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10255902-DS-19 | 10,255,902 | 24,704,603 | DS | 19 | 2167-04-07 00:00:00 | 2167-04-09 09:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R hand cellulitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year-old man with PMH signficant for GERD,
obesity, and recent R hand laceration who presents with
increased R hand and thumb swelling at suture sites.
Last ___, the patient was about to start some house
work with hands on extension ladder when ladder cut his hand
through thick gloves. Seen in urgent care clinic 10 days ago
where stitches placed. 2 days ago, the patient began noticing
increased swelling of hand around thumb, for which he presented
to urgent care. Per report, VS at that time 99.1 141/96 68
97%RA and exam notable for markedly swollen and erythematous R
thumb and thenar eminance. He was subsequently referred to ___
ED.
Upon arrival to ED, initial VS 96.9 77 149/96 15 99%RA. Exam
notable for full but painful thumb ROM, good capillary refill
and lack of pain distal to injury. Labs notable for Chem-7 wnl,
CBC with WBC 11.5 otherwise wnl, coags wnl, lactate 1.7. R hand
X-ray obtained without evidence of fracture but showing
increased soft tissue density. Bedside U/S also conducted and
reportedly negative for drainable collection. The patient was
initially treated with suture removal, cefazolin 1g Q8H x3,
splint, and was watched overnight. In the morning, the patient
was noted to have inappropriate improved with continued
erythema, pain, and swelling. Hand Surgery was consulted and
noted erythema receding from demarcated site, soft compartments,
open laceration without drainage. ED team administered Tdap and
broadening antibiotics to Vanc/Unasyn. The patient is now
admitted to Medicine for further management. VS prior to
transfer 98.4 66 148/99 18 99% RA.
Upon arrival to the floor, VS 97.8 131/106 68 18 95%RA. The
patient has swollen thenar eminence and thumb but otherwise
well-appearing.
ROS:
No fevers, chills, night sweats, or weight changes. No changes
in vision or hearing, no changes in balance. No cough, no
shortness of breath, no dyspnea on exertion. No chest pain or
palpitations. No nausea or vomiting. No diarrhea or
constipation. No dysuria or hematuria. No hematochezia, no
melena. No numbness or weakness, no focal deficits.
Past Medical History:
GERD
Obesity
Plantar fasciitis
s/p R wrist surgery
Social History:
___
Family History:
Parents with HTN and DM
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: 97.8 131/106 68 18 95%RA
General: Well-appearing middle-aged man sitting in chair, NAD
HEENT: NC/AT, EOMI
Neck: Supple
Lungs: CTAB
CV: RRR, +S1/S2, no m/r/g
Abdomen: Soft, NT/ND
GU: No foley
Ext: R hand with deep laceration between thumb and medial first
finger with erythema and induration extending up R thumb and
thenar eminence. Full ROM, intact sensation, tender but no pain
out of proportion.
Neuro: CN, motor, and sensation grossly intact
DISCHARGE PHYSICAL EXAM
Vitals: 98.0 104/55 61 16 98%RA
General: Well-appearing middle-aged man sitting in chair, NAD
HEENT: NC/AT, EOMI
Neck: Supple
Lungs: CTAB
CV: RRR, +S1/S2, no m/r/g
Abdomen: Soft, NT/ND
GU: No foley
Ext: R hand with clean dry dressing in place.
Neuro: CN, motor, and sensation grossly intact
Pertinent Results:
ADMISSION LABS
___ 12:45PM BLOOD WBC-11.5* RBC-4.94 Hgb-14.9 Hct-40.5
MCV-82 MCH-30.2 MCHC-36.9* RDW-12.7 Plt ___
___ 12:45PM BLOOD Neuts-60.7 ___ Monos-5.0 Eos-2.9
Baso-0.5
___ 12:45PM BLOOD ___ PTT-31.4 ___
___ 12:45PM BLOOD Glucose-100 UreaN-18 Creat-1.0 Na-136
K-3.9 Cl-103 HCO3-23 AnGap-14
___ 01:00PM BLOOD Lactate-1.7
DISCHARGE LABS
___ 05:45AM BLOOD WBC-7.7 RBC-4.48* Hgb-13.5* Hct-38.2*
MCV-85 MCH-30.1 MCHC-35.3 RDW-11.8 RDWSD-35.9 Plt ___
___ 05:45AM BLOOD Glucose-113* UreaN-16 Creat-0.9 Na-140
K-4.1 Cl-104 HCO3-25 AnGap-15
___ 05:45AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.0
MICROBIOLOGY
___ BLOOD CULTURE X 2 - PENDING
REPORTS
___ R HAND X-RAY: There is no evidence of fracture,
dislocation or bone destruction. The joint spaces appear
preserved. High attenuation debris is noted along the surface
of the base of the thumb in the first web space with increased
soft tissue density. IMPRESSION: No fracture identified.
Brief Hospital Course:
___ with GERD and recent R hand laceration who presented with
increased R hand and thumb swelling at suture sites consistent
with cellulitis.
# R Hand Cellulitis: Suffered R hand laceration with suture
placement 9 days prior with subsequently development of
swelling, erythema, and pain at laceration site. In the ED, R
hand X-ray without fracture or dislocation. Patient underwent
suture removal and was administered Ancef x3 with inadequate
improvement in exam. As such, Hand Surgery consulted and the
patient was admitted for further management. Antibiotics were
broadened to Vanc/Unasyn with improvement in pain, swelling, and
erythema. The patient was transitioned to PO Bactrim/Augmentin
to complete ___nd scheduled close Hand-Surgery
___ at discharge.
# GERD: Continued home omeprazole 20mg daily
==========================================
TRANSITIONAL ISSUES
==========================================
- STARTED Bactrim/Augmentin to complete 7 day course (last day
___ or per ___ Hand Surgery evaluation
- Patient to elevate RUE and splint hand with spica splint with
2 4x4 between web space held on with kling
- Wound care recs: dry sterile dressing (to be provided by wife
RN)
- Hand Surgery ___ scheduled for ___
- PCP ___ scheduled for ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Omeprazole 20 mg PO DAILY
2. Acetaminophen 325-650 mg PO Q6H:PRN pain
RX *acetaminophen 325 mg ___ tablet(s) by mouth Every 6 hours as
needed for pain Disp #*28 Tablet Refills:*0
3. Amoxicillin-Clavulanic Acid ___ mg PO Q8H
RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by
mouth Every 8 hours Disp #*20 Tablet Refills:*0
4. Ibuprofen 600 mg PO Q8H:PRN pain
RX *ibuprofen 600 mg 1 tablet(s) by mouth Every 8 hours as
needed for pain Disp #*20 Tablet Refills:*0
5. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth Every 12 hours (2 times a day) Disp #*13 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
R Hand Cellulitis
SECONDARY
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during this
hospitalization. You were admitted to ___ for increased
redness, swelling, and pain of your R hand. This was due to
infection of the soft tissues around the site where you were
cut. For this, the prior sutures in your R hand were removed and
you were started on IV antibiotics, which were transitioned to
oral antibiotics at the time of discharge. The Hand Surgery team
saw you and provided recommendations on how to splint and apply
dressings to your hand. They will see you in ___ to assess
how the infection is improving and the wound is healing.
These are the instructions for how to wrap/splint your hand:
- Splint R hand with spica splint with 2 4x4 between web space
held on with kling
- Wound care recs: dry sterile dressing
- Elevate R hand
You are now safe to leave the hospital. Please ___ with
your doctors as ___ and take your medications as
prescribed.
Best of luck in your future health,
Your ___ Team
Followup Instructions:
___
|
10255928-DS-14 | 10,255,928 | 29,880,304 | DS | 14 | 2124-10-24 00:00:00 | 2124-10-25 22:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Penicillins / Motrin / Diclofenac / aspirin / Amoxicillin
Attending: ___.
Chief Complaint:
Generalized weakness, aches
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old Gravida 5 Para 3 status-post repeat
low transverse C-section at ___ on ___
complicated by ___ requiring exploratory laparotomy with
Supracervical Hysterectomy who presents with
approximately 3 week history of generalized fatigue, whole body
aches and weakness. Patient also reports a subjective fever at
home with chills. Patient initially presented to ___
___ on ___ and was diagnosed with a urinary tract
infection and prescribed Macrobid. She was contacted a day later
with result 1 bottle of blood culture with evidence of Strep
Viridans. She was then prescribed Levaquin which she reports
being told to start after her Macrobid. She was scheduled to
start this medication today, but has not yet taken a dose of her
medication.
She represented to the outside hospital on ___ for repeat
Blood cultures which have shown no growth to date.
Her review of systems is significant for generalized weakness
and achiness. She
is tolerating a regular diet and denies any nausea/vomiting,
constipation, diarrhea or vaginal bleeding. She does report some
mild chest discomfort in her mid chest and lower abdominal pain.
Past Medical History:
OB History:
___: Repeat low transverse C section (LTCS) 7#8oz male
infant complicated by post partum hemorrhage requiring
supracervical hysterectomy
2 prior LTCS ___
Spontaneous abortion x 2
GYN History: Denies prior history of sexually transmitted
infection
Past medical history: A thorough review of prior H&P reveals
Hyperthyroidism
Past surgical history:
Low transverse c-section x 3
Exploratory Laparotomy with Supra-cervical hysterectomy
Social History:
No tobacco/ethanol/drugs
Physical Exam:
Admission Physical Exam per Dr. ___:
No acute distress, appears overall well
CV: Regular rate and rhythm
Pulm: Clear to auscultation bilaterally
Back: No costo vertebral angle tenderness
Abd: well healing vertical midline incision, +bowel sounds,
soft, mild tenderness to palpation to right and left of incision
(R>L), no guarding and no rebound
SVE: No tenderness with internal examination, cervix could not
be
appreciated
Pertinent Results:
IMAGING:
___ CT Abd/pelvis w/ contrast:
FINDINGS:
CHEST: The pulmonary arterial tree is well opacified and no
filling defect to suggest pulmonary embolism is seen. The aorta
is normal in caliber and
configuration without evidence of acute aortic syndrome. The
heart and great vessels appear grossly normal with incidental
note of common origin of the brachiocephalic and left common
carotid arteries. No pericardial effusion is seen.
The lung parenchyma appears grossly clear with a 2-mm pulmonary
nodule noted in the right middle lobe (2:30). No evidence of
endobronchial lesion is seen. No pathologically enlarged lymph
nodes are identified.
ABDOMEN: A hypodensity measuring 3 mm in the right hepatic lobe
(3b:99) is
too small to characterize. The spleen, pancreas, gallbladder,
adrenal glands, and kidneys appear grossly unremarkable. Loops
of small and large bowel are normal in size and caliber. No
intra-abdominal free air, free fluid, or lymphadenopathy is
seen. Incidental note is made of a circumaortic left renal vein.
PELVIS: The right ovarian vein is expanded with filling defect
compatible
with thrombus. The patient is reported to have a supracervical
hysterectomy. However, there appears to be soft tissue in the
region of the expected uterus. Fluid in the region of the
expected endometrial canal appears to have a triangular
configuration on the axial images, a configuration which would
typically be seen with uterus. There is surrounding soft tissue
stranding and small amounts of free fluid, of unclear
significance given recent laparotomy. A cyst in the right
adnexal region measuring 3.1 x 2.2 cm (3B:141) could be
paraovarian or exophytic from the right ovary. Fat stranding
surrounds the pelvic loops of large bowel and appendix; however,
is likely secondary to the recent laparotomy. There is
scattered diverticulosis. Soft tissue changes from midline
abdominal incision are noted. No free air or lymphadenopathy is
identified.
No concerning osseous lesion is seen.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Right ovarian vein thrombus.
3. Despite the given history of supracervical hysterectomy,
tissue is seen in the region of the expected uterus with fluid
in a configuration typically seen with a uterine cavity.
Correlation with operative report recommended. If it is
confirmed that the uterus has been removed, this tissue and
fluid collection cannot be clearly explained by CT and further
evaluation with MRI may be performed.
4. 2-mm pulmonary nodule. In a low-risk patient, no further
specific
followup is needed. In a high-risk patient, followup CT at 12
months is
currently advised.
MRI Abd/Pelvis:
There has been a supracervical hysterectomy. The remnant cervix
is noted in situ measuring 6.4 cm craniocaudal x 2.7 cm in AP
diameter. A nabothian cyst is noted in the lower cervix
measuring 9 mm (series 5, image 20).
Post-surgical change / susceptibility artifact is noted at the
resection
margin at the superior aspect of the cervix (series 10, image
48).
The right ovary measures 2.5 x 3.8 cm. Within this, there is a
2.7 x 2.2 cm cystic lesion identified which is hyperintense
relative to ovarian parenchyma on T1-weighted imaging (series
10, image 52) and hyperintense relative to ovarian parenchyma on
T2-weighted imaging (series 5, image 17). It does not
demonstrate internal enhancement (series 1303, image 50) and
findings are compatible with a hemorrhagic / proteinaceous cyst.
The left ovary is unremarkable with dominant physiological
follicles noted in relation to it and measures 1.6 x 2.1 cm
(series 5, image 12).
No pelvic adenopathy or free fluid is noted in the pelvis. No
evidence for
fluid collection or abscess. The visualized bladder, rectum, and
sigmoid
colon are unremarkable. There is evidence for right ovarian vein
thrombosis (series 1302, image 16) unchanged from prior CT
examination ___. Bone marrow signal is normal. No osseous
lesions are identified.
IMPRESSION:
1. The patient is status post supracervical hysterectomy with
remnant cervix noted in situ. Post-surgical changes noted at the
superior margin of the cervix at the resection margin with no
evidence for intra-abdominal abscess or drainable collection
identified.
2. 2.7 x 2.2 cm hemorrhagic / proteinaceous cyst noted in
relation to the
right ovary.
3. Right ovarian vein thrombosis, unchanged from prior CT
examination from
___.
ECHO:
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%). 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. No
masses or vegetations are seen on the aortic valve. The mitral
valve appears structurally normal with trivial mitral
regurgitation. No mass or vegetation is seen on the mitral
valve. The estimated pulmonary artery systolic pressure is
normal. No vegetation/mass is seen on the pulmonic valve. There
is no pericardial effusion.
IMPRESSION: No vegetations or clinically-significant valvular
disease seen. Normal global and regional biventricular systolic
function
MICROBIOLOGY:
Review of Outside hospital records
___ Urine Culture: > 100,000 and > 3 organisms
___ Blood Culture: 1: Strep Viridans, 2: No Growth
___ Blood Culture : No Growth
___ Blood culture: no growth
___ Blood culture: no growth
LABS:
___ 02:40PM BLOOD WBC-4.6# RBC-4.25# Hgb-12.9 Hct-38.5
MCV-91 MCH-30.4 MCHC-33.5 RDW-12.4 Plt ___
___ 09:45AM BLOOD WBC-4.2 RBC-4.30 Hgb-13.9 Hct-40.3 MCV-94
MCH-32.4* MCHC-34.6 RDW-13.1 Plt ___
___ 05:21AM BLOOD WBC-3.7* RBC-4.20 Hgb-13.1 Hct-39.2
MCV-93 MCH-31.1 MCHC-33.4 RDW-13.2 Plt ___
___ 02:40PM BLOOD Neuts-55.6 ___ Monos-5.6 Eos-5.1*
Baso-0.4
___ 05:21AM BLOOD Neuts-47.8* ___ Monos-8.0
Eos-7.4* Baso-0.7
___ 02:40PM BLOOD Glucose-94 UreaN-14 Creat-1.0 Na-138
K-4.2 Cl-104 HCO3-26 AnGap-12
___ 02:40PM BLOOD TSH-1.3
Brief Hospital Course:
Ms. ___ was admitted to the GYN service for further
evaluation of generalized weakness and suspected bacteremia.
Repeat blood cultures were drawn and she was prophylactic ally
placed on clindamycin (due to pencillin allergy) for Strep
viridans growth on a blood culture (1 of 2 bottles) drawn at an
outside hospital. Infectious Disease was consulted for further
recommendations, who recommended an echocardiogram to rule out
vegetations, which was negative. She was also briefly
transitioned to vancomycin to better cover Strep Viridans,
although upon final review of this patient's clinical status
with Infectious Disease, it was determined that the Strep
Viridans was likely a contaminant given that the patient was
afebrile throughout stay, had a normal white count, and had
multiple repeat blood cultures that were negative. Antibiotics
were discontinued and she remained afebrile for >48 hours off
antibiotics.
With regard to her weakness, a TSH and hematocrit were checked
and were both within normal limits. Her symptoms improved
significantly after receiving IV hydration.
Ms. ___ was noted to have an incidental finding of right
ovarian vein thrombus on imaging. Hematology was consulted
regarding this. Although septic thrombophlebitis was unlikely
given afebrile in-house and normal white count,Ms. ___ was
started on anticoagulation therapy given her generalized
symptoms and subjective fevers at home. She was discharged on
lovenox BID and will continue this for 2 weeks per hematology
recommendations, with a follow up CT to reevaluate.
Ms. ___ was discharged home in stable condition on hospital
day 3, afebrile and in stable condition.
Medications on Admission:
Percocet prn
Discharge Medications:
1. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours) for 11 days.
Disp:*22 syringe* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Right ovarian vein thrombus
S/P C/section complicated by DIC requiring supracervical
hysterectomy.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___, you were admitted to the ___ Gynecology service
for observation. You infectious disease work up was negative.
You were diagnosed with a right ovarian vein thrombus for which
you were started on Lovenox (anticoagulation medicine). You will
be taking Lovenox for 2 weeks.
Followup Instructions:
___
|
10255945-DS-28 | 10,255,945 | 27,095,925 | DS | 28 | 2164-04-10 00:00:00 | 2164-04-11 11:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Vancomycin Hcl / Rocephin
Attending: ___
Chief Complaint:
Dysuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ who is s/p renal transplant (DCD, ___ years
ago) with a history of morbid obesity, DMII who presents with
low grade fevers, dysuria and ear pain.
She states she has had bilateral ear pain for the last week or
so. She also has had dysuria with burning with urination and a
feeling of incomplete voiding. She has had fevers to 102 at
home. She is not sure how long the dysuria has been going on
for.
She states she was admitted to another hospital four weeks ago
and completed a course of "uropenem".
She denies changes in hearing but has been dizzy. She denies
visual changes as she is blind at baseline. She denies sinus
pain. She has been having some nasal congestion.
In the ED, initial vs were: 97.2 92 112/57 20 98%
Labs were remarkable for WBC 7.6, Hct 38.5, Plt 311.
Na 136, K 4.5, Cl 97, CO2 24, BUN 13, Cr 0.9, glucose 331.
UA has many bacteria, >182 WBC, large leukocyte, positive
nitrite, ___, 30 protein, 1000 glucose.
Blood cultures and urine culture was sent.
Patient was given CTX and azithromycin.
CXR demonstrated no focal consolidation, no acute process.
Vitals on Transfer: 98.5 95 156/80 18 92% RA
On the floor, vs were: T98.4 P93 BP158/66 R18 O2 sat 96% RA
Past Medical History:
-Renal transplant DCD approx ___ years ago
-morbid obesity
-DMII - insulin dependent
-hx of recurrent UTI and urosepsis - ESBL e. coli organisms in
past
- HTN
- cervical cancer s/p radiation
- depression
- s/p appendectomy, s/p cholecystectomy
- OSA
- blind
Social History:
___
Family History:
+for DM, neg for cancer, neg for heart disease or clot disorder
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T98.4 P93 BP158/66 R18 O2 sat 96% RA
General: Alert, oriented, no acute distress
HEENT: Blind, wearing sunglasses, MMM, no auricular tenderness,
no tympanic membrane erythema, no auricular discharge
Neck: Soft, no LAD, difficult to assess JVD secondary to body
habitus.
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Alert and oriented x3 moving all four extremities,
strength ___ in upper and lower extremities bilaterally,
sensation grossly intact. blind thus EOMI not assessed,
otherwise CN V, VII, VIII-XII intact. Hearing intact bilaterally
R>L
DISCHARGE PHYSICAL EXAM:
VS: Tm 98.9 139/68 95 20
GEN: resting comfortably in bed, NAD, AAOx3, pleasant,
conversational
HEENT: Blind, MMM, no auricular tenderness, no sinus tenderness
Neck: Soft, no LAD, difficult to assess JVD secondary to body
habitus.
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Obese, 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: Mildly macerated skin beneath pannus
Neuro: Alert and oriented x3 moving all four extremities
Pertinent Results:
Admission Labs:
___ 12:43PM BLOOD WBC-7.6 RBC-4.73 Hgb-11.7*# Hct-38.5
MCV-81* MCH-24.8* MCHC-30.5* RDW-15.5 Plt ___
___ 12:43PM BLOOD Neuts-74.6* Lymphs-14.9* Monos-5.1
Eos-4.2* Baso-1.1
___ 05:45AM BLOOD ___ PTT-33.8 ___
___ 12:43PM BLOOD Glucose-331* UreaN-13 Creat-0.9 Na-136
K-4.5 Cl-97 HCO3-24 AnGap-20
___ 12:49PM BLOOD Lactate-2.8*
Pertinent Interval Labs:
___ 05:45AM BLOOD tacroFK-6.4
___ 07:20AM BLOOD tacroFK-5.1
___ 05:30AM BLOOD tacroFK-5.0
Micro:
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Blood Culture x2: no growth to date
Imaging:
CXR ___:
No definite acute cardiopulmonary process.
DISCHARGE LABS:
___ 05:30AM BLOOD WBC-5.5 RBC-4.78 Hgb-11.4* Hct-39.2
MCV-82 MCH-23.9* MCHC-29.1* RDW-15.5 Plt ___
___ 05:30AM BLOOD Glucose-172* UreaN-10 Creat-0.8 Na-141
K-4.6 Cl-103 HCO3-28 AnGap-15
___ 05:30AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.8
Brief Hospital Course:
Mrs. ___ is a ___ year old woman who is s/p renal transplant
(DCD, ___ years ago) with a history of morbid obesity, DMII who
presents with low grade fevers and dysuria consistent with UTI.
# UTI: Patient s/p renal transplant, with history of multiple
UTIs. She has had multiple organisms in the past, including
ESBL. Her most recent strains from ___ were
sensitive to Ciprofloxacin. She was started on Cipro on
admission. Urine culture grew out E.coli sensitive to
Ciprofloxacin and she is discharged to complete a 14 day course.
Of note, her post void residual was ~200cc. Thus residual volume
likely contributing to nidus of bacterial growth. She is
discharged with instructions for scheduled voiding every ___
hours. Also contributing is glucosuria. The patients glucose
in-house ranged between 150s-200s. Tighter glucose control will
likely also help to prevent recurrent UTIs.
# Ear Pain: Ms. ___ presented with a several week history of
bilateral ear pain. The etiology most likely viral URI causing
nasal congestion and eustachian tube dysfunction. There was no
evidence of otitis media or externa on exam. This was monitored
closely in-house given her immunosuppressed state and
possibility of bacterial infection. Her ear pain resolved prior
to discharge.
# S/P Renal transplant: Patient currently ___ years out from DCD
renal transplant. Immunosuppressive regimen includes cellcept
500mg bid, prograf 3mg BID and prednisone 5mg qd. There was no
evidence of acute kidney injury during her hospitalization. Her
goal tacrolimus levels are ___ and her tacro dose was decreased
from 3mg BID to 2mg BID. She was continued on home cellcept and
prednisone.
# DMII: Patient on levemir and humalog with meals at home.
Continued on glargine in-house as levemir is not on formulary
with ISS.
# Anxiety: on PRN Benzodiazepines and Venlafaxine at home and
continued on home venlafaxine and PRN ativan.
# Chronic pain: Patient on PRN oxycodone and fentanyl patch at
home. No fentanyl patch applied while patient was acutely
infected because sweating or fevers can alter dermal absorption.
She was provided with Oxycodone 5mg q4hrs PRN pain.
Transitional:
- PCP follow up for continued monitoring of bilateral ear pain
- Urology follow up for urodynamic testing
- Scheduled voiding
- Patient to have tacro levels drawn on ___ and faxed to
Dr. ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. alpha-d-galactosidase oral qd
2. Ascorbic Acid ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Nephrocaps 1 CAP PO DAILY
5. biotin oral qd
6. Diphenoxylate-Atropine 1 TAB PO Frequency is Unknown
7. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
8. Fentanyl Patch 25 mcg/h TD Q72H
9. Acidophilus (L.acidoph & ___
acidophilus) 175 mg oral qd
10. Lorazepam 1 mg PO Q8H:PRN anxiety
11. Mycophenolate Mofetil 500 mg PO BID
12. Gabapentin 400 mg PO QID
13. Levemir 50 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
14. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
15. PredniSONE 5 mg PO DAILY
16. Omeprazole 40 mg PO BID
17. Tacrolimus 3 mg PO Q12H
18. Ferrous Sulfate 325 mg PO TID
19. Venlafaxine XR 150 mg PO DAILY
20. ZyrTEC (cetirizine) 10 mg oral daily
21. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
22. Gentamicin 0.1% Cream 1 Appl TP DAILY
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Fentanyl Patch 25 mcg/h TD Q72H
4. Gabapentin 400 mg PO QID
5. Levemir 50 Units Bedtime
6. Mycophenolate Mofetil 500 mg PO BID
7. Nephrocaps 1 CAP PO DAILY
8. Omeprazole 40 mg PO BID
9. PredniSONE 5 mg PO DAILY
10. Tacrolimus 2 mg PO Q12H
11. Venlafaxine XR 150 mg PO DAILY
12. Miconazole Powder 2% 1 Appl TP QID:PRN rash
RX *miconazole nitrate 2 % apply moderate amount three times a
day Disp #*1 Bottle Refills:*0
13. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
14. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a
day Disp #*20 Tablet Refills:*0
15. Acidophilus (L.acidoph &
___ acidophilus) 175 mg oral qd
16. alpha-d-galactosidase 0 ORAL QD
17. biotin 0 ORAL QD
18. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
19. Diphenoxylate-Atropine 1 TAB PO Q8H:PRN spasm
20. Ferrous Sulfate 325 mg PO BID
21. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
22. ZyrTEC (cetirizine) 10 mg oral daily
23. Lorazepam 1 mg PO Q8H:PRN anxiety
24. Outpatient Lab Work
Tacrolimus Level
___
Please fax to Dr. ___ at ___
ICD-9 V42.0
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
E. coli urinary tract infection
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 taking care of you. You were admitted with ear
pain and also a urinary tract infection. You were treated with
antibiotics while here, and will need to be on antibiotics for a
total of 14 days. This will also treat a potential ear
infection.
It is important for you to have a scheduled urination schedule,
so that you completely empty your bladder, to minimize your
future infection risks. You should attempt to use the restroom
at least every two hours to completely void your bladder.
Please be sure to complete your antibiotics and to follow-up
with your physicians.
Followup Instructions:
___
|
10256213-DS-6 | 10,256,213 | 27,485,035 | DS | 6 | 2165-02-18 00:00:00 | 2165-02-19 21:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Bacteremia referral to ED
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ otherwise healthy presenting with strep bacteremia. Pt was
seen on ___ with viral symptoms and found to have strep
anginosis bacteremia. The patient was notified of the results
but was in ___ at the time and declined going to the
hospital. Pt returned from ___ on ___ and presented to
___ on ___. Found to have a normal CBC aside from
thrombocytosis, ESR 32. CXR clear. TTE reportedly normal. CT
abd/pelvis reportedly normal. Pt given IV ceftriaxone with plans
to complete a 2-week course. The patient reports he was
discharged home. On ___, he received a call from ___, asking
him to present to the ED for IV antibiotics and to complete a
10-day course.
He denies fevers, N/V/D, URI symptoms and states that he has
only been tired the past few days. The patient reports that he
had small irritated follicles of skin on his scalp, after a
recent hair transplant ~ 1 month ago, which he kept popping. No
current pain or draining lesions.
In the ED, initial vitals were: 97.6 141/75 18 100RA
- Exam notable for: RRR, no murmur. CTAB. NTND abd. No c/c/e.
- Labs notable for: nl CHEM7, WBC 8.2, H/H 12.8/39.1, plt 535.
Blood cultures drawn.
- Imaging was notable for: none
- Patient was given: IV CTX
Upon arrival to the floor, VS: 98.1 114/76 71 19 97RA
Pt reports recent fatigue. No fevers or chills. No chest pain.
No nausea, vomiting or abdominal pain. No diarrhea. No urinary
symptoms.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
NA
Social History:
___
Family History:
- No family history of cardiac disease, sudden cardiac death
Physical Exam:
ADMISSION/DISCHARGE PHYSICAL EXAM:
========================================
VITALS: 98.1 BP 114/76 HR 71 RR18 97RA
GENERAL: Alert, oriented, no acute distress
HEENT: No lesions on scalp, sclerae anicteric, MMM, oropharynx
clear, no oral lesions
NECK: Supple, JVP not elevated, no LAD
RESP: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
ABD: +BS, soft, nondistended, nontender to palpation
EXT: warm, well perfused, 2+ pulses, no edema
Pertinent Results:
LABS:
========
___ 09:27PM BLOOD WBC-8.2 RBC-4.46* Hgb-12.8* Hct-39.1*
MCV-88 MCH-28.7 MCHC-32.7 RDW-12.9 RDWSD-40.6 Plt ___
___ 07:24AM BLOOD WBC-6.4 RBC-4.31* Hgb-12.6* Hct-37.6*
MCV-87 MCH-29.2 MCHC-33.5 RDW-13.2 RDWSD-41.5 Plt ___
___ 09:27PM BLOOD Glucose-94 UreaN-19 Creat-1.0 Na-139
K-3.9 Cl-99 HCO3-29 AnGap-15
___ 07:24AM BLOOD ALT-29 AST-18 AlkPhos-54 TotBili-0.7
___ 07:24AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.5
___ 09:35PM BLOOD Lactate-1.4
MICRO:
=========
___ and ___ Blood cultures pending
Outside Records:
==================
Atrius records
___ ___- blood culture no growth to date
___ and ___ Blood culture:
Preliminary report. No growth to date, final report to follow.
___ 2:46 ___
BLOOD CULTURE
Anaerobic Bottle: No growth 5 days. (A)
BLOOD CULTURE
Strep. anginosus ___ bottles)
Aerobic Bottle. Time to detect positive: 18 hours
(A
AMPICILLIN SENSITIVE
CEFOTAXIME SENSITIVE
CEFTRIAXONE SENSITIVE
CLINDAMYCIN SENSITIVE
ERYTHROMYCIN SENSITIVE
PENICILLIN SENSITIVE
VANCOMYCIN SENSITIVE
IMAGING:
==========
___ CXR: The tip of the left PICC line projects over the low
SVC. No focal consolidation, pleural effusion or pneumothorax
is identified. The size appearance of the cardiac silhouette is
unchanged.
Brief Hospital Course:
Mr. ___ is a ___ year old man with no PMH admitted for
treatment of strep anginosus bacteremia.
# Strep anginosus bacteremia: Initial positive blood culture on
___ with pan-sensitive strep anginosus, ___ bottles, unclear
source, possibly skin infection as S. anginosus frequently
associated with abscess and patient with reported "irritated
hair follicles" recently, although none currently on exam. No
other localizing symptoms, and no symptoms to suggest
intraabdominal abscess and had a negative CT abdomen/pelvis and
TTE at ___. Endocarditis in S. anginosus is
relatively uncommon, even in the presence of high-grade
bacteremia, and usually occurs in the setting of damaged or
prosthetic heart valves. He was admitted briefly inpatient, was
asymptomatic and afebrile, was started on Ceftriaxone 2g daily.
He had a PICC placed, had setup of home infusion services for
help with IC antibiotic and was discharged with PCP ___
(verbal signout given to ___ PCP ___. Plan for Atrius
Infectious disease to follow along outpatient, inpatient ID team
with no further recommendation. He remained culture negative.
Inpatient ID team confirmed dosing of 2g of ceftriaxone daily
for ___nd day ___.
#Anemia: appears at baseline from Atrius records, no evidence of
bleeding. Recommend outpatient screening colonoscopy.
# Thrombocytosis: Likely reactive in setting of bacteremia.
TRANSITIONAL ISSUES:
========================
-Hgb 12.6, at baseline, and stable, but should get colonoscopy
done as regular screening
-Continuing 2g Ceftriaxone daily until ___
-Baseline LFTs: ALT 29, AST 18, AP 54, Tbili 0.7
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. CefTRIAXone 2 gm IV Q 24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 grams IV every
day Disp #*13 Intravenous Bag Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
-Strep Anginosus Bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were briefly admitted to the ___ Medicine Service after
one of your blood cultures was positive for a bacteria called
strep anginosus. All your blood cultures aside from one bottle
did not grow this, but given the risk of serious infection, you
require IV antibiotics.
You are being discharged on Ceftriaxone 2 grams IV taken every
day. You will do a 14 day course of this, ending on ___.
Best wishes
Your ___ Care team
Followup Instructions:
___
|
10256229-DS-15 | 10,256,229 | 26,084,236 | DS | 15 | 2147-09-26 00:00:00 | 2147-09-26 18:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Bactrim / Fenofibrate / Claritin / Benadryl
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
___ Left burr holes for ___ evacuation
History of Present Illness:
___ with well-controlled HIV and small stable aneurysm (last
imaged ___ showing stable 2mm right cavernous carotid artery
aneurysm) presenting w/ headaches. Has been having them for
about
a year. Recently his headaches have been increasing in intensity
and severity. On ___ he went to see his Neurologist, Dr.
___ ordered imaging for ___. He was prescribed a beta
blocker for the headaches, which he reports have not helped.
However, today his headache worsened and presented to the ED per
recommendation of Neurologist. He reports no trauma or any
identifiable cause for the worsening headaches. He takes no
anticoagulants.
Past Medical History:
HIV
Hepatitis C
Social History:
___
Family History:
Mother with lung cancer. Father passed at ___, sister at ___ from
drug addiction, alcoholism in the brother. There are multiple
family members again with aneurysms.
Physical Exam:
Upon admission:
--------------
O: T: 97.7 BP: 155/107 HR: 55 R: 16 O2Sats: 99% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: ___ EOMs full
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.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to 3-2
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
---------------
Upon discharge:
---------------
Exam:
Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious
Orientation: [x]Person [x]Place [x]Time
Follows commands: [ ]Simple [x]Complex [ ]None
Pupils: PERRL ___
EOM: [x]Full [ ]Restricted
Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No
Pronator Drift: [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No
Comprehension intact [x]Yes [ ]No
Motor:
TrapDeltoidBicepTricepGrip
Right5 5 5 5 5
Left5 5 5 5 5
IPQuadHamATEHLGast
Right5 5 5 5 5 5
Left5 5 5 5 5 5
[x]Sensation intact to light touch
Wound:
[x]Clean, dry, intact
[x]Sutures
Pertinent Results:
Please see OMR for pertinent results
Brief Hospital Course:
___ yo M with chronic left SDH with acute components and ~8mm
midline shift.
#L SDH
___ yo M with chronic left SDH with acute components and ~8mm
midline shift. Patient had worsening headache and sudden onset
nausea in ED after initial consultation. Repeat NCHCT shows
stable SDH but increased MLS. Patient was admitted and added on
to the operating room for left craniotomy for ___ evacuation.
Patient underwent a Left burr hole evacuation on ___.
Patient tolerated procedure well, for details please refer to
operative report. Patient recovered anesthesia in PACU and
transferred to stepdown. He remained neurologically stable so
was transferred to floor on ___. He experienced continued
headaches, which were managed with oxycodone and Fioricet. He
also experienced continual nausea, which was treated with
anti-emetics, and he was able to tolerate good PO intake. He
remained neurologically stable. ___ worked with the patient and
recommended home with services. He was discharged to home on
___.
Medications on Admission:
Citalopram 10 mg Tab
Intelence (etravirine)200 mg tablet 1 tablet(s) by mouth BID
Isentress (raltegravir) 400 mg tablet 1 tablet(s) by mouth BID
Selzentry (maraviroc) 300 mg tablet 1 tablet(s) by mouth BID
propranolol 10 mg tablet 1 tablet(s) by mouth three times a day
multivitamin -- Unknown Strength 1 capsule(s) Once Daily
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q4H:PRN Pain - Mild
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
Do not exceed 6 tablets/day
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___
tablet(s) by mouth Q4H PRN Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
3. LevETIRAcetam 1000 mg PO BID
RX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth twice a
day Disp #*7 Tablet Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4H PRN Disp #*30
Tablet Refills:*0
5. Senna 8.6 mg PO BID:PRN Constipation
6. Citalopram 10 mg PO DAILY
7. Etravirine 200 mg PO BID
8. Maraviroc 300 mg PO BID
9. Propranolol 10 mg PO BID
10. Raltegravir 400 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Surgery
- You underwent a surgery called a craniotomy to have blood
removed from your brain.
- Please keep your sutures or staples along your incision dry
until they are removed.
- It is best to keep your incision open to air but it is ok to
cover it when outside.
- Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your activity
at your own pace once you are symptom free at rest. ___ try to
do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if you
are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood swings
are also common.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptoms after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
10256229-DS-16 | 10,256,229 | 20,872,345 | DS | 16 | 2147-10-05 00:00:00 | 2147-10-05 16:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Bactrim / Fenofibrate / Claritin / Benadryl
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
None this admission
Previous admission:
___: L burr hole for subdural hematoma evacuation
History of Present Illness:
___ yo male patient known to neurosurgery and s/p left craniotomy
for ___ on ___. Returns after waking up with sudden onset
severe HA. His head CT shows post-operative changes on the left
and mixed density SDH on thee right.
Past Medical History:
HIV
Hepatitis C
Social History:
___
Family History:
Mother with lung cancer. Father passed at ___, sister at ___ from
drug addiction, alcoholism in the brother. There are multiple
family members again with aneurysms.
Physical Exam:
Exam on admission:
T:98.1 BP: 142/70 HR:60 RR:18 O2Sats:95%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: Slight Anisocoria L>R, round, reactive
EOMs Intact
Lungs: Normal RR, no increased work of breathing noted, equal
lung expansion visualized
Cardiac: RRR.
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 Anisocoric, Left 3.5-3mm Right 3-2.5mm
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: Not tested
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Upon Discharge:
---------------
He is A&Ox3. Answering questions appropriately. PERRL with EOM's
intact. ___. No pronator drift noted. He is moving all
extremities spontaneously; with equal and full strength.
Pertinent Results:
Please see OMR for pertinent results
Brief Hospital Course:
___ yo male with known bilateral SDH, now s/p left burr hole and
evacuation on the left. He presented after waking up with
Sudden onset severe HA.
#Headache
Bilateral Mixed density SDH: Admitted for close observation and
work up. Repeat head CT showed stable mixed density SDH on the
right and post-operative changes on the left. A repeat head CT
was obtained on ___ which was unchanged from previous images.
He states that his headache is better than when arrived. He
given pain medication to use as needed while at ___ until
follow up with Dr. ___. He will follow up with Dr. ___ on
___ with a NCHCT prior to his visit. He is scheduled for
130pm and 2pm with Dr. ___.
Medications on Admission:
- Oxycodone ___ PO Q4hr PRN pain - moderate
- Citalopram 10mg PO daily
- Etravirine 200mg PO BID
- Maraviroc 300mg PO BID
- Propranolol 10mg PO BID
- Raltegravir 400mg PO BID
Discharge Medications:
1. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
2. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN Headache
3. Citalopram 40 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Etravirine 200 mg PO BID
6. LevETIRAcetam 1000 mg PO BID
7. Maraviroc 300 mg PO BID
8. Propranolol 10 mg PO BID
9. Raltegravir 400 mg PO BID
10. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
___ With Service
Facility:
___
Discharge Diagnosis:
Subdural hematoma
cerebral edema
headache
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were seen here for your worsening headache. You received
multiple CT scans that continued to show your bilateral subdural
hematomas with minimal mid line shift, these have remained
stable. Dr. ___ that it is safe for you to be
discharged ___ and follow up with him in three weeks time with
a repeat CT scan. Please call ___ or return to the
Emergency Department for any headaches that are unrelieved by
the prescribed pain medications or for any neurological changes
that you notice.
Followup Instructions:
___
|
10256360-DS-9 | 10,256,360 | 26,199,021 | DS | 9 | 2169-12-20 00:00:00 | 2169-12-24 18:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfur
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
___ female w CHF, anemia brought in by friends due to
confusion. The friend states the patient lives alone, performs
her own ADLs, is typically alert and oriented. This morning when
a friend went to check on her, she was confused. There is
concern
for a fall. Currently, the patient is A and O ×1 (to self) and
complains of pain in her right shoulder and elbow. Denies chest
pain, dyspnea, nausea, vomiting.
Friends believe she fell - she was found "sitting on the edge of
the bed with her things scattered on the floor"
Initial VS: T 100.5 (Tm 100.8) HR 107 BP 150/79 RR 18 O2 94% RA
Exam notable for:
A&O ×1 (to self)
Skin in tact
Bruising on R. shoulder
Tender right upper quadrant, left lower quadrant
1+ pedal edema bilaterally
Tender on passive range of motion to right shoulder and right
elbow
ECG:
SR, HR 100, left axis deviation, normal PR and QRS intervals,
QTc
prolongation (458/502), poor R wave progression, diffuse T wave
flattening/mild inversion in the precordial leads (V2-V6) which
is changed compared to ___
Labs showed:
Leukocytosis 13.5 (neutrophil predominant)
H/H 11.8/36.4 (higher than bl)
Normal chemistry (whole blood K 3.8)
Normal LFTs other than AST 51 (hemolyzed sample)
___ 13.4, INR 1.2
Troponin-T 0.02 --> 0.03
proBNP 2,122
Lactate 1.6
Negative serum/utox screens
UA:
yellow, hazy, SG 1.017, pH 8.0, neg - urobilinogen, bilirubin,
glucose
+LARGE LEUKS, +POSITIVE NITRITES, +30 PROTEIN, +10 KETONE
Urine microscopy:
27 RBC/hpf, 114 WBC/hpf, +MOD Bacteria
2+ hyaline casts, rare mucous, neg - yeast, epithelial cells
Imaging showed (impressions):
1. XR R. shoulder: No acute fracture; chronic changes detailed
2. XR R. elbow: no acute fracture
3. NCHCT: No acute intracranial process, chronic small vessel
disease
4. CT-C spine w/o contrast: no fracture or change in alignment
5. CT Torso w/ IV contrast:
- Submucosal edema involving the ascending colon is most
concerning for infectious or inflammatory colitis. Correlate
clinically.
- Chronic appearing atelectasis in the right lower lobe.
- Mild intrahepatic biliary ductal dilation is of unclear
clinical significance. Please correlate for focal pain and with
lab values.
- Partially visualized occlusion of the left superficial femoral
artery. This finding may be chronic though clinical correlation
is advised.
Consults: none
Patient received:
- Acetaminophen 1000 mg PO (15:00)
- IV NS 1,000 mL (18:00)
- Ceftriaxone 1 gm IV (19:10)
- Azithromycin 500 mg IV (20:00)
Transfer VS were: AF HR 76 BP 131/56 RR 16 O2 96% RA
On arrival to the floor, patient reports that she is very
confused and doesn't understand why she is here. She knows she
is
at "the ___" and remembers learning that we are in
___. When she learns she has a bladder infection, she asks
what she needs to do to fix it. When she learns that her friends
were concerned she may have fallen, she denies this and says she
has no recollection of falling.
With regard to her shoulder pain, she states that her shoulder
has hurt her for ___ years. The pain is bad when she moves it but
today it is no worse than it has been. The medications she takes
at home help minimally and it is unclear how frequently she
takes
them. Her right hip pain is not as bad as her shoulder at
baseline and currently is not bothering her too much.
She does not think she has had a bowel movement in the last
48-72
hours; that being said, she also thinks she has had diarrhea
somewhat recently and was "given medication for this." She notes
fairly significant RUQ pain when she moves around in the bed.
She
feels cold and wants another blanket.
On further questioning, she says that she has no friends or
anyone whom I can speak with. She has no family either. She
doesn't speak with her neighbors. She gets around well at home
using a cane.
ROS negative for chest pain/pressure, difficulty breathing,
cough, or swelling of her lower legs. She doesn't think she's
had
any dysuria or urinary frequency and can't remember if she is
taking her oxybutynin at bedtime. She also doesn't recall having
any fevers or chills.
Past Medical History:
PAST MEDICAL HISTORY (chart review:
1. Anemia (bl hemoglobin ___
2. Congestive heart failure w/ preserved EF (EF 60-70%).
3. Glaucoma.
4. Hearing loss.
5. History of leg edema.
6. Osteoarthritis.
7. Osteoporosis.
8. Renal insufficiency.
9. R. shoulder pain from fracture.
10. Urinary frequency.
11. History of venous stasis ulcers.
12. Vitamin D deficiency.
13. Vitamin B 12 deficiency, resolved on supplementation
Social History:
___
Family History:
nc
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: ___ 2232 Temp: 98.9 PO BP: 154/69 L Lying HR: 75 RR: 18
O2 sat: 95% O2 delivery: RA
GENERAL: NAD except when she moves which causes her to grimace
in
pain from her right shoulder and her RUQ
HEENT: dry lips, OP clear
CV: RRR, no murmurs
PULM: Difficult lung exam due to patient positioning but clear
bilaterally
GI: abdomen soft, hypoactive BS, nondistended, grimacing noticed
on minimal palpation diffusely, though most notably on her RUQ.
No rebound or guarding.
EXTREMITIES: no cyanosis, clubbing, or edema. Skin discoloration
along bilateral distal legs. Right shoulder ROM limited by pain,
no swelling, warmth or erythema and non-tender to palpation.
PULSES: 2+ radial pulses bilaterally
NEURO: AOx2-3 (knows the date w/ prompting). Inattentive. Alert,
moving all 4 extremities with purpose, face symmetric. decreased
sensation of the left leg compared to the right (chronic per
pt).
DISCHARGE PHYSICAL EXAM
GENERAL: NAD, well-appearing
CV: RRR, normal S1/S2, no murmurs, gallops, or rubs
PULM: quiet breath sounds, no wheezes, rales, rhonchi, breathing
comfortably without use of accessory muscles
GI: abdomen soft, NTND, no rebound, no guarding, no ___,
bowel
sounds present
EXTREMITIES: no leg edema
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric.
PSYCH: mood "depressed", affect appropriate
DERM: Warm and well perfused
Pertinent Results:
ADMISSION LABS
___ 02:26PM BLOOD WBC-13.5* RBC-3.80* Hgb-11.8 Hct-36.4
MCV-96 MCH-31.1 MCHC-32.4 RDW-13.1 RDWSD-45.4 Plt ___
___ 02:26PM BLOOD Neuts-90.6* Lymphs-3.0* Monos-5.8
Eos-0.0* Baso-0.1 Im ___ AbsNeut-12.23* AbsLymp-0.41*
AbsMono-0.79 AbsEos-0.00* AbsBaso-0.01
___ 02:26PM BLOOD Glucose-104* UreaN-17 Creat-1.0 Na-137
K-5.7* Cl-97 HCO3-23 AnGap-17
___ 02:26PM BLOOD ALT-12 AST-51* CK(CPK)-311* AlkPhos-50
TotBili-1.0
___ 02:26PM BLOOD CK-MB-2 cTropnT-0.02* proBNP-2122*
___ 02:26PM BLOOD Albumin-4.3 Calcium-9.0 Phos-3.1 Mg-1.8
___ 02:37PM BLOOD Lactate-1.6 K-3.8
DISCHARGE LABS
___ 07:45AM BLOOD WBC-4.9 RBC-3.68* Hgb-11.3 Hct-35.0
MCV-95 MCH-30.7 MCHC-32.3 RDW-13.2 RDWSD-46.0 Plt ___
___ 07:45AM BLOOD Plt ___
___ 07:45AM BLOOD Glucose-113* UreaN-13 Creat-0.9 Na-140
K-3.8 Cl-102 HCO3-26 AnGap-12
___ 07:45AM BLOOD Calcium-9.1 Phos-3.0 Mg-1.9
PERTINENT IMAGES
___ GLENO-HUMERAL SHOULDER (W/ Y VIEW) RIGHT
Three views of the right shoulder were provided. Chronic
deformity again seen involving the proximal right humerus with
flattened articular surface and deformity at the humeral neck
suggesting old injury. No acute fracture is identified.
Flattened glenoid fossa is similar in overall appearance to
prior reflecting chronic degenerative disease. The right
acromioclavicular joint aligns normally. Chronic appearing
right rib cage deformities are indicative of old injury. Soft
tissues are normal.
No acute fracture. Chronic changes as detailed.
___ ELBOW (AP, LAT & OBLIQUE) RIGHT
No acute fracture.
AP, lateral, oblique views of the right elbow were provided.
There is no
acute fracture, dislocation or signs of joint effusion at the
right elbow. A calcific density abutting the lateral epicondyle
of the distal humerus may reflect the sequelae of old injury.
The bones appear demineralized. Soft tissues are unremarkable.
No significant degenerative joint disease.
___ CT HEAD W/O CONTRAST
No intra-axial or extra-axial hemorrhage, edema, shift of
normally midline
structures, or evidence of acute major vascular territorial
infarction.
Prominence of ventricles and sulci reflect age related
involutional changes and appear unchanged from prior exam.
Periventricular and subcortical white matter hypodensities
consistent with chronic microvascular ischemic disease. Basal
cisterns are patent. No significant sinus disease. Mastoid air
cells middle ear cavities are well aerated. The bony calvarium
is intact. Carotid siphon calcification noted.
IMPRESSION:
No acute intracranial process. Chronic small vessel disease.
___ CT C-SPINE W/O CONTRAST
No acute fracture is seen. There is subtle anterolisthesis
again seen at C3 on 4 and 4 on 5, unchanged. Degenerative disc
disease is most pronounced at C5-6 with moderate to severe disc
space narrowing. Ligamentum flavum calcification and
hypertrophy is noted at multiple levels. No prevertebral edema.
Bony structures appear demineralized diffusely. There is
exaggeration of cervical lordosis. Thyroid is grossly
unremarkable. Imaged lung apices are notable for emphysema.
IMPRESSION:
No fracture or change in alignment.
___ CT CHEST W/CONTRAST
1. Submucosal edema involving the ascending colon is most
concerning for
infectious or inflammatory colitis. Correlate clinically.
2. Chronic appearing atelectasis in the right lower lobe.
3. Mild intrahepatic biliary ductal dilation is of unclear
clinical
significance. Please correlate for focal pain and correlate
with lab values.
4. Partially visualized occlusion of the left superficial
femoral artery.
This finding may be chronic though clinical correlation is
advised.
___ LIVER OR GALLBLADDER US (SINGLE ORGAN)
Gallbladder sludge without findings of cholecystitis. CBD
measuring up to 9 mm with no intrahepatic biliary ductal
dilatation or obstructing
stones/lesions identified.
Please note, based on CT from 1 day prior, colitis along the
ascending colon noted likely accounting for reported pain in the
right mid/upper abdomen.
PERTINENT MICRO
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
Dr. ___ is a ___ with dCHF, hypertension, chronic
right shoulder pain secondary to a chronic poorly healed
fracture and right hip OA s/p replacement, who presented with
altered mental status and concern for a urinary tract infection
in addition to colitis of unknown etiology.
ACUTE ISSUES:
===============
# Toxic metabolic encephalopathy
# Dementia
Collateral was given by health-care-proxy Father ___
___. Although Dr. ___ is unclear, it
appears that she has some baseline dementia. The patient
requires additional assistance with IADLs and ADLs. On discharge
she was alert and aware to person, place and time, but had some
attention deficits. Etiology of her AMS was likely
multifactorial from colitis, urinary tract infection and
underlying pain/polypharmacy (oxybutynin (prescribed since
___, tramadol (prescribed since ___. Oxybutinin was held
during her hospitalization. CT head w/o contrast and CT neck w/o
contrast were negative for any acute intracranial process or
fracture. Cardiogenic etiology of AMS was considered, but EKG
was unchanged from prior with diffuse flattening of T waves in
the precordial leads and stable troponemia.
#Colitis
#Sepsis
#Asymptomatic bacteriuria
Patient's urine was positive for pan-sensitive E. Coli. Although
she had polyuria prior to hospitalization, she denies dysuria
raising the possibility of asymptomatic bacteriuria. C.
difficile PCR was negative. CT findings were positive for marked
submucosal edema involving the ascending colon extending 8 cm to
the level of the hepatic flexure, suggestive of segmental
colitis. The patient was started on empirically on ceftriaxone
and flagyl, and transitioned to PO Augmentin on discharge 500 PO
Q12h with the final dose on ___ for a ___hronic right shoulder pain
#Chronic right hip pain
#Osteoarthritis
#Fall
Patient has chronic shoulder and hip pain limiting movement. Due
to an unclear history of a possible fall, x-rays of the elbow
and shoulder were ordered, which were both negative for acute
fracture. CK was trended. The patient was given Tylenol,
Lidocaine patch and tramadol for pain control. Physical therapy
evaluated the patient and ___ following ___ ___
visits.
# Mild intrahepatic biliary ductal dilation
Patient had RUQ tenderness on exam. LFTs were unremarkable,
although a RUQ ultrasound was suggesting of gallbladder sludge
without findings of cholecystitis. CBD measuring up to 9 mm with
no intrahepatic biliary ductal dilatation or obstructing
stones/lesions identified. Dilation of CBD is more than what
would be expected for age-related changes and should be
evaluated as outpatient.
# Occlusion of the left superficial femoral artery.
Per CT report, this may be chronic though clinical correlation
was advised. Her extremities were warm and well perfused.
CHRONIC ISSUES
==============
# Hypertension
Pt was restarted on home lisinopril and labetalol for BP
control.
# Urinary incontinence
Oxybutynin was held given anticholinergic side effects; pt
complained of incontinence. It was restarted on discharge.
# Glaucoma
Continued home Latanoprost 0.005% QHS
# H/o macrocytic Anemia
# Vitamin B12 deficiency
Baseline hemoglobin has improved since initiation of vitamin B12
and ranges between ___ (most recently 10.1 on ___.
Normocytic since ___. Admission hemoglobin 11.8.
# Vitamin D deficiency
# Osteoporosis
Continued vitamin d supplementation
TRANSITIONAL ISSUES
===================
#Antibiotics
- Patient was discharged on a 7-day course of Augmentin 500 q12h
with the final day on ___.
# Incidental imaging findings, please continue to follow as
indicated.
- Multiple prominent mediastinal lymph nodes are noted, however
none met criteria for pathological enlargement.
- Pt has Mild centrilobular emphysema
- Pt has mild intrahepatic biliary ductal dilation with CBD
dilated to 9mm.
- Multiple simple renal cysts
- Extensive atherosclerotic disease
- The left proximal segment of the superficial femoral artery is
occluded which may be chronic.
- Chronic right humeral head fracture
#Patient discharged to the home of ___ (___
member) before plan to transition back to living at home. She
was discharged with home ___, ___, and OT.
#CODE: Full
#CONTACT:
1. Father ___, ___
2. Alternate ___, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D 1000 UNIT PO DAILY
2. Cyanocobalamin 1000 mcg PO 3X/WEEK (___)
3. Labetalol 200 mg PO BID
4. Lisinopril 5 mg PO DAILY
5. Oxybutynin 2.5-5 mg PO QHS:PRN incontinence
6. Lidocaine 5% Patch 1 PTCH TD QAM
7. TraMADol 25 mg PO TID:PRN Pain - Moderate
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Acetaminophen 650 mg PO TID:PRN Pain - Mild
10. Lidocaine 5% Ointment 1 Appl TP TID:PRN shoulder neck pain
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by
mouth Take 1 tablet by mouth every 12 hours. Disp #*9 Tablet
Refills:*0
2. Acetaminophen 650 mg PO TID:PRN Pain - Mild
3. Cyanocobalamin 1000 mcg PO 3X/WEEK (___)
4. Labetalol 200 mg PO BID
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. Lidocaine 5% Ointment 1 Appl TP TID:PRN shoulder neck pain
7. Lidocaine 5% Patch 1 PTCH TD QAM
8. Lisinopril 5 mg PO DAILY
9. Oxybutynin 2.5-5 mg PO QHS:PRN incontinence
10. TraMADol 25 mg PO TID:PRN Pain - Moderate
11. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
#Colitis
#Uncomplicated Urinary Tract Infection
#Toxic metabolic encephalopathy
#Dementia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because you had a fever and
were confused.
WHAT WAS DONE IN THE HOSPITAL?
- We took a CT, or CAT scan, to get pictures of your chest,
abdomen and pelvis. Those pictures were concerning for an
infection in your large intestine called "colitis".
- We took an ultrasound of your liver and gallbladder.
- You were given antibiotics to treat the infection in your
large intestine.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Follow up with your primary doctor.
- Continue taking your antibiotics twice a day through the end
of the day on ___.
- Remember to take all your medications.
It was a pleasure taking care of you at ___.
Your ___ Team
Followup Instructions:
___
|
10256493-DS-5 | 10,256,493 | 26,725,182 | DS | 5 | 2129-08-23 00:00:00 | 2129-08-23 23:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / azithromycin
Attending: ___
Chief Complaint:
Rt foot and shank swelling, pain, erythema, and drainage
(purulent)
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male-to-female (preferred name ___ with history of right
pilon fracture in ___ complicated by nonunion with
polymicrobial (MSSA, S. anginosus, Prevotella) orthopedic
implant-related infection s/p complete hardware removal on
___ followed by 8-week treatment course of
cefazolin/metronidazole (followed by ID/Orthopedics) who
presents with increasing pain and drainage of the right foot.
He originally sustained a pilon fracture of the right lower
extremity in ___ and managed operatively at ___.
Course was complicated by polymicrobial wound infection
requiring hardware removal and then and 8-week course of
cefazolin/metronidazole. She established care at ___ with Dr.
___ and Dr. ___ for a second opinion
regarding treatment in ___. At that time, they recommended
to continue the course of antibiotics as originally recommended
with plans for complex reconstruction vs. BKA. She was seen
again in ___ clinic in early ___, having been off antibiotics
for 3 weeks, with no signs of infection.
On ___, the patient was seen by Dr. ___ in follow-up after
having a CT lower extremity which showed partial bony bridging
of the comminuted distal tibia fracture and the tibiotalar
joint, partial comminuted distal fibula fracture, minimal bony
bridging of the distal tibiofibular joint and vertically
oriented nondisplaced fracture of the fibular strut graft and
oblique fracture of the fibular strut graft. At that
appointment, it was decided that she would attempt to quit
smoking for 6 weeks and then undergo complex reconstruction (as
opposed to BKA). Pain management and smoking cessation was
deferred to his new PCP, ___.
The patient was seen in the ED on ___ for increased
serosanguineous drainage where her leg was evaluated by
Orthopedics. She was discharged and follow-up with orthopedics
(Dr. ___ was recommended. Over the last 2 days, she has had
increasing pain and swelling..
Reports associated low grade temperatures to 100.1F. Denies any
sensory or motor deficits including weakness, numbness or
tingling.
In the ED, initial vital signs were 98.6F HR 90 BP 152/81 RR 18
SpO2 99% RA.
Exam notable for mild edema and tenderness to palpation to
distal third of leg, as well as calcaneal erythema that was
reportedly not significantly warm.
Labs were notable for Cr 0.9, WBCs 7.8, Hgb 12.0, Platelets
200, CRP 30.8 (up from 23 on ___.
Imaging included right ankle plain films and LENIs. Preliminary
U/S results were negative for thrombus.
She received hydromorphone 1mg and vancomycin 1000mg.
Orthopedic Surgery was consulted and recommended no acute
management and follow-up with Dr. ___ as scheduled on ___.
Decision was made to admit to medicine. On arrival to the ward,
pt. reports ongoing rt shank pain, shooting and sharp and
intermittent. Denies ongoing fevers or drainage.
REVIEW OF SYSTEMS:
All other 10-system review negative in detail other than pain,
low grade fever, and drainage of heel as above.
Past Medical History:
- Migraine
- Depression/Anxiety
- Bipolar affective disorder
- Polysubstance abuse (opiates, alcohol)
- Rheumatoid arthritis
- Chronic hepatitis B
- Prostate cancer
- Asthma
- Seizure disorder
- History of C. difficile colitis
- Hyperlipidemia
- GERD
Right pilon fracture history:
- ___ sustained a R pilon fracture, s/p external fixation on
___
- ___ - underwent external fixator removal, with no signs
of
infection at that time
- His course was then complicated by nonunion of the fracture
site
- ___ - he underwent plate fusion and iliac bone grafting
- ___ - Presented with evidence of purulence at his
surgical
site, pt reports a history of bleeding/drainage for several
weeks. He underwent debridement with retention of hardware
- ___ - due to wound dehiscence, he underwent complete
hardware removal and closure with casting. OR cultures grew
MSSA,
S. anginosus and Prevotella for which cefazolin/flagyl were
started
- ___ - underwent cast replacement after presenting with
soaked cast from his ECF, no evidence of infection at that
time.
- ___- established care with Dr. ___, continued on
8 week course of cefazolin/metronidazole
- ___- established care with Dr. ___ performed which
showed partial bony bridging of the comminuted distal tibia
fracture and the
tibiotalar joint, partial bony bridging of the comminuted
distal fibula fracture, minimal bony bridging of the distal
tibiofibular joint, vertically oriented nondisplaced fracture of
the fibular strut graft and oblique fracture of the fibular
strut graft.
- ___- seen in ___ clinic with no signs of active infection
Social History:
___
Family History:
Denies
Physical Exam:
AF and VSS
NAD
Alert, oriented, speech fluent
RRR no MRG
CTA throughout
Soft/NT/ND/BS present
Rt shank and foot/heel with edema and erythema, no dranage. Sl
warm, ttp throughout.
Moves all extremities
Discharge exam:
VS: 98.1, 114/68, 68, 16, 100%RA
Gen: Thin, NAD
HEENT: PERRL, EOMI, MMM
Neck: Supple, no JVD or LAD
Lungs: LCTA-bl, no w/r/r
Heart: RRR, no MRG, nl s1 and s2
Abd: Soft, NTND, no HSM
Ext: RLE with 1+ non-pitting edema, warmth and ttp anteriorly.
2+
DP and ___ pulses. Posterior granular tissue and prior healed
scar. Diffuse ttp from mid shin to plantar surface of
foot.
Neuro: CNII-XII intact, strength ___ in ue and ___ bl
Pertinent Results:
Admission labs:
___ 01:50PM BLOOD WBC-7.8 RBC-4.42* Hgb-12.0* Hct-37.1*
MCV-84 MCH-27.1 MCHC-32.3 RDW-13.4 RDWSD-40.5 Plt ___
___ 01:50PM BLOOD Neuts-65.6 ___ Monos-9.7 Eos-2.6
Baso-0.4 Im ___ AbsNeut-5.12 AbsLymp-1.67 AbsMono-0.76
AbsEos-0.20 AbsBaso-0.03
___ 01:50PM BLOOD Glucose-96 UreaN-18 Creat-0.9 Na-138
K-4.0 Cl-100 HCO3-25 AnGap-17
___ 01:35PM BLOOD Calcium-9.3 Phos-3.2 Mg-2.0
___ 01:50PM BLOOD CRP-30.8*
___ 01:35PM BLOOD Bnzodzp-NEG Barbitr-NEG
___ 01:46PM BLOOD Lactate-0.7
___ 01:50PM BLOOD SED RATE-29
___ 06:34PM URINE Color-Yellow Appear-Clear Sp ___
___ 06:34PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 06:34PM URINE bnzodzp-NEG barbitr-NEG cocaine-NEG
amphetm-NEG mthdone-NEG
Discharge labs:
___ 01:35PM BLOOD WBC-5.1 RBC-4.67 Hgb-12.8* Hct-39.2*
MCV-84 MCH-27.4 MCHC-32.7 RDW-13.2 RDWSD-39.8 Plt ___
___ 01:35PM BLOOD Glucose-96 UreaN-13 Creat-0.9 Na-137
K-4.2 Cl-102 HCO3-26 AnGap-13
RLE US ___:
FINDINGS:
There is normal compressibility, flow, and augmentation of the
right common
femoral, 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.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right lower
extremity veins.
RLE Ankle XR ___:
FINDINGS:
Chronic posttraumatic deformity of the right ankle appears
unchanged from
prior with ghost tracts reflecting prior hardware removal and
bone graft
traversing the tibiotalar joint with partial bony ankylosis
noted. Bones are
demineralized. Soft tissues appear diffusely prominent without
soft tissue
gas or radiopaque foreign body. Heel spurs noted.
IMPRESSION:
As above.
Brief Hospital Course:
___ trans female with PMHx of R pilon fracture ___, cb
MSSA, S. anginosus, Prevotella implant infection s/p hardware
removal on ___ and 8w cefazolin/flagyl), RA, seizure
disorder, h/o C. diff, prostate ca, who presented with
increasing pain and drainage of R foot.
# R foot infection:
Pt presented with ?worsening drainage, reported borderline fever
(tm 100.1) and pain. Found to have elevated CRP at 30.8 with
rising ESR at 29. Per Dr. ___ sx similar to prior
presentation. Given ongoing sx despite prolonged course of abx,
decision made for pt to undergo amputation. Pt was briefly on
Vanc (___) but this was discontinued per ID recs. It was
recommended by ID that pt undergo expedited amputation. Per Dr.
___: "amp will require careful planning, maximizing time pt not
smoking, working with prosthetics before surgery, and
coordinating for surgery to take place in a 2-step process."
Thus pt was discharged after joint discussions with ID, patient,
and Orthopedic surgery with all in agreement w plan. Per ID, if
there is any sign of progression on follow-up, recommend start
antibiotics. Furthermore, ID consult team to be called when pt
is admitted for amputation, prior to surgery. It was also
advised that pt be on antibiotics postop with initial regimen
based on his prior bacteria cultures. ID requested that
Orthopedics send resected bone/tissue to both micro lab and path
at time of surgery. Depending on the findings in these labs, ID
will help determine route, duration, and regimen for antibiotics
treatment. Pt's primary ID physician, ___, is aware of
this plan and plans to schedule pt for an outpatient followup.
At time of discharge, pt's RLE sx were stable. Pt will have
short interval follow-up with ID and orthopedics to establish
date of surgery. Recommend continued close eval of foot by
outpatient doctors.
# h/o Seizure:
Continued lamictal, topomax, gabapentin
Transitional Issues:
- Please ensure expedited follow-up with Orthopedics and ID for
definitive management of foot infection
- Pls cont eval of anemia
- Minimize sedating meds
- Trend ESR/CRP
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Morphine Sulfate ___ 30 mg PO Q4H:PRN pain
2. HydrOXYzine 50 mg PO Q6H:PRN anxiety
3. FoLIC Acid 1 mg PO DAILY
4. DULoxetine 60 mg PO DAILY
5. Donepezil 5 mg PO QHS
6. Acamprosate 333 mg PO TID
7. TraZODone 100 mg PO QHS:PRN insomnia
8. Topiramate (Topamax) 100 mg PO BID
9. LamoTRIgine 150 mg PO DAILY
10. Gabapentin 800 mg PO TID
11. Tamsulosin 0.4 mg PO QHS
12. Atorvastatin 40 mg PO QPM
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. Donepezil 5 mg PO QHS
3. DULoxetine 60 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Gabapentin 800 mg PO TID
6. LamoTRIgine 150 mg PO DAILY
7. Morphine Sulfate ___ 30 mg PO Q4H:PRN pain
8. Tamsulosin 0.4 mg PO QHS
9. Topiramate (Topamax) 100 mg PO BID
10. TraZODone 200 mg PO QHS:PRN insomnia
11. Acamprosate 333 mg PO TID
12. HydrOXYzine 50 mg PO Q6H:PRN anxiety
Discharge Disposition:
Home
Discharge Diagnosis:
Ankle infection
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 ___,
It was a pleasure to participate in your care at ___. You were
admitted for foot pain. You were found to have
continuation/worsening of your foot infection. Your Orthopedic
surgeon and you agreed on a plan for amputation. You were
evaluated by the infectious disease team. You briefly received
antibiotics but these were discontinued subsequently. Please
follow up with your primary doctor, Orthopedist and ID
specialist. Please seek immediate medical attention if your foot
symptoms worsen.
Best Regards,
Your ___ Medicine Team
Followup Instructions:
___
|
10257073-DS-13 | 10,257,073 | 21,590,602 | DS | 13 | 2167-09-13 00:00:00 | 2167-09-14 14:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Headache, pupillary asymmetry
Major Surgical or Invasive Procedure:
Nil
History of Present Illness:
The pt is a ___ with HTN, dyslexia and mild developmental delay
who p/w new ptosis. One week ago, he woke up feeling normal. He
went to the dumpster to throw garbage. He used a plastic
shuffle
to prop up the lids of the dumpster but the shuffle fell and hit
his head. He then develop a bifrontal pressure-like headache
that is intermittent with no associated symptoms such as
photophobia or nausea. He went to the urgent care 2 days later
and was sent home with butalbital for "mild concussion". Then,
two days ago, he went to his PCP who thought his HA was
post-concussive also. Yesterday, he went back to his PCP
because
he continues to have HAs. This time, his PCP noticed left
ptosis
and left pupil being smaller than right pupil. He also happened
to saw his ophthalmologist yesterday who agreed with the exam.
The PCP ordered ___ which reportedly shows an old right
frontal infarct. MRI showed "subacute left temporal and frontal
lobe infarct". MRA reportedly showed "left ICA occlusion and
right ICA 99% stenosis" and unremarkable "basilar and vertebral
arteries". He was then referred to ___ ED for
further evaluation. BP on arrival to OSH was 160/105, EKG NSR.
OSH ED doc attempted to obtain a Neurology consult at his
hospital but neuro never called back so they called us and
requested a transfer for neuro eval.
On repeated questioning, patient denies feeling anything
abnormal
except for the HA after getting hit by the shuffle. His mom,
who
lives with him, did not notice anything abnormal except she
remembers patient complaining about head and neck pain roughly 3
weeks ago which they attributed it to "sleeping funny". Denies
anhydrosis on one side of the face.
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, lightheadedness, vertigo,
tinnitus or hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
- Hypertension: Patient recently diagnosed with hypertension and
started on 5mg daily of lisinopril.
Social History:
___
___ History:
Noncontributory
Physical Exam:
Physical Exam:
Vitals: T: P:72 R: 16 BP: 159/98 SaO2: 97%RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM,
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Grossly attentive. Language is fluent with
intact repetition and comprehension. Normal prosody. There were
no paraphasic errors. Pt was able to name low frequency objects
(had trouble with hammock and cactus). Unable to read at
baseline. Speech was not dysarthric. Able to follow both midline
and appendicular commands. Fund of knowledge intact to president
Obama. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: Pupils L 2mm--> 1.5mm, R 3mm->2.5mm. VFF to confrontation.
III, IV, VI: L ptosis. EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. Bilateral postural tremors in the hands present.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
ON DISCHARGE: Slight anisocoria, improved from one day prior
Pertinent Results:
___ 02:06AM BLOOD WBC-13.5* RBC-5.55 Hgb-16.2 Hct-48.2
MCV-87 MCH-29.1 MCHC-33.5 RDW-12.4 Plt ___
___ 02:06AM BLOOD Neuts-82.1* Lymphs-12.0* Monos-5.2
Eos-0.4 Baso-0.4
___ 09:20AM BLOOD ___ PTT-38.2* ___
___ 09:20AM BLOOD Thrombn-13.0
___ 09:20AM BLOOD ESR-3
___ 02:06AM BLOOD Glucose-111* UreaN-11 Creat-0.7 Na-138
K-3.9 Cl-102 HCO3-27 AnGap-13
___ 09:20AM BLOOD ALT-16 AST-16 LD(LDH)-203 CK(CPK)-107
AlkPhos-86 TotBili-0.7
___ 06:05AM BLOOD Calcium-9.6 Phos-3.4 Mg-2.7*
___ 09:20AM BLOOD Albumin-4.8 Cholest-191
___ 09:20AM BLOOD %HbA1c-5.3 eAG-105
___ 09:20AM BLOOD Triglyc-171* HDL-53 CHOL/HD-3.6
LDLcalc-104
___ 09:20AM BLOOD TSH-1.1
___ 09:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
___ 04:25AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 04:25AM URINE RBC-<1 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
___ 04:25AM URINE CastGr-1* CastHy-3*
___ 08:40AM URINE bnzodzp-NEG barbitr-POS opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
___ 04:25AM URINE Color-Yellow Appear-Hazy Sp ___
REPORTS:
CTA/Head and neck:
Dissection of the bilateral carotid arteries, resulting in
complete occlusion of the left from just distal to its origin to
the carotid sinus, and two areas of significant narrowing of the
right internal carotid artery between the bifurcation and the
carotid canal.
Left frontotemporal cortical and basal ganglia hypodensities
which appear
subacute in chronicity, without associated mass effect or shift
of normally midline structures. Narrowing of distal left MCA
branches.
MRA neck: Bilateral internal carotid artery dissections with
severe
stenosis on the right and apparent occlusion on the left.
MRI Head: acute ischemic stroke of the left infrontal lobe
Brief Hospital Course:
___ was admitted to the stroke service at ___. An OSH MRI
identified a new left frontal stroke (from which he had little
by way of symptoms). We obtained a CTA of his head/neck which
identified significant stenosis of bilateral carotid arteries
(see above). An MRA of the neck with fat suppression sequences
confirmed the presence of thrombi within the carotid arteries
likely related to bilateral carotid dissection. He was
empirically initiated on aspirin and his examination remained
stable throughout his stay. The exact event leading to the
dissection is unclear. In any case, we emphasized the importance
of avoiding strenuous physical activity and violent throwing
movements. He needs to follow up with his PCP and Dr. ___
___ the neurology clinic. Hypercoagulability labs had been
drawn on admission, but in this case all of the evidence points
to a dissection as being the cause for his stroke (and Horner's
syndrome on the left). Carotid dissection was likely related to
trauma; he had no physical examination findings suggestive of
collagen mutation such as Ehlers Danlos syndrome. He was given
strict ED warnings and a letter for work.
The issue of anticoagulation vs antiplatelet therapy in patients
with cervical artery dissections is often raised. The so far
available data do not show superiority of one versus the other
option, hence we opted for antiplatelet treatment as opposed to
to anticoagulation with warfarin.
TRANSITIONAL ISSUES:
- Ensure compliance with aspirin
- F/u hypercoagulability labs drawn on admission
- Repeat CTA versus MRA
Medications on Admission:
Lisinopril 5mg daily
Discharge Medications:
1. Lisinopril 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet,delayed
release (___) by mouth daily Disp #*60 Tablet Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
- Bilateral carotid artery thrombosis secondary to dissection
(likely traumatic)
- Intellectual disability
- Dyslexia
- Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you in the hospital. You were
hospitalized because of a new headache that you developed, and
your primary care doctor noticed that one of your pupils was
smaller than the other. Through a series of physical
examinations, neuroimaging tests and blood tests, we discovered
that you have a condition called "bilateral carotid artery
dissection". This is where a small tear in the blood vessel (on
the inside) leads to the development of a clot within the lumen
of the blood vessel. If dislodged, this clot can travel up to
your brain and cause a temporary or permanent blockage of a
blood vessel in your brain ("STROKE"). We observed that you had
a small a stroke in the left side of your brain - this is not
left you with any significant disability.
To prevent this from happening again, we would like you to
take a daily aspirin (81mg daily). You can take this with your
daily lisinopril (5mg daily). We ask that you do not engage in
ANY STRENUOUS PHYSICAL ACTIVITY, such as lifting heavy objects,
vigorous aerobic exercises, football, or any other fast violent
movements. We may be able to allow you to participate in regular
activity after Dr. ___ you again in his clinic.
Since this is a weekend, we were not able to set your follow
up appointments up. However, our office will contact you with
the date and time of your appointment with our department of
neurology. If you do not hear from them, please call us at ___.
Please do make an appointment with your PCP within the next
week. It was a pleasure caring for you at ___.
Followup Instructions:
___
|
10257475-DS-18 | 10,257,475 | 27,692,166 | DS | 18 | 2152-01-13 00:00:00 | 2152-02-04 15:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
___: Laparoscopic Appendectomy
History of Present Illness:
___ otherwise healthy, recently seen ___ for abdominal pain
with imaging c/f acute appendicitis and subsequently discharged
home on oral antibiotics returns with persistent abdominal pain.
He was tender in the RLQ and despite absence of leukocytosis CT
confirmed persistent acute appendicitis. Given failure of
medical treatment the patients is elected to undergo an
appendectomy.
Past Medical History:
Gastritis & H. pylori
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM
-------------------
Vitals: 97.8 80 114/82 20 96% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, mildly ttp in the RLQ.
Ext: No ___ edema, ___ warm and well perfused
DISCHARGE EXAM
-------------------
98.1 PO115 / 62 L Lying___
GEN: M in NAD, comfortable in bed, AOx3
Chest: RRR
Lungs: CTAB, occasional dry cough
Abdomen: laparoscopic incisions clean, dry, intact with dressing
soft, appropriately tender to palpation, +BS,
Ext: WWP, no LLE
Pertinent Results:
Hematology
COMPLETE BLOOD COUNTWBCRBCHgbHctMCVMCHMCHCRDWRDWSDPlt
Ct
___ 09:30AM
___
___ 05:23PM
___
DIFFERENTIALNeutsBandsLymphsMonosEosBasoAtypsMetasIm
GranAbsNeutAbsLympAbsMonoAbsEosAbsBaso
___ 05:23PM 58.5 26.58.45.00.8
___
BASIC COAGULATION ___, PTT, PLT, INR)Plt Ct
___ 09:30AM 185
___ 05:23PM 216
Chemistry
RENAL & GLUCOSEGlucoseUreaNCreatNaKClHCO3AnGap
___ 09:30AM ___
___ 05:23PM ___
CHEMISTRYTotProtAlbuminGlobulnCalciumPhosMgUricAcdIron
___ 09:30AM 8.63.21.8
Blood Gas
WHOLE BLOOD, MISCELLANEOUS CHEMISTRYLactate
___ 05:30PM 1.6
___ 5:23 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ ABD & PELVIS WITH CO
Persistent uncomplicated acute appendicitis without evidence for
perforation
or abscess.
___
SURGICAL PATHOLOGY REPORT - Final
PATHOLOGIC DIAGNOSIS:
Appendix, appendectomy:
- Acute transmural appendicitis.
Brief Hospital Course:
The patient re-presented on ___ with with clinical and
radiographic evidence of acute appendicitis. He was taken
urgently to the operating room and underwent a laparoscopic
appendectomy on ___. There were no adverse events in the
operating room; please see the operative note for details.
Post-operatively the patient was taken to the PACU until stable
and then transferred to the wards until stable to go home.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with IV pain
medications and transitioned to PO pain medications. Pain was
very well controlled with PO Tylenol and PO Oxycodone.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. Orthostatic
vitals were normal prior to discharge.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Early
ambulation was encouraged throughout hospitalization.
GI/GU/FEN: The patient was tolerating a regular diet prior to
discharge.
ID: Patient was previously sent home for medical treatment of
appendicitis on Amoxicillin-Clavulanic Acid ___ mg PO Q12H.
Post-surgery, antibiotics were discontinued as adequate source
control was achieved through surgery. The patient's fever curves
were closely watched for signs of infection, of which there were
none.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
2. Loratadine 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen [Acetaminophen Pain Relief] 500 mg 2 tablet(s)
by mouth every six (6) hours Disp #*30 Tablet Refills:*0
2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*10 Tablet Refills:*0
3. Loratadine 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You presented to the hospital with abdominal pain. On imaging,
you were found to have appendicitis (inflammation of your
appendix). You underwent laparoscopic surgery for removal of
your appendix. You have recovered, your pain is controlled, you
are tolerating a regular diet, and are now ready to be
discharged to home. Please follow the recommendations below to
ensure a speedy and uneventful 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.
- You may resume sexual activity unless your doctor has told
you otherwise.
HOW YOU MAY FEEL:
- You may feel weak or "washed out" for 6 weeks. You might want
to nap often. Simple tasks may exhaust you.
- You may have a sore throat because of a tube that was in your
throat during the endoscopy.
YOUR BOWELS:
- Constipation is a common side effect of medicine such as
codeine. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
- If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
- After some operations, diarrhea can occur. If you get
diarrhea, don't take anti-diarrhea medicines. Drink plenty of
fluitds 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:
- 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.
WOUND CARE:
- Dressing removal: You may remove the top layer of dressing in
2 days. Keep the steri-strips (white small strips) in place.
- You may shower with any bandage strips that may be covering
your wound. Do not scrub and do not soak or swim, and pat the
incision dry. If you have steri strips, they will fall off by
themselves in ___ weeks. If any are still on in two weeks and
the edges are curling up, you may carefully peel them off.
- Do not take baths, soak, or swim for 6 weeks after surgery
unless told otherwise by your surgical team.
It was a pleasure taking care of you,
--Your ___ Care Team
Followup Instructions:
___
|
10257607-DS-15 | 10,257,607 | 22,248,897 | DS | 15 | 2161-12-10 00:00:00 | 2161-12-16 00:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Heparin Agents
Attending: ___
___ Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
EGD - ___
History of Present Illness:
___ woman who is a Je___'s witness with a past medical
history of porcine artificial mitral valve, AF, CHF, asthma,
CKD, and SLE currently on Xarelto which was transitioned from
Coumadin 3 days presents as a transfer for evaluation of GI
bleed. Patient reports 2 weeks of bloody stool output. Over the
last ___ days she has noted melena reported as dark tarry
stools. She is fatigued. Refusing blood transfusion due to
religious beliefs.
In ED initial VS: 97.4 70 95/56 20 91% RA
Labs significant for: ___: 40.0, PTT: 40.6, INR: 3.6, Hb 5.1, Cr
1.4
Patient was given:
-Pantoprazole 40 mg
-500cc NS
Imaging notable for:
CXR:
Comparison to ___. Massive increase in size of the
cardiac
silhouette that is now moderately enlarged. Stable alignment of
the sternal
wires. Stable position of the valvular replacement. No pleural
effusions.
No pulmonary edema. No pneumonia. No pneumothorax.
Consults:
#GI:
- IV PPI
- large access x 2
- IVF and resiuscitation
- will see patient and plan for likely EGD
- NPO
- would hold anticoagulation for now given no transfusions and
Hgb of 6.
VS prior to transfer: 98.1 71 95/39 20 100% RA
On arrival to the MICU, patient confirms above history. She
remains having blood BMs and is otherwise not in acute pain or
symptomatic. She is HDS.
Past Medical History:
-porcine artificial mitral valve
-AF
-CHF
-asthma
-CKD-
-SLE
Social History:
___
Family History:
No family history of cancer, explicitly including colon,
pancreas, esophagus, and gastric.
Physical Exam:
ADMISSION EXAM
=========================
VITALS: Reviewed in metavision
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, no JVD, neck
supple
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Irregular rate, normal rhythm, PMI noted on chest with
heaves, 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 lesions noted
NEURO: No motor/sensory deficits elicited
DISCHARGE EXAM
==========================
VITALS: T 97.8 HR 100 BP 135/80 RR 22 O2 sat 100%RA
GENERAL: Intubated/sedated.
HEENT: Sclera anicteric, MMM. NC/AT.
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Irregular rate, normal rhythm, PMI noted on chest with
heaves, normal S1 S2, II/VI holosystolic murmur heard over apex.
No rubs or gallops.
ABD: soft, non-tender, non-distended, decreased bowel sounds, no
rebound tenderness or guarding
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: No lesions noted
NEURO: Intubated/sedated
Pertinent Results:
ADMISSION LABS
============================
___ 02:06PM BLOOD WBC-6.9 RBC-1.65*# Hgb-5.1*# Hct-16.1*#
MCV-98 MCH-30.9 MCHC-31.7* RDW-22.4* RDWSD-73.8* Plt ___
___ 02:06PM BLOOD Neuts-73.4* Lymphs-17.6* Monos-7.2
Eos-1.0 Baso-0.1 Im ___ AbsNeut-5.08 AbsLymp-1.22
AbsMono-0.50 AbsEos-0.07 AbsBaso-0.01
___ 03:20PM BLOOD ___ PTT-40.6* ___
___ 02:06PM BLOOD Glucose-85 UreaN-83* Creat-1.4* Na-144
K-4.1 Cl-106 HCO3-21* AnGap-17
___ 02:47AM BLOOD ALT-9 AST-36 AlkPhos-68 TotBili-3.0*
___ 12:57AM BLOOD CK-MB-3 cTropnT-0.03*
___ 12:52AM BLOOD CK-MB-2 cTropnT-0.02*
___ 02:06PM BLOOD Calcium-8.1* Phos-3.7 Mg-2.2
___ 07:48PM BLOOD Glucose-63* Lactate-1.9 Na-146* K-3.0*
Cl-100
RELEVANT STUDIES
============================
___ EGD:
Initially red blood was seen refluxing into the esophagus,
however during withdrawal the esophagus was able to be carefully
examined without evidence of tear or bleeding source.
Blood in the stomach
Active bleeding was seen in two areas in the fundus. Area #1
appeared to be approximately 4mm across with an area of fresh
oozing blood in the center. Bleeding area #2 had a faster rate
of bleeding, and appeared 3mm across and raised. The type of
lesion was not able to be confirmed, potentially bleeding
inflammatory polyps, dieulafoys, or AVMs. (endoclip)
No blood or evidence of bleeding seen in the duodenum.
Otherwise normal EGD to third part of the duodenum
___ TTE:
The left atrial volume index is severely increased. The right
atrium is markedly dilated. Diastolic function could not be
assessed. The right ventricular cavity is moderately dilated
with moderate global free wall hypokinesis. There is abnormal
septal motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets are
moderately thickened. The aortic valve VTI = 62 cm. There is
moderate aortic valve stenosis (valve area 1.0-1.2cm2). Mild
(1+) aortic regurgitation is seen. A bioprosthetic mitral valve
prosthesis is present. The gradients are higher than expected
for this type of prosthesis. Mild (1+) mitral regurgitation is
seen. Severe [4+] tricuspid regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. [In the setting
of at least moderate to severe tricuspid regurgitation, the
estimated pulmonary artery systolic pressure may be
underestimated due to a very high right atrial pressure.] There
is a trivial/physiologic pericardial effusion.
IMPRESSION: A left pleural effusion is present. Ascites is
present.
1) Well seated mitral bioprosthetic valve with moderately
elevated gradients and mild valvular mitral regurgitation.
2) Moderate aortic stenosis by aortic valve gradients and mild
aortic regurgitation.
3) Severe tricuspid regurgitation due to RV annular dilation in
setting of at least moderate pulmonary systolic hypertension as
well as moderate RV dilation and hypokinesis.
Compared with the prior study (images not available for review)
of ___, significant changes have occurred. LV systolic
function appears depressed due to intraventricular LV
dyssynchrony due to post-operative state and also now RV
pressure and volume overload however intrinsic left ventricular
myocardial contractility likely normal.
___ CT HEAD W/O CONTRAST:
T
here is no evidence of acute intracranial process or hemorrhage.
___ RUQ U/S:
1
.
N
o definite sonographic evidence of liver parenchyma abnormality.
2. Small to moderate ascites.
3
.
C
o
n
t
r
a
c
t
e
d
gallbladder with wall edema likely secondary to third spacing.
C
holelithiasis/gallbladder sludge without gallbladder distention.
MICROBIOLOGY
============================
___ 5:50 am BLOOD CULTURE Source: Line-left IJ.
Blood Culture, Routine (Pending):
__________________________________________________________
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
STAPH AUREUS COAG +. HEAVY GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
__________________________________________________________
___ 9:43 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 9:43 am BLOOD CULTURE Source: Line-IJ.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 8:00 pm BLOOD CULTURE Source: Venipuncture 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 8:31 pm BLOOD CULTURE Source: Line-CVL 1 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 8:31 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 2:47 am BLOOD CULTURE Source: Line-IJ.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 2:47 am BLOOD CULTURE Source: Line-IJ.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
DISCHARGE LABS
============================
___ 05:07PM BLOOD WBC-14.1* RBC-1.77* Hgb-5.1* Hct-18.1*
MCV-102* MCH-28.8 MCHC-28.2* RDW-24.6* RDWSD-85.6* Plt ___
___ 04:03AM BLOOD Glucose-100 UreaN-66* Creat-1.5* Na-149*
K-4.9 Cl-113* HCO3-20* AnGap-16
___ 04:03AM BLOOD Calcium-8.2* Phos-5.5* Mg-2.5
Brief Hospital Course:
Ms. ___ is an ___ female who presented as a
transfer from OSH with acute GI bleed and Hgb < 5 on
anti-coagulation. She was admitted to the MICU with hemorrhagic
shock requiring pressors and intubation for EGD.
ACUTE ISSUES:
#Upper GI Bleed: Patient presented with significant anemia and
Hgb 3.9 at nadir in the setting of two weeks of bloody/melenic
stools. GI was consulted and did EGD ___ which showed two
bleeding ulcers in the stomach fundus which were endoclipped.
Hgb stabilized at ~5. Patient is a Jehovah's Witness and thus
family declined transfusion with blood products due to religious
beliefs. While patient required pressors to support
hemodynamics, she did not decompensate after initial GI bleed
and CBC was not trended as she would not want to receive blood
products if Hgb/Hct was below transfusion threshold. She
received two separate doses of IV iron, as well as EPO, folic
acid, aminocaproic acid, and B12. Reticulocyte count was 8%
suggesting appropriate response to blood loss anemia. Patient
received IV PPI BID during admission and was transitioned to PO
PPI upon discharge.
# Acute respiratory failure:
# Ventilator-associated pneumonia: Upon presentation, patient
was initially intubated for EGD. After EGD, patient was unable
to be weaned from the ventilator due to her overall mental
status. She subsequently developed VAP with sputum culture from
___ growing MSSA and was treated with an 8-day course of
Cefazolin. Volume overload also likely contributed to
respiratory failure, and patient was on furosemide drip until
shortly after extubation. She was extubated on ___ and
maintained stable respiratory status, though O2 sat was often
unable to be measured to poor plethysmography.
# Toxic-metabolic encephalopathy: ICU course complicated by
toxic-metabolic encephalopathy which was likely multifactorial
in setting of acute illness, ICU-related delirium, and
ventilator-associated pneumonia. VAP was treated as above and
Seroquel was started during ICU admission. CT head w/o contrast
from ___ showed no evidence of acute intracranial process. Her
mental status improved after extubation.
# Hypotension: Patient was hypotensive upon admission likely in
the setting of hemorrhagic shock and required norepinephrine
which was weaned on ___. TTE was done on ___ to rule out
cardiogenic component of shock. TTE showed normal EF. Patient
was resuscitated with IVF and her pressor requirements were
weaned and discontinued on ___.
#Hypernatremia: Patient was intermittently hypernatremic during
admission. While intubated, her free water flushes were titrated
to replete her total body water deficit. She also received IVF
for hypernatremia. On day of discharge, sodium was 149.
# ___: Likely due to ATN following hemorrhagic shock. Cr was 1.4
on day of admission and peaked at 3.1 before downtrending. Her
Cr on day of discharge was 1.5.
# Code status: The patient's son is the HCP, though there is a
large family of children heavily involved. The son is clear that
he wants the patient to be full code and to pursue all
interventions. Separate discussions with other family members
provided a slightly different opinion. However the family
overall was in agreement with the son/HCP's plan for full code.
# Med rec/PCP: ___ to perform accurate med rec as patient has
not filled meds at listed pharmacy for some time. Listed PCP had
not seen the patient in ___ years. The family noted that the one
medication they knew she should be on is the citalopram.
CHRONIC ISSUES:
=================
# Afib: Prior to admission, patient was anti-coagulated with
rivaroxaban and on rate control. Rivaroxaban was held due to
acute GI bleed. Her rate control medications were held due to
hypotension requiring pressor support. Rivaroxaban was not
re-started upon discharge due to risk of recurrent GI bleed.
Digoxin was held due to renal function and not restarted as
rates controlled.
# SLE: Held home hydroxychloroquine 200 mg PO QD
TRANSITIONAL ISSUES
=====================
[] Seroquel started for acute toxic-metabolic encephalopathy
during ICU admission which improved over the course of the
admission. Would recommend weaning and discontinuing after
discharge as patient did not require this medication prior to
hospitalization and she required it for acute encephalopathy.
[] Patient required furosemide infusion for volume overload in
the setting of fluid resuscitation in ICU. TTE did not show
reduced EF and patient was not discharged on diuretic. Please
monitor daily weights and consider initiation of diuretic if
evidence of weight gain or volume overload. Dose would be
unclear -- at one point as outpatient ___ year ago was on 20mg
torsemide and 2.5mg metolazone.
[] TTE demonstrated evidence of right heart failure, severe TR,
and moderate pulmonary hypertension.
[] Rivaroxaban discontinued in setting of GI bleed. CHADS2-VASC
at least 3, but patient is at significant risk of bleed and
religious preferences dictate no blood transfusions. Further
conversations about anticoagulation indicated. Likely is not a
candidate.
[] Home digoxin held due to renal function and controlled rates
inpatient. Requires discussion about restarting.
[] Suggest transitioning PO PPI to H2 blocker in near future
[] Should have rheumatology follow-up for management of her
lupus, as she was not treated inpatient and was not discharged
on immunosuppressive medications.
[] Consider GI follow-up for GI bleed ongoing management
[] Recommend continuing code status discussion with family
[] Requires accurate med rec
CODE: Full
CONTACT: ___
___: Son
Phone number: ___
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Gabapentin 100 mg PO TID
2. Digoxin 0.125 mg PO DAILY
3. Rivaroxaban 15 mg PO DAILY
4. Hydroxychloroquine Sulfate 200 mg PO DAILY
5. Triamcinolone Acetonide 0.1% Cream 1 Appl TP Frequency is
Unknown
6. Metolazone 2.5 mg PO DAILY
7. Betamethasone Dipro 0.05% Oint 1 Appl TP Frequency is Unknown
8. HYDROcodone-Acetaminophen (5mg-325mg) Dose is Unknown PO
Frequency is Unknown
9. HydrOXYzine Dose is Unknown PO Frequency is Unknown
10. Citalopram 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Docusate Sodium 100 mg PO BID constipation
3. FoLIC Acid 1 mg PO DAILY
4. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
5. Multivitamins W/minerals Liquid 15 mL PO DAILY
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. QUEtiapine Fumarate 12.5 mg PO BID:PRN agitation
8. Senna 8.6 mg PO BID csontipation
9. Citalopram 10 mg PO DAILY
10. HELD- Hydroxychloroquine Sulfate 200 mg PO DAILY This
medication was held. Do not restart Hydroxychloroquine Sulfate
until seeing your PCP or rheumatologist
___ Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Upper GI Bleed
Secondary diagnosis:
Ventilator-associated pneumonia
Toxic-Metabolic Encephalopathy
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 Ms. ___,
It was a pleasure taking care of you at ___.
Why was I here?
- You had a GI bleed which caused you to have low blood counts
and low blood pressure.
What was done for me while I was here?
- You were admitted to the ICU because your blood pressure was
low and you needed medications to increase your blood pressure.
- You were put on a breathing tube to protect your airway. You
also had an upper endoscopy, called EGD, to find a source of
your GI bleed. There were two areas in your stomach that were
bleeding. The Gastroenterologist doctors ___ these ___ to
stop them from bleeding.
- You had pneumonia and were treated with antibiotics.
- You were taken off the breathing tube and no longer needed
medications to keep your blood pressure normal.
What should I do when I go home?
- You should take all of your medications as prescribed. You
should no longer take any blood thinning medications given your
risk of having a repeat GI bleed.
- You should go to all of your follow-up appointments.
- You should tell your PCP if you are having any bloody or black
stools.
- Work with your doctors to arrange ___ appointment to
manage your lupus
We wish you the best.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10257709-DS-10 | 10,257,709 | 20,325,056 | DS | 10 | 2172-01-16 00:00:00 | 2172-01-16 13:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Nausea, loose stools, abdominal cramping
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
This is a ___ old Female with a PMH significant for chronic
tobacco use and extensive, recurrent small cell lung cancer
(with hilar, mediastinal and abdominal lymph nodes, brain
involvement) who recently initiated ___ hospice care now
admitted with nausea, loose stools, and abdominal cramping.
Ms. ___ lives at ___ with her son ___ who recently
informed her of a holistic diet consisting of orange juice that
may benefit her in terms of her cancer diagnosis. Five days
prior to admission she started drinking orange juice from both
___ and the local market, up to ___ eight ounce glasses
per day. Around that time she developed persistent nausea with
episodes of non-bilious emesis occurring once or twice daily.
She had decreased PO intake in this setting and had difficulty
staying hydrated. She also noted the acute onset of loose or
watery, non-bloody stools around this time associated with some
diffuse abdominal cramping - ocassionally with some belching and
abdominal bloating. She has had some mild dizziness while
standing upright in the last few days, without vertigo or true
syncope. She denies recent travel, recent antibiotic use or sick
contacts. She has no fevers, chills or nightsweats. She denies
dysuria, hemturia. No chest pain or trouble breathing. She
recently initiated ___ hospice and this consists of several
aids and ___ visiting RN who assists with her medications.
Of note, the patient was most recently admitted on ___ with
back pain and focal weakness with negative MR imaging and
negative LP. She had some behavioral symptoms noted that
admission which were attributed to progression of her disease.
She was discharged on ___ with initiation of ___ hospice
services.
In the ___ ED, initial VS 97.4 92 113/78 18 100% RA. Labs were
notable for WBC 7.2, HCT 45.0%, PLT 230. Calcium 10.4. Potassium
3.4. Creatinine 0.9. LFTs normal. Patient received ondansetron
IV and metoclopramide in the ED prior to transfer.
ONCOLOGIC HISTORY:
- ___ - CT chest done to evaluate dyspnea/wheeze showed large
infiltrative right hilar mass encasing the entire bronchial tree
contiguous with enlarged mediastinal nodes including
conglomerate right upper and lower paratracheal nodes.
Contralateral mediastinal nodes also involved. Multiple small
pulmonary nodules, some subpleural (4 mm, 5 mm, 3 mm, 3 mm) felt
likely metastases. Nodular thickening of the left adrenal gland
also seen.
- ___ - Bronchoscopy by Dr. ___ tumor invasion and
abnormal mucosa of the entire right main stem not amenable to
stenting. Biopsy revealed small cell carcinoma involving level
7, 4R, and 11R nodes. Level 11L was negative.
- ___ - MRI brain motion degraded but negative
- ___ - PET with large FDG-avid right hilar mass and multiple
enlarged, FDG-avid right hilar, mediastinal, paraesophageal, and
left mediastinal lymph nodes. There was also a proximal right
femoral focus of FDG-avidity (SUV 3.2) without definite CT
correlate.
- ___ - C1 cisplatin (75 mg/m2) and etoposide (100 mg/m2
D1-3)
- ___ - C2 cisplatin (D1) /etoposide (D1-3)
- ___ - PET with complete resolution of FDG-avid disease, no
new disease
- ___ - C3 cisplatin (75 mg/m2, D1), etoposide (100 mg/m2
D1-3),
neulasta day 4 (___)
- ___ - C4 cisplatin (75 mg/m2, D1), etoposide (80 mg/m2
D1-3), + XRT to chest, right ___ femur (___)
- ___ - MRI head negative, PET with FDG-avid perihilar
consolidations in upper lobe and GGO in lower lobe consistent
with radiation pneumonitis or infection
- ___ - CT chest at ___
- ___ - CT torso: unchanged small left upper lobe pulmonary
nodules and left adrenal nodule, right lung radiation
pneumonitis
- ___ - CT torso: slight increase in subcarinal lymph node
(to
12 mm), otherwise stable.
- ___ - CT chest: Growing posterior right hemidiaphragm
nodule,
4.5 x 1.9 cm. New right retroperitoneal lymphadenopathy, 2.0 x
1.6 cm.
- ___ - PET: 4.7 cm soft tissue lesion within the right
hemidiaphragm with significant FDG avidity with smaller avid
soft
tissue nodule at the right ___ costovertebral junction. FDG
avid right retroperitoneal lymph node medial to the right
adrenal
gland.
- ___ - MRI Brain: Single 2.9 cm well-circumscribed
heterogeneously enhancing lesion in the left medial temporal
lobe
with restricted diffusion
- ___ - Right hemidiaphragm, biopsy: Metastatic small cell
carcinoma.
- Seen at ___ and ___ for back pain. Imaging
showed a mass in T12-L1 right neural foramen.
- ___ - admitted to ___, initiated XRT to whole brain and
T12-L1 lesion and her pain regimen was increased.
- ___ - MRI Pelvis: No bony metastatic disease seen
- ___ - Completed XRT 10 sessions
- ___ - Seen by Dr. ___ neurology for symptoms of
sensory
loss, lack of anal sensation, and unpleasant painful paresthesia
in the perineum
- ___ - ___ - admitted for symptoms of cauda equine. LP
without
malignant cells. MRI T/L spine showed questionable enhancement
noted along the nerve roots of the cauda equina, most prominent
from T11-L1 levels. Also per neuro-onc team there were nodules
on spinal cord that were suspicious for spinal cord disease. No
signs of cord compression.
- ___ - XRT initiated from L3-sacral area, Total Dose: ___
cGy
- ___ - C1D1 of Carboplatin and Etoposide
- ___ - MRI Brain: Near complete resolution of the
previously seen enhancing lesion centered in the medial left
temporal lobe.
- ___ - ___ - admitted to ___ for malaise. ANC ~600 but
afebrile on ___. On ___, fever to 101.8 and was
much more confused than baseline. LP negative. Empiric
ampicillin/cefepime/vancomycin. Blood, urine, and CSF cultures
were sent but no source identified. She had no localizing
symptoms. After receiving antibiotics she quickly defervesced
and had no further fevers. Discharged on 3 additional days of
ciprofloxacin. Throughout the admission she complained of a
bothersome epigastric pain. This was thought to be related to
possible gastritis, as no other etiology was evident on CT scan
and KUB. She was started on ranitidine but has been
intermittently refusing it because she just does not feel like
taking pills.
- ___ - ___- admitted to ___. During the admission, she
had an episode of confusion/fever and thus an LP was performed,
which was negative for any infectious source and also was
negative for malignant cells. ___ was 600. Placed empirically on
antibiotics and her symptoms of confusion and fever resolved;
thus presumably the antibiotics did treat an indolent infection
that was not caught on her LP or blood cultures.
- ___ - Port placed by Dr. ___
- ___ - C3D1 Carboplatin and Etoposide
- ___ - admitted to ___, discharged with ___ hospice
PERTINENT ROS: Denies headaches or vision changes. No cough,
nasal congestion, sinus pressure or sore throat. Denies chest
pain, (+) dizziness; no palpitations or diaphoresis. Denies
trouble breathing or shortness of breath with exertion. (+)
nausea or vomiting; (+)abdominal pain, (+) weight loss. No
dysuria or hematuria. Denies muscle weakness, myalgias or
neurologic complaints. No leg swelling. Denies rashes, lesions
or ulcers.
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
1. Extensive, recurrent small cell lung cancer
2. Chronic tobacco use
3. Bicuspid aortic valve with moderate AI (TTE ___, stable
___
4. History of hemorrhoidectomy (___)
Social History:
___
Family History:
Denies significant family history of cardiovascular disease,
early MI, arrhythmia or sudden cardiac death. Denies family
history of breast, ovarian, colonic, or other malignancy.
Physical Exam:
ADMISSION EXAM:
VITALS: 98.2 150/70 58 18 100% RA
GENERAL: Appears in no acute distress. Alert and interactive.
Non-toxic, but some pallor noted.
HEENT: Alopecia. Normocephalic, atraumatic. EOMI. PERRL. Nares
clear. Mucous membranes dry without plaques or exudates.
NECK: supple without lymphadenopathy. JVP not elevated.
___: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2 normal.
RESP: Clear to auscultation bilaterally without adventitious
sounds. No wheezing, rhonchi or crackles. Stable inspiratory
effort without labored breathing.
ABD: soft, minimally tender to deep palpation diffusely,
non-distended, with normoactive bowel sounds. No palpable masses
or peritoneal signs. No significant abdominal scars. No rebound
tenderness or guarding.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses.
Tattoo on left ankle.
NEURO: Alert and oriented x 3. Strength ___ bilaterally, but
limited by decreased energy, sensation grossly intact.
Pertinent Results:
ADMISSION LABS
--------------
___ 12:15AM BLOOD WBC-7.2 RBC-4.99# Hgb-14.7# Hct-45.0#
MCV-90 MCH-29.5 MCHC-32.7 RDW-15.5 Plt ___
___ 12:15AM BLOOD Neuts-82.9* Lymphs-10.9* Monos-5.0
Eos-0.8 Baso-0.5
___ 12:15AM BLOOD Glucose-125* UreaN-25* Creat-0.9 Na-140
K-3.4 Cl-96 HCO3-30 AnGap-17
___ 12:15AM BLOOD ALT-34 AST-27 AlkPhos-102 TotBili-1.2
___ 12:15AM BLOOD Lipase-21
___ 12:15AM BLOOD Albumin-4.2 Calcium-10.4* Phos-2.2*#
Mg-1.9
MICROBIOLOGY DATA: None
IMAGING STUDIES: None
Brief Hospital Course:
___ year old female with history significant for extensive,
recurrent small cell lung cancer (with hilar, mediastinal and
abdominal lymph nodes, brain involvement) who recently initiated
___ hospice care, admitted with nausea, loose stools, and
abdominal cramping likely from medication non-compliance and
opioid withdrawal.
ACTIVE ISSUES
-------------
# Abdominal pain, nausea, vomiting: symptoms of nausea, emesis
and abdominal cramping over the last several days could reflect
a viral gastroenteritis, though a bacterial source or
enteropathogenic organism appears less likely given the lack of
fevers, leukocytosis and bloody stools. Her abrupt decrease in
opioid pain medication in days leading up to admission may
explain her symptoms given the concern for opiate withdrawal.
Given her recent orange juice holistic diet, one might consider
an artifical sweetener or fructose-induced diarrheal illness
whereby poor digestion of fructose causes enhanced motility and
disrupts bacterial flora homeostasis causing abdominal cramping
and a diarrheal illness. C.difficile is possible given her
recent hospitalizations, but she had no further loose stools
following admission. She has no history of diabetes or
autonomic dysfunction - but a paraneoplastic syndrome
surrounding her small cell lung cancer is plausible although
less likely. In addition, she had evidence of mild
hypercalcemia in the setting of her small cell lung cancer,
which could have been contributing to her GI issues. She
improved with IV hydration and IV antiemetics. Her narcotic
regimen was altered by putting her on PRN oxycodone and a
fentanyl patch. Palliative care was consulted to assist with
pain management. She was discharged back to hospice.
# Orthostasis/lighheadedness: symptoms persisted despite IVF
hydration. She worked with physical therapy during her
admission. Cortisol level was checked and normal, followed by a
cosyntropin stimulation test which was also normal.
# Hypercalcemia: evidence of mild hypercalcemia noted in the
setting of known small cell lung cancer. This improved with IV
hydration.
# Small cell lung cancer: recently transitioned to hospice given
burden of disease despite chemotherapy and radiation.
Acetaminophen, oxycodone PRN, and fentanyl patch were employed
for control of pain. Social work was consulted to assist with
disease coping. She was discharged ___ with hospice.
TRANSITIONS OF CARE
-------------------
# Follow-up: patient will be discharged with ___ hospice
services. She has a follow-up appointment with Dr. ___
___ for ___.
# Code status: Full, multiple conversations were had with family
(HCP) but no change in code status was made.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen ___ mg PO BID:PRN pain/fever
2. Docusate Sodium 100 mg PO BID
3. Gabapentin 800 mg PO TID
4. OxycoDONE (Immediate Release) 30 mg PO Q4H:PRN pain
5. OxyCODONE SR (OxyconTIN) 40 mg PO Q8H
6. Psyllium 1 PKT PO DAILY
7. Senna 1 TAB PO BID:PRN constipation
8. Bisacodyl 10 mg PO DAILY:PRN constipation
9. Ondansetron 8 mg PO Q8H:PRN nausea
10. Prochlorperazine 10 mg PO BID:PRN nausea
Discharge Medications:
1. Acetaminophen ___ mg PO BID:PRN pain/fever
2. Gabapentin 800 mg PO TID
3. Bisacodyl 10 mg PO DAILY:PRN constipation
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. Senna 1 TAB PO BID:PRN constipation
6. OxycoDONE (Immediate Release) 10 mg PO TID:PRN for pain
RX *oxycodone 10 mg 1 tablet(s) by mouth three times a day Disp
#*20 Tablet Refills:*0
7. Fentanyl Patch 25 mcg/h TD Q72H
RX *fentanyl [Duragesic] 25 mcg/hour 1 patch applied to back
q72h Disp #*10 Each Refills:*0
8. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 17 grams by mouth
daily Disp #*30 Packet Refills:*0
9. Lorazepam 0.5-2 mg PO Q4H:PRN anxiety, agitation
RX *lorazepam [Ativan] 0.5 mg ___ tabs by mouth every four hours
Disp #*30 Tablet Refills:*0
10. Dronabinol 2.5 mg PO DAILY
RX *dronabinol 2.5 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
11. Docusate Sodium 100 mg PO BID
Discharge Disposition:
___ With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Opiate withdrawal causing abdominal pain, nausea, vomiting
SECONDARY DIAGNOSES:
1. Acute hypercalcemia
2. Small cell lung cancer, extensive disease
Discharge Condition:
Mental Status: Confused - sometimes.
Health care proxy activated
Admitted to hospice
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the Oncology medicine service at ___
___ on ___ regarding
management of your abdominal complaints. We suspect that these
symptoms related to your abrupt discontinuation of your narcotic
medications. If you resume taking narcotic medications in the
future and plan to decrease the dose, it is important to taper
the medication over several days to avoid withdrawal. We also
think the orange juice consumption may have contributed to your
GI complaints and you should limit your intake to ___ glasses
per day. You were feeling somewhat improved at the time of
discharge. You will resume ___ hospice services at this time.
Followup Instructions:
___
|
10257709-DS-5 | 10,257,709 | 24,894,606 | DS | 5 | 2171-07-25 00:00:00 | 2171-08-06 06:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
intractable right sided back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female with hx of extensive small cell lung cancer,
previously treated with four cycles of cisplatin and etoposide,
as well as radiation, recently found to have recurrent disease
with brain met, hemidiaphragm nodule positive on biopsy, as well
as other nodules concerning for metastasis, presents with
complaints of acute on chronic R low back pain.
Pt notes that she has a long history of low back pain, however,
she notes that since she had her nodule biopsy (R
hemidiaphragm), her pain has changed in nature and is acutely
worse. She notes that during the procedure, she developed
"shooting" pain in her R lower back, that wrapped around her
right flank. Her chronic back pain was intermittent,
non-radiating, and not as severe. Now her pain is sharp,
constant, and radiating around R lower flank. Has been getting
mild radiation down posterior thighs bilaterally as well. No
bowel or bladder dysfunction. She has seen multiple providers
regarding this pain, including Palliative Care (Dr ___, PCP
___ (Dr ___ for PCP), and she has visited ED at
___ and ___. Received MRI at both ___
___ and ___. Per pt report, MRIs did not show any
malignancy in area of maximal pain, but did show chronic
degenerative changes. She has been using multiple different
medications to treat her pain, without using a dedicated
regimen. SHe has been obtaining different narcotic
prescriptions from her PCP and the emergency departments, and
has not been taking as prescribed.
From the history, it is extremely difficult to actually
determine what medications she has been taking recently. SHe
has been prescribed Oxcodone 15 mg q8hr prn, previously used
Oxycodone 20 mg BID (but c/o itching). Has also recently been
using percocet. Given the inconsistent history of medication, I
am unable to quatify actual number of milligrams of narcotics
required during a 24 hour period. It is noted in recent
Palliative Care note that she was previously using 60 mg
oxycodone per day.
Pt also endorses significant anxiety. She does admit that her
pain is not as bad when she is distracted. WHen asked, she
agreed that her anxiety may be worsening her symptoms at times.
ROS:
+: as per HPI, plus 8# wt loss/3 weeks, low grade fevers, night
sweats ("for a long while"), anorexia x 1 week, SOB with
anxiety, nausea past week, constipation.
.
Denies:
10 point ROS reviewed and otherwise negative.
Past Medical History:
History of previously treated small cell lung carcinoma
- treated with four cycles of cisplatin and etoposide with
radiation added with cycle 4,completed in ___
- opted against prophylactic cranial irradiation
Small Cell lung cancer, now in recurrence with multiple mets
multiple dog bites in past
Left hand frx in past w hardware
chronic back pain
Social History:
___
Family History:
No history of lung cancer. Sister has COPD.
Physical Exam:
admission exam:
VS: afebrile 141/89 P76 R18 100RA.
GEN: AAOx3. Appears uncomfortable. Tearful at times.
HEENT: eomi, perrl, MMM.
Neck: No LAD. JVP WNL.
RESP: CTA B. No WRR.
CV: RRR. No mrg.
ABD: +BS. Soft, NT/ND.
Ext: No CEE.
Neuro: CN ___ grossly intact. No pain increase on palpation of
area of pain in R lumbar spine/superior sacral area. Straight
leg raise negative.
discharge exam:
AVSS
well appearing, no apparent distress
normal gait
disorganized thought
Pertinent Results:
___ 04:17PM BLOOD Creat-0.7
___ 07:00AM BLOOD ALT-11 AST-16 AlkPhos-82 TotBili-0.2
MRI pelvis: The visualized bone marrow signal is normal
throughout. Specifically, no abnormality is seen in the region
of the right sacroiliac joint. No abnormal enhancement
post-contrast. No erosions identified at the sacroiliac joints.
No fluid within the joint to indicate sacroiliitis. There is
transitional anatomy noted at the left L5/S1 articulation with a
pseudoarthrosis between the transverse process of L5 and both
the ilium and sacral component of the SI joint.
The bilateral femoroacetabular articulations are congruent,
without
significant degenerative change. There is moderate degenerative
change in the lower lumber spine with facet joint hypertrophy
noted at L5-S1.
The urinary bladder and rectum are unremarkable in appearance.
The uterus is
anteverted. No pelvic lymphadenopathy. Visualized muscles are
normal in
signal intensity.
IMPRESSION: No bony metastatic disease seen.
Brief Hospital Course:
___ yo female with hx of extensive small cell lung cancer,
recently found to have recurrent disease with multiple
metastases, presents with complaints of acute on chronic R low
back pain unresponsive to outpatient analgesia. Records obtained
from ___ show mass in T12-L1 right neural foramen. After
multiple discussions she started XRT to whole brain and T12-L1
lesion. Her pain regimen was increased.
# Small cell lung cancer
# Mets to brain
# Mets to back
# Low back pain
Palliative care was consulted for help with uptitrating pain
regimen. The pain was thought to be secondary to metastatic
disease and the T12-L1 lesions. Her pain regimen was increased
to morphine SR 45mg TID, oxycodone ___ 30mg q4H prn, gabapentin
300mg TID and hydroxyzine. With this regimen her pain was
increased to the point where she was mostly comfortable
(___). She started XRT to the lesion of concern in her back.
She also started WB XRT and dexamethasone 4mg BID and compazine
prior to XRT treatment. After completion of her radiation she
will follow up with Dr. ___ consideration of
chemotherapy. Dr. ___ will prescribe ___ medication
as an outpatient.
# Anxiety:
She has had long time anxiety. She was started on hydroxyzine
and ativan prn.
# Constipation:
Likely secondary to narcotics. Her bowel regimen was
aggressively uptitrated. This may need to be adjusted further as
an outpatient.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lorazepam 0.5 mg PO DAILY:PRN anxiety
2. OxycoDONE (Immediate Release) 15 mg PO Q8H:PRN pain
3. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H:PRN pain
4. Acetaminophen 500 mg PO Q8H:PRN pain
5. Psyllium 1 PKT PO DAILY
Discharge Medications:
1. OxycoDONE (Immediate Release) 30 mg PO Q4H:PRN pain
do not drive while on this medication
RX *oxycodone 30 mg 1 tablet(s) by mouth every 4 hours Disp #*90
Tablet Refills:*0
2. Lorazepam 0.5 mg PO Q8H:PRN anxiety
3. Acetaminophen 1000 mg PO Q8H pain
4. Bisacodyl 10 mg PR HS:PRN no BM x 2 days
RX *bisacodyl [Biscolax] 10 mg 1 Suppository(s) rectally every
night Disp #*30 Suppository Refills:*0
5. Dexamethasone 4 mg PO Q12H
RX *dexamethasone 4 mg 1 tablet(s) by mouth every 12 hours Disp
#*40 Tablet Refills:*0
6. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
per day Disp #*60 Capsule Refills:*0
7. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times per day
Disp #*90 Capsule Refills:*0
8. HydrOXYzine 25 mg PO TID
RX *hydroxyzine HCl 25 mg 1 tab by mouth three times per day
Disp #*90 Tablet Refills:*0
9. Lidocaine 5% Patch 1 PTCH TD DAILY (NOT PROVIDED DUE TO
INSURANCE COVERAGE)
RX *lidocaine 5 % (700 mg/patch) 1 patch daily Disp #*14 Unit
Refills:*0
10. Morphine SR (MS ___ 45 mg PO Q8H
do not drive while on this medication
RX *morphine 30 mg 1 tablet extended release(s) by mouth three
times per day Disp #*90 Tablet Refills:*0
RX *morphine 15 mg 1 tablet extended release(s) by mouth three
times per day Disp #*90 Tablet Refills:*0
11. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 packet by
mouth daily Disp #*30 Unit Refills:*0
12. Prochlorperazine 10 mg PO PRN prior to XRT
RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth as
needed Disp #*8 Tablet Refills:*0
13. Senna 2 TAB PO BID
RX *sennosides [senna] 8.6 mg 2 tabs by mouth twice per day Disp
#*120 Tablet Refills:*0
14. TraZODone 25 mg PO HS:PRN insomnia
RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth at bedtime
Disp #*15 Tablet Refills:*0
15. Pravastatin 10 mg PO DAILY
16. Psyllium 1 PKT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Low back pain
Anxiety
Small cell lung cancer
Metastatic
Anxiety
Hyperlipidemia
Constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were hospitalized with uncontrolled back pain. While you
were here your pain medications were changed. You should take
them only as prescribed. If you are not having good control of
your pain please discuss with your outpatient doctors ___ they
___ make adjustments. Do not drive on these medications.
You were started on radiation treatment to your brain and a
lesion in your back. You will need to continue radiation as an
outpatient as scheduled with radiation oncology.
Followup Instructions:
___
|
10257709-DS-7 | 10,257,709 | 20,750,062 | DS | 7 | 2171-09-21 00:00:00 | 2171-09-21 16:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Malaise
Major Surgical or Invasive Procedure:
LP on ___
History of Present Illness:
___ year old female with a history of metastatic small cell lung
cancer, chemotherapy initiated ___ carboplatin/etoposide,
presenting with several complaints including malaise, diarrhea
over the past two days.
Her multiple symptoms included chills, dyspnea, and diffuse,
crampy abdominal pain starting on ___. She had ___ loose bowel
movements today prior to calling her Oncology office. They
totaled ___ today, and none since arriving to ___. She has
also had shortness of breath with both exertion and recumbency,
and decreased exercise tolerance (one block dyspnea).
In the ED she endorsed persistent nausea and decreased PO intake
(essentially no intake) over the past 2 days. No chest pain. No
subjective fevers, though she did not attempt to measure her
temperature.
In the ED:
Initial Vitals: 97.2 96 117/66 16 99% ra
Transfer Vitals: 98 68 120/60 16 99% RA
Meds: Oxycodone 30mg x1
Fluids: 2L NS
ACCESS: 20g
Studies: CTA - no PE (see below)
Review of Systems:
(+) Per HPI
(-) Denies fever, night sweats. Denies visual changes. Denies
headache, rhinorrhea. Denies chest pain or tightness,
palpitations, lower extremity edema. Denies cough. Denies
vomiting, constipation, melena, hematemesis, hematochezia.
Denies dysuria, stool or urine incontinence. Denies rashes or
skin breakdown. All other systems negative.
Past Medical History:
- ___: CT chest done to evaluate dyspnea/wheeze showed large
infiltrative right hilar mass encasing the entire bronchial tree
contiguous with enlarged mediastinal nodes including
conglomerate right upper and lower paratracheal nodes.
Contralateral mediastinal nodes also involved. Multiple small
pulmonary nodules, some subpleural (4 mm, 5 mm, 3 mm, 3 mm) felt
likely metastases. Nodular thickening of the left adrenal gland
also seen.
- ___: Bronchoscopy by Dr. ___ tumor invasion and
abnormal mucosa of the entire right main stem not amenable to
stenting. Biopsy revealed small cell carcinoma involving level
7, 4R, and 11R nodes. Level 11L was negative.
- ___: MRI brain motion degraded but negative
- ___: PET with large FDG-avid right hilar mass and multiple
enlarged, FDG-avid right hilar, mediastinal, paraesophageal, and
left mediastinal lymph nodes. There was also a proximal right
femoral focus of FDG-avidity (SUV 3.2) without definite CT
correlate.
- ___: C1 cisplatin (75 mg/m2) and etoposide (100 mg/m2
D1-3)
- ___: C2 cisplatin (D1) /etoposide (D1-3).
- ___: PET with complete resolution of FDG-avid disease, no
new disease
- ___: C3 cisplatin (75 mg/m2, D1), etoposide (100 mg/m2
D1-3), neulasta day 4 (___)
- ___: C4 cisplatin (75 mg/m2, D1), etoposide (80 mg/m2
D1-3), + XRT to chest, right ___ femur (___)
- ___: MRI head negative, PET with FDG-avid perihilar
consolidations in upper lobe and GGO in lower lobe consistent
with radiation pneumonitis or infection
- ___ CT chest at ___ stable
- ___ CT torso: unchanged small left upper lobe pulmonary
nodules and left adrenal nodule, right lung radiation
pneumonitis ___: CT torso: slight increase in subcarinal
lymph node (to 12 mm), otherwise stable.
- ___ CT chest: Growing posterior right hemidiaphragm
nodule, 4.5 x 1.9 cm. New right retroperitoneal lymphadenopathy,
2.0 x 1.6 cm.
- ___ PET: 4.7 cm soft tissue lesion within the right
hemidiaphragm with significant FDG avidity with smaller avid
soft tissue nodule at the right ___ costovertebral junction.
