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10239917-DS-6 | 10,239,917 | 25,879,119 | DS | 6 | 2179-02-28 00:00:00 | 2179-02-28 22:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
cyclosporine / Sulfa (Sulfonamide Antibiotics) / NSAIDS
___ Drug)
Attending: ___.
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
___ EGD
___ ___ GDA embolization
___ EGD
History of Present Illness:
___ hx of HCV (not known cirrhotic, no EGD), H. Pylori,
excessive NSAID use presenting with episode this AM of large
amount of hematemesis. ___ has been having one episode of
emesis every morning for the past month. Minimal blood
previously on one episode. Regurgitates undigested food on
occasion, but not usually bilious or bloody. This morning had
one large episode, entirely bright red blood with clots. Has
been having epigastric/periumbilical abdominal pain for months
and taking ___ high strength NSAID pills for months. Pain in
RUQ, dull, unable to identify aggravating / alleviating factors
or relationship to meals. Has noted black stools for two weeks.
Recently found to have H. Pylori, but untreated secondary to
insurance. Had CT scan recently with incidentally noted
"pancreatic cysts", scheduled for a biopsy with endoscopy on
___. Has been distended for roughly one month. Has had poor
appetite but denies weight loss or fevers. No diarrhea,
constipation, dysphagia. Has noted increase gas and bloating.
___ presented to OSH where she was found to have Hct of
21.4, ___ guaiac positive stool. No hematemesis or
BRBPR/melena at OSH.
In the ED intial vitals were:98.2, 90 107/54, 16, 99% ra. Rectal
exam noted guaiac negative, ___ stool. Refused NG tube. Labs
notable for Hg 6.5, HCT 21.6 for which 2 unit PRBCs were
ordered. ___ was given Pantoprazole 40mg, Ondansetron. NS at
150cc/hr. Vitals on transfer: 90, 108/50, 16, 98% RA. GI was
consulted and recommended admission to medicine for EGD in am.
On the floor ___ still reports mild RUQ abdominal pain.
Denies nausea at this time.
Past Medical History:
- H.pylori (recent, untreated)
- HCV (no cirrhosis, no treatment)
- s/p ventral hernia repair c/b MRSA wound infection
- EtOH abuse (per records)
- Tobacco abuse
- convulsions ? (per records)
- female stress incontinence
- asthma
- pancytopenia
- pancreatitis
- prolonged QT interval ___
- anxiety
- Mood disorder
- pancreatic lesion, likely pseudocyst
- h/o opioid abuse on methadone
- bulemia
Social History:
___
Family History:
brother with pancreatic problem
father with EtOH abuse, ___ syndrome
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- 98.0 116/61 80 16 98ra
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally except occasional
expiratory wheezes
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, mildly distended, bowel sounds present, +TTP RUQ,
LUQ w/o rebound or guarding, ? HSM ___ not fully
cooperative with exam)
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- ___ intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM:
Vitals 97.9 BP129/77 61 16 100%RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB
CV- Regular rate and rhythm, normal S1 + S2, soft systolic
murmur
Abdomen- Soft, distended, bowel sounds present, epigastric and
LLQ TTP
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- ___ intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
___ 07:00PM BLOOD ___
___ Plt ___
___ 07:00PM BLOOD ___
___
___ 07:00PM BLOOD ___ ___
___ 07:00PM BLOOD ___
___
___ 07:00PM BLOOD ___
___ 07:00PM BLOOD ___
PERTINENT MICRO
___ MRSA Screen +
URINE:
___ 07:00PM URINE ___ Sp ___
___ 07:00PM URINE ___
___
___ 07:00PM URINE ___
___ 7:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
ESCHERICHIA COLI. ___ ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION. SECOND MORPHOLOGY.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMPICILLIN------------ 8 S <=2 S
AMPICILLIN/SULBACTAM-- <=2 S <=2 S
CEFAZOLIN------------- <=4 S <=4 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
NITROFURANTOIN-------- 64 I <=16 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S =>16 R
PERTINENT IMAGING
___ EGD
Findings:
Esophagus: Normal esophagus.
Stomach: Red blood was seen in the stomach body.
Duodenum: Red blood was seen in the duodenum. Large clots in the
second portion of the duodneum. No ulcers or vissible vessels
seen at these sites (bulb and second portion)
Impression: Blood in the stomach body. Blood in the duodenum.
Excude hemobilia or bleeding from the pancreatic ductal system.
No ulcers or visible vessel seen.
___ EGD
Impressoin:
Ischemic ulcers in the stomach body, antrum, and pylorus
Ischemic ulcers in the duodenal bulb and proximal D2
Circumfrential ischemia and ulceration within the distal portion
of D2
Otherwise normal EGD to third part of the duodenum
___ CT ABD w/contrast
1. Medial D2 segment ulcer with surrounding inflammatory changes
in the head and uncinate process of the pancreas consistent with
penetrating ulcer and resultant pancreatitis. Two 12mm sites of
relatively more focal hypodensity in the head and uncinate
process may reflect subcentimeter areas of acute peripancreatic
fluid collection/early pseudocyst formation within the context
of this pancreatitis without drainable collection.
2. Fatty liver.
.
.
___ Interventional Radiology Embolization
IMPRESSION:
Uncomplicated placement of a triple lumen catheter via the right
internal jugular vein. The tip terminates in the SVC and is
ready for use.
.
Successful coil and Gelfoam embolization of an active duodenal
bleed arising from the GDA. Due to pain intolerance, the
___ underwent intubation and was placed on a propofol drip
during the procedure.
.
.
___ PCXR
IMPRESSION:
1. Right IJ line with the tip seen in the upper right atrium. If
the desired position is that of the lower SVC, the line could be
withdrawn by 1.5 cm.
2. Probable left lung atelectasis. Recommended conventional
chest radiography as soon as clinically feasible.
.
Brief Hospital Course:
___ yo F with a history of cirrhosis, H.pylori (untreated) and
NSAID use, presenting with hematemesis, found to have active
bleed in duodenum, transferred to MICU for further management.
.
ACTIVE ISSUES
# UGI bleed- On admission, EGD localized the bleed to general
area of ___ portion of duodenum but not able to further localize
source or intervene. Pt was transfused 2 units of PRBC and
started on pantoprazole drip. Pt subsequently underwent ___
angiogram for localization and embolization. GDA bleed was
coiled by ___ with subsequent cessation of bleeding; no SMA
bleeding was noted by ___. Pt was very agitated in ___, requiring
intubation, but pt was able to be subsequently extubated without
difficulty. Pt's Hct remained stable post procedure,
pantoprazole drip was continued with plans for a relook
endoscopy which identified significant stomach and duodenal
necrosis ___ embolization with the original bleeding lesion
unable to be identified. Sucralfate was added. The ___
Hct had otherwise remained stable and her diet was advanced
without complication. Repeat EGD was performed indicating
diffuse necrosis. ___ did have intermittent fevers thought
to be secondary to this diffuse necrosis, ___ never had
localizing signs/symptoms and denied dysuria. ___ had been
afebrile X 48 hours ___ to discharge.
- discharged on sucralfate and PPI BID
- close f/u with Dr. ___ Dr. ___
- ___ advised to avoid Etoh and nsaids
- EGD was unable to localize primary source of bleed during
hospitalization, repeat EGD should be considered outpatient
.
# H.pylori:
- start triple therapy upon ___ with gastroenterologist
(did not start during hospitalization because of concern of poor
absorption given gastric necrosis on EGD)
- also per pt, Dr. ___ is completing ___ Authorization
paperwork for medications
.
# Abdominal pain: CT a/p consistent with pancreatitis secondary
to penetrating ulcer and pancreatic pseudocyst - likely causing
nausea and vomiting. No recurrent episodes of emesis since
embolization. ___ was discharged with 21 tablets of
oxycodone to last her until her PCP ___ was
also given a letter to be given to the rehab with her last dose
of methadone and detailing the rx of oxycodone that was given to
her for pain control. ___ has close f/u with Dr. ___
Dr. ___ further evaluation of +H pylori and pancreatic
pseudocyst, with possible EUS to further evaluate in the future.
.
# E Coli bacteruria: ___ denied symptoms of dysuria,
hesitancy, urgency.
- did not treat given ___ had no sx localizing to bladder
infection
.
CHRONIC ISSUES
.
# Mood disorder- Pt has history of mood disorder NOS and
anxiety. Pt was continued ton home topiramate. Ativan initially
held in the setting of risk of hypotension.
.
# Polysubstance abuse - pt was given thiamine, folate and MVI,
and monitored with CIWA. Pt initially received 50mg IV methadone
for withdrawl. After confirming ___ home dose, pt was
restarted on home dose 105mg methadone PO daily. She was given
10mg oxycodone Q6H PRN ___ for abdominal pain.
___ was discharged with 21 tablets of oxycodone to last her
until her PCP ___ was also given a letter to be
given to the rehab with her last dose of methadone and detailing
the rx of oxycodone that was given to her for pain control.
.
# EtOH abuse - pt was initially given folate/thiamine/mvi and
placed on CIWA with bzd for score >10. Scored low on CIWA and
___
.
# HCV, chronic- no history of known cirrhosis
.
TRANSITIONAL ISSUES:
- Please consider EGD if indicated- primary source of bleed was
never found on EGD/imaging.
- To: PCP - ___ address chronic pain management. ___ is
currently on methadone. She cannot be continued on NSAIDS given
ischemic stomach and hx of bleed and she should only receive low
doses of oxycodone. She was prescribed a short dose of oxycodone
to last her until PCP ___.
- Monitor pancreatic pseudocyst found on imaging through f/u
with Dr. ___
- ___ to follow up with Dr. ___,
gastroenterologist at ___ and to start H. pylori
therapy at that time
- ___ was discharged on PPI, sucralfate
- Also recommend obtaining f/u chest imaging with CT or CXR to
evaluation "probable left lung atelectasis" seen on PCXR on
___.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
3. Adderall (___) 20 mg oral bid
4. Docusate Sodium 100 mg PO BID
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Ibuprofen 600 mg PO Q8H:PRN pain
7. Lorazepam 1 mg PO BID
8. Methadone 10 mg PO DAILY
9. Naproxen 250 mg PO Frequency is Unknown
10. Thiamine 100 mg PO DAILY
11. Topiramate (Topamax) 50 mg PO BID
12. CloniDINE 0.1 mg PO TID:PRN anxiety
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
2. CloniDINE 0.1 mg PO TID:PRN anxiety
3. Docusate Sodium 100 mg PO BID
4. Fluticasone Propionate NASAL 1 SPRY NU DAILY
5. Lorazepam 1 mg PO BID
6. Methadone 105 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Thiamine 100 mg PO DAILY
9. Topiramate (Topamax) 50 mg PO BID
10. FoLIC Acid 1 mg PO DAILY
11. Adderall (___) 20 mg oral bid
12. Hydrocortisone (Rectal) 2.5% Cream ___ID hemorrhoids
13. Senna 1 TAB PO BID:PRN constipation
14. Sucralfate 1 gm PO QID Duration: 28 Days
RX *sucralfate 1 gram 1 tablet(s) by mouth four times daily Disp
#*28 Tablet Refills:*3
15. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
RX *oxycodone 10 mg 1 tablet(s) by mouth every 6 hours Disp #*21
Tablet Refills:*0
16. Omeprazole 40 mg PO BID ulcers Duration: 28 Days
RX *omeprazole [Prilosec] 20 mg 2 capsule,delayed
___ by mouth twice daily Disp #*112 Capsule
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: gastric and duodenal ulcers, pancreatitis,
pseudocyst in pancreas
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 at ___
___. You were admitted to the hospital because of
bloody vomiting. You were found to have bleeding in your small
intestine. The bleeding was stopped by placing coils through
your artery into the bleeding vessel. A second study showed
that you have ulcers throughout your stomach and small
intestine. Imaging showed that you have an inflamed pancreas
from the ulcers and a cyst in your pancreas. You were started on
a new medication to treat this condition called sucralfate and
protonix. It is important you do not take any medications in the
class of NSAIDS- this includes aspirin, ibuprofen, indomethacin,
ketorolac, diclofenac. Please do not drink any alcohol. You will
start on traetment to treat your H. pylori infection when you
meet with your gastroenterologist.
Please go to your appointment with your primary care doctor to
further discuss pain control. Please see below for your
appointments
Followup Instructions:
___
|
10239919-DS-6 | 10,239,919 | 29,294,389 | DS | 6 | 2168-11-27 00:00:00 | 2168-11-27 20:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
GSW L forearm, R shoulder
Major Surgical or Invasive Procedure:
open reduction internal fixation of left radius and ulna
History of Present Illness:
___ s/p through-through GSWs to L forearm and R shoulder at
1 am. He was placing laundry in his car when he heard gunshots
and realized he was being shot at. He was taken to ___ and had x-rays demonstrating no R shoulder bone
injuries
but did show L proximal ulna/radius comminuted fractures. He
received ancef and was transferred to ___ ED for further
management. He received a tetanus booster in the ___ ED.
Past Medical History:
None
Social History:
___
Family History:
NC
Physical Exam:
A&O x 3
Calm and comfortable, appropriately conversant
RUE
1cm entry wound in superolateral deltoid and 1cm exit wound at
proximal inferior medial upper arm
Arm and forearm compartments soft
Radial, medial, ulnar n SILT
EPL/FDS/DIO fires with ___ strength
2+ radial pulse
Digits WWP
LUE
1cm entry wound in proximal lateral volar forearm and 1cm exit
wound in proximal medial dorsal forearm
Arm and forearm compartments soft
Radial, medial, ulnar n SILT
Significant weakness with finger extension (including thumb) and
wrist extension (___)
Finger flexors and intrinsics fire and intact, though limited by
pain
2+ radial, 1+ ulnar pulse
Digits WWP
On discharge:
NAD, A+Ox3
LUE NWB in sling. SILT r/m/u. 2+ radial pulse, WWP
Pertinent Results:
LABS: Significant for Hct of 37 and INR of 1.1
IMAGING:
R shoulder x-ray - no fractures/dislocations
L forearm x-ray - proximal radius and ulna comminuted fractures
without evidence of joint involvement
Brief Hospital Course:
On ___ the patient was admitted to the ortho trauma service.
The pt underwent open reduction internal fixation of left
proximal ulna/radius fracture.
On ___ the patient continued to recover well. The incision was
healing well. Dressing was c/d/i with orthoplast splint in
place. The patient was seen and fitted by occupational therapy.
The pt was discharge home LUE NWB, elbow ___ in sling when out
of bed, RUE WBAT ___ 325 for DVT prophylaxis, with plans
to follow-up with Dr. ___ in clinic.
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*120 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
left proximal ulna and radius fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take aspirin 325mg daily until follow-up (for 2 weeks)
WOUND CARE:
- You can get the wound wet/take a shower starting 3 days after
your surgery. You may wash gently with soap and water, and pat
the incision dry after showering.
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
Non-weight bearing left upper extremity. Range of motion as
tolerated at the elbow. Wear sling when out of bed. Right upper
extremity weight bearing as tolerated and range of motion as
tolerated.
Followup Instructions:
___
|
10240707-DS-3 | 10,240,707 | 29,602,389 | DS | 3 | 2144-04-28 00:00:00 | 2144-04-28 18:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain and melena
Major Surgical or Invasive Procedure:
EGD ___
EGD with biopsy ___
History of Present Illness:
Mr. ___ is a ___ year old gentleman with history of peptic
ulcer disease, CAD s/p inferior STEMI (___) s/p multiple PCI,
iHFrEF (LVEF 45%), hypertension, atrial fibrillation on
apixaban, and COPD who is presenting with melena x 1 day.
Mr. ___ reports history of GIB several years ago, in the
setting of which he had a NSTEMI and gastric ulcer. Yesterday
night he reported having a melanotic stool, associated with
dizziness/lightheadedness with standing as well as abdominal
pain. Abdominal pain is located in lower abdomen and does not
radiate. He described it as dull. He had one other stool that
was described as melanotic this AM, and then starting having
more loose stools in the AM. He endorses some shortness of
breath. He otherwise denies fevers, chills, chest pain, nausea,
vomiting.
Past Medical History:
- CAD s/p inferior STEMI in ___, s/p multiple PCIs (complex
anatomy), residual disease limited to LAD with 30% ostial
disease.
- NSTEMI in setting of GIB
- Ischemic cardiomyopathy: EF 45% post event
- AF: paroxysmal after MI and when stopping high dose BB, very
symptomatic with CHF, on apixaban for CHADSVASC score of 3,
rhythm control on amiodarone.
- OSA on CPAP
- HTN
- Dyslipidemia with Non-HDL goal of 100 mg/dL, on high dose
statin at goal
- DMII, diet controlled, not on insulin with microalbuminuria
PAST CARDIAC IMAGING:
# ETT-MIBI: ___ METs, fixed basal to mid inferior and
inferoseptal perfusion defects c/w PDA scar with AK. EF 42%
# Cardiac cath ___: pre-op, Findings showed widely patent
stents in the proximal to mid right coronary artery with only
minimal tenderness 10 to 20% in-stent restenosis. There was a
50% ostial posterior descending artery plaque. The left main was
normal. There were areas of plaquing of the proximal half of the
LAD maximally up to 30% just after the origin of the first LAD
diagonal branch and the first septal perforator. The first half
of the first diagonal branch was diffusely diseased maximally up
to 95% in one segment. The left circumflex had insignificant 10
to 20% plaquing in the proximal and mid segments.
# Echo-stress ___: low normal EF without rWMA, 70% predicted
HR, no EKG, no wall motion abnormalities
Social History:
___
Family History:
-Father: stroke, HTN
-Mother: died of "eye cancer"
-no history of colon cancer
Physical Exam:
ADMISSION PE
===============
VITALS: HR 82, BP 107/71, RR, 17, 99% on 2L NC
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mucus membranes, oropharynx clear
NECK: supple, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs
appreciated
ABD: soft, non-distended, bowel sounds present, TTP
periumbililcal, no rebound tenderness or guarding, no
organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: warm well perfused, no rashes
NEURO: AOX3, CN ___ grossly intact, moves all extremities
equally
DISCHARGE PE
==================
T 97.9 BP 108/68 HR 76 RR 18 O2Sat 98% CPAP
GENERAL: Resting in bed comfortably with CPAP, alert, oriented,
in no acute distress
HEENT: Sclera anicteric, oropharynx clear
NECK: supple, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: RRR, normal S1 S2, no murmurs, rubs or gallops
ABD: Soft, large abdominal circumference, non-distended, bowel
sounds present, minor tenderness to palpation in RUQ and R
costal
margin, no organomegaly
EXT: 2+ pulses, no clubbing, cyanosis or edema
SKIN: Warm, well perfused, no rashes
NEURO: AOX3, CN ___ grossly intact, impaired proprioceptive and
vibratory sense in ___ feet
Pertinent Results:
ADMISSION LABS
===============
___ WBC-16.4* RBC-3.22* HGB-10.9* HCT-33.2* MCV-103*
MCH-33.9* MCHC-32.8 RDW-14.3 RDWSD-53.1* PLT COUNT-202
___ ALBUMIN-3.3*
___ LIPASE-48
___ ALT(SGPT)-13 AST(SGOT)-14 ALK PHOS-72 TOT BILI-0.3
___ GLUCOSE-123* UREA N-80* CREAT-1.7* SODIUM-139
POTASSIUM-5.1 CHLORIDE-105 TOTAL CO2-18* ANION GAP-21*
___ URINE BLOOD-NEG NITRITE-POS* PROTEIN-TR* GLUCOSE-NEG
KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-MOD*, URINE
RBC-1 WBC-11* BACTERIA-FEW* YEAST-NONE EPI-1
INTERVAL LABS
==================
___ 07:20AM BLOOD WBC-13.5* RBC-2.66* Hgb-9.0* Hct-27.2*
MCV-102* MCH-33.8* MCHC-33.1 RDW-15.9* RDWSD-59.3* Plt ___
___ 06:50AM BLOOD Glucose-124* UreaN-84* Creat-1.3* Na-141
K-4.2 Cl-111* HCO3-18* AnGap-16
___ 06:50AM BLOOD ALT-12 AST-10 AlkPhos-60 TotBili-0.3
___ 06:50AM BLOOD Calcium-8.6 Phos-2.4* Mg-2.0
___ 01:25PM BLOOD VitB12-513
___ 01:25PM BLOOD %HbA1c-5.3 eAG-105
DISCHARGE LABS
==================
___ 07:35AM BLOOD WBC-10.5* RBC-2.35* Hgb-7.9* Hct-24.2*
MCV-103* MCH-33.6* MCHC-32.6 RDW-16.5* RDWSD-56.9* Plt ___
___ 07:35AM BLOOD Plt ___
___ 07:35AM BLOOD Glucose-99 UreaN-18 Creat-1.1 Na-140
K-4.6 Cl-105 HCO3-18* AnGap-17*
MICRO
=====
___ BCx pending
___ UCx pending
IMAGING
========
CXR ___: No acute cardiopulmonary process.
Last colonoscopy was ___: Polyp at 20cm in the colon
(biopsy). Diverticulosis of the proximal ascending colon to
distal sigmoid colon. Grade 2 internal hemorrhoids. Otherwise
normal colonoscopy to cecum
Brief Hospital Course:
Mr. ___ is a ___ year old gentleman with history of
pepticulcer disease, CAD s/p inferior STEMI (___) s/p multiple
PCI, HFrEF (LVEF 45%), hypertension, atrial fibrillation on
apixaban,
and COPD who is presenting with melena x 1 day found to have a
4cm ulcerated mass in the stomach body concerning for
malignancy.
# Stomach mass:
Patient was found to have a 4cm ulcerated stomach mass that is
concerning for malignancy. Repeat EGD and biopsy were done and
GI recommended a CT Chest/Abdomen/Pelvis to evaluate for
metastasis. The CT C/A/P showed no evidence of metastasis.
Biopsy results preliminarily revealed poorly differentiated
neoplasm with necrosis. Gastroenterology will set up EUS. He
will be referred to a GI-oncologist.
# Acute blood loss anemia secondary to upper GI bleed
Melenic stools on presentation with Hb nadir of 8.1 from
baseline 12.5-15. He is s/p EGD that showed a large mass in the
stomach as above with no active bleeding but with large clots in
the fundus and antrum and stigmata of recent bleeding of the
mass. No intervention was performed as risk outweighed benefit.
Hgb stabilized to 9.0. His home anticoagulation and Apixaban
were held at discharge. Patient remained hemodynamically stable
and was discharged with a Hgb 7.9.
# Leukocytosis
# UTI
Leukocytosis to 16.4 on admission, likely related to upper GIB
and UTI, given pt initial report of dysuria. Preliminary urine
cx revealed E.coli. Patient was given 1 dose of ceftriazone then
transitioned to a 10 day course of cipro (End date: ___. WBC
at discharge was 10.5. Blood cultures were pending on discharge.
# ___: Cr 1.7 on admission likely pre-renal in setting of GIB
and given elevated BUN/Cr ~60. Baseline Cr ranges from 1.2-1.4
per Atrius records. Creatinine mproved during stay and was 1.1
on discharge.
# Paroxysmal atrial fibrillation: CHADs-2VASC 3, current exam is
regular rhythm. Patient's home metoprolol was held and he was
given fractionate Metoprolol Tartrate 25 mg PO/NG Q6H (lower
than 200mg BID dosing he got at home) and was continued on his
home amiodarone. His home anticoagulation and Apixaban was held
in the setting of his GI bleed.
#Peripheral neuropathy: Chart review reveals that this is new
problem. His DMII is well-controlled (A1c 5.8), so unlikely
source. B12 was in normal limits and RPR was non-reactive.
Unsure of etiology.
CHRONIC ISSUES:
# Hypertension: His home blood pressure medications were held in
the setting of his GI bleed. Pt remained normotensive throughout
admission. These were held at discharge and should be restarted
as an outpatient.
# CAD s/p STEMI with multiple PCI in ___: Patient's home
aspirin, metoprolol were held in the setting of his GI bleed. He
was continued on his home atorvastatin.
# HFpEF: Ischemic etiology. No evidence of acute exacerbation.
Patient's home diuretics and metoprolol were held. He was given
metoprolol tartrate during his stay.
# OSA: Uses CPAP at night and when napping
# COPD: Continued albuterol prn
# Gout: Continued home allopurinol
# DM: Well controlled. Daily fingersticks revealed
normoglycemia.
===============================
TRANSITIONAL ISSUES:
===============================
[] Patient will need follow up scheduled with an oncologist that
specializes in GI tumors.
[] GI will call to make a follow-up appointment and schedule
patient of EUS. Please ensure this appointment gets made. GI
will evaluate the need for an EUS pending final biopsy results.
[] Please restart apixaban as outpatient if indicated.
[] Please continue to monitor blood pressure and restart home
anti-hypertensives as needed.
[] Please continue to monitor heart rate and titrate metoprolol
as needed.
[] Patient will continue taking Ciprofloxacin until ___.
[] Follow-up stomach mass biopsy results.
[] Follow-up blood cultures.
[] Patient was discharged on a PPI. Utility of this should
continue to be re-evaluated as an outpatient.
[] RUQUS showed cholelithiasis and hepatic steatosis.
[] Will need follow-up for results of CT Abdomen and Pelvis,
which showed a L adrenal nodule. Recommended non-emergent
adrenal CT/MR exam.
[] Follow-up patient's new onset peripheral neuropathy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 5 mg PO BID A fib
2. Ranitidine 150 mg PO DAILY
3. Metoprolol Succinate XL 200 mg PO BID
4. Atorvastatin 40 mg PO QPM
5. Allopurinol ___ mg PO DAILY
6. Colchicine 0.6 mg PO PRN gout
7. Hydrochlorothiazide 12.5 mg PO DAILY
8. Enalapril Maleate 20 mg PO BID
9. Aspirin 81 mg PO DAILY
10. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
Take 1 tablet, two times a day, until ___.
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice daily
Disp #*8 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily
Disp #*60 Capsule Refills:*0
3. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice daily Disp
#*60 Tablet Refills:*0
5. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate [Toprol XL] 100 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
6. albuterol sulfate 90 mcg/actuation inhalation Q4-6H:PRN
7. Allopurinol ___ mg PO BID
8. Amiodarone 100 mg PO DAILY
9. Atorvastatin 40 mg PO QPM
10. Colchicine 0.6 mg PO PRN gout
11. Ranitidine 150 mg PO DAILY
12. Vitamin D ___ UNIT PO DAILY
13. HELD- Apixaban 5 mg PO BID A fib This medication was held.
Do not restart Apixaban until evaluated by cardiology
14. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until evaluated by cardiology
15. HELD- Enalapril Maleate 20 mg PO BID This medication was
held. Do not restart Enalapril Maleate until evaluated by PCP
16. HELD- Hydrochlorothiazide 12.5 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until evaluated by
PCP
17. HELD- nitroglycerin 0.4 mg sublingual Q5min:PRN (max 2)
This medication was held. Do not restart nitroglycerin until
evaluated by PCP
___:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Melena
Stomach mass
SECONDARY DIAGNOSIS
UTI
___
Peripheral neuropathy
Discharge Condition:
Alert, oriented
Ambulates independently
Discharge Instructions:
Mr. ___,
WHY WERE YOU IN THE HOSPITAL?
- You came to the hospital because of blood in your stool.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You had a procedure to try and find the source of your
bleeding.
- During this procedure, the stomach doctors ___ concerning
mass in your stomach. They collected a sample from the mass and
will analyze it for types of cancer.
- You had an imaging study of your body to see if there were any
other concerning masses.
WHAT SHOULD YOU DO WHEN YOU GO HOME?
- You should follow-up with your primary care physician,
___, and gastroenterology. We have also set up an
(Appointments listed below).
It was a pleasure meeting you and your family. We enjoyed taking
care of you and wish you well!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10241257-DS-15 | 10,241,257 | 23,747,524 | DS | 15 | 2160-05-23 00:00:00 | 2160-05-23 13:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shoulder pain
Major Surgical or Invasive Procedure:
right clavicle ORIF ___ (___)
History of Present Illness:
___ female presents with right clavicle fracture s/p mechanical
fall. The patient was exercising with curtain when she fell
from
a couple feet in the air landing directly on her clavicle where
she felt immediate pain. She stood up and felt presyncopal
secondary to the pain but did not lose consciousness. She
denies
striking her head and she denies any neck pain. She denies
numbness or tingling. No medical problems and denies any
history
of problems to the clavicle.
Past Medical History:
None
Social History:
___
Family History:
Noncontributory
Physical Exam:
On discharge:
General: Alert and oriented, pleasant affect, cooperative with
exam
Right upper extremity:
- Skin intact, moderate tenting of the skin at the midshaft
clavicle, skin does not appear threatened
- RUE in sling
- Soft, non-tender arm and forearm
- EPL/FPL/DIO (index) fire
- SILT axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse
Pertinent Results:
___ 04:35PM BLOOD WBC-8.9 RBC-4.04 Hgb-12.5 Hct-38.7 MCV-96
MCH-30.9 MCHC-32.3 RDW-14.1 RDWSD-50.1* Plt ___
___ 04:35PM BLOOD Glucose-85 UreaN-14 Creat-1.0 Na-141
K-4.1 Cl-104 HCO3-23 AnGap-14
___ 04:35PM BLOOD Calcium-10.1 Phos-2.8 Mg-2.0
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right clavicle fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for right clavicle ORIF, which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with OT who determined that discharge to home was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
nonweightbearing in the right upper extremity, and will be
discharged on aspirin 325 mg daily 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
Do not take more than 4000mg acetaminophen in 24 hours
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*75 Tablet Refills:*0
2. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*28
Tablet Refills:*0
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
Patient may refuse or request partial fill
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*25 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right clavicle fracture
Discharge Condition:
Stable, alert and oriented x3, ambulating without assistance
Nerve block wearing off to the right upper extremity
Sensation intact to light touch in radial, median, ulnar
distribution
Surgical bandage on right clavicle clean/dry/intact
able to A-OK, thumbs up, finger cross
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:
-Nonweightbearing right upper extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add 5 mg oxycodone as needed for increased pain. Aim to
wean off this medication in 1 week or sooner. This is an
example on how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take aspirin 325 mg 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
Followup Instructions:
___
|
10242290-DS-18 | 10,242,290 | 29,976,191 | DS | 18 | 2193-06-18 00:00:00 | 2193-08-01 13:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
leg pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with sudden onset left lower
leg pain which began two days prior to admission. Pain
localized to left popliteal fossa radiating down left leg. No
history of fall or trauma. Denied numbness or tingling, chest
pain, shortness of breath. Pain worse with ambulating but also
endorses pain at rest, constant in nature, not intermittent.
Denied fevers, chills, sweats. No history of bug bites. No
unusual exposures noted. Denies back pain.
Past Medical History:
Diabetes Mellitus Type 2
Hypertension
Hyperlipidemia
GI Bleed - likely secondary to diverticulosis
Anemia
B12 deficiency
Glaucoma
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL:
VS: Afebrile, normotensive, not tachycardic
GENERAL - well appearing, pleasant female in no apparent
distress
HEENT - NC/AT, PERRLA, EOMI, MMM, OP clear
NECK - supple, no midline tenderness, full range of motion
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 - NABS, soft/NT/ND, no rebound/guarding
EXTREMITIES - no c/c/e, 2+ peripheral pulses (radials, DPs), no
popliteal masses, no erythema, no edema, strength ___
throughout; patient able to ambulate with limp on weight bearing
on LLE. Full passive ROM.
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
DISCHARGE PHYSICAL:
VS - Temp 97.1F, BP 130/57, HR 64, R 18, O2-sat 100% RA, FSBS 96
GENERAL - well appearing, pleasant female in no apparent
distress
HEENT - NC/AT, PERRLA, EOMI, MMM, OP clear
NECK - supple, no midline tenderness, full range of motion
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 - NABS, soft/NT/ND, no rebound/guarding
EXTREMITIES - no c/c/e, 2+ peripheral pulses (radials, DPs), no
popliteal masses, no erythema, no edema, strength ___
throughout; patient able to ambulate with limp on weight bearing
on LLE. Full passive ROM. Bony tenderness over L tibia 3-4cm
distal to tibial tuberosity.
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Pertinent Results:
Labs:
___ 01:11PM BLOOD WBC-6.9 RBC-3.79* Hgb-10.1* Hct-31.1*
MCV-82# MCH-26.7* MCHC-32.7 RDW-14.0 Plt ___
___ 01:11PM BLOOD Neuts-70.6* ___ Monos-3.8 Eos-1.1
Baso-0.3
___ 01:11PM BLOOD Glucose-97 UreaN-25* Creat-1.2* Na-141
K-4.0 Cl-104 HCO3-27 AnGap-14
___ 01:11PM BLOOD CK(CPK)-82
Studies:
- UNILAT LOWER EXT VEINS LEFTStudy Date of ___ 1:16 ___
IMPRESSION: No DVT.
- TIB/FIB (AP & LAT) LEFTStudy Date of ___ 3:28 ___
IMPRESSION: No fracture or significant degenerative changes.
- KNEE (2 VIEWS) LEFTStudy Date of ___ 3:28 ___
IMPRESSION: No fracture or significant degenerative changes.
- L-SPINE (AP & LAT)Study Date of ___ 3:28 ___
TWO VIEWS OF THE LUMBAR SPINE: Five non-rib-bearing lumbar
vertebral bodies
are demonstrated. No sclerotic or lytic lesions are identified.
Mild
spondylosis is present without spondylolisthesis. No traumatic
malalignment
is identified. The lower sacrum is obscured by overlying bowel
gas. No free
intra-abdominal air is seen.
Brief Hospital Course:
___ year old female admitted for pain in her left leg,
atraumatic, with negative studies. Pain improved the next day
to the point of being able to ambulate with ___.
1) Leg Pain: Workup with ultrasound and X-rays were negative.
There was initial concern for deep venous thrombosis but this
was ruled out. There was also no evidence of a ___ cyst.
Given that patient was able to work with ___, ambulate without
issue and pain was under control, patient was discharged with
PCP follow up.
.
Inactive issues:
Diabetes Mellitus Type 2 - stable, continued on home medications
.
Hypertension - stable, continued on home medications.
.
Anemia - stable, no acute interventions, recent Hct 31
.
6) Glaucoma - continued on home eye drop regimen
.
Transitional care:
1. CODE: Full
2. Medication changes: START percocet and docusate, all others
the same
3. Follow-up: with PCP as scheduled
4. Contact: Son
5. Pending studies/labs: None
Medications on Admission:
HCTZ 25mg daily
lisinopril 30mg daily
simvastatin 20mg daily
metformin 850mg BID
insulin glargine 20u QHS
Calcium (600)+ Vit D BID
docusate sodium 100mg BID
latanoprost eye drops - to both eyes
artificial tears QID prn
Discharge Medications:
1. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO
every six (6) hours as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day.
4. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
5. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day.
7. insulin glargine 100 unit/mL Cartridge Sig: Twenty (20) Units
Subcutaneous at bedtime.
8. Calcium 600 + D(3) 600 mg calcium- 200 unit Capsule Sig: One
(1) Capsule PO twice a day.
9. latanoprost 0.005 % Drops Sig: ___ drops Ophthalmic once a
day: to both eyes.
10. Artificial Tears Drops Sig: ___ drops Ophthalmic four
times a day as needed for eye dryness: to both eyes.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1) Left lower leg pain
Secondary:
1) Hypertension
2) Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___:
It was a pleasure taking care of you in the hospital during your
stay. You were admitted for pain in your lower left leg - you
had xray studies and an ultrasound which did not reveal a cause
of your pain. This will need to be evaluated as an outpatient
with your primary care physician if the pain persists.
The following medications were ADDED:
1) START Percocet ___ tablets every 6 hours as needed for
pain
2) START Docusate Sodium 100mg, 1 tablet twice a day
No other medications were changed during your admission and your
should take all of your other medications as you normally would.
Followup Instructions:
___
|
10242290-DS-19 | 10,242,290 | 23,880,248 | DS | 19 | 2193-11-07 00:00:00 | 2193-11-07 16:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
headache, nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with a history of DMII on lantus, who presented with
three days of headaches, nausea, vomiting and fatigue. Patient
presented to PCP's office the day prior to admission with
similar complaints. In addition to above symptoms, she reports
increased thirst, subjective fevers but had not taken
temperature, and chills, night sweats, abdominal pain, dysuria
or chest pain. She reports adherence to a diabetic diet but had
not been eating much over the past few days because of nausea
and vomiting.
At the PCP's office day prior to admission, finger stick was
>500. Patient received 10units of humalog, with repeat >500.
This was notable as patient's diabetes is generally very well
controlled. Patient was sent home, and instructed to go to the
ED if repeat finger sticks were elevated. PCP ___ later
that evening and son informed him that 8:30PM finger stick was
122.
On the morning of admission, PCP's office contacted patient to
report that in addition to elevated blood sugar, creatinine was
elevated to 2.0 from baseline 1.0-1.2. Patient had already been
taken to the ED at that point.
In the ___ ED, initial vital signs were T 97.3 BP 132/68 HR 99
RR 20 O2 98% RA. Patient reported ongoing nausea, left upper
quadrant abdominal pain, diarrhea and headache. She was noted
to have a blood glucose of 542, creatinine of 1.8, and
urinalysis was notable for 1000 gluc, 10 ketones, small leuks,
12 WBC and few bacteria. She was given 1 dose of ciprofloxacin
to treat her urinary tract infection as well as 10 units of
regular insulin. She was hydrated with 1L NS @ 150cc/h. She was
admitted for further evaluation of hyperglycemia and acute renal
failure.
On the floor, initial vital signs were T 98.7 BP 148/57 HR 78 RR
18 O2 99% RA. Patient denies pain, ongoing nausea or vomiting.
___ on arrival 291
Review of sytems:
(+) As above. In addition, endorses fever but did not take
temperature, back pain on left> right, now resolved
(-) Denies chills, weight loss. Denies abdominal pain, dysuria,
urgency or frequency, hematuria. Denies vision changes. Denies
weakness, numbness, tingling. Denies rhinorrhea, cough,
shortness of breath, chest pain.
Past Medical History:
# Diabetes type 2- diagnosed in ___ A1c 6.6 (___)
# Hypertension
# Hyperlipidemia
# Glaucoma, open angle
# Diverticulosis: h/o LGIB (adm ___ in ___, s/p 4u PRBCs;
colonoscopy showed diffuse diverticulosis, tagged RBC scan
negative. LGIB presumed due to diverticulosis).
# Possible pulm hypertension: seen on echo ___ - TR gradient
40mmHg.
# Anemia, etiology unclear
# Bilateral duputryen's contracture
# Vitamin D deficiency
Social History:
___
Family History:
Significant for diabetes in "all of the old people"
Father died of complications from diabetes
Physical Exam:
Admission Physical Exam:
Vitals- T 98.7 BP 148/57 HR 78 RR 18 O2 99% RA
General- elderly female in NAD
HEENT- sclera anicteric, PERRL, EOMI, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- poor inspiratory effort, clear to auscultation
bilaterally, no wheezes, rales, ronchi
CV- regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- +BS, soft, non-tender, non-distended, no
rebound/guarding
GU- no CVA tenderness, no foley
Ext- WWP, 2+ ___ pulses, no clubbing, cyanosis or edema
Neuro- CN II-XII grossly intact, motor function grossly normal
Discharge Physcial Exam:
Vitals- T 97.5 BP 113/57 HR 67 RR 18 O2 100% RA
Finger sticks- ___ 358
147
Exam otherwise unchanged
Pertinent Results:
Admission Labs:
WBC 9.7 Hgb 10.9 Hct 34.8 Plts 370
N:77.2 L:18.7 M:2.6 E:0.7 Bas:0.8
.
128 89 35 542
--------------< 542
4.6 23 1.8
.
ALT: 17 AST: 18 AP: 91 Tbili: 0.5 Lip: 45
Alb: 4.6
.
Lactate:1.9
.
Urinalysis- SpecGr 1.016 pH 5.0 Urobil Neg Bili Neg
Leuk Sm Bld Neg Nitr Neg Prot Neg Glu 1000 Ket 10
RBC <1 WBC 12 Bact Few Yeast None Epi 1
Microbiology:
Urine culture ___- no growth
Imaging:
CXR ___- no acute cardiopulmonary process
EKG: Sinus rhythm with frequent PACs, normal axis, normal
intervals, no ST-T wave abnormalities
Brief Hospital Course:
___ yo F with h/o IDDM, htn, hyperlipidemia presenting with
hyperglycemia, acute renal failure and urinary tract infection.
# Hyperglycemia- Patient presented to ED with glucose 542. She
had ketones in her urine and glucosuria, with a mild anion gap
metabolic acidosis, but bicarbonate was not significantly low
and no mental status changes. She received 1L normal saline and
10 units regular insulin SC. She received another liter of NS
overnight and had home metformin held while a regular ISS was
begun on top of her home 20 units of lantus QHS. The presumed
precipitant was a UTI, as no other clear source, and patient
reported subjective fevers. Patient was started on
ciprofloxacin for mildly positive urinalysis, however urine
culture had no growth so ciprofloxacin was discontinued.
She does report worsening sugars, but can not recall over
what period of time, so it is possible that hyperglycemia is
precipitated by insufficient insulin; however, she received
insulin at ___'s office and remained elevated. No evidence of
cholecystitis, hepatitis, toxin ingestion. No evidence of
ischemia on EKG and normal lactate so not concerning for end
organ damage.
Patient was discharged on home regimen: lantus 20mg qHS
with metformin 850mg TID. She will follow-up with her primary
care doctor regarding further necessary changes. She may
benefit from meal-time insulin if sugars continue to be poorly
controlled.
# Acute kidney injury- Creatinine was 2.0 up from baseline of
1.0-1.2. BUN/Cr >20. Likely prerenal in etiology secondary to
dehydration, with polyuria, vomiting and DKA. Received NS
intravenous fluid resuscitation. Lisinopril and HCTZ were held
in setting of ___. Creatinine improved to 1.1 on the day of
discharge(patient's baseline). Lisinopril was held at time of
discharge, but hydrochlorothiazide was restarted. Lisinopril to
be restarted at primary care follow-up.
# + Urinalysis- Urinalysis concerning for infection although
patient denied urinary sx. Fevers, nausea and vomiting also
possibly related to either a UTI or viral gastroenteritis. She
was started on 500mg BID cipro ___ however culture returned
with no growth, and ciprofloxacin was discontinued.
# Anion gap metabolic acidosis- Bicarb 23 on admission with
anion gap of 16. Likely DKA vs starvation ketoacidosis in
setting of possible GI or urinary infection and poor PO intake
and vomiting. Anion gap was 7 on discharge with bicarb 25.
# Hypertension: BPs were stable during hospitaliztion
120-140/50-60. Lisinopril and HCTZ were held in the setting of
___ and attempts at volume repletion. Pt was continued on home
ASA and simvastatin. Hydrochlorothiazide restarted prior to
discharge, but lisinopril was held.
# Glaucoma: patient has stable glaucoma and was continued on
home latanoprost.
# Transitional issues
- Please evaluate whether to restart this patient on lisinopril
at next outpatient visit
Medications on Admission:
Lisinopril 30 mg po daily
Hydrochlorothiazide 25 mg po daily
Simvastatin 20 mg po daily
ASA 81 mg po daily
Lantus 20 units qHS
Metformin HCl 850 MG Tablet as directed
Latanoprost 0.005 % 1 drop into affected eye qHS
Calcium 600 + D 400 MG-UNIT 1 tablet po daily
Acetaminophen 500-1000mg po q6h prn pain
___ ___ UNIT po qweek
Docusate Sodium 100 mg Capsule 1 capsule as needed Four times a
day
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
5. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
6. insulin glargine 100 unit/mL Solution Sig: Twenty (20) Units
Subcutaneous at bedtime.
7. metformin 850 mg Tablet Sig: One (1) Tablet PO three times a
day.
8. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
# Hyperglycemia
# Urinary tract infection
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 during your recent
admission.
You were admitted with elevated blood sugars. You had no
infection found to explain the elevation. It is possible that
you had a viral infection.
The following changes were made to your medication regimen:
- DO NOT take your lisinopril until you follow-up with your
doctor
___ continue the remainder of your medications as prescribed
Followup Instructions:
___
|
10242576-DS-5 | 10,242,576 | 22,828,115 | DS | 5 | 2187-05-15 00:00:00 | 2187-05-15 20:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Necrotizing Pancreatitis, Hyperbilirubinemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of alcohol abuse and hypertension transferred
from ___ for surgical evaluation of necrotizing
pancreatitis.
Patient was originally admitted to ___ on ___
for acute pancreatitis. He had been experiencing progressive
lower back pain bilaterally, radiating to the midline of his
back. He had thought that the back pain was due to injuring
himself during yardwork and brought himself to ___ ED. At
the time, he denied fever, jaundice, chest pain, diarrhea. He
reported heavy etOH use over several days previously, drinking
up to ___ gallon of vodka/whiskey per day. He was discharged
home where he was stable and tolerating PO. He had follow up
blood work two days later with PCP, was found to have uptrending
WBC and elevated Tbili and was referred back to ED. Patient was
then transferred to ___ for further care.
Upon arrival to ___, patient reported constant aching
abdominal pain 7.5 with occasional sharp pain on deep
inhalation. For this reason, he also feels shortness of breath
at times. The pain occasionally gives him the "chills" but
otherwise does not feel feverish. He reports that he weighed
280s at ___ clinic, while previously he was 260 prior to
original ___. He notes that he can not
longer wear his pants because his waist is so wide since
discharge. He feels "fullness in my belly." Reports that he
noticed he had "turned yellow" in his eyes and skin roughly
around ___ during his inpatient stay. Denies nausea, vomiting,
diarrhea, cough, chest pain.
Patient had last drink on ___ and has never experienced
withdrawal symptoms nor delirium tremens.
ROS: As per HPI. 10 point ROS otherwise negative.
Past Medical History:
Hypertension
Obesity
Nephrolithiasis
Alcohol abuse
Appendectomy
Social History:
___
Family History:
Father: MI at ___
Mother: CHF at ___
Reports there are anxiety orders in multiple family members.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
Vital Signs: 148 / 83 93 16 95
General: Alert, oriented, no acute distress. Jaundiced
HEENT: Sclerae icteric, MMM, oropharynx clear, EOMI, PERRL.
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation bilaterally except diminished
breath sounds on left base.
Abdomen: Soft, distended with fluid wave, mild tenderness to
deep palpation diffusely, bowel sounds present, no organomegaly,
no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, 1+ pitting edema
bilaterally
Neuro: CNII-XII intact, moves all extremities
PHYSICAL EXAM ON DISCHARGE:
PHYSICAL EXAM:
Vitals: 99.5 150-160s/80s-90s ___ 18 94-97% RA
General: obese, jaundiced in no acute distress
HEENT:. icteric sclera
CV: RRR. S1, S2. No mrg
Lungs: CTA b/l
Abdomen: Nontender, distention improved from previous ___.
guarding, rigidity
Ext: 1+ ___ edema
Neuro: CN II-XII grossly intact.
Skin: jaundiced
Pertinent Results:
ADMISSION LABS
=======================
___ 01:52AM BLOOD WBC-29.9* RBC-3.89* Hgb-13.7 Hct-37.9*
MCV-97 MCH-35.2* MCHC-36.1 RDW-13.4 RDWSD-48.5* Plt ___
___ 02:25AM BLOOD ___ PTT-31.7 ___
___ 01:52AM BLOOD Glucose-119* UreaN-11 Creat-0.7 Na-133
K-3.4 Cl-97 HCO3-23 AnGap-16
___ 01:52AM BLOOD ALT-65* AST-70* AlkPhos-329*
TotBili-17.4*
___ 07:23AM BLOOD Albumin-2.6* Calcium-7.6* Phos-3.5 Mg-2.0
___ 07:23AM BLOOD Triglyc-196*
___ 07:20AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 01:59AM BLOOD Lactate-1.5
NOTABLE LABS
=====================
___ 07:23AM BLOOD WBC-26.8* RBC-3.53* Hgb-12.5* Hct-34.6*
MCV-98 MCH-35.4* MCHC-36.1 RDW-13.5 RDWSD-47.9* Plt ___
___ 07:20AM BLOOD WBC-23.0* RBC-3.54* Hgb-12.4* Hct-34.6*
MCV-98 MCH-35.0* MCHC-35.8 RDW-13.4 RDWSD-47.8* Plt ___
___ 05:50AM BLOOD WBC-20.9* RBC-3.50* Hgb-12.4* Hct-33.7*
MCV-96 MCH-35.4* MCHC-36.8 RDW-13.7 RDWSD-48.0* Plt ___
___ 06:02AM BLOOD WBC-19.9* RBC-3.60* Hgb-12.6* Hct-35.0*
MCV-97 MCH-35.0* MCHC-36.0 RDW-14.2 RDWSD-49.8* Plt ___
___ 05:05AM BLOOD WBC-19.3* RBC-3.33* Hgb-11.9* Hct-33.1*
MCV-99* MCH-35.7* MCHC-36.0 RDW-14.6 RDWSD-52.8* Plt ___
___ 07:23AM BLOOD ALT-55* AST-52* AlkPhos-271*
TotBili-14.2* DirBili-11.2* IndBili-3.0
___ 07:20AM BLOOD ALT-61* AST-63* AlkPhos-283*
TotBili-16.9* DirBili-13.6* IndBili-3.3
___ 05:50AM BLOOD ALT-55* AST-41* AlkPhos-262*
TotBili-15.1* DirBili-12.6* IndBili-2.5
___ 06:02AM BLOOD ALT-58* AST-53* AlkPhos-318*
TotBili-15.5*
___ 05:05AM BLOOD ALT-51* AST-48* AlkPhos-335*
TotBili-13.3*
DISCHARGE LABS
=======================
___ 05:10AM BLOOD WBC-19.5* RBC-3.45* Hgb-12.1* Hct-34.2*
MCV-99* MCH-35.1* MCHC-35.4 RDW-14.7 RDWSD-53.1* Plt ___
___ 05:10AM BLOOD ___
___ 05:10AM BLOOD Glucose-114* UreaN-5* Creat-0.5 Na-136
K-3.4 Cl-94* HCO3-28 AnGap-17
___ 05:10AM BLOOD ALT-51* AST-51* AlkPhos-421*
TotBili-11.3*
___ 05:10AM BLOOD Calcium-8.0* Phos-3.5 Mg-1.8
MRCP (___)
Lower Thorax: A small left pleural effusion is seen with
compressive left
lower atelectasis
Liver: Again seen is hepatomegaly and there is multifocal is
steatosis.
Biliary: No biliary ductal dilatation or choledocholithiasis.
Cholelithiasis is noted.
Pancreas: Again seen is extensive peripancreatic necrosis and
regions of
parenchymal necrosis in the inferior aspect of the pancreatic
head. The
peripancreatic necrosis is seen predominantly anterior to the
mid body of the pancreas tracking along the anterior margin of
the caudate lobe, lesser sac and superior aspect of the left
anterior pararenal space anterior to the left adrenal gland. The
largest necrotic collection is seen superiorly along the lesser
sac measuring 9 cm. There are small foci of hemorrhage within
the peripancreatic space.
Spleen: Unremarkable.
Adrenal Glands: Unremarkable.
Kidneys: Unremarkable.
Gastrointestinal Tract: There is no intestinal obstruction. A
small amount of ascites is again seen.
Lymph Nodes: No enlarged lymph nodes in the upper abdomen.
Vasculature: The hepatic vasculature is patent. Few
gastroepiploic and
periumbilical collaterals are noted.
Osseous and Soft Tissue Structures: No aggressive osseous
lesions visualized.
IMPRESSION:
Redemonstration of parenchymal and peripancreatic necrosis with
a few foci of hemorrhage in the lesser sac. No biliary ductal
dilatation or
choledocholithiasis.
Multifocal hepatic steatosis.
Brief Hospital Course:
___ with history of hypertension and alcohol abuse, readmitted
to ___ for leukocytosis and hyperbilirubinemia following
___ admission for acute pancreatitis, transferred to ___
for further management of necrotizing pancreatitis.
Patient initially presented to ___ on ___ for
___ back pain. He had been drinking ___ gallons of
whiskey/vodka every ___ days, with most recent drink on ___.
Patient was diagnosed with alcoholic acute pancreatitis and
discharged on ___ after becoming hemodynamically stable and
tolerating PO. Patient's follow up blood work at ___ revealed
leukocytosis of 30k and total bilirubin of 17.4 and patient was
readmitted to ___ on ___. CT imaging revealed
necrotizing pancreatitis and he was transferred to ___ for
surgical evaluation.
Upon transfer, patient was afebrile, hemodynamically stable,
jaundiced with abdomen distention in no acute distress on IV
antibiotics. Labs were notable for direct hyperbilirubinemia. GI
and Surgery was consulted and antibiotics were held due to low
probability of superimposed infection. Alcohlic hepatitis was
also considered and although patient's ___ score was 35,
given necrotizing pancreatitis, steroids were not given. At OSH,
patient was tested for Hep A,B, and C which were negative. At
our hospital, patient was evaluated for possibility of
autoimmune hepatitis, which were negative. MRCP did not show any
blockage in the biliary tree. Suspect elevated bilirubin to be
secondary to alcoholic hepatitis.
Patient was placed NPO, given tramadol for pain, and given LR
for maintenance IV fluids until he was able to tolerate PO.
Patient was hemodynamically stable throughout stay, tolerating
PO with downtrending leukocytosis and bilirubin and was deemed
stable for discharge.
#Necrotizing Pancreatitis:
CT scan concerning for necrotizing pancreatitis. He was recently
admitted for acute pancreatitis, presumed etoh related given his
history of alcohol abuse. No fevers to suggest infectious
necrotizing pancreatitis. General Surgery evaluated patient and
there was no indication for any procedures. GI was consulted who
recommended supportive care. He was NPO, received IVF until he
could tolerate PO. Tramadol was given for pain relief. His
leukocytosis continued to trend downwards and he was stable for
discharge with GI follow up.
Of note, patient was receiving tramadol 50mg q3h on day of
discharge with plan to wean off tramadol while inpatient;
however, patient was eager to leave the hospital without
titration off tramadol.
#Hyperbilirubinemia:
Patient with profound direct hyperbilirubinemia. Hepatology was
consulted. With pancreatitis, concerned for extrinsic
obstruction of the common bile duct. Also concerned for
choledocholithiasis. He received an MRCP which did reveal any
CBD stone or dilatation. Given history of alcohol abuse, suspect
that his hyperbilirubinemia was secondary to alcoholic
hepatitis. He had ___ score>32 on admission, but because
of his necrotizing pancreatitis, held off on his steroids. He
also had negative AMA, anti-smooth antibodies, and hepatitis
serologies. Patient's bilirubin continued to trend downwards
during hospitalization with discharge total bilirubin of 11. He
will follow up PCP with plan to repeat labwork.
#Elevated INR
Initial INR of 1.5 likely nutritionally related. He received 3
days of vitamin K challenge with improvement of INR to 1.2.
#EtOH Abuse
Last drink on ___. Patient reports he is motivated to quit
drinking given his recent hospitalizations. He was provided
information for programs at OS___. Social work saw patien to
encourage his sobriety. He had no evidence of withdrawal while
admitted
#HTN:
Hypertensive with average SBP 150-160s during admission. He was
restarted on home losartan 100mg, HCTZ 25mg, and metoprolol
succinate 50mg
TRANSITIONAL ISSUES
[] Repeat CBC, BMP, LFTs to ensure downtrending leukocytosis and
bilirubin.
[] Patient with inguinal hernia seen on CT scan. Please continue
management as outpatient.
[] Patient seen by psychiatry at ___ who was
concerned for possible anxiety disorder. Please continue
management and consider outpatient psychiatry appointment.
[] Continue to encourage alcohol sobriety.
[] Please continue to monitor BP as outpatient given elevated BP
as inpatient.
# CODE: full (confirmed)
# CONTACT: ___ (wife) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 100 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H
2. Hydrochlorothiazide 25 mg PO DAILY
3. Losartan Potassium 100 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5.Outpatient Lab Work
Diagnosis: Pancreatitis ___
Date: ___
Labs: CBC, LFT, BMP
Fax results to PCP ___ at ___.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Necrotizing Pancreatitis
Hyperbilirubinemia
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 you were admitted?
You were admitted after you were found to have necrotizing
pancreatitis, a complication of acute pancreatitis. In your
blood work, it was found that your white blood count was high,
which was concerning for infection. You also had elevated levels
of bilirubin (found in bile) and it was thought that this was
due to some obstruction within your biliary system, which
secretes bile into your intestines to help digest fatty foods.
What did we do for you?
We were concerned that the obstruction in your biliary system
may have been coming from extrinsic compression due to the
necrotizing pancreatitis. When the extrinsic compression is
extremely severe, this may require surgical intervention and
that's why we were monitoring your bilirubin levels over many
days to evaluate whether the compression would resolve on its
own.
What should you do now?
We encourage your sobriety as we believe that the cause of the
acute pancreatitis was due to alcohol consumption. Patients
often attribute their success in maintaining sobriety through
rehabilitation programs and social support systems such as
alcoholic___ anonymous. We encourage you to seek out these
programs after thorough consideration with your loved ones.
Followup Instructions:
___
|
10242587-DS-22 | 10,242,587 | 26,989,488 | DS | 22 | 2184-06-18 00:00:00 | 2184-06-19 14:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Trauma: fall:
Right anterior 1st rib fracture
Right pneumothorax
pulmonary contusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: Mrs. ___ is an ___ year old woman with a history of
multiple prior repeated falls since ___ (almost once/year as
documented in ___) who presents to the ED after suffering a
mechanical fall out of her bed this morning. She was attempting
to answer the telephone, fell out of bed, and was unable to get
up so pressed her emergency help button and was eventually found
by EMS sitting on the floor. Denies head strike, LOC.
Patient reports that she is very clumsy and unstable at baseline
and typically uses a cane and walker to mobilize. Currently
complains only of pain over her R shoulder and back
Past Medical History:
HTN
depression
IBD
Osteoarthritis
Allergies:
NKDA
Social History:
___
Family History:
Not contributory
Physical Exam:
Physical examination upon admission: ___:
VS - 98.1 82 156/80 18 98%
GEN - NCAT, EOMI, PERRL
HEENT - no hemotympanum, no blood in the nares or oropharynx; R
lateral brow/supraorbital rim ecchymosis; several missing teeth;
no midline cervical tenderness to palpation
___ - RRR
PULM - no resp distress; CTAB; palpable crepitus over R
clavicle,
shoulder and superior/anterior R chest; clavicles and sternum
intact/stable
ABD - soft, nontender, nondistended; no pelvic instability
EXTREM/MSK - ecchymoses over R knee
Physical examination upon discharge: ___:
vital signs: 98.2, hr=79, bp=147/74, rr=20, oxygen saturation
95%
General: Resting in bed, NAD, ecchymosis lat. aspect of right
eye
CV: ns1, s2, -s3. -s4
LUNGS: clear, diminished in bases bil
ABDOMEN: soft, non-tender
EXT: no pedal edema bil., ecchymosis, mild swelling right knee,
no calf tenderness bil., no pedal edema bil
NEURO: alert and oriented x 3, speech clear, no tremors
Pertinent Results:
___ 08:10AM BLOOD WBC-8.7 RBC-4.52 Hgb-13.8 Hct-41.6 MCV-92
MCH-30.4 MCHC-33.1 RDW-13.7 Plt ___
___ 12:15PM BLOOD WBC-7.7 RBC-4.42 Hgb-13.6 Hct-41.4 MCV-94
MCH-30.8 MCHC-32.9 RDW-14.2 Plt ___
___ 12:15PM BLOOD Neuts-76.4* Lymphs-12.9* Monos-7.6
Eos-2.3 Baso-0.8
___ 08:10AM BLOOD Plt ___
___ 12:15PM BLOOD Plt ___
___ 08:10AM BLOOD Glucose-94 UreaN-11 Creat-0.6 Na-141
K-3.9 Cl-101 HCO3-25 AnGap-19
___ 08:10AM BLOOD Calcium-9.5 Phos-2.7 Mg-2.1
___: chest x-ray:
Right apical pneumothorax, subcutaneous emphysema in the right
chest wall, suspect rib fractures though none clearly seen.
Correlate with subsequent CT chest
___: chest:
No acute rib fracture identified.
___: T spine:
No acute fracture or malalignment.
___: right clavicle:
No fracture or dislocation of the right clavicle.
___: right shoulder:
No fracture or dislocation.
___: right elbow:
No fracture or dislocation
___: cat scan of the head:
No acute intracranial process.
___: cat scan of the x-spine:
1. Partially visualized right pneumothorax with fracture of the
right anterior first rib along with right anterior pulmonary
contusion. Subcutaneous emphysema in the right anterior chest
tracking into the right neck.
2. No acute fracture or traumatic malalignment of the cervical
spine.
Multilevel degenerative changes are similar to ___.
___: right knee:
Severe patellofemoral degenerative change including suspected
suprapatellar loose body and trace fluid.
___: chest x-ray:
As compared to the previous image, there is no change in extent
of the known apicolateral pneumothorax and the air collection in
the right soft tissues.
Known right rib fractures. Minimal right pleural effusion.
Moderate
atelectasis in the retrocardiac lung region. Mild cardiomegaly.
Unchanged
elongation of the descending aorta.
Brief Hospital Course:
The patient was admitted to the hospital after a fall. She
reportedly fell from her bed while reaching for the phone. She
pushed her emergency button to call for help. She reportedly did
not strike her head. Upon admission, the patient was made NPO,
given intravenous fluids, and underwent imaging. She was
reported to have a small right pneumothorax, pulmonary
contusion, and a right anterior first rib fracture. Her
respiratory status remained stable. She did not require chest
tube placement. A repeat chest x-ray showed no change in the
extent of the known apicolateral pneumothorax and the air
collection in the right soft tissues. She was noted to have some
subcutaneous emphysema along her right upper shoulder. Her rib
pain was controlled with oral analgesia and she was encouraged
to use the incentive spirometer.
During her hospitalization, the patient's vital signs remained
stable and she was afebrile. She was tolerating a regular diet
and voiding without difficulty. She was evaluated by physical
therapy and recommendations were made for discharge to a
rehabilitation facility.
On HD #2, the patient was discharged in stable condition.
Appointments for follow-up were made with the acute care
service.
Medications on Admission:
celexa 20', fosamax 70', vigamox 0.5% ophthalmic
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Alendronate Sodium 70 mg PO QMON
3. Citalopram 20 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Heparin 5000 UNIT SC TID
6. Ipratropium Bromide Neb 1 NEB IH Q6H
7. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every four
(4) hours Disp #*10 Tablet Refills:*0
8. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Trauma: fall
Right anterior 1st rib fracture
Right pneumothorax
pulmonary contusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital after a fall at home. You
sustained a small collapse to your lung and fracture to your ___
right rib. Your pain has been controlled with pain medication.
You were seen by physical therapy and recommendations were made
for discharge to an extended care facility where you can receive
additional physical therapy.
Please keep your follow-up appointment in the ___ clinic.
Please report any increased shortness of breath, increased rib
pain. If you continue to have right knee swelling or pain,
please follow up with your primary care provider. You may need
to have an arthroscopy of your knee. Please continue to use
your incentive spirometer to keep your lung expanded.
Please report any fever, chills, abdominal pain. Resume your
home medicaitons.
Followup Instructions:
___
|
10242601-DS-5 | 10,242,601 | 23,092,280 | DS | 5 | 2155-05-26 00:00:00 | 2155-05-26 15:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
doxycycline / Lovenox
Attending: ___.
Chief Complaint:
abdominal pain, PO intolerance
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w hx excision L flank/thigh lipoma (___) c/b L flank
hernia now ___ s/p L flank hernia repair w mesh; now returning
w
nausea, vomiting, abdominal pain, minimal flatus and no BM since
prior to surgery.
Past Medical History:
PMH:
fatty liver
abn LFTs
HLD
Bell's palsy left
obesity
prediabetes
witnessed sleep apnea (never tested)
carcinoid tumor of lung
PSH:
Cholecystectomy (in ___
Right thoracotomy, RLL lobectomy ___, ___
Laryngoscop dir/vc stripping w scope
Excision thigh lipoma
Social History:
___
Family History:
Father-prostate cancer at age ___, aortic aneurysm
Mother-hypertension, CVA
Physical Exam:
At admission:
98.2 79 141/99 20 98%RA
General: uncomfortable
___: RRR, no murmurs
Pulm: clear bilaterally
Abdomen: distended, tympanitic, nontender, steri strips in place
over left flank, JP-ss.
Ext: WWP
At discharge:
98.4 74 139/83 18 96 RA
General: NAD, comfortable sitting up in chair
Cardiac: RRR
Pulm: non-labored breathing
Abdomen: soft, nondistended, no rebound, no guarding,
steri-strips in place over left lower abdominal incision
Ext: 2+ pulses, no edema
Neuro: A&Ox3
Psych: appropriate mood and affect
Pertinent Results:
CT A/P (___):
IMPRESSION:
1. Soft tissue stranding, gas, and interspersed fluid in the
left lower
quadrant, amongst a surgical drain, all likely representing
postsurgical
changes from incisional hernia repair. No focal fluid
collection.
2. Gaseous distention of the large bowel, without colitis or
obstruction.
Brief Hospital Course:
Mr. ___ presented to the ___ ED after ___ days of increasing
abdominal distention, discomfort and inability to pass gas or
stool. CT showed expected post-surgical changes, no fluid
collections, and gaseous distention of the large bowel. He was
made NPO, started on IV fluids, and given an aggressive bowel
regimen. He subsequently had a large bowel movement with
immediate improvement in his pain and abdominal distention. Diet
was advanced to regular which he tolerated well. Use of narcotic
pain medications was avoided, and pain was well controlled with
Tylenol and toradol. While he was in house, output from the
surgical drain was minimal (<30 cc) for two consecutive days and
drain was removed on ___.
He was discharged home on ___. At the time of discharge, he
was tolerating a regular diet, voiding spontaneously, ambulating
independently and pain was well controlled with oral
medications.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. Senna 8.6 mg PO BID:PRN constipation
3. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
4. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
6. Polyethylene Glycol 17 g PO DAILY
7. albuterol sulfate 90 mcg/actuation inhalation BID:PRN
8. Aspirin 325 mg PO DAILY
9. Atorvastatin 40 mg PO QPM
10. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
11. Multivitamins 1 TAB PO DAILY
12. Sildenafil 20 mg PO DAILY:PRN before sex
Discharge Medications:
1. Milk of Magnesia 60 mL PO ONCE Duration: 1 Dose
Take once daily for 3 days.
RX *magnesium hydroxide [Milk of Magnesia] 400 mg/5 mL 30 mL by
mouth once a day Refills:*0
2. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
3. albuterol sulfate 90 mcg/actuation inhalation BID:PRN
4. Aspirin 325 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
7. Docusate Sodium 100 mg PO BID
8. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
9. Multivitamins 1 TAB PO DAILY
10. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
11. Polyethylene Glycol 17 g PO DAILY
12. Senna 8.6 mg PO BID:PRN constipation
13. Sildenafil 20 mg PO DAILY:PRN before sex
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
constipation
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 ___ for increasing abdominal pain and
inability to have a bowel movement after your surgery. You were
given an aggressive bowel regimen and have recovered well. You
are now ready for discharge. Please follow the instructions
below to ensure a continued recovery:
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.
- You may start some light exercise when you feel comfortable.
- Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
YOUR BOWELS:
- Constipation is a common side effect of medicine such as
Oxycodone. Minimize use of oxycodone and only take for pain not
relieved by Tylenol or Motrin.
- You should take Colace 100 mg twice daily for the next week as
well as Milk of Magnesia 30 mL daily for the next 3 days.
- If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
- After some operations, diarrhea can occur. If you get
diarrhea, don't take anti-diarrhea medicines. Drink plenty of
fluids and see if it goes away. If it does not go away, or is
severe and you feel ill, please call your surgeon.
PAIN MANAGEMENT:
- Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
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:
- Avoid narcotic pain medication (Oxycodone) if possible;
however, if pain is not relieved with Tylenol and Ibuprofen, you
may take Oxycodone as needed.
- If you have any questions about what medicine to take or not
to take, please call your surgeon.
Followup Instructions:
___
|
10243339-DS-14 | 10,243,339 | 29,743,615 | DS | 14 | 2112-05-23 00:00:00 | 2112-05-23 14:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Prednisone
Attending: ___
Major Surgical or Invasive Procedure:
none
attach
Pertinent Results:
Admission labs:
---------------
___ 05:32AM LACTATE-0.9 K+-3.6
___ 05:30AM GLUCOSE-95 UREA N-15 CREAT-0.8 SODIUM-141
POTASSIUM-3.8 CHLORIDE-108 TOTAL CO2-20* ANION GAP-13
___ 05:30AM estGFR-Using this
___ 05:30AM ALT(SGPT)-20 AST(SGOT)-29 ALK PHOS-59 TOT
BILI-0.7
___ 05:30AM LIPASE-43
___ 05:30AM ALBUMIN-3.8
___ 05:30AM WBC-4.8 RBC-3.98 HGB-12.5 HCT-38.8 MCV-98
MCH-31.4 MCHC-32.2 RDW-13.8 RDWSD-49.8*
___ 05:30AM NEUTS-51.4 ___ MONOS-15.8* EOS-1.7
BASOS-0.4 IM ___ AbsNeut-2.48 AbsLymp-1.47 AbsMono-0.76
AbsEos-0.08 AbsBaso-0.02
___ 05:30AM ___ PTT-39.2* ___
___ 05:30AM PLT COUNT-181
Micro:
------
Imaging:
--------
Secoond opinion read for OSH CT A/P
1. No acute abnormality identified to account for the patient's
lower
abdominal pain.
2. 1 mm nonobstructing calculus in the distal common bile duct
compatible with choledocholithiasis. No intra or extrahepatic
biliary ductal dilatation.
3. Cholelithiasis without acute cholecystitis.
4. Colonic diverticulosis without evidence for diverticulitis.
5. No evidence for colitis or cystitis.
6. Multiple bilateral renal cysts including a hyperdense cyst in
the lower
pole of the right kidney, previously characterized on MRI is
being a
hemorrhagic cyst.
Discharge Labs:
---------------
___ 06:19AM BLOOD WBC-5.8 RBC-4.28 Hgb-13.3 Hct-41.5 MCV-97
MCH-31.1 MCHC-32.0 RDW-13.6 RDWSD-48.8* Plt ___
___ 09:45AM BLOOD ___ PTT-32.5 ___
___ 06:19AM BLOOD Glucose-93 UreaN-18 Creat-0.8 Na-142
K-4.0 Cl-108 HCO3-20* AnGap-14
___ 06:20AM BLOOD ALT-17 AST-23 AlkPhos-61 TotBili-1.2
___ 06:19AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.2
Brief Hospital Course:
Ms. ___ is a ___ female with history of dementia,
atrial fibrillation on warfarin, ?lymphocytic colitis who
presents with acute onset of abdominal pain which has improved.
ACUTE/ACTIVE PROBLEMS:
#Abdominal pain
#C diff colitis
#Choldecolithasis
Patient with acute onset of abdominal pain which has improved.
CT shows non-obstructing 1mm CBD stone and LFTs are not elevated
making choledocholithasis a less likely cause of her abdominal
pain. ERCP was consulted and felt her presentation was not
secondary to this non-obstructive picture and did not recommend
ERCP as no indication. Patient with c. diff testing sent at ___,
which was positive for Toxin B. This was repeated here with
results of a positive PCR but negative Toxin. Discussed with
the GI consultants, and given positive toxin testing at ___ and
high pre-test probability, the patient was felt to have active c
diff colitis. She was stated on oral vancomycin (day 1 = ___
for a planned 10 day course (last episode ___ years ago so not a
recurrence by definition. In addition, patient with history of
lymphocytic colitis for which she is on budesonide.
#Dementia - patient at baseline, continued on home donezpeil and
memantine
#Recent UTI
- u/a at ___ not consistent with infection- urine culture from
___ PENDING at the time of discharge.
#Afib on warfarin
Patient with ?history of afib. Per son she was placed on
warfarin due ?history of TIA. She was continued on her home
Coumadin here once it was determined there would be no
procedure. Discharge INR was 1.9. Her home dose was not
changed. She should have her INR rechecked on ___ (son checks
it and calls in results to PCP).
#Hyperlipidemia
- continued home simvastatin
Patient seen and examined on the day of discharge. Greater than
30 minutes spent on discharge related activities.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 4 mg PO 6X/WEEK (___)
2. Simvastatin 10 mg PO QPM
3. Donepezil 10 mg PO QHS
4. Warfarin 2 mg PO 1X/WEEK (TH)
5. Memantine 5 mg PO BID
6. Budesonide 3 mg PO DAILY
7. Viokace (lipase-protease-amylase) 10,440-39,150- 39,150 unit
oral LUNCH
8. FoLIC Acid 1 mg PO DAILY
9. Caltrate 600 plus D (calcium carbonate-vitamin D3) 600 mg
(1,500 mg)-800 unit oral DAILY
10. Centrum (multivit-min-ferrous
gluconate;<br>multivitamin-iron-folic acid) ___ mg-mcg oral
DAILY
Discharge Medications:
1. vancomycin 125 mg oral QID
RX *vancomycin 125 mg one capsule(s) by mouth four times daily
for 8 more days Disp #*32 Capsule Refills:*0
2. Budesonide 3 mg PO DAILY
3. Caltrate 600 plus D (calcium carbonate-vitamin D3) 600 mg
(1,500 mg)-800 unit oral DAILY
4. Centrum (multivit-min-ferrous
gluconate;<br>multivitamin-iron-folic acid) ___ mg-mcg oral
DAILY
5. Donepezil 10 mg PO QHS
6. FoLIC Acid 1 mg PO DAILY
7. Memantine 5 mg PO BID
8. Simvastatin 10 mg PO QPM
9. Viokace (lipase-protease-amylase) 10,440-39,150- 39,150 unit
oral LUNCH
10. Warfarin 4 mg PO 6X/WEEK (___)
11. Warfarin 2 mg PO 1X/WEEK (TH)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Abdominal pain
Diarrhea
C. difficile infection
Choledocholithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You came in with abdominal pain and diarrhea and were found to
have a stone in your biliary tract for which you were
transferred to our hospital. Fortunately after review of the
scans and your blood tests, it was determined that you did not
need an endoscopic procedure to retrieve this stone as it is
small and not causing any obstruction / blockage. We did find
that you had positive testing for C difficile which likely
explains both your abdominal pain and diarrhea. For this we have
started you on oral vancomycin which you should continue as
directed through ___ (last dose ___
___). This will be a total of 10 days.
Your home medications were unchanged. Your INR on ___ was
1.9, so you are recommended to recheck this tomorrow, ___, and
discuss the result with your PCP to determine if the dose needs
to be adjusted.
Followup Instructions:
___
|
10244410-DS-2 | 10,244,410 | 24,366,040 | DS | 2 | 2174-09-09 00:00:00 | 2174-09-09 15:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Clopidogrel / Coreg
Attending: ___.
Chief Complaint:
Elevated Transaminases
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ yo woman w/ a ___ CAD (s/p cath this month,
no stents placed), A-fib on Coumadin, ESRD on dialysis for a
year (T, R, F), dementia, and pacemaker placement who is
transferred from OSH w/ elevated LFTs, WBC 17K and c/f acute
cholecystitis vs ischemic colitis.
Per her family, she has been complaining of diffuse abdominal
pain worse in the lower abdomen. She also has had intermittent
bloody stools (no known work-up) and belching. Her son was
concerned that she has not had enough fluid removed at her HD
sessions because her runs were cut short due to orthostasis;
last session ___. She also recently had her
metoprolol uptitrated from 25 mg bid to ___ mg bid due to
difficult to control A-fib with RVR. She also takes Coumadin for
her A-fib. She has no prior history of liver disease or alcohol
use. She does not have IBD and is not on Asacol. She was taken
to ___ on ___, where her labs were significant
for: LFTs 500-600s, TBili 1.4, BNP 70,000; on ___ LFT's >1000,
TB 1.5, INR 3.5 (on Coumadin), PLT 103, WBC 21. A CT scan done
at ___ showed ischemic colitis vs. cholecystitis. She was
given CTX and Flagyl. She was then transferred to ___ for
further management. Unfortunately, the wrong CD (w/ records from
___ was sent with her.
Per family pt does not have inflammatory bowel disease and is
not on asacol. Per husband, pt last took Tylenol 3 days ago and
only took 2 tablets. She apparently achieved her dry weight at
her last HD session but sometimes needs additional sessions. She
has a LUE AVF in place.
-In the ED initial VS: 98.0 114 126/64 18 98% Nasal Cannula
-Labs significant for: WBC 20.7, H/H 11.4/36, Plt 103, INR 3.5,
Cr 6.1, K 5.2, Na 130, Cl 86, HCO3 18, ALT 1331, AST 1488, LDH
1628 Alk phos 519, Tbili 1.5, albumin 3.5, positive Hep B
surface ab, lactate 3.6 (trended to 2.9), BNP greater than
assay, and negative serum tox.
-Physical exam: abd diffusely TTP, rales in lungs, no asterixis,
some scleral icterus. She denied shortness of breath. LUE AVF
functioning well.
-Per work-up in the ED: Pt w/ both hepatocellular and
cholestatic pattern, predominatly heptocellular. Serum Tylenol
negative, virus levels pending. Ddx includes shock liver, acute
viral hepatitis, Budd-Chiari, congestive hepatopathy vs
autoimmune hepatitis. Flu swab was negative.
-Imaging showed: CXR with moderate pulmonary edema and bilateral
effusions, RUQ US with patent flow, steatosis, and
cholelithiasis without cholecystitis, and CT with evidence of
third-spacing, aortic atherosclerosis, and splenic infarctions;
no signs of ischemic colitis.
-Surgery was consulted: Since the CT did not show mesenteric
ischemia or an acute abdominal process, no need for surgical
intervention.
-Renal was consulted: Plan for HD/UF early on ___, no need for
urgent dialysis. They felt she could also be given high-dose
Lasix if needed and recommended limited IVF to no more than 250
ccs NS. Recommended cardiac TTE.
-Liver was consulted: Main concern for ischemic etiology of
liver disease in setting of known heart failure. The bloody BM's
over the past several months may also be explained by ischemic
colitis from a low-flow state. Recommended ruling out malignancy
and infection. Recommended TTE. Also requested US with dopplers,
heptatitis serologies, and starting NAC given data showing
improved outcomes even in the setting of minimal acetaminophen
ingestion. Recommended oral NAC to prevent volume overload. Also
recommended considering reversing the INR.
-The patient was unable to tolerate NAC orally and IV was
started.
-VS upon transfer: 98.4 77 160/73 18 100% Nasal Cannula.
Upon arrival to the floor, Ms. ___ was in no acute distress
and was breathing comfortably on 2L NC. She denied any
complaints and said she felt well.
Past Medical History:
CAD (s/p cath this month, no stents placed)
A-fib on Coumadin
ESRD on dialysis for a year (T, R, F)
Dementia
Pacemaker placement
Diabetes
Social History:
___
Family History:
Not relevant to admission
Physical Exam:
Admission Exam
===============
VITALS: 97.1 113/75 76 18 98 2L
GENERAL: Pleasant, lying in bed in no acute distress
HEENT - Normalocephalic/atraumatic, mild scleral icterus.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Diminished breath sounds at the bilateral bases with
mild crackles and diffusely poor air movement. No respiratory
distress.
ABDOMEN: Normal bowel sounds, soft, non-tender even over spleen,
non-distended.
EXTREMITIES: Warm, well-perfused, no stigmata of embolic
disease.
SKIN: Slightly dark, dry skin on the arms.
NEUROLOGIC: Conversing easily but not oriented, unable to recall
facts from her personal history.
Discharge Exam
================
VITALS: T 97.7, HR 65, BP 133/68, RR 18, SaO2 98% RA
GENERAL: Alert, oriented to self and ___, not oriented to
time, NAD
CARDIAC: Irregular rhythm, normal rate, no murmurs
PULMONARY: Breathing comfortably, lungs CTAB
ABDOMEN: Not distended, normal bowel sounds, soft and
non-tender.
EXTREMITIES: Warm, well-perfused, no stigmata of embolic
disease.
NEUROLOGIC: Conversing easily, oriented to self and ___ but
not to time, unable to recall facts from her personal history or
from earlier in current conversation.
Pertinent Results:
Admission Labs
================
___ 12:48PM BLOOD WBC-20.7* RBC-3.48* Hgb-11.4 Hct-36.0
MCV-103* MCH-32.8* MCHC-31.7* RDW-18.6* RDWSD-69.0* Plt ___
___ 12:48PM BLOOD Neuts-82.4* Lymphs-5.9* Monos-9.9
Eos-0.6* Baso-0.4 NRBC-0.6* Im ___ AbsNeut-17.08*
AbsLymp-1.22 AbsMono-2.06* AbsEos-0.13 AbsBaso-0.08
___ 12:48PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-3+ Microcy-NORMAL Polychr-1+ Ovalocy-1+
Schisto-OCCASIONAL Tear ___
___ 12:48PM BLOOD Plt Smr-LOW Plt ___
___ 12:48PM BLOOD Glucose-83 UreaN-57* Creat-6.1* Na-130*
K-5.2* Cl-86* HCO3-18* AnGap-31*
___ 12:48PM BLOOD ALT-1331* AST-1488* LD(LDH)-1628*
AlkPhos-519* TotBili-1.5 DirBili-1.0* IndBili-0.5
___ 12:48PM BLOOD Lipase-21
___ 12:48PM BLOOD proBNP-GREATER TH
___ 12:48PM BLOOD Albumin-3.4*
Liver Work Up/Other pertinent labs
===================================
___ 12:48PM BLOOD HBsAg-Negative HBsAb-Positive
HBcAb-Negative IgM HBc-Negative IgM HAV-Negative
___ 12:48PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:48PM BLOOD HCV Ab-NEGATIVE
___ 12:55PM BLOOD Lactate-3.6*
___ 07:09PM BLOOD Lactate-2.9*
___ 02:11AM BLOOD Lactate-2.9*
___ 01:00PM BLOOD TSH-0.28
___ 07:00PM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 07:00PM BLOOD ___
Imaging
========
___ CXR IMPRESSION:
1. Moderate cardiomegaly, moderate left-sided and small
right-sided pleural effusions, and moderate pulmonary edema,
findings compatible with congestive heart failure. No
pneumothorax detected.
2. Left basilar patchy opacity may reflect atelectasis but
infection is not excluded in the correct clinical setting.
___ Liver US:
IMPRESSION:
1. Patent hepatic vasculature.
2. Echogenic liver suggestive of steatosis. Other forms of
liver disease and more advanced liver disease including
steatohepatitis or significant hepatic fibrosis/cirrhosis cannot
be excluded on this study.
3. Cholelithiasis without evidence for acute cholecystitis.
4. Mild perihepatic ascites and gallbladder wall edema which
suggests third spacing.
5. Pulsatile portal venous flow can be seen with severe right
heart failure.
___ CT Abdomen/Pelvis
IMPRESSION:
1. Moderate cardiomegaly with small bilateral pleural
effusions, reflux of contrast into the hepatic veins and IVC,
gallbladder wall edema, mild ascites, and diffuse anasarca.
Findings are compatible with congestive heart failure and
resultant third-spacing of fluid.
2. A large wedge-shaped hypodense region in the spleen, with 2
smaller
hypodense lesions, are concerning for areas of early infarction.
3. Extensive atherosclerotic disease of the abdominal aorta,
involving the origins of the great vessels and extending into
the iliac arteries.
4. Colonic diverticulosis, without evidence of adjacent wall
thickening or fat stranding. No evidence of bowel obstruction
or ischemic colitis.
___ TTE
The left atrium is mildly dilated. The right atrium is
moderately dilated. No atrial septal defect or patent foramen
ovale is seen by 2D, color Doppler or saline contrast with
maneuvers. There is mild symmetric left ventricular hypertrophy.
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 = 60%). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened. There is a minimally increased gradient consistent
with minimal aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The tricuspid valve leaflets are mildly
thickened. The supporting structures of the tricuspid valve are
thickened/fibrotic. Severe [4+] tricuspid regurgitation is seen.
[In the setting of at least moderate to severe tricuspid
regurgitation, the estimated pulmonary artery systolic pressure
may be underestimated due to a very high right atrial pressure.]
There is no pericardial effusion.
EKG (___):
Atrial fibrillation with a rapid ventricular response.
Intraventricular
conduction delay. No previous tracing available for comparison.
HR 86.
Microbiology
==============
___ Blood culture: NGTD
Discharge Labs
================
___ 08:10AM BLOOD WBC-11.6* RBC-3.18* Hgb-10.5* Hct-32.1*
MCV-101* MCH-33.0* MCHC-32.7 RDW-18.3* RDWSD-66.9* Plt ___
___ 08:10AM BLOOD ___ PTT-104.4* ___
___ 08:10AM BLOOD Glucose-133* UreaN-61* Creat-5.6*#
Na-126* K-4.2 Cl-87* HCO3-24 AnGap-19
___ 08:10AM BLOOD ALT-367* AST-61* AlkPhos-375* TotBili-0.8
___ 08:10AM BLOOD Calcium-9.0 Phos-5.1*# Mg-1.8
Brief Hospital Course:
Ms. ___ is an ___ yo woman w/ a PMH of DM, CHF, CAD (s/p OSH
cath ___, no stents placed), A-fib on Coumadin, SSS with PPM,
HTN, HLD, PUD, ESRD on HD ___ year (TRS), hypothyroidism,
dementia and hemorrhoids who was transferred from OSH w/
elevated LFTs, WBC 17K and unclear abdominal imaging. CT in
___ ED showed multiple splenic infarcts and the absence of a
source of infection.
# Acute Hepatitis:
# Elevated LFTs: Patient received NAC and hepatology was
consulted. Extensive infectious and autoimmune work up was
negative. ALT peaked at 1359, AST 1488, Alk Phos 519. INR
supratherapeutic at ~4 on admission, so INR reversed with
vitamin K per hepatology recommendation to better track
synthetic function. Liver enzymes began downtrending on ___
and home warfarin was resumed. Patient volume up on admission
and received several days of HD, removing significant amount of
fluid. Liver enzymes downtrended as volume status improved,
making ischemia secondary to poor forward flow vs. congestive
hepatopathy the likely cause of LFT abnormalities. Patient's
home atorvastatin held during admission, with plan to resume as
outpatient when liver enzymes return to baseline. Patient
discharged home with services with plan to follow up with PCP
and cardiologist.
# Splenic infarcts: Patient presented with some mild LUQ pain
and was found to have splenic infarcts on CT A/P. Unclear
etiology, but possibly due to cholesterol emboli after recent
cardiac catheterization vs. cardioemboic from Afib. TTE showed
no evidence of thrombus and patient's INR supratherapeutic on
admission. Patient anticoagulated as above and patient's
abdominal pain resolved prior to discharge.
# Acute on chronic diastolic HF: VLEF >55%. Patient
significantly volume up on exam with BNP >70,000. Repeat TTE
showed preserved systolic function and severe TR. Patient
received HD daily from ___ with improvement in volume
status.
# Atrial fibrillation: Patient has known atrial fibrillation and
had recent increase in metoprolol dose to 100 mg BID in the
setting of recurrent episodes of afib with RVR. Patient's
warfarin was held on admission because of supratherapeutic INR.
She was then reversed with PO vitamin K per hepatology
recommendation in order to better assess synthetic function.
Continued on home metoprolol. Warfarin resumed on ___ and
was bridged with heparin due to subtherapeutic INR. She was
monitored on telemetry and remained rate controlled throughout
admission. Discharged on warfarin 5 mg daily with plans to have
INR checked by Dr. ___.
# Hypothyroidism: Patient with history of hypothyroidism on 88
mcg daily Levothyroxine at home. However, it appears patient has
been taking 100 mcg daily since last hospitalization. Patient's
TSH 0.28, at the low end of normal. Patient continued on 88 mcg
daily with plans to have TSH re-checked as outpatient.
# GI bleeding: Patient's family reported BRBPR for several
months prior to admission. Patient had few episodes of BRBPR
during admission, but hemoglobin remained stable. Likely
diverticular bleeding in the setting of anticoagulation but
patient also has a history of hemorrhoids. Patient instructed to
follow up with GI as outpatient.
# ESRD on dialysis: Dialyzed daily ___ to ___, with good
BP tolerance. Patient continued on home medications and renal
diet. Home dialysis scheduled was resumed upon discharge.
# DM: Poorly controlled, type 2, complicated by nephropathy.
Patient hypoglycemic on admission to 38, possibly in the setting
of taking home glipizide. This medication was discontinued
during admission and diabetes was managed on very conservative
Humalog sliding scale with fingersticks 100s-200s. Outpatient
diabetologist should determine what medication (if any) patient
should be on for her diabetes. Patient's husband reported a
recent HgA1c of <7, which is too low given ESRD and age.
# Hypertension: Continued home metoprolol XL 100 mg bid,
isosorbide mononitrate 30 mg daily, and amlodipine 10 mg daily
(unclear if amlodipine had recently been stopped). Blood
pressures well-controlled (averaged 110s-150s/60s-70s). This
regimen was continued on discharge. If patient becomes
hypotensive, consider discontinuing amlodipine.
# CAD s/p cath, no stents: Patient had no CP during admission.
Home atorvastatin held but patient continued on ASA, beta
blocker, and nitrate. Atorvastatin should be resumed once LFTs
return to baseline.
# Hyponatremia: Na fluctuated between 125-130 in the setting of
ESRD. Patient was put on a 1.5L fluid restriction, which she
should continue at home. She was dialyzed as above.
>30 minutes was spent on discharge planning.
Transitional Issues
=====================
-LFTs at discharge: ALT 327, AST 61, AP 375, TBili 0.8.
-Patient should have liver enzymes checked within ___ weeks of
discharge to make sure they return to normal.
-Statin held during admission and on discharge. This should be
resumed once liver enzymes return to baseline.
-Patient hypoglycemic on admission. Glipizide stopped.
Fingersticks ranged mostly 100s-200s on a very gentle Humalog
sliding scale. Patient should follow up with diabetologist to
determine what medication (if any) she should be on for her
diabetes.
-Patient's TSH noted to be low-normal during admission. Patient
may have been taking 100 mcg Levothyroxine at home, versus
prescribed 88mcg daily. Patient resumed on 88 mcg daily dose and
her TSH should be re-checked in 6 weeks as outpatient.
-Patient had episodes of BRBPR during admission and a few
episodes of scant rectal bleeding. Hb stable and patient
reported history of diverticulosis and hemorrhoids. Patient
should undergo evaluation by GI as outpatient.
-Na ranged 125-130 in the setting of ESRD. She was started on a
1.5L fluid restriction.
-Amlodipine 10 mg daily was resumed in addition to metoprolol.
Blood pressures were well-controlled (averaged 130s/60s).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Memantine 10 mg PO BID
2. Metoprolol Succinate XL 100 mg PO BID
3. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
4. Levothyroxine Sodium 88 mcg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Amlodipine 10 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Warfarin 4 mg PO DAILY16
9. Vitamin D ___ UNIT PO DAILY
10. Nephrocaps 1 CAP PO DAILY
11. Calcium Carbonate 750 mg PO TID W/MEALS
12. Aspirin 81 mg PO DAILY
13. Venlafaxine 25 mg PO DAILY
14. GlipiZIDE 2.5 mg PO BID:PRN BG>130
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Calcium Carbonate 750 mg PO TID W/MEALS
3. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
4. Levothyroxine Sodium 88 mcg PO DAILY
5. Memantine 10 mg PO BID
6. Metoprolol Succinate XL 100 mg PO BID
7. Nephrocaps 1 CAP PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Venlafaxine 25 mg PO DAILY
10. Vitamin D ___ UNIT PO DAILY
11. Aspirin 81 mg PO DAILY
12. Outpatient Physical Therapy
___
Diagnosis: R26.2
Prognosis: Good
Length of need: 13 months
13. Warfarin 5 mg PO DAILY16
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
=================
Elevated Transaminases
Splenic Infarcts
Secondary Diagnoses
====================
End Stage Renal Disease on Dialysis
Atrial Fibrillation
Coronary Artery Disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted with elevated liver enzymes.
This was thought to be due to volume overload. You received
several days of hemodialysis and your liver enzymes improved. We
stopped your Lipitor, which should be restarted when your liver
enzymes normalize.
On admission your blood sugars were very low. This may have been
because of your diabetes medication, glipizide. This medication
was stopped during admission. Your blood sugars were checked
frequently and you were treated with insulin as needed. Your
diabetes doctor ___ determine what medications you will be on
for your diabetes.
We wish you all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10244524-DS-21 | 10,244,524 | 29,552,891 | DS | 21 | 2171-08-28 00:00:00 | 2171-08-29 20:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Dilantin Kapseal / Sulfa (Sulfonamide Antibiotics) / Epinephrine
Attending: ___.
Chief Complaint:
seizures
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ LEFT handed woman with a history of post
traumatic
temporal lobe epilepsy and s/p temporal lobectomy, as well as
hypothyroidism and depression who presents to the ED following a
prolonged seizure in the field. She provides a history together
with her boyfriend, ___ at the bedside.
She reports that her physical health has been generally well
lately, but she has been more stressed and moody over the past
two weeks. Her sleep has been off, and ___ says that she has
perhaps been talking in her sleep lately. She was previously on
LAC 200mg BID (in conjunction with CBZ 100mg BID and LTG 200mg
BID) about three weeks ago when she made the increased dose to
LAC 250mg BID. This was largely well tolerated, and ___ was
just noticing yesterday that she had been doing well and just
had
two auras in the past two weeks. Today, she woke up and didn't
feel well, complaining of a nausea and a rising sensation
together with sharp pains in her jaws reminiscent of a typical
aura. She went back to sleep. Then she woke up at 11AM, took an
ativan pill, and walked the dog for about 90minutes. She knew
that she probably should stay home and "take it easy", but
wanted
to take the train to ___ to get some ___ food for
lunch. Around 2pm, she was in the train station when she once
again felt quite poorly. This included severe overwhelming
nausea, a sensation that she needed to hold on to the walls to
walk. She appears to have fallen on the ground at that time, and
bystanders raised concern and called EMS. We don't have a great
account of what was noted in the field. She reports that her
consciousness was "in and out", and believes that she was in
fact
having a seizure. When she arrived in the ED at around 3pm, her
boyfriend confirmed that she was "still in a seizure", for which
ativan was administered. He described that he found her
"twitching, jerking at times, with fluttering of her eyes
underneath her eyelids and was completely out of it". He also
confirmed that this was one of her seizures. The entire event
lasted perhaps 90 minutes. At the time of my interview, she was
awake, alert and able to provide a history.
Review of systems is positive for increased flatulence and
nausea
and occasional vomitting without abdominal pain or nausea. She
explained that they did an "upper scope" which was normal, but
now she wants them to do a "lower scope" as well. She denies any
excess headaches, double vision, head trauma, numbness,
tingling.
She also reports that she is in "perimenopause" at this time,
with irregular periods.
Past Medical History:
PMH:
-epilepsy, seizures started after motorcycle accident ___ years
ago. Status-post partial left temporal lobectomy ___. See Dr.
___ from ___ Epilepsy clinic for more details.
Over the past several months, Dr. ___ has tried to reduce her
CBZ dose as it was felt that some of these events and auras were
probably nonepileptic. The patient had resisted the urge to come
in for an event characterization admission. In general, she
explains that she does not like how she feels when she is on low
doses of CBZ.
- hypothyroidism
- seasonal allergies
- depression
Social History:
___
Family History:
Family Hx: No known history of neurologic disease.
Physical Exam:
On my physical examination, vital signs were HR 82, BP 132/77,
RR
19, 98%. In general, patient is awake, cooperative, pleasant and
in no apparent distress. She was quite tremulous throughout the
interview. The patient had a NCAT head without conjunctival
icterus. Mucous membranes were moist and oropharynx is clear of
lesions. Neck was supple without masses or thyromegaly. Chest
examination revealed regular heart sounds without murmurs, and
lungs were clear to auscultation bilaterally. Belly was soft
without focal tenderness, and extremities were warm and well
perfused with trace lower extremity edema. Skin examination
showed no rashes or lesions.
Neurologically, the patient is awake, alert and oriented x 3.
Able to relate history without difficulty. Attentive, able to
name ___ backward without difficulty. Language is fluent with
intact repetition and comprehension. Normal prosody. There were
no paraphasic errors. Pt. was able to name both high and low
frequency objects. Able to read without difficulty. Speech was
not dysarthric. Able to follow both midline and appendicular
commands.
Cranial nerve examination revealed round, equal and reactive
pupils with full visual fields to confrontation. Extraocular
movements were full without dysconjugate gaze, nystagmus or
diplopia per report. There was no facial asymmetry, ptosis or
facial droop. Hearing is intact to finger-rub bilaterally.
Facial
sensation was normal to light touch. Palate elevates
symmetrically, and the strength of trapezii and SCMs was ___
bilaterally. Tongue was strong bilaterally without atrophy or
fasiculations.
Strength examination showed normal bulk, tone throughout. No
pronator drift bilaterally. No adventitious movements, such as
tremor, noted. Rapid alternating movements were slowed on the
right.
Delt Bic Tri WrE FE IP Quad Ham TA Gastroc
L 5 5 ___ ___ 5 5
R 5 5 ___ ___ 5 5
The sensory examination revealed no deficits to light touch.
The reflex examination revealed
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response: Down
Bedside tests of cerebellar function revealed no intention
tremor
or dysmetria. Gait examination was deferred.
Pertinent Results:
___ 03:20PM BLOOD WBC-4.0 RBC-4.00* Hgb-12.8 Hct-39.9
MCV-100* MCH-32.1* MCHC-32.2 RDW-12.4 Plt ___
___ 03:20PM BLOOD Neuts-60.7 ___ Monos-7.4 Eos-0.1
Baso-0.3
___ 03:20PM BLOOD Glucose-79 UreaN-12 Creat-0.8 Na-139
K-4.3 Cl-100 HCO3-32 AnGap-11
___ 09:10PM BLOOD Carbamz-3.8*
___ 09:10PM BLOOD LAMOTRIGINE-PND
___ 04:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 04:00PM URINE Color-Straw Appear-Clear Sp ___
CXR: IMPRESSION: No evidence of pneumonia. Right lung base
atelectasis.
Brief Hospital Course:
Mrs ___ was hospitalized after a prolonged event concerning
for a seizure. Since she complained about frequent auras while
being hospitalized, we offered to monitor her via LTM, which she
declined. We increased her evening dose of lacosamide to 300mg
and discharged her home as she wished.
Medications on Admission:
1. Carbamazepine (Extended-Release) 100 mg PO BID
2. Fluoxetine 80 mg PO DAILY
3. Lacosamide 250 mg PO BID
___ in the morning
300mg in the evening
RX *lacosamide [Vimpat] 50 mg ___ tablet(s) by mouth twice a day
Disp #*330 Tablet Refills:*2
4. LaMOTrigine 200 mg PO BID
5. Levothyroxine Sodium 150 mcg PO DAILY
6. Lorazepam 1 mg PO HS:PRN anxiety, aura
7. traZODONE 50 mg PO HS:PRN insomnia
Discharge Medications:
1. Carbamazepine (Extended-Release) 100 mg PO BID
2. Fluoxetine 80 mg PO DAILY
3. Lacosamide 250-300 mg PO BID
___ in the morning
300mg in the evening
RX *lacosamide [Vimpat] 50 mg ___ tablet(s) by mouth twice a day
Disp #*330 Tablet Refills:*2
4. LaMOTrigine 200 mg PO BID
5. Levothyroxine Sodium 150 mcg PO DAILY
6. Lorazepam 1 mg PO HS:PRN anxiety, aura
7. traZODONE 50 mg PO HS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
epilepsy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were hospitalized after a prolonged seizure. ___ were stable
while hospitalized, but reported that ___ had several episodes
___ called auras. ___ did not want any further workup with EEG,
and were discharged home.
We increased your evening Vimpat dose to 300mg. Now, ___ should
take Vimpat 250mg in the morning and 300mg in the evening.
Followup Instructions:
___
|
10244524-DS-22 | 10,244,524 | 20,558,795 | DS | 22 | 2172-08-26 00:00:00 | 2172-08-27 20:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Dilantin Kapseal / Sulfa (Sulfonamide Antibiotics) / Epinephrine
Attending: ___.
Chief Complaint:
increasing seizure frequency
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a ___ left-handed woman with a history of
post-traumtic epilepsy s/p temporal lobectomy who presents with
increased seizure frequency with multiple prolonged episodes of
decreased responsiveness and generalized shaking over the last
few days. She is followed by Dr. ___ has not been seen for
over a year. She is currently maintained on lacosamide 250mg QAM
and 300mg QPM, carbamazepine 100mg BID, and lamotrigine 200mg
BID. Her seizures had previously been well-controlled aside from
some occasional auras which she describes as "zoning out" and
staring, but recently she has been having new events
characterized by falling to the floor with altered consciousness
and shaking of her arms and legs. She does not bite her tongue
but is sometimes incontinent of urine. Her boyfriend has
witnessed four of these in the last three days, and says they
can
last up to ___ minutes. During this time her arms and legs are
not stiff but will shake intermittently, and she seems to "go in
and out," at times responding to him but then appearing to lose
consciousness again. He says that she "chokes" and gasps for air
during these events and she looks as if she is going to die. He
says he had to give her "mouth to mouth" during one of them as
he
was afraid she had stopped breathing.
She was admitted to the EMU overnight in ___ of last year for
a
similar prolonged event of decreased responsiveness and limb
twitching lasting 90 minutes. She had several pushbutton events
while on EEG for auras which had no electrographic correlate.
The
plan had been to keep her on EEG monitoring while adjusting her
AED's but she was unwilling to stay as she did not want to be
taken off her medications. Her vimpat was increased empirically
from 250mg BID to ___ at that time and she was advised
to
follow up in clinic. However it appears that she has not yet
done
so.
She presented to the ED on ___ after a seizure, and
admission
to neurology was recommended at that time per discussion with
Dr.
___. However she refused. She then went to ___ ED
the next day on ___ again after a similar episode. Dr. ___
___
advised transfer to ___ for admission but this did not occur.
The patient then called Dr. ___ today to ask if she could have
ambulatory EEG monitoring as she was still reluctant to come in.
Dr. ___ her against this given the frequency and
duration of her events.
Around noon today she again began to feel an "aura," which she
describes as feeling tired with blurry vision, pain in her jaw,
and shortness of breath. She called her boyfriend and told him
she felt like she was going to have another seizure. He called
EMS and they came to her house to find her on the floor. She was
brought to the ___ ED, where she was initially awake and alert
and
appeared to be back to her baseline. However at 3pm she had an
episode of "apparent GTC vs. complex partial seizure w/ loss of
consciousness and drooling / choking. Resolved within 5 minutes
after 2mg IV Ativan. SpO2 100% and breathing comfortably after
event." Neurology was then consulted for further evaluation.
Currently she is awake and alert and with no complaints other
than a dry mouth, asking for something to eat and drink. She
remains hesitant to come into the hospital as "all they do is
take me off my meds and make me seize." She reports that she is
currently going through menopause and thinks her increased
seizure frequency may be related to this, as she used to have
"catamenial epilepsy." She reports that she used to be on a
higher dose of carbamazepine and wonders if she can just
increase
her dose as an outpatient instead of being admitted. I advised
her that this would not be safe given the increased frequency of
their events and their prolonged duration with apparent
respiratory compromise.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
-Post-traumatic epilepsy resulting from a motorcycle accident ___
years ago. Status-post partial left temporal lobectomy in ___.
- Hypothyroidism
- Seasonal allergies
- Depression
Social History:
___
Family History:
No known history of neurologic disease.
Physical Exam:
Admission Physical Exam:
Vitals: 98.41 61 104/63 16 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert and oriented. Able to relate history
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Speech was not dysarthric. 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 4 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: slight R facial asymmetry
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch or pinprick throughout.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
-Gait: Deferred
DISCHARGE PHYSICAL EXAM: no significant change from that above.
Pertinent Results:
ADMISSION LABS:
___ 03:29PM BLOOD WBC-5.4 RBC-4.10* Hgb-13.9 Hct-40.9
MCV-100* MCH-34.0* MCHC-34.0 RDW-11.6 Plt ___
___ 03:29PM BLOOD Neuts-63.7 ___ Monos-6.7 Eos-0
Baso-0.7
___ 03:30PM BLOOD ___ PTT-32.1 ___
___ 03:29PM BLOOD Glucose-91 UreaN-8 Creat-0.9 Na-138 K-4.0
Cl-99 HCO3-34* AnGap-9
___ 03:29PM BLOOD ALT-25 AST-26 AlkPhos-102 TotBili-0.4
___ 03:29PM BLOOD Calcium-9.3 Phos-2.9 Mg-2.2
___ 03:29PM BLOOD Prolact-7.0
___ 03:29PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
URINE:
___ 02:40PM URINE Color-Straw Appear-Clear Sp ___
___ 02:40PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 02:40PM URINE UCG-NEGATIVE
___ 02:40PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Brief Hospital Course:
Ms ___ is a ___ year-old left-handed woman with a history of
post-traumtic epilepsy s/p temporal lobectomy who was admitted
with prolonged episodes of decreased responsiveness and
generalized shaking that last 20 minutes at a time. She was
admitted for characterization of these events given her history
of both epileptic and non-epileptic events. One such event was
captured during her admission and there was no EEG correlate.
This event occurred on ___ after drinking a large amount of
water. She went from sitting upright, to slumping forward, to
gaging on her saliva and hyperventilating. During this episodes
she closed her eyes against the force of the examiner and would
periodically talk to the MD and then return to gaging and
hyperventilating. Her arms and legs periodically shook. There
was no post event lethargy. This event had no EEG correlate.
There was no other EEG abnormalities during her admission. She
refused to make changes in her medications. Seizure precautions
were reviewed.
She was seen by psychiatry who felt that her increase of
non-epilpetic events is related to overwhelming current
stressors and PTSD. They advised no changes in her medications,
but further psychotherapy to address her PTSD.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carbamazepine (Extended-Release) 100 mg PO BID
2. Fluoxetine 80 mg PO DAILY
3. Lacosamide 250 mg PO BID
4. LaMOTrigine 200 mg PO BID
5. Levothyroxine Sodium 150 mcg PO DAILY
6. Lorazepam 1 mg PO HS:PRN anxiety, aura
7. traZODONE 50 mg PO HS:PRN insomnia
Discharge Medications:
1. Carbamazepine (Extended-Release) 100 mg PO BID
2. Fluoxetine 80 mg PO DAILY
3. Lacosamide 250 mg PO BID
4. LaMOTrigine 200 mg PO BID
5. Levothyroxine Sodium 150 mcg PO DAILY
6. Lorazepam 1 mg PO HS:PRN anxiety, aura
7. TraZODone 50 mg PO HS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Non-epileptic spells
Epilepsy
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 while you were admitted to
___. You were admitted with increasing frequency of
non-epileptic spells. Most likely this was a result of
increasing stressors at home. We monitored you on EEG and it
was reassuring that there was no seizure activity. Your
epilepsy medications were not changed.
You were evaluated by our psychiatrists who felt that you would
benefit from more specialized therapy with Dr. ___. You can
continue this at your scheduled appointments.
Followup Instructions:
___
|
10244640-DS-6 | 10,244,640 | 27,820,346 | DS | 6 | 2163-08-27 00:00:00 | 2163-08-29 22:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
"Dyspnea on exertion, cough, lower extremity edema."
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. ___ is an ___ year old woman with history of CAD s/p
angioplasty and stenting in ___, paroxysmal atrial fibrillation
on amiodarone and warfarin, sick sinus syndrome with pacemaker
placed in ___, anemia, HTN and hyper choleresterolemia, who
presented to her PCP the morning of admission with worsening
shortness of breath on exertion, weight gain and lower extremity
edema. She has had progressively worsening generalized fatigue
for the past three months. One week PTA, she presented to her
PCP with one week history of dyspnea on exertion, cough
productive of white sputum and low grade fevers/chills. She was
prescribed two courses of azithromycin over the week PTA for
presumed PNA with R lung base rales and inflitrate on CXR. Her
cough resolved but she persisted with worsening dyspnea on
exertion, weight gain of ___ lbs in 2 weeks from baseline of
120-125 lbs and lower leg swelling. She mentioned that she took
4 doses of azithromycin the last two days PTA and that had upset
her stomach. She had no chest pain, dizziness of palpitations,
no orthopnea, no PND. She has had reduced appetite and noticed
that her mental capacities were not at her baseline. She did
endorse taking all her medications with her husband's help, but
no recent dietary changes or increased salt intake. In the ED,
the vitals were: 96.8, 133/65, 60, 16, 97%RA. ECG showed paced
rhythm with LBBB and left axis deviation, unclear initially if
the branch block was new, CXR with pulmonary edema, troponin
0.07, BNP 8506, WBC 8.7, Na 126, INR 4.3. She was given 20mg IV
lasix and admitted to the medicine floor for diuresis and
monitoring.
Past Medical History:
-Coronary artery disease s/p angioplasty and stenting in ___
-ECHO from ___ w/ LVEF 55-60%, mild mitral and tricuspid
regurgitation
-LBBB documented from ECG in ___
-Paroxysmal atrial fibrillation on amiodarone, digoxin and
warfarin
-Sick sinus syndrome on pacemaker since ___
-Iron deficiency anemia with recent negative GI work-up
-Hypothyroidism induced by amiodarone
-Hypercholesterolemia
-Hypertension
-Cataracts
-Rhinitis
-Varicose veins
Social History:
___
Family History:
Father died of CAD.
Physical Exam:
PHYSICAL EXAM on admission:
Vitals: T 98.1 BP 123/53 HR 70 RR 20 O2 97%2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP 2-3cm, no LAD
Lungs: bilateral basilar crackles, no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, S4 present, no
murmurs or rubs
Abdomen: soft, non-tender, non-distended, hypoactive bowel
sounds, no rebound or guarding, no masses or organomegaly,
small umbilical hernia
Ext: cold and clammy with mild pitting edema, DP not palpable on
left foot, DP and ___ palpable on right foot, no calf tenderness,
no cyanosis or clubbing
Neuro: CN II-XII intact. Strength ___ throughout. Motor and
sensory function grossly normal.
PHYSICAL EXAM on discharge:
Vitals: T 96.1 BP 110/62 HR 60 RR 18 O2 97%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no JVD, no LAD
Lungs: bilateral basilar crackles almost resolved, no wheezes,
rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, S4 present, no
murmurs or rubs
Abdomen: soft, non-tender, non-distended, hypoactive bowel
sounds, no rebound or guarding, no masses or organomegaly, small
umbilical hernia
Ext: warm, moist and well-perfused, DP not palpable on left
foot, DP and ___ palpable on right foot, no calf tenderness,
trace pitting edema, cyanosis or clubbing
Neuro: CN II-XII intact. Strength ___ throughout. Motor and
sensory function grossly normal.
Pertinent Results:
___ 02:15PM BLOOD cTropnT-0.07* proBNP-8506*
___ 09:25PM BLOOD cTropnT-0.04*
___ 06:05AM BLOOD cTropnT-0.02*
___ 02:15PM BLOOD Digoxin-0.5*
___ 06:05AM BLOOD TSH-2.8
CMP:
___ 02:15PM BLOOD Glucose-143* UreaN-15 Creat-0.7 Na-126*
K-5.1 Cl-90* HCO3-24 AnGap-17
___ 06:05AM BLOOD Glucose-96 UreaN-17 Creat-0.7 Na-129*
K-4.6 Cl-92* HCO3-29 AnGap-13
___ 04:28PM BLOOD Glucose-108* UreaN-17 Creat-0.8 Na-136
K-3.9 Cl-97 HCO3-29 AnGap-14
___ 06:15AM BLOOD Glucose-88 UreaN-16 Creat-0.8 Na-134
K-4.6 Cl-97 HCO3-31 AnGap-11
___ 04:05PM BLOOD Glucose-104* UreaN-18 Creat-0.8 Na-138
K-3.8 Cl-98 HCO3-30 AnGap-14
___ 06:20AM BLOOD Glucose-72 UreaN-17 Creat-0.8 Na-135
K-5.0 Cl-98 HCO3-29 AnGap-13
___ 07:15PM BLOOD Glucose-127* UreaN-21* Creat-0.8 Na-136
K-4.3 Cl-97 HCO3-29 AnGap-14
___ 06:35AM BLOOD Glucose-89 UreaN-16 Creat-0.8 Na-134
K-4.4 Cl-96 HCO3-29 AnGap-13
___ 07:20PM BLOOD Glucose-110* UreaN-18 Creat-0.9 Na-135
K-4.8 Cl-98 HCO3-29 AnGap-13
___ 06:05AM BLOOD Calcium-8.6 Phos-4.2 Mg-2.0
___ 04:28PM BLOOD Calcium-8.9 Phos-3.8 Mg-2.0
___ 06:15AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.0
___ 04:05PM BLOOD Calcium-8.6 Phos-4.2 Mg-2.2
___ 06:20AM BLOOD Calcium-8.5 Phos-4.2 Mg-2.1
___ 07:15PM BLOOD Calcium-8.4 Phos-4.6* Mg-2.1
___ 06:35AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.1
___ 07:20PM BLOOD Calcium-9.1 Phos-4.5 Mg-2.2
CBC:
___ 02:15PM BLOOD WBC-8.7 RBC-3.63* Hgb-11.0* Hct-32.6*
MCV-90 MCH-30.2 MCHC-33.6 RDW-13.5 Plt ___
___ 02:15PM BLOOD Neuts-89.8* Lymphs-6.8* Monos-2.3 Eos-1.0
Baso-0.1
___ 06:05AM BLOOD WBC-9.2 RBC-3.58* Hgb-10.8* Hct-32.2*
MCV-90 MCH-30.1 MCHC-33.5 RDW-13.9 Plt ___
___:15AM BLOOD WBC-7.6 RBC-3.66* Hgb-10.7* Hct-33.3*
MCV-91 MCH-29.3 MCHC-32.1 RDW-13.7 Plt ___
___ 06:20AM BLOOD WBC-8.0 RBC-3.82* Hgb-11.6* Hct-35.2*
MCV-92 MCH-30.3 MCHC-32.9 RDW-14.4 Plt ___
___ 06:35AM BLOOD WBC-9.3 RBC-3.84* Hgb-11.4* Hct-35.1*
MCV-91 MCH-29.7 MCHC-32.5 RDW-14.1 Plt ___
Coags:
___ 02:15PM BLOOD ___ PTT-43.9* ___
___ 02:15PM BLOOD Plt ___
___ 06:05AM BLOOD ___ PTT-41.7* ___
___ 06:05AM BLOOD Plt ___
___ 06:15AM BLOOD ___ PTT-40.6* ___
___ 06:15AM BLOOD Plt ___
___ 06:20AM BLOOD ___ PTT-39.7* ___
___ 06:20AM BLOOD Plt ___
___ 06:35AM BLOOD ___ PTT-36.1* ___
___ 06:35AM BLOOD Plt ___
ECG ___: atrial pacing with LBBB and left axis deviation
CXR ___: Perihilar and bibasilar opacities may relate to fluid
overload, underlying aspiration or infection cannot be excluded
in the appropriate clinical setting. Recommended repeat after
diuresis.
Cardiac US ___: no evidence of hemopericardium
Echocardiogram ___: Regional LV systolic dysfunction in the
distribution of the LAD. Mild mitral regurgitation. Mild
pulmonary artery systolic hypertension.
Stress test ___: No anginal symptoms with uninterpretable ST
segments.
Cardiac perfusion nuclear imaging ___: Moderate fixed
perfusion defect of the distal anterior and apex with akinesis.
Mild fixed defect of the septum with hypokinesis in the setting
of LBBB. Reduced LVEF of 39%.
Brief Hospital Course:
1. Congestive heart failure:
The patient has no recorded history of CHF. She presented with
recent dyspnea on exertion, peripheral edema and ___ lbs weight
gain in 2 weeks, there was evidence of fluid overload with lower
extremity pitting edema and mild JVD on exam as well as
pulmonary edema on CXR, elevated BNP and hyponatremia, findings
c/w acute CHF exacerbation. A history of CAD with left VMA and
LVEF 45% on ECHO makes an ischemic etiology likely. TSH was
within normal range, making hypothyroidism a less likely cause
of CHF. Her recent history of productive cough, low-grade
fevers/chills with basilar rales and infiltrate on outpatient
CXR may indicate a recent URI or PNA, now probably resolved with
two courses of azithromycin, which might have triggered this
exacerbation. She has been taking her home meds regularly and
has had no recent changes in dietary sodium intake to suggest
other contributing etiologies. The underlying anemia with no
acute changes in hematocrit may have compounded the shortness of
breath as well. Ms. ___ was fluid ___ and diuresed
with 20mg IV lasix with good urine output response and no
electrolyte abnormalities. Her weight continued to drop
progessively. Her dyspnea and edema steadily improved. She was
switched to 40mg PO lasix initially and then 20mg PO lasix at
discharge. Her discharge weight was 122.2 lbs, approximately 10
lbs less than her admission weight. She remained hemodynamically
stable without desaturations and afebrile throughout her stay.
She was started on lisinopril for her new systolic CHF and
maintained on home dose metoprolol.
2. Coronary artery disease:
She was stable on telemetry, had no substernal chest pain,
nausea or diaphoresis. Her troponin dropped 0.07->0.04->0.02 and
stress test nuclear imaging revealed no acute ischemic changes.
She did however have a fixed perfusion defect on nusclear
stress, suggesting a missed MI in the past. There was no need
for coronary reperfusion and angioplasty. She was maintained on
her home regimen of ASA 81mg and metoprolol.
3. Atrial fibrillation:
INR remained therapeutic. She was maintained on home dose
amiodarione, digoxin and metoprolol with good control of her HR.
4. Sick sinus syndrome on pacemaker:
Stable on ECG and telemetry.
5. Anemia:
The patient has a low hematocrit at baseline, was guaiac
negative and diagnosed with iron deficiency anemia which might
have contributed to pt's long-standing fatigue. Her hematocrit
was stable on this admission. She was supplemented with PO iron
sulfate
6. Hyponatremia:
Her low sodium was thought to be due to low ECV from her newly
diagnosed CHF. This rapidly corrected with duiresis.
7. Hypothyroidism:
TSH wnl. Pt was maintained on home dose levothyroxine.
8. Hypercholesterolemia - home dose rosuvastatin 5mg PO daily.
9. Hypertension - well-controlled on home regimen.
10. Code status this admission - FULL CODE
11. Transitional issues:
-Has follow-up arranged with her cardiologist
-Has been instructed to weigh herself daily and call her MD if
weight increased by 3 pounds or more
-Will need ongoing follow-up in the ___ clinic at ___, she was
initially supratherapeutic on her home ___ dose
Medications on Admission:
-rosuvastatin 5mg daily
-warfarin 1.25mg daily
-metoprolol succinate 25mg BID
-levothyroxine 75mcg daily
-ferrous sulfate 325mg daily
-amiodarone 100mg daily
-digoxin 125mcg half tablet daily
-ASA 81mg daily
-nitroglycerin 0.4mg SL PRN chest pain
Discharge Medications:
1. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO once a day.
4. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO once a
day. Tablet(s)
5. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
6. amiodarone 100 mg Tablet Sig: One (1) Tablet PO once a day.
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO every other day.
8. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO twice a day.
9. digoxin 125 mcg Tablet Sig: Half Tablet PO once a day.
10. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: at
4:00PM .
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Acute systolic congestive heart failure exacerbation
Secondary diagnoses:
CAD s/p MI
Hypertension
Atrial fibrillation
Sick sinus syndrome s/p PPM
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 during your hospitalization
at ___. You were admitted because in the last few weeks you
were becoming short of breath with physical activity. Your
shortness of breath was caused by a condition called "congestive
heart failure", meaning that the pumping action of your heart is
somewhat compromised. We treated you with a medication called
"lasix" to remove fluid from your lungs. An echocardiogram
(ultrasound of the heart) showed that the pumping action of your
heart had diminished over some period of time; a stress test
confirmed this finding. You were also started on a medication
called lisinopril (in addition to lasix) for heart failure. It
will also be important for you to continue your metoprolol.
Please weigh yourself every morning. Call your doctor if you
gain 3 pounds or more.
Please make the following changes to your home medication
regimen:
-START lasix (furosemide) 20mg by mouth daily
-START lisinopril 10mg daily
-INCREASE coumadin (Warfarin) to 2mg daily
-Take all other medications as prescribed
Please make an appointment to have your INR drawn on ___,
___.
Followup Instructions:
___
|
10245082-DS-21 | 10,245,082 | 21,497,971 | DS | 21 | 2177-03-05 00:00:00 | 2177-03-05 18:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Quinine
Attending: ___.
Chief Complaint:
fevers and lethargy
Major Surgical or Invasive Procedure:
___
Bronchoscopy
.
___
Right pleural pigtail catheter placement
.
___
Bronchoscopy, and right thoracotomy, right middle lobectomy with
intercostal muscle flap buttress, decortication.
.
___
Left IJ tunnelled dialysis catheter
History of Present Illness:
This is a ___ M with a recent history of a VATS right lower
lobectomy performed on ___ with a postoperative course
requiring bronchoscopy due to persistent hypoxia and inability
to
clear secretions. He subsequently continued to recover and was
discharged home with ___, home physical therapy, and home O2 on
___. Yesterday the patient was reportedly lethargic at home
with a low grade temperature. Today the patient's daughter
called to report that he had a temperature of 102.1 and hence
the
patient was directed to come to the emergency room for
evaluation.
Upon evaluation, the patient reports that he has had some
lethargy for the past day. He also reports some continuing SOB,
and does get short of breath with exertion. His cough is
productive of sputum, some of it rust tinged.
Past Medical History:
PAST MEDICAL HISTORY:
1. DM2
2. HL
3. HTN
4. PE (___)
5. Knee surgery (___)
6. Appendectomy as a child
7. Rigid Esophagus
PAST SURGICAL HISTORY:
1. ___ Cervical mediastinoscopy
2. VATS RLLobectomy ___
Social History:
___
Family History:
non contributory
Physical Exam:
ON ADMISSION:
Temp: 98.1 HR:112 BP:114/56 RR:16 O2 Sat:94%2L
GENERAL [ ] All findings normal
[ ] WN/WD [x] NAD [x ] AAO [ ] abnormal findings: Some SOB,
appears mildly ill
HEENT [x] All findings normal
[ ] NC/AT [ ] EOMI [ ] PERRL/A [ ] Anicteric
[ ] OP/NP mucosa normal [ ] Tongue midline
[ ] Palate symmetric [ ] Neck supple/NT/without mass
[ ] Trachea midline [ ] Thyroid nl size/contour
[ ] Abnormal findings:
RESPIRATORY [ ] All findings normal
[ ] CTA/P [ ] Excursion normal [ ] No fremitus
[ ] No egophony [ ] No spine/CVAT
[ ] Abnormal findings: Diminished breath sounds at right base,
some coarse crackles on right, left side is clear
CARDIOVASCULAR [x] All findings normal
[ ] RRR [ ] No m/r/g [ ] No JVD [ ] PMI nl [ ] No edema
[ ] Peripheral pulses nl [ ] No abd/carotid bruit
[ ] Abnormal findings:
GI [x] All findings normal
[ ] Soft [ ] NT [ ] ND [ ] No mass/HSM [ ] No hernia
[ ] Abnormal findings:
GU [x] Deferred [ ] All findings normal
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
NEURO [x] All findings normal
[ ] Strength intact/symmetric [ ] Sensation intact/ symmetric
[ ] Reflexes nl [ ] No facial asymmetry [ ] Cognition intact
[ ] Cranial nerves intact [ ] Abnormal findings:
MS [x] All findings normal
[ ] No clubbing [ ] No cyanosis [ ] No edema [ ] Gait nl
[ ] No tenderness [ ] Tone/align/ROM nl [ ] Palpation nl
[ ] Nails nl [ ] Abnormal findings:
LYMPH NODES [x] All findings normal
[ ] Cervical nl [ ] Supraclavicular nl [ ] Axillary nl
[ ] Inguinal nl [ ] Abnormal findings:
SKIN [x] All findings normal
[ ] No rashes/lesions/ulcers
[ ] No induration/nodules/tightening [ ] Abnormal findings:
PSYCHIATRIC [x] All findings normal
[ ] Nl judgment/insight [ ] Nl memory [ ] Nl mood/affect
[ ] Abnormal findings:
.
ON DISCHARGE:
-------------
Vitals:
T: 99.0 P: 71 BP: 133/61 RR: 15 O2sat:
General: slow to arouse, dobhoff ___ place
HEENT: NCAT, MMM
Heart: RRR
Lungs: bilateral rhonchi improving
Abdomen: soft, NT, ND, (+) BS
Extremities: WWP, no CCE, moves all
radial DP ___
R palp palp palp
L palp palp palp
Pertinent Results:
LABS ON ADMISSION:
------------------
___ 04:59PM WBC-21.0*# RBC-3.92* HGB-12.0* HCT-34.1*
MCV-87 MCH-30.6 MCHC-35.1* RDW-12.6
___ 04:59PM PLT COUNT-427
___ 04:59PM ___ PTT-27.8 ___
___ 04:59PM CALCIUM-9.0 PHOSPHATE-2.4* MAGNESIUM-1.9
___ 04:59PM GLUCOSE-181* UREA N-13 CREAT-1.0 SODIUM-133
POTASSIUM-4.0 CHLORIDE-95* TOTAL CO2-26 ANION GAP-16
.
___ Chest CT :
1. Overall growth and progressive gaseous contents of a large
right infrahilar phlegmon, probably an abscess, and larger air
and fluid loculations ___ the dependent right pleural space, are
indirect but strong indications of active connections between
the lungs or airway and the pleurae, even though a discrete
connection from the lower lobe bronchial stump is not visible.
The findings of peripheral alveolitis ___ the left lung conform
to 'spillover' pneumonitis seen ___ such circumstances. Dr.
___ was paged to discuss these findings, at the time
of dictation.
2. Right middle lobe bronchus is still obliterated.
3. Severe coronary artery calcification and possible aortic
valvular
stenosis.
.
___ CT guided drainage :
CT-guided placement of 10 ___ pigtail catheter into the right
complex
pleural air/fluid collection. Requested laboratory analysis
pending
.
___ Cardiac echo :
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. Due to suboptimal technical quality,
a focal wall motion abnormality cannot be fully excluded.
Overall left ventricular systolic function is normal (LVEF
55-65%). The number of aortic valve leaflets cannot be
determined. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. No mitral regurgitation is
seen. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
.
___ Fluoro for HD catheter:
Successful placement of a tunneled hemodialysis access catheter
through the left internal jugular vein approach. The distal tip
is located ___ the right atrium and the proximal lumen at the
SVC/right atrial junction. The catheter is ready for use.
.
___ CXR:
: Compared to the previous radiograph, the patient has received
a new
hemodialysis catheter over a left-sided approach. The course of
the catheter is unremarkable, the tip of the catheter projects
over the right atrium. Otherwise, there is no relevant change.
Unchanged size of the cardiac silhouette. Unchanged mild fluid
overload. Unchanged elevation of the right hemidiaphragm with a
mild-to-moderate right pleural effusion. Focal parenchymal
opacities have newly occurred.
.
___ CXR:
FINDINGS: Monitoring and supporting devices are ___ standard
position.
Moderate right pleural effusion and small left pleural effusions
associated with adjacent lung atelectasis and bilateral
pulmonary vascular congestions is unchanged. Cardiomediastinal
silhouette is stable. No new interval changes ___ the lung.
.
___ LENIs:
IMPRESSION:
No right or left lower extremity DVT.
.
___ 8:42 am BRONCHOALVEOLAR LAVAGE RIGHT BRONCHIAL
ASPIRATE.
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS, CHAINS, AND
CLUSTERS.
3+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final ___:
10,000-100,000 ORGANISMS/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 (Final ___:
YEAST.
.
___ 11:09 am PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
.
UAs
---
___ 12:33PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 03:02PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 11:11AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
.
LABS ON DISCHARGE:
------------------
___ 04:14AM BLOOD WBC-12.3* RBC-2.70* Hgb-8.3* Hct-25.4*
MCV-94 MCH-30.7 MCHC-32.6 RDW-14.7 Plt ___
___ 04:14AM BLOOD Neuts-71.8* ___ Monos-3.9 Eos-3.7
Baso-0.8
___ 04:14AM BLOOD Plt ___
___ 04:14AM BLOOD Glucose-135* UreaN-52* Creat-4.2*# Na-140
K-4.3 Cl-103 HCO3-27 AnGap-14
___ 04:14AM BLOOD Calcium-8.8 Phos-4.6* Mg-2.4
Brief Hospital Course:
Mr. ___ was evaluated by the Thoracic Surgery service ___
the Emergency Room and scans were reviewed. His chest CT showed
a large collection of fluid and air ___ the right pleural space
along with pneumonitis and his WBC was 21K. He was admitted to
the hospital and placed on broad spectrum antibiotics.
.
On ___ he underwent a bronchoscopy to R/O bronchopleural
fistula. There was no visualization of a BPF but the stump was
poorly visualized. He subsequently had a pigtail catheter
placed ___ his right pleural space for drainage but did not
improve. His oxygen requirements increased and he eventually
was intubated and transferred to the ICU. He was taken to the
Operating Room on ___ and underwent a Bronchoscopy, and
right thoracotomy, right middle lobectomy with intercostal
muscle flap buttress and decortication for a bronchopleural
fistula and empyema. He tolerated the procedure well but
required aggressive fluid resuscitation and pressors to maintain
stable hemodynamics.
.
His post op course was complicated by prolonged intubation and
acute kidney injury requiring CVVH on ___ with a high
creatinine of 6.4 and eventually hemodialysis. His kidney
function recovered a bit after 4 days to a creatinine of 2.5 but
unfortunately it was short lived and hemodialysis was restarted
and continues. He had a tunnelled line placed on ___ via
the left IJ and undergoes dialysis every ___ and
___.
.
From a pulmonary standpoint, he was finally weaned and extubated
on ___ and currently undergoes vigorous pulmonary toilet and
is able to cough up his secretions. His chest tubes were
removed 10 days post op and all of his intraop cultures were
negative. His incision sites are healing well. He still uses
1.5-2L nasal cannula oxygen to maintain saturations > 90%.
.
The Speech and Swallow service assessed him on multiple
occasions and felt that he was a high aspiration risk due to his
occasional lethargy. His nutrition requirements are currently
given thru an NG tube (dobhoff) as well as through oral thin
liquid and puree solid feeds. Tube feeds will be stopped when
nutrition requirements are met solely via an oral route.
.
The patient continues on hemodialysis for improvement of the
acute kidney injury he sustained as above. Creatinine is
downtrending nicely.
.
The patient will receive 6 days of ciprofloxacin to cover a
possible urinary tract infection, although to date, urine
culture remains NGTD, the patient is afebrile, and white count
continues downtrending.
Medications on Admission:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY.
2. aspirin 81 mg Tablet, Chewable Sig 1 tab PO DAILY
3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY
4. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H prn pain
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
6. senna 8.6 mg Tablet Sig: Two (2) Tablet PO QHS PRN
Constipation
7. Colace 100 mg Capsule Sig: One (1) Capsule PO BID
8. Glucophage 1,000 mg Tablet Sig: One (1) Tablet PO BID
9. Oxygen at 2 liters/min via nasal cannula, continuous
Discharge Medications:
1. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 6 doses.
2. heparin (porcine) 1,000 unit/mL Solution Sig: 1000 (1000)
units/mL Injection PRN (as needed) as needed for dialysis.
3. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
5. aspirin, buffered 81 mg Tablet Sig: One (1) Tablet PO once a
day.
6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO four times
a day as needed for fever or pain: Do not exceed 4 grams ___ 24
hours.
8. Nasal cannula oxygen
Patient on 1.5-2L via nasal cannula.
9. insulin glargine 100 unit/mL Solution Sig: Forty (40) Units
Subcutaneous QAM.
10. insulin regular human 100 unit/mL Solution Sig: refer to
sliding scale sliding scale Injection four times a day: Please
refer to sliding scale attached with discharge papers ___
addition to standing AM Lantus dose.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Bronchopleural fistula with empyema formation.
Sepsis.
Acute kidney injury.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with fevers, shortness of
breath, and lethargy due to an infection ___ your lung. You
underwent an operation to remove the middle lobe of your right
lung and clean out this infection. You were very sick, and
unfortunately suffered an acute kidney injury for which you are
still receiving hemodialysis.
.
* You have improved daily, and are now breathing on your own
without difficulty or assistance. When you are stronger you
will be able to eat a full and regular diet, but for now, you
are being fed through a feeding tube ___ your nose as well as
with a liquid and puree diet by mouth ___ order to give you
adequate nutrition.
.
* You are being transferred to a rehab facility to help build up
your strength and endurance before returning home.
.
* You will still need to follow-up with Dr. ___ ___ his
clinic on ___ @ 2PM.
.
YOUR MEDS ON ADMISSION:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
2. aspirin 81 mg Tablet, Chewable Sig 1 tab PO DAILY
3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY
4. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H prn pain
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
6. senna 8.6 mg Tablet Sig: Two (2) Tablet PO QHS PRN
7. Colace 100 mg Capsule Sig: One (1) Capsule PO BID
8. Glucophage 1,000 mg Tablet Sig: One (1) Tablet PO BID
9. Oxygen at 2 liters/min via nasal cannula, continuous
.
MEDS ON DISCHARGE:
1. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 6 doses.
2. heparin (porcine) 1,000 unit/mL Solution Sig: 1000 (1000)
units/mL Injection PRN (as needed) as needed for dialysis.
3. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
5. aspirin, buffered 81 mg Tablet Sig: One (1) Tablet PO once a
day.
6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO four times
a day as needed for fever or pain: Do not exceed 4 grams ___ 24
hours.
8. Insulin 40 Lantus QAM and insulin sliding scale.
9. Nasal cannula oxygen Patient on 1.5-2L via nasal cannula.
.
Simvastatin and Metformin should be restarted when patient
stabilized on oral nutrition regimen alone and acute kidney
injury resolved.
Followup Instructions:
___
|
10245522-DS-21 | 10,245,522 | 24,026,534 | DS | 21 | 2169-09-14 00:00:00 | 2169-09-15 10:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Falls, confusion, poor PO intake
Major Surgical or Invasive Procedure:
___: PEG tube placement under ___ fluoroscopic guidance
History of Present Illness:
___ hx of afib on warfarin, HTN, depression, aortic valve
replacement for aortic valve endocarditis presenting with
increasing falls, confusion over the last ___ days. Per wife pt
seems more weak and collapses at home onto his knees. There has
been no fainting. Not all falls witnessed and pt unable to
describe the events fully. Pt is a&o and states he feels tired.
Denies pain. No recent fevers or colds. No cough, abd
pain/n/v/d/urinary sxs. Wife thinks his speech is off but not
sure when this began.
In the ED, initial vitals were: 97.4 88 ___ 17 unable RA
- Exam notable for: mentating
- Labs notable for: flu neg, Na 125, lactate 1.0, UA w/ neg
nitrites/leuks, WBC 13
- Imaging was notable for: CXR- Right-sided consolidation,
worrisome for pneumonia. Recommend followup to resolution.
- Patient was given: CTX, azithromycin, 1.5L NS
Upon arrival to the floor, patient denies any dizziness or
lightheadness laying in bed, but says if he were to stand up he
would feel dizzy. He denies any CP/SOB/abd pain, but expresses a
strong urgent desire to go to the bathroom and has a large foul
smelling watery BM. He says this is not the first time, but
can't say how long this has been going on. He says he has
trouble remembering things. He also endorses that he has not
been eating anything or even been able to drink water for
possibly weeks now, since whenever he tries he regurgitates it
and has trouble swallowing. He is thirsty, but not able to drink
water. He does not feel feverish or chills, but does endorse a
cough of unclear duration
Past Medical History:
- Status post AVR for aortic valve disease secondary to aortic
valve endocarditis, in ___.
- Atrial fibrillation/atrial flutter status post TEE
cardioversion at ___ in ___.
- History of squamous cell carcinoma, status post left neck
radical dissection and chemotherapy, in remission.
- Carotid artery stenosis, apparently near 100% on the right
side per patient, and 60% on left side per patient.
- Question of TIA in ___. History of aortic valve
endocarditis in ___, status post aortic valve replacement.
- Mild to moderate aortic stenosis and mild to moderate aortic
regurgitation.
- Early dementia.
- Depression and anxiety
- Status post knee surgery.
- Status post melanoma resection.
Social History:
___
Family History:
Mother ___ ___
Father ___ ___
Sister Living HTN
Daughter Living WELL
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: 98.0 93/53 53 18 100 RA systolic was 100 after
GENERAL: thin, cachectic man in NAD, A&O X3 (knows year and
month but not date)
HEENT: NCAT, MM very dry,
NECK: supple,
CARDIAC: irreg irregular, w/ mechanical click
LUNGS: crackles at bases, rediced BS in right base
ABDOMEN: soft, NT, ND
EXTREMITIES: WWP, no BLE edema
NEUROLOGIC: moves all extremities well, CN ___ grossly intact
SKIN: no rashes
DISCHARGE PHYSICAL EXAM:
VS: T 98.1 BP 94/60 HR 50 RR 18 O2 95% RA
GENERAL: NAD, dysthymic however mood appears improved, patient
now smiling and has more vigor, AOx3
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: Prominent thyroid/cricoid cartilage with surrounding hard
fibrotic tissue.
