinary tract, this was managed as a
chronic colonization.
TRANSITIONAL ISSUES:
=========================
[] Gabapentin transiently held while inpatient for altered
mental status. Restarted ___, and pt will be discharged on
100mg Gabapentin QHS. If pain is not adequately controlled with
this after 5 days, consider increasing frequency of dose to
100mg twice daily.
[] Diuretics were adjusted during this hospitalization due to
heart and kidney failure as well as hyponatremia. Discharge dose
of Torsemide 10mg QDaily.
[] Will need INR drawn and warfarin dose adjusted on ___,
Warfarin is managed by ___ in ___.
[] Discharge Cr: 1.9
[] Discharge weight: 116.4
[] Discharge Sodium: 143
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Collagenase Ointment 1 Appl TP DAILY
3. HydrALAZINE 50 mg PO TID
4. LevETIRAcetam 500 mg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. Pravastatin 80 mg PO DAILY
7. Senna 8.6 mg PO DAILY
8. Warfarin 2.5 mg PO DAILY16
9. Acetaminophen 1000 mg PO TID
10. Aspirin 81 mg PO DAILY
11. Docusate Sodium 100 mg PO BID
12. Doxycycline Hyclate 100 mg PO Q12H
13. Gabapentin 100 mg PO BID
14. Multivitamins W/minerals 1 TAB PO DAILY
15. TraMADol 50 mg PO Q6H
16. Basaglar KwikPen U-100 Insulin (insulin glargine) 100
unit/mL (3 mL) subcutaneous up to 25 units daily
17. Clotrimazole Cream 1 Appl TP DAILY
18. Furosemide 60 mg PO BID
19. NovoLOG Flexpen U-100 Insulin (insulin aspart U-100) 100
unit/mL subcutaneous up to 25 units daily
20. Lidocaine-Prilocaine 1 Appl TP DAILY
Discharge Medications:
1. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth up to three times
daily as needed Disp #*30 Capsule Refills:*0
2. CARVedilol 6.25 mg PO QHS
RX *carvedilol 6.25 mg 1 tablet(s) by mouth every night Disp
#*30 Tablet Refills:*0
3. CARVedilol 12.5 mg PO QAM
RX *carvedilol 12.5 mg 1 tablet(s) by mouth every morning Disp
#*30 Tablet Refills:*0
4. Isosorbide Dinitrate 40 mg PO TID
RX *isosorbide dinitrate 40 mg 1 tablet(s) by mouth three times
daily Disp #*90 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth daily Disp #*15 Packet Refills:*0
6. Sodium Chloride 1 gm PO TID
RX *sodium chloride 1 gram 1 tablet(s) by mouth three times
daily with meals Disp #*90 Tablet Refills:*0
7. Torsemide 10 mg PO DAILY
RX *torsemide 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
8. Acetaminophen 1000 mg PO Q6H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 6 hours as
needed Disp #*50 Tablet Refills:*0
9. Gabapentin 100 mg PO QHS
RX *gabapentin 100 mg 1 capsule(s) by mouth every night Disp
#*30 Capsule Refills:*0
10. HydrALAZINE 100 mg PO TID
RX *hydralazine 100 mg 1 tablet(s) by mouth every 8 hours Disp
#*90 Tablet Refills:*0
11. LevETIRAcetam 250 mg PO Q12H
RX *levetiracetam 250 mg 1 tablet(s) by mouth every 12 hours
Disp #*60 Tablet Refills:*0
12. Senna 17.2 mg PO DAILY
RX *sennosides [senna] 8.6 mg 2 tablets by mouth once daily as
needed Disp #*30 Tablet Refills:*0
13. TraMADol 50 mg PO Q12H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *tramadol 50 mg 1 tablet(s) by mouth every twelve hours as
needed Disp #*50 Tablet Refills:*0
14. Warfarin 2 mg PO DAILY16
RX *warfarin 2 mg 1 tablet(s) by mouth daily Disp #*15 Tablet
Refills:*0
15. amLODIPine 10 mg PO DAILY
16. Aspirin 81 mg PO DAILY
17. Basaglar KwikPen U-100 Insulin (insulin glargine) 100
unit/mL (3 mL) subcutaneous up to 25 units daily
take 10 units every monring
RX *insulin glargine [Basaglar KwikPen U-100 Insulin] 100
unit/mL (3 mL) 10 units every morning Disp #*1 Box Refills:*0
18. Clotrimazole Cream 1 Appl TP DAILY
19. Collagenase Ointment 1 Appl TP DAILY
20. Docusate Sodium 100 mg PO BID
21. NovoLOG Flexpen U-100 Insulin (insulin aspart U-100) 100
unit/mL subcutaneous up to 25 units daily
Patient requiring only ___ units of Aspart per day.
22. Pravastatin 80 mg PO DAILY
23.Outpatient Lab Work
PLEASE DRAW BLOOD FOR INR MONITORING ON ___ or ___ and
fax results to:
Name: ___.
Location: ___, ___.
Fax: ___
___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
------------
Diastolic Heart Failure, new diagnosis
Acute on chronic kidney disease (stage IV)
Hyponatremia
Seizure disorder related to prior stroke
Hypertension
Diabetes Mellitus
Chronic right lower leg diabetic ulcer
Secondary:
-----------------
prior R. MCA stroke c/b seizure disorder
PAF (paroxysmal atrial fibrillation)
Anemia
Peripheral Artery 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:
Dear ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You had difficulty breathing and were found to have evidence
of heart damage, so you were transferred to ___ for further
management
- You were also experiencing leg pain.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were treated with medications to remove excess fluid from
your body, and to help your heart and kidneys function better.
- You were transferred to the ICU twice because your sodium
levels were too low.
- Your sodium level normalized, and the fluid level in your body
was optimized for both your heart and kidneys to function the
best possible.
- Your pain was managed with Tylenol, gabapentin, and tramadol.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Please continue to take all of your medications and follow-up
with your appointments as listed below.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
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