FDG avid right retroperitoneal lymph node medial to the right
adrenal gland.
- ___: MRI Brain: Single 2.9 cm well-circumscribed
heterogeneously enhancing lesion in the left medial temporal
lobe with restricted diffusion
- ___: Right hemidiaphragm, biopsy: Metastatic small cell
carcinoma.
- Seen at ___ and ___ for back pain. Imaging
showed a mass in T12-L1 right neural foramen.
- ___ - ___: admitted to ___, Initiated XRT to whole
brain and T12-L1 lesion and her pain regimen was increased.
- ___: MRI Pelvis: No bony metastatic disease seen
- ___: Completed XRT 10 sessions
- ___: Seen by Dr. ___ neurology for symptoms of sensory
loss, lack of anal sensation, and unpleasant painful paresthesia
in the perineum
- ___: Admitted to OMED service with cauda equina syndrome,
secondary to spinal metastases, and treated with radiation
therapy
- ___: C1D1 of Carboplatin and Etoposide
OTHER PAST MEDICAL HISTORY:
- History of hemorrhoidectomy ___
- Bicuspid aortic valve with moderate AI on echo ___,
similar on ___
Social History:
___
Family History:
No hx of cancers.
Physical Exam:
Admission Exam:
VITALS:t 98.0 bp118/65 hr 85 rr16 sat 100% on ra
General: chronically ill, alopecia, NAD
HEENT: No cervical LAD, flat JVP
Neck: supple. full ROM
CV: Normal rate, reg rhythm, low S2, no edema
Lungs: CTAB bilaterally, no wheezes, no crackles
GI: Soft, NT/ND
GU: No foley
Ext: warm, well profused
Neuro: Oriented x3, normal attention, no gross deficits
Skin: no rashes
Discharge Exam:
PHYSICAL EXAM:
VITALS: 98 100/54 78 16 96%RA
General: A&Ox3, answers appropriately
HEENT: No cervical LAD, flat JVP
Neck: supple. full ROM
CV: RRR, low S2, no edema
Lungs: CTAB bilaterally, no wheezes, no crackles
GI: Soft, slightly tender to palpation in epigastrium, no
rebound, no guarding, no masses or organomegaly palpated
Ext: warm, well perfused
Neuro: no gross muscle deficits
Skin: no rashes
Pertinent Results:
==================================
Labs
==================================
___ 06:32AM BLOOD WBC-2.7* RBC-3.19* Hgb-9.7* Hct-27.9*
MCV-87 MCH-30.4 MCHC-34.8 RDW-17.5* Plt ___
___ 01:45PM BLOOD WBC-1.2*# RBC-3.53* Hgb-11.2* Hct-30.5*
MCV-86 MCH-31.7 MCHC-36.7* RDW-16.8* Plt ___
___ 05:51AM BLOOD Glucose-98 UreaN-7 Creat-0.6 Na-139 K-3.5
Cl-102 HCO3-28 AnGap-13
___ 10:56AM BLOOD ALT-13 AST-21 LD(LDH)-228 AlkPhos-57
TotBili-0.6
___ 05:51AM BLOOD Calcium-8.4 Phos-3.5 Mg-1.9
___ 01:45PM BLOOD Lipase-15
___ 01:51PM BLOOD Lactate-1.2
==================================
Radiology
==================================
CT chest/abd/pelvis ___
IMPRESSION:
1. Somewhat limited exam, though no evidence of central or
segmental
pulmonary embolism.
2. Enlarged main pulmonary artery trunk, most likely due to
pulmonary
hypertension.
3. Mildly aneurysmal ascending aorta, unchanged from prior
exams. No acute
aortic pathology.
4. Unchanged radiation changes in the right lung. Unchanged 4
mm left upper
lobe ground-glass nodule. No new opacities or nodules.
5. Significant improvement in metastatic disease with with
near-complete
resolution of the right subdiaphragmatic soft tissue lesion and
retroperitoneal lymphadenopathy. No new nodules or
lymphadenopathy.
6. Cholelithiasis without evidence of cholecystitis.
7. No acute abdominal pathology to explain the patient's pain.
CXR ___
FINDINGS: Persistent right upper opacification, with volume
reduction and
traction of the trachea to the right for known post-radiation
changes. This
area appear more opacified, likely for increased vascular
congestion in
patient with mild heart decompensation. Right lung base and
left lung are
still clear. Heart size is still moderately enlarged with mild
aortosclerosis. There is no pleural effusion or pneumothorax.
IMPRESSION: Mild increased opacification of the right upper
consolidation,
likely for mild vascular congestion.
KUB ___
FINDINGS:
Supine and upright images of the abdomen demonstrate
unremarkable bowel gas
pattern with gas seen in nondistended loops of large and small
bowel. There
is no evidence of ileus or obstruction. There is no
intraperitoneal free air.
The bony structures are unremarkable.
IMPRESSION:
No evidence of ileus or obstruction.
CT head ___
FINDINGS:
There is no evidence of hemorrhage, edema, mass effect, or
infarction. The
ventricles and sulci are normal in size and configuration.
There is
periventricular low attenuation suggestive of chronic small
vessel disease.
The basal cisterns appear patent and there is preservation of
gray-white
matter differentiation. No fracture is identified. The
visualized paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
The globes are
unremarkable.
IMPRESSION:
No evidence of acute intracranial process.
==================================
Pathology
==================================
CSF cytology ___
CEREBROSPINAL FLUID:
NEGATIVE FOR MALIGNANT CELLS.
Brief Hospital Course:
___ year old female with a history of metastatic small cell lung
cancer, chemotherapy initiated ___ carboplatin/etoposide,
presenting with shortness of breath, malaise, diarrhea. At
presentation her diarrhea had resolved but she continued to
complain of dizziness when sitting or standing. She was given
IVF for orthostatic symptoms with some improvement. She was
neutropenic with ANC ~600 but afebrile on ___. On ___ morning
she had fever to 101.8 and was much more confused than baseline,
unable to answer questions appropriately and oriented only to
person. She also was having episodes of closing her eyes and
losing attention during conversation, "absence" type spells.
Given concern for meningitis and also to reassess for
leptomeningeal disease, she had an LP performed. She was started
on empiric ampicillin/cefepime/vancomycin. She was seen by
primary neuro-onc Dr. ___ with recommendation to obtain
EEG and to change cefepime to zosyn given concerns for lowering
the seizure threshold. Her CSF studies were not consistent with
bacterial meningitis and ampicillin was stopped the next day but
vanc/zosyn were continued. Though her ANC had improved to ~1000
by the time she had a fever, she was felt to be ill with a
neutropenic infection. Blood, urine, and CSF cultures were sent
but no source has been identified. She had no localizing
symptoms. After receiving antibiotics she quickly defervesced
and had no further fevers. Vancomycin was stopped on HD#6 and
she was continued on Zosyn alone. At discharge her total WBC is
2.7. She will be discharged on 3 additional days of
ciprofloxacin. Throughout the admission she complained of a
bothersome epigastric pain. This was thought to be related to
possible gastritis, as no other etiology was evident on CT scan
and KUB. She was started on ranitidine but has been
intermittently refusing it because she just doesn't feel like
taking pills. If this pain continues she may need further workup
with EGD. She also has reported some mild SOB throughout the
admission. This did not change with nebulizer treatments and no
change with change in her fluid status. Her lungs have remained
clear on exam. She may have mild pulmonary hypertension which
may need further evaluation in the outpatient setting if her SOB
persists.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxyCODONE SR (OxyconTIN) 40 mg PO Q8H
2. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
3. OxycoDONE (Immediate Release) 30 mg PO Q4H:PRN pain
4. Acetaminophen ___ mg PO BID:PRN pain/fever
5. Docusate Sodium 200 mg PO BID
6. Gabapentin 800 mg PO TID
7. Pravastatin 10 mg PO HS
8. Senna 1 TAB PO BID:PRN constipation
Discharge Medications:
1. Acetaminophen ___ mg PO BID:PRN pain/fever
2. Docusate Sodium 200 mg PO BID
3. Gabapentin 800 mg PO TID
4. OxycoDONE (Immediate Release) 30 mg PO Q4H:PRN pain
5. OxyCODONE SR (OxyconTIN) 40 mg PO Q8H
6. Pravastatin 10 mg PO HS
7. Senna 1 TAB PO BID:PRN constipation
8. Ondansetron 4 mg PO Q8H:PRN nausea
9. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
10. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*6 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
febrile neutropenia
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 because you were feeling
poorly at home. You were found to have a low white count but no
clear sign of infection and no fevers. You were given IV fluids
to help treat dehydration and low blood pressure. On the third
hospital day, you had a high fever and were very confused. You
had several tests including blood and urine cultures and a
spinal tap. All of these have been unremarkable and a clear
source of your infection was not found. You did, however,
improve quickly on antibiotics and are continuing to improve.
Followup Instructions:
___
|
10257709-DS-8 | 10,257,709 | 27,350,344 | DS | 8 | 2171-11-18 00:00:00 | 2171-11-21 08:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dehydration, pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with metastatic SCLC who reports worsening pain, unstable
gait and dehydration for ___ days duration.
She was in her usual state of health until a ___ days prior to
presentation. At that time she noted a few things develop
includes worsening pain, "wobbly gait", poor PO intake and
dehydration. A few days ago she was given IVF in clinic and
reports improvement in her gait and dehydration overnight but
the symptoms returned the following day.
She reports that she was taking twice as much pain medication as
prescribed. She was given a one months supply on ___ and
ran out of medications on ___.
Because of the above, she presented to the ED for further
evaluation. Initial vitals of: Pain 7, T 97.4, HR 111, BP
113/62, SvO2 99% RA. She had CTA chest, CT head, CXR, TTE which
showed (prelim): no PE, no acute intracranial process, no acute
cardiopulmary process, and bedside ED TTE negative for
pericardial effusion.
Currently, she notes 1 episode of loose stool. She is able to
walk but feels diffusely weak. She feels like she has a tremor.
She also notes dyspnea for the past ___ weeks.
ROS: Per above. She also notes chronic chills, tremulousness,
constipation and diarrhea, dark (not black) stool 3 days ago,
back pain radiating to both legs, thirst. She denies fevers,
cough, dysuria, urinary retention or incontinence, sensory
change, focal weakness or other symptoms.
Past Medical History:
ONCOLOGIC HISTORY:
-___: CT chest done to evaluate dyspnea/wheeze showed large
infiltrative right hilar mass encasing the entire bronchial tree
contiguous with enlarged mediastinal nodes including
conglomerate
right upper and lower paratracheal nodes. Contralateral
mediastinal nodes also involved. Multiple small pulmonary
nodules, some subpleural (4 mm, 5 mm, 3 mm, 3 mm) felt likely
metastases. Nodular thickening of the left adrenal gland also
seen.
-___: Bronchoscopy by Dr. ___ tumor invasion and
abnormal mucosa of the entire right main stem not amenable to
stenting. Biopsy revealed small cell carcinoma involving level
7,
4R, and 11R nodes. Level 11L was negative.
-___: MRI brain motion degraded but negative
-___: PET with large FDG-avid right hilar mass and multiple
enlarged, FDG-avid right hilar, mediastinal, paraesophageal, and
left mediastinal lymph nodes. There was also a proximal right
femoral focus of FDG-avidity (SUV 3.2) without definite CT
correlate.
-___: C1 cisplatin (75 mg/m2) and etoposide (100 mg/m2 D1-3)
-___: C2 cisplatin (D1) /etoposide (D1-3).
-___: PET with complete resolution of FDG-avid disease, no
new
disease
-___: C3 cisplatin (75 mg/m2, D1), etoposide (100 mg/m2
D1-3),
neulasta day 4 ___: C4 cisplatin (75 mg/m2, D1), etoposide (80 mg/m2
D1-3),
+ XRT to chest, right ___ femur ___: MRI head negative, PET with FDG-avid perihilar
consolidations in upper lobe and GGO in lower lobe consistent
with radiation pneumonitis or infection
-___ CT chest at ___
-___ CT torso: unchanged small left upper lobe pulmonary
nodules and left adrenal nodule, right lung radiation
pneumonitis
___: CT torso: slight increase in subcarinal lymph node (to
12 mm), otherwise stable.
___ CT chest: Growing posterior right hemidiaphragm nodule,
4.5 x 1.9 cm. New right retroperitoneal lymphadenopathy, 2.0 x
1.6 cm.
-___ PET: 4.7 cm soft tissue lesion within the right
hemidiaphragm with significant FDG avidity with smaller avid
soft
tissue nodule at the right ___ costovertebral junction. FDG
avid right retroperitoneal lymph node medial to the right
adrenal
gland.
-___: MRI Brain: Single 2.9 cm well-circumscribed
heterogeneously enhancing lesion in the left medial temporal
lobe
with restricted diffusion
-___: Right hemidiaphragm, biopsy: Metastatic small cell
carcinoma.
-Seen at ___ and ___ for back pain. Imaging showed
a mass in T12-L1 right neural foramen.
-Admitted to ___ ___: Initiated XRT to whole brain and
T12-L1 lesion and her pain regimen was increased.
-___: MRI Pelvis: No bony metastatic disease seen
-___: Completed XRT 10 sessions
-___: Seen by Dr. ___ neurology for symptoms of sensory
loss, lack of anal sensation, and unpleasant painful paresthesia
in the perineum
-___: Admitted for symptoms of cauda equine. LP without
malignant cells. MRI T/L spine showed questionable
enhancement noted along the nerve roots of the cauda equina,
most prominent from T11-L1 levels. Also per neuro-onc team there
were nodules on spinal cord that were suspicious for spinal cord
disease. No signs of cord compression. XRT initiated from
L3-sacral area, ___ Total Dose: ___ cGy
-___: C1D1 of Carboplatin and Etoposide
-___: MRI Brain: Near complete resolution of the previously
seen enhancing lesion centered in the medial left temporal lobe.
A small region of FLAIR hyperintensity remains at the site.
There is no abnormal enhancement. White matter and pontine
signal
abnormalities are most likely the sequela of small vessel
ischemic disease. The appearance is similar to the prior
examination.
-___: Admitted to ___ for malaise. ANC ~600 but
afebrile on ___. On ___, fever to 101.8 and was much more
confused than baseline. LP negative. Empiric ampicillin/
cefepime/vancomycin. Blood, urine, and CSF cultures were sent
but no source identified. She had no localizing symptoms.
After
receiving antibiotics she quickly defervesced and had no
further
fevers. Discharged on 3 additional days of ciprofloxacin.
Throughout the admission she complained of a bothersome
epigastric pain. This was thought to be related to
possible gastritis, as no other etiology was evident on CT scan
and KUB. She was started on ranitidine but has been
intermittently refusing it because she just doesn't feel like
taking pills.
-___: CTA Chest and CT A/P:
*No evidence of central or segmentalpulmonary embolism.
*Enlarged main pulmonary artery trunk, most likely due to
pulmonary hypertension.
*Mildly aneurysmal ascending aorta, unchanged from prior exams.
No acute aortic pathology.
*Unchanged radiation changes in the right lung. Unchanged 4 mm
left upper lobe ground-glass nodule. No new opacities or
nodules.
*Significant improvement in metastatic disease with with
near-complete resolution of the right subdiaphragmatic soft
tissue lesion and retroperitoneal lymphadenopathy. No new
nodules or lymphadenopathy.
*Cholelithiasis without evidence of cholecystitis.
*No acute abdominal pathology to explain the patient's pain.
-___ to ___: Admitted to ___. During the admission,
she
had an episode of confusion/fever and thus an LP was performed,
which was negative for any infectious source and also was
negative for malignant cells. ___ was 600. Placed empirically on
antibiotics and her symptoms of confusion and fever resolved;
thus presumably the antibiotics did treat an indolent infection
that was not caught on her LP or blood cultures.
-___: Port placed by Dr. ___
-___: C3D1 initiated
OTHER PAST MEDICAL HISTORY:
- History of hemorrhoidectomy ___
- Bicuspid aortic valve with moderate AI on echo ___,
similar on ___
Social History:
___
Family History:
No hx of cancers.
Physical Exam:
ADMISSION EXAM:
Vitals: 98.3, 142/86, 97, 16, 96% RA
Pain: ___
HEENT: OP without lesions, anicteric sclera, dry MM
Neck: low JVD
Cardiac: rr, nl rate, systolic flow murmur
Lungs: CTAB
Abd: soft, nontender, nondistended, positive bowel sounds
Ext: wwp, no edema
Neuro: tangential but alert and calm (I know her from
previously, this is her baseline). Strength ___ upper and lower
extremity. Sensation intact to light touch. No apparent tremor.
Psych: pleasant but labile/tangential
DISCHARGE EXAM:
VS: T 98.3 BP 122/60 HR 102 RR 18 O2 sat 99% RA
Gen: well-appearing, not in acute distess
HEENT: moist mucous membranes, OP clear
CV: regular rate and rhythm, no murmurs
Resp: clear to auscultation bilaterally
Abd: soft, nontender
Ext: no edema
Skin: no rash
Pertinent Results:
___ 08:16PM LACTATE-2.2*
___ 08:10PM GLUCOSE-100 UREA N-15 CREAT-0.8 SODIUM-137
POTASSIUM-3.1* CHLORIDE-98 TOTAL CO2-28 ANION GAP-14
___ 08:10PM estGFR-Using this
___ 08:10PM ALT(SGPT)-25 AST(SGOT)-26 ALK PHOS-87 TOT
BILI-1.0
___ 08:10PM cTropnT-<0.01
___ 08:10PM ALBUMIN-3.6 CALCIUM-9.3 PHOSPHATE-1.9*
MAGNESIUM-1.0*
___ 08:10PM WBC-1.2*# RBC-2.69*# HGB-8.0*# HCT-23.8*#
MCV-89 MCH-29.6 MCHC-33.5 RDW-14.6
___ 08:10PM NEUTS-43* BANDS-6* ___ MONOS-6 EOS-6*
BASOS-0 ___ METAS-5* MYELOS-4* PROMYELO-2* NUC RBCS-1*
OTHER-5*
___ 08:10PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-OCCASIONAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL
OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL ELLIPTOCY-OCCASIONAL
___ 08:10PM PLT SMR-RARE PLT COUNT-13*#
___ 08:10PM ___ PTT-30.7 ___
___ CTA Chest
IMPRESSION:
1. No pulmonary embolism.
2. Stable 4 mm ground-glass left upper lobe and 2 mm right upper
lobe nodules.
3. Stable enlargement of the ascending aorta and main pulmonary
artery.
___ CT head
IMPRESSION:
1. No acute intracranial process.
2. Partial opacification of the right mastoid air cells is
likely due to
ongoing inflammation.
Brief Hospital Course:
___ with metastatic SCLC who was admitted with dehydration and
uncontrolled pain, which improved with IV fluids and pain
medication.
# Dehydration: She presented with lightheadedness with position
change, thirst, history of poor PO intake. She was given IV
fluids and she had good urine output. Her symptoms improved.
# Pancytopenia: Likely from chemotherapy. No evidence of
infection. She was on neutropenic precautions. She was given 2U
of pRBCs.
# Small cell lung cancer with mets to bone:
Last chemotherapy a couple of weeks ago. Pt has a follow up appt
with family meeting planned for tomorrow to discuss further
treatment.
Pt was on a neutropenic diet, given IVF and lytes were repleted.
She was on mechanical prophylaxis for DVT ppx. She was presumed
to be full code.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen ___ mg PO BID:PRN pain/fever
2. Docusate Sodium 100 mg PO BID
3. Gabapentin 800 mg PO TID
4. OxycoDONE (Immediate Release) 30 mg PO Q4H:PRN pain
5. OxyCODONE SR (OxyconTIN) 40 mg PO Q8H
6. Senna 1 TAB PO BID:PRN constipation
7. Lorazepam 1 mg PO Q4H:PRN nausea
8. Ondansetron 8 mg PO Q8H:PRN nausea
9. Prochlorperazine 10 mg PO BID:PRN nausea
10. Psyllium 1 PKT PO DAILY
Discharge Medications:
1. Acetaminophen ___ mg PO BID:PRN pain/fever
2. Docusate Sodium 100 mg PO BID
3. Gabapentin 800 mg PO TID
4. Lorazepam 1 mg PO Q4H:PRN nausea
5. Ondansetron 8 mg PO Q8H:PRN nausea
6. OxycoDONE (Immediate Release) 30 mg PO Q4H:PRN pain
RX *oxycodone 30 mg 1 tablet(s) by mouth every 4 hours Disp #*30
Tablet Refills:*0
7. OxyCODONE SR (OxyconTIN) 40 mg PO Q8H
RX *oxycodone [OxyContin] 40 mg 1 tablet extended release 12
hr(s) by mouth every 8 hours Disp #*15 Tablet Refills:*0
8. Psyllium 1 PKT PO DAILY
9. Senna 1 TAB PO BID:PRN constipation
10. Prochlorperazine 10 mg PO BID:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
extensive stage ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ for generalized weakness and
uncontrolled pain. Your symptoms improved with IV fluids and
pain medications. Your red blood cell count was low so we also
gave you a blood transfusion. You were then discharged home.
You have an appointment with your oncologists, Dr. ___
Dr. ___ morning. Please keep that appointment.
Followup Instructions:
___
|
10257888-DS-20 | 10,257,888 | 23,920,406 | DS | 20 | 2161-09-18 00:00:00 | 2161-09-19 15:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
CC: pain
Major ___ or Invasive Procedure:
SI joint injection
History of Present Illness:
This is a ___ year-old with the history below who presented
to the emergency room with acute back pain.
Mr ___ has been suffering from LBP (primarily right-sided
lumbar pain radiating to the R thigh and groin) for years, but
this has historically been relatively well controlled with
steroid injections. Unfortunately, he has experienced
progressive decline over the past several months, despite
ongoing ESIs. The pain seemed to have escalated over the past
___ weeks resulting in one prior ED presentation on ___
(this was just a few days
after his last ESI). At that time, MRI showed multilevel
spondylosis as well as slighy asymmetry of the dorsal epidural
fat on the R at L5-S1 facet level without definitive evidence of
infection; however, repeat imaging was advised if symptoms were
to worsen.
Mr ___ pain was controlled a little better over the
subsequent week, but then progressively worsened again. He
visited urgent care as well as orthopedics yesterday (atrius).
He received a ketorolac shot and elective surgery was discussed
with no definite plans in place.
He then continued to suffer from severe pain that limited his
ability to walk, eventually prompting his presentation to the
ED.
He denies any history of fevers, trauma, constipation, diarrhea,
urinary/fecal incontinence. He does admit to having a tingling
sensation in the same area as his pain. He denies any focal
weakness, but does say he finds it difficult to walk ___ pain.
He denies cough but admits to burning on urination. His review
of systems is otherwise negative.
He spent almost 12 hours in the ED, where pain control was
attempted with oxyocodone 5mg (x3), ketorolac 30mg (x1), Tylenol
1gm (x1), IV dilaudid (1mg x1), PO dilaudid (2mg x1), ibuprofen
400mg (x1) and lidocaine patch (x1). Given insufficient pain
control, a decision was made to admit him to medicine.
VS in the ED were T 99.1, HR 80-104, BP 126-131/80s, RR ___.
Past Medical History:
Chronic lower back pain
s/p recent epidural steroid injections
asthma
Social History:
___
Family History:
Family History: (per records) Asthma in his mother; Cancer in
his
father; ___ - Type II in his maternal grandmother and
sister; ___ in his mother; ___ in his mother.
Physical Exam:
ADMISSION EXAM
VS: T 98.6, BP 133/78, HR 82, satting 94% on RA
General Appearance: in pain, lying on his left side
Eyes: PERLL, no conjuctival injection, anicteric
ENT: MMM, oropharynx without exudate or lesions, no
supraclavicular or cervical lymphadenopathy, no JVD, no carotid
bruits, no thyromegaly or palpable thyroid nodules
Respiratory: CTA b/l with good air movement throughout
Cardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops
Gastrointestinal: nd, +b/s, soft, nt, no masses or HSM
Extremities: no cyanosis, clubbing or edema
Skin: warm, no rashes/no jaundice/no skin ulcerations noted
Back: No TTP over L or S spine.
Neurological: Alert, oriented to self, time, date, reason for
hospitalization. Cn II-XII intact. Strength testing limited on
RLE due to pain.
Psychiatric: pleasant, appropriate affect
GU: no catheter in place
DISCHARGE EXAM
Gen: Anxious but otherwise pleasant, well-appearing middle-aged
male, laying on his L side
HEENT: NCAT, pupils symmetric, sclera anicteric, clear OP
Cardiac: RRR, no r/g/m
Chest: CTAB
Abd: Soft NT ND +BS
Ext: WWP, edema
Back: Non-tender to palpation over spine. TTP over L sacrum
Neuro: Face symmetric, fully oriented, ___ BUE, ___ LLE, RLE
limited by pain but with more mobility than previous (___),
SILT BUE/BLE
Pertinent Results:
ADMISSION LABS:
___ 07:15AM BLOOD WBC-7.6 RBC-4.72 Hgb-14.0 Hct-43.1 MCV-91
MCH-29.7 MCHC-32.5 RDW-12.9 RDWSD-43.7 Plt ___
___ 07:15AM BLOOD Glucose-94 UreaN-17 Creat-0.8 Na-138
K-3.8 Cl-103 HCO3-26 AnGap-13
___ 09:30AM BLOOD CRP-2.2
___ 09:30AM BLOOD SED RATE-PND
___ 07:30AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 07:30AM URINE RBC-2 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-<1
DISCHARGE LABS:
___ 07:54AM BLOOD WBC-8.0 RBC-5.03 Hgb-14.9 Hct-45.9 MCV-91
MCH-29.6 MCHC-32.5 RDW-12.4 RDWSD-41.2 Plt ___
___ 07:54AM BLOOD Glucose-108* UreaN-15 Creat-0.7 Na-136
K-4.4 Cl-101 HCO3-22 AnGap-17
___ 07:54AM BLOOD Calcium-9.7 Phos-3.3 Mg-2.1
IMAGING:
MRI LS SPINE
FINDINGS:
There is no significant change in appearance since the previous
MRI.
At L5-S1 level diffuse disc bulge and severe facet degenerative
changes seen predominantly on the right side with thickening of
the ligaments. There is asymmetric thickening of the ligament
on the right side as before. Given there is no change since the
previous study this appears to be due to a chronic finding
rather than due to an abscess. There is severe narrowing of the
right subarticular recess and foramen with compression of right
S1 and L5 nerve roots as seen previously. There is no abnormal
enhancement identified to suggest an epidural abscess or
phlegmon.
IMPRESSION:
The changes seen at L5-S1 level appear to be due to advanced
degenerative facet and disc disease with severe right
subarticular recess and foraminal narrowing at this level which
could affect the right S1 and L5 nerve roots.
The thickening of the soft tissues adjacent to L5 lamina
appears to be due to thickening of the ligament from
degenerative change. Given unchanged appearance and lack of
adjacent enhancement, abscess or hematoma appear less likely.
R HIP XRAY:
FINDINGS:
There is no fracture or dislocation. Mild degenerative changes
on are noted along the anterior superior acetabulum. There is no
suspicious lytic or sclerotic lesion. There is no soft tissue
calcification or radio-opaque foreign body.
IMPRESSION:
Mild right hip osteoarthritis
Brief Hospital Course:
___ year old man with asthma, here with acute on chronic lower
back pain and sciatica.
# sciatica:
Given progressive nature of symptoms, and history of injections,
as well as questionable findings on last MRI and possible
neurologic findings, underwent MRI. This demonstrated chronic
changes without infection/hematoma. CRP/ESR wnl, no systemic
symptoms or signs of inflammation. X ray R hip showed mild
osteoarthritis. He was treated with standing ibuprofen, standing
acetaminophen, standing tizanidine, gabapentin, and
hydromorphone 0.5-1mg IV q4h PRN (which was transitioned to
oxycodone). He was seen by chronic pain, who made above
adjustments to his regimen and performed an SI joint injection
on ___ with immediate improvement (suggesting beneficial effect
of lidocaine and expected benefit when steroid kicks in). He
was also seen by ___ who recommended continued outpatient ___. Pt
was discharged with short course of acetaminophen/oxycodone in
addition to gabapentin and tizanidine. He will follow-up with
Chronic Pain service in clinic.
# Asthma: continued home advair and albuterol. Respiratory
status stable.
Billing: greater than 30 minutes spent on discharge counseling
and coordination of care.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diazepam 10 mg PO Q8H:PRN anxiety, spasm
2. Nabumetone 750 mg PO BID:PRN pain
3. OxyCODONE--Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN Pain
- Moderate
4. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Albuterol Inhaler ___ PUFF IH Q4H:PRN asthma exacerbation
Discharge Medications:
1. Gabapentin 600 mg PO TID
RX *gabapentin 600 mg 1 tablet(s) by mouth three times per day
Disp #*90 Tablet Refills:*0
2. Tizanidine 4 mg PO TID
RX *tizanidine 4 mg 1 capsule(s) by mouth three times per day
Disp #*90 Capsule Refills:*0
3. Outpatient Physical Therapy
Diagnosis: ankylosing spondylitis
Prognosis: good
4. Albuterol Inhaler ___ PUFF IH Q4H:PRN asthma exacerbation
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
7. OxyCODONE--Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN Pain
- Moderate
RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth
every 6 hours Disp #*32 Tablet Refills:*0
8.Outpatient Physical Therapy
Diagnosis: ankylosing spondylitis
Prognosis: good
9.Durable Medical Equipment
Duration of use: 13 months
Diagnosis: Ankylosing spondylitis
Prognosis: Good
Discharge Disposition:
Home
Discharge Diagnosis:
sciatica
chronic degenerative facet and disc disease with foraminal
narrowing
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 for sciatica.
For this, you had an MRI and an xray. This showed severe chronic
degenerative changes similar to your prior imaging, as well as
mild hip osteoarthritis. You also received pain medications, a
joint injection (at the "SI" joint), and were seen by the pain
team and physical therapists.
You should follow up with your primary care doctor, your
orthopedic surgeon and the pain service.
Followup Instructions:
___
|
10258000-DS-11 | 10,258,000 | 24,747,322 | DS | 11 | 2171-10-22 00:00:00 | 2171-10-22 11:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hip pain
Major Surgical or Invasive Procedure:
No surgical procedures performed.
History of Present Illness:
Mr. ___ is a ___, previously healthy, who reports 2 week
history of R hip pain, atraumatic. He was seeing his PCP for the
___ hip pain as his ambulation became more difficult. PCP referred
to ___ Surgeon in ___ who diagnosed him with
possible
stress fracture of his femoral neck from cam pincer impingement
of his acetabulum and femoral head. However, this was not
clearly
seen no xray. He was prescribed narcotics
which helped minimally and he was provided with stretching
exercises as there was a question of hip flexor tightness. He
returned to his PCP yesterday after 2 days of acute worsening of
his R hip pain. He was unable to ambulate due to pain about the
anterior and lateral hip along with the posterior buttock
region.
No radicular symptoms. No numbness or tingling distally.
As such, his PCP obtained ___ CT scan which demonstrated a small
effusion but no fracture. The effusion was aspirated under
radiology guidance. 10cc of turbid amber color fluid was
retrieved and sent to the lab. He was sent to ___ ED for
further eval.
He reports that his R hip pain is improved after the aspiration
was performed. He reports that his hip pain is currently stable
with IV morphine. No numbness or tingling distally. He has not
been ambulating. His ROM is limited by pain.
He denies any fevers/chills at home.
He denies history of inflammatory arthropathy.
Past Medical History:
HLD
Social History:
___
Family History:
NC
Physical Exam:
Right lower extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- R hip ROM is from ___ degrees of flexion, 30 degrees of
abduction, and 10 degrees of internal and external rotation.
- Full, painless AROM/PROM of knee, and ankle
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Brief Hospital Course:
The patient was admitted for evaluation of possible septic hip.
Hip aspiration from OSH was reviewed with negative gram stain,
negative crystals, WBC 37,000, Cx NGTD. In conjunction with
physical exam, low suspicion for septic hip and surgical
intervention was deferred. The ___ hospital course was
otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications and the patient was voiding/moving bowels
spontaneously. The patient is WBAT in all extremities and will
be discharged home without DVT prophylaxis. There is no
scheduled follow-up. We will continue to follow culture results
and will reach out to patient later in week to update status. 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:
MEDS:
Crestor
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
Do not exceed 4 grams daily
RX *acetaminophen 325 mg 2 tablet(s) by mouth Every 6 hours Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Hip pain
Discharge Condition:
Stable
Discharge Instructions:
You were in the hospital for evaluation of a possible septic
hip. Given your lab results and clinical exam, there is low
concern for septic hip and it was decided to not pursue surgery.
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for evaluation of a possible septic
hip. Given your lab results and clinical exam, there is low
concern for septic hip and it was decided to not pursue surgery.
- Resume your regular activities as tolerated.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated
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:
- No anticoagulation required.
WOUND CARE:
- There is no wound to care for.
Followup Instructions:
___
|
10258020-DS-5 | 10,258,020 | 25,417,296 | DS | 5 | 2122-05-13 00:00:00 | 2122-05-13 16:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ___
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 PMH of severe COPD (he denies history of
this, FEV1 38% predicted, FEV/FVC 57 in ___, not on home
oxygen), HL, hypothyroidism and left carotid endartectomy
presenting with shortness of breath for ___ days. He is a poor
historian. He reports he noticed feeling short of breath
yesterday, denies f/c, cough, PND, orthopnea, CP, increased leg
swelling, sick contacts, recent travel. His dyspnea worsened
this morning. He called his granddaughter and was taken to an
urgent care visit at ___ and sent to ED(he does not remember
this visit and thinks he went straight to the ED). In ED he had
a CTA chest which was negative for a PE and showed scattered
right upper lobe opacities concerning for infection. He was
hypoxic, 92% on 3.5 L, was given Levaquin. He was also
hyperkalemic to 5.9 on whole blood (chem 7 was grossly hemolyzed
8.4), no ECG changes, given calcium gluconate, dextrose and
regular insulin.
Currently he denies SOB while on 4L oxygen. He denies any pain,
headache, sore throat, myalgias, abdominal pain, n/v, diarrhea,
constipation, dysuria, difficulty urinating. He reports he has
mild leg swelling which is his baseline.
ROS: as above, ten point ROS otherwise negative
Past Medical History:
severe COPD (he denies history of this, FEV1 38% predicted,
FEV/FVC 57 in ___, not on home oxygen)
HL
hypothyroidism
left carotid endartectomy
BPH
Gout
Gait disorder
Social History:
___
Family History:
Denies any family history of cardiac disease, pulmonary disease,
cancer. Parents died in late ___.
Physical Exam:
Admission PE
VS: 98.4 160 / 84 89 18 95 4L
Gen: NAD, resting comfortably in bed, overweight
HEENT: EOMI, PERRLA, MMM, OP clear
Neck: well healed scar from L endartectomy
CV: RRR nl s1s2 no m/r/g, JVP difficult to assess but at least
10 cm
Resp: very poor air movement throughout, mild scattered wheezes
Abd: obese, soft, NT, ND +BS
Ext: 2+ b/l edema, chronic venous stasis changes
Psych: pleasant, normal affect
Neuro: CN II-XII intact, ___ strength throughout
Skin: warm, dry, ruddy complexion, no obvious rashes
Discharge PE:
Vital Signs: 98.2 120 / 71 81 18 92% 2.5L NC O2 (87% on RA)
glucose:
.
GEN: NAD, well-appearing, ruddy face, pleasant, interactive
EYES: PERRL, EOMI, conjunctiva clear, anicteric
ENT: moist mucous membranes, no exudates
NECK: supple
CV: RRR s1s2 nl, no m/r/g
PULM: CTA but poor air movement throughout, no r/r/w
GI: normal BS, NT/ND, no HSM
EXT: warm, no c/c, 2+ ___ edema bil, chronic venous changes
SKIN: no rashes
NEURO: alert, oriented x 3, answers ? appropriately, follows
commands, non focal
PSYCH: appropriate
ACCESS: PIV
FOLEY: absent
Pertinent Results:
___ 03:10PM K+-5.9*
___ 01:36PM GLUCOSE-101* UREA N-28* CREAT-1.2 SODIUM-137
POTASSIUM-8.4* CHLORIDE-98 TOTAL CO2-30 ANION GAP-17
___ 01:36PM proBNP-729
___ 01:36PM WBC-6.9 RBC-5.47# HGB-16.1# HCT-52.3*# MCV-96
MCH-29.4 MCHC-30.8*# RDW-14.8 RDWSD-51.4*
___ 01:36PM NEUTS-62.5 ___ MONOS-13.2* EOS-0.9*
BASOS-0.4 IM ___ AbsNeut-4.29 AbsLymp-1.56 AbsMono-0.91*
AbsEos-0.06 AbsBaso-0.03
CTA chest ___
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Scattered right upper lobe opacities are most concerning for
infection with a reactive precarinal lymph node.
3. Mild paraseptal emphysema.
4. Severe calcification of the origin of the left vertebral
artery likely
results in severe narrowing.
5. Severe atherosclerotic disease in the aorta and coronary
arteries.
CXR ___:
IMPRESSION:
Mild interstitial edema. Scattered mild atelectasis.
Top-normal heart size.
ECG (my read): sinus rhythm, poor R-wave progression, no
significant ST-T wave abnormalities
Brief Hospital Course:
___ year old male with PMH of severe COPD (he denies history of
this, FEV1 38% predicted, FEV/FVC 57 in ___, not on home
oxygen), HL, hypothyroidism and left carotid endartectomy
presenting with shortness of breath for ___ days.
#community acquired pneumonia
#acute hypoxic respiratory failure
#acute COPD exacerbation
For evaluation of SOB, hypoxia, a CXR and chest CTA were
obtained. There were no signs of PE, but the chest CT showed bil
upper (RUL>LUL) opacities c/w PNA (bacterial community acquired
pneumonia). He was treated with Levoflox, alb/atrovent nebs,
and prednisone 40 mg daily. He did well on this regimen, and he
was anxious to go home.
There was however, clear signs of chronic hypoxia, COPD: poor
air movement, alkalosis, erythrocytosis, peripheral edema. Per
PCP notes, pt has been on high 80's at rest and refused oxygen
with a desire to avoid hospitalization. His oxygenation was
assessed while off O2 (on room air) and his O2 sats dropped to
87% at rest and down to 85% with ambulation. For this reason,
he was sent home with oxygen.
He is not taking any medications for COPD (was prescribed
Spiriva and combivent) but felt it did nothing to his symptoms.
For this reason, we will defer to PCP regarding retrying these
medications at home.
# hyperkalemia- Mr. ___ was found to have elevated potassium
of 5.7 in setting of met alkalosis. The cause of this was
unclear. There were no EKG changes. He received cagluc,
glucose/insulin in the ED. He also received Kayexalate x1.
Cortisol was on the low end of normal. No adrenal
supplementation was considered needed. His potassium should
ideally be followed up as an outpt.
# leg edema-no other signs of volume overload but could be due
to R.sided heart failure from untreated chronic hypoxia. This
was monitored as input. TTE may be considered as outpt and
diuresis if not improving
# cognitive deficits-poor memory suspected. Outpt neurocog
testing. B12/folate were WNL here.
# HL asa, statin
# hypothyroidism-levothyroxine
# FEN regular, low K diet
# ppx heparin SC
# access PIV
# communication: with pt
# code full for now, see admission note for more info
# dispo: home with services
Code status: Full for now, patient expressed desire to be DNI,
his wife reports they have never discussed it before and wants
him to be full code, given concern for cognitive deficits will
leave full code but should be discussed further with family
given severe COPD
HCP: ___ (wife) ___ (not on file, he reports
form filled out previously)
Dispo: continued inpatient stay until improvement in hypoxia,
likely ___ more days
___ MD
___
p ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 150 mcg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Levofloxacin 750 mg PO Q24H
RX *levofloxacin 750 mg 1 tablet(s) by mouth Q24h Disp #*4
Tablet Refills:*0
2. PredniSONE 40 mg PO DAILY Duration: 4 Days
RX *prednisone 20 mg 2 tablet(s) by mouth Daily Disp #*8 Tablet
Refills:*0
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Levothyroxine Sodium 150 mcg PO DAILY
6.Oxygen
Continuous O2 NC 2.5 L please.
Adjust to maintain O2 sats>90%
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Bacterial community acquired pneumonia
COPD - emphysema
Hyperkalemia
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 real pleasure looking after you, Mr. ___. As you
know, you were admitted with shortness of breath and low oxygen
levels. Chest CT scan showed that there was evidence of a
pneumonia in setting of COPD (emphysema). For this reason, you
were treated with an antibiotic (Levofloxacin) and also given
steroids (prednisone) to address the respiratory compromise from
the COPD. Both these medications should be taken for an
additional 4 days. You were also found to require oxygen - and
you will be sent with oxygen at home.
Please discuss with your primary care doctor about using
inhalers for your emphysema. Since these were tried in the past
and had no effect on your symptoms, we will defer this decision
to you and your primary care doctor.
You also had an elevated potassium level. We recommend
having your potassium level checked when you visit your primary
care doctor.
There are otherwise no new changes to your medication. We
wish you luck and also good health!
Your ___ Team
Followup Instructions:
___
|
10258020-DS-6 | 10,258,020 | 23,994,346 | DS | 6 | 2122-12-29 00:00:00 | 2122-12-30 11:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea, cough
Major Surgical or Invasive Procedure:
___ - Intubated
___ - Extubated
History of Present Illness:
Patient is a ___ year old male with a past medical history of
severe COPD (not on home O2), hypothyroidism, who presented to
the emergency department with worsening dyspnea and cough, was
intubated for hypercarbic hypoxic respiratory failure and
transferred to MICU for further management.
The patient started to have flu like symptoms about 1 week
prior, which included severe cough and nasal discharge. In this
time he also had worsening orthopnea and paroxysmal nocturnal
dyspnea. He presented to his PCP ___ ___ for these complaints
and was noted to be hypoxic to 74% on RA and a CXR done in
office was revealing for bilateral infiltrates concerning for
pneumonia. The pt was referred to the ED for further evaluation
In the emergency department, his initial vital signs were T
98.4, HR 114, BP 159/113, RR 22, O2 sat 97% after being placed
on a non rebreather. His exam was notable for general somnolence
and ronchorous breath sounds bilaterally. The pt denied any
chest pain, hemoptysis, sore throat, myalgias or headaches,
however did endorse chills and worsening of his lower extremity
edema.
Labs significant for:
- WBC 12.0 (66% PMNs, 21% lymphs, 0.2 eos), Hbg 17.0, Plts 307
- Na 141, K 5.2, Cl 97, HCO3 35, BUN 23, Cr 1.0
- proBNP 7816
- Trop 0.02
- pH 7.23, pCO2 89, lactate 1.2
Patient was given:
- 4.5g IV Zosyn
- 500mg IV azithromycin
- 1g IV vanc
- 125mc IV methylprednisolone
Imaging notable for:
CXR: Low lung volumes with patchy right mid lung field and
bibasilar airspace opacities concerning for infection or
aspiration. Mild pulmonary vascular congestion and possible
small bilateral pleural effusions.
Out of concern for persistent severe hypoxia, altered mental
status, and the VBG as listed above revealing for hypercapnia
with altered mental status, the patient was trialed on BiPAP,
however could not tolerate. He was intubated for hypoxic
hypercarbic respiratory failure and placed on midazolam and
fentanyl drips for sedation/analgesia. The pt also then became
hypotensive and so was started on a levophed gtt. He was
transferred to the MICU for further management.
On arrival to the MICU, the pt was intubated and sedated
Past Medical History:
severe COPD (he denies history of this, FEV1 38% predicted,
FEV/FVC 57 in ___, not on home oxygen)
HL
hypothyroidism
left carotid endartectomy
BPH
Gout
Gait disorder
Social History:
___
Family History:
Denies any family history of cardiac disease, pulmonary disease,
cancer. Parents died in late ___.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
GENERAL: Intubated and sedated
HEENT: Sclera anicteric, pupils reactive
NECK: supple, JVP not elevated, no LAD
LUNGS: Course breath sounds bilaterally, mild wheeze, no
crackles appreciated
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, 1+ edema bilat
DISCHARGE PHSYICAL EXAM
=======================
24 HR Data (last updated ___ @ 752)
Temp: 97.8 (Tm 98.6), BP: 157/83 (118-170/64-84), HR: 66
(60-88), RR: 18, O2 sat: 93% (90-93), O2 delivery: 3L (2L-3L),
Wt: 274.05 lb/124.31 kg
GENERAL: NAD
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM
NECK: no JVD
HEART: RRR, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rhonchi, or rales
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no edema. Warm and well-perfused.
PULSES: 2+ peripheral pulses.
NEURO: CN II-XII intact
Pertinent Results:
ADMISSION LAB RESULTS
=====================
___ 01:23PM BLOOD WBC-12.0* RBC-5.67 Hgb-17.0 Hct-54.6*
MCV-96 MCH-30.0 MCHC-31.1* RDW-14.3 RDWSD-50.6* Plt ___
___ 01:23PM BLOOD Glucose-123* UreaN-23* Creat-1.0 Na-141
K-5.2* Cl-97 HCO3-35* AnGap-9*
___ 03:04AM BLOOD Calcium-8.4 Phos-4.3 Mg-1.8
___ 01:29PM BLOOD ___ pO2-79* pCO2-89* pH-7.23*
calTCO2-39* Base XS-6
DISCHARGE LAB RESULTS
=====================
___ 06:20AM BLOOD WBC-9.9 RBC-4.93 Hgb-14.6 Hct-47.3 MCV-96
MCH-29.6 MCHC-30.9* RDW-14.1 RDWSD-49.1* Plt ___
___ 06:20AM BLOOD Glucose-87 UreaN-27* Creat-0.8 Na-144
K-5.3* Cl-97 HCO3-36* AnGap-11
___ 06:20AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.1
MICROBIOLOGY
============
___ Blood cultures: negative
___ Urine culture: negative
___ Sputum gram stain: negative
IMAGING
=======
Echo ___
The left atrium is normal in size. The estimated right atrial
pressure is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size and free wall motion are grossly 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 appears structurally
normal with trivial mitral regurgitation. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Very suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. No definite valvualr pathology or pathologic
flow identified. Mildly dilated ascending aorta.
DISCHARGE LABS:
===============
___ 06:20AM BLOOD WBC-9.9 RBC-4.93 Hgb-14.6 Hct-47.3 MCV-96
MCH-29.6 MCHC-30.9* RDW-14.1 RDWSD-49.1* Plt ___
___ 03:55AM BLOOD ___ PTT-25.3 ___
___ 06:20AM BLOOD Glucose-87 UreaN-27* Creat-0.8 Na-144
K-5.3* Cl-97 HCO3-36* AnGap-11
Brief Hospital Course:
Patient is a ___ year old male with a past medical history of
severe COPD (not on home O2), hypothyroidism, who presented to
the emergency department with worsening dyspnea and cough, was
intubated for hypercarbic hypoxic respiratory failure
MICU COURSE ___
======================
Patient was intubated in the ED and then admitted to the MICU.
He was treated with steroids and azithromycin for COPD
exacerbation and was extubated on ___. He received 1 dose
of CTX for CAP treatment, but this was discontinued on
___. Patient had elevated NT-proBNP, however TTE with good
systolic function. Patient was diuresed with Lasix IV on ___,
but not evidence of significant overload, so no further
diuresis. Patient is stable on 2L NC. Patient was not taking
COPD medications at home and was started on Spiriva and Advair.
ACUTE ISSUES:
=============
# ACUTE ON CHRONIC HYPERCARBIC HYPOXIC RESPIRATORY FAILURE
# ACUTE EXACERBATION OF COPD
Patient presented initially with worsening hypoxia and
hypercapnic respiratory failure. Most likely COPD exacerbation
versus new decompensated heart failure. Patient has been poorly
compliant with his medications, stating that his inhalers do not
work and that is twice does not take them. BNP was markedly
elevated on presentation, but TTE with preserved systolic
function. Patient improved dramatically after treatment of COPD
exacerbation with steroids and azithromycin. ___ have been
triggered by URI given recent history. Pt w/ hx of severe
COPD,FEV1 38% predicted, FEV/FVC 57 in ___.
# HYPOTENSION
Likely in the setting of sedation. He was initially hypertensive
in ED and pressures dropped after being sedated for intubation.
Pt was started on levophed but has since been weaned off.
# HYPERTENSION
After the patient left the MICU, he was noted to be hypertensive
and was started on captopril. His potassium levels were somewhat
elevated so he was transitioned to amlodipine prior to
discharge.
CHRONIC ISSUES:
===============
# HYPOTHYROIDISM
Continued home levothyroxine
# CAD PRIMARY PREVENTION
Continued aspirin and atorvastatin.
TRANSITIONAL ISSUES:
======================
[] The patient was previously noncompliant with Spiriva, Advair
and oxygen. Please encourage him to continue these medications
as an outpatient to prevent further exacerbations of his COPD.
[] The patient was started on amlodipine 5 mg PO daily for
hypertension as an inpatient. Please measure his BP and titrate
as needed.
[] Patient started on home oxygen (had been recommended during a
prior hospitalization but patient did not use)
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atorvastatin 80 mg PO QPM
2. Levothyroxine Sodium 150 mcg PO 5X/WEEK (___)
3. Levothyroxine Sodium 300 mcg PO 2X/WEEK (___)
4. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath,
wheeze
RX *albuterol sulfate [ProAir HFA] 90 mcg ___ INH INH every four
(4) hours Disp #*1 Inhaler Refills:*3
2. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/dose 1
INH INH twice a day Disp #*1 Disk Refills:*2
4. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva Respimat] 2.5 mcg/actuation 1
INH INH daily Disp #*1 Inhaler Refills:*2
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Levothyroxine Sodium 150 mcg PO 5X/WEEK (___)
8. Levothyroxine Sodium 300 mcg PO 2X/WEEK (___)
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
==================
- Acute on chronic hypoxic and hypercarbic respiratory failure
d/t AECOPD.
- Hypertension
SECONDARY DIAGNOSES:
====================
- Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure being involved in your care.
Why you were hospitalized:
==========================
You were hospitalized because you had a cough and were having
difficulty breathing. This is likely due to your underlying COPD
(chronic obstructive pulmonary disease).
What happened in the hospital:
==============================
- You had a breathing tube placed in your throat to help you
breathe.
- The breathing tube was removed and you were given oxygen.
- You were treated with antibiotics to treat an infection in
your lungs.
- You were treated with steroids to reduce inflammation.
- You were given inhalers to help your breathing.
What to do once you leave the hospital:
=======================================
- Continue to use oxygen at home.
- Take all of your medications and inhalers as described below.
- Attend your follow-up appointments as described below.
We wish you the best!
Your ___ Team
Followup Instructions:
___
|
10258020-DS-7 | 10,258,020 | 23,821,088 | DS | 7 | 2124-12-26 00:00:00 | 2124-12-27 06:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
prednisone
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
___ 09:40AM BLOOD WBC-8.5 RBC-4.10* Hgb-12.8* Hct-42.5
MCV-104* MCH-31.2 MCHC-30.1* RDW-15.6* RDWSD-59.8* Plt ___
___ 09:40AM BLOOD Neuts-69.9 Lymphs-18.2* Monos-7.7 Eos-3.6
Baso-0.2 Im ___ AbsNeut-5.91 AbsLymp-1.54 AbsMono-0.65
AbsEos-0.30 AbsBaso-0.02
___ 11:37AM BLOOD ___ PTT-23.9* ___
___ 09:40AM BLOOD Glucose-138* UreaN-15 Creat-0.8 Na-140
K-4.7 Cl-93* HCO3-38* AnGap-9*
___ 09:40AM BLOOD ALT-12 AST-19 AlkPhos-162* TotBili-0.5
___ 09:40AM BLOOD Lipase-22
___ 09:40AM BLOOD cTropnT-0.01
___ 09:40AM BLOOD Albumin-3.9
___ 09:49AM BLOOD ___ O2 Flow-4 pO2-64* pCO2-79*
pH-7.34* calTCO2-44* Base XS-12 Intubat-NOT INTUBA Comment-GREEN
TOP,
___ 09:49AM BLOOD Lactate-1.3
___ 09:49AM BLOOD O2 Sat-88
DISCHARGE LABS:
MICRO:
___ 12:17 pm URINE SOURCE: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
Blood culture x1 from ___ NGTD
Flu A/B NEGATIVE
IMAGING:
Left ___:
No evidence of deep venous thrombosis in the left lower
extremity
veins.
CT C-spine:
1. No acute fracture. 3-4 mm anterolisthesis of C4 on C5 is
felt
to be degenerative in nature. However, if there is high
clinical
suspicion for ligamentous injury, and there are no
contraindications, MRI would be more sensitive.
2. Multilevel degenerative changes as described above.
3. Moderate to severe emphysematous changes are demonstrated
within the bilateral lung apices.
CT L-spine:
1. No acute fracture or traumatic malalignment.
2. Moderate to severe multilevel degenerative changes of the
lower thoracic and lumbar spine are detailed above.
3. A 4 mm nonobstructing stone is demonstrated in the left
kidney.
4. Additional findings described above.
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%
Jarvik, et all. Spine ___ 26(10):1158-1166
Lumbar spinal stenosis prevalence- present in approximately 20%
of asymptomatic adults over ___ years old
___, et al, Spine Journal ___ 9 (7):545-550
CT Head:
1. No acute intracranial abnormality on noncontrast CT head.
Specifically, no acute large territory infarct or intracranial
hemorrhage. No displaced calvarial fracture.
2. Moderate to severe confluent periventricular and subcortical
white matter hypodensities, nonspecific, but compatible with
chronic microangiopathy in a patient of this age. Extensive
punctate calcifications in the bilateral frontal parietal sulci
likely represent atherosclerotic calcifications.
3. Paranasal sinus disease as described above.
4. Additional findings described above.
CTPA:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Emphysema.
3. Trace right pleural effusion and atelectasis at the lung
bases, right greater than left.
Brief Hospital Course:
Mr. ___ is a ___ male PMHx copd dependent on 2L O2 at
baseline, diastolic congestive heart failure (EF by echo 55%
___, htn, hyperlipidemia, hypothyroidism, TIA, bph, gout
presents for evaluation of shortness of breath.
TRANSITIONAL ISSUES:
[ ] re-refer to neurology to evaluate gate disturbances
[ ] Geriatrics referral after DC
ACUTE/ACTIVE PROBLEMS:
#Shortness of breath:
#Acute COPD exacerbation:
#Acute on chronic hypoxic respiratory failure:
#Hypercarbic respiratory failure, likely acute on chronic:
Etiology of increased O2 requirement and SOB likely acute COPD
exacerbation. VBG on admission pH 7.34 with pCO2 79. Patient is
admittedly not compliant with inhalers since he doesn't think
they work, and prefers instead to just use his home O2. CXR
negative for pneumonia. EKG non ischemic and serial trops neg
which makes acs less likely. Other than chronic LLE edema, not
total body volume overloaded. Started on IV SoluMedrol, and
changed to PO prednisone on ___ with plan to complete 5-day
steroid burst for COPD. However, this was stopped after day 3
due to family's concern that it was a significant contributor to
his altered mental status. Also started on standing duonebs, and
course of azithromycin.
- stabilized on nebs, azithro, and fluticasone
- DO NOT GIVE SYSTEMIC STEROIDS THIS WILL MAKE HIM DELIRIOUS
#Fall:
#Abnormal gait:
Pt is s/p likely mechanical fall 2 days prior to presentation.
Imaging workup negative for fractures or dislocations. Patient
has longstanding history of gait disturbance, for which he saw
neurology in ___. At that time, they were concerned for spinal
pathology causing ___ spasticity and weakness and had recommended
consideration of surgery, which patient had deferred. ___ saw
patient, recommended discharge to rehab.
#Confusion/delirium:
#Hallucinations:
Likely mild delirium ___ medical issues as above. Per report
from family, may have some undiagnosed underlying cognitive
difficulties but no frank diagnosis of dementia. Patient had
progressive confusion during stay, which culminated in acute
agitated event on ___ requiring IM Haldol. Seen by geriatrics
consultants, started on Seroquel. Discharge regimen will be
Seroquel 12.5mg HS PRN and should be STOPPED IN ___ DAYS IF HE
REMAINS STABLE
#Renal Stone:
# Urinary retention
CT scan w/ 4mm L sided non obstructive renal stone. Creatinine
at baseline and u/a negative. Pt without any symptoms.
- initiated Flomax for retention prevention
CHRONIC/STABLE PROBLEMS:
#Hypothyroidism:
-continued home levothyroxine
#Hyperlipidemia:
-continued home statin
#Hypertension
-continued home amlodipine
# Contacts/HCP/Surrogate and Communication: HCP is daughter ___
___ ___. HCP#2 ___ ___
# Code Status/Advance Care Planning: FULL, presumed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Levothyroxine Sodium 150 mcg PO DAILY
4. amLODIPine 5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN sob or hypoxia
3. Benzonatate 100 mg PO TID:PRN cough
4. Enoxaparin (Prophylaxis) 40 mg SC DAILY
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
8. QUEtiapine Fumarate 12.5 mg PO QHS:PRN insomnia with
agitation
9. Senna 8.6 mg PO BID:PRN Constipation - First Line
10. Tamsulosin 0.4 mg PO QHS
11. amLODIPine 5 mg PO DAILY
12. Aspirin 81 mg PO DAILY
13. Atorvastatin 80 mg PO QPM
14. Levothyroxine Sodium 150 mcg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
COPD exacerbation
Delirium
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 admitted to the hospital for difficulty breathing,
likely due to an exacerbation of COPD. You were treated with
steroids, antibiotics, and inhalers with improvement. You did
not tolerate steroids and should NOT receive steroids.
While you were admitted, likely as a result of illness and
medications, you became more confused than usual, which required
medical management. You were given a small dose of Seroquel.
We recommend referral to Geriatrics after discharge.
It was a pleasure taking care of you!
Sincerely, your ___ team
Followup Instructions:
___
|
10258162-DS-15 | 10,258,162 | 28,433,140 | DS | 15 | 2150-10-15 00:00:00 | 2150-10-15 09:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
morphine
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Exploratory laparotomy, sigmoid resection, ___ pouch
___
CT-guided drainage of pelvic collection ___
Tunneled R IJ hemodialysis line placement ___
History of Present Illness:
The patient is an ___ y.o. woman who presented to ___
with about 5 days of increasing abdominal pain the became
diffuse and severe by the time of presentation, particularly in
the last 24 hours. She also reported nausea and vomiting of dark
material over this time period. She denied fever, chills, or
diarrhea. The patient was evaluated at ___, including the
acquisition of a
CT abdomen and pelvis which showed free intraperitoneal air with
no identified source. It was decided to transfer the patient to
___ for management.
Past Medical History:
PMH: HTN, breast ca, nonunion humerus fx, anemia NOS,
osteoporosis
PSH: hysterectomy, RLQ incision ?appendectomy, L mastectomy
Social History:
___
Family History:
non-contributory
Physical Exam:
On admission:
VS: 96.0 110 124/87 24 98% 2L
Gen: severe distress secondary to abdominal pain
CV: tachycardic, regular S1 S2
Lungs: CTA B/L
Abd: distended, tense, diffusely acutely tender with rebound and
guarding. Moderate tympany.
On discharge:
General Appearance: Alert, responsive, interactive
HEENT: EOMI
Cardiovascular: (Rhythm: Regular)
Respiratory / Chest: (Breath Sounds: CTA bilateral)
Abdominal: Soft, Non-distended, Ostomy well healed, midline vac
with good placement
Right Lower Extremity : (Pulse - Dorsalis pedis: Present +2)
Left Lower Extremity: (Pulse - Dorsalis pedis: Present +2)
Neurologic: Follows simple commands, Moves all extremities
Pertinent Results:
___ 01:30AM BLOOD WBC-1.6* RBC-3.82* Hgb-9.3* Hct-31.6*
MCV-83 MCH-24.4* MCHC-29.5* RDW-17.7* Plt ___
___ 01:30AM BLOOD Neuts-55.6 ___ Monos-6.6 Eos-0.3
Baso-0.8
___ 12:51AM BLOOD Neuts-49* Bands-9* ___ Monos-9
Eos-0 Baso-0 ___ Metas-4* Myelos-2* NRBC-7*
___ 01:30AM BLOOD Plt ___
___ 05:08AM BLOOD ___ PTT-42.3* ___
___ 01:30AM BLOOD Glucose-124* UreaN-30* Creat-0.9 Na-142
K-4.2 Cl-117* HCO3-16* AnGap-13
___ 12:00AM BLOOD Glucose-68* UreaN-43* Creat-2.3* Na-133
K-5.8* Cl-105 HCO3-16* AnGap-18
___ 05:49AM BLOOD CK(CPK)-5569*
___ 12:00AM BLOOD ___
___ 10:41AM BLOOD ALT-166* AST-492* LD(___)-1152*
CK(CPK)-6871* AlkPhos-54 TotBili-1.4
___ 01:54AM BLOOD ALT-152* AST-77* LD(LDH)-963* AlkPhos-73
TotBili-0.7
___ 05:08AM BLOOD Calcium-6.5* Phos-3.3 Mg-1.7
___ 01:30PM BLOOD calTIBC-124* VitB12-210* Ferritn-49
TRF-95*
___ 02:00PM BLOOD calTIBC-195* Ferritn-303* TRF-150*
___ 02:00PM BLOOD Triglyc-53
___ 01:57AM BLOOD TSH-16*
___ 03:03PM BLOOD Cortsol-92.0*
___ 02:00PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
___ 12:11PM BLOOD HBsAb-POSITIVE HBcAb-NEGATIVE HAV
Ab-POSITIVE IgM HAV-NEGATIVE
___ 01:35AM BLOOD WBC-8.6 RBC-3.01* Hgb-9.1* Hct-28.5*
MCV-95 MCH-30.4 MCHC-32.1 RDW-15.2 Plt ___
___ 01:35AM BLOOD ___ PTT-34.4 ___
___ 01:35AM BLOOD Glucose-104* UreaN-51* Creat-0.9 Na-143
K-4.6 Cl-106 HCO3-33* AnGap-9
___ 01:41AM BLOOD LD(LDH)-211 TotBili-0.4 DirBili-0.2
IndBili-0.2
___ 01:35AM BLOOD Albumin-2.9* Calcium-10.5* Phos-3.8
Mg-2.3 Iron-PND
IMAGING:
___ Pathology of sigmoid colon
Sigmoid colon, resection (A-K):
1. Colon with 3.0 cm perforation; an associated diverticulum is
not seen.
2. Diverticular disease with associated acute inflammation;
margins unremarkable.
3. Three unremarkable lymph nodes.
___ Echocardiogram
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. There
is moderate global left ventricular hypokinesis (LVEF = ___
%). Right ventricular chamber size is normal with moderate
global free wall hypokinesis. 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. Moderate (2+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with moderate global biventricular systolic
function. Moderate mitral regurgitation. Moderate tricuspid
regurgitation. Mild aortic regurgitation.
___ ECG
Sinus rhythm. Atrial ectopy. The P-R interval is short without
evidence of pre-excitation. Compared to the previous tracing of
___ these findings are new.
___ Renal U/S
No hydronephrosis.
___ CT abdomen, pelvis w/o contrast
Limited evaluation without IV contrast.
1. Status post partial distal colectomy with new left lower
quadrant
colostomy and ___ pouch. New fluid collection within the
lesser sac and stable fluid within the left paracolic gutter and
lower pelvis (pouch of ___, without significant interval
change. No intrinsic air is noted. No free air is noted
overall.
2. New hypoechoic lesions within the spleen, not previously
seen.
Differential considerations include developing splenic
infarctions or abscess formations. Recommend attention on
followup examination.
___ CT guided drainage of abscess
Technically successful CT-guided percutaneous drainage catheter
placement to deep pelvic fluid collection. Approximately 50 cc
of purulent material aspirated, and sample sent to microbiology
for analysis.
Brief Hospital Course:
Upon presentation, Ms. ___ was evaluated by the ___ team
and taken immediately to the OR, given her exam and CT revealing
pneumoperitoneum with free fluid in the abdomen. She was found
to have a large sigmoid colon perforation with frank stool in
the peritoneum, and required a resection and ___ procedure.
She was taken post-operatively to the TSICU intubated, sedated,
and requiring levophed and vasopressin for blood pressure
support.
.
Neuro: She was kept intubated and sedated while her pressor and
ventilator requirements were weaned. Upon sedation wean, she
was following commands. Upon extubation, Ms. ___ was
appropriate and oriented x3.
.
CV: The patient appeared ashen on POD 0; an echo showed an EF
of ___ while on levophed and vasopressin, and she was started
on dobutamine which improved both her skin color and her
hemodynamic status. Repeat EF was 45%. Both pressors were
weaned to off on ___. In the setting of acute renal failure
with labile blood pressures, CVVH was utilized rather than HD
until ___, and she received her first bedside ultrafiltration
for 1.4 liters on ___, which she tolerated without issue.
Noted on ICU cardiac monitoring to have runs of what appeared to
be atrial tachycardia with labile heart rate, cardiology
consultation was obtained on ___, and subsequently EP
consultation, who recommended beta-blockade. Her heart rate
improved significantly and blood pressure remained stable.
After several episodes of bradycardia on ___ and ___, EP was
again reconsulted who thought that her bradycardia was secondary
to apneic events. Her propofol was stopped and narcotics were
minimized and she had no further episodes of bradycardia as of
___. Her neosynepherine was also discontinued at this time
secondary to hypertension. She intermittently has had episodes
of atrial fibrillation during which she occasionally has
hypotension though she appears asymptomatic during these
episodes and they have resolved on their own. On ___, she
had her first run of full HD which she tolerated without
difficulty after having a total of 1L taken off. She continued
to have HD runs as deemed appropriate by Renal.
.
Resp: Initially transferred to the TSICU intubated and sedated,
Ms. ___ was volume resuscitated and inadequately diuresed
secondary to acute renal failure. Ventillator support was
weaned to minimal settings and she was extubated on ___, but
became tachypneic to 35 even with noninvasive ventillatory
support, and was reintubated 6 hours later. She was diuresed an
additional 2 liters on CVVH and successfully extubated on ___.
She was subsequently weaned to nasal cannula. After being
transferred to the floor, however, she developed respiratory
distress with saturation down to the ___ as well as a short
episode of non-responsiveness. She was re-intubated and
transferred back to the ICU. Her saturations rapidly returned
to normal once intubated and she underwent broncoscopy with a
mini-BAL which showed comensal respiratory flora. A CT scan
showed likely multi-focal pneumonia and her antibiotics were
broadened from ciprofloxacin/flagyn to vancomycin with zosyn.
She also had a pigtail drain placed on ___ for pleural effusion
which subsequently was switched to a chest tube after the
patient developed a hemothorax. The chest tube was discontinued
when the output was appropriate. On ___ after being
re-intubated for 7 days, she underwent an open tracheostomy
which she tolerated well. The trach site has a small amount of
oozing for the following ___ days which was controlled using
gelfoam and gauze. She tolerated being on minimal pressure
support settings as of ___ and was tolerating ___ hours at
a time on trach mask at the time of discharge.
.
FEN/GI: ___ procedure, Ms. ___ was initially
started on TF ___, but these were frequently held and never
advanced to goal rate secondary to high residuals and two
episodes of emesis. She received TPN from ___ to ___ before
being transitioned back to tube feeds on ___ with return of
bowel function via the stoma. These were advanced to goal,
which she tolerated well. She underwent formal evaluation by
the speech and swallow team on ___, but failed. A dobhoff was
placed ___ for further nutrition, and again after she failed a
second speech and swallow re-evaluation on ___ when she
self-d/c'd the DHT. Nutrition labs were sent on ___. After
being re-intubated on ___, she continued to receive tube feeds
though a dobhoff feeding tube without difficulty. Nutrition
labs were checked appropriately.
.
Wound: On POD1, she had some serous discharge from the wound and
a stitch was placed which improved the discharge. On POD2, some
dusky patches of skin were noted around the middle portion of
the wound and three staples were removed. Skin breakdown with
underlying fat necrosis of the abdominal wound was noted on
___, and the skin staples were removed revealing no purulence.
The wound was packed wet to dry until ___ when a wound VAC was
placed, and this was subsequently changed q3 days. Bedside
debridement to healthy tissue was performed on ___, and the VAC
replaced. The vac was then replaced every three days as
appropriate and the wound was monitored. The ostomy appliance
was also changed as appropriate.
.
Heme: Ms. ___ was transfused 1 unit of pRBC on ___, and
her hct was stable thereafter. She received prophylactic SQH
post-operatively, which was held for three days in the setting
of thrombocytopenia. When a HIT panel was negative, this was
resumed on ___. She continued on SQH for the duration of her
stay and her dosage was changed appropriately after her PTT
began to drift upwards. She received an additional 2U PRBC on
___ and ___ after a pigtail catheter placed to drain a pleural
effusion led to hemothorax and she had a drop in her hematocrit.
She continued to have occasional downward drifting of her
hematocrit attributed to slow oozing from her trach site as well
as poor nutritional status.
.
ID: She was initially covered for frank stool peritonitis with
vancomycin and zosyn, but in the setting of increasing
leukocytosis, these were changed to cipro and flagyl on ___.
When blood, sputum, and urine cultures were negative, a CT of
the abdomen and pelvis was obtained on ___ which revealed a
fluid collection in the pelvis. ___ was consulted and this was
drained via CT-guided drainage on ___ with 200cc of purulent
fluid removed. Her leukocytosis subsequently resolved and she
remained afebrile. The ___ pigtail drain was removed at the
bedside on ___ after no output for 5 days. She will complete a
14 day course of cipro and flagyl on ___. She was started on
fluconazole on ___ after a urine and sputum culture returned
positive for yeast. She was also started on ceftriaxone on ___
after she had a positive urinalysis.
.
Renal: Beginning on POD2, she was noted to have very poor urine
output associated with significant hyperkalemia refractory to
kayexelate, insulin, and lasix. Serial electrolytes were
monitored and repleted. She was resuscitated with crystalloid
as well as intermittent doses of concentrated albumin without
improvement in urine output. Ultimately, nephrology was
consulted and a right IJ HD line was placed for CVVH, which
began ___. Renal ultrasound was unremarkable. In the setting
of acute renal failure with labile blood pressures, CVVH was
utilized rather than HD until ___, and she received her first
bedside ultrafiltration for 1.4 liters on ___, which she
tolerated without issue. She continued to receive CVVH as
hemodynamically tolerated with improvement of her electrolytes.
On ___, she received her first run of full HD which she
tolerated with removal of 1L. Her electrolytes were monitored
throughout the stay.
.
Medications on Admission:
atenolol 100 mg tablet, Evista 60 mg tablet, Latanoprost 0.005%
1
drop each eye q.h.s.
Discharge Medications:
-Dilaudid 0.25mg IV q6h prn for breakthrough pain
-Latanoprost 0.005%, 1 drop each eye qhs
-ASA 325'
-Acetaminophen (Liquid) 1000 mg PO/NG Q6H:PRN pain
-Multivitamins 1 TAB PO/NG DAILY
-Amiodarone 200 mg PO/NG DAILY
-Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN oral pain
-Metoprolol Tartrate 6.25 mg PO/NG BID
-OxycoDONE Liquid 2 mg PO/NG Q6H
-Quetiapine Fumarate 25 mg PO/NG QHS insomnia
-Heparin Flush (1000 units/mL) ___ UNIT DWELL PRN line
flush
-Dialysis Catheter (Tunneled 2-Lumen): DIALYSIS NURSE ONLY:
Withdraw 4 mL prior to flushing with 10 mL NS followed by
Heparin as above according to volume per lumen
-Heparin 5000 UNIT SC DAILY Order date: ___ @ 1656
-PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Perforated sigmoid colon
Ventillator-dependent respiratory failure
Acute renal failure
Discharge Condition:
Mental Status: Nonverbal, follows commands.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Please continue routine tracheostomy, colostomy, and gastric
tube care. Please change the wound VAC q3 days, and inspect the
wound with dressing changes. Please continue enteral feeds at
goal via g-tube.
Followup Instructions:
___
|
10258295-DS-15 | 10,258,295 | 24,989,336 | DS | 15 | 2143-08-18 00:00:00 | 2143-08-20 09:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
labetalol
Attending: ___.
Chief Complaint:
=======================================================
HMED ADMISSION NOTE
Date of admission: ___
=======================================================
PCP: ___, has not established care since coming to US
CC: ___ urgency
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
___ is an ___ yo woman with likely history of chronic
hypertension who was referred to the ED for severe hypertension.
History obtained via her daughter at the bedside who served as
___. The patient has been un the ___ since ___
and has not seen a physician since she immigrated. While in
___ she only had intermittent care because she was poor and
has not had routine follow up. She does report being told she
had high blood pressure while in ___ years ago but she has
never taken medications consistently.
Her current history is as follows. She presented to ___
___ to establish care and on arrival was found
to have BP of 280/120 so she was sent to ___ for evaluation. On
arrival to ___ her BP is recorded to be 300/110. While there she
was complaining of bilateral leg pain with ambulation so
referred to ___ for vascular surgery consultation following
CXR, CT head and CTA which did not show acute thrombosis or
critical limb ischemia.
In the ED, initial vitals were: 98.6 65 255/89 18 100% RA. She
was given Labetalol and Amlodipine with improvement in BPs to
120s. Vascular surgery was consulted because of "dark toes". She
was found to have non-flow limiting stenosis of celiac, and
widely patent SMA on CTA, good distal flow noted into both legs
to level of mid-calf. ABIs performed at beside both ~0.61, which
is in line with history of chronic exercise induced
claudication. Feet were warm, with no arterial ulcers or
ischemic toes. Overall there was no evidence of acute vascular
surgery issue and she did not require systemic anticoagulation.
Admitted to medicine for BP management
On the floor, she appears well, and denies chest pain, shortness
of breath, headache or new vision changes. She does report that
for the last ___ days she has been feeling like she had "bugs
crawling over my body". Her daughter also reports that she has
had odd behavior for the last 3 months, more forgetful than
normal, not answering questions in appropriately all the time
and with poor memory. Patient reports poor vision but says this
has been ongoing for ___ years. She reports left eye is worse
and seems like "everything is bigger" which he daughter
describes as a magnifying glass. However, patient is not worried
about her vision changes. She has RUE weakness which is chronic
but otherwise has no new neuro changes. She reports bilateral ___
pain with exertion.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Otherwise ROS is negative.
Past Medical History:
Likely chronic HTN
"eyes"
Social History:
___
Family History:
Daughter with CAD and cardiomyopathy
Many family members with HTN
Physical Exam:
PHYSICAL EXAM:
Vitals:98.7 PO 145 / 65 70 18 96 Ra
Pain Scale: ___
General: Patient appears overall chronically ill but stable and
no acute distress. She does not answers consistently reliably
and is oriented only to person and ___ not to time. Unable
to do days of week in reverse. Her daughter seems disturbed by
her answers but says her behavior has been off since ___.
HEENT: Vision appears preserved in right eye, left eye without
objective evidence she has vision, she guesses # of fingers with
right eye obscured and cannot find my fingers when asked, left
eye does not blink to threat. PERRL bilaterally
Neck: supple, JVP low, no LAD appreciated
Lungs: Clear to auscultation bilaterally, moving air well and
symmetrically, no wheezes, rales or rhonchi appreciated
CV: Regular rate and rhythm, S1 and S2 clear and of good
quality, ___ systolic murmur LUSB, no rubs or gallops
appreciated
Abdomen: soft, non-tender, non-distended, normoactive bowel
sounds throughout, no rebound or guarding
Ext: Warm to touch, hyperpigmented toes with keratosis over
___ protuberances. No palpable pulses but Dopplerable in DPs
and PTs.
Neuro: RUE weakness and contracted lateral three fingers but per
daughter this is chronic since patients childhood. Otherwise she
is moving all extremities and has intact sensation. Vision exam
as above, CN ___ intact
Physical exam:
T: 98.4, BP: 156/67, HR: 78, RR: 18, O2: 99% RA
Gen: Elderly lady sitting up in bed, no acute distress.
HEENT: NCAT, EOMI, PERRLA, anicteric sclera, clear OP, MMM,
visual fields grossly intact
Cardiac: ___ SEM RUSB, RRR, NS1/S2
Chest: CTAB
Abd: Soft, NT, NABS, ND
Ext: Toes are discolored. No palpable ___ pulses. Dopplerable
pulses.
Neuro: Oriented to person/place/date. Face symmetric. Normal
strength and sensation ___ b/l. CN II-XII grossly intact, ___
strength in ___
Pertinent Results:
ADMISSION RESULTS
___ 01:36AM BLOOD WBC-7.3 RBC-4.24 Hgb-12.8 Hct-38.6 MCV-91
MCH-30.2 MCHC-33.2 RDW-13.0 RDWSD-42.9 Plt ___
___ 01:36AM BLOOD Neuts-46.5 ___ Monos-9.0
Eos-12.3* Baso-1.0 Im ___ AbsNeut-3.39 AbsLymp-2.24
AbsMono-0.65 AbsEos-0.89* AbsBaso-0.07
___ 01:36AM BLOOD ___ PTT-31.5 ___
___ 01:36AM BLOOD Glucose-111* UreaN-13 Creat-0.9 Na-140
K-3.6 Cl-102 HCO3-23 AnGap-19
___ 01:36AM BLOOD cTropnT-<0.01
___ 01:36AM BLOOD Calcium-9.1 Phos-2.9 Mg-2.1
Imaging:
OSH:
CXR PA/LAT: Possible subtle infiltrate in the RML only seen on
PA film. Otherwise normal
CT Head: No hemorrhage, mass effect or shift. No large
territorial infarct. Diffuse global gliotic changes, cortical
atrophy
CT: 60% stenosis just beyond celiac axis, mesenteric vessels are
patent, severe bilateral renal artery stenosis, severe bilateral
atherosclerotic disease in subtrifurcation vessels
===============
PERTINENT INTERVAL RESULTS:
___ 05:46AM BLOOD Neuts-44.8 ___ Monos-5.6
Eos-19.6* Baso-0.6 Im ___ AbsNeut-3.46 AbsLymp-2.25
AbsMono-0.43 AbsEos-1.51* AbsBaso-0.05
___ 08:50AM BLOOD Glucose-152* UreaN-32* Creat-1.9* Na-140
K-3.7 Cl-102 HCO3-26 AnGap-16
___ 07:55AM BLOOD Glucose-133* UreaN-19 Creat-1.1 Na-143
K-3.7 Cl-104 HCO3-27 AnGap-16
___ 07:09AM BLOOD Glucose-122* UreaN-24* Creat-1.4* Na-142
K-4.0 Cl-104 HCO3-26 AnGap-16
___ 05:46AM BLOOD Glucose-103* UreaN-22* Creat-1.1 Na-141
K-3.6 Cl-105 HCO3-24 AnGap-16
___ 05:46AM BLOOD ALT-39 AST-63* AlkPhos-117* TotBili-0.5
___ 01:36AM BLOOD VitB12-339
___ 01:44AM BLOOD %HbA1c-6.8* eAG-148*
___ 07:55AM BLOOD Triglyc-143 HDL-34 CHOL/HD-4.1 LDLcalc-78
___ 01:36AM BLOOD TSH-2.8
___ 07:55AM BLOOD Cortsol-9.0
___ 07:55AM BLOOD HIV Ab-Negative
___ 07:09AM BLOOD METHYLMALONIC ACID-PND
___ 07:09AM BLOOD INTRINSIC FACTOR ANTIBODY-PND
___ 07:55AM BLOOD STRONGYLOIDES ANTIBODY,IGG-PND
___ 06:57PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 06:57PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
___ RPR negative
CXR ___
IMPRESSION:
Compared to chest radiographs ___.
Top-heart size larger today than on ___ is not
accompanied by vascular congestion, edema, or any other signs of
cardiac decompensation. There is no focal pulmonary abnormality
to suggest pneumonia.
MRI BRAIN ___
IMPRESSION:
1. Acute to subacute foci of infarction are seen in the
bilateral occipital lobes, right parafalcine region and right
temporal lobe. Findings appear to be in an embolic
distribution. There is no evidence of acute intracranial
hemorrhage.
2. Severe chronic microangiopathy.
TTE ___
Conclusions
The left atrium is normal in size. No thrombus/mass is seen in
the body of the left atrium. 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%). No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No masses or vegetations are
seen on the aortic valve. Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
ABI ___
FINDINGS:
On the right side, triphasic Doppler waveforms were seen at the
right femoral, biphasic Doppler waveforms were seen at the
popliteal, and monophasic waveforms were seen at the posterior
tibial and dorsalis pedis levels. The right ABI is 0.52.
On the left side, triphasic Doppler waveforms were seen at the
left femoral, biphasic Doppler waveforms were seen at the
popliteal, and monophasic waveforms were seen at the posterior
tibial and dorsalis pedis levels. The left ABI is 0.64.
Pulse volume recordings showed symmetric amplitudes at the thigh
and calf levels with significant decrease in amplitude and
widening of the waveforms from the ankle to the digit levels
bilaterally.
IMPRESSION:
Evidence of significant bilateral tibial disease
CTA HEAD/NECK ___
IMPRESSION:
1. No evidence of hemorrhage, infarction, or mass.
2. Hypodensities in the bilateral temporal lobes reflect air
changes due to chronic ischemia. The acute infarctions seen on
MRI is not obviously seen on CT.
3. Stenoses at the origin and along the course of the left
vertebral artery due to atherosclerotic disease.
4. Multiple intracranial arterial stenoses due to
atherosclerotic disease.
XRAY WRIST R ___
IMPRESSION:
Old fractures of the distal radius and ulna with resultant
positive ulnar variance and dorsal radiocarpal angulation.
Widened scapholunate interval, mild degenerative disease the
base of thumb.
RUQ ultrasound :
Final Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with elevated LFTs and history of
eosoniphilia and strongyloides positive// stone? fatty liver?
TECHNIQUE: Grey scale and color Doppler ultrasound images of
the abdomen were obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The
contour of the liver is smooth. There is no focal liver mass.
The main portal vein is patent with hepatopetal flow. There is
no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD
measures 6 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall
thickening.
PANCREAS: The imaged portion of the pancreas appears within
normal limits,
without masses or pancreatic ductal dilation, with portions of
the pancreatic tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 5.9 cm.
KIDNEYS: Limited views of the right kidney show no
hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are
within normal limits.
IMPRESSION:
Normal abdominal ultrasound.
================
DISCHARGE RESULTS:
___ 06:00AM BLOOD WBC-7.3 RBC-3.74* Hgb-11.2 Hct-34.2
MCV-91 MCH-29.9 MCHC-32.7 RDW-13.0 RDWSD-43.7 Plt ___
___ 06:00AM BLOOD Neuts-43.7 ___ Monos-7.5
Eos-20.0* Baso-0.8 Im ___ AbsNeut-3.18 AbsLymp-2.02
AbsMono-0.55 AbsEos-1.46* AbsBaso-0.06
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD Glucose-101* UreaN-20 Creat-1.1 Na-143
K-4.1 Cl-107 HCO3-22 AnGap-18
___ 06:00AM BLOOD ALT-96* AST-83* AlkPhos-118* TotBili-0.4
___ 06:00AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.2
___ 01:36AM BLOOD VitB12-339
___ 01:44AM BLOOD %HbA1c-6.8* eAG-148*
___ 07:55AM BLOOD Triglyc-143 HDL-34 CHOL/HD-4.1 LDLcalc-78
___ 01:36AM BLOOD TSH-2.8
___ 07:55AM BLOOD Cortsol-9.0
___ 06:00AM BLOOD HBsAg-Positive* HBsAb-Negative
HBcAb-Positive* IgM HBc-PND
___ 07:55AM BLOOD HIV Ab-Negative
___ 06:00AM BLOOD HCV Ab-Negative
___ 06:17PM BLOOD HBV VL-PND
___ 06:57PM URINE Color-Straw Appear-Clear Sp ___
___ 06:57PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 06:57PM URINE CastHy-1*
**FINAL REPORT ___
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
Result Reference
Range/Units
METHYLMALONIC ACID ___ 87-318 nmol/L
THIS TEST WAS PERFORMED AT:
Test Result Reference
Range/Units
INTRINSIC FACTOR BLOCKING Negative Negative
ANTIBODY
Test Result Reference
Range/Units
STRONGYLOIDES AB IGG POSITIVE A
RERERENCE RANGE: NEGATIVE
Strongyloides stercoralis is a parasitic
Nematode found in tropical and subtropical
regions. Because of low larval densities in
feces, stool examination is a relatively
insensitive diagnostic test; antibody detection
offers increased sensitivity. Patients with
latent infections who are immunosuppressed or
receiving immunosuppressive therapy are at risk
of life-threatening hyperinfection. Significant
crossreactivity may be observed in other
helminth infections.
THIS TEST WAS PERFORMED AT:
___ DIAGNOSTICS
___LD B-WEST WING
___, ___
___
Brief Hospital Course:
___ yo woman with likely history of chronic hypertension who was
referred to the ED for severe hypertension, also with complaint
of subacute neurologic decline. Hospital course was notable for
diagnosis of likely embolic CVA, persistent hypertension, likely
recurrent iatrogenic acute kidney injury, and eosinophilia.
# hypertensive urgency to emergency: initial BPs both here and
at OSH with SBP 300, subsequently varying BP from SBP 250 to
130, with an initially gradual
decrease over hours, but then on AM ___ had abrupt drop in ED
from 220 to 130, which may have been too fast for her. Unclear
if she actually had hypertensive encephalopathy, though no PRESS
on imaging, and the renal failure happened after BP control and
not before. Severe bilateral renal artery stenosis may be a
large
contributor to the severity of her BP. Given the mental status
and neuro finding improvements, and lack of watershed infarcts
on imaging, did not see need to start pressors to increase her
BP. Initially started on amlodipine, final regimen uptitrated to
10 mg Amlodipine daily and Carvedilol 6.25 mg BID. She was
allowed to autoregulate, with initial goal <220, then <180, and
finally 140-160 systolic. She was treated with Amlodipine and
Carvedilol with good effect prior to discharge. She was
occasionally given Hydralazine during her admission if SBP was
greater than goal.
# CVA: Acute to subacute occipital CVAs seen on MRI. CTA with
vertebral stenosis without large vessel obstructions. TTE
without embolus or ASD. Telemetry without AF. A1c noted 6.8,
started insulin SS, lipids wnl, started atorvastatin.
___ saw patient and recommended.
# Claudication: Patient has this at home, ABIs showed severe PAD
without critical ischemia. Vascular surgery recommended
outpatient follow-up.
# Encephalopathy / ? Cognitive Decline: Apparently a months long
process of unclear etiology, though since daughter had not been
around patient until only a few months ago, it is possible this
decline was slower. Appears to have improved during admission
per daughter. It is possible there was a superimposed component
of hypertensive encephalopathy, but likely also an underlying
dementia. RPR negative, TSH & Cortisol WNL, HIV negative. B12
noted to be moderately low, so started supplementation per
neurology. Neurology recommends outpatient f/u after acute
illness has been addressed.
# ___:
Initially presented to OSH and ___ ED with Cr wnl. ___
occurred after unexpectedly overly rapid BP control in setting
of RAS, resolved with IVF, but then worsened again after CTA.
Each time, ___ resolved with IVF. Discharge creatinine 1.1
#Elevated LFTs: on discharge LFTs elevated, RUQ ultrasound wnl.
Patient was taking Tylenol standing while hospitalized, this was
changed to prn. Hepatitis serologies sent, Hepatitis C negative,
however Hepatitis B surface antigen and Hepatitis B core
Antibody positive, Hepatitis B surface antibody. At time of
discharge, Hepatitis B viral load is pending on discharge.
# Peripheral Eosinophilia/Strongy:
Possible etiologies include chronic parasitic infection (from
endemic region), malignancy, autoimmune, adrenal insufficiency,
medication (eg AIN). Of these, cortisol WNL. Strongy antibody
was positive and she was treated with Ivermectin x2 days.
# B12 deficiency: borderline. MMA level 306, intrinsic factor
negative. B12 repleted PO as above.
# Blindness:
Pt reported that she was mostly blind on L eye previously, but
this appears to have resolved. Occipital CVAs could explain
this.
# wrist pain: chronic, x ray noted chronic fracture.
TRANSITIONAL ISSUES
- full code
- should follow up with neurology regarding CVA and for
outpatient dementia eval with cognitive neurology
- please avoid ACEi in this patient given risks with bilateral
renal artery stenosis
- labetalol listed as intolerance given abrupt drop in BP after
200mg po dose
- can consider 30d Holter monitor to assess for evidence of
atrial fibrillation as outpatient
- Follow-up with ophthalmology as outpatient
- Follow-up with vascular surgery as outpatient
- Patient's daughter has established care with PCP as outpatient
for her mother and has also purchased BP machine
- Will need f/u CBC w/differential, chemistries and repeat
LFTs/lipids as outpatient(initiated on statin while
hospitalized).
- Hepatitis B viral load is pending at discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth Take one tablet daily
Disp #*30 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
4. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth Every Night Disp
#*30 Tablet Refills:*0
5. Carvedilol 6.25 mg PO BID
Hold for blood pressure (systolic) <100 and heart rate < 60
RX *carvedilol 6.25 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
6. Cyanocobalamin 1000 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 1,000 mcg 1 tablet(s) by mouth
Daily Disp #*30 Tablet Refills:*0
7.Blood Pressure Cuff
Please dispense 1 automated blood pressure cuff
ICD 10: I16.0
Prognosis: Good
Duration of use: 13 months
Discharge Disposition:
Home
Discharge Diagnosis:
hypertensive urgency to emergency
acute kidney injury
eosinophilia, positive strongyloides antibody
hyperglycemia
B12 deficiency
acute kidney injury
severe peripheral arterial disease
elevated hemoglobin A1c
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___ was a pleasure caring for you.
You were admitted for: confusion, high blood pressure.
While you were here: we also found several new strokes, you
developed kidney failure, high levels of blood cells called
"eosinophils" and positive strongyloides antibody (treated with
ivermectin), low levels of vitamin B12, and evidence of vascular
disease in your legs. Thankfully your symptoms improved and
kidney function also improved.
When you go home, you should: continue to take your medicines
and follow-up with your PCP, please check daily blood pressure.
Best wishes in your recovery.
Your ___ team
Followup Instructions:
___
|
10258434-DS-15 | 10,258,434 | 25,037,887 | DS | 15 | 2112-02-24 00:00:00 | 2112-02-24 16:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with a hx of Type 2 diabetes who presented
to the emergency department intoxicated yesterday with
complaints of chest pain. It first developed chest pain ___,
left sided, radiating into his arm with associated SOB, worse
with exertion. Denies nausea, vomiting or diaphoresis. Patient
was at a party and drank a large amount of beer, but denies
using cocaine. He was initially admitted to the ___ service
earlier on morning of ___ for NSTEMI with trop 0.13. However,
he left AMA because he felt better. His serum EtOH level was
325. He returned to the ED given continued chest pain. He
describes the pain as similar in character around 3:30pm,
walking at the time, worse at ___.
Pt seen by cardiology in ED the night prior. Per their read of
EKG, signs of LVH and repolarization without acute ischemic
changes. Today, labs notable for trop 0.17 (up from 0.13), Cr
1.8 (unknown prior baseline). CXR with mild pulmonary
congestion.
He was given tylenol, morphine, nitro, and heparin gtt. He was
started on nitro gtt and was reported to be chest pain free but
was having a headache from the drip.
Vitals prior to transfer: 78 158/90 16 100%.
On the floors, he is currently chest pain free. He also endorses
occasional leg swelling, and now using 3 pillows. He also snores
at night but also has +PND.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Cardiac review of systems is notable for absence of
palpitations, syncope or presyncope.
Past Medical History:
DMII, not currently taking any medications, has not seen a
doctor in some time
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
On admission:
VS: T= 97.9 BP= 155/99 --> 144/88 HR= 80 RR= 16 O2 sat= 95% RA,
Wt 89.3kg
GENERAL: male, appears stated age, in NAD. laying flat in bed.
Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with JVP of 12 cm.
CARDIAC: RRR, normal S1, loud S2, no murmurs. No S3 or S4.
LUNGS: No accessory muscle use. CTAB, no crackles, wheezes or
rhonchi.
ABDOMEN: Soft, +BS, NTND. No HSM or tenderness.
EXTREMITIES: warm, dry, no edema, hyperpigmentation on shins
bilaterally
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ ___ 2+
Left: DP 2+ ___ 2+
On discharge:
VS: 97.1 135/72 (130s-150s systolic) 74 (70s-80s) 18 98%RA
91.8kg
GENERAL: WDWN male, in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 7 cm.
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. 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:
On admission:
___ 03:02AM BLOOD WBC-6.7 RBC-4.70 Hgb-12.9* Hct-39.7*
MCV-84 MCH-27.4 MCHC-32.5 RDW-17.1* Plt ___
___ 03:02AM BLOOD Neuts-57.6 ___ Monos-6.7 Eos-2.2
Baso-0.7
___ 03:02AM BLOOD ___ PTT-41.6* ___
___ 03:02AM BLOOD Glucose-155* UreaN-14 Creat-1.8* Na-139
K-3.8 Cl-100 HCO3-27 AnGap-16
___ 08:47AM BLOOD CK(CPK)-516*
___ 03:02AM BLOOD cTropnT-0.13*
___ 03:02AM BLOOD Cholest-307*
___ 08:47AM BLOOD calTIBC-298 Ferritn-60 TRF-229
___ 03:03PM BLOOD %HbA1c-6.0* eAG-126*
___ 03:02AM BLOOD Triglyc-533* HDL-48 CHOL/HD-6.4
LDLmeas-181*
___ 03:02AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:40PM URINE Hours-RANDOM Creat-88 Na-67 K-33 Cl-68
TotProt-746 Prot/Cr-8.5*
___ 12:40PM URINE Osmolal-374
On discharge:
___ 06:45AM BLOOD WBC-6.3 RBC-3.93* Hgb-11.3* Hct-32.9*
MCV-84 MCH-28.6 MCHC-34.2 RDW-17.3* Plt ___
___ 08:47AM BLOOD ___ PTT-80.1* ___
___ 06:45AM BLOOD Glucose-137* UreaN-14 Creat-1.5* Na-138
K-3.4 Cl-105 HCO3-24 AnGap-12
___ 06:45AM BLOOD CK(CPK)-1288*
___ 06:45AM BLOOD CK-MB-11* MB Indx-0.9 cTropnT-0.08*
___ 06:45AM BLOOD Calcium-8.1* Phos-2.7 Mg-1.8
EKG ___:
Sinus rhythm at upper limits of normal rate. Probable left
ventricular
hypertrophy with ST-T wave abnormalities of strain and/or
ischemia. No previous tracing available for comparison. Clinical
correlation is suggested.
CXR ___:
IMPRESSION: Low lung volumes crowd the pulmonary vasculature
and exaggerate the heart size. Recommend repeat films with
better inspiration for better assessment.
TTE ___:
The left atrium is mildly dilated. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. There is mild regional left ventricular systolic
dysfunction with mild hypokinesis of the basal to mid inferior
segments. There is no ventricular septal defect. The right
ventricular free wall is hypertrophied. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Moderate symmetric LVH with mild regional left
ventricular systolic dysfunction. Thickened right ventricle. No
significant valvular abnormality.
The presence of moderate LVH, thickened RV free wall and
impaired longitudinal strain suggests an infiltrative process
such as amyloidosis.
Brief Hospital Course:
Mr. ___ is a ___ hx of diabetes p/w left sided chest pain x
1 day, concerning for NSTEMI, left AMA, now returning with
continued chest pain.
# Chest pain: Patient presented with chest pain in setting of
alcohol intoxication. Trop was initially elevated at 0.13 (in
setting of elevated Cr of 1.8, baseline unknown). Trop peaked
at 0.18. He was started on heparin gtt as well as nitro gtt
until resolution of chest pain. He was started on atorvastatin
for HLD (total cholesterol 307, LDL 181, HDL 48). He was started
on aspirin 325mg. For his HTN, he was started on carvedilol and
amlodipine (acei was held given elevated Cr). TTE showed
moderate symmetrical LVH and right ventricular thickening,
findings suggestive of infiltrative process such as amyloidosis.
Cardiac catheterization was recommended but patient wished to
leave against medical advice prior to the catheterization. A
discussion of benefits and risks was held (including acute
coronary syndrome and death). He stated understanding of risks
and left against medical advice. Trop had downtrended to 0.08
by time of discharge. He was discharged on aspirin 81mg,
atorvastatin, carvedilol, and amlodipine and given prescription
for sublingual nitroglycerin prn for chest pain.
# Diabetes: He reportedly had hx of DM but was noncompliant with
his home metformin. He was on HISS while in hospital. A1c was
6.0%.
# Renal failure: Unclear baseline Cr in patient. Cr was 1.8 on
admission and improved to 1.5 by time of discharge. Urine
electrolytes were consistent with prerenal etiology.
# HTN: Uncontrolled, unclear duration. He was started on
carvedilol and amlodipine and systolic BPs were 130s-150s by
time of discharge. ACEI was not initiated due to acute kidney
injury.
# EtOH Intoxication: ETOH level in blood was 300s on
presentation and pt was intoxicated. Social work consult was
ordered but patient left before being seen.
Medications on Admission:
NONE (previously on Metformin, but hasn't been taking this for a
while)
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Carvedilol 12.5 mg PO BID
RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet, chewable(s) by mouth daily Disp #*30
Tablet Refills:*0
5. Nitroglycerin SL 0.4 mg SL ASDIR
take one tablet sublingual every 5 minutes as needed for chest
pain
RX *nitroglycerin 0.4 mg 1 tablet sublingually as needed for
chest pain Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Chest pain
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 in the hospital. You were
admitted with chest pain and lab tests that showed possible
stress on the heart as well as kidney damage. It was
recommended that you undergo a procedure called a cardiac
catheterization but you decided to leave against medical advice.
Your heart ultrasound suggested that you may have an infiltrate
disease such as amyloidosis. Please follow-up with your doctor
regarding further evaluation for this. Please also remember to
keep hydrated.
Followup Instructions:
___
|
10258472-DS-20 | 10,258,472 | 24,406,560 | DS | 20 | 2113-03-02 00:00:00 | 2113-03-02 13:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: Mr. ___ is a ___ with PMH seizure disorder on Depakote
who presents with ___ days of symptoms including generalized
abdominal pain, NBNB n/v, fevers (Tm 103 at home)/chills, and
URI
sypmtoms such as cough, nasal congestion, and odynophagia. His
abdominal pain has localized into the RLQ over time. It
intermittently waxes and wanes. He denies anorexia but has had
difficulty with PO tolerance (last episode of emesis this AM).
Of
note, his live-in girlfriend was recently diagnosed withe the
flu. He denies dysuria. He denies any changes in BMs, last this
AM. Earlier today he presented to urgent care with the above
symptoms and underwent CT abdomen/pelvis, which could not rule
out early appendicitis, and he was sent here for further
evaluation.
He has never had a colonoscopy or any abdominal surgery. Family
history is signficant for Crohn's disease in his mother, though
patient denies any personal symptoms suggestive of Crohn's.
Past Medical History:
seizures
Physical Exam:
OBJECTIVE:
Vitals:
24 HR Data (last updated ___ @ 101)
Temp: 98.3 (Tm 98.6), BP: 111/73 (111-121/73-83), HR: 65
(61-92), RR: 16 (___), O2 sat: 96% (94-97), O2 delivery: Ra
Physical exam:
Gen: NAD, AxOx3
Card: RRR
Pulm: breathing comfortably on room air
Abd: Soft, non-tender, nondistended
Ext: No edema, warm well-perfused
Brief Hospital Course:
The patient presented to Emergency Department on ___. Pt was
evaluated by general surgery.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed with oral medications as
needed.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO. Diet was advanced
sequentially to a Regular diet, which was well tolerated.
Patient's intake and output were closely monitored. A small
foreign object was identified in the right lower quadrant on CT
and abdominal Xray. It was felt that continued monitoring of
this object was reasonable and not contributing to the patient's
symptoms.
ID: The patient was admitted for concern of appendicitis. He had
right lower quadrant pain but no fever or leukocytosis and a CT
not consistent with appendicitis. Antibiotics were initiated but
promptly stopped. The patient's fever curves were closely
watched for signs of infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
1. Divalproex (EXTended Release) 1000 mg PO BID
Discharge Medications:
1. Divalproex (EXTended Release) 1000 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
- Right lower quadrant pain of indeterminate etiology
- Subcutaneous foreign object, possibly pin in right lower
quadrant
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
right lower quadrant pain. Please follow the instructions below
to continue your recovery:
Please call your doctor or nurse practitioner or return
IMMEDIATELY to the Emergency Department for any of the
following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
Followup Instructions:
___
|
10258762-DS-15 | 10,258,762 | 24,205,505 | DS | 15 | 2124-01-12 00:00:00 | 2124-01-12 16:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Celexa / Wellbutrin
Attending: ___
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a ___ year old man with history of HTN, CKD, DM, OSA,
depression/anxiety, intellectual disability, drug-induced
parkinsonism, who presents as transfer for worsening confusion
over days, slurred speech, and facial asymmetry, found to have a
right subdural hematoma. Neurology is consulted for ?stroke as
the laterality of his symptoms do not appear to be clearly
correlated to the subdural hematoma.
History is obtained via records brought via transfer as pt
cannot
provide history and family members could not be contacted.
According to EMS and ___ documents, pt was noted
by family and friends to be "not acting right" since yesterday
morning and "had been increasingly confused all week. When she
returned around 6PM to help him with his medications she noticed
he had slurred speech and facial asymmetry. Speaking with his
mother she reports she noticed slurred speech and facial
asymmetry tonight as well around 7PM...he reportedly felt
'spaced
out'...He reports he feels weak all over".
Initial tele-code stroke was called, however upon completion of
CT it was discovered he had a right-sided acute on chronic
subdural hematoma. He was subsequently transferred to ___ for
neurosurgical evaluation.
On history with the patient, he perseverates on discomfort in
his
buttocks. He is unable to provide additional history or ROS.
Past Medical History:
HTN
CKD
DM
OSA
Depression/anxiety
Intellectual disability
Hallucinations
Drug-induced parkinsonism
Social History:
___
Family History:
Unknown
Physical Exam:
==============================================
ADMISSION PHYSICAL EXAM
==============================================
Vitals: temp 96.0, HR 85, BP 138/73, RR 18, spO2 100% NC
General: Asleep, arouses easily. Chronically ill appearing
middle
aged gentleman.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no nuchal rigidity
Pulmonary: Lungs CTA
Cardiac: RRR, nl.
Abdomen: soft, NT/ND.
Extremities: severe pitting edema b/l, lower legs wrapped in
dressings b/l.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to himself, "hospital in ___
and ___. Inattentive. Language is sparse but with
fluent output; pt perseverates on buttock discomfort. Moderate
dysarthria. Can follow simple commands (shows me his thumb, high
fives my hand) but unable to follow more complex tasks such as
confrontational motor examination.
-Cranial Nerves:
II, III, IV, VI: L pupil 4->3mm and brisk. R pupil obstructed by
pterygium. EOMI without nystagmus. BTT bilaterally.
V: Facial sensation intact to light touch.
VII: Left facial weakness with NLFF and decreased activation of
the left lip, improves with emotional smile.
VIII: Hearing intact grossly.
IX, X: Palate elevates symmetrically.
XII: Tongue protrudes in midline.
-Motor: Slightly paratonic throughout. Difficulty cooperating
with confrontational strength examination. He displayed an
initially small amplitude high frequency tremor of the right
upper extremity and the mouth which suppressed with distraction
and increased in amplitude intermittently.
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 4-* 3* 3* 3* 4* 3* 2* 3* 3* 3* 3*
R 3* 4* 5-* 4* 5 4+* 2* 3* 3* 3* 3*
-Sensory: Responds to sensory stimuli including light touch and
pinprick in all extremities.
-DTRs:
Bi Tri ___ Pat Ach
L 3 2+ 2+ 0 0
R 3 2+ 2+ 0 0
Plantar response was mute bilaterally.
-Coordination: No dysmetria on high-fiving with either arm.
-Gait: Deferred.
=
=
================================================================
DISCHARGE PHYSICAL EXAM
=
=
================================================================
General: Awake, alert sitting in a chair in NAD.
HEENT: NC/AT, no scleral icterus, MMM, no lesions noted in
oropharynx
Neck: Supple, no nuchal rigidity
Pulmonary: breathing comfortably on RA
Extremities: 2+ symmetric pitting edema in all four extremities.
Skin: bilateral lower extremity venous stasis dermatitis with
erythematous, friable skin. no open ulcerations.
Neurologic:
-Mental Status: Alert, oriented to self, ___
___ in ___, ___. Inattentive. Language
fluency mildly decreased with reduced spontaneous speech output.
Asks when he can go home. Moderate
dysarthria. Follows very simple axial and appendicular commands
(give me a thumbs up), but is unable to participate in
confrontational strength testing.
-Cranial Nerves:
II, III, IV, VI: L pupil 4->3mm and brisk. R pupil obstructed by
pterygium. EOMI without nystagmus. BTT bilaterally.
V: Facial sensation intact to light touch throughout.
VII: Left nasolabial fold flattening and delayed activation of
left lower face.
VIII: Hearing intact to conversation.
IX, X: Palate elevates symmetrically.
XII: Tongue protrudes in midline.
-Motor: Paratonia present throughout. Right arm pill-rolling
tremor present, as well as jaw tremor. He has significant
difficulty cooperating with confrontational strength
examination, and also has pain limitation, mainly at bilateral
shoulders.
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 2* 4* 4* 4* 5 4* 2* 3* 3* 3* 3*
R 2* 4* 4* 4* 5 4* 2* 3* 3* 3* 3*
*=effort-limited examination. Strength is deemed to be at least
this value, but full strength cannot be excluded.
-Sensory: Responds to sensory stimuli including light touch and
pinprick in all extremities.
-DTRs:
Bi Tri ___ Pat Ach
L ___ 0 0
R ___ 0 0
Plantar response was mute bilaterally.
-Coordination: No dysmetria on observed reaching movements
bilaterally.
-Gait: Able to stand, take a few steps and transfer with two
person assistance.
Pertinent Results:
___ 12:32AM BLOOD WBC-9.2 RBC-3.34* Hgb-10.1* Hct-33.5*
MCV-100* MCH-30.2 MCHC-30.1* RDW-15.9* RDWSD-58.1* Plt Ct-96*
___ 05:15AM BLOOD WBC-6.7 RBC-3.21* Hgb-9.7* Hct-32.3*
MCV-101* MCH-30.2 MCHC-30.0* RDW-15.3 RDWSD-56.9* Plt Ct-93*
___ 12:32AM BLOOD Plt Smr-LOW Plt Ct-96*
___ 01:03AM BLOOD ___ PTT-31.2 ___
___ 12:32AM BLOOD Glucose-162* UreaN-29* Creat-1.4* Na-142
K-4.2 Cl-95* HCO3-33* AnGap-18
___ 05:15AM BLOOD Glucose-195* UreaN-18 Creat-1.2 Na-146*
K-3.6 Cl-99 HCO3-37* AnGap-14
___ 12:53PM BLOOD ALT-<5 AST-6 LD(LDH)-119 AlkPhos-69
TotBili-0.2
___ 12:53PM BLOOD cTropnT-<0.01
___ 12:32AM BLOOD cTropnT-<0.01
___ 05:05AM BLOOD Calcium-8.8 Phos-4.0 Mg-1.7
___ 12:53PM BLOOD %HbA1c-6.5* eAG-140*
___ 05:10AM BLOOD Triglyc-147 HDL-41 CHOL/HD-3.0 LDLcalc-55
Imaging:
___ CXR: No acute intrathoracic abnormality.
___ AXR: Vascular coils in the left upper quadrant.
___ MRI brain: 1. This examination is moderately limited by
motion artifact.
2. Acute on chronic right subdural hemorrhage measuring up to
1.7 cm in
maximal thickness, unchanged compared to the prior CT dated ___.
3. Small amount of adjacent subarachnoid hemorrhage.
4. No evidence of acute infarction.
___ Echo: : Preserved biventricular systolic function. No
clinically significant valvular disease. Normal pulmonary artery
systolic pressure.
Brief Hospital Course:
Mr. ___ is a ___ yo gentleman with HTN, DM, OSA,
depression/anxiety, intellectual disability, and psychosis c/b
drug-induced parkinsonism, who presented with two days of
progressive confusion, as well as several hours of slurred
speech, facial asymmetry and inability to stand. CT head
demonstrated a right-sided small acute and larger chronic
subdural hematoma, and he was admitted to the neurology service
for evaluation for possible superimpose infarct given loss of
ability to ambulate. Exam is significant for left lower facial
droop, which is likely secondary to the subdural hematoma.
Additionally, he was quite somnolent, requiring repeated deep
noxious stimuli to obtained sustained arousal. He was therefore
unable to participate in confrontational strength testing. Toxic
metabolic workup was initiated, which revealed a urinary tract
infection, treated with ceftriaxone. His somnolence improved
with treatemtn of the UTI, though he continued to have
difficulty participating in confrontational strength testing.
MRI was obtained to rule out infarct, which redemonstrates
subdural hematoma, and is without evidence of infarct or other
acute intracranial process.
Echocardiogram performed to evaluate for cardiac etiologies of
BNP 3000 on admission as well as chronic four extremity edema,
and it did not reveal any heart failure.
=============================================
Transitional issues:
- Aspirin stopped this admission; if strong indications for
Aspirin are found, consider risk/benefit of restarting ASA.
- Has subdural hematoma and history of falls. We recommend
consideration of fall precautions and home safety evaluation.
==============================================
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ammonium lactate 12 % topical DAILY
2. Divalproex (EXTended Release) 750 mg PO QPM
3. PALIperidone Palmitate 117 mg IM EVERY 28 DAYS
4. Torsemide 20 mg PO BID
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Lidocaine 5% Patch 1 PTCH TD QAM
7. Benztropine Mesylate 1 mg PO QHS
8. Lantus Solostar (insulin glargine) 100 unit/mL (3 mL)
subcutaneous DAILY
9. irbesartan 150 mg oral DAILY
10. Vitamin D ___ UNIT PO 1X/WEEK (FR)
11. Atorvastatin 40 mg PO QPM
12. Cyanocobalamin 1000 mcg PO DAILY
13. Tamsulosin 0.4 mg PO QHS
14. Prazosin 1 mg PO QHS
15. Potassium Chloride 20 mEq PO DAILY
16. Omeprazole 20 mg PO DAILY
17. Metoprolol Succinate XL 50 mg PO DAILY
18. MetFORMIN (Glucophage) 850 mg PO DAILY
19. MetFORMIN (Glucophage) 1700 mg PO QHS
20. Ferrous Sulfate 325 mg PO DAILY
21. Aspirin 81 mg PO DAILY
22. Allopurinol ___ mg PO DAILY
Discharge Medications:
1. CefTRIAXone 1 gm IV Q24H
2. LevETIRAcetam Oral Solution 500 mg PO BID
3. Allopurinol ___ mg PO DAILY
4. ammonium lactate 12 % topical DAILY
6. Atorvastatin 40 mg PO QPM
7. Benztropine Mesylate 1 mg PO QHS
8. Cyanocobalamin 1000 mcg PO DAILY
9. Divalproex (EXTended Release) 750 mg PO QPM
10. Ferrous Sulfate 325 mg PO DAILY
11. irbesartan 150 mg ORAL DAILY
12. Lantus Solostar (insulin glargine) 100 unit/mL (3 mL)
subcutaneous DAILY
13. Lidocaine 5% Patch 1 PTCH TD QAM
14. MetFORMIN (Glucophage) 850 mg PO DAILY
15. MetFORMIN (Glucophage) 1700 mg PO QHS
16. Metoprolol Succinate XL 50 mg PO DAILY
17. Multivitamins W/minerals 1 TAB PO DAILY
18. Omeprazole 20 mg PO DAILY
19. PALIperidone Palmitate 117 mg IM EVERY 28 DAYS
20. Potassium Chloride 20 mEq PO DAILY
Hold for K >4.5
21. Prazosin 1 mg PO QHS
22. Tamsulosin 0.4 mg PO QHS
23. Torsemide 20 mg PO BID
24. Vitamin D ___ UNIT PO 1X/WEEK (FR)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Subdural hematoma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of left face drooping and
trouble walking. The left face drooping resulted from a SUBDURAL
HEMATOMA, a condition where there is bleeding on the outside of
the brain. Some of the blood has been there for a while, and
some is new. The brain is the part of your body that controls
and directs all the other parts of your body, so damage to the
brain can result in a variety of symptoms.
You also have a urinary tract infection, which caused you to be
very sleepy and confused.
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:
falls
parkinsonism
We are changing your medications as follows:
take an antibiotic for a short period
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10258967-DS-18 | 10,258,967 | 29,642,100 | DS | 18 | 2135-05-02 00:00:00 | 2135-05-02 13:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
shellfish derived
Attending: ___.
Chief Complaint:
right arm swelling and discoloration
Major Surgical or Invasive Procedure:
___ -- repositioning of Port-A-Cath
History of Present Illness:
Mr. ___ is a ___ male with history of stage III
sigmoid colon cancer, resected in ___, and 6 weeks of
chemotherapy reporting 3 days of right arm swelling and
discoloration.
Mr. ___ reports swelling of right arm progressively
worsening for past three days. He also reports reddish/purple
hue
beginning at this time. He denies pain from right arm, but some
discomfort from stretching of skin. He describes his fingers,
hand and lower arm as feeling tight and heavy but not painful.
He
had port placed in right subclavian 6 weeks ago, but has had
poor
return, and he had a hematoma so his PICC was changed to his
left
arm. However, he has continued to have poor return and on his
last two previous appointments he needed TPA to dwell for two
hours before blood return was achieved. His last dose of FOLFOX
was given ___.
Today, Mr. ___ emailed his ___ oncologist, Dr. ___ his symptoms of minor bruising and swelling in the right
upper arm. She was suspicious of DVT and recommended he present
to ER today.
In the ED, initial VS 97.3, 116, 128/94, 99% RA -> 976, 120/86,
16, 96% on RA.
Labs showed WBC 3.5, normal H/H, unremarkable BMP.
Right upper extremity doppler showed extensive nearly complete
occlusive thrombosis of the right upper extremity involving the
right internal jugular, subclavian, and axillary veins. Catheter
noted in the right subclavian vein. Nearly complete occlusive
thrombus of the central portion of the basilica vein and
occlusive thrombus of a portion of the right cephalic vein. CT
head w/o contrast was negative for any acute findings or
underlying mass or edema. CXR showed interval proximal
retraction
of the Port-A-Cath tip now residing in the region of the right
internal jujular vein.
The patient was evaluated by ___ given the right upper extremity
thrombus and malpositioned. ___ will attempt port-a-cath
reposition/replacement on the right side using the existing
pocket but may require left-sided access. They recommended
starting IV heparin and he was made NPO.
On the floor, he denied fever, nausea, change in vision/hearing,
palpitations, SOB. He reports no changes in urination or bowel
movements. He has intermittent nausea with chemo and Compazine
has helped, but he hasn't felt nausea recently. He also denies a
history of significant bleeding, though he has had intermittent
hemorrhoid bleeding. He reports that he took lovenox for a month
after his sigmoid resection.
Past Medical History:
Colon cancer diagnosed 3 months ago
Hyperlipidemia
Surgical History: 20cm colon removed 3 months ago.
R hand reattached ___ - ___ accident
Social History:
___
Family History:
Reviewed and found to be not relevant to this
illness/reason for hospitalization.
Physical Exam:
ADMISSION EXAM:
VITALS: 98.4 PO 127/83 R Sitting 98 20 97% RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs. Right forearm and hand
is
swollen with tight, reddened skin.
SKIN: No rashes or ulcerations noted. Port site is
non-erythematous and not swollen. Ecchymosis distal to the right
antecubital fossa at site of recent peripheral IV insertion.
Equal, palpable radial pulses distally.
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Patient examined on day of discharge. AVSS, continued swelling
of the RUE, unchanged from admission.
Pertinent Results:
LABORATORY RESULTS:
___ Right upper extremity Doppler
Extensive nearly complete occlusive thrombosis of the right
upper
extremity involving the right internal jugular, subclavian, and
axillary veins. Catheter noted in the right subclavian vein.
Nearly complete occlusive thrombus of the central portion of the
basilic vein and occlusive thrombus of a portion of the right
cephalic vein.
IMAGING:
___ CT head w/o contrast
Negative for any acute findings or underlying mass or edema.
___ CXR
Interval proximal retraction of the Port-A-Cath tip now residing
in the region of the right internal jujular vein.
___ 05:28AM BLOOD WBC-3.5* RBC-4.70 Hgb-12.7* Hct-38.3*
MCV-82 MCH-27.0 MCHC-33.2 RDW-27.4* RDWSD-79.6* Plt ___
___ 05:28AM BLOOD ___ PTT-72.1* ___
___ 05:28AM BLOOD Glucose-102* UreaN-23* Creat-0.6 Na-141
K-3.9 Cl-103 HCO3-24 AnGap-14
___ 05:28AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.8
Brief Hospital Course:
Mr. ___ was admitted with a new RUQ DVT in the setting of
his malignancy. He was initially started on a heparin drip.
Interventional radiology repositioned his Port-a-Cath. He was
then started on enoxaparin with a plan for a week of therapy,
then transitioning to apixaban. He will follow up with Dr.
___ ___.
- enoxaparin 100 mg BID x 7 days
- then apixaban 5 mg BID thereafter, indefinitely while
receiving cancer care
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO EVERY OTHER DAY
2. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second
Line
Discharge Medications:
1. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth Twice daily
Disp #*60 Tablet Refills:*0
2. Enoxaparin Sodium 100 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 100 mg/mL 100 mg SC Twice daily Disp #*14 Syringe
Refills:*0
3. Atorvastatin 40 mg PO EVERY OTHER DAY
4. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second
Line
Discharge Disposition:
Home
Discharge Diagnosis:
Cancer associated DVT of the RUE
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with a large blood clot in your right upper
extremity associated with your Port-a-Cath. The interventional
radiologists repositioned your cath. You were also started on
blood thinners; you will take a week of enoxaparin (Lovenox),
and then start on apixaban twice daily. You will need to take
blood thinners while you are being treated for cancer.
Followup Instructions:
___
|
10259372-DS-17 | 10,259,372 | 24,939,888 | DS | 17 | 2122-09-03 00:00:00 | 2122-09-04 13:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
ciprofloxacin / Doxil / some sort of platin
Attending: ___
Chief Complaint:
left cerebellar IPH
Major Surgical or Invasive Procedure:
IVC Filter Placement
History of Present Illness:
___ is a ___ year-old woman with breast cancer
with known metastases to the omentum on chemotherapy, left lower
extremity DVT on coumadin who is transferred for an
intraparenchymal cerebellar hemorrhage.
The patient notes she was feeling ill over the weekend with UTI
symptoms including dysuria. On the morning of presentation she
was febrile up to 101 but decided to go to work anyway. She also
felt generally off and not herself since waking up on ___
morning. She was off balance all day and had 2 falls. At work
her time card slipped out of her hand onto the floor and she
leaned down to pick it up and fell onto the ground. No head
stroke or LOC. Later when she was leaving work she noted she was
listing to the L when she walked and she again fell down, this
time with + head strike but without LOC. When she got home her
family noted she had difficulty walking up the stairs, so she
presented to the hospital. She denies lightheadedness or
vertigo. She did have one episode of vomiting in the morning,
but no subsequent nausea. She has felt that her speech may be
somewhat mildly slurred today. Otherwise denies weakness or
numbnes in her extremeties, episodes of incontinence.
She was seen at an OSH ED where she was found to have a
cerebellar hemorrage. Trop I was also elevated at 1.0 (reference
range ___. She also had low plts and therepeutic INR. She
was transferred to ___. Here INR was 2.6 so she got Kcentra
and Vit K, repeat INR 1.4. In the ED her fever climbed to 105
and she had some shaking chills. She also had some SBPs in the
mid ___ and got IVF boluses for these. She was initially
tachycardic in the 120s but this improved with IVF boluses. UA
was positive so she was started on Vanc/Cefepime. Neurosurgery
was consulted who felt there was no surgical intervention at
this time so neurolgoy was consulted and the patient was
admitted to neurology ICU.
Neuro ROS + and - as above. She also notes that she has chronic
parasthesias in her hands and feet ___ neuropathy. She also has
chronically unsteady gait although ti was worse today She also
has an old L foot drop.
General ROS notable for fever, shaking chills in the ED, and
recent 10 lb weight loss. + dysuria. No CP, SOB, cough. No
nausea, 1 episode of vomiting this AM.
Past Medical History:
- breast cancer diagnosed in ___ with known metastases to
the omentum, lung, pleura which were found about ___ year ago. She
is s/p resection and radiation and chemotherapy. She finished
her IV chemotherapy about 1.5 weeks ago and she is now on only
oral pills. Dr. ___ is her oncologist.
- neuropathy ___ chemotherapy. Also with L foot drop.
- left lower extremity DVT on coumadin
Social History:
___
Family History:
father and sister with heart disease. No family history of
stroke.
Physical Exam:
=
=
=
=
=
=
================================================================
Admission Physical Exam:
Vitals: T: 102.9 110 131/64 18 97% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, No nuchal rigidity
Pulmonary: non labored
Cardiac: regular
Abdomen: ND
Extremities: some bilateral leg swelling
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to read without difficulty. Speech was mildly dysarthric. Able
to follow both midline and appendicular commands. Pt was able to
register 3 objects and recall ___ at 5 minutes. The pt had good
knowledge of current events. There was no evidence of neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Fundoscopic
exam revealed no papilledema
III, IV, VI: EOMI but with 5 beats of R gaze evoked nystagmus.
Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 3* 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
* chronic L foot drop
-Sensory: Decreased pinprick sensation in a stocking
distribution on the legs up to right above the ankles
biletarally. Decreased proprioception at the great toes
bilaterally.
-DTRs:
Bi Tri ___ Pat Ach
L 1 0 0 0 0
R 1 0 0 0 0
Plantar response was mute bilaterally.
-Coordination: Possibly ? subtle dysmetria b/l but really not
bad.