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly. Left sided PEG tube in
place, dressing clean and dry.
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
Pertinent Results:
==============
ADMISSION LABS
==============
___ 07:30PM BLOOD WBC-13.0*# RBC-3.58* Hgb-10.9* Hct-31.0*
MCV-87 MCH-30.4 MCHC-35.2 RDW-13.0 RDWSD-40.8 Plt ___
___ 07:30PM BLOOD Neuts-80.7* Lymphs-6.1* Monos-12.1
Eos-0.2* Baso-0.2 Im ___ AbsNeut-10.51* AbsLymp-0.80*
AbsMono-1.58* AbsEos-0.03* AbsBaso-0.02
___ 07:10AM BLOOD ___ PTT-71.4* ___
___ 07:30PM BLOOD Glucose-105* UreaN-60* Creat-1.3* Na-123*
K-3.9 Cl-83* HCO3-26 AnGap-18
___ 07:10AM BLOOD Albumin-3.0* Calcium-7.9* Phos-2.9 Mg-2.2
Iron-22*
___ 07:10AM BLOOD calTIBC-179* Ferritn-1046* TRF-138*
___ 10:10AM BLOOD TSH-3.4
___ 07:45PM BLOOD Lactate-1.2
===============
IMAGING/STUDIES
===============
Head CT ___
1. No acute intracranial abnormality.
CXR ___
Right-sided consolidation, worrisome for pneumonia. Recommend
followup to resolution.
___ UP EXT VEINS US
No evidence of deep vein thrombosis in the left upper extremity.
Extensive
soft tissue edema noted.
___ NECK W/CONTRAST
The right common carotid artery is occluded from approximately
the thoracic
inlet to the circle of ___. The imaged portion of the right
MCA is patent
and there is some reconstitution of flow into the right carotid
siphon.
Without prior imaging for comparisons, these findings are age
indeterminate.
___ CHEST W/CONTRAST
1. Right middle lobe nonenhancing consolidation with multiple
air
bronchograms, suggestive of pneumonia.
2. Small bilateral pleural effusions, right greater than left.
___ ABDOMEN W/O CONTRAST
Diffuse anasarca with small volume ascites and bilateral small
pleural
effusions.
Collapsed stomach abuts the anterior abdominal wall without
interposed bowel.
___ PLACMENT
FINDINGS:
1. Successful placement of a ___ gastrostomy tube.
IMPRESSION:
Successful placement of a ___ gastrostomy tube. The
catheter should
not be used for 24 hours.
___ CT ABD & PELVIS W & W/O:
1. No evidence of active extravasation. No subcutaneous or
intraperitoneal
collections are identified.
2. Bilateral pleural effusions and adjacent compressive
subsegmental
atelectasis have increased compared to ___. diffuse
anasarca.
=============
NOTABLE LABS:
=============
___ 09:22PM BLOOD Glucose-101* UreaN-13 Creat-0.8 Na-140
K-3.8 Cl-107 HCO3-23 AnGap-14
___ 03:15AM BLOOD Glucose-113* UreaN-13 Creat-0.7 Na-140
K-4.1 Cl-108 HCO3-23 AnGap-13
___ 09:45AM BLOOD Glucose-117* UreaN-13 Creat-0.7 Na-140
K-3.8 Cl-109* HCO3-24 AnGap-11
___ 03:45PM BLOOD Glucose-123* UreaN-15 Creat-0.8 Na-139
K-4.0 Cl-106 HCO3-23 AnGap-14
___ 09:20PM BLOOD Glucose-130* UreaN-16 Creat-0.7 Na-139
K-3.9 Cl-107 HCO3-24 AnGap-12
___ 03:00AM BLOOD Glucose-130* UreaN-15 Creat-0.8 Na-141
K-4.0 Cl-107 HCO3-22 AnGap-16
___ 09:22PM BLOOD Calcium-8.1* Phos-3.6 Mg-1.8
___ 03:15AM BLOOD Calcium-7.8* Phos-3.0 Mg-2.0
___ 09:45AM BLOOD Calcium-7.8* Phos-2.5* Mg-3.1*
___ 03:45PM BLOOD Calcium-8.2* Phos-2.3* Mg-2.2
___ 09:20PM BLOOD Calcium-8.0* Phos-2.4* Mg-2.0
___ 03:00AM BLOOD Calcium-8.0* Phos-2.4* Mg-1.9
===============
DISCHARGE LABS:
===============
___ 05:50AM BLOOD WBC-6.5 RBC-2.89* Hgb-8.5* Hct-26.7*
MCV-92 MCH-29.4 MCHC-31.8* RDW-14.3 RDWSD-46.8* Plt ___
___ 05:50AM BLOOD ___ PTT-38.3* ___
___ 05:50AM BLOOD Glucose-85 UreaN-19 Creat-0.7 Na-140
K-4.0 Cl-102 HCO3-30 AnGap-12
___ 05:50AM BLOOD Calcium-7.8* Phos-3.0 Mg-2.1
Brief Hospital Course:
___ is a ___ with a hx of afib on warfarin, HTN,
depression, aortic valve replacement for aortic valve
endocarditis who presented with increasing falls, confusion, and
poor PO intake, found to have RML pneumonitis, hypotension,
severe coagulopathy, who had a PEG tube placed for continued
nutrition due to extensive esophageal and pharyngeal fibrosis.
Once tube feeds started on ___, he was monitored for
re-feeding syndrome. He required further inpatient care until
___ for bleeding from his PEG tube site, which stopped
once his bridge to warfarin was completed and Lovenox was
stopped.
ACTIVE ISSUES:
===============================
#PEG TUBE SITE BLEED:
Unclear why, ___ following, they are concerned that one of the
tacks may be near a vessel and not clotting i/s/o
anticoagulation.
- OFF Lovenox, and no further bleeding.
#DYSPHAGIA WITH SEVERE PROTEIN CALORIE MALNUTRITION:
Patient presented cachectic with poor very PO intake. Pt
subjectively felt unable to swallow anything, confirmed with
imaging and video swallow study. Poor PO intake likely causing
electrolyte abnormalities and hypotension. H/o radical neck
dissection i/s/o squamous cell carcinoma with ?scar tissue
palpable on exam, likely contributing to/causing symptoms.
- PEG tube placed ___ ___
- Switched to bolus feeds, 240 mL (1 can) 5x/day on ___
#HYPOTENSION:
Likely ___ bleed, and was also on BP meds. ___ also have been
secondary to poor intravascular oncotic pressure given
malnutrition.
- Small IVF boluses, increased tube feed free water flushes. Was
stable.
#HYPERTENSION:
Were holding all anti-hypertensives in setting of hypotension.
Became hypertensive with fluid resuscitation. Back on home PO
meds with PEG tube in as of ___, but held again on ___ for
hypotension.
- HOLDING ON DISCHARGE home lisinopril and hctz given above
bleeding, and earlier trigger for hypotension
#COAGULOPATHY:
INR >13, likely ___ poor PO intake compounded by warfarin intake
with no dose adjustment and no recent INR check. No e/o overt
bleeding, although pt does have some scant hemoptysis. S/P IV
vitamin K 5 mg, now just under 2.0.
- Continued warfarin. STOPPED Lovenox ___
- Goal INR 2.5 - 3.5 met (2.4 on ___, but warfarin dose was
increased and did not want to start Lovenox in case of bleeding
again)
CHRONIC/STABLE ISSUES:
===============================
#ATRIAL FIBRLLATION, MECHANICAL AV:
- AC management per above
#DEPRESSION:
- Back on home oral meds as of ___ with reduced Seroquel
considering malnutrition
#HYPOTHYROIDISM:
- Back on home PO Synthroid as of ___
TRANSITIONAL ISSUES:
====================================
CODE STATUS: Full code
CONTACT: Proxy name: ___
Relationship: Wife Phone: ___
DISCHARGE INR: 2.4
_________________________
FYI:
- The patient was evaluated by speech and swallow, ENT, general
surgery, GI, and ___ in the hospital. He was able to initiate
swallows but unable to complete the action and was grossly
aspirating both thin and nectar liquids. Additionally, he had
very significant narrowing of the esophagus, particularly the
upper esophageal sphincter. For this reason, a PEG tube was
placed by ___ with the use of fluoroscopy because GI and surgery
did not feel they could pass an endoscope safely.
- CT Neck revealed "The right common carotid artery is occluded
from approximately the thoracic inlet to the circle of ___.
The imaged portion of the right MCA is patent
and there is some reconstitution of flow into the right carotid
siphon. Without prior imaging for comparisons, these findings
are age indeterminate."
- Anti-coagulated in the hospital with enoxaparin until the PEG
tube was in place and patient could receive warfarin again, and
goal INR of 2.5 was reached.
- Goal INR is 2.5-3.5 given mechanical aortic valve and a-fib
risk factor
_________________________
TO-DO:
[ ] F/U patient's weight and nutritional status
[ ] F/U patient's mental well-being
[ ] PEG tube exchange with ___ 3 months after discharge (___)
[ ] f/u INR on ___. Should INR drop lower than 2.4, he
should be bridged with lovenox.
_________________________
MEDICATIONS:
- CTX/Azithro ___
- Ceftriaxone (___)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Gabapentin 300 mg PO TID
3. QUEtiapine Fumarate 100 mg PO QHS:PRN insomnia
4. Warfarin 5 mg PO DAILY16
5. Sertraline 100 mg PO DAILY
6. TraZODone 50 mg PO QHS
7. Hydrochlorothiazide 25 mg PO DAILY
8. Levothyroxine Sodium 100 mcg PO 4X/WEEK (___)
9. Levothyroxine Sodium 75 mcg PO 3X/WEEK (___)
Discharge Medications:
1. Gabapentin 300 mg PO TID
2. Levothyroxine Sodium 100 mcg PO 4X/WEEK (___)
3. Levothyroxine Sodium 75 mcg PO 3X/WEEK (___)
4. QUEtiapine Fumarate 100 mg PO QHS:PRN insomnia
5. Sertraline 100 mg PO DAILY
6. TraZODone 50 mg PO QHS
7. Warfarin 5 mg PO DAILY16
8. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication was
held. Do not restart Hydrochlorothiazide until your primary care
physician instructs you to.
9. HELD- Lisinopril 10 mg PO DAILY This medication was held. Do
not restart Lisinopril until your primary care physician
instructs you too.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: severe protein calorie malnutrition, dysphagia,
pneumonia, coagulopathy
Secondary: depression, hypertension, atrial fibrillation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___.
WHY DID YOU COME TO THE HOSPITAL?
You were having falls and some confusion at home, and you were
not able to eat anything.
WHAT HAPPENED WHILE YOU WERE HERE?
We did some tests and felt that because it was so difficult for
you to swallow food, it would be best to place a feeding tube
directly into your stomach. This will allow you to get nutrition
every day and become stronger and healthier.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
Please continue to take all of your medications as directed, and
follow up with all of your doctors as ___ below.
Again, it was a pleasure taking care of you!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10245522-DS-22 | 10,245,522 | 26,710,066 | DS | 22 | 2169-12-20 00:00:00 | 2170-01-01 05:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Increasing redness, swelling, and purulent drainage from upper
abdomen
Major Surgical or Invasive Procedure:
PEG replacement ___
Epicardial Wire trimming ___
PICC placement ___
History of Present Illness:
___ year old male with history of aortic valve replacement (St.
___ for aortic valve endocarditis, complete heart block s/p
dual chamber pacemaker placement ___ Advisa DDD
___, squamous cell carcinoma with L neck radical
dissection with G-tube placement in ___, who presents with
increased redness, swelling, and purulent drainage from upper
abdomen x 1 week.
In ___, patient presented to the ED with similar complaint
of swelling, and redness around upper abdomen. CT demonstrated
2.1 x 3.1 cm subcutaneous hyperattenuating lesion surrounding
the distal tip of the epicardial pacing wires, possibly
representing hematoma in his left upper anterior abdomen,
lateral to the percutaneous G-tube. There was also overlying
skin thickening consistent with erythema seen on physical exam.
Cardiac surgery was consulted regarding epicardial wires, and
patient was sent home on doxycycline 100 mg BID x ___s treatment for cellulitis.
For the past ___ days, he has noticed increased pus-like
discharge from his left upper anterior abdomen. No increased
abdominal pain, chest pain, shortness of breath. No fevers or
chills. He shares that output has been constant, perhaps a
little decreased this AM. He has been covering his site with
bandages/gauze. Yesterday, bandage was soaked, prompting him to
go to urgent care, who recommended he go to ED.
In the ED, initial vitals were: T 98.0, HR 62, BP 141/83, RR
17, SpO2 97% RA.
- Exam notable for: Not recorded.
- Labs notable for: WBC 9.4, Hgb 11.3, platelets 134. INR 1.8
(on Coumadin). Chem panel with Na 129, BUN 35, Cr 0.8. U/A
bland.
- Imaging was notable for:
Abdominal U/S showing:
"3.2 x 2.6 x 1.0 cm ill-defined heterogeneous fluid
collection/phlegmon with sinus tract to the skin surrounding the
distal/inferior tips of epicardial pacing wires, not
significantly changed in size compared to prior exam, allowing
for differences in technique. Persistent overlying skin
thickening raises possibility of superimposed infection, as
previously noted."
CT abd/pelvis showing:
"At the level of the left upper anterior abdomen inferolateral
to the percutaneous gastrostomy tube is a hyperattenuating focus
measuring 3.0 x 1.4 cm with associated skin thickening. This is
nonspecific and may represent a phlegmon given the provided
clinical history. No evidence of drainable fluid collection."
- Cardiac Surgery was consulted who recommended EP and ACS
consults for possible drainage versus pacemaker lead extraction.
- ACS was consulted who felt that the G-tube was not involved.
Felt that the sinus tract from his old pacing wires was the
source of the drainage. Recommended EP input for the plan.
- EP was consulted and did not recommend removal of transvenous
leads to PPM unless bacteremic.
- Patient was given: 2L IVF and doxycycline 100 mg PO x1; blood
cultures were obtained after he received doxycycline.
Of note, patient shares that he is scheduled for PEG replacement
___ ___s esophageal dilation procedure ___.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
- Status post AVR for aortic valve disease secondary to aortic
valve endocarditis, in ___.
- Atrial fibrillation/atrial flutter status post TEE
cardioversion at ___ in ___.
- History of squamous cell carcinoma, status post left neck
radical dissection and chemotherapy, in remission.
- Carotid artery stenosis, apparently near 100% on the right
side per patient, and 60% on left side per patient.
- Question of TIA in ___. History of aortic valve
endocarditis in ___, status post aortic valve replacement.
- Mild to moderate aortic stenosis and mild to moderate aortic
regurgitation.
- Early dementia.
- Depression and anxiety
- Status post knee surgery.
- Status post melanoma resection.
Social History:
___
Family History:
Mother ___ ___
Father ___ ___
Sister Living HTN
Daughter Living WELL
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.9 134/76 56 16 99% RA
General: Alert, oriented, no acute distress, very thin and
cachectic
HEENT: Sclerae anicteric, dry mucous membranes
Neck: Supple, JVP not elevated, no LAD
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Irregularly irregular, mechanical click
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. Area of
erythema around left upper abdomen lateral to PEG insertion site
GU: No foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM:
97.5 PO 177/87 51 18 94 Ra
General: Alert, oriented, no acute distress, very thin and
cachectic
HEENT: Sclerae anicteric, dry mucous membranes
Neck: Supple, JVP not elevated, no LAD
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Irregularly irregular, loud mechanical S2
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. Lateral to a
non inflamed PEG insertion site is some overlying scab without
surrounding erythema.
GU: No foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
___ 07:12AM BLOOD WBC-9.4 RBC-3.89* Hgb-11.3* Hct-33.2*
MCV-85 MCH-29.0 MCHC-34.0 RDW-15.4 RDWSD-47.7* Plt ___
___ 07:12AM BLOOD Neuts-74.7* Lymphs-11.1* Monos-13.2*
Eos-0.2* Baso-0.3 Im ___ AbsNeut-7.03* AbsLymp-1.05*
AbsMono-1.24* AbsEos-0.02* AbsBaso-0.03
___ 07:12AM BLOOD Plt ___
___ 02:09PM BLOOD ___
___ 07:12AM BLOOD Glucose-115* UreaN-35* Creat-0.8 Na-129*
K-4.2 Cl-89* HCO3-29 AnGap-15
___ 06:00AM BLOOD ALT-28 AST-30 LD(LDH)-211 AlkPhos-95
TotBili-0.5
___ 06:00AM BLOOD Albumin-3.6 Calcium-8.6 Phos-2.5* Mg-1.9
___ 12:00PM URINE Color-Straw Appear-Clear Sp ___
___ 12:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
INTERVAL LABS:
___ 06:40AM BLOOD WBC-15.1* RBC-4.37* Hgb-12.7* Hct-38.0*
MCV-87 MCH-29.1 MCHC-33.4 RDW-15.8* RDWSD-50.1* Plt ___
DISCHARGE LABS:
___ 05:22AM BLOOD WBC-9.0 RBC-3.57* Hgb-10.1* Hct-31.2*
MCV-87 MCH-28.3 MCHC-32.4 RDW-15.7* RDWSD-50.0* Plt ___
___ 05:22AM BLOOD Plt ___
___ 05:22AM BLOOD ___ PTT-79.4* ___
___ 05:22AM BLOOD Glucose-91 UreaN-21* Creat-0.7 Na-136
K-4.2 Cl-99 HCO3-31 AnGap-10
___ 05:22AM BLOOD Calcium-8.3* Phos-3.8 Mg-2.1
MICROBIOLOGY:
___ GRAM STAIN-FINAL; TISSUE-FINAL {STAPH AUREUS COAG +,
STAPH AUREUS COAG +}; ANAEROBIC CULTURE-FINAL
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| STAPH AUREUS COAG +
| |
CLINDAMYCIN----------- R R
ERYTHROMYCIN---------- =>8 R =>8 R
GENTAMICIN------------ <=0.5 S <=0.5 S
LEVOFLOXACIN---------- =>8 R =>8 R
OXACILLIN------------- =>4 R =>4 R
RIFAMPIN-------------- <=0.5 S <=0.5 S
TETRACYCLINE---------- <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S <=0.5 S
VANCOMYCIN------------ 1 S 2 S
___ GRAM STAIN-FINAL; WOUND CULTURE-FINAL {STAPH AUREUS
COAG +, STAPH AUREUS COAG +}; ANAEROBIC CULTURE-FINAL
___ BLOOD CULTURE Blood Culture, Routine-FINAL
NGTD
___ BLOOD CULTURE Blood Culture, Routine-FINAL
NGTD
___ BLOOD CULTURE Blood Culture, Routine-FINAL
NGTD
___ BLOOD CULTURE Blood Culture, Routine-FINAL
NGTD
___ ABSCESS GRAM STAIN-FINAL; FLUID
CULTURE-FINAL {STAPH AUREUS COAG +, STAPH AUREUS COAG +};
ANAEROBIC CULTURE-FINAL INPATIENT
___ MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS} INPATIENT
STAPH AUREUS COAG +. SPARSE GROWTH OF TWO COLONIAL
MORPHOLOGIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
RIFAMPIN should not be used alone for therapy.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
STAPH AUREUS COAG +. RARE GROWTH. ___ MORPHOLOGY.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
___ BLOOD CULTURE Blood Culture, Routine-NGTD
___ BLOOD CULTURE Blood Culture, Routine-NGTD
___ URINE URINE CULTURE-FINAL NGTD
STUDIES:
RUQ US ___
FINDINGS:
Transverse and sagittal grayscale and color Doppler images were
obtained of the anterior abdominal wall induration. Again seen
is an ill-defined area of heterogeneous fluid collection with
sinus tract to the skin measuring 3.2 x 2.6 x 1.0 cm, previously
2.1 x 3.1 cm on ___. Distal tips of previously placed
epicardial pacing wires are again noted. There is mild skin
thickening overlying the heterogeneous fluid
collection/phlegmon. However, there is no significant increased
vascularity around the collection.
IMPRESSION:
3.2 x 2.6 x 1.0 cm ill-defined heterogeneous fluid
collection/phlegmon with sinus tract to the skin surrounding the
distal/inferior tips of epicardial pacing wires, not significant
changed in size compared to prior exam, allowing for differences
in technique. Persistent overlying skin thickening raises
possibility of superimposed infection, as previously noted.
CT A/P: ___
FINDINGS:
LOWER CHEST: There is mild dependent atelectasis in the
bilateral lower lobes.
Linear opacity in the left lower lobe likely represents
scarring is unchanged from CT abdomen pelvis ___. There
is a partially calcified right posterior pleural plaque,
unchanged from ___. Epicardial pacing wires are again
noted.
ABDOMEN:
HEPATOBILIARY: The liver is grossly unremarkable aside from
mild periportal edema, unchanged from ___. There is no
evidence of focal lesions.
There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is within normal limits. Small
amount of pericholecystic fluid is unchanged from ___.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of focal lesions or pancreatic ductal
dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation
throughout, without evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis.
There is no perinephric abnormality.
GASTROINTESTINAL: Gastrostomy tube terminates within the
stomach. The stomach is unremarkable. Small bowel loops
demonstrate normal caliber, wall thickness, and enhancement
throughout. The colon and rectum are within normal limits. The
appendix is not visualized but there are no secondary signs of
acute appendicitis.
PELVIS: The urinary bladder and distal ureters are
unremarkable. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is not enlarged.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There is no pelvic or inguinal
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild
atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
Moderate degenerative changes the lumbar spine are noted.
SOFT TISSUES: In the anterior abdominal wall near the course of
the epicardial pacing wires and inferolateral to the course of
the gastrostomy tube, there is a hyperattenuating area measuring
3.0 x 1.4 cm (02:30), mildly decreased in size from CTA ___. There is a lipoma in the anterior subcutaneous tissues of
the upper abdomen (02:20)
IMPRESSION:
At the level of the left upper anterior abdomen inferolateral
to the percutaneous gastrostomy tube is a hyperattenuating focus
measuring 3.0 x 1.4 cm with associated skin thickening. This is
nonspecific and may represent a phlegmon given the provided
clinical history. No evidence of drainable fluid collection.
Echo ___
Conclusions
The left atrial volume index is severely increased. The right
atrium is markedly dilated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Right ventricular chamber size is normal
with mild global free wall hypokinesis. The ascending aorta is
mildly dilated. A mechanical aortic valve prosthesis is present.
The transaortic gradient is higher than expected for this type
of prosthesis. Mild (1+) aortic regurgitation is seen. [Due to
acoustic shadowing, the severity of aortic regurgitation may be
significantly UNDERestimated.] The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. [Due to acoustic
shadowing, the severity of tricuspid regurgitation may be
significantly UNDERestimated.] There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mechanical aortic valve with higher than expected
transaortic gradient and aortic regurgitation. Biatrial
enlargement. Mild symmetric left ventricular hypertrophy with
preserved left ventricular systolic function. Mildly hypokinetic
right ventricle with moderate pulmonary hypertension and at
least moderate tricuspid regurgitation.
Compared with the prior study (images reviewed) of ___,
the transaortic gradient has increased. Moderate pulmonary
hypertension is new. The severity of aortic, mitral, and
tricuspid regurgitation has increased.
___ GT replacement
PROCEDURE: 1. Exchange of a gastrostomy tube.
PROCEDURE DETAILS: Following the discussion of the risks,
benefits and alternatives to the procedure, written informed
consent was obtained from the patient. The patient was then
brought to the angiography suite and placed supine on the exam
table. A pre-procedure time-out was performed per ___
protocol. The upper abdomen and tube site was prepped and draped
in the usual sterile fashion.
The existing tube was injected with contrast and showed
opacification of the gastric rugae. The stay sutures were cut. A
___ wire was advanced through the tube into the stomach. The
existing tube was then removed using gentle traction. A 12
___ Wills ___ tube was advanced over the wire into the
stomach and the pigtail was formed. Contrast injection
confirmed appropriate position. Sterile dressing was applied.
The patient tolerated the procedure well and there were no
immediate post-procedure complications.
FINDINGS:
1. 12 ___ Wills ___ tube in the stomach.
IMPRESSION:
Successful exchange of a gastrostomy tube for a new 12 ___
Wills ___ tube. The tube is ready to use.
CXR ___
IMPRESSION:
Compared to chest radiographs ___ through ___.
Moderate right and small left pleural effusion are new.
Bibasilar atelectasis, mild on the right, moderate on the left,
also new. Low lung volumes exaggerate slight increase in
overall diameter the cardiac silhouette, but pulmonary
vasculature is vague suggesting early cardiac decompensation.
Epicardial and transvenous pacer and pacer defibrillator leads
are unchanged in their respective positions.
New ascending drainage catheter to the left of the midline in
the upper abdomen.
___
FINDINGS:
Re-identified is a left chest cardiac device with associated
dual leads projecting over the right atrium and ventricle, in
unchanged orientation.
Multiple median sternotomy wires are again seen. Epicardial
pacer leads are again noted, unchanged. Partially visualized is
a catheter overlying the left upper abdomen, not fully assessed.
There is a new right arm PICC with tip projecting over the mid
SVC 2.5 cm above cavoatrial junction.
Heart is enlarged, stable. The hila are within normal limits.
There is prominence of the pulmonary vasculature worst
centrally, suggestive pulmonary vascular
congestion/redistribution. Mild interstitial prominence in the
lower lungs, improved since prior, consistent with improving
edema. Left basilar opacity is unchanged prior exam. Right
lower lung aeration is improved from prior exam elsewhere, the
lungs are clear without new focal lung consolidation. There is
no pneumothorax. There is likely a residual small left pleural
effusion, improved. No sizable right pleural effusion,
improved.
IMPRESSION:
1. New right arm PICC.
2. Mildly improved cardiopulmonary findings.
Brief Hospital Course:
___ year old male with history of aortic valve replacement for
aortic valve endocarditis, complete heart block s/p dual chamber
pacemaker placement ___ Advisa DDD ___, squamous
cell carcinoma with L neck radical dissection with G-tube
placement in ___, who presented with increased redness,
swelling, and purulent drainage from upper abdomen x 1 week,
with symptoms concerning for epicardial wire infection,
undergoing epicardial wire clipping on ___ with subsequent
antibiotic course to continue for 2 weeks at rehab.
# MRSA Cellulitis
# ?epicardial lead phlegmon.
Patient presented with history consistent with infected purulent
draining fluid space around his epicardial lead, without
evidence of leukocytosis, signs of pericarditis, or
mediastinitis. CT abdomen/pelvis demonstrated evidence of
hyperattenuating lesion near the course of his old epicardial
pacing wires, and in
the setting of recurrent episodes of increased redness,
swelling,
and purulent drainage, this was concerning. Unfortunately
patient was initiated on antibiotics prior to BCx in the ED. He
was treated with vancomycin and ceftriaxone under advisement of
infectious disease consultants. He was seen by cardiac surgery
who in conjunction with ID decided that source control could
only be achieved with partial removal of infected hardware. He
had an echocardiography that demonstrated increased transaortic
gradient, moderate pulmonary hypertension and severe aortic,
mitral, and tricuspid regurgitation. His epicardial leads were
trimmed by cardiac surgery on ___. His epicardial lead cultures
grew MRSA, so he was continued on vancomycin with a plan to
continue for 2 weeks after his hardware removal on ___ (last
day ___. He was discharged with cardiac surgery follow-up on
___. His wound vacuum was changed on ___, with instructions
from cardiac surgery to either replace the wound vacuum on ___
or change to a wet-to-dry dressing given evidence of good wound
healing already present. He was discharged with a PICC line that
was placed on ___.
# S/p AVR
# Atrial fibrillation: Per prior discharge summary, goal INR is
2.5-3.5 in setting of mechanical heart valve and atrial
fibrillation; For patients with a mechanical aortic prosthetic
valve (other than On-X) and an additional risk factor for
thromboembolic events (atrial fibrillation, previous
thromboembolism, left ventricular systolic dysfunction, or
hypercoagulable condition) or an older generation mechanical
aortic valve prosthesis (eg, ball-in-cage), INR of 3 (2.5-3.5)
is the ideal target. His warfarin was held and he was placed on
a heparin gtt once it became clear he would have an epicardial
lead trimming. Afterward he was resumed on warfarin 6 mg qd,
though he notably remained subtherapeutic on INR at time of
discharge (INR 1.5). Next INR should be drawn ___ for dosing of
warfarin. He continued on a heparin gtt.
# Esophageal and oropharyngeal dysphagia. Patient had a tube
feeding regimen he preferred of Jevity 1.5, 6 feeds daily of
280cc's that was continued. He had a previously planned PEG tube
exchange performed as an inpatient on ___.
# UES stricture: Patient expressed concern early on in the
admission about the need for an esophageal dilation in the
future. This was not pursued actively during this admission due
to his other active issues but warrants outpatient follow-up.
# Hyponatremia: Patient had ongoing trend of hypovolemic
hyponatremia which was thought to be nutritional in nature. This
improved with monitoring of his TFs and slight increase of his
free water flushes to 100 ml q6h.
# Hypertension: Patient on admission demonstrated intermittent
tendency toward hypotension overnight, thought to be ___
hypovolemia and also possibly from an alpha agonism contribution
from his Seroquel. This improved after TF monitoring and also
reduction of seroquel to 50 mg qhs. He was resumed on lisinopril
and HCTZ prior to discharge, though still demonstrated some
intermittent high BPs to SBP 170, thought to mostly be due to
discomfort after his operation.
# Chronic Issues:
# Hypothyroidism: Continued home levothyroxine
# Depression/anxiety: Continued home sertraline 100 mg daily
initially and
trazodone 50 mg daily, though decreased Seroquel to 50 mg qhs
some intermittent predisposition to overnight hypotension,
thought to be due in part to alpha agonism. Patient throughout
the admission demonstrated signs of poor coping to his fatigued
state in the setting of infection and need for intervention. He
demonstrated some signs of acute stress disorder vs. adjustment
disorder, though did not demonstrate suicidal
thoughts/intent/plan.
TRANSITIONAL ISSUES:
- Patient was discharged on course of vancomycin to continue
through ___. Next vanc trough dose should be drawn 7:30 p.m. on
___ with goal of ___.
- Patient has cardiac surgery follow-up scheduled for ___. His
next vacuum dressing change is due ___, though per cardiac
surgery this may be declined in favor of wet to dry dressing
given evidence of good wound healing.
- Patient was resumed on lisinopril and HCTZ prior to discharge,
though he continued to demonstrate intermittent SBPs to 170s in
the setting of discomfort. Should this continue would recommend
increasing lisinopril to ___ mg qd.
- Patient's INR was subtherapeutic at time of discharge (INR
1.5). Goal should be 2.5-3.5 in the setting of his aortic valve
and atrial fibrillation. He was discharged on heparin gtt while
he was maintaining therapeutic range. Last warfarin dose was 6
mg on ___.
- Patient demonstrated some dysthymic affect throughout the
whole admission, with evidence of marked difficult adjusting to
the care requirements of his illness. Should this continue over
time would recommend psychiatry follow-up for treatment of
adjustment disorder vs. MDD.
- Patient expressed concern regarding need for a future
esophageal dilation. This was not addressed actively this
admission due to his other acute needs, though this warrants
follow-up as an outpatient.
# CODE STATUS: Full code
# CONTACT: Proxy name: ___
Relationship: Wife Phone: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO TID
2. Levothyroxine Sodium 100 mcg PO 4X/WEEK (___)
3. Levothyroxine Sodium 75 mcg PO 3X/WEEK (___)
4. QUEtiapine Fumarate 100 mg PO QHS:PRN insomnia
5. Sertraline 100 mg PO DAILY
6. TraZODone 50 mg PO QHS
7. Warfarin 4 mg PO DAILY16
8. Hydrochlorothiazide 25 mg PO DAILY
9. Lisinopril 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Heparin IV per Weight-Based Dosing Protocol
Indication: Mechanical Heart Valve
Continue existing infusion at last documented rate and adjust
subsequent rate as per the heparin nomogram.
Therapeutic/Target PTT Range: 60 - 99.9 seconds
3. Vancomycin 750 mg IV Q 12H
4. QUEtiapine Fumarate 50 mg PO QHS:PRN insomnia
5. Warfarin 6 mg PO DAILY16
6. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*21 Capsule Refills:*0
7. Hydrochlorothiazide 25 mg PO DAILY
8. Levothyroxine Sodium 100 mcg PO 4X/WEEK (___)
9. Levothyroxine Sodium 75 mcg PO 3X/WEEK (___)
10. Lisinopril 10 mg PO DAILY
11. Sertraline 100 mg PO DAILY
12. TraZODone 50 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Epicardial wire space infection
SECONDARY DIAGNOSIS:
Atrial Fibrillation
s/p Aortic valve replacement.
complete heart block s/p dual chamber pacemaker
Squamous cell carcinoma s/p left radical neck dissection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because there was purulent
fluid draining from your abdomen. This was concerning for an
infected space around your old epicardial wire which is no
longer in use. You were evaluated with blood work and imaging
that confirmed the suspicion that your drainage likely
corresponded to an infected pocket of fluid. After being seen by
the cardiovascular surgeons, you received antibiotic treatment
guided by cultures of the fluid. You also had some of the
original wires removed to help prevent the regrowth of bacteria.
You were given a special kind of IV line in your arm to help
continue to deliver antibiotics. You will have continued
follow-up at ___ and will continue to receive
the antibiotics through ___.
Your warfarin seems to be taking a little time to kick in after
your surgery, so you were sent from the hospital to rehab on a
heparin drip that will continue to keep your blood thin until
the warfarin has a chance to work.
It was a pleasure to be involved with your care at ___,
Your ___ Team
Followup Instructions:
___
|
10245748-DS-17 | 10,245,748 | 26,276,035 | DS | 17 | 2179-12-11 00:00:00 | 2179-12-12 15:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Lt sided abnormal sensation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: The patient is a ___ year-old ___
right-handed
smoker with a history of HLD, DM and ? "thick blood" who
presents
with 7 days of left>right weakness and left hemibody numbness.
Interview conducted with help of a professional ___
interpreter over the phone.
Mr. ___ was in his normal state of health one week ago when
developed gradual onset of generalized fatigue and weakness,
left
greater than right, leg more than arm. The weakness was subtle
and did not affect his ability to ambulate or manipulate items
with his left hand. He also had chest pain and was initially
seen at ___ ED (___/) where a stress test was
negative. Other labs were done: TSH 1.2, Free T4 nml, Vit D 20
(low), B12 915, ESR 2.
Three days ago, he developed sudden onset of left hemibody
(face,
arm, leg) numbness that he characterizes as "very little
feeling"
as well as some "tingling". This has remained constant the past
3 days. He was not aware of this sensation on his trunk. He
also reports a holocephalic ___ dull, pressure headache
without phonophobia, photophobia, n/v for the past week. This
morning he also had posterior neck pain, but no stiffness. He
felt he just slept funny overnight. He also feels
lightheadedness and feels that he is going to fall occasionally.
He denies vertigo. Today he called his PCP who referred him to
the ED.
Of note, over the past week Mr. ___ tried to quit smoking. He
has taken aspirin, but prior to the onset of these symptoms, was
taking aspirin unreliably. He tells me aspirin was started by
his PCP because he "has thick blood." He is not clear if there
is a hypercoagulable state in his family or himself. He has not
had blood clots, strokes. No similar episodes of
weakness/numbness. He never required brain imaging. He was
never seen by a neurologist.
ROS: positive as above. + Bilateral tinnitus. No
lightheadedness, or confusion. Denies difficulty with producing
or comprehending speech. Denies loss of vision, blurred vision,
diplopia, vertigo, hearing difficulty, dysarthria, or dysphagia.
Denies bowel or bladder incontinence or retention. The patient
denies fevers, rigors, night sweats, or noticeable weight loss.
Denies chest pain, palpitations, dyspnea, or cough. Denies
nausea, vomiting, diarrhea, constipation, or abdominal pain. No
recent change in bowel or bladder habits. Denies dysuria or
hematuria. Denies myalgias, arthralgias, or rash.
Past Medical History:
PMH/PSH:
- Overweight
- HLD - last LDL 198 ___
- Diabetes - last A1c 7.1 ___
- Vit D deficiency - level 20 on ___
- Diarrhea ___, followed by GI
- Left inguinal hernia
Social History:
___
Family History:
FAMILY HISTORY: Mother and father are healthy. He denies family
history of strokes, blood clots, MIs.
Physical Exam:
PHYSICAL EXAMINATION
Vitals: 98.9 58 120/70 16 100% RA
General: overweight, well appearing Asian man.
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, no guarding
Extremities: Warm, no edema
Neurologic Examination:
Awake, alert, oriented x 3. Able to relate history without
difficulty. Attentive. Per interpreter, his speech is fluent
with
full sentences and intact verbal comprehension. Naming intact.
No
dysarthria. Normal prosody. No evidence of hemineglect. No
left-right confusion. Able to follow both midline and
appendicular commands.
- Cranial Nerves - PERRL 4->2 brisk. VF full to finger wiggle.
EOMI, no nystagmus. V1-V3 with decreased sensation to light
touch
and pin on left hemiface. Does not split the midline. 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 ___- ___ 4+ 5 5- 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
** Of note, there is some giveway weakness on the muscle groups
on the left listed as being weak above. Hard to differentiate
weakness and giveway in this patient.
- Sensory - Decreased sensation to light touch and pin on left
face, arm and leg in a nondermatomal fashion. Left sided is
40-70% of what is felt on the right. He feels the left arm/leg
are "colder" than the right. No exinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response mute on left, flexor on right.
- Coordination - No dysmetria with finger to nose testing
bilaterally. Toe to target normal 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.
Pertinent Results:
IMAGING:
___ and CTA H&N: On my read there is evidence of SVID
bilaterally. No areas of early ischemia or acute stroke. CTA
H&N without stenosis or vasculopathy.
BRAIN MRI: 1. Unremarkable MRI brain without evidence of
infarct.
___ 03:25PM ___ PTT-31.9 ___
___ 03:25PM PLT COUNT-199
___ 03:25PM NEUTS-47.6 ___ MONOS-6.6 EOS-1.2
BASOS-0.9 IM ___ AbsNeut-2.72 AbsLymp-2.49 AbsMono-0.38
AbsEos-0.07 AbsBaso-0.05
___ 03:25PM WBC-5.7 RBC-4.85 HGB-14.3 HCT-43.1 MCV-89
MCH-29.5 MCHC-33.2 RDW-12.0 RDWSD-38.9
___ 03:25PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 03:25PM ALBUMIN-4.6
___ 03:25PM cTropnT-<0.01
___ 03:25PM LIPASE-75*
___ 03:25PM ALT(SGPT)-19 AST(SGOT)-27 ALK PHOS-53 TOT
BILI-0.7
___ 03:25PM GLUCOSE-112* UREA N-18 CREAT-0.8 SODIUM-139
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-25 ANION GAP-15
___ 03:47PM URINE MUCOUS-RARE
___ 03:47PM URINE RBC-0 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 03:47PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 03:47PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 03:47PM URINE UHOLD-HOLD
___ 03:47PM URINE HOURS-RANDOM
Brief Hospital Course:
Mr. ___ is a ___ year-old ___ right-handed smoker
with a history of HLD, DM and ? "thick blood" who presented with
7 days of gradual onset left>right generalized weakness and 3
days of abrupt onset left hemibody numbness. Overall, although
Mr. ___ history is difficult and there are a few features
which are
inconsistent with an abrupt vascular onset, his left hemibody
sensory loss on exam and partial UMN pattern of weakness are
concerning. His stepwise sensorimotor deficit could be the
manifestation of a stuttering lacunar stroke to the
thlamocapsular region or corona radiata. This is especially
important in this young man with multiple vascular risk factors
(HLD, DM, smoking, obesity) who may have a hypercoagulable
disorder (unclear from history). He was admitted and had brain
MRI done which didn't show any evidence of stroke or bleed.
Given his symptoms are much improved and that it was associated
with headache this could be secondary to migraine. We
recommended Mr. ___ to continue taking his home medications and
encouraged to continue to be smoke-free.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. MetFORMIN (Glucophage) 500 mg PO TID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
2. Atorvastatin 80 mg PO QPM
3. MetFORMIN (Glucophage) 500 mg PO TID
Discharge Disposition:
Home
Discharge Diagnosis:
Numbness & tingling
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the Neurology Service after presenting to
ED for evaluation of Lt sided abnormal sensation for the past 3
days. Images from your brain didn't show evidence of a stroke
or bleed. Given your history and physical findings it is very
unlikely that your symptoms are due to a problem with your brain
or your spinal cord. While you were in the hospital your
symptoms improved but were still persistent. Other possible
causes of your symptoms include migraine or stress reaction. We
expect your symptoms to continue to improve. Please continue
taking you aspirin 81 mg daily along with your other home
medications. Also, we encouraged you to continue smoking-free,
as you've been for the past week. Please follow up with your
PCP ___ ___ weeks.
Followup Instructions:
___
|
10245890-DS-14 | 10,245,890 | 28,831,619 | DS | 14 | 2167-11-14 00:00:00 | 2167-11-15 06:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with pmhx CHF, COPD, CAD, s/p recent pacemaker
placement two weeks ago presenting with acute onset SOB and CP
this morning (___). Pt was awoken from sleep with chest pain
and SOB. He endorses a 4.5 weight gain in the past 3 days.
Brought to the ED via ambulance. In the ED he was given a
medication nitro spray.
In the ED, initial vitals were 98.0. HR: 61 paced. BP: 109/47.
O2: 99% ra. RR? 20. He was tachypnic with abdominal breathing,
+JVD, bilateral rales in lung bases, and 1+ bilateral edema.
There was concern for respiratory distress early, put on BiPAP.
No issues with hypotension.
Labs and imaging significant for cardiomegaly (CXR), elevated
BNP, trop negative x1. Bedside cardiac US performed and deemed
negative for pericardial effusion.
Patient was given 20mg iv lasix. U/O 450cc. Pt felt better after
lasix. Patient given PO lunch/fluids in ED.
On arrival to the floor, patient was tacypneic and short of
breath after transferring to inpatient bed. VS were T 97.6 BP
115/62, HR 87, RR 26, 93% on 2.5L. He was given 20mg IV lasix to
improve diuresis and breathing. He denied chest pain, nause,
anlke edemaa. Of note, he also has a productive cough.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, -Hypertension
2. CARDIAC HISTORY:
-PERCUTANEOUS CORONARY INTERVENTIONS: Cath in ___: Right
dominant, LAD 60%, D1 ostial 60-70%, OM1 40%, RCA 40% with
increased right and left filling pressures
-PACING/ICD: SSS s/p PPM placement (___)
-Chronic atrial fibrillation on coumadin
-Congestive heart failure, EF 50%
-Moderate mitral regurgitation
-Mild mitral stenosis MVA 1.5-2 cm2
-Moderate pulmonary artery hypertension
3. OTHER PAST MEDICAL HISTORY:
-Mild COPD
-Anemia, Hct 33
-Colonic adenoma
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION PE:
VS- T=97.6 BP=115/67 HR=87 RR=26 O2 sat=93 on 2.5L
WEIGH: 64.8 KG
GENERAL- Tachypneic unable to speak within taking a breath
between each sentence. Fatigued. Mood, affect appropriate.
HEENT- NCAT. Sclera anicteric. EOMI grossly.
NECK- Supple with JVP of ___
CARDIAC- PMI located in ___ intercostal space, midclavicular
line. Irregular R, normal S1, S2. No m/r/g. No thrills, lifts.
No S3 or S4.
LUNGS- Kyphosis of chest wall. Resp were labored, some accessory
muscle use. Rales on posterior bases. Otherwise no wheezes or
rhonchi.
ABDOMEN- Soft, NTND.
EXTREMITIES- No edema No femoral bruits.
SKIN- No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES-
Right: DP 2+ ___ 1+
Left: DP 2+ ___ 1+
DISCHARGE PE:
O: 98 122/82 58 18 99% RA
WEIGHT: 61.8 KG
GENERAL- Fatigued, but comfortable, NAD in chair
HEENT- NCAT. Sclera anicteric. EOMI grossly.
NECK- Supple with JVP of 8
CARDIAC- PMI located in ___ intercostal space, midclavicular
line. Irregular R, normal S1, S2. No m/r/g. No thrills, lifts.
No S3 or S4.
LUNGS- Kyphosis of chest wall. Soft crackles at bases
bilaterally.
ABDOMEN- Soft, NTND.
EXTREMITIES- No edema No femoral bruits.
Pertinent Results:
ADMISSION LABS:
___ 06:05AM BLOOD WBC-4.8 RBC-3.24* Hgb-10.9* Hct-33.6*
MCV-104* MCH-33.8* MCHC-32.6 RDW-12.8 Plt Ct-83*
___ 06:05AM BLOOD ___ PTT-48.4* ___
___ 06:05AM BLOOD Glucose-115* UreaN-27* Creat-1.3* Na-140
K-4.1 Cl-100 HCO3-30 AnGap-14
___ 05:55PM BLOOD Calcium-9.0 Phos-2.5* Mg-2.2
___ 06:05AM BLOOD proBNP-2111*
DISCHARGE LABS:
___ 06:55AM BLOOD WBC-4.6 RBC-3.03* Hgb-10.3* Hct-31.5*
MCV-104* MCH-33.9* MCHC-32.6 RDW-13.0 Plt Ct-88*
___ 06:55AM BLOOD ___ PTT-32.1 ___
___ 01:40PM BLOOD Glucose-128* UreaN-40* Creat-1.4* Na-139
K-4.0 Cl-96 HCO3-35* AnGap-12
___ 01:40PM BLOOD Calcium-9.0 Phos-3.2 Mg-2.1
CXR:
IMPRESSION: AP chest compared to ___ at 6:01 a.m.:
Previous mild pulmonary edema has improved, although the extent
of pulmonary vascular congestion is slightly more pronounced
today than it was on ___ indicating that cardiac function
could further improve. Severe cardiomegaly is longstanding.
Pleural effusions are minimal, if any. Transvenous right
ventricular pacer lead in standard placement. No pneumothorax.
Brief Hospital Course:
___ with PMHx s/f CAD, HTN, afib, with recent pacemaker
implanted 2 weeks ago, p/w new onset dyspnea, acute on chronic
CHF exacerbation.
# Acute heart failure exacerbation: Admit weight 64.1 kg and
patient was clinically volume overloaded. Had been switched off
torsemide 40 mg once a day, put back on lasix 40 mg, then noted
a 5 pound weight gain over 4 days. He was diuresed several
liters a day with bolus doses of 20 mg IV lasix, down to 61.8 kg
(135 lbs), which per patient is right at his "dry" weight. His
Cr decreased from 1.3 to 1.1. He was trialed on torsemide 20 mg
once a day, however, his Creatinine increased to 1.3/1.4 on this
dose. He still was putting out adequate urine and maintaining an
even to slightly negative fluid balance. On discharge, he was
clinically euvolemic and it was determined that he would be
discharged on 60 mg PO furosemide. He will weigh himself on a
daily basis, and have his creatinine and electrolytes recheck on
___. His weight on discharge was 61.8 kg. He will
see his PCP in one week for follow-up and Dr. ___ in the heart
failure clinic on ___. We have set up telemonitoring for him
as an outpatient to monitor his daily weights.
# Atrial fibrillation: Patient with very difficult to control
AFib, now s/p pacemaker for sick sinus syndrome. Was admitted
on metoprolol succinate 50 mg BID. He was switched to
metoprolol tartrate 75 mg TID, then transitioned to metoprolol
succinate 250 mg once a day by discharge with adequate rate
control. He has transient increases in HR to the 120s, however,
on the new regimen, was much better rate controlled in the
___. For anticoagulation, his INR was 4.2 on admission. He
also had an episode of BRBPR (see below), was given 2 mg PO VitK
on ___. Once his INR < 2 and bleeding had resolved, he was
restarted on his dose of 2.5 mg once a day. He will have his
INR checked on ___.
# BRBPR/Anemia: Patient had one episode of BRBPR in the setting
of straining with a bowel movement. PE revealed a likely
internal hemorrhoid. His Hct remained stable at his baseline of
___ and he had no further episodes. INR reversed with VitK as
above. He was started on stool softners to limit straining.
# Hyperlipidemia: Continued on statin.
TRANSITIONAL ISSUES:
- INR and electrolytes checked on ___
- CODE STATUS: DNR/DNI (Confirmed)
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Simvastatin 20 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO BID
3. Furosemide 40 mg PO DAILY
4. Warfarin 2.5 mg PO DAILY16
Discharge Medications:
1. Simvastatin 20 mg PO DAILY
2. Warfarin 2.5 mg PO DAILY16
3. Docusate Sodium 100 mg PO BID:PRN constipation
Patient may refuse. Hold if patient has loose stools.
RX *Colace 100 mg 1 Capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
4. Senna 1 TAB PO BID:PRN constipation
RX ___ 8.6 mg 1 tablet by mouth once a day Disp #*30
Capsule Refills:*0
5. Furosemide 60 mg PO DAILY
RX *furosemide 20 mg 3 Tablet(s) by mouth once a day Disp #*90
Capsule Refills:*0
6. Metoprolol Succinate XL 200 mg PO DAILY
RX *metoprolol succinate 200 mg 1 Tablet(s) by mouth once a day
Disp #*30 Capsule Refills:*0
7. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 Tablet(s) by mouth once a day
Disp #*30 Capsule Refills:*0
8. Outpatient Lab Work
Please check INR and Chemistry Panel with Creatinine on ___
and have the results faxed to Dr. ___ ___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Congestive Heart Failure
Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were seen in the hospital because of shortness of breath,
thought to be an exacerbation of your heart failure. We gave
you multiple doses of IV lasix and successfully took fluid off
of you so that your breathing improved. We tried giving you
torsemide, however, your kidney numbers increase, so this was
stopped. We are going to discharge you with 60 milligrams of
furosemide once a day.
You should continue to weigh yourself every morning, call MD if
weight goes up more than 3 lbs. You will need to have your
electrolytes checked on ___. You can start your new
dose of lasix tomorrow morning ___.
We also increased your dose of metoprolol to help better control
your atrial fibrillation. You are now on metoprolol succinate
250 mg once a day and you're rates were well controlled.
It was a pleasure taking care of you during your hospital stay.
Followup Instructions:
___
|
10245890-DS-16 | 10,245,890 | 20,493,994 | DS | 16 | 2168-06-25 00:00:00 | 2168-06-28 15:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right lower extremity swelling, erythema and pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ male with a history of atrial
fibrillation, coronary artery disease, heart failure, rheumatic
heart disease, and SSS s/p PPM who presents with right lower
extremity swelling, pain and erythema. He reports his symptoms
started about 10 days ago shortly after removing his sock and
cutting his right shin with his fingernail. He endorses bleeding
after this initial event that stopped within about a minute of
applying a bandage to the area. Since then, his RLE has been
more red and swollen. He and his wife made the decision to come
in after the area became noticeably more swollen and inflamed
one day PTA. He notes that his LLE is normally more swollen than
the RLE at baseline. A visiting nurse placed ___ silver containing
solution which reportedly dried out his skin significantly and
improved the appearance of the lesion. He denies motor or
sensory changes in his lower extremities. No fevers, chills, CP
or SOB. ROS is positive for constipation and otherwise negative.
Past Medical History:
-Hyperlipidemia
-CAD with Cath in ___: Right dominant, LAD 60%, D1 ostial
60-70%, OM1 40%, RCA 40% with increased right and left filling
pressures
-SSS s/p PPM placement (___)
-Chronic atrial fibrillation on coumadin
-Congestive heart failure, EF >55%
-Moderate mitral regurgitation
-Mild mitral stenosis MVA 1.5-2 cm2
-Moderate pulmonary artery hypertension
-Mild COPD
-Anemia, Hct 33
-Colonic adenoma
Social History:
___
Family History:
Mother with asthma who died at ___. Father deceased at ___.
Physical Exam:
On admission:
VS: 97.8 117/71 77 16 92% ra.
GENERAL: Elderly gentleman, conversant, A/O x3, NAD
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, JVD elevated to 9cm
LUNGS: bibasilar crackles ___ up, occasional wheeze
HEART: irregularly irregular, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: THere is bilateral edema of the feet and ankles
bilaterally, ~2+. The left is more edematous than the right.
There is bright red erythema of the lower right shin with 2 dark
~quarter sized lesions which correspond to history of
hemmorhagic bullae
NEURO: awake, A&Ox3, CNs II-XII grossly intact, moving all
extremities
On discharge:
VS: T:97.8 BP: 99/49 HR:79 O2 95% RA
GENERAL: well appearing and resting with feet elevated up on
bed, conversant.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, JVD at 8cm on today's exam.
LUNGS: bibasilar crackles still about ___ up, occasional wheeze
s
HEART: irregularly irregular, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
Extremities: the lateral border has regressed about 1 to 2 cm.
The area looks less erythematous and swollen and it's not tender
to palpation. There is one quarter sized ceiling area of dried
but healing scab.
NEURO: awake, A&Ox3, CNs II-XII grossly intact, moving all
extremities
Pertinent Results:
ADMISSION LABS:
___ 08:15PM BLOOD WBC-3.7* RBC-3.15* Hgb-10.6* Hct-32.7*
MCV-104* MCH-33.7* MCHC-32.4 RDW-13.1 Plt Ct-99*
___ 08:15PM BLOOD Neuts-56 Bands-0 ___ Monos-9 Eos-2
Baso-0 Atyps-2* ___ Myelos-0 NRBC-1*
___ 08:15PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-2+ Microcy-NORMAL Polychr-NORMAL
___ 08:15PM BLOOD ___ PTT-41.7* ___
___ 08:15PM BLOOD Glucose-98 UreaN-28* Creat-1.0 Na-143
K-3.4 Cl-98 HCO3-32 AnGap-16
___ 08:15PM BLOOD Calcium-8.8 Phos-3.1 Mg-2.2
___ 08:24PM BLOOD Lactate-0.7
DISCHARGE LABS:
___ 07:45AM BLOOD WBC-3.3* RBC-3.28* Hgb-11.2* Hct-34.9*
MCV-106* MCH-34.1* MCHC-32.1 RDW-12.8 Plt ___
___ 07:45AM BLOOD Glucose-114* UreaN-26* Creat-1.1 Na-144
K-3.7 Cl-99 HCO3-38* AnGap-11
___ 07:45AM BLOOD Calcium-9.5 Phos-3.0 Mg-2.2
IMAGING:
___ ___
FINDINGS: There is normal respiratory phasicity in the common
femoral veins bilaterally. There is normal compressibility,
flow, and augmentation of the right common femoral, superficial
femoral, and popliteal veins. Normal flow is demonstrated in
the posterior tibial and deep peroneal veins. IMPRESSION: No
evidence of deep vein thrombosis.
TIB/FIB XR ___
FINDINGS: AP and lateral views of the right tibia/fibula.
There is severe diffuse osteopenia and scattered vascular
calcifications. No fracture, focal lytic or scleroic lesion, or
periosteal new bone formation is identified. There may be mild
diffuse soft tissue swelling. Allowing for overlying artifact,
no subcutaneous emphysema or radio-opaque foreign body is
detected. Tiny density anterior to the distal tibia on the
lateral view, approximately 11.3 cm proximal to the tibial
plafond, is likely a small dystrophic calcification, commonly
seen and of doubtful clinical significance. No knee joint
effusion. Please note that if there were specific concern for a
knee or ankle fracture, then dedicated views of the joint would
be recommended. IMPRESSION: No fracture or subcutaneous
emphysema detected.
CXR ___
PA and lateral upright chest radiographs were reviewed in
comparison to ___. The left-sided pacemaker tip
terminates at the level of the expected location of the right
ventricle. There is diffuse cardiac enlargement involving all
the chambers. There is also hyperinflation demonstrated on both
PA and lateral views. Scarring in the right mid lung is
unchanged. There is no evidence of interstitial pulmonary
edema. There is evidence of pleural thickening at the right
lung base. Assessment of the radiograph along the right heart
border demonstrates increased density that might potentially
represent additional atelectasis but interval development of
abnormality in this location cannot be excluded. Assessment of
the patient with chest CT to exclude the possibility of interval
development of right middle lobe process is required.
Brief Hospital Course:
___ with a PMH of CAD, AF, HF, rheumatic heart disease and SSS
s/p PPM presents with right lower extremity cellulitis.
#Cellulitis: The patient developed cellulitis after a trivial
cutaneous injury. He developed hemorrhagic bullae, likely the
results of a staph or strep infection in the setting of
anticoagulation. Minimal improvement occurred with the
application of a silver containing solution. The patient
presented without acute distress and did not appear systmically
ill. A ___ was performed and showed no DVT. A tib/fib XR
revealed no subcutaneous emphysema or evidence of osteomyelitis.
The patient improved with IV vancomycin and was discharged on
Keflex. Erythema regressed 3-4 cm at all borders prior to
discharge. The suspicion for MRSA was low due to infrequent
hospitalizations. Blood cultures all returned negative.
#Atrial fibrillation: The patient was rate controlled on no
nodal agents. Warfarin was continued at 2.5mg daily. INRs were
subtherapeutic during his hospitalization due to the patient
missing a dose on ___. His dose of warfarin was not
increased due to concurrent antibiotic therapy.
#Heart failure/rheumatic heart disease: The patient's most
recent echo showed characteristic rheumatic valve disease and an
EF >55%. The patient takes torsemide 60mg daily unless there is
a significant change in his weight or swelling at which point it
is increased to 80mg daily. The patient appeared euvolemic on
exam. He was discharged on torsemide 60mg daily.
#Sick sinus syndrome: Stable. The patient is s/p a PPM. No
tachyarrhythmias were noted.
#Coronary artery disease: Stable. The patient was continued on
Imdur 30 mg daily. The patient denied CP and SOB. He is not on
aspirin due to systemic anticoagulation with warfarin.
TRANSITIONAL ISSUES:
*******************
1. PCP follow up within 1 week
2. Next INR to be drawn on ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Gabapentin 100 mg PO TID
3. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
hold for sbp<100
4. Simvastatin 40 mg PO DAILY
5. Torsemide 60 mg PO DAILY Start: In am
hold for sbp<100
6. Warfarin 2.5 mg PO DAILY16
7. Cyanocobalamin 1000 mcg PO DAILY
8. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Cyanocobalamin 1000 mcg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. FoLIC Acid 1 mg PO DAILY
4. Gabapentin 100 mg PO TID
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
hold for sbp<100
6. Simvastatin 40 mg PO DAILY
7. Torsemide 60 mg PO DAILY
hold for sbp<100
8. Warfarin 2.5 mg PO DAILY16
9. Cephalexin 500 mg PO Q8H
RX *cephalexin 500 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*24 Tablet Refills:*0
10. Outpatient Lab Work
Please check CBC, Chem 7, ___ on ___
Fax results to:
Name: ___ MD
Address: ___
Phone: ___
Fax: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
RLE Cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to take care of you at ___
___. You were admitted for a right leg infection. We
treated you with IV antibiotics and you improved. It is safe for
you to go home on oral antibiotics.
Please take your medications as prescribed and follow up with
the appointments listed below. Weigh yourself every morning,
call MD if weight goes up more than 3 lbs. This will help keep
you heart failure in control.
The following changes were made to your medications:
STARTED Keflex (cephalexin)
Followup Instructions:
___
|
10245890-DS-18 | 10,245,890 | 20,960,079 | DS | 18 | 2168-09-16 00:00:00 | 2168-09-16 21:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with severe dCHF, afib on coumadin, PPM, CAD, COPD, severe
MR/TR, peripheral neuropathy and foot drop presents with fever.
Of note, he had a recent admission ___ after a fall. That
admission, CTA showed pulmonary edema and he was treated for
hypoxia with diuresis and ___ home on increased torsamide
dose. Also found to have a minimally displaced clavicular fx. he
was d/ced home with 24 hour supervision and home ___.
This evening, he presented to the ___ with c/o shortness of
breath and fevers. Per the son (present in ___ and has been
living with pt), Mr. ___ has been having fevers up to
101.3 for the past 2 days. Mr. ___ also reports chills and
increased productive cough. He denies any other focal symptom.
No recent sick contacts.
Initial ___ vitals: 60 117/62 24 94%RA, labs showed baseline
pancytopenia, UA clear, INR subtheraputic at 1.6, Chem 7 notable
for bicarb 35 which is his baseline. Pt recieved albuterol and
ipratroprium nebs with improvement in his tachypnea and sats.
per RN notes, also given 1L NS. CXR did not show evidence of
PNA. CTA was negative for PE. there were some ___ minimal
pleural effusions and his baseline huge heart but no pulmonary
edema or congestion. Bedside US was negative for pericardial
effusion.
.
Vitals prior to transfer: 98.4 74 120/70 24 98%
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies chest pain, chest pressure, palpitations. Denies nausea,
vomiting, diarrhea, constipation, abdominal pain, or changes in
bowel habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
-Hyperlipidemia
-CAD with Cath in ___: Right dominant, LAD 60%, D1 ostial
60-70%, OM1 40%, RCA 40% with increased right and left filling
pressures
-SSS s/p PPM placement (___)
-Chronic atrial fibrillation on coumadin
-Congestive heart failure, EF >55%
-Moderate mitral regurgitation
-Mild mitral stenosis MVA 1.5-2 cm2
-Moderate pulmonary artery hypertension
-Mild COPD
-Anemia, Hct 33
-Colonic adenoma
Social History:
___
Family History:
Mother with asthma who died at ___. Father deceased at ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T98.4, BP 138/91, HR 108, RR 32 100%/2L
GENERAL: Dyspneic, using accessory muscles, complains of cold
and chills, elderly. A+OX3, no confusion.
HEENT: NC/AT,PERRLA, sclera anicteric, MMM
NECK: JVD to earlobes, no LAD
LUNGS: Coarse Bi basilar crackles ~ ___ way up the lung fields.
No wheezing.
HEART: RRR, no RG, nl S1-S2, ___ systolic murmur heard at apex
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: no edema, chronic vascular and skin changes on ___
___. Weak DP's. Good radial pulses.
NEURO: awake, A&Ox3, motor ___ throughout, no gross CN deficits.
DISCHARGE PHYSICAL EXAM:
VS: T98.2, BP 121/61, HR77, RR18 96%/2L (91-95% on RA)
GENERAL: elderly male, breathing comfortably, no accessory
muscle use, in NAD
HEENT: NC/AT, PERRL, sclera anicteric, MMM, OP clear
NECK: supple, JVD to angle of jaw, no LAD
HEART: irregular rhythm, no MRG, nl S1-S2
LUNGS: Improved breath sounds bilaterally but still decreased in
bases. Faint expiratory wheezes and few rales in bases.
ABDOMEN: soft, non-tender, non-distended, no rebound or
guarding, +BS
EXTREMITIES: no edema, ___ chronic skin changes. diminished
DP's. 2+ radial pulses.
NEURO: awake, A&Ox3, no gross CN deficits.
Pertinent Results:
___ 10:13PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 10:13PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 10:13PM URINE RBC-5* WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 10:13PM URINE MUCOUS-RARE
___ 07:24PM LACTATE-0.9
___ 07:18PM GLUCOSE-117* UREA N-41* CREAT-1.2 SODIUM-139
POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-35* ANION GAP-12
___ 07:18PM estGFR-Using this
___ 07:18PM CALCIUM-9.0 PHOSPHATE-2.9 MAGNESIUM-2.4
___ 07:18PM WBC-3.2* RBC-3.30* HGB-10.9* HCT-33.6*
MCV-102* MCH-33.1* MCHC-32.5 RDW-13.3
___ 07:18PM NEUTS-70 BANDS-0 LYMPHS-16* MONOS-11 EOS-0
BASOS-1 ATYPS-2* ___ MYELOS-0
___ 07:18PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
___ 07:18PM PLT SMR-LOW PLT COUNT-116*
___ 07:18PM ___ PTT-40.9* ___
CTA Chest (___):
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic syndrome.
2. 14 mm left upper lobe solid pulmonary nodule for which
followup with PET-CT is recommended to exclude primary
malignancy, if desired clinically.
3. Massively enlarged heart with severe atherosclerotic disease
of the
coronary arteries, aortic valve and thoracic aorta with a small
pericardial effusion unchanged from ___.
4. Bibasilar changes of chronic aspiration with small bilateral
pleural
effusions.
5. Bronchial wall thickening and bronchiectasis possibly related
to chronic bronchitis.
Brief Hospital Course:
___ with severe dCHF, afib on coumadin, PPM, CAD, COPD, severe
MR/TR, peripheral neuropathy and foot drop presents with report
of fever to 101.3 at home, SOB and tachypnea concern for
infectious pulmonary process.
# SOB: Pt with reported fevers, pancyopenia, and worsening SOB.
DDx includes pulmonary infection vs COPD exacerbation vs ACS vs
dCHF. Patient has severe CHF but no signs of fluid overload on
CTA and weights have been stable (currently 126 down from 132).
BNP is elevated to 1592 but not significantly from baseline in
the low 1000 range. Could still have SOB from elevated filling
pressures. He has increased productive cough with sputum
production so likely infection also with recent infectious
exposure to son with URI. CTA did not show signs of pneumonia.
CK-MB and troponin not significantly elevated so unlikely ACS
and no chest pain. Given pancytopenia and productive cough he
was treat for PNA initially with vanc, zosyn, albuterol and
ipatropium nebs. A respiratory viral screen was negative. Blood
and urine cultures with no growth to date. Pt SOB improved with
this therapy, with O2 sats in low to mid 90's on RA but he
desaturated to low 80's on ambulation. He will require home O2
which was arranged prior to discharge. He was also set up with a
home nebulizer for albuterol and ipratropium. He was
transitioned to levofloxacin to finish his antibiotic therapy as
an outpatient.
# Fever: Per history, none recorded in house. Pt says his
baseline temp is 96.0 and anything above 98.0 is a fever for
him. UA unremarkable. Patient has chronic pancytopenia with
macrocytosis suggestive of MDS and is thus likely immune
suppressed so may not be able to mount significant fever or
leukocytosis. Given his poor clinical condition, chills, immune
supressed state, reported high fever at home and recent
hospitalization he was treated with abx as above.
#Weakness: Pt was very weak on admission which was likely from
current illness and deconditioning in this setting. This mildly
improved with nutritional supplements ensure and ___. It was
recommended that patient go to ___ rehab given his
deconditioned state but he declined and opted for home ___. This
was discussed with geriatrics team who feel he has adequate
supportive care in place at home.
# Afib on coumadin: Not on any nodal agents currently but HR in
the ___. CHADS2 score is 3 and has been on coumadin. INR
subtherapeutic at 1.6 on admission. Given no prior Hx of CVA,
will hold off on bridging. He was continued on warfarin and INR
on discharge was 2.3 with a goal INR of 1.9-2.5 given prior
thigh hematomas while on anticoagulation. Since he was
discharged on levofloxacin he was discharged on a warfarin dose
of 2.5mg daily and will have INR checked next on ___ and
followed by ___ clinic.
Chronic Issues:
# Pancytopenia: All counts at baselines. Pt is on B12
supplementation, although B12 720 when last checked ___
(folate was > assay). Potentially has underlying MDS given
macrocytic MCV and age. Pt not neutropenic, but has been
relatively lymphopenia. Consider outpatient workup.
# Sick sinus syndrome s/p PPM. Pt was monitored on tele with no
acute events.
# CAD: Stable. We continued home Imdur 30mg daily and
simvastatin 40 mg PO DAILY. Pt not currently on aspirin or
beta-blocker.
# HLD: we continued simvastatin 40 mg PO DAILY.
# ___ pain: We continued home dose of gabapentin.
# COMMUNICATION: Son/daughter in law: ___
# CODE STATUS: DNR/DNI, confirmed
Transitional Issues:
1. 14 mm left upper lobe solid pulmonary nodule for which
followup with PET-CT is recommended to exclude primary
malignancy, if desired clinically.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyanocobalamin 1000 mcg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. FoLIC Acid 1 mg PO DAILY
4. Gabapentin 200 mg PO TID
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
hold for SBP < 100
6. Simvastatin 40 mg PO DAILY
7. Warfarin 5 mg PO 3X/WEEK (___)
8. Warfarin 2.5 mg PO 4X/WEEK (___)
9. Acetaminophen 650 mg PO Q6H:PRN pain
10. Torsemide 80 mg PO DAILY
hold for SBP < 100
11. traZODONE 25 mg PO HS:PRN sleep
12. Potassium Chloride 20 mEq PO DAILY
Hold for K > 4.5
Discharge Medications:
1. Home O2
2L vis NC with ambulation only for Sats of 80-85%
On 2L Pt recovers to 91-96%
RA sat 90%
pulse dose for portability
Dx: COPD
2. Nebulizer
nebulizer and accesories
Dx: COPD
3. Acetaminophen 650 mg PO Q6H:PRN pain
4. Cyanocobalamin 1000 mcg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. FoLIC Acid 1 mg PO DAILY
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
8. Potassium Chloride 20 mEq PO DAILY
9. Simvastatin 40 mg PO DAILY
10. Torsemide 80 mg PO DAILY
11. traZODONE 50 mg PO HS:PRN insomnia
RX *trazodone 50 mg 1 tablet(s) by mouth HS:PRN insomnia Disp
#*30 Tablet Refills:*0
12. Ipratropium Bromide Neb 1 NEB IH Q6H
RX *ipratropium bromide 0.2 mg/mL (0.02 %) 2.5 mL IH every six
(6) hours Disp #*84 Cartridge Refills:*0
13. Levofloxacin 750 mg PO Q48H Duration: 4 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth Q48H Disp #*2
Tablet Refills:*0
14. Gabapentin 200 mg PO TID
15. Warfarin 2.5 mg PO DAILY16
RX *warfarin [Coumadin] 2.5 mg 1 tablet(s) by mouth Daily16 Disp
#*30 Tablet Refills:*0
16. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing or SOB
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 3 ml IH 1 NEB
Q4H:PRN wheezing or SOB Disp #*84 Cartridge Refills:*0
17. Outpatient Lab Work
Please have your INR drawn on ___ and have results faxed to
___ clinic.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pneumonia
COPD exacerbation
Weakness
Chronic:
atrial fibrillation
Pancytopenia
CAD
HLD
chronic dCHF
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___. You came to the
hospital because you were having fevers, cough and chills. We
found that you likely have a pneumonia and COPD exacerbation. We
treated you with antibiotics and your symptoms improved. You
will need to use oxygen at home when you ambulate until your
infection improves and your doctor evaluates your oxygen
saturations at your next appointment.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10245890-DS-22 | 10,245,890 | 25,690,189 | DS | 22 | 2170-01-01 00:00:00 | 2170-01-01 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:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with history of diastolic CHF, A. fib (off
coumadin since ___ discharge), pulmonary hypertension, COPD on
home oxygen presenting with worsening dyspnea over past several
days. He was recently discharged on ___ after being treated for
CHF exacerbation. He has had gradual onset shortness of breath
over the last several days. He usually requires 2L O2 at home
for sleep but recently has required 2L O2 all day. He denies any
fevers or chills (temperature recorded as 99.6 at home). No
cough. No chest pain. Mild increased leg swelling. Dry weight on
discharge on ___. Weight today 55.7.
In the ED, initial vitals were temp: 98.2F, Pulse: 61, RR: 22,
BP: 113/54, O2 sat: 97% on 2L nasal cannula.
Labs were significant for proBNP 1491, troponins <0.01, BUN 31,
Cr 0.9, K 3.5, D-dimer 2311.
CXR was significant for stable massive cardiomegaly and
worsening opacities at the lung base on the lateral radiograph
that may reflect pulmonary edema or pneumonia.
Additionally in the ED, D-dimer orderd by mistake but given
elevation significant, will got CTA chest which was negative for
PE.
He received morphine 2mg IV, warfarin 3mg, torsemide 60mg PO,
isosorbide omperazole 40mg. Patient's son gave home meds while
in ED-- omeprazole 40mg and lorazepam 0.5mg.
He was admitted for concern for CHF exacerbation, and increasing
O2 requirement.
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, 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,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
CARDIAC HISTORY:
- CAD with Cath in ___: Right dominant, LAD 60%, D1 ostial
60-70%, OM1 40%, RCA 40% with increased right and left filling
pressures
- SSS s/p PPM placement (___)
- Hyperlipidemia
- Chronic atrial fibrillation on warfarin
- Congestive heart failure, EF >55% (dry weight ~130 lbs)
- Moderate-severe mitral regurgitation
- Moderate-severe tricuspid regurgitation
- Mild mitral stenosis MVA 1.5-2 cm2
- Moderate pulmonary artery hypertension
OTHER PAST MEDICAL HISTORY:
- Mild COPD, on home O2
- Anemia, Hct 33
- Colonic adenoma
- PERIPHERAL NEUROPATHY
- LEFT FOOT DROP
- RENAL CYST
- PULMONARY NODULE
- Gout (on allopurinol)
- Dysphagia ("narrowing" found on video swallow at previous
rehab stay). SLP recommendations in last discharge summary ___
- H/O CLAVICULAR FRACTURE
- s/p bilateral inguinal hernia repair
- s/p left hip fracture fixation (___)
Social History:
___
Family History:
Mother with asthma who died at ___. Father deceased at ___.
Physical Exam:
PHYSICAL EXAM ON ADMISSION (___):
VS:T 98.6 BP 113/60 HR 58 RR 16 O2 sat 97% on 2L
wt= 55.7kg on admission
GENERAL: frail-appearing older gentleman, sitting comfortably in
bed, speaking in full sentences.
NECK: nontender supple neck, no LAD, JVD 8-10 cm
CARDIAC: irregular rate, holosystolic murmur over mitral region.
LUNG: crackles bilaterally in middle and lower lobes, breathing
without use of accessory muscles. no wheezing
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: trace pedal edema below knees. moving all
extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
Pertinent Results:
___ 05:40AM BLOOD WBC-3.8* RBC-2.96* Hgb-10.1* Hct-31.3*
MCV-106* MCH-34.2* MCHC-32.3 RDW-14.1 Plt ___
___ 05:40AM BLOOD Neuts-51.7 ___ Monos-7.2 Eos-5.5*
Baso-0.6
___ 05:40AM BLOOD ___ PTT-40.7* ___
___ 05:40AM BLOOD Plt ___
___ 05:40AM BLOOD Glucose-96 UreaN-31* Creat-0.9 Na-136
K-3.5 Cl-96 HCO3-31 AnGap-13
___ 05:40AM BLOOD cTropnT-<0.01
___ 05:40AM BLOOD proBNP-1491*
___ 05:40AM BLOOD D-Dimer-2311*
___ 05:52AM BLOOD Lactate-0.8
Brief Hospital Course:
Mr. ___ is a ___ male with a history of diastolic
CHF, A. fib (off coumadin since ___ discharge for elevated
INR), CAD, SSS s/p PPM placement (___), pulmonary
hypertension, COPD on home oxygen, recent admission at ___ for
dyspnea treated as CHF exacerbation (___), who presented
with worsening shortness of breath over the last ___ days,
consistent with CHF exacerbation.
# Congestive Heart Failure: Patient presented with shortness of
breath, jugular veinous distention and crackles on exam, with
3.5kg weight gain since previous discharge on ___. He had
trace pedal edema. This was most consistent with CHF
exacerbation. Pneumonia, COPD exacerbation, and pulmonary
embolism were considered unlikely. He had an echocardiogram on
___ that showed worsening ejection fraction, and 3+MR, 2+TR
(now 40-45% down from 55% in ___ and severe mitral
regurgitation, moderate to severe tricuspid regurgitation
(similar to ___ echocardiogram). He was diuresed with 60mg
torsemide PO and 60mg furosemide IV on ___, 60mg furosemide x2
on ___, and 60mg torsemide PO on ___, with a total body
balance of negative ___ liters per day. His shortness of breath
improved. He had hypokalemia following IV diuresis, which
resolved with K administration. Isosorbide Mononitrate (Extended
Release) 30 mg PO DAILY was continued.
# Atrial fibrillation: Patient was in atrial fibrillation
throughout this admission, with rates ___. He remained
asymptomatic. At home, he was on 5mg ___, 2.5mg ___.
He was continued on the lower dose 2.5mg QDaily with INRs
ranging from 2.8-2.2. Discharged on home dose of 5mg five days a
week and 2.5mg ___, with follow up with PCP within one week
to reassess.
# COPD: Patient is on 2L NC at home. He did not have wheezing
on exam during hospital stay. He required 1.5-2L oxygen by
nasal cannula, with occasional ipratropium and albuterol
nebulizers.
# Dysphagia: Patient has had dysphagia chronically and is on
omeprazole 40 mg PO Daily and lorazepam 0.5mg BID at home for
this issue, which were continued during hospital stay. He had
an extensive workup on previous admission. A barium swallow on
___ showed no mass or stricture. Recommendations from speech
and swallow from previous admission were implemented:
1. PO Diet: Thin liquids, regular solids
2. Pills whole, one at a time, with thin liquids
3. Standard aspiration precautions
4. Alternate liquids and solids
# Anemia: Patient has a macrocytic anemia at baseline.
Hemoglobin/hematocrit were stable throughout admission (range
10.1-10.7/30.7-32.7 with MCV 104-107 and normal RDW). B12 and
folate were continued. Continued Cyanocobalamin 1000 mcg PO
DAILY.
Continued FoLIC Acid 1 mg PO DAILY.
# Back pain: Stable. Home oxycodone 2.5mg Q4hr was continued
as needed.
# Gout: Stable. Home allopurinol ___ QDaily was continued.
TRANSITIONAL ISSUES:
===================================
[]Will need to follow up at heart failure clinic for adjustment
of diuretics.
[]He will need his visiting nurse to assist with medication
adherance. He has been having difficulty remembering his
medications and doses. Family states he used to be able to
manage these himself but he has had multiple recent admissions
and he would benefit from close assistance with this. Called ___
and son ___ on ___ prior to discharge and spoke to both
extensively about medication changes and this issue.
[]Regarding warfarin: Patient has goal 1.9-2.5 documented
because of previous spontaneous bleed. He states that he has
been taking 3mg daily prior to this admission, however records
show that he is prescribed 5mg five days per
week(SunMonTueWedThur) and 2.5mg two days per week (___). We
are discharging him on warfarin 2.5mg but he should have INR
drawn ___ and follow up with his PCP ___ for clarification
and adjustment of dose.
[] Please follow up CBC for anemia and thrombocytopenia.
# CODE: DNR/DNI, confirmed with son and patient ___.
# CONTACT: Patient, son ___ home number: ___
Cell phone: ___. Wife ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Calcium Carbonate 500 mg PO TID
4. Cyanocobalamin 1000 mcg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. FoLIC Acid 1 mg PO DAILY
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
8. Omeprazole 40 mg PO DAILY
9. Lorazepam 0.5 mg PO BID
10. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain
11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
12. Senna 8.6 mg PO BID
13. TraZODone 100 mg PO HS:PRN insomnia
14. Vitamin D 800 UNIT PO DAILY
15. Potassium Chloride 40 mEq PO DAILY
16. Warfarin 5 mg PO 5X/WEEK (___)
17. Warfarin 2.5 mg PO 2X/WEEK (FR,SA)
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Calcium Carbonate 500 mg PO TID
4. Cyanocobalamin 1000 mcg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. FoLIC Acid 1 mg PO DAILY
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
8. Lorazepam 0.5 mg PO BID
9. Omeprazole 40 mg PO DAILY
10. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain
11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
12. Potassium Chloride 40 mEq PO DAILY
13. Senna 8.6 mg PO BID
14. TraZODone 100 mg PO HS:PRN insomnia
15. Vitamin D 800 UNIT PO DAILY
16. Spironolactone 12.5 mg PO DAILY
RX *spironolactone [Aldactone] 25 mg 0.5 (One half) tablet(s) by
mouth daily Disp #*16 Tablet Refills:*0
17. Torsemide 60 mg PO DAILY
RX *torsemide [Demadex] 20 mg 3 tablet(s) by mouth daily Disp
#*90 Tablet Refills:*0
18. Warfarin 2.5 mg PO DAILY16
RX *warfarin [Coumadin] 2.5 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
diastolic congestive heart failure
atrial fibrillation
hyperlipidemia
Secondary diagnosis:
COPD
gout
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 Mr. ___,
It was a pleasure to take care of you. You were admitted to the
hospital because you were having difficulty breathing. We found
that you were retaining extra fluid in your lungs and in the
rest of you body. We gave you diuretics and you urinated the
extra fluid out until you were back at your usual weight. You
also had some problems with you swallowing and we continued
-You should continue to take your medications, following the new
updated medication list we have given you. Please ensure that
your visiting nurse and/or your family helps you with the
medications so that you do not miss any important doses.
-You should go to your appointment at the heart failure clinic
next week. They will examine you and adjust your medicaitons if
you need this.
-Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10245890-DS-24 | 10,245,890 | 25,890,425 | DS | 24 | 2170-02-05 00:00:00 | 2170-02-05 16:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o heart failure with preserved EF (LVEF 40-45%,
severe MR/TR), afib on coumadin, pulmonary HTN, and COPD who
presented with one day of dyspnea. He was most recently admitted
to the ___ from ___ to ___ over concern for a fever
and possible infection, although workup did not find a source of
infection. During his admission, his CHF was considered to be
stable. Several days ago, the patient reports a mechanical fall
and reports hip and back pain. He uses a cane at home and was
able to ambulate afterward. He denies head trauma, neck, or
spine pain. The morning of admission ___, the patient
developed dyspnea. He was found to have sats in the ___ by EMS,
which increased to 97% on 4L. His dyspnea is associated with
fevers, chills, and a productive cough. He denies chest pain or
palpitations.
Past Medical History:
CARDIAC HISTORY:
- CAD with Cath in ___: Right dominant, LAD 60%, D1 ostial
60-70%, OM1 40%, RCA 40% with increased right and left filling
pressures
- SSS s/p PPM placement (___)
- Hyperlipidemia
- Chronic atrial fibrillation on warfarin
- Congestive heart failure, EF >55% (dry weight ~130 lbs)
- Moderate-severe mitral regurgitation
- Moderate-severe tricuspid regurgitation
- Mild mitral stenosis MVA 1.5-2 cm2
- Moderate pulmonary artery hypertension
OTHER PAST MEDICAL HISTORY:
- Mild COPD, on home O2
- Anemia, Hct 33
- Colonic adenoma
- PERIPHERAL NEUROPATHY
- LEFT FOOT DROP
- RENAL CYST
- PULMONARY NODULE
- Gout (on allopurinol)
- Dysphagia ("narrowing" found on video swallow at previous
rehab stay). SLP recommendations in last discharge summary ___
- H/O CLAVICULAR FRACTURE
- s/p bilateral inguinal hernia repair
- s/p left hip fracture fixation (___)
Social History:
___
Family History:
Mother with asthma who died at ___. Father deceased at ___.
Physical Exam:
ON ADMISSION:
Vitals: 98.1, 124/87, 80, 20, 98% on 3L.
General: Alert, oriented, no acute distress; temporal wasting,
extremely gaunt
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated
CV: Irregular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Bibasilar crackles bilaterally up to mid lung fields.
Abdomen: Soft, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding. Mildly tender
throughout, which he attributes to constipation.
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro: CNII-XII grossly intact
ON DISCHARGE:
Vitals: 98, 117, 41, 73, 22, 96% on 3L.
Standing weight 53.5 kg
I/O: pMN 600/100, 24hr 1500/150
General: Alert, oriented, no acute distress; temporal wasting,
extremely gaunt
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated
CV: Irregular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Bibasilar crackles. No wheezes or rhonchi.
Abdomen: Soft, non-distended, bowel sounds present.Non-tender.
No organomegaly, no rebound or guarding.
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro: CNII-XII grossly intact
Pertinent Results:
ON ADMISSION
___ 06:45AM BLOOD WBC-5.6 RBC-3.24* Hgb-10.6* Hct-32.8*
MCV-101* MCH-32.7* MCHC-32.3 RDW-13.2 Plt ___
___ 06:45AM BLOOD Neuts-57.4 ___ Monos-7.3 Eos-4.8*
Baso-0.4
___ 04:00PM BLOOD ___
___ 04:00PM BLOOD Glucose-135* UreaN-40* Creat-1.5* Na-138
K-4.0 Cl-98 HCO3-33* AnGap-11
___ 04:00PM BLOOD Calcium-8.7 Phos-3.5 Mg-1.9
___ 08:27AM BLOOD Lactate-1.1
ON DISCHARGE
___ 07:30AM BLOOD WBC-4.3 RBC-2.84* Hgb-9.6* Hct-28.9*
MCV-102* MCH-33.8* MCHC-33.3 RDW-13.6 Plt ___
___ 07:00AM BLOOD ___ PTT-37.3* ___
___ 07:00AM BLOOD Glucose-110* UreaN-60* Creat-1.4* Na-135
K-4.2 Cl-96 HCO3-33* AnGap-10
___ 07:00AM BLOOD Calcium-8.0* Phos-3.9 Mg-2.0
Imaging
CXR ___
Massive cardiomegaly is unchanged. A single lead pacemaker is
present, with the lead ending in the right ventricle. There is
mild pulmonary edema. No focal consolidation to suggest
pneumonia. No pneumothorax or large pleural effusion.
IMPRESSION:
1. Mild pulmonary edema.
2. Stable massive cardiomegaly.
NOTIFICATION: Impression point number 1 was discussed with Dr.
___ By Dr. ___ telephone at 9:53am on ___, 120
minutes after discovery.
___
There is significant cardiomegaly with what appears to be
significant atrial enlargement suggesting possible mitral valve
disease. There is some pulmonary hyperinflation seen. There is a
small right-sided effusion. PA pulmonary edema at this stage is
minimal. Left-sided pacemaker is in situ and
IMPRESSION:
No significant pulmonary edema.
Brief Hospital Course:
___ yo man with heart failure with preserved EF (LVEF 40-45%,
severe MR/TR), afib on warfarin, pulm HTN, COPD (on home 2- 2.5L
oxygen) presented with a day of dyspnea and found to have CHF
exacerbation.
# acute CHF exacerbation: found to have an elevated BNP and
slight volume overload with mild pulmonary edema consistent
with CHF exacerbation. He was diuresed with 60 mg IV Lasix. He
was likely overdiuresed with his initial lasix as he had ___
with a Cr peak to 1.8 from 1.1. He was given IV fluids, and his
Cr downtrended to 1.4 by discharge. A repeat CXR showed
resolution of the pulmonary edema. He was continued on his home
O2 of ___ with good sats. His torsemide was held on discharge.
He was given a script to have his Cr checked and faxed to
cardiology who will adjust his torsemide as needed. A goals of
care discussion was had with his son and HCP. The patient will
be discharged to home with hospice. If the patient is short of
breath or has an increase in weight (his weight on discharge is
53.5 kg or 117.7 lbs), a plan is in place for him to contact
hospice, which will provide symptomatic treatment.
# Hypotension: After the patient was diuresed with IV lasix, he
became hypotensive with BPs to 70/40. He did not have evidence
of cardiogenic shock. The hypotension was thought to be
iatrogenic, not due to primary pump failure. Cardiology/CHF
service was consulted, and home spironolactone and imdur were
held. His home torsemide was also held as above. His blood
pressures were 100s/40s-50s by time of discharge.
# ___: Following initial diuresis with 60 mg IV Lasix, his Cr
bumped from 1.1 to a peak of 1.8. This was thought to be
iatrogenic from overdiuresis and poor forward flow. Diuretics
were held, and he was given IV fluids. His Cr improved to 1.4 by
time of discharge. His torsemide was held on discharge. He was
given a script to have his Cr checked and faxed to cardiology
who will adjust his torsemide as needed.
#Neuropathy: Continues to have burning leg pain radiating from
back down lower bilateral legs, which was previously documented
in discharge summary. This was thought to be due to neuropathic
pain possibly related to back pain. He was seen by neurology,
Dr. ___ year ago, for a similar problem. He was started
on Lyrica and has outpatient neurology follow up.
# Atrial fibrillation: Warfarin was held on admission given
supratherapeutic INR 3.3. It was restartd on ___ with 3 mg
daily. He should have his INR checked on ___ and adjusted for
goal ofn ___. Pt's son would like to continue coumadin and
couamdin monitoring a this time.
# COPD: Patient is on ___ NC at home but not on any home
COPD meds. No evidence of exacerbation.
# Back pain: chronic. Started on liquid oxycodone and continued
home tylenol regimen.
# Constipation: He presented with no BM x 5 days. Bowel regimen
was escalated with standing senna, Colace, miralax, and
lactulose 15mg x 1 with resolution of the constipation.
# Insomnia: Continued home trazodone. Benadryl and Ambien not
given despite sons request given risk of delirium in geriatric
population. Pt was started on Seroquel 25 PO QD QHS with good
effect with discharge scripts for Seroquel.
# Anemia: Chronic. Patient has a macrocytic anemia at baseline.
Continued on home B12 and folic acid.
# Gout: Chronic. Continued on allopurinol ___ daily.
Transitional Issues
1. Patient discharged on home hospice; hospice will management
symptomatic heart failure with IM furosemide as needed and
liquid oxycodone
2. Torsemide held on discharge given ___. should have repeat Cr
checked on ___ resume torsemide if Cr. back at baseline
3. Pt is DNR/DNI
36 minutes was spent on examining the patient, discussing
discharge plan with the family and arranging discharge to home
with home hospice.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Calcium Carbonate 500 mg PO TID
4. Cyanocobalamin 1000 mcg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. FoLIC Acid 1 mg PO DAILY
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
8. Lorazepam 0.5 mg PO BID
9. Omeprazole 40 mg PO DAILY
10. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain
11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
12. Potassium Chloride 40 mEq PO DAILY
13. Senna 8.6 mg PO BID
14. Spironolactone 12.5 mg PO DAILY
15. Torsemide 60 mg PO DAILY
16. TraZODone 100 mg PO HS:PRN insomnia
17. Warfarin 2.5 mg PO DAILY16
18. Warfarin 5 mg PO 5X/WEEK (___)
19. Vitamin D 800 UNIT PO DAILY
Discharge Medications:
1. Pregabalin 75 mg PO BID
2. Allopurinol ___ mg PO DAILY
3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
4. Calcium Carbonate 500 mg PO TID
5. Cyanocobalamin 1000 mcg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. FoLIC Acid 1 mg PO DAILY
8. Lorazepam 0.5 mg PO BID
9. Omeprazole 40 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
11. Senna 8.6 mg PO BID
12. TraZODone 100 mg PO HS:PRN insomnia
13. Vitamin D 800 UNIT PO DAILY
14. Warfarin 2 mg PO 2X/WEEK (MO,FR)
15. Warfarin 3 mg PO 5X/WEEK (___)
16. QUEtiapine Fumarate 25 mg PO QHS PRN insomnia
RX *quetiapine 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
17. Potassium Chloride 40 mEq PO DAILY
18. Outpatient Lab Work
Please check chem 7 on ___ and fax results to ___,
NP at ___
ICD9: 584.9
19. oxyCODONE 20 mg/mL oral ___ mg pain or dyspnea
RX *oxycodone 20 mg/mL ___ mL by mouth q1H Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
acute diastolic CHF exacerbation
Acute Kidney Injury
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 to take care of you at the ___
___. You were admitted for shortness of
breath, which was thought to be due to a congestive heart
failure (CHF) exacerbation. We gave you medication to help
remove some of the fluid from your lungs. We repeated a CXR
which showed the the fluid was removed.
Your kidney function became slighly elevated when we gave you
the water pill and improved with some fluids.
During your stay, your blood pressure dropped, and the
cardiolgogists recommended that we discontinue your aldactone
and imdur for now.
We also started your on a new medication ( Lyrica) for the
neuropathy in your legs. This medication may need to be adjusted
by your primary care doctor and when you have follow up with the
neurologist next week.
We also discussed goal of care with you and your son, and at
this time your family would like to focuse on comfort. You will
be discharged with home hospice. The doctors at ___ be
able to managed most of your symptoms so that you do not have to
come back to the hospital.
Please take your discharge medications as prescribed and follow
up with your PCP. Weigh yourself every morning, call your
cardiolgist if your weight goes up more than 3 lbs.
Your dry weight is 53.5 kg ( 117.7 lbs)
We wish you the best.
- Your ___ Team
Followup Instructions:
___
|
10245923-DS-14 | 10,245,923 | 25,559,531 | DS | 14 | 2121-10-06 00:00:00 | 2121-10-06 20:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Benadryl / Compazine / Hizentra / Imitrex / Maxalt / Percocet /
Percocet / Triptans-5-HT1 Antimigraine Agents / Vicodin / Latex,
Natural Rubber / Synvisc / Ventolin HFA
Attending: ___.
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
___ FLEXIBLE AND RIGID BRONCHOSCOPY, TRACHEOSTOMY REVISION,
___ CANNULA PLACEMENT
History of Present Illness:
___ female past medical history significant for IDDM,
quadricuspid aortic valve status post bioprosthetic replacement
not on anticoagulation, severe asthma requiring intubations and
now with tracheostomy, OSA, VCD, and TBM presenting to the
emergency department with hemoptysis. Patient had one episode
morning of presentation, none since. She was scheduled for
bronchoscopy and stenting at ___ tomorrow, ___, but was
instructed to present today by her outpatient doctors in ___
of
bleeding.
She is from ___ and receives all her care there with
exception of pulmonology. Notably, whe was hospitalized at
___ with asthma exacerbation. She was intubated and
was being assessed for tracheostomy when she was discovered to
have severe AI and underwent biomechanical AVR (not on AC). She
also underwent bronchoscopy which, per report, showed 80%
dynamic
collapse of the trachea. She had a tracheostomy placed. More
recently, she was hospitalized and dx with PNA 2 weeks prior at
___, discharged to complete 10 days of augmentin/cipro which
she
completed last week.
On ___, she underwent repeat EMG guided Botox to the vocal fold
adductors in preparation for stenting. Denied issues after
procedure though it appears increased sputum production began
shortly after. She notes increase sputum production and cough
x2
days and the one episode of hemoptysis today. Denies any fevers,
chills, nasal congestion, abdominal pain, N/V, diarrhea or
dysuria.
- In the ED, initial vitals were:
Today 12:35 5 97.7 112 121/71 20 97% RA
- Exam was notable for:
GA: Comfortable
HEENT: No scleral icterus
Cardiovascular: Normal S1, S2, regular rate and rhythm, no
murmurs/rubs/gallops, 2+ peripheral pulses bilaterally
Pulmonary: Diminished breath sounds bilaterally
Abdominal: Soft, nontender, nondistended, no masses
Extremities: No lower leg edema
Integumentary: No rashes noted
MSK: No spinal midline tenderness
- Labs were notable for:
14.1 10.7 281
35.6
137 98 37 299 AGap=20
5.0 19 1.0
pH 7.39 pCO2 35 pO2 87 HCO3 22
___
FluAPCR: Negative
FluBPCR: Negative
- Studies were notable for:
CTA chest
1. No evidence of pulmonary embolism or aortic abnormality.
2. Mild compression fractures of T9 and T10 new as compared to
CTA chest ___.
3. Lower lobe bronchial wall thickening likely representing
chronic bronchial inflammation.
4. Diffuse scattered ground-glass opacities in both lungs which
could be secondary to air trapping
- The patient was given:
___ 13:58 IVF NS
___ 14:06 IV Diazepam 10 mg
___ 14:11 IV CefePIME
___ 15:17 IVF NS 1000 mL
___ 15:17 IV CefePIME 2 g
___ 15:28 IV Vancomycin
___ 15:38 NEB Levalbuterol Neb .63 mg
___ 16:15 TD Lidocaine 5% Patch 1 PTCH
___ 18:00 IV Vancomycin 1000 mg ___
___ 19:24 IV Ketorolac 15 mg
___ 20:00 SC Insulin
___ 20:12 SC Insulin
___ 20:24 IVF LR
___ 21:39 IVF LR 1000 mL
- Thoracics were consulted
REVIEW OF SYSTEMS:
==================
Per HPI, otherwise, 10-point review of systems was within normal
limits.
Past Medical History:
Asthma
Anemia
Arthritis
Chronic back pain
Delayed gastric emptying
Diabetes mellitus
GERD
Giardiasis
HLD
HTN
IBS
Migraine
Obesity
OSA
Paradoxical vocal fold motion disorder
Prepyloric ulcer
Hiatal hernia s/p gastric fundoplication
Knee surgery laparacos
Rectocele repair
spinal fusion
Tonsillectomy
TAH-BSO
Breast reduction surgery
Social History:
___
Family History:
Mother with asthma
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VITALS: 98.0 146 / 81 93 18 99 Ra
GENERAL: Alert and interactive. Able to speak when covering
valve
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. No apparent JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: diminished BS at bases and R > L, no wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. G-tube clamped w/ c/d/I
dressing
EXTREMITIES: No clubbing, cyanosis; trace nonpitting edema to
mid-tibia, Pulses DP/Radial 2+ bilaterally.
SKIN: Warm. No rashes.
NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. ___ strength
throughout. Normal sensation.
DISCHARGE PHYSICAL EXAM:
======================
24 HR Data (last updated ___ @ 1138)
Temp: 98.3 (Tm 98.3), BP: 131/84 (115-147/84-98), HR: 100
(99-113), RR: 18 (___), O2 sat: 95% (95-99), O2 delivery: RA
GENERAL: Alert and interactive.
HEENT: EOMI MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: No increased work of breathing. decreased air movement
b/l. Diminished BS at bases, no wheezes. Coarse breath sounds
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. G-tube clamped w/ c/d/I
dressing
EXTREMITIES: trace pitting edema,
SKIN: Warm. No rashes.
NEUROLOGIC: No focal deficits
Pertinent Results:
ADMISSION LABS:
==============
___ 10:13PM LACTATE-3.8*
___ 08:15PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-TR* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 08:15PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-1
___ 05:33PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 04:45PM GLUCOSE-299* UREA N-37* CREAT-1.0 SODIUM-137
POTASSIUM-5.0 CHLORIDE-98 TOTAL CO2-19* ANION GAP-20*
___ 03:32PM GLUCOSE-262* UREA N-38* CREAT-1.0 SODIUM-139
POTASSIUM-4.8 CHLORIDE-99 TOTAL CO2-19* ANION GAP-21*
___ 02:51PM PO2-87 PCO2-35 PH-7.39 TOTAL CO2-22 BASE
XS--2 INTUBATED-NOT INTUBA
___ 01:48PM ___ PO2-82* PCO2-30* PH-7.42 TOTAL
CO2-20* BASE XS--3
___ 01:48PM LACTATE-6.2*
___ 01:30PM WBC-14.1* RBC-3.81* HGB-10.7* HCT-35.6 MCV-93
MCH-28.1 MCHC-30.1* RDW-18.0* RDWSD-61.7*
___ 01:30PM PLT COUNT-281
___ 01:30PM ___ PTT-UNABLE TO ___
DISCHARGE LABS:
===============
___ 05:31AM BLOOD WBC-12.2* RBC-4.23 Hgb-12.1 Hct-38.7
MCV-92 MCH-28.6 MCHC-31.3* RDW-17.0* RDWSD-56.9* Plt ___
___ 05:31AM BLOOD Glucose-203* UreaN-22* Creat-0.7 Na-137
K-4.8 Cl-97 HCO3-18* AnGap-22*
___ 05:31AM BLOOD Calcium-9.9 Phos-3.5 Mg-2.0
___ 01:18PM BLOOD ___ pO2-91 pCO2-32* pH-7.39
calTCO2-20* Base XS--4 Comment-GREEN TOP
IMAGING:
========
___
Findings: clean, midline stoma placed between ___ rings
Impression: Other diseases of bronchus not elsewhere classified
Plan: -scheduled nebs, CT trachea, ___
___ TRACHEA W/O CONTRAST
IMPRESSION:
1. Nonspecific ground glass opacities in the right lower lobe
are improved
since ___, possibly infectious or inflammatory. There is
diffuse mosaic
attenuation on dynamic expiration sequences compatible with
moderate air
trapping, without evidence of central airway stenosis.
2. Post tracheostomy, aortic valve replacement, hiatal hernia
repair and
cholecystectomy.
3. Mild hepatic steatosis
___ (PORTABLE AP)
IMPRESSION:
There is a tracheostomy tube in place. Postsurgical changes
from aortic valve
replacement are noted. There are low lung volumes. There is no
focal
consolidation, pleural effusion or pneumothorax. Mild
cardiomegaly is
unchanged. No acute osseous abnormalities are identified.
___ (PA & LAT)
INDINGS:
AP upright and lateral views of the chest provided.Tracheostomy
tube projects
over the superior mediastinum. Midline sternotomy wires and
prosthetic aortic
valve are again noted. No focal consolidation is seen to
suggest pneumonia.
No large effusion or pneumothorax. Cardiomediastinal silhouette
appears
stable with mild cardiac enlargement again seen. No free air
below the right
hemidiaphragm. Imaged bony structures are intact.
IMPRESSION:
No signs of pneumonia. Please refer to same-day CT of the chest
for further
details.
___ CHEST
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Mild compression fractures of T9 and T10 new as compared to
CTA chest ___.
3. Bronchial wall thickening most pronounced in the lower lungs
may reflect
infectious or inflammatory process with associated air trapping.
MICROBIOLOGY:
=============
__________________________________________________________
___ 5:41 am URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
__________________________________________________________
___ 7:33 am BRONCHIAL WASHINGS TRACHEALBRONCHEAL WASH.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
PSEUDOMONAS AERUGINOSA. >100,000 CFU/mL.
Susceptibility testing performed on culture # ___
___.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (___).
__________________________________________________________
___ 1:47 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
__________________________________________________________
___ 12:51 am Staph aureus swab Source: Nasal swab.
**FINAL REPORT ___
Staph aureus Preop PCR (Final ___:
S. aureus Negative; MRSA Negative.
(Reference Range-Negative).
Test performed by PCR.
__________________________________________________________
___ 8:15 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
GRAM POSITIVE BACTERIA. 10,000-100,000 CFU/mL.
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
__________________________________________________________
___ 2:40 pm BLOOD CULTURE 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 1:30 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Brief Hospital Course:
TRANSITIONAL ISSUES:
==================
[] Discharge weight: 171.08 lbs
[] Discharge diuretic: torsemide 10mg PO daily, Spironolactone
25mg PO daily
[] Discharge Cr: 0.7
[] Discharged on Ciprofloxacin until ___ for pseudomonas
growing in sputum
[] Started prednisone taper per IP of 5mg per week. Starting
pred 10mg PO daily on ___, plan to continue 5mg until follow up
with outpatient endocrinology
[] Please see below for ___ tube Care Instructions
[] ___ need CPAP at night as had overnight desaturations
[] will need referral to pulmonary rehab
[] QTc 477 (on cipro and fluconazole)
[] For new thoracic compression fractures: Pt started on
calcitonin nasal spray please ensure discontinuation with in 6
months ___ to ___, Pain managed with tylenol ___ PO
TID, cyclobenzaprine and limited dilaudid for breakthrough
[] Pt to continue home ___ for rehabilitation
[] consider repeat dexa scan if needed
[] Consider initiating bisphosphonates
[] Held home lisinopril as was normotensive, consider restarting
if needed
ASSESSMENT AND PLAN:
====================
___ female past medical history significant for IDDM,
quadricuspid aortic valve status post bioprosthetic replacement
not on anticoagulation, severe asthma requiring intubations and
now with tracheostomy, OSA, VCD, and TBM presenting to the
emergency department with cough, increased sputum and hemoptysis
ACUTE/ACTIVE ISSUES:
====================
#Dyspnea
#Cough:
Recent hx of PNA at OSH with sputum culture growing (per pt's
own documentation) 4+ enterococcus, 4+ pseudomonas, 3+ sensitive
staph with enterococcus resistant to augmentin. She had already
been started on Augmentin with addition of ciprofloxacin after
sensitivities returned. completed Augmentin ___ and Cipro ___.
On admission, the patient underwent CTA without PE. There was
bronchial wall thickening and mosaicism c/w air trapping. She
underwent CT trachea that showed GGOs in the RLL and mild air
trapping. Started on vanc/cefepime which was transitioned to
ceftaz then transitioned to oral cipro once sensitivities
returns. Will complete 2 wks of antibiotics will be on cipro
until ___.
#TBM
#Asthma
#VCD:
Complicated hx of severe asthma s/p multiple intubations and now
tracheostomy. s/p FLEXIBLE AND RIGID BRONCHOSCOPY, TRACHEOSTOMY
REVISION, ___ CANNULA PLACEMENT ___. Continued
levalbuterol, ipratropium, luticasone-saleterol diskus BID,
montelukast, mucomyst. PFTs were attempted, however unable to
complete due to leak from trach. 6 minute walk test was
completed. ___ was consulted and recommended home pt. Pt
encouraged to start pulmonary rehab.
Interventional Pulmonary ___ tube Care Instructions:
1. Mucinex ___ by mouth twice a day (take one tablet at 8am,
one tablet at 8 pm)
2. Please use albuterol nebulizer (2.5 mg) nebulizer twice a day
before you use Mucomyst. Please give yourself treatment at 7am
and 7pm.
3. Mucomyst (N-acetylcysteine) 10% solution - you can use this
undiluted. Use 6 to 10 mL of 10% solution until nebulized given
2
times/day. Please give yourself treatment at 7:30am and 7:30pm
(ideally, ___ minutes after you use albuterol nebulizer).
4. Right after nebulizer treatment with Mucomyst, please use
___ of Saline into the cannula, then suction above and below.
5. Please clean the external opening of the cannula with an
extra
LONG Q-tip 50% saline and 50% hydrogen peroxide daily to keep
insertion site clean.
#Back pain: new thoracic compression fractures note on CT. No
new
neuro deficits. Pt with significant steroid exposure so should
get DXA as outpatient if not already done. Pain managed with
tylenol, calcitonin NS, muscle relaxer, home tramadol, and
dilaudid for breakthrough. ___ reviewed.
#Hx weight gain, ___ edema:
Other than recent AVR, unclear cardiac hx. Denies hx of CHF.
Apparently recently started on torsemide and spironolactone with
improvement in edema. Denies worsening dyspnea around this time.
No CP. Continued home torsemide and spironolactone. Reduced
torsemide 10mg on ___ and weight was stable on that dose which
pt was discharged on.
CHRONIC/STABLE ISSUES:
======================
#HTN: Held home lisinopril, discharged OFF, may restart if
needed.
#OSA: previously on CPAP, not while trached
#GERD: continued home pantoprazole BID. Pt also on fluconazole
for candidiasis seen on EMG-guided Botox, pt to complete 2 wk
course.
#Nutrition: had PEG placed when trached initially but now
tolerating PO.
#IDDM: Managed on lantus, prandial, and ISS. DC back on home
insulin regimen.
# CODE: Full
# CONTACT:
Proxy name: ___
Relationship: husband Phone: ___
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluconazole 100 mg PO Q24H
2. Diltiazem Extended-Release 240 mg PO DAILY
3. Montelukast 10 mg PO QHS
4. Spironolactone 25 mg PO DAILY
5. Ranitidine 300 mg PO QHS
6. Pantoprazole 40 mg PO Q12H
7. Fexofenadine 180 mg PO QHS
8. Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 5 Units Dinner
NPH 18 Units Breakfast
NPH 18 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
9. PredniSONE 15 mg PO DAILY
10. Acetylcysteine 20% ___ mL NEB BID
11. Brovana (arformoterol) 15 mcg/2 mL inhalation BID
12. budesonide 1 mg/2 mL inhalation BID
13. Estring (estradiol) 2 mg (7.5 mcg /24 hour) vaginal unknown
14. Ipratropium Bromide Neb 1 NEB IH Q6H
15. Lisinopril 5 mg PO DAILY
16. Torsemide 20 mg PO DAILY
17. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
18. Aspirin-Caffeine-Butalbital 1 CAP PO Q8H:PRN Headache
19. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
20. Naproxen 500 mg PO BID:PRN Pain - Mild
21. Lidocaine 5% Patch 1 PTCH TD QAM
22. Multivitamins W/minerals 1 TAB PO DAILY
23. nystatin 100,000 unit/gram topical BID
24. Levalbuterol Neb 1.25 mg NEB Q4H:PRN wheezing
25. melatonin 3 mg oral QHS:PRN
26. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Calcitonin Salmon 200 UNIT NAS DAILY
RX *calcitonin (salmon) 200 unit/spray 1 spray nasal once a day
Disp #*30 Spray Refills:*0
2. Ciprofloxacin HCl 750 mg PO Q12H
RX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth twice a day
Disp #*19 Tablet Refills:*0
3. Cyclobenzaprine 5 mg PO TID
RX *cyclobenzaprine 5 mg 1 tablet(s) by mouth three times a day
Disp #*60 Tablet Refills:*0
4. GuaiFENesin ER 1200 mg PO Q12H
RX *guaifenesin 1,200 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
5. HYDROmorphone (Dilaudid) 1 mg PO BID:PRN Pain - Moderate
RX *hydromorphone 2 mg 0.5 (One half) tablet(s) by mouth twice a
day Disp #*5 Tablet Refills:*0
6. PredniSONE 10 mg PO DAILY Duration: 7 Doses
Start: After 15 mg DAILY tapered dose
This is dose # 2 of 3 tapered doses
RX *prednisone 10 mg 1 tablet(s) by mouth once a day Disp #*7
Tablet Refills:*0
7. PredniSONE 5 mg PO DAILY Duration: 7 Doses
Start: After 10 mg DAILY tapered dose
This is dose # 3 of 3 tapered doses
RX *prednisone 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
9. Acetaminophen 1000 mg PO Q8H
10. Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 5 Units Dinner
NPH 18 Units Breakfast
NPH 18 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
11. Torsemide 10 mg PO DAILY
RX *torsemide 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
12. Acetylcysteine 20% ___ mL NEB BID
RX *acetylcysteine 100 mg/mL (10 %) ___ twice a day Disp #*30
Vial Refills:*0
13. Brovana (arformoterol) 15 mcg/2 mL inhalation BID
14. Budesonide 1 mg/2 mL inhalation BID
15. Diltiazem Extended-Release 240 mg PO DAILY
16. Estring (estradiol) 2 mg (7.5 mcg /24 hour) vaginal unknown
17. Fexofenadine 180 mg PO QHS
18. Fluconazole 100 mg PO Q24H
19. Levalbuterol Neb 1.25 mg NEB Q4H:PRN wheezing
RX *levalbuterol HCl 1.25 mg/3 mL 1 1.25 mg/3 mL nebulizer four
times a day Disp #*30 Vial Refills:*0
20. Lidocaine 5% Patch 1 PTCH TD QAM
21. melatonin 3 mg oral QHS:PRN
22. Montelukast 10 mg PO QHS
23. Multivitamins W/minerals 1 TAB PO DAILY
24. nystatin 100,000 unit/gram topical BID
25. Pantoprazole 40 mg PO Q12H
26. PredniSONE 15 mg PO DAILY Duration: 1 Dose
Start: Today - ___, First Dose: First Routine
Administration Time
This is dose # 1 of 3 tapered doses
27. Ranitidine 300 mg PO QHS
28. Spironolactone 25 mg PO DAILY
29. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
30. Vitamin D ___ UNIT PO DAILY
31. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do
not restart Lisinopril until instructed by your physician
___:
Home With Service
Facility:
___
Discharge Diagnosis:
tracheobronchomalacia
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 privilege caring for you at ___.
Please see below for more information on your hospitalization.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You had a cough with sputum production
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- You had a CT done to look for blood clots in your lungs, it
revealed new compression fractures of your spine.
- We managed your spine compression fractures with medication
- We started you on antibiotics for a possible pneumonia
- We consulted the interventional pulmonology team to help us
manage your tracheobronchomalacia
- You underwent a bronchoscopy and your tracheostomy was
revised.
- You had PFTs (attempted)and walk test done.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Weigh yourself every morning, seek medical attention if your
weight goes up more than 3 lbs.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath.
It was a pleasure taking part in your care here at ___!
We wish you all the best!
- Your ___ Care Team
Interventional Pulmonary ___ tube Care Instructions:
___
___ (BID #: ___
1. Mucinex ___ by mouth twice a day (take one tablet at 8am,
one tablet at 8 pm)
2. Please use albuterol nebulizer (2.5 mg) nebulizer twice a day
before you use Mucomyst. Please give yourself treatment at 7am
and 7pm.
3. Mucomyst (N-acetylcysteine) 10% solution - you can use this
undiluted. Use 6 to 10 mL of 10% solution until nebulized given
2 times/day. Please give yourself treatment at 7:30am and 7:30pm
(ideally, ___ minutes after you use albuterol nebulizer).
4. Right after nebulizer treatment with Mucomyst, please use
___ of Saline into the cannula, then suction above and below.
5. Please clean the external opening of the cannula with an
extra LONG Q-tip 50% saline and 50% hydrogen peroxide daily to
keep insertion site clean.
Please call the interventional pulmonology office at
___ with any questions or concerns.
Followup Instructions:
___
|
10246110-DS-8 | 10,246,110 | 24,687,010 | DS | 8 | 2157-02-17 00:00:00 | 2157-02-17 18:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
albuterol
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ yo gentleman with PMH significant for afib sp
ablation on aspirin, multiple myeloma on Revlimid who initially
presented to the ED for 3 days of abd pain, with a code stroke
called given new onset right sided seizure.
Per documentation, the patient's wife reports that he had
been complaining of diffuse abd pain for the past 3 days with
decreased PO intake. Around 11pm the wife called the patient's
PCP given concerns for adbominal pain, and the patient was
referred to the ED.
30 minutes after arriving in triage in the ED, the patient
seemed more "confused.". After receiving 5mg of morphine for his
abdominal pain, the patient developed right handed rhythmic
movements which spread to his right arm and leg, though the
patient was still able to converse during this time.
The patient's movements then developed into full body shaking.
He received 2mg of ativan, with his GTC movements lasting
approximately 30 seconds. After his seizure resolved, he was
noted to have decreased right sided movement compared to the
left, and a code stroke was called.
The stroke team evaluated the patient aand did not find any
focal deficits. NCHCT was WNL. His BP in the ED was SBP to 190s
with a UA showing 100 protein and 300 glucose indicating
possible HTN nephropathy. The patient was also started on
Keppra.
Past Medical History:
#Multiple myeloma, s/p XRT to left shoulder and 4 cycles
bortezomib and dexamethasone.
#Atrial fibrillation s/p catheter ablation (not on
anticoagulation since).
Social History:
___
Family History:
His mother had lung cancer but died of cardiovascular disease.
His father is still living. He has two grown children.
Otherwise, no known family history of malignancy.
Physical Exam:
Admission Physical Exam:
Vitals: ___ 95RA
Gen: Pleasant, calm
HEENT: No conjunctival pallor. No icterus. MM dry. OP clear.
LYMPH: No cervical or supraclav LAD
CV: Normocardic, regular. Normal S1,S2. No MRG.
LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, TTP in epigastric region, sightly distended. No
rebound.
EXT: Trace ___ edema and cool feet.
SKIN: radiation burns on lumbar spine.
NEURO: A&Ox3.
DISCHARGE EXAM:
VS: 98.2 122/72 51 16 97 ra
Gen: Pleasant, calm
HEENT: No conjunctival pallor. No icterus. MM dry. OP clear.
LYMPH: No cervical or supraclav LAD
CV: Normocardic, regular. Normal S1,S2. No MRG.
LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, no TTP, no rebound.
EXT: Trace ___ edema and cool feet.
SKIN: radiation burns on lumbar spine. Dissimenatned vesicular
rash in different stages of injury and healing. Worse on face
and upper chest but present on all extremitites. Almost all
crusted. Right forearm has infiltration from FICU that has
erythema and induration.
NEURO: A&Ox3.
Pertinent Results:
Admission Labs:
--------------
___ 05:20PM GLUCOSE-119* UREA N-21* CREAT-1.0 SODIUM-140
POTASSIUM-3.3 CHLORIDE-101 TOTAL CO2-25 ANION GAP-17
___ 05:20PM ALT(SGPT)-77* AST(SGOT)-65* LD(LDH)-390* ALK
PHOS-95 TOT BILI-1.1
___ 05:20PM cTropnT-<0.01
___ 05:20PM TOT PROT-6.4 ALBUMIN-4.5 GLOBULIN-1.9
CALCIUM-8.0* PHOSPHATE-2.5* MAGNESIUM-2.4
___ 05:20PM %HbA1c-5.3 eAG-105
___ 05:20PM TRIGLYCER-145 HDL CHOL-56
___ 05:20PM PEP-HYPOGAMMAG Free K-4.8 Free L-3.0* Fr
K/L-1.57 IgG-305* IgA-30* IgM-41
___ 05:20PM WBC-4.8 RBC-5.06 HGB-16.6 HCT-45.5 MCV-90
MCH-32.9* MCHC-36.5* RDW-14.3
___ 05:20PM NEUTS-71* BANDS-0 LYMPHS-6* MONOS-22* EOS-0
BASOS-0 ATYPS-1* ___ MYELOS-0
___ 05:20PM PLT SMR-LOW PLT COUNT-105*
___ 05:20PM ___ PTT-31.8 ___
___ 05:56AM COMMENTS-GREEN TOP
___ 05:56AM LACTATE-1.7
___ 04:45AM URINE HOURS-RANDOM
___ 04:45AM URINE HOURS-RANDOM
___ 04:45AM URINE GR HOLD-HOLD
___ 04:45AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 04:45AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 04:45AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100
GLUCOSE-300 KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 04:45AM URINE RBC-3* WBC-2 BACTERIA-NONE YEAST-NONE
EPI-0
___ 04:45AM URINE GRANULAR-8* HYALINE-6*
___ 04:45AM URINE MUCOUS-RARE
___ 01:50AM ___ COMMENTS-GREEN TOP
___ 01:50AM LACTATE-3.5*
___ 01:47AM GLUCOSE-144* UREA N-17 CREAT-0.9 SODIUM-136
POTASSIUM-3.2* CHLORIDE-95* TOTAL CO2-20* ANION GAP-24*
___ 01:47AM GLUCOSE-144* UREA N-17 CREAT-0.9 SODIUM-136
POTASSIUM-3.2* CHLORIDE-95* TOTAL CO2-20* ANION GAP-24*
___ 01:47AM estGFR-Using this
___ 01:47AM ALT(SGPT)-53* AST(SGOT)-43* CK(CPK)-71 ALK
PHOS-96 TOT BILI-1.1
___ 01:47AM LIPASE-94*
___ 01:47AM ALBUMIN-4.7 CALCIUM-9.2 PHOSPHATE-1.0*#
MAGNESIUM-1.9
___ 01:47AM TSH-1.4
___ 01:47AM ASA-NEG ETHANOL-NEG ACETMNPHN-6* bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
___ 01:47AM WBC-4.6 RBC-5.00 HGB-16.6 HCT-44.1 MCV-88
MCH-33.2* MCHC-37.6* RDW-14.4
___ 01:47AM NEUTS-71* BANDS-0 LYMPHS-8* MONOS-19* EOS-0
BASOS-0 ATYPS-2* ___ MYELOS-0
___ 01:47AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 01:47AM PLT SMR-LOW PLT COUNT-137*
___ 01:47AM PLT SMR-LOW PLT COUNT-137*
DISCHARGE LABS:
___ 05:43AM BLOOD WBC-2.7* RBC-2.93* Hgb-9.5* Hct-26.1*
MCV-89 MCH-32.3* MCHC-36.3* RDW-14.7 Plt ___
___ 05:43AM BLOOD Glucose-98 UreaN-7 Creat-0.9 Na-141 K-3.7
Cl-105 HCO3-29 AnGap-11
___ 06:08AM BLOOD ALT-39 AST-23 LD(LDH)-161 AlkPhos-254*
TotBili-0.7
___ 05:43AM BLOOD Calcium-7.9* Phos-3.0 Mg-1.9
PERTINENT LABS:
___ 06:05AM BLOOD calTIBC-148* Hapto-312* Ferritn-700*
TRF-114*
___ 01:47AM BLOOD Lipase-94*
___ 03:44AM BLOOD Lipase-408*
___ 03:44AM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-583*
___ 03:30PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
___ 05:30PM BLOOD HIV Ab-NEGATIVE
___ 03:30PM BLOOD HCV Ab-NEGATIVE
___ 04:10PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 Polys-0
___ Macroph-20
___ 04:10PM CEREBROSPINAL FLUID (CSF) TotProt-42 Glucose-58
LD(___)-17
IMAGING:
CXR ___:
No evidence of free air. Expansile lesion within the right
posterior 9th rib and other lytic ribs lesions in keeping with
myeloma, better evaluated on the concurrent CT.
CT HEAD W/O CONTRAST ___: Normal study
CT ABD PELVIS W/O CONTRAST ___: 1. Minimal haziness around
the SMA which could represent an early vasculitis in the correct
clinical setting, followup can be obtained if symptoms persist.
2. Multiple lytic bony lesions with the largest expansile lesion
involving the right posterior ninth rib, all of which have
progressed since ___, consistent
with patient's history of multiple myeloma. 3. Cholelithiasis
without evidence of cholecystitis. 4. Diverticulosis without
evidence of diverticulitis.
MR HEAD W/ CONTRAST ___: 1. Cortical swelling with elevated
T2 signal in bilateral medial parietal lobes, which may be
secondary to seizure activity. However, given the presence of
associated leptomeningeal contrast enhancement, leptomeningeal
malignancy with secondary cortical swelling cannot be excluded.
2. Multiple small areas of high T2 signal in the subcortical
white matter of the cerebral hemispheres with few small
associated foci of contrast enhancement which appears to be
parenchymal. Diagnostic considerations are broad, including
vasogenic edema secondary to leptomeningeal and/or intravascular
malignancy, vasculitis, PRES, viral infection (including PML),
and medication toxicity.
TTE ___: The left atrium is normal in size. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF = 65%). The aortic root is mildly dilated at the sinus
level. The number of aortic ___ leaflets cannot be determined.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve appears structurally Normal with trivial
mitral regurgitation. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. No obvious intracardiac
mass or thrombus seen.
LIVER GB U/S ___: 1. No sonographic evidence of pancreatitis.
2. Nonspecific wall thickening in a gallbladder with stones and
sludge. In the absence of a sonographic ___ sign,
cholecystitis is unlikely. 3. Multiple hepatic cysts.
POSTIVE MICRO: VZV PCR +VE IN CSF
Brief Hospital Course:
___ yo man with ___ significant for afib sp ablation on aspirin
and kappa light chain multiple myeloma on Revlimid who presented
to the ED for 3 days of abd pain concerning for pancreatitis,
Code stroke was called after new onset of right sided seizure
which resolved. Course was c/b afib with RVR. Transferred to ICU
where controlled with dilt gtt and stabilized on po qid of po
dilt. Had disseminated rash which was found to be disseminated
vzv so started on IV acyclovir. Also had VZV in CSF. Had an
infected PIV site on forearm and ended up having a cellulitis so
was started on IV vanc, switched to PO doxycycline. Dc-ed home
to complete two week course of acylovir IV.
# Disseminated varicella: Prior to admission to ICU, patient had
developed new rash on torso, could not recall onset (days vs
hours?). It was erythematous, papular on the trunk and arms, and
then spread to the face. The lesions were in different stages of
development. Given appearance of exanthem, initial differential
was drug vs viral infection (culprit medications including
recently started keppra for seizure and bactrim, which was
discontinued). Derm was consulted, biopsied lesions and sent for
DFA and viral culture, which was positive for VZV. Dermatology
recommended acyclovir dosed at 20mg/kg. They also recommended ID
consultation. He was started on a two week course of IV
acyclovir (end date ___. Lesions crusted prior to dc. Was
having diarrhea which is likely ___ GI invovlement.
# Atrial Fibrillation: Mr. ___ had to be transferred to the
ICU after he was found to have a HR of 160 on routine vital
signs, asymptomatic. His metoprolol was increased to 12.5 Q8HR.
He then also received 5mg IV x2, and Diltiazem 10mg IV x1 with
HR improving to 110. He then received 30mg PO Diltiazem but
shortly afterwards his HR increased to the 150s, prompting
transfer to the ICU. He was placed on a diltiazem drip. He was
on diltiazem drip for 2 days and then transitioned to Diltiazem
120 mg PO/NG Q6H which was downtitrated to 90 q6. Dc-ed on 360
XL.
# Abdominal Pain: ___ VZV panreatitis. He was managed with IVF
and pain control with morphine.
#Seizure -Neuro was consulted. Per report, focal nature of
seizure concerning for structural lesion, particularly with his
known cancer, history of atrial fibrillation on cancer placing
him at increased susceptibility to stroke. MRI suggested
leptomenigeal spread. He was treated with keppra which was
switched to pregablin. No recurrence.
# Thrombocytopenia - Platelets fell from 105 to 31. Other cell
lines decreased as well and in the setting of dehydration from
pancreatitis, could be some element of hemoconcentration.
Bactrim could also be a culprit which was switched to atovaquone
and counts recovered.
#HTN - On presentation to ED, his systolis were to the 200s and
he was given multiple doses of IV metop and placed on a Dilt gtt
for a short period. This could be essential HTN complicated by
pain; however, in the setting of witnessed seizure and being on
immunosuppresive medications, PRES was also on differential. His
pressures were stable on diltiazem drip and pressures normalised
afterwards.
#MM - Mr. ___ had no evidence of bence ___
proteinuria. Given his new disseminated VZV, the MRI findings
were likely due to VZV and NOT LP spread. Holding revlimid until
he FULLY recovers.
TRANSITIONAL ISSUES:
- BACTRIM SWITCHED TO ATOVAQUONE DUE TO THROMBOCYTOPENIA; COUNTS
RECOVERED
- DILT STARTED DUE TO LEFT ATRIAL TACHYCARDIA; HAS BEEN ON IT IN
PAST
- DC-ED ON ACYCLOVIR IV FOR TOTAL TWO WEEK COURSE - END DATE
___
- DC-ED ON DOXYCYCLINE FOR ARM CELLULITIS FOR TEN DAY COURSE -
END DATE ___
- STARTED ON LOPERAMIDE FOR DIARRHEA LIKELY ___ VZV INVOVLEMENT
OF GI TRACT
- STARTED ON THIMAINE, FOLIC ACID AND MUTLIVITAMIN FOR NUTRITION
- HOLD REVLIMID UNTIL FULLY RECOVERS
- SETTING UP HEM ONC FOLLOWUP WITH NP THIS COMING WEEK; WILL
NEED CHEM PANEL, CBC W/ DIFF
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
2. Aspirin 325 mg PO DAILY
3. Calcium Carbonate 500 mg PO TID
4. Vitamin D 1000 UNIT PO DAILY
5. Dexamethasone 20 mg PO DAILY
6. Lenalidomide 10 mg PO DAILY
Discharge Medications:
1. Acyclovir 700 mg IV Q8H
RX *acyclovir sodium 50 mg/mL 14 ml IV q8 Disp #*20 Vial
Refills:*0
2. Calcium Carbonate 500 mg PO TID
3. Vitamin D 1000 UNIT PO DAILY
4. Aspirin 325 mg PO DAILY
5. Collagenase Ointment 1 Appl TP DAILY
RX *collagenase clostridium histo. [Santyl] 250 unit/gram apply
to arm wound at bedtime Refills:*0
6. Diltiazem Extended-Release 360 mg PO DAILY
RX *diltiazem HCl 360 mg 1 capsule(s) by mouth once a day Disp
#*15 Capsule Refills:*0
7. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth q12 Disp
#*15 Tablet Refills:*0
8. Atovaquone Suspension 1500 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*15
Tablet Refills:*0
10. LOPERamide 4 mg PO TID diarrhea
RX *loperamide 2 mg 2 tablets by mouth q8 Disp #*60 Capsule
Refills:*0
11. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 capsule(s) by mouth once a day Disp #*15
Capsule Refills:*0
12. Pregabalin 150 mg PO BID
RX *pregabalin [Lyrica] 150 mg 1 capsule(s) by mouth q12 Disp
#*30 Capsule Refills:*0
13. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth once a day Disp
#*15 Tablet Refills:*0
14. Mupirocin Ointment 2% 1 Appl TP DAILY
RX *mupirocin 2 % please apply to arm once a day Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Disseminated varicella zoster infection
Atrial Tachyarrhythmia
Pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ with abdominal pain were found to
have a severe zoster infection that had spread throughout your
body. You repsonded to the antibiotic treatment and were
discharged home in a stable condition.
Followup Instructions:
___
|
10246275-DS-10 | 10,246,275 | 24,714,639 | DS | 10 | 2117-09-15 00:00:00 | 2117-09-20 20:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin / Xanax
Attending: ___.
Chief Complaint:
Cough, fevers, chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o F PMH significant for Hodgkin's s/p ABVD and autology
SCT, HTN, IgA nephropathy, CKD, immunoglobulin deficiencies,
recurrent pneumonias who presents with myalgia, malaise, and
productive cough.
Of note, the patient was recently hospitalized for orthopedic
surgery for which her post-operative course was complicated by
hypotension. The patient has multiple recent admissions
___. Please see
discharge summaries for full details. 3 of the 4 admission
appear to be related to pulmonary related complaints.
The patient reports that two days prior to presentation she
developed subjective fevers, chills, and a productive cough and
headache. that has subsequently worsened which is why she
presented to the ED. Her peak flow is reduced from 500 to 250
over hte past few days. She does have an appointment with a ___
pulmonologist tomorrow, but she felt like her symptoms had
worsened causing her to be admitted to ___. Her only other
symptom is left sided chest pain which developed previous to the
onset of fevers, chills, productive cough. She reports that she
finished the 4 weeks of lovenox after the surgery but currently
is wheelchair bound because she is not allowed to apply pressure
to surgically repaired knee. She reports that she visited her
PCP for the ___ chest pain and it was believed to be
secondary to MSK given that it is reproducible on exam. She
reports that this pain has worsened since getting the cough and
fevers. She also reports headaches, lower abdominal pain when
she does not urinated in a while. Her left leg pain is at its
baseline.
In the ED, initial vital signs were: 98.2 84 140/90 16 94%
Labs were notable for negative influenza, normal CBC, chem-7,
lactate. Blood cultures are pending.
Patient was given Albuterol Neb, Levofloxacin 750 mg,
Acetaminophen 650 mg, HYDROmorphone (Dilaudid) 4 mg PO.
Vital Signs prior to Transfer: 99.2 92 128/89 18 98% RA
On the floor, she endorses the history above.
Review of Systems:
(+) per HPI
(-) abdominal pain, nausea, vomiting, diarrhea, constipation,
BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
-Hodgkin's disease IV age ___, s/p ABVD, s/p autoSCT
-Hypertension
-AV block II-III: s/p PPM ___
-Hypothyroidism
-Adrenal adenoma
-Constipation
-CKD (chronic kidney disease), stage III
-Asthma
-Primary ovarian failure
-Immunoglobulin deficiency
-Osteoarthritis
-Obesity
-Pulmonary nodule
-Chronic pain
-IgA nephropathy
-Hyperlipidemia
-Glomus tumor R index finger s/p excision 8d ago
-Hx recurrent PNAs and URIs until ___, has required 7d
admission w/3 unusual organisms isolated (___)
Social History:
___
Family History:
Mother passed away from Breast cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - T:102.9 168/93 18 100%RA
GENERAL: NAD, AOx3, speaking in full sentences
HEENT: AT/NC, PERRL, anicteric sclera, pink conjunctiva, MMM,
NECK: nontender supple neck
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG:decreased breath sounds on left, otherwise CTAB without
wheezing
Left sided reproducible chest pain.
ABDOMEN:obese with ecchymoses, NABS, NT/ND
EXTREMITIES: R knee in brace with well-healed surgical scars.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Vitals - Tm 102.9 Tc 100.3 BP 151/100 HR 102 RR 20 O2 98RA
GENERAL: NAD, AOx3, speaking in full sentences
HEENT: AT/NC, PERRL, anicteric sclera, pink conjunctiva, MMM,
tender over sinuses
NECK: nontender supple neck
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: limited due to poor inspiratory effeort, CTAB without
wheezing
Left sided reproducible chest pain
ABDOMEN: obese with ecchymoses, NABS, NT/ND
EXTREMITIES: R knee in brace with well-healed surgical scars.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
LABS:
___ 12:50PM BLOOD WBC-6.6 RBC-3.97*# Hgb-13.0# Hct-37.5#
MCV-95 MCH-32.7* MCHC-34.5 RDW-14.0 Plt ___
___ 12:50PM BLOOD Neuts-69.7 ___ Monos-5.1 Eos-1.5
Baso-0.5
___ 12:50PM BLOOD Glucose-86 UreaN-13 Creat-0.7 Na-139
K-3.9 Cl-100 HCO3-27 AnGap-16
___ 07:45AM BLOOD Calcium-9.0 Phos-4.4# Mg-2.0
___ 07:45AM BLOOD IgG-757 IgA-81 IgM-81
___ 12:57PM BLOOD Lactate-1.4
MICRO:
___ 02:16PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ STAIN-FINAL; RESPIRATORY
CULTURE-FINALINPATIENT
___ CULTURE-FINALEMERGENCY WARD
___ CULTUREBlood Culture, Routine-FINAL
IMAGING:
___ CXR:
Subtle opacity in the left perihilar region, concerning for
developing
pneumonia, likely within the superior segment of the left lower
lobe.
Brief Hospital Course:
___ y/o F PMH significant for Hodgkin's s/p ABVD and autology
SCT, HTN, IgA nephropathy, CKD, immunoglobulin deficiencies,
recurrent pneumonias who presents with myalgia, malaise, and
productive cough concerning for pneumonia.
# HCAP: febrile on admission. Patient technically meets criteria
for HCAP given the admissions above in the past 3 months. She
was given levofloxacin in the ED, but given recents
hospitalizations initiated on HCAP coverage with plan to narrow.
She reports vancomycin allergy as a rash on her abdomen. Given
how well appearing and that she is on citalopram, tramadol,
buprorpion she is at increased risk of serotonin syndrome, will
defer MRSA treatment with linezolid at this time. She was
started on cefepime and azithro while inpatient and narrowed to
levofloxacin on discharge. Sputum culture without growth. Used
tessilon pearls for cough and albuterol/ipratroprium nebs prn.
Afebrile and symptomatically improved >24hr prior to discharge.
# Chest Pain: Although she is at risk for PE given recent
surgery and immobilization. It was reassuring that she was not
tachycardic and that her chest pain was reproducible on exam.
EKG with underlying RBBB. Pain was controlled with acetaminophen
and home dilaudid. Treated PNA as above.
# Asthma: No symptoms consistent with asthma flare to warrant
steroids. Received fluticasone as beclomethasone is
non-formulary. Continued on albuterol and Symbicort.
# s/p right knee surgery in ___: able to bend knee but still
non weight bearing. Pain control with home dilaudid
Chronic Issues:
# Hypothyroidism:
- continued home levothyroxine
# Chronic Pain Syndrome/ Chronic Knee Pain: Continued outpatient
pain medications
- gabapentin
- dilaudid for pain control
# HTN:
- Continued lisinopril and amlodipine
# GERD-
- cont omeprazole 20mg BID
# Anxiety-
- cont ativan, citalopram
# Isomnia-
- cont ativan and trazodone
# HLd
- c/w simvastatin
# Code:full
# Emergency Contact: ___ - ___
**Transitional Issues**
- Discharged on levofloxacin 7 day course to end ___
- Patient was somnolent on admission and is on multiple sedating
medications, which should be tapered or discontinued as able as
an outpatient
- If patient remains on sedating medications, should have a
speech and swallow eval as outpatient given multiple episodes of
PNA concerning for aspiration
- Patient is on multiple QTc prolonging medications and should
have any unnecessary medications discontinued
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
2. Amlodipine 2.5 mg PO DAILY
3. BuPROPion (Sustained Release) 450 mg PO QAM
4. Citalopram 20 mg PO QHS
5. DiCYCLOmine 10 mg PO DAILY:PRN spasm
6. Gabapentin 900 mg PO TID
7. Levothyroxine Sodium 125 mcg PO DAILY
8. Lisinopril 40 mg PO DAILY
9. Lorazepam 1 mg PO QHS:PRN insomnia
10. Lorazepam 2 mg PO DAILY:PRN anxiety
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 20 mg PO BID
13. diclofenac sodium 1 % TOPICAL BID
14. Ferrous Sulfate 325 mg PO DAILY
15. olopatadine 0.1 % ophthalmic BID
16. Polyethylene Glycol 17 g PO DAILY:PRN constipation
17. Prochlorperazine 5 mg PO Q8H:PRN nausea
18. Simvastatin 20 mg PO QPM
19. TraMADOL (Ultram) 50 mg PO BID:PRN pain
20. Vitamin D 1000 UNIT PO DAILY
21. TraZODone 150 mg PO QHS
22. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN pain
23. Senna 8.6 mg PO BID:PRN constipation
24. DiphenhydrAMINE 25 mg PO Q6H:PRN allergies
25. Ibuprofen 400 mg PO Q8H:PRN pain
26. beclomethasone dipropionate 40 mcg/actuation inhalation BID
27. Montelukast 10 mg PO DAILY
Discharge Medications:
1. Amlodipine 2.5 mg PO DAILY
2. BuPROPion (Sustained Release) 450 mg PO QAM
3. Citalopram 20 mg PO QHS
4. DiCYCLOmine 10 mg PO DAILY:PRN spasm
5. Ferrous Sulfate 325 mg PO DAILY
6. Gabapentin 900 mg PO TID
7. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN pain
8. Levothyroxine Sodium 125 mcg PO DAILY
9. Lisinopril 40 mg PO DAILY
10. Lorazepam 1 mg PO QHS:PRN insomnia
11. Lorazepam 2 mg PO DAILY:PRN anxiety
12. Montelukast 10 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Omeprazole 20 mg PO BID
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Prochlorperazine 5 mg PO Q8H:PRN nausea
17. Senna 8.6 mg PO BID:PRN constipation
18. Simvastatin 20 mg PO QPM
19. TraZODone 150 mg PO QHS
20. Vitamin D 1000 UNIT PO DAILY
21. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth TID prn: cough Disp
#*30 Capsule Refills:*0
22. Levofloxacin 750 mg PO Q24H
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*4
Tablet Refills:*0
23. Acetaminophen 650 mg PO Q6H:PRN pain/fever
24. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
RX *albuterol sulfate 90 mcg ___ puffs IH Q4hr prn: SOB or
wheezing Disp #*1 Inhaler Refills:*0
25. beclomethasone dipropionate 40 mcg/actuation INHALATION BID
RX *beclomethasone dipropionate [Qvar] 40 mcg/actuation 1 puff
IH twice a day Disp #*1 Inhaler Refills:*0
26. diclofenac sodium 1 % TOPICAL BID
27. DiphenhydrAMINE 25 mg PO Q6H:PRN allergies
28. Ibuprofen 400 mg PO Q8H:PRN pain
29. olopatadine 0.1 % ophthalmic BID
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you at ___. You were
admitted with a pneumonia. Please finish your antibiotics
prescription at home and follow up with your primary care
physican and pulmonologist.