-Gait: deferred
=
=
=
=
=
=
================================================================
DISCHARGE PHYSICAL EXAM:
Improved dysmetria with subtle left on right HKS testing. Gait
improved with walker, ___ cleared for d/c on ___.
Pertinent Results:
ADMISSION LABS:
___ 09:00PM BLOOD WBC-10.2 RBC-3.54* Hgb-11.7* Hct-35.4*
MCV-100* MCH-33.0* MCHC-33.0 RDW-17.3* Plt Ct-83*
___ 09:00PM BLOOD Neuts-86.1* Lymphs-5.7* Monos-6.8 Eos-1.3
Baso-0.3
___ 09:00PM BLOOD ___ PTT-37.8* ___
___ 09:00PM BLOOD Glucose-109* UreaN-18 Creat-1.1 Na-137
K-3.2* Cl-102 HCO3-25 AnGap-13
___ 09:00PM BLOOD ALT-18 AST-29 AlkPhos-48 TotBili-0.4
___ 09:00PM BLOOD cTropnT-0.23*
___ 02:20AM BLOOD CK-MB-3 cTropnT-0.13*
___ 09:03AM BLOOD CK-MB-5 cTropnT-0.17*
___ 09:00PM BLOOD Albumin-3.7 Calcium-8.2* Phos-2.1*
Mg-1.4*
___ 09:00PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
DISCHARGE LABS:
URINE:
___ 09:35PM URINE Color-Yellow Appear-Hazy Sp ___
___ 09:35PM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 09:35PM URINE RBC-3* WBC-43* Bacteri-MOD Yeast-NONE
Epi-1
___ 09:35PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
======================================================
IMAGING:
CXR ___: No evidence of acute cardiopulmonary disease
CTA ___:
1. Hyperdense lesion in the midline of the cerebellum measures
approximately
3.3 cm x 2.1 cm, unchanged compared to the prior exam from ___ and is consistent with a focus of hemorrhage. An
underlying lesion cannot be excluded. An MRI would be
recommended for further evaluation.
2. Patent neck and intracranial vessels.
3. Soft tissue mass measuring up to 2.7 cm in the upper right
mediastinum, which possibly is invading into the superior vena
cava, as well as demonstrating mass effect on the left
brachycephalic vein. This is concerning for a metastatic lesion
however a formal chest CT is recommended for further evaluation.
4. 1.4 cm spiculated nodule in the upper right lung is
concerning for a
metastatic focus. Note is also made of enhancing nodularity
along the pleura of the right lung apex. This can be further
evaluated by dedicated CT of the chest.
5. Heterogeneous right thyroid lobe measuring up to 2.4 cm can
be evaluated with a nonemergent thyroid ultrasound.
MRI/MRA ___:
1. Thick peripheral contrast enhancement along the margins of
the hematoma in the cerebellar vermis, including along its
superior portion which does not demonstrate hyperintensity on
precontrast T1 weighted images, which suggests an underlying
mass. Reassessment is recommended after blood products resolve.
2. Cerebellar hemorrhage is stable in size with stable mild
edema and partial effacement of the fourth ventricle. No
supratentorial hydrocephalus.
3. No additional enhancing intracranial lesions are seen.
___ ___:
1. Nonocclusive deep vein thrombus in the left popliteal vein.
2. No evidence of a deep vein thrombosis in the right lower
extremity.
======================================================
Brief Hospital Course:
====================================================
___ is a ___ year-old woman with breast cancer
with known metastases to the omentum, lung, pleura on
chemotherapy, left lower extremity DVT on coumadin who was
admitted with a midline intraparenchymal cerebellar hemorrhage
with mass effect on the ___ ventricle.
# NEUROLOGY (IPH):
The patient was admitted to the Neuro ICU from ___ to ___ where
her INR was actively reversed and anticoagulation was
discontinued. Her cerebellar hemorrhage remained stable on
serial NCHCT imaging. Her neurological exam remained stable
and notable for gait ataxia. Etiology of her IPH was most likely
caused by underlying brain metastasis given contrast enhancing
rim. Neurooncology was consulted and recommended repeat MRI in
___ weeks.
# ID (Urosepsis):
On presentation she was hypotensive, tachycardic, febrile with
ecoli UTI (recent hospitalization 1 month prior with ecoli
bacteremia and ecoli UTI). She was treated with IVF
recusitation and broad spectrum abx (Vancomycin and Cefepime)
starting ___ which were d/c'ed with clinical improvement.
# History of DVT:
She has a left popliteal DVT found 1 month prior to presentation
for which she was on coumadin. Given cerebellar bleed, her INR
was actively reversed and she required IVC filter that was
placed on ___.
# ONCOLOGY (Breast cancer):
She was diagnosed with invasive ductal carcinoma in ___
and is followed by Dr. ___. She is s/p resection,
radiation, chemo. She had recent relapse and was started on
aromazone and afinitor 1 month prior to this hospitalization.
She was found to have a new mass in the mediastinum that was
invading her SVC. Furthermore, her cerebellar IPH was likely
initially a mass. Patient reports that the chest findings are in
fact not new. We did not have records of this from her outside
neurologist. She was given copies of all the new imaging studies
to bring to Dr ___.
# ___:
She had troponinemia without ST changes. Cardiac Catheterization
demonstrated no significant CAD- final read pending at time of
discharge.
# NEUROLOGY (neuropathy):
She has longstanding neuropathy with left foot drop. She
remained on her home Lyrica and Venlafaxine.
====================================================
# TRANSITIONAL ISSUES:
1) Contact: Husband ___ ___
2) ___: Dr. ___ ___ / Dr. ___
___ (___)
====================================================
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes [performed
and documented by admitting resident]
2. DVT Prophylaxis administered by the end of hospital day 2?
(x) Yes
3. Smoking cessation counseling given? (x) Yes
4. Stroke education given (written form in the discharge
worksheet)? (x) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
5. Assessment for rehabilitation or rehab services considered?
(x) Yes
====================================================
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 2.5 mg PO DAILY16
2. Ranitidine 75 mg PO DAILY
3. Pregabalin 75 mg PO DAILY
4. Afinitor (everolimus) 10 mg oral daily
5. Aromasin (exemestane) 25 mg oral daily
6. Potassium Chloride 20 mEq PO DAILY
7. Ondansetron 8 mg PO Q8H:PRN nausea
8. Magnesium Oxide 400 mg PO DAILY
9. Venlafaxine 75 mg PO DAILY
Discharge Medications:
1. walker
One rolling walker for gait instability
2. Potassium Chloride 20 mEq PO DAILY
3. Pregabalin 75 mg PO DAILY
4. Ranitidine 75 mg PO DAILY
5. Venlafaxine 75 mg PO DAILY
6. LOPERamide 4 mg PO QID:PRN loose stool
RX *loperamide [Anti-Diarrheal (loperamide)] 2 mg 2 capsules by
mouth QID:PRN Disp #*30 Capsule Refills:*0
7. Nicotine Patch 14 mg TD DAILY
RX *nicotine [Nicoderm CQ] 14 mg/24 hour Apply 1 patch daily
Disp #*30 Patch Refills:*3
8. Afinitor (everolimus) 10 mg oral daily
9. Aromasin (exemestane) 25 mg oral daily
10. Magnesium Oxide 400 mg PO DAILY
11. Ondansetron 8 mg PO Q8H:PRN nausea
12. Outpatient Physical Therapy
431: Intracerebral hemorrhage
please contact Dr. ___ ___ with any
questions
13. Commode
Please provide for patient with physical handicap
14. Rollator
Please provide for patient with physical handicap
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Intraparenchymal Cerebellar Hemorrhage
Secondary Diagnosis:
Metastatic Breast Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
___ were hospitalized due to symptoms of unstable gait resulting
from an hemorrhagic stroke. A hemorrhagic stroke is a condition
whwere there is bleeding into the brain tissue that disrupts
brain function. 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.
Hemorrhagic stroke can have many different causes. After further
investigation, we feel that your stroke was related to an
underlying brain mass. ___ were seen by our oncology doctors
who ___ outpatient follow up and monitoring.
Please followup with Neurology and your primary care physician
as listed below.
Followup Instructions:
___
|
10259412-DS-7 | 10,259,412 | 22,497,337 | DS | 7 | 2186-08-11 00:00:00 | 2186-08-15 17:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Large right intraparenchymal hemorrhage
Major Surgical or Invasive Procedure:
Right hemicraniectomy with evacuation of clot ___
History of Present Illness:
(provided by his wife at the bedside)
___ with PMHx of depression for which he sought medical
attention in his early ___, two recent episodes of paranoia and
confusion lasting a day resolving with sleep ___, no
medical care sought), and heavy alcohol use ___ pint vodka
daily) and tobacco use ___ ppd since ___ was flown into ___
after being found to have a large right intraparenchymal
hemorrhage at ___. He drives 18 wheelers
with his cousin. They usually drive a circular route from
___ to ___ to ___ back to ___. He lives
in ___ with his wife but has been gone for the last two
months
driving this route with his cousin. During the day while
driving,
his cousin noted that he developed confusion which progressed
over six hours to left sided weakness and unresponsiveness. At
the OSH, his systolic blood pressure spiked to 220s, he was
non-responsive, NCHCT showed the IPH, he was intubated and was
brought to ___ via MedFlight emergently. On arrival, he was
evaluated by neurosurgery who recommended Mannitol 25mg IV,
Keppra 1g, strict SBP < 140, and a CTA head to eval for
underlying vascular malformation. He was noted to lose his left
pupillary reflex so he was taken emergently to the OR for right
hemicraniectomy and hematoma evacuation. He tolerated the
surgery
well and returned to the ICU in stable condition. Neurology was
consulted for long term care of patient with large right
intraparenchymal hemorrhage s/p hemicraniectomy/hematoma
evacuation.
ROS: Unable to obtain secondary to patient being
sedated/intubated.
Past Medical History:
- depression for which he sought medical attention in his early
___
- two recent uncharacterized episodes of paranoia and confusion
lasting a day resolving with sleep ___, no medical
care sought)
- chronic insomnia
- hernia repair (___)
- chicken pox (___)
- no history of headaches, encephalitis, meningitis, trauma
Social History:
___
Family History:
- no family history of headaches or seizures. The patient's
half-brother (same father) had an episode where he was
hospitalized after a severe headache and has been cognitively
different since that hospitalization (the patient's wife was
unable to characterize further)
Physical Exam:
ADMISSION EXAM:
- Vitals: afebrile, ___, 143/56, RR18, 100% MCV
- ___: unresponsive
- HEENT: large dressing over the right head, no drainage or
oozing noted, dressing not taken down
- Neck: Supple, no carotid bruits appreciated. No nuchal
rigidity
- Pulmonary: CTABL
- Cardiac: RRR, no murmurs
- Abdomen: soft, nontender, nondistended
- Extremities: no edema, pulses palpated
- Skin: no rashes or lesions noted.
NEURO EXAM:
- Mental Status: (off sedation), would not open eyes to deep
noxious, non-verbal, did not follow any commands
- Cranial Nerves:
Right 4->2, brisk, Left 4->2 slow, no blink to threat, brisk
corneal on the right, sluggish corneal on the left, strong cough
to deep suctioning.
- Motor: Normal bulk. Increased tone in LUE, LLE. Non-purposeful
withdraw of RUE/RLE to noxious x4, did not cross midline
- DTRs:
Bi Tri ___ Pat Ach
L 2+ 2+ 2+ 4 2
R 2+ 2+ 2+ 2+ 2
Plantar response was mute bilaterally.
Non-extinguishing clonus in the left foot
DISCHARGE EXAM:
Head: incision on R scalp, clean, dry, intact. No purulence or
erythema.
Neuro:
Awake, alert, oriented to hospital, date, year. Language fluent,
no dysarthria. Follows commands. Pupils 5-->3 mm, brisk, EOMI, R
gaze preference, L facial droop. L side increased tone. RUE/RLE
___, LUE ___, L IP 3, L TA 3, ___ 0. Sensation intact on R,
decreased on L to fine touch.
Pertinent Results:
___ 09:58PM BLOOD WBC-5.7 RBC-4.10* Hgb-13.4* Hct-40.8
MCV-100* MCH-32.6* MCHC-32.8 RDW-13.9 Plt ___
___ 09:58PM BLOOD ___ PTT-28.0 ___
___ 02:12AM BLOOD Glucose-90 UreaN-6 Creat-0.6 Na-138 K-3.3
Cl-110* HCO3-19* AnGap-12
___ 02:12AM BLOOD Calcium-7.5* Phos-2.7 Mg-1.5*
___ 02:05AM BLOOD VitB12-433
___ 02:12AM BLOOD Osmolal-290
___ 09:58PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 10:07PM BLOOD Glucose-128* Lactate-1.6 Na-141 K-3.0*
Cl-108 calHCO3-21
___ 09:58PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 09:58PM URINE RBC-1 WBC-0 Bacteri-NONE Yeast-NONE
Epi-<1
___ 02:11PM URINE Hours-RANDOM Creat-29 Na-182 K-18 Cl-189
___ 09:58PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
IMAGING:
___ CT/CTA Head/Neck
IMPRESSION:
1. Interval right craniectomy with removal of the most superior
and lateral aspects of the otherwise unchanged large right
intracerebral hematoma.
2. Stable diffuse right hemispheric sulcal effacement and
grossly
unchanged 5 mm right-to-left shift of midline structures, and
mild compression of the right lateral ventricle. Patent basal
cisterns.
3. No new foci of hemorrhage. No evidence of new large vascular
territorial infarct.
___ CT Head
Stable appearance status post right craniectomy. Moderate right
frontoparietal IPH exerting an unchanged degree of local mass
effect with some evolution of blood products. No evidence of new
hemorrhage.
___ CT Head/C Spine
Status post right craniectomy with unchanged right
frontoparietal
intraparenchymal hemorrhage. Stable 5 mm of midline shift. No
new
intracranial hemorrhage. No acute fracture or traumatic
malalignment
___ CT Sinus/Mandible/Maxillofacial
1. No evidence for a fracture or a focal lesion in the mandible.
Unremarkable appearance of bilateral temporomandibular joints
in closed mouth position.
2. Bilateral maxillary and mandibular dental caries. Multiple
periapical
lucencies in the maxilla bilaterally and a periapical lucency in
the left
mandible, which may be associated with active or prior
infections.
3. Fluid and aerosolized secretions in the paranasal sinuses,
new compared to ___, likely related to prolonged
supine positioning in the inpatient setting.
Brief Hospital Course:
Mr. ___ is a ___ with PMHx of depression for which he
sought medical attention in his early ___, two recent episodes
of paranoia and confusion lasting a day resolving with sleep
___, no medical care sought), and heavy alcohol use
___ pint vodka daily) and tobacco use ___ ppd since ___ who
was flown into ___ after being found to have a large right
intraparenchymal hemorrhage at ___. On
arrival, he was evaluated by neurosurgery who recommended
Mannitol 25mg IV, Keppra 1g, strict SBP < 140, and a CTA head to
eval for underlying vascular malformation which showed no
evidence of vascular abnormality. After several hours, his left
eye became less reactive. He was taken emergently to the OR for
right hemicraniectomy and hematoma evacuation ___. He
tolerated the surgery well and returned to the ICU in stable
condition. He was transferred to the neurology service ___ for
long term care of patient with large right intraparenchymal
hemorrhage s/p hemicraniectomy/hematoma evacuation. He was
treated with a seven day course of keppra and never had any
observed seizure activity. His blood pressure was managed with a
nicardipine gtt which was eventually transitioned to PO BP meds
(lisinopril + labetalol). The po BP meds were stopped when the
patient became overcontrolled, likely due to reduced vascular
tone from prolonged bedbound state. He should sit up during the
day to promote normal vascular tone. BP meds should be started
as an outpatient, if necessary. He had episodic agitation which
was controlled with standing seroquel with prn zydis as needed
for agitation. By ___, he was conversant and able to follow
commands.
He had some difficulty opening his jaw and has longstanding poor
dentition. He was evaluated by the Dental Consult Service, who
recommended tooth extraction. OMFS extracted one tooth and
recommend that the patient follow up at ___ as an outpatient for
additional teeth to be extracted. CT Sinus/Maxillofacial does
not show abscess. Heme/Onc commented on the patient's
persistently elevated WBC and platelet counts as demargination,
reactive thrombocytosis, and possibly excess marrow production
after prolonged suppression from chronic alcohol use.
Currently stable with improved neurologic function.
Neuro:
-Intraparenchymal hemorrhage s/p hemicraniectomy/hematoma
evacuation ___, staples removed ___
- avoid anticoagulants, NSAIDs, or anything else which may
increase bleeding risk
- will return to ___ to have bone replaced over craniectomy
site
CV:
- BP controlled without meds
- needs to sit upright during the day to promote normal vascular
tone
- BP should be monitored as an outpatient, and meds started if
indicated
Teeth:
Patient with longstanding poor dentition, and difficulty opening
jaw
- consulted Dental - needs several teeth extracted
- CT Sinus/Maxillofacial views show caries, no abscess
- OMFS extracted one tooth on ___, will do others as outpatient
at ___
Psych:
- prior episodes of agitation including jerky head movements -
resolved
ABD/GI:
- ground solids, thin liquids
HEME:
- H/H stable, no indication of bleeding
- WBC and platelets elevated, possibly due to reactive
thrombocytosis and demargination during acute illness, as well
as a component of reactive process after longstanding marrow
suppression from chronic alcohol use. Normalized during
admission. Should have CBC rechecked ___ months after discharge;
if elevated, will need referral to ___ at that
time.
Transitional issues:
- should return to ___ to have bone replaced over craniotomy
site, ___ weeks post op from ___.
- should wear helmet when out of bed
- needs a PCP in ___ area to monitor BP and start meds if
necessary
- CBC check ___ months after discharge, with referral to Heme if
WBC and platelets elevated
- follow up in Stroke Clinic
- needs to keep health insurance current
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes [performed
and documented by admitting resident] () No
2. DVT Prophylaxis administered by the end of hospital day 2?
(x) Yes - () No
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
4. Stroke education given (written form in the discharge
worksheet)? (x) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
5. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No [if no, reason not assessed: ____ ]
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. Cyanocobalamin Dose is Unknown PO DAILY
Discharge Medications:
1. Multivitamins 1 TAB PO DAILY
2. Cyanocobalamin 0 mcg PO DAILY
3. Acetaminophen 650 mg PO Q6H:PRN pain or fever
4. Thiamine 100 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Bisacodyl 10 mg PO/PR DAILY
7. Docusate Sodium (Liquid) 100 mg PO BID
8. Senna 8.6 mg PO BID constipation
9. Simethicone 40-80 mg PO QID:PRN bloating
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right intraparenchymal hemorrhage s/p right hemicraniectomy and
hematoma evacuation
Dental caries
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 with symptoms of headache and confusion, and
were found to have a large right sided brain bleed, which
required sugery to prevent swelling and compression of your
brain. The damage to your brain has resulted in significant left
sided weakness, sensory changes, and impaired attention to the
left side.
You were also found to have several dental cavities, which were
treated by tooth extraction. You should follow up at ___ as an
outpatient to have additional teeth extracted.
You are discharged to rehab.
You will have follow up with Neurology and Neurosurgery.
Craniotomy for Hemorrhage
¨ Have a friend/family member check your incision daily for
signs of infection.
¨ Exercise should be limited to walking; no lifting,
straining, or excessive bending.
¨ Increase your intake of fluids and fiber. Continue to take
stool softeners to prevent constipation.
¨ Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
¨ Make sure to continue to use your incentive spirometer
while at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
¨ New onset of tremors or seizures.
¨ Any confusion or change in mental status.
¨ Any numbness, tingling, weakness in your extremities.
¨ Pain or headache that is continually increasing, or not
relieved by pain medication.
¨ Any signs of infection at the wound site: redness,
swelling, tenderness, or drainage.
¨ Fever greater than or equal to 101.5° F.
It was a pleasure caring for you during this admission.
Followup Instructions:
___
|
10259430-DS-10 | 10,259,430 | 29,733,460 | DS | 10 | 2147-05-15 00:00:00 | 2147-05-17 14:17:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tetracycline Analogues / Penicillins / E-Mycin / Amoxicillin
Attending: ___
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with Etoh cirrhosis, CAD, CVA, COPD, Fibromyalgia,
Pancreatitis, who presented to liver clinic with complaints of
malaise, worsening abdominal pain now admitted for
ileus/constipation.
Pt states that she has had abd pain since her last admission 3
weeks ago. She describes it as a diffuse crampy pain that is
worse when she sits up and wonders if it is related to a hernia.
The pain has become worse in the last 2 days corresponding to
not
having a BM. She is passing gas but has associated nausea.
Denies
f/c, dyspnea, vomiting, hematochezia, melena.
She presented to liver clinic yesterday with these complaints.
KUB and abdominal ultrasound were obtained. US negative for
ascites but KUG significant for dilated loops of bowel
concerning
for ileus. Pt was therefore referred to ED for further work-up.
In the ED...
- Initial vitals: 97.7 104 ___ 100% RA
- Exam notable for: N/A
- Labs notable for:
CBC: WBC 7.2, Hgb 10.0, Plt 210
Chem7: WNL, Cr 0.6
LFTs: ALT 32, AST 64, AP 192, TB 3.2
Coags: INR 1.7
- Imaging notable for:
US Abd:
Trace ascites present in the abdominal midline without an
appropriate target for a paracentesis.
CT A/P w/ PO and IV contrast:
1. No acute intra-abdominal or pelvic abnormality identified,
specifically no findings of bowel obstruction.
2. Severe stool burden throughout the colon and rectum which
likely clinically represents constipation.
3. Cirrhotic liver with trace abdominal ascites and multiple
upper abdominal and mesenteric varices. No focal hepatic lesions
identified. Patent portal vein.
- Consults:
Liver:
-Admit to ET
-NPO for bowel rest
-agreed with CT abdomen pelvis with oral and IV contrast
requested by outpt hepatologist attending to rule out possible
causes of mechanical ileus or ___ ileus etc
-IVF as needed
-med rec, confirm she is not taking anything else that my have
led to medication induced ileus
-trend LFTs, INR
-monitor for signs of HE, although at present she is AAOx3, if
concerns may use PR lactulose
-consider surgery c/s if CT abdomen concerning
- Patient was given:
___ 20:36 IV Ondansetron 4 mg
___ 21:35 IV Albumin 5% (12.5g / 250mL) 12.5 g
___ 00:11 IV Albumin 5% (12.5g / 250mL) 12.5 g
On the floor, she endorses the history above.
REVIEW OF SYSTEMS: Positive per HPI, remaining 10 point ROS
reviewed and negative.
Past Medical History:
EtOH Cirrhosis
s/p Laparoscopic cholecystectomy ___
Fibromyalgia
COPD (chronic obstructive pulmonary disease) (HCC)
Cervical dysplasia
Tobacco dependence
Drug abuse, episodic use
HCV (hepatitis C virus)
Allergic rhinitis
Vitamin D deficiency
EtOH dependence
GERD (gastroesophageal reflux disease)
Generalized anxiety disorder
Migraine headache
CAD (coronary artery disease), possible.
Macrocytic anemia
Domestic violence
Lung nodule
Hypopotassemia
Alcohol withdrawal seizure (HCC)
Hypomagnesemia
Hyponatremia
Social History:
___
Family History:
Per scanned document in ___:
Father deceased with heart disease
Mother with HTN
Brother, Sister, 2 sons healthy
1 son died due to overdose
2 daughters with arthritis
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 97.3 ___ 16 100 Ra
GENERAL: chronically ill appearing, in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
ABDOMEN: mildly distended, soft, moderately tender in
epigastrium, Rt side, large ventral hernia, no rebound/guarding
EXTREMITIES: no cyanosis, clubbing, or edema
NEURO: A&Ox3, DOWB WNL, +asterixis, moving all 4 extremities
with
purpose
SKIN: WWP, no excoriations or lesions, no rashes
DISCHARGE PHYSICAL EXAMINATION:
VS: ___ 0739 Temp: 97.9 PO BP: 95/64 R Lying HR: 110 RR: 18
O2 sat: 96% O2 delivery: Ra
GENERAL: chronically ill appearing, in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
ABDOMEN: mildly distended, soft, moderately tender in
epigastrium, Rt side, large reproducible ventral hernia, no
rebound/guarding
EXTREMITIES: no cyanosis, clubbing, or edema
NEURO: A&Ox3, DOWB WNL, +asterixis, moving all 4 extremities
with
purpose. Mild, intermittent R-sided facial droop, appears
fatigable on exam. Tongue midline, no focal neurologic
deficits. Mild R-sided nsytagmus.
SKIN: WWP, no excoriations or lesions, no rashes
Pertinent Results:
Admission Labs:
___ 03:50PM BLOOD WBC-7.2 RBC-3.12* Hgb-10.3* Hct-30.2*
MCV-97 MCH-33.0* MCHC-34.1 RDW-17.7* RDWSD-62.3* Plt ___
___ 03:50PM BLOOD Neuts-42.4 ___ Monos-12.2 Eos-2.8
Baso-0.8 Im ___ AbsNeut-3.04 AbsLymp-2.98 AbsMono-0.88*
AbsEos-0.20 AbsBaso-0.06
___ 03:50PM BLOOD ___ PTT-37.8* ___
___ 03:50PM BLOOD UreaN-9 Creat-0.6 Na-135 K-4.3 Cl-99
HCO3-22 AnGap-14
___ 03:50PM BLOOD ALT-32 AST-64* AlkPhos-192* TotBili-3.2*
___ 03:50PM BLOOD Lipase-33
___ 03:50PM BLOOD Albumin-3.1* Calcium-9.3 Phos-4.5 Mg-1.7
___ 03:50PM BLOOD TSH-2.6
___ 07:55PM BLOOD Lactate-1.8 Na-133 K-5.3*
Interval Labs:
___ 05:52AM BLOOD HAV Ab-POS*
___ 01:10PM BLOOD CK-MB-<1 cTropnT-<0.01
___ 03:50PM BLOOD Lipase-33
___ 06:15AM BLOOD Lipase-35
Imaging:
___ Imaging US ABD LIMIT, SINGLE OR
Trace ascites present in the abdominal midline without an
appropriate target for a paracentesis.
___ Imaging CHEST (PA & LAT)
Still seen is mild vascular congestion with no overt pulmonary
edema,
unchanged since prior study of ___.
___ Imaging ABDOMEN (SUPINE & ERECT)
1. Multiple loops of mildly dilated small bowel, concerning for
ileus.
2. Significant stool burden within the large bowel, suggestive
of
constipation.
___BD & PELVIS WITH CO
1. No acute abdominopelvic abnormality identified.
2. Severe stool burden throughout the colon and rectum which
likely clinically
represents constipation.
3. Cirrhotic liver with trace abdominal ascites and multiple
upper abdominal
and mesenteric varices. Patent portal vein.
Discharge Labs:
___ 07:34AM BLOOD WBC-6.4 RBC-2.91* Hgb-9.6* Hct-27.6*
MCV-95 MCH-33.0* MCHC-34.8 RDW-17.4* RDWSD-59.9* Plt ___
___ 07:34AM BLOOD ___ PTT-43.0* ___
___ 07:34AM BLOOD Glucose-108* UreaN-5* Creat-0.6 Na-135
K-4.7 Cl-102 HCO3-23 AnGap-10
___ 07:34AM BLOOD ALT-34 AST-69* LD(LDH)-196 AlkPhos-150*
TotBili-2.9*
___ 07:34AM BLOOD Albumin-2.9* Calcium-9.3 Phos-3.6 Mg-1.6
Brief Hospital Course:
Ms. ___ is a ___ with EtOH cirrhosis, CAD, COPD, Fibromyalgia,
and
Pancreatitis, who presented to liver clinic with complaints of
malaise and worsening abdominal pain, who was admitted for
concern for ileus and constipation.
# Abd Pain
# Constipation
Appears to be acutely worsened by her recent increased diuretic
doses, compounded by her chronic IBS/constipation. Her abdominal
pain may be in part due to her ventral hernia, vs underlying
liver disease. CT A/P w/ contrast and labs without other
explanation (no ileus or obstruction), lipase wnl. Pt responded
well to suppository and PO laxatives. She should get an EGD as
an outpatent evaluate for gastritis/PUD, given her epigastric
complaints. She was started on an increased dose of omeprazole
for possible gastritis, and also prescribed simethicone for gas.
# EtOH Cirrhosis:
# Hepatic encephalopathy
Hx of EtOH cirrhosis, ___ C, c/b portal hypertension
with
past hx of decompensation by HE, recurrent ascites. Admission
MELD-Na 20 from recent ___. Was encephalopathic on admission,
likely because she had not taken lactulose the day prior, and
had not had a bowel movement in 2 days. Last drink several
months ago per her report. The patient asterixis on exam.
Continued home rifaxamin and
lactulose. The patient has an unknown variceal status, so she
should get an EGD after discharge to evaluate for gastritis and
varices. For her ascites, her Lasix and spironolactone doses
were decreased on admission, as it was felt that her high doses
may have been contributing to her constipation. She was
discharged on a slightly lower Lasix dose, but on her home
spironolactone dose. There was no tappable pocket of ascitic
fluid, so the patient did not have a paracentesis.
#ETOH use disorder:
History of ETOH, reports not drinking since she was hospitalized
several months ago. Has been living with her aunt. ___ AST
with 2:1 ratio suggests some residual inflammation and possible
relapse. Urine tox was negative. Social Work evaluated the
patient while she was admitted. Pt was continued on thiamine,
MVI, and folate.
CHRONIC ISSUES:
===============
#CAD c/b MI: Discussed history with PCP. Pt has missed many
outpatient cardiology appointments, with plans to resume care
soon. She does have good ___ with her PCP. She is not
currently in ASA or statin, which her PCP is considering
resuming (was stopped recently by an OSH during a recent ED
visit, for unclear reasons). Did not resume this admission -
will defer this to outpatient setting.
#Stroke: Pt reports history of stroke ___ years ago, no obvious
residual deficit, and per PCP she has no documented history. She
has no neurological deficits noted on her admission.
#GERD: Continue home omeprazole, increased dose to 40mg BID.
#Hepatitis B/Hepatitis C
Patient was hepatitis B core Ab positive and surface antigen
negative consistent with cleared infection. Also with HCV Ab
positive with undetectable viral load.
TRANSITIONAL ISSUES
===================
#EtOH Cirrhosis
[] Variceal screening: pt should have EGD for variceal
screening; will arrange ___ with Dr. ___. Liver clinic
will contact patient to set-up an appointment in ___
for EGD
#Constipation
[]Pt discharged on significant bowel regimen, including MiraLax,
lactulose, and PRN bisacodyl suppositories. Please f/u to assess
resolution of her constipation.
#EtOH Abuse
[]Pt will benefit from close PCP ___, to encourage
continued sobriety.
CORE MEASURES:
# CODE: Presumed FULL
# CONTACT/HCP: ___- ___ (aunt)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheezing
2. Magnesium Oxide 400 mg PO BID
3. Omeprazole 40 mg PO DAILY
4. Spironolactone 100 mg PO DAILY
5. Ondansetron 4 mg PO Q8H:PRN nausea
6. Thiamine 100 mg PO DAILY
7. Multivitamins W/minerals 1 TAB PO DAILY
8. Rifaximin 550 mg PO BID
9. Lactulose 20 mL PO QID
10. HydrOXYzine 25 mg PO Q6H:PRN anxiety/insomnia
11. Furosemide 60 mg PO DAILY
12. Midodrine 5 mg PO TID
13. Sumatriptan Succinate 50 mg PO DAILY:PRN Headaches/migraines
14. Potassium Chloride 40 mEq PO DAILY
Discharge Medications:
1. Bisacodyl ___AILY:PRN Constipation - Second Line
RX *bisacodyl 10 mg 1 suppository(s) rectally daily Disp #*30
Suppository Refills:*0
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Polyethylene Glycol 17 g PO BID
RX *polyethylene glycol 3350 [ClearLax] 17 gram 1 powder(s) by
mouth twice a day Disp #*60 Packet Refills:*0
4. Simethicone 40-80 mg PO QID:PRN gas pain
RX *simethicone 80 mg 0.5 to 1 tablet by mouth every 6 hours
Disp #*60 Tablet Refills:*0
5. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
7. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheezing
8. HydrOXYzine 25 mg PO Q6H:PRN anxiety/insomnia
9. Lactulose 20 mL PO QID
RX *lactulose 20 gram/30 mL 30 mL by mouth four times a day Disp
#*1 Bottle Refills:*0
10. Magnesium Oxide 400 mg PO BID
11. Multivitamins W/minerals 1 TAB PO DAILY
12. Ondansetron 4 mg PO Q8H:PRN nausea
13. Rifaximin 550 mg PO BID
14. Spironolactone 100 mg PO DAILY
RX *spironolactone [Aldactone] 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
15. Thiamine 100 mg PO DAILY
16. HELD- Midodrine 5 mg PO TID This medication was held. Do
not restart Midodrine until you are told by one of your doctors
17. HELD- Potassium Chloride 40 mEq PO DAILY This medication
was held. Do not restart Potassium Chloride until you see your
PCP
___:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Acute on chronic constipation
EtOH Cirrhosis
Secondary Diagnosis
===================
CAD
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because you had severe
abdominal pain.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- We got imaging of your abdomen, which showed that you do not
have any obstruction, and instead just had a large amount of
stool, likely from your chronic constipation and your diuretic
doses.
- We gave you laxatives and suppositories, and you had bowel
movements afterward.
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Keep your follow up appointments with your doctors
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight changes by more
than 3 pounds
- Please stick to a low salt diet and monitor your fluid intake
- If you experience any of the danger signs listed below please
call your primary care doctor or come to the emergency
department immediately.
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team
Followup Instructions:
___
|
10259430-DS-9 | 10,259,430 | 26,788,880 | DS | 9 | 2147-04-18 00:00:00 | 2147-04-19 21:53:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tetracycline Analogues / Penicillins / ___ / Amoxicillin
Attending: ___
Chief Complaint:
Jaundice
Major Surgical or Invasive Procedure:
Large volume paracentesis ___
History of Present Illness:
This is a ___ with cirrhosis, recently admitted to ___ and discharged to a rehab facility, who is referred for
admission to the ET service for acute decompensated cirrhosis.
She arrived for outpatient follow up in ___ clinic today
and was found to have mild hepatic encephalopathy, jaundice, ___
pitting edema, and abdominal distention. She was unable to
provide much history at that visit. She was referred to the ED
for evaluation and admission.
She says that she thinks she was going to get admitted today
because her ankles were swelling and her belly was getting
bigger. She says her thinking isn't clear and she often forgets
what she is saying. She cannot provide an accurate recount of
her
medications. She thinks she may have been in the rehab facility
for several weeks. She reports her last drink was several months
ago. She isn't sure but thinks she may have had a fever but
doesn't know when. She denies melena, hematichezia, hematemesis.
She is unable to provide further history due to low medical
literacy and inattention. She does say that she has had two
heart
attacks and a stroke in the past. She doesn't think she has had
stents.
Past Medical History:
- Cirrhosis
- previous EtOH use disorder
- s/p Laparoscopic cholecystectomy ___
====PMH per CHA records:
Fibromyalgia
COPD (chronic obstructive pulmonary disease) (HCC)
Cervical dysplasia
Tobacco dependence
Drug abuse, episodic use
HCV (hepatitis C virus)
Allergic rhinitis
Vitamin D deficiency
EtOH dependence (HCC)
GERD (gastroesophageal reflux disease)
Generalized anxiety disorder
Migraine headache
CAD (coronary artery disease), possible.
Macrocytic anemia
Domestic violence
Lung nodule
Hypopotassemia
Alcohol withdrawal seizure (HCC)
Hypomagnesemia
Alcoholic cirrhosis of liver with ascites (HCC)
Hyponatremia
Social History:
___
Family History:
Per scanned document in ___:
Father deceased with heart disease
Mother with HTN
Brother, Sister, 2 sons healthy
1 son died due to overdose
2 daughters with arthritis
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS:98.0 BP92/59 HR 86 20 93 Ra
GENERAL: inattentive, jaundiced, chronically ill appearing,
frequently blinking as if surprised the examiner is still
talking
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, ___ SEM LUSB
LUNGS: crackles to the ___ fields bilaterally
ABDOMEN: grossly distended, + fluid wave, palpable splemomegaly,
mild TTP over spleen
EXTREMITIES: 2+ pitting edema to knees ___
NEURO: oriented x3, alert but inattentive. Moving face and limbs
symmetrically.
SKIN: ___, reddish purple, annular lesions over L
medial malleolus and lateral malleolus, as well as over R medial
malleolus.
DISCHARGE PHYSICAL EXAM:
VS: 24 HR Data (last updated ___ @ 901)
Temp: 97.8 (Tm 98.4), BP: 110/73 (___), HR: 114
(___), RR: 18, O2 sat: 92% (___), O2 delivery: RA
GEN: NAD, AOx3, jaundiced
HEENT: NCAT, MMM, sceral icterus
NECK: No JVD
CV: RR, S1+S2, NMRG
RESP: CTABL, no w/r/r
ABD: Distended, soft, caput medusa, fluid wave+, BS+
GU: Deferred
EXT: WWP, trace lower extremity edema b/l
NEURO: CN ___ grossly intact, MAE, mild asterixis
SKIN: petechial rash noted, most prominently, on R foot/heel.
Also small collections petechiae on b/l forearms, L foot.
Pertinent Results:
___ LABS:
___ 09:00PM BLOOD ___
___ Plt ___
___ 09:00PM BLOOD ___
___ Im ___
___
___ 09:00PM BLOOD ___ ___
___ 09:00PM BLOOD ___
___
___ 09:00PM BLOOD ___
___ 09:00PM BLOOD cTropnT-<0.01
___ 09:00PM BLOOD ___
___ 09:32PM BLOOD Ammonia-<10
___ 09:51PM BLOOD ___
PERTINENT INTERMITTENT LABS:
___ 06:32AM BLOOD ___
___ 06:32AM BLOOD ___
___ 06:32AM BLOOD ___
___ 06:32AM BLOOD ___
___ 06:32AM BLOOD HCV ___
___ 06:32AM BLOOD HCV ___ DETECT
___ 06:44AM BLOOD ___
___ Base XS--1 ___ TOP
___ 06:44AM BLOOD ___
IMAGING:
___ 11:25 ___ ___ CHEST (PA & LAT):
Mild pulmonary vascular congestion without frank pulmonary
edema. Bilateral
pleural effusions, left greater than right. No focal
consolidation.
___ 10:54 ___ ___ LIVER OR GALLBLADDER US:
1. Patent hepatic vasculature with slow velocity and
2. Reversal of the flow in the portal venous system.
3. Cirrhotic morphology of the liver without focal lesions.
Moderate volume
ascites, most notable in the left lower quadrant. Mild
splenomegaly,
measuring 13.0 cm.
4. Small to moderate bilateral pleural effusions.
MICROBIOLOGY:
___ ___ {ESCHERICHIA
COLI}:
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
MEROPENEM , Piperacillin/Tazobactam test result
performed by ___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM------------- S
NITROFURANTOIN-------- 32 S
PIPERACILLIN/TAZO----- R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ FLUID RECEIVED IN BLOOD CULTURE
BOTTLES: NO GROWTH
___ CULTURE: NGTD
___ CULTURE: NGTD
DISCHARGE LABS:
___ 07:35AM BLOOD ___
___ Plt ___
___ 07:35AM BLOOD ___ ___
___ 07:35AM BLOOD ___
___
___ 07:35AM BLOOD ___
___ 07:35AM BLOOD ___
___
Brief Hospital Course:
___ with PMHx EtOh Cirrhosis, MI, CVA, COPD, Fibromyalgia,
Pancreatitis, presented to ___ clinic with decompensated
ETOH cirrhosis with mild hepatic encephalopathy and was referred
for admission.
ACUTE ISSUES:
=============
#ACUTE DECOMPENSATION OF ETOH CIRRHOSIS
#ASCITES
#HEPATIC ENCEPHALOPATHY
MELD Na is 23, Child class C on admission. Cirrhosis thought to
be due to EtOH. Decompensated by ascites and hepatic
encephalopathy. Patient found to have UTI, which could be
triggering decompensation. Per discussion with patient's family,
she was compliant with home medications. Has been getting
monthly therapeutic paracentesis at outside hospital. Underwent
RUQ US with no evidence portal vein thrombus. Diagnostic
paracentesis with no SBP. Underwent therapeutic paracentesis
with 4L removed. Referral was made for therapeutic paracentesis
at ___ which is near her home. The etiology of her
volume overload was initially unclear, so a TTE was done on day
of admission which was unremarkable, EF: 80%. Her diuretics were
uptitrated to Lasix 40mg daily and Spironolactone 100mg daily.
She met with nutrition and was given information on low sodium
diet. For hepatic encephalopathy she was given Rifaxamin 550mg
BID and Lactulose QID. She needs prior authorization for
Rifaxamin, the process has been initiated. Her insurance will
cover short term supply until prior authorization goes through.
#E. Coli UTI:
Patient initially c/o dysuria, frequency, suprapubic pain. Urine
culture with E. Coli. Treated with Ceftriaxone 1g x 3 days
(___). Susceptibilities returned showing resistance to CTX,
Cipro. Patient started on Bactrim DS for ___.
# Coagulopathy, without current bleeding
Suspect due to liver disease, although pt with seemingly poor
PO. Nutrition was consulted. Monitor INR and platelets.
#Hepatitis B/Hepatitis C
Patient was hepatitis B core Ab positive and surface antigen
negative consistent with cleared infection. Also with HCV Ab
positive with undetectable viral load. Please continue to
monitor.
CHRONIC ISSUES:
===============
#ETOH use disorder:
Patient with history of ETOH, reports not drinking since ___
when she was hospitalized. Has been living with her aunt. She
met with social work and was given information on relapse
prevention.
#CAD
Pt with apparent CAD c/b MI. Prior h/o CVA. ASA appears to have
been stopped on most recent admission to ___. Will
continue to hold, can follow up with PCP to discuss restarting.
# Stroke
Pt reports history of stroke ___ years ago, but can provide
minimal information beyond this. Unclear if hemorrhagic vs
ischemic. Can consider restarting statin as an outpatient if
LFTs remain stable.
#HTN
Holding home metoprolol succinate XL 25mg given soft pressures
# CONTACT: ___ (aunt)
# CODE: Presumed FULL
TRANSITIONAL ISSUES:
====================
[ ] Patient will require outpatient therapeutic paracentesis.
Standing order sent to ___ per patient request.
Please call ___ Interventional Radiology Department
at ___ to schedule appointment or if issues with
order.
[ ] Increased Lasix to 40mg daily and Spironolactone to 100mg
daily.
[ ] Please check electrolytes in 1 week.
[ ] Please discuss restarting ASA, statin and beta blocker with
primary care physician. BPs soft during admission, could not
tolerate home metoprolol.
[ ] Patient requires prior authorization for Rifaxamin, we have
initiated the process for approval.
[ ] Please continue to discuss low Na diet with patient.
[ ] Please continue to encourage adherence to relapse prevention
program for ETOH use disorder.
[ ] Patient with urinary tract infection, ensure patient
completes Bactrim x 7 days (___)
[] Consider outpatient EGD to evaluate for esophageal varices.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 4 mg PO Q8H:PRN nausea
2. Furosemide 40 mg PO EVERY OTHER DAY
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheezing
4. Spironolactone 50 mg PO DAILY
5. Sodium Chloride 0.5 gm PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Magnesium Oxide 400 mg PO BID
8. ___ M20 (potassium chloride) 40 mg oral EVERY OTHER DAY
9. HydrOXYzine 25 mg PO Q6H:PRN anxiety/insomnia
10. Thiamine 100 mg PO DAILY
11. Omeprazole 40 mg PO DAILY
12. Lactulose 15 mL PO QID
Discharge Medications:
1. Multivitamins W/minerals 1 TAB PO DAILY
RX ___ 1 capsule(s) by mouth daily Disp
#*30 Capsule Refills:*0
2. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth Twice daily
Disp #*60 Tablet Refills:*0
3. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX ___ 800 ___ mg 1 tablet(s) by
mouth twice a day Disp #*10 Tablet Refills:*0
4. Furosemide 40 mg PO DAILY
5. Spironolactone 100 mg PO DAILY
RX *spironolactone 100 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
6. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheezing
7. HydrOXYzine 25 mg PO Q6H:PRN anxiety/insomnia
8. Lactulose 15 mL PO QID
9. Magnesium Oxide 400 mg PO BID
10. Omeprazole 40 mg PO DAILY
11. Ondansetron 4 mg PO Q8H:PRN nausea
12. Thiamine 100 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Primary diagnosis: Alcoholic cirrhosis
Secondary diagnosis: Urinary tract infection, ascites, hepatic
encephalopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came to ___ because you had abdominal distension and you
were confused.
What we did while you were here?
- We removed fluid from your belly
- We increased your dose of diuretics
- We treated you for a urinary tract infection.
- We increased the medication called lactulose which helps
improve your confusion. We started a new medication called
Rifaxamin.
What you should do when you go home?
- Be sure to finish your Bactrim DS
(sulfamethoxazole/trimethoprim)for your urinary tract infection.
- Please follow up with your primary care physician
- ___ follow up with your liver doctor
- Please take all your medications as prescribed.
We wish you the best,
Your ___ Team
Followup Instructions:
___
|
10259667-DS-17 | 10,259,667 | 24,050,703 | DS | 17 | 2173-01-19 00:00:00 | 2173-01-19 14:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Non healing right foot wound
Major Surgical or Invasive Procedure:
___:
Balloon angioplasty of proximal and distal anastamosis and mid
graft of the right superior femoral artery to peroneal artery
bypass graft. Native peroneal artery angioplasty.
History of Present Illness:
Mr ___ has known vascular disease and a non healing ulcer of
his lateral R foot for the past 6 months. He is followed
locally by his podiatrist, a Dr. ___, as well as Dr.
___. His most recent graft surveillance demonstrated
50-99% stenosis at both the proximal and distal anastomoses of
his vein graft, and he was scheduled for a RLE angiogram in ___.
Over the past week, the right foot has become more red and
swollen, and he has had more tenderness of the forefoot for the
past 2 days so he was admitted electively for angiogram and a
possible catheter based intervention.
Past Medical History:
Coronary artery disease, s/p DES to LAD ___
Hypertension
Hyperlipidemia
Severe PVD
Carotid Disease, no history of stroke
Insulin-dependent diabetes (on insulin pump)
Alcohol dependence - quit ___
OSA with BIPAP at night
Depression
Retinopathy
Severe Autonomic Neuropathy with orthostatic hypotension
Left ___ and ___ toe fractures
Abdominal Hernia
Past Surgical History:
- Right TKR ___ at ___ ___)
- Right superficial femoral-to-posterior tibial artery BPG ___
- Amputations of right great toe ___ c/b gangrene/osteomyelitis
- Amputation of distal right thumb ___
- Left carpal tunnel surgery
- Right trigger finger release
- Tonsillectomy
Social History:
Race:Caucasian
Lives with: Wife and daughter
___: ___
Tobacco: Denies
ETOH: Hx of heavy ETOH use (6pack beer+ daily) - quit ___
Physical Exam:
Physical Exam:
Alert and oriented x 3
VS:BP133/69 HR 76
Resp: Lungs clear
Abd: Soft, non tender
Ext: Pulses: Left Femoral palp, DP dop ,___ dop
Right Femoral palp, DP dop ,___ dop
Graft is dopplerable.
Feet warm, well perfused. Wounds 1x2 cm shallow clean vascular
appearing ulcer at lateral base of R ___ toe. No surrounding
erythema and mild tenderness but no fluctuance.
Left groin puncture site: Dressing clean dry and intact. Soft,
no hematoma but surrounding ecchymosis.
Pertinent Results:
___ 07:08AM BLOOD WBC-4.7 RBC-3.88* Hgb-11.6* Hct-35.6*
MCV-92 MCH-29.9 MCHC-32.6 RDW-13.1 Plt ___
___ 12:20AM BLOOD Neuts-54.2 ___ Monos-8.6 Eos-4.6*
Baso-1.2
___ 07:08AM BLOOD Glucose-205* UreaN-6 Creat-0.7 Na-136
K-3.5 Cl-100 HCO3-27 AnGap-13
___ 07:08AM BLOOD Calcium-8.5 Phos-2.7 Mg-1.8
___ 12:20AM BLOOD %HbA1c-7.0* eAG-154*
Brief Hospital Course:
The patient was admitted to the hosptial and started on
vancomycin, flagyl and cipro for presumed right foot ulcer
infection. He was brought to the operating room on ___ and
underwent an angioplasty in the distal and proximal anastomosis
and mid graft of his superfical femoral artery to peroneal
bypass graft as well as the native peroneal artery. The
procedure was without complications. He was closely monitored
in the PACU and then transferred to the floor in stable
condition where remained hemodynamically stable. His diet was
gradually advanced. He is ambulatory ad lib. He was seen by
podiatry who debrided the wound with instructions to follow up
with his local podiatrist for wound care. He was discharged to
home on oral antibiotics on HD # 3 in stable condition.
Follow-up has been arranged with Dr. ___ in 4 weeks
with surveillance duplex.
Medications on Admission:
Losartan 25''
New Iron 150'
FLudorocortisone 0.05 QHS
Ambien ___ QHS
ASA 81'
Atenolol 25'
Clonidine 0.1 Patch Q7d
Gabapentin 200"
Lipitor 40 QHS
Insulin pump:
2400-0300: 0.55units/hr
0300-0830: 1.2 units/hr
0830-1600: 1.9 units/hr
1600-2100: 1.7 units/hr
___-2400: 0.9 units/hr
Wellbutrin 200 QAM
ZOloft 25 QAM
Xanax ___ QPM PRN insomnia
Discharge Medications:
1. fludrocortisone 0.1 mg Tablet Sig: 0.5 Tablet PO QHS (once a
day (at bedtime)).
2. sertraline 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
4. bupropion HCl 100 mg Tablet Extended Release Sig: Two (2)
Tablet Extended Release PO QAM (once a day (in the morning)).
5. clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTUES (every ___.
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*1 Tablet(s)* Refills:*0*
8. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours).
Disp:*14 Tablet(s)* Refills:*0*
9. insulin pump (self managed)
10. atenolol 50 mg Tablet Sig: 0.5mg Tablet PO DAILY (Daily).
11. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. losartan 25 mg Tablet Sig: One (1) Tablet PO twice a day.
13. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Peripheral Arterial Disease
Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for a question of infection in
a non healing ulcer on your right foot. We did an angioplasty
to open blockages in your leg arteries. This will hopefully
improved the circulation to your foot which will help with
healing the wound.
You were started on 2 new medications:
1. plavix, after the angioplasty to improve blood flow and
prevent clots
2.augmentin for 7 days, for wound infection
Division of Vascular and Endovascular Surgery
Lower Extremity Angioplasty/Stent Discharge Instructions
Medications:
Take Aspirin 325mg (enteric coated) once daily
Take Plavix (Clopidogrel) 75mg once daily
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart (use ___
pillows or a recliner) every ___ hours throughout the day and at
night
Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
Drink plenty of fluids and eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
When you go home, you may walk and go up and down stairs
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
After 1 week, you may resume sexual activity
After 1 week, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking pain medications
Followup Instructions:
___
|
10259755-DS-7 | 10,259,755 | 20,554,996 | DS | 7 | 2184-08-18 00:00:00 | 2184-08-19 14:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
___
Attending: ___
Chief Complaint:
Supra-pubic, right lower quadrant abdominal pain
Major Surgical or Invasive Procedure:
___ ___ drainage of pelvic abscess
History of Present Illness:
Mrs. ___ is a ___ year old female with a history of RNY
gastric bypass ___ years ago and s/p lap appy for acute
appendicitis at ___ 9 days ago who presented to
an OSH earlier this evening with worsening suprapubic/RLQ pain.
She states that her RLQ pain never resolved completely after her
appendectomy. She reports that her appendix was not perforated.
At the OSH her WBC count was 24. A CT of the abdomen and pelvis
was obtained and showed a rim enhancing fluid collection in her
pelvis. She was given a dose of levoquin and flagyl and was
transfered to ___ for potential ___ guided
drainage of the collection. She does report anorexia and chills
as well as non-bloody diarrhea over the last 2 weeks. She denies
fevers, nausea, vomiting, chest pain or shortness of breath.
Past Medical History:
Past Medical History:
obesity
Past Surgical History:
lap appy ___ years ago
b/l carpal tunnel release
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission:
Vitals: 98.3 92 100/54 16 97 RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, TTP suprapubic, no rebound or guarding,
normoactive bowel sounds, no palpable masses, surgical incisions
well healed
Ext: No ___ edema, ___ warm and well perfused
On discharge:
VS: T98.8, 81, 94/56, 14, 97% on room air
Pertinent Results:
___ 07:20AM BLOOD WBC-19.7* RBC-4.36 Hgb-13.5 Hct-39.3
MCV-90 MCH-30.9 MCHC-34.2 RDW-13.0 Plt ___
___ 07:30AM BLOOD WBC-23.1* RBC-4.33 Hgb-13.2 Hct-39.0
MCV-90 MCH-30.4 MCHC-33.8 RDW-13.2 Plt ___
___ 01:24AM BLOOD WBC-24.5* RBC-4.20 Hgb-12.8 Hct-37.9
MCV-90 MCH-30.5 MCHC-33.8 RDW-13.1 Plt ___
___ 01:24AM BLOOD Neuts-77.0* Lymphs-17.9* Monos-4.1
Eos-0.5 Baso-0.4
___ 01:24AM BLOOD Neuts-77.0* Lymphs-17.9* Monos-4.1
Eos-0.5 Baso-0.4
___ 09:10AM BLOOD ___
___ 07:20AM BLOOD Glucose-86 UreaN-12 Creat-0.7 Na-136
K-4.4 Cl-99 HCO3-23 AnGap-18
___ 07:30AM BLOOD Glucose-70 UreaN-12 Creat-0.7 Na-138
K-4.5 Cl-100 HCO3-26 AnGap-17
___ 01:24AM BLOOD Glucose-72 UreaN-13 Creat-0.7 Na-139
K-4.3 Cl-101 HCO3-24 AnGap-18
___ 07:20AM BLOOD Calcium-9.2 Phos-3.9 Mg-2.1
___ 07:30AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.1
IMAGING:
CT A/P ___- rim enhancing pelvic fluid collection, no other
obvious intraabdominal fluid collections
Brief Hospital Course:
Mrs. ___ was admitted to the Acute Care Surgery service
on ___ for management of her pelvic abscess. She was kept NPO
and given IV fluids. She was started on IV Cipro and Flagyl.
On the same day of admission, she underwent a drain placement
via Interventional Radiology. During the procedure, 12mls of
purulent material was aspirated and sent for culture (results
pending). A catheter was placed for further drainage. Mrs.
___ tolerated the procedure well. She was transferred to
the inpatient ward for further management and observation.
On hospital day two, Mrs. ___ diet was advanced to
regular. She was started on an oral pain regimen, along with
oral antibiotics, which will continue for a 7-day course. A
follow-up appointment was established with the ACS service in
approximately one week. In the meantime, ___ will see the
patient once discharged for drain teaching and assessment.
At the time of discharge, Mrs. ___ was afebrile,
hemodynamically stable, and in no acute distress.
Medications on Admission:
MVI
B12
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*14 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 7 Days
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*21 Tablet Refills:*0
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
6. Senna 1 TAB PO BID:PRN constipation
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Pelvic abscess s/p ___ drainage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ on
___ with complaints of right lower quadrant pain. On further
evaluation, you were found to have a pelvic fluid
collection/abscess. You were initially given bowel rest
(nothing to eat) and IV fluids. You were started on IV
antibiotics. On ___, you underwent a drain placement in
radiology. The drain will stay in place until you follow up
with the ___ clinic (appointment noted below).
You should continue to take any medications you were taking
prior to this admission. You should continue to take all doses
of prescription antibiotics (approximately one week in
duration).
DRAIN CARE:
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:
___
|
10259898-DS-4 | 10,259,898 | 23,409,326 | DS | 4 | 2169-01-14 00:00:00 | 2169-01-14 19:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Chief Complaint: Resp failure
Reason for MICU: Resp failure
Major Surgical or Invasive Procedure:
Intubation (OSH)
R CVL (OSH)
Arterial line placement ___
History of Present Illness:
___ yo F with a history of congestive heart failure (EF 20%),
CAD, arrythmia (unclear what is underlying rhythm) s/p dual
chamber Bi-V pacer on sotalol, on warfarin, who presents with
acute onset dyspnea. Report is largely obtained through family
as patient is sedated and intubated.
Patient was in her usual state of health until this morning when
she woke up with dyspnea at rest. She went to her daughters
house at which time she spent ___ minutes breathing heavily
until her daughter called EMS. No vitals were obtained at the
time, but given that she was slumped over and minimally
responsive she was intubated in the field. Her daughter denies
any prodrome of fevers, chills, chest pain, back pain, nausea,
vomiting, diarrhea. She was initially taken to ___
___, at which time she was given 1L NS,
Ceftriaxone/Azithromycin, and transferred to ___.
Upon arrival to the ___ ED, patient was hypotensive to 70
systolic. An urgent RIJ was placed and the patient was started
on norepinephrine. A CVP was transduced which was 3mm Hg, so
patient received 250cc bolus x 2. Total IVF resuscitation was
2L. Patient was sedated with fentanyl and midazolam. A bedside
echo was performed which per the ED physician looked like global
hypokinesis. Peripheral venous O2 sat was 64%, WBC 13, Lactate
2.3. BNP was elevated at 4269, Troponin 0.03. EKG showed A
sensed, V paced at rate of 82. NO STE, STD, TWI.
Past Medical History:
1. sCHF EF 20% (___)
2. HTN
3. HLD
4. Gastritis
5. Osteoarthritis
6. Arrythmia: on sotalol, warfarin, has Bi-V dual chamber
pacemaker
Social History:
___
Family History:
No history of sudden cardiac death, myocardial infacrction.
Physical Exam:
ADMISSION PHYSICAL EXAM:
GENERAL: intubated, sedated
HEENT: ETT in place, NGT in place, difficult to appreciate JVD
LUNGS: Clear to auscultation, no wheezes, rales, rhonchi
CV: tachy, reg rhythm, normal S1 S2, no murmurs, rubs, gallops
ABD: soft, tympanic, mild distention, grimace with RUQ
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis, 1+
edema to mid shin
SKIN: no mottling, clean, dry
DISCHARGE PHYSICAL EXAM:
Vitals- T 98.3 BP 109/95 (90-110s) HR 90 (80-90s) RR 18 O2
100%1LNC.
I/O 180/350 since midnight; ___ yesterday
weight 61.6 <- 61.6 <- 60.8 <- 59.4
General- Alert, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP non elevated, no LAD
Lungs- clear without rales wheezes, rhonchi
CV- irregularly irregular rhythm, normal S1 + S2, no murmurs,
rubs, gallops, pain on palpation of chest
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION:
___ 07:05AM BLOOD WBC-13.0* RBC-4.55 Hgb-13.5 Hct-40.9
MCV-90 MCH-29.7 MCHC-33.1 RDW-14.4 Plt ___
___ 07:05AM BLOOD ___ PTT-35.7 ___
___ 07:05AM BLOOD UreaN-27* Creat-1.2*
___ 10:42AM BLOOD Glucose-154* UreaN-28* Creat-1.1 Na-139
K-4.7 Cl-107 HCO3-22 AnGap-15
___ 07:05AM BLOOD ALT-28 AST-85* LD(LDH)-729* AlkPhos-63
TotBili-0.4
___ 07:05AM BLOOD CK-MB-3 proBNP-4269*
___ 07:05AM BLOOD cTropnT-0.03*
___ 02:44PM BLOOD CK-MB-3 cTropnT-0.01
___ 10:42AM BLOOD Albumin-3.7 Calcium-8.5 Phos-4.8* Mg-2.1
___ 10:42AM BLOOD D-Dimer-4647*
___ 07:39AM BLOOD Type-ART pO2-113* pCO2-44 pH-7.29*
calTCO2-22 Base XS--4
___ 07:13AM BLOOD Glucose-201* Lactate-2.3* Na-139 K-4.9
Cl-107
DISCHARGE:
___ 08:10AM BLOOD WBC-7.7 RBC-3.70* Hgb-11.1* Hct-33.1*
MCV-89 MCH-29.8 MCHC-33.4 RDW-15.4 Plt ___
___ 08:10AM BLOOD ___ PTT-28.3 ___
___ 08:10AM BLOOD Glucose-118* UreaN-35* Creat-1.4* Na-138
K-4.3 Cl-100 HCO3-26 AnGap-16
___ 08:10AM BLOOD Calcium-8.9 Phos-4.0 Mg-2.4
PERTINENT LABS:
___ 07:05AM BLOOD ALT-28 AST-85* LD(___)-729* AlkPhos-63
TotBili-0.4
___ 10:42AM BLOOD ALT-20 AST-51* LD(LDH)-378* AlkPhos-60
TotBili-0.4
___ 03:06AM BLOOD ALT-17 AST-29 LD(___)-233 AlkPhos-52
TotBili-0.8
___ 07:05AM BLOOD CK-MB-3 proBNP-4269*
___ 07:05AM BLOOD cTropnT-0.03*
___ 02:44PM BLOOD CK-MB-3 cTropnT-0.01
___ 07:05AM BLOOD Lipase-67*
___ 10:42AM BLOOD D-Dimer-4647*
___ 05:23AM BLOOD TSH-1.3
___ 05:23AM BLOOD T4-6.3
___ 03:34AM BLOOD Lactate-1.5
STUDIES:
___ CXR:
As compared to the previous image, the patient has been
extubated and the
right internal jugular vein catheter and the nasogastric tube
were removed. There is no evidence of pneumothorax. Moderate
cardiomegaly with elongation of the descending aorta. Left
pectoral pacemaker is unchanged. A minimal right pleural
effusion and right basilar atelectasis have newly appeared.
___ Bilateral LENIS:
No evidence of deep venous thrombosis in the bilateral lower
extremity veins.
___ CXR:
1. Endotracheal tube terminating 3 cm above the carina in
appropriate
position.
2. Moderate cardiomegaly and pulmonary edema.
___ TTE:
The left atrium is markedly dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity is moderately dilated. There
is severe global left ventricular hypokinesis (LVEF = 20 %).
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] There
is significant pacing-induced dyssynchrony. The right
ventricular free wall thickness is normal. Right ventricular
chamber size is normal. with borderline normal free wall
function. The aortic root is mildly dilated at the sinus level.
The ascending aorta is mildly dilated. There are focal
calcifications in the aortic arch. 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. The mitral valve leaflets do not fully coapt.
An eccentric, posteriorly directed jet of Moderate to severe
(3+) mitral regurgitation is seen. Due to the eccentric nature
of the regurgitant jet, its severity may be significantly
underestimated (Coanda effect). Moderate [2+] tricuspid
regurgitation is seen. There is no pericardial effusion.
Brief Hospital Course:
Ms. ___ is an ___ w/ CHF (EF 20%), CAD, Afib on warfarin and
sotalol w/ dual-chamber BiV pacer and ICD admitted to the MICU,
intubated with respiratory failure and cardiogenic shock s/p 2L
diuresis and management of CHF.
#Respiratory failure: Most likely etiology was congestive heart
failure given her cardiomegaly on CXR, elevated BNP, history of
congestive heart failure, minimally elevated WBC and low venous
O2 sat. Has EF of 20% as of ___. Other consideration would be
pneumonia given opacifications on CXR and leukocytosis, however
there was no preceding cough, fevers. Given that patient is
from the community, was started on Ceftriaxone Azithromycin for
CAP coverage. Another consideration for acute respiratory
failure would be aspiration pneumonitis leading to ARDS, however
per report from family the patient has no history of aspiration.
Lastly, pulmonary embolus could cause acute dyspnea, however
would not cause the findings on CXR that are present. Would have
to consider acute ischemic event as precipitant for acute
pulmonary edema. Patient was aggressively diuresed with IV
furosemide and her respiratory failure improved. She was
successfully extubated on ___.
#Shock: most likely cardiogenic given evidence of acute
decompensated heart failure, however, there is a possibility
that this was septic shock given bilateral infiltrates on CXR
and leukocytosis. Was initially on norepinephrine, however was
quickly weaned off.
# Acute decompensated sCHF with EF 20% (from ___: on
carvedilol/lisiniopril/furosemide as outpatient. Initial
precipitant unclear. Patient reports compliance with meds and no
recent dietary indiscretion. Ruled out for ACS. Pneumonia may
have precipitated decompensation as well so treated pneumonia as
below. s/p aggressive diuresis with lasix gtt in MICU, and then
lasix boluses. Received lasix 60mg IV on ___ then back on home
lasix 40mg PO daily for rest of hospitalization. As per below
was switched from carvedilol to metoprolol, switched statin to
atorva 80, and decreased lisinopril due to soft BPs. Maintained
on 2G sodium restriction and will weight herself daily as
outpatient. Continued aspirin and started amio as below.
# Chest pain: per patient and family, patient had chest
compressions in the field prior to intubation. No EMS records
were available. ICD was interrogated and no arrhythmia was
noted. Patient had chest pain on palpation of her chest from
bruising due to chest compressions. She was started on tylenol
and lidocaine patches for the pain which helped.
Device interrogation with: Battery Voltage: ___ years;
Diagnostic information: High rate: Current episode of atrial
fibrillation began12/16 at 9:24 am and currently in atrial
fibrillation. Was AS-VP prior to that. No recent ventricular
arrhythmias noted. Last episode of VT was on ___ in ___ and
terminate with one shock. (ATP not attempted). She has had
several episodes of mode switch for atrial fibrillation.
Mode switch: AMS at 180bpm
# Community acquired pneumonia: GNRs on sputum gram stain, but
nothing grew on culture, Flu swab negative in MICU. Patient
without cough prior to coming in or leukocytosis here. Overall
suspicion for pneumonia low but completed course for CAP.
Continued Levofloxacin for total 5 day course (day 1:
___.
# Atrial fibrillation: on sotalol as outpatient, has Bi-V dual
chamber pacer. After consultation with cardiology, started on
amiodarone bolus + drip in MICU. Restarted carvedilol in MICU as
well. Per records from outpatient cardiologist, Has had
subtherapeutic INR since ___ (1.8 ___, 1.8 ___. On
arrival to cardiology floor, patient had HR in the 100s on
amiodarone. Carvedilol was switched to metoprolol for better
rate control and metop was uptitrated as BP allowed. Warfarin
had been held while in ICU so restarted at 0.5mg daily given
concomittant use of amiodarone. Warfarin uptitrated to home dose
with therapeutic INRs. LFTs and TSH normal during admission.
Received Amiodarone PO 400mg BID for several days, then tapered
to 200 TID for 5 days, and then will take 200mg daily going
forward
# HTN: Held home lisinopril initially given borderline SBP and
restarted at 2.5mg on ___
# CAD/HLD: Started atorvastatin 80 to replace home Simvastatin.
Continued ASA 81 mg PO QD
# GERD: PO Pantoprazole
# Throat pain: likely ___ intubation, chloraseptic spray PRN
# Transitional issues:
- fax h&p and discharge summary to outpatient cardiologist:
___ MD, ___, ___ (___)
tel ___, fax ___
- Will see Dr. ___ on discharge who will coordinate care
with outpatient cardiologist
- lidocaine patches for musculoskeletal chest pain
*** Consider cardioversion as outpatient if remains in atrial
fibrillation***
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 1 mg PO 6X/WEEK (___)
2. Warfarin 2 mg PO 1X/WEEK (MO)
3. Lisinopril 20 mg PO DAILY
4. Simvastatin 40 mg PO QPM
5. Furosemide 40 mg PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Sotalol 80 mg PO BID
8. Aspirin 81 mg PO DAILY
9. Mirtazapine 15 mg PO QHS:PRN insomnia
10. Carvedilol 6.25 mg PO BID
Discharge Medications:
1. Cane
___
Adult RW
Weakness/CHF
Good Prognosis
Lifetime Need
2. Aspirin 81 mg PO DAILY
3. Furosemide 40 mg PO DAILY
4. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. Mirtazapine 15 mg PO QHS:PRN insomnia
6. Pantoprazole 40 mg PO Q24H
7. Warfarin 1 mg PO 6X/WEEK (___)
8. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
9. Amiodarone 200 mg PO TID Duration: 3 Days
take three times daily until ___ then reduce to once daily
RX *amiodarone 200 mg 1 tablet(s) by mouth three times daily for
3 days and then once daily Disp #*40 Tablet Refills:*0
10. Lidocaine 5% Patch 1 PTCH TD QAM pain
RX *lidocaine 5 % (700 mg/patch) apply 1 patch to chest once a
day Disp #*14 Patch Refills:*0
11. Metoprolol Succinate XL 75 mg PO Q12H
RX *metoprolol succinate 25 mg 3 tablet(s) by mouth daily Disp
#*90 Tablet Refills:*0
12. Warfarin 2 mg PO 1X/WEEK (MO)
13. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
14. Amiodarone 200 mg PO DAILY
start daily dosing on ___
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Primary:
Acute systolic congestive heart failure
Community acquired pneumonia
Secondary:
Atrial fibrillation
Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you at ___
___. You were admitted with difficulty breathing and
had to be intubated with a breathing tube for one day. You were
in the ICU with cardiogenic shock but improved with diuresis.
You also had some chest pain from rib bruising after receiving
CPR. This improved with lidocaine patch.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10260010-DS-2 | 10,260,010 | 22,135,673 | DS | 2 | 2166-10-13 00:00:00 | 2166-11-04 10:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with a history of HTN who presents to the
ED s/p fall from 6 foot ladder at his worksite onto a shovel and
a concrete floor his right side. He was brought to the hospital
for evaluation of his chest and right flank pain. He is
otherwise well, and denies nausea, vomiting, fevers, chills, or
abdominal pain. He denies further traumatic pain.
Past Medical History:
PMH:
HTN
PSH:
None
Social History:
___
Family History:
no hx cad, stroke, dm
Physical Exam:
Admission Physical Exam:
Vitals: 98.2 67 147/103 19 100% RA
Gen: NAD, A&Ox3
HEENT: NC/AT, EOMI
CV: RRR
Pulm: easy work of breathing on RA, normal chest rise, tender to
palpation on right side, no crepitus
Abd: soft, nontender, nondistended, no palpable masses or
hernias
Ext: warm and well perfused, tender to palpation over right
lateral thigh
Discharge Physical Exam:
VS: T: 98.1 PO BP: 158/96 HR: 68 RR: 18 O2: 97% RA
GEN: A+Ox3, NAD
HEENT: normocephalic, atraumatic
CV: RRR
PULM: clear bilaterally, no respiratory distress, breathing
comfortably on room air
ABD: soft, non-distended, non-tender
EXT: right lateral thigh with about silver dollar sized area of
ecchymosis. wwp and no edema b/l
Pertinent Results:
IMAIGNG:
___: CT C-spine:
No cervical spine fracture or malalignment.
___: CT Head:
No acute intracranial process.
___: CT Torso:
1. Minimally displaced fracture of the anterolateral right
seventh rib and
nondisplaced fracture of the right sixth rib. No pneumothorax
or associated lung injury.
2. Subcutaneous hematoma overlying the right gluteal region. No
associated fracture.
3. Focal ectasia of the descending thoracic aorta measuring 4.0
cm is chronic.
LABS:
___ 04:51PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:51PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 12:47PM GLUCOSE-113* UREA N-18 CREAT-1.4* SODIUM-143
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-27 ANION GAP-13
___ 12:47PM WBC-10.3* RBC-5.17 HGB-14.5 HCT-44.8 MCV-87
MCH-28.0 MCHC-32.4 RDW-14.5 RDWSD-45.9
___ 12:47PM NEUTS-67.7 ___ MONOS-7.9 EOS-1.7
BASOS-0.5 IM ___ AbsNeut-6.97* AbsLymp-2.22 AbsMono-0.81*
AbsEos-0.18 AbsBaso-0.05
___ 12:47PM PLT COUNT-269
___ 12:47PM ___ PTT-24.3* ___
Brief Hospital Course:
Mr. ___ is a ___ with a history of HTN who presented to the
ED s/p fall from 6 foot ladder at his worksite onto a shovel and
a concrete floor his right side. Imaging revealed minimally
displaced anterolateral right ___ and 7th rib fractures. He was
admitted to the Trauma/Acute Care Surgery service for pain
control and respiratory monitoring. Pain was managed with
acetaminophen, oxycodone and lidocaine patches. The patient
remained stable from a pulmonary standpoint; vital signs were
routinely monitored. Good pulmonary toilet, early ambulation and
incentive spirometry were encouraged throughout hospitalization.
The patient ambulated independently and did not require
physical therapy services.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
lisinopril, hydrochlorothiazide
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
2. Docusate Sodium 100 mg PO BID
Hold for loose stool.
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*10 Tablet Refills:*0
3. Lidocaine 5% Patch 1 PTCH TD QAM rib pain
apply to the area of rib fracture pain for 12 hours and then
remove and leave off for 12 hours
RX *lidocaine 5 % Apply patch to area of rib pain QAM Disp #*15
Patch Refills:*1
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Wean as tolerated. Patient may request partial fill.
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Hydrochlorothiazide 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Minimally displaced fracture of the anterolateral right seventh
rib and nondisplaced fracture of the right sixth rib
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital after sustaining right-sided
rib fractures from a fall. Your pain was managed with pain
medication and your breathing has remained stable. You are now
ready to be discharged home to continue your recovery. Please
note the following discharge instructions:
* Your injury caused right-sided rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 10
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Followup Instructions:
___
|
10260771-DS-11 | 10,260,771 | 25,172,994 | DS | 11 | 2184-01-20 00:00:00 | 2184-01-23 08:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Transient Amnesia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old left-handed man who presents
with transient amnesia. He was last seen well by his wife at
___
when he went inside to take a shower. He emerged at ___
staying,
"I don't know what happened." She started talking to him and
realized that he didn't seem to remember anything that happened
today, or even recent events: he didn't remember his recent
birthday party last week or any of the guests with whom he
interacted, the birth of his grandson 4 weeks ago, etc. He had
no
other symptoms or other odd behaviors. She gave him 4 baby
aspirins and then she brought him to ___,
but
he has no memory of that hospitalization. He was given an NIHSS
of 1 for not knowing the month. He was subsequently transferred
from ___ to ___ for further evaluation. His NIHSS
was initially 0 here now that he does know the month. A Code
Stroke was called to evaluate for the possibility of stroke. His
only risk factor is hyperlipidemia for which he takes a statin.
He has otherwise felt well recently, denies being under any
recent stress, and denies any especially heavy exertion.
He denies prior loss of awareness, loss of consciousness, or
time
lapse episodes. With regards to temporal lobe auras, the patient
denies olfactory hallucinations, gustatory hallucinations,
micropsia, macropsia, frequent ___ or ___,
tableau
visual distortion, sudden unprovoked fear, or epigastric rising
sensation.
On neurologic review of systems, the patient endorses confusion.
Denies headache, lightheadedness.
Denies difficulty with producing or comprehending speech.
Denies loss of vision, blurred vision, diplopia, vertigo,
tinnitus, hearing difficulty, dysarthria, or dysphagia.
Denies muscle weakness.
Denies loss of sensation.
Denies bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the patient denies fevers, rigors,
night sweats, or noticeable weight loss.
Denies chest pain, palpitations, dyspnea, or cough.
Denies nausea, vomiting, diarrhea, constipation, or abdominal
pain.
Denies dysuria or hematuria.
Denies myalgias, arthralgias, or rash.
Past Medical History:
Hyperlipidemia, on statin.
Social History:
___
Family History:
No stroke. No seizure. No neurologic disease. MI
(father and paternal grandfather). ___ cancer (mother).
Physical Exam:
VS T: 98.2 HR: 79 BP: 177/106 RR: 15 SaO2: 95% RA
General: NAD, seated in bed comfortably, well-appearing and
well-nourished middle-aged man.
Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions
Neck: Supple, no nuchal rigidity, no meningismus, no
carotid/vertebral bruits
Cardiovascular: RRR, no M/R/G
Pulmonary: Equal air entry bilaterally, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema, palpable radial/dorsalis pedis
pulses
Skin: No rashes or lesions
___ Stroke Scale - Total [0]
1a. Level of Consciousness - 0
1b. LOC Questions - 0
1c. LOC Commands - 0
2. Best Gaze - 0
3. Visual Fields - 0
4. Facial Palsy - 0
5a. Motor arm, left - 0
5b. Motor arm, right - 0
6a. Motor leg, left - 0
6b. Motor leg, right - 0
7. Limb Ataxia - 0
8. Sensory - 0
9. Language - 0
10. Dysarthria - 0
11. Extinction and Neglect - 0
Neurologic Examination:
- Mental Status - Awake, alert, oriented x name, DOB, month,
year. Attention to examiner easily attained and maintained.
Concentration maintained when recalling months backwards.
Recalls
a coherent history. Structure of speech demonstrates fluency
with
full sentences, intact repetition, and intact verbal
comprehension. Content of speech demonstrates intact naming
(high
and low frequency) and no paraphasias. Normal prosody. No
dysarthria. Verbal registration ___ and recall ___ at 5 minutes,
does not improve with categorical cues. No apraxia. No evidence
of hemineglect. No left-right agnosia.
- Cranial Nerves - [II] PERRL 3->1.5 brisk. VF full to number
counting. [III, IV, VI] EOMI, no nystagmus. [V] V1-V3 without
deficits to light touch bilaterally. [VII] No facial asymmetry.
[VIII] Hearing intact to finger rub bilaterally. [IX, X] Palate
elevation symmetric. [XI] SCM/Trapezius strength ___
bilaterally.
[XII] Tongue midline.
- Motor - Normal bulk and tone. No pronation, no drift. No
orbiting with arm roll. No tremor or asterixis.
[ Direct Confrontational Strength Testing ]
Arm
Deltoids [C5] [R 5] [L 5]
Biceps [C5] [R 5] [L 5]
Triceps [C6/7] [R 5] [L 5]
Extensor Carpi Radialis [C6] [R 5] [L 5]
Extensor Digitorum [C7] [R 5] [L 5]
Flexor Digitorum [C8] [R 5] [L 5]
Interosseus [C8] [R 5] [L 5]
Abductor Digiti Minimi [C8] [R 5] [L 5]
Leg
Iliopsoas [L1/2] [R 5] [L 5]
Quadriceps [L3/4] [R 5] [L 5]
Hamstrings [L5/S1] [R 5] [L 5]
Tibialis Anterior [L4] [R 5] [L 5]
Gastrocnemius [S1] [R 5] [L 5]
Extensor Hallucis Longus [L5] [R 5] [L 5]
Extensor Digitorum Brevis [L5] [R 5] [L 5]
Flexor Digitorum Brevis [S1] [R 5] [L 5]
- Sensory - No deficits to light touch, pinprick, or
proprioception bilaterally.
- Reflexes
=[Bic] [Tri] [___] [Quad] [Gastroc]
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response flexor bilaterally.
- Coordination - No dysmetria with finger to nose or heel-shin
testing. Good speed and intact cadence with rapid alternating
movements.
- Gait - Normal initiation. Narrow base. Normal stride length
and
arm swing. Stable without sway. No Romberg.
Pertinent Results:
___ 10:06PM BLOOD WBC-10.9 RBC-5.10 Hgb-15.3 Hct-44.3
MCV-87 MCH-30.0 MCHC-34.6 RDW-12.7 Plt ___
___ 10:06PM BLOOD ___ PTT-30.5 ___
___ 10:06PM BLOOD UreaN-13
___ 10:12PM BLOOD Glucose-93 Lactate-1.6 Na-145 K-4.1
Cl-104 ___
MRI:Images of the brain appear normal. There is no evidence of
hemorrhage, edema, mass, mass effect, or infarction. The
ventricles and sulci
are normal in caliber and configuration. Diffusion images
appear normal.
CT and CTA head:
Normal head CT, and head and neck CTA. No evidence of
aneurysm
or hemorrhage.
Brief Hospital Course:
Ms ___ ___ h/o HL presented with transient anterograde and
retrograde amnesia in the absence of any other neurologic
deficits or symptoms.
The event lasted about 5 hours.
During this hospital stay we performed multiple tests to
evaluate him for possible stroke.
In MRI, CT and CTA of the brain no focal lesion or abnormality
was found .
As his symptom resolved and we could not find any abnormality in
imaging tests, the diagnosis could be: transient global amnesia.
These are known to follow immersion in cold or warm water and
after
showering. We discussed this at length with the patient and his
wife.TGA is likely a vasospastic
condition.
Medications on Admission:
Unknown(either pravastatin or atrovastatin)
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Pravastatin 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Transient Global Amnesia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neuro exam: Awake , alert and oriented to place, person and time
in details.No focal deficit in sensory, motor or coordination
exam
Discharge Instructions:
Dear Mr ___ you were admitted to hospital as you developed
Transient amnesia which means you could not remember recent
event that happened to you.You were admitted to stroke floor and
we performed CT and CTA of your head and MRI and MRA of your
brain, we did not see any abnormality in your films. Transient
global amnesia is a sudden, temporary episode of memory loss
that can't be attributed to a more common neurological
condition, such as epilepsy or stroke.
During an episode of transient global amnesia, your recall of
recent events simply vanishes, so you can't remember where you
are or how you got there. You may also draw a blank when asked
to remember things that happened a day, a month or even a year
ago. With transient global amnesia, you do remember who you are,
and recognize the people you know well, but that doesn't make
your memory loss less disturbing.
Fortunately, transient global amnesia is rare, seemingly
harmless and unlikely to happen again. Episodes are usually
short-lived, and afterward your memory is fine.
You will be discharged home and you need to continue your home
medications. We did not change your medication. You need to be
followed by your own primary care doctor per schedule.If you
need to have your films CD you can call ___ during week
days.
Followup Instructions:
___
|
10260836-DS-13 | 10,260,836 | 25,474,829 | DS | 13 | 2153-06-04 00:00:00 | 2153-06-19 09:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Celexa
Attending: ___
Chief Complaint:
Right leg pain s/p car strike while on bicycle
Major Surgical or Invasive Procedure:
1. Open reduction internal fixation right tibia fracture with
intramedullary nail.
2. Fasciotomy, right lower leg anterior and lateral compartment.
3. Washout and closure right leg wound
History of Present Illness:
28 women helmeted bicyclist struck side of car, rolled over
windshield, no LOC. Brought to the BI ER for an evaluation by
the trauma team. CT Head, C-Spine, and abdomen/pelvis negative.
Only complains of right leg pain.
Past Medical History:
None
Social History:
___
Family History:
NC
Physical Exam:
AVSS
NAD, AOx3
BUE skin clean and intact
No tenderness, deformity, erythema, edema, induration or
ecchymosis
Arms and forearms are soft
No pain with passive motion
No joint pain
R M U ___
EPL FPL EIP EDC FDP FDI fire
2+ radial pulses
RLE with incisions clean/dry/intact; Appropriate ___
tenderness + mild swelling; AO splint in place
No erythema, induration or ecchymosis
Thighs and legs are soft
Saph Sural DPN SPN MPN LPN ___ FHL ___ TA PP Fire
1+ DP pulses
Contralateral extremity examined with good range of motion,
SILT, motors intact and no pain or edema
Pertinent Results:
___ 05:37AM BLOOD WBC-7.3 RBC-3.21* Hgb-10.2* Hct-30.2*
MCV-94 MCH-31.9 MCHC-33.9 RDW-12.0 Plt ___
___ 05:37AM BLOOD Glucose-116* UreaN-9 Creat-0.6 Na-141
K-3.6 Cl-102 HCO3-27 AnGap-16
___ 05:37AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.0
___ 06:36PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:30PM BLOOD Glucose-88 Lactate-1.2 Na-139 K-4.0
Cl-102 calHCO___-24
Brief Hospital Course:
The patient was admitted to the Orthopaedic Trauma Service for
repair of a right tibia fracture. The patient was taken to the
OR and underwent an open reduction internal fixation right tibia
fracture with intramedullary nail), as well as fasciotomy of the
right lower leg anterior and lateral compartment following
elevated Intraoperative measurement of right lower leg anterior
and lateral compartments careful attention was paid towards
protecting the nerves. The muscle was noted to be viable with
no evidence of muscle necrosis. It was contractile to cautery.
Adequate hemostasis was achieved and a VAC dressing sponge was
placed over the wound. The patient was monitored
postoperatively for pain
control as well as to assess her compartment. She was then
brought back to the operating room 48hrs later, for definitive
closure of her wounds, with no need for skin grafting. The
patient tolerated both procedures without complications and was
transferred to the PACU in stable condition. Please see
operative reports for details. Post operatively pain was
controlled with a PCA with a transition to PO pain meds once
tolerating POs. The patient tolerated diet advancement without
difficulty and made steady progress with ___.
Weight bearing status: Right lower extremity weight bearing as
tolerated in splint until clinic f/u .
The patient received ___ antibiotics as well as
Lovenox for DVT prophylaxis. The incision was clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. The patient was
discharged in stable condition with written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 2 weeks post-operatively. All questions were
answered prior to discharge home and the patient expressed
readiness for discharge.
Medications on Admission:
None
Discharge Medications:
1. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous QPM (once a day (in the evening)) for 2 weeks.
Disp:*14 syringe* 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. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
4. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours)
as needed for Pain.
Disp:*60 Tablet(s)* Refills:*0*
5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
Discharge Disposition:
Home
Discharge Diagnosis:
Right tibia 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:
******SIGNS OF INFECTION**********
Please return to the emergency department or notify MD if you
should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101.5, chills,
redness or drainage at the incision site; chest pain, shortness
of breath or any other concerns.
-Wound Care: Do not remove your splint at anytime and do not
allow any water on the splint. Always securely cover your splint
when taking a shower, to prevent any water entry. Please call
the clinic if your splint gets wet prior to your follow up
appointment, as it may need to be removed. No baths or swimming
for at least 4 weeks. All sutures or staples that need to be
removed will be taken out at your 2-week follow up appointment.
******WEIGHT-BEARING*******
Right lower extremity: Weight bearing as tolerated in splint
until clinic followup
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on ___.
*****ANTICOAGULATION******
- Take Lovenox for DVT prophylaxis for 2 weeks post-operatively.
******FOLLOW-UP**********
Please follow up with ___ in ___ days
post-operation for evaluation. Call ___ to schedule
appointment upon discharge.
Please follow up with your PCP regarding this admission and any
new medications/refills.
Followup Instructions:
___
|
10260867-DS-23 | 10,260,867 | 25,076,557 | DS | 23 | 2131-10-24 00:00:00 | 2131-10-24 14:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
metallic taste
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ s/p LRRT in ___ for ESRD from ___
nephropathy who had recent admission for colitis now presenting
with sour taste in mouth and low urine output.
Yesterday he noticed a sour taste in his mouth which would not
go away no matter how much liquid he drank or what he ate. He
talked to one of his doctors about it who told him it was
probably due to food and nothing serious. Still, he was worried
because the only other time he's had this sensation was years
ago when his original kidneys failed. Today he felt slightly off
and was drinking a large volume of water because he was worried
about protecting his kidneys. He realized by mid-day that he had
only urinated roughly 300cc of urine and felt very bloated. He
became concerned and came to the ER. He denies fever, chills,
rash, nausea, vomiting, diarrhea, constipation, dysuria,
hematuria, HA, weakness. Some recent med changes as listed
below. Had initially reported transient self-resolving abdominal
pain in the ER, but not even reporting this now.
Of note, he was recently admitted to ___ for persistent
diarrhea and colonoscopy showed colitis, thought to be ___ to
his mycophenolate. His mycophenolate was stopped for a few days
and then restarted at a much lower dose (had been 2g BID, now at
250mg BID) and the dose of his tacrolimus was also lowered from
4mg BID to 3mg Qam and 2mg Qpm.
In the ED, initial VS: 97.1 59 123/52 16 100. Transplan surgery
was consulted and said NTD. Nephrology was contacted and
recommended urine studies, CXR, medicine admission. All labs at
baseline and CXR/renal U/S without acute findings. Pt voided 2x
while in the ED, both very large volumes of urine and felt much
better, both physically and psychologically. VS at admission HR
74 RR 16 Temp 97.6 Sat 100%ra BP 161/73.
Currently, pt feels well and has no complaints.
Past Medical History:
ESRD secondary to IGA nephropathy (___)
CAD s/p angioplasty in ___ and ___
Atrial fibrillation
Hypercholesterolemia
Hypertension
GERD
colitis (from mycophenalate)
Social History:
___
Family History:
Denies CAD, No IBD, celiac dz, GI malignancies in
family.
Physical Exam:
VS - 98.3 117/66 67 18 97%
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, ___ systolic murmur
radiating to axilla
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, no focal decitis
Pertinent Results:
___ 04:57PM BLOOD WBC-2.2* RBC-3.93* Hgb-11.0* Hct-32.8*
MCV-84 MCH-28.0 MCHC-33.5 RDW-15.0 Plt ___
___ 07:30AM BLOOD Glucose-77 UreaN-17 Creat-1.3* Na-138
K-4.1 Cl-105 HCO3-30 AnGap-7*
___ 11:00PM BLOOD Glucose-90 UreaN-19 Creat-1.4* Na-133
K-4.1 Cl-100 HCO3-28 AnGap-9
TRANSPLANT U/S
Transplant kidney in the right lower quadrant without
hydronephrosis. Renal vessels are widely patent. Normal
resistive indices, unchanged since prior exams and are normal.
Systolic upstrokes appear blunted raising possibility of renal
artery stenosis, similar in appearance to older ___ exam, but
had not been as apparent on ___ study.
Brief Hospital Course:
___ yo M s/p LRRT in ___ for ESRD from IgA nephropathy who had
recent admission for colitis now presenting with sour taste in
mouth.
.
# Sour Taste in Mouth:
Unclear etiology but appears to be improving. Patient was
concerned because it was a similar taste as he had when his
original kidney failed. Possibly related to GERD symptoms.
Advised patient to take 2 of his omeprazole.
.
# Hx of Renal Transplant
Concern for rejection while in the ED given some slight pain in
the RLQ. However, his Creatinine is at baseline and has improved
this morning. No RLQ pain palpable. Continue cellcept, tacro,
prednisone. Continued bactrim ppx.
# Hypertension:
Bp currently in good range. Continued isosorbide mononitrate ER
30 mg daily. Continued metoprolol tartrate 25 mg Tab BID.
Medications on Admission:
prednisone 2.5 mg daily
Mycophenolate 250 mg BID
Tacrolimus 3mg qam and 2 mg qpm
Bactrim DS three times weekly
Tamsulosin ER 0.4 daily
Pravastatin 20 mg daily,
Aspirin 81 mg daily
omeprazole 20 mg daily,
isosorbide mononitrate ER 30 mg daily
metoprolol tartrate 25 mg Tab BID
Discharge Medications:
1. prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. mycophenolate mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
3. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO QAM (once a
day (in the morning)).
4. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO QPM (once a
day (in the evening)).
5. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
6. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (___).
Discharge Disposition:
Home
Discharge Diagnosis:
Kidney transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted to the hospital due a bad taste in your mouth
and concerns related to your kidney. Your creatinine is at
baseline levels, and the taste may be due to gastric reflux.
Medication changes:
INCREASE omeprazole to 2 tablets daily
Followup Instructions:
___
|
10260936-DS-24 | 10,260,936 | 25,414,626 | DS | 24 | 2140-07-01 00:00:00 | 2140-07-01 18:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fevers, GPC bacteremia
Major Surgical or Invasive Procedure:
Transesophageal echocardiogram ___
History of Present Illness:
Ms ___ is a ___ year old woman with history of native mitral
valve endocarditis with bioprosthetic mitral valve replacement,
presenting with a month of constitutional symptoms, found to
have GPCs in blood drawn by PCP ___ ___.
Ror the past month she has had intermittent myalgias/muscle
cramps and night sweats. Had a subjectiv fever which resulted in
her seeing her PCP on ___ where blood cultures were obtained
which grew gram-positive cocci in pairs and chains. Was told to
present to the emergency department for further evaluation. Of
note, no clear etiology for prior episode of endocarditis (no
IVDU, no dental issues, no other risk factors). She denies any
recent dental procedures or concern for dental infection, no
recent skin infections/abscess, did recently get small abrasions
on her feet from shoes, nothing beyond that. ? skin infection
back in ___, NOT VZV, culture negative. No other history of
infections other than prior h/o sub-acute endocarditis.
In the ED, initial VS were 100.4 129 123/83 18 100%. Received 1g
vancomycin, 1g PO Tylenol, 1 L NS. Written for CTX, unclear if
she recieved it. Transfer VS were 98.8 66 96/58 19 100% RA.
On arrival to the floor, patient reports being nervous, but
otherwise feeling well. Wonders why she has bacteria in her
blood again.
Past Medical History:
- Native valve endocarditis c/b mitral regurgitation in ___
with Strep viridans s/p MVR with bioprosthetic valve
- Anxiety
- Right sacroiliatis
Social History:
___
Family History:
Father with HTN
Grandmother lung cancer.
Physical Exam:
ADMISSION EXAM:
===============
VS - 98.5 ___ 18 98% RA
GENERAL: thin, anxious appearing young woman
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: regular rate, tachycardic, S1/S2, ___ SEM throughout
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes, no concerning lesions
DISCHARGE EXAM:
================
Tm 100.6 in past 24 hrs. BP 100s/60s. HR 95-110. RR 16 Sa02 98%
GENERAL: thin, anxious appearing young woman in NAD
NECK: supple, no LAD, no JVD
AXILLAE: no LAD
MSK: no spinous/paraspinous tenderness
CARDIAC: regular rate, tachycardic, S1/S2, ___ SEM throughout
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, non-tender, no organomegaly
EXTREMITIES: No cyanosis, clubbing, nor edema. Left medial thigh
mildly TTP, but without erythema, edema, induration. Normal ROM
of hip and knee.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no petechiae or ungual findings
Pertinent Results:
ADMISSION LABS:
================
___ 01:15PM BLOOD WBC-7.2 RBC-4.18* Hgb-11.2* Hct-35.4*
MCV-85 MCH-26.7* MCHC-31.6 RDW-13.8 Plt ___
___ 01:15PM BLOOD Neuts-85.0* Lymphs-10.7* Monos-3.8
Eos-0.3 Baso-0.3
___ 01:15PM BLOOD ESR-40*
___ 01:15PM BLOOD Ret Aut-1.9
___ 01:15PM BLOOD Glucose-103* UreaN-9 Creat-0.8 Na-135
K-5.3* Cl-100 HCO3-25 AnGap-15
___ 01:15PM BLOOD Calcium-9.1 Phos-2.8 Mg-2.2 Iron-30
___ 01:15PM BLOOD calTIBC-228* ___ Ferritn-407*
TRF-175*
___ 01:15PM BLOOD CRP-74.6*
___ 02:58PM BLOOD K-5.0
DISCHARGE LABS
==============
___ 07:00AM BLOOD WBC-8.4 RBC-3.64* Hgb-9.6* Hct-30.7*
MCV-85 MCH-26.4* MCHC-31.3 RDW-14.1 Plt ___
___ 07:00AM BLOOD Glucose-112* UreaN-6 Creat-0.7 Na-135
K-4.0 Cl-97 HCO3-30 AnGap-12
___ 05:25AM BLOOD ALT-56* AST-61* LD(LDH)-352* AlkPhos-61
TotBili-0.3
PERTINENT LABS
==============
___ 01:15PM BLOOD ESR-40*
___ 01:15PM BLOOD Ret Aut-1.9
___ 01:15PM BLOOD calTIBC-228* ___ Ferritn-407*
TRF-175*
___ 01:15PM BLOOD CRP-74.6*
___ 08:15AM BLOOD IgG-1357 IgA-183 IgM-350*
___ 08:35AM BLOOD HIV Ab-NEGATIVE
___ 01:31AM BLOOD Genta-4.7*
___ 12:34AM BLOOD Genta-0.3*
IMAGING:
========
CXR ___: normal chest radiograph. prosthetic valve
unchanged from ___.
MICROBIOLOGY:
=============
___ Blood Cultures (Atrius): S viridans ___ bottles
Sensitive to: clindamycin, penicillin, cefoxitin, erythromycin,
ampicillin, vancomycin, ceftriaxone
___ Blood cultures: S mutans ___ bottles:
STREPTOCOCCUS MUTANS
|
CEFTRIAXONE----------- S
CLINDAMYCIN----------- S
ERYTHROMYCIN----------<=0.25 S
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ <=1 S
___ Urine cultures: ___ alpha-hemolytic strep
___ Blood cx x2: PENDING
___ Blood cx x2: PENDING
___ Blood cx x3: PENDING
___ Blood cx x2: PENDING
Brief Hospital Course:
Ms ___ is a ___ year old woman with history of native mitral
valve endocarditis with bioprosthetic mitral valve replacement,
presenting with a month of constitutional symptoms, found to
have GPCs in blood drawn by PCP ___ ___.
ACUTE ISSUES:
=============
# Streptococcus mutans bioprosthetic mitral valve endocarditis:
Patient met sepsis criteria on admission, but was clinically
quite stable. Her blood cultures grew strep mutans (same as ___
cultures). Her last positive cultures were from ___, with all
later cultures being no growth to date. She was initially
treated with vancomycin, ceftriaxone, and gentamicin for
synergy. When speciation returned, vancomycin was discontinued.
She had both a TTE and TEE, the latter of which showed a
moderate-sized vegetation (0.7cm) on the anterior leaflet of the
mitral valve, trivial MR, and an elevated transvalvular
gradient. She had no paravalvular abscess or signs of heart
failure. There were no clear risk factors for her to develop
bacteremia with oral flora. HIV and immunoglobulin levels were
normal. ECG showed no significant conduction abnormality. She
was discharged with a planned 6 week course of ceftriaxone (last
day ___ and planned 2 week course of gentamicin (last day
___. She will require weekly gentamicin levels and labs
while on antibiotics ___ check ___. She will need follow up
TTE in ~6 weeks and will then need to go to cardiac surgery
clinic for follow up. Gentamicin peak on ___ pending at
discharge.
# Tachycardia: Sinus tachycardia. Likely due to
anxiety/bacteremia. She remained tachycardic intermittently
throughout stay without evidence of valvular dysfunction. We
suspect this was related to inflammation and possibly anxiety.
# Anemia: Hemoglobin of 11 mg/dL on admission. She has had
normal hemoglobin in recent past. This was thought to be likely
due to anemia of acute inflammation, supported by iron labs. No
evidence of lysis, though haptoglobin normal in setting of other
elevated inflammatory markers, which is surprising, and LDH is
elevated, though presumably in setting of elevated inflammatory
markers.
# Left thigh pain: Patient started having mild-moderate left
medial thigh pain ___ days after admission. Exam was
unremarkable and DVT was felt to be unlikely. Notably, the
patient had declined subcutaneous heparin as she was walking,
which was reasonable to the medical team. The possibility of
bacterial myositis or osteomyelitis was entertained, but the
symptoms were transient and seemed more consistent with
strain/cramping. She was given NSAIDs. She was instructed to
monitor her symptoms and notify a doctor if worse, as she may
require future imaging to rule out infection from septic emboli
if symptoms persist.
# Anxiety: Unclear anxiety diagnosis. She was given Ativan prn
for anxiety. She was discharged with a limited supply of Ativan.
She should consider psychotherapy or SSRI treatment as an
outpatient.
TRANSITIONAL ISSUES:
=====================
- CODE: FULL
[]Weekly gentamicin peak/troughs x2 weeks, weekly
CBC/BMP/LFTs/ESR,CRP while on ceftriaxone
[]Repeat TTE ~ ___ cardiology follow up
[]PICC removal after ___ when ceftriaxone done
[]outpatient treatment of anxiety disorder
[]Follow up with Dr. ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN headache, fever, call ___ if
giving
2. CeftriaXONE 2 gm IV Q24H
Last day ___
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 grams IV q24
hours Disp #*35 Intravenous Bag Refills:*0
3. Gentamicin 160 mg IV Q24H
Last day ___ (2 wk course)
RX *gentamicin in NaCl (iso-osm) 80 mg/50 mL 160 mg IV daily
Disp #*28 Intravenous Bag Refills:*0
4. Lorazepam 0.25-0.5 mg PO Q6H:PRN anxiety
RX *lorazepam 0.5 mg 1 tablet by mouth every 6 hours as needed
Disp #*24 Tablet Refills:*0
5. Outpatient Lab Work
1.Weekly gentamicin peak & trough (peak <1 hour before infusion,
trough <30 minutes after infusion done).
2.Weekly CBC w/diff, chem7, AST,ALT,AlkPhos,Tbili, ESR/CRP
ICD9 (___.61)
Please fax results to ___ ___ CLINIC)
6. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
RX *sodium chloride 0.9 % 0.9 % ___ mL IV daily and PRN Disp
#*60 Syringe Refills:*0
7. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
#Subacute bacterial endocarditis of bioprosthetic mitral valve
#Streptococcus mutans septicemia
SECONDARY:
#Anxiety disorder, NOS
#Left thigh pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___, it was a pleasure to take care of ___ at ___
___. ___ were admitted for blood cultures growing a
bacteria called streptococcus mutans, a normal mouth organism.
___ were treated with a few antibiotics originally until we
could determine which antibiotics would treat your infection
adequately. An echocardiogram showed that ___ had an infection
of your prosthetic mitral valve, but there was no abscess. There
was some increase in the amount of obstruction caused by the
growing infection on the valves, but ___ did not have signs of
severe valvular disease, such as heart failure. Therefore, we
thought it was safe to treat ___ with 6 weeks of antibiotics
(the first two weeks will be 2 antibiotics) and then repeat an
echocardiogram. It is critical that ___ finish the antibiotics
and then get the repeat echo. We will arrange for ___ to get a
new cardiologist in the Atrius system. ___ will have follow up
with the infectious diseases doctors and after your
echocardiogram is done, Dr. ___. Even if your valve does not
need to be replaced at the end of your antibiotic course, ___
will need regular echocardiograms to monitor your valve
(probably annually) as it will eventually need replacement in
the next few years.
If your left thigh pain worsens significantly, please contact
one of your doctors for ___ and potential imaging.
Please see below for follow up instructions and new medications.
Followup Instructions:
___
|
10261129-DS-15 | 10,261,129 | 22,642,683 | DS | 15 | 2160-11-15 00:00:00 | 2160-11-22 09:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Transient visual changes
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: The patient is a ___ PMHx afib on Xarelto, HTN, HLD,
pre-DM,
aortic stenosis, OSA, and RCC s/p nephrectomy who presents to
the
___ ED ___ with transient visual symptoms.
On the day of presentation, pt was feeling well apart from mild
fatigue. She went to the ___ with her wife when abruptly around
16:00 she noted that, when looking at paintings, the images were
"breaking up". The paintings looked like puzzle pieces that were
"rearranged". There was no flashing of lights, tunnel vision or
dark spots. Symptoms were in both eyes. This had never happened
before. Pt also felt nauseous and lightheaded so she went to sit
down. Sitting down made her feel mildly better. Symptoms
resolved
after about 20 minutes. She then presented to the ___ ED for
further evaluation.
At the time of my assessment, pt denies any ongoing visual
symptoms. She denies any lateralized weakness or numbness now or
prior. She does report ongoing mild fatigue and nausea. She was
able to walk into the ED normally. She has no other complaints
at
this time. She denies any headache. She has not had migraines
since her ___ - she used to have mild migraines with
photosensitivity, nausea and vomiting. She is compliant with her
Xarelto.
On neurologic review of systems, the patient report blurry near
vision requiring glasses, photosensitivity for years following
eye surgery, and chronic hearing loss. Pt denies headache,
lightheadedness, or confusion. Denies difficulty with producing
or comprehending speech. Denies loss of vision, blurred vision,
diplopia, vertigo, tinnitus, dysarthria, or dysphagia. Denies
focal muscle weakness, numbness, parasthesia. Denies loss of
sensation. Denies bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the patient denies fevers, chest
pain, palpitations, cough, vomiting, diarrhea, constipation,
abdominal pain, dysuria or rash.
Past Medical History:
PMH:
Renal cell carcinoma, clear cell type s/p R nephrectomy (___)
Hypertension
Hyperlipdemia
Hypothyroidism
Osteoarthritis
Tracheal stenosis
Obstructive sleep apnea
Moderate aortic stenosis
Endometrial cancer
Sensorineural hearing loss
Pre-diabetes
Afib on Xarelto
Bilateral cataract repair
Eyelid drooping with spasm requiring Botx injections
PSH:
Laparoscopic right radical nephrectomy (___)
Carpal tunnel release ___
Breast reduction ___
Bilateral cataract extraction ___
Laser post capsulotomy, bilateral, ___
Left knee arthroscopy ___
Right shoulder arthroscopy for rotator cuff repair ___
Sleeve gastrectomy and haital hernia repair ___
Social History:
___
Family History:
FAMILY HISTORY:
Brother ___ Bowel Disease; Stroke following
a burst ulcer
Mother (___): Cancer - Colon
Physical Exam:
Admission Exam:
Vitals: 97.4 86 155/85 16 100% RA
General: NAD, resting in bed
HEENT: NCAT, no oropharyngeal lesions, moist mucous membranes,
sclerae anicteric
Neck: Supple
___: RRR
Pulmonary: CTAB
Abdomen: Soft, NT, ND
Extremities: Warm, no edema
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status - Awake, alert, oriented to person, place and
time. Attention to examiner easily maintained. Recalls a
coherent
history. Speech is fluent with full sentences, intact
repetition,
and intact verbal comprehension. Content of speech demonstrates
intact naming (high and low frequency) and no paraphasias.
Normal
prosody. No evidence of hemineglect. No left-right agnosia.
Reading intact.
- Cranial Nerves - Bilateral post-surgical pupils. Mild ptosis
bilaterally with frequent eye blinking. VF full to finger
wiggling. Optic discs appear crisp. EOMI, no nystagmus. Acuity
normal in each eye at foot of bed. V1-V3 without deficits to
light touch bilaterally. No facial movement asymmetry. Hearing
intact to finger rub bilaterally. No dysarthria. Palate
elevation
symmetric. Trapezius strength ___ bilaterally. Tongue midline.
- Motor - Normal bulk and tone. No drift. No tremor or
asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
- Sensory - No deficits to pin bilaterally.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response flexor bilaterally.
- Coordination - No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait - Ambulates independently in a stable manner.
Discharge Neurological Exam: Normal
Pertinent Results:
___ 08:29PM BLOOD %HbA1c-6.3* eAG-134*
___ 05:11AM BLOOD Triglyc-107 HDL-51 CHOL/HD-2.8 LDLcalc-71
___ 04:30PM BLOOD TSH-2.3
___ CT Head
No acute intracranial process.
___ CXR
Mild cardiomegaly without overt pulmonary edema.
___ MRI Brain, MRA Brain/Neck
1. No acute intracranial abnormality including infarct,
hemorrhage or suggest a mass.
2. Patent intracranial vasculature without significant stenosis,
occlusion, or aneurysm.
3. Patent cervical vasculature without significant stenosis, or
occlusion. Note that the origins of the great vessels are not
assessed.
Brief Hospital Course:
Ms. ___ is a ___ yo woman with multiple vascular risk
factors including afib on Xarelto, HTN, HLD, pre-DM, aortic
stenosis, OSA, and RCC s/p nephrectomy who presented with
transient visual symptoms (described as images breaking up),
disorientation and lightheadedness. These symptoms had resolved
by the time of admission to the hospital and did not recur. Her
neurological exam after admission was normal. Her visual
symptoms were not consistent with stroke or TIA and MRI was
negative for stroke. Her symptoms were possibly due to migraine
or intraocular cause (fragmented, kaleidoscope images).
***Transitional issues:
- follow up with outpatient ophthalmologist
- follow up with neurology
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Metoprolol Succinate XL 100 mg PO BID
4. Rivaroxaban 20 mg PO DAILY
5. Vitamin D ___ UNIT PO DAILY
6. Cyanocobalamin 1000 mcg PO 3X/WEEK (___)
7. Docusate Sodium 100 mg PO BID
8. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. Cyanocobalamin 1000 mcg PO 3X/WEEK (___)
3. Docusate Sodium 100 mg PO BID
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Metoprolol Succinate XL 100 mg PO BID
6. Multivitamins 1 TAB PO DAILY
7. Rivaroxaban 20 mg PO DAILY
8. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Visual disturbance
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted with symptoms of abnormal vision,
disorientation, and dizziness. You were evaluated for stroke and
your MRI brain did not show stroke. Your symptoms may have been
due to migraine without headache or due to an intraocular cause.
You should follow up with your ophthalmologist Dr. ___ 1
month. You should call ___ for a follow up with
neurology.
It was a pleasure taking care of you.
Your ___ Team
Followup Instructions:
___
|
10261156-DS-7 | 10,261,156 | 24,317,135 | DS | 7 | 2122-02-13 00:00:00 | 2122-02-13 23:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Painless jaundice
Major Surgical or Invasive Procedure:
ERCP (___)
History of Present Illness:
___ presenting with ___ days of progressive painless jaundice.
Pt reports he was unaware he was jaundiced but reports his niece
___ and had him come in. He believes he was turning more
yellow over the last few days. He denies abd pain. Denies wt
loss, fevers/chills, n/v. Reports some issues with constipation.
Had BM on day of presentation which was normal and light brown.
He reports black stool approx 2 days ago. He reports tea colored
urine for ___ days and generalized pruritis for ___ days. He
reports ___ of poor PO intake.
Pt believes he saw a PCP ___ ___ ago. No past ___ to his
knowledge.
Pt went to ___ where the patient had a right upper
ultrasound performed. On the right upper quadrant ultrasound it
was noticed that the patient had a 9 x 9 x 10 cm triple A. The
patient as such was transferred to ___. The patient continues
to state that he does not have any abdominal pain. He otherwise
denies any fever, chills, nausea, vomiting, diarrhea, dysuria,
back pain, weakness and was of the body or the other, headache,
difficulty walking.
In the ED, initial vs were: 97.8 95 123/63 16 99% RA. Labs were
remarkable for WBC count of 4.6 (78%N, 1% bands, 1% metas, 2%
myelos), Hct 38.3, plt 142, T bili 27.1, D bili 20.4, AST/ALT
112/56, AP 452, BUN/Cr ___, K 4.9, bicarb 21, INR 1.2. UA
with lg leuks, 19 WBC, few bacteria, 1 epi. Ucx pending. No bl
cx sent. Patient was given 1g CTX, 1L NS. CTA abd done showing
infrarenal AAA measuring 9.9x9.7cm without evidence of rupture
and enhancing mass within CBD extending to left hepatic duct
with diffuse intrahepatic biliary duct dilation and adjacent
celiac and periportal adenopathy. ERCP consulted. Vascular
surgery was consulted for semiurgent/elective repair of large
unruptured AAA. The patient has a extensive history of smoking
which is likely a factor in the development of this AAA. the
patient has lots of masses in CBD. Patient will require
admission for further oncologic workup including ERCP. Patient
admitted to ___ given that the patient has a large AAA and if
ruptures will require emergent surgery, has been discussed with
___ as well as bed facilitator. Vitals on
Transfer:94 130/71 18 98%.
Vascular consult:
reviewed CT scan with radiology and vascular team - advised
admission to medicine for workup of CBD mass, intra/extrahepatic
dilation, multiple paraaortic and retroperitoneal lymph nodes.
On the floor, pt is without complaints. Denies pain.
Past Medical History:
- extensive smoking hx
- gout
- constipation
- s/p inguinal hernia repair age ___
Social History:
___
Family History:
denies famHx of cancers, AAA
Physical Exam:
ADMISSION EXAM:
=====================
Vitals: 97.8, 149/72, 80, 22, 100% RA
General: pleasant obese male, jaundiced, in NAD
HEENT: Sclera icteric, MMM with poor dentition, oropharynx clear
Neck: supple
CV: RRR, no murmurs
Lungs: CTAB, breathing comfortably without accessory muscles,
mildly tachypneic
Abdomen: soft, obese, nondistended, audible bruit in midline, no
RUQ tenderness
Ext: Warm, well perfused, 2+ DP pulses, no ___ edema
Skin: jaundiced
Neuro: grossly intact, sensation to light touch intact and
symmetric in ___, ___ strength in ___ at ankles and hips
DISCHARGE EXAM:
=====================
VS:
Tmax(24hrs): 98.4F
BP(24hrs):109-136/47-72
___
SpO2: 99-100% on RA
GEN: Awake and lying in bed. Pleasant. Jaundice skin.
HEENT: Scleral icterus. PERRL. Moist mucous membranes.
CARDIO: RRR. S1 and S2. No murmur appreciated.
LUNGS: CTA b/l.
ABD: BS present. Soft, nondistended, nontender.
EXT: WWP. No ___. Some brusing on UEs from injections.
Pertinent Results:
ADMISSION LABS:
==========================
___ 04:58PM BLOOD WBC-4.6 RBC-4.00* Hgb-13.3* Hct-38.3*
MCV-96 MCH-33.2* MCHC-34.7 RDW-21.2* Plt ___
___ 04:58PM BLOOD Neuts-78* Bands-1 Lymphs-12* Monos-6
Eos-0 Baso-0 ___ Metas-1* Myelos-2*
___ 04:58PM BLOOD ___ PTT-40.1* ___
___ 04:58PM BLOOD ALT-56* AST-112* AlkPhos-452*
TotBili-27.1* DirBili-20.4* IndBili-6.7
___ 04:58PM BLOOD Albumin-3.6 Calcium-9.6 Phos-2.7 Mg-2.2
RELEVANT LABS:
===========================
___ 06:00PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-LG Urobiln-4* pH-5.5 Leuks-LG
___ 07:15AM BLOOD WBC-3.8* RBC-3.91* Hgb-12.5* Hct-37.2*
MCV-95 MCH-32.0 MCHC-33.6 RDW-18.8* Plt ___
___ 07:35AM BLOOD ALT-48* AST-93* AlkPhos-390*
TotBili-24.4*
___ 07:06AM BLOOD ALT-49* AST-96* AlkPhos-363*
TotBili-21.4*
DISCHARGE LABS:
===========================
___ 07:06AM BLOOD WBC-3.7* RBC-3.71* Hgb-11.7* Hct-34.9*
MCV-94 MCH-31.6 MCHC-33.6 RDW-19.2* Plt ___
___ 07:06AM BLOOD Plt ___
___ 10:15AM BLOOD Glucose-97 UreaN-21* Creat-1.4* Na-140
K-3.9 Cl-107 HCO3-22 AnGap-15
___ 10:15AM BLOOD ALT-46* AST-87* AlkPhos-325*
TotBili-21.6*
PERTINENT IMAGING:
===========================
CTAbd/Pelvis (___)
1. Infrarenal abdominal aortic aneurysm measuring 9.9 x 9.7 cm,
extending tothe aortic bifurcation. There is no evidence of
rupture.
2. Enhancing mass which dilates the common bile duct, and
extends to the left hepatic duct with diffuse intrahepatic
biliary ductal dilatation and adjacent celiac and periportal
adenopathy, concerning for cholangiocarcinoma. There isalso
evidence for invasion of the adjacent right hepatic lobe and
caudate lobe.
3. Splenomegaly.
Brief Hospital Course:
PRIMARY REASON FOR ADMISSION: ___ transferred from OSH with
asymptomatic 10cm AAA and painless jaundice with T bili of 27.
ACTIVE ISSUES:
#10cm Infrarenal AAA: In his workup for obstructive jaundice,
patient found to have asymptomatic 9.9 x 9.7 cm AAA with no
evidence of rupture on imaging. Vascular surgery was consulted
and as the anatomy of the aneurysm is not likely amenable with
endovascular repair, recommended keeping sBP in 100s-120s. The
patient denies any history of hypertension and had admission
SBPs in 130s/140s that decreased to goal with low-dose
labetalol. He continued to have pressures in the 110s to 130s
systolic and was discharged on 50mg labetolol (PRN TID for
SBP>130, pt was d/c'd with home nursing) for blood pressure
control.
.
#Painless obstructive jaundice: In workup of jaundice, the
patient was found to have an enhancing mass within the common
bile duct, most concerning for a malignant process such as
cholangiocarcinoma given associated LAD with possible invasion
into the liver. The patient denied pain, and given lack of
fevers, leukocytosis or AMS, concern was low for cholangitis.
Pt underwent ERCP which was significant for a large mass in the
common bile duct with extension into the liver. A stent was
placed; brushing was not performed due to friability and
bleeding at the mass site, but cells were sent for cytology.
LFTs following the proceedure remained stable. After discussion
with GI team pt was discharged with a plan to have LFTs checked
as an outpatient in ___ days. If there is sign of continued
obstruction at that point, a discussion can be had about
intervention. After a family meeting with the patient's proxy,
it was determined he did not wish to stay in the hospital for
further monitoring/testing.
.
___: Patient had Cr of 1.5 on admission, up from 1.2 at OSH
(baseline unknown). Likely pre-renal given patient's recent
anorexia and poor fluid intake over the past few days. Improved
with hydration and was 1.4 at discharge.
.
#Code Status: Niece ___ is HCP. After discussion on ___
w/r/t the significant morbidity and mortality related to AAA
rupture, patient was made DNR/DNI.
CHRONIC ISSUES:
-h/o gout: Not on prophylactic medications
TRANSITIONAL ISSUES:
- Patient has not seen PCP ___ "a couple of years".
- DNR/DNI
- Family meeting prior to discharge:
Pts HCP requested that we have meeting without pt as she did not
want to upset him anymore. She said that she had repeatedly
invloved the patient earlier but that his confusion made him
forget the conversations and each time she brought it up made
him
anxious all over again.
___ has had many discussions in the past with the pt and his
wishes have always been to have no ___ medical diagnostics,
proceedures, or therapies should he have a terminal condition.
She is very confident this is his wish now. We discussed the
probable diagnosis of cholangiocarcinoma and that the prognosis
of this is grim. When asked if he might want chemotherapy or
surgery if it meant prolonging his life or quality of life,
___ said the pt would not desire this. We also explained
that during the ERCP performed the day prior, a stent was placed
to help with biliary drainage. At the time of the family
meeting
we did not know how effective the drainage was, and we told
___ that to effectively monitor the stent, the pt would have
to remain in the hospital. She said the pt would definitely not
want this and even if the stent was not effective, the pt would
not want intervention to correct it (for example percutaneous
drainage). She said the pt's strong wish was to go home.
After speaking with the GI team, the plan was to have LFTs
measured in ___ days. If at that point there is worsening
obstruction, the decision to intervene can be discussed at that
point. The General Medicine team, the GI team, and the pt/proxy
were all in agreement with this plan. The patient was thus
discharged to home with home hospice eval.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Indomethacin Dose is Unknown PO Frequency is Unknown
PRN gout flair
2. Aspirin Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every 12 hours
Disp #*14 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
3. Labetalol 50 mg PO PRN TID for SBP>140
RX *labetalol 100 mg 0.5 (One half) tablet(s) by mouth as needed
Disp #*30 Tablet Refills:*0
4. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
5. Ursodiol 300 mg PO BID
RX *ursodiol 300 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
- Abdominal aortic aneurysm, infrarenal, 10cm
- Common bile duct mass
Secondary Diagnosis:
- Encephalopathy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was our pleasure caring for you while you were at ___. You
were admitted on ___ after your skin turned yellow (had
jaundice). You had imaging of your liver and gallbladder and
were found to have two main problems:
First, you were found to have a mass that was compressing the
ducts, or connecting tubes, between your gallbladder and liver.
This mass is concerning for cancer. You had procedure on ___
where a camera was put down your throat and the liver doctors
___ if they can open the duct.
Second, you were also found to have an enlarged aorta, which is
the largest blood vessel in your body. By keeping your blood
pressure low, we can decrease the risk of the aneurysm
rupturing. The surgeons who specialize in blood vessels
(vascular surgeons) saw you and will continue to be available
but do not think surgery to fix the big blood vessel is
appropriate now.
While you were here you were seen by the palliative care
doctors. You indicated that you do not want further treatment or
interventions for your liver disease or aortic aneurysm. In
accordance with your wishes, you are being discharged home. It
was a pleasure participating in your care.
Followup Instructions:
___
|
10261230-DS-20 | 10,261,230 | 24,308,518 | DS | 20 | 2125-07-21 00:00:00 | 2125-07-22 11:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
toxic ingestion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female college student with history of depression
and ADHD presents after intentional overdose on citalopram and
concerta in suicide attempt. She reportedly took approximately
280 mg citalopram, 200 mg concerta (methylphenidate) and 500mg
diphenhydramine after coming home froma social event where she
was intoxicated and had a physical altercation with one of her
peers. She came home, took the medications, and sent alarming
text messages to her friends, who called campus safety. She
reports progressive symptoms of low mood, apathy, poor
concentration and thoughts of dying to be with her mother who
recently passed due to cancer. Per patient, she consumes about
___ drinks/day, with more on weekends.
In the ED, initial vitals: 98.4 ___ 18 99%. She was
alert and in no distress upon arrival to the ED. Labs showed
negative urine and serum tox screen except EtOH level of 109,
negative UhCG, normal CBC and Chem7 showing HCO3 20 (AG 15). EKG
showed sinus tachycardia with normal intervals. While in the ED
Tmax 99.2F, HR ranged 102-160 in the ED, BP up to 175/95, RR
into the ___ with increased agitation and anxiety, but
consistently satting well on room air. Psychiatry was consulted,
she was ___ due to risk of harm to self and started on
CIWA monitoring. She received a liter of NS, thiamine 100mg PO,
MVT PO x1, folic acid 1mg PO, 4.5L NS and 2mg IV ativan x5.
Toxicology was consulted and recommended Q8H EKGs, 24hr of
telemetry, monitoring for serotonin syndrome, and supportive
care with benzodiazepines and IVF. On transfer, vitals were:
98.4 ___ 18 99%
On arrival to the MICU, she is comfortable but sleepy. She
denies wanting to hurt herself currently and is not happy about
the suggestion of needing longer term psychiatric
hospitalization. She endorses mild diffuse chronic headache and
dry mouth.
Past Medical History:
Depression/Anxiety (Psychiatrist Dr. ___ at ___)
Past suicide attempt by pill ingestion (after death of mother)
ADHD
Social History:
___
Family History:
non-contributory. Patient is adopted, doesn't know ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- T:98.9F BP:176/104 P:126 R: ___ O2: 97% RA
GENERAL: Lethargic but rousable, oriented x3
HEENT: spontaneous lateral nystagmus bilaterally in both
directions, pupils dilated to 6mm, minimal response to light.