Sincerely,
Your ___ medical team
Followup Instructions:
___
|
10246275-DS-11 | 10,246,275 | 24,112,369 | DS | 11 | 2117-12-10 00:00:00 | 2117-12-10 21:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin / Xanax
Attending: ___.
Chief Complaint:
cc: cough
Major ___ or Invasive Procedure:
NONE
History of Present Illness:
___ w/PMH of Hodgkin's disease s/p autologous SCT at age ___,
primary ovarian failure, IgA nephropathy, CKD stage III, HTN,
HL, AV block s/p PPM (chemo related), s/p recent R knee
arthroplasty complicated by post-operative PE, ?IgG deficiency
and recurrent pneumonias and URI's now p/w cough and fever of 3
days. Pt reports mildy productive cough and subjective fevers at
home. Per medical records patient has had several prior
admissions at OSH's for pneumonia with unusual organisms. Pt
seen at ___ yesterday where she had a CXR done that was
non-revealing and was sent home. Pt comes to the ED today given
ongoing symptoms.
In the ED here pt afebrile. CT chest revealed RLL infiltate. Pt
given IV levofloxacin and admitted due to suspected
immunosuppression. Of note pt recently seen in allergy clinic on
___ and had immunoglobulin testing which was not convincing of
hypogammaglobulinemia. Of note, pt did not have complete set of
labs drawn. Pt has not been seen again for follow up yet.
ROS: As noted above, otherwise reviewed in detail and negative
Past Medical History:
-Hodgkin's disease IV age ___, s/p ABVD, s/p autoSCT
-Hypertension
-AV block II-III: s/p PPM ___
-Hypothyroidism
-Adrenal adenoma
-Constipation
-CKD (chronic kidney disease), stage III
-Asthma
-Primary ovarian failure
-Immunoglobulin deficiency
-Osteoarthritis
-Obesity
-Pulmonary nodule
-Chronic pain
-IgA nephropathy
-Hyperlipidemia
-Glomus tumor R index finger s/p excision 8d ago
-Hx recurrent PNAs and URIs until ___, has required 7d
admission w/3 unusual organisms isolated (___)
Social History:
___
Family History:
Mother passed away from Breast cancer
Physical Exam:
Vitals:98.1 130/87 86 18 97%RA
Gen: NAD
HEENT: NCAT
CV: rrr, no r/m/g
Pulm: clear bl
Abd: soft, nt/nd, +bs
Ext: no edema, R knee w/ post op changes
Neuro: alert and oriented x 3, no focal deficits
Exam on discharge unchanged
Pertinent Results:
Admission Labs: ___ 03:50PM
WBC-12.6*# RBC-3.89* Hgb-12.7 Hct-35.6* MCV-92 Plt ___
Neuts-71.5* ___ Monos-4.2 Eos-1.5 Baso-0.4
Glucose-88 UreaN-16 Creat-0.9 Na-142 K-3.5 Cl-101 HCO3-29
AnGap-16
cTropnT-<0.01
Lactate-1.___. Right lower lobe pneumonia with mild pulmonary edema. Trace
pleural
effusions.
2. No pulmonary embolism or acute aortic process.
Brief Hospital Course:
___ w/PMH of Hodgkin's disease s/p autologous SCT at age ___,
primary ovarian failure, IgA nephropathy, CKD stage III, HTN,
HL, AV block s/p PPM (chemo related), s/p recent R knee
arthroplasty complicated by post-operative PE, ?IgG deficiency
and recurrent pneumonias and URI's now p/w cough and fever of 3
days.
# Pneumonia, bacterial
Presented with cough and subjective fever and infiltrate on
imaging concerning for pneumonia. She was started on Levaquin
and monitored overnight. Her symptoms improved and she was
discharged home on Levquin to complete a 7 day course. She was
advised to follow up with her allergist/pulmonologist to discuss
her recurrent pneumonias.
Chronic issues:
# Recent PE
- continued xarelto
# HTN
-Continued lisinopril, amlodipine
# Depression
- continued cymbalta, wellbutrin, trazodone
- continued prn ativan
# Hypothyroidism
- continued levothyroxine
#Chronic pain/fibromyalgia
Patient with complaints of pain in multiple joints. ___ was
reviewed and the patent has no regular narcotic prescribers. She
was not given a new prescription on discharge and advised to
follow up with her PCP/Pain clinic to discuss her concerns
regarding her pain.
Transitional issues:
- Should continue to follow up with Pulmonology/Allergy
regarding additional work up for recurrent lung infections
- Referral made to Pain center to discuss pain concerns
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Qvar (beclomethasone dipropionate) 40 mcg/actuation
inhalation BID
3. Wellbutrin XL (buPROPion HCl) 450 mg oral DAILY
4. Voltaren (diclofenac sodium) 1 % topical BID
5. DiCYCLOmine 10 mg PO DAILY:PRN pain
6. Gabapentin 900 mg PO TID
7. HYDROmorphone (Dilaudid) 2 mg PO BID:PRN pain
8. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN dyspnea
9. Levothyroxine Sodium 125 mcg PO DAILY
10. Lisinopril 40 mg PO DAILY
11. Lorazepam 1 mg PO TID:PRN anxiety
12. Montelukast 10 mg PO DAILY
13. Omeprazole 20 mg PO BID
14. Prochlorperazine ___ mg PO Q8H:PRN nauea
15. Simvastatin 20 mg PO QPM
16. TraMADOL (Ultram) 50 mg PO BID:PRN pain
17. TraZODone 150 mg PO QHS
18. Acetaminophen 500 mg PO Frequency is Unknown
19. Vitamin D ___ UNIT PO DAILY
20. Ferrous Sulfate 325 mg PO DAILY
21. Multivitamins 1 TAB PO DAILY
22. Polyethylene Glycol 17 g PO DAILY
Discharge Medications:
1. Ferrous Sulfate 325 mg PO DAILY
2. Gabapentin 900 mg PO TID
3. HYDROmorphone (Dilaudid) 2 mg PO BID:PRN pain
4. Levothyroxine Sodium 125 mcg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. Lorazepam 1 mg PO TID:PRN anxiety
7. Montelukast 10 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 20 mg PO BID
10. Simvastatin 20 mg PO QPM
11. TraZODone 150 mg PO QHS
12. Vitamin D ___ UNIT PO DAILY
13. BuPROPion (Sustained Release) 450 mg PO QAM
14. Duloxetine 60 mg PO DAILY
15. Rivaroxaban 20 mg PO DAILY
16. Acetaminophen 500 mg PO Q6H:PRN pain
17. Amlodipine 5 mg PO DAILY
18. DiCYCLOmine 10 mg PO DAILY:PRN pain
19. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN dyspnea
20. Polyethylene Glycol 17 g PO DAILY
21. Prochlorperazine ___ mg PO Q8H:PRN nauea
22. Qvar (beclomethasone dipropionate) 40 mcg/actuation
inhalation BID
23. TraMADOL (Ultram) 50 mg PO BID:PRN pain
24. Voltaren (diclofenac sodium) 1 % topical BID
25. Levofloxacin 750 mg PO Q24H
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth daily
Disp #*5 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia
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 during your recent
admission to ___. You were admitted with chest pain and found
to have pneumonia on a CT scan of your chest. There was no
evidence of pulmonary embolus on your CT scan. You will be
treated with Levaquin to complete a 7 day course.
Please discuss a referral to pain management clinic with your
PCP to discuss your concerns regarding pain. Please follow up
with your allergist and pulmonologist to discuss your recurrent
pneumonias.
Followup Instructions:
___
|
10246275-DS-14 | 10,246,275 | 29,954,140 | DS | 14 | 2118-04-27 00:00:00 | 2118-04-27 17:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin / Xanax / clear tape
Attending: ___.
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HMED Admission Note
Date of note: ___, 4:15 pm
PCP: ___, MD, MPH
CC: cough, shortness of breath, fever
HPI: Ms. ___ is a ___ yo female here with recurrent fever and
cough, found to have pneumonia.
She has had multiple pulmonary infections in the past year, for
which she has required hospitalization both in the ___ area
and in ___, most recently in ___. She has been
seen by pulmonary physicians, both at ___ and at ___ (___)
and was diagnosed with likely aspiration. She does not think
this is the cause of her pneumonia as she says she has ___ phD in
the medicine of hard knocks.
On this occasion, for the past week, she has had a cough
productive of green sputum, with low grade fevers. She was seen
in HCA on ___ and then on ___. CXR on ___ was negative.
She was using her nebulizer to see if it helped, but without
effect. She then today had worsening cough and fever to 100.8
and presented to the ED. In the ED, she was noted to be febrile
to 103. CXR showed subtle right middle lobe infiltrate and she
was admitted after receiving cefepime for HCAP.
She was recently admitted from ___ for a redo knee
operation with Dr. ___. Since then she has been
rehabilitating at home. She was also hospitalized in ___ on
the psychiatry service for suicidality and hopelessness.
Her ROS is positive for the following:
Chronic pain in her back and knee
Chronic lower abdominal pain
Poor mood
Intermittent dysuria
Wheelchair use almost exclusively due to ED
Negative for weight loss, palpitations, skin rashs or
ulcerations, and 6 other systems.
___:
PAST MEDICAL HISTORY:
-___ , classic type
-Hodgkin's disease IV age ___, s/p ABVD, s/p autoSCT
-Hypertension
-AV block II-III: s/p PPM ___
-Hypothyroidism
-Adrenal adenoma
-Constipation
-CKD (chronic kidney disease), stage III
-Asthma
-Primary ovarian failure
-Possible Immunoglobulin deficiency (IGG)
-Osteoarthritis
-Obesity
-Chronic pain
-Hyperlipidemia
PAST PSYCHIATRIC HISTORY:
Diagnosis: Reports "official" diagnoses at ___ are chronic
depression, anxiety, PTSD. Reports SSDI for somatization
disorder
and narcissitic personality disorder.
SH: Lives alone, on SSDI. Estranged from brother, both parents
are dead. Prior history of abuse by father. No alcohol or
other drugs. Enjoys reading, writing, and quilting.
FH: No family history of recurrent pneumonias or other
infections.
Home medications:
The Preadmission Medication list is accurate and complete
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
3. Amlodipine 10 mg PO DAILY
4. Benzonatate 100 mg PO TID:PRN cough
5. BuPROPion (Sustained Release) 450 mg PO QAM
6. Citalopram 10 mg PO DAILY
7. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm
8. Voltaren (diclofenac sodium) 1 % topical BID:PRN pain
9. DiCYCLOmine ___ mg PO BID:PRN abdominal spasm
10. Enoxaparin Sodium 40 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
11. Furosemide 20 mg PO TWICE WEEKLY
12. Levothyroxine Sodium 137 mcg PO DAILY
13. Lisinopril 40 mg PO DAILY
14. Lorazepam 1 mg PO BID:PRN anxiety
15. Lorazepam 2 mg PO QHS
16. Morphine SR (MS ___ 15 mg PO Q12H
17. Omeprazole 40 mg PO BID
18. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
19. Prochlorperazine 5 mg PO TID:PRN nausea
20. Simvastatin 20 mg PO QPM
21. TraZODone 225 mg PO QHS
22. Acetaminophen 1000 mg PO TID:PRN pain
23. carboxymethylcellulose sodium 0.5% drops ophthalmic PRN
24. Cetirizine 10 mg PO DAILY
25. Multivitamins 1 TAB PO DAILY
26. omega-3 fatty acids-fish oil 360-1,200 mg oral BID
27. Polyethylene Glycol 17 g PO DAILY:PRN constipation
28. Senna 8.6 mg PO BID
Allergies (Last Verified ___ by ___:
clear tape
vancomycin
Xanax
Past Medical History:
PAST PSYCHIATRIC HISTORY:
Diagnosis: Reports "official" diagnoses at ___ are chronic
depression, anxiety, PTSD. Reports SSDI for somatization
disorder
and narcissitic personality disorder. When asked about the
narcissitic personality disorder patient replies her therapist
once asked her if she believes she is special and she then
stated: "how can you not believe you are unique and special when
you know that you are?"
Hospitalizations: 1 in ___ in ___ for
depression
Current treaters and treatment: Psychiatrist- ___ ___
Therapist- ___
Medication and ECT trials: Multiple med trials. SSRIs
Self-injury: Reports on SA in ___ by taking her pills, (unclear
if pt required subsequent medical care)
Harm to others: denies
Access to weapons: denies
PAST MEDICAL HISTORY:
-Ehlers-danlos
-Hodgkin's disease IV age ___, s/p ABVD, s/p autoSCT
-Hypertension
-AV block II-III: s/p PPM ___
-Hypothyroidism
-Adrenal adenoma
-Constipation
-CKD (chronic kidney disease), stage III
-Asthma
-Primary ovarian failure
-Immunoglobulin deficiency
-Osteoarthritis
-Obesity
-Chronic pain
-Hyperlipidemia
Social History:
___
Family History:
FAMILY PSYCHIATRIC HISTORY:
No family history of psychiatric illness, SA or addictions.
Physical Exam:
Physical exam
Tmax 103, BP 108/59, HR 104 RR 18 95% RA
Gen: In NAD, somewhat somnolent, obese.
HEENT: PERRL, EOMI. No scleral icterus. No conjunctival
injection. Mucous membranes moist. No oral ulcers.
Neck: Supple, no LAD, no JVP elevation.
Lungs: scant wheezes and crackles in Right base, no egophony,
normal respiratory excursion, and normal lung sounds on left.
CV: RRR, no murmurs, rubs, gallops. PPM in place on chest.
Abdomen: soft, diffusely tender to mild palpation.
Extremities: right knee with steristrips over multiple
incisions with no significant surrounding erythema. Limited
range of motion to flexion.
Neurological: alert and oriented X 3, face symmetric. No
pronator drift. Normal finger to nose. Both legs with full
strength
Skin: No rashes or ulcers.
Psychiatric: Appropriate.
GU: deferred.
Pertinent Results:
___ 11:05AM BLOOD WBC-13.6*# RBC-3.65* Hgb-11.3 Hct-34.7
MCV-95 MCH-31.0 MCHC-32.6 RDW-12.7 RDWSD-43.8 Plt ___
___ 11:05AM BLOOD Neuts-88.2* Lymphs-6.5* Monos-3.6*
Eos-1.0 Baso-0.3 Im ___ AbsNeut-11.97*# AbsLymp-0.89*
AbsMono-0.49 AbsEos-0.14 AbsBaso-0.04
___ 11:05AM BLOOD Glucose-113* UreaN-14 Creat-1.0 Na-142
K-4.2 Cl-101 HCO3-27 AnGap-18
___ 11:18AM BLOOD Lactate-3.4*
Imaging:
IMPRESSION:
Subtle right lung base opacity may represent developing
pneumonia.
Brief Hospital Course:
Assessment and Plan: Ms. ___ is a ___ yo female here with
recurrent pneumonia.
Bacterial PNA:
Recurrent based on symptoms and CXR findings. Responded well to
CTX/azithro and transitioned to Levofloxacin. Legionella
negative, Strep sent. Cause of recurrent PNA unclear.
Pulmonary consulted and favored microaspiration/GERD aspiration.
Passed video swallow. IgG deficiency not felt to be
contributing. Recommended outpatient GI eval for pH monitoring
and Immunology re-evaluation for consideration of IVIG trial vs
further work up. Patient understands plan of care.
Post op knee pain:
Continued home medications.
Chronic PE:
History. On Lovenox for prophylaxis and continued
Anxiety/Depression:
Continued home regimen
Hypertension, benign:
held antihypertensives in house. Resumed on discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
3. Amlodipine 10 mg PO DAILY
4. Benzonatate 100 mg PO TID:PRN cough
5. BuPROPion (Sustained Release) 450 mg PO QAM
6. Citalopram 10 mg PO DAILY
7. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm
8. Voltaren (diclofenac sodium) 1 % topical BID:PRN pain
9. DiCYCLOmine ___ mg PO BID:PRN abdominal spasm
10. Enoxaparin Sodium 40 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
11. Furosemide 20 mg PO TWICE WEEKLY
12. Levothyroxine Sodium 137 mcg PO DAILY
13. Lisinopril 40 mg PO DAILY
14. Lorazepam 1 mg PO BID:PRN anxiety
15. Lorazepam 2 mg PO QHS
16. Morphine SR (MS ___ 15 mg PO Q12H
17. Omeprazole 40 mg PO BID
18. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
19. Prochlorperazine 5 mg PO TID:PRN nausea
20. Simvastatin 20 mg PO QPM
21. TraZODone 225 mg PO QHS
22. Acetaminophen 1000 mg PO TID:PRN pain
23. carboxymethylcellulose sodium 0.5% drops ophthalmic PRN
24. Cetirizine 10 mg PO DAILY
25. Multivitamins 1 TAB PO DAILY
26. omega-3 fatty acids-fish oil 360-1,200 mg oral BID
27. Polyethylene Glycol 17 g PO DAILY:PRN constipation
28. Senna 8.6 mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO TID:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
3. Benzonatate 100 mg PO TID:PRN cough
4. BuPROPion (Sustained Release) 450 mg PO QAM
5. Cetirizine 10 mg PO DAILY
6. Citalopram 10 mg PO DAILY
7. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth three times a day
Disp #*21 Tablet Refills:*0
8. DiCYCLOmine ___ mg PO BID:PRN abdominal spasm
9. Enoxaparin Sodium 40 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
10. Levothyroxine Sodium 137 mcg PO DAILY
11. Lorazepam 1 mg PO BID:PRN anxiety
12. Lorazepam 2 mg PO QHS
13. Morphine SR (MS ___ 15 mg PO Q12H
14. Omeprazole 40 mg PO BID
15. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
16. Polyethylene Glycol 17 g PO DAILY:PRN constipation
17. Prochlorperazine 5 mg PO TID:PRN nausea
18. Senna 8.6 mg PO BID
19. Simvastatin 20 mg PO QPM
20. TraZODone 225 mg PO QHS
21. Voltaren (diclofenac sodium) 1 % topical BID:PRN pain
22. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
23. Amlodipine 10 mg PO DAILY
24. carboxymethylcellulose sodium 0.5% drops ophthalmic PRN
25. Furosemide 20 mg PO TWICE WEEKLY
26. Lisinopril 40 mg PO DAILY
27. Multivitamins 1 TAB PO DAILY
28. omega-3 fatty acids-fish oil 360-1,200 mg oral BID
29. Levofloxacin 750 mg PO DAILY Duration: 3 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*3
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Bacterial Pneumonia
GERD
Ehlers Danlos syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with recurrent respiratory symptoms due to a
recurrent pneumonia. You underwent an evaluation for this by
the pulmonary team. You have improved with antibiotics. Please
complete the course as prescribed. The cause of your recurrent
infections is unclear, though it may be related to silent acid
reflux. Please continue your omeprazole and follow the
following measures:
elevate head of bed, refrain from lying supine after meals,
avoid caffeine, chocolate, spicy foods, high fat foods,
carbonated beverages
You have been referred to GI for further evaluation. Please
follow up with your PCP for ongoing care and to arrange
immunology follow up
Followup Instructions:
___
|
10246275-DS-19 | 10,246,275 | 20,097,923 | DS | 19 | 2122-02-02 00:00:00 | 2122-02-04 18:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Xanax / clonidine
Attending: ___.
Chief Complaint:
lightheadedness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
===========================
___ y/o F w/ PMHx Type II-III heart block s/p PPM in ___, CKD
stage III, Ehlers-___ syndrome, Hodgkin's lymphoma at age ___
s/p chemo and autologous BMT, CVID (on IVIG) c/b recurrent PNAs
on doxycycline ppx, HTN, TBI, hypothyroidism, asthma, OSA, and
with psychiatric diagnoses presenting with altered mental status
and atypical chest pain.
She reports being in her USOH until yesterday morning when she
noted "feeling high" after taking 3 doses of suboxone. She
reports that she had recently been switched from her home
___
to suboxone planned 2mg-0.5mg one week ago. Due to possible
prescribing errors, she was given a prescription for suboxone
8mg-2mg which she took starting two days prior. After taking her
dose yesterday morning, she reported that she felt lightheaded
and slightly "off", with some dizziness and mild nausea. She
went
to lay down and felt concerned when it felt like she "forgot how
to breathe." Denies any shortness of breath with this - just
felt
like she had to remind herself to take deep breaths. She denies
any other ingestions or new OTC medications.
She also notes some acute on chronic L sided chest pain that
feels dull and MSK in nature - worse with movement, with
pressure
like sensation when she palpates over the area, with no
radiation
or associated palpitations, SOB, nausea/vomiting, or
diaphoresis.
This typically lasts for a few minutes and self-resolves. It
mildly worsens at the end of a deep inspiration, and doe snot
occur with exertion. She does have a hx of a provoked DVT c/b PE
in the past following a knee surgery after she had been immobile
for several weeks - requiring anticoagulation at that time but
no
longer on anticoagulation. She denies any unilateral leg
swelling
or calf pain. She denies any recent immobility.
- In the ED, initial vitals were:
T98.2, HR 76, BP 103/77, 99% RA
- Exam was notable for:
General: Mentating appropriately, speaking in full sentences
HEENT: Mucous membranes are moist
Neck: Full ROM, no midline tenderness
Cardiac: RRR, soft murmur heard over the R sternal border
Pulm: CTAB
Abd: Soft, nontender, nondistended, obese
Neuro: Awake, alert, and oriented x 3, no slurred speech, CN
___
intact, ___ strength in BUE and BLE. No sensory deficits.
- Labs were notable for:
CMP: BUN 48, Cr 2.5, Ca ___, Phos 9.5
CBC: 12.2 > 12.___ < 254
Trop: <0.01
proBNP: 301
D-dimer: 674
UA: SG 1.028, moderate leuks, neg nitrite, 100 protein, 26 WBC,
no bacteria
Utox: negative
- Studies were notable for:
CXR - no acute cardiopulmonary process
EKG - NSR, known RBBB
- The patient was given:
Nothing
-Cardiology was consulted re: best modality of stress test.
Given
her baseline EKG changes (RBBB) - they required getting a stress
imaging study - ideally ETT-stress ECHO but if unavailable
ETT-MIBI.
-ED physicians spoke to ___ pain clinic ___, ___
beeper) who recommended stopping suboxone and going back to
___ until ___ for smaller strength. They noted it would
be
very unusual for somebody to overdose on suboxone. Recommended
avoidance of flexeril, lyrica, hydroxyzine, ativan until she
feels back to normal
On arrival to the floor, patient reports the above. She
continues
to have some mild L-sided chest discomfort and the sensation
that
she has to remind herself to brathe. She denies any recent
fever/chills, cough, abdominal pain, n/v/d, hematochezia,
melena,
dysuria, hematuria. She does note a hx of overactive bladder
which she is on oxybutynin for and notes small volume urination.
Past Medical History:
-Ehlers-danlos , classic type
-Hodgkin's disease IV age ___, s/p ABVD, s/p autoSCT
-Hypertension
-AV block II-III: s/p PPM ___
-Hypothyroidism
-Adrenal adenoma
-Constipation
-CKD (chronic kidney disease), stage III
-Asthma
-Primary ovarian failure
-Osteoarthritis
-Obesity
-Chronic pain
-Hyperlipidemia
-PULMONARY EMBOLISM
- HYPERTENSION
- IGG SUBCLASS DEFICIENCY
- HYPOTHYROIDISM
- HYPERCHOLESTEROLEMIA
Social History:
Marital status: Married
Children: No
Lives with: ___
Work: ___
Multiple partners: ___
___ activity: Present
Sexual orientation: Male
Sexual Abuse: Past
Domestic violence: Denies
Contraception: N/A
Tobacco use: Never smoker
Alcohol use: Past and Present
drinks per week: 2
Recreational drugs Denies
(marijuana, heroin,
crack pills or
other):
Family History:
Mother ___ BREAST CANCER
Father ___ HYPERCHOLESTEROLEMIA
CORONARY ARTERY
DISEASE
MGM Deceased UTERINE CANCER
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: T98, BP 141/89, HR 86, 94% RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, Sclera anicteric and without injection. MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. ___
systolic ejection murmur, loudest at LUSB. mild chest discomfort
with palpation over L chest wall
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: WWP, no ___ edema. Pulses DP/Radial 2+ bilaterally.
Pertinent Results:
___ 06:10AM BLOOD WBC-10.7* RBC-3.64* Hgb-11.6 Hct-34.2
MCV-94 MCH-31.9 MCHC-33.9 RDW-13.9 RDWSD-47.4* Plt ___
___ 06:10AM BLOOD Plt ___
___ 03:45PM BLOOD Glucose-101* UreaN-26* Creat-0.9 Na-143
K-3.9 Cl-100 HCO3-30 AnGap-13
___ 06:10AM BLOOD ALT-27 AST-30 LD(LDH)-246 AlkPhos-83
TotBili-0.2
___ 04:55PM BLOOD cTropnT-<0.01
___ 03:45PM BLOOD Calcium-9.5 Phos-2.5* Mg-1.7
Brief Hospital Course:
Summary of Admission
=====================
___ y/o F w/ PMHx Type II-III heart block s/p PPM in ___, CKD
stage III, Ehlers-Danlos syndrome, Hodgkin's lymphoma at age ___
s/p chemo and autologous BMT, CVID (on IVIG) c/b recurrent PNAs
on doxycycline ppx, HTN, TBI, hypothyroidism, asthma, OSA, and
with unclear psychiatric diagnoses presented with altered mental
status
and atypical chest pain. Altered mental status resolved, and was
thought to be the result of a new, higher dose of suboxone of
8mg-0.5mg she started one week ago, up from her home dose of
2.mg-0.5mg. She also noted a left-sided pleuritic chest pain.
Her EKG was unchanged from previously and troponins were
negative and repeat d-dimer ruled patient out for PE. The
patient was also found to have an ___, Cr of 2.5 that trended
down to 1.1 after 1 liter of fluids.
Transitional Issues:
=======================
[ ] Opioid dependency: Would attempt to adjust the patient's
medication regimen and clarify dosing with patient.
[ ] Acute kidney injury: Please check Cr as outpatient. If
patient's Cr has improved would consider restarting lisinopril
as this was held upon discharge given her ___.
[ ] The patient was taking large doses of NSAIDS for pain and
was informed that this con be harmful to the kidneys. Would
reinforce this teaching with patient as an outpatient
[ ] The patient is on multiple sedating medications that could
lead to her altered mental status, consider necessity of these
medications and potential for dose reduction given poly-pharmacy
[ ] The patient's hydroxyzine, tizanidine and oxybutynin were
held upon discharge given her AMS. Would recommend restarting
these centrally acting medications slowly.
[ ] Leukocytosis, the patient had a leukocytosis on admission
that had trended down at the time of discharge, no evidence of
infection. Would follow-up any signs of infection and repeat CBC
as clinically indicated.
[ ] Cardiology felt the patient would likely benefit from a
Stress test given her risk factors, would evaluate at next visit
and consider stress testing as an outpatient.
Active Issues
==================
#Altered mental Status:
The patient presented with lightheadedness and dizziness. These
symptoms resolved on their own by the time she was admitted to
the medicine floor. Of note, the patients belbuca prescription
was recently changed to 8mg buprenophrine- 0.5 naloxone from
600mcg buphreorphine 600mcg BID. Per the pt, she was supposed to
be on 2mg-0.5mg and that the 8mg was likely too high. The
patient is on multiple sedating medications which could have
worsened her symptoms.
#Acute kidney injury:
Patient presented with a Cr of 2.5, that trended down to 1.1
after 1 liter of fluids, suggestive of a pre-renal etiology. A
renal ultrasound was negative. She was likely dehydrated iso
altered mental status and possible contribution from recent
NSAID use. Her lisinopril was held upon discharge.
#Pleuritic chest pain:
The patient presented with pleuritic chest pain that was
non-radiating, located on the left side of the chest. Her EKG
was unchanged from previous EKG's, significant for a right
bundle branch block, and flattened T waves. Troponins were
negative. In the ED, the d-dimer level was 674, and then dropped
to 433 when re-checked the next day (once ___ resolved). It was
likely elevated in the setting ___ not representing acute
thrombus. Chest pain resolved spontaneously and was likely
muscular in origin as patient notes pain reproducible on exam
and similar to baseline diffuse pain.
#leukocytosis:
12.2 on admission. 10.7 status post 1L fluid resuscitation. The
patient denies infectious symptoms including fevers, chills,
nausea, vomiting, or diarrhea.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB/Wheeze
3. amLODIPine 5 mg PO DAILY
4. ARIPiprazole 5 mg PO QHS
5. Belbuca (buprenorphine HCl) 600 mcg buccal BID
6. Cetirizine 10 mg PO DAILY
7. DICYCLOMine ___ mg PO BID:PRN abdominal pain
8. Docusate Sodium 100 mg PO BID
9. Escitalopram Oxalate 30 mg PO DAILY
10. Levothyroxine Sodium 137 mcg PO DAILY
11. Lisinopril 40 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Oxybutynin XL (*NF*) 10 mg Other DAILY
14. Omeprazole 40 mg PO BID
15. Polyethylene Glycol 17 g PO BID:PRN Constipation - First
Line
16. Pregabalin 150 mg PO BID
17. rOPINIRole 0.5 mg PO QPM
18. Vitamin D 1000 UNIT PO DAILY
19. Venlafaxine XR 150 mg PO DAILY
20. Tizanidine 4 mg PO QHS
21. Simvastatin 20 mg PO QPM
22. Linzess (linaCLOtide) 72 mcg oral DAILY
23. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
24. Melatin (melatonin) ___ mg oral QHS:PRN
25. Xiidra (lifitegrast) 5 % ophthalmic (eye) BID
26. HydrOXYzine 25 mg PO BID:PRN puritis
27. Doxycycline Hyclate 100 mg PO Q12H
28. MetFORMIN (Glucophage) 1000 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB/Wheeze
3. amLODIPine 5 mg PO DAILY
4. ARIPiprazole 5 mg PO QHS
5. Belbuca (buprenorphine HCl) 600 mcg buccal BID
6. Cetirizine 10 mg PO DAILY
7. DICYCLOMine ___ mg PO BID:PRN abdominal pain
8. Docusate Sodium 100 mg PO BID
9. Doxycycline Hyclate 100 mg PO Q12H
10. Escitalopram Oxalate 30 mg PO DAILY
11. Levothyroxine Sodium 137 mcg PO DAILY
12. Linzess (linaCLOtide) 72 mcg oral DAILY
13. Melatin (melatonin) ___ mg oral QHS:PRN
14. MetFORMIN (Glucophage) 1000 mg PO DAILY
15. Multivitamins 1 TAB PO DAILY
16. Omeprazole 40 mg PO BID
17. Polyethylene Glycol 17 g PO BID:PRN Constipation - First
Line
18. Pregabalin 150 mg PO BID
19. rOPINIRole 0.5 mg PO QPM
20. Simvastatin 20 mg PO QPM
21. Venlafaxine XR 150 mg PO DAILY
22. Vitamin D 1000 UNIT PO DAILY
23. Xiidra (lifitegrast) 5 % ophthalmic (eye) BID
24. HELD- HydrOXYzine 25 mg PO BID:PRN puritis This medication
was held. Do not restart HydrOXYzine until you speak with your
PCP
25. HELD- Lisinopril 40 mg PO DAILY This medication was held.
Do not restart Lisinopril until you speak with your PCP
26. HELD- Oxybutynin XL (*NF*) 10 mg Other DAILY This
medication was held. Do not restart Oxybutynin XL (*NF*)
until you see your PCP
27. HELD- Tizanidine 4 mg PO QHS This medication was held. Do
not restart Tizanidine until you speak with your PCP
___:
Home
Discharge Diagnosis:
Primary Diagnosis
====================
Altered mental status
Opioid intoxication
Atypical chest pain
Acute Kidney Injury
Secondary Diagnosis
====================
HTN
IBS
Depression
Hypothyroidism
GERD
RLS
TD2M
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 for lightheadedness and
dizziness
-A blood test (creatinine) for your kidneys was abnormal
-You were feeling chest pain
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
An EKG was performed to check your heart and was unchanged from
EKGS. A blood test for heart damage (troponins) was negative.
You were given fluids through your IV and afterwards the blood
test for your kidney (Creatinine) improved.
An ultrasound of your kidney was normal.
Some of your home medications were held that may have been
causing you to be more sleepy than normal
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 see your pain management doctor, ___, to find the
correct dose of buprenorphine. A higher than normal dose may
have caused you to feel light headed.
-Please see your primary care doctor ___ upcoming ___. You
take several medications that can make you feel light headed.
-Please remember to hydrate. Your abnormal kidney it may be due
to dehydration.
-Please do not take your lisinopril and NSAIDS (ibuprofen) until
you see your PCP this upcoming ___.
We wish you all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10246275-DS-20 | 10,246,275 | 24,440,720 | DS | 20 | 2122-05-25 00:00:00 | 2122-05-29 09:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Xanax / clonidine
Attending: ___
Chief Complaint:
Nausea, vomiting, chest pain, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female with history of type II-III heart block s/p
PPM in ___, ___-___ syndrome, Hodgkin's lymphoma at age
___
s/p chemo and autologous BMT, CVID (on IVIG) c/b recurrent PNAs
on doxycycline ppx, HTN, hypothyroidism, asthma, OSA, and with
psychiatric diagnoses presenting with nausea, vomiting, chest
pain, and fever.
Last night, patient developed a cough that initially improved
with taking Tums. She went to bed and around 2:58 AM, she
developed chills and body malaise that was unlike her prior
pneumonia presentations. She measured her temperature which was
99.4 (she notes normally her temperature runs as 97 she thought
this was a fever). Later that morning at 8 AM, she had one
episode of liquid nonbloody vomit. She had midline chest pain
associated with the vomiting, that resolved after minutes. She
decided to come to the ED for further evaluation, and thought
that she may have the flu.
She has had recurrent pneumonia, most recently treated 3 weeks
ago. She presented to ___ clinic visit ___ for
similar
symptoms of fever, chills, and cough. She had a negative CXR,
but
was treated with 5-day course azithromycin and 7-day cefpodoxime
200mg BID.
Prior to that, she was last admitted ___ for RLL
pneumonia, found with consolidation on CXR, leukocytosis to 31,
elevated lactate to 4. She was treated with vancomycin,
cefepime,
azithromycin, narrowed to ceftriaxone and azithromycin. She was
discharged on Cefpodoxime 200mg Q12H and Azithromycin 250mg
daily. CXR following treatment showed resolution of
consolidation.
He also describes a bilateral headache that started yesterday
and
has continued to persist today despite Tylenol. Patient
otherwise
does not describe any dizziness or neck stiffness. Patient's
last
IVIG treatment was last week.
In the ED:
- Initial vital signs were notable for: Temp 97.7F BP 171/113 HR
120 RR 18 97% on RA
- Exam notable for: NAD. No erythema of the oral, no cervical
lymphadenopathy. CTAB. Abd with mild to moderate epigastric
pain,
no rebound or guarding.
- Labs were notable for:
BMP: Na 142, K 3.9, HCO3 24, BUN/Cr ___, BG 105, AG 19
CBC: WBC 19.3, H/H 13.3/39.6, plt 239
Trop-T <0.01
UCG negative
Influenza negative
Lactate 2.9->4.1->1.3
UA with 100 prot, otherwise bland
- Studies performed include:
CXR: No acute cardiopulmonary abnormality.
CT Abd/pelvis:
1. No acute abdominopelvic findings.
2. Mild intrahepatic and extrahepatic biliary ductal dilation,
stable to minimally improved from the prior CT.
3. Right lower lobe pneumonia, partially visualized. Please see
report from concurrently performed chest CT for full evaluation.
CT Chest w/o contrast:
-Findings consistent with right lower lobe pneumonia.
-Scattered pulmonary nodules in the right lobe measuring less
than 2 mm each. For incidentally detected multiple solid
pulmonary nodules smaller than 6mm, no CT follow-up is
recommended in a low-risk patient, and an optional CT follow-up
in 12 months is recommended in a high-risk patient.
- Patient was given: IV ketorolac 30mg, po acetaminophen 1000mg,
IV cefepime 2g, IV azithromycin 500mg, IV vancomycin 1000mg,
suboxone, lisinopril 40mg
- Consults: None
Vitals on transfer: Temp 98.3F BP 123/95 HR 95 RR 16 95% on RA
Upon arrival to the floor, pt endorsing bilateral headache and
nausea. During the interview, she had another episode of liquid
vomit associated with ___ epigastric/chest pain.
Past Medical History:
-Ehlers-danlos , classic type
-Hodgkin's disease IV age ___, s/p ABVD, s/p autoSCT
-Hypertension
-AV block II-III: s/p PPM ___
-Hypothyroidism
-Adrenal adenoma
-Constipation
-Asthma
-Primary ovarian failure
-Osteoarthritis
-Obesity
-Chronic pain
-Hyperlipidemia
-PULMONARY EMBOLISM
- HYPERTENSION
- IGG SUBCLASS DEFICIENCY
- HYPOTHYROIDISM
- HYPERCHOLESTEROLEMIA
Social History:
___
Family History:
Mother had breath cancer. Father had CAD and HLD. MGM had
uterine
cancer.
Physical Exam:
ADMISSION EXAM:
VITALS: ___ Temp: 98.3 PO BP: 141/111 R Sitting HR: 94
RR: 18 O2 sat: 96% O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress.
EYES: NCAT. PERRL, EOMI. Sclera anicteric and without injection.
ENT: MMM. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Soft, non distended. Mild tenderness to palpation in
epigastric area
SKIN: Warm. No rash. Significant nonpitting edema in legs.
NEUROLOGIC: AOx3. Strength and sensation grossly intact.
PSYCH: appropriate mood and affect
DISCHARGE EXAM:
VITALS: 24 HR Data (last updated ___ @ 128)
Temp: 97.7 (Tm 97.8), BP: 151/105 (151-174/97-111), HR: 77
(64-77), RR: 19 (___), O2 sat: 95% (93-97), O2 delivery: Ra
GENERAL: Sitting comfortably in bed in no acute distress.
HEENT: Sclera anicteric. Pink conjunctivae.
CARDIAC: Normal rate and rhythm. No murmurs, rubs, or gallops.
RESP: Clear to auscultation bilaterally without wheezes, rhonchi
or rales. No increased work of breathing.
ABDOMEN: Soft, nontender, non distended.
SKIN: Warm. No rash. No pitting edema.
NEUROLOGIC: AAOx3. Motor and sensation grossly intact and
symmetric throughout.
Pertinent Results:
ADMISSION LABS:
___ 09:50AM WBC-19.3* RBC-4.21 HGB-13.3 HCT-39.6 MCV-94
MCH-31.6 MCHC-33.6 RDW-14.3 RDWSD-48.5*
___ 09:50AM PLT COUNT-239
___ 09:50AM NEUTS-87.0* LYMPHS-7.8* MONOS-3.2* EOS-0.9*
BASOS-0.3 IM ___ AbsNeut-16.80* AbsLymp-1.51 AbsMono-0.62
AbsEos-0.17 AbsBaso-0.06
___ 09:50AM GLUCOSE-105* UREA N-24* CREAT-0.9 SODIUM-142
POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-24 ANION GAP-19*
___ 09:50AM ALT(SGPT)-23 AST(SGOT)-31 ALK PHOS-80 TOT
BILI-0.4
___ 09:50AM LIPASE-16
___ 09:52AM LACTATE-2.9*
PERTINENT LABS:
___ 09:52AM BLOOD Lactate-2.9*
___ 04:05PM BLOOD Lactate-4.1*
___ 06:00PM BLOOD Lactate-1.3
___ 07:45AM BLOOD IgG-1141 IgA-59* IgM-80
DISCHARGE LABS:
___ 07:45AM BLOOD WBC-9.8 RBC-4.12 Hgb-13.0 Hct-38.3 MCV-93
MCH-31.6 MCHC-33.9 RDW-13.7 RDWSD-46.2 Plt ___
___ 07:45AM BLOOD Glucose-102* UreaN-13 Creat-0.7 Na-144
K-3.6 Cl-99 HCO3-28 AnGap-17
___ 07:45AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.1
MICROBIOLOGY:
__________________________________________________________
___ 10:44 am SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
__________________________________________________________
___ 11:02 pm URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
__________________________________________________________
___ 10:31 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
__________________________________________________________
___ 3:45 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 9:50 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 9:50 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
IMAGING:
CHEST (PA & LAT)Study Date of ___
FINDINGS:
Left-sided pacer device is noted with leads in the right atrium
and right
ventricle, unchanged. Borderline cardiac silhouette size is
redemonstrated.
The mediastinal and hilar contours are normal. The pulmonary
vasculature is
normal. Lungs are clear. No pleural effusion or pneumothorax is
seen. There
are no acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality.
CT ABD & PELVIS WITH CONTRASTStudy Date of ___
IMPRESSION:
1. No acute abdominopelvic findings.
2. Mild intrahepatic and extrahepatic biliary ductal dilation,
stable to
minimally improved from the prior CT.
3. Right lower lobe pneumonia, partially visualized. Please see
report from
concurrently performed chest CT for full evaluation.
CT CHEST W/O CONTRASTStudy Date of ___
IMPRESSION:
1. Findings consistent with right lower lobe pneumonia.
2. Scattered pulmonary nodules in the right lobe measuring less
than 2 mm
each. See recommendations below.
RECOMMENDATION(S): For incidentally detected multiple solid
pulmonary nodules
smaller than 6mm, no CT follow-up is recommended in a low-risk
patient, and an
optional CT follow-up in 12 months is recommended in a high-risk
patient.
Brief Hospital Course:
___ female with history of high degree heart block s/p
PPM in ___, ___ syndrome, Hodgkin's lymphoma at age
___ s/p chemo and autologous SCT, CVID (on IVIG) c/b recurrent
PNAs, HTN, hypothyroidism, asthma, OSA, and with psychiatric
diagnoses presenting with nausea, vomiting, chest pain, and
fever, found with pneumonia on CT chest. Was treated with IV
antibiotics and transitioned to PO with good improvement in
symptoms and was discharged home.
TRANSITIONAL ISSUES:
====================
[ ] Quantitative immunoglobulins pending at time of discharge.
To be followed up by immunology to determine if dose of IVIG is
appropriate moving forward, given recurrent pneumonia
[ ] Incidental finding: Scattered pulmonary nodules in the right
lobe measuring less than 2 mm each. RECOMMENDATION: For
incidentally detected multiple solid pulmonary nodules smaller
than 6mm, no CT follow-up is recommended in a low-risk patient,
and an optional CT follow-up in 12 months is recommended in a
high-risk patient.
[ ] Discharged on augmentin to complete today 10 day course for
pneumonia, last dose due ___
ACUTE ISSUES:
=============
#Community acquired pneumonia
#Fever/malaise
#Leukocytosis
History of CVID on IVIG c/b recurrent pneumonia (last ___. Presented with fever, n/v, chills found with leukocytosis
(neutrophilic predominance) and RLL consolidation on CT chest.
Flu negative. She was mostly recently treated for pneumonia with
azithromycin and Cefpodoxime 2 weeks prior to admission with no
radiologic evidence on CXR. It is likely that her pneumonia was
undertreated with her antibiotics. Given recurrence and
immunocompromised state, she was initially treated with
vancomycin, cefepime, and azithromycin. Legionella negative.
MRSA swab negative. Strep pneumo pending at time of discharge.
Patient overall improved significantly. She was transitioned to
augmentin for discharge (given mildly prolonged QTc). Per ID
recommendations, she will complete a 10 day course total, ending
___.
#Vomiting
Presented with 2 episodes of vomiting, but no diarrhea. CT
abdomen and LFTs are unremarkable for infectious process. Likely
in the setting of pneumonia and acute illness. No recent sick
contacts or abnormal food ingestion. No further episodes of
emesis during inpatient stay.
#Atypical chest pain
Notes chest pain associated with vomiting, that resolves
subsequently. No ECG changes to suggest ischemia. Managed with
acetaminophen
#Lactic acidosis
Lactate elevated to 4.1 on admission. Given fluid resuscitation
with improvement to 1.3. Likely in setting of infection.
CHRONIC/STABLE ISSUES:
======================
#Hx heart block s/p PPM
ECG with native RBBB. Currently stable.
#CVID on IVIG, c/b recurrent PNAs
Held home ppx doxycycline given pneumonia treatment. Will
instruct patient to resume after abx course completes.
#Chronic pain
Continued home Suboxone, pregabalin, tizanidine. Ibuprofen PRN
pain
#IBS
Continued home dicyclomine. Home linzess not on home formulary.
#Depression
Continued home escitalopram, venlafaxine, aripiprazole.
#HTN
Continued home amlodipine. Held lisinopril on admission given
initial concern for sepsis physiology, but restarted prior to
discharge when stable.
#Hypothyroidism
Last TSH ___ normal at 1.5. Continued home levothyroxine
#GERD
Continued home omeprazole
#T2DM
Held metformin given initial presentation with lactic acidosis.
Managed with Humalog sliding scale.
#Restless leg syndrome
Continued home ropinirole
#HLD
Continued home simvastatin
#Seasonal allergies
Continued home cetirizine
35 minutes spent in DC planning and preparation.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB/Wheeze
3. ARIPiprazole 5 mg PO QHS
4. Cetirizine 10 mg PO DAILY
5. DICYCLOMine ___ mg PO BID:PRN abdominal pain
6. Docusate Sodium 100 mg PO BID
7. Escitalopram Oxalate 20 mg PO DAILY
8. Levothyroxine Sodium 137 mcg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Omeprazole 40 mg PO BID
11. Polyethylene Glycol 17 g PO BID:PRN Constipation - First
Line
12. rOPINIRole 0.5 mg PO QPM
13. Simvastatin 20 mg PO QPM
14. Venlafaxine XR 150 mg PO DAILY
15. Doxycycline Hyclate 100 mg PO Q12H
16. Lisinopril 40 mg PO DAILY
17. Linzess (linaCLOtide) 72 mcg oral DAILY
18. Melatin (melatonin) ___ mg oral QHS:PRN
19. MetFORMIN (Glucophage) 1000 mg PO DAILY
20. Oxybutynin XL (*NF*) 10 mg Other DAILY
21. Pregabalin 150 mg PO BID
22. Tizanidine 8 mg PO QHS
23. Vitamin D 1000 UNIT PO DAILY
24. Xiidra (lifitegrast) 5 % ophthalmic (eye) BID
25. Buprenorphine-Naloxone Tablet (2mg-0.5mg) 1 TAB SL BID
26. Glycopyrrolate 1 mg PO TID
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 (One) tablet(s)
by mouth twice a day Disp #*12 Tablet Refills:*0
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB/Wheeze
4. ARIPiprazole 5 mg PO QHS
5. Buprenorphine-Naloxone Tablet (2mg-0.5mg) 1 TAB SL BID
Consider prescribing naloxone at discharge
6. Cetirizine 10 mg PO DAILY
7. DICYCLOMine ___ mg PO BID:PRN abdominal pain
8. Docusate Sodium 100 mg PO BID
9. Doxycycline Hyclate 100 mg PO Q12H
10. Escitalopram Oxalate 20 mg PO DAILY
11. Glycopyrrolate 1 mg PO TID
12. Levothyroxine Sodium 137 mcg PO DAILY
13. Linzess (linaCLOtide) 72 mcg oral DAILY
14. Lisinopril 40 mg PO DAILY
15. Melatin (melatonin) ___ mg oral QHS:PRN
16. MetFORMIN (Glucophage) 1000 mg PO DAILY
17. Multivitamins 1 TAB PO DAILY
18. Omeprazole 40 mg PO BID
19. Oxybutynin XL (*NF*) 10 mg Other DAILY
20. Polyethylene Glycol 17 g PO BID:PRN Constipation - First
Line
21. Pregabalin 150 mg PO BID
22. rOPINIRole 0.5 mg PO QPM
23. Simvastatin 20 mg PO QPM
24. Tizanidine 8 mg PO QHS
25. Venlafaxine XR 150 mg PO DAILY
26. Vitamin D 1000 UNIT PO DAILY
27. Xiidra (lifitegrast) 5 % ophthalmic (eye) BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
==================
Community acquired pneumonia
Secondary diagnoses:
====================
-History of high degree heart block s/p PPM
-Common variable immunodeficiency
-Chronic pain
-Irritable bowel syndrome
-Major depressive disorder
-Hypertension
-Hypothyroidism
-Type II diabetes mellitus
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 part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for a pneumonia
What was done for me while I was in the hospital?
- You had a CT scan of your lungs which showed a pneumonia in
your right lung
- You were given antibiotics to treat the pneumonia
What should I do when I leave the hospital?
- You should take all your medications as prescribed
- You should schedule a follow up appointment with Dr ___
one week after discharge to determine if you should increase
your IVIG dose.
We wish you the very best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10246275-DS-6 | 10,246,275 | 24,385,579 | DS | 6 | 2117-05-28 00:00:00 | 2117-06-01 16:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin / Xanax
Attending: ___.
Chief Complaint:
Primary Diagnosis: Community Acquired Pneumonia
Major Surgical or Invasive Procedure:
None this hospitalization.
History of Present Illness:
This is a ___ yo F w/ PMHx of NHL, AV block s/p PPM in ___, IgA
nephropathy, and HTN, presenting with a 4 day history of chills,
myalgias, and cough. She first started feeling ill on ___
and presented to At___ on ___ with sore throat, non-productive
cough, shaking chills, temp 101, and some SOB that would improve
with prn albuterol. At that time, her WBC 19.5 and CXR normal.
She was started on doxycycline 100mg bid x10d for a presumed
pneumonia. She started to feel better yesterday, with decreased
chills, cough, myalgias. Last night around 7pm, she noted
profound fatigue, full body aches and today at 5am shaking
chills, temp 99.7, and cough especially when she takes a deep
breath. She took ibuprofen + tylenol.
In the ED, initial VS were 99.5 96 151/99 16 96%RA
Exam significant for new systolic apical ejection murmur
Labs significant for WBC 15.2, d-dimer 1243
Imaging significant for normal CXR and normal CTA.
Received 1 g ceftriaxone, 100 mg doxycycline, 2 L NS.
Transfer VS were 98.2 81 145/100 18 98% RA
On arrival to the floor, patient reports that she is still
experiencing some myalgias, fatigue, headache and cough that is
worse with breathing.
Past Medical History:
-Hodgkin's disease IV age ___, s/p ABVD, s/p autoSCT
-Hypertension
-AV block II-III: s/p PPM ___
-Hypothyroidism
-Adrenal adenoma
-Constipation
-CKD (chronic kidney disease), stage III
-Asthma
-Primary ovarian failure
-Immunoglobulin deficiency
-Osteoarthritis
-Obesity
-Pulmonary nodule
-Chronic pain
-IgA nephropathy
-Hyperlipidemia
-Glomus tumor R index finger s/p excision 8d ago
-Hx recurrent PNAs and URIs until ___, has required 7d
admission w/3 unusual organisms isolated (___)
Social History:
___
Family History:
Mother passed away from unknown type of cancer
Physical Exam:
==========
ADMISSION
==========
VITALS: 98.3 155/92 78 18 97%
GENERAL: NAD, well nourished female
HEENT: AT/NC, EOMI, PERRL, anicteric sclerae, pink conjunctivae,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, ___ systolic murmur at LUSB, no gallops or
rubs
LUNG: CTAB, no wheezes, rales, rhonchi, coughs with deep
inspiration
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema, no ___ nodes ___ lesions. right index finger
wrapped in bandage from globus tumor removal.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, AAOx3
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
=============
DISCHARGE
=============
VITALS: 98.2 123/65 74 18 97% RA
GENERAL: NAD, well nourished female
HEENT: AT/NC, EOMI, PERRL, anicteric sclerae, pink conjunctivae,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, ___ systolic murmur at LUSB, no gallops or
rubs
LUNG: CTAB, no wheezes, rales, rhonchi, coughs with deep
inspiration
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema, no ___ nodes ___ lesions. right index finger
wrapped in bandage from globus tumor removal.
PULSES: 2+ DP pulses bilaterally
NEURO: AAOx3
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
==============
ADMISSION LABS
==============
___ 08:40AM BLOOD WBC-15.2*# RBC-3.79* Hgb-12.3 Hct-36.4
MCV-96 MCH-32.4* MCHC-33.7 RDW-12.9 Plt ___
___ 08:40AM BLOOD Neuts-81.3* Lymphs-12.6* Monos-3.2
Eos-2.6 Baso-0.3
___ 08:40AM BLOOD Plt ___
___ 08:40AM BLOOD Glucose-107* UreaN-25* Creat-0.9 Na-140
K-6.4* Cl-101 HCO3-28 AnGap-17
___ 08:40AM BLOOD D-Dimer-1243*
___ 08:40AM BLOOD IgG-589* IgA-75 IgM-59
___ 08:48AM BLOOD Glucose-108* Lactate-1.6 K-4.0
===========
MICRO
===========
Ucx and Bcx negative
Urinary Legionella negative
Viral res panel negative
===========
IMAGING
===========
CXR ___ual lead pacing device is seen with
leads in the right atrium and right ventricular apex. The lungs
are clear of focal consolidation or effusion. The
cardiomediastinal silhouette is within normal limits. No acute
osseous abnormalities identified.
CTA CHEST ___: No evidence of pulmonary embolus. Diffuse
ground-glass opacities may represent atelectasis or edema, given
Preliminary Reportlow lung volumes.
==============
DISCHARGE LABS
==============
___ 07:00AM BLOOD WBC-9.8 RBC-3.67* Hgb-11.9* Hct-36.2
MCV-99* MCH-32.5* MCHC-33.0 RDW-13.2 Plt ___
___ 07:00AM BLOOD Neuts-63.6 ___ Monos-4.4 Eos-3.3
Baso-0.5
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD Glucose-115* UreaN-12 Creat-0.7 Na-141
K-3.4 Cl-104 HCO3-28 AnGap-12
___ 07:00AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.1
Brief Hospital Course:
This is a ___ yo F w/ PMHx of NHL, AV block s/p PPM in ___, IgA
nephropathy, and HTN, presenting with a 4 day history of chills,
myalgias, and cough, concerning for pneumonia.
================
ACUTE ISSUES
================
#Cough/Fevers/Chills: Most likely URI vs PNA. Cough and pain on
deep inspiration more suggestive of lower respiratory
involvement. CTA chest negative for PE, but shows bilateral
small pleural effusions and diffuse ground-glass opacities and
small effusions, which could suggest an atypical pneumonia. Even
though CXR is not suggestive of pneumonia, her symptoms of
cough, fevers, chills, and CT findings are supportive of a
possible diagnosis of pneumonia. Viral resp screen, blood
cultures, and urine legionella negative. Patient was discharged
on a 7 day course of Cepodoxime (First Day = ___ and was
instructed to finish her course of Azithromycin that she had
previously been prescribed.
#Leukocytosis: Most likely ___ pulmonary infection. Improving in
the setting of antibiotics.
# Systolic apical ejection murmur: Atrius cards note does not
document murmur on exam. In setting of fevers and chills as well
as PPM, concerning for endeocarditis, however TTE does not show
any evidence of vegetations. New murmur msot likely a flow
murmur in the setting of infection.
=================
CHRONIC ISSUES
=================
#Hypothyroidism: continue home Levothyroxine
#Asthma: continue home albuterol and symbicort
#Depression/Anxiety: Continue home bupropion and citalopram and
lorazepam
#HLD: continue home statin
#HTN: continue home lisinopril
=====================
TRANSITIONAL ISSUES
=====================
Patient was discharged on a 7 day course of Cepodoxime (First
Day = ___ and was instructed to finish her course of
Azithromycin that she had previously been prescribed.
- continue CeftriaXONE 1 gm IV Q24H (First Day = ___
- continue Doxycycline Hyclate 100 mg PO Q12H (First Day =
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 900 mg PO TID
2. BuPROPion (Sustained Release) 450 mg PO QAM
3. Levothyroxine Sodium 125 mcg PO DAILY
4. Omeprazole 20 mg PO BID
5. TraZODone 150 mg PO QPM
6. Albuterol Inhaler 90 mcg IH PRN asthma exacerbation
7. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation PRN asthma exacerbation
8. Patanol (olopatadine) 0.1 % ophthalmic PRN
9. Polyethylene Glycol 17 g PO Q48H
10. Simvastatin 10 mg PO QPM
11. Voltaren (diclofenac sodium) 1 % topical PRN knee pain
12. Acetaminophen 1000 mg PO PRN pain
13. DiphenhydrAMINE 50 mg PO Q8H:PRN Allergies?
14. Ferrous Sulfate 325 mg PO QPM
15. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
QAM
16. Multivitamins 1 TAB PO DAILY
17. Lisinopril 20 mg PO QPM
18. Citalopram 20 mg PO QPM
19. Lorazepam 1 mg PO BID
20. Doxycycline Hyclate 100 mg PO Q12H
Discharge Medications:
1. Acetaminophen 1000 mg PO PRN pain
2. Albuterol Inhaler 90 mcg IH PRN asthma exacerbation
3. BuPROPion (Sustained Release) 450 mg PO QAM
4. Citalopram 20 mg PO QPM
5. DiphenhydrAMINE 50 mg PO Q8H:PRN Allergies?
6. Gabapentin 900 mg PO TID
7. Levothyroxine Sodium 125 mcg PO DAILY
8. Lisinopril 20 mg PO QPM
9. Lorazepam 1 mg PO BID
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 20 mg PO BID
12. Polyethylene Glycol 17 g PO Q48H
13. Simvastatin 10 mg PO QPM
14. TraZODone 150 mg PO QPM
15. Voltaren (diclofenac sodium) 1 % topical PRN knee pain
16. Ferrous Sulfate 325 mg PO QPM
17. Patanol (olopatadine) 0.1 % ophthalmic PRN
18. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION PRN asthma exacerbation
19. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
QAM
20. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 8 Days
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp
#*16 Tablet Refills:*0
21. Doxycycline Hyclate 100 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Atypical community acquired pneumonia
Systolic ejection murmur
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 to ___ on ___ due to fevers, chills, and
cough concerning for pneumonia. You were continued on
Doxycycline and started on cefpodoxime. You will complete the
course of doxycycline as prescribed by your PCP. You will
complete a course of cefpodoxime on ___.
While you were here, you were found to have a new murmur. You
had an ECHO performed, which showed evidence of hypertension
(which we know you have). This murmur is most likely a benign,
innocent murmur.
We wish you all the best.
Your Primary ___ Team
Followup Instructions:
___
|
10246275-DS-7 | 10,246,275 | 22,012,583 | DS | 7 | 2117-06-29 00:00:00 | 2117-06-29 22:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin / Xanax
Attending: ___
Chief Complaint:
Pneumonia, Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old Female who pesents with 1 day of cough, fever,
arthralgias, nausea, dysuria who presents with fever of 102,
tachycardia, lethargy found with pneumonia on imaging. Per the
patient she has a history of frequent pneumonias. In the ED she
was found to be markedly lethargic, barely rousable per the ED
notes (she has no memory of all this, and fell apparently per
nursing, although the physician ___ does not mention this).
In the ED initial vitals were 102.1, 120, 121/64, 20, 97%. She
was given 3L of IV fluids, along with ceftriaxone and
azythromycin for CAP. After the fluid boluses she felt dyspneic
and nauseaus.
On arrival to the floor she is much improved, and is not
lethargic at all, although still feels ill. She afebrile at this
time after acetaminophen administration.
Past Medical History:
-Hodgkin's disease IV age ___, s/p ABVD, s/p autoSCT
-Hypertension
-AV block II-III: s/p PPM ___
-Hypothyroidism
-Adrenal adenoma
-Constipation
-CKD (chronic kidney disease), stage III
-Asthma
-Primary ovarian failure
-Immunoglobulin deficiency
-Osteoarthritis
-Obesity
-Pulmonary nodule
-Chronic pain
-IgA nephropathy
-Hyperlipidemia
-Glomus tumor R index finger s/p excision 8d ago
-Hx recurrent PNAs and URIs until ___, has required 7d
admission w/3 unusual organisms isolated (___)
Social History:
___
Family History:
Mother passed away from unknown type of cancer
Physical Exam:
ROS:
GEN: + fevers, + Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: + Nausea, - Vomitting, - Diarhea, - Abdominal Pain, -
Constipation, - Hematochezia
PULM: + Dyspnea, + Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: + Myalgia, + Arthralgia, - Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
PHYSICAL EXAM:
VSS: 99.3, 116/7, 93, 18, 96%
GEN: NAD, sleepy but fully conversant
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, ___ HSM
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: CAOx3, Motor ___ ___ flex/ext/finger spread
On disharge afebrile, lungs remain CTA
Pertinent Results:
___ 12:02PM BLOOD WBC-16.3*# RBC-3.86* Hgb-12.8 Hct-37.9
MCV-98 MCH-33.2* MCHC-33.9 RDW-13.3 Plt ___
___ 12:02PM BLOOD Neuts-89.3* Lymphs-7.8* Monos-2.0 Eos-0.8
Baso-0.1
___ 12:02PM BLOOD Glucose-96 UreaN-29* Creat-1.0 Na-143
K-3.7 Cl-107 HCO3-26 AnGap-14
___ 12:02PM BLOOD HCG-<5
___ 12:07PM BLOOD Lactate-1.7
___ 06:02AM BLOOD WBC-20.7* RBC-3.54* Hgb-11.8* Hct-35.0*
MCV-99* MCH-33.2* MCHC-33.6 RDW-13.2 Plt ___
___ 06:35AM BLOOD WBC-13.4* RBC-3.37* Hgb-11.4* Hct-32.8*
MCV-97 MCH-33.7* MCHC-34.7 RDW-13.8 Plt ___
___ 06:02AM BLOOD Glucose-87 UreaN-19 Creat-1.1 Na-143
K-4.2 Cl-105 HCO3-30 AnGap-12
CHEST (PA & LAT) Study Date of ___ 5:18 ___
IMPRESSION:
Vague opacity in the right mid to lower lung is concerning for
pneumonia.
Blood cultures from ___: NGTD
Urine culture pending
Brief Hospital Course:
___ yo women w/ PMHx of Hodgkins disease s/p autologous SCT,
HTN, stage III CKD, IgA nephropathy, immunoglobulin deficiency,
and recurrent pneumonias p/w cough, fever, arthralgias,
headache, found to have right sided pna.
# Bacterial Pneumonia: Patient was initially treated with
Ceftriaxone and Azithromycin given her fever, cough, and
pneumonia on chest X-ray. She remained afebrile with
downtrending white count. She appeared clinically well
throughout her hospitalization. She was switched to levofloxacin
to complete a week long total course of antibiotics. An ECG was
checked and pt's QT was not prolonged so despite being on
citalopram and trazadone, felt as though brief course of
levofloxacin would be relatively low risk. Pt curious as to why
she gets pneumonia so frequently. It appears that she does have
a history of immunoglobulin deficiency and during her last
hospitalization her IgG was mildly low. I advised her to follow
up with immunology. She was given the name of an allergist and
immunologist here ___ or she can follow up at At___.
# Chronic Stable Asthma: Albuterol was continued. Pt should
hold steroid inhaler until pneumonia resolved.
# Hypothyroidism: Patient's home levothyroxine was continue.
# Chronic Pain Syndrome: Gabapentin, Citalopram, and Diclofenac
cream were continued.
# HTN: Lisinopril
# High grade AV block s/p PPM: Recently interrogated. Mostly in
AsVs.
Transitional:
Will need to complete 4 more days of levofloxacin
Will need follow up CXRay in ___ weeks
Will need to see immunology to evaluate for immunodeficiency,
IgG deficiency, etiology of recurrent pnas
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
3. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN sore throat
4. Citalopram 20 mg PO DAILY
5. TraZODone 150 mg PO QHS
6. Omeprazole 20 mg PO DAILY
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Simvastatin 20 mg PO QPM
9. DiCYCLOmine 10 mg PO DAILY:PRN spasm
10. Gabapentin 600 mg PO TID
11. Lorazepam 1 mg PO QHS:PRN insomnia
12. Lorazepam 2 mg PO DAILY:PRN anxiety
13. diclofenac sodium 1 % topical BID
14. budesonide-formoterol 160-4.5 mcg/actuation inhalation 2
Puff Daily
15. Ibuprofen 400 mg PO Q8H:PRN pain
16. Levothyroxine Sodium 125 mcg PO DAILY
17. olopatadine 0.1 % ophthalmic BID
18. Prochlorperazine 5 mg PO Q8H:PRN nausea
19. BuPROPion (Sustained Release) 300 mg PO QAM
20. Multivitamins 1 TAB PO DAILY
21. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
2. BuPROPion (Sustained Release) 300 mg PO QAM
3. Citalopram 20 mg PO DAILY
4. diclofenac sodium 1 % TOPICAL BID
5. DiCYCLOmine 10 mg PO DAILY:PRN spasm
6. Ferrous Sulfate 325 mg PO DAILY
7. Gabapentin 600 mg PO TID
8. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN sore throat
9. Ibuprofen 400 mg PO Q8H:PRN pain
10. Levothyroxine Sodium 125 mcg PO DAILY
11. Lisinopril 40 mg PO DAILY
12. Lorazepam 1 mg PO QHS:PRN insomnia
13. Lorazepam 2 mg PO DAILY:PRN anxiety
14. Multivitamins 1 TAB PO DAILY
15. olopatadine 0.1 % ophthalmic BID
16. Omeprazole 20 mg PO DAILY
17. Polyethylene Glycol 17 g PO DAILY:PRN constipation
18. Prochlorperazine 5 mg PO Q8H:PRN nausea
19. Simvastatin 20 mg PO QPM
20. TraZODone 150 mg PO QHS
21. Levofloxacin 500 mg PO DAILY Duration: 4 Days
RX *levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth Q24h
Disp #*4 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia
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 cough and fever and
started on antibiotics for pneumonia. You remained afebrile.
Tests for flu were negative. Your white count improved with
antibiotics. You will complete four more days of levofloxacin
Followup Instructions:
___
|
10246786-DS-11 | 10,246,786 | 21,770,092 | DS | 11 | 2161-08-02 00:00:00 | 2161-08-02 19:28:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ with history of diastolic heart
failure/CHFwPEF, hypertension, stage IV chronic kidney disease,
diabetes mellitus type II, and peripheral vascular disease
presenting with shortness of breath. The patient reports that
his symptoms have gotten worse for the past few months, but have
become acutely worsened over the past week. He is now having
some shortness of breath at rest with dyspnea on exertion
walking from his bed to the bathroom. It is now taking him about
five minutes to recover after exertion. The patient has also
noticed increased lower extremity edema. While working with home
___ today, he was noted to desaturate to 84% with ambulation. He
denies orthopnea (two pillows at baseline, stable), chest
pain/pressure, fevers, chills, or cough.
In the ED intial VS: 98 72 192/61 22 93%. Initial labs were
notable for CBC with hematocrit of 31.7% (baseline 33%),
creatinine of 2.7 (baseline 2.5-2.6; ___, troponin 0.02,
BNP 3595. A UA was unremarkable other than some proteinuria. A
CXR showed moderate right sided pleural effusion. The patient
was given furosemide 40mg IV and was admitted for concern of CHF
exacerbation.
Upon arrival to the floor, initial vital signs were 98 179/92 81
20 100%/3LNC 110.4kg. Patient endorsed the above history. He was
without current complaint.
Past Medical History:
1. Hypertension.
2. Diabetes mellitus, type 2.
3. Diastolic dysfunction
4. Diuretic-dependent edema.
5. Peripheral vascular disease with possible left carotid
stenosis, followed by Dr. ___ at ___, possible history
of past TIA.
6. Macrocytic anemia, followed by ___ at ___.
7. History of squamous cell carcinoma.
8. History of gout, on allopurinol.
Social History:
___
Family History:
Not relevant
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- T98 BP179/92 HR81 RR20 100% 3LNC
Wt 110.4kg
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP difficult to appreciate given habitus
Lungs: Diffuse wheeze, crackles on right, dullness to percussion
on right lower aspect
CV: RRR (+)S1/S2 distant
Abdomen: soft, non-tender, non-distended
GU: deferred
Ext: Warm, well-perfused, 2+ ___ edema to knees b/l, area of
erythema on LLE without warmth or tenderness, R big toes with
callous
Neuro: CNs2-12 intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM:
Vitals: Tm98.6 BP196/68->166/65, HR60-70s, RR18, 98RA
___ 114-171
Wt 106.2kg
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, moist mucous membranes, oropharynx
clear
Neck: Supple, JVP 8cm
Lungs: lungs clear, no wheezing
CV: RRR, normal S1 S2, no murmurs
Abdomen: soft, non-tender, non-distended, no rebound or guarding
Ext: Warm, well-perfused, 1+ ___ edema to knees, R great toe with
callous and pink, clean dry intact, nontender, no purulence
Neuro: motor function grossly normal
Pertinent Results:
ADMISSION LABS:
___ 05:42PM BLOOD WBC-10.1 RBC-2.88* Hgb-9.6*# Hct-31.7*
MCV-110*# MCH-33.4* MCHC-30.3*# RDW-20.6* Plt ___
___ 05:42PM BLOOD ___ PTT-32.1 ___
___ 12:57AM BLOOD Glucose-94 UreaN-45* Creat-2.8* Na-143
K-3.7 Cl-104 HCO3-27 AnGap-16
___ 07:40AM BLOOD Calcium-8.3* Phos-4.7* Mg-2.1
DISCHARGE LABS:
___ 06:46AM BLOOD WBC-9.6 RBC-2.68* Hgb-9.1* Hct-29.1*
MCV-109* MCH-33.9* MCHC-31.3 RDW-20.0* Plt ___
___ 06:46AM BLOOD Glucose-107* UreaN-57* Creat-3.3* Na-145
K-3.9 Cl-102 HCO3-30 AnGap-17
___ 06:46AM BLOOD Calcium-8.8 Phos-4.9* Mg-2.3
CARDIAC:
___ 05:42PM BLOOD cTropnT-0.02* proBNP-3595*
___ 12:57AM BLOOD CK-MB-2 cTropnT-0.02*
___ 07:40AM BLOOD cTropnT-0.02*
___ CXR
Interval development of moderate right-sided pleural effusion
since prior. Focal opacity projecting over the spine on the
lateral view
should be followed on subsequent exams.
___ ECG
Sinus bradycardia with sinus arrhythmia and a P-R interval of
360 milliseconds and premature atrial contractions. Non-specific
intraventricular conduction delay. The Q-T interval is 440
milliseconds with QTc interval of 429 milliseconds. Non-specific
T wave abnormalities. Compared to the previous tracing of
___ sinus bradycardia and first degree A-V conduction delay
are present.
___ TTE
The left atrium is mildly dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Right ventricular chamber size and free
wall motion are normal. The ascending aorta is mildly dilated.
The aortic valve leaflets (3) are mildly thickened. There is no
valvular aortic stenosis. The increased transaortic velocity is
likely related to high cardiac output. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Symmetric LVH with normal global and regional
biventricular systolic function. Mild pulmonary hypertension.
Brief Hospital Course:
___ with history of diastolic CHF, CKD, DM2, HTN, PVD presenting
with worsening shortness of breath, found to have elevated BNP
and new pleural effusion, most consistent with CHF exacerbation.
# Acute diastolic CHF exacerbation. History of CHF with
preserved EF, on torsemide at home. Patient reporting increased
SOB and DOE over last 1 month, with worsening lower extremity
edema. BNP elevated to 3595, no baseline here, previously 4000
once in ___ at ___. CXR demonstrating pleural effusion
which is most likely secondary to CHF. EKG with sinus arrhythmia
with very prolonged PR > 300ms and Wenkebach. Troponins only
mildly elevated 0.02 x3, likely mild troponin leak from CHF.
Repeat TTE on ___ showd LVH, preserved EF, likely diastolic HF
from hypertension. Patient was initially treated with furosemide
80mg IV with minimal urine response, but he responded to
furosemide 120mg IV boluses. He was treated with furosemide
120mg IV boluses BID, and he did lose 4 kg over the course of
his admission. Foley was inserted, but due to Foley trauma and
patient discomfort and agitation, this was removed on day of
discharge. He was continued on his home aspirin, statin, and
losartan. His torsemide was increased from 20mg to 40mg.
# Hypertension. Patient reports his BPs at home are
well-controlled, but he was hypertensive here to SBP 190s on
admission. He has had difficulties with BP control per review of
past OMR notes and by Dr. ___. Labetalol was tried initially
in-house but stopped due to asymptomatic bradycardia to HR40s.
Per HYVET trial (treatment of hypertension in ___+ year old
patients), benefit is to treat HTN to target of <150. He
received several doses of hydralazine ___ IV for
hypertension. On day of discharge, he was switched back to his
home HCTZ 12.5mg and we uptitrated torsemide to 40mg daily.
# Chronic kidney disease. Stage IV, followed at ___
Nephrology. Creatinine appears near recent baseline from ___. Cr
2.7 on admission, increased to Cr 3.3 on discharge, likely due
to diuretic use.
# Diabetes. Patient with diabetes, last A1c was 6.4% in ___
at ___. Controlled with insulin sliding scale in-house without
significant difficultues and he was discharged on his home
repaglinide.
# Code: Full, discussed with patient ___
# Emergency Contact: Wife ___
### TRANSITIONAL ISSUES ###
1) Torsemide increased from 20mg to 40mg daily.
2) All other medications unchanged.
3) Follow up with PCP, ___, and Cardiology Dr. ___
consideration of pacemaker.
4) Continue management of difficult to control hypertension.
5) Patient complains of mildly painful right great toe, bruised
and with corn. Low suspicion for gout. Booked Podiatry
appointment.
6) Patient had Foley removed on day of discharge. There was
cranberry colored urine draining secondary to Foley trauma on
insertion. Expect gradual resolution of hematuria over next ___
hours.
7) Please recheck electrolytes at next visit.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 100 mg PO DAILY
2. Allopurinol ___ mg PO DAILY
3. ammonium lactate 12 % topical daily
4. Amlodipine 5 mg PO DAILY
5. Simvastatin 20 mg PO DAILY
6. Torsemide 20 mg PO DAILY
7. Repaglinide 1 mg PO DAILY BEFORE LUNCH
8. Aspirin 325 mg PO DAILY
9. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
10. Donepezil 5 mg PO HS
11. fenofibrate 67 mg oral daily
12. Hydrochlorothiazide 12.5 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Amlodipine 5 mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. Donepezil 5 mg PO HS
5. Hydrochlorothiazide 12.5 mg PO DAILY
6. Losartan Potassium 100 mg PO DAILY
7. Simvastatin 20 mg PO DAILY
8. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
9. ammonium lactate 12 % topical daily
10. fenofibrate 67 mg oral daily
11. Repaglinide 1 mg PO DAILY BEFORE LUNCH
12. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
1) Congestive heart failure, acute, diastolic
2) Essential hypertension
SECONDARY:
1) Chronic kidney disease
2) Diabetes mellitus, type 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to take care of you at ___
___. You were admitted to the hospital because of
shortness of breath. You have congestive heart failure, which is
a condition where the heart muscle is not pumping normally. This
leads to shortness of breath as fluid builds up in your body and
particularly the base of your lungs. You were treated with
medication (Lasix) to help remove extra fluid from your lungs
and legs.
Your torsemide was increased from 20mg to 40mg daily. All your
other medications were continued. Please follow up with your
primary care physician, ___, and cardiologist.
Please weigh yourself every day. Call your cardiologist if you
weight increases by more than 3 pounds, as you may be building
up fluid.
Followup Instructions:
___
|
10246786-DS-13 | 10,246,786 | 29,004,676 | DS | 13 | 2161-09-13 00:00:00 | 2161-09-13 15:35:00 |
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:
thoracentesis
R pigtail placement and removal
Picc placement and removal
___ HD tunneled line placement
History of Present Illness:
___ pmh of DM2, CKD (discussing HD with nephrology), diastolic
heart failure, recent osteomyelitis of foot s/p debridement +
daptomycin/moxi who presents with fever. Pt reports fever to
101.5 earlier today as well as 24 hrs of fatigue, chills, SOB
and productive cough over past several weeks. He states that
since his recent discharge for osteomyelitis, he no longer has
any foot discomfort. Denies dysuria, no diarrea, no abdominal
pain. Podiatry saw pt today and removed stitches and felt
osteomyelitis was healing.
Pt had recent hospitalization from ___: Diabetic foot
infection that failed outpatient treatment-> MRI showed osteo,
sp debridement. Given moxi 400g daily and dpto 480mg q 48hr x 6
weeks to be finished ___. Hospital course complicated with
ARF (baseline Cr 2.7) increased to 3.5. ___ was stopped on that
afmission and torsemide was held briefly and then resumed. Pt
found to have wenkeback as well and was given carvedilol,
however, HR dropped to ___ so BB was stopped.
In the ED intial vitals were: 101 88 172/70 16 100% 4L
- Labs were significant for Cr 4.2, BUN 94, HCT 26.5 (MCV 108) ,
WBC 19.3 (93% Neut),
- Patient had ___ in ED with 300cc yellow fluid. CXR showed
consolidation. ID was called and recc vanco/aztreonam for HCAP
PNA given penicillin allergy.
Vitals prior to transfer were: 98.5 85 150/72 24 95% RA
On the floor, pt is comfortable and conversant. No acute
distress. He reports that his shortness of breath is markedly
improved since the thoracentesis. Denies any cough at this time.
Review of Systems:
(+) see hpi
(-) headache, vision changes, rhinorrhea, congestion, sore
throat, chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
1. Hypertension.
2. Diabetes mellitus, type 2.
3. Diastolic dysfunction
4. Diuretic-dependent edema.
5. Peripheral vascular disease with possible left carotid
stenosis, followed by Dr. ___ at ___, possible history
of past TIA.
6. Macrocytic anemia, followed by ___ at ___.
7. History of squamous cell carcinoma.
8. History of gout, on allopurinol
9. CKD- discussing HD outpatient
Social History:
___
Family History:
No family history of cardiac disease or cancer that he knows of
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- 98.8 ___, HR 88, RR 19, 96ra
General- Alert, oriented, no acute distress, pale appearing
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- crackles in bilateral bases and decreased breath sounds
in right lower base
CV- Regular rate and rhythm, ___ murmur left sternal border
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext- warm, well perfused, edema up to calves bilaterally
DISCHARGE PHYSICAL EXAM:
Vitals: 98.4 152/40 58 18 98% ra
discharge weight: 95kg
General- Elderly male with somewhat flat affect.AOx3
HEENT- Sclera anicteric
Chest- Tunneled line in place on left, incision c/d/i.
Lungs- Crackles at right base along with decreased breath sounds
CV - IRIR, ___ murmur left sternal border that radiates to
carotids
Abdomen - soft, non-tender, non-distended, bowel sounds present,
no rebound/guarding.
Ext- warm, well perfused, no edema, L ___ toe with dry scabbing
no evidence of erythema or bone exposed.
Pertinent Results:
ADMISSION LABS:
___ 05:29PM UREA N-98* CREAT-4.4* SODIUM-142
POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-23 ANION GAP-18
___ 05:29PM estGFR-Using this
___ 05:29PM ALT(SGPT)-18 AST(SGOT)-21
___ 05:29PM ALBUMIN-4.3 CALCIUM-9.0 PHOSPHATE-6.4*#
MAGNESIUM-2.5 URIC ACID-8.1*
___ 05:29PM PTH-78*
___ 05:29PM 25OH VitD-56
___ 05:29PM URINE HOURS-RANDOM CREAT-83 TOT PROT-39
PROT/CREA-0.5* albumin-26.2 alb/CREA-315.7*
___ 05:29PM WBC-9.6 RBC-2.65* HGB-8.6* HCT-28.7* MCV-108*
MCH-32.5* MCHC-30.0* RDW-21.5*
___ 05:29PM NEUTS-76* BANDS-9* LYMPHS-11* MONOS-3 EOS-1
BASOS-0 ___ MYELOS-0
___ 05:29PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL SPHEROCYT-1+
OVALOCYT-1+ TARGET-1+ ELLIPTOCY-OCCASIONAL
___ 05:29PM PLT SMR-NORMAL PLT COUNT-316
PERTINENT LABS:
___ 11:18PM PLEURAL TOT PROT-3.1 GLUCOSE-167 CREAT-4.3
LD(LDH)-93 AMYLASE-21 ALBUMIN-2.0
___ 11:18PM PLEURAL WBC-243* RBC-129* POLYS-12* LYMPHS-80*
MONOS-4* EOS-1* MESOTHELI-1* MACROPHAG-2*
___ 08:13PM LD(LDH)-184
___ 08:13PM TOT PROT-6.4
___ 08:29PM LACTATE-1.3
___ 01:00PM BLOOD calTIBC-229* ___ Ferritn-237
TRF-176*
___ 06:07AM BLOOD TSH-5.9*
___ 06:00PM BLOOD Free T4-0.80*
___ 04:00PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 03:38PM PLEURAL WBC-94* ___ Polys-46*
Lymphs-45* Monos-3* Macro-6*
___ 03:38PM PLEURAL TotProt-3.2 Glucose-135 LD(LDH)-138
Albumin-2.0 Cholest-35
___ 02:51AM BLOOD LD(LDH)-139
___ 02:51AM BLOOD TotProt-5.4* Calcium-7.7* Phos-5.8*#
Mg-2.4
IMAGING:
CXR ___ pre-thoracentesis:
Large area of opacity projecting over the right lower hemithorax
is worrisome for consolidation and possible pleural effusion.
Additional small focus of opacity superior to this concerning
for additional site of infection.
CXR ___ post-thoracentesis:
AP and lateral views the chest were viewed. The
cardiomediastinal and hilar contours are stable. There has been
decrease in the right pleural effusion following thoracentesis.
No pneumothorax is seen. A left PICC line is present in the left
brachiocephalic vein, but the tip is not well visualized.
TTE ___: Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
The right ventricular cavity is mildly dilated with normal free
wall contractility. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve.
Trivial mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion.
IMPRESSION: No vegetations or clinically-significant regurgitant
valvular disease seen. Normal left ventricular systolic
function. Mildly dilated right ventricle with preserved systolic
function. Mild pulmonary hypertension.
CHEST CT ___:
1. Area of consolidation and patchy ground-glass opacities in
the left lower lobe without significant volume loss is
consistent with
inflammatory/infectious process.
2. Large right-sided pleural effusion resulting in complete
collapse of the right lower lobe. Area of hyperdense nodularity
in the posterior/most
dependent portion of the parietal pleura may be related to
residual blood
products from recent thoracocentesis but neoplastic process
cannot be
excluded. If no further thoracocentesis is planned, reassessment
in 4 weeks is recommended since blood products should have
completely resolved by then.
3. Cardiomegaly. Increased caliber of the pulmonary arteries
suggests
pulmonary hypertension.
4. 2.4 cm hypodense left thyroid lobe nodule can be further
assessed by
ultrasound if clinically indicated and if it would alter
management.
5. Splenomegaly.
Tunneled HD Catheter Placement ___: Placement of 23cm
tip-to-cuff tunneled hemodialysis catheter through a left
internal jugular vein approach. The tip is located in the right
atrium and the catheter is ready for use.
CXR ___ After 700cc had drained out ___ thoracentesis: As
compared to the previous radiograph, the patient has received a
small right Pleurx catheter. The extent of the pre-existing
right pleural effusion has decreased. Also decreased are the
areas of pre-existing atelectasis at the right lung base.
However, the moderate amount of right effusion remains.
CXR ___: As compared to the previous radiograph, there is
ongoing increasing opacification of the right lower lung,
associated to air bronchograms. The findings are highly
suggestive of either pneumonia or aspiration. There is no
evidence of pneumothorax. The left hemithorax is unremarkable.
Borderline size of the cardiac silhouette without pulmonary
edema.
The pigtail catheter on the right is in unchanged position.
There is no major pleural effusion.
MICRO
=======
___ 11:18 pm PLEURAL 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 (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
___ 8:13 pm BLOOD CULTURE
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:29 am URINE Source: Catheter.
URINE CULTURE (Final ___: NO GROWTH.
CYTOLOGY
==========
FLUID, PLEURAL, RIGHT (___):
NEGATIVE FOR MALIGNANT CELLS.
Lymphocytes, monocytes, and rare mesothelial cells.
EKG
=====
___: Atrial fibrillation with slow ventricular response.
Extensive non-specific
ST-T wave changes. Probable Q-T interval prolongation. Compared
to the
previous tracing of ___ the rhythm now appears to be atrial
fibrillation
with a slow response. Precordial lead voltage has decreased.
DISCHARGE LABS:
=================
___ 05:18AM BLOOD WBC-9.6 RBC-2.59*# Hgb-8.9*# Hct-26.9*
MCV-104* MCH-34.3* MCHC-33.0 RDW-20.9* Plt ___
___ 05:18AM BLOOD Glucose-98 UreaN-53* Creat-4.1* Na-135
K-4.5 Cl-97 HCO3-28 AnGap-15
___ 05:18AM BLOOD Calcium-7.7* Phos-5.1*# Mg-2.2
Brief Hospital Course:
Mr. ___ is an ___ M with a PMHx of dCHF, HTN, stage IV CKD
(discussing HD), DM2, PAD, recent osteomyelitis sp debridement
and IV antibiotics (completed 2.5/6 weeks) who presented with
fever, hypoxemia, leukocytosis, found to have LLL PNA as well as
fluid overload from end stage renal disease, requiring
initiation of hemodialysis.
ACTIVE DIAGNOSES:
# Sepsis secondary to Left lower lobe healthcare associated
bacterial pneumonia.
WBC 19 and febrile at admission, met criteria for sepsis.
Initial CXR concerning for PNA in RLL. The pt had been
faithfully taking the daptomycin and moxifloxacin he was
discharged on from prior admission for osteomyelitis. He was
initially treated with vancomycin, in addition to home
moxifloxacin for osteo. Antibiotics were later switched back to
home daptomycin and moxifloxacin when thoracentesis chemistries
were transudative. Pt's WBC ct subsequently rose a few days
later, presumably around the time vancomycin became
non-therapeutic (in setting of ESRD). Chest CT revealed LLL PNA,
in addition to large right sided effusion. He was placed back on
vancomycin + moxi and ___ ct trended down. To cover osteo, the
patient's antibiotic course should continue through ___.
# Hypoxia status post large-volume thoracentesis.
Thoracentesis was performed ___, with 2.5L removed around RLL.
That night, pt desaturated into the ___. CXR was concerning for
a new infiltrate in the RLL, ___ ct had risen precipitously, so
meropenem was started in addition to vancomycin and
moxifloxacin. Infectious disease felt that the diagnosis was
actually re-expansion pulmonary edema rather than a new
pneumonia. The pleural catheter was clamped and subsequently
removed. Antibiotic coverage was scaled back to vancomycin,
moxi, and flagyl on ___. To work up the rising white count, a
diff was sent which was notable for 5% bands. Blood and urine
were recultured. C.diff toxin assay could not be run given that
the patient was having formed stools. He was on room air by the
time of discharge.
# End stage renal disease.
Baseline Cr 2.7, during recent admission Cr increased to 4.0 and
was 3.6 at discharge. On admission, Cr 4.4 with BUN 98. Mr.
___ was volume overloaded on exam. Renal was consulted and
recommended aggressive diuresis due to hypoxia. The patient put
out minimal amounts of urine to 120 IV Lasix TID and 10mg
metolazone daily. He continued to desaturate even with large
amounts of supplemental oxygen. The decision was made to
initiate HD. A tunneled central line was placed in the left IJ
on ___ and the patient had his first HD session that day. He
successfully underwent 3 HD sessions and will be scheduled for a
___ schedule. Volume status greatly improved
following initiation of HD and with continued aggressive
diuresis. Transplant surgery was consulted and the patient had
veing mapping performed. He will be scheduled for fistula
placement as an outpatient.
# Right exudative pleural effusion.
The first thoracentesis was performed in the ED as part of the
infectious work-up. 300cc of fluid was removed at that time.
Chemistries were consistent with transudate then. Cytology
negative. Effusion likely a result of end stage renal disease
and fluid overload, as well as decompensated heart failure. The
patient was aggressively diuresed early on in his
hospitalization with inadequate volumes of urine. HD was
initiated on ___ and pleural effusion persisted, not
surprisingly. Chest CT showed complete collapse of the RLL from
this large effusion. A second thoracentesis (therapeutic this
time) was performed on ___, with a total of 2.5 L drained off.
Fluid was cranberry juice colored, with cell counts consistent
with traumatic tap. Chemistries were consistent with exudate,
however the picture may have been clouded by the large amount of
RBCs in the fluid, falsely elevating LDH and total protein.
Pigtail catheter was removed on ___ after concern for
re-expansion pulmonary edema.
# Decompensated diastolic heart failure.
Weight on admission was significantly higher than recent
discharge weight. Pt appeared volume overloaded on exam and
imaging, despite taking torsemide 40mg daily. Decompensation
secondary to worsening renal function. Aggressive diuresis and
initiation of hemodialysis improved volume status greatly.
Weight on discharge 95kg.
# AV Node Disease: An electrophysiology consult was called due
to concerning findings on telemetry. EP diagnosed Mr. ___
with a sick AV node with extremely prolonged AV conduction at
baseline (PR of 360 ms) and also has known Wenckeback. Review of
telemetry strips showed that he probably alternates conducting
through fast and slow pathways while asleep. This may be
exacerbated due to vagal input. He may need outpatient OSA
study. In his ECGs there is evidence of multi-level block. Given
he is asymptomatic there is no acute need for pacemaker.
#Anemia:
Most likely from his CKD. Also has known MDS and is followed by
Dr. ___. B12 recently was tested and was well-repleted. The
patient required 1 RBC transfusion early in his hospital course
for hct < 21. He should have his CBC rechecked on ___ and his
stools guaiac as an outpatient.
# HTN: ___ was stopped on last admission in setting of ARF.
Continued on amlodipine. Started hydralazine and isosorbide
mononitrate this admission. Given that he has started HD, his
pressures were very well controlled during the latter part of
his hospitalization; would attempt to taper off hydralazine if
tolerated by his blood pressure.
# Thyroid nodule: 2.4 cm hypodense left thyroid lobe nodule seen
incidentally on CT scan can be further assessed by ultrasound if
clinically indicated and if it would alter management. TSH was
5.9 and FT4 0.80. Consider repeating TFTs as outpatient when
acute illness resolves.
CHRONIC, INACTIVE DIAGNOSES:
# DM2, controlled:
A1c 5.5% most recently. Held home repaglinide and instead used
ISS. Also held home statin. Repaglinide was restarted upon
discharge.
# Gout: Continued on home allopurinol, renally dosed.
TRANSITIONAL ISSUES:
- Pt is now on HD and has been set up for ___ HD. He
has a history of noncompliance with routine medical care, so he
may need further SW assistance should this prove to be a problem
with HD compliance.
- 2.4 cm hypodense left thyroid lobe nodule seen incidentally on
CT scan can be further assessed by ultrasound if clinically
indicated and if it would alter management
- Consider OSA study given his patterns of AV conduction on
telemetry while sleeping
- Last day of Metronidazole is ___
- Depending on how much insulin the patient is requiring can
think about re-starting his home repaglinide
- Repeat CBC on ___
- should guaiac stools
- Patient has new diagosis of atrial fibrillation and should be
started on coumadin once CBC stabilized and patient can be
compliant with medications.
- CODE STATUS: FULL CODE
- Emergency Contact: Daughter ___: ___ Wife
___: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. moxifloxacin 400 mg oral daily
2. Daptomycin 480 mg IV Q48H
3. Repaglinide 1 mg PO DAILY
4. Allopurinol ___ mg PO DAILY
5. Amlodipine 10 mg PO DAILY
6. Aspirin 325 mg PO DAILY
7. Simvastatin 20 mg PO DAILY
8. Torsemide 40 mg PO DAILY
9. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush
Discharge Medications:
1. Allopurinol ___ mg PO EVERY OTHER DAY
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. moxifloxacin 400 mg oral daily
5. HydrALAzine 25 mg PO Q8H
6. Vancomycin 500 mg IV HD PROTOCOL
7. sevelamer CARBONATE 800 mg PO TID W/MEALS
8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
9. Nephrocaps 1 CAP PO DAILY
10. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
11. Glucose Gel 15 g PO PRN hypoglycemia protocol
12. MetRONIDAZOLE (FLagyl) 500 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Pneumonia, chronic kidney disease ESRD started on HD,
pleural effusion
Secondary: Osteomyelitis, Anemia, Heart Failure
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 meeting you during your recent admission to
___. You were admitted with pneumonia. Fluid around the
infection in your lung was removed in the ER and you were
continued on antibiotics. You also were required to have more
fluid removed while here on the floor with the help of dialysis.
While you were in the hospital, the kidney doctors also saw ___.
You were started on dialysis through you through a line. The
transplant surgeon evaluated you and will call to schedule an
appointment as an outpatient to have a fistula in your arm
surgically placed, so that you can get dialysis through the
fistula.
You were also continued on antibiotics for the infection in your
bone. You will continue those until ___.
Please weigh yourself every morning, call MD if weight goes up
more than 3 lbs. Also, take your medications as prescribed and
follow up with your doctors ___.
Followup Instructions:
___
|
10246786-DS-16 | 10,246,786 | 27,344,677 | DS | 16 | 2162-09-28 00:00:00 | 2162-09-28 13:06:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
___ w/ hx HTN, DMII, ___ (EF>55%), ESRD on ___ HD since ___,
ex-smoker (quit 1970s), presumed myelodysplastic syndrome, p/w
dyspnea and mild somnolence today preceded by ___ weeks
nonproductive cough. HE was seen by ___ who found him to O2 82%
on RA (normally runs 96-100%). He was sent to ___ by ___ MD.
___ triggered for hypoxia at triage for O2 sat 88%RA (not on
home O2). Wife noted that ___ has had a dry cough for 1 week
but unknown if he has had fevers. He remains at baseline with 2
pillow orthopnea and wheelchair bound. ___ did have
scheduled HD yesterday and has not recently missed any sessions,
though dialysis schedule this week was MTF because of the
holidays. Review of systems negative for any fevers, chills,
chest pain, nausea, vomiting, diarrhea. Of note, ___ is
oliguric at baseline.
Further history obtained from daughter was that ___ started
getting URI symptoms on ___ with seemingly productive cough
on ___ though he was unable to produce sputum. He did have a
low grade temperature of 99.5 and was noted to be sluggish. His
daughter noted that ___ started having what appeared to be a
productive cough though he was never actually able to produce
sputum. ___ has not had any sick contacts. He did not get
the flu shot. ___ denies any myalgias.
He has had multiple hospitalizations over the last ___ years for
hyperkalemia in the setting of missed dialysis session
(___), anemia with guaic positive stools and
supratherapeutic INR (etiology not identified - ___,
pneumonia (___), and CHF (___) at which time BNP was
3600.
In the ED initial vitals were: 17:25- 0 99.1 66 157/38 22 88% ea
- Labs were significant for lactate 2.4, VBG 7.42/50, trop 0.09,
BNP 31074 (BNP 3600 in ___ at time of chf exacerbation),
leukocytosis 35.7, h/h 12.5/38.1, thrombocytosis 838 (Noted 550
on ___
- Bedside u/s showed no pericardial effusion but with b/l
pleural effusions
- ___ was given 1g vanc, 4.5g IV pip-tazo empirically for
possible HCAP
Vitals prior to transfer were: 20:24- 0 82 24 96% Nasal Cannula
On the floor, ___ denies any shortness of breath, chest
pain, or discomfort.
Past Medical History:
1. Hypertension.
2. Diabetes mellitus, type 2.
3. Diastolic dysfunction
4. Peripheral vascular disease with possible left carotid
stenosis, followed by Dr. ___ at ___
5. possible history of past TIA.
6. Macrocytic anemia/ presumed myelodysplastic syndrome (not
biopsy-proven)
7. History of squamous cell carcinoma.
8. History of gout, on allopurinol
9. chronic kidney disease stage V, started HD ___
Social History:
___
Family History:
No family history of cardiac disease or cancer that he knows of
Physical Exam:
ADMISSION:
Vitals - T97.7 159/59 HR74 RR30 96%6L NC 93.7kg (Dry weight:
unclear, 92.5kg ___
GENERAL: appears to be in mild distress (thoughe he denies),
speaking in 5 word sentences, audible expiratory coarse breath
sounds, persistent coughing during interview
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: nontender supple neck, unable to assess JVD
CARDIAC: irregularly irregular, bradycardic, S1/S2, ___ sys
murmur LUSB
LUNG: coarse breath sounds throughout, wheezing on expiration,
some use of accessory muscles
ABDOMEN: soft, rounded with accessory muscle use, +BS, nontender
in all quadrants, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: 2+ pitting edema extending up to knees, moving all
4 extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, sensation intact throughout
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
bilateral toes with some eschar though no evidence of active
infection
DISCHARGE:
98.4 116/41-139/49 ___ 95% RA
GEN: NAD
HEENT: conjunctiva pink, sclera anicteric
NECK: supple, no LAD, no SCM use, JVP difficult to appreciated
CV: ___, no m/r/g
LUNG: rhonchi diffusely, prolong expiratory wheezes, both
improved from admission
ABD: obese, soft, nt nd
EXT: trace pitting edema b/l
NEURO: grossly intact b/l
Pertinent Results:
ADMISSION:
___ 05:40PM BLOOD WBC-35.7*# RBC-3.42*# Hgb-12.5*#
Hct-38.1*# MCV-111* MCH-36.5* MCHC-32.8 RDW-20.5* Plt ___
___ 05:40PM BLOOD Neuts-74* Bands-4 Lymphs-12* Monos-9
Eos-0 Baso-0 ___ Metas-1* Myelos-0 NRBC-1*
___ 05:40PM BLOOD Hypochr-OCCASIONAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-OCCASIONAL Polychr-OCCASIONAL
Ovalocy-OCCASIONAL Target-1+ Stipple-OCCASIONAL Tear
___
___ 05:40PM BLOOD Plt Smr-VERY HIGH Plt ___
___ 05:40PM BLOOD ___ PTT-30.2 ___
___ 05:40PM BLOOD Glucose-127* UreaN-36* Creat-5.8* Na-140
K-4.9 Cl-95* HCO3-27 AnGap-23*
___ 05:40PM BLOOD CK(CPK)-24*
___ 05:40PM BLOOD CK-MB-1 cTropnT-0.09* ___
___ 05:40PM BLOOD Calcium-9.6 Phos-4.5 Mg-2.2
___ 05:47PM BLOOD Lactate-2.4*
DISCHARGE:
___ 06:25AM BLOOD WBC-24.3* RBC-2.83* Hgb-10.4* Hct-31.1*
MCV-110* MCH-36.8* MCHC-33.4 RDW-20.3* Plt ___
___ 06:25AM BLOOD Plt Smr-VERY HIGH Plt ___
___ 06:25AM BLOOD Glucose-111* UreaN-56* Creat-7.5*# Na-136
K-5.0 Cl-93* HCO3-26 AnGap-22*
___ 06:25AM BLOOD Calcium-9.0 Phos-6.5* Mg-2.1
IMAGINE:
CXR IMPRESSION:
Persistent small to moderate size right pleural effusion with
right basilar opacity, likely compressive atelectasis. Minimal
streaky left basilar atelectasis. Mild pulmonary vascular
congestion.
Brief Hospital Course:
___ w/ hx dCHF (EF>55%), ESRD on MWF HD since ___, ex-smoker
(quit ___) p/w dyspnea and mild somnolence today preceded by
___ weeks nonproductive cough with concern for hcap and acute on
chronic dCHF.
PRIMARY:
#DYSPNEA: Pt came in with evidence of dyspnea and increased work
of breathing. It was thought to be multifactorial with ESRD,
HCAP, and acute on chronic dCHF all contributing. A chest xray
revealed a persistent right pleural effusion. He received an
additional dialysis session and was started on vancomycin and
zosyn. After dialysis, he had decreased work of breathing. A
repeat CXR revealed persistence of pleural effusion but no
pneumonia. His antibiotics were stopped. He worked with physical
therapy and was found to desaturate to 88% on RA while
ambulating. He recovered quickly. It is unclear how acute or
chronic this may be. He was weaned off all supplemental O2 at
rest and discharged without home O2, which he declined.
#PLEURAL EFFUSION: This appears chronic and unchanged from
previous admissions. He has undergone thoracentesis ___ and
___ with one thoracentesis revealing transudative effusion
and the other one exudative but thought to be 2'/2 traumatic
thoracentesis. His effusions were thought to be 2'/2 ESRD and
dCHF. As his current CXR shows persistent pleural effusion,
without change after multiple HD sessions, and his hypoxia was
not entirely explained, we recommended repeat thoracentesis to
r/o underlying neoplasm esp given his smoking hx. Pt expressed
understanding but declined, said he feels fine and just wants to
go home.
#HCAP: he was initially treated for an HCAP but repeat imaging
did not support this. Antibiotics were stopped.
SECONDARY:
# ESRD on HD (initiated ___, right radiocephalic fistula
created on ___: ___ appears volume overloaded
at this time with persistent right sided pleural effusion.He
maintained usual MWF dialysis schedule.
# Hypertension: maintained on home amlodipine
# Diabetes mellitus, type 2: Insulin sliding scale while in
house
# Peripheral vascular disease with possible left carotid
stenosis, followed by Dr. ___ at ___ s/p debridement of
diabetic foot infection. Current exam with good ___ pulses.
# presumed myelodysplastic syndrome: With chronic leukocytosis.
Most recent smear concerning for metas and myelos. Heme/Onc to
f/u as an outpatient
# Afib - asymptomatic, not on warfarin given risks of bleeding
previously discussed with ___ and family as outpatient.
Coumadin was discontinued in ___ in the setting of elevated
INR 9 and concern for GIB.
# AV Node Disease: Noted on most prior admission with prolonged
AV conduction at baseline (PR of 360 ms) with known Wenckeback.
___ thought to alternate between fast and slow pathways
while asleep, likely exacerbated due to vagal input. Did not
think ___ had acute indication for pacemaker at that time
# Prolonged QTc - noted on previous EKGs. QTc prolonging drugs
were avoided.
# Gout: without gouty flare at this time. Maintained on home
allopurinol
TRANSITIONAL ISSUES:
#Mobility: Pateint has significant mobility issues especially
post dialysis sessions. He requires home ___ as well as family
support to help him regain his strength and balance. He declined
short term rehab.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO EVERY OTHER DAY
2. Amlodipine 10 mg PO DAILY ONLY ON NONDIALYSIS DAYS
3. Aspirin 81 mg PO DAILY
4. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Sertraline 50 mg PO DAILY
7. Renagel 300 mg Other TID
8. Acetaminophen Dose is Unknown PO Q6H:PRN muscle aches
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN muscle aches
2. Allopurinol ___ mg PO EVERY OTHER DAY
3. Aspirin 81 mg PO DAILY
4. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Sertraline 50 mg PO DAILY
7. Amlodipine 10 mg PO DAILY ONLY ON NONDIALYSIS DAYS
8. Renagel 300 mg Other TID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
viral URI
acute on chronic dCHF
ESRD on Dialysis
CHRONIC:
HTN
PVD
DMII
MDS
AFib
GOUT
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:
Mr ___:
You were hospitalized at ___
for difficulty breathing. You were given an extra dialysis
session which helped your breathing. During your stay here, you
had a fall. You were evaluated by physical therapy who
determined that it would be beneficial for you to receive home
physical therapy. You and your family expressed understanding
about your risk to fall at home and decided against
rehabilitation at this time. We will send you home with physical
therapy services.
We did not make any changes to your medications. You should
continue with your home medications as prescribed by your
doctor. You should also continue with your dialysis sessions
every MWF.
All the best for a speedy recovery!
Sincerely,
___ Treatment Team
Followup Instructions:
___
|
10246872-DS-14 | 10,246,872 | 29,955,315 | DS | 14 | 2177-09-28 00:00:00 | 2177-09-28 14:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Thombosed aneurysm.
Major Surgical or Invasive Procedure:
___ angiogram.
History of Present Illness:
___ yo F hx HTN, DM, bilateral ___ lymphedema who presents
with left arm numbness and weakness and seizure. Pt reports
onset
of HA ___ days ago, persistent and severe at times. Two days
ago she developed new onset of Left arm weakness and numbness.
She she had difficulty picking up a cup of coffee and spilled it
on the floor. After this she felt lightheaded and confused, no
LOC, and she suspects she may have had a seizure.
Today a friend came to pick her up for a scheduled appt and
found
her to be confused. EMS was initiated and she was transported to
___ where she had a brief witnessed seizure,
treated with 2mg ativan x 1 and loaded with 1g Dilantin. CT head
showed hyperdense 2.7cm right paramidline middle cranial fossa
mass and wedge-shaped area of hypoattenuation in the Right
posterior parietal occipital lobe suspicious for
subacute/chronic
infarct. SBP at OSH was 200/100. Pt denies loss of vision,
blurred vision, double vision, dizziness. Denies difficulty with
gait.
Past Medical History:
- HTN
- DM
- osteoarthritis
- bilateral ___ lymphedema
Social History:
___
Family History:
No family history of stroke, seizure, aneurysm. Strong
family history of CAD, HTN and DM.
Physical Exam:
==============================
ADMISSION EXAM
==============================
VS: T: 98.2 BP: 145/96 HR:80 RR:18 96%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: EOMs
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: 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: Normal bulk and tone bilaterally. No abnormal movements,
tremors.
Slight pronation on the left
Strength full power ___ throughout.
Sensation: Intact to light touch bilaterally.
Coordination: slow on finger-nose-finger and rapid alternating
movements on left
.
.
==============================
DISCHARGE EXAM
==============================
Pertinent Results:
==============================
ADMISSION LABS
==============================
___ 05:27AM BLOOD WBC-10.7 RBC-4.91 Hgb-14.9 Hct-46.4
MCV-95 MCH-30.4 MCHC-32.1 RDW-12.8 Plt ___
___ 05:27AM BLOOD Plt ___
___ 05:27AM BLOOD ___ PTT-28.0 ___
___ 04:15AM BLOOD Glucose-280* UreaN-16 Creat-0.9 Na-132*
K-4.6 Cl-100 HCO3-22 AnGap-15
___ 05:27AM BLOOD Glucose-280* UreaN-16 Creat-1.0 Na-133
K-4.6 Cl-102 HCO3-23 AnGap-13
___ 05:27AM BLOOD Calcium-9.0 Phos-2.0* Mg-2.1
.
==============================
IMAGING
==============================
___/CTA ___: In comparison to the outside CT of ___,
again seen is a subacute right parietoccipital infarct as well
as a 2.4 x 2.3 cm well-circumscribed hyperdense suprasellar
mass, corresponding to thrombosed aneurysm of the communicating
segment of right internal carotid artery. The opacified portion
of the aneurysm measures approximately 8 mm in diameter. There
is no evidence of hemorrhage or shift of normally midline
structures.
DIABETES MONITORING %HbA1c eAG
___
LIPID/CHOLESTEROL Cholest Triglyc HDL CHOL/HD LDLcalc
___ 05:27 190 201*1 46 4.1 104
Brief Hospital Course:
==============================
BRIEF HOSPITAL COURSE
==============================
The patient was admitted to the ICU on ___ for close
observation.
On ___, her examination remained stable. It was determined she
would undergo a diagnostic angiogram. The risks and benefits of
surgical intervention were discussed and she consented to the
procedure. Post-procedure she was extubated and returned to the
ICU for close monitoring overnight.
On ___, the patient's foley was discontinued. ___ and OT
consults were ordered and she was transferred to the floor.
On ___ Patient remained neurologically stable. She was screened
for rehab.
___, the patient was discharged to rehab with instructions to
follow up on her hemoglobin A1c as well as follow up for her
aneurysm.
Medications on Admission:
atorvastatin 40mg daily
bupropion 150mg daily
diltiazem 180mg BID
furosemide 20mg daily
glimepiride 4mg daily
losartan 100mg daily
metformin 500mg daily
metoprolol 200mg daily
Discharge Medications:
1. Atorvastatin 40 mg PO DAILY
2. BuPROPion (Sustained Release) 150 mg PO BID
3. Diltiazem Extended-Release 180 mg PO Q12H
4. Furosemide 20 mg PO DAILY
5. Losartan Potassium 100 mg PO DAILY
6. Metoprolol Succinate XL 200 mg PO DAILY
7. Potassium Chloride 10 mEq PO DAILY
Hold for K >
8. Acetaminophen 650 mg PO Q6H:PRN Pain or fever > 101.4
9. Aspirin 325 mg PO DAILY
10. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
11. Docusate Sodium 100 mg PO BID
12. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
13. Glucose Gel 15 g PO PRN hypoglycemia protocol
14. Heparin 5000 UNIT SC TID
15. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
16. LeVETiracetam 500 mg PO BID
17. Miconazole Powder 2% 1 Appl TP QID:PRN topical antifungal
18. Ondansetron 4 mg IV Q8H:PRN nausea
19. Senna 8.6 mg PO BID:PRN constipation
20. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
21. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
22. glimepiride 4 mg ORAL DAILY
23. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
Do Not Crush
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Thrombosed aneurysm
Subacute 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:
Discharge Instructions
Dr. ___
___
· You may gradually return to your normal activities, but we
recommend you take it easy for the next ___ hours to avoid
bleeding from your groin.
· Heavy lifting, running, climbing, or other strenuous
exercise should be avoided for ten (10) days. This is to prevent
bleeding from your groin.
· You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
· Do not go swimming or submerge yourself in water for five
(5) days after your procedure.
· You make take a shower.
Medications
· Resume your normal medications and begin new medications
as directed.
· It is very important to take the medication your doctor
___ prescribe for you to keep your blood thin and slippery.
This will prevent clots from developing and sticking to the
stent.
· You may use Acetaminophen (Tylenol) for minor discomfort
if you are not otherwise restricted from taking this medication.
· If you take Metformin (Glucophage) you may start it again
three (3) days after your procedure.
Care of the Puncture Site
· You will have a small bandage over the site.
· Remove the bandage in 24 hours by soaking it with water
and gently peeling it off.
· Keep the site clean with soap and water and dry it
carefully.
· You may use a band-aid if you wish.
What You ___ Experience:
· Mild tenderness and bruising at the puncture site (groin).
· Soreness in your arms from the intravenous lines.
· The medication may make you bleed or bruise easily.
· Fatigue is very normal.
When to Call Your Doctor at ___ for:
· Severe pain, swelling, redness or drainage from the
puncture site.
· Fever greater than 101.5 degrees Fahrenheit
· Constipation
· Blood in your stool or urine
· Nausea and/or vomiting
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
· Sudden numbness or weakness in the face, arm, or leg
· Sudden confusion or trouble speaking or understanding
· Sudden trouble walking, dizziness, or loss of balance or
coordination
· Sudden severe headaches with no known reason
Followup Instructions:
___
|
10246901-DS-10 | 10,246,901 | 22,999,738 | DS | 10 | 2150-03-13 00:00:00 | 2150-03-15 16:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever, Hip Pain
Major Surgical or Invasive Procedure:
___: Left hip aspiration
___: Left Hip Girdlestone procedure
___: Dialysis line removal
___: Temp dialysis line placement
___: Temp dialysis line removal, PEG removal
History of Present Illness:
Mr. ___ is a ___ year old man with hx Afib s/p MAZE on
warfarin, T2DM, ESRD on HD (___), recurrent MRSA
bacteremia, and history of multiple complex admissions who
presents from ___ in ___ for worsening left hip pain
and 1 of 2 blood cultures growing MRSA.
In brief, he had an admission from ___ where he presented
from ___ and was treated for L MRSA
empyema. It is believed, that the empyema lead to MRSA
bacteremia
which lead to multiple complications. Developed bilateral vision
loss s/p intravitreal vancomycin injections on ___. The patient
also developed L toe osteomyelitis and underwent L toe
amputation
on ___. The patient also developed septic arthritis of the L hip
and R shoulder and was s/p washout of the L hip on ___ and R
shoulder on ___. s/p VATS with decortication of the empyema on
___. The MRSA bacteremia also seeded the mitral valve and is s/p
mitral valve vegetation removal on ___ along with MAZE and left
atrial appendage ligation.
Throughout this hosptalization, he was continued on IV vanc and
was discharged to ___ in ___.
He presented from ___ for another
hospitalization from ___ for septic shock in the setting
of
MRSA bacteremia. He was treated with vancomycin/zosyn with
clindamycin added to inhibit toxin production. He was discharged
to ___ on vancomycin. Of note, during this
hospitalization,
he developed ARF and was started on CRRT and transitioned to HD
which was continued at rehab.
He now presents from ___ after developing worsening
L
hip pain for the past 3 weeks. He developed low grade
temperatures and chills starting on ___ at night. Blood
cultures
drawn on ___ grow MRSA in 1 of 2 cultures. Hip exam at the
rehab
also showed concern for septic arthritis of the L hip which he
was transferred to ___ for further management.
In the ED he continued to endorse left hip pain.
Initial vital signs were notable for:
Temp 99.6 HR 84 BP 100/58 RR 16
Exam notable for:
-pain with log roll of left hip
Labs were notable for:
-Lactate 1.7
-BUN 47, Cr 3.1
-CRP 266.6
-WBC 9.2, 82.4% neutrophils
-Hb 7.9, Hct 26.9
-___ 51.8, PTT 43.2, INR 4.8
Studies performed include:
-Hip X-ray showed severe left hip degenerative change with
suggestion of interval progression of degenerative change with
essentially complete loss of the left hip joint space, as well
as
mild to moderate subchondral sclerosis, which may have increased
compared to the prior study. Underlying infection cannot be
excluded on this study.
Orthopedics was consulted and the recs are detailed below.
Upon transfer to the floor, he confirms the difficulties of his
long hospital course. Continues to endorse significant L hip
pain
particularly with movement. He continues to be significantly
limited in the ADLs. Has significant pain with logrolling.
Currently feels cold but without active chills. Endorsing
improvements in mobility in rehab. Denies chest pain, SOB,
nausea, vomiting. Has been having regular BMs that are soft
without blood.
REVIEW OF SYSTEMS:
Complete ROS obtained and is otherwise negative.
Past Medical History:
DM2 on lantus and metformin
HTN
Hyperthyroidism
Afib on rivaroxaban
Past osteomyelitis
MRSA septicemia with empyema, mitral valve endocarditis, R
shoulder and L hip septic arthritis, vertebral osteomyelitis,
bilateral subretinal abscesses
Social History:
___
Family History:
Non-contributory to patient's presenting complaint
Physical Exam:
Admission
=========
4 HR Data (last updated ___ @ ___)
Temp: 99.2 (Tm 99.2), BP: 128/79, HR: 93, RR: 18, O2 sat:
95%, O2 delivery: Ra
___: Chronically ill looking man resting in bed with no
acute
distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally on anterior exam. No
wheezes, rhonchi or rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: L toe ambutation. B/l purpuric rash on the ___ below
the knees with scaling.
MSK: significant pain with attempt at ROM of the L hip. Pain
with
log rolling. No tenderness to palpation at the L hip.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 intact. Moving extremities with purpose.
AOx3.
DISCHARGE
---------
VITALS:
___ 0416 Temp: 97.6 PO BP: 129/80 HR: 71 RR: 16 O2 sat:
100%
O2 delivery: Ra
___: Middle-aged man in NAD, appears older than age
HEENT: MMM
CV: RRR, nl s1/s2, no m/r/g
PULM: CTAB
EXTREMITIES: L toe amputation. L leg shorter than R. Mild
tenderness and edema over left hip. Bilateral chronic
discoloration of the shins, no tenderness/heat/swelling of the
lower extremities.
SKIN: No ___ edema, WWP
NEUROLOGIC: AOx3
Pertinent Results:
Admission
=========
___ 05:18PM ___ PTT-43.2* ___
___ 05:18PM PLT COUNT-200
___ 05:18PM NEUTS-82.4* LYMPHS-6.9* MONOS-8.3 EOS-1.5
BASOS-0.4 IM ___ AbsNeut-7.54* AbsLymp-0.63* AbsMono-0.76
AbsEos-0.14 AbsBaso-0.04
___ 05:18PM WBC-9.2 RBC-3.21* HGB-7.9* HCT-26.9* MCV-84
MCH-24.6* MCHC-29.4* RDW-14.7 RDWSD-45.1
___ 05:18PM CRP-266.6*
___ 05:18PM CALCIUM-8.8 PHOSPHATE-2.8 MAGNESIUM-1.7
___ 05:18PM estGFR-Using this
___ 05:18PM GLUCOSE-137* UREA N-47* CREAT-3.1* SODIUM-136
POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-24 ANION GAP-14
___ 05:27PM LACTATE-1.7
___ 08:00PM URINE MUCOUS-OCC*
___ 08:00PM URINE RBC-4* WBC->182* BACTERIA-MANY*
YEAST-NONE EPI-0
___ 08:00PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-LG*
___ 08:00PM URINE COLOR-Yellow APPEAR-Hazy* SP ___
Discharge
=========
___ 05:10AM
BLOOD WBC-9.4 RBC-2.78* Hgb-8.1* Hct-26.0* MCV-94 MCH-29.1
MCHC-31.2* RDW-15.6* RDWSD-54.3* Plt ___
___ 05:10AM BLOOD
___ PTT-35.7 ___
___ 05:10AM BLOOD
Glucose-107* UreaN-73* Creat-3.7* Na-134* K-5.6* Cl-98 HCO3-25
AnGap-11
___ 03:02PM
BLOOD ZINC (SPIN NVY/EDTA)-PND
___ 03:02PM
BLOOD VITAMIN A-PND
___ 07:21AM
BLOOD Vanco-15.0
MICRO
___ 5:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
RIFAMPIN should not be used alone for therapy.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Reported to and read back by ___ (___) @08:18
(___).
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
___ 5:35 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
CITROBACTER FREUNDII COMPLEX. >100,000 CFU/mL.
Cefepime test result performed by Microscan.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER FREUNDII COMPLEX
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>___ R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Data
=====
___ Hip XR
Again seen severe left hip degenerative change with suggestion
of interval
progression of degenerative change with essentially complete
loss of the left
hip joint space, as well as mild to moderate subchondral
sclerosis, which may
have increased compared to the prior study. Underlying
infection cannot be
excluded on this study.
No obvious fracture seen, but difficult to exclude a
nondisplaced left femoral
neck fracture, if this is of clinical concern, due to
overlapping osseous
structures.
___ CXR
The tracheostomy tube has been removed. Left-sided ___
catheter is
unchanged. Pulmonary edema has also improved. Bilateral
effusions right
greater than left are also unchanged. No pneumothorax is seen
___ Hip XR
Postsurgical changes from left Girdlestone procedure.
___ ECHO
No 2D echocardiographic evidence for endocarditis. If clinically
suggested, the absence of a
discrete vegetation on echocardiography does not exclude the
diagnosis of endocarditis. Normal left
ventricular wall thickness, cavity size, and low-normal global
systolic dysfunction. Mild tricuspid regurgitation.
Mild mitral regurgitation
___ MRI
1. Previously seen discitis and osteomyelitis at C4-5 appears
improved with
apparent resolution of the epidural phlegmo, to the extent can't
be assessed
without contrast n. Bone marrow and intervertebral disc edema
remains.
2. Unchanged bone marrow intervertebral disc edema at T11-T12
without
paraspinal or epidural collection.
3. Degenerative changes of the spine, worst at C3-4, C4-5 and
C5-6, as above.
4. Stable large right pleural effusion.
___ Temp Dialysis Line removal
Successful placement of a temporary HD catheter via the right
internal jugular
venous approach. The tip of the catheter terminates in the
distal superior
vena cava. The catheter is ready for use.
___ TEE
Small to moderate sized (0.9 x 0.4 cm) highly mobile mass which
appears to be associated
with the catheter in the right atrium (clip 70). Thin,
filamentous strands on the left coronary cusp of the aortic
valve (clip 31). Trace aortic regurgitation. Mild mitral
regurgitation. Mildly depressed biventricular function.
Compared with the prior TEE (images reviewed) of ___ , a
mass is now seen on/adjacent to the
catheter in the right atrium. The severity of mitral and
tricuspid regurgitation is significantly reduced on the
current study. A filamentous strand on the left coronary cusp of
the aortic valve could also be appreciated on
the prior study, though it appeared less prominent (clip 60)
___ ___ US
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
___ ECHo
The left atrial volume index is normal. No thrombus/mass is seen
in the right atrium or right atrial appendage.
There is normal left ventricular wall thickness with a normal
cavity size. Overall left ventricular systolic
function is low normal. The visually estimated left ventricular
ejection fraction is 50%. There is no resting left
ventricular outflow tract gradient. Normal right ventricular
cavity size with normal free wall motion. The aortic
sinus diameter is normal for gender with normal ascending aorta
diameter for gender. The aortic arch
diameter is normal. The aortic valve leaflets (3) 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 tricuspid
valve leaflets appear structurally normal. There
is physiologic tricuspid regurgitation. The estimated pulmonary
artery systolic pressure is normal. There is no
pericardial effusion.
___ CXR
PICC line now terminating at the right midclavicular line in
this right
subclavian vein
___ CT
1. Large left gluteal hematoma extending into the proximal
posterolateral
thigh. Active extravasation cannot be evaluated due to lack of
IV contrast.
No evidence of a retroperitoneal hematoma. Postsurgical
appearance of the
left femoral head.
2. New bony erosions and sclerosis of the T11 and T12 vertebral
endplates,
which may represent discitis/osteomyelitis. Endplate edema is
also noted on
the recent MRI of the cervicothoracic spine dated ___. No
paraspinal abscess noted.
3. Stable moderate right and small left pleural effusions with
interval
resolution of left sided empyema.
Brief Hospital Course:
Mr. ___ is a ___ year old man with hx Afib (s/p MAZE on
warfarin), T2DM, CKD V (previously on HD), recurrent MRSA
bacteremia, and history of multiple complex admissions for
widespread MRSA infections, who presented from ___ rehab
for worsening left hip pain, found to have recurrent MRSA
bacteremia and left hip septic
arthritis, now s/p left hip Girdlestone procedure. His course
was complicated by TEE demonstrating a RA thrombus, requiring
Heparin drip. He was also managed for blood loss anemia after
the surgery, intermittently requiring pRBC transfusions. He was
previously on hemodialysis and was oliguric, but had recovery in
renal function during hospitalization, and no longer is
receiving hemodialysis. He was also managed for hyperkalemia
late during his hospital course, which improved with bowel
regimen and daily Lasix.
ACTIVE ISSUES
==============
#L hip pain
#L septic joint
#MRSA bacteremia
Presentation consistent with L hip septic arthritis, with + MRSA
blood cultures. He has a long history of MRSA bacteremia this
year, with R shoulder and L hip septic arthritis s/p washout in
___ of the L hip found to have MRSA infection. During this
admission, he underwent Girdlestone procedure with orthopedic
surgery, who found joint to be frankly purulent, with cultures
growing MRSA. He was started on HD dosed vancomycin. His HD line
pulled ___ was without evidence of growth on line culture. Blood
cultures were clear as of ___. He underwent TEE that did not
demonstrate any evidence of endocarditis. At the time of
discharge, he will leave with PICC in place for vancomycin,
which will be dosed ~q96 hours to achieve ___ trough (total of
6 weeks, Day 1 ___, with last day ___. This dose may
require adjustment to maintain the proper level. Most recent
trough from ___ of 15. He will continue Oxycodone, standing
Tylenol, and lidocaine patch for pain control.
# CKD 5, previously on dialysis
# Urinary retention
# Hyperkalemia
Was started on HD during last hospitalization due to
hypotension-induced ATN and was subsequently oligoanuric.
Initially at this admission, patient required hemodialysis
during hospitalziation on TTS schedule. However, he had
progressively improved renal function, and had 24h Cr clearance
at 350 on ___. He was trialed off dialysis for an extended
period and did not develop any complications necessitating HD.
His Cr leveled off in the 3.2-3.8 range (CrCl of ___. Later
during his stay, he did start to develop hyperkalemia. This was
managed with low K diet, daily standing bowel regimen titrated
to ___ bowel movements daily, and Lasix 80 mg PO daily. This
should be continued and strongly enforced. The patient
occasionally continued to have transient hyperkalemia. For this
situation, we recommend the following: for K of ___,
kayexelate 30 gm once, and for K of >6.5 give dextrose, insulin,
and calcium gluconate.
# Urinary Retention
The patient developed urinary retention requiring frequent
straight caths and bladder scans. He was never able to void on
his own. Urology was consulted, and it was decided to place a
foley catheter, which will be left in place, with follow up in
___ clinic as an outpatient. Continue daily tamsulosin.
# + E. Coli, Enterobacter Urine Culture
UCx (___) grew e coli and enterobacter, but was not treated
given poor U/O, likely representing colonoization, and patient
lacked symptoms. He had repeat urine culture on ___ growing
citrobacter in foul smelling urine, and the decision was made to
treat given urinary retention and poor clearance of bacturiuria.
He was continued on a 7 day course of nitrofurantoin, which was
completed on ___.
# RA Thrombus
Patient developed RA thrombus that was potentially associated
with an HD line, found on TEE. He was started on heparin gtt,
without further complciation such as pulmonary embolism. He was
later bridged back to warfarin, with an INR goal of ___. He has
been attaining this goal level with 3mg warfarin daily.
#Acute on Chronic Anemia
Has required periodic blood transfusions in the weeks after his
operation. Never had evidence of clear GI bleed throughout stay.
He did develop a small left thigh hematoma found on CT imaging
on ___, but blood counts subsequently stabilized off of heparin
drip. Blood counts were stable in the ___ range at the time of
discharge. The patient had iron studies that were consistent
with anemia of chronic disease, which is the most likely
etiology of the patient's underlying chronic anemia.
#Hx of malnutrition
#PEG tube
Patient had PEG placed last hospitaliation, but had vastly
improved PO intake during the current hospitalization, so PEG
tube removed on ___. Currently on renal diet with supplemental
shakes.
# Decubitus ulcers: Stage ___
The patient was seen by wound care team. See page 1 for
recommendations regarding wound care dressings.
CHRONIC ISSUES:
===============
#Atrial fibrillation s/p MAZE procedure and left atrial
appendage ligation
Patient was in normal sinus rhythm throughout hospitalization.
He continued on home amiodarone. He was initially on warfarin,
then transferred to heparin drip due to atrial thrombus, but
then bridged back to warfarin at the time of discharge. INR goal
of ___.
#Type 2 diabetes mellitus
Continued on ISS while in house. Glipizide was held at time of
admission, but can be restarted at discharge.
#hx of keratitis
Continued artificial tears prn
#GERD
Continued home lansoprazole.
Transitional Issues
====================
[ ] Dose vancomycin 500 mg q96 hours, for a goal range of ___.
The frequency of these doses may require adjustment. The last
dose he received was 500 mg on ___. Would recommend checking
vanc levels every 3 days. Next vanc trough due ___. Last day of
vancomycin ___.
[ ] Monitor for hyperkalemia, and continue strict regimen of low
K diet, Lasix 80 mg daily, and standing bowel regimen for ___
bowel movements daily. Patient often needs reinforcement and
encouragement to take bowel reg. Please give kayexelate 30gm
once for K of ___, and for K of >6.5 give dextrose, insulin,
and calcium gluconate.
[ ] F/u with urology for new urinary retention.
[ ] Patient may require insulin sliding scale for control of
blood sugars, but can trial home PO glipizide for control, which
was held at admission
[ ] F/u with renal to determine success off of hemodialysis and
consideration to restart dialysis going forward; nephrology
appointment pending at time of discharge
[ ] Discharged on 3mg warfarin daily; check next INR on ___, if
stable can likely check weekly
[ ] Encourage PO intake
[ ] F/u pending vitamin A and zinc
[ ] Discharge Cr: 3.7
[ ] Discharge Hgb: 8.1
[ ] Discharge K: 5.6
[ ] Discharge INR: 2.3
#CODE: Full
#CONTACT:Proxy name: ___
___: Mother Phone: ___
Mr. ___ is clinically stable for discharge today. The
total time spent today on discharge planning, counseling and
coordination of care today was greater than 30 minutes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Amiodarone 200 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Bisacodyl ___AILY:PRN constipation
5. Docusate Sodium 100 mg PO BID
6. Lidocaine 5% Patch 1 PTCH TD QAM left hip pain
7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
8. Senna 8.6 mg PO BID:PRN Constipation
9. Sodium Chloride 0.9% Flush ___ mL IV Q8H and PRN, line
flush
10. Vitamin D ___ UNIT PO DAILY
11. Warfarin 2.5 mg PO 4X/WEEK (___)
12. Warfarin 3 mg PO 3X/WEEK (___)
13. Aquaphor Ointment 1 Appl TP TID:PRN dry skin
14. Artificial Tears ___ DROP BOTH EYES PRN eye dryness
15. FoLIC Acid 1 mg PO DAILY
16. Hydrocortisone Cream 1% 1 Appl TP QID rash
17. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
18. Midodrine 10 mg PO 3X/WEEK (___)
19. Multivitamins W/minerals 1 TAB PO DAILY
20. Sarna Lotion 1 Appl TP QID:PRN itching, rash
21. Thiamine 100 mg PO DAILY
22. ___ MD to order daily dose IV HD PROTOCOL
23. Heparin Flush (1000 units/mL) ___ UNIT DWELL PRN HD
lumen flushes
24. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
25. Mirtazapine 15 mg PO QHS
26. GlipiZIDE XL 2.5 mg PO DAILY
Discharge Medications:
1. Ascorbic Acid ___ mg PO BID
2. Collagenase Ointment 1 Appl TP DAILY
3. Furosemide 80 mg PO DAILY
4. OxyCODONE (Immediate Release) 5 mg PO Q8H
RX *oxycodone 5 mg 1 tablet(s) by mouth every 8 hours Disp #*21
Tablet Refills:*0
5. Psyllium Powder 1 PKT PO TID
6. sevelamer CARBONATE 800 mg PO TID W/MEALS
7. Tamsulosin 0.4 mg PO QHS
8. Vancomycin 500 mg IV Q96 HOURS
Dosed ~ q96 hours, goal level of ___. Continue until ___
9. Warfarin 3 mg PO DAILY16
10. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
11. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
12. Amiodarone 200 mg PO DAILY
13. Aquaphor Ointment 1 Appl TP TID:PRN dry skin
14. Artificial Tears ___ DROP BOTH EYES PRN eye dryness
15. Aspirin 81 mg PO DAILY
16. Bisacodyl ___AILY:PRN constipation
17. Docusate Sodium 100 mg PO BID
18. FoLIC Acid 1 mg PO DAILY
19. GlipiZIDE XL 2.5 mg PO DAILY
20. Hydrocortisone Cream 1% 1 Appl TP QID rash
21. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
22. Lidocaine 5% Patch 1 PTCH TD QAM left hip pain
23. Mirtazapine 15 mg PO QHS
24. Multivitamins W/minerals 1 TAB PO DAILY
25. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
26. Sarna Lotion 1 Appl TP QID:PRN itching, rash
27. Senna 8.6 mg PO BID:PRN Constipation
28. Thiamine 100 mg PO DAILY
29. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
MRSA bacteremia
Left hip septic arthritis
Acute blood loss anemia
Right atrial thrombosis
CKD V
Urinary tract infection
Urinary retention
Secondary
AF
DM II
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- You came to the hospital for fevers and hip pain
What did you receive in the hospital?
- You had a hip surgery due to a MRSA infection in the hip
- You received antibiotics
- You received hemodialysis, but your kidney function improved
and you no longer needed it by the time you left
- You received blood thinning medication for a clot in your
heart.
- You received blood transfusions for low blood levels
- You received medicines for high potassium and for bowel
movements
What should you do once you leave the hospital?
- Take all your medications and prescribed
- Make sure to take your laxative medications and make sure you
have at least ___ bowel movements per day
- Follow up with all your appointments as below, including
appointments with the orthopedic surgeons, urology staff, kidney
doctors, and infectious disease doctors.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10247657-DS-21 | 10,247,657 | 27,811,765 | DS | 21 | 2133-03-05 00:00:00 | 2133-03-05 19:16:00 |
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
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female past medical history significant for reflux
presenting to the emergency department with epigastric pain
nausea and vomiting since this morning. History obtained with
help of son who was at bedside. Patient takes omeprazole and
normally heartburn goes away, however her omeprazole did not
work
today. She also described a "dullness" which has since resolved.
Patient has not eaten much and has vomited 3 times. Last time
she
vomited was approximately 7 ___ when she arrived to ED. She
reports having a bitemporal headache with these symptoms as
well.
She reports no other symptoms of SOB, cough, dysuria, abdominal
pain, weakness, numbess, tingling, lightheadedness. Has some
chronic mild LBP. She has never had issues with her sodium
before, and she has otherwise been feeling well, with good PO
intake.
In the ED, initial VS were:
97.4 76 141/76 18 98% RA
Exam:
GA: Comfortable
Neuro: Cranial nerves II -XII intact, 5 out of 5 strength
bilaterally upper and lower extremities, full sensation
bilaterally
HEENT: No scleral icterus, dry mucous membranes
Cardiovascular: Normal S1, S2, regular rate and rhythm, no
murmurs/rubs/gallops, 2+ peripheral pulses bilaterally
Pulmonary: Clear to auscultation bilaterally
Abdominal: Soft, nontender, nondistended, no masses
Extremities: No lower leg edema
Integumentary: No rashes noted
ECG: NSR, no TWI or ST changes
Labs showed: WBC 9.4. Lactate 1.2. Na 121->122 (after 1.5L), UA
71 WBC, sm leuk, neg nitrites.
Consults:
Renal: Will see in AM. Please send urine lytes and osms, serum
osms. Please recheck sodium in 2 hours, ensure not increasing by
more than 6 at that point.
Patient received: Ceftriaxone
Transfer vitals stable
On arrival to the floor, confirmed history as above with son.
Patient continues to endorse heartburn but no more chest
dullness. No longer nauseous. No headache.
Past Medical History:
GERD
HLD
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISISON EXAM:
=================
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM:
================
VS:98.0 PO 134/74 L Lying 59 18 95% GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
GU: no suprapubic tenderness
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 10:57PM BLOOD WBC-9.4 RBC-4.14 Hgb-12.3 Hct-34.6 MCV-84
MCH-29.7 MCHC-35.5 RDW-12.3 RDWSD-37.0 Plt ___
___ 10:57PM BLOOD Neuts-83.8* Lymphs-11.4* Monos-3.9*
Eos-0.4* Baso-0.1 Im ___ AbsNeut-7.84* AbsLymp-1.07*
AbsMono-0.37 AbsEos-0.04 AbsBaso-0.01
___ 10:57PM BLOOD Glucose-141* UreaN-12 Creat-0.7 Na-121*
K-4.7 Cl-86* HCO3-20* AnGap-15
___ 06:06AM BLOOD Calcium-8.1* Phos-3.0 Mg-1.8
___ 10:57PM BLOOD Osmolal-248*
___ 06:06AM BLOOD TSH-1.5
___ 10:57PM BLOOD Lactate-1.2
DISCHARGE LABS:
===============
___ 06:09AM BLOOD Cortsol-9.5
___ 06:09AM BLOOD WBC-6.1 RBC-4.07 Hgb-12.0 Hct-35.2 MCV-87
MCH-29.5 MCHC-34.1 RDW-12.8 RDWSD-39.6 Plt ___
___ 06:09AM BLOOD Glucose-89 UreaN-12 Creat-0.8 Na-135
K-4.4 Cl-99 HCO3-22 AnGap-14
___ 02:11PM BLOOD Na-135
___ 06:09AM BLOOD Calcium-9.0 Phos-2.8 Mg-2.1
IMAGING:
CXR ___ evidence of acute pulmonary disease. No
suspicious Findings. If needed clinically, chest CT is much
more sensitive for diagnosing any possible pulmonary malignancy
than radiography.
Brief Hospital Course:
___ yo F with h/o GERD presenting with worsening heartburn and
vomiting, found to be hyponatremic to 121 likely due to
hypovolemia with improvement of sodium to 135 prior to
discharge.
ACUTE ISSUES:
===============
#Hyponatremia
Patient presented mildly symptomatic with Na 121. Initially
thought to be SIADH, however Na quickly improved with IV fluid
resuscitation. Initial urine studies consistent with SIADH
however, repeat urine lytes with dilute urine which is more
consistent with hypovolemia picture after fluid resuscitation.