Sclera anicteric, MM dry, OP clear.
NECK: supple, JVP not elevated, no LAD. Thyroid enlarged
bilaterally, smooth without nodules
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: tachycardic but regular, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN:Warm and dry, no rashes
NEURO: CN II-XII intact and symmetric with several beats of
nystagmus with both extremes of gaze (horizontal only), Strength
___ throughout, several beats of clonus in both ankles. Mild
intention tremor. No hyperreflexia
DISCHARGE PHYSICAL EXAM:
Vitals: 98.6, 142/85 (105-142/80's), 71 (60-70's), 18, 98%RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, moist mucous membranes, oropharynx
clear. Pupils 3->2mm, equal
Neck- supple, no JVD, no LAD
Lungs- Clear bilaterally without wheezing or ronchi
CV- Regular rhythm, no murmurs or ectopy
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
Ext- warm, well perfused, 2+ pulses, no edema
Neuro- CNs2-12 intact, ___ strength ___ UE and ___. No ankle
clonus, normoreflexive DTRs. No tremor or asterixis.
Pertinent Results:
ADMISSION LABS:
=======================
___ 04:25AM BLOOD WBC-8.2 RBC-4.24 Hgb-14.5 Hct-40.5 MCV-96
MCH-34.3* MCHC-35.9* RDW-11.6 Plt ___
___ 04:25AM BLOOD Neuts-48.9* ___ Monos-8.8 Eos-1.2
Baso-0.8
___ 04:25AM BLOOD Glucose-120* UreaN-14 Creat-1.0 Na-140
K-3.5 Cl-105 HCO3-20* AnGap-19
___ 04:30PM BLOOD Calcium-8.7 Phos-3.4 Mg-1.9
___ 04:25AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:30PM BLOOD Lithium-LESS THAN
___ 04:56PM BLOOD ___ pO2-105 pCO2-30* pH-7.47*
calTCO2-22 Base XS-0 Intubat-NOT INTUBA
___ 04:56PM BLOOD Lactate-2.2*
___ 04:30PM BLOOD TSH-1.7
INTERIM LABS:
=======================
___ 07:30AM BLOOD WBC-6.9 RBC-4.01* Hgb-12.9 Hct-39.6
MCV-99* MCH-32.1* MCHC-32.5 RDW-12.1 Plt ___
___ 07:30AM BLOOD Glucose-85 UreaN-13 Creat-1.0 Na-137
K-3.8 Cl-100 HCO3-29 AnGap-12
___ 04:43AM BLOOD CK(CPK)-228*
___ 04:43AM BLOOD CK-MB-2 cTropnT-<0.01
IMAGING:
=======================
___ CXR:
The heart size is within normal limits. Lungs are grossly clear
without
definite consolidation, pleural effusions, or signs for acute
pulmonary edema. There are no pneumothoraces.
EKG:
=======================
___ (4:06am): Sinus tachycardia (rate 149) with terminal T wave
inversions in lead aVF. Diffuse mild non-specific repolarization
abnormalities in the inferolateral leads, likely related to
rate. An ongoing metabolic or less likely ischemic process
cannot be excluded. Clinical correlation is suggested. No
previous tracing available for comparison.
___ (4:56pm): Sinus tachycardia (rate 104) with anterolateral T
wave inversions and more non-specific inferior ST-T wave
changes. These findings may be in keeping with myocardial
ischemia and are new from tracing of ___
___: Sinus rhythm (rate 66) with inferior and lateral T wave
inversions. Compared to the tracing #3 the sinus rate has slowed
further. Repolarization changes are similar.
Brief Hospital Course:
___ woman with history of depression and ADHD, heavy alcohol
use presenting after intentional ingestion of high doses of
Citalopram (~280mg), methylphenidate (~200mg), and
diphenhydramine (~500mg), admitted initially to the MICU for
persistent tachycardia and tachypnea, but improved quickly with
supportive care.
# Anticholingergic, SSRI, and methylphenidate ingestion: She
was initially with evidence of anticholinergic toxicity and
serotonin syndrome (hypertension, tachycardia, warm skin,
mydriasis, nystagmus, xerostomia, clonus and lethargy). EKG
showed normal intervals and she remained normothermic. She
received aggressive IVF and was treated symptomatically with IV
lorazepam with gradual improvement in symptoms. She is stable
with resolution of toxidrome symptoms at discharge.
# T-wave inversions: Found in lateral and inferior leads, not
typical for anticholinergic, SSRI, or amphetamine ingestion per
discussion with toxicology. No chest pain or other symptoms to
suggest ischemia. Lithium toxicity could also cause TWI but
patient denies such an ingestion and lithium level was
undetectable. Cardiac enzymes were negative x 2. EKGs were
reviewed with cardiology fellow on ___ who felt that there
was no acute issue. They were stable on repeat EKGs.
# Depression/Suicide attempt: Patient with history of depression
and past suicide attempt currently with multiple social
stressors. Patient's mother passed away last year and she
reports to have significant emotional lability following her
death. Her closest family support is her maternal aunt who lives
in ___. She had a 1:1 sitter through her stay, and remained
cooperative and calm. She was able to contract for safety in
hospital and denied SI at discharge. Psychiatry ultimately
recommended that she go with her aunt to ___, and seek
psychiatry care there. All psychiatric medications are on hold
at time of discharge.
# ETOH: Reported ___ drinks/night with more on weekends. Last
drink was night of admission, with admission EtOH level 109. No
history of complicated withdrawal. CIWA was not used given
overlap with toxidromes as discussed above, but she did receive
IV benzodiazepines for supportive care for her ingestions. She
recieved IV thiamine.
TRANSITIONAL ISSUES:
#Establish care with psychiatry in ___ and reinitiate
psychiatric medications.
Medications on Admission:
1. Citalopram 10 mg PO DAILY
2. Concerta (methylphenidate) 54 mg oral Daily
3. OCP (patient cannot remember name)The ___
list may be inaccurate and requires futher investigation.
Discharge Medications:
None
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary:
Polysubstance overdose
Alcohol intoxication
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Miss ___,
It was a pleasure taking care of you at ___ ___
___. You were admitted after you overdosed on your
psychiatric medications. You were monitored in the Intensive
Care Unit and recovered from the toxicity of these medications.
You were evaluated by the psychiatrists, who recommend that you
discontinue your psychiatric medications for now.
If you ever have any thoughts of harming yourself or others,
please reach out to 911 or present to the emergency room. Please
establish psychiatric care once you are in ___ with your
aunt, and have your medication regimen reviewed and restarted.
We wish you the best,
___ medicine team
Followup Instructions:
___
|
10261326-DS-16 | 10,261,326 | 29,355,740 | DS | 16 | 2131-09-07 00:00:00 | 2131-09-07 18:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization w/ stents to RCA (___) and OM1
(___)
History of Present Illness:
___ presenting with inferior stemi complicated by bradycardia
and acute stroke.
History provided by family and medical record.
Patient presented 1 ___ after traveling from ___ to visit
family for the holidays. She reportedly last saw her
cardiologist 2 weeks ago and was told everything was okay.
She was in her USOH after arrival on the plane yesterday. Last
night she did complain of some trouble breathing prior to
dinner, but this improved and she was able to eat and drink
without difficulty.
This morning she accompanied her son to the grocery store. While
pushing a cart, she reported her chest hurting, like something
was stuck (she has history of hiatal hernia), but had eaten
minimal food at breakfast. She began trying to cough it up and
then vomited. They went home, where she laid on the cough and
took a nap. She woke up and tried to have some chicken noodle
soup but vomited beforehand. She laid down again but her chest
was hurting more so she was brought to urgent care.
At urgent care, her pain was worsening and described as severe,
sharp, radiating up to neck. She vomited twice. EKG concerning
for STEMI with elevated troponin and low HR. ?Differential
pulses between arms. Given Zofran 4 x 1, nitro 0.4 sl x 1, asa
324 mg and transferred to ___.
In ED, initial vitals: 97.8 45 150/80 18 98% RA
Given heparin gtt, ticagrelor. Pulses symmetric. EKG known LBBB
with sgarbosssa. Sent to cath lab.
Transfer vitals: 62 147/65 18 97% RA
In cath lab, DES placed to RCA. During procedure, had
bradycardia requiring atropine and dopa 10 that was weaned to 2
by transfer. Right venous sheath placed in case of need for
pacer wire. Pacer pads on patient on transfer.
On arrival to the CCU: Patient is altered with dysarthria and
expressive aphasia.
She is accompanied by her family who provides the above history.
REVIEW OF SYSTEMS:
Limited by mental status
Past Medical History:
PAST MEDICAL HISTORY: (all care in ___
1. CARDIAC RISK FACTORS
- Hypertension
2. CARDIAC HISTORY
- History of CAD, last cath ___ years ago
- Unclear remaining cardiac history
3. OTHER PAST MEDICAL HISTORY
- arthritis
- cervical spinal stenosis s/p recent injections
- lower back surgery, unknown year
- anxiety
- overactive bladder
- hiatal hernia
Social History:
___
Family History:
Brother, father, grandfather with pacemakers. No other known
family history of heart disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VS: BP 150/136 HR 85 irregular RR 16 ___ 97 3L NC
GENERAL: elderly female, conversant but dysarthric, speech
non-fluent. Intermittently following commands.
HEENT: PERRL, MM slightly dry, difficult to visualize posterior
OP
NECK: Supple. no appreciable JVP but limited by non-compliance
CARDIAC: Irregularly irregularly rhtyhm
LUNGS: grossly CTA over anterior/lateral lung fields
ABDOMEN: Soft, non-tender, slightly distended. Right groin with
venous sheath and minimal oozing.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
NEURO: per above. notable deficit of speech. Pupils reactive,
moving all extremities, limited by non-compliance. cranial
nerves appear grossly intact. patient intermittently reaches out
extremities and says she feels like she is falling.
DISCHARGE EXAM:
================
VS: 98.1 104-146/58-59 40-53 16 98 RAWeight: 68.1 -> 68.8
- 68.2
I/O: ___
GENERAL: Elderly female, conversant. Follows commands, though
somewhat odd thinking and speech patterns.
HEENT: Sclerae anicteric
CARDIAC: Irregularly irregular this morning, no M/R/G.
LUNGS: CTAB. No wheezing on auscultation.
ABDOMEN: Soft, non-tender.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: R groin hematoma, with bruising tracking along the pelvic
plane.
PULSES: Distal pulses palpable and symmetric.
NEURO: Grossly intact.
Pertinent Results:
ADMISSION LABS:
===============
___ 03:55PM BLOOD WBC-12.6* RBC-4.35 Hgb-14.0 Hct-41.8
MCV-96 MCH-32.2* MCHC-33.5 RDW-12.9 RDWSD-45.6 Plt ___
___ 03:55PM BLOOD Neuts-76.7* Lymphs-12.8* Monos-9.5
Eos-0.2* Baso-0.4 Im ___ AbsNeut-9.62* AbsLymp-1.61
AbsMono-1.19* AbsEos-0.03* AbsBaso-0.05
___ 03:55PM BLOOD ___ PTT-22.7* ___
___ 03:55PM BLOOD Glucose-150* UreaN-16 Creat-0.7 Na-131*
K-4.2 Cl-93* HCO3-23 AnGap-19
___ 03:55PM BLOOD cTropnT-0.22*
OTHER PERTINENT RESULTS:
========================
___ 04:45PM BLOOD cTropnT-0.19*
___ 02:49AM BLOOD CK-MB-289*
___ 10:24AM BLOOD CK-MB-202* cTropnT-4.37*
___ 06:18PM BLOOD CK-MB-101* cTropnT-3.89*
___ 07:05AM BLOOD CK-MB-9 cTropnT-2.73*
___ 10:15AM BLOOD CK-MB-9 MB Indx-5.3 cTropnT-3.22*
___ 05:13PM BLOOD cTropnT-2.41*
___ 10:15AM BLOOD CK(CPK)-170
___ 12:05AM BLOOD TSH-3.5
___ 02:49AM BLOOD Triglyc-77 HDL-90 CHOL/HD-2.0 LDLcalc-73
___ 11:21PM BLOOD %HbA1c-5.1 eAG-100
___ 12:05AM BLOOD ___
MICROBIOLOGY:
=============
___ 02:49AM URINE Color-Straw Appear-Clear Sp ___
___ 02:49AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 02:49AM URINE RBC-4* WBC-2 Bacteri-NONE Yeast-NONE
Epi-0
___ 11:45PM URINE Color-Yellow Appear-Clear Sp ___
___ 11:45PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR
___ 11:45PM URINE RBC-1 WBC-4 Bacteri-NONE Yeast-NONE Epi-1
___ 2:49 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Time Taken Not Noted Log-In Date/Time: ___ 12:32 pm
SEROLOGY/BLOOD ADD RPR TAKEN FROM TUBE ___.
**FINAL REPORT ___
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
Blood Cx from ___ and ___ pending
IMAGING:
========
___ 7:15 ___
CTA HEAD AND CTA NECK
IMPRESSION:
1. Partially degraded images by motion, however no large
territorial infarct is noted.
2. Severe stenosis in the V2 segment of the left vertebral
artery.
3. Superior division of the right middle cerebral artery is
attenuated,
however there is good opacification throughout the right MCA
territory,
perhaps due to collateral flow.
4. Medialization of the proximal cervical segment of the
bilateral common
carotid arteries.
5. Chronic ischemic small vessel disease in the periventricular
white matter.
___ 11:01 ___
CHEST (PORTABLE AP)
IMPRESSION:
1. Recommend upright chest right to distinguish between right
skin fold and, less likely, small pneumothorax.
2. Mild-to-moderate cardiomegaly. Possible pulmonary arterial
hypertension.
3. No focal consolidations.
Portable TTE (Focused views) Done ___ at 3:28:40 AM
The estimated right atrial pressure is ___ mmHg. The left
ventricular cavity size is normal. No LV thrombus is seen, but a
left ventricular mass/thrombus cannot be excluded due to limited
views.. Right ventricular chamber size is normal There is no
pericardial effusion.
IMPRESSION: Very suboptimal study. Normal biventricular cavity
sizes. Unable to assess regional function.
Portable TTE (Complete) Done ___ at 1:30:00 ___ FINAL
Conclusions
The left atrium is mildly dilated. No left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). No
atrial septal defect is seen by 2D or color Doppler. The
estimated right atrial pressure is ___ mmHg. There is mild to
moderate regional left ventricular systolic dysfunction with
severe ypokinesis of the inferior and inferolateral walls. The
remaining segments contract normally (LVEF = 35 %). No masses or
thrombi are seen in the left ventricle. There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild to moderate (___) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is high normal. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
regional systolic dysfunction most c/w CAD (PDA distribution).
Mild-moderate mitral regurgitation most likely due to papillary
muscle dysfunction. Mild aortic regurgitation. Mildly dilated
ascending aorta.
___ 12:17 ___
MR HEAD W/O CONTRAST
IMPRESSION:
1. Scattered supra and infratentorial foci of slow diffusion
likely represent acute/subacute infarcts, likely embolic in
etiology.
2. Chronic ischemic small vessel disease in the periventricular
white matter.
___ 6:00 ___
CT HEAD W/O CONTRAST
IMPRESSION:
1. No evidence of acute infarction. The infarcts visualized on
the recent MRI are below the resolution of CT.
___ CXR
IMPRESSION:
Compared to chest radiographs since ___ most recently ___. Moderate cardiomegaly is stable. No pulmonary edema
pulmonary vascular congestion. Small pleural effusions are new
or newly apparent.
DISCHARGE LABS:
===============
___ 08:26AM BLOOD WBC-7.1 RBC-3.08* Hgb-10.1* Hct-30.4*
MCV-99* MCH-32.8* MCHC-33.2 RDW-14.8 RDWSD-51.7* Plt ___
___ 08:26AM BLOOD ___ PTT-27.7 ___
___ 08:26AM BLOOD Glucose-88 UreaN-18 Creat-0.8 Na-140
K-3.6 Cl-103 HCO3-23 AnGap-18
___ 08:26AM BLOOD Calcium-8.5 Phos-4.7* Mg-2.3
Brief Hospital Course:
Ms. ___ is an ___ old woman with a past medical history of
HTN, HLD, DM, and CAD who initially presented for Code STEMI s/p
cardiac cath w/ ___ and was later seen to have focal
neurologic deficits, including confusion, dysarthria and fluent
aphasia which largely resolved.
ACUTE:
======
# ACUTE CORONARY SYNDROME/Inferior STEMI: CODE STEMI in the ER,
directly to Cath lab with ___ 2 to RCA. ___
confusional state, dysarthria, evaluated as below, deficits
resolved w/in 72 h (see below). Returned to ___ lab on ___
for BMS to OM1. Again had post-procedural confusional state (see
below). On discharge anticoagulation plan was triple therapy
with aspirin, Plavix, and rivaroxaban. Defer to outpt
cardiologist to d/c clopidogrel at that point. Lisinopril was
switched to losartan because of cough.
# ACUTE STROKE: During ___ cath, developed agitation and
dysarthria. Extensive evaluation demonstrated acute and subacute
infarcts consistent with cardioembolic post-procedurally.
Lipids, A1c, TSH were normal. Neurology evaluated the patient
and deficits resolved w/in 72 hours. After ___ cath, had
another episode of confusional state, with hallucinations and
gait instability. An extensive w/u was repeated, though no MRI
ordered this time, and deficits felt to be most likely ___
toxic-metabolic encephalopathy in setting of procedural
anesthesia. B12, RPR, TSH were normal. Pt was treated with
Thiamine and folate supplementation given history of heavy
alcohol use. Discharged on anticoagulation as above.
# ARRHYTHMIA: Reported warfarin on home medications. While
admitted, was persistently in atrial fibrillation, tachy-brady,
with more episodes of bradycardia and idio-ventricular escape
rhythms overnight. Never symptomatic from bradycardia, but did
have occasional palpitations. Given the frequency of
bradycardia, metoprolol was down-titrated prior to discharge,
which the patient tolerated well. Discharged on Rivaroxaban as
above.
# LEUKOCYTOSIS: Mild elevation of WBC on admission, 12.6 on
admission w/ 77% neutrophils, bands not noted; consistent with
stress or infection. Persistently elevated throughout
hospitalization with no evidence of focal infection. By
discharge ___ count had normalized to 7.1.
# HYPONATREMIA: Serum Na 131 on admission. Felt to be ___
hypovolemia w/ recent vomiting prior to admission. Resolved.
#POSSIBLE DEPRESSION/SUICIDAL IDEATION: Throughout her
hospitalization, the pt intermittently expressed a passive wish
to die because it "was her time", but denied that she had any
thoughts of intentionally harming herself. Psychiatry was
consulted and did not think the patient qualified for a ___. She was started on Mirtazapine for depression and to help
with appetite stimulation.
CHRONIC:
========
# DAILY EtOH USE: AvoidED Ativan given visual hallucinations
while taking. Supplemented pt with thiamine, folate, and
multivitamin. She exhibited no signs of withdrawal while here.
# ARTHRITIS: Tylenol prn.
# CERVICAL STENOSIS: Gabapentin 100mg TID for radicular pain.
# ANXIETY: Pt intermittently received her home alprazolam as
needed for anxiety, although we attempted to minimize use given
her above changes in mental status.
TRANSITIONAL ISSUES:
====================
[ ] Anticoagulation plan: triple therapy with 15mg Rivaroxaban
daily, ASA 81, clopidogrel 75mg for 3 months; defer to outpt
cardiologist to d/c clopidogrel at that point.
[ ] Stroke f/u: Needs 3-month neurology follow-up (around
___
[ ] STEMI f/u: pt should f/u with cardiology at ___ before she
leaves the ___ area. She should subsequently establish care
with a cardiologist in ___
[ ] Discharged on 20 Torsemide; please assess whether this is
adequate diuresis in the setting of new myocardial damage
- New Medications: Aspirin 81, atorvastatin 80, clopidogrel 75,
metoprolol succinate 12.5, mirtazapine 15mg, rivaroxaban 15mg,
torsemide 20mg
- Changed Medications: Decreased Losartan from 100 to 20mg
- Stopped Medications: Diltiazem 180mg
-----------------
# Weight on discharge: 68.2 kg
# CODE: full
# CONTACT/HCP: ___ ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Myrbetriq (mirabegron) 50 mg oral unknown
2. Mobic (meloxicam) 15 mg oral DAILY
3. Diltiazem Extended-Release 180 mg PO DAILY
4. Losartan Potassium 100 mg PO DAILY
5. Omeprazole 20 mg PO DAILY:PRN indigestion
6. TraMADol 50 mg PO DAILY:PRN Pain - Moderate
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*1
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth every night Disp
#*30 Tablet Refills:*1
3. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
4. Metoprolol Succinate XL 12.5 mg PO DAILY
RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth
daily Disp #*15 Tablet Refills:*1
5. Mirtazapine 15 mg PO QHS
RX *mirtazapine 15 mg 1 tablet(s) by mouth every night Disp #*30
Tablet Refills:*1
6. Multivitamins 1 TAB PO DAILY
RX *multivitamin [Daily Multi-Vitamin] 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*1
7. Rivaroxaban 15 mg PO DINNER
RX *rivaroxaban [Xarelto] 15 mg 1 tablet(s) by mouth every night
with dinner Disp #*30 Tablet Refills:*1
8. Torsemide 20 mg PO DAILY
RX *torsemide [Demadex] 20 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*1
9. Losartan Potassium 25 mg PO DAILY
RX *losartan 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
10. Mobic (meloxicam) 15 mg oral DAILY
11. Myrbetriq (mirabegron) 50 mg oral unknown
12. Omeprazole 20 mg PO DAILY:PRN indigestion
13. TraMADol 50 mg PO DAILY:PRN Pain - Moderate
14.Outpatient Lab Work
Labs: Complete metabolic panel
ICD 10 code: ___
Please send results to: ___, Fax ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
==================
Inferior ST-elevation myocardial infarction
Cardioembolic strokes
SECONDARY DIAGNOSES:
=====================
Atrial fibrillation on warfarin
Hyponatremia, acute
Cervical stenosis
Anxiety
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 ___,
___ came to ___ because ___ had
chest pain and we found ___ had a heart attack.
What was done during this hospitalization?
- ___ were evaluated and treated for this heart attack. ___
received medications for your heart. ___ had two cardiac
catheterizations with 3 stents placed to keep the arteries
around your heart open.
- ___ were confused after the first catheterization, so we did
blood tests and scans to look for a cause. This was probably
caused by the anesthesia from your procedure. However, the scans
of your head showed small strokes.
- ___ were visited by the Neurologists because of these small
strokes. Fortunately, ___ did not have any physical problems as
a result of these strokes.
What should ___ do now that ___ are going home?
- Take your medications as prescribed
- Please follow up with the cardiologist here before ___ leave
the ___ area. When ___ return home to ___, ___ should
establish care with a cardiologist there, and also see your
primary doctor
- Return to the Emergency Department if ___ have any concerning
symptoms. In particular, if your weight goes up more then 5 lbs
over the course of a week, if ___ become increasingly short of
breath, or if ___ notice worsening swelling in your legs, please
call your doctor or go to the emergency room.
It was a pleasure taking care of ___. Wishing ___ the best in
health!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10261465-DS-9 | 10,261,465 | 25,280,972 | DS | 9 | 2123-07-22 00:00:00 | 2123-07-22 16:57:00 |
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
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ right-handed woman with a past
medical history of hypertension, hyperlipidemia, and diabetes
with a strong family history of stroke, who presents for several
different neurologic complaints.
Her history begins starting ___ of last week when she
developed a new headache. It is left-sided in nature starting
in
the back of her left head and neck and radiates anteriorly on
the
left side with sharp shooting pains. It has been occurring on
and off since ___. No other symptoms with this headache.
Around the same time, she has had intermittent left ear pain as
well as left submandibular tenderness. She feels like she has
had an earache and has been using eardrops at home to treat.
Starting perhaps around the same time, though this is quite
unclear, she reports a subjective sensation of bilateral lower
extremity weakness. It is difficult to get a sense of what is
going on. The left leg may be slightly worse than the right leg
and she has had some mild trouble going downstairs, but
otherwise
no functional limitation and is been able to go about her
business as usual.
Next, starting on ___, she woke up feeling "dizzy". She
describes this as a sense of vertigo (though at times has
trouble
differentiating vertigo from the pain of her headache) that
lasted several hours, from 4 AM to about 8 AM. It was
associated
with a sensation of nausea and bilateral ear fullness,
particularly on the left. With this first episode, there is
also
a whooshing noise in her ears.
She attempted to go to work, but felt quite poorly. She was in
a
cold sweat. Her ears both felt blocked her tongue felt thick
and
she felt physically ill. She had her son pick her up and take
her home.
Since ___, she is continued to fair feel poorly. She has had
several discrete episodes of vertigo, lasting anywhere from 1
minute to about 15. These may be associated with ear fullness
and whooshing, though she is inconsistent about this. She had a
total of 2 episodes of this on ___, 3 episodes yesterday, and
2 discrete episodes today.
To better describe 1 of her episodes, she was sitting at church
today when she suddenly felt vertiginous. She got up walk to
the
bathroom without difficulty and felt quite nauseous. The past
and several minutes she was able to return to the service.
I am told today, that she was evaluated at her doctor's office
and subsequently sent in.
Past Medical History:
-HLD
-DM
-hypothyroidism
Social History:
___
Family History:
Extremely strong paternal family history of stroke. Her father
died of stroke. She has 2 brothers who had strokes. One niece
and one uncle with strokes as well. The family members were all
younger than ___ I am told.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
PHYSICAL EXAMINATION
Vitals:
97.8 80 176/80 18
100% RA
General: NAD
HEENT: NCAT. Exquisitely tender at the left splenius.
Palpation
induces a radicular shooting on the left posterior aspect of her
head which duplicates her headache per reports. Left
submandibular tender lymphadenopathy.
___: RRR
Pulmonary: CTAB
Abdomen: Soft, NT, ND
Extremities: Warm, no edema
Neurologic Examination:
Vestibular evaluation extremely limited secondary to patient
cooperation.
- Mental status: Awake, alert. Able to relate history in
___.
Attentive to examiner. Speech is fluent with full sentences,
repetition and intact verbal comprehension. Naming intact in
___. No dysarthria. Normal prosody. No apraxia. No evidence
of hemineglect. No left-right confusion. Able to follow both
midline and appendicular commands.
- Cranial Nerves: PERRL 3->2 brisk. VF full to number counting.
EOMI, no nystagmus. No skew. There is questionable overshoot
with head thrust to the left. V1-V3 without deficits to light
touch bilaterally. No facial movement asymmetry. Hearing intact
to finger rub bilaterally and Weber. Does not keep eyes open
during attempts to assess vestibular system. Palate elevation
symmetric. Trapezius strength ___ bilaterally. Tongue midline.
While standing with me, at one point she states she becomes
acutely "dizzy". This lasts ___ minutes. Exam is extremely
limited as she keeps her eyes closed except for brief periods of
time. At times during this, left eye may transiently deviate
out.
- 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
*Initially, she states she cannot move the right leg off the bed
and left lower extremity at all. With significant coaching, it
becomes obvious that the left limb is pain limited due to knee
and hip pain on the left but is otherwise fully strong. With
mild coaching, the right leg moves easily. During the interview
she is seen spontaneously moving the legs in bed without any
significant difficulty.
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 2+ 2
R 2+ 2+ 2+ 2+ 2
Plantar response flexor bilaterally
- Sensory: No deficits to light touch, pin, throughout.
Proprioception intact to median movements. No extinction to
DSS.
- Coordination: No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements. Does not cooperate with heel shin.
- Gait: Able to stand and is quite steady. While standing
developed her typical left shooting headache, and must sit down.
==========================================
DISCHARGE PHYSICAL EXAMINATION:
Physical Exam:
Vitals: Tm/c: 98.3 BP: 145-180/74-95 HR: 62-66 RR: ___ SaO2:
97% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM
Pulmonary: Breathing comfortably, no tachypnea nor increased WOB
Cardiac: skin warm, well-perfused.
Abdomen: soft, ND
Extremities: Symmetric, no edema.
Neurologic:
-Mental Status: Alert, oriented x 3. Attentive, able to name ___
backward with one error. Language is fluent no paraphasic
errors.
Naming intact to high and low frequency objects. Able to follow
both midline and appendicular commands.
-Cranial Nerves: PERRL 3->2. EOMI without nystagmus. Facial
sensation intact to light touch. Face symmetric at rest and with
activation. Hearing intact to finger rub. Palate elevates
symmetrically. Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
Delt Bic Tri WrE FFl FE
L 5 ___ 5 5
R 5 ___ 5 5
BLE motor exam is significantly effort limited. She gives bursts
of $ at the r IP, a twitch at the L IP, bursts of 4 at bilateral
hamstring and TA, Gastroc. Hoover's sign present.
-Sensory: Proprioception intact BUE. Intact to LT throughout. No
deficits to light touch, pinprick, cold sensation, vibratory
sense, proprioception throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
Pertinent Results:
___ 03:55PM BLOOD WBC-9.3 RBC-4.45 Hgb-13.5 Hct-40.9 MCV-92
MCH-30.3 MCHC-33.0 RDW-12.0 RDWSD-40.4 Plt ___
___ 04:30AM BLOOD WBC-8.3 RBC-4.31 Hgb-13.1 Hct-38.9 MCV-90
MCH-30.4 MCHC-33.7 RDW-11.9 RDWSD-39.2 Plt ___
___ 05:27PM BLOOD ___ PTT-25.9 ___
___ 04:30AM BLOOD ___ PTT-25.9 ___
___ 03:55PM BLOOD Glucose-90 UreaN-15 Creat-0.6 Na-140
K-3.7 Cl-105 HCO3-22 AnGap-17
___ 04:30AM BLOOD Glucose-101* UreaN-10 Creat-0.6 Na-139
K-3.9 Cl-103 HCO3-23 AnGap-17
___ 03:55PM BLOOD ALT-26 AST-20 AlkPhos-49 TotBili-0.5
___ 03:55PM BLOOD cTropnT-<0.01
___ 03:55PM BLOOD Albumin-4.4 Calcium-9.7 Phos-3.7 Mg-1.9
___ 04:30AM BLOOD %HbA1c-6.5* eAG-140*
___ 04:30AM BLOOD Triglyc-204* HDL-45 CHOL/HD-3.9
LDLcalc-89
___ 06:50PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-6.5 Leuks-NEG
___ 08:06PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-6.5 Leuks-NEG
___ 06:50PM URINE RBC-3* WBC-3 Bacteri-FEW Yeast-NONE Epi-3
IMAGING:
CXR ___:
No acute intrathoracic process.
CTA head/neck ___ Wet read: Non-contrast Head CT: No
hemorrhage or large territorial infarct. No mass
effect. Mild paranasal sinus disease.
CTA Head:
Patent anterior and posterior circulation without evidence of
large aneurysm. However, the vessels diffusely are relatively
attenuated with areas of more focal narrowing as follows: The
proximal right M1 is markedly narrowed, likely from
atherosclerosis. The distal right cavernous ICA is moderately
narrowed.
Hypoplastic or markedly attenuated right A1 segment.
Fetal-type right PCOM circulation. Hypoplastic/attenuated/absent
right P1 segment.
Focal atherosclerotic narrowing of the mid-distal basilar
artery.
Central dural venous sinuses appear patent.
CTA Neck: Cervical carotid and vertebral arteries are patent
without evidence of flow-limiting stenosis or dissection.
Attenuated bilateral V4 segments, moderate on left and mild on
right.
Brief Hospital Course:
Ms. ___ was admitted for stroke rule-out after presenting with
multiple episodes of vertigo. Her vertigo improved
spontaneously, and she had no episodes of vertigo for over 24
hours before discharge. MRI brain was negative for stroke. A1c
6.5%, LDL 89. She was evaluated by ___ who recommended discharge
to home.
Given multiple vascular risk factors and strong family history
of stroke at young age, she was started on ASA 81 for primary
prevention.
The episodes of vertigo are associated with nausea, ear
fullness, and decreased hearing. Given her significant vascular
risk factors, she is certainly at risk for stroke, and we will
investigate this possibility with MRI. Alternate possibilities
include vestibulitis or possibly Meniere's disease, though she
has no history of prior episodes before this presentation. Her
headache is likely occipital neuralgia vs cervicogenic h/a.
Palpation of the GON reproduces her pain. Her headache
improved significantly prior to discharge.
===============================
Transitional Issues:
[ ] Vestibular ___ if vertigo returns
[ ] Follow clinical course of vertigo. If it does not recur,
this episode was likely vestibulitis. If it recurs, further
investigation re: Meniere's may be needed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 500 mg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Simvastatin 40 mg PO QPM
4. Levothyroxine Sodium 100 mcg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*4
2. Levothyroxine Sodium 100 mcg PO DAILY
3. MetFORMIN (Glucophage) 500 mg PO DAILY
4. Simvastatin 40 mg PO QPM
5. Vitamin D 1000 UNIT PO DAILY
6.Outpatient Physical Therapy
Vestibular physical therapy
Discharge Disposition:
Home
Discharge Diagnosis:
Peripheral vestibulopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Sra. ___,
Usted fue ___ hospital debido ha episodios de mareo. Un
MRI demonstro ___ Ud. no ha sufrido un derrame cerebral. Lo mas
probable es ___ fue debido a una problema con ___
oido interno. ___ oido interno es un organo ___
___ de ___.
___ a dar una receta para ir a terapia fisica. Ellos pueden
ayudarle con ___ mareo si ___ mareo regresa.
Por favor ___ con Neurologia y con ___ medico de
atención primaria.
Si experimenta alguno de ___, por favor
___ medica llamando al 911. En particular, ___
un derrame cerebral puede ocurrir de nuevo, por favor ponga
attention ___ o rapida progression de ___ :
- Parcial o completa perdida de vision ___ occur repentinamente
- Repentina inabilidad de producir ___ boca
- Repentina inabilidad de comprender cuando ___
- Repentina debilidad en ___
- Repentina ___
- Repentina perdida de ___
Sinceramente,
___ de Neurologia de ___
Followup Instructions:
___
|
10261509-DS-10 | 10,261,509 | 23,544,020 | DS | 10 | 2117-06-07 00:00:00 | 2117-06-07 17:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Silver Nitrate
Attending: ___.
Chief Complaint:
weakness, sensory change
Major Surgical or Invasive Procedure:
___ pheresis catheter placement
History of Present Illness:
The patient is a ___ year old man with a history of two prior
episodes of acute inflammatory demyelinating polyneuropathy who
returns with increasing weakness and sensory changes over the
past few days prior to admission.
He first experienced symptoms in late ___ and
presented to ___ after one week of slowly progressive,
distal-predominant ascending weakness and sensory loss about
three days after received a tetanus vaccine. His weakness
progressed to the point that he could not ambulate without two
assists. His LP findings were consistent with AIDP, and he was
treated with IVIG x 5 days with subsequent improvement in his
strength. As an outpatient after discharge, he underwent
electromyography which confirmed a demyelinating polyneuropathy
(prolonged distal latencies, prolonged or absent F-waves). Two
weeks later, he had recurrence of weakness and sensory changes
with a new symptom of some loss of sensation with urination. He
was readmitted in ___, was evaluated by the
Neuromuscular service, and underwent IVIG a second time, though
this was complicated by aseptic meningitis, transaminitis, and
leukopenia. Nonetheless, his symptoms did improve and he was
able
to achieve independence with ambulation and ADLs again. He
reported improvement in his weakness after his last
hospitalization in ___, but his sensory disturbances
persisted, including an area of paresthesias covering his nose
and bilaterally across his face along the V2 distribution. He
was
able to return to work (where he works as a ___ which
includes physical labor). When evaluated by Drs. ___ in ___, he had recovered approximately 90% of
his strength with the exceptino of his left leg which remained
weaker.
On ___, he became concerned when he felt significant
fatigue which was unusual for him. The next day, he started
having difficulty with walking up and down stairs. He noticed
that it was becoming harder to write and to pursue his usual
hobbies (requiring fine motor skills, artwork). His paresthesias
persisted during this time but seemed to worsen across his face,
chest, and on the bottom of his feet. Concerned about an
expected
further progression of symptoms, the patient represented to
___
seeking medical attention.
Past Medical History:
[] Neurologic - AIDP (___)
[] Cardiovascular - Hypertension
[] Endocrine - B12 deficiency
Social History:
___
Family History:
No neuromuscular diseases or movement disorders.
Psychiatric disease (mother, sister).
Physical Exam:
ADMISSION EXAM:
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: lcta b/l
Cardiac: RRR, S1S2, no murmurs appreciated
Abdomen: soft, NT/ND, +BS
Extremities: warm, well perfused
Skin: no rashes or lesions noted.
Neurologic:
Mental Status: Awake, alert, oriented to person, place and date.
Able to relate history without difficulty. Attentive, able to
name ___ backward without difficulty. Able to follow both
midline
and appendicular commands. No right-left confusion. Able to
register 3 objects and recall ___ at 5 minutes. No evidence of
apraxia or neglect
Language: speech is clear, fluent, nondysarthric with intact
naming, repetition and comprehension.
Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted. Neck flexor and extensor strength ___. He is mildly weak
in the proximal muscles, left greater than right.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 4+ 5 4+ ___ 5 5- ___ 5
R 5- 5 5- ___ 5 5- ___ 5
Sensory: Intact to light touch. There are patches of pinprick
loss in his UE and ___ b/l, in no clear distribution. There is no
sensory level. Proprioception is intact in the great and ___ toe
b/l. Distal cold temp loss. Vibratory sense absent at left great
toe and 8 secs. at left lateral malleolus; it is 4 seconds at
right great toe.
DTRs:
Bi Tri ___ Pat Ach
L 0 0 0 0 0
R 0 0 0 0 0
Plantar response was flexor bilaterally.
Coordination: No intention tremor or dysmetria on finger-nose,
FNF or HKS bilaterally.
Gait: Good initiation. Narrow-based, normal stride and arm
swing.
Difficulty with toe-walking. Unable to to tandem walk. Romberg
is
positive.
--------
Pertinent Results:
___ 05:30PM WBC-5.7 RBC-4.50* HGB-13.7* HCT-40.4 MCV-90
MCH-30.4 MCHC-33.8 RDW-13.5
___ 05:30PM NEUTS-59.0 ___ MONOS-5.7 EOS-0.3
BASOS-0.6
___ 05:30PM ___ PTT-28.4 ___
___ 05:30PM PLT COUNT-200
___ 05:30PM GLUCOSE-118* UREA N-17 CREAT-0.9 SODIUM-140
POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-27 ANION GAP-16
___ 05:30PM CK(CPK)-350*
___ 05:30PM CALCIUM-10.8* PHOSPHATE-5.6* MAGNESIUM-1.7
___ 09:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
Brief Hospital Course:
___ h/o AIDP p/w progressive weakness and paresthesias
concerning for a third flare, now most likely representing CIDP.
[] Weakness, Sensory Change - The patient presented with proxmal
muscle weakness (worse on the left than right) concerning for a
relapse of AIDP versus chronic inflammatory demyelinating
polyneuropathy. He also had persistent sensory disturbances
worse on the face and feet with patchy pinprick sensory loss. He
was treated with plasmapheresis for 5 courses with good
response. He was evaluated by ___ and OT who cleared him to go
home; he was walking up several flights of stairs and riding on
the exercise bike by the time of discharge. He was started on
gabapentin to help with neuropathic pain. He did endorse
significant depression and even suicidal ideation without a plan
or intent; Psychiatry was consulted and assessed that he was not
an acute safety risk for returning home, but that he would
likely benefit from outpatient followup with a therapist or
psychiatrist with possible benefit from an antidepressant
(possible Bupropion for its stimulatory effect as well as he
might have ADHD-like components to his mood disorder). He also
may look into the option ___ as he reports having failed
multiple antidepressants in the past. He will followup with Drs.
___ for neurological reassessment and
consideration for possible maintenance pheresis.
PENDING STUDIES: None
TRANSITIONAL CARE ISSUES:
[ ] Please determine whether the patient would benefit from
maintenance plasmapheresis.
[ ] Please check to see if the patient has followed up with the
___ clinic or a therapist/psychiatrist near his home town.
Medications on Admission:
Metoprolol succinate 50 mg daily, Vitamin B12 1000
mcg daily
Discharge Medications:
1. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
2. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
3. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Inflammatory demyelinating polyneuropathy
(acute versus chronic)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neurologic: No focal deficits, full strength.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to recurrent symptoms of weakness and
sensory disturbances that most likely represent a recurrence of
your prior syndrome. Given this recurrence but also the
persistence of prior symptoms, it is difficult to determine with
certainty whether this represents a relapsing form of ACUTE
INFLAMMATORY DEMYELINATING POLYNEUROPATHY (also known as
___ Syndrome) or if it represents CHRONIC
INFLAMMATORY DEMYELINATING POLYNEUROPATHY. Nonetheless, the
immediate treatment is the same. While both IVIG and
plasmapheresis are equally effective, we opted to pursue
plasmapheresis this time because you had IVIG twice previously
without full resolution of symptoms and with some associated
adverse effects.
We are adding Gabapentin to your medication regimen:
1. Please take NEURONTIN/gabapentin 100 MG three times daily
(about every 8 hours) for treatment of nerve-related pain.
We would like you to followup with Drs. ___
in the Neurology clinic as listed below.
Please contact the ___ as well as
the therapist resources that our social worker ___
provided for you.
If you experience any of the following symptoms, please seek
medical attention.
It was a pleasure providing you with medical care during this
hospitalization.
Followup Instructions:
___
|
10261569-DS-13 | 10,261,569 | 26,299,168 | DS | 13 | 2171-11-27 00:00:00 | 2171-11-27 15:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics) / ciprofloxacin / nitroprusside
sodium / latex / Penicillins
Attending: ___.
Chief Complaint:
Reason for Consult: Transfer from outside hospital with ___
Major Surgical or Invasive Procedure:
Intubation
Mechanical ventilation
Central line insertion
Catheterization for electrophysiology study
History of Present Illness:
HPC: The pt is a ___ year-old right-handed woman with Hx of HTN,
Anxiety and allergic asthma, who presented with IPH from OSH.
She mentioned that today at 1500 she drove from his work to the
___ after she became SOB with chest discomfort.
She initially developed exertional dyspnea for the past few
months, Which was progressively getting worse during the last
week as she is allergic to mold and she found mold in her closet
she drove to the ___ at 3 pm, at that time she had SOB
with chest discomfort which improved after some rest but did not
have headache, nausea and vomiting with BP of 180/84 and heart
rate of 47. She received ASA 325mg, SL NTG, albuterol and
Ativan. Her BP elevated to 258 and remained higher than 214 for
5 hours despite of getting nitro gtt, she was eventually
admitted to the ICU and at ___ BP dropped to ___ in 15
minutes remained low for 10 min and back to 239 in 20 min.Her
ECG was noted to have high-degree AV block with a narrow QRS.
During the evaluation at ___ Her chest pain resolved
but she developed anxiety, headache and left facial droop and
left side weakness, performed CT showed IPH in R frontal lobe,
at this point as TNG gtt was not working for her and she
developed macular rash she was started on nicardipine drip and
transferred to ___ for further care.
During the transference she was awake and alert and moving all
limbs. At the time of arrival at ___ Her BP was 137/70s and
she was awake, mildly lethargic that she blamed Ativan for that
with headache in right frontal area, nausea and vomiting. She
had left facial droop and left side neglect without weakness in
ext. her ECG was again concerning for high-degree AV block. By
time she became hypertensive again with severe nausea,
intractable vomiting and headache, she was started on
nitroprusside infusion and was transferred for ___ and neck
CTA. While she was on the CT bed she had several episodes of
vomiting and CT was not done,as she was unable to protect her
airway while lying flat in bed, She was intubated for airway
protection and received Norvasc and propofol.
During the intubation there was artifact on telemetry and
concern for more profound bradycardia sp she received atropine
0.5mg x2 with brief (___) increase in HR to ~75-80bpm and
stabilized at at 60-65bpm. CT/CTA was done and did show mild
expantion of IPH in right frontal area, SAH in both hemisphere
with midline shift without herniation.
On neuro ROS, the pt noted sudden onset achy headache in right
frontal area, ___, with nausea and vomiting which started
this evening,she denied loss of vision, blurred vision,
diplopia, dysphagia, lightheadedness, vertigo, dysarthria,
tinnitus or hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness other than left arm
weakness which she thinks is improving, no numbness, or
parasthesiae. No bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. she mentioned that she had a sore throat and cough which
started recently, she also mentioned having diarrhea which is
started 2 months ago, now the stool is formed but still loose
with ___ bowel movement a day, she also noted that she was
diagnosed with UTI and received doxycyclin, changed to
augmentin, but her diarrhea started days before antibiotics, she
denied seeing any blood in the stool. She also mentioned
decreased appetite but mentioned that despite decreased appetite
and loose stool her weight has not been changed 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.
Interval changes:
She is intubated at midnight and transferred to ___, her neuro
exam at 0600 changed and she did not move her left arm and leg,
CT was done which did show intraventricular spreading and
worsening of midline shift, she was started on hypertonic ___
with the goal of keeping Na level 150 to 155.
Past Medical History:
PMH:
1. hepatitis C for ___ years not on treatment
2. HTN for years, between 130-150
3. Anxiety
4. Allergic asthma
5. uterine fibroma s/p hysterectomy
6. Hypothyroidism, currently not on treatment
7. Panic attack
8. Fibromyalgia
Social History:
___
Family History:
Family Hx:
HTN and CAD Father.
Her brother and her son has hx of brain tumor.
There is no history of seizures, developmental disability,
learning disorders, migraine headaches, strokes less than 50,
neuromuscular disorders, or movement disorders.
Physical Exam:
Physical Exam:
EXAM ON ADMISSION:
Vitals:
Time HR BP RR Pox
Yest 21:50 48 137/70 15 100%
Yest 23:56 55 176/53 13 100%
Yest 23:58 62 ___
Today 00:03 68 ___
AT 2355 she was intubated for airway protection as she had
multiple episodes of vomiting
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
Full range of motion OR decreased neck rotation and
flexion/extension.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally. Calves SNT bilaterally.
Skin: Has a erythematous macular rash.
Neurological examination:
- Mental Status:
Eyes spontaneously open but drowsy, oriented x ___ thinks
that she is still in ___. Speech is dysarthric
specially in lip and lingual sounds. The pt. had good knowledge
of current events. Able to relate history 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
Inattentive to ___ backward) Pt. was able to register 3 objects
and recall ___ at 5 minutes as she is inattentive. Able to
follow both midline and appendicular commands There was no
evidence of apraxia She has left visual and tactile neglect.
- Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm in the right side and 2 to 1 in the left
side. Has gaze deviation to the right, but VFF seems intact.
Blinks to threat bilaterally. Funduscopic exam reveals no
papilledema, exudates, or hemorrhages.
III, IV, VI: Eys are deviated to the right, but able to pass the
midline
V: Facial sensation intact to light touch. Good power in muscles
of mastication.
VII:left facial weakness
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline with normal velocity movements.
- Motor: Normal bulk, tone throughout. Has left pronator drift.
Finger tapping is slower in the left hand and has delay in motor
task in the left side in comparison to the right side. No
adventitious movements, such as tremor, noted. No asterixis
noted.
SAbd SAdd ElF ElE WrE FFl FE IO HipF HipE KnF KnE AnkD ___
___
L 5 5 ___ ___ 5 5 5 5 5 5
R 5 5 ___ ___ 5 5 5 5 5 5
- Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout in UE and ___. Has
left side tactile neglect
- DTRs:
BJ SJ TJ KJ AJ
L ___ 3 2
R ___ 3 2
There was no evidence of clonus. Plantar response was mute
bilaterally
- Coordination: No intention tremor, normal finger tapping. No
dysdiadochokinesia noted. No dysmetria on FNF or HKS
bilaterally.
- Gait:deferred
DISCHARGE EXAMINATION:
VITALS: Tmax 98.9/Tcurrent 98.1 BP 133/69 (systolic BP ranging
from 106-163) HR ranging 45-60 RR ___ O2 100% RA
GEN examination: unremarkable.
Neuro:
MS: alert awake, speech is fluent but somewhat tangential and
disinhibited. Good memory of recent events (her medical care).
CN: PERRL, EOMI, L facial droop.
Motor: There is mild motor neglect and weakness on the left side
which are improved during the hospitalization. With multiple
prompting, she is better able to move the left side.
Del Bic Tri WrE FFl FEx IP Quad ___ ___ ___
L 4 4+ 4- ___ 4 5 * 4+ 4+ 4+
R 4+ 5- 4+ ___ 5 5 4+ 5 5
* L Hamstring difficult to test due to impersistency/difficulty
following command, but at least antigravity.
Pertinent Results:
ON ADMISSION:
Laboratory Data:
Na:142, K:3.9, Cl:102, TCO2:23, Glu:155
___: 10.7 PTT: 28.2 INR: 1.0
WBC:15.9 HB:15.3 PLT:268 HCT:44.3
ECG:
High-degree AV block with a narrow QRS and ventricular rate of
~45-55bpm (A-rate ~70-75bpm) with intermittent A-V conduction.
CTA ___ ___
IMPRESSION:
1. Slightly enlarged right frontal hematoma with minimally worse
left-sided midline shift and extension of blood products within
the ventricles.
2. Stable appearance of the subarachnoid blood products. No
evidence of aneurysm or arteriovenous malformation in the
anterior or posterior circulation.
3. Segmental narrowing of several branches of the right middle
cerebral artery which could be seen with vasospasm, however
atherosclerosis or vasculitis could have a similar appearance.
Clinical correlation is advised.
4. Small thyroid nodules with the largest measuring 7 mm.
5. 5 mm nodularity of the right upper lobe probably representing
scarring, however further evaluation with CT scan could be
considered if clinically indicated.
TTE ___:
Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic (EF
75%). Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets are mildly thickened (?#).
There is no valvular aortic stenosis. The increased transaortic
velocity is likely related to high cardiac output. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: no valvular/endocardial lesions suggestive of
carcinoid heart seen.
CXR ___:
IMPRESSION:
1. Appropriately positioned endotracheal tube.
2. Pulmonary vascular congestion.
CT ___ ___:
IMPRESSION:
1. No significant interval change in large right frontal
intraparenchymal hemorrhage with right frontal and left
posterior parietal subarachnoid components.
2. Interval increase of amount of blood layering in the
occipital horns of the lateral ventricles, likely from
continuing re-distribution.
3. No significant change in leftward shift of midline
structures or mass effect on the right lateral ventricle.
MR ___ w/ w/o contrast ___:
IMPRESSION: Right frontal hematoma with no definite underlying
lesion identified. However, evaluation is limited due to
presence of blood products. Suggest repeat MR evaluation in a
few weeks after resolution of acute blood products . Presence of
hemorrhage fluid levels suggest underlying coagulopathy.
Renal U/S ___:
IMPRESSION: Normal renal Doppler ultrasound. No renal artery
stenosis.
CT ___ ___:
IMPRESSION:
1. No significant interval change in large right frontal
intraparenchymal
hemorrhage with bilateral frontal and left posterior parietal
subarachnoid components. Small amount of intraventricular blood
products from redistribution is also stable.
2. No significant change in leftward shift of midline
structures or mass effect on the right lateral ventricle.
EEG ___:
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of the presence of a severe diffuse encephalopathy with
features suggesting more focal structural pathology broadly
present throughout the right hemisphere. There were no
convincing interictal discharges nor were there any sustained
event suggesting unrecognized seizures. It should be noted,
however, this was a technically difficult study to interpret
because the vast majority of the recording was contaminated with
continuous high amplitude muscle artifact.
CT ___ ___:
IMPRESSION:
Large right frontal intraparenchymal hemorrhage with increased
edema and mass effect resulting in mildly increased compression
of the right lateral ventricle, subfalcine herniation, sulcal
effacement, and small right uncal herniation. No new
hemorrhage.
CT ___ ___:
Large right frontal intraparenchymal hemorrhage with associated
vasogenic edema and mass effect, unchanged allowing for
differences in positioning. Resolving intraventricular
hemorrhage. No new hemorrhage.
Brief Hospital Course:
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No
=================================
___ yo RH woman with h/o HTN, anxiety, hep C, and allergic
asthma, who presented from OSH with at least 2 right frontal
intraparenchymal hemorrhages and bilateral subarachnoid
hemorrhages, with intraventricular extension. Initial symptoms
that brought pt to ED included SOB and CP but during evaluation
for this at OSH, SBP went up to 260 and was brought down to 89
with medications, and she developed new-onset left facial droop,
and left-sided neglect. Intubated for airway protection.
Since presentation, has developed a more prominent left-sided
weakness.
As for etiology of her hemorrhage, hypertensive hemorrhage vs
cavernous hemangioma which bled in response to rapid changes in
her blood pressure vs AVM vs vasculitis (given hx of Hepatitis
C) vs. reversible vasoconstriction syndrome (note that CTA shows
some evidence of irregular vessel narrowings) were all
considered at presentation
Pt was in the ICU ___.
# NEURO: ICH with intraventricular extension and bilateral
subarachnoid blood. Pt was observed in the ICU with frequent
neurochecks, and monitored with repeated ___ CTs. Blood
pressure was maintained in a tight range with SBP 130-160,
requiring nicardipine gtt intermittently. She was given mannitol
therapy for part of her stay. MRI showed no evidence for
pre-existing lesion or any microbleeds, making underlying
amyloid angiopathy unlikely. CTA and MRA did not show any
abnormal vessels suggestive of an AVM as a possible source of
her hemorrhage. Conventional angiogram showed no obvious source
of bleeding but did demonstrate spasm of the A1 segment of the
right ACA, so pt was started on nimodipine and monitored with
transcranial Dopplers. Pt was initially started on seizure
prophylaxis with levetiracetam but this was stopped after EEG
was normal and angiogram showed no source of further bleeding.
For headache, pt was kept on topiramate and PRN Fioricet, but
both of these were stopped prior to discharge because she did
not have further headaches.
For other possible etiology, cryoglobulins were checked given
concern for vasculitis in setting of Hep C and were negative.
Due to concern for possible vasospasm from possible reversible
cerebral vasoconstriction syndrome, she was started on
nimodipine. Nimodipine was eventually tapered off.
# ___:
RATE:
High-degree AV block (likely in His bundle), with intermittent
1:1 and 2:1 conduction, no hemodynamic consequence at this time.
Transiently bradycardic but responsive to atropine.
There is likely underlying cardiac conduction disease that is
currently being exacerbated by autonomic effects from either ICH
or possible pheochromocytoma. Carotid manual stimulation has
repeatedly led to VTach, also suggestive of sympathetic
hyperexcitability. Pacer wires were initially inserted but
cardiology EP service recommended not pacing pt now as this here
has led to pacer syndrome with concurrent A-V contraction
leading to hypotension Instead should control HR w/ BBlckr as HR
becomes symptomatic at higher rates. In the ICU, pt was kept on
metoprolol PO 75 mg TID, whichw as ultimately uptitrated to 100
mg TID per cardiology recommendation. She had EP study, and per
cardiology, there was reliable escape rhythm, and they thought
risk of pacemaker lead dislodgement and complications in setting
of planned acute rehab may outweigh the benefit of pacemaker in
the short term and did not place pacemaker at this time. She is
being discharged with a long term heart rate monitoring and she
will need follow up with Dr. ___ as scheduled on ___,
which is VERY important.
*There is instruction with the long term monitor box, but
patient can shower with the monitor. The leads should be
replaced every 3 days AND whenever the leads are loose.*
BLOOD PRESSURE
SBP was kept between 130-160 with nicardipine vs norepinephrine
drip PRN, with escalating doses of scheduled BP medications
(clonidine, lisinopril, amlodipine). To w/u etiology of BP
spikes, have performed renal Dopplers (wnl), 24-hr urine
collection for VMA, metanephrines (moderately elevated but not
suggestive of pheochromocytoma). Endocrine consult was obtained
to help with w/u of possible secondary HTN etiologies such as
pheochromocytoma or carcinoid. Pheochromocytoma was ruled out
with urine VMA/metanephrines and carcinoid was ruled out with
serum HIAA.
On ___ on 1450 during working with ___ her BP dropped to 40
and heart rate increased to 92, she became drowsy, she was
transferred to bed and in less than 2 min her SBP went up to
122.
In terms of her blood pressure medications -
1. Nimodipine is being weaned off as cerebral artery vasospasms
are thought to be less likely, so Nimodipine was changed to 30
mg daily on ___ and STOPPED on ___.
2. Consider weaning off clonidine very slowly if her blood
pressure is well controlled at rehab as it can have rebound
hypertension.
# RESP: she was doing well on room air, intubated for airway
protection after developing intractable vomiting. After
extubation, no active issues. She was started on prn
albuterol/ipratropium nebulizers while in the hospital but these
could be weaned off if not needed in the rehab.
# ENDO: A1C 5.4, nondiabetic. History of hypothyroidism: TSH wnl
# ID/inflammatory: Spiking fevers, leukocytosis, found to have
enterococcus UTI which was treated with vancomycin with
resolution of fevers/leukocytosis. Other work up including ESR
wnl, CRP mildly elevated at 12. ANCA negative.
- history of Hep C: HCV viral load 10 million; cryoglobulins
were checked given concern for vasculitis and were negative.
# Chronic diarrhea(now loose stool with decreased appetite):
Possibility of carcinoid was considered but ruled out as above.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Gabapentin 300 mg PO UNDEFINED
3. traZODONE 50 mg PO HS:PRN imsomnia
4. ALPRAZolam 0.5 mg PO QHS
5. Quetiapine extended-release 150 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
Discharge Medications:
1. Gabapentin 300 mg PO TID
2. Lisinopril 40 mg PO DAILY
3. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Shortness of
breath/wheezing
5. Atorvastatin 20 mg PO DAILY
6. CloniDINE 0.2 mg PO TID
7. Docusate Sodium 100 mg PO BID
8. Heparin 5000 UNIT SC TID
9. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN Shortness of
breath/wheezing
10. Metoprolol Tartrate 100 mg PO TID
11. Senna 1 TAB PO BID:PRN constipation
12. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
13. Lidocaine 5% Patch 1 PTCH TD DAILY
14. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN Cough
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Hemorrhagic infarction in the setting of uncontrolled blood
pressure.
2. Uncontroled HTN
3. High degree heart block
4. Dysphagia
5. UTI s/p treatment with vancomycin
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Neurologic Exam: L facial droop, mild motor neglect/weakness
throughout L side in upper motor neuron pattern. Some mild
weakness on right side as well but better than left.
Discharge Instructions:
Dear Ms ___,
You were hospitalized due to symptoms of left side weakness
resulting from an ACUTE HEMORRHAGIC STROKE, a condition where a
blood vessel ruptured and bled into your brain. The brain is the
part of your body that controls and directs all the other parts
of your body, so damage to the brain can result in a variety of
symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
1. high blood pressure.
Regarding your high blood pressure we performed multiple tests
to find out the cause of your high blood pressure, so far the
tests result did not show any abnormality.
Regarding your heart block, you were evaluated by cardiology
service who recommended EP study. As they felt that you have a
good escape rhythm, pacemaker was not placed. It is very
important that you follow up with the EP (electrophysiology)
cardiologist - Dr. ___ - to monitor your heart rhythm and
to get your pacemaker placed in the future.
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization.
Followup Instructions:
___
|
10262067-DS-5 | 10,262,067 | 27,183,391 | DS | 5 | 2147-03-26 00:00:00 | 2147-03-27 02:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Lisinopril / Percocet / hydrochlorothiazide
Attending: ___.
Chief Complaint:
acute memory loss
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a very pleasant ___ year old right handed woman
with history of hyperlipidemia, hypertension and asthma who
presents with an episode of retrograde amnesia. Patient was
doing well today with no complaints. In the afternoon, she
spoke with her granddaughter who invited her over for dinner
tomorrow night. Ms. ___ accepted the invitation and
called her ___, (now present) to let her know tht she
will not be able to take care of the dog tomorrow night. She
talked to ___ another time later that afternoon. At around
9:15pm, patient had an episode of "cold sweats" lasting
approximately 30 seconds without chest pain or shortness of
breath. Shortly after, she called her daughter, ___. She told
her that she remembers she is going to see her granddaughter
tomorrow but cannot remember why. She also could not remember
anything that happened since 2pm or the day before. She also
does not remember yesterday and that she walked ___ dog. Ms.
___ was repeating the same questions over and over,
despite receiving answers. She did not have any dysarthria,
word finding or comprehension difficulty at that time. She
denies vision changes, focal weakness/numbness, clumsiness. ___
went to her mother's house and she still had forgotten above
events wand was repeatedly asking the same questions. When
asked about stressors, Ms. ___ and ___ tell me she has
been EXTREMELY stressed. She is in the process of selling her
___, moving, packing and doing a lot of complicated paperwork.
She has never had an episode similar to this before. Patient
does tell me that she had a bifrontal headache today --not
pressure, not throbbing, "just a normal headache," which
resolved with taking aspirin. Also, tells me that sometimes, in
the mornings, particularly when it is warm and humid, she feels
"a little bit fuzzy" when she just wakes up. In regards to
memory, she now recalls everything that her daughter has told
her and is no longer asking questions. But, she does not recall
the actual events themselves.
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, lightheadedness, vertigo,
tinnitus or hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
-gastritis on recent EGD
-Asthma
-Hypertension.
-Hypercholesterolemia.
-Appendectomy.
-History of arthroscopic knee surgery.
-History of C-section.
-GERD
Social History:
___
Family History:
Family Hx: (per OMR, confirmed)
-father passed away at age ___ and had a massive MI at age ___
-mother lived to be ___ and had dementia
-son was recently diagnosed with Hodgkin's lymphoma, is
currently status post chemotherapy, undergoing radiation and
doing reasonably well
-No history of strokes, seizures
Physical Exam:
Physical Exam:
Vitals: 98.0 65 168/92 19 98% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated.
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Pt. was able to name both high and low frequency
objects. Speech was not dysarthric. Able to follow both midline
and appendicular commands. Pt. was able to register 3 objects
and recall ___ at 5 minutes, ___ with prompting. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5-
R 5 ___ ___ 5 5 5 5 5 5-
-Sensory: No deficits to light touch, cold proprioception
throughout. Decreased vibratory sense at halluxes, L>R. No
extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was mute bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: not tested
DISCHARGE EXAM normal neurological exam. no memory deficits
noted
Pertinent Results:
Studies:
Labs: CBC, Chem7, INR unremarkable; UA neg for infection;
urine/serum tox neg
NCHCT: no hemorrhage, no dense MCA sign, good grey/white matter
differentiation; white matter small vessel disease present
Brain MR: There is no acute infarct or intercerebral
hemorrhage. The ventricles and sulci are prominent suggesting
age related involutional changes. There is periventricular
small vessel ischemic disease. No diffusion abnormality is
detected. Incidentally noted, is a punctate low signal in the
left parietal lobe on gradient echo imaging which likely
represents microhemorrhage.
MRA head and neck: The circle of ___ and its major branches
are patent. The cervical vertebral arteries and internal
carotid arteries are patent without significant stenosis. There
are no aneurysms >3mm. Incidentally noted, are bilateral
posterior communicating artery infundibula.
IMPRESSION:
1. No evidence of acute stroke.
2. Normal MRA of the head and neck
Brief Hospital Course:
Ms. ___ is a very pleasant ___ year old right handed woman
with history of hyperlipidemia, hypertension and asthma who
presents with an episode of retrograde amnesia in the setting of
recent stressors. She had difficulty recalling events from the
day or 2 prior but was able to recall events in the distant
past. Her daughters noted an acute change and were concerned
for stroke and convinced her to come to the ED. She did not have
any dysarthria, word finding or comprehension difficulty. She
denies vision changes, focal weakness/numbness, clumsiness. A
Code Stroke was called in the ED with NIHSS of 0 and a head CT
was done which was normal. By the following day her
neurological exam remained normal and her memory deficits have
improved. We believe the episode is most consistent with
transient global amensia, as many of the features of her
presenting history are classic for TGA (although she is slightly
older than usual for the diagnosis). Her headache would be
atypical for a migrainous phenomenon and MRI excluded a temporal
lobe ischemic stroke. Her clinical history is less convincing
for seizure. Toxic/metabolic workup was completely normal.
Likely she will have full recovery but we will follow in
outpatient neurology clinic and advised her to come to the ED if
she develops any further memory loss with focal neurologic
signs.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
2. Fexofenadine 180 mg PO BID
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Omeprazole 20 mg PO DAILY
5. Simvastatin 20 mg PO DAILY
6. Valsartan 80 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit Oral daily
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
2. Aspirin 81 mg PO DAILY
3. Fexofenadine 180 mg PO BID
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Omeprazole 20 mg PO DAILY
6. Simvastatin 20 mg PO DAILY
7. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit Oral daily
8. Valsartan 80 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
transient global ischemia
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 ___ after you had
a brief sensation of cold sweats and subsequent memory loss.
Your family was concerned for stroke and brought you to our
hospital where a Code Stroke was called. Our neurologists
examined you in the Emergency Department but found no
abnormalities. A CT scan and MRI of your brain was done and
they were found to normal. There was no evidence of stroke or
other brain lesion to account for your memory loss. Based on
your description of the event we do not believe this is
consistent with a seizure. By the time you were admitted on the
floor you had resolution of your memory problem. We suspect
that the cause of your symptoms is a condition called transient
global amnesia or TGA. TGA is a condition caused by temporary
changes in the part of your brain that regulates memory and this
typically resolves within hours and has no presistent effects.
We made no changes to your medications on this admission, but we
ask that you follow up with your primary care physician and also
___ in clinic as scheduled. Thank you for allowing us to
participate in your care.
Followup Instructions:
___
|
10263098-DS-10 | 10,263,098 | 20,854,118 | DS | 10 | 2153-02-02 00:00:00 | 2153-02-02 10:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
postoperative constipation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with history of ESRD on HD
after renal allograft failure, diabetes, and recent right
colectomy to remove a poorly differentiated cecal carcinoma who
presents with post-operative ileus. He was doing well
post-discharge until
yesterday, when began to feel weak. He went to dialysis and
slept through the treatment. Afterwards, he fell, striking his
left elbow and left knee on cement. He began to develop nausea,
and had multiple episodes of bilious emesis. He has been
passing
flatus but not stool for two days. He endorses cough with green
sputum and fever. He denies chills, chest pain, rash, and
edema.
Past Medical History:
- Living-unrelated renal transplant ___ chronic allograft
nephropathy, graft failure
- Left forearm brachiocephalic AV fistula by Dr. ___ ___
- Hypertension
- Diabetes mellitus type 1: followed at ___, diagnosed with
type 1 diabetes at age ___
- Colonic polyps
- Loss of vision right eye secondary to diabetic retinopathy
- Left hallux gangrene ___
- L4-L5 laminectomy and fusion
- Squamous cell carcinoma in situ sternum, s/p Mohs ___
Social History:
___
Family History:
Notable for diabetes in mother with related renal disease
Physical Exam:
On discharge:
AFVSS
Gen: NAD, A+Ox3
CV: RRR
Pulm: No resp distress
Abd: Soft, NT, ND, incision c/d/i
Ext: WWP
Pertinent Results:
___ 01:25PM BLOOD WBC-8.9 RBC-3.84* Hgb-8.0* Hct-26.0*
MCV-68* MCH-20.8* MCHC-30.6* RDW-19.8* Plt ___
___ 03:45AM BLOOD Neuts-90.0* Lymphs-5.1* Monos-3.7 Eos-1.1
Baso-0.2
___ 07:05AM BLOOD ___
___ 06:00AM BLOOD Glucose-110* UreaN-18 Creat-3.5*# Na-135
K-4.2 Cl-95* HCO3-33* AnGap-11
___ 06:00AM BLOOD Calcium-7.2* Phos-2.6* Mg-2.0
___ 09:10AM BLOOD tacroFK-8.2
Brief Hospital Course:
Mr. ___ presented to the ED on ___ with a
postoperative ileus and constipation. He was admitted for
conservative management and improved greatly, tolerating a
regular diet and having multiple bowel movements prior to
discharge.
Neuro: The patient was stable from a neurologic perspective. He
received his home dose of oxycodone for his chronic back pain.
CV: The patient was stable from a cardiovascular perspective.
Pulm: The patient was stable from a respiratory perspective.
GI: The patient received a nasogastric tube which was removed
when the output had decreased and the patient was adequately
decompressed and passing flatus. His diet was advanced as
tolerated. He was given a bowel regimen and suppositories and
had multiple bowel movements prior to discharge without issue.
GU: The patient was followed by the renal service for his
hemodialysis, which he continued on his normal regimen without
issue.
ID: The patient was monitored for signs and symptoms of
infection. He was found to have a pneumonia and started on
levofloxacin which was renally dosed.
MSK: The patient sustained a wound to his left elbow in the fall
he had prior to his arrival at ___. Wound nurse was
consulted and provided recommendations for wound care which were
provided to the patient. A ___ was set up to assist with wound
care at home and he will follow up with his primary care
physician.
Heme: The patient was stable from a hematologic perspective.
On ___, the patient was discharged to home. At discharge, he
was tolerating a regular diet, passing flatus, stooling,
voiding, and ambulating independently. He will follow-up in the
clinic in ___ weeks. This information was communicated to the
patient directly prior to discharge.
Include in Brief Hospital Course for Every Patient and check of
boxes that apply:
Post-Surgical Complications During Inpatient Admission:
[ ] Post-Operative Ileus resolving w/o NGT
[ ] Post-Operative Ileus requiring management with NGT
[ ] UTI
[ ] Wound Infection
[ ] Anastomotic Leak
[ ] Staple Line Bleed
[ ] Congestive Heart failure
[ ] ARF
[ ] Acute Urinary retention, failure to void after Foley D/C'd
[ ] Acute Urinary Retention requiring discharge with Foley
Catheter
[ ] DVT
[ ] Pneumonia
[ ] Abscess
[x] None
Social Issues Causing a Delay in Discharge:
[ ] Delay in organization of ___ services
[ ] Difficulty finding appropriate rehabilitation hospital
disposition.
[ ] Lack of insurance coverage for ___ services
[ ] Lack of insurance coverage for prescribed medications.
[ ] Family not agreeable to discharge plan.
[ ] Patient knowledge deficit related to ileostomy delaying
discharge.
[x] No social factors contributing in delay of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 200 mg PO Q12H
2. alfuzosin 10 mg oral daily
3. Amlodipine 10 mg PO DAILY
4. Nephrocaps 1 CAP PO DAILY
5. Calcium Acetate 1334 mg PO TID W/MEALS
6. Carvedilol 25 mg PO BID
7. darbepoetin alfa in polysorbat 100 mcg/0.5 mL injection
2x/month
8. FoLIC Acid 2 mg PO DAILY
9. HydrALAzine 50 mg PO BID
10. Levothyroxine Sodium 100 mcg PO DAILY
11. Omeprazole 20 mg PO DAILY
12. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN back pain
13. Pravastatin 10 mg PO QPM
14. PredniSONE 5 mg PO QHS
15. Tacrolimus 2 mg PO Q12H
16. sevelamer CARBONATE 800 mg PO TID W/MEALS
17. Ascorbic Acid ___ mg PO DAILY
18. tadalafil 2.5 mg oral PRN
19. Aspirin 81 mg PO DAILY
20. Vitamin D ___ UNIT PO DAILY
21. NPH insulin human recomb 18 units subcutaneous QAM
22. Zinc Sulfate 50 mg PO DAILY
Discharge Medications:
1. Acyclovir 200 mg PO Q12H
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Carvedilol 25 mg PO BID
5. HydrALAzine 50 mg PO BID
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN back pain
9. PredniSONE 5 mg PO QHS
10. Tacrolimus 2 mg PO Q12H
11. Bisacodyl 10 mg PR QAM
RX *bisacodyl 10 mg 1 suppository(s) rectally once a day Disp
#*15 Suppository Refills:*0
12. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*50 Tablet Refills:*0
13. Levofloxacin 500 mg PO 2X Duration: 2 Doses
500mg to be taken ___ and 500mg on ___.
RX *levofloxacin 500 mg 1 tablet(s) by mouth 2x Disp #*2 Tablet
Refills:*0
14. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth once a
day Disp #*30 Packet Refills:*0
15. alfuzosin 10 mg oral daily
16. Ascorbic Acid ___ mg PO DAILY
17. Calcium Acetate 1334 mg PO TID W/MEALS
18. darbepoetin alfa in polysorbat 100 mcg/0.5 mL injection
2x/month
19. FoLIC Acid 2 mg PO DAILY
20. Nephrocaps 1 CAP PO DAILY
21. NPH insulin human recomb 18 units SUBCUTANEOUS QAM
22. Pravastatin 10 mg PO QPM
23. sevelamer CARBONATE 800 mg PO TID W/MEALS
24. tadalafil 2.5 mg oral PRN
25. Vitamin D ___ UNIT PO DAILY
26. Zinc Sulfate 50 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Postoperative constipation
___-acquired 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 for postoperative constipation
after your recent abdominal surgery. You were also found to have
a pneumonia which we began treating with antbiotics. You were
given bowel rest and intravenous fluids and a nasogastric tube
was placed in your stomach to decompress your bowels. Your bowel
have now started moving again after conservative management. You
have tolerated a regular diet, are passing gas and your pain is
controlled. You may return home to finish your recovery.
Please monitor your bowel function closely. It is important that
you have a bowel movement in the next ___ days. If you notice
that you are passing bright red blood with bowel movements or
having loose stool without improvement please call the office or
go to the emergency room if the symptoms are severe. If you are
taking narcotic pain medications there is a risk that you will
have some constipation. Please take an over the counter stool
softener such as Colace and Miralax to keep your bowel movements
regular. We have also prescribed you a suppository that you can
take as needed. If you have any of the following symptoms please
call the office for advice or go to the emergency room if
severe: increasing abdominal distension, increasing abdominal
pain, nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or extended constipation.
You also sustained a wound to your left elbow after a fall prior
to arrival in the hospital. You were seen by the wound nurses
who recommend changing your dressing daily. You should apply
melgisorb Ag to the wound and a moisture barrier ointment around
the wound, cover the wound with gauze, and wrap with Kerlix. We
will have a visiting nurse assist you with these dressing
changes and recommend that you follow up with your primary care
physician in the next ___ weeks.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities.
Followup Instructions:
___
|
10263098-DS-12 | 10,263,098 | 21,902,074 | DS | 12 | 2153-11-28 00:00:00 | 2153-11-30 20:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Vicodin
Attending: ___.
Chief Complaint:
AVF bleeding
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with complicated PMHx including HTN, afib
on Plavix, PVD, s/p kidney transplant in ___ now on HD, colon
cancer in remission presenting from home after AV fistula would
not stop bleeding during HD session at home today.
Mr. ___ reports got chills and back pain during HD today.
HD session had to be stopped after 2 hours due to his back pain
/ chills. He subsequently had continued bleeding from his HD
site after it was deaccessed. His wife called ___ and he was
brought to the ED. Patient reports cough, denies cp, abdominal
pain, sob, lightheadedness, dizziness. Denies flank pain.
In the ED, initial vitals were: 99.8 80 157/72 95% RA;
temperature climbed to 100.3.
- Labs were significant for hgb/hct 8.5/28.5 (at baseline), WBC
13.8, BUN/Cr 53/4.6, Lactate 1.3, INR 1.2
- Pressure dressing was applied to bleeding AVF with resolution
of bleeding.
- patient received 5 mg PO oxycodone
- Seen by transplant surgery in ED who recommended admission to
medicine for possible fistulogram during admission, otherwise no
acute surgical interventions were indicated.
Upon arrival to the floor, VS T99.2, BP 148/69, HR 88, RR 12.
Patient was without complaints on arrival to the medical floor
except for intermittent cough.
Past Medical History:
-Positive for end-stage renal failure
status post kidney transplant in ___, which has subsequently
failed. He is now on daily hemodialysis at home.
- Colon cancer, status post right hemicolectomy
- peripheral vascular disease,
- diabetes
- HTN
- HLD
- diabetic retinopathy c/b R eye blindness
- Hx SCC in situ sternum s/p ___'s excision,
- Hypothyroidism
- HFpEF
Social History:
___
Family History:
Notable for diabetes in mother with related renal disease
Physical Exam:
ADMISSION EXAM:
Vitals: T99.2, BP 148/69, HR 88, RR 12
General: Ill appearing, Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic
murmur, nor 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, 1+ DP pulses, left foot s/p amp of
___ and ___ toe, small 1cm wound with minimal drainage at ___
toe amp site, left ___ toe with eschar, no erythema; LUE with
AVF, dressing in place - no evidence of active bleeding -
palpable thrill
Neuro: moving all extremities, speech fluent, gait deferred.
DISCHARGE EXAM:
Vitals: Tm 98.8 P 62 BP 137/75 RR 18 SpO2 92-100% RA
Exam:
GENERAL: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
NECK: Supple, JVP not elevated
RESP: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic
murmur, no rubs, gallops
ABD: +BS, soft, nondistended, nontender to palpation. No
hepatomegaly.
GU: no foley
EXT: Feet cool, left foot s/p amputation of ___ and ___ toe,
small 1cm wound at ___ toe amp site, left ___ toe with eschar
without drainage. 2+ radial pulses bilaterally, AVF without
bleeding
NEURO: motor function grossly normal. Unable to detect light
touch in feet bilaterally.
Vitals: Tm 98.8 P 62 (58-67) BP 137/75 (131-145) RR 18 SpO2
92-100% RA
Exam:
GENERAL: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
NECK: Supple, JVP not elevated
RESP: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic
murmur, no rubs, gallops
ABD: +BS, soft, nondistended, nontender to palpation. No
hepatomegaly.
GU: no foley
EXT: Feet cool, left foot s/p amputation of ___ and ___ toe,
small 1cm wound at ___ toe amp site, left ___ toe with eschar
without drainage. 2+ radial pulses bilaterally, AVF without
bleeding
NEURO: motor function grossly normal. Unable to detect light
touch in feet bilaterally.
Pertinent Results:
___ 04:15PM WBC-13.8*# RBC-3.94* HGB-8.5* HCT-28.5*
MCV-72* MCH-21.6* MCHC-29.8* RDW-19.9* RDWSD-50.4*
___ 04:15PM PLT COUNT-143*
___ 04:15PM NEUTS-86.5* LYMPHS-7.3* MONOS-4.8* EOS-0.3*
BASOS-0.4 IM ___ AbsNeut-11.98*# AbsLymp-1.01* AbsMono-0.66
AbsEos-0.04 AbsBaso-0.05
___ 04:18PM ___ PTT-30.3 ___
___ 04:15PM GLUCOSE-199* UREA N-53* CREAT-4.6* SODIUM-137
POTASSIUM-4.2 CHLORIDE-96 TOTAL CO2-29 ANION GAP-16
___ 04:20PM LACTATE-1.3
PERTINENT LABS:
___ 11:05AM BLOOD tacroFK-2.3*
___ 06:15AM BLOOD ALT-27 AST-23 LD(LDH)-135 AlkPhos-385*
TotBili-0.6
___ 06:15AM BLOOD GGT-364*
LABS ON DISCHARGE:
___ 06:15AM BLOOD WBC-7.7 RBC-3.63* Hgb-7.8* Hct-26.7*
MCV-74* MCH-21.5* MCHC-29.2* RDW-19.4* RDWSD-49.9* Plt ___
___ 06:15AM BLOOD Glucose-155* UreaN-52* Creat-5.0*# Na-138
K-4.5 Cl-96 HCO3-29 AnGap-18
IMAGING:
Chest x-ray (___):
IMPRESSION:
A skin fold projecting over the left lateral chest should not be
mistaken for pneumothorax.
Moderate cardiomegaly is accompanied by pulmonary vascular
congestion and
possibly mild pulmonary edema. Heterogeneous appearance of the
lower lungs
particularly the right could be due to chronic lung disease, but
would make it difficult to detect early pneumonia. There is no
pneumonia in the upper lungs. Small right pleural effusion is
likely.
X-ray left foot (___):
IMPRESSION:
Suboptimal exam without definite evidence of osteomyelitis. If
there is
clinical concern, an MRI may be obtained.
Left upper extremity venous ultrasound (___):
IMPRESSION:
Normal appearance of the upper arm AV fistula and fully patent
stent as
described. No pseudoaneurysm.
Left leg venous duplex ultrasound vein mapping (___):
FINDINGS:
The left greater saphenous vein is patent from the ankle through
the saphenous femoral junction. The vein measures 3.9-4.2 mm in
the lower leg, 3.2 mm in the upper calf, 4 mm at the knee and
4.1-6.4 mm in the thigh.
IMPRESSION:
Patent left greater saphenous vein with measurements as
indicated above.
Left leg arterial duplex ultrasound (___):
FINDINGS:
Real-time imaging demonstrates a long stent within the SFA
common the mid
thigh a. flow velocities through this region are is follows:
121 cm/sec and the common femoral artery, 106-153 cm/sec within
the stent itself an 89 cm/sec in the above knee popliteal
artery.
In the lower leg, the peroneal artery stent is also patent with
velocities
ranging from 86 cm/sec proximally, 127-129 cm/sec the mid stent
and 141 cm/sec distally.
IMPRESSION:
Both the left SFA and peroneal artery stents are patent with
flow velocities as indicated above.
Left leg ABIs, Doppler waveforms in PVRs at rest
IMPRESSION:
1. Noncompressible vessel branching the ABIs invalid. There
does however
appear to be flow to the right great toe.
2. Suspect bilateral infrapopliteal tibial disease.
MICRO:
___ 2:06 pm SPUTUM Source: Induced.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
MTB Direct Amplification (Final ___:
CANCELLED. PATIENT CREDITED.
REQUESTED BY ___ ___.
___ 10:30 pm SPUTUM Source: Induced.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
___ 8:02 am SPUTUM Site: INDUCED Source: Induced.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
Brief Hospital Course:
___ with ESRD s/p transplant on HD, afib on Plavix, PVD, colon
cancer in remission, who presented from home with AVF bleed. He
was also found to have +AFB growing Mycobacterium fortitum, and
ulcers on his left third toe and the stump of his second toe.
#AVF Bleed: Resolved with pressure dressing. An ultrasound of
the fistula was obtained and was normal.
#Low grade temperature/leukocytosis: Temperature of 100.3 in ED
with WBC 13.8. Blood cultures were negative for 48 hours, the
patient was afebrile throughout the rest of the admission, and
the leukocytosis resolved with a WBC of 7.7 on discharge.
#Mycobacterium fortitum: Patient presented with a positive AFB
culture at ___ lab. This was speciated as Mycobacterium
fortitum. Three induced sputum smears were negative. Infectious
disease was consulted, and recommended no treatment at this
time, with outpatient follow-up in ___ clinic. He had an
additional 3 AFB sputums obtained during the hospitalization
which were negative.
___ wounds: On admission, had an eschar over an ulcer on his
left third toe, and a minimally draining ulcer over the stump of
his second toe amputation. Non-invasive studies were obtained
which showed suspected bilateral inferotibial arterial disease,
patent left SFA and peroneal stents, and patent left greater
saphenous vein. There was no concern for cellulitis, and
outpatient follow-up was scheduled with vascular surgery.
#ESRD on home HD: Received hemodialysis while in-house. Home
sevelamer, calcium acetate, vitamin D, and nephrocaps were
continued.
#H/o renal transplant: Home tacrolimus, prednisone, and
acyclovir were continued. A tacrolimus blood level was checked
and was 2.3.
#Paroxysmal atrial fibrillation: On Plavix, continued in-house.
Per chart review, there was discussion earlier this year about
starting warfarin, but this was not done due to need for
transfusion while hospitalized in ___. Recommend outpatient
cardiology follow-up to reconsider warfarin therapy.
#HTN: Home carvedilol, hydralazine, amlodipine were continued.
#Hypothyroidism: Home levothyroxine was continued
#GERD: Home Prilosec was continued
#DM: Insulin sliding scale was administered while in-house.
TRANSITIONAL ISSUES:
-Sputum positive for Mycobacterium fortitum. Outpatient ID
follow-up.
-___ diagnostic lower extremity angiography
-CMV viral load pending on discharge
-Isolated elevated alkaline phosphatase, with elevated GGT
suggestive of biliary source. CT abdomen from ___ without
biliary disease. recommend following as an outpatient.
-Patient has paroxysmal afib on Plavix, with record of
discussion to start warfarin in chart. Recommend outpatient
follow-up.
#CODE: Full code confirmed
#COMMUNICATION: ___- ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carvedilol 25 mg PO BID
2. PredniSONE 5 mg PO DAILY
3. Acyclovir 200 mg PO Q12H
4. Amlodipine 10 mg PO DAILY
5. Calcium Acetate 1334 mg PO TID W/MEALS
6. Clopidogrel 75 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. HydrALAzine 50 mg PO BID
9. Levothyroxine Sodium 100 mcg PO DAILY
10. Nephrocaps 1 CAP PO DAILY
11. Omeprazole 20 mg PO DAILY
12. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN for pain
13. Pravastatin 10 mg PO QPM
14. sevelamer CARBONATE 800 mg PO TID W/MEALS
15. Tacrolimus 2 mg PO Q12H
16. Cialis (tadalafil) 2.5 mg oral DAILY:PRN as needed
17. Vitamin D 400 UNIT PO DAILY
18. alfuzosin 10 mg oral DAILY
19. Zinc Sulfate 220 mg PO DAILY
20. NPH 15 Units Dinner
Insulin SC Sliding Scale using REG Insulin
21. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
Discharge Medications:
1. Acyclovir 200 mg PO Q12H
2. Amlodipine 10 mg PO DAILY
3. Calcium Acetate 1334 mg PO TID W/MEALS
4. Carvedilol 25 mg PO BID
5. Clopidogrel 75 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. HydrALAzine 50 mg PO BID
8. Levothyroxine Sodium 100 mcg PO DAILY
9. Nephrocaps 1 CAP PO DAILY
10. Omeprazole 20 mg PO DAILY
11. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN for pain
12. Pravastatin 10 mg PO QPM
13. PredniSONE 5 mg PO DAILY
14. sevelamer CARBONATE 800 mg PO TID W/MEALS
15. Tacrolimus 2 mg PO Q12H
16. Vitamin D 400 UNIT PO DAILY
17. Zinc Sulfate 220 mg PO DAILY
18. alfuzosin 10 mg oral DAILY
19. Cialis (tadalafil) 2.5 mg oral DAILY:PRN as needed
20. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
21. NPH 15 Units Dinner
Insulin SC Sliding Scale using REG Insulin
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Arteriovenous fistula bleed
Peripheral vascular disease
Non-tubercular mycobacterium
SECONDARY DIAGNOSES:
End-stage renal disease
History of 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 caring for you at ___
___. You were admitted because your AV fistula was
bleeding. You were found to have signs of infection, and because
of your sputum culture earlier this month, we continued sputum
collection. You were found to have an infection in your lungs
(that is not tuberculosis) and will see the infectious disease
doctors as ___ outpatient. Because of the ulcers on your toes,
the vascular surgery team also saw you while you were here, and
we got studies of the arteries and veins in your legs. You will
follow up with them as an outpatient.
Please go to the appointments listed below.
We wish you the best!
-Your ___ Team
Followup Instructions:
___
|
10263098-DS-8 | 10,263,098 | 25,742,945 | DS | 8 | 2152-10-07 00:00:00 | 2152-10-09 21:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Vicodin
Attending: ___
Chief Complaint:
Nausea, fatigue
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
HTN, and renal transplant in ___ with CKD due to progressive
allograft nephropathy who presents from ___ clinic with
___ days of worsening nausea/emesis in the context of months of
progressive nausea, fatigue, DOE.
Patient describes ___ months of having a single emesis episode
weekly, with recent worsening in the last 24 hours when he was
"up all night puking". He denies eating shellfish, old food, or
really having much PO intake in the past 3 days. He did not take
his medications this AM, but has taken them previously. He has
been taking NPH insulin and checking sugars daily. He has never
had his gallbladder or appendix removed or had laparotomy. He
does not drink EtOH. No fevers, no sick contacts. He has
occasional abdominal pain 30 minutes post-prandially. He has not
had diarrhea.
He describes weight gain (recently 215->231.7 lbs), worsening
edema, worsening DOE and exercise tolerance ___ yards walking
without stop). He has no chest pain, orthopnea. His Lasix dose
has been a moving target and he takes between 80-240mg daily.
In Dr. ___ today he had some myoclonus and
asterixis. He was referred to ED for labs and admission to sort
out inpatient HD via his new LUE AVF.
He recenlty had stress MIBI, TTE in outpatient setting that were
normal.
In the ED initial vitals were:
Time Pain Temp HR BP RR Pox
Triage 13:40 0 98.0 74 139/91 16 96% RA
Today 17:30 2 98.8 65 148/97 16 97% RA
Labs were significant for:
132 99 102 152 AGap=23
5.9 16 7.4 ___
ALT: 10
AP: 58
AST: 17
Lip: 33
Tbili: 0.2
Alb: 3.0
-Patient was given Morphine and Zofran
-CXR done
On the floor, he has ongoing nausea, but it is improved with
medications in the ED.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes
(baseline left eye blindness), rhinorrhea, congestion, sore
throat, cough, shortness of breath at rest, chest pain,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
#Living-unrelated renal transplant ___ chronic allograft
nephropathy
-status post left forearm brachiocephalic AV fistula by Dr.
___ ___
-underwent dialysis for ___ years prior to transplantation
through a left forearm loop graft
#HTN
#Diabetes mellitus type 1: followed at ___, A1c was 5.8% on
___. Diagnosed with type 1 diabetes ___ years ago at age
___
#Colonic polyps
#Loss of vision Right eye due to diabetic retinopathy
#Left hallux gangrene ___
#s/p L4-L5 laminectomy and fusion
#Squamous cell carcinoma in situ sternum, s/p Mohs ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
98.6 98.1 116/63 66 18 94RA
I/O overnight: 180/320
GENERAL: Elderly man lying in bed in NAD
HEENT: Purple macule at R inner canthus, conjunctiva clear, MMM
NECK: supraclavicular wasting, JVP elevated to 13cm H20
CARDIAC: tachy, regular, normal S1/S2, no S3/s4, soft rub at
LLSB
LUNG: Right lower rales that clear with cough. Breathing
unlabored.
ABDOMEN: nondistended, nontender in all quadrants, LLQ allograft
site non-tender, no rebound/guarding
EXTREMITIES: 3+ edema to sacrum, surgically missing L hallux
PULSES: 1+ DP pulses bilaterally
NEURO: CN II-XII intact, alert, oriented, attentive, mild
asterixis on exam, ___ strength in iliopsoas, quads, hamstrings
bilaterally, otherwise ___
SKIN: scattered purpuric macules on arms, warm and well
perfused, no excoriations or lesions, no rashes
DISCHARGE PHYSICAL EXAM:
Tm 99.3 50 97/56 20 95% RA
GENERAL: Elderly man lying in bed at HD in NAD
HEENT: Purple macule at R inner canthus which draining serous
fluid and excoriated, conjunctiva clear, MMM
NECK: supraclavicular wasting, JVP stably elevated
CARDIAC: Regular, normal S1/S2, no m/r/g.
LUNG: CTAB, normal respiratory effort
ABDOMEN: nondistended, nontender in all quadrants, LLQ allograft
site non-tender, no rebound/guarding
EXTREMITIES: 3+ edema to sacrum, surgically missing L hallux
PULSES: 1+ DP pulses bilaterally
NEURO: CN II-XII intact, alert, oriented, attentive, mild
asterixis on exam, ___ strength in iliopsoas, quads, hamstrings
bilaterally, otherwise ___
SKIN: scattered purpuric macules on arms, warm and well
perfused, no excoriations or lesions, no rashes
Pertinent Results:
ADMISSION LABS:
___ 04:20PM BLOOD WBC-7.4 RBC-3.88* Hgb-9.2* Hct-30.4*
MCV-79* MCH-23.7* MCHC-30.2* RDW-17.8* Plt ___
___ 04:20PM BLOOD Neuts-80.3* Lymphs-12.2* Monos-5.2
Eos-2.0 Baso-0.4
___ 10:50AM BLOOD ___ PTT-30.1 ___
___ 04:20PM BLOOD Glucose-152* UreaN-102* Creat-7.4*#
Na-132* K-5.9* Cl-99 HCO3-16* AnGap-23*
___ 04:20PM BLOOD ALT-10 AST-17 AlkPhos-58 TotBili-0.2
___ 06:05AM BLOOD CK-MB-3 cTropnT-0.13*
___ 02:57PM BLOOD CK-MB-3 cTropnT-0.12*
___ 12:15AM BLOOD CK-MB-2 cTropnT-0.12*
___ 05:52AM BLOOD cTropnT-0.09*
___ 04:20PM BLOOD Albumin-3.0*
___ 06:05AM BLOOD Calcium-7.1* Phos-8.4*# Mg-2.3
___ 05:25AM BLOOD 25VitD-25*
___ 10:51AM BLOOD PTH-139*
___ 06:50AM BLOOD freeCa-1.00*
___ 01:10PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 01:10PM BLOOD HCV Ab-NEGATIVE
___ 04:20PM BLOOD Lactate-1.1
___ 06:05AM BLOOD tacroFK-6.8
DISCHARGE LABS:
___ 05:51AM BLOOD WBC-6.1 RBC-3.36* Hgb-8.0* Hct-26.9*
MCV-80* MCH-23.9* MCHC-29.9* RDW-18.1* Plt ___
___ 05:25AM BLOOD ___ PTT-27.0 ___
___ 05:51AM BLOOD Glucose-133* UreaN-45* Creat-4.5* Na-139
K-4.3 Cl-103 HCO3-27 AnGap-13
___ 05:51AM BLOOD Calcium-6.9* Phos-3.4 Mg-2.0
IMAGING:
___ CXR: PA and lateral views of the chest provided. There is
pulmonary vascular congestion with engorgement of the pulmonary
hilar structures. No large effusions are seen. Heart size
appears stable. No pneumothorax. Imaged bony structures are
intact.
IMPRESSION:
Pulmonary vascular congestion.
EKG ___:
Atrial fibrillation with a rapid ventricular response. Low limb
lead voltage. Intraventricular conduction delay. Prior inferior
and anteroseptal myocardial infarction. Compared to the previous
tracing of ___ no diagnostic interim change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
91 0 ___ 0 -61 113
Brief Hospital Course:
Mr. ___ is a ___ with diabetes type 1, HTN, and renal
transplant in ___ with CKD due to progressive allograft
nephropathy who with acute on chronic nausea and fatigue.
#Fatigue/Nausea/Vomiting:
Improved after initiation of dialysis through LUE fistula, which
was determined to be mature. Subsequently ate well during his
admission. Likely was secondary to uremia given the chronicity
and improvement after HD. Also possible contribution from
diabetic gastroparesis. He had no fevers or leukocytosis during
this admission to suggest infection. Cardiac etiology causing
fatigue and potential GI upset via bowel edema was considered
very unlikely given negative stress MIBI recently and recent
unremarkable TTE. He was given Zofran PRN nausea, placed on a
renal diet, and established with outpatient hemodialysis prior
to discharge.
#Troponin leak:
Downtrending during this admission with no chest pain, and
stable EKGs with no new ischemic findings. Likely secondary to
decreased renal clearance.
#Allograft nephropathy/CKD V: Admitted for uremic symptoms of
fatigue, nausea, vomiting. Initiated on hemodialysis as above.
He was started on Nephrocaps and calcium acetate and calcium
carbonate.
#Immunosuppression: Continued tacro 2mg BID, prednisone 5mg
daily, stopped MMF 500mg BID. Also continued acyclovir 400mg
BID.
#DM type I: Continued home insulin NPH in AM and insulin sliding
scale.
#Hypertension: Stopped amlodipine, clonidine, lisinopril, and
furosemide to allow for additional fluid challenge at outpatient
dialysis. Continued carvedilol.
#Afib: History of RVR, CHADS 2. Continued aspirin, may consider
anticoagulation as outpatient. Continued carvedilol.
#HLD: Continued pravastatin 10mg qhs
#Hypothyroidism: Continued home levothyroxine 100mcg daily
#Anemia of CKD: On darbopoietin. Hgb 9.2 with microcytic
indices.
#Lumbago: Continued home oxycodone.
===================
TRANSITIONAL ISSUES
===================
MEDICATIONS
- STOPPED mycophenolate mofetil (continuing home tacrolimus and
prednisone)
- REPLACED sevalemer with calcium acetate
- STOPPED amlodipine, clonidine, lisinopril, and furosemide to
allow for additional fluid challenge at outpatient dialysis.
___
- Patient to start outpatient dialysis on ___
(details per above)
- Patient scheduled for dermatology ___ to evalute R inner
eye fold skin lesions
- PCP ___ scheduled for ___
OTHER
- Patient found to be in atrial fibrillation with HR 80-90s.
Patient is on aspirin every other day at home. Given high CHADS
score, would consider systemic anticoagulation. However, will
defer to outpatient provider given fall risk
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. alfuzosin 10 mg oral daily
3. Amlodipine 10 mg PO DAILY
4. Carvedilol 25 mg PO BID
5. CloniDINE 0.1 mg PO BID
6. darbepoetin alfa in polysorbat 100 mcg/0.5 mL injection 2x
per month
7. FoLIC Acid 1 mg PO DAILY
8. Furosemide 80 mg PO BID
9. Levothyroxine Sodium 100 mcg PO DAILY
10. Mycophenolate Mofetil 500 mg PO BID
11. Lisinopril 20 mg PO BID
12. Omeprazole 20 mg PO DAILY
13. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN back pain
14. Pravastatin 10 mg PO HS
15. PredniSONE 5 mg PO DAILY
16. Tacrolimus 2 mg PO Q12H
17. sevelamer CARBONATE 800 mg PO TID W/MEALS
18. Ascorbic Acid ___ mg PO DAILY
19. Vitamin D ___ UNIT PO DAILY
20. Aspirin 81 mg PO DAILY
21. NPH 18 Units Breakfast
22. Zinc Sulfate 220 mg PO DAILY
23. tadalafil 2.5 mg oral prn
Discharge Medications:
1. Acyclovir 200 mg PO Q12H
RX *acyclovir 200 mg 1 capsule(s) by mouth Every 12 hours (2
times a day) Disp #*60 Capsule Refills:*0
2. Carvedilol 25 mg PO BID
3. FoLIC Acid 1 mg PO DAILY
4. Levothyroxine Sodium 100 mcg PO DAILY
5. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN back pain
6. Pravastatin 10 mg PO HS
7. PredniSONE 5 mg PO DAILY
8. Tacrolimus 2 mg PO Q12H
9. Calcium Acetate 1334 mg PO TID W/MEALS
RX *calcium acetate 667 mg 3 capsule(s) by mouth 3 times a day
with meals Disp #*90 Capsule Refills:*0
10. Nephrocaps 1 CAP PO DAILY
RX *B complex & C ___ acid [Nephrocaps] 1 mg 1
capsule(s) by mouth daily Disp #*30 Capsule Refills:*0
11. Calcium Carbonate 500 mg PO QID:PRN indigestion
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by
mouth 4 times a day as needed for indigestion Disp #*40 Tablet
Refills:*0
12. Aspirin 81 mg PO DAILY
13. tadalafil 2.5 mg oral prn
14. NPH 18 Units Breakfast
15. Omeprazole 20 mg PO DAILY
16. Ascorbic Acid ___ mg PO DAILY
17. Zinc Sulfate 220 mg PO DAILY
18. darbepoetin alfa in polysorbat 100 mcg/0.5 mL injection 2x
per month
19. alfuzosin 10 mg oral daily
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
Acidosis
Allograft nephropathy
SECONDARY
Atrial fibrillation
Type 1 Diabetes Mellitus
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 this
hospitalization. You were admitted to ___
___ for worsening nausea and fatigue. You were found
to have worsening electrolytes due to your failing kidney
transplant. For this, you were started on dialysis through your
left-sided fistula. We also stopped/changed some of your
medications that were not needed after you started dialysis as
well as to optimize your electrolytes.
You are now safe to go home. Please take your medication as
prescribed and ___ with your doctors as ___.
Followup Instructions:
___
|
10263216-DS-5 | 10,263,216 | 20,341,786 | DS | 5 | 2146-02-26 00:00:00 | 2146-02-26 13:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left Arm Pain
Major Surgical or Invasive Procedure:
Open reduction and internal fixation of left both bones forearm
fracture (___)
History of Present Illness:
___, ___, presents after a snowboarding accident at ___
in which he sustained a midshaft radius and ulna fx, seen by XR
at the mountain, and splinted at the mountain. Pt reports he
was wearing a helmet, had no LOC or head strike, and denies any
other injuries.
Past Medical History:
None
Social History:
___
Family History:
Non-contributory.
Physical Exam:
On Admission:
Gen: NAD
Vitals: 98.8 71 130/61 16 98%
CV RRR
Pulm: Breathing Unlabored
Right upper extremity:
Skin intact
Soft, non-tender arm and forearm
Full, painless AROM/PROM of shoulder, elbow, wrist, and digits
+EPL/FPL/DIO (index) fire
+SILT axillary/radial/median/ulnar nerve distributions
+Radial pulse
Left upper extremity:
Skin intact
Soft, non-tender arm. Extremely tender forearm with obvious
deformity, closed.
Full, painless AROM/PROM of wrist, and digits. Hesitant to move
shoulder or elbow given injury, but denies pain or stiffness.
+EPL/FPL/DIO (index) fire
+SILT axillary/radial/median/ulnar nerve distributions
+Radial pulse
On Discharge:
AFVSS
General - Awake and alert. Sitting up in bed. Oriented x 3.
Left Upper Extremity
- Wounds over radius and ulna intact with staples in place. No
erythema or discharge.
- Fires EPL/FDS/DIO
- Sensation intact to light touch throughout
- Fingers warm and well perfused with brisk capillary refill
Pertinent Results:
___ 11:07PM BLOOD WBC-16.2* RBC-4.82 Hgb-15.1 Hct-42.0
MCV-87 MCH-31.3 MCHC-36.0* RDW-13.5 Plt ___
___ 11:07PM BLOOD Glucose-86 UreaN-10 Creat-0.7 Na-140
K-3.4 Cl-102 HCO3-24 AnGap-17
Left forearm x-rays (___) - per radiology
Midshaft radius and ulnar fractures.
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left both bones forearm fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction and intenal
fixation, which the patient tolerated well (for full details
please see the separately dictated operative report). The
patient was taken from the OR to the PACU in stable condition
and after recovery from anesthesia was transferred to the floor.
The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications. The patient was given perioperative antibiotics and
anticoagulation per routine. The patients 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 was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is non weight bearing in the left
upper extremity in orthoplast splint. The patient will follow
up in two weeks per routine. A thorough discussion was had with
the patient regarding the diagnosis and expected post-discharge
course, and all questions were answered prior to discharge.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain
Never exceed 4000 mg in 24 hours.
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN Severe pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every three (3) hours
Disp #*100 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left both bones forearm 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.
- 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.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
ACTIVITY AND WEIGHT BEARING:
- You may NOT bear weight with the left upper extremity.
Followup Instructions:
___
|
10263247-DS-11 | 10,263,247 | 28,709,120 | DS | 11 | 2146-01-28 00:00:00 | 2146-01-28 22:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ciprofloxacin
Attending: ___
Chief Complaint:
Leukocytosis
Major Surgical or Invasive Procedure:
___ Bone marrow aspiration and biopsy
___ Lumbar puncture, intrathecal chemotherapy
___ Lumbar puncture, intrathecal chemotherapy
___ Bone marrow aspiration and biopsy
___ Lumbar puncture, intrathecal chemotherapy
___ ___ Port-a-cath placement
History of Present Illness:
___ with no significant past medical history presents from home
for evaluation of abnormal labs.
The patient has noticed the progressive onset of dyspnea on
exertion for the last month. He has noted that at first walking
up flights of stairs would get him tired and this progressed to
being dyspneic with slight inclines. 2 days ago he was with
friends who said that he looked anemic. He went to urgent care
who referred him to his PCP for blood work.
His PCP drew his labs and noted his leukocytosis and anemia and
refered him to the ___ ED for further evaluation.
The patient is without fevers or chills. He has no headache or
vision changes. No chest pain. Dyspnea with exertion but no
orthopnea, PND or dyspnea at rest. No abdominal pain. No nausea,
vomiting or diarrhea. No dysuria. No rashes. No night sweats or
weight loss. No sore throat.
Past Medical History:
Hypertension
Social History:
___
Family History:
Non contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: T 97.9 BP 135/76 HR 80 R 18 SpO2 99 Ra
GENERAL: NAD
HEENT: Moist mucous membranes without lesions. No mucositis. No
cervical or supraclavicular LAD.
EYES: Anicteric, PERLL, pale conjunctiva
NECK: Supple, no LAD. No axillary LAD
RESP: No increased WOB, CTAB without wheezing, rhonchi or
crackles
___: RRR no MRG
GI: Soft, NTND no HSM, no masses
EXT: Warm, no edema
SKIN: dry, no rashes
NEURO: CN II-XII intact
ACCESS: PIV
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 525)
Temp: 97.8 (Tm 98.3), BP: 114/73 (108-136/69-79), HR: 79
(77-84), RR: 18 (___), O2 sat: 98% (95-100), O2 delivery: RA
GENERAL: NAD
HEENT: OP clear. No mucositis. No cervical or supraclavicular
LAD. no asymmetric oropharyngeal swelling. MMM
EYES: Anicteric, PERLL, pale conjunctiva
NECK: Supple, no LAD. No axillary LAD
RESP: No increased WOB, CTAB without wheezing, rhonchi or
crackles
___: RRR no MRG
GI: Soft, NTND no HSM, no masses
EXT: ___ strength b/l
SKIN: rash resolved
NEURO: CN II-XII intact, moves all extremities equally
ACCESS: L POC
Pertinent Results:
ADMISSION LABS
___ 09:00AM BLOOD WBC-51.2* RBC-1.96* Hgb-7.3* Hct-21.6*
MCV-110* MCH-37.2* MCHC-33.8 RDW-16.0* RDWSD-61.7* Plt Ct-25*
___ 09:00AM BLOOD Neuts-2* Bands-0 ___ Monos-0 Eos-0
Baso-0 ___ Myelos-0 Blasts-68* NRBC-1* Other-0
AbsNeut-1.02* AbsLymp-15.36* AbsMono-0.00* AbsEos-0.00*
AbsBaso-0.00*
___ 09:00AM BLOOD ___ PTT-27.8 ___
___ 09:00AM BLOOD ___
___ 03:30PM BLOOD Ret Aut-2.10* Abs Ret-0.04
___ 09:00AM BLOOD Glucose-91 UreaN-20 Creat-1.3* Na-141
K-4.4 Cl-101 HCO3-22 AnGap-18
___ 09:00AM BLOOD ALT-21 AST-20 LD(LDH)-447* CK(CPK)-97
AlkPhos-57 TotBili-0.4
___ 09:00AM BLOOD Albumin-4.6 UricAcd-8.5*
___ 03:20PM BLOOD Calcium-9.4 Phos-4.2 Mg-2.0
___ 03:20PM BLOOD VitB12-473
___ 09:00AM BLOOD Hapto-173
___ 03:20PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 03:20PM BLOOD HIV Ab-NEG
TISSUE IMMUNOPHENOTYPING ___
DIAGNOSIS:
FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: Kappa, Lambda,
___, cCD22, cCD3, cCD79a, cMPO, nTdT, and CD antigens 2, 3,
4, 5, 7, 8, 10, 11c, 13, 14, 16, 19, 20, 23, 33, 34, 38, 45, 56,
64 and 117.
RESULTS:
10-color analysis with CD45 vs. side-scatter gating is used to
evaluate for leukemia/lymphoma.
Approximately 65.5% of total acquired events are evaluable
non-debris events.
The viability of the analyzed non-debris events, done by 7-AAD
is 98.9%.
CD45-bright, low side-scatter gated lymphocytes comprise 14.4%
of total analyzed events.
Mature B cells comprise 13.3% of lymphoid-gated events, are
polyclonal and do not co-express aberrant antigens.
T cells comprise 83.0% of lymphoid gated events and express
mature lineage antigens (CD3, CD5, CD2 and CD7).
A minor subset (14.3%) of T cells shows dim/variable loss of CD7
(non-specific finding).
T cells have a normal CD4:CD8 ratio of 1.5 (usual range in blood
0.7-3.0).
There is a population of double-negative (CD4 negative/CD8
negative) T cells comprising 5.3% of CD3 positive cells.
CD56 positive, CD3 negative natural killer cells represent 3.7%
of gated lymphocytes (usual range in blood ___. They
co-express CD2, CD7 and CD8 (subset).
Cell marker analysis demonstrates that the majority (75%) of the
cells isolated from this peripheral blood are in the
CD45-dim/low side scatter "blast" region. They co-express CD34,
___, CD10 (bright), CD19, nTdT, cCD79a and are negative for
CD38, CD33, CD117, CD11c, CD13, CD14, CD16, CD56, CD64, cMPO,
cCD3, cCD22, surface light chains and the T cell antigens.
INTERPRETATION
Immunophenotypic findings in keeping with involvement by
B-lymphoblastic leukemia/lymphoma. Correlation with clinical,
morphologic (see separate bone marrow biopsy report ___
and cytogenetics (see separate reports ___-___ and ___-___)
findings is recommended for further characterization. Flow
cytometry immunophenotyping may not detect all abnormal
populations due to topography, sampling or artifacts of sample
preparation.
___
SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY.
DIAGNOSIS:
HYPERCELLULAR BONE MARROW EXTENSIVE INVOLVEMENT BY ACUTE B-CELL
LYMPHOBLASTIC LEUKEMIA (PRECURSOR B CELL LYMPHOBLASTIC
LEUKEMIA).
MICROSCOPIC DESCRIPTION
Peripheral blood smear:
The smears are adequate for evaluation. Erythrocytes are
moderately decreased in number,
normochromic, macrocytic and have slight anisopoikilocytosis.
Occasional ovalocytes and
polychromatophils are seen. The white blood cell count is
markedly increased. The platelet count is
markedly decreased. A 100 cell differential shows 0%
neutrophils, 0% bands, 33% lymphocytes, 1%
monocytes, 0% eosinophils, 0% basophils, 0% metamyelocytes, 0%
myelocytes, 0% promyelocytes,
and 66% blasts.
Bone marrow aspirate:
The aspirate material is inadequate for evaluation due to lack
of spicules and consists of
lymphocytes, blasts and rare eosinophils. No erythroid
precursors, myeloid precursors or
megakaryocytes seen. A cell differential shows 45% blasts, 0%
promyelocytes, 0% myelocytes, 0%
metamyelocytes, 0% bands/neutrophils, 1% eosinophils, 0%
erythroids, 54% lymphocytes, 0%
plasma cells.
Clot section and biopsy slides:
The core biopsy is adequate for evaluation. It consists of a 0.9
cm long core biopsy composed of
cartilage, trabecular marrow with a cellularity of 90-100%. The
M:E ratio is decreased. There is an
interstitial infiltrate of immature mononuclear cells consistent
with blasts occupying 90% of the
overall cellularity. Scattered erythroid precursors and myeloid
precursors present. Megakaryocytes
are decreased in number
___
SPECIMEN: BONE MARROW
CLINICAL HISTORY: Leukocytosis, anemia and thrombocytopenia,
rule out acute leukemia
CYTOGENETICS PROCEDURE: Unstimulated culture for Giemsa-banded
chromosome analysis.
FINDINGS: An abnormal 46,XY,t(6;9;22)(q23;q34;q11.2) male
chromosome complement with a
three-way translocation involving the long arms of chromosomes
6, 9, and 22 was observed in 3
cells. 17 cells had an apparently normal 46,XY chromosome
complement. A total of 20 mitotic cells
were examined in detail. Chromosome band resolution was 350-400.
A karyogram was prepared on
5 cells.
CYTOGENETIC DIAGNOSIS: 46,XY,t(6;9;22)(q23;q34;q11.2)[3]/
46,XY[17]
INTERPRETATION/COMMENT: Three of the metaphase bone marrow cells
examined had an
abnormal karyotype with a three-way translocation involving
chromosomes 6, 9, and 22 that
generates the ___ chromosome. FISH performed on
peripheral blood confirmed that this
translocation has resulted in the BCR/ABL gene rearrangement
(see ___). BCR/ABL positive
B-lymphoblastic leukemia has been considered the most
unfavorable genetic subtype of B-ALL.
However, therapy with tyrosine kinase inhibitors has improved
the outcome in many cases.
___
SPECIMEN: BLOOD, NEOPLASTIC
REVISED A: Revised to add chromosome analysis and additional
FISH results.
FINDINGS: An abnormal 46,XY,t(6;9;22)(q23;q34;q11.2) male
chromosome complement with a
three-way translocation involving the long arms of chromosomes
6, 9 and 22 was observed in 16
cells. 4 cells had an apparently normal 46,XY chromosome
complement. A total of 20 mitotic cells
were examined in detail. Chromosome band resolution was 400-450.
A karyogram was prepared on
6 cells.
CYTOGENETIC DIAGNOSIS: 46,XY,t(6;9;22)(q23;q34;q11.2)[16]/
46,XY[4]
INTERPRETATION/COMMENT: 80% of the metaphase peripheral blood
cells examined had a
abnormal karyotype with a three-way translocation involving
chromosomes 6, 9 and 22 that produces
the ___ chromosome. FISH has demonstrated that this
translocation, which is a variant of
the more common t(9;22)(q34;q11.2) translocation, has resulted
in the BCR/ABL gene
rearrangement (see below). Historically, BCR/ABL has been
considered the most unfavorable
genetic subtype of B-lymphoblastic leukemia. Recently, therapy
with tyrosine kinase inhibitors has
improved the outcome.
2) FISH: POSITIVE for BCR/ABL. 80% of the interphase peripheral
blood cells examined had a
probe signal pattern consistent with the BCR/ABL1 gene
rearrangement. A variant FISH signal
pattern due to a three-way translocation was detected. The
metaphase chromosome analysis has
shown that a translocation involving chromosomes 6, 9 and 22 is
present (see above). Although
BCR/ABL is an unfavorable genetic subtype of B-lymphoblastic
leukemia, prognosis has improved
with tryrosine inhibitor therapy.
FINDINGS: A total of 200 interphase nuclei were examined with
the ABL1 and BCR dual color dual fusion probe set and
fluorescence microscopy. 40 cells (20%) had 2 red signals and 2
green signals. 160 cells (80%) had ___ yellow (red-green
fusion) signal, 2 red signals and 2 green signals. Normal
cut-off values for this probe set include: 89% for a normal 2
red and 2 green probe signal pattern and 1% for a ___ yellow
(red-green fusion), 2 red and 2 green signal pattern.
nuc ish(ABL1,BCR)x3(ABL1 con BCRx1)[160/200]
3) FISH: NEGATIVE for MLL REARRANGEMENT. No evidence of
interphase peripheral blood
cells with rearrangement of the MLL gene.
Uncultured cells for fluorescence in situ hybridization (FISH)
analysis with the ___ Molecular MLL dual color break
apart probe set: SpectrumOrange directly labeled probe for the
telomeric 3' end of the MLL gene on ___ and
SpectrumGreen directly labeled probe for the centromeric 5' end
of the MLL gene. This probe combination detects
rearrangements of the MLL gene associated with acute myeloid
leukemia and lymphoblastic leukemia.
FINDINGS: A total of 200 interphase nuclei were examined with
the MLL break apart probe set and fluorescence
microscopy. 200 cells (100%) had ___ yellow (red-green fusion)
signals. cells (%) had ___ yellow (red-green fusion) signal,
1 red signal and 1 green signal. Normal cut-off values for this
probe set include: 94% for a normal ___ yellow (red-green
fusion) signal pattern and 1% for a ___ yellow (red-green fusion),
1 red and 1 green signal pattern. nuc ish(MLLx2)[200]
CLINICAL HISTORY: Circulating blasts, concern for acute leukemia
CYTOGENETICS PROCEDURE: Unstimulated culture for Giemsa-banded
chromosome analysis.
CYTOGENETIC DIAGNOSIS: Cell culture for chromosome analysis in
progress. See FISH results
below.
FISH: NEGATIVE for PML/RARA. No evidence of interphase
peripheral blood cells with the
PML/RARA gene rearrangement.
Uncultured cells for fluorescence in situ hybridization (FISH)
analysis with the ___ Molecular PML/RARA dual color
dual fusion translocation probe set: SpectrumOrange directly
labeled probe for the PML gene on ___ and
SpectrumGreen directly labeled probe for the RARA gene on ___.
This probe combination detects the PML/RARA
gene rearrangement brought about by the t(15;17)(q24;q21)
translocation diagnostic of acute promyelocytic leukemia.
FINDINGS: A total of 200 interphase nuclei were examined with
the PML and RARA dual color dual fusion probe set and
fluorescence microscopy. 200 cells (100%) had 2 red signals and
2 green signals. 0 cells (0%) had ___ yellow (red-green
fusion) signals, 1 red signal and 1 green signal. Normal cut-off
values for this probe set include: 89% for a normal 2 red
and 2 green probe signal pattern and 1% for a ___ yellow
(red-green fusion), 1 red and 1 green signal pattern.
nuc ish(PML,RARA)x2[200]
TTE ___
CONCLUSION:
The left atrial volume index is normal. There is no evidence for
an atrial septal defect by 2D/color Doppler.
The estimated right atrial pressure is ___ mmHg. There is normal
left ventricular wall thickness with a normal
cavity size. There is normal regional and global left
ventricular systolic function. Quantitative 3D volumetric
left ventricular ejection fraction is 65 %. There is no resting
left ventricular outflow tract gradient. No
ventricular septal defect is seen. There is normal diastolic
function. 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. There is no
evidence for an aortic arch coarctation. The aortic
valve leaflets (3) appear structurally normal. There is no
aortic valve stenosis. There is no aortic regurgitation.
The mitral valve leaflets appear structurally normal with no
mitral valve prolapse. There is trivial 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.
IMPRESSION: Normal biventricular cavity sizes, regional/global
systolic function. No valvular pathology or
pathologic flow identified. Normal estimated pulmonary artery
systolic pressure.
___ CSF IMMUNOPHENOTYPING
DIAGNOSIS:
FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: Kappa, lambda,
FMC 7, and CD antigens 5, 10, 11c, 19, 20, 23 and 45.
RESULTS:
10-color analysis with linear side scatter vs. CD45 gating is
used to evaluate for leukemia/lymphoma. Approximately 17.4% of
total acquired events are evaluable non-debris events. The
viability of the analyzed non-debris events, done by 7-AAD is
78.8%. CD45-bright, low side-scattered gated lymphocytes
comprise 0.1% of total analyzed events.
INTERPRETATION
Nondiagnostic study. Cell marker analysis was in attempted, but
was nondiagnostic in this case due to insufficient numbers of
cells/insufficient amount of tissue for analysis. Clonality
could not be assessed in this case due to insufficient numbers
of B cells. If clinically indicated, we recommend a repeat
specimen be submitted to the flow cytometry laboratory.
Correlation with clinical, morphologic (see separate cytology
report ___-___) and other ancillary findings is recommended.
Flow cytometry immunophenotyping may not detect all abnormal
populations due to topography, sampling or artifacts of sample
preparation.
Note: The Technical component of this test was completed at
___, ___ / ___ / ___ # ___. The
Professional component of this test was completed at ___
___, Pathology, ___ 200, ___ / ___. This test was
developed and its performance characteristics determined by
NeoGenomics Laboratories. It has not been cleared or approved by
the U.S. Food and Drug Administration. The FDA has determined
that such clearance or approval is not necessary. This test is
used for clinical purposes. It should not be regarded as
investigational or for research. This laboratory is certified
under the Clinical Laboratory Improvement Amendments of ___
(___) as qualified to perform high complexity clinical testing.
___ CSF CYTOLOGY
DIAGNOSIS:
CEREBROSPINAL FLUID:
NEGATIVE FOR MALIGNANT CELLS.
___
CT ABDOMEN/PELVIS W/ CONTRAST
1. Multiple left upper quadrant fluid-filled nondistended bowel
loops are
hyperemic and thickened with adjacent fatty stranding most
consistent with
enteritis.
2. Mild bilateral peribronchovascular opacities and bilateral
lower lobe
predominant thickened bronchial walls could represent
bronchiolitis.
3. Unchanged splenomegaly.
___
CT CHEST W/ CONTRAST
1. Multiple left upper quadrant fluid-filled nondistended bowel
loops are
hyperemic and thickened with adjacent fatty stranding most
consistent with
enteritis.
2. Mild bilateral peribronchovascular opacities and bilateral
lower lobe
predominant thickened bronchial walls could represent
bronchiolitis.
3. Unchanged splenomegaly.
___ BONE MARROW IMMUNOPHENOTYPING
DIAGNOSIS:
FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: Kappa, lambda,
___, cCD22, cCD3, cCD79a, cMPO, nTdT, and CD antigens 2, 3,
4, 5, 7, 8, 10, 11c, 13, 14, 16, 19, 20, 23, 34, 38, 45, 56 and
117.
RESULTS:
10-color analysis with linear side scatter vs. CD45 gating is
used to evaluate for leukemia/lymphoma. Approximately 82.9% of
total acquired events are evaluable non-debris events. The
viability of the analyzed non-debris events, done by 7-AAD is
93.0%. CD45-bright, low side-scattered gated lymphocytes
comprise 4.6% of total analyzed events. B cells comprise 0.2% of
lymphoid gated events, are polyclonal and do not coexpress
aberrant antigens. Cell marker analysis demonstrates that a
subset (3.0%) of the cells isolated from this bone marrow
aspirate are in the CD45-dim/low side-scattered "blast" region.
They coexpress immature antigens CD34, lymphoid associated
antigens CD19, CD10, nTdT, cCD79a, cCD22, surface light chains,
CD11c, cMPO, cCD3. Blast cells comprise 2.4% of total analyzed
events.
INTERPRETATION
Immunophenotypic findings consistent with low level (<5%)
involvement by the patient's known B-cell lymphoblastic
leukemia/lymphoma. Correlation with clinical, morphologic (see
separate pathology report ___ and other ancillary
findings is recommended. Flow cytometry immunophenotyping may
not detect all abnormal populations due to topography, sampling
or artifacts of sample preparation.
Note: The Technical component of this test was completed at
___, ___ / ___ / ___ # ___. The
Professional component of this test was completed at ___
___, ___, ___, ___. This test was
developed and its performance characteristics determined by
NeoGenomics Laboratories. It has not been cleared or approved by
the ___.S. Food and Drug Administration. The FDA has determined
that such clearance or approval is not necessary. This test is
used for clinical purposes. It should not be regarded as
investigational or for research. This laboratory is certified
under the Clinical Laboratory Improvement Amendments of ___
(___) as qualified to perform high complexity clinical testing.
HEMATOPATHOLOGY ___ BONE MARROW
REVISED A:
A CD34 immunostain highlights <5% of the overall cellularity.
***electronically signed out***
Interpreted by: ___, MD
___ out: ___ 19:47
PATHOLOGIC DIAGNOSIS:
SPECIMEN:
BONE MARROW ASPIRATE AND CORE BIOPSY
DIAGNOSIS:
HYPERCELLULAR BONE MARROW WITH MATURING TRILINEAGE HEMATOPOIESIS
AND
FLOW CYTOMETRIC EVIDENCE OF MINIMAL INVOLVEMENT BY
B-LYMPHOBLASTIC
LEUKEMIA/LYMPHOMA; SEE NOTE.
Note: Only very rare immature mononuclear cells consistent with
blasts are seen in the aspirate
smears. A discrete blast infiltrate is not identified in the
core biopsy. CD34 immunohistochemistry is
pending and results will be reported in an addendum. However,
corresponding flow cytometry
detected a small CD34 positive, CD19 positive, CD10 positive and
nTdT positive cell population (see
separate report ___ for full final results). Cytogenetics
work-up revealed no evidence of bone
marrow cells with the three-way translocation involving
chromosomes 6, 9, and 22 that generates the
___ chromosome that was observed in the bone marrow and
peripheral blood collected on
___ (see separate report ___ for full results). The
findings are in keeping with minimal
persistent involvement by the patient's known B-lymphoblastic
leukemia/lymphoma. Correlation with
clinical, laboratory and other ancillary findings is
recommended.
Peripheral blood smear:
The smears are adequate for evaluation. Erythrocytes are greatly
decreased in number and have
mild anisopoikilocytosis. Occasional echinocytes and
ovalocytes/elliptocytes are seen. The white
blood cell count is markedly decreased. Neutrophils show toxic
granulation. The platelet count is
markedly decreased; occasional large and giant platelets are
seen. A 100 cell differential shows:
91% neutrophils, 0% bands, 6% lymphocytes, 3% monocytes, 0%
eosinophils, 0% basophils and 0%
blasts.
Bone marrow aspirate:
The aspirate material is adequate for evaluation and consists of
multiple cellular spicules. The M:E
ratio is 1.4:1. Erythroid precursors exhibit overall
normoblastic maturation. Myeloid precursors show
left shifted maturation including occasional cells with abnormal
nuclear. Megakaryocytes are normal
in number; occasional small hypolobated cells are seen. A 300
cell differential shows: 2% blasts,
10% promyelocytes, 11% myelocytes, 9% metamyelocytes, 25%
bands/neutrophils, 0% eosinophils,
40% erythroids, 2% lymphocytes and 1% plasma cells.
Clot section and biopsy slides:
The core biopsy material is adequate for evaluation. It consists
of a 1.6 cm long core biopsy
composed of cortical bone and trabecular marrow with a
cellularity of 90%. The M:E ratio estimate is
decreased. Erythroid precursors are increased in number and have
mildly left-shifted maturation.
Myeloid precursors are relatively proportionately decreased in
number with left-shifted maturation.
Megakaryocytes are increased in number with loose and tight
clustering seen. Clot sections are
non-contributory.
___ BONE MARROW CYTOGENETICS
CYTOGENETICS REPORT - Final
SPECIMEN: BONE MARROW
CLINICAL HISTORY: Ph+ B-ALL
CYTOGENETICS PROCEDURE: Unstimulated culture for Giemsa-banded
chromosome analysis.
FINDINGS: An apparently normal 46,XY male chromosome complement
was observed in 20 mitotic
cells examined in detail. Chromosome band resolution was
400-450. A karyogram was prepared on
3 cells.
CYTOGENETIC DIAGNOSIS: 46,XY[20] Normal male karyotype.
INTERPRETATION/COMMENT: There is no evidence of bone marrow
cells with the three-way
translocation involving chromosomes 6, 9, and 22 that generates
the ___ chromosome and
was observed in the bone marrow and peripheral blood collected
on ___.
This normal karyotype makes a chromosome abnormality unlikely.
There is a possibility that low grade mosaicism, a subtle or
cytogenetically cryptic
chromosome rearrangement, a non-mitotic neoplastic clone, and/or
copy number neutral loss of heterozygosity would be present and
go undetected with
routine chromosome analysis.
FISH: NEGATIVE for BCR/ABL. No evidence of interphase bone
marrow cells with the BCR/ABL1
gene rearrangement that was previously observed in bone marrow
and peripheral blood collected on
___.
Uncultured cells for fluorescence in situ hybridization (FISH)
analysis with the ___ Molecular BCR/ABL1 dual color
dual fusion translocation probe set: SpectrumOrange directly
labeled probe for the ABL1 gene on ___ and
SpectrumGreen directly labeled probe for the BCR gene on
22q11.2. This probe combination detects the BCR/ABL1
gene rearrangement brought about by the t(9;22)(q34;q11.2)
translocation characteristic of chronic myelogenous
leukemia and seen in some cases of acute lymphoblastic leukemia
and acute myeloid leukemia.
FINDINGS: A total of 200 interphase nuclei were examined with
the ABL1 and BCR dual color dual fusion probe set and
fluorescence microscopy. 200 cells (100%) had 2 red signals and
2 green signals. 0 cells (0%) had ___ yellow (red-green
fusion) signals, 2 red signals and 2 green signals (the abnormal
probe signal pattern associated with the BCR/ABL1 gene
rearrangement previously observed in this patient) . Normal
cut-off values for this probe set include: 89% for a normal 2
red and 2 green probe signal pattern and 1% for a ___ yellow
(red-green fusion), 1 red and 1 green signal pattern.
nuc ish(ABL1,BCR)x2[200]
This test was developed and its performance characteristics
determined by ___.
It has not been cleared or
approved by the ___ Food and Drug Administration (FDA). The FDA
does not require this test to go through premarket FDA review.
This test is used for
clinical purposes. It should not be regarded as investigational
or for research. This laboratory is certified under the Clinical
Laboratory Improvement
Amendments (CLIA) as qualified to perform high complexity
clinical laboratory testing.
CSF CYTOLOGY ___
SPECIMEN(S) SUBMITTED: CEREBROSPINAL FLUID
DIAGNOSIS:
CEREBROSPINAL FLUID:
NEGATIVE FOR MALIGNANT CELLS.
Lymphocytes and monocytes.
___ PORT PLACEMENT
IMPRESSION:
Successful placement of a single lumen chest power Port-a-cath
via the left
internal jugular venous approach. The tip of the catheter
terminates in the
right atrium. The catheter is ready for use.
DISCHARGE LABS
___ 12:00AM BLOOD WBC-1.0* RBC-2.49* Hgb-7.7* Hct-23.1*
MCV-93 MCH-30.9 MCHC-33.3 RDW-16.8* RDWSD-55.0* Plt ___
___ 12:00AM BLOOD Neuts-86* Bands-2 Lymphs-12* Monos-0
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-0.88*
AbsLymp-0.12* AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*
___ 12:00AM BLOOD ___ PTT-28.7 ___
___ 12:00AM BLOOD ___ 12:00AM BLOOD Glucose-128* UreaN-18 Creat-0.7 Na-141
K-4.2 Cl-105 HCO3-22 AnGap-14
___ 12:00AM BLOOD ALT-135* AST-32 LD(LDH)-220 AlkPhos-63
TotBili-0.6
___ 12:00AM BLOOD Calcium-8.2* Phos-3.8 Mg-2.0 UricAcd-2.6*
Brief Hospital Course:
SUMMARY STATEMENT
====================
___ with no significant PMH who initally presented to his PCP
with dyspnea on exertion and decreased exercise tolerance, found
to have elevated WBC with 68% blasts and referred to ED due to
concern for acute leukemia. He underwent bone marrow biopsy and
immunophenotyping and was found to have ___ chromosome
positive ALL. He initiated potanib + hyperCVAD, which he
tolerated quite well. His course was complicated by possible
parapharyngeal abscess, abdominal pain secondary to constipation
likely from vincristine and neutropenic fever due to enteritis.
He was briefly on a course of intravenous antibiotics which was
transitioned to oral antibiotics, which was discontinued prior
to initiating cycle 2 of ponatinib + hyperCVAD. He had a port
placed for chemotherapy/transfusion support on ___ and was
discharged home on ___ with ponatinib and pain medication for
his port site with a planned readmission for cycle 3 of
hyperCVAD.
TRANSITIONAL ISSUES
===================
#PreB Cell ALL w/ ___ Chromosome
Patient presented to his PCP with dyspnea on exertion,
generalized fatigue found to have WBC 51.2 with 68% blasts and
concern for acute leukemia. He underwent bone marrow biopsy
which confirmed Pre-B cell acute lymphocytic leukemia w/ BCR-ABL
translocation ___ chromosome positive). He began cycle
1 w/ dasatinib + hyperCVAD on ___ and was transitioned to
ponatinib once insurance approval was obtained (continued
through C1D14). Rituximab was deferred as he was CD20 negative.
He underwent LP w/ IT methotrexate on ___ and again on ___,
and initial CSF (___) was noted to have only 1 nucleated cell
w/ cytology negative for atypical cells. He tolerated
chemotherapy well w/ nausea as the major side effect, of the
antiemetics, zyprexa seemed to be the most efficacious for the
patient. Neupogen was started for the patient on day 9 which he
continued until count recovery. He was maintained on acyclvoir,
atovaquone (c/f further marrow suppression and transaminitis w/
bactrim) for prophylaxis. He developed severe constipation,
likely secondary to the vincristine as part of cycle 1, which
may have led to an enteritis which briefly caused Neutropenic
fever. Patient was on vanc, cefepime, and flagyl briefly before
discontinuing due to resolution of fever and diagnossi of
enteritis. He was transitioned to ciprofloxacin and flagyl for
enteritis but developed a drug rash likely secondary to
ciprofloxacin. Cipro and flagyl were discontinued in favor of
Augmentin which was then discontinued due to resolution of
enteritis clinically and count recovery. Patient started cycle 2
of hyperCVAD+ponatinib on ___ and tolerated it well while in
house. MTX cleared by 48 hours post-infusion. He had a port
placed on ___ for ongoing need for chemotherapy, labs, and
transfusion support. Patient was discharged home on acyclovir,
atovaquone, and cefpodoxime prophylaxis as well as neupogen. He
was given 3 days worth of oxycodone for port site pain.
#Abdominal pain
#Constipation
Patient developed abdomina discomfort on days ___ of
treatment, initial concern for gastritis, esophagitis given
gnawing epigastric pain, worse w/ food, unrelieved by bowel
movements in context of recent high dose steroids. His stool
guaic was negative so actively bleeding peptic ulcer was less
likely. The patient was symptomatically improving with a GI
cocktail that included famotidine, pantoprazole, simethecone and
sucralfate when he spiked a fever. Given his abdominal pain, a
CT A/P was pursued which demonstrated some mild enteritis. He
was given antibiotics as noted above. Enteritis ultimately
resolved and was likely secondary to vincristine given with
first cycle of chemotherapy. He did not have issues with
constipation during cycle 2 while inpatient. He was discharged
on a bowel regimen.
#Rash
Patient found to have a diffuse morbilliform rash on the chest
and back ___ days following initiation of ciprofloxacin for
bacterial infection prophylaxis while Neutropenic. Cipro was
immediately discontinued in favor of augmentin. Rash resolved
over the next few days, ciprofloxacin added to adverse
reactions.
#Eustachian tube dysfunction
Patient noted to have R>L 'ear fullness', otoscopic examination
was notable for bilateral straw-colored fluid behind tympanic
membrane, without concern for otitis media or other infection.
He was treated symptomatically for eustachian tube dysfunction
w/ cromolyn sodium with noted improvement.
#Paronychia
Shortly following admission pt noted to have R. great toe pain
and tenderenss w/ mild erythema at nail bed. Treated empricially
with 7 day course of vancomycin given concomitant chemotherapy.
Symptoms resolved by day 3 of treatment.
#Parapharyngeal Abscess
Patient was noted to have 4mm parapharyngeal fluid collection on
screening CT-neck on presentation. At the time patient was
entirely asymptomatic without oropharyngeal asymmetry, ertyhema,
hypophonia, or systemic signs of infection. ENT was consulted
initially and given size of the fluid collection there was no
roll for drainage, so scope was not pursued given functional
neutropenia. Given urgent initiation of chemotherapy for his ALL
the patient was treated w/ a 7 day course of Cefepim/Flagyl
(___) with serial improvement on follow-up CT on ___.
TRANSITIONAL ISSUES
======================
[ ] Patient's Truvada PreP was held during this admission. He
was instructed that he would be okay to take it on discharge but
indicated he may stop taking it anyway.
[ ] Patient's HCTZ held during this admission and restarted on
discharge.
[ ] Patient developed a drug rash this admission to
ciprofloxacin; added to adverse reactions and recommend avoiding
fluoroquinolones in the future when possible.
[ ] Patient will have planned readmission to ___ for cycle 3 of
hyperCVAD+ponatinib.
[ ] Patient discharged on 3 day supply of oxycodone for pain at
his port site - port placed ___, left accessed.
[ ] Discharge weight: 195 lbs
[ ] Discharge ANC: 880
[ ] Discharge Cr: 0.7
MEDICATION CHANGES
=====================
New medications:
[ ] Acyclovir 400 mg po q12h
[ ] Atovaquone suspension 1500 mg po daily
[ ] Cefpodoxime proxetil 200 mg po q12h
[ ] Docusate sodium 100 mg po bid
[ ] Famotidine 20 mg po q12h
[ ] Filgrastim-sdnz 480 mcg SC q24h
[ ] Loratadine 10 mg po daily
[ ] Lorazepam 0.5-1 mg po q6h prn for anxiety/insomnia/nausea
[ ] senna 8.6 mg po bid
[ ] Oxycodone 5 mg po q6h prn for pain for 3 days
[ ] Ponatinib 30 mg po daily
[ ] trazodone 50-100 mg po qhs prn
Changed medications:
[ ] None
Discontinued medications:
[ ] None
Contact:
Name of health care proxy: ___
Relationship: boyfriend
Phone number: ___
Code status: full
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. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY PREP
2. Hydrochlorothiazide 12.5 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
RX *acyclovir 400 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
2. Atovaquone Suspension 1500 mg PO DAILY
RX *atovaquone 750 mg/5 mL 10 ml by mouth daily Refills:*0
3. Cefpodoxime Proxetil 200 mg PO Q12H
RX *cefpodoxime 200 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
5. Famotidine 20 mg PO Q12H
RX *famotidine 20 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
6. Filgrastim-sndz 480 mcg SC Q24H
RX *filgrastim-sndz [Zarxio] 480 mcg/0.8 mL 0.8 mL SC DAILY Disp
#*10 Syringe Refills:*0
7. Loratadine 10 mg PO DAILY
RX *loratadine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
8. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety/nausea/vomiting
RX *lorazepam 0.5 mg 1 by mouth bid prn Disp #*60 Tablet
Refills:*0
9. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth q6h prn Disp #*12 Tablet
Refills:*0
10. ponatinib 30 mg PO DAILY
11. Senna 8.6 mg PO BID
RX *sennosides 8.6 mg 1 by mouth twice a day Disp #*60 Tablet
Refills:*0
12. TraZODone 50-100 mg PO QHS:PRN insomnia
RX *trazodone 50 mg ___ tablet(s) by mouth qhs prn Disp #*60
Tablet Refills:*0
13. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY PREP
14. Hydrochlorothiazide 12.5 mg PO DAILY
15. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Acute Pre-B Cell Lymphocytic Lymphoma ___ chromosome)
Febrile neutropenia
Drug rash due to ciprofloxacin
SECONDARY DIAGNOSES
====================
Enteritis
Constipation
Parapharyngeal abscess
Paronychia
Transaminitis
Hypophosphatemia
Pancytopenia
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___!
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were found to have a very high white blood cell count
concerning for a blood cancer.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You were diagnosed with a type of cancer of the blood cells
called acute lymphocytic leukemia (ALL). You were started on
chemotherapy for your ALL which included a regimen of
intravenous medications called hyperCVAD and a pill called
ponatinib.
- You were started a medication to help improve you cell counts
called Neupogen, as well as medications to prevent viral,
bacterial, and fungal infections.
- You were given blood and platelets when your levels of these
were found to be low.
- You were started on antibiotics due to an infection in your
small bowel, and given medications to treat and prevent
constipation due to one of the medications in your chemotherapy.
- You were started on cycle 2 of your chemotherapy as well. You
will be discharged home with a planned readmission to start
cycle 3 of chemotherapy.
WHAT SHOULD I DO WHEN I GO HOME?
- Please be sure to attend all of your appointments, listed
below. Additionally, please take your medications exactly as
prescribed. Note the new medications listed below.
- Enjoy spending time with the twins (but wear a mask during
cold/flu season). Treat the next intern well when you come back
for cycle 3!
- Important medications: Cefpodoxime (bacterial prophylaxis for
neutropenia), atovaquone ("PCP" aka pneumocystic pneumonia
prophylaxis), acyclovir (viral prophylaxis), neupogen (for your
low neutrophil counts)
We wish you the best,
Your ___ care team
New medications:
[ ] Acyclovir 400 mg po q12h (viral prophylaxis)
[ ] Atova___ suspension 1500 mg po daily (pneumocystic
pneumonia prophylaxis)
[ ] Cefpodoxime proxetil 200 mg po q12h (bacterial prophylaxis
while Neutropenic)
[ ] Docusate sodium 100 mg po bid (for constipation)
[ ] Famotidine 20 mg po q12h (for reflux)
[ ] Filgrastim-sdnz 480 mcg SC q24h (for neutropenia)
[ ] Loratadine 10 mg po daily (for allergies)
[ ] Lorazepam 0.5-1 mg po q6h prn for anxiety/insomnia/nausea
(for anxiety/sleep/nausea)
[ ] senna 8.6 mg po bid (for constipation)
[ ] Oxycodone 5 mg po q6h prn for pain for 3 days (for severe
pain at the port site only)
[ ] Ponatinib 30 mg po daily
Changed medications:
[ ] None
Discontinued medications:
[ ] None
Followup Instructions:
___
|
10263482-DS-15 | 10,263,482 | 29,972,141 | DS | 15 | 2151-10-07 00:00:00 | 2151-10-07 14:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cholangitis/choledocolithiasis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx of essential tremor presented to ___ with
fever and elevated ___ transferred to ___ for further
management given concern for cholangitis/choledocolithiasis.
Patient reports doing well until ___ when had some lower
abdominal and epigastric discomfort. This persisted over the
weekend. Some mild nausea. No vomiting. No jaundice. Then on
___ had generalized tremor, felt cold and went to ___
where had elevated transaminases and bilirubin, u/s with stones
but normal CBD, and CT demonstrating thickened gallbladder wall.
Given abx and transferred to ___. Feels better now and LFTs
downtrending.
Past Medical History:
- HLD
- HTN
- osteoarthritis
- Essential Tremor
Social History:
___
Family History:
Father: healthy, lived until ___
Mother: ___ of abdominal cancer (patient unsure of details),
lived
until ___
Brother: ___, alive, Hx of MI
Physical Exam:
GEN: A&Ox3, NAD, resting comfortably
HEENT: NCAT, EOMI, sclera anicteric
CV: RRR
PULM: no respiratory distress
ABD: soft, NT, ND, no rebound or guarding
EXT: warm, well-perfused, no edema
PSYCH: normal insight, memory, and mood
Pertinent Results:
___ 05:45AM BLOOD WBC-6.9 RBC-4.19* Hgb-12.6* Hct-37.7*
MCV-90 MCH-30.1 MCHC-33.4 RDW-13.9 RDWSD-45.6 Plt ___
___ 05:45AM BLOOD Glucose-128* UreaN-18 Creat-1.1 Na-142
K-4.2 Cl-107 HCO3-25 AnGap-10
___ 05:45AM BLOOD ALT-54* AST-56* AlkPhos-77 TotBili-0.4
Brief Hospital Course:
The patient presented as a transfer from ___ for
management of cholangitis/choledocolithiasis subsequent
bacteremia. He was treated non-operatively with antibiotics and
improved throughout his hospital course. His LFTs were initially
elevated and downtrended throughout his hospitalization.
Neuro: The patient was alert and oriented throughout
hospitalization. Pain was very well controlled.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO. Afterwards, the
patient's diet was advanced to a regular, which the patient
tolerated well.
ID: The patient's fever curves were closely watched. The
patient's fever resolved while hospitalized at ___. ID
was consulted for further management of the patient's infection
and bacteremia. He was initially placed on vancomycin,
ceftriaxone, and metronidazole until the blood cultures were
finalized. The patient was narrowed to ceftriaxone after his
cultures were finalized as pan-sensitive Streptococcus
Salivarius. The patient was discharged on a two week course of
ceftriaxone.
HEME: The patient's blood counts were closely watched and his
leukocytosis resolved.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. PrimiDONE 250 mg PO TID
2. Propranolol LA 160 mg PO DAILY
3. Simvastatin 20 mg PO QPM
4. Aspirin 81 mg PO DAILY
Discharge Medications:
1. CefTRIAXone 1 gm IV Q 24H
RX *ceftriaxone in dextrose,iso-os 1 gram/50 mL 1 gm IV Daily
Disp #*14 Intravenous Bag Refills:*0
2. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
3. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
4. Aspirin 81 mg PO DAILY
5. PrimiDONE 250 mg PO TID
6. Propranolol LA 160 mg PO DAILY
7. Simvastatin 20 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Choledocholithiasis
Bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you here at ___
___. You were admitted to our hospital
after transfer from ___ for bile duct obstruction that
was causing your symptoms of pain and bloodstream infection.
Your symptoms resolved, your diet was advanced, however your
blood cultures from ___ were positive for a bacteria
called Streptococcus Salivarius and you will need IV antibiotics
for 14 days. You will also follow-up in clinic for planning of
interval removal of your gallbladder. You are now ready to be
discharged to home. Please follow the recommendations below to
ensure a speedy and uneventful recovery.
ACTIVITY:
- You may go back to your normal daily activities.
- You may resume sexual activity unless your doctor has told you
otherwise.
YOUR BOWELS:
- If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- chest pain, pressure, squeezing, or tightness
- cough, shortness of breath, wheezing
- pain that is getting worse over time or pain with fever
- shaking chills, fever of more than 101
- a drastic change in nature or quality of your pain
- nausea and vomiting, inability to tolerate fluids, food, or
your medications
- if you are getting dehydrated (dry mouth, rapid heart beat,
feeling dizzy or faint especially while standing)
-any change in your symptoms or any symptoms that concern you
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.
ANTIBIOTICS:
- You are being prescribed an antibiotic for your bloodstream
infection. Please administer Ceftriaxone 1 gm every 24 hours for
two weeks.
Please call with any questions or concerns. Thank you for
allowing us to participate in your care. We hope you have a
quick return to your usual life and activities.
-- Your ___ Care Team
Followup Instructions:
___
|
10263764-DS-16 | 10,263,764 | 24,426,788 | DS | 16 | 2162-01-03 00:00:00 | 2162-01-05 15:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Shellfish / Gabapentin / Droperidol / Darvon /
Prochlorperazine / Reglan
Attending: ___.
Chief Complaint:
back pain/urinary retention
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is ___ female with PMH of cauda equina syndrome with
compression of the cauda equina from an arachnoid cyst s/p S1-3
laminectomies and arachnoid cyst drainage by neurosurgery in
___ with a CSF leak and further presentations due to a
post-surgical fluid collection presenting with acute on chronic
back pain and urinary retention.
Per chart biopsy patient has been seen/admitted multiple times
over the preceding years with similar complaints with extensive
neurology/neurosurgerical evaluation. Recently she has been
stable, working and relatively pain free. She reports that she
was in USOH on the day of admission when noticed increasing back
pain in the area of previous operative intervention; area of
S2-S4 arachnoid cyst. Cyst was intervened on by Neurosurgery in
___ with subsequent CSF leak that she reportedly had
percutaneously drained in ___ at ___ then had a further
procedure "cleaning out" after that at ___ but she is unsure
exactly.
In addition to acute back pain, endorses that she was unable to
urinate on the day of admission and went to ___ where a foley
catheter was placed and reportedly returned 900 ml of urine. She
also says she is having a decrease in sensation perianally.
She denies any shooting pain, is having some numbness over the
dorsum of her left foot, this she endorses as chronic as well,
but feels that it is worsening. She reports taht she is only
taking motrin for pain currently.
Pertinent +/-
No recent history of illness, fever, chills, sweats.
Past Medical History:
1. Asthma, uses albuterol p.r.n.
2. ___ type 3, diagnosed in ___.
3. Endometriosis, currently inactive.
4. History of ovarian cyst, inactive.
5. Abdominal pain: Negative colonoscopy, CT scan; sees Dr.
___, ___ and ___, currently thought to be functional
abdominal pain being treated with OCP and dietary modifications.
6. Recent hip pain, caused by subluxation, reduced multiple
times and currently taking Percocet for pain control
7. Mononucleosis ___
Past Surgical History:
1. S/p R MPFL reconstruction ___
2. Hx of hip dislocations s/p reductions on ___ and
___. Right nasal polyp removal
4.S2-S4 laminectomies and arachnoid cyst drainage ___
Social History:
___
Family History:
She has cousins with ___ Danlos, and diabetes.
She denies a family history of cardiac disease, or cancer.
Physical Exam:
VS: 98.7 110/70 98 18 98%RA
Gen: Well appearing, no acute distress
HEENT: EOMI, PERRLA
CV: RRR
Resp: CTA-B
Abd: non-tender, non-distended, +BS
Ext: WWP, no edema
Neuro (performed with neurology)
Mental Status:
Alert, oriented x 3, Fluent Speech
Cranial Nerves: II-XII intact bilaterally
Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
Upper extremities ___ bilaterally.
Left ___: ___ TA and IP otherwise ___ .
Right ___: ___
Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout in UE. In the ___ has
decreased sensation to light touch, pinprick and temperature
involving the dorusm of the left foot up to the mid anterior
shin. ___ examination reveals decreased sensation from
S3-5
Rectal examination performed by spine surgery revealed poor
effort but possibly normal rectal tone and present anal wink.
DTRs: symmetric, 3+ in bilateral ___
No clonus
On Discharge:
Gen: Well appearing, ambulating without appreciable difficulty
Neuro
Mental Status:
Alert, oriented x 3, Fluent Speech
Cranial Nerves: II-XII intact bilaterally
Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
Upper extremities ___ bilaterally.
Left ___: ___ TA and IP otherwise ___ .
Right ___: ___
Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout in UE. In the ___ has
continued mild decreased sensation to light touch, pinprick and
temperature involving the dorusm of the left foot up to the mid
anterior shin. ___ examination reveals again areas of mild
decreased sensation from S3-5
DTRs: symmetric, 3+ in bilateral ___
No clonus
Pertinent Results:
___ 02:25AM BLOOD WBC-5.7 RBC-4.42 Hgb-11.9* Hct-35.9*
MCV-81* MCH-27.0 MCHC-33.3 RDW-15.0 Plt ___
___ 04:20AM BLOOD WBC-4.2 RBC-4.29 Hgb-11.6* Hct-35.1*
MCV-82 MCH-27.1 MCHC-33.0 RDW-15.0 Plt ___
___ 02:25AM BLOOD ___ PTT-30.7 ___
___ 04:20AM BLOOD ___ PTT-30.5 ___
___ 02:25AM BLOOD Glucose-104* UreaN-10 Creat-0.7 Na-141
K-4.3 Cl-108 HCO3-23 AnGap-14
___ 04:20AM BLOOD Glucose-85 UreaN-10 Creat-0.7 Na-142
K-4.3 Cl-106 HCO3-25 AnGap-15
___ 04:20AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.1
MRI (cervical, thoracic, lumbar)
HISTORY: Weakness, incontinence evaluate for acute cord
compression.
Cervical Spine: The vertebral bodies are normal height and
alignment. The
bone marrow signal is unremarkable. There is mild loss of the
normal lordosis
of the cervical spine. The craniocervical junction is
unremarkable. The
spinal cord is of normal signal intensity without any focally
diffuse lesions
or evidence of cord compression. There is no intradural
abnormality.
At C4-C5 there is a mild disc bulge with no evidence of central
canal or
neural foraminal narrowing.
At C5-C6 there is a mild disc bulge causing effacement of the
ventral canal
but no central canal or neural foraminal narrowing.
AT C6-C7 there is a mild disc bulge but no evidence of central
canal or neural
foraminal narrowing.
The remainder of the of C2-C3, C3-C4 and C7-T1 levels are
unremarkable.
Thoracic spine: The thoracic vertebral bodies are normal height
and
alignment. The bone marrow signal is unremarkable. There
spinal cord is of
normal signal intensity with no focal or diffuse lesions. There
is no
evidence of cord compression. There is no intradural
abnormality or evidence
of degenerative changes.
A small 7 mm cyst is noted within the right lobe of the thyroid.
IMPRESSION:
No evidence of cord lesion or cord compression. Mild
degenerative changes in
the cervical spine with mild disc bulges as described above.
MRI Lumbar Spine
FINDINGS: The patient is status post S1-S3 laminectomies. There
is interval
near-complete resolution of the large postsurgical fluid
collection in the
posterior paraspinal soft tissues.
The conus medullaris terminates at L1-L2. The lumbar vertebral
body height
and intervertebral disc space are preserved. There is no lumbar
spine
malalignment. The lumbar spinal canal remains capacious. There
are no
significant degenerative changes. There is no disc herniation,
spinal canal
stenosis or neural foraminal narrowing.
There are post-surgical granulation tissues around the surgical
bed. There
are also extensive granulation tissues extending from the S2
level and
downward, with encroachment of the sacral nerve roots
bilaterally.
IMPRESSION:
1. No evidence of spinal cord compression. Lumbar spinal canal
remains
capacious.
2. Interval near-complete resolution of the large postsurgical
fluid
collection in the posterior soft tissues.
3. Postsurgical changes with S1-S3 laminectomies. Extensive
granulation
tissues extending from the S2 level and downward, with
encroachment of the
sacral nerve roots bilaterally.
Brief Hospital Course:
Ms ___ is a ___ female with Erlos Danlos presenting with
acute on chronic back pain and urinary retention MRI cervical,
thoracic and lumbar spine without appreciable pathology.
# Back Pain/Urinary Retention. On review of record patient with
multiple episodes of urinary retention and/or urinary/bowel
incontinence in the past. In house, MRI cervical, thoracic and
lumbar spine without evidence of cord compression or anatomic
abnl. Neurology consulted who noted inconsistencies on exam,
Neurosurgery, previously very involved in her care, reviewed
images and stated actual improvement in areas of lumbar spine
when compared to prior. They noted concern that patient had
significant drug-seeking during prior admissions. Patient
informed of MRI results and encouraged to follow-up with PCP and
potentially new neurosurgeon as an outpatient to manage her
chronic pain. Prior to discharge her pain was well controlled
with minimal opioids with planned follow-up the genetics dept at
___ as well as patient's PCP.
OUTPATIENT ISSUES:
[] Discharged with small dose of oxycodone
[] Advocate for continued use of anti-inflammatories rather than
opioids for pain control
[] Patient provided number for new neurosurgeon for further
evaluation
# Urinary retention. Differential in our patient included: cord
compression, medication side effect; mechanical/outflow
obstruction. Patient denies any OTC/rx meds known to cause
retention. No anatominal risks for outflow obstruction. MRI
without e/o cord compromise or compression. Patient's foley was
discontinued shortly after arriving to the floor. She quickly
passed a voiding trial and was having no trouble with urination
prior to discharge.
# ? Drug seeking behavior. Per discussion with previous care
teams concern for some degree of narcotics dependance/abuse. In
house patient admitted after receiving IV pain meds in the ED.
Quickly transitioned to PO oxycodone. Patient very appropriate
in discussions regarding opioids and amenable to discharge with
small supply with plan to taper off quickly and return to use of
anti-inflammatories only to treat the pain.
# Contact: patient
# PPX: SubQ heparin
# Dispo: Home, no services
# Consult: neurology; neurosurgery
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 400 mg PO Q8H:PRN pain
2. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Ibuprofen 800 mg PO Q8H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. Omeprazole 20 mg PO DAILY
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
control
RX *oxycodone 5 mg ___ tablet(s) by mouth every 6 hours Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on Chronic Back Pain
Urinary Retention
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___ it was a pleasure taking care of you.
You were admitted to the hospital with back pain and urinary
retention. MRIs of your cervical, thoracic and lumbar spine were
obtained and were negative for spinal cord compression or any
abnormality to explain symptoms. You were also assessed by
neurology who performed a full exam. After review of history and
imaging symptoms were thought to be a manifestation of your
chronic pain. Prior to discharge your pain was well controlled
and you were able to urinate.
Please see changes to medications
Followup Instructions:
___
|
10263994-DS-15 | 10,263,994 | 24,722,853 | DS | 15 | 2138-06-13 00:00:00 | 2138-06-13 18:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ year old man with a PMHx of HLD and
increasing weakness since ___ in the setting of multiple
traumatic injuries, with recent diagnosis of ALS by EMG, who
presents with SOB for the past two weeks, acutely worsening over
the past 24 hours. For the past two weeks, he has been unable to
speak in full sentences, but feels fairly comfortable if lying
still. Last night, he became more SOB at rest which prompted his
presentation to the ED.
Per patient's wife, ___ was perfectly healthy until this past
___, when he fell down 9 stairs as he leaned to pet their new
puppy and hit his head on concrete. He did not have LOC, but did
sustain a large area of swelling on his head. About ___ weeks
later, he again fell off a ladder at 12 feet. He hit his head,
but did not lose consciousness. He didn't seek medical attention
for either of these events. After this second fall, his wife
starting noticing some weakness in his hands, but at this time
he didn't have any speech difficulties. Shortly after this fall
in ___, he had an episode of loss of memory for about ___
hours, and was diagnosed with transient global amnesia. MRI
brain and c-spine at that time were normal per report.
In ___ ___ had a ___ fall in the shower. He fell backwards and
again hit his head. After this fall, it seems he became weaker
in his hands, his speech became more slurred (wife can't tell me
when the slurred speech started), and his balance seemed worse.
More recently at the end of ___, patient had a follow up
with his PCP who checked labs and found that his CPK was
elevated. Because of this, his PCP sent him to the ED; at the ED
he was transferred to ___. According to his
wife, ___ was initially admitted to the ICU with concerns for
his breathing, and there they monitored him, did an EMG but no
other neuroimaging, diagnosed him with ALS and discharged him
with home nursing services and a follow up ___.
He presented to ___ on ___ due to two weeks of worsening
shortness of breath to the point where he could no longer speak
in full sentences. He was evaluated in the ED and subsequently
admitted to the ICU on ___ due to concerns of respiratory
status. He was later transferred to the ___ the next day as
his respiratory status remained stable.
Past Medical History:
HLD
Depression
? ALS
Social History:
___
Family History:
No family history of ALS or other neurodegenerative disease.
Physical Exam:
ADMIT PHYSICAL EXAMINATION
==========================
Vitals: T97.6 HR 60 BP 120/76 RR 18 SaO2 96% RA
General: Awake, appears uncomfortable lying in bed
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted
in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W. Some
supraclavicular retrations with breathing at rest, more
pronounced with speech. Can count to 4 in one breath.
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Takes breaths in between
every other word, becoming very short of breath with
conversation. Able to answer historical questions with one word
answers but wants wife to do the talking. Pt was able to name
both high and low frequency objects. Speech very dysarthric.
Able
to follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Does not bury sclera bilaterally. Some breakdown of
smooth pursuits.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric. Eye closure
slightly weak, buries eyelashes but can be opened by examiner.
Can puff out cheeks with air and maintain. Maintaining open jaw
strong. Tongue pouching in cheeks strong bilaterally.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically. Gag reflex present.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Decreased bulk, normal tone throughout. Atrophy of
interosseous muscles and anatomical snuffbox bilaterally.
Fasiculations noted in the bilateral upper extremities
left>right, as well as bilateral legs. No fasciulations
appreciated in the trunk or on the tongue. When assisted to
sitting up can maintain sitting on his own.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 4- 4+ 4+ ___ 2 4+ 4+ 5 5 5 5 5
R 4- 4+ 4+ ___ 2 4+ 4+ 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 3 3
R 3 3 3 3 3
Plantar response was extensor bilaterally. Crossed adductors
present bilaterally. Suprapatellar reflexes present bilaterally.
Pectoral jerks present bilaterally. Jaw jerk present.
-Coordination: slow tapping of fingers bilaterally because of
weakness.
-Gait: When helped to standing, can walk, with short stride and
does not lift feet much off the ground.
DISCHARGE PHYSICAL EXAM:
========================
Pertinent Results:
ADMISSION LABS:
===============
___ 05:15PM CK(CPK)-555*
___ 01:12PM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 01:12PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 01:12PM URINE RBC-6* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
___ 01:12PM URINE AMORPH-OCC*
___ 06:23AM ___ PO2-76* PCO2-39 PH-7.42 TOTAL CO2-26
BASE XS-0 COMMENTS-GREEN TOP
___ 05:40AM GLUCOSE-94 UREA N-20 CREAT-0.7 SODIUM-144
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-24 ANION GAP-15
___ 05:40AM estGFR-Using this
___ 05:40AM ALT(SGPT)-56* AST(SGOT)-55* ALK PHOS-69 TOT
BILI-0.3
___ 05:40AM LIPASE-21
___ 05:40AM cTropnT-<0.01
___ 05:40AM ALBUMIN-4.4 CALCIUM-9.6 PHOSPHATE-4.1
MAGNESIUM-2.0
___ 05:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 05:40AM WBC-8.2 RBC-4.30* HGB-13.8 HCT-39.5* MCV-92
MCH-32.1* MCHC-34.9 RDW-12.7 RDWSD-42.4
___ 05:40AM NEUTS-52.6 ___ MONOS-9.9 EOS-4.6
BASOS-0.7 IM ___ AbsNeut-4.32 AbsLymp-2.57 AbsMono-0.81*
AbsEos-0.38 AbsBaso-0.06
___ 05:40AM PLT COUNT-212
___ 05:40AM ___ PTT-26.8 ___
IMAGING:
=======
+ ___ CXR: Low lung volumes. Retrocardiac opacity likely
represents atelectasis, although superimposed consolidation is
difficult to exclude.
+ ___ MRI C/T spine:
1. Study is mildly degraded by motion.
2. No evidence of syrinx formation or spinal cord lesion.
3. Extensive spondylotic changes of the lumbar spine most
significant from
L2-L3 through L4-L5 where there is multilevel severe vertebral
canal narrowing resulting in crowding of the cauda equina nerve
roots. There is also multilevel severe bilateral neural
foraminal narrowing.
4. Spondylotic changes of the cervical spine most significant at
C4-C5 where there is mild vertebral canal narrowing and
moderate to severe bilateral neural foraminal narrowing.
5. Mild degenerative changes of the thoracic spine at T8-T9
where there is
mild vertebral canal narrowing.
6. 4 mm right iliac bone non-enhancing probable bone island.
+ ___ C MRI Head:
1. Study is mildly degraded by motion.
2. No acute intracranial abnormality.
3. No evidence of brainstem abnormality.
4. Paranasal sinus disease, as described.
5. 6 mm Tornwaldt cyst.
Brief Hospital Course:
This is a ___ year old male with a clinical and physiological
diagnosis of motor neuron disease (ALS) following a 6 month
course of progressive weakness, shortness of breath, and lingual
dysarthria. The patient and his wife were informed of this
diagnosis today and would like to proceed with experimental
treatment per the ___ clinic at ___ (appointment
scheduled for next week ___.
#Dyspnea
Admission exam is significant for prominent dyspnea with just a
few words of speech, prominent dysarthria, decreased gag reflex,
NIF -30, prominent weakness in the upper extremities, preserved
sensation all over, fasiculations in the arms L>R as well as
legs, and diffuse hyperreflexia. Acute worsening of dyspnea is
not thought to be due to infection as he had no leukocytosis,
fevers or consolidation. Possible aspiration event given history
of coughing when eating, although SLP evaluation without concern
for aspiration event. His NIF/VC were monitored Q4H and were
-60/3L respectively without desaturations. NIF/VC were switched
to Q6H on ___, with initial values of -80/2.29. His
respiratory status has remained stable throughout his
hospitalization and he did not need supplemental oxygen or other
respiratory support.
#Weakness with recent diagnosis ALS
He reports several month history of progressive weakness and
recent falls. He was reportedly diagnosed with ALS at ___.
Exam notable for jaw jerk, palmomental reflex, weakness in all
extremities, fasciculations throughout, and diffuse
hyperreflexia. Given that he has both upper and lower motor
neuron findings on exam as well as confirmatory report from EMG
performed at ___ on ___ support the diagnosis of ALS
this is the most likely diagnosis at this time. In discussion
with neuromuscular service the patient was started on Riluzole
50mg BID and will be enrolled in an experimental treatment
trial. He was evaluated by ___ during his hospitalization who
recommended home services on discharge.
MRI Brain unremarkable. MRI C spine with degenerative changes
but no severe canal stenosis. MRI L spine with degenerative
changes with compression of some cauda equina nerve roots but
would not explain his symptoms or bulbar and b/l arm weakness.
Video swallow evaluation ___ showed intermittent aspiration
with regular liquids. With swallowing strategies, speech
therapists felt that he was safe to continue with diet of thin
liquids with chin tuck and soft solids. Home nursing services
and physical therapy were resumed prior to discharge ___.
#Depression
Patient has a history of depression which is likely exacerbated
in the setting of his symptoms and current diagnosis. He was
restarted on his home dose of Paxil 10mg.
Transitional Issues:
- Pulmonary function testing as an outpatient
- Follow up with ___ clinic
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PARoxetine 20 mg PO DAILY
2. Simvastatin 10 mg PO QPM
Discharge Medications:
1. riluzole 50 mg oral BID
RX *riluzole [Rilutek] 50 mg 1 tablet(s) by mouth twice a day
Disp #*180 Tablet Refills:*2
2. PARoxetine 20 mg PO DAILY
3. Simvastatin 10 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
ALS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted with weakness in both arms and face/tongue.
During this admission you were evaluated by a general
neurologist as well as a neuromuscular specialist and we both
feel that it very likely that your diagnosis is ALS. You also
had a Brain MRI and MRI of your spine. The MRI Brain was
unremarkable. The MRI of your spine showed lumbar spine
arthritis that would not be causing your symptoms as well as
arthritis in your neck that also would not explain all of your
weakness. Your EMG/NCS from ___ was also reviewed, and was
found to be consistent with ALS. We started you on Riluzole 50mg
twice per day.
We have set you up with outpatient follow with our
multidisciplinary ALS center, as well as with home nursing and
physical therapy.
As part of this expedited workup, you also received swallow
evaluation, and were taught some maneuvers to help keep your
swallowing safe. This study will be reviewed by your
neurologists as an outpatient. You also have PFTs set up as an
outpatient to occur the morning of your neurology appointment.
Please see details below.
It was a pleasure taking care of you.
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10264109-DS-6 | 10,264,109 | 29,646,814 | DS | 6 | 2189-07-30 00:00:00 | 2189-07-30 21:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Codeine / Influenza Virus Vaccine
Attending: ___
Chief Complaint:
chest discomfort/pre-syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo female w/ history of hypertrophic cardiomyopathy and HTN
presents with substernal/epigastric discomfort that lasted for
20 mins and begain earlier today w/ associated lightheadedness
and some mild shortness of breath. It is difficult for the
patient to characterize the sensation in her chest. She
describes it has discomfort rather than pain. Symptoms triggered
by exertion while at landfill throwing trash away. States she
got anxious about chest discomfort, became lightheaded and
nearly fainted. Observing family members stated that she looked
very pale during this episode. After approximately 20 minutes,
patient felt back to normal. There was no associated nausea,
diaphoresis. She has been in her usual state of health prior to
this and denies any fevers/chills, abdominal pain, diarrhea,
constipation, dysuria. She has had normal PO intake and notes
normal urine output.
In the ED, initial vitals were 99.80 59 139/48 16 100% RA. In
ED, patient received Aspirin 324 mg. Upon arrival in ED, patient
was actually asymptomatic. While resting in hospital bed patient
acutely developed tachycardia to 133 with BP down to 98/62.
Found to be in a-fib. Patient states that when rhythm changed
she again experienced sensation of chest discomfort, but without
associated lightheadedness. States that while in a-fib she "just
didn't feel like herself". In the ED, she received 2L NS.
Briefly started on procainamide gtt, but discontinued after
discussion with cardiology fellow. Started on heparin gtt. At
19:51, pt. spontaneously converted to SR and reported feeling
much better. Labs in ED, showed WBC 8.4 HCT 38.3 Plt 142. Na 142
K 4.0 Cl 109 HCO3 25 BUN 20 Cr 0.9 Glu 97. Ca 9.6 Mg 1.9 P 2.9.
Trop-T<0.01(2:45PM).
Vitals on transfer:
Today 19:44 98.2 59 103/56 16 100%
On arrival to the floor, patient is completely asymptomatic and
states that she feels completely fine.
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.
Past Medical History:
1. CARDIAC RISK FACTORS: Hypertension (diagnosed ___
2. CARDIAC HISTORY:
Hypertrophic Cardiomyopathy (diagonsed ___ vs. LVH w/
diastolic dysfunction.
3. OTHER PAST MEDICAL HISTORY:
-osteoarthritis
Social History:
___
Family History:
FAMILY HISTORY:
Paternal grandmother had an "enlarged heart" and paternal aunt
also had an enlarged heart and WPW. Father died at ___ with
diabetes, coronary artery disease. Mother died at ___ and had
breast cancer at age ___. Brother is alive and healthy in his
___. She has three children in their late ___ and early ___, all
healthy, six healthy
grandchildren.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.9 60 120/55 22 100% RA
GENERAL: 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 flat JVP.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. Harsh ___ systolic
crescendo-decrescendo murmur heard best at RUSB w/ radiation to
carotids. Murmur became louder with valsalva. 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 peripheral edema
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas
DISCHARGE PHYSICAL EXAM:
Vs: 98.1 114/39 64 18 96% RA
GENERAL: 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 flat JVP.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. Harsh ___ systolic
crescendo-decrescendo murmur heard best at RUSB w/ radiation to
carotids. Murmur became louder with valsalva. 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 peripheral edema
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas
Pertinent Results:
LABS
___ 02:45PM BLOOD WBC-8.4 RBC-4.20 Hgb-13.3 Hct-38.3 MCV-91
MCH-31.6 MCHC-34.7 RDW-13.5 Plt ___
___ 07:02AM BLOOD WBC-5.9 RBC-4.01* Hgb-12.1 Hct-36.8
MCV-92 MCH-30.3 MCHC-33.0 RDW-13.7 Plt ___
___ 07:02AM BLOOD ___ PTT-150* ___
___ 02:45PM BLOOD Glucose-97 UreaN-20 Creat-0.9 Na-142
K-4.0 Cl-109* HCO3-25 AnGap-12
___ 07:02AM BLOOD Glucose-101* UreaN-10 Creat-0.8 Na-145
K-3.9 Cl-112* HCO3-24 AnGap-13
___ 12:37AM BLOOD CK(CPK)-32
___ 07:02AM BLOOD CK(CPK)-28*
___ 02:45PM BLOOD cTropnT-<0.01
___ 07:02AM BLOOD CK-MB-3 cTropnT-<0.01
___ 02:45PM BLOOD Calcium-9.6 Phos-2.9 Mg-1.9
___ 07:02AM BLOOD Calcium-9.7 Phos-3.3 Mg-2.1
___ 07:02AM BLOOD TSH-PND
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
===================================================IMAGING/OTHER
STUDIES:
CXR ___:
FINDINGS: PA and lateral views of the chest are provided. The
heart is
mildly enlarged. The lungs are clear. No signs of CHF or
pneumonia. No
effusion or pneumothorax. Mediastinal contour is normal. Bony
structures are
intact.
IMPRESSION: Mild cardiomegaly. Otherwise, normal.
Brief Hospital Course:
___ yo female w/ history of HOCM vs. LVH w/ diastolic dysfunction
presents with chest pain, near syncope, found to be in a-fib w/
RVR.
# CORONARIES: Patient complaining of chest pain and has
inferolateral ST-T changes. Only risk factor for CAD is HTN.
Cardiac enzymes were negative x3.
# HOCM vs. LVH w/ diastolic dysfunction: Previous ECHOs have
shown evidence of either HOCM or LVH with diastolic dysfunction.
Latest echo from ___ showed asymetric septal
hypertrophy with LVOT gradient of 106mmHg, suggestive of HOCM.
This was to be more formally evaluated with cardiac MRI, but
patient has declined. Either condition would be exacerbated by
instances of decreased preload and atrial filling. Although
patient without known history of a-fib, she did convert to a-fib
in the ED. If she had a-fib at home, this would certainly worsen
her HOCM vs. LVH. Patient received 2L NS in ED. Patient would
benefit from o/p cardiac MR to establish definitive diagnosis.
Patient reports she would be too anxious for MRI. O/p
cardiologist to discuss with MR department sedation options to
try to obtain this study.
# atrial fibrillation w/ RVR - patient has no known history of
a-fib, but cannot say for sure that she has been in a-fib for
<48 hours. In ED, rate was in 130s. She was given 2L NS and
spontaneously converted to NSR with rates in low ___. She was
started on heparin gtt. Only 1 very brief (10 second) episode of
a-fib on overnight tele. Therefore, no need for cardioversion,
and thus no need for TEE. Patient discharged with ___ of hearts
monitoring to determine amount of time spent in a-fib. Patient
discharged on rivaroxaban for anticoagulation and CVA ppx until
a-fib burden is determined. Home amlodipine switched to
diltiazem 180mg daily for better nodal blockade in case patient
dose revert to a-fib. TSH level pending.
# HTN
-continued valsartan, atenolol
-switched amlodipine to diltiazem 180mg PO daily
TRANSITIONAL ISSUES
#F/u TSH
#Patient would benefit from cardiac MRI to distinguish between
competing diagnoses of HOCM vs. LVH w/ diastolic dysfunction.
Patient currently states she would be too anxious for MRI.
Should discuss with MR department about potential sedation
options.
#Pt. discharged on ___ monitoring. Will f/u with Dr. ___ in
3 weeks to review amount of time patient spends in a-fib.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Valsartan 320 mg PO DAILY
2. Atenolol 100 mg PO DAILY
3. Amlodipine 10 mg PO DAILY
Discharge Medications:
1. Atenolol 100 mg PO DAILY
2. Valsartan 320 mg PO DAILY
3. Diltiazem Extended-Release 180 mg PO DAILY
RX *diltiazem HCl [Cardizem CD] 180 mg 1 capsule(s) by mouth
daily Disp #*30 Capsule Refills:*0
4. Rivaroxaban 20 mg PO DAILY
RX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Atrial fibrillation
Secondary: Hypertrophic cardiomyopathy. Hypertension
Discharge Condition:
mental status: clear, coherent
level of consciousness: alert and oriented
ambulatory status: independent
Discharge Instructions:
Dear Ms. ___,
It was our pleasure to care for you at ___. You were admitted
for chest pressure and a rapid heart rate. We found that you
were in a rapid rhythm called atrial fibrillation. We will
treat you with a new medication to control your heart rate and
also a medication to thin your blood. Please also wear a holter
monitor.
Followup Instructions:
___
|
10264661-DS-3 | 10,264,661 | 25,001,910 | DS | 3 | 2166-05-28 00:00:00 | 2166-05-28 16:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Celexa / Wellbutrin / sage
Attending: ___
Chief Complaint:
Parathesias
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo female with opticospinal MS ___ Ig
negative) on Ocrevus with a + JCV who is presenting with 1 day
of
sensory motor changes.
For the past week, she has felt a "tightness in my brain". She
has had a lot of stress at work and was attributing this to
stress.
___ patient first noted pain in left shoulder, described as
sharp
and shooting down arm, feeling like she had a sprain. This
resolved spontaneously.
___ she began to have the sensation of blood rushing to head
with tightness and tingling up base of spine to nape of neck.
Then would spread from back of head to an aching pain her ___
jaws. These episodes cycled throughout the day (cannot quantify)
and would last at most 15 minutes. When she stood up, she
noticed
an irregularity in gait. Left leg felt like its dragging, but
right leg felt weaker. This prompted her to rely heavily on her
cane, when normally able to ambulate without it. She also
noticed
increased spasticity in her L>R lower extremity. Her tongue felt
thick and speech difficult for ___ an hour. Perhaps has
blurriness of left eye, but this happens when she is stressed so
hard to relate to other symptoms. These symptoms are similar to
past flares, but not identical.
After these symptoms, she experienced chest tightness and light
headedness, but didn't feel short of breath or palpitations. She
took hydroxyzine with resolution of chest tightness.
She has not been doing yoga, high intensity workouts, or having
neck manipulation.
Upon arrival to ED, many of these symptoms have improved, but
her
gait still is slightly irregular. She continues to have aching
in
her ___ jaws and increased tone in lower extremities.
Migraines hx: pain normally localized normally left temporal but
can have dull holocranial pain. + photo, nausea, tearing,
tremors. ___
On neuro ROS, the pt denies current headache, blurred vision,
diplopia, dysarthria, dysphagia, lightheadedness, vertigo, new
tinnitus (chronically paroxysmal, had briefly in right ear at
time
of symptoms above)or hearing difficulty. Denies difficulties
comprehending speech. No bowel or bladder incontinence or
retention.
Past Medical History:
Onset: ___
Diagnosis: ___
Flare History:
1. ___: L eye pain, ON; treated with IVMP
2. ___: recurrent L ON poss
3. ___: R numbness from ribs to RLE; treated with oral
dexamethasone (24mg tid x3d, ___, tapering by 1 tab per
day until done (started ___
4. ___: BLE weakness; treated with IVMP x5d
5. ___: BLE weakness; treated with IVMP x5d
6. ___: Continued BLE weakness/numbness and enhancing cord
lesion; treated with 3d IVMP
7. ___: numbness in BLE with spread: treated with IVMP X3d
TREATMENTS AND RESULTS OF TREATMENTS:
Per OMR
1. Low dose gilenya Novartis trial (double ___
2. Gilenya 0.5mg qd ___
3. Tysabri ___ (JCV positive ___ (3.26); JCV Ab
negative ___
4. Ocrevus ___
PMH:
===========
MIRENA
SEBORRHEIC DERMATITIS
ONYCHOMYCOSIS
TINEA PEDIS
MAJOR DEPRESSION
UTERINE FIBROIDS
Social History:
___
Family History:
There is no history of MS in the family.
Her father has diabetes and macular degeneration and also has
trigeminal neuralgia.
Physical Exam:
T: 98.9 HR: 120 BP: 145/86 RR: 20 O2 97% on RA
General: Awake, cooperative, anxious
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no nuchal rigidity
Pulmonary: breathing non labored on room air
Cardiac: warm and well perfused
Abdomen: soft, NT/ND
Extremities: No cyanosis, clubbing or edema bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake, alert, oriented to self, place, time and
situation. Able to relate history without difficulty. Attentive.
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. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. No RAPD. Left red desat. VFF to
confrontation. Fundoscopic exam performed, pale disc on left. R:
___ -1 L: ___.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation 80-85% normal V1-3
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, increased tone BLLE. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ 5 ___ 5 5 5 5 5
R 5 ___ 5 ___ 5 5 5 5 5
-Sensory: Light touch and pinprick 45% normal LUE (chronic) and
60% normal LLE (chronic). No extinction to DSS.
T10 sensory level (unclear chronicity)
-DTRs:
3 throughout, toes mute. ___ beats of clonus ___
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. Slight left dysmetria on FNF
-Gait: Good initiation. Slightly wide based but steady gait.
Difficulty with tandem walk. Romberg absent.
DISCHARGE EXAM
===============
Gen: Well appearing, sitting up in bed at computer
Neuro
MS - Awake, alert, conversant. Normal attention w/in the limits
of normal conversation. Good recall of interval events.
CN
R 4-> 2, L. 3.5 > 2 , slight left APD, no facial asymmetry, no
further deficits to pinprick over face, protrudes tongue midline
Motor - no pronator drift, no adventitious movements or tremor
(L/R)
Delt ___
Bi ___
Tri ___
WEx ___
FEx ___
IP ___
Ham ___
Reflexes 3+ throughout except 1+ achilles, 2 beats clonus on
left
Upgoing toe on left
Decreased sensation to pinprick left hand, decreasd sensation of
right forearm, Possible posterior sensory levels at T4, T10,
Decreased sensation of right leg patchy mid calf. Intact
proprioception
Coordination - no dysmetria
Gait - Tandem gait improved
Pertinent Results:
ADMISSION LABS
================
___ 12:04AM BLOOD WBC-9.8 RBC-4.67 Hgb-13.2 Hct-40.6 MCV-87
MCH-28.3 MCHC-32.5 RDW-12.4 RDWSD-39.2 Plt ___
___ 12:04AM BLOOD Glucose-84 UreaN-10 Creat-1.1 Na-142
K-4.4 Cl-104 HCO3-27 AnGap-11
___ 07:20AM BLOOD Calcium-9.3 Phos-3.5 Mg-2.2
DISCHARGE LABS
================
___ 07:20AM BLOOD WBC-22.7* RBC-4.35 Hgb-12.0 Hct-38.1
MCV-88 MCH-27.6 MCHC-31.5* RDW-12.4 RDWSD-40.0 Plt ___
___ 07:20AM BLOOD Glucose-104* UreaN-11 Creat-0.8 Na-142
K-4.2 Cl-105 HCO3-24 AnGap-13
IMAGING
========
IMPRESSION:
1. Foci of signal abnormalities within the cervical and thoracic
spinal cord without enhancement indicative of demyelinating
disease. Some of the foci show evolution since the prior study
and some other foci are better visualized which could be
secondary to new lesion but none of the foci demonstrate
enhancement to indicate acute areas of demyelination.
2. Mild degenerative changes in the cervical spine.
Brief Hospital Course:
Ms. ___ is a ___ yo female with opticospinal MS ___ Ig
negative) on ocrelizumab with positive JCV ___ on ___
admitted with 1 day of sensory changes up spine and patchy
facial distribution, difficulties with gait, and increased tone
BLLE.
#Multiple Sclerosis
Pt w/ hx of of ___ negative oculospinal MS, w/ multiple
spinal lesions who presented with vague sensory changes
(decreased pinprick to face, arm and patchy area of back and
leg), mild L. IP weakness and gait difficulties. Given concern
for new symptoms, she underwent MRI C and T spine without
evidence of new or enhancing lesions, suggesting that suspended
and distinct thoracic spinal levels and patchy sensory
disturbance were baseline deficits. We did not pursue MRI brain
based on her clinical presentation and given rapidly improving
exam at the time of evaluation and absence of previous brain
lesions. She had no evidence of acute infection. She did receive
1 dose of methylprednisolone while waiting for imaging. At the
time of discharge she felt as though she was back to her
baseline. Her subjective paresthesias, holocephalic
disequilibrium, and gait disturbances resolved at the time of
discharge. We suspect this may have been a pseudo-flare given
rapid improvement. She will follow-up with Dr. ___ in clinic.
We did not make any medication changes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. HydrOXYzine 25 mg PO DAILY PRN Anxiety
2. Baclofen 20 mg PO QHS
3. ocrelizumab 30 mg/mL injection Every 6mo
4. dalfampridine 10 mg oral BID
5. Piroxicam 10 mg PO DAILY
6. vilazodone 40 mg oral daily
7. Vitamin D 5000 UNIT PO DAILY
8. Modafinil 100 mg PO BID
Discharge Medications:
1. Baclofen 20 mg PO QHS
2. dalfampridine 10 mg oral BID
3. HydrOXYzine 25 mg PO DAILY PRN Anxiety
4. Modafinil 100 mg PO BID
5. ocrelizumab 30 mg/mL injection Every 6mo
6. Piroxicam 10 mg PO DAILY
7. vilazodone 40 mg oral DAILY
8. Vitamin D 5000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Multiple Sclerosis Pseudoflare
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came to the hospital with changes in sensation running up
your spine, new problems with walking, left sided facial
numbness, and increased tone and spasticity in your legs.
We gave you one dose of steroids and imaged your cervical and
thoracic spine with an MRI. The MRI showed no new lesions. We
performed lab tests on your blood and urine which were not
concerning for infection. Your symptoms resolved at time of
discharge.
Thank you for allowing us to participate in your care.
- Your ___ Care team
Followup Instructions:
___
|
10264945-DS-5 | 10,264,945 | 22,393,346 | DS | 5 | 2112-08-22 00:00:00 | 2112-08-22 11:57:00 |
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 Leg Pain
Major Surgical or Invasive Procedure:
Irrigation and debridement of right leg wound (___)
Open reduction and internal fixation of right tibia (___)
History of Present Illness:
___ was struck by a car around 7:30 this AM. Right foot run
over, right side of body hit by car. No LOC, head strike or
neck pain. Obvious deformity to RLE.
Past Medical History:
None
Social History:
___
Family History:
Non-contributory.
Physical Exam:
On Admission
Gen: In pain
Heart: RRR
Lungs: breathing unlabored
Ab: soft NT/ND
Right lower extremity:
Small abrasions but possibly puncture wounds to
posterior/lateral leg. Soft, non-tender thigh.
Full, painless AROM/PROM of ankle
___ fire, extremely limited by pain
+SILT SPN/DPN/TN/saphenous/sural distributions grossly intact
but limited exam due to patient cooperation
___ pulses, foot warm and well-perfused
On Discharge
AFVSS
General - Awake and alert. Lying in bed. NAD.
Right Lower Extremity
- Wounds intact with staples in place. No erythema or discharge.
- Sensation intact to light touch throughout
- Fires ___ FHL TA GSC
- Palpable DP pulse
Pertinent Results:
Right Lower Extremity X-rays (___) - per radiology:
Distal tibia and fibula fractures.
CT C-Spine (___) - per radiology:
No evidence of fracture or dislocation.
CXR (___) - per radiology:
No evidence of acute cardiopulmonary process.
AP Pelvis (___) - per radiology:
No evidence of pelvic fracture.
T-Spine X-rays (___) - per radiology:
Unremarkable thoracic spine x-ray examination.
___ 07:40AM
BLOOD WBC-9.4 RBC-5.08 Hgb-15.6 Hct-43.9 MCV-87 MCH-30.7
MCHC-35.5* RDW-13.0 Plt ___
___ 07:43AM BLOOD Glucose-102 Lactate-1.9 Na-148* K-3.7
Cl-105 calHCO3-24
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have an open right tibia fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for irrigation and debridement and
open reduction and internal fixation of right tibia fracture,
which the patient tolerated well (for full details please see
the separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications. The patient
was given perioperative antibiotics and anticoagulation per
routine. The patient worked with ___ who determined that
discharge to home was appropriate. The ___ hospital course
was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is weight bearing as tolerated in the
right lower extremity, and will be discharged on enoxaparin for
DVT prophylaxis. The patient will follow up in two weeks with
his established orthopaedic surgeon at home in ___ while at
home for the holiday vacation. He will subsequently follow up in
our clinic upon returning to ___ or per instructions of his
orthopaedic surgeon in ___. A thorough discussion was had
with the patient regarding the diagnosis and expected
post-discharge course, and all questions were answered prior to
discharge.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
Never exceed 4000 mg in 24 hours.
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Enoxaparin Sodium 40 mg SC QHS Duration: 2 Weeks
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 40 mg/0.4 mL 40 mg sc at bedtime Disp #*14
Syringe Refills:*0
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*100 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right open tibia fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- 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 enoxaparin (Lovenox) 40mg daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Wear your air cast boot at all times when ambulating.
ACTIVITY AND WEIGHT BEARING:
- You may bear weight as tolerated with the right leg.
Followup Instructions:
___
|
10264949-DS-17 | 10,264,949 | 23,660,976 | DS | 17 | 2164-05-28 00:00:00 | 2164-05-30 08:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
latex / IVP dye
Attending: ___.
Chief Complaint:
Nausea and vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo ___ s/p exlap TAH, RSO, pelvic paraaortic lymph node
dissection omentectomy for metastatic endometrial adenocarcinoma
on ___ presenting for new abdominal pain, nausea vomiting
since yesterday afternoon. Patient has known midline hernia, and
was concerned for incarcerated hernia. Reports pain started
acutely yesterday then developed nausea, vomiting. Reports has
___ episodes of emesis yesterday last evening. Last episode of
emesis at 0300. Pain improved after morphine. Reports last bowel
movement 1 day prior. Unsure last flatus. Denies blood in
emesis. Denies dizzy/lightheadedness, fever, chills.
Past Medical History:
PAST MEDICAL HISTORY:
- anxiety
- Denies history of diabetes, hypertension, blood clots or
clotting disorders
PAST SURGICAL HISTORY:
- ___- Ex lap TAH, RSO, omentectomy, pelvic and paraaortic
lymphnode dissection for metastatic endometrial adenocarcinoma
- Ex lap ___ for an ovarian cyst
- Ex Lap ___ for kidney stone and one
- Ex Lap ___ for an ovarian cyst
OB/GYN:
- G3P3 SVD x 3
- Postmenopausal age ___
- ex lap as above for endometrial adenocarcinoma ___
Social History:
___
Family History:
- Sister, maternal and paternal aunt with breast cancer.
- Denies history of uterine ovarian cancer
- Father with colon cancer
Physical Exam:
On day of discharge:
Afebrile, vitals stable
No acute distress
CV: regular rate and rhythm
Pulm: clear to auscultation bilaterally
Abd: soft, nontender, nondistended
___: nontender, nonedematous
Pertinent Results:
___ 09:30PM BLOOD WBC-14.8* RBC-4.29 Hgb-14.5 Hct-41.0
MCV-96 MCH-33.7* MCHC-35.3* RDW-14.2 Plt ___
___ 12:20PM BLOOD WBC-4.1 RBC-3.69* Hgb-12.3 Hct-34.9*
MCV-95 MCH-33.3* MCHC-35.2* RDW-13.2 Plt ___
___ 09:30PM BLOOD Neuts-90.5* Lymphs-5.2* Monos-3.8 Eos-0.3
Baso-0.1
___ 12:20PM BLOOD Neuts-76.7* Lymphs-14.3* Monos-6.0
Eos-2.5 Baso-0.4
___ 09:30PM BLOOD Glucose-148* UreaN-22* Creat-0.8 Na-141
K-4.3 Cl-99 HCO3-25 AnGap-21*
___ 01:15PM BLOOD Glucose-99 UreaN-19 Creat-0.6 Na-141
K-3.9 Cl-105 HCO3-27 AnGap-13
___ 05:59AM BLOOD Glucose-116* UreaN-11 Creat-0.6 Na-141
K-3.9 Cl-104 HCO3-27 AnGap-14
___ 06:00AM BLOOD Glucose-107* UreaN-5* Creat-0.5 Na-140
K-3.7 Cl-105 HCO3-27 AnGap-12
___ 12:20PM BLOOD Glucose-99 UreaN-6 Creat-0.6 Na-140 K-4.0
Cl-103 HCO3-26 AnGap-15
___ 09:30PM BLOOD Albumin-4.9 Calcium-10.4* Phos-5.2*#
Mg-1.7
___ 01:15PM BLOOD Calcium-8.9 Phos-3.8 Mg-1.7
___ 05:59AM BLOOD Calcium-8.6 Phos-3.1 Mg-1.7
___ 06:00AM BLOOD Calcium-8.8 Phos-3.5 Mg-1.6
___ 12:20PM BLOOD Calcium-10.0 Phos-4.0 Mg-1.8
___ 03:27AM BLOOD Lactate-1.9
___ 06:35PM URINE Color-Yellow Appear-Clear Sp ___
___ 06:35PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 06:35PM URINE RBC-<1 WBC-2 Bacteri-FEW Yeast-NONE Epi-0
Urine Culture negative
Brief Hospital Course:
Ms. ___ was admitted to the gynecologic oncology service
for management of a small bowel obstruction.
.
Her hospital course is detailed as follows. She had a
nasogastric tube and was made NPO on admission. Her pain and
nausea were controlled with IV dilaudid and zofran. On hospital
day #1, her urine output was adequate so her Foley catheter was
removed and she voided spontaneously. She complained of dysuria
on hospital day #1; urinalysis and urine culture were negative
for infection and her symptoms resolved spontaneously after
removal of the Foley catheter.
.
Her nasogastric tube was clamped on hospital day #2, and she had
no nausea or residual output. On hospital day #3, her NG tube
was removed and her diet was slowly advanced without difficulty
on hospital days ___. She did not require pain medications
after hospital day #3.
.
She was seen by social work during her admission.
.
By post-operative day #4, her nausea and vomiting had resolved,
she was tolerating a regular diet, voiding spontaneously, and
ambulating independently. She was then discharged home in stable
condition with outpatient follow-up scheduled.
Medications on Admission:
- Celexa 30mg daily
Discharge Medications:
1. Zolpidem Tartrate 5 mg PO HS
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*40 Capsule Refills:*2
3. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 by mouth once a day Disp #*40
Capsule Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
.
You were admitted to the gynecologic oncology service for a
small bowel obstruction. You received a nasogastric tube and
bowel rest. You have recovered well, and the team feels that you
are safe to be discharged home. Please follow these
instructions:
- Take your medications as prescribed.
.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
10265021-DS-4 | 10,265,021 | 22,592,515 | DS | 4 | 2112-03-08 00:00:00 | 2112-03-08 18:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodinated Contrast- Oral and IV Dye
Attending: ___.
Chief Complaint:
Food Impaction
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year-old man with a history of Down
syndrome, intellectual disability, reported dementia, depression
with psychosis on antipsychotic medications, hard of hearing,
OSA, hypothyroidism, chronic constipation, hepatitis, and
dysphagia/aspiration on a modified diet, who presents with
foreign body sensation in his throat.
The patient reportedly choked on a hotdog the day prior to
admission. Per staff at his living facility he coughed a piece
of the hotdog back up, but ever since has been complaining of a
strange sensation in his throat. Since then, the patient has
been unable to tolerate any food or liquids as he just vomits
the contents back up. The patient does complain of a pain in his
throat and upper chest. He does not report abdominal pain.
Full ROS unable to be obtained. Patient alert and responds to
current symptoms but cannot give a detailed history of previous
events.
In ED initial VS: T 98.8, HR 77, BP 154/56, RR 18, O2 sat 93% RA
Labs significant for: WBC 15.6, Hgb 13.4, platelets 120, Cr 1.5,
Na 134
Patient was given: 4% inhaled lidocaine, 1g IV Tylenol, 3g IV
Unasyn
Imaging notable for: CXR- Worsening bibasilar airspace opacities
concerning for aspiration pneumonia. Probable trace right
pleural effusion. Mild pulmonary vascular congestion.
Consults: None
VS prior to transfer: HR 96, BP 105/46, RR 26, O2 sat 98%
Non-Rebreather
In the ED, the patient spike a fever to 101.3F. There was
concern for aspiration PNA vs. pneumonitis. CXR, as above,
showed evidence of aspiration pneumonia/pneumonitis. The patient
was also cultured, given IV Tylenol, and started on Unasyn.
Later in his ED course, the patient became hypoxic to 88% on RA.
He was put on nasal cannula with little improvement, and
switched to high-flow NRB with improvement to 97%. He also had a
slight drop in BP that was fluid responsive.
On arrival to the MICU, he denies mild cough, no fevers, no
pain, no current throat discomfort, no shortness of breath.
Past Medical History:
Down Syndrome
Intellectual disability
Reported dementia
Depression with psychosis on antipsychotic
OSA
hypothyroidism
chronic constipation
hepatitis B
dysphagia/aspiration
chronic eyelid swelling
Social History:
___
Family History:
Unable to obtain due to intellectual disability.
Physical Exam:
ADMISSION PHYSICAL
==================
VITALS: reviewed, afebrile, SBP 120s, stable, on 4L NC
GENERAL: sleeping comfortably when fully examined, initial
evaluation was alert, able to state name
___ anicteric, dry mucous membranes
NECK: supple, JVP not elevated,
LUNGS: inspiratory wheezes and scattered rhonchi bilaterally,
symmetric air entry, no expiratory wheezes
CV: Regular rate and rhythm, normal S1 S2, no murmurs
ABD: soft, non-tender, bowel sounds present
EXT: Warm, well perfused, 2+ pulses, no edema
DISCHARGE PHYSICAL
==================
VITALS: ___ 0659 Temp: 99.7 AdultAxillary BP: 96/61 R Lying
HR: 53 RR: 18 O2 sat: 94% O2 delivery: 2L (asleep)
GENERAL: NAD, communicative with mostly yes/no and 1 word
answers
___: Sclera anicteric, moist mucous membranes
NECK: supple, JVP not elevated
CV: RRR, normal S1 S2, no murmurs
LUNGS: inspiratory wheezes but more scarce, symmetric air entry,
ABD: soft, non-tender, bowel sounds present
EXT: Warm, well perfused, 2+ pulses, no edema
Pertinent Results:
ADMISSION LABS
==============
___ 07:42PM BLOOD WBC-15.6* RBC-3.96* Hgb-13.4* Hct-40.1
MCV-101* MCH-33.8* MCHC-33.4 RDW-15.1 RDWSD-56.7* Plt ___
___ 07:42PM BLOOD Neuts-91.2* Lymphs-4.6* Monos-3.0*
Eos-0.1* Baso-0.3 Im ___ AbsNeut-14.21* AbsLymp-0.71*
AbsMono-0.47 AbsEos-0.01* AbsBaso-0.05
___ 07:42PM BLOOD Glucose-77 UreaN-26* Creat-1.5* Na-134*
K-8.4* Cl-100 HCO3-21* AnGap-13
___ 09:38PM BLOOD K-8.7*
___ 09:47PM BLOOD K-6.1*
___ 10:46PM BLOOD K-4.3
___ 08:02PM URINE Color-Yellow Appear-Clear Sp ___
___ 08:02PM URINE Blood-MOD* Nitrite-NEG Protein-100*
Glucose-NEG Ketone-10* Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 08:02PM URINE RBC-1 WBC-1 Bacteri-FEW* Yeast-NONE
Epi-<1
___ 08:02PM URINE Mucous-RARE*
MICRO
=====
__________________________________________________________
___ 8:02 pm URINE
URINE CULTURE (Pending):
__________________________________________________________
___ 7:45 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
STUDIES
=======
CXR PA and LAT ___
Worsening bibasilar airspace opacities concerning for aspiration
pneumonia. Probable trace right pleural effusion. Mild
pulmonary vascular congestion.
CXR Portable ___
Interval worsening of right lower lobe airspace disease
concerning for
pneumonia/aspiration.
DISCHARGE LABS
==============
___ 07:15AM BLOOD WBC-10.5* RBC-3.51* Hgb-11.7* Hct-36.3*
MCV-103* MCH-33.3* MCHC-32.2 RDW-14.8 RDWSD-56.3* Plt Ct-90*
___ 07:15AM BLOOD Glucose-98 UreaN-21* Creat-1.2 Na-144
K-4.3 Cl-105 HCO3-23 AnGap-16
___ 07:15AM BLOOD Calcium-7.8* Phos-2.0* Mg-2.0
Brief Hospital Course:
Mr. ___ is a ___ year-old man with a history of Trisomy ___,
reported dementia, depression with psychosis on antipsychotic
medications, hearing loss, OSA, hypothyroidism, chronic
constipation, hepatitis, and dysphagia/aspiration on a modified
diet, who presented with foreign body sensation in his throat in
the setting of aspiration of a hot dog (not part of his modified
diet) transferred to the MICU for close monitoring in the
setting of fever and hypoxia to 88% on nonrebreather called out
to the floor for further medical management due to medical
stability and successful weaning to room air.
ACUTE ISSUES
============
# Aspiration
# Food Impaction
Patient with known history of dysphagia and aspiration who
presented after witnessed aspiration event the day prior to
admission. Patient was subsequently able to clear foreign body
(hot dog) without intervention. Patient developed a fever and
became hypoxic in the ED and was subsequently started on Unasyn
for aspiration pneumonia and transferred to the MICU after being
placed on a nonrebreather mask. Given his known aspiration
history, his fever and hypoxia in the ED were likely due to a
presumptive diagnosis of aspiration pneumonitis vs. aspiration
pneumonia. Given clinical and vital sign stability with
improving leukocytosis, his isolated fever was thought to be
more consistent with an aspiration pneumonitis. However, given
aspiration history the patient was continued on Unasyn and
transitioned to levofloxacin prior to discharge for the goal to
complete a 5 day course. Patient had no other localizing
infectious symptoms. Blood and urine cultures were sent but had
not resulted positive growth on until day of discharge. On the
floor, the patient was transiently on 2 L supplemental oxygen
and was successfully weaned off to room air. He was evaluated
by speech and swallow who recommended puréed moist foods with
thin liquids and close supervision. They also recommended an
outpatient video swallow study to further characterize the
patient's dysphagia.
# Leukocytosis - Improving
Patient's leukocytosis was thought to be most likely in the
setting of stress or aspiration event. Blood and urine cultures
were sent but had not yielded positive growth prior to
discharge. His leukocytosis downtrending during his hospital
stay. He was continued on antibiotics as described above.
# CKD
Patient presented to the hospital with a slightly elevated
creatinine of 1.5 compared to baseline of 1.3. His renal
function was closely monitored.
# Code Status
Code status conversation initiated with Guardian. Please clarify
if the family has come to a consensus decision regarding future
care.
CHRONIC ISSUES
==============
# Thrombocytopenia
Chronically thrombocytopenic with stable counts compared to last
admission. His platelet count was trended daily.
# Hypothyroidism
Previously elevated last admission with high TSH of 15. TSH 6
onrepeat testing. Patient was continued on his home dose of
levothyroxine. Recommend repeat TFTs within 2 weeks.
# Constipation
Patient was continued on home docusate.
# Depression with psychotic features
Patient was continued on home mirtazapine and olanzapine.
# Mild transaminitis/Chronic hepatitis
Patient had a mild transaminitis consistent with history of
hepatitis. His LFTs were monitored.
# BPH
The patient continued on home tamsulosin at nighttime.
TRANSITIONAL ISSUES
===================
[]Antibiotics: Continue levofloxain to complete a 5 day course
on ___ for aspiration pneumonia (antibiotics prescription has
been called in to ___ for delivery)
[]Video Swallow: Recommend outpatient video swallow study
[]CXR: Recommend repeat chest xray in ___ weeks to confirm
resolution of current pulmonary findings
[]Thyroid Studies: Repeat TFTs in 2 weeks
[]Cultures: Urine and Blood culture pending, please followup
final report
[]Code Status: clarify whether family has reached consensus
decision on future care
Contact: ___ (group home ___), ___
Code: Patient's family actively discussing code status, please
clarify at ___ visit
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Docusate Sodium 100 mg PO BID
3. Levothyroxine Sodium 125 mcg PO QHS
4. Mirtazapine 15 mg PO QHS
5. OLANZapine 3.75 mg PO QHS
6. Tamsulosin 0.4 mg PO QHS
7. Lactobacillus acidophilus 1 cap oral QHS
8. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. Levofloxacin 750 mg PO DAILY Duration: 4 Doses
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
3. Docusate Sodium 100 mg PO BID
4. FoLIC Acid 1 mg PO DAILY
5. Lactobacillus acidophilus 1 cap oral QHS
6. Levothyroxine Sodium 125 mcg PO QHS
7. Mirtazapine 15 mg PO QHS
8. OLANZapine 3.75 mg PO QHS
9. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
=================
Food impaction
Aspiration pneumonitis
Secondary Diagnoses
===================
Chronic kidney disease
Thrombocytopenia
Hypothyroidism
Constipation
Depression with psychotic features
Chronic hepatitis
Benign prostatic hypertrophy
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you in the hospital!
Why was I admitted to the hospital?
-You came to the hospital because you you had a piece of food
secondary for
What happened while I was admitted to the hospital?
-The piece of food had become unstuck by the time you came to
the emergency department
You were given antibiotics after chest x-ray showed possible
pneumonia and were transferred to the ICU because you needed
extra oxygen
-You did well overnight in the ICU and were transferred to the
medical floor where you had a speech and swallow evaluation and
you are being discharged with special dietary instructions
-Your lab numbers were closely monitored and you were given
medications to treat your medical conditions
What should I do after I leave the hospital?
-Please continue taking all of your medications as prescribed,
details below
-Keep all of your appointments as scheduled
-Please complete taking the course of antibiotic as described
below (the prescription has been called in to ___
___ for delivery)
-We highly recommend that you gear to your special diet to
prevent further episodes of food becoming stuck
We wish you the very best!
Your ___ Care Team
Followup Instructions:
___
|
10265482-DS-5 | 10,265,482 | 29,476,567 | DS | 5 | 2129-04-15 00:00:00 | 2129-04-16 13:48:00 |
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:
-Endotracheal intubation ___
-Video Swallow Evaluation ___
History of Present Illness:
___ ___ male with past history of afib on
coumadin, hypertension, hyperlipidemia, low-grade bladder cancer
___ remission who presents to the ED with dyspnea x 2 days.
Pt states that symptoms began 2 days ago with a cough, mostly
dry but occasionally productive of yellowish sputum. He
describes feeling very wheezy, for which he tried his albuterol
inhaler without relief. SOB is worse with climbing stairs. Can
walk about ___ a block before having to stop due to shortness of
breath (which he states was similar 1 month ago). 2 pillow
orthopnea. Has not noticed ___ edema or weight change, although
does not check regularly. Denies any associated chest pain,
palpitations or lightheadedness. No fevers, chills or recent
sick contacts. Notes that he felt very fatigued, lying ___ bed
all day with decreased appetite. Denies history of similar
symptoms ___ the past. Had been prescribed the albuterol inhaler
to help with his wheeze however has never been diagnosed with
asthma.
___ the ED, initial vitals were: 12:46 0 96.3 81 156/95 35 96%
RA
- Physical exam significant for bilateral exp wheeze, 1+ pitting
edema ___
- ___ showed lactate 1.7, trop <0.01, creat 1.2 (baseline
0.9-1.2), BNP 3807
- CXR showed no definitive consolidation but pulmonary vascular
engorgement with mild interstitial edema
- Patient was administered: Alb/Ipra nebs X 3, 125mg
Methylprednisolone, 2gm magnesium sulfate, 20mg IV lasix.
Vitals on transfer were: 98.7 88 154/78 22 96% Nasal Cannula
On the floor, pt states that his breathing has improved mildly.
Denies any chest pain or palpitations. No other new symptoms.
Past Medical History:
Atrial fibrillation on coumadin
HFpEF (EF 55% on ___
Appendectomy
Epigastric pain, treated for H pylori ___ past
HLD
HTN
Sinusitis
Low grade transitional cell carcinoma of the bladder
BPH
Dysphagia
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYICAL EXAM:
VS: T:98.2 BP:162/74 P:93 R:26 O2:95% 2L NC 97.5 kg
GENERAL: Pleasant gentleman, A&O x 3, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP evelated to earlobe
LUNGS: Moderate air movement with bibasilar crackles and diffuse
expiratory wheeze
CV: Irregular, normal S1 S2, no murmurs, rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: 2+ pitting edema to the knee bilaterally. Warm, well
perfused, 2+ pulses.
SKIN: No rashes.
NEURO: CN II-XII, motor strength and sensation grossly intact.
DISCHARGE EXAM
VS: AF, HR 75, BP 142-146/63-76, RR 18, O2Sat 98% on RA
GENERAL: alert this AM, oriented to self, place, and season, not
year (thinks it's ___. sitting up comfortably ___ bed.
HEENT: MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: good entry bilaterally to bases, no accessory muscle use,
crackles at bilateral bases R worse than left, improved from
yesterday
CV: Regular rate, irregularly irregular rhythm, II/VI systolic
ejection murmur.
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding
EXT: Warm, well perfused, no edema, 2+ DP pulses bilaterally
NEURO: alert, oriented to person and place
Pertinent Results:
___ ON ADMISSION:
==================
___ 12:55PM BLOOD WBC-8.0# RBC-4.52* Hgb-14.4 Hct-42.9
MCV-95 MCH-31.9 MCHC-33.6 RDW-14.3 RDWSD-49.2* Plt ___
___ 12:55PM BLOOD ___ PTT-37.2* ___
___ 12:55PM BLOOD Glucose-126* UreaN-25* Creat-1.2 Na-138
K-4.2 Cl-102 HCO3-23 AnGap-17
___ 12:55PM BLOOD Calcium-9.6 Phos-2.6* Mg-1.8
___ 01:02PM BLOOD Lactate-1.7
KEY RESULTS:
------------
___ 05:14PM BLOOD %HbA1c-6.2* eAG-131*
___ 08:00AM BLOOD TSH-2.4
___ ON DISCHARGE:
==================
___ 07:17AM BLOOD ___ PTT-30.9 ___
___ 07:20AM BLOOD WBC-5.6 RBC-4.18* Hgb-13.3* Hct-40.1
MCV-96 MCH-31.8 MCHC-33.2 RDW-13.8 RDWSD-47.7* Plt ___
___ 07:20AM BLOOD ___
___ 07:20AM BLOOD Glucose-97 UreaN-25* Creat-1.1 Na-143
K-4.2 Cl-109* HCO3-25 AnGap-13
___ 07:20AM BLOOD Calcium-9.6 Phos-3.3 Mg-2.0
MICROBIOLOGY:
=============
___ 12:35 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 9:25 am BRONCHOALVEOLAR LAVAGE SOURCE: BRONCHIAL
LAVAGE.
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
CONSISTENT WITH
CORYNEBACTERIUM OR
PROPIONIBACTERIUM SPECIES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
RESPIRATORY CULTURE (Final ___:
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE POSITIVE.
10,000-100,000 ORGANISMS/ML..
BETA-LACTAMASE POSITIVE: RESISTANT TO AMPICILLIN.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
Urine culture ___: No growth
Blood culture ___: pending
STUDIES/IMAGING:
================
CXR ___: No definite airspace consolidation. Pulmonary
vascular engorgement with mild interstitial edema.
ECHO (TTE) ___: IMPRESSION: Suboptimal image quality.
Symmetric left ventricular hypertrophy with low normal global
systolic function. Pulmonary artery hypertension. Mild mitral
regurgitatio. Moderate tricuspid regurgitation. Mild aortic
regurgitation. Dilated ascending aorta. Biatrial enlargement.
Compared with the report of the prior study (images unavailable
for review) of ___, the estimated PA systolic pressure is
now higher. The other findings are similar.
CT CHEST ___: IMPRESSION:
1. Widespread ___ pattern with predominantly dependent
distribution, coexisting with basilar predominant consolidation
and scattered upper lobe regions of ground-glass and
consolidation. Observed findings are most consistent with
widespread aspiration pneumonia, particularly given clinical
suspicion for aspiration. As these findings are visible on
recent chest radiographs, standard radiographs can be performed
to insure response to therapy.
2. Increased number of mediastinal and hilar lymph nodes, most
likely
reactive ___ the setting of presumed aspiration pneumonia.
3. 1.5 cm cystic lesion ___ the anterior mediastinum is very
likely a thymic cyst and warrants no definite further evaluation
___ the patient is age. If further characterization is deemed
warranted on a clinical basis, MRI of the thymus could be
performed to confirm simple cystic characteristics and to help
exclude the unlikely possibility of a cystic neoplasm ___ this
region.
CXR ___: IMPRESSION: ___ comparison with the study ___, there is continued enlargement of the cardiac silhouette
with worsening congestive failure. The opacification at the
right base is more prominent than on the previous examination.
___ view of the clinical history, this could be consistent with
aspiration pneumonia.
ECHO ___: Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF>55%). The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. 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. Mild (1+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
CXR ___: ET tube tip is 5 cm above the carinal. NG tube passes
below the diaphragm terminating ___ the stomach. Cardiomegaly is
substantial, unchanged. Mild vascular congestion is noted. No
pleural effusion or pneumothorax is clearly seen.
Brief Hospital Course:
Mr. ___ is a ___ ___ male with a history of
afib on coumadin, hypertension, hyperlipidemia, and low-grade
bladder cancer ___ remission who presented to the ED with dyspnea
secondary to newly diagnosed diastolic heart failure
exacerbation. His hospitalization was complicated by tachypnea
secondary to aspiration pneumonitis, with MICU course (see
below), s/p intubation, with follow up BAL revealing
H.influenzae. He was treated initially with vancomycin, which
was dicontinued given speciation, and was covered with Zosyn,
completed course on ___.
MICU COURSE:
======================
Patient admitted to ___ on ___ for acute hypoxia requiring
non-rebreather. CT scan concerning for aspiration pneumonia, so
the patient was started on vanc/zosyn. Intubated for hypoxia,
altered mental status, and inability to protect airway. There
was also concern for pulmonary hemorrhage given INR of 9.
Patient was given 5mg IV vit K, and warfarin was held. He was
bridged. Bronch showed diffuse erythema with copious thick
secretions ___ all subsegments. BAL revealed H. influenzae on
culture, but no evidence of pulmonary hemorrhage. He was
transitioned to monotherapy with zosyn for antibiotic coverage
with plans to end on ___. He was succesfully extubated on
___ after diuresis with lasix back to euvolemia.
=======================
ACTIVE ISSUES:
# Aspiration Pnuemonia/Pneumonitis: Patient showed evidence of
aspiration on speech and swallow evaluation on ___ and was made
NPO on the medicine floor. He was reevaluated on ___ with a
video swallow which revealed mild oropharyngeal dysphagia with
penetration of thin liquids due to swallow delay. Given pt's
recent aspiration PNA requiring intubation and current AMS, he
was cautiously started on diet of pureed solids/nectar-thick
liquids, meds crushed ___ puree, and 1:1 supervision with
meals on ___. He has had no issues on this diet. Pt has been
afebrile on the floor, with saturations of 94-99% on 2L,
successfully transitioned to room air. Repeat speech and swallow
evaluation recommended continuing on nectar thick fluids, with
advancing diet as tolerated at rehab.
# H. influenza pneumonia: Bronchoscopy aspirate grew
pan-sensitive H. flu. He was initially started on Vanc/zosyn and
ended up completing a course of zosyn prior to discharge.
# Newly diagnosed dHF exacerbation ___ Echo LVEF 50-55%): Pt
presented with dyspnea, orthopnea and evidence of volume
overload on physical exam as well as pulmonary edema on CXR.
Clinical picture was most consistent with his first episode of
heart failure exacerbation likely ___ the setting of peumonia.
Troponin was negative ___ the ED and there were no ischemic
changes on EKG (LVH, RBBB). Echo was performed on ___ that
showed LVH with diastolic dysfunction and LVEF 50-55%. Given
that he was lasix naiive, he was started with small dose of IV
lasix however did not have significant urine output until dose
was uptitrated to 80mg IV and eventually required 120mg IV lasix
and a lasix drip. His weight downtrended and symptoms improved
with diuresis. The diuretics were eventually discontinued and he
continued to be euvolemic off of diuretics. He should be seen
by his PCP as well as heart failure clinic.
# Afib with RVR: Pt is anticoagulated with coumadin at baseline
given CHADS2 of 3. See below (coagulopathy) for discussion of
anticoagulation. His rate is controlled with metoprolol at
baseline. Here, heart rates ___ 100-130s, for which diltiazem was
added and uptitrated to 60mg q6hrs, with no significant effect.
His home metoprolol tartrate dose was 100 mg 2 tablets AM and 1
tablet ___ he was transitioned to 100 mg 3/day ___ the hospital,
with improved rate control. As patient later acutely
decompensated ___ setting of pneumonia/pneumonitis (see above),
tachycardia may have been reflective of underlying process
rather than inadequate nodal blockade. We discontinued the
diltiazem, with plan to discharge patient home on home
metoprolol tartrate(200mg qam and 100mg qpm) and Warfarin PO/NG
with frequent INR checks.
# Coagulopathy: INR elevated to 4.1 on admission, continued to
trend up to 9.0 at time of ICU transfer. LFTs stable, platelets
stable, fibrinogen 1300. Coagulopathy felt to be related to poor
nutritional status and infection. At home, he was prescribed 2
mg Warfarin 2 or 3 tablets by mouth daily as directed with a
target INR of 2.0-2.5. Time ___ therapeutic range over past 3
months: 33.2%. His coags were ___: 13.1 PTT: 27.3 INR: 1.5 on
___. He will be discharged on Warfarin (3 mg ___, TH, Sa and
5 mg MWF) with plan to monitor INRs daily.
# Toxic Metabolic Encephalopathy: At baseline, family reports
that patient is alert and oriented with no signs of dementia. On
the floor, patient remained alert and oriented to name only and
requested to speak with deceased family members. ___
concerning for delirium, and steps were taken to remove tethers
and orient the patient frequently. He was not treated with any
sedating medication or anticholinergics. Continued to orient the
patient to person, place, and time.
CHRONIC ISSUES:
# CKD: Cr was 1.2 on admission, which is within range of recent
baseline (___). Improved to 0.9 with diuresis. Medications
were renally dosed.
# HTN: SBP was elevated up to 160's on admission. BP improved
after starting lisinopril. Plan to send home on metoprolol
tartrate (200mg qam and 100mg qpm).
# HLD: Gave Atorvastatin 40 mg PO/NG QPM on the floor. Will send
home on home Simvastatin 40 mg tablet.
# BPH: Continued home finasteride 5 mg PO DAILY, which will be
continued on discharge.
TRANSITIONAL ISSUES
# Patient has remained euvolemic inpatient off of diuretics.
Please monitor I/Os and weight changes.
# Discharged on Metoprolol tartrate (200mg qam and 100mg qpm)
# Weight on the day of discharge: 92 kg
# Coumadin dose at discharge 5 mg MWF, 3 mg ___, ___
needs INR daily until stable
# Please re-evaluate swallowing and advance to soft solids as
tolerated,patient currently on nectar thick liquids per
inpatient speech and swallow evaluation.
# Follow up ___ heart failure clinic
# CODE: Full (confirmed)
# CONTACT: ___ (daughter) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Finasteride 5 mg PO DAILY
3. Metoprolol Tartrate 200 mg PO QAM
4. Metoprolol Tartrate 100 mg PO QPM
5. Simvastatin 40 mg PO QPM
6. Warfarin 5 mg PO 3X/WEEK (___)
7. Warfarin 3 mg PO 4X/WEEK (___)
8. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB, wheeze
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Finasteride 5 mg PO DAILY
3. Warfarin 5 mg PO 3X/WEEK (___)
4. Warfarin 3 mg PO 4X/WEEK (___)
5. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB, wheeze
6. Simvastatin 40 mg PO QPM
7. Metoprolol Tartrate 200 mg PO QAM
8. Metoprolol Tartrate 100 mg PO QPM
9. Senna 8.6 mg PO BID
10. Docusate Sodium (Liquid) 100 mg PO BID
11. Polyethylene Glycol 17 g PO DAILY constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
- Acute diastolic heart failure
- Dysphagia and aspiration pneumonitis
- H. influenza pneumonia
- Acute renal failure
- Toxic-metabolic encephalopathy
Secondary:
- Atrial fibrillation (CHADS 3)
- Hypertension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to take part ___ your care at ___
___. You were admitted to ___
___ because you were short of breath. You
were found to have excess fluid ___ your lungs due to backup from
your heart caused by heart failure. You had an ultrasound of
your heart (echocardiogram) that showed thickening of the walls
of your heart due to high blood pressure and age, which causes
problems with your heart chambers filling (diastolic
dysfunction). You were treated with a diuretic (water pill)
called lasix through an IV to help remove extra fluids, after
which your symptoms improved. This medication was eventually
discontinued because your heart function improved.
During your treatment, you had some trouble breathing because we
think you may have had some fluid get into your lungs
(aspirated). Because of this, you were taken to the intensive
care unit, and had a breathing tube placed. The tube was able to
be removed, and you returned to the hospital floor. You had a
video swallowing evaluation, with recommendation that you have
thickened liquids and soft solids until you are able to swallow
better.
You were also found to have a pneumonia and completed a course
of antibiotics for this infection.
For your fast heart rate (Atrial Fibrillation), we added a
medication called Diltiazem ___ the hospital, but discontinued it
on discharge. You are being discharged on your home dose of
metoprolol. For preventing clots, you were on coumadin, but your
clotting ability was poorly controlled. You were continued on
coumadin, and we recommend you closely follow up with your INR
checks.
After discharge it will be important for you to check your
weight daily and call your doctor if your weight increases by
more than 3lbs ___ one day. You should have a follow up
appointment with your primary care doctor and heart failure
clinic after discharge.
Please schedule an appointment with your doctor (___),
Phone ___, within ___ days of your discharge from the
hospital. To schedule with a new doctor to manage your heart
failure, please call ___ to schedule an appointment,
ideally within ___ days of your discharge from the hospital.
It was a pleasure participating ___ your care - we wish you all
the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10265572-DS-19 | 10,265,572 | 28,461,294 | DS | 19 | 2126-01-20 00:00:00 | 2126-01-21 07:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Reason for Consult: R hand weakness/numbness, ?L facial droop
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a ___ right-handed woman with a history of HTN
and cognitive impairment consistent with Alzheimer's disease
(followed by Dr. ___ who presents with pain and intermittent
tingling along the ulnar surface of her R arm and hand for the
last 3 days. She reports that the day after ___ she was
watching TV when she noticed some pain in her R pinky finger
with
some radiation up the ulnar surface of her arm to her elbow. She
also noted some intermittent tingling in this distribution. She
denies any weakness in her arm or hand and no difficulty using
her hand. She denies any other complaints including headache,
dizziness, changes in vision, difficulty speaking, or difficulty
walking. The pain has now resolved. She saw her PCP today and
was
noted to have a left facial droop with tongue deviation to the
left, along with a wide based gait. She was then sent to the ED
for urgent neurologic evaluation.
She is currently feeling well with no complaints and denies any
pain or numbness/tingling at this time.
She recently saw her PCP ___ ___, during which BP was found to
be high at 160/80. Amlodipine was increased to 10mg daily at
this
visit.
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. No
bowel or bladder incontinence or retention. Denies difficulty
with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
HTN
Cognitive impairment
B12 deficiency
Carotid stenosis
Diastolic dysfunction
Sigmoid colon CA s/p surgery in ___
Social History:
___
Family History:
Denies any family history of neurologic disorders
Physical Exam:
Vitals: 97.2 57 179/66 18 100% RA
General: Awake, pleasant and cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted
Neurologic:
-Mental Status: Alert, oriented to month, does not know date,
says year is "211." Knows president but not vice president.
Somewhat inattentive, names ___ without difficulty but
refueses to attempt backwards. Quite perseverative. Poor short
term recall. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name high frequency but not low frequency objects
(calls cactus "bushes" and hammock "haddock"). Able to read
without difficulty. Speech was not dysarthric. Able to follow
both midline and appendicular commands. There was no evidence of
apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: Face appears symmetric at rest with no flattening of NLF.
Slightly slowed activation of left corner of mouth with smile,
but smile appears symmetric.
VIII: Hearing intact to voice bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue appears to protrude slightly to the left (possibly
related to slight underlying facial asymmetry).
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation
throughout. Mildly decreased vibration at b/l great toes,
proprioception intact. Palpation over the ulnar groove did not
reproduce her symptoms.
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 2 0
R 3 3 3 2 0
Plantar response was flexor bilaterally.
-Coordination: Fine finger movements and rapid alternating
movements slower and somewhat clumsy on the right compared with
left. No intention tremor, no dysmetria on FNF or HKS
bilaterally.
-Gait: Arises independently, good initiation. Mild sway on
Romberg. Gait mildly narrow based but steady with normal stride
and arm swing.
Pertinent Results:
___ 05:10PM BLOOD WBC-5.6 RBC-3.92* Hgb-12.4 Hct-37.3
MCV-95 MCH-31.6 MCHC-33.2 RDW-12.1 Plt ___
___ 05:10PM BLOOD Neuts-61.5 ___ Monos-4.0 Eos-3.1
Baso-0.9
___ 05:10PM BLOOD ___ PTT-28.3 ___
___ 05:10PM BLOOD Glucose-102* UreaN-21* Creat-1.0 Na-140
K-3.7 Cl-105 HCO3-23 AnGap-16
___ 04:50AM BLOOD CK(CPK)-54
___ 04:50AM BLOOD CK-MB-3 cTropnT-<0.01
___ 04:50AM BLOOD %HbA1c-5.6 eAG-114
___ 04:50AM BLOOD Cholest-PND
___ 04:50AM BLOOD Triglyc-PND HDL-PND
___ 04:50AM BLOOD TSH-PND
Brief Hospital Course:
This is a ___ right-handed woman with a history of HTN
and cognitive impairment consistent with Alzheimer's disease
(followed by Dr. ___ who presents with pain and intermittent
tingling along the ulnar surface of her R arm and hand for the
last 3 days. The patient presented to her PCP who observed ___
left facial droop and left tongue deviation so sent her to the
ED. On neurology evaluation in the ED the patient was felt to
have mild right hand weakness and clumsiness so she was admitted
for stroke workup. The patient had an MRI which showed no acute
stroke. A1c (5.6) and cholesterol (LDL 74) were checked. Cardiac
enzymes were negative.
The cause of her right hand weakness and clumsiness may be a C8
radiculopathy likely related to cervical spondylosis. Outpatient
MRI of the cervical spine is recommended non urgently to further
evaluate this.
TRANSITION OF CARE ISSUES: Consider MRI cervical spine, consider
carotid ultrasound to complete stroke risk factor workup as last
study was in ___. Follow up with Dr. ___ as scheduled.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. Donepezil 10 mg PO HS
5. Cyanocobalamin 1000 mcg PO DAILY
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Donepezil 10 mg PO HS
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Amlodipine 10 mg PO DAILY
5. Cyanocobalamin 1000 mcg PO DAILY
6. Lisinopril 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
1. Clumsy Right hand without evidence for cerebral ischemia;
possible cervical spondylopathy.
2. Dementia.
Discharge Condition:
alert, oriented to place and time. Memory is reg ___ --> recall
___ with cues. No facial asymmetry. No dysarthria. VFF. EOMI. No
pronator drift. Full strength in upper and lower extremities.
brisk bic, tri reflexes bilaterally. Decreased right
brachioradialis reflex. Small-fiber sensation intact bilaterally
to pin prick in the hands and arms. Proprioception may be
impaired in the right hand, but exam is contaminated by
cognitive limitations. Gait is wide-based but steady; Romberg
negative.
Discharge Instructions:
Ms. ___,
You were sent to the hospital by your primary doctor for ___ left
facial droop. We also found that your right hand was somewhat
clumsy and slower than the left. Because of a concern for stroke
you had an MRI. The MRI showed no acute stroke. We also checked
your stroke risk factors including A1c and cholesterol. The A1c
was within normal limits (5%) and the cholesterol results are
pending at this time.
Please continue taking all your medications at the same doses as
before (we did not start or change any medicines here). Please
follow up with your primary care doctor and with Dr. ___
(___). It was a pleasure taking care of you --
be well!
Followup Instructions:
___
|
10266028-DS-6 | 10,266,028 | 22,585,653 | DS | 6 | 2123-06-18 00:00:00 | 2123-06-18 20:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
fever, productive cough, back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This patient is a ___ year old male who complains of Back pain,
Fever. ___ yo M w/ h/o IVDU (most recent use ~2 wks ago per pt,
just got out of rehab) p/w fevers, back pain, cough. Pt states
back pain and fevers started today. Has not had pain like this
in past. + cough. No leg weakness, numbness and is able to
ambulate but ambulation is painful in his back. Had not notice
the fevers before he was told he had a fever today.
Past Medical History:
Bipolar Disorder
history of IVDU
history of alcohol wIthdrawal seizures
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION
Temp: 100.8 HR: 94 BP: 114/55 Resp: 14 O(2)Sat: 96 Normal
Constitutional: Uncomfortable appearing, sleepy with coarse
wet cough when awake
Chest: coarse bs throughout
Cardiovascular: early systolic murmur heard at LUSB, ?
holosystolic at RSB
Abdominal: Soft, Nondistended
Extr/Back: Diffuse severe tenderness to palpation at
approximately T12 to L2
Skin: Warm and dry
DISCHARGE
Vitals: 97.7 BP 130/72 HR 94 RR 18 98% RA
GENERAL: Pleasant, well appearing young Caucasian male in NAD.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear.
NECK: Supple, No LAD, No thyromegaly. JVP low
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs
appreciated. + S4
LUNGS: CTAB, good air movement biaterally. subtle faint crackles
at LLL.
ABDOMEN: NABS. Soft, NT, ND. No HSM
BACK: non-tender over spinous processes or on CVA
EXTREMITIES: wwp. injection site at R antecubital vein c/d/I. no
surround erythema. no erythema or swelling in knees.
SKIN: No evidence ___ nodes ___ lesions. no splinter
hemorrhages
NEURO: A&Ox3. Appropriate. Moving all limbs spontaneously, no
tremors.
Pertinent Results:
ADMISSION LABS:
---------------
___ 06:00PM BLOOD WBC-24.7* RBC-3.95* Hgb-11.2* Hct-34.5*
MCV-87 MCH-28.4 MCHC-32.5 RDW-13.1 RDWSD-41.8 Plt ___
___ 06:00PM BLOOD Neuts-76.4* Lymphs-17.6* Monos-5.2
Eos-0.0* Baso-0.2 Im ___ AbsNeut-18.90* AbsLymp-4.35*
AbsMono-1.28* AbsEos-0.00* AbsBaso-0.06
___ 06:00PM BLOOD Glucose-93 UreaN-17 Creat-2.0* Na-137
K-4.2 Cl-101 HCO3-23 AnGap-17
___ 06:00PM BLOOD ALT-42* AST-27 AlkPhos-100 TotBili-0.4
DISCHARGE LABS:
---------------
___ 07:20AM BLOOD WBC-9.4 RBC-4.51* Hgb-12.8* Hct-39.9*
MCV-89 MCH-28.4 MCHC-32.1 RDW-13.1 RDWSD-41.9 Plt ___
___ 07:20AM BLOOD Glucose-93 UreaN-8 Creat-0.9 Na-140 K-4.5
Cl-103 HCO3-28 AnGap-14
MICRO:
------
Six sets of blood Cultures from ___ to ___ all no growth at time
of discharge. Not final.
HIV Antibody NEGATIVE; HIV VL pending at discharge.
Hepatitis panel pending at discharge.
IMAGING:
--------
MRI SPINE ___
1. Study is moderately degraded by motion and is limited for
evaluation of discitis, osteomyelitis or epidural abscess due to
the lack of administration of contrast. 2. Within the limits of
this study, no definite evidence of discitis, osteomyelitis or
epidural abscess. 3. Extensive left lower lobe airspace disease
concerning for aspiration or pneumonia. Atelectasis versus
airspace disease within the dependent aspect of the right lung.
Recommend clinical correlation and evaluation with chest
radiography, if this would change clinical management. 4.
Diffuse mild marrow T1 hypointensity which is nonspecific but
may be seen with chronic anemia or infiltrative processes. 5.
Prominence of the bilateral palatine tonsils with narrowing of
the visualized oropharynx. Findings are nonspecific and may be
seen with systemic infectious or inflammatory processes.
RECOMMENDATION(S): Extensive left lower lobe airspace disease
concerning for aspiration or pneumonia. Atelectasis versus
airspace disease within the dependent aspect of the right lung.
Recommend clinical correlation and evaluation with chest
radiography, if this would change clinical managemen
ECHO ___
The left atrium and right atrium are normal in cavity size.
Normal left ventricular wall thickness, cavity size, and
regional/global systolic function (biplane LVEF = 67%). 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. No masses or vegetations are seen on the aortic
valve. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. No mass
or vegetation is seen on the mitral valve. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: Normal study. No valvular pathology or pathologic
flow identified.
Chest PA/LAT ___
Focal airspace consolidation in at least the superior segment of
the left lower lobe consistent with pneumonia. Linear opacity at
the right lung base likely reflects scarring or subsegmental
atelectasis. Cardiac and mediastinal contours are within normal
limits. Minimal blunting of the left costophrenic angle may
reflect a tiny pleural effusion. No pneumothorax.
Brief Hospital Course:
___ with hx of IVDU, alcohol withdrawal, bipolar disorder
presents with fevers/back pain and productive cough.
#Fevers: Patient with productive cough and evidence of
infiltrate on imaging along with leukocytosis on labs. Treated
with azithromycin, ceftriaxone initially for community acquired
pneumonia then transitioned to levaquin at time of discharge.
Initially concern for endocarditis given IVDU history and
possible new murmur. However, blood cultures x6 sets were all
negative and TTE without evidence of vegetation. Given lung
source, did not pursue TEE. Supposed murmur was in fact an S4.
However, given high risk behavior, HIV VL was sent for acute HIV
and was pending at time of discharge.
#Back pain: Initial concern for paraspinal abscess given fevers
and IVDU history. MR back with no evidence of radiculopathy,
cauda equina, or epidural abscess. Pain appears to be
musculoskeletal in origin given exacerbations with rotation of
back. MRI spine negative. However, also notes worse with
inspiration and thus may represent irritation from PNA. This
pain resolved entirely by hospital day 2 with treatment of
pneumonia. Treated with ice packs and home gabapentin.
#Transaminitis: ALT mildly elevated c/f alcohol hepatitis. No
synthetic dysfunction. Sent hepatitis screen at time of
discharge, which will need to followed as outpatient.
#Hx of IVDU: previously was on Suboxone, however no longer on
medication. Patient would like to follow at ___ and enroll in
___ clinic.
#Bipolar disorder:
-continued wellbutrin
-continued Seroquel
-continued prazosin
#tobacco abuse:
-nicotine gum while in-house
#hx of alcohol withdrawal: Patient recently discharged from ___
___ in ___ for alcohol
withdrawal, treated with Librium and clonidine. Has hx of
withdrawal seizures in past. No evidence of withdrawal on this
admission. Advised patient verbally not to drive given history
of seizures. He has no driver's license and is ineligible for a
year due to a crime.
___: RESOLVED s/p 4L IVF. unclear baseline. Appears euvolemic
on exam and s/p 3L IVF in ED. Potenitally pre-renal in setting
of infection/insensible losses from fevers.
TRANSITIONAL ISSUES
-Will need levaquin until ___ to complete a 5 day course for
CAP.
-HIV VL and hepatitis panel pending at discharge
-Will need referral to ___ clinic
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 600 mg PO TID
2. QUEtiapine Fumarate 75 mg PO QHS
3. Prazosin 2 mg PO QHS
4. BuPROPion (Sustained Release) 100 mg PO QAM
Discharge Medications:
1. BuPROPion (Sustained Release) 100 mg PO QAM
2. Gabapentin 600 mg PO TID
3. Prazosin 2 mg PO QHS
4. QUEtiapine Fumarate 75 mg PO QHS
5. Levofloxacin 750 mg PO DAILY Duration: 3 Doses
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
6. Influenza Vaccine Quadrivalent 0.5 mL IM NOW X1
Discharge Disposition:
Home
Discharge Diagnosis:
primary: community acquired pneumonia
secondary: history of IVDU
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a privilege to care for you at the ___
___. You were admitted with fevers, productive, cough
and back pain. You were found to have a pneumonia on imaging and
your symptoms improved with starting antibiotics. You will need
to take antibiotics until ___ for your pneumonia.
You had one HIV test that was negative, but need another
confirmatory test to definitively conclude that you do not have
this infection. The results of this test is pending at the time
of your discharge and it's important that you follow up with our
doctors as ___ outpatient to review the results.
You will need to call our office tomorrow (see below) to set up
a follow up appointment, where you can also obtain a referral
for our ___ clinic. If you develop any of the danger signs
listed below, please come to the hospital immediately.
We wish you the best,
Your ___ Team
Followup Instructions:
___
|
10266052-DS-13 | 10,266,052 | 28,920,594 | DS | 13 | 2130-08-31 00:00:00 | 2130-08-31 18:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
foot ulcers
Major Surgical or Invasive Procedure:
___ toe amputation on L foot and heel debridement - ___
History of Present Illness:
Patient is a ___ with history of coronary artery disease (DES to
LAD ___ ___, STEMI ___ re-stenosis s/p DES on ___,
HFrEF (LVEF 35% ___, remote internal capsule infarct with
residual L-sided deficits, multiple TIAs, iron deficiency
anemia,
HTN, dyslipidemia, and T2DM (HbA1C 8.7% ___ who presents as
a referral from ___ clinic with multiple lower extremity
lesions (L third toe osteomyelitis, posterior L heel ulceration,
R lateral malleolus ulceration, new hematogenous blisters to the
plantar lateral R heel and L lateral forefoot).
Upon arrival to the ED, patient was afebrile and HD stable. Labs
notable for leukocytosis to 12.1, chronic/stable normocytic
anemia, Na 134, whole blood K 5.0, NGMA,, lactate 2.3, elevated
glucose >250, and normal coags. Plain film of the L foot with
changes concerning for osteomyelitis. Patient was started on
vanc/cefepime/flagyl. Podiatry plans to take patient to OR ___
for L foot debridement to bone with third toe amputation.
- ___ the ED, initial vitals were:
97.85 87 133/77 18 98% RA
- Exam was notable for:
Con: Chronic ill-appearing, no acute distress, sitting down ___ a
wheelchair
HEENT: NCAT. PERRLA, no icterus. EOMI
Neck: no JVD
Resp: No increased WOB, CTAB.
CV: RRR. Normal S1/S2. 2+ radial pulse bilaterally
Abd: Soft, Nontender, Nondistended.
MSK: DP ___ pulses bilaterally minimal palpable. Ulceration on
the
posterior aspect of left heel and ulceration noted on the third
and fourth digit of the left foot. Right foot with ulceration
noted just inferior to right lateral malleolus and right heel.
Neuro: AOx3, speech fluent, no obvious facial asymmetry
Psych: Normal mentation
- Labs were notable for:
___
6.1211.2
___: 12.4 PTT: 28.6 INR: 1.1
K:5.0
Lactate:2.3
12.1>10.3/32.6<163
- Studies were notable for:
FOOT AP,LAT & OBL BILAT
IMPRESSION:
1. Cortical irregularity involving the tuft of the distal
phalanx
of the left third toe concerning for osteomyelitis.
2. Soft tissue ulceration overlying the dorsal aspect of the
left
calcaneus.
3. No radiographic evidence for osteomyelitis involving the
right
foot.
- The patient was given:
cefepime
flagyl
vancomycin
oxycodone 2.5mg
tylenol ___
insulin 4 units
-Podiatry was consulted:
" Pt seen and evaluated, added on for OR tomorrow for L foot
debridement to bone w third digit amputation. Recommend
admission
to medicine, IV abx, please make NPOpMN. Thank you! ___
___
On arrival to the floor, pt endorses that he has pain ___ the
feet
but otherwise feels absolutely well. Denies cough, fevers,
abdominal pain, dysuria, nausea, vomiting. Is slightly anxious
about the surgery tomorrow.
Past Medical History:
B12 DEFICIENCY
CORONARY ARTERY DISEASE
DIABETES TYPE II
HYPERCHOLESTEROLEMIA
IRON DEFICIENCY
HYPERTENSION
BACK CYST
TRANSIENT ISCHEMIC ATTACK
PERIPHERAL NEUROPATHY
H/O STROKE
Social History:
___
Family History:
Son had a stroke 6 months ago (he is ___. Noknown h/o recurrent
miscarriages, DVT, PE, aneurysms.
Physical Exam:
ADMISSION PHYSICAL EXAM
==========================
___ Temp: 97.4 PO BP: 137/72 L Lying HR: 72 RR:
18 O2 sat: 98% O2 delivery: Ra
Con: Chronic ill-appearing, no acute distress, laying ___ bed
HEENT: NCAT. PERRLA, no icterus. EOMI
Neck: no JVD
Resp: CTAB
CV: RRR. Normal S1/S2. 2+ radial pulse bilaterally
Abd: Soft, Nontender, Nondistended.
MSK: both feet have just been wrapped by podiatry, dressings are
c/d/I. femoral pulses palpable. exposed toes are cold but cap
refill appropriate.
Neuro: AOx3, speech fluent, no obvious facial asymmetry
DISCHARGE PHYSICAL EXAM
============================
VITALS:
24 HR Data (last updated ___ @ 2145)
Temp: 97.8 (Tm 98.0), BP: 111/62 (111-131/57-75), HR: 71
(63-71), RR: 18 (___), O2 sat: 99% (98-100), O2 delivery: Ra
1 BM this AM
Con: Chronic ill-appearing, very thin no acute distress, laying
___ bed
HEENT: NCAT. PERRLA, no icterus. EOMI
Neck: no JVD
Resp: CTAB
CV: RRR. Normal S1/S2. 2+ radial pulse bilaterally
Abd: Soft, Nontender, Nondistended.
MSK: L foot wrapped ___ gauze- c/d/i, R foot with chronic well
healing ulcer on heel and lateral malleus. dressings are c/d/I.
femoral pulses palpable. exposed toes are cold but cap refill
appropriate.
Neuro: AOx3, speech fluent, L sided hemiparesis. L arm
contracture. Reduced strength ___ his L leg. Increased tone ___ L
side. No facial asymmetry
Pertinent Results:
ADMISSION LABS
===================
___ 01:07PM BLOOD WBC-12.1* RBC-3.55* Hgb-10.3* Hct-32.6*
MCV-92 MCH-29.0 MCHC-31.6* RDW-13.6 RDWSD-45.5 Plt ___
___ 01:07PM BLOOD Neuts-66.9 ___ Monos-7.6 Eos-3.5
Baso-0.5 Im ___ AbsNeut-8.13* AbsLymp-2.52 AbsMono-0.92*
AbsEos-0.42 AbsBaso-0.06
___ 12:35PM BLOOD Glucose-279* UreaN-24* Creat-1.2 Na-134*
K-6.1* Cl-102 HCO3-21* AnGap-11
___ 07:29AM BLOOD Albumin-3.3* Calcium-10.0 Phos-2.8
Mg-1.4* Iron-60
___ 07:29AM BLOOD calTIBC-243* Ferritn-211 TRF-187*
___ 07:29AM BLOOD %HbA1c-10.6* eAG-258*
___ 07:29AM BLOOD CRP-29.5*
___ 12:59PM BLOOD Lactate-2.3* K-5.0
PERTINENT LABS
===================
___ 05:00AM BLOOD WBC-9.8 RBC-3.27* Hgb-9.5* Hct-30.3*
MCV-93 MCH-29.1 MCHC-31.4* RDW-14.4 RDWSD-47.9* Plt ___
___ 05:00AM BLOOD Glucose-168* UreaN-36* Creat-1.1 Na-141
K-4.8 Cl-106 HCO3-24 AnGap-11
___ 05:00AM BLOOD Calcium-9.4 Phos-3.2 Mg-1.7
MICROBIOLOGY
====================
___ 1:35 pm TISSUE LEFT FOOT ___ DIGIT.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
TISSUE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
___ this
culture.
STAPH AUREUS COAG +. SPARSE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
IMAGING
=====================
___
EXAMINATION: FOOT AP,LAT AND OBL LEFT
INDICATION: ___ year old man s/p left ___ toe amp/heel
debridement// eval s/p
left ___ toe amp and heel debridement
TECHNIQUE: FOOT AP,LAT AND OBL LEFT
COMPARISON: ___
IMPRESSION:
Status post amputation at the proximal phalanx of the third toe.
Postsurgical
changes ___ the soft tissues of the foot. Vascular
calcifications are seen.
Degenerative changes involving the IP joint.
___
TECHNIQUE: Bilateral feet, three views each
COMPARISON: Bilateral foot radiographs ___
FINDINGS:
RIGHT FOOT: No cortical destruction or osteolysis to suggest
osteomyelitis.
Diffuse vascular calcifications are noted. No soft tissue gas.
No acute
fracture or dislocation. Moderate size plantar calcaneal spur.
Moderate
degenerative spurring ___ the midfoot.
LEFT FOOT: Soft tissue ulceration overlies the posterior aspect
of the
calcaneus. There is cortical irregularity involving the tuft of
the distal
phalanx of the third digit which is concerning for
osteomyelitis. No soft
tissue gas. No acute fracture or dislocation. Diffuse vascular
calcifications. Moderate-sized plantar calcaneal spur. Mild
degenerative
changes of the first MTP joint.
IMPRESSION:
1. Cortical irregularity involving the tuft of the distal
phalanx of the left
third toe concerning for osteomyelitis.
2. Soft tissue ulceration overlying the dorsal aspect of the
left calcaneus.
3. No radiographic evidence for osteomyelitis involving the
right foot.
Brief Hospital Course:
SUMMARY
===============
___ with history of CAD (DES to LAD ___ ___, STEMI ___
restenosis s/p DES on ___, HFrEF (LVEF 35% ___, remote
internal capsule infarct with residual L-sided deficits,
multiple TIAs, iron deficiency anemia, HTN, dyslipidemia, and
T2DM (HbA1C 8.7% ___ who presented as a referral from
___ clinic with multiple lower extremity lesions (L third
toe osteomyelitis, posterior L heel ulceration, R lateral
malleolus ulceration, new hematogenous blisters to the plantar
lateral R heel and L lateral forefoot), now s/p L heel
debridement and L third digit amputation. He was originally on
broad spectrum antibiotics vanc/ceftaz/ flagyl. ID was consulted
and recommended de-escalating to augmentin and continuing the
antibiotic course pending return of the biopsy.
TRANSITIONAL ISSUES
======================
[] Patient discharged on augmentin 875 BID for osteomyelitis
pending the return of pathology. If the margins are clear, then
the antibiotic can be discontinued. If the margins are positive,
podiatry should be alerted and patient will likely need further
debridement. Patient's outpatient providers ___ be following up
the pathology.
ABX course:
Continue augmentin pending the return of pathology results
[] HBA1c on admission 10.8% up from 8.7% previously. Insulin
regimen uptitrated during admission, but patient will likely
need further titration as outpatient.