Patient with hypovolemia secondary to GI upset/nausea/vomiting.
Discharge Na 135, plan to recheck Na in ___ days with primary
care physician.
#Sterile pyuria
Pt with nausea/vomiting on admission, with UA showing sterile
pyuria. Deferred antibiotic therapy given urine culture with
mixed flora c/w contamination.
#Chest pain
#Acid reflux
Resolved after 1L fluid bolus and correction of hyponatremia.
Most likely due to GERD. Pt with EKG with no evidence of
ischemia, with 2x troponins negative. CXR unremarkable. Continue
home omeprazole 20mg PO daily. Can consider outpatient workup
for severe GERD, although symptoms improved prior to discharge.
CHRONIC ISSUES:
===============
#HLD
- Continue atorvastatin 5mg daily
#Supplements
- Continue vitamin D 1000u daily
#CODE: Full (discussed with son)
#CONTACT: ___ (son) ___. Daughter ___
TRANSITIONAL ISSUES:
====================
- Please check chemistry panel in ___ days to ensure sodium is
stable. Discharge Na 135.
- Please consider outpatient work up for severe GERD and
consider GI referral if symptoms persist.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Omeprazole 20 mg PO DAILY
2. Vitamin D Dose is Unknown PO DAILY
3. Atorvastatin 5 mg PO QPM
Discharge Medications:
1. Vitamin D 1000 UNIT PO DAILY home med
2. Atorvastatin 5 mg PO QPM
3. Omeprazole 20 mg PO DAILY
4.Outpatient Lab Work
E87.1
Please check chemistry panel (during week of ___
Fax results to ___ attn: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Hyponatremia
Hypovolemia
Sterile pyuria
Chest pain
Hyperlipidemia
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 here?
You came to the hospital because you had nausea and abdominal
pain. You were found to have low sodium levels in your blood.
What we did while you were here?
We gave you IV fluids and carefully monitored your sodium
levels. With the fluid your sodium levels improved. Your
abdominal pain and nausea also improved.
What you should do when you go home?
Please take all of your home medications. Please call your
doctor if your develop abdominal pain, worsening nausea,
dizziness, lightheadedness or headache.
Your ___ Team
Followup Instructions:
___
|
10247690-DS-15 | 10,247,690 | 27,152,936 | DS | 15 | 2130-01-17 00:00:00 | 2130-01-17 14:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
Neosporin / atorvastatin / aspirin / Zetia
Attending: ___
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is an ___ year old female s/p Urgent coronary artery
bypass graft x4: Left internal mammary artery to left anterior
descending artery, and saphenous vein grafts to the diagonal,
obtuse marginal,and distal right coronary arteries on ___. She
had an uneventful post operative course, complicated only by
atrial atrial flutter/fibrillation. She was placed on
Amiodarone and beta-blocker optimized. Hct was stable upon
discharge at 24. Upon getting to rehab yesterday, she felt
"wiped out", lightheaded and nauseous. Unable to tolerate any
oral intake last night. This morning she had a SBP in to 80's
and complained of SOB. Hct resulted at 19. EMS was called for
transfer. Upon transfer, she desatted into the low 80's and was
placed on O2. Currently she is hemodynamically stable on 4 L O2.
Of note, she has a history of ___ bleed admit in ___ with
HCT of 19-transfused 4 units. + Guaiac stool, C- scope and EGD
did not show any obvious source of GIB at that time. Capsule
endoscopy was also done with no active bleeding in small bowel.
In ED she was guaiac negative. She will be readmitted for
transfusion and further workup for bleeding.
Past Medical History:
Hypertension
Hyperlipidemia
CAD/NSTEMI in ___ in setting of anemia- LVEF 40-45% ___ MR
___ bleed admit in ___ with HCT of 19-transfused 4 units.
+ Guaiac stool, C- scope and EGD did not show any obvious source
of GIB
Capsule endoscopy no active bleeding in small bowel.
___: PE on CTA
Peripheral vascular disease, s/p left common ilaiac artery
angioplasty/? stent in ___ at ___
IDDM
Carotid disease - refused CEA in past
? Esophageal stricture - work up in progress
Past Surgical History
Appy
Tonsillectomy
___: Actinic keratosis/other papule right calf, excisional
biopsy
Social History:
___
Family History:
No premature coronary artery disease
Physical Exam:
Pulse:85 Resp:21 O2 sat: 4L 99%
B/P Right: 107/59 Left:
Height: 5'2" Weight: 60 kg
General: Awake, alert in NAD
Skin: Dry [x] intact []
HEENT: PERRLA [x] EOMI []
Neck: Supple [] Full ROM []
Chest: Lungs clear bilaterally [x] Decreased left base
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] softly distended non-tender [x] bowel sounds
+
[x]
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:2+ Left:2+
DP Right:2+ Left:2+
___ Right:2+ Left:2+
Radial Right:2+ Left:2+
Carotid Bruit Right:none Left:none
Pertinent Results:
Abd/Pelvis CT ___
IMPRESSION:
1. No findings to explain the patient's anemia. No
retroperitoneal bleed.
2. Moderate to severe atherosclerotic disease.
3. Diverticulosis without evidence of diverticulitis.
4. Small bilateral low-density pleural effusions.
.
___ 06:10AM BLOOD Hct-23.8*
___ 05:49PM BLOOD Hct-25.2*
___ 05:39AM BLOOD WBC-13.8* RBC-2.59* Hgb-7.7* Hct-24.6*
MCV-95 MCH-29.7 MCHC-31.3* RDW-19.5* RDWSD-62.3* Plt ___
___ 01:30PM BLOOD Hct-26.8*
___ 05:20AM BLOOD WBC-15.3* RBC-2.81*# Hgb-8.2*# Hct-26.3*
MCV-94 MCH-29.2 MCHC-31.2* RDW-19.2* RDWSD-63.0* Plt ___
___ 12:05AM BLOOD Hct-24.8*
___ 11:05AM BLOOD WBC-15.2* RBC-2.08* Hgb-6.5* Hct-20.4*
MCV-98 MCH-31.3 MCHC-31.9* RDW-14.7 RDWSD-50.3* Plt ___
___ 05:02AM BLOOD WBC-12.7* RBC-2.37* Hgb-7.4* Hct-23.1*
MCV-98 MCH-31.2 MCHC-32.0 RDW-14.0 RDWSD-49.3* Plt ___
___ 05:39AM BLOOD Glucose-104* UreaN-42* Creat-1.0 Na-140
K-4.2 Cl-102 HCO3-28 AnGap-14
___ 11:05AM BLOOD Glucose-133* UreaN-49* Creat-1.3* Na-138
K-4.6 Cl-99 HCO3-27 AnGap-17
___ 05:20AM BLOOD Calcium-8.3* Phos-4.4 Mg-2.4
Brief Hospital Course:
Ms. ___ was admitted from our emergency department and
transfused 2 units packed red blood cells with Lasix
administered in between. Her hematocrit increased appropriately
and stayed stable. Her Lasix was increased for better diuresis.
She had two bowel movements during her stay that tested positive
for guaiac but were not frankly bloody or dark.
GI was consulted. It was determined that endoscopy would carry
more risk than benefit given recent MI and CABG. It is
recommended that she follow up with her gastroenterologist, Dr.
___ as an outpatient to schedule EGD in ___ weeks. If
unrevealing- next step would be for capsule study or
colonoscopy.
She was started on BID PPI and hematocrit remained stable. She
will be discharged back to rehab on hospital day 4. Aspirin is
discontinued and should not be resumed, ever.
She did have post-op AFib and remains on Amiodarone for this-
she will not be anti-coagulated. Additionally, bowel regimen
was increased to prevent constipation.
Medications on Admission:
1. Acetaminophen 650 mg PO/PR Q4H:PRN pain or temperature >38.0
2. Amiodarone 200 mg PO BID Duration: 7 Days
then decrease to 200 mg daily until reevaluated by Cardiologist
3. Aspirin EC 81 mg PO DAILY
4. Dextrose 50% 12.5 gm IV PRN glucose < 60
5. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
6. Docusate Sodium 100 mg PO BID
7. Furosemide 40 mg PO DAILY
8. Heparin 5000 UNIT SC BID
9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
10. Metoprolol Tartrate 12.5 mg PO Q8H
11. Ranitidine 150 mg PO DAILY
12. TraMADol 25 mg PO Q4H:PRN Pain - Moderate
13. 70/30 24 Units Breakfast
70/30 24 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
14. Simvastatin 10 mg PO QPM
15. Ascorbic Acid ___ mg PO BID
16. Co Q-10 (coenzyme Q10) 200 mg oral DAILY
17. Cyanocobalamin 1000 mcg PO DAILY
18. Fish Oil (Omega 3) 1200 mg PO DAILY
19. Glucosamine Chondroitin MaxStr (glucosamine-chondroit-vit
C-Mn) 500-400 mg oral DAILY
20. Vitamin D 1000 UNIT PO DAILY
21. HELD- Losartan Potassium 25 mg PO DAILY This medication was
held. Do not restart Losartan Potassium until reevaluated by
Cardiologist
Discharge Medications:
1. Pantoprazole 40 mg PO Q12H
2. Polyethylene Glycol 17 g PO DAILY:PRN constipation
3. Senna 8.6 mg PO BID:PRN constipation
4. Amiodarone 200 mg PO DAILY
5. 70/30 24 Units Breakfast
70/30 24 Units Dinner
Insulin SC Sliding Scale using REG Insulin
6. Metoprolol Tartrate 12.5 mg PO TID
7. Acetaminophen 650 mg PO/PR Q4H:PRN pain or temperature >38.0
8. Ascorbic Acid ___ mg PO BID
9. Cyanocobalamin 1000 mcg PO DAILY
10. Docusate Sodium 100 mg PO BID
11. Furosemide 40 mg PO DAILY
12. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
13. Vitamin D 1000 UNIT PO DAILY
14. HELD- Co Q-10 (coenzyme Q10) 200 mg oral DAILY This
medication was held. Do not restart Co Q-10 until instructed by
PCP or ___
15. HELD- Fish Oil (Omega 3) 1200 mg PO DAILY This medication
was held. Do not restart Fish Oil (Omega 3) until instructed by
PCP or ___
16. HELD- Glucosamine Chondroitin MaxStr
(glucosamine-chondroit-vit C-Mn) 500-400 mg oral DAILY This
medication was held. Do not restart Glucosamine Chondroitin
MaxStr until instructed by PCP or ___
17. HELD- Losartan Potassium 25 mg PO DAILY This medication was
held. Do not restart Losartan Potassium until instructed by PCP
or ___
___ Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
anemia
Hypertension
Hyperlipidemia
CAD/NSTEMI in ___ in setting of anemia- LVEF 40-45% ___ MR
___ bleed admit in ___ with HCT of 19-transfused 4 units.
+ Guaiac stool, C- scope and EGD did not show any obvious source
of GIB Capsule endoscopy no active bleeding in small bowel.
___: PE on CTA
Peripheral vascular disease, s/p left common ilaiac artery
angioplasty/? stent in ___ at ___
IDDM
Carotid disease - refused CEA in past
? Esophageal stricture - work up in progress
Discharge Condition:
Alert and oriented x3 non-focal
Ambulating, deconditioned
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
1+ ___ Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
___
|
10248033-DS-17 | 10,248,033 | 28,841,981 | DS | 17 | 2182-04-09 00:00:00 | 2182-04-10 11:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Urinary retention, confusion, dislodged foley.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o M w/ HTN, HLD, CKD (baseline Cr 1.2), Afib w/ slow
ventricular response s/p single chamber ___
placement, BPH s/p cystoscopy (most recent PSA 3.2 in ___ with
hx of nocturia and recent UTI w/ foley placement who presented
presenting after ___ pulled a Foley catheter out last night. The
patient was seen by urology 2 weeks ago for urodynamic testing.
On ___ ___ is complaining of difficulty urinating and
suprapubic pressure since PCP performed ___ urinalysis. ___ was
diagnosed with a urinary tract infection started on Cipro.
Yesterday, the patient was unable to urinate so a Foley catheter
was placed at his PCPs office. Last night ___ was having a lot of
pain at the tip of the penis so ___ pulled the Foley catheter out
after cutting the balloon tubing. Denies any fevers, chills,
back pain, abdominal pain. ___ had one episode of vomiting last
night. ___ denies any headache, blurry vision, double vision.
In the ED, initial vitals were: Tc:97.8 BP:144/79 90 RR:18
Pox:97%RA got 1L NS x 1, lidocaine jelly, ceftriaxone x1.
Labs were notable for:
Lactate 1.9
U/A with data: hazy, sm leuk, mod bld, 30 protein, 51 RBC, 18
WBC, no bacteria, neg nitrates
Na 127, K 3.3, Cl 90, HCO3 25, BUN/Cr ___
WBC 12.9 w/neutrophil predominance (76.5)
H/H 14.1/39.6
___ 43.4 PTT 39. INR 3.9
On the floor, Patient endorsed that ___ was found to have a UTI,
started on cipro on ___, but continued to have urinary
retention. ___ presented to ___ to see Dr. ___ placed a
foley. On ___, ___ was having penile discomfort and cut the
foley to pull it out. Wife reports pt appearing increasingly
confused since yesterday. Wife relates pt seen at ___
___ yesterday with urinary retention and question UTI,
states foley was placed and unknown abx started. Wife reports
last night pt felt foley was too uncomfortable and removed foley
by cutting with pair of scissors. Denies hematuria. Pt c/o
urinary urgency, awake alert to person and knows ___ in a
hospital. Pt typically oriented x 3 per wife.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation. No recent change in bowel or bladder habits.
Denies arthralgias or myalgias.
Past Medical History:
HLD
HTN
Thyroid nodule
Atrial fibrillation
Basal cell carcinoma (right temple s/p Mohs)
Decreased libido
BCC (trunk)
inguinar hernia s/p repair
cataracts
Chronic Kidney Disease
Social History:
___
Family History:
No family history of bladder cancer.
Physical Exam:
Physical Exam on Admission:
Vitals: Tmax: 97.8 BP:130s-140s/70s-80s HR ___ RR:18 Pox:97%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: AF, no m/r/g.
Lungs: CTAB, no wheezes, rales, rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
mild suprapubic tenderness
GU: Foley. No flank pain. Prostate exam deferred per patient
preference.
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.
=
=
=
=
=
================================================================
Physical Exam on Discharge:
Vitals: T 97.8 BP:130s-140s/70s-80s HR ___ RR:18 Pox:97%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: AF, no m/r/g.
Lungs: CTAB, no wheezes, rales, rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
mild suprapubic tenderness
GU: Foley in place. Small lac at penil entry site. No flank
pain. Prostate exam deferred per patient preference.
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.
Pertinent Results:
Labs o Admission:
___ 10:37AM BLOOD Lactate-1.9
___ 10:15AM BLOOD LtGrnHD-HOLD
___ 10:15AM BLOOD Calcium-9.0 Phos-3.1 Mg-1.9
___ 05:45PM BLOOD Calcium-8.3* Phos-2.6* Mg-1.7
___ 10:15AM BLOOD Glucose-103* UreaN-23* Creat-1.4* Na-127*
K-3.3 Cl-90* HCO3-25 AnGap-15
___ 05:45PM BLOOD Glucose-130* UreaN-18 Creat-1.2 Na-127*
K-3.3 Cl-91* HCO3-26 AnGap-13
___ 10:15AM BLOOD ___ PTT-39.8* ___
___ 10:15AM BLOOD Plt ___
___ 10:15AM BLOOD Neuts-76.5* Lymphs-8.9* Monos-13.8*
Eos-0.1* Baso-0.2 Im ___ AbsNeut-9.85* AbsLymp-1.15*
AbsMono-1.77* AbsEos-0.01* AbsBaso-0.03
___ 10:15AM BLOOD WBC-12.9* RBC-4.37* Hgb-14.1 Hct-39.6*
MCV-91 MCH-32.3* MCHC-35.6 RDW-12.3 RDWSD-41.1 Plt ___
___ 10:32AM URINE Color-Yellow Appear-Hazy Sp ___
___ 10:32AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
___ 10:32AM URINE RBC-51* WBC-18* Bacteri-NONE Yeast-NONE
Epi-0
___ 10:32AM URINE AmorphX-RARE
___ 10:32AM URINE Mucous-RARE
___ 10:32AM URINE
___ 10:32AM URINE Hours-RANDOM
___ 10:32AM URINE Uhold-HOLD
===============================================================
Labs on Discharge:
___ 07:45AM BLOOD WBC-9.7 RBC-4.21* Hgb-13.5* Hct-39.0*
MCV-93 MCH-32.1* MCHC-34.6 RDW-12.4 RDWSD-42.5 Plt ___
___ 07:45AM BLOOD Plt ___
___ 07:45AM BLOOD ___ PTT-38.7* ___
___ 07:45AM BLOOD Glucose-96 UreaN-17 Creat-1.0 Na-131*
K-3.8 Cl-97 HCO3-27 AnGap-11
___ 07:45AM BLOOD Calcium-8.3* Phos-2.4* Mg-2.0
===============================================================
Micro:
___ 10:32 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 10:40 am BLOOD CULTURE
Blood Culture, Routine (Pending):
===============================================================
Clinical Studies/Imaging:
___: CT Head Non-Con
IMPRESSION:
No intracranial hemorrhage or mass effect.
Brief Hospital Course:
Mr. ___ is a ___ y/o M w/ HTN, HLD, CKD (baseline Cr 1.2),
Afib w/ slow ventricular response s/p single chamber ___
scientific placement, BPH s/p cystoscopy (most recent PSA 3.2 in
___ with hx of nocturia and recent enterococcus faecalis UTI
on cipro s/p foley placement, admitted for dislodged foley,
urinary retention, delirium and was found to have
supratherapeutic INR.
#Encephalopathy/Urinary Retention/UTI: Patient was recently
started on cipro for a UTI on ___, and due to urinary retention
had a foley placed for drainage at ___ by Dr. ___
___ subsequently reported discomfort from the foley
and removed it himself. Afterward, ___ was unable to urinate and
per his wife, became more confused, which prompted the ED
presentation. Patient was diagnosed with delirium likely
secondary to urinary retention and UTI. Per discussion with
outpatient urologist Dr. ___ likely developed the UTI
in the setting of recent instrumentation after urodynamic
studies. Patient received ceftriaxone x1 in the ED and was
transitioned to PO Ampicillin, to end on ___. ___ will be
discharged with a foley and follow-up with Dr. ___ on ___ at
___ for foley removal. The team communicated this
with Dr. ___ to facilitate coordination of care. Patient was
AAOx3 on the day of discharge and his mental status was
significantly improved (confirmed with wife/son) with good
urinary output. Patient and family were extensively counseled
about the importance of keeping the foley in the interim until
___ sees Dr. ___.
#Afib on coumadin with supratherapeutic INR: During this
hospitalization, patient also had a supratherapeutic INR (3.2 on
discharge). This was likely in the setting of starting Cipro as
his INR was 2.5 on ___ at ___. As a result, Coumadin was held
during his admission (3.9 on day of admission, 3.2 on day of
discharge). Patient was instructed to check his INR as well as
chemistry on ___. ___ will resume Coumadin beginning ___
(day after discharge). The results will be faxed to Dr. ___
___ (PCP), who will manage his Coumadin in the outpatient
setting. This plan was described in detail with patient and
family prior to discharge.
#Hyponatremia: Patient was hyponatremic on this admission likely
___ hypovolemic hyponatremia as it responded to fluids.
Patient's Na was 131 on discharge. Due to the hyponatremia, his
HCTZ was held on discharge. This was communicated with the
primary care physician, ___.
#HTN: BP 130s-140s. Patient was continued on Lisinopril and HCTZ
was held as described above.
#BPH: Patient was continued on home tamsulosin.
#Overactive bladder: Vesicare was held while patient was in the
hospital as it can worsen delirium.
=
=
=
================================================================
Transitional Issues:
1. Follow-up on urinary retention, UTI (completion of ampicillin
on ___, remove foley for void trial at appointment with Dr.
___ on ___.
2. Follow-up on supratherapeutic INR (3.2 on day of discharge).
Patient will have labs drawn on ___ and the results will be
sent to Dr. ___. Coumadin was held during this
admission but patient will resume it beginning ___ upon
discharge.
3. Please note due to low UOP and hyponatremia, HCTZ was held on
discharge. Please re-start it in the outpatient setting if
clinically indicated.
4. Patient would like to discuss code status with Dr. ___ in
the outpatient setting.
# CODE: Full Code
# CONTACT: HCP (At___), ___, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 6.25 mg PO 3X/WEEK (___)
2. Warfarin 5 mg PO 4X/WEEK (___)
3. Lovastatin 20 mg oral DAILY
4. Multivitamins 1 TAB PO DAILY
5. Vesicare (solifenacin) 10 mg oral DAILY
6. Hydrochlorothiazide 12.5 mg PO DAILY
7. Lisinopril 10 mg PO DAILY
8. Fish Oil (Omega 3) 1000 mg PO DAILY
9. melatonin 1 mg oral QHS
10. Tamsulosin 0.4 mg PO QHS
11. Ciprofloxacin HCl 500 mg PO Q12H
Discharge Medications:
1. Lovastatin 20 mg oral DAILY
2. Fish Oil (Omega 3) 1000 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Tamsulosin 0.4 mg PO QHS
5. melatonin 1 mg oral QHS
6. Vesicare (solifenacin) 10 mg oral DAILY
7. Outpatient Lab Work
Please check your INR and chemistry panel on ___
Indication: Atrial Fibrillation on Coumadin with
Supratherapeutic INR
ICD 10 code: ___.2
Please fax results to Dr. ___
Fax: ___
8. Lisinopril 10 mg PO DAILY
9. Ampicillin 500 mg PO Q6H
RX *ampicillin 500 mg 1 capsule(s) by mouth Every 6 hours Disp
#*11 Capsule Refills:*0
10. Warfarin 6.25 mg PO 3X/WEEK (___)
11. Warfarin 5 mg PO 4X/WEEK (___)
Please resume your regular home dose on ___.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
1. Encephalopathy
2. Urinary retention
3. Urinary tract infection
4. Supratherapeutic INR
Secondary Diagnoses
1. Hypertension
2. Overactive Bladder
3. Benign Prostate Hyperplasia
Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you at ___
___. You were admitted after you had difficulty with
urination due to dislodgment of your foley. In the emergency
room, another foley was placed and you had good urinary output.
You were given one dose of IV antibiotics to continue treatment
for your urinary tract infection, and then were switched to an
oral antibiotic medication (Ampicillin). You should take this
antibiotic every 6 hours, last day will be ___. We have
scheduled you a follow-up appointment with your Urologist, Dr.
___, on ___. We have also communicated with him about your care
while you are here and ___ is aware of your recent
hospitalization. You will continue your foley catheter for
urinary drainage until you see Dr. ___, at which point ___ may
consider removing it.
Additionally, we found that your INR was elevated above goal
(INR 3.2 on ___ during this hospitalization. This was
likely due to your recent antibiotic medication (it interacts
with Coumadin). As a result, we held your Coumadin while you
were here. You should resume taking your home dose of Coumadin
tomorrow (___).
Please have your INR level and blood chemistry checked on
___ at ___. The results will be faxed to your
primary care physician.
Please be sure to take all your medications as instructed, and
follow-up with your physicians at the appointments listed below.
Please be sure to keep your foley and not remove it until you
are seen by Dr. ___.
It was a pleasure to care for you during this hospitalization.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10248160-DS-7 | 10,248,160 | 24,910,217 | DS | 7 | 2163-02-09 00:00:00 | 2163-02-09 15:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
epinephrine / sulfite
Attending: ___.
Chief Complaint:
nausea
Major Surgical or Invasive Procedure:
GJ tube placement
Dilation of sphincter
EGD
History of Present Illness:
___ w/prior breast cancer, abdominal radiation, resulting in
chronic diarrhea, presenting with nausea and vomiting. Patient
reports 2 days of inability to tolerate po or home meds due to
nausea and vomiting. She feels that something is stuck in her
esophagus. She denies any abdominal pain, fevers, or chills. She
has chronic diarrhea maybe worse than usual for the past month.
No chest pain or shortness of breath.
In ED CT with enteritis. Pt given cipro/flagyl, zofran and 2Lns.
ROS: +as above, otherwise reviewed and negative
Past Medical History:
Positive for hypertension and reflux. She also has a prior
history of a uterine cancer and underwent a TAH-BSO followed by
radiation therapy in ___. She has at times diarrhea. She also
has a history of a stress fracture.
Past oncologic history
Pt presented to PCP with palpable left breast mass.
- ___ diag breast imaging: large conglomerate solid mass in
left breast involving almost the entire breast with abnormal
left
axillary LNs.
- ___ CNB: 1.1 cm grade 3 IDLC, ER pos, PR neg, HER2 neg. LN
FNA positive for malignant cells.
- ___ staging evaluation as below, notable for borderline
lymphadenopathy of left supraclavicular region, internal mammary
chain and left axillary regions.
- ___ left mastectomy/ALND: Multiple foci, largest 9.5 cm
grade 3 invasive carcinoma with predominantly pleomorphic
lobular
features, satellite skin foci (T4b), negative deep margin, +ALND
___, stage IIIB.
- ___ start fulvestrant
- ___ complete adjuvant RT
- ___ switch to anastrozole
Social History:
___
Family History:
Negative for breast, ovarian, and any other kind of cancer. Her
mother died at the age of ___ of a myocardial infarction. Her
father died at ___ of heart disease and had a pacemaker. She has
one sister, ___, and one brother, ___, who are still alive.
Physical Exam:
Vitals: T:97.9 BP:90/41 P:65 R:18 O2:96%ra
PAIN: 0
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
Discharge Exam:
110/80 AF 70
Gen: Cachectic female, pleasant
Lung: CTA B
CV: RRR, no m/r/g
Abd: + G tube
Ext: LUE slightly larger than right UE
Pertinent Results:
___ 08:50PM GLUCOSE-96 UREA N-21* CREAT-0.7 SODIUM-145
POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-26 ANION GAP-17
___ 08:50PM ALT(SGPT)-14 AST(SGOT)-38 ALK PHOS-85 TOT
BILI-0.4
___ 08:50PM LIPASE-23
___ 08:50PM cTropnT-<0.01
___ 08:50PM ALBUMIN-4.0 CALCIUM-8.9 PHOSPHATE-2.4*
MAGNESIUM-1.9
___ 08:50PM WBC-8.2# RBC-3.44* HGB-10.9* HCT-32.8* MCV-95
MCH-31.6 MCHC-33.1 RDW-15.2
___ 08:50PM NEUTS-89.3* LYMPHS-5.1* MONOS-5.2 EOS-0.2
BASOS-0.1
___ 08:50PM PLT COUNT-284
___ 12:20AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 12:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
Discharge Labs:
___ 08:25AM BLOOD WBC-4.0# RBC-3.19* Hgb-9.2* Hct-29.4*
MCV-92 MCH-29.0 MCHC-31.4 RDW-15.9* Plt ___
___ 07:20AM BLOOD Glucose-102* UreaN-10 Creat-0.4 Na-137
K-4.0 Cl-102 HCO3-29 AnGap-10
___ 07:20AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.7
U/S - left upper extremity
1. No evidence of deep vein thrombosis in the left upper
extremity.
2. Clot is noted in the cephalic vein at the level of the
proximal forearm.
This is a superficial vein and does not represent a DVT.
3. Superficial, diffuse soft tissue edema is noted in the region
of the
antecubital fossa.
INDICATION: ___ year old woman with esophageal stricture and
malnutrition.
COMPARISON: Esophagogram ___, CT abdomen and pelvis
___.
TECHNIQUE: OPERATORS: Dr. ___ radiology
fellow) and Dr. ___ radiology attending)
performed the procedure. The attending, Dr. ___
supervised the trainee during the key components of the
procedure and has reviewed and agrees with the trainee's
findings
ANESTHESIA: Moderate sedation was provided by administrating
divided doses of 50mcg of fentanyl and 0.25 mg of midazolam
throughout the total intra-service time of 40 during which the
patient's hemodynamic parameters were continuously monitored by
an independent trained radiology nurse. 1% lidocaine was
injected in the skin and subcutaneous tissues overlying the
access site.
MEDICATIONS: Fentanyl and midazolam.
CONTRAST: 20 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 13 min, 412 cGycm2
PROCEDURE: 1. Placement of a ___ ___ gastrojejunostomy
tube.
PROCEDURE DETAILS: Following the discussion of the risks,
benefits and
alternatives to the procedure, written informed consent was
obtained from the patient. The patient was then brought to the
angiography suite and placed semi upright on the exam table. A
pre-procedure time-out was performed per ___ protocol.
Lidocaine jelly and spray was applied to the left nostril and
back of the
throat. An angled glide catheter was advanced through the left
nostril into the stomach under fluoroscopy and glidewire
guidance.
The tube site was prepped and draped in the usual sterile
fashion. A scout image of the abdomen was obtained. The stomach
was insufflated through the indwelling nasogastric catheter.
Using a marker, the skin was marked using palpation to feel the
costal margins and the liver edge was marked using ultrasound.
Ultrasound images were not stored.
Under fluoroscopic guidance, 3 T fastener buttons were
sequentially deployed in a triangular position elevating the
stomach to the anterior abdominal wall. Intra-gastric position
was confirmed with aspiration of air and injection of contrast.
A 19 gauge needle was introduced under fluoroscopic guidance and
position confirmed using an injection of dilute contrast. The
needle trajectory was directed towards the pylorus. A ___
wire was introduced and coiled within the stomach. A small skin
incision was made along the needle and the needle was removed.
A 7 ___ sheath was placed. A Kumpe catheter was then
introduced over the wire and the ___ was exchanged for a
Glidewire. The Glidewire and a Kumpe cathter was used to advance
the wire into the ___ part of the duodenum. The Glidewire was
then exchanged for stiff glidewire. The sheath was then removed
and serial dilations were performed. A peel-away sheath was
placed over the wire. A 14 ___ ___ gastrojejunostomy
catheter was advanced over the wire into position. The sheath
was then peeled away.
The wire and sheath were removed. The catheter was locked by
forming the
retaining loop in the stomach after confirming the position of
the catheter with a contrast injection.
The catheter was then flushed, capped and secured to the skin
with flexi
track. Sterile dressings were applied. The patient tolerated the
procedure well and there were no immediate complications.
FINDINGS:
1. Successful placement of a 14 ___ ___ gastrojejunostomy
tube with its tip in the proximal jejunum.
CT Abd & Pelvis With Contrast (___)
1. No signs of small bowel obstruction. Fluid filled loops of
jejunum and
ileum with areas of wall thickening likely represent enteritis.
2. Extensive atherosclerotic disease with chronic occlusion of
the left common iliac artery with extension into the internal
and external iliac arteries.
3. Multiple thoracolumbar spinal compression deformities,
similar to ___.
KUB ___
COMPARISON: Abdominal radiographs from ___ and ___.
FINDINGS:
Frontal supine and erect abdominal radiographs demonstrate a the
gastrojejunal to the projecting over the left upper abdomen.
There is a nonobstructive bowel gas pattern. Multiple punctate
hyperdensities projecting over the lower abdomen likely
represent flocculation after recent enteric injection of
contrast.
IMPRESSION:
Nonobstructive bowel gas pattern.
EGD Third attempt
A previously noted 5mm benign stricture at 28cm from the
incisors was again visualized. The standard gastroscope was not
able to be traverse the stricture. A 8mm balloon was introduced
for dilation and the diameter was progressively increased to 9
mm successfully.
Stomach: Not examined.
Duodenum: Not examined.
Impression:
A previously noted 5mm benign stricture at 28cm from the
incisors was again visualized.
The standard gastroscope was not able to be traverse the
stricture.
A 8mm balloon was introduced for dilation and the diameter was
progressively increased to 9 mm successfully
Otherwise normal EGD to lower third of the esophagus
Recommendations: Repeat EGD for dilation in 2 weeks with Dr.
___. Will likely need ___ dilation under flurosocopic
guidance.
If any chest or abdominal pain, fevers, bleeding, difficulty
swallowing, nausea, vomiting or any other concerning post
procedure symptom, please call the advanced endoscopy fellow on
call ___ ___.
EGD x2
Impression:
A tight pinhole stricture that appeared at 28 cm from the
incisors was identified. The esophageal mucosa to the level of
the stricture was normal.
At the stricture there was edema, exudate and ulceration seen
likely related to earlier dilation.
A guidewire was passed under fluorosocopic guidance into a
dilated stomach. However, its short angulated path beyond the
stricture suggested a foreshortened esophagus.
With the aid of a biliary balloon, contrast was injected to
better identify the anatomy of the stricture but pooled above
the stricture.
Given, an unusual anatomy that could not be fully defined and
the inflammation due to ealier dilation, the decision was made
to posptpone dilation until after a barium swallow could be
obtained to delineate the stricture.
Recommendations: Obtain Barium Swallow.
___ guided PEG placement on ___ and attempt at further
dilation on ___. If any fever, worsening abdominal pain, or
post procedure symptoms, please call the advanced endoscopy
fellow on call ___/ pager ___.
Additional notes: The procedure was performed by Dr. ___
the GI fellow. The attending was present for the entire
procedure. FINAL DIAGNOSES are listed in the impression section
above. Estimated blood loss = zero. No specimens were taken for
pathology
EGDx1
Findings: Esophagus:
Lumen: A benign intrinsic 5 mm stricture that appeared at 28 cm
from the incisors was seen in the lower third of the esophagus.
The scope did not traverse the lesion. A 8mm balloon was
introduced for dilation successfully.
Other After dilation an attempt was made to pass the baby
endoscope beyond the stricture and the area was too narrow to
allow passage.
Stomach: not examined
Duodenum: not examined
Impression: Stricture of the lower third of the esophagus
(dilation)
After dilation an attempt was made to pass the baby endoscope
beyond the stricture and the area was too narrow to allow
passage.
Recommendations: If any questions or you need to schedule an
office appointment or procedure call ___ MD at
___ or email at ___. To properly
dilate this likely radiation stricture sfely flouroscopy is
needed. I have discussed this with Dr. ___ will dilate
under fluoro today.
Additional notes: FINAL DIAGNOSES are listed in the impression
section above. Estimated blood loss = zero. No specimens were
taken for pathology
Brief Hospital Course:
___ year old female with a history of TAH/BSO in ___ and chronic
diarrhea related to radiation, who has a recent history of
breast cancer (___) treated with left mastectomy and radiation
who presents with nausea, dysphagia and poor PO intake. She was
seen in the ED with possible partial SBO prior to ___. She
returned with nausea and vomiting associated with meds and
dysphagia. She had a CT with enteritis treated with Cipro and
Flagyl x 5 days. She was found to have a benign appearing
distal esophageal stricture.
ACUTE ISSUES:
--------------
ESOPHAGEAL STRICTURE:
She underwent EGD which showed lower esophageal stricture though
unable to dilate on ___. . UGI series confirmed
esoph stricture. On ___, EGD reattempted (benign in appearance)
and it was dilated to 8 mm. Liquids were reattempted but she
was unable to tolerate liquids. Given concerns re:
malnutrition, a PEG tube was requested to be placed by ___ on
___. Repeat dilation was attempted on two more occasions and
was unsuccessful. GI team plans to attempt a repeat dilation in
two weeks. She is to remain NPO until esophageal stricture is
successfully dilated.
HYPERTENSION: BP meds held as she was normotensive without any
blood pressure medication.
Chronic Diarrhea: Per the patient she has had an exhaustive
workup for chronic diarrhea that was performed by her
Gastroenterologist at ___ that revealed that her
diarrhea was secondary to effects of radiation that she had ___
years ago after her hysterectomy. She continued to have
diarrhea while in the hospital on tube feeds, and she had some
response to immodium.
Pain at site of GJ tube: She was evaluated by ___ and and films
that showed the GJ tube was positioned properly. She continued
to have pain along the insertion site several days after
placement - likely structural - she had an adult tube placed
when she is only 60 lbs. She responds to heat packs and tylenol
for the pain. ___ does not feel that the tube needs to be
repositioned.
MALNUTRITION/Weight loss
Hypokalemia, hypomagnesemia, hypophosphatemia all noted on
admission: Likely due to malnutrition and diarrhea. She was
repleted aggressively during her admission and her abnormalities
were corrected.
Her weight on discharge was 65 pounds.
I have talked to her and her niece and friend. They all report
very rapid weight loss in the past few months; they believed
that her recent move was very difficult for her and her diarrhea
worsened during the stress. Her weight loss also accelerated
after she developed an esophageal stricture and was unable to
take PO.
I discussed with her and her HCP at length her overall frailty
and low weight. Perhaps she will be able to gain weight with
tube feeds, but her diarrhea may continue (diarrhea is common
with tube feeds, and she clearly has some underlying
malabsorption secondary to her prior radiation treatment) but it
may not. Should her weight continue to fall, I urged her to
reconsider her goals of care and to consider comfort measures
and discontinuation of the tube.
She is a DNR/DNI, and she would like to return in a few weeks
for reattempt at dilation of the esophageal sphincter. She is
aware of her overall poor health, low weight.
CHRONIC ISSUES:
--------------
BREAST CANCER: Held anastrozole during hospitalization - if
she wishes to continue it at rehab, it would have to be crushed
and then put in G tube. We cancelled her oncology f/u given her
overall poor condition. If her weight improves she may consider
rescheduling f/u.
Code status: DNR/DNI
I discussed her condition in full with her health care proxy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO DAILY
2. anastrozole 1 mg oral daily
3. Omeprazole 40 mg PO DAILY
Discharge Medications:
1. Lansoprazole Oral Disintegrating Tab 30 mg G TUBE DAILY
2. Acetaminophen (Liquid) 650 mg NG Q6H:PRN pain/fever
3. LOPERamide 1 mg PO DAILY:PRN diarrhea
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Enteritis
Dysphagia
Esophageal stricture
Malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to ___ with difficulty swallowing food and
pills. You were taken for an endoscopy which found a stricture
of your esophagus - this was thought to be benign (not cancer).
The stricture was dilated on ___ to 8 mm and but we were
unable to dilate it further. You had a GJ tube placed for
feeding given your weight loss and diarrhea. We are discharging
you to rehab with the hope that you are able to gain weight and
strength as a result of your supplemental feedings. Our
gastroenterologists will contact you at the rehab because they
would like to attempt a dilation again.
When you first were admitted, you seemed to have an infection in
your small bowel which was treated with antibiotics for 5 days.
Followup Instructions:
___
|
10248241-DS-9 | 10,248,241 | 28,501,773 | DS | 9 | 2122-06-09 00:00:00 | 2122-06-09 20:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
cortisone
Attending: ___.
Chief Complaint:
Recurrent falls
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with history of ___, ___
cirrhosis diagnosed ___ s/p TACE x 2 and RFA most recently
___, CKD stage II, DM with diabetic retinopathy,
hypertension, hyperlipidemia, who presents with multiple falls
over the last ___ weeks, with complaints of dizziness and
lightheadedness prior to falling, directly referred by Dr. ___
___ liver clinic today for neurocardiogenic workup of recent
falls.
Patient was seen in liver tumor clinic today, reported to have
had multiple falls over the last ___ weeks. He described feeling
lightheadedness upon standing prior to falling, and has happened
approximately ___ times this week, with injury to his head. Of
note, he saw his PCP about this 3 weeks prior, was found to be
hypotensive at that time and home lisinopril hydrochlorothiazide
was discontinued. Despite stopping his antihypertensives, his
symptoms have persisted. His wife is also noted balance issues
over the last several weeks.
On arrival to the ED, patient confirms history of multiple falls
over the last ___ weeks. Also complaining of mild abdominal pain
over the last week, diffuse, denies any nausea or vomiting.
Denied any fevers, chills, shortness of breath, chest pain, leg
swelling, headache, visual changes or blurry vision.
Initial vitals were:
T 98.6 BP 156/86 HR 89 RR 20 O2 100%RA
Exam notable for:
- Alert, pleasant, conversant, oriented x3, no distress,
slightly jaundiced
- Lungs CTABL, no wheeze or crackle
- RRR +S1S2
- No spinal tenderness, no CVAT
- Abd soft, mildly diffusely tender, nondistended
- BLE with mild 1+ edema to the lower shin, ___ palpated,
symmetric
- No rash noted
Labs notable for:
- WBC 6.1, Hb 12.5, HCT 37.2, PLT 101
- ___ 13.4, PTT 31.6, INR 1.2
- AST 44, ALT 37, ALP 325, T. bili 1.2, albumin 3.1
Imaging was notable for:
EKG: NSR, rate 77, normal axis, normal intervals, no ST or T
wave changes
CXR: Subtle lateral right mid-lung focal ground-glass opacity is
nonspecific, differential diagnosis includes infection or
pulmonary contusion. No obvious rib fracture identified
radiographically although CT is more sensitive.
CT Head WO Contrast: No acute intracranial abnormality. No acute
intracranial hemorrhage
CT C-Spine WO Contrast: No acute fracture or dislocation of the
cervical spine. Minimal anterolisthesis of C2 over C3 is likely
degenerative, but is of indeterminate age given lack of priors
for comparison.
CT Chest/A/P W Contrast:
1. No acute findings in the chest abdomen or pelvis.
2. 3 mm nonobstructing left proximal ureter stone. No
hydroureteronephrosis.
3. Additional chronic findings, as above.
Patient was given:
IV Albumin 25% (12.5g / 50mL) 100 g x2
Upon arrival to the floor, patient confirms the above history.
He notes orthostasis when rising from bed in the morning or at
night. His falls have been predominantly to the right. He
endorses some issues with coordination, as well as with
dysphagia. Does not describe food getting stuck but feels like
his swallowing does not work.
Past Medical History:
Hepatocellular Carcinoma
CKD stage III
DM, type 2
diabetic retinopathy
HTN
hyperlipidemia
gastric ulcer (___)
nephrolithiasis
Social History:
___
Family History:
Family Liver History: maternal uncles X3 with liver disease of
unknown origin
Physical Exam:
ADMISSION PHYSICAL:
===================
PHYSICAL EXAM:
VITAL SIGNS: 98.6 PO 149 / 77L Lying 87 20 96 Ra
GENERAL: NAD, pleasant
HEENT: non icteric sclerae, MMM, no OP lesions. EOMI, no
nystagmus
NECK: JVP not elevated
CARDIAC: ___ SEM, RRR
LUNGS: CTAB, no w/r/r
ABDOMEN: slightly distended, nontender, no appreciable
hepatomegaly/splenomegaly
EXTREMITIES: WWP, no edema
NEUROLOGIC: II-XII intact, FTN testing intact, heel to shin
intact. Sensation/proprioception blunted below knee bilaterally
DISCHARGE PHYSICAL:
====================
VITAL SIGNS: ___ 0712 Temp: 98.1 PO BP: 152/78 L Lying HR:
74 RR: 18 O2 sat: 98% O2 delivery: Ra FSBG: 128
GENERAL: NAD, pleasant
HEENT: non icteric sclerae, MMM, no OP lesions. EOMI, no
nystagmus; no masses, swelling, or redness appreciated over left
neck
CARDIAC: ___ early systolic murmur, RRR
LUNGS: CTAB, with + bibasilar crackles that do not disappear
with repeated inspiration; no r/w
ABDOMEN: slightly distended, nontender, no appreciable
hepatomegaly/splenomegaly; BS+
EXTREMITIES: WWP, no edema
NEUROLOGIC: alert, appropriately interactive; no cogwheeling in
any extremity; no resting tremor appreciated; no asterixis or
tremor appreciated with oustretching of arms
Pertinent Results:
ADMISSION LABS:
===============
___ 11:40AM BLOOD WBC-6.1 RBC-3.92* Hgb-12.5* Hct-37.2*
MCV-95 MCH-31.9 MCHC-33.6 RDW-13.8 RDWSD-47.8* Plt ___
___ 11:40AM BLOOD Neuts-71.3* Lymphs-16.3* Monos-10.4
Eos-1.5 Baso-0.2 Im ___ AbsNeut-4.33 AbsLymp-0.99*
AbsMono-0.63 AbsEos-0.09 AbsBaso-0.01
___ 11:40AM BLOOD ___ PTT-31.6 ___
___ 11:40AM BLOOD Glucose-274* UreaN-23* Creat-1.2 Na-138
K-4.5 Cl-101 HCO3-23 AnGap-14
___ 11:40AM BLOOD ALT-37 AST-44* AlkPhos-325* TotBili-1.2
___ 11:40AM BLOOD cTropnT-<0.01 proBNP-171
___ 11:40AM BLOOD Lipase-41
___ 11:40AM BLOOD Albumin-3.1*
___ 11:40AM BLOOD VitB12-1768*
___ 11:40AM BLOOD TSH-1.5
DISCHARGE LABS:
================
___ 05:08AM BLOOD WBC-5.6 RBC-3.61* Hgb-11.5* Hct-35.0*
MCV-97 MCH-31.9 MCHC-32.9 RDW-13.8 RDWSD-49.4* Plt Ct-81*
___ 05:08AM BLOOD Glucose-84 UreaN-25* Creat-1.2 Na-143
K-4.2 Cl-110* HCO3-19* AnGap-17
OTHER IMPORTANT LABS:
======================
___ 07:50PM URINE Hours-RANDOM Creat-144 TotProt-600
Prot/Cr-4.2*
___ 05:07PM URINE Hours-RANDOM UreaN-634 Creat-173 Na-56
___ 07:50PM URINE U-PEP-AWAITING F IFE-PND
___ 07:20AM BLOOD Folate-6
___:09AM BLOOD %HbA1c-6.0 eAG-126
___ 07:20AM BLOOD Triglyc-251* HDL-27* CHOL/HD-9.0
LDLcalc-166*
___ 07:20AM BLOOD PEP-NO SPECIFI
___ 05:08AM BLOOD ALT-43* AST-63* AlkPhos-338* TotBili-1.2
IMAGING AND OTHER STUDIES
===========================
___ NCHCT: No acute intracranial abnormality. No acute
intracranial hemorrhage.
___ CT C-spine without contrast: No acute fracture or
dislocation of the cervical spine. Minimal anterolisthesis of
C2 over C3 is likely degenerative, but is of indeterminate age
given lack of priors for comparison.
___ CT Chest/Abd/Pelvis with Contrast:
1. No acute findings in the chest abdomen or pelvis.
2. 3 mm nonobstructing left proximal ureter stone. No
hydroureteronephrosis.
3. Additional chronic findings, as above.
___ MRI Head W/ and W/o Contrast:
1. Punctate late acute to early subacute cortical infarct of the
right
superior parietal lobule.
2. No evidence of intracranial metastatic disease.
3. Extensive T2 signal abnormalities in the supratentorial white
matter and pons are nonspecific but likely sequela of chronic
small vessel ischemic disease in this age group.
4. Prominence of the proximal basilar artery is better assessed
on the
subsequent CTA of the head and neck.
___ TTE:
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%). No masses or thrombi
are seen in the left ventricle. Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
___ CTA Head/Neck:
1. No acute hemorrhage or mass effect. Small late acute/early
subacute
cortical infarct seen in the superior right parietal lobe on the
MRI from 1 day earlier is not seen on the present CT.
2. Extensive supratentorial white matter hypodensities are
nonspecific but likely sequela of chronic small vessel ischemic
disease in this age group.
3. Short-segment of mixed plaque mildly narrowing the mid left
common carotid artery. Mild bilateral proximal internal carotid
atherosclerosis without stenosis by NASCET criteria.
4. No evidence for flow-limiting stenosis or saccular aneurysm
in the major intracranial arteries. Mildly ectatic proximal
basilar artery.
5. 12 x 7 mm presumed venous aneurysm or pseudoaneurysm is again
demonstrated at the posterior aspect of the confluence of the
left internal jugular and subclavian veins.
MICRO:
========
None
Brief Hospital Course:
Mr. ___ is a ___ male with history of HCC ___ NASH
cirrhosis diagnosed ___ s/p TACE x 2 and RFA most recently
___, CKD stage II, DM with diabetic retinopathy,
hypertension, hyperlipidemia, who presents with multiple falls
over the last ___ weeks, with complaints of dizziness and
lightheadedness prior to falling, admitted for neuro-cardiogenic
workup of falls.
ACUTE ISSUES
================
# Recurrent Falls:
# Symptomatic Orthostasis:
# Gait Imbalance:
The patient had sustained approximately ___ falls over the week
prior to presentation, which he associated with lightheadedness
on standing and gait imbalances. He also had experienced
multiple falls before that in the preceding months. Of note,
home lisinopril/hydrochlorothiazide was discontinued by PCP 3
weeks prior given falls in the setting of hypotension. After
presentation, it was felt that his falls were possibly secondary
to orthostasis, lower extremity/proximal weakness, and
dysautonomia in the setting of his diabetes. His orthostatic
vital signs were intermittently positive during his admission.
As a result, the patient was given IVF for resuscitation and
given compression stockings. He was also monitored on telemetry
throughout his hospitalization. He was evaluated by neurology,
with the conclusion that his falls were likely multifactorial,
secondary to hypovolemic orthostasis, proprioceptive deficit in
his bilateral lower extremities, vestibular dysfunction, and
likely underlying dementia. The patient also frequent episodes
of hypoglycemia, which could have been contributing to his falls
and gait disturbances. He also underwent brain imaging, the
results of which are discussed below. EEG was obtained and was
normal. The patient was mobilized by ___ with improvement in his
functional status. He also underwent TTE, which showed normal
biventricular function without any significant valvular disease.
For management, he was given fluid repletion, compression
stockings, and underwent vestibular ___, which should be
continued after discharge.
# Parietal lobe infarct:
Patient was found to have late acute to subacute infarct in his
right superior parietal lobe on MRI. It was felt that his
infarct was unlikely to be contributing to his current
presentation. However, given his ongoing dementia, it was felt
that the patient likely had an element of vascular dementia. TTE
was obtained (results discussed above). He was also started on
aspirin 81mg and pravastatin 40mg. Pravastatin was chosen given
his hepatic dysfunction.
# HTN: The patient's anti-hypertensive medications,
lisinopril-hydrochlorothiazide, were held given his history of
recent falls with contribution from orthostasis.
# Cognitive decline/Possible early vascular dementia: per
conversation with the patient and his wife, he has been
suffering issues with his memory as well as changes in his mood
for many months now. Given the CNS imaging consistent with
chronic, small vessel vascular disease, the issue of possible
early cognitive decline attributable to vascular dementia was
raised this admission. This was discussed with him and his wife,
who will continue to follow up with outpatient neurology and
cognitive neurology for further work-up.
CHRONIC ISSUES
=================
# DM type II: Patient was maintained on an insulin regimen with
sliding scale as well. Due to hypoglycemia on admission and
during admission, his insulin regimen was down-titrated at time
of discharge.
# LFT abnormalities
# Hepatocellular Carcinoma
History of ___ ___ NASH cirrhosis s/p TACE TACE x2 and RFA most
recently ___ followed by liver tumor clinic overall being
treated with a palliative intent. Meld-Na 12 on admission, no
evidence of decompensation. Did received albumin in ED. Has
elevated ALP above baseline, however no obvious identifying
cause on CT A/P. Liver MRI and chest CT ___ at
___ showing no residual or recurrent disease in the
liver, and stable subcentimeter pulmonary nodules. Undergoing
continued surveillance with repeat MRI 3 months from now.
#Anemia: Hb on admission 12.5, recent baseline ___. No obvious
sources of bleeding.
#Thrombocytopenia: PLT on admission 101, recent baseline 90-130.
TRANSITIONAL ISSUES:
====================
NEW MEDICATIONS:
-Aspirin 81mg PO daily
-Pravastatin 20mg PO daily
-Polyethylene glycol 17g PO daily
-Senna 17.2mg PO qHS
CHANGED MEDICATIONS:
-Glargine 48 Units Bedtime
-Humalog 32 Units Breakfast
-Humalog 36 Units Dinner
DISCONTINUED/HELD MEDICATIONS:
-None
[] Home safety evaluation and neurocognitive evaluation and
outpatient work-up for possible early signs of dementia
[] Patient will need Ziopatch as outpatient to evaluate for
undiagnosed atrial fibrillation (no evidence this admission on
telemetry)
[] Patient was found to have a pseudoaneurysm at the juncture of
the left subclavian and internal jugular veins. Please evaluate
further with venous ultrasound as an outpatient.
[] patient should follow up with hepatology, neurology, and PCP
after discharge.
[] patient should undergo vestibular ___ and OT at rehab and
after discharge from rehab
[] patient should wear compression stockings to help mitigate
effects of orthostasis
[] patient's home insulin regimen was down-titrated this
admission due to episodes of hypoglycemia and should be
continued to be monitored at rehab
[] patient should have repeat chem10 and LFTs in 1 week (on
___ to assess renal and liver function
Discharge Cr: 1.2
# CODE: DNR/ok to intubate
# CONTACT:
Name of health care proxy: ___
Relationship: wife
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Venlafaxine 50 mg PO BID
2. GlipiZIDE 10 mg PO DAILY
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. Mirtazapine 15 mg PO QHS
5. Glargine 75 Units Bedtime
Humalog 40 Units Breakfast
Humalog 10 Units Lunch
Humalog 45 Units Dinner
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Polyethylene Glycol 17 g PO DAILY
3. Pravastatin 20 mg PO QPM
4. Senna 17.2 mg PO HS
5. Glargine 48 Units Bedtime
Humalog 32 Units Breakfast
Humalog 36 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
6. GlipiZIDE 10 mg PO DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Mirtazapine 15 mg PO QHS
9. Venlafaxine 50 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS/ES:
=====================
-Recurrent falls
-Orthostatic hypotension
-Vestibular neuropathy
-Subacute, late parietal lobe punctate stroke
SECONDARY DIAGNOSIS/ES:
=======================
-Hepatocellular carcinoma
-Non-alcoholic fatty steatohepatitis
-Stage 2 chronic kidney disease
-Hypertension
-Type 2 diabetes mellitus complicated by neuropathy and
retinopathy
-Anemia, chronic
-Thrombocytopenia, chronic
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 in the hospital!
WHY WERE YOU ADMITTED:
- You fell multiple times and we wanted to examine you to see if
there was a reason to explain why you were falling
WHAT HAPPENED IN THE HOSPITAL:
- We gave you fluids to improve your blood pressure
- We did an ultrasound of your heart
- We also did an EEG where we looked at the electrical activity
of your brain, which was normal
- The physical therapists came by and worked with you to improve
your mobility
- The neurologists came and saw you as well
WHAT SHOULD YOU DO AFTER LEAVING:
- Please take your medications as prescribed
- Follow-up with your doctors as ___ below
___ you for allowing us to take part in your care!
Your ___ team
Followup Instructions:
___
|
10248379-DS-8 | 10,248,379 | 21,000,658 | DS | 8 | 2127-04-26 00:00:00 | 2127-04-30 09:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right flank pain, leukocytosis
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ is a ___ female with
nephrolithiasis, a known 6-8 mm right renal pelvis stone. This
has been followed conservatively by Dr. ___ renal
ultrasound in ___.
Yesterday, she developed right flank pain and urinary urgency.
She went to the ED and a CT scan demonstrated an obstructing
right mid ureteral stone, roughly 6 mm. She has mild/moderate
right hydronephrosis. WBC is 17, Cr 0.6, no fevers. On my
evaluation, she is pain and nausea free. She took a dose of
Flomax prior to coming to the ED. No pain meds in ___ hours.
ED
started cipro.
Past Medical History:
IRON DEFICIENCY
HYPERLIPIDEMIA
ELEVATED BLOOD PRESSURE
OBGYN
SMOKER
HYPERTENSION
NEPHROLITHIASIS
HYSTEROSCOPIC POLYPECTOMY, D&C ___
PRIOR CESAREAN SECTION
Social History:
___
Family History:
Non-contributory
Physical Exam:
WdWn male, NAD, AVSS
Interactive, cooperative
Abdomen soft, Nt/Nd
Flank pain minimal
Lower extremities w/out edema or pitting and no report of calf
pain
Pertinent Results:
___ 07:38AM BLOOD WBC-12.2* RBC-3.68* Hgb-11.4 Hct-34.8
MCV-95 MCH-31.0 MCHC-32.8 RDW-14.5 RDWSD-50.7* Plt ___
___ 10:22PM BLOOD WBC-17.8*# RBC-4.03 Hgb-12.6 Hct-39.3
MCV-98 MCH-31.3 MCHC-32.1 RDW-14.8 RDWSD-52.7* Plt ___
___ 10:22PM BLOOD Neuts-86.1* Lymphs-6.2* Monos-6.8
Eos-0.1* Baso-0.3 Im ___ AbsNeut-15.34*# AbsLymp-1.11*
AbsMono-1.22* AbsEos-0.02* AbsBaso-0.05
___ 07:38AM BLOOD Glucose-90 UreaN-11 Creat-0.7 Na-139
K-3.7 Cl-107 HCO3-23 AnGap-13
___ 10:22PM BLOOD Glucose-102* UreaN-12 Creat-0.6 Na-138
K-4.1 Cl-104 HCO3-22 AnGap-16
___ 07:38AM BLOOD Calcium-8.9
___ 11:16PM URINE Color-Straw Appear-Hazy Sp ___
___ 10:22PM URINE Color-Straw Appear-Hazy Sp ___
___ 11:16PM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 11:16PM URINE RBC-21* WBC->182* Bacteri-FEW Yeast-FEW
Epi-1
___ 10:22PM URINE RBC-16* WBC-111* Bacteri-MANY Yeast-NONE
Epi-64
___ 10:22 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
Brief Hospital Course:
Ms. ___ was admitted to Dr. ___, from the
ED, for stone related pain. She is known to Dr. ___
prior procedures and was admitted for observation and made NPO
pending need of surgical intervention with ureteral stenting. On
Hospital day 2 her leukocytosis improved, as did her pain.
Ultrasound obtained and she was advanced in diet and prepped for
discharge home with a plan for outpatient follow up early next
week. Overnight, she was hydrated with intravenous fluids. She
was ambulating without assistance and voiding without
difficulty. Ms. ___ was explicitly advised to follow up as
directed as the indwelling ureteral stent must be removed and or
exchanged.
Medications on Admission:
as noted in ___
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
RX *ciprofloxacin HCl 500 mg ONE tablet(s) by mouth twice a day
Disp #*20 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg ONE capsule(s) by mouth
twice a day Disp #*60 Capsule Refills:*0
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg one tablet(s) by mouth q4hrs Disp #*30 Tablet
Refills:*0
5. Ondansetron ODT 4 mg PO Q8H:PRN nausea
6. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
NEPHROLITHIASIS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-You may experience some pain associated with spasm of your
ureter.; This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control. For pain
control, try TYLENOL FIRST, then ibuprofen, and then take the
narcotic pain medication as prescribed if additional pain relief
is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-You MAY be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine bright orange.
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative, and available over the counter.
The generic name is DOCUSATE SODIUM. It is recommended that you
use this medication.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
Followup Instructions:
___
|
10248673-DS-6 | 10,248,673 | 28,164,505 | DS | 6 | 2177-06-25 00:00:00 | 2177-06-25 11:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Zocor / Lipitor
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
___: Coronary bypass grafting x4: Left internal
mammary artery to left anterior descending artery, and
reverse saphenous vein graft to the posterior descending
artery, obtuse marginal artery, diagonal artery.
History of Present Illness:
CHIEF COMPLAINT: chest pain
___ year old gentleman w/known CAD, carotid stenosis presents 1
month s/p inferior STEMI s/p RCA DES ___ EF 40-45% with
hypokinesis of mid to distal inferior and inferolateral walls as
well as basal inferoseptum and the apex known 3 vessel disease
who has CABG scheduled for end of ___. Presented to ER
on ___ c/o worsening anginal type chest pains, ruled out for
MI, but was admitted for CABG to happen sooner.
Past Medical History:
Coronary Artery Disease
Right Carotid Stenosis
Gastroesophageal Reflux Disease
Gastric Polyps
Diverticulosis
Hyperlipidemia
Past Surgical History
tonsillectomy
dental grafting
Social History:
___
Family History:
Both of his parents died of MI in their ___
Physical Exam:
Preoperative Physical:
VS: 97.3 132/79 69 18 97%RA
GENERAL: NAD. Oriented x3..
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 8cm.
CARDIAC: regular rate rythm, systolic murmer heard at apex
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+
Pertinent Results:
CXR ___: continued opacification at the left base most
likely reflecting pleural effusion and volume loss in the lower
lobe. Mild blunting of the right costophrenic angle persists.
No evidence of vascular congestion.
Echocardiogram
___ PREBYPASS: Preserved LV systolic function with no
segmental wall motin abnormalities, LVEF > 55% The left atrium
is normal in size. Left ventricular wall thicknesses and cavity
size are essentially normal. There is mild symmetric left
ventricular hypertrophy. Right ventricular chamber size and free
wall motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. There are simple atheroma
in the ascending and descending aorta. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
Normal pulmonic and tricuspid valve. There is no pericardial
effusion. Intact interatiral septum. No clot in ___. Normal
coronary sinus. Normal diastolic function. All findings
discussed with surgical team.
POSTBYPASS: essentially unchanged. No segmental wall motion
abnormalities. No dissection seen following removal of aortic
cannula
___ WBC-7.1 RBC-2.89* Hgb-8.3* Hct-26.1* MCV-90 MCH-28.9
MCHC-32.0 RDW-14.1 Plt ___
___ WBC-8.6 RBC-2.66* Hgb-7.8* Hct-23.0* MCV-87 MCH-29.4
MCHC-34.0 RDW-13.9 Plt ___
___ WBC-5.9 RBC-4.87 Hgb-14.1 Hct-42.0 MCV-86 MCH-29.0
MCHC-33.6 RDW-13.5 Plt ___
___ Glucose-177* UreaN-20 Creat-1.3* Na-138 K-3.8 Cl-100
HCO3-29
___ Glucose-99 UreaN-15 Creat-1.3* Na-138 K-4.5 Cl-99
HCO3-33*
___ Glucose-134* UreaN-21* Creat-1.5* Na-141 K-4.3 Cl-101
HCO3-27 AnGap-17
___ ALT-19 AST-27 LD(LDH)-151 AlkPhos-39* Amylase-41
TotBili-0.3
___ Mg-2.1
___ %HbA1c-5.0 eAG-97
___ MRSA SCREEN (Final ___: No MRSA isolated.
Brief Hospital Course:
___ year old gentleman w/known CAD, carotid stenosis presents 1
month s/p inferior STEMI s/p RCA DES ___ EF 40-45% with
hypokinesis of mid to distal inferior and inferolateral walls as
well as basal inferoseptum and the apex known 3 vessel disease
who has CABG scheduled for end of ___. Presented to ER
on ___ c/o worsening anginal type chest pains, ruled out for
MI, but was admitted for Coronary artery revascularization.
Cardiac Surgery Course:
The patient was brought to the Operating Room on ___ where
the patient underwent Coronary bypass grafting x4: Left
internal mammary artery to left anterior descending artery, and
reverse saphenous vein graft to the posterior descending artery,
obtuse marginal artery, diagonal artery.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic support, and
remained an extra day in the ICU for vasopressor support. The
patient was transferred to the telemetry floor for further
recovery. Chest tubes and pacing wires were discontinued
without complication. Chest tubes and pacing wires were
discontinued without complication.
Respiratory: aggressive pulmonary toilet, nebs, incentive
spirometer he titrated off oxygen with room saturations 97%.
Cardiac: Beta-blockers were initiated post-operative day 3 once
off pressors. He developed SVT (combination of Atrial
fibrillation and Atrial flutter w/HR 170s) on POD 4, which
resolved with increased Lopressor to 50 TID. Blood pressure
100-140/70 stable. Plavix, aspirin and statin were restarted.
Renal: Renal function remained with his baseline of 1.3-1.5. He
was gently diuresis with good urine output. Electrolytes were
replete as needed.
Heme: Anemia immediately postop HCT ___ which slowly improved
and on discharge was ___. He was started on Iron 325 mg for
30 days.
GI: Bowel protocol and PPI were continued.
Pain: well controlled with oral analgesics.
Disposition: He was seen by physical therapy, continued to make
steady progress and was discharge to home with ___ on POD5. He
will follow-up as an outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clopidogrel 75 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Rosuvastatin Calcium 20 mg PO DAILY
4. Nitroglycerin SL 0.3 mg SL PRN Chest pain
5. Metoprolol Succinate XL 75 mg PO DAILY
6. NexIUM *NF* (esomeprazole magnesium) 40 mg Oral daily
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. NexIUM *NF* (esomeprazole magnesium) 40 mg ORAL DAILY
4. Rosuvastatin Calcium 20 mg PO DAILY
5. Acetaminophen 650 mg PO Q4H:PRN pain
6. Docusate Sodium 100 mg PO BID
7. Ferrous Sulfate 325 mg PO DAILY Duration: 30 Days
8. Furosemide 40 mg PO DAILY Duration: 7 Days
RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*7
Tablet Refills:*0
9. Metoprolol Tartrate 50 mg PO TID
RX *metoprolol tartrate [Lopressor] 50 mg 1 tablet(s) by mouth
three times a day Disp #*90 Tablet Refills:*1
10. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen [Percocet] 5 mg-325 mg ___ tablet(s)
by mouth four times a day Disp #*40 Tablet Refills:*0
11. Potassium Chloride 20 mEq PO DAILY
RX *potassium chloride 20 mEq 20 mEq by mouth once a day Disp
#*7 Tablet Refills:*0
12. Sodium Chloride Nasal ___ SPRY NU DAILY:PRN nasal stuffiness
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Coronary Artery Disease
Right Carotid Stenosis
Gastroesophageal Reflux Disease
Gastric Polyps
Diverticulosis
Hyperlipidemia
Past Surgical History
tonsillectomy
dental grafting
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema-1+ ___ edema
Discharge Instructions:
Shower daily including washing incisions gently with mild soap
No baths or swimming, and look at your incisions
NO lotions, cream, powder, or ointments to incision
Daily weights.
No driving for approximately one month and while taking
narcotics
No lifting more than 10 pounds for 10 weeks
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
10249110-DS-18 | 10,249,110 | 25,304,245 | DS | 18 | 2118-04-16 00:00:00 | 2118-04-16 15:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Transfer from OSH due to SBP
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ EtOH/HCV cirrhosis complicated by ascites with diuresis
limited due to cramping with requirement of LVP, hepatic
encephalopathy, and grade II-III varices s/p banding who is
transferred from ___ after incidental finding of cell
count c/w SBP.
Went to ___ today for routine paracentesis. WBC of 6000 and
spun hct 41. Ascites analysis showed: WBC HCT,fl Polys Lymphs
Monos Eos NRBC ___ 15:01 6800* 41.0*1 81* 8* 10* 1* 1.
Called back due to concern for SBP and went to ___. Given
ertapenem at 1700. Patient denied any complaints. No
fevers/chills. NO abdominal pain, nausea, vomiting or diarrhea.
No chest pain or shortness of breath. Says he feels well.
In the ED, initial vitals were: T 98, 66, 106/68, 18, 98% RA
- Exam revealed reassuring exam, no abdominal tenderness
- Labs showed Na 129, electrolytes otherwise wnl. ALT 41 / AST
53 / ALP 109 / TBili 2.1, Albumin 3.7, Hgb 10.8, Plt 89.
- Hepatology was consulted who recommended admission to ET
service, giving 1.5g/kg albumin and transitioning to
ceftriaxone.
On evaluation this morning MR. ___ notes that he had
abdominal pain the night before but denies any now. Denies
nausea, vomiting, fever, or chills. This morning patient does
note a cough and SOB. He is unaware of the doses of his
medications. Notes that he feels more confused from night prior.
Of note Mr. ___ was seen in clinic on ___ ___
with recommendation to split Lasix to 20 mg BID and 100 mg
spironolactone BID given prior intolerance due to cramping. IT
was also thought that he could initiate harvoni treatment with
plan for application for meds.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, 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.
Past Medical History:
1. Decompensated EtOH Cirrhosis (c/b diuretic refractory
ascites, esophageal varices s/p banding in ___, hepatic
encephalopathy, no history of GI bleeding)
2. Chronic hepatitis C: genotype 1a, naïve to treatment, HCV
VIRAL LOAD ___: 654,000 IU/mL.
3. Alcohol abuse, last drink ___.
4. Hemorrhagic CVA? in ___
Social History:
___
Family History:
No family history of liver disease, liver
cancer, or colon cancer. He never had a screening colonoscopy.
Physical Exam:
================================
PHYSICAL EXAM ON ADMISSION
================================
Vital Signs: T 98.3, 103/59, 58, 18, 95%RA, weight 79.5kg
General: Alert, oriented to self and place, believes it is the
___. + Asterexis R > L. Intermittent productive cough
HEENT: Sclera anicteric, MMM, oropharynx clear
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, mild distension, bowel sounds present
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
================================
PHYSICAL EXAM ON DISCHARGE
================================
Vital Signs: T 98.2 HR 70 BP 118/68 RR 18 99 RA
General: Alert, no acute distress
HEENT: Sclera anicteric, MMM, NCAT
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, mild distension, bowel sounds present
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro: Alert and oriented to person, place, time, fluent speech,
moving all extremities with purpose, no asterixis
Pertinent Results:
======================
LABS ON ADMISSION
======================
___ 03:01PM ASCITES WBC-6800* HCT,fl-41.0* Polys-81*
Lymphs-8* Monos-10* Eos-1* NRBC-1*
___ 03:01PM ASCITES TotPro-7.6 LD(LDH)-336 Amylase-115
Albumin-3.4
___ 10:00PM BLOOD WBC-4.8 RBC-3.15* Hgb-10.8* Hct-31.8*
MCV-101* MCH-34.3* MCHC-34.0 RDW-14.3 RDWSD-52.7* Plt Ct-89*
___ 10:00PM BLOOD Neuts-70.2 Lymphs-5.6* Monos-20.1*
Eos-3.1 Baso-0.6 Im ___ AbsNeut-3.39 AbsLymp-0.27*
AbsMono-0.97* AbsEos-0.15 AbsBaso-0.03
___ 10:00PM BLOOD Glucose-86 UreaN-17 Creat-0.7 Na-129*
K-4.1 Cl-96 HCO3-24 AnGap-13
___ 10:00PM BLOOD ALT-41* AST-53* AlkPhos-109 TotBili-2.1*
___ 10:00PM BLOOD Albumin-3.7 Calcium-8.2* Phos-3.2 Mg-2.1
___ 10:01PM BLOOD Lactate-1.5
___ 02:30AM URINE Color-AMB Appear-Hazy Sp ___
___ 02:30AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-6.0 Leuks-NEG
___ 02:30AM URINE RBC-161* WBC-4 Bacteri-FEW Yeast-NONE
Epi-0
___ 02:30AM URINE Mucous-FEW
======================
LABS ON DISCHARGE
======================
___ 04:55AM BLOOD WBC-3.4* RBC-2.95* Hgb-10.2* Hct-30.0*
MCV-102* MCH-34.6* MCHC-34.0 RDW-14.4 RDWSD-53.1* Plt Ct-66*
___ 04:55AM BLOOD ___ PTT-49.1* ___
___ 04:55AM BLOOD Glucose-87 UreaN-14 Creat-0.5 Na-127*
K-3.8 Cl-93* HCO3-23 AnGap-15
___ 04:55AM BLOOD ALT-39 AST-55* AlkPhos-102 TotBili-3.4*
___ 04:55AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.0
======================
MICROBIOLOGY
======================
___ - Blood Culture x2 - Pending
___ - Urine Culture - No Growth
======================
IMAGING/STUDIES
======================
RUQ US with Doppler ___
1. Patent hepatic vasculature.
2. Cirrhotic liver with moderate ascites. No focal liver
lesions identified.
3. Somewhat limited study as the patient was not cooperative
with the
examination.
CXR ___
There may be a small area of patchy density or scarring in the
retrocardiac area in the left lower lobe. There is no
pneumothorax or CHF. Aortic calcifications and tortuosity are
present.
MRI Liver with and without contrast ___
Cirrhosis with portal hypertension as evidenced by splenomegaly,
marked
ascites and multiple esophageal and gastric varices. No
concerning hepatic lesions meeting OPTN 5a criteria for HCC.
OSH EGD:
EGD report ___ ___:
INDICATIONS: This is a ___ gentleman with a history of
alcohol/hepatitis C cirrhosis history of esophageal variceal
bleeding here for banding surveillance. He last had esophageal
variceal banding in ___.
DESCRIPTION OF PROCEDURE After alternatives to upper endoscopy
were thoroughly explained informed consent was obtained. All
questions were answered and a physical exam was performed. A
timeout was completed. The patient was placed in the left
lateral decubitus position and a bite block was inserted. After
adequate sedation by anesthesia the pediatric gastroscope was
inserted over the tongue into the proximal esophagus. The
esophagus was notable for 4 chains of grade 1 varices. The Z
line was well seen at the GE junction. The gastroscope was
advanced into the stomach and retroflexed views of the cardia
were notable for portal hypertensive gastropathy. There were no
gastric varices identified. Anterograde views of the fundus and
antrum were notable for portal hypertensive gastropathy. The
gastroscope was advanced through the pylorus into the duodenal
bulb which was normal as was the post bulbar duodenum. The
gastroscope was then withdrawn from the patient and the
procedure completed. The patient tolerated the procedure well
and was transferred to the recovery room in stable condition.
COMPLICATIONS: None
SPECIMENS: None
EBL: None
ENDOSCOPIC IMPRESSION:
4 chains of grade 1 esophageal varices
No gastric varices
Moderate portal hypertensive gastropathy
Normal duodenum
RECOMMENDATIONS:
Continue diuretics
Repeat upper endoscopy in 12 months
Follow-up with Dr. ___ in ___
Brief Hospital Course:
___ w/ EtOH/HCV cirrhosis complicated by ascites with diuresis
limited due to cramping with requirement of LVP, hepatic
encephalopathy, and grade II-III varices s/p banding who is
transferred from ___ after incidental finding of cell
count c/w SBP during therapeutic paracentesis, found to have
hepatic encephalopathy, cough, and shortness of breath.
# SBP: Patient admitted after large volume paracentesis at ___
___ returned consistent with SBP. Initially given ertapenam
at 1700 on ___, subsequently started on IV Ceftriaxone 2g Q24H
for a total of 5 days for SBP treatment. Patient transitioned to
PO ciprofloxacin to continue indefinitely on discharge for SBP
prophylaxis. Blood cultures and urine cultures were negative to
date. The patient left the hospital after the fifth day of IV
antibiotics against medical advice without transition to PO
ciprofloxacin in house or repeat paracentesis for repeat
diagnostic cultures to ensure clearance of infection. The
patient understood the risks of leaving against medical advice
including worsening infection, renal failure, and even death.
The patient understood these risks and decided to leave against
medical advice. The patient will have a large volume
paracentesis at ___ on ___ and the patient's GI doctor
and ___ RNs were contacted about the need for cultures and cell
count to be obtained.
# Hepatic Encephalopathy : Patient with evidence of hepatic
encephalopathy on admission with aterexis and inability to
answer orientation questions. This was likely secondary to
infection given SBP as above. Other infectious workup including
CXR and RUQ were negative for infection, and blood and urine
cultures were negative. Lactulose was uptitrated to Q2H, and his
mental status much improved in concert with antiobiotics for SBP
as above. Lactulose was decreased to home dosing on discharge.
On discharge the patient was alert and oriented x 3 without
evidence of asterixis.
# Decompensated EtOH + HCV Cirrhosis: Child's B, MELD Na 21,
naive to HCV treatment (genotype 1a, viral load ___ on
___. Patient with prior reported intolerance of diuretics
due to severe cramps requiring large volume paracentesis. Up to
date with ___ screening. Not a transplant candidate due to poor
social support per recent clinic visit. The patient's home
diuretic were held in the setting SBP. As above, the patient
left the hospital immediately after his fifth dose of IV
antibiotics and diuretics were not able to be started on house.
# Grade I varices and moderate portal hypertensive gastropathy
based on ___ EGD from ___. Prior history of grade
II-III Varices s/p banding in ___ esophageal and gastric.
Nadolol was restarted prior to discharge given grade I varices
and decompensation this hospitalization. There was no indication
for repeat EGD during the admission, and no evidence of upper GI
bleeding.
# Hyponatremia:
Patient noted to have hyponatremia to 127-128 that improved with
albumin thought to be hypovolemic hyponatremia. Diuretics were
held as above. Sodium on discharge was 127.
# Chronic hepatitis C: genotype 1a, naïve to treatment, ___
VIRAL LOAD ___: 654,000 IU/mL. Recently evaluated as an
outpatient and planning for outpatient Harvoni treatment.
# BPH: Patient recently started on tamsulosin, continued during
the admission. BP remained stable.
# EtOH Abuse: Last drink was ___. SW was consulted
during the admission.
# Tobacco use: Patient given nicotine patch in house
=======================
TRANSITIONAL ISSUES
========================
- Patient will need to continue 500 gm PO ciprofloxacin
indefinitely for SBP prophylaxis
-spironolactone and Lasix held at time of discharge given
persistent hyponatremia
-repeat paracentesis at ___ per schedule on ___
gram stain and culture should be sent and faxed to Dr. ___:
___
-chem-7 should also be checked on ___ and faxed to Dr.
___ ___
-repeat labs at time of follow up with chemistry in ___
clinic ___
-consider restarting diuretics pending follow up Creatinine and
sodium
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Spironolactone 100 mg PO BID
2. Furosemide 20 mg PO BID
3. Lactulose 30 mL PO QID
4. Pantoprazole 40 mg PO Q24H
5. Nadolol 20 mg PO DAILY
6. Magnesium Oxide 400 mg PO BID
7. Tamsulosin 0.4 mg PO QHS
8. Rifaximin 550 mg PO BID
Discharge Medications:
1. Lactulose 30 mL PO QID
2. Nadolol 20 mg PO DAILY
3. Pantoprazole 40 mg PO Q24H
4. Tamsulosin 0.4 mg PO QHS
5. Magnesium Oxide 400 mg PO BID
6. Rifaximin 550 mg PO BID
7. Ciprofloxacin HCl 500 mg PO Q24H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses
====================
# Spontaneous bacterial peritonitis
# Hepatic encephalopathy
# Decompensated EtOH/HCV Cirrhosis
# Chronic hepatitis C
# Grade I esophageal varices
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you during your stay at ___. You
were admitted to the hospital because you were found to have an
infection of the fluid on a routine paracentesis. You were
treated with IV antibiotics for 5 days. You will need to
continue to take oral antibiotics daily to help prevent this
infection from coming back.
We discussed the risk of leaving the hospital prematurely as we
wanted to check for clearing infection with repeat paracentesis
however you chose to leave understanding the risk of worsening
infection and even death.
Your updated medications and appointments are listed below.
We wish you the best!
- Your ___ Care TEam
Followup Instructions:
___
|
10249110-DS-20 | 10,249,110 | 22,584,679 | DS | 20 | 2119-05-08 00:00:00 | 2119-05-10 12:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Diagnostic paracentesis on ___
History of Present Illness:
Mr. ___ is a ___ y/o man with ETOH/HepC cirrhosis
decompensated by diuretic-refractory ascites, HE, chronic
hyponatremia, and recent cholecystitis s/p cholecystectomy in
___, presenting with chronic abdominal pain.
Per patient, he has been having abdominal pain for years now.
This has been a chronic pain described as severe, sharp, and
diffuse across his abdomen. It does radiate to other places in
his body and is not related to eating, moving his bowels, making
urine, or his ascites - he states that the pain does not get
better after his taps. He cannot think of anything that makes
the pain worse except walking around. He does take some
oxycodone that he gets from his friend (5mg tabs, 2 per day)
that helps to take the edge off the pain. He denies any recent
fevers, chills, chest pain/pressure, N/V, hematemesis, diarrhea
(apart from baseline loose stools), constipation, melena,
hematochezia, increased ___ swelling, or LH. He is eating well
and taking all of his medications as prescribed. Of note, he
does not take any Tylenol because he "has too much of it in his
blood already."
He is dependent on serial LVP's now twice a week to remove
ascites given his inability to take diuretics ___ chronic
hyponatremia. Last para was 3 days PTA. Next one due in another
day.
On day of admission, he states that his pain was not really
worse than usual. He just felt that he wanted to come in and be
evaluated. At the OSH (___), he was seen and evaluated
as having "altered mental status." This is similar to multiple
prior presentations, including 1 admission between ___ and ___
at ___. No acute intervention was taken apart from
diagnostic labs and imaging and the patient opted to leave AMA
and present himself to ___ for further work-up. He himself
does not feel there to be any alteration in his mental status.
In the ED, initial VS were:
-97.6 73 93/48 19 100% RA
Exam notable for:
-tenderness, distended abdomen, no asterixis
-Right eye mydriasis, no ptosis
-___ strength ___ to person place and time
Labs showed:
- CBC with WBC 4.1 (75.1%), Hg 9.5, Plt 98
- Chem 10 Na 123, bicarb 16, BUN/Cr ___
- LFTs with AST 66, ALT 31, Alk Phos 140, Lipase 145, Tbili 2.4
(lower than prior), Dbili 0.9, Albumin 2.9
- lactate 2.2
- ___ 16.5, INR 1.5
- Diagnostic peritoneal fluid analysis with 0.5 protein, 129
glucose, 74 WBC with 32% PMNs, 5028 RBCs
- peritoneal fluid gram statin with 2+ poly's, culture pending
- Bcx pending x1
Imaging showed
-NCHCT:
1. Mildly limited exam due to motion. Within these limits, no
acute
intracranial abnormalities.
2. Global atrophy and likely sequela of chronic small vessel
ischemic disease.
-Liver U/S with Doppler:
1. Patent portal vein.
2. Cirrhotic liver. Evaluation of focal lesion is limited in
the setting of nodular echogenicity.
3. Splenomegaly and moderate volume ascites.
Received:
-Ceftriaxone 2g IV x1
-oxycodone 5mg PO x1
On arrival to the floor, patient reports the above history and
endorses abdominal pain as above. No other issues.
Past Medical History:
-ETOH/HepC Cirrhosis (diuretic refractory ascites ___ chronic
hyponatremia requiring biweekly paracentesis, on SBP ppx, prior
HE)
-H/o ETOH abuse (sober since ___
-Hep C s/p Harvoni/Ribavirin in ___ with recurrence of disease
per patient
-Inguinal Hernia
-Cholecystectomy in ___?
-chronic hyponatremia (baseline mid ___
-chronic pancytopenia (likely ___ liver disease)
Social History:
___
Family History:
No family history of liver disease, liver
cancer, or colon cancer. He never had a screening colonoscopy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.6 119/70 66 16 97 Ra
GENERAL: NAD, lying comfortably in bed
HEENT: AT/NC, EOMI, PERRL, mildly icteric sclera, pink
conjunctiva, MMM; tongue midline on protrusion, symmetric smile,
eyebrow raise, and palatal elevation
NECK: supple, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: distended, well healed prior surgical scars; RLQ with
paracentesis site, bandaged, mild bloody shadowing on bandage;
diffusely tender to palpation; patient does not endorse pain
when bed is shaken; BS+; + ascites
EXTREMITIES: no cyanosis, clubbing; WWP, 1+ pitting edema in
b/l ___
PULSES: 2+ DP pulses bilaterally
NEURO: Alert appropriately interactive; sensation to light
touch grossly intact; strength ___ in b/l UE; able to lift both
legs up against gravity
DISCHARGE PHYSICAL EXAM:
VS: T 97.8, HR 74, BP 100/61, HR 16, SPO2 99
GENERAL: Resting comfortably in bed, NAD, anxious to leave
HEENT: NCAT, MMM
HEART: RRR, S1+S2, no m/r/g
LUNGS: CTAB, good air movement bilaterally
ABDOMEN: Soft, + BS, distended abdomen with evidence of recent
surgical scars. diffusely tender to palpation, worse in the
upper right quadrant. Pain worsens when patient sits up (reveals
large ventral hernia)
EXTREMITIES: Warm and well perfused, no edema
NEURO: AOx3
Pertinent Results:
LABS UPON ADMISSION:
___ 08:00PM BLOOD WBC-4.1 RBC-2.88* Hgb-9.5* Hct-28.0*
MCV-97 MCH-33.0* MCHC-33.9 RDW-19.1* RDWSD-67.0* Plt Ct-98*
___ 08:00PM BLOOD Neuts-75.1* Lymphs-5.6* Monos-15.5*
Eos-2.9 Baso-0.2 Im ___ AbsNeut-3.09 AbsLymp-0.23*
AbsMono-0.64 AbsEos-0.12 AbsBaso-0.01
___ 08:00PM BLOOD ___ PTT-35.9 ___
___ 08:00PM BLOOD Glucose-150* UreaN-25* Creat-1.0 Na-123*
K-3.9 Cl-97 HCO3-16* AnGap-14
___ 08:00PM BLOOD ALT-31 AST-66* AlkPhos-140* Amylase-139*
TotBili-2.4* DirBili-0.9* IndBili-1.5
___ 08:00PM BLOOD Albumin-2.9*
___ 08:00PM BLOOD Lactate-2.2*
LABS UPON DISCHARGE:
___ 04:52AM BLOOD WBC-3.3* RBC-2.61* Hgb-8.7* Hct-25.4*
MCV-97 MCH-33.3* MCHC-34.3 RDW-18.8* RDWSD-66.4* Plt Ct-82*
___ 04:52AM BLOOD Glucose-92 UreaN-24* Creat-1.0 Na-124*
K-3.6 Cl-97 HCO3-18* AnGap-13
___ 04:52AM BLOOD ALT-32 AST-46* AlkPhos-141* TotBili-2.4*
___ 04:52AM BLOOD Calcium-7.5* Phos-3.2 Mg-2.1
OTHER:
___ 09:57PM ASCITES TNC-74* RBC-5028* Polys-32* Lymphs-13*
Monos-9* Eos-1* Macroph-45*
___ 09:57PM ASCITES TotPro-0.5 Glucose-129
___ 9:57 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
___ 8:00 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
IMAGING:
___
RUQ US:
IMPRESSION:
1. Patent portal vein.
2. Cirrhotic liver. Evaluation of focal lesion is limited in
the setting of nodular echogenicity.
3. Splenomegaly and moderate volume ascites
___
CT A/P:
IMPRESSION:
1. Mildly limited exam due to motion. Within these limits, no
acute
intracranial abnormalities.
2. Global atrophy and likely sequela of chronic small vessel
ischemic disease.
3. Encephalomalacia of the right anterior temporal lobe.
Brief Hospital Course:
**AGAINST MEDICAL ADVICE DISCHARGE**
Mr. ___ is a ___ y/o man with ETOH/HepC cirrhosis
decompensated by diuretic-refractory ascites, HE, chronic
hyponatremia, and recent cholecystitis s/p cholecystectomy in
___, presenting with chronic abdominal pain of unclear
etiology. Laboratory evaluation was unrevealing, infectious
workup was negative including diagnostic paracentesis, and
abdominal US revealed no portal vein thrombosis. Home
medications were continued.
There was plan for therapeutic paracentesis and further imaging
of the abdomen with CT scan but the patient opted to leave
AGAINST MEDICAL ADVICE. Of note he had a CT scan at an OSH on
___ that showed large ascites, small hematoma at site of CCY
and subacute infarct of the spleen as well as evidence of
cirrhosis.
# Abdominal Pain: Patient has abdominal pain that appears
chronic without any worsening. No evidence of SBP, and abdominal
US showing only cirrhosis and stimagata of portal hypertension.
No PVT. Pt had reassuring exam and had had recent therapeutic
paracentesis with one scheduled for ___. He was also noted to
have ventral hernia on exam, which may be etiology of pain. Had
recent CT at OSH on ___ w/o acute pathology. Plan was for
therapeutic paracentesis and further work up with CT A/P but
patient left AMA prior to this.
#HepC/ETOH Cirrhosis: decompensated by HE, ascites, prior SBP.
Also has large esophageal varices s/p banding in ___. Patient
MELD-Na 124. He was continued on lactulose, rifaximin, nadolol
and ciprofloxacin. He undergoes biweekly large volume
paracenteses with upcoming on ___. We were planning on doing
therapuetic paracentesis but patient left AMA.
CHRONIC ISSUES:
=================
# Chronic hyponatremia: likely ___ chronic volume overload with
excess free water to solute retention I/s/o decompensated liver
disease. Currently as his baseline of mid ___. Na 124 upon
discharge.
#H/O gastritis/erosions: noted on prior EGD
Continued home PPI and sucralfate
#HepC: s/p treatment with harvoni/ribavirin in ___ with good
effect
#BPH: Continue home tamsulosin
#Ongoing tobacco abuse: continue nicotine patch and will request
SW consult
Transitional Issues:
[] Please continue to address pain control, as patient endorsed
using his friend's oxycodone prior to hospitalization.
[] Patient should have follow-up EGD for varices and banding
that was performed on EGD in ___.
[] Patient needs f/u in GI and with PCP
[] Na was 124 on discharge and patient should have repeat labs
within one week
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lactulose ___ mL PO TID
2. Magnesium Oxide 400 mg PO BID
3. Nicotine Patch 21 mg TD DAILY
4. Nadolol 20 mg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Ciprofloxacin HCl 500 mg PO Q24H
7. Rifaximin 550 mg PO BID
8. Tamsulosin 0.4 mg PO QHS
9. Sucralfate 1 gm PO BID
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q24H
2. Lactulose ___ mL PO TID
3. Magnesium Oxide 400 mg PO BID
4. Nadolol 20 mg PO DAILY
5. Nicotine Patch 21 mg TD DAILY
6. Pantoprazole 40 mg PO Q24H
7. Rifaximin 550 mg PO BID
8. Sucralfate 1 gm PO BID
9. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Alcoholic cirrhosis
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 treating you at ___.
Why was I admitted to the hospital?
-You were admitted because you were having abdominal pain.
What happened while I was admitted?
-The blood and imaging tests that we did showed that there was
not a dangerous cause of your abdominal pain.
What should I do when I leave the hospital?
-Please continue to follow-up with your doctors and take ___ of
your medicines as directed.
Your ___ care providers
___ wish ___ h
Followup Instructions:
___
|
10249424-DS-14 | 10,249,424 | 28,042,243 | DS | 14 | 2137-11-24 00:00:00 | 2137-11-24 20:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Minocin / Flagyl / Clindamycin
Attending: ___.
Chief Complaint:
Diabetic Ketoacidosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness: ___ with hx of DM2 with multiple
admissions for hypoglycemia and DKA (A1c 9.2 ___, CKD
(baseline Cr likely 1.0), repeated bouts of diverticulitis s/p
partial colectomy remotely, hypothyroidism, and hypertension
admitted for diabetic ketoacidosis. Patient describes a
month-long history of moderate and sometimes severe crampy
abdominal pain accompanied by dry heaving but no frank emesis
and frequent watery diarrhea (>10 episodes daily) without blood.
She states that she was unable to take significant PO's but
continued to take her full insulin doses (with occasional BSL
checks) and had to be admitted to an OSH (___?) for
"diabetic coma" from low blood sugar (records not presently
available). She states that she was resuscitated in the
ambulance and spent roughly 1 week in the hospital recieving
fluids with continuation of her nausea and poor PO intake. She
was discharged and presented to the OSH ED 2 weeks later for
shortness of breath and was diagnosed per report with a viral
illness and prescribed 3 days of azithromycin and inhalers.
Following this, she describes a progressive worsening of her
abdominal pain, nausea, and poor PO tolerance. She was scared to
take her insulin as she normally does and on the day of
admission felt "outside of her own body". She called her
endocrinologist who sent her to the ED for further evaluation.
.
In the ED, initial vs were: T 98.1, P ___, BP 155/77 R 20 O2 sat
100RA. Patient was found to have an anion gap acidosis with a
bicarb of 15 and a anion gap of 20 with 10 ketones in her urine
and a BSL of 267. She was started on an insulin drip with fluids
until her GAP closed and she was switched to D5 and given 10u
regular insulin. She had a CT abd/pelv with contrast significant
for diverticulosis without diverticulitis and no other acute
abdominal process, and a CXR which looks clean per my read. She
was admitted to medicine for further management.
.
On the floor, she is pleasant and interactive and states that
while she still has belly pain and nausea she is starting to
feel better and more like herself. She denies recent fevers,
chills, chest pain (she denies history of heart attack or CAD
but states she thinks she may have been defibrillated in this
hospital ___ years ago but no mention of this in her DC summaries
and only negative pMIBI from ___ in OMR), dyruria, urinary
frequency, back pain, or rashes.
.
Review of sytems: As per HPI, otherwise negative.
Past Medical History:
Type II Diabetes on insulin
Hypothyroidism
Hypertension
Recurrent episodes of vertigo (___)
Facial Cellulitis - ___
Recurrent Parotitis
GERD
Cholecystectomy ___
Diverticulitis -> Partial colectomy ___
.
Social History:
___
Family History:
Father - died at ___, MI and CVA
Mother - died at ___ of diabetes, stroke, and coronary artery
disease.
Sister - handicap due to a fall at the age of ___ with
brain injury.
Physical Exam:
Vitals: T: 98.2 BP: 122/77 P: 85 R: 18 O2: 98RA ___ 161,254,203
(nph ___ hiss)
General: Alert, oriented, no acute distress but occasionally
with moderate-severe abdominal cramps
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, soft ___ systolic
mumur loudest at apex
Abdomen: Obese, soft, mild tender in the epigastric and
periumbilical areas. Patient with odd prominences in the
epigastric region as well as at xyphoid process which she states
developed after her hemicolectomy, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema although L leg > R leg although she states that's normal
for her, no tenderness, negative ___ bilaterally
Neuro: CNs3-12 intact, ___ motor in all 4 extremities, no gross
sensory deficits
Pertinent Results:
___ 07:25AM BLOOD WBC-6.2 RBC-3.53* Hgb-11.1* Hct-30.3*
MCV-86 MCH-31.5 MCHC-36.7* RDW-13.0 Plt ___
___ 07:30AM BLOOD WBC-8.1 RBC-3.58* Hgb-11.3* Hct-30.3*
MCV-85 MCH-31.5 MCHC-37.3* RDW-13.4 Plt ___
___ 11:25AM BLOOD WBC-14.7* RBC-4.27 Hgb-13.4 Hct-36.5
MCV-85 MCH-31.4 MCHC-36.8* RDW-13.2 Plt ___
___ 11:25AM BLOOD Neuts-85.4* Lymphs-11.2* Monos-2.3
Eos-0.4 Baso-0.6
___ 07:25AM BLOOD Plt ___
___ 07:25AM BLOOD Glucose-192* UreaN-19 Creat-1.0 Na-138
K-3.9 Cl-105 HCO3-26 AnGap-11
___ 07:30AM BLOOD Glucose-155* UreaN-22* Creat-1.1 Na-135
K-4.0 Cl-105 HCO3-22 AnGap-12
___ 07:07PM BLOOD Glucose-109* UreaN-29* Creat-1.4* Na-135
K-3.7 Cl-104 HCO3-18* AnGap-17
___ 02:10PM BLOOD Glucose-173* UreaN-33* Creat-1.5* Na-134
K-3.9 Cl-101 HCO3-19* AnGap-18
___ 11:25AM BLOOD Glucose-267* UreaN-35* Creat-1.6* Na-136
K-4.0 Cl-101 HCO3-15* AnGap-24*
___ 11:25AM BLOOD ALT-29 AST-25 AlkPhos-81 TotBili-0.7
___ 11:25AM BLOOD Lipase-23
___ 07:25AM BLOOD Calcium-9.4 Phos-3.2 Mg-1.9
___ 07:30AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.3
___ 07:07PM BLOOD Calcium-8.2* Phos-3.2 Mg-1.4*
___ 11:25AM BLOOD Albumin-4.4 Calcium-9.1 Phos-3.9 Mg-1.4*
___ 11:40AM BLOOD Lactate-2.1*
___ 11:25AM URINE Color-Yellow Appear-Hazy Sp ___
___ 11:25AM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-70 Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 11:25AM URINE RBC-1 WBC-3 Bacteri-FEW Yeast-NONE Epi-10
TransE-<1
___ 11:25AM URINE CastHy-65*
===
CT Abdomen and Pelvis
Final Report
INDICATION: Generalized abdominal pain, history of
diverticulosis, status
post hemicolectomy. Please evaluate for colitis or
diverticulitis.
COMPARISON: Comparison is made to CT abdomen and pelvis
performed ___.
TECHNIQUE: Intravenous and oral contrast enhanced axial images
were obtained
from the diaphragm to the pelvic outlet. Coronal and sagittal
reformations
were provided.
FINDINGS: The demonstrate lung bases are clear. No pleural
fluid.
The liver is homogenous in attenuation without discrete masses
or lesions. No
intrahepatic biliary ductal dilation. Status post
cholecystectomy, with mild
post-surgical prominence of the common bile duct. A small 8 mm
rounded
hypodensity is noted in the superior aspect of the spleen, new
since ___ and too small to fully characterize though likely
represents a simple
splenic cyst. The pancreas has interdigitating fat, but no
rounded hypodensity
to suggest mass. No pancreatic duct dilation evident. The
bilateral
adrenal glands are normal in contour. The bilateral kidneys are
normal in
size and excrete contrast symmetrically.
The stomach is unremarkable. A minimal filling defect is noted
on the medial
aspect of the second portion of duodenum, may represent recent
food ingestion
or peristalsis. Otherwise, the small bowel is unremarkable.
Extensive
diverticulosis is again noted without surrounding inflammation
to suggest
diverticulitis. Patient is status post a sigmoidectomy with no
evidence of
obstruction at the anastomosis. No bowel wall thickening evident
to suggest
colitis.
The aorta is of normal caliber throughout. The ostia of the
celiac and
superior mesenteric arteries are widely patent. The main portal
vein and its
major tributaries are unremarkable. No retroperitoneal,
mesenteric or
portacaval lymphadenopathy evident.
The appendix is visualized and is unremarkable. The rectum and
bladder are
normal. A large calcified fibroid is identified within the
uterus. The
adnexa are normal. No pelvic sidewall or inguinal
lymphadenopathy evident.
No free fluid within the abdomen.
No suspicious lytic or blastic lesions evident. Minimal
degenerative changes
noted in the lower lumbar spine.
IMPRESSION:
1. Diverticulosis without diverticulitis. No evidence of
colitis. No acute
process.
2. Calcified fibroid uterus.
--
FECAL CULTURE (Pending):
CAMPYLOBACTER CULTURE (Pending):
FECAL CULTURE - R/O VIBRIO (Pending):
FECAL CULTURE - R/O YERSINIA (Pending):
FECAL CULTURE - R/O E.COLI ___:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ___:
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
OVA + PARASITES (Pending):
Brief Hospital Course:
___ with hx of DM2 with multiple admissions for hypoglycemia and
DKA (A1c 9.2 ___, CKD (baseline Cr likely 1.0), repeated
bouts of diverticulitis s/p partial colectomy remotely,
hypothyroidism, and hypertension admitted for diabetic
ketoacidosis.
This patient had an uneventful two day stay while admitted to
the ___. She was admitted for mild diabetic ketoacidosis. She
was also reporting diarrhea and symptoms consistent with
gastroenteritis. Of note, her stool cultures were negative. CT
abdomen and pelvis showed no acute pathological process
intra-abdominaly. Also on physical exam the patient did not have
an acute abdomen. On the floor the patient was given copious
amounts of crystalloid. The patient said that the IV fluids made
her feel much much better. Also she was started back on NPH with
a Humalog sliding scale. Normally she takes 70/30 with 78 units
twice a day. However since she was sick to her stomach and not
eating as much as she normally does, her insulin regimen was
scaled back. On 24 units of NPH b.i.d. with Humalog sliding
scale her finger sticks remained in the low 200s. The patient
was feeling much better on hospital day number 2 and she was
tolerating a normal diet. She expressed the desire to go home.
Since she was not getting as much as she normally does, she was
not restarted on her full dose home insulin. She also did not
want to be on a sliding scale insulin regimen at home.
Therefore, she was started on 30 units of mph twice a day with
strict instructions to record her finger sticks4 times a day and
to call her primary care doctor if her blood sugar was above 300
or below 70. She was discharged on the evening of hospital day
number 2.
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs orally
q
4hrs as needed for dyspnea
CHOLESTYRAMINE (WITH SUGAR) - 4 gram Packet - ___ packets daily
CONJUGATED ESTROGENS [PREMARIN] - 0.625 mg twice daily
IRBESARTAN [AVAPRO] - 300 mg Tablet - once daily
LEVOTHYROXINE [SYNTHROID] - 125 mcg Tablet once daily
PROGESTERONE MICRONIZED [PROMETRIUM] - 100 mg Capsule once daily
SPIRONOLACTON-HYDROCHLOROTHIAZ - 25 mg-25 mg daily
ASPIRIN - 81 mg Tablet daily
INSULIN NPH & REGULAR HUMAN [HUMULIN 70/30] - 78 units BID
MAGNESIUM OXIDE-MG AA CHELATE [MAGNESIUM] - 300 mg BID
.
Discharge Medications:
1. cholestyramine (with sugar) 4 gram Packet Sig: One (1) Packet
PO DAILY (Daily).
2. conjugated estrogens 0.625 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
3. Avapro 300 mg Tablet Sig: One (1) Tablet PO once a day.
4. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. progesterone micronized 100 mg Capsule Sig: One (1) Capsule
PO once a day.
6. spironolacton-hydrochlorothiaz ___ mg Tablet Sig: One (1)
Tablet PO once a day.
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
8. magnesium oxide-Mg AA chelate 300 mg Capsule Sig: One (1)
Capsule PO once a day.
9. Maalox Total Relief (bismuth) Oral
10. benzonatate 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for cough.
Disp:*30 Capsule(s)* Refills:*0*
11. famotidine 20 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*2*
12. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation four times a day as needed for shortness of
breath or wheezing.
13. insulin NPH & regular human 100 unit/mL (70-30) Insulin Pen
Sig: ___ (32) units Subcutaneous twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Diabetic Ketoacidosis
2. Diabetes Mellitus
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 ___. You were admitted
for diabetic ketoacidosis which happens when your blood sugar
gets dangerously high for an extended period of time. Going
forward, it is imperative that you check your blood sugar
carefully everyday and record all your blood sugars carefully
and report them to your doctor. This will be very helpful going
forward in controlling your blood sugar.
-We have made the following changes to your medications.
1. Tessalon perles.
2. PEPCID twice a day
3. Maalox (over the counter) as needed for indigestion.
4. We decreased your insulin regimen while you were in the
hospital because you were not eating well given your
gastrointestinal symptoms to 32 units twice a day. You will
likely require more insulin when you get home. You should check
your sugars before meals over the next week and call Dr ___
your sugars are less than 70 or greater than 400 so that he can
adjust your medications. Regardless, please call his office on
___ with your sugars so he can adjust your medications as
needed.
Followup Instructions:
___
|
10249424-DS-15 | 10,249,424 | 22,626,115 | DS | 15 | 2139-03-30 00:00:00 | 2139-04-01 09:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Minocin / Flagyl / Clindamycin
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ F DM2 (A1c 8 ___, hypothyroidism, chronic diarrhea p/w
___ diarrhea. States that she has had ___ watery BMs during
this time. She intermittently experiences diarrhea due to her
partial colectomy, but this has not been a problem for her over
the past couple of months. There has been no melena or
hematochezia.
Since today, she has developed nausea & inability to tolerate PO
intake (which has been the case for the past couple of days).
Dry heaves, but no vomiting. She has also experienced some
chills over the past couple of days, but no fever or rigors.
In terms of her ROS, she complains of SOB but she has a
difficult time distinguishing this from weakness/low energy.
She also complains of chest "tightness" for several hours
intermittently over the past 2 days but no frank chest pain. She
also complains of urinary frequency without urgency or dysuria.
Of note, she has not been taking her insulin since she has not
been tolerating anything PO. Sugars have been in 300s at home.
VS in the ED: 97.8 89 144/73 14 96%
ED course notable for the following:
- Initial labs: creatinine 1.4, gap 23 (no acidosis)
- CXR:
- CT abdomen:
- U/A: 100 glucose, 40 ketones
- EKG:
- 3L NS
On the floor, the patient complains of ongoing epigastric pain
but otherwise has no complaints.
ROS:
(+): As above
(-): Fevers, rigors, cough, wheeze, dysuria, urinary urgency,
vomiting, melena, hematochezia, hematemesis, join pains,
headache, chest pain, dyspnea on exertion.
Past Medical History:
- DM2 on insulin
---> A1c 8 on ___
- Hypothyroidism (___'s)
- HTN
- Sialolithiasis c/b parotitis
- GERD
- CCY ___
- Diverticulitis
---> Partial colectomy ___
- Vitamin D Deficiency
Social History:
___
Family History:
- Father: Died at ___, MI & CVA
- Mother: Died at ___ ___VA, CAD
Physical Exam:
ADMISSION PHYSICAL:
-------------------
98.8 150/60 72 20 97/RA
GEN: Resting in bed, pallid
HEENT: Mildy dry MM. OP clear
NECK: Supple
COR: +S1S2, RRR, no m/g/r
PULM: CTAB, no c/w/r
___: + NABS in 4Q. Distended, TTP in epigastrium no rebound
EXT: WWP
NEURO: MAEE
DISCHARGE PHYSICAL:
-------------------
O: T 98.89, HR 72, BP 145/50, RR 18, O2 98% RA
GEN: AOx3, appears distressed, calmer on conversation
HEENT: EOMI, MMM, no lesions in OP
NECK: Supple, no JVD
COR: RRR, normal S1 and S2, no m/g/r
PULM: CTAB
___: distended, +BS, TTP in epigastrum, no rebound, negative
___, potential abdominal hernia at proximal end of prior
laparotomy scar unchanged from yesterday, well-healed incisions
from vertical laparotomy and cholecystectomy
EXT: WWP
PSYCH: normal mood and affect
NEURO: no focal neurologic deficits
Pertinent Results:
ADMISSION LABS:
----------------
___ 02:20AM BLOOD Glucose-284* UreaN-28* Creat-1.4* Na-134
K-4.9 Cl-97 HCO3-19* AnGap-23*
___ 02:20AM BLOOD WBC-12.5* RBC-4.16* Hgb-12.7 Hct-36.4
MCV-87 MCH-30.6 MCHC-35.0 RDW-12.6 Plt ___
___ 02:20AM BLOOD Neuts-87.6* Lymphs-8.5* Monos-3.1 Eos-0.4
Baso-0.4
___ 03:15AM BLOOD ___ PTT-29.8 ___
___ 02:20AM BLOOD ALT-20 AST-19 AlkPhos-97 TotBili-1.0
___ 02:20AM BLOOD Lipase-36
___ 02:20AM BLOOD cTropnT-<0.01
___ 11:05AM BLOOD Calcium-8.4 Phos-3.0 Mg-1.3*
___ 02:31AM BLOOD Lactate-1.3
DISCHARGE LABS:
----------------
___ 06:20AM BLOOD WBC-10.3 RBC-3.88* Hgb-12.2 Hct-34.3*
MCV-88 MCH-31.4 MCHC-35.5* RDW-12.8 Plt ___
___ 06:20AM BLOOD Plt ___
___ 06:20AM BLOOD Glucose-260* UreaN-15 Creat-1.0 Na-136
K-4.5 Cl-103 HCO3-21* AnGap-17
___ 06:20AM BLOOD Calcium-8.8 Phos-2.7 Mg-1.6
RELEVANT STUDIES:
-----------------
CT Abd/Pelvis w/o contrast:
1. Findings suggesting duodenitis, primarily involving the first
and second portions and probably the pylorus.
2. Subtle enhancement of the common bile duct may be secondary
to surrounding inflammatory changes.
3. Fibroid uterus.
4. Diverticulosis without evidence of diverticulitis.
Brief Hospital Course:
PRIMARY REASON FOR ADMISSION:
___ F DM2, diverticulosis c/b partial colectomy ___ p/w several
days n/v/d; now with dizziness, abd pain, and abnormal lab
values.
ACUTE DIAGNOSES:
# HHS: Likely secondary to diarrhea & no PO intake in past 2
days. Was given 3L NS in ED. Concern for DKA/HHS on presentation
given anion gap (without acidosis). Last A1c 8% on ___. Gap
closed by last night (gap = 11). Potential triggers include
gastroenteritis, inflammation in duodenum, and volume depletion.
After several discussions with the patient, it became clear
that she does not always take her insulin as recommended by her
medical team. She was advised and encourage to take her insulin
as prescribed and to call her PCP with any additional questions.
# ___: Initial Cr 1.4 in ED, baseline difficult to ascertain but
appears to be 0.9-1.1). On HOD1, Cr improved to 1.1 after IV
fluid administration, making prerenal etiology the likely cause.
# DUODENITIS: Seen on CT performed in ED. Unclear etiology.
Possible due to NSAID use. Pt advised to limit use in future.
Pain largely resolved on discharge.
CHRONIC DIAGNOSES:
# HYPOTHYROIDISM: Continued levothyroxine in house.
# HTN: Held anti-hypertensives due to GI losses, dizziness, ___.
These medications were restarted on discharge.
TRANSITIONAL ISSUES:
# FOLLOW UP: Pt given a follow up appointment with Dr. ___,
who is also scheduling GI follow up.
# DIET: On discharge, pt refusing to eat, although she was noted
to be tolerating POs. She was advised to continue a liquid diet
for now until following up. Labs had been stable & within normal
limits for days.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
3. Cholestyramine 4 gm PO DAILY
___ packets
4. ClonazePAM 0.5 mg PO BID:PRN SOB
5. Estrogens Conjugated 0.625 mg PO BID
6. irbesartan *NF* 300 mg Oral Daily
7. Levothyroxine Sodium 125 mcg PO DAILY
8. liraglutide *NF* 0.6 mg/0.1 mL (18 mg/3 mL) Subcutaneous
Daily
At 10 AM
9. nizatidine *NF* 150 mg Oral BID
10. Aspirin 81 mg PO DAILY
11. Vitamin D ___ UNIT PO DAILY
12. Magnesium Oxide 300 mg PO BID
13. Prometrium *NF* (progesterone micronized) 100 mg Oral DAILY
14. spironolacton-hydrochlorothiaz *NF* ___ mg Oral QD
15. 70/30 79 Units Breakfast
70/30 79 Units Dinner
16. Naproxen Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Hydrochlorothiazide 25 mg PO DAILY
2. Allopurinol ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Cholestyramine 4 gm PO DAILY
5. ClonazePAM 0.5 mg PO BID:PRN SOB
6. 70/30 79 Units Breakfast
70/30 79 Units Dinner
7. Levothyroxine Sodium 125 mcg PO DAILY
8. Vitamin D ___ UNIT PO DAILY
9. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
10. Estrogens Conjugated 0.625 mg PO BID
11. irbesartan *NF* 300 mg Oral Daily
12. liraglutide *NF* 0.6 mg/0.1 mL (18 mg/3 mL) Subcutaneous
Daily
13. Magnesium Oxide 300 mg PO BID
14. nizatidine *NF* 150 mg Oral BID
15. Prometrium *NF* (progesterone micronized) 100 mg Oral DAILY
16. spironolacton-hydrochlorothiaz *NF* ___ mg Oral QD
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Abdominal Pain
SECONDARDY DIAGRNOSIS:
- Diabetes Mellitis 2
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 participate in your care
while you were at ___. You came to the hospital with adominal
pain and diarrhea. While you were here, we found that you blood
sugar was high and your CT scan in the Emergency Department
showed inflammation in the beginning portion of your small
bowels.
When you return home, please continue your normal insulin
regimen of 78U in the morning and evening. You can move to a
normal diet as tolerated.
Followup Instructions:
___
|
10250152-DS-20 | 10,250,152 | 26,489,286 | DS | 20 | 2130-03-04 00:00:00 | 2130-03-04 19:07:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins / Tetracycline
Analogues / Erythromycin Base / Keflex / Compazine /
Chloramphenicol / Percocet / Latex / Demerol / Levofloxacin /
yellow dye / ct scan dye / Tetracycline
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
___ with h/o Hodgkins (s/p chemo and rads in the 1980s),
hypothyroidism, radiation induced aortic
regurgitation/restrictive cardiomyopathy, CAD, HTN presenting
with chest pain and htn. Few days of feeling ill, then today
headache starting just before noon. Developed over 15 min.
Checked BP and SBPs in the 200s. Had some chest discomfort
substernally radiating to left shoulder, so took nitroglycerin
with some relief and came to the ED. BP improved and headache
improved. Chest discomfort and nausea persist.
Of note the pt has a history of chronic atypical chest pain for
which she has had workup in the past. Her cardiologist is Dr.
___ at ___ and has a special
interest in cardiac disease related to chest radiation. She has
had at least ___ stress mibi's in the past that have been
negative, per pt the most recent has been in the last couple of
months and she also had a recent echo and cardiac MRI. Per pt's
report these studies were normal. Per pt she and her
cardiologist have been discussing whether to do a cardiac
catheterization, but have not decided yet.
She has had labile BP in the recnet past; usually SBP ranges
from ___. She is currently on verapamil for BP control as
well as for Raynaud's and migraines. She had been on 160 mg
daily whic was decreased to 120 mg daily about 6 months ago
because of low BPs. Her chest pain syndrome is usually less
severe than what she is experiencing now, and usually is in the
___ the chest nonradiating and not associated with other
symptoms, however it is now more on the left side of her chest,
radiating down her left arm and worse with exertion. Her
atypical chest pain is of unclear etiology but thought to be
related to her autoimmune syndrome which is not well defined,
although no recent changes in her rheum medications (currently
on azathioprine every other day, last was on prednisone 3 months
ago). It is also associated with nausea, although pt has chronic
nausea but this seems more related to her chest pain than her
chronic nausea syndrome.
Initial VS: 98 100 179/85 20 100% ra. In the ED, she received
nitroglycerin for continued chest pain and BP gradually
normalized without any further medication, also received aspirin
325 mg. EKG with lateral ST depressions as compared to prior
that resolved with improvement in BP, trop negative x 2 and
admitted to cardiology service for further workup. CBC,
chemistries wnl. She had another episode of L chest pain
radiating down her arm that resolved while in ED around 1730. No
further chest pain episodes in ED. VS on transfer T 98.2, HR 72,
RR 18, BP 123/51 O2 sat ___ndorses ___ chest pain that goes to a ___ on
exertion. Nitroglycerin helped the pain in ED and prior to
arrival. She also feels nauseated now.
On review of systems, the patient denies any prior history of
stroke, deep venous thrombosis, pulmonary embolism, bleeding at
the time of surgery, myalgias, cough, hemoptysis, black stools
or red stools. The patient denies recent fevers, chills or
rigors. The patient denies exertional buttock or calf pain. All
of the other review of systems were negative.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
1. History of Hodgkin's disease status post splenectomy and
radiation, c/b pericarditis
2. Mild-to-moderate aortic and mitral regurgitation ___
radiation.
3. Restrictive cardiomyopathy-diastolic dysfunction and volume
overload episodes, EF 55% in ___
4. radiation vasculitis- persistent R sided weakness, balance
and wordfinding difficulty
5. History of esophageal stricture, status post dilation
6. History of Sjogren's syndrome.
7. Hypothyroidism.
8. Asthma.
9. tachycardia.
10. ocular migraines
11. History of TIA.
12. Chronic abdominal pain.
13. History of dilated biliary tree and pancreatic duct by MRCP,
status post EUS
14. autoimmune disorder: ?reconstition autoimmunity, with
episodes of fever, polyarthralgias, rash, chest pain that
respond to prednisone and azathioprine. followed by rheumatology
15. Raynaud's
16. atypical chest pain with negative stress mibi ___ and ___
per PCP report from ___
17. chronic uveitis
18. osteopenia
19. hematuria, neg evaluation
20. s/p lap chole and splenectomy
Social History:
___
Family History:
Father with MI at ___ and CHF, colon polyps and obesity. Mother
MI at age ___, HTN, autoimmune disease, obsesity. No family
history of early MI, arrhythmia, cardiomyopathies, or sudden
cardiac death; otherwise non-contributory
Physical Exam:
ON ADMISSION
T-98.1, 186/72 followed by 136/80 (no intervention), P-76,
RR-20, 100RA
Well appearing female in no distress
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with no JVD
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. annular erythematous rash with no scale
on lateral L ankle
PULSES: 2+ distal pulses
ON DISCHARGE
UNCHANGED
Pertinent Results:
ON ADMISSION
___ 02:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:00PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 02:00PM URINE RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-0
___ 02:00PM WBC-5.2 RBC-4.46 HGB-13.0 HCT-41.2 MCV-93
MCH-29.3 MCHC-31.6 RDW-13.3
___ 02:00PM NEUTS-51.7 ___ MONOS-8.7 EOS-1.2
BASOS-0.9
___ 02:00PM GLUCOSE-87 UREA N-15 CREAT-0.7 SODIUM-142
POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-32 ANION GAP-15
___ 02:00PM cTropnT-<0.01
___ 08:45PM cTropnT-<0.01
CXR
IMPRESSION: No evidence of acute disease.
Brief Hospital Course:
___ with h/o Hodgkins (s/p chemo and rads in the 1980s),
hypothyroidism, radiation induced aortic
regurgitation/restrictive cardiomyopathy, CAD, HTN presenting
with chest pain and htn
#Chest Pain: Etiology of chest pain is unclear. She does have a
history of atypical chest pain syndrome, however the quality of
the pain is different. EKG changes in the setting of elevated BP
close to 200s systolic likely in the setting of demand ischemia
as these resolved in the setting of improved BP. Trop negative x
2. Cardiac etiology seemed less likely for her chronic chest
pain and is thought to be related to her autoimmune disorder,
however she may have had chest pain in the setting of demand
ischemia on admission. Repeat ECG in AM was normal. Touched base
with outpatient Cardiologist Dr ___ who
also could not say for certain the origin of her chest pain. Her
office did send over her most recent work-up (see related OMR
note) Patient was discharged chest pain free with plan for
outpatient right and left heart catheterization (to evaluate R
sided pressures given proposed restricitve physiology) and
follow-up with Dr ___. Patient refused beta blocker and
statin while in house. She was concerned beta blocker would give
her reactive resporatory distress and that statins giver her bad
myalgias.
# HTN: pt with history of HTN and labile blood pressures.
Currnetly only tkaing verapamil. BP elevated on arrival to ED
but improved with one dose of SL nitroglycerin and dropped to
___ systolic while in ED, labile BP is a chronic issue and may
be ___ radiation. Patient was discharged with BP 140/60 on home
dose of verapamil. SHe will plan to have an outpatient work-up
of secondary causes of HTN with her outpatient provider.
# asthma: cont home inhalers
# hypothyroidism: cont levothyroxine
# autoimmune disorder: cont azathioprine
# chroniic pain: cont home fentanyl and dilaudid
Transitional Issues
-Patient will be contacted regarding timing of her upcoming
cardiac catheterization
-Was told to return to ED if her symptoms of chest pain recur in
the interim.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Meclizine 12.5 mg PO Q8H:PRN dizziness
2. Verapamil SR 120 mg PO Q24H
hold for SBP <100
3. mometasone *NF* 50 mcg/actuation NU daily
4. Multivitamins 1 TAB PO DAILY
5. Nitroglycerin SL 0.3 mg SL PRN chest pain
6. Fentanyl Patch 25 mcg/h TP Q72H
7. HYDROmorphone (Dilaudid) ___ mg PO Q4-6H:PRN rib pain
8. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
9. Levothyroxine Sodium 100 mcg PO 5X/WEEK (___)
10. Levothyroxine Sodium 75 mcg PO 2X/WEEK (___)
11. Vitamin D 1000 UNIT PO DAILY
12. Azathioprine 25 mg PO EVERY OTHER DAY
13. Aspirin 81 mg PO 1X/WEEK (MO)
14. Cyanocobalamin Dose is Unknown PO Frequency is Unknown
15. DiphenhydrAMINE Dose is Unknown PO Frequency is Unknown
16. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
17. EpiPen *NF* (EPINEPHrine) unknown Injection PRN allergic
reaction
18. Clindamycin 600 mg PO PRIOR TO PROCEDURES
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
2. Aspirin 81 mg PO 1X/WEEK (MO)
3. Azathioprine 25 mg PO EVERY OTHER DAY
4. Fentanyl Patch 25 mcg/h TP Q72H
5. HYDROmorphone (Dilaudid) ___ mg PO Q4-6H:PRN rib pain
6. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
7. Levothyroxine Sodium 100 mcg PO 5X/WEEK (___)
8. Levothyroxine Sodium 75 mcg PO 2X/WEEK (___)
9. Multivitamins 1 TAB PO DAILY
10. Nitroglycerin SL 0.3 mg SL PRN chest pain
RX *nitroglycerin [Nitrostat] 0.3 mg 1 tablet(s) sublingually as
needed Disp #*30 Tablet Refills:*0
11. Verapamil SR 120 mg PO Q24H
12. Vitamin D 1000 UNIT PO DAILY
13. Clindamycin 600 mg PO PRIOR TO PROCEDURES
14. Cyanocobalamin 50 mcg PO DAILY
15. DiphenhydrAMINE 12.5 mg PO PRN allergy
Please continue to take as ___ were at home.
16. EpiPen *NF* (EPINEPHrine) 1 Injection INJECTION PRN allergic
reaction
17. mometasone *NF* 50 mcg/actuation NU daily
18. Meclizine 12.5 mg PO Q8H:PRN dizziness
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
1. Chest pain
SECONDARY DIAGNOSES:
1. Radiation-induced restrictive cardiomyopathy
2. History of Hodgkin lymphoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mrs. ___,
___ were admitted to the Internal Medicine service at ___
___ on ___ regarding management of
your chest pain. ___ had reassuring cardiac enzymes and a
reassuring EKG. We discussed your case with your outpatient
cardiologist, who was involved in the decision-making. ___ were
discharged home without changes in medications. ___ will have an
outpatient cardiac catheterization and follow-up with Dr. ___
___ from cardiology in the coming days.
Please call your doctor or go to the emergency department if:
* ___ experience new chest pain, pressure, squeezing or
tightness.
* ___ develop new or worsening cough, shortness of breath, or
wheezing.
* ___ are vomiting and cannot keep down fluids, or your
medications.
* If ___ are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* ___ see blood or dark/black material when ___ vomit, or have a
bowel movement.
* ___ experience burning when ___ urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* ___ have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* ___ develop any other concerning symptoms.
It was a pleasure taking care of ___, Ms ___.
Followup Instructions:
___
|
10250159-DS-10 | 10,250,159 | 22,582,522 | DS | 10 | 2197-05-19 00:00:00 | 2197-05-19 20:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim / Motrin
Attending: ___.
Chief Complaint:
Bilateral Flank and Leg Pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ year old male with/ HIV on HAART (CD4 817, VL nondetectbale
in ___, DM and CAD/STEMI s/p BMS to LAD (___) presenting
with abdominal/flank pain. Per patient, the pain began gradually
2 days prior to arrival. He is unable to describe it other than
"pain", primarily radiating from the flanks bilaterally to the
front of his abdomen as well as down the legs bilaterally, but
more on the left side. He notes pain in his legs as well, but it
is not sharp radiating pain and is just "pain". He endorses some
mild nausea yesterday, but denies vomiting, history of previous
similar symptoms, blood in his urine, fevers or chills, history
of kidney stones, or any other new symptoms.
In the ED, initial vitals were 98.0 79 120/81 18 100% RA. He
looked uncomfortable, moving around on bed in pain. He had
right CVAT, very mild suprapubic tenderness. GU exam benign,
b/l cremasteric reflex present. He had bilateral back pain
radiating down his legs. Labs showed WBC 5.9K, hemoglobin 11.4,
creatinine 1.4, bicarbonate 21. He received morphine sulfate 4
mg x 3, prochlorperazine 10 mg x 1, ondansetron 4 mg x 2,
lamivudine/darunavir/ritonavir/raltegravir, home metoprolol,
lisinopril, clopidogrel, aspirin, and ___ liters IVFs. CT A/P
showed no acute process. UA showed no evidence of infection,
glucose 1000. Lactate was 1.8. Troponin x 1 was negative, CK
normal. He was unable to tolerate PO.
Currently, the patient reports that his abdominal and flank pain
has totally improved, but that he still has some nausea. His
pain now is centered in both legs, which he has never
experienced before, and he describes as sharp and achey.
Review of systems:
10 pt ROS negative other than noted
Past Medical History:
HIV on HAART
Type II diabetes mellitus, insulin dependent
CAD s/p STEMI (distal LAD) ___ s/p bare metal stent
Chronic kidney disease
Human papillomavirus
Recurrent HSV infection
Oral candidiasis
Hyperlipidemia
Depressed disorder
Molluscum contagiosum (___)
Erectile dysfunction
Social History:
___
Family History:
Mom developed CAD in her ___. She has been treated with
multiple stents. Father died of old age. One brother has
diabetes. No family history of sudden cardiac death.
Physical Exam:
ADMISSION EXAM:
Vitals: 98.4PO 165/85 67 20 97 RA
GEN: Alert, oriented to name, place and situation. Fatigued
appearing, looks uncomfortable, no acute signs of distress.
HEENT: NCAT, Pupils equal and reactive, sclerae anicteric, OP
clear, MMM.
Neck: Supple, no JVD
Lymph nodes: No cervical, supraclavicular LAD.
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
RESP: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, non-tender, non-distended, + bowel sounds.
BACK: mild CVA tenderness bilaterally
EXTR: No lower leg edema
DERM: No active rash.
Neuro: moves all four extremities purposefully, non-focal.
PSYCH: Appropriate and calm.
DISCHARGE EXAM:
24 HR Data (last updated ___ @ 813)
Temp: 98.1 (Tm 99.3), BP: 153/89 (114-153/69-89), HR: 71
(69-73), RR: 16 (___), O2 sat: 95% (93-97), O2 delivery: RA
___ 0813 FSBG: 115
___ 2151 FSBG: 148
___ 1750 FSBG: 192
___ 1136 FSBG: 162
___ 0808 FSBG: 194
___ 0623 FSBG: 152
___ 0044 FSBG: 165
GEN: Alert, NAD
HEENT: NC/AT
CV: RRR, no m/r/g
PULM: CTA B
GI: S/ND, BS present, non-tender
EXT: no ___ edema or calf tenderness, 2+ DP pulses bilaterally
SKIN: no apparent rashes
NEURO: ___ strength in the BLE's
Pertinent Results:
___ 06:20AM BLOOD WBC-5.9 RBC-3.29* Hgb-11.4* Hct-33.8*
MCV-103* MCH-34.7* MCHC-33.7 RDW-12.5 RDWSD-47.1* Plt ___
___ 06:20AM BLOOD Neuts-52.3 ___ Monos-7.4 Eos-1.5
Baso-0.5 Im ___ AbsNeut-3.10 AbsLymp-2.24 AbsMono-0.44
AbsEos-0.09 AbsBaso-0.03
___ 06:20AM BLOOD Glucose-233* UreaN-19 Creat-1.4* Na-139
K-4.6 Cl-104 HCO3-21* AnGap-14
___ 06:20AM BLOOD CK(CPK)-171
___ 06:20AM BLOOD cTropnT-<0.01
___ 06:42AM BLOOD Lactate-1.8
___ 08:00AM BLOOD WBC-5.7 RBC-3.66* Hgb-12.5* Hct-37.0*
MCV-101* MCH-34.2* MCHC-33.8 RDW-12.1 RDWSD-45.1 Plt ___
___ 08:00AM BLOOD Glucose-205* UreaN-11 Creat-1.2 Na-143
K-4.1 Cl-100 HCO3-24 AnGap-19*
___ 08:00AM BLOOD Calcium-9.8 Phos-2.6* Mg-1.8
___ 08:00AM BLOOD VitB12-___
___ 08:00AM BLOOD TSH-0.54
___ 09:46AM URINE Color-Straw Appear-Clear Sp ___
___ 09:46AM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-1000* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5
Leuks-NEG
___ 09:46AM URINE RBC-2 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-<1
URINE CULTURE (Final ___: NO GROWTH.
RPR - PENDING
CT A/P - IMPRESSION:
No evidence of acute process in the abdomen or pelvis.
Brief Hospital Course:
___ year old male with/ HIV on HAART (CD4 817, VL nondetectbale
in ___, DM and CAD/STEMI s/p BMS to LAD (___) presenting
with bilateral flank pain radiating down the BLEs.
# BLE PAIN
# FLANK PAIN
Unclear etiology. Labs largely unremarkable. UA negative for
infection and without blood to suggest stone. CT A/P without
acute process. Neuro exam nonfocal. CK WNL making myopathic
process unlikely. Pain resolved without intervention, and
patient ambulating without issue. Perhaps this represents
atypical presentation of neuropathy, but sudden onset and rapid
improvement seems inconsistent with this. Nevertheless, he was
placed on empiric gabapentin for possible neuropathic component.
TSH, B12 WNL; RPR pending. Muscular strain also possible;
however, pt denies any recent change in activity level. Pain was
resolved at the time of discharge on Tylenol and gabapentin. Pt
was encouraged to f/u closely with his PCP for further
evaluation.
# HIV: continued on home HAART regimen
# CAD s/p STEMI
- continued on home clopidogrel
- continued on home aspirin
- continued on home lisinopril
- continued on home metroprolol
- continued on home statin
# Diabetes: Lantus had been held in the setting of clear liquid
diet, and FSBS were relatively well-controlled off of Lantus.
Therefore, pt was discharged on decreased dose of Lantus with
instructions to closely monitor his FSBS. Lantus dose can be
uptitrated as needed in the outpatient setting.
TRANSITIONAL ISSUES:
- RPR pending, will need to be followed up
- As above, pt was discharged on decreased dose of Lantus.
Insulin regimen can be uptitrated as needed in the outpatient
setting.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Darunavir 600 mg PO BID
4. Etravirine 200 mg PO BID
5. LaMIVudine 150 mg PO DAILY
6. Lisinopril 2.5 mg PO DAILY
7. Raltegravir 400 mg PO BID
8. RiTONAvir 100 mg PO BID
9. Rosuvastatin Calcium 10 mg PO QPM
10. ValACYclovir 500 mg PO Q12H
11. Metoprolol Succinate XL 50 mg PO DAILY
12. Ranitidine 150 mg PO DAILY
13. Glargine 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 325 mg ___ capsule(s) by mouth every 6 hours
as needed Disp #*30 Capsule Refills:*0
2. Gabapentin 200 mg PO BID
RX *gabapentin 100 mg 2 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
3. Glargine 15 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Aspirin 81 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Darunavir 600 mg PO BID
7. Etravirine 200 mg PO BID
8. LaMIVudine 150 mg PO DAILY
9. Lisinopril 2.5 mg PO DAILY
10. Metoprolol Succinate XL 50 mg PO DAILY
11. Raltegravir 400 mg PO BID
12. Ranitidine 150 mg PO DAILY
13. RiTONAvir 100 mg PO BID
14. Rosuvastatin Calcium 10 mg PO QPM
15. ValACYclovir 500 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral Leg Pain
DM
HIV
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You presented to the hospital with pain in your legs and sides.
You lab work and CT scan were overall pretty normal. You were
started on a medicine called gabapentin to treat any nerve pain
causing your symptoms. Your pain has improved. Please follow up
with your PCP as scheduled.
As we discussed, your blood sugars have been reasonably
controlled in the hospital despite you not getting Lantus.
Please use the decreased dose of Lantus as we discussed (15
units at night). Please resume your Humalog sliding scale as you
were doing prior to admission.
Followup Instructions:
___
|
10250159-DS-5 | 10,250,159 | 20,649,635 | DS | 5 | 2191-10-24 00:00:00 | 2191-11-01 22:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
hyperglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with HIV on HAART and NIDDM, presented to the ED
yesterday with hyperglycemia for a week. He reports his blood
sugars have frequently exceeded 400 for the last week, and he
has noted significant lethargy, headaches and blurry vision.
Last ___ he underwent a steroid injection in his shoulder,
and since then has had very high sugars. He continues to take
his metformin daily. He's noted significant polydypsia and
polyuria. His chest pain started a few days ago, and it's
described as difficulty swallowing and a squeezing pain in his
chest. The pain has since resolved with improvement of his blood
sugars.
In the ED, initial VS were: 99.8 90 129/88 18 100. Blood sugar
was 436. He was given insulin to lower his blood sugar. He
developed significant abdominal pain and underwent a CT scan
which was unremarkable. HE received 3L IV fluids.
On arrival to the floor, his blood sugar improved to 237 and his
symptoms had almost entirely resolved. He felt well and hungry.
REVIEW OF SYSTEMS:
(+) chest pain, lethargy, headache, polydypsia and polyuria
(-) fever, chills, vomiting, diarrhea, nausea
Past Medical History:
1. HIV disease ___ - VL < 75 undetectable, CD4 586 -
current regimen includes Darunavir 600 mg 1 tab PO BID,
Ritonavir 100 mg PO BID, Raltegravir 400 mg PO BID, Lamivudine
300 mg PO daily) - genotype resistance testing: resistant to all
RTIs, resistance to Lexiva, Crixivan, Viracept, Reyataz - M41L,
D67N, M184V, L210W, ___, L10F, I13V, L24I, V32I, M36I, K43T,
M61I, A71T
2. Type 2 diabetes mellitus (with nephropathy, but no other
complications)
3. Molluscum contagiosum (___)
4. Human papillomavirus
5. Recurrent HSV infection
6. Anemia
7. Hyperlipidemia
8. h/o oral candidiasis (thrush)
9. Depressive disorder
10. Ceruminosis
Social History:
___
Family History:
Mother is alive, age ___, with DM, CAD, hyperlipidemia; father is
deceased, age ___, died from "Old age"; 5 brothers (one with
diabetes), 1 sister in good health, strong family history of
diabtes, no known history of colon, prostate or skin cancer.
Physical Exam:
DISCHARGE PHYSICAL EXAM:
VS: 98.6 128/80 72 76 99% RA ___ 273
GEN - well appearing, NAD
CV - RRR no murmurs
LUNGS - clear bilaterally
ABD - soft non tender
EXT - no edema
SKIN - warm and dry
Pertinent Results:
Admission Labs:
___ 08:40PM BLOOD WBC-6.3 RBC-4.23* Hgb-15.0 Hct-41.5
MCV-98 MCH-35.5* MCHC-36.3* RDW-12.6 Plt ___
___ 10:35PM BLOOD ___ PTT-20.1* ___
___ 08:40PM BLOOD Glucose-436* UreaN-47* Creat-1.6* Na-133
K-4.9 Cl-93* HCO3-26 AnGap-19
___ 08:40PM BLOOD Albumin-5.3* Calcium-11.0* Phos-3.3
Mg-2.6
Discharge Labs:
___ 08:05AM BLOOD WBC-9.8# RBC-4.65 Hgb-16.1 Hct-45.7
MCV-98 MCH-34.5* MCHC-35.1* RDW-12.7 Plt ___
___ 08:05AM BLOOD Glucose-296* UreaN-31* Creat-1.5* Na-133
K-4.3 Cl-94* HCO3-23 AnGap-20
___ 08:05AM BLOOD Calcium-10.5* Phos-3.6 Mg-2.3
Other Notable labs:
___ 03:28PM BLOOD %HbA1c-7.5* eAG-169*
___ 08:40PM BLOOD CK-MB-1
___ 08:40PM BLOOD cTropnT-<0.01
___ 09:20AM BLOOD CK-MB-1 cTropnT-<0.01
___ 08:40PM BLOOD CK(CPK)-88
___ 09:20AM BLOOD CK(CPK)-114
Microbiology:
___ 9:50 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Imaging:
CT Abdomen/Pelvis:
FINDINGS: A 4-mm nodule in the right lower lobe is unchanged
compared to
___. Otherwise, the lungs are clear. The visualized
heart and pericardium are unremarkable. The lack of IV contrast
limits evaluation of the intra-abdominal organs. However, within
the limitation, the liver is overall normal in contour, and
there is no focal lesion identified. The gallbladder is normal.
The pancreas, spleen, and adrenal glands are normal. The
kidneys are normal in contour, and no stones identified. There
is no mesenteric or retroperitoneal
lymphadenopathy. The stomach and small bowel loops are
unremarkable. There is no evidence of obstruction. There is no
free air. The appendix is normal. The colon is unremarkable.
PELVIS: The bladder and terminal ureters are normal. The
rectum is
unremarkable. There is no free fluid in the pelvis. The
prostate and seminal vesicles are normal. The intra-abdominal
vasculature contours are normal.
BONES: Bones are grossly unremarkable.
IMPRESSION: No acute intra-abdominal process to explain
patient's symptoms.
CXR:
FINDINGS: PA and lateral views of the chest. There is no focal
consolidation, pleural effusion, or pneumothorax. The
cardiomediastinal
contours are normal.
IMPRESSION: No acute cardiopulmonary process
Brief Hospital Course:
___ yo M with HIV on HAART and NIDDM, presented with
hyperglycemia for a week found to have acute renal failure.
# Acute renal failure: Patient presented with frank dehydration
___ hyperglycemia and was found to have acute renal failure.
With IV and PO hydration, Cr initially improved however then
raised again to 1.5. Upon reviewing outpatient records, it
appeared that Cr perhaps was higher than listed in OMR and 1.5
was actually closer to patient's baseline. All medications was
renally dosed and patient was advised to avoid nephrotoxic
agents including NSAIDS.
# Hyperglycemia: Patient presented with hyperglycemia after
recent steroid injection. However blood sugars were persistently
elevated. He was very adamant about not starting insulin
although had been on insulin in the past. He was started on
metformin (at a lower dose given Cr) and glyburide with plans
for close follow up with his PCP ___ 1 day after discharge.
# Chest Pain: Patient had recurrent chest pain on admission
without EKG changes or elevations in biomarkers. Given diabetes,
there was concern for CAD however after exploring outpatient
records, he apparently has had similar complaints in the past
with a negative work-up. Despite this, his last stress test was
in ___ and he may benefit from a repeat stress test as an
outpatient.
TRANSITIONAL ISSUES:
[] close PCP follow up for oral hypoglycemic titration
[] outpatient stress test for chest pain work-up
[] monitor Cr close, if persistent > 1.5, would consider
discontinuing metformin given risk of lactic acidosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Darunavir 600 mg PO BID
2. RiTONAvir 100 mg PO BID
3. Raltegravir 400 mg PO BID
4. Etravirine 200 mg PO BID
5. LaMIVudine 150 mg PO DAILY
6. ValACYclovir 500 mg PO Q12H
7. Multivitamins 1 TAB PO DAILY
8. Aspirin 81 mg PO DAILY
9. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Darunavir 600 mg PO BID
3. Etravirine 200 mg PO BID
4. LaMIVudine 150 mg PO DAILY
5. MetFORMIN (Glucophage) 500 mg PO BID
RX *metformin 500 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
6. Multivitamins 1 TAB PO DAILY
7. Raltegravir 400 mg PO BID
8. RiTONAvir 100 mg PO BID
9. ValACYclovir 500 mg PO Q12H
10. GlipiZIDE 2.5 mg PO BID
RX *glipizide 5 mg 0.5 (One half) tablet(s) by mouth twice a day
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on chronic renal failure
Diabetes Mellulits
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 becasue you felt weak and had
high blood sugars. On admission, your kidneys were also not
working well. After some fluid your kidney function improved.
Your blood sugars remained elevated. We changed your medications
around however on discharge your blood sugar was still elevated.
It is important that you follow up with your doctor TOMORROW
(___) to better adjust your medications.
Followup Instructions:
___
|
10250159-DS-7 | 10,250,159 | 23,529,908 | DS | 7 | 2192-09-09 00:00:00 | 2192-09-09 23:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with bare metal stent to LAD ___
History of Present Illness:
Mr. ___ is a ___ year-old gentleman with HIV (CD4 count 568 in
___, T2DM, hyperlipidemia, who presented with chest pain,
found to have STEMI. Patient works as a ___, was driving at
330PM when he had sudden onset diaphoresis, "rope pulling" CP
w/radiation down L arm and R shoulder pain, with associated
nausea and SOB. After being picked up by EMS, he was noted to
have ST elevations in the septal/anterior leads. At the time,
he was dyspneic and diaphoretic with lightheadedness. He was
given aspirin 325 mg PO, nitroglycerin SL x1 and ondansetron.
He denies any prior history of cardiac disease. Additionally,
he denies any ingestion of drugs or use of PDE inhibitors.
On arrival to the ___ ED, Code STEMI was activated. No vital
signs were recorded. In the cath lab, he was found to have
distal LAD 100% stenosis, predilated at 8 ATM and 3.0 x 18mm BMS
deployed at 14 ATM. Had RFA access, perclosed. Started on
integrilin, to be continued for 4 hours post cath.
On arrival to the floor, patient denied any CP, SOB, nausea or
any discomfort.
REVIEW OF SYSTEMS
On review of systems, he reports recent bronchitis, treated with
five days of azithromycin.
He denies any prior history of stroke, TIA, bleeding at the time
of procedure, 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, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None before today
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
1. HIV disease ___ - VL < 75 undetectable, CD4 586 -
current regimen includes Darunavir 600 mg 1 tab PO BID,
Ritonavir 100 mg PO BID, Raltegravir 400 mg PO BID, LaMIVudine
150 mg PO daily, Etravirine 200 mg PO BID) - genotype resistance
testing: resistant to all RTIs, resistance to Lexiva, Crixivan,
Viracept, Reyataz - M41L, D67N, M184V, L210W, ___, L10F, I13V,
L24I, V32I, M36I, K43T, M61I, A71T
2. Type 2 diabetes mellitus (with nephropathy)
3. Molluscum contagiosum (___)
4. Human papillomavirus
5. Recurrent HSV infection (on suppressive valacyclovir)
6. Anemia
7. Hyperlipidemia
8. h/o oral candidiasis (thrush)
9. Depressive disorder
10. Ceruminosis
Social History:
___
Family History:
Mom alive @ age ___ with CAD with "multiple stents" placed at age
___, DM, HL; father deceased @ age ___ from "old age"; 5 brothers
(one with diabetes), 1 sister in good health. Strong family
history of diabetes. No history of sudden cardiac death. No
known history of malignancy.
Physical Exam:
POST-CATH PHYSICAL EXAM:
VS: T36.8 HR74 BP122/73 18 98%2L
General: Lying in bed, NAD.
HEENT: EOMI, PERRL, clear oropharynx
Neck: No JVD. No thyromegaly, no LAD, no carotid bruits
CV: RRR no m/r/g.
Lungs: CTAB anteriorly
Abdomen: ND, BS present, NTTP, no HSM appreciated
GU: No foley in.
Ext: Warm, well-perfused. no c/c/e
Neuro: Alert and oriented. Moves all four extremities
appropriately, sensation intact
Skin: No rashes
Pulses: Right fem pulse intact, no hematoma or induration.
dressing c/d/i. DP, ___ pulses intact 2+ bilaterally.
DISCHARGE PHYSICAL EXAM:
VS stable, afebrile.
General: NAD
HEENT: PERRL, EOMI, clear oropharynx
Neck: No NVD
CV: RRR no m/r/g
Lungs: CTAB
Abdomen: ND, BS present, NTTP, no HSM appreciated
GU: No foley in.
Ext: Warm, well-perfused. no c/c/e
Neuro: Alert and oriented. Moves all four extremities
appropriately, sensation intact
Pulses: R fem pulse intact, no hematoma or induration, c/d/i
dressing. DP, ___ pulses 2+bilat.
Pertinent Results:
ADMISSION LABS
___ 05:21PM BLOOD WBC-9.6 RBC-4.02* Hgb-13.0* Hct-36.8*
MCV-92 MCH-32.3* MCHC-35.3* RDW-13.4 Plt ___
___ 05:21PM BLOOD ___
___ 08:14PM BLOOD Glucose-222* UreaN-14 Creat-1.1 Na-138
K-3.9 Cl-100 HCO3-27 AnGap-15
___ 08:14PM BLOOD CK(CPK)-332*
PERTINENT RESULTS
___ 08:14PM BLOOD CK-MB-18* MB Indx-5.4 cTropnT-0.88*
___ 02:13AM BLOOD ALT-51* AST-50* CK(CPK)-441* AlkPhos-154*
TotBili-0.3
___ 08:14PM BLOOD CK(CPK)-332*
___ 10:01AM BLOOD CK(CPK)-419*
___ 02:13AM BLOOD CK-MB-23* MB Indx-5.2 cTropnT-1.20*
___ 10:01AM BLOOD CK-MB-19* MB Indx-4.5 cTropnT-0.74*
DISCHARE LABS
___ 07:12AM BLOOD WBC-6.6 RBC-4.40* Hgb-14.3 Hct-41.6
MCV-95 MCH-32.6* MCHC-34.4 RDW-13.0 Plt ___
___ 07:12AM BLOOD Glucose-172* UreaN-14 Creat-1.2 Na-135
K-4.2 Cl-99 HCO3-24 AnGap-16
___ 07:12AM BLOOD Calcium-10.2 Phos-2.8 Mg-1.8
LABS/STUDIES
EKG: NSR rate 69, ST elevations in V3-V5 and peaked T waves in
V2-V5.
CARDIAC CATH:
Left dominant,
LMCA: No angiographic CAD
LAD: Mid ___ D1 50-60% proximal
LCX: Large vessel without significant stenosis
RCA: No significant stenosis
Distal LAD 95% stenosis, predilated at 8 ATM and 3.0 x 18mm BMS
deployed at 14 ATM. Final angiography showed <0% residual,
no dissection and TIMI 3 flow.
Assessment & Recommendations
1. Anterior STEMI.
2. Successful bare metal stent LAD
3. ASA 325 mg daily; Plavix 75 mg daily x ___ year. Continue
Integrilin x 4 hours. Other management per CCU team.
TTE ___
The left atrium and right atrium are normal in cavity size. No
atrial septal defect is seen by 2D or color Doppler. The
estimated right atrial pressure is ___ mmHg. Left ventricular
wall thicknesses and cavity size are normal. There is mild
regional left ventricular systolic dysfunction with hypokinesis
of the mid-anteroseptum and the distal left ventricle, sparing
the lateral wall. The remaining segments contract normally (LVEF
>55%). The apex is trabeculated, but no clot/mass is seen. The
estimated cardiac index is normal (>=2.5L/min/m2). Doppler
parameters are indeterminate for left ventricular diastolic
function. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Regional left ventricular dysfunction c/w CAD (LAD
distribution). Normal biventricular size and global systolic
function. Mild mitral regurgitation.
CXR ___ Normal heart, lungs, hila, mediastinum and pleural
surfaces.
Brief Hospital Course:
___ year-old gentleman with HIV (CD4 count 568 in ___, T2DM,
hyperlipidemia, who presented with chest pain, found to have
STEMI and underwent cardiac cath with BMS to mid-LAD for 100%
stenosis.
# STEMI: Patient presented with STEMI in anterior leads, and
taken to cath lab on presentation to ED, with 100% mid-LAD
stenosis and had a bare metal stent placed. He was started on
integrilin in the cath lab which was continued for 4 hours
following. He was started on ASA, clopidogrel, metoprolol,
lisinopril and pravastatin (given HIV medication), which he
tolerated well. His cardiac biomarkers peaked on day following
his stent placement at CK 441, CKMB 23, troponin 1.2. After PCI
patient had resolution of CP and SOB, and felt well with normal
distal pulses and RFA groin site checks. Echocardiogram showed
regional left ventricular dysfunction c/w CAD (LAD distribution)
and EF >55%. Patient will cont on clopidogrel for 1 month given
BMS placement and will follow up with Dr. ___. Despite his
age, he likely had MI given his HIV status, poorly controlled
DM, and HL with positive family history. Patient was advised
regarding need to better control his diabetes and f/u at ___
per below.
# Diabetes: Mostly diet-controlled per patient with intermittent
PRN QHS lantus and intermittent Humalog as needed for higher
sugars at home. Is not currently on other diabetes meds, and
Hgb A1c was elevated at 7.5. Per last ___ note in ___,
patient was to continue metformin. He was on lantus 10 units
QHS and humalog ISS while in house for BS ranging 170s to 220s.
He was advised to follow up at ___ within the next few weeks
at discharge to clarify his diabetes medications.
# HIV: Has been well-controlled with most recent CD4 count of
568 in ___.
Continued home meds: Darunavir 600 mg PO BID, Etravirine 200 mg
PO BID, LaMIVudine 150 mg PO DAILY, Raltegravir 400 mg PO BID,
RiTONAvir 100 mg PO BID.
TRANSITIONAL ISSUES:
-Needs to continue plavix x1 mo for BMS.
-Was started on metoprolol and lisinopril which were well
tolerated.
-Needs ___ f/u to clarify diabetes meds for better glucose
control.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Darunavir 600 mg PO BID
3. Etravirine 200 mg PO BID
4. LaMIVudine 150 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Raltegravir 400 mg PO BID
7. RiTONAvir 100 mg PO BID
8. ValACYclovir 500 mg PO Q12H
9. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
10. Pravastatin Dose is Unknown PO DAILY
11. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using Glargine Insulin
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Darunavir 600 mg PO BID
3. Etravirine 200 mg PO BID
4. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. LaMIVudine 150 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Pravastatin 80 mg PO DAILY
8. Raltegravir 400 mg PO BID
9. RiTONAvir 100 mg PO BID
10. ValACYclovir 500 mg PO Q12H
11. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
12. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
13. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet extended release 24
hr(s) by mouth daily Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
ST-elevation myocardial infarction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came to the hospital because of chest pain due to heart
attack. You were found to have a blockage of an artery in your
heart, which was opened with a stent. You have been started on
new medications to help your heart heal, and to prevent future
heart attacks. Please take them as directed below and follow up
at the cardiology clinic as listed below.
Your blood sugars have been elevated with a high hemoglobin A1c.
Please follow up at ___ for better control of your diabetes
in ___ weeks.
Followup Instructions:
___
|
10250304-DS-7 | 10,250,304 | 25,717,481 | DS | 7 | 2141-10-07 00:00:00 | 2141-10-08 13:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Avandia / Ceftriaxone / Hydromorphone / lisinopril
Attending: ___.
Chief Complaint:
Seizures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: The patient is a ___ year old woman with past medical
history
notable for left pontine stroke (___), uncontrolled type II DM,
HTN, HLD who presents to ___ ED ___ with events concerning for
seizure. History obtained from pt's husband as pt was recently
given Ativan and was drowsy at time of assessment.
Pt was in a MVC on ___ where she rear-ended another car while
turning right. Following this accident, pt has been anxious and
jittery when hearing loud noises. On ___, pt began to experience
seizure-like events. Per husbands observation, pt first states
that she feels like she cannot breath. She then loses awareness.
She will "chew" with her mouth and jerk her mouth to the left
while experiencing convulsive movements in her bilateral upper
extremities. This will last about 2 minutes in total. Pt will
return to her normal self after a total of 5 minutes. Pt's
husband denies any other seizure semiologies.
Pt was initially brought to ___ where she was diagnosed with
PNES. This report is per husband and records are not readily
available. She was discharged on ___. After discharge, she had
about 10 additional typical events. Her husband was concerned
that these events represented true seizures so he brought her to
an OSH ED.
At OSH ED, pt underwent NCHCT which was unremarkable. She was
transferred to ___ for further management. In the ___ ED,
she
had a 3 minute episode of LOA with "mouth pulled to left, gaze
deviation to left, flexed hypertonic extremities on right". She
began to follow commands about 3 minutes after seizure activity
ended. She was given 1 mg IV Ativan.
At my time of assessment, pt was sedated due to Ativan (it is
unclear whether she also received Ativan at OSH) so it was
difficult to obtain further history. Pt denies any specific
complaints of chest pain, shortness of breath, headache,
numbness
or weakness.
Per husband, pt has never had a concussion, skull fracture,
meningitis, encephalitis, developmental delay, or seizure (prior
to the events this week). There is no family history of seizure.
She had no birth complications.
Past Medical History:
L pontine stroke ___ presented with R sided clumsiness,
possible weakness and slurred speech; no residual deficits
Type 2 diabetes (HbA1C 14.7% in ___
Hyperlipidemia
Hypertension
Social History:
___
Family History:
No family history of seizures or any neurologic
conditions.
Physical Exam:
================================
ADMISSION PHYSICAL EXAM
================================
Vitals: 99.1 ___ 16 95% 2L
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR
Pulmonary: CTAB
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Skin: No rashes or lesions
Neurologic Examination:
**Exam limited by ativan administration**
- Mental Status - Drowsy but arouses to voice. Speaks in ___
word
phrases. Tracks intermittently. Does not follow commands. Does
not answer orientation questions. Mild dysarthria.
- Cranial Nerves - PERRL 3->2 brisk. Blinks to threat throughout
all visual fields. +VOR. +tracks and grossly intact EOM without
nystagmus. Face symmetric.
- Sensorimotor: Antigravity movement in all extremities but
spontaneously moves R > L side. Pt too sedated to comply with
more detailed motor testing. Withdraws to noxious in all
extremities.
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 0
R 1 1 1 1 0
Plantar response flexor bilaterally.
- Coordination - Deferred as pt not following commands.
- Gait - Deferred as pt drowsy.
**During physical exam, pt experienced twitching of right side
of
face lasting about 30 seconds; occuring periorally and
periocularily**
======================
DISCHARGE EXAM
======================
General: NAD, awake, alert
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR
Pulmonary: CTAB
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status - Awake, alert, relays history well.
- Cranial Nerves - PERRL, EOMI with saccadic intrusions, mild
left-sided nasolabial fold flattening
- Sensorimotor: Mild left pronator drift, otherwise full
strength
- DTRs: ___ 1+ bilaterally, difficult to elicit ankle
jerks, downgoing toes
- Coordination - FNF with mild tremor bilaterally
Pertinent Results:
========================
ADMISSION LABS
========================
___ 11:57PM GLUCOSE-340* UREA N-12 CREAT-0.9 SODIUM-140
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-28 ANION GAP-15
___ 11:57PM estGFR-Using this
___ 11:57PM ALT(SGPT)-15 AST(SGOT)-15 ALK PHOS-73 TOT
BILI-0.4
___ 11:57PM ALBUMIN-3.2* CALCIUM-9.8 PHOSPHATE-2.7
MAGNESIUM-2.0
___ 11:57PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 11:57PM WBC-6.3 RBC-4.15* HGB-11.9* HCT-35.6* MCV-86
MCH-28.8 MCHC-33.5 RDW-14.0
___ 11:57PM NEUTS-64.8 ___ MONOS-7.5 EOS-1.7
BASOS-0.3
___ 11:57PM PLT COUNT-180
=========================
IMAGING
=========================
___ CXR:
IMPRESSION:
Prominent interval widening of the upper mediastinum may be
secondary to low lung volumes and technique. Recommend repeat PA
and lateral study and if this finding persists, this must be
evaluated with CT.
=========================
DISCHARGE LABS
=========================
___ 05:03AM BLOOD Glucose-96 UreaN-10 Creat-0.7 Na-140
K-3.7 Cl-104 HCO3-30 AnGap-10
___ 05:03AM BLOOD Calcium-10.0 Phos-3.8 Mg-2.0 Cholest-150
___ 05:03AM BLOOD %HbA1c-14.0* eAG-355*
___ 05:03AM BLOOD Triglyc-98 HDL-48 CHOL/HD-3.1 LDLcalc-82
___ 05:03AM BLOOD TSH-2.0
___ 10:37AM BLOOD SED RATE- 34
Brief Hospital Course:
The patient is a ___ year old woman with past medical history
notable for left pontine stroke (___), uncontrolled type II DM,
HTN, HLD who presented to ___ ED ___ with events concerning
for seizure following a car accident a few days prior, with
recent diagnosis of PNES by ___.
During admission here at ___, she had 4 episodes captured with
a moaning, then left arm extension with right arm flexion, eye
deviation to the right, with jerking of extremities, then
post-ictal left-sided weakness that was noted during the later
events. The events correlated with seizure activity initially
right-sided, then generalized, followed by right-sided slowing.
She was started on Keppra 1000mg po BID, without further seizure
activity. Additionally, her symptoms of feelings of doom and
nightmares resolved following initiation of Keppra. She was sent
home with levetiracetam XR 2000mg daily, due to patient
preference for once-daily dosing.
MRI/MRA brain (___):
1. No intracranial hemorrhage, acute infarct, or mass lesion. No
evidence of
an epileptogenic substrate on dedicated seizure protocol
imaging.
2. Chronic left mid pons infarct and mild chronic
microangiopathy. Mild
generalized parenchymal volume loss.
3. Normal MRA of the head and neck.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Chlorthalidone 25 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. GlipiZIDE XL 10 mg PO BID
4. Losartan Potassium 100 mg PO DAILY
5. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
6. Simvastatin 20 mg PO QPM
7. Docusate Sodium 200 mg PO BID:PRN constipation
8. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Chlorthalidone 25 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
4. Multivitamins 1 TAB PO DAILY
5. Simvastatin 20 mg PO QPM
6. GlipiZIDE XL 10 mg PO BID
7. Keppra XR (levETIRAcetam) ___ mg oral DINNER
RX *levetiracetam 500 mg 4 tablet(s) by mouth at dinner Disp
#*360 Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Epilepsy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were admitted to the hospital for characterization of events
concerning for seizure. ___ were found to have seizures on EEG
monitoring, which resolved after we started ___ on a seizure
medication Keppra. ___ will be continued on Keppra at home. For
ease of dosing, ___ will be continued on Keppra XR 2000mg (4
pills) by mouth daily.
___ had an MRI of the brain which showed changes consistent with
your prior stroke in the lefft mid pons infarct and normal
vessel imaging.
Please follow up with the epilepsy clinic as scheduled. ___ are
currently scheduled for a nurse appointment at the epilepsy
clinic on ___ at 1pm. Please call the epilepsy clinic at
___ for any questions regarding your appointment.
It was a pleasure to be a part of your care team.
___ Neurology Team
Followup Instructions:
___
|
10250304-DS-8 | 10,250,304 | 23,719,557 | DS | 8 | 2144-08-05 00:00:00 | 2144-08-05 15:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Avandia / Ceftriaxone / Hydromorphone / lisinopril
Attending: ___
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o F with a history of pontine CVA, seizure, HTN, poorly
controlled diabetes, brought in by husband for evaluation of
altered mental status and headache. Per report of ED, collateral
obtained from her husband is as follows: she developed confusion
about 8 ___ last night, with generalized difficulty moving and
walking and reported a headache to him around midnight to 1 AM,
which she reported was severe. Unclear if any traumatic injuries
occurred. Patient was somnolent on arrival and was and unable to
relay significant details of recent events
In ED initial VS: T 98.4 HR 120 BP 190/100 RR 16 O2Sat 98%RA
FSBG > 500
Exam: AMS, arousable to mild noxious stimuli, moves all
extremities but without significant effort, slight right facial
droop, unable to comply with evaluation of extraocular
movements, hearing, sensation, coordination. No obvious signs of
injury; clear lungs; no cardiac murmur; soft nontender abdomen.
Labs significant for: Glc 715, corrected Na 140, K 5.2, normal
CBC, mildly elevated AP 183, negative serum/urine tox, trop x 1
negative, UA without ketones but with 1000 Glc, VBG 7.35/___
Patient was given: Ativan 1 mg IM, 3L NS, ASA 300 mg, insulin
gtt, 1 g Tylenol
Imaging notable for:
CTA Head/neck (preliminary result): Somewhat limited by poor
contrast opacification.
There is no aneurysm, dissection, occlusion, or significant
stenosis of the anterior circulation, posterior circulation,
circle ___, bilateral internal carotid arteries, or bilateral
vertebral arteries.
CT C-spine w/o contrast: no fracture or malalignment
CT head w/out contrast: no acute intracranial process
CXR: Bibasilar atelectasis, no evidence of pneumonia
Consults: Neuro: Etiology of her symptoms most likely due to
toxic metabolic encephalopathy due to hyperglycemia.
Hyperglycemia can result in stroke like symptoms. Although, pt
certainly has risk factors for stroke, currently it is difficult
to assess if her symptoms are due to ischemic insult vs just
cause by hyperglycemia. CT head did not show any abnormality.
CTA H&N is pending.
VS prior to transfer: HR 113 BP 141/69 RR 14 100% RA
On arrival to the MICU, the patient reports a right sided
frontal headache that extends posteriorly. She states that the
headache began early last night but then she went to sleep. She
awoke this morning and the headache persisted which is partly
why she was brought to the ED by her husband. She states that
the headache is very severe at present and denies having a
headache history in the past. She denies fevers or recent colds.
She repeatedly states on assessment that 'she's fine, its just
the headache' and is grimacing on assessment.
Past Medical History:
L pontine stroke ___ presented with R sided clumsiness,
possible weakness and slurred speech; no residual deficits
Type 2 diabetes (HbA1C 14.7% in ___
Hyperlipidemia
Hypertension
Social History:
___
Family History:
No family history of seizures or any neurologic
conditions.
Physical Exam:
ADMISSION EXAM:
VITALS: reviewed in Metavision
GENERAL: Arousable to voice, answers questions, appears
uncomfortable, grimacing
HEENT: Sclera anicteric, sluggish pupils though reactive
bilaterally, MMM, oropharynx clear
NECK: supple, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no obvious rashes
NEURO: would not participate in full neuro exam, though able to
lift UE and ___ off bed without difficulty, able to wiggle toes
bilaterally, face symmetric, sensation grossly intact in all
extremities
DISCHARGE PHYSICAL EXAM:
==============================
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes, rales, or rhonchi
CV: RRR, S1/S2, no m/r/g
GI: soft, NT/ND, BS+, no rebound tenderness or guarding, no
organomegaly
MSK: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN2-12 intact, no focal deficits
Skin: No rash or lesion
Pertinent Results:
ADMISSION RESULTS:
___ 07:45AM BLOOD WBC-7.0 RBC-4.80 Hgb-13.8 Hct-40.6 MCV-85
MCH-28.8 MCHC-34.0 RDW-12.3 RDWSD-37.5 Plt ___
___ 07:45AM BLOOD Glucose-715* UreaN-18 Creat-1.1 Na-130*
K-5.2* Cl-87* HCO3-29 AnGap-14
___ 07:45AM BLOOD %HbA1c-15.4* eAG-395*
___ 07:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:53AM BLOOD ___ pO2-26* pCO2-52* pH-7.35
calTCO2-30 Base XS-0 Intubat-NOT INTUBA
STUDIES:
CT HEAD W/O CONTRAST Study Date of ___ 7:39 AM
FINDINGS:
There is no evidence of large territorial
infarction,hemorrhage,edema, or mass
effect. There is prominence of the ventricles and sulci
suggestive of
involutional changes.
There is no evidence of fracture. The visualized portion of the
paranasal
sinuses, mastoid air cells, and middle ear cavitiesare
essentially clear. The
patient is status post bilateral lens replacement. Otherwise
the orbits are
unremarkable.
IMPRESSION:
No acute intracranial process on noncontrast head CT.
Specifically no large
territory infarct or intracranial hemorrhage.
CT C-SPINE W/O CONTRAST Study Date of ___ 7:40 AM
FINDINGS:
Alignment is anatomic.No fractures are identified. There is a
well-defined
sclerotic area in the left aspect of the C5 vertebral body
(2:39) likely
representing a bony island. There is no evidence of significant
spinal canal
or neural foraminal stenosis. A small C5-C6 central protrusion
does not
significantly narrow the spinal canal, which can be seen on MRI
of ___
is no prevertebral soft tissue swelling.There is no
lymphadenopathy by size
criteria. The thyroid is unremarkable. The visualized
aerodigestive tract is
also unremarkable.
IMPRESSION:
1. No acute displaced fracture or traumatic malalignment.
2. Additional findings described above.
CHEST (PA & LAT) Study Date of ___ 8:19 AM
FINDINGS:
AP and lateral views of the chest provided.
There is bibasilar atelectasis. 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:
Bibasilar atelectasis. No evidence of pneumonia
CTA HEAD W&W/O C & RECONS Study Date of ___ 9:56 AM
FINDINGS:
The study is partially degraded due to poor contrast
opacification of the
vessels.
CTA HEAD:
The vessels of the circle of ___ and their principal
intracranial branches
appear otherwise grossly normal without stenosis, occlusion, or
aneurysm
formation. The dural venous sinuses are patent.
CTA NECK:
The carotid and vertebral arteries and their major branches
appear normal with
no evidence of stenosis or occlusion. There is no evidence of
internal carotid
stenosis by NASCET criteria.
OTHER:
There is a 5 mm right upper lobe partially solid/sub solid
pulmonary nodule
(2:9). The visualized portion of the thyroid gland is within
normal limits.
There is no lymphadenopathy by CT size criteria. There is
narrowing debris
within the posterior aspect of the esophagus, likely
representing fluid
contents.
IMPRESSION:
1. Normal head and neck CTA allowing for a partially degraded
study due
overall to poor contrast opacification of the vessels.
2. Part solid 5 mm right upper lobe pulmonary nodule. Consider
further
evaluation with a dedicated CT chest in 3 months.
RECOMMENDATION(S): Part solid 5 mm right upper lobe pulmonary
nodule.
Consider further evaluation with a dedicated CT chest in 3
months.
MICRO:
No positive cultures
DISCHARGE LABS:
___ 06:26AM BLOOD WBC-5.2 RBC-4.11 Hgb-11.9 Hct-35.3 MCV-86
MCH-29.0 MCHC-33.7 RDW-12.5 RDWSD-38.7 Plt ___
___ 06:26AM BLOOD Glucose-226* UreaN-14 Creat-0.8 Na-140
K-4.1 Cl-100 HCO3-28 AnGap-12
___ 06:26AM BLOOD Calcium-9.8 Phos-3.0 Mg-2.0
___ 07:45AM BLOOD %HbA1c-15.4* eAG-395*
___ 07:45AM BLOOD Triglyc-110 HDL-84 CHOL/HD-3.1
LDLcalc-151*
Brief Hospital Course:
***PATIENT LEFT AMA***
Patient left AMA stating she wanted to go home and did not want
to see ___ Diabetes specialist during this hospitalization
as she had had an unpleasant experience with a provider from
___ previously. She declined home insulin and declined
remaining in the hospital for monitoring of her blood sugars in
the setting of her recent hyperglycemia. Risks of her leaving
the hospital with uncontrolled blood sugars were explained to
the patient including organ damage over time, altered mental
status, dehydration, electrolyte imbalances, coma, and death.
Patient understood these risks and had capacity to leave AMA.
___ y/o F with a history of pontine CVA, seizure, HTN, poorly
controlled diabetes, brought in by husband for evaluation of
altered mental status and headache. On arrival, patient was
noted to have BGs in 700s without an associated anion gap. For
this, she was started on an insulin drip. Infectious w/u
returned unremarkable. Neurology was consulted on admission for
her severe headache, and recommended obtaining NCHCT and CTA
head/neck, in addition to LP and brain MRI. NCHCT and CTA
head/neck were unremarkable, and patient refused both LP and
brain MRI. She was noted to have capacity to refuse, as she
understood the risk of death should she have an undiagnosed
subarachnoid hemorrhage or intracranial mass. The team
recommended initiation of insulin and consultation with the
inpatient ___ service, however the patient refused, and was
again felt to have capacity to do so. Her BGs improved to the
100s within 24 hours and she was transferred to the floor.
Insulin was strongly recommended, however she again refused,
saying she does not want to be "dependent on insulin." At time
of discharge her blood sugars were in the 200s and her home
diabetes regimen was restarted. She was started on amlodipine
and her chlorthalidone was discontinued due to possible
contribution to her hyperglycemia.
#Hyperglycemia
#HHS
#Uncontrolled DM: A1C on presentation >15. Patient with long
history of difficult to control DM secondary to medication
non-compliance. Patient adamantly denied medication
non-compliance, and was able to name her 3 diabetes medications.
No clear cause of decompensation--infectious w/u unremarkable.
Hyperglycemia resolved with insulin drip. The medical team
recommended treatment with long acting and short acting insulin,
however patient refused. Home medications were restarted prior
to discharge and pt counseled to stay to monitor ___'s after
restarting home meds but she did not want to stay for further
monitoring.
#Headache
#Somnolence. On initial presentation, there was concern for SAH
and neurology was consulted. NCHCT and CTA head/neck were
unremarkable. Neurology also recommended LP and brain MRI,
however patient refused. Symptoms were felt to be related to her
hyperglycemia, however other etiologies were unable to be ruled
out given patient's refusal of diagnostics.
#HTN: Chlorthalidone was discontinued given the associated risks
of hyperglycemia and HHS. It was replaced with amlodipine. She
was continued on her home losartan.
TRANSITIONAL ISSUES:
========================
#DM2
[ ] Uncontrolled hyperglycemia at discharge in 200s. A1c >15.
Diabetic regimen should be titrated further as an outpatient and
compliance should be assessed further
#HTN
[ ] Chlorthalidone discontinued
[ ] Amlodipine started at 5 mg. This can be uptitrated further
as needed.
#Incidental Findings
[ ] Part solid 5 mm right upper lobe pulmonary nodule.
Consider further evaluation with a dedicated CT chest in 3
months.
Billing: greater than 30 minutes spent on discharge counseling
and coordination of care.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Chlorthalidone 25 mg PO DAILY
2. empagliflozin 25 mg oral DAILY
3. GlipiZIDE XL 10 mg PO DAILY
4. Losartan Potassium 100 mg PO DAILY
5. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
6. Aspirin 81 mg PO DAILY
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Aspirin 81 mg PO DAILY
3. empagliflozin 25 mg oral DAILY
4. GlipiZIDE XL 10 mg PO DAILY
5. Losartan Potassium 100 mg PO DAILY
6. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
RX *metformin 1,000 mg 1 tablet(s) by mouth daily Disp #*90
Tablet Refills:*0
7. HELD- Chlorthalidone 25 mg PO DAILY This medication was
held. Do not restart Chlorthalidone until told to by your PCP
___:
Home
Discharge Diagnosis:
Primary Diagnosis
Hyperglycemia
Toxic Metabolic Encephalopathy
Secondary Diagnoses
Type 2 Diabetes
Hyperlipidemia
Hypertension
History of stroke
History of seizures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure caring for you during your stay at ___.
WHY WAS I HERE?
-Your blood sugars were very high
WHAT WAS DONE WHILE I WAS IN THE HOSPITAL?
-You were given insulin
-Your blood pressure medicines were changed
WHAT SHOULD I DO WHEN I GO HOME?
-You should take your medicines as prescribed.
-You should call your PCP on ___ morning and see her as soon
as possible.
Be well!
Your ___ Care Team
Followup Instructions:
___
|
10250323-DS-20 | 10,250,323 | 25,584,573 | DS | 20 | 2136-09-24 00:00:00 | 2136-09-24 10:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L intertrochanteric femur fracture
Major Surgical or Invasive Procedure:
L intertrochanteric femur fracture ORIF w/ TFN by Dr. ___
___
History of Present Illness:
___ male presents with the above fracture s/p bicycle vs car.
Patient was riding his bicycle home this afternoon when he was
hit onto the left side by a car accelerating from rest. Was
wearing a helmet at this time. Denies head strike or loss
consciousness. Endorses transient paresthesias down to his foot
which immediately resolved. Currently denies any numbness or
paresthesias. Denies any nausea vomiting. Denies any headache
shortness of breath. Denies any abdominal pain.
Past Medical History:
OSTEOPOROSIS
ECZEMATOUS DERMATITIS
Social History:
___
Family History:
noncontributory
Physical Exam:
On discharge:
General: alert and oriented, pleasant affect, follows commands,
NAD
Pulm: breathing comfortably on room air
MSK:
RLE:
- L surgical incision covered w/ gauze and medipore tape in
inferior aspect, tegaderm and gauze in superior
- Skin intact w/ abrasion over hip
- Fires ___
- SILT s/s/sp/dp/t n dist
- Toes WWP
- 2+ DP
Pertinent Results:
___ 07:10AM BLOOD WBC-4.7 RBC-3.13* Hgb-9.4* Hct-28.0*
MCV-90 MCH-30.0 MCHC-33.6 RDW-13.3 RDWSD-43.8 Plt ___
___ 07:30AM BLOOD Glucose-103* UreaN-8 Creat-1.0 Na-138
K-3.8 Cl-101 HCO3-26 AnGap-11
___ 07:30AM BLOOD Calcium-8.1* Phos-3.3 Mg-1.7
LLE doppler US ___ negative for DVT
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 L intertrochanteric femur fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for L hip TFN, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to rehab was appropriate.
The patient experienced resolving urinary retention during the
hospital visit, and a LLE US for DVT evaluation was negative on
___. 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
WBAT in the LLE extremity, and will be discharged on 40mg
enoxaparin subcutaneously qhs 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:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
Do not take more than 4000mg acetaminophen in one day
RX *acetaminophen 325 mg ___ tablet(s) by mouth every six (6)
hours Disp #*75 Capsule Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*56 Capsule Refills:*0
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 Q3H:PRN Pain -
Moderate
Patient may refuse or request partial fill
RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours as needed
Disp #*25 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left intertrochanteric femur fracture
Discharge Condition:
stable
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
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:
- WBAT LLE
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone 5mg 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 40mg subq 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
Followup Instructions:
___
|
10250358-DS-17 | 10,250,358 | 22,882,570 | DS | 17 | 2112-12-07 00:00:00 | 2112-12-07 15:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Diagnostic paracentesis
History of Present Illness:
___ with HTN and recently diagnoses HepC cirrhosis and
metastatic HCC who presents with N/V. Per report symptoms began
approximately 2 days ago. Emesis is no bloody in nauture and
associated with midepigastic discomfort. She reports she has
been having regular bowel movements. She denies chest pain,
shortness of breath, or urinary symptoms. She reported to an OSH
where labs were notable for a bili of 6 from a value of 3.9 at
discharge, a HCT of 40 and sodium of 130. She was given 500 mL
of normal saline, morphine 4 mg IV x 2 and 4 mg of zofran x 2
and transferred to ___ for further management.
Of note pt was recently admitted to ___ in ___ with
intractable N/V at which time she was found to have labs c/w
cirrhosis. HCV VL that admission was 3.4 million. CT abd/pelvis
showed cirrhosis and raises concern for HCC with mets to
lung/colon, subsequent liver bx showed HCC. Pt was also found to
have a portal vein thrombus. She was briefly anticoagulated but
developed guaiac stools and anticoagulation was stopped. She was
discharged on antiemetics and pain medications.
In the ED, initial vs were: 98.2 111 103/61 24 94% 2L (patient
is not on home O2). Labs were remarkable for Na 129 (131 at
recent discharge), AST/ALT 352/90 (c/w last admission), Tbili
6.3. Patient was given zofran, morphine. Dx para was negative
for evidence of SBP. Vitals on Transfer: 96 126/64 16 92%.
On the floor, the patient was sleepy but arousable. She denied
current pain.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias. Ten
point review of systems is otherwise negative.
Past Medical History:
-HTN
-HepC cirrhosis
-Metastatic ___
Social History:
___
Family History:
Son has esophageal cancer, in remission currently. No pancreatic
or any other cancers in the family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 98.3 BP: 145/67 P: 112 R: 18 O2: 93% 2L
General: Sleepy appearing female, oriented, no acute distress
HEENT: Sclera midly icteric, dry mucous membranes, oropharynx
clear
Neck: supple, JVP not elevated, no LAD
Lungs: diffuse wheezes
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: distended, + fluid wave, mildly ttp in epigastrum
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: No asterixis
DISCHARGE Vitals: 98.3 132/69 93 20 98/RA
I/O: ___ (ON) 350/500+ BMx2 (24)
General: Sleepy appearing frail elderly female, oriented, no
acute distress. conversational.
HEENT: Sclera midly icteric, dry mucous membranes, oropharynx
clear
Neck: supple, JVP not elevated, no LAD
Lungs: occ rhonchi with diffuse wheezing, poor resp effort
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: distended, + fluid wave, mildly ttp in epigastrum
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: No asterixis
Pertinent Results:
ADMISSION LABS
___ 10:44PM BLOOD WBC-9.1# RBC-4.63 Hgb-13.1 Hct-41.6
MCV-90 MCH-28.3 MCHC-31.6 RDW-16.8* Plt ___
___ 10:44PM BLOOD Neuts-69 Bands-7* Lymphs-14* Monos-7
Eos-0 Baso-0 Atyps-3* ___ Myelos-0
___ 06:40AM BLOOD ___ PTT-33.2 ___
___ 10:44PM BLOOD Glucose-135* UreaN-20 Creat-0.7 Na-129*
K-4.9 Cl-97 HCO3-20* AnGap-17
___ 10:44PM BLOOD ALT-90* AST-352* CK(CPK)-101 AlkPhos-251*
TotBili-6.3* DirBili-4.3* IndBili-2.0
___ 06:40AM BLOOD Lipase-10
___ 10:44PM BLOOD CK-MB-3 cTropnT-<0.01
___ 10:44PM BLOOD Albumin-2.9* Calcium-8.6 Phos-3.3 Mg-2.0
DISCHARGE LABS
___ 08:03AM BLOOD D-Dimer-2407*
___ 06:20AM BLOOD WBC-9.2 RBC-3.93* Hgb-11.4* Hct-34.9*
MCV-89 MCH-28.9 MCHC-32.5 RDW-17.6* Plt ___
___ 06:20AM BLOOD ___
___ 06:20AM BLOOD Glucose-94 UreaN-25* Creat-0.6 Na-131*
K-4.7 Cl-98 HCO3-20* AnGap-18
___ 06:20AM BLOOD ALT-67* AST-294* AlkPhos-157*
TotBili-6.7*
___:20AM BLOOD Calcium-9.3 Phos-2.4* Mg-2.6
LABS PENDING AT DISCHARGE
VRE swab
MICRO DATA
___ 12:32 am PERITONEAL FLUID
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
IMAGING
___ chest xray
the right hemidiaphragm is mildly elevated. There is volume
loss at both
bases. Heart size is normal. The aorta is slightly calcified.
There is mild pulmonary vascular redistribution. Old rib
fractures are noted on the right. There is hazy increased
opacity in the right lung which could be due to volume loss or
infiltrate. Is increased opacity at the left CP angle could
represent metastatic disease or small infiltrate or effusion.
The known metastatic disease with multiple lung nodules are
better visualized on the prior CT.
Brief Hospital Course:
___ with HTN and newly diagnosed HCV cirrhosis and metastatic
HCC who presents with poorly controlled abd pain and
nausea/vomiting.
# Metastatic Stage IV HCC, HCV cirrhosis: Pt with ongoing N/V
likely related to her metastatic HCC. Diagnostic paracentesis
negative for SBP. Family meeting was held in conjunction with
Palliative care service with plan to transition to home hospice
and focus on comfort care measures only. Prognosis very poor and
given the rapidity of her decline, life expectancy of weeks to
months was relayed to the family who supported patient's wish to
return home as soon as possible. Pt was made DNR/DNI. There was
no evidence of acute process and it was felt that her symptoms
are secondary to her end stage underlying malignancy. She
responded well to low dose oral dilaudid (standing) for pain.
She received compazine and reglan for antiemetics with good
control. She exhibited poor appetite and the family was
encouraged to focus on comfort eating - small bites, frequently
throughout the day and de-emphasized focus on nutrition. No
indication for percutaneous gastric or jejunal feeding tube
given her ascites. Family deferred nasogastric ___ given her
current goals of care and ongoing nausea. Her current bilirubin
level would exclude any palliative chemotherapy. Further w/u of
her elevated bilirubin with repeat CT scan to assess for biliary
obstruction and possible percutaneous drain placement were
declined by the patient and her family.
# Hypoxia- patient with new O2 requirement in the setting of
mild tachycardia. She is wheezy on exam. most likely related to
high degree of malignant pulmonary infiltrate. She was treated
with albuterol nebulizer treatments with plan for treatment of
any SOB or air hunger with opioids.
# Hyponatremia: Na 129 at admission, largely unchanged from 131
at recent admission. Na improved with IVF last admission. Most
likely hypovolemic hyponatremia ___ poor po intake. Improved
with colloid administration consistent with hypovolemia.
# HCV Cirrhosis with metastatic HCC: LFTs at recent baseline,
bili elevated compared to prior. Not anticoagulated for portal
vein thrombosis as it is not clear if this is tumor or clot.
Given short life expectancy and risk of bleeding, will continue
to hold anticoagulation.
# CODE: DNR/DNI, comfort measures only
# CONTACT: ___ (husband) ___
+
=
=
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================================================================
Transitional issues
- dc home with hospice
- Pain control with oral dilaudid, decadron. Antiemetics with
compazine, reglan.
Medications on Admission:
1. Docusate Sodium 100 mg PO BID
2. Omeprazole 20 mg PO DAILY
3. Ondansetron 8 mg PO TID
4. Senna 1 TAB PO BID
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
please do not drive when taking this medication, it will make
you sleepy
6. Bisacodyl 10 mg PO DAILY:PRN constipation
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY:PRN constipation
RX *bisacodyl [Dulcolax] 5 mg 2 tablet,delayed release
(___) by mouth daily Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily Disp #*30 Capsule Refills:*0
3. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule,delayed ___ by
mouth daily Disp #*30 Capsule Refills:*0
4. Senna 1 TAB PO BID
RX *sennosides [___] 8.6 mg 1 tab by mouth twice daily
Disp #*30 Tablet Refills:*0
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
6. Dexamethasone 2 mg PO Q12H
RX *dexamethasone 2 mg 1 tablet(s) by mouth twice daily Disp
#*30 Tablet Refills:*0
7. Guaifenesin ER 600 mg PO Q12H:PRN cough, congestion
RX *guaifenesin 600 mg 1 tablet extended release(s) by mouth
twice daily Disp #*30 Tablet Refills:*0
8. HYDROmorphone (Dilaudid) 0.5 mg PO Q4H
RX *hydromorphone [Dilaudid] 1 mg/mL 0.5 (One half) ml by mouth
q4 Disp ___ Milliliter Refills:*0
9. Metoclopramide 5 mg PO TID
RX *metoclopramide HCl 5 mg 1 tablet by mouth three times daily
Disp #*30 Tablet Refills:*0
10. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 17 grams by
mouth daily Disp #*1 Bottle Refills:*0
11. Prochlorperazine 10 mg PO Q6H:PRN nausea
RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth every 6
hours Disp #*30 Tablet Refills:*0
12. Prochlorperazine 25 mg PR Q12H:PRN nausea
RX *prochlorperazine 25 mg 1 Suppository(s) rectally twice daily
Disp #*30 Suppository Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Metastatic/Stage IV HCC
HCV cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
It was a pleasure taking care of you at ___. You were admitted
with abdominal pain, nausea, and vomiting that are most likely
related to your cancer. This cancer is called hepatocellular
carcinoma and is widely spread. As a result, we focused on
prioritizing your comfort and coming up with a regimen to treat
your symptoms that will hopefully allow you be at home.
Palliative care service was consulted and we have come up with
the following plan for your pain and nausea.
For pain: oral dilaudid
For nausea: compazine suppositories/tablets, reglan tablets,
decadron
Please see the appointments below.
Followup Instructions:
___
|
10250525-DS-8 | 10,250,525 | 22,937,535 | DS | 8 | 2198-10-02 00:00:00 | 2198-10-03 06:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
adhesive / dobutamine
Attending: ___.
Chief Complaint:
Presyncope, chest pressure
Major Surgical or Invasive Procedure:
___ Left Heart Catheterization
History of Present Illness:
___ with diabetes, PAF on Coumadin, and abnormal stress test
yesterday presents after a fall.
Patient underwent dobutamine stress echo yesterday, which showed
inducible VT. She was monitored after the procedure and felt to
be safe for discharge home. She drove herself home and while
walking down the stairs into her building began to feel very
week, as if she couldn't keep her legs from giving way. No
dizziness, lightheadedness. Associated with sweats, nausea, and
mild chest pressure. Patient fell to the ground and hit her
right knee. She continues to feel unwell.
In the ED, initial VS: 96.0 60 120/70 18 97%. Labs notable for
troponin 0.40, creatinine 1.2. Head CT negative for
intracranial process. The patient was given a full strength
aspirin and started on a heparin drip. For knee pain, she
underwent a knee X-ray that showed no evidence of fracture.
Currently, patient reports ongoing pain in her right knee. No
chest pressure or weakness currently.
Past Medical History:
Cardiovascular Issues:
1. Hypertension: lisinopril.
2. Diabetes mellitus (___): HbA1c 6.8 in ___.
3. Dyslipidemia: Prava 10mg, ___: TC140/TG171/H45/L61
4. Non-obstructive CAD: ___, serial 40-50% LAD, RCA MLI.
5. Family history premature CAD: father deceased from an MI.
6. PAF: Intolerant to dronedarone, failed sotalol. On coumadin.
7. Morbid obesity: BMI 45.5
8. Varicose veins
Other Relevant Medical Issues:
-Right-sided breast cancer ___, lumpectomy, XRT, on Arimidex.
-Depression.
-OSA: BiPAP.
-Prior tobacco use.
-Ocular myasthenia.
Social History:
___
Family History:
Two sisters also had breast cancer. One sister with a. fib. One
sister and brother died of heart disease (both s/p CABG). One
sister with ovarian cancer.
Physical Exam:
On admission:
VS - 98.6 134/40 58 20 95 RA
GEN - Morbidly obese woman lying in bed, oriented, no acute
distress
HEENT - NCAT, MMM, EOMI, sclera anicteric, OC/OP clear
NECK - supple, no JVD appreciated (exam limited by habitus), no
LAD
PULM - CTAB, no w/r/r
CV - Distant, RRR, S1/S2, no m/r/g
ABD - soft, NT, ecchymoses at site of insulin injection,
normoactive bowel sounds, no guarding or rebound
EXT - WWP, 2+ pulses palpable bilaterally, + venous stasis
changes, R knee is tender to palpation anteriorly and
posteriorly in a diffuse/non-focal pattern. Able to range knee
with pain. No significant effusion.
NEURO - CN II-XII intact
On discharge:
VS: 99.3/100.5 (8PM) 52 (40s-50s) 123/46 (100s-120s/30s-40s) 18
96%RA
Weight: 113.8 kg -> 112.9
I/O 8hr: 200/400
I/O 24hr: 756/960
Tele: Sinus bradycardia
GENERAL: Obese woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: MMM, EOMI
NECK: JVP difficult to assess given habitus.
CARDIAC: RRR, no m/r/g.
LUNGS: CTAB.
ABDOMEN: Obese, soft, NTND.
EXTREMITIES: No c/c/e. Tenderness to palpation of right knee
joint, and decreased range of motion limited by pain. Negative
anterior drawer test. Positive McMurray test with varus stress.
SKIN: No stasis dermatitis, ulcers, or scars.
PULSES: 2+ DP pulses bilaterally
Pertinent Results:
ADMISSION LABS
___ 12:14PM BLOOD WBC-8.8# RBC-3.91* Hgb-12.7 Hct-37.5
MCV-96 MCH-32.4* MCHC-33.8 RDW-13.4 Plt ___
___ 12:14PM BLOOD Neuts-72.9* Lymphs-17.1* Monos-8.7
Eos-0.6 Baso-0.6
___ 12:14PM BLOOD ___ PTT-37.8* ___
___ 12:14PM BLOOD Glucose-160* UreaN-23* Creat-1.2* Na-136
K-4.9 Cl-101 HCO3-19* AnGap-21*
___ 07:35AM BLOOD Calcium-8.9 Phos-3.7 Mg-1.7
DISCHARGE LABS
___ 06:10AM BLOOD WBC-6.3 RBC-3.34* Hgb-10.6* Hct-32.2*
MCV-96 MCH-31.8 MCHC-33.0 RDW-13.6 Plt ___
___ 02:43AM BLOOD ___ PTT-57.6* ___
___ 06:55AM BLOOD UreaN-19 Creat-1.1 Na-140 K-4.5 Cl-105
___ 06:55AM BLOOD CK-MB-3 cTropnT-0.08*
CARDIAC ENZYMES
___ 12:14PM BLOOD CK-MB-7
___ 12:14PM BLOOD cTropnT-0.40*
___ 06:15PM BLOOD cTropnT-0.28*
___ 07:35AM BLOOD CK-MB-5 cTropnT-0.19*
___ 04:30PM BLOOD cTropnT-0.19*
STUDIES and IMAGING
___ R Knee X-Ray:
No evidence of acute fracture or dislocation.
___ CT Head:
FINDINGS: There is no evidence of acute intracranial
hemorrhage, edema, mass, mass effect, or vascular territorial
infarction. The ventricles and sulci are mildly prominent,
consistent with age-related involutional changes. There are
extensive periventricular and subcortical white matter
hypodensities, suggestive of chronic small vessel ischemic
disease. Calcification of the bilateral cavernous internal
carotid arteries noted. There is no fracture. The visualized
paranasal sinuses, mastoid air cells, and middle ear cavities
are clear.
IMPRESSION:
No acute intracranial process.
___ C. cath
LMCA: No angiographic CAD
LAD: Diffuse disease; Proximal and mid serial 60% stenosis with
focal eccentric 70% stenosis. The lesion involves the origin of
a moderate D1 that is not significantly diseased.
LCX: No significant stenosis
RCA: Diffuse distal disease with up to 60% stenosis
___ C. cath
Findings
ESTIMATED blood loss: <50 cc
Hemodynamics (see above):
Coronary angiography: right dominant
LMCA: No angiographically apparent CAD
LAD: Widely patent stent. Unchanged jailed diagonal with
approximately 50% origin stenosis.
LCX: No angiographically apparent CAD.
RCA: Diffuse disease with serial 50-70% lesions in the mid and
distal segment.
Interventional details
Crossed with the Pressure wire. The resting Pd/Pa was 0.84 and
this decreased to 0.61 with maximal hyperemia indicating a
hemodynamically significant lesion. Predilated with a 2.0 mm
balloon. Attempted to deliver stents over the Pressure wire but
unable. Further dilation with a 2.5 mm balloon. Changed for
Prowater wire. Deployed a 2.5 x 38 mm Promus Element stent.
Deployed a more proximal overlapping 2.5 x 38 mm Promus Element
stent. The stents were postdilated with a 2.5 mm balloon.
Final angiography revealed normal flow, no dissection and 0%
residual stenosis.
Brief Hospital Course:
Ms. ___ is a ___ woman with DM II and recent
(___) abnormal stress test who presents with weakness, chest
pressure, and fall. She was found to have an NSTEMI.
ACTIVE ISSUES
# NSTEMI: Patient presented after fall in setting of presyncope,
weakness, chest pressure, diaphoresis, and nausea and had
troponin elevation, meeting criteria for NSTEMI. Her troponin
peaked at 0.40. She had an abnormal dobutamine stress echo on
day prior to admission with VT induced by exercise. Her
admission EKG was notable for a newly prolonged QTc. She was
started on a heparin gtt, full-strength aspirin, and plavix
loaded. Her statin was changed to atorvastatin 80 mg daily. She
was continued on lisinopril 2.5 mg daily. On ___, she
underwent left heart and is s/p DES to LAD with post-procedure
tropin bump. She continued to have exertional chest pain,
nausea, and hypotension. Repeat cath on ___ revealed diffuse
disease of RCA with 50-70% stenosis. This lesion crossed with
the pressure wire. The resting Pd/Pa was 0.84 and this
decreased to 0.61 with maximal hyperemia indicating a
hemodynamically significant lesion so ___ 2 were placed in the
RCA. She remained chest pain and nausea free after this
intervention.
# Prolonged QTc: Most likely due to ischemia. Patient was
continued on sotolol for atrial fibrillation.
# VT: Likely induced by dobutamine during stress echo. Ischemia
also possible, though less likely. Dobutamine was listed as an
allergy.
# Knee pain: Patient fell prior to presentation onto right
knee. She had no evidence of fracture on x-ray. She received
Tylenol and oxycodone as needed for pain control.
# Atrial Fibrillation: Patient has a history of paroxysmal
atrial fibrillation. Her coumadin was held upon admission
because she was started on a heparin gtt for NSTEMI as above.
She was intermittently in a. fib and in sinus bradycardia. She
was continued on sotolol and warfarin was restarted at her home
dose without a bridge after second cardiac catheterization
(above). Of note, patient did not receive coumadin on the day of
discharge (___).
CHRONIC ISSUES
--------------------
# IDDM: Patient was continued on her home regimen of humalog
75-25. Her metformin was held for catheterization and restarted
on discharge.
# Depression/Anxiety: Continued Sertraline/Xanax.
# GERD: Continued omeprazole.
# History of Breast Cancer: Continued tamoxifen.
# OSA: Continued nasal bipap.
# Transitional issues:
- Code: Full (confirmed)
- Patient did not receive warfarin on the day of discharge to
rehab, so this should be given on arrival.
- Patient scheduled for orthopedics follow up for further
evaluation of knee pain. Further imaging can be considered on
follow up.
- Dobutamine listed as allergy as this resulted in VT during
echo.
- Patient continued on aspirin 81 mg, and plavix given ___ 3
(above) and should continue coumadin for afib.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.5 mg PO BID:PRN anxiety
2. Humalog ___ 26 Units Breakfast
Humalog ___ 26 Units Dinner
3. Lisinopril 2.5 mg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Omeprazole 20 mg PO DAILY
6. Pravastatin 10 mg PO DAILY
7. Sertraline 200 mg PO DAILY
8. Sotalol 120 mg PO BID
9. Tamoxifen Citrate 20 mg PO DAILY
10. Warfarin 7.5 mg PO 2X/WEEK (___)
11. Warfarin 10 mg PO 5X/WEEK (___)
12. Ascorbic Acid ___ mg PO DAILY
13. Aspirin 81 mg PO DAILY
14. Calcium Carbonate 1000 mg PO DAILY
15. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. ALPRAZolam 0.5 mg PO BID:PRN anxiety
2. Ascorbic Acid ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Calcium Carbonate 1000 mg PO DAILY
5. Humalog ___ 26 Units Breakfast
Humalog ___ 26 Units Dinner
6. Lisinopril 2.5 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Sertraline 200 mg PO DAILY
9. Sotalol 120 mg PO BID
10. Tamoxifen Citrate 20 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Warfarin 7.5 mg PO 2X/WEEK (___)
13. Warfarin 10 mg PO 5X/WEEK (___)
14. Atorvastatin 80 mg PO DAILY
15. Clopidogrel 75 mg PO DAILY
16. Nitroglycerin SL 0.3 mg SL ASDIR nausea, chest pressure, or
chest pain
17. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours Disp
#*30 Tablet Refills:*0
RX *oxycodone 5 mg 1 tablet(s) by mouth every ___ hours Disp
#*30 Tablet Refills:*0
18. MetFORMIN (Glucophage) 500 mg PO BID
19. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
- Acute coronary syndrome (NSTEMI with DES to LAD)
- Knee trauma
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 during your admission to the
___. You came in to the
hospital because of weakness, chest pressure and a fall, and you
were found to have an a small heart attack. You had a cardiac
catheterization, which showed two blood vessels in your heart
that were partially blocked. A stent was placed in one of these
vessels to help keep it open.
Followup Instructions:
___
|
10250672-DS-23 | 10,250,672 | 21,069,238 | DS | 23 | 2163-03-30 00:00:00 | 2163-03-30 17:26:00 |
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:
Mr. ___ is a pleasant ___ Pt w/ stage III gastric cancer,
s/p total gastrectomy, partial esophagectomy, and distal
pancreatectomy ___, progressed on ECX, currently in disease
regression on investigational immunotherapy who p/w fevers x 3
days as high as 103.7F.
Yesterday went to see Oncologist who noted fever 101 and did not
give infusion. Labs had been wnl at that time. When he went back
home he had shaking chills/rigors and temp was 103.7. He took
some Advil and it decreased to 101. This AM has not had fevers.
Feels generally fatigued but near baseline and he denies any
focal infectious symptoms. Has some nausea and diarrhea which is
his baseline.
In ED, afebrile at 97.8F. BP 96/63. He received 2gm Cefepime,
1gm
Azithromycin, 1L NS, 1gm Vancomycin, 750 Atovaquone.
On arrival to OMED, pt states that he overall feels well.
Yesterday mowed the lawn. The only new symptom he is having is
that today he feels like there is something that just started to
develop in his mouth, but denied any oral pain, dysphagia,
odynophagia. He has a h/o thrush in past but states this feels
"much worse." He denied any sick contacts. No changes in his
bowel habits. He has not been camping but traveled to ___
where he was near bushes and denied any recent tick exposure.
REVIEW OF SYSTEMS:
10 point ROS reviewed in detail and negative except for what is
mentioned above in HPI
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
___ initially noted an increase in
abdominal gas in ___. This persisted, and he
eventually
presented to his primary care physician in ___.
Symptoms persisted and were then associated with a 10-pound
weight loss, prompting referral to Gastroenterology for
endoscopic evaluation. He underwent endoscopy, which identified
a poorly differentiated gastric cancer with signet ring cell
features. He then underwent CT, which showed diffuse thickening
of the gastric antrum and extensive adjacent lymphadenopathy.
He
initiated neoadjuvant chemotherapy with epirubicin, cisplatin
and
capecitabine (ECX) ___. Following cycle #2, he was
hospitalized with diarrhea and fever. With cycle #3, he
transitioned to epirubicin, cisplatin and fluorouracil (ECF).
His course was complicated by palmar plantar erythrodysesthesia.
He completed six cycles as of ___, and on ___ was taken to the operating room where he underwent total
gastrectomy, partial esophagectomy, and distal pancreatectomy.
Pathology revealed a
6.8 cm diffuse type adenocarcinoma with ___ lymph nodes
involved. Margins were negative. No lymphovascular or
perineural invasion was seen. He was diagnosed with pT4bN3Mx
stage IIIC gastric adenocarcinoma. Surveillance CT ___
showed diffuse mediastinal and intraabdominal adenopathy highly
concerning for cancer recurrence, and biopsy confirmed this
___. Mr. ___ consent for participation in clinical
trial ___
PAST MEDICAL HISTORY (per OMR):
1. Nephrolithiasis.
2. Gastric adenocarcinoma as above.
Social History:
___
Family History:
Notable for a sister who passed away secondary
to lung cancer, father with history of prostate cancer. The
patient has one healthy daughter. His mother had a stroke in
her
___. She also has a history of atrial fibrillation.
Physical Exam:
DISCHARGE PHYSICAL EXAM:
PHYSICAL EXAM:
VITAL SIGNS: 98.7 ___ 16 99%RA
General: NAD, Resting in bed comfortably
HEENT: MMM, does have e/o OP thrush however on tongue which is
significant resolved compared to prior admit, and no mucositis
or blistering lesions
CV: RR, NL S1S2 no S3S4 No MRG
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, soft, NTND, no palpable masses or HSM
LIMBS: WWP, no ___ but he notes b/l hand edema that is chronic
and unchanged, no tremors
SKIN: No rashes on the extremities, port accessed w/o overlying
erythema
NEURO: ___ strength throughout, no asterixis
Pertinent Results:
___ 08:30AM BLOOD WBC-9.2 RBC-3.85* Hgb-8.9* Hct-28.8*
MCV-75* MCH-23.1* MCHC-30.9* RDW-19.1* RDWSD-51.1* Plt ___
___ 05:32AM BLOOD WBC-7.8 RBC-3.85* Hgb-8.7* Hct-28.7*
MCV-75* MCH-22.6* MCHC-30.3* RDW-19.5* RDWSD-51.8* Plt ___
___ 08:30AM BLOOD Neuts-68.0 Lymphs-15.1* Monos-12.6
Eos-3.5 Baso-0.5 Im ___ AbsNeut-6.25* AbsLymp-1.39
AbsMono-1.16* AbsEos-0.32 AbsBaso-0.05
___ 02:35PM BLOOD Neuts-83.4* Lymphs-8.1* Monos-6.9
Eos-0.9* Baso-0.2 Im ___ AbsNeut-11.28*# AbsLymp-1.09*
AbsMono-0.93* AbsEos-0.12 AbsBaso-0.03
___ 05:32AM BLOOD Neuts-43.7 ___ Monos-11.3 Eos-6.5
Baso-1.7* Im ___ AbsNeut-3.41# AbsLymp-2.85 AbsMono-0.88*
AbsEos-0.51 AbsBaso-0.13*
___ 05:32AM BLOOD ___
___ 05:32AM BLOOD UreaN-8 Creat-0.7 Na-140 K-4.3 Cl-104
HCO3-26 AnGap-14
___ 08:30AM BLOOD ALT-27 AST-44* AlkPhos-115 TotBili-0.3
___ 02:35PM BLOOD ALT-25 AST-38 AlkPhos-153* TotBili-0.2
___ 05:32AM BLOOD ALT-20 AST-27 AlkPhos-136* TotBili-<0.2
___ 02:48PM BLOOD Lactate-1.5
___ 02:35PM BLOOD CRP-160.6*
CXR
CXR ___: Right chest wall port is seen in stable position.
There is right-sided pleural thickening versus atelectasis/scar
with blunting of the right lateral and posterior costophrenic
angles similar to recent CT scan. Linear left midlung opacity is
most likely atelectasis. There is no new consolidation. The
cardiomediastinal silhouette is within normal limits. Known
mediastinal adenopathy is not clearly delineated. No acute
osseous abnormalities.
Brief Hospital Course:
___ Pt w/ stage III gastric cancer, s/p total gastrectomy,
partial esophagectomy, and distal pancreatectomy ___,
progressed on ECX, currently in disease regression on
investigational immunotherapy who p/w fevers x 3 days as high as
103.7F w/o any localizing symptoms.
# High Grade Fevers - no documented fever in ED or during
hospital course, however presentation concerning given degree of
reported fever, though pt felt like his "normal self" other than
night sweats. Complete ROS was unrevealing for localizing
process and physical exam only notable for some mild thrush on
the tongue. he was not neutropenic, and remained hemodynamically
stable. CXR and urine culture unrevealing. presented w/ a mild
leukocytosis to 13 but this downtrended. While he was given
antibiotics in the ED (vanc/cefepime/azithro), these were not
continued at all on the floor. His port was without erythema or
pain or drainage. He had no nasal congestion or rhinorrhea or
sore throat or cough, nothing to suggest respiratory infection.
While his alk phos was found to be newly mildly elevated at 136,
all other liver function tests were WNL and reassuring and he
had no RUQ pain.
RUQ ultrasound for completeness showed.....
He had no diarrhea or dysuria.
He has no implanted hardware. While he was at the ___ for a
wedding a few weeks ago he never noted a tick bite or rash and
has no other symptoms that would be consistent with Lyme
disease. He had no leukopenia or signs of hemolysis or worsening
anemia or significant LFT abnormalities which might suggest
other tickborne illness. While his inflammatory markers were
quite elevated which would ordinarily be suggestive for
bacterial infection, in his case he is receiving two
immunostimulators as an outpatient and ultimately it was felt
that the fever as well as the elevated inflammatory markers were
consistent with significant immune response due to these
immunomodulators. Ultimately fevers attributed to self-resolving
viral process versus inflammatory response from
immunostimulating drugs (on clinical trial), as there was no
evidence of bacterial infection. While I did urge him to remain
in the hospital until we had at least 48 hours of negative
culture data, his strong preference was to be able to go home on
___ rather than wait until Am of ___ so he left the hospital
with very close to 48 hrs of culture data and understand that
there are risks that antibiotics in the ED masked an infection,
however his physical exam, labs, and clinical picture has been
so benign other than fever it was reasonable to discharge him.
He knows to call if he has any new symptoms or recurrence of
fever.
# OP thrush - nystatin suspension was very effective. Denies
odynophagia/dysphagia and had normal EGD on ___ (note the
indication was dysphagia, but pt denies having had dysphagia)
# Gastric Ca - Followed by Dr ___ Dr ___ currently
on trial drug (2 immunostimulants, last gioven ___.
Reassuringly disease per recent CT torso ___ notes decreasing
adenopathy and it was felt he is having good response to trial
drugs. He has f/u ___ for next infusion.
# Chronic malignancy related pain - continued home regimen with
good control on oxycontin and oxycodone prn
# Mildly elevated alk phos - mild elevation but new. GGT had
been sent on admission and was also mildly elevated. Recent abd
CT with very small liver lesion, could be ___ metastatic
disease, RUQ u/s was reassuring and nothing to suggest
obstruction or cholangitis at this point. other liver function
tests reassuring. Outpt oncologist to trend LFTs this week.
# Anemia - likely chemotherapy induced, no evidence of bleeding.
In ___ ferritin was only in 30 range, but was upt o 129 at
this point likely consistent with immune response from
immunostimulation therapy. Smear reassuring, low tbili argued
against any hemolysis, and Hct remained stable. Likely anemia of
inflammatory block.
Greater than 30 minutes were spent in planning and execution of
this discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
2. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
3. Cyanocobalamin 1000 mcg IM/SC MONTHLY
Discharge Disposition:
Home
Discharge Diagnosis:
Fever
Gastric cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with fever. We didn't find any signs of
bacterial infection so this was likely due to a virus or due to
significant immune stimulation by the trial drugs you are
getting for your cancer (these work by stimulating the immune
system, so that would make sense).
If you have any more fevers or new symptoms please let your
oncologist know right away.
Followup Instructions:
___
|
10250801-DS-11 | 10,250,801 | 22,161,116 | DS | 11 | 2112-11-19 00:00:00 | 2112-11-22 14:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with hx MS, GERD, constipation, gastroparesis, duodenal
ulcer and multiple UTIs presenting from PCP after found to have
acute lobar nephronia and GNR in urine. Pt endorses chronic
diffuse abdominal pain and nausea thought to be secondary to her
gastroparesis and gallbladder dyskinesia. She underwent a
laparoscopic cholecystectomy on ___. She was initially
recovering well until 2 weeks ago she began experiencing RLQ
pain. Several days ago she also developed R sided flank pain,
fevers to 104, dysuria, increased urinary frequency and
worsening nausea/emesis. She was seen by Dr. ___ in GI three
days ago who recommended a CT abdomen/pelvix in light of her
recent surgery. She also saw her PCP two days ago who prescribed
Cipro for a UTI. She experienced little improvement after taking
antibiotics. Her CT abdomen showed nephronia and she was
referred to the ED.
In the ED, initial vitals were: 97.3 66 111/64 18 98%. She was
given Ceftriaxone 1g and 2L NS bolus. Labs were signficant for
Lactate of 3, Cr. 3.2. She was admitted to medicine for
management of her pyelonephritis and ___.
On the floor, VS on arrival were 97.5, 103/55, 54, 18, 97% on
RA. She states she continues to have diffuse abominal pain and R
sided flank pain.
Past Medical History:
Multiple sclerosis.
Gastroparesis.
GERD.
Duodenal ulcer disease.
Colon adenoma in ___ with recommendation to repeat in
___ years.
Diarrhea and fecal incontinence thought to be secondary to
dysmotility issues and possibly with bacterial overgrowth
syndrome.
hypothyroidism.
Chronic cough, possibly due to micro aspiration.
Chronic postnasal drip with recurrent sinusitis.
Obesity.
Urinary incontinence and recurrent UTIs.
Social History:
___
Family History:
Father's side of family with MS
Physical Exam:
ADMIT PHYSICAL EXAM:
Vitals: 97.5, 103/55, 54, 18, 97% on RA.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: well healing laproscopic scars, + BS, diffuse TTP
especially in RLQ, no guarding, R CVAT
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: ___ strength upper/lower extremities, decreased senation
below knees bilaterally, gait intact
DISCHARGE PHYSICAL EXAM:
Vitals: afebrile since admission. 98.8 58 104/60 16 96%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: no guarding or flinching when palpating abdomen; only
states in flat voice that it is very painful. well healing
laproscopic scars, + BS, no guarding, R CVAT
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: ___ strength upper/lower extremities, gait intact
Back: no flinching, guarding when palpating entire back but
states that it is very painful to palpation diffusely. No pain
when pressing with stethoscope along CVA.
Pertinent Results:
Admit Labs:
___ 04:20PM BLOOD WBC-7.5 RBC-3.91* Hgb-10.8* Hct-33.4*
MCV-85 MCH-27.6 MCHC-32.4 RDW-13.5 Plt ___
___ 04:20PM BLOOD Neuts-49.0* ___ Monos-8.9
Eos-9.8* Baso-0.7
___ 04:20PM BLOOD Glucose-95 UreaN-40* Creat-3.2*# Na-134
K-3.7 Cl-98 HCO3-20* AnGap-20
___ 07:45AM BLOOD Calcium-8.3* Phos-4.3# Mg-1.8
___ 05:58PM BLOOD Lactate-3.0*
DISCHARGE LABS:
___ 07:50AM BLOOD WBC-7.0 RBC-3.53* Hgb-9.9* Hct-30.9*
MCV-88 MCH-28.0 MCHC-32.0 RDW-14.5 Plt ___
___ 07:50AM BLOOD Glucose-93 UreaN-23* Creat-1.6* Na-141
K-4.7 Cl-101 HCO3-29 AnGap-16
___ 12:21AM BLOOD Lactate-0.8
___ 07:50AM BLOOD Calcium-9.3 Phos-3.9 Mg-1.9
PERTINENT IMAGING
CTU
1. Ill-defined hypoenhancing area within the lower pole of the
right kidney
with extension to the posterior and superior aspect is
concerning for acute
lobar nephronia. Correlation with UA and clinical symptoms is
recommended
2. 2mm nonobstructing left renal stone. No hydronephrosis.
RENAL US
1. Mild fullness of the right renal collecting system without
hydronephrosis
appearing similar to the prior CT examination. Corticomedullary
differentiation is preserved bilaterally and there is no
evidence of renal abscess. Please note that ultrasound is
limited for evaluation of nephronia or pyelonephritis.
2. 1 cm right lower pole echogenic renal lesion previously
characterized as angiomyolipoma on MR.
___. The 2 mm left renal stone as seen on CT is not visualized on
this exam.
Brief Hospital Course:
___ with hx MS, GERD, gastroparesis, duodenal ulcer and multiple
UTIs presenting with pan-sensitive Citrobacter pylenephritis
with CT concerning for acute lobar nephronia, as well as ___.
#Acute Pyelonephritis with nephronia: Lobar nephronia found on
CT and follow up with renal US did not show a drainable abscess.
Treated initially with IV ceftriaxone when urine culture grew
out pansensitive citrobacter. Quickly transitioned to IV and
then PO ciprofloxacin when PCP (who is also ID doctor)
recommended switch due to ___ gen cephalosprorins inducing
resistance in citrobacter. A repeat UA and culture done during
the admission showed a clean UA and no growth in the UCx. She
was given an Rx for cipofloxacin for a total of ___nding ___. She will follow up with her PCP ___ ___.
#Acute renal failure: Cr 3.2 on admit from baseline of 1.
Prerenal in setting of decreased PO intake. Resolved mostly with
IVF. 1.6 on discharge. Urine sediment clear and UCx NG on repeat
day before discharge. Fena >1%. Will need to reevaluate after
pyelonephritis fully resolved before further workup is planned.
#Pain: ___ hospital course was complicated by multiple
pain complaints which were migratory and without identified
underlying cause. She had right back pain (side of
pyelonephritis) that spread to left side and severe burning on
urination not controlled with pyridium even after a UA showed no
residual pyuria. She was treated with oxycodone which did help
some, but her pain was not fully controlled at discharge.
Transitional Issues:
-3 week course of cipro 500mg PO q12 ending ___
-f/u with PCP ___ ___
-patient is taking domperidone (non-FDA approved drug for
gastroparesis with black box warning for Qtc prolongation). We
have asked her to stop taking it for the next 3 weeks while she
is on ciprofloxacin
-stool O&P sent at patient's request (states that her ID doctor
at OS___ requested it)
-Cr not at baseline on discharge. Should have repeat labs to
ensure cipro dosing appropriate.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Baclofen 20 mg PO QID spasticity
2. Celecoxib 200 mg oral BID
3. ClonazePAM 0.5 mg PO TID
4. Duloxetine 60 mg PO QHS
5. esomeprazole magnesium 40 mg oral daily
6. Gabapentin 600 mg PO TID
7. Copaxone (glatiramer) 20 mg/mL subcutaneous QHS
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. HydrOXYzine 50 mg PO QID
10. Ondansetron 4 mg PO Q8H:PRN nausea
11. TraZODone 200 mg PO HS:PRN sleep
12. Ursodiol 300 mg PO BID
13. Ranitidine 300 mg PO LUNCH
14. Ranitidine 300 mg PO DINNER
15. Lyrica (pregabalin) 25 mg oral QHS
16. Belviq (lorcaserin) 10 mg oral BID
17. Benzonatate 100 mg PO TID:PRN cough
18. Ipratropium Bromide Neb 1 NEB IH Q6H wheezing
19. Clindamycin 1 Appl TP DAILY
Discharge Medications:
1. Baclofen 20 mg PO QID spasticity
2. Benzonatate 100 mg PO TID
3. Clindamycin 1 Appl TP DAILY
4. ClonazePAM 0.5 mg PO TID
5. Copaxone (glatiramer) 20 mg/mL subcutaneous QHS
6. Duloxetine 60 mg PO DAILY
7. Gabapentin 600 mg PO TID
8. HydrOXYzine 50 mg PO QID
9. Ondansetron 4 mg PO Q8H
10. Ranitidine 150 mg PO HS
11. Ursodiol 300 mg PO BID
12. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every 12 hours
Disp #*30 Tablet Refills:*0
13. Belviq (lorcaserin) 10 mg oral BID
14. Celecoxib 200 mg ORAL BID
15. esomeprazole magnesium 40 mg oral daily
16. Lyrica (pregabalin) 25 mg oral QHS
17. MetFORMIN (Glucophage) 1000 mg PO BID
18. Phenazopyridine 100 mg PO TID Duration: 3 Days
RX *phenazopyridine 100 mg 1 tablet(s) by mouth three times
daily Disp #*9 Tablet Refills:*0
19. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
Duration: 10 Days
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
pyelonephritis with nephronia
Acute kidney injury
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 an infection
in your kidney. We treated you by giving you antibiotics and
making sure you did not have an abscess in your kidney. You will
continue to take the antibiotic for a total of 3 weeks. You will
follow up with your PCP ___ ___ and he will make further
decisions about imaging and follow up.
Sincerely,
Your ___ team.
Followup Instructions:
___
|
10251081-DS-17 | 10,251,081 | 29,684,773 | DS | 17 | 2154-08-19 00:00:00 | 2154-08-19 13:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Acute Blood Loss Anemia, Gastric Bleeding
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
HMED Admission Note
Date seen ___, 9:30 am
=============================================================
PCP: ___
CC: coffee-ground emesis
HISTORY OF PRESENT ILLNESS: ___ with pmhx significant for CLL,
hepatic adenocarcinoma, recent admission to MICU with UGIB
presents from rehab with 1 day of coffee ground emesis. He was
recently admitted from ___ with coffee ground emesis and
aspiration, was intubated in MICU for aspiration concern and had
EGD which showed no active source of bleeding. Barium swallow
was remarkable only for likely gastric outlet obstruction. At
discharge his GIB was felt to be due to ___ tears. He
had been feeling well at ___ until yesterday when he
started to have clear emesis which turned to ___ episodes of
coffee ground emesis. In the ED, he reported lightheadedness,
but denies dyspnea, chest pain, abdominal pain/distention.
In the ED, initial VS were ___ 18 96% RA. Labs
notable for Hgb 9.7, WBC 93.7, Na 146, BUN/Cr 34/0.9, lactate
1.9. GI was consulted and recommended IV PPI. CXR revealed
ill-defined bibasilar opacities, left greater than right,
slightly worse from ___, concerning for aspiration given the
clinical history. He received 80 mg IV pantoprazole and zofran
4 mg IV. He received 1L NS.
On arrival to the floor, patient reports nausea and has just had
another episode of coffee-ground emesis. He denies increased
ostomy output, fevers/chills, myalgias, dyspnea or cough, or
abdominal pain. His emesis started yesterday after eating.
After arrival on the west floor, his daughter requested transfer
to the ___. Prior to his transfer, he received
lorazepam for nausea and vomiting. At present, he is sedated,
but when awoken - does not complain of shortness of breath,
cough, palpitations, nausea.
Per the nursing home staff, ___, his nurse for the past two
days - he had 2 days of clear liquid secretions, before the
vomiting. Emesis was not guiaced. He tended to keep a yankauer
suction tube in the back of his mouth, very far back. He was
cleared for a nectar thick with mechanical soft diet. He was
working with ___.
REVIEW OF SYSTEMS:
Positive as above, otherwise briefly reviewed in 8 systems with
his daughter, at the bedside, as he was sedated by the
lorazepam.
Past Medical History:
-- CLL
-- Ulcerative colitis c/b intestinal perforation s/p colectomy
with ileostomy in ___ at ___
-- Aflutter
-- Essential Hypertesion
-- Hyperlipidemia
-- Chronic cough
-- Urinary obstruction
-- Hx Hydrocele
-- Hx undescended testicle
-- Hx colectomy, hx herniorrhaphy, s/p THR
Social History:
___
Family History:
brother is healthy at ___. His parents lived until ___ and ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - T 97.5 102 130/69 HR 100 24 96% 2L
GENERAL: Sedated, does arouse to questions, ill appearing
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, brown exudate over tongue
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Decreased BS at the left base, and relatively coarse
bilaterally. no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly, ostomy over LUQ with
brown output
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact. AAOx3 (with prompting knows the date).
Moves all extremities, full strength in upper and lower
extremities. Toes are downgoing
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Vitals: AVSS
Gen: NAD, lying in bed, very thin, gaunt
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear, NGT noted with some erythema in posterior
pharynx
Cardiovasc: regular, full pulses, no edema
Resp: normal effort, no accessory muscle use, lungs with diffuse
rhonchi.
GI: scaphoid, soft, NT, ND, BS+
MSK: No significant kyphosis. No palpable synovitis.
Skin: No visible rash. No jaundice.
Neuro: AAOx3. No facial droop.
Psych: Eval limited as he is currently sleepy.
GU: No foley.
Pertinent Results:
___ 12:24AM BLOOD WBC-89.8* RBC-2.95* Hgb-8.2* Hct-28.5*
MCV-97 MCH-27.8 MCHC-28.8* RDW-15.3 RDWSD-51.0* Plt ___
LABS:
Na 146 K 3.9 Cl 103 HCO3 33 BUN 31 Cr 0.7 151 AGap=14
Ca: 8.5 Mg: 2.5 P: 3.0
wbc 88.1, hct 29.4, hgb 8.3, plts 421
HCT 33.5 to 28.4 to 29.4.
Baseline around 30
___: 14.9 PTT: 28.1 INR: 1.4
UA Color Dkamb Appear Hazy SpecGr 1.028 pH 6.0 Urobil 2
Bili Neg Leuk Tr Bld Lg Nitr Neg Prot 100 Glu Neg Ket 10
RBC >182 WBC 5 Bact Mod Yeast Rare Epi <1 Other Urine
Counts CastHy: 3
IMAGING:
___ CXR: Ill-defined bibasilar opacities, left greater than
right, slightly worse from ___ concerning for
aspiration given the clinical history.
EKG: Sinus tachycardia @ 115 bpm. RBBB. QTc 501
.
CT abd/pelvis:
IMPRESSION:
1. No bowel obstruction seen.
2. Grossly similar segment V ill-defined lesion compatible with
patient's
known history of hepatic adenocarcinoma.
3. Consolidation in the right lower lobe concerning for
pneumonia.
Atelectasis/collapse of the left lower lobe.
4. Moderate left and small right pleural effusions.
.
EGD:
Impression: Esophageal dilation
Normal mucosa in the stomach
The stomach lumen and pylorus were patent without any evidence
of obstruction.
Normal mucosa in the duodenum
Otherwise normal EGD to third part of the duodenum
Recommendations: No evidence of mechanical obstruction seen.
Pt likely has paraneoplastic dysmotility of the stomach and
esophagus.
Brief Hospital Course:
This is a ___ with a complex PMH including CLL, UC s/p colectomy
with end-ileostomy, HTN, HL, chronic cough, liver adenocarcinoma
likely cholangio, exudative pleural effusion with atypical
cytology, BPH with obstruction (hx false lumen requiring
urology), atrial flutter, who has had now two admissions for N/V
and aspiration pneumonia, with CT showing apparent gastric
outlet obstruction, but with EGD demonstrating only strong
stomach contractions with a "pseudopylorus" appearance on one
EGD.
# Gastric dysmotility with spasm like contractions creating an
apparent pseudo-obstruction: CT scan showed GOO with high grade
obstruction, but EGD was near normal; one prior showed spasm
like contractions by report. The etiology of this is entirely
unclear. GI is perplexed, though they proposed possibility of a
paraneoplastic phenomenon. Does have cancer and has had surgery,
which puts him at risk for peritoneal adhesive process, but
would be difficult to invoke an extrinsic compressive process
like that that was also dynamic and not seen on CT. He was
started on reglan with apparent improvement, as his NG is now
being used for
TFs without apparent residuals. We have not been able to
definitively rule out more distal obstruction (SBFT recommended
at some point in the past) but the tolerance of tube feeds would
argue against this. I had long discussion with his family today
(about 1 hour long), where I discussed all of the above. We
agreed to keep NG tube for now, work on
deconditioning/dysphagia/aspiration, keep reglan, and see how he
does. If he needs G tube for dysphagia/aspiration, or if he has
another bout of "pseudo-obstruction," it seems quite prudent to
proceed with a PEG, likely a G-J tube which would allow some
G-venting and J-feeding.
- Maintain NG tube with TFs for now
- Monitor gastric residuals
- Continue standing reglan
- If he advances from NGT and begins to take PO, he should be on
a very low residue easy to digest diet to prevent possible
recurrent pseudoobstruction
# Dysphagia/aspiration: Per SLP, unable to take PO. This is
likely related to deconditioning, malnutrition, severe illness,
recent intubation.
- Cont NG tube with tube feeds
- Cont nutrition follow-up
- Cont SLP follow-up
- Has ENT follow-up as outpatient
- Continue hibiclens oral care regimen in effort to reduce risk
of aspiration pneumonia
# CLL
# Likely cholangiocarcinoma: Oncology has been involved and has
said that chemotherapy would be offered only if performance
status were to improve. He faces numerous challenges to this.
Has seen pall care previously. I'm worried his chances of
successfully initiating chemotherapy and tolerating it (let
alone it having a meaningful impact) are becoming too small to
outweigh the pain and suffering it would take to get him there.
However, long discussion with him an his family today, and he
would like to do whatever he can to stay alive. He is very sharp
and as long
as this is the case and there is some chance of making it to
chemo he wants to give it a go.
# Hypernatremia
# Hypophosphatemia, hypokalemia: Improved with TF and
intermittent electrolyte/free water repletion. No current
suggestion of refeeding syndrome.
# Ulcerative colitis c/b intestinal perforation s/p colectomy
with ileostomy in ___ at ___. Not on any medications. No change
in ostomy output.
- Cont routine ostomy care
# Acute hypoxic respiratory failure owing to
# Aspiration pneumonia in setting of vomiting: Improved s/p
course of antibiotics. He received 8 days of cefepime which
ended ___. No evidence of recurrent infection at this time.
At time of discharge he has junky cough and plenty of
secretions, slowly improving, likely residua of pneumonia.
- Cont incentive spirometer
- Offer acapella/chest ___ BID
# Pleural effusion: Last admission he had pleural effusion
drained, c/w malignancy/exudate. He has followup with the IP
service for consideration of PleurX catheter, general followup
of pleural space disease.
- F/u as scheduled with Dr ___
# Possible upper GI bleed given coffee ground emesis: Initial
clinical impression was that he most likely had ___
tears in setting of emesis, however EGD was negative. Given
gastric dysmotility issue, he was given BID PPI to lower risk of
future gastric erosion and bleeding. His Hct was stable this
admission.
- Cont PPI BID for now
# Prolonged QTC: At some point in his hospital stay QT was
prolonged. This was
monitored and improved, in spite of reglan therapy.
# PPX: Heparin; PPI; BR standing/PRN
# Disposition: Plan for ___ tomorrow morning.
# Code status: Full code
# CONTACT: Daughter (HCP) ___ ___
>30 minutes spent coordinating discharge from hospital
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glycopyrrolate 1 mg PO TID
2. Heparin 5000 UNIT SC BID
3. Tamsulosin 0.4 mg PO QHS
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H
5. Vitamin D 1000 UNIT PO DAILY
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Acetaminophen 650 mg PO Q6H:PRN pain, fever
8. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing
9. Glycopyrrolate 1 mg PO Q8H:PRN secretions
10. Ondansetron 4 mg PO Q6H:PRN nausea
11. Omeprazole 40 mg PO BID
Discharge Medications:
1. Acetaminophen (Liquid) 325 mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing
3. Tamsulosin 0.4 mg PO QHS
4. Vitamin D 1000 UNIT NG DAILY
5. Cepastat (Phenol) Lozenge 2 LOZ PO Q4H:PRN sore throat
6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
7. Guaifenesin ___ mL NG Q6H:PRN Cough
8. Lansoprazole Oral Disintegrating Tab 30 mg NG BID
9. Metoclopramide 10 mg NG QIDACHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
hematemesis, nausea, vomiting
likely paraneoplastic process causing dysmotility
cholangiocarcinoma
CLL
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted for evaluation of nausea, vomiting, and
bleeding. You were evaluated by the ___ doctors and had ___
endoscopy and CT scan which were unrevealing. Your symptoms are
felt to be related to poor motility related to your cancer. You
were started on reglan to improve the motility of your stomach.
You had difficulty with your swallowing and had to have nothing
to eat or drink for some time. During this time, you had tube
feedings and had a NGT placed. You tolerated tube feeding after
starting reglan.
The plan at this time is to go to rehab and continue tube
feeding, ___, SLP, and try to liberate yourself from tube feeds
while improving your functional status. If all goes well, you
will improve and you can follow up with the oncologists to
potentially begin a course of chemotherapy.
Followup Instructions:
___
|
10251081-DS-18 | 10,251,081 | 20,728,294 | DS | 18 | 2154-12-01 00:00:00 | 2154-12-01 18:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Left thoracentesis ___
History of Present Illness:
___ yo man with history of CLL and metastatic cholangiocarcinoma
who is admitted from the ED with dyspnea and found to have large
left pleural effusion.
Patient reports progressive dyspnea over the last week with
associated non-productive cough. Sytmptoms have been notably
worsening since ___ night. He now reports DOE with only
short walks and has notced wheeze as well. No fevers or chills.
No night sweats. Patient has some chronic dysphagia. No
abdominal pain, nausea, or vomiting. No change to ostomy output.
He has noticed darker urine with a strong odor. No sick
contacts. Has had recent PNAs and has been in ___ the
within the last few months.
In the ED, initial VS were pain 4, T 100.2, HR 10, BP 114/54, RR
20, O2 95%RA (later reported at 76% RA before adding nasal
cannula). Initial labs were notable for WBC 26.0 (90%L, ANC
2340), HGB 9.1, PLT 264. Normal Chem7 and lactate. UA with
48WBC, 14 RBC and 1 epi. Nitrate negative. Flu negative. CXR
showed large left pleural effusion and mild pulmonary edema.
Patient was given CTX, azithromycin, and 500ml NS prior to
transfer to ___ for further management. VS prior to transfer
were pain 4, T 98.2, HR 101, RR 18, O2 96%RA.
On arrival to the floor, patient has no complaints.
REVIEW OF SYSTEMS:
10 point review of systems was negative except as noted above.
Past Medical History:
PAST ONCOLOGIC HISTORY:
-___: He initially presented to ___ with coffee-ground
emesis, aspiration, and sepsis requiring intubation and MICU
admission. CT Abdomen/Pelvis on admission showed a 5.2 x 3.3 cm
heterogeneous lesion in segment 5 of the liver as well as
severely distended stomach proximal to a focus of high-grade
stenosis in the mid-body. EGD on ___ showed no active source
of bleeding or mass lesion, but retained material in the stomach
and dynamic pseudopylorus in the mid-stomach correlating to the
stenosis seen on CT. However, the pyrlous was widely patent.
-___: Biopsy of liver lesion, which revealed adenocarcinoma
with IHC positive for CK7 and CK19 and negative for CK20 and
CDX-2, overall felt to be consistent with adenocarcinoma of
pancreatobiliary primary, such as intrahepatic
cholangiocarcinoma. Adjacent liver parenchyma had atypical
lymphoid infiltrates consistent with small mature lymphocytes
related to his CLL.
-___: Staging CT Chest showed mediastinal and right hilar
lymphadenopathy, large left pleural effusion, and smaller
loculated right pleural effusion. Thoracentesis on ___
showed exudative fluid with rare atypical cells, likely reactive
mesothelial cells. He was seen by ___ Oncology, told of the
diagnosis of stage IV cancer, and recommended rehabilitation and
re-consideration of chemotherapy if his clinical status
improves. He gradually recovered and was discharged to rehab on
___ with ___ in place as he did not pass SLP
evaluation. His GIB.
-___: Re-admitted with recurrent coffee-ground emesis and
aspiration.
-___: Repeat CT Abdomen/Pelvis showed similar appearing
hepatic lesion, RLL consolidation, and moderate left pleural
effusion. No obstruction was seen on the scan. He was felt to
have gastric dysmotility with spasm-like contractions leading to
pseudo-obstruction. He was kept on standing metoclopramide and
___ kept in place with tube feeds. ___ Oncology again saw
him and set up outpatient follow-up. CA ___, CEA, and AFP were
all normal.
-___: He followed-up with Dr. ___ at ___ Medical
Oncology, who had been following his CLL. He and his family were
interested in anti-cancer treatment. He was felt to have no
clear evidence of metastasis, but overall poor surgical or
chemotherapy candidate due to his poor performance status. His
case was presented at ___ tumor board, and radioembolization
was suggested if his performance status improved. He was
referred to ___ for consideration of locoregional therapy.
-___: CT Torso notable for stable liver mass and enlarging
retroperitoneal lymphadenopathy, largest measuring 2.9 x 1.5 cm.
MRI Head showed a 5 mm calcified meningioma and 6 mm likely
pituitary microadenoma. Case was presented at ___ Liver Tumor
Conference with consensus that the retroperitoneal
lymphadenopathy was likely related to metastatic
cholangiocarcinoma, and thus systemic chemotherapy is
recommended over any locoregional therapies.
PAST MEDICAL HISTORY:
-Intrahepatic cholangiocarcinoma as above.
-CLL with favorable cytogenetics (del13q), on observation.
-Ulcerative colitis c/b intestinal perforation s/p colectomy
with ileostomy ___.
-Atrial flutter with RVR - not anticoagulated and has been in
NSR since ___ per PCP ___.
-Hypertension.
-Hyperlipidemia.
-Anemia.
-Hematuria.
-Osteoarthritis s/p total hip arthroplasty.
-Hydrocele.
-Undescended testicle.
-s/p Herniorrhaphy.
Social History:
___
Family History:
Parents lived until ___ and ___.
Sister - breast cancer in her ___.
He has 8 siblings.
He denies other known family history of malignancy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.2 134/67 82 16 94% 2.5L NC
GENERAL: Pleasant, cachectic. Oriented to person, place, and
month (not year). NAD
HEENT: Thrush over tongue and right buccal mucosa. PERLL, EOMI,
symmetric face, no LAD.
CARDIAC: RRR no MRG.
LUNG: Coarse throughout. Crackles at bases bilaterally. BS
diminished halfway up left lung base.
ABD: Ostomy in place with brown stool. Soft, NT, ND. No HSM.
EXT: No edema, WWP.
PULSES: 2+ pedal pulses
NEURO: AAOx2, CNIII-XII intact. Motor function grossly intact.
FTN intact.
DISCHARGE PHYSICAL EXAM:
VS: 98.0 114/60 84 20 94% RA
GEN: Very pleasant, thin older gentleman speaking in full
sentences in NAD.
HEENT: PERRLA, EOMI. MMM, OP clear.
Neck: Supple, no LAD, no JVD.
Cards: RRR, normal S1/S2, no murmurs/gallops/rubs.
Pulm: Bibasilar crackles, no wheezes or rhonchi.
Abd: Thin, soft, NT, no rebound/guarding, no HSM, no ___
sign; has ileostomy in place with formed brown stool, no
surrounding erythema or induration, +BS
Extremities: WWP, no edema. DPs, PTs 2+.
Skin: No rashes or bruising.
Neuro: AA&Ox3, CNs II-XII intact. ___ strength in U/L
extremities. Sensation intact to LT.
Pertinent Results:
ADMISSION LABS:
___ 10:40AM BLOOD WBC-26.0* RBC-3.24* Hgb-9.1* Hct-30.4*
MCV-94 MCH-28.1 MCHC-29.9* RDW-14.3 RDWSD-48.4* Plt ___
___ 10:40AM BLOOD Neuts-9* Bands-0 Lymphs-90* Monos-0 Eos-0
Baso-0 Atyps-1* ___ Myelos-0 AbsNeut-2.34 AbsLymp-23.66*
AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*
___ 10:40AM BLOOD Hypochr-OCCASIONAL Anisocy-NORMAL
Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL
Ovalocy-1+ Tear Dr-OCCASIONAL
___ 10:40AM BLOOD ___ PTT-29.8 ___
___ 10:40AM BLOOD Glucose-142* UreaN-20 Creat-0.7 Na-141
K-4.0 Cl-101 HCO3-31 AnGap-13
___ 10:40AM BLOOD ALT-12 AST-16 AlkPhos-102 TotBili-0.6
___ 10:40AM BLOOD Lipase-11
___ 10:40AM BLOOD Albumin-3.6
___ 10:58AM BLOOD Lactate-1.4
___ 10:55AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
INTERVAL LABS:
___ 02:42PM PLEURAL Hct,Fl-5.5*
___ 02:42PM PLEURAL ___ Hct,Fl-4.5* Polys-2*
Lymphs-94* ___ Macro-4*
___ 02:42PM PLEURAL TotProt-4.7 Glucose-106 LD(LDH)-373
Albumin-2.8 ___ Misc-BNP = 459
DISCHARGE LABS:
___ 07:52AM BLOOD WBC-13.6* RBC-3.25* Hgb-9.3* Hct-31.9*
MCV-98 MCH-28.6 MCHC-29.2* RDW-13.9 RDWSD-49.9* Plt ___
___ 07:52AM BLOOD Glucose-113* UreaN-21* Creat-0.5 Na-144
K-4.4 Cl-102 HCO3-34* AnGap-12
___ 07:52AM BLOOD LD(___)-127
___ 07:52AM BLOOD TotProt-5.9* Calcium-8.6 Phos-3.7 Mg-2.2
MICRO:
Blood cx ___: NGTD
Urine cx ___: No growth
Pleural fluid cx ___: Gram stain no PMNs, no organisms;
culture no growth (preliminary)
IMAGING:
CXR ___:
Interval resolution of left pneumothorax. Improved pulmonary
edema. Stable left pleural effusion.
CXR ___:
Since a recent radiograph of 2 days earlier, the patient has
undergone left thoracentesis, with near resolution of left
pleural effusion and development of a tiny left apical
pneumothorax. Associated improved aeration in the left mid and
lower lung with mild residual atelectasis remaining. No other
relevant change since recent radiograph.
CXR ___:
1. Large left pleural effusion
2. Mild pulmonary edema seen primarily in the right lung.
3. The heart appears minimally increased in size from the prior
examination which may reflect a small pericardial effusion or
rightward displacement from the large left pleural effusion.
Brief Hospital Course:
Mr. ___ is an ___ man with history notable for CLL
with favorable cytogenetics (del13q) on observation, ulcerative
colitis s/p colectomy/ileostomy in ___, Aflutter, and solitary
liver mass likely intrahepatic cholangiocarcinoma with
metastases to liver and retroperitoneal LNs who presents with
dyspnea, orthopnea, found to have bilateral pleural effusions
with L>>R. Most likely malignant effusions secondary to
metastatic malignancy (thoracentesis fluid met ___ Light's
criteria for exudative effusion), not on chemotherapy. Pt had
thoracentesis on ___ that removed 1.6L of bloody fluid from
chest. Pt will most likely need Pleurex catheter placed as an
outpatient and should follow up with interventional pulmonology.
Post thoracentesis patient had small apical pneumonothorax that
was stable on serial x-rays and patient was asymptomatic. Pt has
previous TTE from ___ with RV failure raising concern for
possible component of heart failure and volume overload,
although HF would not be expected to cause asymmetric pleural
effusions and L-sided effusion was exudative not transudative.
Given that last TTE in ___ showed e/o RV failure, consider
repeat TTE as outpatient. Pt was initially started on
ceftriaxone/azithromycin in the ED for empiric treatment of CAP,
which was d/c'ed on admission given afebrile, chronic
lymphocyte-predominant leukocytosis on CBC/diff, and no obvious
evidence of PNA on CXR.
Pt has Stage IV cholangiocarcinoma metastatic to liver and
retroperitoneal lymph nodes. Home pain regimen continued:
oxycontin 40mg PO qAM and 20mg PO qPM, tramadol for break
through pain. Home methylphenidate was continued in-house. Pt
has not yet started palliative chemotherapy given poor
performance status. Pt will f/u with his outpatient oncologist,
Dr. ___, to decide on a further treatment plan. Consider
palliative care consult as outpatient given recurrent
hospitalizations and not likely chemo candidate at this time.
CLL with favorable cytogenetics and is stable off therapy. CBC
monitored daily and chronic lymphocyte-predominant leukocytosis
was stable throughout admission.
Patient was evaluated by physical therapy who recommended
patient was safe for discharge home with resumption of previous
outpatient services.
TRANSITIONAL ISSUES:
[] Follow up pending pleural fluid cytology, per pathology
highly cellular, consider sending flow cytometry with future
specimen
[] Strongly recommend patient follow up in interventional
pulmonology clinic for pleurX catheter placement given high
suspicion for malignant effusion
[] Follow up pleural fluid cultures and blood cultures pending
at discharge, no growth to date
[] Consider TTE as outpatient given previous evidence of RV
dysfunction on last TTE ___.
CODE STATUS: Full (confirmed)
COMMUNICATION: Patient
EMERGENCY CONTACT HCP: ___ (daughter) ___
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tamsulosin 0.8 mg PO QHS
2. Vitamin D 1000 UNIT NG DAILY
3. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
4. Metoclopramide 10 mg NG QIDACHS
5. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB/Wheeze
6. methylphenidate 10 mg oral QAM
7. MethylPHENIDATE (Ritalin) 5 mg PO QPM
8. OxyCODONE SR (OxyconTIN) 40 mg PO QAM
9. OxyCODONE SR (OxyconTIN) 20 mg PO QHS
10. TraMADol 50 mg PO Q8H:PRN pain
11. Ferrous Sulfate 325 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB/Wheeze
2. Ferrous Sulfate 325 mg PO DAILY
3. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
4. MethylPHENIDATE (Ritalin) 5 mg PO QPM
5. Metoclopramide 10 mg NG QIDACHS
6. Multivitamins 1 TAB PO DAILY
7. OxyCODONE SR (OxyconTIN) 40 mg PO QAM
8. OxyCODONE SR (OxyconTIN) 20 mg PO QHS
9. Tamsulosin 0.8 mg PO QHS
10. TraMADol 50 mg PO Q8H:PRN pain
11. Vitamin D 1000 UNIT NG DAILY
12. methylphenidate 10 mg ORAL QAM
13. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
14. Nystatin Oral Suspension 10 mL PO QID thrush
RX *nystatin 100,000 unit/mL 10 mL ` four times a day Refills:*0
15. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Exudative Pleural Effusion, Left
CLL
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your admission to
___. You came into the hospital
because of shortness of breath and trouble breathing. We found
that you had a large collection of fluid in your left lung
(pleural effusion). You had a procedure to remove the fluid
(thoracentesis) and your breathing improved significantly. This
effusion is likely related to your cancer and may come back
therefore it is very important that you follow up with the
interventional pulmonologists for consideration of a permanent
drain (pleurX catheter).
Please continue to take your medications as directed and follow
up with Dr. ___ as scheduled.
We wish you the best.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10251182-DS-14 | 10,251,182 | 25,082,376 | DS | 14 | 2158-07-14 00:00:00 | 2158-07-15 11:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Vasotec / Ranitidine /
Nafcillin / Pollen
Attending: ___.
Chief Complaint:
fatigue/weakness/fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMHx of HTN, HLD, DM, PVD, CKD (baseline creatinine of
1.3-1.5), CVA, extensive CAD s/p CABG, sCHF (EF35-40%, ___ MR
in ___, and known plavix resistance and ___ ischemic CVA
presenting with fever and weakness. The patient was at baseline
state of health until last night when he developed a fever to
100.8. He started feeling weak, had trouble using his walker
(using walker since stroke), and reports SOB. This morning his
wife noted that he was incontinent of urine overnight due to
being too weak to walk to the bathroom. She called his PCP who
told the pt to report to ED for concern for infection. Had a
similar presentation six weeks prior that he says was similar,
brought him into hospital where he was diagnosed with flu and
possible demand ischemia and discharged home.
Cardiology consulted on pt. They initially were concerned about
possibility of CVA because pt's wife mentioned his speech may be
slurring. On re-examination the wife admits his speech was not
slurring, he is just speaking more slowly. Patient also notes
there is no exacerbation of his underlying stroke sx. Cardiology
was contacted again and they agreed that a neuro consult is not
necessary.
In the ED, initial vitals were 98.5 80 112/58 16 97% ra.
Patient denies fever/chills, current shortness of breath, any
chest pain, any current lightheadedness/pre-syncope. Denies
cough, or changes in urination. ROS as noted above is +
primarily for generalized fatigue, weakness.
Past Medical History:
1. CAD s/p CABG in ___ (SVG--->large bifurcating ramus,
SVG--->first diagonal, SVG--> posterior descending, LIMA--->
left
anterior descending)
2. Systolic Heart failure (EF 35-40%)in ___
3. NSTEMI ___ with CTO of RCA
4. PVD s/p R and L SFA stent ___. HTN
6. Hyperlipidemia LDL 46 HDL ___
7. DMII with A1C of 6.5 however microalbuminuria
8. CKDIII due to DMII and HTN
9. CVA ___ with residual deficits
10. OSA on home CPAP
11. NSTEMI ___
Social History:
___
Family History:
His father died at ___ from coronary artery disease, his mother
at
___ from CAD and cancer (type unknown). He has 2 sisters, 1 of
whom has issues related to diabetes and blood pressure. He has
children who are healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 98.1, 106-127/57-65, 65-68, 18 94% room air - 220lbs
GENERAL: NAD, AAOx3.
HEENT: PERRL, anicteric sclera, MMM. Unable to fully complete
extraocular movements on exam, and notes decreased vision left
visual field.
NECK: nontender, supple neck, no LAD, no JVD
CARDIAC: RRR, normal S1/S2 with distant heart sounds ___
habitus, and no audible systolic murmur at the apex
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: normoactive bowel sounds, nontender, nondistended, no
rebound/guarding
EXTREMITIES: moving all extremities well with RUE tremor, no
cyanosis, clubbing or edema
PULSES: 2+ DP pulses bilaterally
NEURO: chronic left facial droop with CN ___ otherwise intact,
moving all extremities, right UE intention tremor, gait not
assessed
SKIN: warm and well perfused, no visible rashes upper or lower
extremities
DISCHARGE PHYSICAL EXAM:
========================
(___)
VITALS: 98kg up from 97.7
96.6F, 112-117/65-67, pulse 53-56, rr18, 98%O2, 1710 in, 1800
out
GENERAL: NAD, AAOx3. Lying comfortably in bed with CPAP mask on.
HEENT: PERRL, anicteric sclera, MMM. Unable to fully complete
extraocular movements on exam, and notes decreased vision left
visual field.
NECK: nontender, supple neck, no LAD, no JVD
CARDIAC: RRR, normal S1/S2, no audible murmur.
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles.
ABDOMEN: Soft, NT, ND +BS, no rebound/guarding
EXTREMITIES: moving all extremities well with RUE tremor, no
cyanosis, clubbing or edema
PULSES: 2+ DP pulses bilaterally
NEURO: chronic left facial droop with CN ___ otherwise intact,
moving all extremities, right UE intention tremor, gait not
assessed
SKIN: warm and well perfused, no visible rashes upper or lower
extremities
Pertinent Results:
PERTINENT RESULTS:
==================
___ 08:25AM BLOOD WBC-11.9*# RBC-4.19* Hgb-12.2* Hct-37.2*
MCV-89 MCH-29.1 MCHC-32.8 RDW-13.8 Plt ___
___ 10:30AM BLOOD WBC-6.1 RBC-4.17* Hgb-12.3* Hct-37.8*
MCV-91 MCH-29.5 MCHC-32.5 RDW-13.8 Plt ___
___ 08:25AM BLOOD Glucose-175* UreaN-33* Creat-1.6* Na-137
K-3.7 Cl-100 HCO3-25 AnGap-16
___ 10:30AM BLOOD Glucose-172* UreaN-37* Creat-1.6* Na-139
K-3.8 Cl-100 HCO3-29 AnGap-14
___ 05:00PM BLOOD ___ PTT-150* ___
___ 10:30AM BLOOD ___ PTT-43.9* ___
___ 07:10AM BLOOD WBC-5.8 RBC-3.62* Hgb-10.8* Hct-32.7*
MCV-90 MCH-29.9 MCHC-33.0 RDW-13.7 Plt ___
___ 07:00AM BLOOD WBC-6.6 RBC-3.71* Hgb-10.9* Hct-33.7*
MCV-91 MCH-29.4 MCHC-32.4 RDW-13.7 Plt ___
___ 07:10AM BLOOD UreaN-41* Creat-1.5* Na-143 K-4.2 Cl-104
HCO3-27 AnGap-16
___ 07:00AM BLOOD UreaN-43* Creat-1.6* Na-141 K-4.0 Cl-102
HCO3-31 AnGap-12
CARDIAC LABS/ENZYMES:
=====================
___ 08:25AM BLOOD D-Dimer-241
___ 08:25AM BLOOD CK-MB-17* MB Indx-10.1* proBNP-1686*
___ 08:25AM BLOOD cTropnT-0.21*
___ 02:45PM BLOOD cTropnT-0.40*
___ 06:45PM BLOOD CK-MB-17* cTropnT-0.45*
___ 06:50AM BLOOD CK-MB-9 cTropnT-0.33*
___ 10:30AM BLOOD CK-MB-8 cTropnT-0.33*
___ 08:31AM BLOOD Lactate-1.9
IMAGING/STUDIES:
================
ECHOCARDIOGRAM ___:
LEFT ATRIUM: Moderate ___.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Dynamic interatrial septum.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Mild-moderate regional LV systolic dysfunction. Estimated
cardiac index is borderline low (2.0-2.5L/min/m2). No resting
LVOT gradient.
RIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free
wall hypokinesis. TASPE depressed (<1.6cm) Abnormal systolic
septal motion/position consistent with RV pressure overload.
AORTA: Mildy dilated aortic root. Mildly dilated ascending
aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
___ VALVE: Normal tricuspid valve leaflets with trivial
TR. Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
REGIONAL LEFT VENTRICULAR WALL MOTION:
Conclusions
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. There is mild to moderate regional left ventricular
systolic dysfunction with basal to mid inferior and mid to
apical inferolateral akinesis/hypokinesis. The estimated cardiac
index is borderline low (2.0-2.5L/min/m2). The right ventricular
cavity is mildly dilated with mild global free wall hypokinesis.
Tricuspid annular plane systolic excursion is depressed (1.5 cm)
consistent with right ventricular systolic dysfunction. There is
abnormal systolic septal motion/position consistent with right
ventricular pressure overload. The aortic root is mildly dilated
at the sinus level and the ascending aorta. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is trivial mitral
regurgitation.The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild focal left
ventricular systolic dysfunction c/w CAD in RCA territory. Mild
right ventricular dilation and free wall hypokinesis. The septal
motion suggests right venticular pressure overload however
pulmonary pressures could not be determined due to image
quality.
Compared with the prior study (images reviewed) of ___,
findings are similar however global left ventricular systolic
function is slightly more vigorous.
===========================================================
CXR ___:
The patient is status post median sternotomy and CABG. Heart
size remains mildly enlarged. Mediastinal and hilar contours are
unremarkable. Lung volumes are low with streaky opacities in the
lung bases, more pronounced on the left, compatible with areas
of atelectasis. No focal consolidation, pleural effusion or
pneumothorax is seen. Multilevel degenerative changes are again
noted in the thoracic spine with flowing anterior osteophytes
compatible with DISH.
CARDIAC CATH ___
1. Coronary angiography in this right dominant system
demonstrated
severe multi-vessel disease with heavily calcific coronary
system
throughout.
*** The ___ was patent with mild plaquing.
*** The LAD has mild diffsue disease proximally and gives a long
bifurcating diagonal branch before it tapers and becomes
severely
diseased. The Diah has 60% ostial lesion followed by a good size
short segment then severe diffuse disease in sequential segments
tapering to 80%. Distally, the diag branches appear to supply
the proximally occluded RI. The LAD beyond the Diag take off
gives good size S1 and several smaller septals then occludes
distally. The distal LAD(severely and diffusely diseased vessel)
fills via the patent LIMA.
*** The LCx is a small (2.0-2.25 mm) vessel that was heavily
calcified, tortuous, and severely diffusely diseased from origin
to distal. It was supplied by collaterals to the distal RCA
breanches.
*** The RI had a 100% CTO proximally with delayed filling and
possible appearance of ?competitive flow (likely, via
collaterals from the upper of the diagonal branch).
*** The RCA had a 100% CTO proximally with minimal R to R
collaterals.
2. Venous conduit angiography revealed the SVG-RCA, SVG-RI, and
SVG-diagonal grafts to be flush occluded.
3. Arterial conduit angiogrpahy revealed the LIMA-LAD graft to
be patent and the distal LAD to be severely diffusely diseased
with total occlusion distal to the anastamosis.
4. Supravalvular aortography was performed and confirmed no
filling of the vein grafts.
5. Resting hemodynamics revealed markedly elevated left and
right-sided filling pressures consistent with severe diastolic
dysfunction. There was moderately elevated pulmonary arterial
pressure. Preserved cardiac output and index.
FINAL DIAGNOSIS:
1. Severe native three-vessel coronary artery disease.
2. Occlusion of the three vein grafts.
3. Patent LIMA with severe post-anastamosis LAD disease.
4. Markedly elevated left and right-sided filling pressures.
5. Moderate pulmonary hypertension.
6. Preserved cardiac output and cardiac index.
ECHOCARDIOGRAM (___):
LEFT ATRIUM: Moderate ___.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size.
Mild-moderate regional LV systolic dysfunction. No resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size. Mild global RV free
wall hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Mildly dilated ascending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild to moderate (___) MR.
___ VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor subcostal
views. Suboptimal image quality - poor suprasternal views.
Echocardiographic results were reviewed by telephone with the
houseofficer caring for the patient.
Conclusions
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. There is
mild to moderate regional left ventricular systolic dysfunction
with severe hypokinesis of the basal half of the inferior and
inferolateral walls. The remaining segments contract normally
(LVEF = 35-40 %). Right ventricular chamber size is normal with
mild global free wall hypokinesis. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild to
moderate (___) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
regional systolic function c/w CAD (proximal RCA distribution).
Right venticular free wall hypokinesis. Mild-moderate mitral
regurgitation with probable papillary muscle dysfunction.
Compared with the prior study (images reviewed) of ___,
the left ventricular dysfunction is more extensive, right
ventricular dysfunction and mitral regurgitation are new c/w
interim ischemia/infarction.
Brief Hospital Course:
___ with PMHx of HTN, HLD, DM, PVD, CKD (baseline creatinine of
1.3-1.5), CVA, extensive CAD s/p CABG, sCHF (EF35-40%, ___ MR
in ___, and known plavix resistance and ___ ischemic CVA
presenting with fever and weakness in the context of elevated
troponins, but no EKG changes, concerning for NSTEMI.
# NSTEMI:
Given history of CAD and extensive cardiac risk factors,
concerning for MI (NSTEMI Type 1). Patient has known
multi-vessel disease and is s/p CABG w/last cath in ___.
Patient reported fever at home of 100.8, no fevers recorded in
hospital. Infectious workup negative, likely reactive to acute
MI. Was ultimately decided that catheterization would not
provide significant benefit due to diffusely severe disease, and
patent LIMA leading to stenosed LAD. Patient was given 48 hours
of heparin gtt and then transitioned to optimal medical therapy.
Patient also noted that last time he had an MI, he did not
experience chest pain or shortness of breath, but did have
fatigue, consistent with this event.
# Acute on Chronic CKD
Patient baseline Creatinine is 1.0, during hospitalization was
around 1.6 which is concerning for Acute on Chronic CKD. ___ is
likely in the context of demand ischemia, but could also
represent a new baseline for the patient. Will need to follow as
an outpatient.
- please check labs twice weekly to confirm stability
# Hx of Ischemic Stroke
Patient has known weakness on right side of body, these symptoms
appear to have recrudesced in the context of his troponin rise.
Neurology believes that this is due to NSTEMI, and no further
imaging is needed. He has neurology followup scheduled as an
outpatient.
# HLD/CAD/PVD: Statin and medical management as above.
# OSA: Continued on CPAP for him during hospitalization. Please
maintain CPAP every night.
# Depression/Anxiety: Stable, no active issues. Home
medications continued.
TRANSITIONAL ISSUES:
- please ensure patient presents to follow up cardiology and
neurology appointments
- please assist with PCP appointment upon discharge from rehab
- continue CPAP at night
- please see med rec for medication changes - note Viagra is
DISCONTINUED and should be discussed with physician before
reinstating given that he is started on Nitroglycerin SL
- Pantoprazole started instead of Omeprazole due to data on
interaction with anti-platelet agents
- Code: Full
- Contact: wife ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Ascorbic Acid ___ mg PO BID
3. Aspirin 325 mg PO DAILY
4. Atorvastatin 80 mg PO DAILY
5. Bisacodyl 10 mg PR HS:PRN constipation
6. Carvedilol 50 mg PO BID
7. Citalopram 20 mg PO DAILY
8. ClonazePAM 0.5 mg PO QAM
9. ClonazePAM 0.25 mg PO BID
10. Cyanocobalamin 1000 mcg PO DAILY
11. Docusate Sodium 100 mg PO BID
12. Fish Oil (Omega 3) 1000 mg PO DAILY
13. Fluticasone Propionate NASAL 2 SPRY NU DAILY
14. Losartan Potassium 100 mg PO DAILY
15. Omeprazole 20 mg PO DAILY
16. Potassium Chloride 10 mEq PO DAILY
17. Senna 17.2 mg PO HS constipation
18. Spironolactone 12.5 mg PO DAILY
19. TraZODone 25 mg PO HS
20. Cetirizine 10 mg PO DAILY
21. dextran 70-hypromellose 0.1-0.3 % ophthalmic q2h:PRN dry
eyes
22. Glucosamine Sulf-Chondroitin (glucosamine ___ 2KCl-chondroit)
500-400 mg oral qd
23. Torsemide 60 mg PO DAILY
24. Viagra (sildenafil) 100 mg oral prn intercourse
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Ascorbic Acid ___ mg PO BID
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO DAILY
5. Bisacodyl 10 mg PR HS:PRN constipation
6. Carvedilol 50 mg PO BID
7. Cetirizine 10 mg PO DAILY
8. Citalopram 20 mg PO DAILY
9. ClonazePAM 0.5 mg PO QAM
10. ClonazePAM 0.25 mg PO BID
11. Cyanocobalamin 1000 mcg PO DAILY
12. dextran 70-hypromellose 0.1-0.3 % ophthalmic q2h:PRN dry
eyes
13. Docusate Sodium 100 mg PO BID
14. Fish Oil (Omega 3) 1000 mg PO DAILY
15. Fluticasone Propionate NASAL 2 SPRY NU DAILY
16. Pantoprazole 40 mg PO Q24H GERD
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
17. Potassium Chloride 10 mEq PO DAILY
18. Senna 17.2 mg PO HS constipation
19. Spironolactone 12.5 mg PO DAILY
20. Torsemide 60 mg PO DAILY
21. TraZODone 25 mg PO HS
22. Glucosamine Sulf-Chondroitin (glucosamine ___ 2KCl-chondroit)
500-400 mg oral qd
23. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain/discomfort
RX *nitroglycerin 0.4 mg 1 tablet(s) sublingually q5min:prn Disp
#*30 Tablet Refills:*0
24. Losartan Potassium 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Non ST Elevation Myocardial Infarction
Secondary:
Recrudescence of Stroke Symptoms
Fever
Hypertension
Hyperlipidemia
Diabetes Mellitus Type 2
Obstructive Sleep Apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. ___,
You came to ___ due to fatigue
and weakness. You were found to have elevated "troponins"
indicative of damage to your heart from a heart attack. You were
seen by the interventional cardiologists who determined that
performing a cardiac catheterization at this time would have
risks that outweigh the potential benefits. For this reason, we
kept you on anticoagulation (heparin drip) for 48 hours, and
ensured that at the time of discharge you were on an optimal
medication regimen for your heart.
In addition, due to concern that your stroke symptoms had
worsened, you were seen by our neurology experts. They
determined that you did not have a new stroke, instead having
some temporary worsening of your prior stroke symptoms in the
context of your heart attack. These should begin to resolve in
the coming weeks.
Physical therapy saw you and recommends that you go to rehab,
and it is through rehab that you can regain your strength and
return to your normal activities.
It has been a pleasure caring for you here at ___ and we wish
you all the ___ on your recovery!
Kind Regards,
Your ___ Team
Followup Instructions:
___
|
10251182-DS-15 | 10,251,182 | 24,112,664 | DS | 15 | 2158-10-27 00:00:00 | 2158-10-27 14:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Vasotec / Ranitidine /
Nafcillin / Pollen
Attending: ___
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
___ T11-L3 fusion
___ Emergent decompression, revison fusion
History of Present Illness:
Mr. ___ is a ___ y/o male with a history of a stroke who was
ambulating with his walker on ___ and took a step
backwards and lost his balance and fell on the carpeted surface.
He struck his head and back. He denied loss of conciousness at
the time of fall. He presented to the ED on ___ c/o back pain
and had a CT that was read as negative and was discharged home.
He returns today with continued back pain and is found to have a
L1 body fracture.
Past Medical History:
1. CAD s/p CABG in ___ (SVG--->large bifurcating ramus,
SVG--->first diagonal, SVG--> posterior descending, LIMA--->
left
anterior descending)
2. Systolic Heart failure (EF 35-40%)in ___
3. NSTEMI ___ with CTO of RCA
4. PVD s/p R and L SFA stent ___. HTN
6. Hyperlipidemia LDL 46 HDL ___
7. DMII with A1C of 6.5 however microalbuminuria
8. CKDIII due to DMII and HTN
9. CVA ___ with residual deficits
10. OSA on home CPAP
11. NSTEMI ___
Social History:
___
Family History:
His father died at ___ from coronary artery disease, his mother
at
___ from CAD and cancer (type unknown). He has 2 sisters, 1 of
whom has issues related to diabetes and blood pressure. He has
children who are healthy.
Physical Exam:
On admission:
PHYSICAL EXAM:
T: 97.6 BP: 163/82 HR: 81 RR: 20 O2Sats 96% RA
Gen: Lying in bed.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT ___ G
Sensation: Intact to light touch bilaterally.
Reflexes: B T Br Pa Ac
Right ___ 0 0
Left ___ 0 0
No ___ sign.
Negative ankle clonus.
+ Rigid throughout all four extremities.
Exam On Discharge:
A&Ox3, R facial weakness, L eye limited abduction, R pronator
drift.
BUE full ___
RLE: ___
LLE: ___
He does have some muscle flickering to LLE and sometimes RLE
when supporting leg.
Pertinent Results:
___ CT Cspine:
IMPRESSION:
No evidence of fracture or traumatic malalignment. Degenerative
changes as stated.
___ CT Head:
IMPRESSION: No acute findings.
___ CT Lspine:
IMPRESSION:
Transversely oriented fracture through the L1 vertebral body
that extends
through the posterior elements with mild distraction of fracture
fragments. Recommend MRI to evaluate for spinal cord injury.
___ CT Chest:
IMPRESSION:
1. Heterogeneous left adrenal lesion, unchanged in size compared
to the
previous CT from ___, but has grown since ___.
The lesion does not meet criteria for an adrenal adenoma on this
exam. Further evaluation with a nonurgent adrenal protocol CT
should be obtained when clinically appropriate.
2. No acute fracture or subluxation of the thoracic spine.
3. Trace left pleural effusion.
___ MRI Lspine:
1. Unstable fracture through the L1 vertebral body and
bilateral pedicles.
Mild retropulsion with spinal canal stenosis and effacement of
the thecal sac.
There is ligamentous injury with disruption of the anterior
longitudinal
ligament, posterior longitudinal ligament, and ligamentum flavum
at L1.
2. L5-S1 central disc protrusion and facet osteophytes with
moderate spinal
canal and severe bilateral neural foraminal stenosis.
___ MRI Tspine:
1. Acute unstable fracture of L1 extending through the vertebral
body and
posterior elements with 2 mm of anterolisthesis of the superior
fracture
fragment on the inferior fracture fragment and resultant
moderate to severe
canal stenosis and moderate cord compression. No csignal
abnormality.
2. Disruption of the posterior longitudinal ligament, ligamentum
flavum and
likely anterior longitudinal ligament at L1.
3. No additional thoracic vertebral fractures are identified.
___ Portable abdomen
FINDINGS:
Air is seen throughout mildly dilated small and large bowel,
without evidence of obstruction. No evidence of free
intraperitoneal air on this supine view. Degenerative changes
throughout the spine. Known fracture of the L1 vertebra is
partially seen.
IMPRESSION:
Findings consistent with ileus. No evidence of obstruction.
___ CT Lspine
IMPRESSION:
1. Horizontal linear fracture through the body and posterior
elements of L1 involving all 3 columns with increased anterior
displacement as compared to the prior MRI examination. This has
resulted in severe spinal stenosis and neural foraminal
narrowing at this level.
2. There is interval posterior fusion of T12-L3 with associated
postoperative changes.
___ MRI Lspine
Patient is status post posterior fusion from T11 through L3. A
L1 vertebral body and bilateral pedicle fracture is again
demonstrated. There is new edema seen within the lower spinal
cord extending to the termination of the conus. Multilevel
degenerative changes in the lower lumbar spine are unchanged
compared to recent prior studies.
___ CT Head
No acute intracranial abnormality.
___ CT Head
Normal study.
___ MRI Lumbar Spine
Limited radiographic evaluation of the lumbar spine, due to
limitations of patient positioning and an overlying brace.
However, in keeping with
consistent vertebral body numbering used previously, the patient
is status post T11 through L3 posterior fusion without evidence
of hardware loosening or failure. The known horizontal linear
fracture through the body and posterior elements of L1 is not
well seen, including the previously seen anterior displacement
of the superior portion of the vertebral body with respect to
the inferior vertebral body fragment .
Brief Hospital Course:
Mr. ___ was admitted to neurosurgery and placed on bedrest
until further imaging could be done to determine injury and
intervention. A CT Cspine and CT head was negative for injury. A
CT Lspine showed a L1 fracture. A MRI was ordered to better
determine injury for surgical intervention vs. conservative
management. A TLSO was ordered. Medicine was consulted for BP
control and pre-operative clearance.
On ___, Mr. ___ underwent a MRI of his thoracic and lumbar
spine to better qualify his fracture. The injury showed an
unstable one with anterior and posterior ligamentous injury. As
a result, the patient was kept on bed rest. He was fit for his
TLSO brace during this time.
During this time, Mr. ___ abdomen was extremely distended,
drum-like and tympanic on percussion. He was not nauseated nor
vomiting, and also passing flatus. He was given an aggressive
bowel regimen, for which he later had a bowel movement that
evening. The Medicine service continued to assist in the
medical management of this patient, especially in regards to his
fluid status as well as titration of his blood pressure
medications. His initial blood pressure readings were systolic
pressures in the 180-200s, but with tighter titration of
medications, his pressure decreased to the 160-170s.
On ___, Mr. ___ continued to have a distended abdomen. A
KUB film was obtained to rule-out stool impaction, constipation,
obstruction or ileus. Results showed dilated loops of small and
large bowel indicative of an ileus. As a result, the patient
was made NPO except for medications and started on conservative
IV fluids. He was ordered for enemas as needed. Medicine
continued to provide recommendations for fluid management due to
concerns of pulmonary edema and congestive heart failure.
On ___ patient started to have some bowel movements and
abdomen was seen by the Medical team who offered some
recommendations for medication before the OR ___.
On ___ the patient was taken to the OR for a T11-L3 fusion
which he tolerated well but then 30 min post-op patient could
not move his BLE. Emergent CT done and patient taken back to the
OR for decompression and hardware revision. A small dural tear
with duraplasty. ___ transferred to the ICU with MAP goals >
60, post-operatively patient was still unable to move his BLE
with a sensory level of iliac crest. A MRI Lspine was obtained
that showed no compression but showed signal change. Patient's
exam remained unchanged on ___ with no BLE movement or
sensation to noxious stim. MAP goals > 70 and Dexamethasone 4mg
Q6.
On ___, the patient had an episode of blurred vision or
questionable loss of vision. On exam patent had patchy vision,
underwent a cranial CT that showed no evidence of hemorrhage or
new strokes. Patient expressed some suicidal idiations asking
his wife to kill him. Psychiatry was consulted.
On ___, the patient was transferred to the floor in stable
condition.
On ___, X-ray showed stable L-spine with hardware in place.
The patient was on a benzodiazepine taper as per Psychiatry
recommendations. His Cr and Na were elevated and urine studies
indicated volume depletion, so he was given 250 ml NS and his
next dose of torsemide was held.
On ___, the patient remained neurologically stable on
examination. He was re-assessed by the medicine team who
recommended some changes to his insulin regimen. The psychiatric
team did not recommend any changes to his current regimen.
On ___ WBC elevated to 12, an infectious work up was sent. His
chest xray was negative and his urine came back positive on
___. His urine culture showed pseudomonas, pt was started on
cefepime x 7 days. Glargine increased to 25 units at night. His
Foley was discontinued and a voiding trial was attempted
overnight.
On ___ his WBC was trending down. There was 1L urinary
retention after foley removal and straight cath'ed x1. Her
Cefepime was d/c'ed and changed to cipro for sensitive
pseudomonas. On bladder scan he retained 1500cc and was straight
cathed.
On ___, he remained neurologically and hemodynamically stable.
His sodium and WBC level remained stable. Continue with Q 6hrs
catherization if bladder scanned for more than 400. He was
discharged to rehab in stable conditions. His staples were
removed without difficulty. Incision clean dry and intact for
the exception of a small section at the mid incision, it
appeared moist and oozing small amount of sanguinous drainage,
steri-strips applied.
Medications on Admission:
___ 10 mg PO QD
Artificial Tears eye drops
Colace 100 mg capsule BID constipation
Dulcolax (bisacodyl) 10 mg rectal suppository PO QD prn
constipation
Glucosamine Sulfate-Chondroitin 500 mg-400 mg Cap PO QD
One Touch Ultra Test strips
Vitamin B-12 1,000 mcg tablet PO daily
Vitamin C 500 mg tablet PO BID
Acetaminophen 500 mg tablet 1 tab PO QPM prn pain
Aspirin 81 mg tablet,delayed release
Atorvastatin 80 mg tablet PO daily
Carvedilol 25 mg tablet PO daily 1.5 tab PO BID
Citalopram 20 mg tablet PO QD
Clonazepam 0.5 mg tablet 0.5 tab PO TID PRN shaking
Fluticasone 50 mcg/actuation Nasal Spray 2 puff INH QD
Glipizide 5 mg tablet 0.25 tab PO before breakfast
Losartan 100 mg tablet 0.5 tablet PO daily
Nitroglycerin 0.4 mg sublingual tab PO PRN chest pain, can
repeat every 5minutes three times, call ___ if chest pain not
resolved
Omeprazole 20 mg tab PO daily
Potassium chloride ER 10 mEq tab PO daily
Sennosides 8.6 mg tab 2 tab PO QPM
Spironolactone 25 mg tab 0.5 tab PO daily
Torsemide 20 mg tab 2 tablet PO daily
Trazodone 50 mg ___ tablet PO QPM
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H pain
2. Atorvastatin 80 mg PO DAILY
3. Bisacodyl ___AILY
4. Carvedilol 50 mg PO BID
5. Citalopram 20 mg PO DAILY
6. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days
until ___ morning dose
7. ClonazePAM 0.25 mg PO TID:PRN shaking
8. Cyanocobalamin 100 mcg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Fluticasone Propionate NASAL 2 SPRY NU BID
11. Gabapentin 100 mg PO TID
12. Heparin 5000 UNIT SC TID
13. Glargine 25 Units Bedtime
14. Polyethylene Glycol 17 g PO DAILY
15. Lidocaine 5% Patch 1 PTCH TD QAM
16. Simethicone 40-80 mg PO QID
17. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
Please do not drive or operate mechanical machinery while taking
pain meds.
18. Omeprazole 20 mg PO DAILY
19. Losartan Potassium 100 mg PO HS
20. Milk of Magnesia 30 mL PO Q6H:PRN constipation
21. Senna 8.6 mg PO BID
22. Tamsulosin 0.4 mg PO QHS
23. Torsemide 40 mg PO DAILY
24. TraMADOL (Ultram) 25 mg PO Q6H:PRN breakthrough pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
T12 Chance fracture
Small bowel ileus
Constipation
Congestive heart failure
Hemiparalegia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Thoracic/Lumbar Fusion
Dr. ___
**If you have steri-strips in place, you must keep them dry
for 72 hours. Do not pull them off. They will fall off on their
own or be taken off in the office. You may trim the edges if
they begin to curl.
You should wear your brace when out of bed or when your head
of bed is above 30 degrees.
You may put the brace on at the edge of your bed.
You may use a shower chair to bathe without the brace on.
No tub baths or pool swimming for two weeks from your date of
surgery.
Do not smoke.
No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
Limit your use of stairs to ___ times per day.
Have a friend or family member check your incision daily for
signs of infection.
Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort. Pain medication should
be used as needed when you have pain. You do not need to take it
if you do not have pain.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. for two weeks.
Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
Pain that is continually increasing or not relieved by pain
medicine.
Any weakness, numbness, tingling in your extremities.
Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
Fever greater than or equal to 101.5° F.
Loss of control of bowel or bladder functioning
Followup Instructions:
___
|
10251182-DS-18 | 10,251,182 | 28,936,610 | DS | 18 | 2159-03-26 00:00:00 | 2159-03-26 13:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Vasotec / Ranitidine /
Nafcillin / Pollen / broccoli
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a ___ y/o PMHx significant for CAD s/p CABG, ___
(EF 40%), DMII (hgbA1c 6.6% ___, CKD, h/o CVA recently
treated for presumed sacral osteomyelitis now presenting from
his rehab with fevers.
Per report from rehab, patient was complaining of not feeling
good but was unable to be more specific. He had fevers to 101.
He had a negative CXR on ___, negative KUB and was being
treated for a UTI with macrobid. Per report, he has had a
general decline over the past two weeks. Foley last changed 5
days ago.
In the ED, history was obtained from the patient's wife who
stated that the patient has not been himself for the last few
days and has been lethargic. He had a temp today of 101.3. Per
his wife, he has been having a productive cough x10 days. He has
a known sacral ulcer and now has a wound vac.
In the ED, initial vitals were: 100 64 154/82 26 99%
- Labs were significant for leukocytosis, anemia, transaminitis,
dirty UA
- Imaging revealed concern for proctocolitis, sacral osteo,
bladder wall thickening, LLL nodular opacities
- The patient was given 500cc LR, dilaudid, cipro, flagyl, vanc
Upon arrival to the floor, patient's wound vac was off and he
was noted to have copious loose stool with flexiseal. He does
note intermittant abdominal pain and an ongoing cough.
Past Medical History:
1. CAD s/p CABG in ___ (SVG--->large bifurcating ramus,
SVG--->first diagonal, SVG--> posterior descending, LIMA--->
left
anterior descending)
2. Systolic Heart failure (EF 35-40%)in ___
3. NSTEMI ___ with CTO of RCA
4. PVD s/p R and L SFA stent ___. HTN
6. Hyperlipidemia LDL 46 HDL ___
7. DMII with A1C of 6.5 however microalbuminuria
8. CKDIII due to DMII and HTN
9. CVA ___ with residual deficits
10. OSA on home CPAP
11. NSTEMI ___
12. 12. L1 fracture s/p T11-L3 fusion (___) c/b lower
extremity paralysis and wound dehiscence
Social History:
___
Family History:
His father died at ___ from coronary artery disease, his mother
at
___ from CAD and cancer (type unknown). He has 2 sisters, 1 of
whom has issues related to diabetes and blood pressure. He has
children who are healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
==================
Vitals: 97.5 124/56 67 18 97% on RA
General: lying in bed, elderly, chronically ill appearing male
HEENT: NCAT, dry mucous membranes
Heart: normal s1/s2, rrr, no murmurs
Lungs: very limited exam given patient compliance
GI: +BS, soft, nondistended, mildly tender
Genitourinary: foley in place
Neurological: oriented to location, date/year (did not know
month), ___
DISCHARGE PHYSICAL EXAM:
==================
Vitals: RR ___
General: lying in bed, chronically ill appearing male, NAD
HEENT: NCAT, MMM. mild rotary nystagmus of R eye, neither eye
able to cross midline to L
Heart: normal s1/s2, rrr, no murmurs
Lungs: clear anteriorly
GI/GU: foley and rectal tube in place. abdomen soft, non-tender,
non-distended.
Neuro: extraocular motions as above. AOX3
Pertinent Results:
ADMISSION LABS:
===========
___ 06:45PM BLOOD WBC-11.4*# RBC-3.04* Hgb-8.2* Hct-25.3*
MCV-83# MCH-26.9* MCHC-32.3 RDW-13.9 Plt ___
___ 06:45PM BLOOD ___ PTT-37.1* ___
___ 06:45PM BLOOD Glucose-168* UreaN-25* Creat-0.7 Na-134
K-3.2* Cl-100 HCO3-21* AnGap-16
___ 06:45PM BLOOD ALT-121* AST-102* AlkPhos-112 TotBili-0.1
___ 04:50AM BLOOD Albumin-2.5* Calcium-7.9* Phos-2.9 Mg-1.6
___ 01:11AM BLOOD CRP-104.1*
IMAGING/STUDIES:
============
___ CXR: No acute cardiopulmonary abnormality.
___ CT A/P: 1. New sigmoid colon and rectal wall thickening
with adjacent fat stranding,
edema, and multiple prominent pelvic lymph nodes concerning for
proctocolitis.
2. Large sacral decubitus ulcer with extension to coccygeal bone
which
demonstrates irregularity and increased sclerosis concerning for
osteomyelitis
as seen on the previous MR pelvis.
3. Chronically thick-walled bladder may be due to chronic outlet
obstruction
from the patient's benign prostatic hypertrophy, however
infection cannot be
completely excluded. Recommend correlation with urinalysis.
4. Normal appendix.
5. Decreased size of small left pleural effusion. Nodular patchy
opacities in
the left lower lobe could represent aspiration.