[] Recommend offloading heels with Waffle boots while ___ bed.
Betadine dressing to all wounds daily.
ACTIVE ISSUES
====================
#Lower extremity ulcers s/p debridement, concern for infection/
osteomyelitis
Patient with longstanding diabetic peripheral neuropathy, and
with multiple bilateral ulcerations that had been progressing
over the last few weeks, despite intensive care by patient
family and ___. He was seen ___ clinic by podiatry on the day of
admission, with concern for progression of disease and possible
osteomyelitis, confirmed on plain films. Initial CRP 29.5 (___).
Now s/p ___ toe amputation and debridement on ___. He was
originally on broad spectrum antibiotics vanc/ceftaz/ flagyl. ID
was consulted and recommended de-escalating to augmentin and
continuing the antibiotic course pending return of the biopsy.
#Hyperglycemia, history of T2DM
HbA1C 8.7% ___, now 10.8%. Pt reporting medication
compliance. Continued insulin glargine, and increased sliding
scale. Held metformin while inpatient.
#Normocytic anemia, chronic
Pt with chronic normocytic anemia, likely ___ ACD; no suspicion
of active bleed or hemolysis. Iron studies w/o ___ or ___.
CHRONIC ISSUES
================
#CAD s/p STEMI ___ restenosis s/p DES on ___
-on clopidogrel 75mg daily
-on metop succinate ER 50mg BID
-on aspirin 81mg daily
# HFrEF
Euvolemic on exam.
PUMP: LVEF 35% ___
Preload: Lasix as above
Afterload: N/A
NHBK: metoprolol
# Remote internal capsule infarct
# Multiple TIAs
# stroke with residual hemiparesis
Mobility is quite limited, needs assistance with ambulation and
self-care. Has wheelchair, bedside commode at home.
# HTN
Normotensive here. Metoprolol succinate ER 50mg BID
# HLD
Continue atorvastatin 40 mg qPM
#Code status: Full confirmed
#Contact: ___, ___ ___ emergency, ___
call wife: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO BID PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Clopidogrel 75 mg PO DAILY
5. Cyanocobalamin 1000 mcg PO DAILY
6. Gabapentin 300 mg PO TID
7. Metoprolol Succinate XL 50 mg PO BID
8. insulin glargine 100 unit/mL subcutaneous q am
9. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous am
10. Furosemide 20 mg PO DAILY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
2. Sertraline 25 mg PO DAILY
3. Acetaminophen 650 mg PO BID PRN Pain - Mild
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Clopidogrel 75 mg PO DAILY
7. Cyanocobalamin 1000 mcg PO DAILY
8. Furosemide 20 mg PO DAILY
9. Gabapentin 300 mg PO TID
10. insulin glargine 100 unit/mL subcutaneous q am
11. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous am
12. Metoprolol Succinate XL 50 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
Osteomyelitis
SECONDARY DIAGNOSIS
===================
Type 2 Diabetes Mellitus
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. ___,
WHY WAS I ADMITTED TO THE HOSPITAL?
=====================================
- You were seen by the foot surgeons (podiatrists) ___ clinic and
they were concerned that there was an infection ___ the bone ___
your foot.
WHAT HAPPENED WHILE I WAS ___ THE HOSPITAL?
==============================================
- You had surgery to remove your third toe on your left foot.
- You were given antibiotics to treat the infection.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
==============================================
- Take your medications as directed.
- Please go to your appointments listed below.
Take care,
Your ___ Care Team
Followup Instructions:
___
|
10266052-DS-14 | 10,266,052 | 23,481,558 | DS | 14 | 2131-01-11 00:00:00 | 2131-01-15 17:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
___ 02:16PM BLOOD WBC-9.5 RBC-3.15* Hgb-9.4* Hct-30.9*
MCV-98 MCH-29.8 MCHC-30.4* RDW-15.8* RDWSD-56.1* Plt ___
___ 02:16PM BLOOD ___ PTT-31.4 ___
___ 02:16PM BLOOD Plt ___
___ 02:16PM BLOOD Glucose-105* UreaN-32* Creat-1.2 Na-143
K-4.9 Cl-106 HCO3-23 AnGap-14
___ 02:16PM BLOOD proBNP-7436*
___ 02:16PM BLOOD cTropnT-0.02*
___ 02:16PM BLOOD Albumin-3.6 Calcium-10.1 Phos-3.5 Mg-1.5*
___ 05:26PM BLOOD ___ pO2-24* pCO2-51* pH-7.32*
calTCO2-27 Base XS--1
DISCHARGE LABS:
___ 06:18AM BLOOD WBC-11.6* RBC-3.60* Hgb-10.7* Hct-35.0*
MCV-97 MCH-29.7 MCHC-30.6* RDW-14.7 RDWSD-52.8* Plt ___
___ 06:18AM BLOOD Glucose-135* UreaN-41* Creat-1.0 Na-142
K-5.0 Cl-106 HCO3-21* AnGap-15
___ 06:18AM BLOOD Calcium-10.0 Phos-3.2 Mg-1.7
___ 06:52AM BLOOD %HbA1c-6.4* eAG-137*
___ 06:52AM BLOOD Trep Ab-POS*
MICRO:
___ 4:24 pm URINE Source: ___.
**FINAL REPORT ___
REFLEX URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
PROTEUS MIRABILIS. 10,000-100,000 CFU/mL.
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGES:
___ UNILAT LOWER EXT VEINS
1. No evidence of deep venous thrombosis in the left common
femoral, femoral, and popliteal veins. The left calf veins were
not well visualized.
2. Incidental note is made of prominent right inguinal nodes.
If clinically warranted, this can be evaluated on dedicated
ultrasound.
___ CHEST (PA & LAT)
Lungs are low volume with mild pulmonary vascular congestion.
The external pacer lead projects over the right anterior chest
wall. Cardiomediastinal silhouette is stable. There is no
pleural effusion. No pneumothorax is seen. The lateral views is
limited due to patient positioning.
___ CT ___ W/O CONTRAST
1. New (since ___ 5 x 5 mm focal hyperdensity overlying the
left cerebral peduncle is worrisome for small focus of
intraparenchymal hemorrhage with possible adjacent small amount
of edema. Alternatively, finding could represent a small
cavernoma, however, given that this finding was not present on
prior study from ___ and there is concern for adjacent mild
edema, this is probably less likely.
2. Chronic infarcts. Chronic small vessel ischemic disease.
Involutional
changes.
___-SPINE W/O CONTRAST
No acute cervical fracture identified. Multilevel degenerative
changes with multilevel mild narrowing of the central canal.
Concern for partially imaged bilateral pleural effusions.
___ CTA ___ AND CTA NECK
1. Left cerebral peduncle hematoma with adjacent edema,
unchanged in size to
the prior CT of ___ at 1608.
2. Unchanged multifocal chronic infarcts, as described above.
3. Multifocal intracranial vascular stenoses without evidence of
occlusion or aneurysm. Stenoses are most severe in the posterior
cerebral arteries where they are moderate to severe. This is
most consistent with atherosclerotic disease.
4. Patent bilateral cervical carotid and vertebral arteries
without evidence of stenosis, occlusion, or dissection.
5. Bilateral pleural effusions are partially imaged.
6. Enlarged mediastinal lymph nodes are incompletely evaluated
on this study.
If clinically appropriate this could be further evaluated with a
chest CT.
___ CT ___ without contrast
1. Unchanged appearance of a 5 mm left cerebral peduncle
hypodensity with
surrounding edema when compared with CTA ___.
2. Unchanged chronic infarcts, as described above. No new large
territory
infarct, fracture, or mass effect.
___ L knee xray
FINDINGS:
AP and cross-table lateral views of the left knee were provided.
There is
faint calcification in the tibiofemoral joint space, lateral
compartment
suggesting chondrocalcinosis. In addition, there is a small
joint effusion
with suprapatellar calcific density which may also reflect
chondrocalcinosis.
No fracture is seen.
IMPRESSION:
Features of chondrocalcinosis. Small joint effusion.
___ MR ___ without contrast
FINDINGS:
There are small focal areas, most likely consistent with prior
lacunar strokes
within the right internal capsule, left basal ganglia, and
bilateral
cerebellar hemispheres (4: 5, 9, 16, 19). There is no evidence
of acute
infarction.
Previously identified focal hyperdensity within the left
cerebral peduncle is
associated with an area of susceptibility weighted signal
(11:10), most
consistent with small intraparenchymal hemorrhage and mild
surrounding edema.
There is no evidence of hemorrhage, edema, masses, mass effect
or midline
shift. The ventricles and sulci are prominent, likely related
to involutional
changes. Periventricular and subcortical white matter T2/FLAIR
hyperintensities are nonspecific but likely sequelae of chronic
small vessel
ischemic disease.
The orbits are unremarkable. The paranasal sinuses, middle ear
cavities and
mastoid air cells are well aerated. Major intracranial vascular
flow voids
are preserved.
IMPRESSION:
1. Focus of blood products noted within the left cerebral
peduncle, unchanged
from ___, concerning for a focus of intraparenchymal
hemorrhage
with adjacent edema vs a cavernoma.
2. Few scattered chronic lacunar infarcts involving the right
internal
capsule, left basal ganglia and bilateral cerebellar
hemispheres. No evidence
of acute infarction.
Brief Hospital Course:
Mr. ___ is a ___ year old male with PMH of HTN, HLD, CAD s/p
multiple stents (x6 02, 04, 17), IDDMII, right internal capsular
stroke ___ with resulting left spastic hemiparesis, who presents
after being found with labored breathing, pallor, hypoxia, found
to be in mild CHF exacerbation and also found to have new small
IPH vs mass. He was monitored in the ICU for one day due to
intermittent apneic episodes consistent with sleep apnea, and
was called out to the floor on ___. On the floor, patient's
apnea was managed with CPAP, returned back to his home diuretic
dose, and neurologically monitored without concern. He was
incidentally found to have a possible UTI and treated for this
with Macrobid.
TRANSITIONAL ISSUES:
[] Goal of SBP <150 in setting of possible intracerebral
hemorrhage
[] Please ensure f/u in stroke clinic with Dr. ___ in stroke
clinic in ___ months
[] Patient has HFrEF and should be on lisinopril. We trialed
this but he had hyperkalemia so this was discontinued. Please
consider restarting this if felt that he could tolerate it.
[] Patient needs urgent sleep study for possible obstructive
sleep apnea. He was noted to desat to 60% at times while
sleeping or napping - this improved with use of CPAP machine
while in the hospital.
[] Patient discontinued on Plavix in setting of possible
intracerebral hemorrhage and no strong indication for Plavix.
Patient had CAD stent last in ___ so no longer needs Plavix and
discontinuing would decrease risk of cerebral hemorrhage.
[] A1c 6.4 - consider decreasing home insulin dosing to prevent
hypoglycemic episodes which may increase risk for falls. We
decreased his home lantus 30u -> 25u qAM.
[] Fleet Enema was held in setting of interaction with Lasix for
possible issues such as acute phosphate nephropathy. Please
consider if interaction is of concern or if safe to restart.
[] Please repeat CBC to ensure WBC count is back to normal
within 1 week
[] Please repeat BMP within 1 week to ensure potassium stays
within normal
[] Trep-Sure test, RPR negative, reflex treponemal testing sent
to state and pending. Likely does not have syphilils but will
need to ensure appropriate follow-up if testing comes back
positive.
[] Patient found to have UTI, will need five day course of
nitrofurantoin--last day ___
ACUTE ISSUES
=======================
# New IPH vs mass
# Hypertension
Patient presented with new mass noted on CT concerning for IPH.
IPH could be secondary to hypertension, fall, or mass with
surrounding edema. Most likely from hypertension. Neurology
recommended a repeat CT ___ which showed stable appearance of
this 5mm left cerebral peduncle hypodensity. They also
recommended an MRI. MRI - noted with focus of IPH with adjacent
edema vs cavernoma and scattered chronic infarcts with no acute
infarcts. Patient has no new neuro deficits. His blood pressure
is now stable with SBP 120, goal of <150 in setting of brain
lesion. Held Plavix in setting of bleed and as it is no longer
needed as remote stent history. He will have outpatient follow
up in the stroke clinic in ___ months.
# Acute on chronic HFrEF (EF 35% ___
Patient presented with hypoxia and is found to have proBNP
elevation and CT showing bilateral pleural effusions. Home meds
not inclusive of goal directed therapy. There is one outpatient
note in ___ which cites normotension as reason for not
initiating further afterload reduction with lisinopril. He was
given 1x IV Lasix 20mg, then was resumed on home Lasix 20mg as
he was felt to be euvolemic. Metoprolol XL was reduced from 50mg
BID to 25mg BID to see if lisinopril could be added (more room
with blood pressure). However, decision to start lisinopril was
deferred to outpatient in setting of patient having borderline
to high
potassium near time of discharge - he was resumed on his home
metoprolol XL 50mg BID at discharge.
#Fall
#Swollen Knee
Patient with fall at nursing home, unclear story regarding fall.
Knee with erythema. Performed knee arthrocentesis with injection
of Depomedrol, 80 mg/mL mixed with 1 mL 1%Lidocaine. Cell count
reassuring against septic arthritis. Final fluid cultures were
pending at time of discharge.
# Intermittent Apnea, stable
# Hypoxia
In setting of new IPH vs mass, concerning for central process,
however should note that neurology feels the location of his
bleed does NOT seem likely to be a plausible explanation.
Obstructive apnea undiagnosed is possible, vs ___
stokes in setting of CHF. Had instance of desats to high ___
while sleeping, recovers fully upon waking. Initiated on CPAP
but could not get formal sleep study in house so will need to
get upon discharge.
# CAD s/p multiple stents x 6 (last ___
Initially held home aspirin and Plavix but restarted aspirin on
___ after stable ___ CT. Per neurology, recommend single
antiplatelet therapy (ASA) unless dual antiplatelet therapy is
strongly indicated for cardiac protection. No strong indication
for Plavix in setting of stent being not recent, so stopped
Plavix. Continued home atorvastatin 40mg daily
#UTI
Hard to assess the symptoms, no suprapubic tenderness, but UA
concerning for UTI and elevated WBC count. Possible WBC count is
secondary to knee steroid injection but will treat in setting of
patients age and delirium risk factors. Nitrofurantoin for 5 day
course. Last day ___
CHRONIC ISSUES:
# IDDMII
# Complicated by Neuropathy
Not acutely an issue, should pay close attention to control.
Slight dose reduction as unclear his PO intake at this point in
time. Insulin basal of lantus 30u was decreased to 25u given
well controlled BS. Continued home gabapentin. A1c 6.4. Further
downtitration of home insulin should be considered to prevent
hypoglycemia and falls
# Depression
- Continued home sertraline 25mg daily
# Health maintenance
- Continued cyanocobalamin 1000mcg daily
- Continued multivitamin daily
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glargine 30 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
2. Clopidogrel 75 mg PO DAILY
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. Cyanocobalamin 1000 mcg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Furosemide 20 mg PO DAILY
7. Gabapentin 300 mg PO TID
8. Metoprolol Succinate XL 50 mg PO BID
9. Sertraline 25 mg PO DAILY
10. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DAILY
11. Multivitamins 1 TAB PO DAILY
12. Aspirin EC 81 mg PO DAILY
13. Milk of Magnesia 30 mL PO Q72H:PRN If no BM
14. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
15. GuaiFENesin 10 mL PO Q4H:PRN Cough
16. Fleet Enema (Saline) ___AILY:PRN Constipation if
bisacodyl not effective
Discharge Medications:
1. Nitrofurantoin Monohyd (MacroBID) 100 mg PO BID Duration: 4
Days
RX *nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1
capsule(s) by mouth twice a day Disp #*8 Capsule Refills:*0
2. Glargine 25 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. Aspirin EC 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
7. Cyanocobalamin 1000 mcg PO DAILY
8. Furosemide 20 mg PO DAILY
9. Gabapentin 300 mg PO TID
10. GuaiFENesin 10 mL PO Q4H:PRN Cough
11. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DAILY
12. Metoprolol Succinate XL 50 mg PO BID
13. Milk of Magnesia 30 mL PO Q72H:PRN If no BM
14. Multivitamins 1 TAB PO DAILY
15. Sertraline 25 mg PO DAILY
16. HELD- Fleet Enema (Saline) ___AILY:PRN Constipation
if bisacodyl not effective This medication was held. Do not
restart Fleet Enema (Saline) until it is deemed safe to not
interact with lasix for risks like actue phosphate nephropathy
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Intraparenchymal hemorrhage vs mass
Acute on Chronic HFrEF
Left knee swelling and pain
Intermittent apnea
Secondary:
CAD
IDDMII
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:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were having trouble breathing and were found to have extra
fluid in your lungs due to your heart failure. You were also
found to have a small brain bleed likely in the setting of high
blood pressures and pauses in your breathing during sleep
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were given extra Lasix to help you pee off the extra fluid
in your body
- You were started on CPAP at night because of concern for sleep
apnea. You will need a sleep study in order to get a CPAP
machine prescribed for you at home.
- You were found to have a urinary tract infection and were
started on antibiotics for this
- You had a steroid injection into your left knee to help
relieve some of the pain in this knee.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Please continue to take all of your medications and follow-up
with your appointments as listed below.
-Please make sure you have a sleep study soon after you leave
the hospital
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10266070-DS-15 | 10,266,070 | 21,988,230 | DS | 15 | 2167-07-19 00:00:00 | 2167-08-31 09:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This patient is a ___ year old female who complains of RIGHT
LOWER QUADRANT PAIN. pt c/o 2 days of right lower quadrant
pain. Pain worsening and hurts when she walks. Low grade
fever. +nausea +vomiting. Pt went to ___
earlier today and recieved 2 bags of IV fluid. not sexually
active, 2 days late for due menses. ROS o/w entirely
negative: no f/c/ha/rash/cough/cp/sob/dysuria/bleeding.
Timing: Gradual
Quality: Crampy
Severity: Moderate
Duration: Days
Location: RLQ
Context/Circumstances: 2 days late menses
Mod.Factors: ___.
Associated Signs/Symptoms: none
Past Medical History:
anxiety
Social History:
___
Family History:
nc
Physical Exam:
PHYSICAL EXAMINATION: upon admission: ___
Temp: 98.8 HR: 79 BP: 134/75 Resp: 16 O(2)Sat: 100 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nondistended, TTP RLQ
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
___: No petechiae
Pertinent Results:
___ 05:45AM BLOOD WBC-6.2 RBC-3.93* Hgb-11.1* Hct-35.7*
MCV-91 MCH-28.3 MCHC-31.2 RDW-12.5 Plt ___
___ 05:10AM BLOOD WBC-5.8 RBC-3.94* Hgb-11.4* Hct-35.3*
MCV-89 MCH-28.9 MCHC-32.4 RDW-12.9 Plt ___
___ 09:45PM BLOOD WBC-6.3 RBC-4.33 Hgb-12.4 Hct-39.4 MCV-91
MCH-28.7 MCHC-31.5 RDW-12.7 Plt ___
___ 09:45PM BLOOD Neuts-43.7* Lymphs-48.0* Monos-4.9
Eos-2.8 Baso-0.6
___ 05:45AM BLOOD Plt ___
___ 05:45AM BLOOD Glucose-89 UreaN-7 Creat-0.7 Na-139 K-4.3
Cl-105 HCO3-24 AnGap-14
___ 09:45PM BLOOD Glucose-117* UreaN-7 Creat-0.7 Na-139
K-4.1 Cl-107 HCO3-21* AnGap-15
___ 09:45PM BLOOD ALT-18 AST-20 AlkPhos-30* TotBili-0.2
___ 05:45AM BLOOD Calcium-8.9 Phos-4.4 Mg-1.9
___ 05:10AM BLOOD Calcium-8.9 Phos-4.1 Mg-1.9
___: cat scan of abdomen and pelvis:
IMPRESSION: Dilatation of proximal small bowel with associated
minimal bowel wall thickening with gradual tapering to more
collapsed bowel in the mid abdomen. Findings may reflect focal
ileus due to jejunitis versus early small bowel obstruction. No
bowel wall enhancement abnormalities to suggest ischemia. The
appendix is seen and unremarkable.
Brief Hospital Course:
___ year old female admitted to the acute care service with right
lower quadrant pain. Upon admission, she was made NPO, given
intravenous fluids and underwent a cat scan of the abdomen and
pelvis. Cat scan findings showed dilatation of the proximal
small bowel with associated minimal bowel wall thickening with
gradual tapering to more collapsed bowel in the mid abdomen.
These findings were suggestive of focal ileus due to jejunitis
versus early small bowel obstruction. She was medically managed
with bowel rest and continued on serial abdominal examinations.
The abdominal pain resolved and she was started on clear liquids
with progression to a regular diet.
Her vital signs have been stable and she has been afebrile. Her
hematocrit and white blood cell count are normal. She tolerated
a regular diet. She is preparing for discharge home with follow
up with her primary care provider.
Medications on Admission:
Celexa, Yaz (OCP), MVI, Vegetable supplement daily
Discharge Medications:
1. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for loose stools.
4. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for headache.
5. Yaz 1 tablet daily po (as per instructions) recommend
discussing with PCP prior to resuming)
6. multivitamin Tablet Sig: One (1) Tablet PO once a day.
7. Vegetable supplement 1 pill by mouth daily ( please follow up
with PCP prior to resuming)
Discharge Disposition:
Home
Discharge Diagnosis:
abdominal pain ? related enteritis
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 right lower quadrant
abdominal pain and a low grade fever. The source of your
abdominal pain may have been related to an ileus related to an
inflammation in your bowel. You were give intravenous fluids
and your abdominal pain resovled. You are now preparing for
discharge home:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
___
|
10266070-DS-17 | 10,266,070 | 23,056,715 | DS | 17 | 2168-08-02 00:00:00 | 2168-08-02 13:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / vancomycin
Attending: ___.
Chief Complaint:
Fever, headache, back pain.
Major Surgical or Invasive Procedure:
Lumbar puncture.
History of Present Illness:
___ yo female with history of anxiety, migraines, and recent
UTI's presented to the ED with 48 hours of undulating back pain,
fever, chills, HA and nausea. Back pain increased in intensity
over the last 48 hours to ___. Her pain was initially in the
___ her mid back but then moved to the right side. Pain
is worse with movement and standing. Last BM was ___ AM with no
change in back pain or melena. She reports some numbness and
tingling in her legs that radiates from the site of her back
pain. She notes freezing and chills at home with a Tmax of 101.
She denies hematuria, anorexia, abdominal pain, urinary
symptoms, vag bleeding or discharge, incontinence or retention
of urine or stool. She denies recent sick contacts, hospital
exposures, recent travel. She is not sexually active. She got
her flu shot this year. She had a sinus infection two months
ago and two UTI's within the past two months. She often does
not drink a lot of water.
On arrival to the ED, initial vitals were: pain 6 102.0 104
131/73 16 98% on RA. Labs were notable for WBC 8.8 (N 82.7, L
11.0), and lactate 2.1. UA was negative for blood, leukocytes
and bacteria. Renal US did not identify stones and CT Abdomen
was reported as negative. CXR was also negative. MRI back was
done to rule out epidural abscess given her LBP and tingling in
her legs but was also negative. Bimanual exam was negative for
CMT. She received IV morphine for pain and IV vancomycin but
this was stopped d/t redman syndrome. She was given 25mg IV
benadryl w/ effect. Most recent vitals prior to transfer: pain
___ 115/85 18 99% on RA.
Currently, she feels mildly dyspneic with palpitations. She
denies CP. She reports HA without neck pain. She denies abd
pain. She feels dehydrated, fatigued and thirsty.
ROS: per HPI, denies night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
-Anxiety associated with attachment disorder since childhood,
currently controlled on Celexa 10 mg
-Chickenpox in childhood
-Postviral ileus/jejunitis in ___, resolved
-Dysmenorrhea
-ADHD
-Two recent UTI's in ___
-Migraines on prn sumatriptan
-Recent sinus infection ___
Social History:
___
Family History:
Father with treated hepatitis C. Her mother is well. Sister
healthy. PGF with melanoma and depression. PGM with
depression. MGF with RCC. MGM died from amyloidosis.
Physical Exam:
Admission Exam:
VS - 103.0 131/77 116 18 100% on RA
GENERAL - NAD, uncomfortable ill appearing female
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MM dry, OP clear
NECK - supple, no thyromegaly, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
BACK - +marked bilateral CVA tenderness R>L
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Discharge Exam:
VS - 98.3 103/61 60 18 100% on RA
GENERAL - NAD, young female who looks well
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
BACK - no CVA tenderness
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Pertinent Results:
Labs:
___ 04:34AM BLOOD WBC-8.8 RBC-4.51 Hgb-12.9 Hct-39.3 MCV-87
MCH-28.7 MCHC-32.9 RDW-13.2 Plt ___
___ 04:34AM BLOOD Neuts-82.7* Lymphs-11.0* Monos-5.2
Eos-0.6 Baso-0.6
___ 06:58AM BLOOD WBC-9.3 RBC-3.76* Hgb-10.9* Hct-33.8*
MCV-90 MCH-29.0 MCHC-32.3 RDW-13.0 Plt ___
___ 06:58AM BLOOD Neuts-68.5 ___ Monos-6.3 Eos-0.3
Baso-0.8
___ 07:22AM BLOOD WBC-8.0 RBC-3.74* Hgb-10.6* Hct-33.1*
MCV-89 MCH-28.4 MCHC-32.1 RDW-13.4 Plt ___
___ 06:58AM BLOOD ___ PTT-27.9 ___
___ 04:34AM BLOOD Glucose-98 UreaN-11 Creat-0.7 Na-140
K-3.3 Cl-103 HCO3-24 AnGap-16
___ 06:58AM BLOOD Glucose-99 UreaN-3* Creat-0.6 Na-137
K-3.4 Cl-107 HCO3-16* AnGap-17
___ 04:10PM BLOOD Na-140 K-4.0 Cl-111*
___ 07:22AM BLOOD Glucose-94 UreaN-3* Creat-0.5 Na-136
K-4.1 Cl-107 HCO3-21* AnGap-12
___ 04:34AM BLOOD ALT-19 AST-17 LD(LDH)-193 CK(CPK)-106
AlkPhos-41 TotBili-0.2
___ 04:34AM BLOOD Lipase-24
___ 06:58AM BLOOD Calcium-7.3* Phos-2.9 Mg-1.3*
___ 04:10PM BLOOD Mg-2.6*
___ 07:22AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.0
___ 04:34AM BLOOD TSH-1.3
___ 04:34AM BLOOD Free T4-1.3
___ 04:34AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:53AM BLOOD Lactate-2.1*
___ 07:26PM BLOOD Lactate-1.6
Micro:
___ URINE CULTURE-PENDING
___ Blood Culture, Routine-PENDING
___ Blood Culture, Routine-PENDING
___ STOOL C. difficile DNA amplification assay-FINAL
negative
___ URINE CULTURE-FINAL negative
___ Blood Culture, Routine-PENDING
___ Blood Culture, Routine-PENDING
___ Blood Culture, Routine-PENDING
___ Blood Culture, Routine-PENDING
___ URINE URINE CULTURE-FINAL negative
Imaging:
___ MR ___, T, and L-Spine W& W/O Contrast: Axial images at
L4-L5 demonstrate diffuse disc bulge without significant
stenosis. At L5-S1, there is a diffuse disc bulge and bilateral
facet DJD with mild central stenosis. No pathologic enhancement
is noted. IMPRESSION: Limited due to motion. No evidence for
cord compression, epidural abscess or discitis/osteomyelitis.
Mild degenerative changes in the lumbar spine.
___ Chest (Pa & Lat): Normal chest radiographic
examination.
___ CT Abd & Pelvis W & W/O Contrast, Addl Sections:
Unremarkable abdominal and pelvic CT examination.
___ Renal U.S: Unremarkable renal ultrasonographic
examination. Hyperechoic foci in the right kidney do not shadow
or show twinkle artifact, suggesting they are not stones.
Brief Hospital Course:
___ yo female with hx of anxiety and two recent UTI's who
presented with fever, chills, and back pain of unclear etiology.
# Fever to 103.5, back pain, HA of unclear etiology. She looked
ill on presentation. Exam notable for CVA tenderness noted R>L
and pelvic exam without CMT. Labs notable for mild left shift
but normal LFT's and lipase. Thyroid studies and CK within
normal limits. Pregnancy test was negative. Negative urine
cultures, blood cultures, and stool cultures. LP was attempted
but unsuccessful and a ___ guided LP was not pursued as she was
improving. Normal CXR, renal u/s, CT abd/pelvis, and full spine
MRI. She required IVF initially for tachycardia. Initially
felt to be a proximal pyelonephritis but two urine cultures were
negative. She had no risk factors for HIV so this was not
tested. She greatly improved within 24 hours with ceftriaxone
which was then switched to cefpodoxime on day three of the
hospitalization. Her back pain was treated with oxycodone. She
was given notes for school and work.
# Anxiety: Citalopram was initially held given concern for
serotonin syndrome given concomitant sumatriptan use but this
was resumed when fever improved with antibiotics.
# Diarrhea with reported incontinence: Rectal exam with normal
tone. This improved on day 2 of the hospitalization.
TRANSITIONAL ISSUES:
# Code status: Full confirmed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 10 mg PO DAILY
Discharge Medications:
1. Citalopram 10 mg PO DAILY
2. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 7 Days
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp
#*13 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Fever, back pain, anxiety
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 stay here at
___.
You were admitted for a fever and back pain. The cause of your
illness is not clear despite a thorough workup. You improved on
IV antibiotics so this was transitioned to oral antibiotics.
You will need to complete a total course of 10 days of
antibiotics.
Followup Instructions:
___
|
10266122-DS-13 | 10,266,122 | 25,852,195 | DS | 13 | 2152-08-21 00:00:00 | 2152-08-21 17:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex
Attending: ___.
Chief Complaint:
abd pain ,stabbing pain , x 4days
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with history of asthma, schizoaffective disorder, s/p
gastric
bypass approximately ___ years ago, s/p appendectomy presents
with
___ days of right sided pain. Reports the pain is sharp and
stabbing, constant, severe, does not radiate, made worse by oral
intake with no alleviating factors. Has tried ibuprofen w/o
relief. She has associated chills, N&V and has not been able to
tolerate liquids. She also reports an episode of sharp/stabbing
chest pain yesterday that lasted approximately 5 hours, radiated
to left shoulder, that occurred at rest and went away on its
own.
She notes worsening leg swelling. Denies any prior chest pain.
Denies SOB, other abdominal pain, changes in bowel habits,
melena, BRBPR, urinary symptoms, or vaginal bleeding/discharge.
Has IUD.
In the ED, initial VS were: 97.6 127/78 80 20 96%RA
Exam notable for:
General - obese, tearful, no acute distress
HEENT - head NC/AT, PERRLA
Cardiovascular - RRR, palpable DP and radial pulses
Respiratory - CTA bilaterally
GI - abdomen soft, tender in right mid-upper quadrant, no
rebound, no guarding, bowel sounds active
GU - no CVAT
Musculoskeletal - difficult to appreciate ___ edema given body
habitus
Labs showed:
grossly hemolyzed:
141/110/11
----------<98
7.0/20/0.9
whole blood K 3.8
normal cbc, lfts, lipase, negative pregnancy test, negative
troponin
UA with trace blood and bacteria
Imaging showed:
CT abd/pelvis with PO contrast only:
1. Status post Roux-en-Y gastric bypass without acute
abnormalities within the abdomen or pelvis. No bowel
obstruction.
Please note the patient is status post cholecystectomy.
2. Serpiginous sclerosis within the femoral heads bilaterally,
raising
suspicion for osteonecrosis.
CXR PA/LAT
Low lung volumes without focal consolidation or pleural
effusion.
Received:
hydromorphone 0.5mg IV x2 (___, ___)
morphine sulfate 4mg IV x1 (___)
ondansetron 4mg IV x1 (1521)
folic acid/multivitamin/thiamine 1000mL (250cc/hr started ___)
Bariatric surgery was consulted:
Patient seen and staffed with Dr. ___. No acute surgical
pathology on CT scan. Will order nutriotional labs and banana
bag
due to emesis in the setting of gastric bypass.
Transfer VS were: 98 102/66 78 18 96%RA
On arrival to the floor, patient reports 6 days of stabbing RLQ
pain that increased from ___ to ___ in intensity over the
past couple days, is constant, and is accompanied by nausea and
post-prandial emesis. She is unable to tolerate PO intake. She
also notes having chills over the past 3 days. For the past 1
day, she endorses L sided chest pain that radiates to her L arm
lasting ___ hours. Today, she notes having just a few hours
on/off of this stabbing chest pain without associated dyspnea.
REVIEW OF SYSTEMS:
(+)PER HPI
Past Medical History:
PAST MEDICAL AND SURGICAL HISTORY:
schizoaffective disorder
anxiety
asthma
anemia
RNYGB in ___ in ___
2 back surgeries for herniated discs T11/T12 in ___
LP/VP shunts for pseudotumor cerebri in ___ complicated by
meningitis
port-a-cath insertions and removal most recently ___, used
for
ECT therapy
Social History:
___
Family History:
no FH of bowel disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.2 ___ 18 98%RA
GENERAL: NAD, morbidly obese
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, false dentition
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, tender to palpation in RLQ, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, trace nonpitting edema
bilaterally
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
VS98.4, 70-80, 90-130/60-80, ___, high ___ RA
GENERAL: NAD, morbidly obese
HEENT: AT/NC, 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: nondistended, tender to palpation in RLQ, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, trace nonpitting edema
bilaterally
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
================
___ 03:16PM WBC-6.8 RBC-4.60 HGB-12.8# HCT-41.3# MCV-90#
MCH-27.8# MCHC-31.0* RDW-13.8 RDWSD-44.9
___ 03:16PM NEUTS-70.4 ___ MONOS-6.4 EOS-2.4
BASOS-0.7 IM ___ AbsNeut-4.77 AbsLymp-1.34 AbsMono-0.43
AbsEos-0.16 AbsBaso-0.05
___ 03:16PM GLUCOSE-98 UREA N-11 CREAT-0.9 SODIUM-141
POTASSIUM-7.0* CHLORIDE-110* TOTAL CO2-20* ANION GAP-11
___ 03:16PM ALT(SGPT)-11 AST(SGOT)-33 ALK PHOS-68 TOT
BILI-0.3
___ 03:16PM ALBUMIN-3.8 IRON-77
___ 03:16PM LIPASE-43
___ 03:16PM VIT B12-140* FOLATE->20
___ 03:16PM 25OH VitD-18*
___ 03:16PM HCG-<5
___ 09:27PM URINE COLOR-Straw APPEAR-Hazy* SP ___
___ 09:27PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 09:27PM URINE RBC-1 WBC-1 BACTERIA-FEW* YEAST-NONE
EPI-6
___ 09:27PM URINE MUCOUS-RARE*
NOTABLE IMAGING:
================
___ 6:___BD & PELVIS WITH CONTRAST
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits.
There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout.
There is no evidence of focal lesions. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. Patient is
status post cholecystectomy.
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: The patient is status post Roux-en-Y gastric
bypass with
normal appearing anastomoses. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The
colon and rectum are within normal limits. Patient is status
post appendectomy.
PELVIS: The bladder is collapsed and cannot be adequately
evaluated on this examination. There is no free fluid in the
pelvis.
REPRODUCTIVE ORGANS: An IUD is seen within the endometrial
canal. Otherwise, the uterus is unremarkable in appearance. No
adnexal masses.
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: Exaggerated kyphosis of the thoracolumbar junction with
exaggerated
lordosis of the lumbar spine. Serpiginous sclerosis within the
femoral heads bilaterally, raising suspicion for osteonecrosis.
There is no evidence of worrisome osseous lesions or acute
fracture.
SOFT TISSUES: Diastasis of the rectus abdominus containing a
nonobstructed
loop of transverse colon. Otherwise, the abdominal and pelvic
wall is within normal limits.
IMPRESSION:
1. Status post Roux-en-Y gastric bypass without acute
abnormalities within the abdomen or pelvis. No bowel
obstruction. Please note the patient is status post
cholecystectomy.
2. Serpiginous sclerosis within the femoral heads bilaterally,
raising
suspicion for osteonecrosis.
___ 10:24 AM
UGI SGL W/O KUB
FINDINGS:
Thin consistency barium was administered with the patient
upright.
Barium passed freely through the esophagus into the gastric
pouch, through the gastrojejunostomy and then into the proximal
small bowel. There is no evidence of leak or obstruction.
IMPRESSION:
No evidence of leak or obstruction.
DISCHARGE LABS:
================
___ 09:30AM BLOOD WBC-4.3 RBC-4.47 Hgb-12.7 Hct-40.9 MCV-92
MCH-28.4 MCHC-31.1* RDW-13.6 RDWSD-45.3 Plt ___
___ 09:30AM BLOOD Glucose-144* UreaN-9 Creat-0.9 Na-139
K-4.2 Cl-105 HCO3-19* AnGap-15
___ 03:16PM BLOOD VitB12-140* Folate->20
___ 03:16PM BLOOD 25VitD-18*
Brief Hospital Course:
___ with history of asthma, schizoaffective disorder, s/p
gastric bypass approximately ___ years ago, s/p appendectomy
presents with ___ days of right sided abdominal pain, nausea,
and vomiting. The patient says that she vomits ~5min every time
after she eats. The patient's physical exam was notable for
tenderness to left lower quadrant. Labs were notable for HCO3
20, LFTs wnl, lipase wnl, trop <0.01 x2, Vitamin B12 140,
Vitamin 25OH-Vit D 18. CT abdomen pelvis showed no acute
intraabdominal process. Bariatric surgery was consulted and
recommended upper GI with small bowel follow through. The upper
GI with small bowel follow through showed no obstruction or
perforation. The patient was repleted with Vitamin D 50000U then
started on Vitamin D 800U thereafter. The patient's home dose of
B12 was increased to 1000U daily. She had just stopped her PPI a
couple of months prior, so it was thought that her symptoms
could be GERD. She was restarted on a PPI (pantoprazole) daily.
The patient's diet was advanced and the patient was able to
tolerate PO at time of discharge.
#Abdominal pain
#Nausea/emesis
The patient's complaints of nausea/vomiting and abdominal pain
may have been due to GERD; patient was re-initiated on PPI. The
patient's CT A/P showed no evidence of obstruction or other
acute intraabdominal process. Bariatric surgery was consulted
and recommended upper GI with small bowel follow through, which
showed no obstruction or perforation. The patient did notably
have a low B12 at 140 and low Vit D at 18. The patient was
repleted with Vitamin D 50000U then started on Vitamin D 800U
thereafter. The patient's home dose of B12 was increased to
1000U daily.
#Chest pain
The patient complained of chest pain that lasted for ___nd resolved without intervention. The patient's EKG was
not concerning for ACS and troponin <0.01 x2. The patient's
chest pain was thought to be more likely either due to GERD or
musculoskeletal in nature.
CHRONIC ISSUES:
===============
#Schizoaffective disease
#Anxiety
The patient was continued on home risperidone, topiramate,
trazodone, fluphenazine, diazepam.
#Asthma
The patient was continued on home monte___.
#Low back pain
The patient was continued on home lidocaine ointment.
=====================
TRANSITIONAL ISSUES
=====================
- The patient should follow-up with her PCP.
- The patient should continue pantoprazole for 6 months.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Topiramate (Topamax) 150 mg PO Q12H
2. Sertraline 150 mg PO DAILY
3. RisperiDONE 2 mg PO BID
4. Diazepam 5 mg PO TID:PRN anxiety
5. CloNIDine 0.2 mg PO QHS
6. TraZODone 300 mg PO DAILY
7. Cyanocobalamin 500 mcg PO DAILY
8. Fluphenazine 2.5 mg PO DAILY
9. Cetirizine 10 mg PO DAILY
10. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea/wheezing
11. Montelukast 10 mg PO QHS
12. Fluticasone Propionate NASAL 1 SPRY NU BID
13. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Multivitamins 1 TAB PO DAILY
RX *multivitamin [One Daily Multivitamin] 1 tablet(s) by mouth
every day Disp #*30 Tablet Refills:*0
2. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth everyday Disp #*30
Tablet Refills:*0
3. Vitamin D 800 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth
every day Disp #*60 Tablet Refills:*0
4. Cyanocobalamin 1000 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 1,000 mcg 1 tablet(s) by mouth
every day Disp #*30 Tablet Refills:*0
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea/wheezing
6. Cetirizine 10 mg PO DAILY
7. CloNIDine 0.2 mg PO QHS
8. Diazepam 5 mg PO TID:PRN anxiety
9. Ferrous Sulfate 325 mg PO DAILY
10. Fluphenazine 2.5 mg PO DAILY
11. Fluticasone Propionate NASAL 1 SPRY NU BID
12. Montelukast 10 mg PO QHS
13. RisperiDONE 2 mg PO BID
14. Sertraline 150 mg PO DAILY
15. Topiramate (Topamax) 150 mg PO Q12H
16. TraZODone 300 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Abdominal Pain
Nausea/Vomiting
B12 deficiency
Vitamin D deficiency
SECONDARY DIAGNOSES:
Schizoaffective disease
Anxiety
Asthma
Low Back Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you!
WHY WERE YOU IN THE HOSPITAL?
- You were in the hospital for abdominal pain, nausea, and
vomiting.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You were started on vitamin D and increased your vitamin B12
dose, because the levels in your blood were low.
- You had a study that looked at how things move through your
esophagus, stomach, and small bowel, which was normal.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- You should take your medicines as prescribed.
- You should follow-up with your primary care doctor.
Wishing you all the best,
Your ___ Treatment Team
Followup Instructions:
___
|
10266157-DS-15 | 10,266,157 | 20,081,356 | DS | 15 | 2194-03-15 00:00:00 | 2194-03-15 17:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
altered mental status (confusion)
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
___ year-old female with a PMH significant for depression and
anxiety, borderline PD, PTSD, anal squamous cell carcinoma (in
remission), hypothyroidism and surgical hypoparathyroidism,
recent admission to psych facility for SI presenting with
slurred speech and confusion. Pt was recently admitted ___ to
___ for suicidal ideation and transferred to ___
___ psych facility. She was discharged today and per
husband had sudden onset slurred speech, falling, weakness and
agitation. Per husband, she had taken her olanzapine prior to
this episode.
.
In the ED, initial VS: 112 130/44 96%RA. Code stroke was called
for slurred speech. Neurology consult was obtained. CTA head and
neck was unremarkable. At ED, BPs were elevated to 200s for
which she received 10 mg IV hydralazine. HR elevated to 130s;
she received 1 mg IV ativan and IV fluids.
.
REVIEW OF SYSTEMS:
Unable to obtain accurate ROS due to AMS. Pt complains of pain
in hips and back of neck that she states is chronic.
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
1. Major depressive disorder, PTSD, borderline personality
disorder (has required Psychiatric hospitalization at ___
___)
2. Somatization disorder
3. Hypothyroidism (s/p thyroidectomy in ___
4. Hypoparathyroidism (post-surgical), hypocalciuria
5. Anal squamous cell carcinoma (in remission)
6. Colonic diverticulosis, colonic polyps (adenomatous)
7. History of pancreatitis
8. History of ischemic colitis (symptomatic treatment, ___
9. s/p hysterectomy (menorrhagia treatment)
Social History:
___
Family History:
History of alcoholism.
Physical Exam:
ADMISSION EXAM:
.
VS - 97.3 182/82 128 22 96%RA
GENERAL - agitated, repeatedly trying to get out of chair,
tremors of upper extremities
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox1 (self only), CNs II-XII grossly intact,
muscle strength ___ throughout, poor attention
.
DISCHARGE EXAM:
.
VITALS: 97.6 95.2 ___ 92 22 97%RA
I/Os: 1680 | BRP, BM x 1
GENERAL: Appears in no acute distress. Alert and interactive.
Not agitated, or emotionally labile this AM.
HEENT: Normocephalic, atraumatic. EOMI. PERRL 4-2 mm and brisk.
Nares clear. Mucous membranes moist.
NECK: supple without lymphadenopathy. JVD not elevated.
___: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2 normal.
RESP: Clear to auscultation bilaterally without adventitious
sounds. No wheezing, rhonchi or crackles. Stable inspiratory
effort.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses
NEURO: CN II-XII intact throughout. Alert and oriented x 3. DTRs
2+ throughout, strength ___ bilaterally, sensation grossly
intact. Gait deferred. Negative Romberg. Resting tremor noted.
Pertinent Results:
ADMISSION LABS:
.
___ 09:30PM BLOOD WBC-4.7 RBC-3.65* Hgb-11.2* Hct-32.9*
MCV-90 MCH-30.7 MCHC-34.1 RDW-13.3 Plt ___
___ 09:30PM BLOOD ___ PTT-30.0 ___
___ 09:30PM BLOOD Glucose-138* UreaN-25* Creat-1.0 Na-139
K-3.7 Cl-104 HCO3-26 AnGap-13
___ 09:30PM BLOOD cTropnT-<0.01
___ 09:30PM BLOOD Calcium-10.1 Phos-3.8 Mg-1.8
___ 09:30PM BLOOD TSH-0.020*
___ 09:30PM BLOOD T4-17.2* T3-170 Free T4-3.7*
___ 09:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
DISCHARGE LABS:
.
___ 06:05AM BLOOD WBC-3.7* RBC-3.27* Hgb-10.2* Hct-29.4*
MCV-90 MCH-31.0 MCHC-34.5 RDW-13.1 Plt ___
___ 09:30PM BLOOD ___ PTT-30.0 ___
___ 06:05AM BLOOD Glucose-97 UreaN-22* Creat-0.7 Na-141
K-3.8 Cl-110* HCO3-24 AnGap-11
___ 06:05AM BLOOD Ret Aut-2.5
___:05AM BLOOD Calcium-8.8 Phos-4.2 Mg-1.8
.
URINALYSIS: clear, negative for ___, negative for Nitr, no
protein
.
MICROBIOLOGY DATA: None
.
IMAGING:
___ CTA HEAD W&W/O C & RECO - no hemorrhage or bleeding;
grey-white matter differentiation preserved. Anterior and
posterior circulations intact without aneurysm or stenosis.
.
___ CHEST (PA & LAT) - No evidence of acute cardiopulmonary
process. Possible lucencies in left posterior ribs. These could
be further evaluated with bony detail radiographs of the
posterior ribs.
.
___ RIB UNILAT, W/ AP CHEST - The marker overlies the lower
left ribs. No focal lytic or sclerotic lesion or rib fracture is
detected. The lucency suggested on the films from ___ is not
appreciated on the current exam and may have represented ___
artifact.
Brief Hospital Course:
IMPRESSION: ___ with a PMH significant for depression and
anxiety, borderline PD, PTSD, anal squamous cell carcinoma (in
remission), hypothyroidism and surgical hypoparathyroidism,
recent admission to psychiatric facility for SI (discharged
___ ___ after stay at ___ for medical
clearance) presenting with slurred speech and confusion with
agitation.
.
# ACUTE METABOLIC ENCEPHALOPATHY - The patient presented with
lethargy, slurred speech, confusion, and unsteady gait per her
husband after discharge from an inpatient psychiatric facility
the day prior (___). Given her initial
presenting symptoms, a CODE stroke was activated and a CTA head
was negative acute ischemic or hemorrhagic concerns. Neurology
noted no focal deficits on exam - but felt a toxic metabolic
phenomenon was most likely with possible Parkinsonian features.
After laboratory and imaging evaluation, and given a rapid
improvement in her clinical status, this was attributed to
over-ingestion of Olanzapine, which was confirmed with patient
once her mental status returned to baseline. Her TFTs confirmed
an undetectable TSH with elevated free T4. There was some
transient concern for suicidal ideation, but a Psychiatry
evaluation was reassuring. She will be discharged home with ___
psychiatric services with strict home medication monitoring and
home safety evaluation. Once medically stable, we resumed her
home Olanzapine 5mg PO BID per Psychiatry.
.
# HYPERTHYROIDISM - On admission, there was concern for a
component of thyrotoxicosis given her nearly undetectable TSH
(0.024) on prior admission, ___ with elevated TFTs (T4 22.7,
T3 180, Free T4 very elevated). Her dose of Levothyroxine at
that time was decreased from 137 to 75 mcg PO daily. Given her
psychiatric history and antipsychotic use, symptoms of excess
thyroid hormone administration were difficult to elucidate in
her presentation, but she later agreed that she erratically
consumed her medications. Her TSH this admission remains low,
but the adjustment in her dose will not reflect in her
laboratory studies for several weeks given the half-life of
Levothyroxine. We discussed this with ___ and opted to
hold her dosing until her free T4 normalizes and then plan to
resume her Levothyroxine 137 mcg PO daily dosing as an
outpatient.
.
# NORMOCYTIC ANEMIA - Patient has history of normocytic anemia
to 34-35% previously. Post-menopausal, no prior iron studies,
with reassuring B-12 and folate levels in ___. No evidence of
active bleeding noted. Her hematocrit this admission trended
down into the 29%-33% range. Her differential and reticulocyte
count was normal. She had no acute indications for transfusion.
.
# HYPERTENSION - The patient presented with isolated BP of 200
mmHg and 180s systolics on presentation. She received IV
hydralazine in the ED with improvement to the 150-160 systolic
range following admission; without neurologic symptoms. It is
unclear if she was receiving her blood pressure medications at
home given her mental status issues. There was also concern for
hypertension as a secondary effect of hyperthyroid state. She
has no significant cardiac history of note. We increased her
Lisinopril from 5mg to 10 mg PO daily with improvement in her
BP.
.
# SINUS TACHYCARDIA - She presented with a heart rate in the
130s, with an EKG showing no evidence of ischemia (cardia
biomarker negative), notable for sinus tachycardia. The patient
had no chest pain symptoms, oxygen saturations remained stable.
CXR was without acute abnormality. Again, excessive
anti-psychotic medication would produce this physical finding.
No hypoxia or desaturations were noted, and thus there was low
clinical concern for pulmonary embolism. No obvious evidence of
infectious source and she remained afebrile on exam. A limited
infectious work-up was reassurig and her heart rate improved
when her medications were routinely dosed appropriately.
.
TRANSITION OF CARE ISSUES:
1. Monitor hematocrit as an outpatient - reticulocyte count and
differential normal without transfusion needs. Consider checking
outpatient iron studies. Assure age-appropriate screening (e.g.
screening colonoscopy).
2. We increased her home dosing of Lisinopril to 10 mg PO daily.
Titrate as needed.
3. Patient was discharged home with ___ psychiatric services -
will have outpatient psychiatry ___ scheduled for ___
or ___. Has PCP ___ on ___. Will have
___ nurse for strict medication administration monitoring and
will obtain pill lock box. On discharge, patient was instructed
to discard her home medications, and a 1-month supply of each of
her medications was prescribed.
4. Her TSH this admission remained low, but the adjustment in
her dose will not reflect in her laboratory studies for several
weeks given the half-life of Levothyroxine. We discussed this
with ___ and opted to hold her dosing of Levothyroxine
until her free T4 normalizes and then plan to resume her
Levothyroxine 137 mcg PO daily dosing as an outpatient. She will
need weekly TFTs checks and once her TSH and free T4 normalize,
her prior dose can be resumed. This was emailed to her PCP.
Medications on Admission:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
2. sucralfate 100 mg/mL Suspension Sig: Two (2) teaspoons (10
mL) PO four times a day.
3. trazodone 100 mg Tablet Sig: ___ Tablets PO at bedtime.
4. olanzapine 10 mg Tablet Sig: 0.5 Tablet PO twice a day.
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO once a day
(kept on 137 mcg PO daily even on discharge from ___.
___
8. naproxen 500 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for headache.
9. olanzapine 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
Hold for loose stools.
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day: Hold
for loose stools.
Discharge Medications:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. sucralfate 100 mg/mL Suspension Sig: Two (2) teaspoons PO
four times a day.
Disp:*400 mL* Refills:*3*
3. olanzapine 2.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*0*
4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*0*
6. naproxen 500 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for pain.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*1*
9. Outpatient Lab Work
Please have your thyroid function studies checked (TSH, free T4
and total T4) and fax results to your PCP ___ ___. PCP: Dr.
___, FAX ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
1. Mental status changes, confusion
2. Thyrotoxicosis
.
Secondary Diagnoses:
1. Major depressive disorder
2. Borderline personality disorder
3. Somatization disorder
4. Hypothyroidism
5. Post-surgical hypoparathyroidism
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Patient Discharge Instructions:
.
You were admitted to the Internal Medicine service at ___
___ on ___ regarding management of
your mental status changes and confusion. Your medical
evaluation was reassuring, although your thyroid studies
revealed that you had high thyroid hormone intake and we
adjusted the dosing. You were evaluated by Psychiatry who felt
you were safe to go home with a visitng nurse to help with
administering your medications and with supervision while you
are at home.
.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
.
CHANGES IN YOUR MEDICATION RECONCILIATION:
.
* Upon admission, we ADDED: NONE
.
* The following medications were CHANGED:
CHANGED: We changed Lisinopril from 5 to 10 mg by mouth daily
.
* The following medications were DISCONTINUED on admission and
you should NOT resume:
.
DISCONTINUE: Trazodone
HOLD: Levothyroxine (until discussed with your primary care
physician)
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above.
.
Per our meeting this afternoon prior to discharge, it is very
important to have a safe home environment. To this effect, we
recommended:
.
1. Collect all of ___ medications currently in the house and
discard (recommend taking to pharmacy for safe disposal).
2. Fill new prescriptions at pharmacy (provided on discharge).
3. Purchase lock box for all medications in the house.
4. Purchase medication container at pharmacy (recommend maximmum
1-week).
5. Home ___ will draw blood tomorrow (___) and send to your
PCP regarding thyroid function studies.
6. Contact Dr. ___ to schedule an appointment for next
___ or ___.
Followup Instructions:
___
|
10266157-DS-18 | 10,266,157 | 27,281,159 | DS | 18 | 2196-12-30 00:00:00 | 2197-01-12 20:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ hx of anal cancer in remission, pancreatitis and ischemic
colitis (___) presents with abdominal pain. She describes the
abdominal pain as epigastric radiating to her lower abdomen and
a constant squeezing pain. The pain is associated with nausea no
vomiting. She has been having small bowel movements brown stools
that she has been unable to control and walking. She has not
seen any blood or dark black stool. However she states her last
BM was almost a week ago. The pain feels like the pancreatitis
pain she has had before. She has not taken anything for pain
because she was afraid to make it worse. She has not had any
fevers, chills or sweats. She has had decreased appetitie, pain
is made worse with eating. Patient reports not eating anything
for past 6 days as it made the pain worse. Denies odynophagia or
dysphagia. She does endorse weight loss however unclear of how
much. She has had associated lower chest pain that does not
radiate and associated shortness of breath and severe anxiety.
Denies any palptiations. Denies rescent cough, dysuria or recent
illness.
In the ED, initial vitals: 98.0 82 113/74 18 99%
- Exam notable for: soft, nondistended, epigastric tenderness
with guarding no stool in rectal vault, guiac negative mucus
- Labs notable for: Lactate:2.1, trop <0.01, relatively
unremarkable cbc, chem-7, LFTs and Lipase 61
- Imaging notable for: CT abdomen with No definite acute
intra-abdominal process
- Pt given: 2L NS, zofran, 324 ASA, 1 mg IV dilaudid, and ativan
- Vitals prior to transfer: 52 87/61 18 97% RA
On arrival to the floor, pt reports feeling anxious and still
continues to have abdominal pain and sternal chest discomfort.
She states the dilaudid and ativan given to her in the ED helped
her pain mildly. She continues to have nausea, states the pain
is worst in the epigastrium.
ROS: Negative as per HPI
Past Medical History:
1. Major depressive disorder, PTSD, borderline personality
disorder (has required Psychiatric hospitalization at ___
___)
2. Somatization disorder
3. Hypothyroidism (s/p thyroidectomy in ___
4. Hypoparathyroidism (post-surgical), hypocalciuria
5. Anal squamous cell carcinoma (in remission)
6. Colonic diverticulosis, colonic polyps (adenomatous)
7. History of pancreatitis
8. History of ischemic colitis (symptomatic treatment, ___
9. s/p hysterectomy (menorrhagia treatment)
Social History:
___
Family History:
Alcoholism in father. Father died of MI at ___. Mother died of
unknown cause at ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- 97.6 134/86 68 18 99RA
Wt 61.2 Kg (bed)
General- Alert, oriented, in discomfort
HEENT- Sclerae anicteric, dry mucus membranes, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present, no rebound or
gaurding, tenderness in RLQ, RUQ, epigastrium with palpation, no
organomegaly or masses
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:
Vitals- 98.4 78 (68-78) 110/69 (93/55-132/89) 18 97%RA
General- Alert, oriented, sleeping bed comfortably
HEENT- Sclerae anicteric, dry mucus membranes, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present, no rebound or
gaurding, mild tenderness to palpation in RLQ, no organomegaly
or masses
GU- foley in place draining clean yellow urine
Ext- warm, well perfused, no clubbing, cyanosis or edema
Neuro- CNs2-12 intact, PERRL, EOMI, strength equal and bilateral
in UE ___, ___ ___, sensation intact in upper and lower
extremities.
Pertinent Results:
Admission Labs
=====================================
___ 11:29AM COMMENTS-GREEN TOP
___ 11:29AM LACTATE-2.1*
___ 11:05AM GLUCOSE-99 UREA N-8 CREAT-1.1 SODIUM-143
POTASSIUM-3.4 CHLORIDE-104 TOTAL CO2-23 ANION GAP-19
___ 11:05AM estGFR-Using this
___ 11:05AM ALT(SGPT)-16 AST(SGOT)-22 ALK PHOS-52 TOT
BILI-0.5
___ 11:05AM LIPASE-61*
___ 11:05AM ALBUMIN-4.1 CALCIUM-9.6
___ 11:05AM WBC-6.2 RBC-4.55 HGB-14.8 HCT-40.9 MCV-90
MCH-32.6* MCHC-36.3* RDW-13.7
___ 11:05AM NEUTS-69.8 ___ MONOS-5.2 EOS-1.1
BASOS-0.2
___ 11:05AM PLT COUNT-309
Pertinent labs
====================================
___ 07:39AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
___ 07:59AM BLOOD Type-ART O2 Flow-2 pO2-87 pCO2-34*
pH-7.38 calTCO2-21 Base XS--3 Intubat-NOT INTUBA Comment-NASAL
___
___ 07:59AM BLOOD freeCa-1.09*
___ 11:29AM BLOOD Lactate-2.1*
Discharge Labs
====================================
___ 05:20AM BLOOD WBC-5.3 RBC-3.99* Hgb-13.0 Hct-37.4
MCV-94 MCH-32.4* MCHC-34.6 RDW-14.0 Plt ___
___ 05:20AM BLOOD Glucose-82 UreaN-9 Creat-1.0 Na-143 K-4.3
Cl-108 HCO3-27 AnGap-12
___ 05:20AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.1
Imaging
====================================
___ ABD & PELVIS WITH CO
No definite acute intra-abdominal process. Of note the stomach
is unusual in configuration potentially due to imaging during
contraction however focal thickening or underlying lesion along
the greater curvature is not excluded.
___ (PORTABLE AP)
FINDINGS: Linear left basilar opacities likely atelectasis. The
lungs are otherwise clear. The cardiomediastinal silhouette is
stable. No acute osseous abnormalities identified.
IMPRESSION: No acute cardiopulmonary process.
___ HEAD W/O CONTRAST
1. No evidence of acute intracranial hemorrhage or large
vascular territory infarction.
2. Age related cerebral atrophy and cerebral white matter
hypodense foci, likely related to sequelae of small vessel
ischemic disease, also seen on the prior study of ___.
___
EXERCISE RESULTS
RESTING DATA
EKG: NSR, LOW VOLT, TWA
HEART RATE: 66BLOOD PRESSURE: 130/68
PROTOCOL /
STAGETIMESPEEDELEVATIONWATTSHEARTBLOODRPP
(MIN)(MPH)(%) RATEPRESSURE
I0-40.142MG/KG/MIN ___
TOTAL EXERCISE TIME: 4% MAX HRT RATE ACHIEVED: 73
SYMPTOMS:NONE
ST DEPRESSION:EQUIVOCAL
INTERPRETATION: This was an inactive ___ year old woman with a Hx
of MI, remote smoking and anxiety, who was referred to the lab
from the inpatient floor for an evaluation of chest discomfort.
She received 0.142mg/kg/min of IV Persantine infused over 4
minutes. She denied any chest, arm, neck or back discomforts,
shortness of breath, palpitations or symptoms of intolerance to
Persantine throughout the study. There was inversion of the T
waves in the inferolateral leads noted at peak infusion, which
remained inverted for the duration of the study. The rhythm was
sinus with no ectopy seen throughout the duration of the study.
The heart rate and blood pressure responded appropriately to the
Persantine infusion. At 2.5 minutes post infusion, 125mg IV
Aminophylline was given to prevent any potential Persantine side
effects.
IMPRESSION: Non-specific T wave changes noted. No anginal type
symptoms. Appropriate hemodynamic responses to Persantine.
Nuclear report sent separately.
___ PERFUSION PHARM
SUMMARY FROM THE EXERCISE LAB:
For pharmacologic coronary vasodilatation dipyridamole was
infused intravenously
for 4 minutes at a dose of 0.142 milligram/kilogram/min.
TECHNIQUE:
ISOTOPE DATA: (___) 11.0 mCi Tc-99m Sestamibi Rest;
(___) 31.3 mCi
Tc-99m Sestamibi Stress; DRUG DATA: (Non-NM admin) Dipyridamole;
IMAGING METHOD:
Resting perfusion images were obtained with Tc-99m sestamibi.
Tracer was injected approximately 45 minutes prior to obtaining
the resting images. Following resting images and following
intravenous infusion, approximately three times the resting dose
of Tc-99m sestamibi was administered intravenously. Stress
images were obtained approximately 30 minutes following tracer
injection Imaging protocol: Gated SPECT. This study was
interpreted using the 17-segment myocardial perfusion model.
FINDINGS: The image quality is adequate for interpretation.
Left ventricular cavity size is normal. Rest and stress
perfusion images reveal uniform tracer uptake throughout the
left ventricular myocardium. Gated images reveal normal wall
motion. The calculated left ventricular ejection fraction is
71% No prior comparison study is available. IMPRESSION: Normal
myocardial perfusion and function with EF of 71%.
Cardiovascular ReportECGStudy Date of ___ 2:07:26 ___
Sinus bradycardia. Low precordial lead voltage and borderline
low limb lead
voltage. Poor R wave progression which may be a normal variant.
Extensive
non-specific ST-T wave changes. Compared to the previous tracing
of ___
the heart rate has slowed. Inferior ST-T wave changes are less
pronounced.
TRACING #1
IntervalsAxes
___
___
Cardiovascular ReportECGStudy Date of ___ 6:16:10 AM
Sinus rhythm with extensive baseline artifact. Compared to
tracing #1
Q-T interval appears to be more prolonged, though tracing is
marred by
artifact.
TRACING #2
IntervalsAxes
___
___
Micro
====================================
___ 11:10 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 6:39 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
___ 6:33 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
___ year old woman with history of anal cancer in remission,
pancreatitis and ischemic colitis presents with new onset
abdominal pain, nausea, decreased appetite for 1 week. The
patient was put on an increased bowel regimen for constipation
and she had several bowel movements and her pain significantly
improved. She also was started on omeprazole for her history of
peptic ulcer disease. During her hospital stay the patient had a
fall, head CT was negative. She also had an episode of
bradycardia and loss of consciousness and a brief ICU stay. The
patient was found to have decreased responsiveness and a slow
heart rate after attempting to have a bowel movement. In the ICU
no intervention was taken and that patient improved. The patient
had dynamic T wave changes on admission EKG with new T wave
inversions in II, III, AVF. She underwent a nuclear stress which
was normal. Patient will need outpatient follow up with
cardiology and ___ of hearts study.
ACTIVE MEDICAL ISSUES:
#Abdominal pain: The patient had presented with severe cramping
abdominal pain and nausea. CT abdomen/pelvis relatively
unremarkable however stomach showed potential focal
thickening/underlaying lesion along greater curvature. She does
have a history of malignancy (anal cancer), which made that
finding more concerning, with plans for further work up to be
done as an outpatient. Otherwise CT abdomen not concerning for
acute intra-abdominal process. Liver enzymes and lipase were in
normal limits. Patient did report weight loss and decreased
appetite- records showed EGD showing mild peptic ulcer disease.
She was started on omeprazole for peptic ulcer disease.
H.Pylori and EGD should be considered as an outpatient.
Constipation was also considered a source of her abdominal pain
as patient states she has not had bowel movement in over a week
prior to coming to the hospital. The patient was given a bowel
regimen and simethicone for gas. She had several large bowel
movements and her abdominal pain improved significantly.
#Recent Fall + History of Falls+ lower extremity weakness:
Patient had unwitnessed fall in the hospital and she stated she
hit her head. On evaluation there was no evidence of
neurological deficit on exam. As per daughter the patient has
had multiple falls recently. She was advised to use cane at home
however has not been consistently. The patient underwent a head
CT that showed no evidence of ischemia. Patient was was seen and
evaluated by physical therapy that recommended home physical
therapy. Her orthostatics were negative.
#Hypotension: Patient had an episode of hypotension with SBP in
___ in ED. Likely secondary to hypovolemia as patient reported
decreased PO intake for past week. She had no evidence of blood
loss or infection. She was fluid resuscitated with 3L total and
her pressures improved.
#Chest pain: Patient having abdominal pain associated with
chest pain, shortness of breath and anxiety. Chest pain was
substernal. EKG showed TWI in inferior leads, new from previous.
The T-wave changes were thought to be dynamic. CXR unremarkable.
No cough or fevers that were concerning for infectious process.
The patient had negative cardiac biomarkers. Patient underwent a
stress test that show no evidence of ischemia or ischemic chest
pain. Patient will need outpatient ___ of hearts monitoring to
evaluate her bradycardia.
# Bradycardia: During hospital stay the patient had an episode
of bradycardia while attempting to use the bathroom. Her HR
dropped to the ___ with stable blood pressures. She had a
transient loss of conciousness. EKG showed bradycardia and tele
showed no pauses. The patient was transferred to the ICU and
given IVF. Urine toxicology screen was negative. The patients
symptoms improved without intervention. It was likely that the
patient suffered from a vasovagal episode. The patient had a
nuclear stress test and was found to have no evidence of
ischemia. Cardiology was consulted and recommended outpatient
___ of hears monitoring.
CHRONIC ISSUES:
# Depression/psychiatric history: Patient has a history of
depression and previous psychiatric hospitalizations.
-she was stable and continued on home buproprion and olanzapine
# Hypothyroidism: Continue home levothyroxine.
# Hypoparathyridism: Continue home calcitriol.
# CODE STATUS: Full Code
# Contact: husband ___
TRANSITIONAL ISSUES:
=====================
- CT scan of abdomen showed thickening of the greater curvature
of the stomach, given the history of malignancy and peptic ulcer
disease; patient may require EGD
- started on omeprazole daily for dyspepsia and hx of peptic
ulcer disease
- ___ of Hearts Monitor study to evaluate for arrythmia
- Follow up with cardiology, consider daily 81mg Aspirin in
setting of peptic ulcer disease
- Stool softners to prevent further constipation
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion 150 mg PO DAILY
2. Levothyroxine Sodium 112 mcg PO DAILY
3. Calcitriol 0.5 mcg PO DAILY
4. OLANZapine 20 mg PO HS
Discharge Medications:
1. BuPROPion 150 mg PO DAILY
2. Calcitriol 0.5 mcg PO DAILY
3. Levothyroxine Sodium 112 mcg PO DAILY
4. OLANZapine 20 mg PO HS
5. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
6. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Constipation
Peptic Ulcer Disease
Syncope
Bradycardia
SECONDARY DIAGNOSIS
Major Depressive Disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___. You were hospitalized for abdominal
pain. It is likely that your abdominal pain was due to
constipation. During your hospital stay you had a fall, CT scan
of your head was normal. You also had an episode of bradycardia
(slow heart rate), you had a short ICU stay for this. You were
seen by the cardiology doctors and ___ a stress test to
look at your heart, which was normal. It is important that you
follow up with the cardiology team as scheduled for further
outpatient work up which may include a heart monitor. You will
also need to follow up with your primary care doctor. Please
continue to take your medications as prescribed.
We wish you all the best,
Sincerely,
The ___ Team
Followup Instructions:
___
|
10266157-DS-24 | 10,266,157 | 29,105,836 | DS | 24 | 2200-09-18 00:00:00 | 2200-09-18 17:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
Fall, Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female with past medical history significant for
anxiety, depression, hyperlipidemia, hypertension,
hyperthyroidism, insomnia, mild cognitive impairment who
presented from home with weakness after a mechanical fall.
Patient reports that she has become progressively weak over the
past week. Of note, her brother passed away earlier in the week
and per patient and family, she has not been taking in adequate
p.o. intake or her medications as prescribed. Patient suffered
a
fall on ___ with head strike on the right side of her forehead.
Patient denied presyncopal symptoms or loss of consciousness.
The fall itself was unwitnessed. Otherwise denies any pain,
headache, vision changes, nausea, vomiting, fevers, chills,
abdominal pain, chest pain, shortness of breath, diarrhea,
constipation. Patient is currently not on any anticoagulation.
Reports that she had one episode of fecal incontinence after the
fall. Presently denies suicidal or homicidal ideation.
Past Medical History:
PAST PSYCHIATRIC HISTORY (per OMR, confirmed and updated):
Hospitalizations: At least 3 hospitalizations, with last on Deac
4 from ___
Current treaters and treatment: Dr. ___ at ___
___ and ECT trials: Olanzapine, trazodone, bupropion,
mirtazapine, hydroxyzine
Self-injury: History of OD on "pills and alcohol" ___ years ago,
no other history of SIB or SA
Harm to others: Denies
Access to weapons: Denies
PAST MEDICAL HISTORY:
Hypothyroidism s/p thyroidectomy
Hypoparathyroidism
Anal squamous cell carcinoma
Diverticulosis
Pancreatitis
Ischemic Colitis
Concussion with loss of consciousness at age ___
PCP: ___ at ___
Social History:
___
Family History:
Mother ___ disease
Father (deceased)-CHF
Physical Exam:
ON ADMISSION:
=============
ADMISSION PHYSICAL EXAM:
VS: 98.8, 127/66, 64, 18, 95%RA
GENERAL: NAD
HEENT: no signs of trauma, anicteric sclera, dry MM
NECK: supple, no LAD
CV: RRR, S1/S2, +murmur
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, ___
strength
bilaterally in ___, ___ in UE bilaterally, decreased sensation to
light touch in distal ___ otherwise intact, gait not assessed as
patient fearful she would fall again despite reassurance, face
symmetric, negative pronator drift, Romberg not assessed per
patient preference
DERM: warm and well perfused, no excoriations or lesions, no
rashes
ON DISCHARGE:
=============
VS: ___ 0748 T 97.8 BP 157/95 HR 85 RR 16 O2 94 Ra
GENERAL: NAD
HEENT: no signs of trauma, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, soft systolic murmur
PULM: CTAB, no wheezes, rales, crackles, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose,
DERM: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 09:00PM WBC-9.2 RBC-4.35 HGB-13.7 HCT-39.8 MCV-92
MCH-31.5 MCHC-34.4 RDW-12.4 RDWSD-41.1
___ 09:00PM GLUCOSE-122* UREA N-15 CREAT-1.1 SODIUM-135
POTASSIUM-3.7 CHLORIDE-98 TOTAL CO2-19* ANION GAP-18
___ 09:00PM CALCIUM-8.8 PHOSPHATE-3.6 MAGNESIUM-1.7
___ 09:00PM ___ PTT-33.9 ___
___ 05:17PM ALT(SGPT)-22 AST(SGOT)-84* ALK PHOS-67 TOT
BILI-0.6
___ 05:17PM LIPASE-54
___ 05:17PM cTropnT-<0.01
___ 05:17PM TSH-4.7*
___ 05:17PM BLOOD TSH-4.7*
___ 07:10AM BLOOD T4-7.8
___ 07:10AM BLOOD VitB12-1534*
IMAGING:
========
___ CT HEAD W/O CONTRAST
No acute intracranial abnormalities.
___ CHEST (PA & LAT)
No evidence of acute cardiopulmonary disease.
DISCHARGE LABS:
===============
___ 07:37AM BLOOD WBC-5.6 RBC-4.09 Hgb-13.1 Hct-37.3 MCV-91
MCH-32.0 MCHC-35.1 RDW-13.0 RDWSD-42.5 Plt ___
___ 05:30AM BLOOD Glucose-97 UreaN-15 Creat-0.8 Na-142
K-3.5 Cl-104 HCO3-25 AnGap-13
___ 05:30AM BLOOD Calcium-9.0 Phos-3.6 Mg-1.5*
___ 07:10AM BLOOD ALT-13 AST-20 CK(CPK)-88 AlkPhos-58
TotBili-0.7
Brief Hospital Course:
SUMMARY:
========
___ with PMHx significant for anxiety and depression presenting
s/p fall on ___, thought to be orthostatic in the setting of
decreased PO intake, one week after death of younger brother.
TRANSITIONAL ISSUES:
====================
[ ] Pt should not be on benzodiazepines, as she has a history of
dependence and misuse, with difficulty weaning. Please contact
Dr ___ further details if necessary ___
[ ] Concern for volitional poor oral intake in setting of grief
from death of younger brother. Please follow up oral intake. She
has follow up scheduled with psychiatry.
[ ] She will need to follow up with social work at the
___ clinic.
ACUTE ISSUES:
=============
#Fall suspected in setting of orthostasis
#Generalized Weakness
She reported feeling lightheadedness before falling on a wooden
floor on ___, thought to be orthostasis in the setting of
volitional poor PO intake due to death of her younger brother.
No clear infectious etiology. She was monitored on telemetry
with no recorded events. Suspect earlier . Low suspicion for
cardiac or neurologic etiology. She was seen by ___ who felt she
could be discharged to home. She was also seen by nutrition who
recommended Ensure supplements, multivitamin w/ minerals, and
thiamine.
#Anxiety
#Depression
Patient with known anxiety and depression, followed by ___
psychiatry. Now with decreased PO intake after very recent loss
of brother earlier in the week. No active SI/HI. Family
concerned that the patient has not been eating and per my
discussion, patient states that she felt as if she "did not
deserve to eat or drink." When discussed further patient agrees
that she "needs to work on it." She was seen by psychiatry for
safety assessment and felt to be safe for discharge home. She
was started on her home venlafaxine, olanzapine, and mirtazapine
which it appeared she had not been taking.
#Hyponatremia, hypomagnesemia, hypophosphatemia
Suspected in setting of poor po intake, subsequently resolved.
CHRONIC ISSUES:
===============
#Hypertension
Her home amlodipine was held in setting of concern for
orthostasis.
#Hyperlipidemia
She was continued on home pravastatin
#Hypothyroidism
She was continued on home levothyroxine
#Vitamin D Deficiency
25-OH Vit D WNL. She was continued on home vitamin D
supplementation.
#Insomnia
She was continued on home ramelteon
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Mirtazapine 30 mg PO QHS
2. OLANZapine 2.5 mg PO QAM
3. OLANZapine 15 mg PO QHS
4. Celecoxib 200 mg oral DAILY:PRN
5. amLODIPine 2.5 mg PO DAILY
6. Pravastatin 20 mg PO QPM
7. melatonin 1 mg oral QHS
8. Venlafaxine XR 150 mg PO DAILY
9. Levothyroxine Sodium 137 mcg PO DAILY
10. Calcitriol 0.5 mcg PO DAILY
Discharge Medications:
1. Multivitamins W/minerals 1 TAB PO DAILY
2. Thiamine 100 mg PO DAILY Duration: 5 Days
3. amLODIPine 2.5 mg PO DAILY
4. Calcitriol 0.5 mcg PO DAILY
5. Celecoxib 200 mg oral DAILY:PRN pain
6. Levothyroxine Sodium 137 mcg PO DAILY
7. melatonin 1 mg oral QHS
8. Mirtazapine 30 mg PO QHS
9. OLANZapine 2.5 mg PO QAM
10. OLANZapine 15 mg PO QHS
11. Pravastatin 20 mg PO QPM
12. Venlafaxine XR 150 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Fall
SECONDARY DIAGNOSIS:
====================
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- You had a fall
What did you receive in the hospital?
- You received IV fluids for dehydration
What should you do once you leave the hospital?
- Continue to eat and drink plenty of fluids
- Please follow up with social work at the ___ clinic
- Please follow up with your psychiatrist
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10266395-DS-3 | 10,266,395 | 20,282,019 | DS | 3 | 2133-06-08 00:00:00 | 2133-06-08 16:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
ring-enhancing lesions on MRI
Major Surgical or Invasive Procedure:
Lumbar Puncture
History of Present Illness:
Ms. ___ is a ___ year old woman with no significant
medical history presenting with 4 weeks of gait unsteadiness and
right leg weakness. She reports that one morning she woke up and
noticed that she was swaying while walking and her right leg
felt
heavy and like it was slower to respond. She presented to the
PCP
who ___ an 8 day course of antihistamine for BPPV with no
improvement.
Over this time, the gait unsteadiness would be better on some
days and worse on others, but it is constant throughout the day,
any time she walks. She is able to keep working because she
mostly sits at her work. She had one fall in which her right leg
did not respond as quickly as she thought it would: while
getting
out of a car her right leg was caught on the curb and she had a
slight fall in which she could lower herself onto the ground
without headstrike or LOC. She does think that in the past 10
days her leg movements have been improving although she does
still have some difficulty with climbing stairs.
No vision changes or changes in sensation. She is having
difficulty with her coordination in both of her hands.
She also reports that her memory is worse x 2 weeks: when she
forgets things like what she was looking for or why she was in a
certain room, it takes her longer than usual to remember that
again. She also had a few episodes in
the last month where she knows the word she wants to say, but
for
some reason can not say it. She pauses, then replaces the word
with another and continues talking. Her daughter thinks she has
had a change in how accurate her annunciation is. She has a lot
of trouble remembering what she is reading in books and often
will have to reread passages or chapters because she cannot
remember what happened. Sometimes she will finish a book and
won't remember what it is about.
There was one episode about 6 months ago when her daughter was
out for the evening and came home, they talked, her daughter
showered and ate dinner with Ms. ___, and then later in
the evening Ms. ___ did not remember her daughter having
come home or showered.
She had two brief, mild headaches this past month but has not
had significant headache.
She had an MRI brain first without contrast (reportedly IV
access
was the issue) which was consistent with demyelination, so she
had an MRI brain with contrast which revealed multiple scattered
ring-enhancing lesions, so she was referred to the ED.
She denies ever having an episode like this before, or any
episode in her life of weakness, numbness, tingling, difficulty
understanding or producing speech. She has not had recent change
in appetite. No fever, or chills, though she does endorse
occasional night sweats
related to menopause. She had 15 lb weight loss ___ which
she attributes to increased activity while packing and moving
homes and she has not fully regained this weight. She has gained
3 lb back. She denies skin
growths or concerning skin lesions.
She denies dysuria, abdominal pain, urgency and frequency. No
hematochezia or change in stool caliber.
Her last colonoscopy a few years ago was
negative, last mammogram last year was negative. She is a
smoker,
denies history of IVDU. She travels to ___ every ___ years,
most recently ___ x 2 weeks. She had diarrhea during
this
trip and has had diarrhea every time she visits ___. She is a
vegetarian and has had a few bites of lamb and beef in her life,
but to her knowledge has never had pork. She has a history of a
"worm" which she found in her stool in ___ after a trip to
___
in ___, and it was reportedly large enough that she believed
she
had passed part of her small intestine with the bowel movement.
She brought the worm to a doctor and was prescribed a course of
oral medication, which she completed. She has otherwise traveled
to ___ and has no recollection of significant bug bites or
tick bites in her travels. There is a family history of cerebral
hemorrhage in her brother, sister, and nephew, and almost no
family history of cancer.
Past Medical History:
Dupuytren's contracture
uterine artery embolization ___ years ago
tonsillectomy
appendectomy
___ motorcycle accident with right patellar fracture requiring
surgery and complicated by infection
Social History:
___
Family History:
Father: bypass surgeries, pacemaker, stents
Mother: DM, episodes of low blood pressure
Brother, eldest: epilepsy since childhood, mild intellectual
disability
Brother, middle: history of cerebral hemorrhage, currently well
and asymptomatic from this
Brother, youngest: cardiac stents
Sister: death caused by cerebral hemorrhage age ___
Daughter: elevated platelets, stomach "cyst"
Middle brother's daughter: epilepsy in childhood
Sister's son: death caused by "cerebral hemorrhage," though not
confirmed, at age ___
Paternal great aunt: breast cancer
Physical Exam:
Admission Exam:
Vitals: 98.1 84 94/51 16 99% RA
General: NAD, resting in bed
HEENT: NCAT, no oropharyngeal lesions, moist mucous membranes,
sclerae anicteric
Extremities: Warm, no edema
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status - Awake, alert, oriented to person, place and
time. Attention to examiner easily maintained. Recalls a
coherent
history. Speech is fluent with full sentences, intact
repetition,
and intact verbal comprehension. Content of speech demonstrates
intact naming (high and low frequency) and no paraphasias.
Normal
prosody. No evidence of hemineglect. No left-right agnosia.
- Cranial Nerves - PERRL 3->2 brisk. VF full to finger wiggling.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
finger rub bilaterally. No dysarthria. Palate elevation
symmetric. Trapezius strength ___ bilaterally. Tongue midline.
- Motor - Normal bulk and tone. No drift, but very mild
pronation
of the RUE noted; no orbiting. No tremor or asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 4 ___ ___ 5- ___ 5 5
R 4 ___ ___ ___- 5- 5 5
- Sensory - No deficits to light touch bilaterally.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 NA 2
Plantar response flexor bilaterally.
- Coordination - No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait - Normal initiation. Mildly wide base with right leg
slightly externally rotated with slightly shorter strides taken
with right leg. She is steady, however, and ambulates
independently. Negative Romberg. Walks on toes well, drops right
foot once when walking on heels then resumes, able to tandem
gait, though slowly.
Discharge Exam:
___ Temp: 97.6 (tmax 98.5) PO BP: 107/66-122/83 L Sitting
HR:
58-68 RR: ___ O2 sat: 98% O2 delivery: Ra
General: NAD, sitting up in bed
HEENT: NCAT, no oropharyngeal lesions, moist mucous membranes,
sclerae anicteric
AB: no abdominal distension or tenderness, +BS
Extremities: Warm, no edema
Skin: No rashes or concerning lesions
Neurologic Examination:
- Mental Status - Awake, alert, oriented to person, place and
time. Attention to examiner easily maintained. Reports history
easily. Speech is fluent with full sentences and intact verbal
comprehension. Normal prosody. No evidence of
hemineglect. No left-right confusion. Patient is able to name
low frequency and high frequency objects with some hesitance
with low frequency objects (cuticle and hammock). She names 16
"S" words in 1 minute and 19 "L" words in 1 minute. She is able
to easily do serial 7s backward from 100. Intact adding and
multiplying. Able to accurately calculate appropriate change.
Slight hesitancy with luria sequence task. She remembered ___
words at 5 minutes. She remembered ___ words at 5 minutes and
was able to remember an additional word with a prompt and the
___ word with 2 prompts. No errors in praxis and no apraxia. She
does well with trail a12b test. She is able to copy a cube well.
She had some difficulty with go no go testing and with pattern
recognition on ___ matrix test.
- Cranial Nerves - PERRL 4->3 brisk. VF full to finger counting.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
finger rub bilaterally. No dysarthria. Palate elevation
symmetric. Trapezius strength ___ bilaterally. Tongue midline.
- Motor - Normal bulk and tone. No drift but pronation of the
RUE
noted; no orbiting. No tremor or asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ Toe
flex
L 5 ___ ___ 5 4+ 5 4+ 5 4+ 4
R 4 ___ ___ 5 4+ 5* 4 5 4 4
*with giveway
- Sensory - No deficits to light touch bilaterally.
-DTRs:
Bi Tri ___ Pec Pat Ach
L 2 2 2 - 3 2
R 2 2 2 + *NA 2
1 beat clonus bilaterally
*Not tested due to prior knee injury
Plantar response extensor on the right with oppenheim reflex
test and flexor with withdrawal on the left.
- Coordination - No dysmetria with finger to nose testing
bilaterally. Good speed with finger tapping, faster on the right
compared to left. Misses nose with FTN (R worse than L). HTS
difficult bilaterally.
- Gait - Normal initiation. mildly decreased right arm swing
with
slightly shorter stride length with right leg. Steady and
ambulates independently. Negative Romberg. Walks on toes with
asymmetric gait with more time spent on right step. Walks on
heels with slight right foot drop with each step.
Pertinent Results:
WBC 7.2, Hg 12.4, Hct 37.3, MCV 91, PLT 293, Neut 39%, Lymph
49%, Mono 7.3%, Eos 4.1%,
___ 04:15PM BLOOD Glucose: 90 UreaN: 10 Creat: 0.7 Na: 142
K: 4.1 Cl: 103 HCO3: 25 AnGap: 14
___ 04:20AM BLOOD UricAcd: 3.7
___ 04:20AM BLOOD TSH: 1.5
___ 04:20AM BLOOD CRP: 1.3, ESR 6
___ 01:00PM BLOOD b2micro-2.0
___ 04:20AM BLOOD HIV Ab: NEG
UA Large leuks, 29 WBC, negative urine culture
CSF tube 4: WBC 8, RBC 0, Poly 0, Lymph 91, Mono 8, Atyp 1
CSF tue 1: WBC 7, RBC 33, Poly 0, Lymph 89, Mono 10, Plasma cell
1
Pending CSF studies: culture, cytology, toxoplasma gondii PCR,
mycoplasma pneumonia PCR, HSV PCR, enterovirus culture, MS
profile
___ serum studies: peripheral blood smear and cytometry, MS
___,
Second stool O&P pending
IMAGING:
MRI/MRA Brain without contrast ___
IMPRESSION:
1. Multiple and predominantly symmetric subcortical and
periventricular T2/FLAIR white matter lesions, the mainly in a
perivascular
distribution with the largest lesions measuring up to 2 cm. The
lesions
demonstrate peripheral diffusion-weighted hyperintense signal,
without surrounding mass effect. The lesions involve the corpus
callosum. Overall the findings would suggest demyelinating
process. More concerning process such as mass lesions is not
entirely excluded. Recommend further evaluation with contrast.
2. No evidence of acute infarct or intracranial hemorrhage.
3. Unremarkable MRA of the head.
4. Within confines of noncontrast 2D time-of-flight technique,
unremarkable
RECOMMENDATION(S): Recommend repeat examination with contrast
when clinically feasible.
MRI Brain with contrast ___
IMPRESSION:
Many of the previously demonstrated T2/FLAIR hyperintense
supratentorial white
matter lesions demonstrate incomplete thin rim enhancement, and
the 3 mm right
ventrolateral pontine lesion also demonstrates contrast
enhancement. In the
absence of associated edema or mass effect, demyelinating
disease
is most
likely.
RECOMMENDATION(S): Recommend correlation with clinical history
and CSF studies. Also recommend follow up MRI with and without
contrast.
CT Abdomen/Pelvis w/ w/o contrast:
1. No evidence of malignancy in the abdomen or pelvis.
2. Hemangiomas in hepatic segments VII and III. Other scattered
subcentimeter hypodense lesions in the liver are too small to
characterize. These likely represent benign hepatic cysts or
biliary hamartomas however cannot rule out early developing
metastasis and repeat imaging in 3 months is recommended to
evaluate for growth.
3. Large fibroid in the uterine fundus with irregular
calcification.
CT Chest:
Large thyroid containing large cysts or nodules should be
evaluated by
ultrasound for possible malignancy.
Brief Hospital Course:
Ms. ___ is a ___ year old right handed woman with history
of smoking and distant history of a treated parasitic infection
who presented with 4 weeks of gait instability related to mild
right leg weakness as well as memory and speech-production
issues over the past several years. She was found on outpatient
brain MRI to have multiple scattered ring-enhancing lesions seen
mostly at the gray-white matter junction and was referred for
admission for diagnostic work up.
On exam patient has mild right sided weakness with asymmetric
gait which had improved somewhat prior to admission over the
past week. She has pronation of the right upper extremity. She
has 1 beat clonus bilaterally. Toe is extensor on the right. She
has decreased right arm swing when ambulating and has slightly
shorter stride length with the right leg. Cognitive testing
notable for mild difficulty with memory retrieval, task
switching and response inhibition but intact sustained attention
and working memory.
CSF was notable for WBC 8, RBC 0 ___ tube), Protein 32, glucose
69. CSF did have 1 atypical cell and 1 plasma cell reported.
Cytology was sent and pending. MS profile pending. CSF gram
stain was negative. Serum and CSF multiple sclerosis panels are
pending. Cryptoccocal antigen testing in the CSF was negative.
Toxo pending. Acid fast culture in the CSF was negative.
Mycoplasma pneumonia CSF PCR, enterovirus culture, HSV CSF PCR.
Labs throughout admission were notable for no leukocytosis or
eosinophilia, normal uric acid, LDH, B2 microglobulin, TSH, CRP,
ESR. HIV was negative. TB Quantiferon ___ is pending. Because
of the atypical cell and plasma cell, we sent a peripheral blood
smear and peripheral flow cytometry - pending at the time of
discharge. Rapid plasma regain test for syphilis was
nonreactive. First stool test for ova and parasites was
negative.
Patient had a positive urinalysis during admission but was
asymptomatic and urine culture was negative so she did not
receive antibiotics.
Because of the atypical cell and plasma cell, we sent a
peripheral blood smear and peripheral flow cytometry - pending
at the time of discharge.
CT torso for systemic malignancy workup did show thyroid large
nodules or cysts and further imaging with ultrasound was
recommended. However, patient is followed by endocrinologist Dr.
___ had past serial ultrasounds of these lesions
which showed no growth and a FNA biopsy in ___ which showed no
malignant cells. Will defer further thyroid evaluation to Dr.
___ outpatient work up. CT abdomen also showed
hemangiomas in the liver and other hypodense lesions thought to
represent benign hepatic cysts or hamartomas. Repeat CT of the
liver is recommended in 3 months to monitor for growth of these
hypodense lesions as metastasis cannot be excluded. Uterus was
notable for a calcified fibroid which does not require further
evaluation.
Given the appearance of the brain lesions and her diagnostic
work up thus far, a demyelinating process is highest on the
differential. At this time we cannot rule out a metastatic
process or CNS lymphoma. She has no clear red flags on clinical
history to suggest malignancy and she has had some spontaneous
clinical improvement at home without treatment which make
malignancy less likely. Her CT torso showed no obvious malignant
process. CSF protein was normal. CSF cytology is pending. Serum
cytometry and peripheral smear analysis is pending. Results of
pending studies will need to be reviewed and additional testing
may be needed before a malignant process can be excluded. CSF
showed pleocytosis with lymphocytic predominance and patient is
otherwise well appearing so infectious etiology is considered
less likely. Several infectious studies are still pending at the
time of discharge including quantiferon TB serum, Toxoplasma
gondii CSF PCR, Mycoplasma pneumonia CSF PCR, enterovirus
culture, HSV CSF PCR.
Patient was at her neurologic baseline at time of discharge and
stable for outpatient follow up of pending diagnostic studies.
We recommend outpatient physical therapy.
Transitional issues:
[ ] pending CSF studies: culture, cytology, toxoplasma gondii
PCR, mycoplasma pneumonia PCR, HSV PCR, enterovirus culture, MS
profile
[ ] pending serum studies: peripheral blood smear and cytometry,
MS ___,
[ ] f/u second stool O&P
[ ] outpatient 3rd stool O&P
[ ] repeat CT abdomen in 3 months to monitor liver lesions
[ ] Follow up with Neurology; if her diagnostic work up is
inconclusive she may require a repeat lumbar puncture or brain
biopsy; could also consider repeat brain MRI or spinal cord
imaging if patient develops new symptoms
[ ] Follow up with Endocrinology for monitoring and diagnostic
work up of thyroid lesions
[ ] Monitor cognitive functioning
[ ] outpatient physical therapy
Medications on Admission:
No active medications as of ___
Discharge Medications:
No discharge medications.
Discharge Disposition:
Home
Discharge Diagnosis:
Note that the discharge procedure took over 30 min to complete a
detailed examination and address all questions and concerns, as
well as counseling the patient a to the condition and plan.
Mild memory disturbance
Ring-enhancing lesions on Brain MRI
Abnormal Gait
Thyroid cysts
Discharge Condition:
Patient is alert and oriented. She has fluid speech. She is able
to ambulate independently with mild gait asymmetry.
Discharge Instructions:
Dear Ms. ___,
You were admitted to Neurology due to your difficulty walking,
memory changes, and an abnormal brain MRI.
During your admission you had a lumbar puncture and we did a
number of tests on your blood and spinal fluid to help figure
out the cause of your brain lesions.
The lab tests on your blood did not show any evidence of
systemic (full body) inflammation. Your cerebral spinal fluid
did show some inflammation which could suggest that the brain
lesions are due to a demyelinating process or less likely that
they are due to malignancy. We are much less concerned for an
infection at this time and the fact that your walking has
improved without treatment is very reassuring. So far the tests
for infection have been negative.
You also had a CT scan of your chest, abdomen, and pelvis. On
this scan we saw cysts in your thyroid. We reviewed your
endocrinology records from Dr. ___ included a thyroid
ultrasound in ___ that showed cysts as well and know that she
did a biopsy at that time which showed no malignant cells. We
recommend follow up with her regarding additional thyroid work
up.
Your CT scan of the abdomen showed some hemangiomas
(non-cancerous tumor made of blood vessels) in your liver and a
calcified fibroid in your uterus. These do not need additional
evaluation. Your liver also has some spots that could represent
benign (normal) liver cysts or other benign tumors (known as
hamartoma) but we would recommend repeat CT abdomen in 3 months
to make sure that they have not grown as growth could suggest a
malignant process.
We did some tests on your memory during admission and you did
pretty well and had good attention on testing but do have a
little trouble retrieving memories. Your memory difficulties are
likely related to your brain lesions and we will continue to
monitor this over time.
Please resume all medications as prior to discharge unless
otherwise indicated.
You will need close follow up as the pending results return so
that we can discuss the next best steps for evaluation and
treatment if needed.
Thank you for allowing us to participate in your care.
We wish you the best,
The ___ Neurology Team
Followup Instructions:
___
|
10266518-DS-5 | 10,266,518 | 28,290,870 | DS | 5 | 2115-01-30 00:00:00 | 2115-01-30 11:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
ceftriaxone / vancomycin
Attending: ___.
Chief Complaint:
right clavicle pain
Major Surgical or Invasive Procedure:
___
Right sternoclavicular joint debridement.
___
Left SL Power PICC
History of Present Illness:
___ y/o IVDU p/w R shoulder pain and swelling X 2 months. He
describes spontaneous swelling of his right anterior chest
beginning about 2 months ago. The area is red, warm and
swelling waxes and wanes. The area is tender and the pain
radiates over his anterior chest. He also complains of pain
with right arm movement. He denies fevers, chills,
palpitations, SOB, pleuritic
CP, dysphagia, odynophagia.
He has been seen in ___ 2 times, most recently today and
recived a CT neck and chest which showed concern for R S-C
osteomyelitis and possible anterior mediastinitis. He was
transfered for further management.
In the ED his is stable, in little pain, afebrile. Blood
cultures were taken.
Past Medical History:
- back pain starting ___
- low speed MVA
- discitis/osteomyelitis, as above
- anxiety/depression, for which he has been on sertraline, but
is being switched to paxil
Social History:
___
Family History:
DM, HTN
Physical Exam:
98, 75, 128/82, 20, 98%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] Neck supple/NT/without mass
RESPIRATORY
[x] CTA [x] Abnormal findings: Swollen area in R anterior
chest
about 10X10cm. Faintly erythematous, no drainage, mildly warm
to
touch, no ulceration. TTP over R S-C joint
CARDIOVASCULAR
[x] RRR [x] No m/r/g
GI
[x] Soft [x] NT [x] ND
MS
[x] No clubbing [x] No cyanosis [x] No edema
Pertinent Results:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt
Ct
___ 08:05 6.9 4.77 12.1* 40.8 86 25.4* 29.7* 13.9
279
___ 06:27 8.8 4.51* 11.9* 38.3* 85 26.4* 31.1 14.0
287
___ 08:12 7.9 5.21 13.4* 44.3 85 25.7* 30.3* 14.2
297
___ 08:30 11.7* 5.25 13.7* 44.6 85 26.2* 30.8* 14.2
287
___ 11:30 11.7* 5.12 13.1* 43.1 84 25.5* 30.3* 14.1
263
Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 08:30 141*1 11 0.8 138 5.2*2 ___
MODERATELY HEMOLYZED SPECIMEN
___ 11:30 121*1 11 0.8 135 4.0 99 28 12
Vanco
___ 07:30 19.7 ( reflects 1500 mg IV Q 8 hrs prior to
4th dose)
Vancomycin @ Trough
___ 08:10 10.5
Vancomycin @ Trough
___ 10:10 4.4*
___ 3:55 pm TISSUE RIGHT PECTORALES.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
___ 4:10 pm TISSUE DISTAL CLAVICLE.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
Reported to and read back by ___. ___ 12:47PM
___.
STAPH AUREUS COAG +. RARE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___ ___.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED
TISSUE (Final ___:
Reported to and read back by ___. ___ 12:47PM
___.
STAPH AUREUS COAG +. RARE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
___ TTE :
Normal study. Normal biventricular cavity sizes with preserved
global biventricular systolic function. No valvular pathology or
pathologic flow identified
Brief Hospital Course:
Mr. ___ was evaluated by the Thoracic Surgery service in the
Emergency Room and admitted to the hospital for further
managemnent of his right sternoclavicular osteo. He was hydrated
with IV fluids and also evaluated by the Infectious Disease
service for appropriate antibiotic coverage. Vancomycin was
initiated on ___ after blood cultures from OSH grew GPC in
clusters whih eventually MSSA.
He was taken to the Operating Room on ___ where he
underwent resection of the right sternoclavicular joint. The
wound was eventually VAC'd and began to clean up well. The
tissue cultures were + MSSA. He eventually had a left SL power
PICC line placed on ___ for ___ weeks of antibiotic therapy
with Vancomycin. That was the preferred drug as he developed
neutropenia and a rash after treatment with Ceftriaxone during
his earlier admission. He had a cardiac echo which ruled out any
valvular vegetations.
His Vancomycin dose was adjusted on multiple occasions and his
trough was 19.7 which reflrcted 1500 mg Q 8 hrs. The ID service
recommended decreasing the dose to 1250 mg Q 8 hrs. A trough was
done on ___ AM which was 19.6 with a goal of ___.
The final ID plan is for ___ week course of iv vancomycin 1250mg
q8.
Start date: ___
End date: ___ vs ___
Pt should have cbc+diff, basic, lfts, esr, crp and vanc levels
weekly.
Access: 44cm left SL power picc placed ___.
ID follow up during admission to the ___.
On discharge from the ___, he should have ___ clinic follow
up with ___ on ___ at 3pm to discuss
treatment options for Hepatitis C.
He also had some problems with opiate withdrawal on admission,
eventually becoming tachycardic and having muscle cramps as well
as GI upset. He was placed on ___ protocol and his daily
Methadone dose was increased to 20 mg QD. He was given oral
Dilaudid on a prn basis and his symptoms resolved.
The Plastic surgeons feel that the wound needs to improve prior
to surgery and for that reason he was transferred to rehab on
___ where he can get his antibiotics and continue with VAC
dressing changes. He will follow up in the Plastic Surgery
Clinic on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO HS
2. OLANZapine 5 mg PO DAILY
3. Famotidine 20 mg PO DAILY
4. Methadone 10 mg PO DAILY
5. Ibuprofen 800 mg PO Q8H:PRN pain
6. Paroxetine 30 mg PO DAILY
7. TraZODone 100 mg PO HS
Discharge Medications:
1. Famotidine 20 mg PO DAILY
2. Gabapentin 300 mg PO HS
3. Methadone 20 mg PO DAILY
RX *methadone 10 mg 2 by mouth once a day Disp #*60 Tablet
Refills:*0
4. OLANZapine 5 mg PO DAILY
5. Paroxetine 30 mg PO DAILY
6. TraZODone 100 mg PO HS
7. Acetaminophen 1000 mg PO Q6H
8. Heparin 5000 UNIT SC TID
9. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth every three hours
Disp #*60 Tablet Refills:*0
10. Lidocaine 5% Patch 1 PTCH TD DAILY
11. Nicotine Patch 7 mg TD DAILY
12. Lorazepam 1 mg PO Q6H:PRN anxiety
13. Methocarbamol 750 mg PO QID muscle cramps
RX *methocarbamol 750 mg 1 tablet(s) by mouth four times a day
Disp #*60 Tablet Refills:*0
14. Vancomycin 1250 mg IV Q 8H
15. Senna 8.6 mg PO BID
16. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right sternoclavicular osteomylitis
Opiate withdrawal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
* You were admitted to the hospital with an infection in your
right sternoclavicular joint which required debridement and
subsequent dressing changes. You will eventually need the
Plastic surgeons to close the area but in the mean time you will
need IV antibiotics and VAC dressing changes.
* A PICC line was placed for antibiotics and the Infectious
Disease service will determine the course but it's likely ___
weeks. You will need to be hospitalized during that time.
* Continue to eat well and stay well hydrated to help with
healing.
* Get out of bed and walk frequently
* The narcotic medications can cause constipation so make sure
that you take a stool softener or laxative to stay regular.
* You will need to be followed closely by the Plastic Surgery
service and Dr. ___.
Followup Instructions:
___
|
10266554-DS-7 | 10,266,554 | 23,581,194 | DS | 7 | 2173-07-09 00:00:00 | 2173-07-12 14:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tessalon Perles / azithromycin
Attending: ___.
Chief Complaint:
Respiratory Distress
Major Surgical or Invasive Procedure:
Intubated
History of Present Illness:
___ with a history of HTN, recently seen for 7 days of URI
symptoms who presents to the ED with facial swelling and
redness, found to be in respiratory distress and intubated and
subsequently transferred to the FICU.
Ms. ___ had presented to the ED yesterday, ___, with
cough, dyspnea, and subjective fevers for 7 days. She noted a
productive cough with tan colored sputum, nasal congestion, and
night sweats, but denied infectious contacts,
nausea/vomiting/diarrhea, or myalgias/arthralgias. CXR in the ED
was read as normal. She was then discharged home with presumed
URI and given prednisone 50mg, azithromycin 250mg, and tessalon
pearls, all three of which she took. By report, she took the
azithromycin before discharge and had no reaction to it.
Today, she presented to the ED complaining of facial redness and
swelling including the cheeks, forehead and eyes. Vital signs in
the ED at initial presentation were 98.0 80 123/85 18 96%RA. She
was then noted by nursing staff in the waiting area to be in
respiratory distress with accessory muscle use, and her voice
was hoarse and she appeared mildly stridorous. She was
subsequently intubated in the ED with Atomidate/succ ___
without complication. Per report, there was no vocal cord spasm,
difficulty passing the tube, or epiglottitis, but there was
edema superior to the arytenoids. She was sedated with propofol
and fentanyl. She was also given a dose of IV solumedrol before
being transferred to the MICU for further management.
Past Medical History:
Depression
Hypertension
Osteopenia
Plantar fasciitis
Social History:
___
Family History:
Daughter reports allergy causing whole body hives to bacitracin
Physical Exam:
Vitals- T: 98.0 BP: 123/74 P: 65 R: 21 O2: 96%
General: Intubated, sedated.
HEENT: Sclera anicteric, conjunctiva not injected. PERRL.
Neck: supple, unable to evaluate JVP.
Lungs: Mechanical breath sounds, some wheezes heard bilaterally.
No rales or ronchi.
CV: Regular rhythm, distant heart sounds, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: Foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No rash, erythema, or wheals present.
Pertinent Results:
___ 02:01AM BLOOD WBC-9.2 RBC-4.08* Hgb-12.8 Hct-40.3
MCV-99* MCH-31.4 MCHC-31.8 RDW-12.9 Plt ___
___ 08:27PM BLOOD WBC-13.4* RBC-4.30 Hgb-13.7 Hct-43.0
MCV-100* MCH-31.9 MCHC-31.8 RDW-13.0 Plt ___
___ 08:27PM BLOOD Glucose-113* UreaN-19 Creat-0.8 Na-147*
K-4.9 Cl-112* HCO3-26 AnGap-14
___ 08:27PM BLOOD cTropnT-<0.01
___ 08:27PM BLOOD Albumin-3.8 Calcium-8.7 Phos-4.1 Mg-2.1
___ 12:34AM BLOOD Type-ART pO2-83* pCO2-46* pH-7.40
calTCO2-30 Base XS-2
___ 08:07PM BLOOD Type-ART pO2-525* pCO2-52* pH-7.31*
calTCO2-27 Base XS-0
___ 12:34AM BLOOD Lactate-2.3*
Brief Hospital Course:
___ with a recent history of 7 days of URI symptoms presented to
the ED with facial redness/swelling, found to be in respiratory
distress and intubated, and admitted to the MICU. Her symptoms
were likely due to an allergic reaction.
ACTIVE DIAGNOSES
1) Allergic Reaction
The exact etiology for Ms. ___ symptoms are unclear. The
most likely explanation was an allergic reaction to a medicine
that she received just prior to admission, with Tessalon Perles
at the top of the list. Azithromycin is less likely given that
she was given it in the ED on first visit with no problems.
Others diagnoses on the differential include hereditary
angioedema, but highly unlikely given a lack of family history
and no previous signs/symptoms. Additionally, she could have had
an upper airway infection causing swelling, but her quick
improvement suggests against that. After being intubated in the
ED, the patient received IV Solumedrol before coming to the
floor, where famotidine was added to her treatment. She did well
the following day and was extubated.
TRANSITIONAL ISSUES
1) Will require clarification of her allergies.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Azithromycin 250 mg PO Q24H
2. PredniSONE 50 mg PO DAILY
3. Benzonatate 100 mg PO TID
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Allergic Reaction
Discharge Condition:
Patient has normal mental status at discharge and can ambulate
freely.
Discharge Instructions:
Dear Ms. ___,
You were recently admitted to ___
___ because of trouble breathing, and you had to be
intubated, which meant putting a breathing tube down your
throat. We think that you most likely had an allergic reaction
to the Tessalon Perles (also known as benzonatate) that you were
prescribed on your first ED visit. Please do not take this
medication anymore until you have discussed this with your
primary care physician.
It was a pleasure to take care of you. Please do not hesitate to
contact the hospital if you have any questions in the future.
Best wishes,
Your Medical Intensive Care Unit Team
Followup Instructions:
___
|
10266554-DS-9 | 10,266,554 | 23,603,263 | DS | 9 | 2177-08-05 00:00:00 | 2177-08-05 12:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
___ / azithromycin / simvastatin
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ POD ___ s/p VATS->open RULobectomy (___) presents with
increasing shortness of breath since discharge on ___. During
her hospitalization, she required IV Lasix for treatment of a
pleural effusion, and was discharged home breathing comfortably
on room air. Since discharge she has noticed increased shortness
of breath, particularly when lying flat, resolved when sitting
upright. She also notes poor pain control at her incision site,
and she is taking oxycodone 5mg Q6h and Tylenol PRN. She denies
fever/chills, nausea/vomiting. She does endorse a cough, which
is
minimally productive, and has difficulty taking a deep
inspiration.
Past Medical History:
Depression
Hypertension
Osteopenia
Plantar fasciitis
Social History:
___
Family History:
Daughter reports allergy causing whole body hives to bacitracin
Physical Exam:
Vitals: 98.4, 88, 124/68, 18, 96% 2L
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Decreased air movement in R base; thoracotomy and VATS
incisions with staples in place; moderate erythema surrounding,
likely staple reaction
ABD: Soft, nondistended, nontender, no rebound or guarding,
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 12:41AM WBC-8.4 RBC-3.74* HGB-11.6 HCT-35.8 MCV-96
MCH-31.0 MCHC-32.4 RDW-14.3 RDWSD-49.6*
___ 12:41AM NEUTS-67.4 LYMPHS-14.4* MONOS-12.8 EOS-3.8
BASOS-0.4 IM ___ AbsNeut-5.69 AbsLymp-1.21 AbsMono-1.08*
AbsEos-0.32 AbsBaso-0.03
___ 12:41AM ___ PTT-27.1 ___
___ 12:41AM GLUCOSE-111* UREA N-14 CREAT-0.6 SODIUM-136
POTASSIUM-6.7* CHLORIDE-101 TOTAL CO2-21* ANION GAP-14
___ CXR :
Interval increase in the small to moderate right
hydropneumothorax
___ CXR :
1. No pneumothorax or hydropneumothorax.
2. Postsurgical changes including decreased right lung volume
with elevation of right hemidiaphragm, likely atelectasis.
___ Cardiac echo :
Normal global and regional biventricular size and global
function. Mild pulmonary hypertension.
Brief Hospital Course:
Ms. ___ was evaluated by the Thoracic Surgery service in
the Emergency Room and admitted to the hospital for further
management of her shortness of breath/dyspnea. She had 2 +
peripheral edema and was started on Lasix as her weight was 4
lbs above her dry weight. Her room air saturations were 94% but
subjectively she felt dyspneic and was placed on 2 L O2,
maintaining saturations of > 98%. Her right thoracotomy site had
some local erythema, without tenderness or drainage and all
staples were intact.
The medical service evaluated her as well and recommended IV
Lasix and standing nebulizers for 24 hours. She also had a
cardiac echo which was essentially normal except for some mild
pulmonary hypertension. She improved over 24 hours and was able
to participate with Physical Therapy and eventually be
comfortable on room air with ambulatory saturations of 96%. Her
thoracotomy site was healing well, the erythema had not extended
and the staples were removed on ___. Her weight at
discharge is 221 lbs and her dry weight is 219 lbs. She will
continue on Lasix for 2 more days.
As she continued to improve and was stable off of oxygen she was
discharged to home on ___ and will follow up with Dr. ___
in 2 weeks.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Acetaminophen 1000 mg PO Q8H
3. Docusate Sodium 100 mg PO BID
4. GuaiFENesin ER 1200 mg PO Q12H
5. Milk of Magnesia 30 mL PO Q12H:PRN Constipation - First Line
6. Alendronate Sodium 70 mg PO QTUES
7. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
8. Ibuprofen 200 mg PO Q8H:PRN Pain - Mild
9. PredniSONE 3 mg PO DAILY
10. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
Discharge Medications:
1. Furosemide 40 mg PO DAILY Duration: 2 Doses
RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*2
Tablet Refills:*0
2. Potassium Chloride 20 mEq PO DAILY Duration: 2 Doses
RX *potassium chloride 20 mEq 1 tablet(s) by mouth once a day
Disp #*2 Tablet Refills:*0
3. Ibuprofen 600 mg PO Q8H
RX *ibuprofen 600 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
4. Acetaminophen 1000 mg PO Q8H
5. Alendronate Sodium 70 mg PO QTUES
6. amLODIPine 10 mg PO DAILY
7. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
8. Docusate Sodium 100 mg PO BID
9. Milk of Magnesia 30 mL PO Q12H:PRN Constipation - First Line
10. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
11. PredniSONE 3 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right pleural effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
* You were readmitted to the hospital with shortness of breath
and incisional pain which has improved with Lasix and better
pain control. You are now ready for discharge home.
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* You may need pain medication once you are home but you can
wean it over the next week as the discomfort resolves. Make
sure that you have regular bowel movements while on narcotic
pain medications as they are constipating which can cause more
problems. Use a stool softener or gentle laxative to stay
regular.
* No driving while taking narcotic pain medication.
* 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:
___
|
10266720-DS-20 | 10,266,720 | 28,874,848 | DS | 20 | 2134-07-03 00:00:00 | 2134-07-03 22:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L shoulder pain/discharge
Major Surgical or Invasive Procedure:
Bedside arthrocentesis L shoulder
___ guided arthrocentesis L shoulder
History of Present Illness:
___ with h/o of DM, and 2 recent left shoulder surgery (rotator
cuff repair), presenting with L shoulder pain, possible shoulder
joint infection after surgical operation in ___. He had ___
operation in ___ ___, cut muscle, tendon, and then had ___
revision operation in ___ ___, and has had limited mobility
since then.
Over past week, he increasing pain in the posterior aspect of
surgical site with draining. He applied hydrogen peroxide,
draining pus. Now with very limited mobility both active and
passive, increased pain, has been using motrin for pain relief.
In the ED Ortho was consulted w/ concern for septic joint, but
were unable to aspirate any fluid.
Denies Fevers/chills/weakness/numbness/nausea/vomiting/abd pain
In the ED initial vitals were: 97.1 87 128/76 18 98%
- Labs were significant for CRP 26.1, WBC 7.5, Hgb 12.9, plt
212, normal BMP
- Patient was given fentanyl 25mg IV,
Vitals prior to transfer were: 97.9 88 105/71 18 98% RA
On the floor, vitals were 98.2 130/70 102 18 97% RA
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, dysuria,
Past Medical History:
GASTROESOPHAGEAL REFLUX
CHRONIC OBSTRUCTIVE PULMONARY DISEASE GOLD stage 1
DM2
"palpitations"
Social History:
___
Family History:
He is married. He has two adult children. He has two siblings.
His father died of esophageal cancer. His mother died of old
age.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - 98.2 130/70 102 18 97% RA
___: NAD, well appearing male sitting in bed
HEENT: sclera aniceric
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: left shoulder with mild effusion on posterior
aspect. Unable to abduct, adduct with strength ___ to pain.
Unable to flex elbow ___ shoulder pain. Posterior aspect with
dry indurated,erythematous lesion ~1.5cm in diameter.
NEURO: Alert and oriented, answers questions appropriately.
normal sensation in b/l UE, able to move fingers, normal grip
strength
SKIN: warm and well perfused
PERTINENT DISCHARGE PHYSICAL EXAM:
Afebrile, VSS
EXTREMITIES: left shoulder with small amount of purulent
drainage from posterior lesion
ABD: +dry skin, evidence of excoriation
Pertinent Results:
LABS:
=====
___ 04:20PM GLUCOSE-149* UREA N-15 CREAT-0.8 SODIUM-135
POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-27 ANION GAP-14
___ 04:20PM CRP-26.1*
___ 04:20PM WBC-7.5 RBC-4.24* HGB-12.9* HCT-38.9* MCV-92
MCH-30.5 MCHC-33.2 RDW-12.8
___ 04:20PM NEUTS-61.3 ___ MONOS-7.5 EOS-2.7
BASOS-0.6
___ 04:20PM PLT COUNT-212
___ 04:20PM ___ PTT-27.8 ___
___ 07:50AM BLOOD WBC-5.9 RBC-4.12* Hgb-12.6* Hct-38.8*
MCV-94 MCH-30.5 MCHC-32.4 RDW-12.8 Plt ___
___ 07:50AM BLOOD Glucose-155* UreaN-11 Creat-0.9 Na-137
K-4.1 Cl-99 HCO3-30 AnGap-12
___ 01:20AM BLOOD CK-MB-<1 cTropnT-<0.01
MICROBIOLOGY:
==============
___ 5:15 pm JOINT FLUID Source: shoulder.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
Reported to and read back by ___ ___
AT 1218.
STAPH AUREUS COAG +. SPARSE GROWTH. OF TWO COLONIAL
MORPHOLOGIES.
SENSITIVITIES REQUESTED BY ___ ___.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
___ SWAB
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH. OF TWO COLONIAL
MORPHOLOGIES.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
___ BLOOD CULTURE -PENDING
___ BLOOD CULTURE -PENDING
IMAGING:
=========
___ Cardiovascular ECG ___ ___.
Artifact is present. Sinus rhythm. There is an early transition
that is non-specific. Compared to the previous tracing of
___ the rate is slower and atrial ectopy is no longer
present. TRACING #2
___ Cardiovascular ECG ___ ___.
Sinus tachycardia. Atrial ectopy. There is an early transition
that is non-specific. No previous tracing available for
comparison. TRACING #1
___ Imaging INJ/ASP MAJOR JT W/FLUO
FINDINGS: Fluoroscopic images demonstrated subluxation of the
humeral head with respect to the glenoid, as seen on the prior
radiographs ___. IMPRESSION: Technically successful
fluoroscopic guided left shoulder joint aspiration yielding 1 cc
of bloody fluid. This specimen was sent to the laboratory for
evaluation of Gram stain, culture, crystals, and cell
count/differential.
___ Imaging GLENO-HUMERAL SHOULDER
Three views of the left shoulder were provided. There is mild
inferior subluxation of the left humeral head relative to the
glenoid fossa. No acute fracture is identified. No soft tissue
gas or radiopaque foreign body. No soft tissue calcifications.
Mild bony hypertrophy at the left AC joint is unchanged. The
imaged left upper ribs and lung appear normal. IMPRESSION:
Inferior subluxation of the left humeral head at the
glenohumeral joint.
___ Imaging CHEST (PA & LAT)
Unfolded thoracic aorta likely accounts for interval development
of
mediastinal prominence. Low lung volumes without definite sign
of acute
intrathoracic process.
Brief Hospital Course:
___ ___ speaking male with h/o of DM2 and 2 recent left
shoulder surgeries (rotator cuff repair ___, revision
___, presenting with L shoulder pain and drainage consistent
with septic arthritis.
# Septic joint: S/p 2 rotator cuff surgeries in ___, patietn
presented with 1 week h/o L shoulder pain and purulent drainage
from L shoulder surgical site. Ortho was unable to tap in ED, pt
underwent ___ guided tap ___, with joint fluid culture growing
MSSA. Pt was treated with 1g IV cephazolin Q8H (day ___,
increased to 2g Q8H on ___ per ID recs. Pt remained afebrile
and hemodynamically stable throughout admission. Pain was
controlled with PRN PO dilaudid.
On hospital day 6, team was contacted by Dr. ___.
Chief of Orthopedic Surgery at ___ who is a
colleague of the surgeon
who operated on Mr ___ in ___ who had requested that Dr.
___ in the patient's care. After discussion with the
___ orthopedic team, the patient was transferred to ___
___ for surgical washout of L shoulder. He will
likely need extensive ___ of the left shoulder as outpatient
given very limited ROM.
#COPD:
Stable, continued albuterol prn
#DMII;
Held home metformin and prandin while inpatient. Treated with
insulin sliding scale. BGs 100s-200s.
# Tachycardia:
Intermittent episodes of tachycardia this admission. EKG on
admission most consistent with sinus tach vs MAT. Resolved with
5mg IV metoprolol x1. Pt reports a h/o "arrhythmia" treated with
Toprol at home, he is unsure of the dose.
# Code: Confirmed full
# Communication: ___ (son) ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler 2 PUFF IH Q6H sob, wheeze
2. butalbital-acetaminophen-caff 50-325-40 mg oral daily
headache
3. Celebrex ___ mg oral BID prn pain
4. MetFORMIN (Glucophage) 500 mg PO DAILY
5. Pantoprazole 40 mg PO Q12H
6. Cyanocobalamin Dose is Unknown PO DAILY
7. Repaglinide 1 mg PO DAILY
8. Metoprolol Succinate XL Dose is Unknown PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H sob, wheeze
2. Pantoprazole 40 mg PO Q12H
3. Acetaminophen 1000 mg PO Q8H:PRN pain
4. CefazoLIN 2 g IV Q8H
5. Docusate Sodium 100 mg PO BID
6. Heparin 5000 UNIT SC TID
7. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
8. Sarna Lotion 1 Appl TP QID:PRN itch
9. Cyanocobalamin 0 mcg PO DAILY
10. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary: Septic arthritis of the left shoulder, tachycardia
Secondary: Type 2 diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure participating in your care at ___. You were
admitted to the hospital for left shoulder pain and drainage and
found to have a joint infection in that shoulder. You were
treated with antibiotics and are being transferred to ___
___ for a surgery to clean out the infection.
Followup Instructions:
___
|
10267191-DS-19 | 10,267,191 | 26,548,951 | DS | 19 | 2151-05-05 00:00:00 | 2151-05-04 14:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Dilaudid / erythromycin base
Attending: ___
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
___ - T7-T9 laminectomy, T6-T10 fusion
History of Present Illness:
___ with w/ recently diagnosed hepatocelluar carcinoma, who is
admitted from the ___ with progressive back pain found to have
concern for T8 metastatic disease.
Pt reports progresive back pain for the last two months, which
has become unbearable for the last few days. The pain is located
in his mid-back and radiates up to his neck up to ___ with
pain. He denies recent trauma and notes associated right rib
cage pain. He has been taking oxycodone at home without relief.
Because of his symptoms, he presented to ___, where CT
of the abdomen revealed a lesion at T7, T8 and T9 with canal
impingement. OSH labs were notable for ___ at 2am): WBC 6.1,
12.9/39.7, plts 250, Na 143, K 3.9, Cl 102, CO2 28, ___, gluc
117, LFTs WNL (all labs in chart). Pt was sent to ___ for MRI
and further management.
In the ___, initial VS were pain 10, T 98.4, HR 58, BP 109/66, RR
16, O2 97%RA. MRI of C/T spine showed multilevel cervical spine
spondylosis with disc protrusions and cord compression at C3-C4,
C4-C5, and C5-C6. Thoracic spine was notable for possible T8
metastatic disease with breakthrough of the posterior cortex of
T8 with resultant cord compression and possible high cord
signal. Neurosurgery was consulted who deferred surgical
intervention. Patient recieved IV morphine x3, 6mg IV
dexamethasone, 5mg diazepam, and 1000mg tylenol. Patient was
admitted to ___ for further management.
On arrival to the floor, patient reports persistent ___ back
pain. He reports weakness in his right leg which he attributes
to pain and right hip replacement in ___. He has
chronic consitpation and baseline difficulty urinating due to
BPH. He denies recent fevers or chills. No new headache or
visual complaints. He has some mild SOB due to right rib cage
pain. No N/V/D. No lower extremity edema or new rashes.
Remainder of ROS is unremarkable.