6. Unchanged 2.5 cm left adrenal nodule, not completely
characterized on this
exam.
___ CT head:
No acute intracranial process.
MICRO:
=====
BCx - negative
UCx ___ - PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
Piperacillin/Tazobactam sensitivity testing performed
by ___
___.
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
___ C diff - negative
DISCHARGE LABS:
===========
none
Brief Hospital Course:
Patient is a ___ with a history of CVA, paraplegia, CKD,
sacral osteomyelitis who presented with fever, found to have
HCAP, colitis, and possible recurrence of sacral osteomyelitis.
Patient was initially treated with broad spectrum antibiotics.
However, during hospital course, patient indicated wanting to
change goals of care to comfort focused care. Antibiotics and
other medications not directly contributing to comfort and
quality of life were discontinued. Wound vac was not replaced
and rectal tube was left in place for comfort reasons. Hospital
course was complicated by diplopia and rotary nystagmus felt to
be due to recrudescence of prior CVA symptoms in the setting of
illness. Patient was discharged to hospice care.
#Goals of care: During hospital course, patient expressed desire
to shift focus to concentrating on maintaining quality of life
and dignity. He expressing not wanting to continue on any
medications that are not directed contributing to comfort and
wanted to transition to inpatient hospice care. Discussed with
patient that even with stopping his medications, including
antibiotics, he will likely not paas away acutely. Patient
understood and wants to focus on remainder of time being
comfortable. This was also discussed with his wife who is in
agreement with the plan. Given this, majority of medications,
including antibiotics, were stopped. Patient was continued only
on medications for symptom mangement. Patient did not want wound
vac replaced, though did want to continue with dressing changes.
Rectal tube was left in place for comfort. MOSLT was completed
with patient and HCP on ___. Patient indicated DNR/DNI/do not
transfer to hospital unless required for comfort.
# Sepsis of unclear source, most likely pna and colitis: Patient
presented with cough and LLL ground glass opacities concerning
for HCAP. CT also showed signs of proctocolitis which is
concerning for C diff in the context of 1 week of diarrhea,
recent hospitalization and prolonged antibiotic therapy.
However, C diff negative. There is no clinical evidence for
inflammatory of ischemic colitis. CT with possible sacral
osteomyelitis, for which patient completed vanc/ceftaz on ___.
Howveer, it was unclear if radiographic findings represented
recurrence vs expected radiographic findings in setting of
recent osteo. Surgery debrided wound on ___ at the bedside. UCx
with pseudomonas and enterococcus, though in the setting of
chronic foley. ID was consulted and recommended therapy with IV
vanc/ceftazidine/flagyl. Patient was also on PO vanc until C
diff returned negative. Give goals of care transitions (see
above), antibiotics were discontinued on ___.
#oculomotor deficits: During hospital course, patient complained
of worsening diplopia. On exam, patient had rotary nystagmus of
R eye and neight eye was able to cross midline to the L. Patient
has h/o posterior circulation strokes affecting his right pons
and left medulla. Per neurology notes, has had similar
presentation in the setting of illness. CT head non-con
negative. Presentation was likely represents recruduence in the
setting of increased metabolic demand with underlying
infection(s). Vision subseuqently remained stable during
hospital course. Patient had previously been on ASA and
atorvastatin 80mg daily, though this was discontinued on ___
for GOC.
#nutritional status: patient showed signs of poor nutrition with
elevated INR and low albumin. Patient was initially on diabetic
diet. Speech and swallow recommended video swallow, though
patient declined. Diet was liberalized given GOC.
# Anemia: H/H at baseline during hospitalization. Normocytic
without elevated RDW. Etiology unclear, may be due to CKD and
anemia of chronic disease, which is supported by Fe studies. RPI
low, which would be expected in CKD. Stool guaiac was negative.
# DM: Last A1c 6.6% ___. Has history of microalbuminuria.
___ held at last admission due to ___. He was initially
restarted on losartan though this was discontinued, as was
finger checks given GOC.
CHRONIC ISSUES
==============
# CAD: s/p NSTEMI ___. Discontinued home carvedilol,
atorvastatin, aspirin given GOC after which patient had no signs
of angina/discomfort or rebound tachycardia.
# CHF: EF 35-40% on last TTE ___, dry weight ~225. Patient
was not currently on torsemide. No signs of volume overload
during hospitalization.
# Depression/anxiety: Patient displayed no signs of depression
through out his hospitalization and as he made his decision to
transition to hospice care. He wanted to continue his home
citalopram.
#GERD: patient has history of GERD for which omeprazole was
continued, consistent with patient wishes.
TRANSITIONAL ISSUES:
===================
- patient complete MOLST form on ___ indicating DNR/DNI and
do not transport to hospital unless needed for comfort
- continue oxycodone 7.5mg q3h prn: pain and titrate as needed
- continue trazodone, omeprazole, and citalopram, per patient
preference
- please see Page 1 for wound care instructions
- contact:
___
Relationship: spouse
Phone number: ___
BILLING: >30 minutes were spent coordinating Mr ___
discharge from the hospital.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carvedilol 50 mg PO BID
2. Gabapentin 100 mg PO DAILY
3. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
4. Ascorbic Acid ___ mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Bisacodyl 10 mg PO DAILY
7. Citalopram 30 mg PO DAILY
8. Docusate Sodium 100 mg PO BID:PRN constipation
9. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES TID
10. Ferrous Sulfate 325 mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. Heparin 5000 UNIT SC TID
13. modafinil 50 mg ORAL NOON
14. Multivitamins 1 TAB PO DAILY
15. Simethicone 80 mg PO DAILY
16. Omeprazole 20 mg PO DAILY
17. Collagenase Ointment 1 Appl TP DAILY to pressure ulcer
18. Tamsulosin 0.4 mg PO QHS
19. Zinc Sulfate 220 mg PO DAILY
Discharge Medications:
1. Citalopram 30 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. OxycoDONE (Immediate Release) 7.5 mg PO Q3H:PRN pain
RX *oxycodone 5 mg 1.5 tablet(s) by mouth every 3 hours Disp
#*30 Tablet Refills:*0
4. TraZODone 50 mg PO QHS:PRN insomnia
5. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
6. Gabapentin 100 mg PO DAILY
7. Collagenase Ointment 1 Appl TP DAILY to pressure ulcer
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
health care associated pneumonia
colitis
sacral osteomyelitis
Secondary:
paraplegia
sacral decubitus ulcer
history of CVA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ with fevers. We started treating you
with multiple antibiotics because you had evidence of multiple
different infections, including pneumonia and colitis. However,
during the course of your hospitalization, you decided that you
want to shift the focus of your care to focusing on being as
comfortable as possible. Therefore, we stopped medications,
including antibiotics, that were not directly contributing to
your comfort. You will now be transitioning your care to a
___ facility.
It has been a pleasure taking care of you and we wish you all
the best. Please return to the emergency department or call your
doctor if you have any concerns for which you would like medical
attention.
Best,
Your ___ Care Team
Followup Instructions:
___
|
10251262-DS-2 | 10,251,262 | 26,787,243 | DS | 2 | 2185-02-28 00:00:00 | 2185-03-07 21:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
nausea and vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female with past medical history
of hypothyrodism who was doing well until yesterday. She had
three episodes of nonbloody emesis followed by fourth episode at
8 am with streak of blood. She did well throughout the day
until 6 pm when she had one cup full of hematemesis leading her
to present to the ED.
In the ED, initial vitals were HR 66 and BP 121/72. She had ___
cup of hematemesis in the ED. Nasogastric lavage returned >300
cc coffee ground material. Guiaic positive on rectal exam. ROS
positive for heavy menstrual bleeding. Labs notable for HCT of
39.5, normal coags but platelet of 5. Hematology was consulted
and with high probability of ITP, gave IV solumedrol 125 mg for
ITP and jumbo pack of platelets. She was given 1LNS. She was
subsequently transferred to MICU for further evaluation.
In the MICU, she reports no other complaints. She does not
report history of easy bleeding, nose bleeds or bleeding gums.
Her only change in deit has been 2 week history of hawaiin punch
coolaid. She does not drink tonic water. Travel notable for
___ cod two weeks ago when she had pedal edema for one day.
She does not report viral symptoms or sick contacts.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
Hypothyroidism s/p total thyroidectomy and RAI for thyroid
Cancer x ___ years ago
Social History:
___
Family History:
DM2, HTN
Physical Exam:
ADMISSION:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL.
Petechiae under her tongue
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-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
DISCHARGE:
VITALS: 98.2 (97.8-98.3), BP 134/83 (112/65 - 137/80), HR 50
(50-64), RR 16 (___), O2 99%RA (98-99%)
GEN: ___ female, pleasant, alert and fully
oriented, in no acute distress.
HEENT: NCAT, Moist mucous membranes, EOMI, sclera anicteric, no
conjunctival abnormalities, Oropharynx clear, petechia on palate
NECK: supple, no JVD, no lymphadenopathy
LUNGS: Good aeration, clear to auscultation bilaterally, no
wheezes, rales, or ronchi
HEART: Regular rate and rhythm, normal S1/S2, no murmurs, rubs,
gallops
ABD: soft, NT, ND, hypoactive bowel sounds, no rebound
tenderness or guarding, no CVA tenderness
EXT: Upper and lower extremity pulses palpable bilaterally, no
clubbing, cyanosis, or edema. Moves extremities spontaneously
NEURO: Alert and oriented x3. CNII-XII normal. No focal
deficits. Motor function grossly normal
SKIN: clustered area of purpura on left forearm acquired during
hospital stay, which is now improving from over the wknd. Area
of petechia and ecchymosis on right arm. Dark rash on left side
of neck attributed to ___ eczema flares
Pertinent Results:
ADMISSION:
___ 07:57PM BLOOD WBC-4.9 RBC-4.86 Hgb-13.3 Hct-39.8 MCV-82
MCH-27.3 MCHC-33.3 RDW-13.1 Plt Ct-5*
___ 11:49PM BLOOD WBC-5.0 RBC-4.28 Hgb-11.7* Hct-35.2*
MCV-82 MCH-27.5 MCHC-33.4 RDW-13.0 Plt Ct-44*#
___ 07:57PM BLOOD Plt Smr-RARE Plt Ct-5*
___ 11:49PM BLOOD Plt Ct-44*#
___ 07:57PM BLOOD ___ PTT-30.2 ___
___ 07:57PM BLOOD ALT-19 AST-43* LD(LDH)-646* AlkPhos-61
TotBili-0.3
___ 07:57PM BLOOD Hapto-272*
___ 07:57PM BLOOD Albumin-4.0
___ 07:57PM BLOOD Glucose-87 UreaN-9 Creat-0.8 Na-139
K-5.5* Cl-107 HCO3-25 AnGap-13
DISCHARGE:
___ 07:00AM BLOOD WBC-12.2*# RBC-4.54 Hgb-12.6 Hct-37.0
MCV-81* MCH-27.8 MCHC-34.1 RDW-13.3 Plt Ct-81*
___ 07:20AM BLOOD Glucose-88 UreaN-10 Creat-0.7 Na-139
K-3.7 Cl-108 HCO3-26 AnGap-9
___:25AM BLOOD HIV Ab-NEGATIVE
HCV-negative
.
CXR-negative
.
___ positive at 1:40
Brief Hospital Course:
Ms. ___ is a ___ year old af am female with past medical
history of thyroid cancer s/p
thyroidecomy and RAI ___ years ago who presented with bloody
emesis after nausea and vomiting and noted to have severe
thrombocytopenia to 5. Initially managed in ICU with IVIG and
PLT transfusion, then transferred to the floor where a diagnosis
of ITP was made.
.
# Thrombocytopenia: Most likely due to immune thrombocytopenic
purpura. Differential includeed aspartame induced
thrombocytopenia from her hawaiin cool aid, infections (HIV or
HepC) induced thromboyctopenia. Peripheral smear without
shistocytes argued against TTP. Normal coagulopathy. No new
medications to suspect cause of thrombocytopenia . In the ICU,
the patient was started on IV solumedrol 125 mg and gave 1 unit
of platelets. PLT increased to 44 then trended back down, so pt
was started on IVIG. No signs of active bleeding with stable
Hct. Pt was transitioned IV steroids to prednisone 100 mg po
qdaily (1mg/kg). Checked HIV ab and HepC ab, HCV VL, HIV VL
(all negative). After transfer from ICU, pt was continued on PO
Prednisone 1mg/kg, and PLTs trended up, and on discharge were
88. On day of discharge Pt was at her home functional baseline,
tolerating a full diet, moving her bowels, and urinating. There
were no s/s of bleeding. She was discharged on a regimen of 50mg
prednisone BID (pt preference to take BID rather than 100mg
daily).. Taper will be directed by hematology. She was
instructed to follow up for serial CBC monitoring. ITP could
have been promoted by H.pylori, see below.
++++ Pt should continue bactrim for PCP ppx as well as calcium
and vitamin D for bone health while on prednisone therapy.
.
# HEMATEMESIS/UGIB: Differential includes ___ tear
complicated by thrombocytopenia vs peptic ulcer disease vs
variceal bleeding vs gastitits vs dieulafoy's lesion, no history
of NSAID use. Initially managed in ICU. HCT and hemodynamically
stable during entire admission. Pt never experienced any
evidence of GIB during admission. HPylori test done and was
positive. Pt was started on triple therapy of Omeprazole PO,
Clarithromycin 500mg BID, and Amoxicillin 1g BID x 14 days. We
recommended the patient to follow up with GI for an EGD
.
#leukocytosis-likely a result of steroid use. No signs of
infection noticed during admission. Would monitor CBC after
discharge.
.
## TRANSITIONAL
- Discuss with your PCP about EGD to definitively evaluate for
cause of hematemesis and to evaluate for PUD.
- Discuss with Hematology regarding Prednisone taper/dosing
- Monitor your blood glucose since you are now on Prednisone.
Medications on Admission:
. Information was obtained from .
1. Levothyroxine Sodium 175 mcg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 175 mcg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp #*27
Capsule Refills:*0
4. Clarithromycin 500 mg PO Q12H
RX *clarithromycin 500 mg 1 tablet(s) by mouth twice a day Disp
#*27 Tablet Refills:*0
5. Amoxicillin 1000 mg PO Q12H
RX *amoxicillin 500 mg 2 capsule(s) by mouth twice a day Disp
#*54 Capsule Refills:*0
6. PredniSONE 50 mg PO BID
RX *prednisone 50 mg 1 tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*0
7. Outpatient Lab Work
Labs: ___
Please Fax Results To:
Dr. ___
___
ICD-9 287.31
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *Bactrim DS 800 mg-160 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
- Idiopathic Thrombocytopenic Purpura
- Hematemesis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
Thank you for choosing ___. You were admitted for vomiting
blood in the setting of a very low platelet count due to ITP
("immune thrombocytopnia"). You were stabilized in the Intensive
Care Unit with platelet transfusion, Intravenous immunoglobulin
(IVIG), and steroids. With these interventions your platelet
count increased so you are safe for discharge home with
Hematology follow-up. Please have outpatient blood tests done
in 3 days (on ___ to check your platelets, which will
be followed up by Hematology. You have been given a lab slip
for this.
The cause of your initial vomiting and blood are unclear. You
might have had a viral illness causing wretching, resulting in a
small esophageal tear. But it is also possible that you could
have peptic ulcers, which could be supported byt the fact that a
tests suggested that you have H.pylori, a bacteria which can
cause ulcers. You should complete a 2 week course of
antibiotics/acid suppressors in order to eliminate this bacteria
(Amoxicillin, Clarithromycin, and Omeprazole). In addition, you
should have an EGD (upper endoscopy), which has been scheduled
for you.
While on the antibiotics, you should be aware they can cause
side effects of easy sun burn, interactions with alcohol, and
birth defects. Please avoid the sun and use sunblock, minimize
or avoid alcohol consumption, and use two methods of
contraception.
MEDICATIONS
- Start Prednisone (this medication will be tapered down based
on your discussion at your upcoming Hematology appointment)
- Start Omeprazole, Amoxicillin, and Clarithromycin for 2 weeks
Followup Instructions:
___
|
10251310-DS-13 | 10,251,310 | 25,264,026 | DS | 13 | 2124-12-13 00:00:00 | 2124-12-13 18:42:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex / Lipitor / Lasix / meropenem / Colace / doxycycline /
Opioids - Morphine Analogues / Valium
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female with history of ___ transferred to ___ ___ on
___ from her rehab facility for concern for seizure. Of note,
this patient is known to the Neurosurgery service and Dr.
___ a mild TBI and L1 compression fracture s/p fall on
___. We recommended no bracing and follow-up in clinic in 4
weeks with repeat XRs. She was at her rehab when she was noted
to
have uncontrollable shaking of her hands. She was then lowered
to
the ground - no LOC or head strike. Upon arrival to the ___, her
FSBS was in the ___ and she was treated for hypoglycemia. During
the ___ evaluation, she endorses midline tenderness to
palpation
over the lumbar spine for which CT L-Spine was ordered and
showed
worsening of her known L1 compression fracture. Neurosurgery
called to evaluate.
Patient has not been ambulating much at rehab, and has been
using
a walker when doing so. Feels generally weaker, but no focal or
acute weakness. Has chronic right-sided weakness from her MS.
___ numbness/tingling in the extremities, saddle anesthesia
and urinary/fecal incontinence. Lumbar pain has been stable.
Good
relief with Lidoderm patches.
Past Medical History:
PMHx:
Multiple sclerosis
Borderline high BP/cholesterol
Osteoarthritis left knee
Mild TBI and mild L1 compression fracture s/p fall ___
PSHx:
s/p Tonsillectomy
s/P Appendectomy
s/p Excision of chest over breast
Social History:
___
Family History:
NC
Physical Exam:
ON ADMISSION
============
Gen: Elderly woman, no acute distress.
HEENT: PERRL, EOMs grossly intact.
Neck: Supple.
Extremities: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT ___ G
R 5 5 5 5 5 4 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch bilaterally.
Rectal exam deferred (pt in hallway at time of exam, no
concerning symptoms and reassuring exam)
DISCHARGE PHYSICAL EXAM:
===============
Vitals: T98.0, BP 126/75, HR 88, RR 18, 96% Ra
General: Lying comfortably in bed. Alert, oriented, no acute
distress
HEENT: Sclera anicteric, oropharynx clear, dry oral mucosa
Lungs: Clear to auscultation bilaterally, no wheezes or crackles
CV: Regular rate and rhythm; normal S1 + S2; no murmurs, rubs,
gallops
Abdomen: soft, non-tender, distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no edema
Neuro: Short term memory losses, no focal deficits. Intention
tremor in both hands, no resting tremor.
Pertinent Results:
LABS UPON ADMISSION
===========
___ 03:21PM WBC-13.0* RBC-4.71 HGB-14.5 HCT-44.8 MCV-95
MCH-30.8 MCHC-32.4 RDW-13.9 RDWSD-48.8* 1
___ 03:21PM PLT COUNT-383
___ 03:21PM NEUTS-80.7* LYMPHS-12.8* MONOS-4.5* EOS-0.8*
BASOS-0.5 IM ___ AbsNeut-10.50* AbsLymp-1.66 AbsMono-0.59
AbsEos-0.10 AbsBaso-0.07
___ 03:21PM cTropnT-<0.01
___ 03:21PM GLUCOSE-100 UREA N-14 CREAT-0.8 SODIUM-140
POTASSIUM-5.1 CHLORIDE-100 TOTAL CO2-23 ANION GAP-17
___ 06:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-300* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
LABS UPON DISCHARGE
================
___ 05:50AM BLOOD WBC-8.3 RBC-4.39 Hgb-13.6 Hct-41.9 MCV-95
MCH-31.0 MCHC-32.5 RDW-14.3 RDWSD-49.9* Plt ___
___ 05:50AM BLOOD Glucose-113* UreaN-26* Creat-0.8 Na-143
K-4.1 Cl-105 HCO3-25 AnGap-13
___ 07:33AM BLOOD %HbA1c-5.9 eAG-123
___ 05:50AM BLOOD TSH-2.4
IMAGING STUDIES
=================
-MRI head w/ w/o contrast (___)
IMPRESSION:
1. Periventricular and subcortical T2/FLAIR nonenhancing ___
matter
hyperintensities are in a distribution compatible with
demyelinating plaques
given the history of multiple sclerosis, unchanged from outside
hospital exam.
No new lesions.
2. There is interval development of tiny focus of postcontrast
enhancement at
left occipital lobe without signal abnormality on other
sequences. This may
represent a capillary telangiectasia. This could be followed in
3 months to
document stability.
3. Cortical based multiple chronic microhemorrhages suggestive
of cerebral
amyloid angiopathy.
4. Resolving extra-axial hemorrhage as described above.
-CT L-spine (___):
Transitional anatomy noted at the lumbosacral junction.
Assuming the last
rib-bearing level is T12, there is partial sacralization of L5.
Compression fracture of L1 was present on prior exam from
___,
however there has been interval height loss since that time.
There is now 40%
vertebral body height loss, previously 20% vertebral body height
loss. There
is also now retropulsion of the superior aspect of the vertebral
body by
approximately 6 mm. There is paraspinal edema. No other
fracture.
Minimal anterolisthesis of L3 on L4 is unchanged. Remaining
vertebral bodies
are well aligned.
Degenerative changes most notable as follows:
At L2-3, facet joint hypertrophy on the left contributes to
moderate left foraminal narrowing.
At L3-4, there is a disc bulge and facet joint hypertrophy
contributing to mild to moderate canal narrowing though no
significant foraminal narrowing.
At L4-5 there is intervertebral disc height loss, vacuum disc
phenomenon and
disc bulge. In combination with facet joint hypertrophy there is
mild canal
narrowing and minimal foraminal narrowing, right worse than
left.
There is distension of the bladder which is partially
visualized.
Atherosclerotic calcifications noted in the abdominal aorta
which is normal in
caliber.
IMPRESSION:
Compression deformity at L1 has progressed since ___, now with
40%, previously 20% vertebral body height loss and new
retropulsion into the
canal.
-CT C-spine (___):
Minimal anterolisthesis of C6 on C7 is noted, this is likely
degenerative
given chronic changes at the facets, more extensive on the left
than on the
right. Remaining vertebral bodies are preserved in alignment
and they are
preserved in height throughout. Degenerative changes include
intervertebral
disc height loss and posterior osteophytes and uncovertebral
joint hypertrophy
most notable at C4-5 and C5-6. Facet joint hypertrophy is most
extensive on
the right at C2-3 and C3-4. There is no significant canal
narrowing. Mild to
moderate left foraminal narrowing noted at C3-4. There is no
prevertebral
edema.
Thyroid and lung apices are unremarkable.
IMPRESSION:
Degenerative changes without fracture or traumatic malalignment.
-CT head noncon (___):
FINDINGS:
There is no intra-axial or extra-axial hemorrhage, mass, midline
shift, or
acute major vascular territorial infarct. Mild subcortical
___ matter ___
matter hypodensities are likely sequela of chronic small vessel
disease.
Ventricles and sulci are age-appropriate. Basilar cisterns are
patent.
Included paranasal sinuses and mastoids are essentially clear.
Skull and
extracranial soft tissues are unremarkable.
IMPRESSION:
No acute intracranial process.
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
===================
___ female with history of MS and recent falls c/b SDH,
subarachnoid hemorrhage, and L1 compression fracture who
presented from her rehab facility for episode of acute shaking
and hypoglycemia. She was evaluated by neurology, found to have
postural instability associated with proximal muscle weakness in
the setting of disuse. She was evaluated by ___ for CT L-spine
showing interval worsening with retropulsion but no signs for
acute cord compression, managed conservatively. Pt was fitted
for thoracic brace.
See course by problem below for details.
TRANSITIONAL ISSUES:
=================
[] Follow-up MRI in 3 months to monitor stability of new
capillary teleangiectasia found on MRI
[] TLSO brace for all OOB activity or HOB > 30 degrees. Okay to
___ at edge of bed. Brace has been refitted properly by ortho
tech.
[] Follow up with Dr. ___ in ___ (___) in 3 weeks
with lumbar spine XR (AP and lateral) for L1 compression
fracture
[] Continue to assess ___ goals given neurology concerns over
previous overly-aggressive ___ regimen
[] home amantadine reported to be taken 100mg daily by patient
and son, stated that it is prescribed BID for insurance
# CODE: Full code
# CONTACT:
Health Care Proxy: VERIFIED ON: ___
Proxy name: ___
Relationship: Son Phone: ___
ACUTE ISSUES:
============
#Acute Shaking Episode
#Tremors
History of 6 months of progressively worsening episodes of
tremors, mostly of her upper extremities, presented with new
whole body shaking with preserved consciousness. Family believed
associated with moments of stress. There was initial concern for
seizures vs. convulsive syncope vs. MS progression, with
possible contribution from hypoglycemia. While hypoglycemia
possible in setting of poor PO intake, no hypoglycemia detected
during admission. EKG was without suspicion of new arrhythmia.
HEAD MRI revealed unchanged demyelinating plaques and chronic
microhemorrhages suggestive of cerebral amyloid angiopathy with
a new capillary telangiectasia (follow up MRI recommended for 3
months). EEG showed no seizure activity or tendency. TSH, LFTs
WNL except slightly elevated alk phos. Neurology was consulted
to evaluate the patient's tremors. Her tremors were thought to
be from postural instability, induced by attempting to
compensate for her severe proximal ___ weakness(R>L) in
setting of chronic microvascular disease and MS. ___ evaluated by
___ with recommendation to discharge to rehab. It is anticipated
patient will be in rehab for less than 30 days.
#L1 compression fracture
Recent admission ___ ___ischarged to rehab. This
admission she was initially evaluated by neurosurgery with no
surgical intervention although CT L-spine showed interval
worsening with retropulsion. No signs for acute cord
compression. Fitted for TLSO brace which she must ___ with all
activity and head of bed above 30 degrees. She will follow up
with neurosurgery as an outpatient. Pain was managed with APAP
standing, Lidoderm patch qAM and lidocaine cream qPM.
#Hypoglycemia
Notably patient not diabetic but was found with FSBG 50, most
likely from poor PO intake. Follow up labs glucose in the 100s
and no hypoglycemia while monitored inpatient. HbA1c 5.9%.
CHRONIC ISSUES:
==============
#MS
MRI brain showed no new lesions.
Continued home amantadine 100mg daily.
CODE: Full code
CONTACT:Health Care Proxy: VERIFIED ON: ___
Proxy name: ___
Relationship: Son Phone: ___
Proxy form in chart?: No
[x]>30 minutes spent on discharge planning and care coordination
on day of discharge. Patient seen and examined on day of
discharge
Medications on Admission:
1. Amantadine 100 mg PO BID - note pt and son reported taking
once daily
2. biotin 10 mg oral Daily
3. brimonidine-timolol 0.2-0.5 % ophthalmic (eye) 1 gtt L eye
BID
4. Calcium Carbonate 1200 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies
7. Multivitamins 1 TAB PO DAILY
8. Polyethylene Glycol 17 g PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
3. Lidocaine 5% Ointment 1 Appl TP QPM back pain
4. Lidocaine 5% Patch 1 PTCH TD QAM
5. Senna 8.6 mg PO BID:PRN Constipation - First Line
6. Amantadine 100 mg PO BID
7. biotin 10 mg oral Daily
8. brimonidine-timolol 0.2-0.5 % ophthalmic (eye) 1 gtt L eye
BID
9. Calcium Carbonate 1200 mg PO DAILY
10. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies
11. Multivitamins 1 TAB PO DAILY
12. Polyethylene Glycol 17 g PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Proximal muscle weakness
Postural instability
SECONDARY DIAGNOSES
L1 compression fracture
Cerebral amyloid angiopathy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair. Brace required OOB and HOB >30
Discharge Instructions:
Dear Ms. ___,
It was a privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
- You were found to be shaking while at rehab
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
- You had an MRI of your brain. There were no new MS changes on
this MRI compared to your last MRI in ___. The MRI
detected evidence of a vessel disease you had been diagnosed
with in the past (cerebral amyloid angiopathy).
- You had an EEG to measure electrical signals from your brain.
It did not detect evidence of seizure activity.
- You were assessed by neurologists for your shaking. The
shaking was related to muscle weakness as a result of being less
active overall.
- You were assessed by neurosurgeons for your spine fracture.
You were given a brace to wear out of bed.
- Physical therapists worked with you to get in and out of bed
and get used to the brace.
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.
- Wear your brace whenever you leave bed or are sitting upright.
It is okay to put on the brace while you are sitting.
- A follow-up MRI to monitor the vessels in your brain was
recommended for three months from now.
We wish you all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10251549-DS-18 | 10,251,549 | 24,892,555 | DS | 18 | 2122-02-02 00:00:00 | 2122-02-02 15:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
n/v/weakness and elevated troponin
Major Surgical or Invasive Procedure:
ERCP with sphincterotomy ___
History of Present Illness:
___ with hx bradycardia s/p ___ presenting as a transfer from
___ with elevated troponin. He originally presented to
___ with N/V and weakness. He started having nausea last
evening and vomited "all night long". Poor appetite, decreased
UOP. No D/C, fever/chills or dark/bloody bowel movements. Denies
any chest pain or difficulty breathing. He had labs done and a
RUQ US @ ___ as noted below. Surgery @ OSH do not believe
the RUQ US represented cholecystitis. He was found to have a
trop of 0.15 so he was started on a heparin gtt with bolus and
transferred to ___. Required Zofran @ OSH and en route for
ongoing nausea. Notes currently he has some right sided
"soreness" which started after he started vomiting and "I think
it's a pulled muscle". Per EMS report and ER report he had
PVCs/ectopy.
In the ED initial vitals were: 99.1 76 176/81 16 91% RA.
EKG: v-paced
Labs/studies notable for: abc elevated to 17.5, chemistries
including creatinine WNL, trop <0.01, lactate 1.6, normal liver
panel, PTT: 52.6 INR: 1.2. RUQ US: Gallstones, borderling wall
thickness, no biliary dilation, neg sonographic ___
CXR: No acute cardiopulmonary process
Patient was given: IV heparin and 243 mg ASA.
Discussed with cards, agree with admission for medical
management of suspected ACS.
Vitals on transfer: 65 164/75 16 94% RA
On the floor patient only complains of nausea. He is alert and
oriented to person and place but cannot provide his medical
history or his wife's (HCP) contact information
Past Medical History:
1. CARDIAC RISK FACTORS: +hypertension, -dyslipidemia, -diabetes
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: PPM
3. OTHER PAST MEDICAL HISTORY:
Prostate CA (radiation therapy in ___ complicated by bowel
incontinence and impotence
b/l hearing loss
Bradycardia (s/p pacemaker)
recurrent UTI
Hiatal hernia
Aortic aneurysm
intermittent diplopia : s/p prisms
peripheral neuropathy with gait disturbance
hypothyroidism
left and right knee replacements
vertebral fusion
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
===================================
ADMISSION PHYSICAL EXAM:
===================================
VS: T=97.6 BP=157/55 HR=74 RR= 14 O2 sat= 95% 2L
GENERAL: cachectic man in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 8 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars.
PULSES: Distal pulses palpable and symmetric
===================================
DISCHARGE PHYSICAL EXAM:
===================================
97.4PO 120 / 61 73 20 94 ra
Gen: NAD, lying in bed
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear
Cardiovasc: RRR, no MRG
Resp: normal effort, no accessory muscle use, lungs CTA ___.
GI: soft, NT, ND, BS+
MSK: No edema
Skin: Erythematous macules and papules on back
Neuro: AAOx3. Good attention, reasoning
Psych: Full range of affect
Pertinent Results:
===================================
ADMISSION LABS:
===================================
___ 05:15PM BLOOD WBC-17.5* RBC-5.10 Hgb-14.6 Hct-44.6
MCV-88 MCH-28.6 MCHC-32.7 RDW-14.0 RDWSD-45.1 Plt ___
___ 05:15PM BLOOD Neuts-90.8* Lymphs-3.2* Monos-5.2
Eos-0.0* Baso-0.1 Im ___ AbsNeut-15.88* AbsLymp-0.56*
AbsMono-0.91* AbsEos-0.00* AbsBaso-0.01
___ 05:15PM BLOOD ___ PTT-52.6* ___
___ 05:15PM BLOOD Glucose-165* UreaN-31* Creat-0.9 Na-140
K-3.7 Cl-102 HCO3-25 AnGap-17
___ 05:15PM BLOOD ALT-8 AST-25 CK(CPK)-91 AlkPhos-49
TotBili-0.8
___ 05:15PM BLOOD Lipase-738*
___ 05:15PM BLOOD CK-MB-3
___ 05:15PM BLOOD cTropnT-<0.01
___ 09:05PM BLOOD CK-MB-3 cTropnT-<0.01
___ 06:00AM BLOOD cTropnT-<0.01
___ 05:15PM BLOOD Albumin-4.0
___ 06:00AM BLOOD Calcium-8.9 Phos-2.7 Mg-2.0
___ 06:00AM BLOOD Triglyc-123
___ 05:18PM BLOOD Lactate-1.6
===================================
DISCHARGE LABS:
===================================
___ 06:30AM BLOOD WBC-10.1* RBC-4.37* Hgb-12.3* Hct-39.0*
MCV-89 MCH-28.1 MCHC-31.5* RDW-13.9 RDWSD-45.6 Plt ___
___ 06:30AM BLOOD Glucose-150* UreaN-21* Creat-1.0 Na-138
K-3.4 Cl-95* HCO3-28 AnGap-18
___ 06:30AM BLOOD Calcium-8.3* Phos-3.4 Mg-2.0
===================================
IMAGING:
===================================
CT A&P ___
1. Acute pancreatitis with focal parenchymal necrosis involving
the mid to distal body with peripancreatic stranding. No
associated vascular
complications as detailed above.
2. Scattered punctate pancreatic parenchymal foci of
calcification, likely from prior pancreatitis.
3. Free fluid in the pelvis and right paracolic gutter.
4. Left renal intermediate density cyst, may be a hemorrhagic or
proteinaceous cyst.
5. Hiatal hernia containing nonobstructed stomach.
6. Severe osteopenia and severe compression deformity of T12
likely chronic given absence of perivertebral hematoma.
TTE ___
Conclusions
The left atrium and right atrium are normal in cavity size.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is mildly dilated. There is mild to moderate
regional left ventricular systolic dysfunction with near
akinesis of the inferior and distal anterior wall and apex.
There is a small apical left ventricular aneurysm. There is mild
hypokinesis of the remaining segments. Quantitative (biplane)
LVEF = 36 %. The estimated cardiac index is normal
(>=2.5L/min/m2). A left ventricular mass/thrombus cannot be
excluded due to suboptimal image quality. Right ventricular
chamber size and free wall motion are normal. The aortic root is
moderately dilated at the sinus level. The ascending aorta and
aortic arch are mildly dilated. The aortic valve leaflets (?#)
appear structurally normal with good leaflet excursion. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. Moderate (2+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Left ventricular cavity
dilation with regional systolic dysfunction suggestive of
multivessel CAD. Moderate pulmonary artery systolic
hypertension. Moderate mitral regurgitation. Mild aortic
regurgitation. Dilated thoracic aorta.
___ Liver Gallbladder ultrasound:
Sludge in the gallbladder without evidence of stones for acute
cholecystitis.
___ ERCP:
Impression: The ___ film was normal.
Normal major papilla was noted.
Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique.
Contrast medium was injected resulting in complete
opacification.
During initial cholangiogram small filling defect was noted.
The CBD was normal in caliber.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
No evidence of post sphincterotomy bleeding was noted.
Small amount of sludge was extracted successfully using a
Balloon.
Final cholangiogram showed no evidence of filling defects.
Post balloon sweeps good contrast drainage was noted both
endoscopically and fluoroscopically.
Otherwise normal ercp to third part of the duodenum
Recommendations: NPO overnight with aggressive IV hydration
with LR at 200 cc/hr
If no abdominal pain in the morning, advance diet to clear
liquids and then advance as tolerated
Return to ward under ongoing care.
No aspirin, Plavix, NSAIDS, Coumadin for 5 days.
Continue with antibiotics - Ciprofloxacin 500mg BID x 5 days.
Follow for response and complications. If any abdominal pain,
fever, jaundice, gastrointestinal bleeding please call ERCP
fellow on call ___
Brief Hospital Course:
___ with a history of HTN, bradycardia s/p PPM, pAfib not on
anticoagulation, prostate cancer s/p XRT in ___, and a hiatal
hernia, who presented as transfer from ___ for elevated
troponin, was treated medically for an NSTEMI with TTE showing
EF<40%, and was transferred to medicine when he was found to
have a leukocytosis, elevated lipase, and CT A/P concerning for
acute pancreatitis, now s/p ERCP and transferred to ___.
#Acute Pancreatitis: Presented to ___ initially with
complaints of nausea. Here, found to have elevated lipase and CT
scan evidence of pancreatitis. ___ ultrasound showing
gallstones and ultrasound here showing sludge. Likely secondary
to passed stones/sludge. No significant alcohol intake. S/p ERCP
with sphincterotomy and sludge clearance on ___. Currently pain
free, tolerating regular diet. Surgery was consulted and felt
patient was not surgical candidate for cholecystectomy given his
age and comorbidities. Will need Cipro for 5 days post procedure
until ___. Hold all anti-plts and anticoagulants for 5 days
including home aspirin. Aspirin should be resumed on ___.
#Acute toxic metabolic encephalopathy: Likely multifactorial in
etiology from age, acute illness, acute pancreatitis and NSTEMI,
anesthesia after ERCP. Now improved, at baseline mental status.
#Troponinemia: When patient initially presented to ___, he
had nausea, vomiting, and an elevated troponin. At ___, his
troponins were negative x3. He was started on a heparin gtt in
the ED, and was admitted over concern for an NSTEMI. Heparin gtt
was discontinued on ___ and he has remained free of chest pain
Troponin elevation more likely in the setting of demand ischemia
rather than type 1 NSTEMI. He was continued on his BB, ___ and
statin. Holding ASA for 5 days post sphincterotomy then should
be resumed on ___.
#Acute systolic CHF: TTE on ___ showed EF 40% and well as LV
aneurysm. This is decreased from a recent echo demonstrating EF
= 50% in ___. BNP>11K. After receiving fluids in the setting of
pancreatitis, patient went from room air to a 2.5L oxygen
requirement with pulmonary edema on CXR and crackles on physical
exam. This improved when IVF were stopped and given dose of IV
Lasix while on cardiology service. Now on room air, no crackles,
appears euvolemic. He was resumed on his home dose Lasix, BB,
___. Stopped propafenone as it is contraindicated in heart
failure. Cardiology recommended repeat nuclear perfusion study
as outpatient.
#LV Aneurysm: Noted on TTE. Patient was previously felt not to
be candidate for anticoagulation for his pAfib given history of
falls so anticoagulation was not started for this indication
after discussion with cardiology. Patient will follow up with
his outpatient cardiologist.
# pAfib: Not on anticoagulation due to history of falls. Will
stop propafenone as contraindicated in CHF. Will have patient
follow up with his cardiologist ___ in ___
___.
#Depression: Continue home SSRI
#BPH with history of prostate cancer: continue home finasteride,
Flomax.
#Hypothyroid: Continue home synthroid dose
#Constipation: Had large BM ___. Senna/Colace standing, add on
miralax and
bisacodyl prn
#CODE: Full code
#CONTACTS:
-wife ___
-Daughter ___
Transitional Issues:
-Complete 4 more days of ciprofloxacin
-Resume Aspirin 81mg on ___
-Cardiology follow up (scheduled)
>30 min spent on day of discharge in care coordination
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Propafenone HCl 150 mg PO TID
3. Levothyroxine Sodium 88 mcg PO DAILY
4. Finasteride 5 mg PO DAILY
5. Tamsulosin 0.8 mg PO QHS
6. Citalopram 20 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Furosemide 20 mg PO DAILY
9. Furosemide 20 mg PO 3X/WEEK (___)
Discharge Medications:
1. Citalopram 20 mg PO DAILY
2. Finasteride 5 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Levothyroxine Sodium 88 mcg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Tamsulosin 0.8 mg PO QHS
7. Ciprofloxacin HCl 500 mg PO Q12H Duration: 4 Days
8. Atorvastatin 20 mg PO QPM
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Sarna Lotion 1 Appl TP QID:PRN itch/rash on back
11. Senna 17.2 mg PO BID
12. Valsartan 80 mg PO DAILY
13. TraZODone 25 mg PO HS:PRN insomnia
14. Furosemide 20 mg PO 3X/WEEK (___)
In addition to 20mg daily dose
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- acute pancreatitis
- systolic congestive heart failure
- hypertension
Secondary diagnoses:
- depression
- BPH
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. You were admitted to ___
with nausea and fatigue. Your labs showed injury to your heart,
but this improved with time. You also had imaging of your heart
that showed it was not pumping very strong. It will be very
important that you take your heart medicines and follow up with
a cardiologist.
While you were here, your labs and CT scan also showed that you
had inflammation of your pancreas (called pancreatitis). The
pancreas doctors did ___ procedure called an ERCP, and performed a
sphincterotomy and drained sludge from your bile duct. The
surgeons were consulted and did not recommend that you have your
gall bladder removed as it would be high risk given your age and
other health conditions. Please do not resume your aspirin until
___ since you had a sphincterotomy and don't want it to
bleed.
Followup Instructions:
___
|
10251549-DS-19 | 10,251,549 | 24,852,593 | DS | 19 | 2123-03-11 00:00:00 | 2123-03-11 18:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nausea, vomiting, NSTEMI
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Per admission note:
___ hx AF/Coumadin and SSS s/p PPM, aortic aneurysm, sCHF EF
30%, presented to BIDP with n/v and confusion. Pt was in USOH
until 3am ___, when he developed sudden onset of nv and
confusion. Wife brought him to ___ where labs showed AST32, ALT
23, tbili 1.2, lipase 18, WBC 14.5, CTAP with IVPO and RUQUS
showed evidence of acute chole. Received 2LNS, zosyn. Also with
NSTEMI, no ECG changes, likely Type II; did not get ASA. Eval by
BIDP surgery recommended txf to ___ for complex surgery vs
perc drainage by ___. At BIDP, Patient denies a complete ROS
otherwise, though is A&Ox1.
On arrival, pt denies any pain or present symptoms. Now AOx3 and
can say ___ backwards."
In the ED, initial vitals: Temp 98.5 F HR 74 125/71 RR 18 96% RA
- Exam notable for:
alert, oriented x3 (person, hospital in ___, ___
can say ___ backwards
c/p exams normal
abd sntnd, neg ___
- Labs notable for:
WBC 15K hbg 11 MCV 78 plt 292 neutrophils 90%
PTT 31 INR 1.6
Na+ 142 K+ 4.6 HCO3- 16 BUN 23 Cr 1.0
Trop 0.13, MB 7 and 0.15
Lactate 3.2-->3.0-->2.4
LFTs normal lipase 16 Tbili 0.08 alb 3.6
UA >1.050 no WBCs, bacteria
- Imaging notable for:
- Pt given:
0056 ___ APAP 650 mg
0056 ___ ASA 324 mg
0132 ___ Zoysn 4.5 mg
0747 ___ heparin gtt started
- EKG at BIDP: "COMPARED WITH PRIOR ECG WIDE QRS COMPLEXES C/W
RV PACING ARE NEW"
- EKG at ___ (at 18:11): continues to have V-paced, wide QRS
complexes
- Vitals prior to transfer: 98.3 F HR 63 134/63 RR 15
100% NC
In the ED, Mr. ___ was complaining of chest pain and found
to have a troponin of 0.13
On the floor, Mr. ___ was picking at his unfinished
dinner. He reports no pain anywhere. He states he came to the
hospital three days ago because he had nausea and vomiting at
home, and his wife called EMS. He is currently denying any
abdominal pain, nausea, vomiting, diarrhea, although he does
note loss of appetite.
He also denied chest pain, heart palpitations, confusion,
shortness of breath, any swelling anywhere, rashes, pain,
numbness, or headache.
He was able to name the place, month, year, his DOB correctly.
He could not recall his wife ___ phone number.
When asked about his medical history, he stated he has a
pacemaker and neuropathy. He cannot remember any of his
medications as his wife takes care of them.
REVIEW OF SYSTEMS:
Pan negative with the exception of loss of appetite, per HPI.
Past Medical History:
1. CARDIAC RISK FACTORS: +hypertension, -dyslipidemia, -diabetes
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: PPM
3. OTHER PAST MEDICAL HISTORY:
Prostate CA (radiation therapy in ___ complicated by bowel
incontinence and impotence
b/l hearing loss
Bradycardia (s/p pacemaker)
recurrent UTI
Hiatal hernia
Aortic aneurysm
intermittent diplopia : s/p prisms
peripheral neuropathy with gait disturbance
hypothyroidism
left and right knee replacements
vertebral fusion
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 98.2 BP134 / 71 HR67 RR20 95%3.5L
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMD, no JVD
CV: Regular rate and rhythm, normal S1S2, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, no tenderness even over ___,
non-distended, bowel sounds present, no organomegaly, no rebound
or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: moving all extremities equally, gait deferred.
DISCHARGE PHYSICAL EXAM:
========================
VITALS: T 98.0, HR 60, BP 131/45, RR 20, O2 94% RA
GENERAL: NAD, lying comfortably in bed
HEENT: PERRL, EOMI, MMM
NECK: supple, no JVD
CV: regular with rare ectopy, normal rate, S1/S2, II/VI
diastolic
murmur left sternal border
RESP: conversational dyspnea resolved, unlabored, rare scattered
bibasilar
crackles bilaterally
GI: soft, normoactive BS, non-distended, non-tender, no ___
___: no spinous process tenderness
SKIN: scattered ecchymoses
NEURO: awake, alert, conversant, oriented x3, ___ strength
throughout, sensation intact throughout
Pertinent Results:
ADMISSION LABS:
===============
___ 10:15PM BLOOD WBC-15.1* RBC-4.78 Hgb-11.3* Hct-37.2*
MCV-78*# MCH-23.6*# MCHC-30.4* RDW-18.6* RDWSD-51.1* Plt ___
___ 10:15PM BLOOD Neuts-89.9* Lymphs-2.9* Monos-6.3
Eos-0.1* Baso-0.1 Im ___ AbsNeut-13.59* AbsLymp-0.44*
AbsMono-0.96* AbsEos-0.01* AbsBaso-0.02
___ 10:15PM BLOOD ___ PTT-31.1 ___
___ 10:15PM BLOOD Glucose-167* UreaN-23* Creat-1.0 Na-142
K-4.6 Cl-105 HCO3-19* AnGap-18*
___ 10:15PM BLOOD ALT-21 AST-29 AlkPhos-68 TotBili-0.8
___ 10:15PM BLOOD Lipase-16
___ 10:15PM BLOOD cTropnT-0.13*
___ 10:15PM BLOOD Albumin-3.6
___ 06:20PM BLOOD %HbA1c-5.8 eAG-120
___ 06:20PM BLOOD Triglyc-80 HDL-52 CHOL/HD-2.4 LDLcalc-55
___ 10:31PM BLOOD Lactate-3.2*
PERTINENT LABS:
===============
___ 10:15PM BLOOD cTropnT-0.13*
___ 04:00AM BLOOD cTropnT-0.15*
___ 08:40AM BLOOD cTropnT-0.15*
___ 06:20PM BLOOD CK-MB-5
___ 06:20PM BLOOD cTropnT-0.14*
___ 03:55AM BLOOD CK-MB-4 cTropnT-0.18*
___ 04:42AM BLOOD CK-MB-3 cTropnT-0.24*
___ 06:45AM BLOOD cTropnT-0.22*
___ 10:31PM BLOOD Lactate-3.2*
___ 04:25AM BLOOD Lactate-3.0*
___ 08:47AM BLOOD Lactate-2.4*
___ 04:18AM BLOOD Lactate-1.5
IMAGING:
========
___ CT A/P ___
1. Findings concerning for acute cholecystitis. A gallbladder
ultrasound and/or nuclear medicine hepatobiliary study should be
considered for further assessment.
2. Small bilateral pleural fluid collections.
3. Indeterminate left renal lesions for which a renal ultrasound
is
recommended for further assessment when the patient is stable.
4. Severe aortoiliac atherosclerotic calcification.
5. Findings concerning for an acute or subacute L4 vertebral
body
compression fracture.
___ ___:
1. The gallbladder is distended with evidence of some wall
thickening
and pericholecystic fluid. The findings remain suspicious for
acute
cholecystitis. An hepatobiliary nuclear medicine study could be
performed to confirm the diagnosis.
Gallbladder Scan ___
Following the intravenous injection of tracer, serial one-minute
images of tracer uptake into the hepatobiliary system were
obtained for 60 minutes with anterior and right anterior oblique
delayed images at 4.5 hours.
FINDINGS: Serial images over the abdomen show homogeneous
uptake of tracer into the hepatic parenchyma.
Tracer activity is noted in the small bowel at 10 minutes. The
gallbladder was not visualize during the initial 60 minutes of
imaging. The gallbladder was faintly visualized with tracer
activity faint uptake in the gallbladder at 4 hours. The
presence of faint uptake makes complete obstruction of the
cystic duct unlikely, although partial cystic duct obstruction
is possible.
CXR ___
1. No definite evidence of pneumonia.
2. Linear opacities in bilateral lower lobes represent
atelectasis.
3. bilateral pleural effusions are small. at 4.5 hours.
Brief Hospital Course:
___ male with history gallstone pancreatitis, iCMP (EF
35%) with apical aneurysm, paroxysmal atrial fibrillation on
warfarin, SSS s/p PPM, ___ transferred from OSH for
further management of acute cholecystitis and incidental type II
NSTEMI.
ACUTE/ACTIVE PROBLEMS:
#) Acute cholecystitis: radiographic evidence of acute
cholecysitis at OSH. N/V subsided on transfer. Remained
afebrile, hemodynamically stable, without leukocytosis or other
evidence of sepsis. Percutaneous cholecystostomy ultimately
deferred in this regard. Patient received CTX and metronidazole
IV, which was transitioned to ciprofloxacin and metronidazole PO
at discharge for 14-day course. Strategies to limit stone burden
should be explored, as this is his second major hospitalization
for biliary pathology. While he is an unlikely candidate for
surgical intervention, outpatient follow-up with general surgery
should be arranged. Alternatively, ursodiol and dietary
strategies could be implemented.
#) NSTEMI, type II: in the setting of intravascular depletion
and infection on background of cardiomyopathy. Tropinemia likely
exacerbated by underlying renal insufficiency (i.e., suspect Cr
is overestimating GFR in ___. Reportedly, patient had
transient episode of chest pain at OSH, but remained
asymptomatic throughout the duration of hospitalization.
Non-specific ST changes were noted in V5-V6, but deemed
inconsequential. Troponins were trended until plateau and
declination.
#) L4 compression fracture, acute-subacute: incidentally found
on CT A/P. Patient reports numerous falls at home. He denied
back pain and remained continent of urine and stool. Neurologic
exam was within normal limits. MRI was contraindicated due to
pacemaker. Orthopedic surgery cleared patient for activity as
tolerated without log-roll precautions. Soft lumbar collar was
provided, but did not enhance patient comfort.
#) Hypoxia: patient had a minor O2 requirement presumed
secondary to component of pulmonary congestion, given borderline
volume status and equivocal CXR. Aspiration event was postulated
in the setting of encephalopathy at OSH; however, patient had no
evidence of aspiration pneumonia. He received Lasix 40 mg IV
with adequate diuresis and improvement in oxygenation. Home
Lasix 20 mg PO was resumed at discharge.
#) iCMP (35%) with apical aneurysm: presented borderline
hypervolemic. Probable mild exacerbation in setting of
conversational dyspnea and equivocal CXR. Reportedly, suboptimal
diet at home. He received gentle diuresis, as above, given sick
sinus syndrome and inability to ___ response.
Valsartan 40 mg and Lasix 20 mg were added to home amlodipine
2.5 mg and metoprolol tartrate 25 mg QAM. Transitioning to
metoprolol succinate could be considered for optimization of
heart failure therapy.
#) Paroxysmal AFib: CHA2DS2-VASc 4. Per PCP, warfarin recently
increased to 6.5 mg due to persistent subtherapeutic values; at
2.5 mg prior to increase. Home metoprolol tartrate 25 mg was
continued for rate control. Patient was bridged back to warfarin
with heparin drip, and later LMWH, given borderline CHADS2 score
and apical aneurysm. Warfarin was dosed cautiously in the
setting of antibiotics. Of note, his discharge INR was 2.3.
Continue to monitor, especially as Ciprofloxacin course
completes.
#) Social: question of elder neglect at home was raised by
family members, given history of falls and suboptimal medication
compliance. Patient was evaluated by social work. Facilitation
of elder service referral for home care support was recommended.
#) Question of L3 lytic lesion: orthopedic surgery documented L3
lytic lesion; however, records are not indicative of correlative
finding on CT lumbar spine. Orthopedic surgery resident later
attested that comment was erroneous.
CHRONIC/STABLE PROBLEMS:
#) SSS s/p PPM: stable; V-paced.
#) Mood disorder, unspecified: continue home sertraline 50 and
mirtazapine 15
#) Hypothyroidism: continue home levothyroxine
TRANSITIONAL ISSUES:
[] Daily INR with appropriate titration of warfarin dosing
[] Recheck BMP within 1 week of ___, as patient resumed
valsartan and Lasix
[] Please ensure completion of 14-day course of ciprofloxacin
and metronidazole for acute cholecystitis (last day: ___
[] Please involve SW at rehab to facilitate elder service
referral for home care support
[]Consider strategies to reduce stone burden, given two
admissions for gallbladder pathology; that is, low-fat diet,
ursodiol.
[ ] ensure general surgery f/u to discuss elective
cholecystectomy when improved
[] Consider transitioning to metoprolol succinate for
optimization of heart failure and atrial fibrillation control
[] Please arrange dedicated renal ultrasound for incidental
2.4cm exophytic left renal lesion
[] Please consider outpatient DEXA scan in evaluation for
osteoporosis
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Finasteride 5 mg PO DAILY
2. Levothyroxine Sodium 88 mcg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Sertraline 50 mg PO DAILY
5. amLODIPine 2.5 mg PO DAILY
6. Mirtazapine 15 mg PO QHS
7. Warfarin 6.5 mg PO DAILY16
8. Metoprolol Tartrate 25 mg PO DAILY
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Finasteride 5 mg PO DAILY
2. Levothyroxine Sodium 88 mcg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Sertraline 50 mg PO DAILY
5. amLODIPine 2.5 mg PO DAILY
6. Mirtazapine 15 mg PO QHS
7. Warfarin 6.5 mg PO DAILY16
8. Metoprolol Tartrate 25 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Ciprofloxacin HCl 500 mg PO Q12H
3. Furosemide 20 mg PO DAILY Duration: 1 Dose
4. MetroNIDAZOLE 500 mg PO Q8H
5. Valsartan 40 mg PO DAILY
6. Warfarin 2.5 mg PO DAILY16
7. amLODIPine 2.5 mg PO DAILY
8. Atorvastatin 20 mg PO QPM
9. Finasteride 5 mg PO DAILY
10. Levothyroxine Sodium 88 mcg PO DAILY
11. Metoprolol Tartrate 25 mg PO DAILY
12. Mirtazapine 15 mg PO QHS
13. Sertraline 50 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
-Acute cholecystitis
SECONDARY:
-NSTEMI, type II
-L4 vertebral compression fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
You had an infection of your gallbladder.
WHAT HAPPENED IN THE HOSPITAL?
You received antibiotics for the infection, which made you feel
better.
WHAT SHOULD YOU DO AT HOME?
-Please take your antibiotics as prescribed until ___.
-Please eat a low-fat diet to help prevent future gallbladder
infections.
-Please use extra caution when moving around your home and
transitioning from walker to chair.
-Please continue to take all of your medications as prescribed.
-Please follow-up with your PCP and cardiologist after rehab.
-Please follow-up with the surgery team to discuss removal of
your gallbladder.
Thank you for allowing ___ be involved in your care, we wish you
all the best!
Your ___ Team
Followup Instructions:
___
|
10251895-DS-6 | 10,251,895 | 20,130,862 | DS | 6 | 2183-11-02 00:00:00 | 2183-11-02 14:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
___ blurry vision, confusion, headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ M w/ HIV (on genvoya, last CD4 418 in
___ who was sent by his PCP for evaluation of monocular
right
sided vision loss followed by an episode of confusion. He was
in
his usual state of health this morning. He went to the gym and
worked out with his personal trainer, primarily focusing on
lower
extremity exercises without significant upper body workout, no
major lifting or rapid head turning. After the workout, around
9
AM she went to work and was feeling well. At 10 AM she noted
that the vision in his right eye gradually became blurry more
noticeably in the right peripheral vision fields. He states
that
he tested the left eye and noticed the vision to be normal. 10
minutes later she participated at a meeting during which he was
unable to remember the names of his close coworkers including
his
boss and people working right next to him for a long time. This
was atypical for him and has never happened before. He have to
refer to his colleagues as "she" or "he" and had to read their
badges/name plates to correctly identify their names. ___
slurred speech. Symptoms gradually resolved in 30 minutes from
onset. At the onset of the symptoms he also noted a bilateral
frontal headache that he describes as pressure-like, rated 2 out
of 10, non-positional, nonradiating, similar to those that he
typically gets so after a hangover. He denies any associated
symptoms, no focal weakness, numbness, tingling. No abnormal
movements.
He denies any recent illness; however, endorses having 4 drinks
day prior. Denies use of illicits.
Past Medical History:
HIV (on genvoya, last CD4 418 in ___
Social History:
___
Family History:
HTN - parents
HLD - parents
Macular degeneration - grandfather
___ - grandfather
Negative for stroke, epilepsy, MI, diseases, clotting or
bleeding
disorders.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VS: T 97.8, BP 126/86, HR 64, RR 18, SPO2 97% on room air
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive, able to name ___ backward
without difficulty. Speech is fluent with full sentences, intact
repetition, and intact verbal comprehension. Naming intact. No
paraphasias. No dysarthria. Normal prosody. Able to register 3
objects and recall ___ at 5 minutes. No apraxia. No evidence of
hemineglect. No left-right confusion. Able to follow both
midline
and appendicular commands.
- Cranial Nerves: PERRL 3->2 brisk. VF full to number counting.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No drift. No tremor or
asterixis.
[___]
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 2+ 2+ 2+ 2+ 1
R 2+ 2+ 2+ 2+ 1
Plantar response flexor bilaterally
- Sensory: No deficits to light touch, pin, or proprioception
bilaterally. No extinction to DSS.
- 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
========================
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive, able to name ___ backward
without difficulty. Speech is fluent with full sentences, intact
repetition, and intact verbal comprehension. Naming intact. No
paraphasias. No dysarthria. Normal prosody. Able to register 3
objects and recall ___ at 5 minutes. No apraxia. No evidence of
hemineglect. No left-right confusion. Able to follow both
midline
and appendicular commands.
- Cranial Nerves: PERRL 3->2 brisk. VF full to number counting.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. optic disks appear
normal, no papilledema. 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.
[___]
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 2+ 2+ 2+ 2+ 1
R 2+ 2+ 2+ 2+ 1
Plantar response flexor bilaterally
- Sensory: No deficits to light touch, pin, or proprioception
bilaterally. No extinction to DSS.
- 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.
Pertinent Results:
ADMISSION LABS
==============
___ 04:45PM BLOOD WBC-7.0 RBC-4.79 Hgb-14.5 Hct-41.4 MCV-86
MCH-30.3 MCHC-35.0 RDW-13.1 RDWSD-40.5 Plt ___
___ 04:45PM BLOOD Neuts-56.8 ___ Monos-9.8 Eos-0.7*
Baso-0.3 Im ___ AbsNeut-3.95 AbsLymp-2.23 AbsMono-0.68
AbsEos-0.05 AbsBaso-0.02
___ 04:45PM BLOOD Plt ___
___ 04:45PM BLOOD Glucose-92 UreaN-19 Creat-1.1 Na-140
K-4.2 Cl-103 HCO3-23 AnGap-14
___ 04:45PM BLOOD ALT-16 AST-16 AlkPhos-76 TotBili-0.4
___ 04:45PM BLOOD cTropnT-<0.01
___ 04:45PM BLOOD Albumin-4.7 Calcium-9.9 Phos-3.7 Mg-2.0
___ 04:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
DISCHARGE LABS
===============
___ 05:35AM BLOOD WBC-5.7 RBC-4.71 Hgb-14.0 Hct-41.3 MCV-88
MCH-29.7 MCHC-33.9 RDW-13.2 RDWSD-41.9 Plt ___
___ 05:35AM BLOOD Plt ___
___ 05:35AM BLOOD Glucose-89 UreaN-18 Creat-1.1 Na-142
K-4.5 Cl-103 HCO3-26 AnGap-13
___:35AM BLOOD Calcium-9.5 Phos-4.5 Mg-2.0 Cholest-215*
___ 05:35AM BLOOD %HbA1c-5.1 eAG-100
___ 05:35AM BLOOD Triglyc-105 HDL-55 CHOL/HD-3.9
LDLcalc-139*
___ 05:35AM BLOOD TSH-3.1
IMAGING
=======
CTA HEAD W&W/O C & RECONS Study Date of ___
IMPRESSION:
1. No significant intracranial abnormality on noncontrast head
CT. No
evidence of acute large territorial infarction, hemorrhage or
mass effect.
2. Patent cervical intracranial vasculature without evidence of
dissection, stenosis, occlusion or aneurysm formation greater
than 3 mm.
Brief Hospital Course:
Mr. ___ is a ___ year old man w/ HIV (genvoya, last CD4 418 in
___, who presented from his PCP with transient ___
painless blurry vision (loss of right peripheral vision fields),
confusion (difficulty naming work colleagues), and dull
pressure-like frontal headache. His symptoms lasted
approximately 30 minutes and self-resolved, notably had 4 ETOH
drinks the evening prior, reports hangovers with similar
headaches in the past. Neurologic exam was normal, including
normal Fundoscopic exam, no visual abnormalities. CTA head and
neck also normal. Stroke risk factors were checked, notable for
A1C 5.1, LDL 139. Given low suspicion for TIA, stroke,
discharged with outpatient MRI and stroke follow-up.
TRANSITIONAL ISSUES:
====================
[] LDL 139, continue to monitor
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Genvoya (elviteg-cob-emtri-tenof ALAFEN) ___ mg
oral unknown
Discharge Medications:
1. Genvoya (elviteg-cob-emtri-tenof ALAFEN) ___ mg
oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Transient vision changes
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 the ___
___.
You came to the hospital because you developed vision changes
and some confusion. We evaluated you in the hospital with a CT
scan of your head and neck and blood tests which were normal.
Your symptoms got better. We believe it is safe for you to
return home. We are arranging for you to have an MRI of your
brain as an outpatient, you will also follow-up with a
Neurologist as below.
Please continue to take your medications as prescribed and
follow-up with your doctors as ___.
We wish you all the best,
Your ___ care team
Followup Instructions:
___
|
10252334-DS-18 | 10,252,334 | 28,949,404 | DS | 18 | 2111-01-10 00:00:00 | 2111-01-12 15:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
CODE STROKE for unresponsiveness and transient right-sided
weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is an ___ right-handed man with a history of HTN,
CAD s/p CABG, ischemic cardiomyopathy with EF ___,
hypothyroidism, severe PVD with chronic non-healing RLE ulcers,
CKD, and mild dementia who presents from ___ after an
episode of unresponsiveness, followed by reported inability to
move R arm and leg. The history is somewhat unclear, but ___ was
apparently found in bed unresponsive around 5:40pm with no
reports of seizure-like activity. This reportedly lasted about
10 minutes, after which ___ appeared to be unable to move his
right arm and leg and could not grasp the RN's hand on the right
side. EMS was called, and by the time they arrived ___ was awake
and moving all of his extremities symmetrically. ___ was brought
to
the ED, where a code stroke was called.
.
Initial NIHSS was 3, with points for disorientation to his age
and month as well as dysarthria (although not wearing dentures).
A noncontrast CT showed a large calcificed mass in the L
temporal region most likely representing a meningioma. Currently
___ is awake and alert and complaining of pain in his RLE. ___
does not recall any of the events of tonight and thinks that ___
was
brought here due to his R leg pain. Denies any other symptoms.
.
Per records provided, ___ was recently admitted to ___
___ from ___ to ___ for non-healing RLE ulcers.
Culture grew staph aureus which was initially treated with
Zyvox, then found to be methicillin sensitive and changed to
Ancef for which ___ completed a 7 day course. Had periods of
agitation/delirium initially treated with ativan, which made him
too lethargic. ___ was seen by psych and was changed to remeron
at night with zyprexa during the day prn. ___ was discharged to
___ on ___.
.
ROS unable to be obtained reliably from pt. ___ only reports RLE
pain and denies any other symptoms currently.
Past Medical History:
- CAD s/p CABG
- Ischemic cardiomopathy - EF ___. Has reportedly had
non-sustained VT in the past but refused ICD placement.
- L meningioma s/p resection (___): was reportedly on an
unknown AED x ___ year after this, not currently on any AED's.
Head CT at ___ during recent admission
reportedly showed a stable calcified left parasellar mass and
postsurgical changes (no images currently available for our
review).
- Hypothyroidism
- Depression/anxiety
- GERD
- HTN
- IDDM (HBA1c 7.3% during recent admission, managed with ISS)
- Dementia
- CKD
- ___ inguinal hernias
- Anemia
- Severe PVD with recent admission for RLE ulcers
- Pyoderma gangrenosum (BLE) resolving s/p steroids
Social History:
___
Family History:
Noncontributory
Physical Exam:
========================
ADMISSION PHYSICAL EXAM:
========================
GENERAL EXAM:
Vitals: 78 106/61 18 86% 2l
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: RLE wrapped in bandage with soft boot up to knee.
Several healing ulcers present over knee. 1+ edema at b/l
ankles.
Neurologic:
-Mental Status: Alert, oriented to self only. Complains of RLE
pain, otherwise unable to provide further history. Inattentive
and hard of hearing. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Unable to name any objects on stroke card (?limited by
vision) with somewhat bizarre responses - nose, hair, ear. Names
thumb, hand, and watch accurately. Able to read without
difficulty. Speech was mildly dysarthric. Able to follow both
midline and appendicular commands. No evidence of apraxia or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF grossly full to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to loud voice bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No asterixis noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___
L 5 ___ ___ ___ 5 5
R 5 ___ ___ * * 5 5 5
*Give-way weakness in R IP, quad/hamstring limited by pain
-Sensory: Intact to light touch throughout, does not cooperate
with formal sensation testing currently
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response was flexor bilaterally.
-Coordination: No dysmetria on FNF bilaterally.
-Gait: Deferred
========================
DISCHARGE PHYSICAL EXAM:
========================
- Vitals: 97.8 143/85 76 20 100% RA
- General exam: unchanged
- Neuro exam: awake, alert, oriented to self only. Responds
appropriately to simple questions and follows one-step commands.
No tremor or asterixis. No focal neuro deficits found on exam
(limited by cooperation).
Pertinent Results:
ADMISSION LABS:
- WBC-10.9 RBC-3.92* Hgb-9.3* Hct-31.8* MCV-81* MCH-23.8*
MCHC-29.3* RDW-16.1* Plt ___
- Neuts-77.2* Lymphs-11.7* Monos-4.5 Eos-5.9* Baso-0.7
- ___ PTT-31.7 ___
- Glucose-120* UreaN-71* Creat-2.2* Na-138 K-5.0 Cl-101 HCO3-26
AnGap-16
- ALT-20 AST-36 AlkPhos-69 TotBili-0.2
- Albumin-3.9
- Serum tox: ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
- Urine tox: bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG
amphetm-NEG mthdone-POS
- UA: Color-Yellow Appear-Clear Sp ___ Blood-NEG
Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG
Urobiln-NEG pH-5.5 Leuks-MOD RBC-2 WBC-17* Bacteri-FEW
Yeast-NONE Epi-1 CastHy-4*
MICROBIOLOGY:
- UCx ___, final): MIXED BACTERIAL FLORA ( >= 3 COLONY
TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.
PERTINENT LABS:
- %HbA1c-6.7* eAG-146*
- Triglyc-62 HDL-45 CHOL/HD-2.1 LDLcalc-38
EKG (___): The underlying rhythm cannot be ascertained with
certainty, but most QRS complexes appear to be preceded by a low
amplitude P wave of sinus origin. Left bundle-branch block with
secondary repolarization abnormalities. No previous tracing
available for comparison.
___ (___):
1. No acute intracranial hemorrhage.
2. Partially calcified extra-axial mass involving the sella,
left cavernous sinua and left middle cranial fossa; it is most
likely a meningioma. Correlation with prior imaging is
recommended. If further evaluation is clinically indicated,
could obtain an MRI.
3. Encephalomalacia in the left frontal and temporal lobes could
be
post-surgical or from a prior infarct; again correlation with
prior imaging is recommended.
AP CXR (___): No previous images. There is huge enlargement
of the cardiac silhouette in a patient who has undergone
previous CABG procedure and has intact midline sternal wires.
Pulmonary vascularity is essentially within normal limits. Some
ill-defined opacification at the right base suggests some
atelectatic change. The left base is difficult to assess due to
the size of the heart, though the hemidiaphragm is quite sharply
seen. Discordancy of heart size and vascular congestion raises
the possibility of cardiomyopathy or possibly even pericardial
effusion.
EEG ___, wet read): occasional left temporal sharps, no
spike waves or clinical/electrographic seizures.
Brief Hospital Course:
___ is an ___ yo RH M with multiple vascular risk
factors (HTN, HLD, CAD, CHF with EF ___, L temporal
meningioma s/p resection (___) and mild dementia who presents
from ___ after a reported 10-minute episode of
unresponsiveness followed by transient right arm and leg
weakness which had resolved on arrival to the ED. No clear
seizure-like activity reported. ___ in the ED showed large
calcified left temporal mass c/w his known meningioma; no other
acute abnormalities.
# NEURO: Patient was admitted to the General Neurology service
for further workup of his transient right-sided weakness and
unresponsiveness. His overall clinical picture seemed most
consistent with localization-related seizure secondary to his
known meningioma, with a post-ictal Tod's paralysis.
Toxic-metabolic and infectious workup for factors lowering his
seizure threshold were completed, notable only for a mildly
positive UA (urine culture negative). ___ underwent 24 hours of
EEG monitoring which showed occasional left-sided sharp waves
but no ___ spikes or clinical/electrographic seizures. As this
was his first seizure since ___ and ___ is at significant risk
for worsening agitation/encephalopathy with starting
anti-epileptic meds, it was decided to defer treating the
seizure at this point. If ___ has a second seizure, ___ will need
to start an anti-epileptic drug. We would recommend considering
Keppra 250mg PO BID (renally dosed).
Of note patient was initially mildly agitated and
encephalopathic on admission to the hospital. Per discussion
with his treating MDs at ___ it was decided to
discontinue his home dilaudid and decrease his methadone to
2.5mg daily to minimize deliriogenic meds. His gabapentin was
increased from 200mg HS from 200mg BID. ___ tolerated this med
adjustment well and was at his baseline mental status for the
duration of hospitalization.
# CV: patient had mild bibasilar crackles on admission physical
exam so ___ received one extra dose of lasix 20mg. After this his
home cardiac meds were continued.
# RENAL: has known stage IV CKD. Lytes stable throughout
hospitalization.
# DERM: has known pyoderma gangrenosum which has been improving
with steroids per rehab MDs. ___ was seen by wound care team
during hospitalization who assisted with dressings. Will
continue treatment at rehab.
# TOX/METAB: LFTs WNL. UTox +methadone (prescribed). Serum tox
negative.
# ID: UA mildly positive on admission so started IV ceftriaxone,
which was discontinued once UCx returned negative on HD #3.
====================
TRANSITIONS OF CARE:
- Code status = DNR/DNI (confirmed)
- Contact = daughter (HCP) ___: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. Gabapentin 300 mg PO HS
4. Ketoconazole 2% 1 Appl TP MWF
5. lactobacillus acidophilus *NF* 1 tab Oral TID
6. Levothyroxine Sodium 75 mcg PO DAILY
7. melatonin *NF* 1 mg Oral HS
8. Methadone 2 mg PO DAILY
9. Methadone 1 mg PO QHS
10. Mirtazapine 7.5 mg PO HS
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 40 mg PO DAILY
13. Pravastatin 80 mg PO DAILY
14. Senna Dose is Unknown PO HS
15. Sertraline 100 mg PO DAILY
16. Sorbitol 15 mL PO DAILY
17. Acetaminophen 650 mg PO Q6H:PRN pain
18. Bisacodyl ___AILY
19. HYDROmorphone (Dilaudid) 1 mg PO Q8H:PRN pain
20. Milk of Magnesia 30 mL PO DAILY
21. Artificial Tears ___ DROP BOTH EYES QID
22. Calcium Carbonate 1250 mg PO DAILY
23. Carvedilol 12.5 mg PO BID
24. Vitamin D 1000 UNIT PO DAILY
25. Finasteride 5 mg PO DAILY
26. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using UNK Insulin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Bisacodyl ___AILY
4. Calcium Carbonate 1250 mg PO DAILY
5. Carvedilol 12.5 mg PO BID
6. Finasteride 5 mg PO DAILY
7. Furosemide 20 mg PO DAILY
8. Gabapentin 300 mg PO BID
9. Levothyroxine Sodium 75 mcg PO DAILY
10. Methadone 2.5 mg PO DAILY
11. Milk of Magnesia 30 mL PO DAILY
12. Mirtazapine 7.5 mg PO HS
13. Multivitamins 1 TAB PO DAILY
14. Omeprazole 40 mg PO DAILY
15. Pravastatin 80 mg PO DAILY
16. Senna 1 TAB PO HS
17. Sertraline 100 mg PO DAILY
18. Vitamin D 1000 UNIT PO DAILY
19. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using UNK Insulin
20. melatonin *NF* 1 mg Oral HS
21. lactobacillus acidophilus *NF* 1 tab Oral TID
22. Ketoconazole 2% 1 Appl TP MWF
23. Artificial Tears ___ DROP BOTH EYES QID
24. Sorbitol 15 mL PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Likely seizure secondary to left meningioma (s/p resection)
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with an episode of
unresponsiveness and right-sided weakness concerning for a
possible seizure. We monitored you on EEG for 24 hours and found
that you have a small risk for seizures in the future (due to
your old meningioma which causes brain irritation), but since
this is your first seizure in many years we will not start
seizure medications unless your have another. While you were
here we also tapered down your narcotic pain medications as they
may be causing confusion.
.
Please follow up with your doctors at ___.
.
We made the following changes to your medications:
1. STOPPED dilaudid 1mg PO q8hrs PRN
2. CHANGED methadone from 2mg in am + 1mg before bedtime to
2.5mg daily
3. INCREASED gabapentin from 200mg before bedtime to 200mg twice
daily
Followup Instructions:
___
|
10252642-DS-17 | 10,252,642 | 21,053,292 | DS | 17 | 2131-10-26 00:00:00 | 2131-10-31 19:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
opiods / Coumadin / ACE Inhibitors
Attending: ___.
Chief Complaint:
Tachycardia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ female with past medical history
of atrial fibrillation on dabigatran, essential tremor and
asthma, who was seen by her PCP for tachycardia and chest pain
in the setting of symptoms and lab tests concerning for
hyperthyroidism.
The patient was in her usual state of health until ___ when
she noticed increasing fatigue, loss of appetite, watery
diarrhea, increasing dyspnea on exertion and decreased exercise
tolerance. The symptoms became more sever over the previous
several weeks with the patient reporting a 10 pound weight loss.
Two weeks ago, she had labs done with her primary care provider
that showed TSH less than 0.01 and a free T4 greater than 7.7.
She presented back to the ___ office yesterday and was found to
be tachycardic with rates reported to be in the 130s to 140s.
She was sent to the ER at ___ and subsequently to BI with
persistent tachycardia for evaluation of thyroid storm. She was
afebrile and without mental status changes.
In the ED, initial vitals were: 98.6 130 127/92 20 97% RA. Exam
was notable for tachycardia, warm/dry skin. Labs were notable
for: TSH <0.01, fT4 7.7, ALT 225, AST 221, INR 1.4, Tprot 6.3,
proBNP 2266, Trop-T <0.01, Bicarb 21, lactate 1.6. Studies were
notable for CXR w/ no evidence of pulmonary edema. The patient
was given Propranolol 60mg, NS 1000mL, Dabigatran 150mg.
Endocrinology was consulted.
On arrival to the floor, the patient is resting comfortably. She
denies any chest pain or palpitations. She is currently taking
propranolol for a long history of essential tremor and says her
tremor has changed however she has recently noticed a new tremor
in her right lower extremity. She reports feeling jittery and
slightly anxious. She denies any heat intolerance or sweating.
She denies any history of a painful neck, recent or remote sore
throat, dysphagia, dysphonia. She says she has a persistent
nighttime cough that usually resolves on its own and uses her
rescue inhaler ___. She reports intermittent abdominal
fullness with an occasional increase in urinary frequency. She
has not had any iodinated contrast enhanced CT scans. She denies
taking any over the-counter or herbal supplements. Notably, she
previously received amiodarone for her atrial fibrillation. She
received 200 mg daily dose from ___ until ___.
Past Medical History:
- ESSENTIAL TREMOR
- ATRIAL FIBRILLATION
- ASTHMA
- STROKE
- HYSTERECTOMY
- HIP FRACTURE
- SKIN CANCERS
Social History:
___
Family History:
- No family history of endocrine disease
- Brother with asthma
- Family history of tremor
No h/o seizure. Her parents died of multisystem organ failure
at
___ and ___. No clear evidence of MI or stroke. She has 4
brothers who have all had prostate CA. They are all currently
healthy.
Physical Exam:
ADMISSION PHYISCAL EXAM:
=======================
VITALS: ___ 1134 Temp: 97.4 PO BP: 151/52 HR: 71 RR: 18 O2
sat: 98% O2 delivery: RA
GENERAL: Alert and interactive. In no acute distress. Resting
tremor.
HEENT: Moderately diffusely enlarged thyroid. Non-tender to
palpation. No nodules. No lymphadenopathy. No lid lag or
exophthalmos.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Non-distended, non-tender to deep palpation. No
organomegaly.
EXTREMITIES: No pedal edema. Pulses DP/Radial 2+ bilaterally.
SKIN: Warm and well-perfused. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation. Foot
clonus R>L. Normal reflexes.
DISCHARGE PHYSICAL EXAM:
=======================
___ 0412 Temp: 97.4 PO BP: 129/70 R Lying HR: 68 RR: 17 O2
sat: 97% O2 delivery: Ra
GEN: Alert and interactive. No acute distress. Mild resting
tremor unchanged from prior.
HEENT: Moderately diffusely enlarged thyroid. Non-tender to
palpation. No nodules. No lymphadenopathy. Mild lid lag.
COR: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABD: Non-distended, non-tender to deep palpation. No
organomegaly.
EXT: Mild pedal edema bilaterally unchanged from prior. Pulses
DP/Radial 2+ bilaterally.
SKIN: Warm and well-perfused. No rashes.
NEURO: AOx3. CN2-12 intact. Moving all limbs spontaneously. ___
strength throughout. Normal sensation. has essential tremor at
baseline
Pertinent Results:
ADMISSION LABS:
==============
___ 03:34PM BLOOD WBC-7.0 RBC-4.11 Hgb-14.1 Hct-43.5
MCV-106* MCH-34.3* MCHC-32.4 RDW-11.9 RDWSD-46.5* Plt ___
___ 03:34PM BLOOD Neuts-72.7* Lymphs-11.9* Monos-14.7*
Eos-0.1* Baso-0.3 Im ___ AbsNeut-5.08 AbsLymp-0.83*
AbsMono-1.03* AbsEos-0.01* AbsBaso-0.02
___ 03:34PM BLOOD ___ PTT-40.8* ___
___ 03:34PM BLOOD Glucose-97 UreaN-15 Creat-0.8 Na-135
K-4.3 Cl-100 HCO3-21* AnGap-14
___ 09:10AM BLOOD ALT-199* AST-211* LD(LDH)-214 AlkPhos-83
TotBili-0.8
___ 03:34PM BLOOD cTropnT-<0.01 proBNP-2266*
___ 09:10AM BLOOD Albumin-3.5 Calcium-9.7 Phos-3.3 Mg-1.4*
___ 03:34PM BLOOD Cholest-140
___ 12:49PM BLOOD VitB12-1334* Folate-14
___ 03:34PM BLOOD Triglyc-79 HDL-61 CHOL/HD-2.3 LDLcalc-63
___ 06:20AM BLOOD TSH-<0.01*
___ 03:34PM BLOOD T4-33.4* T3-280* calcTBG-<0.20* Free
T4->7.7*
___ 03:42PM BLOOD ___ pO2-46* pCO2-39 pH-7.40
calTCO2-25 Base XS-0 Comment-GREEN TOP
___ 03:42PM BLOOD Lactate-1.6
___ 03:42PM BLOOD O2 Sat-78
OTHER RELEVANT LABS:
===================
Calculated TBG <0.20. Reference Range 0.8-1.3
Anti-Thyroglobulin Ab <20. Reference Range ___
Thyroglobulin 201. Reference Range ___
Thyroid Peroxidase Antibodies <10. Reference range ___
Thyroid Stimulating Immunoglobulin <89. Reference range <140
Iodine, Random ___ ___. Reference range 34-523
DISCHARGE LABS:
===================
___ 06:20AM BLOOD WBC-6.1 RBC-3.62* Hgb-12.2 Hct-36.9
MCV-102* MCH-33.7* MCHC-33.1 RDW-11.7 RDWSD-44.2 Plt ___
___ 09:35AM BLOOD ___ PTT-30.3 ___
___ 06:20AM BLOOD Glucose-80 UreaN-17 Creat-1.0 Na-137
K-4.1 Cl-100 HCO3-28 AnGap-9*
___ 06:20AM BLOOD ALT-204* AST-181* LD(LDH)-181 AlkPhos-78
TotBili-0.4
___ 02:37AM BLOOD CK-MB-3 cTropnT-0.02*
___ 06:20AM BLOOD Albumin-3.0* Calcium-9.7 Phos-4.0 Mg-1.9
___ 06:20AM BLOOD T4-26.8* T3-168 Free T4->7.7*
REPORTS:
===================
___ THYROID SCAN W/UPTAKE (IODINE)
1. No tracer uptake in the thyroid gland, consistent with
subacute
thyroiditis.
___: THYROID U/S
Mild thyromegaly with several subcentimeter nodules.
RECOMMENDATION(S): A ___ thyroid ultrasound is
recommended in ___
years.
___ TTE
LVEF 50-55%. Mild symmetric left ventricular hypertrophy with
normal cavity size, and lownormal regional/global biventricular
systolic function. Restrictive filling pattern. Mild tricuspid
regurgitation. Mild pulmonary artery systolic hypertension.
___: CXR
Comparison to ___. In the interval, the patient has
developed mild
pulmonary edema. Mild enlargement of the cardiac silhouette.
Mild elongation
of the descending aorta. No no pneumonia, no pneumothorax.
ADMISSION EKG:
====================
___: rate 137, narrow complex tachycardia, ectopic atrial
tachycardia vs PSVT vs atrial flutter. borderline left axis
deviated
RELEVANT INTERVAL EKGs:
====================
___: rate 75. sinus rhythm wiht 1st degree AV block. left
axis deviated
___: rate 126. atrial fibrillation with rapid ventricular
response
___: rate 111. accelerated junctional rhythm
Brief Hospital Course:
PATIENT SUMMARY:
================
___ w/ Afib on dabigatran, prior exposure to amiodarone, p/w
tachycardia, low TSH, elevated fT4, low TSI, elevated urine
iodine and negative RAIU c/f subacute thyroiditis secondary to
amiodarone c/b atrial fibrillation with HR 110s and one episode
of atrial tachycardia. At time of discharge, rates were stable
in the 60-70 range.
TRANSITIONAL ISSUES:
====================
[ ] We recommend that you have outpatient lab work performed on
___ or ___ this week. Please obtain: CBC, CMP, TFTs (T3,
fT4, TSH), LFTs. Please ask to have a copy of the results faxed
to the ___ clinic at ___ ___, Attn:
___
[ ] Please note transanimitis while inpatient, suspected to be
due to hyperthyroidism; will need to be trended in outpatient
setting.
[ ] Patient had heart rates in 60-70 range and BPs in the 100
systolic range at time of discharge. She was maintained on a
dosage of propranolol 80mg TID at time of discharge, but can
likely be weaned to 60mg TID in the near future. Please consider
dose reduction at PCP ___ appointment on ___.
[ ] Patient had intermittently low magnesium levels while
inpatient, and was repleted PRN; please consider rechecking in
outpatient setting to ensure normal levels.
[ ] Please follow up with ___ endocrinology as scheduled
below. Will likely need dose reduction in methimazole in near
future (discharged on 10mg daily).
[ ] Discharged on a high-dose steroid. Started on prophylaxis
medications including vitamin D, Pepcid and calcium carbonate.
Bactrim was not started, but outpatient provider can consider
starting this for PJP prophylaxis.
[ ] Blood pressure was noted to be elevated when initially
admitted to the hospital, likely due to hyperthyroidism. Please
trend BP in outpatient setting.
[ ] Echocardiogram was performed that showed an ejection
fraction of 50-55%, evidence of mild TR and Pulmonary Artery
Hypertension. Recommend follow up with your PCP to discuss these
results further and consider any changes to your current
medication regimen.
[ ] ___ recommended patient for outpatient ___, which she had
already been engaged in prior to this hospitalization.
[ ] Long-term steroids increase the risk of fracture. We
recommend that you follow up with your PCP to schedule an
assessment of your bone strength (DEXA scan).
ACUTE/ACTIVE ISSUES:
====================
# Hyperthyroidism / Subacute Thyroiditis
Patient p/w clinical and laboratory findings of hyperthyroidism
with undetectable TSH and significantly elevated fT4. Did not
meet criteria of thyroid storm given lack of hyperpyrexia or
acute mental status changes. Confusion noted occasionally in AM.
U/S demonstrating mild thyromegaly. Negative RAIU. Thyroglobulin
mildly elevated (201), unclear if the elevation represents
thyroid destruction. Low TSI, elevated urine iodine consistent
with subacute thyroiditis due to amiodarone. Started on
methimazole 10mg and prednisone 20mg (later increased to 30mg).
Transitioned to PTU 200mg TID on ___ given persistently elevated
T3, but then restarted methimazole ___ on recommendation of
endocrinology team. T3 decreased to 137. HR well-controlled in
___ with propranolol.
# Atrial Fibrillation / Atrial Tachycardia
Patient missed one dose of home dabigatran on ___ ___. Patient
experienced intermittent atrial fibrillation ___ with HR
110s. Asymptomatic. Likely secondary to hyperthyroidism with
possible contribution from volume overload given physical exam.
Patient given furosemide 20mg IV twice. TTE performed, notable
for mildly dilated left atrium. On ___, patient experienced an
episode of chest discomfort and dizziness. ECG, trops
unremarkable. Found to have atrial tachycardia with HR 140s.
Patient received 1500cc NS. Unresponsive to adenosine. Patient
and metoprolol 10mg and HR subsequently decreased to ___.
Currently sinus with rate controlled in ___ with propranolol 80
TID.
# Transaminitis
ALT 199, AST 211, ALP 83 on admission. Unclear etiology,
possibly secondary to hyperthyroidism. Low probability for
muscle etiology or primary hepatic etiology. Trended while
inpatient. Continued improvement reassuring. Will need ongoing
outpatient ___.
CHRONIC/STABLE ISSUES:
======================
# Hypertension
SBP 160-170s on admission likely in setting of hyperthyroidism.
SBPs now ___ controlled with propranolol with possible
contribution from methimazole.
# CODE: Full (presumed)
# CONTACT: ___ (husband) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN Asthma
2. Sertraline 50 mg PO DAILY
3. Dabigatran Etexilate 150 mg PO BID
4. Montelukast 10 mg PO DAILY
5. Propranolol 20 mg PO TID
6. beclomethasone dipropionate 80 mcg/actuation inhalation BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild/Fever
2. Calcium Carbonate 500 mg PO DAILY
3. Famotidine 20 mg PO Q12H
4. MethIMAzole 10 mg PO DAILY
5. PredniSONE 30 mg PO DAILY
Please continue to take this medication until you ___ with
your endocrinologist.
6. Vitamin D ___ UNIT PO DAILY
7. Propranolol 80 mg PO/NG TID
Please discuss reducing this dose at your PCP ___
appointment on ___.
8. Albuterol Inhaler 2 PUFF ___ Q6H:PRN Asthma
9. beclomethasone dipropionate 80 mcg/actuation inhalation BID
10. Dabigatran Etexilate 150 mg PO BID
11. Montelukast 10 mg PO DAILY
12. Sertraline 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
==================
Hyperthyroidism secondary to amiodarone-induced subacute
thyroiditis
Atrial Fibrillation
Transanimitis
Secondary Diagnosis:
====================
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear ___ was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were in the hospital because your thyroid was overactive.
You were experiencing symptoms including a fast heart rate.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- In the hospital, we performed several tests to determine the
cause of your overactive thyroid. These included several blood
tests, an ultrasound of your thyroid, and a radioactive iodine
uptake imaging study. The results of these tests were consistent
with thyroiditis secondary to your amiodarone medication.
Thyroid dysfunction is a rare but known side effect of
amiodarone that may appear weeks to months after cessation of
the drug. You were treated with a higher dose propranolol to
control your heart rate as well as methimazole and prednisone to
reduce the activity of your thyroid.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please continue to take all of your medications and ___
with your appointments as listed below.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10253057-DS-31 | 10,253,057 | 22,939,697 | DS | 31 | 2185-07-12 00:00:00 | 2185-07-13 10:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of CABG (3-vessel ___, renal xplant (___), and
mild ___ transferred from ___ for
hypoxia. Patient was recently in ___ for 2 weeks visiting
his mother and enjoyed eating out frequently without any
significant complaints. He flew back yesterday and developed
shortness of breath later in the evening when he sat down. He
states it felt as though he could only use half of his lungs but
improved with standing. He denies chest pain, pleurisy, or chest
discomfort limiting his inspiration in any way. He did not,
however, respond to a inhaler treatment at home. He states that
prior to leaving for ___ he had shortness of breath and
cough for which he saw his PCP and was prescribed a 5-day course
of ABX (uncertain which one) with improvement of his symptoms
and no episodes of SOB while on his trip. He presently denies
cough, fevers, chills, but describes chronic BLE edema which is
non-painful and related to his CKD as well as subacute onset of
swelling in his right arm which is also not painful.
.
He presented to OSH ED where he was found to be satting 85% on
RA. His Cr was 4.0 (most recently 6.6 on ___, and trop of 0.03.
Per report, he had a large pleural effusion on CXR. He was given
2 Duonebs, Lasix 60 mg IV, solumedrol 125mg, and placed on ___
mask @ 35% with an O2 Sat of 97% prior to transfer.
Past Medical History:
-ESRD secondary to DM and HTN. ___ AVF, CRT ___ c/b delayed
graft function requiring intermittent HD, maintained on
tacrolimus (tacroFK recently subtherapeutic 2.1 on ___
-BK virus infection: treated with cidofovir pheresis,
leflunomide and cipro, last BK viral load ___ 2170.
-Aortic Stenosis: echo ___ with valve area of 1.3
-Coronary Artery Disease: ___ PCI in ___, NSTEMI, ___ CABG ___
LIMA to the LAD, SVG to D1, SVG to circumflex
-Hyperlipidemia
-Diabetes Mellitus: c/b retinopathy
-Renal osteodystrophy
-Iron Deficiency Anemia
-Nephrotic syndrome with hypoabuminemia
-Bells Palsy
-History of Rhabdomyolysis
-History of left lower lobe pneumonia
-___ Hydrocele repair
Social History:
___
Family History:
Mother: Heart Disease, Still Living at ___. Father: Died of
___ Cancer, age ___. No known family history of renal
problems.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.1, 74, 140/68, 27, 96% of tent mask
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP to angle of jaw @ 30 degrees, no LAD
CV: Regular rate and rhythm, normal S1 + S2, early
crescendo/decrescendo AS murmur loudest base right, pulsus
tardus
Lungs: Rales halfway up lung fields bilaterally
Abdomen: soft, obese, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, 2+ pitting to knees
bilaterally, 1+ pitting of RUE to mid bicep
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation
.
DISCHARGE PHYSICAL EXAM:
VS 98.5 (afeb) 145/61 (145-172/61-81) 69 22 90%RA (90-97%RA)
I/O: ___, BMx1
Weight: 75.7 kg (166.54 lbs)
GENERAL: Very pleasant, looks stated age, comfortable on NC,
NAD.
HEENT: NCAT, Sclera anicteric. PERRL, EOMI. Clear oropharynx.
NECK: Supple with low JVP, no cerv LAD. No carotid bruits.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, inaudible S1 and S2. Mid-peaking systolic murmur at
USB and LLSB, with no radiation to the carotids bilaterally. No
S3 or S4 appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use, moving air well and
symmetrically. Slightly decreased breath sounds at bases
bilaterally.
ABDOMEN: Soft, non-distended, non-tender. No HSM.
EXTREMITIES: Warm and well perfused. 2+ distal pulses. Right
forearm and dorsum of hand with 2+ edema. There is 2+ pitting
edema in ankles bilaterally.
Pertinent Results:
ADMISSION LABS
___ 02:15AM WBC-6.7 RBC-3.00* HGB-8.7* HCT-27.9* MCV-93
MCH-28.9 MCHC-31.1 RDW-15.3
___ 02:15AM NEUTS-87.5* LYMPHS-5.1* MONOS-3.6 EOS-3.3
BASOS-0.4
___ 02:15AM PLT COUNT-149*
___ 02:15AM GLUCOSE-400* UREA N-67* CREAT-4.6*#
SODIUM-134 POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-18* ANION
GAP-21*
___ 02:15AM cTropnT-0.03*
___ 02:15AM ___
___ 02:15AM ___ PTT-32.6 ___
___ 02:24AM LACTATE-1.2
.
RELEVANT LABS:
___ 02:15AM BLOOD ___
___ 02:15AM BLOOD cTropnT-0.03*
___ 01:58PM BLOOD cTropnT-0.03*
___ 02:49AM BLOOD D-Dimer-1080*
.
DISCHARGE LABS:
___ 06:15AM BLOOD WBC-5.4 RBC-2.72* Hgb-7.8* Hct-24.8*
MCV-91 MCH-28.8 MCHC-31.6 RDW-15.2 Plt ___
___ 06:15AM BLOOD ___ PTT-31.9 ___
___ 06:15AM BLOOD Glucose-156* UreaN-78* Creat-5.3* Na-136
K-4.2 Cl-100 HCO3-20* AnGap-20
.
MICROBIOLOGY:
___ Blood cultures x2: no growth to date
___ MRSA Screen: negative
.
IMAGING:
TTE ___:
The left atrium is moderately dilated. The estimated right
atrial pressure is ___ mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are moderately
thickened. There is moderate aortic valve stenosis (valve area
1.0-1.2cm2). Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. Significant pulmonic regurgitation is seen.
The end-diastolic pulmonic regurgitation velocity is increased
suggesting pulmonary artery diastolic hypertension. There is no
pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with mild
symmetric left ventricular hypertrophy and global and regional
biventricular systolic function. Increased left ventricular
filling pressure. Moderate aortic stenosis. Mild mitral
regurgitation. Significant pulmonic regurgitation. Increased
pulmonary artery diastolic pressure.
.
___ CXR (portable):
1. Large left and moderate right effusions and pulmonary
vascular congestion suggest moderate-to-severe pulmonary edema.
2. Asymmetric opacity in the central left upper lobe has
somewhat of a "butterfly" appearance of pulmonary edema.
However, given the unilateral distribution, the presence of an
additional consolidation or mass is likely. Repeat radiographs
should be taken after diuresis. Cross sectional imaging may be
considered at that point if the diagnosis remains in doubt.
.
___ RUE U/S:
FINDINGS: There is normal grayscale appearance, color Doppler
flow, and pulse-wave Doppler waveforms of the right internal
jugular, subclavian, brachial, basilic, and cephalic veins.
There is minimal subcutaneous edema in the right posterior
forearm in the region of symptoms.
IMPRESSION: No DVT in the right upper extremity.
.
___ CXR PA/lat: PA and lateral chest radiographs demonstrate
marked improvement of pulmonary edema with asymmetric residual
opacities in the left perihilar region. There are persistent
bilateral pleural effusions, moderate on the left and mild on
the right as well as associated left lower lobe atelectasis.
Median sternotomy wires and CABG clips are noted. The heart size
is normal. There is no pneumothorax.
IMPRESSION: Marked improvement in pulmonary edema with residual
left
perihilar opacities.
.
___ CXR:
Cardiac silhouette is enlarged. There is a left retrocardiac
opacity and left-sided pleural effusion, which have increased
since the prior study. There are also increased areas of
consolidation in the left upper lobe. These may represent
asymmetric edema versus developing pneumonia. The right lung is
relatively clear.
.
___ CT Chest w/o contrast:
1. Limited evaluation of the left hilum without intravenous
contrast, but no gross enlargement to suggest significant
lymphadenopathy or mass.
2. Multifocal heterogeneous peribronchovascular opacities
suspicious for
pneumonia.
3. Large left pleural effusion with near complete left lower
lobe collapse. Small right pleural effusion.
Brief Hospital Course:
___ with hx of CABG (3-vessel ___, renal xplant (___), and
mild aortic stenosis admitted to the MICU with hypoxia likely
from pulmonary edema.
Mr. ___ is a ___ year old gentleman with PMH of CABG (3-vessel
___, renal transplant ___, failing, sees ___ need
to think about reinitiating dialysis), and mild aortic stenosis
___ 0.9 this admission), transferred from ___ to
___ for management of dyspnea and hypoxia; now ___ MICU
admission, during which he was diuresed for volume overload.
.
# Pulmonary edema: He presented with shortness of breath, rales
and JVD on exam, BNP of 23,000, and evidecne of pulmonary edema
on CXR. He received IV lasix with significant improvement in his
breath and oxygen requirement. EKG did not show ischemic changes
and his troponins were not significantly elevated. Echo showed
normal EF, moderate AS, mild MR, Pulmonary hypertension and mild
LVH. He was transferred to the floor where he continued to
diurese well. By the day of discharge, he was satting well on
RA and had an improved lung exam.
.
# Acute on chronic exacerbation of dCHF (EF 55%). Patient with
heavy O2 requirement on arrival to MICU, portable CXR with
significant pulmonary edema, rales on exam, JVD, BNP of 23,000,
with recent history of possible dietary indiscretion and a
positional component to his dyspnea. TTE this admission with
unchanged systolic/diastolic and valvular function. Volume
overload may be due also to worsening renal function, as kidneys
unable to rid the body of fluid to keep up excretion. PE and PNA
much less likely as etiologies of presenting dyspnea/hypoxia.
CEs ruled out MI, EKG without changes. Patient initially
responded well to IV diuresis, but has since slowed in urine
output. Once on the floor, pt was continued on diuresis with IV
Lasix, then transitioned to PO Lasix 80mg twice a day by
discharge.
.
# Acute on Chronic Kindey Disease ___ Renal Transplant: Patient
with Cr that has been steadily uptrending to the mid 6's
recently. Per outpatient nephrology notes, is likely to need
repeat transplant and possibly dialysis. Improved Cr of 4.6
here, though now slightly increasd to 4.7 (possibly from
aggressive diuresis). Also with GAP of 15 stable from recent
outpatient labs and likely related to worsening renal function
than DKA.
.
# CKD ___ Renal Tx: Patient with Cr that has been steadily
uptrending to the mid 6's recently. Per outpatient nephrology
notes, is likely to need repeat transplant and possibly
dialysis. Pt's Cr remained in the ___ range during this
admission. Sevelamer carbonate 800 mg three times per day with
meals was started during this admission.
.
# Hyperglycemia/DM2 Diet-Controlled: Patient with hyperglycemia
to 400 despite not being on home insulin regimen. Most recent
HbA1c in our system is 6.7 in ___. Patient recieved large
dose of IV steroids at OSH presumably for COPD management
despite having modest 15 pack-year smoking history and no hx of
COPD. He was started on an insulin sliding scale. On admission,
patient with hyperglycemia to 400 despite not being on home
insulin regimen. Most recent HbA1c in our system is 6.7 in
___. Patient recieved large dose of IV steroids at OSH
presumably for COPD management despite having modest 15
pack-year smoking history and no hx of COPD. Pt was discharged
on his home insulin regimen.
.
Medications on Admission:
#AMLODIPINE - 10 mg Tablet - 1 (One) Tablet(s) by mouth once a
day
#CALCITRIOL - 0.25 mcg Capsule - 1 Capsule(s) by mouth day
#CARVEDILOL - 25 mg Tablet - 2 Tablet(s) by mouth twice a day
#FUROSEMIDE - 20 mg Tablet - Daily
#LEFLUNOMIDE - 10 mg Tablet - 5 Tablet(s) by mouth daily
#NIFEDIPINE - 30 mg Tablet Extended Rel 24 hr - 1 Tablet(s) by
mouth twice a day
#PRAVASTATIN [PRAVACHOL] - 20 mg Tablet - 1 Tablet(s) by mouth
once a day
#TACROLIMUS - 1 mg Capsule - 3 Capsule(s) by mouth twice a day
#ASPIRIN - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth daily
#DARBEPOETIN ALFA (in ___ clinic) - 60 mcg/0.3 mL Syringe -
inject 1 s/c once a month
#BACTRIM DS one tab daily
Discharge Medications:
1. calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
3. darbepoetin alfa in polysorbat 60 mcg/0.3 mL Syringe Sig: One
(1) injection Injection once a month.
4. furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
5. leflunomide 10 mg Tablet Sig: Five (5) Tablet PO once a day.
6. nifedipine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO BID (2 times a day).
7. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H (every
12 hours).
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*0*
13. Outpatient Lab Work
Please have your labs checked on ___. Have the
results faxed to Dr. ___: ___, Fax:
___, who may adjust your medications based on the
labs.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Acute on chronic diastolic CHF exacerbation (EF > 55%)
Acute on chronic kidney disease
.
Secondary diagnosis:
___ renal transplant
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 here at ___
___! You were admitted with
shortness of breath, and were found to have fluid in your lungs.
You improved after receiving a several intravenous doses of
Lasix to pull the fluid out of your lungs.
Please note, the following changes have been made to your
medications:
- START furosemide (Lasix) 80 mg by mouth twice daily
- START sevelamer carbonate 800 mg by mouth three times per day
with meals
Continue all of your other medications as you had prior to this
hospitalization.
Please adhere to a low sodium ___ mg) diet. There is a lot of
sodium in food at restaurants and in grocery stores. Please read
the labels on the food that you buy, and add up the total sodium
amounts.
Weight yourself every day, and call your doctor if your weight
goes up more than three pounds. Your weight today was 166.5
pounds.
Please have your labs checked on ___. Have the
results faxed to Dr. ___: ___, Fax:
___, who may adjust your medications based on the
labs.
Please see below for your follow up appointments. It is
especially important that you attend your appointment in the
kidney clinic on ___.
Wishing you all the best!
Followup Instructions:
___
|
10253057-DS-33 | 10,253,057 | 22,750,864 | DS | 33 | 2186-06-30 00:00:00 | 2186-06-30 11:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R great toe gangrene
Major Surgical or Invasive Procedure:
___
1. Ultrasound-guided vascular access of the left common
femoral artery.
2. Catheter placement to the right SFA ___ order.
3. Abdominal aortogram.
4. Right lower extremity angiogram.
___
1. Ultrasound-guided vascular access, left common femoral
artery.
2. Angioplasty of the right popliteal artery with a #3,
then a #4 balloon.
3. Placement of 2 Zilver stents, one a 5 x 80, one a 6 x
80.
4. Balloon to a #4 to a #5 in the right popliteal into the
superficial femoral artery.
5. A right lower extremity angiogram.
6. Catheter placement, right lower extremity ___ order,
into the below-knee popliteal.
7. A Perclose device.
___: Right great toe amputation
History of Present Illness:
___ w/ PMHx notable for ESRD on PD s/p DDRT in ___ failed
___ BK nephrophathy presents to ___ ED from PCP office for
evaluation of black R great toe. Pt reports first noted black
toe
approximately ___ months prior to presentation. He denies
recent trauma or inciting events. Pt was evaluated by podiatry 3
weeks ago as outpatient for nail care of R great toe, but did
not
have any further workup for this discoloration. He endorses pain
in toe with walking, but otherwise denies symptoms of rest pain
or claudication. He has had no fevers, chills, purulent drainage
from toe. He has never been evaluated by vascular surgeon and
has, per report, had no vascular interventions or NIAS.
Past Medical History:
PAD, HTN, Hyperlipiedmia, ESRD s/p failed DDRT in ___ on PD, DM,
hyperparathyroidism, anemia, BK viremia , CAD s/p 3V CABG in
___, moderate AS, anemia, bells palsy, h/p rhabdomyolysis,
PSHx: CABG (___, ___, LUE AVF (___, ___, revision LUE AVF
(___ and ___, ___, LUE AVG (___, ___, DDRT (07, ___, PD
catheter placement (12, ___
Social History:
___
Family History:
Mother: Heart Disease
Father: Died of ___ Cancer, age ___
No known family history of renal problems.
Physical Exam:
Afebrile, vital signs stable
General: NAD
Neuro: A&Ox3
Cardiac: RRR
Pulmonary: CTAB
Abdomen: Soft, NT/ND
Extremities: Warm, well perfused. Right great toe wound c/d/i.
Pulses: Femoral - palpable bilat. ___ - dopplerable bilat
Pertinent Results:
___ 06:15AM BLOOD WBC-5.8 RBC-2.86* Hgb-8.5* Hct-26.9*
MCV-94 MCH-29.7 MCHC-31.6 RDW-16.9* Plt ___
___ 06:40AM BLOOD Glucose-98 UreaN-34* Creat-5.0* Na-135
K-3.4 Cl-96 HCO3-30 AnGap-12
___ 06:40AM BLOOD Calcium-8.1* Phos-3.7 Mg-1.7
___ 3:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 11:40 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Brief Hospital Course:
Patient was admitted to the vascular surgery service at the
___ on ___ secondary to right great toe dry gangrene. The
patient was started on IV-antibiotics and admitted to the floor.
He continued to receive peritoneal dialysis as per his usual
schedule.
On the floor, his vital signs and fever curves were routinely
monitored, and he remained hemodynamically stable and afebrile.
The patient's lab values were monitored routinely.
On ___, the patient underwent 1. Ultrasound-guided vascular
access of the left common femoral artery, 2. Catheter placement
to the right SFA ___ order, 3. Abdominal aortogram, 4. Right
lower extremity angiogram, which went well without complication.
Please refer to operative note for details. After a brief,
uneventful stay in the PACU, the patient arrived back on the
floor.
On ___, the patient underwent non-invasive arterial studies,
which revealed poor right toe pressures (11). It was deemed that
he would be unlikely to heal a right great toe amputation
properly, and thus he was scheduled to undergo an angiogram.
This was performed ___, at which point angioplasty and
placement of 2 Zilver stents were placed. After a brief,
uneventful stay in the PACU, the patient arrived back on the
floor. He remained clinically and hemodynamically stable.
On ___, the patient was taken to the OR for right great toe
amputation, which went well without complication, after a brief,
uneventful stay in the PACU, the patient arrived back on the
floor.
He was made non weight bearing on the right lower extremity. A
physical therapy consult was obtained, and they recommended
rehab for the patient. He was transitioned to oral antibiotics
and plans were made to discharge him to a rehab facility.
At the time of discharge, the patient was able to ambulate with
assistance, tolerating PO, and voiding independently. He was
able to verbalize understanding with the discharge
plan/instructions.
He will follow up with vascular surgery in 2 weeks. He will
continue on oral antibiotics til that time.
Medications on Admission:
carvedilol 25'', nifedipine ER 30', pravachol 20', tacrolimus
1'', ASA 81', glipizide 10', renagel 800''', Bactrim SS qday,
Actos 30', leflunomide 50', lactulose prn
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Carvedilol 25 mg PO BID
3. GlipiZIDE XL 10 mg PO DAILY
4. Pravastatin 20 mg PO DAILY
5. Tacrolimus 1 mg PO Q12H
6. Acetaminophen ___ mg PO Q6H:PRN pain
7. Amoxicillin-Clavulanic Acid ___ mg PO Q8H
RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by
mouth every 8 hours Disp #*21 Tablet Refills:*0
8. leflunomide *NF* 50 mg Oral Daily
9. Lisinopril 5 mg PO DAILY
10. Pioglitazone 30 mg PO DAILY
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. sevelamer CARBONATE 800 mg PO TID W/MEALS
13. Senna 1 TAB PO BID:PRN constipation
14. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone [Oxecta] 5 mg ___ tablet(s) by mouth every 4 hours
Disp #*30 Tablet Refills:*0
15. NIFEdipine CR 60 mg PO DAILY
16. Clopidogrel 75 mg PO DAILY
17. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
this is per renal
18. GlipiZIDE 5 mg PO DINNER
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Peripheral vascular disease
Right great toe dry gangrene
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
MEDICATION:
We increased your nifedipine dose to 60mg daily. We also
started you on augmentin, an antibiotic for your infected toe.
You should continue this until you follow up in the clinic.
You were started on a new medication called Plavix
(Clopidogrel) 75mg once daily. You will take this for 30 days.
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
Continue peritoneal dialysis as you regularly do at home.
WHAT TO EXPECT:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart with pillows
every ___ hours throughout the day and night
Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
Drink plenty of fluids and eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
ACTIVITIES:
You are non weight bearing on your right lower extremity. You
will eventually be able to bear weight thru the heel.
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
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
After 1 week, you may resume sexual activity
After 1 week, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking pain medications
CALL THE OFFICE FOR: ___
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
vascular office ___. If bleeding does not stop, call
___ for transfer to closest Emergency Room.
Followup Instructions:
___
|
10253057-DS-36 | 10,253,057 | 20,746,562 | DS | 36 | 2186-12-29 00:00:00 | 2186-12-29 12:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypotension, hypoglycemia, chronic right foot wound
Major Surgical or Invasive Procedure:
___: angiogram with right superficial femoral artery stent
placement
___: right foot transmetatarsal amputation
___: ___ line placement
History of Present Illness:
___ with multiple medical issues including DMII, HTN, PAD, CAD
s/p CABG in ___, and ESRD s/p failed DDRT in ___ currently on
PD, who presents with hypotension and hypoglycemia.
The patient had a recent admission from ___ for
hypotension, which required ICU stay on pressors. His
hypotension was thought to be most likey a result of GNR sepsis.
Tissue from the OR during revison and debridement of big toe
amputation on ___ showed GPC and GNR on gram stain and
polymycrobial on culture. Swab of wound during last admission
grew enterococcus. He was transitioned to oral antibiotics,
ciprofloxacin and clindamycin, and completed a 10 day course of
antibiotics ___ - ___. He was discharged to rehab on ___.
At rehab his pressures were in the ___ and he was
reportedly hypoglyemic. The patient was asymptomatic, denies
lightheadedness or dizziness. He denies fevers/chills but
reports an episode of sweating. Denies cough, SOB, dysuria. He
reports missing one PD cycle today. He normally does PD ___
daily at rehab.
He was sent to the ED for management. In the ED, initial vs
were: T 97.8 P 73 BP 105/46 R 14 O2 100% RA. Labs were
remarkable for sodium of 130, cr of 5.9, bun of 29, hct of 23.9
(around baseline), wbc of 8.5 with 87% PMNs. Peritoneal fluid
revealed wbc of 193, rbc 8, 10% polys, 67% lymphs, 6% monos, 6%
eos. Blood cx and peritoneal fluid cx pending. Patient was
given 500 ccs of IVF without effect on his blood pressure.
Vitals on Transfer: T 98.3 P 75 BP 92/38 R17 O2 sat 100% RA
On the floor, vs were: 98.1 92/50 80 20 99% RA
Past Medical History:
-ESRD secondary to DM and HTN, s/p failed renal transplant, on
peritoneal dialysis
-history of BK virus infection, no DNA detected ___, on
leflunamide
-Aortic Stenosis: echo ___ with ___ 0.9
-Coronary Artery Disease: s/p PCI in ___, NSTEMI, s/p CABG
(LIMA to the LAD, SVG to D1, SVG to circumflex)
-Hyperlipidemia
-Hypertension
-Diabetes Mellitus: c/b retinopathy
-Renal osteodystrophy
-Iron deficiency anemia
-Nephrotic syndrome with hypoabuminemia
-Bell's Palsy
-History of rhabdomyolysis
-History of left lower lobe pneumonia
CABG (___, ___, LUE AVF (04, ___, revision LUE AVF
(___ and ___, ___, LUE AVG (06, ___, DDRT (07, ___, PD
catheter placement (12, ___, revision of toe amputation
___
Social History:
___
Family History:
Mother: Heart Disease
Father: Died of ___ Cancer, age ___
No known family history of renal problems
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.1 92/50 80 20 99% RA
General: AAOx3, NAD, talkative
HEENT: MMM, NCAT
CV: whistling systolic murmur heard best at LUSB
Lungs: diffuse crackles in both lung fields,
Abdomen: NTD, mildly distended, NABS
Ext: +1 pitting edema to thighs, R big toe amputation with black
areas around red area, no discharge, no erythema or edema
Neuro: grossly intact
Skin: No rashes noted
DISCHARGE PHYSICAL EXAM:
Pertinent Results:
ADMISSION LABS:
___ 11:55AM BLOOD WBC-8.5 RBC-2.55* Hgb-8.2* Hct-23.9*
MCV-94 MCH-32.2* MCHC-34.3 RDW-16.8* Plt ___
___ 11:55AM BLOOD Neuts-87.7* Lymphs-5.8* Monos-4.3 Eos-1.8
Baso-0.3
___ 11:55AM BLOOD Glucose-101* UreaN-29* Creat-5.9* Na-130*
K-3.7 Cl-89* HCO3-28 AnGap-17
___ 07:45AM BLOOD Calcium-7.6* Phos-4.2 Mg-1.5*
___ 12:06PM BLOOD Lactate-1.3
DISCHARGE LABS: - pre dialysis labs (dialysis ___ 07:45AM BLOOD Cortsol-28.4*
___ 07:35AM BLOOD Vanco-18.3
___ 03:45AM BLOOD WBC-6.7 RBC-2.61* Hgb-8.4* Hct-25.3*
MCV-97 MCH-32.1* MCHC-33.0 RDW-16.8* Plt ___
___ 08:50PM BLOOD ___ PTT-34.0 ___
___ 10:45AM BLOOD UreaN-33* Creat-5.3*# Na-131* K-3.8
Cl-90*
___ 03:45AM BLOOD Albumin-1.9* Calcium-7.0* Phos-3.8
Mg-1.5*
___ 07:45AM BLOOD Cortsol-28.4*
___ 07:35AM BLOOD Vanco-18.3
MICRO:
___ blood cultures: negative
___ peritoneal fluid cx: negative
___ peritoneal fluid cx:
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH
STUDIES:
___ CXR:
Interval improvement in mild pulmonary edema. Persistent small
left pleural
effusion and left basilar atelectasis. Possible trace right
pleural effusion.
R UE US ___: No evidence of deep vein thrombosis in the right
upper extremity
veins.
Lower extremity arterial noninvasives at rest ___:
Severe multilevel arterial occlusive disease in bilateral lower
extremities
Brief Hospital Course:
___ with hx of DMII, HTN, PAD, CAD s/p CABG in ___, and ESRD
s/p failed DDRT in ___ currently on PD, who p/w hypotension and
hypoglycemia, both of which quickly resolved, and who underwent
right foot transmetatrsal amputation due to PAD
ACTIVE ISSUES:
# PAD with R foot chronic wound: The patient has chronic PAD
with a right foot wound with toe amputation s/p multiple
revisions. The patient underwent arterial studies and an
angiogram which showed significant peripheral vascular disease.
He had a stent placed in his right superficial femoral artery on
___ for which he will need plavix for 30 days. In addition,
he underwent a right TMA on ___.
# Anemia: The patient is anemic at baseline, with hct 23 on
admission. Likely ___ ESRD. He was given one unit of PRBC on
___, and his hct remained stable during the rest of the
admission. He was started on epogen during his stay.
# Hypoglycemia: The patient had refractory hypoglycemia on
admission, likely due to increased sulfonylurea use in setting
of missed PD dialysis at rehab. He was briefly transferred to
the ICU and was placed on D10 infusion and octreotide. After 48
hours after admission his blood glucose stabilized. He was
started on sliding scale insulin and he did not have any other
hypoglycemic episodes during the admission. Endocrine consulted
and recommended stopping his pioglitazone and glipizide and
starting Januvia 25mg/day at discharge.
# Hypotension: Pt was hypotensive on admission, with SBPs of
___ in the ED. On the floor his SBP was around 100. Etiology
unclear; no obvious sign of infection. One out of two peritoneal
cultures grew rare coagulase negative staphylococcus, which was
likely a contaminant. He was started on antibiotics, but after
one day in the hospital his pressures stabilized and the
antibiotics were stopped. His carvedilol was held during
admission and his pressures remained stable during the rest of
the admission. He should follow up with his PCP for further
management and monitoring.
# Hyponatremia: was hyponatremic earlier this admission; likely
related to fluid retention and change in PD fluid. Nephrology
consulted and recommended PD changes based on his sodium.
CHRONIC ISSUES:
# ESRD: No active issues. The patient was maintained on
peritoneal dialysis. Nephrology consulted. He was continued on
his sevelamer, calcitriol, epogen and leflunamide.
# CAD: No active issues. Aspirin continued; carvedilol held due
to his hypotension.
# HLD: Continued statin.
TRANSITIONAL ISSUES:
- Will need plavix until ___ for stent
- epogen and lab monitoring as outpt by pcp.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pioglitazone 30 mg PO DAILY
2. GlipiZIDE 10 mg PO BID
3. Acetaminophen 650 mg PO Q6H:PRN pain
4. Aspirin 81 mg PO DAILY
5. Calcitriol 0.25 mcg PO DAILY
6. Carvedilol 25 mg PO BID
7. leflunomide 20 mg Oral daily
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
9. Pravastatin 20 mg PO DAILY
10. sevelamer CARBONATE 800 mg PO TID W/MEALS
11. Docusate Sodium 100 mg PO BID
12. Ondansetron 4 mg PO Q8H:PRN nausea
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Senna 1 TAB PO BID:PRN constipation
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Calcitriol 0.25 mcg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Ondansetron 4 mg PO Q8H:PRN nausea
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Senna 1 TAB PO BID:PRN constipation
8. Pravastatin 20 mg PO DAILY
9. leflunomide 20 mg Oral daily
10. Clopidogrel 75 mg PO DAILY
11. Januvia (sitaGLIPtin) 25 mg Oral daily
12. Dextrose 50% ___ gm IV PRN hypoglycemia protocol
13. Epoetin Alfa 10,000 UNIT SC QMOWEFR
14. Warfarin 5 mg PO DAILY16 Duration: 1 Dose
pls dose according to INR
15. sevelamer CARBONATE 800 mg PO TID W/MEALS
16. Simethicone 40-80 mg PO QID:PRN BLOATING
17. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
18. Heparin Dwell (1000 Units/mL) 1000 UNIT DWELL PRN peritoneal
dialysis
Dwell to CATH Volume
19. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
20. Glucose Gel 15 g PO PRN hypoglycemia protocol
21. Bisacodyl ___AILY:PRN no daily BM
22. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone [Oxecta] 5 mg 1 tablet, oral only(s) by mouth q 3
hours Disp #*60 Tablet Refills:*1
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Peripheral arterial disease
Hypoglycemia due to oral diabetes medications
right upper extremity deep vein thrombosis / non-occlusive to
basilic and axillary veins. Clot in subclavian and internal
jugular as well
Chronic Kidney Disease / on dialysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you during your stay. You were
initially admitted to the hospital on ___ for low blood
sugars and low blood pressure. You briefly were transferred to
the ICU for management of your low blood sugars, however, your
hypoglycemia quickly resolved. The cause of the low blood sugar
is likely due to your oral diabetic agents, glipizide and
pioglitazone, having an increased effect due to your renal
disease. Endocrine consulted and recommended starting Januvia
25mg/day instead of those medications at discharge.
Your right foot wound was also evaluated during your stay.
Vascular surgery performed an arteriogram on the right leg and
placed a stent in one of the arteries of your leg. In addition,
your toes on the right foot were amputated due to poor blood
supply to the area. You should take plavix until ___ due to
the stent placement.
You had a blood clot in your right arm. You were started on
blood thinners for this.
You were also anemic during admission. This is likely due to
your chronic kidney disease. You were started on epogen
injections and were given a blood transfusion. You should
continue the epogen injections to maintain your blood counts.
Because you have kidney disease and are on peritoneal dialysis,
you should weigh yourself every morning to ensure you are not
retaining fluid. Call your physician if your weight goes up
more than 3 lbs.
Followup Instructions:
___
|
10253119-DS-16 | 10,253,119 | 26,345,305 | DS | 16 | 2169-08-06 00:00:00 | 2169-08-07 21:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ y/o M with PMHx significant for IDDN, HTN,
HLD, abdominal wall hernia s/p repair 2 months ago, obesity,
reported history of PE after surgery, nephrolithiasis who went
to planned lithotripsy today was found to be hypotensive with
acute on chronic back pain and directed to the ED at ___
___ now being admitted to ___ for ongoing
management.
Of note, patient endorses being diagnosed with dementia and is
at times a poor historian. Per patient report, he had fasted for
the planned surgical procedure and this morning felt dizzy and
lightheaded. He denies any chest pain, new abdominal pain (has
chronic pain after surgery), n/v or dysuria. He further denies
any new shortness of breath (chronic sob with exertion ___
years). He notes acute on chronic back pain as well and this
caused him to double over in pain today. Per patient, he has
chronic back pain which has been going on for years and is
attributed to osteoarthritis. About one day prior to
presentation he noted acute worsening of this pain. It is
located in the R flank area and is nonradiating and constant. It
is assocaited with some nausea but no vomiting. Today at his
appointment he had an attack of the pain and doubled over. Due
to this pain as well as his hypotension, the planned lithotripsy
was deferred and he was directed to the ___.
In the ___, he complained of back pain and was
hypotensive on arrival to ___ ___. He was bolused with IVF and
had a CT abd/pelvis which was unrevealing (showed nonobstructing
R sided renal stone). He was then seen by the intensivist who
recommended IV heparin gtt given his recent history of PE
(post-surgical). Per patient report he denies a history of PE;
however, per records, patient had a post-surgical PE. He was
initially placed on coumadin; however, due to alopecia, this was
discontinued. He says he took the last dose about 2 weeks ago.
In the ED, initial vitals were: 97.7 56 84/53 18 100% 3L
- Labs were significant for cr 1.0, PTT 65 on heparin gtt
- Imaging revealed no ___ DVT, CXR unrevealing
- The patient was given Dilaudid, Vanc, Zosyn
Vitals prior to transfer were: 58 90/64 18 98% RA
Upon arrival to the floor, patient is lying comfortably in bed.
He is conversant.
Past Medical History:
- IDDM
- HTN
- HLD
- Abdominal wall hernia s/p repair 2 months ago
- Obesity
- Depression
- Insomnia
- Nephrolithiasis (bilaterally per patient report)
- Osteoarthritis
- Gout
- Divertiulosis
Social History:
___
Family History:
Not relevant to the current hospitalization
Physical Exam:
ADMISSION
=========
Vitals: 97.6 101/63 56 18 95% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM
Neck: Supple
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: well healed scar present, soft, non-tender,
non-distended, bowel sounds present
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: oriented to hospital and date, ___ strength and sensation
grossly intact
Back: tenderness to palpation of lumbar spine as well as right
flank
DISCHARGE
==========
Vitals: 98.0 138/98 79 20 100%RA
General: well-appearing, NAD, speaking comfortably, alert and
awake.
HEENT: EOMI, PEERLA, MMM, oropharynx clear
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: CTAB, normal excursion, no respiratory distress
Abdomen: well healed scar present, soft, non-tender, protuberant
but nondistended, +BS.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, nonfocal
Pertinent Results:
ADMISSION
=========
___ 07:45PM BLOOD WBC-7.0 RBC-3.62* Hgb-10.1* Hct-33.2*
MCV-92 MCH-27.9 MCHC-30.4* RDW-16.1* RDWSD-53.7* Plt ___
___ 07:45PM BLOOD Neuts-55.7 ___ Monos-6.3 Eos-4.0
Baso-0.3 Im ___ AbsNeut-3.88 AbsLymp-2.34 AbsMono-0.44
AbsEos-0.28 AbsBaso-0.02
___ 07:45PM BLOOD ___ PTT-65.1* ___
___ 07:45PM BLOOD Glucose-128* UreaN-12 Creat-1.9* Na-144
K-4.8 Cl-111* HCO3-20* AnGap-18
___ 07:45PM BLOOD ALT-20 AST-16 AlkPhos-64 TotBili-0.4
___ 07:45PM BLOOD proBNP-109
___ 07:45PM BLOOD cTropnT-0.01
___ 07:18AM BLOOD Albumin-3.4* Calcium-8.1* Phos-3.7
Mg-1.5*
___ 07:45PM BLOOD D-Dimer-319
___ 08:15PM BLOOD Lactate-1.7
DISCHARGE
=========
___ 07:02AM BLOOD WBC-5.1 RBC-4.22* Hgb-11.5* Hct-38.2*
MCV-91 MCH-27.3 MCHC-30.1* RDW-16.1* RDWSD-53.1* Plt ___
___ 07:02AM BLOOD ___ PTT-77.4* ___
___ 07:02AM BLOOD Glucose-62* UreaN-8 Creat-0.7 Na-140
K-3.8 Cl-107 HCO3-21* AnGap-16
___ 07:18AM BLOOD ALT-66* AST-51* LD(LDH)-165 AlkPhos-77
TotBili-0.3
___ 07:02AM BLOOD ALT-52* AST-23 AlkPhos-77 TotBili-0.1
___ 07:02AM BLOOD Calcium-9.2 Phos-3.0 Mg-1.6
IMAGING
==========
___ US ___: No evidence of deep vein thrombosis in the bilateral
lower extremity veins
CXR ___: No acute cardiopulmonary process.
Renal US ___: Normal renal ultrasound. No evidence of
hydronephrosis.
Brief Hospital Course:
___ y/o M with PMHx significant for IDDN, HTN, HLD, abdominal
wall hernia s/p repair 2 months ago, obesity, recent bilateral
PEs ___ not taking anticoagulation, nephrolithiasis who
was hypotensive at ___ and trasnferred to ___ for
further evaluation.
ACTIVE ISSUES
=============
# Hypotension:
Patient was found to be hypotensive to the ___ systolic at the
OSH, although was reportedly mentating well. Hypotension may
have been due to poor PO intake in the setting of preparation
for surgery. There was no evidence of hemorrhagic shock
clinically outside they hypotension, no findings on CT
abd/pelvis, and no active GIB evidence seen. Patient did not
meet SIRS criteria, and there was no evidence of a source of
sepsis (negative UA, no meniningismus, negative CXR). Blood
cultures at ___ was negative to discharge. Patient also
had no EKG changes and negative troponins, making a cardiogenic
etiology or pulmonary embolism less likely. He received 4L IVF
prior to admission, with appropriate response in SBP to the 110s
systolic. His blood pressures subsequently remained stable, and
he was discharged with a BP of 138/90 with no issues of
hypotension during admission and otherwise asymptomatic.
# Pulmonary Embolus:
Patient had a PE diagnosed at ___ on ___. He
was discharged on lovenox and coumadin, but stopped coumadin
prior due to alopecia. Plan had to take fondiparinux prescribed
by his PCP but never picked it up. As a result, while here, he
was treated with a heparin drip and subsequently received two
doses of apixiban before plan to continue fondiparinux, already
available to patient at his Rite-Aid by his PCP, as an
outpatient as apixiban and other oral anticoagulants required
prior authorization.
# Acute Kidney Injury:
Patient had a creatinine of 1.9 on admission, with unclear
baseline renal fx. Creatinine subsequently downtrended to 0.7 by
discharge. Etiology most likely hypovolemia resolved with
fluids. CT showed a non obstructing right sided kidney stone,
but renal US ___ did not demonstrate hydronephrosis. Urinating
freely with no other issues.
CHRONIC ISSUES:
===============
# Psych:
Pt was very lethargic early in the admission following
administration of his seroquel. All home sedatives and
psychoactive medications were held on this admission. We have
recommended stopping his diazepam and ativan for now with
avoidance of ambien. He should reconsider his dose of seroquel
or other medications to avoid excessive somnolence. He should
also consider establishing care with psychiatry for further
assistance with his depression and med adjustment.
# Back pain:
Per pt is chronic and not currently worse. He had one acute
episode of right sided low back pain while as an inpatient,
which was constant in nature. This acute exacerbation may have
been due to a kidney stone.
# Anemia:
Unclear baseline, but stable from OSH. No significant drops
during his inpatient stay, discharged with Hb of 11.5.
# IDDM:
Maintained on home dose lantus with ___, home dose metformin
held and restarted on discharge.
# GERD:
Maintained on home dose omeprazole
# BPH:
Maintained on home dose tamsulosin
# Hypertension:
Held clonidine, hctz, losartan in the setting of ___, restarted
losartan on discharge
# Gout:
Held allopurinol in the context ___
TRANSITIONAL ISSUES
======================
- Pt was very lethargic early in the admission following
administration of his seroquel. He is on a number of sedatives
and psychoactive medications which were held on this admission.
We have recommended stopping his diazepam and ativan with
avoidance of ambien. He should reconsider his dose of seroquel
or other medications to avoid excessive somnolence. Consider
establishing care with psychiatry for further assistance for his
depression.
- We stopped his clonidine, HCTZ, and Losartan in the context of
hypotension, and he has remained normotensive in the hospital.
Recommended resuming lorsartan for now and can add-on or adjust
medications after re-check with PCP.
- We were unable to discharge him on Apixiban because of lack of
prior authorization, so discharged him on previously prescribed
fondiparinux instead. Consider alternative anticoagulation for
ease administration if desired.
# CODE STATUS: full
# CONTACT:Next of kin ___ (Aunt) ___ (healthcare
proxy)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Tamsulosin 0.4 mg PO QHS
3. QUEtiapine Fumarate 200 mg PO QHS
4. Ambien (zolpidem) 10 mg oral QHS
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
7. Topiramate (Topamax) 100 mg PO QHS
8. Amitriptyline 200 mg PO QHS
9. Aspirin 81 mg PO DAILY
10. Diazepam 10 mg PO DAILY
11. Glargine 48 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
12. Senna 8.6 mg PO BID
13. Allopurinol ___ mg PO DAILY
14. Citalopram 40 mg PO DAILY
15. CloniDINE 0.3 mg PO QPM
16. Hydrochlorothiazide 12.5 mg PO DAILY
17. Losartan Potassium 100 mg PO DAILY
Discharge Medications:
1. Amitriptyline 200 mg PO QHS
2. Aspirin 81 mg PO DAILY
3. Citalopram 40 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Senna 8.6 mg PO BID
6. Tamsulosin 0.4 mg PO QHS
7. Topiramate (Topamax) 100 mg PO QHS
8. Allopurinol ___ mg PO DAILY
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
11. Losartan Potassium 100 mg PO DAILY
12. Fondaparinux 7.5 mg SC DAILY
RX *fondaparinux 7.5 mg/0.6 mL 1 injection IM daily Disp #*30
Syringe Refills:*0
13. QUEtiapine Fumarate 200 mg PO QHS
Please discuss with your primary care doctor about your dosing.
14. Glargine 48 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home
Discharge Diagnosis:
Hypotension
Deep Vein Thrombosis
Pulmonary Embolism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
Thank you for choosing to receive your medical care at ___
___.
You were admitted for low blood pressure. Your low blood
pressure was likely caused by your not being able to take oral
food and fluids in the context of your surgical procedure with
no evidence of infection or other clear causes. In the hospital,
your blood pressure normalized to your usual range.
You also have a history of clots coming from your legs to your
lungs. You were started on a blood thinning medication,
Apixiban, which should help manage these clots and prevent
future clots from forming and damaging your lungs.
Unfortunately, right now insurance will not cover this
medication, but you should pursue getting it with your PCP. In
the interim, you should continue to use the fondaparinux that
has been ordered by your primary care doctor and is presently at
___ pharmacy for you to pick-up. You need to stay on this
blood thinner due to the clots in your lungs.
We are changing your home medications around a little following
discharge, in order to prevent repeat episodes of low blood
pressure and extreme sleepiness.
- You should hold taking the following medications until seen by
your primary care doctor: Ambien, Diazepam, Clonidine, and
Hydrochlorothiazide
- You should reconsider your dose of seroquel with your primary
care doctor or discuss establishing care with a psychiatrist to
better adjust your medications since you were hard to arouse
while in the hospital.
We wish you all the best with your ongoing recovery.
Regards,
Your entire ___ care team.
Followup Instructions:
___
|
10253146-DS-10 | 10,253,146 | 26,685,114 | DS | 10 | 2183-05-18 00:00:00 | 2183-05-18 12:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Slurred speech
Major Surgical or Invasive Procedure:
tPA
History of Present Illness:
Ms. ___ is a ___ old right-handed woman with a past
medical history of afib on aspirin, ___, CKD and hyperlipidemia
who presents with sudden onset slurred speech and left-sided
weakness.
Patient was sitting at home with her son watching TV, when she
had sudden onset left hemibody weakness and slurred speech.
This
occurred between 3 and 3:15 ___. EMS was called and by the time
of their arrival patient was back to normal, total time
approximately 5 minutes. She was taken to ___ where her
initial neurologic exam was nonfocal. Shortly afterward, she
had
a noncontrast head CT which was unremarkable. Blood pressure
was
elevated to 220/101 on arrival. A nicardipine drip was started.
She developed left-sided weakness once again with ___ stroke
scale of 5 and the decision was made to proceed with TPA. TPA
was administered at 1645, approximately 1 hour and 45 minutes
after onset of symptoms. She was transferred to ___ for
further management.
On arrival to ___, her exam had worsened. Blood pressure was
noted to be in the high ___ systolic and the nicardipine drip
was
discontinued. On my evaluation, patient had an ___ stroke scale
of 12. She was taken emergently to the CT scanner for rule out
hemorrhagic conversion. She also had a CTA head and neck to
rule
out vessel cut off. IV fluids were started to improve
perfusion.
Past Medical History:
Afib on Aspirin
___
CKD
Hyperlipidemia
Hypothyroidism
Osteoporosis
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: Awake, interactive
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic (initial exam with blood pressure in the ___:
-Mental Status: Alert, oriented to self, age and month. She
follows simple commands and has non-fluent speech but is mildly
dysarthric. She describes the stroke card as "kids playing"
"blanket."
-Cranial Nerves:
PERRL 3 to 2mm and brisk. There is a right gaze preference and
she can come to midline but not across it. No blink to threat
in
the left. Prominent left facial droop. Tongue midline.
-Sensorimotor:
Left upper extremity is plegic without movement to noxious
stimuli. Left lower extremity withdraws to noxious stimuli in
the plane of the bed. Right side is spontaneous and
antigravity.
-DTRs:
___ response was extensor on the left, flexor on the right.
-Coordination: Finger to nose is normal on the right
-Gait: Deferred
DISCHARGE PHYSICAL EXAM:
-Mental Status: Alert, awake, oriented to person, place. Pt able
to provide adequate history. 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. L motor neglect noted,
improving.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. LUE to antigravity, LLE in
plane of bed. Full strength of R hemibody. No adventitious
movements, such as tremor, noted.
-Sensory: Decreased sensation to LT over L hemibody, intact over
RUE/RLE. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was extensor on L, flexor on R.
-Coordination/Gait: Deferred.
Pertinent Results:
___ 05:10AM BLOOD WBC-10.8* RBC-3.42* Hgb-10.4* Hct-32.1*
MCV-94 MCH-30.4 MCHC-32.4 RDW-14.0 RDWSD-48.4* Plt ___
___ 09:15AM BLOOD WBC-12.8* RBC-3.80* Hgb-11.5 Hct-36.0
MCV-95 MCH-30.3 MCHC-31.9* RDW-14.1 RDWSD-48.6* Plt ___
___ 06:40AM BLOOD ___ PTT-27.3 ___
___ 05:10AM BLOOD Glucose-111* UreaN-19 Creat-1.2* Na-139
K-3.4 Cl-102 HCO3-24 AnGap-16
___ 09:15AM BLOOD Glucose-129* UreaN-25* Creat-1.5* Na-142
K-4.3 Cl-103 HCO3-24 AnGap-19
___ 09:20AM BLOOD CK(CPK)-105
___ 06:40AM BLOOD CK-MB-3 cTropnT-<0.01
___ 09:20AM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:10AM BLOOD Calcium-7.6* Phos-2.9 Mg-2.3
___ 09:15AM BLOOD Calcium-8.4 Phos-3.9 Mg-2.3 Cholest-207*
___ 09:15AM BLOOD %HbA1c-6.2* eAG-131*
___ 09:15AM BLOOD Triglyc-181* HDL-44 CHOL/HD-4.7
LDLcalc-127
___ 05:10AM BLOOD Osmolal-292
___ 06:40AM BLOOD Digoxin-1.6
___ H&N
1. Focal occlusion of a distal right superior M2 branch of the
right MCA with asymmetrically decreased distal arborization of
the right M3/M4 segments of the MCA with multiple areas of
terminal partial/ subtotal vascular occlusion. While there is
no CT evidence of infarct, this may be due to acuity and infarct
in the right MCA territory is suspected, and further evaluation
with noncontrast head MR is recommended.
2. No intracranial hemorrhage.
3. 3 mm aneurysm at the origin of the left superior cerebellar
artery.
4. Remainder of the circle of ___ arterial vasculature is
grossly patent.
5. Patent cervical arterial vasculature without significant
stenosis,
occlusion, or dissection.
6. Moderate global atrophy and areas of periventricular white
matter
hypodensities in a configuration most suggestive of chronic
small vessel
ischemic disease.
7. Heterogeneous 23 mm right thyroid lobe nodule with dense
calcifications.
The ___ College of Radiology guidelines suggest thyroid
ultrasound for further evaluation if not already obtained.
8. 4 mm left upper lobe pulmonary nodule. The ___
Society guidelines for pulmonary nodule guidelines suggest for
pulmonary nodules less than or equal to 4 mm, no follow-up
needed in low-risk patients, and 12 month follow-up in high risk
patients.
___ HEad w/o
Acute infarcts in the right MCA distribution.
___
Motion limited study. No obvious acute intracranial
abnormalities are
identified.
___
1. There is no evidence acute intracranial hemorrhage.
2. Sequelae of prior infarcts, involutional changes and likely
chronic
microvascular ischemic changes.
Brief Hospital Course:
Pt presented to ___ as Code Stroke due to sudden onset of
slurred speech, left facial droop, and left sided weakness
suggestive of R MCA stroke. She received tPA on ___ at 1645.
She underwent CT/CTA that did not show any hemorrhage or vessel
cut off. She was admitted to the Stroke Service, particularly to
the Stepdown Unit for post tPA monitoring. Antiplatelet agents
and anticoagulants were held for 24 hours s/p tPA and pt
received thorough neurochecks per postTPA protocol. She was
monitored on telemetry with Atrial Fibrillation shown
(previously diagnosed). Due to repeat CT appearing stable, she
was started on Eliquis. Due to an aspiration event pt was
started on antibiotic course, specifically
Ceftriaxone/Azithromycin, for 7 days. Pt's respiratory status
and neurological status were seen to be stable during hospital
course. On ___, pt developed severe headache which was evaluated
with NCHCT seen to be stable. This pain was treated with prn
pain med regimen. On ___, pt had decreased urine output
attributed to decreased fluid intake and home Lasix was held. Pt
received occasional fluid boluses and was encouraged to take
more PO fluids. Due to appearing clinically stable, patient will
be discharged from the hospital to acute rehab.
Transition Issues:
-Aspirin has been stopped. and
-She is now taking Eliquis 2.5mg twice a day.
-Pt will need to work at ___ on improving her functional
status and be evaluated for further services upon discharge home
-Pt will need to follow up with her PCP and ___ in the
near future
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.25 mg PO DAILY:PRN as directed
2. Metoprolol Tartrate 25 mg PO TID
3. Furosemide 20 mg PO DAILY
4. Digoxin 0.25 mg PO DAILY
5. Aspirin 325 mg PO DAILY
6. Vitamin D Dose is Unknown PO DAILY
Discharge Medications:
1. Apixaban 2.5 mg PO BID
2. QUEtiapine Fumarate 12.5 mg PO QHS Agitation
3. Vitamin D 800 UNIT PO DAILY
4. ALPRAZolam 0.25 mg PO DAILY:PRN as directed
5. Digoxin 0.25 mg PO DAILY
6. Furosemide 20 mg PO DAILY
7. Metoprolol Tartrate 25 mg PO TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute ischemic stroke
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid ___
or cane).
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of slurred speech and L
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:
Atrial Fibrillation
Congestive Heart Failure
High Cholesterol
We are changing your medications as follows:
Please start taking Eliquis 2.5mg twice daily and stop taking
Aspirin. Continue taking Seroquel 12.5mg at bedtime to help with
agitation and sleep.
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10253211-DS-19 | 10,253,211 | 24,215,447 | DS | 19 | 2198-10-06 00:00:00 | 2198-10-08 21:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ibuprofen
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
___ female with no cardiac history presents with neck tightening
2 days ago while chasing her granddaughter. The tightening
radiated down the left arm and was not relieved by rest. The
discomfort lingered throughout the day, and she had no
associated symptoms such as SOB, diaphoresis, or nausea. The
next morning it was gone, and she presented for a scheduled
surgery for trigger finger. She shared this history preop and
was sent to the ED.
In the ED initial vitals were 98.0 68 142/80 16 100% RA. She had
a normal EKG and negative troponins x2, negative chest x-ray and
negative d-dimer. Exercise stress this AM showed dynamic
inferolateral STD which normalized with rest. Cardiology was
consulted and recommended admission to ___. She was given ASA
325mg, Nicotine lozenge, Vicodin x1, Percocet x1, docusate x1.
VS at transfer: 97.7 62 143/71 16 100% RA.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
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:
Depression/anxiety
Trigger finger
Seasonal allergies
Chronic pain from burn to right hip
Social History:
___
Family History:
Mother with DM and HTN, father MI age ___, died of MI age ___
Physical Exam:
PHYSICAL EXAMINATION:
VS: T97.8 BP 109/73 HR 61 RR 16 O2 99%RA
GENERAL: Female appears stated age in NAD. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of <5cm
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: 2+ bilateral radial/pedal
DISCHARGE EXAM
VS: T97.6 BP 139/76 HR 53 RR16 O2 100%RA
GENERAL: Female appears stated age in NAD. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of <5cm
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: 2+ bilateral radial/pedal
Pertinent Results:
___ 03:40PM BLOOD WBC-6.6 RBC-5.01 Hgb-14.5 Hct-43.3 MCV-86
MCH-28.8 MCHC-33.4 RDW-13.7 Plt ___
___ 03:40PM BLOOD Glucose-84 UreaN-12 Creat-0.7 Na-139
K-3.9 Cl-107 HCO3-23 AnGap-13
___ 03:40PM BLOOD cTropnT-<0.01
___ 10:10PM BLOOD cTropnT-<0.01
___ 05:05PM BLOOD CK-MB-1 cTropnT-<0.01
___ 07:14AM BLOOD CK-MB-1 cTropnT-<0.01
___ 07:26AM BLOOD CK-MB-1
___ 03:40PM BLOOD D-Dimer-284
___ 07:14AM BLOOD %HbA1c-6.0* eAG-126*
___ 07:14AM BLOOD Triglyc-102 HDL-49 CHOL/HD-4.8
LDLcalc-168*
EKG ___
Sinus rhythm. Delayed R wave progression in the precordium.
Non-specific
T wave flattening in the inferior leads and lead aVL. No
previous tracing
available for comparison.
STRESS ___
INTERPRETATION: This ___ yo woman with h/o smoking was referred
to
the lab from the ED following negative serial cardiac enzymes
for
evaluation of chest discomfort. The patient exercised for 6.75
minutes
of ___ protocol and was stopped for marked ischemic EKG
changes with
ST elevation. The peak estimated MET capacity was 7.9, which
represents
an average exercise tolerance for her age. There were no reports
of
chest, back, neck, or arm discomforts during the study. At peak
exercise, there was 2-2.5 mm horizontal ST segment depression in
the
inferolateral leads with 1-1.___levation in aVR. The
patient was
administered a 325 mg asa and the ST elevation resolved by 1.5
minutes
of recovery. The inferolateral ST segment depression became
downsloping
in recovery and resolved completely by 10 minutes of recovery.
Rhythm
was sinus with rare isolated APBs in early recovery. The heart
rate and
blood pressure responses were appropriate during exercise and
recovery.
IMPRESSION: Marked ischemic EKG changes with ST elevation in aVR
in the
absence of anginal type symptoms. Average functional capacity.
ED
attending and cardiology fellow notified.
Cath ___. Selective coronary angiography of this right-dominant system
demonstrated no angiographically-apparent flow-limiting
stenoses. the
LMCA, LCX, and RCA were normal. The LAD had mild disease.
2. Limited resting hemodynamics revealed systemic hypertension
with a
central aortic pressure of 156/70.
FINAL DIAGNOSIS:
1. No significant coronary artery disease.
2. Risk factor modification.
3. Smoking cessation
EKG ___
Sinus bradycardia. Late R wave progression in the precordium.
Non-specific
ST-T wave changes in leads V2-V3. Compared to tracing #4 the
non-specific
ST-T wave changes in leads V2-V3 are more apparent.
ECHO ___
Conclusions
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
Brief Hospital Course:
___ female with only known cardiac risk factor to be smoking
presents with unstable angina and ST changes on stress test
found to have only diffuse mild disease on cath, no
interventions.
# CORONARIES: No h/o CAD, risk factors positive only for
smoking. LDL here was mildly elevated at 168 with HDL 48, A1C
was 6.0. She presents with unstable angina and 2-2.5 mm
horizontal ST segment depression in the inferolateral leads with
1-1.___levation in aVR, concerning for ischemia. However,
cath was essentially clean. Followup echo was without wall
motion abnormalities, EF 55%. This patient will benefit from
risk factor reduction. She was counseled to quit smoking. She
was discharged on
TRANSITIONAL ISSUES:
The patient will require rescheduling of surgery for trigger
finger
Started Simvastatin 40mg daily
Changed Aspirin to 81mg daily
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Betamethasone Dipro 0.05% Oint 1 Appl TP BID:PRN itching
2. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
3. Lidocaine 5% Patch 1 PTCH TD DAILY pain
apply for 12 hours as needed for pain
4. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO TID pain
hold for sedation, RR< 12
5. Aspirin 650 mg PO TID:PRN pain
6. Docusate Sodium 100 mg PO QHS:PRN constipation
7. Mirtazapine 30 mg PO HS
Discharge Medications:
1. Aspirin 81 mg PO DAILY pain
RX *aspirin 81 mg 1 tablet(s) by mouth once daily Disp #*30
Tablet Refills:*0
2. Docusate Sodium 100 mg PO QHS:PRN constipation
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth once
daily Disp #*30 Capsule Refills:*0
3. Lidocaine 5% Patch 1 PTCH TD DAILY pain
RX *lidocaine 5 % (700 mg/patch) apply for 12 hours as needed
for pain Disp #*10 Transdermal Patch Refills:*0
4. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
RX *clobetasol 0.05 % apply twice daily Disp #*1 Container
Refills:*0
5. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN pain
hold for sedation, RR< 12
6. Simvastatin 40 mg PO DAILY
RX *simvastatin 40 mg 1 tablet(s) by mouth once daily Disp #*30
Tablet Refills:*0
7. clotrimazole-betamethasone *NF* ___ % Topical BID
8. Betamethasone Dipro 0.05% Oint 1 Appl TP BID:PRN itching
9. Mirtazapine 30 mg PO HS
RX *mirtazapine 30 mg 1 tablet(s) by mouth once daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure participating in your care at ___
___.
You were admitted because you were having chest pain. You
underwent some testing, and it was found that you did not have a
heart attack. However, the blood vessels supplying your heart
are slightly narrowed. An echocardiogram (ultrasound of the
heart) was done and it was normal.
It is important that you quit smoking to prevent further heart
problems in the future. In addition, your cholesterol is
elevated and it is important that you take simvistatin. Finally,
we have changed the dose of aspirin for you to take.
MEDICATION CHANGES:
- STARTED: Simvistatin 40mg Take one tablet once daily
- CHANGED: Aspirin 81mg Take one tablet once daily
Followup Instructions:
___
|
10253349-DS-10 | 10,253,349 | 22,627,882 | DS | 10 | 2187-04-10 00:00:00 | 2187-04-13 13:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / lisinopril / Reglan / vancomycin / shellfish
derived / ceftazidime / Cephalosporins
Attending: ___.
Chief Complaint:
Influenza
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M w/ uncontrolled DM1 ESRD on HD ___, central pontine
myelinosis w/ baseline quadriplegia, neurogenic bladder
requiring
straight cath every other day, Stage IV decubitus ulcer, colonic
fistula requiring diverting colostomy, presents with productive
cough and fever. Patient states that his baseline he has a
persistent cough. Over the last few days cough is increasing
frequency as well as with thickening green and yellow sputum. He
has noted subjective fevers with temps reported as high as 101
at
his facility. Reportedly yesterday had a chest x-ray and flu
swab
which were negative. Patient requires intermittent cathing. He
denies any chest pain or shortness of breath. Denies any
abdominal pain, nausea vomiting or diarrhea. Of note, the
patient
is motor quadriplegic. However he does have sensation throughout
his extremities peer
In the ED, initial VS were: 101.0 97 146/90 16 98% RA
Exam:
-Quadriplegic.
-Lungs are rhonchorous
-No murmurs or rubs, not tachycardic
-Abdomen soft, nontender, nondistended
-No swelling in the lower extremity
Labs showed: WBC to 10.2, anemia to 9.4, Flu +, K 6.1 normalized
to 4.5, lactate 1.9, repeat CBC pending, UA +
Imaging showed: Moderate left pleural effusion with left
retrocardiac atelectasis. Difficult to exclude superimposed
pneumonia.
Consults: Renal/HD, with HD done today, without additional fluid
taken off
AST also involved with discussion of antibiotics, decision for
Cefepime as tolerated ceftazidime, and Linezolid for MRSA
coverage.
Patient received: Albuterol and Ipratropium nebs, PO
Oseltamavir,
IV Cefepime, IV Zofran, IV clindamycin-> switched to IV
linezolid, IV insulin, PO omeprazole, PO montelukast
Transfer VS were 100.8 97 92/48 18 95% 2L NC
Of note, he was recently admitted from ___ for UTI and
pneumonia. He was initially treated broadly with meropenem, with
then narrowed to ertapenem for ESBL E Coli, which he finished
the
course on ___.
On arrival to the floor, patient reports feeling "okay", notes
phlegm in throat, no dyspnea, chest pain, or pleurtitic pain. He
has had some swelling of his right arm since antibiotic
administration in the ED, he is unsure to which antibiotic. He
has no abdominal pain, has had poor appetite in the last 2 days,
with some nausea. He says overall pruritis has improved, still
does occur. He felt he was discharged too soon, and is concerned
he has continuing bladder infection, has had low amounts of
urine
with straight caths (being done q48h).
Past Medical History:
Type I DM
ESRD on HD ___
Quadriplegia from ?HD initiation/hyponatremia/CPM
OSA on CPAP
GERD
Stage 4 presacral left buttock decubitus ulcer c/b diverting
colostomy
MRSA bacteremia ___ RIJ HD line infection
Colostomy
Tracheostomy s/p removal
PEG s/p removal with open connection between stomach and skin
Retinopathy
Pseudomonas osteomyelitis of sacral ulcer in ___
Asthma
HLD
Neurogenic bladder requiring intermittent catheterization
Gastroparesis
Oropharnygeal dysphagia s/p PEG s/p removal
Hx of ESBL in urine
Reactive thrombocytosis
Neuropathy
HTN
UTI due to enterococcus
Social History:
___
Family History:
Mother with asthma, father with diabetes
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 99.4 101/63 Lying 95 17 97 Ra
GENERAL: NAD, sitting up, appears flushed over face and upper
body
HEENT: PERRL, anicteric sclera, pink conjunctiva, MMM, trach
site
c/d/I
CHEST: RUE tunneled HD catheter c/d/i
NECK: supple, no LAD, no JVD
HEART: distant heart sounds, RRR, S1/S2, no murmurs
LUNGS: CTAB aside from crackles at L base
ABDOMEN: nondistended, nontender in all quadrants, LLQ with
colostomy bag with stool
EXTREMITIES: 1+ edema in ___, limited movement of upper and ___ at
baseline, RUE at site of antecubital IV erythematous, flaking
skin, slightly more swollen, good pulses bilaterally,
excoriations b/l hands
NEURO: A&Ox3
DISCHARGE PHYSICAL EXAM
VS: 24 HR Data (last updated ___ @ 643)
Temp: 98.7 (Tm 99.1), BP: 116/78 (111-118/74-78), HR: 76
(72-83), RR: 18 (___), O2 sat: 100% (96-100), O2 delivery: Ra,
Wt: 183.86 lb/83.4 kg
GENERAL: NAD, sitting up, no longer flushed, but has dry,
flaking
skin on upper torso and face
HEENT: PERRL, anicteric sclera, pink conjunctiva, MMM, trach
site
c/d/I
CHEST: RUE tunneled HD catheter c/d/i
NECK: supple, no LAD, no JVD
HEART: distant heart sounds, NR,RR. S1/S2, no murmurs
LUNGS: CTAB aside from crackles at L base
ABDOMEN: Nondistended, nontender in all quadrants, LLQ with
colostomy bag with stool
EXTREMITIES: 1+ edema in ___, limited movement of upper and ___ at
baseline. Excoriations throughout. Across BUE and chest dry skin
with several flaking patches. Mild TTP b/l
heels, no lesions
NEURO: A&Ox3
Pertinent Results:
ADMISSION LABS
=============
___ 04:05AM BLOOD WBC-10.2* RBC-3.73* Hgb-9.4* Hct-31.0*
MCV-83 MCH-25.2* MCHC-30.3* RDW-17.4* RDWSD-52.3* Plt ___
___ 04:05AM BLOOD Neuts-78.0* Lymphs-8.5* Monos-5.0
Eos-7.5* Baso-0.6 Im ___ AbsNeut-7.94* AbsLymp-0.87*
AbsMono-0.51 AbsEos-0.76* AbsBaso-0.06
___ 04:05AM BLOOD Glucose-141* UreaN-23* Creat-6.3* Na-140
K-6.1* Cl-96 HCO3-27 AnGap-17
___ 09:45AM BLOOD ALT-19 AST-29 AlkPhos-738* TotBili-0.9
___ 09:45AM BLOOD Calcium-8.2* Phos-4.8* Mg-2.1
___ 05:20AM URINE Color-Yellow Appear-Cloudy* Sp ___
___ 05:20AM URINE Blood-MOD* Nitrite-NEG Protein-300*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-LG*
___ 05:20AM URINE RBC-40* WBC->182* Bacteri-MOD* Yeast-NONE
Epi-0
PERTINENT LABS
=============
___ 12:27AM BLOOD Neuts-81.6* Lymphs-3.7* Monos-1.1*
Eos-13.0* Baso-0.1 Im ___ AbsNeut-15.88* AbsLymp-0.72*
AbsMono-0.22 AbsEos-2.52* AbsBaso-0.01
___ 07:30AM BLOOD Neuts-50 Bands-2 Lymphs-5* Monos-2*
Eos-40* Baso-1 ___ Myelos-0 AbsNeut-11.75*
AbsLymp-1.13* AbsMono-0.45 AbsEos-9.04* AbsBaso-0.23*
___ 08:57AM BLOOD Neuts-53 Bands-0 Lymphs-2* Monos-1*
Eos-43* Baso-1 ___ Myelos-0 AbsNeut-8.75*
AbsLymp-0.33* AbsMono-0.17* AbsEos-7.10* AbsBaso-0.17*
___ 06:35AM BLOOD Neuts-46 Bands-0 Lymphs-10* Monos-0
Eos-43* Baso-1 ___ Myelos-0 AbsNeut-6.76*
AbsLymp-1.47 AbsMono-0.00* AbsEos-6.32* AbsBaso-0.15*
DISCHARGE LABS
=============
___ 10:28AM BLOOD WBC-14.5* RBC-3.79* Hgb-9.5* Hct-31.2*
MCV-82 MCH-25.1* MCHC-30.4* RDW-17.0* RDWSD-50.4* Plt ___
___ 10:28AM BLOOD Neuts-49.2 Lymphs-15.2* Monos-3.5*
Eos-31.1* Baso-0.4 Im ___ AbsNeut-7.12* AbsLymp-2.20
AbsMono-0.51 AbsEos-4.50* AbsBaso-0.06
___ 10:28AM BLOOD Glucose-112* UreaN-24* Creat-5.3* Na-144
K-4.4 Cl-101 HCO3-29 AnGap-14
MICRO
=====
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 CFU/mL.
LINEZOLID Sensitivity testing per ___ ___ (___)
___ @
1142.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 1 S
NITROFURANTOIN-------- 32 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ <=0.5 S
STUDIES
=======
CXR ___
Moderate left pleural effusion with left retrocardiac
atelectasis. Difficult
to exclude superimposed pneumonia.
Brief Hospital Course:
Mr. ___ is a ___ year old man with a history of recurrent
multi-drug resistant UTIs in the setting of neurogenic bladder,
quadriplegia after central pontine myelinosis, stage IV decubius
ulcer s/p diverting colostomy, type I diabetes, and
ESRD on HD,with recent admission for UTI and pyocystitis, who
presented with fevers and was found to have influenza and UTI.
ACUTE ISSUES
===========
# Influenza
Presented with fevers; found to be flu positive. Treated with 5
day course of Tamiflu post-HD. Symptoms improved.
# Recent and Recurrent Pyocystitis
# Neurogenic Bladder w/ Pyuria
Last admission had been on meropenem for ESBL E coli,
transitioned to ertapenem, then finished course. Presented with
worsened U/A and UCX with Enterococcus. Started on Linezolid and
transitioned to po Linezolid. Increased straight
catheterizations from QOD to daily straight cath with sterile
saline flushes per previous urology recommendation. Straight
caths draining dark amber urine at time of discharge with
flushes removing some ongoing sediment.
# Cephalosporin Allergic Reaction
# RUE swelling
# Eosinophilia
High grade peripheral eosinophilia noted last admission which
had been present since ___ but worsened after reaction to
ceftriaxone/ceftazidime. Flow cytometry obtained and negative
for leukemic features. This admission, eosinophilia initially
low. Received 1 dose of cefepime and reported increased itching
and redness. Subsequent rise in eosinophils consistent with
cephalosporin reaction. No facial swelling, throat swelling,
difficulty breathing noted. Eosinophil count downtrended and
symptoms improved with benadryl, atarax, and triamcinolone
(body) and hydrocortisone (facial) creams. Transitioned from
steroid to eucerin cream as skin appeared mostly dry. Patient
noting ongoing burning in mouth with eating after pills however
with exam reassuring and improving eosinophilia at discharge.
CHRONIC ISSUES;
=================
# Hx of Drug Induced Liver Injury
# Elevated Alk Phos
Pt has a history of possible drug induced liver injury (although
no offending drug identified), and has been seen in liver clinic
as follow up. A liver bx showed nonspecific cholestasis, mixed
inflammation and scattered hepatocyte degeneration. An MRCP was
done which showed IPMNs that need to be followed up in 6 months.
# Stage IV decub ulcer
# Chronic pain
Continued regular dressings and wound care with home oxycontin &
oxycodone for pain.
# ESRD on HD
Continued dialysis on home schedule T/R/Sa. Last HD ___
___.
# Type I DM
Home regimen of 15u Lantus on days recieving dialysis and 22u
on non dialysis days in addition to being continued on Humalog
at each meal and before bedtime.
# Recurrent Effusions
L sided pleural effusion tapped ___, transudative and
negative. Noted to still be present on CXR.
# Asthma
Continued on home advair, fluticasone, montelukast and given
albuterol nebs as needed.
# Quadriplegia
In the setting of central pontine myelinolysis several years
ago.
# Fungal rash
The patient was given miconazole cream topically every day.
# Autonomic dysfunction
Continue on home midodrine on HD days and metoprolol.
# GERD
Continue home Omeprazole 40mg BID.
TRANSITIONAL ISSUES
=================
[ ] Should continue po Linezolid through ___ for 10 day course.
[ ] Continue daily straight caths with 50cc sterile NS flushes
indefinitely to prevent recurrent UTIs
[ ] Should not receive any future cephalosporins as multiple
documented reactions to different cephalosporins.
[ ] Should receive a bath once daily (no more frequently as
concern for dry skin) and apply eucerin cream afterwards.
[ ] Stopped loratidine and switched to cetirizine bid
[ ] Stopped patient's Metoprolol as BPs normal, patient
refusing, and no clear indication. Would consider restarting if
BPs rise.
[ ] Needs repeat MRCP in 6 months to assess intraductal
pappilary mucinous neoplasms found in pancreas last admission.
[ ] Consider gastric emptying study due to nausea which may be
___ gastroparesis with prolonged diabetes course.
[ ] Ensure followup with infectious disease, hematology,
hepatology, urology.
#CODE: Full (presumed)
#CONTACT: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN sob
2. Ascorbic Acid ___ mg PO BID
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
4. Citalopram 20 mg PO DAILY
5. DiphenhydrAMINE 25 mg PO BID PRN pruritis
6. Fluticasone Propionate NASAL 1 SPRY NU BID
7. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
8. HydrOXYzine 50 mg PO BID
9. Metoprolol Tartrate 25 mg PO BID
10. Miconazole 2% Cream 1 Appl TP DAILY
11. Midodrine 10 mg PO 3X/WEEK (___)
12. Montelukast 10 mg PO QHS
13. Ondansetron 4 mg PO Q8H:PRN nausea
14. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe
15. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
16. Senna 8.6 mg PO DAILY:PRN constipation
17. sevelamer CARBONATE 1600 mg PO TID W/MEALS
18. Simethicone 80 mg PO TID
19. Vitamin D 1000 UNIT PO DAILY
20. Belladonna & Opium (16.2/30mg) ___ID:PRN Bladder
Spasms
21. Brovana (arformoterol) 15 mcg/2 mL inhalation BID
22. Loratadine 10 mg PO EVERY OTHER DAY
23. Nephro-Vite (B complex-vitamin C-folic acid) 0.8 mg oral qam
24. ___ (B complex-vitamin C-folic acid) 0.8 mg oral DAILY
25. Zeasorb (miconazole) (miconazole nitrate) 2 % topical Daily:
PRN
26. Ertapenem Sodium 500 mg IV DAILY
27. Omeprazole 40 mg PO BID
28. Ursodiol 300 mg PO TID
29. Budesonide Nasal Inhaler 2 mls nasal BID
Discharge Medications:
1. Cetirizine 10 mg PO BID
RX *cetirizine 10 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
2. Glargine 22 Units Breakfast
Humalog 3 Units Breakfast
Humalog 3 Units Lunch
Humalog 3 Units Dinner
Humalog 3 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Linezolid ___ mg PO Q12H
RX *linezolid ___ mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*7 Tablet Refills:*0
4. Zinc Sulfate 220 mg PO DAILY Duration: 14 Days
RX *zinc sulfate 220 mg (50 mg zinc) 1 capsule(s) by mouth daily
Disp #*9 Capsule Refills:*0
5. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN sob
6. Ascorbic Acid ___ mg PO BID
7. Belladonna & Opium (16.2/30mg) ___ID:PRN Bladder
Spasms
8. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
9. Brovana (arformoterol) 15 mcg/2 mL inhalation BID
10. Budesonide Nasal Inhaler 2 mls nasal BID
11. Citalopram 20 mg PO DAILY
12. DiphenhydrAMINE 25 mg PO BID PRN pruritis
13. Fluticasone Propionate NASAL 1 SPRY NU BID
14. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
15. HydrOXYzine 50 mg PO BID
16. Miconazole 2% Cream 1 Appl TP DAILY
17. Midodrine 10 mg PO 3X/WEEK (___)
18. Montelukast 10 mg PO QHS
19. Nephro-Vite (B complex-vitamin C-folic acid) 0.8 mg oral
qam
20. Omeprazole 40 mg PO BID
21. Ondansetron 4 mg PO Q8H:PRN nausea
22. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe
23. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
24. ___ (B complex-vitamin C-folic acid) 0.8 mg oral
DAILY
25. Senna 8.6 mg PO DAILY:PRN constipation
26. sevelamer CARBONATE 1600 mg PO TID W/MEALS
27. Simethicone 80 mg PO TID
28. Ursodiol 300 mg PO TID
29. Vitamin D 1000 UNIT PO DAILY
30. Zeasorb (miconazole) (miconazole nitrate) 2 % topical
Daily: PRN
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
================
Influenza
Pyocystitis
SECONDARY DIAGNOSES
===================
End Stage Renal Disease
Quadriplegia
Type 1 Diabetes Mellitus
Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because you had the flu.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We gave you Tamiflu, a treatment for the flu
- We found you had a bladder infection, and we gave you an
antibiotic for that infection.
- The first antibiotic you had caused an allergic reaction, so
we added that to your allergy list and gave you medicine to help
treat the reaction.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10253349-DS-14 | 10,253,349 | 25,160,516 | DS | 14 | 2188-05-19 00:00:00 | 2188-05-19 15:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / lisinopril / Reglan / vancomycin / shellfish
derived / ceftazidime / Cephalosporins / meropenem
Attending: ___
Chief Complaint:
Missed HD Sessions
Major Surgical or Invasive Procedure:
Dialysis
History of Present Illness:
Mr. ___ is a ___ year old male with PMH significant type 1
DM,
ESRD on HD TTS, central pontine myelinolysis (secondary to
correction of hyponatremia) and subsequent quadriplegia, history
of stage 4 sacral decubitus ulcer complicated by colonic fistula
s/p diverting colostomy, previous HD-line assoc. MRSA bacteremia
(___), and history of recurrent multi-drug resistant
UTIs in the setting of neurogenic bladder presenting after
missing two hemodialysis sessions.
In the ED he stated that he missed his last two dialysis
sessions
(last session was ___ because the transport did not come. He
has had progressively worsening shortness of breath and cough
since then. He notes a cough productive of clear phlegm and
subjective chills. He denied any fever, chest pain, or vomiting.
Initial vitals:
T 99.3, HR 88, BP 142/92, RR 18, Sat 97% RA
- Exam notable for:
Head NC/AT, prior trach site on neck is clean/dry/intact
Tunneled dialysis line in right upper chest is clean/dry/intact
with no surrounding erythema
RRR
Coarse breath sounds throughout all lung fields, no wheezing
Abdomen soft and nontender, colostomy bag in LLQ is pink with no
surrounding erythema or tenderness, green/brown material in
ostomy bag
Fistula in LUE has palpable thrill, stitches still in place
Bilateral ___ edema
- Labs notable for:
WBC 10.1 Hgb 9.1 Hct 30.9 Plt 167
___ 20170
Trop-T 0.18 -> 0.18
Flu A/B Negative
UA: Cloudy, Large Leuk Esterase, Small Blood, Many Bacteria, WBC
> assay, 6 epi cells
- Imaging notable for:
CXR:
Similar opacification of the left lung base likely due to
moderate pleural
effusion and atelectasis. Mild pulmonary vascular congestion
without definite
pulmonary edema or focal consolidation.
- Pt given:
PO/NG OxyCODONE (Immediate Release) 10 mg
IV Insulin (Regular) for Hyperkalemia 10 units
IV Dextrose 50% 12.5 gm
IV DiphenhydrAMINE 25 mg
PO Omeprazole 40 mg
PO/NG Montelukast 10 mg
IV Meropenem 500 mg
IV Heparin (Hemodialysis) 4000 UNIT
IV DiphenhydrAMINE 25 mg
- Vitals prior to transfer:
T 98.1, HR 96, BP 142/78, RR 21, Sat 96% RA
On arrival to floor from HD session patient reports that
currently he feels...
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 I DM
ESRD on HD ___
Quadriplegia from hyponatremia/CPM
OSA on CPAP
GERD
Stage 4 presacral left buttock decubitus ulcer c/b diverting
colostomy
MRSA bacteremia ___ RIJ HD line infection
Tracheostomy s/p removal
PEG s/p removal with open connection between stomach and skin
Retinopathy
Pseudomonas osteomyelitis of sacral ulcer in ___
Asthma
HLD
Neurogenic bladder requiring intermittent catheterization and
with recurrent UTIs
Gastroparesis
Oropharnygeal dysphagia s/p PEG s/p removal
Neuropathy
HTN
Social History:
___
Family History:
Mother with asthma, father with diabetes Type I, and also died
on
HD
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
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, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
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:
========================
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, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: CTAB 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 and flaking over face/chest, no rashes or
notable
lesions.
Neuro: CNII-XII intact, ___ strength BUE. Wiggles toes b/l
Pertinent Results:
ADMISSION LABS:
===============
___ 01:40AM BLOOD WBC-10.1* RBC-4.24* Hgb-9.1* Hct-30.9*
MCV-73* MCH-21.5* MCHC-29.4* RDW-17.5* RDWSD-44.8 Plt ___
___ 01:40AM BLOOD Neuts-75.0* Lymphs-11.1* Monos-4.2*
Eos-9.0* Baso-0.4 Im ___ AbsNeut-7.60* AbsLymp-1.12*
AbsMono-0.42 AbsEos-0.91* AbsBaso-0.04
___ 01:40AM BLOOD Glucose-273* UreaN-43* Creat-7.9* Na-130*
K-7.6* Cl-93* HCO3-23 AnGap-14
___ 01:40AM BLOOD ALT-9 AST-49* CK(CPK)-100 AlkPhos-266*
TotBili-0.5
___ 01:40AM BLOOD CK-MB-3 ___
___ 01:40AM BLOOD cTropnT-0.18*
___ 01:40AM BLOOD Albumin-3.3* Calcium-8.2* Phos-5.8*
Mg-2.3
___ 01:48AM BLOOD Lactate-2.1* K-5.7*
___ 09:24AM BLOOD K-5.1
___ 04:00AM URINE Color-Yellow Appear-Cloudy* Sp ___
___ 04:00AM URINE Blood-SM* Nitrite-NEG Protein-300*
Glucose-70* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG*
___ 04:00AM URINE RBC-0 WBC->182* Bacteri-MANY* Yeast-NONE
Epi-6
___ 04:00AM URINE WBC Clm-MANY*
___ 03:25AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
DISCHARGE LABS:
===============
___ 07:07AM BLOOD WBC-8.6 RBC-3.92* Hgb-8.3* Hct-28.9*
MCV-74* MCH-21.2* MCHC-28.7* RDW-17.5* RDWSD-46.0 Plt ___
MICROBIOLOGY:
=============
___ 4:00 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
SUMMARY:
========
___ with PMHx of IDDM1, ESRD on HD TTS, central pontine
myelinolysis and subsequent quadriplegia, hx of stage 4 sacral
decubitus ulcer c/b colonic fistula s/p diverting colostomy,
recurrent MDR UTIs in the setting of neurogenic bladder who
initially presented after missing two HD sessions due to
transportation issues. On arrival to ED he was straight cathed
with purulent drainage, received a dose of meropenem with
allergic reaction then vancomycin x1. Antibiotics were held
after these two doses given low suspicion for UTI. He was
monitored for 24 hours off antibiotics without any clinical
signs or lab abnormalities suggesting infection. Patient
underwent two HD sessions during hospitalization ___ and ___.
Notably urine culture from admission growing > 100k colony
forming units pansensitive Klebsiella however culture felt to
represent chronic colonization in patient with neurogenic
bladder/ESRD, cath dependent, without signs/symptoms of urinary
tract infection.
TRANSITIONAL ISSUES:
====================
-Follow up appointments: PCP
-___ at discharge 8.6
-Hgb at discharge 8.3
[]Should have CXR repeated within ___ weeks of discharge to
ensure resolution of plural effusions after restarting HD
[]Would benefit from social work assistance to look into
additional resources for patient/switching transport/aid
services given difficulties resulting in multiple
hospitalizations
ACUTE ISSUES:
=============
# ESRD on HD TTS
# Missed HD Sessions
Has had issues with transportation at home. Patient missed HD
___ and ___ prior to admission because transport was not
coming to help him. Home services have been a recurrent issue
for patient he and had a recent admission in ___ when
home aides did not come to see him and he was unable to be
catheterized for multiple days leading to UTI. He underwent HD
before admission to floor ___ and received a second session
___.
#?Recurrent pyocystitis
#Neurogenic bladder
Patient catheterized in ED with purulent drainage. UA at that
time with pyuria and many bacteria seen. Otherwise asymptomatic.
Received one dose of meropenem in ED with allergic reaction
treated with benadryl. Then received one dose of vancomycin
before coming up to medicine floor. Antibiotics were stopped on
arrival to medicine floor given low suspicion for UTI due to
lack of symptoms and overall labs/vitals not suggestive of
infection. He was monitored off antibiotics for 24 hours without
any signs of infection and was felt safe to be discharged home
off antibiotics. Urine culture from ED had resulted with
pansensitive klebsiella prior to discharge however, this was
felt to represent chronic colonization and not true infection.
#Pleural effusions
CXR on admission with pleural effusions but no evidence of
pulmonary edema or focal consolidations. Likely in the setting
of volume overload given missed HD sessions as above. Subjective
dyspnea improved after HD with ultrafiltration. Should have CXR
repeated as outpatient to ensure resolution of effusions.
CHRONIC/STABLE ISSUES:
======================
# HTN
No antihypertensive medications, volume management with HD
# Chronic Anemia
Hgb near recent baseline during admission. On mircera q2wk next
dose ___
# H/o stage IV decub ulcer
# Chronic pain
Continued home oxycontin & oxycodone for pain
# Asthma
Continued home advair, albuterol, montelukast
# GERD
Continued home Omeprazole 40mg BID, simethicone 80 mg PO/NG TID
# Itching
Continued home diphenhydramine, cetirizine. Held hydroxyzine iso
long QTc
# Depression
Continued home citalopram
# Eye care
Continued home Brimonidine Tartrate 0.15% drop q8h
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN shortness of
breath
2. Bisacodyl 10 mg PR QHS:PRN Constipation - First Line
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
4. Cetirizine 10 mg PO DAILY
5. Citalopram 20 mg PO DAILY
6. DiphenhydrAMINE 25 mg PO BID:PRN pruritis
7. Fluticasone Propionate NASAL 1 SPRY NU BID
8. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
9. HydrOXYzine 50 mg PO BID
10. Lidocaine Jelly 2% 1 Appl TP BID
11. Omeprazole 40 mg PO BID
12. Ondansetron 4 mg PO Q8H:PRN nausea
13. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain -
Moderate
14. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
15. OxyCODONE SR (OxyconTIN) 10 mg PO QAM
16. Senna 8.6 mg PO DAILY:PRN Constipation - First Line
17. sevelamer CARBONATE 1600 mg PO TID W/MEALS
18. Simethicone 80 mg PO TID
19. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN xerosis
20. Ursodiol 300 mg PO TID
21. Vitamin E 1000 UNIT PO DAILY
22. Belladonna & Opium (16.2/30mg) ___ID:PRN bladder
spasms
23. Brovana (arformoterol) 15 mcg/2 mL inhalation BID
24. Miconazole 2% Cream 1 Appl TP DAILY
25. Nephro-Vite (B complex-vitamin C-folic acid) 0.8 mg oral QAM
26. Zeasorb (miconazole) (miconazole nitrate) 2 % topical
DAILY:PRN
27. Glargine 22 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
28. Montelukast 10 mg PO DAILY
Discharge Medications:
1. Glargine 22 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN shortness of
breath
3. Belladonna & Opium (16.2/30mg) ___ID:PRN bladder
spasms
4. Bisacodyl 10 mg PR QHS:PRN Constipation - First Line
5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
6. Brovana (arformoterol) 15 mcg/2 mL inhalation BID
7. Cetirizine 10 mg PO DAILY
8. Citalopram 20 mg PO DAILY
9. DiphenhydrAMINE 25 mg PO BID:PRN pruritis
10. Fluticasone Propionate NASAL 1 SPRY NU BID
11. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
12. HydrOXYzine 50 mg PO BID
13. Lidocaine Jelly 2% 1 Appl TP BID
14. Miconazole 2% Cream 1 Appl TP DAILY
15. Montelukast 10 mg PO DAILY
16. Nephro-Vite (B complex-vitamin C-folic acid) 0.8 mg oral
QAM
17. Omeprazole 40 mg PO BID
18. Ondansetron 4 mg PO Q8H:PRN nausea
19. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain -
Moderate
20. OxyCODONE SR (OxyCONTIN) 10 mg PO QAM
21. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
22. Senna 8.6 mg PO DAILY:PRN Constipation - First Line
23. sevelamer CARBONATE 1600 mg PO TID W/MEALS
24. Simethicone 80 mg PO TID
25. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN
xerosis
26. Ursodiol 300 mg PO TID
27. Vitamin E 1000 UNIT PO DAILY
28. Zeasorb (miconazole) (miconazole nitrate) 2 % topical
DAILY:PRN
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
ESRD
Volume Overload
Hyperkalemia
SECONDARY DIAGNOSIS:
====================
Anemia
HTN
Asthma
GERD
Chronic Pain
Pruritis
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___.
WHY WERE YOU IN THE HOSPITAL?
- You were admitted to the hospital because you had missed two
dialysis sessions as an outpatient and were feeling short of
breath.
WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL?
-You received dialysis twice while in the hospital which helped
get the extra fluid out of your body making it easier to breathe
and corrected some of your electrolyte imbalances
-There was concern in the emergency department that you might
have a urinary tract infection so they gave you antibiotics.
After further review it was felt that it was relatively unlikely
that you currently had a urinary tract infection and antibiotics
were stopped
-We monitored you for a day off antibiotics to ensure that there
were no signs of infection and that you were safe to be
discharged home.
WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL?
- Continue to take all your medicines as prescribed below.
- Show up to your appointments as listed below.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10253349-DS-9 | 10,253,349 | 29,706,165 | DS | 9 | 2187-03-29 00:00:00 | 2187-04-01 10:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / lisinopril / Reglan / vancomycin / shellfish
derived / ceftazidime
Attending: ___
Chief Complaint:
Dysuria
Major Surgical or Invasive Procedure:
___ Thoracentesis with drainage of 1100 mL pleural fluid
___ Midline placed in right arm for IV meropenem regimen
History of Present Illness:
___ yo M w/ uncontrolled DM1 ESRD on HD ___, central pontine
myelinosis w/ baseline quadriplegia, neurogenic bladder
requiring
straight cath every other day, Stage IV decubitus ulcer, colonic
fistula requiring diverting colostomy, jaundice of unknown
etiology recently presenting with pneumonia and UTI.
Of note he was discharged from ___ on ___, that hospitalization
was notable for:
- acute pyocystis and complicated cystitis with culture growing
MDR ESBL E. coli. Put on ceftazidime and developed a drug rash.
Bladder spasms were symptomatically managaed with belladonna and
flexeril. Urology was consulted who recommended foley catheter
for source
control during antibiotic therapy, as well as flushes 2 times
daily while on antibiotics. He was discharged home on PO
bactrim. Several days after completing bactrim, he noticed pus
when flushing the urinary catheter.
Given his prior urine culture sensitivities and his several
documented allergies. he was started on IV meropenem for empiric
coverage of urinary tract infection after reviewing his UA. Xray
was also concerning for pneumonia. He was admitted to the
medical service for further management.
Past Medical History:
Type I DM
ESRD on HD ___
Quadriplegia from ?HD initiation/hyponatremia/CPM
OSA on CPAP
GERD
Stage 4 presacral left buttock decubitus ulcer c/b diverting
colostomy
MRSA bacteremia ___ RIJ HD line infection
Colostomy
Tracheostomy s/p removal
PEG s/p removal with open connection between stomach and skin
Retinopathy
Pseudomonas osteomyelitis of sacral ulcer in ___
Asthma
HLD
Neurogenic bladder requiring intermittent catheterization
Gastroparesis
Oropharnygeal dysphagia s/p PEG s/p removal
Hx of ESBL in urine
Reactive thrombocytosis
Neuropathy
HTN
UTI due to enterococcus
Social History:
___
Family History:
Mother with asthma, father with diabetes
Physical Exam:
ADMISSION EXAM
==============
VS: 99.2 F, BP 153/112, HR ___, RR 18, 99% RA
GENERAL: NAD, pleasant, A/Ox3
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, trach scar, no LAD, no JVD, R subclavian catheter
for HD with surrounding erythema that he reports is chronic
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: upper lung fields CTAB although poor lung sounds
generally
ABDOMEN: mildly distended, non-tender and soft to palpation,
ostomy bag covered and surrounding area without erythema. Fungal
powder noted under the pannus and intertriginal folds, swollen
scrotum without tenderness
EXTREMITIES: atrophied, cool to touch with 2+ pulses, 1+ pitting
edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: extensive scaling on the forehead and cheeks, excoriations
on the upper extremities without a definite rash seen
DISCHARGE EXAM
===============
24 HR Data (last updated ___ @ 749)
Temp: 98.3 (Tm 99.5), BP: 137/80 (92-137/62-83), HR: 87
(71-87), RR: 18 (___), O2 sat: 99% (95-100), O2 delivery: Ra,
Wt: 194.22 lb/88.1 kg
GEN: Well appearing in bed, laying comfortably in bed
HEENT: soft neck, JVD not appreciated ___ habitus, no
lymphadenopathy
CVD: RRR, no m/r/g
PULM: CTAB no accessory muscle use - anterior exam completed as
patient unable to roll easily
ABD: Distended, mildly tender to palpation
EXT: 1+ non-pitting edema in ___
SKIN: Dry flaky skin/scalp, excoriations over chest and arms
GU: no foley
Pertinent Results:
ADMISSION LABS
================
___ 09:19PM BLOOD WBC-20.3* RBC-4.18* Hgb-10.7* Hct-35.2*
MCV-84 MCH-25.6* MCHC-30.4* RDW-16.7* RDWSD-50.7* Plt ___
___ 09:19PM BLOOD Neuts-56.4 Lymphs-11.5* Monos-2.0*
Eos-29.0* Baso-0.8 Im ___ AbsNeut-11.43* AbsLymp-2.33
AbsMono-0.40 AbsEos-5.87* AbsBaso-0.16*
___ 09:19PM BLOOD Hypochr-NORMAL Anisocy-1+*
Poiklo-OCCASIONAL Macrocy-OCCASIONAL Microcy-1+* Polychr-NORMAL
Ovalocy-OCCASIONAL Target-OCCASIONAL Tear Dr-OCCASIONAL
___ 09:19PM BLOOD ___ PTT-29.4 ___
___ 09:19PM BLOOD Glucose-76 UreaN-16 Creat-4.4*# Na-141
K-5.1 Cl-99 HCO3-30 AnGap-12
___ 09:19PM BLOOD ALT-22 AST-18 AlkPhos-869* TotBili-1.4
___ 09:27PM BLOOD Lactate-1.8
PERTINENT INTERVAL LABS
=========================
___ 06:19AM BLOOD GGT-288*
___ 07:42AM BLOOD %HbA1c-6.6* eAG-143*
DISCHARGE LABS
================
___ 05:44AM BLOOD WBC-11.9* RBC-3.63* Hgb-9.3* Hct-30.6*
MCV-84 MCH-25.6* MCHC-30.4* RDW-18.6* RDWSD-55.4* Plt ___
___ 05:44AM BLOOD Neuts-40.7 Lymphs-16.1* Monos-3.2*
Eos-39.1* Baso-0.4 Im ___ AbsNeut-4.84 AbsLymp-1.92
AbsMono-0.38 AbsEos-4.65* AbsBaso-0.05
___ 05:44AM BLOOD Glucose-282* UreaN-20 Creat-5.4*# Na-141
K-5.1 Cl-99 HCO3-28 AnGap-14
___ 05:44AM BLOOD ALT-20 AST-17 LD(LDH)-317* AlkPhos-1179*
TotBili-0.9
___ 05:44AM BLOOD Calcium-8.6 Phos-5.4* Mg-2.1
STUDIES/IMAGING
================
___ CXR
Persistent left basal opacity likely atelectasis and effusion,
difficult to exclude a superimposed pneumonia. Dialysis
catheter tip terminates in the right atrium.
___ Renal US
1. No hydronephrosis.
2. No sonographic evidence of pyelonephritis.
3. Bladder wall thickening, correlate with urinalysis for
cystitis.
4. At least moderate left pleural effusion.
___ CT Chest w/ Con
1. Increase in a small moderate pleural effusion, with
overlying compressive
atelectasis.
2. No new pulmonary nodules. No discrete pulmonary masses or
infectious
foci.
___ TTE
The left atrium is normal in size. The estimated right atrial
pressure is at least 15 mmHg. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF = 70%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Doppler parameters
are most consistent with normal left ventricular diastolic
function. Right ventricular chamber size and free wall motion
are normal. The diameters of aorta at the sinus, ascending and
arch levels are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
IMPRESSION: normal study
___ RUQ US
No evidence of intra or extrahepatic biliary dilatation.
Splenomegaly.
___ MRCP:
IMPRESSION:
1. Study degraded by motion and breathing artifact, no evidence
of biliary
obstruction identified.
2. Incidental likely small side-branch IPMNs, largest measuring
1.1 cm in the
pancreatic head. Recommend follow-up MRCP in 6 months.
3. Moderate-sized left pleural effusion and associated
subsegmental
atelectasis.
MICROBIOLOGY
=============
___ 10:08 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. 10,000-100,000 CFU/mL.
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
___ MRSA Swab Negative
___ Sputum Culture Negative
___ Pleural Fluid Culture Negative
___
ALKALINE PHOSPHATASE ISOENZYMES
Test Result Reference
Range/Units
ALKALINE PHOSPHATASE (ALP) 1270 H 40-115 U/L
LIVER ISOENZYME 78 H ___ %
BONE ISOENZYME 22 L ___ %
INTESTINE ISOENZYME 0 L ___ %
MACROHEPATIC ISOENZYME 0 <=0 %
PLACENTAL ISOENZYME 0 <=0 %
___
Flow cytometry
Non-specific T cell predominant lymphoid profile; diagnostic
immunophenotypic features of involvement by leukemia/lymphoma
are not seen in this specimen. Correlation with clinical and
other ancillary findings is recommended. Flow cytometry
immunophenotyping may not detect all abnormal populations due to
topography, sampling or artifacts of sample preparation.
Brief Hospital Course:
Mr. ___ is a ___ year old man with a history of recurrent
multi-drug resistant UTIs in the setting of neurogenic bladder,
quadriplegia after central pontine myelinosis, stage IV decubius
ulcer s/p diverting colostomy, type I diabetes, and ESRD on HD,
who was admitted for ESBL E. coli pyocystitis.
# UTI
# Pyocysitits
The patient presented with symptoms concerning for UTI with
pyocystitis after a recent admission for similar symptoms and
completion of a course of antibiotics. Given the patient's
history of multi-drug resistant organisms and allergies to
penicillin and ceftazidime, he was started on empiric meropenem
while awaiting urine culture data. A renal US was done which was
reassuring for no pyelonephritis or hydronephrosis, and findings
consistent with cystitis. Urology was consulted and recommended
Foley placement to promote bladder drainage. Urine cultures
eventually grew ESBL E. Coli, sensitive to meropenem, so the
patient was continued on this and then transitioned to Ertapenem
on day of discharge with plans to treat as complicated UTI with
a 14 day course (___). Patient should continue Q48 hour
bladder catherizations and flushes with 30 ml sterile NS if
patient desires. Follow up with infectious disease is also being
arranged out of consideration for prophylactic therapy in the
setting of recurrent and multi-drug resistant UTIs.
# Left Pleural Effusion
# Cough
The patient presented with a productive cough and CXR
demonstrating a left sided pleural effusion. A thoracentesis was
done on ___ with removal of 1100cc of fluid consistent with
transudate, making pneumonia less likely. The patient remained
afebrile throughout course and had symptomatic improvement with
nebulizers, indicating possible asthma exacerbation as cause of
cough. A CT of the chest was unremarkable. Fluid thought to be
___ ESRD. He was recommended a low salt diet and 1.5L fluid
restriction.
# Eosinophilia
The patient was noted to have high grade peripheral
eosinophilia, that on review of chart, had been present since
___, however worsened recently after he had a drug reaction
to ceftriaxone/ceftazidime in ___. Outside records were also
obtained that demonstrated eos in the blood dating as far back
as ___, however each time a differential was checked, the
patient was on antibiotics. Heme Onc was consulted and felt that
his high level of eosinophils were possibly due to drug
hypersensitivity reaction to cephalosporins. Other causes of
eosinophilia were not considered likely as he had previously
tested negative for strongyloides, AM cortisol was within normal
limits, and there were no signs of autoimmune/rheumatologic
processes or malignancy. Reassuringly, there was also no
evidence to suggest end organ damage, including cardiac, as a
TTE was obtained which showed normal cardiac function. As the
definite cause of eosinophilia was not determined, the patient
was discharged with plans for Hematology follow up. After
discharge his flow cytometry resulted which did not show any
features of lymphoma or leukemia.
# Hx of Drug Induced Liver Injury
# Elevated Alk Phos
Pt has a history of possible drug induced liver injury (although
no offending drug identified), and has been seen in liver clinic
as follow up. A liver bx showed nonspecific cholestasis, mixed
inflammation and scattered hepatocyte degeneration. Alk phos was
elevated and trended upwards, GGT was also elevated. Liver was
consulted and were concerned for further drug injury,
particularly given hypothesis of eosinophilic drug reaction as
above. Otherwise the differential also included PBC/PSC, sepsis,
or extra-hepaticobiliary pathology. He was treated
symptomatically for pruritis with hydroxazine, and LFTs trended.
A RUQ US was done which showed no intra or extrahepatic biliary
dilatation. An MRCP was then done which showed IPMNs that need
to be followed up in 6 months. Patient has outpatient hepatology
follow up scheduled. His ALP isoenzymes resulted after discharge
and seem to be most consistent with drug induced pathology.
Follow up was scheduled for the patient within 2 weeks of
discharge. The results were discussed with the hematology team
who will review results with the patient.
# Stage IV decub ulcer
# Chronic pain
Wound care was consulted for the patient's stage IV decub ulcer.
They provided regular dressings and wound care. He was continued
on home oxycontin and oxycodone for pain.
# ESRD on HD
Renal was consulted for continued dialysis. He was dialyzed as
per his home schedule on ___, and ___. A
renal diet was initiated as patient's phos continued to rise on
phos binders.
#Type I DM:
___ was consulted for assistance in managing the patient's
insulin. He was given his home regimen of 15u Lantus on days
recieving dialysis and 22u on non dialysis days in addition to
being continued on Humalog at each meal and before bedtime.
# Asthma
The patient was continued on home advair, fluticasone,
montelukast and given albuterol nebs as needed.
# Quadriplegia
In the setting of central pontine myelinolysis several years
ago.
# Fungal rash
The patient was given miconazole cream topically every day.
# Autonomic dysfunction
He was continued on home midodrine on HD days and metoprolol.
# GERD
He was continued on home Omeprazole 40mg BID.
# MISC
The patient did express some concern over being discharged with
the fear that he may redevelop pyocystitis and pyuria. He was
reassured that he had had several days of antibiotic therapy
with a drug much broader than bactrim and that his coverage
should be sufficient. He was advised that should be develop
fever or chills, or any recurrent pyuria, to return to the ED
for further evaluation. He was felt to be medically stable for
discharge given appropriate antibiotic therapy and downtrending
of his liver enzymes, with adequate control of his pruritus.
TRANSITIONAL ISSUES
===================
*** Labs for follow up***
- Please send LFTs to ___ Liver clinic ___
[] Please monitor the patient's CBC differential. Suspect that
eosinophilia is caused by drug reactions, please check CBC with
differential 1 week after he finishes his course of antibiotics
on ___. Flow cytometry was sent prior to discharge to be
followed up by outpatient hem/onc at arranged follow-up.
[] The patient's AlkPos continued to rise this admission. Please
re-check AlkPhos and other liver function tests 1 week after
discharge.
Glucose management:
===================
[] The patient's blood glucose were poorly controlled this
admission. Please be sure to check finger blood glucose sticks
with every meal. Do not administer insulin within two hours of a
previous dose as this can lead to insulin stacking.
Glargine 22 Units Breakfast on non HD days, 15 units breakfast
on HD days
Humalog 3 Units Breakfast
Humalog 3 Units Lunch
Humalog 3 Units Dinner
Humalog 3 Units Bedtime
carb count 1:20 carbs with 1:40 CF. goal BG of 160-220
Follow up:
==========
[] Patient requires a repeat MRCP in 6 months to assess his
intraductal papillary mucinous neoplasms found in his pancreas
[] Consider gastric emptying study as patient continues to have
nausea which may be ___ gastroparesis with prolonged diabetes
course
[] Ensure follow up with infectious disease, hepatology, urology
Discharge Weight: 88.1 kg (194.22 lb)
#CODE: Full (presumed)
#CONTACT: ___ ___
Time spent coordinating the discharge of this complex patient:
60 minutes
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN sob
2. Ascorbic Acid ___ mg PO BID
3. Bisacodyl 10 mg PR QHS:PRN constipation
4. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
5. Citalopram 10 mg PO DAILY
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY
7. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
8. HydrOXYzine 50 mg PO BID
9. Loratadine 10 mg PO EVERY OTHER DAY
10. Metoprolol Tartrate 25 mg PO BID
11. Midodrine 10 mg PO 3X/WEEK (___)
12. Montelukast 10 mg PO QHS
13. Omeprazole 40 mg PO DAILY
14. Senna 8.6 mg PO DAILY:PRN constipation
15. sevelamer CARBONATE 1600 mg PO TID W/MEALS
16. Simethicone 80 mg PO TID
17. Ursodiol 300 mg PO DAILY
18. Vitamin D 1000 UNIT PO DAILY
19. Belladonna & Opium (16.2/30mg) ___ID:PRN Bladder
Spasms
20. Brovana (arformoterol) 15 mcg/2 mL inhalation BID
21. Budesonide Nasal Inhaler 2 mls nasal BID
22. Nephro-Vite (B complex-vitamin C-folic acid) 0.8 mg oral qam
23. ___ (B complex-vitamin C-folic acid) 0.8 mg oral DAILY
24. Zeasorb (miconazole) (miconazole nitrate) 2 % topical Daily:
PRN
25. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - Severe
26. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
27. DiphenhydrAMINE 25 mg PO BID PRN pruritis
28. Glargine 15 Units Breakfast
Humalog 3 Units Breakfast
Humalog 3 Units Lunch
Humalog 3 Units Dinner
Humalog 3 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
29. Miconazole 2% Cream 1 Appl TP DAILY
Discharge Medications:
1. Ertapenem Sodium 500 mg IV DAILY Duration: 2 Days
Please give after dialysis as dialyzed off
RX *ertapenem [Invanz] 1 gram 500 mg IV daily Disp #*2 Vial
Refills:*0
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN sob
3. Ascorbic Acid ___ mg PO BID
4. Belladonna & Opium (16.2/30mg) ___ID:PRN Bladder
Spasms
5. Bisacodyl 10 mg PR QHS:PRN constipation
6. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
7. Brovana (arformoterol) 15 mcg/2 mL inhalation BID
8. Budesonide Nasal Inhaler 2 mls nasal BID
9. Citalopram 20 mg PO DAILY
10. DiphenhydrAMINE 25 mg PO BID PRN pruritis
11. Fluticasone Propionate NASAL 1 SPRY NU BID
12. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
13. HydrOXYzine 50 mg PO BID
14. Loratadine 10 mg PO EVERY OTHER DAY
15. Metoprolol Tartrate 25 mg PO BID
16. Miconazole 2% Cream 1 Appl TP DAILY
17. Midodrine 10 mg PO 3X/WEEK (___)
18. Montelukast 10 mg PO QHS
19. Nephro-Vite (B complex-vitamin C-folic acid) 0.8 mg oral
qam
20. Omeprazole 40 mg PO BID
21. Ondansetron 4 mg PO Q8H:PRN nausea
22. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe
RX *oxycodone 5 mg 1 capsule(s) by mouth every 6 hours Disp #*24
Capsule Refills:*0
23. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
RX *oxycodone [OxyContin] 20 mg 1 tablet(s) by mouth every 12
hours Disp #*6 Tablet Refills:*0
24. ___ (B complex-vitamin C-folic acid) 0.8 mg oral
DAILY
25. Senna 8.6 mg PO DAILY:PRN constipation
26. sevelamer CARBONATE 1600 mg PO TID W/MEALS
27. Simethicone 80 mg PO TID
28. Ursodiol 300 mg PO TID
29. Vitamin D 1000 UNIT PO DAILY
30. Zeasorb (miconazole) (miconazole nitrate) 2 % topical
Daily: PRN
31.Outpatient Lab Work
ICD10: K71
Please complete AST, ALT, Alk Phos, total bili on ___
Fax results to: ___, MD ___
32.Insulin
Glargine 22 Units Breakfast on non HD days, 15 units breakfast
on HD days
Humalog 3 Units Breakfast
Humalog 3 Units Lunch
Humalog 3 Units Dinner
Humalog 3 Units Bedtime
carb count 1:20 carbs with 1:40 CF. goal BG of 160-220
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY
=======
Pyocystitis
Drug induced liver injury
Eosinophilia
SECONDARY
=========
Type I Diabetes Mellitus
End stage renal disease
Nausea
Pleural effusion
Stage IV decubitus ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
Why were you admitted to the hospital?
- You have were having symptoms concerning for a UTI, including
pus when catheterized.
- You recently developed a cough.
What was done while you were in the hospital?
- We tested your urine and it showed that you had a urinary
tract infection.
- An ultra sound was done which showed that you did not have a
kidney stone or bladder obstruction.
- A foley catheter was placed to help drain your bladder.
- You also had a chest tube inserted in your chest to drain
fluid out of your lungs.
- You were given antibiotics to treat your infection. A special
type of IV was placed so that you could continued to receive IV
antibiotics when you leave the hospital.
- An echocardiogram of your heart was done which was normal.
- An ultrasound of your belly which showed no problems in your
liver. The liver team evaluated your abnormal labs and will
follow up with you as an outpatient.
- You had a special MRI of your abdomen done which showed
intraductal papillary mucinous neoplasms that need to be
followed in 6 months.
What should you do when you go home?
- Please ensure repeat MRI of your abdomen in 6 months
- Please follow up with your outpatient doctors as listed below.
- Please take all your medications as directed.
Wishing you all the best!
Your ___ Care Team
Followup Instructions:
___
|
10253747-DS-11 | 10,253,747 | 20,015,522 | DS | 11 | 2121-06-29 00:00:00 | 2121-06-30 20:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Naltrexone / aspirin / Oxycodone
Attending: ___.
Chief Complaint:
Rash
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ M w/ DM type II, Alcoholic cirhosis c/b ascites
and esophageal varices who presents with diffuse rash,
rhinorrhea and nonproductive cough.
Patient recently discharged for alcohol intoxication and fall.
He was discharged with oxycodone as new medication for rib pain.
Patient denies any other medications or OTCs. He noticed a rash
developed ___ on his arms. Over following few days, it
spread down his trunk and legs. He also began noticing
nonproductive cough and rhinorrhea. While blowing his nose, he
had epistaxis. On day of admission, rash continued to worsen on
lower extremities and he also has developed a sore throat. He
notes that he has been living in homeless shelters, and has been
exposed to many people with sneezing and coughing. Patient says
rash is very similar to prior vasculitis he had from Naltrexone.
Of note, his rib pain has been slowly improving since last
admission.
No fevers nor neck stiffness.
___ ED course:
- initial vitals: 96.5 HR 89 139/80 16 sat 100% RA
- guiac positive brown stool
- WBC 6 no bands, Eos 1.7%, creat 0.8, Bil 1.6
- PLT 100, INR 1.3
- U/A neg, urine tox neg, serum tox neg
- CXR: no acute process
- CT Head noncont: No significant intracranial pathology.
- Liver c/s: admit for rash work up
On arrival to floor, patient denies dyspnea and feels
comfortable.
ROS: Full 10 pt review of systems negative except for above.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness. Denies shortness of
breath. Denies chest pain or tightness, palpitations. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias.
Past Medical History:
- EtOH cirrhosis c/b varices, ascites
- Hypertension
- DM type II c/b neuropathy
- Varices, Grade I-II on ___ EGD
- Alcohol abuse
- Hx Gastritis
- Hx leukclastic vasculitis in response to naltrexone
Social History:
___
Family History:
Grew up in a home for children with his brother and sister. He
does not know what his family history is beyond that his brother
and sister both have DM, HTN.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.9 152/85 HR 94 sat 100% on RA wt: 102.7 kg
Gen: NAD
HEENT: clear OP
CV: normal rate, regular, no murmur
Pulm: CTAB, nonlabored
Abd: soft, NT, ND
GU: no Foley
Ext: no edema
Skin: purpuric macules and patches over inner arms, lower trunk,
and diffusely on legs
Neuro: A&O, logical
Psych: appropriate affect
DISCHARGE PHYSICAL EXAM:
VS: 98.5 137/83 84 18 100% ra
Gen: NAD
HEENT: clear OP
CV: normal rate, regular, no murmur
Pulm: CTAB, nonlabored
Abd: soft, NT, ND
GU: no Foley
Ext: no edema
Skin: nonblanching purpuric macules and patches scattered and
coalescing over inner arms, lower trunk, and diffusely on legs
Pertinent Results:
LABS ON ADMISSION
___ 08:40AM BLOOD WBC-6.8 RBC-3.28* Hgb-10.9* Hct-31.5*
MCV-96 MCH-33.1* MCHC-34.5 RDW-13.1 Plt ___
___ 08:40AM BLOOD Neuts-83.8* Lymphs-10.7* Monos-3.6
Eos-1.7 Baso-0.2
___ 08:40AM BLOOD ___ PTT-37.9* ___
___ 08:40AM BLOOD Plt ___
___ 08:40AM BLOOD Glucose-128* UreaN-15 Creat-0.8 Na-130*
K-5.2* Cl-101 HCO3-20* AnGap-14
___ 08:40AM BLOOD ALT-41* AST-88* AlkPhos-131* TotBili-1.6*
___ 08:40AM BLOOD Albumin-2.8* Calcium-7.9* Phos-2.6*#
Mg-1.9
___ 08:40AM BLOOD CRP-27.5*
___ 08:40AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 08:40AM BLOOD LtGrnHD-HOLD
___ 08:42AM BLOOD Lactate-1.7 K-4.9
___ 08:00AM URINE Color-Yellow Appear-Hazy Sp ___
___ 08:00AM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 08:00AM URINE RBC-34* WBC-2 Bacteri-FEW Yeast-NONE
Epi-<1 TransE-<1
___ 08:00AM URINE CastGr-1*
___ 08:00AM URINE Mucous-OCC
___ 08:00AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
LABS ON DISCHARGE
___ 06:20AM BLOOD WBC-6.2 RBC-3.41* Hgb-11.3* Hct-33.2*
MCV-97 MCH-33.2* MCHC-34.1 RDW-13.4 Plt ___
___ 06:20AM BLOOD Plt ___
___ 06:20AM BLOOD ___ PTT-40.3* ___
___ 06:20AM BLOOD Glucose-114* UreaN-23* Creat-1.0 Na-137
K-4.6 Cl-108 HCO3-23 AnGap-11
___ 06:20AM BLOOD ALT-34 AST-51* AlkPhos-145* TotBili-0.9
___ 07:20AM BLOOD Cryoglb-NO CRYOGLO
MICRO
___ 8:00 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 1:29 pm SWAB Source: Rectal swab.
**FINAL REPORT ___
R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final ___:
No VRE isolated.
IMAGING
ECG: Sinus rhythm. Early R wave transition. Compared to the
previous tracing of ___ the findings are similar.
Chest PA/Lat ___: No acute cardiopulmonary process.
CT head noncon ___: Redemonstration of age advanced atrophy.
No significant intracranial pathology.
Brief Hospital Course:
Hospital course: ___ M w/ DM type II, Alcoholic cirhosis
___ class B; MELD 11) c/b ascites and esophageal varices
in the past, who presents with a nonblanching, purpuric,
pruritic eruption of macules and patches on his bilateral arms,
legs and abdomen thought to be ___ leukocytoclastic vasculitis
triggered by oxycodone. Of note he was diagnosed with LCV in
___ in association with naltrexone. He was treated with
triamcinolone ointment 0.1% twice a day for one-two weeks, and
discharged with plans for PCP and dermatology follow up.
Active issues:
# Rash: He presented with a nonblanching, purpuric, pruritic
eruption of macules and patches on his bilateral arms, legs and
abdomen. Of note he was diagnosed with leukocytoclastic
vasculitis in ___ in association with naltrexone, and had
recently been prescribed oxycodone for rib pain after a fall. He
was treated with triamcinolone ointment 0.1% twice a day for
one-two weeks, and discharged with plans for PCP and dermatology
follow up.
# EtOH cirrhosis: ___ class B; MELD 11. c/b hx varices
Grade I-II in ___, ascites in the past. As of ___ RUQ
U/S, no ascites; well maintained with minimal diuretics. He is
up-to-date on his EGDs; and a recent CT abdomen with contrast
did not show any lesion concerning for HCC. Home spironolactone
was continued.
# Alcohol Abuse: Negative serum & urine tox screen. Per review
of OMR, was still drinking earlier this month, however,
expressed motivation to stop ___ the death of his brother from
alcoholic cirrhosis. He was treated with CIWA monitoring,
thiamine, folate, and multivitamins daily.
#Viral URI: Presenting with rhinorrhea, cough, epistaxis. Lungs
were clear, he was afebrile, and his chest xray was reassuring
against pneumonia. Epistaxis was isolated in the setting of
blowing his nose and did not recur.
Chronic issues:
# Hypertension: home Atenolol was continued
# DM type II: c/b neuropathy. Well-controlled w/ last HgbA1c
6.0%. Recently on Metformin, which he reports was discontinued.
No home insulin. He was treated with Humalog SS while inpatient.
Transitional issues:
-steroid creams can thin the skin if used too much; use it twice
a day for ___ weeks; do not use the ointment on areas that are
no longer red and itchy
-given grade ___ varices seen on EGD, consider changing atenolol
to nadolol; this can be considered at your next liver follow up
appointment, which may be scheduled around ___ or ___
-you have been scheduled for a CT scan of your abdomen on
___ by your liver doctors
___ on ___:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Spironolactone 50 mg PO DAILY
5. Thiamine 100 mg PO DAILY
6. OxycoDONE (Immediate Release) 2.5-5 mg PO Q8H:PRN pain
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID
RX *triamcinolone acetonide 0.1 % apply to red, itchy areas of
skin twice a day Refills:*1
4. Spironolactone 50 mg PO DAILY
5. Thiamine 100 mg PO DAILY
6. Atenolol 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
leukocytoclastic vasculitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
with a rash that we think may be from oxycodone, which was a new
medication for you. Please continue to use the steroid cream
twice a day for a week or two; apply it to areas of your skin
that are red and itchy (avoid the face/groin, that are not
affected anyhow). Do not use it longer or more frequently as it
can thin the skin. Please follow up with your primary care,
dermatology, and liver doctors.
Additionally, please be reminded that you had previously been
scheduled for a CT scan of your abdomen on ___ by your
liver doctors. ___ follow up with them in clinic after this.
___ wishes,
Your ___ Liver Team
Followup Instructions:
___
|
10253747-DS-17 | 10,253,747 | 29,493,248 | DS | 17 | 2124-02-07 00:00:00 | 2124-02-08 22:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Naltrexone / aspirin / Oxycodone
Attending: ___.
Chief Complaint:
foot swelling
Major Surgical or Invasive Procedure:
___: Diagnostic and therapeutic paracentesis - 6L removed
History of Present Illness:
Patient is a ___ year old man with history of Charcot deformity
of right foot, prior alcohol abuse, alcoholic cirrhosis (Child
Class B), portal HTN, CKD, R foot Charcot Disease presenting
from his outpatient ___ clinic for R foot swelling and
tenderness in the setting of a recent podiatric reconstructive
surgery.
Mr. ___ had Charcot deformity elective reconstructive surgery on
___. At that time he had a medial column fusion, Achilles
tendon lengthening, and excision debridement to the level of the
bone. His post operative course was complicated by a hemoglobin
drop of unknown origin (stable after transfusion, hyponatremia
(resolved with hydration), C. diff, acute worsening of his
kidney disease (resolved with holding diuretics). He was
discharged to rehab on ___.
Podiatry note on ___ noted some drainage from the site and with
concern for cellulitis and he was started on Keflex.
Patient presented today in ___ clinic and was found to have
a worsening right foot infection with both incision sites
showing dehiscence despite antibiotic treatment. He denies
noticing any increased pain, erythema, or swelling of the foot.
He endorses some chills and subjective fevers, though he did not
have a temperature. He denies night sweats.
In the ED, initial VS were T: 98.4 HR:84 BP: 136/87 RR: 14
O2sat:97%
RA Exam notable for a swollen R foot that was tender to
palpation.
Labs showed: Sodium 130, Bicarb 21, BUN 29. H/H: 8.2/25.6. No
leukocytosis (8.2), Lactate 1.1
Imaging showed: Negative bilateral LENIs, foot xray with edema
but no evidence of osteomyelitis or necrotizing fasciitis.
Received Vancomycin 1000 mg, Pip/Tazo 4.5 mg
Transfer VS were T: 99.0 HR: 86 BP:121/77 RR: 19 O2sat:100% RA
Podiatry was consulted consulted and requested a medicine
admission given prior complicated hospital course.
Decision was made to admit to medicine for further management.
On arrival to the floor the patient was hemodynamically stable,
and reported the story as above. He additionally reports a 20 lb
weight gain associated with increased stomach girth over the
last month. His last paracentesis was on ___.
Spironolactone was held while he was in the hospital for his
foot surgery. Per patient he had a history of ascites about one
year ago for which diuretics were started. He denies SOB, but
endorses discomfort. He denied jaundice, pruritis, changes in
urine or stool color, and increased bleeding.
Past Medical History:
- Alcoholic cirrhosis c/b grade 1 varices, ascites
- Hypertension
- H/o Type 2 Diabetes c/b neuropathy, last HbA1c 5.6% in ___
- Past history of alcohol abuse (last drink ___
- Hx Gastritis/GERD
- Leukoclastic vasculitis in response to naltrexone
- Chronic Kidney Disease
Social History:
___
Family History:
Grew up in a home for children with his brother and sister. He
does not know what his family history is beyond that his brother
and sister both have DM, HTN.
Physical Exam:
ADMISSION EXAM
===============
ADMISSION PHYSICAL EXAM:
VS: T: 98.4 BP: 147/84 HR: 90 RR:16 O2sat: 97% RA
GENERAL: NAD
HEENT: PERRL, anicteric sclera with some injection, MMM, good
dentition
NECK: nontender supple neck, no LAD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Distended and tense, positive fluid wave, no tenderness
to palpation in all four quadrants
EXTREMITIES: extremities warm and perfused. RLE with increased
edema, swelling, and TTP. Right foot in dressings. Left foot
with flaking skin, swelling, but no TTP.
NEURO: CN II-XII grossly intact
DISCHARGE EXAM
==============
VS: 98.0/98.5 BP: 123-141/75-82 HR: ___ RR: ___ O2sat:
98-100% RA. Todays weight: 108.5 kg (from 107.4 kg yesterday)
GENERAL: NAD
HEENT: anicteric 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: Distended with a positive fluid wave (though diminished
from pre-para). +BS in all four quadrants. Some TTP in the right
mid-gastric region. No rebound, guarding, or peritoneal signs.
EXTREMITIES: Right foot appearance mostly unchanged from
yesterday, slightly less fluid. with two ~4 inch incisions.
About 1-2 cm of surrounding erythema and a small amount of
serous drainage. TTP in the right mid-calf, similar to
yesterday, but diminished tenderness from prior.
NEURO: CN II-XII grossly intact.
SKIN: warm and well perfused
Pertinent Results:
ADMISSION LABS
===============
___ 01:40PM BLOOD WBC-8.1 RBC-3.10* Hgb-8.2* Hct-25.6*
MCV-83 MCH-26.5 MCHC-32.0 RDW-15.6* RDWSD-46.3 Plt ___
___ 01:40PM BLOOD Neuts-79.4* Lymphs-10.2* Monos-5.1
Eos-4.3 Baso-0.5 Im ___ AbsNeut-6.39* AbsLymp-0.82*
AbsMono-0.41 AbsEos-0.35 AbsBaso-0.04
___ 07:54AM BLOOD ___ PTT-32.5 ___
___ 01:40PM BLOOD Glucose-94 UreaN-28* Creat-1.1 Na-130*
K-4.6 Cl-100 HCO3-21* AnGap-14
___ 01:40PM BLOOD ALT-22 AST-41* AlkPhos-158* TotBili-0.6
___ 01:40PM BLOOD Osmolal-285
___ 01:44PM BLOOD Lactate-1.1
___ 03:10PM URINE Osmolal-361
STUDIES
==============
Bilateral LENIs: ___
IMPRESSION:
1. No definite deep venous thrombosis in the right or left lower
extremity
veins although limited assessment of the right calf veins.
2. Subcutaneous edema without drainable fluid collection.
3. Right inguinal lymphadenopathy.
Right foot X-ray: ___
IMPRESSION:
Diffuse soft tissue edema concerning for cellulitis. No soft
tissue gas or
radiopaque foreign body. No definite signs of hardware
migration or failure.
No convincing evidence for osteomyelitis though evaluation is
limited given
marked midfoot deformity.
Liver US: ___
IMPRESSION:
1. Patent hepatic vasculature.
2. Cirrhosis with sequela of portal hypertension including large
volume
ascites and splenomegaly.
3. Cholelithiasis.
MICRO
==============
Wound Culture: ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
STAPH AUREUS COAG +. RARE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
RIFAMPIN should not be used alone for therapy.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
in this
culture.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| STAPH AUREUS COAG +
| |
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
CLINDAMYCIN----------- <=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=1 S <=0.5 S
LEVOFLOXACIN---------- 0.5 S
MEROPENEM------------- 0.5 S
OXACILLIN------------- =>4 R
PIPERACILLIN/TAZO----- 8 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- =>16 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
___ 3:56 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (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):
INTERVAL LABS
==============
___ 04:55PM ASCITES TNC-209* RBC-209* Polys-13* Lymphs-8*
Monos-0 Eos-1* Mesothe-2* Macroph-76*
___ 04:55PM ASCITES TotPro-0.7 Creat-1.0 LD(LDH)-42
Albumin-0.2
DISCHARGE LABS
==============
___ 08:25AM BLOOD WBC-8.3 RBC-3.07* Hgb-8.0* Hct-25.5*
MCV-83 MCH-26.1 MCHC-31.4* RDW-15.5 RDWSD-46.6* Plt ___
___ 08:25AM BLOOD Neuts-74.4* Lymphs-10.0* Monos-8.4
Eos-6.1 Baso-0.5 Im ___ AbsNeut-6.21* AbsLymp-0.83*
AbsMono-0.70 AbsEos-0.51 AbsBaso-0.04
___ 08:50AM BLOOD Glucose-117* UreaN-27* Creat-1.1 Na-135
K-4.1 Cl-106 HCO3-24 AnGap-9
___ 08:45AM BLOOD ALT-16 AST-31 AlkPhos-150* TotBili-0.4
___ 08:50AM BLOOD Calcium-7.6* Phos-3.3 Mg-2.1
Brief Hospital Course:
Mr. ___ presented to the ___ ED from his outpatient ___
clinic with concern for worsening foot infection despite
treatment with Keflex. Upon arrival to ___ he was noted to
have a right foot cellulitis, without evidence of osteomyelitis
on X-ray, hyponatremia as well as the ascites in the setting of
known alcoholic cirrhosis. He was admitted to the medical
service and podiatry was consulted. He was started on
Vancomycin and Ceftazidime and wound cultures were sent. Wound
swab showed mixed culture results with coag + staph and
pseudomonas. His wound dressings were changed daily by podiatry
using a compressive dressing. He improved and on ___ his
antibiotics were narrowed to ciprofloxacin and
Sulfameth/Trimethoprim after culture sensitivities came back.
For his ascites secondary to cirrhosis a diagnostic and
therapeutic paracentesis on ___ removed 6 liters and
provided symptomatic improvement. Peritoneal fluid analysis
showed no evidence of SBP and evidence of portal HTN (SAAG
>1.1). Right upper quadrant ultrasound also showed evidence of
portal hypertension and cirrhosis. He was initially put on a 1.5
L fluid restriction in the setting of his hyponatremia, however
this resolved on ___. He was then put on a fluid and sodium
restriction of his cirrhosis and nutrition was consulted for
further management.
HOSPITAL SUMMARY BY PROBLEM
#R FOOT CELLULITIS:
The patient presented from his outpatient clinic after concerns
for worsening infection with increased swelling, erythema and
discharge despite outpatient treatment with Keflex. He presented
with no signs of systemic infection or sepsis (afebrile, no
leukocytosis, and hemodynamically stable). He was broadened to
Vancomycin and Ceftazidime and podiatry was consulted and
managed daily wound care. Given right lower extremity swelling
and calf pain in the setting of recent surgery there was concern
for a DVT however bilateral lower extremity US showed no
evidence of DVT. His CBC was obtained daily to monitor for signs
of infection.
#ALCOHOLIC CIRRHOSIS (CHILD CLASS B):
He presented with a history of chronic alcoholic cirrhosis c/b
grade 1 varices and ascites. Patient presents with evidence of
significant new ascites, accumulated over the last month (per
patient 20 lbs). His last therapeutic paracentesis had been on
___, however prior to that his ascites had been managed with
diuretics. He was put on his home diuretics, and the doses were
increased due to new ascites. A diagnostic paracentesis was done
on ___ and showed 13 PMNs, a negative gram stain and
SAG>1.1 consistent with an exudative origin (portal HTN) and no
infection. A therapeutic paracentesis was done on ___ and
removed 6 liters of fluid. He was put on water restriction of 2
L/day and sodium restriction of 2 g/day. As he had an elevated
INR (1.3) in a setting of recent antibiotic coverage and
possible nutritional deficiency, he was started on PO vitamin K.
Finally as he was Childs Class B with grade ___ esophageal
varices and he was started on nadalol 20 mg daily.
#HYPONATREMIA:
Presented with a mild asymptomatic hyponatremia (130). Patient
appeared volume overloaded with significant ascites. Most
likely etiology was considered hypervolemic hyponatremia, from
ADH release in the setting of liver disease. He was put on
water restriction to 1.5 L/day. On hospital day 2 his
hyponatremia resolved (130-->133). We continued to trend his
sodium level throughout his hospitalization.
#RECENT HISTORY OF C.DIFF
Was hospitalized with a recent history of C.diff during his
prior hospitalization(last day of PO vanc planned for ___. He
reported no recent history of diarrhea or constipation. As he
was undergoing current antibiotic treatment he was kept on PO
vanc 125 q6h throughout his hospitalization as C. diff
prophylaxis. This should be continued until 2 weeks after the
last day of vanc/ceftazidime.
#CHORNIC ISSUES:
He was kept on glargine 14 units with an insulin sliding scale
for his diabetes. His blood sugars were monitored regularly
throughout his hospitalization. For his history of
GERD/Gastritis his home pantoprazole was continued. He was
given Zofran as needed for nausea.
TRANSITIONAL ISSUES
=====================================
[ ] Currently receiving PO Vancomycin 125 PO q6h as c. diff
prophylaxis. Should continue receiving this until 2 weeks after
the completion of his cipro and Bactrim
[ ] Will need outpatient follow-up with podiatry to determine
end date of antibiotics. For now, continue Cipro/Bactrim until
Podiatry says it is OK to stop.
[ ] Continue follow-up with Hepatology. Will likely need
regular outpatient paracentesis
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Pantoprazole 40 mg PO Q24H
4. Rifaximin 550 mg PO BID
5. Thiamine 100 mg PO DAILY
6. Vitamin D ___ UNIT PO DAILY
7. Lidocaine 5% Patch 1 PTCH TD QAM
8. Vancomycin Oral Liquid ___ mg PO Q6H
9. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
10. Furosemide 20 mg PO DAILY
11. Spironolactone 50 mg PO DAILY
12. Glargine 14 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
2. Multivitamins W/minerals 1 TAB PO DAILY
3. Nadolol 20 mg PO DAILY
4. Ondansetron 4 mg PO Q8H:PRN NAUSEA
5. Sulfameth/Trimethoprim DS 2 TAB PO BID
6. Vancomycin Oral Liquid ___ mg PO Q6H
take until 2 weeks after finishing Cipro/Bactrim
7. Furosemide 40 mg PO DAILY
8. Spironolactone 100 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Glargine 14 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
11. Lidocaine 5% Patch 1 PTCH TD QAM
12. Pantoprazole 40 mg PO QPM
13. Rifaximin 550 mg PO BID
14. Thiamine 100 mg PO DAILY
15. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth every 6 hours Disp #*30
Tablet Refills:*0
16. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Right foot cellulitis
Alcoholic cirrhosis
Discharge Condition:
Condition: Clear and coherent
Mental status: Alert and interactive
Ambulatory status: non-weight bearing right leg, ambulates with
crutches
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital for a right foot infection
related to the surgery that your recently had. To treat your
infection we gave you IV antibiotics, and had the foot doctors
change your ___ daily. We additionally analyzed what was
causing your infection so we could target our antibiotics
better.
While you were here we noticed that you had a lot of fluid in
your stomach because of your liver disease. We removed some of
this fluid to help with discomfort. We analyzed it and found
that it was not infected. We restricted your fluid and salt
intake and increased your dose of diuretic to try to prevent
this fluid from coming back.
It was our pleasure taking care of you. Please do not hesitate
to contact us with questions,
Your ___ Care Team
Followup Instructions:
___
|
10253747-DS-23 | 10,253,747 | 26,096,572 | DS | 23 | 2126-08-18 00:00:00 | 2126-08-19 07:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Naltrexone / aspirin / Oxycodone
Attending: ___
Major Surgical or Invasive Procedure:
Large volume paracentesis ___ with removal 6L ascites
attach
Pertinent Results:
ADMISSION LABS
=================
___ 10:03PM ___ PTT-44.0* ___
___ 04:00PM URINE HOURS-RANDOM
___ 04:00PM URINE UHOLD-HOLD
___ 04:00PM URINE COLOR-Yellow APPEAR-CLEAR SP ___
___ 04:00PM URINE BLOOD-LG* NITRITE-NEG PROTEIN-100*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NORMAL PH-6.0
LEUK-SM*
___ 04:00PM URINE RBC-5* WBC-11* BACTERIA-FEW* YEAST-NONE
EPI-<1
___ 04:00PM URINE MUCOUS-RARE*
___ 02:44PM ___ PO2-49* PCO2-22* PH-7.37 TOTAL
CO2-13* BASE XS--10
___ 02:44PM LACTATE-2.1*
___ 02:44PM O2 SAT-80
___ 02:30PM GLUCOSE-137* UREA N-55* CREAT-2.4*
SODIUM-134* POTASSIUM-4.4 CHLORIDE-111* TOTAL CO2-12* ANION
GAP-11
___ 02:30PM estGFR-Using this
___ 02:30PM ALT(SGPT)-26 AST(SGOT)-56* ALK PHOS-198* TOT
BILI-2.4* DIR BILI-1.3* INDIR BIL-1.1
___ 02:30PM LIPASE-23
___ 02:30PM ALBUMIN-2.0*
___ 02:30PM WBC-16.9* RBC-2.53* HGB-8.1* HCT-23.4* MCV-93
MCH-32.0 MCHC-34.6 RDW-15.9* RDWSD-53.5*
___ 02:30PM NEUTS-90.2* LYMPHS-2.2* MONOS-6.4 EOS-0.0*
BASOS-0.2 IM ___ AbsNeut-15.26* AbsLymp-0.37*
AbsMono-1.08* AbsEos-0.00* AbsBaso-0.03
___ 02:30PM PLT COUNT-112*
DISCHARGE LABS
=====================
___ 05:45AM BLOOD WBC-5.8 RBC-2.57* Hgb-7.8* Hct-24.3*
MCV-95 MCH-30.4 MCHC-32.1 RDW-15.3 RDWSD-53.0* Plt ___
___ 05:45AM BLOOD Plt ___
___ 05:45AM BLOOD Glucose-117* UreaN-53* Creat-2.4* Na-138
K-4.9 Cl-107 HCO3-19* AnGap-12
___ 05:45AM BLOOD ALT-18 AST-36 AlkPhos-190* TotBili-1.3
___ 05:45AM BLOOD Albumin-2.7* Calcium-8.9 Phos-6.0* Mg-1.9
PERTINENT IMAGING
======================
MR LEFT ANKLE W AND W/O CONTRAST ___
IMPRESSION:
-Neuropathic changes affecting the subtalar and midfoot joints
with no
evidence of osteomyelitis.
-Moderate-sized ankle joint effusion with evidence of synovitis.
-Posterior tibial and peroneus longus and brevis tenosynovitis.
TEE ___
IMPRESSION: No discrete vegetation or abscess seen. Normal
global left ventricular systolic function. Mild mitral
regurgitation. Mild to moderate tricuspid regurgitation. Mild
pulmonary artery hypertension.
TTE ___
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and normal systolic function. Mildly dilated
right ventricle with normal sysotlic function. No vegetations
seen. Moderate tricuspid regurgitation. Moderate pulmonary
artery systolic hypertension. No 2D echocardiographic evidence
for endocarditis.
MR ___ SPINE W AND W / OUT ___
IMPRESSION:
1. Moderate to severe motion degradation, particularly on the
sagittal images
results in limited evaluation, particularly at the levels of
interest of
L5-S1.
2. Within this limitation, endplate signal changes at L5-S1 with
associated
loss of disc height are overall similar to ___,
and there is no
definite paravertebral phlegmonous change.
3. Similar grade 1 anterolisthesis of L5 upon S1, with moderate
left neural
foraminal narrowing contacting the exiting L5 nerve root.
PREVALENCE: Prevalence of lumbar degenerative disk disease in
subjects
without low back pain:
Overall evidence of disk degeneration 91% (decreased T2 signal,
height loss,
bulge)
T2 signal loss 83%
Disk height loss 58%
Disk protrusion 32%
Annular fissure 38%
MICROBIOLOGY
====================
___ 8:50 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 5:40 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
Susceptibility testing performed on culture # ___-___
___.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___ (___)
___ AT 13:38.
___ 2:33 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
RIFAMPIN should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.5 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
====================================
Mr. ___ is a ___ year old man with history of EtOH cirrhosis
complicated by portal HTN, esophageal varices s/p TIPS ___,
DM, and CKD who presented after a fall
and with leg pain. He subsequently was found to have MRSA
positive blood cultures unknown source (negative TTE/TEE). He
was treated with vancomycin initially and transitioned to
daptomycin for ___uring this hospitalization he had
unremarkable TTE/TEE as well as a left foot MRI not concerning
for infection. He has known EtOH cirrhosis and had large volume
ascites with a large volume paracentesis on ___ that was
uncomplicated. He will be discharged to ___ with ___ services
for continuation of antibiotic treatment.
========================
TRANSITIONAL ISSUES
=========================
[ ] Diagnosed with MRSA bacteremia this admission. He will
continue on IV daptomycin 600 mg IV q24h on discharge.
Duration of OPAT regimen
Start date: ___
Stop date: ___
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
LAB MONITORING RECOMMENDATIONS:
Weekly safety labs: CBC/diff, BUN/ creat, CPK, ALT, AST, CRP
[ ] He has a history of alcoholic cirrhosis. Please continue to
counsel on importance of alcohol cessation.
[ ] Please note that his carvedilol was increased to 12.5mg BID,
please continue to monitor BPs in the outpatient setting.
DISCHARGE CREATININE: 2.4
CODE: Full
CONTACT: ___
Relationship: friend
Phone number: ___
ACTIVE ISSUES:
=====================
# GPC bacteremia
## Hx MRSA bacteremia
He was found to have a GPC bacteremia (+ blood cutlures on ___,
___, and last + on ___ of unclear source. TTE/TEE negative
for vegetations. Left foot MRI unrevealing. MR ___ spine was
likewise unrevealing for infection. Blood cultures were stopped
after he had several days of negative cultures. He was initially
on vancomycin and then swtiched to daptomycin with a plan for
outpatient antibiotics for 4 weeks. He will continue on
daptomycin (PICC was placed) through ___ and is enrolled in
OPAT with plan for antibiotic administration at ___ via his
___.
# ___ on CKD
# low bicarbonate
Baseline Cr 1.4. Presented with Cr 2.4 therefore with an acute
kidney injury on chronic kidney disiease and nephrology was
consulted. There was concern for pre-renal ___ given his acute
bacteremia vs infectious GN. Urine lytes were sodium avid with
bland urine sediment, and renal ultrasound ruled out post-renal
obstruction. UPEP did not show monoclonal antibodies. He was
continued on sodium bicarbonate 1300mg PO TID and a phos
restricted diet.
#HTN
His pressures wee in the systolic 150-170's while on 6.25 BID
carvedilol, so it was increased to 12.5mg BID. Coreg was also
indicated for variceal prophylaxis.
#Chronic normocytic anemia
Patient reported 1 episode of brown emesis prior to
admission,and ED exam notable for guaiac positive stool in
rectal vault. Hb
8.1 on admission, at baseline. He was recently started on iron
supplementation in outpatient setting. His H/H hovered around
his baseline but did slowly decline without evidence of active
bleed, and he received a total of 3uPRBCs during his stay. On
day of discharge he was hemodynamically stable with H/H
7.8/24.3.
# Leg pain
# Fall
On presentation he noted that he had fallen and hit his head
after feeling that his legs were weak. Head CT was unremarkable.
Notably, he has a history of charcot foot and peripheral
neuropathy secondary to his diabetes. During his stay he
continued to complain of worsening weakness. Diabetic neuropathy
+ generalized weakness from GPC bacteremia (MRSA) together
likely explanatory. MRI spine w/o obvious mass or infection.
#EtOH cirrhosis
MELD 25 on admission. Complicated by hepatic encephalopathy,
portal HTN with refractory ascites and esophageal varices status
post TIPS ___ with revision ___. ALT was elevated from
baseline teens to 26, and AST from ___ up to 56, with Alk phos
up to 198 and bilirubin 2.4 on admission. For his ascites, he
had a RUQUS that demonstrated a patent TIPS on ___. He had a
paracentesis on ___ with removal of 6L ascites. Regarding his
hepatic encephalopathy, he presented with asterixis on exam and
was continued on rifaximin and lactulose, with improvement in
his mental status during his stay. He has a history of grade I
esophageal varices (last EGD ___ and his coreg was
increased. He did not have any evidence of bleeding during his
stay. He was maintained on a low salt diet and continued on
thiamine, folate, vitamin C, vitamin D, cyanocobalamin, MVI. He
will follow up with outpatient hepatology in ___.
# Dyspnea
He presented with exertional dyspnea noted when ambulating, no
dyspnea at rest or prior to admission. CXR and EKG were
unremarkable. No
associated cardiac symptoms. His primary symptom was either with
exertion or during fevers. The latter was likely secondary to
physiologic response to fever; the former deconditioning + mild
splinting secondary to ascites. On day of discharge he was
satting well and comfortable on RA.
#Hyponatremia
Na 134 on admission, likely in setting of cirrhosis as above.
Patient also noted poor PO intake over the last 2 days. During
his stay he was able to tolerate PO intake and his sodium
normalized.
CHRONIC ISSUES:
===============
#DM
#Peripheral neuropathy
Last A1c 5.7% in ___. No insulin or oral diabetes medications
at home. He was treated with sliding scale insulin as an
inpatient.
#BPH
Recent hospital course was complicated by urinary retention
requiring catheterization. He was continued on his home
Tamsulosin 0.4mg PO qd
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. CARVedilol 6.25 mg PO BID
2. FoLIC Acid 1 mg PO DAILY
3. Lactulose 30 mL PO BID
4. Metoclopramide 5 mg PO TID:PRN nausea
5. Multivitamins 1 TAB PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. rifAXIMin 550 mg PO BID
8. Thiamine 100 mg PO DAILY
9. TraMADol 50 mg PO BID:PRN Pain - Severe
10. Vitamin D ___ UNIT PO DAILY
11. Ascorbic Acid ___ mg PO BID
12. Cyanocobalamin 1000 mcg PO DAILY
13. Ferrous GLUCONATE 324 mg PO DAILY
14. Sodium Bicarbonate 650 mg PO BID
15. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Daptomycin 600 mg IV Q24H
RX *daptomycin 500 mg 600 mg IV once a day Disp #*21 Vial
Refills:*0
2. CARVedilol 12.5 mg PO BID
RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Lactulose 30 mL PO TID
RX *lactulose 10 gram/15 mL (15 mL) 30 ml by mouth three times a
day Disp #*1 Bottle Refills:*0
4. Sodium Bicarbonate 1300 mg PO TID
RX *sodium bicarbonate 650 mg 2 tablet(s) by mouth three times a
day Disp #*180 Tablet Refills:*0
5. Ascorbic Acid ___ mg PO BID
6. Cyanocobalamin 1000 mcg PO DAILY
7. Ferrous GLUCONATE 324 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Metoclopramide 5 mg PO TID:PRN nausea
10. Multivitamins 1 TAB PO DAILY
11. Pantoprazole 40 mg PO Q24H
12. rifAXIMin 550 mg PO BID
13. Tamsulosin 0.4 mg PO QHS
14. Thiamine 100 mg PO DAILY
15. TraMADol 50 mg PO BID:PRN Pain - Severe
16. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
=======================
MRSA BACTEREMIA
SECONDARY DIAGNOSIS:
=======================
DIABETIC NEUROPATHY
ACUTE KIDNEY INJURY ON CHRONIC KIDNEY DISEASE
ABDOMINAL ASCITES SECONDARY TO CIRRHOSIS
HYPONATREMIA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
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 after feeling unwell and
falling.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
- You were found to have bacteria growing in your blood and
given antibiotics. You will need to continue taking these
antibiotics when you leave the hospital.
- The extra fluid in your belly was removed.
- Your blood pressure was high when you came in and your
medications were increased to control your blood pressure
- You had an MRI of your foot and your spine that did not show
any sign of infection.
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.
- You must never drink alcohol again. If you drink again there
is a good chance that you could die.
We wish you all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10253803-DS-16 | 10,253,803 | 29,975,375 | DS | 16 | 2145-05-14 00:00:00 | 2145-05-18 20:41:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors / Lisinopril / Adhesive Tape
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH of CAD s/p CABG, iCHF (EF 25% on ___,
bronchiectasis, COPD, presenting with worsening DOE and b/l leg
pain for 2 weeks. The patient reports that he was asked to come
to the ED by his cardiologist, Dr. ___ wanted to have him
admitted for a possible catheterization, when he was found to
have a hemaglobin of 6.1, and was admitted.
Pt reports that for the past two weeks he has had increased DOE,
and can only go up around 5 steps before he needs to stop. About
a month ago he was able to climb 30. He reports that he never
feels SOB at rest, and only requires one pillow at night, which
is unchanged. He has not experienced any chest pain. He has a
chronic dry cough, unchanged for several years. He was recently
seen by a pulmonologist for follow up of his
tracheobronchomalacia, which has been stable. His shortness of
breath is not changed with his Spiriva.
The patient also reports lower leg pain while walking since
___. Now can only waslk 150 ft before experiecing pain.
Resolves with rest.
Pt reports not experiencing any changes in bowel habits, no
diarrhea, no melena or bloody stool. Also no n/v. Urine is
light, not red or brown. He is not on home anticoagulation. Pt
has not experienced any bruising, night sweats, chills, or
weight loss. He is of ___, and Native ___
decent. His diet has not changed recently, and consists of a lot
of fish and chicken, and eats spinach three times a week. He
does endorse recently craving popsicles and ice cubes.
In the ED, initial vitals were: 97.6 74 125/54 18 100%
Labs were notable for: Lactate 2.3, BNP 1235, H/H 6.1/23.4 (most
recent Hgb in our system is 12.6 from ___, normal coags, and
CHEM 10. Stool was guaiac negative.
Chest x-ray showed persistent faint hazy opacities predominantly
in the right lung but also to a small extent at the left lung
base compatible with chronic infection and bronchiectasis.
Patient was given: ___ 14:45 IH Ipratropium Bromide Neb x
1.
Consults: none
On the floor, satting at 97% on RA, reported no pain and
breathing comfortably
Past Medical History:
Hypertension
Hyperlipidemia
CAD, s/p CABG x 2 in ___
CRT-D ___
Tracheobronchomalacia and right main stem bronchus stenosis, s/p
Y stenting and bronchus intermedius silicone stenting in ___
with removal in ___ d/t bleeding and granulation tissue, on
___ s/p right thoracotomy and tracheobronchoplasty with
ringed graft with posterior splinting
GERD
CHF
Ischemic Cardiomyopathy-EF ___
Sleep apnea, on CPAP
Lung nodule-stable since ___
S/P vocal cord polyp removal
H/O pneumothorax after bronchoscopy with chest tube
H/O mediastinal lymphadenopathy
H/O pleural effusion, s/p thoracentesis ___
Episode of acute renal failure in ___
Tonsillectomy
Social History:
___
Family History:
Heritage - ___, Native ___. No history of
cardiac disease.
Physical Exam:
================
EXAM ON ADMISSION
================
Vitals: T 97.9 P 79 BP 135/43 RR 18 97%RA
General: Alert, oriented, no acute distress, able to speak
comfortably in complete sentences
HEENT: Sclera anicteric, conjunctival pallor, EOMI, PERRL
Neck: Supple, unable to appreciate JVP, no LAD
CV: Regular rate and rhythm, heart sounds distant, but unable to
appreciate murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally with good air movement,
no wheezes, rales, rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Skin: pallor
================
EXAM ON DISCHARGE
================
Vitals: T: 98.1 BP: 128/65 P: 69 R: 18 O2: 99
General: Alert, oriented, no acute distress, pallor
Lungs: Diffuse wheezes,
CV: distant heart sounds, RRR, no m/r/g
Abdomen: soft, non-tender, non-distended
Ext: Warm, well perfused, no edema
Skin: pallor
Pertinent Results:
===================
LABS ON ADMISSION
===================
___ 01:40PM BLOOD WBC-7.9 RBC-3.65* Hgb-6.1*# Hct-23.4*#
MCV-64*# MCH-16.7*# MCHC-26.1*# RDW-20.8* RDWSD-47.5* Plt ___
___ 01:40PM BLOOD Neuts-68.7 Lymphs-17.3* Monos-11.0
Eos-1.8 Baso-0.8 Im ___ AbsNeut-5.40 AbsLymp-1.36
AbsMono-0.86* AbsEos-0.14 AbsBaso-0.06
___ 01:40PM BLOOD ___ PTT-32.9 ___
___ 01:40PM BLOOD Ret Man-3.4* Abs Ret-0.12*
___ 01:40PM BLOOD Glucose-125* UreaN-17 Creat-1.2 Na-138
K-4.3 Cl-103 HCO3-27 AnGap-12
___ 01:40PM BLOOD LD(LDH)-194
___ 01:40PM BLOOD proBNP-1235*
___ 01:40PM BLOOD Calcium-9.2 Phos-4.0 Mg-2.1 Iron-15*
___ 01:40PM BLOOD calTIBC-503* Hapto-227* Ferritn-5.5*
TRF-387*
___ 01:54PM BLOOD Lactate-2.3*
===================
LABS ON DISCHARGE
===================
___ 05:43AM BLOOD WBC-7.2 RBC-3.90* Hgb-7.1* Hct-26.5*
MCV-68* MCH-18.2* MCHC-26.8* RDW-23.0* RDWSD-55.4* Plt ___
___ 05:43AM BLOOD Glucose-137* UreaN-13 Creat-1.0 Na-141
K-4.3 Cl-103 HCO3-27 AnGap-15
___ 05:43AM BLOOD Calcium-9.1 Phos-3.9 Mg-2.4
___ 06:56AM BLOOD Hgb-7.9* Hct-28.8*
===================
MICROBIOLOGY
===================
___ - Blood cx x1 - NGTD
===================
IMAGING
===================
___ CXR -
Persistent faint hazy opacities predominantly in the right lung
but also to a small extent at the left lung base compatible with
chronic infection and bronchiectasis, better assessed on prior
CT trachea.
Brief Hospital Course:
Mr. ___ is a ___ yo male with a hx CABG, COPD, and
AICD/Pacemaker coming in with worsening exertional dyspnea and
b/l leg pain for the past week, found to be anemic with a Hgb of
6.1
===================
ACTIVE ISSUES
===================
#Iron deficiency anemia:
In the ED, the patient was found to have a Hgb of 6.1. He was
guaiac negative. He was transfered to the Medicine service, and
was transfused a unit of PRBCs over 4 hours. He was monitored on
tele during the transfusion to assess oxygenation status. The
patient tolerated the transfusion well. Further labs showed TIBC
503 Hapto 227 Ferritin 5.5 TRF 387. He was started on PO iron
supplements. A repeat h/h on ___ showed a Hgb of 7.1. The
patient received a second unit of PRBCS, which he again
tolerated well. On discharge, the patient reported that his
breathing was much improved, and that he was able to walk around
the unit without feeling short of breath.
#Dyspnea:
Though initially thought to be due to CHF, on exam the patient
did not exhibit signs of being fluid overloaded and a CXR showed
no pulmonary edema. The patient's symptoms improved after
receiving transfusions of PRBCs. He was also continued on his
home fluticasone and albuterol.
#Bilat leg pain:
The patient initally presented with bilateral leg pain of
unclear etiology, with recent vascular studies that did not show
signs of arterial disease. He did not experience this pain
during his hospitalization.
# Chronic Systolic CHF:
Secondary to ischemic cardiomyopathy with last known LVEF
___. The patient was continued on his home medication
regimen, which includes lasix 40mg daily, imdur 30mg daily,
losartan 50 mg daily, simvastatin 20 mg daily, and metoprolol
100mg daily. He received his PRBCs over 4 hours, as discussed
above, and did not experience increased dyspnea.
===================
CHRONIC ISSUES
===================
#CAD - s/p CABG ___:
The patient was continued on his home aspirin 81mg daily, as he
was guaiac negative and had no symptoms associated with an
active GI bleed. His other cardiac medication were continued as
above.
#OSA - The patient was continued on his home CPAP.
#Hypertension - Patient's home medications were continued as
above
#Hyperlipidemia- Home ezetimide was continued
#GERD - The patient's home pantoprazole 40mg BID was continued
#Insomnia - Patient was continued on his home lorazepam 1mg QHS
===================
TRANSITIONAL ISSUES
===================
- The patient does not currently have a PCP, and should
follow-up with his new PCP, ___.
- The patient will have an h/h done on ___, with results faxed
to ___.
- The patient's PCP should ___ the need for his high dose of
pantoprazole, considering that PPIs may contribute to poor iron
absorption.
- The patient's PCP should schedule him for an outpatient
colonoscopy and EGD (previously saw ___ to assess for a GI
bleed as the cause of his iron deficiency.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN cough
or shortness of breath
2. Ezetimibe 10 mg PO DAILY
3. fluticasone 50 mcg/actuation nasal BID
4. Furosemide 40 mg PO DAILY
5. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
6. Lorazepam 1 mg PO QHS
7. Losartan Potassium 50 mg PO DAILY
8. Pantoprazole 40 mg PO Q12H
9. Simvastatin 20 mg PO QPM
10. Tiotropium Bromide 1 CAP IH DAILY
11. Aspirin 81 mg PO DAILY
12. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Ezetimibe 10 mg PO DAILY
3. Furosemide 40 mg PO DAILY
4. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
5. Lorazepam 1 mg PO QHS
6. Losartan Potassium 50 mg PO DAILY
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Pantoprazole 40 mg PO Q12H
9. Simvastatin 20 mg PO QPM
10. Tiotropium Bromide 1 CAP IH DAILY
11. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN cough
or shortness of breath
12. fluticasone 50 mcg/actuation nasal BID
13. Outpatient Lab Work
ICD 280.9: Iron Deficiency Anemia.
Please check a hemoglobin and hematocrit on ___ or ___.
Please fax the results to ___, MD, fax ___
14. Ferrous Sulfate 325 mg PO BID
RX *ferrous sulfate [iron] 325 mg (65 mg iron) 1 capsule(s) by
mouth three times a day Disp #*90 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
- iron deficiency anemia
- leg pain
- dyspnea
Secondary Diagnoses
- ischemic cardiomyopathy
- coronary artery disease
- 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 very nice to meet you and to be a part of your care team
at ___. You came to the
Emergency Room to be admitted for a cardiac catheterization, but
we found that you do not have enough red blood cells (anemia),
and so you were admitted to the Medicine Service. We gave you
some blood, and your anemia got better. We also gave you some
iron to take, and you should continue to take this at home as
instructed below. We know that your anemia is because of low
iron, but we did not discover why your iron is so low.
We would like for you to have a colonoscopy and EGD to look for
possible reasons for your anemia. This will be scheduled by your
primary care provider. When you take the bowel prep for your
colonoscopy, be sure to carefully follow the instructions for
fluid repletion and on the final day of the prep (when you drink
the Mag Citrate), take a half dose of your Lasix.
As you know, your heart is not working as well as it used to,
and so you should weigh yourself every day, and call Dr. ___
___ your weight increases by more than 3 pounds.
We were not able to schedule you an appointment with Dr. ___
___ enough for you to see after your hospitalization. Instead
you will be seeing Dr. ___, who is also an excellent
physician. Please see below for the details.
We were glad to see you breathing better when you left us, and
we wish you the best of luck!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10253803-DS-18 | 10,253,803 | 21,618,989 | DS | 18 | 2146-08-06 00:00:00 | 2146-08-06 20:18:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors / Lisinopril / Adhesive Tape / vancomycin
Attending: ___
Chief Complaint:
Fever, cough, shortness of breath
Major Surgical or Invasive Procedure:
Right ankle arthrocentesis (attempted) ___
History of Present Illness:
Mr. ___ is a ___ m with hx MI, CABG, pacemaker/defib with
recent site infection in ___, CHF with EF 20% in ___,
tracheobroronchiomalacia s/p repair, who presented for
evaluation of fever and cough. Patient has had fevers to 101 at
home for the past week, and has had a cough and sense of
congestion on the right side of his chest for the past 3 days.
He reported some pleuritic chest pain with breathing at the base
of his right lung yesterday. He also reported 1 week of right
ankle pain that he attributed to his gout.
In the ED, initial vitals: 98.6 76 143/65 18 98% RA
- Exam notable for: WBC of 11.3, Cr of 1.4 ___ 1.1) BNP of 7K
- CXR showed new right middle and right lower lobe
consolidation, concerning for pneumonia. Probable small right
pleural effusion.
Pt given Clindamycin 600 mg IV ONCE, CefePIME 2 g IV ONCE,
Levofloxacin 750 mg IV ONCE, Ipratropium Bromide Neb 1 Neb IH
ONCE,
and Albuterol 0.083% Neb Soln 1 Neb IH ONCE.
On arrival to the floor, patient was overall stable and in no
acute distress. He confirmed the history above. He reported
cough, fever, shortness of breath on exertion, but no chest
pain.
ROS:
No night sweats, or weight changes. No changes in vision or
hearing, no changes in balance. 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:
Chronic systolic heart failure - Ischemic Cardiomyopathy, EF 20%
Hypertension
Hyperlipidemia
CAD, s/p CABG x 2 in ___
CRT-D ___
Tracheobronchomalacia and right main stem bronchus stenosis, s/p
Y stenting and bronchus intermedius silicone stenting in ___
with removal in ___ d/t bleeding and granulation tissue, on
___ s/p right thoracotomy and tracheobronchoplasty with
ringed graft with posterior splinting
GERD
Sleep apnea, on CPAP
Lung nodule-stable since ___
S/P vocal cord polyp removal
H/O pneumothorax after bronchoscopy with chest tube
H/O mediastinal lymphadenopathy
H/O pleural effusion, s/p thoracentesis ___
Episode of acute renal failure in ___
Tonsillectomy
Social History:
___
Family History:
Heritage - ___, Native ___. No history of
cardiac disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: 98.6 80 150/65 18 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Decreased air entry on the right, inspiratory/expiratory
wheezes on the right side
CV: RRR, Nl S1, S2, No MRG
Abdomen: soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Tenderness on palpation of right ankle, no erythema and
no swelling.
Neuro: CN2-12 intact, no focal deficits
DISCHARGE PHYSICAL EXAM:
========================
Vitals: 97.8, 137/74, 63, 18, 97%RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Decreased air entry on the right, inspiratory/expiratory
wheezes on the right side
CV: RRR, Nl S1, S2, No MRG
Abdomen: soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Tenderness on palpation of right ankle, no erythema and
no swelling.
Neuro: CN2-12 intact, no focal deficits
Pertinent Results:
ADMISSION LABS:
===============
___ 02:20PM ___ PTT-31.3 ___
___ 02:20PM PLT SMR-NORMAL PLT COUNT-382#
___ 02:20PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-OCCASIONAL
___ 02:20PM NEUTS-76* BANDS-0 LYMPHS-13* MONOS-8 EOS-2
BASOS-0 ATYPS-1* ___ MYELOS-0 AbsNeut-8.59* AbsLymp-1.58
AbsMono-0.90* AbsEos-0.23 AbsBaso-0.00*
___ 02:20PM WBC-11.3*# RBC-4.65 HGB-13.7 HCT-41.9 MCV-90
MCH-29.5 MCHC-32.7 RDW-12.5 RDWSD-41.1
___ 02:20PM proBNP-7267*
___ 02:20PM estGFR-Using this
___ 02:20PM GLUCOSE-220* UREA N-26* CREAT-1.4* SODIUM-134
POTASSIUM-3.7 CHLORIDE-95* TOTAL CO2-22 ANION GAP-21*
___ 04:05PM LACTATE-1.9
DISCHARGE/PERTINENT LABS:
=========================
___ 06:43AM BLOOD WBC-10.7* RBC-4.42* Hgb-12.9* Hct-40.2
MCV-91 MCH-29.2 MCHC-32.1 RDW-12.6 RDWSD-41.9 Plt ___
___ 06:43AM BLOOD Glucose-143* UreaN-22* Creat-1.0 Na-137
K-4.7 Cl-99 HCO3-23 AnGap-20
MICROBIOLOGY:
=============
___ 4:13 am URINE Source: ___.
URINE CULTURE (Final ___: NO GROWTH.
___ 3:40 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 2:20 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 1:00 pm MRSA SCREEN Source: Nasal swab.
MRSA SCREEN (Pending):
IMAGING:
========
CHEST XRAY (___):
New right middle and right lower lobe consolidation, concerning
for pneumonia. Probable small right pleural effusion.
RIGHT ANKLE (AP, MORTISE & LATERAL) (___):
No acute fractures or dislocations are seen. Surgical clips are
seen within the medial soft tissues. There are vascular
calcifications. There are large calcaneal spurs adjacent to the
pain marker. There is no ankle joint effusion. There are mild
degenerative changes of the midfoot best seen on the lateral
view. There is normal osseous mineralization. No erosions are
seen.
Brief Hospital Course:
Mr. ___ is a ___ m with history of MI, CABG, pacemaker/defib
with recent site infection in ___, CHF with EF 20% in ___, tracheobroronchiomalacia s/p tracheobronchoplasty in
___, who presented with fever, cough, and shortness of breath
of 6 days duration. Chest X-ray was consistent with right middle
and lower lobe pneumonia.
Active Issues:
# CAP: Patient presented with fever and cough with CXR evidence
of consolidation, highly suggestive of pneumonia. Patient was
hospitalized within the last 90 days for ICD pocket infection,
so initially started on treatment for HAP. Was subsequently
de-escalate given good clinical response and low risk of
hospital acquired resistant pathogens. Patient was initially
started on IV cefepime and ciprofloxacin, then was switched to
Augmentin/Doxycycline. His interventional pulmonary provider ___.
___ was contacted given his history of tracheobronchomalacia,
who recommended a 14 day course of Augmentin/Doxycycline given
the inherent difficulty of clearing secretions in such patients.
# ___:
Creatinine was elevated to 1.4 on admission from a baseline of
1.1. Likely prerenal azotemia given volume depletion and
concurrent infection (FeUrea 14%). IVF not given given the
patient's high blood pressure and CHF with EF of 20%. Furosemide
was held for 24 hours and creatinine dropped to 1.0, the
patient's known baseline.
# Right ankle pain: Patient reports several days of ankle pain
similar to prior episodes of gout. Previously seen at an urgent
care 5 days PTP and was given 3 doses of colchicine with minimal
improvement. During this admission, there were no signs of
inflammation on physical exam, but patient was complaining of
persistent pain, particularly with weight bearing. Ankle plain
films did not show any fracture but identify large calcaneal
spurs that may be responsible, in part, for the pain.
Rhematology was consulted and attempted an ankle arthrocentesis
which was not successful. They recommended colchicine 0.6mg BID
until symptoms resolve, then 0.6 mg daily until his outpatient
___ in 4 weeks.
#. LFT abnormalities: Transaminases, AlkP, and LDH elevated from
prior baseline, last checked ___, hence unclear chronicity, but
downtrending at discharge. Has no GI symptoms or
myalgias/cardiac chest pain to suggest muscle/myocardial source.
HCV Ab was negative in ___. Mildly elevated LDH is hemolyzed
and of unclear significance, associated with stable Hct, hence
unlikely to reflect hemolysis. LFTs should be rechecked at PCP
___.
Inactive Issues:
#. COPD/Tracheobronchomalacia: Home regimen was continued.
#. CAD/ischemic CM: Home regimen was continued, with the
exception of torsemide, which was held on the day of admission
in the setting ___ as above and resumed thereafter.
Transitional Issues
===================
# Patient should continue taking augmentin/doxycycline for a
total of 14 days (day ___, last ___ as recommended by
his outpatient interventional pulmonary provider, Dr. ___.
# Patient was instructed to use a flutter valve 2 to 4 times a
day to help expectorate mucus, he will eventually need to use it
chronically whenever he has cough.
# Patient should follow up with interventional pulmonary
provider (Dr. ___ as scheduled.
# Patient was discharged on colchicine 0.6 mg BID for a gout
flare of his right ankle and was instructed to continue taking
it twice daily until his symptoms resolve, then switch to 0.6 mg
daily until his appointment with rhematology.
# Patient should ___ with rhematology as scheduled.
# If ankle pain does not resolve at the time of PCP visit,
please consider referral to rhematology earlier. Patient is
difficult to treat if resistant to colchicine given his CHF and
borderline renal function. Prednisone could be an option, but
could potentially exacerbate his CHF.
# Please repeat chest imaging 4 weeks after resolution of
pneumonia.
# Patient had abnormal LFTs versus uncertain baseline (last
checked years ago). Please repeat LFTs as outpatient and
consider further diagnostic evaluation if the LFTs remain
abnormal.
# Patient had microscopic hematuria on UA, which should be
rechecked in the outpatient setting.
# CODE STATUS: Full (confirmed)
# CONTACT:
- Health care proxy: ___
- Relationship: wife
- Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Ezetimibe 10 mg PO DAILY
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN Nasal
congestion
4. Tiotropium Bromide 1 CAP IH DAILY
5. Furosemide 40 mg PO DAILY
6. Isosorbide Mononitrate (Extended Release) 60 mg PO QAM
7. Losartan Potassium 100 mg PO DAILY
8. Metoprolol Succinate XL 200 mg PO DAILY
9. Pantoprazole 40 mg PO Q12H
10. Simvastatin 20 mg PO QPM
11. Aspirin 81 mg PO DAILY
12. Vitamin D 400 UNIT PO DAILY
13. Ferrous Sulfate 325 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth every six (6) hours Disp #*60 Tablet Refills:*0
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*24 Tablet Refills:*0
3. Colchicine 0.6 mg PO DAILY
RX *colchicine 0.6 mg 1 tablet(s) by mouth twice a day Disp #*90
Tablet Refills:*0
4. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day
Disp #*24 Tablet Refills:*0
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
6. Aspirin 81 mg PO DAILY
7. Ezetimibe 10 mg PO DAILY
8. Ferrous Sulfate 325 mg PO DAILY
9. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN Nasal
congestion
10. Furosemide 40 mg PO DAILY
11. Isosorbide Mononitrate (Extended Release) 60 mg PO QAM
12. Losartan Potassium 100 mg PO DAILY
13. Metoprolol Succinate XL 200 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Pantoprazole 40 mg PO Q12H
16. Simvastatin 20 mg PO QPM
17. Tiotropium Bromide 1 CAP IH DAILY
18. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Community-acquired Pneumonia
SECONDARY DIAGNOSES
===================
Acute gout
Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you. You were admitted to the
___ because you were having
fever, cough, and shortness of breath. You were diagnosed with a
community-acquired pneumonia and you were started on
antibiotics. Your breathing subsequently improved and your fever
resolved. You will continue your current antibiotics for a total
of 14 days (last day ___. You should also use the flutter
valve at least twice a day to help expectorate mucus, as
instructed by our respiratory therapy team.
You also had recently had a gouty attack in your right ankle. We
were not able to give you steroids in the joint space, but we
started you on colchicine. You should continue taking colchicine
twice a day until resolution of the pain, then once daily until
your appointment with rhematology.
We wish you a speedy recovery,
Your ___ Care Team
Followup Instructions:
___
|
10253919-DS-11 | 10,253,919 | 20,517,461 | DS | 11 | 2163-04-08 00:00:00 | 2163-04-09 13:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
LLE Erythema/Hypotension
Major Surgical or Invasive Procedure:
R IJ central line placement
History of Present Illness:
The patient is a ___ with a history of HTN, atrial fib/flutter
s/p pacemaker, and multiple DVTs on lifelong coumadin who
presents with right lower leg erythema, swelling, and pain that
began earlier this evening. He was in his usual state of health
until this subacute pain began, and he later described an
intense cold feeling as well as trembling. This prompted an ED
visit.
.
He immediately triggered on admission to the ED with a BP of
63/38, though he was otherwise afebrile with tachycarida to 100.
His BP was checked several times in the left arm, yielding
___ on each of these assays. He states that he's had
similar swelling and pain before, and that he had to do "shots
in the belly." He maintained normal mentation throughout. Labs
were notable for bandemia to 19%, lactate to 2.9, ___ to cr 1.6,
and an INR of 3.6. Trauma ultrasound revealed no bleed. CTA
chest revealed no massive PE, and no intraabdominal acute
pathology. CVL was placed and he was resuscitated with 4LNS.
Got one gram vancomycin. Placed on low dose norepinephrine with
bolstering of pressure to mid-90s systolic prior to transfer.
.
Upon arrival to the MICU, his initial vitals were T:96.3
BP:99/43 P:78 R:22 O2: 99RA. He is currently in no pain and has
no complaints. He claims to have been asymptomatic during his
hypotension, though his wife found him to be more confused than
usual. With regard to his RLE erythema, he denies previous
episodes of cellulitis. He has baseline edema without erythema
or pain bilaterally. He also mentioned urinary frequency over
the preceding ___ days without dysuria or hematuria.
Past Medical History:
1. Hypertension.
2. Osteoarthritis.
3. Benign prostatic hypertrophy status post transurethral
resection of the prostate.
4. Status post hernia repair.
5. History of depression.
Social History:
___
Family History:
NC
Physical Exam:
Vitals: T:96.3 BP:99/43 P:78 R:22 O2: 99RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no LAD, no JVD appreciated
CV: Regular rate and rhythm, normal S1 + S2, ___ SEM at the
right ___ ICS
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: +foley
Ext: diffuse erythema and warmth encompassing the right leg from
ankle to tibial tuberosity. Tender to touch. Neuro: CNII-XII
intact, ___ strength upper/lower extremities, grossly normal
sensation, 2+ reflexes bilaterally, gait deferred,
finger-to-nose intact
Pertinent Results:
Labs on admission and dc:
___ 12:54AM BLOOD WBC-8.2 RBC-4.30* Hgb-13.4* Hct-38.1*
MCV-89 MCH-31.2 MCHC-35.2* RDW-14.1 Plt ___
___ 12:54AM BLOOD Neuts-74* Bands-19 ___ Monos-4 Eos-0
Baso-0 ___ Myelos-0
___ 08:05AM BLOOD WBC-5.9 RBC-3.92* Hgb-11.8* Hct-37.0*
MCV-94 MCH-30.1 MCHC-31.8 RDW-13.9 Plt ___
___:54AM BLOOD ___ PTT-29.7 ___
___ 08:05AM BLOOD ___ PTT-30.9 ___
___ 12:54AM BLOOD Glucose-218* UreaN-32* Creat-1.6* Na-136
K-3.2* Cl-102 HCO3-23 AnGap-14
___ 08:05AM BLOOD Glucose-258* UreaN-28* Creat-1.2 Na-139
K-4.5 Cl-99 HCO3-32 AnGap-13
___ 03:56 Red Clear 1.034
DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone Bilirub
Urobiln pH Leuks
___ 03:56 LG NEG TR NEG TR NEG NEG 5.0 TR
MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE
RenalEp
___ 03:56 >182* 112* FEW NONE 1
Imaging:
TTE ___:
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The aortic root is mildly dilated at the sinus level. 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. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion. There are no echocardiographic signs of
tamponade.
IMPRESSION: Normal regional and global biventricular systolic
function. No significant valvular abnormality seen. Anterior
echo-lucent space may be due to a loculated pleural effusion or
a pericardial cyst. No evidence of tamponade.
CTA ___:
IMPRESSION:
1. Suboptimal contrast bolus with mixing artifact limits
evaluation for PE.
Within this limitation, there is no evidence of central
pulmonary embolism.
2. No acute aortic injury.
3. Approximate 9.3 cm x 3.2 cm x 7.5 cm anterior mediastinal
cystic lesion
without enhancement and with fluid density and extending to the
base of the
heart. This is most consistent with a pericardial cyst.
4. Right adrenal lesion, previously characterized as myelolipoma
or adenoma,
is unchanged since ___.
5. Uncinate process small cystic lesions as above, unchanged
since prior
examination, likely represents a small focus of side branch
IPMN.
6. Persistent cholelithiasis.
7. Unchanged fat-containing left inguinal hernia.
8. Unchanged enlarged prostate.
9. Small hiatal hernia.
___ ___:
IMPRESSION: No right lower extremity DVT.
Brief Hospital Course:
Assessment and Plan: Mr. ___ is a ___ with afib/flutter,
and ?previous DVTs who presents with RLL pain/erythema and who
was found to be profoundly hypotensive with bandemia and ___.
# SEPTIC SHOCK: Felt to be due to cellulitis and possible UTI.
Received ~ 8 liters NS for fluid resuscitation and was on
norepinephrine briefly. Started on vanc/cefepime for cellulitis
and presumed UTI. Urine culture was negative, but tx for seved
days with Ciprofloxacin as culture was obtained after antibiotic
administration. He remained in intensive care unit overnight
only.
# Cellulitis. Initially well responded to vancomycin, however
given negatie nasal swab and no evicence of abcess, was changed
to ___ was negative.
Slow but steady improvement in erytheme and induration was made
and he was transition to PO Keflext on ___. He was diuresed
with lasix for lower extremity edema and was discharged on a
week's course of lasix. ACE bandages are to be applied on daily
basis at time of discharge.
# ACUTE KIDNEY INJURY: due to hypoperfusion. Improved to 1.2
(baseline 1.1 with IVF). Lisinopril was held at discharge until
patient completes course of lasix at which point it can be
reinstituted. HCTZ was likewise held at discharge.
# ATRIAL ARRHYTHMIA: has both atrial flutter and fibrillation
patterns in previous EKGs/telemetry. According to cards notes,
spends about 35% time in atrial arrhythmia. During his ICU
stay, he remained often in atrial fibrillation although
occasionally was atrial paced or venticular paced. As patient
was diuresed his rate normalized and he remained in SR vast
majority of the time.
Multiple indicental findings on CTA:
MEDIASTINAL MASS: seen on CTA, pericardial cyst (benign).
ADRENAL NODULE: unchanged from prior exam
PROSTATIC ENLARGEMENT: stable
Transition issues:
- PO diuretics for 1 week with lab follow up
- Resumption of home lisinopril and potentially HCTZ pending
above
- Cellulitis f/u with Dr. ___.
Medications on Admission:
BUPROPION HCL - 75 mg Tablet - 1 Tablet(s) by mouth once a day
DIAZEPAM - (Prescribed by Other Provider; takes PRN only) - 10
mg Tablet - 1 Tablet(s) by mouth once a day as needed for only
PRN
DORZOLAMIDE-TIMOLOL [COSOPT] - 0.5 %-2 % Drops - 1 ggts od twice
a day
DOXAZOSIN - 2 mg Tablet - 2 Tablet(s) by mouth at bedtime
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth once a day
HYDROCHLOROTHIAZIDE - 12.5 mg Tablet - 1 Tablet(s) by mouth once
a day dispense tablet only
LATANOPROST [XALATAN] - (Prescribed by Other Provider) - 0.005 %
Drops - 1 gtt once a day
LISINOPRIL - 10 mg Tablet - 0.5 (One half) Tablet(s) by mouth
once a day
SIMVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth once a day
WARFARIN [___] - 4 mg Tablet - 1 Tablet(s) by mouth once a
day extra ___ tab 3 days per week
Discharge Medications:
1. bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. dorzolamide-timolol ___ % Drops Sig: One (1) Drop
Ophthalmic BID (2 times a day).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. doxazosin 2 mg Tablet Sig: Two (2) Tablet PO once a day.
7. diazepam 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for anxiety.
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
9. Keflex ___ mg Capsule Sig: One (1) Capsule PO three times a
day for 7 days.
Disp:*21 Capsule(s)* Refills:*0*
10. warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day.
11. warfarin 2 mg Tablet Sig: One (1) Tablet PO ___
___: in addition to 4mg tablet for total of 6mg.
12. Outpatient Lab Work
CBC, INR and Chem 7 on ___ and results to be faxed to
___.
Phone: ___
Fax: ___
13. potassium chloride 20 mEq Packet Sig: One (1) PO once a day
for 7 days.
Disp:*7 packets* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Septic shock due to cellulitis and urinary tract
infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with severe infection of your
leg and urine. You were treated in the intensive care unit
followed by treatmet for cellulitis (infection of the leg).
With antibiotics your symptoms improved although significant
amount of swelling and redness in your leg persisted.
You were given water pills to help get rid of some of the water
in your legs. In addition, you required wrapping of your legs
with ACE bandages to help get rid of the fluid.
The following changes were made to your medications.
STARTED:
- Furosemide 20mg daily for one week
- Keflex ___ three times daily
- Potassium 20 meq daily for one week
STOPPED:
- Hydrochlorothiazide
- Lisinopril (until you complete your furosemide)
Please ensure that you elevate your legs daily and wrap them
with ACE bandage.
Should you develop any symptoms concerning to you, please call
Dr. ___, ___ or go to the emergency room.
You have an appointment with Dr. ___ at the end of
___, but his office will contact you to set up a follow up
within the next week. If you don't hear from him by middle of
next week, please call his office.
Please also obtain labs to check your coumadin level next week.
Followup Instructions:
___
|
10254097-DS-6 | 10,254,097 | 27,317,316 | DS | 6 | 2138-11-10 00:00:00 | 2138-11-10 16:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Ativan / Abilify
Attending: ___
Chief Complaint:
Seizures
Major Surgical or Invasive Procedure:
Intubated ___
Extubated ___
___ guided LP
History of Present Illness:
The patient is a ___ year old woman with a past medical history
of
epilepsy (on keppra and depacote), bipolar disorder,
schizophrenia who presents as transfer from ___ for status
epilepticus. Per EMS, she began to have tonic-clonic movements
and left eye deviation approximately one hour prior to arrival.
She received 6 mg IM versed by EMS prior to ___. At ___,
she received 2 mg Ativan, 1g keppra, and was intubated for
airway
protection. SBP dropped to SBP ___ with propofol, switched to
fentanyl and versed. CT head at ___ negative. Labs notable
for
WBC 18.
Patient intubated and sedated, unable to obtain review of
systems.
Past Medical History:
Epilepsy
Bipolar disorder
Social History:
___
Family History:
Unknown
Physical Exam:
Admission Physical Exam:
Vitals: 96.8 HR 93 BP 108/46 RR 18 97% Intubation
General: sedated
HEENT: C collar in place, intubated
Pulmonary: clear anteriorly
Cardiac: RRR
Abdomen: soft, NT/ND
Extremities: purple hue in all extremities but warm with pulses
present
Neurologic:
-Mental Status: intubated and sedated
-Cranial Nerves: PERRL 3 to 2mm and brisk. +corneal, +gag
-Motor/Sensory: Normal bulk, tone throughout. When off sedation
moved forceful antigravity throughout, on sedation does not
withdraw to pinch or any noxious
Discharge
Vitals: ___ 1137 Temp: 98.0 PO BP: 135/82 R Lying HR: 92
RR:
18 O2 sat: 95% O2 delivery: Ra
Neck: supple
CV: regular rate and rhythm
Abdomen: obese, non-tender to palpation
Ext: 3+ edema in both hands and feet
movements of R > L arms and legs
Neuro:
MS- eo spont, follows commands with all extremities, appropriate
and interactive. Does not recall significant details of personal
past.
CN- Pupils 3->2 mm, brisk. EOMI but needs prompting. VFF to
confrontation. Symmetric facial activation. Tongue midline. ___
shoulder shrug.
Sensory/Motor-
RUE: 5- deltoid, 5 triceps, 5 biceps
LUE: 5- deltoid, 5 triceps, 4+ biceps
RLE: strong resistance at IP, 3 in quads. Ankles appear
contracted/plantar flexed. Wiggles toes and ankles.
LLE: strong resistance at IP,3 in quads. Ankles appear
contracted/plantar flexed. Wiggles toes and ankles.
Reflexes- deferred
Pertinent Results:
=======
IMAGING
=======
CT HEAD WITHOUT CONTRAST:
7 mm hypodensity in the right medial temporal lobe may reflect a
chronic infarct (02:14). Asymmetric hypodensity along the left
medial
frontal lobe in the ACA territory appears well-defined and
measures up to 2.7 cm in AP dimension (02:23). This is not have
the typical appearance of an acute infarction is likely
artifactual in nature. Otherwise, no
evidence of hemorrhage or edema. The ventricles and sulci are
prominent,
greater than expected for age.
There is extensive paranasal sinus disease involving the
bilateral maxillary sinuses, ethmoid air cells, and sphenoid
sinuses. Middle ear cavities and mastoid air cells are clear.
Visualized portions of the orbits are unremarkable.
Evaluation of the head and neck vessels is suboptimal in the
setting of poor contrast bolus timing. Within this limitation:
CTA HEAD: Visualized vessels of the circle of ___ are grossly
patent without evidence of high-grade stenosis, occlusion, or
aneurysm
formation.
CTA NECK: The visualized carotid and vertebral arteries appear
patent within the limits of this examination without evidence of
flow-limiting stenosis or occlusion.
OTHER: Bilateral upper lobe airspace opacities are incompletely
evaluated and may reflect either atelectasis or pneumonia.
Echocardiogram ___: CONCLUSION: The left atrial volume index
is normal. There is mild symmetric left ventricular hypertrophy
with a normal cavity size. There is normal regional and global
left ventricular systolic
function. Quantitative biplane left ventricular ejection
fraction is 70 %. There is no resting left ventricular outflow
tract gradient. There is Grade I diastolic dysfunction. Normal
right ventricular cavity
size with normal free wall motion. The aortic sinus is mildly
dilated with normal ascending aorta diameter for gender. The
aortic valve leaflets (3) appear structurally normal. There is
no aortic valve stenosis. There is no aortic regurgitation. The
mitral valve leaflets are mildly thickened with no mitral valve
prolapse. There is trivial mitral regurgitation. The pulmonic
valve leaflets are normal. The tricuspid valve leaflets appear
structurally normal. There is physiologic tricuspid
regurgitation. The
pulmonary artery systolic pressure could not be estimated. There
is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global biventricular systolic
function. No significant valvular regurgitation or stenosis
detected. Mildly dilated aortic root.
MRI Head ___
IMPRESSION:
1. No evidence of intracranial hemorrhage, masses, or
infarction.
2. Opacification of the paranasal sinuses and mastoid air cells,
likely from intubation.
MRI C/T/L spine: ___:
IMPRESSION:
1. Normal appearance of the spinal cord and conus medullaris.
2. In the cervical spine, there is mild spinal canal narrowing
at C4-C5 and C5-C6 without spinal cord contact, and moderate
right C5-C6 and C6-C7 neural foraminal narrowing.
3. In the lumbar spine, there is mild narrowing of the thecal
sac without mass effect on the intrathecal nerve roots. At
L2-L3 and L3-L4, traversing nerve roots are contacted in the
subarticular zones. At L4-L5, exiting left L4 nerve root is
contacted in the moderately narrowed neural foramen. At L5-S1,
traversing right S1 nerve root is displaced by disc protrusion.
4. T2 and STIR hyperintensity of the medial aspect of the right
psoas muscle and of the bilateral posterior paravertebral
muscles, superimposed upon fatty atrophy. Diagnostic
considerations include myositis of uncertain etiology.
Denervation injury is less likely given the diffuse
distribution.
Rhabdomyolysis may be considered in an appropriate clinical
setting.