Past Medical History:
PAST ONCOLOGIC HISTORY
-- ___: Presented to the hospital with worsening hip pain
and had a right sided hip replacement. He did not have any
abdominal pain at that time, but his hip pain continued to get
worse despite the surgery. and thus he presented to the ER on
-- ___: Presented to the ___ after falling down
at home. He presented to ___ and at
that time workup to evaluate his hip pain involved imaging
studies that demonstrated an incidental finding of a liver mass
that was concerning for cancer. The patient did not have any
evidence of cirrhosis on imaging and his alpha-fetoprotein level
per MD note was negative per hospital records. The patient
reports that a CT scan done in ___ for a different reason
had
demonstrated a 2.8 x 2.1 lesion in the right lobe of the liver
that is presumed to be the same liver lesion that is now evident
on imaging- but nothing was done about that lesion. Per the
patient, he was told recently that may have been a lesion on the
liver noted on some imaging test ___ years ago, but he was
never informed of that at that time. He was tested for hepatitis
B and was negative. The patient
underwent a liver biopsy on
-- ___: Liver biopsy demonstrated hepatocellular
carcinoma, well differentiated.
--___: Initial clinic visit at ___
PAST MEDICAL HISTORY:
1. Severe anxiety.
2. Depression.
3. Osteoarthritis.
4. Hyperlipidemia.
5. Gout.
6. Abdominal surgery.
7. Hernia repair, inguinal.
8. Laparoscopic repair of hernia.
9. Degenerative disc disease.
10. Diabetes.
11. The patient reports a small MI in his ___ and has also had
prior history of mild heart attacks.
Social History:
___
Family History:
The patient has an older brother who passed away secondary to
liver cancer, he was a heavy drinker. He also had older brother
who died recently in ___ from unknown etiology. His father
was a heavy drinker and alcoholic. Mother passed away secondary
to stroke. The patient also has two daughters, one daughter who
lives in ___ and one daughter who lives in ___
and is suffering from heroin addiction. His family is not
involved in his care.
Physical Exam:
ADMISSION:
VS: BP 100/60 T 98.4 HR 69, RR 18, O2 99%RA
GENERAL: Chronically ill appearing man lying on his left side.
HEENT: NC/AT, EOMI, PERRL, OP clear, JVD not elevated
CARDIAC: RRR, nl S1 and S2, ___ SEM
LUNG: Nonlabored on RA; CTAB no w/r/rh
ABD: +BS, soft, NT/ND, no r/g, no stigmata of chronic liver
disease
EXT: No lower extermity pitting edema
PULSES: 2+DP pulses bilaterally
NEURO: CN II-XII intact. Equal and symetric 4+/5 strength in his
upper extremities, strength limited moderately by pain. ___
strength in right toe extension, flexion, and knee flexion. Also
moderately limited by pain. Full strength LLE. Mute ankle jerk
reflexes bilaterally. FTN intact b/l.
SKIN: Warm and dry
LABS: See attached
DISCHARGE:
AAO x 3
Delt Bi Tri Grip IP Q Ham AT ___ ___
R 4- 5 4 5 ___ 2 4 4
L 4- 5 4+ 5 4+ 5 4 5 5 5
*Bends knee on L when asked to lift leg consistently.
Incision closed with staples. 1 drain stitch, c/d/i
Pertinent Results:
ADMISSION:
___ 10:00PM BLOOD WBC-5.3 RBC-4.01* Hgb-12.5* Hct-36.3*
MCV-91 MCH-31.0 MCHC-34.3 RDW-12.9 Plt ___
___ 10:00PM BLOOD ___ PTT-33.6 ___
___ 10:00PM BLOOD Plt ___
___ 10:00PM BLOOD Glucose-187* UreaN-24* Creat-0.8 Na-140
K-3.9 Cl-104 HCO3-27 AnGap-13
DISCHARGE:
MICRO:
___ 10:25PM URINE Color-Yellow Appear-Hazy Sp ___
___ 10:25PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 10:25PM URINE RBC-1 WBC-1 Bacteri-MOD Yeast-NONE Epi-<1
___ 10:25PM URINE Mucous-OCC
___ 07:02AM URINE Hours-RANDOM TotProt-6
IMAGING:
___ CT HEAD w/ CONTRAST IMPRESSION:
1. No acute intracranial abnormality.
2. Please note that MRI of the brain is more sensitive for the
evaluation of intracranial metastatic disease or acute infarct.
___ MR ___ spine IMPRESSION:
1. Large osseous metastasis of the T8 vertebral body with new
pathological fracture with epidural extension causing increased
spinal cord compression at T8. There is abnormal T2 cord signal
extending from T7 to T8-9, new from
recent prior MRI on ___ (series 5 image 8). No post
biopsy
hematoma.
2. Scattered osseous metastases without epidural tumor in the
thoracic and lumbar spine. No evidence of metastatic disease in
the cervical spine.
3. Degenerative disc and joint disease in the lumbar spine
resulting in severe spinal canal stenosis at L4-5.
4. Spondylosis in the cervical spine deforming the spinal cord
at C3-4 through C5-6, but no cord signal abnormality.
___ intraoperative fluoroscopy
Intraoperative images from posterior fusion extending from
T6-T10. Please see
the operative report for further details.
___ CXR
As compared to ___ chest radiograph, the patient has
undergone spinal
surgery and has been intubated with an endotracheal tube in
standard position.
Right subclavian vascular catheter terminates in the lower
superior vena cava,
with no visible pneumothorax. Lungs are clear except for linear
atelectasis at
the left lung base.
Brief Hospital Course:
___ with w/ recently diagnosed hepatocelluar carcinoma, who is
admitted from the ___ with progressive back pain found to have
concern for T8 metastatic disease with concern for cord
compression. Patient admitted with concern for irritractable
back pain. Started with IV morphine, transitioned to PCA, then
to oral regimen with long and short acting morphine. Patient
found to be delirious during later OMED course. Found to have
UTI with acute urinary retention, started on ceftriaxone and
foley placed with improvement of symptoms. Patient found to have
___ on afternoon of ___. Evaluated by neurosurgery
who determined need for acute surgical intervention. Patient and
HCP were consenting to risks/benifits. Patient transferred to
___ service where...
# AMS
Patient started to become increasing altered following his
course of radiation therapy in the setting of uptitrating pain
medicaiton. Patient found to be somnelent and unarrousable to
sternal rub on AM of ___, recovered quickly with narcan 1mg.
Clear drug overdose with a number of potential causes: pt with
acute urinary retention possibly leading to retention of
excreted morphine metabolites. Patient has also recieved a
signficant amount of opiate narcotics during this admission. Pt
also started haldol 1 mg PO QHS last night for the first time.
Patient also recently found to have +UTI on UCx, Started on CTX
___.
-Reduced MS ___ to 30 mg BID, MS ___ with very cautious use
-Continue Ceftriaxone for 7 day course (d1: ___
-Continue foley catheter, monitor I&Os
-Monitor sx
-Continue Haldol 1 mg PO QHS for now as opiates primary suspect
for AMS
# Back pain: ___ to progressive metastatic carcinoma. Initial
MRI showed some concern for cord compression, neurosurgery
deferred surgical management on admission and recommended
continued treatment medically with IV steroids and monitored
neuro exam. Spinal biopsy on ___ revealed metastatic HCC.
Rad onc consulted, ___ radiation therapy sessions completed on
___. Continued to have significant pain especially after
radiation, but no saddle anesthesia, bowel/urine incontinence.
Pain management consulted and following, started and
transitioned off PCA. Now on oral ___ and long acting morphine.
Patient found to have ___ weakness on afternoon of ___. F/u
MR ___ spine read revealed pathological fracture of T8 +
worsened chord compression. Patient transferred to ___ service
where...
- Neuro check q4 hours
- Hold further tapering of dexamethasone for now, re-instate 4mg
BID
- appreciate pain recommendations: MS ___, MS contin, standing
tylenol, gabapentin
- d/c lidocaine patch as patient c/o back pain while placing and
little subjective pain relief reported
- per neurosurg, activity as tolerated
- standing bowel regimen while on narcotics
- IV morphine for breakthrough
- IV toradol prior to radiation
# metastatic HCC: Had been presumed to be limited stage and a
candidate for surgical resection. HW, now with metastatic bony
lesions, confirmed with biopsy. No evidence of liver
dysfunction. Patient to follow-up with Dr. ___ as
outpatient following discharge.
# Severe anxiety/depression.
Increased home celexa from 20 mg to 40 mg PO daily. Intially
given valium PRN anxiety but d/c'd in setting of delirum. Social
work, Pall care, and psychiatry all consulted. Psych diagnosed
adjustment disorder in setting of terminal illness. Wish to
re-eval prior to discharge.
#Constipation: Pt reports lifelong issues with constipation,
reports hesitance given backpain. Will help soften stools for
easier passage.
-Continued standing colace, polyethelene glycol, senna with
laculose PRN
# Hyperlipidemia.
Held simvastatin in setting of acute illness
# Gout.
Con't home allopurinol
# Diabetes: Not on meds at home. ___ worsen in setting of
steroids. Placed on HISS.
# CAD: The patient reports a small MI in his ___ and has also
had
prior history of mild heart attacks. Not on a CAD regimen at
home, aside from simvastatin
- Holding simvastatin
On ___, the Neurosurgery service was re-consulted due to
concerns of an exam change in the patient's lower extremities.
A MRI was completed and showed a new pathologic fracture of T8,
worsening compression, and increased cord edema from T7 to T9.
During the evening, the primary team call and stated the patient
was Team no longer moving his lower extremities. He had
decreased rectal tone as well. Mr. ___ was emergently taken
to the operating suite where he underwent a laminectomy and
fusion from T7-T9 and fusion from T6 to T10. Mr. ___
tolerated the procedure well and there were no intraoperative
complications. Please see the operative report for further
details. He was transferred to the ICU for close neurologic
monitoring and further management.
On ___, Mr. ___ was extubated successfully. A central line
was placed so pressors could be initiated to keep the patient's
mean arterial pressure > 85. A figure-of-eight brace was
ordered for the patient to prevent his thoracic surgical wound
from dehiscence.
On ___, Mr. ___ continued to recover well. He was seen by
Physical Therapy and was mobilizing from bed to chair with
assistance. He was continued on pressors to keep his MAP up.
On ___, the patient's neurologic examination remained stable.
He remains on pressors for a MAP >85. The drain was removed and
he was re-started on SQH.
On ___, the Dexamethasone was stopped. A family meeting was
held with Social Work, Neurosurgery, Palliative Care and
Oncology to determine the plan moving forward.
On ___, the patient's neurologic examination remained stable.
The pressors were stopped today and his MAP requirement was
liberalized. It was determined he would be transferred to the
___ service on ___.
ON ___ Patient was neurologically stable. Awaiting transfer to
OMED. Patient worked ___. He was screened for rehab placement.
___, the patient was neurologically stable. His pain
medications were adjusted as he was still experiencing bilateral
rib pain. He was found to have a pressure ulcer developing
which was evaluated. He was screened for rehab. He was
discharged to rehab with follow up instructions.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Magnesium Oxide Dose is Unknown PO Frequency is Unknown
2. Simvastatin 20 mg PO QPM
3. Allopurinol ___ mg PO DAILY
4. Cyclobenzaprine 5 mg PO TID:PRN pain
5. Potassium Chloride 10 mEq PO DAILY
6. Furosemide 20 mg PO DAILY
7. Citalopram 20 mg PO DAILY
8. Diazepam 5 mg PO Q12H:PRN anxiety
9. Ibuprofen 800 mg PO BID:PRN pain
10. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Citalopram 20 mg PO DAILY
3. Diazepam 5 mg PO Q12H:PRN anxiety
RX *diazepam 5 mg 1 tablet by mouth Every 12 hours as needed
Disp #*30 Tablet Refills:*0
4. Acetaminophen 325-650 mg PO Q6H:PRN pain
5. Bisacodyl 10 mg PO DAILY constipation
6. Gabapentin 900 mg PO TID
7. Ketorolac 15 mg IV Q8H Duration: 5 Doses
8. Lidocaine 5% Patch 1 PTCH TD QPM
9. Morphine Sulfate ___ 15 mg PO Q4H:PRN pain
RX *morphine 15 mg 1 tablet(s) by mouth Every 4 hours as needed
Disp #*60 Tablet Refills:*0
10. OxyCODONE SR (OxyconTIN) 40 mg PO Q8H
RX *oxyCODONE 1 tablet by mouth Every 8 hours Disp #*30 Tablet
Refills:*0
11. Polyethylene Glycol 17 g PO BID constipation
12. Sarna Lotion 1 Appl TP QID:PRN itching
13. Tizanidine 4 mg PO Q12H:PRN Spasm
14. Furosemide 20 mg PO DAILY
15. Simvastatin 20 mg PO QPM
16. Potassium Chloride 10 mEq PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Acute spinal cord compression
2. Compression from T8 Hepatocellular metastasis.
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:
Surgery
Your dressing may come off on the second day after surgery.
Your incision is closed with staples or sutures. You will need
staple removal.
Do not apply any lotions or creams to the site.
Please keep your incision dry until removal of your staples.
Please avoid swimming for two weeks after staple removal.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
*** You must wear your figure of eight brace at all times when
out of bed. You may apply your brace sitting at the edge of the
bed. You do not need to sleep with it on.
*** You must wear your brace while showering.
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon.
Do NOT smoke. Smoking can affect your healing and fusion.
Medications
***Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc
until cleared by your
neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation.
Followup Instructions:
___
|
10267238-DS-6 | 10,267,238 | 28,119,182 | DS | 6 | 2139-05-10 00:00:00 | 2139-05-10 18:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Laparoscopic appendectomy
History of Present Illness:
___ presents with 24h h/o right lower quadrant abdominal pain.
Reports that the pain started last night in his back and
gradually moved anteriorly to the right lower quadrant. He
reports no nausea or vomiting but he has had no appetite and had
subjective fevers and chills. Does not report changes in bowel
habits. No prior similar episodes in the past. He has never had
a colonoscopy in the past.
Past Medical History:
Past Medical History:
HIV+, in treatment (per pt's report normal CD4 count and
undetectable viral load)
Past Surgical History:
tonsillectomy, I+D of inguinal abscess
Social History:
___
Family History:
Has DMII, HTN, Hypercholeterolemia in the family.
Physical Exam:
Admission Physical Exam:
Vitals:99.4 83 ___ 100% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, mildly tender to palpation in the RLQ,
no rebound or guarding.
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam;
VS:
HEENT:
GEN:
CV:
PULM:
ABD:
EXT:
Pertinent Results:
IMAGING:
___: CT abdomen/pelvis:
1. Findings compatible with uncomplicated acute, early
appendicitis.
2. No hydronephrosis or kidney stone.
LABS:
___ 05:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 04:55PM GLUCOSE-100 UREA N-9 CREAT-0.9 SODIUM-136
POTASSIUM-3.9 CHLORIDE-96 TOTAL CO2-26 ANION GAP-18
___ 04:55PM WBC-11.5*# RBC-4.50* HGB-13.6* HCT-40.3
MCV-90 MCH-30.2 MCHC-33.7 RDW-12.2 RDWSD-39.8
___ 04:55PM NEUTS-75.0* LYMPHS-17.5* MONOS-6.8 EOS-0.0*
BASOS-0.3 IM ___ AbsNeut-8.61* AbsLymp-2.01 AbsMono-0.78
AbsEos-0.00* AbsBaso-0.03
___ 04:55PM PLT COUNT-212
Brief Hospital Course:
Mr. ___ is a ___ y/o M who presented to ___ on ___
with RLQ abdominal pain. Admission abdominal/pelvic CT revealed
early, acute appendicitis. WBC was elevated at 11.5. The patient
underwent laparoscopic appendectomy, which went well without
complication (reader referred to the Operative Note for
details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor on IV fluids, and oral oxycodone
and acetaminophen for pain control. The patient was
hemodynamically stable.
When tolerating a diet, the patient was converted to oral pain
medication with continued good effect. Diet was progressively
advanced as tolerated to a regular diet with good tolerability.
The patient voided without problem. During this hospitalization,
the patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. Dolutegravir 50 mg PO DAILY
3. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with acute appendicitis
(inflammation of the appendix). You were taken to the operating
room and underwent laparoscopic removal of your appendix. This
procedure went well. You are now tolerating a regular diet and
your pain is better controlled. You are now ready to be
discharged home to continue your recovery.
Please follow the discharge instructions below to ensure a safe
recovery while at home:
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:
___
|
10267286-DS-8 | 10,267,286 | 25,873,734 | DS | 8 | 2118-04-17 00:00:00 | 2118-04-17 22:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
strawberries / ___
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Left heart catheterization
History of Present Illness:
Mr. ___ is a ___ year old man with hypertension, obesity,
gout and GERD who presented via ___ for work-up of an
episode of chest pain that began while at work. He had been
recently diagnosed with bronchitis while on vacation and
received azithromycin and prednisone for this episode about ___
weeks ago. He then reports an episode of mid-sternal chest pain
that began the night prior to his presentation here. The pain
was central in his chest with radiation to his arm, back and up
into his throat. The pain was crushing and increased over ___
minutes; also was associated with diaphoresis and shortness of
breath, though he remained without nausea, vomiting or
palpitations. He felt so poorly that he presented directly to
___ where he was found to be febrile to ___. He also had a
CTA at ___ which was negative for dissection and PE
and negative Troponin X 2.
In the ED, initial vital signs were: 100.5 73 156/96 18 98% RA.
Exam was notable for clear lung exam. Labs were notable for
Troponin negative X 2 in the ED. CBC was within normal limits
and UA was negative. Cr was 1.1 and Glucose was 188. CXR showed
bibasilar atelectasis. The patient was given Morphine 4mg,
Aspirin 81mg X 2, 1L NS IVF, Tribenzor, Allopurinol ___,
Omeprazole 20mg and Potassium repletion. He ultimately had
Stress Test that showed a possible angina equivalent. Cardiology
was consulted and recommended admission for cardiac cath and
optimization of high blood pressure to goal of SBP<140. Vitals
prior to transfer were: 98.4 66 133/74 19 96% RA.
Upon arrival to the floor, the patient reports the history
above. He currently feels improved without chest pain, SOB or
nausea.
Of note, he reports a negative ETT ___ years ago.
REVIEW OF SYSTEMS: Per HPI, reports fevers with chest pain, now
resolved. Denies headaches, chills, visual changes, ongoing
chest pain, shortness of breath, palpitations, nausea, vomiting,
diarrhea, lower extremity swelling.
Past Medical History:
HYPERTENSION
GOUT
GERD
HOME MEDICATIONS:
TRIBENZOR
ALLOPURINOL
ASPIRIN
OMEPRAZOLE
Social History:
___
Family History:
Family history of MI in both his mother and father
Physical Exam:
ADMISSION EXAM
==============
VITALS: 99.1 150/96 60 18 99 RA
GENERAL: pleasant, in no apparent distress, lying in bed
HEENT: NC/AT, no scleral icterus, EOMI
NECK: supple
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops
PULMONARY: clear to auscultation anteriorly, no wheezes
ABDOMEN: +BS, soft, non-tender, non-distended, obese
EXTREMITIES: warm, well-perfused, no edema
NEUROLOGIC: A&Ox3, CN II-XII grossly normal
DISCHARGE EXAM
===============
VS: Afebrile 128/73 61 13 99RA
GENERAL: pleasant, in no apparent distress, lying in bed
HEENT: NC/AT, no scleral icterus, EOMI
NECK: supple
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops
PULMONARY: clear to auscultation anteriorly, no wheezes
ABDOMEN: +BS, soft, non-tender, non-distended, obese
EXTREMITIES: warm, well-perfused, no edema. 2+ DP pulses, 1+ L
radial pulse. R wrist in TR band from procedure, R hand is warm.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal
Pertinent Results:
ADMISSION LABS
==============
___ 06:55PM BLOOD WBC-8.8 RBC-4.73 Hgb-14.2 Hct-40.4 MCV-85
MCH-30.0 MCHC-35.1 RDW-13.3 RDWSD-41.1 Plt ___
___ 06:55PM BLOOD ___ PTT-28.6 ___
___ 06:55PM BLOOD Plt ___
___ 06:55PM BLOOD Glucose-188* UreaN-15 Creat-1.1 Na-138
K-3.2* Cl-100 HCO3-29 AnGap-12
___ 06:55PM BLOOD cTropnT-<0.01
STUDIES
=======
___ LHC
Coronary Anatomy: Dominance: Right
The LMCA, LAD, Cx and RCA had no angiographically apparent CAD.
Impressions:
1. No significant CAD.
Recommendations
1. Medical Management.
___ ETT
INTERPRETATION: This is a ___ year old referred to the lab from
the
Emergency Room after negative serial enzymes, for the evaluation
of
chest pain. The patient was exercised on ___ treadmill
protocol for
12 minutes and stopped for fatigue. The peak estimated metabolic
capacity was ___ METs, a good exercise tolerance for age. There
were
two symptoms at rest: throat tightening ___ at rest progressing
to
___ in exercise; chest pressure ___ at rest progressing to
___ in
exercise. These symptoms resolved to pre exercise levels (___).
There
was .___levation in AVR with exercise. The rhythm was
sinus with
rare PVCs. The blood pressure and heart rate responses were
appropriate.
IMPRESSION: Possible anginal equivalent with non specific ECG
changes
to the good workload achieved. Normal hemodynamic response.
DISCHARGE LABS
==============
___ 09:20AM BLOOD Glucose-149* UreaN-15 Creat-0.9 Na-138
K-3.5 Cl-102 HCO3-23 AnGap-17
___ 09:20AM BLOOD Calcium-8.9 Phos-2.7 Mg-2.3
___ 01:33AM BLOOD cTropnT-<0.01
Brief Hospital Course:
Mr. ___ is a ___ year old man with hypertension, obesity,
gout and GERD who presented via ___ for work-up of an
episode of crushing substernal chest pain, with negative enzymes
x2, but with a stress test with possible angina equivalent,
underwent a left heart catheterization, which was negative for
any lesions.
#CHEST PAIN: Patient presented with an episode of chest pain
that is concerning for anginal equivalent, despite negative
enzymes both at an OSH and at ___. He is s/p stress test in
the ED that demonstrated a possible anginal equivalent, and was
admitted for a left heart catheterization. The procedure was
without complication, and showed clean coronaries. The patient
remained asymptomatic after the stress test and was
hemodynamically stable throughout his stay.
#HYPERTENSION: He was continued on his home ___, which the
patient had brought from home.
#GOUT: Continued home Allopurinol ___ daily.
#GERD: Continued home Omeprazole 20mg daily.
TRANSITIONAL ISSUES
===================
- no medication changes
- consider further evaluation of non-cardiac etiologies of chest
pain
# CODE STATUS: FULL (presumed)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tribenzor (olmesartan-amLODIPin-hcthiazid) 40-10-25 mg oral
DAILY
2. Allopurinol ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Fish Oil (Omega 3) 1000 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Viagra (sildenafil) 50 mg oral ONCE:PRN erectile dysfunction
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Fish Oil (Omega 3) 1000 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Tribenzor (olmesartan-amLODIPin-hcthiazid) 40-10-25 mg oral
DAILY
7. Viagra (sildenafil) 50 mg oral ONCE:PRN erectile dysfunction
Discharge Disposition:
Home
Discharge Diagnosis:
Chest pain
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you were having chest
pain and a stress test was concerning for a vessel blockage in
your heart.
While you were here, you underwent a left heart catheterization,
which was negative for any blockages. This means that the chest
pain you were feeling was not likely due to your heart. It may
have been the infection that you had earlier this week.
Moving forward, please continue to take your home medications as
you were. It will be important to follow up with your primary
care doctor, ___ a week of leaving the hospital.
We wish you the best,
Your ___ care team
Followup Instructions:
___
|
10267341-DS-11 | 10,267,341 | 23,440,785 | DS | 11 | 2151-08-13 00:00:00 | 2151-08-13 13:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
unwitnessed fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ PMH of severe Alzheimer's dementia who presents from
___ after unwitnessed fall.
Blood glucose was normal. In the ED, CT head, chest, and c-spine
were performed, which revealed new L ___ & 10th rib fx, RUL
spicculated mass, and T6, T10, T12, L1 compression fxs of
indeterminate age. She was at her baseline mental status of AAO
x 1. She was evaluated by the trauma service, managed
non-operatively, and was given 1g ceftriaxone for UTI and 5mg
olanzapine x1 in the ED. She was admitted briefly to the trauma
service and started on PO cipro.
Overnight at 4am on ___, she went into afib with RVR to 120s and
was given 5mg IV metoprolol and 0.5mg IV haldol. She was
subsequently transferred to the medicine service.
Upon transfer, she is somnolent, and responds only with
non-sensical noises. Does not follow commands. No urine output
from 0700 to 1300, bladder scan shows 530cc.
Review of Systems: Unable to obtain.
Past Medical History:
hypothyroidism
Alzheimers dementia (severe, AAO x 1 at baseline)
Afib
HLD
HTN
Anemia
PVD
Social History:
___
Family History:
Non-Contributory
Physical Exam:
ADMISSION EXAM:
=================
Temp: 97.2 HR: 98 BP: 141/91 Resp: 18 O(2)Sat: 97 room air
Constitutional: Initially boarded and collared. She is
quite demented.
HEENT: Extraocular muscles intact
No C-spine tenderness.
Chest: Clear to auscultation
Cardiovascular: No murmur
Abdominal: No obvious tenderness
GU/Flank: No clear-cut spine tenderness
Extr/Back: No obvious long bone findings
Skin: Warm and dry
Neuro: No lateralizing motor findings but again this is a
very limited exam
Psych: Severe dementia but she is awakened she is alert
DISCHARGE EXAM:
=================
Vitals- 97.8 110s-150s/80s-100s ___ 18 96-99%RA
General: Lying in chair poolside, alert but difficult to
understand
HEENT: dry MM, PERRL
CV: irregular, no m/r/g
Lungs: CTAB anteriorly, no wheezes or rales
Abdomen: soft, non-tender, non-distended
Ext: no edema, WWP, abrasions to bilateral knees on lateral
aspects.
Pertinent Results:
ADMISSION LABS:
=================
___ 09:50AM WBC-4.3 RBC-4.23 HGB-13.1 HCT-40.5 MCV-96
MCH-31.0 MCHC-32.5 RDW-13.4
___ 09:50AM GLUCOSE-120* UREA N-25* CREAT-0.7 SODIUM-142
POTASSIUM-5.8* CHLORIDE-107 TOTAL CO2-25 ANION GAP-16
___ 10:00AM URINE RBC-1 WBC-13* BACTERIA-MANY YEAST-NONE
EPI-0
___ 10:00AM URINE BLOOD-NEG NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-TR
___ 10:00AM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 10:00AM LACTATE-1.9 K+-4.6
LAST LABS:
================
___ 07:10AM BLOOD WBC-5.6 RBC-4.81 Hgb-14.5 Hct-46.4 MCV-96
MCH-30.1 MCHC-31.2 RDW-13.2 Plt ___
___ 07:10AM BLOOD Glucose-87 UreaN-16 Creat-0.5 Na-149*
K-3.5 Cl-109* HCO3-28 AnGap-16
___ 07:10AM BLOOD Calcium-9.2 Phos-2.5* Mg-2.1
CT Chest with contrast ___
IMPRESSION:
1. 3.1 cm spiculated solid mass in the right upper lung with
air bronchograms
and pleural tagging is concerning for invasive adenocarcinoma.
Additional 1.2
cm right apical partially solid and ground-glass opacity is also
concerning
for adenocarcinoma, either minimally invasive or in situ.
Additional smaller
nodules in the right lung.
2. Acute left lateral rib fractures of third and tenth ribs.
Multiple wedge
compression fractures of T6, T10, T12, and L1 are of
indeterminate age.
3. Tortuous calcified aorta without aneurysmal dilatation or
dissection. No
active extravasation.
CT Head W/o Contrast ___:
IMPRESSION: Chronic changes as described above. Otherwise,
negative head CT.
Specifically, no evidence of intracranial hemorrhage.
CT Spine W/o contrast ___:
IMPRESSION:
1. No evidence of fracture.
2. Unchanged mild anterolisthesis of C3 on C4 and C4 on C5 is
likely
degenerative in nature.
3. Right lung apex lesion is incompletely evaluated. Please
see chest CT
from today for further information.
Pelvis AP Only ___:
IMPRESSION:
No acute fracture or dislocation.
Brief Hospital Course:
___ w/ PMH of severe Alzheimer's dementia who presents from
___ after unwitnessed fall, found to have new rib
fractures and Afib w/ RVR.
# Goals of care: Addressed with family and HCP during this
admission. The patient's Alzheimer's dementia has advanced to
the point that she is not taking good po, causing hypernatremia.
Given that tube feeds/intravenous therapy would not help her
quality of life or extend her life, it was decided not to
continue checking labs to minimize discomfort from needle
sticks. In line with these goals of care, her lung mass was not
worked up and she was not anticoagulated for Afib. No further
lab checks and ideally, no further hospitalizations if she can
be made comfortable there.
# Rib/Vertebral body fractures: To be managed medically.
Admitted to the surgical service following a presumed
unwitnessed fall at a nursing home facility on ___.
Acute left lateral rib fractures of ___ and 10 rib. Multiple
compression
wedge fx of T6,T10, T12, L1 age indeterminate. A CT head and
neck done at the time were negative other than chronic changes.
A pelvis film revealed no fractures. It is difficult to tell
when/if the patient is in pain. Given that she seemed most
agitated in the evenings, she was given 0.5mg iv morphine qHS
for pain control for known rib fractures.
# Afib w/ RVR: Due to her not taking PO metoprolol at times. The
AM of ___ she was triggered for a rapid heart rate in the
150s which was found to be A-fib with RVR. The patient was
treated with 5 mg lopressor which rate controlled her to the
___. She was also given 0.5 mg of IV haldol for agitation with
good relief. A tertiary survey did not reveal any new findings
or changes, and final reads were consistent with the reads from
___. The ___ protocol was initiated and the patient was
transferred to the medical service AM of ___. Her rates were
controlled w/ 25 mg metop tartrate bid. Deferred anticoagulation
given recurrent falls, quality of life, and life expectancy.
# Dementia: End Stage. Baseline mental status AAOx1 with
intermittent agitation. Agitation likely to be worsened by UTI,
pain from rib fractures, new environment, procedures.
___ recommended 24 hour care. Her agitation was controlled with
standing seroquel 37.5mg qHS. Speech and swallow evaluated the
patient twice during the hospitalization and recommended
aspiration precautions, pureed solids, nectar thick liquids.
# UTI: >100K E coli, resistent to CTX. Complicated given age,
nursing home. Afebrile w/o leukocytosis. Got 1g ceftriaxone in
ED, cipro on the floor but stopped given QTc 460. Completed 5
day course of Cefepime 1g q24 (last day = ___.
# Hypothyrodism: TSH 4.8. Free T4 wnl at 1.2. Continued
levothroxine at 37.5mg daily.
# RUL mass: CT Chest in the ED revealed a 1.2 x 0.8 cm right
apical partly solid and ground glass opacity (3:11) as well as a
3.1 x 2.3 cm predominantly solid spiculated mass in the right
upper lung (3:28) with air bronchograms and pleural tag
concerning for adenocarcinoma. Few additional smaller nodules in
the right lung. No pulmonary embolism. Deferred further workup,
in conjunction w/ HCP, given that diagnostic procedures and
treatment of likely lung cancer would not improve her quality or
quantity of life and may worsen them.
# Urinary retention: Resolved. Likely from narcotics, haldol,
and/or UTI.
Transitional Issues:
# Not checking labs, as per goals of care.
# Aspiration precautions, pureed solids, nectar thick liquids.
# Code: DNR/DNI (confirmed w/ HCP)
# Communication: Patient
# Emergency Contact: ___
Relationship: daughter/HCP
Phone number: ___
Proxy form in chart: No
Comments: alternate is daughter ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 37.5 mcg PO DAILY
2. Polyethylene Glycol 17 g PO DAILY
3. QUEtiapine Fumarate 25 mg PO QHS
4. Lidocaine 5% Patch 1 PTCH TD QAM
5. Ibuprofen 200 mg PO Q8H:PRN Pain
Discharge Medications:
1. Levothyroxine Sodium 37.5 mcg PO DAILY
2. Polyethylene Glycol 17 g PO 2X/WEEK (MO,TH)
3. QUEtiapine Fumarate 50 mg PO QHS
4. Metoprolol Tartrate 25 mg PO BID
5. Ibuprofen 200 mg PO Q8H:PRN Pain
6. Lidocaine 5% Patch 1 PTCH TD QAM
7. Acetaminophen 1000 mg PO Q8H:PRN pain
Do not exceed 3gm per day.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Rib fractures
Atrial Fibrillation
Urinary Tract Infection
Alzheimers dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital after a fall. You were found
to have rib fractures, for which you were treated with pain
control. The fractures will heal on their own. You also had a
urinary tract infection, for which you completed treatment with
intravenous antibiotics. Additionally, you were found to have an
abnormal heart rhythm called atrial fibrillation, for which you
were started on a medication called metoprolol to control your
heart rate. You will be transferred to a skilled nursing
facility and continue to receive care from the doctor there.
Followup Instructions:
___
|
10267709-DS-23 | 10,267,709 | 23,426,210 | DS | 23 | 2181-11-11 00:00:00 | 2181-11-11 14:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
___
Attending: ___.
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
Lumbar puncture at bedside
Lumbar puncture by ___ fluoroscopy
History of Present Illness:
___ is a ___ year-old man with history significant for
extensive, subcortical ischemic disease (i.e. Bis___'s
disease), with progressive dementia, gait instability, and
urinary incontinence. He says he has been followed by Dr. ___ ___ Neurology) since his first infarct in ___. His wife
brought him to our ED today via ambulance from home. Her stated
reason is a waxing and waning deterioration since he last saw
Dr.
___ tried a new medication a week ago for possible NPH.
Dr. ___ from the last scheduled clinic visit
(___)
mentions recent progression of gait instability (thought by the
wife to be related in part to progressive RLE weakness),
increasingly frequent episodes of urinary incontinence (said by
the wife to be related to occasional inability to make it to the
bathroom before urinating), and decreased cognitive capacity
with
increasing lethargy.
AT that time, they discussed the possibility of shunting for
possible NPH. His ventricles are large (but with more of an ex
vacuo appearance) and technically the ___ ratio is >0.31
(increasing by my measurement -- 0.32 in ___, 0.36 now in
___.
Dr. ___ that any benefit may be short-lived at best
(i.e. ___, and suggested a trial of Diamox. He started
taking 1gm/d Diamox last ___, but this was discontinued
___ (took it ___ with Dr. ___ -- the wife
contacted him because throughout the ___ holiday ___,
the patient was unusually sleepy and had difficulty standing on
his own. Despite stopping the Diamox, he has had increase
urinary
incontinence to the point that his wife got a bedside commode
and
Depends diapers on ___. Yesterday (___), he seemed better
(more awake, more able to stand and walk). But this morning, he
seemed more confused. He awoke around 4am with urinary
incontenince. He feel when she tried to help him to the
bathroom.
His speech was "drifting" around 5am with possible word-finding
difficulty, but appropriate yes/no answers. Around 9am he told
his wife, ___, I need to buy some presents," which
concerned
her for increased confusion. Of note, he feels and she agrees
that he is dehydrated, having drunk just one cup of water all
day
atop generally poor PO intake this past week. The wife emailed
Dr. ___ she says called her and recommended evaluation
in
the ED. The ED performed a NCHCT, which is not remarkably
changed
from prior head imaging, and then consulted me (Neurology) for
guidance re. their concern for NPH diagnosis treatment.
Review of Systems: difficult to obtain due to letharic/laconic
patient. He denies headache. Denies visual changes including
double-vision. Says hearing is stably poor, and wife agrees.
Denies vertigo/dizziness. Endorses fatigue and sleepiness, but
denies any focal weakness, numbness, parasthesiae. Endorses
increased urinary incontinence (and the strong odor of urine
appeared ___ through our interview). No dysuria. Endorses
increased difficulty with gait, not sure why. Denies fever,
chills, change in weight, cough, shortness of breath, chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No diarrhea. Denies arthralgias
or myalgias.
Past Medical History:
CVA
Prostate cancer
CABG x 5 (___)
Coronary artery disease
Diabetes mellitus
Barrett's esophagitis
History of constipation and urgency with defecation
Stroke in ___, closely followed by neurology
Prostate cancer
Gait disorder - works with ___
Social History:
___
Family History:
no family history of repeated ischemic strokes in family
Physical Exam:
T: 97.8F
P/HR: 70
BP: 128/69
RR: 14
SaO2: 100% RA
General: Lying in ED stretcher with home blanket brought by
wife.
___, cooperative, NAD.
HEENT: Obese face/neck. Droopy lids (sleepy). Normocephalic and
atraumatic. No scleral icterus. Mucous membranes are dry; tongue
crusted. No lesions noted in oropharynx.
Neck: Supple, no nuchal rigidity. No carotid bruits. No
lymphadenopathy.
Back: groans with mild LBP/strain sitting up.
Pulmonary: Lungs CTA bilaterally posteriorly (no crackles).
Non-labored breathing.
Cardiac: RRR, normal S1/S2, no loud M/R/G in noisy ED. Sternal
CABG scar, healed.
Abdomen: Obese. Soft, non-tender, and non-distended.
Extremities: Warm and well-perfused, no clubbing, cyanosis,
bilateral mild pitting ___ to low to mid-shin. 2+ radial, DP
pulses bilaterally. Old LLE saphenous vein-harvest scar.
Hairless
___. Many white/yellowish dry/crusted skin placques
(?fungal).
Skin: no gross rashes or lesions noted.
*****************
Neurologic examination:
Mental Status:
Somnolent and inattentive, which greatly limits the present
examination. Frequently looks to wife for answers. Long latency
before answering, sometimes no answer. Cannot tell ___ or
___.
Oriented to his and wife's names and "hospital" but not
___. Tells me it is the year of his 40th wedding
anniversary (wife say it was ___. Speech is sluggish and
hypophonic, but not dysarthric. Language is fluent with intact
repeition of short sentences. Naming intact to high-frequency
objects. Follows some simple commands. Motor perseveration.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL, 3.5 to 2mm, sluggish. Visual fields are grossly full,
though exam is limited by inattention.
III, IV, VI: Bilateral lid droops. EOMs full and conjugate; no
nystagmus. Frequent saccadic intrusions during smooth pursuits.
V: Facial sensation intact and subjectively symmetric to light
touch V1-V2-V3.
VII: ?R-lower facial droop, mild; wife says this is
longstanding.
No ptosis, no flattening of either nasolabial fold. Normal,
symmetric but incomplete bi-facial elevation with weak smile.
Brow elevation is symmetric. Eye closure is strong and
symmetric.
VIII: Hearing grossly intact and subjectively equal to
finger-rub
next to ears bilaterally.
IX, X: Palate elevates symmetrically with phonation.
XI: ___ equal strength in trapezii bilaterally.
XII: Tongue protrusion is midline.
-Motor:
?RUE slight pronator drift, but patient moving and inattentive
with testing. No asterixis. Bilateral mild intention tremor.
Slightly increased RLE tone. No spacticity.
Delt Bic Tri WE FE IO | IP Q Ham TA ___
L ___ 5 5 5 4- 4+ 5 4+ 4+
R ___ 5 4+ 4+ 3 4 5 4+ 4+
-Sensory:
No gross deficits to light touch or pinprick, but pt unreliable
w.r.t. differences and proprioception testing. Difficulty
finding
nose with RUE eyes-closed Finger-to-nose suggests RUE
proprioceptive deficit; better on the Left. Bilateral
astereoagnosia (cannot discriminat any coins q/d/n/p in either
hand).
-Reflexes (left; right):
Pec/delt (++;+++)
Biceps (++;+++)
Triceps (++;++)
Brachioradialis (++;++)
Quadriceps / patellar (++;++)
Gastroc-soleus / achilles (0/+;0/+)
Plantar response was indeterminate (tickle response) bilaterally
-- possibly up-going initially, moreso on the Right.
-Coordination:
RUE Finger-nose-finger mildly ataxic (LUE ~not). RLE moderately
ataxic (wobbles on shin); LLE smooth. No gross
dysdiadochokinesia
noted on rapid-alternating movements, though neither side is
smooth or quick. Clumsy fine-finger and overall hand movements
bilaterally, seems worse on the Right.
-Gait:
Not attempted at this time, due to no walker and wife and
examiner concern for fall without support (pt "slipped" down to
ground multiple times at home despite assitance over past few
days).
Pertinent Results:
Labs on admission:
___ 11:45AM ___ PTT-28.2 ___
___ 11:45AM PLT COUNT-191
___ 11:45AM NEUTS-42.0* LYMPHS-52.1* MONOS-3.7 EOS-1.7
BASOS-0.5
___ 11:45AM WBC-11.0 RBC-3.80* HGB-12.4* HCT-34.9* MCV-92
MCH-32.8* MCHC-35.7* RDW-12.9
___ 11:45AM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
___ 11:45AM TSH-1.0
___ 11:45AM ALBUMIN-4.1 CALCIUM-10.5* PHOSPHATE-3.1
MAGNESIUM-1.6
___ 11:45AM cTropnT-<0.01
___ 11:45AM ALT(SGPT)-21 AST(SGOT)-42* ALK PHOS-81 TOT
BILI-0.4
___ 11:45AM estGFR-Using this
___ 11:45AM GLUCOSE-180* UREA N-25* CREAT-1.1 SODIUM-142
POTASSIUM-4.1 CHLORIDE-111* TOTAL CO2-21* ANION GAP-14
___ 05:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 05:00PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 05:00PM URINE GR HOLD-HOLD
___ 05:00PM URINE UHOLD-HOLD
___ 05:00PM URINE HOURS-RANDOM
___ 05:00PM URINE HOURS-RANDOM
___ 08:47PM %HbA1c-6.6* eAG-143*
Imaging studies:
NON-CONTRAST HEAD CT: There is no intracranial hemorrhage. There
is no
parenchymal edema or mass effect. The ventricles and sulci are
globally
prominent with greater dilation of the left occipital and
temporal horns.
This is unchanged from prior studies and likely all reflecting
volume loss,
with no specific evidence of normal pressure hydrocephalus.
There is no shift
of midline structures or effacement of the basal cisterns.
There are extensive periventricular and subcortical white matter
hypodensities, the appearance and extent of which is unchanged
from prior
studies, likely reflecting sequelae of chronic small vessel
ischemia.
Additional hypodensity is noted in the left pons. Small focal
infarct seen on
___ MRI cannot be differentiated from these
underlying changes.
There is no loss of gray-white matter differentiation to suggest
acute
territorial infarct. There is mild cavernous carotid
calcification. The
visualized paranasal sinuses and mastoids are clear.
IMPRESSION:
1. No acute intracranial hemorrhage or other acute intracranial
process.
2. Extensive periventricular subcortical white matter
hypodensities, likely
reflect the sequelae of chronic small vessel ischemia.
Additional hypodensity
within the left pons is also unchanged from prior studies, and
likely reflects
a similar process.
3. No specific evidence of normal pressure hydrocephalus.
Prominence of
sulci and ventricles likely reflects global volume loss and is
stable.
MRI CERVICAL SPINE WITHOUT CONTRAST
HISTORY: Worsening gait instability with hyperreflexia and
positive Babinski.
Sagittal imaging was performed with short TR, short TE spin echo
and long TR,
long TE fast spin echo technique. Axial gradient echo and long
TR, long TE
fast spin echo imaging were performed. No contrast was
administered. No
prior cervical spine imaging studies are available for
comparison.
FINDINGS: Alignment of the cervical spine is normal. Vertebral
body signal
intensity appears normal. The spinal cord appears normal in
signal intensity.
There are changes of degenerative disc disease at each level
from C3 to C7
with disc bulges encroaching on the spinal cord.
Axial images at C2-3 demonstrate no significant abnormalities.
At C3-4, there is a mild bulge slightly indenting the spinal
canal and
slightly flattening the anterior surface of the spinal cord. The
neural
foramina appear normal.
At C4-5, a midline disc bulge encroaches on the spinal canal and
flattens the
anterior surface of the spinal cord. The neural foramina appear
normal.
At C5-6, there is spinal stenosis due to a combination of
ligamentum flavum
thickening and bulging of the intervertebral disc. This appears
to indent the
spinal cord.
At C6-7, there is a disc protrusion in the midline that indents
the spinal
canal and just contacts the anterior surface of the spinal cord.
There is
mild narrowing of the neural foramina bilaterally.
The C7-T1 level appears normal.
CONCLUSION: Degenerative disc disease with disc bulges and
protrusions
encroaching on the spinal canal and the anterior surface of the
spinal cord.
MR HEAD NEURO WITHOUT CONTRAST, ___
HISTORY: Worsening gait instability.
Sagittal short TR, short TE spin echo imaging was performed
through the brain.
Axial imaging was performed with ___ TR, long TE fast
spin echo,
gradient echo, and diffusion technique. No contrast was
administered.
Comparison to a head CT of ___.
FINDINGS: There is no evidence of recent infarction. There are
extensive
changes of chronic ischemia including periventricular white
matter
hyperintensities on ___, numerous old lacunes in the putamen
bilaterally,
and old foci of hemorrhage in the left putamen, body of the left
caudate
nucleus, pons, and left frontal lobe. The ventricles and sulci
are dilated in
an atrophic pattern. There is no evidence of mass effect.
CONCLUSION: Extensive changes of chronic ischemia with lacunes
and old
hemorrhages. No evidence of new hemorrhage or recent infarction
Brief Hospital Course:
___ yo M with Biswanger's who presented with acute on chronic
deterioration in gait, urinary continence and confusion. This
happened in the setting of attempting diamox as an outpatient
for possible NPH.
He was admitted and given IVFs
On the day after admission, he was noted to have increased
confusion and agitation, there was concern for meningitis. His
LP was w/o WBCs. He did not have signs or symptoms infection.
The next day he improved. Attention turned to his NPH.
A large volume LP revealed a gait that was notable for increased
speed, but overall balance was unchanged. He remained unable to
walk unassisted. He was tested 2 hours later and his gait had
slowed down again.
The next day he underwent serial gait exams which revealed a
wide fluctuation in baseline gait.
This fact, in addition to his comorbidities that vascular
disease and cervical spondylosis also are contributing to his
gait and congitive difficulties, and also on considering
possible complication from VP shunt, led to recommending against
a permanent shunting procedure.
He was seen by ___ who recommended rehab. He will be discharged
to rehab.
There are no current signs of infection LP without WBCs, U/A
bland, no peripheral leukocytosis and he appears to have
recovered close to his baseline mental status but continues to
have gait difficulties.
.
Transitional issues:
1. NPH: unclear response to Large volume tap despite increased
size of ventricles. It is possible that underlying disease is
masking any potential benefit from this intervention.
1. Biswanger's: it is possible that his repeated stroke are the
result of CADASIL. Notch3 gene mutation could not be assessed
inpatient ___ cost) and will be defered to outpatient setting.
2. His HTN was noted to be less than ideally controlled, his
Enalapril was increased to 10mg daily with good response.
Medications on Admission:
1. Plavix 75
2. ASA 325
3. enalapril 5
4. MTP-succ 25 (decreased from 50 ___
5. simvastatin 20
6. niacin 500 qhs
7. sertraline 100mg (PTSD)
8. ranitidine 150mg bid
9. Ca/vitD
10. MVI
11. omega-3/vitE
12. tizanidine 2mg qid "for gait" (?tight RLE muscles per wife)
13. glimepiride 0.05mg qhs only if suppertime FSBG is >130
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for ___ or pain/headache.
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety, agitation.
15. enalapril maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
17. niacin 500 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Normal pressure hydrocephalus
Biswanger's
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital because of concern for changes
in your mental status.
It was determined that the medication Diamox likely led to a
state of dehydration that then led to confusion.
This medication was stopped and you were given fluids through
the IV which eventually helped.
Given your urinary incontinence, gait problems and confusion,
you were assessed for a condition called NPH (normal pressure
hydrocephalus). Excess fluid was removed from your back in an
attempt to improve your ability to walk. This did not result in
the large improvement we were hoping for. Thus we are
recommending AGAINST the surgery to place a permanent shunt in
your brain.
You will continue working with physical therapy to help improve
your walking ability.
You will follow up with Dr. ___ as an outpatient.
Please note following medication changes:
STOP:
- Diamox
- TIzanidine
INCREASE:
- Enalapril to 10mg daily
Followup Instructions:
___
|
10267709-DS-24 | 10,267,709 | 24,654,608 | DS | 24 | 2181-12-12 00:00:00 | 2181-12-13 09:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Fever and cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with hx of NPH, Binswanger's disease with
recent admission for worsening confusion, gait abnormality, and
urinary incontinence s/p large volume LP, now recently dced from
rehab, p/w fever, cough x1 wk.
Per records, the pt was admitted ___ after presenting with
acute on chronic deterioration in gait, urinary continence and
confusion. This happened in the setting of attempting diamox as
an outpatient for possible NPH. He was admitted and given IVFs.
On the day after admission, he was noted to have increased
confusion and agitation, LP ruled out meningitis, so out of
concern for NPH worsening, a large volume LP was done with mild
improvement. The pt was then dced to rehab.
Per the pt's wife, the pt had been in rehab for 3wks, just
discharged ___. She states that last ___ the pt began
sneezing, with rhinorrhea. On ___ he developed a cough for
which he was given nebulizers, which per the patient helped
improve his cough and breathing. On ___ the pt was dced and
the pt's wife noticed frequent coughing, especially after
eating, and ?worse with lying down. The pt denies SOB, was
without fever, or diaphoresis, but the wife was concerned re:
audible breathing. Over the past few days the wife has noted
increased cough, weakness, and some confusion, so she decided to
call ___ to bring him to the ED.
In the ED, initial VS: 101.6 116 34 155/69 96% 4.5L (unclear if
he got nebs in the ambulance). He had an ekg unchanged from
prior, labs significant for wbc 13.7, lactate 1.7. He was given
tylenol 1g, combivent neb. vanc/ctx/azithro given. Pt had CT
head without acute process, cxr with possible mild congestion.
Currently, 96.8 126/49 108 16 95%3L FSG 289. The pt has fatigue,
and per the wife, mild confusion, with persistent cough. He also
had some urinary incontinence which seems to be baseline. The pt
denied headache, vision changes, chest pain, sob. He is
chronically hard of hearing.
REVIEW OF SYSTEMS:
Denies chills, night sweats, headache, vision changes, sore
throat, cough, shortness of breath, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria .
Past Medical History:
Stroke in ___, closely followed by neurology
Vascular dementia
Prostate cancer
CABG x 5 (___)
Coronary artery disease
Diabetes mellitus
Barrett's esophagitis
History of constipation and urgency with defecation
Gait disorder - works with ___
Social History:
___
Family History:
No hx of early stroke, otherwise non-contributory
Physical Exam:
Admission exam:
VS - 96.8 126/49 108 16 95%3L FSG 289
GENERAL - mildly uncomfortable, fatigued, intermittent paroxysms
of cough
HEENT - dry mucous membranes, L eye mildly extroverted, PERRLA
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - bibasilar crackles
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - abdoment mildly distended, no discomfort, no masses or
HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox1 (not oriented to date or location), moving
all extremities
Disharge exam - unchanged from above, except as below:
GENERAL - lying in bed comfortably, occasional coughing, NAD
HEENT - MMM, PERRLA
LUNGS - crackles at the lung bases bilat
NEURO - awake, A&Ox1 (name only), no focal defecits
Pertinent Results:
Admission labs:
___ 06:35PM BLOOD WBC-13.7* RBC-3.22* Hgb-11.3* Hct-30.7*
MCV-95 MCH-35.1* MCHC-36.9* RDW-12.9 Plt ___
___ 06:35PM BLOOD Neuts-78.7* Lymphs-17.2* Monos-3.5
Eos-0.4 Baso-0.2
___ 07:37AM BLOOD ___
___ 06:35PM BLOOD Glucose-224* UreaN-15 Creat-0.9 Na-138
K-4.0 Cl-105 HCO3-23 AnGap-14
___ 06:35PM BLOOD ALT-13 AST-15 AlkPhos-71 TotBili-0.3
___ 06:35PM BLOOD Calcium-8.9 Phos-1.9* Mg-1.7
___ 05:06PM BLOOD Lactate-1.7
Imaging:
CT head (___):
1. No acute intracranial process.
2. Brain parenchyma atrophy with secondary ex vacuo dilatation
of the
ventricles, unchanged from the prior exam.
3. Extensive small vessel disease and prominent perivascular
spaces,
unchanged from prior exam.
4. Paranasal sinus disease, progressed from prior studies.
CXR (___): No signs of pneumonia. Possible mild congestion.
CXR (___): Right basilar opacity consistent with infection.
Left basilar
opacity may represent a second focus of infection.
Discharge labs:
___ 07:21AM BLOOD WBC-16.1* RBC-3.12* Hgb-10.6* Hct-30.1*
MCV-96 MCH-34.0* MCHC-35.2* RDW-12.7 Plt ___
___ 07:21AM BLOOD ___ PTT-28.0 ___
___ 07:21AM BLOOD Glucose-156* UreaN-13 Creat-0.8 Na-137
K-3.7 Cl-105 HCO___ AnGap-14
Brief Hospital Course:
Mr. ___ is a ___ with hx of T2DM, vascular dementia with
recent admission for worsening confusion, gait abnormality, and
urinary incontinence s/p large volume LP from ?NPH, now recently
discharged from rehab, p/w fever, cough x1 wk.
#Aspiration PNA and cough: Despite initial CXR showing no clear
infection, second CXR showed a RLL infiltrate concerning for
aspiration with a possible LLL opacity as well. Speech and
swallow evaluation did not find evidence of obvious aspiration
with solids or liquids. He was started on Augmentin 875/125mg
q12h the day prior to discharge and tolerated this well, he has
an intolerance to fluoroquinolones. We advised Mr. ___ and
his wife to make sure that he is sitting straight up, takes
small bites of food and takes pills one at a time to reduce the
risk for further aspiration. His cough had improved somewhat
during this admission and physical therapy cleared him for
discharge to home. He will follow-up with his PCP ___
___ discharge.
#Positive BCx: Had ___ bottles of initial BCx positive for
Coag(-) staph. Thought to be contaminant, he remained afebrile
at discharge and WBC was downtrending. All 4 bottles on repeat
BCx were negative. He received 2 doses of vancomycin while
repeat BCx were pending, which was stopped when there was no
subsequent culture growth.
#Fever/leukocytosis: Most likely from his aspiration PNA, WBC
count was downtrending at discharge and he had no further
fevers. His UA was not suggestive of a UTI. We entertained
meningitis as a potential cause given his recent LP, but his MS
was at baseline according to his wife, he has no neck
pain/stiffness and he remained afebrile while on the floor. We
also initially considered C.diff given that he was recently
admitted to a rehab facility, but he had no diarrhea and WBC
count was improving.
# Tachycardia: Unclear cause, but was thought to be due to
volume depletion from poor PO intake at admission. We
considered PE given his immobility and Well's score of 3, but he
was not hypoxic and had no evidence of DVT on exam, we did not
pursue any testing for PE. He had intermittent episodes of
sinus tachycardia to the 100-110s during admission, which was
thought to be from ongoing poor PO intake as well as some
periods of mild agitation.
#Confusion/vascular dementia/possible prior NPH: Unclear history
of NPH during last admission, CT this admission seems unchanged
from prior head CT and enlarged ventricles likely from ex vacuo
changes. His urinary incontinence appears to be at baseline and
his gait was stable enough for ___ to recommend discharge to
home. His outpatient neurologist was contacted who reports that
he has had a slow decline over the past few years, likely
related to his vascular dementia. Seroquel was on his
medication list at admission, but he did not receive any during
this hospitalization and he will not be discharged on this
medication.
#T2DM: Blood sugar remained moderately well controlled during
this admission, ranging from mid ___ 200s. At admission,
he was only taking glimepiride PRN for blood sugar over 130 at
night, which was recommended by his ___ diabetes specialist.
He was covered with an insulin sliding scale during this
admission. His diabetic medications should be re-evaluated as
an outpatient once his infection has resolved, last A1c was
6.1%, suggesting good control at home. Mildly elevated sugars
as an inpatient are likely in the setting of his pneumonia, as
described above.
#Coagulopathy: INR mildly elevated to 1.5 at admission, trended
down to 1.3 at discharge. Likely in the setting of poor PO
intake.
#CAD: No chest pain during this admission, he was continued on
his home doses of ___, metoprolol and enalapril
#HTN: BP remained well controlled, he was continued on his home
doses of metoprolol and enalapril
#GERD/Barrett's esophagitis: Continued on home dose of
ranitidine
#Depression: Continued on home dose of setraline.
#Code status during this admission: FULL CODE
#Transitional issues:
-Blood cultures from ___ and ___ should be followed up to
ensure no additional bottles are positive, only ___ positive
for coag(-) staph at time of discharge
-Should have diabetes medications re-evaluated as an outpatient
once his illness resolves and blood sugar is better controlled,
PRN glimepiride held at discharge.
-Will be discharged on 7 day course of Augmentin for aspiration
PNA
-We have stopped PRN Seroquel at discharge, he did not receive
or require this during this admission
Medications on Admission:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for ___ or pain/headache.
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. quetiapine 12.5 mg Tablet Sig: One (1) Tablet PO PRN anxiety
15. enalapril maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
17. niacin 500 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. calcium carbonate-vitamin D3 600 mg calcium- 200 unit Capsule
Sig: Two (2) Capsule PO twice a day.
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. omega-3 fatty acids Capsule Sig: Three (3) Capsule PO
once a day.
10. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. niacin 500 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO QHS (once a day (at bedtime)).
12. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
___ puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
Disp:*QS 1 month* Refills:*1*
13. sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. dextromethorphan-guaifenesin ___ mg/5 mL Liquid Sig: ___
mL PO every four (4) hours as needed for cough for 7 days: Call
your doctor if still coughing after 7 days.
Disp:*1 bottle* Refills:*0*
15. enalapril maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) patch Topical every ___ (72) hours as needed for
pain: Apply to affected area.
17. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO every twelve (12) hours for 6 days: Last day ___.
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Aspiration pneumonia
Secodnary diagnoses:
Type 2 Diabetes
Hypertension
Vascular dementia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your admission to
___ for fever and cough. You were found to have pneumonia
which was thought to be caused by aspiration, or food/liquid
accidentally going into the lungs. We have given you
antibiotics to take for a total of 7 days. Please make sure to
eat sitting up straight, take small bites, eat slowly and take
pills one at a time. There was no evidence of a urinary tract
infection. One out of 8 blood cultures were positive and you
were briefly on IV antibiotics for this, but these were stopped
because this was thought to be caused by contamination and not a
true infection. We did note some sinus congestion on your
initial head CT from the emergency room, which may have
contributed to your coughing and fever.
The following changes were made to your medications:
START dextromethorphan/guaifenesin sugar-free ___ every 4
hours as needed for cough
START Augmentin 875/125mg by mouth every 12 hours for 6 more
days (last dose on ___
START albuterol as needed for cough or shortness of breath
We suggest that you STOP Glimepiride since it can cause low
blood sugars at night.
Followup Instructions:
___
|
10267709-DS-34 | 10,267,709 | 27,073,079 | DS | 34 | 2185-10-08 00:00:00 | 2185-10-08 18:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Levaquin
Attending: ___.
Chief Complaint:
Shortness of breath, vomiting
Major Surgical or Invasive Procedure:
PICC placement and removal
History of Present Illness:
Mr. ___ is a ___ gentleman with a past medical
history significant for recurrent UTIs, prostate cancer, CAD s/p
CABG x 5, systolic heart failure (EF ___, distant CVA,
vascular dementia, and NPH presenting with shortness of breath
and vomiting.
Per wife, he was diagnosed with a UTI yesterday by his PCP and
started on amoxicillin. In the evening, his wife noted the
patient to be more short of breath and called EMS. He was found
to be hyperglycemia ___ unknown). On transport to the ED, he
became nauseated and vomited several times. He has baseline
confusion but is slightly more confused than baseline.
Of note, he was recently admitted to ___ from ___ to
___ for a transient episode of decreased responsiveness
that resolved spontaneously and was thought to be due to
hypoglycemia. His Lantus dose was decreased from 36 units to 30
units daily.
On arrival to the ED, initial VS: T 101.2, HR 138 (sinus
rhythm), BP 127/67, RR 27, SaO2 97% RA. On exam, he was moving
all extremities and following commands, abdomen was diffusely
tender to palpation, and prostate was tender. Labs notable for
WBC 24.3 with 61% PMNs (baseline WBC around 18), HCO3 20 with AG
18, Cr 1.2, glucose 463, BNP 178, negative troponin, and
negative serum tox screen. Lactate was initially 4.6 but
improved to 1.6 after 2.5L IVF. U/A from PCP's office the
morning of admission showed 61 WBCs, few bacteria, negative
nitrites, 1000 glucose, negative ketones, 1 RBC and urine
culture is pending.
Given heart failure history, he was given a total of 2.5L IVF
with improvement in HR from 140s-150s to 110s-120s. He received
10u IV insulin for blood sugars in the 400s. He was given
vancomycin and ceftriaxone for a presumed UTI and admitted to
the ICU given persistent tachycardia.
On transfer, vitals were: T:98 BP:129/67 P: 108 R: 18 O2: 99%
On arrival to the MICU, patient was arousable and responsive to
name. ___ to self and to hospital. Perseverated on hospital
name when responding to date. Denied pain anywhere. Did endorse
some shortness of breath. Collateral from wife indicates he
began feeling ill with diaphoresis, worsening confusion, and
"groin pain" on ___. He had taken 3 pills of amoxicillin
without improvement. Had been having decreased PO intake.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
cough. Denies chest pain or tightness, palpitations. Denies
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. Denies arthralgias or myalgias.
Past Medical History:
NPH
Stroke in ___, multiple TIA's since then and closely followed
by neurology
Vascular dementia
Binswanger's disease
Gait disorder - works with ___
Chronic lymphocytic leukemia - diagnosed in ___
GI Bleed (___)
Prostate cancer ___ s/p seed implant, followed yearly
CABG x 5 (___)
Coronary artery disease
Hypertension
Diabetes mellitus
Barrett's esophagitis
History of constipation and urgency with defecation
Anemia since ___
Colonic polyps - due ___
Seborrheic keratosis
Actinic keratosis
Social History:
___
Family History:
No hx of early stroke, otherwise non-contributory
Physical Exam:
ADMISSION
Vitals: T:98 BP:129/67 P: 108 R: 18 O2: 99%
GENERAL: Lethargic, responsive to name
___ anicteric, dry mucous membranes, oropharynx
without erythema or lesion
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, poor inspiratory
effort, 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: Multiple SKs
NEURO: AAOx2, II-XII intact, moves all extremities, follows
commands. ___ strength in ___ UE, ___ strength in LLE, ___
strength in RLE
DISCHARGE EXAM:
VS: 97.7-152/59-72-20-100RA
AM ___ ___
YEsterday's ___: ___
GEN - Alert, NAD, oriented to self, feeding self slowly in bed
___ - NC/AT, MMM, EOMI, OP clear
NECK - Supple, no cervical LAD
CV - irregularly irregular
RESP - CTA B no w/r/r
ABD - soft, nontender, nondistended, BS+
SKIN - No rashes
NEURO - Nonfocal, doesn't know year or month, knows hospital
(___), self.
PSYCH - Calm, cooperative, answers simple questions, pleasant,
easily smiles
GU - Condom cath
Pertinent Results:
ADMISSION
___ 12:55AM BLOOD WBC-24.3* RBC-3.69* Hgb-12.6* Hct-37.1*
MCV-101* MCH-34.1* MCHC-34.0 RDW-12.3 RDWSD-45.4 Plt ___
___ 12:55AM BLOOD Glucose-463* UreaN-24* Creat-1.2 Na-142
K-4.3 Cl-104 HCO3-20* AnGap-22
___ 12:55AM BLOOD ALT-20 AST-15 AlkPhos-136* TotBili-0.7
___ 12:55AM BLOOD Albumin-3.9 Calcium-10.1 Phos-3.5 Mg-1.6
___ 01:10AM BLOOD ___ pO2-37* pCO2-46* pH-7.32*
calTCO2-25 Base XS--2
___ 01:10AM BLOOD Lactate-4.3*
DISCHARGE LABS
___ 06:10AM BLOOD WBC-21.5* RBC-3.15* Hgb-10.7* Hct-31.9*
MCV-101* MCH-34.0* MCHC-33.5 RDW-12.7 RDWSD-46.3 Plt ___
___ 06:10AM BLOOD Glucose-128* UreaN-16 Creat-1.0 Na-141
K-3.8 Cl-108 HCO3-26 AnGap-11
___ 06:10AM BLOOD Phos-3.6 Mg-1.9
MICROBIOLOGY
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
___ MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
___ URINE URINE CULTURE-FINAL {ESCHERICHIA COLI}
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-FINAL
{STAPHYLOCOCCUS, COAGULASE NEGATIVE}; Anaerobic Bottle Gram
Stain-FINAL; Aerobic Bottle Gram Stain-FINAL EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY WARD
___ URINE URINE CULTURE-FINAL {ESCHERICHIA COLI}
___
Culture workup discontinued. Further incubation showed
contamination
with mixed fecal flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>___bd Pelvis ___. No acute intra-abdominal or intrapelvic process to explain
patient's
symptoms. No obstruction. Appendix not directly visualized,
however there are no secondary signs of acute appendicitis seen.
2. Multiple retroperitoneal lymph nodes measuring up to 1.0 cm
in short axis are significantly larger since ___. Given
patient's history of prostate cancer, further imaging with
PET-CT is recommended.
3. Diffuse coronary calcifications. Small hiatus hernia.
Colonic
diverticulosis. Other incidental findings, as above.
RECOMMENDATION(S): Recommend FDG PET-CT for further evaluation
of enlarged retroperitoneal lymph nodes, as above.
CT Pelvis ___
_______
Final Report
INDICATION: ___ year old man with history of prostate cancer s/p
brachytherapy, recurrent UTI's, here with urosepsis and prostate
tenderness on
exam. Evaluate for prostatitis or abscess.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images
were acquired
through the pelvis following intravenous contrast administration
with split
bolus technique.
IV Contrast: 130 mL Omnipaque.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on
PACS.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 3.1 s, 38.6 cm; CTDIvol = 7.9 mGy
(Body) DLP = 266.3
mGy-cm.
Total DLP (Body) = 266 mGy-cm.
COMPARISON: CT from ___.
FINDINGS:
PELVIS: The prostate is small and contains brachytherapy seeds,
and does not
demonstrate any low attenuating areas to suggest abscess. No
periprostatic
inflammation. The urinary bladder does not demonstrate wall
thickening or
perivesicular inflammation. The distal ureters opacify
normally.
Imaged small and large bowel are normal in caliber. There is no
free fluid in
the lower abdomen or pelvis.
No pelvic sidewall or inguinal lymphadenopathy.
VASCULAR: The lower abdominal aorta and iliac vessels
demonstrate mild
atherosclerotic calcification without aneurysm.
BONES: No concerning osseous lesions or fracture. Moderate
degenerative
changes of the lower lumbar spine.
SOFT TISSUES: There is fat within a right inguinal hernia.
IMPRESSION:
-Small prostate containing brachytherapy seeds, however with no
specific
evidence of prostatitis or prostatic abscess.
-No urinary bladder inflammation.
-No free fluid in the pelvis.
Brief Hospital Course:
BRIEF HOSPITAL COURSE
___ M with vascular dementia, stroke, NPH, and CABG, CLL with
stable WBC in ___, recently admitted for toxic metabolic
encephalopathy, recurrent UTI's, h/o prostate ca s/p
brachytherapy, here with urosepsis with ecoli in urine and coag
neg staph in blood, transferred from FICU ___. Mental status
dramatically improved from baseline, converted CTX to PO cipro,
DC'd dapto because coag neg staph is most likely contaminate
(was getting it for h/o VRE). Has been lethargic for weeks, only
now improving so suspect ___ subacute infection. Severely
deconditioned, plan to go to rehab post discharge with
transition to home. Though has chronic leukocytosis, afebrile
with clinical improvement.
ACTIVE MEDICAL ISSUES
# Sepsis, ___ E coli Urinary Tract Infection: Patient presents
with several day history of increasing confusion/lethargy,
diaphoresis, shortness of breath, and nausea/vomiting. Per wife,
patient has been urinating more and complaining of "groin pain".
He presented to ED with SIRS criteria with fever, tachycardia,
tachypnea, and leukocytosis. He was recently treated for UTI by
his PCP and received 3 doses of amoxicillin and also has a
history of VRE UTI. UA positive in ED with reported prostate
tenderness. Wife also reports occasions where he has recently
aspirated water. Concern was highest for prostatitis. Lactate
normalized s/p 2.5L IVF. Tachycardia and tachypnea resolved
after fluid resuscitation. We initially covered broadly for
prostatitis with vancomycin/cefepime. Urine and blood cultures
then turned positive, with coag neg Staph in blood and E coli in
urine sensitive to cipro. Daptomycin was given concern for
history of VRE in urine, but speciated as coag neg staph so DC'd
___. Cefepime narrowed to ciprofloxacin. CT negative for
prostate abscess. Urine culture growing E.coli, sensitive to CTX
and cipro. Prostate tenderness on ED exam also raised concern
for possible prostatitis, as well
as subacute onset according to his wife. ___ CT negative
for any prostatic inflammation or abscess.
- Plan to treat for 14 day course, last day ___.
- Will need urology appt upon discharge (Dr. ___, which is
in process.
# Bacteremia, contaminant: Coag neg staph in blood from ED, e
coli in urine on two samples, staph is likely contaminant.
Remains afebrile without signs or symptoms of infection. Off of
daptomycin since ___.
# Toxic Metabolic Encephalopathy: Resolved, wife reports best
mental status she has seen in weeks, implicating possible role
of subacute smoldering infection rather than acute cystitis.
# Leukocytosis: Likely related to CLL, in range with recent
baseline, mildly elevated on admission. He is currently
clinically improvemed at time of discharge, though WBC slightly
elevated. Would follow clinically, recheck WBC in 1 week, trend
fever curve.
# Retroperitoneal lymphadenopathy: Noted on CT, radiology
recommending followup PET CT, conveyed to his wife by team.
# Diabetes Mellitus Type II: Decreased home glargine to 30 units
QHS ___ AM hypoglycemia. Continue ISS. Goal blood sugars 200s
(per wife, he becomes altered at blood sugars lower than 200).
He had previously had lantus decreased during last hospital
admission ___, but was increased back to 32 prior to
admission. Continue to monitor, change prn.
CHRONIC MEDICAL ISSUES
# Hypertension: Restarted enalapril and metoprolol once sepsis
resolved. Converted metoprolol to long-acting.
# Coronary artery disease: History of CAD, s/p distant CABG. No
chest pain, shortness of breath prior to or during this
admission. Continued home clopidogrel, ASA, and statin.
# GERD/Barrett's esophagitis: Continued home pantoprazole.
# Depression: Continued home dose of sertraline and
methylphenidate.
TRANSITIONAL ISSUES
- Recommend PET-CT given enlarged intraabdominal lymph nodes and
history of prostate cancer
- needs urology f/u with Dr. ___
- cipro ends ___
- WBC elevated in history of CLL, however generally is stable,
and patient is clinically much improved w/o white count. Recheck
in 1 week, but otherwise am not concerned re: new infection.
- Please consider changing insulin as needed; patient's lantus
was decreased to 30 units ___ AM hypoglycemia during
hospitalization (had also been decreased during last
hospitalization to 30 units but was increased prior to
readmission).
- Prior to discharge, patient will need additional equipment
including hospital bed, ___ lift, and wheel chair in order to
ensure safe return to ___ home environment. Please t/b with wife
to ensure this is in place prior to d/c from rehab.
- Full code, confirmed.
- Contact: Wife ___ ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Enalapril Maleate 5 mg PO DAILY
6. Lidocaine 5% Patch 1 PTCH TD QPM
7. Methylin (methylphenidate) 5 mg oral BID
8. Metoprolol Tartrate 12.5 mg PO BID
9. Pantoprazole 40 mg PO Q24H
10. Senna 8.6 mg PO BID
11. Sertraline 12.5 mg PO DAILY
12. Sucralfate 1 gm PO QID
13. Calcium Carbonate 500 mg PO DAILY
14. Fish Oil (Omega 3) 1000 mg PO DAILY
15. Vitamin D 1000 UNIT PO DAILY
16. Glargine 32 Units Bedtime
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Calcium Carbonate 500 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Enalapril Maleate 5 mg PO DAILY
7. Glargine 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
8. Methylin (methylphenidate) 5 mg oral BID
RX *methylphenidate [Methylin] 5 mg 1 tablet(s) by mouth twice
daily Disp #*10 Tablet Refills:*0
9. Pantoprazole 40 mg PO Q24H
10. Senna 8.6 mg PO BID
11. Sertraline 12.5 mg PO DAILY
12. Sucralfate 1 gm PO QID
13. Vitamin D 1000 UNIT PO DAILY
14. Fish Oil (Omega 3) 1000 mg PO DAILY
15. Lidocaine 5% Patch 1 PTCH TD QPM
16. Metoprolol Succinate XL 25 mg PO DAILY
17. Polyethylene Glycol 17 g PO DAILY:PRN constipation
18. Bisacodyl ___AILY:PRN constipation Duration: 1 Dose
19. Ciprofloxacin HCl 500 mg PO Q12H Duration: 8 Days
ends ___
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
UTI - e. coli
Sepsis
toxic metabolic encephalopathy
Coagulase-negative staphlococcus bacteremia (contaminent)
Type 2 DM with hypoglycemia
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 because of a severe urinary tract infection
that improved with antibiotics. It is possible this is related
to your prostate, and a urology appointment will be made for
you.
The lymph nodes in your lower abdomen are enlarged, and we need
to rule out the possibility that this could be caused by
recurrence of prostate cancer. Please call your primary care
doctor to arrange what is called a PET CT scan.
You will be discharged on a new antibiotic for a short time to a
rehab. We wish you the best of luck!
Followup Instructions:
___
|
10267773-DS-36 | 10,267,773 | 29,287,033 | DS | 36 | 2119-11-19 00:00:00 | 2119-11-19 16:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o man with history below presents with two days of
n/v/abdominal pain, characteristic of his 'flares' of
gastroparesis. In the ED he was found to be hemodyamically
stable without major laboratory abnormality (ag 16, bicarb 20,
fsbg 200-250). He was given IVF and IV narcotic pain
medication (dilaudid) and admitted for further evaluation and
management for diabetic gastroparesis
He describes his pain as being in the LUQ without radiation. He
denies fever, hematemesis, diarrhea, blood per rectum. It
started two days ago, he cannot name an inciting event. He
denies alcohol use or symptoms of a UTI. He denies chest pain
or shortness of breath.
ROS: He describes his pain as being in the LUQ without
radiation. He denies fever, hematemesis, diarrhea, blood per
rectum. It started two days ago, he cannot name an inciting
event. He denies alcohol use or symptoms of a UTI. He denies
chest pain or shortness of breath. All other systems reviewed
and negative.
Past Medical History:
- Diabetes mellitus, type I
- Gastroparesis confirmed on gastric emptying study at ___
(gastric emptying study at ___ on ___ normal however pt
rec'd Reglan prior to study), followed by Dr. ___ in GI
- Esophagitis on ___ EGD
- Hypertension
- Depression
Social History:
___
Family History:
2 aunts with DM.
Physical Exam:
AF and VSS. FSBG 200.
NAD
Alert, oriented, speech fluent
MMM
No JVD
RRR
CTA throughout
Bowel sounds diminshed. TTP diffusely. No HSM, no rebound, no
guarding.
No edema
No rash
Moves all extremities
Independently ambulatory.
Pertinent Results:
___ 02:10AM PLT COUNT-335
___ 02:10AM NEUTS-68.3 ___ MONOS-3.7 EOS-0.8
BASOS-0.3
___ 02:10AM WBC-8.0 RBC-4.22* HGB-11.8* HCT-35.2* MCV-83
MCH-28.0 MCHC-33.5 RDW-13.4
___ 02:10AM ALBUMIN-4.5
___ 02:10AM ALT(SGPT)-19 AST(SGOT)-14 ALK PHOS-111 TOT
BILI-0.8
___ 02:10AM estGFR-Using this
___ 02:10AM GLUCOSE-221* UREA N-11 CREAT-1.1 SODIUM-135
POTASSIUM-3.9 CHLORIDE-97 TOTAL CO2-21* ANION GAP-21*
Brief Hospital Course:
## Nausea/vomiting: Mr. ___ was re-admitted for an
exacerbation of his typical nausea-vomiting syndrome. He was
treated with bowel rest, pain meds, and anti-emetics. His diet
was advanced without difficulty. GI was consulted and
recommended MR enterography, the results of which are pending at
this time but preliminarily non-diagnostic. Per disussion with
Radiology over the phone, there may be an area of proctitis with
an abnormal appearance. The GI service is aware of this and
plans to do colonoscopy as outpatient next week if he has not
been re-admitted. Records from ___ were reviewed and an array of
studies was negative, including MRI, endoscopy, and gastric
emptying study. If the MRE is negative, would recommend
consulting the Neuro/Autonomic service for further evaluation
and management. His pain and nausea had reportedly completely
resolved by the time of discharge.
## Hyperglycemia: He had hyperglycemia with mild metabolic
acidosis on admission, which resolved with IV fluids and
resuming his home Insulin regimen.
## Stable chronic issues: HTN, depression.
Medications on Admission:
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
4. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO DAILY
(Daily).
10. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
11. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
12. magnesium citrate Solution Sig: Three Hundred (300) ML
PO DAILY (Daily) as needed for Constipation.
13. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
14. insulin glargine 100 unit/mL Solution Sig: ___ (36)
units Subcutaneous at bedtime.
15. insulin aspart 100 unit/mL Solution Sig: Fifteen (15) units
Subcutaneous three times a day: with meals.
16. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every ___
hours as needed for pain for 5 days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Medications:
1. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO DAILY (Daily).
2. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO DAILY
(Daily).
8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
9. senna 8.6 mg Tablet Sig: ___ Tablets PO BID (2 times a day)
as needed for constipation.
10. insulin glargine 100 unit/mL Solution Sig: ___ (36)
units, insulin Subcutaneous at bedtime.
11. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
12. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain.
13. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day): with meals.
Disp:*60 Tablet(s)* Refills:*0*
14. ondansetron 4 mg Tablet, Rapid Dissolve Sig: ___ Tablet,
Rapid Dissolves PO every eight (8) hours as needed for nausea.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
15. insulin aspart 100 unit/mL Solution Sig: Fifteen (15) units
Subcutaneous three times a day: before meals.
Discharge Disposition:
Home
Discharge Diagnosis:
Functional abdominal pain with nausea and vomiting.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for your typical syndrome of abdominal pain
and nausea and vomiting. No clear cause was found to explain
this syndrome.
You were found to be iron-deficient. Iron supplements were
prescribed, to be taken twice daily with meals.
Followup Instructions:
___
|
10267773-DS-40 | 10,267,773 | 22,697,251 | DS | 40 | 2120-02-18 00:00:00 | 2120-02-18 17:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ MEDICINE ATTENDING ADMISSION NOTE
Date: ___
Time: 02:06
The patient is a ___ year old with cyclic vomiting syndrome,
multiple admissions for nausea/vomiting and narcotic seeking
behavior who presents with intractable vomiting and LLQ pain
similar to his prior episodes, onset yesterday. He recently was
admitted ___ with the same complaints but signed out AMA
after the team decided to engage in non-narcotic analgesia. He
returned and was readmitted on ___, was able to tolerate
breakfast and lunch on ___. He was going to be discharged
with social work consultation for home insecurity, but eloped
prior to being discharged. He was subsequently seen in the ED
five times with similar presentations since his last admit.
He currently states that he has had intractable nausea for the
past 24 hours which has not responded to po reglan/zofran. He
states he could not keep any meals down today, and presents for
symptom relief. He also complains of LLQ abdominal pain which is
___ in intensity. He endorses his usual constipation and
denies f/c or diarrhea.
In ER:
VS: 96.7 ___ 16 100% RA, ___ LLQ pain
PX: Oriented x3. amb ind.; R POC. accessed w/ 20g ___ power
port needle. +Bld Return
Studies: CBC: stable anemia, CHEM10 & u/a: wnl
Fluids given: 1L NS
Meds given: ondansetron 4 mg IVx1, metoclopramide 10 mg IV x1,
hydromorphone 1 mg IV x2, lorazepam 1 mg IV x1, potassium
chloride 40 mEq /500 ml NS IV x1
Consults called: None
VS prior to transfer to the floor: 98.2, 92, 16, 127/89, 100%RA
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies visual changes, headache, dizziness, sinus
tenderness, neck stiffness, rhinorrhea, congestion, sore throat
or dysphagia. Denies chest pain, palpitations, orthopnea,
dyspnea on exertion. Denies shortness of breath, cough or
wheezes. Denies heartburn, diarrhea, BRBPR, melena. No dysuria,
urinary frequency. Denies arthralgias or myalgias. Denies
rashes. No increasing lower extremity swelling. No
numbness/tingling or muscle weakness in extremities. No feelings
of depression or anxiety. All other review of systems negative.
Past Medical History:
- Diabetes mellitus, type I
- cyclic vomitting (diagnosed at ___, by GI)
- NO evidence of gastroparesis: gastric emptying study at ___
perviously and at ___ on ___ normal, followed by Dr.
___ in GI
- Esophagitis on ___ EGD
- Hypertension
- Depression
Social History:
___
Family History:
2 aunts with DM.
Physical Exam:
VS: 97.4 163/115 (after emesis; repeat 110/83) 94 20 100% RA;
___ LLQ pain
GEN: No apparent distress
HEENT: no trauma, pupils round and reactive to light and
accommodation, no LAD, oropharynx clear, no exudates
CV: regular rate and rhythm, no murmurs/gallops/rubs
PULM: Clear to auscultation bilaterally, no
rales/crackles/rhonchi
GI: soft, non-tender, non-distended; no guarding/rebound
EXT: no clubbing/cyanosis/edema; 2+ distal pulses; peripheral IV
present
NEURO: Alert and oriented to person, place and situation; CN
II-XII intact, ___ motor function globally
DERM: no lesions appreciated
Pertinent Results:
___ 08:00PM GLUCOSE-191* UREA N-9 CREAT-1.1 SODIUM-139
POTASSIUM-3.3 CHLORIDE-101 TOTAL CO2-22 ANION GAP-19
___ 08:00PM ALT(SGPT)-17 AST(SGOT)-14 ALK PHOS-121 TOT
BILI-0.4
___ 08:00PM LIPASE-32
___ 08:00PM WBC-7.8 RBC-3.94* HGB-10.4* HCT-31.4* MCV-80*
MCH-26.3* MCHC-32.9 RDW-15.0
___ 08:00PM NEUTS-75.4* ___ MONOS-4.2 EOS-1.2
BASOS-0.7
___ 08:00PM PLT COUNT-273
___ 06:00AM ALT(SGPT)-19 AST(SGOT)-14 ALK PHOS-117 TOT
BILI-0.2
___ 06:00AM LIPASE-38
___ 06:00AM ALBUMIN-4.3
___ 06:00AM WBC-6.3 RBC-4.06* HGB-10.5* HCT-33.3* MCV-82
MCH-25.7* MCHC-31.4 RDW-15.0
___ 06:00AM NEUTS-59.6 ___ MONOS-4.0 EOS-2.2
BASOS-1.2
___ 06:00AM PLT COUNT-214
___ Radiology ABDOMEN (SUPINE & ERECT):
FINDINGS: There are no dilated loops of large or small bowel,
although a
number of small air-fluid levels are present in the right lower
quadrant.
Most and perhaps all of these are colonic. No free air is seen.
Stool and
air are seen throughout most portions of the colon. As seen
previously, small calcifications are unchanged within the lower
pole suggesting phleboliths. Leftward convex curvature is
centered at the thoracolumbar junction.
IMPRESSION: Several nonspecific air-fluid levels in the right
lower quadrant, but no evidence for gastric distention or
findings strongly suggestive of bowel obstruction.
Brief Hospital Course:
Assessment and Plan:
#. Nausea/Vomiting/abdominal pain: Per outpatient
gastroenterologist Dr. ___, these episodes are likely
secondary to cyclic vomiting, chronic pancreatitis, colonic
dysmotility, IBD (rectal thickening), or diabetic enteropathy.
Gastroparesis is unlikely given his normal gastric emptying
study while having symptoms. His plan was to minimize narcotics
as his pain seems to be related to his constipation.
- Did NOT give opiates. Instead, gave IV tylenol and dose of
Toradol. Also gave aggressive bowel regimen
#. Constipation: Chronic, likely from narcotics.
- Senna, bisacodyl for constipation. Also added high dose
Miralax
#. Type I Diabetes Mellitus: Will treat with reduced doses of
insulin glargine given NPO. Resumed home dose of Lantus 36
units with Aspart on discharge
#. Anemia: Iron deficiency with low Ferritin (12 in ___.
- Iron supplementation
#. Hypertension: Stable.
- Continued home lisinopril
#. Depression: Stable.
- Continued home mirtazapine
Medications on Admission:
1. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS
2. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
3. pantoprazole 40 mg (E.C.) One Tablet, Delayed Release (E.C.)
PO Q24H
4. ferrous sulfate 300 mg (60 mg iron) One Tablet PO twice a
day.
5. ondansetron 8 mg Film Sig: One (1) film PO Q8H as needed for
nausea.
6. metoclopramide 10 mg One Tablet PO QIDACHS
7. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. insulin glargine 100 unit/mL Solution: 36U SubQ at bedtime.
9. Novolog 100 unit/mL Solution Sig: 15U SubQ three times a day:
Before meals.
10. bisacodyl 5 mg (E.C.) One Tablet PO DAILY prn constipation.
11. polyethylene glycol 3350 17 gram Powder One PO DAILY
12. gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q8H
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
14. senna 8.6 mg Tablet Sig: ___ Tablets PO BID as needed for
constipation.
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for fever or pain: limit to 4 grams per day.
2. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
Disp:*60 Capsule(s)* Refills:*0*
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
10. Miralax 17 gram Powder in Packet Sig: One (1) packet PO
twice a day.
Disp:*60 packets* Refills:*2*
11. Lantus 100 unit/mL Solution Sig: ___ (36) units
Subcutaneous at bedtime.
12. insulin aspart 100 unit/mL Solution Sig: Fifteen (15) units
Subcutaneous three times a day: with meals.
13. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain, generalized
Nausea with vomiting
Constipation
Type 1 diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for treatment for your recurrent symptoms of
abdominal pain and nausea. The most likely contributor of your
symptoms is constipation.
It is very important that you take stool softeners to move your
bowels regularly. Please take all home medications as before
Additionally, it is VERY important that you call your GI doctor
for an appointment (___). You have missed the previous
appointments, and need to be scheduled for a colonoscopy.
Followup Instructions:
___
|
10267773-DS-42 | 10,267,773 | 28,395,860 | DS | 42 | 2120-09-02 00:00:00 | 2120-09-02 13:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ pmh cyclic vomiting syndrome, multiple admissions and ED
visits for nausea/vomiting and narcotic seeking behavior, IDDM,
chronic abdominal pain of unknown etiology, presents with severe
generalized abdominal pain and vomiting since yesterday morning.
Pain is burning, ___ in intensity, left-sided, and relieved
with dilaudid/ativan/zofran/reglan. Pt states he has not been
able to hold down any PO. He usually has BM every 2 days, and
last had a BM ___ days ago. Vomit nb/nb, no blood in stool, no
f/s/c/d. Pt has been going to many hospital EDs for care
(___), was last at ___ per patient 4 days ago
for episode which was "exactly the same." Pt states he often
needs to go to EDs for treatment with pain meds more than once
per week. Pt has a portacath for IV access.
.
Pt with 8 ED presentations at ___ since ___, last was
___. He has previously left AMA when the inpatient team
refused to give him IV dilaudid. GI teams previously believed
this to be cyclic vomiting, chronic pancreatitis, colonic
dysmotility, IBD (rectal thickening), or diabetic enteropathy.
Teams on previous admissions have avoided narcotics to avoid
exacerbating his chronic constipation and have suggested a
regimen of IV tylenol and toradol.
.
Previous workup for his pain included an MRE which showed rectal
thickening, a gastric emptying study most recently that showed
rapid gastric emptying, an EGD with mild erythema and mild
duodenitis, and a CT abdomen pelvis that was normal. A visit
with gastroenterology (Dr. ___ in ___ did not reveal an
acute process, but rather focused on constipation as a possible
cause and an emphasis to minimize use of narcotics for his pain.
.
In the ED, Vitals included Pain 10, T 98.7, HR 86, BP 146/86, RR
18, O2 98% ra. Labs were significant for lactate 2.9, WBC 13.1
(86N, 9.3L), glu 213. Serum tox was negative for ASA, EtOH,
Acetmnphn, Benzo, Barb, Tricyc. LFTs / lipase were wnl. He was
ruled out for DKA. He was given dilaudid 1mg x 2, Ondansetron
2mg x 2, Metoclopramide 5mg, Lorazepam 2mg, and IV fluids. No
imaging was performed. He continued to have vomiting and was
unable to tolerate PO despite antiemetics, and was admitted for
acute exacerbation of his chronic abdominal pain.
Past Medical History:
- Diabetes mellitus, type I
- cyclic vomitting (diagnosed at ___, by GI)
- NO evidence of gastroparesis: gastric emptying study at ___
perviously and at ___ on ___ normal, followed by Dr.
___ in GI
- Esophagitis on ___ EGD
- Hypertension
- Depression
- hyperlipidemia
Social History:
___
Family History:
2 aunts with DM.
Physical Exam:
Vitals: T: 98.6 F, BP: 167/86 mmHg, HR 77 bpm, RR 18 bpm, O2:
100 % on RA.
Gen: ___ male, rocking in bed, vomiting into
bedpan, numerous tattoos.
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Supple, No LAD. JVP low. Normal carotid upstroke without
bruits. No thyromegaly.
CV: RRR. normal S1,S2. No murmurs, rubs, clicks, or ___.
LUNGS: CTAB. No wheezes, rales, or rhonchi.
ABD: BS present. No reaction to stethescope pressure. Diffusely
tender. Soft, ND. No HSM. No abdominal bruits.
EXT: WWP, NO CCE. Full distal pulses bilaterally.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. CN ___ grossly intact. Preserved sensation
throughout. ___ strength throughout. ___ reflexes, equal ___.
Normal coordination. Gait assessment deferred
PSYCH: Mood was anxious, insistent, and affect was not normal.
Pertinent Results:
___ 02:24PM PLT COUNT-218
___ 02:24PM NEUTS-86.2* LYMPHS-9.3* MONOS-4.1 EOS-0.1
BASOS-0.3
___ 02:24PM WBC-13.1* RBC-4.52* HGB-13.2*# HCT-38.1*#
MCV-84# MCH-29.2# MCHC-34.6 RDW-14.0
___ 02:24PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 02:24PM ALBUMIN-4.5
___ 02:24PM LIPASE-22
___ 02:24PM ALT(SGPT)-15 AST(SGOT)-14 ALK PHOS-119 TOT
BILI-1.3
___ 02:24PM estGFR-Using this
___ 02:24PM GLUCOSE-213* UREA N-12 CREAT-0.9 SODIUM-134
POTASSIUM-3.3 CHLORIDE-97 TOTAL CO2-23 ANION GAP-17
___ 02:27PM LACTATE-2.9*
___ 02:27PM COMMENTS-GREEN TOP
KUB:
Brief Hospital Course:
SUMMARY: ___ y/o M with pmh likely cyclic vomiting syndrome, type
1 diabetes mellitus, frequent admissions and ED visits for
nausea/vomiting and narcotic seeking behavior who was admitted
for nausea/vomiting and abdominal pain, consistent with prior
presentations.
.
# Abdominal pain: his symptoms include diffuse abdominal pain,
nausea, vomiting, consistent with his history of cyclic vomiting
syndrome. He is currently followed by Dr. ___ and Dr.
___ the GI department at ___, and by his PCP ___.
___ at ___. Differential
includes medication seeking, cyclic vomiting, mesenteric
ischemia, chronic constipation, chronic pancreatitis, colonic
dysmotility, IBD (rectal thickening), diabetic enteropathy or
musculoskeletal pain. He has a history of numerous ED admissions
for the same symptoms, and previously left the ___ AMA when
team treated with non-narcotic analgesics. Discussion with Dr.
___ that he visits hospitals around the city with the
same symptoms demanding IV dilaudid and benadryl. KUB showed no
abnormalities. He was treated with IV fluids, NPO, standing IV
tylenol 1g TID and Toradol 15mg IV Q6H, and zofran / reglan for
his nausea. He received IV dilaudid in the ED, but he was not
given narcotics on the floor. He left AMA on the morning of
___, after refusing his insulin, fingersticks, and physical
exam. His IV was removed, and he eloped before 7:30AM. He was
discouraged from AMA the on ___, and was told of negative
consequences including worsening of his symptoms and death.
.
# Elevated lactate: He presented with elevated lactate to 2.9.
This was likely secondary to dehydration in the setting of
vomiting and inability to take PO. He was treated with IV
hydration, and his lactate improved to 1.3 on hospital day two.
.
# Chronic constipation: he had not been taking any of his
medications as an outpatient, including his usual miralax and
stool softener regimen. KUB showed moderate fecal load, and no
other abnormalities. He was prescribed an aggressive bowel
regimen for narcotic induced constipation, however he was unable
to take many of his PO medications.
.
CHRONIC ISSUES:
# Type I Diabetes: serum glucose 218 on admission. His home
glargine dose was decreased to half, and his insulin aspart was
held while NPO
.
# Iron Deficiency Anemia: last ferritin was 12 in ___, he
continues to have a microcytic anemia. We continued his home
iron supplementation
.
# Depression: continued home mirtazapine
.
# Hypertension: continued home lisinopril
.
# Hyperlipidemia: continue home pravastatin
.
FOLLOW-UP ISSUES
- Please encourage him to follow up with his primary care
physician for management of his abdominal pain. Discourage
visits to ED and admissions for inpatient management of
abdominal pain.
- He will need outpatient psychiatry follow up as well for his
chronic pain.
Medications on Admission:
- mirtazapine 15 mg HS
- pravastatin 40mg DAILY
- pantoprazole 40 mg Q24H (every 24 hours).
- lisinopril 20 mg DAILY
- ferrous sulfate 300 mg Daily
- gabapentin 200 mg PO Q8H
- senna 8.6 mg BID
- bisacodyl 5 mg DAILY as needed for constipation.
- Lantus: ___ units at bedtime.
- insulin aspart: Fifteen units three times a day: with meals.
- Zofran 4 mg every eight hours as needed for nausea.
- Reglan (unknown dose)
- Percocet 2 tablets Q6H
Discharge Medications:
- mirtazapine 15 mg HS
- pravastatin 40mg DAILY
- pantoprazole 40 mg Q24H (every 24 hours).
- lisinopril 20 mg DAILY
- ferrous sulfate 300 mg Daily
- gabapentin 200 mg PO Q8H
- senna 8.6 mg BID
- bisacodyl 5 mg DAILY as needed for constipation.
- Lantus: ___ units at bedtime.
- insulin aspart: Fifteen units three times a day: with meals.
- Zofran 4 mg every eight hours as needed for nausea.
- Reglan (unknown dose)
- Percocet 2 tablets Q6H
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Acute on chronic abdominal pain
Secondary:
- Diabetes mellitus
- Depression
- Drug seeking behavior
Discharge Condition:
Stable. Patient was not in acute distress, and left AMA.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital for management of your acute
on chronic abdominal pain. Laboratory and radiology tests did
not show a definitive cause for your symptoms. We understand
that you have been to many hospitals this year for your
abdominal pain. You were treated with tylenol, toradol, zofran,
reglan, and medications to relieve your constipation. You left
on ___ against medical advice, and were informed of possible
consequences of your actions, including worsening
pain/nausea/vomiting, and even death.
Followup Instructions:
___
|
10268150-DS-15 | 10,268,150 | 24,152,227 | DS | 15 | 2174-10-06 00:00:00 | 2174-10-06 14:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Lipitor / Demerol / diltiazem / latex
Attending: ___
Chief Complaint:
Trauma
Major Surgical or Invasive Procedure:
___ Left Hip TFN
History of Present Illness:
___ female with past medical history significant for A. fib (on
___ last dose on ___ and lumbar spine fusion presents to
the hospital after losing her balance. She had a head strike but
no loss of consciousness. Had pain in the left hip and could not
ambulate afterwards. Presented to twice daily MC and
evaluation found to have SAH and left comminuted
intertrochanteric femur fracture.
Past Medical History:
Afib on ___
GERD
MI s/p stent
HTN
HLD
PNA
Depression
Social History:
___
Family History:
Unremarkable
Physical Exam:
AVSS
NAD, A&Ox3
___: Incision well approximated. Dressing clean and dry. Fires
FHL, ___, TA, GCS. SILT ___ n distributions. 1+ DP
pulse, wwp distally.
Pertinent Results:
___ 07:45AM BLOOD WBC-12.4* RBC-3.42* Hgb-10.8* Hct-32.5*
MCV-95 MCH-31.6 MCHC-33.2 RDW-18.2* RDWSD-62.4* Plt ___
___ 03:50AM BLOOD Neuts-85.6* Lymphs-7.6* Monos-5.7
Eos-0.4* Baso-0.2 Im ___ AbsNeut-14.47* AbsLymp-1.28
AbsMono-0.96* AbsEos-0.06 AbsBaso-0.04
___ 07:45AM BLOOD Plt ___
___ 06:25AM BLOOD Glucose-169* UreaN-16 Creat-0.8 Na-138
K-4.4 Cl-101 HCO3-25 AnGap-12
___ 06:25AM BLOOD Calcium-8.4 Phos-2.2* Mg-1.9
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was
initially admitted to the TSICU with the following injuries
1. Left temporal SAH stable on CT over 24 hours and with normal
neurologic exam in Q1H neuro checks for 24 hours. The patient
was evaluated by Neurosurgery with the following
recommendations:
- Q4H neurologic checks
- Okay for prophylactic ___ BID dosing to start ___ at ___
for DVT prophylaxis
- No Keppra
- Continue to hold ___ in the setting of intracranial
hemorrhage
2. Left IT hip fracture managed by Orthopaedic Surgery
The patient was taken to the operating room on ___ for left
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 extended care facility 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
WBAT in the LL extremity, and will be discharged on heparin 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:
pravastatin 80 mg', Lanoxin 125 mcg', Vitamin D3 2,000 unit',
Celexa 10 mg', ___ 150 mg''
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Docusate Sodium 100 mg PO BID
3. Heparin 5000 UNIT SC BID
4. OxyCODONE (Immediate Release) 2.5-7.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth q6hr Disp #*20 Tablet
Refills:*0
5. Senna 8.6 mg PO BID:PRN Constipation - First Line
6. Citalopram 10 mg PO DAILY
7. Digoxin 0.125 mg PO DAILY
8. Pravastatin 80 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left IT hip fracture
___
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:
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:
Out of bed with assistance
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 use subq heparin daily until you can restart your
___ cleared by neurosurgery
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
Followup Instructions:
___
|
10268311-DS-10 | 10,268,311 | 23,042,403 | DS | 10 | 2184-04-15 00:00:00 | 2184-04-15 14:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
amoxicillin / Ativan
Attending: ___
Chief Complaint:
AMS in pt with CNS Lymphoma
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
The patient is a ___ with hx of CLL as well as primary CNS
lymphoma here with confusion.
He initially presented with dizziness in ___ to ___
where he had an MRI ___ showing R frontal enhancing lesion and
R temporal lesion felt to be consistent with meningioma but
biopsy of which showed diffuse large B cell lymphoma. He had BM
biopsy and tonsillar biopsy consistent with CLL. He was treated
with MTX and Rituxan but developed renal failure which lead to a
prolonged hospitalization.
He then started on Rituxan and Temodar as second line palliative
therapy. Follow up imaging showed mostly right hemisphere
lesions.
Repeat ___ ___ showed new enhancing mass in posterior limb
of L internal capsule 8x14mm. R frontal lobe lesion not
significantly changed from prior exam. R parietal lobe
unchanged.
MRI ___ ___ which can be seen in our system showed
vasogenic edema and contrast enhancement in the lesions note
above. There was also small area of restricted diffusion in
posterior limb of left internal capsule.
Due to this progression with new lesion, there has been
discussion of transferring Mr ___ oncologic care to ___
specifically to explore the possibility of stereotactic
radiation. He has seen radiation oncology in ___ who was
helping to coordinate this.
Pt's wife reports that the patient saw a Dr ___ here at ___
on ___ but there is no note yet in our system.
Previously the patient had good functional status - was walking
around without any assistive device and going about his life as
usual with most recent neuro exam (___):
"NEURO: Cranial nerves II through XII grossly intact. Gross
light touch intact throughout. Motor ___ bilateral symmetric
throughout. No drift, but positive Romberg, though the patient
has normal finger-nose-finger, I did get a sense of mild
right-sided neglect on limited exam."
For the last two weeks, patient's wife reports that he has been
having waxing and waning confusion - "sometimes he is crystal
clear and sometimes he is confused". He has been intermittently
sleeping more as well. She did feel that intermittently it would
seem like he was ignoring her as he would not respond to her
questions for several minutes at a time. Interestingly, when
asked about abnormal movements, she notes that when driving
recently, he has intermittently been making a petting motion
with
his right arm on the steering wheel which he has never done
previously.
On ___, he was climbing a ladder to fill a bird feeder in the
tree when he fell, striking his right face and right side of his
body. He was taken to ___ where they performed the
appropriate CTs which revealed non displaced pelvic fracture and
no bleed on HCT. He was sent home. However since then, he has
been consistently confused, at times making babbling sounds that
do not make any sense, increased somnolence. He has had right
leg
pain, numbness, tingling which make him unable to walk and he
has
urinated on the ground as he cannot make it to the bathroom. His
wife also noted that both his legs were swollen. For these
reasons, she brought him to ___ where they got a ___
which reportedly showed increased edema surrounding his L
internal capsule lesion.
He was transferred to ___ for further management.
On my eval, patient is only able to tell me that he fell two
days
ago and since then has been very tired with right leg pain and
numbness that makes him unable to walk. He is initially
cooperative with the beginning of the exam then loses patience
and refuses to cooperate.
On neurologic review of systems, the patient denies headache or
confusion. Denies difficulty with producing or comprehending
speech. Denies loss of vision, blurred vision, diplopia,
vertigo,
dysphagia.
On general review of systems, the pt denies recent fever or
chills. Denies cough, shortness of breath. Denies chest pain.
Denies nausea, vomiting, diarrhea, or abdominal pain. No
dysuria.
Past Medical History:
CNS Lymphoma
CLL
Social History:
___
Family History:
- "Father deceased, age ___. Mother deceased, age ___, with
dementia. One son, age ___, with hypertension. One daughter,
deceased at age at age ___ from accidental overdose. Another
survived severe trauma, and the other reportedly well. One
brother, age ___, with "prostate issues," removed, thouhh not
specifically reporting a history of cancer. No other family
history of cancer or blood disorder to his knowledge."
Physical Exam:
=== ADMISSION EXAM ===
Vitals: 98.8F, HR 76, 155/73, 95% on RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, dry mucous membranes, no
lesions noted in oropharynx
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR
Abdomen: soft, NT/ND
Neurologic:
-Mental Status: Alert, Oriented to ___ but not date stated the
date was ___. Unable to give a detailed history.
Inattentive, unable to name ___ backwards got to ___, then
started counting forwards. Unable to ___ backwards. Language
is fluent with intact repetition and comprehension. 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 - followed a 3 step command on the second try. There
was
no evidence of neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. VFF to confrontation.
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, +paratonia.
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___
L 5 ___ ___ --- 4+ -----------------
R 5 ___ ___ 4+* 4+ -----------------
After testing the upper extremities and the IPs and Hamstrings,
he refused further testing and only lifted TAs slightly to
noxious. * for R Quad weakness refers to giveway.
-Sensory: No deficits to light touch, pinprick throughout. No
deficits to proprioception in UE. No extinction to DSS.
-DTRs:
___ ___ Pat Ach
L 3 3 1 0
R 3 3 1 0
Plantar response was flexor bilaterally. No ankle clonus.
-Coordination: No dysmetria on FNF bilaterally.
-Gait: Not tested.
************
NEURO ICU TRANSFER EXAMINATION
General: ill-appearing elderly gentleman, lying with eyes closed
HEENT: atraumatic, increased oral mucous secretions, on shovel
mask
Neck: supple
CV: regular rate, intermittently tachycardic
Lungs: mildly tachypneic, diffusely rhonchorous
Abdomen: distended, nontender, no rebound
GU: no hernia
Ext: warm, well perfused, no edema
Neuro:
- MS: eyes closed, opens occasionally to voice, grimaces to
noxious stimuli, does not reliably follow commands
- CN: PERRL, face symmetric, unable to assess cough/gag
reflexes, does not protrude tongue
- Motor: ___ full strength against resistance, LLE at least
antigravity proximally and distally, RLE not assessed secondary
to known pelvic fracture
- Sensory: responds to noxious stimuli throughout
- DTRs: ___ 3+, knees 2+, ankles 1+, toes flexor
Skin: no rash
=== DISCHARGE EXAM ===
General: ill-appearing elderly gentleman, lying with eyes
closed, coarse breathing.
HEENT: atraumatic, increased oral mucous secretions, on shovel
mask
General Medical Examination deferred ___ CMO.
Neuro:
- MS: eyes closed, opens occasionally to voice, does not
reliably follow commands
- Remainder of exam deferred.
Pertinent Results:
=== LABS ===
___ 07:01PM BLOOD WBC-8.6 RBC-3.84* Hgb-12.6* Hct-37.8*
MCV-98 MCH-32.8* MCHC-33.3 RDW-13.9 RDWSD-50.3* Plt ___
___ 07:01PM BLOOD Neuts-96.5* Lymphs-1.7* Monos-1.3*
Eos-0.1* Baso-0.1 Im ___ AbsNeut-8.28* AbsLymp-0.15*
AbsMono-0.11* AbsEos-0.01* AbsBaso-0.01
___ 07:01PM BLOOD Glucose-126* UreaN-26* Creat-1.1 Na-140
K-3.6 Cl-104 HCO3-25 AnGap-15
___ 07:01PM BLOOD ALT-9 AST-12 AlkPhos-75 TotBili-0.7
___ 05:00PM BLOOD LD(LDH)-288*
___ 07:01PM BLOOD Lipase-32
___ 07:01PM BLOOD Albumin-3.8 Calcium-8.8 Phos-2.7 Mg-1.9
___ 06:55AM BLOOD TSH-1.1
___ 05:00PM BLOOD PEP-NO SPECIFI b2micro-2.1
___ 07:33PM BLOOD Lactate-1.4
___ 06:12AM BLOOD Lactate-1.4
___ 06:21AM BLOOD Lactate-2.2*
___ 06:12AM BLOOD Type-ART pO2-79* pCO2-34* pH-7.42
calTCO2-23 Base XS--1 Intubat-NOT INTUBA
___ 06:21AM BLOOD ___ pO2-127* pCO2-35 pH-7.38
calTCO2-22 Base XS--3
___ 05:40PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 09:38PM URINE pH-4 Hours-24 Volume-1200 Creat-130
TotProt-38 Prot/Cr-0.3*
=== IMAGING ===
- CXR (___)
Allowing the difference in positioning of the patient and
technique, bibasilar opacities right greater than left are
unchanged, as mentioned before could be atelectasis or pneumonia
in the appropriate clinical setting. There are no new lung
abnormalities. No other interval change from prior study.
- MR ___ (___)
1. Interval increased enhancing component of a left basal
ganglia lesion now measuring approximately 2.5 cm in greatest
dimension previously measuring 1.6cm. Associated edema pattern
canal extends to the left mesial temporal cortex and into the
left cerebral peduncle, with mild effacement of the left
temporal horn.
2. There is also interval increase size of a 9 mm right splenium
of the corpus callosum and 2 mm right marginal gyrus cortical
lesion on FLAIR, without definitive associated enhancement.
3. There is a new FLAIR hyperintense nonenhancing lesion in the
right
cerebellar hemisphere (series 10, image 6), although there was
subtle
diffusion-weighted hyperintense signal on the prior exam this
region.
4. These above lesions are associated with diffusion-weighted
hyperintense
signal.
5. 4 mm nodular enhancement in the left internal auditory canal
may represent a Schwannoma, however the vermis involvement is
not excluded and close attention on followup is recommended.
6. Extra-axial right anterior falcine and right anterior
temporal lobe
homogeneously enhancing lesions are identified, unchanged from
prior exam.
- MR ___ (___)
1. Severely limited study due to patient inability to tolerate
examination, motion degradation, incomplete sequences, and lack
of intravenous contrast.
2. Within these limitations, left basal ganglia and right corpus
callosum
splenium parenchymal signal intensity abnormalities have
progressed compared to ___ prior MRI.
3. Right greater left bifrontal and right cerebellar hemisphere
parenchymal signal intensity abnormalities grossly unchanged.
4. Within limits of study, partially visualized right anterior
temporal
convexity mass grossly stable in size compared to prior exam.
Previously
noted additional similar masses along anterior falx are not
visualized on
current exam, likely due to lack of intravenous contrast. If
clinically
indicated, consider repeat exam with contrast when patient can
tolerate study.
- CT Chest (___)
1. No evidence of malignancy in the thorax.
2. Small bilateral pleural effusions and bibasilar atelectasis.
- CT Abdomen Pelvis (___)
1. No evidence of malignancy in the abdomen or pelvis.
2. Cholelithiasis.
3. Massively enlarged prostate measuring 7.8 x 6.0 cm.
4. Moderate atherosclerotic disease of the abdominal aorta.
Brief Hospital Course:
Mr. ___ is an ___ man with PMHx of HTN and CLL ___
years ago) with CNS lymphoma (___) presenting with 2
weeks of confusion with significant worsening after fall from
ladder on ___. Following continued neurologic decline and
significant aspiration event, patient was made CMO this
admission and discharged to hospice.
# CNS Lymphoma, CMO
He presented to ___ due to AMS in the setting of
right facial trauma and non-displaced pelvic fracture after
falling from a ladder. Follow-up CT at ___ showed
worsening of his CNS lymphoma (posterior left internal capsule
lesion) and he was transferred to ___ for further management.
He was admitted to the Neurology service for further evaluation
and possible treatment of CNS lymphoma. Neuro-Oncology was
consulted.
As part of evaluation he underwent CT torso and CT abd/pelvis w/
no signs of metastasis. TTE shows normal biventricular function.
He poorly tolerated MR head and initially did not receive
contrast, though he was later able to complete the study, which
demonstrated significant interval progression. LP was attempted
to aid in staging, but he was unable to tolerate this. On family
discussion with neuro-oncology (Dr. ___ the decision was
made to try another round of methotrexate (which he previously
had not tolerated at ___, and if he did not tolerate it, to
proceed to comfort measures only. Prior to initiation of this
treatment however, he had an aspiration events and experienced a
rapid respiratory decline requiring NRB. He was transferred to
the ICU for stabilization and consideration of intubation while
goals of care were discussed (family had wanted to proceed with
aggressive chemotherapy, but had previously not wanted
Intubation).
Upon discussion with Neuro-oncology and the patient's wife,
including extensively detailing the high risk of prolonged
intubation and/or other risks of intubation in an elderly and
medically ill gentleman, she opted to maintain his DNR/DNI
status and to forego the plan on high dose methotrexate.
Palliative Care was consulted and spoke with the wife
extensively about his goals of care, and it was determined that
he should be made comfort measures only. He was started on
morphine IV q2h prn, standing acetaminophen 1000mg q6h for
dyspnea and pain, as well as scopolamine, glycopyrrolate,
haloperidol, and Ativan prn per comfort measure orders. He was
subsequently transferred back to floor.
He was subsequently discharged to Hospice.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Potassium Chloride 20 mEq PO DAILY
3. Dexamethasone 4 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
CNS Lymphoma
Aspiration Event
Comfort Measures ONLY
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic and not arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dr. ___,
You were admitted to the Neurology service for evaluation and
management of your CNS lymphoma. While here, you were treated
by the Neurology and Neuro-Oncology Team. After an event of
aspiration and with extensive discussion with your wife and
family by your doctors, decision as made to focus on your
comfort and time home, rather than aggressive treatment of your
Lymphoma. You were made Comfort Measures Only (CMO) and
transitioned to hospice care.
It was a pleasure taking care of you,
Your ___ Care Team
Followup Instructions:
___
|
10268465-DS-16 | 10,268,465 | 29,489,623 | DS | 16 | 2149-11-10 00:00:00 | 2149-11-10 16:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Dob Hoff tube replaced
History of Present Illness:
___ year old man with a history of
diabetes mellitus, gastroesophageal reflux disease,
hyperlipidemia, and hypertension s/p coronary artery bypass
graft
x5/ AVR on ___. Post op course complicated by delirium, AF,
___ requiring HD. He was transferred to rehab yesterday and
overnight was reported to have mental status changes, pulled out
DHT. He was transferred to ___ who transferred him to ___ ED
due to elevated creatinine and troponin. Of note, wife was
unhappy with rehab choice.
Past Medical History:
CAD
AS
dysphagia
respiratory failure
AFib
Diabetes Mellitus Type II
Gastroesophageal Reflux Disease
Hyperlipidemia
Hypertension
Osteoarthritis, back and shoulders
Social History:
___
Family History:
Father: prostate cancer
Mother: breast cancer, died of old age
Physical Exam:
Pulse:94 Resp:18 O2 sat:96% RA
B/P Right:112/64 Left:
Height: Weight:
General:Awake, alert in NAD, oriented to name and year
___: Dry [x] intact []
HEENT: PERRLA [x] EOMI []
Neck: Supple [] Full ROM []
Chest: Lungs clear bilaterally [x] Exp wheezes
Heart: RRR [x] tachy Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x] well-perfused [x] Edema: trace
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: none
Pertinent Results:
___ 06:01AM BLOOD WBC-10.0 RBC-3.09* Hgb-9.1* Hct-27.3*
MCV-88 MCH-29.4 MCHC-33.3 RDW-14.6 Plt ___
___ 06:01AM BLOOD ___
___ 07:00AM BLOOD ___ PTT-34.2 ___
___ 05:12AM BLOOD ___ PTT-33.6 ___
___ 06:01AM BLOOD Glucose-96 UreaN-55* Creat-5.9*# Na-138
K-4.6 Cl-96 HCO3-28 AnGap-19
___ 07:00AM BLOOD Glucose-130* UreaN-69* Creat-6.1* Na-135
K-4.6 Cl-93* HCO3-25 AnGap-22*
___ 06:01AM BLOOD Glucose-96 UreaN-55* Creat-5.9*# Na-138
K-4.6 Cl-96 HCO3-28 AnGap-19
___ 06:01AM BLOOD Calcium-8.5 Phos-6.6* Mg-2.3
Brief Hospital Course:
Mr. ___ was re-admitted from Rehab for altered mental status.
His mental status was found to be consistent with his mental
status at discharge 2 days ago, A&O x ___. There were no focal
deficits. Dob Hoff tube was re-placed and tube feeds resumed.
He was dialyzed on ___. He was transferred back to ___
___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Cetirizine 10 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Heparin Flush (10 units/ml) 1 mL IV DAILY and PRN, line flush
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. Metoprolol Tartrate 100 mg PO TID
7. OLANZapine 2.5 mg PO QHS
8. Ranitidine (Liquid) 150 mg PO DAILY
9. Simvastatin 20 mg PO QPM
10. Heparin Flush (1000 units/mL) ___ UNIT DWELL PRN line
flush
11. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
12. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
13. ___ MD to order daily dose PO DAILY
14. Glargine 10 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Cetirizine 10 mg PO DAILY
2. Insulin SC
Sliding Scale
Fingerstick q6h
Insulin SC Sliding Scale using REG Insulin
3. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
4. Simvastatin 20 mg PO QPM
5. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
___ MD to order daily dose PO DAILY
goal INR ___, dx: AFib
7. Acetaminophen 650 mg PO Q6H:PRN pain, fever
8. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN sob/wheezing
9. Calcium Acetate 667 mg PO TID W/MEALS
10. Aspirin 81 mg PO DAILY
11. Heparin Dwell (1000 Units/mL) ___ UNIT DWELL PRN
dialysis
Dwell to CATH Volume
12. Sarna Lotion 1 Appl TP TID:PRN itchy rash
13. Heparin Flush (10 units/ml) 1 mL IV DAILY and PRN, line
flush
14. Lidocaine 5% Patch 1 PTCH TD QAM
15. Metoprolol Tartrate 100 mg PO TID
16. OLANZapine 2.5 mg PO QHS
RX *olanzapine 2.5 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
17. Ranitidine (Liquid) 150 mg PO DAILY
18. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x5,
left internal mammary artery to left anterior descending artery,
saphenous
vein sequential graft to obtuse marginal 1, 2 and 3, and
saphenous vein graft to posterior descending artery.
Aortic Stenosis s/p Aortic valve replacement with a 23 mm ___.
___ tissue valve.
Acute Renal Tubular necrossis on Hemodialysis
Silent Aspiration postoperative
Diabetes Mellitus
Hyperlipidemia
Back/shoulder arthritis
GERD
Obstructive Sleep Apnea (uses CPAP)
Discharge Condition:
Alert and oriented x2-3, nonfocal
OOB with lift
No incisional pain
Incisions:
Sternal - healing well, no erythema or drainage
No edema
Discharge Instructions:
Renal: Hemodialysis. Renal Dose medications. Monitor fluid
balance
Diabetic: Monitor blood sugars keep well control.
Warfarin for atrial fibrillation: INR Goal 2.0-2.5 Please dose
accordingly.
Dysphagia Therapy: repeat swallow prior to diet advancement for
silent aspiration.
___ line Care and 20 cc Normal Saline Flushes per Protocol.
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
10268533-DS-14 | 10,268,533 | 20,468,518 | DS | 14 | 2184-03-02 00:00:00 | 2184-03-03 11:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fevers, thigh pain
Major Surgical or Invasive Procedure:
Laparotomy, takedown of multiple enteric fistulae, resection of
ileum and cecum within an end ileostomy and aspiration of left
thigh.
History of Present Illness:
Ms ___ is a ___ yo female with new diagnosis of Crohn's
disease, recent treatment of psoas abscess with known ileopsoas
fistula, s/p prolonged antibiotic course and psoas drain who
presents with fevers and recurrent thigh pain after antibiotics
and drain discontinued.
Pt's symptoms began ___ ___ after she fell at home and
developed persistent back pain. She sought care at a
___, who referred her for an MRI and diagnosed her with
an iliopsoas abscess. She presented to an OSH, where she had ___
drainage with cultures growing E. coli. She was treated with a 4
week course of ceftriaxone with drain ___ place from early
___ to early ___. Because of insurance issues, she did
not follow up ___ general surgery or infectious disease as an
outpatient.
She then presented to OSH again on ___ for worsening left sided
hip/back pain, increased drainage from percutaneous drain.
Repeat CT scan at that time showed enlargement of the ileopsoas
abscess and fistulization with the small bowel. There was also
concern for enhancement of the distal ileum, concerning for
inflammatory bowel disease. She had a colonoscopy with biopsy
results eventually returning consistent with crohn's disease.
She was treated with vanc/zosyn, transitioned to zosyn/flagyl.
She had MRI sacrum which was concerning for sacral
osteomyelitis. Her cultures returned with pan-sensitive
pseudomonas and ___ albicans. She was also found to have LLE
DVT and small bilateral PE so she was started on coumadin and
transferred to ___ for further evaluation.
She was at ___ from ___, during which time her antibiotics
were transitioned to zosyn, fluc based on culture data. She was
followed by GI, ID, and the colorectal service with plan to
perform surgery pending resolution of infection and optimization
of nutritional status so she was started on TPN. A follow up MRI
was not concerning for sacral osteomyelitis, but there was
concern that the abscess was communicating with the ileopsoas
bursa so orthopedics aspirated her hip joint with negative
cultures. She was discharged with OPAT and GI follow up. She was
doing well as an outpatient and was able to advance her diet,
tolerating full PO nutrition. Her drain had stopped putting out
and due to clinical improvement, her antibiotics were
discontinued on ___ and her drain was pulled on ___.
She was feeling well until yesterday morning when she developed
fevers to 100.6 at home, recurrent pain ___ her left thigh
similar to prior with swelling of her left thigh. Her appetite
has been normal and she was able to eat a full meal today. She
feels that her stomach is more distended but she had a normal
bowel movement this morning and is passing gas, denies any
bloody or melanotic bowel movements. She has no hip pain, full
ROM at hip, ambulating at baseline. No symptoms of dizziness,
shortness of breath or chest pain. She presented initially to
___, where she had a CT scan that reportedly
showed recurrence of her psoas abscess and she was transferred
to ___.
Initial VS ___ the ED:100.8 112 16 122/66 100% RA ___ pain left
thigh. Exam notable for mild tenderness to palpation ___ LLQ.
Labs notable for WBC 16.2 with 87% PMN, INR 6.7, h/h 7.5/24.0
(baseline ___, creatinine 0.4, Mg 1.5. Patient was given
zosyn, tylenol and morphine for pain control. Colorectal surgery
consult was placed. VS prior to transfer: 98.9 89 118/62 16 100%
RA
Past Medical History:
dx with b/l lower lobe PEs and LLE DVT ___
possible Crohn's disease (biopsies) not currently on treatment
recurrent psoas abscess
Social History:
___
Family History:
None. Denies history of IBD. Mother with HTN, obesity.