====
LABS
====
___ 03:50AM BLOOD WBC-16.3* RBC-4.94 Hgb-15.5 Hct-51.3*
MCV-104* MCH-31.4 MCHC-30.2* RDW-14.2 RDWSD-55.1* Plt ___
___ 10:06AM BLOOD WBC-15.6* RBC-4.64 Hgb-14.5 Hct-48.5*
MCV-105* MCH-31.3 MCHC-29.9* RDW-14.4 RDWSD-56.1* Plt ___
___ 12:45AM BLOOD WBC-23.4* RBC-4.02 Hgb-12.8 Hct-42.0
MCV-105* MCH-31.8 MCHC-30.5* RDW-14.6 RDWSD-56.0* Plt ___
___ 03:40AM BLOOD WBC-14.5* RBC-4.06 Hgb-12.7 Hct-43.5
MCV-107* MCH-31.3 MCHC-29.2* RDW-14.5 RDWSD-57.4* Plt ___
___ 12:05AM BLOOD WBC-7.3 RBC-3.41* Hgb-10.8* Hct-36.1
MCV-106* MCH-31.7 MCHC-29.9* RDW-14.6 RDWSD-57.4* Plt ___
___ 12:05AM BLOOD WBC-10.6* RBC-3.74* Hgb-11.8 Hct-39.3
MCV-105* MCH-31.6 MCHC-30.0* RDW-14.3 RDWSD-55.0* Plt ___
___ 06:08AM BLOOD WBC-8.1 RBC-3.53* Hgb-11.4 Hct-37.1
MCV-105* MCH-32.3* MCHC-30.7* RDW-15.3 RDWSD-55.3* Plt ___
___ 02:38PM BLOOD WBC-8.8 RBC-3.72* Hgb-11.8 Hct-38.8
MCV-104* MCH-31.7 MCHC-30.4* RDW-16.0* RDWSD-56.1* Plt ___
___ 03:50AM BLOOD Glucose-150* UreaN-9 Creat-0.6 Na-144
K-5.0 Cl-104 HCO3-22 AnGap-18
___ 03:40AM BLOOD Glucose-116* UreaN-4* Creat-0.3* Na-149*
K-3.6 Cl-113* HCO3-24 AnGap-12
___ 05:00PM BLOOD Glucose-147* UreaN-10 Creat-0.3* Na-144
K-3.5 Cl-103 HCO3-32 AnGap-9*
___ 02:38PM BLOOD Glucose-148* UreaN-3* Creat-0.3* Na-146
K-4.2 Cl-106 HCO3-30 AnGap-10
___ 03:50AM BLOOD ALT-17 AST-31 CK(CPK)-511* AlkPhos-74
TotBili-0.3
___ 12:45AM BLOOD CK(CPK)-286*
___ 01:07AM BLOOD CK(CPK)-57
___ 03:50AM BLOOD CK-MB-3 cTropnT-0.04* proBNP-195
___ 10:06AM BLOOD CK-MB-4 cTropnT-0.02*
___ 03:50AM BLOOD Albumin-3.6 Calcium-9.3 Phos-3.8 Mg-1.8
___ 12:45AM BLOOD Calcium-8.5 Phos-2.1* Mg-2.8*
___ 01:07AM BLOOD Albumin-2.6* Calcium-8.7 Phos-2.4* Mg-1.8
___ 02:38PM BLOOD Calcium-9.4 Phos-2.9 Mg-2.1
___ 10:57PM BLOOD %HbA1c-6.1* eAG-128*
___ 01:07AM BLOOD Triglyc-186*
___ 04:50AM BLOOD Ammonia-<10
___ 01:07AM BLOOD Osmolal-296
___ 01:07AM BLOOD TSH-0.93
___ 01:07AM BLOOD TSH-0.93
___ 06:08AM BLOOD Valproa-61
___ 02:38PM BLOOD Valproa-65
=================
ELECTROPHYSIOLOGY
=================
-___ EEG
IMPRESSION: This is an abnormal continuous ICU EEG monitoring
study because of severe diffuse background slowing and voltage
attenuation, with
superimposed frontally maximal fast frequencies sometimes with a
spindle-like appearance. These findings are indicative of severe
diffuse cerebral
dysfunction, which is nonspecific as to etiology. Common causes
include toxic and metabolic encephalopathies, drug effects, and
infections. In this case, the frontal fast frequencies suggest
some component of drug effect. No epileptiform discharges or
electrographic seizures are present.
-___ EEG
IMPRESSION: This is an abnormal continuous ICU EEG monitoring
study because of generalized slowing of background indicative of
moderate-severe
encephalopathy. Common causes include toxic and metabolic
encephalopathies, drug effects, and infections. There are no
focal slowing, epileptiform discharges, or electrographic
seizures. Compared to the prior day's recording, the background
is slightly improved.
-___ EEG
IMPRESSION: This is an abnormal continuous ICU EEG monitoring
study because of generalized slowing of background indicative of
a moderate-severe encephalopathy. Common causes include toxic
and metabolic encephalopathies, drug effects, and infections.
There are no focal findings, epileptiform discharges, or
electrographic seizures. Compared to the prior day's recording,
there is no significant change.
-___ EEG
Pending
-___ EEG
IMPRESSION: This is an abnormal continuous ICU EEG monitoring
study because of intermittent slowing in the left temporal lobe,
indicative of cerebral dysfunction in this region. Mild slowing
of posterior dominant rhythm is indicative of mild
encephalopathy, which is nonspecific as to etiology. Common
causes include toxic and metabolic encephalopathies, drug
effects, and infections. There are no epileptiform discharges or
electrographic seizures. Compared to the prior day's recording,
background is improved, but focal slowing in the left temporal
region is now apparent.
Brief Hospital Course:
___ with history of adult-onset epilepsy (on levetiracetam and
valoproate), bipolar disorder, HTN and ___
transferred from ___ with seizure and concern for
convulsive status epilepticus. Patient was intubated for airway
protection on ___ and admitted to the TSICU. Later transferred
to NeuroICU. Due to concern for meningitis, patient was started
on empiric meningitis coverage. After 2 failed LP attempts at
bedside, patient underwent ___ guided LP, which was negative for
bacterial meninigitis or HSV. She was found to have Moraxella
CAP and Enterobacter UTI treated with continued vancomycin and
ceftriaxone. She briefly required pressor support on Neo.
Patient extubated on ___. She was diuresed with Lasix but was
hypotensive and required pressor support for another day. She
was transferred to the floor overnight on ___ and monitored
until ___ without any significant events.
# Moraxella PNA and Citrobacter UTI treated with 4 days of
vancomycin and 7 days of ceftriaxone.
#Seizures - Likely due to Moraxella PNA and Citrobacter UTI. No
structural cause on MRI found. Monitored on EEG without further
seizures.
- Valproate increased from 500mg ___ ___ to 1000mg BID.
- Increased Keppra from 750mg BID to ___ BID
#Positive blood culture
- ___ BC bottles growing GPCs in clusters
- was already on Vanc
- repeat BCx negative
#Chronic Leg Weakness - Patient did not recall reason for her
leg weakness which has been present for ___ years per patient.
MRI pan-spine did not show any lesions which would fully explain
the extent of weakness.
#A-Fib with RVR
- briefly overnight in neuroICU
- converted to SR after metoprolol 5 mg x2 and diltiazem 5 mg
x1.
- No further episodes on telemtry
- started on metoprolol 12.5 mg Q8
- likely in setting of acute illness; did not start
anticoagulation
Transitional Issues:
[] ___ need holter for long-term monitor for AFib
[] F/u with PCP ___ ___ weeks
[] Will arrange follow-up with ___ Epilepsy (call ___
if not contacted in next week)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LevETIRAcetam 750 mg PO BID
2. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
3. Divalproex (DELayed Release) 500 mg PO BID
4. Atenolol 25 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Pravastatin 40 mg PO QPM
7. Omeprazole 20 mg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
9. Milk of Magnesia 30 mL PO Q6H:PRN constipation
10. Bisacodyl 10 mg PR ___ Constipation - Second Line
11. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
Discharge Medications:
1. Divalproex (DELayed Release) 1000 mg PO BID
RX *divalproex [Depakote] 500 mg 2 tablet(s) by mouth twice a
day Disp #*120 Tablet Refills:*2
2. LevETIRAcetam Oral Solution 1000 mg PO Q12H
RX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*2
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. Atenolol 25 mg PO DAILY
5. Bisacodyl 10 mg PR ___ Constipation - Second Line
6. FoLIC Acid 1 mg PO DAILY
7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
8. Milk of Magnesia 30 mL PO Q6H:PRN constipation
9. Omeprazole 20 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
11. Pravastatin 40 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Status epilepticus
Secondary diagnoses:
Pneumonia
Urinary tract infection
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear ___,
You were admitted due to continuous seizures in the setting of
pneumonia and urinary tract infection. You underwent CT and MRI
scans of your head which did not show acute abnormalities which
could cause your seizures. You had an ___ lumbar puncture
to get a sample of your spinal fluid, which tested negative for
bacterial infection.
Your infections were treated by antibiotics.
We also performed an MRI of your spine to look for causes of
your leg weakness, but did not find any explanation. This is
chronic. Please contact your PCP to discuss your medical record.
Your medications were changed as follows:
Increased Keppra to 1000mg twice per day
Increased Depakote to 1000mg twice per day
Please take your medications as prescribed.
Thank you for the opportunity to participate in your care.
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10254384-DS-12 | 10,254,384 | 25,500,237 | DS | 12 | 2125-02-13 00:00:00 | 2125-02-13 13:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ___
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Alcohol intoxication, abd pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of EtOH use disorder, opioid use disorder, HCV
presenting with EtOH intoxication/withdrawal. History is
obtained
from transfer and ED records, as pt is somnolent at time of
arrival to the floor ___ diazepam then phenobarbital
administered
in the ED. Per EMS run sheet, pt was found sitting in the lobby
of the fire station, awake and alert, stating, "I want to go to
detox." VS were HR 140, BP 160/100, 97% RA. At that time, he
stated that he had not had a drink x 24h, although he
subsequently stated that his last drink was the day of
presentation. Per EMS run sheet, was he was noted to have
"dyskinetic movements, slow response, dilated pupils, and
tremor." He denied HA, lightheadedness, dizziness, chest pain,
SOB, N/V, but endorsed lower abdominal pain x3 days. Pupils were
documented as asymmetric at that time. EMS was unable to place
IV, and pt apparently endorsed long history of IVDU, with dx of
HCV. Pt was transferred to ___ ED for further
care.
Notes from ED suggests that pt reported fall onto a chair,
landing on his stomach, in day prior to presentation.
Labs at ___ were notable for WBC 15.2, Hb 12.2,
plt
156, BUN 12, Cr 0.7, ALT 155, AST 339, Tbili 2.2, Dbili 1.4, alk
phos 204. Lipase 3859, Serum EtOH 143, negative for salicylates,
negative for acetaminophen. VBG 7.43/46.
Imaging at ___ including CT abd/pelvis revealed:
"1. Mild diffuse peripancreatic stranding consistent with
pancreatitis.
2. Mild edema around the head of the pancreas. Pancreatic head
1.7 cm x 2 cm hypointense area across the full width of the
pancreatic head, which may be due to the pancreatitis, but
transection of the pancreas cannot be entirely excluded. If the
patient is able, MRI abdomen without and with contrast is
recommended.
3. Diffuse hepatic steatosis.
4. Two short segment (4 cm long) intussusceptions in the small
bowel without obstruction, likely transient."
Head/cervical spine CT ___:
Cervical spine findings:
The bony rings of C1 through C7 are intact, without fracture or
dislocation. Vertebral body heights are preserved.
Straightening of the normal cervical lordosis is likely
positional or due to spasm.
Intervertebral disc spaces heights are preserved.
Prevertebral soft tissues and the atlantodens interval are
within
normal limits.
The cervical soft tissues are normal. The lung apices
demonstrate biapical scarring and emphysematous changes.
Cervical spine impression:
1. No acute fracture or subluxation in the cervical spine.
2. Straightening of the normal cervical lordosis, which is
either positional or due to spasm.
Chest x-ray ___:
Impression:
No acute abnormality or significant change.
Given concern for possible pancreatic transection, pt was
transferred to ___ for further surgical evaluation.
Prior to transfer to the ___ ED, he received Tdap, 2 L IV
fluid, Ativan 2 mg IV x2
In the ___ ED:
VS 99.2, 122, 144/91, 97% RA
Exam notable for complete spinal midline tenderness, soft
abdomen
with focal tenderness in epigastric area
Labs notable for WBC 12.0, Hb 11.1, Plt 117, ALT 111, AST 269,
alk phos 169, Tbili 2.3, lipase 520
INR 1.3
BUN 11, Cr 0.5, lactate 1.7
Mg 1.4
Imaging:
CTA torso:
1. Findings consistent with acute interstitial edematous
pancreatitis. No
evidence of pancreatic laceration.
2. Reactive periportal and peripancreatic lymphadenopathy.
3. Interval resolution of left upper quadrant small bowel
intussusception,
confirming transient etiology.
4. Persistent short segment right lower quadrant small bowel
intussusception,
which may be transient.
5. Likely hepatic steatosis.
Received:
IVF - per ___, 1L only, but per RN and MD discussion, received
3L
Diazepam 10 mg
Phenobarbital 780 mg (10 mg/kg)
Mg sulfate 4 gm
Evaluated by trauma surgery - no surgical concerns, ok to d/c
c-collar, no evidence of pancreatic transection.
On arrival to the floor, patient is somnolent, denying pain,
minimally interactive.
Past Medical History:
opioid use disorder
alcohol dependence
HCV
Social History:
___
Family History:
reviewed, non-contributory to current hospitalization
Physical Exam:
GEN: young male, disheveled, NAD, alert
HEENT: Pupils are dilated, anisocoria with L>R pupil, both
pupils
reactive to light and accommodation, anicteric, MMM
LYMPH: no anterior/posterior cervical, supraclavicular
adenopathy
CARDIOVASCULAR: borderline tachycardic, no murmurs, rubs, or
gallops
LUNGS: clear to auscultation bilaterally without rhonchi,
wheezes, or crackles posteriorly
GI: soft, Non-tender,
normoactive bowel sounds, no rebound or guarding
EXTREMITIES: no clubbing, cyanosis, or edema
GU: no foley
SKIN: multiple tattoos, small scab at R forehead, multiple
pinpoint scabs over dorsum of bilateral hands, no splinter
hemorrhages or apparent track marks; warm to palpation
NEURO: A/Ox3, move all extremities
Pertinent Results:
___ 06:05AM BLOOD WBC-4.9 RBC-3.25* Hgb-9.8* Hct-29.5*
MCV-91 MCH-30.2 MCHC-33.2 RDW-14.6 RDWSD-48.5* Plt Ct-87*
___ 06:05AM BLOOD Plt Ct-87*
___ 05:35AM BLOOD Glucose-97 UreaN-7 Creat-0.5 Na-138 K-4.2
Cl-103 HCO3-26 AnGap-9*
___ 05:35AM BLOOD ALT-64* AST-144* AlkPhos-161*
TotBili-2.0*
___ 06:05AM BLOOD Lipase-110*
___ 05:35AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.0
EXAMINATION: CTA TORSO
INDICATION: ___ hx of EtOH abuse, now s/p fall from standing,
concern for
pancreatic injury// Triple phase abdominal CT with pancreatic
protocol.
Concern for traumatic pancreatic injury.
TECHNIQUE: Chest, abdomen, and pelvis CTA: Later arterial
post-contrast
images were acquired through chest, abdomen, and pelvis.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation
and reviewed on
PACS.
DOSE:
Total DLP (Body) = 985 mGy-cm.
COMPARISON: CT from outside institution ___.
FINDINGS:
VASCULAR:
The celiac axis, SMA, ___, renal and iliac arteries and their
major branches
are patent with no signs of occlusive or aneurysmal disease. The
portal system
including SMV, splenic and portal veins is patent. The renal
veins, iliac
veins and IVC are patent and demonstrate normal caliber.
There is no abdominal aortic aneurysm. There is minimal calcium
burden in the
abdominal aorta and great abdominal arteries.
CHEST: The thoracic aorta and great vessels are within normal
limits. The
heart is within normal size. No axillary, mediastinal or hilar
lymphadenopathy. The lungs are clear without masses or
opacifications. No
pleural effusion. No appreciable pneumothorax. No acute
fracture is seen.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates decreased attenuation
throughout. There
is no evidence of focal lesions. There is no evidence of
intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within
normal limits,
without stones or gallbladder wall thickening. There are
enlarged periportal
and peripancreatic lymph nodes, possibly reactive.
PANCREAS: The pancreas enhances homogeneously, however there is
peripancreatic
fat stranding, predominately around the pancreatic head
concerning for acute
pancreatitis. No evidence of peripancreatic fluid collections.
No definite
evidence of pancreatic laceration.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram.
There is no evidence of stones, focal renal lesions, or
hydronephrosis. There
are no urothelial lesions in the kidneys or ureters. There is no
perinephric
abnormality.
GASTROINTESTINAL: A left upper quadrant small bowel jejunal
intussusception
seen on prior study from same day is resolved. A right lower
quadrant small
bowel short-segment intussusception approximately 3 cm is again
visualized
(2:179, 603:23). Otherwise, the remaining small bowel loops
demonstrate
normal caliber, wall thickness and enhancement throughout. Colon
and rectum
are within normal limits. There is no evidence of mesenteric
lymphadenopathy.
RETROPERITONEUM: There is no evidence of retroperitoneal
lymphadenopathy.
PELVIS: The urinary bladder is homogeneous opacified from
excreted IV contrast
from prior study. The distal ureters are unremarkable. There
is no evidence
of pelvic or inguinal lymphadenopathy. There is no free fluid
in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are
grossly
unremarkable.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. Findings suggest acute pancreatitis. No definite evidence of
pancreatic
laceration.
2. Likely reactive periportal and peripancreatic
lymphadenopathy.
3. Interval resolution of left upper quadrant small bowel
intussusception,
confirming transient etiology.
4. Persistent short segment right lower quadrant small bowel
intussusception,
which may be transient.
5. Likely hepatic steatosis.
Brief Hospital Course:
___ with hx of EtOH use disorder, opioid use
disorder, HCV presenting with EtOH intoxication/withdrawal and
acute pancreatitis.
# Abdominal pain:
# Acute pancreatitis:
# EtOH use disorder with intoxication, then withdrawal:
# Alcoholic hepatitis: last drink ___ out. Received appropriate
10 mg/kg phenobarbital load in ED, after diazepam 10 mg -
reviewed with pharmacy prior to administration of phenobarbital.
mental status is now alert and responds appropriately. CT
imaging
and labs suggestive of both acute pancreatitis as well as
alcoholic hepatitis. BISAP score is 2, although difficult to
intermittent in setting of concomitant EtOH withdrawal.
Discriminant function <32.
Utox in fact negative for meth/opioids/cocaine
Addiction psych consult apprec
- CIWA no score >24hrs, dc
- Social work consult
- Addiction psych consulted
- MVI/folate/thiamine
- start buprenorphine 2mg BID per psych
- start acamprosate 333mg TID per psych, outpatient provider to
transition to 666 TID in a few days
#HypoK
#HypoMag
-replete
# HCV: Per EMS run sheet, pt reported hx of HCV.
- LFTs downtrending
- Will need outpatient hepatology/ID f/u
# Thrombocytopenia: In setting of alcoholic hepatitis.
- Trend platelets
GENERAL/SUPPORTIVE CARE:
# Nutrition/Hydration: low fat diet
# Bowel Function: senna
# Lines/Tubes/Drains: PIVs
# VTE prophylaxis: Heparin sc
# Consulting Services: SW
# Contacts/HCP/Surrogate and Communication: ___
___ - none working number
# Code Status/ACP: presumed Full
# Disposition:
- Anticipate discharge to: home
- Anticipated discharge date: ___
___, MD
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amphetamine-Dextroamphetamine 30 mg PO BID
2. Gabapentin 600 mg PO TID
3. Hydrochlorothiazide 25 mg PO DAILY
4. Mirtazapine 15 mg PO QHS
5. Naloxone Nasal Spray 4 mg IH Frequency is Unknown
6. CloNIDine 0.2 mg PO TID
7. HydrOXYzine 50 mg PO TID
Discharge Medications:
1. Acamprosate 333 mg PO TID
RX *acamprosate 333 mg 1 tablet(s) by mouth three times a day
Disp #*21 Tablet Refills:*0
2. Buprenorphine 2 mg SL BID
3. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Nicotine Patch 21 mg/day TD DAILY
RX *nicotine 21 mg/24 hour take 1 patch daily, take off old
patch daily Disp #*28 Patch Refills:*0
6. Thiamine 100 mg PO TID
RX *thiamine HCl (vitamin B1) [Vitamin B-1] 100 mg 1 tablet(s)
by mouth daily Disp #*30 Tablet Refills:*0
7. Naloxone Nasal Spray 4 mg IH ONCE opioid overdose Duration:
1 Dose
8. Amphetamine-Dextroamphetamine 30 mg PO BID
9. CloNIDine 0.2 mg PO TID
10. Gabapentin 600 mg PO TID
11. Hydrochlorothiazide 25 mg PO DAILY
12. HydrOXYzine 50 mg PO TID
13. Mirtazapine 15 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Alcoholic pancreatitis
Alcoholic hepatitis
Alcohol withdrawal
Opioid use disorder
Discharge Condition:
Good, ambulatory without assist
Discharge Instructions:
Mr. ___,
You were admitted to the hospital due to alcoholic
pancreatitis/hepatitis, and alcohol withdrawal. Your
pancreatitis resolved with IV fluids, and your alcoholic
hepatitis is improving. We treated your alcohol withdrawal with
phenobarbitol and Ativan. You are now completely detox'ed from
alcohol. Please do not drink any more alcohol, and take
acamprosate as prescribed.
Our addiction team evaluated you, and restarted you back on
suboxone for opioid use disorder.
Followup Instructions:
___
|
10254837-DS-19 | 10,254,837 | 29,440,753 | DS | 19 | 2189-12-23 00:00:00 | 2189-12-27 21:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / Cymbalta / trazodone
Attending: ___.
Chief Complaint:
Malaise/Fatigue/Cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with past medical history Type II DM,
hypertension, hyperlipidemia, OSA on CPAP, ?bipolar disorder,
fibromyalgia, obestiy s/p gastric bypass ___, non-ischemic
cardiomyopathy EF ___, presenting with a one week
history of progressive cough, fevers, chills, night sweats.
Cough is dry but has also been productive of green/minimal dry
blood. This developed over days and did not occur suddenly.
These symptoms were associated with malaise as well as
arthralgias and myalgias. She has noted decreased appetite and
notes the smell of food makes her nausous. She has had headache
as well. During the week she had minimal dyspnea on exertion
which has improved. She initialy thought this was related to a
fibromyalgia flare, but given that symptoms did not improve she
came to ___ ED for further evaluation/management. She denies
leg swelling, erythema in the lower extremities, or recent
travel. She does have chest discomfort (subcostal), flank
discomfort, and epigastric discomfort when she coughs. Also has
dizziness when getting up from a seated position.
She denies dysuria, chest pain, chest pressure, vomiting,
numbness or weakness in any of the extremities. She does have a
known sick contact with her grandson living at home who had
similar symptoms.
In the ED, initial vitals were: 98.2, 78, 134/77, 22, 98% on
RA. In the ED: labs were notable for urinalysis showed neg
leuks, neg nitrite, trace protein, few bacteria. Pro-BNP 2,705,
D-dimer 944. Troponin negative x 1. FluAPCR, FluBPCR negative.
Chemistry panel normal except for creatinine 1.6 (baseline
1.4-1.5). CBC notable for H/H 10.7/32.8 (baseline 12.6/39.7).
CXR obtained which showed cardiomegaly, pulmonary edema, and
probable multifocal pneumonia. Preliminary bilateral lower
extremity ultrasound shoed "1.no acute deep venous thrombosis in
the bilateral lower extremity veins. 2. Right ___ cyst."
Given ___, deferred CTA given risk of contrast nephropathy.
In the ED: patient received ceftriaxone 1 gram IV x 1,
azithromycijn 500 mg IV x 1. Patient received dilaudid 0.25 mg
IV x 1, morphine sulfate 5 mg IV x2, acetaminophen 650 mg PO x
1, ondansetron 4 mg IV x 1.
On the floor, patient continues to have cough. She believes she
is feeling much better than she did in the Emergency Department.
Pain is better controlled and hear weakness/fatigue has
improved. She currently feels thirsty.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia,+
Hypertension
2. CARDIAC HISTORY: Non ischemic cardiomyopathy, idiopathic, EF
___ on this admission
3. OTHER PAST MEDICAL HISTORY:
PELVIC INFLAMMATORY DISEASE
PELVIC PAIN (FEMALE), UNSPEC
BIPOLAR I DISORDER, MOST RECENT EPISODE MIXED MH
ARTHRALGIA - HAND
ARTHRALGIA - KNEE
TOBACCO DEPENDENCE
NONUNION OF FRACTURE - L SCAPHOID
FIBROMYALGIA
NEUROPATHY, UNSPEC
OSTEOARTHRITIS, LOCALIZED PRIMARY - KNEE
Achilles Tendinitis
Morbid Obesity
Fibroids, intramural
CHF (congestive heart failure)/Cardiomyopathy
Renal insufficiency
___: Community acquired pneumonia.
Social History:
___
Family History:
Mother with glaucoma, Aunt with diabetes, no family history of
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vital Signs: 99.0, 137/82, 77, 18, 100% on RA.
General: Alert and orietned x 3. Coughing intermittently during
examination leading to grimace as causes pain.
HEENT: Sclera anicteric, dry mucous membrane, oropharynx clear,
pinpoint pupils, EOMI, neck supple, JVP not elevated.
CV: RRR, S1 and S2 present, ___ murmur at apex.
Lungs: Right lower lobe crackles, rest of lung examination clear
to auscultation with no wheezes, rales or rhonchi.
Abdomen: soft, surgical laparoscopic scars from previous
gastgric bypass surgery, muscle tenderness in epigastric and
flank.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no pitting edema in the
lower extremities.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally.
DISCHARGE PHYSICAL EXAM
=======================
Vitals: 98.5, 122/99, 74, 18, 99% on RA.
General: Alert and orietned x 3. Not coughing during physical
examination.
HEENT: Sclera anicteric, moist mucous membranes, no elevated
JVD.
CV: RRR, S1 and S2 present, ___ murmur at apex.
Lungs: Right lower lobe crackles, rest of lung examination clear
to auscultation with no wheezes, rales or rhonchi.
Abdomen: soft, surgical laparoscopic scars from previous
gastgric bypass surgery. Subcostal muscles non-tender to
palpation.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no pitting edema in the
lower extremities.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally.
Pertinent Results:
ADMISSION LABS
==============
___ 06:43AM BLOOD WBC-6.4 RBC-4.30 Hgb-10.7* Hct-32.8*
MCV-76*# MCH-24.8*# MCHC-32.5 RDW-16.0* Plt ___
___ 06:43AM BLOOD Neuts-72.8* ___ Monos-4.8
Eos-4.2* Baso-0.2
___ 06:43AM BLOOD Plt ___
___ 06:43AM BLOOD ___ PTT-26.1 ___
___ 06:43AM BLOOD Glucose-99 UreaN-18 Creat-1.6* Na-138
K-3.7 Cl-102 HCO3-24 AnGap-16
DISCHARGE LABS
==============
___ 06:43AM BLOOD WBC-6.4 RBC-4.30 Hgb-10.7* Hct-32.8*
MCV-76*# MCH-24.8*# MCHC-32.5 RDW-16.0* Plt ___
___ 09:05AM BLOOD Glucose-159* UreaN-19 Creat-1.5* Na-137
K-4.0 Cl-104 HCO3-22 AnGap-15
___ 09:05AM BLOOD Calcium-8.8 Phos-4.7* Mg-1.9
LIVER STUDIES
=============
___ 06:43AM BLOOD ALT-14 AST-27 AlkPhos-59 TotBili-1.0
___ 06:43AM BLOOD Lipase-20
CARDIOLOGY STUDIES
==================
___ 06:43AM BLOOD proBNP-2705*
___ 06:43AM BLOOD cTropnT-0.01
ANEMIA LABS
===========
D-DIMER
=======
___ 06:43AM BLOOD D-Dimer-838*
___ 06:43AM BLOOD D-Dimer-944*
URINE STUDIES
=============
___ 01:45PM URINE Color-Yellow Appear-Hazy Sp ___
___ 01:45PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 01:45PM URINE RBC-1 WBC-3 Bacteri-FEW Yeast-NONE Epi-9
___ 01:45PM URINE CastHy-3*
FLU STUDIES
===========
___ 07:49AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
MICROBIOLOGY
============
___ 6:43 am BLOOD CULTURE
Blood Culture, Routine (Pending): PENDING AT THE TIME OF
DISCHARGE.
IMAGING
=======
___: CHEST (PA AND LATERAL)
FINDINGS:
PA and lateral views the chest provided demonstrate persistent
moderate
cardiomegaly. Scattered pulmonary opacities are noted most
confluent in the right lower lung which could reflect multifocal
pneumonia versus asymmetric pulmonary edema. No large pleural
effusions are seen. Mediastinal contour is normal. Bony
structures are intact.
IMPRESSION:
Cardiomegaly, pulmonary edema and probable multifocal pneumonia.
___: VENOUS DUPLEX BILATERAL LOWER EXTREMITIES
FINDINGS:
There is normal compressibility, flow and augmentation of the
bilateral common femoral, superficial femoral, and popliteal
veins. Normal color flow and compressibility are demonstrated in
the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral
veins bilaterally.
There is a right medial popliteal fossa (___) cyst. No left
medial
popliteal fossa (___) cyst.
IMPRESSION:
1. No acute deep venous thrombosis in the bilateral lower
extremity veins.
2. Right ___ cyst.
Brief Hospital Course:
___ year old female with past medical history Type II DM,
hypertension, hyperlipidemia, OSA on CPAP, ?bipolar disorder,
fibromyalgia, obestiy s/p gastric bypass ___, non-ischemic
cardiomyopathy EF ___, presenting with a one week
history of progressive cough, fevers, chills, night sweats with
chest X-ray notable for right lower lobe consoldiation
consistent with community acquired pneumonia.
#Community Acquired Pneumonia: Ms. ___ presented with seven
day history of progressive cough in setting of fevers, chills,
night sweats, myalgias and CXR showing right lower lobe
consolidation. Given that she lives at home and has not been
hospitalized recently she was treated for community acquired
pneumonia. She was initially started on ceftriaxone and
azithromycin during hospitalization, with subsequent transition
to PO levofloxacin. End date for levofloxacin will be ___.
To suppress the cough, she was treated with guaifenesin-codeine.
After initial treatment with antibiotics and cough suppressant,
her symptoms improved. Ambulatory oxygen saturation at the time
of discharge was 98-100% on RA.
#Elevated D-Dimer: As part of work-up for Ms. ___ cough,
she underwent D-dimer which was 944. She underwent ultrasound of
the bilateral lower extremities which did not reveal evidence of
DVT. A CTA was deferred as patient has history of chronic kidney
disease with creatinine of 1.5-1.6. Also, patient's Wells score
was questionably 1, with question of hemoptysis. As noted above,
she symptomatically improved with antibiotics and cough
suppression, with no evidence of chest pain. As noted above,
ambulatory oxygen saturation was 98-100% on RA.
#Non-ischemic cardiomyopathy (___): ___ EF: ___. Thought
to be non-ischemic as previous workup at ___ negative for acute
cause of the decreased EF. Elevated BNP with proBNP 2,705. She
was continued on carvedilol 12.5 mg PO BID, furosemide 60 mg PO
PRN:dyspnea/leg swelling. Her valsartan was held during
hospitalization initially due to elevated creatinine. At the
time of discharge, Ms. ___ blood pressure was well
controlled without the valsartan 320 mg PO daily. Given that
patient has a history of heart failure with reduced ejection
fraction, it will be critical to remain on an ___. This will
need to be addressed as an outpatient after improvement of her
blood pressure (blood pressure was likely decreased in the
setting of acute illness). This will need to be titrated along
with carvedilol to her blood pressure. She appeared euvolemic
during hospitalization.
#Anemia: H/H 10.4/33.3. This is below baseline from prior H/H
prior to her gastric bypass surgery. Given microcytic anemia s/p
gastric bypass surgery, there was concern regarding nutritional
deficiency as a cause of the anemia. Vitamin B12 normal at 549,
folate normal at 16.8. Iron studies were notable for a ferritin
of 74 and total serum iron of 27. This is consistent with iron
deficiency anemia. Patient will require outpatient colonoscopy
to evaluate for microcytic anemia. She may require iron
supplementation as well.
#Acute on Chronic Kidney Disease: Secondary to hypertension.
Creatinine on admission 1.6. Baseline 1.4-1.5. Likely in the
setting of poor PO intake given illness. Creatinine downtrended
after gentle hydration. As noted above, valsartan was
discontinued in the setting of well controlled blood pressure
without the valsartan. Re-starting valsartan will need to be
re-addressed as an outpatient given her history of heart failure
with reduced ejection fraction.
Transitional Issues
====================
[]f/u with PCP to ensure resolution of pneumonia and to titrate
blood pressure meds; pt's valsartan was held while inpatient due
to ___, and continued to be held as pt was normotensive off of
it. Was discharged off valsartan given normal BPs, although will
require valsartan as outpatient given history of heart failure
with reduced ejection fraction.
[]recommend further evaluation of anemia as outpatient; no
evidence of active bleeding during admission. Please consider
colonoscopy given evidence of iron deficiency anemia.
[]f/u with cardiologist (Dr. ___ for continued management of
her non-ischemic cardiomyopathy including the need to re-start
valsartan and downtitrate medication.
# CODE: Full Code
# CONTACT: ___ (daughter) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Acetaminophen 1000 mg PO TID:PRN pain
3. Valsartan 320 mg PO DAILY
4. Amlodipine 5 mg PO DAILY
5. Furosemide 60 mg PO DAILY:PRN volume overload
6. Carvedilol 12.5 mg PO BID
7. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO TID:PRN pain
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. Furosemide 60 mg PO DAILY:PRN volume overload
7. Levofloxacin 500 mg PO Q24H Duration: 5 Days
8. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Community Aquired Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
It was a pleasure caring for you during your admission to ___
___. You were admitted for
evaluation of ongoing cough, fever and were found to have
pneumonia. You were started on antibiotics while you were in
the hospital. You will be discharged on an antibiotic that you
need to take for 5 more days (take your first dose on ___.
One of you blood pressure medications (Valsartan) was stopped.
It was not restarted as your blood pressures were normal.
Please touch base with your primary care physician about
restarting your Valsartan. Should you develop worsening
shortness of breath, fevers or chest pain, please ___ to your
nearest ED for evaluation.
We hope you continue to feel better.
- Your ___ Team
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10254837-DS-21 | 10,254,837 | 28,752,151 | DS | 21 | 2191-08-30 00:00:00 | 2191-08-31 10:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / Cymbalta / trazodone
Attending: ___.
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
___: 1 unit packed red blood cell transfusion.
___: EGD
History of Present Illness:
___ year old woman with history of diabetes mellitus,
hypertension, hyperlipidemia, morbid obesity s/p gastric bypass,
sleep apnea, non-ischemic cardiomyopathy with EF of ___
(___), LBBB, CKD, presenting with dyspnea on exertion and
recent syncope.
She notes feeling short of breath over the past ___ weeks when
walking approximately 1 block. She is unable to walk up a flight
of stairs. Denies cough/fever/lower extremity edema/PND. She has
orthopnea where she sleeps with 5 pillows which has been stable.
She continues to take torsemide 20 mg Po daily.
She notes that she has had epigastric abdominal discomfort over
the past week. She has been using NSAID's over the past two
months due to chronic pain. She does acknowledge that her stools
are dark red/blood mixed in the stool, however, denies any black
stools.
She did experience syncope 1 week prior to presentation. This
occurred when she stood up, felt lightheaded. She denied any
chest pain or palpitations prior to these episodes.
Due to the dyspnea on exertion, presented to ___ ED.
In the ED, initial vitals: 99.2, 93, 129/92, 20, 100% on RA.
- Labs notable for: H/H 6.7/24.9 (baseline ___. proBNP 4,777.
Chemistry was notable for a creatinine of 1.4 (baseline
1.2-1.4).
- CXR showed marked cardiomegaly with chronic pulmonary vascular
congestion, but no frank pulmonary edema.
- Pt given: Magnesium sulfate, 40 mg IV pantoprazole, 2 grams
Magnesium sulfate, 1000 mg acetaminophen, ondansetron 4 mg IV x
1. Lactate was 1.6.
On arrival to the floor, pt reports the shortness of breath has
improved. Denies chest pain, chest pressure, chest palpitations,
nausea, vomiting diarrhea. She does note epigastric discomfort
and lower quadrant abdominal discomfort.
ROS: Please see HPI.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia,+
Hypertension
2. CARDIAC HISTORY: Non ischemic cardiomyopathy, idiopathic, EF
___ on this admission
3. OTHER PAST MEDICAL HISTORY:
PELVIC INFLAMMATORY DISEASE
PELVIC PAIN (FEMALE), UNSPEC
BIPOLAR I DISORDER, MOST RECENT EPISODE MIXED MH
ARTHRALGIA - HAND
ARTHRALGIA - KNEE
TOBACCO DEPENDENCE
NONUNION OF FRACTURE - L SCAPHOID
FIBROMYALGIA
NEUROPATHY, UNSPEC
OSTEOARTHRITIS, LOCALIZED PRIMARY - KNEE
Achilles Tendinitis
Morbid Obesity
Fibroids, intramural
CHF (congestive heart failure)/Cardiomyopathy
Renal insufficiency
___: Community acquired pneumonia.
___: admitted for dyspnea on exertion, found to have iron
deficiency anemia requiring blood transfusion.
Social History:
___
Family History:
Mother with glaucoma, Aunt with diabetes, no family history of
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals: 97.9, 124/76, 97, 19, 99% on RA. 156.7 (174 lb on
___
General: Pleasant affect, laying in bed comfortably in NAD.
HEENT: Conjunctival pallor appreciated, EOMI, PERRL.
Neck: supple, JVP not elevated.
Lungs: Clear to auscultation bilaterally, no wheezes.
CV: RRR, S1 and S2 present.
Abdomen: soft abdomen, prior surgical scars are well healed,
minimal epigastric discomfort, no rebound or guarding, minimal
lower abdominal discomfort, normoactive bowel sounds.
Ext: warm, well perfused, no lower extremity.
DISCHARGE PHYSICAL EXAM
=======================
Vitals: 97.4-97.9, 127-137/85-96, 91-96, 18, 97-99% on RA (174
lb on ___
General: Laying in bed comfortably in NAD, breathing
non-labored.
HEENT: Conjunctival pallor appreciated, EOMI, PERRL.
Neck: supple, JVP not elevated.
Lungs: Clear to auscultation bilaterally.
CV: RRR, S1 and S2 present.
Abdomen: soft abdomen, epigastric tenderness to deep palpation,
normoactive bowel sounds, no rebound or guarding.
Ext: warm, well perfused, trace lower extremity edema.
Pertinent Results:
ADMISSION LABS
==============
___ 11:45AM BLOOD WBC-6.4 RBC-3.74* Hgb-6.7*# Hct-24.9*#
MCV-67*# MCH-17.9*# MCHC-26.9*# RDW-22.4* RDWSD-52.0* Plt ___
___ 11:45AM BLOOD Neuts-66.5 ___ Monos-10.1 Eos-2.0
Baso-1.1* NRBC-0.3* Im ___ AbsNeut-4.23 AbsLymp-1.26
AbsMono-0.64 AbsEos-0.13 AbsBaso-0.07
___ 11:45AM BLOOD Glucose-156* UreaN-33* Creat-1.4* Na-141
K-4.0 Cl-101 HCO3-23 AnGap-21*
___ 11:45AM BLOOD ALT-33 AST-56* LD(LDH)-376* AlkPhos-148*
TotBili-0.7 DirBili-<0.2
___ 11:45AM BLOOD Lipase-18
___ 11:45AM BLOOD proBNP-___*
___ 11:45AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.7 Iron-14*
DISCHARGE LABS
==============
___ 05:21AM BLOOD WBC-6.2 RBC-4.17 Hgb-8.0* Hct-28.9*
MCV-69* MCH-19.2* MCHC-27.7* RDW-23.9* RDWSD-57.8* Plt ___
___ 05:21AM BLOOD ___ PTT-25.4 ___
___ 05:21AM BLOOD Glucose-68* UreaN-40* Creat-1.4* Na-140
K-3.2* Cl-102 HCO3-22 AnGap-19
___ 05:21AM BLOOD ALT-28 AST-30 LD(LDH)-243 AlkPhos-135*
TotBili-1.0
IRON STUDIES
============
___ 11:45AM BLOOD Iron-14*
___ 11:45AM BLOOD calTIBC-494* ___ Ferritn-8.3*
TRF-380*
IMAGING
=======
___: CHEST X-RAY (PA AND LATERAL)
FINDINGS:
The heart is markedly enlarged but overall unchanged in size
from the prior
radiograph on ___. The lungs are clear. There is
no pleural
effusion or pneumothorax. There is mild pulmonary vascular
engorgement which appears chronic without overt signs of
pulmonary edema. No acute osseous abnormality is demonstrated.
IMPRESSION:
Marked cardiomegaly with chronic pulmonary vascular congestion,
but no frank pulmonary edema.
___: CT HEAD WITHOUT CONTRAST
IMPRESSION: There is no evidence of an acute intracranial
abnormality.
___: LIVER/GALLBLADDER ULTRASOUND
IMPRESSION:
1. Diffusely echogenic kidneys bilaterally consistent with renal
parenchymal disease.
2. Cholelithiasis without cholecystitis.
Brief Hospital Course:
___ w/ non-ischemic cardiomyopathy (EF ___, CAD, HTN, T2DM,
morbid obesity s/p gastric bypass, CKD and OSA presenting with
dyspnea and recent syncope and found to have anemia.
# Iron Deficiency Anemia: Patient presented with shortness of
breath and lightheadedness. She was noted to be anemic with H/H
of 6.7/24.9 (baseline ___. Lab evaluation revealed iron
deficiency with serum iron 14, ferritin 8.3 consistent with iron
deficiency. Patient noted to have epigastric pain associated
with eating and epigsatric tenderness to palpation. GI was
consulted due to concern of gastric versus duodenal ulcer in the
setting of recent NSAID use. EGD performed which showed "normal
esophagus. Evidence of a previous Roux-en-Y gastric bypass was
seen. Mild erythema of the mucosa was noted in the stomach
consistent with mild gastritis." Recommendation was for
outpatient colonoscopy, as they did not believe patient having
acute blood loss.
She received one unit of packed red blood cells during
hospitalization with improvement of H/H to 8.0/28.9.
Additionally, patient likely has iron deficiency anemia in the
setting of gastric bypass leading to iron malabsorption. She may
benefit from IV iron infusion as an outpatient.
Additional evaluation of anemia showed normal haptoglobin
indicating that patient was not hemolyzing.
Orthostatics performed prior to discharge which were negative.
She was able to ambulate without shortness of breath.
# Right Upper Quadrant Abdominal Discomfort: Patient noted to
have right upper quadrant abdominal pain when eating. RUQ US
performed as patient had elevated alk phos to 148. RUQ US showed
cholelithiasis with a 0.8 cm mobile gallstone but no
cholecystitis. As this may represent biliary colic, patient will
benefit to referral to General Surgery for evaluation.
# Syncope: Patient states she had one episode of syncope week
prior to presentation in setting of lightheadedness. Etiology
thought to be secondary to anemia. EKG performed which did no
show ischemic changes. She did not experience chest pain, chest
pressure, or chest palpitations. She remained on telemetry
without any abnormal rhythm. CT head to assess for intracranial
process was negative.
# HFrEF: EF ___ in ___ which is thought to be non-ischemic
cardiomyopathy. Given normal blood pressure, continued aspirin
81 mg PO daily, valsartan 240 mg PO daily, torsemide 20 mg PO
daily, atorvastatin 80 mg PO daily.
# CKD: Creatinine 1.4 on admission. Of note, on patient's
abdominal ultrasound it was notable for "diffusely echogenic
kidneys bilaterally consistent with renal parenchymal disease."
Further evaluation as an outpatient is recommended.
# Fibromyalgia: continued baclofen and cyclobenzaprine.
# Depression: Held sertraline at the time of discharge in the
setting of prolonged QTc of 500. Can obtain repeat EKG as
outpatient and re-start sertraline as indicated.
TRANSITIONAL ISSUES
===================
-Holding sertraline in the setting of prolonged QTc.
-obtain repeat EKG as outpatient and consider re-starting
sertraline.
-Avoid NSAID's as gastritis noted on EGD.
-Consider referral to General Surgery for evaluation of
symptomatic cholelithiasis.
-Patient will require outpatient colonoscopy given iron
deficiency anemia.
-Patient may benefit from intravenous iron infusions given her
history of gastric bypass to treat iron deficiency anemia.
-Evaluate for chronic kidney disease as outpatient given
evidence of "diffusely echogenic kidneys bilaterally consistent
with renal parenchymal disease."
-Obtain repeat CBC as outpatient.
-If source of anemia not identified as outpatient, please ensure
patient is up to date on cancer screening including breast and
cervical cancer screening, and consider additional anemia workup
as outpatient.
-Code Status: Full Code (confirmed)
-Communication: ___ (daughter): ___
>30 minutes spent coordinating discharge home
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO TID:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Valsartan 240 mg PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Sertraline 50 mg PO DAILY
8. Cyclobenzaprine ___ mg PO HS:PRN pain
9. Torsemide 20 mg PO DAILY
10. Baclofen ___ mg PO TID:PRN Pain - Mild
11. Cyanocobalamin 1000 mcg PO DAILY
12. HydrALAZINE 10 mg PO TID
13. Ursodiol 300 mg PO BID
Discharge Medications:
1. Acetaminophen 500 mg PO TID:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Baclofen ___ mg PO TID:PRN Pain - Mild
5. Cyanocobalamin 1000 mcg PO DAILY
6. Cyclobenzaprine ___ mg PO HS:PRN pain
7. Ferrous Sulfate 325 mg PO DAILY
8. HydrALAZINE 10 mg PO TID
9. Omeprazole 40 mg PO DAILY
10. Torsemide 20 mg PO DAILY
11. Ursodiol 300 mg PO BID
12. Valsartan 240 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
-Iron deficiency anemia
-Abdominal Pain NOS
-Syncope
-Heart Failure Reduced Ejection Fraction
-Chronic Kidney Disease
-Fibromyalgia
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 ___ due to
shortness of breath when walking. You were found to be anemic.
In order to evaluate the cause of the anemia, you underwent an
upper endoscopy. This showed mild inflammation of the stomach,
called gastritis.
You received 1 unit of blood which improved your blood counts
and symptoms.
It will be critical for you to have a colonoscopy performed as
an outpatient to evaluate your blood loss.
The ultrasound of your abdomen did show gallstones in your
gallbladder. If you continue to have abdominal pain with eating,
please discuss with your primary care physician referral to ___
General Surgeon for evaluation of the gallstones.
Your ultrasound also showed possible renal disease. Your
creatinine was stable during hospitalization. Please follow-up
with your primary care physician to discuss these results.
Please avoid using sertraline until you follow up with your
primary care physician. We recommend checking an EKG prior to
re-starting this medication.
Please also avoid non-steroidal inflammatory medications
(ibuprofen or naproxen) as this can lead to worsening of the
stomach inflammation.
Please bring this paperwork to your appointment with your new
primary care physician.
It was truly a pleasure taking care of you during your
hospitalization! We wish you all the best!
Sincerely,
Your ___ Care Team.
Followup Instructions:
___
|
10254956-DS-4 | 10,254,956 | 21,618,706 | DS | 4 | 2179-04-13 00:00:00 | 2179-04-14 23:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
Intubation ___
___ tube placement ___
EGD ___
TIPS ___
Diagnostic paracentesis x2
Balloon retrograde transvenous obliteration of gastro renal
shunt with alcohol, Amplatzer plug and coils
Placement of a 10 mm x 6 cm x 2 cm Viatorr covered stent.
Post-stenting balloon angioplasty of the TIPS shunt with a 10 mm
balloon.
History of Present Illness:
History obtained from chart review and from pt's daughter.
Per daughter: has had intermittent AMS episodes for a while with
elevated ammonia. w/u negative, thought to be ___ liver disease
and ?partially treated BrCa. Has had scopes in past but felt to
be possible nosebleeds. ~1 month ago had ___ and capsule
study at ___ which showed only a small gastric ulcer which
was clipped. She gets intermittent transfusions. Daughter thinks
patient no longer drinking, however in ___ records, pt
states she still drinks ___ drinks nightly.
In terms of recent psych history, had concern from her
oncologist that she was manic. Sent her to ___ on ___
for medical clearance for admission to ___. Pt had prior
admission for presumed Bipolar d/o, however at this admission,
there was concern that she actually has frontotemporal dementia
with behavioral disturbance.
On arrival to the ED, initial vitals were 99.1, 111, 118/69, 18,
95% RA. While in the ED, she was initially normotensive but
tachycardic to the 120s. She then had ~500cc hematemesis and
altered mental status with BP 60/40. She was intubated for
airway protection, and massive transfusion protocol was
initiated. She had 3 large PIVs placed and received 3U uncrossed
PRBCs and 1U FFP. Her hypotension resolved within ~5 minutes
without use of pressors. She was started on octreotide and
protonix gtts, and got CTX for SBP prophylaxis. She was also
noted to be febrile to 101.0.
Labs were significant for: Hb 6.2 (was ___ last admission), INR
1.7, HCO3 19 with AG 13, lactate 2.4. AST 52, ALT 27, Al Phos
176.
Imaging was significant for: CXR with R perihilar opacities.
Hepatology was consulted who recommended urgent EGD.
On transfer, vitals were: 97.8, 84, 113/78, 18, 94%
On arrival to the MICU, pt is intubated and sedated.
Review of systems:
Unable to obtain d/t patient intubated/sedated
Past Medical History:
EtOH cirrhosis w/portal HTN
Anemia
HTN
Incarcerated hernia s/p small bowel resection
Breast adenocarcinoma, incompletely treated
Frontotemporal dementia
Social History:
___
Family History:
Unknown
Physical Exam:
PHYSICAL EXAM ON ADMISSION
==========================
GENERAL: Intubated, sedated, pale
HEENT: Sclerae anicteric
NECK: supple, JVP not elevated, no LAD
LUNGS: Mechanical breath sounds bilaterally, no wheezes, rales,
rhonchi
CV: Tachycardic, regular rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, moderately distended, bowel sounds present, no
organomegaly. Cannot assess tenderness/guarding d/t patient
sedation.
GU: Foley in place
EXT: Warm, well perfused, 2+ pulses, 2+ pitting edema
SKIN: No lesions, not jaundiced.
NEURO: Sedated
ACCESS: 3 PIVs
PHYSICAL EXAM ON DISCHARGE
==========================
VS: Tmax 98.6 BP 110-120/40-60s HR 60-80s RR ___ on
RA
GENERAL: Intermittently pleasant and agitated, in no acute
distress
HEENT: Normocephalic, atraumatic, no scleral icterus
HEART: RRR, normal S1/S2, no murmurs rubs or gallops
LUNGS: Clear to auscultation anteriorly, without wheezes or
rhonchi
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or edema
NEUROLOGIC: Odd affect/tangential/confabulating
ACCESS: None
Pertinent Results:
=================
LABS ON ADMISSION
=================
___ 09:33PM BLOOD WBC-8.8 RBC-2.81* Hgb-6.2* Hct-21.8*
MCV-78*# MCH-22.1*# MCHC-28.4* RDW-19.9* RDWSD-54.4* Plt ___
___ 09:33PM BLOOD Neuts-70.6 Lymphs-11.0* Monos-13.1*
Eos-4.2 Baso-0.5 Im ___ AbsNeut-6.18* AbsLymp-0.96*
AbsMono-1.15* AbsEos-0.37 AbsBaso-0.04
___ 09:33PM BLOOD ___ PTT-31.1 ___
___ 09:33PM BLOOD Glucose-142* UreaN-12 Creat-0.7 Na-139
K-5.0 Cl-107 HCO3-19* AnGap-18
___ 09:33PM BLOOD ALT-27 AST-52* AlkPhos-176* TotBili-0.6
___ 09:33PM BLOOD Albumin-2.8* Calcium-8.7 Phos-3.2 Mg-1.7
___ 11:29PM BLOOD Type-ART Rates-20/ Tidal V-350 PEEP-5
FiO2-40 pO2-95 pCO2-43 pH-7.27* calTCO2-21 Base XS--6
As/Ctrl-ASSIST/CON Intubat-INTUBATED
___ 12:20AM BLOOD Lactate-2.4*
___ 06:46AM BLOOD freeCa-1.54*
___ 12:15AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 12:15AM URINE Color-Yellow Appear-Clear Sp ___
___ 12:15AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
___ 12:15AM URINE CastGr-1* CastHy-5*
==============
PERTINENT LABS
==============
___ 06:30AM BLOOD %HbA1c-5.0 eAG-97
___ 06:30AM BLOOD Triglyc-97 HDL-19 CHOL/HD-4.4 LDLcalc-45
============
MICROBIOLOGY
============
Blood cultures (___): No growth.
Urine culture (___): No growth.
Sputum culture (___): YEAST. SPARSE GROWTH.
C. diff (___): Negative
---
___ 02:21PM ASCITES WBC-103* ___ Polys-80*
Lymphs-12* Monos-1* Eos-7*
___ 02:21PM ASCITES TotPro-1.3 Albumin-0.8
___ Peritoneal fluid culture: Negative
=========
IMAGING
=========
CXR (___)
IMPRESSION: Endotracheal tube terminates 1.1 cm above the
carina. Recommend withdrawal by approximately 2.5 cm for more
optimal positioning.
Persistent mild elevation of the right hemidiaphragm. Right
perihilar
opacities could be due to atelectasis, however, infection or
aspiration or not excluded.
---
EGD: (___)
Impression: Normal mucosa in the esophagus
Varices at the fundus (injection)
Normal mucosa in the duodenum
Gastric antral clip at pyloris was found from previous
procedure.
Otherwise normal EGD to third part of the duodenum
---
CXR (___):
IMPRESSION: Comparison to ___, 22:37. Placement of
___ device. The
previous feeding tube is no longer visible. No evidence of
complications such
as pneumothorax. Appearance of the heart and the lung
parenchyma is stable.
---
TIPS (___):
FINDINGS:
1. Pre-TIPS portosystemic gradient of 33 mmHg.
2. CO2 portal venogram showing patency of the intrahepatic
portal venous
system.
3. Contrast enhanced portal venogram showing a moderate-sized
short gastric
varix.
4. Post-TIPS portal venogram showing appropriate flow through
the TIPS without
evidence of a previously demonstrated short gastric varix.
5. Post-TIPS right portosystemic gradient of 11 mmHg.
6. 800 cc of clear ascitic fluid removed during paracentesis.
9. Left renal venogram demonstrates a moderate-sized gastro
renal shunt.
10. During balloon retrograde trans venous obliteration of the
gastro renal
shunt, a mild amount of contrast was seen extravasated into the
soft tissues
which was consistent with rupture of the shunt. This was
subsequently treated
with placement of both 0.035 coils and a 12 mm Amplatzer plug.
Post
embolization venograms demonstrate continued minimal
extravasation into the
soft tissues with predominant stasis within the outflow
component of the
gastro renal shunt.
IMPRESSION:
Successful right internal jugular access with transjugular
intrahepatic
portosystemic shunt placement with decrease in porto-systemic
pressure
gradient.
800 cc of clear ascitic fluid removed during paracentesis.
Successful balloon retrograde transvenous obliteration of a
gastro renal shunt
complicated by rupture of the shunt with extravasation into the
soft tissues.
This was subsequently treated with 0.035 coils and a 12 mm
Amplatzer plug.
---
CXR (___): Worsened pleural effusions. Worsened bibasilar
opacities, likely atelectasis,
consider pneumonia or aspiration in the appropriate clinical
setting.
Increased heart size, mildly increased pulmonary vascularity.
---
CXR (___): In comparison with the study of ___, the
nasogastric tube extends at
least to the gastric antrum. The endotracheal tube tip is in
unchanged
position. Continued enlargement of the cardiac silhouette with
minimal
vascular congestion. Retrocardiac opacification again is
consistent with spot
volume loss in the left lower lobe and pleural effusion.
---
CXR (___): In comparison with the earlier study of this
date, there has been placement of
a right subclavian PICC line that extends well into the right
atrium. It
could be pulled back approximately 5 cm if the desired position
is at or just
above the cavoatrial junction.
Continued enlargement of the cardiac silhouette with pulmonary
vascular
congestion, left effusion, and volume loss in the left lower
lobe.
---
RUQ US (___):
1. Patent TIPS with normal velocities.
2. Cirrhotic liver morphology without evidence of focal lesion.
3. Moderate ascites.
4. Cholelithiasis without evidence of cholecystitis.
=================
LABS ON DISCHARGE
=================
___ 06:41AM BLOOD WBC-6.3 RBC-2.99* Hgb-8.7* Hct-28.4*
MCV-95 MCH-29.1 MCHC-30.6* RDW-21.4* RDWSD-74.0* Plt ___
___ 06:41AM BLOOD Plt ___
___ 06:50AM BLOOD Glucose-91 UreaN-5* Creat-0.6 Na-140
K-3.9 Cl-109* HCO3-19* AnGap-16
___ 06:41AM BLOOD ALT-24 AST-37 LD(LDH)-360* AlkPhos-192*
TotBili-1.2
___ 06:50AM BLOOD Calcium-9.0 Phos-2.9 Mg-1.7
Brief Hospital Course:
HOSPITAL COURSE
===============
___ y/o woman history of alcoholic cirrhosis who presented with
hematemesis with course complicated by massive upper
gastrointestional bleeding. She was in critical condition in the
ICU, underwent TIPS on ___ with resultant hemodynamic
stability and transfer to the floor. Her course was complicated
by abnormal behavior and labile affect, which per collateral
from daughter have been subacute for past six months. She was
evaluated by neurology and psychiatry who suspected ___
syndrome in setting of prolonged EtOH use. She was treated with
high dose thiamine and discharged on oral thiamine.
ACTIVE ISSUES
=============
# ___
# Behavioral disturbances: Per daughter, within past year
patient was diagnosed by PCP with ___ but no formal
neuropsychiatric testing or outpatient neuro/psych eval. Has had
subacute decline in mental status over prior 6 months. Patient
also with intermittent "staring spells" during which she did not
speak for 30 seconds at a time. Consulted neurology for staring
spells, stated unlikely to be seizure given low frequency.
Consulted psychiatry, per their recs discontinued aripiprazole
2mg daily and quetiapine 12.5 BID PRN on ___ started
OLANZapine 5 mg PO QHS titrated up to 5mg TID by time of
discharge. Most likely diagnosis ___, received IV
thiamine in ICU and discharged on PO. At time of discharge,
patient intermittently agitated and content, often singing in
the hallways.
# Acute blood loss anemia:
# Hemorrhagic shock; resolved:
# Upper gastrointestinal bleed: Patient with known portal HTN
(recannulized umbilical vein on CT ___ year ago), although per
daughter, recent EGDs have not shown esophageal varices. Did
have small gastric ulcer previously. Unclear precipitant of
episode. Patient was hemodynamically stable on admission but
given hematemesis was admitted to MICU. During EGD, she became
hypotensive and bleeding gastric varux was seen during EGD. This
was unable to be clipped. ___ placed, sent to ___ for stat
BRTO, however balloons burst, got TIPS instead. After ___
procedure, ___ was removed with no active bleeding
visualized. She was on octreotide gtt, ceftriaxone for SBP ppx
for 7 days (Day ___, and protonix BID. She remained
hemodynamically stable following the TIPS placement and did not
require any further blood transfusions. Repeat ultrasound one
week after TIPS showed patent TIPS with normal velocities.
# Hypoxemic respiratory failure: Patient was initially intubated
for airway protection in setting of hematemesis. Post-procedure
she required ongoing intubation/mechanical ventilation given
encephalopathy. CXR was notable for pulmonary edema as well, and
she received IV diuresis prior to extubation. She was extubated
___ and afterwards stable on room air.
# Alcoholic Cirrhosis: C/b portal hypertension, varices,
ascites. No known history of HE. No evidence of SBP during this
admission. Lactulose restarted on ___ with improvement in
mental status. Patient received high dose IV thiamine this
admission and was discharged on indefinite PO thiamine.
Lasix/spironolactone were discontinued after TIPS.
CHRONIC ISSUES
==============
# Breast cancer: Continue letrozole 2.5 daily
# DMII: ISS while inpatient.
TRANSITIONAL ISSUES
===================
[] New medications
- Multivitamins W/minerals 1 TAB PO DAILY
- OLANZapine 5 mg PO TID
- Omeprazole 20 mg PO DAILY
- Rifaximin 550 mg PO/NG BID
[] Changed medications
- Lactulose 30 mL PO TID changed to 15 mL TID
[] Stopped medications
- ARIPiprazole 2 mg PO DAILY
- Furosemide 20 mg PO DAILY
- Haloperidol 2 mg PO QHS
- LORazepam 0.5 mg PO Q6H:PRN anxiety
- Magnesium Oxide 400 mg PO DAILY
- Multivitamins 1 TAB PO DAILY
- Pantoprazole 40 mg PO Q24H
- Spironolactone 100 mg PO DAILY
- Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
[] Please contact patient's PCP ___.
___ he will refer the patient to a local
gastroenterologist, who should be seen in the next month
[] Patient psychiatric regimen changed to OLANZapine 5 mg PO
TID. If inadequate, may consider uptitrating, but check qTC to
ensure not prolonged (qTC on discharge 447)
[] Outpatient hepatologist to re-evaluate whether lactulose and
rifaximin are needed long term for hepatic encephalopathy
# CODE: Full (confirmed)
# Contact: ___ - Daughter ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO DAILY
2. Spironolactone 100 mg PO DAILY
3. Letrozole 2.5 mg PO DAILY
4. Albuterol Inhaler 2 PUFF IH Q4-Q6H
5. ARIPiprazole 2 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. LORazepam 0.5 mg PO Q6H:PRN anxiety
8. Magnesium Oxide 400 mg PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
11. Multivitamins 1 TAB PO DAILY
12. Thiamine 100 mg PO DAILY
13. Vitamin D ___ UNIT PO DAILY
14. Lactulose 30 mL PO TID prn
15. Haloperidol 2 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY:
- Hemorrhagic shock
- Acute blood loss anemia
- Upper gastrointestinal bleed
SECONDARY:
- Alcoholic cirrhosis
- ___ syndrome
- Coagulopathy
- Breast cancer
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory with walker
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you. You came to the hospital
because you were vomiting blood. Your blood counts were low, and
you got blood transfusions. You had a procedure to stop the
source of your bleeding, and this procedure was successful.
During the hospitalization you demonstrated abnormal behavior.
You were evaluated by neurology and psychiatry who are concerned
that you have damage to your brain due to your use of alcohol
(Korsakoff syndrome). You were treated with high dose thiamine
and should continue taking oral thiamine on discharge. You will
be discharged to an ___ facility where you can get the on
going care that you need.
We wish you the best of health.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10255103-DS-16 | 10,255,103 | 20,895,838 | DS | 16 | 2131-11-16 00:00:00 | 2131-11-16 12:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right knee pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ male who has a history of a right ACL injury
status post patellar tendon replacement allograft who presents
to
the emergency department as a transfer from an outside hospital
concern of the Patellar dislocation and Tibial plateau fracture.
Patient states that he was running in soccer and attempting to
get to the through glass when he had a sudden onset of knee pain
and felt that his knee popped out. It was severe that he was
taken to the local emergency room where x-rays were obtained
that
showed a dislocation. There was concern that he had decreased
pulses in the distal aspects of the dislocation by the emergency
room physician did not In regard emergent reduction because the
patient was neurovascular intact otherwise. Therefore he got
splinted and sent him to a higher level of care. On arrival the
patient denies any knee pain or any other pain and for that
matter.
Past Medical History:
denies
Social History:
___
Family History:
NC
Physical Exam:
Gen: A&Ox3, NAD
Right lower extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender thigh and leg, though tender and swollen
about the knee. Knee is warmer than contralateral.
- Full, painless AROM/PROM of hip, knee, and ankle
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 2+ ___ pulses, foot warm and well-perfused
Pertinent Results:
___ 07:55PM GLUCOSE-90 UREA N-14 CREAT-1.0 SODIUM-141
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-21* ANION GAP-19
___ 07:55PM estGFR-Using this
CTA Right leg:
IMPRESSION:
1. No evidence of vascular injury.
2. Comminuted minimally depressed small fracture of the
posterior aspect of
the medial tibial plateau.
3. Cortical irregularity of the lateral femoral condyle may
reflect an
impaction fracture.
4. Likely disruption of the anterior cruciate ligament, though
this would be
better assessed with MRI.
5. Moderate lipohemarthrosis.
Brief Hospital Course:
Patient was admitted to the orthopaedic trauma service for knee
dislocation. Your CTA demonstrated no vascular injury, though it
did suggest you may have an ACL tear and possible impaction
injuries to the tibia and femur. No acute surgical intervention
was warranted.
He was placed in a knee immobilizer and made weight bearing as
tolerated. He ambulated with little difficulty on HD1 and it was
determined that he was safe for discharge home with plan for
outpatient follow up with Dr. ___. He will need an MRI as
an outpatient.
While admitted, he received 40mg lovenox for DVT prevention.
Analgesia consisted of Tylenol and ibuprofen, which he tolerated
well.
All questions were answered prior to discharge, and he states
understanding of discharge plan.
Medications on Admission:
denies
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Enoxaparin Sodium 40 mg SC Q24H Duration: 28 Days
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 1 syringe SC Daily Disp #*28 Syringe
Refills:*0
3. Ibuprofen 400 mg PO Q8H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Right knee dislocation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
******SIGNS OF INFECTION**********
-Please return to the emergency department or notify MD if you
experience severe pain, increased swelling, decreased sensation,
difficulty with movement; fevers >101.5, chills, redness or
drainage at the injury site; chest pain, shortness of breath or
any other concerns.
******MEDICATIONS***********
-PAIN MEDICATION: Ibuprofen, Tylenol, and if needed,
oxycodone
-Do not operate heavy machinery or drink alcohol while taking
pain meds. As your pain improves please decrease the amount of
oxycodone. This medication can cause constipation, so you should
drink ___ glasses of water daily and take a stool softener
(colace) to prevent this side effect.
-ANTICOAGULATION: enoxaparin 40 mg daily for 2 weeks
-Resume your pre-hospital medications with adjustments as noted
on discharge medication list.
WEIGHT BEARING:
You may weight bear as tolerated in your injured knee. Please
keep you knee immobilizer on at all times, especially when
bearing weight. You may remove while bathing
Followup Instructions:
___
|
10255285-DS-5 | 10,255,285 | 26,808,677 | DS | 5 | 2130-03-24 00:00:00 | 2130-03-24 20:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
L percutaneous nephrostomy placement
History of Present Illness:
___ y/o M with history of depression, alcohol abuse, bladder
cancer s/p multiple TURBTs/BCG therapy, alcohol abuse, recurrent
falls, and recent left subcapsular hematoma who presented to ED
at urging of his outpatient physicians. He recently had a PCP
appointment where his Cr was found to be 4.8, from a baseline
1.5. On the way home from the doctor he stumbled and fell on the
sidewalk (outside ___) but was not injured, no LOC. He
went home (where he reports having another fall without LOC) and
then heard from his PCP the next day informing him of the
abnormal labs, at which point he was referred to the ED.
He reports normal urine output but says that his urine was
darker last week. He says that he has been feeling at his usual
state of health recently. He denies headache, vision changes,
weakness, new paresthesias, chest pain, shortness of breath, or
abdominal pain. he also denies any neck or back pain.
On arrival to the ED, initial vitals were 97.3 68 106/61 16
100%. He had a negative FAST exam. There was no gross
hydronephrosis or distended bladder on bedside u/s. Urology was
consulted and a renal U/S and CT abd/pelvis were obtained.
Urology recommended urgent PCN placement and the patient was
taken to ___ from the ED before arrival to the floor.
Additionally, in the ED his K was noted to be 5.6 (no symptoms,
no ECG changes) and he was given kayexolate with repeat K 4.6.
Head CT was unremarkable. He was started on ceftriaxone for a
presumed UTI.
Also while in the ED he began to show passive suicidal ideation
and psych was consulted. Per their evaluation, he did not meet
___ criteria. Psych will continue to follow while inpatient.
On arrival to the floor he is now s/p L PCN placement. He is
stable, denies pain.
Past Medical History:
Bladder ca as above
Cervical spine disease
DM II
HTN
CKD
BPH
ETOH abuse
Chronic pancreatitis
Depression
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission:
VS - Temp 98.4 F, BP 140/70, HR 88, R 16, O2-sat 97% RA
General: Awake, alert male lying in bed, NAD
HEENT: no scleral icterus, poor dentition, OP clear, bandage on
forehead
Neck: supple, no cervical ___. No carotid bruits.
CV: RRR, nl S1 S2, no r/m/g appreciated.
Lungs: CTAB
Abdomen: soft, NT/ND. No organomegaly. +BS.
GU: no Foley.
Ext: WWP, +2 pulses. No pedal edema.
Neuro: A+Ox3, attentive. CN II-XII intact. Motor and sensory
function grossly intact.
Skin: 2 small scabs over L shin (pt aware, says they are from
recent fall), no rashes. L percutaneous nephrostomy tube noted
with bloody urine in bag. Site is dressed, exam deferred, no
pain upon minimal palpation.
Gait: Deferred due to having just returned from PCN tube
placement.
Discharge:
General: Awake, alert male lying in bed, NAD
HEENT: no scleral icterus, poor dentition, OP clear, bandage on
forehead
Neck: supple, no cervical ___. No carotid bruits.
CV: RRR, nl S1 S2, no r/m/g appreciated.
Lungs: CTAB
Abdomen: soft, NT/ND. No organomegaly. +BS.
GU: no Foley.
Ext: WWP, +2 pulses. No pedal edema.
Neuro: A+Ox3, attentive. CN II-XII intact. Motor and sensory
function grossly intact.
Skin: 2 small scabs over L shin (pt aware, says they are from
recent fall), no rashes. L percutaneous nephrostomy tube noted
with clear urine in bag. Site is dressed, no erythema,
tenderness or drainage, no pain upon minimal palpation.
Pertinent Results:
Admission Labs:
___ 10:50PM BLOOD WBC-9.3 RBC-2.96* Hgb-8.7* Hct-26.8*
MCV-90 MCH-29.2 MCHC-32.3 RDW-13.3 Plt ___
___ 10:50PM BLOOD Neuts-78.0* Lymphs-13.5* Monos-6.0
Eos-2.0 Baso-0.4
___ 10:50PM BLOOD Plt ___
___ 07:44AM BLOOD ___
___ 10:50PM BLOOD Glucose-159* UreaN-91* Creat-4.8*# Na-135
K-5.8* Cl-103 HCO3-16* AnGap-22*
___ 10:50PM BLOOD ALT-14 AST-9 AlkPhos-86 TotBili-0.2
___ 10:24AM BLOOD Lactate-0.9
.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
___ 08:45 5.9 2.96* 8.7* 27.1* 92 29.5 32.2 13.5 231
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 08:45 388*1 55* 2.3* 140 4.7 ___
.
MICROBIOLOGY:
___ URINE URINE CULTURE-FINAL {BETA
STREPTOCOCCUS GROUP B} INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY WARD
___ URINE URINE CULTURE-FINAL {BETA
STREPTOCOCCUS GROUP B} EMERGENCY WARD
Imaging:
Head CT (___):
IMPRESSION: No acute intracranial process.
Renal U/S (___):
IMPRESSION:
1. New moderate left hydronephrosis and hydroureter. The
ureteric dilatation extends from the level of the renal pelvis
through its insertion on the bladder.
2. Layering debris within the left renal pelvis and proximal
ureter, possibly due to urinary stasis, although correlation
with clinical signs/symptoms of pyonephrosis is recommended.
3. Posterior bladder wall thickening, left greater than right,
likely corresponding to patient's known bladder mass.
CT Abd/Pelv (___):
IMPRESSION:
1. Interval removal of the left ureteral stent with new mild
left
hydroureteronephrosis, likely due to obstruction at the left
ureterovesicular junction from known bladder cancer along the
posterior left bladder wall. Left ureteral wall thickening and
surrounding fat stranding may be due to an underlying infectious
or inflammatory process.
2. Interval decrease in size in left subcapsular renal fluid
collection, consistent with resolving hematoma.
3. Sigmoid diverticulosis with no evidence of diverticulitis.
4. Cystic lesion in the pancreatic head is unchanged in size
since the most recent prior study, and is incompletely
characterized on this exam. Followup MRI could be considered for
further evaluation.
5. New chyluria, suggestive of injury or obstruction of the
lymphatic vessels and communication with the collecting system,
possibly due to prior urological intervention
Brief Hospital Course:
ASSESSMENT & PLAN: ___ y/o M with history of depression, alcohol
abuse, bladder cancer s/p multiple TURBTs/BCG therapy, alcohol
abuse, recurrent falls, and recent left subcapsular hematoma who
presented to ED at urging of his outpatient physicians for ___
(creatinine of 4.8, from a baseline 1.5).
# ___: Presented with a Cr of 4.8 from a reported baseline of
1.5. He is well known to the Urology service given his h/o
bladder cancer s/p multiple interventions and ongoing BCG
treatment. Renal u/s showed new L hydronephrosis and hydroureter
and CT scan showed obstruction at the level of the UVJ
consistent with a stricture at the prior resection site. Given
these findings, urology recommended urgent ___ placement
of L percutaneous nephrostomy tube. His procedure was uneventful
and his Cr quickly downtrended and was 2.3 at time of discharge.
Urology will continue to follow.
# Bacturia: Found to have positive UA and started on ceftriaxone
in the ED. No leukocytosis, no apparent symptoms. ___ reported
purulent urine during L PCN placement, so he was cultured from
nephrostomy output and urine which both grew >100,000 group B
strep, with transition to levofloxacin on discharge with total
___ntibiotics.
# Alcohol abuse: Patient with h/o alcohol abuse with last known
drink just prior to arrival in ED. He was placed on a CIWA
protocol but did not score during this admission and did not
require benzodiazepines. No B12 or folate deficiencies on lab
studies. He should follow up with his PCP on discharge from
rehab who can arrange outpatient psychiatry follow up.
# Depression/Suicidal ideation: Pt reported passive SI per ED
with no plan and reportedly said "I'm not going to actually do
it." Did not meet ___ criteria per psych evaluation. On
arrival to the floor he denied suicidal ideation and was
consistently talking about future plans including "needing to
pay rent". We continued his paxil and his wellbutrin was
restarted once it was clear that he was not withdrawing. He
should follow up with psychiatrist on discharge from rehab and
outpatient social work resources.
#Gait: Patient with a history of multiple falls in the setting
of EtOH abuse, including two in the past week. Did not report
any recent changes in his gait, and it appears to be a chronic
rather than acute issue. Head CT was unremarkable. He was placed
on strict fall precautions throughout this admission. He had a
non traumatic fall inhouse and should continue to be monitored
for fall prevention in rehab.
# HTN: Stable this admission. Home losartan was held in the
setting of ___. Home labetalol was continued. Urology can assess
at follow up when to restart losartan.
# DM2: He had elevated blood sugars inhouse. His glyburide was
held inhouse. He was started on lantus 12U in house. He was
discharge on lantus and glyburide. His continued need for
insulin should be reassessed at rehab.
TRANSITIONAL:
- f/u with urology as outpatient
please manage nephrostomy bag daily
Please provide physical therapy
please check glucose fingers sticks QID and assess continued
need for insulin.
please check Cr on ___ to evaluate for continued downward
trend (last Cr 2.3). Has Urology f/u ___.
Please Call Brother ___ at ___ or ___ and
Health Care Proxy ___ at ___ to reassure
patient and with updates.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion 100 mg PO BID
2. Finasteride 5 mg PO DAILY
3. GlyBURIDE 5 mg PO BID
4. Labetalol 200 mg PO BID
5. Losartan Potassium 50 mg PO DAILY
6. Paroxetine 20 mg PO DAILY
7. Simvastatin 40 mg PO DAILY
8. Tamsulosin 0.4 mg PO HS
9. Terazosin 5 mg PO HS
Discharge Medications:
1. Finasteride 5 mg PO DAILY
2. Labetalol 200 mg PO BID
3. Simvastatin 40 mg PO DAILY
4. BuPROPion 100 mg PO BID
5. GlyBURIDE 5 mg PO BID
6. Paroxetine 20 mg PO DAILY
7. Tamsulosin 0.4 mg PO HS
8. Terazosin 5 mg PO HS
9. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
10. Glargine 12 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
11. Multivitamins 1 TAB PO DAILY
12. Levofloxacin 500 mg PO Q48H
until ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
___
Discharge Condition:
Mental Status: Clear and coherent.
Mental Status: Confused - sometimes.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you at ___. As you
know, you came to the hospital because your primary care doctor
noticed an abnormal lab result that showed your kidneys were not
functioning properly. When you got to the hospital we found
evidence of an obstruction in your urinary system which was
blocking urine from leaving your kidney. Our urology team
recommended placing a tube in your left kidney in order to
releive the obstruction and give your urine a way out. You did
well with the procedure and your kidney function quickly
improved. Please take your prescribed antibiotics and follow up
with the urology team.
We also had our physical therapy team see you because of your
history of falls and instability when walking and they
recommended that you go to rehab.
Your blood sugars were high thus we started you on some insulin.
Followup Instructions:
___
|
10255285-DS-6 | 10,255,285 | 22,659,615 | DS | 6 | 2130-04-06 00:00:00 | 2130-04-07 09:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Left-sided nephrostomy tube placement
History of Present Illness:
___ yo w/bladder CA presents w/ worsening renal functional and
AMS. Of note pt admitted ___ for new L hydronephrosis and
hydroureter w/ ___ to 4.5 due to ureteral stricture after TURBT.
Perc nephrostomy tube was placed and Cr improved to 2.3 upon
discharge. Pt was hyperglycemic during admission and lantus was
started during his stay and continued on discharge. At rehab
today, Cr 3.6 and pt noted to be somnloent. Per urology, perc
nephrostomy flushes well and good position confirmed by US; no
hydro either kidney. He was referred to ED for further
evaluation.
In ED pt found to he hypoglycemic to 48. Improved to 215 -> 147
->187. Head CT without acute process.
On arrival to floor pt complains of feeling the need to urinate
despite having a foley and perc nephrostomy. Sensation is
painful. Denies confusion. Reports normal appetite, good PO
intake. No nausea, emesis or diarrhea.
ROS: +as above, otherwise reviewed and negative
Past Medical History:
Bladder cancer
Cervical spine disease
Diabetes
Hypertension
Chronic kidney disease
BPH
Alcohol abuse
Chronic pancreatitis
Depression
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM
--------------
Vitals: T:97.7 BP:113/70 P:66 R:18 O2:100%ra
PAIN: 3
General: nad
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd
Ext: no e/c/c
Skin: no rash
GU: foley and L perc nephrostomy tubes in place
Neuro: alert, follows commands
DISCHARGE EXAM
--------------
VS: T 98.6 BP 107/66 P 67 R 16 Sat 98% on RA
GEN: Alert, oriented to name, place, not to date, able to name
days of week backwards. Fatigued appearing but comfortable, no
acute signs of distress.
HEENT: NCAT, Pupils equal and reactive, sclerae anicteric, OP
clear, MMM.
Neck: Supple, no JVD
Lymph nodes: No cervical, supraclavicular LAD.
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
RESP: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, non-tender, non-distended, + bowel sounds.
BACK: nephrostomy tube site c/d/i
EXTR: No lower leg edema, no clubbing or cyanosis
DERM: No active rash.
Neuro: non-focal.
PSYCH: Appropriate and calm.
Pertinent Results:
ADMISSION LABS
--------------
___ 06:50PM GLUCOSE-50* UREA N-86* CREAT-4.2*# SODIUM-140
POTASSIUM-4.8 CHLORIDE-107 TOTAL CO2-20* ANION GAP-18
___ 06:56PM LACTATE-0.7
___ 06:50PM WBC-8.8 RBC-3.21* HGB-9.3* HCT-28.6* MCV-89
MCH-28.9 MCHC-32.4 RDW-13.6
___ 06:50PM NEUTS-70.6* ___ MONOS-6.2 EOS-3.1
BASOS-0.5
___ 06:50PM PLT COUNT-231
___ 06:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
___ 10:30PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 10:30PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 10:30PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
___ 10:30PM URINE RBC-2 WBC-62* BACTERIA-NONE YEAST-NONE
EPI-<1
___ 10:30PM URINE HYALINE-1*
___ 10:30PM URINE MUCOUS-RARE
DISCHARGE LABS
--------------
___ 06:35AM BLOOD WBC-6.2 RBC-2.83* Hgb-8.5* Hct-25.3*
MCV-89 MCH-30.1 MCHC-33.6 RDW-13.8 Plt ___
___ 06:35AM BLOOD Glucose-149* UreaN-48* Creat-2.4* Na-136
K-5.2* Cl-103 HCO3-22 AnGap-16
___ 06:35AM BLOOD Calcium-9.5 Phos-4.2 Mg-1.8
IMAGING
-------
Head CT on admission:
IMPRESSION: No evidence of acute intracranial process.
Chest X-ray ___
IMPRESSION: Nodular opacity projecting over the left suprahilar
region for which dedicated non-urgent chest CT is suggested. No
acute cardiopulmonary process.
Renal ultrasound ___:
IMPRESSION:
1. Resolution of left hydronephrosis.
2. Decreased size of left renal subcapsular hematoma.
MICROBIOLOGY
------------
Blood culture ___: no growth
Urine culture ___: no growth
Urine culture ___: no growth
Brief Hospital Course:
___ year old male with transitional cell cancer resulting in
urinary obstruction and need for left-sided nephrostomy tube
presents with acute kidney injury.
ACTIVE ISSUES
------------
# Acute kidney injury: possible transient tube malfunction,
nephrostomy tube replaced by Interventional Radiology while the
patient was admitted. Creatinine did not improve initially
after nephrostomy tube placement, indicating possible acute
tubular necrosis that was slow to resolve. Urine output was
adequate, with no urine output from the urethra after Foley
removal, but adequate output from the nephrostomy tube. Patient
was treated for a urinary tract infection upon admission, with
the patient given levofloxacin, last day ___. Renal
ultrasound was performed after nephrostomy tube placement, with
improved findings and reduction in hydronephrosis. Renal was
consulted during the patient's stay, and stated to expect slow
recovery of renal function. Creatinine on discharge was 2.4.
Creatinine should be followed up twice per week initially at his
post-acute care facility.
# Agitation: patient frequently agitated during his hospital
stay, most times at night. During the day he was most times
alert and oriented x 2, and able to say the days of the week
backwards. Haloperidol was given to control agitation, and
should be considered if he gets agitated at his post-acute care
facility. He did not require any antipsychiotics for >48 hours
before discharge.
# Urinary tract infection: patient was administerd levofloxacin
empirically for a possible urinary tract infection, last dose
___. Urine culture showed no growth.
# Diabetes mellitus: patient was hypoglycemic during his stay
and his insulin glargine was held for a portion of his stay.
Patient eventually became hyperglycemic and his insulin glargine
and sliding scale insulin was resumed. His glyburide dose will
be held on discharge in favor of sliding scale insulin to be
administered at his post-acute care facility.
INACTIVE ISSUES
---------------
# Incidental lung nodule: patient will need CT follow-up as an
outpatient. His PCP was notified of the finding.
TRANSITIONS OF CARE
-------------------
# Follow-up: patient will follow up with Urology upon discharge.
His creatinine should be followed up two times per week
initially upon discharge. There are no pending labs at the time
of leaving the hospital.
# Code status: Full
# Contact: ___, friend and HCP, ___, brother
___, ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. Labetalol 200 mg PO BID
3. Simvastatin 40 mg PO DAILY
4. BuPROPion 100 mg PO BID
5. GlyBURIDE 5 mg PO BID
6. Paroxetine 20 mg PO DAILY
7. Tamsulosin 0.4 mg PO HS
8. Terazosin 5 mg PO HS
9. Thiamine 100 mg PO DAILY
10. Glargine 12 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
11. Multivitamins 1 TAB PO DAILY
12. Levofloxacin 500 mg PO Q48H
Discharge Medications:
1. BuPROPion 100 mg PO BID
2. Finasteride 5 mg PO DAILY
3. Labetalol 200 mg PO BID
4. Multivitamins 1 TAB PO DAILY
5. Paroxetine 20 mg PO DAILY
6. Simvastatin 40 mg PO DAILY
7. Tamsulosin 0.4 mg PO HS
8. Terazosin 5 mg PO HS
9. Thiamine 100 mg PO DAILY
10. Acetaminophen 1000 mg PO Q8H:PRN pain
11. Glargine 12 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Acute kidney injury
Urinary tract 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:
Dear Mr. ___,
It was a pleasure caring for you at the ___. You came for
further evaluation of altered mental status and kidney
dysfunction. A nephrostomy tube was placed to improve drainage
of your kidneys. Your kidney function is at this time slowly
recovering. You also received antibiotics for a possible
urinary tract infection. It is important that you continue to
take your medications as prescribed and follow up with your
urologist.
Good luck!
Followup Instructions:
___
|
10255285-DS-8 | 10,255,285 | 28,874,151 | DS | 8 | 2130-07-19 00:00:00 | 2130-07-19 13:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Lisinopril
Attending: ___.
Chief Complaint:
dehydration
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w recent L thoracotomy and LUL sleeve lobectomy, LLL wedge
resection on ___, discharged two days ago, here with
fatigue. On arrival to the ED he was noted to be tachycardic to
140s in atrial fibrillation with RVR, and hypotensive to ___.
He
responded briskly to 2L of fluids to SBP 110s and HR in the ___.
He does endorse not eating or drinking much since discharge. On
his admission, rehab was recommended, however he was highly
motivated to be discharged to home and we set up home physical
therapy. He does note that similar to his admission, he gets
short of breath easily (walking 20+ feet). He also presents
realizing that it is hard for him to take care of himself. He
denies any nausea, vomiting, abdominal pain, chest pain,
palpitations, bloody bowel movements, or neurological changes.
He is back to baseline level of EtOH drinking (3 drinks / day).
Past Medical History:
Bladder cancer
Cervical spine disease
Diabetes
Hypertension
Chronic kidney disease
BPH
Alcohol abuse
Chronic pancreatitis
Depression
Social History:
___
Family History:
Non-contributory
Physical Exam:
BP 133/66 HR 95 RR 16 100% on RA
GENERAL
[x] WN/WD [x] NAD [x] AAO [ ] abnormal findings:
HEENT
[x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric
[x] OP/NP mucosa normal [x] Tongue midline
[x] Palate symmetric [x] Neck supple/NT/without mass
[x] Trachea midline [x] Thyroid nl size/contour
[ ] Abnormal findings:
RESPIRATORY
[x] CTA/P [x] Excursion normal [x] No fremitus
[x] No egophony [x] No spine/CVAT
[x] Abnormal findings: thoracotomy incision c/d/i without
erythema
CARDIOVASCULAR
[x] RRR [x] No m/r/g [x] No JVD [x] PMI nl [x] No edema
[x] Peripheral pulses nl [x] No abd/carotid bruit
[ ] Abnormal findings:
GI
[x] Soft [x] NT [x] ND [x] No mass/HSM [x] No hernia
[ ] Abnormal findings:
GU [x] Deferred
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
NEURO
[x] Strength intact/symmetric [x] Sensation intact/ symmetric
[x] Reflexes nl [x] No facial asymmetry [x] Cognition intact
[x] Cranial nerves intact [ ] Abnormal findings:
MS
[x] No clubbing [x] No cyanosis [x] No edema
[x] No tenderness [x] Tone/align/ROM nl [x] Palpation nl
[x] Nails nl [ ] Abnormal findings:
LYMPH NODES
[x] Cervical nl [x] Supraclavicular nl [x] Axillary nl
[ ] Abnormal findings:
SKIN
[x] No rashes/lesions/ulcers
[x] No induration/nodules/tightening [ ] Abnormal findings:
PSYCHIATRIC
[x] Nl judgment/insight [x] Nl memory [ ] Nl mood/affect
[x] Abnormal findings: odd affect
Pertinent Results:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
___ 07:05 8.5 3.11* 9.5* 29.3* 94 30.7 32.6 14.4 451*
___ 14:00 8.6 3.02* 9.1* 28.7* 95 30.1 31.7 14.6 461
Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 07:05 194*1 39* 1.9* 137 4.7 ___
___ 14:00 209*1 50* 2.6* 1362 5.6* 101 14*3 27*
___ CXR :
Postsurgical changes in the left hemithorax with decreased
subcutaneous
emphysema in the left chest wall. Previously identified left
apical
pneumothorax now appears to have resolved with small amount of
fluid seen in the pleural space. No definite pneumonia
visualized
Brief Hospital Course:
Mr. ___ was evaluated by the Thoracic Surgery service in the
Emergency Room and admitted to the hospital for further
management of his severe dehydration and atrial fibrillation.
His heart rate returned to normal with IV lopressor and his oral
dose was decreased from 50 BID to 25 BID as his blood pressure
was 100/60. He tolerated this dose well and was able to
maintain sinus rhythme in the 55-75 range.
He was rehydrated with IV fluids for 48 hours and his renal
function returned to baseline with a creatinine of 1.9. His
left chest incisions were healing well and use of the incentive
spirometer was encouraged. His room air oxygen saturations were
98%.
He was evaluated by the Physical Therapy service and was
initially orthostatic but this resolved in 24 hours and he was
able to continue treatment. a short term rehab stay was
recommended to help increase his mobility and endurance.
His blood sugars were initially elevated > 200 but he was
started on Lantus 12 units qhs along with his routine glipizide
BID. The Lantus was recommended at his last hospitalization by
the ___ but he was not sent home on it as he was new
to insulin and refused to check his blood sugars qid and learn
administration. Currently his sugars sre in the 120-200 range.
He may be more amanable to learning insulin administration as
his rehab time progresses.
The Scial Worker also talked to him about abstaining from
drinking alcohol and offered him outside assistance for
counselling which he refused but again, maybe in time he will be
more ameable to help.
He was discharged to rehab on ___ and will follow up in the
Thoracic Clinic in 2 weeks.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. BuPROPion 100 mg PO BID
3. Metoprolol Tartrate 50 mg PO BID
4. Simvastatin 40 mg PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. multiv-min-FA-lycopene-lutein 0.4mg-300mcg 250 mcg oral
daily
7. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500-125
mg-unit oral daily
8. Aspirin 81 mg PO DAILY
9. Tamsulosin 0.4 mg PO HS
10. Paroxetine 20 mg PO DAILY
11. GlipiZIDE 5 mg PO BID
12. Vitamin B Complex 1 CAP PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. Acetaminophen 650 mg PO Q6H
15. Docusate Sodium 100 mg PO BID
16. Milk of Magnesia 30 mL PO Q12H:PRN constipation
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. BuPROPion 100 mg PO BID
3. Finasteride 5 mg PO DAILY
4. GlipiZIDE 5 mg PO BID
5. Metoprolol Tartrate 25 mg PO BID
6. Paroxetine 20 mg PO DAILY
7. Simvastatin 40 mg PO DAILY
8. Tamsulosin 0.4 mg PO HS
9. Vitamin B Complex 1 CAP PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. FoLIC Acid 1 mg PO DAILY
12. Heparin 5000 UNIT SC TID
13. Thiamine 100 mg PO DAILY
14. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500-125
mg-unit oral daily
15. Docusate Sodium 100 mg PO BID
16. Ferrous Sulfate 325 mg PO DAILY
17. Milk of Magnesia 30 mL PO Q12H:PRN constipation
18. multiv-min-FA-lycopene-lutein 0.4mg-300mcg 250 mcg oral
daily
19. Aspirin 81 mg PO DAILY
20. Glargine 12 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hypovolemic shock
Lactic acidosis
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
* You were readmitted to the hospital 2 days after being
discharged from your lung surgery with Dehydration. You were
rehydrated with IV fluids and your kidney function is back to
baseline. You are being transferred to rehab prior to going home
to try to recover from your surgery, increase your activity and
continue pulmonary toilet.
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage.
* Use Tylenol for pain. Make sure that you have regular bowel
movements. Use a stool softener or gentle laxative to stay
regular.
* No driving for 4 weeks.
* Take Tylenol ___ mg every 6 hours.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk ___ times a day and gradually increase your activity as
you can tolerate.
Call Dr. ___ ___ if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms
that concern you.
Followup Instructions:
___
|
10255285-DS-9 | 10,255,285 | 26,298,504 | DS | 9 | 2131-04-02 00:00:00 | 2131-04-02 22:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending: ___.
Chief Complaint:
s/p fall, hyperglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male hx. afib not on coumadin, EtOH abuse, lung
cancer s/p lobectomy, HTN, chronic pancreatitis, bladder CA,
stage III CKD, frequent falls presenting with fall and
hyperglycemia.
Patient reports falling last night in his apartment after
standing up from sitting. Says as soon as he stood up had
feeling that the 'room was spinning' and fell down. Reports
+headstrike. Denies chest pain, dyspnea, or loss of
conscioussness. No tongue biting, loss of bowel or bladder. He
reports 2 falls over the last month, neither of which invovled
LOC. He walks with a cane at baseline every since a CVA last
year that left him with transient left foot drop. He ___
fevers/chills, no nausea or vomiting. He does reports ___ weeks
of loose stools/diarrhea, ___. No abdominal pain, so sick
contacts. He is a heavy drinker, reports ___ drinks vodka/day,
last was 3d ago. Has had withdrawal in the past no seizures but
possible DTs at ___ many years ago. Not feeling tremulous at
this time.
For the fall, patient presented to ___ urgent care today where
___ was negative for acute process, blood glucose noted to be
350, was given 5U regular insulin SQ, repeat glucose 450 so sent
to ___ ED.
In the ED initial vitals were: 97.4 95 137/90 18 98%.
- Labs were significant for H/H 9.6/29.1, chemistries notable
for Bun/Cr 44/2.6 (b/l ___, u/a with sm leuks no bacteria. ___
was 425.
- Patient was given 1L NS and 10u IV insulin.
On the floor, patient has no complaints other than being hungry.
Past Medical History:
CANCER - BLADDER
DEPRESSIVE DISORDER
PROSTATIC HYPERTROPHY - BENIGN
HYPERCHOLESTEROLEMIA
Colonic adenoma
PROTEINURIA
HYPERTENSION - ESSENTIAL, UNSPEC
MENINGITIS - BACTERIAL, UNSPEC
SPINAL STENOSIS - LUMBAR
SPONDYLOSIS - CERVICAL
CARPAL TUNNEL SYNDROME
ANEMIA, UNSPEC
Pancreatitis
DM (diabetes mellitus) type II controlled with renal
manifestation
Neuropathy, diabetic
Body mass index
___
H/O nephrostomy
CKD (chronic kidney disease) stage 3, GFR ___ ml/min
Left foot drop
bh
Lung mass
Pancreatic cyst
S/P lobectomy of lung
Non-small cell lung cancer
A-fib
Alcoholism /alcohol abuse
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission PE:
Vitals - 98.6 147/88 hr 93 16 96% RA
GENERAL: awake, alert, NAD
HEENT: EOMI, PERRLA, OMM no lesions
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
NEURO: CN II-XII intact, strength ___ in UE b/l, ___ in RLE ___
in LLE
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
.
Discharge PE:
Vitals: 98.1, 130/75, 57, 16, 98% RA
Orthostatics negative
GENERAL: elderly male, talkative, sitting on the side of the
bed, in NAD
NECK: supple
CARDIAC: RRR, no murmurs
LUNG: CTAB, breathing comfortably
ABDOMEN: soft, NT, ND
EXTREMITIES: no ___ edema
NEURO: ___ strength in ___ at hips and knees
Pertinent Results:
Admission Labs:
___ 06:20PM BLOOD WBC-6.4 RBC-3.27* Hgb-9.6* Hct-29.1*
MCV-89 MCH-29.4 MCHC-33.0 RDW-14.2 Plt ___
___ 06:20PM BLOOD Glucose-296* UreaN-44* Creat-2.6* Na-137
K-4.8 Cl-104 HCO3-24 AnGap-14
.
Discharge Labs:
___ 06:05AM BLOOD WBC-5.8 RBC-2.93* Hgb-8.7* Hct-26.3*
MCV-90 MCH-29.5 MCHC-32.9 RDW-14.2 Plt ___
___ 06:05AM BLOOD Glucose-272* UreaN-42* Creat-2.6* Na-139
K-4.4 Cl-108 HCO3-23 AnGap-12
___ 06:05AM BLOOD Mg-1.8
.
>> IMAGING:
___ HEAD CT W/O CONTRAST
No evidence of acute intracranial process.
.
___ Imaging CHEST (PA & LAT)
Expected postoperative changes of left upper lobectomy without
superimposed acute cardiopulmonary process.
Brief Hospital Course:
___ year old male hx. afib not on coumadin, EtOH abuse, lung
cancer s/p lobectomy, HTN, chronic pancreatitis, bladder CA,
stage III CKD, frequent falls presenting with fall and
hyperglycemia.
.
# Frequent falls: Pt describes lightheadedness with standing
leading to fall. Multiple prior falls as well. Orthostatics neg.
Tele without events and EKG not ischemic. Falls are likely
multifactorial from EtOH abuse and multiple comorbidities. Pt
evaluated by ___ and felt safe for discharge.
.
# T2DM/hyperglycemia: previously on glipizide, but this was
stopped when HbA1C was in 5-range. However HbA1C has been
uptrending in the months off meds and now with hyperglycemia to
400 range. No clear event occurring to cause sudden
hyperglycemia so suspect this is simply progression of his DM
off meds. He very strongly prefers trying oral agents to insulin
and PCP started glipizide the day of presentation, which seems
reasonable. Encouraged pt to check blood sugars.
.
# EtOH abuse: reports ___ per day with remote history of what
sounds like DTs. No signs/sx withdrawal at this time. CIWA
scores <10
.
# CKD: stage III, baseline Cr anywhere from 2.0-2.4, most
recently 2.8. Cr 2.6 on admission stable.
.
# Lung cancer: s/p lobectomy ___, invasive squamous cell as per
atrius records
# Bladder cancer: s/p BCG injections
# HTN: hold losartan as above, cont metop
# Hx. CVA: aspirin, statin
# afib: ?paroxysmal, history not immediately clear, sinus on
admission, not on coumadin which may be because of recurrent
falls, continue aspirin
# HLD: simvastatin
# BPH: continue finasteride, tamsulosin
# Depression: paroxetine, wellbutrin
.
>> Transitional issues:
# Code: DNR/DNI
# Emergency Contact: ___: Friend
Phone number: ___ Cell phone: ___ alternate;
friend ___ ___
# Pt to f/u with PCP for DM ___ start glipizide
(e-prescribed by PCP ___ ___
# OP ___ recommended (Script provided)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion (Sustained Release) 100 mg PO BID
2. Metoprolol Tartrate 25 mg PO BID
3. Simvastatin 20 mg PO QPM
4. Losartan Potassium 25 mg PO DAILY
5. Finasteride 5 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Thiamine 100 mg PO DAILY
9. Ferrous Sulfate 325 mg PO DAILY
10. Acetaminophen 325 mg PO Q6H:PRN pain
11. Paroxetine 20 mg PO DAILY
12. Aspirin 81 mg PO DAILY
13. Tamsulosin 0.4 mg PO HS
14. GlipiZIDE 5 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. BuPROPion (Sustained Release) 100 mg PO BID
3. Ferrous Sulfate 325 mg PO DAILY
4. Finasteride 5 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Metoprolol Tartrate 25 mg PO BID
7. Paroxetine 20 mg PO DAILY
8. Simvastatin 20 mg PO QPM
9. Tamsulosin 0.4 mg PO HS
10. Thiamine 100 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Acetaminophen 325 mg PO Q6H:PRN pain
13. GlipiZIDE 5 mg PO DAILY
14. Losartan Potassium 25 mg PO DAILY
15. Outpatient Physical Therapy
Diagnosis: frequent mechanical falls
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: mechanical fall, hyperglycemia
Secondary diagnosis: diabetes, chronic pancreatitis, alcohol
abuse
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 in the hospital. You were
admitted after a fall. You were also found to have high blood
sugars at your doctor's office. You should start taking the
glipizide 5mg every morning as prescribed by your PCP for your
diabetes. Please try to check your blood sugars at home ___
daily if possible.
You should also be very careful when getting up from lying or
sitting to standing to prevent further falls. The physical
therapists saw you and thought you were safe to go home. You
should use your cane when walking, including in your home.
Please call your PCP's office on ___ to make an appointment
to be seen in the next week.
Please continue to take all of your home medications. The only
new medication will be the glipizide which is waiting for you at
your pharmacy (sent yesterday by your PCP).
Followup Instructions:
___
|
10255286-DS-4 | 10,255,286 | 25,868,656 | DS | 4 | 2169-08-28 00:00:00 | 2169-08-28 14:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
back pain, weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ woman with history of HTN, HLD,
PMR/GCA on chronic steroids, osteoarthritis, scoliosis, gout who
presents with back pain.
The patient reports that she has a history of chronic bilateral
lower back pain, however, it worsened over the past ___ days.
She
denies any trauma. No lifting or twisting movements. She reports
that she had similar pain previously that radiated to her
thighs,
for which she received an epidural injection that provided
relief
for several months. She states that her current pain is similar
in quality to that pain, but more severe. The pain is limiting
her ability to walk. She denies any numbness or tingling. She
denies any headaches, scalp pain/tenderness, jaw claudication;
she has been on a stable prednisone dose for many months. No
weakness with lifting her arms overhead to comb her hair. She
gets gout in her hands and big toes; no recent flares. She
denies
any fevers at home prior to admission. She has a chronic dry
cough for several years; no shortness of breath. No dysuria; she
has had urinary incontinence for over ___ years for which she
takes oxybutynin. No abdominal pain, nausea, vomiting, changes
in
bowel habits.
The patient initially presented to ___. There, her Tmax
was
100.0, other vitals stable. Labs notable for WBC 8.7, Hb 11.5,
BMP wnl, LFTs wnl. UA bland. Lumbar spine plain films
demonstrated scoliosis and degenerative changes. CXR negative.
CT
A/P showed possible renal neoplasm but no acute process. The
patient was given Tylenol. The patient was subsequently
transferred to ___ for further care, specifically for MRI to
exclude spinal infection as a cause of her symptoms.
Of additional note, the patient recently saw rheumatology in
___ at ___. Per notes from that visit, she was diagnosed
with biopsy negative giant cell arteritis/polymyalgia rheumatica
in ___ and apparently had a dramatic response to prednisone.
She
has been on tapering prednisone doses since. For the past 6
months, she has been on 7.5 mg daily. Was also on methotrexate
15
mg weekly for over a year but it was stopped for unclear reason.
She has a history of scoliosis and spinal stenosis that
responded
well to epidural injections in the past. CRP was 10 at that
time.
Plan at that visit was to continue prednisone at current dosing.
In the ED, vitals notable for: 97.8 (afebrile) 85 130/76 16 96%
RA
Exam notable for:
- Msk-mild lumbosacral tenderness, moving all 4 extremities. ___
strength in all 4 extremities, incision intact to light touch in
all dermatomes, negative straight leg raise bilaterally
- Neuro-A&O x3, CN ___ intact, normal strength and sensation in
all extremities, normal speech and gait.
Labs notable for: WBC 7.4, BMP wnl; CRP 126.7; UA with few bact,
5 WBC, neg leuks, neg nit
Imaging: MRI C/T/L spine; NCHCT
Patient given: Keppra 500 mg x2, metoprolol tartrate 50 mg x2,
simvastatin 40 mg, prednisone 7.5 mg, losartan 75 mg, sertraline
100 mg, allopurinol ___ mg, oxybutynin 10 mg, Tylenol ___ mg
Of additional note, her ED course was complicated by some
confusion, and her son reports that his mother has seemed more
confused recently.
On arrival to the floor, the patient reports that her back pain
feels much improved, now a ___. She denies any other complaints
at this time.
Past Medical History:
- Temporal arteritis/PMR on chronic prednisone
- Lumbar spinal stenosis
- Degenerative disk disease
- Scoliosis
- Osteopenia/osteoporosis
- Osteoarthritis
- Question of rheumatoid arthritis
- Bilateral rotator cuff tears
- Hypertension
- Hyperlipidemia
- Seizure disorder
- Breast cancer s/p lumpectomy
- CKD
- Urinary incontinence
- Gout
- Depression
- S/p bilateral TKR
- S/p spontaneous R femoral fracture in ___ while on
bisphosphonates
Social History:
___
Family History:
No known family history of rheumatoid arthritis.
Physical Exam:
Admission Physical Exam:
========================
VITALS: 98.1 150/90 73 18 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
CV: Heart regular, no murmur
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.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, strength ___ in bilateral upper and lower
extremities, sensation intact to light touch in upper and lower
extremities; joint deformities in bilateral fingers
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: Very pleasant, appropriate affect
Discharge Physical Exam:
========================
VITALS: see Eflowsheets
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
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.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, strength ___ in bilateral upper and lower
extremities, sensation intact to light touch in upper and lower
extremities; joint deformities in bilateral fingers
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: Very pleasant, appropriate affect
Pertinent Results:
Admission Labs:
===============
___ 07:11PM BLOOD WBC-7.4 RBC-4.26 Hgb-12.3 Hct-37.7 MCV-89
MCH-28.9 MCHC-32.6 RDW-15.8* RDWSD-50.9* Plt ___
___ 07:11PM BLOOD ___ PTT-28.0 ___
___ 07:11PM BLOOD Glucose-89 UreaN-17 Creat-1.0 Na-144
K-3.6 Cl-105 HCO3-24 AnGap-15
___ 05:38AM BLOOD Calcium-8.6 Phos-3.8 Mg-1.9
___ 07:11PM BLOOD CRP-126.7*
Imaging:
========
MRI Spine:
1. No evidence of epidural collection or abnormal enhancement.
2. Multilevel degenerative changes throughout the entire spine,
most
pronounced at L3-L4 and L5-S1 where there is severe spinal canal
stenosis with effacement of the CSF space, severe neural
foraminal narrowing and meant of the lateral recesses, as
detailed above.
3. Multilevel cervical spondylosis with disc herniations
resulting in
remodeling of the ventral cord but without cord signal
abnormality and
multilevel mild and moderate neural foraminal narrowing, most
pronounced at C5-C6.
4. Mild degenerative changes along the thoracic spine, most
pronounced at
T12-L1 where there is a disc bulge resulting in spinal canal
stenosis with
remodeling of the ventral cord but no cord signal abnormality.
CT Head:
No acute intracranial process. Severe small vessel disease.
Discharge Labs:
===============
___ 04:30AM BLOOD WBC-10.2* RBC-3.87* Hgb-10.9* Hct-33.8*
MCV-87 MCH-28.2 MCHC-32.2 RDW-15.3 RDWSD-49.2* Plt ___
___ 04:30AM BLOOD Glucose-79 UreaN-33* Creat-1.2* Na-143
K-3.9 Cl-106 HCO3-25 AnGap-12
___ 04:30AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.9
___ 04:30AM BLOOD CRP-80.3*
Brief Hospital Course:
Ms. ___ is a ___ woman with history of HTN, HLD,
PMR/GCA on chronic steroids, osteoarthritis, scoliosis, gout who
presented with back pain.
ACUTE/ACTIVE PROBLEMS:
# Acute on chronic low back pain
# History of GCA/PMR on chronic prednisone
# Osteoarthritis
# Possible history of inflammatory arthritis
# Lumbar spondylosis and spinal stenosis: Patient with history
of chronic lower back pain, likely multifactorial but primarily
due to lumbar spondylosis and spinal stenosis who presented with
atraumatic worsening of lower back pain with radiation to her
anterior thighs consistent with pain secondary to lumbar
degenerative joint disease. MRI demonstrated no cord compression
or cauda equina compression, and no evidence of spinal
infection, but did demonstrate multilevel degenerative spinal
disease.
Patient with maximum temperature of 100.0 at outside hospital,
but no true fevers and no evidence of infection including spinal
infection on MRI.
Given her known history of PMR which has presented at times as
thigh pain as well as an elevated CRP of 126 (ESR was 45, normal
for patient age), rheumatology was consulted. They did not find
any evidence of active polymyalgia rheumatica or any other
inflammatory cause of back pain. They did not recommend any
changes to current prednisone dose.
Cause of CRP elevation was unclear, but no infection was found
as above and CRP had spontaneously downtrended to 80 at time of
discharge.
Pain spontaneously improved and her exacerbation was felt to be
likely musculoskeletal or secondary to lumbar disc disease. She
was seen by ___ who recommended rehab.
# Possible renal mass: CT A/P at outside hospital demonstrated
2.1 cm lesion on left kidney suspicious for renal neoplasm, as
well as renal and hepatic cysts. She will need MRI for further
evaluation but this was unable to be performed as an inpatient.
Discussed with patient's primary care office who will order scan
as an outpatient. Patient and her daughter are both aware of
need for renal MRI to exclude malignancy
# Encephalopathy, resolved: Patient initially presented with
waxing and waning
sensorium in the ED. On arrival to the floor, she was lucid and
linear. She had no signs or symptoms of infection and basic
infectious workup was negative. She also had no metabolic
derangements to explain confusion. NCHCT was without acute
process but did show chronic small vessel changes that would
likely predispose to delirium. Overall her initial altered
mental status in the ED was felt to likely be delirium in the
setting of severe pain. She had no episodes of confusion while
admitted
CHRONIC/STABLE PROBLEMS:
# Hypertension: continued home metoprolol, losartan, amlodipine
# Hyperlipidemia: CoQ-10 help while inpatient as non-formularly
# Seizure disorder: continued home Keppra
# CKD: Per chart, unknown baseline Cr. Creatinine remained in
1.0-1.2 range
# Gout: continued home allopurinol
# Depression: continued home sertraline
# Urinary incontinence: continued home oxybutinin
> 30 minutes spent on discharge coordination and planning
Transitional Issues:
====================
- needs renal MRI to further evaluate suspicious renal lesion
- should have CRP rechecked as an outpatient to ensure
downtrending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 50 mg PO BID
2. Oxybutynin XL (*NF*) 10 mg PO DAILY
3. Sertraline 100 mg PO DAILY
4. PredniSONE 7.5 mg PO DAILY
5. Losartan Potassium 75 mg PO DAILY
6. amLODIPine 10 mg PO DAILY
7. Allopurinol ___ mg PO DAILY
8. LevETIRAcetam 500 mg PO BID
9. Co Q-10 (coenzyme Q10) 10 mg oral DAILY
10. Centrum Silver
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein)
0.4-300-250 mg-mcg-mcg oral DAILY
11. Colchicine 0.6 mg PO DAILY:PRN Gout flare
12. FoLIC Acid 1 mg PO DAILY
13. magnesium 12 mg oral DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Allopurinol ___ mg PO DAILY
3. amLODIPine 10 mg PO DAILY
4. Centrum Silver
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein)
0.4-300-250 mg-mcg-mcg oral DAILY
5. Co Q-10 (coenzyme Q10) 10 mg oral DAILY
6. Colchicine 0.6 mg PO DAILY:PRN Gout flare
7. FoLIC Acid 1 mg PO DAILY
8. LevETIRAcetam 500 mg PO BID
9. Losartan Potassium 75 mg PO DAILY
10. magnesium 12 mg oral DAILY
11. Metoprolol Tartrate 50 mg PO BID
12. Oxybutynin XL (*NF*) 10 mg PO DAILY
13. PredniSONE 7.5 mg PO DAILY
14. Sertraline 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Back pain
Secondary:
Polymyalgia rheumatica
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You came in with back pain. We think the pain was likely due to
a muscle strain or pinched nerve. You had an MRI which did not
show any sign of fracture or infection in the spine.
You were also seen by the rheumatologists who felt that your
polymyalgia was under good control. They did not recommend any
changes to your prednisone dose.
At Metro West you had a CT scan that showed a lesion on your
kidney. It will be very important to have an MRI as an
outpatient to make sure that this lesion is not cancer. We spoke
to Dr. ___ and they are working on arranging this
for you.
You are now going to rehab to work on getting stronger.
It was a pleasure taking care of you, and we are happy that
you're feeling better!
Followup Instructions:
___
|
10255684-DS-17 | 10,255,684 | 20,171,184 | DS | 17 | 2124-12-10 00:00:00 | 2124-12-10 11:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Dizziness, Dysarthria, Right Facial Droop
Major Surgical or Invasive Procedure:
s/p tPA (administered at OSH)
History of Present Illness:
Ms. ___ is an ___ year old right handed woman with a history
of hypertension, hyperlipidemia, osteoarthritis, bilateral
Carpal Tunnel
Syndrome status post left wrist entrapment release who presented
from ___ where she had presented with
dysarthria, dizziness, and a right facial droop. Last known well
time was 0930 hours on ___ at which time she had been
having breakfast with her husband. On ambulation to the
bathroom, she noted extreme dizziness (room spinning) and
unsteadiness which did not resolve. She noted she felt like she
was about to fall and called out to husband saying, "I think I'm
having a stroke". Her husband caught her from falling and
noticed that Ms. ___ was dysarthric with a right facial
droop. She reports no deficit in understanding what was being
said to her and was able to come up with the words to
communicate which was understood by her husband.
Ms. ___ husband and son who was visiting on his vacation
brought her to ___ where initial evaluation
revealed a NIHSS of 5, scored for right facial droop, sensory
loss in right mandibular distribution, and right
pronator drift. Non-contrast Head CT Scan raised concern at
___ for a dense left MCA sign for which tPA was
administered at 1225 hours on ___. A repeat head CT showed
dissolution of this sign at which time she was transferred to
___ for further intervention.
On arrival, Ms. ___ had continued dizziness and nausea. She
was slightly sleepy per the family, but still answering
questions appropriately. She was assessed as having a NIHSS of
3, scored for partial gaze palsy noted to be an intranuclear
opthalmoplegia with right beat nystagmus in left eye and
inability to abduct right eye past midline on left gaze, right
nasolabial fold
flattening, and diminished pinprick in her right upper
extremity. She was admitted to the Neuro ICU for further
management.
On neurologic review of symptoms, Ms. ___ reports some
lightheadedness status post CT Angiogram study, and tingling in
right first 3.5 digits which is her baseline due to carpal
tunnel syndrome. She denies headache, loss of vision, blurred
vision, diplopia, dysphagia, tinnitus or hearing difficulty. No
recent neck manipulations. Denies difficulties producing or
comprehending speech. Denies clumisness, notable weakness in
arms or legs. Has tingling in right hand at baseline. No bowel
or bladder incontinence or retention.
On general review of systems, she 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 vomiting, diarrhea, abdominal pain.
Past Medical History:
- Hypertension on Atenolol/Chlorthalidone
- Hyperlipidemia on Simvastatin
- Gout on Allopurinol
- Osteoarthritis
- Anxiety on Xanax as necessary
Social History:
___
Family History:
___ disease, Diabetes ___ in father. ___
___ also in siblings. Breast cancer in sister, ___
cancer in deceased sister.
Physical Exam:
INITIAL PHYSICAL EXAMINATION:
Vitals: T: 98.1F, P: 82 - NSR, R: 16, BP:132/66, SaO2: 98%
on Room Air
General: Awake, though sleepy, no acute distress
HEENT: NC/AT, MMM, no lesions noted in oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: WWP, 2+ radial, DP pulses bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
___ Stroke Scale score was : 3
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 1 (partial gaze palsy, see exam)
3. Visual fields: 0
4. Facial palsy: 1 (R nasolabial fold flattening)
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: 1 (diminished pinprick in R upper arm)
9. Language: 0
10. Dysarthria: 0
11. Extinction and Neglect: 0
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Can read and name all items on stroke card
without
dysarthria- calls hammock "canopy", others correct. Describes
picture without evidence of visual neglect. Interestingly uses
right eye primarily to describe image (due to dysconjugate
gaze).
Normal prosody. There were no paraphasic errors. Able to
follow
both midline and appendicular commands. Pt. was able to register
3 objects and recall ___ at 5 minutes. There was no evidence of
apraxia or neglect (visual or sensory).
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm on L and 4mm to 3mm on right and brisk. VFF
to confrontation. Funduscopic exam deferred.
III, IV, VI: Has ptosis in Left eye. In primary gaze if focusing
on object, gaze is conjugate. If not actively focusing left eye
is depressed and laterally deviated ("down and out"), with down
and right gaze, eyes are conjugate. With left gaze, there is
nystagmus in L eye and inability to adduct R eye (INO). With
upgaze, there is inappropriate lateral deviation of left eye;
right appropriately elevates.
V: Facial sensation intact to light touch, and pinprick.
VII: Slight Right NLF flattening, normal activation. Forehead is
spared.
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. Possible cupping in right
hand without pronation or drift. No tremors or asterixis
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 4+ 5 5 5 5 5 5
R 5- ___ ___ 4+ 5 5 5 5 5 5
IP exam is somewhat limited by patient's sleepiness and lack of
effort.
-Sensory: Decreased cold sensation on left foot compared to
right. Diminished vibratory sense (8s on left 6s on right
bilateral great toes). Intact to pinprick throughout. No
extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 0 1
R 2 2 2 0 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. Mild dysdiadochokinseia on
Right compared to left. Normal FNF on right. Slight ataxia with
toe to finger right.
-Gait: deferred.
Neurological Exam at Discharge:
INO on left gaze, which was present on admission is
significantly improved. She has mild proximal right upper and
lower extremity weakness. Mild dysmetria on FNF on right
Pertinent Results:
___ 07:34PM GLUCOSE-137* UREA N-19 CREAT-1.0 SODIUM-138
POTASSIUM-3.2* CHLORIDE-97 TOTAL CO2-26 ANION GAP-18
___ 07:34PM CK(CPK)-89
___ 07:34PM CK-MB-5 cTropnT-0.12*
___ 07:34PM CALCIUM-9.6 PHOSPHATE-4.8* MAGNESIUM-1.6
___ 03:10AM BLOOD WBC-9.8 RBC-3.79* Hgb-11.8* Hct-35.4*
MCV-93 MCH-31.3 MCHC-33.5 RDW-13.3 Plt ___
___ 04:33AM BLOOD ___ PTT-22.8* ___
___ 03:10AM BLOOD Glucose-148* UreaN-16 Creat-0.9 Na-136
K-3.8 Cl-97 HCO3-26 AnGap-17
___ 03:10AM BLOOD CK-MB-5 cTropnT-0.13*
___ 03:10AM BLOOD %HbA1c-5.5 eAG-111
MRI brain Multiple puncatate acute right cerebellar infarctions.
No intracranial hemorrhage.
Echo: The left atrium is elongated. No thrombus/mass is seen in
the body of the left atrium. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. Left ventricular wall thicknesses are normal.
The left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. There is boderline mild
global left ventricular hypokinesis (LVEF = 50 %). There are two
calcified false tendons seen in the LV apex. No LV thrombus is
seen.There is no ventricular septal defect. The right
ventricular cavity is mildly dilated with borderline normal free
wall function. The diameters of aorta at the sinus, ascending
and arch levels are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild to
moderate (___) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
CTA head and neck:
1. The patient's known right cerebellar infarcts are better
demonstrated on MRI exam of ___.
2. No evidence of dissection, stenosis, or aneurysm formation
of the cervical or intracranial vessels.
3. Biapical patchy ground glass opacities and small
consolidations likely
represent infection, inflammation or aspiration.
CT Torso:
1. No evidence of malignancy in the chest, abdomen or pelvis.
2. Bilateral, patchy ground-glass opacities involving the lungs,
which may represent atypical inflammation. There is no evidence
of focal consolidation or lymphadenopathy.
3. Pancreas divisum morphology without evidence of
pancreatitis.
4. Sigmoid diverticulosis without diverticulitis.
Brief Hospital Course:
NEUROLOGIC:
Ms. ___ presented to an OSH with symptoms of dizziness,
dysarthria and right facial droop. She received tPA at OSH and
was transferred to ___ for further evaluation and management.
She says that after receiving the tPA, her dysarthria had
improved. She was admitted to the ICU s/p tPA for monitoring.
She had an MRI of her brain which showed multiple small right
sided middle cerebellar peduncle and right cerebellum strokes.
To evaluate for the etiology of the strokes, she had a TTE,
which did not reveal an LV thrombus or PFO. She was monitored on
tele and did not develop any irregular heart rhythms. A CT scan
or her torso was performed and showed no signs of malignancy.
Given that no clear etiology of her stroke was identified,
outpatient Holter monitoring was ordered for further evaluation
of paroxysmal a. fib. For her stroke, her ASA was increased to
325 mg daily. A bedside speech and swallow was also successfully
performed and a heart healthy diet was started. She was seen by
___, who cleared her for d/c home with a walker and home ___.
CARDIOVASCULAR / PULMONARY:
The patient was evaluated with troponins which came back as
slightly elevated at 0.12 and on repeat study 0.13. Her EKG was
also obtained which showed initially normal sinus rhythm, was
repeated with the second troponin showing a sub-1mm ST change in
the V1 and V2 leads and findings of a left bundle branch block.
Her repeat EKG showed neither of these abnormalities. Of note,
the patient has not complained of any palpations, pain or
tightness in her chest, shortness of breath, diaphoresis, or
nausea.
PROPHYLAXIS:
While under management, the patient wore pneumoboots as
prophylaxis against deep venous thrombosis. Due to tPA
administration, prophylactic subcutaneous heparin was withheld
until 24 hours after dosing. The patient also received
ranitidine for acid reflux.
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 76) - () No
5. Intensive statin therapy administered? (for LDL > 100) () Yes
- (x) 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 given? (x) Yes - () No
8. Assessment for rehabilitation? (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) NA
Medications on Admission:
- Aspirin 81mg daily
- Simvastatin 10mg each evening
- Atenolol/Chlorthalidone 50/25mg each evening
- Allopurinol ___ mg each evening
- Xanax as necessary for anxiety
- Tylenol ___ each evening
Discharge Medications:
1. ALPRAZolam 0.5 mg PO TID:PRN anxiety
2. Simvastatin 10 mg PO DAILY
3. Allopurinol ___ mg PO DAILY
4. Atenolol 50 mg PO DAILY
5. Chlorthalidone 25 mg PO DAILY
6. Outpatient Physical Therapy
home ___ for further endurance and balance training.
7. Aspirin 325 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
right middle cerebellar peduncle and cerebellum strokes
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neurological Exam at Discharge:
INO on left gaze, which was present on admission is
significantly improved. She has mild proximal right upper and
lower extremity weakness. Mild dysmetria on FNF on right.
Discharge Instructions:
You were admitted to the hospital with symptoms of sudden onset
dizziness, slurred speech and right facial droop. You were
initially seen at another hospital, where you received tPA,
which is a clot-busting medication used in the setting of an
acute stroke. You were then transferred to ___ and
monitored in the ICU for 24 hours before going to the Neurology
floor. You had an MRI of your head, which showed small strokes
in the back part of your brain called the cerebellum. As part of
the evaluation for the cause of the strokes, you had an
echocardiogram of your heart and a CT scan of your torso. There
was no evidence of a cardioembolic cause of the stroke on the
echo. The CT did not show any evidence of cancer. Lab work that
was checked showed no evidence of diabetes (HgbA1c 5.5) and your
cholesterol is well controlled (LDL 76). To complete the
evaluation for the cause of your stroke, you will need to
schedule an appointment to wear a heart monitor as an outpatient
to see if your heart will intermittently develop an abnormal
rhythm. The number to schedule this is below. For the stroke,
your Aspirin dose was increased from 81 mg to 325 mg daily.
Followup Instructions:
___
|
10255799-DS-20 | 10,255,799 | 27,970,282 | DS | 20 | 2125-02-23 00:00:00 | 2125-02-23 10:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
penicillin
Attending: ___.
Chief Complaint:
hiatal hernia
Major Surgical or Invasive Procedure:
Exploratory laparotomy, reduction, crural plication, gastropexy,
g-tube x2
History of Present Illness:
___ with PMHx of DVT on Coumadin, known hiatal hernia presenting
to ___ with massive gastric-hiatal hernia as a transfer from
___. The patient recently suffered a left wrist fx after
a fall. Patient was at rehab where she had not been having any
bowel movement for several days associated with nausea and
vomiting brown liquid. She was seen at ___, CT was
concerning for obstructing hiatal hernia. Lactate was 5, she was
given 3L IVF. The patient was sent to ___ for further
management. In the ED she was found to be hypoxic to ___ on a
NRB, tachypneic, hypotensive to ___. R femoral CVL placed, she
was started on norepinephrine. An NGT was placed and about 3L of
gastric contents were suctioned out. The patient's respiratory
status improved somewhat, transferred to TICU on a face mask
with
sats around 89.
Past Medical History:
PMH: DVT, HTN, hiatal hernia, GERD, ischemic LLE s/p
thrombectomy
PSH: ORIF of L wrist, left groin cutdown and thrombectomy,
hysterectomy, kidney stone removal, tosnilectomy as a child
Social History:
___
Family History:
N/C
Physical Exam:
--ADMISSION--
GEN: NAD
HEENT: PERRt
CV: RRR
PULM: Coarse breath sounds b/l
ABD: Soft, nondistended, nontender
--DISCHARGE--
VS: T:98.5 HR:72 BP: 142/52 RR: 16 97%O2 sat
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: -LAD, mucous membranes moist, trachea midline, EOMI,
PERRL.
CHEST: Clear to auscultation bilaterally, (-) cyanosis.
ABDOMEN: (+) BS x 4 quadrants, soft, mildly tender to palpation
incisionally, non-distended. Incisions: clean, dry and intact,
dressed and closed with steristrips. 2 G-tubes in her
epigastrium in place w/ a ___ drain connected to bulb suction.
EXTREMITIES: Warm, well perfused, pulses palpable, (-) edema
Pertinent Results:
Labs
___ 04:00PM BLOOD WBC-13.4*# RBC-3.38* Hgb-10.6* Hct-33.1*
MCV-98 MCH-31.4 MCHC-32.0 RDW-13.3 RDWSD-47.9* Plt ___
___ 07:20PM BLOOD WBC-15.8* RBC-3.44* Hgb-10.8* Hct-33.4*
MCV-97 MCH-31.4 MCHC-32.3 RDW-13.2 RDWSD-47.4* Plt ___
___ 01:37AM BLOOD WBC-17.3* RBC-3.35* Hgb-10.7* Hct-32.0*
MCV-96 MCH-31.9 MCHC-33.4 RDW-13.2 RDWSD-46.2 Plt ___
___ 04:07PM BLOOD WBC-16.7* RBC-3.17* Hgb-10.0* Hct-30.1*
MCV-95 MCH-31.5 MCHC-33.2 RDW-12.9 RDWSD-45.1 Plt ___
___ 01:39AM BLOOD WBC-15.7* RBC-3.06* Hgb-9.5* Hct-29.4*
MCV-96 MCH-31.0 MCHC-32.3 RDW-13.0 RDWSD-45.9 Plt ___
___ 01:59AM BLOOD WBC-10.8* RBC-2.68* Hgb-8.2* Hct-25.7*
MCV-96 MCH-30.6 MCHC-31.9* RDW-12.9 RDWSD-45.5 Plt ___
___ 01:50AM BLOOD WBC-11.8* RBC-2.81* Hgb-8.7* Hct-27.3*
MCV-97 MCH-31.0 MCHC-31.9* RDW-13.1 RDWSD-46.8* Plt ___
___ 02:08AM BLOOD WBC-13.2* RBC-2.84* Hgb-8.8* Hct-27.4*
MCV-97 MCH-31.0 MCHC-32.1 RDW-13.2 RDWSD-47.0* Plt ___
___ 02:45AM BLOOD WBC-12.9* RBC-2.88* Hgb-8.6* Hct-28.1*
MCV-98 MCH-29.9 MCHC-30.6* RDW-13.3 RDWSD-47.8* Plt ___
___ 06:05AM BLOOD WBC-12.8* RBC-2.84* Hgb-8.6* Hct-27.5*
MCV-97 MCH-30.3 MCHC-31.3* RDW-13.4 RDWSD-47.7* Plt ___
___ 04:44AM BLOOD WBC-15.5* RBC-2.94* Hgb-8.8* Hct-28.7*
MCV-98 MCH-29.9 MCHC-30.7* RDW-13.5 RDWSD-48.1* Plt ___
___ 05:20AM BLOOD WBC-14.7* RBC-2.77* Hgb-8.4* Hct-26.8*
MCV-97 MCH-30.3 MCHC-31.3* RDW-13.7 RDWSD-48.5* Plt ___
___ 05:47AM BLOOD WBC-19.1* RBC-2.79* Hgb-8.6* Hct-27.2*
MCV-98 MCH-30.8 MCHC-31.6* RDW-13.9 RDWSD-49.5* Plt ___
___ 05:59AM BLOOD WBC-12.7* RBC-2.52* Hgb-7.6* Hct-24.3*
MCV-96 MCH-30.2 MCHC-31.3* RDW-13.8 RDWSD-49.0* Plt ___
___ 05:36AM BLOOD WBC-13.7* RBC-2.55* Hgb-7.7* Hct-24.4*
MCV-96 MCH-30.2 MCHC-31.6* RDW-13.6 RDWSD-47.7* Plt ___
___ 04:37AM BLOOD WBC-9.7 RBC-2.42* Hgb-7.2* Hct-23.0*
MCV-95 MCH-29.8 MCHC-31.3* RDW-13.7 RDWSD-47.5* Plt ___
___ 04:44AM BLOOD WBC-10.2* RBC-2.52* Hgb-7.6* Hct-23.8*
MCV-94 MCH-30.2 MCHC-31.9* RDW-13.7 RDWSD-47.0* Plt ___
Brief Hospital Course:
Ms. ___ is a ___ female with history of DVT on Coumadin
and known hiatal hernia who presented with abdominal, nausea,
vomiting, and dyspnea and transferred from ___
with concern for obstructing hiatal hernia. An NGT was placed in
the ED with immediate return of about 2L. She had an element of
hypovolemic shock given hypotension with systolics in the ___,
elevated lactate, and ___. She also had moderate respiratory
distress requiring oxygenation on a re-breather. Review of her
OSH CT also suggested that she had a pneumonia given findings of
consolidation in her lungs. Due to her tenuous status, she was
admitted to the ICU for close monitoring.
She required Levofed to maintain her blood pressure. After
aggressive fluid resuscitation, she was able to wean off of
pressors on HD2. Her lactate improved as did her ___ (with
creatinine returning to normal). On HD2, she was intubated due
her tenuous respiratory status and also in anticipation for
bronchoscopy and endoscopy. She underwent bronchoscopy with no
significant findings. After BAL was sent, she was started on
broad spectrum antibiotics. She also underwent an upper
endoscopy on HD2 due to concern for gastric ischemia - this
showed normal pink mucosa with some fibrinous debris but no
findings to suggest ischemia. INR was supratherapeutic; Coumadin
was held and she did not receive reversal.
The patient was extubated on HD5. For nutrition, she was started
on TPN. Orthopedic services was consulted for a Right shoulder
displaced transverse fracture, for which they recommended to
keep patient on in sling, and no plans to operate at that time.
On HD 6 patient had right arm CT that showed a Comminuted
displaced fracture at the level of the surgical neck of the
right proximal humerus. On HD 7 patient had an UGI which showed
no leak, consequently her NGT was discontinue and she was
progress to clears which she tolerated with minor difficulty.
On HD 8 patient had 1 episode of emesis and NGT was put back in
place; she also complained of SOB for which she was evaluated
with an CXR which showed unchanged large hiatal hernia with an
increased, adjacent, moderate right pleural effusion associated
with atelectasis. Subsequently the decision was taken to take
the patient to the operating room on HD 9 for an explaratory
laparotomy, reduction of the stomach into the abdominal cavity
with crural plication, gastropexy, g-tube x2. Subsequently
patient tolerated intubation and was transferred to the floor.
On HD 10 ___ evaluated the patient and the G-tubed was OK to be
used for medications, the dPCA was discontinue & the coumadin
restarted.
On HD 12 patient foley was d/c, and started on tube feeds &
regular diet. On HD 13 patient was evaluated by geriatric
service and all of there recommendations were followed, patient
rehabilitation screening was started. Upon discharge patient is
tolerating PO diet and will continue with tube feeds overnight.
Patietn will be discharged to an extended care facility for
continuation of her rehabilitation.
Medications on Admission:
Aspirin 81 mg PO DAILY
Atenolol 50 mg PO DAILY
Calcium Carbonate 500 mg PO QID:PRN heartburn
Lisinopril 10 mg PO DAILY
Warfarin 5 mg PO DAILY
TraZODone 25 mg PO QHS:PRN anxiety/sleep
Omeprazole 40 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. Calcium Carbonate 500 mg PO QID:PRN heartburn
4. Docusate Sodium (Liquid) 100 mg PO BID
5. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every
four (4) hours Disp #*30 Tablet Refills:*0
6. Lisinopril 10 mg PO DAILY
7. Polyethylene Glycol 17 g PO BID
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 powder(s)
by mouth twice a day Refills:*0
8. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*30 Capsule Refills:*0
9. Warfarin 5 mg PO DAILY16 Duration: 1 Dose
10. TraZODone 25 mg PO QHS:PRN anxiety/sleep
11. Omeprazole 40 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Hiatal hernia
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 ___ and
underwent an exploratory laparotomy, with reduction of your
stomach into the stomach, with fixation of your stomach with 2
gastric-tubes. You are recovering well and are now ready for
discharge. Please follow the instructions below to continue your
recovery:
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 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.
General Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
___
|
10255799-DS-21 | 10,255,799 | 21,909,114 | DS | 21 | 2125-03-22 00:00:00 | 2125-03-22 22:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
penicillin
Attending: ___.
Chief Complaint:
wound dehiscence
Major Surgical or Invasive Procedure:
Wound washout, wound vac placement
History of Present Illness:
___ s/p paraesophageal hernia repair, gastropexy, and G-tube
x2 for gastric volvulus on ___ who had uneventful recovery
and discharged ___ to rehab on tube feeds, tolerating diet,
and Coumadin for h/o DVT resumed. Rehab course complicated by
bilateral upper extremity fractures from falls. Was seen in
follow up clinic on ___ ___ staples and JP
drain were removed. ___ was reported from facility that she
had large amounts of
purulent drainage from abdominal incision and was referred to
the
ED for evaluation.
Past Medical History:
PMH: DVT, HTN, hiatal hernia, GERD, ischemic LLE s/p
thrombectomy
PSH: ORIF of L wrist, left groin cutdown and thrombectomy,
hysterectomy, kidney stone removal, tosnilectomy as a child
Social History:
___
Family History:
N/C
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97.7, 102, 101/60, 16, 98% RA
Gen: NAD, non-toxic
CV: RRR
Pulm: no respiratory distress
Abd: soft, non-tender, non-distended. Midline wound healing well
except for a 2-cm area of dehiscence at the inferior-most aspect
that is actively draining purulent fluid mixed with blood, not
malodorous. Wound probes 3 cm deep with intact underlying fascia
and 5 cm superiorly beneath skin. No surrounding erythema. G
tubes capped and sutured in place at left and right abdomen with
small amount of thick purulent fluid from entrance site; no
erythema.
Ext: wwp, no edema
DISCHARGE PHYSICAL EXAM:
VS: T98.4 HR83 BP103/54 RR18 SpO296RA
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: mucous membranes moist, trachea midline, EOMI
CHEST: Clear to auscultation bilaterally
ABDOMEN: soft, soft, non-tender, non-distended, wound vac in
place to suction without leak, G tubes capped and sutured in
place at left and right abdomen with
small amount of thick purulent fluid from entrance site; no
erythema.
EXTREMITIES: Warm, well perfused, pulses palpable
Pertinent Results:
CT Abd&Pelvis w/ Contrast ___:
1. Appropriate placement of both gastrostomy tubes.
2. Expected postoperative changes at the gastroesophageal
junction. No fluid collection identified.
3. Fluid and foci of air within the midline incision, in keeping
with known wound dehiscence.
Brief Hospital Course:
___ s/p paraesophageal hernia repair, gastropexy and G-tubex2
for gastric volvulus p/w with wound dehiscence and purulence
from abdominal wound incision from previously paraesophageal
hernia. Incision opened on presentation ___ and debrided.
Minimal discharge and output at that time. Wound was left open
and packed with wet to dry dressings TID. On ___, she was
found to be hypostensive but responded appropriately with an IVF
bolus. Later that day INR was found to be 2.0 and a foley was
placed secondary to persistent urinary retention. Urine cultures
were sent and a UA was ordered which subsequently came back as
negative. On ___ a wound vac was placed to continuous
suction over her abdominal wound. On ___ she continued to
do well and was screened for rehab facilities. On ___, she
was sent to rehab in good condition with the appropriate
followup.
Medications on Admission:
1. Aspirin 81 mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. Calcium Carbonate 500 mg PO QID:PRN heartburn
4. Docusate Sodium (Liquid) 100 mg PO BID
5. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
6. Lisinopril 10 mg PO DAILY
7. Polyethylene Glycol 17 g PO BID
8. Senna 8.6 mg PO BID:PRN constipation
9. Warfarin 5 mg PO DAILY16 Duration: 1 Dose
10. TraZODone 25 mg PO QHS:PRN anxiety/sleep
11. Omeprazole 40 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Calcium Carbonate 500 mg PO QID:PRN heartburn
4. Docusate Sodium 100 mg PO BID
5. Omeprazole 40 mg PO DAILY
6. Polyethylene Glycol 17 g PO DAILY
7. Senna 8.6 mg PO BID:PRN constipation
8. TraZODone 25 mg PO QHS:PRN anxiety/sleep
9. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol [Ultram] 50 mg 1 tablet(s) by mouth every 6 hours
Disp #*60 Tablet Refills:*0
10. Atenolol 50 mg PO DAILY
11. Warfarin 5 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
wound dehiscence
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were seen at ___ for evaluation of your abdominal wound
dehiscence and discharge. There were no signs of infection. Your
wound was cleaned out and the purulent material drained. A wound
vac was placed on your wound to allow it to heal. Please take
the following precautions as listed below (as applicable):
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:
___
|
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