Physical Exam:
Admission Exam:
Vitals: T: 97.9 BP:117/70 P:97 R: 16 O2: 100%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, tender to palpation ___ LLQ at site of previous
drain, no surrounding erythema or discharge, distended abdomen,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, left thigh more swollen than right but no overlying
erythema or warmth, intact pulses
Discharge Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, appropriately tender, no rebound tenderness or
guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, left thigh more swollen than right but no overlying
erythema or warmth, intact pulses
Pertinent Results:
Admission Labs:
___ 10:40PM BLOOD WBC-16.2* RBC-3.06* Hgb-7.5* Hct-24.0*
MCV-78*# MCH-24.4* MCHC-31.2 RDW-15.9* Plt ___
___ 10:40PM BLOOD Neuts-87.1* Lymphs-9.0* Monos-3.5 Eos-0.3
Baso-0.1
___ 10:40PM BLOOD ___ PTT-65.3* ___
___ 10:40PM BLOOD ___
___ 06:25AM BLOOD ESR-105*
___ 10:40PM BLOOD Glucose-93 UreaN-5* Creat-0.4 Na-134
K-3.9 Cl-95* HCO3-23 AnGap-20
___ 10:40PM BLOOD ALT-12 AST-22 LD(LDH)-221 AlkPhos-113*
TotBili-0.3
___ 10:40PM BLOOD Lipase-12
___ 10:40PM BLOOD Calcium-8.0* Phos-3.2 Mg-1.5* Iron-11*
___ 10:40PM BLOOD calTIBC-169* Hapto-550* Ferritn-136
TRF-130*
___ 06:25AM BLOOD CRP-GREATER TH
___ 10:50PM BLOOD Lactate-1.1
Micro Data:
___ 4:08 pm ABSCESS Source: iliopsoas abscess.
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
FLUID CULTURE (Final ___:
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT ___ this culture..
Work-up of organism(s) listed below discontinued (excepted
screened
organisms) due to the presence of mixed bacterial flora
detected
after further incubation.
ESCHERICHIA COLI. SPARSE GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Preliminary): RESULTS PENDING.
FUNGAL CULTURE (Preliminary):
Imaging:
___ CT Guided Drain placement: IMPRESSION: CT-guided placement
of an 8 ___ ___ catheter within a left iliopsoas abscess.
100 cc of purulent material was hand aspirated. The catheter
was attached to a JP bulb.
Brief Hospital Course:
___ yo female with new diagnosis of entero-enterofistulas thought
to be ___ Crohn's but not yet definitively diagnosed, recent
DVT/PE, psoas abscess who was admitted with recurrence of
iliopsoas abscess ___ the setting of known fistulas. Active
issues during this hospital course are summarized as follows:
# Sepsis ___ iliopsoas abscess: Pt had recent psoas abscess with
ileopsoas fistulas, off antibiotics ___ and drain pulled ___.
Now admitted with recurrent symptoms, abscess on OSH CT scan.
WBC elevated and pt tachycardic and febrile, meets criteria for
sepsis. Patient was started on zosyn and ID, colorectal surgery,
GI were consulted. Patient was taken to ___ on ___ and drain was
placed with frank pus draining. Initial culture revealed
pan-sensitive E. coli. As this is patient's ___ recurrence of
iliopsoas abscess, pt was transferred to the colorectal surgery
service on ___. On that day, she underwent an exploratory
laparotomy, small bowel resection, and end ileostomy (please see
operative note for further details). After a brief and
uneventful stay ___ the PACU, the patient was transferred to the
floor for further post-operative management. The patient was
transitioned to clears on POD#2. She tolerated this well. Her
pain was well controlled with a dilaudid PCA, and she was
eventually transitioned to po pain medications. She ambulated
independently. The patient was transitioned to a regular diet
when she had ostomy output and production of gas. Due to high
ostomy output, she was started on loperamide and psyllium
wafers. Throughout her surgical course, she was on IV zosyn and
fluconazole. On ___, her incision began to show signs of
infection. She was continued on IV zosyn and fluconazole, and
vancomycin was added to her regimen. An ID consult was
initiated, leading to decision to treat with IV Zosyn and PO
fluconazole for a total of 2 weeks (first day ___. A PICC
line was placed on ___, and she was then discharged home to
continue IV antibiotics.
# Enterentero fistulas/Suspected Crohn's disease: Suspected
diagnosis of Crohn's disease ___ the setting of iliopsoas
fistulas, but with no significant GI symptoms ___ the past. The
initial outpatient plan for management was to have MRE on ___,
monitoring for recurrence of infection, and if all stable,
likely start will anti-TNF agent. However, ___ the setting of
recurrent infection, deferred starting any immunosuppression.
Unfortunately, previous GI biopsies did show definitive evidence
of Crohn's disease. Hep B serologies were negative. Pt
reportedly had recent negative PPD but this is not documented ___
the chart. St. ___ biopsy/colonoscopy reports can be found ___
the scanned inpatient record from her admission ___.
# Supratherapeutic INR with hx ___: ___ ___, pt was found
to have small bilateral PEs and a LLE DVT. She was started on
warfarin. Pt supratherapeutic on admission to 6.7. She reports
difficulty maintaining therapeutic range at home. Given 1 unit
FFP and Vitamin K 2mg PO ___ and 1mg PO ___. When INR fell
below 2, pt was started on Heparin gtt for bridge. She restarted
oral warfarin without issue prior to discharge. She was
instructed to take 1mg on ___ (day of discharge) and then
resume her usual regimen on ___. Her INR will be followed by
her PCP.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 3 mg PO DAILY16
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
Do not take more than 3000mg of tylenol ___ 24 hours, do not
drink alcohol while taking.
RX *acetaminophen 500 mg 2 tablet(s) by mouth q6hrs Disp #*60
Tablet Refills:*0
2. Psyllium Wafer 1 WAF PO BID
Decrease amount if ___ are noticing that your ostomy output has
decreased substantially.
RX *psyllium 1 wafer by mouth twice a day Disp #*60 Packet
Refills:*0
3. Loperamide 2 mg PO QID
Decrease amount if ___ are noticing that your ostomy output has
decreased substantially.
RX *loperamide [Anti-Diarrhea] 2 mg 1 tab by mouth four times a
day Disp #*120 Tablet Refills:*2
4. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q3h Disp #*50 Tablet
Refills:*0
5. Fluconazole 400 mg PO Q24H
RX *fluconazole 200 mg 2 tablet(s) by mouth daily Disp #*24
Tablet Refills:*0
6. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
RX *heparin lock flush (porcine) [heparin lock flush] 10 unit/mL
2 mL IV every eight (8) hours Disp #*36 Syringe Refills:*0
7. Sodium Chloride 0.9% Flush 10 mL IV X6
For PICC line, administer before and after infusion of
antibiotics
RX *sodium chloride 0.9 % [Normal Saline Flush] 0.9 % 10 ML IV 6
times per day Disp #*72 Syringe Refills:*0
8. Piperacillin-Tazobactam 4.5 g IV Q8H
RX *piperacillin-tazobactam [Zosyn] 4.5 gram 4.5 grams IV every
8 hours Disp #*162 Gram Refills:*0
9. Warfarin 3 mg PO DAILY16
RX *warfarin 1 mg 1 tablet(s) by mouth daily Disp #*1 Tablet
Refills:*0
10. Outpatient Lab Work
Lab Test: ___
ICD-9: 453.82
Fax result to patient's PCP, ___: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Crohn's disease, ileal-psoas fistula & abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
___ were admitted to the hospital after a Open Small Bowel
Resection for surgical management of your fistula/abscess
related to Crohn's Disease. ___ have recovered from this
procedure well and ___ are now ready to return home. Samples
from your small bowel were taken and this tissue has been sent
to the pathology department for analysis. ___ will discuss these
pathology results at your follow-up appointment and your GI
follow-up with Dr. ___. If there is an urgent need for the
surgeon to contact ___ regarding these results they will contact
___ before this time. ___ have tolerated a regular diet, are
passing gas and your pain is controlled with pain medications by
mouth. ___ may return home to finish your recovery.
Please monitor your bowel function closely. If ___ have any of
the following symptoms please call the office for advice or go
to the emergency room if severe: increasing abdominal
distension, increasing abdominal pain, nausea, vomiting,
inability to tolerate food or liquids, prolonged loose stool, or
extended constipation.
___ have a long vertical incision on your abdomen.Please monitor
the incision for signs and symptoms of infection including:
increasing redness at the incision, opening of the incision,
increased pain at the incision line, draining of
white/green/yellow/foul smelling drainage, or if ___ develop a
fever. Please call the office if ___ develop these symptoms or
go to the emergency room if the symptoms are severe. ___ may
shower, let the warm water run over the incision line and pat
the area dry with a towel, do not rub.
The pigtail ___ drain was removed from your left side. Please
keep this covered with a dry sterile gauze dressing for 48
hours. After this time ___ may shower without the dressing.
Please monitor this for signs and symptoms of infection as
listed above. Please call the clinic if ___ notice any of these
symptoms.
___ have a new ileostomy. The most common complication from a
new ileostomy placement is dehydration. The output from the
stoma is stool from the small intestine and the water content is
very high. The stool is no longer passing through the large
intestine which is where the water from the stool is reabsorbed
into the body and the stool becomes formed. ___ must measure
your ileostomy output for the next few weeks. The output from
the stoma should not be more than 1200cc or less than 500cc. If
___ find that your output has become too much or too little,
please call the office for advice. The office nurse or nurse
practitioner can recommend medications to increase or slow the
ileostomy output. Keep yourself well hydrated, if ___ notice
your ileostomy output increasing, take ___ more electrolyte drink
such as Gatorade. Please monitor yourself for signs and symptoms
of dehydration including: dizziness (especially upon standing),
weakness, dry mouth, headache, or fatigue. If ___ notice these
symptoms please call the office or return to the emergency room
for evaluation if these symptoms are severe. ___ may eat a
regular diet with your new ileostomy. However it is a good idea
to avoid fatty or spicy foods and follow diet suggestions made
to ___ by the ostomy nurses. ___ will continue to take the
medication imodium to slow the output. Please call the
Colorectal Surgery Clinic if the output is not ___ the correct
range.
Please monitor the appearance of the ostomy and stoma and care
for it as instructed by the wound/ostomy nurses. ___ stoma
(intestine that protrudes outside of your abdomen) should be
beefy red or pink, it may ooze small amounts of blood at times
when touched and this should subside with time. The skin around
the ostomy site should be kept clean and intact. Monitor the
skin around the stoma for bulging or signs of infection listed
above. Please care for the ostomy as ___ have been instructed by
the wound/ostomy nurses. ___ will be able to make an appointment
with the ostomy nurse ___ the clinic 7 days after surgery. ___
will have a visiting nurse at home for the next few weeks
helping to monitor your ostomy until ___ are comfortable caring
for it on your own.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. ___ Dr. ___ may
gradually increase your activity as tolerated but clear heavy
exercise with Dr. ___.
___ will be prescribed a small amount of the pain medication
Oxycodone. Please take this medication exactly as prescribed.
___ may take Tylenol as recommended for pain. Please do not take
more than 4000mg of Tylenol daily. Do not drink alcohol while
taking narcotic pain medication or Tylenol. Please do not drive
a car while taking narcotic pain medication.
Thank ___ for allowing us to participate ___ your care! Our hope
is that ___ will have a quick return to your life and usual
activities. Good luck!
Followup Instructions:
___
|
10268730-DS-4 | 10,268,730 | 26,634,469 | DS | 4 | 2142-11-02 00:00:00 | 2142-11-06 07:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p ___
Major Surgical or Invasive Procedure:
___ Washout, debridement, removal of foreign bodies, and
closure of wounds of left upper extremity.
History of Present Illness:
Mr. ___ is a ___ year old female transferred from ___
___ following ___ v. ___. Pt reports she was celebrating
___ year of sobriety by binge drinking x 2 days prior to the
accident. Notes report she had been drinking for 15 days. Pt
is unable to give further details about accident, but EMS
records report that the car was found flipped onto the driver's
side, with pt's arm out of the open window. Unknown if any
LOC. Pt was reportedly restrained and airbags reportedly
deployed.
Pt reports pain in LUE - lacerations irrigated and wrapped at
OSH. Pt pan-scanned at OSH. C-spine cleared by OSH.
Past Medical History:
PMH: hypothyroidism, EtOH abuse
PSH: C-section x 3, b/l tubal ligation
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission:
PE: 98.0 86 120/63 16 98%RA
Gen: intoxicated
Head: NCAT, PERRLA, no hemotympanum
Neck: no midline tendernes, no pain with passive rotation,
flexion or extension
___: RRR
Pulm: CTA b/l
Chest: no abrasions, chest stable, tender over sternum
Abd: soft, NT, ND, +BS
Ext: no obvious long bone deformities, palpable distal pulses
b/l, intact motor & sensation, LUE with extensive abrasions
including 3 to subcutaneous fat, small R knee abrasion
Back: no midline tenderness, no step offs
On discharge:
VS: T98.9, 64, 116/68, 18, 96% on room air
Pertinent Results:
___ 12:30AM BLOOD WBC-13.5* RBC-4.10* Hgb-12.8 Hct-37.7
MCV-92 MCH-31.2 MCHC-33.8 RDW-13.7 Plt ___
___ 12:30AM BLOOD Neuts-58.9 ___ Monos-4.1 Eos-1.3
Baso-0.8
___ 12:30AM BLOOD Plt ___
___ 12:30AM BLOOD ___ PTT-30.5 ___
___ 12:30AM BLOOD Glucose-85 UreaN-10 Creat-0.7 Na-143
K-4.1 Cl-109* HCO3-24 AnGap-14
IMAGING:
___ ECG
Baseline artifact. Sinus rhythm with vertical P wave axis.
Vertical to
borderline rightward QRS axis. Low voltage diffusely.
Non-specific ST-T wave
change. Combination of findings is not diagnostic but may be
seen with chronic
obstructive pulmonary disease, etc. No previous tracing
available for
comparison. Clinical correlation is suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
78 138 98 ___ 68
___ Hand
3 views of the left hand demonstrate no evidence of fracture or
dislocation.
A foreign body is noted adjacent to the ___ metacarpal.
IMPRESSION:
Foreign body adjacent to the ___ metacarpal. No evidence of
fracture.
___ Heel
Unremarkable appearance of the right heel. Irregular appearance
of at least one of the hallux sesamoids, possible a normal
variant, although a sesamoid fracture of indeterminant age is
not excluded. If symptoms orphysical findings refer to the
site, then dedicated foot and sesamoid views could be
considered.
Brief Hospital Course:
Mrs. ___ was admitted to the Acute Care Surgery service on
___ for further management of her left upper extremity
injuries. As discussed above, she was found to have extensive
LUE abrasions and lacerations. Outside imaging revealed no
other acute injuries. Her c-collar was cleared once she was
sober and could be done clinically at the bedside. She was
taken to the Operating Room on the same day of admission for
thorough washout and closure of her lacerations. She tolerated
the procedure well and was transferred to ___ for recovery.
Please see the operative report for further details.
During her recovery on the inpatient ward, Mrs. ___ was
clinically stable throughout her stay. Pain management was her
biggest issue and was managed with narcotic and non-narcotic
analgesics. The patient described some right lower heel pain
when ambulating, so a plain film of the area was completed. It
showed no acute injury/fracture.
The patient was seen by social work and occupational therapy
during her stay. Occupational Therapy felt that, through their
evaluation, the patient would benefit from cognitive
rehabilitation as an outpatient. Although the patient didn't
know if she struck her head or lost consciousness during her
accident, her cognitive deficits may be attributable to
long-time alcohol use. To err on the side of caution, Mrs.
___ was advised to follow-up with a cognitive neurologist
as an outpatient. Lastly, the patient required extra overnight
stays due to social issues pertaining to her disposition
status. Social work and case management was very involved in
the discharge planning of this patient.
Mrs. ___ was discharged on ___, where she was afebrile,
hemodynamically stable and in no acute distress. her LUE JP
drain was discontinued on the same day without issues. Prolene
sutures remained in place. A follow-up appointment with ACS was
established within a week of discharge so her wound could be
assessed. ___ services were also established to provide wound
care/assessments in the meantime. The patient was given a
prescription for Keflex for 7 days, as well.
Medications on Admission:
Levothyroxine 25 mcg daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Cephalexin 500 mg PO QID Duration: 7 Days
Last dose is ___.
RX *cephalexin 500 mg 1 capsule(s) by mouth four times a day
Disp #*12 Capsule Refills:*0
3. Levothyroxine Sodium 25 mcg PO DAILY
4. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Traumatic injury to left upper extremity with wounds.
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 ___ on
___ after you were involved in a motor vehicle collision. On
further evaluation, you were found to have a left upper
extremity injury requiring you to go to the Operating Room for a
washout. Since that time, you have recovered on the inpatient
ward.
You were seen by both Occupational and Physical Therapy. It is
recommended that you follow up with Dr. ___ Cognitive
___ based on Occupational Therapy's evaluation. You may
bear weight on your lower extremities since you were found to
have no injuries. Due to some pain in your right lower
extremity, you have been given a cane for assistance with
walking.
A follow up
Followup Instructions:
___
|
10268877-DS-13 | 10,268,877 | 25,076,101 | DS | 13 | 2181-05-04 00:00:00 | 2181-05-28 08:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors / Penicillins
Attending: ___
___ Complaint:
SOB, cough, fever
Major Surgical or Invasive Procedure:
Decubitus ulcer debriedment
History of Present Illness:
___ CHF, DM and peptic ulcer, s/p UGIB, PEA arrest now trach
dependent pw necrotic sacral ulcer and intermittent oozing from
GI tube site sent ___ from ___ with unclear history. Per
EMS, at ___ EKG done with STE ___ inferior leads after
saw ST changes on tele. Given asa and nitro, BP 134/75 after
nitro and then called EMS later. Never had chest pain. Found to
be diaphoretic by EMS; no STE found on EKG. Fever to 101.2 on
arrival to ___ ED. Patient denies CP. Reports SOB but this has
been since trach placement- has not recently worsened. NO abd
pain. Pain ___ sacral ulcers. Had some bleeding from area around
g-tube yesterday.
___ ED, initial VS were: 101.2 84 130/70 100%. Evaluation
revealed ?RLL opacity. Labs were significant for lactate of 3.5,
troponin 0.09, INR 1.6 and UA. 2L IVF.
On arrival to the MICU, HD stable, on FiO2 35% and mentating
well.
Past Medical History:
Recent hospitalized: ___: UGIB ___ gastric ulcers, s/p
PEA arrest, couldn't wean from vent-->tracheostomy performed on
___
PEG placed ___
- NIDDM
- hx of UGIB ___ peptic ulcer (___)
- CHF
- HTN
- CAD s/p MI
Medications HOME:
- amitriptyline 25mg hs
- amlodipine 5mg
- furosemide 40mg
- glipizide 5mg
- losartan 25mg
- Metoprolol succinate 100mg
Allergies: PCN, ACE inhibitors
Social History:
___
Family History:
unable to obtain
Physical Exam:
On admission:
Vitals: T BP 119/62 HR60 RR25 SpO2 95% CMV FiO2 35%
General: Alert, oriented, no acute distress, trach
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD, trach site benign
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: rhonchorous breath sounds bilaterally, slight crackles ___
RLL
Abdomen: soft, obese, non-tender, bowel sounds present, no
organomegaly, g-tube site with open wound, no active bleeding or
discharge, no surrounding erythema.
GU: Foley and flexiseal draining
Skin: 8x5cm sacral decub, unstageable ulcer with mildly
erythematous rim, no appreciable warmth, not inappropriately
tender around wound.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema; no calf tenderness or asymmetry
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred, interacting
appropriately
On discharge:
VS: 97.8 153/74 84 19 95 T mist
General: Alert, oriented, no acute distress, trach
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, trach site benign
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: rhonchorous breath sounds bilaterally, slight crackles ___
RLL
Abdomen: soft, obese, non-tender, bowel sounds present, no
organomegaly, g-tube site with open wound, no active bleeding or
discharge, no surrounding erythema.
GU: Foley and flexiseal draining
Ext: warm, well perfused, covered ___ brace, 2+ pulses, no
clubbing, cyanosis or edema; no calf tenderness or asymmetry
Neuro: grossly normal sensation, gait deferred, interacting
appropriately
Pertinent Results:
Admission labs:
___ 07:14PM BLOOD WBC-8.0 RBC-3.49* Hgb-9.7* Hct-30.8*
MCV-88 MCH-27.9 MCHC-31.6 RDW-19.0* Plt ___
___ 07:14PM BLOOD Neuts-81.6* Lymphs-10.4* Monos-4.5
Eos-3.3 Baso-0.2
___ 01:47AM BLOOD ___ PTT-33.2 ___
___ 07:14PM BLOOD Glucose-250* UreaN-55* Creat-1.0 Na-135
K-3.9 Cl-97 HCO3-26 AnGap-16
___ 01:47AM BLOOD ALT-33 AST-35 CK(CPK)-19* AlkPhos-418*
TotBili-1.1
___ 07:14PM BLOOD CK-MB-2 cTropnT-0.09*
___ 01:47AM BLOOD CK-MB-2 cTropnT-0.08*
___ 01:47AM BLOOD Calcium-7.6* Phos-4.4# Mg-2.3
___ 07:26PM BLOOD Lactate-3.5*
___ 09:05PM BLOOD Lactate-2.3*
___ 02:02AM BLOOD Lactate-1.9
Radiology
Echo ___: The left atrium is mildly dilated. Left ventricular
wall thicknesses are normal. The left ventricular cavity is
moderately dilated with severe global left ventricular
hypokinesis (LVEF = <20 %). The apical half of the heart is not
seen as there were no apical windows. The right ventricular
cavity is moderately dilated with moderate global free wall
hypokinesis. The ascending aorta is mildly dilated. The aortic
valve leaflets are mildly thickened (?#). No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Suboptimal image quality. Left ventricular dilation
with severe global biventricular hypokinesis.Mild mitral
regurgitation. Pulmonary artery hypertension. No discrete
vegetations identified.
Compared with the prior study (images reviewed) of ___,
biventricular systolic function is now more depressed, the left
ventricular cavity is more dilated, and the estimated PA
systolic pressure is lower (may reflect impaired right
ventricular systolic function). As viewed ___ the parasternal
windows, valve morphology and the severity of mitral
regurgitation are similar.
UNILAT UP EXT VEINS US LEFT ___
INDICATION: Patient with bacteremia secondary to line infection.
Assess for dvt. PRELIMINARY REPORT: Gray-scale and color Doppler
images of bilateral subclavian, left internal jugular, axillary
vein demonstrate normal flow and compressibility. There is
non-occlusive thrombus involving the brachial vein. There is an
additional non-obstructive thrombus involving the basilic vein.
The cephalic vein demonstrates normal flow and compressibility.
IMPRESSION: Non-obstructive thrombus involving the left brachial
and basilic veins.
CXR
___ No significant interval change since prior. Pulmonary
vascular congestion. Bibasilar opacities potentially due to
atelectasis; however, infection is not excluded.
___: ___ comparison with study of ___, the PICC extends only
to the left brachiocephalic vein before its junction with the
superior vena cava. Continued low lung volumes may account for
some of the prominence of the transverse diameter of the heart.
Bibasilar opacification most likely reflects atelectatic
changes. Possibility of supervening pneumonia would have to be
considered ___ the appropriate clinical setting. The pulmonary
vascular congestion is less prominent than on the prior study.
Micro
Blood culture ___: Acinetobcter, Klebsiella
Sputum culture ___: Acinetobcter, Klebsiella
Urine culture ___: Negative
PICC ___: Acinetobacter, klebsiella
Blood cx ___: NGTD
Blood Culture, Routine (Final ___: NO GROWTH.
WOUND CULTURE (Final ___:
ACINETOBACTER BAUMANNII COMPLEX. >15 colonies.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
KLEBSIELLA PNEUMONIAE. >15 colonies.
Piperacillin/tazobactam sensitivity testing available
on request.
CEFEPIME sensitivity testing confirmed by ___.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ACINETOBACTER BAUMANNII COMPLEX
| KLEBSIELLA PNEUMONIAE
| |
AMIKACIN-------------- <=2 S
AMPICILLIN/SULBACTAM-- <=2 S =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- =>64 R 4 S
CEFTAZIDIME----------- 16 I =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- 1 S =>4 R
GENTAMICIN------------ =>16 R 8 I
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- 0.5 S
MEROPENEM------------- <=0.25 S
TOBRAMYCIN------------ <=1 S 8 I
TRIMETHOPRIM/SULFA---- <=1 S =>16 R
URINE CULTURE (Final ___: NO GROWTH.
C. DIFFICILE DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
KLEBSIELLA PNEUMONIAE. MODERATE GROWTH.
Piperacillin/tazobactam sensitivity testing available
on request.
CEFEPIME: sensitivity testing performed by ___.
ACINETOBACTER BAUMANNII COMPLEX. MODERATE GROWTH.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| ACINETOBACTER BAUMANNII
COMPLEX
| |
AMPICILLIN/SULBACTAM-- =>32 R <=2 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- I =>64 R
CEFTAZIDIME----------- =>64 R 8 S
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R 1 S
GENTAMICIN------------ <=1 S =>16 R
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- 0.5 S
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
FUNGAL CULTURE (Preliminary): YEAST.
MRSA SCREEN (Final ___: POSITIVE FOR METHICILLIN RESISTANT
STAPH AUREUS.
Brief Hospital Course:
___ CHF, DM and peptic ulcer, s/p UGIB, PEA arrest now trach
dependent pw necrotic sacral ulcer and intermittent oozing from
GI tube site sent ___ from ___ with unclear history.
#Acinetobacter Bacteremia/Sepsis: Patient with acinetobacter
bacteremia. Had elevated lactate on admission which trended
downward with gentle fluid boluses and IV abx. Otherwise,
patient did not have fever or leukocytosis. ID was consulted and
patient had his PICC line removed and placed on line holiday.
He was initially placed on vanc/cefepime which was narrowed to
cefepime when blood grew GNR, which was then switched to
Meropenem (___). The source of his bacteremia is
likely PNA or PICC line, however he also has a sacral decubitus
ulcer. As his abx therapy is 2 weeks, he does not require ID
follow up.
#Sacral Decubitus ulcer: Patient with worsening breakdown of
his decubitus ulcer. Wound care followed the patient while here
and recommended debridement. Patient went to OR on ___ for
debridement of necrotic ulcer and wound vac was placed by ACS.
Bone biopsy was taken to see if he has osteomyelitis. Results
of bone biopsy are pending. He will require wound vac changes
every ___ days, and will need follow up with surgery ___ one
month.
#SOB: initially patient described dyspnea and was started on
HCAP coverage. He grew acinetobacter and klebsiella ___ his
sputum. he was initially placed on vanc/cefepime and then
meropenem as GPC was thought to be contaminant/colonization. He
had no episodes of dyspnea and tolerated trach mist for most of
his hospitalization.
#Decreased Urine Output: patient has episodes of oliguria
(UOP<30cc/hr) periodically during admission. Attempts were made
to flush foley and obtain bladder ultrasound (which showed
minimal urine) with no improvement. He received periodic fluid
boluses. His FeNa and FeUrea indicated a pre-renal azotemia, so
he was subsequently given additional fluid boluses. Nephrology
was consulted and they recommended IV lasix, which he was
started on with good effect.
#CAD: per records, had ST elevations at ___. EKG here
shows RBBB, no STE and no chest pain. Elevated tropsx 2 however
all troponins were stable, risk factors for repeat STEMI:
previous MI, HTN, CHF.
#sCHF: systolic dysfunction. last echo ___ showed EF ___.
Fluid was given ___ small boluses due to his sCHF, however he had
no acute exacerbation of CHF while hospitalized.
#Elevated INR: patient had INR elevated on admission with no
subsequent change throughout his hospitalization. Likely causes
include malnutrition versus liver disease versus antibiotic
interaction. He had no episodes of bleeding while ___ house.
#Anemia: normochromic. No acute blood loss. Has had anemia with
hct ___ low ___ ___ last hospitalization when had GIB due to
peptic ulcers. He had guaiac negative stools and had stable HCT
throughout hospitalization.
#DM: on glipizide, amitriptyline presumably for neuropathic
pain. He was placed on ISS and had no issues ___ house.
#HTN: baseline 120-130s. ___ house he was initially normotensive
with no medications, on discharge his metoprolol and losartan
were re-started at half their normal dose. he should follow up
with his pcp at ___ to check blood pressure and better titrate
his ___ regimen.
Transitional issues:
-He should see his PCP regarding his ___ medications
-He should follow up with Surgery ___ 1 month.
-He should finish a 14 days course of meropenem (___)
-PCP should follow up on bone biopsy results
-Goals of care should be re-evaluated.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/CaregiverwebOMR.
1. Amitriptyline 25 mg PO HS
2. Amlodipine 5 mg PO DAILY
3. Furosemide 40 mg PO DAILY
4. GlipiZIDE XL 5 mg PO DAILY
5. Losartan Potassium 25 mg PO DAILY
6. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Medications:
1. Losartan Potassium 12.5 mg PO DAILY
hold for sbp<100 or hr<60
RX *losartan 25 mg 0.5 (One half) tablet(s) by mouth once a day
Disp #*15 Tablet Refills:*0
2. Amitriptyline 25 mg PO HS
3. GlipiZIDE XL 5 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day
Disp #*15 Tablet Refills:*0
5. Albuterol Inhaler ___ PUFF IH Q6H:PRN Wheeze/sob
6. Meropenem 500 mg IV Q6H Duration: 9 Days
RX *meropenem 500 mg every six (6) hours Disp #*54 Unit
Refills:*0
7. Furosemide 40 mg IV DAILY
RX *furosemide 10 mg/mL 4ml once a day Disp #*15 Unit Refills:*0
Discharge Disposition:
Expired
Facility:
___
Discharge Diagnosis:
Acinetobacter/Klebsiella bactermia/pneumonia
Sacral Decubitus ulcer
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. ___,
It was a pleasure taking care of you at ___
___. You were brought to the hospital for concerns
of a heart attack, but we do not think you had a heart attack.
You were admitted due to an infection ___ your blood and lungs
and a blocked gastric tube. You were treated with antibiotics
and had surgery to debride the large ulcer on you lower back.
After surgery, your blood pressure dropped and you needed 30
seconds of chest compressions. Your blood pressure was improved
after this. Your gastric tube is now working.
Followup Instructions:
___
|
10268954-DS-5 | 10,268,954 | 29,470,632 | DS | 5 | 2194-04-22 00:00:00 | 2194-05-14 23:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ceclor
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ w/no significant PMH who presented as a
transfer from ___ for management of an ileal abscess.
Briefly, he was in USOH until ___ when he began experiencing
diffuse abdominal pain with bloading. This worsened over the
weekend and spread to his flanks, with vomiting x1. He presented
to ___ where he underwent a CT at ___ that was
concerning for large abscess (? perforated appendix vs ileal
intramural abscess). He was then transferred to ___ surgery
service for further management for management. ___ was consulted
to drain abscess, but felt drainage was not possible given the
location and degree of inflammation. He was managed medically
with a plan to reduce the inflammation and reattempt drainage.
On ___ he developed chest pain while eating. EKG had diffuse ST
elevations (1-2mm leads I, II, V2-V6) and TWI in III and aVF.
Cardiology was consulted; troponins were elevated 0.43 and were
found to be down-trending on repeat measurements. Cardiology
recommended echo, which showed mild to moderate AI with
eccentric aortic regurgitation jet. Overall cardiology felt his
presentation was most consistent with pericarditis. Given the
ileal location of his absces, GI was consulted for ?Crohn's.
They had a low suspicion for Crohns, but he will require
outpatient colonoscopy to definitvely rule out IBD.
He was then admitted to the medicine service. On admission, he
felt well and denied CP. He endorsed a rash on his sternum which
has been present ___ years. Endorses diarrhea ___ episodes per
week. He endorses consuming a large amoutn of raw and cooked
seafood at home and spends time with his girlfriend's dog and
cat on the weekends. Otherwise ROS negative in detail as below.
No history of skin ulcers, eye redness, eye pain.
Past Medical History:
Pneumomediastinum, Age ___, unclear etiology, resolved
spontaneously
Social History:
___
Family History:
No history of IBD or AI disorders. Denies FH of premature CAD.
Physical Exam:
Admission:
Vitals: 98.5 80 117/69 20 95%
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, slightly distended with some guarding on deep
palpation. Focal tenderness in the right lower quadrant. No
rebound tenderness. Normoactive bowel sounds. No palpable
masses.
Ext: No ___ edema, ___ warm and well perfused
Discharge:
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, II/VI decrescendo late systolic / DM,
Abdomen- soft, no tenderness in RLQ. ND bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU- no foley
skin: scattered erythamatous papules coalescing into plaques on
his sternum.
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION:
___ 05:57PM cTropnT-0.43*
___ 11:27PM CK-MB-8 cTropnT-0.38*
___ 01:20AM WBC-14.6* RBC-4.36* HGB-14.2 HCT-40.7 MCV-93
MCH-32.5* MCHC-34.8 RDW-12.8
___ 01:20AM LIPASE-13
___ 01:20AM ALT(SGPT)-15 AST(SGOT)-23 ALK PHOS-71 TOT
BILI-0.6
HCO3-28 AnGap-15
___ 01:20AM BLOOD ALT-15 AST-23 AlkPhos-71 TotBili-0.6
DISCHARGE:
___ 07:49AM BLOOD WBC-7.7 RBC-4.73 Hgb-15.1 Hct-45.4 MCV-96
MCH-32.0 MCHC-33.3 RDW-13.2 Plt ___
___ 06:24AM BLOOD UreaN-11 Creat-0.8
___ 03:40PM BLOOD Na-142 K-4.4 Cl-101
___ 07:49AM BLOOD Glucose-100 UreaN-9 Creat-0.8 Na-139
K-5.3* Cl-101 HCO3-28 AnGap-15
MICROBIOLOGY:
___ Blood cultures x 2-pending
___ Urine culture-no growth
___ Blood culture-pending
___ Stool culture-no organisms found
IMAGING:
___ AP Chest Xray
The lung volumes are normal. Normal size of the cardiac
silhouette. Normal hilar and mediastinal structures. No pleural
effusions. No pulmonary edema. No pneumonia. No pneumothorax.
___ ECG
Normal sinus rhythm. Within normal limits. No previous tracing
available for comparison.
___ TTE
Preserved regional and global biventricular systolic function.
Mild-moderate aortic regurgitation without evidence of a
bicuspid aortic valve or dilatation of the aortic root.
___ TEE
No 2D echocardiographic evidence of endocarditis.
___ MRE
Preliminary-The intramural collection in the terminal ileum seen
on the prior CT has decompressed. There is no longer a large
fluid component. The continues to be extensive mural enhancement
edema and thickening of the terminal ileum. There is associated
mesenteric edema. On series 11, image 66, there is enhancement
tracking from the inflamed terminal ileum to a adjacent loop of
small bowel. This may represent a developing enteroenteric
fistula. The remainder of the small bowel appears normal without
evidence of stricture. The visualized abdominal organs (liver,
spleen, pancreas, adrenal glands, kidneys) appear normal.
Brief Hospital Course:
# Ileal Abscess: At ___ he receieved a CT abdomen/pelvis
w/
PO/IV contrast that a 4x5x6cm fluid collection near terminal
ileum and thickened appendix, ileum and cecum. Transferred to
___ for further management. ___ felt the abscess was not
amenable to drainage given the location and degree of
inflammation, and medical management w/IV cipro/flagyl was
attempted in order to reduce the size of the abscess and
associated inflammation. His abdominal exam significantly
improved, and he defervesced. The etiology of the abscess was
not clear. Given the involvement of the appendix, it was
considered possible that the inciting process was perforatation
in the setting of prior appendicitis. However, surgery felt the
imaging findings were more suggestive of an ileal source. GI was
consulted re: ? Crohn's disease. Inflammatory markers were only
mild elevated (ESR 25/CRP140) and given the patient's
presentation they were not very suspicious of IBD, however
outpatient colonoscopy is planned in ___ to confirm. The patient
was continued on cipro/flagyl and transition to a PO regimen for
discharged, which he tolerated well. MRE on ___ confirmed
interval improvement in the ileal abscess.
# Myopericarditis: On ___ the patient developed CP while eating.
The pain was pleuritic in nature, non-radiating, and substernal,
with some improvement leaning forward. EKG showed diffuse ST
elevation (1-2mm in I, II, V2 - V6) and TWI in III and aVF.
Trops were elevated at 0.43 and downtrended (-> 0.38 -> 0.37). A
TTE ___ showed normal biventricular function, no apical
ballooning, and aortic regurgitation. Cardiology was consulted,
and felt this was most likely pericarditis, with involvement of
myocardium placing it in the category of myopericarditis.
Coronary artery spasm was also considered to be a possible cause
of the chest pain and troponinemia. Obstructive CAD was
considered unlikely given the patient's age and abscence of risk
factors. He was treated with colchicine 0.6 mg BID for
pericarditis, to continue for 1 week after discharge. He was
also provided sublingual nitroglycerin as empiric treatment for
coronary artery spasm in case the chest pain recurred.
Infectious disease was consulted with the question of whether a
single infectious process was underlying his ileal abscess and
myopericarditis. The ID team felt that this was unlikely, and
that the pericarditis was most likely viral in etiology.
# Aortic regurgitation: TTE ___ showed a mild to moderate AR.
Given the presence of AR as well as significant infectious
burden without clear etiology, a TEE was obtained to rule out
endocarditis. TEE ___ showed no valvular vegetations and mild
to moderate AR as seen on TTE ___.
# Moderate to Heavy ETOH use - Given the patient's history of
heavy alcohol use, he was monitored for signs of alcohol
withdrawal. He briefly did show signs of minimal agitation and
was placed on a CIWA scale, but did not require any treatment
with benzodiazapenes.
TRANSITIONAL ISSUES
[ ] continue antibiotics until follow up with GI on ___
[ ] f/u on blood cultures - pending as of discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain, fever
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*28 Tablet Refills:*0
3. Colchicine 0.6 mg PO BID Duration: 7 Days
RX *colchicine [Colcrys] 0.6 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*14 Tablet Refills:*0
4. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*42 Tablet Refills:*0
5. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
___ your MD if requiring more than 1.
RX *nitroglycerin 0.4 mg 1 tablet(s) sublingually Q5MIN:PRN Disp
#*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
ileal abscess
Secondary Diagnoses
pericarditis
aortic regurgitation
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 hospitalization at
___. You were admitted for an infection in your abdomen. You
were treated with antibiotics, and your infection improved. You
also developed inflammation in the sac around your heart. This
was treated with anti-inflammatory medicines and also improved.
Sincerely,
your ___ Team
Followup Instructions:
___
|
10268967-DS-6 | 10,268,967 | 23,040,526 | DS | 6 | 2163-03-14 00:00:00 | 2163-03-14 22:15:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / naproxen / Levaquin
Attending: ___.
Chief Complaint:
RECTAL BLEED
Major Surgical or Invasive Procedure:
None`
History of Present Illness:
Patient is a ___ year old male with HTN, CLL, AS s/p percutaneous
AVR, history of previous GI bleeds with known diverticulosis who
complains of BRBPR.
He states that he had ___ episodes of bright red bleeding today.
He reports that his stool is brown. Feelings of lightheadedness
when he would get up from standing, but otherwise no headache,
nausea, vomiting, abdominal pain, chest pain, shortness of
breath. He denies melena, hematochezia. Denies recent diet
changes. Denies fevers/chills. Patient takes Iron for GI
bleeding. Was taken off of coumadin, lasix after last GI
bleeding episode. He reports that these episodes are no
different from his prior bleeds. Reports that in the days
leading up to the GI bleed, he has had a good appetite. Denies
using ASA and warfarin, reporting that these had been
discontinued in the past because of GI bleeding. Denies using
ibuprofen.
He states he has had several episodes of painless rectal
bleeding over several years. He has had an extensive GI workup
in the past (in ___ where he spends his winters), which
reveal diverticula, but otherwise no source for bleeding such as
tumor was found. Last work-up was about ___ year ago, which
included colonscopy, endoscopy. In the ED, patient states that
he would prefer to go home, but is amenable to staying in
hospital for blood transfusion, repeat labs.
In the ED, initial vitals: 97.7 62 116/48 16 100%. Patient's HCT
notable for being 27.9. WBC 32.2, which higher than normal for
his CLL. Rectal exam notable for BRBPR with brown/maroon stool.
2 PIVs placed. No episodes of GI bleeding in ED per report. EKG
notable for atrial fibrillation. Patient also type and crossed.
Vitals prior to transfer:
Currently, the patient is lying in bed in NAD with no
complaints.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation.
Past Medical History:
S/P PERCUTANEOUS AVR ___
HYPERTENSION
AORTIC STENOSIS
S/P TONSILLECTOMY, ADENOIDECTOMY
S/P BILAT INGUINAL HERNIA REPAIR S/P RIGHT THR.
S/P MVA
Social History:
___
Family History:
No family history of GI bleed.
Physical Exam:
Admission physical exam:
VS - Temp 97.4F, BP 131/36, HR 54, R 20, O2-sat 100% RA
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD, no cervical LAD
HEART - PMI non-displaced, RRR, nl S1-S2, ___ systolic murmur
best appreciated at the LLSB
LUNGS - Good air movement, resp unlabored, no accessory muscle
use, crackles at the bases bilaterally. No wheezes.
ABDOMEN - NABS+, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - Dry scaling, skin. No rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Discharge physical exam:
Vitals: T 97.6 BP 114/36 HR 55 RR 17 O2 Sat 96% on RA
General: Patient lying in bed in NAD
CV: Irregularly irregular. No M/R/G
Lungs: Good air movement, resp unlabored, no accessory muscle
use, crackles at the bases bilaterally. No wheezes.
Abdomen: NABS+, soft/NT/ND, no masses or HSM, no
rebound/guarding
Extremities: WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
Pertinent Results:
Admission labs:
___ 02:45PM BLOOD WBC-32.2*# RBC-2.79* Hgb-9.4* Hct-27.9*
MCV-100* MCH-33.6* MCHC-33.7 RDW-17.3* Plt ___
___ 02:45PM BLOOD ___ PTT-27.2 ___
___ 02:45PM BLOOD Glucose-93 UreaN-37* Creat-1.1 Na-137
K-4.8 Cl-102 HCO3-24 AnGap-16
Discharge labs:
___ 08:10AM BLOOD WBC-25.1* RBC-2.85* Hgb-9.6* Hct-27.6*
MCV-97 MCH-33.7* MCHC-34.9 RDW-17.0* Plt Ct-94*
___ 08:10AM BLOOD Glucose-87 UreaN-35* Creat-1.2 Na-139
K-4.0 Cl-105 HCO3-25 AnGap-13
Brief Hospital Course:
Patient is a ___ year old male with HTN, CLL, AS s/p percutaneous
AVR, history of previous GI bleeds with known diverticulosis who
complains of BRBPR.
#. BRBPR: Patient with a history of rectal bleeding, with
extensive work-up including colonoscopy and endoscopy ___ year
ago. Per patient, previous studies revealed diverticula, but
otherwise no source for bleeding such as tumor was found. Two
peripheral IVs were maintained through the admission. The
patient received 1 unit of pRBCs during this admission; however,
patient's hematocrit did not bump appropriately to the 1 unit.
Though, his HCT remained stable with his admission HCT. Patient
had no further episodes of BRBPR during his admission. Patient
stated that he did not want to undergo further work-up with
colonoscopy/EGD in light of recent work-up ___ year ago. Patient
was instructed to follow-up with his primary care physician for
repeat hematocrit check; he was instructed to return to the
emergency department if his bleeding returned.
#. Atrial fibrillation: Patient not on a beta blocker as an
outpatient. Not on anticoagulation as an outpatient in light of
GI bleeds. He was monitored on telemetry with no episodes of
RVR.
#. Hypertension: Held amiloride-HCTZ in setting of GI bleed.
Blood pressures remained stable through admission.
Amiloride-HCTZ was restarted upon discharge.
#. CLL: Patient's white count elevated from baseline of 19. No
blasts on differential to suggest acute transformation to
leukemia.
CODE STATUS: DNR/DNI
TRANSITIONAL ISSUES: Repeat hematocrit check ___ with PCP.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. amiloride-hydrochlorothiazide *NF* ___ mg Oral daily
2. multivitamin *NF* ONE Tablet Oral daily
Discharge Medications:
1. amiloride-hydrochlorothiazide *NF* ___ mg Oral daily
2. multivitamin *NF* 0 Tablet ORAL DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Lower GI bleed
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:
It was a pleasure taking care of you during your hospitalization
at ___.
You were hospitalized with bright red blood per rectum. You were
admitted and received 1 unit of packed red blood cells. You
hematocrit remained stable. You had no further episodes of
bloody bowel movements.
We are discharging you home; you will need to follow-up with Dr.
___ a repeat CBC, next ___.
No medication changes were made during this admission.
If you experience further bleeding, then please return to the
emergency department for further evaluation.
Followup Instructions:
___
|
10269308-DS-15 | 10,269,308 | 29,042,615 | DS | 15 | 2157-03-07 00:00:00 | 2157-03-10 05:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Dyspnea, ill, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male dual renal-transplant pt on MMF and tacro with
chief complaint of cough, shortness of breath.
Presents with cough and shortness of breath that began two days
prior to admission. Tmax 100.7 on ___, with nonproductive cough
accompanied by vauge headache, malaise, muscle aches. rhinorrhea
and sinus congestion. No nausea, vomiting, abdominal pain,
kidney pain. Had one episode of diarrhea did morning of
presentation. Has been drinking Gatorade and urinating "a lot",
but decreased solid intake as no appetite. Did get flu shot this
year. No dysuria, burning or urgency. Feels weak overall.
Patient sought care initially at ___'s office. Exam notable for
On exam with diffuse wheezing, nothing focal in lungs. O2 sat
94%, maintains this with ambulation. Peak flow 250. Given
nebulizer in office with some symptomatic improvement. Given
symptoms and immunosuppression, referred to ED for infectious
workup.
In the ED, initial vital signs were: VS 102.7, 106, 135/67, 20,
99% RA
- Exam was notable for:
Lying on side, non-toxic appearing
White coat on tongue, no oral lesions
Mild bilateral wheeze, no respiratory distress
IV/VI systolic murmur
Abdomen soft, non-tender including graft, no bruits
appreciated.
- Labs were notable for: no leukocytosis, H/H 13.6/41.9,
thrombocytopenia (124). INR 2.3. Mg 1.3, P 2.43. Cr increased
from 0.9-1.0 -> 1.3. Lactate initially 2.1 -> 1.9. U/A with mod
___, WBC 10, prot 30. Ruled out for flu.
- Imaging:
CXR No definite evidence pneumonia.
- The patient was given:
Acetaminophen 1000 mg PO, 1000 mL NS, Levofloxacin 750 mg PO,
Albuterol 0.083% Neb Soln.
- Consults: Renal - Transplant -- recommended Levofloxacin for
PNA and GU coverage and admission for futher workup.
Upon arrival to the floor, 98.4 133/67 94 18 99%RA
Complains of feeling weak. Initially with trouble sitting up
from bed, but able to, and able to walk to bathroom. Says UOP
this time was "not a lot." Denies UTI sx. Endorses continued
cough, "chest cold congestion" feeling in chest. No sore throat,
+ rhinorrhea. Endorses SOB. Used ibuprofen at home for fevers,
with improvement in sx. No APAP.
REVIEW OF SYSTEMS:
[+] per HPI
[-] Denies visual changes, pharyngitis, chest pain, abdominal
pain, nausea, vomiting, constipation, hematochezia, dysuria,
rash, paresthesias, weakness
Past Medical History:
-h/o fistula s/p repair, c/b seizures and cord compression
-Hypertension
-Dyslipidemia
-History of gloerulonephritis, then received cadaveric renal
transplant, ___ yrs ago, on immunosuppressants in past,
transplant failed ___ years ago and now on hemodialysis.
-___ renal transplant
-Anemia
-Coagulase negative staphylococcal bacteremia
-Community-acquired pneumonia
-Duodenal ulcers status post thermal therapy/injection
-Pericardial effusion
-Obesity
-Osteopenia
Social History:
___
Family History:
No history of seizure or stroke
Physical Exam:
ADMISSION EXAM
==============
VITALS - 98.4 133/67 94 18 99%RA
GENERAL - pleasant, coughing, non-toxic appearing
HEENT - normocephalic, atraumatic, dry mucous membranes
NECK - supple, no LAD, no thyromegaly, JVP flat
CARDIAC - regular rate & rhythm, normal S1/S2, no murmurs rubs
or gallops
PULMONARY - diffusely wheezing
ABDOMEN - normal bowel sounds, soft, non-tender, non-distended,
no organomegaly. No pain over kidney donor site
EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or
edema. Chronic venous stasis changes on right lower extremity
SKIN - without rash
NEUROLOGIC - A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout. Gait assessment deferred
PSYCHIATRIC - listen & responds to questions appropriately,
pleasant
DISCHARGE EXAM
==============
Vitals: T:98.2 BP:126/71 P:89 R:20 O2:95RA
General: Alert, oriented, no acute distress, sitting up in bed
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, no
LAD
Lungs: No audible wheezing, inspiratory and expiratory wheezing.
CV: Irregular, irregular
Abdomen: soft, non-tender, obese, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis , 1+
non pitting edema bilaterally
Skin: Xerotic, scattered seborrheia
Neuro: Aox3, Cn2-12 in tact, grossly non focal
Pertinent Results:
ADMISSION LABS
===========
___ 04:35PM PLT COUNT-124*
___ 04:35PM ___
___ 04:35PM NEUTS-73.5* LYMPHS-11.2* MONOS-14.3* EOS-0.4*
BASOS-0.3 IM ___ AbsNeut-5.23# AbsLymp-0.80* AbsMono-1.02*
AbsEos-0.03* AbsBaso-0.02
___ 04:35PM WBC-7.1 RBC-4.60 HGB-13.6* HCT-41.9 MCV-91
MCH-29.6 MCHC-32.5 RDW-14.2 RDWSD-47.3*
___ 04:35PM CALCIUM-8.8 PHOSPHATE-2.3* MAGNESIUM-1.3*
___ 04:35PM estGFR-Using this
___ 04:35PM GLUCOSE-98 UREA N-14 CREAT-1.3* SODIUM-136
POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-22 ANION GAP-18
___ 04:43PM LACTATE-2.1*
DISCHARGE LABS
===========
___ 08:02AM BLOOD WBC-9.6 RBC-4.37* Hgb-12.7* Hct-39.6*
MCV-91 MCH-29.1 MCHC-32.1 RDW-14.1 RDWSD-46.8* Plt ___
___ 08:02AM BLOOD Plt ___
___ 08:02AM BLOOD ___ PTT-30.9 ___
___ 08:02AM BLOOD Glucose-127* UreaN-35* Creat-1.0 Na-138
K-4.6 Cl-104 HCO3-26 AnGap-13
___ 08:02AM BLOOD Calcium-9.6 Phos-3.6 Mg-2.1
___ 08:02AM BLOOD tacroFK-6.2
MICRO
====
___ 7:00 am STOOL CONSISTENCY: FORMED Source:
Stool.
**FINAL REPORT ___
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
__________________________________________________________
___ 9:57 am STOOL CONSISTENCY: FORMED Source:
Stool.
**FINAL REPORT ___
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
__________________________________________________________
___ 5:20 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI IN SHORT
CHAINS.
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
LEGIONELLA CULTURE (Final ___: NO LEGIONELLA
ISOLATED.
__________________________________________________________
___ 1:22 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.
__________________________________________________________
___ 8:22 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
__________________________________________________________
___ 1:00 pm Immunology (CMV)
**FINAL REPORT ___
CMV Viral Load (Final ___:
CMV DNA not detected.
Performed by Cobas Ampliprep / Cobas Taqman CMV Test.
Linear range of quantification: 137 IU/mL - 9,100,000
IU/mL.
Limit of detection 91 IU/mL.
This test has been verified for use in the ___ patient
population.
__________________________________________________________
___ 10:23 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
__________________________________________________________
___ 10:03 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 6:15 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
__________________________________________________________
___ 4:15 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
STUDIES
=====
CXR
-___
Final Report
FINDINGS: The lungs are well inflated and clear. Branching
opacities in the retrocardiac region likely reflective vessels
and mild atelectasis. There is no focal consolidation, pleural
effusion, or pneumothorax.. Cervical spine hardware is
partially imaged.
IMPRESSION: No definite evidence pneumonia.
Renal Transplant U/S
The left iliac fossa transplant renal morphology is normal.
Specifically, the
cortex is of normal thickness and echogenicity, pyramids are
normal, there is
no urothelial thickening, and renal sinus fat is normal. There
is no
hydronephrosis and no perinephric fluid collection.
The resistive index of intrarenal arteries ranges from 0.70 to
0.78, within
the normal range. The main renal artery shows a normal
waveform, with prompt
systolic upstroke and continuous antegrade diastolic flow, with
peak systolic
velocity of 122 cm/sec, previously 110 cm/sec. Vascularity is
symmetric
throughout transplant. The transplant renal vein is patent and
shows normal
waveform.
IMPRESSION:
Normal renal transplant ultrasound.
Brief Hospital Course:
___ year old male dual renal-transplant (___) on MMF and
tacro with chief complaint of cough, shortness of breath, fever
concerning for atypical/viral pneumonia, inpatient course c/b
afib with rvr.
ACTIVE ISSUES
=========
# Afib with RVR. H/o afib s/p dig/amio and cardioversion. He
presented this admission in sinus rhythm and converted to afib
sometime ___ thought likely in setting of infection/stress
with possible contribution from excess beta agonist activity
with frequent albuterol. With regards to his afib, his heart
rates increased to 120s asymptomatic and his home dose of
Metoprolol Tartrate 50mg BID was increased to 50mg q6hrs. He was
started on amiodorone 400mg, after consultation with his
outpatient Cardiologist Dr. ___ will continue with
this dose until his follow up appointment. Plan was for ___
of Hearts monitor to be worn with results sent to Dr.
___ patient did not have a land line and in
discussion with Dr. ___ was deferred. With
regards to his anticoagulation, INR was 1.8 on the day of
discharge. He was discharged on 3mg of warfarin with lovenox
bridge given prior stroke history after discussion with Dr. ___,
___ outpatient primary care provider. He will have a
repeat INR checked on ___. This information was
relayed by telephone to the ___ clinic at ___ prior
to the patients discharge.
# Bronchitis/Viral PNA. He presented with diffuse wheezing and
hypoxia. Flu and RVP were negative. CXR was w/o focal
consolidation. He was treated with a 6 day course of
Levofloxacin. After 48 hours of limited improvement, he was
started on IV solumedrol, with PO prednisone taper with interval
improvement in his wheezing and SOB. For his wheezing, he was
initially started on Duonebs and albuterol prn, but in the
setting of worsening his afib with rates in the 120s, his
inhalers were changed to ipratropium and levalbuterol
respectively. He was sent home with ipratropium to be taken
until otherwise directed in outpatient follow up. Breathing was
much improved, with decreased wheezing and improved exercise
tolerance prior to discharge.
# DUAL RENAL TRANSPLANT (___). On MMF/Tacro. Renal
transplant was consulted. Home MMF was initially held, then
restarted after clinical improvement. Tacrolimus was decreased
to 0.5mg BID on discharge.
# ___: AKIN ___ by Cr on admission thought likely ___ to
hypovolemia due to dehydration. Cr normalized near baseline 1.2
after IVF. Renal transplant ultrasound was wnl. UA with pyuria,
but patient was asymptomatic, with negative culture so no
additional antibiotics were given.
CHRONIC ISSUES
===========
# HTN: Lasix and losartan were initially held but restarted
prior to discharge.
TRANSITIONAL ISSUES
==============
# Bronchitis/Viral PNA
- Discharged with Ipratropium inhaler
- Completed 6 day course of treatment with Levofloxacin on ___
- Radiology follow up of the patient 4 weeks after completion of
antibiotic therapy (Completed ___, Evaluate around ___ for
documentation of it resolution of left lower lobe pneumonia is
recommended.
- Discharged on Prednisone Taper
60mg daily: ___
50mg daily: ___
40mg daily: ___
30mg daily: ___
20mg daily: ___
10mg daily: ___
5mg daily: ___
Stop: ___
# H/o Squamous Cell Carcinoma. Dr. ___ a lengthy
discussion with the patient about the importance of f/u for his
known squamous cell carcinoma. Appointment with Dermatology was
made on discharge to f/u on recommended evaluations.
# Dual renal transplant/Immunosuppressive regimen
- Tacrolimus 0.5mg BID
- MMF 500mg BID
# Afib
- Discharged on Metoprolol succinate 100mg BID and Amiodorone
400mg daily to be continued until follow up with Dr.
___ on ___
- INR 1.8 on the day of discharge
- Discharged on 3mg Warfarin daily and lovenox ___ BID as
bridging therapy after discussion with Dr. ___
- ___ INR should be drawn on ___ at PCP ___.
Results faxed to: ___ ACMS att: Dr. ___ at
___
# TSH
- Recommend rechecking TSH in ___ weeks after discharge for low
TSH value in setting of normal T4.
# CONTACT: mother is emergency contact person, ___ #
___
# CODE STATUS: FULL
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 25 mg PO DAILY
2. Metoprolol Tartrate 50 mg PO BID
3. Warfarin 6 mg PO DAILY16
4. Pravastatin 40 mg PO QPM
5. Tacrolimus 1 mg PO Q12H
6. Furosemide 20 mg PO DAILY
7. Omeprazole 20 mg PO BID:PRN stomach pain
8. Minocycline 50 mg PO Q12H
9. Mycophenolate Mofetil 500 mg PO BID
Discharge Medications:
1. Ipratropium Bromide Neb 1 NEB IH Q6H
RX *ipratropium bromide [Atrovent HFA] 17 mcg/actuation 1 puff
inhaled every 6 hours Disp #*1 Inhaler Refills:*0
2. Benzonatate 200 mg PO TID
RX *benzonatate 200 mg 1 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*1
3. Furosemide 20 mg PO DAILY
4. Minocycline 50 mg PO Q12H
5. Mycophenolate Mofetil 500 mg PO BID
6. Pravastatin 40 mg PO QPM
7. Omeprazole 20 mg PO QHS
8. Guaifenesin ___ mL PO Q6H:PRN cough
RX *guaifenesin [Expectorant] 100 mg/5 mL ___ mL by mouth every
six (6) hours Refills:*0
9. Outpatient Lab Work
ICD10: I48.0
Dx: Atrial Fibrillation
Please draw INR on ___
Fax results to: ___ ACMS att: Dr. ___ at ___
10. PredniSONE As directed mg PO DAILY Duration: 12 Days
RX *prednisone 10 mg As directed tablet(s) by mouth Daily Disp
#*26 Tablet Refills:*0
11. Losartan Potassium 25 mg PO DAILY
12. Amiodarone 400 mg PO DAILY
RX *amiodarone 400 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
13. Metoprolol Succinate XL 100 mg PO BID
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
14. Enoxaparin Sodium 120 mg SC BID Duration: 7 Days
Start: ___, First Dose: Next Routine Administration Time
Please use BID until you have repeat INR with your PCP ___
___
RX *enoxaparin 120 mg/0.8 mL 1 syringe SC twice a day Disp #*14
Syringe Refills:*0
15. Tacrolimus 0.5 mg PO Q12H
RX *tacrolimus 0.5 mg 1 capsule(s) by mouth Q12h (every 12
hours) Disp #*60 Capsule Refills:*1
16. Warfarin 3 mg PO DAILY16
RX *warfarin 3 mg 1 tablet(s) by mouth Daily Disp #*10 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
=================
Bronchitis
Secondary Diagnosis
===================
Atrial fibrillation
Cerebral vascular accident
DUAL RENAL TRANSPLANT (___)
Acute Kidney Injury
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your
hospitalization. Briefly, you were hospitalized with wheezing,
fevers, and difficulty breathing. You were treated for a
pneumonia with an antibiotic called Levofloxacin. You were also
given steroids to help with your breathing. You should continue
taking these steroids (prednisone) at decreasing doses according
to the scheduled outlined below. You were also give a
prescription for an inhaler (Ipratropium). Use this inhaler as
prescribed.
Please notify your doctor if your breathing does not improve.
Take it easy for a few days until you are feeling better before
participating in any strenuous physical activity.
For your heart, you were restarted on the medication amiodorone
and continued at a higher dose of metoprolol. Call his office
with any questions.
Your INR was difficult to control this admission due to multiple
medications that can cause your INR to change. Your Coumadin
dose was lowered and your INR fell to 1.8. This is below your
therapeutic range and therefore you were started on lovenox (a
shot) to take twice per day (once in the morning and once at
night) along with your Coumadin until you follow-up with Dr. ___
on ___. Your Coumadin was decreased to 3mg daily on
discharge.
You will have a visiting nurse come to the house on ___ to
evaluate your medications and assist you with your lovenox shot.
We wish you the best,
Your ___ Treatment Team
Prednisone Taper
================
50mg daily: ___ daily: ___
30mg daily: ___
20mg daily: ___
10mg daily: ___
5mg daily: ___
Stop: ___
New or Changed Medications:
=============================
Start prednisone as above
Start ipratropium for wheezing
Start lovenox for anticoagulation
Start amiodarone for atrial fibrillation
Stop metoprolol tartrate
Start metoprolol succinate 100mg twice daily
Followup Instructions:
___
|
10269308-DS-16 | 10,269,308 | 26,322,272 | DS | 16 | 2157-04-15 00:00:00 | 2157-04-19 19:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old man w/ paroxysmal a fib, mild aortic stenosis, HTN,
prior stroke w/ residual left-sided hemiparesis, and recent
hospitalization for PNA (tx levoflox) w/ subsequent recurrence
of a fib s/p successful ___ yesterday (still on amio and
warfarin), and CRF ___ focal and segmental glomerulosclerosis
s/p bilateral renal transplant (on Prograf and Cellcept) p/w
dyspnea. Pt woke suddenly at 2AM and felt very SOB and per son,
he was working hard to breathe and breathing heavily. He coughed
up a lot of mucus and then felt his breathing improve. They then
went outside and the patient immediately felt relief in the
cooler air. They note that the apartment is small, stuffy and
dry. He denies any CP, h/a, n/v/d, or abdominal pain. Feels much
better now.
Of note he stopped his Lasix (unsure why taking) a few days ago
in preparation for his cardioversion.
Past Medical History:
-h/o fistula s/p repair, c/b seizures and cord compression
-Hypertension
-Dyslipidemia
-History of gloerulonephritis, then received cadaveric renal
transplant, ___ yrs ago, on immunosuppressants in past,
transplant failed ___ years ago and now on hemodialysis.
-___ renal transplant
-Anemia
-Coagulase negative staphylococcal bacteremia
-Community-acquired pneumonia
-Duodenal ulcers status post thermal therapy/injection
-Pericardial effusion
-Obesity
-Osteopenia
Social History:
___
Family History:
No history of seizure or stroke
Physical Exam:
ADMISSION
VS: 98.7 90 140/83 18 95%RA
General: NAD
HEENT: MMM, NCAT
Neck: JVD 3CM above clavicle
CV: RRR
Lungs: crackles bilaterally at bases
Abdomen: s/nt/nd
Ext: warm, well perfused
Neuro: CN ___ intact. Decreased strength in left arm, chronic
contracture
Skin: multiple seb keratoses on back
DISCHARGE
VS: 96.2 60-90s 110-120s/50-60s 20 98%RA
General: NAD
HEENT: MMM, NCAT
Neck: JVD 3CM above clavicle
CV: RRR
Lungs: end exp wheezes at mid and lower lung fields
Abdomen: s/nt/nd
Ext: warm, well perfused
Neuro: CN ___ intact. Decreased strength in left arm, chronic
contracture
Skin: multiple seb keratoses on back
Pertinent Results:
ADMISSION LABS
___ 10:10AM BLOOD WBC-9.5 RBC-3.90* Hgb-11.3* Hct-36.5*
MCV-94 MCH-29.0 MCHC-31.0* RDW-15.4 RDWSD-53.0* Plt ___
___ 10:10AM BLOOD Neuts-70.8 Lymphs-17.3* Monos-11.2
Eos-0.2* Baso-0.2 Im ___ AbsNeut-6.70* AbsLymp-1.64
AbsMono-1.06* AbsEos-0.02* AbsBaso-0.02
___ 07:30AM BLOOD ___
___ 10:10AM BLOOD Glucose-117* UreaN-16 Creat-1.2 Na-140
K-4.7 Cl-105 HCO3-25 AnGap-15
___ 04:30AM BLOOD Calcium-9.3 Phos-3.0 Mg-1.6
___ 04:30AM BLOOD tacroFK-8.5
___ 10:22AM BLOOD Lactate-2.4*
DISCHARGE LABS
___ 04:35AM BLOOD WBC-8.4 RBC-3.90* Hgb-11.3* Hct-36.2*
MCV-93 MCH-29.0 MCHC-31.2* RDW-15.4 RDWSD-52.6* Plt ___
___ 04:35AM BLOOD Plt ___
___ 04:35AM BLOOD ___
___ 04:35AM BLOOD Albumin-3.5 Calcium-9.3 Phos-3.1 Mg-1.7
___ 04:35AM BLOOD ALT-9 AST-16 AlkPhos-102 TotBili-1.0
___ 04:35AM BLOOD tacroFK-8.8
MICRO
___ URINEURINE CULTURE-FINALno growth
___ BLOOD CULTUREBlood Culture, Routine-FINALno growth
___ BLOOD CULTUREBlood Culture, Routine-FINALno growth
IMAGING
___ CXR PA/LAT
Bilateral pulmonary opacities as well as central venous
congestion suggests mild to moderate pulmonary edema.
___ CXR PA/LAT
IN COMPARISON TO ___, CARDIOMEGALY AND PULMONARY
VASCULAR CONGESTION
ARE PERSISTENT FINDINGS, ACCOMPANIED BY MILD INTERSTITIAL EDEMA.
THERE ARE NO
CONFLUENT SEGMENTAL OR LOBAR AREAS OF CONSOLIDATION TO SUGGEST
THE PRESENCE OF
PNEUMONIA. BILATERAL PLEURAL EFFUSIONS ARE SMALL IN SIZE.
Brief Hospital Course:
___ year old man w/ paroxysmal a fib, mild aortic stenosis, HTN,
prior stroke w/ residual left-sided hemiparesis, and recent
hospitalization for PNA (tx levoflox) w/ subsequent recurrence
of a fib s/p successful DCCV yesterday (still on amio and
warfarin), and CRF ___ focal and segmental glomerulosclerosis
s/p bilateral renal transplant (on Prograf and Cellcept) p/w
dyspnea and findings concerning for pulmonary edema.
#HCAP: Given fever and immunosuppression, patient treated HCAP
although no clear consolidation. Pt treated w/ IV
vancomycin/cefepime/flagyl for HCAP which was further narrowed
to PO cefpodoxime (day ___, last day= ___. UCx and
Blood cultures NGTD
#Dyspnea:. CXR notable for pulmonary edema in the setting of
held home lasix prior to cardioversion. Pt given IV lasix
boluses for diuresis and started on Torsemide 10mg daily on
discharge. Treated for HCAP as above w/ Abx and duonebs.
#Afib: s/p cardioversion. Pt converted back to atrial
fibrillation while inpatient and patient continued on coumadin,
amiodarone, and metoprolol. INR supratherapeutic on admission so
held on ___, restarted on ___ at home dose. However, INR 1.8
on ___ and given recent cardioversion, patient was given a dose
of lovenox in the hospital as a bridge and will have INR checked
in 2 days for follow up.
#Renal Transplant: stable, Cr at baseline and without tenderness
-continued home MMF, tacro
-new donor specific Abs so will have tac goal ___
Transitional Issues
-INR, Chem 7, Tacro to be drawn morning of ___
-new donor specific Abs on this admission so tacrolimus goal
___ Will need to be addressed at next transplant clinic appt.
-Patient converted back in to afib on this admission. He will
follow up with cardiology for atrial fibrillation management
-new medications : cefpodoxime for HCAP, last day ___
___ Torsemide 10mg daily
-Discontinued meds: Lasix 20mg daily
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Benzonatate 200 mg PO TID
2. Furosemide 20 mg PO DAILY
3. Mycophenolate Mofetil 500 mg PO BID
4. Pravastatin 40 mg PO QPM
5. Omeprazole 20 mg PO QHS
6. Losartan Potassium 25 mg PO DAILY
7. Amiodarone 200 mg PO DAILY
8. Tacrolimus 0.5 mg PO Q12H
9. Warfarin 3 mg PO 2X/WEEK (MO,TH)
10. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
BID
11. Warfarin 4.5 mg PO 5X/WEEK (___)
12. Metoprolol Succinate XL 100 mg PO BID
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Benzonatate 200 mg PO TID
3. Losartan Potassium 25 mg PO DAILY
4. Metoprolol Succinate XL 100 mg PO BID
5. Mycophenolate Mofetil 500 mg PO BID
6. Omeprazole 20 mg PO QHS
7. Pravastatin 40 mg PO QPM
8. Tacrolimus 0.5 mg PO Q12H
9. Cefpodoxime Proxetil 400 mg PO Q12H
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice daily Disp #*6
Tablet Refills:*0
10. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
BID
11. Torsemide 10 mg PO DAILY
RX *torsemide 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
12. Warfarin 3 mg PO 2X/WEEK (MO,TH)
13. Warfarin 4.5 mg PO 5X/WEEK (___)
14. Outpatient Lab Work
ICD 10 atrial fibrillation I48.2
INR drawn ___, goal ___, email to ___
15. Outpatient Lab Work
ICD 10 Z94.0 kidney transplant
please have chem7 and tacro and faxed to ___ ATTN:
___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Pulmonary edema
Hospital acquired pneumonia
Atrial fibrillation
s/p renal transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ with shortness of breath and fever
after your recent cardioversion. You were given IV lasix to help
you urinate this extra fluid and antibiotics for a possible
pneumonia. You will need to continue cefpodoxime (an oral
antibiotics) until ___. You will continue oral
lasix. You also reverted to atrial fibrillation while in the
hospital so you will need to follow up with your cardiologist to
manage this. You will need to follow up with your kidney doctor
as scheduled below.
Please have labs drawn on ___ so that they can be sent to
your kidney doctor and the anticoagulation nurse. Please have
them drawn early in the morning and do not take your morning
prograf dose until you have the labs drawn.
It was a pleasure to care for you!
-Your ___ Team
Followup Instructions:
___
|
10269467-DS-10 | 10,269,467 | 29,191,715 | DS | 10 | 2117-09-19 00:00:00 | 2117-09-19 17:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Racing heart
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ yo ___ (___-speaking) female with PMH significant for
hypertension presenting with episodes of racing heart and
epigastric pain. Patient felt epigastric and left chest pain
over the last ___ days which was associated with palpitations, a
sensation of tension on her neck and head. Has had similar
episodes previously and was started on antihypertensives in
___ which were changed to Amiloride-HCTZ after a
consultation at ___. Patient denies any fevers, chills,
shortness of breath, nausea, vomiting, weight changes, hot or
cold intolerance, diarrhea, ___ pain or swelling.
In the ED, initial VS were 99.3 124 174/80 16 100% RA. She
received full dose aspirin, mylanta, donnatol, viscous
lidocaine, zofran, morphine. EKG show sinus tachycardia. A
bedside U/S revealed aorta < 2 cm, CXR was normal, tropsx2 and
d-dimer were negative. Lactate was elevated at 2.4. The patient
received 2L IVF and continued to be tachycardic to the 130s with
elevated lactate, and was triggered for persistent tachycardia.
Abd CT showed no acute intraabdominal process. Patient was
admitted for further evaluation.
Upon transfer to the floor, 97.4 126 22 99% 155/100. Patient
stated her discomfort was persistent, but much improved.
Past Medical History:
Hypertension
Social History:
___
Family History:
One son died of kidney disease
Physical Exam:
Admitting Exam:
VS - Temp 97.1 F, 171/98 BP , 108 HR , 18RR , O2-sat 97% RA
GENERAL - well appearing woman in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, oropharynx dry
NECK - supple, enlarged thyroid bilaterally no JVD, no carotid
bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, 1+ systolic murmur hear that radiates
to carotids, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Discharge Exam:
VS - Tmax 98.9 F, Tcurr: 96.9 146/73 BP , 74 HR , 18RR , O2-sat
96% RA
GENERAL - well appearing woman in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, oropharynx dry
NECK - supple, enlarged thyroid bilaterally, no JVD, no carotid
bruits, no LAD. Heart sounds heart briskly in the carotids.
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored
HEART - tachycardic, 1+ systolic murmur, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no rebound or guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Pertinent Results:
LABS:
On admission:
___ 12:55PM GLUCOSE-144* UREA N-15 CREAT-0.9 SODIUM-140
POTASSIUM-3.0* CHLORIDE-97 TOTAL CO2-32 ANION GAP-14
WBC-7.2 RBC-4.68 HGB-13.7 HCT-40.4 MCV-86 MCH-29.2 MCHC-33.8
RDW-12.6
ALT(SGPT)-20 AST(SGOT)-22 ALK PHOS-116* TOT BILI-0.6 LIPASE-32
.
URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG RBC-<1 WBC-0
BACTERIA-NONE YEAST-NONE EPI-0
.
FREE T4-1.2 TSH-0.68
D-DIMER-273 cTropnT-<0.01
.
___ 04:50AM BLOOD Lactate-2.5*
___ 10:55AM BLOOD Lactate-1.6
.
On discharge:
___ 05:30AM Glucose-82 UreaN-21* Creat-1.1 Na-140 K-3.1*
Cl-98 HCO3-36* AnGap-9
WBC-8.5 RBC-4.41 Hgb-13.0 Hct-37.8 MCV-86 MCH-29.6 MCHC-34.5
RDW-12.9 Plt ___
.
DIAGNOSTICS:
CHEST (PA & LAT) ___ FINDINGS: PA and lateral views of the
chest were obtained demonstrating clear well expanded lungs
without focal consolidation, effusion, pneumothorax. Heart size
is top normal. Mediastinal contour is normal aside from an
unfolded thoracic aorta. Bony structures are intact. A focal
eventration of the right hemidiaphragm noted. No free air below
the right hemidiaphragm
.
CT ABD & PELVIS WITH CONTRAST ___ IMPRESSION:
No acute abdominal or pelvic processes. No explanation for
patient's
epigastric pain based on CT findings.
.
THYROID U.S. ___ IMPRESSION: Small bilateral thyroid
nodules which by ultrasound criteria do not demonstrate any
worrisome features. Routine followup in ___ years is suggested.
.
TTE (Complete) ___ IMPRESSION: The left atrium is normal
in size. The estimated right atrial pressure is ___ mmHg. There
is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The right ventricular free wall
is hypertrophied. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Trivial mitral regurgitation is seen.
Moderate to severe [3+] 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.
Brief Hospital Course:
#Tachycardia: Patient was admitted for evaluation of persistent
tachycardia despite 3L IVF and pain control in the ED. On
evaluation patient was noted to have a goiter, and there was
suspicion for an abnormal thyroid as a possible etiology of her
tachycardia. Patient had a thyroid ultrasound to assess her
enlarged thyroid which did not show any concerning
irregularities. TSH was in normal range (.68) as was free T4. On
exam patient was also found to have a 1+systolic murmur and an
trans thoracic was obtain to further evaluate this. The Echo
revealed 3+ tricuspid regurgitation. Patient was also placed on
telemetry with no irregularities noted. Patient's heart rate
trended down from 100+ to 74 on the morning of discharge. It is
possible that the patient had tachycardia in the setting of
decreased intravascular volume with tricuspid regurgitation,
that resolved as patient had increased IVF. The patient will
follow up with a cardiologist as an outpatient.
#Epigastric pain: Patient's description of her pain was actually
more fitting of palpitations which coincided with her
tachycardia. CT Abd/Pelvis showed no acute intraabdominal
process. LFTs and lipase were normal. GERD or gastritis less
likely given her clinical presentation and description of her
discomfort. On discharge, patient was not experiencing any
epigastric pain.
#Hypertension: Patient had a history of hypertension and had
Amiloride-HCTZ,ramipril and nifedipine as home meds which she
stated she took on some days. The patient was given HCTZ and
ramipril while in hose and her BP seemed well controlled on this
regimen. Given concern for lack of compliance with multiple
medications, and inability to pay due to limited insurance
coverage. Patient was discharged with lisinopril-HCTZ
combination pill which is part of the ___ affordable
formulary. The patient will follow up with her PCP, ___.
___, at ___ for further assessment.
#Elevated Lactate: On presentationm, the patient's lactate was
elevated at 2.5. Likely secondary to dehydration, but as it
resolved after fluid administration and there was no evidence of
infection.
Transitional Issues:
-She will follow up with her new PCP to assess adherence to her
anti-HTN regimen and monitor how she is doing.
-She should see cardiology non-urgently for management and/or
surveillance of very well compensated tricuspid regurgitation.
Medications on Admission:
Amiloride-HCTZ: 50 mg daily
Nifedipine: 20 mg daily
Ramipril: 5 mg daily
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q8H (every 8
hours) as needed for pain.
2. lisinopril-hydrochlorothiazide ___ mg Tablet Sig: One (1)
Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Tachycardia
Tricuspid regurgitation
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were evaluated for your fast heartrate. You had several
tests including a chest x-ray which was normal and an ultrasound
to look at your heart (an ECHO) which showed one of your valves
(the tricuspid valve) was leaky. This might be the cause of your
symptoms. Please follow-up with your doctor on ___ regular basis
to evaluate this.
The following changes were made to your medications:
#START lisinopril-HCTZ 12.5mg-25mg by mouth daily
.
#STOP Amiloride-HCTZ: 50 mg
#STOP Nifedipine: 20 mg
#STOP Ramipril: 5 mg
Followup Instructions:
___
|
10269842-DS-26 | 10,269,842 | 25,619,331 | DS | 26 | 2146-08-03 00:00:00 | 2146-08-03 17:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Epigastric pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with multiple surgeries in the past and recurrent SBOs,
presenting with epigastric abdominal pain yesterday at noon, up
to ___, associated with nausea and vomiting x1. It remained
centered on the epigastric region and did not radiate.Her last
meal was lunch and she has not felt hungry since this pain
began.Her last BM was yesterday and was normal. She stopped
passing flatus yesterday morning. Had some nausea/vomited x1
upon arrival to the ED.
ROS:
(+) Pain, N/V per HPI, tinnitus
(-) Denies fevers, chills, headache, dizziness, hematemesis,
BRBPR, chest pain, shortness of breath, urinary frequency,
urgency
Past Medical History:
Small Bowel obstruction,Polymyalgia Rheumatica, Afib,
HTN,hypothyroid, tinnitus
Past Surgical History: Cholecystectomy, appendectomy,
hysterectomy, sigmoidectomy for diverticulitis, lumbar
laminectomy, rectal fissure repair, Left TKA, Left sjoulder
hemiarthroplasty, Right shoulder surgery
Social History:
___
Family History:
Father died of prostate cancer, mother,HTN, died of a stroke
Physical Exam:
General: A&O, NAD
HEENT:no scleral icterus, mucus membranes moist
Cardiac: RRR, No M/G/R
Pulmonary: Clear to auscultation b/l, No W/R/R
Abdomen:soft, nondistended, nontender tender,normoactive bowel
sounds
Extremities:no ___ edema, ___ warm and well perfused
Pertinent Results:
MICRO: MRSA screen, Urine culture and blood cultures pending
(___)
ABX: None
IMAGING: Abdominal CT: Preliminary Report: Stomach is markedly
distended and fluid filled. Proximal loops of small bowel are
dilated up to 4 mm. Distal loops of small bowel are collapsed,
compatible with small bowel obstruction.
2. Bilateral consolidations at the lung bases, likely reflect
aspiration and/or infection in the appropriate clinical setting.
___ 04:35AM BLOOD WBC-10.7 RBC-3.47* Hgb-8.8* Hct-27.5*
MCV-79* MCH-25.3* MCHC-31.9 RDW-16.1* Plt ___
___ 12:49AM BLOOD WBC-10.1 RBC-3.51* Hgb-8.9* Hct-28.3*
MCV-81* MCH-25.3* MCHC-31.5 RDW-16.5* Plt ___
___ 11:15PM BLOOD WBC-10.1# RBC-4.30 Hgb-11.0* Hct-34.1*
MCV-79* MCH-25.6* MCHC-32.2 RDW-16.3* Plt ___
___ 04:35AM BLOOD Glucose-93 UreaN-13 Creat-1.1 Na-141
K-3.3 Cl-108 HCO3-26 AnGap-10
Brief Hospital Course:
This is an ___ year old female with history of recurrent SBO who
presented to the ED with nausea, vomiting abdominal pain,
abdominal imaging was done which was consistent with SBO.
Patient was treated conservatively with an NGT,intravenous
fluids and bowel rest.Of note patient had developed respiratory
issues and was placed on a shovel mask for low oxygen
saturations and was transferred to the intensive care unit for
further monitoring. Incidentally patient was found to have
pneumonia on chest xray and was started on IV antibiotics
(Levofloxacin ___. Of note while in the ICU patient was
noted to have an episode of agitation during the night and
received Lorazepam and Zyprexa with mild improvement. Patient
respiratory status continued to improve and her oxygen was
weaned and she was transferred from the sicu to the floor.
Patient SBO was resolved and she was passing gas and the diet
was advanced to clears which was tolerated well.Thus the
nasogastric tube was subsequently discontinued and her diet was
slowly advanced to clears which was tolerated well. Hospital
day 3, the diet was advanced to regular. Patient had no further
abdominal pain patient was also restarted on all of her home
medications. Hospital day 4, she received a Dulcolax
suppository, and bowel regimen (senna and colace). Shortly
thereafter patient had a bowel movement.
At time of discharge patient was doing well, passing gas, and
tolerating a regular diet Patient was discharged home on
Levofloxacin PO for 3 days to complete a 7 day course. She had
no further respiratory issues and her vital signs were stable.
Patient received discharge instructions and will follow-up with
Dr. ___ as needed.
Medications on Admission:
amiodarone 200mg TIW ___
amlodipine 5mg daily
ammonium lactate lotion
atenolol 50mg daily
levothyroxine 150mcg morning
ompeprezole 20mg daily
prednisone 4mg daily
ropinirole 1mg bedtime
tramadol 1mg PRN pain
trazodone 50mg PRN sleep
warfarin 3mg ___ tabs qd
calcium 500+D BID
docusate sodium 100mg BID
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO MWF
(___).
2. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. prednisone 1 mg Tablet Sig: Seven (7) Tablet PO DAILY
(Daily).
5. trandolapril 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. ropinirole 1 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
10. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Hold for loose stool.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1.small bowel obstruction
2.pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with to the hospital with complaints of
abdominal pain, nausea, and vomiting. Abdominal imaging was done
which showed a small bowel obstruction which was medically
managed with bowel rest,nasogastric tube and hydration. Once you
started passing gas, your diet was slowly restarted which you
tolerated well. You also had some respiratory issues during your
hospitalization and a chest xray was done which showed pneumonia
and you were started on an antibiotic (Levofloxacin). You will
need to continue taking your antibiotic for 3 more days; please
take exactly as prescribed even if you are feeling better. You
may resume your other home medications. Please call Dr.
___ if you develop nausea, vomiting, increasing
abdominal pain, distention, large decrease in bowel movements or
flatus, or any other questions or concerns.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
Followup Instructions:
___
|
10269842-DS-28 | 10,269,842 | 23,486,265 | DS | 28 | 2147-04-15 00:00:00 | 2147-04-16 15:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of recurrent SBOs, most recently last month (___.
___), and two months ago requiring admission to ___ now p/w
abdominal pain. Patient states that symptoms began last night
after eating dinner; pain is located mostly in lower quadrants.
She initially attributed the pain to 'gas' and took 'Gas-X'
without much relief, then proceeded to have nausea with some
non-bloody, non-bilious emesis last night. She has had a few
episodes of emesis this morning as well, and decided to present
to the ED for care.
She otherwise states her symptoms are very similar to that of
her
previous SBOs. She most recently was seen at ___
three weeks ago and was treated conservatively for an SBO. The
month prior she was admitted to the ACS service for SBO, also
treated conservatively. Her hospital course was notable for afib
with RVR requiring admission to the ICU for rate-control, she
was
eventually transferred to the floor and her diet advanced
slowly.
She has been tolerating a soft diet for the past few weeks with
abdominal pain. Her last bowel movement was yesterday,
non-bloody. She remembers last passing gas yesterday evening
Past Medical History:
PMH: Polymyalgia rheumatica, AF on coumadin, HTN, graves disease
s/p radioiodine ablation -> now hypothyroid,GERD, HL, SBOs
PSH: TAH/BSO, appendectomy, open CCY, sigmoid colectomy
___,
Lumbar laminectomy, rectal fissure repair, Left TKA, Left
shoulder hemiarthroplasty, Right shoulder surgery
Social History:
___
Family History:
Father died of prostate cancer, mother,HTN, died of a stroke
Physical Exam:
Admission:
PE: VS:98.1 64 134/67 22 99% 2LNC
General: in no acute distress. Elderly caucasian female sitting
up in ED stretcher.
HEENT: sclera anicteric, mucus membranes tacky, nares clear,
trachea at midline. NGT in place, sumping with yellowish fluid
CV: irregularly irregular, normal rate. No appreciable murmurs,
rubs, gallops
Pulm: clear to auscultation bilaterally
Abd: hypoactive bowel sounds, mildly tender to palpation in
bilateral lower quadrants without localization. Mildly
distended.
Well-healed midline laparotomy incision. Well-healed paramedian
incision.
MSK: warm, well perfused
Neuro: alert, oriented to person, place, time
Discharge PE:
General: NAD
HEENT:NC/NT, MMM
PULM: CTA
CV: irregularly irregular, normal rate, NO MRG
ABD: Soft, NT, ND +Flatus
MSK: warm, well perfused
Neuro: AXOX3
Pertinent Results:
___ 05:40AM BLOOD WBC-8.9# RBC-4.31 Hgb-13.7 Hct-40.8
MCV-95 MCH-31.8 MCHC-33.6 RDW-14.2 Plt ___
___ 05:20AM BLOOD WBC-5.8 RBC-3.87* Hgb-12.2 Hct-36.4
MCV-94 MCH-31.6 MCHC-33.6 RDW-14.0 Plt ___
___ 05:40AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Tear
Dr-OCCASIONAL
___ 05:40AM BLOOD ___ PTT-42.9* ___
___ 05:40AM BLOOD Plt ___
___ 05:20AM BLOOD ___ PTT-44.8* ___
___ 05:20AM BLOOD Plt ___
___ 05:30AM BLOOD ___
___ 07:10AM BLOOD ___
___ 05:20AM BLOOD ___ PTT-40.7* ___
___ 05:40AM BLOOD Glucose-127* UreaN-21* Creat-1.1 Na-138
K-HEMOLYSIS Cl-102 HCO3-24
___ 05:20AM BLOOD Glucose-75 UreaN-15 Creat-1.0 Na-140
K-3.9 Cl-104 HCO3-26 AnGap-14
___ 05:30AM BLOOD Glucose-151* UreaN-10 Creat-1.0 Na-140
K-3.8 Cl-107 HCO3-27 AnGap-10
___ 07:10AM BLOOD Glucose-82 UreaN-7 Creat-0.9 Na-141 K-3.9
Cl-107 HCO3-29 AnGap-9
___ 05:40AM BLOOD ALT-17 AST-56* AlkPhos-60 TotBili-0.4
___ 07:10AM BLOOD Calcium-9.2 Phos-2.5* Mg-2.0
___ 05:30AM BLOOD Calcium-9.2 Phos-2.2* Mg-2.2
___ 05:20AM BLOOD Calcium-9.1 Phos-2.9 Mg-1.7
___ 05:40AM BLOOD Albumin-4.2
___ 05:48AM BLOOD Comment-GREEN TOP
___ 02:50PM BLOOD Lactate-0.6
___ 05:48AM BLOOD Lactate-2.4* K-4.6
Imaging:
___ KUB
IMPRESSION:
Early or partial small bowel obstruction.
Brief Hospital Course:
The patient was admitted to the General Surgical Service for
evaluation and treatment of partial small bowel obstruction.Tthe
patient arrived on the floor NPO, on IV fluids with a NG tube in
place. The patient was hemodynamically stable.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI/GU/FEN: the patient was made NPO with IV fluids. Diet was
advanced when appropriate, which was well tolerated. Patient's
intake and output were closely monitored, and IV fluid was
adjusted when necessary. Electrolytes were routinely followed,
and repleted when necessary. On day of discharge pt tolerated
regular diet without any issues. Pt had flatus as well.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection.
Medications on Admission:
Amiodarone 200' ___, metoprolol 12.5'', atenolol 50',
Levothyroxine 150', Omeprazole 20', oxybutynin ER 5', Prednisone
4', Ropinirole 1 qHS, Tramadol 50'' PRN, Trandolapril 2'',
Trazodone 25 qHS PRN, Coumadin ___, Colace 100'' ,
prophylactic
keflex ___ prior to dental procedures, calcium/Vit D, FeSO4,
senna
Discharge Medications:
1. Levothyroxine Sodium 150 mcg PO DAILY
2. Metoprolol Tartrate 12.5 mg PO BID
3. Omeprazole 20 mg PO DAILY
4. PredniSONE 4 mg PO DAILY
5. Ropinirole 1 mg PO QPM
6. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
7. Trandolapril 2 mg PO BID
8. traZODONE 25 mg PO HS:PRN insomnia
9. Warfarin 3 mg PO DAILY16
10. Docusate Sodium 100 mg PO BID
11. Amiodarone 200 mg PO MWF
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
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 surgical service due to a small bowel
obstruction. You were watched on the floor and your diet was
advanced without any issues.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 20
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
10270200-DS-2 | 10,270,200 | 20,981,761 | DS | 2 | 2122-02-12 00:00:00 | 2122-02-13 13:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
acetaminophen / iodine
Attending: ___.
Chief Complaint:
Cough, abnormal blood work
Major Surgical or Invasive Procedure:
IT MTX ___
History of Present Illness:
___ year old with history of previously diagnosed, treated
leukemia (unclear subtype; unclear prior treatment) who presents
from ___ with a CBC revealing 16% blasts.
She states she developed shortness of breath started 2 weeks
ago, felt like allergies acting up at first. Had severe
coughing, green to yellow sputum. Chest pain came couple days
later after constant coughing. She had a runny nose that felt
like turned into chest congestion. She says her cough is 50%
better. She says the shortness of breath is about the same. She
says the runny
nose is 90% better. Chest pain is about the same.
Has been sprycel since ___. Last time she received IV
chemotherapy was in ___.
Given her pulmonary symptoms, patient went to ___. CXR was
unremarkable. Was given CTX, duoneb, methylprednisolone 125
prior to transfer. Pertinent labs included: WBC 33.9, Cr 0.52.
In the ED,
- Initial Vitals: 98.8 102 193/82 20 94% RA
- Exam: Nontoxic-appearing; lungs with slight expiratory wheezes
- Labs:
---WBC 20.1 with 16% other, H/H wnl, plt 71
---Uric acid 7.6, BMP wnl asid from HCO3 18
---LFTS wnl
---Lactate 4.8 > 5.1 > 3.5
- Imaging:
---CXR: unremarkable, no acute cardiopulmonary process
- Consults: hem/onc consulted - low concern for leukostasis
given low CBC counts and percentage, low concern for TLS or DIC
based on initial labs. FICU admission, 125mg solumedrol for
cytoreduction, 300mg allopurinol once, get CTA chest if CXR
negative for PE work up; trend CBC w/ diff q6H; TLS labs and
coags q6H x1 then q12H if normal
- Interventions: in the ED, received IVF 2L, oxycodone 5mg once
and allopurinol ___.
In the ICU, patient states that she feels a bit better since
coming to the hospital. Overall, she thinks her breathing
symptoms have been improving. She still has some chest pain when
she takes a big breath.
Past Medical History:
Hypertension
Asthma
Breast cancer
Hidradenitis suppurativa
PTSD
Social History:
___
Family History:
Mother - colon cancer
___ grandmother - brain cancer, breast cancer
Paternal grandmother - breast cancer
No one with diabetes or hypertension
Physical Exam:
ADMISSION
=========
VS: reviewed in metavision
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection. MMM.
NECK: supple
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Inspiratory crackles bilaterally, faint inspiratory
wheezes bilaterally
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: Warm. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout.
DISCHARGE
=========
VS: 98.8 temp, 163 /93 L lying down, HR 104, RR 20, ___ 96 on Ra
General: Sad-appearing female sitting in bed, eating breakfast,
wheezing while talking
HEENT: pupils equal, symmetric facies, poor dentition
CV: Regular rate, distant heart sounds
PULM: Increased work of breathing, shortness of breath;
bibasilar
crackles at posterior lung fields (improved after diuresis late
AM)and wheezing in upper fields; intermittent cough
ABD: Increased body habitus, soft, non tender, non distended,
bruising improving across abdomen near umbilicus
NEURO: Speech fluent, no gross focal neuro deficits
Pertinent Results:
ADMISSION
=========
___ 10:50PM ___ PTT-24.7* ___
___ 10:50PM PLT SMR-VERY LOW* PLT COUNT-71*
___ 10:50PM HYPOCHROM-1+* ANISOCYT-1+* MICROCYT-1+*
OVALOCYT-2+* TEARDROP-1+* RBCM-SLIDE REVI
___ 10:50PM HOS-AVAILABLE
___ 10:50PM NEUTS-19* BANDS-3 LYMPHS-57* MONOS-1* EOS-1
___ METAS-1* MYELOS-2* NUC RBCS-0.6* OTHER-16* AbsNeut-4.42
AbsLymp-11.46* AbsMono-0.20 AbsEos-0.20 AbsBaso-0.00*
___ 10:50PM WBC-20.1* RBC-4.89 HGB-11.3 HCT-36.7 MCV-75*
MCH-23.1* MCHC-30.8* RDW-22.1* RDWSD-51.3*
___ 10:50PM ALBUMIN-4.3 CALCIUM-9.0 PHOSPHATE-4.5
MAGNESIUM-1.9 URIC ACID-7.6*
___ 10:50PM ALT(SGPT)-14 AST(SGOT)-15 LD(LDH)-417* ALK
PHOS-67 TOT BILI-0.2
___ 10:50PM estGFR-Using this
___ 10:50PM GLUCOSE-179* UREA N-12 CREAT-0.6 SODIUM-139
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-18* ANION GAP-19*
___ 11:05PM LACTATE-4.8*
___ 01:20AM URINE MUCOUS-RARE*
___ 01:20AM URINE RBC-1 WBC-3 BACTERIA-NONE YEAST-NONE
EPI-1
___ 01:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-1000* KETONE-10* BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 01:20AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 01:20AM URINE UCG-NEGATIVE
___ 01:20AM URINE HOURS-RANDOM
___ 01:28AM HCG-<5
___ 01:28AM cTropnT-<0.01
___ 01:32AM LACTATE-5.1*
___ 02:30AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 02:49AM HIV Ab-NEG
___ 02:49AM HBsAg-NEG HBs Ab-NEG HBc Ab-NEG HAV Ab-NEG
___ 03:28AM PLT SMR-VERY LOW* PLT COUNT-75*
___ 03:28AM HYPOCHROM-1+* ANISOCYT-1+* MICROCYT-1+*
OVALOCYT-2+* TEARDROP-1+* RBCM-SLIDE REVI
___ 03:28AM NEUTS-34 BANDS-7* ___ MONOS-0* EOS-0*
___ MYELOS-3* NUC RBCS-0.7* OTHER-16* AbsNeut-8.04*
AbsLymp-7.84* AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*
___ 03:28AM WBC-19.6* RBC-4.64 HGB-10.8* HCT-35.7 MCV-77*
MCH-23.3* MCHC-30.3* RDW-21.7* RDWSD-52.6*
___ 05:04AM ___ 05:04AM ___ PTT-25.7 ___
___ 05:04AM HAPTOGLOB-171
___ 05:04AM CALCIUM-8.4 PHOSPHATE-3.5 MAGNESIUM-1.9 URIC
ACID-5.6
___ 05:04AM LD(LDH)-384*
___ 05:04AM GLUCOSE-205* UREA N-11 CREAT-0.5 SODIUM-139
POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-18* ANION GAP-16
___ 05:16AM freeCa-1.17
___ 05:16AM GLUCOSE-214* LACTATE-3.5*
___ 05:16AM ___ PO2-76* PCO2-36 PH-7.37 TOTAL CO2-22
BASE XS--3
___ 12:24PM PLT COUNT-91*
___ 12:24PM NUC RBCS-1.1*
___ 12:24PM WBC-27.8* RBC-4.93 HGB-11.5 HCT-37.3 MCV-76*
MCH-23.3* MCHC-30.8* RDW-22.2* RDWSD-51.7*
___ 12:24PM CALCIUM-8.9 PHOSPHATE-2.9 MAGNESIUM-1.8 URIC
ACID-4.7
___ 12:24PM GLUCOSE-285* UREA N-12 CREAT-0.5 SODIUM-139
POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-17* ANION GAP-20*
PERTINENT INTERMITTENT LABS:
=========================
___ 09:05
Report Comment:
SOURCE:LP//CSF//TUBE#4; #4
ANALYSIS
Total Nucleated Cells, CSF2#/uLE
RBC, CSF600*#/uLE
Polys21 %
Bands4 %E
Lymphs34 %E
Monocytes24 %E
Metamyelocytes1 %E
Blasts16 %E
Other0 %E
IMAGING
=======
___ CXR: Right chest Port-A-Cath terminates in the proximal
right atrium. Lung volumes are low. No focal consolidation is
seen. No pleural effusion or pneumothorax. The
cardiomediastinal silhouette is not enlarged.
IMPRESSION:
Low lung volumes. No acute cardiopulmonary process.
___ ___:
Some of the images were repeated due to motion artifact on the
initial scan, but images through the posterior fossa and lower
cerebrum remain mildly limited by motion artifact.
There is no evidence of acute hemorrhage, edema, mass effect, or
loss of
gray/white matter differentiation. Ventricles, sulci, and basal
cisterns are normal in size. All components of the right
lateral ventricle is slightly larger than the left, consistent
with congenital or developmental etiology for the asymmetry.
There is no evidence of fracture. The almost completely imaged
right
maxillary sinus appears nearly completely opacified with a
possible fluid
level (5:2). Small mucous retention cysts are partially
visualized in the
lower portion of the left maxillary sinus. There is a small
focus of
dependent secretions versus dependent mucosal thickening in the
left sphenoid sinus. There are no pneumatized right mastoid air
cells. Bilateral mastoid antra, left mastoid air cells, and
bilateral middle ear cavities appear grossly well-aerated. The
orbits are unremarkable.
IMPRESSION:
1. Mildly motion limited exam.
2. No evidence for acute intracranial abnormalities.
3. Near complete opacification of the right maxillary sinus with
a possible fluid level. Small amount of dependent secretions
versus dependent mucosal thickening in the left sphenoid sinus.
Please correlate clinically with any associated infectious
symptoms.
___ Lung Scan:
Ventilation and perfusion images demonstrate a nonsegmental
matched
defect in the right lower lobe, best seen on the right posterior
oblique views. Chest x-ray shows a right chest Port-A-Cath with
tip terminating in the cavoatrial junction. Cardiomediastinal
silhouette is normal. Additionally, there is no acute focal
consolidation, no pneumothorax, no large pleural effusion and no
pulmonary edema.
IMPRESSION: Nonsegmental matched defect in the right lower lobe
compatible with a very low likelihood ratio for recent pulmonary
embolism.
___ TTE:
The left atrial volume index is normal. The estimated right
atrial pressure is ___ mmHg. There is mild symmetric left
ventricular hypertrophy with a normal cavity size. There is
normal regional and global left ventricular systolic function.
Quantitative biplane left ventricular ejection fraction is 73 %
(normal 54-73%). Left ventricular cardiac index is normal (>2.5
L/min/m2). There is no resting left ventricular outflow tract
gradient. Tissue Doppler suggests a normal left ventricular
filling pressure (PCWP less than 12mmHg). Normal right
ventricular cavity size with normal free wall motion. Tricuspid
annular plane systolic excursion (TAPSE) is normal. The aortic
sinus diameter is normal for gender with normal ascending aorta
diameter for gender. The aortic arch diameter is normal with a
normal descending aorta diameter. There is no evidence for an
aortic arch coarctation. The aortic valve leaflets (?#) appear
structurally normal. There is no aortic valve stenosis. There is
no aortic
regurgitation. The mitral valve leaflets appear structurally
normal with no mitral valve prolapse. There is trivial mitral
regurgitation. The pulmonic valve leaflets are not well seen.
The tricuspid valve leaflets
appear structurally normal. There is physiologic tricuspid
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
IMPRESSION: Normal study. Normal biventricular cavity sizes and
regional/global biventricular systolic function. No valvular
pathology or pathologic flow identified. Normal estimated
pulmonary artery systolic pressure.
___ MRI Head w and w/o Contrast
There is no evidence of hemorrhage, edema, masses, mass effect,
midline shift or infarction. The ventricles and sulci are
normal in caliber and
configuration. There is no abnormal enhancement after contrast
administration.
Bilateral orbits are unremarkable. Near complete opacification
of right maxillary sinus is noted. Mucous retention cyst is
noted in the floor of the left maxillary sinus. There is
partial opacification of bilateral mastoid air cells. Diffusely
hypointense bone marrow signal is likely related to patient's
known history of ALL.
IMPRESSION:
1. No intracranial mass is identified.
2. Near complete opacification of right maxillary sinus. Small
mucous
retention cyst in the left maxillary sinus. Partial
opacification bilateral mastoid air cells.
___ CERVICAL, THORACIC,
1. Motion limited exam.
2. Diffusely low bone marrow signal, in keeping with the known
LLL, without
evidence for focal suspicious marrow lesions.
3. No evidence for epidural or intrathecal malignancy.
4. Mild degenerative changes in the cervical and thoracic spine,
and at L4-L5,
as detailed above.
5. At L5-S1, epidural lipomatosis moderately narrows the thecal
sac with small
contribution from degenerative changes. Endplate and facet
osteophytes
contact the traversing S1 nerve roots in the subarticular zones
with possible
impingement on the right.
6. While the spleen is not fully imaged, the lower pole of the
spleen extends
to the mid left kidney and slightly remodels the upper half of
the left
kidney. Splenomegaly cannot be excluded on the basis of this
exam.
___, NON-OBSTETRIC
On the transabdominal images, the uterus measures up to 6.4 x
7.2 x 12.5 cm.
The uterus is bulky with many fibroids, some with
calcifications. Endometrium
measures 9-10 mm in width, within normal limits in a
premenopausal patient. A
subserosal fibroid along the right uterine fundus measures 2.6 x
3.0 x 3.1 cm
with calcification. Isoechoic but heterogeneous intramuscular
fibroid along
the right anterior uterine body measures 2.7 x 3.3 x 3.0 cm. An
additional
intramuscular fibroid is located posterior to the left of
midline in the
uterine body to fundus, measuring up to 3.1 x 3.1 x 2.8 cm. The
right ovary
could not be identified. The left ovary is difficult to
visualize due to
distance from the probes, but measures approximately 3.5 x 2.7 x
4.4 cm. The
transabdominal images suggests the presence of follicle
measuring about 2.4
cm. Trace free fluid is within physiological range.
IMPRESSION:
Fibroid uterus.
___ MR ___ Spine w/o Contrast
1. No epidural hematoma.
2. Possible subdural fluid collection L4, L5.
3. Abnormal marrow signal, consistent with infiltrative process.
4. Mild degenerative changes.
___ Pathology - Tissue
Immunophenotypic findings consistent with minimal involvement
(1% of non-debris events) by patient's known B-cell acute
lymphoblastic leukemia (B-ALL). Correlation with clinical,
morphologic (see separate pathology report ___,
cytogenetics (___), and other ancillary findings is
recommended. Flow cytometry immunophenotyping may not detect all
abnormal populations due to topography, sampling or artifacts of
sample preparation.
The chromosome study usually consists of analysis of 20 mitotic
cells. The cultures set up from this bone marrow sample only
produced 3 cells suitable for cytogenetic analysis. These cells
appeared to be karyotypically normal. However, FISH detected the
BCR/ABL1 gene rearrangement that was observed in blood collected
on ___ (see below). These findings are consistent with
persistence of the patient's known Ph+ B-lymphoblastic leukemia.
___ CT Chest w/o Contrast, CT Abd/ Pelvis w/o Contrast
1. No CT evidence of malignancy within the chest. Somewhat
limited evaluation of the pulmonary parenchyma due to
respiratory motion.
2. Visualization of the interventricular septum suggestive of
anemia.
3. Centrilobular emphysema.
1. Splenomegaly compatible with patient's Diagnosis of a LL. No
significant adenopathy is identified within the abdomen or
pelvis.
2. 7.5 cm right adrenal mass which is indeterminate. Recommend
comparison to prior imaging if available otherwise recommend
dedicated adrenal CT or MRI for further characterization.
3. 2 cm right renal angiomyolipoma which is benign.
4. Fibroid uterus.
___ MRI Abd w w/o contrast
1. Exam is limited by difficulty with breath holding,
particularly on in and out of phase imaging.
2. A 6.5 cm right adrenal lesion is consistent with an adrenal
cyst. No
suspicious features.
3. Splenomegaly.
DISCHARGE
=========
___ 12:00AM BLOOD WBC-5.5 RBC-3.27* Hgb-8.7* Hct-29.3*
MCV-90 MCH-26.6 MCHC-29.7* RDW-26.7* RDWSD-85.9* Plt ___
___ 12:00AM BLOOD Neuts-51.1 ___ Monos-5.3 Eos-1.0
Baso-0.2 NRBC-0.6* Im ___ AbsNeut-2.48 AbsLymp-2.02
AbsMono-0.26 AbsEos-0.05 AbsBaso-0.01
___ 12:00AM BLOOD Glucose-201* UreaN-18 Creat-0.5 Na-143
K-3.8 Cl-101 HCO3-24 AnGap-18
___ 12:00AM BLOOD ALT-34 AST-13 LD(LDH)-220 AlkPhos-64
TotBili-0.3
___ 10:50AM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-791*
___ 12:00AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.1 UricAcd-4.8
OTHER PERTINENT LABS
====================
___ 12:00AM BLOOD VitB12-336
___ 12:00AM BLOOD TSH-0.31
___ 05:33AM BLOOD %HbA1c-6.2* eAG-131*
___ 02:49AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG
___ 01:28AM BLOOD HCG-<5
___ 12:00AM BLOOD CMV IgG-POS*
___ 02:49AM BLOOD HIV Ab-NEG
___ 02:49AM BLOOD HCV VL-NOT DETECT
Brief Hospital Course:
SUMMARY
===========
___ with Ph+ B-cell ALL (MRD positive s/p ___ ___ course
I,II & IV), most recently on dasatinib (off since ___
insurance); h/o breast & ovarian cancer per patient ; mood
disorders; and hidradenitis suppurativa s/p 8 lymph node
surgeries who comes in from ___ with a CBC revealing 16%
blasts. She was initially admitted to the ICU for monitoring
though she remained stable and did not require pheresis. She was
later transferred to the floor for further management of her
ALL. no urgent need for pheresis and in stable condition. She
presented with productive cough and difficulty breathing, and
remained for continued workup of relapsed ALL. Her hospital
course was complicated by acute hypoxic respiratory failure,
vaginal bleeding with anemia, adjustment disorder, and urinary
incontinence.
ACUTE ISSUES:
===========
#Relapsed Ph+ B cell ALL
She was admitted to the medical ICU for an elevated lactate,
which remained stable, and hypertension, for which she was
switched from her home metoprolol to labetalol. Her labs showed
no evidence of DIC or TLS, and there was low concern for
leukostasis given relatively low counts. She clinically remained
well. She was transferred to the ___ service for further
treatment, and restarted on dasatinib and prednisone therapy.
Outside records confirmed her diagnosis, and she was found FISH
positive for BCR-ABL testing on her peripheral blood. She
underwent LPs to further characterize her disease, and treated
with IT MTX. Additional workup included CT Chest, Abd/Pelvis,
notable for adrenal mass and centrilobular emphysema, with
further characterization of adrenal cyst with MR ___. Her bone
marrow bx ___ showed karyotypically normal cells with
FISH positive for BCR/ABL.
The team discussed beginning ___ Part B, which the patient
was initially open to. She was started on prophylactic
medications, including allopurinol, acyclovir, micafungin, and
Bactrim. Her urine pH did not rise to an appropriate level, and
during this time, after further discussion with Ms. ___, the
team deferred chemotherapy treatment during this admission. With
Ms. ___, the team decided to continue with dasatinib and
prednisone, with further discussion of cancer treatment options
and goals of care as an outpatient. The patient verified that
she had 1.5 months of dasatinib at home so a refill prescription
was deferred at time of discharge.
#PTSD
#Adjustment disorder with anxiety
We managed her mood symptoms with anti-anxiety medications,
discharging her on her home regimen of clonazepam 1mg BID. The
psychiatry team was consulted for management of mood, with
alternative medicine recommendations; however, she preferred to
remain on her benzodiazepine regimen. The psychiatry team was
also consulted after she expressed strong desire to leave the
hospital against medical advice; during both of these occasions,
the team noted that she did not have capacity to leave. After
continued discussions with the patient over multiple days, a
collective decision was made to discharge Ms. ___ with
dasatinib and prednisone taper, with close outpatient follow up.
#Dyspnea
#Acute hypoxic respiratory failure
She described intermittent episodes of shortness of breath. She
received a VQ scan on ___, which showed low likelihood of
PE. A CTA Chest was deferred given her stated allergy to IV
contrast. CT chest ___ showed centrilobular emphysema
without acute bacterial infection. She was also found positive
for Rhinovirus on admission, likely contributing to her dyspnea.
She was continued on nebulizers and steroids as above. On the
floor, she had recurrent episodes of acute hypoxic respiratory
failure. CXR consistent with flash pulmonary edema. She was
given IV Lasix as needed with good response. She was discharged
home with plan to use Lasix po intermittently for weight gain.
#R-sided migranous headache
#Back pain
There was initial concern for CNS involvement, as she had
endorsed prior CNS involvement of her disease. An MRI brain did
not reveal an intracranial mass; she also underwent
fluoroscopy-guided lumbar puncture without infection. Her
immunophenotyping CSF was non-diagnostic due to insufficient
number of cells. MR spine revealed degenerative changes; a later
___ MR spine revealed no epidural hematoma, possible
subdural fluid collection L4, L5, and abnormal marrow signal,
consistent with infiltrative process; she did not display any
focal neurological deficits. She noted that her headache has
been persistent and of similar severity over the past year. She
also endorsed back pain radiating from her biopsy site down her
right leg. No focal neurological deficits were noted during her
stay. Symptoms were managed with pain medications, including
oxycodone, and were well controlled by time of discharge.
#Urinary incontinence
#Urge incontinence
#Glucosuria
#Hematuria
Her UAs were remarkable for glucosuria, initially, and CaOxalate
crystals with hematuria later in her stay. Her urinary
incontinence may have been due to her prior pregnancies, given
symptoms consistent with urge incontinence. No bacteria was
found in her urine.
#Abnormal uterine bleeding
Ms. ___ endorsed intermittent vaginal bleeding throughout
her stay. Her Hct was monitored closely and remained stable.
Pathology results from ___ were obtained, and gynecology
was consulted, with workup including transvaginal pelvic U/S and
repeat TSH, with final recommendations to consider
progesterone-based treatments. These treatments were deferred,
as there was low suspicion for continued vaginal bleeding. She
should follow up with OBGYN for further evaluation and
consideration of endometrial biopsy.
#Anemia
#Thrombocytopenia
We replaced her blood products as needed; her discharge Hgb was
8.7 and discharge platelet count 137. Her Hgb electrophoresis
was unremarkable. She should follow up as an outpatient for
further evaluation.
CHRONIC ISSUES:
===============
# COPD/Asthma
No e/o acute exacerbation on admission per ICU; however, poor
aeration and some wheezing was noted during her stay. She was
continued on nebs, while on prednisone for ALL as above.
# HTN
She was managed with antihypertensive medications, and her
discharge medications were amlodipine, HCTZ, labetalol, and
lisinopril.
# Hyperglycemia
Her A1c is 6.2%. She had been on metformin at home for
hidradenitis suppurativa. Her rising blood glucose was
attributed to steroid dosing, as well as increased food
consumption. She was placed on ISS and lantus.
TRANSITIONAL ISSUES:
====================
[] Continue dasatinib daily at home
[] Prednisone taper - take 50mg (5 tablets) daily for two days
(end ___, 40mg (4 tablets) daily for two days (end ___,
then 30mg (3 tablets) daily for two days (end ___ , then
20mg (2 tablets) daily for two days (end ___, and then 10 mg
(1 tablet) daily for two days (end ___ before stopping
completely
[] F/u in ___ clinic for further management of ALL
[] Repeat blood pressure at follow up clinic, titrate
medications as needed
[] Consider outpatient psychiatry evaluation for further
titration of medications
[] Recommend OBGYN referral for repeat endometrial biopsy
[] Recommend rechecking blood glucose at follow up appointment
while on prednisone and then repeating Hgb A1c in 3 months
[] Should remain off PPIs/H2 blockers while on dasatinib
[] Discharged on Lasix 40mg po prn for weight gain >2 lbs in a
day
[] Discharge weight 95.7Kg, discharge Cr 0.5
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 1 PUFF IH Q6H:PRN sob
2. Tiotropium Bromide 1 CAP IH DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. DiphenhydrAMINE Dose is Unknown PO DAILY PRN seasonal
allergies
5. ClonazePAM 1 mg PO BID:PRN anxiety
6. Gabapentin 1600 mg PO BID
7. Hydrochlorothiazide 25 mg PO DAILY
8. Lisinopril 40 mg PO DAILY
9. MetFORMIN (Glucophage) 500 mg PO BID
10. Metoprolol Tartrate 100 mg PO BID
11. Omeprazole 20 mg PO DAILY
12. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
13. meloxicam 7.5 mg oral daily prn pain
Discharge Medications:
1. Acyclovir 400 mg PO BID
RX *acyclovir 400 mg 1 capsule(s) by mouth twice a day Disp #*60
Tablet Refills:*0
2. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Cyanocobalamin 1000 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 1,000 mcg 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
5. DASatinib 140 mg PO DAILY )
( )
6. Furosemide 40 mg PO DAILY
Take 1 tablet if your weight increases by greater than 2 pounds
in a day.
RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
7. Labetalol 600 mg PO TID
RX *labetalol 300 mg 2 tablet(s) by mouth three times a day Disp
#*180 Tablet Refills:*0
8. PredniSONE 50 mg PO DAILY Duration: 2 Days
RX *prednisone 10 mg 5 tablet(s) by mouth daily for 2 days (end
___ Disp #*30 Tablet Refills:*0
9. PredniSONE 40 mg PO DAILY Duration: 2 Doses
Tapered dose - DOWN
10. PredniSONE 30 mg PO DAILY Duration: 2 Doses
Tapered dose - DOWN
11. PredniSONE 20 mg PO DAILY Duration: 2 Doses
Tapered dose - DOWN
12. PredniSONE 10 mg PO DAILY Duration: 2 Doses
Tapered dose - DOWN
13. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth once a day Disp #*30 Tablet Refills:*0
14. Albuterol Inhaler 1 PUFF IH Q6H:PRN sob
RX *albuterol sulfate 90 mcg 2 puffs inhaled every six (6) hours
Disp #*1 Inhaler Refills:*0
15. ClonazePAM 1 mg PO BID:PRN anxiety
16. Fluticasone Propionate NASAL 1 SPRY NU DAILY
RX *fluticasone propionate [Flonase Allergy Relief] 50
mcg/actuation 1 spray intranasal once a day Disp #*1 Spray
Refills:*0
17. Gabapentin 1600 mg PO BID
RX *gabapentin 400 mg 4 capsule(s) by mouth twice a day Disp
#*90 Capsule Refills:*0
18. Hydrochlorothiazide 25 mg PO DAILY
RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
19. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
20. MetFORMIN (Glucophage) 500 mg PO BID
RX *metformin 500 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
21. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
22. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1
capsule inhaled once a day Disp #*30 Capsule Refills:*0
23. HELD- DiphenhydrAMINE Dose is Unknown PO DAILY PRN seasonal
allergies This medication was held. Do not restart
DiphenhydrAMINE until instructed by your doctor
24. HELD- meloxicam 7.5 mg oral daily prn pain This medication
was held. Do not restart meloxicam until instructed by your
doctor
25. HELD- Omeprazole 20 mg PO DAILY This medication was held.
Do not restart Omeprazole until instructed by your cancer
doctor.
Discharge Disposition:
Home
Discharge Diagnosis:
#PRIMARY DIAGNOSIS
================
Relapsed Ph+ B Cell ALL
#SECONDARY DIAGNOSIS
==================
Centrilobular emphysema
Acute respiratory failure
Abnormal uterine bleeding
Adjustment disorder with anxiety
PTSD
Urinary incontinence
Hidradenitis suppurativa
Migranous headache
Low back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you at ___
___.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
===================================
You were transferred from ___ after your blood work was
concerning for relapsed leukemia.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
======================================
- You were initially treated in the ICU for close lab monitoring
while your leukemia medications were restarted.
- You received a chemotherapy drug in your cerebrospinal fluid
using guided imaging.
- You were transferred to the medical floor for continued
treatment and monitoring.
- You continued to have irregular vaginal bleeding and our
OB/Gyn colleagues evaluated you, including an ultrasound of your
pelvic area. With your input, we decided that we were not going
to start medications.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
============================================
Please continue to take your medications as prescribed, and
follow up with the cancer team.
- Continue taking the dasatinib daily
- You should continue taking the prednisone for ten more days,
decreasing the dose every two days: take 50mg (5 tablets) daily
for two days (end ___, 40mg (4 tablets) daily for two days
(end ___, then 30mg (3 tablets) daily for two days (end
___ , then 20mg (2 tablets) daily for two days (end ___,
and then 10 mg (1 tablet) daily for two days (end ___ before
stopping completely
- Do not take omeprazole (home medications) while you are on the
dasatinib
- Please monitor your weight daily. If your weight increases by
greater than 2 pounds in a day, please take the Lasix
(furosemide) 40 mg daily. You should NOT take the Lasix unless
your weight increases.
- Please follow up with your cancer team as well as your primary
care provider
___ wish you the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10270602-DS-14 | 10,270,602 | 26,675,635 | DS | 14 | 2135-11-25 00:00:00 | 2135-11-27 02:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ G1 at 22w6d GA with pelvic pain since this morning.
Describes two types of pain - one is like her period, and the
other is an exacerbation of her hip flexor tendonitis pain. She
reports that the hip flexor pain in chronic, and she previously
took narcotics and had ___ for this. However, she has not been
seen for this for approximately ___ years.
She has also been experiencing other cramping pain for the past
___, which feels like a period. This pain occurs at night,
but normally resolves after taking APAP. The pain did not
resolve with APAP this morning, however, and so she presenting
to the ED for evaluation.
She denies VB, LOF. +AFM. Had 'dry heaves' this AM, but no
current N/V. No fevers/chills. Was given 1mg dilaudid in the ED
with moderate effect.
Past Medical History:
PNC: ___ ___ by ultrasound
Labs: Rh+/RI/HbsAg neg/RPRNR/HIV neg
Genetics screening: declined
- U/S on ___ for fetal EF and ?VSD showed an anterior placenta
previa, expected to resolve
PObHx: G1
PGynHx: No history of LEEP or other cervical procedure
PMHx: asthma, ? PCOS with neg w/u per pt, anxiety/OCD
PSHx: shoulder surgery
Social History:
Denies ___, works as ___
Physical Exam:
Admission Exam
PE:
97.6, HR86, RR18, 100%
General: NAD. Does not appear intoxicated or to be having
regular
painful CTX.
Abdomen: abdomen tender throughout, no rebound or guarding, RLQ
tenderness > LLQ and rest of abdomen
SSE: Normal external anatomy, cervical os 0.5cm dilated/long, no
blood in vaginal vault.
SVE: deferred
TOCO: flat
Disharge Exam
AVSS
NAD, AOx3
Abd: soft, mildly tender, no rebound/guarding
Ext: wwp
Pertinent Results:
___ 11:45AM GLUCOSE-103* UREA N-9 CREAT-0.5 SODIUM-135
POTASSIUM-3.4 CHLORIDE-103 TOTAL CO2-20* ANION GAP-15
___ 11:45AM estGFR-Using this
___ 11:45AM WBC-9.2 RBC-4.04* HGB-12.2 HCT-34.3* MCV-85
MCH-30.1 MCHC-35.6* RDW-13.0
___ 11:45AM NEUTS-85.3* LYMPHS-11.3* MONOS-2.6 EOS-0.6
BASOS-0.1
___ 11:45AM PLT COUNT-172
___ 11:35AM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 11:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-8.5*
LEUK-NEG
___ 11:35AM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 11:35AM URINE AMORPH-OCC
___ 11:35AM URINE MUCOUS-RARE
Brief Hospital Course:
___ G1 h/o hip flexor tendonitis and abdominal pain who was
admitted to antepartum ___ for monitoring. Her repeat WBC
the next day normal. She was given tylenol around the clock and
oxycodone. Her pain was thought to be likely MSK related. On
___ patient endorsed that dying was better than pain but
repeatedly denied SI and initially had a sitter. Ortho saw her
on ___ and thought that her differential included flexor
tendinitis, femoralacetbular impingement, pelvic musculosketal
strain or non-orthopaedic etiology including hernia. Given that
this was a chronic issue, ortho recommended outpatient f/u which
was scheduled on ___. Patient in stable condition upon
discharge with follow up scheduled.
Medications on Admission:
albuterol, qvar, fluoxetine, fluticasone propionate, fluticasone
salmetrol, montelukast, zofran prn, pnv
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
2. Fluoxetine 20 mg PO DAILY
3. Fluticasone Propionate NASAL 2 SPRY NU BID
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. ___ 10 mg PO DAILY
6. Prenatal Vitamins 1 TAB PO DAILY
7. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q6hrs Disp #*10 Tablet
Refills:*0
8. Diazepam 5 mg PO Q12H:PRN pain/anxiety Duration: 1 Dose
RX *diazepam 2 mg ___ tablets by mouth every 12 hrs Disp #*30
Tablet Refills:*0
9. Diazepam 5 mg PO ONCE:PRN pain, insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
pregnancy at 23wks
abdominal pain
left hip flexor pain
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the antepartum service for observation due
to abdominal pain and hip flexor pain. Your clinical
presentation was most consistent with musculoskeletal pain. You
were given medications to control your pain. You had no
obstetric concerns during this admission.
Followup Instructions:
___
|
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